Pidcock Handouts

8/14/2019 Pidcock Handouts

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Selecting Appropriate and

Effective Equipment: Choosing the right equipment

Mobility

Purpose

Design

Painful sitters

Difficulty with proper alignment

Orthopedic Issues

Loss of passive joint mobility

Fixed contractures

Loss of stability

Scoliosis

Optimizing the environment

House

School

Recreation

Car


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MobilityImportant determinants of

ambulation potential

Energy Expenditure Spasticty

Contractures

Pain

Ambulation Categories

Community

Household

Exercise

Nonamulatory

Community ambulators

Pelvic control with at least fair strength in

hip flexors bilaterally and in at least oneknee extensor


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Potential benefits

Ability to overcome functional barriers

Increased self esteem

Cardiopulmonary exercise

Neurologic predictors for

ambulation

Level of injury below T11 associated withincreased potential for ambulation

Complete tetraplegia do not become

community ambulators

Chronologic age is not by itself a

prognostic factor

Mechanical devices to assist

ambulation Hip-knee- ankle-foot orthosis (e.g.

reciprocating gait brace)

Knee-ankle-foot orthosis (e.g. Scott-Craig

brace)

Ankle-foot orthosis

Rehabilitation for ambulation

training

Strengthening of the lower and upper

extremities

Control of the pelvis and trunk

Joint stabilization

Goals

Prevent or accommodate orthopedic

deformities Prevent skin break down from pressure

Provide trunk stability to enhance armfunction

Promote independent mobility

Facilitate independence in the activities ofdaily living


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Planning a seating system

Angle between the seat and the back

surfaces

Tilt of the system in space

Type of seating surface

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

Opening the angle (making it

more than 90 degrees)

At 90 degrees of hip flexion need to beavailable

Over 90 degrees may reduce spasticity

But may also destabilize trunk support

May force low back extensors to fire

increasing lumbar curve

Using head, shoulder, and back

extensors 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

A slight tilt may help sit more

upright against gravity

Tilt-in-space base

Provides adjustment

for seat tilt while

holding hip, knee, and

ankles in place

The Seat

Planar

Contoured

Custom molded

Sitting on flat surfaces may cause

increased pressure over bony

prominences

Some types of foam will reshape

in response to body weight


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Blocks can be added to the sitting

surface to provide lateral as well

as posterior supports

High density foam shapes can be

placed under more flexible foam

to create a contoured cushion

Seat Surface

Does the seat provide enough support?

Is the seat the proper depth?

Does the seat provide enough pressure

relief?

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

Posterior pelvic tilt affects body

posture

Discomfort Finding a balance

point

Shortening of the

hamstring muscles

Falling into anterior pelvic tilt

Weakness

Very low tone Hip flexion

contractures


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Sitting in a sling seat increases

asymmetries

Firm sitting surface provides a

good base of support

Back Surface

Does the back surface provide enough

support?

Is the seat the proper depth?

Is the back support high enough?

Support to the back of the pelvis

can help maintain good

alignment

If the seat is too deep then the

pelvis will tilt back causing the

pelvis to round

Is the back support high enough?

Fair trunk control should rise to the

middle 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 used

to prevent the pelvis from

slipping A belt across the

waist will encourage

posterior pelvic tilt

A rigid bar may be needed with

excessive trunk extension

Hip guides to control pelvic

position

Knee supports

A spacer may be

needed to keep thelegs in a neutral

position

It should start at the

front of the knee and

move 1/3 of the way

up the thigh

Trunk supports

Leaning to one side

or the other Muscle imbalance

Poor postural control

Discomfort

Perform a functional

task


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Three point control is needed to

maintain trunk position

Proper position of the straps is

very important

The strap should pass

over the shoulder to a

point at or slightly

below the shoulder

line

The bottom should be

securely tethered

Y straps tend to bind against the

side of the neck putting pressure

over neck blood vessels

H straps work well but should not

be tethered to the lap belt

Standing Frames Gait trainers


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Orthopedic surgery: Should we

or shouldnt we?Decisions to treat

Based on degree of contracture

Whether the joint motion covers afunctional range

Belief that surgery will improve the natural

history

Common Clinical Patterns: Lower Limbs

Physiology of Contractures

Mobile tissues usually separated by thinlayers of loose areolar connective tissue

Immobility causes reorganization of theloose connective tissue

Once soft tissues are involved - muscleshortening may follow

Orthopaedic surgery

3 major goals

Remove or diminish muscle imbalance

Prevent bony deformity

Correct bony deformity

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

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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