More than one way to skin a cat

I would like to describe one of the situations I encountered on my Neuro outpatient placement. The patient I was treating suffered from a right LACS stroke, and suffered from an abnormal increase in tone on his left side, which presented very similar to rigidity, however it was not velocity dependent, feeling much the same whether the arm was passively moved rapidly or slowly.

Much of the treatment on this patient focussed on dissociating his left scapula from the trunk. The use of SIMMS on lat dorsi was very effective in improving shoulder ROM. Hand stereognosia was enhanced to improve hand placement in functional reaching tasks. One thing that became apparent through treating this patient was keeping him focussed solely on the task of reaching.

If he yawned during the treatment, his left arm returned to its flexor synergy with significant strength. At one time he literally pulled his arm out of my hands. Another time one of the physios came rushing into the treatment gym and spoke loudly with one of the other patients, which surprised my patient, and resulted in this increased tone and the increased flexor synergy once again.

The increased tone in his left leg also led to an altered gait pattern. I attempted some facilitated walking with him, holding his left arm abducted from his body in an effort to decrease upper limb tone and to facilitate weight transfer. I did this after advice from my supervisor. Another physio in the gym made suggestions on my positioning, which I found difficult as I was probably 8 inches taller than the patient. I also tried facilitating from his unaffected side, which proved more effective.

I was trying to do the best for the patient and was receiving different information from two very experienced and excellent physios. It was frustrating as I didn't want to play one physio against the other, so I tried what they both suggested. In the end, all of their suggestions were equally effective, although one was more comfortable for me. What I want to get across is that there may be many ways to obtain the required outcome, and it is as much about the outcome of the treatment as it is about what is most comfortable for the physio performing the treatment. I also found out today that the patient has recently been discharged from physio, so it is encouraging to hear that he has progressed even further.