Week 4- Acute Physiotherapy Management Of Acquired Brain Injuries Flashcards
What are the aims of an acute assessment?
- Establish baseline function for patients with newly acquired injury
- Identify key areas of impairment (new and existing injuries) to direct treatment and discharge planning
- Anticipate likelihood of complications arising (e.g. respiratory infection, contracture, should subluxation)
- Ascertain degree to which patient can actively participate in therapy and optimise their mobility
- Establish need for ongoing physiotherapy
- Determination of diagnosis/ prognosis
What is included in an acute assessment
• Standard neurological S/E and P/E performed
• Conduct early (aim for within 24 hours of symptom onset, or referral)
• Modify based on patient’s presentation
• Prioritise based on patient’s presentation and purpose of assessment
• Remember:
– It may take a few sessions to complete a full assessment
– Always consider how you will complete assessment – planning is key
– Test order is flexible, omit tests inappropriate for patient’s ability
– Analyse how a patient moves independently before using handling to assist
– Compare patients’ activity and deficits to parameters derived from normal movement performance
How do you prioritise an acute assessment
- Cardiorespiratory Assessment
• Life threatening complications must be managed first - FunctionalAssessment
• Early mobilisation maximises rehabilitation potential and minimises risk of many complications
• Assessment skills unique to physiotherapists
• Recommendations underpin manual handling utilised by MDT
• Patient centred and goal directed
• Functionally meaningful and task-specific - AssessmentofImpairments
• Determination of diagnosis
• Determination of prognosis
• Guide physiotherapy management
• Discharge planning
What are the considerations (questions) for planning an acute functional assessment
- Is the patient medically stable? Has the patient been medically cleared for mobility? What are the patient’s current/ baseline obs?
- Is the patient alert/ cooperative? Do they have sufficient comprehension for safe mobility? How will you communicate with the patient?
- Does the patient have pain? Is the pain managed?
- Does the patient have the physical capability to move? Do they have adequate sensation? Do they have the required ROM? Are they able to load bare through their limbs?
- What medical adverse events is the patient most at risk of? How may the risk be minimised? How will you monitor your patient? What will you do if an adverse event occurs?
- Is the patient at risk of injury? How may the risk be minimised?
- What are the patient’s risk factors for falling? How may their risk of falls be minimised?
- What is the goal of the assessment? Is the environment appropriately setup?
- What level of assistance are you expecting to provide? …… 1A, 2A, 3A, 4A… equipment?
- Are any supportive/ protective/ safety devices required? Are they fitted?
What are strategies to enhance communication
What are the minimum requirements of patient to attempt standing
• Medically stable/ medical clearance for mobility
– e.g. BP, HR, Hb, INR, WB status, ICP, seizures, stability of neurological deficit
• Cooperative with some level of comprehension
– Functional tasks often better understood than assessments of impairments
• Pain managed
• DVT screen NAD
• Minimum strength grade 3/5 or able to move against gravity throughout full ROM for hip F/E, knee E, ankle PF/DF in at least one lower limb (ideally both)
• Attachments managed
• Clinical protocols adhered to
What some common acute measurement tools
What are key aspects of any treatment plan
• Functional Movement Re-Education
– Bed mobility, sitting balance, sit to stand, standing balance, transfers, gait, UL function, outdoor/ community mobility, high level balance, specific ADLs…
• Strengthening
– Targeted to areas of weakness with consideration of optimisation for neuroplasticity
• Flexibility
– Management and prevention
• Physical activity and exercise (cardiorespiratory fitness)
– Extremely important for functional independence, secondary prevention and health promotion
• Interventions for specific impairments and complications as indicated – Consider treatment strategies
– e.g. stretching, pain management, sensory training, equipment prescription
What are aims of acute Physiotherapy treatment
• Provide respiratory care
– Improve respiratory function
– Prevent/ manage respiratory complications
• Optimise musculoskeletal integrity
– Prevent/ minimise/ manage secondary adaptive changes in soft tissue
• Promote the restoration of motor function
• Discharge planning
Neurological physiotherapists provide stimulus via movement to engage patient response – do not wait for the patient to wake up or move before starting treatment
What are acute treatment considerations
• Ensure comprehensive understanding of pathophysiology, primary sensorimotor impairments, complications, compensations and adaptive changes
• Ventilation does not preclude mobility activities (remember this isn’t just walking, it can include passive)
• Early mobilisation = gold standard
• Acute patients may be unstable
• Focus on function and goals, never simply at the improvement of impairments
• Consider sequence of normal development
– Ocular control, postural control, coordination, limb control
• Optimise motor learning
– Consider stage of learning (cognitive, associative, autonomous)
– Understand variables that affect learning (individual, environment, task)
– Enrich rehabilitation environment
Explain respiratory function in neurological functions
Pulmonary complications including pneumonia, atelectasis and ARDS are the most frequent medical complications associated with acute ABI
Ventilation
• Patients with mild to moderate brain injuries (GCS >8) with adequate ABGs, no respiratory dysfunction or signs of deterioration not usually ventilated
• Patients with severe brain injuries (GCS ≤ 8) require immediate intubation, oxygenation and ventilatory support as hypoventilation may be present
Aims of Physiotherapy
• Improve respiratory function
• Prevent/ manage respiratory complications by ensuring adequate ventilation and clearing of excessive secretions
What are treatment options for respiratory impairments
Indicated based on the patient’s presentation (i.e. based on assessment)
– Ventilatory techniques
• e.g. ACBT, DBE, SBE, DV, positioning, incentive spirometry
– Airway clearance techniques
• e.g. ACBT, P&V, PEP, MHI
– Airway management and suction
• e.g. airway insertion, airway suction
– Physical activity to improve aerobic fitness/ endurance
• e.g. continuous/ repeated exercise such as walking, riding, functional task practice
What are musculoskeletal complications after a ABI
Musculoskeletal integrity complications in ABI patients include:
• Disuse atrophy —> changes in muscle length, volume and cross-sectional area —> weakness and atrophy)
• Soft tissue contractures
– High risk muscle groups: hip and knee flexors, ankle plantar flexors and invertors, shoulder adductors and internal rotators, elbow flexors, forearm pronators, wrist and finger flexors, thumb flexors and adductors (especially biarticular muscles)
• Decreased bone mass and density
Aims of Physiotherapy
• Optimise musculoskeletal integrity
– Prevent/ minimise/ manage secondary adaptive soft tissue changes
– Prevent bone loss
What are musculoskeletal treatment options
Indicated based on the patient’s presentation (i.e. based on assessment)
– AROM, AAROM, PROM, application of passive stretch (to at risk soft tissues)
• PROM/ brief stretch have little to no effect on preventing or treating contracture
• PROM may cause soft tissue damage
– Performed too vigorously or in too large a range —>muscle micro tears —> bleeding into muscle —> ossification (myositis ossificans – form of heterotopic ossification)
– Sustained passive stretch by positioning or using equipment
• e.g. Tilt table for calf stretch and weight-bearing stimulus to maintain bone mineral density
– Splinting and casting
• Consider if positioning ineffective; prevention and management; resting vs short term
– WB activities, antigravity movements/ positions to load bone and cartilage
– Task-specific training that incorporates through range movements
• Strengthen + lengthen
What is restoration of function
- Primary impairments are variable and complex
- Neurological impairments + associated physical injuries impact function
- Consider secondary musculoskeletal, cardiorespiratory, metabolic sequelae
Aims of Physiotherapy
• Promote the restoration of motor function
• Train the individual to perform everyday actions
