Faculty of physical therapy Cairo University

QUADRIPLEGIA
Presented by: Abeer abd elmoghny Asmaa elsayed Nermin mounir Omnia Mohamed

Under supervision of Dr /GEHAN MOUSA

Quadriplegia
Definition:
It is partial or complete paralysis involving all four limbs and trunk including respiratory muscles as a result of damage of the cervical spinal cord.

Causes of lesion:
Trauma to neck, back, spinal cord, or brain Whiplash in a motor vehicle collision Vertebral fracture crushing spinal cord, dislocation causing spinal cord compression, or disc prolapse Glioma A brain tumor that is created within the glial cells Metastatic tumors Cancer that spreads from bone to bone Multiple Myeloma A cancer of the white blood cells Osteoporosis A disease of the bone that induces fractures Multiple Sclerosis A disease of the immune system that attacks the spinal cord Acute disseminated encephalomyelitis An immune deficiency similar to Multiple Sclerosis that attacks the brain Tuberculosis A deadly disease caused by mycobacteria that attacks the immune system, bones, and joints

Types of lesion:
1) Complete: the damage is so extensive that no nerve impulses from
brain reach below the level of spinal cord Loss of voluntary movement of parts innervated by segment, this is irreversible Loss of sensation Spinal shock

2) Incomplete: where some or all of the nerves escape lesion injury.

Some function is present below site of injury More favorable prognosis overall Are recognizable patterns of injury, although they are rarely pure and variations occur.

Clinical picture:
The patient passes through two stages: 1) Spinal shock stage. 2) Spastic stage.

1) Spinal shock stage:

-Loss of consciousness. -Complete sensory loss below level of lesion. -Complete flaccid paralysis of all muscles. -Absence of bladder and bowel reflexes. -Abolishing of superficial & deep reflexes. -Respiration affection. -It may be last from hours to days or weeks (2 to 6 weeks) depending on whether lesion is complete or incomplete, spinal or cerebral, high or low spinal lesion.

2) Spastic stage:
Gradually the cells in the isolated cord recover independent function although no long controlled by the brain. The reflexes return and the stage of spasticity begins. Spasticity in the lower limbs extensors more than in the upper limb flexors (antigravity muscles)

Clinical picture according to level of injury:

C1 to C3 Injuries Functional Movement

No movement in the arms or legs Very little movement in the neck and head (C3) Ventilator dependent for breathing Difficulty speaking clearly and loudly

Respiratory Care

Mobility

Can operate a power wheelchair with mouthsticks, chin controls, sip and puff, tongue controls, and possibly head controls Power tilt recommended for pressure relief Fully dependent on caregivers for everything Technology can substitutes many functional losses

Daily Living

C4 Injuries Functional Movement

Head and neck control Can shrug the shoulders Typically not ventilator dependent Many initially require ventilator support but are able to be weaned off Quad cough assistance Patient with complete lesion at c4 has loss of vasomotor control as result of paralysis of vasoconstrictors ,there is marked vasodilatation ;this causes blockage of nasal air passages which adds to the difficulties of respiration without tracheostomy ,this phenomena known as Guttmanns sign.

Respiratory Care

Mobility

Can operate a power wheelchair with head controls or sip and puff controls

Daily Living

Fully dependent on caregivers for everything Technology can substitutes many functional losses

C5 Injuries Functional Movement

Can move arms with shoulder and bicep muscles

Respiratory Care

No ventilator assistance Quad cough assistance Can operate a power wheelchair with hand controls Can operate a manual wheelchair for short distances on flat surfaces (emotion wheelchair is the best choice) Power tilt recommended for pressure relief (manual pressure relief by leaning side to side)

Mobility

Daily Living

Independence possible with specially designed equipment (drinking, eating, bathing, driving)

C6 Injuries Functional Movement

Can move head, neck, arms, triceps, and wrists Quad cough assistance Can use a manual wheelchair for most daily activities Power wheelchairs can be used for convenience No power tilt, can independently perform pressure relief Independence achieved with training and specially designed equipment (drinking, eating, bathing, driving, turning in bed)

Respiratory Care

Mobility

Daily Living

C7 and C8 Injuries Functional Movement

Can move head, neck, arms, triceps, wrists, and has different degrees of finger function

Respiratory Care

Quad cough assistance

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Mobility

Can use a manual wheelchair Power wheelchairs can be used for convenience No power tilt, can independently perform pressure relief Independence achieved with training and specially designed equipment (drinking, eating, bathing, driving, turning in bed, manual transfers, household chores)

Daily Living

Initial management goals in spinal cord injury

1. Prevention of secondary injury and neurological deterioration. The key to recovery is the number and quality of surviving axons traversing the injured segment. The spine should be immobilized. Secondary neuronal injury will be minimized by maintaining spinal cord perfusion and oxygenation. SCI causes a functional sympathectomy, the results of which are vasodilatation, increased venous capacitance and relative hypovolemia, all of which contribute to hypotension and reduced cord perfusion. Above T4 the sympathetic drive to the heart is also lost resulting in loss of the ability to increase cardiac output in response to hypotension. This neurogenic shock may be exacerbated by hypovolemia due to other injuries Good oxygenation should be maintained with ventilatory support as required. Systemic hypotension should be corrected by volume replacement and vasopressors to maintain the mean systemic arterial pressure at 90mmHg, and central venous pressure at510mm .Neurogenic shock may be distinguished from hypovolemic shock secondary to associated injuries by the presence of warm peripheries and bradycardia. 2. Identification and management of associated injuries. The history and examination will give clues to both these and the pattern of spinal injury that is to be expected. The presence of head injury, limb fractures, peripheral nerve injury, and spinal shock can make an accurate neurological examination impossible during the initial assessment.

3. Determination of the degree and extent of neurological injury:

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(a) Sensory examination: at each of the key dermatomal points .Two aspects of sensation are examined: pin prick and light touch. Sensation is scored as absent (0), impaired (1), or normal (2) and a total score calculated .Anal sensation is assessed by digital examination. Joint position sense can also be recorded. (b) Motor examination: each of the key myotome is assessed. Treatment of the spinal injury itself is directed towards two parallel concerns: restoration of spinal alignment/stability and promotion of neurological recovery. These two aims are not independent; restoration of alignment is important not only in preventing subsequent painful and progressive deformity but also in facilitating neurological recovery

Conservative management
The basis of conservative management is fracture reduction and bed-rest until the fracture is stable enough for mobilization. In the cervical spine reduction can be achieved and maintained with traction. Following mobilization, stability can be maintained by an external orthosis.

The role and timing of decompressive surgery

The timing and role of decompressive surgery is even more controversial. The single widely accepted indication for decompression is progressive neurological deterioration due to spinal cord compression. There is strong evidence that early decompression improves neurological recovery after SCI. Even in the presence of an incomplete injury, the evidence for neurological benefit from surgical intervention is not in controvertible.

Post-operative complications:
Skin Breakdown pneumonia Osteoporosis and Fractures Heterotopic Ossification Spasticity Urinary Tract Infections
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Autonomic Dysreflexia Deep Vein Thrombosis Pulmonary Embolism Orthostatic Hypotension Cardiovascular Disease Neuropathic / Spinal Cord Pain

1) Pressure sores:
It is skin breakdown caused by unrelieved pressure that damages the skin and underlying tissue.

Stages of pressure sores and how to care for them: Pressure sores are categorized into four key stages depending on
their age and severity. It is always wise to seek medical advice from a Doctor or health care giver if you suspect the start of a pressure sore when away from a hospital environment. As with most potential complications it is best to intervene as early as possible to prevent the problem worsening.

STAGE ONE How to recognize: Skin is not broken but is red or

discolored. The redness or change in color does not fade within 30 minutes after pressure is removed.

What to do:
1. Keep pressure off the sore! 2. Maintain good hygiene. Wash with mild soap and water, rinse well, pat dry carefully (but gently). Do not rub vigorously directly over the wound. 3. Evaluate your diet -- are you getting enough protein, calories, vitamins A and C, zinc and iron? All of these are necessary for healthy skin. 4. Review your mattress, wheelchair cushion, transfers, pressure releases, and turning techniques for possible cause of the problem.
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5. If the sore seems to be caused by friction, sometimes a protective transparent dressing such as Op-Site or Tegaderm may help protect the area by allowing the skin to slide easily.

6. If the sore does not heal in a few days or recurs, consult your Doctor or health care provider. STAGE TWO How to recognize: The epidermis or topmost layer of the
skin is broken, creating a shallow open sore. Drainage may or may not be present.

What to do: Follow steps 1-4 under Stage One. Consult your health care
provider for further treatment, which may include the following:

Cleanse the wound with saline solution only and dry carefully. Apply either a transparent dressing (such as Op-Site or Tegaderm), a hydrocolloid dressing (such as DuoDERM), or saline dampened gauze. The first two types of dressing can be left on until they wrinkle or loosen (up to 5 days). If using gauze, it should be changed twice a day and should remain damp between dressing changes. Check for signs of wound healing with each dressing change. If there are signs of infection (see Signs of trouble), Doctor or health care provider for alternative wound care ideas and review of possible causes (see step 4 under Stage One).

STAGE THREE How to recognize: The break in the skin extends through
the dermis (second skin layer) into the subcutaneous and fat tissue. The wound is deeper than in Stage Two.

What to do: Follow steps 1-4 under Stage One and the additional steps
under Stage Two. Always consult your health care provider. Wounds in this stage frequently need additional wound care with special cleaning or debriding agents. Different packing agents, and occasionally, antibiotics
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(creams or oral pills) may be required. You may also qualify for a special bed or pressure-relieving mattress that can be ordered by your Doctor or health care provider.

STAGE FOUR How to recognize: The breakdown extends into the

muscle and can extend as far down as the bone. Usually lots of dead tissue and drainage are present.

What to do: Consult your Doctor or health care provider right away.
Surgery is frequently required for this type of wound.

Signs of an infected bed sore include:

Bad smell from the sore Redness and/or warmth around the sore Swelling around the sore area. Tenderness around the sore Yellow or green pus

Signs that the infection may have spread or be spreading:

General overall feeling of weakness Fever or chills Mental confusion or difficulty concentrating Rapid heartbeat

Prevention of bed sores:

Appropriate seating / equipment - It is important that any

equipment provided, such as seating or beds, give good support to all areas of the body - spreading load evenly. Relieving pressure from areas at risk - Pressure should be relieved from the body at regular intervals - especially over bony prominences or areas of concern. It is important to allow time for blood to flow normally to pressure areas so that skin cell oxygen levels can be restored. If a person cannot change positions independently, they will need to be assisted by a care giver. Appropriate manual handling techniques - To reduce the effect of friction and shear on the skin, appropriate manual handling
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techniques and equipment need to be used. Slide sheets and hoists can be useful to reduce shear when transferring or repositioning although a thorough risk assessment should be completed. Using pressure relief equipment - Pressure relief equipment may include mattresses, cushions, bed cradles and joint protectors. Some products may have a pressure relief rating to assist health professionals choose the correct products for their client. These ratings have been provided by the product's suppliers, and are intended as a guide only. A full assessment by an appropriate health professional in conjunction with product suppliers as required is strongly advised.

Skin Management
Pressure sores are one of the worst potential complications of a spinal cord injury. However with appropriate skin management techniques you can prevent them.

In order to prevent skin sores, you must:

Check your whole body frequently Relieve skin pressure Take routine care of your skin

Check your whole body, but pay special attention to bony areas: By inspecting your skin regularly, you can spot a problem at the
very beginning. Checking your skin is your responsibility and the way to spot the warning signals of a problem. Don't just ask someone else how your skin looks. If you need someone to help you check, you must be able to tell him or her what to look for.

How Often?

At least twice daily. Morning and evening when dressing or undressing are recommended. Check more frequently if you are increasing sitting or lying times.
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Checking whenever recommended Watch For?

you

change

position

is

Any areas previously broken and healed over - scar tissue breaks easily.

What Are Redness, blisters, opening in skin, rashes, etc. Feel You for heat in red areas with the back of your fingers. Looking For? Equipment Long-handled mirrors. If you need help, ask Needed? someone to position mirrors for you - one at the head and one over the pressure point. Which Check the areas shown in the diagram Parts To below on the front, back, and sides of Check? your body. Remember: Bony areas of the body are the most likely to get sores, so be sure and look at them. When checking your skin, don't forget your groin areas for rashes or sores from tight clothing. Men who wear an external catheter should check the penis carefully for sores or irritations.

Relieve Skin Pressure: In addition to routinely checking your skin, a

second important way to prevent pressure sores is to relieve skin pressure by changing position or being positioned so that pressure is taken off a bony area. The purpose of relieving pressure is to let the blood supply get to the
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skin. If pressure is not relieved, blood will continue to be pressed out of a blood vessel and will not get to the skin to keep it healthy

Pressure Relief in a Wheelchair: Weight shifts are the most

essential techniques for preventing pressure on the skin and muscle of the sacrum (tailbone) and each hip. Use the method you and your therapists have found to be the most effective for you. Know your skin tolerance at all times. The frequencies with which you do weight shifts vary from time to time.

Cushions: A cushion for your wheelchair is essential. Cushions provide

pressure relief and weight distribution and thus aid in the prevention of pressure sores. Many types of cushions exist, but there is no "ideal" cushion. Use the cushion recommended by your physical therapist/physiatrist.

If air is used in the cushion, check to see that it is filled correctly. If you are going to a different altitude, there will be a change in your cushion. If your cushion is made of foam, check to see that it is firm and in good condition. If it gets dry, powdery and loses its firmness, replace it immediately. Use only good quality foam. Polyurethane foam with a density of 1.2 and compression of 30 to 35 is recommended. In case of body weight change, you may need to change the width of your chair, the frequency of your weight shifts, and the type of cushion you use.

Never use rubber air rings or rubber doughnuts. They are dangerous because they block the flow of blood to the skin inside the leg. Weight shifts are essential. The cushion alone will not prevent pressure sores. In Addition:

Make sure the foot pedals of your wheelchair are adjusted to the right height for you. If your foot pedals are too high, it will put pressure on your hips; Sit up straight in your chair. Slumping or slouching leads to added pressure over the end of your tailbone.

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Lifting your bottom from the wheelchair may be managed by lifting through your arms and taking your body weight for at least 30 seconds. If you don't have sufficient strength to do this yourself assisted relief can be practiced by leaning forwards or to one side.

2) Respiratory problems:
Spinal cord injuries can weaken the abdominal and chest muscles; sometimes movement of these muscles is completely impaired. If diaphragm muscles are completely paralyzed patient will be incubated and may have to stay on a ventilator for a period of time; some people can learn to consciously breath and can thus stay off the ventilator for periods of time. Even if breathing is not directly impaired, pt is still at greater risk of pneumonia. Pulmonary Embolism PE - Pulmonary Embolism is caused by part of a Deep Vein thrombosis travelling from the leg to the lungs. This can lead to a partial or complete lung obstruction. Onset of a pulmonary embolism can be sudden, with symptoms of shortness of breath, a fast heartbeat, chest pain, or a blue tinge to the fingers, toes or lips. Immediate medical assistance is necessary.

Managing respiratory complications: Respiratory exercises. Medication to prevent lung infection. Changing position frequently. Turning in the bed every 2 hours. Chest percussion

3)Osteoporosis and Fractures :

The majority of people with SCI develop osteoporosis. In people without SCI, the bones are kept strong through regular muscle activity or by bearing weight. When muscle activity is decreased or eliminated and the legs no longer bear the body's weight, they begin to lose calcium and phosphorus and become weak and brittle. It generally takes some time for osteoporosis to occur. In people who use standing frames or braces, osteoporosis is less of a problem. Generally, though, 2-4 years following SCI some degree of bone loss will occur. Using the legs to provide support in transferring is helpful in increasing the load on the bones, which may reduce or slow down the osteoporotic process. Standing using a standing frame or a standing
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table also helps prevent weakening of the bones and so does using braces for functional or parallel bar walking. Newer techniques, such as electrical stimulation of the leg muscle may decrease osteoporosis as well. Unfortunately, at the present time, there is no way to reverse osteoporosis once it has occurred. The main risk of osteoporosis is fracture. Once the bones become brittle, they fracture easily. An osteoporotic bone takes much longer to heal. Fractures are also a potential problem to the newly injured person often caused by inappropriate handling of their limbs post injury too.

4) Heterotopic Ossification:
Heterotopic ossification is a condition not well understood that occurs in acute spinal cord injury and consists of the laying down of bone outside the normal skeleton, usually occurring at large joints such as the hips or knees. The primary problem with Heterotopic ossification, or HO, is the risk for joint stiffening and fusion. Should the hip or knee become fused in a certain position, a surgical release is necessary to allow range of motion to occur. Unfortunately, it takes between 12 and 18 months for Heterotopic bone to mature once it has developed. Activities that are used to prevent the development of HO include range of motion programs and other functional activities that move the joints within a functional range. Currently treatment is limited with the exception of preventing the joint fusion (termed amyloses)

5) Spasticity:
After spinal cord injury the nerve cells below the level of injury become disconnected from the brain. Following the period of spinal shock changes occur in the nerve cells that control muscle activity. Spasticity is an exaggeration of the normal reflexes that occur when the body is stimulated in certain ways. After spinal cord injury, when nerves below the injury become disconnected from those above, these responses become exaggerated. Muscle spasms, or spasticity, can occur any time the body is stimulated below the injury. This is particularly noticeable when muscles are
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stretched or when there is something irritating the body below the injury. Pain, stretch, or other sensations from the body are transmitted to the spinal cord. Because of the disconnection, these sensations will cause the muscles to contract or spasm. Almost anything can trigger spasticity. Some things, however, can make spasticity more of a problem. A bladder infection or kidney infection will often cause spasticity to increase a great deal. A skin breakdown will also increase spasms. In a person who does not perform regular range of motion exercises, muscles and joints become less flexible and almost any minor stimulation can cause severe spasticity. Some spasticity may always be present. The best way to manage or reduce excessive spasms is to perform a daily range of motion exercise program. Avoiding situations such as bladder infections, skin breakdowns, or injuries to the feet and legs will also reduce spasticity. There are three primary medications used to treat spasticity, baclofen, Valium, and Dantrium. All have some side effects and do not completely eliminate spasticity. There are some benefits to spasticity. It can serve as a warning mechanism to identify pain or problems in areas where there is no sensation. Many people know when a urinary tract infection is coming on by the increase in muscle spasms. Spasticity also helps to maintain muscle size and bone strength. It does not replace walking, but it does help to some degree in preventing osteoporosis. Spasticity helps maintain circulation in the lefts. IT can be used to improve certain functional activities such as performing transfers or walking with braces. For these reasons, treatment is usually started only when spasticity interferes with sleep or limits an individual's functional capacity.

6)

Urinary Tract Infections:

UTI - Urinary Tract Infection is a common complication for individuals with voiding dysfunction. An infection occurs when bacteria grows in the bladder. The most common way for a UTI to occur in individuals with spinal cord injury is for bacteria to enter the bladder while catheterizing. Other ways are from delayed use of the toilet or incomplete emptying of urine.

Signs of a Urinary Tract Infection

Fever Chills Pain with urination
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Increased spasticity. Blood in urine Cloudy urine

Bladder Management after SCI Suprapubic Catheter:A tube is inserted through the abdomen and into
the bladder, where a balloon on the end holds it in place. It remains in the bladder and drains constantly, so the bladder is never full.

Indwelling Catheterizations: The bladder is drained by having a

tube inserted which then drains urine into a bag. Most commonly seen in early hospital stage of rehabilitation and not normally used again unless infection is a problem. Tube can be clamped to allow bladder muscle to expand.

Intermittent Catheterizations: You drain your bladder several times

a day by inserting a small rubber or plastic tube. The tube does not stay in the bladder between catheterizations. Several different discrete types of intermittent catheter are available and this is one of the common preferred methods of bladder management post hospital stay. External Bladder Control Methods: Condom Drainage A condom catheter is a way to drain the bladder without putting a catheter (rubber tube) inside urethra. A condom catheter is a rubber sheath that is put over penis. It is also called a Texas catheter. The catheter allows bladder to empty without using a urinal, bedpan, or toilet. The condom catheter is hooked to a plastic tube which leads to a bag. The urine stays in the bag until it is emptied into the toilet. External Continence Device (ECD) An ECD is a method of continence management that attaches only to the tip of the penis using hydrocolloid, a hypoallergenic adhesive commonly used in wound care. Urine is directed into a collection bag and does not come in contact with skin.

Spontaneous Voiding
The bladder muscles contract to start the bladder-emptying process. This may be under your control (voluntary) or not (involuntary)

Normal Voiding
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This is done under control. When the bladder gets full, messages are sent to the sacral level of the spinal cord and carried to the brain. The brain sends messages back to the bladder to contract and to the sphincter muscle to open, so patient can void.

Sphincterotomy
This surgical process weakens the bladder neck and sphincter muscle to allow urine to flow out more easily. After this surgery, you will urinate involuntarily, and must wear a collection device.

Stimulated Voiding Voiding is encouraged in one of several ways, such as: Anal or Rectal Stretch
This method for relaxing the urinary sphincter is usually used along with an abdominal corset and valsalva Crede This method involves manually pressing down on the bladder. Tapping The area over the bladder is tapped with the fingertips or the side of the hand, lightly and repeatedly, to stimulate detrusor muscle contractions and voiding. Valsalva This method involves increasing pressure inside the abdomen by bearing down as if you were going to have a bowel movement. Bladder Augmentation Surgical enlargement of the bladder.

7) Autonomic Dysreflexia
It is related to disconnections between the body below the injury and the control mechanisms for blood pressure and heart function. It causes the blood pressure to rise to potentially dangerous levels.

Causes of AD:
Skin infection or irritations, cuts, bruises, abrasions Pressure sores (decubitus ulcer) Abdominal discomfort Bone fractures Full bladder Bladder infection Sever constipation

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Signs & Symptoms:

Pounding headache (caused by the elevation in blood pressure) Goose Pimples Sweating above the level of injury Nasal Congestion Slow Pulse Blotching of the Skin Restlessness Hypertension (blood pressure greater than 200/100) Flushed (reddened) face Red blotches on the skin above level of spinal injury Sweating above level of spinal injury Nausea Slow pulse (< 60 beats per minute) Cold, clammy skin below level of spinal injury

Treatment of AD:
The treatment for Autonomic dysreflexia involves removing the reason for the stimulation. One of the first things a patient can do is to sit up. This naturally decreases blood pressure. If there is a catheter in place, it should be checked to be certain that there is not a kink in the tubing. If there is not a catheter in place, the patient should be catheterized. The bowels should be checked to be certain there is no stool in the rectum. If the symptoms are caused by skin breakdown, the patient should get to an emergency department as soon as possible.

Prevention of AD:
The following are precautions can take which may prevent episodes of Autonomic dysreflexia: Frequent pressure relief in bed/chair Avoidance of sun burn/scalds Maintain a regular bowel program. Well balanced diet and adequate fluid intake Compliance with medications Persons at risk and those close to them should be educated in the causes, signs and symptoms, first aid, and prevention of autonomic dysreflexia. If you have an indwelling catheter:
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o Keep the tubing free of kinks o Keep the drainage bags empty o Check daily for grits (deposits) inside of the catheter. If patient on an intermittent catheterization program, catheterization as often as necessary to prevent overfilling. If patient has spontaneous voiding, make sure he has an adequate output. Perform routine skin assessments. All bladder and bowel related equipment should be kept clean.

8) Orthostatic Hypotension:
Orthostatic Hypotension - occurs when there is an inability for the circulatory system to adapt to moving to an upright position. Treatment: Wheel chair with elevated foot rest Tilting table

Physical therapy treatment:

1) Improve / Maintain Normal or Baseline Ventilation and oxygenation
Clearance of Airways Improve Chest Expansion Improve Breath Sound Improve Cough Effectiveness Improve Breathing Pattern

Role of physical therapy in ICU:

2) Improve / Maintain Musculoskeletal System within functional Limit.

Improve ROM Improve Muscle Strength and Endurance Prevent Joint Deformities and Contractures Prevent DVT Prevent Swelling

3) Improve Circulatory System Function

4) Improve / Maintain Neurological System and Cognitive status within Functional Limits.
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5) Improve / Maintain Level of Functional Status within patient's tolerance .

Respiratory exercises:
(A) INTUBATED tracheostomy) Unconscious PATIENTS: (endotracheal tube or

1. Pre-treat with bronchodilator if the patient presents with severe bronchospasm (20 min. before treatment). 2. Modified postural drainage positions, usually with the head of the bed flat unless patient has an increase in intracranial pressure above 30 mmHg, then the head of the bed should be elevated to 30 degrees. If there are no other contraindications then the following should be done: Use pulmonary hygiene techniques to mobilize secretions such as vibration, percussion, rib springs and shaking. Endotracheal suctioning to clear retained secretions using sterile techniques. 3. The best position for relaxation, decreased dyspnea and improved ventilation and oxygenation are with the head of the bed elevated to 30 degrees and lying on well aerated lung.

Conscious
Proceed with the same procedures done with the unconscious patient, and then encourage the following: Independent efforts of inspiration and coughing Coordinate upper extremities mobility with inspiration and expiration to improve lung expansion

(B) EXTUBATED OR NON-INTUBATED PATIENTS Unconscious

Modified postural drainage position, usually with the head of the bed elevated to 30 degrees, and then performs the following: 1. If no contraindications, then use pulmonary hygiene techniques to mobilize secretions. 2. Use neurophysiological facilitation of respiration to facilitate deep breathing, increase lung volume and increase thoracic expansion 3. Use tracheal tickle technique to elicit a cough, if not successful, then use nasopharyngeal suctioning to clear the retained secretions 5. Side lying is the best position to improve oxygenation and ventilation.

Conscious

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Modified postural drainage position, usually with head of the bed elevated to 30 degrees, and then encourages the following: 1. Teach patient effective coughing and huffing to clear retained secretions. 2. If cough is non-effective and productive, then nasopharyngeal suctioning should be performed using sterile techniques 3. If patient has restrictive lung disease, then teach patient segmental, sustained maximal inspiration, diaphragmatic breathing exercises and use of incentive spirometer to increase lung volume. 4. Teach patients with COPD pursed lip breathing exercises to decrease dyspnea and prolong exhalation phase.

ROM exercise
To avoid contractures and deformities, concentrate on the following:

Unconscious

1. Passive ROM of upper and lower extremities including prolonged stretching. 2. Use of splints (by keeping most joints in the neutral or functional position). Inhibitive casting or patients shoes can also be used. 3. Proper positioning for all joints of the body.

Conscious

Proceed with the same procedures done with the unconscious patient, in addition to the following: 1. Active, active assistive ROM of upper and lower extremities. 2. Strengthening exercises of upper and lower extremities.

Circulatory exercise
Unconscious
To prevent DVT and swelling, concentrate on the following: PROM, elastic bandage, compression unit and limb elevation.

Conscious

Proceed with the same procedures done with the unconscious patient in addition to the following: 1. Use ice pack to decrease swelling. 2. Encourage active exercise of all extremities and trunk

Orientation to the vertical position

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Once radiographic findings have established stability of the fracture site, or early fracture stabilization methods are complete, the patient is cleared for upright activities. Initially, upright activities can be initiated by elevating the head of the bed and progressed to a reclining wheel chair with elevating leg rests Use of the tilt table provides another option for orienting the patient to the vertical position.

TILTING TABLE
Indications Physical therapists use tilt tables to provide early weight bearing experiences for patients too weak to stand on their own. Tilt tables also help patients with orthostatic hypotension--a significant drop in blood pressure that occurs when they move from a prone to a sitting position. Procedure To use a tilt table, the patient lies on top of the table on her back. The physical therapist secures the safety straps around the patient, and then slowly elevates the table, putting the patient into a standing position, while monitoring her blood pressure and heart rate throughout the treatment. Prevention Tilt table treatments can prevent osteoporosis via weight bearing, as well as ankle contractures, blood clots, pulmonary embolism and other bed rest complications for the hospitalized patient.

Mat programs
1. Rolling : to begin training and to facilitate rolling ,several approaches can be used Flexion of head and neck with rotation. Extension of head and neck with rotation. Bilateral ,symmetrical upper extremity rocking with outstretched arms Crossing the ankles

2. Prone on elbows Weight bearing & weight shifting. Rhythmic stabilization. Manual approximation. Unilateral weight bearing onto one elbow. Forward, backward &side to side progression. Strengthening serratus anterior and other scapular muscles.

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3. Prone on hand: Lateral weight shifting Approximation Scapular depression and prone push up

4. Supine on elbows: Lateral weight shifting. Side to side movement.

5. Pull ups: the purpose of this activity is to strength the biceps and shoulder flexors in preparation for wheel chair propulsion. 6. Sitting : Initial activities will focus on practice in maintaining the position, during early sitting; a mirror may provide important visual feedback. Manual approximation Balancing activities Sitting push up

Transfer
Transfer training is generally initiated once the patient has achieved adequate sitting balance It is necessary prerequisite skill to many other functional activities Training is usually initiated on a firm mat surface and progresses to alternate surfaces by using a sliding transfer

Long range planning

An important aspect of long range rehabilitation planning involves educating the patient in life long management of the disability. Consideration must be given to housing, nutrition, transportations, and finance, maintaining functional skills and level of physical fitness & social or recreational activities.

Sensory reeducation
It is a therapeutic program using sensory stimulation to help sensory impaired patients recover functional sensibility in the damaged area and learn adequate functioning.
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Sensory reeducation uses a variety of therapeutic, rehabilitation and educational techniques to help sensory impaired patient recover sensibility, fine discrimination abilities and the ability to perform other tasks involved in daily living and work activities. Some forms of stimulation used are : Electrical stimulation. Stroking the skin with frictional materials. Massage. Vibration Pressure. Tactile stimulation.

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