1. EXERCISE AFTER STROKE Specialist Instructor Training Course L8b The role of the Specialist Exercise Instructor Programme Design John Dennis / Sara Wicebloom-Paul/ Bex Townley

2. Content Planning the programme Cautions / considerations Programming guidelines Teaching skills Introduction to ‘tailoring’

3. Learning Outcomes At the end of this session you should be able to: Describe how to design a class/ exercise Demonstrate understanding of programming skills, and how they can be used to enhance a class and, Apply them to stroke survivors across a range of impairments Discuss adaptations for stroke-specific problems e.g. tonal changes.

4. Essential Reading Further detail about the topics discussed in this session can be found in section 8.3 – 8.5 and 12 of the course Manual and tailoring worksheets in the directed learning pack

5. Planning the Programme Exercises need to fit the stroke population Exercises need to fit the individual Risk areas need to be assessed for each participant Document and remind yourself of these regularly.

6. Teaching & Instructing Participants in Exercise after Stroke Adapting: “ the condition specific adaptations (modifications) to session aims; structure, content,teaching and programming that need to be made to ensure optimal safety and effectiveness with participants after stroke” Tailoring: “the highly individual prescriptive solutions (adjustments,additions,exclusions) that are required to tailor the adapted exercise intervention to each participant’s health, functional and/or psychosocial/emotional needs” (Dinan (2007) Skills Active Level 4 NOS) Exercise Programming Guidelines

7. ‘Tailoring’ (an introduction) What is ‘tailoring’ in the context of exercise and fitness after stroke? What is the ultimate aim of a tailoring solution or strategy? How do we know if your tailoring has been effective? What are the challenges faced by instructors when tailoring exercise for a group of participants with stroke? What ‘is it’ we need to potentially tailor?

8. Special Considerations, Cautions & Adaptations Starting Point for Exercise Programming: Low cardio-vascular fitness Long rehabilitation period Previous medical illness, inactivity prior to / since CVA Movement disorders Hemiplegia / other deficit -> decreased activity Other neurological / cognitive / communication deficits

9. Considerations -----------------------------------0-------------------------------------- Low Normal Tone High Management of abnormal tone / associated reactions Emphasise postural alignment / symmetry /core stability Relationship between strength and tone Prioritise functional training activities Management of fatigue Awareness of pain e.g. shoulder = Tailor to individual needs/function

10. Key considerations Individualised / tailored requirements Upper limbs tend to require extensor related work Lower limbs tend to be weaker in flexor patterns but need a proportion of both flexor and extensor related work Trunk needs to be both extensor / flexor but aligned correctly, especially with pelvis Safe management of a group of people with a range of impairments

11. Exercise Programming Guidelines

12. STARTER Session Aims Improve all components of fitness Prioritise cardiovascular, neuromuscular function Improve balance/ posture/ gait/ functional strength/ performance of IADLs Increase confidence Motivate/educate ↑ habitual postural alignment Provide opportunities to socialise Achieve long and short term personal goals

13. Session Content Simpler, fewer exercises Order of exercises Steady pace Step by step transitions – spacing, rest intervals etc. Moderate intensity Group and 1-2-1 communication

14. Programming Principles Multilevel, multi-activity FITT – Evidence based Choice: self / instructor directed options Involve stroke participants in planning, evaluation and delivery Buddy systems to empower and recruit Specialist trained exercise professionals

15. Teaching Skills ↑ time mgmt, preparation, patience ↑ teach and instruct posture ↑ skilful teaching position ↑ clarity of instructions - visual and verbal ↑ observation, adaptation, tailoring ↑ awareness of individual needs and exercise risk ↑ communication skills: sensitivity / firmness ↑ discussion time pre and post session ↑ skills for using touch in exercise guidance

16. Exercise for participants after stroke must be evidence- based, safe, effective & enjoyable.

17. References 1. Harold Rubin, MS, ABD, CRC, Guest Lecturer November 23, 1999 www.therubins.com. 2 Quittian M. : Rehabilitation in coronary heart disease. Value, indications and contraindications of exercise therapy] Fortschr Med.1994 Mar 20;112(8):97-100. 3. Gibbons RJ, Galady GJ, Beasley JW, et al. ACC/AHA guidelines for exercise testing: executive summary. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Exercise Testing). Circulation. 1997;96:345-354. 4. Mead G, Dinan S. Smith M. et al Loughborough College Stroke Module. 2005.(restricted access) 5. Larry Derstine J., Moore G. E. (eds)1997 ACSM’s exercise management for persons with chronic disease and disabilities. Champaign, IL.: Human Kinetics.