Exercise and Fitness Training After Stroke

EXERCISE AND FITNESS TRAINING AFTER STROKE:

Physical Activity & Health Specialist Exercise Instructor Training Course

TUTORIALS &
DIRECTED LEARNING PACK

CONTENTS

TUTORIAL: WELCOME & COURSE INTRODUCTION

TUTORIAL AIMS:

The aims of this introductory tutorial are:

For you to establish a baseline for this course by clarifying the following:

•Your perceived baseline in terms of knowledge and skills;

•Your goals and expectations of the course

•For us to gauge your background and understand your learning needs.

Group Discussions: BACKGROUND

In order for us to understand your learning needs better; please tell us something about
your background:

1. For how long have you been an Exercise Instructor/Physiotherapist/Other…?

1. Which practice format are you most familiar with (e.g. one-to-one, small group sessions, large exercise classes)?

1. Which “special populations” have you worked with and for approximately how long?

1. Have you had any experience in working with people after stroke? If so, what has your experience been so far?

1. How/when will you be using time for course study?

NB If you have any special educational needs (SEN)? Please speak directly to your course tutor at the earliest possible opportunity to discuss any special education needs in confidence.

Question 2: YOUR BASELINE

1. What do you think is your current level of knowledge about stroke? Did you complete the pre-course reading recommendations? What are your strengths and limitations?

1. What do you think about the level of your ability to engage with people with stroke in an informal setting (e.g. having a conversation etc.).

1. How do you feel about working with people who have had a stroke? Can you explain those feelings?

1. How do you estimate your current level of ability to work in an exercise setting with people who have had a stroke? What are your strengths and limitations?

Question 3: YOUR EXPECTATIONS

The question below is for your personal use, but we will discuss selected key findings in the group.

1.What do you expect to achieve following the completion of this course? Please try and be as specific as you can be. You may wish to think about:

• Knowledge and understanding
• Skills and competencies
• Short-term and long-term goals.
• What do you expect of your course tutors?

1. What are your expectations of the course itself (e.g. workload, level)?

4.What do you expect of yourself?

5.What do you expect of the group?

6.What other expectations do you have?

Question 4: ACHIEVING YOUR GOALS

The question below is for your personal use, but we will discuss selected key findings in the group.

Having discussed your baseline and your expectations, how do you think you are going to achieve your goals? Think about the processes you will need to get involved in. Will you need any assistance/ resources to do so? If so, what and when?

Question 5

Is there anything else you would like to discuss at this stage? Please discuss with your tutor any questions or concerns you may have.

DIRECTED LEARNING:

STROKE: INTRODUCTION, IMPACT, RECOVERY & CO-MORBIDITIES (Chapters 2 & 3)

These questions aim to test and embed your knowledge learned on the course.

STROKE

1. What is a stroke? Compare and contrast the three main types of stroke in terms of their incidence and underlying mechanism.

1. What is the difference between a stroke and a TIA? Why is it important to seek medical advice following a TIA?

1. What are the core signs of a stroke? Why is it essential to contact the emergency services in case of a stroke?

1. Which medical conditions may mimic a stroke?

1. What is the impact of stroke in terms of death, disability and costs to society?

1. What are the possible effects of a stroke and why do these vary between people?

1. What are the main impairments in the following functions after stroke: motor, speech and language, sensory (including visual), memory, emotion, continence and praxis? Give examples of how each impairment might impact on the ability to participate in exercise.

1. Amidst the diversity in stroke symptomatology, there are four main patterns. What is the most frequently used stroke classification and why is it useful to have an understanding of this?

1. What are the main risk factors for ischemic and haemorrhagic stroke?

1. Do exercise instructors have a role in primary stroke prevention? If so, what could this involve?

1. In terms of the most common longer-term complications from stroke:
2. What are the main causes of post stroke pain? Shoulder pain is common after stroke. What are the possible explanations for this? How could the specialist exercise instructor avoid an increase in shoulder pain?

1. What are the main reasons for the increased risk of falling after stroke and how could this be prevented in an exercise setting?

1. Compare and contrast “spasticity” with “contracture” and think about the implications of each for participating in exercise.

1. Why are mood disorders and depression common after stroke? How could a specialist exercise instructor take these problems into consideration?

1. What does “cognition” involve and how may cognitive impairment manifest itself in exercise classes?

1. Why is fatigue common after stroke? How could specialist exercise instructors take this into consideration?

1. What are the most common comorbidities in stroke and what are their implications for participating in exercise?

1. In terms of recovery after stroke:
2. When does most of the recovery typically occur?

1. Are there any patterns in recovery that can be discerned?

1. Is there a limit to recovery after stroke? If not, what are key factors in continuing recovery and what is the potential role of the specialist exercise instructor in this process?

14.What is the role of each of the following tests in stroke medicine:-

a.A brain scan?

b.An ECG?

c.A carotid Doppler?

The answers to these questions can be found on the LLT EfS Student webpage but we suggest you attempt to answer them first and then check your answers.

Notes:
DIRECTED LEARNING:

STROKE MANAGEMENT SERVICES AND SECONDARY PREVENTION (Chapter 4)

These questions aim to test and embed your knowledge learned on the course.

1. What are the key components of a stroke service?

1. What is a stroke unit and which models are currently in existence?

1. What services are available after stroke following discharge from hospital? Briefly describe the role of each service.

1. In which settings may rehabilitation after stroke take place?

1. Of all people who experience a stroke, what is the proportion of patients under the age of 65 years? Which special services are there for this population?

1. Many people who have experienced a stroke have a carer. Provided that the person who has had a stroke agrees, exercise instructors may involve the carer in aspects of their exercise programme. What are your own thoughts on which aspects of the exercise programme you would involve the carer in? How you would do this and what do you think the benefits could be for the person who has had the stroke?

1. Which stroke-specific treatments are available in the acute stage after stroke?

1. What are the various forms of general supportive care in the acute stage after stroke?

1. Which Health Care Professions (HCPs) together make up the Multidisciplinary team in the patient’s journey after stroke?

1. What is the main role of each of the following HCPs in stroke rehabilitation? Summarise the key stroke-related problems that each profession addresses:
2. Physiotherapist

1. Occupational Therapist

1. Speech and Language Therapist

1. Dietician

1. Orthotist/ Prosthetist

1. Clinical Psychologist

1. Orthoptist

1. Social Worker

1. In what ways may the members of the MDT communicate?

1. What is “secondary prevention” and why is this important after stroke?

1. Which secondary stroke prevention strategies may be used after stroke?

1. What are the main effects and side effects of the following drugs:
2. Aspirin

1. Clopidogrel

1. Dipyridamole

1. Warfarin

1. Statins

1. Thiazide Diuretics

1. ACE Inhibitors

1. Beta-blockers

1. Calcium antagonists?

The answers to these questions can be found on the LLT EfS Student webpage but we suggest you attempt to answer them first and then check your answers.

Notes:

DIRECTED LEARNING QUESTIONS:

PHYSICAL FITNESS AFTER STROKE (Chapters 5 & 6)

These questions aim to test and embed your knowledge learned on the course.

1. Define the following key concepts:
2. Cardiorespiratory fitness

1. Muscular strength

1. What are the main effects of normal ageing on:
2. Maximal oxygen uptake

1. Explosive leg extension power?

1. What are the main effects of stroke on physical fitness and how can these be explained?

1. What is currently known about physical fitness and physical function after stroke and what is the relationship between these two factors?

1. In theory, what are the benefits of exercise after stroke?

1. The evidence on which “exercise after stroke” is based is relatively new and much is still to be learned. Can you give one example of a study on mixed aerobic and strength training after stroke, listing:
2. The number of participants

1. The intensity (i.e. duration, frequency, session length)

1. The effects following the intervention?

1. Same as for question 6 but applied to a study on strength training alone.

1. Same as for question 6 but applied to a study on aerobic training alone.

1. With respect to the STARTER trial:
2. Describe the general content of each session.

1. Compare and contrast the week 2 with the week 12 session – what are the main changes?

1. What do you think is the rationale for including the following exercises:
2. Mixed standing/ seated exercises?

1. Sit to stand?

1. Back of arm strengthener?

1. What is the relevance of the STARTER trial for your own work as an exercise instructor for people after stroke?

1. What are the key questions that future research into exercise after stroke needs to address? Select 3 questions that are most important to you and explain your rationale for choosing these.
2. What is an “absolute contraindication” and what are the absolute contraindications for exercise after stroke?

1. What is a “relative contraindication” and what are the relative contraindications for exercise after stroke?

The answers to these questions can be found on the LLT EfS Student webpage but we suggest you attempt to answer them first and then check your answers.

Notes:

DIRECTED LEARNING:

REFERRAL GUIDELINES AND THE ROLE OF THE EXERCISE INSTRUCTOR (Chapters 7 & 8)

These questions aim to test and embed your knowledge learned on the course.

1. Which medico-legal requirement do exercise instructors need to comply with when participants self-refer to an exercise referral scheme?

1. What are the key responsibilities of the health care professional (HCP) referring a person to an exercise referral scheme following stroke?

1. Which information should be provided to the exercise instructor by a physiotherapist (or other health care professional) referring a person for exercise after stroke?

1. Which parameters may be useful for the purpose of self-monitoring in the context of exercise after stroke?

1. Which factors should be assessed by the exercise instructor prior to exercise?

1. Compare and contrast “adapting” and “tailoring” an exercise programme.

1. Which factors does the exercise instructor need to consider in terms of the starting point of an exercise programme for a person after stroke and why?

1. What are the key session aims for exercise after stroke and what is their underlying rationale?
2. How can the exercise instructor adapt the session content to the needs of the person after stroke?

1. What are the exercise programming recommendations for stroke survivors published by the American Heart Association (2004) in terms of:
2. Aerobic exercise

1. Strength training

1. Flexibility

1. Neuromuscular exercise?

1. What are the recommendations for exercise after stroke, based on the STARTER trial (Mead et al. 2007) in terms of:

1. Frequency

1. Intensity

1. Time/ duration

1. Type of exercise

1. Despite the AHA and STARTER guidelines, the authors of this course syllabus highlight that “It is not yet possible to make firm recommendations with respect to the ‘FITT’ (frequency, intensity, time/duration, and type of exercise) principles”. Discuss this statement.

1. What are the current guidelines for best practice for exercise after stroke in terms of:
2. Staff: participant ratio

1. Programming principles

1. Teaching skills

1. In the context of generic risk assessment for exercise, which factors need to be considered in relation to:
2. The facility

1. Equipment

1. People/ activities

1. In the context of specific risk assessment for exercise after stroke, consider the following factors in detail. Explain the action(s) you would take for each factor to enhance the health and safety:
2. Tone and posture

1. Fatigue

1. Progression

1. Tailoring to individual capabilities

1. Pain

1. Falls

1. Orthoses/splints/aids

1. Ongoing monitoring of people exercising after stroke is essential. Which factors need to be monitored and why are they important?

1. Which conditions may cause people to become unwell during exercise, which symptoms need to be monitored and what action should be taken if required?

1. What are the medico-legal requirements exercise instructors need to comply with when completing notes on people exercising after stroke?

1. Under what condition may a participant be allowed back into exercise after having been unwell?

1. In addition to the statutory emergency action plan, what else should be in place in an exercise facility accommodating people who have had a stroke?

1. If a person develops symptoms of a recurrent stroke which action should be undertaken?

1. What action should be taken if a participant with ischaemic heart disease develops chest pain?

1. What action should the exercise instructor take in case:
2. A participant has not attended exercise for two consecutive weeks without having given a reason?

1. Terminates the exercise referral programme?

1. Exercise instructors working with people after stroke should comply with ethical and professional standards:
2. Do you know your local guidelines on data protection?

1. What are the key points from the Department of Health Guidelines for Exercise Referral (2001)

The answers to these questions can be found on the LLT EfS Student webpage but we suggest you attempt to answer them first and then check your answers.

DIRECTED LEARNING:

OBSERVATION VISIT TO STROKE SETTING & BRIEF WRITTEN REPORT

You will be expected to undertake one visit to a stroke specific setting, ideally prior to Day 3 of the course when there is a dedicated stroke visit discussion . The visit is considered to be an important step in the process of becoming a competent EfS instructor. It is designed to raise your awareness and broaden your understanding of stroke and the diverse impact it may have on individuals. The visit will provide the opportunity to develop your skills of observation and evaluation of functional movement and give an insight into the diverse exercise prescription needs of patients after stroke. You will be required to write up a brief report on your visit and your experience by the final day of the course (Day 6). This report can be in any format you prefer ( eg notes or in full) and will not be assessed but must be recorded as completed on your Final Candidate Assessment Summary Sheet ( eg like CPR evidence). The visit and report provide crucial practice in the preparation for, and the writing of, your final summative Case Study assessment assignment.

It is a requirement of this course (and qualification) for you to complete this observational visit and report.

THE OBSERVATION VISIT

The visit should take place in either a clinical rehabilitation setting OR in a community stroke group setting (e.g. an exercise, sports or other activity session or social gathering or information session run by Different Strokes, the Stroke Association, Chest Heart and Stroke etc who often employ exercise instructors and physiotherapists on a weekly basis). Details to help you organise, prepare, learn from and write up these visits are outlined below.

Note: when making contacts with a potential host organisation, please remember that your hosts undertake/facilitate these visits on top of their normal work load – we are most grateful for their generous assistance. Please also remember that you are an ambassador for this course and for future Exercise and Fitness Training after Stroke student instructors. EfS is a relatively new service initiative and there may well be instructors who have not yet been able to undertake the L4 training yet have considerable experience and great communication skills with this group of patients. Please encourage and praise the positives, identify the gaps and evaluate and learn from their skills. Thank you for your consideration.