1. EXERCISE AFTER STROKE Specialist Instructor Training Course L10 CHANGING BEHAVIOUR: EXERCISING IN THE LONG RUN http://www.fotosearch.co.uk/photos-images John Dennis, Frederike van Wijck, Bex Townley

2. Questions What motivates you to continue to exercise ? What do you think may motivate a person who has had a stroke to: – take up exercise, – continue to exercise? What may the barriers to exercise be and how can you help to overcome these?

3. Learning outcomes At the end of this course, you should be able to : demonstrate a sufficient understanding of exercise behaviour, and goal setting in relation to stroke demonstrate an ability to apply this effectively in practice with people who have had a stroke “design and adapt appropriate progressive physical activity programme(s) after stroke using findings from the physical/exercise assessments, medical information, national good practice guidelines, principles of exercise training, consultation, patient/client goals....” L4 Skills Active Stroke NOS

4. Content 1.Introduction: Motivation: what is it? 2.Motivation after stroke 3.Motivation: how can it be understood? Sources of Motivation Theories of Motivation (Drive Reduction and Incentive) 4.Enhancing motivation through goal setting 5.Case study 6.Summary and implications for exercise instructors

5. MOTIVATION: a definition Motivation refers to the dynamics of behaviour; factors that affect the:  initiation  direction  intensity  persistence of behaviour

6. MOTIVATION AFTER STROKE Common problems with motivation and emotion after stroke: Anxiety and depression: > 50% of stroke patients in hospital Apathy: < 25% Gainotti, G. In: Halligan et al., (2003), p.378.

7. MOTIVATION AFTER STROKE Following your stroke, you experience… Weakness down one side of your body Difficulty expressing yourself Fatigue Depression And now your GP wants you to exercise…..

8. Factors that may affect adherence to exercise - in stroke: Lack of research to begin with! Four most common barriers (Rimmer et al. 2008): –Cost of the program –Lack of awareness of facilities –Lack of transportation –Lack of knowledge of how to exercise Common concerns (Wiles et al. 2008) –Risk and safety –Monitoring, support and interaction

9. Factors that may affect adherence to exercise - in stroke: Key motivators (Carin Levy et al. 2009): –Enjoyment –Something to look forward to –Perceived improvements, e.g.: physical functioning: achievement confidence quality of life –Opportunity to socialise

10. MOTIVATION: HOW CAN IT BE UNDERSTOOD? SOURCES OF MOTIVATION General sources: –Intrinsic –Extrinsic More specific sources: –Biological: e.g. survival –Emotional: e.g. pleasure, fear (avoidance) –Cognitive: e.g. expectation, belief –Social: e.g. peer pressure, cultural norms and values How may this explain M’s motivation to exercise?

11. DRIVE REDUCTION THEORY OF MOTIVATION Assumption: Behaviour is geared towards maintaining physiological homeostasis. Homeostasis Steady state/ equilibrium/ set point] Primary drivers are of a biological nature

12. DRIVE REDUCTION THEORY OF MOTIVATION: the basic idea CONTROL SYSTEM SENSOR Homeostatic system:. Claude Bernard, physiologist (1813-1878) Homeostasis ( 'omeo stasis) Steady state/equilibrium/ set point

13. Drive Reduction theory and exercise Start from a realistic level, based on current; Impairments Abilities (activities) Co-morbidities Motivational / personality characteristics

14. Incentive theory and exercise Incentive : “tending to incite” Assumption : behaviour is goal-directed, geared towards positive outcomes. Important factors: - expectancy - value of outcome to individual

15. Enhancing Motivation by Goal setting Why? Provide incentive, focus attention, take ownership of the rehabilitation process, enhance self efficacy What? short term -> long term SMART! How and by whom? –Discuss… (further reading: Wade 2009)

16. Goal setting: how and by whom? Ask participants about their goals (LT, ST) and needs Prioritise Negotiate – where necessary Agree SMART goals and - if participant agrees, inform family/ carer Plan route to success Chart the goals Assess goal attainment (participant feedback, outcome measures) Adjust original goals – if necessary

17. Case Study; BT BT shows up at the local leisure centre enquiring about returning to classes following a stroke.

18. Case study BT BT 59 years of age – x 3 TIA’s and 3 small hemorrhagic bleeds 18 months ago resulting in; dysarthria, visual impairment at the time majorly impacting on balance and confidence. Reports making ‘full’ recovery (no obvious impairments) But has weakness R side and LOC “Just wants to get back to normal and get her life back” “I need to get back into my exercise classes” But ‘anxious’ about seeing everyone again Gained 2 stone in weight since stroke Has been important for her to come off all medications

19. As an exercise instructor wanting to support this lady to exercise, 1.what do you now need to do, 2.and how would you approach goal setting and supporting BT to achieve the goal she has set out (to return to her classes)

20. Goal setting BT recently sought advise from GP to return to exercise, this request has been supported. On meeting BT in first consultation, what would be included in your discussions with her? what else do you need to know in order to formulate and agree realistic goals? What do you think might be reasonable goals for exercise? Do/what if your recommendations conflict with her goals?

21. Case study BT Agreed plan for next 2 weeks (as then going on holiday); Attend gym x2 pw initially in order that exercise duration can be flexible and self managed Agreed not to exceed exercise programme discussed After performing a warm up and 3 minutes on cycle, BT commented “ I don’t think I can go back to my class afterall…do you?” BT has attended a posture balance and fitness session with much fewer participants, background music and tailored exercise, encouraged to manage own rest periods - and completed 60 minute class no problems

22. SUMMARY AND IMPLICATIONS FOR EXERCISE INSTRUCTORS 1 Start goal setting from a realistic level, based on : –Impairments, Abilities (activities), Co-morbidities –Motivational / personality characteristics Taking into consideration : –Level of self-efficacy –Stage of readiness –Previous and projected participation levels –Expected outcome from chosen interventions Working towards: –Personally relevant goals

23. SUMMARY AND IMPLICATIONS FOR EXERCISE INSTRUCTORS 2 Find out from your participants: –What motivates them? Consider all sources of motivation. –What barriers do they perceive? How can you tip the balance: –Increase motivators –Lower the barriers?

24. Essential Reading Further detail about the topics discussed in this session can be found in section L10 of the course syllabus.