Bold: not hesitating or fearful in the face of actual or possible danger or rebuff; courageous and daring: a bold hero.

As we discussed in the last blog (episode 1) when a new patient comes into the clinic, for their initial physiotherapy assessment, we need to ‘really get to know’ what they are struggling with in their movement control. Their stroke, or brain injury, or spinal cord injury, or whatever their neurological condition is, will have impacted on their ability to function efficiently in their day to day lives. Tasks such as standing and preparing a meal, or doing the school run, or drying themselves after a shower will be harder to achieve and more effortful. They know that they can be better than they are at the moment, they are connected to their bodies and they know they should be able to improve, but they are struggling to make it happen themselves. So they boldly come for help, to improve and develop their functional skill.

We, as physiotherapists, identify the key ‘critical cues’ to the patients movement and function difficulties during the assessment, and linking this to the neurophysiology and human movement control literature helps us to create a ‘movement diagnosis’.

But what is a movement diagnosis, I hear you ask? Well, a movement diagnosis does the same thing as a medical diagnosis; it describes what’s causing your difficulty with movement. A diagnosis is the starting point for a treatment plan, and treatment intervention, and so an accurate movement diagnosis is essential if you are going to have a clear pathway to tackling a patients movement problems. Without a movement diagnosis you are just fishing around in the dark. So an accurate, clear and insightful movement diagnosis is where each initial assessment has to get to, each time, so that you know where to begin the treatment journey.

But making a movement diagnosis is complex, because human movement is complex! Human movement is influenced by all sorts of factors, such as the ability to activate muscles, the strength within the muscle, the alignment of the joints, and limbs, the orientation and perception of the person moving in their environment, musculoskeletal factors, as well as emotions! Its a big mix of everything, shaping and driving how we move and function in our own lives.

Our bold patients tell us what their day to day difficulties are with their movement and posture, and we use our detective skills to drill down deeply and get to grips with where the key issues really are, and what we need to do to change them.

For example, I saw a new assessment patient who had recently been discharged home from the stroke unit, and the critical cues I picked up from him were both verbally, and physically:

“I have to think all the time to keep my weak knee straight, otherwise it will collapse and I feel like I will fall, so I can’t stand up to make a coffee because I can’t concentrate on the coffee machine and my knee at the same time, I just sit down to make my coffee now”

“When I try and put my stroke foot down on the floor I have to press it down or it floats off the floor on its own, but when I press it down too much it shakes”

From these critical cues, and through the assessment findings, I was able to create these movement diagnoses:

1. Reduced postural control (note: which in normality is more automatically created rather than volitionally) through the leg, which should create linear extension in response to gravity and standing, means that the whole limb is not well aligned and posturally active as a background of stability on which to create standing balance for the function of moving and reaching to make his coffee.

1. His hemiplegic (stroke) leg is held in a flexor pattern at the hip and knee, partly through the associated reaction that occurs when he looses his balance in standing as he is not able to stand and balance correctly through either leg, and partly through a flexor withdrawal response when his foot is loaded with his body weight. This flexor withdrawal response is a hyper-reflexic reaction to stretch in the intrinsic muscles of his foot, and the extrinsic muscles within his calf. He also has clonus in his lower leg which is triggered through stretch of these muscles. This makes standing on a pair of legs impossible and therefore effects his function in standing, and stepping, and is a key reason why he was unable to walk successfully.

These movement diagnoses then form the basis of the ‘clinical hypothesis’ which is the underpinning of why you are doing what you are doing when you start your treatment pathway.

The Model of Bobath Clinical Practice is a great model for taking the therapist through the process of Clinical Reasoning ref: www.bbta.org.uk. This is the process that links the patient in front of you, and their potential to improve in their function, with the neurophysiology and movement science. It gets you through the complex job of assessing your neurological patient, and takes you to the point of knowing where you are going to start with your treatment programme.

Not fishing around in the dark, but knowing the clinical reasoning thread that is going to transform your patients ‘hope that they could be better’, into actually starting to change and becoming better at what they want to do. Now that sounds like a bold step forwards, and definitely worth doing.

If you want to explore your potential to be better than you are right now, and you want your physiotherapist to understand your movement difficulties more thoroughly, then why not give us a call and book your ‘initial assessment’ at TherapyMatters? We are always friendly and effective, and we are keen to work with you to help you on your recovery journey.

www.therapy-matters.co.uk

info@therapy-matters.co.uk

tel: 01244 579616

Bold: not hesitating or fearful in the face of actual or possible danger or rebuff; courageous and daring: a bold hero

We all know that it is never easy to create a change in our lives, and strike out in search of something different, something new. Gathering the will power and positive mental attitude is quite tricky, but even trickier when you already feel ‘down on yourself’ and you are the new patient arriving at a physiotherapy clinic.

I am often reminded of how impressive it is, and brave, when a new patient comes to the clinic for their ‘initial assessment’. Coming into a new environment, no matter how friendly, warm and welcoming, can be daunting. And yet our patients do this, arriving for their assessment, because they have knowledge of their own bodies, and their own difficulties, and they know that they could be better than they are now. They know, even if their current recovery journey has been tough, that they can be more ‘recovered’ than they are now. They can improve. And they want that improvement, they thirst for it and dream of it, in their near future. And so they come to us.

So what do they need from the professional physiotherapist that they meet, who takes them through their initial assessment? They need someone who can get under their skin, who can ‘know’ and understand their movement and function issues deeply, and transform that into a clear, clinically reasoned movement diagnosis and hypothesis. And then to deliver the treatment that will start to take them forwards, step by step, one foot in front of the other, dealing with their impairments, guiding them through it, and making it happen.

When we assess a new patient at the clinic, we listen to their description of their difficulties and start our clinical reasoning from the very beginning of meeting them. We listen out for the ‘critical cues’ that the patient shares about their every day life and we start to develop our clinical hypotheses. Why is coming down the stairs more difficult than going up for them? How does that problem link to the difficulty getting their heel down when they walk? Why does their arm stiffen up when they stand up from a chair? Can they be less heavy through their stick? and when they are less heavy through the stick does their shoulder pain reduce? Why are those things linked together?

It is detective work, digging deep into the problem, understanding what they are telling us, and looking at that through the lens of the neuroscience, and neurophysiology. Knowing how the body works, how it moves from various postures, and how we function through movement control as human beings, gives the physiotherapist the background ‘blue print’ that we can compare our patients problems against. And then, with the clear idea of what the problem is, and why it is there, based on the science, and what more ‘efficient’ movement control would look like – we can begin.

The physiotherapist can then understand what the patients potential for change might be, how to tap into that potential to change, and how to formulate the treatment programme that will allow them to achieve that change as best as possible.

And so then, the ‘new’ recovery journey can begin for the patient. We have a clear idea of their impairments, we have formulated a movement diagnosis, we understand the patients potential to change, and we have developed our first clinical hypotheses.

So now; lets get working on making it happen.

If you want to explore your potential to be better than you are right now, why not give us a call and book your ‘initial assessment’ at TherapyMatters? We are always friendly and effective, and we are keen to work with you to help you on your recovery journey.

www.therapy-matters.co.uk

info@therapy-matters.co.uk

tel: 01244 579616

Derek has shown improvement in stopping the irritating clonus he had been experiencing in his right leg (clonus is repetitive, involuntary, jerky muscle contractions due to a hyper-reaction when a muscle is stretched or a limb is loaded with weight). This means he can now sit and settle into different positions more easily and not be disturbed as regularly by his ‘sewing machine leg’. Derek continues to have difficulty actually feeling his right hand and foot, and so finding any specific movement is very challenging. Nevertheless he is delighted with the change in his ‘jigging leg’, which he found to be very upsetting and embarrassing, so it’s a big relief to him and his levels of frustration.

In order for us to be able create good quality movements, our brains need to be aware of and able to feel the body part we want to move. If a body part hasn’t been moved for a while, the brain tends to ‘forget’ it is there and so is less likely to move it automatically.  If Derek could consistently feel his hand and foot, he would be more likely to move them in the future. This would also help him to create a more balanced and stable trunk, and so give him more chance of achieving his tooth-brushing goal.

Giving lots of sensory stimulation to Derek’s right foot has helped his brain re learn how to pay attention to his foot, and to become more aware of where it is in relation to the rest of his leg and body. I have been ‘hands on’ moving individual toes, muscles and bones to help his brain to ‘remap’ his foot, and different textures to bombard the sensory receptors on his skin.

Derek’s foot can settle on the floor better, which means he can adopt a more active sitting position with his right leg helping him to balance. This has allowed him to achieve a more symmetrical standing posture, and start to put more weight through his right leg.

We completed similar work with Derek’s right hand, resting it on a bench to support the weight of the limb. Derek was encouraged to look at his hand while I worked on it, as this would help his brain to link the sensations he was beginning to feel with the part of his hand they were coming from. Derek’s wife was very involved in this part of the session, watching and learning what I was doing so that she could continue this important work with Derek for short periods each day, and improve the chances of regaining the sensation in his hand. We worked here with caution as intense hand therapy can sometimes be very tiring and we didn’t want to make Derek feel weary or tired as he had the rest of his day to manage after his physiotherapy session.  Having short breaks and changing the tasks during the session enabled us to review his cognitive energy levels and make sure he was doing okay. 

By the end of the session Derek felt he was more aware of his right hand and foot and more in contact with the surfaces that they were touching and interacting with.  He felt that he was steadier when he moved from sitting, up into standing, and that he was more confident to load his right leg again.  This had a great result at the beginning of his walking when he set off from sitting – he was steadier, stronger, and more upright in his posture, as he crossed the room with his stick.  He was also aware that he was less heavy on his stick too, which was an exciting moment for him and his wife to experience, compared to how heavy he had felt he had had to be previously. Derek felt safer and more balanced!

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.

Derek often struggled to remember where his right arm was and he could only move it by using his other arm to help.  It would not stay where he put it and it would often be in the way.  He regularly needed help from his family as activities needing two hands, like tying his shoelaces, or cutting up his dinner was impossible. This frustration was further compounded by shoulder pain. Even using his ‘good arm’ was hard, as he often lost his balance, even if he was sitting down.  His right leg was also difficult to move and swollen and uncomfortable.  He felt he was too dependent on his stick when he was standing or taking steps, and he could not climb steps or stairs.

From my assessment I could see why Derek was having the difficulties he described.  He was less aware or ‘attentive’ of his right side, which meant he would be subconsciously using his left side more to keep his balance, and do everything he would previously have been able to do with both sides.Derek’s right side was much weaker and had ‘lower muscle tone’ than the left, and he had reduced control in the movements of his pelvis, trunk and ribs. Consequently Derek’s trunk had become stiffer and was unable to work properly to hold him up against gravity and help his balance. This reinforced his body’s new reliance on his left side to stabilise him.

In addition to the original neurological deficit, the position, length and role of his muscles had altered, impacting the way his joints were positioned at rest, and during movements. This was most evident around Derek’s right shoulder and hand, andalso within his foot and ankle.  This explained the difficulties Derek was having in being able to let his right foot settle on the floor with weight equally on both legs.  When he stood up he had to shift his trunk over his left leg, which pulled his right side backwards and left, allowing him to ‘lever’ his right leg through to step, which simultaneously disrupted his balance. This explained exactly why Derek was worried about falling over.

Now we had a clearer idea of the specific issues that Derek was struggling with from the neurological impairments he had due to his stroke, I discussed the key things we would target in physiotherapy sessions, and what I expected to see change with treatment.  Derek was very clear about the key things he wanted to see change as quickly as possible; the things that he found most frustrating.  We discussed Derek’s goals, and ‘what he wanted to do’.