Bold Journeys In Rehabilitation Episode 2

Episode 2: how do we know where to begin with our patients treatment journey?

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: 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.

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