FACTS FACTS. A Team Approach to Wound Care on the Lower Limb A Physical Therapist s Perspective

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1 A Team Approach to Wound Care on the Lower Limb A Physical Therapist s Perspective James G. Spahn, MD, FACS Sharon Lucich, PT, CWS Jaimee Haan, PT, CWS 1 FACTS Pressure ulcers are the result of an ischemic event, and not a crush injury Soft tissue distortion leads to Ischemic necrosis (pressure ulcer). 2 FACTS Contact with a support surface causes either volumetric support of the body or distortion of the soft tissue trapped between the bony prominence and the support surface. Since the body is three-dimensional, volumetric support (flotation) is needed to maintain proper tissue orientation. 3 1

2 FACTS Nutritionally and mobility impaired patients are at risk for developing pressure ulcers. 4 FACTS Pressure ulcers may start immediately, but often are not recognized until 3-7 days later. High incidence of pressure ulcers may occur on bed, surgery, ER, transportation cart, and seating surfaces. 5 FACTS Continuum of care is needed during the acute, sub-acute, and chronic levels of care. Patients at risk are usually discharged to rehab, since they are not rehabilitated at time of discharge. 6 2

3 FACTS Protocols decrease incidence by 50% 1 Usage of pressure-reducing devices alone can cause an increase in incidence Moody BL, Fanale JE, Thompson M. Vaillancourt D, Symonds G, Bonasoro C. Impact of staff education on pressure sore development in elderly hospitalized patients. Archives of Internal Medicine. 1988; 148: Lyder CH, Preston J, Grady JN, Scinto J, Allman R, Bergstrom N, Rodeheaver G. Quality of care for hospitalized medicare patients at risk for pressure ulcers. Archives of Internal Medicine. 2001; 161: Clinical Protocols Nutrition Mobilization Ambulate Turn Passive Range of Motion Support Surface Bed, Chair, Cart, Emergency Room, Operating Room Incontinence Care Wound Care Continuum of Care Treatment of other general medical conditions 8 FACTS Heel ulcers constitute 30% of all pressure ulcers in hospital settings. (Dekeyser, Dejarger, Meyst and Evers, 1994) The heel consistently ranks as the second most common location for pressure ulcers. (Barczak, Barnett, Childs, Bosley, 1997) Acute care heel prevalence is between 8-17% (1992) 15-23% (1997) 9 3

4 FACTS Heel ulcers constitute 30% of all pressure ulcers in hospital settings. (Dekeyser, Dejarger, Meyst and Evers, 1994) The heel consistently ranks as the second most common location for pressure ulcers. (Barczak, Barnett, Childs, Bosley, 1997) Acute care heel prevalence is between What s Wrong With This Picture? 8-17% (1992) 15-23% (1997) 10 Hospital Bed Simulation Pressure = 19mmHg (3 high density foam, air mattress and bed. Clothing)

5 Greater Trochanter Ischial Tuberosity Heel Ischial Tuberosity New Pressure Ulcers Source: Hospital Replacement Mattresses. Journal of ET Nursing. Johnson, Daily & Franciscus. Heel Greater Trochanter Board 2 Foam 3 Foam 4 Foam Static Air Strain % on Various Surface Type Air on Foam 14 Criteria for lower extremity protection In a horizontal postion: 1. Provide volumetric support of calf (circulation) 2. Protect skin (address bony prominences) 3. Maintain skeletal integrity (footdrop & lateral rotation) 15 5

6 Remember! No support surface by itself adequately protects the heel at all times

7 19 20 The Effects of Extended Bedrest (Microgravity) blood volume in red cell mass in muscle strength and work capacity in maximum cardiac output Loss of calcium, phosphate, and mass from bones Most of these same effects also occur in people who lie in bed for an extended period of time. Guyton AC, Hall JE, Textbook of Medical Physiology. Philadelphia: Saunders; 1996, p

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9 Mobility Rating Self Mobility Assisted Mobility Active Range of Motion Passive Range of Motion Immobility 25 Neutral 26 Venous Dependency 27 9

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11 31 Contouring Static Air (Flotation) Contouring Solid (Distortion) 32 Maintain Skeletal Integrity Foot Drop Lateral Rotation Fractures 33 11

12 Foot Risk Awareness Peripheral vascular Arterial Venous Contracture of leg Deformity of foot Skin viability General health Durability Shape of heel No Yes 34 Foot Risk Awareness + Mobility of patient = Foot Risk assessment scale Mobility of patient Ambulatory Ambulatory with assistance Non-ambulatory 35 Clinical Protocols Nutrition Mobilization Ambulate Turn Passive Range of Motion Support Surface Incontinence Care Wound Care Continuum of Care Lower Extremity Protection Bed, Chair, Cart, Emergency Room, Operating Room Treatment of other general medical conditions 36 12

13 Product Should: Elevate heel (Dewedge) Protect sides of foot and ankle Neutralize weight of lower extremity (Delever) Maintain and promote circulation Address foot drop and lateral rotation of ankle Allow access to the foot for inspection/treatment Facilitate the musculoskeletal pump Fulfill regulatory requirements 37 Physical Therapy Perspective on Ankle Foot Orthosis (AFO s) Jaimee Haan, PT CWS Sharon Lucich, PT CWS 38 Basic Anatomy of the Lower Extremity 39 13

14 General Terminology Dorsal: (Dorsum) Top of the foot Plantar: Bottom of the foot Medial: Towards midline Lateral: Away from midline Proximal: Nearer to the trunk Distal: 40 Farther away from the trunk Moore, K, Dalley, A: Clinically Oriented Anatomy, 5 th Ed., 2006 Hip Pelvis Femur Thigh Femur Lower Leg Tibia Fibula Bones of the Leg 41 Bones of the Ankle and Foot Hoppenfeld, Stanley: Physical Examination of the Spine and Extremities,

15 Main Muscles of the Leg ANTERIOR: Knee extensors Quadriceps Femoris Ankle Dorsiflexors Anterior Tibialis Extensor Hallicus Longus Extensor Digitorum Longus 43 Main Muscles of the Leg POSTERIOR: Hip extensors Gluteus Maximus (Buttock ) Knee flexors (Hamstrings) Biceps Femoris Semitendonosus Semimembranosus Ankle Plantarflexors Gastrocnemius Soleus Achilles Tendon 44 Biomechanics of the Lower Extremity 45 15

16 Joint Motion Range of Motion: (ROM) The amount of motion available at a joint Active Range of Motion (AROM): Amount of motion available at a joint by a subject during unassisted voluntary movement Passive Range of Motion (PROM): Amount of motion available at a joint attained by an examiner without the assistance of the subject 46 Goniometry: Measurement of joint angles created by the bones of the body Goniometer: Tool used for goniometry 0 o 45 o 30 o 47 Knee ROM Ankle ROM 0 o ROM of the Hip Flexion: Bending of the hip joint Extension: Straightening of the hip Joint 48 16

17 ROM of the Hip Abduction: Movement of the femur away from midline Adduction: Movement of the femur towards midline 49 ROM of the Hip External (or Lateral) Rotation: Rotation of the femur away from midline Internal (or Medial) Rotation: Rotation of the femur toward midline Neutral Position: No internal or external rotation 50 ROM of the Knee Flexion: Bending of the knee Extension: Straightening of the knee Hoppenfeld, Stanley: Physical Examination of the Spine and Extremities, 1976 Hyperextension: Knee extension beyond neutral 51 17

18 Common Types of Knee Deformity Genu Varum: Genu Valgum: Genu Recurvatum: 52 Hoppenfeld, Stanley: Physical Examination of the Spine and Extremities, 1976 ROM of the Foot and Ankle Plantarflexion: Ankle joint flexion Movement of the bottom of the foot in the caudal (tail) and posterior direction Dorsiflexion: Ankle joint extension Movement of the top of the foot in the cranial (head) and anterior direction 53 ROM of the Foot and Ankle Abduction: Movement in a sideways direction away from midline of the foot Adduction: Movement in a sideways direction towards midline 54 18

19 ROM of the Foot and Ankle Pronation: Rotation of the foot so that the sole of the foot faces a lateral (away from midline of the body) direction Supination: Rotation of the foot so that the sole of the foot faces a medial (toward midline of the body) direction 55 ROM of the Foot and Ankle Inversion: A combination of supination and adduction of the foot Eversion: A combination of pronation and abduction 56 Ankle Alignment Neutral Position: The ankle is considered to be in neutral when the foot is at a right angle with the tibia Subtalar Neutral: The point at which the subtalar joint is fully supinated and then carried two-thirds of the way through maximum pronation Relevance: when positioning a foot in a splint the goal is to achieve neutral alignment of the ankle and the subtalar joint 57 19

20 58 Gait Cycle 59 Standing Alignment and Balance Base of Support 60 20

21 Phases of Gait Cycle STANCE PHASE SWING PHASE 61 Abnormal Gait Patterns Foot slap Weak dorsiflexors cause foot to slap down Occurs at the beginning of heel strike 62 Abnormal Gait Patterns Toe scuff Lack of dorsiflexion Occurs during midswing 63 21

22 Abnormal Gait Patterns High steppage gait Loss of dorsiflexion Inability to decelerate dorsiflexors Knee lifts higher than normal to allow foot to clear the floor Occurs during midswing Leg Length discrepancy? 64 Abnormal Gait Patterns Hip hike Leg Length discrepancy? 65 Abnormal Gait Patterns Balance issues 66 22

23 Common Foot/Ankle Impairments Requiring the Use of an AFO 67 Foot Drop An abnormal neuromuscular condition of the lower leg and foot characterized by an inability to dorsiflex or evert the foot May be due to damage to the Common Peroneal Nerve or dorsiflexors AFO can be used for treatment if surgery not an option 68 Foot Drop (cont) Splinting Philosophy Stabilize ankle in neutral position to maintain functional ankle range of motion to allow standing and ambulation (walking) Provide medial and lateral stabilization of the hip joint (Use stabilization bar if available on the AFO) 69 23

24 Plantarflexion Contracture Abnormal, usually permanent, condition of the ankle joint characterized by plantarflexion and fixation; caused by atrophy and shortening of muscle fibers ( heel cord ) Goal: Maintenance of current ROM to enable adequate skin care and functional use 70 Spasticity A state of increased muscular tone with exaggeration of tendon reflexes Common in patients with closed head injuries, spinal cord injuries, cerebral palsy or stroke Can cause deformity and limit functional movement 71 Spasticity (cont) Splinting Philosophy Apply mechanical force to correct or prevent contractures Shortened muscles cause increased muscle tone; splinting at the ankle puts the gastroc/achilles on a prolonged stretch allowing lengthening to occur in the collagen of the soft tissue and re-form to the appropriate length Provides sensory stimulation which alters muscle tone to promote normal movement patterns 72 24

25 Splinting Philosophy Precautions Spasticity (cont) 73 Plantar Fasciitis Repetitive micro-trauma to Plantar Fascia (fibrous band that supports the arch of the foot) Causes pain on plantar surface of heel and medial aspect of foot with weight bearing 74 Heel Pressure Ulcer Development of a wound due to mechanical stresses: pressure, shear Prevention/Treatment Supports the ankle while a patient is confined to bed for prolonged periods of time decreases the risk of heel breakdown Prevents prolonged pressure and shear forces of the heel moving across the bed 75 25

26 General Splinting Terminology and Techniques 76 Common Terminology Splint: An orthopedic device for immobilization, restraint, or support of any part of the body Orthosis: A force system designed to control, correct, or compensate for a bone deformity, deforming forces, or forces absent from the body 77 Traditional Orthotics Posterior leaf spring AFO Patellar-tibia bearing AFO Floor reaction AFO Conventional AFO 78 26

27 Traditional Orthotics Foot or Shoe Orthotic (Insole) Diabetics Pronated/Supinated foot Hinged ankle foot orthosis Rigid ankle foot orthosis 79 Rigid Ankle Foot Orthosis (AFO) Static Splints Immobilize Help prevent further deformity Help prevent contractures 80 Heel Presure Relieving Ankle Foot Orthosis (AFO) 81 27

28 Heel Presure Relieving Ankle Foot Orthosis (AFO) 82 Splinting (AFO) Precautions Fit An ill-fitting ankle-foot orthosis can cause harm to the patient The ankle joint should be positioned in the splint at the correct therapeutic angle When a patient wears an AFO with padding in supine (lying on their back), the distal tibia is elevated relative to the proximal tibia and femur; This encourages knee hyperextension Signs of improper fit: skin redness, edema (swelling), joint stiffness, pain, skin rash, decreased circulation 83 Splinting (AFO) Precautions Skin Assessment The clinician should don the AFO properly and leave in place for minutes Red areas should not be present 20 minutes after removal of AFO Educate patient/family to report any rashes or other skin reactions Edema Assessment If AFO straps are applied too tight, issues with edema above and below straps may result and can cause skin breakdown

29 Splinting (AFO) Precautions Timing Splint schedules should be provided and patient, family and education regarding splint schedule should be provided Compliance Education of all parties involved in the patient s care is key to increasing patient compliance Education should include explanation of the goal of wearing the splint, and should be repetitive and consistent 85 Splint Schedule Please wear the splint according to the following schedule: Day: 2 hours on, 2 hours off Night: On all night Special Instructions: Contact Name/Number: Precautions: redness, pain, swelling, rash or reduced sensation 8am-10am 10am-12pm 12pm-2pm 2pm-4pm 4pm-6pm 6pm-8pm 8pm-10pm 10pm-8am OFF ON OFF ON OFF ON OFF ON ALL NIGHT 86 HCPCS Code: L4398 Foot Drop Splint/Recumbent Positioning Device A prefabricated ankle-foot orthosis which has all of the following characteristics: Designed to maintain the foot at a fixed position of 0 degrees; and, Not designed to accommodate an ankle with a plantarflexion contracture; and, Used by a patient who is nonambulatory; and, Has a soft interface 87 29

30 HCPCS Code: L4396 Static AFO Prefabricated ankle-foot orthosis which has all of the following characteristics: Designed to accommodate either plantar fasciitis or an ankle with a plantarflexion contracture up to 45 degrees; and Applies a dorsiflexion force to the ankle; and, Used by a patient who is minimally ambulatory, or nonambulatory; and, Has a soft interface 88 Medicare Reimbursement for HCPCS code L4396 (Static AFO) Covered if all criteria 1-4 met or if criterion 5 is met 1. Plantarflexion contracture (718.47) with passive dorsiflexion of at least 10 degrees (non-fixed); and, 2. Reasonable expectation of ability to correct contracture; and, 3. Contracture interfering with functional abilities; and, 4. Used as component of therapy program which includes active stretching 5. Plantar fasciitis (728.71) For plantarflexion contracture: Pre-treatment PROM must be measured w/ goniometer and documented There must be documentation of stretching program carried out by professional or caregiver Reimbursement denied for Fixed contracture Footdrop without an ankle flexion contracture A component of a static AFO that is used to address positioning of knee or hip because effectiveness has not been established Evaluation of patient, measurement and fitting of orthosis are included in the allowance for the orthosis. There is no separate payment for these services 89 Other Medicare Reimbursement Codes L1930 L2820 Plastic Splint Soft interface Instead of L4396 L4360, L4386 Walking boot L4396 Static AFO L4398 Foot drop splint/recumbent positioning device L4392 Replacement interface GY modifier must be added if AFO used solely for treatment of edema and/or for prevention or treatment of a pressure ulcer Must indicate why e.g. used to treat pressure ulcer 90 30

31 Questions?? 91 Thank You! Jaimee Haan, PT, CWS Sharon Lucich, PT, CWS 92 31