pidcock presentation

8/14/2019 Pidcock Presentation

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Selecting Appropriate andEffective Equipment:


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Choosing the right equipment

Mobility Purpose

Design Painful sitters

Difficulty with proper alignment


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Orthopedic Issues

Loss of passive joint mobility Fixed contractures

Loss of stability Scoliosis


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Optimizing the environment

House School

Recreation Car


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Mobility


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Important determinants ofambulation potential

Energy Expenditure

Spasticty

Contractures

Pain


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Ambulation Categories

Community Household

Exercise Nonamulatory


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Community ambulators

Pelvic control with at least fair strength inhip flexors bilaterally and in at least one

knee extensor


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Potential benefits

Ability to overcome functional barriers Increased self esteem

Cardiopulmonary exercise


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Neurologic predictors forambulation

Level of injury below T11 associated with

increased potential for ambulation

Complete tetraplegia do not become

community ambulators

Chronologic age is not by itself aprognostic factor


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Mechanical devices to assistambulation Hip-knee- ankle-foot orthosis (e.g.

reciprocating gait brace)

Knee-ankle-foot orthosis (e.g. Scott-Craigbrace)

Ankle-foot orthosis


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Rehabilitation for ambulationtraining

Strengthening of the lower and upper

extremities

Control of the pelvis and trunk

Joint stabilization


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Goals

Prevent or accommodate orthopedicdeformities

Prevent skin break down from pressure

Provide trunk stability to enhance armfunction

Promote independent mobility Facilitate independence in the activities of

daily living


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Planning a seating system

Angle between the seat and the backsurfaces

Tilt of the system in space Type of seating surface


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The Angle

Whatever is needed to maintain the pelvis in an neutral or slights

anterior pelvic tilt

achieve the proper lumbar curve

provide a base for good spinal alignment


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Opening the angle (making itmore than 90 degrees)

At 90 degrees of hip flexion need to be

available

Over 90 degrees may reduce spasticity

But may also destabilize trunk support

May force low back extensors to fire

increasing lumbar curve


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Using head, shoulder, and backextensors to remain upright


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Upright support options

Anterior harnesses or chest straps Upper extremity support like a tray

Tilting slight tilt may be enough to sit more upright

against gravity


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A slight tilt may help sit moreupright against gravity


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Tilt-in-space base

Provides adjustment

for seat tilt whileholding hip, knee, and

ankles in place


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The Seat

Planar Contoured

Custom molded


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Sitting on flat surfaces may causeincreased pressure over bony

prominences


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Some types of foam will reshapein response to body weight


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Blocks can be added to the sitting

surface to provide lateral as well

as posterior supports


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High density foam shapes can beplaced under more flexible foam

to create a contoured cushion


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Seat Surface

Does the seat provide enough support? Is the seat the proper depth?

Does the seat provide enough pressurerelief?


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The pelvis and lower extremities

A firm base of support is needed fromwhich to function

The base needs to be

Stable

Symmetric

Supportive The pelvis position should be neutral or

slightly tipped forward


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Posterior pelvic tilt affects bodyposture

Discomfort

Finding a balance

point Shortening of the

hamstring muscles


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Falling into anterior pelvic tilt

Weakness Very low tone

Hip flexion

contractures


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Sitting in a sling seat increasesasymmetries


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Firm sitting surface provides agood base of support


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Back Surface

Does the back surface provide enoughsupport?

Is the seat the proper depth?

Is the back support high enough?


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Support to the back of the pelviscan help maintain good

alignment


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If the seat is too deep then thepelvis will tilt back causing the

pelvis to round


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Is the back support high enough?

Fair trunk control should rise to themiddle of the shoulder blade

Poor trunk control should rise to the

shoulder

Increase extensor tone should rise to the

shoulder


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Positioning belts or bars are usedto prevent the pelvis from

slipping

A belt across thewaist will encourage

posterior pelvic tilt


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A rigid bar may be needed withexcessive trunk extension


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Hip guides to control pelvicposition


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Knee supports

A spacer may beneeded to keep the

legs in a neutral

position It should start at the

front of the knee and

move 1/3 of the wayup the thigh


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Trunk supports

Leaning to one sideor the other

Muscle imbalance

Poor postural control Discomfort

Perform a functional

task


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Three point control is needed tomaintain trunk position


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Proper position of the straps isvery important

The strap should passover the shoulder to a

point at or slightly

below the shoulder

line

The bottom should besecurely tethered


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Y straps tend to bind against theside of the neck putting pressure

over neck blood vessels


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H straps work well but should notbe tethered to the lap belt


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Standing Frames


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Gait trainers


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Orthopedic surgery: Should weor shouldnt we?


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Decisions to treat

Based on degree of contracture Whether the joint motion covers a

functional range

Belief that surgery will improve the natural

history


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Common Clinical Patterns: Lower Limbs


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Physiology of Contractures Mobile tissues usually separated by thin

layers of loose areolar connective tissue

Immobility causes reorganization of theloose connective tissue

Once soft tissues are involved - muscleshortening may follow


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Orthopaedic surgery

3 major goals Remove or diminish muscle imbalance

Prevent bony deformity

Correct bony deformity


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Orthopaedic Surgery: Goals

Muscle-tendon surgery restore dynamic alignment

improve agonist-antagonist balance

Osteotomies realigns osseous levers

correct torsional deformities

Arthrodesis

stabilize severely subluxed, painful arthritic joints


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Musculotendinous Procedures

Lengthening of the tendon Tendo Achilles lengthening

Hip adductor tenotomy

Lengthening of the musculotendinous

junction or fascia

Strayer, Vulpius, or Baker lengthenings

www.wemove.org


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Defining the functional problem

Joint contracture: loss of passive range of motion

muscle-tendon unit

dynamic which is braceable

fixed which requires surgery

ligament or joint capsule

Gait deterioration

Joint instability or torsional deformity Pain


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