Away from the track; Physio & Delirium Management

Patient in her 90's, post- hemi arthroplasty for #NOF.

• Day one: "I think you're the devil. I don't believe you. You're not to touch me. I'm not getting up.... The water tastes off, I think it has been poisoned. You're one of them, they're watching me from next door - I can hear them".  - patient mobilised out to chair, tolerated sitting for 15minutes and returned to bed.
• Day four: "oh you're the Phil I keep hearing about.... I'm a practical lady, of course I can get myself up [out of bed]" - patient mobilised with standing hoist, then with zimmer frame ~5m to commode.

Patient in her late 80's, post- proximal femoral nail antirotation (PNFA) for #NOF.

• Day one to five: laughing histically at anything and everything, pleasantly confused and cooperative. Seemingly happy to walk with the  healthcare staff and a walking frame. "I'm a bit sore you know, it's not usually like this... the colour scheme here is really nice... I always have lunch in the dining room - shall we go there now?". - patient mobilising varying distances up to 20m with nursing staff

Patient in his 70's,  post- open reduction, internal fixation (ORIF) for tibial plateau #.

• Day one: patient aggressive toward staff and fighting to get himself out of bed. "Fuck off, go away, leave me now, I'm leaving, you cannot hold me here, there is nothing wrong with me.... " - no attempt to mobilise with physio as patient unable to cooperate with instructions and aggression was inappropriate.

Patient in her 70's, post- revision of her total hip joint replacement (THJR) following dislocation.

• Day one: "Yes I know what you're here to do, right lets go [get up out of bed]. I need go to the toilet, so lets hurry"  - patient mobilised up with steady-eddie to commode and taken to toilet.
• Day two: "I feel like I'm on another plain. I saw bars up there earlier [pointing to the ventilation on the ceiling] and thought I was in jail. I feed drowsy and not sure that I should trust you" Patient mobilised with walking frame ~1.5m to chair.
• Day three: "What's the point, I can't get out of my house, nor afford a taxi, I have no family or friends, my sisters have died and it's just me.... ". - Patient declined to mobilise with physio.
• Day four: "I'm feeling much better today, my bowels are slowly moving - I'm currently on a bed pan and it's uncomfortable on my hip, but I need it, it comes in bursts and squirts". - Later in the day,  the patient mobilised ~15m using frame with the physio.

Background

Delirium is a transient state of acute confusion, often contributing to a patient's prolonged stay in hospital. It is a serious condition that has a rapid onset, fluctuates over the day and is associated with altered consciousness and disordered cognition, inattention, poor recall of events, impaired judgement and hallucinations. Patients experiencing delirium can be irritable and/or anxious.

Delirium clinically diagnosed and classified into three sub-types, hyperactive, hypoactive and mixed. Clinicians use the 4AT screening tool (see below).

Predisposing risk factors include: pre-existing cognitive impairment, dehydration/malnutrition, multiple comorbidities, visual/hearing impairment, physical frailty, history of previous delirium.

Precipitating risk factors include: catheterisation, consitpation, medications, environmental/physical restraint, sleep deprivation, hypoxia, surgery, drug withdrawl, neurological events.

Delirium has a high previlence in hospital, especially affecting ICU, neurological (e.g. stroke), general medicine and surgical/orthopaedic patients.

So what can physiotherapist's do about it?

Identify delirium early.
Physiotherapists usually have early patient contact, usually for early mobilisation if they're new to the ward. Nurses and family present are also instrumental in identifying abnormalities suggestive of delirium. The screening of delirium should be routinely applied to anyone with risk factors. The physiotherapist is able to assist in the management directly and indirectly...


Strategies to prevent and manage delirium.

• Orientate the patient to the ward and what the usual processes are on the ward, as well as day/time using a clock or allowing natural light into the bedspace.
• Encourage a small number of familiar faces to be bedside during the day. Call upon hospital volunteers as required.
• Early mobilisation, and mobilisation throughout the day. Promoting sitting out of bed, in a chair, for meals and establish expectations for a daily routine similar to the patient's usual routine if able. Avoid pyjama paralysis if able. Set-up participation activities, the ward may have an activities trolley.
• Minimise use of restraint (physical/environmental), including that of placing walking aids away from the patient. Provide appropriate equipment if necessary and ensure nursing staff know how to safely mobilise the patient.Use a patient 'watch' (staff member) that engages proactively rather than sitting back and watching.
• Coordinate with nursing and occupational staff about use of sensory aids such as magnifying glasses and provide handouts suitable for the patient.
• Educate the patient and family about delirium, and ask that they inform staff if they experience signs/symptoms.
• Ensure effective pain management, including educating the patient about seeking patient medication
• Document delirium symptoms, AT4 screening tool score, and inform the multidiciplinary team.

Implementing the above will help to get your patients back on track.

10 Alternative Manual Chest Physiotherapy Techniques

Chest physiotherapy techniques address multiple problems: pain, fatigue, sputum retention, disordered breathing patterns, shortness of breath, and promote an improvement in a condition. In a hospital setting, an on-call physiotherapist is more likely to see a patient requiring chest physiotherapy than for a mobility, musculoskeletal issue or screening a patient for safe discharge. Chest physiotherapists are called upon to reduce the rapid decline in respiratory-related conditions, which may, for example, help a patient avoid intubation. On the ward, the chest physiotherapist is trying to aid the patients recovery and restore them to their baseline. The techniques used by day-to-day chest physiotherapists traditionally include:

• Active cycle of breathing technique / breathing control / diaphragmic breathing / autogenic drainage / pursed-lip breathing, forced expiration technique / huff / postural drainage / glossopharyngeal breathing
• Acapella / flutter / bubblePEP / incentive spirometer / ParaPEP nebuliser
• Resting positions / fatigue management / activity pacing / education / mobilising / walking aids
• Wound bracing / chest binder
• Manual therapy / postural correction / percussions / vibrations
• Manual or machine ventilation, cough assist device, intermittent positive pressure breathing
• Nasopharyngeal, oropharyngeal, tracheal suctioning
• Respiratory muscle training, corrective dysfunctional breathing training, exercise prescription

However, there are manual chest physiotherapy techniques that hold mixed levels of evidence for their use that shouldn't be forgotten. Waldemar Kolaczkowski (1989) proposed a system of Manual Breathing Assist Techniques (MBAT) which include:

• Superficial stroking and bouncing pressures on the chest for relaxation
• Deep stroking/frictions/trigger pointing for respiratory muscles
• Stretching of intercostal muscles to improve chest mobility
• Springing the ribs to increase depth of inspiration
• Lifting the ribs to increase ventilation and aid in secretion clearance
• Clapping percussion and course vibrations for secretion clearance
• Manually lifting the shoulder or rotating the pelvis in side-lying to increase air entry

Manual therapy in chest physio is akin to that of manual and soft tissue therapy for musculoskeletal physiotherapists. Each technique has its place, and likely works best in conjunction with another technique and/or followed with education. These techniques are most useful in an acute time-frame and should be substituded for other techniques the patient can complete independently away from the physiotherapist. The listed techniques below are 10 useful techniques that aren't on the top of the chest physiotherapy toolbox, but should be considered when selecting an intervention.

Here are 10 Alternative Manual Chest Physiotherapy Techniques

Stretch of intercostal muscles. Position: Supine / Side lying        Purpose: Aids expiration / Increased mobility of thorax Technique: Applying a caudal glide to the lateral aspect of the ribs to stretch of the intercostal muscles during a passive expiration. The ‘intercostal stretch’ is performed by applying a caudal glide to the lateral aspect ‘bucket-handles’ of the ribs. When applied during a passive expiration, the intercostal muscles may be stretched to increase the mobility of the thorax and aid expiration. If the patient can tolerate it, the therapist may wish to briefly hold this stretch at the end of the breath out and release before the patient breathes in. The intercostal stretch is best performed on a patient in supine lying, long sitting or side lying positions. Patients with a barrel chest shapes, increased thoracic rigidity or those with a bias of accessory muscle use may benefit most from this technique.

Rib Springing Position: Side lying / Long lying Purpose: Increased depth of inspiration            Technique: Increasingly more pressure toward end-expiration with a quick release at the beginning of inspiration. The ‘rib springing’ technique is performed by applying a short, low amplitude squeeze or push on the antero-lateral aspect of the ribs to promote inhibition of expiratory muscles and passive recoil to allow greater inspiration volume. Alternatively, the technique can be performed by applying a long, increasingly greater pressure toward end-expiration with a quick release on inspiration.  The rib springing technique is best performed on a patient in side-lying or long lying positions. This technique would benefit patients with dysfunctional breathing patterns.

Shoulder and scapular elevation Position: Side lying, patients head in slight flexion Purpose: Increase air entry / ventilation; Increase thoracic mobility Technique: Lift the shoulder during inspiration. Gentle vibration to further elevate the shoulder during the beginning of expiration. The ‘shoulder and scapular elevation technique’ is performed with the patient in side lying, with their head slightly flexed. The therapist will position their hands around the scapular and axilla, stabilising the patients arm between the therapist’s arm and body, or with the patients arm supported at their side. The therapist coordinates the lift of the shoulder and/or scapular with the patient’s inspiration. This technique encourages greater mid-upper thorax mobility and ventilation. This technique works well with vibrations during expiration.

Rotation in side-lying Position: Side lying Purpose: Increase air entry / ventilation; increase thoracic mobility. Technique: Stabilise the shoulder with one hand, and rotate the hip posteriorly with the other hand during inspiration, then returning to a neutral position during expiration The ‘rotation in side-lying technique’ is performed with the patient in side-lying. Ensure the patient is well supported by pillows, including opening the thorax by placing pillows under the patient’s arm. The therapist stabilises the patients shoulder with one hand, rotating the pelvis posteriorly with the other hand during inspiration. The therapist guides the pelvis back to a neutral position during expiration. This technique increases mobility and ventilation to the mid-lower thorax. A short stretch may be applied at the end of inspiration to reduce thorax rigidity.

Peri-oral facilitation Position: Supine / long lying / side-lying Purpose: Ventilation Comment: Unconscious patient – not currently ventilated. Technique: glide the external nasal septum downward or distract the nasal cavity The ‘peri-oral facilitation technique’ is performed by the therapist on a patient with a low Glasgow Coma Score and in uncooperative with treatment to improve minute ventilation. The therapist glides the external nasal septum inferiorly, contacting the patient peri-orally. The glide can be held for the duration of the treatment, or more commonly coordinated with a breath in. Similarly, a lateral glide can be applied either side of the external nasal passage to reduce inspiratory resistance.

Clapping on maximal inspiration Position: Side lying / Supine / Prone Purpose: Loosen secretions at maximal dilation of bronchioles Comment: Requires patient cooperation for holding of inspiration ~3s, 3-4 claps Technique: Perform cupped percussions 3-4x during a held inspiration for ~3s. The ‘clapping on maximal inspiration technique’ is performed by applying slow percussions while the patient holds a maximal breath in. The patient is asked to hold a large breath in for ~3s whilst the therapist performs 3-4 claps or percussion with one or both hands. The patient is best positioned in side lying, supine or prone. The technique is intended to loosen secretions with maximal dilation of the bronchioles.

Course vibrations on expiration Position: Side-lying Purpose: Loosen secretions from distal bronchioles Comment: Combines well with shoulder elevation technique Technique: Course / large amplitude vibrations down chest handle or localised. The ‘course vibrations on expiration technique’ is performed by applying course, large amplitude vibrations whilst the patient breathes out. The technique can be applied locally over one region during expiration, or the therapist may wish to vibrate progressively inferiorly along the chest wall during a single expiration. The intention is to assist the mobilisation of secretions. This technique is best performed with the patient positioned in side-lying

Costal lifting on inspiration +/- vibrations Position: Supine / long lying Purpose: Increased depth of inspiration / Clearing secretions Technique: Lifting lung or chest with inspiration with vibrations / assisted expiration The ‘costal lifting on inspiration technique’ is performed with the patient in supine or long lying positions. The therapist lifts the ribs unilaterally or bilaterally during inspiration. This technique promotes increased ventilation to the targeted segment, usually the lower ribs. The technique allows greater ventilation to distal segments, and can be coupled with vibrations to assist with the mobilisation of secretions.

Manually Assisted Cough Position: Long Lying Purpose: Increase the end-expiratory peak cough flow Comment: Therapists hands placed on lower ribs or inferiorly to sternum (depending on patient preference). Technique: The patient is asked to cough. The physiotherapist coordinates a firm downward pressure at the moment of the forced expiration or cough. The ‘manually assisted cough’ is performed by providing a compression of the lower ribs or applying a hooking compression to upper abdominals toward the diaphragm when the patient braces to cough. The aim is to increase the forced expiration pressure to clear secretions. This technique is best applied on a patient in a long lying position.

Manual facilitation of breathing techniques: autogenic drainage & diaphragmic breathing Position: Any Purpose: To facilitate the teaching of autogenic drainage Comment: As per autogenic drainage technique, or to challenge the patient to breathe deeply during diaphragmic breathing. Technique: The therapist can position their hands on the patient’s lower ribs, adjusting the pressure placed to restrict and encourage breathing through the expiratory reserve lung volume. The therapist would reduce pressure to encourage breathing at higher inspiratory volumes as per the usual autogenic drainage technique. The Manual facilitation of breathing techniques are a means to train patients a better technique, here we will demonstrate how to facilitate autogenic drainage and diaphragmic breathing. Manual facilitation of autogenic drainage begins with the patient in a relaxed position, either long lying or supported sitting. The patient will have been educated about breathing control and taught to monitor apical breathing. The therapist would then describe autogenic drainage and how they would restrict the lungs to illustrate and facilitate an effective technique. To facilitate the technique, the therapist would then restrict the expansion of the lower ribs by holding the ribs firm or applying an inferior myofascial glide. The patient will breath in until they reach the therapists resistance, ending the breath in when the patient began to apically breathe. The patient would breathe out. After 3-4 breaths, the therapist would lessen their restraint off the lower ribs. This would be repeated through to tidal breathing at increased capacities. The therapist would assist the high volume tidal breathing by facilitate lifting of the ribs through a myofascial glide superiorly with their hands on either the lower and or upper chest. Manual facilitation of diaphragmic breathing begins with the patient placing each other their hand on the upper and lower chest, feeling for the rise and fall of the lower chest and consciously minimising the rise and fall of the upper hand. To facilitate and drive the lower chest/diaphragm the therapist could place one hand on the patients upper abdomen and ask that the patient breathe to lift the therapist's hand when they breathe in. A mild-moderate firm pressure should be applied by the therapist to challenge the patient.