Normalising Postural Tone and Teaching the Patient to Move Selectively and Without Excessive Effort

Abstract

Perhaps the most important and difficult task for the therapist is to normalise muscle tone and teach the patient how to move easily in a normal pattern. When the tone is too low, the patient will be unable to support himself or parts of his body against gravity. Where tone is too high and spasticity is a problem, the patient will be able to move only with great effort in stereotyped mass patterns against the resistance of the hypertonic antagonists. One or other of these problems may be predominant, but very often there is a mixture of the two, or a state of muscle tone which fluctuates between the two. How the patient moves or is positioned throughout the day will influence the tone considerably (Chaps. 5 and 10). Striving to move unaided in whatever way he can in the presence of hyper- or hypotonus will in turn lead to further tone abnormalities. From the beginning he should therefore learn to move selectively and be assisted sufficiently so that the mass movement synergies do not become habituated, with tone increasing further as a result. It has even been postulated that, “what is usually called spasticity is in most cases following stroke unnecessary muscular activity which has become habitual, certain muscles, those whose mechanical advantage is greatest, contracting persistently to the disadvantage of others” (Carr and Shepherd 1982). Not only does repeated use of abnormal movement increase hypertonicity, but the habitual patterns are difficult to change later and may even prevent the return of useful functional activity for patients for whom such recovery might otherwise be possible. “It seems likely that frequent repetition of adaptive motor patterns may generate stronger neural connections, these patterns, rather than more effective patterns, becoming “learned” or more stable” (Carr and Shepherd 1996). During treatment the principles of facilitation should be followed, after tone has become as normal as possible. The treatment is not a series of isolated exercises but a sequence of activities to achieve a specific aim. When a therapeutic activity has normalised tone, a selective movement is practised and then used in a functional way. Although one part of the body cannot be treated in isolation, as each part influences the others, this chapter deals more specifically with trunk and lower limb activity and Chap. 8 with the trunk and upper limbs.