Bookmarked Flashcards
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
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 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 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
What are the types of ataxia and how to treat each type?
- Cerebellar – core stability and coordination exercises
- Vestibular – Cooksey cawthorne exercises
- Sensory – sensory stimulation++
Stability and coordination
Mental Practice, Mirror therapy.
Approximation, hold and place, tapping – for cerebellar and sensory ataxia
Truncal - Gym ball work/Basic pilates/Core stability work (TiMS)
UL - U and LL and truncal splints/lycra/Weighted movements, Passive to AAROM and strengthen for the U and LL in supine and side-lying, Strengthening exercises for UL - GRASP exercises/use of activehand/CIMT, UL Functional activities with facilitation/saebo flex/FES
Truncal and LL - LL and truncal splints/lycra/Weighted movements, Passive to AAROM and strengthen for the U and LL in supine and side-lying, Balance work in standing – changing BOS, automatic reactions, proactive, reactive, dual tasking, eyes closed. Also change the task and environment. Gait work – facilitated stepping, forwards, backwards, sideways, onto step. Use of walking aids
What is high tone and how do we reduce it?
- High tone = Increased resistance to passive movement
- High tone LL (think which muscles will be tight) – stretches, soft tissue mobs, prepare foot – joint mobs in ankle and foot for standing and gait work, Passive to AAROM and strengthen particularly the opposing muscles for the U and LL in supine and side lying
- High tone UL (think which muscles will be tight) – stretches, soft tissue mobs, prepare hand - joint mobs in wrist and hand for hand work, Passive to AAROM and strengthen particularly the opposing muscles for the U and LL in supine and side lying, Strengthening exercises - GRASP exercises/use of activehand, CIMT, UL Functional activities with facilitation/saebo flex/FES
- High tone trunk (think about which muscles will be tight) - trunk mobs (stretches),
- Medication (Baclofen, tizanidine, botox injections) + positioning/splinting management + heat therapy + hydrotherapy (the pressure, heat and buoyancy of the water helps in stretching) + mental practice + mirror therapy
What is low tone and how do we activate it
Low tone = Diminished resistance to passive movement
Low tone LL (think which muscles you particularly want to strengthen) – may have to prepare foot if joints stiff – joint mobs in ankle and foot for standing and gait work. Passive to AAROM and strengthen for the U and LL in supine and side lying, Step round transfers and rotunda, Standing with table support/OSF, Balance work in standing – changing BOS, automatic reactions, proactive, reactive, dual tasking, eyes closed. Also change the task and environment. Gait work – facilitated stepping, forwards, backwards, sideways, onto step. Use of walking aids. Think about Shoulder supports and positioning
Low tone UL (think which muscles you particularly want to strengthen) –prepare hand – may have to prepare hand if joints stiff - joint mobs in wrist and hand for hand work. Passive to AAROM and strengthen for the U and LL in supine and side lying, Strengthening exercises - GRASP exercises/use of activehand/CIMT, UL Functional activities with facilitation/saebo flex/FES/CIMT
Low tone trunk - Rolling, Moving from lying to sitting, Trunk mobs, Transfers with sliding board, Step round transfers and rotunda, Standing with table support/OSF, Balance work in standing – changing BOS, automatic reactions, proactive, reactive, dual tasking, eyes closed. Also change the task and environment. Gait work – facilitated stepping, forwards, backwards, sideways, onto step. Use of walking aids. Think about Shoulder supports and positioning
Mirror therapy
Environmental effects influencing high tone
- Environment - Warm, relaxing, comfortable
- Therapist’s approach - Soft voice, calm instructions, not rushing, reassurance
- Base of support - Large/ supportive
- Centre of gravity - Central
- Therapeutic handling - Slow, gentle, consistent movements
- Support - Dependent of associated reactions, may give less support with specific attention to areas wanting to activate, if stretching may give increased support to increase base.
- Speed of movement - Slow, consistent speed
- Reinforcement - Specific practice in order to avoid over stimulation to high tone areas
Environmental effects influencing low tone
- Environment - Stimulating, cool, music
- Therapist’s approach - Clear, precise instructions, increase voice volume, vary tone of voice, lots of encouragement
- Base of support - Small base of support/ reduce
- Centre of gravity - Outside base of support/ challenging with assistance as required
- Therapeutic handling - sensory feedback + , tapping, sensory stimulation to area trying to activate
- Support - Support for vulnerable areas (G/H joint) , Ensure safety
- Speed of movement - Increased speed
- Reinforcement - Continued repetition and sensory & motor stimulation of movement pattern
How to treat sensory deficit
Maximise sensory input
Sensory stimulation for hand
Approximation, hold and place, tapping
Mental Practice, Mirror therapy
Passive to AAROM and strengthen for the U and LL in supine and side lying, CIMT
Rolling, Moving from lying to sitting, Trunk mobs, Trunk stability work, Transfers with sliding board, Step round transfers and rotunda, Standing with table support/OSF, Balance work in standing –changing BOS, automatic reactions, proactive, reactive, dual tasking, eyes closed. Also change the task and environment. Gait work – facilitated stepping, forwards, backwards, sideways, onto step. Use of walking aids.
How to treat Rigidity - PD
Movement and stretching
Stretches (PD warrior), Relaxation techniques, Postural work
Medication - madopar and sinemet
How to treat Bradykinaesia - PD
Cueing – visual, auditory, kineasthetic
Cueing techniques – use of metronome, gait work,
Rolling, Moving from lying to sitting, Trunk mobs, Passive to AAROM for the U and LL in supine and side lying
