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EXERCISE AND FITNESS TRAINING AFTER STROKE:

Physical Activity & Health Specialist Exercise Instructor Training Course

TUTORIALS & DIRECTED LEARNING PACK

Later Life Training Dec 2011 1

CONTENTS

Chapter in Manual for Directed Learning Questions

PAGE For use on the course or at home

Tutorial: Welcome & Course Information

3-4 Course

2 & 3 Directed Learning: Stroke - Introduction, Impact, Recovery & Co-morbidities

5-8 Home

4 Directed Learning: Stroke Management Services and Secondary Prevention

9-11 Home

5 & 6 Directed Learning: Physical Fitness After Stroke 13-15 Home

7 & 8 Directed Learning: Referral Guidelines and the Role of the Exercise Instructor

17-20 Home

Directed Learning: Observation Visit to Stroke Setting & Brief Written Report

21-26 Home

Tutorial and Directed Learning: Preparation for the Practical Teaching Workshop, Day 5

27-28 Home & Course

Session Plan Templates 29-30 Home

Directed Learning & Course Practical’s: EfS Problem solving/Tailoring Process

31-43 Home & Course

Tutorial & Practical: Outcome Measures (Formative Assessment)

44-49 Course

10 Directed Learning: Health Behaviour Change Case Studies 51-53 Home

Directed Learning: Referral Pathways 55 Home

Tutorial and Directed Learning: Risk Assessment

Example Documentation-Risk Assessment

57-59

61-63

Course & Home


TUTORIAL: WELCOME & COURSE INTRODUCTIONTUTORIAL 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…?

2. Which practice format are you most familiar with (e.g. one-to-one, small group sessions, large

exercise classes)?

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

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

experience been so far?

5. 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?

2. 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.).

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

feelings?


4. 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.

2. What do you expect of your course tutors?

3. 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.

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

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

4. Which medical conditions may mimic a stroke?

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

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

7. 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.

8. 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?

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


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

11. In terms of the most common longer-term complications from stroke: a. 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?

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

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

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

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

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

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

13. In terms of recovery after stroke:a. When does most of the recovery typically occur?

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


c. 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?

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

3. What services are available after stroke following discharge from hospital? Briefly describe the

role of each service.

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

5. 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?

6. 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?

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

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


9. Which Health Care Professions (HCPs) together make up the Multidisciplinary team in the

patient’s journey after stroke?

10. What is the main role of each of the following HCPs in stroke rehabilitation? Summarise the key

stroke-related problems that each profession addresses:

a. Physiotherapist

b. Occupational Therapist

c. Speech and Language Therapist

d. Dietician

e. Orthotist/ Prosthetist

f. Clinical Psychologist

g. Orthoptist

h. Social Worker

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


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

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

14. What are the main effects and side effects of the following drugs:

a. Aspirin

b. Clopidogrel

c. Dipyridamole

d. Warfarin

e. Statins

f. Thiazide Diuretics

g. ACE Inhibitors

h. Beta-blockers

i. Calcium antagonists?



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:

a. Cardiorespiratory fitness

b. Muscular strength

2. What are the main effects of normal ageing on:

a. Maximal oxygen uptake

b. Explosive leg extension power?

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

4. What is currently known about physical fitness and physical function after stroke and what is the

relationship between these two factors?

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

6. 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:

a. The number of participants


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

c. The effects following the intervention?

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

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

9. With respect to the STARTER trial:

a. Describe the general content of each session.

b. Compare and contrast the week 2 with the week 12 session – what are the main

changes?

c. What do you think is the rationale for including the following exercises:

i. Mixed standing/ seated exercises?

ii. Sit to stand?

iii. Back of arm strengthener?

10. What is the relevance of the STARTER trial for your own work as an exercise instructor for

people after stroke?

11. 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.


12. What is an “absolute contraindication” and what are the absolute contraindications for exercise

after stroke?

13. What is a “relative contraindication” and what are the relative contraindications for exercise

after stroke?



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?

2. What are the key responsibilities of the health care professional (HCP) referring a person to an

exercise referral scheme following stroke?

3. Which information should be provided to the exercise instructor by a physiotherapist (or other

health care professional) referring a person for exercise after stroke?

4. Which parameters may be useful for the purpose of self-monitoring in the context of exercise

after stroke?

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

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

7. 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?

8. What are the key session aims for exercise after stroke and what is their underlying rationale?


9. How can the exercise instructor adapt the session content to the needs of the person after

stroke?

10. What are the exercise programming recommendations for stroke survivors published by the

American Heart Association (2004) in terms of:

a. Aerobic exercise

b. Strength training

c. Flexibility

d. Neuromuscular exercise?

11. What are the recommendations for exercise after stroke, based on the STARTER trial (Mead et

al. 2007) in terms of:

a. Frequency

b. Intensity

c. Time/ duration

d. Type of exercise

12. 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.

13. What are the current guidelines for best practice for exercise after stroke in terms of:

a. Staff: participant ratio

b. Programming principles


c. Teaching skills

14. In the context of generic risk assessment for exercise, which factors need to be considered in

relation to:

a. The facility

b. Equipment

c. People/ activities

15. 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:

a. Tone and posture

b. Fatigue

c. Progression

d. Tailoring to individual capabilities

e. Pain

f. Falls

g. Orthoses/splints/aids

16. Ongoing monitoring of people exercising after stroke is essential. Which factors need to be

monitored and why are they important?

17. Which conditions may cause people to become unwell during exercise, which symptoms need to

be monitored and what action should be taken if required?

18. What are the medico-legal requirements exercise instructors need to comply with when

completing notes on people exercising after stroke?


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

20. 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?

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

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

23. What action should the exercise instructor take in case:

a. A participant has not attended exercise for two consecutive weeks without having given

a reason?

b. Terminates the exercise referral programme?

24. Exercise instructors working with people after stroke should comply with ethical and

professional standards:

a. Do you know your local guidelines on data protection?

b. What are the key points from the Department of Health Guidelines for Exercise Referral

(2001)



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 VISITThe 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.


STROKE OBSERVATION VISIT AND REPORT GUIDANCE

1. The Clinical Rehabilitation/Health Setting

Aim: The aim of this visit is for you to enhance your understanding of a person’s experiences after a

stroke, gain a better understanding of typical problems after stroke, expand your knowledge about

rehabilitation, develop your observation and evaluation of the diverse exercise needs and reflect on

the implications of what you have observed for your own role.

Setting: typical settings are outpatient services of local hospitals, community or domiciliary

services. Try to find a local service to you or contact the Stroke Charities to help identify the

nearest appropriate clinical rehabilitation setting.

Preparation: to help you focus on some key issues during this visit and when writing up your

short report, you may wish to consider the following points:

Regarding the person(s) with stroke:

What appear to be their main difficulties (consider motor, sensory, and functional

impairments, communication and cognitive difficulties, pain, fatigue and mood) and how

do these affect them?

What are their main rehabilitation/functional/exercise goals – if any?

Are the family/ carer(s) involved? If so, in what way?

Regarding the health professional(s) HCPs i.e. as appropriate to your chosen setting :

Which HCP(s) do you observe and what are their roles?

What aspects of professional behaviour do you observe?

What do you observe in terms of communication between the HCP and the person

with stroke, their family/carer(s)?

What techniques does/do the HCP(s) use to motivate the person?

Reflection/ Consideration pointers: following your visit, take some time to think about what

you have observed and what you have learned from this before writing your brief report. You

may wish to consider the following questions:

Re. the impact of stroke: what were the key issues and how do you think you would take

these into consideration as a specialist exercise instructor?


What were the main rehabilitation etc goals – were they what you would expect or were

there any surprises?

What did you think about the intensity and complexity of the rehabilitation input – was

there anything you had not expected?

What did you learn about the role of HCPs/social care etc professionals in stroke

rehabilitation/recreation settings?

What did you learn about professional behaviours (including communication and

motivation, monitoring health and safety, respecting the person’s dignity) that you think are

good practice for your own role?

What else did you learn that you think is of value to you?

2) The Stroke Charity or Other Community and/or Care Setting

Aim: The aim of this visit and the reflective writing account is to enhance your understanding of

the person’s journey after a stroke, gain a better understanding of typical problems after stroke

and how these may impact on the life of the person, their family and/ or carer(s) and reflect on

the implications of your observations for your own role.

Setting: Chest Heart and Stroke Scotland, Different Strokes, The Stroke Association or similar.

Also Day Centres etc .

Note: Chest Heart and Stroke require visitors interacting with people who have had a stroke to

have Enhanced Disclosure (ED) Scotland or a Criminal Records Bureau (CRB) Check. Therefore,

only those of you with an ED or CRB qualify to visit CHSS and participate in their activities.

Different Stroke do not have such a requirement and The Stroke Association groups vary locally.

All three organisations are aware of, and involved in, the development of, this course and will

welcome your visit.

Preparation: to help you focus on some key issues during this visit, you may wish to consider the

following points:

Regarding the person(s) who has/ have had a stroke:

What appear to be their main difficulties (consider motor, sensory, and functional

impairments, communication and cognitive difficulties, pain, fatigue and mood) and

how do these affect them?


How do/does the person(s) appear to cope with their difficulties? E.g. are there any

alternative communication or mobility strategies, are tasks or the environment adapted

in anyway? If so, how?

Is there anything in particular that the person(s) seem(s) to enjoy? If so, what do you

think this is?

Reflection/Consideration pointers: following your visit, take some time to think about what you

have observed and what you have learned from this. When writing up , you may wish to

consider the following questions:

Re. the impact of stroke: what were the key issues and how do you think you could take

these into consideration as a specialist exercise instructor?

What have you learned about individual coping strategies after stroke and how does this

inform you? Were there any surprises?

What did you think people enjoyed about the activity? Is there anything you can learn from

this for your own practice?

What else did you learn that you think is of value to you?

OPTIONAL CASE STUDY – Additional Study (i.e. Practice for the Final Summative Case Study Assignment)

Writing Case Studies about individual patients in an integral part of the skill set of all multi-

disciplinary professionals working with patients. It requires practice to develop and/or maintain

these skills. It is strongly recommended that you prepare for the writing of your final Case Study

Assessment assignment by practicing the following familiarisation Preparation Case Study 1 with an

appropriate individual stroke participant. This Preparation Case Study is optional, not assessed

formatively but will give invaluable experience in developing your analytical skills. The course

Physiotherapy Tutor will build on, and extend, this experience and your skills, through guided

analysis and problem solving of a video case study on Days 3/4 of the course.

Aim: The aim of this Preparation Case Study is for you to gain a better understanding of typical

problems after stroke and what their implications may be for participating in exercise.

Importantly it is designed to enable you to have the opportunity to apply the theoretical and

practical concepts and approaches you have learnt on the course to the prescription and


programming of exercise for a specific individual. This allows you to practice for your final

summative Case Study Assessment.

Recommendation: The Preparation Case Study should be a MAXIMUM of TWO sides of A4 and

should be done in note form, i.e. a summary of all the points that you would include in a full

case study. This should include an overview of the medical, rehabilitation, personal and social

history etc. Further guidance on the areas to cover is given on page 29. The rationale for your

tailored exercise programming decisions for this individual should also be included (eg. an

example of how you would use critical analysis of the literature and the course manual as the

basis to plan your programme). This could be done in note form or in bullet points as preferred.

Use the following headings to guide the writing of the Preparation Case Study to ensure each

important point is considered.

The Case Study Individual: A volunteer who has been medically discharged after their stroke, is

ambulatory and actively engaged in some form of regular physical activity (e.g. exercise session,

walking, swimming. This individual could be recruited during your Stroke Charity Visit or could

be a participant from your own or a colleague’s exercise setting. Friends and/or relatives should

be used only if recruitment is proving difficult.

Setting: An exercise setting – either your own or that of one of your colleagues on this course.

Working in pairs: You are welcome to PAIR UP with a peer on the course to do this preparatory

and writing up work together for this Preparation Case Study. This is particularly helpful if you

have not undertaken this sort of work before or for a long time. NB. Please remember that for

your final Case Study Assessment you MUST do the final written work on YOUR OWN.

Procedure: This Preparation Case Study is based on your routine observations and notes from a

person who has had a stroke and who participates in exercise.

A note on data protection: in order to ensure anonymity of the person in your case study,

please ensure that there are no actual personal details on your documents or any other

information from which the person could be identified. E.g. you should use a name that

ensures the person cannot be recognised (e.g. Mr. A., Mrs. B.).


A note on ethics: The person who is the subject of this case study should give consent to

their information being used, but it must be made clear to the person what the information

is used for and that the information is anonymous and will be kept confidential.

Information to be included: NB. If all the information below is not available from the individual

and/or the group organiser, then make a clear note. Ensure you record as much information as

possible.

o Background:

Demographic information: age, gender, social status (i.e. employed, married

etc.), hobbies. Please see the note above re. data protection.

Stroke-related information: type of stroke, time after stroke, medication, any

impairments, any aids (e.g. ankle-foot orthosis).

o Exercise after stroke:

Exercise-related information: the level and content of the exercise programme,

social context (i.e. individual- or group-based).

Rationale: what is the rationale for each of the aspects of the current exercise

programme (i.e. on what basis did you and/or your colleague select the specific

level and content of the programme?).

Adherence: are there any issues with adherence to the programme? E.g. how do

you encourage motivation to continue participation? Have you thought about

long-term maintenance – how do you think this could be achieved?

o Reflection/Consideration:

What worked well in this exercise programme and why? E.g. what do you think

the person particularly enjoyed about his/ her programme?

Were there any stroke-related difficulties that the person experienced during

exercise and if so, what were they? How could these be explained? How were

they taken into consideration in the exercise programme and was this effective?

If not, what were the problems that will need to be resolved?

Are there any specific challenges you experienced in this situation and if so,

what were they? What have you done so far to address these and what further

work (i.e. developing knowledge, skills) will be required?


TUTORIAL AND DIRECTED LEARNING: PREPARATION FOR THE PRACTICAL TEACHING WORKSHOP, DAY 5

Following on from the Practical workshops on days 1, 2, 3 and 4 you will be delivering a Peer Led

Practical Teaching Workshop on Day 5

During the Peer-Led Practical Teaching Workshop, on Day 5 of the course, you will teach

specific exercises to your peers. You will receive feedback from your peers and both verbal and

written feedback from your tutors. You will also have the opportunity to practice self-evaluation of

your teaching.

Students on Level 4 courses report that this is one of the most valuable sessions for professional and

personal development. In order to make the most of this opportunity, it is important to prepare as

fully as possible.

DAY 5 TEACHING PREPARATION

On Day 4 you will be given 3 exercises to plan and deliver to your peers for your teaching workshop on Day 5:

ONE mobility exercise OR pulse raising activity

ONE circuit exercise to introduce, then teach ONE circuit rotation

ONE group strength exercise OR cool down stretch

Session Preparation and Planning

In preparation for your teaching practise and to practise your session planning for summative assessment plan, compile a list of stroke specific teaching points for the exercises you have been allocated, and consider the tailoring requirements for the following impairments;

AFO / High tone upper limb/ Visual Impairment / Flaccid Arm / Low tone upper limb

You can use the session plan template on page 29 to plan your exercises and the tailoring

worksheets on page 31 to support this learning. Remember that to be competent to work with

stroke patients, you will need to demonstrate that you can supervise, adapt and tailor exercise for

both groups, and individuals.


Please practice your allocated exercises in preparation for day.

NOTES:


L4 Exercise and Fitness after Stroke Specialist Instructor Training Course- Practical Session Plan

ComponentEquipmentExercise Name Purpose

Duration/Reps (STARTER week 7/8)

Stroke Specific Teaching Points(to ensure effectiveness and safety)

Detail example of each of the following for a variety of impairments;1)Adaptation & Tailoring 2)Exercise Progression

Component: Equipment: Ex Name:Purpose:

Candidate Name:____________________________ Course Name:_____________________Course Code: EfS____________________ Page: ___ of ___

Candidate Signature: ____________________Date:_____/_____/_____ Assessor Name:___________________________ Date:____/_____/_____

IV Name: ______________________________Date:____/_____/______

L4 Exercise and Fitness after Stroke Specialist Instructor Training Course- Practical Session Plan

ComponentEquipmentExercise Name

Duration/Reps (STARTER week 7/8)

Stroke Specific Teaching Points(to ensure effectiveness and safety)

Detail example of each of the following for a variety of impairments;1)Adaptation & Tailoring 2)Exercise Progression


Purpose

Component: Equipment: Ex Name:Purpose:

Candidate Name:____________________________ Course Name: _____________________Course Code: EfS____________________ Page: ___ of ___

Candidate Signature: ____________________Date:_____/_____/_____ Assessor Name:___________________________ Date:____/_____/_____

IV Name: ______________________________Date:____/_____/______


EfS PROBLEM SOLVING/TAILORING:

What is the definition of ‘tailoring?’ (Review Chapter 8 and ppt L8b)

Specialist Exercise and Fitness after Stroke Instructors should approach ‘tailoring’ as a problem solving process. It is not a ‘one size fits all approach’. Tailoring solutions are very individual. The ability to think through the problem (i.e. the impairment limitation) in order to still achieve the desired outcome (the exercise/activity) is an essential skill. Instructors should reach successful tailoring solutions based on sound rationale. Working with the participant to achieve effective tailoring solutions is part and parcel of the excellent communication skill required with this population.

The Tailoring Process/Rationale:

1. What do you see (& know) / what is the impairment?

2. What is the limitation of the impairment/s? (Joint action/ROM)

3. What activities will the impairment effect? (ADL’s, STARTER exercises) and what risks may they pose during exercise?

4. What tailoring to the impairment could be put in place to still achieve the desired exercise?

5. Review your tailoring, is it achieving its aim?

6. Monitor, monitor, monitor – for associated reactions, adverse responses, posture/tonal changes, and review if needed

7. Progress the exercise if appropriate

The following worksheets are designed to help your own problem solving/tailoring skills for stroke impairments. Answer sheets are not provided as tailoring solutions are many and highly individual. You will have opportunity to use these worksheets on course and for home study. The worksheet is a tool to aid your decision making process in order to effectively rationalise your tailoring solutions with participants. This worksheet may also support your learning in preparation for your written case study (for submission on day 6).


Exercise Name:

1. What are the joint actions involved in this exercise?

2. What are the main muscles Involved?

3. What impairments will particularly impact on ability to perform this exercise? What limitations do the impairments present? What activity limitation could be present with this impairment? (List some examples)

Impairment Impairment Limitation Activity Limitation

3. For the impairment/s you listed above, what tailoring strategies could be used to ensure safety and effectiveness of this exercise? (Consider grip, support requirements, base of support)

4. Review your tailoring solutions; is the exercise still doing what it should do? (Achieving the desired exercise outcomes)



Exercise Name:

1. What are the muscle groups/muscle actions involved in this exercise?

a. Muscles Involved?

b. Muscle and joint actions?







Exercise Name:










Exercise Name:










Exercise Name:










Exercise Name:










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EfS TUTORIAL & PRACTICAL: OUTCOME MEASURES

(NB. Formative Assessment)FORMATIVE ASSESSMENT:

The aim of this session is to give you the opportunity to practice administering (carrying out), according to

published protocol, a number of specific outcome measures recommended for use in an Exercise after

Stroke setting and to evaluate their properties. The outcome measures are:

1. 6 minute walk test/ 10 metre walk test

2. Visual Analogue Scale

3. Timed Up and Go

4. Stroke Impact Scale

Relevance for formative assessment:

You will be expected to give evidence to your course tutors of your ability to competently apply one of

these outcome measures to an individual during Day 4 of the practical workshop using the appropriate

protocol.

Station 1: TIMED WALKING TESTS

There are a number of different timed walking tests, which typically measure the time taken to cover a set

distance, or the distance covered in a set period of time (Wade, 1992). Commonly used variations are the

6 minute walk test and the 10 meter walk test.

6 minute walk test (6MW test)

Introduction:

The 6 minute walk test (6MW test) was designed to measure the maximum distance a person could walk

within this period of time. A functional test reflecting the patient’s submaximal aerobic capacity, the

6MW test is commonly used with patients with cardiac or pulmonary conditions. In some patients

however, this test measures maximal oxygen uptake (Scheffer et al., 2002).

Note that protocols for the 6MW test may vary slightly, depending on the population they are used with.

These variations are sometimes based on health and safety considerations (e.g. falls risk), sometimes on

practicalities (e.g. available space). Since slight variations (e.g. instructions or chairs placed along the

trajectory) may influence the results, it is important to stick with a particular protocol, once this has been

chosen. Compare two variations of the 6 MW test protocol below:

Protocol 1:


“The 6MW was conducted along a 30- 2.3-m linoleum hallway marked in 1-m increments. A line was made

at each end of the walkway to indicate where the person was to turn. Researchers were positioned at each

end of the walkway in case any subject had a problem. Subjects walked alone during the 6MW unless the

researcher felt that they were unsafe. Subjects wore a heart rate monitor or carried a pulse oxygen

monitor in order to track the resting heart rate between trials. Subjects were instructed to “walk as far as

possible in 6 minutes.” They were given standardized encouragement at 1, 3, and 5 minutes during the

walk: “You’re doing a good job” (minute 1), “You’re halfway done” (minute 3), “You have 1 minute to go”

(minute 5). Each subject had a practice trial and then rested until heart rate returned to the baseline level.

A second 6MW trial followed the rest period. Distance walked during each trial was recorded to the

nearest meter. Data from the second 6MW trial were used in the analysis, as it has been suggested that 2

tests are necessary to achieve reproducible results.”(Steffen et al., 2002)

Protocol 2:

A chair should be placed mid-way between two cones, placed at a minimum distance of 20m apart. Use a

stopwatch to time 6 minutes and a system for counting laps.

The participant starts after having been given a clear command. He/she walks round the cones until 6

minutes have been completed. The participant stops on countdown to finish time. At finish time, the last

lap distance is measured from the cone that was passed last. The total distance is then calculated. If the

participant stops during the test or needs to sit down (e.g. due to angina), he/she fails the test

(Willenheimer & Erhardt, 2000).

References

STEFFEN TM, HACKER TA, MOLLINGER L (2002). Age- and Gender-Related Test Performance in

Community-Dwelling Elderly People: Six-Minute Walk Test, Berg Balance Scale, Timed Up & Go Test,

and Gait Speeds. Physical Therapy 82 (2): 128-137.

WADE DT (1992) Measurement in Neurological Rehabilitation, Oxford, Oxford University Press.

WILLENHEIMER R, ERHARDT L (2000) Value of 6-min-walk test for assessment of severity and prognosis of

heart failure The Lancet 355 (9203): 515 -516.

WORLD HEALTH ORGANISATION (2001). International Classification of Functioning, Disability and Health.

Available from http://www.who.int/classifications/icf/en/


http://www.who.int/classifications/icf/en/

10 meter walk test

Protocol:

Set up a 10 m walkway, e.g. two lines, perpendicular to the direction of travel, and at a distance of 10m

apart. The participant is asked to walk at their preferred speed, using any aid needed (including personal

support, Wade, 1992). The participant starts 2m before the starting line and finishes 2 m over the finishing

line. Time is started as the leading foot first crosses the starting line and ends as the leading foot first

crosses the finishing line, respectively. If possible, the average of 3 tests should be taken, after a practice

trial.

Tutorial Questions:

1. Choose one of the protocols described above for the 6MW or 10m walk test and set up the test.

Check this has been done according to protocol.

2. One assessor carries out the test and records the result. Ensure you have included at least two

repetitions.

3. Ask another assessor to repeat step 2.

4. Compare your results:

a. Within the same assessor

b. Between the two assessors

Are there any differences? How large are they and how can they be explained?

5. In your opinion, what are the strengths and limitations of using this test with people after stroke?

Consider health and safety, as well as the generic properties of a measurement instrument (i.e.

validity, reliability, etc.).

6. In terms of the WHO International Classification of Functioning, Disability and Health (2001), what

construct(s) do the 6MW and 10m walk tests measure (i.e. impairment/ activity limitation/ disability)?

Please explain your answer.


Station 2: VISUAL ANALOGUE SCALE

Introduction:

Visual Analogue Scales are used widely in health care settings to obtain a measure of a patient’s

perception of a health issue. There is a considerable body of research on the properties of the VAS.

“Pain” is probably the most widely assessed issue, but other examples include overall well-being and

function. A VAS can be horizontal or vertical.

Protocol

The VAS comprises a line of 10 cm long without any numbers or subdivisions.

Each end of the line is anchored with an extreme statement reflecting the issue being measured, e.g. “zero

represents no pain whatsoever and 10 represents the worst possible pain”.

The assessor explains the VAS to the participant and clearly explains what the anchors stand for. The

participant is then asked to mark the line at a position that indicates their current perception of the issue

being measured. The location of this mark is then measured in millimetres from the lower end. Problems

have been observed when people with stroke use VAS – please refer to Price et al. (1999).

Reference

PRICE CIM, CURLESS RH, RODGERS H (1999) Can Stroke Patients Use Visual Analogue Scales? Stroke 30:

1357-1361.

Tutorial Questions:

1. Decide on an issue you wish to measure and make a VAS. Check that this has been done according to

protocol.

2. One assessor carries out the test and records the result.

3. If available, ask another assessor to repeat step 2, using the same scale and focusing on the same

issue.

4. Are there any differences between the two assessors in how they carry out the test? If so, how could

these differences influence the results?


Consider the generic properties of a measurement instrument (i.e. validity, reliability, etc.).


construct(s) do the 6MW and 10m walk tests measure (i.e. impairment/ activity limitation/disability)?



Station 3: TIMED UP & GO

Introduction:

The Timed Up & Go was designed to assess basic mobility skills in frail elderly people, living in the

community. It is based on the Get-Up and Go test by Mathias et al. (1986), which was originally scored on

an observational scale. Time taken to perform the test is simple to measure and improves the robustness

of the results.

Protocol:

“The “timed Up & Go" measures, in seconds, the time taken by an individual to stand up from a standard

arm chair (approximate seat height of 46 cm), walk a distance of 3 meters, turn, walk back to the chair,

and sit down again. The subject wears his regular footwear and uses his customary walking aid (none,

cane, or walker). No physical assistance is given. He starts with his back against the chair, his arms resting

on the chair's arms, and his walking aid at hand. He is instructed that, on the word "go," he is to get up and

walk at a comfortable and safe pace to a line on the floor 3 meters away, turn, return to the chair, and sit

down again. The subject walks through the test once before being timed in order to become familiar with

the test. Either a wrist-watch with a second hand or a stop-watch can be used to time the performance..”

(Podsiadlo & Richardson, 1991, p. 142).

References

PODSIADLO D & RICHARDSON S (1991). The Timed "Up & Go": A Test of Basic Functional Mobility for Frail

Elderly Persons. Journal of the American Geriatric Society 39: 142-148.

SHUMWAY-COOK, A., BRAUER, S., & WOOLLACOTT, M. (2000). Predicting the probability for falls in

community-dwelling older adults using the timed up & go test. Physical Therapy, 80(9): 896-903.

Tutorial Questions:

1. Set up the test and check this has been done according to protocol.

2. One assessor carries out the test and records the result. Ensure you have included at least two

repetitions.

3. Ask another assessor to repeat step 2.

4. Compare your results and try and explain any differences:

a. Within the same assessor b. Between the two assessors


Consider health and safety, as well as the generic properties of a measurement instrument (i.e.

validity, reliability, etc.).


construct(s) do the 6MW and 10m walk tests measure (i.e. impairment/ activity limitation/ disability)?



Station 4: STROKE IMPACT SCALE (SIS)

Introduction:

The Stroke Impact Scale is a self-report measure, which is administered in interview form. A study has

also indicated that administering the SIS by mail is feasible, with omissions being relatively infrequent

(Duncan et al., 2002). The SIS has been developed on the basis of interviews with stroke patients, their

carers and health care professionals (Duncan et al., 1999, 2001) and covers the following domains:

strength of the affected limbs, gait, stair climbing and transfers, ability to use the affected hand in ADL,

independence in general ADL, participation in leisure, voluntary activities and paid employment, cognition,

emotion and communication, as well as overall recovery. Apart from the last item, which is scored on a

vertical visual analogue scale, each item is scored on a five-point scale.

Protocol:

Read through the SIS Guide for Administration and familiarise yourself with the information. Then, read

through the actual scale.

References in Appendix 5 of Manual.

Tutorial Questions:

1. How is the SIS administered?

2. What does the SIS require in terms of the participant’s cognitive and communication skills?

3. Can a proxy be used if the participant is unable to respond appropriately?

4. From the SIS, select one domain and administer all the items in this domain to your colleague.

5. Check in the Guide whether you have followed the instructions correctly. Also obtain feedback from

your colleague on how you administered the items.

6. Now score the items, using the information in the Guide.

7. In your opinion, what are the strengths and limitations of using the SIS with people after stroke?

Consider validity, reliability, sensitivity, practicability and communicability of the test.


construct(s) do the 6MW and 10m. walk tests measure (i.e. impairment/ activity limitation/ disability)?



NOTES:


DIRECTED LEARNING: HEALTH BEHAVIOUR CHANGE CASE STUDIES

Directed Learning:

The aim of this session is to apply the knowledge you may already have and information from the session

on changing behaviour and motivation to the facilitation of longer-term physical activity participation by

people with stroke. It will explore the challenges that may be encountered, and help you move towards

solutions and suggestions to make the most of available opportunities.

Question 1: Enhancing physical activity by a person with a stroke.

Consider the following case study:

Mrs. A has been referred to you for exercise by her GP, following her stroke 14 months ago. Mrs. A, who

is 64 years of age, experienced a TACS that affected the right side of her body. Some function has

returned to her legs and her husband feels that Mrs. A should now try to get back to exercise. They used

to enjoy walking in the country together and he feels it is time that Mrs. A “builds up her stamina”.

Mrs. A’s medical details indicate she is eligible for exercise and you are keen to provide her with an

exercise programme. However, when you assess Mrs. A’s readiness for exercise, she indicates that she

merely made an appointment with you because her husband had “sent her”.

When you question this a little further, it emerges that Mrs. A has given up hope that she will ever be able

to walk in the country. She indicates that she can only walk a very short distance (around 500 yards) with

the support of one person, and fatigues quickly. Sometimes she feels even too tired to get up in the

morning. Mrs. A tells you that she used to be quite fit and enjoyed a range of outdoor activities, but she

now feels weak and clumsy after her stroke. She has gained weight and indicates that she “does not like

her body” any longer. She says that she is aware that she should be doing more exercise but she can’t see

herself coming into the gym with all these “lycra types”, as she refers to the other users of the gym.

Question 1:

1. On the basis of the information above, what is your interpretation of Mrs. A’s:

a. Level of self-efficacy?

b. Stage of Change?


2. Starting from Mrs. A’s stage of change, devise a careful plan that is tailored to this stage and that aims

to help Mrs. A progress to the Maintenance stage. Consider in particular:

a. Mrs. A.’s level of self-efficacy

b. Mrs. A’s perception of the decisional balance (i.e. costs vs. benefits)

3. Which stroke-specific challenges do you think you may encounter going through this process of

change with Mrs. A? How would you handle these challenges?

Question 2 (for reflection only):

Changing health behaviour and you

1. Have you ever been given advice by a health care professional (HCP) to improve your health behaviour

(e.g. to stop smoking, reduce drinking, eat better, take medication, exercise (!)) – and taken it up

successfully?

What motivated you to follow this advice?

Can your motivation best be explained through the Incentive or the Drive Reduction Theory (see

Chapter 10)? Why do you think this is so?

2. Have you ever been given advice by a HCP to improve your health behaviour – and not taken it up?

Why did this happen?

To try and understand this (common) situation, let’s consider the Stages of Change model:

a. Which stage were you at when you received the advice?

b. How did you perceive the costs and benefits of the behavioural change at that time?


c. Did you think the HCP recognised the stage of change you were at and did they tailor their

advice accordingly?

d. Looking back, how could the HCP have helped you be more successful at changing your health

behaviour? What can you learn from this situation for your own practice?

Now let’s try and explain the same situation by considering Self-efficacy.

e. What can you say about your level of self-efficacy at the time you were advised to change your

health behaviour?

f. Do you think the HCP recognised this and tailored their advice accordingly?

g. Could this have been done more effectively – if so, how?

2. Has your own success - or difficulty with - changing your personal health behavioural informed

your work? If so, how? How do you think you may apply this experience successfully to your work

involving people with stroke in an exercise setting?


NOTES:


DIRECTED LEARNING: REFERRAL PATHWAYSSESSION AIM:

This session focuses on writing referral reports by Specialist Exercise Instructors. Although services may

vary in their protocols, good practice would suggest that it is appropriate for the Specialist Exercise

Instructors to feed back relevant information to the referrer. This task provides you with an opportunity

to practice writing a report about a fictitious case study, obtain feedback on content and presentation, and

share ideas on good practice.

Procedure:

Consider the video footage of Mr R on the website. Imagine that this client has completed his 12-week

exercise programme and you are preparing a report to feed back relevant information to the referrer (i.e.

the client’s physiotherapist) about progress made.

Compile a concise, accurate and professionally presented report on any progress that he has made during

the course of his exercise programme. You may wish to refer to the template “Participant Passport

Information” (p. 129 of the course manual), which comprises the following headers:

1. Name

2. Address

3. DoB

4. Telephone Number

5. Health Problems

6. Stroke information

7. Medication e.g. with relation to exercise and mood.

8. Assessments: before and after

9. Reported functional improvements/complications

10. Further concerns/recommendations


NOTES:


TUTORIAL & DIRECTED LEARNING: Risk Assessment (Example documentation)

SESSION AIM:

This session focuses on all aspects of risk assessment as part of legal and moral obligations to ensure

exercise venues, contents and environments are safe and appropriate for the populations using them (i.e.

stroke survivors).

It provides example documentation for you to use whilst on course and for the risk assessment required as

part of your summative Case Study assessment assignment.

Why Risk Assess?

There are both legal and moral obligations to carrying out an assessment of exercise-related risk prior to

participation, particularly where the exercise is supervised, as well as possible cost implications if an

assessment is not completed, not sufficient or current. Once completed, the risk assessment should be

periodically reviewed to ensure it is still up to date with the patient’s health and fitness status and

relevant to your organisation. The importance of ongoing risk rating becomes clearer when we consider

the types of risk to be stratified.

What kind of risk is being assessed?

In the exercise context, risk stratification is a process by which the medical history of a client is assessed

and stratified to determine the level of risk of a health/disease event occurring either acutely ( during or

following) exercise) or predicted for the future, as a direct result of exercise participation . Typically a

rating of low, medium or high risk of such an event is established. However, this is not a static rating and

the exercise professional should note changes in health and fitness condition that can either increase or

decrease an individual’s level of risk. For example an individual who has medical treatment (e.g. medicine

or surgery) that significantly reduces symptoms and associated problems may also reduce their level of

risk.

Risk Stratification is Not a Single Rating. Risk stratification is rarely a single measure or rating as a number

of different medical aspects can be risk stratified. Individuals, especially stroke patients over the age of 50

years, could have a number of conditions/co-morbidities that each need to be risk stratified and evaluated

and an overall rating of risk arrived at. Furthermore there are two general aspects of risk stratification that

need to be determined for each condition:

1. What is the risk of an “acute” event occurring from physical exertion (here and now)

2. What is the risk of an individual developing a specific condition over-time (chronically) for the

future?


What does a risk assessment need to be?

It must be suitable and sufficient for the activity/ environment work is happening.

These are not defined in regulation, but in practical terms mean:

- The risk of assessment should identify the risks arising from, or connected to work.

- The level of detail in the risk assessment should be proportionate to the risk.

- Once the risks are assessed, insignificant risks can usually be ignored.

- The level of risk arising from the work activity will determine the intensity of the risk assessment.

What are Hazards?

Hazards can come in a variety of forms:

- Physical – Mechanical, Electrical, Noise, Lighting, others

- Biological - Allergies, Health Status, Medications

- Chemical – Dust, Fumes, Corrosives

- Ergonomic – Unsuitable equipment, poor working/occupational posture

Identifying Hazards can help determine the level of risk by asking ‘What If…?’ scenario questions

surrounding the environment/ activity

- Personal Observation - Workforce Consultation

- Previous Experience - External Advice

Questions you should ask to determine risk are:

- Who might be harmed and how

- The Likelihood of risk

- The Severity of risk

Ways to reduce the Likelihood and or Severity of risk could be

- Hard Control measures – Protective devices, Housekeeping, activity layout.

- Soft Control measures – Procedures, Culture, Campaigns / Posters, training/Induction

Methods of preventing an occurrence or controlling risk could include:

- Elimination of something or activity

- Substitution of something or activity

- Engineering controls (modifying /safeguarding machinery)

- Administrative control such as procedures, supervision of those working

Welfare Arrangements such as rest and toilet breaks.

Hydration and privacy.


Calculating and Stratifying Risk

To determine what risks require further action through the above methods you can calculate risk through

rating Likelihood and Severity on a scale of 1-5

Likelihood = 1 Unlikely 2 May happen 3 Likely 4 Very Likely 5 Certain

Severity = 1 Minor (1st Aid) 2 Minor (treatment off site) 3 Injury over 3 days

4 Major injury (RIDDOR reportable) 5 Death

Risk Rating = Likelihood x Severity/Co-morbidities

If the Risk Rating is between 1-4 = Low Risk, Existing control measure must be maintained

If the risk Rating is between 5-10 = Medium Risk, Action required soon to control. Interim measure may

be

necessary in short term

If the risk rating is between 12-25 = High Risk, Action required urgently to control. Further resources

may be required.


Notes:


Health and Safety Checklists follow

Health and Safety Venue Assessment for L4 Exercise after Stroke SessionVenue Information and contactsVenue Name Date of Assessment / Review date

Contact Person / Details for Venue Person(s) writing assessment

Address of Venue

Client InformationMaximum number within class Any known special requirements of client group i.e.

Medical/Overall Risk Stratification /BehaviouralNO YES (if yes please indicate action below)Are support Staff required

First Aid and FireLocation of First Aid Kit Fire Exits

First Aider on call during class Fire Fighting equipment locations

Location of Telephone Fire Assembly point

Venue specific procedure for 1st Aid Venue Specific procedure for Fire

Site InformationLocation / Distance of toilets Wheelchair access

Car Parking Information Hearing aid loop?

Equipment Used: Safety Points. Equipment Name Hazards or Risks Associated Controls in place to reduce risk Likelihood (L) x Severity (S) = Risk (R) Risk Rate

L S =R H / M / L

L S =R H / M / L

L S =R H / M / L

L S =R H / M / L

L S =R H / M / L


EfS Environmental / Exercise/ Client Based Risk AssessmentPotential Risk Hazards or Risks Associated Controls in place to reduce risk Likelihood (L) x Severity (S) = Risk (R) Risk Rate

Ceiling Height L S =R H / M / L

Floor L S =R H / M / L

Obstacles L S =R H / M / L

Temperature / Ventilation L S =R H / M / L

Equipment L S =R H / M / L

Access to venue (i.e. car loading etc) L S =R H / M / L

Privacy / Protection issues L S =R H / M / L

Exercise / Skill Choices L S =R H / M / L

Health/ Suitability of Clients L S =R H / M / L

Lighting/Distractions L S =R H / M / L

Other L S =R H / M / L


Medium or High Level Risk Continuation Assessment for L4 Exercise After Stroke Session

Name of Risk Original Risk Rating Further Action taken to reduce risk rating Revised Risk RatingLikelihood (L) x Severity (S) = Risk (R) LevelL S =R H / M / L

L S =R H / M / L

L S =R H / M / L

L S =R H / M / L

L S =R H / M / L

L S =R H / M / L

L S =R H / M / L

L S =R H / M / L

L S =R H / M / L

L S =R H / M / L

L S =R H / M / L

L S =R H / M / L

L S =R H / M / L

L S =R H / M / L

L S =R H / M / L



Documents

Later Life Training€¦ · Web viewNo physical assistance is given. He starts with his back against the chair, his arms resting on the chair's arms, and his walking aid at hand