ICF ASSESSMENT IN ORTHOPAEDICS LUNELLE L PIENAAR MSC

ICF ASSESSMENT IN ORTHOPAEDICS LUNELLE L PIENAAR MSC PHYSIOTHERAPY (US), BSC PHYSIOTHERAPY (UWC) FACULTY OF HEALTH SCIENCES 1 UNIVERSITY OF CAPE TOWN

APPLICATION OF THE ICF ASSESSMENT Orthopaedics relate to disorders/ disease that occurs within the musculoskeletal system. v • • Use of the ICF in orthopaedic assessment: The ICF framework provides a useful assessment format as it recognizes the influence of the environment and personal factors on the health condition of the patient. The ICF is used for assessment and documentation of a patient’s level of function after sustaining an orthopaedic injury that requires medical intervention. Functional problems can occur due to any of the following orthopaedic conditions: 2 1. Fracture of the bone either pathological or traumatic and ruptures of muscles, ligaments or tendons. 2. Congenital and metabolic disease that results in skeletal deformities requiring surgery to correct the deformity. 3. Arthritic and rheumatologic disease.

FUNCTIONAL PROBLEMS Orthopaedic conditions can affect either the daily activities and/or participation of the patient, therefore resulting in the following functional problems: o Limited ability of the patient to walk independently. o Limitations in moving around in bed and the ability to get in and out of the bed. o Decreased independence with self care personal hygiene activities like washing, toilet use, dress and undress and performing household tasks. o As well preventing the involvement of the patient in their work, sporting and other activities. 3

The procedure followed when conducting a physiotherapy orthopaedic assessment in a hospital: 1. Review of patient’s medical folder and X-rays to determine which structure sustained injury and how it has affected the function of that structure. 2. Conduct an interview with the patient to establish the patient’s baseline activities prior to the injury. 3. Physical examination of the affected area. In the physical examination the involved area is assessed through observation and palpation, testing range of movement and muscle power. Using the ICF the patient’s current functional ability will be tested to determine how the injury has contributed to the problems within activity and participation domains. 4 PHYSIOTHERAPY ORTHOPAEDIC ASSESSMENT

CASE SCENARIO 5 Mrs Moses is a 45 year old female who sustained a midshaft tibiofibular fracture on the right as a result of a motor vehicle accident 3 days ago. She is day 1 post ® Open Reduction Internal Fixation.

CASE SCENARIO CONTINUED Social history 6 The patient lives with her husband 1 child in an informal housing structure. Her husband is unemployed and she is the sole breadwinner in the house. She is eager to return to work, where she works as an admin clerk. However, she fears that she will not be able to negotiate the two flights of stairs at work after 6 weeks when she is scheduled to return to work. Prior to the accident she was very active; she did all the cooking and house work. Mrs Moses enjoys reading and watching TV. She does not smoke, but drinks socially. She relies on public transport to go to work and the shops.

The sandy terrain that the patient needs to negotiate to her informal dwelling The communal toilets that the patient has to access. These are situated on the periphery of the settlement area. Outside the House The exterior of her dwelling The communal tap used for drawing water for cooking and washing. Top-right image by John Charalambous on Flickr (CC BY-ND). All other images used with permission from Ad van Zeeland ( Aa. Vee. Zet on. Youtube) 7 THE HOUSE

THE HOUSE Vinyl flooring is often used in informal dwellings Inside the House The confined space that the patient uses for cooking, watching TV and sleeping Top-left image by Mark Blacknell on Flickr (CC BY-NC-SA). All other images used with permission from Ad van Zeeland ( Aa. Vee. Zet on. Youtube) 8 The child’s bed used to store blankets during the day

PHYSICAL ASSESSMENT Observation: • Swelling visible on (R) lower leg, measure mid calf 45 cm (L), 60 cm (R). • Bandage over anterior surface of patellar tendon, slightly blood stained, but dry at present. • Increased temperature on the right compared to the left (L) leg. Bed function: 9 • The patient relies on the assistance of the nursing staff to reposition her up/down and sideways in bed as the leg is very painful.

Transfers • She is able to sit up in bed, but needs help to lift leg sideways to sit upright over the edge of the bed. • She can stand up from sitting with assistance of one person. Balance • Walked about 5 m with the assistance of physiotherapist using the walking frame yesterday then had to sit down to rest complaining of feeling very tired. 10 • Static and dynamic sitting balance is good. • In standing the patient has good static balance, although dynamic balance is fair. Mobility

Health Condition = Fracture Body Function & Structure Fracture of the tibiofibular resulted in damage to muscles surrounding the fracture site Impairment is the inability to fully weight bearing on right leg Activities Limitation Participation Restriction Problem with independent bed mobility, transfer out of bed and walking with frame Unable to work or perform house work Personal Factors Loss of income, husband unemployed, stairs at work; these are considered as barriers to the rehabilitation process Patient is motivated and this can facilitate her rehabilitation process 1 Environmental Factors

WHAT IS THE ROLE OF THE PHYSIOTHERAPIST IN MANAGING PROBLEMS OF ACTIVITY LIMITATION AND PARTICIPATION RESTRICTION Activity limitation: • Prescribe strengthening exercises for the muscles of the lower limbs and upper limbs that assist transfers in and out of bed. • Correct the method of getting in and out of bed if this is incorrect and practice the technique with the patient. • Perform balance exercises to assist mobility with walking frame then progress to crutches as she will be unable to weight bear fully on the affected leg and this will affect her balance. • Progressively increase distance walked so she can get to mobilise in her house, then shops and eventually work. • As soon as she’s able, the patient needs to be taught how to climb up and down stairs as she needs to be able to do this to get to work, get in and out of a bus, taxi or train. Participation restriction 12 • Refer to other health professionals e. g. social worker to assist with financial support. • Provide continuity of services by referral to community health center physiotherapist and occupational therapist.

REFERENCES Jelsma Jennifer. 2009 Use of the international classification of functioning, disability and health: A literature survey. J rehabil med; 41: 1– 12 Resnik Linda, Allen Susan. 2007. Using international classification of functioning, disability and health to understand challenges in community reintegration of injured veterans. Journal of rehabilitation research & development; 44 (7) : 991 -1006 13 Grill Eva, Ewert Thomas, Chatterji Somnath, Kostanjsek Nenad, & Gerold Stucki. 2005. ICF core sets development for the acute hospital and early post-acute rehabilitation facilities. Disability and rehabilitation, ; 27(7/8): 361 – 366

CREATIVE COMMONS LICENSE ICF Assessment in Orthopaedics by Lunelle Pienaar, Physiotherapy Division, Department of Health and Rehabilitation Sciences, University of Cape Town (2010) is licensed under a Creative Commons Attribution-Non. Commercial-Share. Alike 2. 5 South Africa License. Please see http: //creativecommons. org/licenses/by-nc-sa/2. 5/za/ for terms and conditions. All images created by external parties retain their original licenses (see image references on slides). Source work available at vula. uct. ac. za 14 Permissions beyond the scope of this license may be available at www. healthedu. uct. ac. za or healthoer@uct. ac. za