pt 159 treatment planning in pt

17 March 2010 Edward James R Gorgon MPhysio PTRP

PT 159 Treatment Planning in PT

Goal setting and treatment planning for

neurological cases

Learning objectives Discuss applications of principles of physical

therapy for people with neurological conditions in goal setting and treatment planning

Identify important considerations and issues in goal setting and treatment planning for specific neurological conditions

Identify remediable problems and clinically important outcomes for a given case

Edward James R Gorgon MPhysio PTRP

Learning objectives Argue the prognosis and therapy goals for a

given case Justify the treatment approach and strategies

for a given case Prescribe tactics that are appropriate for a

given case and that contain acceptable parameters

Use the FOR style correctly in documentation


Neurological conditions that are commonly referred to PT

Acquired brain injuries / lesions stroke (or cerebrovascular disease)

traumatic brain injury multiple sclerosis

Spinal cord and peripheral nerve injuries Neurodegenerative conditions

Parkinson’s disease Alzheimer’s disease



Path to movement dysfunction in CNS conditions

Functional recovery after damage to the CNS


Resolution of edema, diaschisis (“neural shock”)

Synaptogenesis Redundancy in nervous system functional

organization Bilateral representation of some

neurological functions in the brain Ada & Canning (1990)

Principles of physical therapy for central

neurological conditions Principles rooted in biological principles

relating to brain plasticity Use of a body part enhances its function

The ipsilateral hemisphere may contribute to motor control [bilateral symmetrical arm movement]

Sensory stimulation may enhance plasticity

Spasticity can be reduced (pharmacologically)


Hallett M (2002). Recent advances in stroke rehabilitation.


neurological conditions Principles rooted in empirical evidence

Task-oriented practice can promote recovery of locomotor ability

Stroke: Salbach et al (2004) [RCT]; Yang et al (2006) [RCT]

Parkinson’s disease: Cakit et al (2007) [RCT]; Miyai et al (2001) [small RCT]; Canning et al (2007) [case series]

Multiple sclerosis: Geisser et al (2007) [case series]



neurological conditions Principles rooted in empirical evidence

Early and intensive task-oriented practice of tasks can promote recovery of functional ability

Continuing physical therapy or commitment to physical activity can help maintain functional gains

Fitness training and prevention / reduction of deleterious effects of physical inactivity are paramount in neurophysiotherapy


Approaches to intervention


Movement re-education Neurofacilitation / neurophysiological

approaches Motor learning approach Compensatory approach

Common PT strategies


Therapeutic exercise Manual therapy Functional activity training Biofeedback, electrical stimulation Thermal (heating or cooling) agents Orthoses (mobility aids, seat, footwear) Environmental modification Patient and caregiver education

Impaired PHYSICAL INACTIVITY and FITNESS

Impairments in ATTENTION Changes in MUSCLE FIBERS and

CONNECTIVE TISSUES Impaired UPPER LIMB DEXTERITY Joint PAIN


Key issues in neurophysiotherapy

Stroke

Key clinical problems Clinical course and prognosisPhysiotherapy interventions

Important considerationsHelpful readings

Key clinical problems: impairments and activity limitations – variable


Stroke

StrokePrognosis – variable

No loss of consciousness

No / minimal involvement of vital functions

Incomplete motor paresis on admission

Recovery of sensory function within 48 hours

Recovery of reflex activity within 48 hours

Recovery of speech function

Environmental enrichment pre-injuryEdward James R Gorgon MPhysio PTRP


Significant change in motor function and functional ability during rehabilitation stay

Early intensive, task-specific training

No / few risk factors for a repeat stroke

No / minimal degree of perceptual impairment

High level of perceived social support

High level of patient motivation



Presence of large brain lesion

Prolonged stay in acute care or delayed onset of focused rehabilitation (more than 24 days)

Presence of flaccidity / severe muscle weakness 1 month post-stroke


StrokePrognosis – walking Van Peppen, et al. (2007)

Initial walking ability within 2 weeks post-stroke Degree of motor paresis of paretic lower limb Presence of homonymous hemianopsia Sitting balance Urinary incontinence Advanced age Initial functioning (ADLs) within 2 weeks post-stroke


StrokePrognosis – ADLs Van Peppen, et al. (2007)

Barthel Index score within 2 weeks post-stroke* Urinary incontinence within 2 weeks post-stroke Level of consciousness within 48 hours post-stroke Advanced age Status following recurrent stroke Degree of motor paresis Sitting balance within 2 weeks post-stroke Orientation in time and place Level of perceived social support


StrokePrognosis – upper limb use Van Peppen, et al. (2007)

Severity of arm paresis at 4 weeks post-stroke (using Fugl-Meyer Assessment)

Severity of upper limb paresis Voluntary grip function or wrist and finger extension

within 4 weeks post-stroke Muscle strength of paretic lower limb


Prognosis – possible outcomes Minimal neurological dysfunction

Chronic moderate to severe functional disability

Coma or death


Stroke

16 March 2009 Edward James R Gorgon MPhysio PTRP

What is the evidence for physiotherap

y for stroke?

StrokeHelpful readings

O’Sullivan SB, Stroke. In O’Sullivan SB, Schmitz TJ (2007). Physical Rehabilitation: Assessment and Treatment (5th ed.). Philadelphia: F. A. Davis Company.

Carr JH, Shepherd RB (2003). Stroke Rehabilitation: Guidelines for Exercise and Training to Optimize Motor Skill. London: Butterworth-Heinemann.

Van Peppen RPS, Hendriks HJM, Van Meeteren NLU, Helders PJM, Kwakkel G (2007). The development of a clinical practice stroke guideline for physiotherapists in The Netherlands: A systematic review of available evidence. Disability and Rehabilitation, 29, 767-83.

National Stroke Foundation (2005). Clinical guidelines for stroke rehabilitation and recovery. Australia.

Traumatic brain injury



Brain injury caused by trauma to the head

(including the effects upon the brain of other

possible complications of injury notably

hypoxaemia and hypotension, and

intracerebral haematoma)

UK Medical Disability Society (1988)



An insult to the brain, not of degenerative or congenital

nature but caused by an external physical force, that may

produce a diminished or altered state of consciousness,

which results in impairment of cognitive abilities or

emotional functioning… may be either

temporary or permanent and cause partial

or total functional disability or

psychosocial maladjustment

Harrison & Dijkers (1992)





Primary injury

MechanismAcceleration-deceleration injuries Rotational injuriesPenetration / missile injuries

Closed versus open injuriesClosed: coup-contrecoup lesionsOpen: skull fractures

Secondary injury

Cerebral hemorrhage / hematomaEpidural, Subdural, Intracerebral

Cerebral edema leading to increased intracranial pressure, brain distortion, herniationFocal, Generalized

Biochemical damage

Key clinical problems: impairments and activity limitations – variable



Prognosis – variable Cause, severity and location of injury

Age and overall health of the individual

Cognition, behavior, and communication

Co-morbid conditions (e.g., fractures)

Onset and quality of medical and rehabilitation

management

Family and social support Edward James R Gorgon MPhysio PTRP



Traumatic brain injurySeverity of brain injury

Glasgow Coma Scale (GCS) score: eye opening, best motor response, verbal responseMild (GCS 13-15), Moderate (GCS 9-12), Severe (GCS 3-8)Deep coma? Severe vegetative state?

Duration of comaMild (<15 min), Moderate (<6 hr), Severe (<48 hr), Very severe (>48 hr)

Post-traumatic amnesiaMild (<1 hr), Moderate (<24 hr), Severe (<7 d), Very severe (>7 d)

Prognosis – possible outcomes Minor / residual neurological deficits

Partial recovery of functions

Stupor

Coma

Vegetative state

Persistent vegetative state



Physiotherapy interventions Improvement of motor function

Consideration of associated musculoskeletal injuries

Provision of written and illustrated plan for other members of the team, including family / carers

Accommodation of patient’s normal environment and activities as far as possible



Physiotherapy interventions Proper positioning and techniques to improve joint

mobility and posture (especially if with spasticity)

Exercises to improve respiration, muscle strength, motor control, endurance, and overall conditioning

Activities to improve balance, gait, and mobility

Environmental adaptation (including seat, aids) for safety and mobility

Sensory stimulation and behavioral modification

Caregiver education



Physiotherapy evidence More intensive training: strong evidence

Continued outpatient therapy: moderate evidence Turner-Stokes, et al. (2005)

Serial casting for ankle contracture: strong evidence No added benefit of TTBWS: strong evidence Functional fine motor retraining : moderate evidence Specific STS training: moderate evidence Teasell, et al. (2007)

Multisensory stimulation programs in coma or vegetative states: no evidence Lombardi, et al. (2002)



Important considerations Cognitive deficits: thinking, memory, reasoning

Sensory problems: vision (e.g., neglect, field defects), hearing, touch, pain

Communication disorders: expression, understanding

Behavior / mental health issues:depression, anxiety, personality

changes, aggression, social inappropriateness



Traumatic brain injuryHelpful readings

Fulk GD & Geller AS, Traumatic Brain Injury. In O’Sullivan SB, Schmitz TJ (2007). Physical Rehabilitation: Assessment and Treatment (5th ed.). Philadelphia: F. A. Davis Company.

New Zealand Guidelines Group (2006). Traumatic brain injury: diagnosis, acute management and rehabilitation. Wellington, NZ.

Multiple sclerosis



Chronic, unpredictable / variable, often

disabling demyelinating CNS disease that

affects adults aged 20-40 years and is

characterized by exacerbation and remission

Multiple sclerosis


Multiple sclerosisKey clinical problems: impairments

Fatigue

Muscle weakness and spasticity

Impaired coordination and balance (ataxia, postural and intention tremors, hypotonia, truncal weakness)

Altered sensations* (numbness, paresthesias, impaired proprioception, dysesthesias, hyperpathia)


Multiple sclerosisKey clinical problems: impairments

Limitation of motion, postural malalignment

Impaired vision (blurring, scotoma, nystagmus, diplopia)*

Cognitive deficits

Depression, euphoria, emotional dysregulation

Bladder, bowel, sexual dysfunction


Multiple sclerosisKey clinical problems: activity limitations

Impaired walking and other mobility skills

Impaired reaching-grasping-manipulation for self-care tasks


Multiple sclerosisClinical course – variable

Relapsing-remitting

Primary-progressive

Secondary-progressive

Progressive-relapsing


Multiple sclerosisPrognosis – variable

Number of symptoms upon onset

Clinical course of disease

Complications

Onset before or after 40 years

Neurological status at 5 years


Multiple sclerosisPhysiotherapy interventions

Early focus on patient and caregiver education and self-management

Correction of (inefficient) compensatory strategies and malalignments

Strength and endurance training for weak muscles and to correct muscle imbalance

Orthotic prescription to improve limb movement functional mobility

Gait training to improve walking ability



Balance training; if required, training on compensations and modification of environment to decrease risk of falling

Stretching and proper positioning to relieve spasticity / muscle spasms

Proper seating, postural alignment and pressure relief to alleviate pain Patterned (weighted) movements and limb stability

exercises to decrease tremors



Exercises therapy to increase muscle power, exercise tolerance, and aspects of mobility, and decrease fatigue (without documented deleterious effects)

Neill, et al. (2006); Reitberg, et al. (2005); Snook & Motl (2009)

Weight-supported treadmill training to improve strength, spasticity, endurance, balance, mobility, and quality of life Geisser, et al. (2007)


Multiple sclerosisImportant considerations

Effects of impaired physical activity Motl, et al. (2005); White & Dressendorfer (2004); Zalewski

(2007)

Fatigue Kos, et al. (2008)

Heat intolerance

Cognitive and speech deficits

Emotional, social and vocational issues


Multiple sclerosisHelpful readings

O’Sullivan SB, Multiple Sclerosis. In O’Sullivan SB, Schmitz TJ (2007). Physical Rehabilitation: Assessment and Treatment (5th ed.). Philadelphia: F. A. Davis Company.

Zalewski K (2007). Exploring barriers to remaining physically active: a case report of a person with multiple sclerosis. Journal of Neurological Physical Therapy, 31, 40-45.

Parkinson’s disease



Characterized by the progressive death of selected

but heterogeneous populations of neurons… results

in a regional loss of striatal dopamine,

most prominently in the dorsal and

intermediate subdivisions of the

putamen, a process that is believed

to account for akinesia

and rigidity Lang & Lozano (1998)



Parkinson’s diseaseCardinal clinical features

Bradykinesia / akinesia

Rigidity

Resting tremors in the limbs or jaw

Postural instability


Parkinson’s diseaseVersus parkinsonism due to other causes

Asymmetry of signs and symptoms

Presence of resting tremors

Good response to levodopa


Parkinson’s diseaseClinical course – progressive; variable


Prognosis – variable Slow progression of symptoms, if of the tremor-dominant type; infrequent occurrence of cognitive impairments

Rapid progression of symptoms, if of the akinetic-rigid type; rigidity and

hypokinesia initially, then balance and gait problems

(+) young age

(-) recurrent falls and physical inactivityEdward James R Gorgon MPhysio PTRP


Parkinson’s diseasePhysiotherapy interventions

Prevention of physical inactivity

Prevention of falls

Improvement of functional ability

Decrease in limitations in daily activities


Parkinson’s diseasePhysiotherapy interventions – early

Prevention of physical inactivity

Prevention of fear of movement or falling

Prevention of limitations in daily activities

Preservation or improvement of physical capacity (aerobic endurance, muscle

strength, joint mobility)

Patient education and exercise therapy


Parkinson’s diseasePhysiotherapy interventions – mid

Preservation or improvement of function and activities in 5 key areas: transfers, body posture, reaching and grasping, balance, and gait / walking

Prevention of falls

Exercise therapy (focus on activities), with cognitive movement and cueing strategies and with caregiver involvement


Parkinson’s diseasePhysiotherapy interventions – late

Preservation of vital functions

Prevention of complications

Supported exercise therapy; postural correction in bed / wheelchair;

education on pressure sore and contracture prevention (largely involving caregiver)


Parkinson’s diseasePhysiotherapy interventions – mid-late


Parkinson’s diseaseImportant considerations

Effects of physical inactivity and fear of fall

Side effects of drugs, e.g. on-off phenomenon, dyskinesias, orthostatic hypotension

Physical and mental fatigue

Cognitive and speech deficits

Depression


Parkinson’s diseaseHelpful readings

O’Sullivan SB, Parkinson’s Disease. In O’Sullivan SB, Schmitz TJ (2007). Physical Rehabilitation: Assessment and Treatment (5th ed.). Philadelphia: F. A. Davis Company.

Royal Dutch Society for Physiotherapy (2006). KGNF guidelines for physical therapy in patients with Parkinson’s disease. Dutch Journal of Physiotherapy, 114 (Supplement).

pt 159 treatment planning in pt

Documents

focused physical therapy

physical activity

therapy goals

neurological functions

functional recovery

salbach et

geisser et

cakit et