Acute Ax and Rx Flashcards
How will patients feel
- Scared
- Anxious
- Tired
- Hungry
- Thirsty
- Disorientated
Plus their family members will have the same emotions
How will the subjective be affected
Consent & goals - in best interest
PC,HPC,PMH,DH - medic, nursing notes, GP, etc
SH & SQ - from family and friends
Communication and consciousness - not looked at
How will the objective Ax be affected
Observation - of AROM, functional assessments (rolling, L-S, Sitting balance)
PROM - encourage AROM/functional assessments
Strength, special tests - will not be assessed
ADD respiratory assessment - basic observations to ensure stable to mobilise, auscultation
Trunk observation in sitting (functional Ax)
- Symmetry/muscle activity/curves
- Weightbearing
- Level of pelvis
- Skin creases
- Levels of scapulae
- Levels of shoulders
- Arm position
- Head position
Trunk AROM in sitting (functional Ax)
- Ant/post pelvic tilt with flex/ext of trunk
- Lateral pelvic tilt with side flex of trunk
- Combination
- With arm reaching
- Righting reactions – head and trunk
- Not flexion/extension/side flexion/rotation
Trunk PROM in sitting (functional Ax)
- Passive movement of trunk/pelvis with one and two people
- Repeat AROM but do as passive as possible
Think about:
• Where you put your hands
• Speed
• Range
• Support
• Resistance
What would you observe in an ataxic trunk
What would you observe in sitting? Lack of stability - swaying, uneven weightbearing
What would you observe with movement? Poor co-ordination and smoothness of movement, abrupt weight transference
What is an acute illness
An illness with rapid or abrupt onset generally with short, severe course requiring prompt treatment
What are joint Ax
Ax often done with OTs = joint Ax
You need to decide who assesses what but generally the OTs will ask the subjective assessment and the PTs will do the physical assessment (although OTs may do the UL assessment)
In the community you may take on a generalist assessment which might involve assessment of nursing skills such as skin integrity and continence.
Advantages of joint assessments – the patient is not answering the same questions over and over again and repeating the same tasks
Name the neurological acute conditions
TBI
CVA
SCI
MS flare-up
Guillain-Barre syndrome
What is the medical management of an acute stroke (RCP guidelines 2016)
– Stroke is a “medical emergency”
– Everyone with acute stroke should be admitted to a hyperacute stroke unit within 4 hours of arrival to hospital
– Brain imaging within 1 hour of admission
– Thrombolysis (thrombus breakdown) – Alteplase
– Thrombectomy (thrombus removal)
– Asprin – anticoagulants
– Management of blood pressure
– Management of hydration
– Maintenance of oxygen levels
– Treatment of co-existing medical condition
What are the aims of acute neuro-rehabilitation
- Means of communication - Discuss with SALT/family/give them time
- Prevent secondary respiratory complications - Positioning/sputum clearing techniques/mobilisation(!)
- Prevent development of pressure areas - Positioning (every 2-4 hours)/splinting, mattresses
- Identify means of nutrition / hydration - Liaise with nurses and dietician (vital for maintaining BP and pressure care)
- Maintain muscle length and joint range of movement - PROM/soft tissue mobs/joint mobs/positioning/splinting
- Prevent secondary MSK problems: Prevent contractures (mainly tendons) and deformities - PROM/soft tissue mobs/joint mobs/positioning/splinting
- Management of continence - Liaise with nurses
- Facilitate sensory feedback - PROM/AAROM/soft tissue mobs/joint mobs
- Promote alignment (subluxation?) - PROM/soft tissue mobs/joint mobs /positioning/splinting
- Prevent or manage abnormal tone - PROM/soft tissue mobs/joint mobs/ positioning/splinting/medication
- Facilitate muscle activity - AAROM
- Encourage movement - Bed mobility/transfer out of bed/sitting balance
- Pain relief - PROM/soft tissue mobs/joint mobs/ positioning/splinting/medication
- Provide advice to other members of the team - Re. positioning/resp care/pain relief/transfer methods
- Provide information and education for family - Re. positioning/communication/PROM/ sensory work
- Identify transfer method
- Laying foundations for ongoing rehabilitation
Main early treatment techniques
- Medication
- PROM
- AAROM
- Soft tissue mobs
- Joint mobs
- Positioning (24 hour postural management)
- Splinting
- Sitting work
- Transfer methods
- Respiratory care
Considerations for acute TBI for lying to sitting
– Observations = are they homeostatic stable to mobilise
○ HR - 60-100bpm
○ RR - 12-16 bpm
○ BP - 120/80 mmHg ideally
○ pO2 - if low = pale, clammy, high WOB, confusion
○ Consciousness
– Any lines and drains - roll to side with equipment
– Affected side - Always roll to non-affected side to be wary of subluxation of GHJ and so pts can push off with non-affected arm
Considerations for acute SCI for lying to sitting
– Flaccidity - initial spinal shock and vasogenic oedema (swelling) causing disruption of motor nerve transmission
– Autonomic Dysreflexia - increase BP and drop HR can cause death.
○ Cause - bladder & bowel issues
○ Symptoms - hot & sweaty below lesion; cold & clammy above lesion (more common T6 and above)
– Impairment of vasomotor control – monitor BP, HR, RR
– Postural hypotension
– Problems with bladder & bowel function
– Unstable spine
– You will need to use an abdominal binder to maintain abdominal pressures - maintain BP
Considerations for positioning for neurological patients
- Respiratory care
- Development of high tone
- Development of pressure areas
- Sensory feedback
- Pain
What does correct positioning achieve?
• Promotes normal body alignment and the patient’s perception of midline.
• Permits equal distribution of weight through hips and feet, reducing the development of pressure sores and tissue breakdown.
• Encourages relearning of sitting balance and postural control, improving function.
• Patients become more comfortable, less tired and easier to handle.
• Prevents further deterioration, such as painful joints, contractures and deformity.
Eases the care-load of the patient
Correct positioning for L-sided weakness seated
- Both buttocks are well back in the chair. Consider packing under the left buttock, e.g. a folded towel under the cushion, to encourage more even weight distribution through both sides.
- Hips, knees and ankles are bent to 90 degrees
- Knees are comfortably apart, in line with hips. Feet are flat on the floor
- The left arm is supported on a pillow if it is floppy
Correct positioning for L-sided weakness in bed
Lying on right side – left side well forward with arm and leg supported on pillow
Supine - Consider packing under left side to promote even weight bearing. Support shoulder & arm comfortably on a pillow
Lying on left side – right hip well behind. Pillow at back & under right leg (as 30o tilt)
Correct positioning for L-sided weakness in sitting
- Both buttocks are well back in the chair. Consider packing under the right buttock, e.g. a folded towel under the cushion, to encourage more even weight distribution through both sides.
- Hips, knees and ankles are bent to 90 degrees
- Knees are comfortably apart, in line with hips. Feet are flat on the floor
- The right arm is supported on a pillow if it is floppy
Correct positioning for L-sided weakness in bed
Lying on left side – right side well forward with arm and leg supported on pillow
Supine - Consider packing under right side to promote even weight bearing. Support shoulder & arm comfortably on a pillow
Lying on right side – left hip well behind. Pillow at back & under left leg
(as 30o tilt)
How would you progress trunk stability and trunk mobility in a patient post CVA/TBI?
Present with Hemiplegia so considerations patient may:
- Lean toward their unaffected side and compensate with this side
- They might fall to their affected
Sitting balance (static/ dynamic), Sit out in appropriate chair – increasing time gradually as able, trunk mobilisation and facilitation of pelvic movement in sitting, strengthening of core muscle/ trunk muscles, perch sitting
Progress realignment of trunk, i.e. strengthening the affected side and improve the quality of the movement by sitting balance work hands on:
- Try with two people, one on pelvis one on trunk
- Try actively involving the arms
- Try with a gym ball behind, at the side, in front and the patient sitting on the gym ball
How would you progress trunk stability and trunk mobility in a patient post SCI?
Awareness of what level injury is at/ total or partial paralysis – which trunk muscles are innovated, ensuring no hinging at injury especially for thoracic injury, may be more appropriate to ensure correct supported seating depending on injury level and full spinal cord injury
Progress with Sitting balance work hands OFF:
- Can introduce as HEP
- Promotes independence
- Use form of sensory feedback - mirror, tactile, verbal
How do you transfer a patient post CVA/TBI and how does it differ to a transfer with a SCI patient?
CVA/TBI present with hemiplegia so can transfer towards the affected or the unaffected side:
- Without transfer board with two people
- With a transfer board
- Step round transfer
- Transfer with a rotunda
- Hoist transfer if unable to maintain sitting balance / unable to stand for step round transfer for stroke/ TBI
SCI may present with trunk instability and no movement in LL so considerations in transfer include:
- Where to put feet?
- Which way to lean? Forwards
- Care with what? LL and Cx
- Paraplegic SCI – likely be able to teach e.g banana board transfers early
Also need abdominal binder to maintain abdominal pressure for BP
What are the benefits of standing?
- High COG/ small BoS – improve balance and strengthen trunk musculature, development of postural control, maintenance of functional ranges of movement and skill acquisition in components of gait
- Increased WB increasing proprioception awareness in turn leads to increase extensor activity
- Increased strength/motor recruitment
- Psychological benefits – boost in self confidence, motivation. Improved sense of well-being and quality of life related to standing and a general sense of improved fitness
- Visual stimulation
- Increased BMD
- Decreased risk of secondary MSK complications
- Cardiovascular benefits
- Respiratory benefits
- Relieves pressure
- Bladder/bowel sensation and movement
How would you stand an early stroke or TBI patient? How does this differ with a SCI patient?
If level of deficit post stroke/TBI allows can attempt standing with:
- Check observations before and during getting patient into standing
- Have plinth behind and sturdy support on unaffected side
- Block affected knee
- Support affected arm
- Weight transference, tapping, approximation
SCI may present with overall trunk instability and loss of LL motor control:
- SCI may need to commence upright stance position with use of mechanical aids (tilt table/electric standing frame/OSF) in order to splint lower limbs and trunk and to accommodate for BP changes/ regulation – gradual increase to vertical especially for Cx injury due to risk of AD
- Also need abdominal binder to maintain abdominal pressure for BP
What are the pros and cons of mechanical aids?
Pros:
- Conform to manual handling guidelines
- Allow early rehab of heavy patients
- Allow rehab of very disabled patients
- Allows for grading of movement
- Require fewer staff
Cons:
- Activity level is restricted by equipment
- Not “normal” sensation of standing
- Reduced feedback to therapist re activity etc
What problems can arise when standing acute patients?
- BP/HR
- Autonomic dysreflexia (SCI)
- Bowel/bladder
- Respiratory dysfunction
- Colour/sweating
What provides stability in the GH joint?
- Direction of glenoid fossa: up / fward / lat (when arm is dependent)
- Glenoid labrum
- Capsule - superior part
- Rotator cuff
What are the types of GHJ subluxations?
Superior (least common)
Due to tight supraspinatus and/or deltoid
Low tone + high tone
Inferior subluxation (most common)
Seen in low tone
- Scapula loses stability on thorax causing shoulder depression and medial rotation
- Humerus in relative abduction
- Joint unprotected by stability of capsule & supraspinatus leading to inferior subluxation (postural asymmetry may contribute)
Anterior subluxation:
Due to tight pecs and lat dorsi
May get anteroinferior sublux
What are the recognised treatment options early post-stroke and TBI?
- Care of shoulder: education, positioning, supportive device
- Strengthening
- Sensory retraining
- Mirror box therapy
- Mental Practice
- FES
How do you take care of the shoulder in this early stage?
- Education – educating family and carers about care of shoulder
- Positioning for support
- Potential use of supportive devices (subcuff’s/sling) during therapy sessions focused on lower limb
- Ensure safe and supportive handling of UL
- Pain management
What strengthening techniques can you use at this early stage?
- Holding
- Following
- Placing (isometric)
- Combine with taping
- Combine with approximation
Adjuncts:
- Mirror box therapy
- Sensory retraining
- Mental practice
- Compensatory techniques
- Spasticity management – botox, FES
How do you use mirror therapy in treatment and how would you explain it to the patients?
Procedure:
- Patient sits with the affected arm behind the mirror
- Focuses on the reflection and imagines it is the affected limb. May cause emotional response, dizziness or nausea
- Recommended to exercise for 10 min every day
- May explain that being able to visually see unaffected mirrored hand ‘tricks’ brain into thinking this is the unaffected hand and this makes it easier to move
Activities without object:
- Unilateral movement of the ‘good’ arm only
- Bilateral movements
- Guiding of the affected arm by the therapist
- Guiding of both arms by the therapist
Activities with object:
- Unilateral movements of the ‘good’ arm with an object
- Bilateral movements with an object in the non-affected hand
- Bilateral movements with guidance of the affected arm by the therapist
- Bilateral movements while imagining objects in hands
What outcome measures could you use for your Upper limb assessment?
- Oxford scale – strength testing
- ROM (goniometer)
- 9 hole peg test/SARA - Co-ordination and UL function
- ADL measures – timed or videoed ADLs – PADLs, DADLs
- Modified Ashworth Scale (MAS) - tone
- Fugl-meyer or Nottingham Sensory Assessment - sensation
- Action Research Arm test
- Wolf Motor Function Test
What is autonomic dysreflexia
A serious, acute medical event whereby noxious stimuli causes an increase in blood pressure which the anatomic nervous system is unable to control or regulate leading to cardiovascular response of further increase of blood pressure and increased heart rate.
Usually seen in spinal cord injury patients who have had damage to T6 and above, can have life threatening implications unless treated immediately
What is tenodesis grip
The ability to passively utilise the natural propensity to create a finger flexion through wrist extension due to tension in long finger flexors in the absence of motor activity in fingers/ wrist flexion
What is postural hypotension
sustained reduction of systolic blood pressure of at least 20 mmHg or diastolic blood pressure of 10 mmHg within 3 minutes of standing, usually accompanied by symptoms of dizziness/ loss of balance/ pale complexion/ sweating / lack of verbal communication/ vacant episode
Who are the other members of the MDT team
- Doctors (Consultant, Registrar, Core Trainee Specialty Training, Trust Grade, Foundation Year 1 &2)
- Pharmacists
- Occupational Therapists (OTs)
- Therapy assistants
- Nursing staff
- Health care assistants
- Speech and Language Therapists (SALTs)
- Dieticians
- Psychologists
- Social workers
- Orthotists
What is the role of doctors
To diagnose, treat and manage patients medical plan including decision making with regards to active care, palliative or end of life care
What is the role of pharmacists
Managing medication doses and interactions, prescribing and assisting medical team with subscribing medication, communication with patients surrounding management of medication
What is the role of OTs and therapy assistants
OTs:
Assessment of physical, sensory, cognitive problems in functional activities in order to assist rehabilitation / address barriers affecting emotional/ social/ physical needs/ May be specialists in: Equipment/ adaptation assessment, splinting, seating/ postural management equipment, cognitive assessment
Therapy assistants:
Assisting therapy staff with assessment and treatment
What is the role of nursing staff and health care assistants
Nursing staff:
Medication administration, management of plan for continence, skin/ pressure management, caring for physical needs of patient, taking regular observations of patient, depending on speciality: ITU/ clinic nurse/ ward nurse/ community nursing/ school nurse – will include wide variety of roles and responsibilities
Health care assistants:
Assisting nursing staff with practical care of patients
What is the role of SALTs
Assessment and management of people experiencing communication, swallowing, eating and drinking difficulties or support/ treatment for people experiencing cognitive/ psychological problems with speaking and communicating
What is the role of dieticians
Assessment and treatment around assisting individuals with dietary advise, planning, nutrition advise and treatment
What is the role of the psychologists
Assessment and treatment for behavioural, emotional and psychological problems, counselling, CBT, lifestyle advise and assistance with social integration/ management, liaison with medical team r.e appropriate medications.
What is the role of social workers
Provide advice/ support, assists services in local community to provide appropriate care for patients, assist in decisions surrounding housing/ accommodation, level of care provided outside of hospital, discharge destination – in liaison with MDT/ patient/ family members
What is the role of the orthotists
Assessment and provision of orthotics and adaptive aids – splints, AFOs, braces, specialist footwear
