Observing the patient for tone issues

Q1: Does the patient have a joint(s) which are not being moved regularly through normal movement?

A: If Yes This person may be at risk of developing contractures. They will need assistance to move joints on the affected side through normal range of movement provided there are no contraindications such as infection or bony injury. A joint not being moved may lead to joint stiffness and tendon shortening and this may particularly have an effect on those muscles which are more likely to develop spasticity after stroke e.g. antigravity muscles – flexors in upper limb and extension in lower limb. So an elbow held in flexion may lead to shortening in the elbow flexors particularly if there is an increase in tone.
A: If No Continue to encourage the person to move joints while sitting or lying down.

Q2: Is your patient positioned to reduce the risk of developing spasticity in chair, bed and during transfers?

A: If Yes The person will be supported with all joints in neutral position e.g. lumbar spine supported, hips and knees at 90 degrees. Affected arm supported using pillows as necessary to support shoulder, elbow, wrist and fingers. Check position regularly. Limbs should be positioned where possible with muscles in a lengthened position, e.g. when sitting. Check this position is restored after transfers and checked regularly.
A: If No Change the person’s position and if required seek advice on best chair available. Check this position is restored after transfers and checked regularly.

Q3: Is the patient positioned in symmetry?

A: If Yes Check this position is restored after transfers and checked regularly.
A: If No Reposition the person with additional support if they have difficulty maintaining a symmetrical position.

Q4: Can the patient move their head?

A: If Yes Encourage scanning to left and right of the body provided there are no other contraindications.
A: If No Check with medical staff that there are no contraindications and prompt the person to move their head.

Q5: Does the patient require an orthosis?

A: If Yes If supplied with an orthosis the patient should be wearing this as recommended.
A: If No You should still be aware of the patients position. An orthotic referral may need to be considered.

Q6: Is the patient sliding down the bed or chair?

A: If Yes How would you correct this? Chair: consider shape and size, cushion, one way glide sheet, additional pillows or a rolled towel, footplates or foot stool.
A: If No Either your patient is able to correct and maintain sitting or you are doing this very well for them and using the appropriate equipment.

Q7: Can the patient stand up and if so is this symmetrical?

A: If Yes Make sure that all staff are aware of the recommended technique for this persons transfers.
A: If No Liaise with physiotherapy to chose equipment or use techniques which should be used consistently to remind and encourage the person to stand up in symmetry and normally.

Q8: Is the patient using a turner pulling themselves up to standing, only using their unaffected arm?

A: If Yes Staff should discourage the patient from pulling up as this affects their symmetry and tone. Be aware of any other trigger factors.
A: If No Staff should continue to monitor and be aware of any trigger factors which may affect tone.

Q9: Does the patient have any triggers or aggravating factors which may affect tone?

A: If Yes Treat any UTI, infections, pain, monitor fatigue and plan rest periods, encourage good hydration, ask about any possible medication which can affect tone.
A: If No Continue to observe for any changes in the persons tone which can be treatable such as any UTI, infections, pain, monitor fatigue and plan rest periods, encourage good hydration, ask about any possible medication which can affect tone.