Options 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.

Appropriate

Implement a regime of stretches – stretches can maintain tissue length if undertaken regularly. In this situation slow sustained stretches would hopefully improve the hands posture and Alan’s ability to undertake hand hygiene.

Work on the active control of his arm – by increasing the control of his arm in particular the extensor activity of his hand and wrist Alan’s tone and hand posture may be improved. This approach would not be done in isolation and would be combined with stretches and splinting.

Consider medical spasticity management – physical treatment alone may not be enough to mange his spasticity. Consideration should be given to medical management of spasticity early on to reduce some of the consequences of spasticity.

Provide him with a hand splint as an adjunct to therapy – hand splinting is generally used as an adjunct to therapy to assist with maintaining muscle and soft tissue length and help control muscle tone.

Inappropriate

Provide him with an arm sling to use at all times – Alan has some good recovery of movement in his shoulder and elbow. The provision and constant use of a sling may reduce this motor recovery. The main problem to be addressed is his hand posture and it’s hygiene. A sling will encourage flexion at the shoulder, elbow and wrist and in this case will not address Alan’s main issues and, potentially, may be more detrimental.

Keep working on his leg and hope his arm gets better – if left untreated, a vicious cycle could develop in which unopposed contraction in affected muscle groups leads to further abnormal limb postures, resulting in further soft tissue shortening and biomechanical changes in the contracted muscles. This in turn prevents muscle lengthening and could increase the aggravating factors (e.g. skin breakdown) and perpetuates further tonicity.

Stretches should only be undertaken by professional staff, as self practice may cause trauma – to maximise the outcome of stretches there needs to be frequent practice. The best way to do this is actively involve patients and carers. It is important to educate, demonstrate and regularly review with patients and carers the appropriate technique to prevent trauma. It is vital that Alan can self manage his tone in the future and therefore education on stretches is important.