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
