Positioning and Early
Mobilisation in Acute Stroke
Claire Simcox Highly Specialist Physiotherapist
Stroke and Neurology
Objectives
• Discuss the importance of good positioning in acute
stroke
• Discuss shoulder care in acute stroke
• Review seating options for stroke patients
• Discuss the importance of early mobilisation
• Review aids and equipment to facilitate mobility of
stroke patients
Positioning Seating Mobilisation
Care and support of the affected upper limb
Hemiplegic shoulder pain (HSP)
• Around one quarter of patients develop HSP following
stroke, which is associated with poor recovery of arm
movement and function
• Multi-factorial cause
- subluxation, soft tissue damage, spasticity
• May result from trauma caused by incorrect moving and
handling
Upper limb after stroke
Subluxation
Reducing the risk of HSP
• Careful positioning with weight of limb supported
• Careful handling of the affected arm
• Avoid mechanical stress and excessive range of motion
(RCP 2016)
Positioning the upper limb
Always ensure the affected arm is well supported
Bexhill Arm Rest
Positioning the upper limb
Use pillows to support affected arm whilst seated (chair)
Positioning the upper limb
DO NOT allow the affected arm to hang / be unsupported
X X X
Handling the upper limb- rolling
X
Handling the upper limb- transfers
X X
Supporting the upper limb during
transfers & mobility
Slings should only be used
for transfers and walking
When in bed / chair sling
should be removed and arm
positioned appropriately
Positioning Seating Mobilisation
Care and support of the affected upper limb
Aims of Positioning
Avoid
- Skin damage
- Limb swelling
- Shoulder pain and
subluxation
- Contractures
- Aspiration and
respiratory complication
Promote:
- Comfort
- Maintenance of soft
tissue length
- Function
- Hydration and nutrition
(RCP 2016)
Supine
• Neutral head, neck and trunk alignment
• Upper limb supported
• Neutral hip/knee/ankle position
• Least recommended bed position
Advantages May enhance cerebral perfusion
Disadvantages
Risk of aspiration
Difficulty swallowing
Reduced social interaction
Side lying – weaker side
• Neutral head, neck, and trunk alignment • Upper limb alignment - scapular protraction, shoulder flexion and external rotation • Lower limb alignment
Advantages Able to use unaffected upper
limb
Disadvantages
Difficult to align affected side
Risk of shoulder injury
Side lying – stronger side
• Neutral head, neck, and trunk alignment • Upper limb supported • Lower limb alignment
Advantages Able to position affected side
Encourage use of affected side
Disadvantages
Unable to use unaffected upper
limb
Sitting upright
• Neutral head, neck and trunk
• Upper limb supported
• Neutral hip/knee/ankle position
Advantages Improved lung volumes and oxygenation
Reduced risk of aspiration
Optimal position to swallow safely
Patient able to eat, drink and socially interact more easily
Disadvantages
May reduce cerebral perfusion
May be tiring to maintain for prolonged periods
Adjuncts to Positioning
Positioning Seating Mobilisation
Care and support of the affected upper limb
Seating stroke patients
• Safe seating is considered an essential component of early
mobilisation and rehabilitation post-stroke
• Seating should enable a position that is erect, symmetrical and
aligned to support the natural anatomical structure of the body and
prevent the development of complications
• Different seating options are available dependent upon the patient’s
impairments
Seating options
Standard armchair
- Independent sitting balance or
minimal assistance to maintain sitting
balance
- Upper limb support may be required
Seating options
Wheelchair
- Provides more support than
regular armchair
- Can be used with alternative back
rests, lumbar rolls, lateral supports, arm
rest, cushions
- Enables patient transport
Lateral support and back rest
Bexhill arm rest
Seating options
Specialist wheelchair e.g. tilt in space
- Patients with limited head and trunk control
- Patients with limited physical endurance
Seating considerations
• Transfer method into and out of chair
• Physical ability to maintain seated position
- medical stability - head and trunk control
- physical endurance - pusher syndrome
• Cognitive and behavioural state
- confusion and disorientation - fluctuating attention
- impulsivity - reduced insight
• Team decision – Communication is vital!
Positioning Seating Mobilisation
Care and support of the affected upper limb
How Does Stroke Affect Mobility?
Stroke
Weakness
Balance
Vision
Inattention /
Neglect
Spasticity
Cognition
Sensory
Impairment
Pain
Nutrition
Plus many more……
Effects of immobilisation
Body system Effect
Musculoskeletal muscle weakness and wasting
reduced bone density
Respiratory reduced lung volumes
increased work of breathing
increased risk of lung collapse and pneumonia
Cardiovascular orthostatic intolerance
increased resting HR, decreased maximal cardiac output,
increased risk of DVT
Psychological reduced mood
increased risk of depression
Early mobilisation (24-48hrs)
• Early mobilisation aims to reduce the risks of bed
rest/inactivity and minimise post-stroke complications
• Early start of intensive stroke rehabilitation may be
associated with:
- greater and faster improvement of activities after stroke
- reduced length of hospital stay
Very early mobilisation
• AVERT study
• 2000 patients
• 92% mobilised with 24 hours (23% within 12 hours)
• Average of 6 times per day (therapists and nursing)
• No effect on immobility related complications
• No effect on walking recovery
• Greater disability at 3 month follow up
Benefits of early mobilisation
• Optimal time to commence mobilisation is not clear from the
literature
• Very early mobilisation i.e. within 24 hours post stroke is safe
and feasible
• However, the addition of very frequent mobilisation within 24
hours may not offer additional benefit and is not recommended
(AVERT, 2015)
Mobilising stroke patients
Mobilising a stroke patient requires individualised assessment of patient’s
impairments
- Cognition: alertness, confusion, safety awareness, neglect
- Communication: do they follow commands? can they express their needs?
- Vision: visual field loss e.g. hemianopia; diplopia
- Head and trunk control
- Lower limb function: extensor muscles to weight-bear, flexor muscles to
step
- Upper limb function: important for different types of equipment e.g. stick,
frame
Risk assessment for mobilising stroke
patients
T - Task
I - Individual
L - Load
E - Environment
Transfer and mobility methods
Hoist
Rota-stand
Pivot transfer
Step transfer
Walking frame
Walking stick
No aids
Dependent
Independent
•Used for patient’s with a foot drop
•Help to clear the foot from the
floor which helps with stepping
during mobility/ transfers when
worn inside a shoe
•Common pressure areas need to
be checked regularly (heel, along
edges of AFO) to prevent pressure
areas.
Ankle-Foot Orthoses (AFO)
Summary:
• Positioning requires a 24 hour approach by all members of the
MDT and is individual to each patient
• Specialist equipment is available to facilitate early seating /
mobilisation of acute stroke patients
• Mobilisation should begin within 24-48 hours of stroke – initially at
a low intensity
• Particular attention needs to be paid to the affected upper limb at
all times
References
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