Fatigue, fitness and exercise

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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
•
•
•
•
•
•
•
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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?
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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:
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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?
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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!
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Smooth
Efficient
Coordinated
Graded
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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
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•
•
•
Impairment levels ?
Activity capabilities?
Participation restrictions?
Other risk factors?
Risks ~ the Individual:
•
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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)
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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
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•
•
•
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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
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•
•
•
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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
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