92 Physiotherapy: An Essential Tool in Neurocritical Care

Rosmari Aparecida Rosa Almeida de Oliveira ¹, Esther Cecilia Wilches Luna ², Silvia Maria de Toledo Piza Soares ¹, Beatriz Eugenia Fernàndez Hurtado ²

¹ Physiotherapy College of Pontifícia Universidade Católica de Campinas-PUC-Camp Campinas (SP), Brazil

² Universidad del Valle, Faculty of Health, School of Human Rehabilitation, Cali, Colombia

92.1 Introduction

Currently, there is a worldwide trend to create specialized intensive care units (ICU). According to two reports (2001 and 2006) by the Royal College of Physicians of London, intensive care management of patients suffering from stroke (cerebrovascular accident [CVA]) appears to reduce hospitalization, degree of sequelae and mortality [1]. In Brazil, especially in private health services and large cities, it is not uncommon to find within the same hospital highly specialized facilities for the care of cardiac, surgical, and transplant patients. And among who benefit most from this segmentation are neurological patients.

A neurological ICU may be operated within a general ICU or at a separate location. What defines it is not the physical space but rather the technology resources available for monitoring and treating diseases of the brain, coupled with human resources specialized in neurointensive care [2], including the physiotherapist.

Until recently, neurological disorders in the acute phase were treated with a passive therapy. The patients were kept alive but sedated, with treatment aimed solely to maintain clinical stability until the disorder spontaneously regressed. With the advent of scientific and technological medicine, therapy has become more active: neurological changes and blood metabolism are rigorously monitored so that early intervention can be instituted and undesired consequences avoided or minimized [3]. A typical example is thrombolytic therapy in ischemic stroke.

Worldwide, although neurological diseases are not a leading cause of mortality, the incidence of stroke and traumatic brain injury (TBI) is increasing as is the number of survivors with disabilities.

From a functional standpoint, neurological patients, such as those recovering from TBI, have severe limitations that significantly impair their quality of life, in addition to the psychosocial and financial burden on both the family and society [4]. The clinical manifestation of nervous system diseases is closely related to the site or sites of injury and their respective extension [5]. Therefore, it is essential to understand the nature and complexity of the entire nervous system in relation to the interventions by the multidisciplinary team member to ensure that such treatment is safe, effective and not harmful.

The physiotherapist has an important role in the intensive care of the neurologically ill owing to the risk of respiratory complications, the frequent need for mechanical ventilator assistance, and the presence of motor deficits, among others. The physiotherapist plays an active part in assisting patients; this work requires continuous training and improvement, as well as collaboration with doctors, nurses, nutritionists and other team members.

Preventing complications, restoring function and improving the neurological functional status of patients in order to achieve the greatest degree of independence are among the goals of physical therapy in neurointensive care. The rehabilitation process begins in the ICU and views the patient as a whole individual, taking an approach that does not isolate the neurological system, but rather integrates it with other systems, adjust treatment to the course of illness and recovery to obtain better results.

Hence, it is not advisable for the therapist to work solely according to a protocol. This does not mean ignoring treatment protocols; protocols are important for guiding a group of professionals in the conduct of day-to-day treatment, avoiding hasty decisions and therapeutic abuse. On the other hand, neurointensive physiotherapy, treatment and pre-defined goals can ignore the fluctuating clinical conditions commonly described by patients in the acute neurological phase which requires a more refined therapeutic approach.

Some studies report that respiratory physiotherapy in critically ill patients can bring about undesirable consequences, such as impaired oxygen transport resulting from the adverse effects on venous return, cardiac output and systemic blood pressure. In theory, respiratory physiotherapy applied to the patient’s chest, increases intrathoracic pressure [7,8]. This, in turn, leads to decreased venous return, and both can impair cardiac filling, resulting in increased intracranial pressure [9,10]. On the other hand, cardiovascular effects are indeed observed in hypovolemic patients, and the possible temporary increase in intracranial pressure is not reflected in brain injury when cerebral autoregulation is preserved. In practice, physiotherapy and motor rehabilitation need to be informed by the monitoring of brain energy metabolism, for example, as tools to guide the intensity, duration and type of interventions that can be applied to the patient at a given moment.

There are still few studies in neurointensive physiotherapy that add to scientifically based evidence. This does not diminish the importance of physical therapy or that it is not practiced; instead, clinical trials in this segment are lacking. In general, scientific research investigating the technical resources and the activities of the physical therapist in neurointensive care require more rigorous methodological design. We need measures of the expressive point of view of monitoring neurological status and the sample size, as in any study design, with the aim to improve physiological outcomes and clinical outcomes such as achieving a lower incidence of pneumonia, shorter duration of mechanical ventilation and hospitalization, among others.

Thus, in the following pages we will discuss physical therapy in acute-stage neurological patients hospitalized in an ICU.

Finally, there is a popular saying in neurointensive care that says: «If you cannot help, at least do not hinder.» In other words, there is little or nothing you can do to reverse the damage from the primary neurological injury, but incorrect therapeutic management of neurological patients in the acute phase may worsen secondary injury, increasing the degree of disability.

92.2 Neurointensive Vision for Physical Therapy

92.2.1 Characteristics of Neurointensive Patients

The most frequent reasons for admission to a neurointensive ICU are: head trauma, stroke, spinal cord trauma, brain surgery (mainly tumour resection and clamping of aneurysms), among others.

The clinical picture is often characterized by prolonged hospitalization and mechanical ventilation, frequent need for tracheostomy due to immobility and bed restriction. This condition is usually associated with pulmonary complications.

In this context, the appropriate management and support of physical therapy will include: assessment of dysfunction, monitoring, and neurointensive physiotherapy.

Assessment of Dysfunction and Monitoring

The importance of evaluation and monitoring of dysfunctional neurointensive patients resides in the early detection of clinical abnormalities which can be reversed before permanent sequelae ensue. The neurological workup is usually extensive and thorough. In the ICU, the assessment should be rapid and encompass level and content of consciousness, pupil assessment and motor response patterns (muscle tone, reflexes and strength), as well as adequate monitoring of cerebral blood flow and metabolism.

Monitoring of respiratory function will examine the rates of gas exchange and respiratory mechanics (Table 92.1), facilitate the evaluation of pulmonary complications such as hypoxemia and hypercapnia. Both may increase the damage to the airway adjacent to primary lesions, the so-called twilight zone of brain injury.

Table 92.1. Evaluation of gas exchange and respiratory mechanisms in neurointensive care.

During assessment, the physical therapist will observe the chest and monitor radiological changes, which will guide the diagnosis and monitoring of potential lung disorders, besides the need for physical therapy interventions.

Assessment of cardiovascular function will check for heart rate (HR) and mean arterial pressure (MAP). Continuous electrocardiography (ECG) can identify common cardiac arrhythmias in acute neuropathy [12], and changes in MAP can be correlated to intracranial hypertension. In some acute situations, physical therapy may be contraindicated.

In emergency situations, evaluation is performed concurrently with the basic manoeuvres recommended for the initial treatment of neurological and neurosurgical patients. The team must be integrated and well-trained in order to preserve life. Therapeutic priorities follow the sequence: A – Airway maintenance; B – collateral ventilation/oxygenation; C – circulation; and D – the deficit. Also, further investigation should be performed as soon as possible.

In the neurological workup, the therapist must be properly trained to assess the following parameters.

92.2.2 Content and Level of Consciousness

The level of consciousness is the degree of behavioural warning the individual shows that can be determined by the level of response given by the patient to external stimuli. The Glasgow Coma Scale (GCS), devised by Teasdale and Jennett in 1974, [13], initially totalled 14 points and was subsequently amended in 1975, with the addition of 1 point for a total of 15 points. It is used to monitor the level of consciousness after TBI according to the following scores: ≤8 (severe coma); 9-12 (moderate coma); and 13-15 (mild coma) (Table 92.2).

Table 92.2. Glasgow Coma Scale (GCS). Teasdale and Jennett (1974) [13], subsequently modified by Jennett et al. (1977) [14].

Besides being used to monitor the patient during the acute phase, ECG is also applied as an index of neurological prognosis. This scale has a positive predictive value of 80-90% for assessing prognosis, with 10-20% of patients who may have an incorrect prediction of their prognosis [15].

Frequently been used in the ICU to evaluate the degree of sedation in neurological patients is the Ramsay scale [16] (Table 92.3). The neurophysiologic responses to verbal, visual, tactile, and proprioceptive stimulation depend on the ascending activating reticular formation and cerebral cortex.

Since the contents of consciousness are the sum of all cognitive and affective functions of humans, such as language, praxis, memory and gnosis, they depend on the function of the cerebral cortex [17] and should be evaluated by asking simple questions concerning the patient’s orientation in time, place and person. According to the answer, consciousness is classified as directed or disoriented. At first, the patient may respond to questions coherently or be unable to answer even after being prompted. Some clinical conditions such as hypoxemia and hypercapnia aggravate the state of disorientation and should be rectified immediately once detected.

Table 92.3. Ramsay Sedation Scale [16].

Pupils

Pupillary examination will evaluate pupil diameter, symmetry and light reflexes (Table 92.4); abnormalities in pupillary size and reactivity may be indicative of structural damage extending from the thalamus to the bridge.

Since some pupil changes can alert to the need for urgent therapeutic intervention, they should be monitored several times a day and during physiotherapy. Complications such as intracranial bleeding and cerebral edema may cause increased intracranial pressure and/or brain herniation, resulting in changes of the pupils, which can vary rapidly from isocoria to anisocoria or mydriasis and non-reactivity of one or both pupils. In such situations, early intervention can determine the patient’s prognosis.

Table 92.4. Pupillary assessment.

Patterns of Motor Response

Brain lesions can produce pathological patterns of motor response; those most frequently observed in the ICU are:

• Decortication: posture of adduction and flexion of the elbow, wrist and finger flexion of the upper limb, as well as hyperextension, plantar flexion and internal rotation of the lower limb. These changes are suggestive of dysfunction in the deep supratentorial regions of the internal capsule.
  
• Decerebrate: posture of adduction, extension and hyperpronation associated with upper limb extension and plantar flexion of the lower limb, suggestive of high spinal cord injury, above the red nucleus, extending to the diencephalon.
  
• Paresis: partial inability to perform voluntary movements. It may consist of several deficits, such as loss of selective motor control of balance, righting reactions, primitive reflexes and sensitivity, as well as the presence of abnormal muscle tone.
  
• Plegia: the total inability to perform voluntary movements, including deficits that can result from injury to the pyramidal tract, extrapyramidal system, cerebral cortex (premotor, primary motor and somatosensory) and the cerebellum. Depending on the extent and severity of injury, the patient presents a clinical picture of paralysis with spasticity, hyperreflexia or hyporeflexia (sagging).

But among the abnormal reflexes, the one most frequently encountered in clinical practice in the ICU is the plantar cutaneous reflex which, when positive (Babinski sign), indicates a loss of pyramidal function which can be transient depending on the patient’s condition.

92.2.3 Brain Hemodynamics

Brain hemodynamics is characterized by a balance of the intracranial components (brain tissue, blood and cerebrospinal fluid [CSF]) being able to tolerate small increases in volume without changing intracranial pressure (ICP). Therefore, an increased volume in one or more components will be accompanied by a decrease in others. However, when there is damage that interferes with brain compliance, even minor expansion of the intracranial content can significantly increase ICP, contributing to the loss of cerebral autoregulation.

Monitoring brain hemodynamics includes the evaluation of cerebral metabolic and circulatory function. The coupling of these functions depends on the mechanisms of cerebral autoregulation. Thus, cerebral autoregulation is the brain’s ability to maintain blood flow constant regardless of variations in blood pressure, while satisfying the brain’s metabolic demands.

The conditions that lead to augmented aerobic metabolism increase the production of carbon dioxide, responsible for vasodilation and appropriate increased microcirculatory cerebral blood flow. In contrast, anaerobic metabolism, concomitant with a reduction in carbon dioxide, mediates vasoconstriction and flow reduction.

Cerebral blood flow can be calculated by the formula: CBF = CPP / CVR (CBF = cerebral blood flow, CPP = cerebral perfusion pressure, CVR = cerebral vascular resistance). The normal CPP range is 60-95 mmHg. For monitoring CPP, Langfitt and colleagues (12) proposed calculating the difference between MAP and ICP, i.e., CPP = MAP – ICP (MAP = mean arterial pressure, ICP = intracranial pressure).

Thus, maintenance of MAP, generally >100 mmHg in adults, helps to ensure adequate CPP. The parameter of normal peak is <10 mmHg in adults, whereas peaks ≥20 mmHg characterize intracranial hypertension (ICH).

The adequacy of cerebral blood flow to meet metabolic demand can be used to monitor cerebral of oxygen extraction (CEO₂).This represents the true and most important parameter of proportionality between CBF and oxygen consumption. CEO₂ is understood as the difference between oxygen supply and consumption, estimated in clinical practice, the difference between the arterial and venous saturation of oxygen (the latter is obtained from the jugular bulb catheter). Normal values for CEO₂ are 33% for adults, with a range of variation of approximately 24 to 42%. Values above and below normal represent hyper-or low flow in cerebral oxygen consumption, respectively.

These notions of brain hemodynamics guide the team in physiotherapy management and clinical or surgical treatment which require the coupling of neurological function, cardiovascular and respiratory diseases.

92.3 Physical Therapy

92.3.1 Respiratory Therapy

Techniques and Resources of Respiratory Therapy

Respiratory therapy aims to minimize the retention of endobronchial secretions and maximize ventilation and oxygenation (18). When performed during mechanical ventilation, respiratory therapy helps to adjust ventilation parameters, weaning and extubation. The use of noninvasive mechanical ventilation is increasingly reported in the literature [19].

Respiratory complications are more frequent in neurocritically ill patients: pneumonia, acute respiratory failure, neurogenic pulmonary edema and atelectasis [20]. Under these conditions, physiotherapy techniques use protective strategies of mechanical ventilation to minimize the symptoms and degree of lung injury [21,22].

Respiratory therapy may promote a temporary rise in intrathoracic pressure and consequent reflex in cerebral hemodynamics and intracranial pressure [9]. Therefore, patients should be approached with special care for each of the techniques applied at the time of therapy.

Bronchial Hygiene

Chest physiotherapy is included most ICU treatment protocols in the developing countries. Its role is quite varied, depending on location and tradition of service, level of education, training and experience, and especially the patient characteristics.

In some ICUs the physical therapist will evaluate and monitor all patients daily while in others, the service is performed only upon request. This helps to determine the character of its action, intervention and outcomes.

The features and therapeutic techniques in respiratory therapy include the following.

Stimulation of Cough

Stimulation of cough is a common technique to treat respiratory complications resulting from the accumulation of secretions, especially in patients with cognitive impairment (no response to verbal commands) and those with high spinal cord injury, in whom paralysis of the trunk and abdomen muscles reduces the ability to generate effective cough. In such patients, there is a close relationship between motor level and peak expiratory flow during cough [23]. Jaeger and colleagues [24] studied the efficacy of three methods of cough stimulation in patients with high spinal cord injury. The methods involved coughing without manual assistance, with assistance from the therapist, and abdominal electrical stimulation. The effectiveness of the technique was measured by peak expiratory flow. Electrical stimulation-induced cough was more effective than manually assisted cough; however, abdominal electrical stimulation is not a common practice in the ICU.

Inducing coughing is undesirable in patients with increased intracranial pressure. It is contraindicated because it leads to an increase in intrathoracic pressure, decreasing venous return, thereby increasing cerebral blood flow. However, when cerebral autoregulation is preserved, intracranial pressure returns to normal levels immediately after the procedure, demonstrating adequate compliance of the nervous system. Under such conditions, cough can be used as a resource during bronchial hygiene therapy.

Endotracheal Suction

A constant concern in neurological patients is the aspiration of pulmonary secretions because this can negatively affect the cerebrovascular status by increasing intracranial pressure. Therefore, brain damage can ensue not only from the primary trauma but also secondarily to reduced oxygen to the brain as a result of cerebral edema, ischemia and increased intracranial pressure.

Tracheal aspiration refers to the effective removal of endotracheal secretions, aseptically through a suction system. Airway access for the procedure can be achieved by two methods or systems: open and closed. The first is the most widespread and routinely used in clinical practice. It involves disconnecting the patient from mechanical ventilation for the aseptic introduction of a the probe for aspiration. The second system refers to a multi-use probe enclosed in a plastic cover which is connected to an endotracheal tube and ventilator circuit, allowing aspiration without interrupting mechanical ventilation.

Considering the secondary respiratory complications of neurointensive patients in the acute phase, the closed system seems to be more advantageous as it allows continuation of mechanical ventilation and maintenance of positive end-expiratory pressure (PEEP), thus reducing the partial pressure of oxygen in arterial blood (PaO₂) and increased partial pressure of carbon dioxide in arterial blood (PaCO₂) and minimizing the risk of contamination and respiratory infections.

With either system it is recommended that the patient be adequately sedated to avoid psychomotor agitation and be properly positioned (supine rise from 35 to 40°). There is no consensus in the literature on performing this procedure in the presence of impaired cerebral compliance. Some authors suggest the use of lidocaine diluted in 0.9% saline solution directly into the tracheal tube or intravenously administered [25,26].

Bruyas (1981) and Thiesen and colleagues (2005) [9,27], at the time of endotracheal aspiration, reported a significant increase in ICP due to stimulation of the cough reflex, which increases intrathoracic pressure and therefore decreases venous return, interfering directly with brain metabolism. Some authors have recommended adequate sedation combined with topical anesthesia and neuromuscular blockers in order to avoid psychomotor agitation and stimulation of the cough reflex, and thus effects on ICP and CPP and MAP [25,28-30].

The aspiration time should not exceed 15 / 2 to prevent hypoxemia; the suction pressure should not exceed 120 mmHg or the suction flow rate 16 l/min to avoid mucosal trauma.

Intratracheal instillation of 0.9% saline solution, while feeding, can be used with caution to thin thick bronchial secretions and plugs, as saline instillation may trigger a reflex cough and Valsalva manoeuvre, significantly increasing the ICP [31].

Aspiration should be performed only when pulmonary auscultation reveals rales, the mechanical ventilator display indicates increased peak inspiratory, deterioration of oxygenation demonstrated by a drop in oxygen saturation, and when the movement of secretions is audible during respiration. The technique should not be performed at regular intervals because the risk of routine aspiration outweigh its benefits [31].

Despite its being a widely used procedure in neurological patients, endotracheal suctioning is associated with complications including, hypoxemia, changes in partial pressure of carbon dioxide, tracheal mucosal injury, increased intracranial pressure, hypertension, bradycardia and arrhythmias. It can also result in damage to the mucosa and mucociliary system, which is usually operator-dependent, the amount of pressure used, and the establishment of this procedure as a routine [32].

Another study suggested that hyperventilation and hyperoxygenation performed before tracheal aspiration can avoid significant changes in cerebral hemodynamics [33]. Hypoxemia is one of the most significant complications in neurological patients, since the magnitude of the decline of PaO₂ and oxygen saturation (SaO₂) and increased partial pressure of carbon dioxide (PaCO₂) can trigger bradycardia, coronary vasoconstriction and supply blood to the tissues, causing cerebral ischemia, worsening the prognosis.

There is consensus [34,35] that additional oxygen can be administered in ventilated neurological patients during tracheal aspiration procedures.

Conventional Manoeuvres

Conventional physical therapy manoeuvres include compression, vibration, locking and unlocking chest manoeuvres, postural drainage, tapping and ventilatory patterns. These manoeuvres can also be used in neurological patients. However, some care must be observed.

In the study by Thiesen et al. [9] effects were observed of conventional physiotherapy manoeuvres on cerebral perfusion pressure and intracranial pressure in head-injured patients, with peaks of up to 30 mmHg. The authors concluded that the manoeuvres did not significantly affect cerebral perfusion pressure. Of the manoeuvres studied, tracheal aspiration led to an evident increase in ICP, which returned to baseline 1 minute after the procedure. It is understood that in patients with preserved cerebral autoregulation, the return of ICP to baseline values is rapid, without generating unwanted effects in CPP, so that tracheal aspiration can be performed if necessary.

Chest physiotherapy manoeuvres tend to increase intrathoracic pressure by increasing lung volume. They are indicated in the treatment of alveolar collapse because elevated PaCO₂ causes vasodilation, with a consequent increase in cerebral blood flow and ICP. Therefore, in situations where alveolar collapse is accompanied by hypercapnia, one of the benefits of chest manoeuvres is to reduce PaCO₂.

Thoracic Manoeuvres

Manoeuvres of manual chest physiotherapy (chest compression, locking and unlocking manoeuvres, thoracic breathing pattern, directed or contralateral) for the reversal of alveolar collapse tend to increase intrathoracic pressure by increasing lung volume and warrant caution in these patients. Often the failure is responsible for the increased intracranial pressure owing to increased PaCO₂, which is responsible for vasodilation and the consequent increase in cerebral blood flow. Therefore, the increase in lung volume resulting from re-expansion manoeuvres may be beneficial in treating alveolar collapse by reducing PaCO₂, even if some degree of intracranial hypertension is generated, especially when cerebral autoregulation is preserved.

Alveolar Recruitment

Alveolar recruitment has been indicated for the treatment of alveolar collapse observed in the acute respiratory distress syndrome (ARDS), where hypercapnia can be tolerated. In patients with neurological injury alone, the ventilation strategy will differ from those previously mentioned because it seeks to achieve greater control of the amounts of CO₂ in arterial blood. Therefore, in patients with concomitant brain injury and severe respiratory failure there is a conflict in the therapeutic principles that guide ventilatory support.

Studies investigating with the effect of positive end-expiratory pressure (PEEP) on ICP have been inconsistent [10,36-38]. Shapiro and Marshall [38] reported increased ICP after using 4-8 cmH₂O PEEP and decreased CPP in 50% of cases. In contrast, Frost [36] observed no peaks with the use of high PEEP.

Importantly, another study found a significant reduction in CPP during PEEP only in patients with low central venous pressure (CVP), suggesting the deleterious effect of hypovolemia during ventilation with PEEP [37]. Some authors have suggested that PEEP may cause a significant increase in ICP only in patients with low-compliance brains [38-40].

For these reasons, it is of fundamental importance to join the efforts of the multidisciplinary team in therapeutic decision making, taking into account the risk-benefit ratio for patients where hypoxia is a major risk factor for complications after injury or brain surgery.

Despite the many studies, mostly experimental, on alveolar recruitment manoeuvres, few clinical trials have investigated the effects of these manoeuvres in acute respiratory failure in neurological patients. Studies by Huynh and Wolf [41,42] concluded that PEEP of up to 15 cmH₂O did not lead to a drop in CPP nor an increase in ICP in patients after neurosurgery.

In another study evaluating 43 patients after severe neurological injury with respiratory failure and undergoing recruitment manoeuvres using pressures up to 60 cmH₂O for 30 seconds, there was a deterioration in cerebral hemodynamics, with increased ICP and decreased CPP. Since the authors noted an improvement in blood oxygenation, they recommended routine use of this manoeuvre.

Muscle Training

Recent studies have addressed the complications of mechanical ventilation in the short term, such as reducing the mass and contractile properties of respiratory muscles. In a study by Capdevila and colleagues [44], 48 hours of mechanical ventilation were sufficient to reduce respiratory muscle strength by around 20 to 30%, the ability to generate strength, fatigue resistance and atrophy of type IIa and IIb fibres of the respiratory muscles in rats. Also, Hering and colleagues [45], in a study in pigs with oleic acid-induced lung injury, found that mechanical ventilation in 80% of cases reduced blood flow to respiratory muscles in comparison to spontaneous breathing, despite improvement of the oxygenation index.

These factors contribute to our understanding that suppression of spontaneous breathing during mechanical ventilation in patients with primary or secondary neuromuscular disorders adversely affects respiratory muscle activity, impairing the removal of ventilatory support.

In this case, the muscle training has a key role in the permanent removal of mechanical ventilation [46]. Stiller and Huff [47] reported that training the muscles of the neck and upper chest in ventilator-dependent quadriplegic patients may improve the vital capacity and allow the ventilator to be disconnected for longer periods.

The use of abdominal weight and load resistance muscle training in 11 patients with complete cervical lesion showed significant differences in forced vital capacity, maximum voluntary ventilation, and maximal inspiratory pressure. However, there was no difference between the two techniques studied by Derrickson and colleagues [48].

In other neuromuscular disorders, muscle training can also improve strength and endurance, as reported by McCool and Tzelepis [49]. The authors reviewed seven studies on muscle training, involving a total of 75 patients whose training regimen included the use of inspiratory resistance load and isocapnic hyperpnoea. The patients with lower neuromuscular disorders showed significant increases in muscle strength and endurance. Patients with more severe disorders were retainers of carbon dioxide, where there was little change in muscle strength or endurance. No adverse effects were reported in these patients.

Besides the effects on the performance of respiratory muscles, muscle training appears to improve lung function and reduce dyspnoea, as in cases of myasthenia gravis and multiple sclerosis [50]. In such patients, we observed a reduction in periods of pulmonary exacerbation, improved exercise tolerance, cough effective, and less need for mechanical ventilation. In addition, the type of tracheal access must be considered because these patients remain under prolonged mechanical ventilation. Some studies comparing very early tracheostomy intubation with mechanical ventilation reported that tracheostomy assists in weaning from mechanical ventilation and decreases the incidence of infections due to easier suctioning the airways, and generates greater degree of comfort, better mobility, communication and power for the patient [18].

92.3.2 Motor Assessment

Recommended instruments for the assessment of neurological patients in the ICU.

The aims of physiotherapy assessment and intervention in neurological and neurosurgical patients in the ICU are to detect and identify complications, making a detailed assessment of the degree of function and weaknesses. Standardization of physiotherapy assessment and intervention in neurological and neurosurgical patients supports decision making in line with the best scientific evidence and available resources.

Objective clinical assessment will require reliable and valid scales that are appropriate to what we want to measure, that establish a baseline before starting treatment, and that allow us to record the degree and duration of response to treatment. Evaluation includes careful measurement, accompanied by judicious assessment of the results, which will help to create an appropriate intervention plan and permit its modification according to the patient’s specific needs.

The goal of rehabilitation is to reduce the level of disability, reaching the maximum of functional independence, participation and integration in social and economic life. To measure the achievement of these objectives, rehabilitation must have assessment tools to objectively quantify the level of disability which a patient presents at a given time and to measure changes that occur prospectively in rehabilitation treatment. The use of rating scales helps to prioritize areas where we must act in the planning of rehabilitation and then allows us to compare the effectiveness and efficiency of treatments.

Physiotherapy assessment and intervention in critically ill patients is aimed at early identification of deficits secondary to the injury, providing timely interventions to existing or emerging gaps, preventing or reducing the risk of further complications, and promoting well-being to facilitate recovery in relation to mobility, health, and preservation of the patient’s social role.

Prolonged immobilization, lack of active movement, impaired sensation and proprioception, and altered level of consciousness lead to deficits in aerobic capacity, muscle performance, joint mobility, and integumentary and sensory integrity, which must be identified and treated early to ensure the quality of care and the necessary continuity of care during all phases of the disease.

The American Physical Therapy Association (APTA) [51] has recommended specific criteria for intervention and monitoring the use of testing and measurement.

Tests and measures are essential resources for evaluation; they identify deficits, functional limitations and disability, allowing the selection of interventions and the documentation of changes in patient status so that the scope of outcomes which are the endpoints of the intervention can be indicated.

In the ICU, tests and measures should be selected and applied according to the patient’s clinical condition, so that dynamic process deficits and limitations can be interpreted and identified. Depending on the state of consciousness, the tests can measure clinical and hemodynamic status and deficits (Table 92.5).

Some authors recommend evaluating the effectiveness of rehabilitation using scales such as the Cognitive Functioning Scale, the Rancho Los Amigos Scale, the Barthel Index, the Mini Mental Test, and the Disability Rating Scale (DRS) [52,53].

Scales for assessing functionality at the beginning and end of rehabilitation intervention that may demonstrate its effectiveness include the scales described below.

Deficit	Tests and measures
Impaired aerobic capacity	Cardiovascular symptoms and signs Pulmonary symptoms and signs Evaluation of physiological response to postural changes Brain monitoring
Impaired respiratory muscle performance	Maximum static pressures (PImax and PEmax) Nasal pressure sigh
Impaired muscle performance	Strength, endurance and muscle strength in functional activities
Impaired joint mobility	Goniometry
Impaired alertness/attention and cognition	Glasgow Coma scale (GCS) Rancho Los Amigos Levels of Cognitive Functioning (LOCF) Mini Mental test
Impaired integumentary integrity	Braden scale
Impaired ventilation	Auscultation Arterial blood gases Pulse oximetry Capnography Pulmonary symptoms (dyspnea)
Impaired breathing	Only gold members can continue reading. Log In or Register to continue Share this: Click to share on Twitter (Opens in new window) Click to share on Facebook (Opens in new window) Related Related posts: Neuroscience Critical Care: Two Experts’ Point of View Neurocritical Care of Patients With Arteriovenous Malformations Pathophysiology of Intracranial Hypertension Endocrinology of Acute Brain Injury Monitoring Brain Chemistry by Microdialysis During Neurointensive Care Acute Paraplegias and Quadriplegias of Non-traumatic Cause Stay updated, free articles. Join our Telegram channel Join Tags: Intensive Care in Neurology Jan 2, 2017 | Posted by admin in NEUROLOGY | Comments Off on Physiotherapy: An Essential Tool in Neurocritical Care Full access? Get Clinical Tree Get Clinical Tree app for offline access Get Clinical Tree app for offline access