Exercise programming for post-rehabilitation stroke clients Part 2 - ceu

American Fitness, May-June, 2002 by Maribeth Salge

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.

Emergency Plan

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.

Preliminary Steps

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.

Medication

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.

Starting Point

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.

Cardio Training

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.