Her movement disorder is an inconsistent right "hemiplegia". She actively
holds her foot in a strongly inverted position when being observed and
claims she is unable to put her foot to the floor. On examination, it is
clear to me and other clinicians that this is active movement rather than
spasm, as she gets tired after a few minutes or if she is distracted by eg
her pet dog jumping up and licking her and her foot assumes a normal
position. Passive movement of her knee is met with variable levels of
assistance and resistance from her. There is no muscle wasting. In the days
when she did walk publicly, she used to stagger the width of the room and
land comfortably in her chair. When she was living in the hostel, she coped
with an 8 inch threshold to her shower independently.
She also claims to be unable to use her right hand, yet impressively can
roll her own cigarettes ! She holds it in a variety of positions but
frequently little, ring & middle fingers held together in extension, but
flexed at the MCP joints.

The jury is out on whether or not she is doing this in a calculated manner
or whether she is unaware of what she is doing. My own view is that it is
probably a bit of both - and that just because we're not sure why , that
shouldn't stop us from trying to encourage something a little more normal !

If anyone out there has had a patient like this before, please let me know
your ideas !

Nikki Adams   [log in to unmask]  Wakefield UK
----- Original Message -----
From: "Lee, Noemi" <[log in to unmask]>
To: <[log in to unmask]>
Sent: Thursday, December 21, 2000 9:33 AM
Subject: Re: School for Bravery


> Could you please describe your patient's "movement disorder"?
> Why assuming that it might be psychologicaly rather than cognitively
> related?
>
> Noemi
>
> -----Original Message-----
> From: mdne adams [mailto:[log in to unmask]]
> Sent: 20 December 2000 22:35
> To: [log in to unmask]
> Subject: Re: School for Bravery
>
>
>
> Chris, thanks for your reply,
>
> You ask the six million dollar question here ! "What do you feel is
> maintaining your client's movement disorder ?"
>
> This patient is the subject of much debate in the mental health services
and
> medical health services as to the whys & wherefores of her movement
disorder
> and repeated attendance at Casualty with a variety of symptoms. She will
not
> acknowledge that there may be a psychological component to her
difficulties,
> which has effectively excluded her from direct dealings with
Psychologists,
> as she won't consent to this.  She has a complex and traumatic social
> history including divorce, time spent in a hostel, and recent rehousing in
a
> bungalow. The System has therefore inadvertantly supported her disability
by
> bailing her out of a miserable situation and she has mastered the art of
> getting help and sympathy from family members, friends, neighbours and
> anyone passing by using her movement disorder (and of course contact with
> the Health services who unwittingly reinforce it all over again every time
> she presents herself for reexamination, and the Benefits Agency who have
> granted her lower rate Disabled Living Allowance) This has become a
> well-entrenched habit and we are well aware that it will be very
difficult,
> if not impossible, to reach all the people that currently maintain her in
> her illness behaviour.
>
>  This is why we're particularly keen to temporarily pluck her out of this
> environment, help her to achieve a major change in her behaviour and most
> importantly give her an acceptable, publicly understandable excuse and
> reason for making a recovery - bravery through physical exercise. There
have
> already been several multidisciplinary meetings about her, and there are a
> number of people available who are willing to encourage wellness behaviour
> in the future - but this is probably too daunting to achieve without the
> admission to a unit specialising in this sort of approach first.
>
> So Chris, if you or anyone else knows of such a unit, or you have any
other
> ideas, please let me know. So far, my own involvement has been observation
> of her movement disorder in her 3 different home environments over the
last
> year or so, and repeated offers from me to meet her at a local swimming
pool
> of her choice, which she hasn't yet taken me up on.
>
> This is a challenge to all concerned - ideas very welcome
>
> Nikki Adams  [log in to unmask] <mailto:[log in to unmask]>  Wakefield
>
> ----- Original Message -----
>
> From: Chris Murphy <mailto:[log in to unmask]>
> To: [log in to unmask] <mailto:[log in to unmask]>
> Sent: Wednesday, December 20, 2000 12:26 AM
> Subject: Re: School for Bravery
>
> A quick question regarding your question. What do you feel is maintaining
> your patients movement disorder. To change behaviour you need, as you
point
> out, not to reinforce the maintaining factor. The school of bravery
> programme follows a behavioural model which the cognitive behavioural
> programmes incorporate as this has been proven to be very successful.
> However the question of what is maintaining your patients behaviour is
> paramoiunt as this needs addressing initially and correct educzation of
> partners and relatives can be very useful in treatment regimes.
>
> Cheers
>
>
> Chris
>
> ----- Original Message -----
> From: mdne  <mailto:[log in to unmask]> adams
> To: [log in to unmask] <mailto:[log in to unmask]>
> Sent: Monday, December 11, 2000 7:33 PM
> Subject: School for Bravery
>
> About 15 years ago in the UK there was a lot of interest in Joyce
William's
> "School for Bravery" programme, which was a method for changing "illness
> behaviour" into "wellness behaviour". She did this at Doncaster Royal
> Infirmary, and also ran courses on it that were attended by many PTs from
> all over the UK - who then set up their own "School for Bravery"
programmes.
>
>
>  I am really keen to find out if anyone is still running such a scheme, or
> anything like it - I have already contacted Doncaster and they don't do it
> any more. The illness behaviour that my client is exhibiting is a movement
> disorder rather than chronic pain behaviour - what I think she needs is a
> friendly group environment, where illness behaviour is totally ignored and
> wellness behaviour lavishly praised.
>
> Anywhere in the UK would be a possibility as I believe a strong case for
> funding it could be made.
>
> Here's hoping !
>
> Nikki Adams Community Physical Disability Team Wakefield
> [log in to unmask]