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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