MS PP2 Assessment Revision Guidance PDF

**[PP2 Assessment Revision Guidance]** Moderate evidence regarding physio interventions: **1. Niche Focus:** - - - **2. Research Complexity:** - - - **3. Diverse Patient Populations** - - **4. Blinding and Placebo Effects** - - - ### **5. Variation in Treatment Ap...

**[PP2 Assessment Revision Guidance]** Moderate evidence regarding physio interventions: **1. Niche Focus:** - - - **2. Research Complexity:** - - - **3. Diverse Patient Populations** - - **4. Blinding and Placebo Effects** - - - ### **5. Variation in Treatment Application** - - - ### **6. Difficulty in Measuring Outcomes** - - - +-----------------------------------------------------------------------+ | **MSK** | | | | +--------------------------------+--------------------------------+ | | | **Problem** | **Intervention** | | | +================================+================================+ | | | Back pain | - - | | | +--------------------------------+--------------------------------+ | | | Neck pain | - - | | | +--------------------------------+--------------------------------+ | | | Tendinopathy | - - | | | +--------------------------------+--------------------------------+ | +=======================================================================+ | **Spinal mobility: Range of motion mobility exercise** | +-----------------------------------------------------------------------+ | [References:] | | | | **Sterling** et al. (2019). Best Evidence Rehabilitation for Chronic | | Pain Part 4: Neck Pain. Journal of clinical medicine | | | | **NICE** Guidelines (2020) Low back pain and sciatica in over 16s: | | assessment and management. | | [[https://www.nice.org.uk/guidance/ng59/resources/low-back-pain-and-s | | ciatica-in-over-16s-assessment-and-management-pdf-1837521693637]{.und | | erline}](https://www.nice.org.uk/guidance/ng59/resources/low-back-pai | | n-and-sciatica-in-over-16s-assessment-and-management-pdf-183752169363 | | 7) | | | | [NICE guidance:] | | | | NICE Guidelines (2020): Low back pain and sciatica in over 16s: | | Assessment and Management | | | | - - | | | | [Aim of treatment:] | | | | To improve spinal range of motion by addressing stiffness and | | maintaining flexibility, thereby reducing pain and improving | | function. | | | | [Summary of the Treatment: ] | | | | - - - | | | | [Indications:] | | | | - - - - | | | | [Contraindications:] | | | | - - - | | | | [Limitations:] | | | | - - | | | | [Further considerations:] | | | | - - - - | +-----------------------------------------------------------------------+ | **Spinal mobility: Manual therapy** | +-----------------------------------------------------------------------+ | [References:] | | | | **Miller** et al. (2010). Manual therapy and exercise for neck pain: | | A systematic review. | | | | **Foster** et al. (2018). Prevention and treatment of low back pain: | | evidence, challenges, and promising directions. | | | | **Rubinstein** et al. (2013). Spinal manipulative therapy for acute | | low back pain: an update of the cochrane review. | | | | **Shabbir** et al. (2021). Clinical outcomes of maitland mobilization | | in patients with Myofascial Chronic Neck Pain: A randomized | | controlled trial. | | | | **NICE** Guidelines (2020) Low back pain and sciatica in over 16s: | | assessment and management. | | https://www.nice.org.uk/guidance/ng59/resources/low-back-pain-and-sci | | atica-in-over-16s-assessment-and-management-pdf-1837521693637 | | | | [NICE guidance: ] | | | | NICE Guidelines for both neck and Lumbar pain - does list manual | | therapy as a modality of treatment but only as a treatment package | | with exercise. | | | | **C-spine:** | | | | [[https://cks.nice.org.uk/topics/neck-pain-non-specific/management/ma | | nagement/]](https://cks.nice.org.uk/topics/neck-pain-non- | | specific/management/management/) | | | | [**L-spine:** | | h[ttps://www.nice.org.uk/guidance/ng59/resources/low-back-pain-and-sc | | iatica-in-over-16s-assessment-and-management-pdf-1837521693637](https | | ://www.nice.org.uk/guidance/ng59/resources/low-back-pain-and-sciatica | | -in-over-16s-assessment-and-management-pdf-1837521693637)]{.underline | | } | | | | [Aim of the treatment: ] | | | | - - - - - | | | | - | | | | [Lumbar] | | | | Mobilisations appear to be no better than other existing therapies | | for treating back pain. Mobilisations if used as a course of | | treatment should be based on cost, preference of patient and provider | | and safety. | | | | Rubinstein et al., (2012) | | | | Manual therapy is listed as a second line or adjunctive treatment | | option, advocating for treatments, such as, exercise therapy, | | activity advice and education for both acute and chronic lower back | | pain. | | | | Foster et al. (2018) | | | | [Summary of the Treatment: ] | | | | - - | | | | Manual Therapy for C-spine and neck pain should be used as an | | adjunctive treatment to exercise and advice. | | | | Grades 1-2 should be used to reduce pain and irritability (Pain Gate | | Theory). | | | | Grades 3-4 address the stiffness | | | | - - - - | | | | | | | | - - - | | | | | | | | - - | | | | [Indications:] | | | | - - - - | | | | [Contraindications:] | | | | - - - - | | | | [Limitations:] | | | | - | | | | [Further considerations:] | | | | - - | | | | (Miller et al., 2010) | | | | Grade 3 & 4 used to stretch the joint capsule and passive tissues to | | increase ROM. | | | | (Shabbir et al., 2021) | +-----------------------------------------------------------------------+ | **Spinal: Strengthening exercise** | +-----------------------------------------------------------------------+ | [References:] | | | | **Mueller** & Niederer (2020). Dose-response-relationship of | | stabilisation exercises in patients with chronic non-specific low | | back pain: a systematic review with meta-regression. *Scientific | | Reports*. | | | | **Grooten** et al. (2022). Summarizing the effects of different | | exercise types in chronic low back pain - a systematic review of | | systematic reviews. | | | | **NICE** Guidelines (2020) Low back pain and sciatica in over 16s: | | assessment and management. | | [[https://www.nice.org.uk/guidance/ng59/resources/low-back-pain-and-s | | ciatica-in-over-16s-assessment-and-management-pdf-1837521693637]{.und | | erline}](https://www.nice.org.uk/guidance/ng59/resources/low-back-pai | | n-and-sciatica-in-over-16s-assessment-and-management-pdf-183752169363 | | 7) | | | | [NICE guidance:] | | | | - - | | | | [Aim of the treatment:] | | | | Strengthen spinal muscles to support and stabilise the spine can help | | relieve back and neck pain, particularly in low back pain cases | | | | Pilates, resistance training, motor control, and yoga demonstrated | | low-moderate evidence for positive effects on pain and disability | | with CLBP compared to no intervention.. Something is better than | | nothing | | | | Grooten et al., 2022 | | | | [Summary of the Treatment:] | | | | Core and back strengthening using progressive resistance exercises, | | ideally as part of a supervised program, using own body weight, | | bands, or hand-held weights to train a specific muscle group. This | | can be progressed using the FITT principle. | | | | [Indications:] | | | | - - - - | | | | [Contraindications:] | | | | - - - - - | | | | [Limitations:] | | | | Patient engagement and regular progression are required to see | | benefits. | | | | [Further considerations:] | | | | Focus on addressing the impairments | | | | Anterior pelvic tilt: strengthen glutes and hamstrings | | | | Posterior pelvic tilt: iliopsoas (knee to chest exercise using band | | for resistance) | | | | Motor control/taping: can be useful for patients with excessive, | | muscle-protective movement patterns to restore basic motor control | | patterns. | | | | Limited evidence that motor control exercises have a clinically | | worthwhile effect over exercise | | | | (Nieclever & Muller, 2020) | +-----------------------------------------------------------------------+ | **Spinal: Neural mobilisation** | +-----------------------------------------------------------------------+ | [References]: | | | | **Coppieters & Butler** (2008). Do 'sliders' slide and 'tensioners' | | tension? An analysis of neurodynamic techniques and considerations | | regarding their application. Manual therapy, | | | | **Richard & Wayne** (2008) Neural Mobilization: A Systematic Review | | of Randomized Controlled Trials with an Analysis of Therapeutic | | Efficacy | | | | Neural mobilization (NM) techniques, including \"sliders\" and | | \"tensioners,\" may improve pain, range of motion, and function in | | patients with conditions involving neural tension or irritation. | | | | - - | | | | (Ellis & Hing, 2013) | | | | - - - | | | | (Coppieters & Butler, 2008) | | | | **Key Techniques**: | | | | 1. **Sliders (Neural Gliding)**: | | | | - Movement alternates between elongating and relaxing the nerve | | without significant tension. | | | | - Promotes large excursions of the nerve, facilitating its | | glide within the nerve bed. | | | | - **Advantages**: Minimal strain on the nerve, better patient | | compliance​​. | | | | 2. **Tensioners**: | | | | - Apply controlled elongation to the nerve to increase its | | length and flexibility. | | | | - Lesser excursion compared to sliders but beneficial in | | chronic stiffness. | | | | [NICE guidance:] | | | | No direct NICE guidance, but neural mobilizations are common in | | physical therapy. | | | | [Aim of the treatment:] | | | | - Reduce nerve compression and pain, promote nerve gliding to | | relieve radiculopathy symptoms. | | | | - Restore normal movement of peripheral nerves relative to their | | surrounding tissues (nerve bed). | | | | - Reduce symptoms such as pain, tingling, or numbness caused by | | altered neurodynamics. | | | | [Summary of the Treatment:] | | | | - Ask about pain throughout | | | | - Slowly stretch the nerve | | | | - If pain is there is positive test | | | | - Take out a stretch and see if pain goes away | | | | - If so, prescribe this as a slider to get used to the movement | | then slowly work into the stretch. - can be disturbing for | | patients and most of them don\'t like it so you introduce sliding | | the nerve.\ | |  | | | | | | | | - **Upper Limb Tension Tests (ULTT)**: | | | | - **Median** Nerve Bias: (indication: carpal tunnel syndrome, | | cubital tunnel syndrome and non acute cervical | | radiculopathy.) Shoulder abduction, elbow extension, wrist | | supination, finger/wrist extension.\ | | | | - **Radial** Nerve Bias: (indication: Tingling down the thumb | | side of the forearm) Shoulder girdle depression, elbow | | extension, medial arm rotation & forearm pronation, wrist, | | fingers flexion and shoulder abduction.\ | |  | | | | - **Ulnar** Nerve Bias: (indication: Pain or dysfunction on 4th | | and 5th finger, grip weakness) shoulder girdle depression, | | shoulder abduction, Shoulder external rotation, elbow | | flexion, wrist extension​.\ | | | | | | | | - - - | | | | [Indications:] | | | | - - - - - | | | | [Contraindications:] | | | | - - - - - - - | | | | [Limitations:] | | | | May require adjunct therapy if symptoms are severe or persistent. | | | | Patient tolerance to movements | +-----------------------------------------------------------------------+ | | +-----------------------------------------------------------------------+ | [References:] | | | | **Stevens** & Tan (2014). Effectiveness of the Alfredson protocol | | compared with a lower repetition-volume protocol for midportion | | Achilles tendinopathy: a randomized controlled trial.\ | | **Kongsgaard** et al. (2009). Corticosteroid injections, eccentric | | decline squat training and heavy slow resistance training in patellar | | tendinopathy. *\ | | ***Mantovani** et al. (2020). "Does isometric exercise improve leg | | stiffness and hip pain in subjects with Achilles tendinopathy? A | | feasibility study."\ | | **Parkinson** et al. (2011). Involvement of Proteoglycans in | | Tendinopathy. | | | | **NICE**. (2016). Extracorporeal shockwave therapy for Achilles | | tendinopathy. In Interventional Procedures Guidance. | | https://www.nice.org.uk/guidance/ipg571 | | | | [NICE guidance:\ | | ]**Tendon Loading Exercises:** **NICE guidelines** do not | | provide specific recommendations on tendon loading exercises. | | However, they offer general advice for musculoskeletal conditions, | | including: | | | | **Extracorporeal Shockwave Therapy**: | | | | - NICE guidelines approve its use in cases of chronic tendinopathy | | that do not respond to conservative measures, including Achilles | | and patellar tendinopathy. It is recommended only after careful | | consideration of other interventions​​. | | | | - Patients should be made aware of the uncertainties surrounding | | the procedure\'s effectiveness and provided with clear written | | information. | | | | For tendinopathy specifically, practice relies heavily on systematic | | reviews and evidence-based protocols like the Jill Cook tendinopathy | | continuum rather than NICE guidelines directly. These focus on | | progressive loading strategies as the cornerstone of treatment. | | | | [Aim of the treatment: ] | | | | - - - | | | | [Stages of Loading:] | | | | 1. - Focus: Reduce load while maintaining activity. | | | | - Techniques: | | | | - Offloading (reduce load but maintain activity to | | encourage remodelling with Type 1 fibres): Taping (can | | help control inflammation and pain, increase functional | | activity), orthotics. | | | | - Mobilisation of adjacent joints to reduce tension. | | | | - Medications: Tenocyte inhibitors (e.g., ibuprofen) to | | limit proteoglycan overproduction. | | | | i. Overproduction can disrupt the structural integrity | | and function of the tendon.\ | | **Parkinson** et al. (2011) | | | | 2. - Focus: Progressive loading through isometric and isotonic | | exercises. | | | | - Techniques: | | | | - Gradual return to functional activities. | | | | - Incorporate strengthening of related joints/muscles to | | redistribute forces. | | | | 3. - Focus: High-load exercises for tendon remodelling. | | | | - Techniques: | | | | - Eccentric and plyometric exercises. | | | | - Lifestyle advice, including managing systemic issues like | | diabetes or cholesterol​​. | | | | - If acute signs such as pain at rest, tenderness to | | palpation and soreness during activity manifest again you | | can start to use acute phase treatment options | | | | - If after week 6-12 of progressive treatment, no | | improvements have been seen, refer to orthotics or back | | to GP if ? another co-morbidity is influencing (e.g- | | T2DM). | | | | - Start to increase loading as able with Isometric | | Exercises in a staged progressive manner. | | | | [Example Protocols:] | | | | - - - | | | | - - - | | | | [Indications:] | | | | - - - - | | | | [Contraindications:] | | | | Acute ruptures, significant inflammation, or non-mechanical pain. | | | | [Limitations: ] | | | | Tendons with advanced degenerative changes may not fully recover. | | | | Requires patient commitment to prolonged rehabilitation programs. | +-----------------------------------------------------------------------+ +-----------------------------------------------------------------------+ | **CVR** | | | | - - - - | | | | - - - - | | | | +--------------------------------+--------------------------------+ | | | **Problem** | **Intervention** | | | +================================+================================+ | | | Low O2 | - - - | | | +--------------------------------+--------------------------------+ | | | Low volumes | - - - | | | +--------------------------------+--------------------------------+ | | | Secretions | - - - - - - | | | +--------------------------------+--------------------------------+ | | | | **How to assess effectiveness of respiratory interventions:** | | | | - - - - - - - - - - - | +=======================================================================+ | | +-----------------------------------------------------------------------+ | [References:] | | | | [NICE guidance:] | | | | Recommended as part of self-management in chronic respiratory | | conditions. | | | | [Aim of the treatment:] | | | | Improve respiratory mechanics and reduce WOB. | | | | [Summary of the Treatment: ] | | | | Includes positioning, ACBT, PEP devices, and breathing retraining. | | | | [Indications:] | | | | Post-surgical recovery, COPD, bronchiectasis. | | | | [Contraindications:] | | | | Severe fatigue or inability to follow instructions. | | | | [Limitations:] | | | | May require patient training and compliance. | +-----------------------------------------------------------------------+ | | +-----------------------------------------------------------------------+ | [References:] | | | | **National Asthma Council Australia.** (2016). *INHALER TECHNIQUE FOR | | PEOPLE WITH ASTHMA OR COPD*. | | https://extranet.who.int/ncdccs/Data/AUS\_D1\_Inhaler\_Technique\_Inf | | opaper-FULL-UPDATED-11-1.pdf | | | | **NICE**. (2023). *Assessment for long-term oxygen therapy \| Chronic | | obstructive pulmonary disease in adults \| Quality standards \| | | NICE*. | | | | [NICE guidance:] | | | | No specific guidance on inhaler technique NICE recommends Healthcare | | professionals ensure that they assess the person's inhaler technique | | when starting or changing treatment and at least annually during | | treatment. | | | | [Aim of the treatment: ] | | | | - Ensure that the prescribed medication reaches the lungs & | | delivers the correct dose. | | | | - Good inhaler technique maximises the effectiveness of the | | medication, leading to better control of respiratory symptoms and | | function. | | | | - Proper inhaler use increases likelihood that individuals will | | adhere to their treatment plan. | | | | - Effective inhaler use can contribute to cost-effective management | | of respiratory conditions by reducing the need for additional | | medications, emergency healthcare visits and hospitalisations. | | | | - Regular correct use can prevent exacerbations, reduce risk of | | sudden worsening of symptoms. | | | | [Summary of the Treatment: ] | | | | - | | | |  | | | | [MDIs] (meter dosed inhalers) - you need to breathe in | | slow and steady and, at the same time, press the canister on the | | inhaler once. Continue to breathe in slowly over 3-5 seconds, until | | your lungs feel full. | | | | [DPIs] (Dry powder inhaler) - you need to breathe in | | quickly and deeply until your lungs feel full. This makes sure the | | medicine is completely inhaled | | | | Tips: | | | | - Shake the inhaler well Prior to use (only applicable if MDI) | | | | - Sit or stand up straight and breathe out gently and fully before | | using an inhaler. | | | | - Slightly tilt your chin up as it helps the medicine reach your | | lungs. | | | | - Put your lips around the mouthpiece of the inhaler to make a | | tight seal. | | | | - Start to breathe in slowly and steadily and at same time press | | the canister on the inhaler once. | | | | - Continue to breathe slowly until your lungs feel full | | | | - Take the inhaler out of your mouth and with lips closed hold your | | breath for up to 10 seconds or for as long as you are | | comfortable. | | | | - Then breathe out gently away from your inhaler. | | | | - If prescribed more doses than one wait 30 seconds to a minute and | | shake the inhaler again and repeat the steps. | | | | - When finished replace the cap on the inhaler | | | | - Rinse mouth afterwards if steroid inhaler | | | | [Indications:] | | | | Chronic asthma, COPD, acute bronchospasm, or inhaler users. | | | | [Contraindications:] | | | | Those who have confusion/delirium. Person needs to be conscious, | | alert, and be able to sit or stand in an upright position. Facial | | trauma around the mouth ? | | | | [Limitations: ] | | | | Those who have poor coordination, reduced sensory awareness ,limited | | range, grip to use the device effectively. | +-----------------------------------------------------------------------+ | **The Vest:** mainly for chronic patients not acute and CF patients. | +-----------------------------------------------------------------------+ | [References:] | | | | ***Bronchiectasis Toolbox** (2024). High frequency chest wall | | oscillation*. Webpage. Available at: | | https://bronchiectasis.com.au/paediatrics/airway-clearance/high-frequ | | ency-chest-wall-oscillation. | | | | **NICE**. (2018). The Vest for delivering high-frequency chest wall | | oscillation in people with complex neurological needs. *Medtech | | Innovation Briefing*. https://www.nice.org.uk/guidance/mib159 | | | | [NICE guidance:] | | | | - - - - | | | | [Aim of the treatment:] | | | | - - - - - | | | | [Summary of the Treatment: [THE VEST airway clearance system \| 3D | | Animation Video - | | YouTube](https://www.youtube.com/watch?v=v4nh68K1184)] | | | | - - - | | | | [Indications:] | | | | Cystic fibrosis, bronchiectasis, chronic mucus hypersecretion. | | | | [Contraindications:] | | | | - - - - - - - - - - - - | | | | [Limitations:] | | | | - - - - - | +-----------------------------------------------------------------------+ | **HiFlow nasal 02 therapy** | +-----------------------------------------------------------------------+ | [References:] | | | | **O\'Driscoll** et al. (2017). British Thoracic Society Guideline for | | oxygen use in adults in healthcare and emergency settings. | | | | **Renda** et al. (2018). High-flow nasal oxygen therapy in intensive | | care and anaesthesia. | | | | [NICE guidance:] nil | | | | **British Thoracic Society Guideline for oxygen use for adults in | | healthcare and emergency settings (2017):** recommends HFNO as an | | alternative to reservoir mask treatment in patients with acute | | respiratory failure without hypercapnia | | | | - - | | | | **British Journal of Anaesthesia (2018):** outlines benefits to HFNO, | | such as: | | | | - - - - - | | | | [Aim of the treatment:] | | | | High flow nasal oxygen (HNFO) is used in critical care and certain | | acute medical wards, namely for patients requiring high | | concentrations of oxygen (FiO2 \>40%).It is indicated for patients | | with type 1 respiratory failure; potential pathologies include | | pneumonia, pulmonary oedema and asthma. | | | | HFNO delivers a flow of up to 60L/minute via a nasal cannula, with an | | FiO2 of up to 100%. This is used to improve oxygenation by providing | | humidified, titrated oxygen. | | | | [Summary of the Treatment: ] | | | | [Indications:] | | | | - - - - - - - - - - - - | | | | [Contraindications:] | | | | - - - - - - - - - - - | | | | [Limitations:] | | | | - - - - - - - - - | +-----------------------------------------------------------------------+ | **NIV: (BiPAP/CPAP)** | | | | BiPAP: bilevel positive airway pressure. Pressure is always positive | | - going in while inhaling and exhaling. When inhaling stronger than | | when exhaling. | | | | CPAP: continuous positive airway pressure. Pressure is always | | positive - going in. When inhaling and exhaling using the same | | pressure. | +-----------------------------------------------------------------------+ | [References:] | | | | **Davies** et al. (2018). British Thoracic Society Quality Standards | | for acute non-invasive ventilation in adults. | | | | [NICE guidance:] | | | | Follows protocols for managing Type I and Type II respiratory failure | | and chronic conditions like COPD. | | | | - - - | | | | [Aim of the treatment:] | | | | - - - - - | | | | [Explanation for rx:] | | | | - - - | | | | [Summary of the Treatment: ] | | | | - - | | | | [Indications:] | | | | - - | | | | +--------------------------------+--------------------------------+ | | | Continuous Positive Airway | Bi-Level Positive Airway | | | | Pressure (CPAP) | Pressure (BiPAP) | | | +================================+================================+ | | | ONE constant pressure | Changes between TWO pressures | | | | | | | | | Active assisted inspiration | Inspiratory pressure delivers | | | | | a tidal breath: | | | | Splints airways open | | | | | | Inspiratory positive airway | | | | Helps with OXYGENATION | pressure (IPAP) Assist | | | | | inspiration, aids | | | | Increases mean airway | ventilation/TV. | | | | pressure, and will improve | | | | | ventilation to collapsed areas | Expiratory positive airway | | | | of the lung. | pressure (EPAP) Eliminates | | | | | exhaled air through the | | | | Type 1 resp failure | expiratory port, reducing | | | | | re-breathing, encourages lung | | | | | recruitment, and stents open | | | | | the upper airway | | | | | | | | | | Helps with oxygenation & | | | | | hypercapnia | | | | | | | | | | Type 1 and 2 resp failure | | | +--------------------------------+--------------------------------+ | | | | [Contraindications:] | | | | - - - - | | | | [Limitations:] | | | | - - - | | | | [Side effects:] | | | | - - - - - - - - | +-----------------------------------------------------------------------+ | **MI:E (cough assist) -** pressure both in out. Can be adjusted | | manually, ?can be used with inhaling and exhaling triggering. | | Pressures can be the same or can be diff. | +-----------------------------------------------------------------------+ | [References:] | | | | **Spear**, L. (2019). Cough Assist for Effective Airway Clearance | | Therapy. | | | | [NICE guidance:] nil | | | | [Aim of the treatment: ] | | | | - - - - - - - - - | | | | [Summary of the Treatment:] | | https://www.youtube.com/watch?v=1ohB6PDYqCY | | | | delivering positive pressure then rapidly cycling negative pressure | | to simulate a cough. Insufflation and exsufflation can be changed to | | the patients needed and does not need to be equal and opposite | | pressures. | | | | Exhale -35cmH20 & 2.0 sec and Inhale +25cmH20 & 2.0 sec | | | | [Indications:] | | | | - - - - - - - | | | | [Contraindications:] undrained pneumothorax, PE (without | | anticoag) bronchopleural or tracheoesophageal fistula, patient | | refusal | | | | [Limitations:] | | | | - - - - - - - - - | | | | [Further things to consider:] | | | | - - - - - | | | | [Side effects:] | | | | - - - - - - - - | +-----------------------------------------------------------------------+ | **IPPB: Intermittent positive pressure breathing -** pressure when | | inhaling & manual exhale. (Assisted big breath | | in!) | +-----------------------------------------------------------------------+ | [References:] | | | | **Thornton** et al. (1974). Intermittent positive pressure breathing | | (IPPB) in chronic respiratory disease. | | | | **Nicolini** & **Grecchi** (2013). Comparison of Intermittent | | Positive Pressure Breathing (IPPB) and Temporary Positive Expiratory | | Pressure (TPEP) in Patients With Severe Chronic Obstructive Pulmonary | | Disease. | | | | [NICE guidance:] nil | | | | - Short treatment periods and proper ventilator settings are | | crucial to avoid adverse effects like hypercapnia. | | | | - High oxygen concentrations can be safely used in IPPB provided | | adequate ventilation and careful monitoring are ensured. | | | | The two techniques (IPPB and TPEP) improves quality of life and lung | | function in patients with severe COPD. IPPB demonstrated a | | significant greatest effectiveness to improve dyspnea and quality of | | life tools (MRC, CAT) than TPEP. (Nicolini & Grecchi (2013) | | | | [Aim of the treatment:] | | | | - - | | | | - - - - - - | | | | [Summary of the Treatment: [How to use your cough assist - | | YouTube](https://www.youtube.com/watch?v=1ohB6PDYqCY)] | | | | Inspiratory Pressure no higher than 35 | | | | On manual insp pressure 20, medium flow, and 0 if no exp required. | | | | [Indications:] | | | | - - - - - - | | | | [Contraindications:] | | | | - - - - - - - - - | | | | [Limitations:] | | | | - - - - - - | | | | - | | | | [Precautions:] | | | | - - - - - | | | | [Other things to consider:] | | | | - - - - | +-----------------------------------------------------------------------+ | | +-----------------------------------------------------------------------+ | [References:] | | | | **Main** et al. (2016). *Cardiorespiratory physiotherapy : adults and | | paediatrics* | | | | **Chang** et al. (2023). Adverse effects of non‐intubated airway | | suctioning: a clinical data‐based study. *Journal of Clinical | | Nursing* | | | | [NICE guidance:] No NICE guidelines for airway | | suctioning. | | | | [Aim of the treatment:] | | | | - The removal of airway secretions/foreign material by artificial | | means, using an applied negative pressure. | | | | - Oropharyngeal (OPA) and nasopharyngeal (NPA) suction is a | | technique intended to stimulate a cough to remove excess | | [sputum](https://www.physio-pedia.com/Sputum) and/or aspirate | | secretions from the | | [airways](https://www.physio-pedia.com/Upper_Respiratory_Airways) | | that cannot be removed from a patient's own spontaneous effort. | | | | [Summary of the Treatment: | | ] | | | | - Help guide insertion of the catheter into the airway (but is not | | essential) | | | | - Range of sizes | | | | - Measured from the nostril to the tragus | | | | - Can stay in situ for short periods (usually 24 hours) depending | | on local guidelines | | | | - Eases discomfort of suction for patient needing frequent suction | | | | For adults: [catheter size:] 8-14, [suction | | pressure:] 20kPa | | | | [How to suction step by step: [Lifestyle Trader 2025 \| Live Trading | | Event](https://www.youtube.com/watch?v=979jWMsF62c)] | | | | - - - - - - - - - - - - | | | | [Indications:] | | | | - - - - | | | | [Contraindications:] | | | | - - - - - - - - - - - - - - - - | | | | [Limitations/Complications:] | | | | - - - - - - - - - - - | +-----------------------------------------------------------------------+ | | +-----------------------------------------------------------------------+ | [[https://www.csp.org.uk/system/files/csp\_physiowork\_critical\_care | | \_2011.pdf]](https://www.csp.org.uk/system/files/csp_phys | | iowork_critical_care_2011.pdf) | | | | The Chartered Society of Physiotherapy (2011). *Physiotherapy works: | | critical care*. | | [[https://www.csp.org.uk/publications/physiotherapy-works-critical-ca | | re\#:\~:text=Respiratory%20physiotherapy%20interventions%20may%20incl | | ude,strengthening%2C%20breathing%20exercises%20and%20mobilisation]{.u | | nderline}](https://www.csp.org.uk/publications/physiotherapy-works-cr | | itical-care#:~:text=Respiratory%20physiotherapy%20interventions%20may | | %20include,strengthening%2C%20breathing%20exercises%20and%20mobilisat | | ion). | | (CSP, 2011) | | | | Pathmanathan, N., Beaumont, N., & Gratrix, A. (2014). Respiratory | | physiotherapy in the critical care unit. *Continuing Education in | | Anaesthesia Critical Care & Pain*, *15*(1), 20--25. | | [[https://doi.org/10.1093/bjaceaccp/mku005]](https://doi. | | org/10.1093/bjaceaccp/mku005). | | | | (Pathmanathan et al., 2014) | | | | NICE. (2009). *Recommendations \| Rehabilitation after critical | | illness in adults \| Guidance \| NICE*. | | [[https://www.nice.org.uk/guidance/CG83/chapter/Recommendations\#key- | | principle-of-care]](https://www.nice.org.uk/guidance/CG83 | | /chapter/Recommendations#key-principle-of-care) | | | | (NICE, 2009) | | | | [NICE guidance:] | | | | Perform a short clinical assessment to determine the patient\'s risk | | of developing physical and non-physical morbidity | | | | For patients at risk of physical and non-physical morbidity, perform | | a comprehensive clinical assessment to identify their current | | rehabilitation needs. | | | | - Agree on short-term and medium-term rehabilitation goals based on | | the comprehensive clinical assessment. | | | | - During the critical care stay, the patient may not gain full | | consciousness or may not have full capacity to give formal | | consent. Therefore, the patient\'s family and/or carer should | | also be involved. | | | | - The comprehensive clinical assessment and the rehabilitation | | goals should be collated and documented in the patient\'s | | clinical records. | | | | - For patients at risk, start rehabilitation as early as clinically | | possible, based on the comprehensive clinical assessment and the | | rehabilitation goals. Rehabilitation should include: | | | | | | | | - measures to prevent avoidable physical and non-physical | | morbidity, including a review of previous and current medication | | | | - nutrition support, based on the recommendations in the [[NICE | | guideline on nutrition support for | | adults]](https://www.nice.org.uk/guidance/cg32). | | | | - an individualised, structured rehabilitation programme with | | frequent follow-up reviews. The details of the structured | | rehabilitation programme and the reviews should be collated and | | documented in the patient\'s clinical records. | | | | - Give patients the following information during their critical | | care stay. Also give the information to their family and/or | | carer, unless the patient disagrees. | | | | - Information about the patient's critical illness, | | interventions, and treatments | | | | - Equipment used during patient's critical stay | | | | - If applicable, information about any possible short or | | long-term physical and non-physical problems that may require | | rehabilitation. | | | | [Aim of the treatment:] | | | | Physiotherapy is an important intervention that [prevents and | | mitigates adverse effects] of prolonged bed rest and | | mechanical ventilation during critical illness. | | [Rehabilitation] delivered by the physiotherapist is | | tailored to the patient\'s needs and [depends on conscious state, | | psychological status, and physical strength]. It | | incorporates any active and passive therapy that promotes movement | | and includes mobilisation. | | | | Early progressive physiotherapy, with a [focus on | | mobility] and walking whilst ventilated, is essential in | | [minimising functional decline.] | | | | Early rehabilitation of mechanically ventilated patients results in | | improved respiratory and limb muscle strength and better functional | | independence at hospital discharge, both in exercise capacity and | | basic activities of daily living. (CSP, 2011) | | | | - Reduce secretion retention, atelectasis, and pneumonia | | | | - Maintain or recruit lung volume | | | | - Improve regional/global ventilation and compliance, improve | | ventilation/perfusion mismatch, reduce airway resistance and work | | of breathing | | | | - Optimise oxygenation and ventilationImprove respiratory and | | peripheral muscle strength | | | | - Decrease patient\'s dependency on the ventilator and improve | | residual function | | | | - Minimise post-operative complications | | | | - Reduce patient morbidity and mortality and prevent increased | | length of ICU and hospital stay | | | | [Summary of the Treatment:] | | | | **Positioning:** Reduces pressure in the lungs and can help prevent | | atelectasis, improving oxygenation and lung function. | | | | **Airway clearance techniques:** | | | | - - - | | | | **Mechanical ventilation support:** | | | | - - | | | | **Mobilisation:** | | | | - - | | | | **Manual techniques:** | | | | - - | | | | **Weaning support:** | | | | - - | | | | [Indications:] | | | | **Positioning:** Patient with reduced mobility, compromised lung | | function and/or after surgery | | | | **Airway clearance techniques:** | | | | - - - | | | | **Mechanical ventilation support:** | | | | - - | | | | **Mobilisation:** | | | | - - | | | | **Manual techniques:** | | | | - - | | | | **Weaning support:** | | | | - - | | | | [Contraindications:] | | | | **Positioning:** patient with unstable spinal injuries, hemodynamic | | instability or recent rib fractures,high ventilator dependency. In | | some cases brain injuries, surgeries, intracranial pressure, unstable | | blood pressure. | | | | **Airway clearance techniques:** | | | | - - - | | | | **Mechanical ventilation support:** | | | | - - | | | | **Mobilisation:** | | | | - - | | | | **Manual techniques:** | | | | - - | | | | **Weaning support:** | | | | - - | | | | [Limitations:] | | | | **Positioning:** adequate staffing, specialised equipment to prevent | | complications, time intensive- limited by tolerance, spinal stability | | and skin breakdown | | | | **Airway clearance techniques:** | | | | - - - | | | | **Mechanical ventilation support:** | | | | - - | | | | **Mobilisation:** | | | | - | | | | **Manual techniques:** | | | | - - | | | | **Weaning support:** | | | | - - | +-----------------------------------------------------------------------+ +-----------------------------------------------------------------------+ | **Neuro** | | | | +--------------------------------+--------------------------------+ | | | **Problem** | **Intervention** | | | +================================+================================+ | | | Low tone | - - - - | | | +--------------------------------+--------------------------------+ | | | dizziness | - - - | | | +--------------------------------+--------------------------------+ | | | Dexterity: skill in performing | - - | | | | tasks, especially with the | | | | | hands. | | | | +--------------------------------+--------------------------------+ | | | | Exercise: GRASP, mirror box therapy | +=======================================================================+ | | +-----------------------------------------------------------------------+ | [References: ] | | | | - **Chern** et al. (2013). Static ankle-foot orthosis improves | | static balance and gait functions in hemiplegic patients after | | stroke. | | | | - **Choo & Chang** (2021). Effectiveness of an ankle-foot orthosis | | on walking in patients with stroke: a systematic review and | | meta-analysis. | | | | - **NICE** (2023). Recommendations \| Stroke rehabilitation in | | adults \| NICE Guidance. | | [[https://www.nice.org.uk/guidance/ng236/chapter/Recommendations\ | | #walking-therapies-and-group-circuit-training]](https://w | | ww.nice.org.uk/guidance/ng236/chapter/Recommendations#walking-therapi | | es-and-group-circuit-training) | | | | [NICE guidance:] [[Recommendations \| Stroke | | rehabilitation in adults \| Guidance \| | | NICE]](https://www.nice.org.uk/guidance/ng236/chapter/Rec | | ommendations#walking-therapies-and-group-circuit-training) | | | | - - - | | | | [Aim of the treatment:]\ | | Splints could be for the upper limb and lower limb, these can either | | be dynamic or static. There are multiple different types that you can | | come across, and may need to refer to orthotics for support. | | | | - - - - | | | | Anterior splint - if a patient has hamstring weakness and uses | | anterior splint can push the knee into hyperextension as it pushes | | the knee back. If using the posterior splint, the patient can rely | | upon the splint and knee won\'t hyperextend. This might help with | | weakness as well. | | | | [Summary of the Treatment: ] | | | | [[https://drive.google.com/file/d/13Qc6hCkCJl75-d7gE5\_j8sign0MN9lcF/ | | view?usp=sharing]](https://drive.google.com/file/d/13Qc6h | | CkCJl75-d7gE5_j8sign0MN9lcF/view?usp=sharing) | | | | [Indications:] | | | | - - - | | | | [Contraindications:] | | | | - | | | | [Limitations:] | | | | - - - - - | +-----------------------------------------------------------------------+ | **Splints: Saebo Glove (Dynamic splint)** | +-----------------------------------------------------------------------+ | [References:] | | | | **Alexander** et al. (2021). SaeboGlove therapy for upper limb | | disability and severe hand impairment after stroke (SUSHI): Study | | protocol for a randomised controlled trial. | | | | **Kabir** et al. (2022). Hand Rehabilitation Devices: A Comprehensive | | Systematic Review. Engineering and technology.\ | | **NICE**. (2023). Stroke rehabilitation in adults. In NICE Guideline. | | https://www.nice.org.uk/guidance/ng236 | | | | [NICE guidance:] No NICE guidelines | | | | Promotes repetitive, functional-based rehabilitation and | | self-practice for improving upper limb function in [[stroke | | rehabilitation]](https://docs.google.com/document/d/12760 | | kDfMRa4sM6cYNZ9UO6AV_KVOzx3rEFRjZsa-kkg/edit?usp=sharing) | | | | - - - - - | | | | [Aim of the treatment:] | | | | For both neurological impairment and orthopaedic injuries. | | | | To address upper limb impairments, especially impaired active digit | | extension, which affects grasp/release functions, quality of life, | | and prognosis​. Allows for more access to independent, repetitive, | | functional-based activities resulting in reduced need for assistance | | of another. | | | | [Summary of the Treatment: ] | | | | [[https://drive.google.com/file/d/1JIlcGvw6T2VqCbpNNqk0JrOyRuyH4Ypq/v | | iew?usp=sharing]](https://drive.google.com/file/d/1JIlcGv | | w6T2VqCbpNNqk0JrOyRuyH4Ypq/view?usp=sharing)\ | | [[https://drive.google.com/file/d/1jlX0jRck7Xh2ZJ0qBix9j7LAFFI91lxv/v | | iew?usp=sharing]](https://drive.google.com/file/d/1jlX0jR | | ck7Xh2ZJ0qBix9j7LAFFI91lxv/view?usp=sharing) | | | | [Indications:] | | | | - - - | | | | [Contraindications:] | | | | Severe joint deformities in the hand or elbow. | | | | Significant arthritis. | | | | Mild-moderate tightness/spasticity or greater in the hand or elbow. | | | | Moderate to severe swelling in the hand. | | | | Open wounds. | | | | Unable to follow basic commands. | | | | Latex allergy. | | | | Inability to tolerate the splint due to pain or severe spasticity | | | | [Limitations:] | | | | Access to the Saebo Golve- financial restrictions. | | | | Time since stroke, the longer the wait to use the glove, the lower | | the outcome is. | | | | Patients must be able to close or squeeze their hand minimally. | | | | Patients must have minimal to no tightness or spasticity in the | | fingers or wrist. | | | | Patients struggling to get the glove on by themselves. | | | | Compliance of the patient. | +-----------------------------------------------------------------------+ | **Taping (Kinesio Taping - KT)** | +-----------------------------------------------------------------------+ | [References:] | | | | **[UL:\ | | ]Deng** et al. (2021). Effect of kinesio taping on | | hemiplegic shoulder pain: A systematic review and meta-analysis of | | randomized controlled trials.\ | | **NICE**. (2023). Stroke rehabilitation in adults. NICE Guideline. | | https://www.nice.org.uk/guidance/ng236 | | | | **[LL:]** | | | | **Hu** et al. (2019). Kinesio Taping for Balance Function after | | Stroke: A Systematic Review and Meta-Analysis. Evidence based | | complementary and alternative medicine. | | | | **Koseoglu** et al. (2017). Can kinesio tape be used as an ankle | | training method in the rehabilitation of the stroke patients? | | | | **Wang** et al. (2019). Use of Kinesio taping in lower-extremity | | rehabilitation of post-stroke patients: A systematic review and | | meta-analysis. | | | | [NICE guidance:] | | | | NICE guidelines highlight the importance of adjuncts like kinesio | | taping in rehabilitation for improving alignment, function, pain, | | stability and mobility in stroke patients. Ma