EXERCISE AFTER STROKESpecialist Instructor Training Course

L7b Physiotherapy assessment and clinical risk (Effects of Stroke on Physical Function; “Normal”

Movement; Abnormal Tone)

Mark Smith, John Dennis, Frederike van Wijck

Learning OutcomesAt the end of this session, you should be able to:

• Demonstrate an understanding of the physiotherapist’s role in rehabilitation & referral processes to exercise after stroke.

• Demonstrate awareness of risks associated with a rehabilitation and referral on to exercise intervention

Effects of stroke on physical function• Reduced range of movement (passive,

active)• Reduced strength• Altered tone• Altered sensation• Impaired coordination• Difficulties with ADL• Fatigue• Reduced fitness

Compensations

• With paralysis other parts of the body will “compensate” for the loss of control or ability to function.

• seen in over-activity or over-use of the “unaffected” side.

• bias toward “unaffected” side, making it more difficult for the patient to use the “affected” side.

“pusher syndrome”

What is it about“Normal Movement…?”

• Smooth• Efficient• Coordinated• Graded

• Goal orientated• Specific Patterns• Automatic• Voluntary

What physiotherapy neuro-rehabilitation is all about!

Normal Movement

4 component parts to normal movement

• Normal postural tone• Normal sensation • Movement patterns • Smooth coordination

Postural / Muscle Tone

• The degree of tension or activity present in muscles which allows us to maintain an upright posture against gravity and yet still move around.

Muscle Tone

• Must be high enough to provide stability• Must be low enough to allow movement• Body segments should be able to be

placed in space allowing normal movement, both at voluntary and automatic level

• Normal tone will vary according to the size of the base of support and the anatomical alignment of the individual

• A brain lesion affecting movement will render muscle tone abnormal

Muscle Tone

Standing

Sitting

Lying down

HYPOTONICITY

SPASTICITY

Normal Range

Base of support and impact on tone

• Physical support can alter postural tone– Large BOS reduces tone– Small BOS increases tone

• Provides stability where necessary muscle activity may be lacking

Normal Movement

4 component parts to normal movement

• Normal postural tone• Normal sensation • Movement patterns • Smooth coordination

VisionInner ear / vestibular system

Proprioception / Joint position sense

Voice Other sounds

Painful stimuli

Temperature

Touch

Neglect- clinical manifestations

Normal Movement

4 component parts to normal movement

• Normal postural tone• Normal sensation • Movement patterns • Smooth coordination

Balance Reactions

• Equilibrium

• Righting

• Saving

Work to produce base for purposeful, functional movements

Normal Movement

4 component parts to normal movement

• Normal postural tone• Normal sensation • Movement patterns • Smooth coordination

INPUT

Stimulus identification

Response selection

Response programming

Motor program

muscles

OUTPUT

spinal cord

comparatordesired state

error

Reflexes

proprioceptive feedback

exteroceptive feedback

after Schmidt & Wrisberg,

(2000)

Shoulder Problems after Stroke• Why can

shoulders be so problematic following a stroke?

• As instructors what ‘risks’ do we need to be aware of?

Management of Subluxation

• Shoulder Supports

• Strapping

•Handling

• Alignment• Facilitation• Inhibition

Types of Risk

• Generic Risks: environmental, equipment (covered yesterday) modes of delivery, communication)

•Clinical Risks…

Risks ~ the individual

• Impairment levels ?• Activity capabilities?• Participation restrictions?• Other risk factors?

Risks ~ the Individual:

• Joint range of motion• Weakness and active control• Tonal behaviour• Balance, transfers and coordination• Sensation and perception• Memory and thinking• Communication• Comorbidities/ medication

 

activity

  

individual environment   

Risks may arise from the interaction between the individual, the activity

and the environment.

Risk ~ activity

• Type of activities• Type of equipment• Speed of exercise in group format• Physical demands of activity• Complexity of the activity (e.g.

number of components, need for parallel-processing)

• Interaction with others?

B-blockers Slowing of heart rate with reduced response to exercise. Likely to impact on intensity of exercise. Can cause lethargy, tiredness and low blood pressure.

Diuretics Clients will tend to know how soon after taking a tablet, they experience the diuresis and can thus alter timing to avoid coinciding with exercise. Can also cause postural hypotension or excessive thirst.

Nitrates Spray or tablets should be taken to class and used in the event of chest pain during exercise. Those who know they get exercise induced chest pain should take spray/tablet before exercising.Can cause a sudden drop in blood pressure.Peripheral vasodilatation may have effect on exercise capacity.

Antidepressants Increases postural instability.Can precipitate arrhythmias (abnormal rhythm of the heart)

Sedative hypnotics and anxiolytics

Increases postural instability, drowsiness and impaired concentration

Antipsychotics Increases postural instability and can cause movement disorders including Parkinsonian features as well as abnormal writhing movements.Can have sedative properties

Eye drops Can cause blurring of vision after insertion Can produce slowing of the heart rate

Risk ~ environment

• Access and facilities• Staff expertise• Staff: individual ratio• Interaction with others

See L8: risk assessment by the exercise professional

Essential Reading

Further detail about the topics discussedin this session can be found in section L7of the course syllabus.