Management of spasticity continues to be a significant and challenging part of my caseload. I’ve been on educational days, seminars and am aware of national and local guidelines. All are very well organised and structured with the focus often on the use of Botulinum Toxin. Management of aggravating factors and triggers are relevant and general and focal therapy principles are provided such as postural management strategies, splinting and FES, but the trick is; how do I apply that to my patients?
The Spasticity in adults: management using Botulinum Toxin (2019) guidelines statesthe principal aims of physical therapy are to:
• maintain muscle and soft tissue length across joints
• strengthen weak muscles and facilitate neurological recovery
• facilitate care giving (passive functional improvements)
- facilitate active control of any residual movements to allow for active participation in tasks active functional improvements)
These are good guiding principles, but the challenge is to make it bespoke for my patients and understand the interrelationship of all these factors in their presentation; in essence the specific clinical reasoning in the application of these principles. Easier said than done!
A patient on my caseload was diagnosed with a left sided hemiplegia. They presented with a community level of mobility and marked increased flexor tone in the arm. There were some flickers of activity distally in their hand but any movement of the arm away from the body was in a very flexed and circumducted pattern. My challenge was how to manage the increased flexor tone to improve the reach pattern and start to access some of the potential activity in the left hand.
Where to start? Changes in alignment and reach pattern could be achieved in sitting with improved postural activity and proximal alignment, but this was only with preparation and didn’t carry over into everyday tasks. A marked increase in flexor tone was also noted on standing and in walking. On further assessment, their left leg presented with proximal weakness at the hip and knee, and stiffness in both the foot, and the hip flexors.
Compensatory activity was also noted through the right side especially within the hip and shoulder girdle. I spent considerable time deepening the assessment of the alignment in their left leg, understanding the relationship between the left hip and foot to then achieve a much more active leg to stand on. This was also coupled with a focus on improving alignment and stability through the right side as the compensatory strategies had significantly impacted on their ability to achieve right single leg stance.
Improving intralimb alignment within both legs, and improving interlimb alignment and co-ordination between the limbs, allowed the patient to achieve more efficient sitting to standing, and gait. I also focussed on supporting the patient to practice whole tasks independently. Treadmill training was also used, again focussing on specifics of alignment and reducing compensatory strategies. Through the development of more efficient gait and lower limb activity improved postural alignment and activity was noted, and this in turn lead to a better reach pattern.
With reduced flexor tone and spasticity in the arm I was able to focus on the specifics of upper limb alignment and activity, using task practice to link with improved function.
So, what did I learn from the process? Are the guidelines and advice on therapy correct, absolutely. However, the challenge is to develop them further, be specific identifying areas of weakness and malalignment. Understand the nervous system you are working with; how do the different systems work together to produce the functional activity. Yes, utilise the principles of strengthening, lengthening and linking to functional practice but on the background of clear and precise clinical reasoning. This will allow you to direct your intervention more precisely, helping to achieve improved patient functional outcomes.
If you would like to learn more about how you can develop your knowledge and skills, with a focus on clinical reasoning, for your patients recovery, then consider signing up to one of our BBTA courses – look at the website for more information – www.bbta.uk.org