what-when-how
In Depth Tutorials and Information
during the movements to prevent injury. For adults
with moderate impairment open chain strengthening
activities should be done slowly and controlled
throughout the range of motion to maintain
stability around the joint with lower weight and
increased repetition.
7
NMES can also be applied in
combination with these activities to improve their
effectiveness. As with all activities NMES should be
applied in a balanced way to ensure that one muscle
does not overpower another muscle and further
increase the risk of injury.
4.
Standard orthopedic bracing could be difficult with
this population due to smaller size and altered body
structure, but can be helpful in giving the patient
more confidence and proprioception during the
rehabilitation process even though they do not offer
sufficient support. For the more impaired patient,
orthotics like ankle foot orthoses, knee ankle foot
orthoses for the limbs and thoraco-lumbo-sacral
orthoses for the spine for sitting and standing weight
bearing help to maintain alignment and reduce
fracture, but there must be a balance. Any added
weight to a functional activity can increase the
fracture when moving in an open kinematic chain.
Also immobilization can lead to further weakness
of a muscle leading to pain and loss of mobility.
17
Please refer to Chapter 50 for more details on the
needs and benefits of these devices.
5.
Strengthening should start with isometric exercises
augmented by neuromuscular electrical stimulation
to assist with strengthening activities. For those
adults with an increased cardiac risk it is necessary
to monitor their cardiac status and follow the
recommended precautions during all strengthening
activities. Individuals with higher functioning
may require modification of the progression of
exercises to closed chain to reduce the lever force
on the limbs. Strengthening activities which involve
co-contraction of muscle and force along the long
axis of the bone reduce the chance of fracture and
increasingly approximate the functional activities
of the patient. Most adults with OI who participate
in and want to get back to sports, will know the
extent to which they can participate in these types
of exercise. For higher impact exercises maintaining
stability with co-contraction through the range of
motion will decrease the likelihood of fracture and
ligamentous injury. Again NMES can be applied
with strengthening activities but should be done so
in a balanced way to ensure that one muscle group
does not generate more force than the other, causing
injury. Cardiovascular and endurance activities
should also be part of the treatment modality. Lower
resistance and reduced weight bearing activities are
recommended. Recumbent bikes, seated steppers/
elliptical and treadmills are generally effective. One
must check for cardiac precautions before instituting
these activities and monitor cardiac status and
maintain precautions during the treatment session.
6.
Aquatic therapy is a critical component of
service especially in the more impaired patient.
Weight bearing can be gradually increased in this
environment and the isokinetic property of the water
offers resistance to movement giving the opportunity
for strengthening and for proprioceptive feedback.
7.
Proprioceptive activities should be modified.
Proprioceptive neuromuscular facilitation (PNF) and
the use of the pool environment are great starting
points for this type of care. They can be advanced to
partial weight bearing closed chain activities and full
weight bearing within the limitations of the patient's
weight bearing status.
8.
Weight bearing advancement is directed by the
physician for both sitting and standing accompanied
by the appropriate bracing, but general guidelines
are to start with the distribution of weight through
as much surface area as possible. For sitting this
generally means that one is starting in a reclined
position on the appropriate cushion and progressing
toward vertical sitting under the direction of the
physician. The same applies for standing; one
needs to distribute weight among all four limbs by
adding crutches and then progressing to a higher
functional level of weight bearing on the bilateral
lower extremities for higher-level adults. The use of a
stander is appropriate for more impaired individuals
following the same progression of weight bearing. A
vibratory plate has been shown to be an effective tool
in adults with osteoporosis.
18,19
A recent pilot research
study has shown this modality to be beneficial for
improved mobility in children and adolescents with
OI, but more work needs to be done regarding this
modality.
20
In the case of the more impaired adult with OI the
goals may have to be modified so that the adult with
OI can maintain their independence. These adaptations
can be simple additions like household adaptive equip-
ment for reaching and ADL activities to more compli-
cated custom seating and power mobility systems or
home modifications. The services of an occupational
therapist are imperative to determine the ADL adapta-
tions. The physical and/or occupational therapist can
help with assessing any home modifications that are
needed. When evaluating an individual for adaptive
equipment the physical or occupational therapist should
perform a movement analysis of the individual's daily
activities and functional environment. This analysis
will identify areas or movements that could lead to fur-
ther injury. For non-ambulatory adults proper seating
