Physical Assessment & Physiotherapy Intervention Plan

Patient Summary (from Hospital Card)

PHYSICAL ASSESSMENT

1. Subjective Assessment

• History of Present Illness: Ascending pattern - weakness and tightness started in the lower limbs and progressed to involve the upper limbs. This ascending pattern raises high suspicion for conditions such as Guillain-Barre Syndrome (GBS), transverse myelitis, or cervical spinal cord pathology.
• ICU admission indicates acute onset with significant functional compromise.
• Young female (25 yrs) - consider demyelinating disease (MS), neuromyelitis optica (NMO), GBS, or acute transverse myelitis as primary differentials.

2. Objective Assessment (To Be Performed by Physiotherapist)

A. Neurological Status

B. Functional Assessment

• Bed mobility: Ability to roll, bridge, sit up at edge of bed
• Respiratory function: Chest expansion (cm), SpO2, breath sounds, cough strength
• Bladder/bowel: Assess for neurogenic bladder (Kegel exercises ordered - suggests bladder involvement)
• Skin integrity: Pressure area risk (Braden Scale) - ICU patient is high risk

C. Key ICU-Specific Assessment Points

• Ventilation status (self-ventilating vs. ventilator-assisted)
• Lines and monitoring (IV lines, catheter - precautions for mobilization)
• Pain/discomfort level (NRS 0-10) with movement
• Hemodynamic stability before each PT session (HR, BP, SpO2)

PHYSIOTHERAPY INTERVENTION PLAN

1. CHEST PHYSIOTHERAPY (Priority in ICU)

• Breathing exercises: Diaphragmatic breathing, segmental breathing, pursed-lip breathing - 10 repetitions, 3-4 times/day
• Percussion and vibration: Manual or mechanical percussion over lung fields (anterior, lateral, posterior) to loosen secretions
• Postural drainage: Position changes (head-down tilt where hemodynamically tolerated) to drain lung segments
• Assisted coughing/huffing: Manually-assisted cough by therapist (hand placement on lower thorax) given weak cough due to respiratory muscle weakness
• Deep breathing incentive spirometry: If able to cooperate
• Suctioning: Via nursing team if patient cannot clear secretions independently

Frequency: 2-3 sessions/day minimum in ICU

2. RANGE OF MOTION (ROM) EXERCISES - Upper & Lower Limbs

• 10 repetitions per movement, slow and controlled
• 2 times/day
• Progress from passive (therapist-guided) → active-assisted → active as strength improves
• Avoid overstretching - stay within pain-free range
• Pay particular attention to ankle dorsiflexion (prevent foot drop) and shoulder external rotation (prevent frozen shoulder)

3. BED SITTING (Progressive Sitting Tolerance)

• Phase 1 (Days 1-3): Head-of-bed elevation 30° → 45° → 60° (15-minute increments, monitor BP/HR)
• Phase 2 (Days 3-5): Supported sitting at edge of bed (with therapist and nurse support, legs dangling)
• Phase 3 (Days 5+): Unsupported sitting balance activities at bedside

• Monitor for orthostatic hypotension (drop >20 mmHg systolic)
• Use TEDS stockings and abdominal binder to reduce pooling
• Stop if SpO2 drops below 94% or patient reports dizziness

4. BRIDGING EXERCISES

• Patient supine, knees flexed 90°, feet flat on bed
• Instruct patient to lift hips off the bed, hold 5-10 seconds, slowly lower
• Grades:
  • Grade 1 (if very weak): Therapist assists hip lift passively, patient holds
  • Grade 2: Active-assisted bridging with therapist supporting at pelvis
  • Grade 3: Independent bridging
• 10 repetitions x 2-3 sets, twice daily
• Progress to single-leg bridging as strength allows

5. KEGEL EXERCISES (Pelvic Floor Muscle Training - PFMT)

• Identify pelvic floor muscles (instruct patient to imagine stopping the flow of urine)
• Contract for 5 seconds → relax for 10 seconds
• 10 repetitions per set, 3 sets per day
• Progress hold time to 10 seconds as tolerated
• Can be performed supine in ICU setting
• Monitor for breath-holding (instruct normal breathing during contractions)

6. POSITIONING AND PRESSURE CARE

• 2-hourly repositioning (supine, right lateral, left lateral rotation)
• Proper limb positioning:
  • Hips in neutral, not excessive external rotation
  • Knees slightly flexed (pillow under knees)
  • Ankles in neutral (footboard or ankle-foot orthosis [AFO] to prevent foot drop)
  • Arms: shoulders in slight abduction, elbows extended, hands in functional position (wrist splints if needed)
• Heel offloading with pillows under calves
• Pressure-relieving mattress

7. SPLINTING / ORTHOTIC MANAGEMENT

• Resting hand splints: If upper limb spasticity develops (maintain wrist/finger extension)
• Ankle-foot orthoses (AFO): To prevent foot drop (loss of ankle dorsiflexion)
• Wear schedule: 2 hours on / 2 hours off; check skin integrity at each removal

MONITORING AND PROGRESSION CRITERIA

• MRC muscle grades (UL and LL separately)
• Sitting tolerance (minutes)
• Bridging repetitions achieved
• Any adverse events

GOALS OF PHYSIOTHERAPY

IMPORTANT CLINICAL NOTE