Exercise and Fitness Training After Stroke
Specialist Instructor Training Course
WELCOME
1.
2.
3.
4.
5.
6.
7.
Introductions
Course Background
Learning outcomes
Summary of Content
Approaches to learning
Study materials
Assessment
Intro/Resources Check
• Pre-course reading & welcome letter/observational visit letter
• (Stroke competencies website and online learning)
• EfS Manual;
Summative assessment pack
Hard copy of power-point presentations
Tutorials and directed learning pack
Course time table
STARTER circuit cards
Exercise after Stroke
Specialist Instructor Training Course
Course Development Project Team:
Prof.Gillian Mead
Prof. Marie Donaghy
Dr. Frederike van Wijck
Dr. Susie Dinan-Young
Mr John Dennis
Mr Mark Smith
Ms Sara Wicebloom-Paul
Ms Bex Townley
What is a stroke?
A stroke occurs when an artery supplying the brain
either blocks or bursts
Course Background
Physical fitness is essential for
physical activity. Important
components of physical fitness for
health gain especially after stroke;
• Cardiorespiratory
(or endurance)
• Muscle strength and power
In the UK:
•
•
•
•
Every year, 150,000 people have a stroke
Stroke: 3rd most common cause of death
Stroke: most common cause of severe disability
More than 250,000 people live with stroke-related
disabilities
Following a stroke, many people experience:
-
Reduced strength, mobility, endurance
Difficulties with walking, balance and (ADL)
Problems with sensation
Problems with thinking and planning
Problems with emotion and motivation
Communication difficulties
Cardiovascular fitness may be 40% below that of
healthy counterparts
What is being done ?
- Stroke prevention
- Research: exercise may be beneficial after stroke
- Royal College of Physicians: recommendations for
exercise after stroke
- Scottish Government: policy documents on exercise
after stroke
- Many consultants refer stroke patients for exercise
- Many people refer themselves after stroke ….
BUT…
• There are no ‘standardised’ national stroke-specific exercise
referral schemes
• There is only one Exercise after Stroke specialist exercise
instructor training course endorsed by Skills Active for REPs at
Level 4, this one.
• The ARNI Functional Training After Stroke Course focuses on
functional tasks and experiential strategies
The Evidence Base
• Published evidence on need for exercise after stroke
• Published research on effects of exercise after
stroke:Literature,Team’s own research (The STARTER trial)
• Template: DoH development-funded Exercise for the
Prevention of Falls and Injuries
• Relevant educational standards
Educational Standards and Benchmarks
 QMU, Edinburgh accredited (SHE Level 2 Undergraduate)
 Scottish Credit and Qualifications Framework level 8 (20 credit)
 Skills Active standards:
Design and agree a physical activity programme with people after stroke
Deliver, review, adapt and tailor a physical activity programme with people after
stroke
 Register of Exercise Professionals Level 4, Skills Active endorsed
 Chartered Society of Physiotherapy benchmarks
 The Quality Assurance Agency for Higher Education.
Key learning outcomes
At the end of the course, you should be able to:
• Demonstrate a sound working knowledge and understanding
of:
– Stroke
– Evidenced based exercise after Stroke
• Design, deliver and evaluate safe and appropriate exercise
programmes for people after stroke
• Communicate and refer effectively
• Observe relevant professional standards including; ethics,
professional boundaries and health & safety regulations.
Course Content
Days 1 & 2
• Stroke; impact, incidence and classification
• Specialist instructor advanced skills for level 4
• Safe effective Circuit management for participants with stroke
• Guidelines for exercise referral, introduction
Days 3 & 4
• Programme design and delivery
• Adapting and tailoring exercise, therapy led approaches
• Problem solving, risk assessment, emergency procedures
• Outcomes measures (OM’s)
Day 5
• Theory paper
• Communication, Changing behaviour and goal setting; applied
• Practical (formative) assessment
• Implementation
Day 6 (7)
• Summative Practical Assessment , session plan and case study submission
Approaches to Learning
• Amount of credit: 20. 200 hours of student work in total
• Approach to learning and teaching:
Problem solving:
– 43 hours of contact time
• keynote lectures by specialists
• practical sessions
– 157 hours of (self) directed learning
Study materials
•
•
•
•
•
•
Course Manual
Summative assessment pack
Directed Learning Pack
Power-point presentations
Other literature, resources: book chapters, journal papers
Student page on website
• www.laterlifetraining.co.uk/login.php
• Username: EfS_Student
• Password: EfSLLTStudent20096
Summative Assessment
Day 5
• One 2 hour theory paper; 30 MCQ and 5 short answer
Day 6
• One 30 min practical assessment STARTER class and selfevaluation
• A one hour STARTER session plan (week 7/8)
• Case Study;
- One 1500 word coursework based on a clinical case study
(video based, access via website)
• Detailed information in your Candidate Assessment Pack
• Observational visit to stroke setting and short report – not
marked but must be completed
Acknowledgements
• Reference Group to ensure that the work was robustly
scrutinised, contains academic national leads in the field of stroke,
medicine, therapy,nursing, education, research, social services and
patients for the course but continued to be the group for the guidelines
• Funders:
-Scottish Government
-Chest Heart Stroke Scotland
-Edinburgh Leisure
-Glasgow Health Board
EXERCISE AFTER STROKE
Specialist Instructor Training Course
L6
Exercise after stroke:
theory and evidence
Overview of Session
• What is fitness training?
• How randomised controlled trials are designed
• Systematic review of fitness training after
stroke (2004)
• STARTER
• Systematic review (2008)
• Contraindications to exercise training
Learning outcomes
After this session you should be able to:
• Describe what is known, and what is not known about
the effects of exercise on stroke recovery.
• Discuss the strengths and limitations of the evidence
for exercise after stroke
• Explain how the STARTER trial informs the current
course
• State the recommendations for exercise after stroke
• List the contra-indications for exercise after stroke
Physical Fitness
A set of attributes which people have or achieve,
that confers the ability to perform physical activity;
Cardiorespiratory fitness (central and peripheral components)
Muscular strength (maximum force that can be generated by
A muscle) and muscle power (rate at which muscular force
Can develop during a single muscle contraction)
Body composition (relative amounts of muscle and adipose
tissue)
Physical Fitness Training
• Planned, structured regimen of regular physical exercise
deliberately performed to improve one or more components of
physical fitness (UHDHHS 1996)
• Physical fitness training after stroke may, in theory
– Improve function
– Reduce disability
– Improve quality of life
– Improve mood
– Reduce fatigue
– Reduce the risk of falls
– Improve vascular risk factors and so reduce risk of
recurrent stroke and death
Design of a Randomised Controlled Trial
Patients
Baseline assessments
Randomised
Intervention
Control
Assessments at end of interventions
Systematic reviews and meta-analyses
• Combines results of all trials of the same (or
similar) intervention
• Provides a more precise measure of the
effectiveness (and risk) of an intervention than
a single trial
• Widely used to guide clinical practice
Cochrane Systematic Review Physical
fitness training after stroke
How?
Extensive literature search and scrutiny of trials by 3
Reviewers
We found;
12 trials (289 patients) BUT
Only 4 trials (60 patients) used ‘mixed’ training
Only 2 trials (33 patients) of adequate length to improve
fitness
Little information on feasibility
More trials needed
Saunders Greig Young Mead 2004
What has happened since 2004?
• More trials have been performed, including our own
STARTER trial
• A further systematic review and meta-analysis has
been performed to determine the effect of physical
fitness training on
–
–
–
–
–
–
–
Death
Dependence
Death and dependence
Disability
Physical function, physical fitness
Mood, fatigue
Whether benefits are retained after training complete
Aims of STARTER
• Determine feasibility of physical fitness
training after stroke
• Obtain data about the effect of physical fitness
compared with an attention control
intervention
• Use STARTER results to design a bigger trial
STARTER design
Independently ambulatory, completed rehabilitation, no confusion or
contraindications to exercise?
Baseline assessments
Randomised
Fitness training
Relaxation
(both three times a week for 12 weeks)
Repeat assessments at end of interventions and 4/12
Assessments
• Disability
Nottingham extended ADL
Functional independence
measure
• Function
Sit to stand
Timed up and go
Functional reach
Elderly mobility scale
Rivermead motor index
• Quality of life (SF-36)
• Mood (HADS)
• Physical fitness
Comfortable walking
velocity
Walking economy
Leg extensor power
Important baseline characteristics
Exercise (n=32)
Relaxation (n=34)
Age (mean, SD)
72 (10.4)
71.7 (9.6%)
Number (%) men
18 (56)
18 (53%)
TACS
PACS
LACS
POCS
uncertain
1
16
10
4
1
1
16
9
8
0
Time between stroke and
baseline (median, IQR)
171 (55-287)
147.5 (78.8-235.5)
Median (IQR) FIM
117.5 (114-121)
117.5 (112.8-122)
Fitness training intervention
• Devised by a Clinical Exercise Instructor in
collaboration with a Specialist Stroke Physiotherapist
(Mark Smith)
• Progressive in duration and intensity
• Warm up and cool down
• Cycling, marching, stepping, staircase, ball raises,
chest press
• Resistance band exercises, sit-to-stand, arm press
Relaxation (attention control)
•
•
•
•
Same venue as exercise class
Same instructor
3 times a week, 12 weeks
Performed seated
– Deep breathing
– Progressive muscle relaxation (no muscle
contraction)
– During 12 weeks: progression
Feasibility: recruitment
Ambulatory patients assessed
(RIE, Liberton and AAH)
Eligible
Agreed to take part
301
147
80
changed their minds
developed contraindications
died
-14
-11
-1
Additional Recruitment (WGH)
Total
12
66
Feasibility: attendance
• Median number of classes attended was
– 36 (IQR 30 to 36.75) for exercise
– 36 (IQR 30.5 to 37) for relaxation
• At post-intervention assessment
– 64 (97%) attended 1st post-intervention
assessment
– 62 (94%) attended 2nd post-intervention
assessment
Outcomes in exercise group
Baseline
1st postintervention
2nd postintervention
Role physical (SF36)
75.0
90.6*
78.1
General health (SF-36)
62
72*
63.5
Vitality (SF-36)
53.0
58.9*
55.3
Mental health (SF-36)
70
80*
75
Role emotional (SF-36)
87.5
100*
100
Functional reach (cm)
24.5
28.5*
26.5
Timed up-and-go (s)
12.3
11.4*
12.2
Sit to stand (s)
1.49
0.95*
1.11*
Leg extensor power (affected leg)
(w/kg)
1.01
1.19*
1.18*
Comfortable walking speed m/s
0.66
0.73*
0.70
Walking economy (VO2 ml/kg/m)
0.128
0.126*
0.127
Results are mean or median, * p<0.05 from baseline.
No statistically significant changes in other variables
Outcomes in relaxation group
Baseline
1st postintervention
2nd postintervention
Mental health
70
80*
80*
Leg extensor power
(unaffected leg)
1.12
1.26*
1.27*
Comfortable walking 0.67
speed (m/s)
0.74*
0.74*
Mean or median, * p<0.05 from baseline.
No statistically significant changes in other variables
Differences between groups
1st post-intervention assessment
Exercise better than relaxation
Quality of life: role physical
Physical function: timed up and go
Physical fitness: walking economy
2nd post-intervention assessment
Exercise better than relaxation
Quality of life: role physical
Qualitative sub-study (benefits)
• Enjoyment
– The class itself
– Socialising
– Getting out of the house
• Tuition
– Endless praise for Irene (the exercise instructor)
– Participants felt ‘well looked-after’
– Irene had a major role in the success of the class
Qualitative sub-study (benefits)
• Perceived benefits from both classes:
– Physical recovery
– Getting back into a routine
– Improved mood and wellbeing
– Confidence
• Long term effects
– Learning new skills
– Practising at home
– Attending other classes
To quote one participant…….
It was back in November and it was no joke
That was the time that I suffered a stroke….
Round came time for relaxation class
Others were there who’d been in the same boat…
The things we learned were useful and good….
The lady who ran the class is an excellent woman
Her voice is gentle and booming……
Thanks to the excellence of the wonderful Irene
Conclusions
• Trial design was feasible
• Exercise was more beneficial than relaxation
for some outcomes
• Not all benefits were maintained long-term
• These results are included in the updated
Cochrane systematic review and meta-analysis
Physical Fitness Training
for Stroke Patients
Protocol first published:
Cochrane Library, Issue 4, 2001
Review first published:
Cochrane Library, Issue 1, 2004
Review updated:
Cochrane Library, Issue 4, 2009
Cochrane Library, Issue 4, 2011
Cochrane Library, Issue 4, 2013
Systematic Review
Literature Search
MEDLINE, EMBASE,
CINAHL, SPORTDiscuss
electronic databases
Hand
searching
Pending
references
Other databases
and websites
Screened
N=7508
Excluded
N=29
Not relevant N=7433
RCTs Ongoing
N=16
Cardio
N=22
n=995
RCTs included
N=45 n=2188
Resistance
N=8
n=275
Cannot be classified
N=17
Mixed
N=15
n=918
13 new trials +
32 previously
included
Number of patients randomised in trials of
physical fitness training after stroke
Research in exercise after stroke is increasing…
Trial participants
• Average age 64 years (i.e. younger than the
median age of stroke onset of 72)
• 60% men, 40% women
• Majority were ambulatory
• Time since stroke: 8.8 days to 7.7 years
Results
Primary & Secondary Outcomes
• Primary
Effects of training on death & dependence unclear
Exercise improves of disability
• Secondary
Exercise improves physical fitness
Exercise improves walking
Exercise improves balance
Other benefits unclear
Results
Secondary Outcome Measures
Outcome
Cardio
Strength
Mixed
Adverse events
?
?
?
Physical fitness
VO2
Strength
?
Walking

ns

Function
Balance
?
?
Quality of life
?
?
?
Mood
?
?
?
Results
Maximum walking speed (5-10 metres)
Cycle Ergometer
Treadmill
Treadmill
Treadmill
Treadmill
Treadmill – backward walking
Treadmill – forward walking
Treadmill
Over-ground walking
Treadmill
Circuit training including walking
Treadmill
Circuit training including walking
Treadmill
Treadmill + over-ground walking
Treadmill + over-ground walking
+ 7.37 m/min 95%CI [3.70 to 11.03]
Results
More Walking Performance Outcomes
Intervention
Cardio
Training
Resistance
Training
Mixed
Training
Walking
Outcome
End of intervention
End of follow-up
N (n)
Mean Difference (95% CI)
Sig.
N (n)
Mean Difference (95% CI)
Sig.
MWS
13 (609)
7.37 m/min (3.70, 11.03)
P < 0.0001
5 (312)
6.71 m/min (2.40, 11.02)
P = 0.002
PWS
8 (425)
4.63 m/min (1.84, 7.43)
P = 0.001
2 (126)
0.72 m/min (-6.78, 8.22)
NS
6-MWT
10 (468)
26.99 metres (9.13, 44.84)
P = 0.003
4 (233)
33.37 metres (-8.25, 74.99)
NS
MWS
4 (104)
1.92 m/min (-3.50 to 7.35)
NS
1 (24)
-19.8 m/min (-95.77, 56.17)
NS
PWS
3 (80)
2.34 m/min (-6.77 to 11.45)
NS
-
-
-
6-MWT
2 (66)
3.78 metres (-68.56 to 76.11)
NS
1 (24)
11.0 m/min (-105.95, 127.95)
NS
MWS
-
-
-
-
-
-
PWS
9 (639)
4.54 m/min (0.95 to 8.14)
P = 0.01
4 (443)
1.60 m/min (-5.62, 8.82)
NS
6-MWT
7 (561)
41.60 metres (25.25 to 57.95)
P < 0.00001
3 (365)
51.62 metres (25.20, 78.03)
P = 0.0001
Conclusions
Physical fitness training after stroke
• Training improves disability, physical fitness,
walking performance & balance
• Benefits are confined to cardiorespiratory and
mixed training
• Benefits are exercise-specific
• Further research is required
(e.g. optimal ‘prescription’, long-term benefits, risks, costs, non-ambulatory
patients)
What we don’t know
• Effect of fitness training on many important outcomes
e.g. mood, fatigue, falls, disability, dependence and
death
• Effect on vascular risk factors
• Optimum type of training
• Optimum mode, frequency, intensity, duration
• Timing (e.g. in-patient, after usual rehab)
• Whether any benefits are retained longer-term
• Feasibility of exercise delivery to non-ambulatory
patients
• Might some benefits be mediated by social interaction?
• How to ensure people continue exercise after initial
training programme
Implications for exercise classes after
stroke
• Exercise training may improve walking ability if
cardiorespiratory training is included
• Disability may be improved by
cardiorespiratory training or mixed training
• Effects of strength training alone are uncertain
• Further research is needed
Absolute contraindications to exercise
training
•
•
•
•
•
•
•
•
•
•
•
•
Uncontrolled angina
Recent myocardial infarction
Resting systolic blood pressure
>180 mmHg or resting diastolic BP
of >100mm Hg
Significant drop in BP during
exercise
Uncontrolled resting tachycardia
>100 beats per minute
Unstable or acute heart failure
New or uncontrolled arrhythmia
Severe stenotic or regurgitant
valvular heart disease
Hypertrophic obstructive
cardiomyopathy
Third degree heart block
Acute aortic dissection
Acute myocarditis or pericarditis
•
•
•
•
•
•
•
•
Unstable diabetes
Uncontrolled visual or vestibular
disturbances
Recent injurious fall without
medical assessment
Proven inability to comply with the
recommended adaptations to the
exercise programme and inability
to maintain an upright posture in
sitting
Febrile illness
Extreme obesity, with weight
exceeding the recommendations or
the equipment capacity (usually
>159kg [350 lb.])
Acute pulmonary embolus or
pulmonary infarction
Deep venous thrombosis
Relative contraindications
•
•
•
•
•
•
•
•
Cardiomyopathy
Moderate stenotic valvular heart disease
Complex ventricular ectopy
Left main coronary artery stenosis
Electrolyte imbalance
Tachyarrhythmias or bradyarrhythmias
High degree atrio-ventricular block
Mental or physical impairment leading to inability to
exercise adequately
Acknowledgements
• Dr Dave Saunders, Lecturer, University of
Edinburgh
• Dr Carolyn Greig, Senior Research Fellow,
University of Edinburgh
• Professor Archie Young, Emeritus Professor,
University of Edinburgh
• Hazel Fraser and Brenda Thomas Cochrane
Stroke Group http://www.dcn.ed.ac.uk/csrg
EXERCISE AFTER STROKE
Specialist Instructor Training Course
L5
Physical fitness after stroke
background
Overview of talk
•
•
•
•
Physical activity and fitness defined
Components of physical fitness
Impact of stroke on fitness
Relation between fitness and function after
stroke
• The need for exercise!
Learning outcomes
After this session you should be able to:
• Define “physical fitness”
• Describe and explain the impact of stroke on
fitness
• Describe and explain the impact of reduced
fitness on function after stroke
Physical activity
• All bodily movement produced by the
contraction of skeletal muscle and which
substantially increases energy expenditure
(USDHHS 1996)
• Includes the muscular work required for
– Walking
– Maintaining posture
– Activities of daily living
– Occupational, leisure and sporting activities
What happens to physical activity after
stroke?
• After major stroke, patients are often immobile
due to the neurological effects of stroke
• Stroke in-patients: only 13% of time engaged
in physical activity (Bernhardt 2004)
• Even relatively minor neurological deficits may
lead to a reduction in physical activity
• Paucity of literature on levels of physical
activity after stroke, particularly after minor
stroke
ActivPalTM physical activity monitoring
Physical fitness………….
Is a set of attributes, which people have or
achieve, that relate to the ability to
perform physical activity (USDHHS 1996)
Is improved by activity and reduced by
inactivity
Components of physical fitness
Cardiorespiratory fitness;
• Relates to an individual's ability to perform physical
activity for an extended period. Conferred by Central
capacity of the circulatory and respiratory systems to
supply oxygen
(USDHHS 1996)
• Peripheral capacity of skeletal muscle to utilise
oxygen
(Saltin & Rowell 1980)
Components of physical fitness cont...
Muscle strength;
Maximum force that can be generated by a muscle or
muscle group.
Ability to sustain repeated muscular actions or a single
static contraction is 'muscular endurance' (USDHHS 1996)
Muscle power;
Rate of generation of strength
Body composition;
Includes total and regional bone mineral density, and the
relative amounts and distribution of adipose tissue, muscle
and other vital parts of the body (USDHHS 1996).
What happens to physical fitness after
stroke?
• Physical fitness is related to physical activity
• After stroke, activity falls
• So might physical fitness be reduced?
Aerobic fitness (endurance) after stroke
Peak V02 synthesised from
16 studies (Dave Saunders
2007 unpublished)
Muscle strength and power after
stroke
We recruited 11 patients who had made an apparently full
neurological recovery several months after their stroke
We measured;
– Muscle strength
– Power output of both lower limbs
We found that muscle strength and power output in both
limbs were significantly lower than age and sex matched
values from the population
Greig et al 2001
Measurement of maximum voluntary isometric knee
extensor strength
Measurement of lower limb extensor power during a
single maximal leg extension
Might these impairments in aerobic
fitness, muscle strength and muscle
power have consequences for
function, mobility, quality of life?
Influence of impaired leg extensor power on
function after stroke?
• In 66 ambulatory patients, who had completed their
rehabilitation, there were associations between impaired LEP
in both the affected and unaffected limbs and
–
–
–
–
–
–
–
–
–
Timed up and go
Sit to stand
Functional reach
Comfortable walking velocity
FIM
Rivermead motor index
Nottingham extended ADL
SF36
Elderly mobility scale
(Saunders et al 2008)
LEP and function in 66 people after stroke (STARTER)
Timed 3-m up and go (sec)
Functional reach (cm)
40
30
20
10
0
0
1
2
60
40
20
0
3
0
2
3
LEP (WKg-1)
1.2
7
1.0
6
Chair rise time (sec)
Walking Velocity (m.sec -1)
LEP (WKg-1)
1
0.8
0.6
0.4
0.2
5
4
3
2
1
0
0.0
0
1
2
LEP (WKg-1)
3
0
1
2
3
LEP (WKg-1)
Affected (■) and unaffected
(□) legs
Relationship between aerobic fitness
and function
• 74 people with chronic hemiparetic stroke
demonstrated that walking ability was
independently related to
– Cardiovascular fitness
– balance
– paretic leg strength
Patterson 2007
Why is fitness impaired after stroke?
• Reduced physical activity after stroke
• Reduction in fitness may pre-date stroke (age
and co-morbidities)
• Direct effect of hemiparesis
Mechanisms of reduced fitness after
stroke
Increasing Age
Courtesy Dave
Saunders 2008
Comorbid Disease
STROKE
Pathology
Fitness
Impairments
Cycle of
Detraining
Physical
Inactivity
Direct Effect
of Stroke
Functional
Limitations
Other
Impairments
Process of
Disablement
DISABILITY
Summary
• Physical fitness is reduced after stroke
– Muscle strength
– Muscle power
– Aerobic fitness
• Mechanisms include
– Direct effect of hemiparesis
– Pre-stroke impairments
– Reduced physical activity after stroke
• Impairments in physical fitness are associated
with reductions in functional ability
Physical fitness essential for physical
activity
Cardiorespiratory
Muscle strength and power
Essential Reading
Further detail about the topics discussed in this
session can be found in section L5 of the course
syllabus.
EXERCISE AFTER STROKE
Specialist Instructor Training Course
L7a
Referral Guidelines
Overview
John Dennis/ Bex Townley
Content
Referral Process: an overview
• Risk management: protocols & pathways
• Standards of practice:
– Referral by HCP
– Self-referral
• Formalities: Referral information
Learning Outcomes
• Show awareness of the role of exercise referral schemes after
stroke in the patient pathway
• Demonstrate awareness of the main risks associated with
exercise after stroke
• Describe the correct protocols for working with HCPs
• Demonstrate knowledge of professional standards related to
exercise referral
Essential Reading: L7
Further detail about the topics discussed
in this session can be found in sections of
the manual:
7.1, 7.2, 7.3, 7.4
Referral process, overview
Patient journey
A&E
Stroke
Unit
Discharge
Community-based rehabilitation
Ex Ref S
Active lifestyle
Exercise Referral Schemes
National Institute for Health and Clinical Excellence (NICE):
“An exercise referral scheme directs someone to a service
offering an assessment, development of a tailored
physical activity programme,monitoring of progress and
follow-up.
They involve participation by a number of professionals
and may require the individual to go to an exercise facility
such as a leisure centre.”
Benefits of ERS after stroke?
• Secondary stroke prevention
• General health improvement / risk reduction
• Long term improvement/ maintenance:
– Aerobic fitness
– Functional capabilities
• Social/ psychological benefits
• Encourage self-management of healthy lifestyle
• Risk management: evidence-based safe, effective exercise
Modifiable risk factors for
stroke











hypertension (high blood pressure)
smoking
heart disease
high cholesterol level
excess alcohol intake
diabetes
elevated haematocrit (increase in red blood
cells)
stress
use of oral contraceptives (especially for
women who smoke)
obesity
sedentary lifestyle
Non- modifiable risk
factors for stroke




age
sex
race
family or individual history of
stroke or TIA
General risks associated with exercise
Hazards of exercise after stroke
• Musculoskeletal injury
• Cardiac status: up to 30-40% of stroke clients may
have underlying coronary artery disease that may be
‘silent’
> sudden cardiac death 1:100,000
General risks associated with exercise
Risk reduction:
• American Heart Association:
In U.S. Pre-requisite to referral for exercise (Gordon et al
2004):Graded exercise testing with ECG.
In GB required only for known cardiac patients.
If this cannot be performed: lighter sub-optimal intensity
exercise or clinical judgement by stroke consultant
/cardiologist
General risks associated with exercise
Risk reduction:
Scottish Intercollegiate Guidelines Network (SIGN
Guideline Cardiac Rehabilitation 2002) Clinical risk
stratification based on:
– history and examination
– resting ECG combined with a functional capacity test (e.g. shuttle
walking/ or a six minute walking test) sufficient for most clients
– Exercise testing and ECG: only for high-risk clients.
General risks associated with exercise
Risk reduction:
Consensus course team and reference group re.
exercise after stroke:
• Treadmill exercise testing is not necessary prior to
referral to exercise after stroke,
• A functional test such as the 6 minute walk, in
combination with detailed referral information, is
usually sufficient.
Other risks factors associated with exercise
• Fluctuating blood sugar levels (if diabetic)
• Overload from exercise
• Lack of temperature control
• Other pathologies e.g. osteoarthritis, PD
• Side effects from drugs
Pathways
Access to specialist session or general exercise
referral session:
• Referred through medical/ AHP “circuit” (stroke
consultant, SNS, physiotherapist)
• Signposted by exercise professional
• Self-referred
National Standards of Practice
Establish a formally agreed process for the selection,
screening and referral of specific patients
(DoH, 2001,p. vii)
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4009671
Medico-legal requirement:
Before being eligible to participate, each potential
client must obtain the acknowledgement of current
suitability to exercise from GP in the form of a
referral.
National Standards of Practice
• When increased physical activity is recommended by a HCP,
this is distinct from a referral.
• When the individual is specifically referred for exercise by the
HCP, responsibility for the health and wellbeing of the
participant remains with the referrer. Responsibility for safe and
effective management, design and delivery of the exercise
programme passes to the exercise and leisure professionals.
• The exercise professional must not accept a person through a
referral system where the patient’s HCP has declined to make a
referral.
(DoH, 2001, p. 11)
Referrer’s knowledge
• A good understanding of stroke and its effects on function
• Lifestyle and genetic pre-morbid risks
• Risks associated with:
–
–
–
–
stroke impairment
any co-morbidities
medication and its side-effects
exercise
• The patient’s readiness to exercise
National Standards of Practice
•
Once referrer has decided to refer a patient for exercise:
information -> exercise professional
•
Referrer responsibilities:
– Identify pathology, medication and impact on safety and comfort during
activity
― Stratify risk (during/ following exercise)
– Educate client on early detection of important symptoms
– Monitor and review progress
•
Referrer information: section 7.4 course manual
•
Patient consent for transfer of information
That’s all very well, but…
• In your experience:
– Example of good practice?
– Example where you were uncertain?
– Example of poor practice?
• In case of uncertainty:
– How did you resolve this, where did you look for information/
guidance?
• In case of poor practice:
– what action did you take and why?
– Could you prevent this from happening again, how?
Summary
• Exercise referral systems after stroke provide opportunity to
continue the rehabilitation journey
• Safety first!
• National Quality Assurance Framework for ERS:
-Referral must be provided by relevant HCP
-Exercise professional must be provided with
sufficient information prior to admitting a potential
client to exercise.
As an exercise professional, what
information do you require from the
referrer of a person with stroke? (L7b)
As an exercise professional, what
information do you require from the
referrer of a person with stroke? (L7b)
As an exercise professional, what
information do you require from the
referrer of a person with stroke? (L7b)
What is a stroke?
A stroke occurs when an artery supplying the brain
either blocks or bursts
Definition of a stroke
• Sudden onset
• Focal neurological disturbance e.g. speech problem, limb
weakness
• Vascular in origin (i.e. blood clot or bleed)
• Definition includes subarachnoid haemorrhage (bleeding
which occurs from a small swelling in blood vessel in the brain)
which presents with severe headache with or without focal
neurology.
• Previously, symptoms had to last more than 24 hours, but
the American Heart Association guidelines (2009) propose
that patients with a visible ischaemic event on magnetic
resonance imaging are categorised as ischaemic stroke
even if event lasts for <24 hours
Stroke 2009;40:2276-2293, Stroke. 2011;42:3612-3613
Definition of Transient Ischaemic Attack (TIA)
• It had previously been defined as sudden onset of focal
neurological disturbance, assumed to be vascular in
origin, and lasting <24 hours
• However, in 2009, the definition was amended to include
magnetic resonance brain imaging criteria
– a brief episode of neurological dysfunction caused by
focal brain or retinal ischemia, with clinical symptoms
typically lasting less than one hour, and without
evidence of acute infarction on brain imaging
Stroke 2009;40:2276-2293
How common is a stroke?
• 3rd most common cause of death
• Commonest cause of severe adult disability; 50% survivors
disabled at 6 months
• 120,000 strokes per year in UK
• A stroke occurs every 5 minutes in the UK (www.nhs.uk)
• In USA: about 795,000 suffer a stroke and 140,000 die each
year (http://www.strokecenter.org/patients/about-stroke/strokestatistics/)
3rd Most Common Cause of Death
Neurological effects of stroke (and TIA)
• Weakness down one side of body (opposite side of brain)
• Poor balance
• Sensory symptoms (e.g. numbness)
• Speech problems
– Language (usually dominant i.e. left side of brain) (affects both production of
language and understanding)
– Articulation
•
•
•
•
•
•
Swallowing problems
Visual problems (e.g. double vision, loss of visual field)
Dyspraxia (difficulty with complex tasks)
Perceptual problems e.g. neglect
Memory and thinking
Incontinence
Symptoms Depend on part of Brain Affected
Is it a Stroke or not?
• Other medical conditions can ‘mimic’ a stroke (brain tumour, seizure,
migraine, low blood sugar, infection)
• About a fifth of patients with suspected stroke turn out not to have had
a stroke
• Brain scans essential to exclude some stroke ‘mimics’ (e.g. Brain
tumour) and to differentiate haemorrhagic from ischaemic stroke
• Two main types of brain scans: Computed tomography (CT) and
magnetic resonance (MR)
• CT is the most accessible type of imaging and is quick to perform. MR
now available in most hospitals, but not all patients are able to tolerate
it
• CT is usually the ‘first-line’ brain imaging-it can identify fresh blood
very easily and so distinguish ischaemic from haemorrhagic stroke,
and it can identify some stroke mimics e.g. brain tumours
Two Main Types of Stroke
• Haemorrhage (due to bleeding into the brain):
cause about 15% of strokes
• Ischaemic (due to a blocked blood vessel): cause
about 80% of strokes
Oxfordshire Community Stroke Project
Classification for: Haemorrhagic and Ischaemic Stroke
TACS
• Visual field loss
• Weakness arm or leg
• Dysphasia or inattention
or dyspraxia
PACS
• Only two of the three
symptoms of TACS
LACS
• Weakness or sensory loss
• No other symptoms
POCS
• (brain stem or cerebella
symptoms)
TOAST classification-which
considers aetiology
• Large-artery atherosclerotic infarction,
(extracranial or intracranial)
• Embolism from a cardiac source
• Small-vessel disease
• Other determined cause e.g. dissection,
hypercoagulable states, sickle cell disease
• Infarcts of undetermined cause
(Adams et al Stroke. 1993; 24: 35–41)
Referral for exercise:
Classification of Patients
(data from STARTER)
35
30
25
20
number
15
10
5
0
TACS
PACS
LACS
POCS
Possible descriptions of stroke
when patients referred for exercise
Pathological subtype
• Ischaemic, infarction
• Description of likely cause
e.g. embolic
• Haemorrhagic,
‘intracerebral
haemorrhage’, ‘ICH’,
‘PICH’
Classification
• Oxfordshire Community
classification
• Site of lesion on brain
scan
– Middle cerebral artery
territory, posterior
cerebral artery territory
Risk Factors for Ischaemic Stroke
Common
• Hypertension
• Diabetes mellitus
• Cigarette smoking
• Atrial fibrillation
• Carotid stenosis
• Cardiac disease
• Alcohol
• High cholesterol
• Obesity
• Reduced physical activity
• Diet
Rarer
• Vasculitis
• Polycythaemia
• Leukaemia
• Hyperviscosity
• Thrombophilias
• Anti-phospholipid syndrome
• Neurosyphilis
• Endocarditis
Risk Factors and Causes of Haemorrhage
Primary Intracerebral Haemorrhage
• Hypertension
• Coagulation disorder
• Aneurysm
• Arterio-venous malformation (AVM)
• Cigarette smoking
• Amyloid angiopathy
• Drug abuse
Causes of Ischaemic Stroke
• Blood clot forms in artery in brain e.g. middle cerebral, or
small deep artery in brain
• Blood clot forms at another site and ‘travels’ to brain
(embolism)
– Aorta (main artery in chest)
– Carotid artery (in neck)
– Heart
Blood Tests for Stroke
• Blood glucose (for diabetes and low sugar)
• Cholesterol
• Full blood count
– Anaemia (low haemoglobin) or polycythemia (too many
red cells)
– White cells (? Infection)
– Platelets (? Too many or too few)
•
•
•
•
Electrolytes (e.g. sodium and potassium)
Urea and creatinine (kidney function and hydration)
ESR (for inflammation)
Blood clotting (for haemorrhagic stroke)
Other tests
• Chest X-ray (heart size, lungs)
• Electrocardiogram (ECG)
• Some patients may have carotid Dopplers (to look for
narrowing of carotid artery)
• Some patients may have echocardiography (i.e.
ultrasound of the heart) to look for blood clot in heart and
abnormalities of the heart valves)
Summary
• Stroke is 3rd most common cause of death
•
•
•
•
Most common cause of adult disability
85% are Ischaemic (blocked artery)
Symptoms depend on part of brain affected
Oxfordshire Community Stroke Project
Classification frequently used to categorise
patients
• Different causes and risk factors for stroke
EXERCISE AFTER STROKE
Specialist Instructor Training Course
L3
Stroke: the first few days
Prof. Gillian Mead
Reader and Consultant
The University of Edinburgh
Stroke is a Medical Emergency
Face Arm Speech Test (Time..)
Helps public recognise symptoms of stroke;
•
•
•
•
Can they smile? Does one side droop?
Can they lift both arms? Does one drop?
Is their speech slurred or muddled?
Test all three symptoms
Of course, there can be other focal neurological symptoms
too (and not all of the above symptoms are due to a stroke)
Acute Management (1)
• Ischaemic stroke
– Aspirin (within 48 hours of onset)
– Clot busting drugs
• given within 6 hours of onset reduced risk of death dependency
• Benefits greater if given as soon as possible after symptom onset
• Associated with a risk of bleeding into the brain Lancet 2012; 379: 2364–
72RCP guidance recommends treatment wthin 3 hours, consider treatment
3-6 hours
– Decompressive craniectomy (lifting a flap of the skull to relieve pressure) in a
tiny proportion of younger patients who develop potentially fatal brain swelling
• Haemorrhagic stroke
– Neurosurgery (only occasionally) to remove blood
– Reverse blood clotting defects
– Early Blood pressure lowering-one trial (N Eng J Med Craig Anderson 2013)
showed benefit; some centres now implementing this, whilst others believe
more evidence is needed
Acute management (2)
• Intermittent pneumatic compression of legs
– reduces risk of clots in legs and reduces risk of death at 6
months (clots collaboration May Lancet 2013)
• General supportive
–
–
–
–
–
Intravenous fluids (for patients who can’t swallow)
Nutrition (nasogastric tube, modified diet, normal diet)
Oxygen (if oxygen levels low)
Bowel and bladder care
Prevention of pressure sores (? Pressure relieving mattress, regular
turns)
– Control blood glucose
• Best outcomes if patient is admitted to a stroke unit
What is a stroke unit?
• Organised inpatient (stroke unit) care can be considered a
complex organisational intervention comprising
multidisciplinary staffing providing a complex package of care
to stroke patients in hospital
• Care can be provided in a dedicated ward (stroke, acute,
rehabilitation, comprehensive), by a mobile stroke team or in
a mixed rehabilitation ward.
Stroke Unit Trialists' Collaboration. Organised inpatient (stroke unit) care for
stroke Cochrane Database of Systematic Reviews. 2013.
Cochrane Systematic Review of Stroke Units
• 28 randomised controlled trials with 5855 participants.
• Stroke unit care reduced the odds of
– Death
– Death or institutionalisation
– Death of dependency
• Any patients characteristics associated with better outcomes?
– The magnitude of benefit seemed greater for participants with moresevere stroke.
– Stroke unit benefits are apparent across a range of participant
subgroups (age, sex, initial stroke severity and stroke type).
– Mild strokes-no significant effect on death but had a reduced risk of
dependency
• Outcomes better when stroke unit based in a discrete ward
Why do stroke units improve outcomes?
• Care co-ordinated by a multidisciplinary team
• Team meets to discuss patients at least weekly
• Nurses have expertise in rehabilitation
• Team consists of professionals interested or specialising in
stroke
• Regular in-service training for staff and involvement of carers
in patient care
• ? Early mobilisation, rapid treatment of complications of
stroke
Langhorne1995.
Rehabilitation Aims to Minimise Functional Effects of
Stroke
• Core team
–
–
–
–
–
Physician
Nurses
Physiotherapist
Occupational therapist
Speech and language
therapist
– Social worker
– Dietician
• Others who may be
consulted
–
–
–
–
–
–
–
Psychologist
Psychiatrist
Vascular surgeon
Radiologist
Rheumatologist
Optometrist
Orthotist
Scottish Stroke Care Audit
• National Audit allows
each health board to
evaluate care against
published standards
–
–
–
–
–
Brain imaging
Aspirin
Stroke Unit access
Swallowing assessments
Neurovascular clinic
access
http://www.strokeaudit.scot.nhs.uk/
Complications from stroke during hospital admission
frequency %
60
50
40
30
20
10
0
re c urre nt
s t ro k e
s e izure s
urine
inf e c t io ns
c he s t
inf e c t io ns
o t he r
inf e c t io ns
f a lls
pa in
a nxie t y
de pre s s io n
e m o t io na lis m
c o nf us io n
Patterns of Recovery
• Rate of recovery generally most rapid in the first few weeks
• If a patient deteriorates, consider medical complications,
recurrent stroke
• There is no absolute end to recovery, but most rapid
improvement is within the first 6 Months (RCP guidelines
2012)
• Some patients continue to recover for several years
• Mechanisms underlying recovery are complex and include
– Restoration of blood flow (and so neurones not irreversibly
damaged may recovery)
– Neuroplasticity
– Functional adaptations
Summary
• Stroke is a medical emergency: Act FAST!
• Acute treatments can improve outcome
• Stroke Unit care improves outcomes
• Medical complications are common after stroke
• Pattern and rate of recovery is highly variable
Essential Reading
Further detail about the topics discussed in this
session can be found in section L3 and L4 of
the course syllabus.
EXERCISE AFTER STROKE
Specialist Instructor Training Course
L4
Stroke: the longer term
Prof. Gillian Mead
Consultant
The University of Edinburgh
Secondary prevention (general)
•
•
•
•
•
Healthy diet
Exercise
Alcohol
Weight reduction
Stop smoking
• Advice given at time of stroke, advice reinforced after hospital
discharge by GP, practice nurse
• (see CHSS, SA, Different Strokes information leaflets)
Secondary prevention
• Ischaemic
– Antiplatelets (e.g. aspirin, clopidogrel or occassionally dual
antiplatelets)
– Blood pressure lowering medication
– Cholesterol reduction
– Warfarin or one of the newer oral anticoagulants e.g.
apixaban, dabigatran, Rivaroxaban e.g. atrial fibrillation or
if blood clot demonstrated in the heart
– Carotid endarterectomy for severe carotid stenosis (if on
the side of the stroke lesion)
• Haemorrhagic
– Consider treatment of underlying cause (e.g. arteriovenous
malformation)
– Blood pressure lowering medication
Drugs for secondary stroke prevention (STARTER n=66)
80
%
70
60
50
40
30
20
10
0
antiplate le ts
anticoagulants
ACE-
thiazide
be ta-block e rs
calcium antag
alph block e rs
Longer term problems after stroke
(relevant to exercise delivery)
•
•
•
•
•
•
•
•
•
Pain
Fatigue
Mood disorders (anxiety, depression, emotionalism)
Falls and fractures
Cognitive impairment
Seizures
Infections (urine, chest most common)
Bladder and bowel problems
Contractures
Pain is common
• Stroke related pain
– Complications e.g. DVT
– Central post stroke pain (typically burning,
shooting)
– Shoulder pain (hemiparetic side) in 25%
– Pressure sores
– Limb spasticity
• Non-stroke related
– e.g. arthritis
Shoulder pain
• Affects 25% of patients
• More common in severe
strokes
• Causes are
multifactorial
• Optimum treatment
uncertain
• Advice from
physiotherapist
Central post-stroke pain
• Burning, icy, lancinating, lacerating, shooting,
stabbing, clawing
• May respond to antidepressants
(amitryptiline), anticonvulsants (gabepentin)
Falls
• In the first six months after discharge, half to
three-quarters of patients fall
• Causes
– Patient related factors e.g. muscle weakness and
wasting, incoordination, loss of awareness of
midline
– Environment e.g. uneven floors, footwear
– Drugs e.g. sedatives, antihypertensives
va
n
Study
A
Ly
nc
h
pl
er
os
ae
ss
or
le
y
N
M
ta
ub
la
de
r
er
f
le
s
W
S
G
de
r
In
g
Le
eg
ar
d
02
02
20
07
20
06
20
05
20
20
01
20
20
01
19
99
19
83
Prevalence (%)
Prevalence of fatigue after stroke
80
70
60
50
40
30
20
10
0
Potential mechanisms of post-stroke
fatigue
Stroke
Pain
Depression
Direct physical mechanisms
Sleep disturbance
Treatment
Reduced mobility
FATIGUE
Behavioural avoidance and de-conditioning
Adapted from Wessely, Hotopf and Sharpe 1998
therapy
Mood disorders
• Depression in around 25%
• Anxiety in around 20%
• Emotionalism (20%) sudden outbursts of
laughing or crying
Cognitive impairment
• Memory and thinking problems
• May precede stroke or occur as a result of
stroke
• Affects around 20% of patients at 6 months
(MMSE of 23 or less)
• Can get worsening of cognitive impairment as
a result of other medical problems e.g.
infection
Co-morbidities
• Diagnosable condition which exist in addition
to main condition
• May have caused stroke (e.g. atrial fibrillation)
• Co-morbidity e.g. angina may be caused by a
common risk factor (e.g. high blood pressure)
• May be unrelated to stroke e.g. gout
Co-morbidities in STARTER
%
50
45
40
35
30
25
20
15
10
5
0
hypertension
IHD
Cancer
Diabetes
LVF
arthritis
other
Drugs for co-morbidities in STARTER
n=66
25
%
20
15
10
5
0
analgesics
ulcer drugs
inhalers
steroids
thyroxine
diuretics
digoxin
antidepress
Relevance of co-morbidities to
exercise delivery
• Hypertension: drugs may cause postural hypotention and
dizziness, beta-blockers: measurement of pulse rate to
measure intensity of exercise
• Ischaemic heart disease: exercise can carry risks.
– Avoid if unstable angina
– Exercise within limitations of stable angina.
– Congestive cardiac failure: tailor to breathlessness and fatigue
• Diabetes mellitus: exercise may precipitate hypoglycaemia.
Seek medical advice prior to taking up classes. Strategies
may include
– Reduction of insulin dose prior to exercise
– Take additional carbohydrate prior to exercise.
– Avoid injecting insulin into exercising muscle as absorption increases
and so risk of ‘hypos’
Services for people after a stroke
• In-patient care (rehabilitation, terminal care, long-term NHS
care)
• Out-patient care (e.g. neurovascular clinics)
• Early supported discharge services
• Primary care team
– GP (quality outcomes framework)
– District nurse
– Practice nurse
•
•
•
•
Respite care, day hospital
Domiciliary physiotherapy
Long-term nursing home care
Charities (e.g. advice lines, CHSS stroke nurses)
Younger stroke patients
• 25% of patients are under 65
• Similar neurological effects as older patients
• Need to consider impact on employment, finances
and relationships
• All age stroke units, young stroke units
• In Lanarkshire: young stroke worker
• Different Strokes: charity set up by younger stroke
patients for younger patients
Department of Health: National Stroke
Strategy
•
•
•
•
•
•
•
•
•
•
•
10 point action plan
Awareness (recognition of symptoms)
Preventing stroke
Involvement
Acting on warnings
Stroke as a medical emergency
Stroke unit quality
Rehabilitation and community support
Participation (planning housing, transport)
Workforce (skill mix)
Service improvement
Summary
• Early management of stroke
– Acute treatment (aspirin and clot busting drugs for ischaemic stroke)
– Secondary prevention (aspirin, antihpertensive drugs, statin, warfarin,
carotid endarterectomy)
– Rehabilitation (on a stroke unit by a multidisciplinary team)
• Long-term problems (pain, fatigue, cognitive impairment,
mood disorders, falls, infections)
• Co-morbidities (ischaemic heart disease, diabetes have
important implications for exercise delivery)
• Stroke in a national context: stroke strategies exist for UK
Essential Reading
Further detail about the topics discussed in this
session can be found in section L3 and L4 of the
course syllabus.
The University of Edinburgh
EXERCISE AFTER STROKE
Specialist Instructor Training Course
L8a
The role of the Specialist Exercise Instructor
Assessment Procedures
J Dennis/S Wicebloom Paul / S Dinan Young
Bex Townley
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
Patient Inclusion criteria
• Must have GP / other “permission”= agreed
referral path
• Passport/ Referral must be fully completed
• 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 Specialist Exercise Instructor
1. What do you want to know about the participant?
2. What documents will you need in place to record information?
3. Who can tell you what you need to know?
Assessment – Agreeing Goals
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 Specialist Instructors
What tools do you use to assess/measure progress?
Assessment Tools and Outcome Measures
•
•
•
•
•
•
•
10 metre walk
6 min walk
Timed Balances – Tandem & SLS
Timed up & Go
Tinetti Balance & Gait (Falls Risk)
Stroke Impact Scale
Postural map
Triggers Back to Referrer/Medical Review
Essential that if any of the following are noticed the patient is
reviewed by the physiotherapist/referred back via pathway
protocols:
•
•
•
•
•
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
EXERCISE AFTER STROKE
Specialist Instructor Training Course
L8b
The role of the Specialist Exercise
Instructor
Programme Design
John Dennis / Sara Wicebloom-Paul/ Bex Townley
Content
•
•
•
•
•
Planning the programme
Cautions / considerations
Programming guidelines
Teaching skills
Introduction to ‘tailoring’
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.
Essential Reading
Further detail about the topics discussed
in this session can be found in section
8.3 – 8.5 and 12 of the course Manual
and tailoring worksheets in the
directed learning pack
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)
‘Tailoring’ (an introduction)
• What is ‘tailoring’ in the context of exercise and fitness
after stroke?
• What is the ultimate aim of a tailoring solution or
strategy?
• How do we know if your tailoring has been effective?
• What are the challenges faced by instructors when
tailoring exercise for a group of participants with stroke?
• What ‘is it’ we need to potentially tailor?
Special Considerations, Cautions & Adaptations
Starting Point for Exercise Programming:
• 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
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
• Safe management of a group of people with a range of
impairments
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 Content
•
•
•
•
Simpler, fewer exercises
Order of exercises
Steady pace
Step by step transitions – spacing, rest
intervals etc.
• Moderate intensity
• Group and 1-2-1 communication
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.
DAYS 1 & 2 OVERVIEW
Days 1 & 2 key learning outcomes
• Demonstrate a sound working knowledge of:
Stroke: diagnosis, types, effects, recovery, risk factors,
prevention, co-morbidities
•
•
•
•
Treatment, rehabilitation and services after stroke
Physical fitness after stroke
Effectiveness of exercise after stroke: evidence-base
Contra-indications to exercise
•
Deliver safe and appropriate exercises to people after
stroke: teaching guidelines.
•
Demonstrate an understanding of the exercise referral
guidelines: role of referrer
By days 3 & 4
• Process information from weekend 1:
– Session handouts: key points
– Course syllabus: chapters L1-7
– Self-assessment questions L1-7
– Directed learning: Stroke visits & case study
• Prepare by reading: chapters L8-10
What’s next? Days 3 & 4
DESIGNING, ADAPTING, DELIVERING
• Assessment procedures for the Exercise Practitioner
• Programme design and evidence-based practice
• Adapting and tailoring exercises
• Risk assessment
• Problem solving
• The role of the AHP in stroke rehabilitation:
– Occupational Therapy
– Speech and Language Therapy
• Changing behaviour and goal setting
• Assessment briefing
EXERCISE AFTER STROKE
Specialist Instructor Training Course
T2
The Role of AHPs in
Stroke Rehabilitation
Content
• What is an Allied Health Professional (AHP)?
• What do AHP’s do?
– Physiotherapy (PT), Occupational Therapy (OT), Speech & Language
Therapy (SALT)
• 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 and demonstrate understanding of the role
of AHP’s in stroke care.
Essential Reading
Further detail about the topics discussed in
this session can be found in section [3.2],
[4.3], [L7], [L9] 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/
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
Students – please list some AHP’s
Podiatrist
Radiographer
Dietician
Orthotist
Prosthetist
Orthoptist
Art Therapist
The Role of AHP in Stroke Rehabilitation
Speech and Language Therapy
Content
The role of 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
an 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.
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.
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
What is the impact of a communication disability?
• Loss of identity
• Social isolation and loneliness
• Loss of employment
opportunities / financial security
• Loss of leisure opportunities
• Difficulty in personal
relationships
A Shared Problem?
Communication: Giving and Receiving
Getting the message
Message in
Giving the message
Message out
Aphasia / Dysphasia
• This is a language disorder
• Affects both message in (receptive dysphasia) and
message out (expressive dysphasia)
– 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-AD0A-B07B8344F6EB
Expressive Aphasia / Dysphasia
•
•
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
Receptive / Expressive Aphasia
•
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!)
Cognitive
impairment
Thoughts/ideas/knowledge
Meanings / semantics
Word store
Aphasia
Speech sounds
Articulatory
dyspraxia
Speech Dysarthria
(lips,tongue,voice)
Motor programming
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
Cognitive
impairment
Thoughts/ideas/knowledge
Meanings / semantics
Word store
Aphasia
Speech sounds
Articulatory
dyspraxia
Speech Dysarthria
(lips,tongue,voice)
Motor programming
More subtle communication difficulties
• Processing emotional content
– Facial expression
– Appreciating humour
• Prosody
– Flat tone
– Understanding related to stress, rhythm
• Conversational skills
– Making inferences
Where is communication breaking down?
Instructor & Participant
• 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
Key Points about communication disorders
• There is a diverse range of communication difficulties
following stroke
• Severity varies from person to person
• Pattern of problems varies from person to person
• Communication difficulties and their impact can change over
time
• The impact on the individual and their family will depend on
their circumstances
• Severity of impairment does not necessarily match the impact
on activity and participation
Exercise Specialist problem solving
• Good communication is key to your
professional role.
• Is one form of communication more difficult
than another?
• Can this person use other forms of
communication?
• Could I adapt to make this easier?
• Find what is available and support if required.
• Apply the principles of effective
communication wherever possible – and
keep trying...!
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 to make communication
successful
• 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
Further reading
• Connect: the communication disability network:
http://www.ukconnect.org/
• Speakability: http://www.speakability.org.uk/
• Stroke Core Competencies for Health and Social
Care Staff (the STARS project):
http://www.strokecorecompetencies.org/node.asp?id=core
• www.stroketraining.org
Some places for support
Talk For Scotland Toolkit
http://www.communicationforumscotland.org.uk/
The Role of AHP in Stroke Rehabilitation:
Occupational Therapy
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.
OT – Implications for Exercise Specialists
• Cognition
• Attention and memory
• Sensation and perception
• Planning, taking action and monitoring
Cognition / Information processing
Cognition involves:
•
•
•
•
•
•
•
•
thinking
believing
perceiving
remembering
judging
planning
problem solving
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?
•
•
•
•
•
•
Distractability / poor concentration
Slowed thinking & processing
Lack of awareness of “what goes on”
Difficulty doing more than 1 thing at a time
Tiredness / fatigue
Perseveration: inability to disengage e.g. step-up.
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, smell
or sight, e.g.:
1. Impaired depth distance - results in a different image of
an object received by the retina of each eye
2. 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
How can you tailor exercise for a participant
with neglect?
•Prompt awareness of affected side
•Monitor use of equipment
•Watch for obstacles (and other people!)
•Monitor posture & movement, especially 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 & unco-operativeness.
(Heilman 1979)
Understanding Apraxia
Normal Praxis involves:
• Forming an idea:
• Planning the action
• Putting the plan into action
> motor execution
Dyspraxia may affect any of the above abilities.
How do you know if a participant has apraxia?
• Problems tend to occur when simple movements are
combined in sequence to reach goal, and/or when tools are
used.
• 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
How can you enable a participant with apraxia to
participate in exercise?
(Student Led)








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
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?






Distractible
May need prompting
Unrealistic expectations
Unrealistic plans; difficulty with goal setting
Difficulty with time management
Launching into an activity
How do you know a participant may have
executive dysfunction?
 Inappropriate behaviour (e.g. disinhibition, anger)
 Difficulty monitoring self – and effecting change when things
go wrong
 Difficulty making a plan – and sticking to it until its completion
 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
The Role of AHP in Stroke
Rehabilitation:
Physiotherapy
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
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 / deconditioning
Physical Rehabilitation Aims In Stroke
•
•
•
•
•
•
•
•
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
Compensations
• Where there is paralysis, other parts of the body will
“compensate” for the loss of control or ability to
function.
• This may present as 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.
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
Which approach to treatment and rehabilitation?
• Comparison studies and systematic reviews show no statistical
difference in outcome 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.
• Dynamic balance of control between therapists
and patient.
What is
“Normal Movement…?”
What physiotherapy neuro-rehabilitation is all about!
•
•
•
•
Smooth
Efficient
Coordinated
Graded
•
•
•
•
Automatic
Voluntary
Goal orientated
Specific Patterns
What is
“Normal Movement…?”
There are 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
HYPERTONICITY
Standing
Normal Range
Sitting
Lying down
HYPOTONICITY
Base of support and impact on tone
• Physical support can alter postural tone
– Large BOS reduces tone
• Provides stability where necessary muscle activity may
be lacking
– Small BOS increases tone
Sensory-motor Feedback Loop
Voice
Vision
Other sounds
Inner ear /
vestibular system
Painful stimuli
Temperature
Touch
Proprioception / Joint
position sense
Balance Reactions
• Equilibrium
• Righting
• Saving
Work to produce base
for purposeful,
functional movements
Co-ordination
"the ability to integrate muscle movements into
an efficient pattern of movement" (Schurr,
1980)
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
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
Essential Reading
Further detail about the topics discussed
in this session can be found in section L7
of the course syllabus.
EXERCISE AFTER STROKE
Specialist Instructor Training Course
L7b Referral Processes:
Physiotherapy assessment, readiness for exercise, risk
stratification and referral procedures
(Effects of Stroke on Physical Function; “Normal” Movement;
Abnormal Tone)
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
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”
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
EXERCISE AFTER STROKE
Specialist Instructor Training Course
L7b Physiotherapy assessment and clinical risk
(Effects of Stroke on Physical Function; “Normal” Movement;
Abnormal Tone)
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
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”
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
Balance Reactions
• Equilibrium
• Righting
• Saving
Work to produce base
for purposeful,
functional movements
Shoulder Problems after Stroke
• Why can shoulders
be so problematic
following a stroke?
• As instructors what
‘risks’ do we need
to be aware of?
Management of Subluxation
•Handling
• Shoulder Supports
•
•
•
• Strapping
Alignment
Facilitation
Inhibition
Types of Risk
• Generic Risks: environmental, equipment (covered
yesterday) modes of delivery, communication)
• Clinical Risks…
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
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
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
Essential Reading
Further detail about the topics discussed
in this session can be found in section L7
of the course syllabus.
Exercise & Fitness After Stroke: Specialist Instructor Training
Course
T6- The Impact of stroke: Disorders in
motor control, perception, cognition,
communication, emotion and motivation
A Short Case Study. E
E is a 44 year old lady, Stroke 1991 resulting in a
Right Sided Hemiplegia.
Referred to the Community Stroke team urgently
for psychological intervention.
Initial assessment revealed by the patient;
• Left Handed, worked as a barmaid, has 14 year old
daughter.
• History leading to CVA (self-blamed), belief that it 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 hour
disability.
Current social history is
• Lives with daughter/ground floor flat,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 Outpatients.
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, reviewed yearly
• Falls each month – mainly outside
• Never had appropriate 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.
• E 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)
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.
EXERCISE AFTER STROKE
Specialist Instructor Training Course
T11
Generic Risk and Risk Management
Systems (EAP’s)
J. Dennis/Bex Townley
Content
•
•
•
•
•
What is risk
Identifying, AND REDUCING risk
Venues & Exercise areas
Systems
On the floor – adverse events & emergency
action procedures
Learning Outcomes
At the end of this session, you should be able to:
• List risk types and how they apply to exercise
settings
• Describe the risk assessment process
• Demonstrate competency in risk assessment
• Discuss your own typical area risk assessment
• Discuss and rationalise what to do in the event of an
emergency, or potential emergency/adverse event
Essential Reading
Further detail about the topics discussed in this
session can be found in section [8.6-8.8] of the
course syllabus, and the risk assessment
documentation in the summative assessment
pack
Risks may arise from the interaction between
the individual, the activity and the
environment.
activity
individual
environment
Types of Risk
• Generic Risks (environmental, equipment,
modes of delivery, communication)
• Clinical Risks…
Generic Risk Assessment
•
•
•
•
•
Access
Environment
Equipment
Participants
Instructors…how do we effect risk? What do
we to reduce risk?
• Communication
Systems & Organisation
•
•
•
•
•
•
•
Communication in an emergency
Emergency action plan in place - documented
Staff trained in Emergency Operating Procedures
Manual/people handling training recommended
Medical history /screening
Emergency contact numbers
First Aid Qualifications Up to date
Adverse Events V’s Emergency
• On the floor?
• Potential emergency?
• Rationale for action taken?
Person Falls
Reason for
fall? What
happened?
DECISION
Do they
usually get up
unassisted?
Ability to
communicate
clearly?
Would you be
able to instruct
them off the
floor?
Rationalize
actions to
take
DECISION
(Clients
Falls
History?)
DECISION
First Aid Protocols
Is it safe &
appropriate to
instruct them off the
floor?
Considerations for
the other
participants?
Summary
• First Aid certification
• Manual /people handling
• Check area risk assessments and ensure inclusion
of stroke population hazards/risks
• Document your systems and disseminate
Essential Action
Find out/re-visit your adverse events and EAP’s
in your workplace, identify who you need to
contact to agree if issues of joint working
Summative Assessment
As part of your practical assessment you will
be required to complete a risk assessment
for any venue (real or otherwise) to evidence
your completion of a risk assessment for the
session.
Instructing Off the Floor?
Following assessment , if safe/appropriate;
•Make safe other participants
•Notify others if required/prepare for help
•Place chairs, prepare to support upright trunk position
•Roll on to affected side
•Unaffected arm -push into upright sit
•Unaffected arm onto chair to assist
•Unaffected leg used to push backside onto second chair
EXERCISE AFTER STROKE
Specialist Instructor Training Course
L8c
The role of the Specialist Exercise Instructor
Clinical Risks & Monitoring of Participants
John Dennis
Content
• What is clinical risk
• Monitoring of participants
• Participant self monitoring
Learning Outcomes
At the end of this session, you should be able to;
• Explain/ demonstrate understanding of clinical
risks and how to identify them
• Apply principles of risk management and
monitoring of participants
• Discuss how to avoid risks in your classes.
Essential Reading
Further detail about the topics discussed in this
session can be found in section 8.6 – 8.8 of the
course manual
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
Clinical Risk
Health
• Stable? (cardiac, cognitive, performance, deteriorated since
referral?
• Appropriate class / location/access?
• Changes in limb power / sensation / balance / tone?
• Change in endurance / fatigue?
Falls
• Causes variable – cardiac, sensory, balance, weakness, tonal
• Need strategy to manage participants post fall
Clinical Risk
Impairment Issues
•
•
•
•
•
•
•
Soft tissue changes
Joint integrity
Tone
Weakness
Other movement disorders
Sensory
Cognitive
Clinical Risk
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
• Fatigue Issues
• Mode of delivery e.g. Too intense too soon
• Participant Equipment Splints, footwear,
spectacles, hearing aids, walking sticks, etc.
Clinical Risk
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
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)
Content
1.
2.
3.
4.
Measuring outcomes: why (not)?
The ICF
General principles of outcome measurement
Using outcome measures
- Specific suggestions for the exercise-after-stroke setting
Why are they not used?
Common reasons for not using outcome measures:
• 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!
• It takes time away from the actual exercise
• It is a burden for participants
Do you??!
Why we do use them
•
•
•
•
Screening: testing eligibility for exercise
Baseline assessment: establishing starting point
for exercise programme
Follow-up assessment: charting change
following exercise
Monitoring: to chart adherence and identify
adverse effects
This session: baseline and follow-up assessment using outcome measures
SCIENCE V COMMON SENSE
Science:
“knowledge, ascertained
by observation and
experiment, critically
tested, systematised
and brought under
general principles”
Common sense:
“The natural ability to
make good
judgements”
Cambridge English Dictionary
Collins English Dictionary
SCIENCE V COMMON SENSE
• Exercise/ rehabilitation/ health care
needs to be based on science and
research!
• Common sense is not good enough for exercise
instructors/ health care professionals
Content
1.
2.
3.
4.
Measuring outcomes: why (not)?
The ICF
General principles of outcome measurement
Using outcome measures
- Specific suggestions for the exercise-after-stroke setting
International Classification
The International Classification of Functioning,
Disability and Health (ICF) provides a general
framework for outcome measurement in clinical
practice.
“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
Outcome measures and the ICF
• Consider the outcome measures you use in
your work ?
• 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?
Content
1. Measuring outcomes: why (not)?
2. The ICFGeneral principles of outcome
measurement
3. General principles of outcome measurement
4. Using outcome measures
- Specific suggestions for the exercise-after-stroke setting
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)
Statistical relevance
Choosing your Outcome Measure
- how to go about it
T
NO
H
Safe?
YES
I
NO
N
Relevant?
YES
K
NO
Science
Robust?
A
YES
NO
Practicable?
YES
GO
G
A
I
N
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:
Does the measure give 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 in a clinical /
work setting
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 of data
• Type of data
• Format and presenting data
• Standardisation of the information
Summary - general principles of
measurement:
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)
Statistical relevance
Content
1.
2.
3.
4.
Measuring outcomes: why (not)?
The ICF
General principles of outcome measurement
Using outcome measures
- Specific suggestions for the exercise-after-stroke setting
Outcome Measures
Suggested outcome measures for exercise after
stroke:
•
•
•
•
6 min. walk/ 10 m. walk
Timed up and Go
Visual Analogue Scale (VAS)
Stroke Impact Scale
+ Register: for monitoring adherence
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
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 -
Solution?
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
Pitfalls of measurement –
and how to fix them
Problem
• Error:
Solutions:
• Errors:
– Systematic
– Random
– Calibrate your instrument
– Use standardised protocol
• Wrong signals:
– False +
– False -
• Wrong signals:
– Check sensitivity
– Verify with other information
Errors are inherent in any form of measurement!
Always be aware and try to reduce.
Summary
Outcome measures are necessary to:
• Establish baseline for exercise
• Evaluate change following exercise
-> science underpinning your work
EVIDENCE BASED PRACTICE
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/
EXERCISE AFTER STROKE
Specialist Instructor Training Course
L10 CHANGING BEHAVIOUR:
EXERCISING IN THE LONG RUN
John Dennis , Frederike van Wijck, Bex Townley
http://www.fotosearch.co.uk/photos-images
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. Introduction: Motivation: what is it?
2. Motivation after stroke
3. 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
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
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 by 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)
But has weakness R side and LOC
• “Just wants to get back to normal and get her life back”
• “I need to get back into my exercise classes”
But ‘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?
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?
Essential Reading
Further detail about the topics discussed in this
session can be found in section L10 of the course
syllabus.
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…
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 (& AHP)
• + NON stroke specific
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–
–
–
–
–
***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.
3. EAS: Guidelines for Best Practice
Key guidelines for EAS service providers:
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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:
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–
–
–
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
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
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
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 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.