Physiotherapy

Introduction:

This document aims to provide interim guidance about the standards of physiotherapy management for SMA patients in home care setting as well as in Hospital care settings. The guidelines are for the physiotherapists, for the parents of Spinal Muscular Atrophy children and their caregivers, so that they can receive standard of care to combat their disabilities and also make them stay away from COVID 19 infection. In these current scenarios COVID 19 pandemic is continuing to make things difficult upon the people in our country and across the world for few months. So it is very important to understanding the fact that the children with disabilities and other special needs are now facing additional crisis as they are failing to receive conventional medical management due to various reasons brought about by the pandemic. As individuals with SMA often has difficulties performing the basic functions of life, such as walking, eating, swallowing , breathing , so that recommended standard of care of SMA is often complex and comprehensives, requiring the involvement of multi – disciplinary specialists, including Ped- neurologist, Ped – pulmonologist, Orthopedics, Clinical psychologist, Dietician – Nutritionist, Ped – physiotherapist, Occupational therapist, Orthotist and prosthetist. The role of Ped – Physiotherapist is such vital in the optimal functioning and management of patient with SMA .

ROLE OF PHYSIOTHERAPY

The focus of physiotherapy for SMA patients is to set up a multimodal approach to deal multiple symptoms as discuss earlier, prevention of infection is also very important part of therapeutic standards. Physiotherapist aim to optimize function by maintain muscle strength, improve muscle tone, maintain Full ROM of joints, prevent tightness, contracture and deformities due to muscular imbalance, restore body balance and control of equilibrium, improving fine motor skill to maintain independency in Activities in daily living as much as possible, and most important to maintain bronchial hygiene and optimum respiratory function .

Multi-modal physiotherapy approach:

SAFER ACCSES TO PHYSIOTHERAPY RESOURSES

Standard precautions refer to work practices that are applied to all patients receiving physiotherapy care in health facilities, regardless of their diagnosis or presumed infectious status so as to minimize the risk of transmission of infectious agents in all situations. Standard precautions minimize the likelihood of transmission of infectious agents between physiotherapist and patients, and from patient to patient.So therefore infection free, fall preventive and barrier free architecture in physiotherapy set – ups is highly recommended for SMA patients. [8],[1],[7]

 

HOSPITAL BASED RESOURSES RECOMENDATION

  • OUT PATIENT PHYSIOTHERAPY SERVICES
  • TIME SPECIFIC APPOINTMENT
  • ISOLATED ENTRY AND CORRIDOOR TO THE PHYSIOTHERAPIST STATION ONLY FOR SPECIALLY NEEDED CHILDREN
  • THERAPIST PEDIATRIC REHABILITATION UNIT SHOULD BE TOTALLY ISOLATED FROM COVID 19 OR HIGHLY CONTAGIOUS DISSEASE WARD
  • PHYSIOTHERAPIST AND ALL HEALCARE STAFF ASSOCIATED WITH THE PEDIATRIC REHAB UNIT MUST GO THROUGH REGULAR HEALTH MONITORING BY CHECKING BODY TEMPERATURE, RESPIRATORY RATE, HEART RATE, SPO2 AND DOCUMENTED THOUGHROLY.
  • NO ONE (PHYSIOTHERAPIST OR THE PATIENT) SHOULD ALLOW FROM CONTAINMENT ZONE AS DECLAIRED BY THE GOVERNMENT OF THE SPECIFIC STATE FOR THE PEDIATIC REHAB UNIT FOR THE SPECIAL NEE DED CHILD UNTIL NEW GOVRNMENT ORDER.
  • BARRIER FREE ARCHITCTURE AS WHEELCHAIR ACCSESSIBILTY LIKE RAMP AND LIFT MUST BE INCORPORATED SEPARATELY FOR ONLY FOR CHILDREN WITH DISABILITY
  • FLOORING SHOULD BE NON SLIPPERY AND TOILET FACILILTY MUST BE THERE AS REQU IRED FOR DISABLE PATIENTS.
  • ALL THE FURNITURES, THERAPEUTIC EQUIPMENTS MUST BE SANITIZE WITH DISINFECTANT LIKEISO PROPANOL 70% OR 1% SODIUM HYPOCHLORATE ACCORDING TO THE HUMAN INFECTION CONTROL PROTOCOL.
  • THERAPIST MUST WEAR PERSONAL PROTECTIVE EQUIPMENT IN ORDER AND GUIDELINE AND DISINFECTANT THEMSELVES AFTER EVERY CHILD SEEN.

PLAN FOR SAFE ACCESSESBILITY SHOWING IN FLOWCHART

RECOMMENDATION FOR PATIENT AND PHYSITHERAPIST

SMA PATIENT ENTERED IN HOSPITAL WITH THEIR PARENTS
WEARING MASK IS NECESSARY AND MAINTAIN PHYSICAL
DISTANCING FROM OTHERS, MAKE A QUE AND STAND ON FOOT
MARK
APPEARED IN HEATH CHECK UP POINT FOR RECORD HR,RR,SPO2
RECORD HISTORY OF FEVER,COLD AND COUGH,ANY OTHER SYMPTOMS
CONTAINMENT ZONE AND PATIENT RECENT ADDRESS
IF ALL OK STCKER/FORM PROVIDED MENTIONING HEALTH
PARAMETERS FOR SAFE ENTRY
MANDETORY HAND SANITIZATION DONE IN HAND SANITIZATION
POINT
BY USING SEPERATE CORRIDOOR ISOLATED LIFT OR WHEELCHAIR
ACSSECIBLE RAMP
ENTERRED IN THERAPY UNIT
PHYSIOTHERAPIST ENTERED IN HOSPITAL
START THERAPY SESSION BY ASSESMENT AND PLANNED
THERAPEUTIC APPROACH, GUIDELINE GIVEN FOR HOME MAINTENENCE
STCKER/FORM PROVIDED MENTIONING HEALTH PARAMETERS FOR SAFE
ENTRY
HAND WASHING DONE
ENTERED THERAPIST CHANGING ROOM
WEAR SCRUB SUIT ,CHANGE OUTSIDE MASK
DONNING OF PPE ,HEAD CAP, GLOVES, FACE SHIELD, SHOE COVER, OUTER LAYER PLASTIC APPRON
ENTER THERAPY UNIT
DOFF OFF PPE, GLOVES, HEAD CAP, MASK ACCORDINGLY
HAND SANITIZATION DONE
  • IN PATIENT PHYSIOTHERAPY SERVICES
  • PATIENT CAN GET NECESSARY PHYSIOTHERAPY IN IN- PATIENT DEPARTMENT AS IF WHEN REQUIRED.PHYSIOTHERAPIST ASSESS AND SET UP SPECIFIC PROTOCOL WITH CONSULTATION WITH RESPECTIVE PEDIATRIC CONSULTANT.
  • THERAPIST MUST WEAR PERSONAL PROTECTIVE EQUIPMENT DISINFECTANT THEMSELVES AFTER EVERY PATIENT SEEN.
  • PHYSIOTHERAPIST WORKING IN IN- PATIENT PEDIATRIC UNIT MUST DOFF PPE AND WEAR NEW PPE BEFORE ENTERING OUT PATIENT UNIT AND VICE VERSA.

PLAN FOR SAFE ACCESSESBILITY SHOWING IN FLOWCHART

SMA PATIENT ADMITTED TO PEDIATRIC IN PATIENT UNIT,
PEDIATRIC ICCU, PEDIATRIC ITU, AND GENERAL WARD.
AFTER GETTING REFERRAL, PHYSIOTHERAPIST ASSES AND PLAN
FOR THERAPYACCORDINGLY BY TAKING GUIDENCE FROM RESPECTIVE CONSULTANT
BEFORE AND AFTER TOUCHING THE PATIENT PHYSIOTHERAPIST
MUST FOLLOW THE INFECTION CONTROL GUIDELINE SET BY THE RESPECTIVE IN -PATIENT DEPARTMENT, LIKE WEARING PPE, HAND HYGIENE, DONNING AND DOFFING SEQUENCE

Home- based physiotherapy resourses

  • SELF MONITORING BY PHYSIOTHERAPIST BY CHECKING BODY TEMPERATURE,RESPIRATORY RATE, HEART RATE, SPO2 AND DOCUMENTED THOROUGHLY.
  • IT’LL BE BETTER TO REEDUCATE PARENTS THE TECHNIQUES AND MEASURES.
  • SEPARATE ROOM FOR EXERCISE MUST BE PROVIDED.
  • ALL THE EXERCISE EQUIPMENT MUST BE CLEANED WITH SOAP WATER OR DISINFECTANT.
  • AFTER TREATMENT THERE MUST BE ESTABLISHED PROPER DOFFING AREA FOR PPE.
  • PHYSIOTHERAPIST MUST GUIDE PARENTSAND CAREGIVERS TO MAINTAIN PERSONAL HYGIENE AND ETIQUATE OF MASK, PPE WHILE DOING THERAPY AT HOME.

PLAN FOR SAFE ACCESSESBILITY SHOWING INFLOWCHART

RECOMMENDATION FOR PATIENT AND PHYSITHERAPIST

PHYSIOTHERAPIST ENTERED IN HOME.
BEFORE ENTERING HOME PHYSIOTHERAPIST MUST PUT EVERYTHING IN A BOX AND KEEP IT OUTSIDE THE ROOM.
AFTER PROPER HAND WASHING AND SANITIZATION PHYSIOTHERAPIST WEAR PPE HEAD CAP MASK FACE SHIELD AND START TREATMENT.
START THERAPY SESSION ACCORDING TO THE NEEDS INFRONT OF PARENTS .

Physiotherapy with social distancing

If there is will there is a way,in these pandemic situation basic emphasis should be on to control spreading infection to save patient with comorbidities. The use of standard precautions is the primary strategy for minimizing the risk of transmission of microorganisms in health-care facilities. Standard precautions are to be followed for all patients, irrespective of their infection status. These are to be used to avoid contact with blood, body fluids, secretions and excretions regardless of whether contaminated grossly with blood or not; non-intact skin; and mucous membrane.One of the best option to get help from virtual media as video consultation or sharing of video with specific demonstration of exercise required by patient.

  • VIDEO CONSULTATION THROUGH APPROPRIATE NETWORK APPLICATION
  • SHARING EXERCISE REGIME ON VIDEO THROUGH SOCIAL MEDIA PLATFORM.
  • BY USING TRANSPERRENT PLASTIC/ FIBER GLASS BARRIER TO DEMONSTRATE EXERCISE TO PARENTS BY USING ARTIFICIAL MODEL.

“Physiotherapists assess, plan and implement rehabilitative programs that improve or restore human motor functions, maximize movement ability, relieve pain syndromes, and treat or prevent physical challenges associated with injuries, diseases and other impairment”. (WHO) Specific assessment for SMA (age specific) Using Assessment scale [9] HINE (Hammersmith Infantile Neurological Examination) – For 2 to 24 months of infants. CHOP INTEND (Children’s Hospital of Philadelphia Infant Test Of Neuro-Muscular Disorders – for 3months to 21 yrs.

Various aspects which need to be discussed are:

  • Conventional therapies
  • Chest physiotherapy
  • Breathing exercises
  • Requirement of equipments at home

CONCLUSION:

It is necessary to continue physiotherapy intervention even in COVID 19 pandemic situation, we must follow some regulation and maintain outmost hygiene and care toward SMA patients to protect them from infection ,not only COVID from other type of infection too. Here some recommendation stated which can be beneficial to develop standardized protocol of care for avoiding any infection and live their live without any fear.

Resource:

  1. MINISTRY OF HEALTH AND FAMILY WELFARE GOVRNMENT OF INDIA, COVID 19 Guidelines online publish http://WWW.mohfw.gov.in/lastassesed on 5th may 2020.
  2. Andrea Turolla, Giacomo rossettini, Antonello Viceconti,AlvisaPalese, Tommaso Geri,(2020): Musculoskeletal Physical therapy during the COVID 19 Pandemic is Telerehabilitation the answer?,APTA Journal,OXFORD UNIVERSITY published,April 17 ,2020.
  3. Jason R Falvey,Cindy Kraft,Diana Kornetti(2020): The Essential Role of Home- and Community- Based Physical Therapistsduring the COVID- 19 Pandemic,APTA Journalphysical therapy vol 100,issue 7,1058-1061
  4. Lefebvre S, Burglen L,et. Al(1995): Identification and characterization of a spinal Muscular atrophy-determining gene. Cell, 80: 155-65.
  5. Wang CH, Finkek RS, BertiniES,Schroth M, et. Al (2007):All participants of the international Conference on SMA Standard of Care In Spinal Muscular Atrophy. JChild Neurol.2007Aug; 22(8):1027-49.
  6. Yasser Saleem, Stacy Gropack, (1893) -Aquatic therapy for a child with type III spinal Muscular Atrophy in Physio and Occupational therapy in Pediatics Nov,2010 ,Vol.30(4).familial basis; in German], 3: 427-470.
  7. Hitesh lal, Deepak Kumar Sharma,Lalit Maini (2020): Out Patient Department practices in orthopaedics amidst COVID 19: The Evolving Model, J CLIN ORTHOP TRAUMA. JUL- AUG;(4):700-712,MAY 18, 2020.
  8. WHO interim recommendation on obligatory hand hygiene against transmission of COVID19,https://WWW.who.int/who-documents-detail/interim-recommendation-onobligatory-hand-hygiene-against-transmission of covid-19,available online on 5 may 2020.
  9. Karen Patterson, Annie DeMark Thompson (2018: The Role of Therapy in your childs Life. Being a part of the team!;Annual Cure SMA Conferenc; http:/WWW.curesma.org – annual conference 2018