1. EXERCISE AFTER STROKE Specialist Instructor Training Course T2 The Role of AHPs in Stroke Rehabilitation

2. Content What is an Allied Health Professional (AHP)? What do AHP’s do? –Physiotherapy (PT), Occupational Therapy (OT), Speech & Language Therapy (SALT) Principles & practice of AHP management of stroke (clinical reasoning and evidence- based practice).

3. Learning Outcomes At the end of this session, you should be able to: Describe and demonstrate understanding of the role of AHP’s in stroke care.

4. Essential Reading Further detail about the topics discussed in this session can be found in section [3.2], [4.3], [L7], [L9] of the course syllabus.

5. The Evidence … Cochrane Collaboration Library: http://www.cochrane.org/ http://www.cochrane.org/ Google Scholar: http://scholar.google.co.uk/ http://scholar.google.co.uk/ http://www.knowledge.scot.nhs.uk/ http://www.askdoris.org/

6. 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

7. Students – please list some AHP’s Podiatrist Radiographer Dietician Orthotist Prosthetist Orthoptist Art Therapist

8. The Role of AHP in Stroke Rehabilitation Speech and Language Therapy

9. Content  The role of SLT  Communication difficulties and their impact  Aphasia / dysphasia and dysarthria  What you can do to help

10. Learning outcomes By the end of this session, you should be able to demonstrate an 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.

11. The role of the SLT Provision 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.

12. 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?

13. What is the i mpact of a communication disability? Loss of identity Social isolation and loneliness Loss of employment opportunities / financial security Loss of leisure opportunities Difficulty in personal relationships A Shared Problem?

14. Communication: Giving and Receiving Getting the message Giving the message Message in Message out

15. Aphasia / Dysphasia This is a language disorder Affects both message in (receptive dysphasia) and message out (expressive dysphasia) –Understanding speech and writing –Finding words and constructing sentences –Writing responses Example: http://www.strokecorecompetencies.org/labyrinth/mnode_client.asp?id=24422&parent=2442 7&mode=remote&sessID=17D98D3C-4BD6-4D8E-AD0A-B07B8344F6EB http://www.strokecorecompetencies.org/labyrinth/mnode_client.asp?id=24422&parent=2442 7&mode=remote&sessID=17D98D3C-4BD6-4D8E-AD0A-B07B8344F6EB

16. 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

17. 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!)

18. Thoughts/ideas/knowledge Speech (lips,tongue,voice) Meanings / semantics Word store Speech sounds Motor programming Cognitive impairment Aphasia Articulatory dyspraxia Dysarthria

19. 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=24 422&parent=24426&mode=remote&sessID=17D98D3C-4BD6-4D8E- AD0A-B07B8344F6EB

20. Thoughts/ideas/knowledge Speech (lips,tongue,voice) Meanings / semantics Word store Speech sounds Motor programming Cognitive impairment Aphasia Articulatory dyspraxia Dysarthria

21. More subtle communication difficulties Processing emotional content –Facial expression –Appreciating humour Prosody –Flat tone –Understanding related to stress, rhythm Conversational skills –Making inferences

22. Where is communication breaking down? Instructor & Participant 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

23. Key Points about communication disorders There is a diverse range of communication difficulties following stroke Severity varies from person to person Pattern of problems varies from person to person Communication difficulties and their impact can change over time The impact on the individual and their family will depend on their circumstances Severity of impairment does not necessarily match the impact on activity and participation

24. Exercise Specialist problem solving Good communication is key to your professional role. Is one form of communication more difficult than another? Can this person use other forms of communication? Could I adapt to make this easier? Find what is available and support if required. Apply the principles of effective communication wherever possible – and keep trying...!

25. 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 to make communication successful Principle 3: Match the way you communicate to the ways people understand

26. 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

27. 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.

28. 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.

29. 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.

30. 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.

31. 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

32. Further reading Connect: the communication disability network: http://www.ukconnect.org/http://www.ukconnect.org/ Speakability: http://www.speakability.org.uk/ http://www.speakability.org.uk/ Stroke Core Competencies for Health and Social Care Staff (the STARS project): http://www.strokecorecompetencies.org/node.asp?id=core http://www.strokecorecompetencies.org/node.asp?id=core www.stroketraining.org

33. Talk For Scotland Toolkit http://www.communicationforumscotland.org.uk/ Some places for support

34. The Role of AHP in Stroke Rehabilitation: Occupational Therapy

35. 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).

36. 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.

37. OT – Implications for Exercise Specialists Cognition Attention and memory Sensation and perception Planning, taking action and monitoring

38. Cognition / Information processing Cognition involves: thinking believing perceiving remembering judging planning problem solving monitoring

39. Attention and Memory Characteristics of normal attention: Ability to - –Focus –Divide –Maintain –Disengage, shift, re-engage

40. How do you know if a participant has problems with attention? Distractability / poor concentration Slowed thinking & processing Lack of awareness of “what goes on” Difficulty doing more than 1 thing at a time Tiredness / fatigue Perseveration: inability to disengage e.g. step- up.

41. 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)

42. Sensation and perception: Sensory impairments Inability to use information from touch, hearing, taste, smell or sight, e.g.: 1.Impaired depth distance - results in a different image of an object received by the retina of each eye 2.Hemianopia Common problems with sensation

43. Visual field defects http://www.dwp.gov.uk/img/visual-stroke.jpg

47. 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

48. 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!

49. Common problems with sensation/ perception after stroke Impaired body schema Distortions 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)

50. 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

51. Can you recognise these neglect presentations?

52. How can you tailor exercise for a participant with neglect? Prompt awareness of affected side Monitor use of equipment Watch for obstacles (and other people!) Monitor posture & movement, especially affected side Coach use of neglected side Encourage participants to verbally & visually self-cue

53. 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)

54. Understanding Apraxia Normal Praxis involves: Forming an idea: Planning the action Putting the plan into action > motor execution Dyspraxia may affect any of the above abilities.

55. What are these dyspraxia issues?

56. How do you know if a participant has apraxia? Problems tend to occur when simple movements are combined in sequence to reach goal, and/or when tools are used. 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

57. 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

58. 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”

59. 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?

60. How do you know if a participant may have executive dysfunction?  Distractible  May need prompting  Unrealistic expectations  Unrealistic plans; difficulty with goal setting  Difficulty with time management  Launching into an activity

61. How do you know a participant may have executive dysfunction?  Inappropriate behaviour (e.g. disinhibition, anger)  Difficulty monitoring self – and effecting change when things go wrong  Difficulty making a plan – and sticking to it until its completion  Difficulty with problem solving; difficulty transferring what has been learned to a new situation (the plan does not quite fit)

62. 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

63. The Role of AHP in Stroke Rehabilitation: Physiotherapy

64. Learning Outcomes At the end of this session, you should be able to : Demonstrate an understanding of the physiotherapist’s role in rehabilitation & referral processes to exercise after stroke. Demonstrate awareness of risks associated with a rehabilitation and referral on to exercise intervention

65. Physiotherapy Governed & regulated by 2 National bodies. Health Professions Council & Chartered Society of Physiotherapy ensure following processes: –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

66. Effects of stroke on physical function Reduced range of movement (passive, active) Reduced strength Altered tone Altered sensation Impaired coordination Difficulties with ADL Fatigue Reduced fitness / deconditioning

67. 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

68. Compensations Where there is paralysis, other parts of the body will “compensate” for the loss of control or ability to function. This may present as over-activity or over- use of the “unaffected” side. Bias toward “unaffected” side, making it more difficult for the patient to use the “affected” side.

69. “pusher syndrome”

70. Evidence-Based Therapy Practice? The Evidence! The Practice?

71. 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

72. Body Weight Supported Gait Re- training on Treadmill after Stroke…

73. 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 approach to treatment and rehabilitation?

74. What is “Normal Movement…?” Smooth Efficient Coordinated Graded Automatic Voluntary Goal orientated Specific Patterns What physiotherapy neuro-rehabilitation is all about!

75. What is “Normal Movement…?” There are 4 component parts to normal movement Normal postural tone Normal sensation Movement patterns Smooth coordination

76. Postural / Muscle Tone The degree of tension or activity present in muscles which allows us to maintain an upright posture against gravity and yet still move around.

77. Muscle Tone Must be high enough to provide stability Must be low enough to allow movement Body segments should be able to be placed in space allowing normal movement, both at voluntary and automatic level Normal tone will vary according to the size of the base of support and the anatomical alignment of the individual A brain lesion affecting movement will render muscle tone abnormal

78. Muscle Tone Standing Sitting Lying down HYPOTONICITY HYPERTONICITY Normal Range

79. Base of support and impact on tone Physical support can alter postural tone –Large BOS reduces tone Provides stability where necessary muscle activity may be lacking –Small BOS increases tone

82. Sensory-motor Feedback Loop

83. Vision Inner ear / vestibular system Proprioception / Joint position sense Voice Other sounds Painful stimuli Temperature Touch

84. Balance Reactions Equilibrium Righting Saving Work to produce base for purposeful, functional movements

85. Co-ordination "the ability to integrate muscle movements into an efficient pattern of movement" (Schurr, 1980)

86. 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

87. Shoulder Problems after Stroke What can make shoulders so problematic following a stroke? As instructors what ‘risks’ do we need to be aware of?

88. Shoulder Problems after Stroke John Denis Shoulder Girdle taught video session

89. Management of Subluxation Shoulder Supports Strapping Handling Alignment Facilitation Inhibition

91. Management of Splints/Ankle Foot Orthosis (AFO) Movement analysis – video (Neil)

93. B-blockersSlowing of heart rate with reduced response to exercise. Likely to impact on intensity of exercise. Can cause lethargy, tiredness and low blood pressure. DiureticsClients will tend to know how soon after taking a tablet, they experience the diuresis and can thus alter timing to avoid coinciding with exercise. Can also cause postural hypotension or excessive thirst. NitratesSpray or tablets should be taken to class and used in the event of chest pain during exercise. Those who know they get exercise induced chest pain should take spray/tablet before exercising. Can cause a sudden drop in blood pressure. Peripheral vasodilatation may have effect on exercise capacity. AntidepressantsIncreases postural instability. Can precipitate arrhythmias (abnormal rhythm of the heart) Sedative hypnotics and anxiolytics Increases postural instability, drowsiness and impaired concentration AntipsychoticsIncreases postural instability and can cause movement disorders including Parkinsonian features as well as abnormal writhing movements. Can have sedative properties Eye dropsCan cause blurring of vision after insertion Can produce slowing of the heart rate

94. Essential Reading Further detail about the topics discussed in this session can be found in section L7 of the course syllabus.