ICU with full spinal precuations: Is PROM indicated?

[Danae00]

I feel like an idiot for asking this, but how else will I learn? I keep coming across the phrase "full spinal precautions" when reading articles about patients in the ICU with major trauma (high falls, MVAs, etc). However I can't seem to find what exactly these precautions are exactly and how they relate to us PTs.

Obviously as PTs there is not a lot we will be doing since you need to keep the spine straight. That said, is it possible to do PROM of the upper and lower limbs? Ankle DF/PF? What about hip and knee flex/ext if you keep the spine aligned?

Such a simple question, so hard of an answer to find. Google you let me down!

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[Fiveoboy11]

I feel like an idiot for asking this, but how else will I learn? I keep coming across the phrase "full spinal precautions" when reading articles about patients in the ICU with major trauma (high falls, MVAs, etc). However I can't seem to find what exactly these precautions are exactly and how they relate to us PTs.

Obviously as PTs there is not a lot we will be doing since you need to keep the spine straight. That said, is it possible to do PROM of the upper and lower limbs? Ankle DF/PF? What about hip and knee flex/ext if you keep the spine aligned?

Such a simple question, so hard of an answer to find. Google you let me down!

Spinal precautions - no bending (avoid behond 90, sometimes pt will have a TLSO on so it will also prevent this), no twisting, no lifting (within reason - absolutely nothing remotely heavy, no lifting anything from floor). Follow the precautions for exercise and functional mobility to the letter, but keep in mind the pt will still do these things throughout the day without even realizing it. For example, patient's will lift their front wheeled walker on occasion to move it, and they will bend slightly with transfers/bed mobility. This is ok. You can do therapeutic exercises with the patient while taking into consideration the above precautions. Yes, you can do hip, knee, and ankle, UE exercises. Sometimes in weight bearing, but mostly while laying down or sitting, especially early on, and as you mention, because they are in the ICU.

 

[TraumaPT]

Several thoughts:

1. PROM is useful to check ROM if AROM is limited, to work joints of extremities with stabilized fractures when the patient is unable to actively move/unconscious, for joints at risk of contracture (you'll get more bang for your buck by teaching the nursing staff how to position the patient - having PT stretch the joints once a day is not turning up much by way of statistical significance in research), or when PROM is specified in the physician's order due to the nature of the injury (patellar fx come to mind).

Otherwise, PROM is rather a waste of the PT's skills. The immobile patient in ICU is frequently repositioned by the nursing staff for pressure relief and hygiene, so the joints are being moved regularly. In my trauma ICU practice, PROM is almost never indicated, because there are so many more helpful things I can be doing.

2. If the patient is conscious/able to cooperate, and the spine is not stabilized, AROM/isometrics within the spinal precautions is a terrific idea. I avoid extreme flexion angles at the proximal joints, based on my own nonscientific observation that I get a little flex and ext in the spine when I do that. I avoid resistive exercise.

3. If the spine is stabilized, surgically/orthotically/both, and there are no other medical or musculoskeletal contraindications to getting up, then up we get, ICU or not. Examples of medical contraindications would be unstable hemodynamics, patient on sedatives/paralytics and unable to participate, CSF leak with lumbar drain, etc. (Brain injury/CVA patients who are unable to participate do get the full upright treatment if OK with Neurosurg. A wise colleague refers to it as the Vertical Alarm Clock.)

4. Some surgeons have special precautions for some or all of their spine patients; these should be elucidated in the orders. For example, one practice operating in my hospital limits sitting time to 20 minutes every 2 hours; standing and walking are unlimited. Get to know your Neurosurg and Ortho/Spine docs and their preferences.

In fact, check out your ROM question with your surgeons; some may have idiosyncratic precaution preferences.

So, to sum it all up: PROM is literally the least you can do for the vast majority of your patients. Surgeon preferences for activity may vary (and may have no support in research). Get your ICU patients up! Hooray!

 

[Danae00]

Thank you for your answers! It was very helpful!

I realize that I missed some important information in my question that I erroneously figured would be assumed based on my question (inquiring about PROM). I was thinking of a patient who is quite unstable in the ICU (think septic, ARDS) and unconscious and has been for many days/weeks and is on full spinal precautions.

My reason for asking is that I was concerned that after a week+ of them only being turned by staff they may start to lose range. Given the very long road to recovery from such a serious illness (assuming they survive) I wanted to avoid them having to deal with contractures to the list. But given what you all have told me about spinal precautions PROM of the extremities would definitely be possible.

Whether this would be done by the PTs, or whether we just ensure that a TA or someone else in the ICU was doing it (i.e. nursing staff) is a bit of a different question and would likely be site specific I'd imagine.

Thanks again!

PS: Just wanted to say that I agree that concious patients should be up and moving ASAP!!