Physiotherapy Assessment & Management

Patient Summary (from referral form)

PHYSIOTHERAPY ASSESSMENT

A. Subjective Assessment

• History of presenting complaint: Progressive limb weakness starting in right upper limb, then right lower limb, then left upper limb over 10 days. Abnormal body movements (likely seizure-related) x 5 days.
• Background: Known case of HIE (birth history - perinatal hypoxia-ischemia). Temporal lobe infarct noted on imaging. Recurrent seizures ongoing.
• Key questions: Birth history (gestation, mode of delivery, Apgar scores, NICU stay), seizure type and frequency, antiepileptic medications, feeding status (oral vs tube), respiratory status, developmental history prior to acute deterioration.

B. Objective Assessment (to be performed)

1. Neurological Status

• Level of consciousness - modified Glasgow Coma Scale / AVPU
• Tone assessment - modified Ashworth Scale for spasticity; assess all four limbs
• Motor power - Medical Research Council (MRC) grading (0-5) in each limb segment
  • R UL: shoulder, elbow, wrist, hand
  • R LL: hip, knee, ankle, toe
  • L UL: same segments
  • L LL: baseline tone and power
• Reflexes - Deep tendon reflexes (biceps, brachioradialis, knee, ankle), plantar response (Babinski)
• Primitive reflexes - Moro, ATNR, grasp reflex (persistence suggests cortical injury)

2. Developmental Assessment

• Assess developmental milestones for 18-month-old:
  • Motor: Can/could walk independently? Sitting ability? Head control?
  • Fine motor: Pincer grasp, object transfer
  • Compare current function to pre-illness baseline
• Use Hammersmith Infant Neurological Examination (HINE) or Bayley Scales if accessible

3. Respiratory / Chest Assessment

• Respiratory rate and pattern (normal: 25-35/min at 18 months)
• Chest expansion - symmetry, accessory muscle use
• Auscultation - air entry, crepitations, wheeze (aspiration risk in neurologically impaired child is high)
• Cough effectiveness - voluntary and reflexive
• Secretion assessment - audible secretions, color if suctioned
• Oxygen requirement and SpO2
• Risk of aspiration - swallowing screen (given seizures and encephalopathy)

4. Posture & Range of Motion

• Resting posture - scissoring, fisting, opisthotonus?
• Passive ROM of all limbs - note any contracture or joint restriction
• Skin integrity - especially over pressure areas (sacrum, heels, occiput)

5. Functional Assessment

• Head control (expected by 4 months - regression present?)
• Sitting ability
• Any voluntary reaching or purposeful movement

PHYSIOTHERAPY MANAGEMENT

IMMEDIATE PRIORITIES (HDU setting)

1. Chest Physiotherapy (Priority in HDU)

• Positioning: Semi-recumbent (30-45°) to reduce aspiration risk and aid lung recruitment; regular position changes every 2 hours (supine, left lateral, right lateral, prone if medically stable)
• Secretion clearance:
  • Percussion and vibration (modified chest PT) - gentle, age-appropriate
  • Postural drainage positions as tolerated (avoid head-down if raised ICP is suspected)
  • Nasopharyngeal suctioning if secretions copious and cough insufficient
  • Assisted cough techniques (manual rib spring)
• Breathing exercises: Deep breathing facilitation through positioning and handling
• Frequency: 2-3 sessions/day in HDU; reassess after each session

2. Neurological/Limb Physiotherapy

• 24-hour positioning plan to prevent deformity:
  • Avoid prolonged fisting (use soft hand rolls)
  • Maintain neutral hip/knee alignment
  • Avoid hip adduction/internal rotation (anti-scissoring positioning)
  • Ankle in neutral using ankle foot splinting/towel rolls to prevent equinus

• All limbs, 2x daily
• Gentle, slow, full range
• Hold each position 20-30 seconds
• Avoid pain - watch facial expression and vitals during handling
• Focus on: shoulder abduction/external rotation, elbow extension, wrist/finger extension, hip abduction/extension, knee extension, ankle dorsiflexion

• Tactile: light touch, stroking, textured materials on limbs
• Proprioceptive: joint compression during handling
• Visual and auditory stimulation appropriate to age

• Facilitation of normal movement patterns
• Inhibition of abnormal tone and primitive reflex patterns
• Weight bearing through limbs (once medically stable) to facilitate normal sensory experience and motor development

3. Seizure Precautions During PT

• Always liaise with nursing/medical team regarding seizure frequency and last seizure
• Do NOT perform chest PT during or immediately after a seizure episode
• Ensure padded environment, bed rails up during sessions
• Have call bell/nurse alert system in place
• Stop session if seizure occurs; place in recovery position

MEDIUM/LONG-TERM MANAGEMENT (Post-HDU)

GOALS OF PHYSIOTHERAPY

• Maintain clear airways and prevent chest complications (atelectasis, aspiration pneumonia)
• Maintain joint ROM and prevent contractures
• Optimize positioning to reduce abnormal tone

• Regain or compensate for lost motor milestones
• Facilitate head control and trunk stability
• Improve voluntary limb movement and weight-bearing

• Maximize functional independence appropriate to neurological prognosis
• Prevent secondary complications (contractures, scoliosis, pressure sores)
• Support family in long-term care management

IMPORTANT CONSIDERATIONS

1. Prognosis: HIE with temporal lobe infarct carries significant risk of long-term neurodevelopmental disability - Adams & Victor notes "mortality rate of 20% in the newborn period and 25% rate of neurodevelopmental disability in survivors." The family must be counseled by the medical team alongside the rehabilitation plan.
2. Seizure control: Effective seizure management (antiepileptics) is a prerequisite for optimal PT response. Coordinate PT timing around seizure medications.
3. Multidisciplinary team: This child needs input from Pediatric Neurology, Physiotherapy, Occupational Therapy, Speech-Language Therapy (for swallowing/feeding), and developmental pediatrics.
4. Prognostic monitoring: Tools like Prechtl's General Movement Assessment and Hammersmith Infant Neurological Examination (HINE) can help track neurological recovery and guide rehabilitation intensity, as supported by recent evidence (PMID 34673463).

Note: A tailored rehabilitation protocol case report for HIE (PMID 39398677) published in 2024 supports individualized therapy approaches combining passive ROM, sensory stimulation, and developmental facilitation for this population.