The Royal Marsden Hospital Manual of Clinical Nursing Procedures - Lisa Dougherty [237]
A survey of physiotherapists identified that the most common aims of positioning for patients with stroke were modulation of muscle tone (93%), prevention of damage to affected limbs (92%) and supporting and stabilizing body segments (91%) (Chatterton et al. 2001). Expert opinion identifies that these factors promote recovery where recovery is likely (Barnes 2001, Edwards 1998, Hawkins et al. 1999, Pope 2002).
Altered tone and abnormal patterns of movement
Tone is defined clinically as ‘the resistance that is encountered when the joint of a relaxed patient is moved passively’ (Britton 1998). Alterations in tone will affect functional recovery in patients with neurological problems and require careful management. This can be through positioning, splinting if required and oral and focal pharmacological intervention (Barnes 2008).
Increased tone and spasticity are disorders of spinal proprioceptive reflexes. Spasticity is defined as:
a motor disorder characterised by a velocity dependent increase in tonic stretch reflexes (muscle tone) with exaggerated tendon jerks, resulting from hyperexcitability of the stretch reflex, as one component of the upper motor neurone syndrome. (Barnes 2001, p.1)
Normal movement is dependent on a neuromuscular system that can receive, integrate and respond appropriately to multiple intrinsic and extrinsic stimuli. Where this is altered through CNS or PNS disease, abnormal movement patterns will exist which will affect patients functionally. Key components include:
normal postural tone
reciprocal innervation of muscles
sensory: motor feedback and feedforward mechanism
balance reactions (Edwards 2002b)
biomechanical properties of muscle (Edwards 1998).
The influence of altered tone and abnormal patterns of movement is key to therapeutic theories regarding the recovery of motor control in patients with neurological problems. Patients may attempt to perform functional skills as prerequisites of activities of daily living, but without appropriate background postural tone and normal properties of muscle, these movements will be performed in an abnormal way.
Joint protection
Positioning is suggested as a strategy to prevent hemiplegic shoulder pain and to prevent loss of range of movement (Ada et al. 2005, Dean et al. 2000, Kaplan 1995). This aims to prevent the patient’s functional deterioration (Gloag 1985). Dean et al. 2000 identified that these complications often prevent a patient’s full participation in rehabilitation, contributing to poor upper limb functional outcome. Several factors were described for this.
Glenohumeral subluxation due to lack of muscular activity around the shoulder.
Trauma to the shoulder complex through unsuitable exercise.
Trauma through inappropriate handling of the patient by staff during transfers.
Dean et al. 2000 acknowledged that consistency in education was essential for these common problems. Ada et al. 2005 recommended that patients with little upper limb function in the early stages after a stroke undergo a programme of positioning of the affected shoulder. Their study showed statistical significance in maintaining shoulder range when compared with patients who received standard upper limb care of arm support and exercise only. Such specific joint positioning requires assessment by the physiotherapist for each individual patient.
Soft tissue changes and contractures
With increased tone, joint range and subsequent function are at risk. Restriction in the range of movement is not always simply through increased tone of the relevant muscles. The surrounding soft tissues, tendons, ligaments and the joints themselves can develop changes leading to an increased likelihood of them being maintained in a shortened position (Barnes 2008); a secondary biomechanical component of spasticity is often seen in patients with functional mobility problems. Adaptation of the mechanical