OCCUPATIONAL THERAPY ST BARNABAS HOSPITAL

PROTOCOLS

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PROVINCE OF EASTERN CAPE ISEBE LEZEMPILO/ DEPARTMENT OF HEALTH ST BARNABAS HOSPITAL ST BARNABAS ST BARNABAS HOSPITAL HOSPITAL OCCUPATIONAL THERAPY P. O. Box 15 DEPARTMENT Libode LIBODE
5160 Tel: 047 568 6872 Fax: 047 568 7100

POLICY DOCUMENTS INDEX Protocol 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 TITLE HEAD INJURY PROTOCOL CARDIAC REHABILITATION PROTOCOL CEREBRAL PALSY PROTOCOL CVA OCCUPATIONAL THERAPY TREATMENT PROTOCOL PROTOCOL ON OT INTERVENTION WITH BURN INJURIES SPINAL CORD INJURY OT PROTOCOL ASSESSMENT AND TREATMENT OF A PATIENT WITH ARTHRITIS NEONETAL AND EARLY INTERVENTION PROTOCOL FLEXOR TENDON INJURIES PROTOCOL EXTENSOR TENDON PROTOCOL RADIAL NERVE PROTOCOL ULNAR NERVE PROTOCOL MEDIAN NERVE PROTOCOL BOUTONNIERE DEFORMITY PROTOCOL MALLET FINGER PROTOCOL BRACHIAL PLEXUS PROTOCOL CARPAL TUNNEL SYNDROME PROTOCOL AMPUTEES PROTOCOL

HEAD INJURY PROTOCOL PURPOSE: To provide comprehensive, accurate assessment findings, realistic patient specific treatment interventions in accordance to nature of injury PROCEDURE ASSESSMENT Duration: 1 Hour A) Background information (nature of injury, medical history and biographical information) B) PRE-FUNCTIONAL Level of consciousness Muscle Tone. Range of movement Co-ordination Balance Perception Cognition Posture

C) FUNCTIONAL Mobility Self care (bathing, dressing, feeding, toileting, grooming) Domestic work Work Interpersonal relationships Leisure See Annexure: Assessment Format TREATMENT GOALS Duration: Based on medical and functional prognosis Improve pre-functional components. Prevent contractures

 Mobility training (need for mobility aid e.g. wheelchair, walking aid) Prevent contractures (use of splints) Assistive devices to aid with activities of daily living Family counselling in terms of home care Provide recommendations for adaptations to home environment Sensory stimulation Perceptual Training All functional areas Counselling of patients family PHASE ONE A) Intensive care phase 1. Physical 1. Normalizing muscle tone 2. Controlling abnormal reflex activity 3. Preventing contractures 4. Improving balance, co-ordination, righting reactions. 5. Sensory re-education 6. Sensory stimulation B) Psychological 1. Reducing anxiety and fear 2. Building up IPRS 3. Orientation 4. Improving memory and concentration 5. Improving motivation and c-operation 6. Counseling especially to family C) Functional 1. All aspects of daily living. PHASE TWO Patient now more cooperative and treatment sessions can now be longer and more dynamic. Particular emphasis on retraining functional ability in all spheres especially personal management and mobility. Patient should be incorporated in a fairly well balanced day programme to include occupational therapy, physiotherapy, speech, rests etc. LATE PHASE Focus on discharge, home and work. Family counseling, prepare home programmes. Patient usually comes as out patient regularly, gradually decrease, later monthly checkups until not necessary.

Home programme Exercises Correct body positioning Exercises

DESIGNATION: . SIGNATURE:.................................. DATE:......................... CARDIAC REHABILITATION PROTOCOL OBJECTIVES To provide uniform OT services for patients with cardiac conditions To assist patients with cardiac dysfunction in achieving maximal functional level of independence To educate patients and families regarding ongoing treatment and ensure consistent home management of the patients after discharge To assist the families and patients in adjusting to the disability and life changes PROCEDURE The priority of assessment and procedures should be determined by each individual patients needs A full assessment can begin during the doctors first physical examination of the patient As a member of the multi-disciplinary team, the OT listens for problem areas in personal care, social or interpersonal, work and leisure times spheres The OT can thus already provide comments and information regarding the doctors immediate referral and enquiry Before the OT interviews the patient personally, s/he should consult the patients file for results and special evaluations The OT interview should be planned after the results of the stress ECG and angiogram are known, as treatment will be planned according to these results, especially regarding energy saving principles The OT must always be aware of patients blood pressure, pulse rate and fitness level The main points to be obtained during first interview include the following: The patients psychological condition

 Problems being experienced presently including sleep disturbances, anxiety, tension, stress, relationships, and working environment. The patients limited insight regarding his/her condition should be established. The OT should listen to the patient effectively throughout the interview and reflect the patients feelings ASSESSMENT Patients basic background information Include space for specific diagnosis example: Myocardial infarction/Angina pectoris Tools used in Cardiac assessment: Heart rate; Blood Pressure; ECG readings; signs and symptoms of cardiac dysfunction and heart sounds. Classify pt according to four functional categories.

CLASSIFICATION OF PATIENT CLAS 1: Pts with cardiac disease but without resulting limitations of physical activity. Ordinary physical activity does not cause undue fatigue, palpitation, dispnea or anginal pain. CLAS 2: Pts with cardiac disease resulting in slight limitation of physical activity. They are comfortable at rest. Ordinary physical activity results in fatigue, palpitation, dyspnea, or anginal pain. CLAS 3: Pts with cardiac disease resulting in marked limitation of physical activity. They are comfortable at rest. Less than ordinary physical activity causes fatigue, palpitation, dyspnea or anginal pain. CLAS 4: Pts with cardiac disease resulting in inability to carry on any physical activity without discomfort. Symptoms of cardiac insufficiency or of anginal syndrome may be present even at rest. If any physical activity is undertaken, discomfort is increased. Chart review: Conduct a thorough chart review if available. Familiarize yourself with the patients condition and understand any specific precautions before first pt contact is established. Patient interview Obtain activity history. Pre-Admission Current Status

Activity

Status Bed Mobility Transfers Functional Ambulation Self-care Hygiene Dressing

Bathing Toileting Homemaking/Gr ocery shopping Vocational and Avocational Endurance (typical day) Monitored Self-Care Evaluations: Choose a low-level (an activity that require a low energy expenditure) self-care activity based on the patients past medical and functional history. ORTHOSTATS: Supine Sit Stand Sit Supine Heart rate Blood pressure PRECAUTIONS AND CONTR-INDICATIONS Monitor the patient for shortness of breath, chest pain, nausea, vomiting, dizziness and fatigue Adhere to activity guidelines for the designated MET level (MET = metabolic cost of activity based on rates of oxygen consumption during the activity). If an appropriate response to any MET level of activity occurs, notify the doctor, modify or discontinue the activity and revise the patients treatment program

Avoid activities that involve isometric muscle work, straining and breath holding, or extensive arm holding over head Be aware that patient who has undergone open-heart surgery should avoid lateral arm exercises that stretch the chest and pull on the incision Know the options of referring physicians and facilities before recommending that the patient return to prior level of sexual activity Be aware that exercises are contra-indicated for the following conditions Unstable angina Resting diastolic blood pressure 120mmHg or resting systolic blood pressure 200mmHg Uncontrolled arterial or ventricular arrhythmias Second or third degree heart attack block Orthostatic systolic blood pressure drop of 29mmHg or more Resent embolism either systemic or pulmonary Thrombophlebitis Dissecting aneurysm Fever greater than 37,7C Uncompensated heart failure Primary, active pericarditis Severe aortic stenosis Acute systemic illness Resting heart rate greater than 120 beats/ minute in a patient with a recent MI.

TREATMENT Patients are usually seen once or twice on an out patient basis The main aim of the session/s is to educate the patients with regards to the following: Improve the patients and the familys insight into the condition and the future implications Information about activity requirements, energy saving skills and principles Discuss the possible need for lifestyle modification and explore methods of pursuing these changes Stress management - maintaining a balance of activities - day and time management - reducing the source of stress - problem solving - relaxation therapy Assist the patient and his family in their psychological adjustment to the disease

Improve social skills for example, assertiveness ( may) necessitate long term follow up Work related - suggestions regarding: alternative methods or alterations in work setting - work visitations, if appropriate Written information together with the practical execution of energy saving principles and stress management can be given to each patient The required amount and type of treatment sessions are determined by the amount of problems experienced by the patient and the progress of the patient, for example, during the practical execution of the program, the blood pressure and pulse rate must be taken before and after each activity.

Compiled by: N. N. Tikilili Assistant Director: Occupational Therapy Date: 12 April 2007 Date of review: April 2008

CEREBRAL PALSY PROTOCOL OBJECTIVES To assist patients achieve maximal level of function and independence in ADL within the limitations of their disabilities

To facilitate normal developmental milestones through stimulation and handling To educate caregivers regarding their childrens conditions and their role in management

PROCEDURE Management of individuals is done in a multi disciplinary approach On first contact, a patients file should be opened and a file number be allocated. The file should be kept on current patients file and will only be removed when the patient has been discharged. Assessment of all referred cases should include: A) HISTORY q Establish reason for referral e.g. delayed milestones. q Detailed birth history and developmental history. B) PRE-FUNCTIONAL COMPONENTS q Muscle tone abnormality (hypotonia/spastic muscle) q Poor range of movement (active and passive) as a result of spasticity. q Abnormal postural patterns, reflexes and righting reactions. (Based on the above assessment findings, one can deduce the type of cerebral palsy ie. athetoid, hemiplegic, ataxic, spastic quadriplegic.) C) DEVELOPMENTAL MILESTONES q Head control (prone ,supine & sitting) q Trunk control q Mobility o Rolling o Pull to sit o Sitting o Creeping o Crawling o Pull to stand o Standing o Walking
q

Hand Function Hands to midline Reaching Gross grasp Releasing Manipulating objects Bilateral hand use

Functional Assessment Feeding Toileting Play General behaviour Patients should be reassessed at every contact and progress note should be noted on the patient file.

TREATMENT Monthly individual treatment should commence with clear explanation of childs condition, possible causes, effects and planned treatment for the child. Treatment entails the following but is not limited to the mentioned Positioning to facilitate normal movements and prevent contracture formation Stimulation to reach following developmental milestone ADL training Splinting if necessary Education of caregivers on management of a CP child Issuing of home programmes Assistance with regards to school placement Prevent contracture formation through passive exercises and stretching and massage. Normalisation of muscle tone through use of weight bearing and passive exercises. Encourage normal developmental patterns, through positioning and NDT. Teach caregiver correct positioning to carry over as a home programme. Useful with feeding and adapted play methods, in order to gain maximum sensory and motor stimulation. Use of pillows, CP chairs and wedges for positioning. Specially adapted play activities to encourage motor development and sensory stimulation. Wheelchairs or buggies are arranged for children with severe disabilities. Later stages, when child is able to sit independently, has bladder, bowel control and is able to focus, appropriate school placements are arranged. Provide positioning for various functional activities that is feeding etc. Provide assistive devices in terms of wheelchairs. Patients should be given home programmes - see attached on handling CP child

HOME PROGRAMME Please see attached booklets: q Handling a CP child q Activities for hand control q Home programme for self care activities i.e. dressing. LENGTH OF TREATMENT Therapy begins as soon as the child presents with delayed milestones or any abnormality in development. Therapy is a long, ongoing process. It largely comprises of out patient therapy and carry - over of treatment as home programmes. It is a teamwork approach, together with rehabilitative team, medical doctors and caregivers.

Compiled by: N. N. Tikilili Assistant Director: Occupational Therapy Date: September 2007 Date of review: September 2009

CVA OCCUPATIONAL THERAPY TREATMENT PROTOCOL OBJECTIVES To provide uniform Occupational therapy services for the patients with CVA / Stroke To assist patients with CVA/ Stroke in achieving maximal functioning level of independence To educate patients and their families regarding ongoing treatment and ensure consistent home management of the patient on discharge To assist patients and their families in adjusting to the disability and life changes PROCEDURE SCREENING AND ASSESSMENT The priority of assessment procedures should be determined by each individual patients needs. A full functional and physical assessment follows as soon as possible after the doctors first medical examination of the patient The OT must always be aware of the patients blood pressure and pulse rate during assessment. (the pt. should be full conscious and stable ) Important information relating to patients condition can be obtained from the patients bed letter, nursing personnel and other team members involved in the management of the patient The following information must be obtained during the initial screening and assessment: Background information Clinical history: current and previous medical history

 Social history: Family relationships, roles, lifestyle, support network, career and responsibilities. Environmental considerations : Accommodation , layout, adaptations needed, Functional Abilities: bed mobility, transfers, general mobility, self care, personal hygiene. Physical sensory impairments: tonal problems, pain, sensory problems and hemiplegia Cognitive impairments: short term memory, attention and concentration, executive functioning Perceptual difficulties: body image, dyspraxia, agnosia and unilateral neglect Communication difficulties: dysarthria, expressive and receptive aphasia Psychological impairments: mood, liability, adjustment to disability, feelings about self and others Motivation and attitude

TREATMENT PROTOCOL ON OT INTERVENTION WITH BURN INJURIES PURPOSE: To provide comprehensive assessment findings, formulate realistic patient treatment interventions in accordance to nature of injury. PROCEDURE ASSESSEMENT A) Background information (nature of injury, medical history and biographical information) B) PRE-FUNCTIONAL 1. Pain 2. Range of Movement 3. Muscle strength 4. Endurance 5. Function limited due to extent of burns C) FUNCTIONAL 1. Mobility 2. Self care (bathing, dressing, feeding, toileting, grooming) 3. Domestic work 4. Work

5. Interpersonal relationships 6. Leisure TREATMENT GOALS 1. Maintain joint mobility 2. Maintain general muscle strength and endurance 3. Maintain or improve functional ability 4. Promote psychosocial adjustment to pain and body image changes. 5. Improve pre-functional components 6. Prevent contractures (use of splints) 7. Scar management (pressure garments) Pressure Garments Early Stages Apply garment as soon as possible, usually 3-4 weeks after burn or grafting. The doctor usually recommends. Any open or tender areas can be padded or bandaged and the garment worn over this. The first garment is usually lined with a soft material and is not very tight. Intermediate stage The skin is stronger and no longer needs dressing. Garment tension increases. Rehabilitation Stage Garment tension is strong to decrease keloid/ scar formation. May need to make new garment every 3-4 weeks due to short lifespan omaterial PRESSURE GARMENTS Selection of Garment Design The following should be considered. Location of burn Location grafts/donor site

Stage of healing Tensile strength of healed burn

Wearing Regime 1. Should be worn 23-24 hours per day, only remove when bathing or eating (if wearing face mask) 2. Two sets of garments should be provided, ie. Wear one, wash one

3. Garments should be worn inside out to prevent seams from causing pressure sores. 4. Avoid rolling or creasing of the garment as this could cause swelling. 5. The tighter the garment, the more effective it is. Washing Regime 1. Hand wash in luke warm water using mild detergent 2. Don't wring or iron garments 3. Don't hang out to dry in the sun or in front of a heater. This is to prevent the elastic from perishing too quickly. Guidelines to patients on the use of pressure garments 1. Explain to patient purpose and importance of pressure garment usage. 2. Counsel patient on the consequences of non adherence to pressure garment therapy and provide booklet on pressure garment care. 3. If swelling or loss of sensation or cyanosis of the skin occurs, the patient must be advised to discontinue wearing and contact his/her OT as soon as possible. 4. Advise the patient that after several hours of wearing, the burnt areas may become darker in colour. This is a natural reaction to pressure on the skin and the patient need not become anxious over this. 5. Inform the patient hat blisters may sometimes occur during the healing process. These areas must be covered in padding before applying the garment. NOTE: blisters caused by application of pressure garments should result in discontinuation of pressure garment wearing. 6. If there is discomfort (eg in contracted areas), foam inserts may be applied. If this continues, the doctor may be consulted for contracture release. 7. If the patient should lose or gain considerable weight, it will reduce the efficiency of the garment or cause it to become too tight. Adjustments will need to be made by the therapist. 8. Advise patient not to use petroleum lotions or vitamin E oil while wearing garments as this reduces the efficiency of the garment by destroying the fabric elastic. 9. Advise patient on out patient follow-up Usually once a month for approximately 8 months. Thereafter, depending on progress, every 2-3 months All garments must be brought to any appointments so that all can be checked and altered if necessary.

Provide a contact telephone number should the patient experience any problems

Advise the patient that when the burn scar has matured and is no longer active , the garments be slowly discontinued, e.g. 12 hours on, 12 hours off

Home programme: Pressure garment care and usage Prescribed exercises

Massage technique for scar management

Compiled by: N. N. Tikilili Assistant Director: Occupational Therapy Date: September 2007 Date of review: September 2009

SPINAL CORD INJURY OT PROTOCOL OBJECTIVES: To provide uniform OT service to all patients with Spinal Cord Injuries (SCI) To assist the patients with a SCI to achieve and maintain maximum independence in their community, after being rehabilitated in a spinal unit PROCEDURE: The most important initial indicator: level of lesion (partial/ complete & stable/ unstable fracture of the vertebrae) ACUTE PHASE Physical assessment should include: Muscle strength ROM Endurance Hand function Posture Balance Bladder and bowel status Skin integrity(pressure points or areas) Neurological assessment should include: Sensation Muscle tone Reflexes Psychological assessment should include: Level of creative ability, where appropriate. Stage of grief Insight Support structure Taking the above assessment into account, the Therapist must plan the patient treatment. ACUTE PHASE: (SHOCK PHASE, IMMOBILIZED IN BED)

Ward rounds will be done with multi-disciplinary team discussing patient and treatment Immobilization stage: NO flexion, rotation or extension of spinal cord or neck Positioning: position to prevent shortening of muscles or contractures (specifically important for the muscles below SC lesion) Pressure care: position patient on ripple-mattress, sheepskin etc. if available Splinting: for high SC lesion anti-deformity splints Active ROM at joints, which are able to move Passive ROM at joints, which are unable to move Light ADL activities e.g. eating, writing and self care Assistive devices: universal cuff Psychological support: assist patient to develop insight into the diagnosis and prognosis

ACTIVE: (SITTING UP, MOBILIZATION AND REHABILITATION) Bed mobility and transfers Sitting in wheelchair: develop upright tolerance Wheelchair mobility training High priority in this phase should be pressure relief in different positions Start bladder and bowel regime in conjunction with the medical team Sexual counselling: see attachment on sexuality Active and passive ROM exercises should be maintained regularly to prevent contractures Splinting: continuous splinting, necessary (e.g. tenodesis splint) Static and dynamic balance in sitting Physical endurance and co-ordination, especially with C& T lesions Muscle strength: progressive resistive exercises and activities applied to innovative and partially innovative muscles Assistive devices and adaptive methods for ADL activities e.g. button hook, wash mitten, universal cuff, transfer board, adaptive dressing methods etc Psychological support & improvement of social skills and communication especially with caregivers and family members REHABILITATION PHASE: (PREPARATION FOR DISCHARGE) Work adjustments, home environment adaptations

Consultation with employer to discuss possible ways of accommodating patient in the workplace Family education Home visits, where appropriate Discharge patient with necessary assistive devices Follow-up at rehabilitation outreach clinic or OPD

COMPLICATIONS THAT COULD OCCUR DURING TREATMENT ORTHOSTATIC HYPOTENSION: due to lack of muscle tone in the abdomen and lower extremities, pooling of blood in these areas with resulting in decreased blood pressure when the patient suddenly changes position (especially supine to upright). The patient will present with dizziness, nausea and loss of consciousness. Patient needs to be tipped backwards and legs elevated until symptoms have subsided AUTONOMIC DYSREFLEXIA: this is a phenomenon seen in patients whose injuries are above T4-T6 level. It is caused by reflex reaction of the autonomic nervous system in response to some stimulus, such as a distended bladder, fecal mass, bladder irritation, rectal manipulation, thermal or pain stimuli, and visceral distension. The symptoms are immediate pounding headache, anxiety, perspiration, flushing, chills, nasal congestion, hypertension and bradycardia. Autonomic dysreflexia is a medical emergency and life threatening. The patient should not be left alone. It is treated by placing the patient in an upright position and removing anything restrictive such as elastic stockings to reduce blood pressure. The bladder should be drained or leg bag tubing should be checked for obstruction. Blood pressure and other symptoms should be monitored until back to normal. Occupational therapists must be aware of symptoms and treatment because dysreflexia can occur any time after the injury. If autonomic dysreflexia occurs during a treatment session, the therapist should position the patient upright and get a doctor immediately

Compiled by: N. N. Tikilili Assistant Director: Occupational Therapy Date: 12 September 2007

Date of review: September 2009

PROTOCOL ON THE ASSESSMENT AND TREATMENT OF A PATIENT WITH ARTHRITIS PURPOSE: To provide comprehensive assessment findings, formulate realistic patient treatment interventions in accordance to nature of injury. PROCEDURE ASSESSEMENT A) Background information (nature of injury, medical history and biographical information) B) PRE-FUNCTIONAL 1. Life style analysis 2. The OT gains clear insight into all activities of daily living of the patient and analyze those specific tasks, which result in

excessive stress to the joints. Assess how the working day can be re-structured in order to provide more rest and minimal activity. Determine patients support systems. Is the family willing to co-operate and take over chores at home? 3. Pain 4. Range of Movement 5. Muscle strength 6. Endurance 7. Hand Function 8. Balance C) FUNCTIONAL 1. Mobility 2. Self care (bathing, dressing, feeding, toileting, grooming) 3. Domestic work 4. Work 5. Interpersonal relationships 6. Leisure TREATMENT GOALS 1. Prevent joint stress , pain and deformity (Educate patients on joint protection principles)1 2. Maintain joint mobility 3. Maintain general muscle strength and endurance 4. Maintain or improve functional ability 5. Develop adaptation and problem solving skills to deal with changes to lifestyle. 6. Promote psychosocial adjustment to chronic disability, pain and body image changes. 7. Improve pre-functional components. 8. Prevent contractures 9. Mobility training (need for mobility aid e.g. wheelchair, walking aid) 10. 11. 12. Prevent contractures (use of splints) Assistive devices to aid with activities of daily living. Application of ergonomic principles.

13. Provide recommendations for adaptations to home environment

1

GENERAL PRINCIPLES 1. Never work beyond the patients pain threshold, i.e. Working within the limits of the pain is acceptable but the moment the intensity of the pain becomes worse with activity the patient should stop what s/he is doing. 2. Re-define your daily activities or routines with your OT, to ensure that they can include a work rest work process throughout the day. 3. Never perform activities which result in excessive stress to the affected joints, rather try another method or use other parts of the body to compensate e.g. instead of pushing self up from chair with wrists use forearms. Alternatively, where necessary get family members to take over those chores for the patient. 4. Always ensure that affected joints are resting in the most comfortable and normal position possible. At night place a pillow between knees and thighs of patient and pillows for forearm and wrist may also help to ease the pain. 5. Daily exercise routine based on exercises given by your Physiotherapist and Occupational therapist is important. Gentle walking on flat green grassy terrain and swimming are excellent activities. Home programme: 1. Implementation of joint protection principles 2. Practice energy conservation. 3. Ergonomic adaptation to home environment. Compiled by: N. N. Tikilili Assistant Director: Occupational Therapy Date: 12 September 2007 Date of review: September 2009

NEONETAL AND EARLY INTERVENTION PROTOCOL OBJECTIVE: To provide uniform OT services to all babies at risk To implement a programme for babies at risk in order to ensure that they receive optimal treatment PROCEDURE: Doctors at neonatal unit must refer babies with the following diagnoses to OT, using the OT referral form. o Babies with birth complications o Premature babies o Prolonged hospitalisation o CP o Congenital deformities/ birth defects o Hydrocephaly o Microcephaly o Erbs palsy o Klumpkes palsy The therapist then signs the referral form on the space provided, to indicate that the referral has been taken note of, and then assesses the baby within 24 hours of referral The Therapist opens a file for the baby where the referral and all the assessment forms will be kept For all babies, the Neonatal assessment form and developmental checklist will be used for assessment purposes After assessment, individual treatment takes place and then on discharge from the hospital, babies are referred to Early Intervention Clinic for follow up. Individual treatment will include: o Consultation / counselling about the condition/ problem to caregiver, as well as prognoses o Discussing treatment goals and what therapy will entail mainly promotion and preventative unless diagnoses require rehabilitative intervention o Discussing frequency of follow up sessions o Discussion on the role of caregiver in therapy o Explanation of basic stimulation areas and issuing the stimulation sheet o Give opportunity for questions and clarity o Book baby for EI Clinic o First follow up appointment must be approximately 1 month after being discharged from the hospital

 On each follow up visit, the baby must be reassessed according to

milestone development using the developmental checklist: 0 12 months Babies are seen until they are 9 months of age or discharged when normal trends of development are picked up on 3 consecutive visits The babies that get discharged from EIP must be noted and a discharge summary is to be given to the mother filled in duplicate, one copy filed in the department Babies over 9 months of age that still need to be followed up, will be discharged from EIP and booked for either CP clinic or individual therapy.

Compiled by: N. N. Tikilili Assistant Director: Occupational Therapy Date: 12 September 2007 Date of review: September 2009

FLEXOR TENDON INJURIES PROTOCOL In these injuries, the pulleys are supplied. They are applied to each of the fingers involved at the time of operation. The posterior slab is applied with the hand in position of function with the wrist in a neutral position. No dressing is applied over the fingers involved. Occupational therapy is instituted immediately to teach the patient to use the pulley, that is to allow the patient to extend his finger and pulley to flex the finger. Therapist will first assess the patient before teaching pulley. Therapist must open the file and record the findings as well as progress. When the patient is conversant with the technique, he is discharged if wound is clean. Weeks after the operation, the pulley, sutures and the plaster are removed. A protective plaster slab is applied to wrist in a neutral position. The patient is referred in a weeks time that is 1 month after operation, to occupational therapy department. Therapist must assess the patient again and can start with non-resistive exercises. After 6 weeks the therapist can do active resistance exercises. The therapist can assess the active and passive movements. The therapist can construct and design a splint. The patient may require active and passive splints for a reanalysis or any further treatment.

Compiled by: N. N. Tikilili Assistant Director: Occupational Therapy Date: 12 September 2007

Date of review: September 2009

EXTENSOR TENDON PROTOCOL OBJECTIVES: PROCEDURE: These injuries are normally caused as a result of trauma. Tendons involved are the following: EDC, EIP, EIP, EDM, EPL, EPB, ECRL, ECRB, ECU. The extensor tendons are divided into zones 8 zones The prognoses and treatment differs from one zone to the next

ZONE 1 AND 2: (DIP and middle phalanx) Injuries at this level are to the terminal extensor tendon and often leads to the development of Mallet finger deformity These injuries are sometimes repaired surgically, but often simple reapproximation of the tendon through immobilization allows the tendon to heal without surgical repair The DIP is immobilised for 6 weeks: either closed by means of splints or open with K- wires TREATMENT 0 6 WEEKS The DIP joint is immobilised in 0 to 15 hyperextension by means of a static splint The splint is worn continuously for 6 weeks post-injury (24 hours a day) The DIP joint should be kept in extension when the splint is removed to clean the hand. Exercises are performed to maintain range of movement of uninvolved joints. 6 7 WEEKS Initiate gentle AROM with emphasis

CARPAL TUNNEL SYNDROME PROTOCOL OBJECTIVES PROCEDURE Signs and symptoms Weakness or clumsiness in the use of the hands. Hyperaesthesia or Para aesthesia in the distribution of median nerves aggravated by use. Awakening from sleep with pain in the wrist or numbness of fingers Symptoms intermittent Proximal migration of pain might occur. + Phalen test any onset of numbness in less than a minute is considered diagnostic of carpal tunnel syndrome. + Tunnel sign ( median distribution) Decreased sensibility in the median nerve distribution and thenar atrophy are advanced signs Treatment / Conservative Splint the wrist in neutral position to be worn 24 hour a day for 4 weeks and thereafter only at night for another 4 weeks Patient is to avoid repeated wrist flexion Ultrasound (physiotherapy) No response is an indication for operative treatment Post operative treatment

Hand and wrist can be splinted in slight dorsi-flexion for 5 days Wrist flexion should be avoided for 10 days Reduce oedema with active mobilisation, elevation, compression, or contrast baths Scar management Activity modification Strengthening and back to work from 4 weeks post op Grip strength assessment and intervention from 6 weeks post op Sensation assessment and intervention from 3 months post op

BURNS PROTOCOL OBJECTIVES To provide uniform OT services for patients with burns conditions To assist patients with burns in achieving maximal functional level of independence To educate patients and families regarding ongoing treatment and ensure consistent home management of the patients after discharge PROCEDURE Upon referral, the Therapist has to check the history including severity and location of burns, need for splinting and positioning to prevent contractures. The therapist has to conduct an assessment on range available and functional abilities. The Therapist also has to start building rapport with the patient for emotional support. Treatment at this stage entails the following: - Education of staff and patient on correct positioning - Activities to encourage PROM to maintain joint range - Maintainance of available skills

PHASE 2: day 3 to a week a patient must attend OT daily for continuous assessment on ROM, muscle strength, sensation, motivation and emotional adjustment and treatment. Active movements start

BURNS PROTOCOL FOR BOTH ADULTS AND CHILDREN 1. IN PATIENTS PHASE ONE After admission day 1 of the patient the occupational therapist introduces himself/herself and briefly discuss the role of O.T, scare management, positioning and pressure garment. Therapist with team members attends ward rounds where appropriate referral will take place. Therapist can also do her /his informal ward rounds where appropriate referral in order to screen the patients. Therapist will assess the severity of the burns, correct positioning and determine the need for splinting where possible to prevent contractures and prevent joints from becoming stiff. Therapist will also maintain a full range of movements by doing passive movements. Building a relationship for later co-operation (emotional support). Education of patient and staff in the ward on importance of correcting positioning. Pictures can be put against the wall of the patient to remind the patient and nursing staff. Note must also be made in the file.

PHASE 2 Within 3 days to a week a patient will be attending Occupational Therapy treatment daily. Continuous assessments are done throughout their stay in hospital. These assessments include: range of movement, sensation, and muscle strength, conation (motivation and emotions). Healing of wounds. Therapist will start with active movements and exercises. Active and Passive movements helps with: active bold flow to help the healing process, decrease swelling, prevent stiffness

contracture joints, improve functional abilities to help the patient to be more independent, better endurance and maintenance of muscle strength, lessen the pain. Patients are treated individual or in a group through meaningful activities. Treatment in groups can be done in the morning or afternoon (Time for group depends on the therapist and ward schedule. Files are opened all information is recorded. SKINGRAFTS

First 7 days after skin graft there is no mobilization. Splinting should be done over major joints. After 7 days therapist can start with active movements.

2. OUT PATIENTS Patients should be given an appointment 4 weeks after discharge to come back to follow up. On this appointment the following should be checked: Range of movement in all affected limbs. Healing skin ( no open wounds can be covered with pressure garments) Measure the pressure garments (deduct 15% for adults and 10% for children in beginning phase) called the rule of 9. Patients are seen every 4 weeks for follow up until 4 months thereafter only every 8 weeks. Supply the patient with 3 garments and renew first set every 3 months if needed. Explain to the patient how to care for their garments. If the patients are not using the first sets, not to supply with more set until that they are using it 24 hours a day. Purpose of a pressure garment is growing, it helps to decrease scar hypertrophy, and prevent deformities. Discharge the patient if his hyperopic scar has been achieved. Pressure garments should be used for at least 24 months ( 2 yrs) if stopped to early hypetrophic scars can develop again

Compiled by: N. N. Tikilili Assistant Director: Occupational Therapy Date: 12 September 2007 Date of review: September 2009

AMPUTEES PROTOCOL

OBJECTIVES To provide a uniform OT services for all patients. To assist patients to achieve maximal level of function and independence in ADL within the limitations of their disabilities. PATIENTS REFERED TO OT Patients with the following conditions should be referred to OT Upper limber amputees Finger amputees Both unilateral and bilateral lower limber amputees WHEN SHOULD PATIENTS BE REFERED TO OT If possible all patients should be referred before amputation is done for correct assessment of their abilities and counselling, otherwise all should be referred as soon as possible after amputation. PROCEDURE All referred patients should be seen immediately Assessment should include the following: stump condition, position of the stump, psychosocial adjustment to amputation, range of movement, contractures, functional limitations and abilities. If patient is referred before amputation, counselling should be carried out to explain and prepare patient for amputation. OT management is as follows Upper limb amputations Correct stump bandaging Stump hygiene Positioning Patient education and counselling Balance and postural retraining Dominance retraining if necessary Functional retraining Sensory retraining/desensitization if necessary

Finger amputation Oedema reduction Patient educational counselling Hand function training

 ROM training Lower limb amputation Correct stump bandaging Stump hygiene Positioning Patient education and counselling Balance and postural retraining Dominance retraining if necessary Functional retraining Mobility retraining:- bad mobility - transfers - wheelchair training

patients are seen as both in and out patients

Compiled by: N. N. Tikilili Assistant Director: Occupational Therapy Date: 12 September 2007 Date of review: September 2009

ERBS PALSY PROTOCOL OBJECTIVES To provide uniform OT services in the management of babies with Erbs palsy To implement a programme where babies with Erbs palsy can receive treatment immediately and thus prevent permanent disability PROCEDURE Screening of all referred cases to include looking for the following symptoms: - Arm hangs limply. - Arm in internal rotation. - Forearm in pronation. - Fingers flexed. - Moro reflex and biceps jerk absent on affected side. Assess the babys range of movement in the shoulders and normal development of the baby. Educate the caregiver on what Erbs palsy is and what caused it. Show the caregiver how to do abduction-external rotation exercises. These exercises should be done at least 10 repetitions, 3 times daily. Both shoulders are abducted at 90, the elbows flexed at 90 and the dorsal surface of the arms should touch the surface of the bed. These exercises can be done every time the caregiver changes a nappy. Give follow up dates. If there is no improvement after 3 months refer the caregiver to orthopaedic surgeon for possible surgical intervention.

BACK PAIN PROTOCOL OBJECTIVES To provide a standard guide management of back pain. in the prevention and

PROCEDURE Identification of patients from wards and out patient department Referral to physiotherapy. Intervention: a. Education on: - Diagnosis and prognosis - Posture - Back saving principles in functional activities. - Ergonomics - Adjustments to home environment. - Use of assistive devices. b. Training on pain management strategies: - Relaxation therapy - Energy saving principles and day planning. c. Issuing of appropriate assistive devices Refer to orthopaedic center for orthosis e.g back brace. Refer to nearest orthopaedic clinic for intervention by orthopaedic surgeon if necessary.