PPA tut8a

Operation and Features of the Sliding Tilt Table

  - Functional Adjustments: The tilt table is equipped with up/down height adjustments and a tilt function. The height is adjustable to facilitate different transfer methods, such as slide transfers from wheelchairs, hoist transfers, or direct stepping.   - Foot Plate Configuration: Foot plates can be set at a standard $90^{\circ}$ angle, or adjusted into slight plantar flexion or flexion depending on whether the goal is to increase range of motion or provide a greater stretch.   - The Pendulum: Unlike older models that require guessing the incline, this model features a built-in pendulum on the side that indicates the exact angle of tilt. This allows for precise monitoring, such as setting a patient to exactly $25^{\circ}$.   - Shoulder and Underarm Blocks:     - These are often placed above the shoulders during exercises like squats to prevent the patient from sliding up or down the table.     - They can also be repurposed as underarm blocks to stabilize the trunk and prevent unwanted movement.   - Sliding Mechanism and Locking System:     - The Switch: The release switch points toward the head to lock and toward the feet to be free to move/slide.     - The "Click": A mechanical click is required for the table to be truly locked; a visual alignment alone does not guarantee security.     - Positioning: For therapeutic exercises, the sliding bed should be locked in the middle. Placing it too close to the top prevents heel raises, while placing it too close to the bottom prevents squats.     - Model Limitation: On this specific model, once the table is tilted, the sliding mechanism becomes nearly impossible to unlock. Ideally, a practitioner would lock it while horizontal, tilt the patient, and then unlock it, but this unit requires the user to be securely strapped in and unlocked before or while tilting depending on the specific model's limitations.

Patient Transfer and Safety Assessment

  - Initial Assessment for Long-term Bedbound Patients: When treating a patient who has been horizontal in the ICU for a period such as two weeks, several factors must be considered:     - Pressure Injuries: Check for the development of bedsores or pressure-related skin breakdown.     - Deconditioning: Expect the patient to be significantly physically deconditioned due to inactivity.     - Vitals and Blood Pressure: This is the primary concern. Moving from a horizontal to a vertical plane after long-term bed rest often causes orthostatic hypotension (blackheadedness/dizziness).   - Vital Sign Protocol: Check vitals before beginning. Keep equipment nearby during the tilt. If the patient feels unwell or dizzy, return the table to a horizontal position immediately.   - Standard Securement:     - Always use three straps to secure the patient.     - The lowest strap should be positioned as low as possible on the thighs and fastened tightly.     - All components—wheels, foot plates, and sliding beds—must be locked before the patient is transferred onto the table.

Weight Bearing and Clinical Progression

  - Angle Progression: There is no universal starting angle. A common protocol is to start at $20^{\circ}$, assess patient response, and increase by $5^{\circ}$ to $10^{\circ}$ increments. A target of $45^{\circ}$ may be achieved by the end of a session.   - Weight-Bearing Restrictions: If a patient is on partial weight-bearing (PWB) status, the tilt table can be used at lower angles (e.g., $40^{\circ}$) to ensure they are not taking their full body weight.   - Comparison to Body Weight Support: Practitioners rarely take a patient to a full $90^{\circ}$ on a tilt table because, at that point, a standard standing board with body weight support is generally more appropriate.   - Single Leg Work: The table allows for single-leg weight-bearing exercises, though shifting weight between legs while tilted is physically difficult for the patient.

EMG-Triggered Stimulation (ETS) and PC1 Protocol

  - Rationale: ETS is used as a motivator for patients who have some muscle activity but cannot produce visible joint movement. It provides visual feedback via numbers and physical feedback when the stimulation "clicks in."   - The Requirement of a "Flicker": ETS will not work for patients with a $0/5$ on the Manual Muscle Testing (MMT) scale. It requires a minimum microvoltage of muscle activity (a twitch or flicker) to trigger the machine.   - Setting Up the Device:     - Cabling: Plug the cable into Channel 1.     - Program Selection: Select the "ETS" program and use the "PC1" sub-setting.     - Threshold Settings: For healthy individuals, set the threshold high (above $100$, specifically around $110$). For clinical patients, the threshold is set lower to ensure they can successfully trigger the stimulation, but high enough to require effort.   - The Execution Cycle:     - Increase interest and intensity until the patient feels the stimulation and the desired movement is achieved.     - The machine counts down from $5$ seconds.     - When the screen says "Work," the patient attempts the contraction (e.g., wrist extension).     - Once the EMG activity hits the pre-set threshold, the E-Stim triggers to complete the movement.

Mirror Box Therapy and Neural Retraining

  - Physical Setup: A mirror box is a right-angle triangle with a vertical mirror. The affected limb is placed inside the box (hidden from view), while the unaffected limb is placed on the outside.   - The "Brain Trick": The core mechanism is to trick the brain into thinking the affected hand is moving perfectly by having the patient watch the mirror reflection of their healthy hand.   - Key Instructions: The patient must look strictly into the mirror at the reflection. They should not look at the hand inside the box, which may not be moving or may be moving poorly.   - Training Strategy: Exercises are set up similarly to standard task training. For example, if a patient is working on thumb abduction, they do high repetitions with the healthy thumb while watching the reflection to fire the neural pathways for the affected side.   - Dosage: Effectiveness relies on high repetition. Practitioners should start with $2$ to $3$ reps to check form, then set goals of $20$ to $30$ reps per set.

Mental Practice and Motor Imagery

  - Definition: A training strategy where patients cognitively rehearse a physical movement without actual muscle contraction.   - Application for Weakness and Fatigue: Mental practice is an excellent adjunct for patients who are too weak to move (MMT score of $0$) or for those who fatigue quickly before reaching a high enough dosage of physical reps.   - Implementation Techniques:     - Steps: Dissect a movement into small, repeatable parts.     - Visual Aids: Use videos of the movement or video loops of the patient themselves performing the task on their healthy side.     - Audio/Transcripts: Use voice-over instructions or have the patient read a script of the movement steps to themselves.   - Target Populations: This is effective across neurological populations, including stroke, Traumatic Brain Injury (TBI), Spinal Cord Injury (SCI), and patients with Deep Brain Stimulation (DBS).

# Questions & Discussion   - Q: Why would you pick ETS over normal E-Stim?     - A: ETS is superior for motivation and active participation once the patient has a "flicker" of movement. If the patient has zero activity ($0/5$ MMT), ETS will not turn on and standard E-Stim must be used instead.   - Q: Is mirror therapy a form of Cognitive Behavioral Therapy (CBT)?     - A: No. It targets neural pathways and motor imagery rather than the psychological frameworks associated with CBT, though both involve brain-based retraining.   - Q: Does timing of mental practice matter (before or after physical practice)?     - A: Research generally focuses on mental practice as an addition to conventional therapy. Specific studies on the optimal timing (pre vs. post) are less definitive in standard clinical practice.   - Q: How many straps are used on the tilt table?     - A: Three straps are used for safety during the ascent and descent, though one may be removed depending on the specific exercise being performed once the table is stable.