Effect of stroke and their intervention: In standing Posture

Effect of stroke and their intervention: In standing Posture OTprinciple
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The ability to assume and maintain a standing posture is very important to perform many types of activities. It may also play an important role in the eventual discharge destination for a  hospitalized client who is recovering from a stroke. Impaired upright posture may be manifested as increased risk of fall and less than normal functional outcomes. 

Early training in upright control is very necessary for stroke rehabilitation programs because many daily activities, play, and leisure require control of a standing posture. 

After a stroke, commonly postural strategies are impaired. For example ankle, hip, and stepping strategies. 

Similar to the deficit seen while sitting click here to know more about the deficits after a stroke and their intervention in sitting posture. Upright standing posture is characterized by:-

  • Asymmetric weight distribution in lower extremities and trunk while standing 
  • Inability to bear weight through the affected leg 
  • Fear of falling and knee-buckling
  • Weakness (unable to support the body weight on limbs) 
  • Spasticity that will affect proper alignment. For example, plantar flexion spasticity affects weight-bearing through the sole of the foot 
  • Perceptual dysfunction 
  • Loss in upright posture control and balance strategies
Effective upright control depends on following automatic postal reactions:
  1. Ankle strategy: These are used to maintain the center of mass over the base of support when movement is centered on the ankles. Ankle strategies control small, slow, swaying movements such as standing in a line, engaging in conversations while standing. Ankle strategies are most effective when the base of the support is firm and larger than the foot such as the floor. Ineffective ankle strategies and balance may be due to ankle weakness, loss of ankle range of motion, and proprioceptive deficits.
  2. Hip strategy: These are used to maintain or restore equilibrium. Hip strategies are used specifically when the surface is smaller than the feet. Example walking on a beam.
  3. Stepping strategy: This is used when the ankle and hip strategies are ineffective or perceived to be ineffective. In this strategy, steps are taken to widen the base of support. For example, your response when standing on a bus unexpectedly stops.

Loss of postural reactions and inability to bear and shift weight onto affected legs will result in functional limitations such as gait deviation and inability to climb stairs, transfer and perform daily activities that require upright posture including BADLs and IADLs, and an increased risk of fall.

Assessment and evaluation

To know the more specific cause of dysfunction the therapist should do an assessment. During an assessment process the therapist should observe what happens when patients do the following things:

  • Move their center of mass over their base of support 
  • Move from one kind of surface to a different
  • During functioning on a narrow base of support
  • Postural alignment (shifting of weight from one side of the body) 
  • Patient’s limits of stability 
  • The width between feet during functional activities 
  • What presents do after losing their balance?

Treatment/Intervention

The following treatment or intervention strategies are used to improve patient’s functional activity in standing posture after a stroke:

  1. Establishing the symmetric base of support with proper alignment to prepare to engage in activities. The starting alignment should provide ample proximal stability and support for engagement in the functional tasks. 
  • The therapist may use hand-on support or visual or verbal feedback to establish proper alignment as follows:
    • Feet should be approximately hip-width apart
    • Equal weight bearing on both the feet
    • The pelvis should be in the neutral position
    • Both knees slightly flexed
    • The trunk should be properly aligned and symmetric
  1. Improve the person’s ability to bear and shift weight through the more affected lower extremity. Weight-bearing should be in a graded pattern. For example, if a person is unable to stand because of postural imbalance or insecurity, sitting on a high surface with partial weight-bearing on lower limbs may be suggested. 

As the client improves full standing should be encouraged followed by progression to full weight-bearing on the affected leg through graded weight shift. The environment is modified according to the client’s need to elicit the required weight shift.

  1. Improving dynamic reaching activities in multiple environments to developed task-specific weight-shifting activities. For example, kitchen activities such as cleaning the sink and accessing overhead cabinets require mastery of multiple postural adjustments and balance strategies.
  1. Therapists may use the environment to grade the task difficulty and provide external support. Proper use of the environment, improves client confidence and balancing skill and also decreases fear of falling. For example, working in front of a countertop using one hand for support and using a Walker for support.
  1. Using graded functional task improve clients upright control keeping in mind the patient need and requirement.  Examples include activities that require shifting of body weight, balance, strategies, and the ability to wear weight through both lower limbs.

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