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DIRECTED LEARNING:
REFERRAL GUIDELINES AND THE ROLE OF THE EXERCISE
INSTRUCTOR (Chapters 7 & 8)
These answers are examples for your reference. If filling this in an exam situation, each point should be
accompanied by an explanation unless it is intended as a list of items. Use these as reminder tests and
embed your knowledge learned on the course. More detailed information is available through the course
manual or external references mostly available on the student web page.
1. Which medico-legal requirement do exercise instructors need to comply with when
participants self-refer to an exercise referral scheme?

DoH 2001 publication: Exercise referral systems: A national quality assurance framework

http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGu
idance/DH_4009671
2. What are the key responsibilities of the health care professional (HCP) referring a person to
an exercise referral scheme following stroke?

A patient-centred approach requiring judging the patient’s medical status of health,
physical impairments , functional abilities and personal and social barriers to participation
in exercise

Motivational interviewing prior to considering for referral

Selection of patients and initiation of the referral process

The exercise/physical activity assessment

Referral documentation

Long-term physical activity and support plans
3. Which information should be provided to the exercise instructor by a physiotherapist (or
other health care professional) referring a person for exercise after stroke?

Summary of impairments related to completing physical activities

Medications

Contributing barriers to exercise

Special risks
Example referral form is supplied in the training manual.
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4. Which parameters may be useful for self-monitoring in the context of exercise after stroke?

Provided outcome measures - 10m walk/6 min walk, TUAG, VAS.

HR – useful for monitoring intensity of effort

BMI – for monitoring general health (up or down)

BP - for monitoring own stroke/cardiac risks

Reps/resistance/weight/change of exercise tailoring for each timed exercise e.g. circuit
5. Which factors should be assessed by the exercise instructor prior to exercise?

Confirmation of abilities (note: not impairments) e.g. ability to grip handrail, to see
instructor from both sides, to manage a step-up etc noting if there is tonal or balance
issues to monitor

Motivation for proposed programme

General health on that day

Medication check – what they are on and if taken

Discuss risks and how to manage them
6. Compare and contrast “adapting” and “tailoring” an exercise programme.
Adapting
–
should have general exercise programme construct and characteristics altered specifically
for those in general with a stroke
–
should be low level Borg 3-4 to match population with low fitness levels
–
should be low for those with possible hidden cardiac risks
–
should vary between upper limb and lower limb exercises
–
is fitness, balance and strength related
–
evolves as the general programme progresses
Tailoring
–
is specific changes made for the individual to each exercise option
–
takes account of individual disabilities, tonal changes, vision and communication issues
–
effectively is a personalised programme within a programme
–
requires specific and individual monitoring of participants
–
is a constantly evolving process as exercises progress
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7. Which factors does the exercise instructor need to consider in terms of the starting point of
an exercise programme for a person after stroke and why?

Low fitness after rehabilitation

Low capacity to train constantly

Poor understanding of what is expected in a physical exercise programme

Difficulty with learning of exercises

Difficulties with communication and self-expression and poor confidence in speaking out

Higher risk levels of falls

Higher risk levels of cardiac event
8. What are the key session aims for exercise after stroke and what is their underlying
rationale?

Improve all components of fitness:
It is necessary for any programme to have variation, whether this is primarily strength and
balance or cardiac endurance and performance. These variations can be incorporated into
either the main body of a programme of serve as different parts of the warm up.

Prioritise cardiovascular, neuromuscular function:
This is due to the low level of fitness of stroke patients at point of discharge from
rehabilitation and from possibly a previously sedentary lifestyle.

Improve balance/posture/gait/functional strength/performance of IADLs:
All exercise programmes should possess components that directly reflect everyday function
i.e. an athlete would train in both individual components of movements, and practice the
actual full movements that their sport requires. People with stroke are no different.

Increase confidence:
The benefits of this will lead the participant to transfer their learned skills and improved
neuromuscular function into increasing their everyday activities, thus enhancing their
confidence (see chapter 10).

Motivate/educate to improve habitual postural alignment:
This will assist participants with their everyday activities; by reducing increased tone, the
resistance to their movement will be reduced and this in turn will increase the efficiency of
movement. It may also help control pain from muscle cramps and postural pain syndromes.
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
Provide opportunities to socialise:
The confidence improvements that participants will gain from participating in exercise is
probably the most difficult to measure, but one should be aware of the benefits that group
socialising can give when many of this population remain relatively socially isolated.

Achieve long and short term personal goals:
Goal setting is vital so that each participant knows what their goal is and that it is SMART (see
chapter 10).
9. How can the exercise instructor adapt the session content to the needs of the person after
stroke?

The initial decision should be based on the referral recommendations re. the required
aims and components for the participant’s programme

Next, the appropriate levels of intensity need to be selected that the participant will be
able to work to

The exercises selected e.g. STARTER trial will need to be safe and effective for that
selected stroke population
10. What are the exercise programming recommendations for stroke survivors published by the
American Heart Association (2004) in terms of:
a. Aerobic exercise

Large-muscle activities (e.g., walking, treadmill, stationary cycle, combined arm-leg
ergometry, arm ergometry, seated stepper)

Increase independence in ADLs

Increase walking speed/efficiency

Improve tolerance for prolonged physical activity

Reduce risk of cardiovascular disease

40%–70% peak oxygen uptake; 40%–70% heart rate reserve; 50%–80% maximal heart
rate; RPE 11–14 (6–20 scale)

3–7 d/wk

20–60 min/session (or multiple 10-min sessions)
b. Strength training
•
Circuit training
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•
Weight machines
•
Free weights
•
Isometric exercise
•
Increase independence in ADLs
•
1–3 sets of 10–15 repetitions of 8–10 exercises involving the major muscle groups
•
2–3 d/wk
c. Flexibility
•
Stretching
•
Increase ROM of involved extremities
•
Prevent contractures
•
2–3 d/wk (before or after aerobic or strength training)
•
Hold each stretch for 10–30 seconds
d. Neuromuscular exercise?
•
Co-ordination and balance activities improve level of safety during ADLs
•
2–3 d/wk (consider performing on same day as strength activities)
•
Recommended intensity, frequency, and duration of exercise depend on each
individual patient’s level of fitness. Intermittent training sessions may be indicated
during the initial weeks of rehabilitation.
11. What are the recommendations for exercise after stroke, based on the STARTER trial (Mead
et al. 2007) in terms of:
•
Frequency - 3x weekly showed significant benefits in walking speed
•
Intensity
•
Chosen lowest resistance on each element and progressed in increments e.g.
theraband colour, weights of objects etc.
•
•
At BORG scale 13-16 RPE
Time/duration
 Started lower @ 15 minutes for circuit section progressing to 40 mins
•
Type of exercise
Mix of
•
Warm up
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•
Endurance component began in Week 1 as a circuit of cycle ergometry, raising and
lowering a ball, shuttle walking and standing chest press performed consecutively
•
Between each circuit station, patients walked or marched in place to ensure
continuous movement. A stair climbing and descending exercise was added in Week 4
•
Resistance training included upper back strengthening and triceps extension exercise,
both performed seated using elastic resistance training bands, pole-lifting exercise
performed standing, sit-to-stand exercise, resisted by body mass
•
Gentle cool-down and flexibility exercises lasting 10 - 15 minutes
12. Despite the AHA and STARTER guidelines, the authors of this course syllabus highlight that
“It is not yet possible to make firm recommendations with respect to the ‘FITT’ (frequency,
intensity, time/duration, and type of exercise) principles”. Discuss this statement.
•
Evidence is clear re: types of delivery re: circuit/group (English et al)
•
Benefits are clear re. walking components (STARTER)
•
Individual exercise benefits were not individually measured therefore cannot comment
specifically on each re. frequency, intensity, time and type, however, the overall effect
produced significant improvements in control groups for specific tasks e.g. walking speed
13. What are the current guidelines for best practice for exercise after stroke in terms of:

Staff: participant ratio


1: 8 or 2:16 + unqualified learner
Programming principles

Multilevel, multiactivity: It is important that exercise professionals can recognise that
every stroke participant is very different in their capabilities of managing each
exercise, therefore, programmes should reflect this in the variety of exercises
performed and relate these to everyday activity (e.g. sit to stand) (Carr & Shepherd
1998). Some participants may manage 2-5 with additional support and others 20-30
with added resistance.

FITT – Evidence based: Freq, Intensity, Time/duration, Type of exercise. This is a core
principle in all aspects of sports science. Every single exercise in a circuit must have a
rationale regarding its suitability and how it is carried out in order to comply with the
overall aim of the circuit and the requirement of the participant.
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
Choice: self/instructor directed options: If an exercise doesn’t fit, don’t use it! It is
best to find an alternative and tailor it to the participant’s needs, than to force a
participant into managing an exercise badly. If the participant also has a particular
wish to improve in a certain activity e.g. sit-stand, it may be best to base any ‘extra’ or
switch exercises to match this training need.

Involve stroke participants in planning, evaluation and delivery: If exercise
professionals apply the above principle and involve the participants in the process of
tailoring the exercise programme to their needs, then the entire experience is likely to
be more positive. Involving the participant in the process of planning, undertaking and
evaluating the exercise programme enables a sense of ownership, is more likely to
enhance self-efficacy which, in turn, is an important factor in self-management after
stroke. Ultimately, the aim is to enable people who have had a stroke to manage and
enhance their own physical activity.

Buddy systems to empower and recruit: Use available buddy systems to encourage
each participant. There will be times when everyone will experience ‘down days’ when
performance is at less than expected levels. If exercise professionals allow the social
development of a group, then natural buddies will form, allowing exercise
professionals to allocate appropriate partners. Glasgow Exercise Referral Scheme has
developed this further into a formal relationship where appointed buddies are given
further training in exercise management. The signs are that this works well and
encourages compliance with turn ups.

Specialist trained exercise professionals: You are this! In addition, you must keep up
the standards with “spotters” and any other assistants so that your programme is
quality assured.

Teaching skills

Exercise for people after stroke must be evidence-based, safe, effective and
enjoyable. Exercise should not be a chore but enjoyable, motivating and fun. Find out
what motivates each participant and try to design the exercise programme around his
or her goals. Be aware of gender preferences re. exercise and be sensitive to people’s
need for dignity and respect.

Awareness of individual needs and exercise risk: The exercise professional will have
every client’s exercise risks on paper, but these must be learned by heart so that when
taking a group, the exercise professional will immediately be able to respond to any
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reduced performance or exercise difficulty. Only then is the exercise professional able
to know when to adjust an exercise on the spot effectively without compromising the
safety of a participant.

Punctuality, preparation, patience: Allow plenty of time for the group to develop both
socially and, if the exercise professional is well prepared and equipment is well set-up
in advance of a class, to allow a population with varying disabilities to operate it, then
the class should run to time and achieve its goals.

Perform and coach posture: Demonstrating a well-aligned posture and monitoring
clients’ posture throughout the session is essential to ensure that exercises carried out
by participants are safe and effective.

Skilful teaching position to allow observation, adaptation, tailoring: The exercise
professional’s position in the class must be such that he/she can keep an eye on all
participants and be able to assist individuals where required. Where classes are bigger
and a “spotter” is required to assist, then the exercise professional’s position leading
the class must be where the “spotter” can also use the exercise professional with a
participant to demonstrate and help tailor exercises to individuals.

Communication skills

Clarity of instructions - visual and verbal: Clear, simple instructions for each exercise in plain English and not in so-called “sport-speak” should be thought out in advance of
running any class so that it is easy to understand.

Sensitivity/firmness: It is important for the exercise professional to know which of
their clients need some prompting, which will respond by a quiet word of
encouragement in their ear, and which may require a gentle calming of their ‘overexuberance’ and overworking of exercises.

Discussion time pre and post session: Participants need this not just for socialising but
also to gently acclimatise to their programme, discuss their needs and feelings for the
day and give the exercise professional some useful information about how their
attempt at the programme is likely to be on that day. Remember: after a stroke,
performance may vary greatly on a day-to-day basis, much more than even in a
stressed athlete!
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14. In the context of generic risk assessment for exercise, which factors need to be considered
in relation to:

The facility

Space: access to the building and the exercise area, as well as the area itself, needs to
be assessed for risks of tripping or falling. Making sudden changes of direction to
avoid equipment or walls could cause loss of balance and ultimately a fall.

Floor surface: it is essential that this be a non-slip surface and the surface should be
checked for evidence of other factors which could make it slippery e.g. dust or sand. It
is likely that a number of activities may occur in this space; consequently, it may be
necessary to brush the floor before each session. Floor surfaces should also be
checked for loose tiles, broken or loose floor panels and any uneven surfaces. Where
there is a risk, it is the instructor’s responsibility to decide whether adequate controls
can be instigated to enable the session to take place.

Windows: opening windows can present a hazard in warm weather, especially where
participants are likely to move near to the edges of a room. Checks should be made
that open windows do not present an obstruction.

Temperature: low temperatures reduce co-ordination and muscle power and could
increase susceptibility to falls. The temperature of the room should be comfortable.

Lighting: ensure good but not blinding lighting and avoid ‘deep’ shadows or bright
lights shining on floor surfaces.
Where shadows are present in someone with
impaired vision, they may see a step where there is none, or worse, fail to see an
obstacle, misjudge a movement and, therefore, experience a fall.

Equipment
•
Objects: All equipment must be checked for damage and correct set up. Obstacles
to be stepped onto should have a non-slip base and be totally stable. Care should
be taken when using exercise steps that these have been correctly set up and that
any removable top is firmly in place. Mats can provide different surfaces to walk
over, but should be checked for non-slip backing and any damaged edges.
Although equipment may be checked and safe, the layout and positioning of the
equipment may present a hazard, perhaps for those entering the room or wishing
to access chairs. Consequently, equipment must be set up to ensure that less
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confident participants are not forced to negotiate various obstacles before they
are confident.
Although the programme is movement-based, there should be chairs provided for
those who require a rest. These should be checked for stability and safety.
•
Handrails: less confident individuals should be able to hold onto a handrail or
other solid object. Given that this may have to take considerable weight, it should
be tested prior to each session.
•
Footwear: slippers, sandals and loose-fitting shoes may all contribute to a trip.
Thick-soled trainers reduce proprioceptive feedback and often cause a trip
because of the thickness of the sole and the ease of 'catching' on steps and
'sticking' to certain floor surfaces. Ideally, laced, thin-soled shoes with a moderate
non-slip heel are recommended.
•
Glasses: bifocal and varifocal lenses are widely used and require extra care on
stairs, exercise steps or circuit layouts using different levels. It is safer to have
single lens glasses so that the stairs cannot be viewed out of focus through reading
lenses. Even if people have worn them for many years, the ageing nervous system
is less able to quickly adapt between different foci. It is useful to remind
participants that a correct posture will also enhance the efficiency of any type of
lens, i.e. keeping the head and neck erect and only looking down with the eyes.

People/activities
Probably the greatest risks occur from the activities which participants are asked to
perform and the level of supervision of these activities. The high-risk nature of the group
means that ratio of supervision to participant will depend, ultimately, on the functional
abilities and disabilities within the group. The safety and effectiveness of the session will
rest with the skill of the instructor, who will use their expertise and observation to control
and challenge participants. Adequate staff training is consequently an essential control
measure.
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15. In the context of specific risk assessment for exercise after stroke, consider the following
factors in detail. Explain the action(s) you would take for each factor to enhance the health
and safety:
a. Tone and posture
“Closely monitor the effect of exercise on tone and posture and utilise strategies to
minimize increasing tone” (Dinan, 2006 and Dennis, 2007).
In many cases, tone in the affected limb may already be increased; this requires that the
effect of exercise, particularly resistance work, should be monitored closely. The following
tips are designed to prevent/manage increased tone during exercise:- Ensure appraisal of postural alignment prior to and during each exercise.
- The strengthening of the reciprocal muscle group to one with increased tone/spasticity
may lead to a reduction in tone and will address any muscle imbalance (e.g. if the biceps
have increased tone, then ensure there is a significant amount of work for the triceps
group to be undertaken). Based on this rationale, in upper limb work: ensure lateral
versus medial rotation (i.e. outward rather than inward rotation). For example, when
abducting and extending the shoulder joint in a triceps strengthening exercise, ensure
that the palm and the forearm are facing forward and the thumb leads the movement
outward and backwards.
- Ensure that, wherever possible, movement and posture are as symmetrical as possible
and where assistance is needed, try to promote self-assistance i.e. with client’s active
control, rather than the instructor assisting. (Note: assisted movement is a specific
physiotherapy technique that requires specialist training).
- Avoid quick movement as this may increase tone/spasticity or cause a muscle spasm.
Slow, controlled, fluid movements allow the muscle to lengthen/shorten without
triggering hyperreflexia.
- Remember that just because a muscle group shortens or resists stretching where there is
increased tone/spasticity, this does not mean that the muscle fibres are strong. They
may still need active strengthening (Rimmer, 2005).
- Where, despite the above preventative measures, altered tone is present and has
adversely affected posture, it is important to monitor posture and alignment (e.g. poor
rowing technique with too great a degree of trunk flexion can result in hyperreflexia in
the leg).
- If the increase in tone resolves, then continue the original activity, paying particular
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attention to posture, alignment and fatigue. This neuromuscular response to different
postural positions is highly individual and, therefore, exercise for people after stroke
must be tailored carefully. There are general rules that might guide you into finding an
alternative position in which tailoring the exercise will work (see Box 11).
- Where there is an adverse response (e.g. an unresolved change in the client’s baseline
tone status and/or their degree of movement control), the exercise should be
temporarily discontinued by changing the activity and engaging the client in an active
recovery activity (e.g. interspersing marching, walking during step endurance training,
stretching or mobility during resistance training may be effective in preventing or
resolving these problems).
-
Where restoration of movement is not possible through postural or positional
corrections, the exercise professional should assist the client using current physical
therapy guidelines. This can involve the instructor directing the client to self-assist or,
where appropriate, using therapy guidelines to assist the client with a movement. For
example, where physical effort generates patterns of increased muscle tone, or where
the individual is unable to generate sufficient force to perform a movement in a normal
pattern (e.g. if the biceps curl causes an adverse, involuntary increase in muscle tone in
the biceps and anterior shoulder muscles), the client can be directed to self-assist their
affected side with their non-affected side. This can be done by linking the fingers, so the
unaffected (or less affected) side can assist the affected side to stretch the arms upwards
or forwards, as symmetrically as possible.
b. Fatigue
Fatigue is common after stroke. Avoid undue fatigue by utilising the Fartlek (speed play)
and Interval Conditioning (intensity play) training principles i.e. alternating more energetic,
brisker phases of movement with slower, easier, active, recovery phases and by
interspersing resistance with stretching and mobility exercises.
c. Progression

Progress all components slowly and cautiously:
Progress with the smallest possible increments. Assess for progression in the normal way
(i.e. every 2-3 weeks in endurance performance and every 3-4 weeks with resistance
training) but, be extremely conservative with both endurance and resistance increases.
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d. Tailoring to individual capabilities

Tailor the exercises to the individual’s disabilities:
People who have had a stroke often have a wide range of disabilities because stroke
manifests itself in many different ways, and people may well have co-morbidities such as
arthritis, heart disease, peripheral vascular disease, diabetes and obesity. For example,
tailor for no upper limb power, weak grip, poor balance or co-ordination. Each exercise
would then be tailored from the approved version for each individual, for example, for
weak grip, the pole lift would be altered by the strong hand supporting the grip of the
weak hand.

Tailor exercises for participants wearing splints
An ankle-foot orthosis (AFO) is a device that is worn on the lower part of the leg and foot
to control the motion of the ankle and foot, provide stability and prevent deformities.
This is usually made of stiff plastic and, thereby, facilitates functions such as standing and
walking. However, due to its stiffness, it also restricts ankle movements, therefore, it is
important to realise the effect this can have for ADLs and for exercises that require
maximal amounts of ankle flexion/extension.
e. Pain
Work in the pain free and strain free range of movement:
This is best practice for all participants. This is particularly important to monitor if the
participant has had problems with a subluxation of/flaccidity at their shoulder joint.
Extreme care should be taken to ensure the shoulder joint in these individuals is not taken
through more than half range in an upward cycle due to the risk of causing joint damage
and significant pain that is difficult to treat.
f. Falls
Monitor risk of falls:
It is common knowledge that after a stroke, if gait is altered from a normal pattern, the
risk of falls is increased. It is logical to assume that those with a history of falls have an
even greater likelihood of sustaining injury through a fall than a person with no history of
falls performing the same exercise. Indeed, one study involving self-directed walking with
older people with a history of falls, showed an increase in the number of injurious falls
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(Ebrahim, 1997). Although this may have been due to lack of strength and general
preparation of the participants, nevertheless, it indicates the need for extra caution and
precautions with this vulnerable client group in an exercise setting. Any form of activity
with a high-risk group presents potential hazards and every effort must be made to put
effective control measures in place and have emergency procedures ready, should an
incident occur.
16. Ongoing monitoring of people exercising after stroke is essential. Which factors need to be
monitored and why are they important?

Tone changes - may cause increase in disability and pain

Performance of tasks – e.g. reps, resistance, breathlessness, fatigue – may indicate poor
sleep, or ongoing/new hidden medical illness
17. Which conditions may cause people to become unwell during exercise, which symptoms
need to be monitored and what action should be taken if required?

Cardiac condition – may be hidden (30%)

UTI

Respiratory condition e.g. COPD
Condition
Symptoms
Action
Cardiac
A sudden onset of chest pain
(angina pectoris) and
breathlessness/collapse. Cardiac
arrest.
A sudden onset of focal
neurological symptoms such as
writhing and twisting movements
with or without loss of
consciousness.
Sweating, thirst, irritability,
confusion, visual blurring and
difficulty concentrating.
Reassure and support keeping
warm and calm – call for
medical attention, CPR?
Epileptic
Diabetic
hypoglycaemia
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Reassure and protect limbs from
damage by clearing the area
around until episode ends – call
for medical help.
Stop exercise, give sugary drink
(i.e. Lucozade) or glucose tablets
which diabetic should be
carrying, followed by
carbohydrate – arrange escort if
required.
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Respiratory
Allergy
Infections
Shortness of breath, wheeze
cough.
Stop exercise, rest position
sitting up and leaning forwards.
Administer inhaler if
appropriate.
Anaphylaxis
Maintain airway “Epipen” if
carried – call for medical help.
Temperature change, fatigue,
Stop exercise. Patient to report
flushing and reduced performance to GP. Rest sitting up, make
sure taking enough fluids or
medications e.g. prescribed
antibiotics.
18. What are the medico-legal requirements exercise instructors need to comply with when
completing notes on people exercising after stroke?

Notes should be kept in locked area

Should contain activity Hx and Plan

Should contain attendance record

Must be in black ink

Must be held together with referral documentation

Must be held at site of exercise delivery
19. Under what condition may a participant be allowed back into exercise after having been
unwell?

Re-check by GP or other designated HCP
20. In addition to the statutory emergency action plan, what else should be in place in an
exercise facility accommodating people who have had a stroke?

Record book for incidents

Own records of incident

Defib machine
21. If a person develops symptoms of a recurrent stroke, which action should be undertaken?

999

Inform GP

Inform NoK

No return to exercise until re-referral
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22. What action should be taken if a participant with ischaemic heart disease develops chest
pain?

Use GTN spray, if not settling call 999

Rest for session

Report to GP for continuation
23. What action should the exercise instructor take in case:
a.
A participant has not attended exercise for two consecutive weeks without having given
a reason?

b.
Contact the participant, if unavailable contact GP/referrer
Terminates the exercise referral programme?

Contact referrer

Discuss possible other activities
24. Exercise instructors working with people after stroke should comply with ethical and
professional standards:
a. Do you know your local guidelines on data protection? (p.129)
b. What are the key points from Department of Health Guidelines for Exercise Referral (2001)
(p.100)
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