Making the switch from working in a non-orthopedic setting like neuro or pediatrics to an acute orthopedic setting can be a challenge when you’re unfamiliar with joints.
It definitely was a hard change for me after almost solely working with neurological and outpatient geriatrics for the first year and a half of my career.
I was really unfamiliar with all of the precautions and the high pain levels, so I had to do a lot of self-teaching to get in the groove.
In this post, I wanted to make the transition easier for you by covering the biggest aspects occupational therapists encounter when working in the orthopedic setting.
You will read about the major joints in this post since they are the most common orthopedic diagnoses you will see in the acute, SNF, home health or inpatient rehab settings.
Please note that these are generalized precautions, and your patients may have different situations and needs. Also be sure to check the doctor’s orders in case anything is different.
This post includes mainly precautions with some home safety. A more in-depth home safety post will be coming soon.
Hip Replacement Surgery
Following a total hip replacement/arthroplasty, or other hip surgery following a fracture, your patient may have several precautions.
These can include weight-bearing precautions and/or anterior/posterior hip precautions. On the other hand, the individual may have no restrictions at all depending on the surgeon. If there are precautions in place, these are the main ones you will see.
- Non-weightbearing: 0% of body weight
- Toe-touching weight-bearing: Up to 20% of body weight
- Partial weight-bearing: 20-50% of body weight
- Weight-bearing as tolerated: This one is literally “as tolerated,” so it can be up to 100% if the patient is able to tolerate that.
- Full weight-bearing: 100% of body weight (Source: AboutJoints.com)
Anterior Hip Precautions
- No stepping backwards with surgical leg (lead with non-surgical leg when backing up to toilet, chair, etc.)
- No hip extension
- No external rotation (turning outwards) of the surgical leg
- No crossing legs
- Sleep on surgical side when side lying (Source: Duke Health)
Posterior Hip Precautions
- No bending the hips forward past a 90 degree angle (no forward flexion)
- No crossing the legs
- No twisting the hip or toes inward (Source: Aurora Health Care)
For a list of detailed pictures of these hip precautions and home safety measures, you can print out this Hip Precautions and Hip Safety Handout from St. Vincent’s Hospital in Birmingham, AL.
Whether the patient does or does not not have any specific precautions, a hip kit is recommended for lower body dressing due to the difficulty of bending forward to put on and take off shoes, socks, and pants.
The hip kits generally include a reacher, long handled shoe horn, long handled sponge, dressing stick and sock aid to prevent the patient from breaking precautions and making the task possible.
Knee Replacement Surgery
Total knee replacements will have less precautions to follow but are oftentimes more painful for the patient than hip replacements.
These tips can help increase the patient’s function and mobility following a total knee replacement.
- Always use the assistive device provided (usually rolling walker) until cleared by the doctor or physical therapist.
- When ambulating, lead with the walker, then the surgical leg, followed by the non-surgical leg, being sure to keep the walker close
- Keep the surgical leg elevated and extended with a towel roll under the heel when sitting or laying down
- Avoid twisting the surgical leg
- Avoid sitting in low chairs or surfaces. For example, use a bedside commode over the toilet or next to the bed as low toilets are more difficult to get up from following a knee replacement. Most insurance companies provide bedside commodes, but if not they can be purchased on Amazon. The patient can also purchase a raised toilet seat with handles if a bedside commode is not covered.
- Lower body dressing is usually difficult for knee surgeries as well, so the hip kit will also be invaluable for donning/doffing socks, shoes and threading pants.
Spinal surgeries, whether elective or not, may also be extremely painful for the patient the first few days. The general precautions are as follows, but do keep in mind they may differ for your patient.
Spinal Precautions (“The BLT’s”)
- No bending forward past 90 degrees
- No lifting over 5 or 10 pounds, depending on the doctor’s orders
- No twisting the trunk during any activities
- In addition to the BLT’s, instruct the patient to use the log rolling method during bed mobility tasks to avoid twisting the spine. This may take some repetition as patients forget this one more often than not and end up twisting when getting out of bed.
- If the patient is provided a brace, they must always wear it when out of bed until the doctor states otherwise. A really great intervention following the surgery is instructing them on putting it on without twisting.
For a great resource to provide your patients, you can print out this Activities of Daily Living After Spinal Injury or Surgery handout from the University of Washington Medical Center.
And along with the prior orthopedic surgeries, hip kits are invaluable to patients following spinal surgery or injury to adhere to spinal precautions and make dressing tasks achievable.
Shoulder replacements/arthroplasties are less commonly seen in the rehab setting since many of these patients go home shortly after the surgery. Many of these surgeries are only seen by physical therapists on an outpatient basis or 1-2 visits in the acute setting.
The general precautions immediately following shoulder arthroplasty are as follows, but may differ on an individual basis.
- Keep sling on affected arm for at least one week, including when sleeping. Some resources state to wear the sling for 4-6 weeks while sleeping and while entering the community
- No pushing up from affected upper extremity
- The sling may be removed gradually over the course of the week to move the elbow, wrist and hand several times a day, as well as during Pendulum exercises (if prescribed)
- No lifting objects heavier than a coffee cup
- While lying supine, place a small pillow or towel roll behind the elbow to avoid shoulder hyper-extension (Cleveland Shoulder Total Shoulder Arthroplasty/Hemiarthroplasty Protocol)
- No external rotation beyond 30 degrees in scaption (Source: TMI Sports Medicine)
ADL Education Following Shoulder Surgery
Along with the previous precautions, patients will also need to be cognizant of their operative shoulder during ADLs. Further education regarding ADLs can include these general precautions:
- No pushing up from chair, toilet, bed, etc. with the surgical arm for X amount of weeks (X = doctor’s recommendation)
- No hygiene tasks reaching back during toileting with operative arm until cleared
- Upper body dressing is generally the most challenging task after this surgery. The best way to educate your patient in completing upper body dressing is to wear button-up, loose fitting shirts and to not use operative arm during the task. To doff the shirt, start with taking the shirt off the non-operative arm first, then gently slide the shirt off of the non-operative arm.
- To don a shirt, start with the operative arm first by gently sliding the shirt onto it with the non-surgical arm, then pull the unaffected arm in, buttoning with the non-surgical arm. After the shirt is on, the sling can be applied.
- Use the non-surgical arm for all other basic ADLs until cleared (grooming, eating, bathing, dressing, cooking, etc.)
I hope this gives you basic crash course in working with your first orthopedic patients!
If you’re still feeling stuck or that you need more information on a particular joint, be sure to dig into your Pedretti’s Occupational Therapy: Practice Skills for Physical Dysfunction textbook or your Radomsky Occupational Therapy for Physical Dysfunction textbook, depending on what your school required. They both have really in-depth information on occupational therapy in the orthopedics setting.