Acute Care Physical Therapy Neurology and Neurosurgery – Flashcards
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What is a Laminectomy?
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excision of the laminae, or posterior vertebral arch via an anterior or posterior approach (posterior most common). May be performed independently to excise disk material or as part of a spinal fusion.
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What is a Discectomy?
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decompression of nerve root material by removing intervertebral nuclear disk material; used for chronic disc herniation and/or nerve root impingement. This procedure may be accomplished via a microdiscectomy or laminectomy.
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What is a Microdiscectomy?
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less invasive than a laminectomy; involves decompression of nerve root(s) and excision of extruded disk material through an incision made in the inferior aspect of the lamina.
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What is a Foraminotomy?
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the surgical enlargement of the intervertebral foramen to increase the exit space surrounding a spinal nerve; decompresses spinal nerve root impingement.
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What is a Vertebroplasty?
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injection of cement to a localized area of the spine to repair a compression fracture.
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What is a Spinal Fusion?
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a union or arthrodesis, of two or more vertebrae; used to immobilize specific vertebrae and strengthen the integrity of a compromised vertebral column. May involve insertion of bone graft segments between involved vertebrae. Approach may be anterior or posterior (posterior most common) and may, or may not, include instrumentation, also referred to as fixation, (involves pedicle screws, and/or rods and/or plates).
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What is the most common region for a spinal fusion?
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L5-S1
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What are the implications for the more superior and inferior vertebra in a patient with a spinal fusion?
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These regions will have to increase their movement to pick up the motion in those segments
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What is a posterior fusion including instrumentation?
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adjacent vertebrae connected with screws and rods but without interruption of disc.
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Graft material may by autologous, bone taken from the what?
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anterior or posterior iliac crest, non-autolgous bone, typically from a cadaver, or manufactured substitutes such as hydroxylapatite.
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Patients can take a shower how many days post-Op Lumbar Fusion?
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5 days post surgery
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How long does it take bone to heal?
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6-8 weeks
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Patients Post-Op Lumbar Fusion are typically on bedrest for at least what?
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24 hours
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If pt has a dural tear they typically must be what?
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FLAT in bed for a minimum of 24 hours.
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True or False: Do not scrub the incision after a Lumbar Fusion.
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True
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What are some General Precautions for Lumbar Fusion Patients?
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-Avoid sitting on low surfaces (knees should NOT be higher than hips) -Avoid chairs & toilets that are too low, use a recliner and order a commode. -Do not sit with your legs straight or crossed for prolonged periods of time. -Avoid valsalva during toileting. (Pain medications can cause constipation) -Do not lift objects heavier than 5 pounds (applies to own body weight as well). -Do not bend at the waist (bend at the knees). -Avoid strenuous activity (no pushing, pulling, no vacuuming, mowing the lawn). -Do not twist (log roll to maintain neutral spine).
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What should you not do to determine their strength in patients Post-Lumbar Fusion?
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Do not break test the patient to determine their strength; a general sense of the patient's strength should be described.
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What are some Acute Care Physical Therapy Implications for patients Post-Lumbar Fusion?
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-Assess sensation; emphasis on corresponding dermatomes. (L5-S1) -Patient/Family education essential; teach precautions, instruct family on how to don/doff brace when appropriate. -Decreased arousal may be related to an adverse pharmacologic response; notify the MD immediately. -Pain management is essential; coordinate with nursing to optimize use of pain medication. -Notice what patient is connected to and manage accordingly.
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How long do they typically leave a Hemovac or a J-P drain drain in?
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A day or two
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Can you put a brace over a Hemovac or a J-P drain line?
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Not recommended
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What is a PCA and can you push the button?
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Patient Controlled Analgesic; and no only the patient can.
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Where do you wanna make sure a Foley bag is with a patient?
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Below the level of the bladder
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What should you do if a Peripheral IV/A-line comes out?
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Put pressure over the opening and page nursing
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In a patient with an A-line what level should the transducer be in relation to the patient?
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The level of the heart
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In a patient with a feeding tube that is running what level of the bed should it be elevated to?
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30 degrees
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What are some Activity Guidelines Post-Op Lumbar Fusion?
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-Limit ambulation distance to less than 200' at a time. -Complete basic ADL training, bed mobility and transfer training. -Instruct pt on log roll technique for getting out of bed. -Limit ambulation on the steps to one full flight no more than twice a day. -No resistive exercises; patient may complete non-resistive exercises with low repetitions as long as long as it does not contradict any of the post-operative precautions. -Typically 6 weeks post-op once spinal precautions lifted strengthening program may begin (usually will wait for out-patient physical therapy).
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Explain the Log Roll Technique:
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-Bend your knees. -Roll onto your side without twisting your back. -Gently bring your legs over the side of the bed while slowly pushing up with your arms. (Your back should stay relatively straight). -To lie down: Lower yourself onto your side (on your elbow) while raising your legs onto the bed with knees bent. Gently roll onto your back without twisting.
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An LSO brace supports what?
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T10-S1
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An TLSO brace supports what?
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T6-T10
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A brace is ideally donned/doffed in what position?
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supine by someone other than the patient (prevents the patient from twisting).
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In patients with Thoracic Surgery, there is the same general activity precautions as individuals with lumbar spine surgery except pt's can do what?
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sit on a low surface, cross legs and sit "bolt upright."
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A T1-T2 will typically have what type of collar?
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have Philadelphia collar with Thoracic extension
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A T3-T5 will typically have what type of collar?
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bracing no man's land" come up from LSO with chest plate or use a Minerva brace
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True or False: a patient with a cervical fusion, a brace MUST be worn at all times.
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true
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True or False: For Miami J, Philadelphia braces, patients should have 2 when discharged to home. (One for shower use.)
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True
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True or False: Cervical Laminectomy patients' do not need to wear a brace
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True
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A Miami J is better for someone with what?
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increased secretions sec to material more durable; liners can be washed.
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What are some Cervical Surgery General Activity Guidelines?
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-Do not lift objects heavier than 5 pounds (applies to own body weight as well). -Avoid strenuous activity (no pushing, pulling, no vacuuming, mowing the lawn). -Do not twist (log roll to maintain neutral spine). -Fusion patient's typically must wear a Philadelphia collar, halo or Miami J. Laminectomy pt's do not need a collar; occasionally may wear soft collar for comfort. -Do not bend at your waist to pick up objects. You should bend at the knees and squat to pick up objects. No reaching overhead for heavy objects.
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What are some Physical Therapy Implications for patients with cervical fusions?
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-Do not break test the patient to determine their strength; a general sense of the patient's strength should be described. -Assess sensation; emphasis on corresponding dermatomes. -Patient/Family education essential; teach precautions, and instructions regarding brace (if applicable). -Teach family PROM technique for pt's with limited PROM to avoid frozen shoulder; address subluxation if UE flaccid. -Pain management is essential; coordinate with nursing to optimize use of pain medication. -Patients can attend another level of care if needed. Lower extremity strength training is permitted.
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What is a Burr Hole?
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A small hole is made in the cranium with a specialized drill. This procedure may be used to evacuate an extracerebral clot such as a subdural or epidural hematoma, access brain tissue for a brain biopsy, access the brain for placement of ICP monitoring systems, or to place stereotactic devices. A series of burr holes may be used to perform a craniectomy.
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What is a Craniotomy?
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The surgical removal of a section of bone (bone flap) from the skull to provide access to the brain. This procedure may be used to remove a tumor, clip an aneurysm, and/or to repair damage to the cerebrum. A craniotomy is named according to the area of bone that is affected. (i.e. frontal, occipital or tempoparietal craniotomy.)
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What is a Craniectomy?
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Similar to a craniotomy except that a bone flap is removed. This procedure is often done to decompress brain tissue and/or to fight infection. The excised bone may be stored in a bone bank, or placed within the subcutaneous tissue of the abdomen in order to maintain blood supply.
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True or False: Patients without a bone flap should wear a helmet whenever out of bed to protect the exposed area after a craniectomy
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True
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What is a Cranioplasty?
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Involves replacing the bone flap excised during a craniectomy. The replacement flap may be the original bone removed, a graft, or acrylic material. This procedure typically takes place three to six months after a craniectomy and is indicated in order to restore the protective properties of the skull and for cosmesis.
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The WHO classification divides astrocytomas into four grades, what are they?
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-Grade I, Pilocytic Astrocytoma -Grade II, Low-Grade Astrocytoma -Grade III, Anaplastic Astrocytoma -Grade IV, Glioblastoma Multiforme (GBM or Glioblastoma)
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What is the the most common and most malignant of the glial tumors?
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Glioblastoma multiforme (GBM)
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What is the the prognosis for patients with glioblastoma multiforme (GBM)?
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is very poor; the median survival with treatment is approximately twelve months.
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What is a GLIADEL® Wafers?
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small, dime-sized biopolymer wafers, implanted along the floor and walls of the cavity the tumor once occupied, that slowly dissolve releasing localized chemotherapy immediately following surgical removal of tumor.
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What is the GliaSite?
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a balloon catheter is inserted into the cavity of a removed brain tumor for delivery of a liquid radiation source, referred to as brachytherapy. (Pt must wear special hat and remain in room during treatment.)
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What is the treatment for GBM?
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Surgical removal via craniotomy
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What is a nerve sheath tumor often located on the vestibular portion of the 8th cranial nerve; typically benign and slow growing?
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Acoustic Neuroma/Vestibular Schwannoma
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In patients with Acoustic Neuroma/Vestibular Schwannoma the vestibulocochlear nerve is located within close proximity to the facial nerve; patients therefore may present with what?
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facial paralysis that may or may not resolve
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In patients with Acoustic Neuroma/Vestibular Schwannoma, post-op day 2 patients should begin what?
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vestibular rehab program
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What are some Craniotomy Post-op Precautions?
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-Observe for CSF leak: clear water-like substance leaking from orifice (sometimes nose) -No lifting greater than 5 pounds, driving or hanging head down for 6 weeks -Avoid strenuous and/or jarring activity for 6 weeks -Watch for signs and symptoms of post-operative vasospasm and/or hydrocephalous -If patient still has external ventric do NOT mobilize patient unless ventric is clamped.
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What is hydrocephalous?
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Increase CSF
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What is a Transphenoidal Adenectomy (TSA)?
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-Excision of pituitary tumor; accessed through patient's nose -No intracranial incision involved -Pt not allowed to blow nose minimum of 6 weeks
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What is a Arteriovenous Malformation (AVM)?
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-A disorganized collection of abnormally thin and dilated blood vessels that directly shunt arterial blood into the venous system without the typical system of connecting capillaries. -As a result, blood flow is accelerated and the pressure is elevated within the malformed vessels of the AVM. These impairments predispose the lesion to hemorrhage in the surrounding area if the AVM leaks or ruptures.
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What is a Brain Aneurysm?
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-Weak, abnormal bulging of an intracranial artery. -Aneurysms may rupture and cause a subarachnoid hemorrhage (SAH)
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What is a Saccular aneurysm?
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Saccular aneurysm most common of the two types. Also known as a "berry" aneurysm because of its shape, consisting of a neck and stem.
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What is a Fusiform aneurysm?
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Fusiform aneurysm is less common; consists of outpouching of an arterial wall on both sides of the artery. Does not have a stem
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What is the Medical Management for patients with aneurysms?
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-Surgical Clipping verses coil embolization, also called endovasular coiling. -Surgical clipping involves craniotomy with inserted of a tiny metal clip across the neck to stop blood flow into the aneurysm. After clipping the aneurysm, the bone flap is replaced, and the wound is closed.
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What is a Coil Embolization?
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-Real-time X-ray technology, called fluoroscopic imaging used to visualize the patient's vascular system. -Catheter inserted into femoral artery and thread up into the head of the unruptured aneurysm. -Tiny platinum coils are threaded through the catheter and into the aneurysm, blocking blood flow and preventing rupture. -Coils made of platinum; visible via X-ray and be flexible enough to conform to the aneurysm shape.
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What are some of the Physical Therapy Implications for Coil Embolization?
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-If the patient had a brain surgery involving a craniotomy or craniectomy, be sure to implement the craniotomy precautions. -Confused patients with impaired motor function are typically at an increased risk for falling. Do not leave them unattended. Replace any restraints removed during therapy. -TBI patients may experience a delayed onset of secondary pathology. Report any unusual signs and/or symptoms immediately. -Thoroughly assess cognition; use appropriate tools for document (i.e. Rancho, GCS, CRS-R). -Treat patient in quiet environment to avoid over-stimulation.
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What is Hydrocephalous?
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Abnormal accumulation of cerebrospinal fluid (CSF) within cavities called ventricles inside the brain.
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What is Communicating hydrocephalus?
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Communicating hydrocephalus is caused by either an overproduction of CSF or malabsorption.
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What is Obstructive hydrocephalus ?
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Obstructive hydrocephalus is caused by a blockage of CSF flow within the ventricles or CSF pathways.
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Aqueductal stenosis and spina bifida are two examples of conditions of conditions that often involve what?
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hydrocephalus
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What is a Ventriculo-peritoneal Shunt?
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A small catheter is passed into a ventricle of the brain; a valve which controls flow of fluid is attached to the catheter; another catheter is attached to the pump and tunneled under the skin, behind the ear, down the neck and chest and into the peritoneal cavity (abdominal cavity) to drain excess CSF from the brain to the abdomen. Risks include shunt malfunction or infection.
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What is a Endoscopic Third Ventriculostomy?
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often referred to as an ETV, Third Ventriculostomy, or Third Vent): a tiny burr hole is made in the skull and a neuroendoscope (a small camera which is attached to medical instrument) is utilized to enter the brain. The physician will then make a small hole (several millimeters) in the floor of the third ventricle to allow the CSF to flow from the blocked ventricles into surrounding the brain.
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Normal intracranial pressure in adults is what?
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8 to 18mm Hg
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Normal intracranial pressure in babies is what?
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10-20mm Hg
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What are some symptoms of Intracranial Pressure increasing?
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headache, change in mental status, nausea, emesis, altered level of consciousness, seizure, coma.
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What is a Ventriculostomy?
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intraventricular catheter placed through a burr hole into the lateral ventricle; allows for both monitoring and for therapeutic drainage of CSF to reduce the ICP. Risk for infection with this device because it is invasive
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What is a Subarachnoid Screw (ICP Bolt)?
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A hollow screw inserted through a burr hole drilled into the dura mater; relatively easy to install, but accuracy less than ventriculostomy drain. (no drainage)
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What is a Epidural Sensor?
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Sensory device placed through a burr hole just over the epidural covering. Since the epidural lining is not perforated this procedure is less invasive; disadvantage is lack of CSF drainage if needed.
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Licox measures what?
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oxygenation
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What are some of the implications for Normal Pressure Hydrocephalus (NPH)?
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-An accumulation of cerebrospinal fluid that causes the ventricles in the brain to become enlarged with little or no increase in pressure. -Adult-onset normal pressure hydrocephalus describes those cases that occur in older adults (age 50 and older). The majority of the NPH population is 60 years or older. -NPH is typically idiopathic. May also develop as the result of a head injury, cranial surgery, subarachnoid hemorrhage, meningitis, tumor or cysts, as well as subdural hematomas, bleeding during surgery and other infections. -NPH characterized by complaints of gait disturbance (difficulty walking), mild dementia and impaired bladder control. -Spinal tap may help to determine need for VPS.
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What is the most common type of stroke?
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Ischemic MCA
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What are the three types of Ischemic strokes?
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-Embolic -Thrombotic -Lacunar
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What are some of the implications of a TIA?
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-Symptoms include focal deficits of an ischemic stroke and typically follow a vascular distribution -Reversible; no infarction of cerebral tissue -Symptoms must resolve within 24 hours 35% of patients who have had TIAs have a stroke within 5 years -5% of patients with TIA have stroke within 48 hours -Work-up essential to determine cause
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What is the timeframe for TPA?
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up to 6 hours
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What are the symptoms and signs of an Anterior stroke?
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impairments associated with cortical function: aphasia, neglect, paresis following pattern of anterior artery distribution (i.e. face, arm, leg)
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What are the symptoms and signs of an posterior stroke?
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impairments related to brainstem, cerebellar function: dysphagia, ataxia, decreased arousal, impaired vision
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What are some of the Medical Interventions for Stroke?
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-Should be viewed as an emergency -Treatment depends on Stroke Type -Ischemic may qualify for TPA and/or anticoagulation; enrollment in research study -Hemorrhagic- watch and wait; may require Neurosurgery; hemicranietomy -Keep BP low for hemorrhagic -Determine Cause to prevent recurrence -BP management/Lifestyle changes
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What are some of the implications for Tissue Plasminogen Activator tPA?
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-Must rule out hemorrhagic stroke first (HCT) -Thrombolysis; powerful "clot-buster" FDA approved 1996 3 hour window -Clinical diagnosis of ischemic stroke -No recent trauma, surgery, or bleeding -Rapidly improving symptoms (?TIA) -Treatable within 3 hours of onset (for iv) -CT without ICH or major early infarct signs -Normal glucose and platelets (±PT/PTT)
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What are some Physical Therapy Precautions for patients with stroke?
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-Acute stroke patient's typically on bed rest for the first 24 to 48 hours. Check the activity order. -Many stroke patients are taking an anticoagulant and are considered a fall risk. -Monitor vital signs carefully be aware of the mean arterial pressure (MAP) ranges for your patient. Ischemic strokes may run up to 130-140; hemorrhagic strokes may need to be less than 110 -MAP= (2(DBP) + SBP)/3 -If pt presenting with new "stroke-like" symptoms place flat and call MD
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What is Sympathetic Storm?
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Sometimes the sympathetic nervous system will "take over".
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What is Acquired Brain Injury?
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Damage to the brain caused by strokes, tumors, anoxia, hypoxia, toxins, degenerative diseases, near drowning and/or other conditions not necessarily caused by an external force.
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What are the implications for Rancho Los Amigos Levels of Cognitive Functioning?
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Can be utilized throughout the plan of care; shows progression through levels. Pt may plateau at any level.
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What are the implications for The Glascow Coma Scale (GCS)?
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often used the field for trauma patients. May used for assessing low level patients. More generalized.
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On the GCS a score of 13-15 indicates what?
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Mild head injury
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On the GCS a score of 9-12 indicates what?
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Moderate head injury; altered consciousness.
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On the GCS a score of <8 indicates what?
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Severe head injury and are comatose.
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What is the JFK Coma Recovery Scale?
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-Purpose is to assist with differential diagnosis, prognostic assessment and treatment planning in persons with disorders of consciousness -Initially described by Giacino and colleagues in 1991; restructured by Giacino and Kalmar and republished in 2004 as the JFK Coma Recovery Scale-Revised (JFK CRS-R) -Use for Rancho levels less than IV, GCS <8; patients thought to be in a vegetative or minimally conscious state
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The JFK-R consists of what?
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-Scale consists of 23 items with six subscales: -Auditory, Visual, Motor, Oromotor, Communication & Arousal functions. -Subscales comprised of heirachically-arranged items associated with brain stem, subcortical and cortical processes. -Lowest item on each subscale represents reflexive activity; highest items represent cognitively-mediated behaviors.
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What are some of the Treatment Considerations for BI?
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-Decrease stimulation in environment -Brief Commands -Once person speaks to patient at a time -Co-treat to accomplish more -Coordinate Medication with therapy if needed -Be flexible in sequence of treatment -Model calm behavior -Offer options -Set limits
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What is an LTACH?
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Long-term care hospital
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What is Multiple Sclerosis (MS)?
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-Characterized by an inflammatory process that causes demyelination, which is destruction of myelin sheath within the CNS, causing impaired neurotransmission. -The etiology of MS is unknown. Some researchers attribute causes to include viral infections and/or an autoimmune response occurring in genetically susceptible individuals. In addition, some researchers have attributed increased incidence of MS within certain geographical regions. -Multiple sclerosis is often managed pharmacologically with the use of interferons, immunosuppressive agents, and hormones; steroids are commonly administered during exacerbations.
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What is Benign MS?
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Abrupt onset with mild symptoms and few exacerbations. Remissions are near complete with minimal or no disability.
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What is Exacerbating-remitting MS?
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Increased frequency of attacks with sudden onset of symptoms with partial or complete remission of symptoms after exacerbations. Patients often go for long periods between attacks; but may be left with permanent disabilities.
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What is Remitting-progressive MS?
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Similar to exacerbating-remitting except the remissions are fewer with decreased resolution of symptoms. The disease becomes cumulative and disability increases; most common type of MS.
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What is Progressive MS?
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Insidious onset without remission, leads to progressive loss of function and severe disability.
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What is Guillain-Barre Syndrome (GBS)?
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-Also called acute idiopathic polyneuritis. -Etiology of GBS is unknown; approximately 40-60% of patients report a preceding bacterial or viral infection. -A lower motor neuron disease that involves rapid demyelination which causes motor weakness, arefelxia, and sensory abnormalities. -Symptoms typically begin distally with fine parestheseas in toes and/or hands, and develop into acute motor weaknesses and sensory disturbances that ascend symmetrically to the upper body and may involve respiratory, bulbar, and/or autonomic failure. -At the peak of its course, which is typically seven to 14 days, some patients require ventilation.
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What is Myasthenia Gravis (MG)?
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A chronic, progressive autoimmune disease; antibodies bind to and degrade acetylcholine (Ach) receptors located within the neuromuscular junction disrupting the transmission of nerve impulses.
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What muscles are affected with Myasthenia Gravis (MG)?
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Ocular muscles, speaking and swallowing
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What are some of the treatment options for MG?
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Treatment options include cholinesterase inhibitors, immunosuppressive medications, plasmapheresis, thymectomy and intravenous immunoglobulin (IVIG).
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What are some of the Physical Therapy Implications for Myasthenia Gravis (MG)?
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-Assess cranial nerves. -Do not over-fatigue the patient during the evaluation. Develop an efficient way to limit the verbal responses required from the patient. -Conduct the most essential parts of the exam first, and provide rest periods throughout the session. -Assess the integrity of the patient's respiratory system by carefully monitoring respiratory rate, pulsoximetry and the patient's use of accessory muscles to facilitate breathing.
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What is Amyotrophic Lateral Sclerosis (ALS)?
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-Rapidly progressive , fatal, degenerative disease that affects both upper and lower motor neurons. -Characterized insidious onset of asymmetrical weakness. Additional symptoms include: muscle cramping and fasciculations, hyperreflexia, and cranial nerve dysfunction with intact sensation and cognition. -ALS progresses rapidly; researchers estimate that by the time patient identifies his or her first symptom, 80% of the motor neurons in the affected region have already been destroyed. -The median survival time is approximately 4 years after onset of symptoms. Currently there is no known cure for ALS. -The etiology of ALS is unknown.
