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Positioning and Early Mobility

July 12th 2016/ Sara Gawned (Principal Physiotherapist –

Neurosciences)

Outline

Review the positioning and mobility recommendations

in key guidelines.

Develop an understanding of the consequences of

immobility on the systems of the body.

Develop an awareness of the use of different

equipment in the delivery of postural management and

early mobility.

Positioning and Early Mobility/ St George’s University Hospitals NHS Foundation Trust

The dangers of going to bed

Asher 1942

Look at the patient lying alone in bed

What a pathetic picture he makes.

The blood clotting in his veins.

The lime draining from his bones.

The scybola stacking up in his colon.

The flesh rotting from his seat.

The urine leaking from his distended bladder and the spirit

evaporating from his soul.

Teach us to live that we may dread unnecessary time in bed. Get

people up and we may save patients from an early grave.


Why is positioning and

early mobility important?

Regain function

Reduce complications

Patient benefit

EBP

Use of best practice

guidelines

Positioning and Early Mobility / St George’s University Hospitals NHS Foundation Trust

Guidelines – What do they say?


NICE Stroke Rehabilitation in Adults 2013

Treatment for people with movement difficulties after

stroke should continue until the person is able to

maintain or progress function either independently or

with assistance from others.

Manage shoulder pain after stroke using appropriate

positioning.


RCP National Clinical Guideline for Stroke

2012

All patients should be assessed within a maximum of 4

hours of admission for their:

• Immediate needs in relation to positioning, mobilisation, moving and handling

Positioning:

When lying and when sitting, patients should be

positioned in such a way that minimises the risk of

complications

Assisted to sit up as soon as possible.


RCP National Clinical Guideline for Stroke

2012 continued

Mobility:

All patients with reduced mobility

regularly assessed to determine the most

appropriate and safe methods of transfer and

mobilisation

Mobilised within 24 hours of stroke onset

Offered frequent opportunity to practice functional

activities


Healthcare for London Stroke Strategy for

London 2008

100% of patients with appropriate seating,

posture and positioning within 24 hours of

admission to a Stroke Unit



Nursing

OT

Physio

Is it safe?


AVERT – is early safe?

Phase II Feasibility and Safety trial suggested very early mobility (VEM) was safe and feasible (Bernhardt et al, 2008)

Full trial efficacy and safety results suggest a less favorable outcome at 3 months for the VEM group

Both groups had a median time to first mobility of less than 24 hours

Over course of trial the time for first mobilisation for the usual care (UC) group reduced by 28 mins each year

VEM group had more frequent out of bed sessions

(The AVERT Trial Collaboration Group, 2015)


AVERT – Dose / response

Shorter more frequent mobilisations were associated

with greater odds of favorable outcome at 3 months

MRS 0 – 2

Walking 50m unaided

Less frequent, longer mobilisations were more likely to

result in worse outcomes

Consider what this means for delivery of rehabilitation for

nurses and therapists


Muscle

Skeletal

Respiratory


RESPIRATORY SYSTEM

16 Positioning and Early Mobility / St George’s University Hospitals NHS Foundation Trust

How do we breathe?

Inspiration

The action of breathing is due to changes in pressure within the thorax

Firing of inspiratory nerves from respiratory centres

Intercostals/Diaphragm contract

(Diaphragm flattens, rib cage moves up and out)

Expansion of chest cavity creating –ve pleural pressure

Lung expands and air rushes in


How do we breathe?

Expiration

Feedback from stretch receptors in lung/rib cage and chemoreceptors in aortic and

carotid bodies

Diaphragm and intercostal muscles relax, return to resting

position

Size of thoracic cavity reduces

Air flows out of lungs

Positioning and early Mobility / St George’s University Hospitals NHS Foundation Trust

18

Normal mechanics of cough

What makes an effective cough?

Ability to inspire 85-90% of total lung

capacity

Intact bulbar function, enabling rapid closure of the glottis

Contraction of abdominal and intercostal expiratory muscles to generate a peak cough flow

Affected by weakness of:

Inspiratory/expiratory intercostal muscles

Abdominal muscles

Bulbar function

Positioning and Early Mobility / St George’s University Hospitals NHS Foundation Trust 19

Implications poor chest wall alignment

Musculoskeletal Changes

Pain

Joint Stiffness

Increased Work of Breathing

Poor Cough

Retention of Secretions

Fatigue

Regional Hypoventilation

Poor resting position of diaphragm


Positioning and FRC in full

Already recognise

that general changes

in position can

improve functional

residual capacity

(FRC) – Lumb, 2000


Postural Drainage

Aids clearance of retained secretions

Adopt positions assisted by gravity to drain excess secretions from the lungs

Can aid management of aspiration pneumonia


How can we influence this?

Positioning and

Mobility

Alignment of ribs

Resting position of diaphragm

Length of intercostal

muscles

Reduce over

activity or spasticity

Reduce muscular fatigue

Postural drainage

of secretions

Increasing lung

volumes (FRC)


MUSCULOSKELETAL SYSTEM



Muscle weakness

Immobilisation

Muscle wasting

Joint damage

CNS Damage

UMN lesion

Negative Positive

Weakness

Limited movement

Soft tissue changes Pain Excessive or inappropriate movement

Impedes rehab Impairs function Damages tissue

Static

Increased tone

Reduced ROM

Dynamic

Spasms

Associated Reactions

Normal muscle function

Work concentrically, eccentrically or synergistically in movement

Provide postural stability

Provide selective/active movement


Changes to muscle with immobility

Loss of strength

Loss of muscle mass

Greatest in the postural muscles


Changes to skeletal system with immobility

Loss of bone density

Increase in the excretion of calcium in the urine and stool

Involvement: long bones; develops from the bone marrow

outward

Fibrofatty connective tissue within the joint space (15 days)

Atrophy of joint articular cartilage (1 month) (Evans et al 1960 from

Petty and Moore, 2004)


How can we influence this?


Prevention of musculoskeletal adaptations Optimisation of functional movements Normalising sensory and proprioceptive

input

24 hour management – limb care through positioning, seating, mobilising

Optimisation of long term function by minimising

secondary changes

HOW DO WE ASSESS ABILITY

TO MOBILISE


Clinical Observations

Are they medically stable from a stroke perspective?

What does the patients observation chart say:

Consider the patients observations in comparison to

normal values

Consider the individual trend of the patients

observations

Continually monitor observations during session

32

Physical Assessment

Selective or voluntary movement ability (UL, LL and

Trunk)

Ability to detect sensation

Awareness of self in space (proprioception and body

schema)

Co-ordination (UL and LL)

Midline awareness/sitting balance

Signs of over-activity

33

Other considerations

Fatigue

Communication

Ability to understand verbal instructions

Ability to communicate

Cognition

Ability to process information during and after

mobilising

Ability to plan and sequence movement

Safety

Behaviour

Presentation title / St George’s University Hospitals NHS Foundation Trust

HOW DO WE PUT THIS INTO

PRACTICE?


Know your equipment – Positioning aids


Know your equipment… Seating


Know your equipment… transfer aids


Case Study 1

39 year old male with a large left MAC infarct following

left carotid dissection

GCS E4, V3, M6; Respiratory and CVS stable

Severe weakness right upper limb, mild weakness left

trunk and lower limb

Mild receptive apahasia, severe expressive aphasia

Normal diet and fluids

Reporting pain in right shoulder

Low mood


What would you need to consider when assessing

whether this patient can sit out of bed?

What would you suggest as appropriate seating for this

patient?

What are the benefits of seating this patient?


Case Study 2

82 year old female with a right thalamic infarct

GCS E2, V1, M5; SpO2 94% on FiO2 40%, RR 18, CVS

stable

Dysphagic NGT insitu

Aspiration pnuemonia with radiographic changes within

right lung fields

Poor cough due to reduced conscious level


What might you consider when positioning this patient?

Can we seat this patient?


Summary

Immobility/bed rest negatively affects all systems of the

body

Early, less frequent out of bed sessions in the acute post

stroke phase appears more favorable than very early,

more frequent out of bed sessions

The risk of developing serious complications within the

respiratory and musculoskeletal systems can be limited

by staff with an understanding of the physiological and

psychological benefits of positioning/mobility

Knowledge and appropriate use of equipment is

important to facilitate this aspect of care


References

Bernhardt, J., Dewey, H., Thrift, A., Collier, J. & Donnan, G. (2008). A very early rehabilitation trial for stroke (AVERT): phase II safety and feasibility. Stroke, 39(2), pp. 309 – 396.

Bernhardt, J., on behalf of the AVERT Collaboration Group (2016). Prespecified dose-response analysis for A Very Early Rehabilitation Trial (AVERT). Neurology, 86, pp. 1 – 8.

Lumb, A.B. (2010). Nunn’s Applied Respiratory Physiology 7 ed. Edinburgh: Churchill Livingstone.

Petty, N.J. and Moore, A.P. 2001. Neuromusculoskeletal Examination and Assessment 2nd Ed. Edinburgh: Churchill Livingstone.

The AVERT Trial Collaboration Group (2015). Efficacy and safety of very early mobilisation within 24 h of stroke onset (AVERT): a randomised controlled trial. The Lancet, 386 (9988), pp. 46 – 55.


positioning and early mobility...nice stroke rehabilitation in adults 2013 treatment for people with...

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