The post about clinical reasoning has stimulated a response from ‘Anne’ who talks about the need for a ‘hands on’ approach to effectively assess and treat her patients. She says “I am also aware that leg muscles after stroke may respond differently in supine, sitting, standing or walking so I am keen to get somebody on their feet straight away if possible to check muscle activity. And to me using a’ hands on’ approach gives me the best information of how and when muscles become active”.
Here’s my thoughts on ‘hands –on assessment’
I think, if I may be so bold, that one of the issues that lead you to believe that handling/ Bobath skills are needed to asses and treat is connected to the clinical reasoning around your observation that muscles respond differently in different positions and that you like to get folk on their feet to check ‘muscle activity’. Now then, [the easily shocked and indignant may want to get some smelling salts at this point] – muscles are muscles. They contract (and relax) and that’s pretty much it. They aren’t ‘active’ is some positions and not others.
A muscle contracts when there is sufficient drive from the motor neurones to exceed the contraction threshold, and whether that contraction produces movement depends on whether sufficient force is produced by the contraction to overcome any forces acting against it (like gravity or resistance). I am assuming that by ‘active’ you mean whether the muscles are producing a discernible contraction either by seeing or feeling movement or contraction. What one actually needs to assess is how strong the muscle is (ie how much force it produces). This is done quickly and simply using the MRC Oxford scale. Only able to produce a flicker of at the muscle or tendon = Grade 1; movement with gravity counterbalanced = MRC Grade 2, against gravity = MRC 3; against resistance = MRC 4); full function = grade 5. Then + or – scores are added to identify whether the movement is possible through full range or not – Remember the old force/ length curve; the most force is produced when a muscle is in mid-range). It is quick and easy to assess using the Motricity Index (which is derived from the MRC Oxford scale). It takes 5 minutes, max. There is no need to undertake elaborate and time consuming assessments to work out if you can see/ feel muscles contracting in endless different positions. If one knows why patients can’t move as they would normally (primarily because they are weak) and now to interpret the results of the Motricity Index, it is a quick and simple job. A ‘hands-on’ approach isn’t needed. Of course if one is not familiar with the Motricity Index (or any other objective measure), it does take some practice with become familiar with the results, how to interpret them and connect to the choice of interventions, but it isn’t difficult.
Anne goes on to talk about the treatments she would choose “If at all possible I move towards walking but as I don’t have a treadmill or any other electromechanical device, I need to use my hands to assist the patient. ……. I am confident that I get good early results and that I work evidence based. However, I have since realised that providing this walking practice is not as easy as I make it look. ….. Several of my colleagues have had a go with the same patients as they understand the principles and in theory it sounds straight forward. They have not been able to get any gait pattern going because they don’t have the handling training/experience to coordinate all the movements. What would they do with a patient instead? Exercises in sitting? Maybe walking practice with assistance of more than 1 person? Is this best practice, not to practise walking because you don’t have the handling skills?
Here’s my thoughts: How to treat walking without a treadmill or gait-trainer? I don’t doubt, Anne, that you do have fabulous handling skills and get people to walk beautifully when others can’t. But what do the patients do once you let go of them? The evidence based way would to be to give them assistive walking devices (walking aids, an AFO, slider shoe, maybe FES) as necessary so that they can walk safely, may be with assistance/ supervision (at least to start with until they are safe to be independent). Then they would be able to walk, even if they have to make do with your less skilled colleagues. If using EBP, one would then get the patient practising walking a lot (plus other mobility tasks such as STS, transfers, balance activities, bed mobility). The number of repetitions needed for motor learning are far in excess of these achieved when the therapist is ‘hands on’. All the time the task and environment need to be manipulated to enable safe function, build motor skill, strength, endurance, efficiency, and confidence but not fretting about quality of movement. They also need to exercise (and the choice of exercise depends on the strength, which you know from the results of the Motricity Index) to build up their strength, endurance, range. Of course one wouldn’t stop as soon as the patient can put one foot in front of another, but keep progressing the demands made on them – reducing the assistance, increasing repetitions, duration, complexity etc as their ability improves. The skill of the therapist lies in being able to tailor the practice conditions (by manipulating task and environment) to promote motor learning and enable safe function.
No magic handling skills required beyond what, I would hope, students learn while training and 1st qualified. Obviously one gets better at it with time and experience but the advanced skill is in the brain, not the hands.