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40
Orthopedic Conditions: Hip Fractures and
Hip, Knee, and Shoulder Replacements
Lynne F. Murphy, Sonia Lawson
LEARNING OBJECTIVES
After studying this chapter, the student or practitioner will be
able to do the following:
1. Describe the etiology and medical management of hip
fractures and hip, knee, and shoulder joint replacements
and their effect on participation in occupations.
2. Identify precautions associated with hip fractures and joint
replacements and their effects on intervention plans and
occupational performance.
3. Outline client factors, performance patterns, and
performance skills that are appropriate to include in the
occupational therapy evaluation.
4. Develop occupational therapy goals that promote
occupational engagement, utilizing information
gained from the occupational profile and evaluation
results.
5. Explain intervention procedures that incorporate
precautions, ensure safety, and promote occupational
performance in daily tasks.
6. Discuss the emotional and social impact of hip fractures
and joint replacements on occupational performance and
performance patterns.
CHAPTER OUTLINE
Introduction to Orthopedic Conditions, 1005
Emotional and Social Factors for the Orthopedic
Patient, 1005
Rehabilitation Team, 1006
SECTION 1: HIP FRACTURES AND
REPLACEMENT, 1007
General Medical Management of Fractures, 1007
Etiology of Fractures, 1007
Medical and Surgical Management, 1007
Types of Hip Fractures and Management, 1008
Femoral Neck Fractures, 1008
Intertrochanteric Fractures, 1009
Subtrochanteric Fractures, 1009
Fall Prevention, 1009
Hip Joint Replacement, 1010
Etiology and Medical Management, 1010
Special Considerations for Hip Replacements, 1011
Role of Occupational Therapy for Clients With Hip Fracture
or Hip Replacement, 1012
Evaluation and Intervention, 1012
Client Education, 1012
Specific Training Techniques for Participation in
Occupations, 1013
Evidence Regarding Occupational Therapy
Intervention, 1016
SECTION 2: KNEE JOINT REPLACEMENTS, 1017
Etiology and Medical Management, 1017
Special Considerations for Knee Replacements, 1018
Medical Equipment, 1019
Role of Occupational Therapy for Clients With Knee Joint
Replacement, 1019
Evaluation and Intervention, 1019
Specific Training Techniques for Participation in
Occupations, 1019
Evidence Regarding Occupational Therapy
Intervention, 1021
SECTION 3: SHOULDER JOINT
REPLACEMENTS, 1021
Etiology and Medical Management, 1022
Special Considerations for Shoulder Joint
Replacements, 1023
Role of Occupational Therapy for Clients With Shoulder
Joint Replacement, 1024
Evaluation and Intervention, 1024
Therapeutic Exercise Considerations, 1024
Specific Training Techniques for Participation in
Occupations, 1026
Evidence Regarding Occupational Therapy
Intervention, 1026
Summary, 1027
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1004
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CHAPTER 40 Orthopedic Conditions
1005
KEY TERMS
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Anterolateral approach
Arthroplasty
Codman’s pendulum exercises
Degenerative joint disease
Hip precautions
Knee immobilizer
Minimally invasive technique
Open reduction and internal fixation
Osteoarthritis
Osteoporosis
INTRODUCTION TO ORTHOPEDIC CONDITIONS
Hip fractures and lower extremity (LE) joint replacements are
two orthopedic conditions that occur with a relatively high
frequency. The Centers for Disease Control and Prevention
(CDC) reported that more than 300 million hip fractures
occurred in 2010, with the majority in older adults.41 According
to the American Academy of Orthopaedic Surgeons (2014),
more than 1 million joint replacements were performed in
2011, with hip and knee replacements making up the majority.23
Shoulder replacements total approximately 53,000 per year in
the United States.62 Age-related changes in older adults contribute most to falls resulting in hip fractures or the need to have a
joint replaced. Persons who have been involved in activities or
occupations that put great amounts of stress on their joints,
over time, may experience pain and degeneration as they get
older. In addition, older individuals are more likely to have
orthopedic problems such as osteoporosis and arthritic joint
changes as a part of the aging process. When joint problems
occur at the hip, knee, or shoulder, in particular, temporary or
more long-lasting disability may result. When individuals need
to have these joints repaired, there is a period of time in which
the joint is unstable, which limits an individual’s participation
in meaningful daily occupations. However, medical and rehabilitative advances continue to make orthopedic conditions
easier to manage with less of an impact on occupational
performance.
The elderly population is most at risk for hip fractures,
primarily due to age-related changes in muscle strength, bone
density, postural alignment, sensory function (eg, vision
impairment, decreased proprioceptive awareness), and nervous
system function.32 Reduced balance, coordination, and mobility
are potential risk factors for falls.3 Postmenopausal women, in
particular, develop osteoporosis to a greater degree than men
and thus tend to have more hip fractures when they fall.20
Mobility is compromised in the elderly population because
of decreased flexibility, diminished strength, reduced vision,
decreased proprioceptive awareness, slowed reaction time, and
the use of assistive ambulatory aids such as canes and walkers.
Many elderly people become more cautious when moving
about and are fearful of falling. This fear may contribute to
more sedentary behavior, which can lead to further declines in
strength and mobility. In some cases, individuals use a cane or
walker improperly, which contributes to a fall. Not seeing a step
or threshold may also cause a fall, as does tripping over items
in the home (eg, throw rugs, cords).60
Individuals with a history of osteoarthritis, degenerative
joint disease, or other rheumatic diseases that limit occupational performance are primary candidates for joint replacement. Individuals who elect to undergo these surgical procedures
usually have been living with increasing pain in their joints for
many months or years, and their ability to perform daily tasks
Posterolateral approach
Shoulder sling and swathe
Weight-bearing restrictions
is limited. By having the painful joint replaced, they hope to
return to a more active and satisfying lifestyle. Occupational
therapy (OT) plays a key role in identifying the many functional
problems imposed by these acute and chronic orthopedic
conditions and promoting compensatory or remediation
approaches to facilitate the return of the orthopedic client to
optimal performance of safe, independent, and meaningful
occupations.
This chapter is divided into sections that include a discussion
of hip fractures; hip, knee, and shoulder joint replacements; the
associated medical and surgical management; and occupational
therapy evaluation and intervention for these conditions. The
Occupational Therapy Practice Framework, Third Edition, is
used to discuss the role of occupational therapy for persons
with these conditions. Specific areas addressed in the chapter
are occupational therapy evaluation of performance skills,
occupational therapy interventions addressing specified occupations, the social and emotional implications of hospitalization
and decreased functional abilities, and the interprofessional
healthcare team approach in both the acute hospital and rehabilitation settings.
Emotional and Social Factors for the Orthopedic Patient
Attention to emotional and social issues is critical in the overall
rehabilitation for the orthopedic client. Many clients in this
population are faced with a chronic disability (eg, rheumatoid
arthritis), a life-threatening disease (eg, cancer), chronic pain,
or consequences of the aging process. The loss or potential loss
of mobility and physical ability that limits participation in areas
of occupation is a major concern for most of these clients.
Adjusting to loss is stressful and requires an enormous amount
of physical and emotional energy.35 An awareness of and a
sensitivity toward the psychosocial challenges of the person
with an orthopedic problem are critical for the delivery of
optimal client care.48
Clients with a chronic orthopedic disability often experience
one or all of the following challenges: disease of a body part,
fear, anxiety, change in body image, decreased functional ability,
joint deformity, and pain. Interventions for a client with a
chronic orthopedic condition must address these issues, especially in a preoperative phase or if a person chooses to decline
surgery. The occupational therapy practitioner should be alert
for signs of depression, guilt, anxiety, or fear that may impede
participation in valued occupations. These emotions inhibit the
client’s progress and further damage the client’s self-image. In
a postoperative phase, clients may also experience pain, fear of
operated extremity use, fear of falling, or unexpected delays in
recovery that can also have detrimental effects on emotional
health.48
Occupational therapists can help clients acknowledge and
express emotional factors related to their condition, which can
ultimately enhance the intervention process. One way to ease
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1006
PART VI Intervention Applications
anxiety and fear is to make sure the client understands procedures and interventions, as well as the likelihood of a positive
outcome. Taking time to answer questions and provide additional information can be crucial for successful adjustment. In
addition, communication with the entire healthcare team is
important to ensure that these emotional needs are considered
in all aspects of healthcare management.
The elderly client experiencing disability deals with additional issues specific to the aging process, such as fear of
dependence and relocation trauma. With the onset of a disability late in life, the client may be forced to let go of independence and self-sufficiency.35 This can be a devastating experience
for some clients, and prolonged grieving may be necessary
before adjustment. Others may use dependence for secondary
gain, remaining in the hospital for extra attention or manipulating their support systems to avoid taking responsibility for
themselves and others. When individuals are removed from
their familiar environment, confusion, disorientation, and
emotional lability may result. Practitioners must take these
factors into consideration when implementing an intervention
plan and provide supports as needed.
Learning to cope and adjust to the changes resulting from
chronic disability or the aging process is a critical aspect of
recovery. Practitioners must realize that the client has relinquished a great deal of functional independence as a result of
disease or disability. The occupational therapist must address
the emotional and social issues resulting from this loss while
focusing on maximizing the client’s ability to participate in
areas of occupation that are meaningful.35
OT PRACTICE NOTES
It is important for the occupational therapist working with clients who
have orthopedic impairments or conditions to have a good understanding of the site, type, cause of the condition, any surgical procedures
performed, and treatment precautions before starting the evaluation and
intervention processes. A basic understanding of fracture healing and
medical management procedures or protocols is also necessary to
appreciate the risks, cautions, and implications to occupational performance. The occupational therapist is advised to review additional
medical resources if more specific information is needed regarding
surgical techniques and healing concerns.
Rehabilitation Team
Optimal rehabilitation for the orthopedic conditions discussed
in this chapter requires coordination among the interprofessional team. Collaboration, communication, and clear role
delineation among members of the interprofessional team are
essential for an effective and efficient therapy program. In addition to the client, the team usually consists of a primary physician or surgeon, nursing staff, an occupational therapist or
assistant, a physical therapist or assistant, a dietician, a pharmacist, caregiver, and a social worker or case coordinator. Many
facilities have a protocol or critical pathway that outlines each
team member’s responsibilities and a time frame for accomplishing assigned tasks and goals related to the client’s rehabilitation. Regular team meetings to discuss each client’s ongoing
progress and discharge plans are necessary for coordinating
individual intervention programs. Members from each service
usually attend each meeting to provide information and consultation. Clients are the most important members of the team.
They are involved in goal setting and establishing a plan of care,
and they must be able to engage in the interventions specified
by other team members. Informal caregivers (eg, spouses,
partners, significant others) should be considered part of the
healthcare team, as they provide a good deal of care at home
once the patient is discharged. Oftentimes restrictions and
protocols must be followed weeks after joint repair, and the
caregiver is responsible for ensuring those directions are followed in the home setting.
The role of the physician or surgeon is to manage medical
needs and inform the team of the client’s medical status. This
includes information regarding medical history, diagnosis and
treatment of the present problem, and information regarding
the surgical procedure performed. The physician specifies any
precautions or contraindications that all members of the team
must enforce. Information provided may include the type of
fixation or prosthesis inserted, the anatomic approach used in
the surgery, weight bearing or other types of precautions, and
contraindications such as movements that could endanger the
client or impede healing. The physician is also responsible for
ordering specific medications, overseeing the client’s medication regimen, and directing pain-management approaches. The
physician orders specific therapies and approves any change in
the therapy program resulting from a change in the client’s
medical status.
The nursing staff is responsible for the physical care of the
client during hospitalization, including care and monitoring of
the surgical incision and administering prescribed pain medication according to the established pain management protocol.
The orthopedic nurse must have a thorough understanding of
the surgical procedures and movement precautions for each
client. The nurse takes care of proper positioning using pillows
and wedges, especially in the first few days after surgery. As the
client’s therapy program progresses, the client starts to take
more responsibility for proper positioning and physical care.
The nurse works closely with occupational and physical therapists and caregivers to carry through self-care and mobility
skills that the client is learning in therapy.
The physical therapist is responsible for evaluation and
intervention in the areas of musculoskeletal status, sensation,
pain, skin integrity, and mobility (especially gait and bed mobility). In most cases involving joint replacement and surgical
repair of hip fracture, physical therapy is initiated on the first
day after surgery along with occupational therapy. Adhering to
the prescribed precautions of the protocol, the physical therapist
obtains baseline information, including range of motion
(ROM), strength of all extremities, muscle tone, and mobility.
A treatment program that includes therapeutic exercises, ROM
activities, transfer training, and progressive gait activities is
established. The physical therapist is responsible for recommending the appropriate assistive device to be used during
ambulation. As the client’s ambulation status advances, instruction in stair climbing, managing curbs, and outside ambulation
is given.25,38 In the case of shoulder replacements, the physical
therapist implements mobility training that allows the client to
protect the shoulder, works with occupational therapy to
prevent movement that is not permitted, and may progress the
client through the postsurgery protocol gradually increasing
ROM and strength of the shoulder.
The dietician consults with each client to ensure that adequate
and appropriate nutrition is received to aid the healing process.
The pharmacist monitors the client’s pain management and
medication routine and provides information and assistance to
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CHAPTER 40 Orthopedic Conditions
clients and their caregivers regarding any medications to be
continued at home after discharge.
The role of the case coordinator is to ensure that each client
is being discharged to the appropriate living situation or facility
and the availability of durable medical equipment as recommended by physical and occupational therapy practitioners.
The case coordinator is usually a registered nurse or social
worker with a thorough knowledge of available community
resources and nursing care facilities. With input from the
healthcare team, the case coordinator works with caregivers to
make arrangements for ongoing therapy after acute hospitalization, for admission to a rehabilitation facility or skilled nursing
facility for further intensive therapy if needed, or for home
healthcare as appropriate. The case coordinator works closely
with the interprofessional team and is instrumental in coordinating discharge plans.
The occupational therapist is concerned primarily with
improving performance in daily activities and meaningful
occupations but may also create exercise programs to address
limitations in specific neuromusculoskeletal body functions/
client factors as a basis for occupational performance. Focus is
placed on safe execution of functional mobility, performance of
activities of daily living, and performance of instrumental
activities of daily living. The specific role of the occupational
therapist will be discussed in detail in each of the following
sections.
SECTION 1: HIP FRACTURES AND
REPLACEMENT
THREADED CASE STUDY
Mrs. Hernandez, Part 1
Mrs. Hernandez, a 70-year-old Latina grandmother to three small children, fell outside of the senior center that she attends three times a
week for exercise. She sustained a femoral neck fracture of her right
hip. Prior to the fall, she had been experiencing increasing right hip pain
due to osteoarthritis and degenerative joint disease, and she was concerned about increasing weakness in the right leg. She remembers not
lifting her right leg high enough to clear the entrance step to the center
where she tripped up the steps, and she was unable to catch herself
and fell on her right hip. The fracture was repaired with a total hip
replacement that was performed using an anterior approach, minimally
invasive procedure. Movement precautions include no hip extension or
crossing the legs and weight bearing as tolerated on the right lower
extremity. Mrs. Hernandez is usually very active; she attends swimming
classes twice a week, helps her daughter care for her three children,
and heads two committees at her church. These activities became
important to her after her husband died 5 years ago. They give her a
sense of purpose and help her feel connected with others. Mrs.
Hernandez lives alone in an apartment with elevator access. Her daughter and grandchildren live 15 minutes away and often visit and involve
her in many of their family activities.
Mrs. Hernandez was referred for occupational therapy because of her
difficulty with functional mobility and completing her daily activities.
When asked about what bothered her most about her fall and subsequent
hip replacement, she said that she was worried that she would no longer
be able to participate in the swimming classes she enjoys so much, nor
would she be able to drive herself to all of her appointments and churchrelated activities. This would make her dependent on her children and
church friends. She was afraid of losing her independence, which she
valued greatly. She is hoping that the occupational therapy she receives
will help her drive again as soon as possible and allow her to remain as
independent as possible so that she is not a burden to anyone.
1007
Critical Thinking Questions
1. When completing the occupational profile, what additional information would the occupational therapist need to gather during the evaluation to supplement the information already provided in the case
scenario?
2. Identify important areas of occupation and performance skills to
address first when educating Mrs. Hernandez to safely perform her
daily activities.
3. What prerequisite performance skills should be addressed with Mrs.
Hernandez before the occupational therapist directly addresses her
ability to drive again?
GENERAL MEDICAL MANAGEMENT
OF FRACTURES
In general, a fracture occurs when the bone’s ability to absorb
tension, compression, or shearing forces is exceeded.22 The
healing process begins after the fracture. Osteoblasts, cells that
form bone, multiply to mend the fractured area. Adequate
blood supply is necessary to supply the cells with oxygen for
proper healing. The fracture site may be protected during the
postsurgical healing process by internal fixation, such as pins,
plates, screws, or wires. In rare cases in which extra protection
is needed, an external abduction brace may be used for the hip.
This metal brace extends around the pelvis and down the thigh
of the fractured hip and prevents movement, especially hip
abduction, according to settings determined by the orthopedic
surgeon. Other types of braces or casts may be used for fractures
of other parts of the lower extremity (eg, a knee immobilizer).
It may take several months for a bone fracture to heal completely. The time needed varies with the age, health, and nutrition of the client; the site and configuration of the fracture; the
initial displacement of the bone; and the blood supply to the
fragments.
Etiology of Fractures
Trauma is the major cause of fractures. In most cases, the
trauma occurs as a result of falling. Poor lighting, throw rugs,
and unmarked steps are environmental hazards that can lead to
a fall. Osteoporosis is a bone disease that typically results in
decreased bone density, most commonly in the vertebral bodies,
the neck of the femur, the humerus, and the distal end of the
radius. Because the bone becomes porous and therefore fragile,
the affected bones are prone to fracture as a result of a fall or
other traumatic event. A pathologic fracture can occur in a bone
weakened by disease or tumor, as with osteomyelitis and cancers
that have metastasized to the bone.22
Medical and Surgical Management
The goals of fracture management are to relieve pain, maintain
good position of the bone, allow fracture healing, and restore
optimal function to the client. Reduction of a fracture refers to
restoring the bone fragments to normal alignment.22 This can
be done by a closed procedure (manipulation) or by an open
procedure (surgery). The physician performs a closed reduction by applying force to the displaced bone to realign the
bone. Depending on the nature of the fracture, the reduction
or realignment is maintained by a cast, brace, traction, or
skeletal fixation. With open reduction, the fracture site is
exposed surgically so that the bone fragments can be aligned.
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PART VI Intervention Applications
The fragments are held in place with internal fixation such as
pins, screws, a plate, nails, or a rod. Further immobilization by
a cast or a brace may be deemed necessary by the orthopedic
surgeon. Closed reductions and open reduction and internal
fixation (ORIF) must be protected from excessive forces during
bone healing. Therefore weight-bearing restrictions may be
indicated.22
There are several levels of weight-bearing restrictions. The
physician indicates at which level the client should be placed
based on the surgical technique selected and the stability of the
surgical repair. Elderly clients may not have the upper extremity
strength to support their body during non-weight-bearing
precautions. The surgeon may take this into account and use a
more stable procedure to allow the client to bear weight at tolerance (WBAT) through the operated leg, thereby sparing overexertion of the upper extremities. Restrictions are reduced as
the fracture site heals and becomes stronger.15 The levels of
weight-bearing restrictions are listed in Box 40.1.
BOX 40.1
Weight-Bearing Restrictions
NWB (non–weight bearing) indicates that no weight at all can be placed
on the extremity involved.
TTWB (toe-touch weight bearing) indicates that only the toe can be
placed on the ground to provide some balance while standing—90%
of the weight is still on the unaffected leg. In toe-touch weight
bearing, clients may be instructed to imagine that an egg is under
their foot.
PWB (partial weight bearing) indicates that only 50% of the person’s
body weight can be placed on the affected leg.
WBAT (weight bearing at tolerance) indicates that clients are allowed to
judge how much weight they are able to put on the affected leg
without causing pain that may limit function.
FWB (full weight bearing) indicates that clients are able to put 100% of
their weight on the affected leg.30
From Early MB: Physical dysfunction: practical skills for the
occupational therapy assistant, St. Louis, 1998, Mosby.
TYPES OF HIP FRACTURES AND MEDICAL
MANAGEMENT
Knowledge of hip anatomy is necessary for understanding the
medical management of hip fractures. An anatomy and physiology reference text should be consulted for details. Figs. 40.1 and
40.2 illustrate a normal hip joint and the common locations and
directions of fractures (fracture lines). The names of the fractures generally reflect the site and severity of injury and may
signal the form of medical treatment that will be used. For
example, a femoral neck fracture will typically be treated with
femoral neck stabilization.50
Femoral Neck Fractures
Femoral neck fractures, which include subcapital, transcervical, and basilar fractures, are common in adults over 60 years
old and occur more frequently in women. If the bone is osteoporotic, fracture may result from even a slight trauma or rotational force.35 Treatment of a displaced fracture in this area is
complicated by poor blood supply, osteoporotic bone that is
not suited to hold metallic fixation, and a thin periosteum
covering the bone. The type of surgical treatment used is based
on the amount of displacement and the vascular supply in the
femoral head as well as the age, health, and activity level of
the client.
Internal fixation or hip pinning (application of a compression screw and plate) is generally used when displacement is
minimal to moderate and blood supply is intact. With a physician’s approval, a client is usually able to begin limited outof-bed activities 1 day after surgery. Per physician’s orders,
weight-bearing restrictions may be necessary, with the aid of a
walker or crutches for at least 6 to 8 weeks while the fracture is
healing. Weight bearing may be limited beyond this time if
precautions are not observed or if delayed union occurs.50
With severe displacement or in the case of a femoral head
with poor blood supply (avascular), nonunion (a poorly healing
Anterior superior
iliac spine
Ilium
Anterior inferior
iliac spine
Femoral head
Acetabular
labrum
Greater
trochanter
Transverse
acetabular
ligament
Pubis
Neck of femur
Ligament of
head of femur
(cut)
Ischium
Ischial tuberosity
Lesser trochanter
Femur
FIG 40.1 Normal hip anatomy. (From Reese NB, Bandy WD: Joint range of motion and muscle
length testing, ed 3, St. Louis, 2017, Elsevier.)
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CHAPTER 40 Orthopedic Conditions
1009
client is allowed out of bed 1 day after surgery, pending the
physician’s approval.50
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Subtrochanteric Fractures
FIG 40.2 Levels of femoral fracture. 1, Subcapital. 2, Transcervical. 3, Basilar. 4, Intertrochanteric. 5, Subtrochanteric. (From
Porter S, editor: Tidy’s physiotherapy, ed 15. 2013, Churchill
Livingstone, Elsevier.)
fracture site where new bone does not form), and degenerative
joint disease, the femoral head is surgically removed and
replaced by an endoprosthesis (referred to more simply as
prosthesis). This joint replacement is called a hemipolar arthroplasty, often referred to as a hemiarthroplasty.38,50 Several types
of metal prostheses can be used for a hemiarthroplasty; each
has its own shape and advantages to best fit the client’s size.
Weight-bearing restrictions are sometimes indicated. Surgeons
may also choose to perform a total joint replacement depending
on the integrity of the joint and anticipated activity level of the
client. A total hip replacement may offer better patient satisfaction and functional outcomes for people who are very active.12
Depending on the surgical procedure used with a hemiarthroplasty or total hip arthroplasty (replacement), posterolateral or
anterolateral approach, specific precautions for positioning the
hip must be observed to prevent dislocation. These precautions
are the same as those advised for a total hip replacement, which
will be outlined later in this chapter. Clients with a hemiarthroplasty or total hip replacement can usually begin limited outof-bed activity, with a physician’s approval, about 1 day after
surgery.38,50,56
Intertrochanteric Fractures
Fractures between the greater and lesser trochanter are extracapsular, or outside the articular capsule of the hip joint, and
the blood supply is not affected. Like femoral neck fractures,
intertrochanteric fractures occur mostly in women but in a
slightly older age group. The fracture is usually caused by direct
trauma or force over the trochanter, as in a fall. The preferred
treatment for these fractures is an ORIF. A nail or compression
screw with a side plate is used. Weight-bearing restrictions must
be observed according to the surgeon’s orders for up to 6 to 8
weeks during ambulation, with gradual increases in the amount
of weight taken through the affected leg over this time.15 The
Subtrochanteric fractures 1 to 2 inches below the lesser trochanter usually occur because of direct trauma, as in falls, motor
vehicle accidents, or any other situation in which there is a
direct blow to the hip area. These fractures make up 10% to
30% of hip fractures and are most often seen in persons younger
than 60 years old or in older clients with severe osteopenia
(significant bone loss) who have a low velocity fall.43 These
fractures can be the most challenging to repair due to the
muscle attachments in this area that can cause forces on the
fracture site, impairing proper fracture healing.17 An ORIF is
the usual treatment. A nail with a long side plate or an intramedullary rod is used. An intramedullary rod is inserted
through the central part of the shaft of bone to help maintain
proper alignment for bone healing.22
In all types of hip fractures, the practitioner should observe
for and address any subsequent issues from the hip fracture that
can impact the rehabilitation process and the client’s ability to
regain the skills needed to complete daily activities. Such issues
can be reactions of the body to the surgery such as soft-tissue
trauma, edema, and bruising that occur around the fracture or
surgical site.22,38,50 These issues can greatly affect the amount of
pain and discomfort that a client may experience.
FALL PREVENTION
Another issue that frequently occurs for older adults after hip
fracture due to a fall is fear of falling. Frequent falls in older
adults can signal to the client and family members that there is
a decline in function, which could lead to changes in independence and performance of desired and valued occupations.
Psychologically, the client with frequent falls may fear the loss
of independence and hide falls from others or under-report the
number of falls that have occurred over time. A fear of falling
may also lead older adults to reduce their activity level so as not
to put themselves in a position to fall in the community. They
stay in places that are familiar and risk social isolation and
further decreases in strength and mobility. These functional
decreases can lead to more falls.60 It is important for the interprofessional team to be attuned to clues related to fall history
for the client and potential negative psychosocial reactions to
the fall.
Occupational therapists can work with other team members
to provide fall prevention education and training. Occupational
therapists can teach adaptive strategies, make environmental
recommendations, explore community resources, and teach
exercises that address strength, mobility, and balance. Physical
therapists can also address fall prevention through therapeutic
exercise and teaching correct use of an appropriate assistive
device for ambulation. Information regarding local communitybased fall prevention programs can be provided to the client
and family. These programs, typically held at area senior centers,
include education and exercise classes specifically geared to
improving the body structures and functions that help reduce
the risk of falling.16 The Stopping Elderly Accidents, Deaths and
Injuries (STEADI) Program obtained through the CDC is one
example of a comprehensive fall prevention program. Materials
and resources for professionals and the community can be
accessed from the CDC website.16
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1010
PART VI Intervention Applications
HIP JOINT REPLACEMENT
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Etiology and Medical Management
Restoration of joint motion and management of pain by total
hip replacement, also called arthroplasty or bipolar arthroplasty,
is sometimes indicated when a person experiences decreased
occupational performance often due to chronic disease processes. Common examples are osteoarthritis, degenerative joint
disease, or rheumatoid arthritis, although other rheumatic and
systemic diseases may also be present. Osteoarthritis and degenerative joint disease may develop spontaneously in middle age
and progress as the normal aging process of joints accelerates.
Degenerative changes may also develop as the result of trauma,
congenital deformity, or a disease that damages articular cartilage. Weight-bearing joints such as the hip, knee, and lumbar
spine are usually affected. In the hip, there is a loss of cartilage
centrally on the joint surface and formation of osteophytes on
the periphery of the acetabulum, producing joint incongruity.
Pain originates from the bone, synovial membrane, or fibrous
capsule and from muscle spasm. When movement of the hip
causes pain and limited mobility, the muscles shorten, which
can result in a hip position of flexion, adduction, and internal
rotation that causes a painful limp.45
Rheumatoid arthritis (RA) (see Chapter 38) may involve the
hip joint but because RA affects smaller joints before larger
joints in the body, the hip is typically not affected until later
stages of RA. Arthroscopic surgery can be performed early in the
disease process to limit fibrotic damage to the joint and tendon
structures.22 However, once there is significant joint damage, a
hip replacement may be the only alternative. Other disease
processes (eg, lupus and cancer) and some medications (eg,
corticosteroids such as prednisone) can compromise the blood
flow to the hip joint and lead to avascular necrosis (AVN, a
condition in which bone cells die because of poor blood supply)
or osteoporosis; either condition results in a painful hip.45
When conservative forms of management for the pain and
decreased mobility (eg, cortisone injections, modified activity,
pain medication) are no longer successful, a total joint replacement is considered to restore an individual’s ability to more
fully participate in daily occupations. Consideration of the total
joint replacement relies on a client’s ability to comply with a
rehabilitation program, the probability of a positive outcome
given other medical issues the client may be facing, and the
probability of a significant improvement in functional ability.38,39
There are two mechanical components to this type of prosthesis.
A high-density polyethylene socket is fitted into the acetabulum,
and a metallic or ceramic prosthesis replaces the femoral head
and neck. Methylmethacrylate or acrylic cement fixes the components to the bone (Fig. 40.3). Hip replacements can last for
15 to 20 years or more before a revision is needed to insert a
new prosthesis. Wear and tear on the hip prosthesis is greater
for more active people, who may then require a revision sooner
than for those who are more sedentary. Those who have their
hip replaced at a young age will likely have to undergo a revision
in later years.37
Various surgical approaches are used with the goal of choosing a technique that will provide the best stability for the client
and reduces the occurrence of complications. The specific
approach is selected based on the surgical skill or technique of
the orthopedic surgeon, severity of the joint involvement,
anatomic and biomechanical structure of the client’s hip,
and history of past surgery to the hip.13,50 There are two main
FIG 40.3 Hip prosthesis. (From Black J, Hawks J: Medical
surgical nursing: clinical management for positive outcomes,
ed 8, St. Louis, 2009, Elsevier.)
BOX 40.2
Hip Precautions
Posterolateral Approach
• No hip flexion greater than 90 degrees
• No internal rotation
• No adduction (crossing legs or feet)
Anterolateral Approach
• No external rotation
• No adduction (crossing legs or feet)
• No extension
From Early MB: Physical dysfunction: practical skills for the
occupational therapy assistant, St. Louis, 1998, Mosby.
approaches, anterior and posterior, that indicate from which
direction the surgeon opened the hip for the replacement. Both
of these techniques have variations that involve the surrounding
muscles of the hip to a greater or lesser degree. Muscles that
must be displaced during the surgery are not able to support
the joint postsurgery. This results in instability in certain directions of movement. With an anterolateral approach, the client
will be unstable in external rotation, adduction, and extension
of the operated hip and usually must typically observe precautions to prevent these movements for 6 to 8 weeks. Hip abduction may be prohibited as well with this surgical approach. It is
important for the occupational therapist to carefully read the
surgeon’s postoperative orders. If a posterolateral approach is
used, the client will be unstable primarily with hip flexion and
must be cautioned not to move the operated hip past specific
ranges of flexion (usually 90 degrees) and not to internally
rotate or adduct the leg for 6 to 8 weeks. Failure to maintain
these hip precautions during muscle and soft-tissue healing
may result in hip dislocation (Box 40.2).
In younger people, some surgeons may choose to replace the
hip using a hybrid technique in which the acetabular socket is
not cemented but the femoral component is cemented. In this
case,17 the use of biologic fixation (bony in-growth instead of
cement) secures the prosthesis. This can increase the strength
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CHAPTER 40 Orthopedic Conditions
of the fixation at the prosthesis interface and can also decrease
the possibility of loosening the prosthesis. In other words, new
bone grows into openings in the prosthesis, and this secures the
prosthesis to the bone. This noncemented approach can be used
for both components of the prosthesis. The precautions following the surgery are identical to those of the anterior or posterior
hip replacements, but they may involve an additional restriction
on weight bearing.38
Many orthopedic surgeons use a minimally invasive technique to perform the posterolateral and anterior approaches for
hip replacement. This technique reduces the amount of trauma
to the muscle and soft tissue structures and allows for faster
recovery. The traditional posterolateral surgical technique
requires that a long (about 10 inches) incision be made and
muscles detached to get to the hip joint. In the minimally
invasive technique, two incisions of approximately 2 inches are
needed and no detachment of muscles is required. Because no
muscles are detached, the hip is more likely to remain in a stable
position during the healing process. Similarly, for an anterior
approach, a small vertical incision is made on the anterior
surface of the hip joint with the hip placed in hyperextension.
In addition to a faster recovery, this particular technique minimizes the risk of dislocation and postoperative limp.46,50 The
minimally invasive techniques are not appropriate for all total
hip replacements or arthroplasties. Persons with severe damage
to the hip joint or who have anatomic or biomechanical
contraindications will require the traditional surgical method.
Hip precautions that are identified for the posterolateral and
anterolateral approaches are indicated for persons receiving a
minimally invasive technique.55
To reinforce use of proper hip precautions during occupational performance and to guide intervention and discharge
planning, the occupational therapist must know the type of
surgical procedure that was performed. For example, someone
with a hip replacement in which the minimally invasive technique was used may tolerate more activity after surgery than
someone who underwent the traditional surgical technique.
Clients with total hip replacements usually begin out-of-bed
activity the same day of the surgery or the day after.
Hip resurfacing is another method of repairing a damaged
and painful hip. This technique, less commonly used and with
mixed evidence for efficacy over a total hip replacement, is a
variation of the total hip replacement.45 Designed for younger
clients, the resurfacing technique preserves more of the bone of
the femur should a total hip replacement be needed in later
years. The surface of the femoral head is reshaped and then
capped by a metallic shell. The acetabular cavity also receives a
metallic cup or socket. Both are held in place by methylmethacrylate (acrylic cement). This technique preserves the femoral
head and neck. With this technique, no weight-bearing restrictions apply.18,45
In summary, the occupational therapist must be informed
of the surgical technique, movement precautions, and weightbearing restrictions before beginning the evaluation and
intervention of clients recovering from hip replacement surgery.
Restrictions on weight bearing for any of the techniques vary
in terms of amount of pressure and length of time, and the
orthopedic surgeon will specify these limits. A walking aid,
usually a walker or crutches, is necessary for at least the first
month while the hip is healing and muscles are becoming
stronger.38 The occupational therapist has the responsibility of
working with the inter-professional team to educate clients
1011
about their hip precautions and restrictions to allow the surgery
to heal optimally without adverse effects such as dislocation. A
joint that becomes dislocated may need additional surgery for
repair. Strategies for completing daily tasks during the recovery
process are implemented that allow the client to retain as much
independence as possible while maintaining hip precautions
and weight-bearing restrictions.
Special Considerations for Hip Replacements
Individuals with joint changes that increase pain may have
multiple joint involvement (ie, both knees or hips, shoulders).
With less frequency than for knee replacements, some clients
opt to have two hip joints replaced during the same hospitalization, with procedures spaced apart by a few days. This can
complicate the rehabilitation process because the client will not
be able to rely on the nonoperated leg when walking, transitioning between seated and standing positions, and performing
daily occupations.
It is important for the occupational therapy practitioner to
be aware of complications or special procedures that occurred
during a client’s surgery and to verify precautions or risks with
the physician. Surgeons will make specific recommendations
based on the client’s particular situation, surgical procedures
used, or postoperative concerns. Common complications that
can occur days or months after the surgery include dislocation
of the hip joint, degeneration of the components of the prosthesis, fracture of bone next to implanted parts, loosening of
prosthetic parts, and infection of the joint after surgery. A
special procedure for individuals at high risk for a hip dislocation after surgery involves using an abduction brace to immobilize the hip joint.22 This brace adds extra movement restrictions
to the performance of daily tasks. Worn component parts, bone
fractures, and sometimes dislocations must be repaired surgically. Additionally, clients with hip replacements are required to
take prophylactic antibiotics for any future dental work or
surgery to prevent infection at the joint replacement site.47
The implantation of metal and plastic parts makes that area
more susceptible to infection. Individuals living with a hip
replacement must manage this chronic situation for the rest
of their lives.
Postsurgical pain is often managed with a regimen of medications, such as epidural or periarticular anesthetics, patientcontrolled analgesia, oral analgesics or opioids, or peripheral
nerve blocks, although side effects and effectiveness are variable
with individual clients. The pain may be caused by the trauma
to soft tissues, edema surrounding the hip joint that places
pressure on the incision, or improper positioning. Many hospitals that have a coordinated joint replacement program implement a pain management program in which clients receive
regular and timely pain medication to allow optimum recovery
and participation in their rehabilitation program. Other
methods of pain control amenable to use by rehabilitation
professionals include the use of superficial cold modalities,
proper positioning during transitional movements, and a
balance of rest and activity.
Medical Equipment
The OT practitioner should be familiar with the following
equipment that is commonly used in the treatment of hip
fracture and total hip replacement:
Hemovac. During surgery, a plastic drainage tube is inserted at
the surgical site to assist with postoperative drainage of
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1012
PART VI Intervention Applications
FIG 40.4 Abduction wedge. (Courtesy Performance Health,
Warrenville, IL.)
blood. It has an area for collection of drainage and may be
connected to a portable suction machine. The unit should
not be disconnected for any activity because this may create
a blockage in the system. The Hemovac is usually left in place
for 1 to 2 days after surgery.
Abduction wedge. Large and small triangular foam wedges (Fig.
40.4) are used when the client is supine to maintain the lower
extremities in the abducted position.
Balanced suspension. This is fabricated and set up by an orthopedic technician and can be used for about 3 days after
surgery. It balances the weight of the elevated leg by weights
placed at the opposite end of the pulley system. Its purpose
is to support the affected lower extremity in the first few
postoperative days. The client’s leg can be taken out of the
device for exercise only.50
Reclining wheelchair. A wheelchair with an adjustable backrest
that allows a reclining position is used for clients who have
hip flexion precautions while sitting.
Commode chairs. The use of a commode chair instead of the
regular toilet aids in safe transfers and allows the client to
observe necessary hip flexion precautions.
Sequential compression devices (SCDs). SCDs are used postoperatively to reduce the risk of deep vein thrombosis. They are
inflatable, external leggings that provide intermittent pneumatic compression of the legs.22
Antiembolus hose. These are thigh-high elastic hosiery items
that are worn 24 hours a day and removed only during
bathing. Their purpose is to assist circulation, prevent edema,
and thus reduce the risk of deep-vein thrombosis.22
Patient-controlled administration IV. Patient-controlled analgesia (PCA) is delivered through an IV; patient-controlled
epidural analgesia (PCEA) is delivered through an epidural
line. A prescribed amount of medication is programmed by
the physician and nursing staff to allow the client to selfadminister pain medication by pushing a button to inject a
safe amount. When dosages have reached a limit, the machine
will not administer medication even if the button is pushed.
Incentive spirometer. This portable breathing apparatus is used
to encourage deep breathing and prevent the development
of postoperative pneumonia.
ROLE OF OCCUPATIONAL THERAPY FOR CLIENTS
WITH HIP FRACTURE OR HIP REPLACEMENT
After a hip replacement or surgical repair of a fractured hip, OT
typically begins when the client is ready to start getting out of
bed, usually the day of surgery or the following day. The actual
time varies, depending on the age and general health of the
client and on surgical events or medical complications involved.
Before any physical assessment, it is important to introduce and
explain the role of OT and complete an occupational profile.
This profile involves gathering information regarding the client’s occupational history, prior functional status in activities
of daily living (ADLs) and instrumental activities of daily living
(IADLs), descriptions of performance contexts (eg, home
environment and social support available), and the client’s
goals. The goal of OT is for the client to maximize performance
skills in daily occupations, with all movement precautions
observed during activities. The role of the occupational therapist and assistant is to teach the client ways and means of performing daily occupations safely.35
Evaluation and Intervention
The occupational therapist’s role is to assume responsibility for
performing any assessments necessary for a complete evaluation. In addition to an occupational profile, an assessment of
the psychosocial issues related to the surgery and the surgery’s
impact on the client’s lifestyle is completed via interview. A
baseline physical evaluation is necessary for determining
whether any physical limitations not related to surgery might
prevent functional independence. Performance skills and client
factors such as upper extremity (UE) ROM, muscle strength,
sensation, and coordination and status of cognitive skills are
assessed before a functional evaluation is made, as these can
impact the client’s ability to fully participate in the rehabilitation
program. Evaluation of activities of daily living, instrumental
activities of daily living, and functional mobility is necessary for
clinical reasoning and holistic intervention planning. During
evaluation, it is also important to observe and document any
signs of pain and fear at rest or during movement.
Based on evaluation results and a thorough clinical reasoning process, the occupational therapist creates an intervention
program of functional activities that gradually enables the client
to regain the abilities and skills necessary to participate in
identified areas of meaningful occupation. The therapist introduces and trains clients in the use of assistive devices, proper
transfer techniques, and ADL and IADL techniques while
maintaining hip and weight-bearing precautions. An occupational therapy assistant may play a large role in this training.
Both the occupational therapist and the occupational therapy
assistant are involved in treatment planning, documentation,
and discharge planning (including the recommendation of
equipment and home exercise programs).
Client Education
Although hip fractures are never a planned occurrence, hip
replacements are usually planned and scheduled to be performed on a specific date. Occupational therapists often provide
education classes for individuals at risk for fractures and those
planning joint replacement. As mentioned earlier in the chapter,
for the person who may be at risk for falling, attending a class
on fall prevention is a wise recommendation. Topics may
include home modifications (eg, removal of throw rugs, telephone cords, and clutter), safe transfer techniques, use of public
transportation, and community mobility tips. The person who
is having an elective total joint replacement may benefit from a
class offered before surgery that explains the surgical procedures
and precautions, introduces assistive devices, describes the
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CHAPTER 40 Orthopedic Conditions
therapy process, and describes the typical recovery period so
that the client can be best prepared.
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Specific Training Techniques for Participation
in Occupations
Some common assistive devices are useful for many people with
hip fractures or hip replacements (Fig. 40.5 ). Helpful assistive
devices or adaptive aids include a dressing stick, sock aid, longhandled sponge, long-handled shoehorn, reacher, elastic shoelaces, leg lifter, elevated toilet or commode seat, three-in-one
commode, and shower chair or bench. Walker bags are helpful
for people using walkers who need to carry small items from
one place to another. The OT clinic should have samples of
these devices that are available for client use during the intervention process.
The training procedures outlined in the following sections
apply to hip fractures and the different types of hip joint
replacement. The positions of hip instability for the specific
FIG 40.5 Assistive devices for ADLs. A, Reacher. B, Sock aid.
C, Long-handled sponge. D, Dressing stick. E, Long-handled
shoehorn. F, Leg lifter.
1013
types of surgical procedures for hip replacement are important
to remember. For the posterolateral approach (traditional or
minimally invasive), positions of instability include adduction,
internal rotation, and flexion greater than 90 degrees. For the
anterolateral approach (traditional or minimally invasive),
positions of instability include adduction, external rotation,
and excessive hyperextension.
Bed Mobility
The supine position with an abduction wedge (see Fig. 40.4) or
pillow in place is recommended in bed. If a client sleeps in the
side-lying position, sleeping on the operated side is recommended if tolerable. When sleeping on the nonoperated side,
the client must keep the legs abducted with the abduction
wedge or large pillows supporting the operated leg to prevent
hip adduction and rotation. The client is instructed in getting
out of bed on both sides, although initially it may be easier to
observe precautions by moving toward the nonoperated leg.
Careful instruction is given to avoid adduction past midline. It
is important to determine the type and height of the client’s bed
at home. When getting in and out of bed initially, the client may
use a leg lifter to help the operated leg move from one surface
to another. Some clients have an overhead trapeze bar placed
on the bed to assist with bed mobility. It is important to wean
the client away from using this device because he or she will
most likely not have one at home.
The best procedure for moving from the supine position to
sitting on the edge of the bed is to have clients support the
upper body by propping up on their elbows, then moving the
lower extremities toward the side of the bed in small increments, and following with the trunk and upper extremities (Fig.
40.6 ). The client should gradually turn in this manner until he
or she can lower the legs out of the bed and push the trunk into
the sitting position. Following a posterior approach hip replacement, the occupational therapist should observe the client when
sitting to ensure that the client is not flexing the hip more than
90 degrees. If so, the client can extend the knee, which will cause
the hip to be less flexed and widen the hip angle so that precautions are maintained.
Transfers
It is always helpful for the client to observe the proper technique
for transfers before attempting the movement.
FIG 40.6 Bed mobility.
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PART VI Intervention Applications
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OT PRACTICE NOTES
One way to help therapists understand the impact of maintaining the
proper hip position during the healing process is for the therapist to tape
a goniometer to his or her own hip when positioned at 90 degrees and
attempt to do the transfers listed next. Therapists will soon discover the
difficulty of maintaining the proper hip position during functional
activities!
Chair. A firmly based chair with armrests is recommended.
To move from standing to sitting, the client is instructed to back
up to the chair, extend the operated leg forward, reach back for
the armrests, and slowly lower to the sitting position. For the
person with a posterolateral approach, care should be taken not
to lean forward when sitting down (Fig. 40.7). To stand, the
client extends the operated leg and pushes up from the armrests.
Once standing, the client can reach for an ambulatory aid, such
as a walker if it is being used. Because of the hip flexion precaution for the posterolateral approach, the client should sit on the
front part of the chair and lean back (see Fig. 40.7). Firm
cushions or blankets may be used to increase the height of chair
seats and may be especially helpful if the client is tall. Low
chairs, soft chairs, reclining chairs, and rocking chairs should be
avoided.1
Commode chair. Three-in-one commode chairs with armrests can be used in the hospital and at home (see Fig. 40.7).
For the person with a posterolateral approach, the height and
angle can be adjusted so that the front legs are one notch lower
than the back legs; thus with the client seated, the precautionary
hip angle of flexion is not exceeded. A person with an anterolateral approach may have enough hip mobility to use a standard
toilet seat safely at the time of discharge. All clients should wipe
between the legs in a sitting position or from behind in a standing position and use caution to avoid forward flexion of the hip
greater than 90 degrees, or rotation of the hip. The client is to
stand up and step to turn to face the toilet when flushing so as
to avoid hip rotation.1 Comfort height toilets (17-inch seat
height) can be considered for installation at home as a permanent modification that eases transfers to the toilet.
Shower stall. Nonskid strips or stickers are recommended in
all shower stalls and tubs. When the client is entering the shower
stall, the walker or crutches go first, then the operated leg
(taking care to avoid active hip abduction if the client is not
allowed to perform this motion), and then the nonoperated leg.
Installation of a shower chair with adjustable legs or a stool and
grab bars is strongly encouraged to prevent the client from
losing balance and to maintain weight-bearing precautions. An
alternate method to enter the shower stall is to back up to the
edge or rim of the shower while using the walker for balance,
then stepping into the shower while looking down at the feet
and shower rim for safety.
Tub shower (without shower doors). The client is prohibited
from taking a bath sitting on the floor of the tub. This action
puts the client at severe risk of causing damage to the impaired
joint as well as other types of injuries. A tub chair or tub transfer
bench is strongly recommended to preserve hip precautions.
The client is instructed to back up to the tub chair or bench
using the walker or crutches for support. Then the client should
reach for the backrest, extend the operated leg, and slowly lower
to a seated position. The legs can then be lifted into the tub as
the client leans back, using a leg lifter or bath towel if needed
to support the operated leg. A handheld shower is helpful in
directing the water for an effective and comfortable bath.
Sponge bathing at the sink is an alternative activity,1 although
use of a long-handled sponge or reacher is recommended to
avoid hip flexion when bathing the lower extremities.
Car. Bucket seats in small cars should be avoided. The client
is instructed to have a helper move the front passenger seat back
as far as it will go and recline the back support in order to
observe the hip flexion precaution. Then the client is instructed
FIG 40.7 Chair/commode transfer technique. Client’s right hip has the hip replacement. The
nonoperated leg is used for weight bearing during sitting and standing from the chair/commode.
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CHAPTER 40 Orthopedic Conditions
to back up to the seat, hold onto a stable part of the car, extend
the operated leg, and slowly sit in the car. Remembering to lean
back, the client then slides the buttocks toward the driver’s seat.
The upper body and LEs move as one unit to turn to face the
forward direction. Firm pillows in the seat may be necessary to
increase the height of the seat. Prolonged sitting in the car
should be avoided. If transferring to the front passenger seat is
a problem, transferring to the back seat of a four-door car is an
alternative. The client backs to the seat, extends the operated
leg, and slowly sits in the car. Then he or she slides back so that
the operated leg is resting on the seat fully supported. Clients
should not return to driving until given permission by their
surgeon, even if the operated leg is not the leg used for operating the controls. Certain pain medications may cause driving to
be unsafe.
Lower-Body Dressing
The client is instructed to sit in a chair with arms or on the edge
of the bed for dressing activities. The client is instructed to
avoid hip flexion, adduction and rotation, or crossing the legs
to dress. The client must refrain from crossing the operated
extremity over the nonoperated extremity at either the ankles
or the knees. Assistive devices may be necessary for observing
precautions (see Fig. 40.5 ). To maintain hip precautions, the
client uses a reacher or dressing stick to put on and remove
pants and shoes. For pants and underwear, the operated leg is
dressed first by using the reacher or dressing stick to bring the
pants over the foot and up to the knee. A sock aid is used to
don socks or knee-high stockings, and a reacher or dressing
stick is used to doff them. A reacher, elastic laces, and a longhandled shoehorn can also be provided.1 It is also prudent for
the occupational therapist or occupational therapy assistant to
discuss clothing choices with the client for ease of dressing.
Slip-on shoes with a nonslip sole, for example, may be easier to
put on with appropriate adaptive equipment than sneakers with
elastic laces.
Lower-Body Bathing
The section on transfers describes the proper method of getting
in and out of the shower or tub. Sponge bathing at the sink is
indicated until the physician designates that it is safe for the
client to shower. Many surgeons use a waterproof bandage over
the incision, which protects the site from infection thereby
allowing the client to shower before the incision is healed. Care
must be taken for clients who are given permission to shower
early on in the recovery process. Pain medication and effects
from anesthesia may make the patient dizzy when standing or
sitting for long periods. The client must be monitored closely.
A sponge bath may still be the safest alternative. A long-handled
bath sponge or back brush is used to reach the lower legs and
feet safely. Soap-on-a-rope is used to prevent the soap from
dropping, and a towel is wrapped on a reacher to dry the lower
legs.1 Once showering is approved, a handheld shower head is
recommended to direct the water and provide a more comfortable shower.
Hair Shampoo
Until able to shower, the client is instructed to obtain assistance
for shampooing hair. The client can have a helper wash the hair
while the client is supine, using pillows for back support and a
bucket or bowl to catch the water poured from a pitcher to rinse
the hair. Another method involves having the client sit in a chair
1015
with the back to the sink. The client leans backward to position
the head over the sink while the helper washes the hair. The
client can also visit a hair salon until he or she is able to perform
hair washing independently. If unable to obtain any assistance,
the client may shampoo the hair while standing at the kitchen
sink with a handheld sprayer, observing hip precautions at all
times. Because bending forward at the kitchen sink can be
performed with less than 90 degrees of hip flexion, most clients
can observe the proper hip precautions using this method.
Homemaking
The client should initially refrain from heavy housework, such
as vacuuming, lifting, and bed making. Kitchen activities can be
initiated in therapy, with suggestions made to keep commonly
used items at countertop level or within easy reach. The client
can carry items by using an apron with large pockets, sliding
items along the countertop, using a utility cart, attaching a small
basket or bag to a walker, or wearing a fanny pack around the
waist. Reachers are provided to grasp items in low cupboards
or retrieve items from the floor (Fig. 40.8 ). Items in the refrigerator should be kept on the higher shelves, with only light
items that can be obtained with the reacher on lower shelves.
For cooking activities, it is recommended that the client use the
stovetop or microwave oven rather than placing items in the
oven, as it is difficult to maintain hip precautions when reaching
in or out of the oven. Washing dishes should be done at the sink
or using the top level only of an automatic dishwasher. The
occupational therapy practitioner should also instruct the client
in relevant energy conservation techniques for instrumental
activities of daily living.
Sexual Activity
Persons with a hip fracture or hip replacement will have difficulty performing sexual activities in their usual manner. It is
recommended that such persons refrain from sexual activity for
a few weeks as specified by their physician so that they maintain
the movement precautions applicable to their condition.38
However, the occupational therapist must create an environment in which the client feels comfortable enough to ask personal questions. The therapist can do this by being open-minded
and realizing that sexual activity is an important and meaningful activity of daily living. For clients with a hip replacement,
the therapist can suggest participating in sexual activity while
side-lying on the nonoperated side when they are allowed to
resume this activity. Hip abduction precautions can be maintained by placing pillows between the knees. To prevent excessive external rotation at the hips while in the supine position,
the client can place pillows under the knees.38 Written information with diagrams can be helpful when addressing such a
personal issue. The client can read this information privately or
with his or her partner.
Caregiver Training
A family member, friend, or caregiver should be present for OT
intervention sessions so that any questions may be answered.
Appropriate supervision recommendations and instruction
regarding activity precautions are given at this time. So that they
fully understand the impact of following the hip precautions,
caregivers should be encouraged to practice doing the adapted
activities as well. Instructional booklets on hip fractures and
total hip surgery may be purchased from the American Occupational Therapy Association to supplement training.1
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1016
PART VI Intervention Applications
FIG 40.8 Functional activities.
Evidence Regarding Occupational Therapy Intervention
A limited number of studies have examined OT intervention for
hip joint replacements and hip fractures. Mikkelsen and colleagues examined the effects of reduced (less strict) posterior hip
precautions along with the use of assistive devices on patient
outcomes versus outcomes for patients who followed strict
movement precautions but also used assistive devices.40 They
found that initially there were better outcomes for those patients
following the strict movement precautions, but after 6 weeks
there was no difference. However, patients with the reduced
restrictions returned to work at a higher rate than those who
followed the strict movement precautions. It was important for
both groups in this study to have been trained properly to use
assistive devices for daily activities. Therapists should still be sure
to follow the surgeon’s directions regarding hip precautions.40
Sirkka and Branholm examined life satisfaction in 29
Swedish older adults who suffered a hip fracture. Participants
reported a significant decline in their ability to perform hobbies
and social activities after their hip fracture and that these
activities were more important than self-care activities.57 Elinge
and colleagues also found that social interaction was affected
more than other areas of occupation for older adults who have
had a hip fracture. Therapists can use the results of these
studies to support addressing all areas of occupation and not
just ADL.26 By designing an intervention that targets the client’s prior performance patterns and emotional and social
needs, the occupational therapist can play a key role in the
client’s psychosocial adjustment to physical limitations and in
maximizing the client’s return to participation in meaningful
activities.
THREADED CASE STUDY
Mrs. Hernandez, Part 2
1. When completing the occupational profile, what additional information
would the occupational therapist need to gather during the evaluation
to supplement the information already provided in the case scenario?
Mrs. Hernandez’s occupational profile revealed that she has many roles
that she finds meaningful: grandmother, church member, and swimmer.
She also seems to value being independent. She not only does things
with her daughter and her family but also has interests and activities in
which she participates on her own. Supporting contextual factors include
an accessible home, a daughter nearby who involves her in many activities
with her children, and church friends who can offer some assistance.
Nonsupportive contextual factors include an inaccessible swimming pool
and the fact that she lives alone. Additional information that would be
useful to obtain from Mrs. Hernandez for the occupational profile includes
but is not limited to specific information about the arrangement of furniture
and other items in her home, how willing her daughter is to assist Mrs.
Hernandez with her needs or whether the daughter is already assisting
with some IADLs, prior surgeries or conditions that would impact the
current plan of care or lead to additional falls, history of falls, and equipment or home modifications already established. This information will aid
the occupational therapist in planning for discharge and specific equipment recommendations.
2. Identify important areas of occupation and performance skills to address
first when educating Mrs. Hernandez to safely perform her daily
activities.
Client factors that must be assessed before training Mrs. Hernandez to
perform her daily activities safely, including driving, are strength, ROM,
sensation, cognition, coordination, and pain. These factors will impact the
extent to which she will be able to engage in and learn the prerequisite
performance skills needed to optimize her independence in ADLs and
IADLs. The occupational therapist must first be sure that Mrs. Hernandez
understands the hip precautions and is able to recall them. Then the
occupational therapist must address her ability to move herself in and out
of bed and perform toileting functions while observing the hip precautions.
These prerequisite skills will prepare her for more advanced skills like
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CHAPTER 40 Orthopedic Conditions
1017
THREADED CASE STUDY—cont’d
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Mrs. Hernandez, Part 2
dressing, bathing, driving, and home management activities. Because she
lives alone, she needs to be able to complete all of her ADLs and IADLs
independently. The therapist should be sure to address the prerequisite
skills first and progress Mrs. Hernandez to more complex ADL tasks that
increase her confidence to return home and resume her typical occupations and performance patterns.
3. What prerequisite performance skills should be addressed with Mrs.
Hernandez before the occupational therapist directly addresses her
ability to drive again?
Because driving allows Mrs. Hernandez to get to her swimming classes,
church meetings, and her daughter’s home, this is placed as a priority in
SECTION 2: KNEE JOINT REPLACEMENTS
ETIOLOGY AND MEDICAL MANAGEMENT
Knee pain affects the mobility and functional performance of
many adults, often due to osteoarthritis in people aged 50 and
older. In fact, this knee pain and loss of function are the primary
reasons that some people elect to have knee joint replacements.42
Knee pain is often due to osteoarthritis or degenerative joint
disease, trauma or injury to the knee, or other rheumatic conditions and may be compounded by obesity or aging. Surgical
knee replacement may be chosen by individuals to alleviate
pain, increase motion, and maintain alignment and stability
of the knee joint when conservative treatment has failed.
Performance in occupations increases the likelihood of the
intended result.
The process of knee replacement involves cutting away the
damaged bone (as little bone as possible) and attaching prosthetic components of a new joint.61 Various types of prostheses
are used, depending on the severity and region of knee damage
(Figs. 40.9 and 40.10). A partial or unicompartmental knee
FIG 40.9 Knee prosthesis. (From Black J, Hawks J: Medical
surgical nursing: clinical management for positive outcomes,
ed 8, St. Louis, 2009, Elsevier.)
the list of problems, and she verbalizes that this issue is most important.
Mrs. Hernandez should have demonstrated relative independence in different types of transfers, especially car transfers, before she considers
driving again. It is important that she obtain medical clearance from
her physician or surgeon before resuming driving activities. The occupational therapist can assist her in identifying other community mobility
resources available to her until she resumes driving and can complete
other assessments directly related to driving, such as an off-road driving
assessment.
arthroplasty (UKA) is indicated if there is medial or lateral
compartmental damage between the femur and tibia. The UKA
is often placed with a minimally invasive technique, which
allows greater knee flexion (up to 90 degrees) more quickly after
surgery.51 Because limited ligaments and structures of the joint
are disrupted, increased stability is obtained immediately.44
Total knee replacement, or total knee arthroplasty (TKA), is
indicated when two or more compartments of the knee are
damaged. Various prosthetic devices are chosen based on the
medical condition and activities performed by the client.36 A
fixed weight-bearing prosthesis allows only flexion and extension of the knee, as the polyethylene tibia insert is locked into
the tibial tray.54 A rotating platform prosthesis, or mobile
weight-bearing prosthesis, allows the slight rotation normally
available at the knee, as the tibial component is not locked. This
allows for more normal function at the knee, but it has a slightly
higher risk of mechanical failure.54 The rotating platform is
typically used for younger, more active people, or for women,
as they typically have more rotation available at the knee than
men.31 Both types of prostheses typically decrease pain, improve
functional mobility, and enhance quality of life for individuals
with degenerative knee conditions. They can be put in place
with various surgical techniques, including minimally invasive
approaches, in which there is less damage to the quadriceps
tendon and the medial collateral ligament, which may improve
range of motion at the knee and lead to faster postoperative
recovery.59 The prosthesis can be cemented to the bone with
acrylic cement or not cemented. With a cemented prosthesis,
clients are usually able to bear weight as tolerated on the operated leg. With a noncemented prosthesis, initial weight bearing
is usually avoided or restricted. The choice to use cement to
hold the prosthesis in place is typically based on the preference
of the surgeon. However, the noncemented procedure requires
that the client does not have any other health issues that would
slow bone growth, which would extend the time frame for
restricted weight bearing.
Clients typically start out-of-bed activities on the first day
after surgery, pending the physician’s approval and with appropriate assistance or supervision. An ambulatory device, such as
a walker or crutches, may also be used for greater stability. If
the knee joint is unstable following surgery for any reason, the
physician may indicate that a knee immobilizer or other brace
should be used to preserve knee joint alignment (Fig. 40.11).
The client should avoid excessive rotation at the knee for up to
12 weeks after surgery. There is usually no restriction on flexion
and extension of the knee. In fact, maintaining the mobility of
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PART VI Intervention Applications
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Femur
LCL
MCL
Metal
Plastic
Button
Metal
CL
Fibula
Tibia
FIG 40.10 Total knee replacement. The metal aspects of the prosthesis cover the distal portion
of the femur and the end of the tibia. There is a polyethylene plastic-bearing surface (plastic)
between the metallic aspects of the two surfaces. The patella is replaced by a polyethylene
button. The medial collateral ligament (MCL), lateral collateral ligament (LCL), and cruciate ligaments (CL) are retained. (From Early MB: Physical dysfunction: practical skills for the occupational
therapy assistant, ed 3, St. Louis, 2013, Mosby; modified from Calliet R: Knee pain and instability,
ed 3, Philadelphia, 1992, FA Davis.)
the knee is important to ensure adequate mobility during
healing, and to regain normal motion and function.14,25,38,50
Some surgeons recommend the use of a continuous passive
motion (CPM) device to provide slow, controlled movement
with the intent of improving functional range of motion and
reducing postsurgical edema, although there is limited evidence
of the long-term effectiveness of the CPM machines.7,10,25
SPECIAL CONSIDERATIONS FOR KNEE
REPLACEMENTS
FIG 40.11 A knee immobilizer is used to support and stabilize
the knee joint during mobility. (From Ignatavicius D, Workman
ML: Medical-surgical nursing: patient-centered collaborative
care, ed 8, St. Louis, 2016, Elsevier.)
As with hip replacements, individuals with joint changes that
result in increasing pain may have multiple joint involvement
(ie, both knees). Some clients opt to have two joints replaced
during the same hospitalization, either during the same surgery
or with procedures 3 to 7 days apart. This can complicate the
rehabilitation process because the client will not be able to rely
on the nonoperated leg when walking, transitioning between
seated and standing positions, and performing daily occupations. However, it eliminates the need for an additional hospitalization if both knees are affected. The orthopedic surgeon
should discuss these options with the client to determine the
most appropriate course of action.
It is important for the occupational therapy practitioner to
be aware of complications or special procedures that occurred
during a client’s surgery and to verify precautions or risks with
the physician. Surgeons will make specific recommendations
based on the client’s particular situation, surgical procedures
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CHAPTER 40 Orthopedic Conditions
1019
used, or postoperative concerns. Common complications
include dislocation of the prosthesis, degeneration of parts,
fracture of bone next to implanted parts, loosening of prosthetic
parts, and infection of the joint after surgery.22
Some clients describe postsurgical pain that is more significant following total knee replacement as compared to total hip
replacement. This is often managed with medications, such as
epidural or periarticular anesthetics, patient-controlled analgesia, oral analgesics or opioids, or peripheral nerve blocks,
although side effects and effectiveness vary with individual
clients.27 Other methods of pain control amenable to use by
rehabilitation professionals include the use of superficial cold
modalities, proper positioning during transitional movements,
use of CPM machines after therapy if approved by the physician, and balance of rest and activity.
As with hip replacement, the emphasis in rehabilitation is
on maintaining or increasing joint motion, slowly increasing
the strength of surrounding musculature, decreasing swelling,
and increasing the client’s independence and participation in
areas of occupation, particularly ADLs. The occupational
therapist’s role in this process is primarily to educate the client
who has undergone joint replacement about applying adaptive
techniques for ADLs and IADLs with limited mobility while
maintaining any joint precautions for movement or weight
bearing.
• Continuous passive motion (CPM) machine. This mechanical
device supports a joint and can be set to move slowly through
a designated range of motion to promote controlled movement in the operated joint.
Medical Equipment
Following the occupational profile, an assessment of the motor,
cognitive, social, and emotional factors is recommended, specifically as they relate to occupational performance. Performance
of motor skills such as upper extremity (UE) ROM, muscle
strength, sensation, and coordination must be assessed to
determine if any adaptations should be made to functional
mobility or use of adaptive equipment. Mental functions such
as memory, problem solving, and sequencing must be considered in light of potential precautions, safety awareness, and
performance of occupations. Activities of daily living and other
relevant occupations should be evaluated through standardized
assessments, direct observation, or interview as the context and
client condition allow. The skilled occupational therapist should
be able to identify if social or emotional concerns are present,
including pain, fear of falling, hesitation to resume normal
activities, or concerns about surgical healing.
OT intervention planning requires careful consideration of
evaluation data and clinical reasoning skills to determine how
the specific client’s needs and concerns can be addressed
through a program of functional activities that gradually
enables a person to resume meaningful occupations. The therapist introduces and trains clients in the use of assistive devices,
proper transfer techniques, and ADL and IADL techniques
while ensuring safe positioning of the knee and prosthetic
components. Discharge planning should be considered early, as
many clients are able to return home within a few days if ADL
and IADL function can be restored. Clients who need additional
rehabilitation to regain occupational performance, who have
limited community support, and with inhibitory contexts may
be recommended for inpatient rehabilitation after the acute
hospital stay.
The OT practitioner should be familiar with the following
equipment that is commonly used in the treatment of knee
replacement:
• Hemovac. During surgery, a plastic drainage tube is inserted
at the surgical site to assist with postoperative drainage of
blood. It has an area for collection of drainage and may be
connected to a portable suction machine. The unit should
not be disconnected for any activity because this may create
a blockage in the system. The Hemovac is usually left in place
for 1-2 days after surgery.
• Commode chairs. The use of a commode chair instead of the
regular toilet aids in safe transfers and allows the client to
limit flexion of the knee during toileting.
• Sequential compression devices (SCDs). SCDs are used postoperatively to reduce the risk of deep vein thrombosis. They
are inflatable, external leggings that provide intermittent
pneumatic compression of the legs.22
• Antiembolus hose. This elastic hosiery may be extended up
to the knee or over the knee and on the thigh, depending on
physician preference They are worn 24 hours a day and
removed only during bathing. Their purpose is to assist
circulation, prevent edema, and thus reduce the risk of deepvein thrombosis.22
• Patient-controlled administration IV. Patient-controlled
analgesia (PCA) is delivered through an IV; patient controlled epidural analgesia (PCEA) is delivered through an
epidural line. A prescribed amount of medication is programmed by the physician and nursing staff to allow the
client to self-administer pain medication by pushing a button
to inject a safe amount. When dosages have reached a limit,
the machine will not administer medication even if the
button is pushed.
• Incentive spirometer. This portable breathing apparatus is
used to encourage deep breathing and prevent the development of postoperative pneumonia.
ROLE OF OCCUPATIONAL THERAPY FOR CLIENTS
WITH KNEE JOINT REPLACEMENT
After a knee replacement, OT typically begins on the first postoperative day, but there may be some variation depending on
the general health of the client and on the physiologic response
to surgery. Before any physical assessment, it is important to
introduce and explain the role of OT and complete an occupational profile. This profile involves gathering information
regarding the client’s occupational history, prior functional
status in ADLs and IADLs, descriptions of performance contexts
(eg, home environment and social support available), and the
client’s goals. The goal of OT is for the client to maximize
performance of daily occupations, with all movement precautions observed during activities. This often involves improving
activity tolerance, addressing functional mobility, and providing education in the use of adaptive equipment.21 The role of
the occupational therapist and assistant is to teach the client
ways and means of performing daily occupations safely.35
Evaluation and Intervention
Specific Training Techniques for Participation
in Occupations
Following any type of knee replacement, the occupational
therapist should encourage weight bearing as specified by the
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1020
PART VI Intervention Applications
surgeon, and knee flexion and extension as allowed by pain level
and surgical outcomes. It is encouraged that the leg be supported by the occupational therapist when a client is moved
from sitting with the legs elevated—for example, in a recliner
or geri-chair—to seated with feet on the floor in preparation
for transfers or standing. Clients may also be encouraged to
participate in deep breathing and relaxation as methods of pain
control.
Bed Mobility
The supine position is recommended when the client is resting
in bed, with the knee fully extended. Although it is acceptable
for a small towel or bolster to be placed under the knee to allow
slight flexion for pain control periodically, the client is encouraged to keep the knee extended and the hip in a neutral position
when sleeping. This encourages full extension that will be
needed for ambulation. A knee immobilizer or other supportive
brace can be used if indicated by the physician. As in hip
replacement, a pillow or wedge can be placed between the legs
if this is necessary for side-lying and if the person lies on the
nonoperated side. A CPM machine may be used for several
hours a day following surgery to facilitate recovery and increased
range of motion,33 and the client must use this in a supine
position. However, use of the CPM machine is often discontinued prior to returning home, when more activities are resumed.
To enter or exit the bed, clients can move freely and specific
techniques can be identified according to client preferences.
There are no restrictions that dictate bed mobility procedures.
Transfers
Typically, the client can bend freely at the hips if only the knee
has been replaced, and this motion may compensate for
the more painful knee ROM, often in flexion. Armrests are
generally helpful and allow better upper extremity support
for the transitions between sitting and standing on a postoperative knee.
Chair or commode chair. To move from standing to sitting,
the client is instructed to back up to the chair, extend the operated leg forward, reach back for the armrests, and slowly lower
to the sitting position. To stand, the client extends the operated
leg and pushes up from the armrests. Once standing, the client
can reach for an ambulatory aid, such as a walker if it is being
used. As in hip replacement procedures, low chairs, soft chairs,
reclining chairs, and rocking chairs should be avoided.1 If a
client has bilateral knee replacements, it may be uncomfortable
to flex either knee to promote the sit-to-stand transitions. In
this case, to move from standing to sitting, the client again backs
up until he or she feels the back of the chair, then takes a small
step forward with both feet. Then the client reaches back for the
armrests and gently lowers the body onto the chair, slowly
advancing the feet forward if necessary until a seated position
is achieved. To move from seated to standing, both feet are
placed slightly forward and the arms are used to raise the buttocks off the chair. Then the client can flex forward at the hips
and slowly move the feet back toward the chair until the lower
extremities are fully supporting the body. Only then should the
client release the armrests and reach for a walker or other
ambulatory device placed in front of him or her. Three-in-one
chairs are often recommended for use, as they can be placed
over a toilet in order to raise the height and provide armrests,
thereby improving safety during transfers. In addition, the
three-in-one can be used as a stand-alone commode if
necessary when the home environment does not support easy
access to a bathroom on all levels of the home. Comfort height
toilets (17-inch seat height) can be considered for a permanent
modification at home that can allow for easier transfers to
the toilet.
Shower stall. Nonskid strips or stickers are recommended in
all shower stalls and tubs. Several methods are possible for
movement in shower stalls, and the occupational therapist
should problem-solve with the client to determine which
method is safest. As in the hip replacement methods, the walker
or crutches may go first, then the operated leg, and then the
nonoperated leg. An alternate method to enter the shower stall
is to back up to the edge or rim of the shower while using the
walker for balance, then stepping into the shower while looking
down at the feet and shower rim for safety. Installation of a
shower chair with adjustable legs or a stool and grab bars is
strongly encouraged to help the client maintain balance and
preserve endurance.
Tub shower (without shower doors). As in the method for hip
replacements, the client is prohibited from taking a bath sitting
on the floor of the tub, as this action puts the client at severe
risk of causing damage to the knee when transitioning to or
from the tub floor. Although a tub seat can be used as in the
hip replacement techniques, it is not necessary, as hip flexion is
permitted after a knee replacement. To maintain balance during
the transfer, it is recommended that the client stand next to the
tub, with the hands placed on the short wall of the head or foot
of the tub. Then by flexing the hip and knee, or alternately by
extending the hip and knee, the client can side-step into the tub
while using the upper extremities to maintain balance (Fig.
40.12 ). A grab bar may be added for safety as needed.
Car. Bucket seats in small cars should be avoided. Benchtype seats are recommended. The client is instructed to have a
helper move the front passenger seat back as far as it will go.
Then the client is instructed to back up to the seat, hold onto a
stable part of the car, extend the operated leg, and slowly sit in
the car. The client is able to lean forward at the hip for clearance
of the upper body and head as they move into the car. The
upper body and LEs move as one unit to turn to face the
forward direction. Prolonged sitting in the car should be
avoided. If transferring to the front passenger seat is a problem,
transferring to the back seat of a four-door car is an alternative.
The client backs to the seat, extends the operated leg, and slowly
sits in the car. Then he or she slides back so that the operated
leg is resting on the seat, fully supported. Clients should not
return to driving until given permission by their surgeon, even
if the operated leg is not the leg used for operating the controls.
Sports utility vehicles, vans, or trucks typically have higher seats
and may make the transfers easier for some clients.
Lower-Body Dressing and Bathing
The dressing of lower extremities presents a problem only if the
client is unable to reach his or her toes, which is usually done
by leaning forward at the hips or raising the feet onto a footstool.
If necessary, the techniques described for hip replacement can
be used, including the use of adaptive equipment. The client
should also be instructed in donning and doffing the knee
immobilizer or other brace, if used. The client should be cautioned to prevent torque or rotation at the knee joint when
dressing by not twisting the body or leg while bearing weight
on the operated leg. Clients can take a sponge bath in the initial
stages of recovery and typically are not approved to shower until
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CHAPTER 40 Orthopedic Conditions
1021
FIG 40.12 Tub transfers following knee replacement.
the margins of the incision have healed,2 approximately 7 to 10
days after the surgery. Showering may be permitted if a waterproof dressing covers the incision.
SECTION 3: SHOULDER JOINT REPLACEMENTS
Homemaking
Homemaking and caregiver training follow the same procedures
as for hip replacement techniques, although hip movement is
not restricted. Care should be taken when standing or sitting
for extended periods of time, to avoid prolonged static positioning of the knee and for pain management.
Mrs. Green, Part 1
Sexual Activity
Much like those with hip replacements, persons with a knee
replacement will have difficulty performing sexual activities in
their usual manner. It is recommended that they refrain from
sexual activity for a few weeks so that they maintain the movement precautions applicable to their condition.38 For clients
who have questions about the level of sexual activity allowed
during the healing process, the therapist may need to suggest
ways for the client to position the operated leg during sexual
activity to maintain precautions or to minimize discomfort.
Side-lying on the nonoperated side is one option. Clients with
knee replacements or weight-bearing precautions should refrain
from kneeling.38 Written information with diagrams can be
helpful when addressing such a personal issue.
Evidence Regarding Occupational Therapy Intervention
Occupational and physical therapies are typically initiated in
inpatient settings as soon as permitted by surgeons following
knee replacements. In fact, a greater intensity of post-op rehabilitation has been proved to enhance patient outcomes, including improved scores on standardized ADL assessments (ie,
Functional Independence Measure) in the areas of self-care,
transfers, locomotion, and cognition.5 Home care and outpatient rehabilitation are also important for the client who needs
continued support during recovery. Fewer days between discharge from the inpatient setting and the initiation of outpatient
services are associated with greater return of function and lower
pain levels.10
THREADED CASE STUDY
Mrs. Green is an 80-year-old with degenerative joint disease that is
affecting many of the joints in her body. She’s already had bilateral knee
replacements, and now her orthopedic surgeon says she would benefit
from a reverse shoulder replacement of her dominant right arm. Mrs.
Green lives alone and manages her self-care and most housekeeping
tasks independently. She has a housekeeper to do the heavy cleaning
once a month. She has made some modifications to her home so that
she does not need to reach very far—for example, she has moved the
microwave oven and most frequently used dishes and glasses to the
countertop. Additionally she moved her hanging clothes to the doorknobs in her bedroom and has a handheld showerhead. She uses a
reacher and long shoehorn when dressing. Mrs. Green drives and just
recently stopped working part-time. She keeps herself busy by visiting
with friends and knitting. She is an avid knitter, known to make beautiful
scarves and Christmas stockings for family members. This is the activity
that is most meaningful to her and the reason she has decided to go
ahead with the surgery.
The reverse shoulder replacement technique was chosen because the
muscles supporting the shoulder girdle were weak due to prior rotator
cuff problems. Mrs. Green received home-based therapy 2 days after
the surgery when she was discharged home. She had to rely on her
adult children to help care for her as well as her sister who came to live
with her for 2 weeks. Because of the postsurgery pain and movement
precautions, Mrs. Green had great difficulty completing self-care tasks,
bed mobility, and transfers. This frustrated her greatly, especially her
inability to perform toilet hygiene with her nondominant hand. The
majority of the therapy sessions were spent figuring out compensatory
strategies for Mrs. Green.
Eventually, Mrs. Green became stronger, and after 6 weeks the movement precautions were lifted and she was able to progress faster in her
physical rehabilitation. After about 4 months Mrs. Green was able to
resume all of her prior occupations, including knitting and driving. She
reports a lot less pain during activity but still has some range-of-motion
limitation, which she had been informed prior to surgery might not
improve to normal limits.
Continued
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PART VI Intervention Applications
THREADED CASE STUDY—cont’d
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Mrs. Green, Part 1
Critical Thinking Questions
1. What could Mrs. Green have done to better prepare for the surgery
knowing that her dominant hand/arm would be immobilized for
6 weeks?
2. How could the therapist utilize caregiver training in this case?
3. Identify self-care tasks that would pose a particular problem due to
her movement and weight-bearing precautions (no passive or active
shoulder extension or external rotation; no active movement in any
direction; only passive shoulder flexion and abduction to about 80
degrees allowed, non–weight bearing)
4. Mrs. Green did not have any movement precautions with her right
hand, wrist, or forearm. How could you enable Mrs. Green to use her
right hand as an assist (while it was still in the sling) during daily
activities without breaking her movement precautions at the
shoulder?
The shoulder complex is not a single joint, as functional
upper extremity use relies on consideration of the glenohumeral, acromioclavicular, sternoclavicular, and scapulothoracic
joints (Fig. 40.13). Musculature acts upon the joints to allow
complex movements of the shoulder in elevation and depression, retraction and protraction, and rotation of the scapula, as
well as flexion, extension, rotation, and horizontal movements
typically measured at the glenohumeral joint. The occupational
therapist must carefully analyze shoulder dysfunction to determine the potential deficits, to develop interventions, to protect
the joints, and ultimately to promote and facilitate upper
extremity function during occupations.
Just as osteoarthritis has been described as a contributor to
pain that often leads to hip or knee replacement, this orthopedic
condition can also contribute to shoulder pain and dysfunction.
Other inflammatory or anatomic conditions, biomechanical
forces that may cause damage to the shoulder complex, or
proximal humerus fractures are often sources of shoulder pain
and dysfunction.11,28 Conservative medical treatments may
include oral or injected drugs designed to decrease pain and
inflammation.34 In addition, therapeutic exercise and activity
modifications may be used to control pain and promote function. In this chapter, only conditions that may result in various
types of shoulder replacements will be considered due to the
need for rehabilitation following these surgical interventions.
ETIOLOGY AND MEDICAL MANAGEMENT
The type of damage to the shoulder complex typically dictates
the type of medical intervention by the orthopedic physician.
People who suffer a humeral fracture typically undergo a hemiarthroplasty or humeral head replacement. In this procedure,
the humeral head and fractured area are removed and replaced
with an endoprosthesis. A total shoulder arthroplasty (TSA),
also referred to as a total shoulder replacement (TSR), is more
Acromioclavicular
joint
Clavicle
Coracoid
process
Acromion
Coracoacromial
ligament
Subacromial
bursa
Supraspinatus
tendon
Subscapularis
tendon
Greater
tubercle
Lesser
tubercle
Bicipital
tendon
Biceps
muscle
(long head)
Scapula
Subscapularis
muscle
Glenohumeral
joint
FIG 40.13 Shoulder complex. (From Miller MD, Hart J, MacKnight JM: Essential orthopaedics.
Philadelphia, 2010, Saunders. Adapted with permission from Anna Francesca Valerio, MD.)
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CHAPTER 40 Orthopedic Conditions
1023
FIG 40.14 A, Total shoulder arthroplasty. B, Reverse shoulder arthroplasty. (By permission of
Mayo Foundation for Medical Education and Research. All rights reserved. Copyright The Mayo
Clinic, 2014.)
often performed for a person with degenerative or inflammatory conditions such as osteoarthritis (Fig. 40.14). In this procedure, the humeral head is replaced by a ball-shaped prosthesis
and the glenoid is resurfaced or replaced with a prosthetic
component.34 A reverse total shoulder arthroplasty (RTSA), also
referred to as a reverse total shoulder replacement (RTSR), is
indicated for patients with a degenerative or inflammatory
condition present in the shoulder complex, but also with some
involvement or deficiency of the rotator cuff. In some cases, this
procedure is also used when a revision of a traditional TSA is
required. When the rotator cuff is extremely weak or damaged,
the muscles are unable to effectively support the newly repaired
joint so a reverse technique is indicated. In the RTSA, the ball
and socket of the glenohumeral joint are reversed; the semicircular ball is placed in the glenoid and a polyethylene cap is
implanted into the humerus. In this procedure, good deltoid
function is needed to stabilize the joint without as much reliance on rotator cuff muscles for support.6,34,53
All of these procedures are expected to eventually decrease
the patient’s pain, improve functional use of the shoulder over
time, and enhance quality of life.34 However, when compared
with the hemiarthroplasty or replacement of the humeral head,
the TSA typically has greater range of motion results and higher
patient satisfaction ratings as well as a decreased need for revisions, as further glenoid wear is not a factor.49 The most common
postoperative complications for any of the shoulder surgeries is
loosening of the glenoid component, loosening of the humeral
component, glenohumeral joint instability, or rotator cuff tears.
These complications have an incidence of only about 10% to
16% in the 3 to 5 years after surgery and approximately 22% in
the 10 to 15 years after surgery.29,58 Full shoulder ROM is not
typically achieved with shoulder replacements, but the pain
relief and moderate increases in ROM make the surgery
worthwhile for many individuals. A typical prosthesis will last
15 to 20 years in the majority of patients, depending on the
particular conditions of the patient and how the joint is used
or protected.34
SPECIAL CONSIDERATIONS FOR SHOULDER
JOINT REPLACEMENTS
Because orthopedic concerns and surgical techniques may vary
among surgeons, so also will the particular postoperative precautions. The occupational therapist should be familiar with the
procedures and should communicate openly with the surgeon
to ensure movements of the shoulder that promote patient
safety, prevent complications, and progress function as efficiently as possible.
In the initial postoperative phase, soft tissues that surround
and support the joint must be preserved for healing, and the
glenohumeral joint must be maintained in the appropriate
anatomic position. Pain and inflammation are controlled as
prescribed by the physician. As with those who have had total
hip and knee replacements, the client is provided with a pain
medication regimen that provides a consistent level of pain
relief to allow full participation in the rehabilitation program.
Although active range of motion is encouraged in the joints of
the elbow, wrist, and hand, only passive range of motion is
permitted in the shoulder joint and only for motions specified
by the surgeon. Activities of daily living should be restored, but
typically in compensatory or adaptive patterns as the operative
shoulder should not have undue resistance placed on it.
A shoulder sling is typically used for 3 to 4 weeks following
shoulder surgery, which is worn when the patient is moving or
sleeping (Fig. 40.15). A swathe (a long, wide strap that encircles
the arm in the sling and the trunk) may also be prescribed to
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PART VI Intervention Applications
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ROLE OF OCCUPATIONAL THERAPY FOR CLIENTS
WITH SHOULDER JOINT REPLACEMENT
As in the other types of joint replacement, occupational therapy
typically begins on the first postoperative day if there is no
adverse response to the surgery. Introduction of the role of OT
and expected types of interventions should precede the gathering of data for the occupational profile. In shoulder replacements, it is vital to understand hand dominance and how this
may influence occupational performance, especially if the
dominant hand is on the side of the surgical intervention. The
goal of OT is for the client to maximize performance of daily
occupations, but therapeutic exercise and activities must be
advanced carefully in consideration of movement precautions
and typical patterns of upper extremity use in occupations.
Shoulder use is carefully advanced in the 12 weeks following
surgery, but full recovery of function may take up to
9 months.4,9,19,63
Evaluation and Intervention
FIG 40.15 Sling with the swathe. (Courtesy North Coast
Medical, Inc., Gilroy, CA.)
BOX 40.3
Precautions
Total Shoulder Replacement
No weight bearing through surgical upper extremity
No lifting more than 1 to 2 lbs with surgical upper extremity
Avoid shoulder extension past neutral
Avoid shoulder abduction past 45 degrees
Avoid shoulder external rotation past 30 degrees
Avoid internal rotation past 60 degrees
Limit shoulder PROM in flexion to approximately 90 to 100 degrees
provide extra support and protection for the arm and to prevent
prohibited movement. These may be removed for therapeutic
activities and when seated with the upper extremity in a supported position (with the humeral head approximated in the
glenoid fossa). The sling (and swathe) should be worn during
functional activities, during ambulation, and when sleeping to
preserve the shoulder joint position. For approximately 6 to 8
weeks, patients may not bear weight on the operated upper
extremity, may not lift items weighing more than 1 to 2 pounds
with the operated upper extremity, and should avoid the following motions: shoulder extension past neutral, shoulder
abduction past 45 degrees, external rotation past approximately
30 degrees, and internal rotation past approximately 60 degrees.
They may not participate in any resistive activities in internal
or external rotation. When sleeping, a pillow or towel roll
should be placed under the scapula or elbow as needed for
comfort to ensure that the shoulder in supported in the front
of the body and in adherence to the precautions (Box 40.3).
Pain management is usually achieved in the postoperative
phase with patient-controlled anesthesia, which can be administered through an epidural line or a pump with a line inserted
into the surgical site. This can be supplemented with superficial
cold therapies, movement restrictions and sling wear, and
activity modification. After a few days, the anesthesia lines
are replaced with oral analgesics or anti-inflammatory
medications.
Following the occupational profile, an assessment of the motor,
cognitive, social, and emotional factors is recommended, specifically as they relate to occupational performance. Upper
extremity assistive range of motion (AROM) and muscle
strength can be tested in joints of the elbow, wrist, and hand.
However, movement, weight bearing, and resistance precautions must be observed in the shoulder in the postoperative
phase. Only gentle, controlled passive range of motion (PROM)
should be conducted in all shoulder movements. Sensory function and coordination are assessed distally as well, although
analgesics inserted through joint or epidural catheters may
mask sensory abilities for a few days after surgery. Mental functions such as memory, problem solving, and sequencing must
be considered in light of precautions, safety awareness, and
performance of occupations. Activities of daily living and other
relevant occupations should be evaluated through standardized
assessments, direct observation, or interview as the context
and client condition allow. Social or emotional concerns may
include fear of participation in appropriate therapeutic exercise,
hesitation to resume normal activities, or concerns about surgical healing.
OT intervention planning will focus on the following two
primary areas: (1) appropriate therapeutic exercise and resuming normal occupations and (2) primarily routines involving
activities of daily living and instrumental activities of daily
living. Therapeutic exercise must be designed to promote controlled movement within precautions so that eventual return of
full upper extremity function is possible, avoiding long-term
complications of adhesive capsulitis, soft tissue contractures, or
bony abnormalities such as heterotopic ossification. Occupations may need to be modified during healing to promote the
client’s active participation while advancing shoulder use
appropriately. Performance in both of these areas will be used
to determine discharge planning and consideration of inpatient
rehabilitation or home and outpatient care.
Therapeutic Exercise Considerations
Total Shoulder Replacement
In the immediate postoperative phase, patients are permitted to
perform active assistive range of motion (AAROM) and PROM
only of the shoulder in protected ranges. Passive range of
motion is typically limited to 90 degrees of shoulder flexion, 45
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CHAPTER 40 Orthopedic Conditions
1025
FIG 40.16 Codman’s (pendulum) exercises.
degrees of shoulder abduction, and extension only to neutral.
Specific surgical precautions should be followed related to
internal and external rotation, but clients are typically permitted to lay the hand across the abdomen in internal rotation, to
about 30 degrees of external rotation. Codman’s pendulum
exercises may be initiated on the first postoperative day. After
removal of the sling, the client is instructed to bend forward by
flexing at the hips, allowing up to 90 degrees of passive shoulder
flexion, with the arm hanging perpendicular to the floor. The
nonoperated upper extremity should rest on a counter or
tabletop surface, and a wide base of support with the feet should
be maintained to avoid a risk of falls. By shifting the body
weight, the arm may passively move in anterior-posterior
motions, lateral motions, small clockwise circles, and small
counter-clockwise circles (Fig. 40.16).52 Depending on the
surgeon’s preference, distal AROM should also be performed
several times daily to avoid distal edema and to promote functional hand use. Over the next 2 to 4 weeks, larger PROM ranges
may be initiated at the shoulder. These may include table slides,
in which the client sits next to a table with the operated UE
supported on the table, and he or she slowly leans forward and
allows the shoulder to passively flex. Some physicians allow
dowel exercises (the client holds a wooden dowel with both
hands) so that the nonoperated UE can be used to assist movement of the operated UE.
Approximately 4 to 6 weeks following the surgery, and if
PROM is gradually increasing and normal movement patterns
are observed, precautions related to movement may be relaxed.
Greater PROM is expected, but weight bearing and lifting are
still restricted. Active-assisted therapeutic exercise and carefully
executed overhead pulley exercises may be initiated. The therapist should assess glenohumeral and scapula-thoracic mobility
to ensure normal movement patterns. Light strengthening can
be initiated in the elbow, wrist, and hand joints in preparation
for greater functional use. Some physicians will allow for a light
weight to be added to Codman’s pendulum exercises. Shoulder
strengthening and full movement through all planes is typically
initiated 6 weeks postoperative. Monitored therapeutic exercise
to ensure return to full AROM and strength may continue from
the 6 weeks through several months as indicated.4,63
Reverse Total Shoulder Replacement
As for patients with a traditional total shoulder replacement,
these patients are permitted to perform AAROM and PROM
only of the shoulder in protected ranges in the immediate postoperative period. Passive range of motion is typically limited to
90 degrees of shoulder flexion, 45 degrees of shoulder abduction,
and extension only to neutral (see Box 40.3). Because there is
limited support of the rotator cuff, there should be no actions
that require reaching behind the back, which consists of combined shoulder adduction, extension, and internal rotation.6
Specific surgical precautions should be followed related to
internal and external rotation, but it is typically permitted for
the client to lay the hand across the abdomen in internal rotation,
to about 30 degrees of external rotation if the shoulder is slightly
flexed. Although therapy begins post-op day 1, Codman’s pendulum exercises (see Fig. 40.16) may only be performed with the
permission of the surgeon due to rotator cuff instability. PROM
only may be performed for the first 5 to 7 days post-op. Active
movement of the distal extremity should be delayed until all
anesthesia or nerve blocks that may have been used during
surgery for pain control have cleared the patient’s system and
good motor control returns. Approximately 5 to 7 days after
surgery, the patient may begin isometric exercise in the scapula
and shoulder and AAROM, up to 90 degrees of flexion and
abduction and up to 30 degrees of external rotation. AROM may
be initiated approximately 2 weeks post-op, as long as the glenohumeral joint remains stable and pain is managed. Table slides,
dowel exercises, and pushing items up an incline board may assist
in moving from AAROM to AROM. From weeks 2 to 6, gains are
expected in AROM, isometric control, and shoulder stability.
Light strengthening may begin in about week 6, although the
occupational therapist should carefully monitor progression,
and moderate strengthening may begin around week 12.9
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PART VI Intervention Applications
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Specific Training Techniques for Participation
in Occupations
Regardless of the type of surgical procedure performed, the
occupational therapist must ensure that the client is able to
safely and effectively participate in occupations. Basic activities
of daily living are typically addressed first within the parameters
of precautions and allowed movements. Ambulation is generally not affected by the shoulder replacement if balance is
functional and there are no other lower extremity problems;
however, significant adaptations may be needed for bed mobility, ADLs, and other areas of occupation. The occupational
therapist can encourage the patient to use the hand on the side
of the operated shoulder as a stabilizer or assist for light activities that do not require weight bearing or strength (eg, holding
toothpaste, buttoning lower buttons, stabilizing paper for
writing, or holding a washcloth while soaping it up with the
other hand).
Sleeping Positions and Bed Mobility
The sling (and swathe) is worn during sleeping, usually for the
first 4 to 6 weeks following the shoulder replacement. A pillow
or towel roll should be placed under the scapula or elbow as
needed for comfort to ensure that the shoulder is supported in
the front of the body, in slight flexion, and in adherence to the
precautions. When entering or exiting the bed or when changing positions in bed, the client may roll over the nonoperated
shoulder only. The client may need to adjust sleep arrangements
to allow for optimal bed mobility that protects the operated
shoulder. Core and lower extremity strength and positioning
may support movement to and from the bed, but for clients
who do not have this level of strength, care must be taken that
clients do not use the operated arm to push themselves up. Bed
ladders or pulls, bed rails, or leg lifters may be needed to assist
with bed mobility. Bed mobility routines including those associated with going to the bathroom at night should be addressed
to anticipate problems that might arise around providing a safe
path to the bathroom, managing clothing and hygiene at the
toilet, getting back into bed, and adjusting the aforementioned
pillows or towel rolls. (See Chapter 10 for additional ADL and
IADL suggestions.)
Functional Mobility
If a cane was required prior to the surgery, it should be used
with the nonoperated UE only. Physical therapy practitioners
typically address balance, ambulation, and gait with the client.
If a cane is needed, the occupational therapist should ensure its
safe use during homemaking tasks or other instrumental activities of daily living. Use of the operated UE should also be
avoided during transfers to avoid weight bearing.
Upper-Body Dressing and Bathing
Clothing should be chosen for ease of dressing and with consideration of sling wear. Button front shirts will be easiest to use
for dressing, though oversized tops made of stretchy material
may also be suitable. The client should sit while dressing and
bend forward at the waist to promote passive flexion of the
shoulder while extending the elbow to put the operated arm in
the sleeve first. Once this sleeve is pulled onto the upper extremity and the client returns to sitting upright, he or she can reach
around the back to pull the shirt to the other side and to reach
to slide the nonoperated arm into the other sleeve. The client
can use the hand of the operated shoulder to stabilize and assist
in buttoning the shirt. Women should use a bra with the closure
in the front so it can be managed like the button-front shirt.
The occupational therapist should also ensure that the client is
aware of how to put the sling on and off over the clothing.
Additional adaptations to clothing or technique may be needed
for the client who also has limited shoulder motion on the
nonoperated side, as there typically is bilateral joint involvement with osteoarthritis.
For bathing, the sling is removed and a sponge bath can be
completed when the client is seated. A rolled towel can be used
to support the arm when bathing while seated. A waterproof
dressing should be placed over the surgical site if the client will
shower during the first week after the surgery. Once sutures or
staples are removed, the client can shower normally. Precautions should be maintained during bathing, no matter what
method is used. A long-handled sponge may help the client
reach the back using the nonoperated arm.
Lower-Body Dressing and Bathing
It is recommended that the client sit to pull on pants and
underclothes in order to maintain balance and avoid the need
to use the operated arm to brace the body during a potential
fall. Leaning forward in the seated position will also ensure that
precautions are maintained. Again, clothes should be chosen for
ease of dressing; for example, slip-on shoes will prevent the
necessity of tying shoes.
Homemaking
Following shoulder replacements, ambulation is typically unaffected. However, homemaking will need to be done with the
shoulder in the sling for the first few weeks. The nonoperated
arm can be used primarily for cooking and homemaking, and
lifting should be limited in accordance with precautions. A few
pieces of adaptive equipment may be helpful, such as a rocker
knife or pan stabilizer. The occupational therapist should
analyze how the client typically performs household activities
to determine if adaptive equipment or compensatory techniques
should be used to protect the operated shoulder.
Evidence Regarding Occupational Therapy Intervention
Limited evidence exists that examines specific occupational
therapy interventions for people with a shoulder replacement.
However, researchers have examined the quality-of-life and
return-to-prior-activity levels for this population. Zarkadas and
colleagues collected data from patients on their activity level after
having their shoulder replaced with a total replacement technique or a hemiarthroplasty. Patients reported having the most
difficulty with overhead activities, combing/curling their own
hair, washing/drying the back, sleeping on the operated side, and
dressing/undressing, as well as other leisure activities.64
Boardman and colleagues evaluated the effectiveness of a
home-based exercise program for 77 individuals after shoulder
replacement.8 Because most patients return to the home setting
within a few days of the surgery, much of the rehabilitation
occurs either at home or in an outpatient therapy program. The
researchers found that a sequence of exercises, progressing from
active hand, forearm, elbow motion, and passive shoulder
motion to using a pulley, then a wand or cane exercises, isometric exercises, and ending with Thera-Band exercises, produced
good outcomes, with 70% of patients maintaining motion
gained during the surgical procedure without causing softtissue healing complications.8
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CHAPTER 40 Orthopedic Conditions
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These studies support intervention priorities that address
participation in daily activities, especially self-care tasks, and
provide thorough training in home exercises that will help the
patient maintain movement precautions and prevent soft-tissue
complications while allowing for the maximum functional
ability during the healing process.
THREADED CASE STUDY
Mrs. Green, Part 2
1. What could Mrs. Green have done to better prepare for the surgery
knowing that her dominant hand/arm would be immobilized for
6 weeks?
It is likely that Mrs. Green was seeing either an occupational therapist
or a physical therapist before deciding to have her shoulder replaced.
The therapist was aware of her prior knee replacements and the assistive devices she already used. Mrs. Green could be directed to practice
using the assistive devices she already had with her nondominant arm
for completing ADL and IADL tasks. Additionally, the therapist could
have provided her with information or suggested she attend a preoperative class to learn tips for postsurgery activity.
2. How could the therapist utilize caregiver training in this case?
Unlike lower extremity joint replacements, when an individual’s arm
is immobilized, especially the dominant arm, the ability to perform daily
activities can become impossible and a caregiver is needed. It is important to prepare clients for shoulder replacement surgery so that a
caregiver can be identified before the surgical procedure in order to best
prepare him or her for assisting the client. Caregivers can be taught the
movement and weight-bearing precautions as well as any home exercises that should be performed daily. Caregivers need to learn ways to
assist the client during mobility (eg, bed mobility, transfers, and ambulation) so that he or she uses proper body mechanics and ensures
movement precautions are maintained. If the caregiver cannot be
trained prior to the surgery, it is important to incorporate this training
during postsurgery rehabilitation.
3. Identify self-care tasks that would pose a particular problem due to
her movement and weight-bearing precautions (no passive or active
shoulder extension or external rotation; no active movement in any
direction; only passive shoulder flexion and abduction to about 80
degrees allowed, non–weight bearing).
Mrs. Green would have problems with upper body dressing/bathing
because she might be tempted to actively move her arm to manage
clothing or to wash under her arms. Pulling up her pants/underwear
might be difficult if she is unable to pull up both sides evenly without
rotating her trunk and potentially extending her operated shoulder.
Because Mrs. Green is unable to use her dominant arm for self-care
tasks, she would likely use many compensatory movements with her
nondominant arm in her efforts to complete tasks that she did in a more
coordinated way with her dominant arm. This increases the potential of
performing active movement or passively moving the shoulder in directions that are not permitted.
4. Mrs. Green did not have any movement precautions with her right
hand, wrist, or forearm. How could you enable Mrs. Green to use her
right hand as an assist (while it was still in the sling) during daily
activities without breaking her movement precautions at the
shoulder?
Mrs. Green could use her right hand to stabilize objects (eg, small food
packages) while using her left hand to open the package and perform
some fine motor tasks (eg, screwing on the toothpaste top, buttoning
lower buttons). She could hold very lightweight objects (eg, pen, paper,
toothbrush) during transport.
SUMMARY
Hip fractures and hip, knee, and shoulder replacements are
orthopedic conditions in which OT intervention may speed the
client’s return to optimal participation in daily activities safely
and comfortably. OT evaluation and intervention begin with
1027
obtaining the client’s occupational profile and an assessment of
the emotional and social issues related to the surgery and the
surgery’s potential impact on the client’s lifestyle. Awareness of
and a sensitivity to the psychosocial challenges of the person
with an orthopedic problem are critical for the delivery of
optimal occupational therapy.
The protocol for other areas of OT intervention is determined
by the surgical procedure performed and by the precautions
prescribed by the physician. Clients who have weight-bearing
precautions must be trained to observe these safety measures
during all ADL and IADL routines. A simulation of the
home environment or a home assessment will prepare the
client for potential problems that may arise after discharge.
Areas to assess include the entry, stairs, bathroom, bedroom,
sitting surfaces, and kitchen. Recommendations to remove
throw rugs and slippery floor coverings and obstacles are
made because the client will most likely be using an assistive
device for ambulation. A kitchen stool or utility cart may be
indicated. It is important to assess and instruct the client and
caregiver regarding ADLs and IADLs with adaptive equipment,
as well as any movement precautions. Home therapy may be
indicated after a hospital stay to ensure safety and independence in daily occupations if these goals were not met during
hospitalization.
In addition to the ADL and IADL strategies previously specified, the occupational therapist should be sure to address all
areas of occupation that may be difficult for the client, as well
as those that may pose a safety risk. Occupations such as caring
for a pet, navigating through a cafeteria for meals, traveling in
vehicles other than cars, and attending religious or other community activities that require specific transfers (ie, to a church
pew) are all examples of activities that may be part of a client’s
typical performance pattern and should be addressed by occupational therapy. The occupational therapist can assist the client
in approaching meaningful occupations safely, observing any
movement precautions that are required, and suggesting and
demonstrating alternative methods and assistive devices.
Preoperative teaching programs are invaluable in aiding
client adjustment. These classes familiarize clients with the
hospital, nursing, physical therapy, occupational therapy, and
discharge planning. Procedures and equipment, concerns
regarding hospitalization, discharge, and therapy are addressed.
Participation in this type of class has been shown to relieve
anxiety and fear, empower the client during the hospitalization,
and decrease the hospital length of stay.
REVIEW QUESTIONS
1. Explain the difference in precautions for the anterolateral
and posterolateral approaches for a hip replacement.
2. When a client is transferring from one surface to another,
what is the general procedure to follow to ensure the safety
and protection of the involved side?
3. List the most common types of adaptive equipment used
during rehabilitation of hip fractures and LE joint replacements, and describe their purpose.
4. Describe how the case coordinator and occupational therapist can work together to ensure a safe discharge for the
client.
5. List two specific suggestions for performing sexual activities for someone with a hip replacement.
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PART VI Intervention Applications
6. What information should be obtained when completing
the occupational profile?
7. Identify two factors that affect fracture healing.
8. Identify two ways an occupational therapist can address the
psychosocial adjustment to LE joint replacement and hip
fracture.
9. Why are weight-bearing precautions observed with
an ORIF?
10. Compare the rehabilitation techniques of clients with a hip
replacement to those of clients with a knee replacement.
11. What are the benefits of conducting client education preoperative classes for persons who are at risk for falls or who
are planning a joint replacement?
12. How might a person’s rehabilitation program be affected
by bilateral joint replacements?
13. How do shoulder precautions limit daily activities?
14. During what activities would the occupational therapist
suggest that a client wear a sling or swathe following a
shoulder replacement?
15. During what activities would the occupational therapist
suggest that a client opt not to utilize a sling following a
shoulder replacement?
16. Identify one key exercise that a person should perform
multiple times daily following a shoulder replacement.
How will you ensure client safety during this exercise?
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CHAPTER 40 Orthopedic Conditions
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