Evidence is convincing; early mobility improves recovery after stroke. Earlier the better, because moving body parts, if possible, stimulate the alive brain cells – neurons – to take over some of the jobs lost due to the death of their neighbors.
Evidence suggests it needs to be done as early as possible, even within 24 hours after a stroke for “better recovery”, according to the American Heart Association and the American Stroke Association.
The activity could be as simple as sitting on the bed. Obviously, not all who suffered can do that.
However, sitting on the bed has to be followed up with intermittent standing and later with well-coordinated therapeutic exercise sessions.
This recommendation appears in the Stroke journal published in 2014. The statement came as a result of research findings that early mobility improves the chances of earlier walking ability and functional recovery.
The above findings came from a powerful randomized controlled study.
About the study
A research team compared assigned 71 stroke patients to two groups. Their mean age was 74.7. Their blood pressure, heart rate, oxygen saturation, and temperature were monitored. Among those who were safer to sit, one group received the usual standard care. and, the other group were mobilised early with a follow-up of intensive moblisation at regular inervals. Then their performance was compared on one primary outcome: the number of days required to walk 50 meters unassisted. They found that the intervention group returned to unassisted walking significantly faster than the standard intervention group (p=0.032; 3.5 median days versus 7 median days). Moreover, the other functional outcomes as measured by the Barthel index was better at 3 months in the intervention group.
The above study appeared in the Stroke journal in 2010.
However, there is a catch here. Starting physical activities early alone is not enough; it needs to be done consistently according to the above statement. This is the most difficult part.
Exercise and physical activities become effective if those are done consistently.Stroke Journal, 2014
Challenges in implementing these findings
Research reveals that although many who experience a stroke event can do exercises, they choose not to do. As a result, with time, not only their ability to walk but the ability to carry out daily activities also declines. This is because, with time, their heart-lung fitness too deteriorates.
Many factors contribute to this unfortunate situation; lack of knowledge, system inefficiency, and inadequate emphasis by healthcare professionals are the main reasons.
How to improve early mobility after a stroke
The experts recommend starting a planned exercise program as soon as the person is medically stable. The following are the specific recommendations from the American Health and Stroke associations;
The goal here is to regain or exceed pre-stroke level activity level as soon as and as much as possible. This should be started at the hospital and continued at home once discharged. The continuity is the key here for the success.
The critical principles here are;
- Maintaining the progressive task difficulty
- Functional practice
- Inclusion of aerobic (heart-lung) and strengthening exercises
The modes of adhering to above principles are;
- Treadmill exercises: Research has shown that aerobic treadmill exercise as early as within 6 days up to 6 months after stroke improves heart-lung fitness and walking distance.
- Cycling ergo-meter
- Recumbent stepper
- Chest-deep water
- Functional exercises
It is critical for the patient to develop the skills and confidence for eventual self-management of physical activity and an exercise training program.
It is critical for the patient to develop the skills and confidence for self-management of physical activity and an exercise training program.Stroke Journal, 2014: The statement from the American Heart and Stroke Associations
Experts recommend everyone to undergo graded exercise testing with ECG monitoring prior to the start of a graded exercise program. However, if the physician decides that screening for fitness is not possible due to lack of facilities, they further suggest not delaying the exercising but to tailor a program in order to suit the patient’s capability.
Due to lack of accessibility to graded exercise testing with ECG monitoring facility, experts recommend use of near-best simple test – “six minutes walk test”.
It is so critical to start a movement as early as possible; that is the key message here. For those who cannot do the exercise ECG testing, that should not be an excuse for exercise program; the recommendation is to initiate a lower-intensity one.
Whenever the prescribed exercise ECG testing is not done, a lower-intensity exercise program should be started.Stroke journal, 2014; the statement from the American Heart and Stroke Associations
About 85 percent of those who experience a stroke will have some sort of weakness in one or both of their upper limbs. This post discusses recommended methods of improving upper limb weakness.
A stroke occurs as a result of an interruption to the blood supply to a part of the brain that controls body movements and sensory inputs from body parts. There are two types of strokes: ischemic and hemorrhagic. Although some of the damage is permanent, still some can be recovered with specific exercises.
Evidence shows that “high-intensity, repetitive, task-specific practice” clearly improves motor recovery after a stroke event. However, the practices to regain lost functions of arms are different from legs’. Let us look at how best practice guidelines translate this evidence into recommendations for practice.
The Canadian stroke best practice guidelines published in 2019 recommends the following principles and methods to improve the function of the upper limbs.
The Guideline recommends two principles for those who experienced a stroke event less and more than six months.
- Create activities that are meaningful, engaging, repetitive, progressively adaptable, task, specific, goal-oriented.
- Create activities of daily living, that encourage the use of the affected limb.
Specific treatment methods
We need to be knowledgeable and creative to use these methods because the selection of method/s depends on the function affected.
Strong evidence from a Cochrane review exists that exercise for the affected arm is more effective than both arms. The Canadian stroke best practice guidelines also do not recommend both arm training when one arm is affected.
Recommended exercise/treatment methods
- Range of motion (ROM) exercises (passive and active-assisted)
- Mental imagery
- Functional electrical stimulation for the wrist and forearm muscles to reduce motor impairment and improve function
- Constraint-induced movement therapy for those who at least 20 degrees of active wrist extension and 10 degrees of active finger extension, with minimal sensory deficits and normal cognition
- Mirror therapy as an adjunct for those with very severe paresis
How do we know that these methods are effective?
A large number of research has demonstrated the effectiveness of the exercises. I will mention here one important study.
J. Leipert and colleagues mapped the cortical areas of the brain’s both sides of 13 individuals who were living with a stroke for more than six months. They found that the area of the affected side was significantly smaller than the area of the non-affected side. After subjecting them for 12-days of constraint-induced movement therapy, they re-mapped the same areas. Then, they found that those areas of the affected side were significantly enlarged. They published these findings in the Stroke journal in 2001.
Interventions with no evidence
It is also important for us to know the treatment methods with no sufficient evidence to date. According to a Cochrane review published in 2015, these are as follows;
- Music therapy
- Repetitive trans cranial magnetic stimulation
- Electrical stimulation
A guideline resource for exercise providers
The Ontario Stroke Network provides a useful guideline for community-based exercise providers; here is the link.
Carers’ role in exercises
Research has shown one gain better results when carers assist in rehab exercises.
An excellent resource
This video clip presented by an Occupational Therapist, Mitchel Edwards describes useful exercises to improve upper limb weakness. However, keep in mind that this is for informational purpose only and you need to obtain your health care professional’s guidance.
This glossary covers the terms used in the promotion of physical fitness. it includes the terms, physical activity, exercise, and types of exercises. The proper understanding of these terms and concepts are critically important in improving care for those living with a stroke.
All guidelines recommend for anyone living with a stroke should consult a physician and undergo medical screening to decide the suitability of exercises and range of motions.
Physical fitness refers to a situation in which someone can do their expected physical activities – activities of daily living, leisure – without undue fatigue (Saunders et al. 2016). When physical fitness is declining, the range of physical activities including Activities of Daily Living (ADL) will become increasingly difficult and vice versa.
The concept entails a set of attributes. It includes the ability to carry out the activities of daily living with vigor and alertness, without undue fatigue, and with ample energy to enjoy leisure-time activities and to meet unforeseen emergencies (Carl J Caspersen and colleagues).
Physical fitness includes the following five components:
- Heart and lung (cardiorespiratory) fitness: another name for this term is “endurance” which refers to the ability to do physical activities for an extended period than usual.
- Muscle strength: this refers to the ability of a certain muscle or a muscle group to exert certain force such as pushing, pulling, or lifting.
- Muscle power; refers to the ability to do single powerful action or a movement.
- Balance; refers to the ability to maintain balance and posture while moving or stationary.
- Range of motion (flexibility); this refers to the ability to do all movements around a joint.
- Body composition; refers to the relative amount of fat or fat-free mass.
Physical activity is defined as any bodily movement produced by skeletal muscles that result in energy expenditure (Carl J Caspersen and colleagues).
Physical activities can either be planned or unplanned. Exercise refers to planned physical activities.
Exercise refers to a sub-set of physical activity that involves planned, structured, and repetitive bodily movement that is done to maintain or improve one or more components of physical fitness (CDC US). These should be done with the purpose of improving physical fitness. For example, some may carry out their job-related or household physical activities with the aim of spending energy. Those activities are considered exercise (Carl J Caspersen and colleagues).
Light- moderate physical activities:
These activities include moderately-paced or leisurely walking or bicycling, slow swimming or dancing, and simple gardening (CDC).
Vigorous physical activities
These activities include fast walking, fast bicycling, jogging, strenuous swimming or sports, aerobic dance, or strenuous gardening (CDC)
Vigorous physical activities: These activities might include fast walking, fast bicycling, jogging, strenuous swimming or sports play, vigorous aerobic dance, or strenuous gardening.
These activities include strenuous muscular contractions such as weight lifting, resistance training, push-ups, sit-ups, etc (CDC).
Leisure-time physical activities; exercise, sports, or any other activity done during leisure time.
Types of physical fitness (exercise) training
- Heart-lung (cardio-respiratory) programs: to improve heart and lung fitness
- Resistance training programs: to improve muscle strength and muscle power
- Flexibility (stretching) training programs
- Balance maintenance training programs
- Mixed training programs: a combination of the above two types
Mode of training:
This refers to the methods employed for the type of training; for heart-lung training, it could be either walking, running, or cycling. It could be stationary too with or without an instrument/machine.
Dose of training:
The dose of training refers to the amount of training (the program length – number of weeks or months, duration of a session, and the intensity (amount of work or effort).
This refers to a prescription that includes mode, type, and a dose of the exercise recommended.
Workplace wellness programs not only detect those at risk of getting a stroke and coronary heart disease but prevent occurrence also. Overall, these interventions promote general well-being.
As a general measure, the strategy is one of the cost-effective interventions of health promotion.
Employees spend most of their time in the workplace throughout the most productive period of their lives. Carrying out wellness programs yield many dividends not only to themselves but employers and society at large also. The program managers too can save their valuable time, money, and limited resources because the workplaces gather apparently healthier individuals into one place.
Therefore, well-known advocacy organizations promote employee wellness programs. The American Heart Association is one of them.
Return – on-investment is very high
The benefits of workplace wellness programs do not limit to stroke or coronary heart disease prevention. Research shows that the return-on-investment on workplace wellness programs is very high. Just consider one facet of workplace wellness programs – weight reduction.
A group of researchers, quoting other researches wrote in their article that workplace weight management programs aimed at achieving 5 percent weight reduction would reduce annual medical cost and absenteeism costs by 90 $ per overweight employee.
Components of a workplace wellness program
A workplace wellness program usually employs a multi-modal strategy. These are as follows:
1. Screening for risk factors, interventions, and follow-up
As highlighted in the Geoffrey Rose seminal paper on “sick individuals and sick populations”, screening for risk factors bring many advantages;
- The screening easily attracts both employees, employers, as we ll as health professionals.
- The follow-up actions and results are quick because those who are at risk can be sent for immediate intervention.
- The motivation levels among all stakeholders are high and hence lifestyle modifications for them could potentially be successful.
Screening for weight, aerobic fitness levels, tobacco use, dietary habits, blood pressure, blood sugar, heart health, and lipid profile is the most common screening activities. These tests are done at the worksite. The findings are used to assess current and future risk levels for non-communicable diseases, particularly for coronary heart disease, diabetes, and cancer.
Health screening is always coupled with relevant referrals for further assessments, follow-ups, and medical interventions.
An example framework for a workplace wellness program
Following is a conceptual framework that I created to implement a workplace wellness program in Sri Lanka in 2015. This program is continuing to date and we, as a group, presented some of its findings as a poster at the 2016 Sri Lanka Medical Association Annual sessions.
Behavior change interventions
These interventions are aimed at everyone regardless of their individual risk status. It may consist of include interactive health education sessions, individual or group counseling sessions, promotive educational materials – electronic or otherwise, and creating supportive environments to sustain behavior changes. Supportive environments can be created by ways of providing incentives – financial or otherwise, formulating policies such as healthy food policy, etc.
Do health promotion at workplace work?
The policy statement from the American Heart Association
Are you doing only the muscle strength exercises? The evidence suggests you change it a little bit: blend cardio into it. Researchers have concluded that cardio with strength training exercises yields better walking ability, walking speed, and body balance (to a certain extent).
And, they also have concluded that muscle strength exercises alone do not improve walking ability.
The emphasis on cardio is a recent finding; traditionally, the rehab programs have been focused on gait training and balance.
This emphasis on cardio is because many who survive the stroke live with low levels of heart fitness; and, it could also be due to that those with low heart fitness are more likely to face a stroke.
What are the suitable cardio exercises?
Walking and cycling are the two commonest cardio exercises. The cardio strengthens the heart. That is why it is called cardio. However, prior to engaging in cardio, the physician should assess the heart fitness and the physiotherapist should recommend the types of cardio that need to follow. The Heart and Stroke Foundation has published an excellent patient guide. You can access this brochure through this link.
What are muscle fitness exercises ? (resistance or strength training)
Some common examples of muscle fitness include pushing, pulling with elastic bands, and lifting weights. In these types of exercises, we do not exert pressure on the heart as much as in walking and cycling.
Range of motions and body balance exercises
Invariably, when we engage in the above two types of exercises, we certainly involve our joints with different types of range of motions and exercises that improve body balance.
About the research
In 2015, David Saunders and his team reviewed 58 clinical trials that compared people with a stroke and engaged in special exercise sessions with a similar group of people who followed usual care. The total number of study participants involved in all these trials was 2797.
In this study, they classified physical fitness into three groups: heart fitness (endurance) training, muscle fitness (strength) training, and mixed training (a combination of the above two forms).
You can access the article through this link; https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6464717/
Do you have any comments, ideas, or suggestions about how to blend cardio with strength exercises? Please initiate a discussion about it.
A guideline resource for exercise providers
The Ontario Stroke Network provides a useful guideline for community-based exercise providers; here is the link.
This is great news for the caregivers of those with speech and language difficulties.
This is how it works: do they need something to tell? such as I need water. they see the visual, click it, we hear it. The good thing is that we can customize it for our needs. Loads of pictures are available as pictograms.
This is the link:https://www.cboard.io/.
Enter the website; You will see the front page as shown below. Then, start your Cboard.
Then, sign up.
Then, you will receive an email for confirmation.
unlock it. now, you can build a board. Once you registered you can enter into a page below and can start build your own boards.
This is what I built; a simple one.
Are you happy?
Similarly, you can customize your board according to your requirements.
More importantly, you can download its app to your phone too.
A variety of urine absorbent products for men exist in the market. Some products – pull-ups and diapers – wear both men and women. I wrote about those in one of my earlier posts.
This post is about urine absorbent products for men.
Men wear inserts, as its name by itself implies, are placed inside the diaper or brief. For men, some products exist in the market to contain urine as it comes out of the penis. One such product is the pouch (leaf).
Leafs or Pouches: Inserts for men who dribble urine
The pouches or leafs are for men who dribble urine in very little amounts. As its name implies it covers only the penis so that urine does not spread around the scrotum and groin area. It holds about 1-2 ml of urine.
Baby diapers (size 1) are creative alternatives some people use particularly during day time. You can wrap it around the penis. Obviously, it is not suitable for men whose penis is now retracted. These products can hold little more urine than pouches. The main advantage of this over pads is that you can remove it if it is wet and can insert a new one during the day easily.
Pads (also called liners, leaves, sheaths, shields or guards)
Unlike pouches and baby diapers, pads (sheaths or guards) cover the groin allowing urine to spread around the area. Not only men who dribble but those who leak a lot of urine also wear these. Pads have an adhesive strip on the outer layer to paste it on to either brief or adult diaper with tabs with the aim of keeping it in place.
These pads are available in small and large sizes. While small ones are used by men who dribble urine large sizes are used by those who leak moderate – large amounts of urine.
Small disposable pads
The following is an example of small incontinence pads with its outer and inner views.
large incontinence pads
HOW TO USE A PAD
The following video clip published by continence product advisor.org shows you the step-by-step about wearing a pad.
- The incontinence pads for adults include diapers, briefs, and inserts.
- These are structured into three layers: inner, middle, and outer.
- The inner layer lies in contact with the skin, permeates urine and body fluids into the middle absorbent layer.
- The outer layer does not allow to leaking of urine out of the diaper.
Stroke carers cannot evade the problem of urine /fecal incontinence which is one of the most challenging. It drains out all the energy, innumerable number of hours, and money.
Stroke carers need to have a very good understanding of incontinence pads in order to manage the urine incontinence satisfactorily. The knowledge definitely saves not only the carer’s money but improves the quality of life of the carer as well as the person living with a stroke too.
My aim of this post is to broaden the readers’ knowledge about adult diapers and briefs; however, I invite caregivers to share your knowledge, experience, and new information that this post does not include. It will definitely be an immense help for those who are facing the difficulties I spell out here.
Before going any further, I invite you to read one of my earlier posts about the anatomy of the bladder. because you will have an understanding of various forms of urine incontinence that occur such as “stress incontinence” and “urge incontinence”.
Adult diapers or briefs?
First of all, a word of caution: the word, “diaper” may carry a certain degree of stigma for an adult because it is a thing for babies – the adult version of a nappy; hence adults may prefer the word, “brief” to “diaper”. I believe this is crucial in protecting the affected’s dignity. However, even the government of Canada website uses the term “adult diapers”.
When to use?
Adult diapers and briefs are intended for those who experience “moderate to heavy” urine incontinence. This is what the book says. But determining the “moderate-heavy” incontinence is challenging. Experts agree that those who pass more than 100 ml urine within 24 hours are having “moderate-heavy incontinence”. And, those who pass less than 100ml are experiencing a “light” degree of incontinence.
How do you decide that?
I will deal with that problem later. You need to be able to estimate the leaking volume because this is one of the criteria manufacturers adhere to when producing incontinence products.
First of all, I will describe here the main parts of a diaper or a brief.
Anatomy of adult diapers and briefs
A standard diaper consists of three layers: the inner layer, the middle pad, and the outer layer. The following is the basic structure of an adult incontinence brief.
The inner layer (top sheet) – the inner layer
The inner layer lies in direct contact with the user’s skin; the fabric here is non-woven material to enable urine and other body fluids permeating down into the middle absorbent pad.
The middle absorbent pad – the middle layer
The absorbent pad – the most important section – consists of super absorbent polymer – of course, a synthetic type – which can absorb water as much as 20 times more than its weight. Some products contain fluff pulp too.
The outer layer (back sheet) – the outer layer
Unlike the inner layer, this one is made up of woven fabric designed not to allow trapped body fluids seeping through onto clothes or bed linen.
Elasticated wraps and self-adhesive tabs
Since a diaper is an adult version of a nappy, it holds itself with its elasticated wraps around the thighs and self-adhesive resealable tabs around the waist.
What are the adult diapers and briefs?
Broadly speaking, adult urine absorbent types exist in two forms: pull-ups and diapers with tabs (tape-attachment diapers). Most of these products are disposable; few varieties exist as reusable too.
Briefs are also called “pull-ups” which are like shorts – you can call it as a type of underwear too – to which the absorbent materials are built into it. Those are ideal for those who are not bed-bound it does not hinder walking and other body movements. However, sometimes those who cannot sit or stand, wear this type too.
Pull-ups come in various sizes: small or medium, large or extra-large, and XXX large. The government of Canada website publishes item numbers and prices per each size for provinces and territories.
Diaper with tabs
This type is ideal for bed-bound clients. It also comes in different sizes like pull-ups. The advantage of this type is that we can adjust with the tab to make it snug fit properly. Companies sold these under the term “adult briefs (tape-on)”. According to the Cochrane research database, this type is the most cost-effective one for men with moderate-heavy urine incontinence.