Abstract
Given the potential of exercise to positively influence so many physical and psychosocial domains, the Fitness and Mobility Exercise (FAME) Program was developed to address the multiple impairments arising from the chronic health condition of stroke. We present the details of this exercise program and the evidence which has shown that the FAME Program can improve motor function (muscle strength, balance, walking), cardiovascular fitness, bone density, executive functions and memory. The FAME Program can help to improve the physical and cognitive abilities of people living with a stroke and reduce the risk of secondary complications such as falls, fractures and heart disease.
Keywords: stroke, rehabilitation, exercise, cognition, physical activity, cardiovascular fitness, walking
Stroke is a leading cause of neurological disability in older adults.1 At age 55, there is a lifetime risk of stroke of 1 in 5 in women and 1 in 6 for men.2 It is expected there will be an increase in the number of people living with stroke because of the aging population, an increase in diabetes and obesity (all risk factors for stroke), as well as better acute management leading to a reduction in deaths.1
The risk factors for stroke include age, obesity, hypertension, elevated blood cholesterol, carotid stenosis, atrial fibrillation, cigarette smoking, diabetes mellitus and heart disease.3 Thus, it is likely that individuals prior to having a stroke are not particularly active given existing health conditions. The stroke event then causes a number of additional functional limitations which include muscle weakness, pain, spasticity, cognitive dysfunction and poor balance. The burden of these impairments, combined with a further reduction in activity can then lead to a vicious cycle of decline in function and disability status.4
This article will review selected impairments and functions affected by a stroke and the potential effects of a specific exercise program (Fitness and Mobility Exercise Program) on health domains.
Exercise and motor function
A major component of stroke rehabilitation has been the application of exercise to improve motor function. Exercise has been used to improve muscle strength post-stroke, although this is a relatively new application of exercise in this population. It has been well known that the ability to generate force is impaired in stroke due to a variety of mechanisms, including reduced corticospinal drive to the spinal motoneurones,5 transynaptic degeneration of spinal motor neurons,6 reduced number of motor units especially large units,6 and altered mechanical properties of the muscle which contribute to increased joint stiffness.7 However, strength training in persons with spasticity has been controversial in the past. Bobath8 advocated that decreased muscle strength was due not to weakness but to the opposition of spastic antagonists and that strenuous activity would increase spasticity and reinforce abnormal movement. A recent study9 found that co-activation of the knee extensors and flexors was greater in stroke compared to controls, but this co-activation did not relate to muscle strength.
Recent evidence has demonstrated that muscle strengthening exercises (e.g., using weights, elastic bands) can improve muscle strength post-stroke without increasing spasticity, but may not always lead to improvements in functional tasks that require both muscle strength and coordination (e.g., rise from a chair, walking).10, 11,12 This evidence suggests that a combination of muscle strengthening and task-specific exercises may be necessary to enhance transfer to functional tasks. Alternatively, strengthening exercises during functional tasks (e.g., repetitive sit to stand) may facilitate performance of these tasks. However, muscle strengthening, simply for the sake of strengthening, should not be disregarded in stroke rehabilitation because there are many positive effects from such exercise. For example, strength training can reduce adipose tissue,13 reduce C-reactive protein which is an inflammatory marker associated with heart disease and improve bone strength which is particularly important since osteoporosis is common on the paretic side.14
Exercise has been extensively used to improve the ability to perform functional motor tasks. One of the most common methods of improving gait is through repetitive task-specific exercise (e.g., practicing overground walking with physical assistance or assistive devices, treadmill walking).11 There has been much emphasis on walking ability because individuals with stroke cite “improved walking” as one of their most important goals.15 Consequently, much of time in stroke rehabilitation is spent practicing walking.16 The majority of stroke survivors recover independent walking by 6 months post-stroke,17 albeit with altered gait patterns and slower gait speeds.
Exercise and secondary prevention of complications
In addition to motor function, there is a growing recognition of the value in exercise applications that address secondary complications post-stroke. The economic impact of fall-related fractures has generated a surge of interest in utilizing exercise to improve balance, reduce falls and minimize fall-related injuries post-stroke. In many regards, stroke impairments create an ideal recipe for falls. The majority of individuals with stroke do ambulate, however, these individuals often have a multitude of fall-risk factors including slow postural reflexes, incoordination of muscle activity, muscle weakness on the stroke-affected side, proprioceptive loss, visual deficits, urinary incontinence, coupled with impairments in cognition and judgment.
Individuals with stroke often fall while walking18 and they often land on the stroke-affected side or on their hands and knees.19 Fragility fractures are common following a stroke and are defined as a fracture from standing height or less since an individual with normal bone loss can usually withstand a fall from this height without fracture. Individuals with stroke have a 7-fold increase in fragility fracture risk in the first year post-stroke compared to similar aged groups without a stroke.20 The elevated risk of fractures results from an increased frequency of falls post-stroke, coupled with bone loss which is especially large in the first 6 months following a stroke.21 The primary mechanism behind osteoporosis post-stroke is a reduction of mechanical skeletal loading. This occurs from the reduced muscle pull on the bone from impaired muscle activation, and in the case of the lower limb, a decreased ability to weightbear on the affected leg. In addition, poor nutrition (e.g., vitamin D deficiency) and pharmacological agents commonly used after stroke, such as anticoagulants, have been associated with bone loss.22,23
Exercise is also important for the prevention of secondary complications related to cardiovascular related events (e.g., a heart attack, a second stroke). Cardiovascular disease is the leading cause of death in chronic stroke.24,25 Cardiac-related death occurs at least double the rate observed in age-matched controls.26 The prevalence of cardiovascular co-morbidity in stroke survivors is high: heart disease has been reported in up to 75% of cases, hypertension in 50–84%24 and impaired glucose tolerance and type 2 diabetes mellitus in 80%.27 Up to 30% of people with stroke go on to have another stroke within 5 years.28
In the majority of cases, cardiovascular pathology is a significant contributing factor underlying the occurrence of the stroke. Obesity is also a co-existing factor and a study of 1711 new consecutive stroke admissions found that 76% of patients were overweight and 42% obese.29 We have reported that VO2peak (i.e., gold standard for cardiovascular fitness) in chronic stroke is less than half of values reported in age-matched healthy adults30 and is lower than the minimum 15 ml·kg−1·min−1 required for daily living.31 Thus, it is critical to determine effective secondary prevention interventions that modify cardiovascular risk factors in this population.
Interestingly, an epidemiological link exists between cardiovascular disease and osteoporotic fractures. Sennerby et al.32 studied over 30,000 twins and their data suggested genetic factors in the association between cardiovascular disease and osteoporotic fractures. In addition, the two conditions share some common pathophysiological processes and risk factors.33 Those with low bone mass density are at higher risk of myocardial infarction and stroke.34 We have reported a relationship between cardiovascular health (measured by peak oxygen consumption) and tibial bone geometry has been found in chronic stroke.35
Exercise and cognitive and psychosocial functioning
Although exercise has primarily been used to improve physical functions post-stroke, there is emerging research which suggests that aerobic exercise may improve depressive symptoms in older adults,36 as well as cognitive function in older adults with or without dementia.37,38 Depression is common after stroke with prevalence rates as high as 72%.39,40, 41 and has a negative impact on activities of daily living42 and health-related quality of life.43 A systematic review of randomized controlled trials that utilized exercise for the treatment of clinical depression found that a prescription of three 30-minute sessions per week of aerobic exercise at 60–80% of maximum heart rate, for at least 8 weeks was effective in reducing depressive symptoms.44 Impairments in executive function, attention and memory have been found in up to 78% of individuals with stroke.45,46 Thus, the use of exercise to reduce depression or improve cognitive functions post-stroke may be important adjuncts to other available treatments.
Objective of the FAME Program
Given the potential of exercise to positively influence so many physical and psychosocial domains, we developed an exercise program for people living with a stroke to address the multiple impairments arising from this chronic health condition. The Fitness and Mobility Exercise (FAME) Program was developed to improve motor function (muscle strength, balance, general mobility including walking), cardiovascular fitness, and bone density. The complete Guidelines are available at www.rehab.ubc.ca/jeng. We wanted to optimize the physical ability of people living with a stroke and to minimize the risk of secondary complications such as falls, fractures and heart disease. The FAME Program was developed as a group program to minimize resources. In addition, our participants reported that the group setting was motivating, socially stimulating and a key aspect that enhanced their adherence to the program. Thus, the social aspect of the program is a core element of the program. The FAME Program was intended to serve as a complement to healthy living. We also advocate that people with stroke ensure they have appropriate pharmacological management if required (e.g., for heart disease, high blood pressure, depression, osteoporosis) and appropriate nutritional diet.
Requirements of the community setting
We have undertaken the FAME Program in multi-purpose rooms in a variety of settings, including community centres, church halls and hospital treatment areas. Other ideal settings might be a hospital gym or daycare. The size of the room will be dependent on the number of participants. The room should comfortably fit a chair and step class exercise riser (stepper) for each person and sufficient room to walk around the chairs and steppers with arms out wide. Some of the chairs should have arm rests. It is useful to have risers of different heights and most brands can be stacked to vary the height. Weights or elastic bands can be added to the program, especially for participants of higher function to provide increasing challenge. Heart rate monitors are highly recommended if a cardiovascular component is implemented. Lastly, a music system (can be as simple as a radio or portable CD player) for background music is useful.
Participant inclusion and exclusion criteria
Our clinical trials have focused on individuals with chronic stroke (at least 6 months) who can ambulate and have typical presentations of mild to moderate stroke. Thus, our participants have included people with stroke with mobility problems ranging from fairly slow walking speeds of 0.3 m/s to fairly normal walking speed of 1.0 m/s.47,48,49 All participants have been ambulatory to some extent. As typical with stroke, many of the participants required assistive devices such as canes, walkers and/or ankle-foot orthoses to ambulate. Some subjects have required the use of a power wheelchair for daily mobility, but could stand and walk short distances (e.g., 3 metres) with minimal supervision. Minimally, participants should be able to safely and independently 1) rise from a chair (arm rests can be used), 2) stand (hand support of a chair can be used) and 3) walk 3 metres (assistive devices can be used). In contrast, we have had a small number of participants with mild stroke who could play tennis or ski, and these individuals felt they benefited from the specific graded conditioning of the program for their stroke impairments. We found that varying levels can be helpful in a group setting because it creates a culture of encouragement among the varying functional levels of people. Furthermore, higher functioning individuals may be able to work more independently while the instructor can then spend more time with those who may need supervision on some exercises.
This program was not designed for individuals who require physical assistance to perform standing exercises while holding onto a support. It may be possible for such an individual to participate if they have a caregiver who is trained and willing to assist with the exercises. This would need to be assessed on an individual basis.
Some participants may not be able to speak in the language of instruction due to aphasia or because they speak a different language. It is important that these individuals are able to communicate when necessary (perhaps through pictures or a family member) to ensure that the participant is not experiencing any adverse effects such as pain or fatigue. Thus, those with receptive or expressive aphasia will need to be evaluated on an individual basis to determine their ability to follow instructions and communicate their needs.
Since our research trial required the completion of a number of evaluation forms, our participants were screened by the Folstein Mini-Mental State Exam50 and had values close to normal. What is actually required is that participants must be able to pay attention, follow instructions and mimic exercises for one hour. Most importantly, participants must be aware of their safe limits of ability. Since this is a group program and one-on-one supervision is not available, an individual with impulsive tendencies may not be appropriate, nor is an individual who has poor judgment who may not recognize whether they will lose their balance on a specific exercise. It is important if a cardiovascular component is used that participants have sufficient language skills and cognitive function to understand the concept of “perceived exertion” and “target heart rates” so that overexertion does not occur.
Instructor requirements
We do recommend that a clinician (e.g., physical therapist, occupational therapist, nurse) who has experience in stroke be directly involved in the program as there will be some subjectivity as to who should participate in the program depending on the physical and cognitive abilities of the clients, the instructor:client ratio, caregiver assistance and availability of volunteers.
All instructors and volunteers should have first aid and CPR. The ratio of instructor to client will depend on the level of participants but our trials were undertaken with 1 instructor plus 1 assistant/volunteer for 10 participants (1:5 ratio). Our published clinical trials used lead instructors that were physical therapists, occupational therapists, recreation therapists, kinesiologists or fitness instructors with previous experience with the stroke population. The lead instructor should be an individual who has some clinical experience with stroke, as well as exercise prescription. This instructor should have an understanding of issues specific to stroke (e.g., presentation of stroke, transfers, spasticity, assistive devices, physical and cognitive impairments, co-morbidities). The lead instructor should be able to make judgments as to whether a participant should be excluded from the program or should be referred to seek their physician for advice. In addition, the lead instructor should be able to progress the exercises safely to avoid falls, excessive muscle soreness or fatigue and cardiovascular stress. We have used supporting assistants who were kinesiologists, recreation therapists, fitness instructors, students and volunteers. Depending on the experience of the instructors, a workshop may be required to provide an overview of the details of the FAME Program, define the roles of the instructors, and provide information on the presentation of stroke. With our instructors, we discuss the common stroke impairments of muscle weakness, aphasia, neglect, cognitive dysfunction, incontinence, spasticity, and shoulder pain and discuss possible strategies in dealing with these impairments within the context of an exercise program. We also discuss current stroke treatment and medication, assistive devices, and transfers. Lastly, we discuss possible secondary complications of stroke (falls, fractures, heart disease, obesity) and what considerations they pose for safe exercise. Role playing a practice session of the FAME Program can ensure that instructors are prepared for the program.
Participant screening
If possible, the participant should be assessed in person or over the telephone to ensure that the participant is ambulatory and can follow instructions. In addition, all participants should be screened using standard screening tools. We have used the Modified Physical Activity Readiness Questionnaire (PAR-Q)51 and the Physical Activity Readiness Medical Examination (PARmed-X).52 The PAR-Q is a short 7 question screening tool and is often used for community-based programs. The PARmed-X is a more rigorous checklist of medical conditions to be completed by a physician with their patient if they have had positive responses to the PAR-Q. The PARmed-X can be used to convey clearance for physical activity participation. As the majority of individuals with stroke have cardiovascular co-morbidity, we require an exercise stress test for those entering a program with an intensive cardiovascular component. Our original trials with the FAME Program47,48 did not have an intensive cardiovascular component but focused on the components of functional strengthening, balance and agility and participants did not undertake a stress test.
Some partners/spouses may want to participate in the exercise program to improve their own health or to enjoy an activity with their partner. If so, they should undertake the same screening procedures. The ability to offer the program to partners/spouses may be dependent on their abilities and available space.
Promoting a safe exercise experience
Our experience is that the program can be done safely in a controlled environment. A competitive milieu can add to the fun of the program. However, we have avoided activities such as relays as we have found that excitement and spontaneity can increase the risk of falls in this population. For example, we used one warm-up exercise where two groups of participants sat on chairs in a circle and passed a ball from one to another in the circle. They were encouraged to “race” against the other team. In her enthusiasm and excitement, one participant actually fell off her chair while trying to pass the ball quickly to her neighbour. We have found that participants can make significant gains in a controlled (but still fun) environment that minimizes risks. Furthermore, there are many different ways to make the activities enjoyable without creating a “race-like” milieu. We have also avoided activities that have a sense of unpredictability. For example, tossing a balloon between standing participants or walking on foam are both excellent tasks for improving balance and can be safely done with a one-on-one spotter, however, may be risky without direct supervision. Instructors may find there are some periods that they can provide one-on-one supervision, but this will depend on the instructor-participant ratio and the severity of the impairments of the group. The FAME Program activities were designed to minimize one-on-one supervision to make the program less resource-intensive. The current program has options for arm support (wall/chair) for the most part. The program may include more difficult balance and walking activities if sufficient staffing is available to individually “spot” the participants.
Instructors and participants should be aware of signs and symptoms of when to stop the exercise. Participants should consult their physician if dizziness, chest pain or shortness of breath occurs. Participants with pain should have the exercises modified to work in a pain free range. Any participant who falls in the program should be referred to their physician or emergency care if any discomfort persists. Hip protectors are highly recommended for all participants, and particularly for any participants who have fallen in the past. Any participants with known osteoporosis or osteopenia should avoid spine flexion and twisting exercises.
FAME Program Exercises
This one hour program has been undertaken with a frequency of 2 or 3 times per week, and has achieved successful outcomes with durations ranging from 2 to 6 months. Ideally, a minimum 4 month program is recommended to allow a graduate increase in effort and to achieve sustainable benefits. We have shown benefits of the FAME Program over an 8 week session if undertaken three times per week and over a longer duration (6 months) if only undertaken twice a week. We recommend an additional self-directed home exercise session (e.g., 30 minute walk) if the program is only twice a week to meet minimal physical activity guidelines, unless the individual is participating in other physical activities during the week. If appropriate screening (e.g., stress test) and a cardiovascular component is used (e.g., training intensity greater than 60% of heart rate reserve is used), we recommend a longer program duration of at least 4 months so that a gradual increase in training intensity can be implemented.
The first part of the FAME Program consists of a short 10 minute warm-up of simple whole body exercises (e.g., marching, arm swings, standing with hands on knees making circular movements) followed by gentle stretching exercises (e.g., calf muscle stretch, hamstring muscle stretch, thigh muscle stretch, trunk side stretch). A loss of joint range is common following stroke due to weakness, muscle stiffness, spasticity and inactivity. After the warm-up, the major components address 1) functional strengthening, 2) balance and agility exercises and 3) aerobic fitness exercises.
Functional strengthening involves tasks that address muscle weakness through repetitive coordinated movements that challenge lower limb muscles. Altered motor coordination is evident following a stroke and improvements in movements can be accomplished by utilizing functional movements and postures under challenging conditions. Thus, most of the functional strengthening exercises are done in standing which has advantages in forcing weight-bearing and muscle activity through the limb affected by the stroke, improving bone density through limb loading, and challenging balance.
Balance and agility exercises include slow and fast movements. Slower tai-chi like movements challenge the centre of mass to be moved to varying extents over the base of support (e.g., lunges). Faster movements (e.g, quick step in different directions) improve the rate of voluntary movement and the ability to weight-bear on the paretic limb. Our most popular agility exercise was a task where the participant was asked to try to push the instructor off balance.
The third component focuses on aerobic fitness where the cardiovascular system is challenged to work at a preset training level. Many of the activities overlap into all three of these components. For example, fast walking and walking with longer than usual steps were used as part of the aerobic component, but these tasks will also strengthen plantarflexor and hip flexor muscle activity, in addition to agility. Table 1 details examples of each of these components. Lastly, a short cool-down can replicate some of the stretching performed during the warm-up.
Table 1.
Functional Strengthening Exercises | Agility Exercises |
Sit to stand | Step up so 2 feet on stepper, then step down |
Standing, rise on toes | Step sideways so 2 feet on stepper and step down over other side of stepper |
Standing, lift toes to rest on heels | Stand and do quick lunge on command |
Standing, push-up against the wall | Try to push instructor off balance |
Standing, back against wall, bend knees and hold | Rise from chair, walk around chair and sit down |
Fast walking | Slow Balance Exercises |
Walking with long steps | Standing, forward reach |
Endurance and Fitness Exercises | Heel to toe standing |
Fast walking | Heel to toe walking |
Walking with long steps | Standing on 1 leg |
Sit-to-stand | Lunge position (weight-shift forward/backward, side to side) |
Step up or step sideways onto steppers | Add slow head movements during the above exercises (look up/down, side to side) |
Individualization and progression
Not all exercises should be done in the first few classes as participants will need several sessions to become familiar with them and to increase their tolerance to exercise. The FAME Program is designed to require minimal “hands-on” assistance to encourage independent ability and to reduce resources needed for “spotting”. Exercises are graded in their levels and progressed according to ability. Thus, individuals may commence the activity with hand support using the back of a sturdy chair and the instructors can progress the individual to “no support” when safe.
Functional strengthening and balance exercises can be progressed from 2 sets of 5 repetitions of each exercise to a maximum of 3 sets of 10 repetitions. In addition, the total time limit for each of these components (functional strengthening, balance, agility) is approximately 15 minutes. If cardiovascular screening (stress test) is not performed, a moderate intensity should be undertaken in the program. Intensity can be monitored by different methods such as a heart rate monitor, ratings of perceived exertion or a talk test (i.e., are they out of breath while speaking). It is recommended that two different methods be used to more accurately assess the participant’s exertion. Exercise can commence at levels just above resting heart rate and work towards intensities of 50–60% age-predicted heart rate maximum, perceived exertion of “fairly light” to a maximum of “somewhat hard” and participants should be able to converse comfortably with little effort. In addition, exercise should be intermittent with rests and gradually increase to continuous.
In our published trial with a cardiovascular component,49 participants were screened by a stress test and the protocol commenced at 40–50% heart rate reserve, with increments of 10% heart rate reserve every 4 weeks, up to 70–80% heart rate reserve, as tolerated. The cardiovascular component was superimposed on the functional strengthening and agility components, and thus was the same exercises, but with targeted heart rate training. The cardiovascular component was gradually increased from 10 minutes to 30 minutes of continuous exercise. We found that some participants could raise their heart rate with traditional aerobic exercises (fast walking, step up on steppers), while others with poor balance needed other methods to increase their heart rate. For example, one individual found that repetitive sit to stands with intermittent marching while holding onto the back of a chair was effective. Another found that stepping sideways was more stable and could raise his heart rate in this manner more than walking forwards.
Participants should be asked regularly if they are experiencing excessive fatigue or pain after the exercise session (fatigue or pain that interferes with daily activity or sleep). Knee joint pain is common in older adults and modifications may be required for some tasks such as the repetitive sit to stand tasks.
Strategies for grouping participants
Individuals with stroke have many different impairments, as well as a wide range of severity of these impairments. The first exercise class can be challenging for the instructor(s) especially if a previous in-person assessment was not undertaken. The class can be undertaken in two different formats. A single group format can be used with a small class where all participants move through the components together. In larger groups with multiple instructors, the class can be run as a circuit where there is a common warm-up and cool-down period, but then participants are divided into groups and rotate through different stations (e.g., functional strengthening station, balance station or agility station). Each instructor is then designated a station and the participants rotate from station to station as a small group. If the room is restrictive in space or there is not sufficient equipment (e.g., weights) for every participant, the circuit may provide a space and equipment solution. Specific grouping of participants in the circuit may also be beneficial. For example, our instructors found that they preferred a mixture of low and high functioning participants in each small group as that allowed them to provide more supervision to the low functioning participants. If a circuit format is used, it is important to bring the group back together at the end (can be done as a cool-down) to acknowledge the whole group and close the session. We usually carried out the first class (and sometimes second class) as a single group format and then grouped participants into the circuit format after that. Groups were flexible as participants were sometimes absent/late or because an instructor felt a different grouping was appropriate due to personalities or physical abilities. In addition, groups were altered to allow all participants to meet each other over the course of the sessions.
Maximizing adherence and having fun
Adhering to regular exercise is difficult for everybody. Encouraging socialization and fun can help to increase adherence and participation. There is no doubt that a charismatic instructor can make a huge difference in motivating participants. However, a number of general initiatives can be done to maximize adherence.
Facilitate understanding of the importance of exercise
Providing context behind the objectives of the exercise program can facilitate adherence as it provides a focus and purpose for the instruction.53 The first class should briefly discuss why exercise is specifically important for people with stroke. As each new exercise is introduced, the purpose of that exercise should be explained. Later classes can reinforce the potential benefits of specific exercises from time to time.
Promote socialization
Activities which promote participants to know one another better are essential for adherence. Some activities and ideas are described below:
Have participants and instructors wear name tags for the first few sessions. Plastic pin-on badges are inexpensive and can be re-used. Participants can leave the name badges with the instructor at the end of class to prevent the badges from getting lost. Encourage the instructors to say the names of participants so people hear the names and can learn them quickly.
Use the warm-up at the beginning to generate a short dialogue on one topic that the group can contribute to. “Anyone going to the Garden Show this weekend?” “Did you hear that Gail is a new grandmother” “Did you know that instructor Bill just got engaged?” “Did you know that Vancouver set a new record for rain last month?”
Ensure that individuals who do not regularly contribute to the warm-up or cool-down conversations (e.g., due to shyness, aphasia) are provided with an opportunity to contribute to the group or on a one-on-one level with an instructor. One possible way is to start the topic of a conversation by asking a question that requires a raised hand or yes/no response from the group. For example, “who thinks it’s a good idea that they are building the new shopping mall across the street?”
Transportation is often the top barrier to attending an exercise program. If participants are in agreement, post a sheet where participants can record their home location and look for car pool partners. Encourage participants to car pool with others who drive or with caregivers.
Have an after-class potluck tea (healthy snacks and juice) during a session about mid-way through the semester, after the final class or in celebration of a special event (prior to a holiday break).
Set up a venue where participants can exchange phone/e-mails if the group is in agreement.
Take a group digital photo and e-mail to the class.
Distribute a 1 page monthly newsletter if resources are available. We presented Healthy Heart recipes, announcements of local events (e.g., local flower show), gardening tips, health tips (e.g., benefits of calcium on bone) and the occasional personal announcement (participant announced a new grandchild).
Promote fun activities in the class
We found that many participants enjoyed background music, especially if they were familiar with the music. But they did not want loud music as in a traditional aerobic class (disaster for those with hearing devices), nor do they want to attempt to do their exercises to any regimented musical “beat”. Participants often brought their favorite CD which were played and this created a focal point of discussion for the classes.
Special events can help to add variety, spirit and humour to the day. For example, encourage the celebration of events such as wearing green on the week of St. Patrick’s Day or include singing of Christmas or Hanukkah songs during the warm-up of a day close to these holidays. Mid-way through the semester, we often had participants volunteer to lead the warmup or cool-down.
Our older adult participants like the predictability and repetition of the program. They felt that knowing the program made them feel comfortable and less stressed. Thus, new exercises or variants of exercise can be introduced, but should be done slowly with the majority of the program remaining the same. It is also important that the exercises cover the necessary components of muscle strengthening, balance, agility and aerobic fitness and these exercises have been designed to do such. However, longer programs (e.g., 6 month program) can afford to designate part of a one day per month to an alternative exercise activity. For example, we had one participant who taught a simple ball-room dance and another who taught a line-dance to the group. Such activities need to consider the abilities of the participants and whether all participants can safely engage in these activities.
Feedback and assessment
Assessment can be used as a measure of feedback for the participant, in addition to informing the instructors of participant progress. In reviewing the positive results to a self-directed exercise program, Olney et al.54 suggested that their follow-up assessment may have provided incentive to adhere to the exercise program. A number of simple valid clinical tests can be used to measure progress. Ambulatory tests include the Timed up and Go Test (time to stand up from a chair, walk 3 meters, turn around and walk back to the chair and sit down)55 or the longer 6 Minute Walk Test (distance walked over 6 minutes using a long hallway or rectangular path).56 The Functional Reach Test (forward reach distance while standing) is also a simple measure of balance function.57 One caution is that maintenance of function (rather than improvement) may be considered a positive outcome given the known functional decline that occurs in the chronic phase of stroke.58
Evidence for the FAME Program
The FAME Program has been tested in four different clinical trials with people with chronic stroke. The first trial was an 8 week program to examine the feasibility of an exercise program in this population and found that the program was effective in improving multiple health domains. Participants experienced meaningful improvements in pain, muscle strength, walking endurance, activities of daily living, energy levels, mobility and self-perceived quality of life.47 Importantly, the improvements in the physical outcome measures were retained at least 1 month after the cessation of the program. Standard outcome measures capture many important aspects of any trial, but individual stories shared by our participants also add qualitative evidence. For example, one participant lacked the mobility and coordination to put on his pressure stockings for ankle and foot swelling which had been present since his stroke occurred 5 years ago. Thus, he required a caregiver to assist him each day with this task. He was elated after the study when he found that he no longer experienced the ankle/foot swelling and no longer required pressure stockings.
The second trial focused on changes in postural control and utilized a 10 week FAME Program group, as well as a control group which undertook a program with stretching and weight-bearing activities.48 All participants were assessed for their postural reflexes. They stood on a platform and were attached to an overhead harness. The platform was then translated unexpectantly and the participants were asked to try to remain standing. The magnitude of the perturbation was such that healthy older adults would find the perturbation very gentle and easy to recover from. After the program ended, the translating platform test showed that the FAME Program resulted in faster lower extremity postural reflexes (reflexes that the body uses as a first-line defence to recover from a fall). In particular, the paretic rectus femoris was 27 ms faster after the FAME Program and this change is similar to the length of a monosynaptic stretch reflex and is suggestive of functional significance. In addition, those in the FAME Program group fell less during the platform test compared to the control group. The FAME Program group also improved more on a step task where they were asked to step forward as fast as possible in response to an auditory cue. Furthermore, we tracked the number of falls that occurred in the community over the following 12 months once the programs ended. Importantly, there were significant group differences in the falls over these 12 months. For participants who had fallen prior to the trial (therefore, those at most risk), the FAME Program group had 53% of these participants falling in the 12 months, compared to 87% of the control group.
The third trial was a 5 month program where we introduced a graded cardiovascular component, as well as assessment of cardiovascular fitness and bone density.14 Participants were screened by a standard cardiovascular stress test which permitted a higher intensity of aerobic fitness training compared to the other trials. As expected, walking endurance, mobility and balance were improved. Cardiovascular fitness was improved by approximately 10% in the FAME Program group compared to the control group (upper extremity program). Paretic hip bone density was lost over the 5 months in the control group, but maintained in the FAME Program group. In addition, the FAME Program group gained more tibial trabecular bone content and cortical bone thickness on the paretic side.59
Lastly, we recently undertook a feasibility study to determine the potential effects of the FAME Program on cognition.60 This study combined a 2 times a week FAME Program with a one hour per week recreation program. The participants with stroke experienced improvements in memory, executive functions, as well as in a dual-task test (walking while talking). We cannot determine whether the positive impact on executive functions was due to the exercise component, recreation component, social aspects of the programs or a combination of these components. However, this pilot study demonstrates the potential for improving executive function and memory with exercise in the stroke population.
Current use of the FAME Program
A variety of programs for people living with chronic stroke have been developed, but the FAME Program stands alone in showing that it is effective for so many health domains. The FAME Program was designed primarily for the stroke population, however, some centres are using it for frail older adults, Parkinson’s disease, or multiple sclerosis. In addition, it was developed for the community setting, however some centres have utilized the FAME Program as an inpatient or outpatient-based group program, and as an adjunct to regular one-on-one therapy. The FAME Program can help to improve the physical and cognitive abilities of people living with a stroke and reduce the risk of secondary complications such as falls, fractures and heart disease.
Acknowledgments
The FAME Program was developed in Vancouver, Canada with invaluable assistance from Andrew Dawson, Kelly Chu, Maria Kim, Daniel Marigold, Sif Gylfadóttir, Marco Pang and Jocelyn Harris. We also acknowledge the support from the Heart and Stroke Foundation of BC and Yukon (operating grant), Canadian Institutes of Health Research (operating grant) and Career Award (MSH-63617 to JJ Eng) and Michael Smith Foundation for Health Research (Scholar Award to JJ Eng).
References
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