Exercise and Fitness Training After Stroke Specialist Instructor Training Course Autumn 2010 Day 3-5 slides T2 The Role of AHPs in Stroke Rehabilitation: Content • What AHP’s do…(Art & Music Therapy, Dietetics, Physio*, OT*, Orthotics*, Podiatry, Psychology, Radiography & SLT*) (*=Course content) • Principles & practice of AHP management of stroke • Clinical reasoning and evidence-based practice Learning Outcomes At the end of this session, you should be able to: • Describe the role of AHP’s (allied health professionals) in stroke care • Discuss the rationale for different types of management • Demonstrate understanding of the roles of AHPs • Demonstrate basic understanding in where & how to adapt/ tailor programmes to suit stroke population needs. Essential Reading Further detail about the topics discussed in this session can be found in section [3.2] & [4.3] of the course syllabus. The Evidence… • Cochrane Collaboration Library: http://www.cochrane.org/ • Google Scholar: http://scholar.google.co.uk/ • http://www.knowledge.scot.nhs.uk/ • http://www.askdoris.org/ Physiotherapy The Chartered Society of Physiotherapy (CSP) defines the essence of physiotherapy as; "…a health care profession concerned with human function and movement and maximising potential: it uses physical approaches to promote, maintain and restore physical, psychological and social well-being, taking account of variations in health status it is science-based, committed to extending, applying, evaluating and reviewing the evidence that underpins and informs its practice and delivery the exercise of clinical judgement and informed interpretation is at its core." (CSP curriculum framework , January 2002). Physiotherapy Governed & regulated by 2 National bodies. Health Professions Council & Chartered Society of Physiotherapy ensure following processes: – Gather referral information – Conduct clinical interview – Conduct Systematic approach to clinical assessment (Observations + Assessment) – Drawing up a problem list – Formulating a treatment plan using Best available evidence and process of Clinical reasoning – Goal setting with the patient – Deliver interventions – Outcome assessment…feedback to original Ax and goals 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” Physical Rehabilitation Aims • • • • • • • • To normalise muscle tone To restore motor function To control compensation strategies To maintain muscle length and ROM To re-educate balance To retrain walking and restore mobility To facilitate skill acquisition To improve fitness More detail in Physiotherapy? • Physio and Orthotics Assessment (Ax) and links to exercise will be covered in lecture 7b The Role of AHP in Stroke Rehabilitation: Occupational Therapy CONTENT 1. Introduction to the role of OT in stroke 2. Information processing: a model 3. Problems with information processing after stroke: a) Attention and memory b) Sensation and perception c) Planning, taking action and monitoring 4. Summary and implications for exercise instructors. OT Role: Assessment of … • Functional activity limitations using activity analysis, i.e. the components of movement are individually identified, • Skills for the performance of self care (e.g. washing, dressing, feeding), domestic (e.g. shopping, cooking, cleaning), work and leisure occupations. • Skills which impact on each activity (e.g. sensorimotor, cognitive, perceptual and psychosocial impairments) • Assessment of social environment (e.g. family, friends, relationships). • Assessment of physical environment (e.g. home and workplace). OT Role: Intervention by… • Redevelopment of physical, sensory, cognitive, and perceptual skills through activity and practice. • Promote the use of purposeful, goal orientated activity. • Teach new strategies, and compensatory techniques to aid independence. • Assess and advise on appropriate equipment and adaptations to enhance independent function including seating, bathing aids etc • To assess, advise and facilitate, transport and mobility issues such as driving or coping with public transport • To facilitate the transfer of care, from acute stages through rehabilitation and discharge. • Liaise with support groups, and voluntary bodies. Information processing Cognition involves: • thinking • believing • perceiving • remembering • judging • planning • problem solving • monitoring Information processing Problems • Attention and memory • Sensation and perception • Planning, taking action and monitoring Attention and Memory Characteristics of normal attention: Ability to: – Focus – Divide – Maintain – Disengage, shift, re-engage How do you know if a participant has problems with attention? • • • • • • • fatigue more limited attentional capacity lack of awareness of “what goes on” slowed thinking & processing distractability/ poor concentration difficulty doing more than 1 thing at a time perseveration: inability to disengage e.g. step-up. Memory: main types DECLARATIVE/ explicit facts & figures (Thinking) PROCEDURAL/ implicit skills and operations (Doing) Different types of memory use different neural pathways Three Stages of memory 1. Sensory memory e.g. seeing visual demonstration / hearing prompts Forgetting problems: mainly due to lack of attention 2. Short-term/ working memory: e.g. trying to remember instructions prior to action taking place Forgetting problems: mainly due to information overload (interference), lack of rehearsal (decay) 3. Long-term memory: e.g. childhood memories Forgetting problems: mainly due to problems retrieving information How can you enable a participant with attentional/ memory problems to participate in exercise? Reduce distraction • Be selective and concise (e.g. don’t give too many instructions/ too much feedback • Encourage association with what is familiar (e.g. make it functional!) • Rehearse/ problem solve (over and over!) • Test understanding of information (i.e. can they actually do it?) • Use prompts (e.g. priming, cues) • Use “prosthetic memory” (e.g. exercise sheets, sticky notes in strategic places) Sensation and perception: Common problems with sensation Sensory impairments Inability to use information from touch, hearing, taste, proprioception or sight, e.g.: • Impaired depth distance Results in different image of an object received by the retina of each eye • Hemianopia Visual field defects http://www.dwp.gov.uk/img/visual-stroke.jpg Perception “Perception is the process through which raw sensations from the environment are interpreted using knowledge and understanding of the world so they become meaningful experiences”. • Is not a passive process simply absorbing and decoding information • The brain is bombarded with stimuli and actively creates coherent information about the world • Individuals fill in missing information and draw on past experiences to give meaning to what we see, hear or touch I cdnuut blveiee that I cluod aulaclty uesdnatnrd what I was rdaneig. The phaonmmeal pweor of the hmuan mnid. Aoccdrnig to rscheearch at Cmabrigde Uinervtisy, it deosn’t mttaer in waht order the ltteers in a wrod are, the olny iprmoatnt tihng is that the frist and lsat ltteer be in the rghit pclae. The rset can be a taotl mses and you can sitll raed it wouthit a porbelm. This is bcuseae the huamn mnid deos not raed ervey lteter by istlef but the wrod as a wlohe. Amzanig huh? Yaeh and I awlyas thought slpeling was ipmorantt! Common problems with sensation/ perception after stroke Impaired body schema Distortions in visual & proprioceptive image of own body. Inability to relate body parts to one another. Unilateral neglect/ visuo-spatial neglect/ hemi-inattention A definition: “Unilateral neglect refers to a difficulty in detecting, acting on, or even thinking about information from one side of space”. (Manly & Robertson in Halligan et al., 2003 p. 92) How do you recognise “neglect” after stroke? Neglect is a failure to attend to "what goes on" on the side contralateral to the afftected hemisphere,and may present as:• Having no notion of the affected side of the body • Being unaware of anything being "wrong" with the affected side (anosognosia) • Failing to recognise visual, auditory and/ or somatosensory stimulation • Forgetting food on plate • Unable to recall locations • Difficulty reading Can you recognise these neglect presentations? How can you tailor exercise for a participant with neglect? •Watch for obstacles (and other people!) •Monitor use of equipment •Monitor posture & movement, especially affected side •Prompt awareness of affected side •Coach use of neglected side •Encourage participants to verbally & visually self-cue Problems with planning & taking action Apraxia/ Dyspraxia: Disorder of learned skilled movements not caused by weakness, abnormality of tone or posture, abnormal movements such as tremors, & poor cognition comprehension & uncooperativeness. (Heilman 1979) What are these dyspraxia issues? Understanding Apraxia Normal Praxis involves: • Forming an idea: • Planning the action • Putting the plan into action: motor execution Apraxia may affect any of the above abilities. How do you know if a participant has apraxia? • May perform well in familiar surroundings • May perform well if the task is simple • May perform well if few items are required to complete task • Problems tend to occur when simple movements are combined in sequence to reach goal, and/or when tools are used. How can you enable a participant with apraxia to participate in exercise? Break activity into component parts Keep verbal cues to minimal Guide limbs through movements demanded by task Use visual prompts (e.g. cards) Work on gross patterns, then fine Provide appropriate verbal feedback Do not use mirror images Allow patient to succeed (goal setting) to reduce anxiety Executive Dysfunction and the Brain Working memory (recency) Monitoring Emotional associations Normal Executive function involves: Identifying priorities Identifying risks Forming a plan Carrying out plan Thinking creatively Thinking in abstract terms Managing time Engaging in complex social behaviour Reflecting Adjusting goals/ plans “Life management” How do you know if a participant may have executive dysfunction? Unrealistic plans; difficulty with goal setting Unrealistic expectations Launching into an activity Difficulty with time management Difficulty making a plan – and sticking to it until its completion Distractible May need prompting How do you know a participant may have executive dysfunction? Inappropriate behaviour (e.g. jokes, disinhibition, anger) Difficulty monitoring self – and changing when things go wrong Difficulty with problem solving; difficulty transferring what has been learned to a new situation (the plan does not quite fit) How can you adapt exercise for a participant with executive dysfunction? Assess: Risks: to self and others? Appropriate: to participate in a group? Suggestions for practice: Explain purpose of session and each exercise Provide a clear plan Monitor participant Prompt to work independently Manage behaviour if required OT - Summary and implications OT concentrates on : • Impaired attention and memory • Neglect • Altered sensation and perception • Apraxia and executive dysfunction OT aims to: Enable each patient to achieve the highest level of independence possible. • Exercise instructors need to understand these problems, assess associated risks and appropriately tailor each exercise for individuals. The Role of AHP in Stroke Rehabilitation Speech and Language Therapy Content The role of the SLT Communication difficulties and their impact Aphasia/dysphasia and dysarthria What you can do to help Learning outcomes By the end of this session, you should be able to demonstrate a sound understanding of: • the potential effects of stroke on speech and language capability • the potential impact of impaired communication on the ability to participate in exercise • the importance of good communication for your role as specialist exercise instructor working with participants with a stroke. Essential Reading • Further detail about the topics discussed in this session can be found in section L9 of the course syllabus. • Stroke Core Competencies for Health and Social Care Staff (the STARS project): http://www.strokecorecompetencies.org/node.asp?id=core Additional sources • Connect: the communication disability network: http://www.ukconnect.org/ • Speakability: http://www.speakability.org.uk/ The role of the SLT Provision of: Assessment for diagnosis of dysphagia and communication problems Information to patients, carers and staff about impairments/ abilities & guidance for safe swallowing and the facilitation of communication. an individualised speech assessment and language therapy care programme, e.g.: ―Support / regular re-assessment ―regular / intensive therapy Facilitating access to : support groups, such as Chest Heart and Stroke Scotland for and provision of augmentative and alternative forms of communication. other professional support, particularly where this will enhance recovery of/ compensatory strategies for communication function. Communication: Giving and Receiving Getting the message Message in Giving the message Message out What is the impact of a communication disability? • Difficulty in personal relationships • Social isolation and loneliness • Loss of identity • Loss of employment opportunities/financial security • Loss of leisure opportunities A Shared Problem? What methods of communication do you use in your day to day work with clients? Writing Speech & language Eye contact Drawing Communication Tone and volume of voice Body posture Gesture Facial expression Cognitive impairment Thoughts/ideas/knowledge Meanings / semantics Word store Aphasia Speech sounds Articulatory dyspraxia Speech Dysarthria (lips,tongue,voice) Motor programming Aphasia / Dysphasia • This is a language disorder • Affects both message in and message out for both you and the person with aphasia – Understanding speech and writing – Finding words and constructing sentences – Writing responses Example: http://www.strokecorecompetencies.org/labyrinth/mnode_client.asp?id=24422 &parent=24427&mode=remote&sessID=17D98D3C-4BD6-4D8E-AD0AB07B8344F6EB Dysarthria • This is a motor speech disorder • Affects: – message out for the person with dysarthria – message in for you as the listener Example: http://www.strokecorecompetencies.org/labyrinth/mnode_client.asp?id=24422&pa rent=24426&mode=remote&sessID=17D98D3C-4BD6-4D8E-AD0AB07B8344F6EB More subtle communication difficulties • Processing emotional content – Facial expression – Appreciating humour • Prosody – Flat tone – Understanding related to stress, rhythm • Conversational skills – Making inferences Main types of Aphasia and the brain • Non-fluent aphasia (Broca’s aphasia) • Fluent aphasia (Wernicke’s aphasia) Non-fluent aphasia (e.g. Broca’s) • • Speech comprehension: Largely intact, but may be compromised if speech is very complex Speech production: Difficulty producing speech: - Hesitant, non-fluent - Problems with word finding -> circumlocution - Limited vocabulary - Telegraphic style, simplified grammatical structure - Abnormal intonation - Often some dysarthria Fluent aphasias (e.g. Wernicke’s) • Speech production: - Fluent, but often nonsensical - Difficulty arranging sounds into coherent speech (“wort salat”) - New words (neologisms), jargon - Repetition of sounds • Speech comprehension: - Difficulty distinguishing sounds -> - Impaired comprehension -> - Patient often unaware (their comprehension is impaired!) Where is communication breaking down? • Message in – Am I understanding? – Is he/she understanding me? • • • • • Hearing Vision Thinking Environment Mode of communication • Message out – Am I putting this across well? – Has he/she had the opportunity to respond? • • • • • Mode of communication Language used Time Thinking Finding the right words Start problem solving • Is one form of communication more difficult than another? • Can this person use other forms of communication? • Could I adapt to make this easier? Key Points about communication disorders • Severity of varies from person to person • Pattern of problems varies from person to person • Communication difficulties and their impact changes over time • The impact on the individual and their family will depend on the people and their circumstances • Severity of impairment does not necessarily match the impact on activity and participation Some places for support Talk For Scotland Toolkit http://www.communicationforumscotland.org.uk/ Communication Support Principles • Principle 1: Recognise that every community or group may include people with communication support needs • Principle 2: Find out what support is required • Principle 3: Match the way you communicate to the ways people understand Communication Support Principles • Principle 4: Respond sensitively to all the ways an individual uses to express themselves • Principle 5: Give people the opportunity to communicate to the best of their abilities • Principle 6: Keep trying Effective Communication: Prepare • Plan how you might approach trying to get your message across • Make sure you have their full attention. • Choose a place where there is less distraction • Position yourself well to maintain eye contact. Effective Communication: Observe • Pick up and respond to signs of: • tiredness • Stress • frustration • low mood. • Display of emotion very common and can be an effective communication when there are no words. Effective Communication: Respect • Treat the person as an adult • Do not talk across them • Wait for a reply even it seems a long time in coming • Check if they want help – don’t assume • Be patient and be prepared to repeat things • Try to persist – don’t just give up without agreeing. Effective Communication: Check • Establish a reliable “yes” and “no”. • Thumbs up / down • Pointing to chart – tick and cross • Recap and check that you have understood each other • Do not ever pretend that you have understood – be honest. Effective Communication: Encourage • Accept any method of communication • Understand the aim is to get the message across – not demanding speech • Encourage the use of props • Be positive and as encouraging as possible. • Remember the value positive social contacts have on feelings of well-being SLT Summary You should have a good understanding of:• The role of SLT in stroke rehab • How good communication is key to your professional role • the diverse range of communication difficulties & how Aphasia is common after stroke • where to find the support and what is available. • How to apply principles of effective communication wherever possible – and keep trying...! Acknowledgements • Mark Smith - Consultant Physiotherapist • John Dennis – Neuro-rehabilitation specialist physiotherapist • Frederike van Wijck – Reader in Neuro rehabilitation • Pauline Halliday - Clinical Specialist Occupational Therapist • Helen Atkin - Clinical Specialist Occupational Therapist • Sheena Borthwick - Speech and Language Therapist L7b Referral Guidelines Part B: Physiotherapist’s Role and referral to exercise process 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 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 Voice Vision Other sounds Inner ear / vestibular system Painful stimuli Temperature Touch Proprioception / Joint position sense Neglect – clinical manifestations Balance Reactions • Equilibrium • Righting • Saving Work to produce base for purposeful, functional movements 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) Evidence-Based Therapy Practice? • The Evidence! • The Practice? Promising Physical Interventions – Cochrane • Treadmill Training: Moseley et al., 2009 • Electromechanical – and robot-assisted gait training: Mehrholz et al., 2008 • Electromechanical – and robot-assisted arm training: Mehrholz et al., 2009 • Force Platform: Barclay-Goddard, 2009 • Repetitive task training: French et al., 2009 • PT – Strengthening/Repetition, Pollock et al, 2009 • Constraint Therapy: Sirtori et al., 2009 • Fitness training: Saunders et al., 2009 Treadmill Gait Retraining with Unweighing after Stroke… Management of Subluxation •Handling • Shoulder Supports • • • • Strapping Alignment Facilitation Inhibition Interventions that should be routinely incorporated… • Lower limb strengthening • Provision of Ankle Foot Orthoses (AFOs) • Goal-orientated repetitive movement • Shoulder support / positioning • Early supported discharge for selected patients • Cardiovascular fitness - reconditioning A question about manual guidance.... The more “hands-on” the better? Hands on - Bobath • Concept based on clinical experience • Re-education of normal movement through facilitation • Inhibition of abnormal reflexes and movements • Most widely used approach in the UK Hands off - Motor ReLearning • Based on theories of motor control and biomechanics • (re)- acquisition of functional tasks • Teaching and learning techniques • Repetitive task practice • Independent problem solving Comparison • Similarities – Normal movement analysis and re-education – Brain able to adapt and re-learn – Discourage compensations • Differences – Facilitation v's active learning – Tone management vs. tone not an issue – Pattern centered v's functional tasks Note: boundaries becoming less distinct Strengths and Limitations Bobath • Does not require high level verbal comprehension • Manual handling issues • Limited to therapy sessions • High level of handling skill required • Bobath based on theory and observation – concept not supported by evidence Motor Re-learning • Functional • Patient more actively involved • Practice can continue out with therapy • Requires good patient comprehension • Motor re-learning additionally based on evidence in related fields Which do physio’s choose? • Comparison studies and systematic reviews show no difference between approaches (Pollock et al., 2009) • Difficulties with research due to variability in level of skill of clinicians and differences between patients So… • An eclectic approach allows adaptation to individual patients and situations • Balance of control between therapists and patient 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 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? 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 Referrer’s Assessment process (1) • • • • • • • • Health history Stroke medical history Medications Joint integrity & ROM Tonal status Sensory Status Movement components and quality Postural alignment (in exercise) Referrer’s Assessment process (2) • Balance capabilities • Activity status • ADL functional status • Exercise tolerance estimate • HR training capabilities • Cognitive and communication Status • Readiness to exercise • Review of exercise class types • Overall risk assessment Referral information 1 • • • • • Name, address & tel., dob, CHI GP Details NOK and contact details Health Problems Cardiac History: any left ventricular function or heart failure deficits • Other relevant medical history: any signs/ symptoms of respiratory failure, falls/ fracture history, back pain, joint replacement? Referral information 2 • • • • • • • • Time since stroke / date of stroke Functional levels post stroke Fatigue Hearing / visual impairments Other perceptual impairments Cognitive / perceptual impairments Use of aids – walking / other Medication relevant to exercise prescription and any limiting factors 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 Referral information 3 • • • • • • Name and location of rehabilitation service Dates How many classes attended Relevant tests completed and results Blood Pressure Agreed Training Heart Rate Referral information 4 • • • • • • • • Personal exercise considerations and limitations Tone / spasticity Contractures Splinting Difficulty donning/ doffing equipment Ability to self monitor/ pace self Readiness to exercise General activity levels L8a The role of the Specialist Exercise Instructor Part A: Assessment Procedures J Dennis/S Wicebloom Paul / S Dinan Young Content • • • • Criteria for inclusion Contra-indications to exercise Instructor Assessment of participant Referral back to healthcare Learning Outcomes At the end of this session, you should be able to: • List/ describe assessment process • Explain/ demonstrate understanding of assessment process and clinical risk • Apply knowledge to exercise class and each planned exercise • Discuss risks and procedures should anything be outside expected parameters What symptoms do you see? Depend on which part of the brain is affected • Motor symptoms • Sensory symptoms • Speech and language problems • Swallowing problems • Visual problems • Problems with memory and thinking • • • • Emotional changes Dyspraxia Perceptual problems Incontinence of urine and faeces Longer-term issues can be: • • • • Depression and anxiety Fatigue Neuropathic pain Loss of plan to action Inclusion criteria • Must have GP / other “permission”= agreed referral path • Passport / Referral must be fully filled out • Participant’s own responsibility is clear • Readiness to exercise Contra-indications -absolute – Recent electrocardiogram changes or recent myocardial infarction Systolic blood pressure >180mm Hg Diastolic blood pressure >100mm Hg – severe stenotic or regurgitant valvular heart disease – Uncontrolled arrhythmia hypertension and/or diabetes – Unstable angina – Third degree heart block or Acute progressive heart failure. – Acute aortic dissection – Acute myocarditis or pericarditis – Acute pulmonary embolus or pulmonary infarction --Deep venous thrombosis – Extreme obesity, with weight exceeding the recommendations or the equipment capacity (usually >159kg [350 lb.]) – Severe mental or physical disabilities The risk of a cardiovascular incident occurring is low! (Quittian M 1994, Mead G 2005,ACSM 2001 Rimmer J, 2005) Relative Contraindications – cautions Cardiomyopathy Moderate stenotic valvular heart disease Complex ventricular ectopy Uncontrolled metabolic disease. Left main coronary artery stenosis Electrolyte imbalance Tachyarrhythmias or bradyarrhythmias High degree atrioventricular block Mental or physical impairment leading to inability to exercise adequately (Quittian 1994, Mead 2005,ACSM 2001 Rimmer 2005) Assessment by Exercise Instructor:1 Confirm • Health History with participant (Revised PARQ) • Medication • Functional abilities • Stratify for risk during Exercise • Linked report from Referring PT (or agreed health professional) Identify • Activity History / current status • Support Networks e.g. Transport / family etc. • Interests / Preferences / Cultural etc. • Readiness to exercise Assessment by Exercise Instructor: 2 Confirming function-specific to session content: • • • • • • Baseline tonal status Gait, grip, balance & vision ( see “Tools”) Ability to interpret & follow instructions Ability to use equip: chairs / gym equip etc. Enquiry of capability to transfer from floor Record safety equip required: assist on/off bike etc. Assessment by Exercise Instructor:3 Confirming participant expectations and outcomes from exercise programme: • Agreeing initial participant centred SMART goals • Form long-term SMART goals • Give specific safety & cautions / exclusions • Give self monitoring safety guidelines Assessment Tools for Exercise Instructors: 1 • No of reps per exercise • Timed reps • Weight / resistance per exercise • Borg scale e.g. Breathlessness / effort scale • Pulse per CV exercise (where equip avail.) (meds?) • Weight monitoring • Goals achieved • Subjectives – stairs, fatigue, enjoyment, SOB, & other functional anecdotes. Assessment Tools for Exercise Instructors: 2 • • • • • • • 10 m walk 6 min walk Timed Balances – Tandem & SLS Timed up & Go Tinetti Balance & Gait (Falls Risk) Stroke Impact Scale Postural map Importance of links with Physiotherapist /referrer • Essential that if any of the following are noticed and problematic that the patient is reviewed by the physiotherapist • Repeated Falls reported • Increase in slowness of movement execution • Increase in weakness and / or deterioration in co-ordination • Changes in speech or facial looks • Unexpected deterioration in performance of planned exercise programme If the unthinkable happens... • Is it 999 - usual first aid & resuscitation? • If no, tell client to report ASAP to GP • Inform Site manager • Complete relevant section of incident report form • Inform referring party. • No return until GP agrees or re-referred L8b The role of the Specialist Exercise Instructor Part B: Programme Design John Dennis / Sara Wicebloom-Paul Content • • • • Planning the programme Cautions / considerations Programming guidelines Teaching skills Learning Outcomes At the end of this session you should be able to: • Describe how to design a class/ exercise • Demonstrate understanding of programming skills, and how they can be used to enhance a class and, • Apply them to stroke survivors across a range of impairments • Discuss adaptations for stroke-specific problems e.g. tonal changes. Therapy Led Approaches Planning the Programme • Exercises need to fit the stroke population • Exercises need to fit the individual • Risk areas need to be assessed for each participant • Document and remind yourself of these regularly. Exercise Programming Guidelines Teaching & Instructing Participants in Exercise after Stroke Adapting: “the condition specific adaptations (modifications) to session aims; structure, content,teaching and programming that need to be made to ensure optimal safety and effectiveness with participants after stroke” Tailoring: “the highly individual prescriptive solutions (adjustments,additions,exclusions) that are required to tailor the adapted exercise intervention to each participant’s health, functional and/or psychosocial/emotional needs” (Dinan (2007) Skills Active Level 4 NOS) Special Considerations, Cautions & Adaptations Start Point: • Low cardio-vascular fitness • Long rehabilitation period • Previous medical illness, inactivity prior to / since CVA • Movement disorders • Hemiplegia / other deficit -> decreased activity • Other neurological / cognitive / communication deficits What is Altered / abnormal muscle tone? • Altered tone is an abnormal response to stimuli, resulting in alteration in muscle function • Therapists refer to this usually as; Low (or Reduced) Normal High (or Increased) Abnormal Tone - Low Tone • Flaccid / poor muscle response • Poor movement control • Limbs / joints very prone to injury e.g. shoulder ↓ safety – insufficient generation of muscle force which may / may not be in the correct sequence. E.g. core stability muscles. Abnormal Tone – High Tone. • Over-activity of muscles • Presents with restricted movement speed, range, coordination, or altered pattern of sequencing of movement • May be high enough to prevent ‘voluntary’ control of movement - ‘spasticity’ • Joints, tendons very prone to injury in areas of lesser tone where mixed pattern evident e.g. anterior shoulder Considerations -----------------------------------0-------------------------------------Low Normal Tone High • Management of abnormal tone / associated reactions • Emphasise postural alignment / symmetry /core stability • Relationship between strength and tone • Prioritise functional training activities • Management of fatigue • Awareness of pain e.g. shoulder = Tailor to individual needs/function Key considerations • Individualised / tailored requirements • Upper limbs tend to require extensor related work • Lower limbs tend to be weaker in flexor patterns but need a proportion of both flexor and extensor related work • Trunk needs to be both extensor / flexor but aligned correctly, especially with pelvis. Exercise Programming Guidelines STARTER Session Aims • Improve all components of fitness • Prioritise cardiovascular, neuromuscular function • Improve balance/ posture/ gait/ functional strength/ performance of IADLs • Increase confidence • Motivate/educate ↑ habitual postural alignment • Provide opportunities to socialise • Achieve long and short term personal goals Session environment • • • • Risk assessment and access Equipment Toilets Refreshments / social area Session Content • • • • Simpler, fewer exercises Order of exercises Steady pace Step by step transitions – spacing, rest intervals etc. • Moderate intensity Programming Principles • • • • • • Multilevel, multi-activity FITT – Evidence based Choice: self / instructor directed options Involve stroke participants in planning, evaluation and delivery Buddy systems to empower and recruit Specialist trained exercise professionals Teaching Skills • • • • • • • • • ↑ time mgmt, preparation, patience ↑ teach and instruct posture ↑ skilful teaching position ↑ clarity of instructions - visual and verbal ↑ observation, adaptation, tailoring ↑ awareness of individual needs and exercise risk ↑ communication skills: sensitivity / firmness ↑ discussion time pre and post session ↑ skills for using touch in exercise guidance Exercise for participants after stroke must be evidence-based, safe, effective & enjoyable. References 1. Harold Rubin, MS, ABD, CRC, Guest Lecturer November 23, 1999 www.therubins.com. 2 Quittian M. : Rehabilitation in coronary heart disease. Value, indications and contraindications of exercise therapy] Fortschr Med.1994 Mar 20;112(8):97100. 3. Gibbons RJ, Galady GJ, Beasley JW, et al. ACC/AHA guidelines for exercise testing: executive summary. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Exercise Testing). Circulation. 1997;96:345-354. 4. Mead G, Dinan S. Smith M. et al Loughborough College Stroke Module. 2005.(restricted access) 5. Larry Derstine J. , Moore G. E. (eds)1997 ACSM’s exercise management for persons with chronic disease and disabilities. Champaign, IL.: Human Kinetics. Exercise & Fitness After Stroke: Specialist Instructor Training Course T6- The Impact of stroke: Disorders in motor control, perception, cognition, communication, emotion and motivation (student led workshop) A case study E is a 44 yr old lady who had a Stroke in (1991) resulting in a Right Sided Hemiplegia. Referred to the Community Stroke team urgently for psychological intervention. Initial assessment revealed by the patient, • She was previously Left Handed, worked as a barmaid, and has a 14 year old daughter. • History leading to CVA (self-blamed), was self administered increasing risk factors of: Contraceptive pill, Heavy Smoking (She did not count Passive smoking due to occupation), Not recognising signs of TIA from previous collapse resulting in 4 hr disability. Current social history is • Lives with daughter in ground floor flat with 5 steps • Not going out unless for essentials • Uses buses/taxis for distances greater than 200 yds • No social links except 1-2 friends that have stayed and visit. • Poor psychological state – feeling suicidal with plans for suicidal outcome. • Previous therapy was inpatient PT for approx. 2 months, and 2 years ago by PT at Community Out-patients. Present levels of function are: • Walking limited by pain in R>L legs which fatigue quickly then lose control. • AFO worn from 6/12 post CVA and reviewed yearly • Falls each month – mainly outside • Never had approp rehab for upper limb, don’t really use it other than to hold bag or use a steadier for other hand. Don’t see point in rehab now for it. • Dressing, grooming, toileting, showering, shopping, cooking , cleaning etc done by self but very slow due to fatigue and low mood. • EMcM was accepted for input by the team for urgent Psychological Ax and imminent PT. (as it was strongly suggestive was that mood was directly related to feelings of poor functional ability and altered self-image) Q. What would you see as most impactful issues? Q. If this lady presented for exercise how would you assess her and tailor your approach with relation to full inclusion in your class? (non-physical) L8c The role of the Specialist Exercise Instructor Part C: Generic Risks & Monitoring of Participants John Dennis Content • • • • Risk types Identifying risks Monitoring of participants Participant self monitoring Learning Outcomes At the end of this session, you should be able to; • List risk types / describe how they apply to exercise classes • Explain/ demonstrate understanding of risks and how to identify them • Apply principles of risk management and monitoring of participants • Discuss how to avoid risks in your classes. How do we know about risks? • From effective communication from referrer. (if necessary read between the lines) • From robust assessment by instructor • Close observation of participants & interactions with environment/ others (continued assessment) • By knowledge imparted • By knowledge internalised Risks Generic risks Clinical risks • • • • •Health •Falls •Impairment issues •Ability issues •Fatigue issues •Mode of delivery •Participant equipment •Added participant risks Environmental Equipment Modes of delivery Communication Generic risks Environmental • • • • Floor surfaces quality & space Obstructions/ fire exits/ alarms / phones Lighting Temperature / ventilation Generic Risks 2 Exercise Equipment • • • • • Damage Non slip surfaces Positioning of participants and equipment Handrails or chair backs Music equipment / volume Generic Risks 3 Modes of Delivery • Speed / Intensity / angle of action / Timing / Frequency of exercises • Time between each new exercise • Types of ex. Alternately • Groups or individuals • Spotting systems Generic Risks 4 Communication • Sight issues • Speech issues • Deafness • Confusion / cognitive impairment Clinical Risk 1 Health • Is this stable – cardiac, cognitive, performance, deteriorated since referral? • Is participant in appropriate class / location? • Any change in limb power / sensation / balance / tone? • Any change in endurance / fatigue? Clinical Risk 2 Falls • Causes variable – cardiac, sensory, balance, weakness, tonal • Need strategy to manage participants post fall Clinical Risk 3 Impairment Issues • • • • • • • Soft tissue changes Joint integrity Tone Weakness Other movement disorders Sensory Cognitive Clinical Risk 4 Ability Issues • Functional limitations • Clinical limitations e.g. co-morbid pathologies, medication issues • Balance deficits • Gait difficulties • Transfer difficulties • Cognitive changes • Behavioural changes Clinical Risk 5 • Fatigue Issues • Mode of delivery e.g. Too intense too soon • Participant Equipment Splints, footwear, spectacles, hearing aids, walking sticks, etc. Clinical Risk 6 Added Participant risks: • Behaviour – May be unaware of personality changes • Alcohol / drugs – policy is clear! Monitoring • • • • • • Tone Deterioration in performance Decreased co-ordination / balance Increased weakness Fatigue Co-morbitities / pathologies Monitoring 1. Risk / avoid Increased Abnormal levels of tone Strategies to reduce risks - Ensure Check posture at start/ during each exercise +/- secure limb Ensure lateral (outward) upper limb rather than medial (inward) rotation in resistance exercises Ensure self-assisted solutions Monitoring 2 • Low tone / subluxation at shoulder (and other joints) Joints, especially the shoulder - can be pulled out of alignment if the is a traction force greater than the participant can actively support. Monitoring 3 Risk / Avoid Strategy /Solution ↑ associated reactions (shoulder) “Correct posture” modalities / functional activities e.g. walk, bike, avoid rowing ↓ postural alignment / symmetry Stop exercise / check posture, alignment and resistance level. If reoccurs -> change activity Safety Risk / Avoid Strategy /Solution ↓ postural stability ↑ falls ↑ fatigue Avoid via Fartlek / active rests etc ↓ visual field / acuity / hearing Effective positioning of visual and aural cues kinaesthetic awareness/ sensory neglect Regular position shifts on equipment Cognitive / communication difficulties Ensure chair/ wall supported options Ensure Instructions simple and understood Consult person peers, family members for communication tips. Avoid any chances of missed educational opportunities Monitor closely the self monitoring of clients for: Pain Excess SOB Tonal change ROM Participant Self-monitoring • • • • • • Body mass index charts / weight Reminders on heart rate Blood pressure Timed balance No of repetitions / circuit components achieved Self feedback questionnaire T10 OUTCOME ASSESSMENT Why, what and how? Dr. Frederike van Wijck & John Dennis Learning Outcome Plan a safe, effective and appropriate intervention, i.e.: • Design and adapt appropriate progressive physical activity programme(s) after stroke using findings from the physical/ exercise assessments, etc… Demonstrate competency in relevant assessment procedures: • Monitor clients’ progress against agreed goals Content 1. Measuring outcomes: why? 2. Measurement: general principles 3. Measuring outcomes: what? – General framework: the ICF – Specific suggestions for the exercise-after-stroke setting 4. Using outcome measures in an exercise after stroke setting: how? Outcome measure – a definition: “ a test or scale administered by therapists that has been shown to measure accurately a particular attribute of interest to patients and therapists and is expected to be influenced by the intervention” (Mayo, 1995) 1. Measuring outcomes: why? 1. Screening: testing eligibility for exercise 2. Baseline assessment: establishing starting point for exercise programme 3. Follow-up assessment: charting change following exercise 4. Monitoring: to chart adherence and identify adverse effects This session: baseline and follow-up assessment using outcome measures 1. Measuring outcomes: why not? Common reasons for not using outcome measures: • It takes time away from the actual exercise • It is a burden for participants • It’s complex and a hassle for the instructors • You need training – we don’t have time for that • What do these measures tell you anyway – I know if something works! Do you??! Measuring transit is an example of SCIENCE VS. COMMON SENSE Science: “knowledge, ascertained by observation and experiment, critically tested, systematised and brought under general principles” Cambridge English Dictionary Common sense: “normal understanding, good practical sense in every day affairs, general feeling (of mankind or community)” Oxford English Dictionary MORAL OF THE STORY: • Common sense is not good enough for exercise instructors/ health care professionals; • Exercise/ rehabilitation/ health care needs to be based on science! Content 1. Measuring outcomes: why? 2. Measurement: general principles 3. Measuring outcomes: what? – General framework: the ICF – Specific suggestions for the exercise-after-stroke setting 4. Using outcome measures in an exercise after stroke setting: how? 2. Measurement: general principles Question: What makes a good measure? Anyone’s watch Salvador Dali’s watch Greenwich clock 2. Measurement: general principles Characteristics of good outcome measures: 1. Relevant 2. Valid 3. Reliable 4. Sensitive to change 5. Practicable 6. Results can be easily communicated (Wade, 1992) Characteristics of good outcome measures Relevance: the pertinence of the information Consider: Is this information useful – what does it tell me? What am I going to do with the information? Characteristics of good outcome measures Validity: the measure does what it is purported to do Consider: • Which idea/ construct does this measure address? Characteristics of good outcome measures Reliability: the measure gives the same result each time the same quantity is measured. Consider: – Intra-rater variation – Inter-rater variation -> Importance of protocols! (tutorial) Characteristics of good outcome measures Sensitivity to change: the measure can detect changes that are relevant Consider: • On what scale is/ are the item(s) scored? E.g.: – 0/ 1 or Yes/ No – 0-10 (Visual Analogue Scale) • Floor and ceiling effects Characteristics of good outcome measures Practicability: the measure is quick and easy to use Consider: • Amount of information required • Duration of the process • Complexity of the process • Burden on client (and you!) Characteristics of good outcome measures Communicability: The results can easily be reported and understood Consider: • Amount • Format • Standardisation of the information Content 1. Measuring outcomes: why? 2. Measurement: general principles 3. Measuring outcomes: what? – General framework: the ICF – Specific suggestions for the exercise-after-stroke setting 4. Using outcome measures in an exercise after stroke setting: how? 3. Measuring outcomes: what? A general framework for outcome measurement in clinical practice: the ICF International Classification of Functioning, Disability and Health “Aim of the ICF classification is to provide a standard language and framework for the description of health and health-related states.” http://www.who.int/classification/icf/intros/ICF-Eng-Intro.pdf ICF definitions Impairments are problems in body function or structure such as a significant deviation or loss. Activity limitations are difficulties an individual may have in executing activities. Participation restrictions are problems an individual may experience in involvement in life situations. ICF model http://www.who.int/classification/icf/intros/ICF-Eng-Intro.pdf The ICF: A general framework for outcome measurement in rehabilitation Activity Limitations Health Condition Impairments Participation Restrictions Outcome measures and the ICF Which outcome measures do you use in your work ? Where do they fit within the ICF? Can you think of one outcome measure in each of the ICF domains for a person who has had a stroke? Outcome measures for exercise after stroke Activity Limitations Example? Person with stroke Impairments Participation Restrictions Example? Example? 3. Measuring outcomes: what/ how? Suggested outcome measures for exercise after stroke specifically : • 6 min. walk/ 10 m. walk • Timed up and Go • Visual Analogue Scale (VAS) • Stroke Impact Scale + Register: for monitoring adherence Onto: Measuring Outcomes: how? • • • • http://figuredrawings.com/Animation.html 6 min. walk/ 10 m walk VAS Timed up and Go Stroke Impact Scale 6-minute walk test Construct: maximum walking distance in 6 minutes • Relevance: functional test for exercise endurance, O2 uptake • Validity: good • Reliability: high • Sensitivity: ? • Practicability: good • Reporting: easy (distance (m)) • Normative data for healthy people aged 60-89 yrs: 345-623 m (Steffen et al., 2002) Timed Up and Go Construct: time to stand up from arm chair, walk 3 m, turn, walk back, sit down • Relevance: functional test for basic mobility for frail elderly in community • Validity: acceptable • Reliability: moderate - high • Sensitivity: ? • Practicability: good • Reporting: easy (time (s)) • Normative data for healthy people aged 60-89 yrs: 7-12 s (Steffen et al., 2002) VAS Construct: person’s perception of a particular construct • Relevance: depending on what is assessed. Can be used to assess individual goal attainment • Validity: generally good • Reliability: generally high • Sensitivity: high • Practicability: caution with stroke, esp. higher cortical problems and neglect (Price et al., 1999) • Reporting: easy Correct use of VAS in stroke Price et al. (1999), p. 1359. Correct use of VAS in stroke Price et al. (1999), p. 1360. Stroke Impact Scale Construct: the person’s perceived impact of stroke across range of domains (incl. movement, ADL, cognition, communication, emotion, participation) • Relevance: high • Validity: good (devised with target population) • Reliability: moderate – very high • Sensitivity: each item on 5-point scale + one VAS item • Practicability: mixed • Reporting: time-consuming but can be done by mail • Normative data: not applicable • Interpretation: change between 10-15 points clinically meaningful (Duncan et al., 2003) Pitfalls of measurement – and how to fix them Problem • Error: – Systematic – Random • Wrong signals: – False + – False - Solutions: • Errors: – Calibrate your instrument – Use standardised protocol • Wrong signals: – Check sensitivity – Verify with other information Summary Outcome measures are necessary to: • Establish baseline for exercise • Evaluate change following exercise -> science underpinning your work EVIDENCE BASED PRACTICE Choosing your Outcome Measure how to go about it NO T Safe? YES H NO I Relevant? YES N K NO Science Robust? A YES NO Practicable? YES GO G A I N References • DUNCAN, P. W., LAI, S. M., BODE, R. K., PERERA, S. & DEROSA, J. (2003b) Stroke Impact Scale-16: A brief assessment of physical function. Neurology, 60, 291-6. • DUNCAN, P. W. Stroke Impact Scale (SIS). Rehabilitation Outcomes Research Centre, US Department of Veteran Affairs. Available from: http://www1.va.gov/rorc/stroke_impact.cfm (last accessed 05/12/05). • WADE, D. T. (1992) Measurement in Neurological Rehabilitation, Oxford, Oxford University Press. • WORLD HEALTH ORGANISATION (2001). International Classification of Functioning, Disability and Health. Available from http://www.who.int/classifications/icf/en/ L10 CHANGING BEHAVIOUR: EXERCISING IN THE LONG RUN John Dennis & Frederike van Wijck Questions • What motivates you to continue to exercise? • What do you think may motivate a person who has had a stroke to: – take up exercise, – continue to exercise? • What may the barriers to exercise be and how can you help to overcome these? Learning outcomes At the end of this course, you should be able to : • demonstrate a sufficient understanding of exercise behaviour, and goal setting in relation to stroke • demonstrate an ability to apply this effectively in practice with people who have had a stroke • “design and adapt appropriate progressive physical activity programme(s) after stroke using findings from the physical/exercise assessments, medical information, national good practice guidelines, principles of exercise training, consultation, patient/client goals....” L4 Skills Active Stroke NOS Content 1. 2. 3. 4. Introduction: Motivation: what is it? Motivation after stroke Case study 1 Motivation: how can it be understood? • • Sources of Motivation Theories of Motivation (Drive Reduction and Incentive) 4. Enhancing motivation through goal setting 5. Case study 2 6. Summary and implications for exercise instructors MOTIVATION: a definition • Motivation refers to the dynamics of behaviour; factors that affect the: initiation direction intensity persistence of behaviour MOTIVATION AFTER STROKE Common problems with motivation and emotion after stroke: • Anxiety and depression: > 50% of stroke patients in hospital • Apathy: < 25% Gainotti, G. In: Halligan et al., (2003), p.378. MOTIVATION AFTER STROKE Following your stroke, you experience… • • • • Weakness down one side of your body Difficulty expressing yourself Fatigue Depression And now your GP wants you to exercise….. Factors that may affect adherence to exercise - in stroke: • Lack of research to begin with! • Four most common barriers (Rimmer et al. 2008): – – – – Cost of the program Lack of awareness of facilities Lack of transportation Lack of knowledge of how to exercise • Common concerns (Wiles et al. 2008) – Risk and safety – Monitoring, support and interaction Factors that may affect adherence to exercise - in stroke: • Key motivators (Carin Levy et al. 2009): – Enjoyment – Something to look forward to – Perceived improvements, e.g.: • physical functioning: achievement • confidence • quality of life – Opportunity to socialise Case Study One M is a 44 yr old lady Stroke 17 years ago (1991) Right sided hemiplegia. Referred to the team urgently for psychological intervention. Initial assessment revealed: • • • • Left handed, previously worked as a barmaid Has 14 year old daughter History leading to CVA (self-blamed)... Increasing risk factors of: Contraceptive pill / heavy smoking, and she did not count passive smoking due to occupation / not recognising signs of TIA from previous collapse resulting in disability for 4 hour duration. Current social history: • • • • Lives with daughter in ground floor flat ; 5 steps Not going out unless for essentials Uses bus/taxi for distances greater than 200 yds No social links except 1-2 friends that have stayed and visit. • Poor psychological state – feeling suicidal with plans for suicidal outcome. Present levels of function: • Walking limited by pain in R>L legs which fatigue quickly then lose control. • AFO worn from 6/12 post CVA and reviewed yearly • Falls each month – mainly outside • Never had appropriate rehab for upper limb; “doesn’t really use it” other than to hold bag or use as steadier for other hand;“doesn’t see any point in rehab for it now”. • Dressing, grooming, toileting, showering, shopping, cooking , cleaning etc. done by self but very slow due to fatigue and low mood. Goal setting 1 • Initial goals were easily achievable in order to reinforce success of input and to allow her sense of achievement to tackle her mood levels. • Start and maintain a regular exercise programme in house • Start walking to shops • Reports back on use of right hand during ADL’s and attempts to type Goal setting 2 Later goals were about bigger issues e.g. • Improve self-belief/ self – worth • Seek future employment / improve health • Go swimming regularly (enjoyed prior to CVA) • Improve walking style > reduce worry / anxiety levels of feelings towards how others might see her. • Look at possibilities of training towards some form of employment (voluntary to start with) Where did M get to? • Completed computer course – uses both hands for some tasks • Looking at possibilities of 9 hours voluntary work • Gait: much smoother / more efficient • Psychological state: stable • Weekly swimming • Linked up with 2 regular friends for weekly trips out. MOTIVATION: HOW CAN IT BE UNDERSTOOD? SOURCES OF MOTIVATION • General sources: – Intrinsic – Extrinsic • More specific sources: – Biological: e.g. survival – Emotional: e.g. pleasure, fear (avoidance) – Cognitive: e.g. expectation, belief – Social: e.g. peer pressure, cultural norms and values How may this explain M’s motivation to exercise? DRIVE REDUCTION THEORY OF MOTIVATION Assumption: Behaviour is geared towards maintaining physiological homeostasis. Homeostasis Steady state/ equilibrium/ set point] Primary drivers are of a biological nature DRIVE REDUCTION THEORY OF MOTIVATION: the basic idea CONTROL SYSTEM Homeostasis ( 'omeo stasis) Steady state/equilibrium/ set point SENSOR Homeostatic system: . Claude Bernard, physiologist (1813-1878) Drive Reduction theory and exercise Start from a realistic level, based on current; • Impairments • Abilities (activities) • Co-morbidities • Motivational / personality characteristics Incentive theory and exercise Incentive : “tending to incite” Assumption : behaviour is goal-directed, geared towards positive outcomes. Important factors: - expectancy - value of outcome to individual ENHANCING MOTIVATION THROUGH GOAL SETTING Why? What? How? By whom ? Goal setting • Why? Provide incentive, focus attention, take ownership of the rehabilitation process, enhance self efficacy • What? short term -> long term SMART! • How and by whom? – Discuss… (further reading: Wade 2009) Goal setting: how and by whom? • • • • • • • • Ask participants about their goals (LT, ST) and needs Prioritise Negotiate – where necessary Agree SMART goals and - if participant agrees, inform family/ carer Plan route to success Chart the goals Assess goal attainment (participant feedback, outcome measures) Adjust original goals – if necessary Case study BT • BT 59 years of age – x 3 TIA’s and 3 small hemorrhagic bleeds 18 months ago resulting in; dysarthria, visual impairment at the time majorly impacting on balance and confidence. • Reports making ‘full’ recovery (no obvious impairments) • Reports weakness R side • Reports loss of confidence • “Just wants to get back to normal and get her life back” • “I need to get back into my exercise classes” • Reported feeling ‘anxious’ about seeing everyone again • Gained 2 stone in weight since stroke • Has been important for her to come off all medications Goal setting • BT recently sought advise from GP to return to exercise, this request has been supported. • On meeting BT in first consultation, what would be included in your discussions with her? what else do you need to know in order to formulate and agree realistic goals? • What do you think might be reasonable goals for exercise? • Do/what if your recommendations conflict with her goals? BT Goals v’s Ex Prof Recommendations? BT wanted to resume previous exercise classes: (Regular ETM sessions/choreographed routines/hand weights - approx.. 12-16ppl) She perceived she was ‘back to normal’ and keen to get going in classes and in the gym She wants to exercise everyday Case study BT Questions to BT: How active have you been in the last 18 months/3 months When was the last time you got out of breathe Are you performing all of the daily tasks that you did prior to the stroke How do you feel being back in the studio today How will you feel meeting everyone in the group again Would you feel comfortable returning to your usual class tomorrow? Do you have any concerns about returning to the class Case study BT Agreed plan for next 2 weeks (as then going on holiday); • Attend gym x2 pw initially in order that exercise duration can be flexible and self managed • Agreed not to exceed exercise programme discussed • After performing a warm up and 3 minutes on cycle, BT commented “ I don’t think I can go back to my class afterall…do you?” • BT has attended a posture balance and fitness session with much fewer participants, background music and tailored exercise, encouraged to manage own rest periods - and completed 60 minute class no problems SUMMARY AND IMPLICATIONS FOR EXERCISE INSTRUCTORS 1 Start goal setting from a realistic level, based on : – Impairments, Abilities (activities), Co-morbidities – Motivational / personality characteristics Taking into consideration: – Level of self-efficacy – Stage of readiness – Previous and projected participation levels – Expected outcome from chosen interventions Working towards: – Personally relevant goals SUMMARY AND IMPLICATIONS FOR EXERCISE INSTRUCTORS 2 • Find out from your participants: – What motivates them? Consider all sources of motivation. – What barriers do they perceive? • How can you tip the balance: – Increase motivators – Lower the barriers? L11 Exercise and fitness training after stroke Service implementation and evaluation: how it works in practice Dr. Catherine Best, Dr. Frederike van Wijck, John Dennis, Dr Susie Dinan-Young & Rebecca Townley Content 1. 2. 3. 4. 5. 6. Introduction EAS Services : a survey 2010 Guidelines for best practice Professional requirements EAS Service Model Summary 1. Introduction – what ? Evidence of the need for Exercise and fitness training after stroke (EAS) services - Research: exercise can be beneficial after stroke - Royal College of Physicians: recommendations for exercise after stroke - English & Scottish Government: policy documents on exercise after stroke - Many medical & AHP refer stroke patients for exercise - Many people after stroke self refer for exercise…. 1. Introduction – who ? EAS service professionals & stakeholders - National : the Public Health Depts of the 4 countries The Regional Health Authorities PCTs/GP Consortia/Community Health Partnerships etc Commissioners Stroke Management Clinical Networks (Stroke MCN) Stroke secondary & primary medical & AHP professionals ( refers) & researchers (evaluation) - ER Co-ordinators & exercise professionals - Stroke participants/patients - …. 1.Introduction-Where? What? How? EAS services : some questions • • • • • • Where do people with stroke go for exercise? What kind of exercise services are available? How do they run? What do they provide? How do we know if they are effective? Safe? How do we know if the exercise professionals are qualified? Many questions – but no satisfactory answers, until… Content 1. 2. 3. 4. 5. 6. Introduction EAS Services : a survey 2010 Guidelines for best practice Professional requirements EAS Service Model Summary 2. EAS services in Scotland: a survey Scotland-wide scoping exercise: Aims: • To identify content and structure of EAS services in Scotland • To identify and disseminate best practice Methods: • Internet survey • Interviews with selected services ( 2010 Best, Mead, van Wijck, Smith, Dennis, Dinan-Young, Fraser, Donaghy) 2. EAS services in Scotland: a survey Results : ( findings) 1. 14 stroke-specific with an aerobic component: Rehabilitation extensions; to aid transition to community exercise (3) Leisure centre services ; to encourage PA in community (3) Charity collaborations; respond to members requests (8) 2. Significant variation in content, FITT, qualifications, training and experience, referral criteria and process Led By Rehab Setting: PT/stroke nurses with assistants Leisure Setting: EP’s in collaboration with PT Charity Collaborations: EP’s, Personal Trainers PT Referral HCP HCP none Inc/ Excl medical criteria variable none Evaluation Standard outcome measures varies; may include BP,physical performance, activity Q none Duration 8-10 weeks ongoing ongoing Cost Free approx. £3 per session £0 - £2 Staff ratio 1 to 7 1 to 5 1 to 10 Other exercise and physical activity options • ARNI Trust: Functional training after stroke (L4 CPD & AHP) • + NON stroke specific – – – – – – ***Mutipathology exercise classes** Cardiac rehabilitation Disability swimming groups and disability sports groups Generic exercise referral schemes Extend, class diamonds (exercise for older people) Personal trainers • Without aerobic evidence for stroke – Chair-based exercise in stroke charity support group meetings – Pilates, yoga, tai chi etc. Content 1. 2. 3. 4. 5. 6. Introduction EAS Services: a survey. 2010 Guidelines for best practice EAS Service model Professional requirements Summary 3. EAS: Guidelines for Best Practice Key guidelines for EAS service providers: • • • • • • • Governance Preparation and risk assessment for exercise Referral systems and procedures Pre-exercise assessment and ongoing review Specialist Exercise Professional training Content, frequency and duration Record keeping 3. EAS: Guidelines for best practice Other good practice points: • EP to make personal contact before 1st session • Carer/ volunteer to accompany client to 1st session • EAS service to: – – – – Provide transport as appropriate Arrange in-service staff ‘stroke awareness’ training Refer back for Orthotics etc assessment if required Invite trainee EPs/ HCPs (does not affect staff: client ratio) 3. EAS: Guidelines for best practice Available to download from: http://exerciseafterstroke.org.uk/ All UK Stroke MCNs and Cardiovascular Networks, the Stroke NGOs and the CSP,ACPIN, Skills Active & REPS were emailed direct with these guidelines in November 2010 Content 1. 2. 3. 4. 5. 6. Introduction EAS Services: a survey. 2010 Guidelines for best practice Professional requirements [exam] EAS Service model Summary 4. EAS : Professional requirements Whatever the country ( England, Scotland, Wales, Ireland ) & type of Ex Referral service model, there are a number of ethical and professional standards that all Exercise Professionals must adhere to when working with all patient populations. •See Section 8.10 in course syllabus [exam] 4. EAS : Professional requirements 3. National Skills Active Physical Activity Standards for People after Stroke (Unit D561): • Design and agree a physical activity programme with people after stroke • Deliver, review, adapt and tailor a physical activity programme with people after stroke This Exercise after Stroke course is based on these National Occupational Stroke Instructor Standards Content 1. 2. 3. 4. 5. 6. Introduction EfS Services: a survey. 2010 Guidelines for best practice Professional requirements EAS Service Model Summary 5. EAS: Referral Process • See page 18 Fig.2 of Best Practice Guidance for the Development of Exercise after Stroke Services in Community Settings 5. EAS: Service Model Management • See page 13 Fig.1 of Best Practice Guidance for the Development of Exercise after Stroke Services in Community Settings 5. EAS: Local Service Model Content 1. 2. 3. 4. 5. 6. Introduction EAS Services: a survey. 2010 Guidelines for best practice Professional requirements EAS Service Model Summary 5. EAS Service Implementation: Summary • EAS is a relatively new and fast developing area • Three different service models UK wide • Suggested guidelines for best practice for EAS services (incl. methods for service evaluation) • Single professional, ethical and medico-legal standards for EAS ExP – wherever the patient lives! Essential Reading Further detail about the topics discussed in this session can be found in section L8 of the course syllabus. Please Note: information on professional, ethical and medicolegal standards is core assessment material