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 • The ARNI Functional Training After Stroke Course focuses on functional tasks and experiential strategies. EfS CPD 1 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 • The role of specialist exercise instructor • Outcomes measures and formative assessment Day 5 • Theory paper • Communication, Changing behaviour and goal setting; applied • Practical (formative) assessment • Implementation Day 6 (7) Summative Practical Assessment 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 (or 7) • One 45 min practical assessment STARTER class • 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 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 metaanalyses • 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 • Theraband 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 speed (m/s) 0.67 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 metaanalysis Systematic review: Literature Evaluation MEDLINE EMBASE CINAHL SportDiscus WOK Screened N=155 Excluded N=95 CCTR CSG - SR Pending N=22 Ongoing N=15 Included RCTs N=23 n=1147 Cardio N=11 n=629 PeDRO Strength N=4 n=158 (2004 N=11, n=289) Mixed N=9 n=360 Other Number of patients randomised in trials of physical fitness training after stroke Trial participants • Average age 67 years (i.e. younger than the median age of stroke onset of 72) • 60% men, 40% women • 82% ambulatory • Time since stroke: 8.8 days to 7.7 years Results Outcome Cardio Strength Mixed Disability ? ? ? Adverse events ? ? ? Physical fitness . Walking ns ns Function ? ? ? Quality of life ? ? ? Mood ? ? ? VO2 Strength ? 8/24 RCTs involving follow-up show no retention of benefits Results Cardiorespiratory Training When: Mostly during usual care Mode: Most Involved walking Outcome N (n) WMD (fixed) 95% C.I. Signif. Maximum Speed 8 (462) 6.47 m·min-1 2.37, 10.6 p=0.002 Comfortable Speed 4 (356) 5.15 m·min-1 2.05, 8.25 p=0.001 Walking Endurance 3 (296) 38.9 metres 14.3, 63.5 p=0.002 Functional Ambulation 4 (228) 0.72 0.46, 0.98 p<0.00001 Control MeanControl SD Total Weight Results Mean Difference IV, Difference Fixed, 95% CI Mean Mean Difference IV, Fixed, 95% CI Mean Difference Mean SD Total Weight IV, Fixed, 95% CI 16.2 13.8 7 5.6% 19.20 [1.93, 36.47] 7.07 46.04 10 0.3% [-69.97, 16.2DURING 13.8 7 5.6% 9.00 19.20 [1.93, 87.97] 36.47] 58.2 38.4 10 1.8% 15.00 [-15.74, 45.74] 7.07USUAL 46.04 CARE 10 0.3% 9.00Mode [-69.97, 87.97] N 58.2 38.4 10 1.7% 39.60 [7.84, 45.74] 71.36] 58.2da Cunha 38.4 2002 10 1.8% [-15.74, 13 15.00Treadmill 6.22 19.49 -0.22 [7.84, [-7.47, 7.03] 58.2Glasser 38.4 198637 10 32.0% 1.7% 39.60 20 Gait trainer71.36] 36Pohl 13.2 6.60 [-2.15, 6.22 19.49 37 21.9% 32.0% -0.22 [-7.47,15.35] 7.03] 2002a 25 30 Treadmill 19.2 21.6 7.20 [-0.72, 15.35] 15.12] 36Pohl 13.2 25 26.8% 21.9% 6.60 [-2.15, 2002b 78 30 Treadmill* 177 90.1% 5.93 [-0.72, [1.61, 10.24] 19.2Bateman 21.6 2001 78 26.8% 7.20 15.12] 73 Cycle* 39%Eich 2004 177 90.1% 5.93 [1.61, 10.24] 50 Treadmill 39%Pohl 2007 155 Gait trainer IV, Fixed, 95% CI 48AFTER 29.4 47 47 48USUAL 29.4 CARE 47 Salbach 200447 9.9% 9.9% 9.9% 91 9.9% Maximum Walking Speed 11.40 [-1.61, 24.41] 11.40 11.40 [-1.61, [-1.61, 24.41] 24.41] Circuit 11.40 [-1.61, 24.41] OVERALL EFFECT -1 2.37, 100.0% 6.47 [2.37, 10.57] 6.47 m·min224 10.57 p=0.002 = 33% 224 100.0% = 33% (P = 0.43), I² = 0% (P = 0.43), I² = 0% 6.47 [2.37, 10.57] -100 -100 -50 0 50 Favours control 0 Favours training -50 50 Favours control Favours training 100 100 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 • Mr 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 Essential Reading Further detail about the topics discussed in this session can be found in section L6 of the course syllabus. 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 (WKg-1) 1.2 7 1.0 6 Chair rise time (sec) Walking Velocity (m.sec -1) LEP (WKg-1) 1 0.8 0.6 0.4 0.2 5 4 3 2 1 0 0.0 0 1 2 LEP (WKg-1) 3 0 1 2 3 LEP (WKg-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) As an exercise professional, what information do you require from the referrer of a person with stroke? (L7b) L2 - 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) • Symptoms last more than 24 hours • 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. Definition of Transient Ischaemic Attack (TIA) • • • • Sudden onset Focal neurological disturbance Assumed to be vascular in origin Lasts <24 hours • Symptoms improve because blocked blood vessel spontaneously unblocks and blood supply returns How common is a stroke? • 3rd most common cause of death • Commonest cause of disability; 50% survivors disabled at 6 months • 120,000 strokes per year in UK • 15,000 strokes per year in Scotland • Approx. 700 hospital admissions per year in Edinburgh • 2.3 million deaths due to stroke per year in U.S 3rd Most Common Cause of Death Symptoms Depend on part of Brain Affected Cortex (movement, sensation, intellect, language etc) Cerebellum (balance and control of movement) Brain stem (controls breathing, blood pressure, sleep etc) 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) • Speech: 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 stroke ‘mimics’ • Two main types of brain scans: CT and MR • CT is the most accessible type of imaging. MR less widely available 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 CT Scan of a Patient with a Haemorrhagic Stroke Fresh blood shows up as a white ‘blob’ http://www.strokecenter.org/radiology/browser.aspx, case #14832 Examples of Scans - Ischaemic Stroke 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) Total Anterior Circulation Syndrome (TACS) • 60 year old lady • Found on floor by husband • Right sided weakness (no movement in arm, slight movement leg) • Looking to left and ‘ignoring’ right side • Right facial droop • Right visual field loss • Drowsy • No speech and not following commands • Sounded ‘chesty’ Partial anterior circulation syndrome (PACS) • 80 year old man • Sudden onset right hand weakness whilst drinking a cup of tea, spilt tea • Difficulty finding the ‘right words’ • Able to understand people • Vision fine, leg fine • Symptoms improved over 48 hours, only mild right hand weakness remained Typical stroke (Lacunar Syndrome) • 58 year old lady • Walking down the road • Suddenly noted tingling in right arm and then some weakness in right arm and leg • Speech was normal • 5 years ago had had a similar episode on left side of body Typical Stroke (Posterior Circulation Syndrome) • • • • • • 65 year old man Sitting in a chair Suddenly room starting spinning Tried to get up, felt like he was ‘drunk’ and fell over Double vision Vomited Referral for exercise: Classification of Patients (data from STARTER) 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 Left Atrial Thrombus http://content.nejm.org/cgi/content/full/328/11/771/F1 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) Electrocardiogram (shows electrical rhythm of heart) Echocardiography (left ventricular thrombus) http://content.nejm.org/cgi/content/full/346/18/e5 Colour duplex Doppler from tight internal carotid stenosis Summary • Stroke is 3rd most common cause of death • Most common cause of disability • 85% are Ischaemic (blocked artery) • Symptoms depend on part of brain affected • Oxfordshire Community Stroke Project Classification in widespread use • Different causes and risk factors for stroke L4 Stroke: the longer term Dr. Gillian Mead Reader and Consultant Overview of talk • • • • Stroke prevention (lifestyle and drugs) Longer term post-stroke problems Co-morbidities (and drugs for comorbidities) Services for people after stroke Learning Outcomes At the end of this session, you should be able to: • Describe the measures for stroke prevention • Describe the impact of stroke in the longer term • Demonstrate knowledge and understanding of the most common co-morbidities of stroke, their medications, and how these may impact on a person’s capacity to exercise. • Explain the role of exercise in the context of stroke prevention • Outline the various services for people with stroke • Identify relevant government policy and published national guidelines on stroke 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: general Secondary prevention • Ischaemic – Antiplatelets (aspirin and dipyridamole, or sometimes clopidogrel) – Blood pressure lowering medication – Cholesterol reduction – Warfarin for atrial fibrillation – Carotid endarterectomy for severe carotid stenosis • Haemorrhagic – Treat underlying cause (e.g. arteriovenous malformation) – Blood pressure lowering medication Drugs for secondary stroke prevention (STARTER n=66) 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 Prevalence of fatigue after stroke 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 Drugs for co-morbidities in STARTER n=66 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 L3: Stroke is a Medical Emergency Face Arm Speech Test 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 (only within 4.5 hours of symptom onset) – Decompressive craniectomy (lifting a flap of the skull to relieve pressure) in a tiny proportion of patients • Haemorrhagic stroke – Neurosurgery (only occasionally) to remove blood – Reverse blood clotting defects Acute management (2) • 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) • Best outcomes if patient is admitted to a stroke unit What is a stroke unit? • Organised stroke unit care is provided by multidisciplinary teams that exclusively manage stroke patients in; – a dedicated ward (stroke, acute, rehabilitation, comprehensive) – with a mobile stroke team or – within a generic disability service (mixed rehabilitation ward). Stroke Unit Trialists' Collaboration. Organised inpatient (stroke unit) care for stroke Cochrane Database of Systematic Reviews. 2007. Cochrane Systematic Review of Stroke Units • 31 trials, 6936 patients, compared stroke unit care with an alternative service • 26 trials (5592 participants) compared stroke unit care with general wards • Stroke unit care reduced the odds of death, institutionalised care and dependency • Outcomes independent of patient age, sex or stroke severity • Better when stroke units 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 Patterns of recovery are variable function time A 58 year old man • A shop keeper, drives a car • Sudden onset of left arm and leg weakness, and slurred speech • Presented at 6 hours, given aspirin • Admitted to a stroke unit • 2 days later weakness was improving • 3 weeks later: slightly weak finger grip and reduced power left leg, ready for hospital discharge • Long-term issues….driving, returning to work, secondary stroke prevention • • He would like to know whether he will make a full recovery A 70 year old lady • Sudden onset of severe right sided weakness and dysphasia, drowsy; found lying on floor by husband • Unable to swallow, so required nasogastric feeding • Over the next few weeks, developed pneumonia, requiring antibiotics and oxygen • Recovered from pneumonia but still had severe dysphasia and no movement in her right side • No real neurological recovery at 2 months, required PEG tube feeding • Decision made in consultation with family that nursing home care required Patterns of Recovery • Rate of recovery generally most rapid in the first few weeks • If a patient deteriorates, consider medical complications, recurrent stroke • 95% have completed functional recovery by 3 months • But some patients continue to recover for several years • Recovery related to – 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 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? • 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 (Allied Health Professionals) in stroke care. Essential Reading Further detail about the topics discussed in this session can be found in section [3.2] & [4.3] of the course syllabus. The Evidence… • Cochrane Collaboration Library: http://www.cochrane.org/ • Google Scholar: http://scholar.google.co.uk/ • http://www.knowledge.scot.nhs.uk/ • http://www.askdoris.org/ 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 The Role of AHP in Stroke Rehabilitation Speech and Language Therapy Content The role of the SLT Communication difficulties and their impact Aphasia/dysphasia and dysarthria What you can do to help Learning outcomes By the end of this session, you should be able to demonstrate a sound understanding of: • the potential effects of stroke on speech and language capability • the potential impact of impaired communication on the ability to participate in exercise • the importance of good communication for your role as specialist exercise instructor working with participants with a stroke. Essential Reading • Further detail about the topics discussed in this session can be found in section L9 of the course syllabus. • Stroke Core Competencies for Health and Social Care Staff (the STARS project): http://www.strokecorecompetencies.org/node.asp?id=core Additional sources • Connect: the communication disability network: http://www.ukconnect.org/ • Speakability: http://www.speakability.org.uk/ The role of the SLT Provision of: Assessment for diagnosis of dysphagia and communication problems Information to patients, carers and staff about impairments/ abilities & guidance for safe swallowing and the facilitation of communication. an individualised speech assessment and language therapy care programme, e.g.: ―Support / regular re-assessment ―regular / intensive therapy Facilitating access to : support groups, such as Chest Heart and Stroke Scotland for and provision of augmentative and alternative forms of communication. other professional support, particularly where this will enhance recovery of/ compensatory strategies for communication function. Communication: Giving and Receiving Getting the message Message in Giving the message Message out What is the impact of a communication disability? • Difficulty in personal relationships • Social isolation and loneliness • Loss of identity • Loss of employment opportunities/financial security • Loss of leisure opportunities A Shared Problem? What methods of communication do you use in your day to day work with clients? Writing Speech & language Eye contact Drawing Communication Tone and volume of voice Body posture Gesture Facial expression Aphasia / Dysphasia • This is a language disorder • Affects both message in and message out for both you and the person with aphasia – Understanding speech and writing – Finding words and constructing sentences – Writing responses Example: http://www.strokecorecompetencies.org/labyrinth/mnode_client.asp?id=24422&parent=24427&mode= remote&sessID=17D98D3C-4BD6-4D8E-AD0A-B07B8344F6EB 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 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!) Where is communication breaking down? • Message in – Am I understanding? – Is he/she understanding me? • • • • • Hearing Vision Thinking Environment Mode of communication • Message out – Am I putting this across well? – Has he/she had the opportunity to respond? • • • • • Mode of communication Language used Time Thinking Finding the right words SLT Summary You should have a good understanding of:• The role of SLT in stroke rehab • the diverse range of communication difficulties & how Aphasia is common after stroke SLT – Implications for Specialist Exercise Instructors • Good communication is key to your professional role. •where to find the support and what is available. •How to apply principles of effective communication wherever possible – and keep trying...! Exercise Specialist problem solving • Is one form of communication more difficult than another? • Can this person use other forms of communication? • Could I adapt to make this easier? Key Points about communication disorders • Severity of varies from person to person • Pattern of problems varies from person to person • Communication difficulties and their impact changes over time • The impact on the individual and their family will depend on the people and their circumstances • Severity of impairment does not necessarily match the impact on activity and participation Communication Support Principles • Principle 1: Recognise that every community or group may include people with communication support needs • Principle 2: Find out what support is required • Principle 3: Match the way you communicate to the ways people understand Communication Support Principles • Principle 4: Respond sensitively to all the ways an individual uses to express themselves • Principle 5: Give people the opportunity to communicate to the best of their abilities • Principle 6: Keep trying Effective Communication: Prepare • Plan how you might approach trying to get your message across • Make sure you have their full attention. • Choose a place where there is less distraction • Position yourself well to maintain eye contact. Effective Communication: Observe • Pick up and respond to signs of: • tiredness • Stress • frustration • low mood. • Display of emotion very common and can be an effective communication when there are no words. Effective Communication: Respect • Treat the person as an adult • Do not talk across them • Wait for a reply even it seems a long time in coming • Check if they want help – don’t assume • Be patient and be prepared to repeat things • Try to persist – don’t just give up without agreeing. Effective Communication: Check • Establish a reliable “yes” and “no”. • Thumbs up / down • Pointing to chart – tick and cross • Recap and check that you have understood each other • Do not ever pretend that you have understood – be honest. Effective Communication: Encourage • Accept any method of communication • Understand the aim is to get the message across – not demanding speech • Encourage the use of props • Be positive and as encouraging as possible. • Remember the value positive social contacts have on feelings of well-being Some places for support Talk For Scotland Toolkit http://www.communicationforumscotland.org.uk/ The Role of AHP in Stroke Rehabilitation: Occupational Therapy CONTENT 1. Introduction to the role of OT in stroke 2. Information processing: a model 3. Problems with information processing after stroke: a) Attention and memory b) Sensation and perception c) Planning, taking action and monitoring 4. Summary and implications for exercise instructors. OT Role: Assessment of … • Functional activity limitations using activity analysis, i.e. the components of movement are individually identified, • Skills for the performance of self care (e.g. washing, dressing, feeding), domestic (e.g. shopping, cooking, cleaning), work and leisure occupations. • Skills which impact on each activity (e.g. sensorimotor, cognitive, perceptual and psychosocial impairments) • Assessment of social environment (e.g. family, friends, relationships). • Assessment of physical environment (e.g. home and workplace). OT Role: Intervention by… • Redevelopment of physical, sensory, cognitive, and perceptual skills through activity and practice. • Promote the use of purposeful, goal orientated activity. • Teach new strategies, and compensatory techniques to aid independence. • Assess and advise on appropriate equipment and adaptations to enhance independent function including seating, bathing aids etc • To assess, advise and facilitate, transport and mobility issues such as driving or coping with public transport • To facilitate the transfer of care, from acute stages through rehabilitation and discharge. • Liaise with support groups, and voluntary bodies. OT - Summary and implications OT concentrates on : • Impaired attention and memory • Neglect • Altered sensation and perception • Apraxia and executive dysfunction OT aims to: Enable each patient to achieve the highest level of independence possible. • Exercise instructors need to understand these problems, assess associated risks and appropriately tailor each exercise for individuals. OT – Implications for Exercise Specialists • Cognition • Attention and memory • Sensation and perception • Planning, taking action and monitoring 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? • • • • • • • fatigue more limited attentional capacity lack of awareness of “what goes on” slowed thinking & processing distractability/ poor concentration difficulty doing more than 1 thing at a time perseveration: inability to disengage e.g. step-up. How can you enable a participant with attentional/ memory problems to participate in exercise? • Reduce distraction • Be selective and concise (e.g. don’t give too many instructions/ too much feedback • Encourage association with what is familiar (e.g. make it functional!) • Rehearse/ problem solve (over and over!) • Test understanding of information (i.e. can they actually do it?) • Use prompts (e.g. priming, cues) • Use “prosthetic memory” (e.g. exercise sheets, sticky notes in strategic places) Sensation and perception: Common problems with sensation Sensory impairments Inability to use information from touch, hearing, taste, proprioception or sight, e.g.: • Impaired depth distance Results in different image of an object received by the retina of each eye • Hemianopia Visual field defects http://www.dwp.gov.uk/img/visual-stroke.jpg Perception “Perception is the process through which raw sensations from the environment are interpreted using knowledge and understanding of the world so they become meaningful experiences”. • Is not a passive process simply absorbing and decoding information • The brain is bombarded with stimuli and actively creates coherent information about the world • Individuals fill in missing information and draw on past experiences to give meaning to what we see, hear or touch I cdnuut blveiee that I cluod aulaclty uesdnatnrd what I was rdaneig. The phaonmmeal pweor of the hmuan mnid. Aoccdrnig to rscheearch at Cmabrigde Uinervtisy, it deosn’t mttaer in waht order the ltteers in a wrod are, the olny iprmoatnt tihng is that the frist and lsat ltteer be in the rghit pclae. The rset can be a taotl mses and you can sitll raed it wouthit a porbelm. This is bcuseae the huamn mnid deos not raed ervey lteter by istlef but the wrod as a wlohe. Amzanig huh? Yaeh and I awlyas thought slpeling was ipmorantt! Common problems with sensation/ perception after stroke Impaired body schema Distortions in visual & proprioceptive image of own body. Inability to relate body parts to one another. Unilateral neglect/ visuo-spatial neglect/ hemi-inattention A definition: “Unilateral neglect refers to a difficulty in detecting, acting on, or even thinking about information from one side of space”. (Manly & Robertson in Halligan et al., 2003 p. 92) How do you recognise “neglect” after stroke? Neglect is a failure to attend to "what goes on" on the side contralateral to the afftected hemisphere,and may present as:• Having no notion of the affected side of the body • Being unaware of anything being "wrong" with the affected side (anosognosia) • Failing to recognise visual, auditory and/ or somatosensory stimulation • Forgetting food on plate • Unable to recall locations • Difficulty reading Can you recognise these neglect presentations? How can you tailor exercise for a participant with neglect? •Watch for obstacles (and other people!) •Monitor use of equipment •Monitor posture & movement, especially affected side •Prompt awareness of affected side •Coach use of neglected side •Encourage participants to verbally & visually self-cue Problems with planning & taking action Apraxia/ Dyspraxia: Disorder of learned skilled movements not caused by weakness, abnormality of tone or posture, abnormal movements such as tremors, & poor cognition comprehension & unco-operativeness. (Heilman 1979) Understanding Apraxia Normal Praxis involves: • Forming an idea: • Planning the action • Putting the plan into action: motor execution Apraxia may affect any of the above abilities. What are these dyspraxia issues? How do you know if a participant has apraxia? • • • • May perform well in familiar surroundings May perform well if the task is simple May perform well if few items are required to complete task Problems tend to occur when simple movements are combined in sequence to reach goal, and/or when tools are used. How can you enable a participant with apraxia to participate in exercise? (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? Unrealistic plans; difficulty with goal setting Unrealistic expectations Launching into an activity Difficulty with time management Difficulty making a plan – and sticking to it until its completion Distractible May need prompting How do you know a participant may have executive dysfunction? Inappropriate behaviour (e.g. jokes, disinhibition, anger) Difficulty monitoring self – and changing when things go wrong Difficulty with problem solving; difficulty transferring what has been learned to a new situation (the plan does not quite fit) How can you adapt exercise for a participant with executive dysfunction? Assess: Risks: to self and others? Appropriate: to participate in a group? Suggestions for practice: Explain purpose of session and each exercise Provide a clear plan Monitor participant Prompt to work independently Manage behaviour if required The Role of AHP in Stroke Rehabilitation: Physiotherapy Physiotherapy The Chartered Society of Physiotherapy (CSP) defines the essence of physiotherapy as; "…a health care profession concerned with human function and movement and maximising potential: it uses physical approaches to promote, maintain and restore physical, psychological and social well-being, taking account of variations in health status it is science-based, committed to extending, applying, evaluating and reviewing the evidence that underpins and informs its practice and delivery the exercise of clinical judgement and informed interpretation is at its core." (CSP curriculum framework , January 2002). Physiotherapy Governed & regulated by 2 National bodies. Health Professions Council & Chartered Society of Physiotherapy ensure following processes: – Gather referral information – Conduct clinical interview – Conduct Systematic approach to clinical assessment (Observations + Assessment) – Drawing up a problem list – Formulating a treatment plan using Best available evidence and process of Clinical reasoning – Goal setting with the patient – Deliver interventions – Outcome assessment…feedback to original Ax and goals 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 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 Body Weight Supported Gait Retraining on Treadmill after Stroke… A question about manual guidance.... The more “hands-on” the better? Hands on - Bobath Hands off - Motor Re-Learning • Concept based on clinical experience • Re-education of normal movement through facilitation • Inhibition of abnormal reflexes and movements • Most widely used approach in the UK • Based on theories of motor control and biomechanics • (re)- acquisition of functional tasks • Teaching and learning techniques • Repetitive task practice • Independent problem solving Comparison • Similarities – Normal movement analysis and re-education – Brain able to adapt and re-learn – Discourage compensations • Differences – Facilitation v's active learning – Tone management vs. tone not an issue – Pattern centered v's functional tasks Note: boundaries becoming less distinct Strengths and Limitations Bobath • Does not require high level verbal comprehension • Manual handling issues • Limited to therapy sessions • High level of handling skill required • Bobath based on theory and observation – concept not supported by evidence Motor Re-learning • Functional • Patient more actively involved • Practice can continue out with therapy • Requires good patient comprehension • Motor re-learning additionally based on evidence in related fields Which do physio’s choose? • Comparison studies and systematic reviews show no 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. 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 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 Content 1. Measuring outcomes: why? 2. Measurement: general principles 3. Measuring outcomes: what? – General framework: the ICF – Specific suggestions for the exercise-after-stroke setting 4. Using outcome measures in an exercise after stroke setting: how? Outcome measure – a definition: “ a test or scale administered by therapists that has been shown to measure accurately a particular attribute of interest to patients and therapists and is expected to be influenced by the intervention” (Mayo, 1995) 1. Measuring outcomes: why? 1. Screening: testing eligibility for exercise 2. Baseline assessment: establishing starting point for exercise programme 3. Follow-up assessment: charting change following exercise 4. Monitoring: to chart adherence and identify adverse effects This session: baseline and follow-up assessment using outcome measures 1. Measuring outcomes: why not? Common reasons for not using outcome measures: • It takes time away from the actual exercise • It is a burden for participants • It’s complex and a hassle for the instructors • You need training – we don’t have time for that • What do these measures tell you anyway – I know if something works! Do you??! SCIENCE VS. COMMON SENSE Science: “knowledge, ascertained by observation and experiment, critically tested, systematised and brought under general principles” Cambridge English Dictionary Common sense: “normal understanding, good practical sense in every day affairs, general feeling (of mankind or community)” Oxford English Dictionary • Common sense is not good enough for exercise instructors/ health care professionals; • Exercise/ rehabilitation/ health care needs to be based on science! 2. Measurement: general principles Characteristics of good outcome measures: 1. Relevant 2. Valid 3. Reliable 4. Sensitive to change 5. Practicable 6. Results can be easily communicated (Wade, 1992) Characteristics of good outcome measures Relevance: the pertinence of the information Consider: Is this information useful – what does it tell me? What am I going to do with the information? Characteristics of good outcome measures Validity: the measure does what it is purported to do Consider: • Which idea/ construct does this measure address? Characteristics of good outcome measures Reliability: the measure gives the same result each time the same quantity is measured. Consider: – Intra-rater variation – Inter-rater variation -> Importance of protocols! (tutorial) Characteristics of good outcome measures Sensitivity to change: the measure can detect changes that are relevant Consider: • On what scale is/ are the item(s) scored? E.g.: – – • 0/ 1 or Yes/ No 0-10 (Visual Analogue Scale) Floor and ceiling effects Characteristics of good outcome measures Practicability: the measure is quick and easy to use Consider: • Amount of information required • Duration of the process • Complexity of the process • Burden on client (and you!) Characteristics of good outcome measures Communicability: The results can easily be reported and understood Consider: • Amount • Format • Standardisation of the information 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) 3. Measuring outcomes: what? A general framework for outcome measurement in clinical practice: the ICF International Classification of Functioning, Disability and Health “Aim of the ICF classification is to provide a standard language and framework for the description of health and health-related states.” http://www.who.int/classification/icf/intros/ICF-Eng-Intro.pdf ICF definitions Impairments are problems in body function or structure such as a significant deviation or loss. Activity limitations are difficulties an individual may have in executing activities. Participation restrictions are problems an individual may experience in involvement in life situations. ICF model http://www.who.int/classification/icf/intros/ICF-Eng-Intro.pdf The ICF: A general framework for outcome measurement in rehabilitation Activity Limitations Health Condition Impairments Participation Restrictions Outcome measures and the ICF Which outcome measures do you use in your work ? Where do they fit within the ICF? Can you think of one outcome measure in each of the ICF domains for a person who has had a stroke? Outcome measures for exercise after stroke Activity Limitations Example? Person with stroke Impairments Participation Restrictions Example? Example? 3. Measuring outcomes: what/ how? Suggested outcome measures for exercise after stroke specifically : • 6 min. walk/ 10 m. walk • Timed up and Go • Visual Analogue Scale (VAS) • Stroke Impact Scale + Register: for monitoring adherence Onto: Measuring Outcomes: how? • • • • http://figuredrawings.com/Animation.html 6 min. walk/ 10 m walk VAS Timed up and Go Stroke Impact Scale 6-minute walk test Construct: maximum walking distance in 6 minutes • Relevance: functional test for exercise endurance, O2 uptake • Validity: good • Reliability: high • Sensitivity: ? • Practicability: good • Reporting: easy (distance (m)) • Normative data for healthy people aged 60-89 yrs: 345-623 m (Steffen et al., 2002) Timed Up and Go Construct: time to stand up from arm chair, walk 3 m, turn, walk back, sit down • Relevance: functional test for basic mobility for frail elderly in community • Validity: acceptable • Reliability: moderate - high • Sensitivity: ? • Practicability: good • Reporting: easy (time (s)) • Normative data for healthy people aged 60-89 yrs: 7-12 s (Steffen et al., 2002) VAS Construct: person’s perception of a particular construct • Relevance: depending on what is assessed. Can be used to assess individual goal attainment • Validity: generally good • Reliability: generally high • Sensitivity: high • Practicability: caution with stroke, esp. higher cortical problems and neglect (Price et al., 1999) • Reporting: easy Correct use of VAS in stroke Price et al. (1999), p. 1359. Correct use of VAS in stroke Price et al. (1999), p. 1360. Stroke Impact Scale Construct: the person’s perceived impact of stroke across range of domains (incl. movement, ADL, cognition, communication, emotion, participation) • Relevance: high • Validity: good (devised with target population) • Reliability: moderate – very high • Sensitivity: each item on 5-point scale + one VAS item • Practicability: mixed • Reporting: time-consuming but can be done by mail • Normative data: not applicable • Interpretation: change between 10-15 points clinically meaningful (Duncan et al., 2003) Pitfalls of measurement – and how to fix them Problem • Error: – Systematic – Random • Wrong signals: – False + – False - Solutions: • Errors: – Calibrate your instrument – Use standardised protocol • Wrong signals: – Check sensitivity – Verify with other information Summary Outcome measures are necessary to: • Establish baseline for exercise • Evaluate change following exercise -> science underpinning your work EVIDENCE BASED PRACTICE Choosing your Outcome Measure how to go about it NO T Safe? YES H NO I Relevant? N YES K NO Science Robust? A YES NO Practicable? YES GO G A I N References • DUNCAN, P. W., LAI, S. M., BODE, R. K., PERERA, S. & DEROSA, J. (2003b) Stroke Impact Scale-16: A brief assessment of physical function. Neurology, 60, 291-6. • DUNCAN, P. W. Stroke Impact Scale (SIS). Rehabilitation Outcomes Research Centre, US Department of Veteran Affairs. Available from: http://www1.va.gov/rorc/stroke_impact.cfm (last accessed 05/12/05). • WADE, D. T. (1992) Measurement in Neurological Rehabilitation, Oxford, Oxford University Press. • WORLD HEALTH ORGANISATION (2001). International Classification of Functioning, Disability and Health. Available from http://www.who.int/classifications/icf/en/ 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 – – – – – – ***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: • • • • • • • Governance Preparation and risk assessment for exercise Referral systems and procedures Pre-exercise assessment and ongoing review Specialist Exercise Professional training Content, frequency and duration Record keeping 3. EAS: Guidelines for best practice Other good practice points: • EP to make personal contact before 1st session • Carer/ volunteer to accompany client to 1st session • EAS service to: – – – – Provide transport as appropriate Arrange in-service staff ‘stroke awareness’ training Refer back for Orthotics etc assessment if required Invite trainee EPs/ HCPs (does not affect staff: client ratio) 3. EAS: Guidelines for best practice Available to download from: http://exerciseafterstroke.org.uk/ All UK Stroke MCNs and Cardiovascular Networks, the Stroke NGOs and the CSP,ACPIN, Skills Active & REPS were emailed direct with these guidelines in November 2010 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.