By Maribeth Salge, MA, PT, ATC, CSCS, RCEP, AFP, CES.

This article is the first segment of a two part series related to exercise programming for post-rehabilitation stroke clients (i.e., those who have completed physical and/or occupational therapy). Part one will focus on definitions, demographics and challenges related to post-rehab clients. This article does not suggest the services of a personal trainer could substitute a formal rehab program, but is intended to be an educational tool for personal trainers interested in developing programs for post-rehabilitation stroke clients.
Before working with post-rehab clients, it is essential for the personal trainer to be aware of his or her scope of certification and the legal issues that may arise as a result of practicing outside such parameters. Clarity can be ensured by outlining to the client and his or her health care team, what services will be provided. Additionally, personal trainers must not misrepresent their credentials to the public, healthcare professionals or third party payers (e.g., insurance carriers). Know your professional boundaries and respect legally protected titles and designations (e.g., PT, OT, Athletic Trainer). Misrepresentation of credentials is not only illegal, but also diminishes the integrity of the personal training profession.

Stroke

Stroke is a common name for a cerebral vascular accident (CVA), the third most common cause of death. A stroke can occur at any age and is caused by a sudden impairment of blood circulation in the brain. The blood supply to a particular area is either interrupted or diminished and without oxygenated blood, brain tissue dies.

Common causes of CVA include thrombosis, embolism or hemorrhage due to an aneurysm. Factors that put one at risk for stroke include hypertension, diabetes, coronary artery disease, obesity, elevated blood lipid levels, smoking and alcoholism. Although 20 percent of CVAs occur in individuals younger than age 65, they most often strike the elderly.

In addition to risk factors, specific precursors to strokes include prolonged hypertension, cardiac arrythmia, rheumatic heart disease, cardiac enlargement, high serum triglycerides, obesity, physical inactivity, gout, postural hypertension and heredity. The early signs of an impending stroke are a sudden onset of:

• Blurred, dimness or loss of vision, especially in one eye.
• Confusion.
• Dizziness.
• Severe headache.
• Difficulty speaking.
• Numbness or tingling in the face or limbs.
• Loss of movement or weakness in the face or limbs.
• A stroke will not affect all areas of the brain equally. The resulting neurological impairment depends on both the size and location of the area to which the blood flow was impaired. There may be good and bad days or good and bad hours. It is important for the personal trainer to remember that each client's condition is different. While a client may fit a particular profile, not every behavior or symptom will be observed.

Flaccid and Spastic Paralysis

Typically, the most visible sign of a stroke is paralysis on one side of the body (hemiparesis). The paralysis may be either flaccid or spastic in nature. Flaccid paralysis is an absence of muscle tone in which the affected limb lies limp. It is important to use proper equipment, such as an arm sling, to support the weight of the limb and protect the joint from excessive stress. On the other hand, spastic paralysis is greatly increased muscle tone resulting in a lack of movement. Typically, clients experiencing spastic paralysis are only able to use the involved limb in a limited manner because they lack the motor control needed for most activities.

Left Hemiparesis

Paralysis on the left side of the body (left hemiparesis) is a result of injury to the right side of the brain. Clients with left hemiparesis usually have spatial perceptual deficit, thus can describe an action better than they can perform it. Moreover, clients may be impulsive, impatient, abrupt or careless. The client may aggressively insist he or she can perform a task or exercise on his or her own when they cannot. Often, the client will attempt to cover for his or her inability by becoming argumentative. When this occurs, simply ask the client to demonstrate the activity. In addition to carefully evaluating the client's ability to follow safety guidelines, the trainer may also need to use frequent verbal cueing and positive feedback to keep the client on track. Since family members may overestimate the client's ability, keep them informed on the client's performance and improvement.

Right Hemiparesis

Clients with paralysis on the right side of the body (right hemiparesis), sustained damage on the left side of the brain. Clients with right hemiparesis usually have difficulty with speech and language, such as substituting terms with inappropriate words or phrases. While left sided brain injury clients tend to be somewhat cautious, anxious or disorganized when attempting a new task, right-sided brain injury clients tend to be impulsive or aggressive. The client will need encouragement, feedback and indications of progress. Keep instructions simple and use demonstrations often. Although the client may have difficulty with speech, he or she still has the ability to learn and communicate. Give the client time to express his or her thoughts and use family members as resources in effective means of communication.

One-sided Neglect

Regardless of the side of the brain the damage occurred, a client may experience one-sided neglect. Although this condition is more common in left hemiplegics, one-sided neglect is thought to result from a combination of visual field impairments and abnormal sensation on the involved side of the body. At times, the client will not recognize the limbs or acknowledge objects or people on their affected side. For example, the client may run into an object that appears to be in plain view. The trainer needs to be aware of one-sided neglect in order to keep the environment safe for the client. Additionally, the trainer can provide cues and encouragement to use the impaired side. At times, this may prove frustrating for the client and patience is necessary.

Memory

Memory problems are common in post-rehab clients. The trainer can assist the client by establishing a fixed routine, keeping instructions simple and using memory aids as well as familiar activities. For example, when an exercise is being taught, compare it to an activity with which the client is familiar. Again, enlisting the help of family can be very helpful. Contact the rehab professionals who worked with the client during therapy to obtain information regarding appropriate memory aids.

Emotional Liability

One of the most disturbing aspects of working with a post-rehab client may be his or her unpredictable loss of emotional control, also known as emotional liability. The client may laugh or cry at inappropriate times, swear or use incorrect terms for familiar objects. At first, emotional liability can be unsettling for the personal trainer, but it is important the trainer realize this behavior is not indicative of anger, sadness or joy. When emotional liability is exhibited, the best approach is to remain calm. After ascertaining the client is not in pain or physical distress, the trainer should redirect the client's attention. This can be done by changing the subject of conversation, going outdoors or playing music. By interrupting the behavior, the trainer assists the client in moving on to more productive activities.

Clients who have completed rehabilitation following a stroke have special needs. By understanding the impact a stroke has on their client's lives, personal trainers are better prepared to develop and implement effective and safe exercise programming. In part 2, guidelines and precautions for exercise will be discussed.

Maribeth Salge, MA, PT, ATC, CSCS, RCEP, AFP, CES, co-owns MJS Health Consultant in Cocoa, Florida, and specializes in physical therapy, athletic training, sports performance enhancement and personal training. She holds a master's degree in exercise physiology and is AFAA, NATA, ACSM, NSCA and ACE certified.

[Part 2]