Management of Severe-Mod Deficits

Question 1

Neuro ICU Must Do’s

Answer 1

 Mobilize patient ASAP
 Check for orders in medical chart
 Talk with nursing
 Will likely need multiple people

Question 2

What should you monitor in neuro ICU?

Answer 2

 Intracranial pressure
 Hemodynamics
 Vitals

Question 3

How to set up environment in neuro ICU

Answer 3

 Prediction of patient’s mobility/ability
 Consider medical constraints- lines/drains/monitors

Question 4

Common barriers to mobility - intrinsic to patient

Answer 4

 Elevated ICP
 Neurological storming
 Unstable hemodynamics
 Absence of Bone Flap
 Pain
 Decreased arousal
 Impaired cognition
 Physical impairments
 Obesity
 Unstable spine
 Surgical precautions

Question 5

what is neurological storming

Answer 5

hypothalamic stimulation of sympathetic nervous system and adrenal glands causing increase in corticosteroids and catecholamines- symptoms include altered LOC, increased posturing, dystonia, HTN, hyperthermia, tachycardia, tachypnea, diaphoresis, and agitation

Question 6

Common barriers to mobility - extrinsic

Answer 6

 External Ventricular drains that cannot be clamped
 Lines/Tubes
 Staffing/resources
 Fear/Uncertainty/Safety/Knowledge
 Adequate Equipment
 Inappropriate or absence of activity orders
 Timing of PT consults

Question 7

things to consider when mobilizing s/p stroke

Answer 7

 Severity and Type
 Timing
 Interventions received- tPA, evacuation, thromectomy
 Hemodynamic parameters
 Neuroimaging
 Discussion with MD/RN
 Close monitoring with activity

Question 8

things to consider when mobilizing s/p TBI

Answer 8

 Severity of injury
 Presence of skull/facial fractures- CSF leaking
 Intracranial Pressure parameters
 Neurologic Storming
 Bone Flap/Helmut

Question 9

Daily Assessments

Answer 9

 Avoid any injury
– People moving patients need appropriate training
— UEs
— Safety
 Emphasis to maximize active involvement

Question 10

Neurologic factors to consider for positioning needs

Answer 10

– Normalize tone
– Decrease influence of pathologic reflexes
– Facilitation to midline
– Interaction with environment
– Awareness of body and body part

Question 11

Musculoskeletal factors to consider for positioning needs

Answer 11

prevent ROM issues

Question 12

Physiologic factors to consider for positioning needs

Answer 12

 Prevent skin irritation/breakdown
— Ability to move
— Sensation
— Visual/Perceptual
— Bony prominences
— Be good about bowel/bladder management and hygeine
 Minimize medical problems
— NG or PEG tube – 30 degrees HOB elevated to decrease risk of aspiration
— ICP pressure monitor

Question 13

features of UMN lesion

Answer 13

deficits in motor behavior, weakness, slowness of movement, loss of dexterity, fatiguability

Question 14

Positive features of UMN lesion

Answer 14

exaggerations of normal phenomena or release phenomena
 Tone, exaggerated tendon jerk, clonus
 Flexor withdrawal, extensor or flexor spasms

Question 15

adaptive features of UMN lesion

Answer 15

 Physiological, mechanical, and functional changes in muscle and other soft tissue
 Adaptive Motor Behavior
 Abnormal Posturing- immobility, disuse changes to soft tissue, adaptations in resting length of muscles
 Abnormal Patterns of movement- synergy, difficulty controlling muscles, difficulty in timing, imbalance in strengths

Question 16

Exaggerated Reflexes - STNR

Answer 16

 Flexion of neck elicits flexion of UE, Extension LE
 Extension of neck elicits extension of UE, flexion LE

Question 17

Exaggerated Reflexes - ATNR

Answer 17

Extension to side facing, flexion to side not facing

Question 18

Exaggerated Reflexes - Tonic Lumbar

Answer 18

Rotation to R- elicits flexion RUE, extension RLE, extension LUE, flexion LLE

Question 19

How do exaggerated reflexes impact us?

Answer 19

• initial conditions
• positioning in bed and chair

Question 20

What is spasticity and when should you manage it?

Answer 20

• velocity dependent resistance to passive movement
• Need to manage when it limits person’s ability to move, move fully, or for therapist to move person

Question 21

Prevent noxious stimuli – both internal and external

Answer 21

 Internal stimuli- pain, pressure sores, agitation, constipation,
incontinence
 External stimuli- positioning in bed or wheelchair

Question 22

Prevent consequences of spasticity

Answer 22

 Tightness
 Contracture
 Sores

Question 23

Physical management of spasticity

Answer 23

 Range of motion to maintain or increase muscle length
 Slow sustain traction to improve mobility and reduce pain; consider joint mobilization Grade 1 and 2
 Prolonged stretch- Evokes a higher threshold response
 Stimulus- slowly applied, maintained stretch to inhibit or dampen muscle contraction and tone

Question 24

Exteroceptive Stimulation for Management of Spasticity

Answer 24

 Neutral warmth- applied for 10-20 minutes- useful for managing high arousal and increased sympathetic activity, impact tone/spasticity
 Generalized inhibition of ton
 Wrapping body or parts with warm towel
 Monitor for overheating- patient will not be able to tell you-cognition/communication

Question 25

Techniques for using a stimulus to dampen muscle contraction and tone

Answer 25

 Manual contacts  Inhibitory splinting/casting – dynamic splinting, tone inhibiting serial casting  WEIGHT BEARING- weightbearing normalizes tone --- Sitting with limbs supported --- Standing Frame- long prolonged stretch; great tool for lower level patient- get prolonged stretch, get upright for attention/engagment

Question 26

Pharmacologic Management of Spasticity

Answer 26

 Second line of defense or adjunct to physical management  Need to understand if patient has more general or focal spasticity

Question 27

Generalized spasticity

Answer 27

- extensor spasms - oral medication

Question 28

Focal Spasticity

Answer 28

clenched hand, PF contracture unresponsive to physical management and oral medication  Phenol block – washes general area  Botox (more expensive)- more precise

Question 29

Surgery for Spasticity Management

Answer 29

 Surgery- last option  Last resort when all other attempts to manage have failed  Could be neurologic- insertion of baclofen pump  Could be musculoskeletal- tendon lengthening

Question 30

How to Manage agitation

Answer 30

 Activate parasympathetic division of autonomic nervous system  Calming effect for a high arousal patient - Neutral warmth - Rocking - Stroking paraspinals - Maintained touch/support

Question 31

Cognitive Dysfunction Ranchos Level II/III

Answer 31

 Elicit response to sensory input  Elicit specific response  Increase ability to focus and sustain attention  Consider ability to track object, reach for object  Utilize for functional activities --> Rolling: having them reaching for picture across body for example

Question 32

Cognitive Dysfunction Ranchos Level IV

Answer 32

 Decrease intensity, duration, and frequency of agitation  Increase attention to environmental stimuli  Try to engage in movement – try to move uncontrolled and non-purposeful movement →controlled and purposeful movement  Principles of treatment- limit external stimuli  Consistency in place, staff, time if possible  Structure patient/therapist interaction  Explanation of activities/goals  Communication- calm, clear, concise  Give choices as able  Response to inappropriate behavior  Behavior contract

Question 33

Cognitive Dysfunction Ranchos Levels V and VI

Answer 33

 Rancho Levels 5 and 6  Decrease confusion  Improve orientation- A&O x 4  Improve cognitive processes - Attention, selective attention, attention span - Recent memory - Categorization/Organization  Incorporate cognitive function into functional activities

Question 34

Where should activities be performed for Ranchos Level V and VI

Answer 34

 Treatment should occur in actual setting patient will perform  Poor carryover of an activity

Question 35

What should be provided for Ranchos level V and VI

Answer 35

 Written instructions/Pictures

Question 36

Cognitive Dysfunction Levels 7 and 8

Answer 36

 Adapt activities to more complex tasks, environments  Consider carryover  Removal of structure  Interactions

Question 37

essential elements of rolling

Answer 37

 Rotation and flexion of neck  Hip and knee flexion  Flexion of shoulder and protraction of shoulder girdle  Rotation in trunk

Question 38

significant impairments of rolling

Answer 38

 Extremity hypertonicity  Loss of Trunk Control  Extremity Weakness  Loss of alignment due to muscle shortening  Pain

Question 39

undesirable compensatory patterns

Answer 39

 Grabbing and pulling with unaffected arm  Use of excessive hypertonicity in arm/leg  Learned disuse of hemiparetic limbs

Question 40

movement elements of sidelying to sitting

Answer 40

 Lateral flexion of the trunk  Extended arm- weightbearing through forearm  Body weight taken over hip

Question 41

essential elements of sidelying to sitting

Answer 41

 Lateral flexion of neck  Lateral flexion of trunk  Legs lifted and lowered over side of bed

Question 42

significant impairments that interfere with sidelying to sitting

Answer 42

 Weakness of trunk and extremities  Loss of alignment  Inability to accept weight through extremities  Hypertonicity of extremities

Question 43

undesirable compensatory patterns for sidelying to sitting

Answer 43

 Sitting straight up  Use unaffected arm to pull body up and out of bed  Patient hooks leg under affected leg to lift both over bed