EXERCISE AFTER STROKESpecialist Instructor Training Course

T2The Role of AHPs in

Stroke Rehabilitation:

Content

• What is an Allied Health Professional (AHP)?

• What do AHP’s do?

• Principles & practice of AHP management of stroke (clinical reasoning and evidence-based practice).

Learning Outcomes At the end of this session, you should be

able to:

• Describe and demonstrate understanding of the role of AHP’s (Allied Health Professionals) in stroke care.

Essential Reading

Further detail about the topics discussed in this session can be found in section [3.2] & [4.3] of the course syllabus.

The Evidence…

• Cochrane Collaboration Library: http://www.cochrane.org/

• Google Scholar: http://scholar.google.co.uk/

• http://www.knowledge.scot.nhs.uk/

• http://www.askdoris.org/

Acknowledgements

• Mark Smith - Consultant Physiotherapist

• John Dennis – Neuro-rehabilitation specialist physiotherapist

• Frederike van Wijck – Reader in Neuro rehabilitation

• Pauline Halliday - Clinical Specialist Occupational Therapist

• Helen Atkin - Clinical Specialist Occupational Therapist

• Sheena Borthwick - Speech and Language Therapist

Students – please list some AHP’s

The Role of AHP in Stroke Rehabilitation

Speech and Language Therapy

Content

The role of the SLT

Communication difficulties and their impact

Aphasia/dysphasia and dysarthria

What you can do to help

Learning outcomes

By the end of this session, you should be able to demonstrate a sound understanding of:

• the potential effects of stroke on speech and language capability

• the potential impact of impaired communication on the ability to participate in exercise

• the importance of good communication for your role as specialist exercise instructor working with participants with a stroke.

Essential Reading• Further detail about the topics discussed in this session

can be found in section L9 of the course syllabus.

• Stroke Core Competencies for Health and Social Care Staff (the STARS project): http://www.strokecorecompetencies.org/node.asp?id=core

• Connect: the communication disability network: http://www.ukconnect.org/

• Speakability: http://www.speakability.org.uk/

Additional sources

The role of the SLTProvision of:

Assessment for diagnosis of dysphagia and communication problems Information to patients, carers and staff about impairments/ abilities

& guidance for safe swallowing and the facilitation of communication. an individualised speech assessment and language therapy care

programme, e.g.:―Support / regular re-assessment―regular / intensive therapy

Facilitating access to : support groups, such as Chest Heart and Stroke Scotland for and

provision of augmentative and alternative forms of communication. other professional support, particularly where this will enhance

recovery of/ compensatory strategies for communication function.

Communication: Giving and Receiving

Getting the message Giving the message

Message in Message out

What is the impact of a communication disability?

• Difficulty in personal relationships

• Social isolation and loneliness

• Loss of identity• Loss of employment

opportunities/financial security

• Loss of leisure opportunities

A Shared Problem?

Communication

Speech &language Eye

contact

Gesture

Facial expression

Body posture

Tone and volume of voice

Drawing

Writing

What methods of communication do you use in your day to day work with clients?

Aphasia / Dysphasia

• This is a language disorder

• Affects both message in and message out for both you and the person with aphasia– Understanding speech and writing– Finding words and constructing sentences– Writing responses

Example: http://www.strokecorecompetencies.org/labyrinth/mnode_client.asp?

id=24422&parent=24427&mode=remote&sessID=17D98D3C-4BD6-4D8E-AD0A-B07B8344F6EB

Dysarthria

• This is a motor speech disorder

• Affects: – message out for the person with dysarthria– message in for you as the listener

Example: http://www.strokecorecompetencies.org/labyrinth/mnode_client.asp?

id=24422&parent=24426&mode=remote&sessID=17D98D3C-4BD6-4D8E-AD0A-B07B8344F6EB

Thoughts/ideas/knowledge

Speech(lips,tongue,voice)

Meanings / semantics

Word store

Speech sounds

Motor programming

Cognitive impairment

Aphasia

Articulatory dyspraxia

Dysarthria

More subtle communication difficulties

• Processing emotional content– Facial expression– Appreciating humour

• Prosody– Flat tone– Understanding related to stress, rhythm

• Conversational skills– Making inferences

Expressive Aphasia/Dysphasia• Speech comprehension:

Largely intact, but may be compromised if speech is very complex

• Speech production:Difficulty producing speech:- Hesitant, non-fluent- Problems with word finding -> circumlocution - Limited vocabulary- Telegraphic style, simplified grammatical structure- Abnormal intonation- Often some dysarthria

Receptive/Expressive Aphasia

• Speech production:- Fluent, but often nonsensical- Difficulty arranging sounds into coherent speech (“wort salat”)- New words (neologisms), jargon- Repetition of sounds

• Speech comprehension:- Difficulty distinguishing sounds ->- Impaired comprehension ->- Patient often unaware (their comprehension is impaired!)

Where is communication breaking down?

• Message in– Am I understanding?– Is he/she

understanding me?• Hearing• Vision• Thinking• Environment• Mode of communication

• Message out– Am I putting this across

well?– Has he/she had the

opportunity to respond?• Mode of communication• Language used• Time• Thinking• Finding the right words

SLT Summary

You should have a good understanding of:-

• The role of SLT in stroke rehab

• the diverse range of communication difficulties & how Aphasia is common after stroke

SLT – Implications for Specialist Exercise Instructors

• Good communication is key to your professional role.

•where to find the support and what is available.

•How to apply principles of effective communication wherever possible – and keep trying...!

Exercise Specialist problem solving

• Is one form of communication more difficult than another?

• Can this person use other forms of communication?

• Could I adapt to make this easier?

Key Points about communication disorders

• Severity of varies from person to person

• Pattern of problems varies from person to person

• Communication difficulties and their impact changes over time

• The impact on the individual and their family will depend on the people and their circumstances

• Severity of impairment does not necessarily match the impact on activity and participation

Group Tasks - communication

Communication Support Principles

• Principle 1:

Recognise that every community or group may include people with communication support needs

• Principle 2:

Find out what support is required

• Principle 3:

Match the way you communicate to the ways people understand

Communication Support Principles

• Principle 4:

Respond sensitively to all the ways an individual uses to express themselves

• Principle 5:

Give people the opportunity to communicate to the best of their abilities

• Principle 6:

Keep trying

Effective Communication: Prepare

• Plan how you might approach trying to get your message across

• Make sure you have their full attention.

• Choose a place where there is less distraction

• Position yourself well to maintain eye contact.

Effective Communication: Observe

• Pick up and respond to signs of:• tiredness • Stress• frustration • low mood.

• Display of emotion very common and can be an effective communication when there are no words.

Effective Communication: Respect

• Treat the person as an adult

• Do not talk across them

• Wait for a reply even it seems a long time in coming

• Check if they want help – don’t assume

• Be patient and be prepared to repeat things

• Try to persist – don’t just give up without agreeing.

Effective Communication: Check

• Establish a reliable “yes” and “no”. • Thumbs up / down• Pointing to chart – tick and cross

• Recap and check that you have understood each other

• Do not ever pretend that you have understood – be honest.

Effective Communication: Encourage

• Accept any method of communication

• Understand the aim is to get the message across – not demanding speech

• Encourage the use of props

• Be positive and as encouraging as possible.

• Remember the value positive social contacts have on feelings of well-being

Talk For Scotland Toolkit

http://www.communicationforumscotland.org.uk/

Some places for support

The Role of AHP in Stroke Rehabilitation:

Occupational Therapy

CONTENT

1. Introduction to the role of OT in stroke2. Information processing: a model3. Problems with information processing

after stroke:a) Attention and memoryb) Sensation and perceptionc) Planning, taking action and monitoring

4. Summary and implications for exercise instructors.

OT Role: Assessment of …• Functional activity limitations using activity analysis, i.e. the

components of movement are individually identified,

• Skills for the performance of self care (e.g. washing, dressing, feeding), domestic (e.g. shopping, cooking, cleaning), work and leisure occupations.

• Skills which impact on each activity (e.g. sensorimotor, cognitive, perceptual and psychosocial impairments)

• Assessment of social environment (e.g. family, friends, relationships).

• Assessment of physical environment (e.g. home and workplace).

OT Role: Intervention by…• Redevelopment of physical, sensory, cognitive, and perceptual

skills through activity and practice.• Promote the use of purposeful, goal orientated activity. • Teach new strategies, and compensatory techniques to aid

independence.• Assess and advise on appropriate equipment and adaptations

to enhance independent function including seating, bathing aids etc

• To assess, advise and facilitate, transport and mobility issues such as driving or coping with public transport

• To facilitate the transfer of care, from acute stages through rehabilitation and discharge.

• Liaise with support groups, and voluntary bodies.

OT - Summary and implicationsOT concentrates on :• Impaired attention and memory• Neglect• Altered sensation and perception• Apraxia and executive dysfunction

OT aims to:

Enable each patient to achieve the highest level of independence possible.

• Exercise instructors need to understand these problems, assess associated risks and appropriately tailor each exercise for individuals.

OT – Implications for Exercise Specialists

• Cognition

• Attention and memory

• Sensation and perception

• Planning, taking action and monitoring

Information processing

Cognition involves:• thinking• believing• perceiving• remembering• judging• planning• problem solving• monitoring

Attention and Memory

Characteristics of normal attention:

Ability to:– Focus– Divide– Maintain– Disengage, shift, re-engage

How do you know if a participant has problems with attention?

• fatigue• more limited attentional capacity• lack of awareness of “what goes on”• slowed thinking & processing• distractability/ poor concentration• difficulty doing more than 1 thing at a time• perseveration: inability to disengage e.g.

step-up.

How can you enable a participant with attentional/ memory problems to

participate in exercise?

• Reduce distraction

• Be selective and concise (e.g. don’t give too many instructions/ too much feedback

• Encourage association with what is familiar (e.g. make it functional!)

• Rehearse/ problem solve (over and over!)

• Test understanding of information (i.e. can they actually do it?)

• Use prompts (e.g. priming, cues)

• Use “prosthetic memory” (e.g. exercise sheets, sticky notes in strategic places)

Sensation and perception:

Sensory impairmentsInability to use information from touch,

hearing, taste, proprioception or sight, e.g.:

• Impaired depth distanceResults in different image of an object received by the retina of each eye

• Hemianopia

Common problems with sensation

Visual field defects

http://www.dwp.gov.uk/img/visual-stroke.jpg

Empathy Task -Visual Impairment

Perception

“Perception is the process through which raw sensations from the environment are interpreted using knowledge and understanding of the world so they become meaningful

experiences”.

• Is not a passive process simply absorbing and decoding information

• The brain is bombarded with stimuli and actively creates coherent information about the world

• Individuals fill in missing information and draw on past experiences to give meaning to what we see, hear or touch

I cdnuut blveiee that I cluod aulaclty uesdnatnrd what I was rdaneig. The phaonmmeal pweor of the hmuan mnid. Aoccdrnig to rscheearch at Cmabrigde Uinervtisy, it deosn’t mttaer in waht order the ltteers in a wrod are, the olny iprmoatnt tihng is that the frist and lsat ltteer be in the rghit pclae. The rset can be a taotl mses and you can sitll raed it wouthit a porbelm. This is bcuseae the huamn mnid deos not raed ervey lteter by istlef but the wrod as a wlohe.Amzanig huh? Yaeh and I awlyas thought slpeling was ipmorantt!

Common problems with sensation/ perception after stroke

Impaired body schemaDistortions in visual & proprioceptive image of own

body. Inability to relate body parts to one another.

Unilateral neglect/ visuo-spatial neglect/ hemi-inattention

A definition:“Unilateral neglect refers to a difficulty in detecting, acting on, or even thinking about information from one side of space”.

(Manly & Robertson in Halligan et al., 2003 p. 92)

How do you recognise “neglect” after stroke?

Neglect is a failure to attend to "what goes on" on the side contralateral to the afftected hemisphere,and may present as:-

• Having no notion of the affected side of the body • Being unaware of anything being "wrong" with the affected

side (anosognosia) • Failing to recognise visual, auditory and/ or somatosensory

stimulation

• Forgetting food on plate

• Unable to recall locations

• Difficulty reading

Can you recognise these neglect

presentations?

How can you tailor exercise for a participant with neglect?

•Watch for obstacles (and other people!)

•Monitor use of equipment

•Monitor posture & movement, especially affected side

•Prompt awareness of affected side

•Coach use of neglected side

•Encourage participants to verbally & visually self-cue

Problems with planning & taking action

Apraxia/ Dyspraxia:

Disorder of learned skilled movements not caused by weakness, abnormality of tone or posture, abnormal movements such as tremors, & poor cognition comprehension & unco-operativeness.

(Heilman 1979)

Understanding Apraxia

Normal Praxis involves:

• Forming an idea:• Planning the action • Putting the plan into action: motor execution

Apraxia may affect any of the above abilities.

What are these dyspraxia issues?

How do you know if a participant has apraxia?

• May perform well in familiar surroundings• May perform well if the task is simple• May perform well if few items are required to

complete task• Problems tend to occur when simple movements

are combined in sequence to reach goal, and/or when tools are used.

Empathy Task-Dyspraxia

How can you enable a participant with apraxia to participate in exercise?

(Student Led) Break activity into component parts Keep verbal cues to minimal Guide limbs through movements demanded by

task Use visual prompts (e.g. cards) Work on gross patterns, then fine Provide appropriate verbal feedback Do not use mirror images Allow patient to succeed (goal setting) to reduce

anxiety

Normal Executive function involves:

Identifying priorities Identifying risks Forming a plan Carrying out plan Thinking creatively Thinking in abstract terms Managing time Engaging in complex social behaviour Reflecting Adjusting goals/ plans

“Life management”

These men are installing bollards to stop cars parking on the pavement outside a sports bar.

They are cleaning up at the end of the day.

How long will it be before they realise?

How do you know if a participant may have executive dysfunction?

Unrealistic plans; difficulty with goal setting Unrealistic expectations Launching into an activity Difficulty with time management Difficulty making a plan – and sticking to it until

its completion Distractible May need prompting

How do you know a participant may have executive dysfunction?

Inappropriate behaviour (e.g. jokes, disinhibition, anger)

Difficulty monitoring self – and changing when things go wrong

Difficulty with problem solving; difficulty transferring what has been learned to a new situation (the plan does not quite fit)

How can you adapt exercise for a participant with executive dysfunction?

Assess: Risks: to self and others? Appropriate: to participate in a group?

Suggestions for practice: Explain purpose of session and each exercise Provide a clear plan Monitor participant Prompt to work independently Manage behaviour if required

The Role of AHP in Stroke Rehabilitation:

Physiotherapy

PhysiotherapyThe Chartered Society of Physiotherapy (CSP) defines the essenceof physiotherapy as;

"…a health care profession concerned with human functionand movement and maximising potential: it uses physicalapproaches to promote, maintain and restore physical,psychological and social well-being, taking account ofvariations in health status

it is science-based, committed to extending, applying, evaluatingand reviewing the evidence that underpins and informs itspractice and delivery

the exercise of clinical judgement and informed interpretation isat its core." (CSP curriculum framework , January 2002).

PhysiotherapyGoverned & regulated by 2 National bodies. Health ProfessionsCouncil & Chartered Society of Physiotherapy ensure followingprocesses:

– Gather referral information– Conduct clinical interview– Conduct Systematic approach to clinical assessment

(Observations + Assessment)– Drawing up a problem list– Formulating a treatment plan using Best available

evidence and process of Clinical reasoning– Goal setting with the patient– Deliver interventions– Outcome assessment…feedback to original Ax and goals

Physical Rehabilitation Aims In Stroke

• To normalise muscle tone• To restore motor function• To control compensation strategies• To maintain muscle length and ROM• To re-educate balance• To retrain walking and restore mobility• To facilitate skill acquisition• To improve fitness

Evidence-Based Therapy Practice?

• The Evidence!

• The Practice?

Promising Physical Interventions – Cochrane

• Treadmill Training: Moseley et al., 2009

• Electromechanical – and robot-assisted gait training: Mehrholz et al., 2008

• Electromechanical – and robot-assisted arm training: Mehrholz et al., 2009

• Force Platform: Barclay-Goddard, 2009

• Repetitive task training: French et al., 2009

• PT – Strengthening/Repetition, Pollock et al, 2009

• Constraint Therapy: Sirtori et al., 2009

• Fitness training: Saunders et al., 2009

Body Weight Supported Gait Re-training on Treadmill after

Stroke…

Hands on - Bobath

• Concept based on clinical experience

• Re-education of normal movement through facilitation

• Inhibition of abnormal reflexes and movements

• Most widely used approach in the UK

Hands off - Motor Re-Learning

• Based on theories of motor control and biomechanics

• (re)- acquisition of functional tasks

• Teaching and learning techniques

• Repetitive task practice

• Independent problem solving

A question about manual guidance....The more “hands-on” the better?

Comparison• Similarities

– Normal movement analysis and re-education– Brain able to adapt and re-learn– Discourage compensations

• Differences– Facilitation v's active learning– Tone management vs. tone not an issue– Pattern centered v's functional tasksNote: boundaries becoming less distinct

Strengths and Limitations

Bobath• Does not require high

level verbal comprehension

• Manual handling issues

• Limited to therapy sessions

• High level of handling skill required

• Bobath based on theory and observation – concept not supported by evidence

Motor Re-learning

• Functional• Patient more actively

involved• Practice can continue

out with therapy• Requires good patient

comprehension• Motor re-learning

additionally based on evidence in related fields

So…• An eclectic approach allows adaptation

to individual patients and situations.• Dynamic balance of control between

therapists and patient.

• Comparison studies and systematic reviews show no statistical difference in outcome between approaches. (Pollock et al., 2009)

• Difficulties with research due to variability in level of skill of clinicians and differences between patients.

Which do physio’s choose?

Interventions that should be routinely incorporated…

• Lower limb strengthening

• Provision of Ankle Foot Orthoses (AFOs)

• Goal-orientated repetitive movement

• Shoulder support / positioning

• Early supported discharge for selected patients

• Cardiovascular fitness - reconditioning