Transcript Outcome measures - Later Life Training

EXERCISE AFTER STROKE
Specialist Instructor Training Course
L10 CHANGING BEHAVIOUR:
EXERCISING IN THE LONG RUN
John Dennis , Frederike van Wijck, Bex Townley
http://www.fotosearch.co.uk/photos-images
Questions
• What motivates you to continue to exercise?
• What do you think may motivate a person
who has had a stroke to:
– take up exercise,
– continue to exercise?
• What may the barriers to exercise be and
how can you help to overcome these?
Learning outcomes
At the end of this course, you should be able to :
• demonstrate a sufficient understanding of
behaviour, and goal setting in relation to stroke
exercise
• demonstrate an ability to apply this effectively in practice
with people who have had a stroke
• “design and adapt appropriate progressive physical activity
programme(s) after stroke using findings from the
physical/exercise assessments, medical information,
national good practice guidelines, principles of exercise
training, consultation, patient/client goals....”
L4 Skills Active Stroke NOS
Content
1. Introduction: Motivation: what is it?
2. Motivation after stroke
3. Motivation: how can it be understood?
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Sources of Motivation
Theories of Motivation (Drive Reduction and Incentive)
4. Enhancing motivation through goal setting
5. Case study
6. Summary and implications for exercise
instructors
MOTIVATION: a definition
• Motivation refers to the dynamics of behaviour;
factors that affect the:
 initiation
 direction
 intensity
 persistence of behaviour
MOTIVATION AFTER STROKE
Common problems with motivation and
emotion after stroke:
• Anxiety and depression: > 50% of stroke
patients in hospital
• Apathy: < 25%
Gainotti, G. In: Halligan et al., (2003), p.378.
MOTIVATION AFTER STROKE
Following your stroke, you experience…
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Weakness down one side of your body
Difficulty expressing yourself
Fatigue
Depression
And now your GP wants you to exercise…..
Factors that may affect adherence
to exercise - in stroke:
• Lack of research to begin with!
• Four most common barriers (Rimmer et al.
2008):
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Cost of the program
Lack of awareness of facilities
Lack of transportation
Lack of knowledge of how to exercise
• Common concerns (Wiles et al. 2008)
– Risk and safety
– Monitoring, support and interaction
Factors that may affect adherence
to exercise - in stroke:
• Key motivators (Carin Levy et al. 2009):
– Enjoyment
– Something to look forward to
– Perceived improvements, e.g.:
• physical functioning: achievement
• confidence
• quality of life
– Opportunity to socialise
MOTIVATION: HOW CAN IT BE
UNDERSTOOD?
SOURCES OF MOTIVATION
• General sources:
– Intrinsic
– Extrinsic
• More specific sources:
– Biological: e.g. survival
– Emotional: e.g. pleasure, fear (avoidance)
– Cognitive: e.g. expectation, belief
– Social: e.g. peer pressure, cultural norms and values
How may this explain M’s motivation to exercise?
DRIVE REDUCTION THEORY OF
MOTIVATION
Assumption:
Behaviour is geared towards maintaining
physiological homeostasis.
Homeostasis
Steady state/ equilibrium/ set point]
Primary drivers are of a biological nature
DRIVE REDUCTION THEORY OF MOTIVATION:
the basic idea
CONTROL
SYSTEM
Homeostasis ( 'omeo stasis)
Steady state/equilibrium/ set point
SENSOR
Homeostatic system: .
Claude Bernard, physiologist
(1813-1878)
Drive Reduction theory and exercise
Start from a realistic level, based on current;
• Impairments
• Abilities (activities)
• Co-morbidities
• Motivational / personality characteristics
Incentive theory and exercise
Incentive : “tending to incite”
Assumption : behaviour is
goal-directed, geared towards positive
outcomes. Important factors:
- expectancy
- value of outcome to individual
Enhancing Motivation by Goal setting
• Why?
Provide incentive, focus attention, take ownership
of the rehabilitation process, enhance self efficacy
• What?
short term -> long term
SMART!
• How and by whom?
– Discuss…
(further reading: Wade 2009)
Goal setting: how and by whom?
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Ask participants about their goals (LT, ST) and needs
Prioritise
Negotiate – where necessary
Agree SMART goals and - if participant agrees,
inform family/ carer
Plan route to success
Chart the goals
Assess goal attainment (participant feedback,
outcome measures)
Adjust original goals – if necessary
Case Study; BT
BT shows up at the local leisure centre
enquiring about returning to classes
following a stroke.
Case study BT
• BT 59 years of age – x 3 TIA’s and 3 small hemorrhagic
bleeds 18 months ago resulting in; dysarthria, visual
impairment at the time majorly impacting on balance
and confidence.
• Reports making ‘full’ recovery (no obvious impairments)
But has weakness R side and LOC
• “Just wants to get back to normal and get her life back”
• “I need to get back into my exercise classes”
But ‘anxious’ about seeing everyone again
• Gained 2 stone in weight since stroke
• Has been important for her to come off all medications
As an exercise instructor wanting to
support this lady to exercise,
1. what do you now need to do,
2. and how would you approach goal
setting and supporting BT to achieve
the goal she has set out (to return to
her classes)
Goal setting
• BT recently sought advise from GP to return to
exercise, this request has been supported.
• On meeting BT in first consultation, what would
be included in your discussions with her? what
else do you need to know in order to formulate
and agree realistic goals?
• What do you think might be reasonable goals for
exercise?
• Do/what if your recommendations conflict with
her goals?
Case study BT
Agreed plan for next 2 weeks (as then going on holiday);
• Attend gym x2 pw initially in order that exercise duration
can be flexible and self managed
• Agreed not to exceed exercise programme discussed
• After performing a warm up and 3 minutes on cycle, BT
commented “ I don’t think I can go back to my class
afterall…do you?”
• BT has attended a posture balance and fitness session
with much fewer participants, background music and
tailored exercise, encouraged to manage own rest
periods - and completed 60 minute class no problems
SUMMARY AND IMPLICATIONS FOR
EXERCISE INSTRUCTORS 1
Start goal setting from a realistic level, based on :
– Impairments, Abilities (activities), Co-morbidities
– Motivational / personality characteristics
Taking into consideration:
– Level of self-efficacy
– Stage of readiness
– Previous and projected participation levels
– Expected outcome from chosen interventions
Working towards:
– Personally relevant goals
SUMMARY AND IMPLICATIONS FOR
EXERCISE INSTRUCTORS 2
• Find out from your participants:
– What motivates them? Consider all sources of
motivation.
– What barriers do they perceive?
• How can you tip the balance:
– Increase motivators
– Lower the barriers?
Essential Reading
Further detail about the topics discussed in this
session can be found in section L10 of the
course syllabus.