1. EXERCISE AFTER STROKE Specialist Instructor Training Course L8a The role of the Specialist Exercise Instructor Assessment Procedures J Dennis/S Wicebloom Paul / S Dinan Young Bex Townley

2. Content Criteria for inclusion Contra-indications to exercise Instructor Assessment of participant Referral back to healthcare

3. Learning Outcomes At the end of this session, you should be able to: List/ describe assessment process Explain/ demonstrate understanding of assessment process and clinical risk Apply knowledge to exercise class and each planned exercise Discuss risks and procedures should anything be outside expected parameters

4. Essential Reading Further detail about the topics discussed in this session can be found in section [L8] of the course manual

5. Patient Inclusion criteria Must have GP / other “permission”= agreed referral path Passport/ Referral must be fully completed Participant’s own responsibility is clear Readiness to exercise

6. Contra-indications -absolute –Recent electrocardiogram changes or recent myocardial infarction Systolic blood pressure >180mm Hg Diastolic blood pressure >100mm Hg –severe stenotic or regurgitant valvular heart disease –Uncontrolled arrhythmia hypertension and/or diabetes –Unstable angina –Third degree heart block or Acute progressive heart failure. –Acute aortic dissection –Acute myocarditis or pericarditis –Acute pulmonary embolus or pulmonary infarction --Deep venous thrombosis –Extreme obesity, with weight exceeding the recommendations or the equipment capacity (usually >159kg [350 lb.]) – Severe mental or physical disabilities The risk of a cardiovascular incident occurring is low! (Quittian M 1994, Mead G 2005,ACSM 2001 Rimmer J, 2005)

7. Relative Contraindications – cautions Cardiomyopathy Moderate stenotic valvular heart disease Complex ventricular ectopy Uncontrolled metabolic disease. Left main coronary artery stenosis Electrolyte imbalance Tachyarrhythmias or bradyarrhythmias High degree atrioventricular block Mental or physical impairment leading to inability to exercise adequately (Quittian 1994, Mead 2005,ACSM 2001 Rimmer 2005)

8. Assessment by Specialist Exercise Instructor 1.What do you want to know about the participant? 2. What documents will you need in place to record information? 3. Who can tell you what you need to know?

9. Assessment – Agreeing Goals Confirming participant expectations and outcomes from exercise programme: Agreeing initial participant centred SMART goals Form long-term SMART goals Give specific safety & cautions / exclusions Give self monitoring safety guidelines

10. Assessment Tools for Specialist Instructors What tools do you use to assess/measure progress?

11. Assessment Tools and Outcome Measures 10 metre walk 6 min walk Timed Balances – Tandem & SLS Timed up & Go Tinetti Balance & Gait (Falls Risk) Stroke Impact Scale Postural map

12. Triggers Back to Referrer/Medical Review Essential that if any of the following are noticed the patient is reviewed by the physiotherapist/referred back via pathway protocols: Repeated Falls reported Increase in slowness of movement execution Increase in weakness and / or deterioration in co-ordination Changes in speech or facial looks Unexpected deterioration in performance of planned exercise programme

13. If the unthinkable happens... Is it 999 - usual first aid & resuscitation? If no, tell client to report ASAP to GP Inform Site manager Complete relevant section of incident report form Inform referring party. No return until GP agrees or re-referred