Prevention Of Contracture Research Articles

Seniors rehabilitatin – clinical implications and therapy planning

<b>Introduction.</b> Aging is a natural and prevalent process. It concerns all organs and systems, even if there are no signs of pathology. At present there is no age limit which indicates specifically the beginning of senility. The border between physiology and pathology is blurred; consequently, the treatment of some geriatric diseases is difficult, especially when preventive measures have not been taken. Rehabilitation should focus on personal well-being of the patients and improving their quality of life. <b>Aim.</b> The aim of this article is to discuss issues concerning the planning of complex rehabilitation of geriatric patients and its management. <b>Materials and methods.</b> This article analyses selected clinical aspects of: osteoarthritis, osteoporosis, pulmonary and circulatory disturbances, prevention of bedsore and contractures in bedridden patients. The process of planning the therapy, including cardiologic and orthopaedic rehabilitation, is presented. The application of the Get Up and Go Test to evaluate patients’ fitness and the SMART principle when planning a rehabilitation course is proposed. Essential factors in a correctly planned therapy of geriatric patients are emphasised. <b>Discussion.</b> Due to scientific evidence confirming the efficiency of regular physical activity in the case of senior patients, they should be motivated to undertake physical exercises and to cooperate. Rehabilitation aims at: improving general well–being, allowing to maintain an independent way of life, reducing the risk of some diseases and easing their course, reducing pain and disability effects. Complex geriatric rehabilitation concerns every patient in terms of motion ability, pain release, as well as psychological and social spheres of life. Properly conducted and systematically undertaken physical activities can improve physical and mental health of senior patients, even though they do not stop the aging process itself. Orthopaedic devices for geriatric patients decrease their disability. Improvement in motor functioning, personal care skills and independence restores patients’ self-confidence, reinforces their social and cultural integration and allows them to become professionally active again. <b>Conclusions.</b> Geriatric patients suffer from various diseases and require personalised rehabilitation. A well planned rehabilitation and physical therapy program should include all factors influencing the quality of life of such patients and should provide rehabilitation aims. Rehabilitation should be long-termed, complex and involve elements of prophylactics.

Development and prevention of ischemic contracture ("stone heart") in the pig heart.

Stone heart (ischemic contracture) is a rare and serious condition observed in the heart after periods of warm ischemia. The underlying mechanisms are largely unknown and treatment options are lacking. In view of the possibilities for cardiac donation after circulatory death (DCD), introducing risks for ischemic damage, we have investigated stone heart in pigs. Following cessation of ventilation, circulatory death (systolic pressure <8 mmHg) occurred within 13.1 ± 1.2 min; and a stone heart, manifested with asystole, increased left ventricular wall thickness and stiffness, established after a further 17 ± 6 min. Adenosine triphosphate and phosphocreatine levels decreased by about 50% in the stone heart. Electron microscopy showed deteriorated structure with contraction bands, Z-line streaming and swollen mitochondria. Synchrotron based small angle X-ray scattering of trabecular samples from stone hearts revealed attachment of myosin to actin, without volume changes in the sarcomeres. Ca2+ sensitivity, determined in permeabilized muscle, was increased in stone heart samples. An in vitro model for stone heart, using isolated trabecular muscle exposed to hypoxia/zero glucose, exhibited the main characteristics of stone heart in whole animals, with a fall in high-energy phosphates and development of muscle contracture. The stone heart condition in vitro was significantly attenuated by the myosin inhibitor MYK-461 (Mavacamten). In conclusion, the stone heart is a hypercontracted state associated with myosin binding to actin and increased Ca2+ sensitivity. The hypercontractile state, once developed, is poorly reversible. The myosin inhibitor MYK-461, which is clinically approved for other indications, could be a promising venue for prevention.

Implantation and tracing of green fluorescent protein-expressing adipose-derived stem cells in peri-implant capsular fibrosis

BackgroundAdipose-derived stem cells (ASCs) have been reported to reduce fibrosis in various tissues. In this study, we investigated the inhibitory role of ASCs on capsule formation by analyzing the histologic, cellular, and molecular changes in a mouse model of peri-implant fibrosis. We also investigated the fate and distribution of ASCs in the peri-implant capsule.MethodsTo establish a peri-implant fibrosis model, customized silicone implants were inserted into the dorsal site of C57BL/6 wild-type mice. ASCs were harvested from the fat tissues of transgenic mice that express a green fluorescent protein (GFP-ASCs) and then injected into the peri-implant space of recipient mice. The peri-implant tissues were harvested from postoperative week 2 to 8. We measured the capsule thickness, distribution, and differentiation of GFP-ASCs, as well as the cellular and molecular changes in capsular tissue following ASC treatment.ResultsInjected GFP-ASCs were distributed within the peri-implant capsule and proliferated. Administration of ASCs reduced the capsule thickness, decreased the number of myofibroblasts and macrophages in the capsule, and decreased the mRNA level of fibrogenic genes within the peri-implant tissue. Angiogenesis was enhanced due to trans-differentiation of ASCs into vascular endothelial cells, and tissue hypoxia was relieved upon ASC treatment.ConclusionsWe uncovered that implanted ASCs inhibit capsule formation around the implant by characterizing a series of biological alterations upon ASC treatment and the fate of injected ASCs. These findings highlight the value of ASCs for future clinical applications in the prevention of capsular contracture after implant-based reconstruction surgery.

Comparing Polyurethane and Acellular Dermal Matrix Implant Cover in Prepectoral Breast Reconstruction: Short-term Complications.

The authors retrospectively reviewed patients undergoing prepectoral direct-to-implant reconstruction from June 2018 to January 2022. Two cohorts were defined based on the interface material used: ADM versus PU. Total drainage volume, time to drain removal, and acute complications (hematoma, seroma, infection, and explantation) were analyzed. Forty-four breast reconstructions were performed in 35 patients (10 bilateral); implants were covered with ADM in 23 cases and with PU foam in 21. Median total drainage volume (500 versus 515 cc for ADM and PU, respectively) and time to drain removal (9 versus 8 days) were not affected by the interface material used, but seromas and infections occurred exclusively in the ADM cohort (seromas in four of 23 of cases, P = 0.109; infections in three of 23 cases, P = 0.234). Overall complications occurred more often in cases reconstructed with ADM, but the difference was nonsignificant (P = 0.245). The use of interface materials is generally considered a prerequisite for state-of-the-art prepectoral breast reconstruction for a variety of reasons, including the prevention of capsular contracture. In this study, PU coating tended to be associated with fewer short-term complications than ADM, including seroma and infection.

From ancient Egypt to the dermatologic office: An overview of skin substitutes and modern-day applications in dermatologic surgery.

Skin grafting (specifically xenografting) dates back to as early as 1500 before Christ (BC)in the Ebers papyrus, an Egyptian medical papyrus.In 1503, the use of human skin allograft was described in the manuscript of Branca of Sicily, and among the Hindu Tilemaker Caste approximately 2500-3000 years ago, surgeons repaired defects secondary to nose amputations of those who committed adultery and thievery. Over the years, many advancements in skin grafts/substitutes and their applications have propelled the field to focus on better graft survival, contracture prevention, cosmesis, and quality of life.We provide a general overview of skin substitutes (SS) with a particular focus on placental SS and their current applications in dermatologic surgery.

Challenges in surgery of deep burns

Introduction. Full-thickness burns pose a significant challenge in terms of surgical management, particularly when concurrent trauma of other organs is involved. Traditional treatment of deep burns includes early excision or debridement of necrotic tissue, followed by skin grafting or flap reconstruction. There are numerous challenges such as poor overall general condition, polytrauma, questionable wound bed viability, limited donor sites. Thus, we have to consider skin substitutes. INTEGRAR is an acellular dermal substitute which creates a native dermis. The aim of this case was to share our experience of the treatment by skin substitutes in a polytraumatized burn patient. Case outline. We present a case report of a 46-year-old man with severe work-related contact burn wounds associated with multiple rib and vertebral fractures, as well as lungs contusion with localized bilateral hemothorax. Patient suffered from third-degree burns to the lower extremities, extending to scrotal and gluteal area, which included 15% of the total body surface area. The patient underwent early excision of necrotic tissues with subsequent skin autografting on the right leg; however, due to partial failure of autografts, we had to perform allografting followed by autografting because of limited local donor sites and poor general condition. Successive debridement and partial osteotomy resulted in the left knee defect with exposed patella. Therefore, in order to reconstruct the consequent defect and prevent joint contracture, the defect was finally covered by INTEGRAR. Conclusion. Our experience has highlighted that INTEGRAR prevents functional disability and furthermore, it leads to optimal aesthetic results.

Residual limb support devices on wheelchairs for people with transtibial amputations: A scoping review and survey of rehabilitation professionals in Nova Scotia.

To determine what research evidence exists for the use of residual limb supports (RLSs) for people with transtibial amputations and to describe clinicians' use of such supports in Nova Scotia. Scoping review of published and gray literature using Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews as a guide and an anonymous online and paper-based clinician survey. We identified 22 publications meeting criteria for review. Seventeen (77%) of the publications were practice guidelines or systematic reviews about care of people with lower-limb amputations, 4 (18%) involved research about the design of stump supports, and 1 (5%) researched the use of supports. Generally, the use of RLSs was recommended (e.g., to prevent contractures, control edema, and to provide comfort), but many authors acknowledged that the evidence was weak, and additional evidence in support of these treatment goals could not be found. We received 44 survey responses from health care professionals involved with the care of people with transtibial amputations in Nova Scotia. Of the 43 health care professionals who responded to the question "… what percent of patients/clients with transtibial amputations do you estimate receive stump supports …," the mean (standard deviation) was 86.1% (21.1). The most common reasons for recommending a stump support were to prevent knee contracture (38 [86.4%]), and to prevent swelling (13 [29.5%]). Most clinicians who provide services to people with amputations in Nova Scotia believe that RLSs have benefits such as the prevention of contractures, the reduction of edema, and improved patient comfort. However, there is little high-quality research evidence to support their use. There is a need to perform the necessary research or to modify practice guidelines.

Study of the effectiveness of the experimental model of immobilization contractures in rats

Immobilization contractures are a common complication that can arise following prolonged immobilization of a joint or limb. They occur due to a combination of factors, including muscle atrophy, joint stiffness, and tissue adhesions. The aim of the study was to study the effectiveness of the experimental model of immobilization contractures in rats. The experimental study was conducted on 21 non-linear white male rats aged 6 months. We used 4-week plaster immobilization to evaluate the severity of changes in the knee joints of experimental rats. The immobilization and post-immobilization period in our study lasted 4 weeks each. Every week, the angles of extension and flexion, range of motion and severity of contracture were measured. During the period of immobilization, there was a progressive impairment of the function of the immobilized knee joints of all experimental animals. Thus, at the end of the 4th week of immobilization, the limits of flexion and extension on the immobilized limb gained high statistical significance in comparison with both the opposite intact limb and with 1st week of immobilization. In the post-immobilization period (from the 5th to the 8th week of the study), a progressive recovery of the studied indicators was observed. The indicators of extension and flexion of the limbs after immobilization were significantly differed from the initial values, but were also significantly better than the values at the end of the immobilization period. As for the range of motion, this indicator for both limbs was significantly higher than the values at 4th week of the study, but was also significantly lower than the initial values. Limitation of movements after immobilization was statistically significant both when compared with the opposite limb and when compared with baseline and 4th week of immobilization data. Experimental model of 4-weeks plaster immobilization of the knee joint allows to create a persistent pronounced limitation of movements and can be used for further study of various methods of prevention and treatment of immobilization contractures. Keywords: knee joint; immobilization contractures; experiment; rats.

Sex-specific role of myostatin signaling in neonatal muscle growth, denervation atrophy, and neuromuscular contractures.

Neonatal brachial plexus injury (NBPI) causes disabling and incurable muscle contractures that result from impaired longitudinal growth of denervated muscles. This deficit in muscle growth is driven by increased proteasome-mediated protein degradation, suggesting a dysregulation of muscle proteostasis. The myostatin (MSTN) pathway, a prominent muscle-specific regulator of proteostasis, is a putative signaling mechanism by which neonatal denervation could impair longitudinal muscle growth, and thus a potential target to prevent NBPI-induced contractures. Through a mouse model of NBPI, our present study revealed that pharmacologic inhibition of MSTN signaling induces hypertrophy, restores longitudinal growth, and prevents contractures in denervated muscles of female but not male mice, despite inducing hypertrophy of normally innervated muscles in both sexes. Additionally, the MSTN-dependent impairment of longitudinal muscle growth after NBPI in female mice is associated with perturbation of 20S proteasome activity, but not through alterations in canonical MSTN signaling pathways. These findings reveal a sex dimorphism in the regulation of neonatal longitudinal muscle growth and contractures, thereby providing insights into contracture pathophysiology, identifying a potential muscle-specific therapeutic target for contracture prevention, and underscoring the importance of sex as a biological variable in the pathophysiology of neuromuscular disorders.

A nonsurgical approach in management of burns induced microstomia: a review

Burns of head and neck region causes skin contracture which will result in microstomia and loss of skin flaccidity. The prevention and management of microstomia contracture is an important aspect of facial burn. The goal of microstomia repair include the reconstruction of orbicularis sphincter for adequate lip functioning, obtaining lip symmetry and well positioned scar and adequate mouth opening. The standard treatment for the prevention and management of contracture includes compression therapy, grafting, mouth splinting, scar massage, excercise, patient education. These types of maxillofacial prosthetic appliances may be indicated, in conjunction with or without surgery these appliances can be use to improve the reduced mouth opening caused by burns or other traumatic injuries With proper education and motivation of operator and the patient use of these appliances will not only improve the reduced mouth opening but also improve form, function, esthetics, and also enhance the patient’s quality of life.

Anterior Interosseous Nerve Syndrome.

Anterior interosseous nerve syndrome (AINS) is a rare form of peripheral neuropathy which involves disruption of the anterior interosseous nerve. The pathophysiology of AINS remains unclear. AINS typically initially presents with forearm pain and may gradually progress to palsy of the deep muscles of the anterior forearm. Diagnosis of AINS requires thorough patient history and physical exam. EMG is the preferred diagnostic study and classically reveals abnormal activity and prolonged latency periods within the evoked action potentials of the FPL and PQ. Due to the self-limiting nature of AINS, there is general agreement that conservative and symptomatic management should be explored for up to 6 months as first line therapy, which usually includes analgesics and nonsteroidal anti-inflammatory drugs, contracture prevention, hand therapy, and hand splinting. Surgical options such as internal neurolysis and minimally invasive endoscopic decompression may be explored if functional recovery from conservative management is limited.

Seek and you shall find—retrieval of a retained fractured intravenous cannula by Z-plasty incision: a case report

Peripheral venous cannulation is a common invasive procedure. Fracture of an intravenous cannula is rare and an under-reported complication of peripheral venous cannulation. Embolization of the intravenous fragment into the central venous system is potentially fatal. Urgent surgical retrieval, which is performed through a transverse or longitudinal incision, is the treatment of choice. We herein present the use of Z-plasty incision for the retrieval of a retained fractured peripheral intravenous cannula in a 61-year-old Nigerian man on hemodialysis for chronic kidney disease. The major benefits of this innovation are facilitation of access for exploration and prevention of joint contracture.

Bridging the Gap between Clinical Service and Academic Education of Hand-Splinting Practice: Perspectives and Experiences of Thai Occupational Therapists.

A gap in knowledge about current splinting practice exists between the educational program and clinical service. To bridge this gap, we investigated the perspectives and experiences of Thai occupational therapists regarding contemporary hand splinting practices in clinical use. A mixed-method study was designed. An explanatory sequential mixed methods design was used. In the first quantitative phase, a survey questionnaire was mailed to occupational therapists. The questions were regarding contemporary hand splinting practices in clinical use at seven hospitals in the capital city of Bangkok and outskirt areas. In the second phase, semi-structured interviews were completed to explore expert occupational therapists’ perspectives on practice in the same hospital settings. Transcripts were analyzed using thematic analysis. The results showed that most conditions receiving splints were nerve injuries, orthopedics, and stroke, which represented the service frequency of splint types: functional resting (100%), cock-up (93.3%), and thumb spica splints (80%). Bone and joint deformity prevention ranked first with muscle contracture prevention being ranked second, and the third-ranked was maintaining range of motion. Three themes emerged from the interviews: starting with the patient condition; effective function and value; knowledge and experiential skills. Perspectives and experiences of occupational therapists in splinting practice contribute to education based on the reality of practice. Integrated numerical and textual data of professional skills and knowledge in actual splinting practice can be reflected through splints and orthoses program revisions to meet future learning outcomes.

Comparison of the effect of Range of Motion exercises versus stretching techniques in prevention of burn contractures of upper limb; RCT- A Randomized clinical trial

Background: Burn is an injury which affects approximately all systems of body and is very common among accidental injuries which causes burden on hospitals. A lot of treatment interventions are introduced until now for the management of burn to lessen complications and increase quality of life in survivors. Methodology: Forty-eight patients who complete selection criteria were included in this study. Written informed consent was obtained from every participant in this study before starting any physical examination. Participants was allocated into two groups randomly. On 1stday range of motion at involved joints was assessed using goniometry. Group A is treated with stretching techniques, while group B is treated with Range of Motion exercises. Conventional treatment for both groups’ participants includes isometrics exercise and anti-contracture positioning. Treatment frequency was 3 times a week. Results: Comparison of all upper extremityjoint movements at baseline and 4th week has shown that there was a significant difference between post treatment range of motion with p value of less than 0.05 showing that group A is more effective in improving shoulder flexion after burn injury.Comparison of mean of all measured range of motions in group A and B was 57.08 degree ±28.29 and 59.25 degree±33.52 in pre-treatment and 96.66 degree ±36.35 and 81.49 degree ±33.10 post-treatment. Conclusion: Stretching techniques are more effective in the prevention of post burn contractures than Range of Motion exercises, as more improvement was noted in range of motion at joints of upper limb in patients after stretching. Keywords: ROM (Range of motion), RCT (randomized controlled trail)

What's New in Orthopaedic Trauma.

What's New in Orthopaedic Trauma.

The Role of Verteporfin in Prevention of Periprosthetic Capsular Fibrosis: An Experimental Study.

Capsular contracture (CC) characterized by excessive fibrosis is one of the most common complications after silicone implant surgery. Verteporfin (VP), an inhibitor of Yes-associated protein 1 (YAP1), has recently been found to reduce the fibrotic process. The aim of this study was to use an in vivo rabbit model to evaluate the efficacy of VP for the prevention of CC. Twenty-four New Zealand rabbits received 10-cc smooth saline silicone implants inserted in the dorsal skin and were randomly divided into 2 groups to receive 2 mL VP (1.5 mg/mL) or 2 mL phosphate-buffered saline solution instillation in the implant pocket. When the animals were killed on Day 60, capsule formation was observed both macroscopically and microscopically. Histologic evaluation included capsule thickness, fibrosis degree, and myofibroblast (α smooth muscle actin positive) content. In addition, the YAP1 expression level was examined by immunofluorescence staining. Transforming growth factor β1, collagen I, and connective tissue growth factor expression were measured by real-time quantitative polymerase chain reaction. The VP-treated group exhibited thinner, more transparent capsules and less fibrosis than the control group at 60 days postsurgery (P < 0.05). Moreover, the VP treatment significantly reduced α smooth muscle actin, YAP1, transforming growth factor β1, collagen I, and connective tissue growth factor expression levels in the capsular tissues (P < 0.05). VP reduced capsule formation after silicone implantation by inhibiting YAP1-mediated mechanical signaling, thereby attenuating excessive collagen deposition in the rabbit model. This preclinical study may provide a feasible strategy to prevent periprosthetic capsular fibrosis in clinical application.

Complete Implant Wrapping with Porcine-Derived Acellular Dermal Matrix for the Treatment of Capsular Contracture in Breast Reconstruction: A Case-Control Study.

BackgroundCapsular contracture (CC) represents one of the most common complications in breast reconstruction surgery, impairing final result and patients’ well-being. The role of acellular dermal matrixes (ADM) has been widely described for the treatment and prevention of contracture. The aim of the study was to evaluate the efficacy and safety of complete implant coverage with porcine-derived ADM in preventing CC limiting complications. In addition, patients’ reported outcomes were evaluated in order to define the role of ADM in improving sexual, physical and psychosocial well-being and satisfaction.Methods42 patients who underwent surgical treatment of 46 contracted reconstructed breasts from May 2018th to May 2019th were collected in the two groups (ADM group vs. Control group).ResultsThe ADM group showed lower rate of CC recurrence and a higher rate of implant losses and minor complications. A significant difference was observed in red breast syndrome (27.3% in the ADM group vs. absent in control the group) and skin ulceration rates (18.2% in the ADM group vs. 4.18% in the control group). As for patients’ perceived outcomes, the ADM group showed a statistically significant higher postoperative Satisfaction of Breast Scale score compared to the control group. In addition, a significant difference was observed in the improvement of Physical Well-Being of the Chest Scale and the Satisfaction of Breast Scale after surgery, in favor to the ADM group.ConclusionComplete implant coverage with ADM may reduce the risk of CC recurrence in breast reconstruction. An accurate patient selection allows minimizing complications improving patient well-being and satisfaction.Level of Evidence IVThis journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

577 Expanding Outpatient Burn Therapy Services to Address Social Determinants of Health

IntroductionOccupational and Physical Therapist provide acute services to burn-injured patients and continue treatment well into their functional recovery for mobility, strengthening, scar management, contracture prevention and return of independence. Unfortunately, we recognized that patients encountered obstacles when attempting to access these services in the outpatient setting. It was evident that these impediments frequently coincided with social determinants of health (SDOH). According to Healthy People 2020, SDOH represent the cumulative influences of individual, cultural, community and societal attributes on health and quality-of-life. Self-pay patients accounted for 12% of clinic patients. However, patients with coverage were not always receiving adequate therapy due to lack of burn knowledge among community-based therapist. By expanding outpatient burn clinic services, we are better positioned to meet the needs of all burn-injured patients in our community.MethodsA plan was outlined to increase the presence of Occupational and Physical Therapy (OT/PT) in the outpatient burn clinic. Pertinent literature was reviewed, and a presentation was developed to establish need and outline a model for integration of services. The inpatient OT/PT department managers collaborated with the Burn Director and Burn APRN on projecting staffing and equipment needs. Multidisciplinary cost analysis was completed. Guidelines for outpatient burn rehabilitative therapy staffing and a description of services were developed.ResultsAfter much collaboration and effort, and with community support, our PT/OT inpatient burn staff provide rehabilitative therapy to all patients attending outpatient burn clinic two days weekly. Additionally, educational material, hands on range of motion training and free new and donated compression garments are readily available during all four burn clinics weekly. The new outpatient burn clinic opened in 2021, equipped with two large showers and a designated therapy room, ready to wear compression garments, putty, and assistive devices designed to further support burn recovery. Attendance for burn outpatient visits increased significantly from 2015 to 2018.ConclusionsTransportation, childcare, employment restrictions, individual health and wellness beliefs, lack of funding and access to technology represent examples of blockades to healthcare care. This multidisciplinary effort increased the availability and scope of rehabilitative services in the outpatient burn clinic patient, allowing patients to receive comprehensive burn wound care and rehabilitative therapy in one location to promote healing, manage pain, improved function, maximizes independence and reintegrate into their family and community.

588 Utilizing a Quality Improvement Approach to Increase Compliance with Patient Positioning in the Burn Unit

IntroductionPatient positioning, notably positioning patients in “anti-deformity positioning”, is a standard practice in burn rehabilitation as it assists with edema management, scar contracture prevention, and wound healing. Successfully and consistently providing proper positioning of burn patients requires the combined effort of the multi-disciplinary burn team. The primary goal at our center was to increase the frequency that patients were correctly positioned to over 90% at the time of random audits.MethodsAt a medium-sized, academic burn unit, once to twice weekly audits were conducted by burn lead therapists on the compliance of proper patient positioning over a 6-month period. Using this data as a trigger, a quality improvement project was designed using the PDSA (Plan-Do-Study-Act) cycle to help identify reasons behind lack of compliance. Surveys were distributed to the therapy and nursing staff to identify any barriers to care. Effects on positioning compliance post-intervention were monitored.ResultsIn the 6 months prior to intervention, our patients were positioned correctly an average of 76% of the time. Therapy and nursing surveys identified the following barriers to care: Nursing needed more education on positioning, and the approach was too heavily reliant on nursing efforts alone. To address these barriers, therapists provided education to both day and night shift nurses, communicated daily about positioning expectations, shifted the project from a nursing approach to a multidisciplinary approach, and made changes in therapy workflow. Immediately following the intervention, the compliance rates were 91% for the first month and 85% for the second month.ConclusionsCoordinating efforts of the entire burn team improves consistency for positioning in burn patients. Utilizing the PDSA cycle allowed us to identify areas for improvement and to develop appropriate interventions aimed at both increased education for nursing staff and workflow improvements for our therapists. Following the completion of our interventions we were able to obtain an immediate improvement in our compliance with proper positioning of burn patients.

Dysvascular Transtibial Amputation Due To Artery Stenosis: A Case Report Study

Below-knee (BK) amputation is one of the most commonly performed actions in dysvascular cases, but rare caused by arterial stenosis. Those had significant impacts on clinical functions and affect the contralateral limb, so its need adequate supervision during rehabilitation programs. The report are to describe the stump wound healing of the patient after amputation surgery, stump preparation at pre-prosthetic phase, prevention of knee contracture, prosthetic preparation and use, gait training and evaluation of unaffected limb. A 44-years old female with right below-knee amputation caused by stenosis of right peroneal and dorsalis pedis artery, and the wound in the residual limb was not healed within 4 weeks. She got rehabilitation to accelerate stump healing and stump shaping, maintain knee flexibility, muscle strengthening, cardiovascular endurance, transfer and ambulation. She had good compliance to the programs and achieved independent ambulation using the prosthetic within 6 months. Improvement in residual limb healing within 6 weeks, pain reduction from VAS score 3 to zero, and stump shape changes from buldging to conical. And also in knee joint range of motion, transfer ability, gait pattern using BK prosthetic (by modifying shoe components), and the patient's ability to carry out ADL (BI score 75 to 100). Laser therapy, stump shaping, flexibility exercise, strengthening exercise, endurance exercise, ambulation exercise and prosthetic use on transtibial dysvascular amputation showed good results for ADL. Careful examination to the unaffected limb could identify early occurence of stenosis. Early intervention could prevent future ischaemia and amputation.