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Minimizing Preoperative And Postoperative Limping

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Question:

Discuss about the Minimizing Preoperative and Postoperative Limping.
 
 

Answer:

Introduction

The paper deals with the case study of Mrs. Anitha Smith. She has been referred to occupational therapist after total hip replacement. Occupational therapy refers to team of social workers, nurses, physiotherapist working as a part of multidisciplinary team. The aim of the occupational therapy is to enhance self-independence of client and ensure safety during recovery process (Blom et al., 2016). The paper highlights the occupational performance issues observed after interview with the client. The strengths of clients are identified and based on overall assessment SMART (Smart Measurable Achievable Realistic Time bound) goals and interventions are discussed. The intervention strategies are developed as a part of the role of occupational therapist based on evidence from literature.

In order to develop interventions for the client an interview was conducted to gain sufficient knowledge on her background. The background assessment was guided by the Person-Environment-Occupational Performance (PEOP) model. It is a transactive system model  that helps focus on the client’s extrinsic and intrinsic influences on activities of daily living (Arcand-Dusseault & Egan, 2015).

Mrs. Anitha Smith is 76 years old living in single storey house in a small town. She was social, active and independent before the surgery. Mrs. Anita is not having good sleep due to facilities schedule. She is lacking good nutrition as she is having slow meals. She has good fluid intact and has lost weight recently. She needs physical assistance for moving out of bed as she has low body strength and restricted flexibility due to which she is toileting on bed. It may severely impact her daily life activities. She is under medication for pain and blood pressure.

Her mental function is not intact due to post surgery medications. She is stressed due to pain and poor mobility. She has poor mental well being due to  recent death of her husband.  She seems to have good self esteem. The patient has reduced balance. Nneuromusculoskeletal and functions related mobility such as joint mobility, joint stability, gait patterns, are all impacted in the replaced hip. She has good coordination and is mentally alert. She has good reasoning when focused.

Mrs. Anita loves her independence, good work ethic and gives importance to social participation. Currently she is dependent on state pension income. She lives in her one storey building with just one step at the back of entrance. Her home has here bedrooms and two bathrooms. She is widow, living alone. She is friendly and exhibits socially appropriate behavior. She has support of friends but she is withdrawing from communication. She has no loved ones nearby her.

Mrs. Anita engages in wide range of occupations. She loves going out with friends, travelling, shopping, gardening activities and home Management. She is involved in self-care and kitchen work. She independently involves in grocery shopping.

 

Occupational performance issues

It is evident from the PEOP assessment of Mrs. Anita that the primary issues are:

  • Her physical mobility led to inability to manage transfers that is chair, bed and toilet. She has not attempted self care and has been toileting on bed. It has great impact on occupational performance of Mrs. Anita. Lack of mobility is adding to lack of endurance. Increasing strength and endurance can improve the dynamic balance (Horstmann et al., 2013).
  • Pain Management is necessary to relieve mental distress and anxiety. Addressing pain related issue may help Anita better focus on other activities of daily living and have good sleep and relieve fatigue (Emerson et al., 2014)
  • Bereavement due to death of spouse and surgical complications. Anita’s occupational performance is effected due to both physical and mental stress. Loneliness and decreased communication with neighbors and friends will further  deteriorate mental well being (Ollivier et al., 2014)
  • She is not able to manage dressing and washing safely. Assistance for such personal activities may lead to embracement and loss of dignity.
  • Need of adequate support to prepare meals. For the past few days Anita has been cooking slow meals and is not having adequate diet which caused her to lose weight.
  • Need of adaptive equipment (kitchen trolley, perching stools in bathroom) to practice domestic tasks after discharge such as cooking. Such equipment can be used to carry out activities easier. Without which she will continue to have poor quality of life due to unmanageable lifestyle (Singh & Lewallen, 2014)
  • Lack of adaptive equipment and assistance may increase the risk of fall and in future. I will increase the risk of girdle instability, gait disturbance, and hip pain.
 

Identification of client’s strength

Based on the PEOP model of assessment it was found that Mrs Anita’s strength is her high self esteem, social support from neighbors and friends. Social connectedness will help overcome emotional stress and gain confidence (Brembo et al., 2017). She has good coordination, is mentally alert, and is indicative of good cognition. She has good reasoning when focused. She is following the doctors instructions and the given hip precautions.  It means if she is educated about the precautions to be taken to improve mobility she will recover quickly. It indicates that she will participate actively in recovery process (Goyal et al., 2017). In addition, she values her independence and was independent prior to hip replacement. She is motivated to return home. Therefore, providing adequate support and technique to improve her physical independence will restore her previous activities such as cooking, home Management, shopping and others.

Considering the occupational performance issues it can be concluded that the required performance skills are: gripping walker, controlling limbs, control of walker, have proper gait cycle and improve balance. The required body functions are: mobility of joints, and improved lower body strength. After interview and assessment specific, achievable, measurable and realistic and time bound occupational therapy goals are set for patient.

SMART goals:

  • Ms Anita will be able to walk by using 4 wheel walker within 3 weeks
  • Increase client’s ability to complete a simple painting in standing (slow efforts to increase consecutive time during each stand)- in 2 weeks
  • Refer Ms Anita to Physiotherapy to increase her dynamic stability in hip within 8 weeks
  • Ms Anita will be able to shower herself independently and safely within 4 weeks by using require assistive devices like shower stool hand grabs
  • Home assessment will be completed by occupational therapist within 1 week to ensure client’s home is safe for discharge
  • Relaxation technique will be used to eliminate mental stress and anxiety- Within 1 month
 

Interventional strategies

Mrs. Anita can receive health care service at her home. Initially, she will continue the inpatient rehabilitation. After achieving the short-term goals such as using the walker, she will be discharged. Prior to which she will be given a facility protocol for hip replacement.  Prior to discharge the patient will be provided with guidelines and materials for education on her illness to ensure safety. It includes how to ensure safe environment such as removing obstacles from path to prevent fall and ensure sufficient lighting in washroom, kitchen and hall area (Goyal et al., 2017).

Mrs. Anita will be given training on use of assistive device such as  walker with precautions during bathing and technique to get in and out of tub, and in shower, getting in and out of car.  Walker is assistive device that prevents fall and risk of injury by helping to balance and maintain hip position (Mikkelsen et al., 2014).Training on yard work, laundry and shopping using appropriate shoes, walker, gait belt, glasses followed by training on having grip and control of walker will be provided to the client.

To improve mobilization, the client will be trained by physiotherapist  on post operative exercises. Exercises that can be performed while on bed-

  • Ankle pumps (10 repetitions every 5-10 minutes)
  • Heel slides and Quad sets (10 repetitions 3-4 times per day)

Standing exercises holding firm surfaces to complete a simple painting in standing

  • Standing knee raises but not higher than waist
  • Standing hip abduction includes movement of hip, knee and foot
  • Standing hip extensions

These exercises are designed to restore strength, dynamic stability and mobility to hip. It will help client to return to daily life activities or occupations (Villadsen et al., 2014).

Training on advanced exercises and activities (to be repeated 4 times a day with ten times each session)

  • Resistive hip flexion- standing with feet lightly apart and forward motion of one leg with knee kept in straight position
  • Resistive hip abduction-outward stretching of leg by standing sideways from door
  • Resistive hip extensions- stretching of leg while facing the door attached with tubing and restore previous position
  • Excercycling-
  • Walking (slowly initially with care until regain of balance)- walk initially for 5-10 minutes and increase the time after improvement in strength and endurance

Advanced exercises are necessary because hip muscles are weakened due to pain after fall and surgery (Villadsen et al., 2014).

 


Training and instruction on correct use of assistive devices such as trochanter roll. Trochanter roll aid in hip alignment when the body is unable to support itself without causing injury. It prevents external rotation of hip (Blom et al., 2016). It is important for client to learn to change positions properly on bed to relieve pressure with a little pain possible. Transferring to bed is risky and holds high risk of fall and injury (Mikkelsen et al., 2014). Training includes teaching how to use trapezbar when transferring in bed and kitchen trolley. The patient requires instructions on use of compression stockings. She will given instructions on method of wearing of SCD device. Daily use of compression stockings helps to reduce the development of deep vein thrombosis and aid in pain Management (Singh & Lewallen, 2014).

Music therapy has been found effective technique for relaxation in various chronic diseases. It is in effective in marinating body-mind in calm and composed state. Music will help Anita  to relax and relieve stress caused by pain and bereavement (Hsu et al., 2016).

Conclusion

In conclusion, occupational therapy is vital for helping patients of hip replacement surgery to improve functional limitations while promoting safety and success. The assignment was helpful in providing deep insights into occupational therapy interventions for hip replacement. It helped in developing reasoning skills, assessment based on the interview and identification of risks and strength associated with client.

 

References

Arcand-Dusseault, C., & Egan, M. (2015). Occupations and personal projects: A comparison of the concepts. British Journal of Occupational Therapy, 78(5), 303-310.

Blom, A. W., Artz, N., Beswick, A. D., Burston, A., Dieppe, P., Elvers, K. T., ... & Lenguerrand, E. (2016). Occupational therapy in total hip replacement: systematic review and feasibility randomised controlled trial.

Brembo, E. A., Kapstad, H., Van Dulmen, S., & Eide, H. (2017). Role of self-efficacy and social support in short-term recovery after total hip replacement: a prospective cohort study. Health and Quality of Life Outcomes, 15(1), 68.

Emerson, R. H., Barrington, J. W., Olugbode, O., Lovald, S., Watson, H., & Ong, K. (2014). Comparison of Local Infiltration Analgesia to Bupivacaine Wound Infiltration as Part of a Multimodal Pain Program in Total Hip Replacement. Journal of surgical orthopaedic advances, 24(4), 235-241.

Goyal, N., Chen, A. F., Padgett, S. E., Tan, T. L., Kheir, M. M., Hopper, R. H., ... & Hozack, W. J. (2017). Otto Aufranc Award: A multicenter, randomized study of outpatient versus inpatient total hip arthroplasty. Clinical Orthopaedics and Related Research®, 475(2), 364-372.

Horstmann, T., Listringhaus, R., Brauner, T., Grau, S., & Mündermann, A. (2013). Minimizing preoperative and postoperative limping in patients after total hip arthroplasty: relevance of hip muscle strength and endurance. American Journal of Physical Medicine & Rehabilitation, 92(12), 1060-1069.

Hsu, C. C., Chen, W. M., Chen, S. R., Tseng, Y. T., & Lin, P. C. (2016). Effectiveness of music listening in patients with total knee replacement during CPM rehabilitation. Biological research for nursing, 18(1), 68-75.

Mikkelsen, L. R., Petersen, M. K., Søballe, K., Mikkelsen, S., & Mechlenburg, I. (2014). Does reduced movement restrictions and use of assistive devices affect rehabilitation outcome after total hip replacement? A non-randomized, controlled study. European journal of physical and rehabilitation medicine, 50(4), 383-393.

Ollivier, M., Frey, S., Parratte, S., Flecher, X., & Argenson, J. N. (2014). Pre-operative function, motivation and duration of symptoms predict sporting participation after total hip replacement. Bone Joint J, 96(8), 1041-1046.

Singh, J. A., & Lewallen, D. G. (2014). Patient-level improvements in pain and activities of daily living after total knee arthroplasty. Rheumatology, 53(2), 313-320.

Villadsen, A., Overgaard, S., Holsgaard-Larsen, A., Christensen, R., & Roos, E. M. (2014). Postoperative effects of neuromuscular exercise prior to hip or knee arthroplasty: a randomised controlled trial. Annals of the rheumatic diseases, 73(6), 1130-1137.

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