Unit 5 - Neuro and Pediatrics Floors

Common Neurological Diagnoses Seen in Acute Care

• Traumatic Brain Injury (TBI)

• Cerebrovascular Accident (CVA/Stroke)

• Spinal Cord Injury (SCI)

• Multiple Sclerosis (MS)

• Parkinson’s Disease (PD)

• Wide spectrum of presentation and recovery potential

Traumatic Brain Injury (TBI) Overview

• Common causes: motor vehicle accidents (51%), falls (27%)

• Severity: Mild, Moderate (GCS 9–12), Severe (GCS 3–8)

Traumatic Brain Injury (TBI) Overview

Mild TBI (Concussion)

• Physical: Headaches, nausea, vomiting, dizziness, balance problems, fatigue

• Cognitive: Confusion, difficulty concentrating, memory problems, delayed processing

• Emotional: Irritability, anxiety, depression, mood swings

Traumatic Brain Injury (TBI) Overview

Moderate to Severe TBI

• Physical: Persistent headaches, repeated vomiting, seizures, loss of coordination, slurred speech, numbness or tingling, weakness

• Cognitive: Confusion, disorientation, impaired memory, problem-solving, and abstract thinking

• Emotional: Personality changes, disinhibition, apathy, aggression, agitation

• Other: Loss of consciousness, impaired vision

Glasgow Coma Scale

TBI: Key Considerations

• Improve physical function, prevent contractures, improve respiratory function

• Hypertonus:

  • Contributes to contractures

  • Worsened by immobility and poor positioning

• Muscle Weakness: More severe in patients with severe TBI

  • hormonal disturbances

  • hypercatabolism

• Physical Inactivity: extreme in acute care. Increases risk for chronic diseases (e.g., diabetes, heart disease). Adults ≥45 at higher risk

TBI: Key Considerations

Disorders of Consciousness (DOCs)

• Continuum: Coma → Vegetative State (VS) → Minimally Conscious State (MCS)

  • Persistent vs Permanent:

    • Persistent >1 month

    • Permanent after 3 months (non-trauma) or 12 months (trauma) 

  • MCS: Inconsistent awareness; requires careful, repeated assessment

  • Emergence: Functional communication or object use

  • Agitation common in early stages due to disorientation

• Prevalence of spasticity in patients with DOCs ranged from 59% - 89%

Spinal Cord Injury (SCI) Overview

• Common causes: motor vehicle accidents (MVA) (38%), falls (32%)

• Deficits: Sensory, motor, autonomic

• Types:

  • Incomplete or complete

  • Paraplegia: Lower trunk/legs

  • Tetraplegia: All four limbs + trunk

• Assessment: AISA Levels A–D

Spinal Cord Injury (SCI) Overview

ASIA A

• Complete

• no sensory or motor function is preserved in S4-S5

Spinal Cord Injury (SCI) Overview

ASIA B

• incomplete

• the preservation of sensory function without motor function below the neurological level and includes S4-S5

Spinal Cord Injury (SCI) Overview

ASIA C

• incomplete

• the preservation of motor function below the neurologic level. muscle function of more than half key muscles below this level is less than 3/5

Spinal Cord Injury (SCI) Overview

ASIA D

• incomplete

• the preservation of motor function below the neurologic level. muscle function of at least half of key muscles below this level is equal to or greater than 3/5

Spinal Cord Injury (SCI) Overview

ASIA E

• normal

• muscle and sensory function are intact 

Spinal Cord Injury (SCI) Overview

C4 lesion: Expected level of function

spontaneous breathing

Spinal Cord Injury (SCI) Overview

C5 lesion: Expected level of function

elbow flexion

Spinal Cord Injury (SCI) Overview

C6 lesion: Expected level of function

wrist extension

Spinal Cord Injury (SCI) Overview

C7 lesion: Expected level of function

elbow extension

Spinal Cord Injury (SCI) Overview

C8-T1 lesion: Expected level of function

finger flexion

Spinal Cord Injury (SCI) Overview

T1-T12 lesion: Expected level of function

intercostal and abdominal muscles — trunk control

Spinal Cord Injury (SCI) Overview

L1-L2 lesion: Expected level of function

hip flexion

Spinal Cord Injury (SCI) Overview

L3 lesion: Expected level of function

knee extension

Spinal Cord Injury (SCI) Overview

L4 lesion: Expected level of function

ankle DF

Spinal Cord Injury (SCI) Overview

L5 lesion: Expected level of function

toe extension

Spinal Cord Injury (SCI) Overview

S1-S2 lesion: Expected level of function

ankle PF

Spinal Cord Injury (SCI) Overview

S2-S4 lesion: Expected level of function

rectal sphincter tone

SCI: Key Considerations

Recent Injury

• Spinal protection: brace, halo, body jacket, internal fixation

• Avoid pulling on LE; logroll for turning

SCI: Key Considerations

Chronic Injury

• Risk of osteoporosis in vertebrae & long bones

• Even mild strain may cause fracture (e.g., during transfers)

SCI: Key Considerations

Positional Syncope

Watch for fainting when moving from supine to sitting due to BP changes

SCI: Key Considerations

Above T6 Injuries

• Impaired sympathetic response

• ↓ HR response, blood pooling, ↓ vasoconstriction

• Monitor for orthostatic hypotension (SBP ↓ ≥20 mmHg, DBP ↓ ≥10 mmHg)

SCI: Key Considerations

Autonomic Dysreflexia (AD)

• Triggered by noxious stimuli (e.g., bladder/bowel distention)

• Signs: ↑ BP (>20 mmHg above baseline), ↓ HR, headache, flushing, sweating

• Risks: Retinal/cerebral hemorrhage, MI, CHF, death

• Management: Immediate stimulus removal, BP/HR monitoring, medication based on HR

Stroke: Key Considerations

Unilateral Neglect:

• Impairs balance & weight shift; ↑ rehab LOS, ↓ FIM/GG scores at DC

• Strong predictor of poor outcomes and fall risk

Stroke: Key Considerations

Therapeutic Strategies

• Constraint-induced movement therapy (CIMT) improves UE function with some wrist/finger movement

• Corticospinal integrity = key for hand dexterity recovery

Stroke: Key Considerations

Rehabilitation Impact

• Inpatient rehab reduces LOS and improves function

• Specialized IRF stroke rehab linked to greater independence, survival

Stroke: Key Considerations

Prognosis

• Ischemic stroke = slower functional gains vs. hemorrhagic

• Walking speed = strongest predictor of community ambulation

• Fall risk: 73% incidence in mild/moderate stroke within 6 months

Stroke: Key Considerations

Poor Prognostic Indicators for Independent Living (1-year post-stroke)

• Advanced age, female gender, non-lacunar stroke

• Hemiparesis, prior hemiplegia, homonymous hemianopia

• Incontinence, low ADL function, decreased consciousness

• Visual/spatial deficits, no stroke unit transfer

Stroke: Key Considerations

Internal carotid

Stroke: Key Considerations

Middle cerebral artery

Stroke: Key Considerations

Anterior cerebral artery

Stroke: Key Considerations

Posterior cerebral artery

Stroke: Key Considerations

Vertebral or basilar artery

Stroke: Key Considerations

Posterior inferior cerebellar artery

Stroke: Key Considerations

Anterior inferior and superior cerebellar arteries

Parkinsonism Overview

Idiopathic

slow, progressive, basal ganglia disorder

Parkinsonism Overview

Secondary

from tumors, infections, or medications (e.g. certain antipsychotics)

Parkinsonism Overview

Medication

• Sinemet (dopamine agonist): Levodopa/Carbidopa

• “On-off” effect → fluctuation in motor and non-motor symptoms.

• Time sessions after meds

• Dyskinesias may occur at peak dose

Parkinsonism Overview

Balance

• Comprehensive balance assessment is essential

• Movement initiation delays and postural rigidity impair protective extension

PD: Key Considerations

Motor symptoms

• Resting tremor, bradykinesia, rigidity, postural instability

• Freezing episodes, shuffling/festinating gait, stooped posture

• Arm swing, masked facial expression,

• Dysarthria/dysphagia

PD: Key Considerations

Non-motor symptoms

• Fatigue, depression, cognitive decline

• Autonomic/GI/cardiopulmonary involvement

PD: Key Considerations

Fall risk

• Impaired protective reactions & delayed movement initiation

• Balance assessment is critical in acute care

PD

Early to mid-stage 

PD

late or advanced-stage

PD

end-stage

Multiple Sclerosis (MS) Overview

Autoimmune CNS disorder, most common demyelinating disease

Multiple Sclerosis (MS) Overview

Relapsing-remitting

Exacerbations with recovery

Multiple Sclerosis (MS) Overview

Secondary progressive

Starts RR, becomes progressive

Multiple Sclerosis (MS) Overview

Progressive relapsing

Flare-ups with lasting deficits

Multiple Sclerosis (MS) Overview

Primary progressive

Continuous decline from onset

Multiple Sclerosis: Key Considerations

Common Symptoms

• Fatigue (reported by >80%)

• Optic neuritis → visual changes often first sign

• Sensorimotor, balance, and coordination deficits

Multiple Sclerosis: Key Considerations

PT Implications

• Monitor for fatigue, vision issues, coordination changes

• Symptom fluctuation with disease course → adjust interventions accordingly

Types of Tone: Review

Hypotonia

Seen in: CP, SCI, MS, muscular dystrophy

Types of Tone: Review

Spasticity

Seen in: Stroke, SCI, MS

Types of Tone: Review

Dystonia

Seen in: CP, stroke, TBI, brain tumors, encephalitis, medications

Types of Tone: Review

Rigidity

• Types: Lead pipe or cogwheel

• Seen in: PD

Common Tone Patterns: Review

Decorticate Posturing

Common Tone Patterns: Review

Decerebrate Posturing

Tone Assessment

Tone Management

• Slow, controlled movements

• Weight-bearing activities

• Modalities (if available): NMES, cold/heat

• Positioning to inhibit tone

• Medications

Interventions for Tone Management

Hypertonia

NMES, weight-bearing activities, positioning, orthotics, mirror therapy

Interventions for Tone Management

Spasticity

NMES, casting + pharmacology

Interventions for Tone Management

Rigidity

NMES, exercise

Interventions for Tone Management

Research

serial casting versus thirty (30) minutes of stretching

Early Mobility

Benefits

Reduced length of stay, improved outcomes

Early Mobility

Guidelines

• Begin ASAP once medically stable

• Bed mobility → sitting EOB → standing/walking as tolerated

• Include simple cognitive stimulation for TBI/MS

Early Mobility

Considerations for neuro populations

• Fatigue (MS/PD)

• Motor planning deficits (CVA)

• Orthostatic hypotension (SCI)

Common Pediatric Diagnoses in Acute Care

• Congenital conditions (present at birth): CP, Congenital Muscular Torticollis (CMT), Spina Bifida, congenital heart defects

• Genetic conditions (caused by DNA mutation(s)): Duchenne Muscular Dystrophy (DMD), Spinal Muscular Atrophy (SMA), Osteogenesis Imperfecta (OI), Rett Syndrome, Fragile X Syndrome, Down Syndrome

• Acquired conditions: TBI, SCI, burns, orthopedic injuries

• Acute illnesses: cancer, infections, respiratory conditions/distress (e.g. Cystic Fibrosis (CF) exacerbations, pneumonia)

• Post-surgical: trauma, non-traumatic orthopedic surgeries (posterior spinal fusion, pectus excavatum), thoracic/abdominal, neurological, cardiac, amputations

Pediatric Prognostic Factors

• Age at time of injury/diagnosis

• Severity and location of injury

• Prior function and developmental status

• Family support and resources

• Access to early intervention, prior physical therapy and/or specialized care

Pediatric Evaluation in Acute Care

• Focus on safety and function: bed mobility, transfers, ambulation

• Developmentally appropriate assessment methods and standardized tools

  • General: PEDI, AM-PAC "6-Clicks" (peds version)

  • Neurological function:

    • TBI: Pediatric Rancho Level of Cognitive Functioning Scale and Pediatric Rancho LOC

    • SCI: ASIA

  • Developmental Assessments: PDMS-2/PDMS-3, GMFM-66 or GMFM-88

  • NICU (many require training): TIMP, HINE, GMA

• Need for equipment? Assistive Technology?

Pediatric Frequency and Dosage in Acute Care Setting

Consult

1-2 visits total

• Chronic impairments and developmental delays

• Little to no risk for loss of skills

• Need referral to next level of care or community resources

Pediatric Frequency and Dosage in Acute Care Setting

Occasional

1-2x/wk

• A potential for weekly/monthly progress toward functional goals

• At risk for loss of skills for prolonged hospitalization

• Currently receiving early intervention therapy services or needs referral

Pediatric Frequency and Dosage in Acute Care Setting

Regular

3-4x/wk

• New impairments and functional limitations

• Potential for daily/weekly progress toward functional goals

• Currently receiving therapy services, or likely to be referred to outpatient

Pediatric Frequency and Dosage in Acute Care Setting

Frequent

5x/wk

• Acute loss of functional skills due to injury or illness

• Good to excellent potential for daily progress

• High risk for deconditioning without skilled PT

• Potential referral to inpatient rehab or high-frequency outpatient

Pediatric Frequency and Dosage in Acute Care Setting

Intense

>6x/wk

• Acute loss of functional skills due to injury or illness

• Excellent potential for daily progress or at high risk for loss of function with a lower frequency

• Potential referral to inpatient rehab or high-frequency outpatient

Safety Considerations in Pediatric Acute Care

Medical & Environmental Awareness

• Know your lines: IVs, NG/G-tubes, O2, EVDs, telemetry

• Monitor alarms before mobilizing

• Observe for clutter, fall risks, and safe transfer space

Safety Considerations in Pediatric Acute Care

Physiological Awareness

• Review most recent vitals (age-appropriate norms)

• Watch HR, RR, BP, SpO₂ during activity

• Stop if: ↓SpO₂, arrhythmia, mental status change, vomiting, increased distress

Safety Considerations in Pediatric Acute Care

Developmental & Behavioral Cues

• Adjust expectations by age and development

• Use child-friendly language and play-based approaches

• Partner with caregivers for comfort and support

Safety Considerations in Pediatric Acute Care

Interprofessional Check-ins

• Confirm orders: activity level, bedrest status

• Clarify precautions after procedures or med changes

• Collaborate with RN/MD if unsure about safety

Pediatric Early Rehab Strategies

• Prevent contractures

• Early mobility

• Chest physiotherapy when indicated

• Promoting participating in daily activities

• Sensory stimulation and play-based interventions

• Family involvement positioning: promote alignment, from day one

Pediatric Long-Term Rehab Planning

• Continuum of care: transition from acute care to inpatient rehab, home, or outpatient/early intervention

• Goal setting: short-term functional goals, long-term developmental milestones

• School re-integration and adaptive strategies

• Ongoing team communication and care coordination

Family and Caregivers: Pediatrics

• Diagnosis and expected outcomes

• Family-centered care

• Family and caregiver involvement in therapy sessions

• Safe handling and mobility techniques

• Equipment training (braces, walkers, wheelchairs)

• Signs of complications or regression

• Home exercises and strategies for ongoing support

Neuro

Why Discharge Planning Matters

• patients are very high-risk:

  • Readmission

  • Falls

  • Functional decline

  • Unpredictable hospital course

• Discharge decisions impact long-term function and quality of life

• Planning starts at day 1 of admission

Neuro

Key Discharge Considerations

Neurological Diagnosis & Prognosis

Each condition (CVA, TBI, SCI, MS, PD) has a unique recovery trajectory

Neuro

Key Discharge Considerations

Current Functional Status

• Mobility (e.g., transfers, gait)

• Cognition and communication abilities

• Continence and overall ADL performance

Neuro

Key Discharge Considerations

Support System

• Availability of caregivers 

• Home setup and accessibility

• Transportation and community support

Neuro

Key Discharge Considerations

Medical Complexity

• Comorbidities and medication management

• Presence of feeding tubes, seizures, tracheostomy, or ventilators

• Anticipated medical needs post-discharge

Discharge: Stroke

• Admission to inpatient rehab influenced by age, incontinence, living situation, and insurance coverage

• 44.9% discharged to community; 55.1% to institutional care

• Community-discharged patients:

  • Younger, still working

  • Less dysphagia/tube feeding,

  • Shorter time from onset to rehab, less severe deficits 

  • Greater and faster functional gains during stay

• Early mobilization predicts favorable outcomes

Discharge: TBI

• Longer time to rehab is associated with greater disability

• Longer rehab LOS linked with:

  • Tracheostomy at admission

  • Transfers due to complications

    • Infection

    • Seizure

    • Respiratory needs

    • Neuro changes

Discharge: MS

• Predictors of rehab success:

  • Relapsing-remitting course

  • Shorter disease duration

  • Less severe baseline impairments including balance

• Balance impairment = negative predictor of rehab outcome

• IPR improves ADL autonomy, especially in early-stage MS

Discharge: PD

• Positive predictors of ADL improvement after IPR:

  • Younger age, high baseline ADL impairment

  • Strong dexterity skills and steady gait

• ≥3 daily mobilizations linked to:

  • Shorter LOS

  • Higher likelihood of home-to-home discharge

Neuro

Discharge Planning

Ongoing Rehabilitation Needs

Inpatient rehab, SNF, home health, outpatient

Neuro

Discharge Planning

Cognitive Screening Results

Impact on safety, independence, and follow-up care