Exercise and Fitness Training After Stroke
Specialist Instructor Training Course
Autumn 2010
Exercise after Stroke
Specialist Instructor Training Course
Course Development Project Team:
Dr. Gillian Mead
Dr. Susie Dinan-Young
Ms. Sara Wicebloom- Paul
Mr. John Dennis
Mr. Mark Smith
Prof. Marie Donaghy
Dr. Frederike van Wijck
Bex Townley
WELCOME
1.
2.
3.
4.
5.
6.
7.
Introductions
Course Background
Learning outcomes
Summary of Content
Approaches to learning
Study materials
Assessment
Course Background
Physical fitness essential for
physical activity
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 - The Patient’s Pathway
Days 1 & 2
• Stroke; impact, incidence,classification, AHP’s)
• Specialist instructor skills for level 4’
• Safe effective Circuit management for stroke survivors’
• 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
Day 5
• Outcome assessment
• Communication, Changing behaviour and goal setting;applied
• Problem solving/inc case study and formative assessment
• Implementation
Day 6 Assessment
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
• tutorials
• practical sessions
– 157 hours of (self) directed learning
Study materials
• Course Manual
• Powerpoint presentations - booklet
• Other literature and resources: book chapters, journal papers
• Student page on website www.laterlifetraining.co.uk/login.php
• Username: EfS-Student Password: StrokeLLT2003
Summative Assessment
Day 6
• One 2 hour theory paper; MCQ and short answer
• One 30 min practical assessment
Case Study Submission
• One 1500 -word coursework based on:
– a clinical case study (video based) combined with;
– one hour session plan
• Further information in your Candidate Assessment pack
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
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)
35
30
25
20
number
15
10
5
0
TACS
PACS
LACS
POCS
Possible descriptions of stroke
when patients referred for exercise
Pathological subtype
• Ischaemic, infarction
• Description of likely cause
e.g. embolic
• Haemorrhagic,
‘intracerebral
haemorrhage’, ‘ICH’,
‘PICH’
Classification
• Oxfordshire Community
classification
• Site of lesion on brain
scan
– Middle cerebral artery
territory, posterior
cerebral artery territory
Risk Factors for Ischaemic Stroke
Common
• Hypertension
• Diabetes mellitus
• Cigarette smoking
• Atrial fibrillation
• Carotid stenosis
• Cardiac disease
• Alcohol
• High cholesterol
• Obesity
• Reduced physical activity
• Diet
Rarer
• Vasculitis
• Polycythaemia
• Leukaemia
• Hyperviscosity
• Thrombophilias
• Anti-phospholipid syndrome
• Neurosyphilis
• Endocarditis
Risk Factors and Causes of Haemorrhage
Primary Intracerebral Haemorrhage
• Hypertension
• Coagulation disorder
• Aneurysm
• Arterio-venous malformation (AVM)
• Cigarette smoking
• Amyloid angiopathy
• Drug abuse
Causes of Ischaemic Stroke
• Blood clot forms in artery in brain e.g. middle cerebral, or
small deep artery in brain
• Blood clot forms at another site and ‘travels’ to brain
(embolism)
– Aorta (main artery in chest)
– Carotid artery (in neck)
– Heart
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
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.
Stroke Unit, Royal Infirmary,
Edinburgh 2000
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
60
frequency %
50
40
30
20
10
0
re c urre nt
s t ro k e
s e izure s
urine
inf e c t io ns
c he s t
inf e c t io ns
o t he r
inf e c t io ns
f a lls
pa in
a nxie t y
de pre s s io n
e m o t io na lis m
c o nf us io n
Patterns of recovery 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
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)
80
%
70
60
50
40
30
20
10
0
antiplatelets
anticoagulants
ACE-
thiazide
beta-blockers
calcium antag
alph blockers
Longer term problems after stroke
(relevant to exercise delivery)
•
•
•
•
•
•
•
•
•
Pain
Fatigue
Mood disorders (anxiety, depression, emotionalism)
Falls and fractures
Cognitive impairment
Seizures
Infections (urine, chest most common)
Bladder and bowel problems
Contractures
Pain is common
• Stroke related pain
– Complications e.g. DVT
– Central post stroke pain (typically burning,
shooting)
– Shoulder pain (hemiparetic side) in 25%
– Pressure sores
– Limb spasticity
• Non-stroke related
– e.g. arthritis
Shoulder pain
• Affects 25% of patients
• More common in severe
strokes
• Causes are
multifactorial
• Optimum treatment
uncertain
• Advice from
physiotherapist
Central post-stroke pain
• Burning, icy, lancinating, lacerating, shooting,
stabbing, clawing
• May respond to antidepressants
(amitryptiline), anticonvulsants (gabepentin)
Falls
• In the first six months after discharge, half to
three-quarters of patients fall
• Causes
– Patient related factors e.g. muscle weakness and
wasting, incoordination, loss of awareness of
midline
– Environment e.g. uneven floors, footwear
– Drugs e.g. sedatives, antihypertensives
va
n
Study
A
Ly
nc
h
pl
er
os
ae
ss
or
le
y
N
M
ta
ub
la
de
r
er
f
le
s
W
S
G
de
r
In
g
Le
eg
ar
d
02
02
20
07
20
06
20
05
20
20
01
20
20
01
19
99
19
83
Prevalence (%)
Prevalence of fatigue after stroke
80
70
60
50
40
30
20
10
0
Potential mechanisms of post-stroke
fatigue
Stroke
Pain
Depression
Direct physical mechanisms
Sleep disturbance
Treatment
Reduced mobility
FATIGUE
Behavioural avoidance and de-conditioning
Adapted from Wessely, Hotopf and Sharpe 1998
therapy
Mood disorders
• Depression in around 25%
• Anxiety in around 20%
• Emotionalism (20%) sudden outbursts of
laughing or crying
Cognitive impairment
• Memory and thinking problems
• May precede stroke or occur as a result of
stroke
• Affects around 20% of patients at 6 months
(MMSE of 23 or less)
• Can get worsening of cognitive impairment as
a result of other medical problems e.g.
infection
Co-morbidities
• Diagnosable condition which exist in addition
to main condition
• May have caused stroke (e.g. atrial fibrillation)
• Co-morbidity e.g. angina may be caused by a
common risk factor (e.g. high blood pressure)
• May be unrelated to stroke e.g. gout
Co-morbidities in STARTER
%
50
45
40
35
30
25
20
15
10
5
0
hypertension
IHD
Cancer
Diabetes
LVF
arthritis
other
Drugs for co-morbidities in STARTER
n=66
25
%
20
15
10
5
0
analgesics
ulcer drugs
inhalers
steroids
thyroxine
diuretics
digoxin
antidepress
Relevance of co-morbidities to
exercise delivery
• Hypertension: drugs may cause postural hypotention and
dizziness, beta-blockers: measurement of pulse rate to
measure intensity of exercise
• Ischaemic heart disease: exercise can carry risks.
– Avoid if unstable angina
– Exercise within limitations of stable angina.
– Congestive cardiac failure: tailor to breathlessness and fatigue
• Diabetes mellitus: exercise may precipitate hypoglycaemia.
Seek medical advice prior to taking up classes. Strategies
may include
– Reduction of insulin dose prior to exercise
– Take additional carbohydrate prior to exercise.
– Avoid injecting insulin into exercising muscle as absorption increases
and so risk of ‘hypos’
Services for people after a stroke
• In-patient care (rehabilitation, terminal care, long-term NHS
care)
• Out-patient care (e.g. neurovascular clinics)
• Early supported discharge services
• Primary care team
– GP (quality outcomes framework)
– District nurse
– Practice nurse
•
•
•
•
Respite care, day hospital
Domiciliary physiotherapy
Long-term nursing home care
Charities (e.g. advice lines, CHSS stroke nurses)
Younger stroke patients
• 25% of patients are under 65
• Similar neurological effects as older patients
• Need to consider impact on employment,
finances and relationships
• All age stroke units, young stroke units
• In Lanarkshire: young stroke worker
• Different Strokes: charity set up by younger
stroke patients for younger patients
Department of Health: National Stroke
Strategy
•
•
•
•
•
•
•
•
•
•
•
10 point action plan
Awareness (recognition of symptoms)
Preventing stroke
Involvement
Acting on warnings
Stroke as a medical emergency
Stroke unit quality
Rehabilitation and community support
Participation (planning housing, transport)
Workforce (skill mix)
Service improvement
Summary
• Early management of stroke
– Acute treatment (aspirin and clot busting drugs for ischaemic stroke)
– Secondary prevention (aspirin, antihpertensive drugs, statin, warfarin,
carotid endarterectomy)
– Rehabilitation (on a stroke unit by a multidisciplinary team)
• Long-term problems (pain, fatigue, cognitive impairment,
mood disorders, falls, infections)
• Co-morbidities (ischaemic heart disease, diabetes have
important implications for exercise delivery)
• Stroke in a national context: stroke strategies exist for UK
L5
Physical fitness after stroke
background
Dr. Gillian Mead
Reader and Consultant
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
The University of Edinburgh
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
Physical fitness essential for physical
activity
Cardiorespiratory
Muscle strength and power
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).
Muscle strength
Maximum force that can be generated by a muscle or muscle group
Ability to sustain repeated muscular actions or a single static contraction is
'muscular endurance' (USDHHS 1996)
Muscle power
Rate of generation of strength
Body composition
Includes total and regional bone mineral density, and the relative amounts and
distribution of adipose tissue, muscle and other vital parts of the body (USDHHS
1996).
What happens to physical fitness after
stroke?
• Physical fitness is related to physical activity
• After stroke, activity falls
• So might physical fitness be reduced?
Aerobic fitness (endurance) after stroke
Peak V02 synthesised from 16 studies (Dave Saunders 2007 unpublished)
Muscle strength and power after
stroke
We recruited 11 patients who had made an apparently full
neurological recovery several months after their stroke
We measured
– Muscle strength
– Power output of both lower limbs
We found that muscle strength and power output in both limbs
were significantly lower than age and sex matched values
from the population
Greig et al 2001
Measurement of maximum voluntary isometric knee
extensor strength
Measurement of lower limb extensor power during a
single maximal leg extension
Might these impairments in aerobic
fitness, muscle strength and muscle
power have consequences for
function, mobility, quality of life?
Influence of impaired leg extensor power on
function after stroke?
• In 66 ambulatory patients, who had completed their
rehabilitation, there were associations between impaired LEP
in both the affected and unaffected limbs and
–
–
–
–
–
–
–
–
–
Timed up and go
Sit to stand
Functional reach
Comfortable walking velocity
FIM
Rivermead motor index
Nottingham extended ADL
SF36
Elderly mobility scale
(Saunders et al 2008)
LEP and function in 66 people after stroke (STARTER)
Timed 3-m up and go (sec)
Functional reach (cm)
40
30
20
10
0
0
1
2
60
40
20
0
3
0
2
3
LEP (WKg-1)
1.2
7
1.0
6
Chair rise time (sec)
Walking Velocity (m.sec -1)
LEP (WKg-1)
1
0.8
0.6
0.4
0.2
5
4
3
2
1
0
0.0
0
1
2
3
0
LEP (WKg-1)
Affected (■) and unaffected (□) legs
1
2
LEP (WKg-1)
3
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
Comorbid Disease
STROKE
Pathology
Fitness
Impairments
Cycle of
Detraining
Physical
Inactivity
Direct Effect
of Stroke
Functional
Limitations
Other
Impairments
Process of
Disablement
DISABILITY
Courtesy Dave Saunders 2008
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
L6
Exercise after stroke:
theory and evidence
Dr. Gillian Mead
Reader and Consultant
Outline of talk
• 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
The University of Edinburgh
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)
Median (IQR) FIM
171 (55-287)
147.5 (78.8-235.5)
117.5 (114-121)
117.5 (112.8-122)
Fitness training intervention
• Devised by a Clinical Exercise Instructor in
collaboration with a specialised 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 0.67
speed (m/s)
0.74*
0.74*
Mean or median, * p<0.05 from baseline.
No statistically significant changes in other variables
Differences between groups
1st post-intervention assessment
Exercise better than relaxation
Quality of life: role physical
Physical function: timed up and go
Physical fitness: walking economy
2nd post-intervention assessment
Exercise better than relaxation
Quality of life: role physical
Qualitative sub-study (benefits)
• Enjoyment
– The class itself
– Socialising
– Getting out of the house
• Tuition
– Endless praise for Irene (the exercise instructor)
– Participants felt ‘well looked-after’
– Irene had a major role in the success of the class
Qualitative sub-study (benefits)
• Perceived benefits from both classes:
– Physical recovery
– Getting back into a routine
– Improved mood and wellbeing
– Confidence
• Long term effects
– Learning new skills
– Practising at home
– Attending other classes
To quote one participant…….
It was back in November and it was no joke
That was the time that I suffered a stroke….
Round came time for relaxation class
Others were there who’d been in the same boat…
The things we learned were useful and good….
The lady who ran the class is an excellent woman
Her voice is gentle and booming……
Thanks to the excellence of the wonderful Irene
Conclusions
• Trial design was feasible
• Exercise was more beneficial than relaxation
for some outcomes
• Not all benefits were maintained long-term
• These results are included in the updated
Cochrane systematic review and 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
1200
1000
800
600
patients
400
200
0
12 trials in 2004
24 trials in 2007
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]
Control
Mean Difference
7.07
46.04
10
0.3%
[-69.97,
87.97]
16.2DURING
13.8
7 Weight
5.6% 9.00
19.20
[1.93, 95%
36.47]
Mean
SD Total
IV, Fixed,
CI
58.2
38.4
10
1.8%
15.00
[-15.74,
45.74]
7.07USUAL
46.04 CARE
10
0.3%
9.00
[-69.97,
87.97]
N
Mode
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 15.00
Treadmill
16.2
13.8
7
5.6%
19.20
[1.93,
36.47]
6.22
19.49
-0.22 [7.84,
[-7.47,71.36]
7.03]
58.2Glasser
38.4 198637
10 32.0%
1.7%
39.60
20
Gait
trainer
7.07
46.04
10
0.3% 9.00
[-69.97,
87.97]
36Pohl
13.2
6.60
[-2.15,
a 25
6.22
19.49
37 21.9%
32.0%
-0.22
[-7.47,15.35]
7.03]
2002
30
Treadmill
58.2
38.4
10
1.8%
15.00
[-15.74,
45.74]
19.2
21.6
7.20
[-0.72, 15.35]
15.12]
36
13.2
25 26.8%
21.9%
6.60
[-2.15,
2002b 78
30
Treadmill*
58.2Pohl
38.4
10
1.7%
39.60
[7.84,
71.36]
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*
6.22
19.49
37 32.0%
-0.22 [-7.47, 7.03]
39%Eich
177
90.1%
5.93
[1.61, 10.24]
2004
50
Treadmill
36 13.2
25 21.9%
6.60
[-2.15, 15.35]
39%
2007 78 26.8%
155
Gait
trainer15.12]
19.2Pohl
21.6
7.20
[-0.72,
177
90.1%
5.93 [1.61, 10.24]
39%
48AFTER
29.4
47
9.9% 11.40 [-1.61, 24.41]
47
9.9% 11.40
48USUAL
29.4 CARE
47
9.9%
11.40 [-1.61,
[-1.61, 24.41]
24.41]
Salbach 200447
91
Circuit
9.9%
11.40
[-1.61, 24.41]
IV, Fixed, 95% CI
Maximum Walking Speed
48OVERALL
29.4
47
9.9% 11.40 [-1.61, 24.41]
EFFECT
47 100.0%
9.9% 11.40
-1
6.47[-1.61,
[2.37, 24.41]
10.57]
6.47 m·min224
2.37, 10.57 p=0.002
= 33%
224 100.0%
6.47 [2.37, 10.57]
= 33%
(P = 0.43), I² = 0%
224 100.0%
(P = 0.43), I² = 0%
= 33%
Mean Difference
IV, Fixed, 95% CI
-100
-100
6.47 [2.37, 10.57]
-100
-50
0
50
Favours
control 0 Favours training
-50
50
Favours control Favours training
100
-50
0
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
L7a
Referral Guidelines Part A:
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.”
Why refer to an 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.
EXERCISE AFTER STROKE
Specialist Instructor Training Course
T11
Provider Risk Management
J. Dennis
Content
• A exercise area
• B systems
• C on the floor
Learning Outcomes
At the end of this session, you should be able to:
• Describe the risk assessment process
• Demonstrate competency in risk assessment
• Discuss your own typical area risk assessment
• Demonstrate competency in assisting someone
off the floor after a fall
Essential Reading
Further detail about the topics discussed in this
session can be found in section [8.6] of the
course syllabus.
Facility
•
•
•
•
•
•
Floor surfaces- sound & clean
Handrail – secure
Windows - no obstruction
Temperature – controllable
Mirrors in avoidable position
Swing doors – controllable
Equipment
•
•
•
•
•
Adequate ice packs accessible
Blankets available
Obstacles – steps checked for set up
Mats – non-slip
Positioning of equipment chairs – stable &
safe
• Music – volume / type
Systems & Organisation
•
•
•
•
•
•
Alarm / Phone working
Emergency action plan in place
All staff trained in Emergency Operating Procedures
Specific individual needs accommodated
Medical history available & all participants screened
Emergency contact numbers available
Off the floor?
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