1. EXERCISE AFTER STROKE Specialist Instructor Training Course L8c The role of the Specialist Exercise Instructor Clinical Risks & Monitoring of Participants John Dennis

2. Content What is clinical risk Monitoring of participants Participant self monitoring

3. Learning Outcomes At the end of this session, you should be able to; Explain/ demonstrate understanding of clinical risks and how to identify them Apply principles of risk management and monitoring of participants Discuss how to avoid risks in your classes.

4. Essential Reading Further detail about the topics discussed in this session can be found in section 8.6 – 8.8 of the course manual

5. How do we know about risks? From effective communication from referrer. (if necessary read between the lines) From robust assessment by instructor Close observation of participants & interactions with environment/ others (continued assessment) By knowledge imparted By knowledge internalised

6. Risks Generic risks Environmental Equipment Modes of delivery Communication Clinical risks Health Falls Impairment issues Ability issues Fatigue issues Mode of delivery Participant equipment Added participant risks

7. Clinical Risk Health Stable? (cardiac, cognitive, performance, deteriorated since referral? Appropriate class / location/access? Changes in limb power / sensation / balance / tone? Change in endurance / fatigue? Falls Causes variable – cardiac, sensory, balance, weakness, tonal Need strategy to manage participants post fall

8. Clinical Risk Impairment Issues Soft tissue changes Joint integrity Tone Weakness Other movement disorders Sensory Cognitive

9. Clinical Risk Ability Issues Functional limitations Clinical limitations e.g. co-morbid pathologies, medication issues Balance deficits Gait difficulties Transfer difficulties Cognitive changes Behavioural changes

10. Clinical Risk Fatigue Issues Mode of delivery e.g. Too intense too soon Participant Equipment Splints, footwear, spectacles, hearing aids, walking sticks, etc.

11. Clinical Risk Added Participant risks: Behaviour – May be unaware of personality changes Alcohol / drugs – policy is clear!

12. Monitoring Tone Deterioration in performance Decreased co-ordination / balance Increased weakness Fatigue Co-morbitities / pathologies

13. Monitoring 1. Risk / avoidStrategies to reduce risks - Ensure Increased Abnormal levels of tone  Check posture at start/ during each exercise +/- secure limb  Ensure lateral (outward) upper limb rather than medial (inward) rotation in resistance exercises  Ensure self-assisted solutions

14. Monitoring 2 Low tone / subluxation at shoulder (and other joints) Joints, especially the shoulder - can be pulled out of alignment if the is a traction force greater than the participant can actively support.

15. Monitoring 3 ↑ associated reactions (shoulder) “Correct posture” modalities / functional activities e.g. walk, bike, avoid rowing ↓ postural alignment / symmetry Stop exercise / check posture, alignment and resistance level. If reoccurs -> change activity Risk / AvoidStrategy /Solution

16. Safety ↓ postural stability ↑ falls ↑ fatigue ↓ visual field / acuity / hearing kinaesthetic awareness/ sensory neglect Cognitive / communication difficulties  Ensure chair/ wall supported options  Avoid via Fartlek / active rests etc  Effective positioning of visual and aural cues  Regular position shifts on equipment  Ensure Instructions simple and understood  Consult person peers, family members for communication tips. Risk / AvoidStrategy /Solution

17. Avoid any chances of missed educational opportunities Monitor closely the self monitoring of clients for:  Pain  Excess SOB  Tonal change  ROM

18. Participant Self-monitoring Body mass index charts / weight Reminders on heart rate Blood pressure Timed balance No of repetitions / circuit components achieved Self feedback questionnaire