Exercise after Stroke:



Exercise after Stroke:

Physical Activity & Health

Specialist Exercise Instructor Training Course

SELF-ASSESSMENT QUESTIONS

L3 STROKE IMPACT, RECOVERY AND COMORBIDITIES

These questions are based on Lecture 3 and Chapter 3 of the course syllabus. The answer guidelines will indicate what information is required and how to structure your answer. The number in brackets refers to the page in the course syllabus where you can find the required information.

QUESTIONS: STROKE

1. A stroke may impact on a range of different functions.

A. List the most common impairments after stroke that affect the following functions: motor, speech and language, sensation or perception, attention or memory, emotion, continence and praxis.

B. Explain how each may affect a person’s ability to participate in exercise.

C. Select two different impairments, listed under 1a, and discuss how you would manage the risk associated with each in the context of an exercise setting.

1. Shoulder pain is common after stroke. What are the possible explanations for this? How could the specialist exercise professional avoid an increase in shoulder pain?

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

3. What are the explanations for low mood after stroke? How could a specialist exercise professional take low mood into consideration when designing an exercise class?

4. Many stroke rehabilitation services in the UK terminate around 6 months after the acute event. What is the rationale for this and what is the evidence to support it?

5. List the most common co-morbidities observed in people with stroke and explain why they tend to occur alongside a stroke.

6. Consider two different co-morbidities and discuss their implications for the safety and efficacy in an exercise setting.

ANSWER GUIDELINES: pto

ANSWER GUIDELINES

1. The answer should refer to information on pp. 39-57 and could include the following information:

|A. Stroke-related impairment |B. Possible impact on exercise |

|Motor impairment: e.g. hemiparesis (p. 39) |Weakness, e.g. reduced grip force, which may reduce the ability|

| |to hold onto the handle bar of an exercise bike |

|Communication impairment: e.g. Broca’s dysphasia |Difficulty expressing oneself when feeling pain, discomfort or |

|(p. 41) |symptoms of any kind |

|Perceptual impairment: e.g. unilateral neglect (p.|Lack of awareness of affected body side or side of space. May |

|46) |fail to notice obstacles on affected side or own limb position |

|Memory impairment: e.g. difficulty processing |Difficulty understanding complex instructions and learning new |

|information |skills |

|Emotional difficulty: emotionalism |Embarrassed working in groups due to emotional liability |

|Continence impairment: urinary incontinence |Required to visit the toilet at regular intervals |

|Impaired praxis: apraxia |Difficulty using objects in their intended way or copying |

| |movements from the instructor |

C: any impairment may be selected. E.g. Urinary incontinence: in addition to the client’s normal continence management (e.g. “pad and pants”), the exercise instructor should ensure easy and safe access to appropriate toilet facilities and sufficient staff attending to accompany a client where required.

2. This question refers to pp. 47-49. The answer should include the following:

▪ Causes of shoulder pain should include an explanation involving the following factors: adhesive capsulitis, subluxation, tears in the rotator cuff, shoulder-hand syndrome. E.g. paresis of the muscles that normally stabilise the shoulder joint allow the ball of the humerus to slide away from the shallow socket of the scapula, causing a subluxation.

▪ Avoiding an increase in shoulder pain during exercise: the specialist exercise instructor should carefully assess the client upon referral and specifically ask for shoulder pain, as well as available range of shoulder movement. Should there be any shoulder pain or limited range of movement, the specialist exercise instructor should liaise with the client’s physiotherapist/ GP. Exercises need to be carefully tailored to ensure they do not exceed the pain-free range of movement. During class, careful monitoring of the condition needs to be undertaken.

3. A list of all factors mentioned on p. 56 is sufficient. In terms of implications for exercise, risk assessment of the individual, activities, and environment is essential. Specific examples should be given here (e.g. remove tripping hazards).

4. This question refers to pp. 52-53. The answer should include the following:

[This question goes beyond the syllabus, but based on your life experience, I’m sure you would have a good answer]. There may be a neurological explanation (e.g. imbalance in neurotransmitters following stroke leading to emotionalism), a psychological explanation (e.g. sudden loss of function is likely to affect mood and confidence, and may lead to despair) and a social explanation (e.g. the loss of independence and a role in life). A stroke is a crisis in most people’s lives and therefore the reaction to a stroke is likely to involve complex emotions. There is no simple answer as to how these problems should be taken into consideration by an exercise instructor, but patience, active listening, preserving a person’s dignity and empathy may all come into play. Remember that, as an exercise instructor, you are part of a team and that in some cases participants may need to be referred to their GP for treatment or counselling.

5. This question refers to section 3.3 (pp. 57-59), which presents evidence of the timeline of recovery after stroke. A landmark study by Jørgensen et al. (1995) showed that 80% of stroke patients had reached their best level of function at 6 weeks after the acute event. Thus, it is often assumed that most patients will have reached a “plateau” at 6 months after stroke and that further rehabilitation will no longer be effective – or cost effective. However, it is important to realise that recovery continues in many cases, albeit at a slower rate. Some changes may be small in absolute terms, but they may nevertheless be of considerable functional importance to individuals. A key factor in continuing the recovery process is motivation. Thus, it is essential that exercise instructors set goals with their clients and find out what motivates them. Ideally the exercises/ activities should be designed around the activities that are meaningful to the client – and remember the enjoyment factor!

6. This question refers to section 3.4 (pp. 60-66). A common co-morbidity is heart disease – in a range of different forms. It is sufficient to know the various comorbidities and essential to know how to manage the risks they present. You are not required to explain the underlying physiological mechanism that links each co-morbidity with stroke.

7. Any two different comorbidities may be selected. E.g. diabetes mellitus: guidance on how to manage this condition is provided on pp. 64-65. Implications that should be discussed in detail are:

▪ Careful assessment and medical advice prior to exercise

▪ Checking blood sugar as required prior to, during and after class as appropriate

▪ Monitoring for symptoms of hyper- and hypoglycaemia during class

▪ Knowing how to act if these symptoms are observed

▪ Keeping detailed and accurate notes

▪ Liaising with the client’s GP where required

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