Assessment, treatment and the ‘Hands-on’ apporach

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.

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2 thoughts on “Assessment, treatment and the ‘Hands-on’ apporach

  1. Sarah. I will fire this blog entry to my Twitter and LinkedIn colleagues today. I hope for comments from physiotherapy students learning about evidence based therapy, from newly qualified physiotherapists entering the dark side and therapists wanting to know more about hard core exercise based therapy. All the best, Glyn.

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  2. Hi Sarah and Glyn.

    As Glyn has asked so kindly I thought I would leave some feedback since joining the ‘dark side’ and qualifying 2.5 years ago. I have been following your blogs Sarah on both the iCSP and here so hopefully my comments reflect someone who is new to their physio career and trying to work within the best EBP to help patients improve.
    I personally work in an independent paediatric setting which uses a number of the ‘dark’ techniques and equipment such as treadmill, therasuit, spider and functional electrical stimulation along side all of the new Saebo products which we use daily.

    My response is aimed at perhaps not just this blog but all of the information that I have read from you recently. With still a lot of therapists using passive stretches alone I have found it a breath of fresh air to see more and more therapists realising the true potential of muscle strengthening and how it can improve patients with and without spasticity. I am privileged enough to be in a working environment where we use lots of pioneering equipment that helps to improve the children we work with and really reinforce the whole quality vs quantity debate from other blogs. Looking more into the motor relearning research and the amount of practice needed to learn, consolidate and actually be functional in a skill it would be completely unrealistic to expect a child or adult to learn a skill that required a completely ‘hands on approach’. This I completely agree is where equipment like the treadmill comes in so handy to assure that there are options outside of therapy for patients to be progressing.

    We use FES every day in clinic with positive effects on strength therefore function and follow progressive resisted muscle strengthening programs which are regularly monitored. I personally have seen such a change in all of the children that I have worked with (the ones with less neurogenic weakness obviously progressing quicker) and am baffled as to why some therapists still do not think that FES is an efficient and safe way to treat CP. We always check the standard contraindications with families and check with consultants if not sure. It is a cheap and easy way to help progress muscle strength (again recent research supports this) where the children do not even need to be performing a task to gain benefit from! What could be better than secret physio!

    Thinking more from a recent students point of view I do feel as if lots of the treatment ideas given from lecturers, especially those not still treating can be dated and always restricted by finance as they expect most new therapists to go into services unable to fund such advancements. I class myself as very lucky to have attended Walkaide courses, Saebo days and the Neurological Expo in London (amongst others) to understand that the medical advances are staggering. Why oh why are we still seeing restricted programs given out to children with no muscle strengthening components?

    Muscle strengthening works, its evidence based and most of all it makes perfect sense! You strengthen a muscle and it will have more contractile force, if that contractile force like you said Sarah exceeds the demand of gravity or resistance then there is more opportunity for function. More opportunity for function means more independence. This allows for an increased quality of life and a brighter future for the children struggling with movement and weakness. This is not even taking into consider the possible benefits from neuroplasticity or neurogenesis which again need opportunity (to which you need strength and practice).

    All of your blogs Sarah have made perfect sense and I feel, although I still have much to learn, that I can treat and help the patients on my caseload to have a better future. This is an approach that has not been lead by my heart, instead my head. I am open to learning at any point in my career and would start passive stretches again tomorrow if this is what I saw clinically helped or was indicated in the research (including NICE guidelines). This applies too for Bobath, I just feel from my understanding and experience of both approaches muscle strengthening works much more. This was felt also from other colleagues when recently attending the introductory Bobath course. I felt the approach was very closed and not willing to take any direct questioning on how it improves its patients. The course was very costly and I was left with limited treatment ideas or really any real handling skills that I would use daily in clinic. Again I hope this is helpful and on the topics that have been raised as this will be my first post on the blogs!

    I am open to comments and feedback from anyone interested in anything raised in this comment!

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