WEEK 3 - PHYSIO MANAGEMENT OF NEUROLOGICAL CONDITIONS IN THE ACUTE SETTING

Question 1

describe the pathology Guillain Barre Syndrome

Answer 1

GBS

• An inflammatory disease of the PNS – the most common cause of acute flaccid paralysis
• Autoimmune disorder – aberrant immune response to infection (e.g. resp; gastro)
• Typical presentation:
  
  • Weakness and sensory signs in the legs that progress to arms and cranial muscles (ascending weakness)

Question 2

Be able to describe the clinical course of Guillain Barre Syndrome

Answer 2

Progressive Phase

• Disease progression can be rapid. Most patients reach maximum disability within 2 weeks (98% reach peak by 4 weeks)
• About 20 % develop respiratory failure
• Cardiac arrhythmias and BP instability can occur – autonomic nervous system involvement

Plateau Phase

• After progression, plateau phase of persistent, unchanging symptoms can last days, weeks or even months

Recovery Phase

• Improvement in strength and function
• About 80% of patients are able to walk independently 6 months after disease onset
• Relapses of GBS can occur in 2 – 5% of patients
• Fewer than 15% have a substantial long-term disability

Question 3

Be able to describe the physiotherapy management in relation to the acute phase for a person with GBS (medical)

Answer 3

Medical treatment:

• IV immunoglobulins and plasmapheresis (lessen the severity and accelerate recovery)

Progressive Phase:

• Supportive care in ICU may be necessary (patients at risk of respiratory failure)
• Mechanical ventilation if respiratory function progressively deteriorates
• Tracheostomy may be needed in patients intubated for 2 weeks who do not show improvement

Question 4

Be able to describe the physiotherapy management in relation to the acute phase for a person with GBS (physiotherapy)

Answer 4

Physiotherapy management of GBS

Progressive Phase (Acute/Ascending phase):

• Monitor respiratory function – regular Vital Capacity measurement
  
  • If VC drops below about 14 ml/kg, mechanical ventilation is required
• Respiratory care if ventilated in ICU
• Maintain PROM
• Regular muscle charting (Oxford Scale) to monitor change

Plateau Phase

• Increasing upright posturing (consider tilt table if ICU/prolonged RIB)
• Gentle stretching and passive, active-assisted and active ROM as tolerated.
• Be guided by fatigue – be very conservative in this phase.
• No strengthening exercises

Question 5

describe the acute medical and physiotherapy management of stroke

Answer 5

Physiotherapy management - acute stroke

Respiratory management
- assess cranial involvement - ability to protect airway
- aspiration
- chest infection

Positioning (consult with OT and nursing staff)
- in bed
- wheelchair

• Assess vision
• Assess sensation – LT, sharp/blunt, kinaesthesia as appropriate
• Passive ROM and muscle length; facilitation of activation as appropriate
• Mobilisation / rehab
• medical stability - treatment may initially be bed based and progress to gym setting
• acitvation of postural muscles
• orientation and movement through space
  As medical stability allows: Bed mobility and postural control – SOEB and make clinical decision about standing & further functional assessment

REMEMBER - STRONG EVIDENCE SUPPORTING EARLY MOBILISATION (WITHIN 48HRS) WHEN MEDICALLY STABLE)

Question 6

describe the role of the trunk in function and how motor impairments of the trunk impact on sitting function

Answer 6

• trunk control involves
  
  • the ability of the muscles across the trunk, pelvis, and hip to keep the body upright against gravity
  • to control weight shifts of the body for various functional movements
  • to maintain the centre of mass within the base of support during postural adjustments

The trunk acts as a stable base from which efficient movements of the limbs can occur and is essential for balance and daily functioning

Likely impairments

• Verticality impairment
• cognitive dysfunction
• motor impairment
• Impaired APA
• Proprioceptive impairment

Question 7

Assessing trunk control (5)

Answer 7

Key observations

• Ability to sit without support:
  
  • If using hands to maintain sitting, can person sit without using hands
  • How long ?
• Postural alignment:
  
  • Tone of trunk (observation and palpation)
  • Pelvis/thorax/head
  • Hip/knee/ankle & foot contact & alignment
  • Upper limbs
• Antigravity extension :
  
  • Is the person able to extend their trunk (upright against gravity) & how ?
• Movement control (dissociation):
  
  • A/P and lateral tilt ; upper trunk / lower trunk
  • distance and control (how) in different directions (reach)
    
    • How : counterpoising , which segments ? (able to dissociate or for example does trunk just lean)
  • control of weight transfer side to side
• Saving response
  
  • Yes / no ; effective or not ; too early or too late