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EXERCISE AFTER STROKE Specialist Instructor Training Course L7b Referral Processes: Physiotherapy assessment, readiness for exercise, risk stratification and referral procedures (Effects of Stroke on Physical Function; “Normal” Movement; Abnormal Tone) Mark Smith, John Dennis, Frederike van Wijck Learning Outcomes At 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…?” What physiotherapy neuro-rehabilitation is all about! • Smooth • Efficient • Coordinated • Graded • Goal orientated • Specific Patterns • Automatic • Voluntary 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 SPASTICITY Standing Normal Range Sitting Lying down HYPOTONICITY 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 Voice Vision Other sounds Inner ear / vestibular system Painful stimuli Temperature Touch Proprioception / Joint position sense 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 error Stimulus identification Response selection Response programming comparator desired state Motor program spinal cord Reflexes muscles proprioceptive feedback OUTPUT exteroceptive feedback after Schmidt & Wrisberg, (2000) Management of Subluxation •Handling • Shoulder Supports • Alignment • Facilitation • Inhibition • Strapping Risks may arise from the interaction between the individual, the activity and the environment. activity individual environment 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 Risks may arise from the interaction between the individual, the activity and the environment. activity individual 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? Risks may arise from the interaction between the individual, the activity and the environment. activity individual environment Risk ~ environment • Access and facilities • Staff expertise • Staff: individual ratio • Interaction with others •… See L8: risk assessment by the exercise professional The physiotherapist’s role in referring a person with stroke for exercise activity individual Therapist or Exercise Instructor environment Referral Information What information do you need from your referrer? 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 Essential Reading Further detail about the topics discussed in this session can be found in section L7 of the course syllabus.