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Selecting Appropriate and
Effective Equipment: Choosing the right equipment
Mobility
Purpose
Design
Painful sitters
Difficulty with proper alignment
Orthopedic Issues
Loss of passive joint mobility
Fixed contractures
Loss of stability
Scoliosis
Optimizing the environment
House
School
Recreation
Car
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MobilityImportant determinants of
ambulation potential
Energy Expenditure Spasticty
Contractures
Pain
Ambulation Categories
Community
Household
Exercise
Nonamulatory
Community ambulators
Pelvic control with at least fair strength in
hip flexors bilaterally and in at least oneknee extensor
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Potential benefits
Ability to overcome functional barriers
Increased self esteem
Cardiopulmonary exercise
Neurologic predictors for
ambulation
Level of injury below T11 associated withincreased potential for ambulation
Complete tetraplegia do not become
community ambulators
Chronologic age is not by itself a
prognostic factor
Mechanical devices to assist
ambulation Hip-knee- ankle-foot orthosis (e.g.
reciprocating gait brace)
Knee-ankle-foot orthosis (e.g. Scott-Craig
brace)
Ankle-foot orthosis
Rehabilitation for ambulation
training
Strengthening of the lower and upper
extremities
Control of the pelvis and trunk
Joint stabilization
Goals
Prevent or accommodate orthopedic
deformities Prevent skin break down from pressure
Provide trunk stability to enhance armfunction
Promote independent mobility
Facilitate independence in the activities ofdaily living
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Planning a seating system
Angle between the seat and the back
surfaces
Tilt of the system in space
Type of seating surface
The Angle
Whatever is needed to
maintain the pelvis in an neutral or slights
anterior pelvic tilt
achieve the proper lumbar curve
provide a base for good spinal alignment
Opening the angle (making it
more than 90 degrees)
At 90 degrees of hip flexion need to beavailable
Over 90 degrees may reduce spasticity
But may also destabilize trunk support
May force low back extensors to fire
increasing lumbar curve
Using head, shoulder, and back
extensors to remain upright
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Upright support options
Anterior harnesses or chest straps
Upper extremity support like a tray
Tilting
slight tilt may be enough to sit more upright
against gravity
A slight tilt may help sit more
upright against gravity
Tilt-in-space base
Provides adjustment
for seat tilt while
holding hip, knee, and
ankles in place
The Seat
Planar
Contoured
Custom molded
Sitting on flat surfaces may cause
increased pressure over bony
prominences
Some types of foam will reshape
in response to body weight
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Blocks can be added to the sitting
surface to provide lateral as well
as posterior supports
High density foam shapes can be
placed under more flexible foam
to create a contoured cushion
Seat Surface
Does the seat provide enough support?
Is the seat the proper depth?
Does the seat provide enough pressure
relief?
The pelvis and lower extremities
A firm base of support is needed fromwhich to function
The base needs to be
Stable
Symmetric
Supportive
The pelvis position should be neutral or
slightly tipped forward
Posterior pelvic tilt affects body
posture
Discomfort Finding a balance
point
Shortening of the
hamstring muscles
Falling into anterior pelvic tilt
Weakness
Very low tone Hip flexion
contractures
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Sitting in a sling seat increases
asymmetries
Firm sitting surface provides a
good base of support
Back Surface
Does the back surface provide enough
support?
Is the seat the proper depth?
Is the back support high enough?
Support to the back of the pelvis
can help maintain good
alignment
If the seat is too deep then the
pelvis will tilt back causing the
pelvis to round
Is the back support high enough?
Fair trunk control should rise to the
middle of the shoulder blade Poor trunk control should rise to the
shoulder
Increase extensor tone should rise to the
shoulder
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Positioning belts or bars are used
to prevent the pelvis from
slipping A belt across the
waist will encourage
posterior pelvic tilt
A rigid bar may be needed with
excessive trunk extension
Hip guides to control pelvic
position
Knee supports
A spacer may be
needed to keep thelegs in a neutral
position
It should start at the
front of the knee and
move 1/3 of the way
up the thigh
Trunk supports
Leaning to one side
or the other Muscle imbalance
Poor postural control
Discomfort
Perform a functional
task
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Three point control is needed to
maintain trunk position
Proper position of the straps is
very important
The strap should pass
over the shoulder to a
point at or slightly
below the shoulder
line
The bottom should be
securely tethered
Y straps tend to bind against the
side of the neck putting pressure
over neck blood vessels
H straps work well but should not
be tethered to the lap belt
Standing Frames Gait trainers
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Orthopedic surgery: Should we
or shouldnt we?Decisions to treat
Based on degree of contracture
Whether the joint motion covers afunctional range
Belief that surgery will improve the natural
history
Common Clinical Patterns: Lower Limbs
Physiology of Contractures
Mobile tissues usually separated by thinlayers of loose areolar connective tissue
Immobility causes reorganization of theloose connective tissue
Once soft tissues are involved - muscleshortening may follow
Orthopaedic surgery
3 major goals
Remove or diminish muscle imbalance
Prevent bony deformity
Correct bony deformity
Orthopaedic Surgery: Goals
Muscle-tendon surgery
restore dynamic alignment improve agonist-antagonist balance
Osteotomies
realigns osseous levers
correct torsional deformities
Arthrodesis
stabilize severely subluxed, painful arthritic joints
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Musculotendinous Procedures
Lengthening of the tendon
Tendo Achilles lengthening
Hip adductor tenotomy
Lengthening of the musculotendinous
junction or fascia
Strayer, Vulpius, or Baker lengthenings
www.wemove.org
Defining the functional problem
Joint contracture: loss of passive range of motion
muscle-tendon unit dynamic which is braceable
fixed which requires surgery
ligament or joint capsule
Gait deterioration
Joint instability or torsional deformity
Pain
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