Stroke Carer

Resources

• Ontario Stroke Network: Post-stroke community-based exercise guidelines
• Fitness and mobility exercise (FAME) program for stroke:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3266302/
• FAME program for chronic stroke:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3226792/
• Manual for basic exercises for stroke: https://www.oatext.com/manual-of-basic-physiotherapeutic-exercises-for-family-and-caregivers-of-stroke-patients.php#gsc.tab=0
• Physical activity and exercises recommendations for stroke:https://www.ahajournals.org/doi/pdf/10.1161/STR.0000000000000022
• At-home exercises for stroke survivors:https://strokeconnection.strokeassociation.org/Spring-2019/At-home-Exercises-for-Stroke-Survivors/

Canadian best practices guidelines

• Management of upper extremity following stroke: https://www.strokebestpractices.ca/recommendations/stroke-rehabilitation/management-of-the-upper-extremity-following-stroke
• Range of motion exercises for shoulder, arm, and hand: https://www.strokebestpractices.ca/recommendations/stroke-rehabilitation/range-of-motion-and-spasticity-in-the-shoulder-arm-and-hand

If you have more guidelines, manuals, and other resources related to exercises for stroke, please send us.

Clinicians’ handbook

• Clinical consequences of stroke: http://www.ebrsr.com/sites/default/files/Chapter%201_Clinical%20Consequences_0.pdf
• Recovery and organized care: http://www.ebrsr.com/sites/default/files/EBRSR%20Handbook%20Chapter%202_Brain%20Reorganization%2C%20Recovery%20and%20Organized%20Care_2020.pdf
• Mobility rehabilitation: http://www.ebrsr.com/sites/default/files/Chapter%203_Lower%20Extremity_2020_ML.pdf
• upper extremity rehabilitation: http://www.ebrsr.com/sites/default/files/EBRSR%20Handbook%20Chapter%204_Upper%20Extremity%20Post%20Stroke_ML.pdf
• Cognitive rehabilitation: http://www.ebrsr.com/sites/default/files/EBRSR%20Handbook%20Chapter%205_Rehab%20of%20Cognitive%20Impairment.pdf
• Medical complications post-stroke: http://www.ebrsr.com/sites/default/files/EBRSR%20Handbook%20Chapter%206_Medical%20Complications.pdf
• Depression and community re-integration: http://www.ebrsr.com/sites/default/files/EBRSR%20Handbook%20Chapter%207_Depression%20and%20Community%20Reintegration_2020_ML.pdf
• Important clinical studies in stroke rehabilitation: http://www.ebrsr.com/sites/default/files/2013-working-copy-of-the-most-influential-studies_jan14-2014.pdf

US resources

• Post-stroke rehab fact sheet: https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Fact-Sheets/Post-Stroke-Rehabilitation-Fact-Sheet

E-learning resources

• For physiotherapists:http://courses.strokengine.ca/

The American Heart Association and the American Medical Association recommend that we should self-monitor blood pressure. They say the activity has a “high potential to improve the diagnosis and management of high blood pressure”.

This recommendation appeared in the Journal of Circulation published on June 22, 2020.

Why do they say that?

It is simply because that the place where we take the reading matters.

Yes, the place matters; when we measure blood pressure at a healthcare center, the reading is likely to be higher than the actual. This is called “white-coat syndrome”.

This is so significant; as a result, the American Heart Association and the American Medical Association issued a joint statement in this regard. This post is about that.

This statement says that “out-of-office high blood pressure is associated with a higher risk for heart problems independent of office-measured blood pressure readings”.

It further says this: “Self-measured BP monitoring has a high potential for improving the diagnosis and management of hypertension in the United States

How to measure blood pressure accurately at home

You can follow this free online course to learn how to measure your blood pressure accurately. This is an initiative of the Pan American Health Organization joined by the World Hypertension League, the Lancet Commission on Hypertension Group and Hypertension Canada, and Resolve to Save Lives, academically developed by a group of highly qualified experts recognized worldwide.

According to Dr. Norm Campbell, the Emeritus Professor at the University of Calgary, It is recommended to re-train all healthcare professionals on how to measure blood pressure every six months. This is based on the evidence that up to 50 percent of readings are potentially misclassified as either having high blood pressure or normal blood pressure.

Five steps that we should follow while measuring blood pressure

1. Select a validated automated or semi-automated device
2. Select the right cuff-size for the person being measured; it comes in three sizes: small, medium, and large.
3. Prepare the person being measured; e.g. pain, anxiety, and stress elevate the normal blood pressure temporarily; And smoking, chewing tobacco, tea, and coffee also elevate blood pressure and it will come back to normal after 30 minutes of stopping those.
4. Measure the blood pressure: Should sit comfortably 5 minutes immediately before the measurement. Both – who measures and who being measured should not be talking. The environment should not be too cold or too hot for the person being measured. Should be seated with back support and the arm should be bare. The cuff should be at the level of the heart. The legs should not be crossed. The feet should be flat on the floor. The cuff should not be too tight or too loose. A couple of fingers should be able to insert between the cuff and the arm. Measure the blood pressure: If this is the first time, repeat the measurement in the other arm. If one arm’s reading is higher, wait one minute, repeat it again at the same arm. And wait another 1 minute, get the third reading. the higher reading should be used as the correct one. If the first reading is higher than the next second and third readings, the first reading should be discarded and the other two readings should be averaged.
5. Record the readings: The final two readings, arm, cuff size, heart rate, age, gender, date, and the use of any anti-high blood pressure medications

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.

How?

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?

In 2014, a group of researchers reviewed the published evidence and found that such programs yield many health and financial benefits.

The policy statement from the American Heart Association

In 2014, The American Heart Association issued a detailed statement backed by ample evidence to support workplace wellness programs and its effectiveness in promoting heart health.

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.

Hyperbrain

This resource contains an excellent collection of learning materials from the University of Utah and the products are licensed under creative commons.

Stroke prevention

This European website provides a comprehensive list of resources to prevent stroke re-occurrence and promote a healthier lifestyle.

I will be adding more resources with time to this post. If you, the readers of this post wish to add more useful resources, I am inviting you all to write back.

Stroke

This journal is a publication of the American Heart Association; some of its articles are in open access. In other words, we can read the full paper without a subscription.

Journal of Stroke

This is an open-access journal licensed under creative commons; that means anyone can use its content by giving due recognition for the journal as well as the authors of the article.

Physical Activity and Exercise Recommendations for Stroke Survivors

This is a detailed evidence-based scientific statement from the American Heart Association published in 2004 on the Circulation journal.

In June 2020, The Lancet Neurology published a very important Declaration proclaimed by the World Stroke Organization (WSO) on stroke and dementia.

The WSO predicts that by 2050, about 200 million stroke survivors will be in the world. And because of the close link between stroke and dementia, we could expect about 106 million living with dementia; and, thereafter, each year, we may encounter over 30 million new stroke patients.

The most notable statement, to me, in their declaration, is this:

Rather than finding why they say this, I focus my attention on what they propose to do.

Let us find out what they have to say about this.

First of all, it is worthwhile to note that they recommend a common prevention strategy for both stroke and dementia because both problems share the same risk factors.

And, these risk factors contribute not only to stroke and dementia but other leading non-communicable diseases also.

What are those?

• Elevated blood pressure
• Abnormal blood lipid levels
• Smoking
• Alcohol
• Physical inactivity
• Salt and sugar
• Unhealthy diet

As we can see that the above risk factors fall into two broad categories;

• Biological (elevated blood pressure and abnormal lipid levels)
• Behavioral or lifestyle; however, behavioral risk factors in turn contribute to elevated blood pressure and abnormal lipid levels.

Now let us look at what the World Stroke Organization (WSO) suggests doing differently to address those risk factors.

A paradigm shift:

Abandoning graded risk categorization and adoption of a risk continuum scale

The first is that their appeal for a paradigm shift of risk classification; they recommend abandoning mild, moderate, and high-risk categorization for heart and stroke problems; instead re-framing stroke risk along a continuum.

Population-wide prevention strategies

They underscore the need of adopting a population-wide approach to reduce the negative impact of behavioral (lifestyle) risk factors. Quite correctly, they also emphasize the need for integrating into the WHO HEARTS initiative, and the establishments and programs at all levels, global, national, and local.

Individual level interventions

Of course, individual interventions – screening for risk behaviors – also necessary; more specifically, poor diet, physical inactivity, alcohol use, and smoking and biological risk factors – elevated blood pressure and abnormal lipid profiles.

The WSO has introduced a free stroke riskometer app to aid this intervention strategy.

Combining community interventions with medicines and behavioral interventions for people at risk of stroke

They highlight five lifestyle risk factors (smoking, physical activity, diet, alcohol consumption, weight) based on evidence.

Implementation strategies

The WSO suggests several evidence-based implementation strategies. These are as follows;

• Using community health workers serving in other community health programs: They bring forward a meta-analysis of 16 RCTs as supportive evidence.
• Combining medical (medications for blood pressure and lipid level screening, medication for the needy) interventions with lifestyle modifications
• Integrating stroke and dementia strategies with WHO HEARTS Initiative
• Imposing taxes on unhealthy food, tobacco, and smoking and dedicate the revenue to prevention, screening, and treatment interventions.

The 2015 published Cochrane review (1) found only five studies that evaluated community walking sessions for people living a stroke. And, they concluded that the quality of evidence of these studies was very low. Furthermore, only 266 individuals had been involved in all five studies and two of the programs “mimicked” community programs.

Walking certainly improves walking ability and speed after a stroke event; the activity itself brings a multitude of benefits not only economically but socially also.

I could not find any reviews published after 2015.

Citations

1. Barclay RE, Stevenson TJ, Poluha W, Ripat J, Nett C, Srikesavan CS. Interventions for improving community ambulation in individuals with stroke. Cochrane Database of Systematic Reviews 2015, Issue 3. Art. No.: CD010200. DOI: 10.1002/14651858.CD010200.pub2.

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.

Communication is one of the biggest barriers when dealing with an individual with a stroke. Some can understand very well but unable to express their needs and wants. That situation, obviously, not only the affected but their caregivers too make frustrating immensely.

How can make this situation improve?

I am introducing you to a relatively simple method that I come across: the use of iconic symbols.

Iconic symbols

Imagine that you want to know what your loved one wants to eat now. Still, you know what their preferences are. When you prepare their most liked food items, you can picture those plates and collect them into a picture gallery.

You can use the following link and follow the steps to make a “choice board” and then print it; it is free for non-commercial purposes.

Please note that I do not have any sort of connection with this organization.

Here is the link; https://connectability.ca/visuals-engine/.

As you can see this is meant for children; however, it can be used for anyone to create your own tool.

Choosing the template

As you can see, there are several templates. Choosing the template depends on your requirements.

Choice boards

If you want to create a tool that includes several choices such as for different food items, you can select 4 or 6 images template. When you click the image box,it will pop up a dialogue box. You can upload the photos you took earlier. And, later you can save it into a stick and print.