Ot For Orthopaedic Conditions

OCCUPATIONAL THERAPY FOR
ORTHOPAEDIC CONDITIONS
FORTHCOMING TITLES
Research Methods for Therapists

Avril Drummond
Group W ork in Occupational Therapy
Linda Finlay
Stroke: Recovery and Rehabilitation
Polly Laidler
Caring for the Neurologically Damaged Adult
Ruth Nieuwenhuis
HIV and Aids Care
S. Singh and L. Cusack
Speech and Language Disorders in Children
Dilys A. Treharne
Spinal Cord Rehabilitation
Karen Whalley-Hammell
THERAPY IN PRACTICE SERIES
Edited by Jo Campling
This series of books is aimed at 'therapists' concemed with rehabilitation in a

very broad sense. The intended audience particularly includes occupational
therapists, physiotherapists and speech therapists, but many titles will also be
of interest to nurses, psychologists, medical staff, social workers, teachers or
volunteer workers. Some volumes are interdisciplinary, others are aimed at one
particular profession. All titles will be comprehensive but concise, and practical
but with due reference to relevant theory and evidence. They are not research
monographs but focus on professional practice, and will be of value to both
students and qualified personnel.
1. Occupational Therapy for Children with Disabilities

Dorothy E. Penso
2. Living Skills for Mentally Handicapped People
Christine Peck and Chia Swee Hong
3. Rehabilitation of the Older Patient
Edited by Amanda J. Squires
4. Physiotherapy and the Elderly Patient
Paul Wagstaff and Davis Coakley
5. Rehabilitation ofthe Severely Brain-Injured Adult
Edited by fan Fussey and Gordon Muir Gi/es
6. Communication Problems in Elderly People
Rosemary Gravell
7. Occupational Therapy Practice in Psychiatry
Linda Finlay
8. Working with Bilingual Language Disability
Edited by Deirdre M Duncan
9. Counselling Skills for Health Professionals
Philip Burnard
10. Teaching Interpersonal Skills
A handbook of experientialleaming for health professionals
Philip Burnard
11. Occupational Therapy for Stroke Rehabilitation
Simon B.N Thompson and Maryanne Morgan
12. Assessing Physically Disabled People at Horne
Kathy Maczka
13. Acute Head Injury
Practical management in rehabilitation
Ruth Garner
14. Practical Physiotherapy with Older People
Lucinda Smythe et al.
15. Keyboard, Graphie and Handwriting Skills
Helping people with motor disabilities
Dorothy E. Penso
16. Community Occupational Therapy with Mentally Handicapped Adults
Debbie Isaac
17. Autism
Professional perspectives and practice
Edited by Kathryn Ellis
18. Multiple Sclerosis
Approaches to management
Edited by Lorraine De Souza
19. Occupational Therapy in Rheumatology
An holistic approach
Lynne SandIes
20. Breakdown of Speech
Causes and remediation
Nancy R. Milloy
21. Coping with Stress in the Health Professions
A practical guide
Philip Burnard
22. Speech and Communication Problems in Psychiatry
Rosemary Gravell and Jenny France
23. Limb Amputation
From aetiology to rehabilitation
Rosalind Ham and Leonard Cotton
24. Management in Occupational Therapy
Zielfa B. Maslin
25 .Rehabilitation in Parkinson's Disease
Edited by Francis /. Caird
26. Exercise Physiology for Health Professionals
Stephen R. Bird
27. Therapy for the Burn Patient
Annette Leveridge
28. Effective Communication Skills for Health Professionals
Philip Burnard
29. Ageing, Healthy and in Control
An alternative approach to maintaining the health of older people
Steve Scrutton
30. The Early Identification ofLanguage Impainnent in Children
Edited by James Law
31. An Introduction to Communication Disorders
Diana Syder
32. Writing for Health Professionals
A manual for writers
Philip Burnard
33. Brain Injury Rehabilitation
A neuro-functional approach
Jo Clark- Wilson and Gordon Muir Giles
34. Living with Continuing Perceptuo-motor Difficulties
Theory and strategies to help children, adolescents and adults
Dorothy E. Penso
35. Counselling and Psychology for Health Professionals
Edited by Rowan Bayne and Paula Nicolson
36. Occupational Therapy for Orthopaedic Conditions
Dina Penrose
Occupational Therapy for
Orthopaedic Conditions
DINA PENROSE
Head Occupational Therapist, Royal Orthopaedic Hospital,
Birmingham, UK
IU!ll Springer-Science+Business Media, B.V.

Distributed in the USA and Canada by Singular Publishing Group Inc., 4284 41 st Street, San Diego,
Califomia 92105
First edition 1993
© 1993 Dina Pemose

Originally published by Chapman & Hall in 1993.
Typeset in 10/12 point Times Roman by DSC Corporation Ltd., Comwall, England
ISBN 978-0-412-39370-9 ISBN 978-1-4899-3085-9 (eBook)

DOI 10.1007/978-1-4899-3085-9
Apart from any fair dealing for the purposes of research or private study, or criticism or review, as
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ANSIINISO Z 39 .48-199X and ANSI Z 39.48-1984
Contents
Acknowledgements x
Preface Xl
1. Rheumatoid arthritis
2. Total hip replacement 28
3. Other hip surgery 40
4. Knee surgery 53
5. Backpain 64
6. Spinal surgery 79
7. Shoulder surgery 89
8. Elbow surgery 99
9. The hand 106
10. Bone tumours 146
11. Pain control 171
12. Resett1ement 181
Appendix - Useful addresses 194

Index 201
Acknowledgements
I am indebted to many staff of all disciplines at the Royal Orthopaedic Hospital,

Binningham, for their help so willingly given during the preparation of this
book.
I wish to acknowledge the he1p given by medical staff in their particular areas
of interest: Mr C. Bradish (limb length discrepancy), Mr Simon Carter (bone
tumours), Dr P. Grigoris (hip and knee replacements and revision surgery) and
Mr M. Waldram (hand surgery). I also with to thank Mr J.C.T. Fairbank
(Nuffield Orthopaedic Centre, Oxford, fonnerly of the Royal Orthopaedic
Hospital) for his help with the section on low back pain and spinal surgery.
I am grateful to Lynda Gwilliam, occupational therapist at the Hand Unit,
Wrightington Hospital, Wigan, for her help with rehabilitation following sur-
gery to the hand and elbow in rheumatoid arthritis, and to Tina Dolan, occupa-
tional therapist at the Disablement Services Centre, Selly Oak, for her assistance
over wheelchairs and artificiallimbs. My thanks to Frances Burton, occupa-
tional therapist with Wiltshire Social Services (fonnerly ofthe Royal Orthopae-
dic Hospital) and to Jan Puddephatt, tutor at the West Midlands School of
Occupatiünal Therapy, für reading my first draft, and für their helpful sugges-
tions and comments.
Thanks are also due to Judy Dawson, Librarian at the Research and Teaching
Centre, Royal Orthopaedic Hospital, for übtaining reference works; the Medical
Illustration Department, Selly Oak Hospital, forprinting the X-ray photügraphs;
Mr R. Grimer (Consultant, Bone Tumour Service) für pennission to use the
illustrations ofbone tumour surgery; Josie Cardall for her help with the prelim-
inary typing and for being my general factotum throughout; and to Ann Weaver
for putting the manuscript on to a word processor.
Lastly I must record my gratitude to my husband Patrick, for his patience and
support, and for keeping me 'fed and watered' as I worked.
Dina Penrose
Binningham
Preface
This book is written with occupational therapy students in mind, as a guide to

newly qualified occupational therapists and for those returning to work after a
break in service. Over the years I have been asked many times by newly
appointed staffwhether I could recommend a book to prepare them for working
with orthopaedic patients. I hope this small volume will fill the gap in the
literature on the subject, and that it will be useful as a quick reference book. I
hope it mayaiso fall into the hands ofthose in other disciplines and enable them
to understand and appreciate the contribution of the occupational therapist to
the rehabilitation team.
This is the era ofjointreplacement, with ever-increasing demand forprimary
and revision surgery. Improved implants and improved surgical techniques are
constantly being researched. Surgery for bone tumour is less mutilating and
more hopeful than ever before. Operations to release tendons and soft tissue
contractures, tendon transfers, osteotomies, spinal fusion, joint fusion, etc. are
performed on patients with neurological problems, thus improving function and
appearance and preventing further deformity. These are some examples of
procedures in this exciting and fast-developing field, while hospital beds are
occupied for an ever shorter period of time and the potential for occupational
therapy is enormous. 'If surgery is to be successful, the importance of assessing
the patient as a human being cannot be over-emphasised' (Souter, 1987). This
is precisely the approach of the occupational therapist.
The reader is expected to be familiar with the anatomy and physiology of the
locomotor system. Background information on the conditions presenting for
elective orthopaedic surgery (i.e. operations planned in advance) is included, to
enable the reader to understand the processes which are taking place within the
patient's body and mind. Results of surgery are also presented to give an
informed overall picture.
While orthopaedics and trauma tend to be mentioned in tandem, it is not
within the scope of this book to include trauma, which is a vast subject in its
own right, requiring a companion volume.
For convenience I have used the personal pronoun 'he' when referrlng to the
patient or surgeon, and 'she' when referring to the physiotherapist or occupa-
tional therapist.
In an attempt to avoid monotonous repetition, I have used synonyms such as
joint replacement and arthroplasty, indwelling prosthesis and implant, and
elective and cold orthopaedic surgery.
REFERENCE
Souter, W.A. (1987) Surgical management of rheumatoid arthritis, in S.P.F.
Hughes, M.K. Benson and C. Colton (eds.) Orthopaedics: The principles and
practice of musculoskeletal surgery, Churchill Livingstone, Edinburgh.
1
Rheumatoid arthritis
Rheumatoid arthritis is a chronic, inflammatory, systemic disease, affecting

multiple joints and characterized by periods of exacerbation and remission. The
smalljoints are usually affected first, andjoint involvement is usually symmet-
rical.
THE DISEASE PROCESS

The synovial membrane is hypertrophied, highly vascular and packed with
inflammatory cells. This aggressive tissue:
erodes cartilage and subchondral bone;
infiltrates tendon mechanisms, restricting glide, and can ultimately lead to
tendon rupture;
invades connective tissue;
produces sensory and motor nerve compressions, especially in closed
compartments such as the median nerve as it passes beneath the flexor
retinaculum in the carpal tunnel.
The results ofthis tissue invasion are:
pain
instability
contracture
muscle weakness
subluxation and deformity.
The degree of damage and the individual's perception of the disease will
result in varying degrees of functionalloss.
Phases of the disease

The disease can be arbitrarily divided into three phases: acute, sub-acute and
chronic.
The acute phase is characterized by inflamed, swollen, painful joints, general
malaise and raised temperature.
RHEUMATom ARTHRITIS
During the sub-acute phase the disease is less active and better controlled by
medication. The patient's condition remains stable for longer periods oftime,
but joint deformity is progressing.
By the chronic phase the disease is no longer active, but the residual
mechanical problems in and around the joints will produce pain, instability or
stiffness, resulting in loss of function.
Management of the disease

Management of the disease is largely medical, but therapeutic measures and
surgical intervention can minimize the effects of the disease. Evaluations and
treatment are an ongoing process, and the multidisciplinary team approach,
involving rheumatologist, orthopaedic surgeon, nurses, physiotherapist, occu-
pational therapist, orthotist and social worker, is essential.
During the acute phase medical management frequently involves admission
to hospital for complete or partial bedrest. During the sub-acute phase, limitation
ofphysical activity will be in keeping with the systemic and local manifestations
of the disease. A vast selection of drugs are also used to control rheumatoid
arthritis. They include:
• analgesics
non-steroid anti-inflammatory drugs (NSAIDs)
corticosteroids
• intramuscular gold injections
• injections ofhydrocortisone directly into the joint.
Careful monitoring ofthe effects ofthese drugs on the patient is essential, as
many have unpleasant and potentially dangerous side effects. The hydrocorti-
sone injections give long-Iasting relief, but repeated injections cause destruction
ofthe cartilage. Anaemia is common in the acute phase, due to the sequestering
of iron in the tissues, but as this resolves on remission iron supplements are
unnecessary.
SURGICAL INTERVENTION
This must be preceded by careful evaluation of the patient and their problems.
This is often carried out by the occupational therapist in consultation with the
surgeon, rheumatologist and physiotherapist. The process of deformity in the
rheumatoid limb is complex, and no single procedure can give the desired result.
The combination of operations must be chosen which will give the patient the
best possible pain relief and restoration of function with the least number of
hospital admissions. The patient's total physical condition must also be consid-
ered, e.g. it would be very unwise to perform bilateral wrist replacements on a
2
SURGICAL INTERVENTION
patient who has gross lower limb problems, as the punishment imposed on the
wrists by the use of crutches would lead to early deterioration of the implants.
It is much wiser to defer hand surgery until the lower limbs have received
attention. If this is not possible it would be preferable to settle for one wrist
arthrodesis for strength, and one arthroplasty for dexterity.
When deciding the course of action, the patient' s attitudes, expectations and
ability to cope must be taken into account. Clear explanations, ineluding the
advantages and limitations of surgery, must be given, and specific goals must
be set against which to measure post-operative results.
The general rule for upper limb surgery is to work from proximal to distal,
as a hand that cannot be positioned adequately, or have power transmitted
through it because ofpain or instability at proximal joints, is reduced in function.
In addition to the proximal to distal rule, certain priorities should be observed,
in particular that nerve compressions should be dealt with as a matter ofurgency,
and tendon compressions should be a very elose second. Because of her elose
and frequent contact with the patient, the occupational therapist is often the first
10 notice these compressions, and the need forvigilance cannot be over-emphasized.
The aims of surgery are to:
1. relieve pain;
2. maintain and improve function;
3. prevent further deterioration;
4. improve appearance.
The patient should be in a sub-acute or chronic phase of the disease before
surgery is performed. Surgery may be preventive, or ofa repair orreconstructive
nature. An example ofthe former is synovectomy, which is performed to prevent
the bulky hypertrophic synovium further damaging a joint. Examples of repair
or reconstructive surgery are repair of ruptured extensor tendons of the fmgers,
and osteotomy to re-align a defective limb. While joint replacements will be the
main surgery under discussion, it must be stated that arthrodesis, principally of
the wrist, thumb and PIP joints, is a viable surgical option. The aim is to achieve
a balance between optimum function or mobility and optimum stability.
As orthopaedic surgery has made dramatic advances in recent years, the
range of procedures available for the rheumatoid upper limb has expanded
accordingly. From simple excision arthroplasty has evolved the use ofimplant
surgery, with implants available for shoulder, elbow, ulnar head, wrist, MCP
and PIP joints of the fingers and the thumb. The various surgical procedures
will be discussed in the relevant chapters.
To summarize surgery for the rheumatoid upper limb:
1. Meticulous surgery is essential as the tissues are delicate and the deformities
complex.
3
RHEUMATOm ARTHRITIS
2. It is important to recognize that the disease still exists, although the joints
may have been replaced, and that therapeutic and prophylactic measures
are still appropriate.
3. It is not uncommon for patients to go through a phase of 'flare-up'
following surgery, and appropriate systemic and local measures must be
employed.
4. Realistic goals must be set, as a complete return to normal is not possible.
5. Treatment must be a co-ordinated effort between the members of the
multidisciplinary team.
Abrief mention must be made of certain surgical procedures which are
frequently encountered on the orthopaedic ward, and which are employed in the
surgical management of rheumatoid arthritis. One is ankle arthrodesis, either
fusion of the talo-tibial joint, or a tripie arthrodesis of the talo-calcaneo,
talo-navicular and calcaneo-cuboidjoints, both ofwhich offer good pain relief.
Ankle replacement has become available, and would benefit the rheumatoid
patient as in theory it would be preferable to the impact forces transmitted
upwards to other joints after arthrodesis. However, considerable muscle power
would be required to stabilize such ajoint (Souter, 1987).
The spine is affected most noticeably in the cervical area. At the atlanto-axial
joint, erosion of the odontoid process produces an unstable joint with subluxa-
tion, endangering the spinal cord. A rigid collar wom day and night is supplied
as a matter ofurgency, and fusion ofthe cervical spine may be indicated, after
which a closely moulded collar is fitted before the patient is allowed to mobilize.
THERAPEUTIC MANAGEMENT
The occupational therapist and physiotherapist, working together, can comple-
ment each other's treatments and reinforce each other's teaching. The occupa-
tional therapist, as part of the multidisciplinary team, can make a considerable
contribution to the patient's well-being by helping to relieve pain, improving
functional ability and aiding psychological adjustment to disability.
Depending on the clinical phase of the disease, the objectives of treatment
are:
1. to educate and reassure the patient about the disease;
2. to instruct in the methods of energy conservation, and explain the benefits;
3. maintain or increase joint mobility;
4. maintain or increase strength and endurance;
5. prevent or minimize, by appropriate splinting, adaptations and joint
protection techniques, the effects of the disease on the joint structures;
6. maintain or improve function, enabling the patient to achieve maximum
independence;
4
THERAPEUTIC MANAGEMENT
7. provide the environment, support and advice to facilitate the individual's

psychological adjustment to disability;
8. resettle the patient at horne, work and socially.
Splinting
Splinting is frequently used during all phases of the disease. Its use may be
therapeutic, prophylactic, functional, pre-operative or post-operative.
Therapeutic splinting decreases joint pressure and inflammation by eliminat-
ing painful movement and reflex muscle spasm during the acute phase of the
disease. An example of this type of splinting is the resting splint for the hand
and wrist. This splint supports the joint structures and discourages muscle
spasm, which increases pain and encourages positions of deformity, notably at
the metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints. The
resting splint positions the wrist in slight ulnar deviation and maximum painfree
extension up to 30°, the thumb in abduction and opposition, the MCP joints in
zero deviation and functional flexion of 30°, and the PIP joints in 10-15° of
flexion. The wearing ofthe resting splint during the acute phase is balanced with
gentle passive or active exercise to the point of discomfort, without stretching,
at least twice daily.
Prophylactic splinting is used both during and immediately following an
acute phase, and during the sub-acute phase. Prophylactic splinting aims to
maintain optimum joint alignment for function, and to prevent contractures
developing in non-functional positions. Although there is no concrete evidence
that prophylactic splinting prevents joint deformities by minimizing dynamic
forces, there is enough clinical evidence to make it worthwhile. An example of
such a splint is the MCP joint stabilizer, which aims to prevent ulnar deviation
at the MCP joints.
Functional splinting is aimed at unstable or painful joints and is used
extensively during the sub-acute and chronic phases of the disease. Painful,
unstable joints cannot transmit power, therefore function is impaired. This is
particularly true ofthe wrist joint, where pain and instability inhibit finger flexor
power. A wrist support will stabilize the joint and eliminate pain on movement,
and frequently results in dramatically improved hand function.
Pre-operative splinting is used to stretch soft tissue contractures to facilitate
surgery.
Post-operative splinting is used extensively following reconstructive surgery
to the upper limb. It aims to:
1. provide mobility in prescribed arcs of movement;
2. assist in post-operative strengthening;
3. prevent or minimize post-surgical adhesions;
5
RHEUMATOID ARTHRITIS
4. maintain surgically achieved alignment.

Examples ofthese splints will be described with the relevant surgery.
OCCUPATIONAL THERAPY ASSESSMENT

By the time the patient with rheumatoid arthritis needs surgery, there will be
considerable joint damage and probably deformity.
A complete occupational therapy assessment covers local environmental
aspects and function, including the social and psychological needs ofthe patient.
Observation shows that by this stage many patients will have ceased to be in
employment. Housewives are usually working in that they are performing
household tasks.
At their first meeting the therapist may gently shake hands with the patient.
This can give considerable information to the therapist in an informal way, at
least so far as the right hand is concemed! Power, deformity, subluxation, skin
temperature and sweating can be roughly estimated. This introduction gives the
therapist the opportunity to explain her role to the patient.
Ifjoint measurement has been carried out by the physiotherapist it is pointless
to duplicate the exercise. As the patient's condition fluctuates frequently and
varies according to the time of day, the assessment is better carried out over
several sessions. This is less tiring for the patient and enables a repetition of
some tests, if this is thought desirable.
Pressures oftime often lead to therapists utilizing a checklist of questions as
to whether patients are able to perform activities,but results are often inaccurate.
Compared to answering a therapist's questions at a personal interview, patients
appear to admit to difficulties more readily in a self-administered questionnaire
(Speigel et al., 1985). It is preferable for the occupational therapist to take the
patient through a practical assessment.
The activities of daily living (ADL) assessment must include:
1. personal care: dressing, washing and bathing, toileting and hygiene,
grooming and feeding;
2. mobility: walking, stair management, transfers on and off chair, bed and
possibly wheelchair;
3. housework: cooking, cleaning, laundry, shopping, handling money;
4. supporting activities: lifting, reaching for, handling and carrying objects;
5. communication: writing, use oftelephone, handling a book.
Various assessment forms have been devised for the recording of ADL
assessment. One form covering assessment of the above activities under broad
headings (Figure 1.1) and a second form breaking down dressing activities,
including putting on and removing splints and other appliances (Figure 1.2),
should suffice. Grading makes for concise reporting.
6
South Birmingham Health Authority

OCCUPATIONAL THERAPY
ASSESSMENT REPORT
NAME: REGNO.
ADDRESS AGE:
ACIIYIIY DAIE
CHAIRMANAGEMENT
WALKING
CLIMB STAIRS
IN AND OUT OF BED
DRESS
MANAGE OWN TOlLET
WASH
SHAVE
COMBHAIR
IN AND OUT OF BATH
ABLETOFEED
MAKE POT OF TEA
MAKE LIGHT MEAL
COOKDINNER
TIDYBED
LIGHT CLEANING
REMARKS SIGNED
OCCUPATIONAL THERAPIST
Figure 1.1 Sampie form for general ADL assessment
7
ROYAL ORTHOPAEDIC HOSPITAL - BIRMINGHAM, 31

OCCUPATIONAL THERAPY DEPARTMENT
NAME: NUMBER:
ADDRESS' DATE OF BIRTH'
ACTIVITY DATE DATE DATE DATE
GARMENTSOVERHEAD
SillRT/CARDIGAN/COAT
PANTS/TROUSERS
SOCKS/STOCKINGSITIGHTS
SHOES
SMALL BUTTONS
ZIPS
SHOELACES
TIE
APPLIANCE/CALIPER
HAT
GLOVES
KEY TO GRADING 1) Independent, using aids if necessary

2) Needs to be talked through activity
3) Minimal assistance needed
4) Considerable assistance needed
5) Unable to perform activity
REMARKS: SIGNED:
OCCUPATIONAL THERAPIST
Figure 1.2 Sampie form for dressing assessment
8
This fonn should also record what aids were used, how long the activity took
to complete, how tired the patient became and what action is necessary to
improve perfonnance.
If a patient does weH in his ADL assessment, it must be remembered that
while he can cope in the hospital setting, he may not manage so weH on
discharge, when he has to contend with every task, both personal and domestic,
on a daily basis.
Hand assessment may be required. This is covered in Chapter 9.
For many patients a pre-discharge horne assessment is necessary. During this
the occupational therapist assesses:
1. the patient's ability to get in and out of a car, and instruct accordingly;
2. mobility outdoors from car to front door, and indoors over carpets and
on stairs;
3. accessibility and layout ofthe horne: steps, stairs, doorways, etc.;
4. position of toilet and bathroom in relation to living room, bedroom and
stairs;
5. arrangement offurniture in relation to access and mobility;
6. accessibility of electric power points;
7. accessibility of regularly used utensils and foodstuff;
8. hazardous loose mats and other obstacles: these must be identified and
their removal negotiated;
9. availability of adequate, nourishing food supply in the pantry;
10. patient's ability to get in and out of an armchair, on and offbed and toilet,
in and out ofbath or shower, if appropriate;
11. patient's ability to make hot drink;
12. patient's ability to operate heating system;
13. whether the light switch is operable from the bed;
14. whether the patient can summon help ifhe lives alone.
Aids in situ should be noted, those needed should be noted and requisitioned,
and inappropriate equipment should be removed and replaced if necessary with
more suitable models.
If a work assessment is required, the therapist should enquire as to what the
patient' s job involves, the working conditions, and how he travels there. Details
ofwork assessment are covered in Chapter 12.
Because ofthe far-reaching effects ofrheumatoid arthritis in tenns ofpain,
disability and defonnity, there are profound psychological effects on the patient.
In her assessment the therapist should include her estimate of the patient's
attitude towards his disease, disability and appearance, and whether he is
resentful, angry, frustrated or depressed.
An education programme in a group setting, giving accurate infonnation
about the disease, suitable literature, benefits available, diet, tools and adapta-
9
RHEUMATOIDARTHRITIS
tions for daily living, is helpful. It is important that both patient and family
members are correctly inforrned, otherwise they may obtain inaccurate infor-
mation from a lay source.
JOINT PROTECTION PROGRAMME

Since trauma aggravates an arthritic joint, the concept of joint protection arose.
The aims of joint protection are to relieve pain and to help prevent deforrnity
and further damage to joints. The principles of joint protection are to:
I. use proper body mechanics, i.e. use the strongest joint to perforrn a task,
e.g. use hips and knees for lifting rather than the spine, push rather than
puH heavy objects, slide objects along the ground and along worktops,
and use wheels where possible rather than lift or carry;
2. use eachjoint in its most stable plane, e.g. approach activities squarely, such
as standing directly in front of a drawer to open it;
3. spread the load oflifting or carrying over several joints, e.g. carry a tray
across the forearrns;
4. maintain range ofmovement and muscle strength, e.g. fuHy flex and extend
the elbows when sweeping or ironing;
5. avoid activities which encourage ulnar drift, e.g. use of small handles or
wringing out cloths;
6. avoid prolonged static grasp of tools, etc., e.g. knitting, crochet, holding a
book to read it;
7. avoid overdoing an activity, respect pain when it occurs, and stop to rest;
8. wear any splints provided.
The patient should be taught to recognize and avoid activities which:
1. put pressure on the radial side of any fmger;
2. put strong pressure on the thumb.
As alternative hobbies to knitting or crochet, bilateral hand activities such
as weaving and macrame should be suggested. Aremedial exercise for ulnar
drift is to place the hand flat on the table, then move each finger in turn up and
over towards the thumb.
Positioning of the joints at rest is part of the joint protection programme.
Because of generalized pain, patients are apt to rest with pillows underthe knees.
This should be discouraged, as it may lead to the development of flexion
contractures ofthe hips and knees. At rest the legs should be straight, with the
feet supported at right angles to prevent the development of equinus deforrnity.
If there is a tendency to flexion deforrnity at hips or knees, some part of each
day should be spent lying prone on a single bed. The feet must be over the edge
ofthe bed to prevent equinus deforrnity.
10
ENERGY CONSERVATION
Joints may be protected from deformity if a joint protection programme is

implemented soon after diagnosis. When damage has already occurred the
application ofthe principles will still be beneficial in delaying further deterio-
ration and relieving pain.
ENERGY CONSERVATION
In the early stages of the disease a patient may try to maintain former activity
levels, and push himself too hard. Energy conservation is, therefore, important
at this stage and for patients in whom the disease process is more advanced. The
concept is closely allied to joint protection. To conserve energy the patient
should:
1. have at least one daily rest of an hour or more;
2. balance rest and activity, e.g. by working for 20 minutes, then resting for
five minutes, etc.;
3. pace work, so that only a little heavy work is done daily, interspersed with
light tasks;
4. use labour-saving equipment where possible;
5. arrange equipment and materials within easy reach;
6. adjust work surfaces to a suitable height for the job in hand;
7. sit rather than stand;
8. leam to accept help when it is necessary;
9. leam to eliminate unnecessary tasks.
Tools for living are provided as enabling devices and to protect the joints
from damage by avoiding positions which cause deformity. While the occupa-
tional therapist will discuss the foregoing with the patient, and explain the how
and why of joint protection and energy conservation, there is a limit to how
much the patient can retain, so many Occupational Therapy departments give
patients booklets setting down this information and giving details of suitable
tools for living. The booklets are written for easy understanding and suggest
various methods for putting the principles into practice and sources of supply
for the tools. If it is of A5 size, the patient is more likely to keep it on his
bookshelf.
The United States Department of Health and Human Services published a
workbook in 1985 entitledRehabilitation Through Learning (Furst et al., 1985).
Its aim was to enable people wishing to take some responsibility for managing
their illness to do so with help from professionals and their own family. The
workbook comprised four units as follows:
1. Body position: patients to note daily what energy-draining positions they
observe, the cause and solution.
11
2. Rest: patients time activities, noting rest periods, and record the scale of
pain and fatigue following the activity. This enables the planning ofmore
appropriate rest periods.
3. Activity analysis: patients break down a selected activity into component
parts, decide on rest breaks, consider body position, work surface heights,
location of materials and what gadgets will be used. Also make a weekly
timetable, spreading out heavy tasks. At the end of each day the tasks
completed are ticked and any remaining are redistributed.
4. Joint proteetion: worksheets help patients distinguish 'normal' joint pain
from that caused by overdoing activities. Pain should wear off within an
hour offmishing an activity. Other worksheets record whether patients use
joint protection methods ofwhich they are aware.
In 1987 a research paper published in the American Journal ojOccupational
Therapy compared the results of traditional energy conservation training with
the results achieved after using this workbook-based programme for three
months. Follow-up ofpatients having had traditional training suggested that the
methods were not effective in changing patients' behaviour. Conversely, using
the workbook-based programme, 67% of patients had improved in measures of
pain and fatigue and 47% were more physically active. This suggests that the
development of behavioural awareness and problem-solving skills gave the
patients some measure of control over their disease (Furst et al., 1987).
COUNSELLING
When a person is first told he has rheumatoid arthritis he is shocked and becomes
anxious and possibly depressed. He has, in fact, to go through the stages of
grieving for his lost health. By the time he needs orthopaedic surgery he has
recovered from the initial shock, but is still subject to bouts of depression. This
is a normal response to having to adapt to live with a painful, potentially
disfiguring disease. Occasionally antidepressant drug therapy may be required if
the depression syndrome is present: i.e. disturbed sleep, weight loss, apathy, etc.
The patient may be pre-occupied with his symptoms, and needs help in
expressing his fears. If he feels he has lost control over his life, he is likely to
be angry, but he cannot easily express this openly because he needs the help of
his family and the hospital staff and feels he cannot take it out on them.
The body image of the patient with rheumatoid arthritis may take a hard
knock. He may have to suffer the indignity of difficult mobility and possible
visible deformity, and if on steroids, his appearance is further altered by the
development of a fat 'moon' face.
In an informal setting the patient can be encouraged to verbalize his fears,
anger and resentment, and must be reassured that these feelings are normal. He
12
PROMOTION OF INDEPENDENCE
must be treated with respect, recognizing that he has sentiments and aspirations
like anybody else, and this will have a positive effect on his self-esteem. Careful
listening to the patient is helpful, just to let hirn express his frustration. It will
also demonstrate ifhe has any misconceptions aboutthe disease and enable these
to be rectified. The patient's problems should not be minimized, but he should
know that although prognosis is difficult, most patients do not develop severe
disability and that, by following the joint protection and energy conservation
programmes, he can take some control over his disease.
The patient's partner or family may also need counselling. Their attitudes
depend on their relationship before the onset of the illness. They may be
overprotective, resentful, etc. They may find commitment to a long period of
care daunting, and their plans for the future are in limbo. Some partners respond
positively and selflessly, while others cannot cope with the situation and
withdraw from it, with the possibility of divorce. Frequently there is role
reversal, especially where the breadwinner becomes arthritic, and this may be
hard for both partners to accept, leading to the loss of self-esteem on the one
hand and possible resentment on the other. Any financialloss imposes further strain.
The social worker' s help may be invaluable here. The carer must be advised against
becoming so wrapped up in the patient's care that he becomes socially isolated,
and he will do his caring job better if he takes time off for recreation.
If the patient needs help with intimate functions such as bathing or toileting,
this is degrading. Such problems should be discussed with the occupational
therapist, who is best placed to resolve the difficulty and promote maximum
independence and dignity in the patient.
Mobility
The occupational therapist supplements the physiotherapist's treatment for
mobility. Many patients eventually need a walking aid, and a walking stick is
often sufficient. It is important that it is of the correct height: if too short the
patient will stoop, if too long the wrist is forcibly extended, thus damaging the
joint. To obtain the correct length, the patient should be wearing his normal
shoes, stand erect, and be measured from the greater trochanter to the ground.
Alternatively, the stick should be placed upside down on the ground and the
length marked on the stick at the wrist crease. Any surplus is sawn off, and the
ferrule re-applied. The ferrule should be wide-based and regularly renewed. The
stick should be held in the hand opposite the affected leg, so that the body weight
is transferred through the arm and thence through the stick. If two sticks are
needed the patient is taught the four point gait pattern, i.e. one stick forward,
then the opposite foot, second stick forward, then the second foot.
13
RHEUMATOIDARTHRlTIS
If crutches are needed, the physiotherapist will assess for them and teach their
use, but the occupational therapist must monitor their correct use when carrying
out her part ofthe rehabilitation programme. Axillary crutches are contra-indi-
cated, because of the danger of damage to the gleno-humeral joint. Foreann
crutches are more weight-relieving than sticks. The length ofthe crutches should
be adjusted so that the elbows are held in 15-20° of flexion. The handles of
sticks and crutches may need padding or moulding for the individual patient.
Fischer sticks are useful for this reason. Ifthumbs are severely affected, gutter
crutches may be necessary, weIl padded along the gutter. The height should be
adjusted so that the shoulders are not hunched, and the same applies to pulpit
frames. For all walking aids, wide-based ferrules are essential.
A wheelchair may be needed for outdoor use, to enable carers to take the
patient out shopping or socially. Thought must be given as to whether the patient
is to propel the wheelchair himself or whether it is to be attendant pushed, the
latter being more likely. If severely disabled, even iftemporarily so, assessment
for elevating legrests, extended backrest, etc. may be needed. Cushioning to
protect the ischial tuberosity area is necessary and anti-pressure cushioning may
be indicated. The depth of the cushioning affects the balance of the patient in
the wheelchair. A powered wheelchair or scooter may enable the individual to
achieve greater independence out of doors.
If a wheelchair is needed for indoor use, an electrically powered model
should be considered at an early stage, as it helps to preserve function in the
upper limbs and conserves energy. The home must be assessed to ensure that
there is enough space to get through doors, to turn around and to determine
whether ramps are needed. A patient who cannot stand to transfer needs a model
with removable arms plus a transfer board, and patient and carer must be trained
in their use.
Seating
Correct seating is essential. If the patient' s armchair is unsuitable his pain is
aggravated and his independence adversely affected in that he finds it difficult
to get up to go to the toilet, get his meals, answer the door, etc.
It is surprising how few patients with rheumatoid arthritis have suitable
chairs. This may be due to cost, or perhaps they have left it too long before
obtaining one, so that going out to buy one has become virtually impossible.
The nearest Disabled Living Centre will supply details of furniture dealers and
manufacturers who will visit a patient at home to try out chairs. Social Services
departments may supply achair, but many provide only the means of raising
them, which may be inadequate for the rheumatoid patient. If Social Services
state that they cannot supply achair, the social worker can approach a charity,
such as Arthritis Care, for help with funding.
14
The Disabled Living Centre is the best place to go for assessment for a
suitable armchair. They usually have a good range of chairs and the patient
receives the undivided attention ofthe therapist. It is important to allow plenty
of time and when achair seems right, the patient should sit in it for 20-30
minutes, because sometimes achair feels right at first but becomes intolerable
after ten minutes or so.
When assessing for an armchair, the following points should be considered:
The patient should wear his usual house shoes.
Choose firm fabric upholstery (vinyl causes sweating).
Seat height should be from floor to the bend behind the knees, with knees
at right angles and feet resting flat on the floor.
Seat depth is from back ofbuttocks to bend behind the knees, minus one to
two inches (2.5 to 5-cm).
Seat width should be the width at the hips plus four inches (1 Ocm) each side
to allow for changing position.
Backrest contours should support the whole length ofthe spine, including
the head.
Backrest angle to suit the individual.
Armrests should support the arms, without hunching the shoulders.
Armrests should be level or sloping upwards at the front, reaching right to
the front of the chair to assist in rising. A shaped wooden handgrip is
helpful.
Armrests should be padded to accommodate painful elbows and rheuma-
toid nodules.
No crossbar to brace front legs of chair, as this impedes rising.
More severely disabled patients may require a spring-lift chair, which must
be carefully adjusted according to the user' s weight, so that there is no danger of
being catapulted out as he rises. Electrically operated chairs ofvarious designs
may be appropriate. In some only the seat rises, in others seat and arms rise and
in others the whole chair rises. In many the seat tilts forward as weIl as rising.
The patient should be instructed in rising from achair correct1y, to minimize
stress on the joints. He should move forward a little on the seat, place one foot
a little in front of the other, grasp the chair arms, keeping the hands pointing
forwards, lean slightly forward and rise.
Patients should be discouraged from piling cushions into chairs. They detract
from the arm height, making rising more difficult, and soft seats impede rising.
If an otherwise suitable chair sags in the seat, a board cut to size may be placed
on it, and a slim cushion placed on top. A low chair is better raised from below,
so the proportions of the chair are unaffected and it is more stable than
cushioning. Standard methods of raising chairs include raising blocks, sleeves
and frames. A platform may be constructed as a one-off, but must be designed
15
and constructed by a competent technician in order that the patient is not put at
risk. Other accessories include a small bead cushion to support the lumbar or
cervical spine. Tripillows or L-shaped cushioning are contra-indicated, as they
encourage rounded shoulders and crowded chests. A footstool is unnecessary if
the seat height is correct. It is difficult to place and may present a hazard.
Should office seating be required, assessment follows similar lines with easy
adjustability being a priority:
weIl padded fabric upholstery;
seat angle adjustable from level to 10° downward, to avoid pressure behind
the knees;
seat height adjustable, to suit task being undertaken;
backrest adjustable for height and angle;
arrnrests optional, about 11 inches (28 cm) long, to get close enough to
desk;
five star base for stability, with glides being safer than castors on uncarpeted
floor.
Personal activities of daily living

Toileting may present serious difficulties. Possible solutions include:
raised toilet seat andJor frame, or combination aid;
handrails on walls beside toilet cause less strain on arthritic upper limbs;
spring-lift toilet seat. Precautions as for spring-lift chair;
ladies may find a loop attached to the inside skirt hem helpful, to be held
in the teeth while adjusting the clothing;
bottom wiper/sponge on an angled handle for hygiene purposes, with
built-up handle ifnecessary;
ideally, provision of a bidet or clos-o-mat.
Bathing problems are common and solutions include:
essential provision of non-slip bath or shower mat;
bath board and seat are standard provision by community agencies. If
lowering into the bath, there is stress on the upper limbs when getting up
anddown;
mangar type ofbath aid avoids stress on upper limbs and enables patient to
get right down into water;
handrails in strategie positions on wall, across bath or outer side ofbath;
special chunky waste plug;
lever or adapted taps;
ideally, step-in or walk-in shower, but expensive to install;
handrail and shower seat also needed;
16
long-handled sponge, long flannel with tape loops either end, or a washing
mitt with soap pocket;
bath robe as alternative to towel.
Grooming is important as it detracts from any deformity. Padded, length-
ened or angled handles on combs, toothbrushes, make-up equipment, etc., Stirex
scissors, toothpaste squeezers and mirrors placed at strategic angles all help in
this respect. It may help if the elbows are supported on a table or worktop to
perform these tasks.
Dressing is more easily done while seated and resting the elbows on the
dressing table may help to get clothes over the head. It is also helpful to choose:
garments a size larger than needed;
lightweight clothing in knitted fabrics, in natural fibres for comfort;
clothes with few fastenings, any fastenings being at the front, using velcro,
large buttons and large tabs on zip-pulls;
elastic waistbands, shoelaces and elasticated or clip-on ties.
Tools likely to help with dressing include:
dressing stick;
button hook;
long reacher, with forearm extension ifwrist is unstable;
long shoehorn;
sock or tights aid. If the patient is on steroids or has thin shiny skin, the
skin on the shins may be damaged by a gutter type aid. The Brevetti type
is safer.
Obtaining comfortable footwear is a major problem. Surgical footwear is
only prescribed if the patient's needs cannot be met by purchasing standard
shoes. 'Off-the-peg' orthopaedic shoes are available from several specialist
firms; details are listed in the Disabled Living Foundation Handbook, Section
14. These shoes are lightweight, broad, with a deep toe space and available with
velcro fastenings. Shoes may be made on the individual's own last, giving a
perfect fit until further joint changes occur. There should be no hard toecaps and
materials should be suede or very soft leather, with feit for some indoor shoes
although this gives little support.
When buying shoes, both feet should be measured while standing and the
shoes fitted while wearing any insoies or other appliances normally worn. It is
better to buy shoes late in the day, as the feet tend to swell as the day wears on.
If the shoe is to be adapted, it is wise to check that they can be changed if the
technician finds them unsuitable. Solid heels are needed for fitting calipers. If
metatarsalgia or calcaneal spurs are present, plastazote insoies can be fitted by
the occupational therapist. Lace up or velcro fastenings give better support.
17
RHEUMATOIDARTHRlTIS
Bucldes are awkward to fasten. If a patient has to wear boots for instability at
the ankle joint, a wooden or polypropylene boot remover may be useful.
Because many patients find the weight of the bedclothes over the feet
intolerable, a bed cradle may be required.
Eating and drinking tools may be necessary. Patients should try several types
of adapted cutlery to find that best suited to their needs. Generally , thick handles
are most appropriate, angled towards the mouth. The handles should be shaped
to accommodate any deformity, or have the thicker part of the handle on the
ulnar side ofthe hand. Cutlery should be as unobtrusive as possible, especially
ifthe patient eats in company. Cups and mugs must be lightweight, preferably
with two handles, or the second hand should be used to support the cup, to
prevent the fingers being forced into ulnar deviation. A plate with a deep inward
curved rim helps in the control offood and is more acceptable than a plate guard.
Dycem matting holds the plate still.
Housing adaptations
For many rheumatoid patients a bungalow or ground floor flat would be ideal,
but often an existing house has to be adapted. It is preferable for a patient to
remain in his own locality, where he is more likely to have friends and support.
If a transfer is essential for the patient's safety, the social worker negotiates for
this and the occupational therapist may be asked to write a supporting letter.
Warden-controlled accommodation provides security and a suitably appointed
horne, but there are few younger neighbours to provide stimulation and help
and, as the population around is elderly, the frequency of funerals can be
depressing. If younger people have to move horne, they are likely to miss the
support of old friends. They also have to consider proxirnity to their workplace and
possible disruption oftheir children's education ifthey have to change school.
If the patient is to remain in his existing horne, necessary adaptations may
include the following:
• uneven paths relaid and handrails provided, especially ifthere are steps or
slopes;
grabrails on the door frame, at the optimum height for the patient' s use,
bearing in mind the limitations imposed by arthritic shoulders;
draught excluders at the threshold replaced by flexible type attached to base
ofdoor;
a shallow porch with a second front door make access difficult;
automatically opening garage doors. Up-and-over doors strain the shoul-
ders;
doors may need adaptation to allow walking frame or wheelchair access.
Sliding or folding doors, a door rehung to open outwards or on the opposite
18
side of the frame may facilitate access;

lever type dOOf handles;
furniture arranged to allow plenty of circulation space ifwalking frame or
wheelchair used;
short-pile carpets make for easier mobility. Avoid loose mats;
high level controls necessary on gas and electric fires. Central heating on
a time-switch is ideal. District Council grants may be available for instal-
lation of central heating. Gas and Electricity Boards will adapt controls to
enable easier operation. Outside help is needed if solid fuel heating is used;
stairs may be difficult, especially if steep or winding. A second handrail
provides extra security and support, but the patient should not put stress on
the arms by hauling himselfup;
astair or through-floor lift may be necessary. This entails skilIed assessment
with the lift company concemed. Provision is usually through the Social
Services department and may take many weeks due to assessment and
committee procedures. Local councils may make agrant towards installa-
tion;
if there is a downstairs toilet and bathroom, bringing the bed downstairs
should be a short-term solution only. This situation fosters the invalid role
and does not promote quality of life;
if a new toilet is installed, it should be raised on a plinth;
aseparate shower to replace the bath;
for a patient living alone, an emergency alarm system may be advisable.
To afford legitimate callers access, a two-way communication may be
wired up to the doOf bell.
The grant system for housing adaptations does change from time to time. If
a patient is on Income Support, adaptations are carried out free of charge,
otherwise assistance is means-related. In some cases an Environmental Health
grant is 'topped up' by Social Services. The procedure is slow and ponderous
and patients may have to wait many months, sometimes up to two years, for
adaptations. The occupational therapist must therefore make satisfactory tem-
porary arrangements.
Household tasks
The occupational therapist should enquire as to what help the patient has at
horne. The amount the patient undertakes should depend on his physical
condition, with adaptation being continuous as the disease progresses and as life
tasks alter. The ability to adapt enables the patient to maintain the maximum
possible independence. Patient and therapist together should plan the week's
activity, spacing out the more arduous tasks and deciding which the patient
19
RHEUMATOm ARTHRITIS
would be willing to omit aitogether and which could be allocated to a helper.

With regard to kitchen activities, the following suggestions put into practice
the principles of joint protection and energy conservation:
use oflightweight saucepans, bowls, ete.;
filling kettle from a plastie jug and using minimum amount of water
necessary;
jug kettle is lighter than traditional kettle and ean be tilted instead oflifted;
use ofkettle and/or teapot tipper when pouring;
use of wire saucepan basket in pan to make straining of vegetables an
automatie proeess, leaving the water in the pan;
split level eooker and adapted eontrol knobs;
eleetrie can openers are indispensable. Different types should be tried
before purehase;
the Rex vegetable peeler with its wide grip is popular;
serrated or sealloped blade knives are rated more highly by patients with
rheumatoid arthritis than the ergonomieally shaped knife, with handle at
right angles to the blade.
eleetrie earving knives are heavy, therefore less useful;
potatoes may be washed and boiled in their skins to save work and preserve
nutritional value;
• patients should try a variety of bottle and jar openers to find the one best
suited to them;
use of a stabilizer such as the Belliclamp;
if an eleetrie mixer is used, it must be on astand;
• use of eleetrie plugs with handles;
lever type or adapted water taps;
keep to simple reeipes and proeedures.
If no ear is available, shopping should be done frequently, so that there is
little to earry, and should be earried in a bag aeross the shoulders, in a trolley or
a small bag in each hand.
Heavy cleaning is to be avoided, but dusting and polishing using a sheepskin
polishing mitt is benefieial exereise. If stairs are a problem, the patient should
ensure that upstairs chores are done before eoming down in the moming. An
automatie washing machine with a tumble dryer is aboon. When hand washing,
the patient must not wring out the clothes. A potato masher will press out a lot
ofwater, ready for the washing to go in the spin dryer. Easy-eare fabries should
be chosen as far as possible and only the bare minimum of ironing done, sitting
on aperehing stool to rest the legs. Bedmaking is much easier if duvets are used,
although help will be needed when changing the cover. Moving cleaning
materials and other items around on a trolley saves energy.
Holding seissors with the index finger ahead ofthe loop gives more control
20
Figure 1.3 Method of manipulating scissors

and less discomfort (Figure 1.3). Stirex type scissors are lightweight and do not
aggravate the thumb joints, but are not efficient at cutting through thicker cloth.
Very occasionally, environmental control equipment, such as POSSUM, will
be needed and in the event ofthis, the suppliers ofthe equipment employ staff
to assess and instruct the patient. Intercom systems are frequently used and are
easily operated.
Hoists are sometimes required for the handling of severely disabled patients,
needing careful assessment and instruction in use. Unless the occupational
therapist is assessing for such equipment regularly, it is advisable to turn to an
expert for help, with the Disabled Living Centre as the first point of contact.
Communication
If the fingers or thumb of the dominant hand are stiff or painful, a padded pen
or one with a moulded holder may be helpful. Finger yokes or pens pushed
through a rubber ball may be easier to hold. It is harmful for the patient to write
for long because ofthe static muscle action.
Useful telephone adaptations include large push buttons and a holder, so that
the hand is not in a static position while holding the handset.
Sexual problems
Various elements in arthritis (or any other physical disability) contribute to
emotional and sexual problems. Such elements include physical appearance,
negative body image, pain, loss of or abnormality of function and the effect of
drugs. This may lead to the individual feeling unattractive to the opposite sex,
where even the development of a friendship is hampered, let alone a flirtation
or courtship. Because emotional relationships are so vitally important, this
problem must be addressed, and certain staff, including occupational therapists,
may develop special counselling skills in this area.
21
Comparatively few patients of childbearing age will be encountered but their

needs will differ from the sexual needs later in life. Contraception is a matter
for the general practitioner or family planning elinic to advise on as to the best
method for the individual. The couple must consider whether they can cope with
the demands ofbringing up a family.
The subject of sexual relationships applies to single people as weIl as to
couples and is not an easy one to address. If one looks in the nursing profile
under' expressing sexuality', invariably one finds that the nurse has written 'not
discussed'. There has been a tendency to regard people with disabilities as
sexless, although their needs are becoming more recognized. Ifthe occupational
therapist feels unable to advise on such matters, she must be sure to know to
whom to refer the patient who needs advice. The patient must be aware that he
can obtain help in this respect, although the decision to seek help should be left
to hirn. Discreet alternatives are to have the address ofthe Sexual and Personal
Relationships ofthe Disabled (S.P.O.D.) organization on a poster in the depart-
ment, or to supply an information pack to the patient containing a copy of
Arthritis: Sexual Aspects and Parenthood published by the Arthritis and Rheu-
matism Council.
If the arthritis existed pre-maritaIly, or if both partners are disabled, fewer
problems may arise. There are various manifestations of sexual disability for
the arthritis sufferer. Deformity makes a person feel less physically attractive
and fear of rejection causes anxiety, with the knock-on effect of impotence or
frigidity. Depression, fear, pain and medication may suppress the sex drive.
Deformed hands may make foreplay difficult. Pain in the woman's hips may
make it uncomfortable for her to bear her partner' s weight, and pain in the man' s
arms may make it painful to take weight on them, if the traditional position is
adopted. An arthritic husband who has lost his breadwinner role and who has
sexual difficulties suffers loss of manhood. Other situations drain energy that
might be directed towards sex: due to her husband's arthritis, the wife has to be
the breadwinner and housewife: the wife with arthritis struggling to manage
horne and family: the wife has arthritis and is severely disabled, so the husband
has to be breadwinner and do domestic chores, etc.
The couple should be encouraged to discuss their problems together and to
find mutually acceptable solutions. An analgesic taken shortly before inter-
course, or a change of position, may solve the problem. Depending on which
partner has arthritis, and which joints are worst affected, alternative positions
may be attempted, such as the woman lying on top ofthe man, the couple lying
on their sides with the man entering from behind, or the man sitting on achair
with the woman sitting astride hirn. Where it is not possible to achieve inter-
course, the couple might indulge in caressing, stroking, kissing, etc., and even
lying elose together in bed may give them the sense of eloseness they need.
22
Hobbies
While a feature of rheumatoid arthritis is fatigue and sufferers require frequent

rest periods, it is important to remember that their minds are still active and they
may wish for the company of others with similar interests. Even the person who
is content to watch television may need adaptations to the controls. Creative
writing or painting are possible hobbies to encourage, with the likelihood of
having to modify the pen or brush. Various craft aetivities are valuable in
maintaining funetion and some loeal authorities employ eraft instruetors for
people with disabilities. For those who enjoy reading, a book holder is needed
so that the hand joints are not stressed.
The person with arthritis should be eneouraged in the pursuit of an interest
and possibly belong to a club. Some organizations eater specifieally for his
needs, among them Arthritis Care, who also run several holiday hotels (see also
Chapter 12).
Travel
For many patients with arthritis, the ear is their link with the outside world. A
transfer board may solve any diffieulty in getting in and out of the ear, or a
swivel ear seat ean be fitted. A two-door ear is easier to enter than a four-door,
as the doors are wider. There are ears on the market whieh aeeommodate a
wheelchair-bound driver, but they are expensive. Back supports may be required
and should be sampled in the patient's car before purehase. Correct1y adjusted
head restraints proteet against whiplash injury in the event of a bump, and extra
mirrors may be needed if the patient's neek is affeeted. Automatie gears,
power-assisted steering and servo-assisted brakes are desirable. Alteration to
hand eontrols, adaptations to the handbrake, steering wheel knobs, ete. are
available. Several driving associations (addresses in appendix) give advice on
all aspeets of driving.
If mobility is appreeiably restrieted, the patient must be told how to obtain
an 'orange badge', entitling hirn to park in restrieted or prohibited plaees, for
ease ofaeeess to shops, bank, ete. (see also Chapter 12).
A person whose mobility is severely affeeted and who is under retirement
age should be given a form to apply for Mobility Allowanee from the Depart-
ment of Social Seeurity. He will be assessed by an independent doetor before
this is granted. The money may be used to travel by taxi, to maintain his own
ear, or to aequire a ear on the Motability Seheme (see Chapter 12 for details).
People with rheumatoid arthritis possessing Department of Social Security
vehieles must be medieally assessed annually to ensure that they are still fit to
drive.
23
Independent mobility using a car is especially important when we consider

public transport. Although most buses designate the front few seats for the use
ofthe elderly or disabled people, a person with rheumatoid disease may find it
difficult to grasp the handrail, get up the step or tuck his feet safely away once
seated. Travel by underground has other problems: congestion, long distances
to walk. Rail travel, unless accompanied, is daunting: narrow difficult steps,
formidable gaps between steps and platfrom, unwieldy door handles. IfBritish
Rail are notified in advance, staff are helpful in transporting chairbound passen-
gers in good lifts and allowing travel in the guard's van ifthe traveller cannot
get out ofthe wheelchair. This denies the traveller the dignity he deserves, but
this situation is on line for improvement. Airlines, if alerted when the flight is
hooked, make excellent provision for those with disabilities.
Looking after babies and smaII cbildren

While pregnant mothers usually have relieffrom their arthritis symptoms, they
may return post-natally. Everything possible should be done by the mother for
her child, but if she has to accept help in practical tasks, every effort should be
made to ensure that she can cuddle her baby. Ifthere is any danger ofthe baby
being dropped offher knee, he can be fastened into a harness and a walking rein
looped over her shoulder to secure him.
Bottlefeeding requires much manual dexterity, so breastfeeding is to be
encouraged. The child can then be weaned straight onto baby mugs. Flexible
plastic bibs are convenient, as fastening and cleaning them is easy.
Disposable nappies are easier to handle than towelling squares and eliminate
the laundry problem. Two major distributors of nappies provide free home
delivery. It is important to choose the right sized nappy and those with a long
strip allowing adjustment when fastening the self-adhesive tabs are preferable.
The baby should be changed on a high surface suited to the mother's height.
Once baby grows and becomes stronger, he needs a toy to distract him while
being changed. Baby wipes make cleaning easier.
Small babies are easily bathed in the kitchen sink. A baby bath which fits
across the normal bath is available and can be filled from a shower head or hose.
It has its own waste plug. Otherwise, the mother needs the full bath carrying for
her. A baby bath wrap makes for easier drying.
A child born to a parent with arthritis tends to adapt quickly and leams to
co-operate. He can be taught to dress himself at an earlier age and to climb up
to his parent's level for help. It is important that he recognizes that this is the
only time he may climb onto fumiture. The type of clothing chosen should be
similar to that chosen for the parent.
When the time comes for toilet training, it is easier to use tbe adaptor seats
for normal toilets, with a sturdy box for the child to climb onto the seat.
24
ANKYLOSING SPONDYLITIS
Baby furniture such as cots, high chairs, prams and pushchairs can present
problems in lifting the child in and out, and in operating movable parts. Selection
of such items should be done on an individual basis, with regard to the particular
difficulties of the parent.
Safety gates are needed to protect the child from the danger of stairs. To
enable the baby to be carried more safelyon the stairs, there should be a handrail
each side and the baby should be held facing forwards with the parent' s arm
around bis body under his arms.
Once the child is toddling, he should be held by reins when on the road. When
in parks and playgrounds, he must leam not to run off out of sight and sound of
his parent.
Because the parent may be on drugs to control the arthritis, special care must
be taken to ensure the child cannot get at them. This is particularly important as
the child-proof containers may have been changed to a type more easily opened
by the parent.
SUPPORT GROUPS
These may be set up for the mutual support of patients but it may be appropriate
to have occasional multidisciplinary professional input. Patients are able to air
their frustrations conceming the effects of their illness and their fears of future
incapacitation. They can discuss their practical problems and leam how others
solve theirs. They can also exchange experiences about community resources,
local facilities and leisure interests. If a professional is present, her role is to
listen, then perhaps suggest solutions to problems and correct any misapprehen-
sions which have become evident. These groups mayaiso be involved in
campaigning in such matters as local access, benefits, etc.
ANKYLOSING SPONDYLITIS
Ankylosing spondylitis is the chiefofthe seronegative arthroses. It differs from
rheumatoid arthritis in that the rheumatoid factor is absent, the sacro-iliac joints
and spine are involved,joint inflammation is asymmetrical, more than five times
as many men as women are affected, and iritis occurs and may lead to visual
impairment.
The onset tends to occur in the early twenties and starts in the sacro-iliac
joints then progresses up the lumbar spine into the thoracic and cervical spine.
The attachments of the ligaments to the hones become inflamed, then heal by
forming small knobs ofnew hone. Eventually the whole ligament becomes hone
and results in the development ofthe 'bamboo spine'. The typical deformity is
of a round-shouldered man, sometimes bowed almost at right angles to the legs,
while the cervical spine may be extended so that he can look ahead.
25
The pain and stiffness are relieved by exercise but aggravated by rest,
especially when in bed. Bending and twisting become increasingly difficult, as
does turning the head. The pain ceases once rigidity has occurred. Ifboth spine
and hips stiffen, walking and sitting become very difficult.
Treatment concentrates on correcting the posture, with physiotherapy to
maintain mobility of all spinal joints plus breathing exercises, with exercise
periods twice daily. Swimming is encouraged, as back stroke is excellent
therapy, with breast stroke providing specific exercise for shoulder and hip
joints, and front crawl to exercise the spine. Diving and contact sports are
contra-indicated. Analgesia and anti-inflammatory drugs are prescribed.
If the spine has not already fused, the maintenance of good po sture ensures
that, when fusion does occur, it will be in a good functional position. To this
end a firm mattress should be used, without a pillow. 1fthis last is intolerable,
one slim pillow is permitted. The armchair should have a high, firm backrest,
supporting the whole spine including the cervical spine. Sitting for any length
of time is not tolerated. If the hips have ankylosed, a saddle type seat may be
required for a working chair and a recliner for an armchair. Office seating is
needed as for rheumatoid arthritis, plus padded arrnrests as these patients tend
to use their forearms when changing position.
The most likely surgery for these patients is hip replacement. Occasionally
corrective spinal osteotomy is performed, aimed at straightening the spine.
The National Ankylosing Spondylitis Society funds research into the disease .
and provides education and information for the patient on a wide range oftopics
(address in appendix).
REFERENCES
Disabled Living Foundation (1988)Information Service Handbook (Section 14:
Footwear), Disabled Living Foundation, London.
Furst, G.P., Gerber, L.H. and Smith, c.B. (1985) Rehabilitation Through
Learning: Energy conservation and joint protection - a workbook for per-
sons with rheumatoid arthritis, US Govt Printing Office, Washington DC
Greengross, W. Arthritis: Sexual aspects and parenthood, Arthritis and Rheu-
matism Council, Chesterfield.
Hughes, M.K Benson and C. Colton (eds.) Orthopaedics: The principles and
Spiegel, lS., Hirshfield, M.S. and Spiegel, T.S. (1985) Evaluating self-care
activities; comparison of a self-reported questionnaire with an occupational
therapist interview, British Journal ofRheumatology, 24, 357-61.
26
FURTHER READING
FURTHER READING
Atherton, J., Chatfield, J., Clarke, A.K. and Harrison, R.A. (1979) Easy Chairs
for the Arthritic, DHSS Aids Assessment Programme, DHSS.
Atherton, J., Clarke, A.K. and Harrison, R.A. (1981) Office Seating for the
Arthritic and Low Back Pain Patients, DHSS Aids Assessment Programme,
DHSS.
Baker, G.H.B. (1981) Psychological management ofthe patient with rheuma-
toid arthritis, Clinics in Rheumatic Diseases, 7, no. 2,455-67.
Bradshaw, E.S.R. (1985) Food Preparation Aids for Rheumatoid Arthritis
Patients, Part 2A, DHSS Aids Assessment Programme, DHSS.
Brattstrom, M. (1973) Principles of Joint Proteetion in Chronic Rheumatic
Disease, Wolfe Medical Books, London.
Caruso, L.A. et al. A.H.P.A. Task Force (1986) Roles and functions of occupa-
tional therapy in the management of patients with rheumatic diseases,
American Journal ofOccupational Therapy, 40, no. 12, 825-9.
Clarke, A., Allard, L. and Braybrooks, B. (1987) Rehabilitation in Rheumatol-
ogy: The team approach, Martin Dunitz, London.
Furst, G.P., Gerber, L.H., Smith, C.C., Fisher, S. and Shulman, B. (1987) A
programme for improving energy conservation behaviours in adults with
rheumatoid arthritis, American Journal ofOccupational Therapy, 41, no. 2,
102-11.
Melvin, J.L. (1980) Rheumatic Disease: Occupational therapy and rehabilita-
tion, F.A. Davis, Philadelphia.
Nichols, P.J.R. et al. (1980) Rehabilitation Medicine: The management of
physical disabilities, 2nd Edn, Butterworths, London.
Orford, J. (1987) Coping with Disorder in the Fami/y, Croom Helm, London.
Panayi, G.S. (1980) Essential Rheumatology for Nurses and Therapists,
Bailliere Tindall, London.
Pedretti, L.W. (1980) Occupational Therapy Practice Skills for Physical Dys-
fonetion, Mosby, St Louis.
Salter, M. (1988) Altered Body Image, Wiley, Chichester.
Trombly, C. (1983) Occupational Therapy for Physical Dysfunction, 2nd edn,
Williams and Wilkins, Baltimore.
Wilshere, E.R., Cochrane, G.M. and O'Brien, P.M. (1989) Parents with Dis-
abi/Wes. Equipment for Disabled People Series, Oxfordshire Health
Authority,Oxford.
27
2
Total hip replacement
This is probably the operation most associated with orthopaedic wards. It is also
one of the most quoted when hospital waiting lists are under discussion. It is
mainly the elderly who need hip replacement and, with increased longevity and
the expectation of better quality of life, this surgery is in ever-increasing
demand. Improving techniques and prostheses allow younger people to have
hip replacements, adding to the demand.
REASONS FOR TOTAL HIP REPLACEMENT

Hip replacement is most often prescribed for primary osteo-arthritis, which is
the process ofjoint degeneration in the elderly. It is colloquially referred to as
'wear and tear', but there is no obvious cause of tbis. The process starts with
weakening and destruction ofthe cartilage. The underlying hone becomes hard
and sometimes cystic. In the advanced stages there is complete loss of cartilage
from large areas ofthe joint surface (eburnation). New bone forms at the joint
margins (osteophytes) and the joint becomes fibrosed.
Secondary osteo-arthritis follows some obvious predisposing cause, e.g.
congenital dislocation ofthe hip, acetabular dysplasia, Perthes' disease, rheu-
matoid arthritis, trauma or infection ofthe joint.
Pain and stiffness are first feit when rising after aperiod ofrest. This becomes
progressively worse until the patient finds it hard to bend down to put on his
socks or cut his toenails. Limping may be noticed early. Internal rotation,
abduction and extension are the first movements to be lost. If a fixed deformity
develops the leg lies in external rotation and adduction and therefore appears
short. This also causes a limp. Patients present with pain in the groin. Pain may
also be feit in the buttock, over the greater trochanter and down the leg to
just above the knee. This is because the hip and knee are supplied by the
same nerves.
OUTLINE OF SURGERY
The Chamley low-friction arthroplasty has stood the test of time. It consists of
a stainless steel femoral component and a high density polyethylene acetabular cup,
28
OUTLINE OF SURGERY
Figure 2.1 Chamley total hip replacement, showing broken wires with
displacement of greater trochanter
each fixed with methylmethacrylate bone cement to give greater bonding power.
The cement hardens within a few minutes, so fixation is secure very quickly.
During the operation the head and part ofthe neck ofthe femur are removed.
The greater trochanter used to be removed and replaced after the prosthesis was
in place (Figure 2.1), but this has been largely discontinued and the greater
trochanter may be left in situ throughout. The greatest threat to the operation is
infection and in order to guard against this, the operation is performed within a
'Chamley tent' or otherultra-clean-air system. Antibiotics are usually employed
as an additional precaution.
Complications following hip replacement include deep vein thrombosis and
the waming sign of this may be pain in the calf. This may lead to pulmonary
embolism. Very occasionally the femoral shaft fractures during surgery and,
even more rarely, the acetabulum fractures.
Continuing developments include the use of components with perforations
or porous coatings into which the bone grows, eliminating the need for cement
(Figure 2.2). The thinking behind this is that there is less chance ofthe prosthesis
29
TOTAL HIP REPLACEMENT
Figure 2.2 Total hip replacement; Harris Galante cup with bias stern,
uncemented
loosening, but this is debatable. This technique can be useful for younger
patients but the patient must be non-weightbearing for aperiod post-operatively.
If the prosthesis does not become secure over its total surface, or becomes
infected, the revision surgery can be more difficult.
The Exeter system consists of a collarless, double-tapered, wedge design of
femoral stern, with a choice of femoral head and acetabular cup. An intramedull-
ary plug at the distal end of the femoral component prevents bone cement
migrating into the intramedullary canal. As it engages, the tapered design
30
PRE-OPERA TIVE OCCUPATIONAL THERAPY
transmits load through the cement to the bone, ensuring a tight fit and a reduction
in shear stress, aimed at reducing the incidence of loosening.
PRE-OPERATIVE OCCUPATIONAL THERAPY

Because of the possibility of having to revise the surgery later, the joint is
allowed to degenerate considerably prior to surgery. Meanwhile analgesics,
anti-inflammatory drugs and physiotherapy are used. The patient is provided
with a stick to relieve weightbearing and is asked to limit his weightbearing
activity. Because patients with arthritic hips have problems with activities of
daily living (ADL), occupational therapy intervention is indicated whether or
not the patient is to undergo surgery.
Increasingly, hospitals are undertaking pre-operative assessment ofpatients
on a day-patient basis to ensure that the patient is fit for surgery on admission.
The patient is X-rayed, has blood tests, blood pressure check, electrocardio-
gram, urine test and is checked to exclude dental decay, ulcers or other potential
sources of infection. The surgery is explained and admission normally follows
within two to three weeks. The patient meets the physiotherapist and the
occupational therapist who explain their respective roles so that the patient
understands and accepts the reason for all the questions asked of him. These
questions include the following:
1. Does the patient live alone? Ifwith a carer, is the carer fit?
2. Does he live in a house, bungalow or flat?
3. If in a flat, is there a lift?
4. Is the accommodation owner-occupied, council or privately rented
property? This is relevant when requesting adaptations to property.
5. Where is the toilet? If downstairs, is it indoors? If outside, is there a covered
way to reach it; are there steps to negotiate?
6. Where is the bathroom? Is there a separate shower? Are any bathing aids in situ?
7. Is there at least one sturdy stair-rail?
8. Does the patient sleep upstairs?
9. Is the bed fmn and high enough to rise from, i.e. 20-24 inches from floor
to top ofmattress, depending on patient's height?
10. Has he an armchair from which he can rise easily?
11. Has he any aids to enable easy rising from the toilet?
12. Does he wear slip-on or lace-up shoes?
13. Question for ladies: are tights or stockings worn?
14. Does he normally have help with cooking or housework?
15. Can mea1s be taken in the kitchen? If not, is there level access from kitchen
to living room?
16. What commitments does he have to family, work, other?
31
Armed with the above information, the occupational therapist gets a pieture
ofthe patient in his horne setting and can requisition necessary equipment from
community agencies. The patient must be instructed in the safe and correct use
of any tools supplied and all equipment must be fitted by a competent person.
Equipment which may be required includes:
raised toilet seat, suited to the patient's height;
toilet frame or handrails on wall;
high seat chair or raising devices;
bed raising devices;
long reaching tool;
long shoehom;
stocking or tights gutter;
elastic shoelaces;
trolley to transport meals from kitchen to living room;
bath board and seat (these are usually regarded as low priority by commu-
nity agencies).
It is useful to give the patient a handout summarizing what has transpired as
areminder, as he will be bombarded with information at this pre-operative
assessment.
Altematively, the patient may be referred to the occupational therapy depart-
ment as soon as he goes onto the waiting list. He then attends for assessment as
above, or if staffing levels permit, ahorne assessment is carried out. Ifthe latter,
the therapist can assess suitability of chairs, etc. at first hand without having to
depend on the patient's sometimes doubtful descriptions. Patients are thus
enabled to cope more comfortably in the time running up to their surgery.
Generally the onus should be on the patient to obtain a suitable chair and bed
and advice conceming these items should be given. In cases of real need, referral
may be made to community agencies and a social worker, and information given
conceming benefits available.
POST-OPERATIVE MANAGEMENT
Prior to surgery the patient is allowed to perform any movement of which he is
capable. F ollowing surgery, healing must take place in the soft tissues to provide
stability. It is possible to dislocate the new hip while the soft tissues are still
weak. Opinions differ depending on the individual surgeon and the surgical
approach, but a general rule is to take precautions for three months post-oper-
atively.
In order to prevent dislocation, the hip movements which the patient must
avoid are adduction, flexion beyond 90° and rotation. Usually a 'Chamley
wedge' or a fat pillow is placed between the legs while lying in bed, to prevent
32
these movements. Patients are nonnally up on the second post-operative day.

The physiotherapist oversees the walking and general mobility. She teaches the
patient to rise from bed, chair and toilet by sliding the operated leg forward, then
taking the weight on the anns, sliding forward in the chair (avoiding wriggling
forward) and rising without flexing the trunk onto the thighs, taking the strain
on the unoperated leg. To sit down this procedure is reversed.
Authorities disagree about which side of the bed the patient should get in and
out. Generally the patient is taught to get in and out on the operated side as there
is a reduced chance of adduction of the operated leg. What is more important is
to ensure that there is no adduction across the midline ofthe body, no rotation
and no flexion beyond 90°.
Weightbearing on the new hip is commenced at once, using a walking frame
and progressing to two sticks within a few days as the patient gains stability and
confidence. Just before discharge the physiotherapist teaches the technique of
stair management. The rule for this is easily remembered: 'Good up to heaven,
bad down to hell', i.e. the good (unoperated) leg leads going upstairs and the
bad (operated) leg leads going downstairs. The following leg is brought up to
the first but not past it, in the manner of a young child negotiating stairs.
OCCUPATIONALTHERAPY
Aims:
to enable the patient to be independent in ADL;
to promote healing and restore muscle power;
• to encourage a positive attitude and gradual return to anormal lifestyle.
Objectives: following instruction by the occupational therapist and practice in
a safe environment, the patient will be able to:
• perform all necessary activities ofdaily living with use ofappropriate tools;
• understand how to protect his prosthesis, supported by a written list of' do' s
and don'ts';
• perform gentle activity within the prescribed limits.
The flow chart (Figure 2.3) is a convenient method for monitoring the
achievement of objectives, particularly useful if a collaborative care planning
system is in operation. Collaborative care planning is a multidisciplinary ap-
proach to the assessment and management ofan episode ofcare, in collaboration
with the patient. Its purpose is effective use of resources by the clear planning,
implementation and monitoring of the total treatment package. Pre-admission
screening, objectives, daily care plans, post-discharge follow-up and clinical
audit are included in the plan, and the paperwork for each discipline is open-plan
on the clipboard at the foot of the patient' s bed. If the patient has already been
33
OCCUPATIONAL THERAPY DEPARTMENT T.H.R.
NAME'
-----
NUMBER' DATE:
Pre-Op Op. Day 1 Day2 Day 3 Day4 Day 5 Day6 Day7 Day 8 Day9 Day 10 Day 11 Day 12 Day 13 etc
Assess loan As Pre-
horne hlhand Op (ifnot
situation already
accom., done)
he\p,aids
already
supplied
Access for
toilet aids
Teach use
ofdressing Monitor
aids
Order
necessary
equipment
Kitchen
tpractice if
appropriate
Confirm
Discharge date Check equiprnent elivered
to supplying andfi ed
agencywhen
known
Horne visit for high
risk patients
Observe correct
rnovement patterns
Figure 2.3 Flow chart for monitoring achievement of objectives following T .H.R.
-
assessed and instructed during the pre-admission screening, the objectives on

the chart will be modified accordingly.
It is important that the patient does not sit in a deep, low chair. If a high chair
is not available, an existing chair should be adapted by raising from beneath so
as not to alter the balance of the chair, using Langharn raisers, sleeves or blocks.
With these last, it is necessary to place the chair against a wall for stability, in
case the chair moves back as the patient sits down. Piles of cushions make the
seat too soft to rise from and may cause the hips to rotate, thus risking
dislocation. They also take up space so that the full benefit of the arms of the
chair are not feIt when rising. Only one extra cushion should be placed on the
seat, and that a slim one, with a board beneath it to provide a firmer base. A
Putnam wedge will comfortably adapt a carver chair. A pillow may be placed
at the back of a deep chair to hold the patient forward.
Some swelling ofthe foot and lower leg is usual for a few weeks after surgery
due to congestion ofthe veins in the leg. The leg must be kept up when at rest,
the foot level with the hip, and the ankle regularly rotated 20 times in each
direction to encourage contraction of gastrocnemius and soleus, assisting ve-
nous return by the pumping action ofthe musc1es. To avoid overflexion at the
hip, the patient should lean back a little in the seat. Later, when the swelling has
subsided, he should sit with the knees slightly lower than the hips.
The patient' s bed at horne may need raising with Langharn or St Relier raisers
or similar. The height ofthe top ofthe mattress from the floor should be higher
than the armchair seat, as he has to rise without the assistance of armrests.
Depending on the patient's height, 20-24 inches (51-61 cm) is a good height
for the bed. If the mattress is soft, a board should be placed under at least the
middle of it and preferably under its whole length. Rarely does a patient alter
his bedroom layout after surgery, so he may get in and out ofbed on the opposite
side from when he was in hospital, but he must follow the same basic method.
Only very occasionally it is necessary to turn the bed round. The patient should
sleep on his back with a pillow between his legs to prevent turning over in his
sleep. Later, after discussion with his surgeon, he may lie on his side, again with
a pillow between the legs to prevent the uppermost leg crossing the midline.
Most patients require only a raised toilet seat to make them independent in
the toilet, the height ofthe seat depending on the patient's height. Occasionally
a toilet frame is also needed, or a combined frame and raised seat. The method
of getting up and down as taught in hospital is followed. To flush the toilet, the
patient should either turn towards the unoperated side to do so, or he must avoid
spinning round on the operated leg, instead taking small steps to turn round to
face the flush handle.
Bathing is risky and unless the patient already has suitable bathing equip-
ment, it is wiser to refrain from bathing until three months post-operatively.
Pedretti (1981) and Trombly (1983) advocate getting into the bath side-on,
35
lifting the leg over the side by bending the knee. This depends on the height of
the bath or the length of leg of the patient in question. The favoured method in
Britain is to use a bath board, sitting on it and leaning back slightly to avoid
overflexion of the hip, then lifting the leg carefully over the side of the bath.
Showering is then possible while sitting on the board, or the patient may move
down onto a bath seat. It is inadvisable to sit on the floor of the bath, as the hip
is already flexed to 90°. Any reaching to manipulate taps or plug, or washing
the feet, overflexes the hip. The feet may be washed using a long-handled sponge
or a sponge held in a reaching tool. Use of aseparate shower is safer, using a
non-slip mat. The patient must not bend to wash the feet.
Dressing should be performed sitting down. To avoid overflexion ofthe hip,
a reacher should be used, putting the operated leg into pants first. Hosiery must
be put on with a tool for the purpose. This requires careful instruction, as many
patients find it difficult to master. A helper is needed if anti-embolism stockings
are worn. If elastic shoe laces are used, they must not be stretched before tying,
and a long shoehorn is essential. The shoe tongue may either be held in place
by threading the laces through a small hole punched in it, or by pulling the tongue
through to the outside, below the laces.
A dropped object can be picked up with a long reacher or the patient can be
taught a safe way of picking items up, provided the other hip is sound. He can
steady hirnself on a sturdy piece of fumiture, put his operated leg out behind
hirn, then bend down, taking the strain on the unoperated leg.
A patient living alone, or who looks after another person, needs kitchen
practice pre-discharge. Usually making a hot drink and perhaps a piece oftoast
is sufficientto assess competence in the kitchen, observing the patient' s mobility
and use ofhis sticks, including any tendency to leave them behind! The patient
can be reminded ifhe does anything which could cause dislocation, and safety
in handling gas or electricity and boiling liquid is checked. Moving a kettle or
pan of water is difficult when using two sticks, so the patient must be taught to
handle a kettle while holding the stick in the other hand, and to avoid carrying
these utensils if possible. He should be instructed to slide pans along work
surfaces, but if these are not continuous he must put the pan down on a surface
a little ahead ofhim, take a few steps using his sticks, pick up the pan and move
it another stage, etc. Any necessary tools for living should be supplied and, if
the therapist is not satisfied that the patient is safe, the assessment should be
repeated, perhaps cooking a full meal so that vegetable preparation and tin
opening mayaiso be assessed.
Vacuuming and heavy housework should be avoided for the first three
months after surgery, but simple cooking, washing up, dusting and polishing
while standing and walking around gently are excellent exercise for the hip.
Frequently used items should be conveniently sited, as climbing and bending
are forbidden. Use ofthe oven should be confined to times when a helper is at
36
RESURFACING TOTAL IDP REPLACEMENT
hand, and fires with low controls must be left to a helper. Patients should be
advised to sit down for 20 to 30 minutes, then get up and move around for a
while, before sitting down again, graduaHy extending the active period.
To get in and out of a car, the car must be parked away from the kerb to gain
the maximum height from ground to seat top. The seat back should recHne
slightly and a firm cushion or Putnam wedge be placed on the seat if it is low.
The seat should be pushed as far back as possible and the window wound right
down. The patient should turn his back on the car, hold the door on one side and
the door frame on the other, and sit down. He should then pull hirnselfback as
far as necessary in order to swing his legs round together to bring them into the
car. The procedure should be reversed for getting out. The patient should not
drive until the surgeon has approved it at the foHow-up clinic.'
Sexual activity may be resumed after three months, iflying on the unoperated
side with the operated leg resting on a pillow, for either sex. A man may He on
his back with the woman astride hirn. It is advisable for a woman to wait three
to four months before lying on her back for intercourse; then a pillow should be
placed to prevent the operated hip being pressed out too far.
THE OUTLOOK FOLLOWING HIP REPLACEMENT

Total hip replacement is a routine operation, but is nevertheless major surgery.
Elderly patients take longer to recover, partly because ofthe length oftime it
takes to excrete the anaesthetic residue. The period ofhospitaHzation gets ever
shorter, but every patient is safely mobile and capable of managing stairs on
discharge. Three months later he can expect to bend down more freely. By the
time six months have elapsed, he reaHy feels the benefit of surgery and the
successful operation achieves 90-95% restoration offunction.
RESURFACING TOTAL mp REPLACEMENT

The acetabulum and articulating surface only ofthe femoral head are replaced
(Figure 2.4). The first attempts at this procedure have been largely abandoned
because of early failure. Work is proceeding on a modified form with metaion
metal articulation. The thinking behind the technique is that there is no femoral
stern to loosen and, ifthe surgery should fail, revision or conversion to a formal
hip replacement can more easily be effected. It is too early for results to be
evaluated.
Occupational therapy involvement is similarto that fortotal hip replacement.
It is particularly important to protect the joint in the early post-operative weeks
and the patient may not bear weight fuHy for six weeks or more, and then uses
two sticks for a further six weeks.
37
Figure 2.4 Resurfacing total hip replacement, metaion metal components
REVISION OF TOTAL HIP REPLACEMENT

Because of the increasing demand for hip replacement, especially in younger
people, there is a corresponding rise in the need for revision surgery. The main
reason for revision is loosening of either component. The other reasons for
revision are deep infection, recurrent dislocation and fractures. As with primary
arthroplasty, pain and loss offunction are the criteria for surgery.
When revision is performed, the old prosthesis is removed, the area thor-
oughly cleaned and every trace ofbone cement removed, especially in the case
of infection. The operation is considerably more difficult than for primary
surgery and the cost very much greater. When the prosthesis is removed, the
bone surface is usually smooth and sclerotic, so the bone-cement interface
is much less strong in arevision and is reduced still further in any subsequent
revision. Bone grafting may be performed if there is loss of bone stock and
this entails a much longer period of either bedrest or non-weightbearing post-
operatively.
Deep infection is treated with antibiotics, with debridement of the joint and
short-term closed suction drainage. If this fails, the implant may be removed
38
FURTHER READING
and arevision perfonned using antibiotic-loaded acrylic cement. This is done

in one stage ifthe offending organism is a 'friendly' bug, i.e. one whichresponds
readily to antibiotics. If an 'unfriendly' bug, i.e. one which is more resistant to
antibiotics, is the cause of infection, the implant may be removed, then some
weeks or months later when it is believed the infection has cleared, the revision
is perfonned. The disadvantages ofthis latter regime are the cost to the patient,
his family and the hospital, risks involved in further surgery and the patient's
frustration and incapacitation between the two stages.
Occupational therapy intervention is similar to that for primary surgery, but
it is even more important to observe the precautions against dislocation and
ensure the patient has all the equipment available to enable hirn to protect the
arthroplasty to get the longest possible life out of it. Because this surgery is
tailored to the individual patient, the time sc ale varies considerably from one to
another and the patient's goals are modified accordingly.
REFERENCES
Pedretti, L.W. (1981) Occupational Therapy Practice Skillsfor Physical Dys-
function, Mosby, St Louis.
FURTHER READING
Ahnfelt, L., Herberts, P., Malchau, H. and Andersson, G.BJ. (1990) Prognosis
oftotal hip replacement, Acta Orthop Scand, 61, no.238, 9-12.
Browne, P.S.H. (1985) Basic Facts in Orthopaedics, 2nd edn, Blackwell Sci-
entific Publications, Oxford.
Fairburn, S.M (1985) Daily activities following hip replacement: a handout,
British Journal ofOccupational Therapy, 48, no.6, 167-8.
Hardinge, K. (1983) Hip Replacement: The facts, Oxford University Press,
Oxford.
Hughes, S. (1989) A New Short Textbook ofOrthopaedics and Traumatology,
Edward Amold, London.
Johnson, R., Thomgren, K.G. and Persson, B.M. (1988) Revision oftotal hip
replacement for primary osteoarthritis, Journal of Bone and Joint Surgery,
70--B, no.l, 56-61.
Snorrason, F. and Karrholm, 1. (1990) Early loosening of revision hip arthropla-
sty, Journal ofArthroplasty, 5, no. 3,217-27.
Steinbrink, K. (1990) The case for revision arthroplasty using antibiotic- loaded
acrylic cement, Clinical Orthopaedics and Related Research, 261, 19-22.
39
3
Other hip surgery
OSTEOTOMY
This is sometimes perfonned to provide pain relief in the younger patient. One
type is the McMurray osteotomy, in which the femur is surgically divided
between the greater and lesser trochanters and the shaft ofthe femur displaced
medially, followed by internal fixation with a nail and plate. This redistributes the
weightbearing stresses on the joint. Healing takes up to three months. It is
frequently a holding operation until joint replacement is carried out later.
Because the hip joint is left intact, the precautions needed following hip
replacement are unnecessary. However, depending on the height, build and
general fitness of the patient, he may need provision of a raised toilet seat or
frame and the occupational therapist should ensure that he can dress his lower
half. Ifthe patient's seating at horne is low, this should be rectified.
ARTHRODESIS
This operation is less common than it used to be but may be the procedure of
choice in younger patients following trauma or septic arthritis. It relieves the
hip pain and stabilizes the joint, but a considerable proportion of patients
complain ofback and knee pain afterwards. The operation involves removal of
the remaining cartilage and reshaping the femoral head to fit the acetabulum. A
bone graft may be inserted and the whole is intemally fixed. A common
complication ofthis procedure is non-union. Patients may be immobilized in a
hip spica for three months or longer while healing takes place. The operation causes
shortening on the affected side and the patient has then to wear a shoe raise.
Occupational therapy for this patient is essential. At this stage the aims are:
to encourage a positive and adaptive outlook;
to maintain the maximum activity level possible under the imposedrestrictions.
The therapist's assessment should include the same details as for total hip
replacement. It is necessary to make both short-tenn and long-tenn arrange-
ments for his independence. To enable hirn to cope at horne while wearing the
hip spica, the following tools for living may be required:
raised toilet seat with a dip side to accommodate the hip spica/stiffhip;
handrail on wall or toilet frame, the latter floor-fixed for stability;
40
PELVIC OSTEOTOMY
high commode, with oval-to-round adaptor to accommodate dip side toilet

seat raise;
bedpan and urinal, if above toilet aids not available;
Femicep toilet aid for female patients;
bedraising device;
high seat chair with sloping backrest;
long reacher;
long shoehorn.
It is easier for the patient to have his bed downstairs at first, with a commode
provided ifthere is no downstairs toilet. In some households this is a problem,
owing to lack of space and privacy. Ifthe patient remains upstairs, he is isolated
from family and social contact.
More permanent arrangements are necessary later and, if horne conditions
warrant it, rehousing may be considered. Once the joint has arthrodesed, the
patient can manage stairs by the child' s technique already described. Permanent
equipment will include:
a second handrail alongside the stairs;
provision of achair with a divided seat, so that the stiff hip is comfortably
accommodated and the spine is supported in the optimum position;
permanent handrails by the toilet;
long-handled sponge;
referral to Social Services department for provision of aseparate shower.
Car adaptations may be required, e.g. entering the driving seat of a British car
will be all right if the left hip is affected, but difficult if the right hip is
arthrodesed. The patient should be furnished with all the information he needs
to resolve any driving problem.
Sexual activity
The woman with an arthrodesed hip has a problem regarding positioning. She
should be given the opportunity to discuss this with an understanding member
of staff, or given details of SPOD. Alternative methods of achieving sexual
pleasure, such as caressing or sex aids, may be suggested. Some patients may
be encouraged and reassured that a professional person has recommended this,
since it demonstrates that such methods are acceptable and medically approved.
PELVIC OSTEOTOMY
One technique for osteotomy of the innominate bone is the Chiari osteotomy
(Figure 3.1).
41
OTHER HIP SURGERY
Figure 3.1 Chiari pelvic osteotomy

The procedure is used for younger patients presenting with sub luxation or
recurrent dislocation ofthe hip. The operation involves the medial displacement
of the distal part of the pelvis, thus deepening the roof of the acetabulum and
distributing pressure over a greater area ofthe head ofthe femur. Post-opera-
tively, the hip is immobilized in a hip spica, with the hip in 20 - 30° of abduction,
for three weeks or more. After removal ofplaster, passive and active exercises
are commenced and after one more week, partial weightbearing is allowed. The
patient may be discharged while wearing the hip spica, and if so the occupational
therapist will arrange for equipment to be provided as for short-terrn provision
for the patient with an arthrodesed hip.
This surgery gives better results when perforrned as primary surgery and on
patients where there is litde arthritis. Aprerequisite is a good range of hip
movement. Following surgery there is good correlation between pain relief and
function. There may be some shortening, producing a slight limp. If the
operation should fail, the improved acetabular bone stock makes total hip
replacement easier.
Alternative pelvic osteotomies include the Salter's and shelf operations
(Figure 3.2).
42
GIRDLESTONES EXCISION ARTHROPLASTY
Figure 3.2 Salter's and 'shelf pelvic osteotomies
GIRDLESTONES EXCISION ARTHROPLASTY

This may be a salvage operation following a failed joint replacement, or a
holding operation while awaiting clearance of infection in two stage revision
surgery (see p.39) The head and neck ofthe femur are excised and soft tissue,
usually gluteal musele fibres, is interposed between the acetabulum and femur.
This forms a false joint which is painfree and mobile, but unstable (Figure 3.3).
The patient requires a walking frame or crutches to mobilize. Some older
patients experience difficulty in managing the Girdlestones hip.
Occupational therapy assessment ineludes the same details as for total hip
replacement, but there is no need for precautions against dislocation. Adapta-
tions and tools for living will be needed permanently ifthe operation is a salvage
procedure, and the patient needs items similar to those required following hip
replacement. The aims of occupational therapy are as for hip arthrodesis. The
objectives are for the patient to:
perform all necessary ADL tasks safely, using appropriate tools;
understand and adapt to the imposed physicallimitations;
be safely mobile within these imposed limits.
43
OTHER HIP SURGERY
Figure 3.3 Girdlestones excision arthroplasty
CONGENITAL DISLOCATION OF THE HIP

There are a number of procedures for correction of this condition. Early
splintage is usual, with the hips held in abduction in a frog pIaster for three to
six months. The principle behind this treatment is that the maintenance of
constant pressure on the femoral head deepens the acetabulum. The child under
a year old may have an adductor tenotomy, or a toddler may have a pelvic
osteotomy to correct the defective acetabulum. After these operations, im-
mobilization in hip abduction pIasters is standard for variable periods oftime.
Occupational therapy input is normally only for assessment and requisition
of a suitable buggy or wheelchair to accommodate the cumbersome pIaster. A
suitable car seat mayaiso be required. Because the child is very young, his
parents will be attending to his personal needs, but they should be consulted as
to any specific difficulties which the occupational therapist can deal with on an
ad hoc basis.
A significant proportion of these patients develop secondary arthritis and
present later in life for further surgery.
PERTHES' DISEASE
This condition affects children between the ages ofthree and ten years. Over a
period of two to three years, the femoral head becomes denser, after which it
44
FEMORAL FRACTURES
appears to fragment, then eventually the bone texture returns to nonnal. During
these changes, defonnity of the femoral head and thickening of the neck of
femur commonly occur. Subluxation of the hip and secondary arthritis may
follow.
The hip is res ted with skin traction applied, until the pain and muscle spasm
have resolved. A 'broomstick' pIaster may then be applied with the hips
abducted and internally rotated; this is retained for nine months after which the
child is non-weightbearing for approximately 15 months. Alternatively, an
innominate (pelvic) osteotomy is perfonned, when immobilization is for two to
three months only.
With regard to occupational therapy, the same applies as for congenital hip
dislocation, but as the child is older he needs individual assessment for a
wheelchair and for toilet aids. Pants or trousers will need adaptation to fasten
along the insides of the legs and crotch.
SUPPED FEMORAL EPIPHYSIS

This condition is occasionally encountered on the orthopaedic ward. Internal
fixation by threaded pins prevents further displacement and stimulates epiphy-
seal fusion if the condition is treated early (Hughes, 1989). If displacement is
considerable, a wedge may be removed from the femoral neck to prevent
stretching soft tissue attachments ofthe displaced epiphysis, or a subtrochanteric
osteotomy may be perfonned. Occupational therapy intervention is unlikely to
be necessary.
While the juvenile conditions mentioned are not exhaustive, they do repre-
sent the most usual methods of treatment of hip disorders in the very young,
which will require occupational therapy intervention.
FEMORAL FRACTURES
Fractures ofthe femur belong in the field oftrauma but may be encountered on
the orthopaedic ward. These fractures may be caused by direct or twisting force,
osteoporosis or bone tumour.
Osteoporosis is a decrease in bone density, the bone becoming porous and
rarified with an increased risk of fractures. The causes are mainly:
• post-menopausal honnone changes;
• old age, Le. over 65 years;
• immobility;
prolonged use of corticosteroids.
Less common causes include nutritional deficiency, osteogenesis imperfecta,
osteomyelitis and certain endocrine imbalances.
45
OTHER HIP SURGERY
Osteoporosis produces a tendency to fracture of the neck offemur, especially

in the elderly female. The bone is not mineral-deficient, as in the case of
osteomalacia. Treatment of generalized osteoporosis is directed at maintaining
weightbearing mobility and the use of oestrogens, calcium and vitamin D.
The general aims oftreatment for a fracture are to:
relieve pain;
reduce the fracture to a good anatomical position;
immobilize the fracture to promote healing;
restore function.
Fractures of the femoral shaft

Treatment depends mainly on the age of the patient. Conservative treatment is
by traction, using a Thomas's splint, for three months. Alternatively, a cast-
brace or piaster cylinder may be fitted after partial union of the fracture at eight
weeks. Internal fixation of a fractured femoral shaft involves the use of an
intramedullary nail. This has the advantage of allowing weightbearing within
one to two weeks and is therefore preferable for the older patient.
Fractures of the hip

Fracture of the neck of femur at the subcapital site is the most common in the
elderly patient. In approximately 5% of these cases, the two fragments are
impacted with slight abduction ofthe femur. This fracture is stable and may be
fixed by various means, including Garden screws, a nail and plate or with a
compression screw and plate (Figures 3.4, 3.5 and 3.6).
Intertrochanteric fractures ofthe hip are treated by compression screw ornail
and plate. Subtrochanteric fractures are fixed by intramedullary rod or compres-
sion screw and long plate.
In the other 95% of cases of fractured neck of femur, the bone ends are
displaced, usually with the shaft rotated and displaced upwards due to the pull
of the thigh muscles. The leg is rotated laterally, there is limb shortening and
severe pain on movement. Treatment is by internal fixation to avoid the
complications arising from prolonged bedrest in the elderly, i.e. hypostatic
pneumonia, osteoporosis, muscle wasting, pressure sores and urinary tract
infections. The most probable surgical procedures are:
compression screw and plate. The dynamic hip screw is a variation of
this;
excision ofthe femoral head, followed by hemi-arthroplasty;
total hip replacement.
46
FEMORAL FRACTURES
Figure 3.4 Garden screw for fractured neck of femur
Reasons for more radical surgery include:

1. The blood supply to the head and neck of the femur may be severely
disrupted by the fracture, leading to avascular necrosis and collapse of
the head and neck of femur later.
2. Approximately one third ofthese fractures fail to unite or are slow to do so.
1fthis occurs, the neck ofthe femur is gradually absorbed, the head offemur
and trochanter come closer together, the fixation loosens and the bone
fragments displace.
3. Secondary osteo-arthritis often follows fractured neck offemur.
Hemi-arthroplasty
The advantage of replacement of the femoral head is the rapid relief of pain and
return to mobility. The Thompson hemi-arthroplasty and the Austin-Moore
prosthesis are commonly used (Figure 3.7).
The cause of pathological fracture of the neck of femur must be sought and
treated. It may be due to osteomyelitis, osteomalacia, tumour, following radia-
47
OTHERHIP SURGERY
Figure 3.5 Nail and plate fixation for intertrochanteric feature offemur
tion, Paget's disease and some forms ofrickets. These fractures may not unite
ifthe bone is infected or ifthere is a malignant tumour.
The patient is up mobilizing a few days after surgery. The physiotherapist
teaches static quadriceps exercises. Musc1e power must be restored early to
prevent atrophy andjoint stiffness. Every part ofthe body should be exercised
as much as possible to maintain physical strength and stimulate the circulation,
which promotes healing.
The aims of occupational therapy are:
to keep the patient as active and mobile as possible, to promote healing;
to encourage a gradual return to full activity.
To this end the patient should be encouraged to dress in day clothes and look
after his personal needs, given the necessary tools. These tools will be similar
to those required following total hip replacement and assessment should broadly
follow the same lines. The patient who has had hemi-arthroplasty should take
the same precautions as for total hip replacement. The pinned and plated femur
will be somewhat stiff, but there is no danger of dislocation.
48
AMBULATION TRAINING
Figure 3.6 Compression hip screw
AMBULATION TRAINING
Although this is the responsibility ofthe physiotherapist, ambulation is all-im-
portant in the rehabilitation of patients following hip surgery and the occupa-
tional therapist reinforces the teaching of the physiotherapist when she is
retraining the patient in daily living activities.
When the patient is non-weightbearing he uses crutches. Ifaxillary crutches
are used, the patient should push down onto the handgrips with his hands and
the crutch pads should be two fingers' width from the axillae. The crutch tips
are placed six to eight inches either side ofthe patient's feet and the handgrips
adjusted so that the elbows are in 15° offlexion.
Ifthe patient is non-weightbearing, the three point gait is used. The crutches
are moved forward together, then the good leg swung forward to a point either
just ahead of or just behind the crutches, which is a more stable position than
with the foot in line with the crutches.
At home, the patient may have to negotiate stairs. Unless the physiotherapist
is present, the occupational therapist must be certain of the technique for stair
49
OTHER HIP SURGERY
Figure 3.7 Austin-Moore prosthesis for fractured neck offemur
management with crutches. It is important that a sturdy handrail is in situ before

stairs are attempted. The two crutches are held in one hand, one in position for
support, the second held at right angles to it. Alternatively, the second crutch
may be left downstairs and a third crutch kept upstairs. The good leg goes up
first followed by the crutch, and when descending stairs, the crutch is put on the
lower step first followed by the good leg.
For partial weightbearing, axillary or elbow crutches may be used. The bad
leg and both crutches are brought forward together, the amount ofweight borne
depending on the amount of pressure the patient puts through the crutches. This
method is used for 'toe-touching' or minimal weightbearing.
50
FURTHER READING
The two point gait is the usual method for partial weightbearing. One crutch
and the opposite foot are brought forward together, then the opposite crutch and
the second foot brought forward.
For full weightbearing the foUT point gait is used, with one stick being put
forward, followed by the opposite leg, then the second stick put forward, then
the second foot. This is the usual method of ambulation taught to patients being
discharged home on two sticks.
Although hip patients have normally progressed to sticks before discharge
from hospital, it may be advisable for a walking frame to be provided for a short
time after discharge for the patient who has to get up to use the toilet in the night.
REFERENCES
Hughes, S. (1989) A New Short Textbook of Orthopaedics and Traumatology,
Edward Arnold, London.
FURTHER READING
Beary III, J.F. et al. (1987) Manual ofRheumatology and Outpatient Orthopae-
dic Disorders, 2nd edn, Little Brown Medical, London.
Browne, P.S.H. (1985) Basic Facts in Orthopaedics, 2nd edn, Blackwell Sc i-
Calvert, P.T., August, AC., Albert, J.S., Kemp, H.B. and Catterall A (1987)
The Chiari pelvic osteotomy, Journal ofBone and Joint Surgery, 69-B, no.
4,551-5.
Crenshaw, AH. (ed.) (1987) Campbell's Operative Procedures Vol. 4, Mosby,
StLouis.
Davies, M. (1988) Sexual problems and physical disability, in C.J. Goodwill
and M.A Chamberlain (eds.) Rehabilitation of the Physically Disabled
Adult, Croom Helm /Sheridan Medical, London.
Fisher, 1. and Jackson, M. (1988) Walking aids, in C.J. Goodwill and M.A.
Chamberlain (eds.) Rehabilitation ofthe Physically Disabled Adult, Croom
Helm /Sheridan Medical, London. .
Oxford.
Hogh, 1. and MacNicol, M.F. (1987) The Chiari pelvic osteotomy, Journal of
Bone and Joint Surgery, 69-B, no. 3, 363-73.
Osterkamp, J.O., Caillouette, J.T. and Hoffer, M.M. (1988) Chiari osteotomy in
cerebral palsy, Journal ofPaediatric Orthopaedics, 8, no. 3, 274-7.
51
OTHER HIP SURGERY
Zlatic, M. et al. (1988) Late results ofChiari's pelvic osteotomy, International

Orthopaedics, 12, 149-54.
52
4
Knee surgery
While occupational therapists in medical rehabilitation centres carry out heavy

workshop activities with patients following some knee surgery, many patients
undergoing elective surgery for knee conditions remain in hospital for a very
short time and there may be insufficient incapacity to merit occupational therapy
intervention. Occupational therapy input is necessary for rheumatoid arthritis
affecting the knee joint (see Chapter 1 for pathology, etc.) and also for osteo-
arthritis of the knee.
OSTEO-ARTHRITIS OF THE KNEE

The actual disease process as it affects the joint is as described for osteo-arthritis
of the hip. It is mainly the elderly who are affected and the condition is
aggravated by obesity. Ifthe medial compartment ofthe knee is affected, genu
varum (bow leg) results, and if the lateral compartment is affected, it causes
genu valgum (knock knee). Secondary osteo-arthritis may result from an old
injury or from recurrent dislocation of the patella.
Arthritic knees restrict the patient's mobility when walking, negotiating
stairs, rising from chairs and bending to tie shoelaces or cut toenails. Because
of the pain, the patient spends more time in his chair, resulting in increased
immobility due to wasting of the quadriceps muscles in particular and
stiffening ofthe joint, sometimes to the point of developing a fixed flexion
deformity. 1fthis occurs the patient is still further incapacitated. Treatment
is by physiotherapy to strengthen the quadriceps muscles and stretch out
flexion contracture. Serial splinting may be required to achieve the latter.
The patient should rest with the knee in extension. Anti-inflammatory drugs
are prescribed and an injection of hydrocortisone directly into the joint
affords pain relief.
If the patient is obese his weight should be reduced. Walking aids are
provided to reduce the weight being put through the joints. Occupational therapy
intervention is directed at provision of tools to maintain independence and to
relieve the pain of struggling with difficult daily activities. Tools for living
required may include:
53
KNEESURGERY
high seat chair and legrest;

bedraising devices;
raised toilet seat and/or toilet frame, or handrail on wall;
bathing aids;
second stair-rail;
grabrails by big access steps;
long shoehom;
sock/stocking or tights aids;
elastic shoelaces.
If the patient is unable to have knee surgery for health reasons, he may
deteriorate to the point of a wheelchair existence. Knee arthroplasty offers pain
relief and restores mobility.
TOTAL KNEE REPLACEMENT

The knee is a more difficult joint for successful replacement than the hip as its
structure is more complex. There are two separate articulations within the one
joint, i.e. the patello-femoral and the tibio-femoral joints. The tibio-femoral is
a modified hinge joint, flexion and extension being the main movements, but
some rotation with the knee in flexion and very slight passive abduction and
adduction take place. Strong ligaments and tendons provide stability. The knee
works in conjunction with the hip and ankle joints in supporting the body weight
when standing erect. It is therefore a major stabilizing joint and also a major
mobilizingjoint, enabling walking, sitting, kneeling, squatting and kicking. The
medial compartment ofthe tibio-femoraljoint and the patello-femoraljoint are
most commonly affected by arthritis and, at later stages, all three compartments
are destroyed.
Although a knee replacement may be performed with confidence on the
older, less active patient, the results are on the whole somewhat less satisfactory
than with hip replacement.
There are varying types of prosthesis, including the surface replacement, the
hinge, the unicompartmental, the patello-femoral and the rotating hinge replace-
ment. The hinge type prosthesis (e.g. the Stanmore total knee replacement)
produces a simple flexion and extension movement, suitable when there is
considerable joint destruction in the more infirm patient. This type of prosthesis
is prone to loosening in an active patient.
With the surface type ofprosthesis (e.g. the Kinematic total knee replace-
ment, Figure 4.1), each articular surface is properIy shaped and a metal femoral
component is cemented in place over the femoral condyles and a polyethylene
component attached to the tibia. An optional extra is a polyethylene component
for the articular surface of the patella. This prosthesis more nearly imitates the
54
TOT AL KNEE REPLACEMENT
Figure 4.1 Total knee replacement, Kinematic type (a) anterio-posterior
natural knee joint, but must be aligned very carefully and depends on strong
ligaments for stability.
The rotating hinge prosthesis, as its name suggests, allows flexion, extension
and rotation and the link prosthesis is an example ofthis type.
The successful total knee replacement produces a stable, painfree knee with
at least 90° of flexion.
55
KNEESURGERY
Figure 4.1 Total knee replacement, (b) lateral view
REVISION OF TOTAL KNEE REPLACEMENT

The most common reasons for revision ofknee replacement are loosening and
deep infection, although loosening ofthe newer implants is less common. Other
reasons include patellar problems such as subluxation, dislocation and fractures.
Poor axial alignment may lead to stress at the bone-cement interface, causing
loosening. The failure rate of the older hinged prosthesis is high, but the less
constrained prosthesis causes less stress at the interface.
There are many factors to be considered when revision is to be undertaken:
the reason for failure of the primary, possible infection, deficient bone stock
56
OSTEOTOMY
and/or supporting soft tissues, balancing of the collateral ligaments, ease of

removal ofthe old implant and the patient's motivation for rehabilitation.
Surgeons have their own preferences for the type of implant they employ for
revision surgery. The greater the bone loss and instability, the more need there
is for a more constrained type of prosthesis. A condylar prosthesis is suitable
only when bone stock and collateralligaments are good. An intramedullary stern
may provide better fixation.
Removal ofthe old implant is time-consuming and often difficult, especially
with a porous coated implant, and significant bone loss may result. Where there
is infection every particle of old cement must be removed. If the bone stock is
satisfactory, insertion ofthe new prosthesis is as for the primary, in one or two
stages, as for revision surgery of the hip. Antibiotic-Ioaded acrylic cement is
commonly used in the revision of infected knee implants. Bone grafts and
allografts are used to make up deficient bone stock. When bone stock is very
poor, custom-made endoprosthetic replacements may be used.
After revision of total knee replacement, mobilization is more difficult and
the post-operative programme is individualized. Results are generally less good
than for primary arthroplasty. There is sometimes extension lag. Surgery is
considered successful if the patient has little or no pain, if he can flex the knee
to 90° and if the joint is stable. A survey has demonstrated that the success rate
for revised knee replacements declines gradually for each subsequent revision
(Rand and Bryan, 1988). In patients with rheumatoid arthritis, the survival rate
of the prosthesis is better than for those with osteo-arthritis, probably because
the patient with rheumatoid disease is less active.
Precautions following revision include avoidance oflifting more than 30 lbs
(13.5 kg) weight, no kneeling and no sudden change in direction, acceleration
or deceleration.
OSTEOTOMY
If the knee joint is painful and deformed but still reasonably mobile, tibial
osteotomy may be performed. This operation is dependent on the joint surfaces
being relatively intact.1t is a solution to the genu varum deformity. A wedge of
bone is removed from the lateral aspect of the tibia just below the knee joint.
The bone is then re-aligned in the correct position, so that the weight is
transferred directly down the leg. Altematively, a dome upper tibial osteotomy
can be performed (Figure 4.2). Recovery is slow and the operation is used more
for younger patients. Valgus deformity of the knee is better treated with a
supracondylar medial wedge osteotomy.
57
KNEESURGERY
Figure 4.2 Dome tibial osteotomy
ARTHRODESIS
The most likely candidate for knee arthrodesis is the patient with severe
rheumatoid arthritis or chronic infection ofthe knee. While this surgery relieves
pain, it causes another disability and may be performed on one knee only. The
articulating surfaces of the tibio-femoral joint are excised and the two bones
firmly fixed together by means of a long Kuntscher nail, or by external fixation
using compression clamps. The knee then becomes stable but because it is now
stiff, the patient's leg projects awkwardly when sitting so that it is difficult to
accommodate when using public transport, when getting in and out of many
types of car, and creates problems when negotiating stairs.
PATELLECTOMY
This is occasionaUy performed on patients with arthritis affecting only the
patello-femoraljoint, or for chondromalacia ofthe patella. The latter condition
may be caused by trauma or recurrent dislocation of the patella, distorting the
articular cartilage. This produces pain, possible effusion into the joint, and
allows the knee to give way.
DEBRIDEMENT
Loose pieces ofbone and cartilage sometimes separate from the bone ends and
float about inside the joint, causing pain and loss of function. The loose particles
are removed and the irregular surfaces trimmed. The outcome is variable and
the long term effects of doubtful value. Knee replacement at a later date is likely.
58
Patients recovering from total knee replacement are required to achieve 90° of
knee flexion before discharge. If the knee flexion is not satisfactory after two
weeks, manipulation under anaesthetic may be carried out. A continuous passive
motion (CPM) machine which continually flexes and extends the knee is used
for some part ofeach day. Because ofthe good range ofknee flexion achieved
before discharge, patients are on the whole not in need of any tools for living,
provided the contralateral knee is reasonably sound. Many patients develop
good hip flexion to compensate for the knee restrietion pre-operatively, so
dressing the lower half is usually no problem.
However, ifbilateral knee replacement is carried out simultaneously, ifthe
other knee is arthritic or if the patient suffers from rheumatoid arthritis, occu-
pational therapy intervention is necessary. Occupational therapy aims and
objectives are similar to those for hip replacement (see p. 33). Equipment which
may be required includes:
raised toilet seat andJor toilet frame or handrails on wall;
high seat chair;
bedraising devices;
bath board and possibly bath seat.
Ifthe hip joints are also arthritic, the patient needs tools for living as previously
described for arthritic hips but it is usual for the hip joints to be replaced first.
If the patient has rheumatoid arthritis, he needs a fuH occupational therapy
assessment as described in Chapter 1, mainly because his upper limbs should
not be stressed in an attempt to protect the new knees when rising from the sitting
position. The same considerations apply to patients who have had patellectomy
or tibial osteotomy.
The patient with an arthrodesed knee needs occupational therapy interven-
tion. Depending on the method of fixation, he will be discharged horne to await
healing either in a pIaster cylinder from groin to ankle, or with compression rods
still in situ. Occupational therapy aims are similar to those for hip arthrodesis.
If in a cylinder piaster, the patient may need:
raised toilet seat with a dip side to accommodate the piaster, and possibly
a toilet frame;
high seat chair and legrest;
sock gutter to put on short sock to keep foot warm;
long shoehom and elastic shoelaces;
long-handled sponge to reach the foot.
Mounting and descending stairs must be done in the child's manner already
described.
59
KNEESURGERY
Figure 4.3 Pants adaptations for use with external fixation operations
Ifthe patient is discharged wearing the apparatus for external fixation, he

needs the above equipment plus a bed cradle to protect the sheets from the
metalwork. He will appreciate advice on wrapping old sheeting or similar
around the ends of the metal bars to protect the lower sheet. Looselegged
pants are needed over a cylinder pIaster. Over external fixation, loose pants
are needed, possibly with the side seam opened up and a ternporary gusset
inserted. Sidefastening underpants can be substituted, similar to baby waterproof
pants, obtainable from specialist suppliers (address in appendix). Alternatively a
garment may be made up as illustrated and tied over the hips (Figure 4.3).
Once the knee has arthrodesed, the patient needs the listed equipment plus
bathing aids permanently. A bath board or a stool at least as high as the side of
the bath enables the patient to raise the leg over the side ofthe bath. Ifhe drives
a British car, he will have difficulty bringing his right leg into the car, ifthat is
the one which is arthrodesed. He must be given the necessary information in
case he needs adaptations to bis car. He will get used to sitting at the end of a
row of seats in places of entertainment and by the gangway on the appropriate
side if travelling by public transport.
The success of coping after this operation depends on the condition of the
opposite knee and on the strength ofthe patient's arms. Clearly, only one knee
can be arthrodesed, so the other knee must be either unaffected or should be
60
LIMB LENGTH DISCREPANCY
assessed as suitable for replaeement. If the latter, astair lift may be neeessary
to prevent additional stress on the knee replaeement.
LIMB LENGTH DISCREPANCY

The usual eauses of this eondition are:
1. True shortening due to:
eongenital or developmental abnormality;
growth arrest at the epiphysis due to trauma or infeetion;
overgrowth eaused by a healing fraeture or osteotomy.
2. Apparent shortening, due to hip disloeation or pelvie obliquity.
Surgieal eorreetion ofthis condition depends on the accurate calculation of
bone growth, based on the normal growth at specific skeletal ages. The distal
femoral epiphysis contributes 37% to total growth ofthe leg, while the proximal
tibial epiphysis contributes 28%. The relative size ofthe individual is taken into
aceount and the timing of surgery is crueial.
Surgical methods of femoral shortening are only applicable for differenees
of less than 5 cm and obviously result in loss of height. In theory, limb
lengthening is preferable. The three principal methods are the Wagner mid-di-
aphyseal osteotomy and the DeBastiani and Ilizarov methods of callotasis
(eallus distraetion).
In the Wagner method, when the required distraction gap is achieved it is
packed with eancellous bone graft and intemally fixed. When the graft is solid
the fixation is removed and replaced with a semi-flexible tubular plate, which
is later removed when the medullary canal and cortex formation have beeome
normal. The patient is partially weightbearing throughout.
The DeBastiani technique involves proximal submetaphyseal corticotomy,
with distraction at 1 mm daily commeneed 10-14 days later, using a dynamic
axial fixator. This fixator is locked rigid when the required distraction is
aehieved and when bone consolidation has oceurred, the fixator serew is
released and dynamic axial loading commenced until cortex formation has
become normal.
The Ilizarov method involves proximal eorticotomy ofthe tibia, elose to the
metaphysis. The Ilizarov frame is a device in whieh wires pass through bone
and soft tissue from one side of the limb to another, at multiple levels and in
several planes, in order to achieve stability (Figure 4.4). Cyelic axial dynamiza-
tion oeeurs which stimulates bone regeneration. Distraction is commenced at
10-14 days post-operatively and proceeds at the rate of 1 mm per day. The frame
is removed when the medullary canal and cortex formation have become
normal, the regenerated bone is elinically stable and the patient feels the limb
firm beneath his weight (Tachdjian, 1990).
61
KNEESURGERY
Figure 4.4 Ilizarov frame for leg lengthening surgery

Indications for the Ilizarov method ofdistraction osteogenesis are limb length
discrepancy of more than 5 cm and functional impairment. Contra-indications
are joint instability and poor bone stock. The patient must be weIl motivated
and cooperate with the treatment.
Physiotherapy is directed at maintaining and increasing the range of move-
ment of the joints above and below the site of surgery, plus increasing muscle
power.
Occupational therapy intervention is mainly aimed at provision of a suitable
wheelchair for outdoor use. If the femur is lengthened, additional width in the
wheelchair seat is necessary to accommodate the fixator. If the lower leg is
62
FURTHER READING
lengthened, an elevating legrest is needed. The home will need provision of

ramps to facilitate access. Provision of other tools for living is as for external
fixation ofthe arthrodesed knee (see p.59).
REFERENCES
Rand, J.A and Bryan, R.S. (1988) Results ofrevision total knee arthroplasties
using condylar prostheses, Journal ofBone and Joint Surgery, 70-A, no. 5,
738-44.
Tachdjian, M.O. (1990) Paediatric Orthopaedics Vol. 4, W.B. Saunders,
Philadelphia.
FURTHER READING
Hanssen, AD. and Rand, J.A (1988) A comparison ofprimary and revision
total knee arthroplasty using the Kinematic stabilizer prosthesis, Journal of
Bone and Joint Surgery, 70-A, no. 4, 491-8.
Oxford.
Hughes S. (1989) A New Short Textbook of Orthopaedics and Traumatology,
Insali, J.N. (1986) Revision ofTotal Knee Arthroplasty, Instructional Course
Lectures, American Academy of Orthopaedic Surgeons, Chicago.
Kaufer, H. and Matthews, L.S. (1986) Revision ofTotal Knee Arthroplasty:
Indications and contra-indications, Instructional Course Lectures, American
Academy ofOrthopaedic Surgeons, Chicago.
Norkin, C. and Levangie, P. (1989) Joint Structure and Function : A com-
prehensive analysis, F.A Davis, Philadelphia.
Rand, J.A, Peterson, L.F.A, Bryan, R.S. and Ilstrup, D.M. (1986) Revision of
Total KneeArthroplasty, Instructional Course Lectures, American Academy
ofOrthopaedic Surgeons, Chicago.
63
5
Back pain
The spine supports the whole body and is involved in almost every movement
we make. Aseries of curves provides resilience and absorbs shock as we walk.
There is an extensive ligamentous system to the spine which, with the vertebral
muscles, supports the spinal column. Nerve roots are situated close to the spinal
structures and may become trapped or subjected to pressure, particularly in the
lumbar spine where the stresses are greatest at L4-L5 and L5-S 1 levels.
In Britain, approximately 33,000,000 working days are lost each year
through back complaints (Tanner, 1987). The highest incidence is in the middle
years, when the most stress is put on the spine. Causes oflow back pain include:
heavy manual work;
incorrect lifting techniques;
poor posture;
obesity;
poor working conditions: poorly designed furniture, inaccessible controls,
restricted space, etc.;
long distance driving;
pregnancy, lifting and carrying children;
• physically less fit as age advances;
sports undertaken by older age group, e.g. bowls and golf, which involve
bending and twisting.
Most low back pain is the result of mechanical problems, due to poor body
mechanics, structural abnormality or defective vertebrae. A smaller percentage
ofback pain is caused by inflammation, infection or spinal tumours. In low back
pain resulting from internal organic problems such as kidney or uterine disor-
ders, the pain is unaffected by mobility.
Back pain is manifested in many ways and the treatment and outcome are
variable.
MECHANICAL PROBLEMS
The annulus fibrosus, or outer layer of the intervertebral discs, is composed of
fibrous cartilage. The nucleus pulposus, or inner part, is flexible and gel-like.
64
MECHA}ßCALPROBLEMS
The discs act as shock absorbers between the vertebrae. They do not 'slip' but
they can prolapse due to sudden heavy work when an individual is out of
condition, e.g. digging the garden in spring. Heavy lifting, especially when
combined with rotation of the spine, may cause the outer layer of cartilage to
rupture, allowing the nucleus to protrude and press on the posterior longitudinal
ligament, causing back pain. If the disc presses on the nerve root it will cause
pain to travel down the leg, possibly with pins and needles or numbness in the
area supplied by that nerve. The straight leg raise is often reduced (normal
flexion is 70 - 90°) and this, with signs of nerve root compression, is the routine
diagnostic test for the condition.
Facet joint strain is caused by the vertebrae being misaligned due to slack
ligaments or to a twisting or jolting injury. Pain may radiate to the thighs or
buttocks but there is no sharp pain or numbness down the leg.
After the age of 30 years, the intervertebral discs begin to dry out, resulting
in space narrowing and degeneration by the age of 60. This disc degeneration
may cause problems with the facetjoints as they are deformed. This causes low
back pain when standing and inability to lie prone. In the early stages, attention
to posture and exercises will be helpful. Spondylosis, or degenerative arthritis,
is a sequel of disc degeneration. Osteophytes may grow on the intervertebral
joints and may cause narrowing ofthe spinal canal, resulting in trapped nerves
and compressed blood vessels. The condition is known as spinal canal stenosis
and the symptoms are pins and needles, numbness, cramps and pains in the legs
on walking. The symptoms are relieved by sitting down or bending forwards,
which widens the spinal canal. Patients with this complaint may be able to cycle
and walk upstairs in comfort, in spite of severe limitation in walking distance.
Sacro-iliac joint pain is commonly caused by pregnancy and is a nagging
ache, aggravated by bending and.twisting.
Ligament injuries heal slowly and sometimes incompletely, causing chronic
low back pain. The ligaments tend to harden in old age so the spine stiffens and
stabilizes.
Spondylolysis is a small crack across the neural arch. It may be congenital
or due to a fall onto the bottom, or occur as a stress fracture in sports people.
Spondylolisthesis may develop as a sequel to spondylolysis. Part of the
vertebra may fracture and displace, causing deformity. Treatment is by decom-
pression or spinal fusion.
Scoliosis is a lateral spinal curve, occurring in childhood or adolescence.
Since it causes deformity and early degeneration, surgery is usually required.
Fractures of the vertebrae are usually due to falls, road trafiic accidents or
sports injuries. There is a possibility of spinal cord damage, in which case the
patient is usually transferred to the nearest spinal injuries centre. It is not within
the scope of this book to cover this subject. The condition which is more likely
to be met on the orthopaedic ward is the crush fracture of the vertebra, which
65
BACKPAIN
occurs in the osteoporotic spine. The vertebra becomes wedge-shaped and the
deformity tends to remain as kyphosis Of scoliosis. Treatment is by rest and
analgesics. Keeping elderly people physically active helps to prevent these
fractures because stress on bone encourages the osteoblasts to lay down new
bone cells.
Non-specific back pain has various causes, possibly the most common being
poor posture. There are differing manifestations of POOf po sture, but that most
likely to cause low back pain is the stance with exaggerated pelvic tilt and slack
abdominal muscles. The condition is aggravated by obesity and wearing high-
heeled shoes. Poor sitting posture in soft chairs with inadequate lumbar support
causes stretched ligaments in the lumbar area.
Sports people, gymnasts and dancers are prone to non-specific back pain.
Their joints tend to be hypermobile, leading to premature 'wear and tear'.
In myofascial dysfunction, taut 'knots' occur in the muscle, causing pain
which is aggravated by exercise. An example is the muscle spasm in the
trapezium muscle over the upper scapula, causing referred pain into the neck
and base ofthe skull. Such cases often respond to local injection ofnovocaine.
Psychological pressure causes tension in the back muscles, producing pain.
Frequently patients presenting with this kind ofpain with no clear physical cause
are dismissed as attempting to opt out of difficult situations. This is possible but
the patient should be assessed very carefully, since his pain may be genuine and
he needs help, be it physical Of psychological.
NON-MECHANICAL PROBLEMS
The following conditions produce back pain as a result of inflammation or
disease.
Tuberculosis ofthe spine is the most common infection, occurring mainly in
the Asian community. Back pain develops insidiously and is not relieved by
rest. The systemic symptoms oftuberculosis are present: pyrexia, night sweats,
weight loss and debility. Treatment is by antibiotics and excision ofthe diseased
bone, followed by spinal fusion with bone grafting.
Osteomyelitis is an infection of a vertebral body, which may eventually
collapse, with probable neurological complications. A local abscess may occur
as a further complication. The precise cause must be identified and specific
antibiotics prescribed. A pIaster cast is applied to prevent spinal deformity and
the area usually fuses in three to six months.
Osteomalacia is a disease similar in effect to osteoporosis. The bones
weaken, small crush fractures of the vertebrae and consequent stoop develop
and there is loss ofweight. Vegan Asians are prone to it due to dietary deficiency.
Treatment is by a few days rest, plus administration of calcium and vitamin D,
hormone replacement therapy and sodium fluoride.
66
DIAGNOSTIC TESTS
Paget's disease is the excessive fonnation of dense bone with areas of

rarefaction, therefore a tendency towards pathological fracture. Back pain rnay be
due also to spinal canal stenosis. Treatment is either by injection of calcitonin which
lowers the blood calcium and makes it available to the bones, or by diphosphonates.
Arachnoiditis is inflammation ofthe nerve sheaths in the spinal canal, which
can no longer glide smoothly through the intervertebral foramina. It may be the
result of an earlier injury or due to a now discontinued fonn of spinal investi-
gation. Pain is persistent, with possible feelings ofheat or tingling in the limbs.
It is unrelated to movement but may be relieved by trunk extension. It is treated
mainly by analgesics as there is a high recurrence rate after surgery.
Ankylosing spondylitis causes back pain of non-mechanical nature (see
Chapter 1).
Bone tumours may be primary or, more usuaHy, metastatic (see Chapter 10).
Ifthe tumour is intraspinal, pain will be accompanied by progressive neurological signs.
DIAGNOSTIC TESTS
The surgeon will observe the patient's movements and will test for extension
and for forward and lateral flexion of the spine, nerve root involvement,
sensation and power. He will check for leg length discrepancy and rotation of
the hips to exc1ude them as the cause of pain. The patient will be asked to
describe his pain, its severity, how it may be triggered, whether it occurs at rest,
how often it occurs, etc. A nerve pain is sharp and precise in location, while pain
from inflamed soft tissues is duB and vague in location.
Radiographs demonstrate some abnonnalities, such as increased lumbar
lordosis, scoliosis, narrowed disc space, osteo-arthritis, spondylolisthesis and
facetjoint asymmetry. Many spinal abnonnalities do not show up and specific
tests may be necessary.
For radiculogram, a special dye injected into the vertebral canal occupies the
space behind the vertebral bodies and the discs, so that any protrusion of the
disc blocks the flow of dye. The lesion will then appear on X-ray.
Discogram involves a radio-opaque fluid being injected under anaesthetic
directly into the intervertebral disc, using X-ray to guide the needle. This
precise1y identifies a disc problem.
Computerized axial tomography (CAT) scan reveals soft tissue abnonnality
as weH as bone. A beam of X-rays is passed through the body and records a
transmitted signal on the other side, this infonnation being processed by
computer. In this way, pictures ofslices across the patient's body enable more
accurate diagnosis.
Magnetic resonance imaging (MRI) is a development from the CAT scan,
giving a very finely detailed picture. As X-rays are not used, it is thought to be
without risk and the procedure is entirely painless.
67
BACKPAIN
When a bone scan is perfonned, a solution containing aminute amount of

radio-active material is injected into a vein and is taken up by the bones, any
hyperactive areas showingup as 'hot spots'. These areas may be due to infection,
healing fracture or a tumour. The scan provides an early and very accurate
diagnosis. There is a wait of two to three hours between injection and scan.
There are no side effects.
NON-SURGICAL MANAGEMENT OF BACK PAIN

The aims oftreatment are to:
alleviate pain;
restore function/mobility;
avoid residual disability;
prevent recurrence;
prevent development of chronic back pain.
The basic treatments are:
I. Bedrest. Inflamed tissues are rested and gravity eliminated. A finn mattress and
one pillow only is allowed and the treatment continued for up to three weeks.
2. Analgesics and, ifindicated, non-steroid anti-inflammatory drugs (NSAIDs).
3. Pelvic traction. The lower end ofthe bed is raised and the traction pulls
upwards on the pelvis, decreasing the lordosis, opening up the foramina,
minimizing any annular bulging and overcoming spasm of the erector
spinae muscles.
4. Immobilization in a corset. This helps to relieve muscle spasm and improve
posture by decreasing the lumbar lordosis and supporting the abdominal
muscles. It is a possible substitute for bedrest in milder cases.
5. Manipulation. There must be a full medical assessment before
manipulation, since it is of no benefit in the treatment of a prolapsed disc
and can be disastrous where disease is present. A chiropractor aims to
reposition specific vertebrae with thrusting techniques. The osteopath uses
rhythmic stretching of ligaments around the offending joint(s) to restore
range of movement.
Mobilization phase
The aims of exercise are to:
1. restore nonnal range of movement;
2. improve the power ofthe spinal and abdominal muscles, thereby reducing
stress on bones and joints;
3. improve posture to prevent recurrence.
68
NON-SURGICAL MANAGEMENT OF PAIN
Mobilization should be gradual after complete bedrest. Extremes of move-

ment and any stretching of an irritable nerve must be avoided. The physiother-
apist will teach specific exercises, depending on the site and cause of the pain.
Pelvic tilting and spinal extension exercises are commonly taught.
Patients frequently ask what type of exercise they may safely undertake.
When walking, the arms should be free to swing, which produces a few degrees
of rotation with weightbearing which improves the strength ofthe annular fibres
of the discs. Swimming provides excellent exercise, apart from breast stroke if
the swimmer holds his head c1ear ofthe water. Cyc1ing is good, provided upright
handlebars are used and a spongy saddle to absorb shock.
Posture
When standing correctly, a plumbline should pass in front ofthe ear, through
the shoulder, just behind the lumbar curve, through the hip joint and just in front
ofthe knee and ankle. Slight variations may occur, depending on the individual' s
body shape. Ifposture is correct, balance is maintained using minimal energy.
Conversely, poor posture results in imbalance, fatigue and possible pain.
Two concepts of posture exist, one emphasizing the importance ofdecreasing
the pelvic tilt, the other advocating maintaining the lumbar lordosis at all times.
Cailliet (1988) believes both have their merits depending on the individual patient.
Po sture is influenced by heredity, culture, occupation, mechanical abnormal-
ities and habits formed early in life, which become deep-seated in neuromuscular
proprioception. Po sture modification requires time and commitment and mon-
itoring by a professional person.
Pedretti (1981) lists the correct postures for proper body mechanics as
follows:
1. Sitting: use a lumbar support in the chair, or a footstoo1. Get up and
move around every 45 minutes (this is an arbitrary figure).
2. Lying: on the back, use a pillow under the knees. On the side, use a pillow
between the legs.
3. Lifting: keep feet apart, bend knees, tighten abdominal musc1es, avoid
twisting, retain lumbar lordosis, hold object c1ose.
4. Carrying: as for lifting and hold object at waist level.
5. Reaching: if above the shoulders, use steps.
6. Pushing: in preference to pulling. Push with legs or entire body weight to
initiate movement.
7. Pulling: avoid if possible. If it must be done, retain the lumbar lordosis, bend
knees, keep feet well apart, use body weight to puB, not back musc1es.
8. Mounting stairs: walk on the front part ofthe foot.
69
BACKPAIN
The Back School

The Back School concept is directed at the patient with persistent back pain to enable
hirn to take some control ofhis own treatment (Cailliet, 1988). Hs aims are:
to encourage a positive attitude and maintain anormal lifestyle;
to improve the condition of the tissues needed for proper function;
to assist recovery and prevent recurrence of pain.
The objectives are to enable the patient, following instruction and practice:
to understand the basic anatomy and physiology of his back;
to strengthen and maintain in good trim the musculature of his spine and
abdomen, by regular performance of specific exercises;
to be aware of, and avoid, harmful positions and activities;
to perform all necessary ADL tasks, with the aid of any tools deemed
necessary.
The Back School may be run by the physiotherapist or the occupational
therapist, or both together. Typically, the programme is covered in four to six
sessions over aperiod of two weeks or more. This programme consists of:
1. explanation of the basic anatomy and physiology of the spine;
2. instruction in body mechanics, i.e. use ofthe spine with the least amount of
stress;
3. instruction of exercises to build up tolerance and endurance, improve
po sture and, in the upper limbs, to aid lifting and carrying. patients are
wamed to stop an exercise if it causes pain;
4. advice on how to approach all aspects of daily living activity, to put the least
stress on the spine;
5. instruction in energy conservation;
6. advice on stress management and instruction in simple relaxation
techniques.
1fthis Back School concept was incorporated into the orientation programme
when employees started a new job, the employers could take steps to minimize
the risk of injury by identifying the potentially damaging tasks and educating
the employees accordingly. The scheme would be ofmutual benefit to employer
and employee.
Physiotherapy for persistent back pain

In addition to the exercises and postural training, the physiotherapist may use
any ofthe following in the treatment ofback pain:
70
hydrotherapy;
massage;
ice packs;
superficial heat, especially before exercise or manipulation;
• ultrasound, especially for sports injuries;
short wave diathermy (a high frequency wave which prornotes tissue
healing);
interferential (a low frequency wave which reduces inflammation and
temporarily relieves pain);
transcutaneous electrical nerve stimulation (TENS).
This last is based on the 'gate' control theory of pain perception which is
discussed in Chapter 11.
THE ANAESTHETIST'S ARMOURY

When back pain has failed to respond to the foregoing forms of non-surgical
treatment, the anaesthetist has at bis disposal the following methods of pain relief:
1. Lumbar epidural injection. Tbis consists of a local anaesthetic and
soluble steroid injected into the epidural space, used in the treatment of
sciatic pain. A second or third injection may be necessary at weekly
intervals. For more intractable problems, an indwelling catheter may be
employed, topped up as necessary.
2. Nerve root block injection. This is used only after all other treatment has
failed. Local anaesthetic and steroid are injected into the specific nerve root.
3. Facet joint injections. The local anaesthetic and steroid are injected directly
into the damaged facet joint.
Other techniques are available but these three are most widely used.

The occupational therapist must first acquaint herselfwith the patient's medical
history. At the initial interview she must explain her role regarding his treatment.
She should then ask about his horne situation; whether he lives alone, in what
type of accommodation, what support is available, what special responsibilities
he has, etc. If he is employed, she should ask what his job involves, how he
travels to it and discover his attitude towards it. Careful observation of the
patient's movements, walking, sitting, reaching, etc. will demonstrate any
limitation in movement and any groaning or grimacing should be noted. Posture,
standing and sitting tolerance should be assessed and his performance noted
when he is given a bulky parcel, weighing about 7lbs (3 to 3.5 kg) to Hft and carry.
71
BACKPAIN
Functional perfonnance must be assessed, noting any difficulty in getting in

and out of chair, bed or bath, on and off the toilet and dressing his lower half.
The therapist should ask the patient how his back pain affects his daily life,
and she must be prepared to listen. The tale told, and the way it is told, may be
very revealing and may enable the therapist to make a psychological assessment
of the patient, noting whether he is depressed, angry or frustrated.
The occupational therapist will now be in a position to plan the treatment,
which may include:
• instruction in correct posture;
• instruction in lifting techniques;
• advice on back care;
• provision oftools for living;
• possible referral to social worker or clinical psychologist;
• possible referral to Disablement Resettlement Officer.
Ifthe patient's episode ofpain is acute in nature, it is wiser to teach proper
body mechanics rather than provide tools for living. These tools should be
provided only for long-tenn or recurrent back pain, and then only the minimum
tools supplied, as they might reinforce the invalid role. Possible tools include:
• reasonably high chair with good lumbar support;
• flnn bed of suitable height;
work surfaces suited to the patient's height;
• toilet seat raise, toilet frame or handrails;
long reacher;
long shoehom;
• sock or tights aid;
elastic shoelaces;
• long-handled sponge;
perching stool to avoid standing for long periods;
long-handled dustpan and brush;
• long-handled gardening tools.
Advice on back care

The physiotherapist may teach the techniques of lifting and instruct in postural
improvement, and the occupational therapist will reinforce and build on this.
Lifting is so crucial to the care of the spine that some detail is necessary. To
enlarge on the brief mention made in the Pedretti reference:
Test the object to be lifted. If it is too heavy or awkward, get help.
Stand with feet apart, the leading foot pointing in the direction of travel.
Never lift and twist at the same time.
72
Bend the knees, using hip and thigh muscles to lift, with the object between
the knees.
Hold load close to the body.
• When rising, 'uncurl' the spine gradually. Do not regain the lumbar lordosis
too quickly.
Follow the above sequence in reverse to put an object down.
When lifting with one arm, e.g. a bucket, the above principles should be
followed but the free hand must be placed on the bent knee to support the trunk.
Lifting above shoulder height increases the lordosis and alters the balance, and
lifting an object above head height is even more hazardous. One foot must be
placed behind the other and the weight transferred onto the back foot as the
object is lifted down. Sturdy steps should be used if possible.
Seating
Sitting imposes additional stress on the spine and low back pain is usually
increased by sitting in a low chair with the back bent into a C shape. Firm
upholstery is to be preferred. Ideally, achair should be made to measure and the
roles as laid out in Chapter 1 may be followed. There should be enough seat
space to enable changing position, as sitting too long in one position will
aggravate the pain.
People who sit long hours at a desk need an ergonornically designed chair.
The seat height and angle and the backrest angle should be adjustable, and it
should be possible to lean forwards over the desk and lean back to talk in achair
which will accommodate both positions. The Droopsnoot does this by virtue of
a rocker base. With this chair, as with others with a forward inclining seat, such
as the Balans seats, the knees are bent so that the feet are positioned beneath the
hips which encourages a good natural position for the spinal curves. The Putnam
wedge placed on the chair seat has a similar effect. (Details ofsuppliers in appendix.)
The desk top should be at elbow height and sloping upwards away from the
user, with a holder for copy material, in order to prevent neck strain.
Various portable backrests are available for adapting unsuitable chairs and may
be used in cars, at places ofentertainment, etc. They usually consist of a moulded
framework to support the lumbar curve and should be adjustable. A cheap,
simple support may be made with a small towel rolled up or a small cushion
lightly filled with polystyrene beads, tucked into the lumbar curve when sitting.
If an existing chair is too low but otherwise supportive, it should be raised
from below by one of the methods suggested in Chapter 1.
Sitting with the legs slightly apart puts less stress on the spinal muscles than
with the legs together. If suitable clothing is wom, decency need not be
sacrificed!
73
BACKPAIN
It must be remembered that since back pain has various causes and the
individual 's build is another variable, the rules regarding seating must remain flexible.
Mattresses
These should be firm but the surface should 'give' a little to accommodate the
body contours. Ifthe mattress is too soft, a board must be placed beneath it. The
board must be wide enough to allow for rolling over in sleep and should reach
from the head to at least below the buttocks.
Patients who are considering buying an 'orthopaedic' mattress should be
advisedthatthese are nobetterthan a goodqualityfirmmattress and are more expensive.
Back sufferers will find the use of pillow support helpful, as suggested
earlier. In addition, when lying on the side, a pillow in the hollow beneath the
waist may help.
Getting out ofbed often presents problems. The patient should He on his side,
bend both knees, lower the feet to the floor, at the same time pushing the trunk
up with the hand, to prevent lateral flexion or rotation of the spine. The height
ofthe bed should be 20-24 inches (51-61 cm), depending on the individual's
height, to enable easy rising.
Batbing
A non-slip mat on tbe floor oftbe bath or shower is essential for safety, and a
handrail on the wall, at the optimum position for security and support, is
desirable. The patient may find he can more easily get in and out ofthe bath by
standing side on to it, bending the nearer knee and lifting the leg sideways over
the side ofthe batb, then repeating the process with the other leg. Ifthe batb is
high, a platform may be used with this method.
Patients may be tempted to lie in a warm bath to obtain comfort. The position
in which they lie is harmful and causes more pain afterwards. Standing to shower
is preferable and the hair may be washed at the same time. Ifthere is no shower,
the hair should be washed while kneeling in the bath.
The teeth may be brushed while standing erect. The only time when bending
is necessary is when rinsing the mouth and then the hips and knees should do
tbe work.
Dressing
Tbe problems occur when dressing the lower half, and in order to do this it may
be more comfortable to stand with the back against a wall and bring the foot up
to get clothing on. The foot may be placed on a stool in order to tie the shoelaces.
Tbe patient should be reminded not to stretch any elastic laces before tying tbem
74
in a permanent bow, as there will then be no remaining elasticity to enable easy

slipping on and offthe shoes. Shoes with a low heel and resilient soles to absorb
shock should be wom.
It is important to wear clothing suited to the job in hand. Old or dirty clothing
should be wom for handling dirty work, so that items may be held close to the
body without fear of spoiling clothing.
Housework
Back pain is a good excuse for avoiding this! Long-handled implements should
be used where appropriate and an upright vacuum cleaner may be used, walking
to and fro with it, not bending either forwards or laterally if suffering an acute
episode. To reach under fumiture, the patient should kneel on one knee and if
'getting down to the job', he should kneel on a pad, support the body weight
with one hand and work with the other. Wben cleaning windows or otherwise
reaching upwards, a sturdy stool should be used and care taken not to over-reach.
If a bucket of water is used, it should have the minimum of water in it.
It is wise to get each member ofthe household to clean the bath after use. It
is easier to clean it before getting out, or a good bubble bath will clean both bath
andbather.
Use of fitted sheets and duvets make bedmaking simpler. Wben changing
bed linen, the job should be done in the kneeling position and care taken not to
reach across a double bed, but to approach the bed from both sides.
Kitchen
Ideally the work surface height should be correct for the height of the individual,
with a continuous level surface to include the cooker top so that items may be
slid along rather than carried. A high-level oven is to be preferred, otherwise it
is necessary to kneel to use the oven. Regularly used items should be stored
within easy reach, and tumtables inside cupboards or shelves on the inner side
of cupboard doors help in this respect.
If standing is painful, a perching stool may be used for preparation of meals
but there may then be tension in the back muscles or the patient may weil slump
into a poor postural position. If the pain is caused by a trapped nerve, the patient
may find reliefby resting the affected leg on a footstool while standing.
Laundry
If the bowl is not high enough for handwashing in comfort, it may be put on the
drainer or placed on a second bowl uptumed in the sink. The clothes should be
swirled in the water and not lifted up and down, and only a little should be
75
BACKPAIN
washed at a time. It is necessary to kneel to load a frontloading washing machine.

When emptying the machine a basket should stand ready on a stool to receive
the washing, and rotating of the trunk during this procedure is to be avoided.
The laundry should be wheeled out on a trolley for hanging out and a prop or
pulley system used so that the clothes line is not too high.
When ironing, the board should be adjusted to two inches below elbow height
and only essential ironing done, a little at a time. A stool or footstool may be
used as described for kitchen activities.
Shopping
This should be done a little at a time if possible and the load evenly divided
between two bags. A shopping trolley is difficult to unload and dragging it
causes rotation stresses on the spine. If the handle is high enough to be pushed
without stooping, a trolley is suitable. When shopping by car, the heavier bags
should be placed close at the front ofthe boot and the lighter items further back.
The same mIes apply to carrying and loading luggage.
Driving
Driving is a major factor in the aggravation of low back pain, especially if the
driving seat is poorly designed or the driver is uncomfortable or tense. If the
seat is over-hard, every bump orvibration is transmitted up the vertebral column.
The backrest should support the lumbar curve, with extra support ifnecessary.
Alternatively, the driving seat may be replaced with a more supportive model.
The pedals should be in a direct line with the legs, allowing the heels to rest
comfortably on the floor.
To get into a car, the seat should be moved weIl back. The driver should sit
on the seat, bending the hips and knees but maintaining the lumbar curve, and
should then bring the legs into the car, avoiding twisting the spine. It may then
be necessary to move the seat position forward to reach the controls. On a long
joumey, the driver should stop and walk about at intervals.
Sport
Injury is less likely to occur ifthe individual warms up first. Contact sports may
be contra-indicated, and golf, tennis serving and cricket bowling involve rota-
tion ofthe spine. Jogging is contra-indicated, as itjars the spine. Any walking
or sporting activity demands that well- padded, resilient shoes are worn in order
to absorb shock.
76
Gardening
When digging (or clearing snow) a small spade should be used, or a small border
fork ifthe soil is heavy clay. The work should be done from the hips and knees,
using the body weight to push the spade into the ground and keeping the back
straight. Only a little digging should be done at a time and never if the soil is
wet. A Terrex spade with a spring-loaded device to ease the work may be used,
or the task delegated. Rakes and hoes should be used while standing erect.
Wheelbarrows must be lightly and evenly loaded and the initial lifting and
lowering of the handles done by bending the knees. The two-wheeled barrow
causes less stress to the spine.
Mowing machines should be pushed forward using the body weight, and
hover machines avoided. Hand weeding and planting out should be performed
as for floor-Ievel kitchen activities. 'Easi-kneelers' are not helpful to back
sufferers, since one has to bend down an extra few inches to reach the ground.
Special weeding tools are available, but no one weeder seems to be suited to the
uprooting of every type ofweed.
Looking after babies and small children

When carrying children, the principles oflifting should be observed. A cot with the
sides lowering right down or a bed with cot sides should be used, and the knees
and hips bent for lifting the child in and out. Nappies must be changed on a high
surface and the same applies to bathing a baby. The bath may be mIed and baled out
using a jug to avoid heavy lifting, or a Sunflower Shallowbath or similar
adaptation used in the bath, while kneeling to bath the child. A toddler can be
encouraged to climb onto adesignated stool for help with dressing or to be picked
up. If a toddler starts to bounce or wriggle while being held, he must be put down.
Caring for the elderly or handicapped

Carers are at risk ifthey have to turn, lift or carry disabled relatives. This risk
increases as the carer grows older and the elderly relative deteriorates or the
handicapped child grows. Caring for an orthopaedic patient in piaster is heavy
and the patient is unwieldy, so it follows that the carer needs advice and
equipment to protect his back, for his own sake and for that of his dependent.
Astart can be made by advising on equipment for use in the ward, and this can
be continued into the horne situation. Carers must be taught correct lifting
techniques to maintain their own physical fitness by doing exercises for spinal
and abdominal muscles and, if they have a back problem, must wear a lumbar
support when lifting. They should also be advised on diet for the dependent, to
prevent them becoming overweight.
77
BACKPAIN
It is important that bed, chair, commode or toilet heights are the same to
enable sliding transfers withouthaving to lift. A turntable also helps with
transfers and a monkey pole over the bedhead enables the dependent person to
help hirnself. A hoist may be provided after careful assessment and instruction
in use. Simpler lifting aids are available including the patient handling sling,
which in effect lengthens the carer's arms so that he can keep his back straighter
when reaching forward to lift.
Sexual problems
Sexual problems are usually due to pain but complaining ofback pain may be
an excuse to avoid sexual activity. Anxiety or depression may cause inability to
achieve an erection, producing further anxiety. This may require counselling
and possible medication.
The pain problem may be overcome by:
a simple analgesie half an hour before intercourse;
use of a firm mattress, with a pillow under the lumb ar spine;
possible reversal of traditional male and female positions;
the woman on all fours, with her partner approaching from behind;
the man sitting on achair with his partner sitting astride hirn;
both partners lying on their sides.
If sexual intercourse is too painful and frustrating after these suggestions
have been tried, it may be preferable for the couple to concentrate on other
aspects ofloving intimacy.
A booklet incorporating the foregoing, from 'Advice on Back Care' onwards,
may be drawn up and given to patients to remind them to take continuing
responsibility for their own back care.
REFERENCES AND FURTHER READING

See lists following Chapter 6.
78
6
Spinal surgery
Spinal surgery is performed on only four patients in every 10,000 recorded

attacks oflow back pain (Jayson, 1987). Conservative treatment is always tried
first.
Criteria for spinal surgery include:
radiological evidence of loss of disc space;
persistent sciatica;
persistent neurological signs, with muscular weakness and loss of tendon
reflexes;
progressive spinal abnormality and deformity;
disease such as TB or tumour.
It is useful for the occupational therapist to know in broad outline what is
involved in the most frequently performed spinal operations.
DISCECTOMY
The more usual discectomy procedure is the removal ofthe whole disc to prevent
recurrence, although if most of the disc is in place, the protruding piece only
may be removed along with any loose fragments of cartilage. If the vertebra is
likely to displace, the surgeon will perform a spinal fusion between the vertebrae
adjacent to the discectomy. The patient may then wear a lumbar corset for a few
weeks post-operatively. He may return to work within four to six weeks, or three
months ifhis work is heavy.
Decompression
If spinal canal stenosis is caused by a disc protrusion, discectomy is performed.
This may be accompanied by decompression to widen the spinal canal and
prevent pressure on a nerve root. Small pieces of bone are removed to widen
the spinal canal. There are two types of decompression:
1. laminectomy, with partial or complete removal of the lamina of the vertebra;
2. facetectomy, where bone is removed from the inner edge of the facet joint.
79
SPINAL SURGERY
The patient begins to mobilize two to three days after surgery, and is
discharged after seven to ten days. He must avoid lifting and strenuous exercise
for three months.
SPINAL FUSION
This operation is carried out if there is excessive mobility in the lumbar spine
or ifthere is facet joint damage. The latter may be caused by spinal degeneration,
failed back surgery or as a later result of disc trauma. Spinal fusion is performed
to relieve spondylolisthesis, where the misaligned vertebrae are damaging
nerves, causing pain, numbness and tingling in the legs. It is also the procedure
used to treat the TB spine.
There are differing techniques for the operation, as surgeons develop their
own methods (Figure 6.1). One is the interbody fusion where the disc space is
Figure 6.1 Alzar spinal fusion
80
SPINAL FUSION
Figure 6.2 Posterior segment fixator in situ
filled with bone chippings, usually from the ilium. Another is the posterolateral
fusion, in which slivers ofbone from the ilium are placed over the facetjoints
between the transverse process, on one or both sides of the vertebrae. A third
technique is the spinal fusion done in two stages: the first a posterior fusion,
then if this is considered to be insufficiently stable, an anterior fusion is
performed a few weeks later.
Post-operatively the patient is on bedrest for two weeks or more, then may
wear a pIaster cast or corset for six to eight weeks. It takes about six to 12 months
for the patient to feel the full benefit from the operation. Because the fusion has
reduced movement in one area, the adjacent joints will be more stressed.
Adhesions may result from post-operative inflammation. This may result in
chronic back pain.
The posterior segment fixator (PSF) for the spine aims to reduce interverte-
bral deformity by means of screws anchored in the vertebrae through the
pedicles (Figure 6.2). This stabilizes the vertebral segments and allows early
81
SPINAL SURGERY
mobilization without the need for external back supports. The device may be
used to correct spinal instability, scoliosis, infections, tumours, spondylolisthe-
sis and may act as a stabilizer while healing takes place following spinal fusion.
It may be left in situ or removed at a later date.
INSERTION OF A HARRINGTON ROD

This operation is one which is performed for severe scoliosis, usually in an
adolescent. For the whole length of the scoliosis, the spinous processes are
removed and the outer layers ofbone chipped back to form flaps. A telescopic
Harrington rod is inserted to open up the curve for distraction on the concave
side, and another rod may be used for compression on the convex side. Chips
ofbone, usually from the ilium, are laid along the curved section and the bone
flaps turned down over them. The patient is discharged after two to three weeks,
and is off work for another month. He must avoid sports for six to 12 months.
The rods are removed later, when the fusion is solid. While this surgery
improves the patient's appearance, it does result in a very stiffback.
HALO TRACTION
This is sometimes used in the treatment of scoliosis or as a form of splinting
following spinal fusion. It consists of a metal 'halo' round the skull penetrating
the outer part of the skull by means of four screws, with four distraction bars
connecting the halo to a pelvic hoop which is held by two pins inserted through
the ilium and sacrum. Distraction proceeds at the rate of 1 mm per day. Spring
balances on the distraction bars record the pressures very carefully. The patient
is carefully monitored for signs of double vision, neck pain, pain in limbs or
around the screw holes in the skulI, sensory abnormalities and muscle weakness.
The patient is encouraged in personal independence. The most obvious
precaution is to remind the patient to pay attention to his unaccustomed height
when going through doors, otherwise a very unpleasant and possibly damaging
jolt will occur.
The use of a monkey pole is contra-indicated in this case.
POST-OPERATIVE PRECAUTIONS AFTER SPINAL SURGERY

The immediate precautions are rest, and probably wearing a back support when
mobile. The longer term precautions are covered by 'Care of the Spine' in
Chapter 5. The patient who has had any kind of spinal surgery should be
encouraged to think positively, to accept that the cause ofhis back pain has been
dealt with, and to work towards a normal lifestyle, while taking sensible
precautions.
82
POST -OPERATIVE PRECAUTIONS
The physiotherapist teaches the patient how to get in and out ofbed, in the
method described in the previous chapter. When on bedrest the patient may
usually lie in the position he finds most comfortable, provided the spine is not
rotated. A pillow between the knees when side-Iying and/or a pillow under the
waist curve will help to prevent undesirable positions. When rolling over, the
patient should turn the whole body, head and legs in one smooth movement. If
the facet joints are involved, lying prone is uncomfortable and lying on the back
increases the lordosis, causing pain. Lying on the side with hips and knees bent
approximately at right angles is more comfortable.
As the patient starts to mobilize, the physiotherapist encourages him to 'walk
tall' and to concentrate on his posture. Short walks are gradually lengthened as
strength returns, and after exercise the patient lies on the bed to rest. No walking
aids are used. Standing is avoided in the early days.
Sitting is delayed until seven days post-operatively, and for three to four
weeks in the case of spinal fusion. At first the patient sits just to eat meals,
gradually progressing to longer periods in achair. Sitting up in bed with the legs
outstretched is not allowed. Crossing the legs is contra-indicated, as this causes
a tilted pelvis, spinal imbalance, compression ofthe discs and possible pressure
on a nerve root on the side to which the leg is crossed.
Surgical corsets and spinal supports

Since a significant proportion of patients are fitted with spinal supports im-
mediately following surgery, and since the wearing ofthese supports has some
bearing on the daily living activities of the patient, it is useful for the occupa-
tional therapist to know the theory behind this provision and the types of support
which may be used.
The purpose of the corseting is to restrict movements of the lumbar spine to
allow healing to proceed, and to encourage use ofthe hips and knees for bending
activity. 'Off-the-peg' corsets have no place in this context, as they never fit
properly.
The types ofback support include:
1. Corsets made to measure. These include corsets with a pocket enclosing
a mouldable panel, which is moulded to the patient's back in the same
way as for splinting ahand, with the patient lying prone.
2. Neofract moulded jackets with a zipped fastening, so they are removable
for bathing or lying down. They have the advantage ofbeing rigid and really
supportive without the weight and bulk of pIaster ofParis.
3. PIaster ofParis cast. This is sometimes applied after spinal fusion. It restricts
movement for 24 hours a day and is worn for approximately six to eight
weeks. It is heavy and claustrophobic.
83
SPINAL SURGERY
When a patient is wearing any ofthese supports, it is apparent that when he

sits down, the corsetlsupport is pushed up. This is especially obvious with the
pIaster cast, and some ofthese are moulded in a vest-like shape, which may push
up almost to the patient's ears. Not surprisingly, the patient is depressed by this
cumbersome and ugly contraption and needs much encouragement and some
suggestions as to how to minimize the problems it causes. Not least of these
problems is the frequently encountered one oftoilet hygiene, because the patient
cannot twist to reach the anal area. It is important that an efficient tool is
provided so he can maintain his independence in this most intimate task. A
sponge on an angled handle approximately nine inches long, with a slit in the
sponge on the outer rim to slot in the ends of the toilet paper, is helpful. The
shorter ofthe long-handled sponges commercially available is suitable.
During the wearing of a spinal support, the patient is doing static exercises
to strengthen his spinal extensors and abdominal muscles. The support is a
means to an end and should be wom for a limited period, as prescribed by the
surgeon. If it is wom for too long, the patient' s musculature becomes dependent
on it and these soft tissues weaken and become ineffective, leading to collapse
of the spine. Once the prescribed period for wearing the support has expired,
the corset should be dispensed with so that the muscles and ligaments may take
over their normal function. A corset may be retained to wear intermittently,
when doing heavier work, undertaking prolonged activity, during a long car
joumey, or to use briefly during an acute episode.
The aims and objectives of both physiotherapy and occupational therapy are
similar to those listed under the Back School concept in Chapter 5.
Use of correct seating with adequate spinal support is important. To rise from
his chair, the patient should move forward in the seat and push upwards and
forwards with the hands from the chair arms, maintaining the lumbar curve. If
rising from achair without arms, 'walking' the hands up the front of the thighs
may facilitate standing. The patient should stand up straight before starting to
walk.
Once the patient is able to use the ward toilet, the occupational therapist
should ascertain whether he needs any toilet aids on discharge. Such provision
will depend on what type of surgery has been performed, the patient's height,
age, and whether he is wearing any spinal support. He should try out toilet aids
so that he is familiar with their use. Any necessary equipment should be
requisitioned from the community agency in time for it to be fitted in readiness
for the patient's discharge.
Bending down is avoided for at least four weeks in the case of spinal fusion,
much longer if bone grafting has been employed, possibly less in the case of
84
CERVICAL SPINE
decompression. The surgeon will advise the patient on this, depending on the
surgical technique adopted. Meanwhile the patient is encouraged to get used to
bending from the hips and knees instead. A long reacher is needed from the
outset for spinal fusion patients, and may be in use for many weeks. Most
patients will be independent in dressing by their discharge date, using a long
reacher for putting on pants and trousers, and if sciatic pain was present before
surgery, the leg in which this pain was experienced should be put into the pants
first. Putting socks or tights on while lying on the bed may preclude the use of
aids.
If the patient is wearing a pIaster cast he will be limited in what clothing he
can wear, as his girth will be much increased by the bulk of the pIaster. Track
suits are useful as they are loose fitting and are relatively inexpensive. Some
patients may need referral to the social worker for help in purchasing larger sizes
in clothing.
Tools for living

Similar items to those listed for back pain will be needed. The need for
equipment is greater than for back pain which has been conservatively treated,
but the patient is given to understand that the equipment will be needed for a
limited period, until healing has taken place.
If achair is obtained for a patient on short term loan, he should be made aware
that while he is borrowing this chair he should be taking steps to obtain a suitable
chair for himself for permanent use. The necessary information for doing this
is best provided in an information sheet after verbal andlor practical instruction.
A flow chart is useful to monitor achievement of objectives (Figure 6.3).
So far we have considered only pain in the lumbosacral area. The occupational
therapist's services are also needed after surgery to the cervical spine and the
coccyx.
CERVICAL SPINE
Neck postural pain due to work at a desk with the head bent for long periods,
possibly with the shoulders hunched, leads to chronic muscular tension. Advice
on suitable office fumiture may be given, as discussed in Chapter 5.
Facetjoint problems in the cervical spine cause aching and sharp twinges of
pain, with pins and needles or numbness in the hands and possibly loss of
balance, headache, tinnitus and referred pain in the side of the face, ear or neck.
Vertebro-basilar insufficiency is due to vertebral artery compression, prob-
ably caused by osteophytes giving rise to spinal canal stenosis. Turning the head
or stretching the neck then causes giddiness or blackouts.
Brachialgia is caused by protrusion of a cervical disc pressing on a nerve
85
OCCUPATIONAL THERAPY DEPARTMENT SP. SURG.
_ ...
NAME' -- NUMBER' DATE'
- - -
Pre-Op Op. Day 1 Day2 Day3 Day4 Day 5 Day6 Day7 Day 8 Day9 Day 10 Day 11 Day 12 Day 13 ete
Introduce As pre-op
self. check ifnot
horne aIready done.
situation, Loan
help, HlHand
aCCOffi,etc
Whenpt.
upto W.c. Monito progress
assess ."
needs
Discuss AD Dressing
solutions an practice
~
precautions lowerhalf
incl. wotk Tools neede ?
Preliminary Detailed Check equipmenl
referral to referral plus delivered and
supplierof expected fitted
equipment discharge date
Teach
technique
for inloU!
ofbath
Figure 6.3 Flow chart for monitoring achievement of objectives following spinal surgery
COCCYDINIA
root, producing severe pain down the arm to the hand, possibly with numbness
or pins and needles. There mayaiso be upper limb weakness.
Patients with rheumatoid arthritis with instability of the atlanto-axial joint
may present with symptoms of spinal cord compression, causing neurological
signs in the lower limbs, e.g. spasticity, sensory loss or incontinence.
Patients with any of the conditions listed above, with the exception of
postural pain, may require a cervical collar to provide support, reduce pressure
and prevent undesirable movement. This will relieve pain and allow inflamma-
ti on to subside. Standard collars are adequate in mild cases but a moulded collar
in thermoplastic splinting material or block leather may be indicated, which may
be fitted by the orthotist, physiotherapist or occupational therapist. The aim is
to achieve a closely fitting, highly supportive splint to prevent movement ofthe
cervical spine. While there is some controversy over this, it should reach from
the occipital condyles down to the seventh cervical vertebra or lower at the back,
and support the chin and reach to the manubrium sterni at the front. Depending
on the surgeon's directions, the patient will wear the collar for 24 hours a day
or during the day only, for a variable length of time. lt should be discarded
gradually, but retained for use on car journeys. In cases of instability of the
atlanto-axial joint, the collar is worn until the instability is resolved and not
discarded until the surgeon has confirmed that it is safe to do so.
The patient may be more comfortable when Iying down if the pillow is
twisted in the middle to form a 'butterfly' to stabilize the neck. Various pillows,
shaped to accomrnodate the cervical curve, are available. Alternatively, a small
towel may be rolled up and wrapped around the neck at night.
Fusion ofthe cervical spine may be unavoidable. The operation carries some
risk of paraplegia or even death. A neurosurgeon is therefore often called in to
perform the surgery. Post-operatively the patient is discharged after ab out four
to ten days wearing a rigid collar. He may be able to return to work in a month
at the surgeon' s discretion, or after two months if his work involves lifting or
driving.
COCCYDINIA
This is due to a fall onto the coccyx. lt is very painful and may persist for a long
time. An injection oflignocaine or marcaine may relieve the pain, but occasion-
ally surgery is necessary.
Coccygectomy involves the removal ofthe last two or three segments ofthe
coccyx. In the case ofnon-union ofa fractured coccyx the fragment is removed.
Post-operatively the patient is up in a few days and may return to work in two
to three weeks.
The main problem before and imrnediately after surgery is sitting comfort-
87
SPINAL SURGERY
ably. An anti-pressure type cushion may be needed to disperse the load, or a

cushion provided with a channel running centrally from front to back, so that
there is aspace beneath the coccyx. If the patient fmds bending is also painful,
he may need a reaching tool for a few weeks.
In over 30% of cases, surgery fails to relieve low back pain and many patients
seek further surgery (Cailliet, 1988). Ifthe patient's pain continues for over six
months, chronic back pain is considered to have developed, although Cailliet
writes that some authorities consider that six weeks of persistent pain constitutes
chronic pain. The aim in the treatment of low back pain is to prevent develop-
ment of chronic pain syndrome, because of its high emotional cost to the patient
and his family and the high financial cost to the employer and the cost ofhealth
care. The occupational therapist has much to offer in the prevention and
treatment of this syndrome, and this is discussed in Chapter 11.
REFERENCES FOR CHAPTERS 5 AND 6

Cailliet R. (1988) Low Back Pain Syndrome, F.A. Davis, Philadelphia.
Jayson, M.V. (1987) Back Pain: Thefacts, 2nd edn, Oxford Medical Publica-
tions, Oxford.
Tanner, J. (1987) Beating Back Pa in , Dorling Kindersley, London.
FURTHER READING
Mounayer, B. and Wyn-Williams, S. (1989) The Back Shop Book, Macdonald,
London.
Willer, A.P. and Rowland, D. (1985) Back to Backs. Published by the authors,
available from Wimbledon Physiotherapy Clinic, 28a Wilton Grove, London
SWI93QX.
88
7
Shoulder surgery
By eomparison with hip and knee surgery, relatively few operations have been
performed on the shoulder. Those whieh have have been mainly for repair of
fractures of the proximal humerus, and for theurnatoid and osteo-arthritis of the
shoulder joint.
THE ROTA TOR CUFF

At the glenohumeral joint, movement takes plaee between the humerus and
seapula, and between the seapula and ehest wall, when the arm is abdueted. The
stability of the joint depends largely on the muscles and tendons surrounding it,
the tendons being inserted into the tuberosities ofthe humeral head. The tendons
involved are subseapularis anteriorly, and supraspinatus, infraspinatus and teres
minor posteriorly, and these blend with and reinforee the joint eapsule. Collee-
tively they are referred to as the rotator euff.
In the event of a fall, the rotator euff is vulnerable and there may be extensive
damage, depending on the direetion ofthe fall. The most likely tendon to be tom
is that of the supraspinatus resulting in the inability to initiate abduetion,
although onee the arm is passively abdueted, the deltoid takes over in raising
the arm. Following a tear in the rotator euff, rest is usually reeommended for a
short period, then mobilization eommeneed quiekly to prevent stiffness devel-
oping. Repair surgery is possible but trieky. Lesions of the rotator euff are
signifieant in the prognosis following shoulder replaeement.
If eonservative treatment for glenohumeral arthritis fails, any of the follow-
ing operations may be eonsidered:
1. total shoulder replaeement;
2. hemi-arthroplasty;
3. arthrodesis.
TOT AL SHOULDER ARTHROPLASTY

This operation involves the replaeement ofthe humeral head and the resurfaeing
of the glenoid eavity. There are eonstrained, uneonstrained and semi-eon-
strained types of prostheses.
89
SHOULDERSURGERY
The constrained prosthesis consists of a linked ball and socket joint which
produces a rotating unit but does not allow for the small amount of shift that
occurs during rotation, when the humeral head moves upwards in the glenoid
cavity. On abduction the head of the humerus descends in the glenoid cavity.
The glenohumeral joint is therefore a minimally constrained joint with a wide
range of mobility, depending largely for its stability on the musc\es of the
shoulder girdle. The constrained prosthesis therefore limits the restoration of
mobility, and there is a tendency for the glenoid component to loosen. Initially
Figure 7.1 Neer 11 total shoulder replacement
90
TOTALSHOULDERARTHROPLASTY
pain relief is good but once the prosthesis loosens, pain recurs. The Stanmore
prosthesis is an example of a more constrained arthroplasty. If the rotator cuff
is damaged, a constrained prosthesis must be used.
An unconstrained arthroplasty depends for its stability on an intact rotator
cuff. The prosthesis consists of a metal humeral component and a glenoid
component with a keel for fixation. The glenoid component is of high-density
polyethylene, or metal-backed high-density polyethylene, cemented in place.
The Neer II prosthesis is an example and more nearly resembles the natural
shoulder joint (Figure 7.1). The unconstrained type may become semi-con-
strained by using a glenoid component with a lip posteriorly, to resist subluxa-
tion when the arm is abducted.
A survey of70 total shoulder replacements conducted in Ontario, Canada,
demonstrated that with both rheumatoid and osteo-arthritis, pain relief was
satisfactory in approximately 90% ofpatients. Both groups achieved increased
range of movement but the improvement was greater with the osteo-arthritis
group (Hawkins et al., 1989). Ifthe rotator cuff is intact, the patient can expect
to gain forward flexion and elevation beyond 90°, and considerably more if he
had osteo-arthritis. On average, range of movement post-operatively is 50-65%
of normal with rheumatoid disease and 75 -80% of normal with osteo-arthritis.
Later, loosening ofthe glenoid component or dislocation may occur with a
constrained prosthesis. With unconstrained prostheses, later complications may
include glenoid component loosening or wearing, dislocation, humeral compo-
nent loosening or rotator cufftear. A severely disabled patient with rheumatoid
arthritis who has to use crutches will increase the stresses on the shoulder and
exacerbate the problem ofloosening (Souter, 1987).
Removal of the humeral component for revision is difficult, but is rarely
necessary. Revision of the glenoid component is more likely, and if the bone
stock is poor, may necessitate bone grafting. The prosthesis can be expected to
last for many years, especially with patients with rheumatoid disease who have
more restricted mobility.
Rehabilitation for total shoulder replacement

Aims and objectives are broadly as those following hip replacement.
The muscles ofthe shoulder girdle are likely to have atrophied due to disuse
prior to surgery, so rehabilitation is aimed at building up these muscles and
mobilizing the shoulder joint. Depending on the surgeon's preference, passive
exercises by the physiotherapist are started on the second to fifth post-operative
day, aiming at forward elevation and external rotation, with internal rotation a
!ittle later. Most patients are discharged one or two weeks after surgery but
attend for physiotherapy for another two months. They progress through passive
and assisted to active movement, and are also expected to perform exercises at
91
SHOULDERSURGERY
horne. Most authorities recommend pendulum exercises and shoulder shrug-

ging. Around four to six weeks post-operatively, patients are given resisted
exercise. The supporting sling may be discarded at any time from one week after
surgery, once the patient is comfortable.
Daily Iiving activities

Because the patient had restricted movement and pain prior to admission, he
may a1ready have appropriate tools for living. The type oftools he now needs include:
long angled-handle sponge and comb;
Manoy or other rocker knife;
Dycem matting;
dressing stick;
• front-fastening clothing ofloose fit.
Because he can use his hand, the patient may be able to perform most
two-handed tasks provided shoulder elevation is not needed. Dressing the
affected arm first and undressing it last may need to be reinforced. Kitchen
activity incorporating the principles ofjoint protection must be undertaken (see
Chapter 1).
The patient should be encouraged to discard tools for living gradually as he
becomes able. In the long term, a patient who has had shoulder arthroplasty ,
should avoid heavy lifting, tugging and jerky movements, and any extreme
movements which force the joint. Sports, such as golf, should also be avoided.
CUP ARTHROPLASTY
This operation may be used for rheumatoid patients. A hemispherical stainless
steel cup is cemented onto the prepared humeral head. Its advantage is that it
does not damage the medullary cavity ofthe humerus, and may be converted to
a total arthroplasty or to arthrodesis in the event of failure.
HEMI-ARTHROPLASTY
This is replacement of the humeral head and may be used for patients with
rheumatoid or osteo-arthritis ofthe shoulder. However, the articulation between
the metal humeral head and the bone ofthe glenoid eventually wears away the
cartilage and then causes bonyerosion, so the long term effects are disappoint-
ing. The principles ofbipolar arthroplasty may overcome this problem (Figure
7.2). A clinical comparison between the results ofhemi-arthroplasty and total
arthroplasty (Bell and Gschwend, 1986) reported that, in a trial group, 59% of
hemi-arthroplasties were satisfactory but the remaining 41 % still had a painful
92
SHOULDER ARTHRODESIS
Figure 7.2 Principle ofbipolar arthroplasty
shoulder, while the range of movement was significantly better in the group who
had had total arthroplasty.
Physiotherapy aims to achieve maximum possible mobility. Passive and then
assisted exercises are carefully increased as tolerated. The patient is taught
exercises to perform at home, or may attend as an outpatient for up to eight
weeks post-operatively. Pendulum exercises are typical during this period. If
the tuberosities on the humeral head are intact, exercises for muscle strength
may be commenced about two weeks after surgery.
The movements required to perform daily living tasks are forward elevation
and internal and external rotation, particularly necessary for dressing and
grooming. For the first few weeks patients may need some assistance in these
tasks. As function improves, they must be encouraged to use the joint to its
maximum potential.
SHOULDER ARTHRODESIS
This operation is more rarely encountered as methods of shoulder arthroplasty
improve. It is more useful for osteo-arthritic shoulders, as it affords pain relief
and reasonable function. It is a less satisfactory procedure for rheumatoid
93
SHOULDERSURGERY
shoulders, as multiple joints are involved. The shoulder is fixed in approxi-

mately 30--45° ofabduction, 20° offlexion and 15° ofexternal rotation, which
is a good functional position. The shoulder is immobilized in a shoulder spica
piaster for three months until union is sound, after which the physiotherapist
starts to re-educate the scapular muscles for compensatory movement.
While the patient is in piaster, he will need a number oftools for living. The
bulky piaster necessitates larger size clothing, which should be of a stretchy
fabric, with few fastenings. The dressing method of the affected arm into the
clothing first and out last must be adopted. Because the hand is in an elevated
position, the only way the two hands can be used together will be in an unnatural
position. Tools such as Dycem matting, rocker knife, plate bunker and wire
saucepan basket are necessary. The patient should practise opening jars by
holding them steady between the knees, and straining vegetables either into a
colander in the sink or through a wire saucepan basket.
RECURRENT DISLOCATION OF THE SHOULDER

This is often the result of asports injury to a young man, and is apt to dislocate
on abduction and external rotation. The usual operation is the Putti-Platt
procedure, in which the range of external rotation is limited by taking a tuck in
the anterior joint capsule and another tuck in the subscapularis tendon. After
Surgery, the patient has his arm bound to his side for six weeks, before gende
mobilization is commenced. The condition also occurs in female patients with
congenital joint laxity, but instead of surgery patients are advised to restrict their
physical activity.
FRACTURES OF THE PROXIMAL HUMERUS

While these fractures come under the category of trauma rather than cold
orthopaedics, they do on occasion appear on the orthopaedic ward. These
fractures are quite common in older people and are caused by a fall on the
outstretched arm. C.S.Neer, the surgeon who pioneered the Neer shoulder
replacement, classified humeral fractures into seven groups:
I. Undisplaced fractures, which heal after immobilization in a collar and
cuffsling.
2. Fracture through the anatomical neck (rare).
3. Fracture through the surgical neck, with rotator cuffunimpaired.
4. Fracture ofthe greater tuberosity, with rotator cuffruptured.
5. Fracture of the lesser tuberosity, possibly also including displacement of
the surgical neck, and possibly involving the greater tuberosity.
6. Fracture dislocation, when the head ofthe humerus may be separated from
94
REMEDIAL OCCUPATIONAL THERAPY
its blood supply. There mayaiso be involvement ofthe brachial plexus and
axillary blood vessels.
7. Fractures involving the articular surfaces.
Treatment of these fractures varies according to the fracture site. In most
cases, some surgery is required. Where blood supply to the humeral head is lost,
a hemi-arthroplasty is performed. This applies to group two, the complex cases
in group five, some of group six, and group seven where over 50% of damage
is done to the joint surfaces. Treatment by internal fixation applies to groups
three, four, five and six ifthe blood supply to the humeral head is unimpaired,
and in group seven when there is 20-50% damage to the joint surfaces.
REMEDIAL OCCUPATIONAL THERAPY FOLLOWING SHOULDER

SURGERY
The aims of occupational therapy are:
to ensure the patient's independence in ADL;
to encourage perseverance in the rehabilitation programme;
to improve muscle power and range of movement.
Following a programme ofremedial therapy, the patient is expected:
to be independent in all necessary areas of ADL;
to understand the precautions necessary for protection ofthe prosthesis;
to have full functional use ofthe affectedjoint.
The normal range of movement for the shoulder joint is forward flexion 180°,
extension 60°, horizontal abduction up to 120° when external rotation enables
abduction to continue up to 180°, adduction with some flexion to 45°, external
rotation to 80-90° and internal rotation to 70-80°. The last two may be measured
functionally by asking the patient to reach the back ofhis head (external rotation)
and putting his forearm along the back ofhis waist (internal rotation). Alterna-
tively, the elbow may be held close to the trunk, flexed to 90°, and the degree
of forearm movements measured outwards (external rotation) and across the
trunk (internal rotation).
Should the patient be referred for remedial treatment, close cooperation with
physiotherapy is essential. Initially activities should be light and working in the
inner range of movement, progressing towards the outer range (i.e. the more
extreme limits ofmovement).
Sampie treatment programme

The patient should face the work and be far enough away from it so that he does
not substitute elbow and forearm movement for the shoulder exercise. The
95
SHOULDERSURGERY
programme may be commenced 12 days post-operatively if the tuberosities,

rotator cuff and glenoid were intact, or six weeks post-operatively if any were
damaged prior to surgery.
1. Initially support the forearm in a suspension sling and roll putty to and
fro on a level surface. After two days, discard sling to work.
2. Work on an inclined surface, at 20°, rolling putty, polishing wood, playing
solitaire, etc.
3. As (2), gradually increasing angle ofwork surface.
4. Substitute sanding for polishing.
5. Stack lightweight blocks and build towers of stacking discs.
6. Walk the fingers up a smalliadder with numbered rungs. Measure progress
by the number of the rung reached.
7. As (5), gradually increasing the weight ofthe blocks and discs.
8. Use of guillotine and printing press, standing to use guillotine.
9. U se of guillotine, cutting thicker card, progressing to sitting to use guillotine.
The above activity aims for forward flexion. At the same time, rotation of
the shoulder is obtained by:
1. Manoeuvring a wire maze to get a bead from one side to the other.
2. Building towers of discs, picking up the discs with the elbow extended and
forearm pronated, turning them over, and putting them down with the
forearm supinated.
3. Grasping abaton with both hands close together and elbows extended, and
twisting it clockwise and anti-clockwise. Grade by using heavier batons.
During the first 2-6 weeks, depending on the pre-operative state ofthe joint,
the patient must be warned not to lean on the operated arm. The treatment
programme should be carrled out in 5-10 minute sessions, preferably for four
sessions daily. The patient is discharged three weeks after surgery, but treatment
may be continued for up to eight weeks, or more if the rotator cuff was
previously damaged.
Care must be taken not to stress the joint unduly. Once adequate range of
movement and power for the functions required for the patient' s lifestyle have
been achieved, it is advisable to stop pushing for too much improvement, as this
could shorten the life of the prosthesis.
LIMB LENGTHENING
The methods described for leg lengthening in Chapter 4 are also employed in
the treatment of arm length discrepancy. This deformity binders a child from
participation in school sports, among other activities. During the wearing ofthe
fixation device on the humerus, dressing and feeding present problems. Loose
96
FURTHER READING
clothing with baggy or batwing sleeves with elasticated cuffs are wann and
comfortable. Sleeveless tops can be adapted by opening the side seam on the
same side as the ann lengthening and attaching velcro dabs. Dungarees and
pinafore skirts provide extra winter wannth. Capes are a good substitute for
coats. The ann with the Ilizarov frame on will have to be put into gannents first
when dressing, and last out when undressing. The Disabled Living Foundation
Clothing and Footwear Advisory Service is a useful source ofinfonnation and
provide a list of workshops which will alter clothes and may make some
gannents to order.
Feeding difficulties may be present regardless of whether the dominant or
non-dominant ann is being treated, and a Manoy or Nelson knife or a Splayd
may be useful. The ann wearing the frame may be used to stabilize a plate, but
a plate guard or a Dycem mat may facilitate eating.
REFERENCES
Bell, S.N. and Gschwend, N. (1986) Clinical experience with total arthroplasty
and hemi-arthroplasty of the shoulder using the Neer prosthesis, Interna-
tionalOrthopaedics, 10,217-22.
Hawkins, R.J., Bell, R.H. and Jallay, B. (1989) Total shoulder arthroplasty,
Clinical Orthopaedics and Related Research, 242, 188-94.
FURTHER READING
Cofield, R.H. and Edgerton, B.C. (1990) Total Shoulder Arthroplasty: Compli-
cations and revision surgery, Instructional Course Lectures, American Acad-
emy of Orthopaedic Surgeons, Chicago.
Jonsson, E. et al. (1986) Cup arthroplasty of the rheumatoid shoulder, Acta
Orthop Scand, 57, 542-6.
Mills, D. and Fraser, C. (1989) Therapeutic Activities for the Upper Limb,
Winslow Press, Bicester.
Naylor, A. (1955) Fractures and Orthopaedic Surgery for Nurses and Physio-
therapists, E. and S. Livingstone Ltd, Edinburgh.
Post, M. (1988) The Shoulder: Surgical and nonsurgical management, 2nd edn,
Lea and Febiger, Philadelphia.
97
SHOULDERSURGERY
Thornhill, T.S. and Barrett, W.P. (1988) Total shoulder arthroplasty, in C.R.
Rowe (ed.) The Shoulder, Churchill Livingstone, Edinburgh.
Trombly, C. (1983) Occupational Therapy for Physical Dysfunction, Williams
and Wilkins, Baltimore.
Watson, M. (1988) Letter on shoulder replacement in British Medical Journal,
296, 1346-7.
98
8
Elbow surgery
In the elbow joint the main articulation is between the humerus and ulna, at
which flexion and extension occur. The radius articulates with the humerus only
in flexion. Within the single joint capsule is a separate pivot joint, the proximal
radio-ulnar joint. This functions with the distal radio-ulnar joint at the wrist to
rotate the forearm. When the elbow is fuHy extended with the palm facing
anteriorly, the forearm is slightly abducted on the humerus, giving rise to the
carrying angle.
The complexity and unique construction ofthe elbow has meant that research
into elbow arthroplasty has lagged behind that for the joints of the lower limb.
Perhaps for this reason some surgeons still advocate synovectomy for treatment
ofthe rheumatoid elbow. Wbile this affords only minor improvement in range
of movement, it gives dramatic pain relief and induces aremission which can
last from three to five years (Souter, 1987).
TOTAL ELBOW REPLACEMENT

Types of elbow replacement include the older semi-constrained prosthesis with
metal components and a high density polyethylene hinge, and the improved
unconstrained prosthesis with one metal and one polyethylene component,
designed to resurface the joint. The Souter-Strathclyde and the Wadsworth total
elbow arthroplasties are the most frequently used in the Uni ted Kingdom. The
Souter-Strathclyde (Figure 8.1) is closely modeHed on the normal anatomy of
the trochlear joint on the anterior aspect of the ulna, with a stirrup-shaped
humeral component with a wide area of fixation. The ulna component is a
dovetailed keel in the olecranon process, and a short stern into the meduHary
cavity of the ulna (Souter, 1987). The Wadsworth prosthesis is indicated
where there is excessive bone loss or very porotic bone, as it has a longer stern.
These unconstrained prostheses imply the provision of some rotation and
laxity ofthe joint. Improvements continue to be made, with the aim ofbiological
fixation rather than cement, in the hope of reducing the risk ofloosening.
Indications for total elbow replacement are pain, instability and loss of
function. Suitable candidates are patients with rheumatoid destruction of the
elbow and those suffering from post-traumatic osteo-arthritis ofthe elbow. In
99
ELBOW SURGERY
Figure 8.1 Souter-Strathclyde total elbow replacement
the case of the patient with rheumatoid arthritis, careful timing of surgery is
important. Any surgery for reconstruction ofthe joints ofthe lower limb should
be performed first, to prevent stress on the elbow by the use of crutches. Total
elbow arthroplasty is contra-indicated in patients with infected joints.
Post-operatively the physio- and occupational therapist have considerable
input. Initially the elbow joint is rested for five days. This period may vary
according to the surgeon's opinion. Then gentle flexion, extension, pronation
and supination exercises are commenced. Between exercise sessions the elbow
is rested and supported in an elbow splint with the joint flexed at 90°. Exercise
is gradually built up over a six week period, when the splint is discarded and
light function is commenced.
100
OCCUPATIONAL THERAPY FOLLOWING TOT AL ELBOW
REPLACEMENT
The aims and objectives oftreatment are similar to those for hip replacement.
In the immediate post-operative period, if the patient lives alone he will
need items such as a Manoy knife or Splayd fork, dressing stick, long-han-
dled comb and front-fastening clothing. He will also need kitchen practice
to familiarize him with using the unoperated arm to handle kettles, saucepans
and cooking pots.
Tools for living
The occupational therapist must assess the patient' s ability to rise from his chair,
bed and toilet, without having to lever himself up with his arms. If she finds he
has to use his arms for any ofthese activities, appropriate equipment should be
provided, which may include:
high seat chair, or raising blocks or other device to raise existing chair;
spring-lift chair, ifrising problems are severe;
raised toilet seat;
bedraising blocks;
bath aids, to prevent levering up from the base of the bath;
a second stair-rail, so that the patient can use the unoperated arm to hold
the stair-rail for climbing and descending stairs;
ifthe patient has to depend on the stair-rail, referral for a stairlift.
Force is exerted on the elbow joint when lifting or carrying a heavy object
and when leaning on the hand. Torsional stress on the long lever ofthe forearm
occurs when a person works with the shoulder abducted. These actions should
therefore be avoided following elbow replacement. Any weight carried should
not exceed 1kg (2.2Ibs) for two to three months post-operatively, then gradually
increasing the weight permitted up to a maximum of 5 kg. Therefore, the patient
must be educated in ways of avoiding heavy lifting and carrying, e.g. walking
to and fro to carry severallight loads. Provision of an Etwall trolley enables the
patient to wheel heavier objects around, ifthere are no thresholds or steps in the
way. A shopping trolley saves carrying but entails dragging a heavy weight and
this, coupled with hauling it up kerbs, produces unacceptable stress on the
elbow. A push-type trolley is satisfactory. Pressure such as that required to clean
windows should be avoided, and shifting fumiture is forbidden unless it is on
easy running castors. Digging and heavier gardening tasks should be delegated.
The reasons for these precautions must be explained to the patient.
101
ELBOW SURGERY
RESULTS OF TOTAL ELBOW REPLACEMENT

Relief of pain is almost universal. Improvement in range of movement is related
to the pre-operative condition of the joint. If restricted movement was due to
pain, mobility is greatly improved by surgery, but ifthe joint was stiff, improved
motion is less significant. Recent reviews of both the Souter-Strathclyde and
Wadsworth prostheses demonstrated that functional flexion, adequate extension,
good pronation and supination were restored (Burt et al., unpublished review).
Since rheumatoid patients have multiple joint involvement, the general rule
for upper limb surgery is to work from proximal to distal joints (see Chapter 1)
for best functional ability. A review ofpatients who had replacements ofboth
shoulder and elbow joints in the same arm (Friedman and Ewald, 1987) revealed
that 75% ofthem obtained more functional benefit from the elbow arthroplasty
than from the shoulder surgery. One conclusion drawn was that if one joint was
more painful and immobile than the other, the worse joint should be replaced
first.
Early post-operative complications, such as transient ulnar nerve palsy, are
usually successfully overcome. The longer term complications which have
occurred with hinge prostheses include loosening in a significant number of
cases (Morrey, 1985). The incidence ofhumeralloosening is much higher than
that ofthe ulnar component (Gschwend et al., 1988). Later instability may occur
as a result ofwearing ofthe articulation device (Morrey, 1985). These same
causes offailure are listed by Souter (1987). Deep infection is also possible.
Clearly there have to be revision procedures and salvage operations to deal with
these failures.
REVISION OF TOTAL ELBOW REPLACEMENT

The aim with elbow arthroplasty is to remove the minimum ofbone stock at the
time ofprimary surgery, so that revision is facilitated should it become neces-
sary. Preservation ofthe humeral condyles is important, partly for stability and
also because the flexor and extensor tendons are attached to them.
Indications for revision of total elbow replacement are loosening of either
component, bone fracture due to resorption ofthe bone as a result ofloosening,
instability, recurrent dislocation or deep infection. If the coupling mechanism
fails in a hinge prosthesis, only the coupling mechanism needs revision.
Removal of the prosthesis tends to be difficult, as the bone cortex may be
damaged during removal of the cement and a fracture may occur. If a second
arthroplasty is to be inserted, a different type of implant is used. The range of
movement after revision surgery has been found to be almost identical to that
obtained after primary surgery (Morrey, 1985).
If bone stock is inadequate or if deep infection has occurred, revision may
102
REMEDIAL OCCUP A TIONAL THERAPY
be impossible. In the case of infection, the usual procedure of removal of all

foreign material, wound dosure and insertion of suction drains until swabs
prove negative and soft tissues have healed is carried out. Then salvage surgery
may be performed, possibly in the form of interpositional arthroplasty.
Interpositional arthroplasty may occasionally be used in the treatment ofthe
younger post-traumatic arthritis patient. The ends of the humerus, ulna and
radius are excised, contoured to facilitate the pivoting of the ulna against the
humerus, and soft tissue interposed between the bony surfaces (Wright and
Steward, 1985). The patient must be motivated to co-operate fully in the
rehabilitation programme. Results of these interpositional arthroplasties are
generally good, giving pain relief and reasonable elbow flexion.
Simple excision of the radial head is still occasionally indicated. It relieves
pain but interferes with the other structures within the joint and may therefore
cause secondary problems. Resection arthroplasty, in which the ends of hu-
merus, radius and ulna are resected, leaving a flail arm, is carried out only to
eradicate an intractable joint infection. Elbow arthrodesis is also unacceptable,
as there is no optimum position in which to fuse the joint.
Elbow fractures are particularly disabling and are prone to complications
such as damage to the brachial artery and the median and ulna nerves. Theyare
not normally treated on the cold (elective) orthopaedic ward, and it is not within
the scope ofthis book to discuss fractures and dislocations ofthe elbow.
REMEDIAL OCCUPATIONAL THERAPY

Resumption of activities of daily living as a gradual process normally provides
all the 'occupational therapy' a patient with rheumatoid arthritis needs. In the
case ofthe youngerpost-trauma patient, occupational therapy may be prescribed
as an adjunct to physiotherapy. Aims and objectives are then similar to those
following shoulder replacement.
Normal range ofmovement for the elbow is flexion-extension 0-150°,80°
each for pronation and supination. The most useful arcs of movement are
30-130° of flexion and 50° each of pronation and supination. Provided these
measurements can be attained, it is unnecessary to push for a greater range than
this, and it may even be contra-indicated. Extension lag is usual following elbow
surgery, and full extension is not essential for most activities.
Sam pie treatment programme

To obtain the correct movement of flexion and extension the work must be
placed directly in front of the patient and dose to hirn.
1. Rest the forearm on a skateboard, push to and fro on a level surface.
103
ELBOW SURGERY
2. Polish wood with a to and fro action.

3. Knead and roll soft dough.
4. Play various hand games on a large board.
5. Sand a board with to and fro action; increase resistance by using coarser
sandpaper.
6. As (3) and (4) but using dough of stiffer consistency and games with
heavier pieces.
7. Build towers with discs.
8. Weave with a long shuttle; macrame knotting.
9. Use of guillotine. Increase resistance by cutting more sheets ofpaper at a
time.
10. Stool seating.
Simultaneously, a programme to obtain pronation and supination requires
that the patient's elbow is held close to his body, flexed to 90° and the work
placed directly in front ofhim:
1. Use the wire maze game.
2. Twist abaton, with elbows flexed, holding baton with hands close
together.
3. Use of computer game with mercury activation switch attached to
wristband.
4. Build towers of discs, picking up disc with forearm pronated and putting
it down with forearm supinated.
5. Use ofMeccano.
6. Table football.
The activities should be carried out for periods of 5-10 minutes, preferably
daily for four sessions per day. Throughout, care must be taken to avoid passive,
forced or jerky movement at the joint. Pronation is necessary for placing objects
on a horizontal surface, so many activities achieve this movement. Supination
may be slower to recover, and compensatory movement is lacking. Possibly the
most important task requiring supination is holding out the hand for change. It
therefore needs to be worked at!
REFERENCES
Friedman, R.J. and Ewald, F.C. (1987) Arthroplasty ofthe ipsilateral shoulder
and elbow in patients who have rheumatoid arthritis, Journal oi Bone and
Joint Surgery. 69-A, no. 5,661--6.
Gschwend, N., Loehr, J., Ivosevic-Radovanovic, D., Scheier, H. and Munzin-
ger, U. (1988) Semi-constrained elbow prostheses with special reference to
the GSB III prosthesis, Clinical Orthopaedics and Related Research, 232,
104-11.
104
FURTHER READING
Morrey, B.F. (1985) Revisionjointreplacement, inB.F. Morrey(ed.) TheElbow

and fts Disorders, W.B. Saunders, Philadelphia.
practice 0/ musculoskeletal surgery, Churchill Livingstone, Edinburgh.
Wright, P.E. and Steward, M.J. (1985) Fascial arthroplasty ofthe elbow, in B.F.
Morrey (ed.) The Elbow and fts Disorders, W.B. Saunders, Philadelphia.
FURTHER READING
Burt, A., Burger, T. and Gwilliam, L. Review of Patients having had Elbow
Replacement at Wrightington Hospital, Wigan, unpublished paper.
Figgie, M.P., Inglis, A.E., Mow, C.S., Wolfe, S.W., Sculco, T.P. and Figgie III,
H.E. (1990) Results of reconstruction for failed total elbow arthroplasty,
Clinical Orthopaedics and Related Research, 253, 123-32.
Figgie III, H.E., Inglis, A.E., Ranawat, C.S. and Rosenberg, G.M. (1987) Results
of total elbow arthroplasty as a salvage procedure for failed elbow recon-
structive operations, Clinical Orthopaedics and Related Research, 219,
185-93.
Ljung, P., Lidgren,L. andRydholm, U. (1989) Failure ofthe Wadsworthelbow,
Acta Orthop Scand, 6, no. 3, 254-7.
London, J. (1985) Custom arthroplasty and hemiarthroplasty ofthe elbow, in
B.F. Morrey (ed.) The Elbow and fts Disorders, W.B. Saunders, Philadel-
phia.
Madsen, F., Gudmundson, G.R., Sojbjerg, J.O. and Snappen, o. (1989) The
Pritchard Mark II elbow prosthesis in rheumatoid arthritis, Acta Orthop
Scand, 60, no. 3,249-53.
Mills, D. and Fraser, C. (1989) Therapeutic Activities /or the Upper Limb,
Morrey, B.F. and Bryan R.S. (1985) Total joint replacement, in B.F. Morrey
(ed.) The Elbow and fts Disorders, W.B. Saunders, Philadelphia.
Norkin, C. and Levangie, P. (1989) Joint Structure and Function: A com-
prehensive analysis, F.A. Davis, Philadelphia.
Sjoden, G.O.J., Blomgren, G.G.A. and Lindgren, J.U. (1985) The Souter total
elbow replacement in rheumatoid arthritis, Scandinavian Journal 0/ Rheu-
matology, 1,219-22.
Trancik, T., Wilde, A.H. and Borden, L.S. (1987) Capitellocondylar total elbow
arthroplasty, Clinical Orthopaedics and Related Research, 223, 175-80.
Trombly, C. (1983) Occupational Therapy for Physical Dysfunction, Williams
and Wilkins, Baltimore.
Turner, A. (1981) The Practice o/Occupational Therapy: An introduction to
the treatment 0/physical dysfunction, Churchill Livingstone, Edinburgh.
105
9
The hand
Several complete volumes have been written on the subject ofhand rehabilita-
tion and it is not within the scope of this book to cover the topic in any detail.
However, the occupational therapist working on the orthopaedic ward must be
competent to handle those conditions she may encounter. These include surgery
for the rheumatoid hand, tendon injuries, trauma which presents a continuing
problem, post-traumatic arthritis and congenital abnormalities.
VERSATILITY OF THE HAND

The hand has multiple functions:
infinitely fine to powerful movement, including prehensile action;
used in nearly all activities of daily living;
major organ of sensation;
used in self-protection;
gentle or violent tactile communication;
gesticulation during speech;
communication with the deaf;
the 'eye' ofthe visually handicapped.
ARCHITECTURE OF THE HAND

The hand is a complex organ. Many individual movements are difficult to
isolate, so any impairment will affect total function. The bony structure of the
hand forms the foundation for its function, and is based on aseries of arches.
The transverse arches are first, the arch formed by the carpal bones, and second,
the arch formed by the metacarpal heads, this latter being very flexible. The
longitudinal arch is formed by the metacarpal and phalangeal bones and is also
very adaptable. The oblique arch is formed by the thumb in abduction and
opposition to the little finger. The stable element in the arched hand is main-
tained by the shafts ofthe second and third metacarpal bones (Figure 9.1a).
When at rest, the normal hand maintains all these arches, with all the muscles
relaxed and in a balanced state. The metacarpophalangeal (MCP) joint of the
106
ARCHITECTURE OF THE HAND
(a) the hand arehes
(b) At rest, the fingers progressively flex

towards the ulnar side ofthe hand
Ce) In flexion, the fingertips eonverge

on the scaphoid
Figure 9.1 Architecture ofthe hand
index finger is flexed at approximately 25°, the proximal interphalangeal (PIP)

joint flexed at approximately 45°, and the distal interphalangeal (DIP) joint
flexed at approximately 15°, with the thumb anterior to the phalanges ofthe
index finger. The palm is hollowed and the fingers progressively flexed, with
107
THEHAND
the index finger straightest and the little finger most flexed (Figure 9. I b). The
fingertips converge towards the scaphoid bone (Figure 9. lc).
HAND ASSESSMENT
The surgeon may require an occupational therapy assessment of the hand of a
patient he is considering for surgery, to enable hirn to decide on the most
appropriate procedure. The purpose ofhand assessment is, therefore, to docu-
ment deformity, hypo-aesthesia, grip and function. Repeated hand assessments
gauge improvement and recovery or record deterioration. They are often per-
formed together with a physiotherapy assessment.
At the outset it is essential to read the case notes, to leam the history,
definitive diagnosis and reason for performing the assessment. At the initial
interview with the patient, a brief explanation of the procedure helps to allay
anxiety. Hand dominance must be established. Details ofthe patient's family
role, occupation and leisure interests demonstrate the uses to which he puts his
hands. The patient should be asked which are his problem areas in order of
severity, to assist in later decision-making regarding action or order of surgery.
On examination, the shoulders and elbows should be checked for limitation
in movement. The affected and normal hands are compared. Any differences
are noted as to the position ofthe hand at rest, skin colour, texture and sweating,
scars, oedema, muscle wasting, contractures or other deformity and condition
ofthe nails. Palpation ofthe affected hand provides information as to the skin
condition, subluxed joints, boggy areas due to synovitis, tender areas and scars
with fibrosis.
Ifthe hand is painful, the patient should be asked to describe the pain, some
adjectives being suggested, such as severe pain, discomfort, continual, intermit-
tent, aching, throbbing, buming, tingling, stabbing, etc. He should be asked if
°
anything appears to trigger the pain, or if anything relieves it. A visual analogue
may help hirn describe the pain. This is scaled from to 10, the patient making
a subjective rating ofhis pain on the line, thus:
Painfree I ° 1 2 3 4 5 6 7 8 9 10 1
1 The worst pain
imaginable
Observation of how the patient uses his hand provides additional informa-
tion. As the hand is also an organ of communication, the patient may hide the
hand due to embarrassment.
If the physiotherapist has measured range of joint movement, it is unneces-
sary for the occupational therapist to duplicate this. If it falls to the occupational
therapist to measure joint range, the goniometer is the most usual instrument to
use (Figure 9.2). The wrist is measured along the shafts ofthe ulna and fifth
108
HAND ASSESSMENT
Figure 9.2 Measurement of MCP (left) and PIP (right ) joint flexion using
goniometers
metacarpal, with the ulnar styloid as the axis. The MCP joints are measured
individually, over the shafts ofthe metacarpal bones and the proximal phalan-
ges, over the dorsum of the joint. The IP joints are measured over the adjacent
phalanges and over the dorsum of the IP joints, with the MCP joints extended
in order to measure the DIP joints properly, as they normally flex right into the
palm. The carpometacarpal joint of the thumb is measured along the shafts of
the first and second metacarpals (Figure 9.3). The MCP joint ofthe thumb is
measured along the shafts ofthe first metacarpal and the proximal phalanx, over
Figure 9.3 Positions for measurement ofradial (left) and palmar (right) abduc-
ti on of the thumb
109
THEHAND
the dorsum of the joint with the thumb abducted. The IP joint of the thumb is
measured along the shafts of the proximal phalanges, over the dorsum of the
joint. If oedema is present, the goniometer should be held along the mid shafts
of the bones instead of over the dorsum. Where there is significant discrepancy
between active and passive range, both figures should be recorded. Joint
measurements of the normal hand should also be recorded for comparison.
Normal ranges of joint movement in the hand are:
wrist flexion 70-80°, extension 70-75°;
radial deviation at the wrist 20°, ulnar deviation 20°;
pronation 0-80°, supination 0-80°;
MCP joints 0-90° flexion, PIP joints 0-1000 flexion, DIP joints 0-80° flexion;
• thumb carpometacarpal extension 15-45°, abduction 0-70°;
thumb MCP joint 0-50° flexion;
thumb IP joint 0-80° flexion.
Hyperextension of a finger joint is recorded as a minus number, extension as
zero, extension lag as a plus number. The range of movement is therefore
recorded as, for example:
extension = lQ and 11
flexion 75 70
The total active flexion of one finger is 175°.
Pronation and supination are measured starting with the forearm and hand
placed in the 'thumbs up' position. Excursion movements may be measured
with a mler (Figure 9.4). In abduction the distance between the fingertips can
Figure 9.4 Measurement of finger abduction (left) and total finger flexion
(right) using a mler
110
HAND ASSESSMENT
be measured. If opposition is incomplete, the distance between the thumb tip

and the base of each finger is measured. Total finger flexion can be measured
at right angles from the transverse palmar crease to the tips ofthe fingers (normal
registers zero). Extension lag ofthe MCP and IP joints may be measured in this
way, with the hand placed on the table in supination. Total span is also measured
with amier.
Odstock tracings are a recognized method ofrecordingjoint range, especially
suitable for rheumatoid patients. Soldering wire covered in flexible plastic
tubing is used to follow the dorsal aspect of each digit at its maximum range of
flexion and extension, then tracing along the wire to record the reading on a
chart. The joint positions must be marked (Figure 9.5). To do this the patient
sits with the elbow supported on a table, with the wrist in neutral or slight
extension. The flexion tracing is superimposed on the extension tracing, using
the proximal phalanx as the baseline. Subsequent recordings are traced in a
different colour, and each colour code dated.
Hand tracings are a useful method ofrecording abduction ofthe MCP joints,
ulnar deviation, thumb extension, and apparent shortening due to subluxation
or flexion deformity. It involves tracing around the patient's spread hand,
marking the joint positions. Again, subsequent tracings are in a different colour
and the colour code dated.
Any oedema is most accurately measured by water displacement methods,
plunging the hand in a tank with graduations marked on the inner walls.
Jewellers' ring measures mayaiso be used to measure oedema in the fingers.
Key baseline, nonnal extension - - - -

flexion, first reading _. -._.-
flexion, later reading i , I ,
MCP, ,
PIP
<
DIP
~
MCP PIP
~
DIP
I
I
I
\
\
\~' /
/ ;'
; .
i \\
~ "DIP
- -"'DIP I
I
• .".A"
.... I
/
Figure 9.5 Odstock tracings. On the left, the normal hand. On the right,
demonstrating improved flexion following surgery
111
THEHAND
If there is not a concurrent assessment by the physiotherapist, the patient' s

muscle power should be graded according to the Medical Research Council's
Oxford Scale (Adams and Hamblen, 1990), comparing the normal against the
affected side. The gradings are as folIows:
O--No contraction
l-A flicker
2-Active movement through full range with gravity eliminated
3-Active movement through full range against gravity
4--Active movement through full range with some resistance
5-Normal muscle strength as compared with unaffected side.
Normal grip strength varies greatly from one person to another. Therefore,
comparison has to be made between the normal and affected hand. A sphygmo-
manometerwill record a low reading. Five readings should be taken, with a short
rest between them. Repetitive measurements are important in distinguishing the
malingering patient. Each measurement should be taken by the same therapist
in the same way, using the same machine.
Pinch grip mayaiso be recorded using a sphygmomanometer, measuring
pinch hetween thumb and each finger in turn. Ifthe patient is only able to use
lateral pinch or three-point pinch this should be recorded as such.
Sensation assessment is performed after nerve damage. The patient is told
what to expect. His hand is cradled either in a bead cushion or on a bed ofputty,
which restricts extraneous movements which may distort results (Moran, 1986).
The patient's eyes are closed or his vision blocked by some means. For testing
this condition, a hard blunt object is used to test static or moving touch. The
two-point discrimination test may be used, with the aid of a paper clip used as
a caliper. With the points weil apart, the patient's fingers are gently touched
longitudinally on the pulps or the whole palmar surface. The patient is asked
whether he feels one or two points, administered at random, with the points
progressively brought closer together. However, two-point discrimination is a
judgement not a primary sensation, and depends in part on the patient's intelli-
gence (Wynn Parry, 1981).
Testing for temperature sensation may be carried out using a cold and a
warmed teaspoon. The areas of lost or abnormal sensation should be recorded
on a basic hand drawing. Stereognosis tests may be used, with common objects
heing identified by feel, offering the largest objects to identify first. Pairing
objects by the sense oftouch is an alternative method.
Proprioception, or joint position sense, may be affected in high median and
radial nerve lesions. It is tested by holding the patient's finger on both sides,
then moving it slightly in flexion or extension and asking the patient to identify
the movement made. The localization test was devised by Wynn Parry (1981).
For this, the therapist touches a point on the patient's band, moving her finger
112
HAND ASSESSMENT
slightly to prevent adaptation ofthe nerve endings. The patient is asked to open
his eyes and point to the area where he was touched. Two pictures are used to
record results, one to record where the therapist touched the patient, the other
to record where the patient thought he was touched, and the two compared.
The Tinel test documents the level of recovery of a nerve after injury, which
grows from proximal to distal at the rate of 1 mm per day. The occupational
therapist taps along the course of the affected nerve, from the distal point to the
proximal, and the patient will experience pins and needles at the site of nerve
regeneration.
During the functional assessment, the various types of grip are tested. The
most frequently used grip is the precision grip in its three forms: tip to tip or
pulp to pulp between thumb and index finger, lateral (key) pinch in which the
pad ofthe thumb is held against the lateral surface ofthe index finger, and tripod
(chuck or three-point pinch) in which the thumb, index and middle finger
converge to hold an object. Interdigital pinch is effective adduction between the
index and middle fingers.
Power grip is used to wield tools strongly, with the tool held diagonally across
the palm, the fingers and thumb flexed around it and the wrist in ulnar deviation.
The MCP joints are in ulnar deviation, and the smaller the tool and the more
tightly it is grasped, the greater the degree of ulnar deviation. If the ring and
little fingers are weak, this grasp will be ineffective. Sustained grasp is main-
tained by the wrist flexors.
Cylinder grip involves opening the hand so that the thumb and fmgers form
a 'C' around an object, then the muscIes contract to hold it. It depends on the
integrity ofall the digits, the interossei and the web space and efficiency ofthe
thumb muscles.
Span grip depends on the hand arches and demands that all digits are
extended and abducted first, then the distal phalanges flex to hold the disco
Ball grip depends on the efficiency of the thenar and hypothenar muscles,
and the functioning of the hand arches.
In hook grip, the hand arches are flattened and the fingers flexed at the PIP
joints.
Plate grip involves strong opposition of the thumb and flexion of the MCP
joints, with extension ofthe IP joints and a stable wrist.
The types of grip may be assessed as folIows:
Pinch grip: picking up a pin (fine) and a pencil.
• Lateral pinch: picking up and holding a Yale type key .
• Tripod grip: writing with pen or pencil.
Interdigital pinch: holding a cigarette between the fingers.
Power grip: holding and effectively using a hammer.
Cylinder grip: picking up a tumbler ofwater.
113
THEHAND
Span grip: opening a jar with a screw top or a pull-off lid.

Ball grip: holding different sized balls.
Hook grip: carrying a bag.
Plate grip: holding a plate level.
Pronation and supination: pouring water from one glass to another and back
again.
In all the above, it is important to watch for trick movements.
Dexterity and co-ordination are tested by asking the patient to perform a
number of common tasks: using a pair of scissors, striking a match, opening and
closing a safety pin, fastening an open-ended zip, fastening a wrist watch,
handling change in a purse or pocket, threading a needle, signing their name,
etc. Any deviation from the normal action in performing these activities is recorded.
Finally, independence in the functions of daily living should be assessed. It
is more relevant to first ask the patient what his difficulties are, to ensure that
the assessment is more appropriate to his needs. The Odstock Hospital Hand
Function Chart takes this a step further, by asking the patient to select from the
chart the tasks that are relevant to hirn, and to grade the ease with which the
tasks are performed, as easy, fair, difficult or impossible. The patient and
therapist then discuss why these tasks present problems, choosing from a list of
reasons which include pain, weakness, thumb problems, MCP joint problems,
IP joint problems, wrist or any other joint problems, tendon problems, sensory
problems, etc. When the reasons are totalled, the reasons for dysfunction
become clear and the analysis is especially helpful if the assessment is to be
followed by aperiod of remedial treatment. (N.B: A patient with rheumatoid
arthritis may have grossly deformed hands, yet have relatively good function as
compared with another whose hands are minimally deformed but more painful.)
When compiling the hand assessment report, it is convenient to use standard
forms. A national standard assessment form is the ideal, but the assessment
system should at least be the same across all hospitals in the same group. A
sub-committee of the British Orthopaedic Association, all members of the
British Society for Surgery of the Hand, met with a view to recommending a
design for an assessment form for routine use in Accident and Emergency
departments and hand clinics (Robins, 1986). They recognized that no chart
could cover all hand conditions but concluded that charts should be simple and
consistent in design and flexible in application. The requirements for Accident
and Emergency hand charts are distinct from those for specialist hand clinics.
For the latter, separate charts are required, any or all ofwhich may be used for
one assessment. They include:
range of movement chart, recording active and passive readings, with space
for Odstock tracings;
sensory chart, with basic hand illustration;
114
REHABILlT A TIVE TREATMENT OF THE HAND
functional assessment chart.

The chart for use in Accident and Emergency departments includes recording
in diagrammatic form scars, tissue damage, sensory loss, etc. and mayaiso be
helpful to use with orthopaedic patients.
The combined charts provide the basis for a treatment plan, and may be useful
at a later date ifneeded in medico-Iegal claims. They are available in A4 pads
from Pilgrim's Press (address in appendix) and it is hoped that they will become
routinely used.
Hand assessment with a young child

Provided he is of average intelligence, a child can be assessed by the same
procedure as an adult from the age of four to five years. With a younger child,
it is necessary to provide a box of suitable toys and guide the child through
experimentation with them, closely observing his handling of them. It is a
time-consuming process. It is very important that the room is quiet with no
distractions, so that concentration is enhanced. The occupational therapist must
also be aware ofthe ages at which different aspects ofhand function develop.
Basically the same pattern is followed as for adults, but the functional
assessment of grip plays a larger part and this may be assessed by observing
activities such as the following:
Pinch grip: threading large beads on astring, picking up a crayon.
Lateral pinch: picking up a book or pieces of a wooden jigsaw puzzle.
Tripod grip: scribbling with a crayon.
Interdigital pinch: squeezing plasticine between the fingers.
Power grip: playing with a toy hammer and matrix.
Cylinder grip: holding appropriate kind ofmug ofmilk or fruitjuice.
Span grip: undoing a screw top or pull-off top of a jar of sweets.
Ball grip: playing ball using balls of different sizes.
Hook grip: carrying a toy suitcase.
Plate grip: offering a biscuit on a plate to parent.
Pronation and supination: playing with Russian dolls or similar toy, un-
screwing successive barrels to find small doll in the centre.
Co-ordination: use of paper-cutting scissors, undoing a small parcel, dress-
ing a doll or playing with construction toys.
REHABILITA TIVE TREATMENT OF THE HAND

Referrals for specific treatment will vary according to the specialization ofthe
unit in question. The most likely requests will be for splinting following surgery
for rheumatoid arthritis, rehabilitation after reconstruction surgery, trauma,
tendon surgery and surgical correction of congenital deformity.
115
THEHAND
Fibrosis can be minimized by controlled mobilization initiated early, other-

wise scar tissue contracts and the joint stiffens. Once the wound has healed,
remodelling continues for up to a year, while the scar tissue develops the strength
and shaping to allow proper function. During this time, passive and active
exercises and splinting will assist the remodelling process. The splint may be
static or dynamic, intermittent or constant.
Patients whose hands require elective orthopaedic or plastic surgery arrive
at this stage for various reasons. Functionalloss may be due to pain which has
not been adequately controlled, so that the hand has been overprotected.
Oedema after injury or surgery is reduced by elevation and ifthis precaution is
neglected, fibrosis occurs.
Stiffjoints may result from severe pain, fibrosis, soft tissue contractures and
adhesions, damaged blood vessels causing ischaemia, nerve lesions leading to
paralysis, fractures near the joint, or to overlong immobilization. Function is of
paramount importance and a stiffjoint may be more functional than a flail one.
Similarly, a musele that is slightly contracted may have a useful tenodesis effect.
The principle oftenodesis action is that as the proximal joint is moved in one
direction, the distal joint moves passively in the opposite direction. Forexample,
in a radial nerve lesion flexion is present at the wrist and fingers but extension
is absent, so a wrist extension splint may produce finger flexion. Patients with
tetraplegia can sometimes make use ofthis passive grasp.
In addition to the motor deficiencies, sensory changes occur if nerves are
damaged. Nerve injury will cause hypo-aesthesia, changing through
hyperaesthesia as regeneration occurs. Hyperpathia is an exaggerated painful
response to touch, which can follow a nerve lesion, and such a condition may
be treated by the implantation of neurostimulators as described in Chapter 11,
or nerve block may be administered by the anaesthetist.
Aims of rehabilitative occupational therapy

Once pain and oedema are under control, the broad aims are to:
1. improve range of movement;
2. improve musele power;
3. restore function;
4. re-educate sensation, ineluding pain relief;
5. attend to socio-economic and psychological needs.
Documentation of deformity, range of movement and sensation, as already
described, is essential.
The physiotherapist and occupational therapist must liaise closely, although
the physiotherapist usually works with the patient first. Early intensive treatment
is believed to be more beneficial than a treatment plan spread more thinly over
a long period. It is important to explain the treatment to the patient early.
116
REHABILITATIVE TREATMENT OF THE HAND
The patient should be placed in the optimum position for the activity in
question. This may be sitting or standing, and the work must be at the correct
height and angle to obtain the required movement. The patient is less likely to
use trick movements ifhe is seated. The patient with an oedematous hand must
work with the hand in elevation to reduce the swelling. Work may be placed on
a Varitable, on adjustable shelving or an easel, or placed vertically on the wall
to achieve this.
Progression of treatment
As with all remedial treatment, progression is through passive, assisted, active
and resisted activities, working from gross through to fme movements. While
the physiotherapist gives passive exercise, the occupational therapist may not
become involved until the patient is capable of assisted movement. Use of
pulleys and suspension slings or a limb balancer may be used with various
activities. Bilateral activities are to be preferred early in treatment, as this
provides rhythm, facilitates a better pattern of movement and prevents neglect
ofthe affected hand. Cord knotting and weaving are useful activities. If possible,
an activity related to the patient's interests and skills should be chosen.
Some activities for gross hand movement

Exercises in warm water and kneading and rolling oftheraplast, sanding, use of
a guillotine, printing machine, Nomeq 'hand grab', span games, Russian dolls,
table football and solitaire using large pegs.
Some activities for medium hand movement

Vamishing small woodwork items, paper folding, sorting nuts and bolts, use of
scissors, weaving, threading large beads, draughts, dominoes, rolling crepe
bandages, various adaptations of solitaire, use of clothes pegs.
Some activities for fine hand movement

Origami, writing, drawing, composing type, macrame with fine twine, use of
tweezers, solitaire with map pins, drawing pins and dress pins, sewing, making
a chain with paper clips, untying string with a pin.
Remedial games
Games are readily adaptable for all types ofhand exercise. Solitaire pieces can
be chunky, weighted, magnetic or attached to the board with velcro to provide
117
THEHAND
resistance. By placing the board in different positions, further movements can

be obtained. The patient is instructed in the method of picking up the pegs in
the manner which gives the required movement, and is watched carefully to
ensure that the desired action is obtained. Solitaire is useful in that it does not
need another player. Many other games are suitable for adaptation, but require
a partner.
Simple but effective treatment media can be improvised from items such as
rubber bands on a nail board, cat's cradle games, marbles, rice and clothes pegs.
At the other end ofthe spectrum, computer games, word processors, typewriters
or pianos provide effective hand exercise.
Grasp
This is obtained by the use of rubber syringe bulbs for games such as puff
football, and squeezing water from one flask to another, using gross grasp. It
mayaiso be obtained by the use of a large firm sponge, using it to transfer the
water from one bowl to another.
Wrist flexion and extension

This action is achieved with the use ofa 'skijump' board, to which the ann is
fastened proximal to the wrist, with the hand over the end of the board. The
object is to pick up shapes by flexing the wrist and then extend the wrist to 'post'
the shapes through a postbox in front ofthe 'ski jump' (Figure 9.6). There are
variations on this theme (Figure 9.7). Table tennis using the back ofthe hand,
either with a bat strapped onto the hand or wearing a stiff glove, obtains flexion
and extension of the wrist.
Figure 9.6 Apparatus to assist with hand and wrist rehabilitation, reduce oedema
etc. The wooden box is covered with carpet for comfort. The forearm is positioned with
the wrist at the higher end, to facilitate flexion or extension
118
REHABILITATIVE TREATMENT OF THE HAND
Figure 9.7 Similar apparatus with adjustable upright to encourage wrist flexion
in picking up objects, and extension in "posting" them through holes in upright
MCP flexion and extension

Games using rubber syringe bulbs are useful here too, but ensuring that the IP
joints are straight. The same applies to the activity with a sponge to transfer
water from one bowl to another. Solitaire may be played using tongs or clothes
pegs to move the pieces, keeping the IP joints straight. Rubber bands may be
stretched over a nail board to play the 'boxes' game, and cat's cradle, rolling
theraplast or bandages, walking the fingers up a smalliadder placed close to the
patient and games involving flicking a ball up a slope are all useful activities.
IP flexion and extension

The bulb syringe games are again suitable, using gross grasp, and the same
applies to the sponge squeezing activity. The rubber band 'boxes' game, cat's
cradle, bandage rolling, flicking games and tweezer games are suitable. With
tweezers, ablocker must be used to prevent the MCP joints compensating. Putty
pinch and solitaire using tongs and clothes pegs to pick up the pieces are also useful.
Pinch grip
The bulb syringe games and the sponge squeezing activity are suitable, using
the thumb with either the index finger alone or with the index and middle fingers.
Tweezers, putty pinch, threading beads and solitaire using pins, tongs or clothes
pegs to move the pieces may be tried. Darts uses tripod grip.
119
THEHAND
Finger abduction and adduction
Solitaire may be used, picking up the pieces between the index and middle
fingers, and a tug-of-war game can be played with a piece ofpaper held between
these same two fingers. Putty may be squeezed between all the fingers.
Ingenious minds will invent other ways of obtaining movements required,
and the section on occupational therapy in the work by Wynn Parry (1981) gives
many ideas. Coiled pottery, breadmaking and other baking activities provide
much excellent hand exercise. Use ofthe FEPS (flexion, extension, pronation
and supination) adaptor with printing and use of the wire twisting machine
provide a range ofuseful remedial actions, particularly iffull use is made ofthe
different handle attachments.
If staff time is limited, the patient may be given a supplementary programme to
follow at horne, with suggested activities and a timetable. He must keep arecord of
his self-treatments and the occupational therapist must monitor the programme.
Sensory re-education
This aspect ofremedial treatment is mainly associated with nerve lesions. The
selected patient must be well-motivated, intelligent, and should already have
return of protective sensation and touch perception in the fingertips (Moran,
1986). The rationale behind sensory re-education is that the patient with sensory·
impairment can use learning mechanisms to make the most ofhand function, in
spite of the nerve fibres being somewhat disorganized as compared with the
pre-morbid state. The brain gradually responds more efficiently to the reduced
sensation, and as it does so, motor function also improves. The sensory stimu-
lation must be carried out early, once the above criteria can be met.
The patient is blindfolded, then given some form of sensory stimulus such
as an everyday object to hold, which he is asked to identify. Ifhe is correct, he
is told so, but if incorrect he is shown the object, to link the experience of vision
with the sense of touch. Later in the session, the process is repeated so that he
integrates the visual memory with the present experience. The sessions should
be short and frequent, the maximum time being 15 minutes up to three times
daily (Moran and Callahan, 1986).
Localization training is also carried out. Blindfolded, the patient is touched
on the hand. With the blindfold removed, he is asked to point to the spot where
he was touched. Ifincorrect, the stimulus is repeated while he watches. He then
closes his eyes and concentrates while the stimulus is repeated. This concentra-
tion, feedback and repetition are crucial to the re-education programme.
Texture discrimination employs pieces of wood covered with different
grades of sandpaper and pieces of different fabric. The patient is asked to feel
two blocks and say whether they are the same or different, and as treatment
120
HAND SURGERY ON THE ORTHOPAEDIC WARD
progresses, the two grades become more alike. Wooden blocks can have letters
stuck on them made of velcro hooks or coarse to medium sandpaper, and the
patient asked to identify the letter. All these exercises are carried out with the
eyes closed or the vision blocked.
Ifmotor function is adequate, the patient may be blindfolded, then asked to
pick objects out of a bowl of rice, starting with large items working towards
smaller. Plastic alphabet letters may be used in a similar manner. Everyday
objects may be put into a closed bag, and the patient asked to identify them by
fee!. At first objects are dissimilar but as progress is made, the objects chosen
are more alike. While his eyes are closed, the therapist may draw letters on the
patient's hand with her finger, and the patient asked to identify them.
The sensory training can be integrated into the motor fimction programme
by drawing the patient's attention to the textures and shape ofthe objects used.
The use of drills, saw, hammer, etc. will cause vibration, which makes a positive
contribution to sensation training.
The use of sensory re-training is valuable in the desensitizing of the finger
stump following amputation.
HAND SURGERY ON THE ORTHOPAEDIC WARD

As mentioned earlier, the majority of surgery will be for the rheumatoid hand.
It may be helpful at this point to look back at Chapter 1 at the general effects of
the disease, and specifically at the effects on the hand. The inflammation in the
synovium around the carpus affects the capsule and ligaments supporting the
joint, and ligaments may become stretched. The palmar and dorsal pull of the
muscle tendons becomes unbalanced, the proximal row ofcarpal bones migrates
towards the palmar surface, the distal row of carpals migrates dorsally, and
sub luxation occurs. The extensor carpi ulnaris tendon may be damaged in the
process, and may slip towards the palm and become a flexor. Because the
extensor carpi radialis longus and brevis and the flexor carpi radialis are now
unopposed, radial deviation ofthe wrist and ulnar deviation ofthe MCP joints
occur. The elongation of the radial collateral ligaments contributes to the
deformity. Palmar subluxation of the MCP joints is also caused by slack
ligaments.
Boutonniere deformity is due to the disruption ofthe extensor mechanism at
the PIP joint, resulting in flexion ofthe PIP joint and hyperextension ofthe DIP
joint. It is difficult to treat. The extensor tendon may be re-attached more
proximally but may then cause mallet finger. Activities aim at flexion of the
distal joint and extension of the proximal, with the use of a Capener splint
(Figure 9.8).
Mallet finger is caused by a ruptured extensor tendon proximal to the distal
phalanx, so that this phalanx is flexed by the pull of the flexor digitorum
121
THEHAND
Figure 9.8 Capener splint
profundus tendon, and a portion ofbone may be involved. Surgical repair may
leave permanent stiffness so treatment is by splinting the DIP joint in extension
for six weeks to unite the tom tendon (Hughes, 1989). Ifthe splint is removed
during this time, the finger must be supported.
Swan neck deformity is caused by imbalance ofthe flexor digitorum super-
ficialis causing hyperextension of the lax PIP joint, with secondary flexion of
the DIP joint. It may be treated with a small splint to prevent hyperextension of
the proximal joint, or by a two-stage flexor tendon graft with a silastic rod.
Synovectomy
Synovectomy is indicated when bone destruction is not advanced but prolifer-
ation of synovial tissue is marked. The inflamed synovium surrounding the joint
is excised and ifthe tendons are involved, tenosynovectomy may be performed.
Good results are obtained when this operation is performed in the dorsum ofthe
hand, and will slow down the damage which may cause ruptured tendons. The
procedure usually has to be repeated, as the benefits rarely persist. A secondary
effect of flexor synovitis is carpal tunnel syndrome.
Carpal tunnel syndrome

The median nerve may be compressed at wrist level under the transverse carpal
ligament (flexor retinaculum) as it passes in the carpal tunnel with the tendons
of the finger flexors and the tendon of flexor pollicis longus. There is first a
sensory loss, commonly at night, which may extend into the forearm. Motor
weakness of abductor pollicis brevis, opponens pollicis, flexor pollicis brevis
and the first and second lumbricals ensues. The patient is inclined to be clumsy
and drop things, and complains ofbuming pain with numbness and then tingling
in the thumb and first two fingers and halfthe ring finger, especially during the
night and early moming. Two-point discrimination can be tested in the distri-
bution of the median nerve. Treatment is by splinting and injection of steroid,
122
WRIST SURGERY
and if the problem is not resolved, then electromyographic testing before

surgical division ofthe flexorretinaculum. Although the condition is commonly
a result of rheumatoid arthritis, it may be due to various causes including Colles'
fracture. Usually only one wrist is operated on at a time, even ifthe condition
is bilateral, so that the patient can cope with daily living activities. Unless there
are complicating circumstances, the only specific occupational therapy needed
may be the provision of a night resting splint with the wrist in no more then 30°
of extension. A Futuro splint wom at night decreases symptoms.
WRIST SURGERY
Rheumatoid disease of the wrist joint leads to deformity, pain, instability and
loss offunction. Osteo-arthritic changes may occur secondary to trauma, when
pain may be severe and function impaired. Surgery is indicated in such cases.
In radiocarpal arthritis, where the proximal row of carpal bones is most
affected, a proximal row carpectomy may be performed. The wrist is im-
mobilized for four weeks, then range of movement and strengthening exercises
commenced, with a protective palmar wrist splint for a further eight weeks or
more. The disadvantage ofthis procedure is that the resulting musculotendinous
shortening reduces the strength in the fingers. However, it may allow movement
in an otherwise painful wrist. Proximal row carpectomy is normally done at the
time of Swanson total wrist replacement.
Total wrist replacement

The most commonly used implant in replacement of the wrist joint is made of
silicone rubber which is protected by titanium grommets (Figure 9.9). This
implant was designed by Alfred Swanson in the early 1960s and has gone
through several stages of evolution. Other types of prosthetic design have been
used, including unconstrained metal prostheses with high density polyethylene
articulation (e.g. the Meuli), but these are not extensively used so the following
discussion will be confined to the Swanson silicone implant.
This implant acts as an inert spacer which is inserted after excision of the
proximal row of carpal bones. The implant is inserted into the distal radial
medullary cavity, and through the capitate into the third metacarpal, and not
cemented. Encapsulation ofthe implant occurs to hold it in place. An essential
part ofthe surgical procedure is careful re-alignment oftendons and ligaments
to balance the wrist joint. Silicone arthroplasty ofthe wrist joint aims to provide
pain reliefwith some movement. Excessive movement, i.e. greater than 30° of
flexion or extension, increases the incidence offracture ofthe implant which is
then frequently associated with pain, and often necessitates re-operation. This
may be revision ofthe implant or arthrodesis may be chosen.
123
THEHAND
Figure 9.9 Total wrist replacements: Swanson silastic implant on the left. On
right, Meuli prosthesis, showing eccentric placement of anchoring sterns
Wrist replacement is used almost exclusively for rheumatoid disease. Con-
tra-indications are previous infections ofthe joint, ruptured wrist exterisors or
insufficient bone stock. However, patients who do heavy manual work or who
use crutches or otherwalking aids are also unsuitable candidates. Success ofthe
surgery depends on the severity of the disease and musculotendinous balance.
The Swanson implant has proved successful in the relief of pain, improvement
of function and correction of deformity, with patients expressing satisfaction
with the results. In addition, as cement is not used, revision surgery is facilitated.
POST-OPERATIVE CARE
Initial splinting ofthe wrist in the neutral position is maintained for three weeks.
The overall time for immobilization depends on the nature of the patient's
disease. Some patients with rheumatoid arthritis have very stitTjoints as a result
of the disease process, while in others the joints are lax and unstable. Patients
with lax, unstable joints need splinting for much longer than those in the first
category, so that previously lax structures can shorten.
Early treatment includes routine care of adjacent joints and reduction of
swelling. Particular attention is paid to maintaining good excursion of the
extensor digitorum tendons, as they are routinely moved outside the extensor
retinaculum and are therefore subcutaneous and at risk of adherence to the
healing scar if full excursion is not maintained.
124
POST -OPERATIVE CARE
After the initial period of immobilization, be it three or six weeks, movement

of the wrist joint is commenced. The aim is not to achieve a wide range but to
limit the arc of movement to 30 0 each side of neutral, with 50 radial and 100
ulnar deviation. For most patients this range is not difficult to achieve. Simple
wrist exercises followed by normal activity are all that is required to restore
function. It is essential to teach the patient joint protection methods so that they
do not exceed the stated range of movement, and to guard against rotary strains
which may tear the implant.
The maximum weight a patient can lift depends entirely on his own muscu-
lature, and it is essential to stress that any weight that cannot be controlled by
the wrist muscles must not be attempted. Weightbearing through the joint is
prohibited, and any patient whose lifestyle places heavy demands on the implant
is a failure of the pre-operative selection process and would be instructed to
wear a strong wrist support during heavy activity. The versatility ofthe hand is
aided by the ability ofthe wrist to place the hand in a variety ofpositions.1t is,
therefore, preferable to maintain a mobile wrist, especially in those people
whose livelihood depends on tbis. A wrist arthroplasty will not provide full
range of movement, but such a range is not needed for function. Since rheuma-
toid arthritis tends to affect corresponding bilateral joints, many surgeons
choose to arthrodese one joint and replace the other, to obtain maximum
function. This, for example, will render a patient independent in the sensitive
issue of toilet hygiene, which requires a mobile wrist. This achievement of
maximum function is especially important, as other joints will be involved, and
the cumulative effect of several impaired joints is very disabling.
Patients with post-traumatic arthritis of the wrist are likely to develop
loosening of a wrist prothesis, due to the normality of their other tissues and
higher levels of activity. It is, therefore, preferable for these patients to have an
arthrodesis instead.
Wrist arthrodesis
This may be used to stabilize the wrist either as a primary operation or as a
salvage procedure, for deep infection, prosthetic loosening, musculotendinous
imbalance, or in the case of ruptured wrist extensors in the patient with
rheumatoid disease. The joint surfaces are excised and fixation achieved by one
ofthe following methods:
a Steinman pin through the carpus into the radius;
a Steinman pin into the medullary cavity of the third metacarpal;
a Rush pin into the base of the third metacarpal, plus astapie across the
radiocarpal joint (Figure 9.10).
125
THEHAND
Figure 9.10 Wrist arthrodesis using staples to aid fixation
Occasionally bone grafting is employed to augment the fixation, ifbone stock

is deficient. Immobilization is maintained for six to 12 weeks after surgery, until
bonyunion.
No remedia 1 occupational therapy is required but the patient may need help
in becoming independent in the activities of daily living, with possible provision
oftools for living, such as tap tumers,jar openers, etc. By the time he has reached
this stage, the patient with rheumatoid arthritis may weIl have many tools
already.
126
MCP JOINT REPLACEMENT
MCP JOINT REPLACEMENT

There are other types of semi-constrained MCP implants ofmetal and plastic
but the Swanson silastic implant, or the similar Niebauer reinforced with
Dacron, are by far the most popular (Souter, 1987).
Indications for surgery include disorganized MCP joints with severe pain,
ulnar drift so great that tripod grip is impossible and which is not correctable by
soft tissue surgery, subluxation or dislocation ofthe joint, radiological evidence
ofjoint destruction, and flexion contractures ofthe MCP and PIP joints where
the palmar skin is macerated (Souter, 1987). MCP joint replacement may be the
treatment of choice for a patient with lesserproblems but whose life tasks require
pinch rather than power grip.
The nature of the MCP joints is somewhat different from that of the wrist
and a much wider range ofmovement is expected. However, the nature ofthe
implant is the same. Excision of the joint surfaces, with synovectomy of the
joint, is followed by insertion of an inert flexible spacer into the intramedullary
canals ofthe bones either side ofthe joint being replaced. This is subsequently
surrounded by a synovial-like layer oftissue that provides stability.
The use of these implants has not been without problems. Peimer (1989)
believes the most serious fault is the wear-induced debris which occurs in the
joint, causing inflammation and secondary bone and joint damage. This is called
silicone synovitis. The damage is related to the length oftime since implantation,
and follow-up surveys ofunder three years will not demonstrate these problems.
These silicone implants should not be used where they will be employed for
prolonged, repetitive or forceful work. Souter names the failure to regain power
of grasp or pinch grip as a disappointing feature of this surgery. If silicone
synovitis occurs, an alternative arthroplasty or joint fusion may be necessary.
Surveys report significant pain relief and an improvement in ulnar deviation.
Bieber et al. (1986) report improved flexion and extension. lengen et al. (1986)
report unchanged range of movement, but a move towards extension, with the
hand more open. At the long term evaluation deterioration of the implant has
occurred, but one has to remember the progressive nature of rheumatoid disease
and balance that fact with any possible deficiencies in the procedure.
Post-operative occupational therapy

The regime most commonly followed is based on that described by Swanson
hirnself (Swanson et al., 1978), early controlled movement being the main
principle. Movement wearing a lively outrigger splint is commenced at approx-
imately three to five days post-operatively The splint should support the joints
in the neutral position, protect against ulnar deviation, and allow maximum
flexion ofthe joint. Frequent, short periods of exercise are encouraged. Initially
127
THEHAND
it may be necessary to assist the movements and it is always necessary to check

that movement is taking place at the level ofthe MCP joints and not at the PIP
joints. If the patient has a tendency to concentrate their movements at the PIP
joints, then these joints can be immobilized to concentrate flexion forces
towards the MCP joints.
Passive stretching and flexion traction splints for the MCP joints are intro-
duced at three weeks post-operatively. The splint is used for short periods
several times a day, and alternated with the outrigger. The outrigger is discarded
at approximately six weeks but therapy, both formal and informal, is continued
for several months. The expected outcome is a functional arc of flexion and
extension at the MCP joints, with a greater flexion range in the ulnar digits and
pulp-to-pulp opposition to all digits.
Long term protection of silastic MCP joint replacements is essential and the
occupational therapist should ensure that the patient has the necessary knowl-
edge, tools and adaptations to implement joint proteetion techniques.
Alternative surgery for the MCP joints

A procedure less frequently performed now is simple excision ofthe metacarpal
heads, with or without insertion of interpositional membrane (tendon), or
construction of a fascial or ligamentous sling (Souter, 1987).
BASAL THUMB JOINT SILASTIC ARTHROPLASTY

These implants are also of Swanson design, and the criteria for surgery are as
for arthroplasty of the MCP joints. The trapezium is excised and part of the
trapezoid may be removed to better accommodate the implant, which is then
inserted into the intramedullary canal of the thumb metacarpal.
Surveys of surgery on a group of patients who had had these arthroplasties
at least 5.5 years previously reported 95% patient satisfaction (Hofammann et
al., 1987). By this time a few had considerably deteriorated but results proved
that the procedure can relieve pain and improve function over several years.
Pinch and grip strength require a stable carpometacarpal joint, and this increases
in the majority of cases. Because of later complications, the technique is
recommended only for the elderly or the patient whose activity is very limited.
Interpositional arthroplasty using tendon is an alternative. The MCP joint ofthe
thumb may be arthrodesed.
Occupational therapy foUowing basal thumb joint arthroplasty

Post-operatively the hand is splinted on the palmar aspect for approximately
two weeks. This splint is then replaced by a thumb opponens splint for a further
128
SURGERY INVOLVING TENDONS
four to six weeks, although surgeons differ in their preference for the type of
splint used. After this, gentle active exercise is commenced, while a resting
splint may be used at other times. Splinting is discontinued at approximately ten
weeks after surgery.
SURGERY INVOLVING TENDONS

Primary tendon repair may be carried out, secondary to trauma. On the cold
orthopaedic ward, tendon transfer is the more likely procedure, performed on
patients with rheumatoid arthritis or those who have contractures due to neuro-
logical conditions. Tendon transfer enables another muscle to perform the
function of a damaged or absent one. There are many different transfers
available as surgical options.
Wehave already looked at the effect of rheumatoid disease on synovial
joints, and the possibility of tenosynovitis. Rheumatoid nodules mayaiso
develop within the tendons. Both these processes interfere with the gliding of
the tendons within their sheaths. The extensors of the fingers are particularly
vulnerable and may rupture due to erosion or attrition when passing over the
ulnar styloid, or due to mechanical stress. The tendons usuaHy snap in a
particular order, starting with the little finger, progressing to the ring and then
the middle finger, causing the typical dropped finger. Repair is by suturing the
distal fragment to the surviving extensors of the adjacent fmger or using a
palmaris graft. FoHowing extensor tendon repair, the hand should be splinted
for four to six weeks, either with the PIP joints immobilized but allowing the
DIP joints to flex, or some surgeons prefer fuH palmar slab splint. The joint is
then mobilized, possibly using a dynamic splint to assist in proximal joint
extension.
Goniometer measurements are useful for monitoring progress and for giving
feedback to patients. Eight weeks after repair, exercise can be more vigorous
and some gende resisted exercise commenced, aimed at useful function. Night
extension splints may be required for several more weeks.
The flexor tendons are stronger, and repair within the flexor sheath often
results in stiffness. Repair is by suturing the severed ends together, foHowed by
protective splinting. Tendon grafts are used for failed flexor tendon repair.
Treatment aims to aHow protected movement, and passive movement is delayed
until 12 weeks post-operatively. After this period, the aim is for fuH range of
movement followed by developing grip strength, while still aHowing full finger
extension. A splint such as a Klevier rubber band splint allows protected
movement. If the nerve is also damaged, splinting may be required for three
weeks before movement is commenced. Ifheavy activity is appropriate, it must
be built up in a graded manner.
129
THEHAND
Tenolysis
This is the surgical release of adhesions, particularly in the tendon sheath, to
allow improved gliding of the tendon. Imrnediately after surgery, exercise is
comrnenced and a night splint applied. Wearing of this splint alternates with
exercise periods for up to six months.
Occupational therapy following tendon surgery

After flexor tendon surgery, any activity which involves picking up objects is
therapeutic and various (adapted) hand games may be used, involving light
repetitive grip in the early stages. A variety of tool handles should be used to
obtain the various types of grip, and the different attachments on the wire
twisting machine and the FEPS adaptation are ideal. Handles may need to be
lightly padded or covered with a textured material at first. Later a double finger
stall may encourage use ofthe affected digit ifrecovery is slow. Woodwork and
gardening provide excellent gradable activity.
After extensor tendon repair, games or activities involving flicking move-
ments ofthe fingers, cat's cradle games, and trying to break a match placed over
the dorsum of the middle finger and under the distal phalanges of the index and
ring fingers are useful.
NERVE INJURIES
As these are usually the result of trauma, relatively few cases will be found on
the cold orthopaedic ward. However, Erb's palsy is a brachial plexus lesion
caused by a birth injury, usually a breech presentation. In mild cases, slow
recovery takes place. In more severe cases, the shoulder is held in adduction and
internal rotation and soft tissue contractures may develop and lead to fixed
deformity. The mother is taught to put the limb through the full range of
movement to prevent this. If fixed deformity does occur, osteotomy, tendon
transfer or shoulder arthrodesis may be performed.
Brachial plexus lesions are most often caused by motorcycle accidents, when
the shoulder and neck are distracted, causing avulsion ofthe roots ofthe brachial
plexus. 1fthis occurs the prognosis is very poor, repair being impossible. Ifthe
lesion is preganglionic, without avulsion ofthe nerve roots, the effects are either
axonotmesis or neurotmesis. Axonotrnesis results in very slow and possibly
incomplete recovery, the nerve sheath being intact. Neurotmesis is a complete
severence of the nerve, but repair by suture or grafting is possible. Again
recovery is only partial, taking two to three years.
Nerve regeneration proceeds at the rate of 1 mrn per day. It is important,
therefore, that the patient is assessed early, provided with night resting and
130
NERVE INJURIES
Figure 9.11 Hemi-ann sling, useful for control of the humerus after brachial
plexus lesion
working splints, given any necessary training in daily living activities, and an
intensive therapy programme for a few weeks. A limb balancer is helpful to
support the affected anno During this period the patient is given a supplementary
programme to follow at horne, using wide shoulder movements such as polish-
ing, assisting the affected with the good anno Wearing a Futuro type support
splint or a working splint, any kind of activity is beneficial. Sensory assessment
and stimulation fonn part ofthe treatment plan. The position ofthe humerus is
controlled by a hemi-ann sling, worn under clothing, to prevent shoulder
subluxation. The design facilitates positioning without pulling on the back of
the neck, and is commercially available (Figure 9.11).
If it is feasible, the patient should return to work as soon as possible, so that
he does not get out of the work habit and become increasingly depressed. It is
likely that work assessment and re settlement will be necessary.
A flail ann splint is available from Hugh Steeper via the Limb Fitting Centre.
It is like the skeleton of an ann prosthesis, and it enables the patient to use his
ann during the recovery period. He receives a ten-day training course in use of
the prosthesis, and is then encouraged to resurne work. Different distal attach-
ments can be fitted to the prosthesis according to need.
Pain is usuaUy severe. It may be relieved by transcutaneous electrical nerve
stimulation (TENS) given by the physiotherapist, who also gives the patient an
131
THEHAND
exercise routine to follow at horne, and hydrotherapy mayaiso be used. The

alternative to the intensive course of treatment is for the patient to attend for
treatment two or three times a week for several months, up to two years.
Whichever course is adopted, re-assessment will be needed at intervals over the
two years. After three years, the muscle fibres become fibrosed and no further
motor recovery occurs.
Radial nerve lesions may be caused by axillary pressure or damage at the
time offracture ofthe humeral shaft. The radial nerve supplies the extensors of
the elbow, wrist, fingers and thumb, and the supinatorofthe forearm. The typical
picture is that of dropped wrist. Ifthe patient flexes the wrist fully the MCP and
IP joints will extend, and this tenodesis effect may be used at first until recovery
occurs. Grasp and release movements are used with a variety of activities and
using tools with different shaped handles.
Median nerve lesions most often occur at the wrist joint and the effect has
been described under carpal tunnel syndrome. The flat or 'monkey' hand is the
typical deformity, with the thumb adducted and the thenar eminence and thumb
web atrophied in long-standing cases. Sensory impairment is apparent on the
palmar surface ofthe hand overthe thumb, first and second fingers and the radial
half ofthe ring finger. Pronation and wrist flexion are weak and the DIP joints
are extended if the lesion is above the wrist. When making a fist, only the ring
and little fingers fully flex. The level of muscle involvement depends on the
level where the nerve lesion occurred. A thumb splint is required after surgical
repair, holding the thumb in abduction and opposition. The median nerve is
essential for opposition, tripod and lateral pinch grip.
Ulnar nerve lesions around the elbow or ulnar aspect of the forearm result in
the typical claw hand deformity, with the ring and little fingers hyperextended
at the MCP joints, the IP joints flexed, hypothenar wasting, and apparent
flattening of the arches of the hand. Excursion of the digits is weak, as is the
whole hand, due to paralysis ofthe interossei and adductor pollicis. Most fine
movements are absent, and power, span and hook grip are affected. Sensation
is lost over the ulnar side of the hand, the little finger and ulnar aspect of the
ring finger. Ifthe lesion is at wrist level or distal to the wrist, the short muscles
of the hand only are affected, and only the fingers lack sensation. A knuckle
duster splint is required to correct hyperextension of the MCP joints and to
restore the transverse arch of the hand.
The splints must be worn while the patient works with the hand, and early
use is encouraged with all types oflesion. A variety oftools and activities must
be employed using repetitive movements, probably padding handles and con-
trols with foam.
If regeneration is not possible, tendon transfer surgery may be employed in
order to gain some function.
132
REFLEX SYMPA THETIC DYSTROPHY
DUPUYTREN'S CONTRACTURE
Patients with this condition are often admitted for orthopaedic or plastic surgery.
The condition is due to thickening of the palmar aponeurosis, commonly with
fibrosis and contracture of the ring and little fingers. It may progress to the
middle and index fingers or thumb. Surgery involves excision of the affected
palmar fascia, with careful preservation of the digital nerves. Occasionally
amputation may be indicated. Some patients are left with an open wound after
fasciectomy. This is known as the open palm technique.
Post-operatively, exercise of shoulder and elbow helps to maintain good
circulation, and at two to three days careful stretching exercises, with gentle
flexion, extension and abduction ofthe fingers and opposition ofthe thumb, are
commenced. Splinting regimes vary but a night splint wom for six months
post-operatively may be indicated.
Ifpain and increasing stiffness and swelling occur, this must be reported
to the surgeon immediately, as it may be the onset of reflex sympathetic
dystrophy.
REFLEX SYMPATHETIC DYSTROPHY
This term has been suggested as an umbrella phrase for disabilities which have
as common signs and symptoms vasomotor instability associated with pain,
oedema and skin changes. It includes Sudeck's atrophy and shoulder-hand
syndrome. It may occur very soon after soft tissue injury or surgery, Colles'
fracture or crush injuries, or may not develop until some weeks after the
predisposing cause. It may be due to an exaggerated reaction of the sympathetic
nervous system. The earlier signs and symptoms are severe pain in the hand,
with oedema, skin colour and temperature changes, excessive sweating and
reluctance to move the hand. Later, the skin becomes dry, cold, shiny and blue,
the hand stiffens and osteoporosis occurs. Pain is the primary cause, with other
changes being secondary, and inactivity becomes the secondary causative factor
(Cailliet, 1986).
Prevention is better than cure. After injury or surgery, the hand is elevated
to relieve oedema and venous congestion. The joints above and below the
affected one should be left free and movement encouraged, while the affected
part is comfortably immobilized.
Once the condition has occurred, the pain cycle must be interrupted quickly
with analgesics. Unaffected joints must be moved actively and often, and
passive movements avoided. Movement should be through the full range and
isometric exercises used to reduce oedema and venous congestion. Guanethi-
dine block or TENS may be used to relieve pain.
133
THEHAND
FINGER AMPUTATION
1fthis is encountered on the orthopaedic ward it may be as a result oftrauma, a
tumour, or the last resort in the treatment ofDupuytren's contracture. A cmde
digit may be moulded and attached to the hand in the same way as an old-fash-
ioned finger stool, in order to maintain movement patterns while engaging in
some absorbing activity. This is only practicable when the scar has fully healed.
The patient must be encouraged to touch objects. Gentle tapping of the stump
helps to desensitize it, so that the patient gains the confidence to use it. This is
important because the sensory input lessens the sensation of phantom pain.
CONGENITAL ABNORMALITIES
Congenital abnormalities of the hand are many and varied. The following are
those most likely to be admitted for orthopaedic or plastic surgery.
Syndactyly
This implies two or more digits joined together, and appears bilaterally in nearly
50% of cases. The middle and ring finger are most often affected. In simple
syndactyly the union is by soft tissue only, while complex syndactyly involves
the bone, muscles and blood supply. The aim of surgery is to separate the fingers.
A wide web space is necessary to enable the patient to hold a larger object.
Timing of surgery is important, depending on the deformity itself and the stage
of development ofthe child. Early surgery is indicated iftwo digits of disparate
length are joined, otherwise secondary deformity in the form of flexion contrac-
ture will develop in the longer digit. Surgery prior to starting school is desirable,
to prevent teasing and to avoid interrupted schooling later.
Camptodactyly
This is a flexion deformity of the little finger, and may involve the ring and
middle fingers, only the PIP joint being affected. Secondary hyperextension of
the MCP joint may be present. It is not evident at birth and may not even be
noticed until the adolescent growth spurt. Static and dynamic splinting is the
treatment of choice, maintained for at least a year. Some authorities recommend
night splinting up to skeletal maturity.
Absent thumb
The thumb accounts for 45% ofhand function. As children are very adaptable,
the child without a thumb usually becomes adept at using his hand, substituting
134
CONGENITAL ABNORMALITIES
interdigital pinch for handling small objects. In time the web space between the
digits widens and some rotation of the index finger occurs, so it becomes more
like a thumb. The child still has difficulty in handling larger objects.
Pollicization is the usual procedure for this condition. It fulfils the need to
handle larger objects and makes the defect less noticeable and more socially
acceptable. Surgery involves the transposition ofthe index finger and widening
the web space. Some modification of the appearance of the new thumb is
necessary, because the PIP joint ofthe index finger simulates the MCP joint of
the thumb. Again, surgery is desirable before the child starts school.
Pollicization using a toe to form a thumb may be performed. It is useful where
other digits are absent or deformed. Cosmetically the second toe is more
acceptable than the great toe and leaves the donor foot with better function and
appearance. The epiphyses are intact after the transfer, so the toe/thumb contin-
ues to grow with the child.
Radial club hand

This deformity is due to total or partial absence of the radius, usually with an
unstable wrist and possible deformity of the radial digits. The condition is
frequently bilateral and other congenital deficiencies are often present. The
appearance is of a shortened forearm, with the radial side shorter and a promi-
nent ulnar head. The more radius there is, the less the deformity. The ulna is
also shortened, and the thumb deformed or absent. The greater the degree of
radial deviation and thumb abnormality, the greater is the disability. The ulnar
side of the hand is functional, the child becoming accustomed to use the little
finger to pick up objects.
The soft tissues are involved, with the superficial radial nerve usually absent
below the elbow, while the superficial dorsal branch ofthe median nerve takes
over sensory distribution. This latter nerve is in a vulnerable position during
surgery, as it is superficially situated on the radial aspect of the forearm. The
radial artery is usually absent, while the median artery takes over its function.
Many muscles are fused together, or are abnormal in their origins and insertions.
Children adapt to the disability and become independent in daily living
activities, but have to use two hands to perform them.
Treatment depends on the severity ofthe deformity, functional impairment,
age and physical condition of the child, and many need no treatment. Others
cannot be helped by surgery. If passive correction is possible, it is maintained
by splinting until skeletal maturity. The most commonly used surgical procedure
is centralization of the hand over the ulna, to increase function, stabilize the
wrist and improve appearance. Surgery is best performed up to the age ofthree
years. A second operation, such as pollicization, may be needed.
135
THEHAND
Hypoplastic digits
Distraction lengthening techniques may be employed to improve under-devel-
oped thumbs and fingers, providing the metacarpals are adequate.
Cleft hand
This is a central defect ofthe hand, typically V-shaped with a cleft between the
metacarpal bones, so the hand is divided into two compartments. It is often
combined with syndactyly, and other skeletal abnormalities are common. The
atypical cleft hand is U-shaped. The thumb and little finger are present but other
digits may be missing or rudimentary.
Surgery for the typical cleft hand deformity is aimed at improving function,
with abduction and opposition the main goal. For the atypical cleft hand, the
aim is to obtain effective opposition between radial and ulnar sides ofthe hand.
Cerebral palsy
Orthopaedic surgery can be of real benefit to the cerebral palsy patient, mainly
directed towards correcting fixed deformity. To this end various types oftendon
release are performed, including release ofthe thumb contracted into the palm.
Juvenile rheumatoid arthritis

Physiotherapy and hand splinting with drug therapy is the treatment of choice
in childhood. Surgical joint reconstruction, synovectomy and tendon surgery
may be considered in adolescence.
OCCUPATIONAL THERAPY FOR PATIENTS WITH CONGENITAL

DEFORMITY
This is most appropriate in the area of detailed functional assessment, to help
the surgeon decide on whether to operate and which operative procedure to
adopt. Subsequently there may be a few weeks of remedial treatment, when
splinting may be requested. The child must be encouraged to use both his hands,
with provision ofbilateral activities to achieve this. The parents must be made
aware of the need to use both hands, otherwise the affected hand will not
function to its full potential.
SPLINTING
In this small volume it is impossible to go into the subject of splinting in any
depth, and some excellent books on the topic are listed at the end ofthis chapter.
136
SPLINTING
As referrals will be received for splinting, the general principles will be

covered. The work may be shared with an orthotist, a physiotherapist, or both.
It is essential that the referral is signed by the surgeon and gives specific
instructions, as an unsuitable splint can cause real damage. The therapist must
understand the underlying condition, the aims and implications ofthe splintage.
Discussion between patient, doctor and therapist is also necessary after the splint
is made.
The three types of splint are the resting (static) splint, the working (semi-
dynamic) and the lively (dynamic) splint. The first two have no moving parts,
but the lively splint uses hinges, elastic, rubber bands, spring wire and outriggers
to move with the patient, assisting, correcting or resisting movement.
Resting splints are used to treat skeletal and joint problems. The purposes of
resting splints are to:
immobilize the joint( s) in the optimum position while healing takes place;
support painful and inflamedjoints and soft tissue;
correct soft tissue imbalance, and prevent overstretching of weak tissues;
prevent or correct deformity.
W orking splints support the joints in their most functional position, and allow
neighbouring joints to mobilize.
Lively splints are used in the treatment of kinetic problems, i.e. muscles,
nerves, etc. They are supplied in order to:
maintain joint mobility;
replace lost function in damaged tissues and maintain tendon glide;
prevent deformity by the prevention of adhesions and muscle contractures;
correct deformity, including soft tissue imbalance and contractures;
provide joint stability;
restrict unwanted movement;
remove accumulated oedematous fluid by the pumping action of muscles;
maintain any improvement gained through therapy;
strengthen movement through applied resistance.
Principles of splinting
The splint must maintain the optimum functional position, taking the anatomical
arches ofthe hand into account. This position is with the wrist in 25° extension,
the MCP joints in 40° flexion, the PIP joints in 30° flexion, the DIP joints in 10°
flexion and the thumb in palmar abduction, but allowing the index finger to flex
past it. The measurements are approximate guidelines.
If the hand is to be immobilized for a long time, it should be splinted in the
'safe position'. Ligaments should be on the stretch when the joints are im-
137
THEHAND
mobilized, and to achieve this the MCP joints should be splinted in 90° flexion
and the IP joints fully extended. The wrist is splinted in 30° extension, and the
thumb in palmar abduction. This position is indicated for soft tissue injuries of
the hand but is contra-indicated after nerve or tendon repair.
A working or lively splint must not extend beyond the palmar crease, as this
will prevent normal movement of the MCP joints. Similarly, the bulk of the
thenar eminence must be free and the edges ofthe splint flanged outwards so as
not to impede thumb action. As much as possible ofthe palmar surface must be
free, so as not to interfere with sensation.
The splint must not cause pressure over the areas where sensation is abnor-
mal, nor over bony prominences. The dorsal aspect of the hand is vulnerable
over the prominences ofthe MCP and IP joints, and the palmar surfaces ofthe
MCP joints are vulnerable in rheumatoid arthritis. The metacarpal arch must be
carefully supported, and any fixed deformity accommodated.
No joint should be needlessly immobilized. No part ofthe splint must impede
circulation. Ifthere are any incisions on the palmar surface, the digits should be
placed in flexion and worked towards extension. If an incision is on the dorsal
surface, splinting should be in the neutral position and the digits worked towards
flexion and extension.
Mechanics of splinting
This applies particularly to dynamic splinting. Biomechanics is a science in
itself and readers who wish to know more are referred to the work by Malick
(1982). Basically, force produces movement in the form of compression,
assistance or stretch, by the use of elastic materials or springs. The amount of
pressure applied to correct deformity should be a little more than the pressure
exerted by the deformity itself (Turner, 1981). Excessive pressure may cause
ischaemia, nerve compression or skin ulceration. Pressure is reduced and
friction eliminated by distributing the force over as wide an area as possible.
Three points of pressure are required to provide balanced forces in splinting,
e.g. the forearm-hand splint has a middle force supplied by the strap across the
dorsum of the wrist, while the proximal and distal ends of the splint supply the
counter-forces. (Moran, 1986). The principles ofleverage also apply, e.g. in the
forearm-hand splint, the forearm trough supplies the force arm, the wrist forms
the fulcrum, and the palmar pan acts as the resistance arm (Moran, 1986) (Figure 9.12).
Rigidity is important to avoid distortion. Curving the splinting material
increases rigidity, e.g. the gutter of a forearm splint is halfthe circumference of
the forearm. This should be two thirds the length of the forearm and flanged
outwards at the edges to avoid pressure. A second layer of splinting material is
often necessary to strengthen the wrist joint. A cylinder splint is the most rigid
construction.
138
SPLINTING
Figure 9.12 Palmar pan resting splint, showing three contact areas correspond-
ing to the lever system of mechanics
Directional pull is important when splinting the fingers in flexion. Since the
fingers converge in flexion, a finger flexion cuff (traction splint) should have
each flexion assist individually adjusted to take account of the descent of the
metacarpal heads towards the ulnar side, and the attachment should be elose
together on the palmar aspect at the wrist. If the fingers are pulled down straight,
ulnar drift will occur on extension. Any finger hooks must be applied to the
proximal half of the naH, to avoid levering the nails away from the naH beds.
Traction must be applied at 90° to the axis of the joint being mobilized,
otherwise the fmger cuff will cause pressure at one edge. High profile outriggers
provide a better angle ofpull than do low profile outriggers (Fess and Philips, 1987).
Design of the splint

Standard splint patterns should be used as a rough guide only, as each splint
should be individually tailored to the patient. With regard to design, the patient' s
circumstances must be considered, e.g. ifhe lives alone he will have to put the
splint on and off independently. Ifhe works, it must be compatible with his job.
It must be as simple and unobtrusive as possible, allow for optimum function,
smooth fit, and do the job for which it was prescribed. The patient's skin
condition and any altered sensation will affect the choice of material used.
Splinting materials
While the orthotist uses a variety of materials, the occupational therapist uses
low temperature thennoplastics almost exelusively. The exception is plastazote,
a high temperature thennoplastic for which a special oven is required. This
139
THEHAND
makes a comfortable lightweight cylinder splint, but needs a reinforcing strip

ofvitrathene (another high temperature thermoplastic) for added strength. It is
too bulky for any other hand splints, but is frequently used for cervical collars.
It is very warm in wear.
Low temperature thermoplastics are softened in a hot water pan and moulded
either over a thin stockinette tube or directly onto the skin. Different materials
have different properties. Aquaplast and Orfit become transparent when they
are ready for moulding, and the material sticks to itself readily and may stick to
the pan. A few drops of detergent help prevent the latter. These materials are
rigid when set. Orthoplast and Sansplint are less mouldable and may be easier
for the inexperienced therapist to use. Orthoplast does not stretch or stick to
itself. It is slightly pliable when set. Perforated thermoplastics allow for some
cooling effect but a hole may coincide with a bony prominence and cause extra
pressure, and in the stretchier materials the holes may enlarge too much and
leave a weak spot.
Hexcelite resembles string vest material coated with thermoplastic. It is cool
and lightweight but rather rough, so requires careful finishing and may be
contra-indicated for patients with rheumatoid arthritis. It may have to be used
in double thickness for strength, and it is springy.
Fitting the splint

Because the patient may be apprehensive, an explanation of the procedure
re-assures hirn. If the patient is a young child, he may be allowed to mould a
scrap of the splinting material hirnself to give hirn confidence. The patient
should be seated comfortably, with his forearm resting on a clean towel on a
table of suitable height. All tools and materials should be assembled in readiness
and the splinting material manufacturer' s instructions for use followed to obtain
good results. After removal from the hot water, the splint is dabbed dry before
application to the patient. The forearm section is wrapped around with crepe
bandage from proximal to distal, and the thumb wrapped separately, to enable
the therapist to concentrate on the hand section.
Use of gravity is helpful. A palmar splint can be applied and moulded with
the forearm supinated, then before it sets, the arm and splint are turned over and
the forearm trough moulded with the forearm pronated (Salter, 1987). If the
forearm trough is moulded in supination, the forearm will migrate out of it in
use (Moran, 1986). Gravity assists when fitting a dorsal splint in pronation.
The forearm must be correctly aligned with the third metacarpal, especially
for an extension splint. The therapist then observes that the metacarpal heads
form a line oblique to the axis of the forearm. Any clenching of the fist
demonstrates the descent of the metacarpal heads towards the ulnar side. The
splint should therefore be longer and higher on the radial side, and any outrigger
140
SPLINTING
bar should follow this oblique line and be positioned just proximal to the PIP
joints.
The splinting material should be eased over bony prominences. Cutting a
hole may increase pressure around the prominence and padding must be avoided
as it alters the fit ofthe splint. Any crowding ofthe fmgers in a palmar resting
splint is remedied by the addition of interdigital ridges, which gives added
strength through the girder principle.
In thumb splints, the web space must be maintained, with the thumb in wide
abduction. Ifthe aim is to increase the range ofmovement at the carpometacar-
pal joint, the force must be exerted on the metacarpal bone.
Finisbing toucbes
After moulding, the splint should be re-applied to check for fit, tight areas eased
using a heat gun, rough edges smoothed and all corners rounded. For comfort
the splint may be lined with very thin self-adhesive material. Straps and
reinforcements, etc. are attached according to the manufacturer's instructions.
For hinges, one rivet is used; for straps, two rivets are needed. When using
self-adhesive velcro, the thermoplastic is wiped with pIaster solvent to take off
the gloss, then the back of the velcro warmed with the heat gun before
application to ensure stronger bonding. The use of velfoam or similar is
convenient with velcro hooks, and the wider the strap, the less is the likelihood
ofundue pressure. Straps should be placed as near as possible to the ends ofthe
splint, to hold it firmly in place and where they will not cause pressure. The best
place for a wrist strap is just distal to the ulnar styloid. On completion, the splint
should be fitted onto the patient and checked to ensure it achieves its objective.
Patient instruction
The patient must be warned to remove the splint if numbness or pins and needles
occur, and to come back for adjustment ofthe splint. Any redness should subside
within 20 minutes of removing the splint after wearing it for 30 minutes. If it
does not, the splint needs adjustment. .
Frequently the splint is worn in conjunction with an exercise programme,
and should be easily removable for these sessions. The patient must be taught
how to put the splint on and adjust it correctly, and he must be told when he is
to wear it and when it is to be removed. He must be told that he may wash the
splint in tepid water only, and not leave it in a hot place, e.g. a car window,
otherwise it will distort. A written instruction sheet is helpful as areminder.
The splint should be checked weekly to ensure correct fit. Unless the plan is
very short term, periodic review is necessary, because changes in hand shape,
etc. will alter the fit and the splint will need adjustment or replacement.
141
THEHAND
Splinting for specific conditions

For details on specific splinting, the reader is directed to the list ofbooks at the
end of the chapter.
COUNSELLING AND PSYCHOLOGICAL MANAGEMENT

Early in the chapterthe versatility ofthe hand was discussed and attention drawn
to the fact that the hand is very much on show. Impaired function, clumsiness
and deformity are therefore much in evidence. The patient suffers from altered
body image and both the functional disability and the outward appearance of
the hand will cause emotional disturbance. People use both hands in most
activities of daily living; there can be few jobs where the hands are not used to
some extent, and socially the hands are very important. Therefore, the problem
is forever making its presence feIt. Many patients keep the affected hand in their
pocket. It may not be used, resulting in an atrophied, stiff, possibly oedematous
and non-functional hand.
If the patient injured his hand at work, he may have a compensation case
pending which may delay recovery. The patient will be averse to retuming to
the place where the injury occurred. The patient with rheumatoid arthritis is
probably concemed about the functionalloss and developing deformity in his
hands. The congenitally deformed patient usually has fewer psychological
problems, as he does not suffer loss as such and has no alteration in body image.
It is not until the child starts school that his problems arise, because ofthe natural
cruelty of children to those who are 'different'.
The patient's family mayaiso find it difficult to accept the effect on their
member's hand, and may themselves need help. Counselling may therefore be
desirable for both the patient and his family. The therapist may help the patient
to consider and talk through his thoughts and feelings about his hand condition,
releasing any pent-up feelings of resentment, anger or blame, and mouming the
loss either offunction or beauty ofhis hand. The main role ofthe therapist is to
listen attentively and with empathy, allowing the patient to express his feelings,
and not simply brushing them aside with a thoughtless 'cheer up' remark.
From the practical standpoint, the therapist can help the patient by teaching
him to touch and explore the damaged area, or to study the deformity, thereby
encouraging acceptance of it. The patient must be given the responsibility of
caring for the hand. He may have to be helped in adjusting to a different role,
lifestyle or employment. Most important, he must be enabled to be independent
in daily living activities.
142
REFERENCES
TOOLS FOR LIVING

Necessary tools will vary considerably, according to the cause of the hand
condition. Tools which may be required for patients with rheumatoid disease
are listed in Chapter 1. Children with congenital deformities readily adapt and
rarely need gadgetry. The items most likely to be required are:
tap turners;
jar, bottle and can openers;
adapted cutlery;
Dycem matting;
writing aids;
flat tray purse;
elastic shoelaces;
handle adaptations, including angled handles, for implements at horne and
at work.
For information on:

1. Hand Rehabilitation The books marked with an asterisk in the
following lists.
2. Splinting The books marked with a dagger in the following lists.
REFERENCES
Adams, J.c. and Hambien, D.L. (1990) Outline of Orthopaedics, 11th edn,
Churchill Livingstone, Edinburgh.
Bieber, E.J., Weiland, A.J. and Volenec-Dowling, S. (1986) Silicone rubber
implant arthroplasty ofthe metacarpophalangeal joints for rheumatoid arthri-
tis, Journal ofBone and Joint Surgery, 68-A, no. 2, 206-9.
*Cailliet, R. (1986) Hand Pain and Impairment, 3rd edn, F.A. Davis, Philadel-
phia.
tFess, E.E. and Philips, CA (1987) Hand Splinting: Principles and methods,
2nd edn, Mosby, St Louis.
Hofammann, D.Y., Ferlic, D.C. and Clayton, M.L. (1987) Arthroplasty ofthe
basal joint ofthe thumb using a silicone prosthesis, Journal ofBone and Joint
Surgery, 69-A, no. 7, 993-7.
Jensen, C.M., Boeck-Styns, M.E.H. and Kristiansen, B. (1986) Silastic
arthroplasty in rheumatoid MCP joints, Acta Orthop Scand, 57, 138-40.
tMalick, M.H. (1982) Manual on Dynamic Hand Splinting with Thermoplastic
Material, 2nd edn, Hamarville Rehabilitation Center, Pittsburgh.
143
THEHAND
Moran, C.A. (ed.) (1986) Hand Rehabilitation, Churchill Livingstone, Edin-

burgh.
Moran, C.A. and Callahan, A.D. (1986) Sensibility, measurement and manage-
ment, in C.A. Moran (ed.) Hand Rehabilitation, Churchill Livingstone,
Edinburgh.
Peimer, C.A. (1989) Arthroplasty of the Hand and Wrist: Complications and
fai/ures, Instructional Course Lectures, American Academy of Orthopaedic
Surgeons, Chicago.
Robins, R.H.C. (1986) Hand assessment charts,Journal ofHand Surgery, ll-B,
no. 2, 287-98.
*Salter, M.I. (1987) Hand Injuries: A therapeutic approach, Churchill Living-
stone, Edinburgh.
practice ofmusculoskeletal surgery, Churchill Livingstone, Edinburgh.
Swanson, A.B., Swanson, G. and Leonard, J. (1978) Post-operative rehabilita-
tion programme in flexible implant arthroplasty ofthe digits, in J.M. Hunter,
L.H. Schneider, E.J. Mackin and J.A. Bell (eds.) Rehabilitation ofthe Hand,
Moshy, St Louis.
Turner, A. (ed.) (1981) The Practice of Occupational Therapy, Churchill
Livingstone, Edinburgh.
*Wynn Parry, C.B. (1981) Rehabilitation ofthe Hand, 4th edn, Butterworths,
London.
FURTHER READING
Alnot, J.Y. (1988) Wrist arthroplasties, in J.P. Razeman and G.R. Fisk (eds.)
The Wrist, Churchill Livingstone, Edinburgh.
tBarr, N. and Swan, D. (1988) The Hand: Principles and techniques ofsplint-
making, 2nd edn, Butterworths, London.
Beckenbaugh, R.D. and Linscheid, R.L. (1988) Arthroplasty, in D.P. Green et
al. (eds.) Operative Hand Surgery, Val.], 2nd edn, Churchill Livingstone,
Edinburgh.
*Boscheinen-Morrin, J., Davey, U. and Conolly, W.B. (1985) The Hand:
Fundamentals oftherapy, Butterworths, London.
Burt, A. (1986) Physiotherapy followingjoint replacements in the hand, Phys-
iotherapy, 72, 44-58.
Carter, P.R. (1991) Reconstruction of the Chi/d's Hand, Lea and Febiger,
Philadelphia.
Cooney I1I, W.P., Beckenbaugh, R.D. and Linscheid, R.L. (1983) Total wrist
144
FURTHER READING
arthroplasty: problems with implant failures, Clinical Orthopaedics and

RelatedResearch, 187,121-8.
Dent, J.A., Smith, M. and Caspars, l (1985) Assessment of hand funetion: a
review of some tests in eommon use, British Journal of Occupational
Therapy, Deeember, 360--2.
Galley, P.M. and Forster, A.D. (1990) Human Movement: An introductory text
for physiotherapy students, Churehill Livingstone, Edinburgh.
Laurenee, M. (1980) Surgery, in G.S. Panayi (ed.) Essential Rheumatology for
Nurses and Therapists, BailIiere Tindall, London.
Leonard, l, Swanson, A.B. and Swanson, G. (1984) Post-operative Carefor
Patients with Silastic Finger Joint Implants, Orthopaedie Reeonstruetive
Surgeons PC, Grand Rapids, Miehigan.
MeCombe, P.F. and Millroy, P.J. (1985) Swanson silastie wrist arthroplasty: a
retrospective study of fifteen eases, Journal of Hand Surgery, 9-B, No. 2,
199-201.
Meuli, H. (1983) Meuli total wrist arthroplasty, Clinical Orthopaedics and
Related Research, 187, 107-11.
*Mills, D. and Fraser, C. (1988) Therapeutic Activities for the Upper Limb,
Roberts, C. (1989) The Odstoek hand assessment, British Journal of Occupa-
tional Therapy, July, 256-61.
Robinson, C. (1986) Brachial plexus lesions: management, British Journal of
Occupational Therapy, May, 147-50.
Robinson, C. (1986). Brachial plexus lesions: functional splintage, British
Journal ojOccupational Therapy, Oetober, 331-4.
Summers, B. and Hubbard, M.lS. (1984) Wrist joint arthroplasty in rheumatoid
arthritis: a comparison between the Meuli and Swanson prostheses, Journal
ofHand Surgery, 9-B, no. 2,171-6.
Swanson. A.B. and Swanson, G. (1982) Flexible Implant of the Radiocarpal
Joint: Surgical technique and long-term results, Ameriean Aeademy of
Orthopaedic Surgeons Symposium on Total Joint Replaeement ofthe Upper
Extremity, Mosby, St Louis.
145
10
Bone tumours
A general practitioner meets on average only two cases of primary bone tumour
in his career. It is, therefore, not surprising that frequently a bone tumour has
become advanced before it is diagnosed, having been treated meanwhile as
'growing pains', osteo-arthritis or other more familiar conditions.
TYPES OF BONE TUMOUR

A tumour is a space-occupying lesion and is not necessarily malignant. Benign
tumours, although symptomatic requiring removal, are not life-threatening and
do not metastasize.
Osteoclastoma, more commonly called giant cell tumour (GCT), is usually
benign but approximate1y 10% become malignant.
Primary bone tumours include chondrosarcoma, osteosarcoma,
fibrosarcoma, Ewing's sarcoma, malignant GCT, and malignant tumours of
bone marrow: myeloma and lymphoma.
PATHOLOGY
Chondrosarcoma is a tumour of cartilage, occurring mainly in the 30 to 60 year
age group. It is found in the tlat bones of the trunk and the ends of the long
bones, more often the proximal ends. The patient complains of pain and
swelling, sometimes occurring as a noticeable increase in size of a pre-existing
lump. Radiographs show destruction of the cartilage with areas of calcification.
This tumour grows slowly. It tends to metastasize late to the lungs. There is also
a tendency to local recurrence. Radiotherapy and chemotherapy are not effec-
tive. Treatment is by radical excision or endoprosthetic replacement (EPR) of
the diseased bone (endo = indwelling, prosthetic = artificial part).
Osteosarcoma is a high1y ma1ignant tumour, occurring in the 10 to 30 year
age group, 50% oflesions appearing at the distal end offemur or proximal tibia.
It affects the metaphysis, extending along the medullary cavity and eroding the
cortex, eventually lifting or extending through the periosteum. The patient
complains of constant non-mechanical pain, limps and presents with a hot,
tender swelling. Radiographs reveal the typical picture of Codman's triangle
146
PATHOLOGY
Figure 10.1 Osteosarcoma, showing sun-ray spicules on radiograph, as tumour

penetrates periosteum, and Codman's triangle as the periosteum is elevated
(reproduced by kind permission ofthe Bone Tumour Service, Royal Orthopae-
dic Hospital, Birmingham)
and sun-ray spicules (Figure 10.1). EPR may save the limb, or amputation may
be necessary. Chemotherapy is prescribed but the survival rate is poor, only
50 - 60% ofpatients living beyond five years.
Parosteal sarcoma is a variation of osteosarcoma, arising from the perios-
147
BONE TUMOURS
teum, and does not usually extend into the medullary cavity. It is slow growing,
and patient survival rate is 80% at five years. Treatment is by resection and
occasionally chemotherapy. Paget's sarcoma is another variation of osteosar-
coma occurring in about 1% of patients with Paget' s disease, having a very poor
prognosis, similar to radiation-induced sarcoma.
Malignant GCT is a tumour of young people between the ages of 20 to 40
years, usually not occurring until skeletal maturity. The majority oflesions are
in the ends of long bones, especially the distal femur, proximal tibia and distal
radius. The tumour extends up to the articular cartilage, rarely penetrating it.
The lesion gradually expands the cortex without penetration. The patient pres-
ents with aching or discomfort and swelling. Treatment is by excision, some-
times with bone grafting, or by EPR. There is a tendency to local recurrence.
Those GCTs which are malignant metastasize readily.
Ewing's sarcoma is alesion within the bone marrow. It is very malignant,
affecting children and young adults between the ages of 5 and 30 years. It
spreads in the same way as osteosarcoma but is particularly permeative, extend-
ing along the medullary cavity of a long bone. It mayaiso occur in the pelvis or
ribs. The patient presents with pain, especially at night, with a hot, tender
swelling, and may have general systemic symptoms such as fever and abnormal
blood cell counts. Radiographs may show a typical 'onion skin' ossification as
a result of periosteal elevation (Figure 10.2). Treatment is by chemotherapy,
Figure 10.2 Ewing's sarcoma, showing 'onion skin' ossification
148
'TUMOUR WORK-UP'
occasionally radiotherapy and surgery by major EPR or amputation. The sur-

vival rate is poor, only 50% living for a further five years.
Fibrosarcoma, now referred to as malignant fibrous histiocytoma, occurs in
adults of all ages, but mainly in the 30 to 50 age group. It most often occurs
towards the end of the shaft of the femur or tibia and may arise secondary to
bone necrosis. The patient complains of pain, often followed by swelling or
pathological fracture. Treatment is by chemotherapy and surgery.
Multiple myeloma is a malignant condition where there are a number offoci
ofbone destruction, most commonly in the vertebrae but also in the flat bones,
upper ends of femur and humerus, and the skull. Radiographs show lytic or
punched-out lesions, e.g. 'pepper pot skull'. The condition rarely occurs before
the age of 40 years. The patient presents with pain, anaemia and general malaise.
Treatment is by radiotherapy, chemotherapy and steroids, with spinal fusion or
fixation of pathological fractures as appropriate.
Malignant lymphoma is a rapid-growing tumour ofhaemopoietic tissue, and
affects all ages but the very young. It most commonly affects the pelvis and
femur. If only bone is affected, the prognosis is better than when other lymphoid
tissue is also involved.
Bony metastases are 40 times as common as primary bone tumours. They
are bloodborne deposits of malignant cells, arising from a primary tumour in
the breast, prostate, kidney or other organ. The patient may not have noticed
any symptoms of the primary. The primary is sought out and treated first, but
in 10-20% of cases the primary tumour is not found. The metastases commonly
occur in the vertebrae, proximal bones, ribs and skull. Patients present with
persistent pain and possible pathological fracture, which requires internal fixa-
tion. If the primary can be found and is treatable, treatment of a single bony
metastasis may effect a cure. Otherwise the treatment for bony metastases is
largely palliative, to prolong life and make it more comfortable. Chemotherapy
is used, with radiotherapy for specific lesions.
Soft tissue lesions are included with bone tumours as the same team is best
able to treat them, much being common to both conditions. Liposarcoma, a
tumour of fatty tissue, and synovial sarcoma, a malignant condition of synovial
tissue, are usually treated by wide excision.
'TUMOUR WORK-UP'
This is the protocol which the medical team follow when a patient with bone
tumour is admitted to hospital, in preparation for the surgery which usually
ensues. Urgent referral ofbone tumours is desirable. It is important to diagnose
the type and extent ofthe tumour quickly. In addition to taking a history ofthe
case, diagnostic tests are commenced:
149
BONE TUMOURS
radiographs of the affected area and the chest;

blood tests, biochemical screen, liver function tests and serum proteins;
bone scan to determine extent ofthe lesion and exclude other lesions in the
skeleton;
computerized axial tomography (CA T) or magnetic resonance imaging
(MRI) scan to assess soft tissue involvement, and check lungs, etc. for
metastases;
biopsy for histological analysis.
From the results of these tests the medical team can determine whether
surgery and/or chemotherapy may be beneficial. The oncologist and orthopae-
dic surgeon together make an individual plan of treatment, according to the
patient's age, size, general physical condition and the type oftumour.
After biopsy, ifthe lesion is in the lower limb, the physiotherapist instructs
the patient in the use of crutches, as the combined effect ofthe tumour and biopsy
may have weakened the bone making a fracture possible if weight is borne on
it. The patient continues non-weightbearing until surgery. Active exercise is
contra-indicated, as tumours are vascular and increased blood supply to the
tumour as a result of exercise could cause the tumour to metastasize, as weIl as
increase the risk of fracture of a fragile bone.
If the tumour is of a type responsive to chemotherapy, treatment is com-
menced as soon as blood tests show the patient can withstand it. Three to five
treatments, usually at three week intervals, are given prior to surgery. This may
shrink the tumour, making it less vascular, making limb salvage surgery easier
and safer. The size ofthe tumour is monitored and ifit fails to respond, surgery
may be performed earlier.
CHEMOTHERAPY
While patients treated by surgery alone have been found to have a 25% chance
of survival to five years, those treated by combined surgery and chemotherapy
have a 50% survival rate. The result with Ewing's sarcoma is even more
encouraging; an increase in'the survival rate up from 15% to 50%.
Pre-operatively, chemotherapy is used as above and is continued post-oper-
atively to kill any occult micrometastases which may be present at the time of
diagnosis. In the treatment of osteosarcoma, high dose methotrexate is used in
conjunction with leucovorin, the first to inhibit multiplication of ceIls, the
second to rescue normal cells. Vincristine may be used to promote the uptake
of methotrexate by the cancer cells. Methotrexate crystalizes in acid urine,
causing kidney damage, so sodium bicarbonate is given intravenously to alka-
linize the urine. One of the alternative drug combinations is cisplatin and
adriamycin. As many drugs cause nausea, anti-emetics are given initiaIly.
150
SURGERY FORBONE TUMOURS
Lorazepam given at the start oftreatment enables the patient to sleep throughout,
making it more tolerable.
These cytotoxic drugs have unpleasant and potentially dangerous side ef-
fects, the most noticeable being nausea, vomiting and hair loss. Bone marrow
depression occurs and the patient's blood must be checked before each course
to ensure that it has recovered from the previous course. Other side effects
include allergy, diarrhoea or constipation, peripheral neuropathy, stomatitis,
skin rashes, cardiac toxicity, pneumothorax and renal tubular necrosis. Pro-
longed treatment causes cirrhosis of the liver, other liver and renal disorders,
defective osteogenesis and defective spermatogenesis. As a result of a low white
blood cell count, resistance to infection is low and the patient must be protected
from infectious diseases. Chickenpox and measles are very dangerous and
should be avoided for six months after chemotherapy, although a prophylactic
injection can be given if the patient is known to have been in contact with a
person with these infections.
Strict precautions are taken in the preparation and administration of these
drugs, to protect patients and staff, as they are very toxic.
RADIOTHERAPY
This may follow surgery for Ewing's sarcoma, myeloma, soft tissue sarcomas and
some bony metastases. It may be used curatively or as palliation to ease symptoms.
SURGERY FOR BONE TUMOURS

This may involve scraping away the affected bone (curettage) or excising the
affected area back into healthy tissue. If the tumour is aggressive or extensive,
EPR of the diseased bone may enable the limb to be preserved. EPR is similar
to joint arthroplasty with diseased bone being replaced by metal components,
e.g. titanium or cobalt chrome alloy (Figures 10.3 and 10.4). The prosthesis is
custom-made to the correct length and shape to fit the individual patient,
ensuring that the limb is the same length as the contralateral limb. With the
growing child, the parents' heights are used to estimate his ultimate height, and
the prosthesis made in two parts which telescope together. It is lengthened at
intervals by 6 mm at a time, by distracting the two ends and slipping a spacer
between the two components.
The same surgeon should perform the biopsy and the definitive operation. The
tumour is removed with an intact layer of healthy tissue with the biopsy scar, to
eliminate contamination ofthe operative field. The prosthesis is inserted and fixed
with bone cement. Soft tissues are sutured around the prosthesis, sometimes using
a tube of terylene net. Reliance is then placed on a tube of scar tissue forming
around the prosthesis for muscle attachment. This initial strength of muscle
151
BONE TUMOURS
Figure 10.3 Endoprosthetic replacement offemur and knee (reproduced by kind

permission ofthe Bone Tumour Service, Royal Orthopaedic Hospital, Birmingham)
attachment is therefore very fragile and must be treated with care. After closure
of the wound no drains are used, nor interrupted sutures, to reduce the risk of
infection which would prejudice the survival ofthe prosthesis.
Bone grafting may be employed to bulk up the bone following curettage or
excision, with the ilium as the donor site. The fibula is frequently used for
grafting and may be used to form strut grafts where considerable bone has been
lost from the pelvis (Figure 10.5).
152
SURGERYFORBONETUMOURS
Figure 10.4 Endoprosthetic replacement of section of pelvis and hip joint

(reproduced by kind pennission ofthe Bone Twnour Service, Royal Orthopaedic
Hospital, Birmingham)
The aim of surgery is to cure the patient. It may save the limb but if blood
vessels, nerves or a neighbouring joint are involved in the tumour, the limb
cannot be salvaged. Amputation is a last resort, either to save life or as a
palliative measure to remove the source of severe pain. As advances are made
in the treatment ofbone tumours, amputations become fewer.
Results are encouraging. With osteosarcoma, ifthe patient survives the first
two years, he stands an 80% chance of being alive five years later. The
development ofa good gait pattern depends on the patient's efforts and co-op-
153
BONE TUMOURS
Figure 10.5 Fibular graft following excision of pelvic tumour (reproduced by

kind pennission of the Bone Tumour Service, Royal Orthopaedic Hospital,
Binningham)
eration with the physiotherapy programme. Loosening ofthe EPR after ten years
may occur, but the EPR can be revised. Sometimes a knee prosthesis requires
re-bushing, i.e. replacement of the polyethylene bush through the hinged
prosthesis, through which the joint is bolted. As withjoint arthroplasty, there
is interest in uncemented prostheses which may decrease the chance of
loosening.
Research continues into improved prostheses and techniques, use of allo-
grafts, better targetted drugs, radio-active isotopes which seek out metastases
direcdy, etc. The increasing use ofMRl scanning will enable earlier diagnosis
and better surgical planning which in turn will improve the success ofsurgery,
increasing the chance of survival.
THE CARE AND COUNSELLING OF THE PATIENT AND HIS

FAMILY
Ifthe reader considers the sections on tumour work-up and chemotherapy from
the point ofview ofthe patient and his family, it is clear that there will be great
emotional shock. Contributory factors include:
154
PHYSIOTHERAPY
diagnosis of a dreaded disease;

swift removal from familiar surroundings to hospital;
diagnostic tests, some possibly frightening, certainly stressful;
restricted activity, possibly bedrest, with resulting loss of dignity;
chemotherapy, unpleasant and frightening, with up to four drip-stands
round the bed;
• prospect of major surgery ahead;
• loss of eamings and other financial stress;
anxiety about the effect ofthe illness on other family members.
Consequently every member of the treatment team must recognize the
patient's distress, and be able to counsel hirn and his family. At the outset the
medical team must explain the patient's treatment plan, allay unfounded fears
and encourage his co-operation. Honesty is the best policy, so that the patient
does not conjure up nightmares or unreal expectations. This lays the foundation
for trust and prevents that trying situation when all concemed are avoiding the
truth.
Staff must be prepared to take time over assessments and explanations. The
patient will be anxious and want answers to many questions. He must be
reassured that no question is too trivial to ask. The social worker may work
especially closely with the occupational therapist at this point. The social
worker's role is to offer practical help and support with socio-economic prob-
lems, and to encourage the patient and his family to express their distress, fear
and anger. Any member ofthe rehabilitation team may be engaged in counsel-
ling, which involves non-judgemental listening to the patient and his family,
and this in itselfhas a healing effect. The section on counselling in Chapter 1 is
equally applicable to the tumour patient. He may need to go through the
mourning process, because there may have to be some alteration to his lifestyle,
e.g. a change of job or giving up a favourite sport. His body image will have
altered, even if there is no marked alteration in his outward appearance. The
temporary 10ss ofhair alters his appearance, but a wig is supplied, although male
patients tend to prefer wearing a cap.
PHYSIOTHERAPY
For each patient the physiotherapist makes an individual treatment plan, based
on the muscles, etc. involved in surgery. She also carries out chest physiotherapy
immediately after the operation.
After EPR of a bone in the lower limb, the patient exercises in bed. If the
knee is affected, he is up after three days, but is on bedrest for two weeks if the
proximal femur or pelvis is involved. Most patients are discharged about two
weeks post-operatively, partially weightbearing, with a programme of exercises
155
BONE TUMOURS
to follow at horne. Six weeks after surgery the patient returns for one week of
intensive physiotherapy, at the end ofwhich he is fully weightbearing. Follow-
ing curettage or bone grafting, he remains non-weightbearing for longer, to
allow the bone to bulk up after curettage, or to unite after grafting.
If the shoulder or humerus is replaced, the elbow and wrist only are worked
up to six weeks, then work commenced on the shoulder. If the rotator cuff is
involved, the arm is immobilized across the chest initially and bandaged to the
trunk if there is risk of subluxation. Mobilization proceeds more slowly and
cautiously.
Occupational therapy intervention varies according to the surgery, the patient' s
circumstances and the prognosis. Patients with involvement of pelvis, proximal
femur, spine, shoulder, elbow and forearm, especially of the dominant hand,
may have daily living problems. When the lesion is from the knee downwards,
occupational therapy intervention may be unnecessary, unless the bone has
fractured and the patient is wearing a pIaster cylinder.
Initially the occupational therapist should explain her specific role to the
patient. On admission the patient may have no daily living difficulties but this
may change following surgery. An elderly patient discharged on crutches to
await surgery may be unable to negotiate stairs and be unable to reach her WC.
In this case a bed downstairs and a commode may be called for. Even if there
are no daily living problems at this stage, the patient is reassured that help is
available should the need arise.
The occupational therapy assessment includes information conceming the
patient's family support, his horne facilities, and his employment and leisure
interests. If surgery is imminent, it is wise to estimate what equipment will be
necessary on discharge and alert the providing community agency so that they
have the opportunity to assemble the items needed. Early discharge is normal
and equipment must be provided immediately for the patient's security and
protection.
Tools for living depend on the site ofthe lesion and the needs ofthe patient.
Ifthe hip joint is involved, provision should be made as fortotal hip replacement.
If surgery involves the pubic ramis, the patient should be assessed for indepen-
dence in rising from chair, bed and WC and bending to reach the feet. Ifpelvic
reconstruction is to be performed, either by fibula strut graft or by EPR, the
patient will be immobilized in a hip spica for six to 12 weeks. Necessary
equipment may then include:
• single bed with monkey pole, downstairs;
• bedraising blocks;
156
bedpan and waterproof mattress cover;

commode if the patient can position over it;
raised toilet seat, with dip side on patient's affected side;
• oval-to-round adaptor to position raised toilet seat as above on commode;
Femicep urinal (for females);
an extra-long reaching tool.
Toilet provision is a matter for individual assessment, as it depends on the
patient's build and on the slight angle of abduction and/or flexion in which the
hip is immobilized. Sitting is problematic, but a high-seated chair with a sloping
back may suffice and the younger patient may manage to use a settee piled
strategically with cushions, provided he has assistance with rising. The patient
is mobile on crutches but unable to manage stairs. After the second stage of
pelvic reconstruction when the EPR is inserted, no additional equipment is
necessary.
When the upper limb is involved it is important to establish hand dominance.
After surgery, the patient is more disabled for a time. The type oftools required
may include a Manoy knife and plate, Dycem mat, bread buttering board,
Belliclamp, etc. If he is using the clumsier non-dominant hand to manipulate
them, the patient will need extra training in the use ofthese tools.
When spinal surgery is performed, provision oftools for living is as for spinal
fusion. It must be made clearto the patient that any tools for living are intended
as temporary aids and that he will be able to return all or most ofthem after his
week of intensive physiotherapy. The older patient may need to rely on the
raised toilet seat for longer.
Before discharge the patient's independence in dressing and grooming
activities should be checked, and ifhe lives alone, he should practise making a
hot drink and a snack. If family help is not forthcoming, he should be assessed
for provision ofhome help and meals on wheels. After the intensive physiother-
apy he should be able to prepare and cook a main meal, and should be assessed
for safety and competence in doing this.
Time should be expended on the kitchen practice, the therapist sitting down
and drinking a cup oftea or sharing a meal with the patient. This cosy, domestic
situation encourages confidences in a relaxed atmosphere. The patient may
reveal fears or previously unmentioned problems, so that steps can be taken to
deal with them. Because ofthe severity oftheir pain before treatment, patients
may have been aggressive towards family members and now feel guilty. Talking
about it helps to relieve these guilt feelings.
The patient and his partner may come to the kitchen together, and once the
drink has been made the therapist may withdraw, but be within calling distance.
This enables the couple to talk, weep or console each other in the privacy which
is lacking on the ward. The partner or family should be involved in the
157
BONE TUMOURS
rehabilitation programme and the patient encouraged gradually to resume his

fonner roles and interests. Contact sports are to be avoided, so another absorbing
interest may have to be sought out.
Occupational therapy with the paediatric bone tumour patient

Much of the above applies equally to the treatment of children. The social
worker supports the family network, since the parents are pre-occupied with the
siek child. There may be other children at horne who also need their parents'
loving care. These healthy children may have goilt feelings or be jealous of the
attention the siek child is receiving. The parents may feel goilty at giving less
attention to their healthy children, and may be blarning themselves for the siek
child's illness. Frequently the family's emotional suffering is as great as the
patient's: theirs is the watehing and waiting role, while the patient has the more
active role to play in his own rehabilitation
Regarding daily living activities, teenage patients will have similar require-
ments to adults. They are inclined to shun much of the available equipment
because of its connotations of abnonnality, so only the most essential items may
be accepted and these should be of a design which is as unobtrusive as possible.
Few tools for living are required for younger children as they are very adaptable,
have adults to wait on them and can more easily be lifted around. Many parents
appreciate the provision of an outdoor wheelchair or buggy to enable them to
cope; with other children at horne, the mother is busy and the affected child
cannot be left alone in the house while she shops and takes siblings to and from
school.
Education is disrupted, as the child may have repeated episodes ofhospital-
ization for chemotherapy and prosthetic lengthening surgery. Unless there is
teaching provision within the hospital, it may fall to the occupational therapist
to liaise with the younger child's teachers to provide schoolwork at the correct
level, and to use play activities to facilitate nonnal psychosocial development
and help the child express his fears and emotions. Education is an important
issue for the adolescent, as it is difficult to provide the appropriate teaching in
hospital at this level and future career prospects are at stake.
AMPUTATION
If there is a likelihood of amputation being necessary, the patient is warned
before signing the consent fonn for surgery. Despite this, the reaction on
recovery from the anaesthetic is one of shock and dismay and the rehabilitation
team must encourage the patient to mourn for the limb in the same way as
mourning the loss of a loved one. The patient feels a great sense of loss and
worries as to how he will manage without the limb.
158
AMPUTATION
The sensitive attitude ofthe nurses and physiotherapists will help the patient
through the early days. Their looking at and handling the stump without disgust
and their confident attitude towards it help the patient's self-image. He must be
encouraged to look at the stump, handle it and care for it early on, to enable hirn
to accept the situation. Those who have never seen an amputation stump fear
the sight, often imagining something grotesque. A good surgeon leaves an
adequate flap of skin and musele to elose over the bone end, leaving it neat and
well-padded to prevent soreness later.
Lower limb amputation

For eradication of a bone tumour, the below-knee site is the lowest likely to be
encountered. Retention of the knee joint is a valuable asset, enabling easier
fitting of a prosthesis and rendering it more functional. Disarticulation through
the knee joint without severing the bone enables earlier fitting of a prosthesis.
The mid-thigh or above-knee amputation produces an ideal stump for fitting a
prosthesis. With each of these sites, the physiotherapist gives exercises to
prevent the development of flexion contractures. If allowed to develop, such
contractures prevent the patient weightbearing through the prosthesis. Lying
prone helps to prevent this complication.
Disarticulation through the hip joint leaves no stump and the scar is anterior
to the joint, so that the patient does not bear weight on it when sitting.
Rehabilitation is easier than might be expected. Hindquarter amputation in-
volves removal of the whole leg plus the ischium, pubis and all or most of the
ilium. Again the scar is on the anterior aspect. Fitting ofthe prosthesis may be
delayed for many weeks, depending on healing, the patient's physical state and
any concurrent treatment.
Patients are mobilized quickly after surgery, standing out at about the second
or third day, progressing to hopping with a walking frame after the high
stumpless amputations, then onto crutches. Where there is a stump, a pneumatic
post-amputation mobility (PP AM) aid is used within a week to maintain the
walking pattern, and the massaging effect of this aid helps to reduce oedema.
Physiotherapy aims to develop balance, maintain mobility in the remaining
joints, prevent contractures, develop strong hip abductors and quadriceps mus-
eles in below-knee amputations, strong hip abductors and extensors in above-
knee amputation and improve power in the upper limbs.
The occupational therapist complements the physiotherapist' s work, observ-
ing the patient's positioning and movement while assessing for independence,
and reinforcing the physiotherapist's instructions.
The patient may prefer to sit on a soft seat, but sitting on a finn one prepares
hirn for weightbearing on the ischium when he gets his prosthesis following hip
disarticulation. As the ischial tuberosity is preserved after hip disarticulation,
159
BONE TUMOURS
sitting is easier than after hindquarter amputation, when the patient's sitting
balance is altered. A cushion made of calico filled loosely with polystyrene beads
is helpful, the patient nestling into the cushion so that the spine is perpendicular.
Checking the level ofthe shoulders is invalid: the spine may still be curved.
If the patient is in agreement, a wheelchair should be ordered early so that
quality of life is improved by the ability to go further afield than is possible on
crutches. Even after he has become proficient on his prosthesis, it is advisable
for the patient to retain the wheelchair, as it may be needed if the prosthesis
needs repair or if he develops stump problems. Because speed of provision is
important at this stage in order to improve morale, a standard 8L wheelchair
may be ordered with the rear wheels set back three inches for those with high
amputation to balance the front ofthe wheelchair and prevent tipping due to the
lost weight at the front. An 8BL is contra-indicated following high amputation
since, even with the rear wheels set back, both the wheelbase and the castors
are too small for this model to be sufficiently stable in use.
For the patient who is not to be fitted with a prosthesis, a more careful
wheelchair assessment is necessary. The width should equal the width of the
patient across the hips plus two inches, and the depth should measure the
distance from the back of his bottom to the bend behind the knee minus two
inches (5 cm). Lower backrests allow more arm function but offer less trunk
stability. The seat height should be measured from beneath the lower thigh to
the base ofthe shoe heel, plus an extra three inches (7.6 cm) for floorclearance.
Use of a cushion affects the last measurement and affects the height of the
armrests, which should be at the level ofthe forearms with the elbows flexed at
90°. Detachable armrests facilitate transfer, and desk-style armrests and a tray
attachment are available. A model with larger castors is more stable.
The space available within the horne must he taken into account when assessing
for a wheelchair. Access needs to he ramped, with the maximum incline at 1 in 12.
Doors must he at least 32 inches (81.5 cm) wide. Doors at right angles to narrow
corridors may prove impossible to negotiate, the turning circle for a wheelchair
being 60 inches (152.5 cm). It rnay help to rehang a door to open the opposite way,
or on the opposite side ofthe frame, to obtain extra space. Bathroorns, heing almost
universally cramped, should have doors opening outwards.
Tools for living which may be needed after high level amputation depend on
the patient's age, but may include:
high seat chair, or raising device on existing chair;
raised toilet seat and frame;
bedraising blocks and possibly a monkey pole;
commode and walking frame for night use;
helping hand reacher;
bath board, seat and non-slip mat.
160
AMPUTATION
The mattress must be firm, for ease ofmovement, for getting in and out ofbed
and to prevent flexion contractures. If the mattress sags, a fracture board must
be placed beneath it.
Dressing problems as such are rare, but the patient should sit to dress as balance
is affected. Kitchen practice is important because of altered mobility and the
inherent hazards. The light workshop rnay be more appropriate for some patients
to practise mobility while engaged in any activity other than pure walking. The
patient should stand and walk as much as he can tolerate, using appropriate walking
aids. When standing at a work surface there is a danger that, because the patient still
feels the limb he will forget that it is no longer there, and may take a side-step onto
the amputated side and fall. To prevent this, a stool should be provided at the correct
height for the stump to rest on. It is useful if the patient can use the pp AM aid while
he is in the occupational therapy department, so that his stance and gait rnay be
observed to ensure that he maintains the correct patterns. He should stand erect and
not develop the habit of leaning forward at the hips, and when walking should
elevate the pelvis to swing the prosthesis through, avoiding swinging it out side-
ways. Figure 10.6 illustrates a flowchart for monitoring achievement of objectives
following hip disarticulation or hindquarter amputation.
The patient is discharged home well before the prosthesis is supplied. The
waiting time is variable, depending on healing, residual oedema, concurrent
treatment, the age of the patient and his general fitness. It is helpful if the
occupational therapist can give broad answers to the patient's questions con-
cerning the future prosthesis. Except in the case of hip disarticulation or
hindquarter amputation, a temporary prosthesis may be supplied initially to
enable earlier weightbearing yet allowing for stump changes. The socket is the
most important part ofthe prosthesis, as it is the part which comes into contact
with the stump and through which the weight is borne. Total surface contact is
the aim, to prevent congestion in the end of the stump. A woollen stump sock
is worn to adjust fit and prevent chafing, a cotton sock to achieve fmer fit and
a nylon sock enables gliding to take place between stump and socket when the
limb is being put on. Materials used in the making of prostheses are lightweight,
hardwearing, rigid polypropylene, glassfibre laminate and flexible polymers,
with a fairly natural appearance. They are body-powered in conjunction with
gravity. Shoes with broad-based heels and non-slip soles are required and should
be light in weight, as walking with a below-knee prosthesis uses 20% more
energy and with an above-knee prosthesis 40% more energy than walking with
two normallegs. With most prostheses it is necessary always to wear the same
height heel, but the prosthetist can re-align the ankle to adjust the prosthesis and
some models may be adjusted by the patient.
Training in the use ofthe prosthesis is carried out by a physiotherapist with
specialist skills at the limb fitting centre. She teaches the patient to walk, manage
stairs, transfers, etc. and how to get up from a fall.
161
OCCUPATIONAL THERAPY DEPARTMENT HIGH AMP.
NAME' NUMBER' ~
Pre-Op Op. Day 1 Day2 Day3 Day4 Day5 Day6 Day7 Day8 Day9 Day 10 Day 11 Day 12 Day 13 etc
Introduce Aspre-{)p
self.ched<, ifnot
horne previously
situation, clone
accom,
he1p, woIk,
etc
Order Cheekwhen
wheel- wheelehair
ehair due for deliver
Whenpt. Teach
uptoW.C.
assess for
Monito progress use of
bath aids
--
_'>0
adaptations
Whenpt. Supplybead
sittiog out M nitor eushion
provide if appropriate
cushioning
Prelirninary Detailed referral
referral and expected
~supplier discharge date ensure
of equipmenl delivayofequipm:nt
GiveNALD
infonnation
futehen Probable
-----.;>.
~sessm.ent i home
ppropnate visit
Monitor positioniJ gande rreet gait pa ernswhile i OT's ca"
Figure 10.6 Flow chart for use following hip disarticulation or hindquarter amputation
AMPUTATION
Upper Iimb amputation

This is much less common than lower limb amputation. The below-elbow and
mid-humeral sites are more easily fitted with prostheses. The remaining joints
of the affected arm must be mobilized to prevent development of stiffness or
contractures. The physiotherapist puts the patient's two arms through the full
range of movement at regular intervals.
If the amputation is through the shoulder joint (disarticulation), or a fore-
quarter amputation in which the clavicle and scapula are removed along with
the whole arm, disability is much greater. After disarticulation, the shoulder line
is maintained and the prosthesis is useful. After forequarter amputation the
shoulder line is lost, the new outline resembling a raglan sleeve. A simple
lightweight prosthesis will be supplied to restore the shoulder line, andlor a
cosmetic limb, useful only for positioning. Meanwhile it improves the patient's
morale ifthe occupational therapist makes up a temporary shoulder pad offoam
or plastazote. This may be encased in cotton fabric for comfort and is held in
place inside aT-shirt with a dab of velcro. Similarly the patient who has
undergone a scapulectomy will have a pronounced dropped shoulder line. For
female patients, these operations cause problems with bra straps and fastenings.
Asports bra with straps close together at the back may be suitable, otherwise
the bra may be altered to a halter neckline and fastened at the front.
Independence in dressing is aided by the wearing ofknitted fabries, clothes
with few fastenings or velcro tabs, elasticated waistbands, ties, laces, etc.
Clothes management in the toilet may be aided by a woman holding up her skirt
in her teeth, and a man using a button hook to fasten his trousers waistband. A
cuddly thick bathrobe enables easy drying after a bath, and a suction nailbrush
mayaiso be used for brushing dentures.
Kitchen activities using a Manoy knife and plate, Dycem mat, bread buttering
board, fixed potato peeler, Belliclamp, etc. encourage independence in cooking.
Following amputation ofthe dominant arm, fine skills must be built up in the
remaining hand, because the prosthetic arm will be the assisting one. This is
significant when planning return to work. The person with an academic or
administrative job can manage reasonably well and the manual workermay cope
adequately using his prosthesis. The person whose work requires precision, such
as a draughtsman or a silversmith, may be seriously handicapped.
The patient is discharged horne early and may become very proficient in the
use of only one arm while he awaits his prosthesis. Well-motivated patients are
ingenious in devising coping methods. Holding objects between the knees to
position them, and use ofthe teeth, compensate to a large extent.
The patient will be asking questions about the prosthesis soon after the
amputation, so it is helpful to know some answers. Cosmetic limbs are designed
to improve the patient's body image and appearance, without attempting to
163
BONE TUMOURS
improve function, e.g. those supplied following forequarter amputation. Body-

powered prostheses use the remaining movement in the affected limb or, via a
hamess, use movements of the opposite limb. The greater the amount of limb
removed, the less mechanically efficient is the prosthesis. There are specialized
attachments for manipulating tools but the split hook is the most useful. A
working prosthesis is also supplied with an interchangeable cosmetic hand.
Electrically powered prostheses are becoming more popular and use recharge-
able batteries. Since 1982, hybrid systems have been developed for above-elbow
amputations. These are body-powered elbow mechanisms with myo-electric
hand control, or servo-switch control attached to clothing. In myo-electric
prostheses the electrodes are sited over the flexor and extensor muscles to obtain
the required movement. It is usual for a body-powered prosthesis to be supplied
first to accustom the patient to wearing one, and because it is lighter in weight.
After an amputation, the patient is individually assessed and measured for his
prosthesis, then re-assessed at intervals as the stump may alter in shape. The
occupational therapist who treats the patient on the orthopaedic ward is unlikely
to be the one who later trains hirn in the use of the prosthesis. Training in use
of the limb involves activities of daily living, cookery, bilateral hand activities
of all kinds, remedial and construction games, and heavier activities such as
woodwork. In this way the patient leams to master use of the prosthesis in all
kinds of situations, so that it becomes apart of hirn. Liaison with the school or
workplace mayaiso feature in the programme.
In the early days, if the amputation is at a high level, the patient leams to
adjust to the altered balance. However the lost sensation on the affected side is
a permanent disability, unlike the restoration offunction which is achieved by
provision ofthe prosthesis.
Stumppain
Pain in the stump end may be due to infection, adhesions, vascular problems or
neuroma, and is solved with prompt medical attention. Aneuroma is a mass of
proliferated nerve fibres at the end of a severed nerve, and may be treated by
local injection or occasionally by surgery. If stump pain persists, it may prevent
the wearing of a prosthesis.
Phantom Iimb pain

This differs from stump pain in that it is felt beyond the amputation site. It is
due to the sensory nerve endings in the stump producing an image of the
amputated limb in the cerebral cortex. Its intensity varies and it may be
permanent or transient. For most patients it gradually fades, but persists in some
cases and may be severe. If the patient's pain was poorly controlled prior to
164
AMPUTATION
amputation, the phantom limb pain tends to be related in intensity to the pain
feit at that time. It may be helped by ultrasound, TENS, percussion over the
stump, or by hypnosis. Once the prosthesis is fitted it becomes more acceptable,
as the patient feels as ifhe is moving his own limb.
Altered body image

Where malignant disease is present, there are likely to be systemic symptoms
such as weight loss, fatigue, pain and malaise. These may cause altered facial
contours, body shape or physical function. Knowledge ofthe changes occurring
within his body makes the patient anxious, depressed and apprehensive.
Surgery causes scarring: minor with a biopsy, major for a wide excision,
mutilation following amputation. Chemotherapy causes hair loss and other side
effects. Radiotherapy has local and systemic side effects, skin changes being
common and very noticeable. This treatment is feared because ofits associations
with bums, radio-activity, sterility and radiation-induced cancers.
Even if the patient's body changes are not visible to the outside world, he
knows ofthem. Body image, therefore, has two facets: the actual body changes,
and the feelings the patient has towards them. The bodily alterations may be
rapid, but the patient's adjustment to them is a much more gradual process.
Amputation is a devastating and disfiguring operation. Adjustment requires
four distinct phases (Walters, 1981):
1. The impact of the knowledge that a limb must be amputated.
2. Retreat, during which the patient grieves for the loss ofthe limb.
3. Acknowledgement, as the patient becomes ready and able to take an active
part in his rehabilitation.
4. Reconstruction, as the patient assurnes responsibility for his own care and
future development.
In order to help the patient progress satisfactorily through these stages of
adjustment, five steps have been suggested (Donavon and Pierce, 1976). The
patient should be encouraged to:
1. accept the appearance of the operation scar;
2. touch and explore the area;
3. leam to care for the scar;
4. become independent in daily living activities;
5. accept his altered appearance, if necessary adjusting his lifestyle.
The patient should be prepared for the ordeal of facing the outside world
again, because within the hospital he is in a sheltered environment. It may help
hirn to discuss how he will explain his amputation to others. The next step may
be venturing out of the ward to the hospital shop, then perhaps an outing to a
165
BONE TUMOURS
local cafe or pub, accompanied by a supportive relative or therapist. The longer

he holds back from meeting the world at large, the harder is the adjustment.
Amputation is especially devastating to the adolescent. Physical appearance
is tremendously important to hirn, and he is already struggling with emotional
and physical changes. As a result ofthe surgery and possible chemotherapy, he
has to depend on his parents longer than he would wish, and frequent periods
ofhospitalization interfere with his educational and social development. Previ-
ous plans for a career and involvement in sports may have to be modified or
abandoned. The whole family needs support and the therapeutic team must
encourage a positive attitude towards rehabilitation and supply accurate infor-
mation. The most acceptable fragment of information for an adolescent bone
tumour patient in receipt of Mobility Allowance is that he is legally entitled to
drive at the age of 16.
Sexual counselling
If a person looks good, he tends to feel good, and vice versa. This is important
regarding sexual attraction, therefore the adolescent who has had an amputation
must make a special effort over his dressing and grooming. This will improve
his self-image and confidence, and largely overcome the initial disadvantage.
If the patient already has a partner, both are likely to be frightened of the
effect of scarring or mutilation. To one who is scarred, touch by a loved one is
important for his security and self-esteem. Some people are repelled by scars
and stumps and need help in overcoming this.
Couples may experience great difficulty in resuming relationships. Fatigue
or pain may reduce the sex drive. Anxiety or the effects oftreatment can cause
impotence or frigidity. Ifthe patient requests any information conceming sex,
staff should either supply the information, or point the patient towards a source
of help. A marriage guidance counsellor or spon are valuable contacts. To
enable embarrassed people to seek help, the addresses ofthese two organizations
should be displayed in a patients' circulation area.
Chemotherapy andradiotherapy have a damaging effect on fertility, and prior
to treatment young men are offered the facility of a sperm bank so that they may
still father a child.
SUPPORT GROUPS
The social worker may obtain funding for equipment, holidays, travel to and
from hospital, etc. on the patient's behalf, from the Malcolm Sargent Cancer
Fund for Children up to the age of 18 years, and for adults from the Macmillan
Fund.
The BACUP and Cancerlink organizations provide information and support
166
THE ROLE OF THE THERAPIST WITH THE TERMINALLY ILL
for patients and their carers (addresses in appendix). The National Association
for Limbless Disabled produce a magazine for members and provide a network
of people who have themselves experienced amputation, who will empathize
with and encourage new amputees.
THE ROLE OF THE OCCUPATIONAL THERAPIST WITH THE

TERMINALLY ILL PATIENT
On occasion the prognosis is very bleak, and the patient is diagnosed as
terminally ill. He may or may not remain on the orthopaedic ward, but the
occupational therapist will at least initiate a programme for his benefit. This is
somewhat of a volte-face for the therapist, as her goal is usually improvement
and/or independence for the patient. It is possible for the rehabilitation team to
overlook the patient who is not going to recover, leaving hirn feeling abandoned.
Occupational therapists, having studied the physical and psychological aspects
ofhuman occupation, are uniquely able to contribute to the care ofthe terminally
ill. Attainable goals may be set, leading to improved quality ofwhat remains of
life.
The patient and his family have first to come to terms with the prognosis.
Unless they are aware of the terminal nature of the illness, it is impossible to
follow a realistic programme. Elizabeth Kubler-Ross (1969) described the
stages through which an individual passes on learning tragic news: denial and
isolation, anger, bargaining with fate, depression and finally acceptance. Both
patient and family members are involved in this process.
Often the victim of a bone tumour is young and has just realized how much
life has to offer. It is then especially hard to come to terms with the prognosis,
particularly if the patient does not yet feel ill. Denial of anxiety is abnormal and
staff must be aware that deep down the patient is anxious. Feelings of anxiety
may be suppressed by excessive talking, either to prevent his mind dwelling on
his fate or to prevent others talking about it. Early on anger may be displayed,
but as physical energy wanes, depression replaces anger. If the patient can be
encouraged to complete outstanding tasks, he is more likely to settle into a mood
of acceptance. Referral to occupational therapy is a positive step, encouraging
hope which is essential to survival, but false hopes must not be raised.
The patient can become childish and demanding to cover up the unacceptable
and degrading process of physical deterioration. He fears becoming a burden
on his family. Loss of familiar roles is painful and the whole family have to
adjust to their changing role relationships. Ifthe patient loses his social role, he
may become isolated to the point of feeling worthless. Occupational therapy
intervention evaluates what prevents the patient carrying out his previous
activities, and will take into account:
167
BONE TUMOURS
the patient's role within the family;

the patient's socio-economic role;
functional problems, maximizing areas where function is unimpaired;
effects of treatment and fatigue;
what has been most important to the patient in his life, and what he would
stilllike to achieve.
A plan of action is now possible. The patient's involvement in making this
plan is vital. It gives hirn a feeling of control, lacking in his previous treatment.
Family members should be incorporated into this programme, to help them
adjust to the altering circumstances. They must be reassured that their fears,
frustrations and even resentment are normal. Open communication is important
and the therapist herself may express feelings of sadness, to empathize with the
group. Her own approach should be quietly positive and moderately cheerful,
but not overly so, as this displays a lack of sensitivity and professional confi-
dence.
The goals of oncology rehabilitation have been divided into four parts (Dietz,
1981 ):
prevention of potential disability;
restoration to pre-morbid levels of activity;
support through the stages ofprogressive disease;
palliative treatment to prevent complications during increasing disability.
The last two goals may be summed up as enabling the patient to live to the full
what remains of his life. Key tasks include maintenance of independence by
whatever tools are necessary. Quickly provided housing adaptations such as
handrails and halfsteps may be of benefit. Chair and bedraising blocks may
maintain independence and dignity. Prevention of a housebound existence by
means of a wheelchair, plus portable ramps, may enable the patient to come and
go independently. All ofthis gives the patient some control over his environment
and reduces his feelings of being a burden on his family. Advice on energy
conservation (Chapter 1) will help to alleviate the fatigue inherent in terminal
illness. Relaxation methods (Chapter 11) may help to relieve pain and stress.
The use of activity maintains strength, co-ordination and dexterity, and
engages the patient in a meaningful task, promoting self-esteem and mastery of
his environment. This meaningful task must relate to the patient's satisfying
achievements in the past, and fulfil some ambition for his remaining lifespan.
The carer should have a contingency plan for coping with the patient if he
attempts too much. If it is his work which gives the patient the greatest
satisfaction, the aim should be to keep hirn there as long as practicable.
Pain is controlled by opiates, given before the pain returns. In this way a
lower dose is needed, side effects are avoided and addiction does not occur.
168
FURTHERREADING
Once the correct dose is found, pain is controlled and the mind remains clear.
Ifthe pain increases, the dosage is increased accordingly.
Care and support of staff dealing with the terminally ill

Staff who work with the terminally ill are prone to stress. It is inevitable that
staff are saddened by the decline and death of patients they have come to know
weIl. If staff become irritable, find it hard to concentrate, begin to smoke or
drink more heavily, sleep badly, have digestive disturbances or find it hard to
'unwind' , they are suffering the effects of stress. It is important to recognize this
and to take time to withdraw and talk it over with people who understand, usually
fellow workers. If staff do not acknowledge their own grief they become unable
to cope with the demands made upon them. Iheir personal and domestic life
mayaiso suffer. Ihis can lead to a breakdown in the situation, when they have
to leave the job.
Apart from the mutual support among the team members, a formal support
network may be desirable, under the auspices of a trained counsellor. Above all,
it is essential that each team member has an absorbing outside interest that
refreshes and restores them. Ihis enables staffto become more closely involved
with and supportive towards the patients while they are present with them,
without detriment to their own physical and mental health.
REFERENCES
Dietz, 1.H. (1981) Rehabilitation Oncology, Wiley, New York.
Donavon, M. and Pierce, S. (1976) Cancer Care Nursing, Prentice Hall, London.
Kubler-Ross, E. (1969) On Death and Dying, Macmillan, London.
Walters, 1. (1981) Coping with a leg amputation, American Journal ojNursing,
81, l349-52.
FURTHER READING
Boren, H.A. (1985) Adolescent adjustment to amputation necessitated by bone
cancers, Orthopaedic Nursing, 4, no. 5, 30-32.
Brown, P.S.H. (1985) Basic Facts in Orthopaedics, 2nd edn, Blackwell Scien-
tific Publications, Oxford.
Davies, M. (1988) Sexual problems and physical disability, in C.J. Goodwill,
C. lohn, and M.A. Chamberlain (eds.) Rehabilitation oj the Physically
Disabled Adult, Croom HelmlSheridan Medical, London.
Downie, P.A. and Kennedy, P. (1981) Lifting, Handling and Helping Patients,
Faber, London.
169
BONE TUMOURS
Harn, R. and Cotton, L. (1991) Limb Amputation, Chapman and Hall, London.
Hambrey, R.A. and Withinshaw, G.(1990) E1ectrically powered upper 1imb
prostheses: their development and application, British Journal of Occupa-
tional Therapy, J anuary, 7-11.
Humm, W. (1977) Rehabilitation ofthe Lower Limb Amputee, 3rd edn, BailIiere
Tindall, London.
Lloyd, C. (1989) Maximising occupational role performance with the terminally
i11 patient, British Journal ofOccupational Therapy, June, 227-9.
Luff, R. (1988) Amputations, in C.J. Goodwill and M.A Chamberlain (eds.)
Rehabilitation of the Physically Disabled Adult, Croom HelmJSheridan
Medical, London.
Melzack, R. et al. (1988) Challenge of Pain, rev. edn, Penguin Books,
Harmondsworth.
NichoIs, P.J.R. et al. (1980) Rehabilitation following amputation, in Rehabili-
tation Medicine: The management of physical disability, 2nd edn,
Butterworths, London.
Oelrich, M. (1974) The patient with a fatal illness, American Journal of
Occupational Therapy, 28, no. 7,429-32.
Price, B. (1986) Keeping up appearances, Nursing Times, 82, 58-61.
Sa1ter, M. (1988) Altered Body Image, Wiley, Chichester.
Stedeford, A. (1984) Facing Death, Heinemann Medical Books, London.
Strong, 1. (1987). Occupational therapy and cancer rehabilitation, British Jour-
nal ofOccupational Therapy, January, 4-6.
Tigges, K.N., Sherman, L.M. and Sherwin, F.S. (1984) Perspectives on the pain
ofthe hospice patient: the roles ofthe occupationa1 therapist and physician,
in P. Cromwell (ed.) Occupational Therapy and the Patient with Pain,
Haworth Press, New York.
170
11
Pain control
Pain may be classified into three types: intennittent, acute and chronic. The
orthopaedic patient is prone to all three types to some degree, and while the
orthopaedic surgeon can abolish or relieve pain in many situations, a significant
number of patients have to learn to live with their pain. Such is the nature of the
pain of rheumatoid arthritis, metastatic bone disease, phantom pain following
amputation and some back pain. There also arises the situation where a patient
admitted for joint replacement is found to be medically unfit for surgery, and is
discharged still in pain. With these cases there is clear physiological reason for
the pain.
Acute pain has its uses. It teIls us when something is wrong, so that we can
protect ourselves from danger or take remedial action. Magdi Hanna (1988) lists
five characteristics of acute pain:
The cause is known and recognizable.
The pain is ofno more than a month's duration.
Pain is accompanied by anxiety.
Treatment is fairly simple and effective.
The outcome is complete eure.
Magdi Hanna lists the following characteristics which distinguish chronic
benign pain:
The cause is difficult to diagnose.
Pain is oflong duration, possibly for years.
The patient is depressed, with probable behaviour and personality changes.
Treatment is complicated and may require a combination ofmethods.
Complete eure is rare.
Pain is a subjective experience and different people have differing levels of
pain tolerance. This may be influenced by childhood attitudes towards pain,
cultural background and personality type. This last is the indecisive, diffident
person, who may enjoy receiving sympathy and concern and uses pain as an
excuse to escape from difficult situations.
Chronic pain persists after the original condition has cleared and the warning
signs are no longer useful. The body's response to pain is similar to the stress
171
PAIN CONTROL
response. If this state of affairs becomes chronic it becomes an illness in itself.

The patient develops pain behaviour: groaning, grimacing, poor posture, atten-
tion seeking and inactivity. The pain wears him down, he is depressed, debili-
tated, neglects his appearance, does not eat or sleep well, moves little, takes no
interest in his surroundings, and his relationships with family and colleagues
are adversely affected. His status becomes that ofan invalid. Brena (1978) lists
five sequelae seen in chronic back pain, regardless of its presumed cause: drug
dependency (takes 'pills although they do no good'); decreased function; disuse
(loss ofpower and flexibility); depression; and disability (inability to work or
carry out normal daily living activities). Cailliet (1988) describes this cycle as
SAD, i.e. Somatic, leading to Anxiety, leading to Dependency and disability.
This chronic pain syndrome does not improve, nor does it tend to progress.
As there is no apparent physical cause for the pain, the surgeon is inclined to
abandon the patient or refer him to a psychiatrist, both of which are likely to
cause resentment.
If compensation for a back injury is pending, the doctor may suspect the
patient' s motives, so the patient may exaggerate the symptoms to try to convince
the doctor of his pain. This makes diagnosis difficult and may lead to distrust
between doctor and patient. Jayson (1987) writes that there is no evidence to
support the view that 'compensation neurosis' is a common occurrence.
The patient with chronic pain syndrome may be admitted onto the orthopae·
dic ward for assessment. He must be treated with patience and understanding.
It is important to gain his trust and co-operation, and counselling skills are
essential. In addition to the above characteristics, the patient talks interminably
about his pain, and as each possible solution fails, he grows more despondent.
Although a complete cure is rare, some forms of treatment can relieve the
problem. Melzack and Wall (1988) list four major approaches to the relief of
chronic pain: pharmacological, surgical, sensory and psychological. While she
will be actively involved in the last ofthese, the occupational therapist will find
a background knowledge ofthe other three useful.
THE PHARMACOLOGICAL APPROACH

This includes the administration of analgesics and NSAIDs. If pain is continu-
ous, analgesics are given at regular intervals before the pain returns. Ifthe pain
is worse at certain times, the analgesic is given 20 minutes before the pain is
due. Indomethacin suppositories bypass the stomach and are more slowly
absorbed, so give longer term pain relief. These drugs act directly on inflamed tissues.
Narcotic drugS act by interfering with the transmission of pain signals
between the brain and the painful area, and include opium and morphine.
Morphine acts in a similar way to the endorphins released by the mid-brain,
inhibiting pain. A placebo may be beneficial, as it may cause the release of
172
IRE SENSORY APPROACH
endorphins. According to Melzack and Wall (1988), a survey showed that 75%
ofpatients experienced pain relieffrom morphine, while 35% ofpatients given
placebos experienced pain relief, large placebos being more effective than small
and two placebos being more effective than one!
Tranquillizers may be used in conjunction with mild analgesics to reduce
anxiety and promote relaxation. Anti-depressants may be used to relieve anxiety
and to act as a night sedative.
THE SURGICAL APPROACH

Nerve block injection, using guanethidine, block the action of noradrenaline
secreted at the sympathetic nerve endings, thus relieving pain, while the sensory
fibres are not affected. Sympathectomy is another method, where a long needle
is used to reach the sympathetic nerve ganglia. A local anaesthetic is used first
to test that the right area has been located, then a destructive fluid such as alcohol
is injected.
Neuro-stimulators may be implanted for the relief of intractable pain,
especially where a nerve had been irreparably damaged. Minute electrodes
are implanted in the epidural space, usually in the thoracic spine. Wires
running just beneath the skin are connected to a tiny generator, which is
powered by long-life batteries. The system works by closing the 'pain gate',
and it also increases the blood supply to the area. In a very small minority
of cases a neuro-stimulator is implanted in the brain, where it appears to encourage
endorphins, but since the procedure carries a high risk it is rarely performed.
THE SENSORY APPROACH

This is the approach ofthe physiotherapist and includes massage, manipulation,
traction, use of superficial heat, ice packs, and TENS. This last uses the 'gate
control' theory of pain. It is thought that neural mechanisms in the dorsal horns
ofthe spinal cord control the flow ofnerve impulses from the periphery to the
cord cells that project to the brain, acting like a gate. Part of the theory is that
larger, faster conducting fibres carrying sensation can block the impulses from
the smaller, slower conducting fibres carrying pain, so that the modulatory
influence of the 'gate' affects the somatic input before the pain is perceived.
The process is similar to the jamming of a radio signal. The TENS equipment
consists of a small box with batteries and controls to regulate the power and
frequency of impulses. Electrodes attached to the site causing the pain aim to
close the 'pain gate' via sensory nerve pathways. Over 50% of patients obtain
long term relief of pain with this treatment. TENS machines interfere with the
ftmction of cardiac pacemakers and mayaiso affect heart rhythm in some
patients, hence the warning signs in physiotherapy departments.
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PAIN CONTROL
The sensory approach also includes acupuncture, which relieves symptoms

but does not treat the cause of the pain. It may help by closing the 'pain gate'
or by causing the release of endorphins in the brain.
THE PSYCHOLOGICAL APPROACH

Because of the physical and psychiatrie input in her training, the occupational
therapist can playa large part in the rehabilitation ofthe chronic pain sufferer.
It does require time and patience in listening attentively to the patient at the
outset. Counselling plays an important part, listening to the patient's out-
pourings, which will probably release a great deal of anger and resentment.
There is little need to talk back to the patient, other than to make a comment to
show that he is being understood or to ask whether you have understood
correctly by repeating what has been said. Observation ofhis body language is
important to gain additional information, which may be used in the treatment
plan. Examples of this are tension and grimacing, indicating pain. Movement
patterns, e.g. walking, getting in and out of achair, reaching for objects, etc.,
also give a clue as to pain level.
THE OCCUPATIONAL THERAPIST'S ROLE

The occupational therapist assesses the patient's horne situation, obtaining
details of any family living at horne and what support is available. This may
reveal whether there are problems within the family. If the patient works,
information is gleaned as to what activities are involved, what job satisfaction
is gained, and whether the patient is resentful or angry ifhe feels that the work
was the original cause ofhis illness. The psychological damage caused by injury
is often as disabling as the physical damage. It is also helpful to know if the
patient was a hypochondriac prior to the onset of pain. Discussion concerning
the family and work roles will demonstrate how the patient's self-image is
affected, and enquiry into his leisure interests will indicate how his social role
has altered.
Having elicited this information, goals should be set. These include the
re-establishment of occupational roles within the family and employment, and
resumption of leisure interests. Increasing achievement in these areas leads to
increased confidence and self-esteem. The means of achieving these goals
include:
assessment and instruction regarding difficult activities of daily living;
education in proper body mechanies;
increasing activity levels;
• counselling;
174
relaxation training and stress management;

work assessment and re settlement.
Each of these treatment areas may be applied to any form of chronic pain,
but the problems in daily living activities are possibly more relevant to chronic
back pain than to any other condition, and the section on tools for living in
Chapter 5 suggests solutions. However, it must be remembered that the patient's
pain has passed its useful purpose, so the fuller details on coping with acute back
pain should not be communicated, otherwise the chronic pain syndrome may
be reinforced.
Education in proper body mechanics has been covered in Chapters 1 and 5,
regarding rheumatoid arthritis and back pain respectively.
Increasing activity levels should be a gradual process, related to the patient's
interests and occupational roles. The principles of proper body mechanics
should be employed when carrying out activities. The length of time spent in
activity and the required energy output should both be increased. Treatment may
be on an individual or group basis. The latter is useful in improving socialization
and discouraging pain behaviour.
While assessing and treating the patient, the opportunity for counselling
may arise spontaneously and the opportunity should be grasped. The family may
need to be involved iftheir co-operation is needed for more effective treatment.
Work assessment and re settlement are discussed in Chapter 12.
Relaxation training, especially in group sessions, is a valuable therapy. Stress
management is closely related but also involves observation of what increases
pain, and at what time of day pain is at its worst. Active periods may then be
timed when the pain is more tolerable, and triggering situations avoided as far
as possible.
Relaxation helps to control pain in several ways. It gives the patient some-
thing positive to do and the activity distracts the mind from pain. Also, pain
causes tension and muscle guarding to protect the area from further pain. If
relaxation can be induced, muscular tension is reduced, blood flow is increased
and relief from pain ensues.
Relaxation techniques
By lying down to rest, weight and pressure are taken offthe intervertebral joints
and discs, allowing healing. If a suitable position is adopted, tense muscles relax
and pain is relieved. Patients will find different positions suit their individual
needs, but the following may be tried:
Lie on the back on a firm base, with no more than one pillow.
As above, but support the lumbar curve by placing a small pillow or folded
towel in the hollow.
175
PAIN CONTROL
Lie with several cushions under the calves, with hips and knees at right
angles, or the same position with the calves resting on a cushioned chair
seat. This flattens the lumb ar lordosis and is termed the Fowler's
position.
Side-lying, with a pillow between the legs to prevent the spine twisting. A
second pillow may be needed in the waist hollow.
If the patient finds a sitting position which is relaxing, this is acceptable. The
spine and limbs must be weIl supported.
Having achieved a comfortable position, the patient can be instructed in any
ofthe following relaxation techniques:
1. The alternate muscle tighten, muscle relax method, starting with the feet
and working upwards, ending with the facial muscles. The patient finally
rests in a relaxed state, breathing slowly and easily, using the abdominal
muscles for breathing in preference to the chest muscles. Breathing out
through the mouth and with the lower jaw relaxed greatly aids relaxation
throughout.
2. The patient closes his eyes and concentrates on his breathing. He then
focuses on the thought 'My left arm is heavy' for a time, then repeats this
procedure with each limb in turn. Ifhe repeats the procedure with 'My left
arm is warm,' ete., the proeess ean lead to an inereased flow ofblood to the
area, with beneficial effect. This is a kind of self-hypnosis and may be
carried through to concentration on a thought such as 'My pain has almost
gone.'
3. The playing of soothing music may help a patient to relax. This is a very
personal choice, so great care must be taken if working with a group,
otherwise increased tension could be the end result!
A simple myographic biofeedback machine attached to the fingertips may
help the patient to learn to control his tension at will. The machine works by
measuring electrical skin resistance. With the electrodes on the fingertips, the
machine emits a loud sound when the patient is tense and goes quieter the more
relaxed he becomes. He learns how to reduce his tension by whatever me ans
suits hirn best. Ifhe is told at the outset that the machine will help to relieve his
pain, it has a placebo effect.
Coping strategies
Melzack and Wall (1988) list six coping strategies for dealing with chronic pain:
Imagine you are somewhere pleasant.
Imagine the pain is trivial, e.g. tingling rather than pain.
Imagine the pain is due to a different, exciting cause.
176
Concentrate on external matters instead, such as a specific task or watehing

a specific event.
• Focus the attention on reciting a poem or doing some mental arithmetic.
Focus on the pain, but as ifyou are about to write an article on it, so that
you are detached from the pain itself.
Particular procedures suit different kinds of pain and different personalities.
These coping strategies may make the pain more bearable, but do not abolish
it. Two or more methods combined are more effective. The second strategy has
proved most helpful in coping with severe pain, e.g. the pain of amputation or
rheumatoid arthritis.
Guided imagery
This technique, described by Broome and Jellicoe (1987), is an elaboration of
Melzack and Wall's first coping strategy. The patient can leam to divert his
attention from pain by picturing himself elsewhere, such as by the sea on a
summer day, or in a quiet wood, or beside a log fire in a cosy room. By this
means he takes himself out of the pain situation and into a new painfree
place.
Meditation
This is a different type of meditation from religious contemplation. There are
several methods, and again different methods suit different personalities. The
occupational therapist's objective is to get the patient to relax, and the aim of
meditation is to concentrate on a distracting object, sound or word to the
exclusion of all other thoughts.
Traditionally the lotus position is adopted for meditation, but the patient with
chronic pain must adopt a position which is comfortable for hirn. In a quiet place
he focuses his attention on one ofthe following:
• an imagined object, e.g. astar, diamond, etc.;
• areal object directly ahead ofhim, e.g. a candle flame;
asound rhythmically repeated, e.g. 'omm, omm';
a colour, or colour range, pethaps passing through the colours ofthe spectrum.
Initially concentration may be maintained for only a very short time before
other thoughts intrude. With practice, the time will be gradually extended and
will induce relaxation, and in some cases can eure psychosomatic illness
(Chaitow, 1985).
Tactile meditation is another technique. A set ofworry beads or a few smooth
rounded pebbles are used for this, and are held loosely in one hand while the
177
PAIN CONTROL
other is used to move them slowly and rhythmically through the fingers,
consciously feeling each one, counting them and listening to the sound they
make. This should be pursued for about ten minutes.
A similar method is based on an old Oriental proverb, 'Whatever you are
doing, enjoy doing it'. The occupational therapist can guide the patient through
a simple task, e.g. peeling an apple, washing the hands, picking a rose, etc. For
example, select the finest rose, cut the stern carefully, study the thoms and
ponder on their purpose, note the glossy leaves, revel in the colour, shape and
scent of the flower and stroke its velvety petals. All other thoughts should be
excluded while doing this, the patient completely absorbed in the task, reducing
stress, distracting the mind from pain and gaining more satisfaction from life.
Broome and Jellicoe, two clinical psychologists, have written a self-help
guide to pain management (1987). It is directed at people who are motivated to
help themselves, and includes asking themselves searching questions such as,
'Is this loss of interest only because ofthe pain, or are there other causes?' and
'Do I sometimes use the pain as an excuse not to do something I dislike doing?'.
It helps patients to understand and monitor their pain, explains relaxation
techniques and goal setting, and may be recommended to patients to back up
the treatment they are receiving.
Any ofthe foregoing techniques may be taught by the occupational therapist,
and once the patient has discovered which method best suits hirn, he can
continue with his own treatment, giving hirn a sense of mastery over his illness.
ALTERNATIVE MEDICINE
Acupuncture has already been mentioned in the section on the sensory approach.
Hypnosis can be ofvalue in this context, although relatively few people can be
helped. Only 30% are deeply susceptible to hypnosis, with another 30% being
moderately susceptible (Melzack and Wall, 1988). Relaxation precedes hypno-
sis and the process lowers the blood pressure and slows the metabolic rate. Given
the patient' s trust, the hypnotist can enable hirn to control his perception of pain,
so that even when he wakens from the trace, the pain is more bearable. The
patient can also be taught to hypnotize hirnself.
PAIN CLINICS
Pain clinics in Britain tend to concentrate on the relief of pain by drugs or
injections such as those described in the chapter on back pain. Acupuncture and
hypnosis may be included and, less frequently, chiropractic methods.
Pain clinics in the United States, and a few in Britain, employ different
methods, based on a combination of methods of treatment, including drugs,
TENS and behaviour modification.
178
REFERENCES
As has already been described, people who have been in pain for a long time
show typical symptoms. Other people are at first sympathetic, so reinforcing the
pain behaviour. Pain clinics ofthe American type aim at reversing this behaviour
pattern. The patient's co-operation is necessary and an agreement is made
between patient and clinic. Pain behaviour is ignored, while patients who do not
complain and try to be active are praised and encouraged. Analgesics are given
in gradually reduced dosage. The family's active co-operation is also necessary.
Goals are set and progress monitored.
The use of operant conditioning is similar. Because body and mind are so
inextricably linked, the patient may come to associate the pain in his body with
the tasks and responsibilities he formerly disliked. A balance must be achieved
between the patient's life tasks and his physical condition. The aim oftreatment
is to enable the patient to live and ftmction with his pain. He enters into a contract
to co-operate with the treatment programme and to talk about his pain only to
staff, and then only when specifically asked about it. The occupational therapy
assessment and treatment plan are similar to that already described, with the
addition of the cognitive behavioural approach to pain in which the patient is
taught to analyse and identify his own problems and to discover his own ways
of dealing with them. Patients have to be made aware oftheir negative attitudes,
and keep a diary of events which trigger tension, then examine with the therapist
the sequence of events from this tension being aroused to the way in which the
patient's cognition seemed to contribute to the pain. Patients are then taught to
interrupt this sequence by re-examining events more rationally and directing
their attention elsewhere. The family is involved in the treatment plan, and is able to
observe the patient' s acbievable activity level, so that they can reinforce the treatment.
This last approach is unlikely to be carried out on the orthopaedic ward, but
serves as information as to what further treatment is available when conven-
tional methods have failed.
REFERENCES
Brena, S.F. (1978) Chronie Pain: Ameriea 's hidden epidemie, Athenium SMI,
NewYork.
Broome, A. and Jellicoe, H. (1987) Living with Pain, British Psychological
Society/Methuen, London.
Cailliet, R. (1988) Low Baek Pain Syndrome, 4th edn, F .A. Davis,
Philadelphia.
Chaitow, L. (1985) Your Complete Stress-Proojing Programme, Thorsons
Publishing Group, Wellingborough.
Hanna, M. (1988) Management of chronic pain, in C.J. Goodwill and M.A.
Chamberlain (eds.) Rehabilitation olthe Physieally Disabled Adult, Part 11,
Croom HelmiSheridan Medical, London.
179
PAIN CONTROL
Jayson, M.V. (1987) Back Pain: The facts, 2nd edn, Oxford Medical Publica-
tions, Oxford.
Melzack, R. and Wall, P.D. (1988) The Challenge oj Pain, Penguin Books,
Harmondsworth.
FURTHER READING
Giles, G.G. and Allen, M.E. (1986) Occupational therapy in the treatment ofthe
patient with chronic pain, British Journal ojOccupational Therapy, January,
4--8.
Melzack, R. and Dennis, S.G. (1978) Neurophysiological foundations ofpain,
in R.A. Stembach (ed.) The Psychology ojPain, Raven Press, New York.
Rogers, S.R., Shuer, J. and Herzig, S. (1984) Use offeedback techniques for
persons with chronic pain, in P. Cromwell (ed.) Occupational Therapy and
the Patient with Pain, Haworth Press, New York.
Strong, J. (1987) Chronic pain management: the occupational therapist's role,
British Journal ojOccupational Therapy, August, 262-3.
180
12
Re settlement
Many orthopaedic patients have problems relating to employment, manifested

in taking considerable sick leave through to having ceased work owing to the
effects oftheir disability. The first may need rehabilitation to build up stamina
to return to work, the second may need assessment for alternative work and
vocational guidance.
The labour market has undergone many changes, with automation leading to
fewer manual jobs. With high employment costs, the worker need not be fully
fit, but he is required to do the job competently within a specified time limit.
Firms who employ more than 20 staff are required by law to employ at least 3%
as registered disabled people.
Work improves self-esteem, gives a feeling ofusefulness, alleviates depres-
sion and facilitates socialization. It implies improved income and enhanced
quality of life. It is therefore an essential part of the total rehabilitation and
re settlement of the patient.
PRELIMINARY WORK ASSESSMENT

The patient's occupation is stated on his hospital admission form and in her
initial assessment the occupational therapist can ask for details ofwhat this work
involves. Ifthe patient has had a long period offwork, he should be asked ifhis
job is being held open for hirn. Ifhis previous job is no longer suitable, his firm
may consider redeployment. An alternative may be to adapt the job, e.g. by
providing suitable equipment or controls or altering the position of work. The
patient may be capable of returning to similar work after aperiod of intensive
rehabilitation.
If alternative employment is necessary, local opportunities and training
schemes should be explored. A young patient on the threshold of a career may
need guidance towards suitable training. Another patient may benefit from
sheltered working conditions. For all these situations a basic work assessment
is needed. Ifthe individual' s potential eaming capacity is very low and he would
lose benefits, it may be better to channel his energies in another direction.
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RESETTLEMENT
DETAILED WORK ASSESSMENT

The patient should first be independent in most activities of daily living,
including toileting, and independently mobile, with a wheelchair if necessary.
He should have reached an advanced stage of rehabilitation, with good balance
and co-ordination, and reasonable strength and range of movement commensu-
rate with the type of work he will be seeking. He should also be psychologically
ready, with good concentration and motivation.
Ideally the occupational therapist should visit the patient's place ofwork to
obtain an accurate picture of the working conditions and to see precisely what
the work entails. Is the work indoor or outdoor, clean or dirty, noisy or quiet,
alone or with others? Is there machinery? Is there a production line in which the
workers are interdependent, resulting in pressure to keep up the pace? Is the
work stimulating and varied, or is it repetitive and potentially boring? Any
particular skills required for the job should be noted, including the position in
the work hierarchy, communication skills, relationships with employer and
fellow employees and ability to make decisions or use initiative.
The patient's physical capacity to walk about, stand for any length oftime,
sit in comfort, lift or carry heavy or awkward objects, bend down, stretch up,
climb ladders, operate machinery or drive must be assessed as appropriate.
Balance, co-ordination, manual dexterity and adequate sensation in the hand are
required in varying degrees for most jobs. Speed of work is an important factor.
Strong grasp of the type appropriate to the work is necessary, e.g. power grip
for wielding a hammer, tripod grip for holding a pen, etc. Clumsiness, tremor
or lack of sensation may be a hazard.
If alternative employment is required, it is necessary to carry out a work
assessment to enable the patient to be matched with ajob vacancy. This differs
somewhat from the previous procedure. The work in which the patient was
previously engaged is relevant but various areas of work may be tested,
including manual, clerical and technical. Contracted-out work or processes
carried out in various hospital departments may be used for this purpose, and
the results of any productive work must be examined for quality. Literacy,
numeracy and learning capacity are assessed. The patient is instructed by
demonstration, and by verbal and written means, to discover his best learning
method. Psychological assessment includes observation ofhis interactions with
his fellow 'workers' and relationship with his supervisor, and his dependence
on others. His attitude towards work is assessed, including the interest and
motivation he displays, his ability to make decisions, concentrate, show initia-
tive, manage time effectively and cope with pressure. His appearance is noted,
attendance record and punctuality monitored, and an opinion formed as to his
reliability and honesty. The assessment is documented under the following
broad headings:
182
REHABILITATION TOWARDS RETURN TO WORK
name, address, date ofbirth and diagnosis;

fonner employment and/or educational attainments;
physical assessment;
psychological assessment;
preferred method of leaming;
type ofwork thought to be most suited to the patient.
REHABILITATION TOW ARDS RETURN TO WORK

Ifthe occupational therapy department has the facilities to simulate the patient's
workplace, rehabilitation may be carried out there. The patient is required to
arrive at the department independently and on time, appropriately attired. He
should bring his packed lunch or buy his lunch as he would at the works canteen.
The speed at which he works and the hours he puts in should gradually
approximate to his nonnal work, so that he builds up stamina for a full working
day. Any difficulties should be discussed with the employer, with a view to solving
them possibly by the provision of adapted tools, equipment or improved access.
The link between occupational therapy work assessment and the

Employment Rehabilitation Centre
There is a nationwide network ofEmployment Rehabilitation Centres (ERCs).
Ideally the patient should progress routinely from the medical scene in hospital
to the employment rehabilitation scene at the ERC. Relatively few occupational
therapy departments have the staff or the facilities to operate a dynamic work
rehabilitation programme. Where these facilities are needed, the therapist may
recommend referral to the ERC as being in the patient's best interests. Because
medical staffhave contact with occupational therapists, it is to them that patients
are referred for work assessment. However, if the patient is referred to the
Disablement Resettlement Officer (DRO) based at the Job Centre, he is likely
to be referred on to the ERC for assessment.
The average length of attendance at the ERC is approximately six weeks.
Because it is equipped like a factory and run on similar lines, the setting is more
realistic. The work available indudes electrical work, electronics, assembly
work, engineering,joinery, gardening, commercial and business work. Physical
exercise sessions are incorporated and clients are trained in seeking work and
interview techniques. Note that the patient has now become the client, a subtle
difference which gives a psychological boost. His progress is regularly reviewed
by a team composed ofthe ERC manager, the DRO, a medical officer, a social
worker and a psychologist.
The assessment of each dient is broken down into six component parts,
which are necessary for every dient and every type of work, although the
183
RESETTLEMENT
relative importance of each part varies from one job to another. These compo-
nents include assessment of:
the medical condition;
the physical capacity at the time, and the projected potential after rehabil-
itation;
the psychological state, including adjustment to the physical disability;
• intelligence, literacy and numeracy;
social skills;
ability in practical skills.
While attending the ERC clients are paid a maintenance allowance.
The Disablement Resettlement Officer

The DRO is responsible for placing disabled people in employment. He advises
on training schemes, vocational guidance, suitable job vacancies and alternative
employment. He may require confidential reports from the doctor and from the
occupational therapist regarding work assessmen~.
He may suggest that his client registers as a disabled person on the register
maintained by the Department ofEmployment. Patients have to be substantially
disabled for at least a year to be eligible for this register. Being registered may
facilitate the finding of a suitable job, especially in reserved occupations such
as passenger lift attendants and car park attendants, and in Sheltered Placement
Schemes (SPS). SPS are sponsored by Remploy, many local authorities and
voluntary bodies and offer sheltered work in factory conditions in a wide variety
ofjobs, usually under contract from local fmns. Workers are paid a living wage
and are expected to work a standard working week, although their pace is slower
than that required in the open market. The sponsor is the employer and their
costs are offset by the host firm 's contribution in wages, plus a contribution from
the Department ofEmployment.
Other help available through the DRO includes:
• The Job Introduction Scheme: an allowance of (45 per week (1992) to be
paid to an employer for a six week trial period if he takes on a disabled
person about whose ability he is doubtful.
Ifwork is considered to be part ofthe rehabilitation process for a disabled
person recommended by a doctor and approved by the Department of
Health, earnings of (40.50 per week (1992) are allowed without having to
surrender Invalidity Benefit.
Contact for application for training at any of the five residential training
colleges for disabled people, offering courses of approximately six months
duration, covering clerical work, telephonist and reception work,
184
COMPENSA nON
gardening, electronics, woodwork, etc. The colleges are distributed across

England, at Banstead Place, Surrey (school leavers); Finchale Training
College, Durham; Portland Training College, Mansfield; Queen Elizabeth
Training College, Leatherhead; and St. Loyes College, Exeter.
A grant for a person on the disabled persons register who incurs extra travel
costs to work because ofhis disability.
Schemes to provide special tools or equipment to enable a disabled person
to work.
The Disablement Advisory Service

The Disablement Advisory Service (DAS) links up with the services of the
DRO. Both are contactable at the local Job Centre, and the DAS offers:
provision of funds for modified machinery or adaptations at the workplace,
e.g. ramps, lifts, adapted toilets, etc., for a specific disabled person. The
maximum grant is ;(6000 (1992);
a data bank of information available to employers and occupational thera-
pists to enable disabled people to overcome problems encountered at work;
advice and practical help to employers on how to use the skills of disabled
employees to the full, and gives ongoing support;
advice and assistance in setting up schemes for home-based work in
information technology.
Royal Society for Disability and Rehabilitation (RADAR)

This organization provides information regarding employment-related difficul-
ties. Their Mobility Officer will provide details on local schemes to enable
disabled people to get to and from work. The organizer of the Rehabilitation
Engineering Movement Advisory Panel (REMAP) supplies addresses of local
panels who design and make up one-off adaptations or tools to overcome a
specific problem at work. Labour is free but acharge may be made for materials.
The Housing/Access Officer ofRADAR and the Centre for Accessible Envi-
ronment advise on adaptations to premises to accommodate a disabled worker
(addresses in appendix).
COMPENSATION
A patient with a compensation case pending may consciously or unconsciously
hold back on progress. Unfortunately, compensation cases often take years to
reach a settlement. Meanwhile the solicitor sometimes advises the patient to
limit his activities in order to obtain more in damages. This delays recovery.
185
RESETTLEMENT
The situation is further aggravated if the solicitor does not want the patient to
return to work until after the claim is settled. The longer he remains off siek, the
more difficult it is to settle back into work. Because ofloss of earnings as a result
of an injury, the patient is naturaHy eager to gain as much in compensation as
possible.
In the ca se of a compensation case pending, occupational therapy progress
must be weH documented so that an accurate report can be compiled if requested
by the solicitor.
Not every patient with a compensation case pending exhibits 'compensation
neurosis', but if satisfactory progress is not being made, this may weB be worth
considering.
SOCIAL RESETTLEMENT
Resettlement at horne has been implicit in each chapter, and we have now
considered re settlement at work. An essential part ofthe latter is the patient's
ability to travel to and from work. Transport is also the key to re settlement into
the community. Most patients on discharge horne are mobile about the house,
using a walking aid ifnecessary, but out-of-doors mobility may be very limited.
A wheelchair or car adaptations may be necessary.
Wheelchairs
Wheelchair assessment for patients who have rheumatoid arthritis and who have
had lower limb amputation has been covered in the relevant chapters. Others
may need a wheelchair in the short term, e.g. while they are non-weightbearing
or while they are immobilized in long leg cylinder pIasters. A wheelchair may
be obtainable for short-term loan from the Distriet Wheelchair Service, Social
Services or from a voluntary body such as the British Red Cross Society. Fittings
such as elevating legrests may not be readily available, and it may expedite
provision ifthe resources ofthe heavy workshop or the hospital works depart-
ment are tapped, to make up L-shaped padded boards. These are made comfortable
by placing one cushion on the seat part. A wheelchair with an elevating leg-
rest is awkward to manoeuvre in tight corners, knocking into people and objects,
but fortunately they are rarely needed for a long period.
Patients who need wheelchairs for long-term use require a more detailed
assessment, with re-assessment at regular intervals to ensure that their needs are
being met. Such patients are those with neurological disorders, paraplegia,
tetraplegia, etc. who may need orthopaedic surgery for release of contractures,
spinal surgery, etc. F or these patients, the foHowing points should be considered
when choosing a suitable model:
186
SOCIAL RESETILEMENT
Is the wheelchair for regular or occasional use?

Is it to be used indoors or out?
• Iffor indoors, are doors wide enough, and is there adequate turning space?
Whieh is the most appropriate model: self-propelled, attendant pushed or
electric?
Is it to be used on rough or hilly terrain?
What does the patient intend to do while in the wheelchair: cook, deskwork,
go shopping, gardening, ete.?
• Is a folding model needed, for carrying in a car boot? (An L by the model
number in the NHS list indicates lightweight.)
Are any special features necessary: rear wheels set back, reclining back
rest, etc.?
Are any extra features necessary: tray, desk armrests, safety strap, ete.?
Is apressure cushion needed?
The patient' s height and weight are recorded on the referral form, with the
diagnosis and any physical or mental problems which might affeet his ability to
control the wheelchair. An electrically powered model may be more appropriate
for the patient with progressive disease. The needs and ability of an attendant
are important; he may not be fit enough to push the laden wheelchair up a slope
or lift it into a car boot. Most NHS wheelchairs have detaehable armrests and
adjustable foot-rests which swing outwards to facilitate getting in and out.
Backrest angles vary, and folding backrests are mueh less supportive, although
a bracing device is available. Elevating legrests and supportive seating are
needed on models with a fully reclining backrest.
Patients with limited shoulder extension may be unable to reach rear propel-
ling wheels on standard models, but the Beneraft six wheeler has the propelling
wheels directly beneath the shoulder joints. Front propelling wheels pose
problems as the legrests do not swing outwards, although the footrests flip
upward to allow aecess from the front ofthe wheelehair. Ifthe patient has to do
a sideways transfer, the large front wheels are an obstacle, especially in models
with larger wheels. Larger eastors are more stable and cope better with rough
ground and kerbs. Brake levers must be well within the patient's reach, with
extended levers if the grip is weak to make them easier to operate. Solid tyres
may be preferred on indoor wheelchairs, but pneumatic tyres absorb shock on
an outdoor model. If any tyres become wom or are not maintained at the correct
pressure, the brakes will not be effeetive.
Mobile arm support attacbments are available for patients with very weak
upper limbs, as in museular dystrophy, tetraplegia or severe rheumatoid arthritis.
One-arm drive wheelchairs are rarely needed for ortbopaedie patients. The
wheelchairs supplied through the Distriet Wheelchair Service are adequate for
the needs of most patients. Ifthe patient is wheelchair bound, he is supplied with
187
RESETTLEMENT
an indoor and an outdoor model, the latter being heavier and more robust. Ifhe
lives on two levels with a connecting stairlift, he is allowed a further wheelchair
for use upstairs. He will have two pairs of armrests if appropriate, for domestic
use and for office work. He is supplied with a manual of instructions for use and
maintenance to ensure safety, with details ofthe local contact for repair, which
is free. It is essential that the patient quotes his reference number when
requesting repair. He can obtain this number by contacting the District Wheel-
chair Service.
Although the range of statutory chairs has been extended, a much wider range
is available commercially. The youngerpatient confined to a wheelchairusually
obtains a lightweight model which is very manoeuvrable, but this is not usually
supplied by the District Wheelchair Service.
A patient who is unable to raise himself by his arms to relieve the pressure
on his bottom needs anti-pressure cushioning, to which he is entitled along with
the wheelchair and for which he is individually assessed. A vailable cushions
include sculpted foam, water and foam, gel, air cell and silicone types. The
patient with scoliosis, if not completely corrected by surgery, will also need
lateral support in the form of foam fit systems or swing-away thoracic supports.
If the wheelchair is to be used long-term, ramps are necessary wherever
access is required. In the short-term, temporary portable ramps can be supplied
quickly at 10w cost. The gradient ofthe ramp should be no more than 1 in 12,
the surface must be non-skid and the side edges raised.
A person confined to a wheelchair is at a dis advantage in company. People
carrying on a conversation while standing will be talking over his head. A
Mangar booster will enable the permanently chairbound person to raise himself
to talk to standing colleagues face-to-face.
Mobility allowance
This is a non-contributory benefit payable to an individual who is unable, or
virtually unable, to walk for at least 12 months. It is payable whether the
c1aimant works or not, provided he satisfies the medical, residential and age
conditions. A doctor appointed by the Department of Health assesses the
patient's mobility, using whatever walking aid is appropriate. If the walking
ability is likely to improve a short-term award is made, lasting for a minimum
of a year. If the walking disability is permanent, the allowance may be made up
to the age of 80 years, providing the application was made before the age of 65
years. Payment ofMobility Allowance is not affected by periods in hospital or
residential care, but is affected by certain other criteria. For full details, see
DHSS Leaflet HB5 (DHSS, 1990).
Persons receiving Mobility Allowance may be entitled to certain other
benefits. Among these are:
188
SOCIAL RESETTLEMENT
exemption from Road Tax;

inclusion in the Orange Badge Scheme;
entitlement to drive at the age of 16 years;
exemption form vat when buying motability cars and car adaptations;
medical exemption from wearing a seat belt;
british railcard for disabled people;
severe disablement allowance if ofworking age but unable to work;
disability premium in calculating Income Support and Housing Benefit.
The Motability scheme was set up to enable people with Mobility Allowance
to obtain a car or electric wheelchair at a reduced price. Cars may be bought on
hire purchase or hired, and electric wheelchairs may be acquired on hire
purchase. The person receiving Mobility Allowance agrees to Social Security
paying all or part ofthe allowance to Motability Finance Ltd for the duration of
the lease or hire agreement. The Mobility Allowance award must be for at least
the period ofthe lease or hire agreement. Any extra cost must be paid in a lump
sum at the outset, and this includes the cost of any adaptations to the car (full
details in DHSS Leaflet HB 5).
The Orange Badge Scheme enables appreciably disabled people to park in
restricted areas, to facilitate access to shops, banks, places of entertainment, etc.
The badge must be displayed on the windscreen. It entitles the holder to park
for up to two hours on double yellow lines, free parking at parking meters and
parking without a time limit in limited waiting areas. The holder must not park
where he causes obstruction or a hazard. The badge is obtained through the
Social Services department.
The Motability facility and Orange Badge Scheme may be used by the carer
on behalf ofthe disabled person ifhe is unable to drive hirnself.
The disabled driver

The patient with limited mobility may be very dependent on his car to go to
work, the shops, or for social contact. It may be impossible for hirn to manage
public transport. The doctor in charge of the case has to judge whether the
individual is competent to drive, and the orthopaedic patient with no neuro log-
ical dysfunction or psychiatric problem is usually deemed fit. Most patients
merely require a car with automatic transmission and possibly power-assisted
steering. The occupational therapist may have to carry out a basic assessment
in the patient's own car. This will include the patient's ability to get in and out
of the car, suitability of the driving seat, manipulation of the controls and
pinpointing what adaptations are necessary. This is adequate for most patients
hut if the condition is progressive or he has had an amputation, a specialist
assessment may be needed. The Mobility Centre at Banstead Place or the
189
RESETTLEMENT
Mobility Advice and Vehicle Infonnation Service (MAVIS) set up by the

Department of Transport may be of assistance (addresses in appendix).
The range of movement required for driving is not great. More than 65° of
flexion defonnity at elbow or knee causes problems. Limitation of hip flexion
can usually be accommodated by inclining the backrest of the driving seat
slightly. Limited shoulder movement is oflittle consequence. Weak grip or loss
of an ann may be overcome by fitting a steering wheel knob.
Results of assessments ofvarious adaptations for cars have been recorded in
the DHSS Disability Equipment Assessment Programme. Their reports cover
the assessment of backrests, replacement car seats, supplementary mirrors
(necessary where there are cervical problems), handbrake adaptations and
steering wheel knobs. The Scoliosis Association publish an infonnation sheet
on 'Scoliosis and car seats' .
Car conversions may be carried out by the main car manufacturers or by
specialist companies. Types of conversions include alteration of the accelerator
pedal from right to left side, conversion to hand controls, or power steering,
joystick steering, switch extensions, handbrake release and conversions for
passengers. Taillifts can be fitted to the rear of some vehicles. A swivel seat
can be fitted to either front seat, to enable it to be swung round by 90° to enable
easier entrance and exit. For the severely disabled, hoists and lifts are available.
Automatie garage doors are useful although car ports may be preferable. The
disabled driver may require help at a self-service petrol station, or if he is in
trouble on the motorway. Various 'Help' signals are on the market, and certain
motoring organizations offer specific help to the disabled motorist.
A person who develops a disability which may affect his driving ability must
infonn the Driving and Vehicle Licensing Centre (DVLC) at Swansea. The
DVLC Medical Advisory Branch may then require a medical examination and
report. The insurance company must also be infonned of any disability which
may affect driving capability.
Because of limitations on the therapist's time, a file or leaflet containing
relevant infonnation on driving should be made available to the patient to give
hirn encouragement in picking up the threads ofhis life again.
Leisure activities
Leisure activity fulfils certain needs. It enables a person to relax, meet and
perhaps compete with others with like interests, gives opportunities for self-de-
velopment, leadership and creativity, and may be used as an alternative to
employment. It provides opportunities for achievement and the means of
retaining or regaining self-esteem.
Patients should be encouraged to resurne their fonner interests if possible,
and if necessary the means of adapting these activities to the present situation
190
SOCIAL RESETTLEMENT
should be explored. Ifthe patient is unable to resurne previous interests, he needs

information in order to experiment with new ones. He needs to be able to
contribute to any group he joins and not simply be on the receiving end. The
aim is to integrate into community activities ifpossible, and Physically Handi-
capped and Able-Bodied (PHAB) clubs are useful.
The choke of activity must be within the patient's capabilities. It requires
courage to attempt something new and he needs the support of family and
friends. Research into what is available must take into ac count travel to the
venue and its accessibility to the person concemed. Equipment or tools can be
adapted if necessary, either by a little ingenuity or by REMAP.
Membership of specific societies will provide information on necessary
equipment, and the Directory ofGrant-Making Trusts (Charities Aid Founda-
tion, 1991) provides details of charities who will consider making a contribution
towards the cost of such equipment. This directory is usually available in the
reference section of public libraries.
Frequently contact sports are contra-indicated for orthopaedic patients, but
other sporting activities may be suggested. Swimming is excellent exercise and
many public baths set aside a time when the baths are open solely for disabled
people and their families for their greater comfort. Horse riding, sailing, camp-
ing and the Disabled Olympics are possibilities, and people with disarticulation
ofthe hip have leamed to ski. Spectator sports lead to social integration.
Gardening is within the reach of any disabled person, using adapted tools
and a suitably planned garden. Various specialist societies cater for all tastes,
e.g. alpines, cacti, fuchsias, etc. For specific help Horticultural Therapy may be
approached, and Gardens for the Disabled Trust make grants to adapt garden
layouts and purchase special tools. There are several demonstration gardens
nationwide and gardening is frequently used in sheltered employment. Merely
tending his own front garden or window box, a disabled person will meet
passers-by and thereby become involved with the local community.
While some disabled people are unable to go out to pursue their interests or
prefer to use their computer or knitting machine at horne, others wish to engage
in cultural activities, go to concerts or the theatre, visit libraries, museums and
art galleries. This should be encouraged, plus active participation in the fields
of music, art and drama. The arts bring great pleasure to those who practise them
and to those who observe. People can discover hidden talents and a creative
outlet, can share ideas and experiences, and develop physical and perceptual
skills. There are theatre companies who employ disabled actors, who are
exploring new areas of artistic experience for both actors and audiences. Access
to the relevant public buildings and the provision of toilet facilities is steadily
improving.
Disabled people and their families need holidays either together or sepa-
rately: the choice should be theirs. Most holiday brochures state whether they
191
RESETTLEMENT
have facilities for people with disabilities, and lists of special accommodation
are published by organizations such as RADAR. Arthritis Care runs several
holiday hotels. Transport advice is available from RADAR and from Holiday
Care Service; the latter also provide experienced volunteers to help disabled
people on holiday and may help with funding. More organized holidays can be
booked via Across, which caters for holidays abroad. The occupational therapy
department should make this type of information available to patients, as many
ofthem look forward to a holiday when they are better. Having information to hand
enables them to make positive plans and may help with goal setting. Once a holiday
has been undertaken, social resettlement is weIl under way.
QUALITY OF LIFE
While retraining in the activities of daily living and provision of tools and
adaptations make up the largest part of the resettlement programme, it is
important that the further aspects of re settlement discussed in this chapter are
addressed. These contribute to quality of life, which encompasses all features
ofthe person's integration into the community, including any means ofmini-
mizing his disability. Employment, social and leisure activities contribute to this
enrichment oflife.
Quality of life may be judged by four criteria (Blunden, 1988). These are
physical, cognitive, material and social well-being. While the patients we have
been considering may be somewhat lacking in physical weIl-being, the remain-
ing three areas are open to them. Cognitive weIl-being can be summed up as
being content with one's lot, and material weIl-being as having an adequate
income, ahorne and some means of transport. Social weIl-being entails being
known, respected and valued on one's own merits, with choice in as many areas
as possible, and competence in mobility and communication skiIls. The social
dimension of quality of life tends to be overlooked in the provision of services
for people with disabilities. The Attenborough Report on Arts and Disabled
People (Camegie UK Trust, 1985) does not accept that the arts are no more than
the 'icing on the cake'. The occupationa1 therapist is weIl placed to make any
relevant information available and point her patient towards fuIl social resettle-
ment.
REFERENCES
Blunden, R. (1988) Quality of 1ife in persons with disabilities: issues in the
development of services, in R.I. Brown (ed.) Quality ofLife for Handicapped
People, Croom Helm, London.
Camegie UK Trust (1985) The Attenborough Report: Arts and disabled people,
Bedford Square Press/NCVO, London.
192
FURTHER READING
Charities Aid Foundation (1991) Directory of Grant-Making Trusts, CAF,

Tonbridge.
Department ofHealth and Social Security (1984-1986) Disability Equipment
Assessment Programme Booklets, DHSS Publications Unit, Heywood,
Lancs.
Department ofHealth and Social Security (1990) A Guide to Non-Contributory
Benejits for Disabled People, Leaflet HB5, DHSS Publications Unit, Hey-
wood, Lancs.
FURTHER READING
Clarke, A., Allard, L. and Braybrooks, B. (1987) Rehabilitation in Rheumatol-
ogy: The team approach, Martin Dunitz, London.
Disabled Living Foundation (1988) Information Service Handbook, Sections 6
and 8, Disabled Living Foundation, London.
Employment Service Leaflets (1990) Available from local Employment Service
offices, address in Telephone Directory.
Goodwill, J. (1988) Car driving for the disabled, in C.J. Goodwill and M.A.
Chamberlain (eds.) Rehabilitation of the Physically Disabled Adult, Croom
HelmJSheridan Medical, London.
Kennedy, M. (1986) Able to work? British Journal ofOccupational Therapy,
November, 354-6.
Nichols, P.J.R. et al. (1980) Rehabilitation Medicine: The management of
physical disabilities, 2nd edn, Butterworths, London.
Occupational Therapists' Reference Book (1990) Parke Sutton LtdIBritish
Association ofOccupational Therapists, Norwich.
Turner, A. (ed.) (1981) The Practice ofOccupational Therapy: An introduction
to the treatment ofphysical dysfunction, Churchill Livingstone, Edinburgh.
Western, P. (1987) Leisure pursuits, in E. Bumphrey (ed.) Occupational Ther-
apy in the Community, Woodhead-Faulkner, Cambridge.
193
Appendix
USEFUL ADDRESSES
ACROSS TRUST
Bridge House, 70/72 Bridge Road,
East Molesey, Surrey KT8 9HF
081-783-1355
ARTHRITIS CARE
5 Grosvenor Crescent, London
SW lX7ER
071-235-0902
ARTHRITIS AND RHEUMA TISM COUNCIL

Copeman House, St. Mary's Court,
St. Mary's Gate,
Chesterfield S41 7TD
0246-558033
BACUP (BRITISH ASSOCIATION OF CANCER UNITED PATIENTS)

121/123 Charterhouse Street, London ECI M 6AA
071-608-1661
(Also FREEPHONE for calls outside London: 0800-181199)
BANSTEAD MOBILITY CENTRE

Damson Way, Orchard Hill,
Queen Mary's Avenue, Carshalton, Surrey S5 4 NR
081-7701151
BRITISH AMPUTEE SPORTS ASSOCIATION

(Contact) Mr John Fisher, 17 Douglas Road,
Harpenden, Herts AL5 2EN
0582-460105
194
APPENDIX
BRITISH SPORTS ASSOCIATION FOR THE DISABLED

34 Osnaburgh Street, London NWI 3ND
071-383-7277
BRITISH RED CROSS SOCIETY

9 Grosvenor Crescent, London
SW IX 7EJ
071-235-5454
CAMPING FOR THE DISABLED

20 Burton Close, Dawley, Telford,
Shropshire TF 4 2 BX
0743-761889 (Daytime)
0952-507653 (Evenings)
CANCER RELIEF MACMILLAN FUND

15/19 Britten Street,
London SW 3 3 TZ
071-351-7811
CANCERLINK
17 Britannia Street, London
WC lX9JN
071-833-2451
CENTRE FOR ACCESSIBLE ENVIRONMENT

35 Great Smith Street,
London SWIP 3BJ
071-222-7980
COMPUTABILITY-CENTRE
c/o Mr Tom Mangan,
POBox 94,
Warwick CV34 5WS
0926-312847
195
APPENDIX
DHSS AIDS ASSESSMENT PROGRAMME

DHSS Store
Health Publications Unit,
No. 2. Site,
Manchester Road,
Heywood, Lancs OLl02PZ
0706-366287
DISABLED DRIVERS' ASSOCIATION

Ashwellthorpe Hall,
Ashwellthorpe, Norwich, Norfolk
NRl6lEX
050841-449
DISABLED LIVING FOUNDATION

Clothing and Footwear Advisory Service,
380/384 Harrow Road,
London W9 2HU
071-289-6111
DISABLED PHOTOGRAPHERS' SOCIETY

PO Box 130, Richmond,
Surrey TWI0 6XQ
EQUIPMENT FOR DISABLED PEOPLE

Publications from:
Mary Marlborough Lodge,
Nuffield Orthopaedic Centre,
Headington, Oxford OX3 7LD
0865-750103
GARDENING FOR THE DISABLED TRUST

Julia Sebline, Secretary,
Hayes Farm House, Hayes Lane,
Peasmarsh, Nr.Rye, East Sussex TN31 6XR
196
APPENDIX
HOLIDAY CARE SERVICE

2 Old Bank Chambers, Station Road, Horley
Surrey RH6 9 HW
0293-774535
HOMECRAFT SUPPLIES LTD.

Siding Road,
Low Moor Estate,
Kirby-in-Ashfield,
Nottingham NG17 7JZ
0623-754047
Supply Droopsnoot and Balans type chairs
HORTICULTURAL THERAPY
Goulds Ground, Vallis Way, Frome,
Somerset BAll 3DW
0373-464782
MAUBRI FASHIONS
Unit 13 B, Springfield Industrial Estate,
Farsley, Leeds LS28 5 LY
0532-553274
MAVIS (MOBILITY ADVICE AND VEHICLE INFORMATION

SERVICE)
Department ofTransport,
Transport and Road Research Laboratory,
Crowthome, Berks RG 11 6AU
0344-770456
NATIONAL ANKYLOSING SPONDYLITIS SOCIETY

5 Grosvenor Crescent, London SWIX 7ER
071-235-9585
197
APPENDIX
NALD (NATIONAL ASSOCIATION FOR LIMBLESS DISABLED)

31 The Mall, Ealing, London W5 2PX
081-579-1758/9
NATIONAL BACK PAIN ASSOCIATION

31/33 Park Road, Teddington, Middx
TW 11 OAB
081-977-5474
PHAB (PHYSICALLY HANDICAPPED AND ABLE BODIED)

National Office, 12/14 London Rd, Croydon
CR02TA
081-667-9443
PILGRIM'S PRESS
Caxton House, Ongar,
Essex CM5 9RB
0277-364060
PUTNAMS
Eastem Wood Road,
Langage,
Plympton,
Devon PL7 5ET
0752-345678
Supply Putnam Wedge
RADAR (ROYAL ASSOCIATION FOR DISABILITY AND

REHABILITATION)
REMAP (REHABILITATION ENGINEERING MOVEMENT
ADVISORY PANELS)
BOTH THE ABOVE AT:
25 Mortimer Street,
London WIN 8 AB
071-637-5400
198
APPENDIX
REMPLOYLTD
415 Edgware Road, Cricklewood,
London NW2 6 LR
081-452-8020
RIDING FOR THE DISABLED ASSOCIATION

Avenue R, National Agricultural Centre,
Kenilworth, Warwicks CV8 2LY
0203-696510
SCOLIOSIS ASSOCIATION (UK)

2 Ivebury Court,
325 Latimer Road,
London W10 6RA
081-964-5343
SPOD (SEXUAL AND PERSONAL RELATIONSHIPS OF THE

DISABLED)
286 Campden Road, London N7 OBJ
071-607-8851
A.J. WAY & CO. LTD

Unit2,
Sunters End,
Hillbottom Road,
Sands Industrial Estate,
High Wycombe,
Bucks HP12 4HZ
0494-471821
Supply Droopsnoot chair
WIDER HORIZONS
(an organization for promoting wider interests among handicapped people)
Hon. AdministratorlTreasurer,
Mr A.B. Fletcher, Westbrook,
Back Lane, Malvem, Worcs WR14 2HJ
199
INDEX
Absent thumb 134 Back pain, see Low back pain

Activities of daily living, see Back school 70
A.D.L., personal Body image 12, 155, 165
Activities, remedial 117-20 Body mechanics 69
A.D.L., personal Brachial plexus lesions 130
lower limb 35-6,40--1
rheumatoid arthritis 16--17 Callotasis 61
spinal 74-5, 84-5 Camptodactyly 134
upper limb 92, 101, 114 Car
Alternative medicine 68, 178 conversions 190
Ambulation training 49-51 ingress and egress 37
Amputation 158-9 Carpal tunnel
fmger 134 decompression 123
forequarter 163 syndrome 122
hindquarter 159 C.A.T. scan, see Scans
hip disarticulation 159 Cerebral palsy 136
lower limb 159-62 Cervical spine 4, 85-7
shoulder disarticulation 163 Chairs
upper limb 163 office 16
wheelchair provision 160 raising methods 15
Ankylosing sponylitis 25-6, 197 rising from 15
Arachnoiditis 66 spring-lift 15
Arthrodesis see also Seating
hip 40 Charnley hip replacement 28-9
knee 58, 59 Chemotherapy 150--1
shoulder 93-4 Child, hand assessment for 115
wrlst 125-6 Children, caring for 24-5,77
Artificiallimb, see Prosthesis Chondrosarcoma 146
Assessment Chronic pain
fonns 6-8, 114-5, 183, 198 coping strategies 175-8
functional 6--9 counselling 174
home9 drug therapy 172-3
pre-operative 2, 31-2 physiotherapy 173
201
INDEX
Chronic pain contd. Discectomy 79

psychological approach 178-9 Discogram 67
surgical intervention 173 Driving 23, 41, 76, 189-90
syndrome 88,171-2 organizations 194, 196, 197
Cleft hand 136
Clothing 17,60,96-7, 197 Elbow
Club hand, see Radial club hand A.D.L. 101
Coccydinia 87 alternative surgery 103
Coccygectomy 87-8 indications for replacement
Collaborative care planning 33 99-100
Communication 21 joint structure 99
Compensation 142, 185-6 precautions following replacement
Congenital hand deformity 134-6 101, 103
Congenital dislocation ofhip 44 rehabilitation following
Control oftreatment by patient 12, replacement 100, 103-4
13,168,178 replacement 99
Corsets, see Spinal supports results of surgery 102
Counselling Employment Rehabilitation Centre
amputation 165-6 (ERC) 183
chronic pain syndrome 174-5 Endoprosthetic replacement (EPR)
hand 142 151-3
rheumatoid arthritis 12-13 Energy conservation 11-12,20, 168
tumour 154-5 Equipment for disabled people 196
Cultural activities 191 Ewings sarcoma 148-9
Cup arthroplasty 92 External fixation ofknee 59-60
Curettage 151
Fibrosarcoma, see M.F .H.
Debridement ofknee 58 Footwear 17-18
Decompression of spine 79 Fractures 45
Deformity, prevention of 1(}-11 femoral shaft 46
DHSS Aids Assessment Programme hip 46-9
190, 196 humerus94
Disabled Living Centre 15,21 pathological47-8
Disabled Living Foundation 196 surgical intervention 47
Disablement Advisory Service vertebrae 65
(DAS) 185 Functional assessment 6,71-2,
Disablement Resettlement Officer 113-4
(DRO) 183-5
Disarticulation Gardening r91, 196, 197
hip 159 Gate control theory of pain 173-4
shoulder 163 Giant cell tumour 148
Disc, see Prolapsed intervertebral disc GirdIestones excision arthroplasty 43
202
INDEX
Grants 19 housework following 36

Grieving 12, 142, 165, 167 indications for 28
Grip information leaflets 32
strength 112 personal A.D.L. 35
types of 113--4 precautions following 32-7
pre-operative assessment 31-2
Halo traction 82 results of surgery 37
Hand revision surgery 38
A.D.L. 114 seating following 35
architecture of 106-8 sexual activity 37
assessment forms 114-5 surgical intervention 29-31,38
congenital deformity 134-6 Hobbies, see Leisure
counselling 142 Holidays 192, 197
examination 108 Horne assessment 9
functional assessment 113--4 Household tasks 19-21,36,75-6
functions of 106 Housing adaptations 18-19
grip strength 112 Hypnosis, see Alternative medicine
joint measurement 108-11 Hypoplastic digits 136
oedema 111
paediatric assessment 115
pain 108, 131, 133 Ilizarov technique 61-2
proprioception 112 Information leaflets
rehabilitation 116, 128 backpain 78
remedial occupational therapy hip replacement 32
116-20 rheumatoid arthritis 11
sensation 112-3, 116 splinting 142
sensory re-education 120-1
splinting 136--42 Joint
for joint replacement 124, 127, measurement 108-11
128-9 protection 10--11,12,20,125
for nerve injuries 131, 132 replacement, see under
structure, see Hand, architecture of appropriate joint
surgery 121--4, 125-6, 127-30,
133,135-6 Kitchen practice
types of grip 113--4 after amputation 161, 163
Harrington rod 82 backpain 75
Hemi-arthroplasty hip replacement 36
hip 47 rheumatoid arthritis 20
shoulder 92 tumour 157
Hindquarter amputation 159-60 Knee
Hip arthrodesis 40 arthrodesis 58, 59-60
Hip replacement bi-lateral replacement 59
203
INDEX
Knee contd. Mobility

joint structure 54 aids, see Walking aids;
replacement types 54-6 Wheelchairs
revision surgery 56-7 Allowance 188-9
Motability 189
Leisure M.R.1. scan, see Scans
activities 23, 76-7, 190-2 Multiple myeloma 149
organizations 195, 196, 199 Muscle power measurement 112
Lifting techniques 72
Limb length discrepancy National Association for Limbless
arm 96-7 Disabled 167, 198
leg 61 National Back Pain Association
surgical intervention 61-2 198
Low back pain Nerve injuries 130-2
A.D.L. 71-8 Neuro-stimulators 173
beds 74
caring for others 77-8 Odstock Hospital
causes 64 hand function chart 114
mechanical 64-6 tracings 111
non-mechanical 66-7 Oncology rehabilitation 168
conservative treatment 68-9 Orange badge scheme 23,189
diagnostic tests 67-8 Osteoarthritis
housework 75 hip 28
leisure activities 76-7 knee 53
pain relief 71 Osteomalacia 66
physiotherapy 70-1 Osteomyelitis 66
posture 69 Osteoporosis 45-6
seating 73 Osteosarcoma 146-8
sexual problems 78 Osteotomy
tuberculosis of spine 66 femoral 40-1
Lymphoma 149 pelvic 41-2
tibia157-8
McMurray osteQtomy 40 Oxford Scale, see Muscle power
Median nerve lesions 132 measurement
Metacarpophalangeal (MCP) joints
remedial occupational therapy Paediatric
following replacement 127-8 bone tumour patients 158
replacement surgery 127 hand assessment 115
splinting 127 hip conditions 44-5
Metastatic bone disease 149 Paget's disease 67
M.F.H. (malignant fibrous Pain 108,133,164,171-2
histiocytoma) 149 behaviour 172
204
INDEX
Pain contd. R.A.D.A.R. (Royal Association for

clinics 178-9 Disability and Rehabilitation)
coping strategies 176-7, 178 185,198
relief 71, 168-9 Radial club hand 135
see also Chronic pain Radial nerve lesions 132
Patellectomy 58 Radiculogram 67
Patient taking control of own Radiotherapy 151
treatment 12, 13, 168, Range of movement, normal
178 elbow 103
Pelvic osteotomy 41-2 hand 110
Perthes' disease 44 shoulder 95
Phantom limb 164-5 Reflex sympathetic dystrophy 133
Physiotherapy Relaxation techniques 175-6
back pain 69-71 Remedial games, see Activities,
elbow 100 remedial
hand 116 Remedial occupational therapy
hip conditions 33, 48 elbow 100, 103-4
leg lengthening 62 hand 116-21,130,131
rheumatoid arthritis 2, 4 shoulder 91-2, 93, 95-6
shoulder conditions 91-2, 93 Remploy 184, 199
tumour 155-6 Residential training colleges for
Pollicization 135 disabled people 184-5
Positioning Results of surgical intervention
joints 10 elbüw 102
patients 117, 175-6 hand 124, 127
Posture 69 hip 37
PP AM (pneumatic post-amputation knee 55, 57
mobility) aid 159, 161 spinal 88
Pre-operative assessment tumour 153-4
hand 108-15 Resurfacing ofhip 37
hip replacement 31-2 Revision surgery
rheumatoid arthritis 2 elbow 102
Prolapsed intervertebral disc 65 hand 123, 124, 127
Proprioception 112 hip 38
Prosthesis knee 56-7
lower limb 161 shoulder 91
upper limb 163-4 Rheumatoid arthritis
Psychological assessment 9, 66 caring für children 24-5
Putti-platt procedure 94 clothing 17
energy conservation 11-12, 20
Quality oflife 167, 168, 192 functional assessment 6
205
INDEX
Rheumatoid arthritis contd. hip conditions 37, 41

horne assessment 9 rheumatoid arthritis 21-2
housework 19-21 spinal conditions 78
housing adaptations 18-19 Shoulder
joint protection 10, 12,20 A.D.L. 92
juvenile arthritis 136 arthrodesis 93-4
leisure activities 23 dislocation 94
medical management 2 joint structure 89
mobility 13-14 precautions following replacement
pathology 1-2, 121-2 96
personal care 16-18 rehabilitation 91-2, 93, 95-6
pre-operative assessment 2-3 remedial occupational therapy
psychological assessment 9 95-6
seating 14--15 replacement 89-91
sexual problems 21-2 Silicone (silastic) implants 123-4,
splinting 127-8
functional 5-6 Slipped femoral epiphysis 45
prophylactic 5 Social worker 13, 155
post-operative 124, 127, 128-9 Soft tissue sarcomas 149
support groups 194 Spinal supports 83-4
surgical intervention 3-4, 122-8 Spinal surgery
therapeutic management 4--5 A.D.L. following 84--5
transport 23-4 for chronic back pain 173
Role reversal13, 22 decompression 79
Rotator cuff 89 discectomy 79
fusion 65, 80, 82
Scans 150 indications for 79
bone 68 posterior segment fixator 81
CAT (computerized axial precautions following 82
tomography) 67 scoliosis 82
MRI (magnetic resonance Splinting
imaging) 67 design 139
Scoliosis 65, 82, 199 fitting/moulding 140
Seating 14--16,35,73 materials 139-40
suppliers 197, 198, 199 mechanics 138-9
see also Chairs metacarpophalangeal joint
Sensation 112, 116 replacements 127-9
Sensory re-education 120-1 precautions 140
Sexual and personal relationships of principles 137
the disabled 199 rheumatoid arthritis 5
Sexual problems types 137
after amputation 166 wrist replacement 124
206
INDEX
Spondylolisthesis 65 holistic assessment 156-7

Spondylolysis 65 paediatric patients 158
Spondylosis 65 pain relief 168-9
Sports for disabled people 191, pathology 146-9
194-5 results of surgery 153-4
Stump pain 164 support groups 194, 195
Sudeck's atrophy, see Reflex surgica1 intervention 151-4
sympathetic dystrophy terminal illness 167-9
Support groups 25, 166-7 types of 146
Syndacty1y 134
Synovectomy 3,122 Ulnar nerve 1esions 132
Tendon repair 129, 130 Walking aids 13-14,49-50

Teno1ysis 130 Wheelchairs 14, 44, 160, 186-8
T.E.N.S. (transcutaneous e1ectrica1 Work
nerve stimu1ation)71, 131, 133, assessment 181
173 for new emp10yment 182-3
Terminal illness 167-9 for return to work 182
Thumb surgery 128-9 ethics 181
see also Pollicization rehabilitation 183-4
Tinel test 113 Wrist
Transport 23-4, 186 arthrodesis 125-6
Tubercu10sis of spine 66 precautions following
Tumours, bone replacement 125
body image 165 rehabilitation 124
c1inical protocol149-50 remedia1 occupational therapy 118
counselling 154-5, 165-6 replacement 123-4
207

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OCCUPATIONAL THERAPY FOR

Research Methods for Therapists

This series of books is aimed at 'therapists' concemed with rehabilitation in a

1. Occupational Therapy for Children with Disabilities

IU!ll Springer-Science+Business Media, B.V.

© 1993 Dina Pemose

ISBN 978-0-412-39370-9 ISBN 978-1-4899-3085-9 (eBook)

Appendix - Useful addresses 194

I am indebted to many staff of all disciplines at the Royal Orthopaedic Hospital,

This book is written with occupational therapy students in mind, as a guide to

Rheumatoid arthritis is a chronic, inflammatory, systemic disease, affecting

THE DISEASE PROCESS

Phases of the disease

Management of the disease

7. provide the environment, support and advice to facilitate the individual's

4. maintain surgically achieved alignment.

OCCUPATIONAL THERAPY ASSESSMENT

South Birmingham Health Authority

IN AND OUT OF BED

MANAGE OWN TOlLET

IN AND OUT OF BATH

MAKE POT OF TEA

MAKE LIGHT MEAL

Figure 1.1 Sampie form for general ADL assessment

ROYAL ORTHOPAEDIC HOSPITAL - BIRMINGHAM, 31

KEY TO GRADING 1) Independent, using aids if necessary

Figure 1.2 Sampie form for dressing assessment

JOINT PROTECTION PROGRAMME

Joints may be protected from deformity if a joint protection programme is

Personal activities of daily living

side of the frame may facilitate access;

would be willing to omit aitogether and which could be allocated to a helper.

Figure 1.3 Method of manipulating scissors

Comparatively few patients of childbearing age will be encountered but their

While a feature of rheumatoid arthritis is fatigue and sufferers require frequent

Independent mobility using a car is especially important when we consider

Looking after babies and smaII cbildren

REASONS FOR TOTAL HIP REPLACEMENT

PRE-OPERATIVE OCCUPATIONAL THERAPY

these movements. Patients are nonnally up on the second post-operative day.

assessed and instructed during the pre-admission screening, the objectives on

THE OUTLOOK FOLLOWING HIP REPLACEMENT

RESURFACING TOTAL mp REPLACEMENT

Figure 2.4 Resurfacing total hip replacement, metaion metal components

REVISION OF TOTAL HIP REPLACEMENT

and arevision perfonned using antibiotic-loaded acrylic cement. This is done

high commode, with oval-to-round adaptor to accommodate dip side toilet

Figure 3.1 Chiari pelvic osteotomy

Figure 3.2 Salter's and 'shelf pelvic osteotomies

GIRDLESTONES EXCISION ARTHROPLASTY

Figure 3.3 Girdlestones excision arthroplasty

CONGENITAL DISLOCATION OF THE HIP

SUPPED FEMORAL EPIPHYSIS

Osteoporosis produces a tendency to fracture of the neck offemur, especially

Fractures of the femoral shaft

Fractures of the hip

Figure 3.4 Garden screw for fractured neck of femur

Reasons for more radical surgery include:

Figure 3.6 Compression hip screw