BRIGHAM & WOMENS HOSPITAL Department of Rehabilitation Services Physical Therapy

Standard of Care: Neuroscience

Physical Therapy Management of the patient with neurological disorders and/or s/p neurosurgical procedures

Case Type / Diagnosis: This standard of care applies to any patient with a progressive (e.g. multiple sclerosis, Parkinsons disease, Amyotrophic lateral sclerosis) or nonprogressive (e.g. cerebral vascular accident (CVA), traumatic brain injury, and spinal cord injury) neurological disorder as well as any patient s/p a neurosurgical or neurovascular procedure. Refer to the ICU standard of care for additional information for patients who require prolonged intensive care. Indications for Treatment: Impaired motor function and/or sensory integrity associated with a progressive or nonprogressive disorder of the central nervous system (CNS), acute or chronic polyneuropathy, or peripheral nerve injury. Impaired arousal, ROM, motor control associated with coma, near coma or vegetative state. Prevention or reduction in the risk of falls/loss of balance

Contraindications / Precautions for Treatment: Refer to the Neuroscience Precautions and Considerations for Rehab Services handout (Appendix I). Considerations for patients who require spinal orthoses: 1. Each surgeon has different specifications for orders depending on the patients diagnosis and surgical procedure. Refer to the Back Brace Precautions handout in the Orthotic and Prosthetic Resource Manual for surgeon preferences. Clarify brace wearing schedule and activity orders with MD as needed. 2. General precautions: A. Miami J collar: worn 24 hours per day. Needs to change to Philadelphia collar for showering, OTs will teach the patients this. B. For patients who require a spinal orthosis for stability, patients will likely be on logrolling precautions until the brace is fit. Generally the brace must be donned in supine. C. Occasionally, if the brace is for comfort only, the patient may be allowed out of bed prior to the brace fitting. This is the case for most orthomolds and soft corsets. 3. Refer to the Spinal Orthotics Resource Guide for further information on the brace specifications.

Standard of Care: Neuroscience

Physical Therapy Management of the patient with neurological disorders and/or s/p neurosurgical procedures Examination:
This section is intended to capture the minimum data set and identify specific circumstance(s) that might require additional tests and measures.

1. Chart Review A. HPI & PMH Onset and duration of symptoms and reason for admission Past medical/surgical history, including pre-admission cognitive status B. HC Medical treatment, previous or ongoing, that may impact rehab progression Pertinent laboratory and diagnostic tests C. Medications Patients with neurologic dysfunctions may be treated with various pharmacological agents. These may include anticonvulsants, osmotic diuretics, adrenocorticosteroids, muscle relaxants and antiparkinsonian medications. In addition, these patients may also be receiving antibiotics, antihypertensives, thrombolytics, anticoagulants, immunomodulation agents, chemotherapy, and medications for pain control. Many of these agents have side effects, which may present as neurological symptoms such as: confusion, sedation, movement disorders, weakness, dizziness, headaches or neuropathies. It is helpful to know the direct and indirect effects of these agents and their rehab implications. If a patient's functional status is not improving or is worsening in a manner not consistent with changes in their medical status, it may be medication related. It may be helpful to discuss this with the physician as s/he may change the dosage or switch to an alternative drug resulting in improvement of the patient's symptoms. (Refer to the Neuroscience Resource Manual or Physician Desk Reference for neuropharmacological references.) 2. Social History Prior functional level, use of assistive devices and/or adaptive equipment Home environment and current/potential barriers to returning home Family/caregiver support system available Family, professional, social and community roles Patients goals and expectations of returning to previous life roles 3. Physical Examination Select the appropriate examination measurements as indicated by the patients diagnosis and the location(s) of their neurological lesion(s). Not all examination measures are pertinent for each patient. Refer to the Neuroscience Reference Manual and/or a Neurological Rehab Text (e.g. Umphred) for further details. Vital signs (HR, BP, RR, SpO2, as indicated) Cranial Nerve Assessment 2

Standard of Care: Neuroscience

Physical Therapy Management of the patient with neurological disorders and/or s/p neurosurgical procedures 4. Sensation: sharp/dull, proprioception, light touch, double simultaneous stimulation Vision: field cut, diplopia Skin integrity: potential areas for skin breakdown Pain Range of motion (ROM) Motor function: gross movement, presence of abnormal movement patterns, functional testing, gross strength and MMT Tone (Modified Ashworth Scale) Coordination Reflexes Balance, balance reactions and functional balance tests (e.g. Berg Test for Balance, Functional Reach, Timed Up and Go, Tinetti Performance Oriented Assessment of Mobility) Postural alignment Mobility Endurance/ability to monitor fatigue

Cognitive-Perceptual and psychological considerations Mental status/Cognition o Level of consciousness o Orientation o Level of cognitive functioning (Refer to the Ranchos Los Amigos Scale of Cognitive Functioning) o Ability to follow commands o Language ability and comprehension o Neglect, perceptual impairments o Safety awareness Psychological considerations o Assess patients coping mechanisms to altered functional status Teaching/learning considerations o Patients goals, motivators and learning style

Evaluation / Assessment: The primary goal for inpatient physical therapy for a patient with a neurological disease or disorder is to maximize his/her functional independence and safety while minimizing secondary impairments. Potential impairments include but are not limited to: impaired mental status, cognition, sensation, motor function, tone, balance and gait as well as decreased strength, ROM, and endurance. 3

Standard of Care: Neuroscience

Physical Therapy Management of the patient with neurological disorders and/or s/p neurosurgical procedures The predicted optimal level of improvement for these patients is to return to the highest level of functioning in their home, work and community environments and resume their previous life roles over the course of 1-12 months using the appropriate assistive, orthotic and/or adaptive devices. The timeframe for optimal recovery is large given the wide range of impairments that are resultant of disorders of the central and peripheral nervous system. This prognosis may need to be modified due to any of the following factors: presence of co-morbidities, complications or secondary impairments, decreased cognitive status, barriers to returning to previous living environment and any other factors that may influence the patients ability to achieve functional independence. Age specific considerations in this population include all the normal physiological changes that occur with aging. See Geriatric Physical Therapy: A Clinical Approach, by Lewis and Bottomley for more details. The physical therapist will consider all of the patients impairments whether they are disease or age based and will determine a comprehensive assessment, prognosis and rehabilitation plan for each patient. Individual and measurable goals should be formulated for each patient taking into consideration the patients status and their own goals. Anticipated goals may include: (1-6 weeks) 1. Maximize functional mobility 2. Normalize tone 3. Minimize abnormal movement patterns 4. Maximize balance in sitting and standing, with or without assistive device 5. Maximize safety awareness with all functional mobility 6. Prevent loss of ROM and function by proper positioning and splinting 7. Increase arousal and/or attention during therapy sessions Treatment Planning / Interventions Established Pathway _X_ Yes, see attached. ___ No Craniotomy and spinal surgery pathways Stroke pathway (in progress) ___ Yes, see attached. _X__ No

Established Protocol

Standard of Care: Neuroscience

Physical Therapy Management of the patient with neurological disorders and/or s/p neurosurgical procedures Interventions most commonly used for this case type/diagnosis.
This section is intended to capture the most commonly used interventions for this case type/diagnosis. It is not intended to be either inclusive or exclusive of appropriate interventions.

1. Intervention Initiate physical therapy intervention, as appropriate, given the patients medical status, precautions and activity orders as indicated by the physicians orders. Refer to the Neuroscience Resource Manual for pertinent reference articles, handouts and measurement tools. A. Functional Mobility Training Bed mobility, rolling, bridging and supine sit activities Transfer training (bed chair wheelchair commode), using adaptive equipment, as appropriate (e.g. slide board) Balance Training Sitting and standing activities, as indicated Gait Training Pre-gait activities Assistive device prescription, as indicated Progress to stair training, as appropriate, prior to discharge home Wheelchair (w/c) Mobility and Management Tone Inhibition/Facilitation Neurofacilitation or inhibition techniques described by Voss et al. Vibration Reflex inhibiting positions Thermal modalities Serial Casting Facilitation of normal movement patterns Manual techniques including neurodevelopmental techniques (NDT) described by Bobath; proprioceptive neuromuscular facilitation described by Voss et al; and sequential sensorimotor recovery stages described by Brunnstrom. Refer the specific texts for detailed treatment techniques. Vestibular stimulation Therapeutic exercise program Progress from supine and sitting P/AA/AROM/resistive exercises and standing AROM/resistive exercises for UE/LEs, using facilitation techniques, as indicated.

B. C.

D. E.

F.

G.

Standard of Care: Neuroscience

Physical Therapy Management of the patient with neurological disorders and/or s/p neurosurgical procedures H. Endurance Training Increase tolerance to sitting in bedside chair Depending on medical, cognitive and physical status, the patient may not be able to transfer bed chair. Recommend stretcher chair transfers or EZ-lift transfers to the RN staff. Coordinate therapy sessions around the patients out of bed schedule to optimize the effectiveness of therapy and limit the patients fatigue. Progress time, distance and frequency of ambulation or w/c mobility. Recommend activity schedule to other healthcare providers or family members, as appropriate. Lower extremity splinting and bracing Available options include: o Rolyan resting foot splint o Multi-podus boots. Ask RN or unit secretary to order via Compass Medical o Custom-made devices. Ask the orthotist (Jon Hamel) from Hanger Prosthetics and Orthotics to evaluate the patient and obtain a prescription from the M.D.

I.

2. Patient/Family Education A. Discuss realistic expectations regarding function, appropriate level of assist that the patient requires from family and their anticipated rehab progression. B. Provide emotional support to the patient and family as needed. C. Instruct the patient in relevant precautions, pacing and safe activity progression D. Instruct the patient and family members in the following and assess their understanding via return demonstration: Safe mobility techniques encouraging maximal independence. Therapeutic exercise and endurance program, if applicable 3. Frequency of Treatment Patients will have follow-up physical therapy treatments based on individual need. The frequency of treatment for each patient will be determined by the acuity of his or her impairments and functional limitations. Refer to the BWH Guidelines for Frequency of Physical Therapy Patient Care in the Acute Care Hospital Setting, Neuromuscular Practice Pattern.

Standard of Care: Neuroscience

Physical Therapy Management of the patient with neurological disorders and/or s/p neurosurgical procedures 4. Recommended Referrals to Other Providers Discuss the patients need for additional services with the primary team. A patient may benefit from the following services as indicated: Occupational Therapy: For a patient who presents with cognitive or perceptual impairments, UE weakness or tone, or any other impairment that affects his or her ability to perform activities of daily living independently and for a patient who has UE splinting and/or adaptive equipment needs Speech and Swallowing: For a patient who presents with impairments that affect his or her ability to swallow without difficulty and/or who presents with a new language impairment. Care Coordination: For a patient who has a complicated discharge situation and the care coordination team is not involved. Social Work: For a patient who has a complicated social history and he or she requires additional support or counseling. Re-evaluation / assessment Reassessment will occur under the following circumstances: all physical therapy goals are met, significant change in medical status occurs, patient is discharged from services or facility, failure to respond to physical therapy intervention and/or within 10 days from the previous assessment. Discharge Planning Discharge planning will occur on an individual basis depending on the patients medical, physical and social needs. Discharge planning is a coordinated effort that occurs with the physician, care coordinator, nurse, physical and occupational therapists, the patient and his or her family. A. If the patient continues to have significant impairments and functional limitations and/or complicated medical needs at the time of discharge from the acute hospital, he or she may be discharged to an extended care facility e.g. acute or sub-acute rehabilitation facility, or skilled nursing facility (SNF). The patient will continue to progress towards their physical therapy goals at the alternate inpatient facility, as appropriate. B. If the patient has met all inpatient physical therapy goals, he/she may be discharged home with or without services. Consider the following resources for continued therapy: Home PT (e.g. VNA) Outpatient PT for patients who have a high level of function but continue to have specific impairments Outpatient Occupational Therapy Cognitive Clinic Adult Day Programs

Standard of Care: Neuroscience

Physical Therapy Management of the patient with neurological disorders and/or s/p neurosurgical procedures Bibliography / Reference List APTA Guide to Physical Therapy Practice, Second Edition. Physical Therapy 81:(1); 2001. Bobath, B. Adult Hemiplegia: Evaluation and Treatment (2nd Edition). London: William Heinemann Medical Books Limited, 1985. Brunnstrom, S. Movement Therapy in Hemiplegia: A neurophysiological approach. New York: Harper and Row Publishers, 1970. BWH Department of Rehabilitation Services Guidelines for frequency of physical therapy patient care in the acute-care hospital setting BWH Neuroscience Precautions and Considerations for Rehabilitation Services handout Hamel J and Finkel A. Spinal Orthotics Resource Guide, 2001 Lewis CB, Bottomley JM. Geriatric Physical Therapy: A Clinical Approach. E. Norwark, CT: Prentice Hall, 1994. Malone T, Physical and Occupational Therapy: Drug Implications for Practice. Philadelphia: Lippincott Williams & Wilkins Publishers, 1989. Paz JC, West MP, Acute Care Handbook for Physical Therapists, Second Edition. Boston: Butterworth-Heinmann, 2002. Umphred DA. Neurological Rehabilitation. Boston: Mosby, 1995. Voss DE, Ionta MK, Myers BJ. Proprioceptive Neuromuscular Facilitation: Patterns and Techniques (3rd Edition). Cambridge: Harper and Row Publishers, 1985. Wall, N. Stroke Rehabilitation. In MK Logigian (ed), Adult Rehabilitation: A Team Approach for Therapists. Boston: Little, Brown and Company, 230-231.

Standard of Care: Neuroscience

Physical Therapy Management of the patient with neurological disorders and/or s/p neurosurgical procedures APPENDIX I Neuroscience Precautions and Considerations for Rehabilitation Services Vital sign precautions: Blood pressure parameters may be set greater than normal to maintain adequate perfusion to the brain or lower than normal to prevent further injury to the brain. Check chart, flow sheet and MD order entry for specific parameters. Precautions associated with diagnostic procedures: Cerebral Angiography: Patients are on bed rest for 6-8 hours with involved hip and knee immobilized. Defer therapy until activity orders are advanced. Patients may be seen for UE splinting needs as appropriate Lumbar puncture: Patients are on bed rest for 4-6 hours after procedure. Short-term complications from LP include: headache, backache, bleeding at needle site, CSF leak, voiding difficulty, and fever. Electroencephalography (EEG): There are two 24 hour monitored beds on 10C and 10D. They have closed circuit video and audio monitoring at the nurses station and in the EEG lab on 9B. Generally there are no contraindications for treating these patients, check activity orders prior to rehab treatment. Myelography:

Depending on type of dye used, patient may be on bed rest with specific HOB instructions because the dye may cause a seizure if it reaches the cranium. Short-term complications include: headache, back spasm, fever, nausea or vomiting.

Precautions associated with surgical procedures

Ventriculoperitoneal Shunt (VPS): Patients are generally on bed rest for 24 hours. Generally gradual elevation of HOB will be ordered by MD prior to out of bed activity. Patients s/p VPS for normal pressure hydrocephalus may be allowed to progress their activity more quickly, check activity orders. 9

Standard of Care: Neuroscience

Physical Therapy Management of the patient with neurological disorders and/or s/p neurosurgical procedures Craniotomy: Head of bed is generally kept greater than or equal to 30 degrees. Seizure Precautions: see below Craniectomy: Be aware of location of craniectomy and do not apply direct pressure to that area. Helmet is often required for all out of bed activity. Positioning restrictions may vary; keep head of bed greater than or equal to 30 degrees after surgery.

Precautions associated with specific diseases or conditions Spinal Cord Injury: Autonomic dysreflexia is a potential serious complication for a patient with a cervical or high thoracic lesion and requires immediate action. o Symptoms include: headache, bradycardia, hypertension and diaphoresis. Return patient to reclined sitting position, remove any possible irritants (e.g. kinked Foley tube, restricted clothing) and, notify RN immediately. o See articles in the Neuroscience Standards of Care notebook for further information. Orthostatic hypotension is possible during early mobilization. Use thigh high compression stockings, ace wraps on the legs and abdominal binder to minimize orthostasis. Cerebrovascular Accident: Symptoms occur suddenly and differ depending on the part of the brain affected. Notify RN and MD if you note any of the following new symptoms during therapy sessions: o Weakness or numbness of face, arm or leg, especially on one side of the body o Sudden confusion, trouble speaking or comprehending o Blurry, dimming, or no vision in one or both eyes o Difficulty swallowing o Difficulty walking, dizziness, loss of balance or coordination o Severe or unusual headache without a known cause Patients s/p tPA are on bed rest for approximately 24 hours and physical therapy is deferred until activity orders are advanced. Cerebral aneurysm precautions: Frequent neurological signs are monitored by RN since the pt is at risk for rebleed, vasospasm, or hydrocephalus. The risk for vasospasm is greatest 4-12 days following a Subarachnoid Hemorrhage (SAH). 10

Standard of Care: Neuroscience

Physical Therapy Management of the patient with neurological disorders and/or s/p neurosurgical procedures Goal is for minimal stimulation and pt will be on bed rest. Therapy should be deferred, except for positioning needs, until physician clears patient for activity.

Signs and symptoms of vasospasm and/or hydrocephalus include: decreased level of enlarged, unequal pupils changes in neurological consciousness or decreased reactivity signs related to BP agitation nausea/vomiting decreased HR change in speech positive pronator drift increased BP seizures blurred vision changes in respiratory pattern headache weakness dizziness CSF leak: Vital sign and position restrictions will be documented in the MD orders, chart, and flow sheet. If CSF drainage increases during PT intervention, stop treatment and notify RN immediately.

Seizure Precautions: For patient with history of seizures: 1. Establish seizure history, including prodrome or aura 2. This may be done by chart review or interview If patient has a seizure: Alert nursing staff Stay with patient and observe seizure activity, note time. Place patient on side with soft object under head and loosen clothing. o The chief dangers during a seizure are physical injury, aspiration and tongue biting. Try to prevent injury by moving all objects/furniture away from patient. Do not restrain, try to move patient or put anything in their mouth. Observe the patient for the following: Time of onset and duration of seizure activity Progression of seizure activity Body parts involved Sequence of movements Unilateral vs. bilateral face and or limb involvement Tonic or clonic movement Head or eye deviation to one side 11

Standard of Care: Neuroscience

Physical Therapy Management of the patient with neurological disorders and/or s/p neurosurgical procedures Loss of consciousness Change in respiration, apneic periods, color of lips and skin Automatisms: lip smacking, chewing, swallowing, eyelid fluttering Dilation or constriction of pupils, diaphoresis Fecal or urinary incontinence Any injury sustained during episode Length and characteristics of post-ictal state

Once a seizure has ceased and patient is safe and coherent, identify: Presence or absence of aura (smell, visual, auditory, talk irrationally)
What was the patient was doing just before the seizure and any precipitating factors

Document above observations and condition of the patient Clarify activity orders prior to resuming therapy with the patient. Depending on the type of seizure, therapy may need to be deferred until the following day.

Device-specific Precautions: External ventricular drainage system (EVD): Patients are usually on bed rest and head of bed must be kept at ~ 30. Do not adjust the height of the bed since it will change the relationship between the level of the patients ventricular system and the external drain. The external auditory meatus is the anatomical reference for the correct drain alignment. MD order is needed for all OOB activity. RN must clamp EVD prior to OOB and EVD should never be clamped for longer than 30 minutes, unless ordered by the physician. Normal ICP range is 4-15 mmHg, generally monitor will alarm at 20 mmHg Avoid all activities that will increase intracranial pressure (ICP) including: o Flat supine and trendelenburg positioning o Extreme hip flexion o Extreme lateral neck flexion o Valsalva maneuver o Isometric exercises o Coughing o Pain o Agitation Lumbar Drain:

MD order is needed for all OOB activity. RN must clamp the drain prior to OOB and should never be clamped for longer than 30 minutes, unless ordered by the physician.

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Standard of Care: Neuroscience

Physical Therapy Management of the patient with neurological disorders and/or s/p neurosurgical procedures Drain may be re-leveled and opened by RN while patient is sitting in a chair, so generally the patient does not have to remain in bed after the therapy session.

References BWH Nursing Clinical Practice Manual BWH Nursing Policies BWH Rehab Services Neurosurgery Standards of Care Paz J and West M. Acute Care Handbook for Physical Therapists, Second Edition. Boston: Butterworth-Heinemann, 2002.

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Standard of Care: Neuroscience

Physical Therapy Management of the patient with neurological disorders and/or s/p neurosurgical procedures APPENDIX II
Brigham & Women's Hospital: Plan for Stay for Craniotomy for Tumor Patients
Day of Surgery
Maintains optimal neurological function Maintains effective airway Physical Status

ICU Transfer Day 1 Neuro Floor Day 2 Neuro Floor Day 3 Neuro Floor Day 4 Day of Discharge
Maintains optimal neurological function Effective cough and airway clearance Maintains optimal neurological function Maintains optimal neurological function Maintains optimal neurological function Optimal neurological function. Stable for discharge

Absence of increased Absence of increased Absence of increased Absence of increased ICP ICP ICP ICP

Absence of increased Absence of increased Remains seizure free Remains seizure free Remains seizure free Remains seizure free ICP ICP Maintains normovolemia Hemodynamically stable Maintains normovolemia Hemodynamically stable for transfer Appropriate diet as tolerated Remains seizure free Decadron Taper Discussed

Activity

Effective cough and airway clearance

Transfer from ICU

Pt. Tolerates increased activity Increased independence with activities of daily living Pt/Fam verbalize questions/fears and articulate understanding of information given

Pt ambulating if appropriate

Increased activity and strength

Prevention of venous PT/OT consult if stasis appropriate. Pt. Tolerate OOB Pt/Fam free of anxiety Pt/Fam satisfied with and confusion information, guidance regarding surgery and and support offered postoperative course

Emotional Support

Pt and family able to cope

Pt/Family Education

Pt/Fam orientation to ICU environment

Pt. Education initiated Pt safety needs addressed/initiated

D/C education Knowledge about completed w/ pt/family medication name, dose, frequency, route & potential adverse effects Able to name danger signs and appropriate action to take

Adequate understanding of information given by physician about diagnosis & surgery Pt/Family discuss expected LOS/discharge plan

D/C education Pt/family verbalize completed w/ pt/family understanding of neurosurgery D/C planner

D/C Planning

D/C date and plan D/C destination Pt/Family demonstrate D/C orders and scripts established/discussed confirmed w/ pt/family clear understanding of written and pt/family care upon discharge demonstrate understanding Pt. Family express Adequate understanding of understanding of home care services or recovery trajectory ECF D/C to home or ECF

2003

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Standard of Care: Neuroscience

Physical Therapy Management of the patient with neurological disorders and/or s/p neurosurgical procedures APPENDIX III
Brigham & Women's Hospital: Plan for Stay for NSU Spine Surgery Patients
Day of Surgery
Physical Status Maintains optimal neurological function

Post Op Day 1
Maintains optimal neurological function

Post Op Day 2
Maintains optimal neurological function

Post Op Day 3
Maintains optimal neurological function

Day of Discharge
Optimal neurological function. Stable for discharge

Maintains effective airway Effective cough and airway clearance Hemodynamically stable Hemodynamically stable for transfer Appropriate diet as tolerated Effective cough and airway clearance Appropriate collar/brace ordered Pt. Tolerates increased activity PT/OT consult if appropriate. Pt. Tolerate OOB Pt OOB/ambulating if appropriate Pt ambulating TID Pt demonstrated proper body mechanics for mobility/use of needed

Activity Emotional Support

Pt/Fam free of anxiety Pt/Family strength and and confusion regarding coping mechanisms surgery and postoperative assessed course Pt/Fam education initiated Pt education continued Discharge education initiated with pt/family D/C education completed Knowledge about w/ pt/family medication name, dose, frequency, route & potential adverse effects

Pt/Family Education

Adequate understanding of information given by physician about diagnosis & surgery

Pt/Family verbailze Able to name danger understanding of signs and appropriate neurosurgery D/C planner action to take

D/C Planning

Pt/Family discuss D/C destination confirmed Pt/Family demonstrate expected LOS/discharge w/ pt/family clear understanding of plan care upon discharge

D/C orders and scripts written

Pt/family understand and Pt/Family agree with accept discharge plan discharge plan Pt/Fam planning for D/C to home, rehab or 10AM discharge in 24 hrs ECF

K.Weber, PT Completed 4/03 Reviewed: Lorraine Downey 9/03 Finalized: 9/03 2005, Department of Rehabilitation Services, Brigham & Womens Hospital, Boston, MA 15