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Excellence in specialist and community healthcare
Positioning and Early Mobility
July 12th 2016/ Sara Gawned (Principal Physiotherapist –
Neurosciences)
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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
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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.
Positioning and Early Mobility/ St George’s University Hospitals NHS Foundation Trust
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Why is positioning and
early mobility important?
Regain function
Reduce complications
Patient benefit
EBP
Use of best practice
guidelines
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Guidelines – What do they say?
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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.
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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.
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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
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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
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Positioning and Early Mobility / St George’s University Hospitals NHS Foundation Trust
Nursing
OT
Physio
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Is it safe?
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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)
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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
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Muscle
Skeletal
Respiratory
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RESPIRATORY SYSTEM
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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
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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
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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
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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
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Positioning and FRC in full
Already recognise
that general changes
in position can
improve functional
residual capacity
(FRC) – Lumb, 2000
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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
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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)
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MUSCULOSKELETAL SYSTEM
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Positioning and Early Mobility / St George’s University Hospitals NHS Foundation Trust
Muscle weakness
Immobilisation
Muscle wasting
Joint damage
CNS Damage
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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
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Normal muscle function
Work concentrically, eccentrically or synergistically in movement
Provide postural stability
Provide selective/active movement
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Changes to muscle with immobility
Loss of strength
Loss of muscle mass
Greatest in the postural muscles
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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)
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How can we influence this?
Positioning and Early Mobility / St George’s University Hospitals NHS Foundation Trust
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
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HOW DO WE ASSESS ABILITY
TO MOBILISE
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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
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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
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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
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HOW DO WE PUT THIS INTO
PRACTICE?
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Know your equipment – Positioning aids
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Know your equipment… Seating
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Know your equipment… transfer aids
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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
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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?
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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
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What might you consider when positioning this patient?
Can we seat this patient?
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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
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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.
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