Ptha 2435 - Rehab Techniques - Cameron And Monroe Book And Hays Lecture - Exam 3

Front 1

What is the rate of limb amputation in the U.S.? ***

Back 1

52.4 per 100,000

Front 2

What are the primary causes of most lower extremity limb amputations? ***

Back 2

- underlying vascular disease

- diabetes

Front 3

What are some less-common causes of limb amputation? ***

Back 3

- trauma
- malignancy
- congenital limb abnormalities
- occasionally elective surgery to improve function or correct malformation

Front 4

What is an open amputation? ***

Back 4

- skin is not sutured
- indicated when the operative site is contaminated

- usually involves guillotine amputation (severing muscle without suturing)
- edges of skin tractioned to help retain length until able to close

Front 5

What is a closed amputation? ***

Back 5

skin edges are stapled or sutured together

Front 6

What is a myoplasty? ***

Back 6

the underlying muscles are sutured to one another

Front 7

What is a myodesis? ***

Back 7

underlying muscles are sutured through holes drilled in the bone

Front 8

What is done with the bone endings following amputation? ***

Back 8

bone edges are beveled to reduce sharp osteophytes.

Front 9

What is done with the nerve endings following amputation? ***

Back 9

- nerves are severed under tension so that they retract within the mm bellies, not near the skin

- this decreases the risk of local pain.

Front 10

What is the most common etiology of amputation in the U.S.? ***

Back 10

peripheral vascular disease (PVD), particularly arteriosclerosis

Front 11

Who is the typical patient with PVD? ***

Back 11

- male
- mid-sixties

history of
- diabetes
- coronary artery disease
- hypertension
- smoking

Front 12

When is amputation used on patients with PVD? ***

Back 12

treatment of last resort after possibly many years of
- pain
- claudication (ischemia within a muscle belly that causes calf pain—do not push through)
- recurrent skin ulcers and
- edema

resulting in
- osteomyelitis and/or
- gangrene

Front 13

Name some minor LE amputations. ***

Back 13

- phalangeal (toe disarticulation)
- ray resection
- transmetatarsal
- LisFranc (tarsometatarsal joint)
- midtarsal disarticulation (Chopart’s)
- hindfoot (e.g., Boyd or Pirosom)

(Boyd - amputation at the ankle with removal of the talus and fusion of the tibia and calcaneus)

(Pirosom - ???)

Front 14

What is a ray resection? ***

Back 14

removal of a metatarsal and its phalanges

Front 15

What issues arise in a patient after undergoing a ray resection? ***

Back 15

- creates a foot that is abnormally narrow

- reduces the BOS in standing

Front 16

Which ray resection is most troublesome? Why? ***

Back 16

- loss of the first ray is particularly disabling

- because it usually takes much of the load when walking on level and unlevel surfaces
(OK, wouldn’t that be all surfaces then?)

Front 17

Where is the amputation in a Chopart’s disarticulation? ***

Back 17

- between the talus and navicular on the medial side of the foot

- between the calcaneus and the cuboid on the lateral side of the foot

Front 18

Name some major LE amputations. ***

Back 18

- Syme’s
- ankle disarticulation
- transtibial
- transfemoral

- hip disarticulation
- transpelvic
- translumbar

Front 19

What is a Syme’s amputation? ***

Back 19

- transsection of the distal tibia and fibula through the bone
- with preservation of the calcaneal fat pad

- fat pad is sutured to the anterior portion of the distal shank
- patient can walk short distances without a prosthesis

Front 20

What is a hip disarticulation amputation? ***

Back 20

separation of the femur from the acetabulum

Front 21

What is the primary reason for a hip disarticulation amputation? ***

Back 21

usually due to malignancy

Front 22

What is a transpelvic amputation? ***

Back 22

removal of any portion of the pelvis and all distal parts

Front 23

What is the primary reason for a transpelvic amputation? ***

Back 23

- also usually due to malignancy (as hip disarticulation)

- less often due to trauma or soft tissue infection

Front 24

What is a translumbar amputation? ***

Back 24

entire pelvis and all distal parts removed

Front 25

What is/are extremely important to avoid with amputees? ***

Back 25

joint contractures!!

Front 26

Why are joint contractures to be avoided with amputees? ***

Back 26

they limit patient’s ability to
- dress
- transfer and
- use prosthetics

Front 27

Contractures commonly associated with transtibial amputation: ***

Back 27

- hip flexion

- knee flexion

Front 28

Contractures commonly associated with transfemoral amputation: ***

Back 28

- hip flexion
- hip abduction
- hip external rotation
(because the muscles performing these actions are stronger and the leg is light)

Front 29

What are some of the main contributing factors to joint contractures in amputees? ***

Back 29

- muscle imbalances
- inactivity
- faulting positioning (including prolonged sitting)

Front 30

How can one stretch joint contractures in an amputated limb? ***

Back 30

- lie prone and/or

- add weight to residual limb

Front 31

Depression is common in amputees. What are some of the major contributing factors (besides the obvious loss of limb)? ***

Back 31

- phantom limb pain
- residual limb pain
- back pain

Front 32

What is phantom sensation? ***

Back 32

- patient feels the missing part like it is still there

- usually felt for the rest of their lives

Front 33

What is phantom pain? How does it manifest? ***

Back 33

- patient feels pain in the missing body part

- besides pain, burning, electrical shocks, etc. may also be felt

Front 34

For how long does phantom pain typically last? ***

Back 34

- it usually subsides within the first year after amputation

Front 35

For what cardiovascular signs/symptoms should a patient who has had a LE amputation be checked? ***

Back 35

circulatory status – of both the residual limb and remaining extremity
- color changes (red = infection; blue/pale = ischemia)
- temperature changes (warmth = infection, cold = ischemia)
- skin breakdown

Front 36

For what integumentary signs/symptoms should a patient who has had a LE amputation be checked? ***

Back 36

as for circulatory changes:
- color changes (red = infection; blue/pale = ischemia)
- temperature changes (warmth = infection, cold = ischemia)
- skin breakdown

also:
- dermatitis – reactions to the new materials that are coming in contact with the skin such as gel or cotton/wool liners or shrinkers, elastic wraps
- irritation at brim margins and under suspension of prosthesis

- check sensation if a PVD or DM patient
- check before donning and after doffing prosthesis

Front 37

What are the goals of preoperative care for patients undergoing LE amputation? ***

Back 37

- prepare the patient for life after amputation surgery

- to begin rehabilitation

Front 38

What types of treatment should be included in preoperative care for patients undergoing LE amputation? ***

Back 38

- psychological counseling
- joint mobility – prevent contractures, active ROM
- general conditioning – improve strength and endurance; gentle exercise of trunk & all extremities

- functional activities – taught self care, transfers, & gait with a walker or crutches (better to practice ahead of time; balance greatly affected)
- bed and wheel chair positioning - lie prone as much as tolerable, avoid positions of contracture

Front 39

What are the goals of early postoperative management for patients who have undergone LE amputation? ***

Back 39

- foster wound healing

- promote maximum function – pain reduction, edema control, mobility, strengthening

Front 40

When does early postoperative management of patient who has undergone LE amputation begin? ***

Back 40

when the patient is medically stable

Front 41

What types of treatment are used to promote wound healing in a patient who has undergone LE amputation? ***

Back 41

- electrical stimulation
- UV
- ultrasound
- intermittent pneumatic compression
- hydrotherapy
- negative pressure (vac)

- to create a clean, stable wound environment to facilitate healing

Front 42

How is edema control managed in a patient who has undergone LE amputation? ***

Back 42

- three types of dressings used:
--- soft dressings
--- semi-rigid dressings and
--- rigid dressings

- promotes wound healing, reduces pain, and facilitates prosthetic fitting (wrap hip/knee in extension)
- should be used until patient is wearing prosthesis most of the day, or until the wound is healed and the residual limb is no longer painful.

Front 43

For how long following LE amputation does the residual limb volume fluctuate? ***

Back 43

limb volume change continues for an average of 120 days after surgery

Front 44

What types of dressings are used for edema control following LE amputation? ***

Back 44

three types of dressings are used:
- soft dressings – ace/elastic wraps most commonly used; shrinker socks
- semi-rigid dressings – unna dressing, air splint
- rigid dressings - plaster

Front 45

What are the advantages and disadvantages of using ace/elastic wraps (soft dressings) on the residual limb to control edema following LE amputation? ***

Back 45

advantages:
- inexpensive
- application and removal are simple
- easy access to inspect the wound

disadvantages:
- must be reapplied several times per day
- difficult for patients with transfemoral amputation to apply
- may cause adductor roll and breakdown if not applied correctly

Front 46

What are the advantages and disadvantages of using shrinker socks (soft dressings) on the residual limb to control edema following LE amputation? ***

Back 46

advantages:
- relatively easy to apply
- compresses uniformly

disadvantages:
- issued by the prosthetist
- transfemoral sock may need a belt with garters for suspension
- sometimes biking shorts or gel socks may be used

Front 47

What are the advantages of using unna dressing (semi-rigid dressing) on the residual limb to control edema following LE amputation? (No disadvantages presented in lecture.) ***

Back 47

- decreased healing time due to consistent edema control

- accelerated rehabilitation especially with transfemoral (consistently keeps level of compression)

(I found two disadvantages listed—it cannot get wet, and because it must dry fully, dressing changes can take a long time.)

Front 48

What are the advantages of using an air splint (semi-rigid dressing) on the residual limb to control edema following LE amputation? (No disadvantages presented in lecture.) ***

Back 48

advantages:
- easy to apply and remove
- is self-suspending
- provides uniform pressure, so limited weight bearing usually allowed

disadvantages:
- bulkiness
- susceptibility to punctures

Front 49

Describe the rigid dressings used postoperatively for patients who have undergone a LE amputation. ***

Back 49

- multiple layers; outermost could be plaster, webbing for suspension
- remains on the limb until suture removal, if tolerated well

- may be the foundation for an immediate postoperative prosthesis (IPOP) if a pylon with foot is plastered into the dressing

Front 50

What is an IPOP? What are its advantages and disadvantages? ***

Back 50

advantages:
- controls edema
- permits early ambulation

disadvantages:
- heavy
- requires shoulder harness
- sitting is awkward
- it is difficult to inspect the wound (may have to cut window)
- requires considerable skill to apply

Front 51

What types of interventions are used for pain management of phantom pain following LE amputation? ***

Back 51

- keep compression on limb with dressing discussed

conservative phantom pain control includes:
- massage
- resistive exercise of the contralateral limb
- relaxation
- acupuncture
- modalities such as: US, TENS, and biofeedback

Front 52

How is joint mobility maintained in a patient following LE amputation? ***

Back 52

- active exercise

positioning
- no pillows under the lumbar spine, between the thighs, or under the residual limb
- in WC must have limb extended up on projection under the seat (order special cushion or use sliding board)

- splinting – joint nearest to amputation always extended in splint or rigid/semi-rigid dressing

Front 53

How is postoperative strengthening carried out with a patient who has undergone a LE amputation? ***

Back 53

focus on:
- hip extensors (hamstrings and gluteals) and
- abductors/hip hikers (gluteus medius, quadratus lumborum)— important for walking

- for transtibial amputations, work on knee extensors as well

- various resistance can be used to increase strength and reduce energy consumption, including:
- manual
- active
- elastic
- pulley and
- isokinetic exercises

Front 54

What exercises are beneficial to the strengthening program of a patient who has undergone LE amputation? ***

Back 54

- bridging
- hip extension
- hip abduction –sidelying
- quad sets
- knee extension
- straight leg raises (SLRs)
- hip adduction

- general exercise program for the trunk, UEs and uninvolved LE

- see also pg. 172, table 12-1 and VHI handouts for exercises

Front 55

What types of holistic care are recommended for patients who have undergone LE amputation? ***

Back 55

- peer counseling for the patient and family (support group)

- general conditioning program
- standing on the intact foot in parallel bars, walker, or crutches; if patient has IPOP, attach pylon
(they can weight bear only up to 25# until the sutures are removed)
- gait training & transfers as able

- wheelchair for temporary or permanent use should have its rear wheels displaced posteriorly so that the new change in person’s center of gravity will not cause the WC to tip backward.
- to make transfer easier, no foot rests on WC if patient has a bilateral amputation

- patient education:
---care of the remaining extremity
---avoidance of risk activities that slow healing and increase risk of further amputation
--- especially if due to PVD, instruct patient to avoid smoking, bathing in hot water, avoid use of heating pads, don’t expose feet to radiator or fire, don’t wear tight hose or circular garters
---protect feet by wearing closed-toed shoes at all times
--- inspect skin daily (mirror), wash, dry well, use lotion
--- cut toenails straight across or go see podiatrist
--- inspect shoes before and after use

Front 56

Is every LE amputee a candidate for a prosthesis? ***

Back 56

no, they are contraindicated for:
- patients with severe cardiovascular or pulmonary disease that would make use of prosthesis unsafe
- most patients with dementia
- patient that is unmotivated (delay order until they show interest in rehabilitation)

medical factors that may influence prescription of a prosthesis:
- neuropathy
- arthritis
- lack of skin integrity
- contracture
- weakness

Front 57

What are some LE prosthetic options—partial foot amputation? ***

Back 57

- no prosthesis necessary for phalangeal amputation, may want shoe filler in toe box

- transmetatarsal amputation requires a custom made, total contact socket attached to a shoe filler

Front 58

What are some LE prosthetic options—Syme’s amputation and ankle disarticulation? ***

Back 58

- specialty foot made for this kind of prosthesis
- custom made plastic socket
- may or may not have a side wall opening depending on if distal end is bulbous or more streamlined

Front 59

What are some LE prosthetic options—transtibial amputation? ***

Back 59

- consists of a foot, shank, socket, and suspension
- SACH foot is the basic nonarticulated foot
--- it is inexpensive and available in a wide range of sizes
--- it has a compressible heel, a rigid longitudinal keel , and a rubber-like toe section

- energy storing (dynamic or energy response) foot:
---is nonarticulated, and relies on recoil during the late stance period
--- has a carbon-fiber leaf spring, which is more expensive than the SACH foot

Front 60

What is a SACH foot? ****

Back 60

solid ankle, cushioned heel

Front 61

Describe articulated feet. ***

Back 61

- have a separation between the foot and the shank, allowing more motion to occur around one or more axial bolts

- may have a metal single-axis joint in place of ankle, with dorsiflexion bumper to anterior and planterflexion bumper posterior; toe bumper and toe belting to prevent excessive motion in forefoot

Front 62

What is a shank? ***

Back 62

- the portion of the prosthesis between the foot and the socket

- usually shaped to match the contralateral limb

- exoskeletal (crustacean) – a rigid weight-bearing outer shell of plastic or wood
- endoskeletal – rigid central weight-bearing metal or plastic pylon and a cosmetic cover

- torque absorber may be installed to absorb transverse stress
--- helpful for those who play golf or walk on uneven terrain

Front 63

What is a socket? ***

Back 63

- “the most important part of the prosthesis”, because it contacts the patient’s skin

- custom made of plastic that is either entirely rigid or flexible on the inside with a rigid frame

Front 64

What is the most important part of the prosthesis? ***

Back 64

- the socket, because it contacts the patient’s skin

Front 65

Describe some of the transtibial socket types. ***

Back 65

- basic transtibial socket is the patellar tendon bearing (PTB)
- there is also weight bearing throughout the tolerant areas; this is used less often than the newer types

- newer socket designs: total surface-bearing and hydrostatic models
--- total surface-bearing socket: has the basic contours of the PTB but are designed to be worn with a compressible liner and are usually suspended by a distal attachment
--- hydrostatic socket: smoother contours and is most appropriate for short, fleshy residual limbs; distal tissue cushions the bottom of the socket

Front 66

How is the transtibial socket lined? ***

Back 66

- most transtibial sockets are worn with one or more interfaces or liners
--- oldest type is a thermoplastic foam liner replica of the limb which can be modified by the prosthetist fairly easily by adding or removing foam
--- may wear socks made of wool, cotton, or Orlon acrylic

- never wear more than 15 ply of socks
- patient may wear a liner made of silicone or polyurethane, sometimes with gel-filled or mineral oil filled channels to equalize pressure within the socket

Front 67

Which areas are pressure-tolerant for weight bearing on a transtibial prostheis? Which are not? ***

Back 67

pressure tolerant areas:
- patellar ligament
- triceps surae belly
- medial tibial flair (flare, maybe?) (a.k.a. pes anserinus)

areas that do not tolerate pressure well:
- tibial tuberosity, crest, and condyles
- fibular head
- hamstring tendons
- distal ends of the tibia and fibula

Front 68

What is the suspension of a prosthesis? ***

Back 68

the component that keeps the prosthesis on during the swing phase of gait

Front 69

What is the simplest, most adjustable, and least expensive type of transtibial suspension? ***

Back 69

- the supracondylar cuff, which buckles or velcros around the distal thigh

- may have additional waist belt or fork strap

Front 70

Name a transtibial suspension option other than the supracondylar cuff. ***

Back 70

- rubberized sleeve from distal thigh to the proximal portion of the prosthesis may be used
- it requires two strong hands to don and will not fit a very large thigh, however

- the supracondylar suspension— a brim that extends over the medial and lateral femoral epicondyles and the socket covers the patella
- used on very short limbs

- silicone liner and a metal pin that lodges in a receptacle in the proximal portion of the shank
- during swing the liner squeezes creating a distal suction
- this could compromise skin health but special valves can be incorporated to limit the amount of vacuum

Front 71

Describe the basic transfemoral amputation prosthesis options. ***

Back 71

- consists of a foot, shank, knee unit, socket, and suspension
- any foot can be used but the basic SACH foot and the single axis foot are more likely to be used
.
- endoskeletal shank with its cover is more cosmetic, not to mention lighter, so is more often used; but cover is not very durable and may wear out from normal sitting

- torque absorber may be included between the thigh unit and knee

- many designs of knee units, see p. 177, table 12-3 for component options
--- single axis knee unit with a transverse bolt is most often used
--- simple design and works well for most patients

Front 72

Describe the different friction mechanisms for transfemoral amputation prostheses. ***

Back 72

friction mechanism
- resists shank movement during the swing phase of gait to prevent excessive knee flexion during early swing and abrupt extension at late swing
- a constant friction is simplest

fluid friction
- have a cylinder containing either oil (hydraulic) or air (pneumatic) which provide variable friction
- amount of friction changes with patient’s walking velocity; more when fast, less when walking slow

computer-controlled fluid friction control mechanism
- uses information from ankle and knee motion sensors to adjust resistance according to gait velocity and alterations in terrain
- patient can traverse stairs using reciprocal stepping
-“Rheo Knee” or “C – leg”

Front 73

What is an extension aid (transfemoral prosthesis)? ***

Back 73

- a mechanism for extending the shank at the end of swing phase so that the patient can be sure that the knee will be straight at the time of heel contact

- can be external or internal designs

Front 74

What is a stabilizer mechanism (transfemoral prosthesis)? ***

Back 74

- simplest is a manual lock which has a spring-loaded pin that when engaged locks the knee in full extension, providing maximal stability
- patient walks with a stiff knee, and must unlock it to sit
- hydraulic and microprocessor controlled knee units enable the wearer to walk more normally with controlled knee flexion

Front 75

Describe the basic socket of the transfemoral prosthesis. ***

Back 75

- newer type is a flexible socket seated in a rigid frame

two principal designs: quadrilateral socket or ischial containment socket
- quadrilateral socket
--- older design
--- ischial tuberosity rests on the posterior brim of the socket & supports considerable weight
--- anterior wall has a sizable convexity over the femoral (Scarpa’s) triangle
--- medial brim is level with posterior brim, while lateral and anterior brims are approximately 2.5 inches higher
--- will rarely see

- ischial containment socket
--- extends above ischial tuberosity with medial brim covering part of the ischiopubic ramus
--- anterior wall is somewhat lower than posterior wall, and is relatively narrow to provide greater stability

Front 76

What are the advantages of the socket of the transfemoral prosthesis? ***

Back 76

- more comfortable when seated
- cooler to wear
- easier to modify but is somewhat more difficult to fabricate.

Front 77

Describe the suspension of the transfemoral prosthesis. ***

Back 77

total suction suspension
- suction that is controlled with an air expulsion valve in the distal portion of the socket
- most used type of transfemoral socket

partial suction suspension
- involves the use of a suction valve which when used creates a difference in pressure between the inside of the socket and the outside
- this pressure, however, is not enough to suspend the prosthesis during swing
- requires Silesian belt or a webbing lanyard to suspend (e.g., suspenders.)

- less often used is the pelvic band which helps to control hip abduction, hip adduction, and rotation; it is heavy, has a metal hip joint & pelvic strap

Front 78

What are the advantages of and precautions for the total suction socket of the transfemoral prosthesis? ***

Back 78

- advantages
--- no socks or liner needed
--- lightest type of suspension

- precaution
--- patient’s limb volume must not fluctuate

Front 79

What are the characteristics of prostheses for bilateral amputations? ***

Back 79

- individuals with bilateral amputations should have prostheses with feet that are identical in design & manufacture because patients can detect subtle differences between the actions of the feet

- the feet should be shorter than preamputation size to ease transition during stance phase, and they should be wider to increase stability

- bilateral transfemoral prostheses may be short, nonarticulated “stubbies” that provide more stability

Front 80

What types of prosthetic education must be provided to amputees? ***

Back 80

- at a minimum, teach patient how to don prosthesis and transfer from one seat to another

also
- dressing
- transfers
- balance and gait training
- wearing schedule

Front 81

Describe the dressing sequence for patients with prostheses. ***

Back 81

dressing (easiest sequence)
- don undergarments
- place the trouser leg or panty hose on the prosthesis
- put a sock and shoe on the prosthesis
- don the prosthesis
(p. 181, table 12-4)

Front 82

Describe transfer training for patients with prostheses. ***

Back 82

transfers
- move towards the strongest, or sound leg
- use chairs with arm rests
- progress to transfers to and from a toilet, car, and other seating surfaces

Front 83

Describe balance and gait training for patients with prostheses. ***

Back 83

balance and gait training
- goal is to enable the patient to place equal weight on both limbs
- help the patient to learn to walk with steps of even length & to control the knee unit
- PNF techniques; exercises listed P. 183, Table 12-5
- use of parallel bars or unweighting, progressing to rolling walker

Front 84

Describe the wearing schedule progression for patients with prostheses. ***

Back 84

wearing schedule
- carefully monitor the residual limb for skin irritation
- initially, patient should wear prosthesis for 5-15 minutes, then remove it so that the skin may be assessed; gradually increase the wearing time to patient tolerance

Front 85

Describe the gait compensations noted with transtibial amputations. Transfemoral amputations. ***

Back 85

transtibial
- longer step length
- longer step time
- longer swing time
- higher activity of the biceps femoris on the amputated side

transfemoral
- asymmetrical, caused by a combination of anatomical and prosthetic limitations
- lack of sensation, pain, contracture, weakness, instability, incoordination, and slow gait velocity may be correctable
- see Table 12-6 & 12-7 and match them to the handout provided

Front 86

Describe the care necessary for the residual limb and prosthesis, post amputation. ***

Back 86

- skin protected against abrasions
- if accommodated to the prosthesis, check the skin each evening; reddened or discolored areas should resolve within 10 minutes, if not, return to prosthetist for adjustment

- maintain flexibility (full ROM) & strength; esp. hip and knee extensors (abductors as well)

- prosthetic care: clean socket by wiping it with a damp cloth nightly, brush the knee unit and articulated foot unit, inspect the appliance for signs of wear or malfunction

Front 87

All prosthetic feet do which of the following? ***

a. compress at heel contact
b. permit the wearer to tip toe
c. accommodate shoes of various heel heights
d. store energy during early stance and midstance

Back 87

a. compress at heel contact

Front 88

The distal end of the keel in a SACH foot does which of the following? ***

a. permits midfoot inversion
b. is the site of forefoot hyperextension
c. absorbs shock
d. releases substantial stored energy

Back 88

b. is the site of forefoot hyperextension

Front 89

A resilient socket liner makes it easier for the client to do which of the following? ***

a. make adjustments to accommodate volume changes
b. wear snugly fitting trousers
c. eliminate wearing a sock
d. perspire less when wearing the prosthesis.

Back 89

a. make adjustments to accommodate volume changes

Front 90

As compared with a cuff, supracondylar brim suspension provides more of which of the following? ***

a. distal weight bearing
b. resistance to knee hyperextension
c. adjustability
d. mediolateral stability

Back 90

d. mediolateral stability

Front 91

As compared with a transfemoral exoskeletal shank, an endoskeletal shank is more of which of the following? ***

a. easy to adjust
b. durable
c. unrealistic in appearance
d. heavy

Back 91

a. easy to adjust

Front 92

Which of the following is true about hydraulic swing phase control knee units? ***

a. are unsuitable for polycentric axis systems.
b. increase resistance when the client walks faster.
c. decrease stance stability when the client walks faster.
d. exaggerate knee flexion in early swing phase.

Back 92

b. increase resistance when the client walks faster.

Front 93

A transfemoral prosthesis has a knee unit with a manual lock. Which of the following is true about this prosthesis? ***

a. provides stability during early stance.
b. requires that the client remain sitting with an extended knee.
c. should be slightly longer than the contralateral intact extremity.
d. is more difficult to don than a prosthesis without a manual lock.

Back 93

a. provides stability during early stance.

Front 94

As compared with a totally rigid socket, a transfemoral socket which includes flexible plastic is more of which of the following? ***

a. durable
b. comfortable
c. warm
d. difficult to adjust

Back 94

b. comfortable

Front 95

Periphereal vascular insufficiency is a dysfunction of….? ***

Back 95

blood flow in the extremities

Front 96

To what does peripheral vascular insufficiency often lead? ***

Back 96

soft tissue ischemia and ulceration

Front 97

Where is peripheral vascular insufficiency most common? ***

Back 97

in the distal lower extremities where the vessels are longest

Front 98

What is LEVD? What are its signs and symptoms? ***

Back 98

- lower-extremity vascular disease

- causes pain, tissue loss, and changes in appearance and function

Front 99

Which type of ulcer is most common on the LE? ***

Back 99

venous (75% - 80%)

Front 100

What other types of ulcers are seen on the LEs? ***

Back 100

- arterial
- mixed
- together totaling 20% - 25%

Front 101

Name and describe the layers of tissue comprising both arteries and veins. ***

Back 101

- tunica intima – innermost layer comprised of endothelium
- tunica media – middle layer comprised of smooth muscle and elastic connective tissue
- tunica adventitia – outermost layer, connective tissue made of collagen fibers

Front 102

What level is a critical level of stenosis in an artery? ***

Back 102

50%

Front 103

What signs, symptoms and pathologies can a critical level of stenosis in an artery cause? ***

Back 103

- tissue ischemia
- pain at rest

- non-healing wounds
- gangrene

Front 104

What is another term for stenosis in the arterial system? ***

Back 104

arterial insufficiency

Front 105

Arterial insufficiency can be caused by …. ***

Back 105

- cholesterol deposits (atherosclerosis)
- blood clots (emboli or thrombi)
- damaged, diseased or weak vessels

Front 106

How do arterial insufficiency wounds heal? ***

Back 106

- they generally do not heal unless tissue perfusion is restored

- often they progress to amputation of part or all of a limb

Front 107

What is the difference in the tissue layers of veins and arteries? ***

Back 107

- tissue is generally thinner in veins

- less muscular (tunica media)

Front 108

How is the blood in the LEs moved through the veins back to the heart? ***

Back 108

- through assistance from valves in the veins that prevent backflow of blood

- also by assistance from skeletal muscles which move the blood with their contractions (muscular pump)

Front 109

What are some causes of venous insufficiency? ***

Back 109

- incompetent venous valves
- deep vein obstruction or thrombosis
- arteriovenous fistula
- failure of muscular pump (due to paralysis, decreased ROM at ankle, or ankle deformity)

Front 110

How does venous pressure in the LEs vary? ***

Back 110

- high in standing or resting postures (90-100 mm Hg)

- low when walking (less than 20 mm Hg)

Front 111

Venous hypertension and peripheral edema is likely without contraction of the _________ muscle, which empties the deep veins, pushing blood back toward the heart and reducing the pressure. ***

Back 111

gastrocnemius

(although more than once I’ve heard of the soleus as the “heart of the LE”)

Front 112

What is LEAD, and what are some other names for it? ***

Back 112

- lower extremity ARTERIAL disease

- peripheral vascular disease (PVD)
- peripheral ARTERIAL occlusive disease (PAOD)
- peripheral ARTERIAL disease (PAD)

Front 113

What is the definition of LEAD/PVD/PAOD/PAD? ***

Back 113

atherosclerotic disease of the aorta and arteries of the lower extremity

Front 114

Approximately 90% of arterial problems in the legs are caused by ________. ***

Back 114

atherosclerosis

Front 115

Atherosclerosis causes: ***

Back 115

- narrowing and hardening of the arterial vessels
- increased blood pressure and resistance
- decreased blood flow

Front 116

What substances contribute to atherosclerosis? ***

Back 116

- plaque
- lipids
- cholesterol
- calcium salts (calcification of the vessel)

Front 117

How does atherosclerosis progress to limb amputation? List the steps. ***

Back 117

- atherosclerosis progresses to
- inadequate nutrition and oxygenation of the tissues, which leads to
- cell death, followed by
- tissue necrosis/ulceration, then
- amputation of limb

Front 118

What are the reversible and irreversible risk factors for LEAD/PVD/PAD/PAOD? *

Back 118

reversible:
- smoking
- diabetes mellitus
- hypertension
- hyperlipidemia
- obesity
- physical inactivity

irreversible
- male gender
- advanced age
- strong family history

Front 119

What is the single most important preventable risk factor for LEAD/PAD/PAOD/PVD? ***

Back 119

smoking

(associated with increased amputation rates, lower success rates after vascular surgeries, increased risk for MIs, stroke, and death)

Front 120

What are some of the risk factors for venous ulcers? ***

Back 120

- thrombophilia (tendency to form blood clots)
- DVT/phlebitis
- varicose veins (if untreated, a 20-50% risk of developing an ulcer)
- family history of venous disease

- trauma
- high number of pregnancies

- obesity
- sedentary lifestyle and occupation (sitting/standing with feet dependent for long periods)
- advanced age: 60-80 years old most prevalent

Front 121

Differentiate between arterial and venous insufficiency ulcers based on location. ***

Back 121

the malleoli especially – lateral for arterial, medial for venous

Front 122

At the ankle, is the BP typically higher or lower than the brachial BP? ***

Back 122

equal to, or slightly higher

Front 123

What is the ABI? ***

Back 123

ankle-brachial index, which is equal to the systolic pressure at the ankle divided by the systolic pressure at the brachial artery

Front 124

What is a healthy ABI? ***

Back 124

1.0 – 1.4

lower than that consider LEAD (< 0.9), moderate arterial insufficiency (0.5 – 0.8), ischemia (< 0.4)
(is that <= 0.4 then?)
table 29.1 on p. 460

Front 125

How else may BP be measured at the LE? ***

Back 125

by Doppler ultrasound at the dorsalis pedis pulse site

Front 126

Hemosiderosis of the LE would result from _______ insufficiency. ***

Back 126

venous

Front 127

What skin conditions may be caused by venous insufficiency? ***

Back 127

- hemosiderosis

- venous dermatitis

Front 128

What are the goals for LEAD intervention? ***

Back 128

- increase arterial blood flow; if this cannot be achieved with conservative measures or medication than surgical revascularization or amputation is considered.
- decrease pain
- improvement of exercise tolerance

- risk factor modification
- prevention and/or treatment of complications
- meticulous foot care/hygiene

Front 129

How is pain managed in LEAD patients? ***

Back 129

- systemic analgesics
- TENS
- visual imagery
- relaxation

- pain may be lessened when LE is in dependent position

Front 130

What type of exercise program is instituted with LEAD patients? ***

Back 130

- graduated exercise to increase blood flow
- walking program if in earlier stages can improve flow even in patients with intermittent claudication

- severe arterial disease patient may need to limit walking due to ulcers, resting leg pain, and healing potential (ischemia too great)
- ensure precautions are taken to protect feet & proper use assistive device

Front 131

What modalities may be used to increase wound healing in a LEAD patient? ***

Back 131

- TENS
- HVPC (high-voltage pulsed current)
- intermittent pneumatic compression (dynamic) – usually only used on patients with venous insufficiency, however there is some evidence that patients with limb-threatening disease for whom surgery is not an option may benefit from IPC, alternating hold and relax every few seconds for 45 minutes to 1 hour, 3-4 times per day

Front 132

What role does nutrition play in the treatment of a LEAD patient? ***

Back 132

- good nutrition is essential for patients with wounds

- consultation by a dietitian strongly recommended

Front 133

What are some surgical treatment options for LEAD patients? ***

Back 133

- revascularization
- angioplasty – usually a bypass graft from the saphenous vein to the superficial femoral artery

- amputation if the tissue site is beyond the point of salvage

Front 134

What was given as the “most important teaching point” for LEAD patients/treatment? ***

Back 134

- the negative impact of tobacco (in any form) on tissue perfusion & wound healing

Front 135

What are the areas of education for patients with LEAD? ***

Back 135

- chronic disease management (DM, HTN) and the effects of these diseases on LEAD
- reduction of hyperlipidemia and proper diet
- compliance with medications
- need for regular follow-up with health care provider

- use of properly fitting shoes and footwear
- pressure reduction for heels, toes, and bony prominences
- wearing socks or hose with shoes
- routine professional nail and foot care

- importance of exercise
- smoking cessation to slow progression of atherosclerosis and decrease the risk of cardiovascular events, including death
- neutral or dependent position for legs
- avoidance of chemical, thermal, and mechanical trauma

Front 136

What are the goals/desired outcomes for treatment of LEVD patients? ***

Back 136

- decrease edema
- prevent or resolve ulcers
- return patient to optimal level of functional activity
- educate the patient and family

Front 137

What is the most critical intervention for LEVD patients, with or without ulcers? ***

Back 137

compression therapy

Front 138

For how long does compression therapy last for LEVD patients? ***

Back 138

it is required for the patient’s lifetime to prevent recurrence of ulceration because a compromised venous system does NOT recover

Front 139

What is the current thought on treatment parameters for compression therapy with LEVD patients? ***

Back 139

the current recommendation is that patients should be offered the strongest compression with which they can comply

Front 140

What types of compression therapy are available for LEVD patients? What level of pressure is recommended for each? ***

Back 140

- static compression with an elastic or inelastic device may be used; many types available:
--- multi-layered
--- single layered
--- pressure gradient stockings
--- paste
--- orthotic
(generally 30-40 mm Hg at the ankle is recommended)

- dynamic compression: intermittent pneumatic compression pumps can be used in addition to bandages or stocking in nonambulatory patients; multichamber best, generally applied for 30-60 minutes, BID @ 30-50 mm Hg

- compression bandages with visual guides to direct how much stretch should be applied
--- with all of these, the bandage should be stretched until the boxes become square (see pics on p. 468-469)

- Velcro fastening compression device

Front 141

What type of compression therapy is not recommended for LEVD patients? Why? ***

Back 141

- antiembolism stockings (e.g., TED hose)
- they do not provide sufficient compression for the patient with venous insufficiency. (only 13-18 mm Hg)

- long stretch elastic wraps (ACE) are not recommended for compression in patients with venous ulcers
(for the same reason, I guess??)

Front 142

What are the contraindications and precautions for compression therapy in LEVD patients? ***

Back 142

no compression (in any form) for patients with:
- symptomatic heart failure (can possibly cause system overload)
- thrombus (possibility of dislodge)
- also not appropriate if an arterial revascularization has been performed on the involved limb

- if ABI is less than 0.5, all forms of static compression are contraindicated

- carefully monitor a patient with neuropathy because they may not recognize symptoms of ischemia such as pain, numbness, or tingling

Front 143

What are the areas of education for patients with LEVD? ***

Back 143

- chronic disease management and the effects of these diseases on LEVD
- compliance with medications
- proper diet and weight control
- importance of exercise
- need for regular follow up with health care provider

- use of properly fitting shoes and footwear
- wearing socks or hose with shoes
- routine professional nail and foot care

- elevated position for legs (above the heart for 1-2 hours, 1-2 times per day, and at nighttime—elevate foot of bed on blocks, if necessary)
- avoidance of chemical, thermal, and mechanical trauma

Front 144

What types of therapeutic exercise interventions are used for patients with LEVD? ***

Back 144

- isometrics – quads & hams
- active and active-resistive ROM for LEs
- ankle pumps
- short arc quads
- standing toe and heel raises

- encourage aquatic therapy, swimming, and cycling

Front 145

What should be emphasized during gait training with patients with LEVD? ***

Back 145

- stress improving heel-to-toe pattern and push-off to activate the calf pump

- encourage walking and exercise breaks at home and work

Front 146

A noninvasive test therapists may use to screen for lower extremity arterial compromise is which of the following? ***

a. MRI
b. MMT
c. ABI
d. X-ray

Back 146

c. ABI

Front 147

How much pressure is considered “standard” for compression to treat venous insufficiency? ***

a. 20 to 28 mm Hg
b. 30 to 40 mm Hg
c. 10 to 15 mm Hg
d. 9 to 12 mm Hg

Back 147

b. 30 to 40 mm Hg

Front 148

Infection may NOT be obvious in patients with arterial compromise because of which of the following? ***

a. reduced perfusion
b. sensory loss
c. trophic changes
d. bony deformities

Back 148

a. reduced perfusion

Front 149

Successful treatment of leg ulcers requires attention to which of the following? ***

a. adequate blood flow
b. prevention of infection
c. controlling systemic factors
d. all of the above

Back 149

d. all of the above

Front 150

The most important aspect of venous ulcer intervention is which of the following? ***

a. antibiotic therapy
b. topical steroids
c. compression therapy
d. surgery

Back 150

c. compression therapy

Front 151

Which of the following ABI values is associated with lower extremity intermittent claudication? ***

a. 0.3
b. 0.5
c. 0.8
d. none of the above

Back 151

b. 0.5

Front 152

Which of the following statements about venous ulcers is true? ***

a. the ulcer tends to be deep and dry.
b. the ulcer tends to be shallow and wet.
c. the ulcer has a punched-out appearance.
d. wound bed is most often necrotic.

Back 152

b. the ulcer tends to be shallow and wet.

Front 153

Leg pain that increases with lower extremity elevation is associated with which of the following? ***

a. arterial insufficiency
b. venous insufficiency
c. neuropathic disease
d. none of the above

Back 153

a. arterial insufficiency

Front 154

Venous insufficiency may be a complication in which of the following? ***

a. a seated occupation
b. valvular incompetence
c. obesity
d. all of the above

Back 154

d. all of the above

Front 155

The most common cause of venous ulcer recurrence is which of the following? ***

a. weight gain
b. nonadherence to compression therapy
c. trauma
d. none of the above

Back 155

b. nonadherence to compression therapy

Front 156

Treatment of severe arterial insufficiency usually involves which of the following? ***

a. walking program
b. increase in dietary protein
c. surgical intervention
d. compression

Back 156

c. surgical intervention

Front 157

What causes neuropathic ulcers? ***

Back 157

- mechanical stress combined with

- sensory loss

Front 158

With what pathologies are neuropathic ulcers associated? ***

Back 158

- diabetes mellitus
- spina bifida
- Hansen’s disease (a.k.a., leprosy)
- in some cases PVD

Front 159

What percentage of diabetes patients will experience a neuropathic ulcer during their lifetime? Of these, how many will ultimately result in a LE amputation? ***

Back 159

- 15 percent

- 14 to 24 percent

Front 160

Why do neuropathic ulcers most often occur on the feet of patients with diabetes mellitus? ***

Back 160

- because the feet are generally the first areas affected by peripheral neuropathy, and

- the feet often sustain abnormal mechanical forces or minor trauma during standing and walking

Front 161

What is the cause of sensory neuropathy? What is its effect? ***

Back 161

- caused by damage to the small nerve fibers; occurs with diabetes and is exacerbated by uncontrolled hyperglycemia

- prevents patient from feeling pressure of a callus or foreign body, the pain of minor trauma or puncture wounds, or the friction of poorly fitting shoes

Front 162

At what points of the foot are patients most susceptible to injury due to neuropathic ulcers? ***

Back 162

- interdigital spaces (between the toes)

- lateral portion of first metatarsal head
- second or third metatarsal head
- lateral portion of fifth metatarsal head

-tarsal-metatarsal joint in Charcot deformity
- plantar heel

Front 163

What is motor neuropathy? What is its result? ***

Back 163

- damage to the large nerve fibers

- results in atrophy and weakening of intrinsic muscles of foot
- force imbalances in the foot and LE cause tendons to deviate in alignment
- structural deformities develop
- p. 478, table 30-2 and 30-3

Front 164

What is autonomic neuropathy? What is its result? ***

Back 164

- damage to the large nerve fibers and the sympathetic ganglia

- reduces sweat and oil in skin
- skin becomes dry and inelastic
- fissures can deepen, allowing bacteria to enter and infection to occur

Front 165

What are the two defects that lead to hyperglycemia? ***

Back 165

- defects in insulin secretion (damage to beta cells)

- defects in insulin action (insulin resistance)

Front 166

With what sequelae is long-term hyperglycemia associated? ***

Back 166

damage, dysfunction, and failure of various organs, especially
- eyes
- kidneys
- nerves
- heart
- blood vessels

Front 167

What are the classic signs of hyperglycemia? ***

Back 167

- increased urination
- increased thirst
- unexplained weight loss

can also cause:
- blurred vision
- fatigue
- balance and gait impairments
- GI abnormalities

Front 168

What are the most common complications of hyperglycemia? ***

Back 168

- impaired wound healing

- suppressed immune responses

Front 169

Describe type I diabetes. ***

Back 169

- caused by progressive autoimmune destruction of the insulin secreting beta cells in the pancreas
- usual onset in puberty
- accounts for approximately 10% of all patients with diabetes

Front 170

Describe type II diabetes. ***

Back 170

- most common form of diabetes in older adults
- generally caused by a combination of insulin resistance and beta-cell failure
- insulin resistance progresses over time causing beta cells to produce less insulin

- diabetes results when the body cannot compensate for combined defects in insulin action and secretion, which results in elevated blood glucose levels
- excess circulating glucose causes tissue and organ damage, including neuropathic ulcers (NUs).

Front 171

What is the most common form of diabetes in older adults? ***

Back 171

type II

Front 172

How does diabetes affect the musculoskeletal system? ***

Back 172

- it exaggerates the normal aging process and
- adds to the impairments and functional limitations associated with the musculoskeletal system

- affects joint mobility and ROM, especially in the foot
- decreases soft tissue extensibility and joint capsule mobility
- causes reduced ROM and increased functional limitations

Front 173

How does diabetes affect the neuromuscular system? ***

Back 173

- sensory and reflex impairments in balance and gait are common

may result in:
- impaired joint proprioception
- reduced skin sensation
- paresthesias (e.g., burning, tingling) and
- gait and balance disturbances

gait changes may include:
- wide BOS
- marching or steppage gait (toe to heel) or
- slap-foot

- balance disturbances during transfers and gait.

Front 174

How does diabetes affect the cardiovascular system? ***

Back 174

- peripheral vascular disease is 4-6 times more common in people with diabetes
- intermittent claudication – calf pain caused by inadequate oxygen supply to muscle tissue at rest or with activity; claudication at rest suggests the presence of severe PVD

- check pedal pulses to screen for poor peripheral circulation
- check proximal pulses if pedal is absent or faint and report your findings to the supervising PT and nurse

Front 175

What are the three stages of interventions for patients with or at risk for neuropathic foot ulcers? ***

Back 175

- prevention for the high-risk foot
- treatment of the wound
- management of the foot after wound healing

Front 176

What is important to accomplish during all three stages of intervention for patients with or at risk for neuropathic foot ulcers? ***

Back 176

- patients should have good glucose control

- off-loading of the high pressure areas of the foot

Front 177

What items should patient education cover for patients with or at risk for neuropathic foot ulcers. ***

Back 177

- blood glucose control/exercise
- footwear
- daily foot inspection
- good foot care (clean, dry, good socks)

Front 178

What numbers are pertinent to blood glucose control. What are the desired limits? ***

Back 178

- self testing of capillary glucose – kept below 200 mg/dl to optimize wound healing, lower is better

- clinic testing of glycosylated hemoglobin levels (HbA1C) — goal to prevent complications is 7%

Front 179

What are the primary means of blood glucose control for people with type 2 diabetes? ***

Back 179

- eating correctly

- exercise or regular activity

Front 180

How does exercise benefit patients with diabetes/with or at risk for neuropathic foot ulcers? ***

Back 180

- after exercise, insulin sensitivity increases so that cells are better able to take up glucose from the blood.

- exercise has been shown to prevent and reverse some microvascular muscle changes in people with diabetes

Front 181

What types of regular daily exercise are required for older adults with or at risk for neuropathic foot ulcers? ***

Back 181

- cardiovascular/aerobic exercise - stationary bike, walking program, treadmill, swimming (wear shoes)
- progressive resistive training (PRT)
- stretching to achieve or maintain ROM if tolerated (may require offloading of painful areas or wounds)

Front 182

What considerations must be given to orthoses with patients having or at risk of developing neuropathic foot ulcers? ***

Back 182

- orthotics may be required for a patient with peripheral motor neuropathy that causes a foot drop
- however, much care must be taken to preserve integrity of the skin and prevent neuropathic ulcers
- orthotics must fit properly
- skin should be checked before donning and after doffing orthotics

Front 183

What are the footwear guidelines for breaking in new shoes for the patient with or at risk of developing neuropathic ulcers? ***

Back 183

- p. 485, box 30-3 and box 30-4

Front 184

What are the guidelines for care of the diabetic foot? ***

Back 184

- p. 485, box 30-5

Front 185

What are the criteria for treatment of diabetic wounds? ***

Back 185

- treat infection (in pt with DM not as much drainage because lack of circulation)
- control blood glucose levels
- debride
- provide moist wound environment
- off-load (it is generally accepted that even brief periods of bearing weight on a neuropathic wound, such as walking from the bed to the bathroom, will delay or prevent healing; this must be stressed to the patient)

Front 186

Describe the procedure for application of a total contact cast to offload a diabetic wound. ***

Back 186

total contact cast procedure:
- wound is cleaned, debrided, and a saline-moistened gauze dressing applied to the open area
- gauze is anchored with a gauze roll and cotton or lamb′s wool is placed between the toes
- a bias stockinette is placed on the extremity from the toes to above the knee

Front 187

What is Medicare’s responsibility for footwear and orthotics for DM patients? What is the procedure? ***

Back 187

- reimburses 80% of the cost of footwear and orthotics for patients with diabetes and associated foot problems
- physician certifies need of diabetic shoes and inserts
- provider furnishes them and bills Medicare (usually an orthotist)
see p. 490, Box 30-9

Front 188

What other devices are available to help protect the diabetic foot? ***

Back 188

- special socks with antimicrobial fibers or silicone gel bottoms
- toe caps
- toe separators
- tubular foam and
- hammertoe splints may help to protect the diabetic foot

Front 189

Neuropathic ulcers are associated with which of the following? ***

a. sensory and autonomic neuropathies
b. poorly fitting shoes with inadequate distribution of pressure during the gait cycle
c. diabetes
d. all of the above

Back 189

d. all of the above

Front 190

A Charcot foot is which of the following? ***

a. collapse of the foot arch resulting in a rocker sole
b. caused by consistently wearing shoes that are too short
c. not severe enough to be of concern to a patient with diabetes
d. caused by macrovascular disease.

Back 190

a. collapse of the foot arch resulting in a rocker sole

Front 191

Which of the following statements is true about ROM of the diabetic foot? ***

a. limitations are of minor concern in the formation of a neuropathic wound
b. ROM limitations may cause abnormal peak pressures during gait and thereby contribute to ulcer formation
c. measuring ROM during a foot examination is important only if there is an ulcer present
d. only ankle dorsiflexion limitations impact the risk for ulceration

Back 191

b. ROM limitations may cause abnormal peak pressures during gait and thereby contribute to ulcer formation

Front 192

Which of the following is the highest risk factor for neuropathic ulcers? ***

a. peripheral neuropathy with loss of sensation
b. peripheral vascular disease
c. high blood glucose levels
d. foot deformities

Back 192

a. peripheral neuropathy with loss of sensation

Front 193

Neuropathic ulcers usually occur on which of the following? ***

a. on the distal digits
b. above the ankle
c. on the weight-bearing surfaces of the foot
d. on the dorsal IP joints
e. a, b, and c
f. a, c, and d

Back 193

f. a, c, and d

Front 194

Which of the following exercises is appropriate for a patient with a neuropathic ulcer? ***

a. step aerobics
b. closed chain lower extremity exercises
c. treadmill
d. bicycle

Back 194

d. bicycle

Front 195

The purpose of any off-loading device for a patient with a neuropathic ulcer is which of the following? ***

a. to protect the dressing
b. to allow the patient to ambulate without pain
c. to distribute the plantar foot pressures and reduce stress at the wound site
d. to avoid use of ill-fitting shoes

Back 195

c. to distribute the plantar foot pressures and reduce stress at the wound site

Front 196

Inspection of the neuropathic foot includes which of the following? ***

a. skin
b. nails
c. shoes and socks
d. a and b
e. all of the above

Back 196

e. all of the above

Front 197

Instructions in self-care for the patient with a neuropathic ulcer include which of the following? ***

a. foot and skin protection
b. total contact casting
c. debridement
d. all of the above

Back 197

a. foot and skin protection

Front 198

What are the functions of skin? ***

Back 198

- protection (infection, puncture, UV rays)
- temperature regulation
- biochemical organ/immunologic function

- conservation of body fluids
- excretion/secretion

- vitamin D production

- storage of fat
- physical appearance
- personal identity
- sensation
- allows motion and function

Front 199

What two tissue layers comprise the skin? ***

Back 199

- epidermis

- dermis

Front 200

What are the accessory organs of the skin? ***

Back 200

- nails
- hair

- sebaceous glands
- sweat glands

Front 201

Describe the structure and function of the epidermis. ***

Back 201

structure
- thin layer
- keratinocyte
- basal layer
- avascular

function
- protection
- water proofing
- regeneration

Front 202

What are the layers of the epidermis (superficial to deep)? ***

Back 202

- stratum corneum (keratin layer)
- stratum lucidum (clear layer)
- stratum granulosum (granular layer)
- stratum spinosum (spiny layer)
- basal layer (basement membrane)

Front 203

What are the layers of the dermis (superficial to deep)? ***

Back 203

- papillary dermis

- reticular dermis

Front 204

Describe the structure and function of the dermis. ***

Back 204

- papillary layer – loosely organized collagen and elastin
- reticular layer – densely packed collagen and elastin fibers (strength); merges with subcutaneous tissue

- reservoir of skin
- resists mechanical shear forces

Front 205

Describe the structure and function of the subcutaneous layer of skin. ***

Back 205

- loose connective tissue with fat
- pacinian corpuscles
- sweat glands

- shock absorption
- body insulation

Front 206

What are the three stages of soft tissue healing? ***

Back 206

- inflammatory phase (acute)
- proliferative phase (subacute)
- remodeling/maturation phase (chronic)

Front 207

Describe the inflammatory phase of soft tissue healing. ***

Back 207

- days 0 – 6
- inflammatory reaction

- coagulation
- wound debridement
- prepares the wound for the repair phase

Front 208

Describe the proliferative phase of soft tissue healing. ***

Back 208

- days 3 – 20
- proliferation and repair

- wound contraction (contracts to 60-80% of previous normal state; biggest concern with burns)
- serves to make the repair tissue viable and reestablishes tensile strength in injured tissue

- proliferation of new blood vessels
--- endothelial buds become patent vessels

- formation of new connective tissue
--- fibroplasia
--- fibroblasts secrete collagen
--- collagen becomes tropocollagen, then fibrils, then fibers
--- collagen fibers are randomly oriented

Front 209

Describe the remodeling/maturation phase of soft tissue healing. ***

Back 209

- day 9 to ??? (can take years)
- maturation of scar

- period of scar maturation and remodeling of the connective tissue matrix
- remodeling done through collagen turnover (traumatize to increase collagen production—part of the reason behind debridement)

- how scar remodels is not completely understood, but:
--- process tries to mimic the CT structure of the tissue being repaired
--- type of tension applied to the scar will affect how it remodels (Wolff’s Law!!!)

(Me: Perhaps he meant Davis’ Law? Wolff’s Law deals with remodeling of bone, Davis’ Law deals with remodeling of soft tissue.)

Front 210

What are the clinical considerations for burn wounds during the inflammatory phase of healing? ***

Back 210

- “the protection phase” (positioning and splinting)

concerns:
- pain
- edema/effusion
- limited movement
- decreased function

Front 211

What are the general treatment goals for burn wounds during the inflammatory phase of healing? ***

Back 211

- control pain, swelling, and spasm through:
--- rest
--- compression
--- elevation
--- immobilization

- maintain soft tissue/joint mobility and integrity (working with soft tissue around burn)
- avoid undue physical stress to injured area

Front 212

What is the biggest concern with respect to regaining function after a burn? ***

Back 212

wound contraction (since the wound will contract to 60-80% of previous normal state; this greatly affects ROM)

Front 213

What are the clinical considerations for burn wounds during the proliferative phase of healing? ***

Back 213

- “the controlled mobility phase”

- new tissue is fragile!! (even scars sometimes)
--- monitor for signs of inflammation
--- start active exercise in mid-range
--- intensity, positions of exercise determined by patient response

- look for restricted motion!

concerns:
- pain at point of tissue stress (work with nursing for proper meds and their timing)
- edema (slowly resolving)
- development of contractures (scar < tendon < muscle < ligament/joint)
- weakness (due to disuse)— potentially severe
- decreased functional use of involved and associated areas

Front 214

What are the general treatment goals for burn wounds during the proliferative phase of healing? ***

Back 214

- promote healing of injured tissues
--- monitor tissue for response to treatment
--- protect healing tissue

- progressively restore soft tissue, muscle and joint mobility
--- PROM to AAROM/AROM
--- increase scar mobility
--- increase ROM of associated areas

- strengthen involved and associated areas
--- mild resistance
--- closed-chain exercise
--- progress as tolerated (monitor pain and tissue responses!)

- maintain integrity and function of related areas

-pain/swelling control as required

Front 215

What is Wolff’s Law? ***

Back 215

- states that bone in a healthy person or animal will adapt to the loads under which it is placed
--- if loading on a particular bone increases, the bone will remodel itself over time to become stronger to resist that sort of loading
--- the converse is also true

(Me: Odd he mentioned this law with respect to the remodeling/maturation phase for burn wounds. Perhaps Davis’ Law is what was meant, since that is the soft tissue corollary to Wolff’s Law? It describes how soft tissue models along imposed demands.)

Front 216

Roughly how many burn wounds occur annually? How many victims are hospitalized? ***

Back 216

- about 2 million

- 50,000 – 70,000 annually

Front 217

What type of burn injury is most prevalent? Who are the typical victims? ***

Back 217

- 78.5% are thermal injuries

- 70% male
- 63% Caucasian

Front 218

What areas are most commonly burned? ***

Back 218

- arms and hands (25%)
- legs and feet (16%)

- upper trunk (6%)
- lower trunk (3%)

- other areas (5%)

Front 219

Who are the high-risk populations for burn injuries? ***

Back 219

- children
- elderly

- disabled
- military

Front 220

What is the “Rule of Nines”? On whom is it not accurate? ***

Back 220

- initial estimation of body surface area (BSA)
- adult anatomical areas each equal 9% (or a multiple thereof)
--- each arm = 9%
--- each leg = 18%
--- front or back of torso each = 18%
--- head = 9%
--- perineum/genital area is last 1%

- is not accurate for infants or children, as their heads are larger and legs are smaller
--- each arm = 10%
--- each leg = 15%
--- front or back of torso each = 16%
--- head = 18%
--- perineum/genital area = 1%

Front 221

How is the palm used to gauge body surface area (BSA)? ***

Back 221

- Rule of Nines - patient’s palmar surface (hand + fingers) = 1% of TBSA

- Rule of Accuracy – patient’s palm = ½% of TBSA

(Me: According to what I could dig up, these are more often used in first aid, whereas the Lund-Browder chart is what is used in hospitals.)

Front 222

What is the clinical importance of burn depth determination? ***

Back 222

affects:
- wound care
- excision and grafting
- outcomes

Front 223

Describe a superficial burn and its healing time. ***

Back 223

- superficial, or first-degree burn
- epidermis is red but unblistered (e.g., sunburn)
- heals in 3-7 days

Front 224

Describe a superficial partial thickness burn and its healing time. ***

Back 224

- superficial partial thickness, or second-degree burn
- painful, blistered, weeps fluid

- dermis uninjured
- epidermal appendages at risk
(hair follicles, sebaceous glands, sweat glands, apocrine glands, and mammary glands are considered epidermal glands or epidermal appendages, because they develop as downgrowths or diverticula of the epidermis into the dermis)

- intact capillary refill
- should not scar

- heals spontaneously in 2 weeks, even if unattended/untreated

Front 225

Describe a deep partial thickness burn and its healing time. ***

Back 225

- deep partial thickness, or deep second-degree burn

- can heal spontaneously in 3 weeks
- risk of scar contracture

Front 226

Describe a full thickness burn and its healing time. ***

Back 226

- full thickness, or third-degree burn
- no capillary refill

- will NOT spontaneously recover
- requires skin grafting
- must remove tissue until it bleeds—need blood to heal and for graft to adhere)

Front 227

Describe a subcutaneous burn and its healing time. ***

Back 227

- to the subcutaneous tissue, or fourth-degree burn
- underlying tissue also affected
- underlying tendons, etc. visible

- will NOT spontaneously recover
- requires skin grafting

Front 228

How does the tissue affected by either epidermal or superficial partial thickness burns heal? ***

Back 228

Reepithelialization through migration of cells from sweat glands and hair follicles (if they’re still there, otherwise secondary closure)

Front 229

How does the tissue affected by deep partial thickness burns, full thickness burns, or subcutaneous burns heal? ***

Back 229

- skin graft put into place, initially it is white
- fibrin clot forms between graft and wound bed
- graft becomes pink
- anastomosis (surgical connection between two structures)
- angiogenesis (growth of new capillary blood vessels)
- graft “takes”

Front 230

What is the difference in tensile strength and pliability between skin and scar tissue? ***

Back 230

skin
- tensile strength – 0.82 kg/mm2
- 60% elongation

scar tissue
- tensile strength – 12.0 kg/mm2
- 16% elongation

- the scar tissue is strong, but not very elastic at all

Front 231

What are the effects of tissue stress on healing wounds? ***

Back 231

- collagen fibers orient in direction of stress applied to young scar
- 6 hours per day showed length change in young scar

- 3.5 month old scar had no change in length after 1 month of tension treatment
- summary, the tissue has to be stretched early, or the contracture is permanent

Front 232

Why is it important that the collagen in the repair tissue be stressed? ***

Back 232

- if the collagen tissue is not stressed, it will form in a disorganized manner (envision a wad of rubber bands tangled in a large mass) and cannot elongate effectively

- if the collagen tissue is stressed, it will lie down in an organized manner and allow greater ROM (imagine the same rubber bands all hooked on the same start and end points—excursion will be much greater)

Front 233

What is an approximate timeline for ROM loss due to soft tissue injury? ***

Back 233

limitation -----------------------time to ROM loss
- burn scar contracture-----------1-4 days
- tendons and sheaths------------5-21 days
- adaptive mm shortening-------2-3 weeks
- ligament and joint capsule----1-3 months

Front 234

What does the stress-strain curve depict? ***

Back 234

- the relationship between the force required to deform a material and the resultant deformation
- all materials deform under load

- ascend through elastic movement (can go back to original shape), to yield point, then descend, become deformed plastically (will not “snap back” once yield point is passed) and reach break point

- dependent on temperature and speed as well (although this was not mentioned)

Front 235

What is successive length induction? ***

Back 235

length of biological tissue increases and the force required to change it decreases with repeated application

(like repeatedly blowing up a balloon, eventually it stays bigger to begin with and is easier to inflate)

Front 236

What is stress relaxation? How is it applied? ***

Back 236

- a constant strain is applied over time, and biological tissues respond with a relaxation of corresponding stress (the relaxation in response to creep after tissue is subject to prolonged loading)

- creep can be administered by
--- static splinting
--- serial casting
thus inducing stress relaxation

Front 237

What is creep? ***

Back 237

low load over prolonged duration that provides greater tissue elongation

- can be administered by
--- static splinting
--- serial casting

Front 238

How do prolonged, low-load tensile stresses (i.e., creep) affect collagen? ***

Back 238

encourages collagen production
- collagen fibrils
- fibroblast cells
- cell DNA
- produce collagen

Front 239

What are the sequelae of burn trauma? ***

Back 239

while burn trauma is primarily a disorder of the integument, other sequelae include:
- decreased muscle mass due to:
--- bedrest
--- hypermetabolism
--- altered protein synthesis

- decreased CV status due to:
--- inhalation injury
--- bedrest
--- hypermetabolism

decreased bone mineral density due to:
--- change in calcium
--- osteoblastic & osteoclastic precursors

- alterations in peripheral nervous system function due to:
--- edema
--- prolonged bedrest
--- circumferential burns
--- positioning

Front 240

What is the purpose of burn rehabilitation? ***

Back 240

prevention and treatment of burn scar contracture deformity and hypertrophic scarring

and to
- mitigate muscle wasting
- increase strength and endurance
- improve CV function
- prevent or minimize nerve damage
- maximize function
- improve appearance

Front 241

What is a lack of sufficient extensible tissue to permit full ROM? ***

Back 241

contracture

Front 242

What are the primary aspects evaluated for burn rehabilitation? ***

Back 242

- ROM
- strength
- sensation
- edema

burn wound assessment
- location – skin creases, overlying joints, apertures
- extent - % TBSA (usually 1 day of hospitalization per %--30% burn would = one-month hospital stay)
- depth – spontaneous healing, graft, potential for contracture

Front 243

What are the objectives for treatment of a burn wound? ***

Back 243

- protect tissue integrity (especially skin grafts)
- prevent and correct deformity due to contractures
- prevent and treat hypertrophic scarring

- improve cardiovascular endurance and muscle strength
- maximize functional independence
- education and reintegration

Front 244

What are the steps of intervention progression for burn patients according to the Baylor/UVA model? ***

Back 244

steps taken as tissue heals and tissue mobility increases
- injury
- edema control/pain management
- flexibility
- strength
- proprioception
- endurance
- power
- skilled activity
- full activity

Front 245

When and how often are burn patients treated by physical therapy? ***

Back 245

- usually in the early morning

- therapist-assisted treatment 1-4 times daily, 1-5 times per week
- patient’s HEP should include ROM exercises to be done every waking hour

(patient should be pre-medicated as needed)

Front 246

What is the duration and intensity of treatment for contracture risk areas? ***

Back 246

duration of treatment:
- day – functional use and/or ROM exercises or dynamic/static progressive stretch (SPS) exercise splint
- night – static resting positioning/splinting

intensity of treatment:
- scar blanching (from red, inflamed look to white)
- pain approximately 3-5 out of 10
- gentle prolonged stretch/elongation

Front 247

What are the commonly used treatment interventions for burn patients? ***

Back 247

- positioning
- splinting
- exercise
- lower extremity and gait training
- scar control

Front 248

What are the general positioning guidelines for burn patients? *

Back 248

body area--------------contracture predisposition----------preventive positioning
anterior neck------------------neck flexion------------------------neck ext/hypertext
anterior axilla-------------shoulder adduction------------------shoulder abduction
posterior axilla------------shoulder extension---------------------shoulder flexion
antecubital space-----------elbow flexion--------------------------elbow extension
volar forearm------------------pronation---------------------------------supination
volar wrist------------------------flexion------------------------------------extension
dorsal hand/finger------MCP hyperext/IP flex---------------------MCP flex/IP ext
--------------------------------thumb adduction----------------thumb palmar abduction
palmar hand/finger----finger flex/thumb opp----------finger ext/thumb radial abd
hip---------------------------flexion/adduction/ER-----------extension/abduction/neutral
knee------------------------------flexion--------------------------------------extension
ankle------------------------plantar flexion--------------------------------dorsiflexion
dorsal toes----------------hyperextension---------------------------------flexion
plantar toes--------------------flexion--------------------------------------extension

(per his picture the hips should each be abducted 10 degrees—20 degree angle between legs )

Front 249

What are the indications for exercise for burn patients? ***

Back 249

- prevent/decrease edema and promote circulation

- prevent scar tissue contractures and deformity
--- elongate scar to increase range of motion (also compression)

- prevent muscle atrophy and deconditioning
--- increase strength and endurance

- prevent tendon adherence and shortening
--- increase tendon gliding and length

- prevent ligament and joint capsule shortening
--- increase ligament and joint length

- prevent loss of function and maximize functional independence

Front 250

What types of exercise are used for burn patients? ***

Back 250

- ROM (active preferred, if pt is able) to limit contractures
- conditioning for strength and endurance
- functional for ADLs, work and leisure

Front 251

Which types of ROM exercise are used on burn patients? Which is the most preferred? ***

Back 251

- AROM – most preferred
- AAROM – therapist assists, place and hold
- PROM

Front 252

What are some contraindications and precautions for PROM? ***

Back 252

- for finger burns of indeterminate depth, PROM delayed until wound closure of PIP joint
- suspected heterotopic ossification bone (idiopathic bone formation in joint, esp in arms/elbows)
- exposed tendons

Front 253

How should stretch be applied to areas of burn wounds? ***

Back 253

- stretch opposite the burn
- tight enough when scar blanches white
- also patient’s response should be no more than 3-5 on a base-10 pain scale

Front 254

What were the two (rhyming) tenets of burn rehabilitation? ***

Back 254

- emphasize the extreme to achieve the mean

- easy to maintain, hard to regain

Front 255

How are conditioning exercises introduced to and conducted with burn patients? ***

Back 255

- following tissue elongation

- strengthening – increase muscle strength opposite the contracture
- uninvolved extremities (don’t neglect)

- increase endurance

Front 256

How are functional exercises incorporated into treatment for burn patients? ***

Back 256

- following maximal scar tissue elongation
- reinforce tissue elongation program
- increase patient abilities, confidence and self-esteem

Front 257

What occurs in the UEs and LEs of burn patients when placed in dependent position? ***

Back 257

- increase in hydrostatic pressure
- painful for patient

- inadequate venous return
- tissue engorgement
- increased edema

- bleeding from fragile blood vessels (“tattooing”) (hemosiderin staining, I assume?)

- have to cover (compression) both burn and donor areas

Front 258

How does hydrostatic pressure vary in the body? ***

Back 258

- neck – 0
- shoulder – 6
- arm – 8
- abdomen – 22
- hand – 35

thigh – 40
ankle – 90

Front 259

For which burn patients are LE compression wraps necessary? How are they applied? What purpose do they serve? ***

Back 259

- for all burned, grafted or harvested areas when dependent

- up to about 3-4” above where wound stops

- decrease orthostatic hypotension
- avoid edema to improve cell perfusion
- decrease micro capillary trauma
- prelude to definitive control of hypertrophy scar formation

Front 260

What equipment exists to initially help patients get upright? ***

Back 260

- total lift chair
- standing table
- tilt table

Front 261

What are the benefits of early ambulation for burn patients? ***

Back 261

- prevents thromboemboli and decubiti

- maintains strength and cardiovascular conditioning
- maintains bone density

- promotes independence
- may be preceded with tilt or standing table

Front 262

What are the concerns for burn patients during ambulation? ***

Back 262

- vital signs
- orthostatic hypotension

- inhalation injury
- IV lines, catheter lines, etc.

Front 263

What four factors comprise a burn scar assessment? ***

Back 263

- vascularity
- pliability
- height (in mm)
- compliance (hours per day garments and splints are worn)

Front 264

What are the values for vascularity in burn scar assessment? ***

Back 264

- 0 – normal
- 1 – pink
- 2 – red
- 3 – purple

Front 265

What are the values for pliability in burn scar assessment? ***

Back 265

- 0 – normal
- 1 – supple
- 2 – yielding
- 3 – firm
- 4 – banding
- 5 – contracture

Front 266

What are the values for height in burn scar assessment? ***

Back 266

- 0 – normal
- 1 - >0 to 1
- 2 - >1 to 2
- 3 - >2 to 4
- 4 - >4

Front 267

What two types of grafts are used on burn patients? ***

Back 267

- sheet skin graft

- mesh skin graft

Front 268

When does a burn scar mature? How do you differentiate between an immature and mature burn scar? ***

Back 268

- 6 months to 2-5 years

- immature
--- red
--- raised
--- rigid/firm

- mature
--- avascular/white
--- flat
--- pliable/soft

Front 269

With decreased mortality comes increased risk of ________ in burn patients. ***

Back 269

disability

Front 270

What percentage of all burn patients seen in hospitals will form hypertrophic scars? **

Back 270

80%

Front 271

What two types of scars can form during the healing process for a burn wound? ***

Back 271

- hypertrophic scar

- keloid scar

Front 272

What is hypertrophic scarring? ***

Back 272

overgrowth of dermal components within boundaries of wound

Front 273

What is keloid scarring? ***

Back 273

overgrowth of dermal components beyond boundaries of wound

Front 274

What types of pressure dressings are used on burn patients? ***

Back 274

- elastic wrap - Ace wraps
- self-adherent elastic bandage - Coban tape
- tubular support bandage - Tubigrip

- clothing adaptations (e.g., bicycle shorts, etc.)
- custom-made compression garments

Front 275

Which burn patients require pressure garments? ***

Back 275

- no pressure support required if burn will heal in less than 10 days (superficial)
- pressure support may be required if the burn wound will take 10-14 days to heal (superficial partial thickness)--especially for dark-complected individuals

- any race or age advised to use pressure if burn wound will heal in 14 - 21 days (partial/deep thickness)

- pressure support is mandatory for all burn wounds that require > 21 days to heal (full thickness/subcutaneous)

Front 276

How much pressure is required for burn wounds at various points on the body? ***

Back 276

- elastic bandage to trunk – 3-4 mmHg
- elastic bandage to extremity – 10-15 mmHg
- Tubigrip to extremity – 10-20 mmHg
- pressure garment – 25 mmHg

Front 277

What is capillary closing pressure? ***

Back 277

approximatey 24 mm Hg

Front 278

What is important to remember about the properties of pressure bandages (e.g., Ace, Tubigrip, etc.)? ***

Back 278

they lose about 50% of compression capability after about 4 weeks

Front 279

What is Coban tape? ***

Back 279

a type of self-adherent elastic bandage

Front 280

What benefit do custom compression garments provide? ***

Back 280

they enable the skin to tolerate shear forces

Front 281

Name some other methods of scar control (besides elastic wrap, self-adherent elastic bandages, tubular support bandages, and custom-made compression garments.) ***

Back 281

- silicone gel sheets
- transparent face mask

- medical interventions (surgical revisions, steroid injections, or topical creams)
- silver noted to decrease scarring (and infection)

Front 282

Partial thickness burns differ from superficial burns in which of the following ways? ***

a. partial thickness burns are less painful than superficial burns
b. partial thickness burns do not blister, and superficial thickness burns commonly blister
c. partial thickness burns affect the dermis, and superficial burns affect the epidermis
d. partial thickness burns do not require dressings, and superficial burns do require dressings

Back 282

c. partial thickness burns affect the dermis, and superficial burns affect the epidermis

Front 283

You see a patient with full-thickness burns to his arms and hands. Which of the following would you expect to happen during the first few weeks after the burn injury? ***

a. the patient will be treated with intravenous fluids, wound care, and physical therapy and be scheduled for skin grafting surgery
b. the patient will be treated on an outpatient basis and followed for 2-6 weeks to see if the wounds heal
c. physical therapy will not be consulted to see this patient until the surgeons have decided whether to perform skin grafting
d. the burns wounds will render physical therapy treatment of the patient ineffective secondary to severe pain and edema

Back 283

a. the patient will be treated with intravenous fluids, wound care, and physical therapy and be scheduled for skin grafting surgery

Front 284

You are treating a 53-year-old patient with general weakness 2 weeks after a 22% total body surface area (TBSA) burn injury. What is the most likely cause of his weakness? ***

a. disuse and burn injury related pain
b. disuse and increased catabolism secondary to the burn injury
c. disuse, bed rest, and wound contraction
d. disuse, fluid loss, and damaged nerves in the skin

Back 284

b. disuse and increased catabolism secondary to the burn injury

Front 285

A common etiology of burn injury is which of the following? ***

a. chemical
b. flame
c. contact
d. scald
e. all of the above

Back 285

e. all of the above

Front 286

In which position should the patient’s shoulder rest after an axillary burn? ***

a. 30 degrees of shoulder abduction and neutral rotation
b. functional position
c. 180 degrees of shoulder abduction with 45 degrees of horizontal flexion
d. 90 to 110 degrees of shoulder abduction with slight horizontal flexion

Back 286

d. 90 to 110 degrees of shoulder abduction with slight horizontal flexion

Front 287

Anticontracture positioning is recommended for which of the following? ***

a. only adults
b. only for patients with hypertrophic scaring
c. only for patients with full thickness burns
d. after the scar has completed forming and is “mature”
e. any patient with a contracting scar
f. only for patients who do not tolerate splinting

Back 287

e. any patient with a contracting scar

Front 288

ROM for scar tissue lengthening is thought to be the most beneficial during which phases of healing? ***

a. proliferation phase
b. remodeling phase
c. proliferation and remodeling phases
d. acute open wound phase and directly after grafting
e. mature phase

Back 288

c. proliferation and remodeling phases

Front 289

Ambulation training is often started as soon as a burn patient is medically stable and able to follow directions to help achieve which of the following outcomes? ***

a. improved strength
b. increased ROM
c. edema control
d. improved aerobic capacity
e. all of the above

Back 289

e. all of the above

Front 290

What is an orthosis ? ***

Back 290

orthopedic appliance used to support, align, prevent, or correct deformities of a body part or improve the function of movable parts of the body. (a.k.a., brace)

Front 291

What is an orthotist? ***

Back 291

specially trained HCP who designs, fabricates, and fits orthoses (C.O. or C.P.O. – Certified Orthotist or Certified Prosthetist/Orthotist)

Front 292

What is a pedorthist? ***

Back 292

designs, fabricates, and fits patients with foot orthoses

Front 293

What is a splint? ***

Back 293

an orthosis for temporary use

Front 294

Orthotic devices are named by…. ***

Back 294

the joints they encompass

Front 295

What is an FO? AFO? KAFO? ***

Back 295

- foot orthosis
- ankle-foot orthosis
- knee-ankle-foot orthosis

Front 296

What is an HKAFO? THKAFO? ***

Back 296

- hip-knee-ankle-foot orthosis

- trunk-hip-knee-ankle-foot orthosis

Front 297

What is an SO? LSO? TLSO? ***

Back 297

- sacroiliac orthosis
- lumbosacral orthosis (e.g., Williams)
- thoracolumbosacral orthoisis (e.g., Boston)

Front 298

What types of braces are used for scoliosis? ***

Back 298

- Milwaukee – metal frame, chin and occiput supports

- Boston – turtle shell

- Charleston – bending brace

Front 299

What is an LS FEL? TLS FE? TLS FEL? ***

Back 299

- lumbosacral flexion-extension lateral control orthosis
- thoracolumbosacral flexion-extension control orthosis
- thoracolumbosacral flexion-extension lateral control orthosis

Front 300

What is a CO? Name two types. ***

Back 300

- cervical orthosis

- Philadelphia (sturdier flesh-colored one)
- Miami (flimsier blue and white one)

Front 301

What is an HO? WHO? BFO? EO? ***

Back 301

- hand orthosis
- wrist-hand orthosis

- balanced forearm orthosis
- elbow orthosis

Front 302

What is a Williams brace? ***

Back 302

- rigid brace
- lumbosacral orthosis (LSO)

- commonly prescribed to limit movement in patients with spondylolysis or spondylolisthesis
- front elastic band, so you can bend forward, but side uprights limit how much you can bend laterally
- also limits extension

Front 303

What is a Knight brace? ***

Back 303

- a.k.a., ladder-back
- rigid brace
- thoracolumbosacral orthosis (TLSO)

- tapered pelvic and thoracic bands
- paraspinal and lateral uprights (ladder-back)
- corset-type abdominal front with truss buckle fastening and side-lace adjustment
- anterior, posterior, and lateral control at lumbar spine
- if straps over shoulders, becomes Knight-Taylor

Front 304

What is a Jewett brace? ***

Back 304

- commonly prescribed for kyphosis and osteoporosis as well as the treatment of compression fractures or fractures on the front side of the spine

- uses three points of pressure to help control the
- flexion of the spine and thoracic and thoracolumbar areas of the spine

Front 305

What are the three primary functions of orthoses? ***

Back 305

- resist motion/give support
- assist motion (e.g., dorsiflexion)
- transfer force from one area to another (e.g., metatarsal bar that shifts the load off the MT heads and onto the heel—tipping mechanism/rocker bar)

Front 306

Regardless of its purpose, an orthosis must be ________. ***

Back 306

- comfortable

- patients less likely to comply if uncomfortable
- discomfort can be due to ill fit, which can ultimately cause friction or compression of vessels, skin breakdown, or worse

Front 307

How can the pressure applied by an orthosis be minimized? ***

Back 307

by maximizing the area covered by the orthosis

Front 308

How should the orthosis fit? ***

Back 308

snug but not constrictive

Front 309

What can happen to a patient with an ill-fitted orthosis? ***

Back 309

- at the very least, the patient will not comply with wearing due to discomfort

- too tight – could cause compression of vessels, which could lead to skin breakdown or worse
- too loose – could cause friction, also leading to skin breakdown or worse

Front 310

How is force applied by the orthosis? ***

Back 310

- three-point force system
- principal force and two counter forces

- e.g., genu valgum controlled by a KAFO that applies lateral pressure to medial knee & two counter forces towards the medial thigh & ankle coming from the lateral aspect of the orthosis.

Front 311

Of what materials are orthoses commonly constructed? ***

Back 311

- primarily plastics and metal
- some use silicone, leather, cork, rubber, wood, or cloth components

Front 312

What types of plastics are used in orthoses? ***

Back 312

- synthetic
- organic (carbon containing—non-adjustable)

- as a group are lightweight, easily shaped, strong, easily cleaned, corrosion resistant, and available in many colors
- thermoplastics: become malleable when heated & then retain their shape once cooled
- can be reheated by the orthotist to make adjustments

Front 313

What precautions should be taken with plastic orthoses? ***

Back 313

- caution patient that some plastics will be easily altered by heat such as warm water
- do not leave orthosis in a hot car!

Front 314

What types of metals are used in orthoses? ***

Back 314

- most are alloys (combination of elements; at least one is a metal)
- as a group are strong, stiff, fatigue resistant, and impervious to the effects of environmental heat

- stainless steel used because of its strength but it is heavier and stiffer
- if weight is an issue, aluminum or titanium are often used, although aluminum is too weak to use for orthotic joints (hinges), and titanium is expensive

Front 315

How is silicone used in orthoses? ***

Back 315

as an excellent interface between an orthosis and tender portions of skin

Front 316

How is leather used in orthoses? ***

Back 316

- used for straps and shoes

- may use kidskin or deerskin to line shoe uppers to protect hammer toes etc.

Front 317

How is cork used in orthoses? ***

Back 317

- most common wood used in orthoses

- lightweight and resilient & is used primarily for shoe lifts and arch supports

Front 318

How is rubber used in orthoses? ***

Back 318

- has considerable elasticity, shock absorbency, and toughness
- synthetic rubber, such as neoprene, is less expensive & more resistant to corrosion but may be less elastic than natural rubber
- used in elastic straps, soles of shoes, sponge rubber for padding

Front 319

How is fabric used in orthoses? ***

Back 319

- cotton, wool, and various synthetic fabrics used

- cotton is strong, absorbs perspiration readily, and is hypoallergenic; used in corsets and abdominal fronts on trunk orthotics

Front 320

What purpose does the shoe serve with respect to orthotics? ***

Back 320

- serves as a foundation for LE orthosis
- transfers body weight to the ground
- redistributes weight toward pain-free areas
- protects the wearer from the bearing surface & the weather

- preferred style: has a lace stay, wide inlet (Blucher)
- a broad, low heel provides greatest stability and distributes force evenly between front and back of shoe

Front 321

Describe a foot orthosis. ***

Back 321

- appliance that applies forces to the foot

could be:
- the shoe itself
- an insert inside the shoe
- an internal modification affixed inside the shoe or
- an external modification attached to the sole of the shoe

Front 322

What is the “insert” portion of the foot orthosis? ***

Back 322

ridged, semi-ridged, or flexible arch support with or without a wedge (post)/heel cup

Front 323

What is an internal modification for a foot orthosis? An external modification? ***

Back 323

- internal modification: secured arch support, metatarsal pad

- external modification: metatarsal bar, lift, wedge heel

Front 324

What are foot orthoses designed to do? ***

Back 324

- relieve pain over painful weight-bearing sites by transferring weight-bearing stresses to pressure-tolerant sites (e.g., for spurs or arthritis)
- improve foot balance and/or alignment
- equalize foot/leg length

Front 325

What are the components of an AFO? ***

Back 325

- foundation
- ankle control
- a superstructure
- in some cases foot control also

- may also wear for assist with knee extension

Front 326

What is the foundation of an AFO? ***

Back 326

- shoe and

- a plastic or metal component, most often a plastic insert (thermoplastic) that can be moved from shoe to shoe of the same height

Front 327

How do heel height and shoe fit affect use of an AFO? ***

Back 327

- if shoe heel is too low, uprights of the orthosis will incline posteriorly, increasing tendency of the wearer’s knees to extend/hyperextend.
- if shoe heel is too high, knee may not extend sufficiently and will become unstable

- must have larger-size shoe for insert & foot to have enough room; must be careful with sensation loss

Front 328

Describe the older-style AFO foundation. ***

Back 328

- stirrup or caliper
- U-shaped metal fixture riveted to the shoe through the shank; arms join the brace uprights at the ankle and connect to calf band

Front 329

How do AFOs limit ankle motion? ***

Back 329

- solid or hinged AFO will limit ankle plantar flexion and/or dorsiflexion or assisting ankle motion
- can include anterior and/or posterior stops to limit motion

- assists can be spring loaded and facilitate motion: usually DF assist
- can have bilateral channels to stop one motion while assisting with the other

- posterior leaf spring AFO recoils in early swing phase to lift the patient’s foot (prevent foot drop)

Front 330

How do AFOs provide foot control? ***

Back 330

- involves limiting mediolateral motion

- solid ankle & hinged AFOs have rigid sides that restrict transverse, sagittal and frontal plane movements.
- metal orthosis may have valgus correction strap that exerts a laterally directed force that restrains pronation

Front 331

Describe the superstructure of an AFO. ***

Back 331

- proximal portion: uprights and a shell, band, or brim

plastic AFOs
- have a single upright or shell, broad shell minimizes pressure
- are molded over a cast of the patient’s leg
- should fit snugly for maximum control

metal-leather AFOs
- have medial & lateral uprights
- are usually made of aluminum or carbon graphite
- have a posterior calf band made of plastic or leather-upholstered metal
- band has leather buckle or velcro anterior closure

Front 332

What contraindications and precautions should be considered with the superstructure of an AFO? ***

Back 332

- contraindicated for a person with ankle and leg volume fluctuation (e.g., CHF, lymphedema, etc.)
- contraindicated over wounds

- care must be taken to not impinge on peroneal nerve at fibular head region.

Front 333

Why is the term “Ground-reaction AFO” a misnomer? ***

Back 333

because all AFOs utilize ground reaction forces (posterior leaf spring, etc.)

Front 334

Describe a KAFO. ***

Back 334

- thigh band/shell – posterior bands or plastic thigh shells for added stability of orthosis, leverage

- knee joints – bilateral hinge design; provide medial-lateral support

- distal components are similar to the AFO (shoe, foot attachment, ankle control, uprights); may use carbon fiber or titanium uprights to reduce weight

Front 335

What features are incorporated into a KAFO to prevent knee flexion/hyperextension? ***

Back 335

- knee cap or anterior band to prevent knee from buckling

other features to prevent knee flexion/hyperextension:
- drop ring/lock — falls into place when required
- Pawl lock with bail release — engaged by hitting back of knee on edge of chair to unlock (not to be used by a patient with a knee flexion contracture because it can’t lock without extension)
- stance-phase knee lock – locks in late swing, just before heel contact, unlocks at the heel-off phase

Front 336

What type of KAFO is commonly used with adult paraplegics? ***

Back 336

- Craig-Scott KAFO

- specially designed to allow a patient to stand with posterior lean/hyperextension of hips

**** She specifically mentioned this with respect to a test question!!! ****

Front 337

Describe an HKAFO. ***

Back 337

- a KAFO with a pelvic band and hip joints

- metal hinged hip joint connects lateral upright of the KAFO to the pelvic band
- joint prevents hip abduction, adduction, and rotation

Front 338

Describe a THKAFO. ***

Back 338

- incorporates a lumbosacral orthosis attached to a KAFO (or to an HKAFO?)

- may be used by a patient with spinal cord injury to allow them to experience orthotically assisted ambulation
- very energy consuming to use, even when combined with electrical stimulation

Front 339

How are trunk orthoses named? ***

Back 339

- usually named for the section of the torso encircled
- also for type of control provided
- sometimes the inventors name

Front 340

For what reasons are trunk orthoses worn? ***

Back 340

to reduce the disability caused by:
- low-back pain
- neck sprain
- scoliosis or
- other musculoskeletal or neuromuscular disorders

Front 341

How do trunk orthoses assist SCI patients? ***

Back 341

- support the trunk, thereby assisting in control of spinal motion
- controls motion of the lumbar region
- compress the abdomen to improve respiration

Front 342

Describe the structure and function of corset/binder trunk orthoses. ***

Back 342

- fabric orthosis with no horizontal rigid structures, may have vertical rigid stays

primary effect:
- to compress abdomen to increase intra-abdominal pressure, thereby increasing spinal stability and
- to reduce stress on posterior spinal musculature

Front 343

What detrimental effects can long-term use of a corset or elastic binder have? ***

Back 343

may promote
- muscle atrophy
- contracture
- psychological dependence

Front 344

Describe the structure and function of rigid LSOs and TLSOs. ***

Back 344

- various types, depending on level to be restricted and motions to be restricted
- hard plastic horizontal and vertical components hold the trunk rigid
- components can be designed to control trunk flexion/extension/lateral motions

- usually used after spinal fx/surgery
- held in place by partial corset/velcro straps
- motion restricted by a series of three-point pressure systems

Front 345

What is a CASH orthosis? ***

Back 345

- Cruciform Anterior Spinal Hyperextension orthosis
- TLS flexion-control orthosis
- similar to a Jewett (a cross instead of an oval)

- prefabricated orthosis
- uses three point biomechanical leverage principle to restrict flexion and stabilize the spine

Front 346

For what patients is the CASH (or Jewett) typically used? How is it made more comfortable? ***

Back 346

- patients with kyphosis and osteoporosis
- treatment of compression fractures or fractures on the front side of the spine

- addresses sternal discomfort, especially for osteoporosis patients, by providing option of two articulating contoured pads positioned on the pectoral region
- disperses pressure of the posterior force and applies it to the more resilient muscular anatomy

Front 347

Name, and describe the structure and function of the various orthoses used for treating scoliosis. ***

Back 347

- Milwaukee – metal frame with chin and occipital supports
- Boston – turtle shell
- Charleston – bending brace

- apply forces to maintain alignment of or realign vertebral column and thoracic cage
- TLSO worn 23 hrs/day by children and adolescents that are still growing (supposedly only at night for Charleston)
- must be worn snugly, less effective with the presence of obesity.

- long-term follow-up indicates that scoliosis orthoses usually only prevent the curve from increasing beyond its original contour

Front 348

Name and describe the various types of cervical orthoses. ***

Back 348

- cervical collars – most common are soft
- Philadelphia collar – used post cervical fracture (sturdier, flesh toned collar we have)
- Miami collar – cheaper, flimsier, blue and white collar we have

- moderate control – requires a 2-, 3-, or 4-post cervical orthosis (some combination of chin and occiput)

- maximum control – Minerva (head strap) or halo (screws in the scull)

Front 349

What two types of wrist-hand orthoses (WHO) are commonly used? ***

Back 349

- assistive

- substitutive

Front 350

Describe the function of the basic opponens orthosis. Is it assistive or substitutive? ***

Back 350

- keeps the thumb pad beneath the palmar surfaces of the index & middle fingers
- helps patient use residual motor power to achieve palmar prehension

- assistive

Front 351

Describe the function of the prehension orthosis. Is it assistive or substitutive? ***

Back 351

- allows patient with tetraplegia to grasp an object, hold it, and release it voluntarily

- substitutive

Front 352

What are the PTAs main roles with respect to orthoses? ***

Back 352

- education of the patient and family in proper use and maintenance of orthosis
- ensure proper wear of orthosis
- inspect skin both before and after treatment

Front 353

On what facets of the use of the orthosis is the PTA responsible? ***

Back 353

educating patient and family how to
- properly don and doff the orthosis (generally supine for trunk orthoses)
- use proper undergarments (T-shirt under trunk orthoses, long socks under AFOs, etc.)
- clean orthosis with soap and water or alcohol swabs as recommended by C.O/C.P.O
- inspect skin for breakdown before donning and after doffing (any redness should resolve within 30 minutes)

Front 354

What considerations should the PTA take when gait training a patient with a trunk orthosis? ***

Back 354

- use gait belt over orthosis

- do not hold the orthosis to support the patient

Front 355

An ankle foot orthosis (AFO) worn with a shoe that has a heel higher than that for which the orthosis was made will cause the wearer to have which of the following? ***

a. experience laterally directed force at the knee at midstance.
b. maintain the knee extended during stance phase.
c. experience medially directed force at the ankle at midstance.
d. flex the knee excessively in early stance.

Back 355

d. flex the knee excessively in early stance.

Front 356

Which of the following cervical orthoses most restricts neck motion? ***

a. four-post
b. rigid collar
c. three-post
d. two-post

Back 356

a. four-post

Front 357

The orthosis that is secured directly to the skeleton is which of the following? ***

a. Minerva
b. Milwaukee
c. Taylor
d. Halo

Back 357

d. Halo

Front 358

The best candidate for a scoliosis orthosis has which of the following? ***

a. immature spine with a moderate curve.
b. immature spine with a severe curve.
c. mature spine with a severe curve.
d. mature spine with a moderate curve.

Back 358

a. immature spine with a moderate curve.

Front 359

Orthoses are used for which of the following purposes? ***

a. to assist motion
b. to prevent motion
c. to maintain alignment
d. to protect a body part
e. all of the above

Back 359

e. all of the above

Front 360

Orthoses are often helpful for which of the following dysfunctions? ***

a. poor balance
b. decreased sensation
c. weakness
d. poor endurance

Back 360

c. weakness

Front 361

What is the difference between a splint and an orthosis? ***

a. a splint is a temporary orthosis
b. splints and orthoses are used on different parts of the body
c. both A and B
d. none of the above

Back 361

a. a splint is a temporary orthosis

Front 362

Orthoses are designed to provide which of the following functions? ***

a. support musculoskeletal deviations
b. correct musculoskeletal deviations
c. improve the function of moveable parts of the body
d. all of the above

Back 362

d. all of the above