Talking: The Golden Ticket - Exercise and Stroke

 

Stroke is one of Australia’s biggest killers and a leading cause of disability, but more than 80% of strokes can be prevented.

In this episode of ‘Talking Physio’, National Chair of the Neurology Group Dr Natalie Fini, Lecturer in neurological physiotherapy at the University of Melbourne, and Dr Elizabeth Lynch, Research Fellow at the University of Adelaide, chat about the vital role of physical activity in stroke rehabilitation.

References
Dr Natalie Fini, National Chair of the Neurology Group. Lecturer in neurological physiotherapy at the University of Melbourne.
Dr Elizabeth Lynch, Research Fellow at the University of Adelaide. 

 

Narrator

Hello and welcome to the Talking Physio podcast. In this episode, Dr Natalie Fini, lecturer in neurological physiotherapy at the University of Melbourne, and Dr Elizabeth Lynch, Research Fellow at the University of Adelaide, chat about the vital role of physical activity in stroke rehabilitation. Before we dive in, this episode has been brought to you by the Physiotherapy Research Foundation - supporting the promotion and translation of research - and sponsored by FlexEze, the exclusive partner of the Physiotherapy Research Foundation. FlexEze, Australia's number one heat wrap, has been clinically proven to be effective for back pain relief; lasting up to 15 hours. Let's get started.

Natalie

So Liz, I guess it would be good if we started by talking about what the role of physical activity in neurological rehab is.

Elizabeth

Yep. So my experience has mainly been in stroke and as a physiotherapist, pretty much our whole role is, in stroke rehab, is about promoting physical activity. So most people that come in to inpatient stroke rehab, their goal is to get walking again. And I haven't worked in, have you worked in community?

Natalie

I have worked a bit in community as well, but again, it's often around mobility and getting people more active and certainly in inpatients, the most important thing we can do is get people up on their feet.

Elizabeth

Yep and, you know, I think there's heaps of research coming out now about how important it is to practice the task so that if people are having trouble getting out of bed, you need to practice getting out of bed. If they're having trouble standing up, practice standing up over and over again, 'til you have the muscle strength to be able to do it easily, as well as relearning those motor patterns and your balance and everything else that goes into the complex activity that really seems quite simple when it's automatic. So practicing standing up, practicing walking, practicing balance and all those things I think come under the umbrella of physical activity. I think probably something as physiotherapists we need to be more mindful of, is being really specific about addressing things like strength, addressing things like cardio respiratory. So, I don't work in the clinical setting anymore because I've moved into research, but when I reflect back on my own practice, I don't think I did that well at all in terms of being really specific about strength and cardio respiratory fitness.

Natalie

I think there's a lot of evidence now about strength training for neurological conditions and about actually implementing the guidelines. You know the ACSM guidelines and doing our strength training in a very specific and progressive way. And with cardio respiratory fitness, the sad thing is during physio sessions, we don't induce a training effect, so we have to be much, much better at working our patients harder and inducing a training effect. Aerobic fitness has been shown to improve all sorts of things and for healthy people, it improves our thinking and our mood. It's just so important. We know the benefits of physical activity, just so far reaching, it's a preventative strategy for so many chronic health conditions. And it helps us maintain our weight, maintain our blood pressure, maintain good cholesterol and glucose levels. And, most importantly, it improves our mood.

Elizabeth

Do you reckon when you work in the clinical setting like, how easy is it to address fitness 'cause we wouldn't have had the equipment I don't reckon in the gym that I was working in?

Natalie

In the settings that I've worked in, we've had some good fitness equipment, like in normal gyms like cross trainers, steppers, bikes and treadmills. It's very feasible to get stroke patients, or any neuro patients, on these pieces of equipment, and I think we should use them more. But not just throw them on the bike for 20 minutes and leave them there. Actually, do a training program with them, you know, working intervals or do some hip work. I think we need to be really mindful of actually including fitness training in our programs.

Elizabeth

Sorry, would you do like stress testing before you started fitness?

Natalie

So, um, the jury's a bit out. So last conference Sandy Billinger came out and she has a great exercise test on her website on the KU, the Kansas University website, that you can download and run with your patients. And so each centre is going to have a bit of, you know, will their doctors require medical clearance or not? So I can't remember  which researcher, there's between Janice  Eng and Marilyn MacKay-Lyons, one says that you need to do  exercise testing before working your patients, and the other one says you don't. So the jury's a bit out.

Elizabeth

So I know with Janice Eng, because I went and visited her in Canada, so she was saying that with the dose trial that they did, they did do stress testing first, but it was a barrier because people were scared to do it without the stress testing. But what she was advocating for was that physios get involved and learn how to do stress testing, because once we do do that, that's going to be an enabler to, a) it's up upskilling us in being really savvy and precise about fitness testing, but also upskilling  us, which I think seems really good sense.

Natalie

And I think it's really important that this is included in entry level physio education. It's not hard to do. It's just about monitoring heart rate and blood pressure while you're doing an exercise test with patients, and it's generally self-limiting, so it's quite safe. It's not working our patients to a level that they're going to have a heart attack, so it's something that should definitely be included. I think one of the really hard things for physiotherapists is that we have so much to work on with our patients.

Elizabeth

Yep.

Natalie

We have to get them up and walking to get them home when they're in an impatient setting. But we also have people whose arms aren't working and we need to work on that. We need to work on their fitness. We need to work on their strength. We need to work on their task specific training. So there is a lot and it's about prioritising and making the best use of our time.

Elizabeth

And I think there's a role there for teaching people to be empowered. So teaching our, the patients that we work with, giving them the skills so that they know what would be beneficial; what will aid their recovery. What will aid secondary prevention if it is a stroke, but also dealing with their diabetes or their obesity or whatever else they've got going on with their comorbidities. But if we can see ourselves as guides, or as teachers, or as coaches, rather than people that need to be there for every single session, if our patients are safe  to be able to do stuff, either  semi supervised, or on their own, or with family assisting. But I think there's a lot of scope for us to be really clever about the way we're using our time when, as you say, our time is really limited and the people that we work with have got such diverse broad needs that you know you can't just address one thing and really meet all their needs, I don't think.

Natalie

Even in the best rehab centres, people get two hours of physio a day and that's the most they're going to get time with you. So absolutely, we need to be empowering them to do some work on their own, or use the family members that are there to help them. Can the nurses set them up on the ward to give them something else to do? Because "What happens for the other 22 hours a day?" is one of my favourite sayings, because you might do something beautifully in your therapy session, but if the patient can't replicate that, you know, it's only going to happen within those sessions with you, and we need to get our patients empowered to move and function on their own.

Elizabeth

So I'm just, this is just kind of thinking this through for this podcast  really, like on the hierarchy of what we should be doing as  physios, what do you reckon, it seems to me like we should address function first and foremost, but then be mindful, almost with function  you need to address strength as well you know, because strength will help you function. Cardio respiratory fitness is almost like icing on top. Or do you reckon that's fundamental and should be addressed every single time too?

Natalie

It's a really hard one and it's very patient dependent, I guess, because some, for example, a lot of stroke survivors don't even have the fitness to be able to complete their ADLs. So fitness is...

Elizabeth

Really?

Natalie

Yeah, so fitness is actually really important. Or they're at the level that that if they lose some fitness, they're going to lose their independence. That's how bad stroke survivors’ fitness can be. So we absolutely need to work on it, and it can be starting very slowly. Yeah.

Elizabeth

Yeah, oh that surprises me, actually that they're so unfit that they can't do their ADL's.

Natalie

I can't remember the stat, but there's a lot of stroke survivors are at risk of losing their independence.

Elizabeth

Wow.

Natalie

You know, our patients are often quite unfit, and in hospital we're always worried about hospital acquired infections. But we also need to be concerned with hospital acquired deconditioning, which we know happens to a lot of patients in hospital.

Elizabeth

And there's, there's been a lot of, a lot more awareness on that now, I think. So, the whole End PJ Paralysis. So you were saying that that is big in Victoria. I've only seen it on Twitter, actually from the UK. So it's, it is becoming so much more, we're so much more aware of it. But I think physios are leading that. I think nurses are as well, and I think the more that we can be really sensible about everyone owning this, as well as thinking about when you're in hospital, it's such a weird environment compared to home. Everything smells funny. It looks funny. You lose the autonomy of your body almost. Like, "Am I allowed to get up and get myself a drink?" You know?

Natalie

I've got that red Falls Risk band on my wrist, I'm not allowed to get up.

Elizabeth

Yes.

Natalie

That's what our patients are thinking.

Elizabeth

And, and all this stuff, "Am I allowed? Am I allowed to do this, about me? Which I think we need to get, you know, this moves into the power and autonomy side of things, but it's, the hospitals are weird environments, and I think when we work in hospital settings, we forget how strange it is until you go in with a family member and you think, "Oh  my God, this is weird." And I think being mindful of that and obviously patients need to be safe. We don't want people falling over and fracturing. But I think we're so focused on the fear of falls that we've, have moved too far. And I think now, with some of these End PJ Paralysis things, we're starting to move in the right direction but needs to keep moving that direction more.

Natalie

Still, I think we still have a long way to go, and I think as physiotherapists we really need to own physical activity. We have great skills in exercise prescription, but what we have that's really special is we have great movement analysis skills and a really good understanding of neurological conditions and how we can get our patients moving best. And that's why really we are experts for physical activity in neuro and we need to have the confidence about that too.

Elizabeth

Yep. And I think it's almost a professional responsibility that we make sure that we are doing in practice what we know will benefit our patients. So not just doing, like you said, not just doing what we're doing in the gym, but making sure that that carries over throughout the day in a safe way, in a responsible way, but giving people the power and the safety, setting them up safely, so that they can continue to look after their physical activity when we're not around with whatever assistance it is that they need.

Natalie

That's right. And I think there's a lot of common misconceptions about physical activity and about our treatment. What do you think about that for patients, Liz?

Elizabeth

Yes, so looking back, and you'll see this more in particular cultural groups where they feel that they're very sick and they need to be looked after. And different age groups will be more like that than others. So you know, young people will tend to be very gung ho and tend to get up and not wait till they're told that you're allowed to. And they might be labelled as impulsive or safety risk or whatever. But other people on the flip side where they're very, they want to stay in bed and they want to be looked after and they want to rest and they want to wait to the recovery will happen, and that's when we will take  that role as a, providing with the right information and potentially coaching and certainly involving, if it is a cultural thing, involving the family in that information exchange as well, so that people understand the harms that can come from too much rest and the benefits that can come from being active. And then we need to get people on board so that they feel listened to, but also that they're doing what they need to, to look after the health.

Natalie

Absolutely. And I think, as physios, I think one thing we're often worried about is fatigue in our neurological clients. And we know that fatigue is a big problem for many of our patients and we need to respect that. But, um, I guess one thing I always, I'm an educator now and one thing I always tell my students is: don't ask your patients if they're tired. They will tell you. So we're always such lovely people as physios. You know, "How you going?" "Are you tired?" Don't ask your patients if they're tired. They will tell you. You will see it in their face. You will see it as their movement deteriorates. So yeah, don't pop that idea in their head, I guess.

Elizabeth

Yeah, and I think the other thing with some of this neurological fatigue that people will have, it's not something that will tend to go away with rest. It often isn't something that gets worse with exercise. And so I think that's what we need to be mindful of. And for some people it does and then, like you said, respond to that. But if someone is fatigued, it's not necessarily going to go away if they're resting, and it certainly will get worse if they're deconditioned, so that everything is much harder. Sometimes fatigue is, it's almost, I think as physios, we're quite used to the idea of chronic pain, and you learn to manage that condition without necessarily stopping what you would do because of that condition. And fatigue is something that, long term people learn to do pacing and maybe doing bursts of activity throughout the day, but and after a stroke if you have reasonably new fatigue, we do have a role there to share what we know, which you know, I think there's heaps  more work to be done in this space. I think we don't understand fatigue very well at all yet. But what we do know at this point, is that fatigue should not preclude physical activity. You should do physical activity, regardless of fatigue, within the limits of that person's symptoms and preferences.

Natalie

Absolutely. I think one of the other misconceptions that we have is that as physios we love to put our hands on patients because, you know, we feel like we're helping, we're making a difference. And we often are. And there's certainly a place for hands on, particularly in the early days to help our patients experience movement and to demonstrate or facilitate how the movement should be. But I think sometimes we do over handle, and we don't take our hands off quickly enough to empower our patient because, as we were talking about before, we're not with them 24 hours a day. So knowing when to take your hands off is an important skill too.

Elizabeth

Yeah, and I think if someone, for instance, if someone can't get out of a chair without assistance, you absolutely need to put the hands on. But if someone can get out of the chair and it looks wonky, that's when you can use other techniques other than your hands to help them stand up. And you know, so sometimes you might guide them with your hands and then say, "Try and do that same movement without my hands on." I've heard of patients who've gone home, who've been worried about doing activities because it might not be perfect, because they might be using the wrong patterns. On the flipside, you've got patients who are going home using patterns that might be uneven, but they're independent, and I think if it was me, give me independence over perfection any day. And that's not to say we don't work on quality of movement. We absolutely should. We absolutely should work on quality of moving and balance, but be creative about the ways we do that and don't get stuck in one particular groove of how to do that. Use hands on. Use hands off. Use coaching. Use all sorts of cues and see what works for that person. But make sure that you've given them the empowerment and the skills to be able to do that when you're not there.

Natalie

So I think it's about having a lot of different tools in our toolbox and also remembering that we need to have some evidence based tools in our toolbox too, and we know that there's things that have been shown to work, and we absolutely should be trying those techniques out, but we need to have other tools as well for when that might not work for your patient.

Elizabeth

Yeah. So, Nat, last night when we were talking about this podcast you were telling me about your research which I actually didn't know much about. Can you go into that now?

Natalie

Well, uh, it's, I've done a longitudinal study and followed stroke survivors up for two years, and we were measuring a whole lot of things, but the main thing was physical activity over that time, and we looked at associations between different physical activity variables and different cardiovascular risk factors. And one of the things, a couple of things that stood out was that actually participating in moderate to vigorous physical activity, or  MVPA, was important and was associated  with better outcomes in cardiovascular risk factors. And this was more so than doing light physical activities or simply than the number of steps taken. So we found that MVPA is actually important. So it's a little bit disappointing, it means...

Elizabeth

So you know, for the consumer, that's where you say huffing and puffing.

Natalie

Huff and puff.

Elizabeth

So you're sweating?

Natalie

Ah yeah, at least huffing and puffing, so um.

Elizabeth

How would, how would stroke survivors normally get exercising that, that hard?

Natalie

Yeah, so for a lot of our stroke survivors, just walking will get them working at that level of 3 METs, which is MVPA. So that's working their body quite hard. So unfortunately, it showed that we need to get them working to quite a hard level for them rather than just accumulating a little bit more and often throughout the day.

Elizabeth

So is that like the, if you do the perceived rate of exertion is that, what is that 4 or 5?

Natalie

Uh, yeah.

Elizabeth

Here I am showing my ignorance why we need this podcast. 

Natalie

So it's, it's um, so that you can usually talk while you're doing it.

Elizabeth

Yep.

Natalie

But you probably can't sing.

Elizabeth

Right.

Natalie

Yeah. But it is different, and the studies of actually what MET levels are for stroke  survivors of mild, moderate and severe severities  have not been done. But the other big association was that about doing a 10 minute bout of moderate to vigorous physical activity was associated with better cardiovascular outcomes too, so we need to achieve that level of moderate to vigorous physical activity, but then we need to get our patients to sustain it for a period of time as well, and that can be beneficial for their secondary prevention and their health.

Elizabeth

And so was your study just observing a cohort? Or did you assign people to do a particular amount of exercise?

Natalie

No, it was just observing a cohort.

Elizabeth

So how many people were actually doing MVPA?

Natalie

So most patients could do MVPA and achieved more than 30 minutes of MVPA.

Elizabeth

That surprises me.

Natalie

Yeah, but when we looked at it in those who were achieving bouts, ah, MVPA in bouts, the numbers and percentages were much, much lower. So we had around, I think it was 73% in the seventies for most time points that we were achieving MVPA. But the percentages were much, much lower. So, like around a quarter of the cohort, were achieving it in bouts.

Elizabeth

Because we hear about how inactive strokes survivors are in the community.

Natalie

Yeah.

Elizabeth

And so you're saying 73% of people are exercising the MVPA?

Natalie

Well, so that's because they just walk a little bit, so they walk for a couple of minutes here and a couple of minutes there throughout the day, and they were getting to their MVPA.

Elizabeth

Wow.

Natalie

But a lot less of the cohort were sustaining it.

Elizabeth

So these aren't going to the gym and exercising?

Natalie

No, this is just doing, so a lot of our stroke survivors get to that level just by doing their ADLs, yeah.

Elizabeth

Wow, so then they should be doing that more....

Natalie

More

Elizabeth

....so they can do their ADLS without being puffed?

Natalie

Yeah.

Elizabeth

It comes back to that first point. Got it.

Natalie

Yeah.

Elizabeth

And so I guess if we're looking at physical activity, there's all different sorts of ways that we can frame that. So I know that Coralie English and her team in Newcastle, they're doing a lot of work on looking at really focusing on sedentary time and breaking up sedentary time and how we can do that. And so she's got some lab studies where they've got really quite tightly protocalised people coming into the lab, and they're looking at, um.

Natalie

Blood pressure. So that it found a really, a positive effect. So breaking up sitting just by doing some standing exercises every 30 minutes, I think it was. That was shown to have a beneficial effect on blood pressure in stroke survivors, and blood pressure is the most important risk factor. So if we can find a treatment that reduces blood pressure, that's fantastic.

Elizabeth

Yeah, and I think that's one of the things like we talk about the physical activity being the golden bullet. It is the Holy Grail. It's the thing that addresses so many, so many, health conditions. But then how do we ask people to be more physically active when it's more difficult? We know in healthy, normal people - this morning I didn't go for a run. Actually, I did. I did go out with my son, but it was shorter than what it would need to be because we're doing the couch to 5k. You know, so I quite often don't to the exercise I should be doing. And I have no excuses other than my life is busy and poor me, sort of thing. Whereas if it's harder to get dressed and it's harder to exercise and it's cold and it's raining, or whatever, we need to - in changing behaviour for anyone is really difficult and changing behaviour for people who have more difficulty getting up and ready in the morning, it's harder again. And so I think there's a lot of work to be done to  look at how to encourage, how to facilitate activity for everybody, regardless of whether or not they've got a neurological disability. Neurological condition.

Natalie

I did a, a fantastic workshop. I think it was last conference actually, with Taryn Jones and Cath Dean, about behaviour change, and the penny dropped a little bit for me then. I think, as physios naturally we love to exercise. That's part of the reason we probably did the course, and it's something we do. And even for us who love exercising, it's hard for us to get in our five sessions of 30 minutes every week. But something that Taryn and Kath pointed out in their workshop, was that for some people, exercise is actually aversive. People hate it. And for those patients that are not familiar with exercise and haven't done it before, it's a really, really hard sell for us to get them to take this up.

Elizabeth

Yeah, and certainly some work that Emily Ramage in, from Uni Newcastle is doing, is doing this coproduction work for an exercise intervention for people with stroke to reduce their secondary stroke risk. One of the things that the consumers fed back is that: I hate exercise. Hate it. I like to move. And so this is now about getting up and moving, so that it's being framed differently so that we're not putting people off, and I think that's really interesting. That's just something that we hadn't considered. And the benefits of involving the consumers in your research came through loud and clear with that sort of thing. If we can market it better, so it's more enticing, wonderful. If it means that's going to help people opt in to our research program, that's great for us as researchers. But if it can inform us how to deliver interventions more effectively, that's going to be really hopeful for us in our profession, I think.

Natalie

Definitely. And, um, I think it also highlights that we need to have proper conversations with each patient individually and find out what it is they like to do, target our program to them individually, and we're working together to do this.

Elizabeth

Yeah.

Natalie

So we've got all this great evidence and emerging evidence about the benefits of physical activity for our patients, but I guess some of the barriers are the health system and how can we, what changes would we like to see being made?

Elizabeth

Because certainly in the community it's often really hard to access. You know, you hear about stroke survivors will tell us once they've left the hospital system, they go into this black hole and there's nothing there once, once they finish their rehab, they go out and there's nothing and people are living with strokes for a really long time, and they, you know, they're getting older and they've still got a stroke. I think that's a real concern in terms of longevity and quality of life.

Natalie

And there are some Medicare outpatient sessions that stroke survivors can access, but the problem is they're very limited. And to make a change, you know our neuro patients are very complex, so it can't all be done in a few sessions. It'll take a few sessions for a therapist to get their head around the patient, and then to really delve into how can we make a difference and make a change? I guess that's a problem. And also, you know, the funding for those sessions is often very limited, and there's often a gap fee for patients to have to pay, so that's quite a limitation. And it would be great if that Medicare, if that was expanded, I guess.

Elizabeth

Yeah, and the other kind of potential in this area, I think, is some of that work that Marie-Louise Bird has been doing. So she was in Canada with Janice Eng and did a project, I think, where physiotherapists trained up community workers in gyms?

Natalie

Yeah.

Elizabeth

Is that right?

Natalie

So people they at least had some sort of personal training towards EP kind of qualification, because it's a bit different in Canada than what it is here.

Elizabeth

But it was people, so that people with strokes could exercise in gyms right?

Natalie

Yep.

Elizabeth

And so that was really promoting better community services available for people with strokes so that they could then continue their beneficial exercise - because that that was framed as exercise  I  think.

Natalie

It was the FAME program.

Elizabeth

Yeah, so about making services available to people with stroke to continue their rehab in the community setting, out, so it was more like community based versus health system based.

Natalie

Yeah so get out of the hospital, out of the health system and into just community gyms. And watch this space because hopefully Marie-Louise will be implementing the FAME program around Australia, so that would be...

Elizabeth

That would be very cool.

Natalie

Very exciting. And I guess we know that in other areas, we know that stroke survivors and most people with neurological conditions, are at risk of deterioration and at further cardiovascular risk, so risk of more health problems. So another really great thing would be funding for multidisciplinary reviews. You know, at least annually, to identify any areas that they're not meeting recommendations. You know, whether that's their blood pressure, their physical activity, their diet. So a multidisciplinary approach, and then the appropriate interventions can be commenced and we can address these problems before another event happens.

Elizabeth

And I think that's really important too, in terms of looking after the carers of people with stroke, because they are so neglected. And they cover such a load that making sure that we're looking after the stroke survivor is in turn helping to prevent carer burnout and overload. They're doing so much work, so that we need to be mindful and respectful and responsible to make sure that the stroke survivors aren't deteriorating, when we could, like you say, nip it in the bud, by doing things like multidisciplinary review clinics and referral to appropriate services.

Natalie

So I guess, um, to sum up, physical activity is the golden bullet. It's something we should definitely be getting our patients more active, addressing fitness a little bit more while people are inpatients. We should certainly not be discharging people from hospital without some sort of ongoing physical activity program. It needs to be addressed before they go home. It's really, really important, and I just want to highlight that physios are experts in this space and we should own it. And I'm going to throw over to Liz to talk about our fantastic actions collaboration.

Elizabeth

So we've got a collaboration, which is a physiotherapist, but other health professionals as well, who are working to do research to improve the outcomes for people with stroke using physical activity. And so that's a group of Australian and New Zealanders at this stage, with predominately physios, there's one physiologist in there, and so we're trying to get people who are working in this field or researching this field, to build a collaboration, to build what we know and what we're doing in terms of this. And then there's also this falls under, I don't know if it falls under the umbrella of or is aligned with.

Natalie

It's very much aligned with the Physios for Physical Activity Group, which is a group of physios of all different disciplines, and the one thing we all, all physios have in common is physical activity. So no matter what patient population you're working with, it comes back to physical activity. And so Christina Ekegren and Breanne Kunstler started up this collaboration of physios who are interested in physical activity, and it's a great thing to be part of, and they have a fantastic website with lots of resources.

Narrator

That was Dr Natalie Fini, lecturer in neurological physiotherapy at the University of Melbourne, and Dr Elizabeth Lynch, Research Fellow at the University of Adelaide. And you've been listening to another episode of Talking Physio brought to you by the Physiotherapy Research Foundation and FlexEze. Thanks for listening and make sure you catch the next episode of the Talking Physio podcast.

This podcast is a Physiotherapy Research Foundation (PRF) initiative supported by FlexEze – the exclusive partner of the PRF.

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