Category: Advancing Modules

Why consider managing spasticity?

Q. Why consider managing spasticity? Select the crosses next to the labels to find out the possible the benefits of spasticity management.

Considerations in the management of spasticity

  • Side effects from medications (medications may impact on patients known risk factors and may cause distressing side effects)
  • Tone may be used to allow function (if you reduce the patient’s overall tone then this may reduce their functional ability, as they may use the tone in other muscle groups to achieve tasks e.g. standing to transfer)
  • Spasticity may not be an issue to the patient (the patient may not identify it as a problem and may not wish intervention)

Options for managing Alan’s tone

There are a number of options which you could now consider for managing Alan’s tone.

Q. Listed below right are possible options for managing Alan’s tone, but which are appropriate and which are inappropriate? Drag and drop the management options into the correct columns.

Concern 1: Alan’s arm and hand

A picture of Alan's hand
Alan has some good active movement at his shoulder and elbow but due to the increased tone in his hand he has limited functional ability. (For more information on tone, click on the Additional Information box below). There are some positive signs of recovery with flickers of activity in his fingers and wrist but this is hindered by increased tone. Despite intensive therapy (stretches and exercises) his hand and wrist tend to sit in a flexed posture with the fingers pressing into his palm. The skin of his palm tends to sweat and there is an offensive smell coming from his hand. Alan finds cleaning his hand difficult and is distressed by its appearance. You think that by managing his tone you can help his hand hygiene, skin condition and potentially improve his hand activity.

 

Alan’s concerns

A picture of Alan, he looks concerned

Alan has discussed with his key worker what his main concerns are:

  1. Alan is very concerned about his arm function and in particular he is distressed by his tightly clenched fist and thinks his hand looks ugly.
  2. Alan is concerned about his walking and says that it is very important to him that he gets back on his feet so that he can walk Patch.

See additional information or a description of the role of the key worker.

Case 3: Mr Alan Ash

Alan Ash portrait

Scenario

Alan Ash riding a bicycle
Mr Alan Ash is a very active 65 year old gentleman who recently retired from his job as a physical education teacher. He lives alone in his basement garden flat and has a dog called Patch. He regularly meets up with his brother who lives nearby.

While out cycling, Alan lost his balance and fell off his bike. At the time he didn’t think anything of this and managed to safely cycle home. The following morning, however, he found he was dragging his right leg, having difficulty getting dressed and was dropping things. Following contact with NHS 24 (111 service) he was taken to hospital by ambulance. Alan’s CT scan showed a left hemisphere lacunar infarct.

Two weeks after his stroke he was transferred to a stroke rehabilitation unit. He is now nine weeks post stroke.

Additional reading

Cochrane Library Systematic Reviews:

Langhorne P, Wu O, Rodgers H, Ashburn A, Bernhardt J. (2017). A Very Early Rehabilitation Trial after stroke (AVERT): a Phase III, multicentre, randomised controlled trial. Health Technology Assessment, 21(54):1-120.doi: 10.3310/hta21540.

Langhorne P, Collier JM, Bate PJ, Thuy MNT, Bernhardt J. Very early versus delayed mobilisation after stroke. Cochrane Database of Systematic Reviews 2018, Issue 10. Art. No.:CD006187. DOI: 10.1002/14651858.CD006187.pub3.

Langhorne  P, Ramachandra  S. Organised inpatient (stroke unit) care for stroke: network meta‐analysis. Cochrane Database of Systematic Reviews 2020, Issue 4. Art. No.: CD000197. DOI: 10.1002/14651858.CD000197.pub4.

Legg  LA, Lewis  SR, Schofield‐Robinson  OJ, Drummond  A, Langhorne  P. Occupational therapy for adults with problems in activities of daily living after stroke. Cochrane Database of Systematic Reviews 2017, Issue 7. Art. No.: CD003585. DOI: 10.1002/14651858.CD003585.pub3.

Mehrholz  J, Thomas  S, Elsner  B. Treadmill training and body weight support for walking after stroke. Cochrane Database of Systematic Reviews 2017, Issue 8. Art. No.: CD002840. DOI: 10.1002/14651858.CD002840.pub4.

Pollock A, Baer G, Pomeroy VM, Langhorne P. Physiotherapy treatment approaches for the recovery of postural control and lower limb function following stroke. Cochrane Database of Systematic Reviews 2007, Issue 1. Art. No.: CD001920. DOI: 10.1002/14651858.CD001920.pub2.

States RA, Pappas E, Salem Y. Overground physical therapy gait training for chronic stroke patients with mobility deficits. Cochrane Database of Systematic Reviews 2009, Issue 3. Art. No.: CD006075. DOI: 10.1002/14651858.CD006075.pub2.

Key Messages

  • Early mobilisation is a key element of stroke unit care and involves the entire multidisciplinary team.
  • There are many potential benefits of early mobilisation after stroke which may result in fewer complications and enhance outcomes.
  • The implementation of an agreed, structured timetable should be considered to ensure best early rehabilitation without causing excess fatigue for the patient.
  • The evidence supporting physical management techniques after stroke is constantly evolving and it is important to keep abreast of this in order to incorporate novel techniques into clinical practice.

For more information on fatigue visit STARS AM 10: Scenario Mr McGuire

Joan’s progress

It is now four weeks since Joan’s stroke. She continues to be very motivated to carry out her therapeutic activities in both the ward and therapy settings. She can now walk short distances with supervision on the ward. Joan has some recovery of the movement in her arm and hand, and can hold and release objects. She is independent in self-care activities provided the materials are to hand. Her discharge home has been planned with continuing rehabilitation from the early supported discharge team in the community.

Joan thinking about her home

How could you manage the situation?

As a result of these observations the team decides that Joan needs a more organised timetable which addresses the timing, intensity and nature of the interventions. The team get together and discuss how best to manage her fatigue and also enhance her activity levels.

Select the crosses next to the headings below to find out how you could maximise the benefits of early mobilisation for Joan.

CHSS: Positioning for People Affected by Stroke [.pdf]

Joan now has an organised timetable and is better able to actively participate in therapy. What does her therapy involve?