By Maribeth Salge, MA, PT, ATC, CSCS, RCEP, AFP, CES.
This article is the second installment in a two-part series specific to post-rehabilitation stroke clients (i.e., those who have completed physical and/or occupational therapy). It focuses on the development and implementation of an exercise program for these clients. The following approach presumes rehabilitation was successfully completed, the physician and rehab team agree the patient no longer requires medical monitoring (e.g., blood pressure, ECG, pulse oximetry, etc.) and would benefit from an exercise program with a certified personal trainer. As indicated in Exercise Programming for Post-Rehabilitation Stroke Clients-Part One (March/April 2002 issue), this article is not intended to imply the services of a personal trainer could substitute a formal rehab program. Instead, it is intended to be an educational tool for the personal trainer interested in developing programming for post-rehabilitation stroke clients.
Since a cerebral vascular accident (CVA) can occur during exercise, the personal trainer needs to be familiar with the signs and symptoms of an impending stroke (refer to Exercise Programming for Post Rehabilitation Stroke Clients-Part One). If the client exhibits any of these symptoms or experiences unusual feelings, the session should be terminated and the client's physician should be contacted immediately. Even if the symptoms pass, the client could be experiencing a transient ischemic attack (TIA), which must be evaluated by a physician.
It is essential to have an emergency plan before working with any client, particularly post-rehab stroke, cardiac and pulmonary clients. The plan should be in writing and reviewed on a regular basis. Keep in mind that not all areas have access to 911 emergency services. In these locations, the personal trainer should program the local ambulance, fire and police department phone numbers into speed dial for easy access.
Prior to initiating an exercise program for the post-rehab stroke client, the trainer needs to obtain a health history form, a signed consent, a physician's referral/release for exercise and, if possible, a copy of the client's rehab records. The physician's referral/release form should indicate the trainer's credentials and state that no medical monitoring (e.g., blood pressure, ECG, pulse oximetry, etc.) will be performed.
A request for exercise precautions should also be included. Specific questions to ask include: Are there any movement, weight bearing or exercise restrictions? Are there any sensory deficits that need to be considered? Are there any cognitive deficits? Additionally, if age predicted target heart rate range is not appropriate, ask the physician to provide a training intensity limit. This will help the trainer understand the precautions before implementation. If medical language used in communication from the physician is unfamiliar, do not hesitate to get clarification.
In order to provide continuity of care, the personal trainer is advised to contact the rehab professional (e.g., physical therapist, occupational therapist, clinical exercise physiologist or athletic trainer) regarding the client's current exercise program. Rehab professionals are valuable sources of information, allowing trainers to update client's current exercise program rather than starting over. By continuing an established program, the transition from rehab to post-rehab can be made smoothly. Once the program has been reviewed and updated, the trainer should give a copy to the client's physician for approval.
Most post-rehab stroke clients are prescribed a variety of medications, such as blood thinners, vasodilators and antihypertensives. These medications will affect the physiological response to exercise. Blood thinners make the client more susceptible to bruising and can possibly cause them to bleed into a joint, if even a slight injury is sustained. Clients on vasodilators need a longer cool down period to avoid post-exercise hypotension. Certain blood pressure medications slow heart rate response, therefore, refrain from using target heart rate range to determine intensity during cardio training.
It is important to watch for signs of fatigue, especially early in the program. The client may have had an extended period of inactivity following his or her CVA, so even a client who was active prior to his or her stroke will need to progress slowly and multiple rest periods may be needed. Most post-rehab stroke clients are very deconditioned. This physical state leaves room for tremendous improvement in fitness levels. Depending on the level of physical impairment following a CVA, the client may be able to perform a variety of cardio, strength and flexibility exercises.
Many clients may need to perform exercises from a seated position until the personal trainer is familiar with the client's physical ability and degree of balance impairment. This procedure minimizes undue fatigue and the risk of falling. Modality choices for cardio training may include an exercise bike, upper body ergometer or Nu-Step. Due to increased risk of falls, treadmills are not a good exercise method for a client with balance problems. Use physician established guidelines or Borg scale rating for training heart rate range. Since the client may be deconditioned, use the amount of time a client can tolerate continuous activity, at a given work load, as a method of measuring progress.
Strength training exercises should focus on function related activities. Rather than being able to use a prescribed amount of resistance, repetitions and sets, the trainer will have to experiment with each aspect, based on the client's degree of deconditioning. Using lighter weights and higher repetitions is the preferred method of training. Also, recognize the need for joint protection strategies on the involved side. Common joints of concern are the shoulders, knees and ankles.
Muscle weakness can significantly alter joint mechanics, thereby causing pain and/or impingement, indicating a need to modify the exercise. Be aware of any discomfort the client may experience, other than the normal feeling of muscular exertion, particularly when exercising the involved side. Since each client is unique, contacting the client's rehab professional regarding prior strength training specifics and joint protection is essential.
When a client has mobility restrictions, the trainer needs to use a variety of resistance devices, such as resistance bands, ankle weights or stability balls, to provide a challenging, yet safe strengthening program. Additionally, balance can be enhanced by using devices, such as DynaDiscs, while performing seated strength exercises. For the more advanced client, DynaDiscs can also be used to stand on while performing strengthening exercises. Since this is an advanced training technique, use caution. As with any client, focus on form and posture at all times.
Flexibility is important for clients with limited mobility. Stretches for all major muscle groups should be performed on the uninvolved side. At least three times per week, each stretch should be held 20 to 30 seconds and repeated three to five times each. The client will most likely require assistance in performing stretches on the involved side. However, the personal trainer should not perform assisted stretching without first consulting the rehab professional who previously treated the client. To avoid worsening any joint problem the client may have, the rehab professional can relay proper methods of assisted stretching to the trainer.
Accurate record keeping is essential when working with clients, but particularly those referred by medical professionals. The trainer should keep an up-to-date file on each client, including dates and times of sessions, communications with physicians and rehab professionals as well as any comments regarding sessions from the client or family members. Documentation allows the trainer to track progress as well as note problems. Provide regular updates, either per request or on a monthly basis, to the referring physician.
Exercise specifics for all aspects of the program should be charted, including mode, duration and intensity of aerobic activity, sets, reps and resistance levels for strength training. Include information on flexibility exercises and the type of assistance (if any) required. The trainer should note the client's tolerance and response to the exercise session. The personal trainer should also sign and indicate his or her credentials on all documentation. For more information, refer to AFAA's Client Programming: Development and Documentation or ACSM's Exercise Management for Persons with Chronic Disease and Disability.
Working with post-rehab stroke clients can be challenging. The personal trainer needs to be resourceful and versatile to successfully meet this challenge. Advanced certifications (such as AFAA's Fitness Practitioner [AFP], ACSM's Health and Fitness Instructor or ACE's Clinical Exercise Specialist) can provide additional education and the experience required to work successfully with this type of client. Through education, patience and communication with medical professionals and the client, trainers will be able to effectively design and implement exercise programs for the post-rehab stroke client.
Maribeth Salge, MA, PT, ATC, CSCS, RCEP, AFP, CES, co-owns MJS Health Consultants in Cocoa, Florida, specializing 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.
- ACSM's Exercise Management for Persons with Chronic Disease and Disabilities, Human Kinetics Publishers, 1997.
- ACSM's Guidelines for Exercise Testing and Prescription, 5th Edition, Williams and Wilkins Publishers, 1995.
- ACSM's Resource Manual for Guidelines for Exercise Testing and Prescription, 2nd Edition, Williams and Wilkins Publishers, 1993.
- Client Programming: Development and Documentation, Aerobics and Fitness Association of America, 1996.
- Clinical Exercise Specialist's Manual-ACE's Source for Training Special Populations; Cotton, Richard T. and Anderson, Russ E. American Council on Exercise, 1999.
- Health Care Essentials, Aerobics and Fitness Association of America, 1997.
- Stroke: Why Do They Behave That Way? Fowler, Roy S. and Fordyce, W.E., American Heart Association, 1974
This information is taken directly from AFAA's web site (http://www.afaa.com) and all acknowledgements should be given to such.