1. EXERCISE AFTER STROKE Specialist 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

2. 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

3. 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

4. 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.

5. “pusher syndrome”

6. What is it about “Normal Movement…?” Smooth Efficient Coordinated Graded Goal orientated Specific Patterns Automatic Voluntary What physiotherapy neuro-rehabilitation is all about!

7. Normal Movement 4 component parts to normal movement Normal postural tone Normal sensation Movement patterns Smooth coordination

8. 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.

9. 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

10. Muscle Tone Standing Sitting Lying down HYPOTONICITY SPASTICITY Normal Range

11. 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

14. Normal Movement 4 component parts to normal movement Normal postural tone Normal sensation Movement patterns Smooth coordination

15. Vision Inner ear / vestibular system Proprioception / Joint position sense Voice Other sounds Painful stimuli Temperature Touch

16. Neglect- clinical manifestations

17. Normal Movement 4 component parts to normal movement Normal postural tone Normal sensation Movement patterns Smooth coordination

18. Balance Reactions Equilibrium Righting Saving Work to produce base for purposeful, functional movements

19. Normal Movement 4 component parts to normal movement Normal postural tone Normal sensation Movement patterns Smooth coordination

20. INPUT Stimulus identification Response selection Response programming Motor program muscles OUTPUT spinal cord comparator desired state error Reflexes proprioceptive feedback exteroceptive feedback after Schmidt & Wrisberg, (2000)

22. Shoulder Problems after Stroke Why can shoulders be so problematic following a stroke? As instructors what ‘risks’ do we need to be aware of?

23. Management of Subluxation Shoulder Supports Strapping Handling Alignment Facilitation Inhibition

26. Types of Risk Generic Risks: environmental, equipment (covered yesterday) modes of delivery, communication) Clinical Risks…

27. Risks ~ the individual Impairment levels ? Activity capabilities? Participation restrictions? Other risk factors?

28. 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

29. activity individual environment Risks may arise from the interaction between the individual, the activity and the environment.

30. 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?

31. B-blockersSlowing of heart rate with reduced response to exercise. Likely to impact on intensity of exercise. Can cause lethargy, tiredness and low blood pressure. DiureticsClients 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. NitratesSpray 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. AntidepressantsIncreases postural instability. Can precipitate arrhythmias (abnormal rhythm of the heart) Sedative hypnotics and anxiolytics Increases postural instability, drowsiness and impaired concentration AntipsychoticsIncreases postural instability and can cause movement disorders including Parkinsonian features as well as abnormal writhing movements. Can have sedative properties Eye dropsCan cause blurring of vision after insertion Can produce slowing of the heart rate

32. Risk ~ environment Access and facilities Staff expertise Staff: individual ratio Interaction with others See L8: risk assessment by the exercise professional

33. Essential Reading Further detail about the topics discussed in this session can be found in section L7 of the course syllabus.