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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.