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The Biomechanical Approach

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Kenneth Curtis

on 27 February 2014

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Transcript of The Biomechanical Approach

The Biomechanical Approach
Theories & Concepts
Case Study!
Take away points!
Domains of Concern and Key Principles
Applies the concepts of kinetics (study of how forces produce motion in body parts) and kinematics (study of motion of body parts) to occupational engagement

Main concern is on the musculoskeletal system and physical health.

Focuses on range of motion (ROM), strength, and endurance in regards to occupational performance

(Pedretti's, 2011)
Strengths & Limitations

Anatomy and physiology determine function.

Humans are biomechanical beings whose ROM, strength, and endurance have physiological and kinetic potential. (Smith, Weiss, Lehmkuhl, 1996).

Activities of daily living require a basic level of strength, endurance, & range of motion (Willard & Spackman, 2003).

Humans can participate in occupations efficiently when they are able to assume correct biomechanical positions and movements. (Rybski, 2004).

A clients limitations are amenable to change (Rybski, 2004).
ROM, strength and endurance can be objectively measured and it is
easy to track
Directly address the impairments
that limit occupational performance

~Dance like no one is watching!~
- The Biomechanical model is the best choice for everything.
Just kidding
! ...but it definitely has a time and place)

- Sometimes it is appropriate for OTs to take a more physical approach
as long as it is closely related to occupational performance
(e.g., Consider that 130 degrees of knee flexion might be required to participate in Tai Chi which the client values, the OT could set this as a reasonable goal)

- Biomechanical model is not usually used alone. This model is
usually partnered with other models
for a more holistic approach.
The Biomechanical Model
Primary authors: Baldwin, Taylor, Trombly, Licht

1. Hip Precaution Protocol

2. Post Surgery Exercises

3. Work Hardening (or equivalent)

What is the Biomechanical Model
Domains of Concern and Key principles
Theories, Concepts and Assumptions
Application of Model: Case Study
Function / Dysfunction
Evaluation & Assessment
Intervention Strategies

deterioration and
existing movement for occupational performance

A form of remediation to
movement for occupational performance

Objectives of the Biomechanical Model
Burroughs, B.R., Hallstrom, B., Golladay, G.J., Hoeffel, D., & Harris, W.H. (2005). Range of motion and stability in total hip arthroplasty with 28-, 32-, 38-, and 44-mm femoral head sizes. The Journal of Arthroplasty, 20(1), 11-19.

Cockburn, J.T., Thomas, F.N., & Cockburn, O.B. (1997).
Solution-focused therapy and psychosocial adjustment to orthopedic rehabilitation in a work hardening program
. Journal of Occupational Rehabilitation, 7(2),

Cuthbert, S., & Goodheart, G. (2007). On the reliability and validity of manual muscle testing: a literature review.
Chiropractic and Osteopathy
, 15(4), 4-15

Dutton, R. (1995). Biomechanical frame of reference. In Clinical reasoning in physical disabilities (pp. 29-80). Baltimore, MD: Willams & Wilkins

Enseki, K. R., & Berliner, M. (2013). Rehabilitation following total hip arthroplasty surgery. Topics in Geriatric Rehabilitation, 29(4), 260-26

Gilbey, H.J., Ackland, T.R., Wang, A.W., Morton, A.R., Trouchet, T., & Tapper, J. (2003). Exercise improves early functional recovery after total hip arthroplasty. Clinical Orthopaedics and Related Research, 408, 193-200.

Jackson, J., Gray, J.M & Zemke, R. (2002). Optimizing abilities and capacities: Range of motion, strength, and endurance. In Trombly, C.A., & Radomski, M.V. (Eds.), Occupational therapy for physical dysfunction (5th ed.) (pp. 463-480). Baltimore, MD: Lippincott Williams & Wilkins.

Kielhofner, G. (2009). The biomechanical model. In Conceptional Foundations of Occupational Therapy Practice (4th ed.) (pp.65-83). Philidelphia, PA: F.A. Davis Company.

McMillan, I.R. (2011). The biomechanical frame of reference in occupational therapy. In Duncan, E.A. (Ed.), Foundations for practice in occupational therapy (5th ed.) (pp. 179-193). London, UK: Churchill Livingstone Elsevier Ltd.

Pedretti, L. W. (1996). Occupational therapy: Practice skills for physical dysfunction(7th ed.). St Louis, MO: C.V. Mosby.

Areas for Assessments with Mr. Tran


(Burroughs et al., 2005)

Manual Muscle Testing
(Cuthbert & Goodheart, 2007)

6 Minute Walk Test
(Enseki & Berliner, 2013)

Range of Motion
· Active ROM: range of movement an individual can produce using voluntary muscle contraction
· Passive ROM: range of movement possible when an outside force moves a joint
· ROM allows bending, reaching, pulling, lifting, and grasping

· The power of a muscle to resist movement
· To perform optimally you must have adequate strength to do the tasks that make up our occupations

· Ability to sustain muscle activity
· Determines the extent to which someone can do the tasks that make up their occupational life

Client Population
Most effective with clients who have
orthopaedic disorders (ex. fractures, rheumatoid arthritis)
lower motor neuron disorders resulting in weakness and flaccidity (ex. peripheral nerve injuries, Guillian Barré Syndrome, polio, spinal cord injuries)
hand injuries
cardiopulmonary disease

Clients must have an intact brain and central nervous system to produce isolated, voluntary and coordinated movements (Rybski, 2004 )
Focus of Assessment
Assumption of the Model
Focus of evaluation and assessment in the biomechanical model:
Standardized objective tests of occupational performance
Self-report measures of how impairments limit occupational performance (e.g. DASH, Manual Ability Measure)
: active and passive ROM
Manual muscle tests
Dynamometry (grip and pinch strength testing)
Sensory testing (e.g. Semmes Weinstein Monofilament Examination, 2-point discrimination)
Coordination testing
Provocative tests (tests used to provoke underlying symptoms)
Circumferential or volumetric measures to quantify edema
Pain scales
Examination of skin integrity/wounds
Borg Rating of Perceived Exertion Scale (endurance)
Ergonomic evaluations
6 minute walk test
Successful human motor activity is based on physical mobility and strength.

Purposeful activities can be prescribed to remediate loss of ROM, strength, and endurance.

Activities can be graded progressively to meet particular demands within an intervention program.

Participation in activities involving repeated, specific, and graded movements maintain and improve function.

If ROM, strength, and endurance are regained, a client will automatically use these prerequisite skills to regain functional skills.

The principle of rest and stress; the body needs time to heal itself and then gradually add stress to the musculoskeletal and cardiovascular systems to regain normal function.
Types of Assessment
(Ashier, 1996; Ekes & Holm, 1997 in Rybski, 2004 table 11-2 p.148.)
To reduce the poor fit between the physical components of the person and the physical demands of the occupation.
Goals of Intervention

Maintenance and Prevention
: Avoid the development of a gap between an individual's functional ability and demands of a task or prevent the gap from getting larger

: Improving the capacity for motion, strength and endurance

Determining Intervention Goals

Intervention goals are determined based on the
residual potential
of the individual.

Residual Potential
is the capacity of an individual to increase their range of motion, strength, and endurance.

ADL retraining
Work hardening
Active, active assistive, passive ROM exercises
High-load brief stretch
Low-load prolonged stretch
Orthoses (static and dynamic)
Endurance training
Joint protection techniques
Physical agent modalities
Therapeutic exercise
Sensory retraining
Joint mobilization
Tendon gliding
Nerve gliding
Educating individuals about proper body mechanics

Types of Interventions
Hip Precautions

Educate Mr. Tran on the following hip precautions to prevent further injury.

Do not bend your hip past 90 degrees
Do not cross legs for at least 8 weeks
Do not twist on your operated leg
Do not jar your hip
Do not push or carry heavy items
Do not try to sit in bottom of tub for at least 3 months

(Ververeli, Lebby, Tyler, & Fouad, 2009)
Self Care: Bathing, dressing
Productivity: works as a delivery man
Providing for his family
Being a productive member of society
58-year-old man
Age related decline
High residual potential
Saving for retirement
Supportive role
Supporting children ages 18 and 21 who will likely be pursuing further education
Supporting wife and mother in law
PEO and Theoretical Approach
Capacity for movement and ability to produce adequate ROM, strength and endurance for activities.

Ability to produce effective biomechanical positions and efficient movement that positively impact occupational performance
Decreased capacity for movement and inability to produce adequate ROM, strength and endurance for activities.

Impairments to strength, ROM, coordination or endurance that negatively impact occupational performance.
(Rybski, 2004)
Post Surgery Exercises
Hip and knee bending
Lie on back
On operated side slide heel towards your buttocks
Keep knee cap pointing to the ceiling
Hold for 5 sec
10reps each leg
Work towards increasing number of sets and times/day.
Sideways leg slide
Lie on back
Slide legs as far apart as you can
keep knees and toes pointing to the ceiling
Hold for five seconds
10 reps
Work towards increasing number of sets and times/day
Partial squats
Stand upright holding onto walker
Distribute weight evenly between both feet
Slowly bend knees slightly
Return to full standing position
Repeat 10 times
Also want prevent upper body muscle wasting while recovering so may suggest upper body strength exercises such as bicep curls using soup cans.
Work Hardening
Energy Conservation
Add info or delete!
Case Study: Wrap Up
Improve Mr. Trans ROM, strength and endurance.

Evaluated by re-administering assessments.

Maintenance and improvement of biomechanical components to physically perform self care tasks (i.e., toileting, bathing and dressing) and work-related tasks.
The focus of intervention is on
individual clients' abilities
Activities used in intervention can be
non-purposeful and not engaging
since the
focus is on the physical performance
of occupation (risk of neglecting environmental, cognitive, & psycho-emotional aspects of occupational performance; Pedrettti, 1996)
Increases in ROM, strength and endurance
do not always translate to improved
occupational performance. (Dutton, 1995)
(Saskatchewan Surgical Initiative, 2012)
Poor Fits
- ROM + dressing LE
- ROM/strength + transfers (tub/toilet)
- Strength/endurance + work related tasks (hours, carrying, stairs)
- Pain + ADLs and iADLs
- Institutional environment (hip prec.) + occupational demands

Good Fits
- Cognitive components (problem solving, planning, memory) + occupational roles (caregiver, worker, etc.)
- Affective components (motivation) + occupational demands (work = pay)
- Social environment (family support) + ADLs and IADLs

Theoretical approach:
Physical approach (biomechanical)
Aims to progressively increase a client's strength and endurance [back] to a level where they can tolerate work-specific tasks.
Often exercises work similar muscles that a PT would address but tasks are more functional based.
Melissa Robinson, Dave Burzynski, Justin Krupa, Kenneth Curtis, Lindsay Sinclair, Hanin Al-Helo, Sarah Beaudin
(Kielhofner, 2009)
(Kielhofner, 2009)
(Kielhofner, 2009)
(Kielhofner, 2009)
(Cockburn, Thomas & Cockburn, 1997)
Pendleton, H.M., & Schultz-Krohn, W. (Eds.). (2011). Occupational therapy: Practice skills for physical dysfunction (7th ed.). St. Louis, MO: Mosby.

Rybski, M., & Van Ost, L. (2004). The biomechanical approach. In Kinesiology for occupational therapy. (pp.147-176) Thorofare, NJ: Slack.

Saskatchewan Surgical Initiative. (2012). Total Hip Replacement. Retrieved January 20, 2014 from http://www.sasksurgery.ca/pdf/hip-replacement-patient-booklet-aug2012.pdf

Schell, B.A.B., Gillen, G., & Scaffa, M.E. (2013). Motor function and occupational performance. In Cohn, E.S. (Ed.), Willard and Spackman’s occupational therapy (12th ed.) (pp.750-778). Baltimore, MD. Lippincott Williams & Wilkins.

Smith, L. K., Weiss, E. L., & Lehmkuhl, L. D. (1996). Brunnstrom's Clinical Kinesiology (5th ed.). Philadelphia: F. A. Davis Co.

Ververeli, P.A., Lebby, E.B., Tyler, C., & Fouad, C. (2009). Evaluation of reducing postoperative hip precautions in total hip replacement: A randomized perspective study. Journal of Orthopedics, 32(12).

(Gillen, 2013, p.754)
(Gillen, 2013, p.754)
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