Articles
Stroke Wellness & Fitness Program at the University
of Kansas Medical Center
Dr. Denise Gobert, PT, Ph.D.
I. Overview
The Stroke Survivors Wellness & Fitness Program
is a community exercise program geared toward improving
the stroke survivor's health through a structured
program incorporating aerobic, strength and balance
training. The program is currently housed in the
Balance & Mobility Research Laboratory at the
University of Kansas Medical Center (KUMC) in Kansas
City, Kansas. The program includes five 8-week
exercise courses scheduled according to the school
year's semesters: Spring, Summer, and Fall. Both
the Spring and Fall semesters include two courses
while the Summer semester only includes on course.
The aerobic exercise program incorporates both
upper and lower extremity reciprocal movements
using the computerized recumbent stepper, NuStep
TRS 4000 Cross Trainer. Exercise objectives are
to increase and maintain cardiovascular fitness
and total body strength in efforts to prevent secondary
stroke and improve overall health and fitness.
In addition, there is an emphasis on the use of
hemiparetic limbs to reinforce proper limb alignment
and stability during movements. To accomplish this,
the involved limb is secured to the exercise machine
handgrips and actively supported during each exercise
session. Although all participants are encouraged
to enroll regardless of health, each participant
is initially required to tolerate at least 6 minutes
on the NuStep at the lowest resistance level without
any signs of discomfort or physiological distress
in order to participate in the program. Each participant
with physician's approval is then asked to participate
in aerobic exercise sessions according to tolerance
levels at least two times a week.
Aerobic exercise training is conducted over the
exercise period with specific outcome tests and
measures performed on a regular basis. Vitals signs
(HR, BP, O2 saturation rate) are monitored before,
at mid-point, and at the end of each exercise session.
Participants are asked to stop if there are any
indications of cardiac distress or discomfort such
as angina. To ensure safety, a cardiologist from
the Department of Cardiology at the University
of Kansas Medical Center, is on pager at all times
during the program's exercise times. All sessions
are supervised by a neurotrained physical therapist
with cardio rehab background along with four other
staff members with nursing and clinical rehab experience
to ensure participant safe progression.
II. Participation
Over a period of one year, the program has enrolled
over 50 male and female participants with an average
age of 61 years of age. Participants are stroke
survivors from the surrounding Kansas City community
who sign up through the American Stroke Foundation
Stroke House (a non-profit community service group)
and who wish to participate in a fitness program.
All participants provide written consent to participate
in the program according guidelines reviewed by
the Human Subjects Committee of the University
of Kansas Medical Center. In addition, each participant
provides documentation of physician's approval
to participate in the program and fill out a simple
Ready for Exercise Medical History Form. An inclusion
criterion specifies that the participant is in
stable medical condition and that both the upper
and lower extremities are able to tolerate movement
activity on the recumbent stepper without discomfort.
Participant recruitment and retention supported
by a very active social network among participants
which encourages continued participation in all
the exercise programs.
Participants exercise at least twice
a week in aerobic activities during the eight-week
exercise module. Many "social" exercise
mini-groups encourage participants to continue
in the new life-styles including exercise and healthy
lifestyles to prevent secondary stroke.
III. Marketing
The program gets publicity through a partnership
with the American Stroke Foundation (ASF), a non-profit
organization geared toward enhancing the quality
of life for both stroke survivors and their caregivers.
In addition, the university has a newsletter which
features various aspects of the program as part
of its health information program. The best marketing
occurs, however, on a personal basis through participant
word of mouth.
IV. Motivation
The program is supported by research grant funding,
has enrolled over fifty participants thus far in
the program, and is about to "graduate" twelve
level-three participants into their own personal
home programs. Research funding will continue for
at least another two years. Referrals come from
local physicians, rehabilitation therapists, hospitals,
and community organizations for stroke survivors.
The use of the NuStep exerciser is currently being
used in many clinical and community centers, however,
knowledge of its use as a safe and aerobic exercise
for disabled populations is still limited. Therefore,
a database is currently being created from this
program to provide the basis for needed information
to help establish protocols specific to the stroke
survivor using this mode of aerobic exercise.
V.
Program Enhancement
In addition to the aerobic exercise, a balance
program is also included using sessions of group
training in both static and dynamic balance skills
with techniques based on neuro-rehabilitation methods.
Participants work at least once a week on basic
postural control of body symmetry both in static
and dynamic tasks such as sit to stand and walking
with and without appropriate assistive devices.
Balance activities combine concepts based on a
customized combination of Tai Chi (Yang Style),
Toga and Pilates. All participants are asked to
participate one day each week in the balance program.
VI.
Educational Content
Caregivers are provided with a reading area where
current journals and brochures with helpful information
about health and caregiving concerns. Participants
at the third functional level also participate
in a structured curriculum developed by the department
of Preventive Medicine which addresses health
behaviors and global health trends in the community.
Regular health seminars feature local professionals
and leaders as invited speakers to help facilitate
group discussions and participation.
VII. Supportive
Services
The program also provides two different community
support groups, one for the caregivers and the
other for the participants. Both groups meet monthly
during the fall and spring semesters. Staff from
the program also participates in local health seminars
and workshops to help promote safe exercise programming
for chronic stroke survivors.
VIII. Outcomes of
Performance and Quality of Life
Indices of Cardiovascular
Fitness: The cardiovascular
response to exercise training is documented using
both objective and subjective fitness measurements.
A pulse oximeter is used to assess arterial oxygen
saturation. The pulse oximeter is widely used in
clinical settings for detection of arterial oxygen
saturation rates. Heart rate is monitored with
the Polar Heart Rate System. To measure systolic
and diastolic blood pressures, a stethoscope and
sphygmomanometer are used. Values are measured
during each exercise session. The Borg Perceived
Rate of Exertion (PRE) scale will be used to document
each participant's subjective level of intensity.
All measurements are compared to baseline values
taken at the beginning of the program to track
progress in fitness levels. In addition, any incident
of re-hospitalization or subsequent stroke incidents
are recorded and kept in each participant's personal
database.
Measurement of Physical Performance: In addition,
functional performance is tested for balance and
mobility skills using a computerized system called
the EquiTest Smart Balance Master. Testing protocols
include the following assessments: Sensory Organization
Test (SOT - testing sensory feedback efficiency
for static balance control), Sit-To-Stand (STS
- testing control from sitting to standing position),
and the Walk Across (WA - assessment of step and
stride control during walking). Last of all, grip
strength is monitored using a dynanometer to quantify
progression in upper extremity strength during
the exercise period. All measurements are compared
to baseline values taken at the beginning of the
program to track progress in fitness levels.
Measurements of Quality of
Life: The program uses
the well-known Short Form-12 Health Survey standardized
questionnaire and the Beck Inventory II Depression
Inventory to document coping strategies and depression
status during the course of the program. Total
scores are divided into Mental Health and Physical
Health subscales. Measurements are conducted every
three months to compare values with baseline values
taken at the beginning of enrollment in the program.
Program Progression
The overall goal of the wellness
program is for each participant to assume an
independent healthy lifestyle, which includes both
proper diet and exercise to prevent secondary stroke.
Therefore, participants receive education about
both proper diet and exercise during the course
of their participation in the program. In addition,
participants are encouraged to progress according
to tolerance through three levels of functional
performance. Level 1 is the lowest level of function
where participants might require assistance with
transfers and are wheel-chair bound for mobility.
Level 2 is for participants who can tolerate at
least thirty minutes of aerobic activity and are
able to ambulate using an Assistive device. Level
3 is for participants who are able to walk independently
requiring minimum assistance with exercises and
who have made progress toward an independent personal
fitness program without supervision.
It is very encouraging to see that after one year
of participation many participants have even felt
the stamina and courage to participate in community
activities such as a community charity walk to
raise funds for stroke support and research. In
April 2003, 25 participants participated in a 4-mile
walk at the Kansas City Zoo sponsored by the American
Stroke Foundation called "Walk on the Wild
Side." The group called themselves "The
NuSteppers" and was able to raise over $4,000
for support of stroke research and programming.
One participant was even able to ambulate using
a cane after being a non-ambulator for four years
in a motorized chair.
