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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.