WEEK 4 - PHYSIO MANAGEMENT OF NEURO CONDITIONS IN THE ACUTE SETTING PT2

Question 1

Aims of acute medical management of TBI

Answer 1

• stabilise patient - maintain life
• prevent further/secondary neurological damage
  
  • maintain adequate oxygenation
  • maintain adequate cerebral perfusion
• limit / cease bleeding
• monitor ICP and conscious state
• prevent complications - e.g seizures, resp problems, DVT
• improve LOC
• manage other chest, abdominal and musc injuries

Question 2

Key physio interventions for the acute TBI patient

Answer 2

• resp function, may have tracheostomy
• maintain ROM to pervent/minimise soft tissue adaptations (facilitate/encourage active movement as possible)
• avoid vigorous or forced movements - vary speed and direction
• positioning to help maintain ROM
• consider resting splints or casting to preserve alignment and maintain ROM and muscle length
• Commence sitting and standing for anti- gravity extension when patient medically stable. Consider tilt table if no/minimal movement
• Initially sit out for short periods (15 to 20mins) in adapted seating e.g. tilt recline WC – achieve optimum posture to maintain length, protect vulnerable joints, for respiration, communication, social interaction
• Ventilation doesn’t preclude sitting and standing – monitor saturation levels and vital signs

Question 3

general principles of intervention for acute TBI

Answer 3

General Principles of intervention

• Monitor: before, during and after treatment
• Parameters:
  
  • ICP
  • CPP
  • BP/MAP (mean arterial pressure)/rhythm
  • SpO2/ETCO2 (end tidal CO2 - 35-45)

Question 4

Demonstrate understanding of the term FND

Answer 4

FND is characterised by symptoms that are unexplained by neuropathology (normal imaging)

FND can manifest in various clinical presentations including

• motor and sensory symptoms
• speech dysfunction
• non epileptic seizures or loss of consciousness

Question 5

Aetiology - BPS model for FND (factors)

Answer 5

• Risk factors
  
  • sexual and physical abuse relevant in a proportion of patients
  • personality traits
  • neurological disease
• triggering factors
  
  • trauma may be relevant in a proportion
  • physical triggering events may be common (injury, surgery, illness)
  • dissociation and panic is a common at symptoms onset
• maintaining factors
  
  • biological e.g neuroplastic changes
  • psychological e.g avoidance behaviour
  • social e.g work and family roles

Question 6

describe the assessment of FND in an acute setting

Answer 6

Hoover’s sign

Identify inconsistency

• hoovers sign for weakness
  
  • inability to press affected heel into the bed
  • pressure under the affected heel when SLR on unaffected side

Question 7

describe the management of FND in an acute setting

Answer 7

Treatment for FND
Principles:

• Interdisciplinary treatment that addresses illness beliefs and self directed attention through goal directed rehab focused on function, automatic movement, education and cognitive behaviour therapy

prognosis

• very common to have isolated episode spontaneously recover
• for worse affected - recurrent symptoms, poorer prognosis
  Community Neurohabilitation Team
• physio
• OT
• speech and language therapy
• Neuropsychology

Clinical Psychology

Multidisciplinary rehab

• neurorehab service
• specialist FND rehab

Question 7

Criteria for initiating treatment - FND (3)

Answer 7

1. The patient should have received an unambiguous diagnosis of FND by a physician.
2. The patient should have some openness to the diagnosis or confidence in the diagnosis.
3. The patient desires improvement and can identify physiotherapy treatment goals.

Question 8

demonstrate understanding of the term lateropulsion with pushing in ABI

Answer 8

“Patients with PB are characterized by pushing strongly towards the affected body side with a high risk of falling. These patients resist attempts at passive correction of the posture, pushing strongly with their non-affected limbs”

Question 9

Alignment Disorders (3)

Answer 9

Ipsilateral lateropulsion - brainstem lesion
- leaning to the side of the lesion (lateral medullary stroke)

Contraversive pushing - hemiparesis (cortex)
- body posture aligned to the affected side (away from the lesion)
- resistance to passive correction of alignment
- use of non-paretic extremities

Poor spatial orientation / body in space awareness
- with or without deviation of alignment to the paretic side
- poor ability to interpret environment, and orientate body appropriately
- attention, visual perception, object manipulation, HCD

Question 10

Be able to describe the assessment and treatment of lateropulsion with pushing

Answer 10

Assessment

1. Spontaneous trunk posture
2. Use of non-paretic limbs to push
3. Resistance to passive correction of tilt

Factors to consider during assessment:
- Can the person sit &/or stand independently ? (consider BOS/environment)
- Observe self – selected posture, are there obvious signs of pushing)

• Assess patient’s willingness to move towards their unaffected side
• How does the patient do this, does weight transfer occur?

Assess response to displacement towards the unaffected side
- Degree of resistance
- Features of resistance (pushing with limbs, trunk, what about the head)
- Consider the patient’s response to handling (does handling tend to increase pushing beahviour, what if you modify your handling

Does the patient have trunk motor impairment – underactive, overactive muscles?

Does the patient seemed confused about movement, is the patient overwhelmed by instructions ?