Following the assessment with Derek we identified key things to achieve. We were keen for Derek to learn to manage the irritating ‘clonus’ in his right leg as soon as he could.
To allow him to develop this skill, we needed to improve his attention to the right leg, to feel or perceive the foot particularly, and to begin to control its movements through visualisation techniques. Achieving this first goal would contribute towards all other goals, as it would provide the foundations for Derek to develop better awareness of the right side of his body, and give him access to cortical or conscious control of the movement and posture of his right hand side. If he could manage the shaking and uncontrolled clonus (repetitive involuntary, jerky muscle contractions due to a hyper-reaction when a muscle is stretched or a limb is loaded with weight) in his leg muscles he would also have more confidence to put weight on the leg, and that would allow him to start to strength train the muscles too, which were very weak.
Other short-term goals included the development of sufficient activity within his trunk to enable him to keep his balance whilst in sitting and using his left arm to clean his teeth. Another goal for Derek was to be able to keep his right foot in contact with the floor whilst moving between sitting and standing. Achieving this goal would mean he had gained more trunk control and length and strength in his calf muscles and hamstrings, with better awareness of his right foot position. This in turn will improve Derek’s potential to achieve his long-term goal of being able to walk further, with less effort and to be less reliant on his stick, as he would have become more balanced, more stable and stronger.
Derek was primarily keen to be pain free in his right arm. A further goal was to reduce the impact his heavy and dependent arm had on his posture and balance, thereby minimising its interference with Derek’s movements, such as leaning forwards to stand up. We wanted Derek to be able to place his arm on a surface and it remain in that position whilst Derek moved around it, for example to let it rest on the arm of his chair while he turned round towards the left hand side to watch the TV, or to rest on the wash hand basin while he brushed his teeth. We agreed that developing the ability to control the involuntary tightening of the forearm muscles would be a really positive step, as it would give us the chance to explore and develop any underlying activity within his hand and arm.
We worked in this physiotherapy session to improve Derek’s trunk control and postural activity, so that he could activate and move more efficiently around his pelvis and trunk in sitting. We continued to develop this improved movement control by working into the task of moving from sitting to standing, and improving the interaction of Derek’s foot on the floor. Working into the stiff and shortened muscles of Derek’s calf and foot allowed him to improve the posture and alignment of his foot which made the sensory awareness during weight bearing more ‘awake’. This helped Derek to load his right leg better with more of his weight so that his standing was more equal over both legs by the end of the session. It had been a very successful treatment session, and we were excited to see the impact of these changes on his week ahead of him.