Artigo - Papel do personal trainer na reabilitação de pacientes com AVE

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The role of personal trainers for stroke
rehabilitation
Lori Burkow-Heikkinen*{
*West Bloomfield, MI USA
{White Lake, MI, USA
Objective: Stroke is the third leading cause of death and the leading cause of adult disability
around the world. The aim of this paper is to introduce the medical community to the
importance and benefit of using the expertise available through personal trainers.
Methods: A qualified personal trainer should have an educational background in anatomy,
physiology, cardiovascular, orthopedic, rehabilitation and neurology. The major equipments
required to perform the extra challenges are revised. Equipment and exercise evaluation of a
patient is suggested in these additions to regular rehabilitation process.
Results: The major requirement for an advanced personal trainer is a bachelor’s degree in
exercise science or related field, with additional educational background in neurology,
rehabilitation, orthopedic, anatomy and physiology. It is hypothesized that initiating a
supervised, total body exercise program following a cardiovascular accident, one can elicit a
positive response towards the activities of daily living. Typically, the physical or occupational
therapist will work on just the affected side or portion of the body. Working with a personal
trainer, he or she will work on balancing both sides of the body, improving overall strength and
coordination, resulting in greater total body recovery.
Conclusion: By detailing what a qualified personal trainer for stroke rehabilitation can do, in
combination with appropriate medical screening and following an appropriate structure course
of recovery that adheres to specific programming, a patient can achieve the benefits of training.
This training seeks to minimize the risk of additional adverse events or injury while restoring
strength and function after a stroke event. [Neurol Res 2009; 31: 841–847]
Keywords: Stroke; personal trainer; neurology; rehabilitation medicine; occupational therapy;
fitness equipment
INTRODUCTION
Stroke is the third leading cause of death and leading
cause of adult disability in the USA and Europe.
Annually, 700,000 people in the USA suffer a stroke
with a survival rate of y66%. In China, they have two
million strokes per year. Many studies have demon-
strated that a regular fitness program in a healthy
individual drastically reduces the rate of morbidity as
well as decreases major health problems1. Utilizing the
same assumption, prevention of major health problems
is one of the goals of regular exercise, is also applied to
stroke patients. Research supports that stroke patients
who continue to participate in activity and exercise
should reduce their risk factors thus extending their life,
reducing the likelihood of a second event and restoring
activities of daily living. It is the purpose of this paper to
present to the medical community the value for patients
to work with a qualified personal trainer. It is important
to be able to recognize those qualifications of those
persons who are able to do the job and do it correctly.
QUALIFICATION OF A PERSONAL TRAINER
A ‘personal trainer’ is defined as a fitness professional that
develops and implements an individualized approach to
physical fitness, generally working one-on-one with a
patient. A trainer may also help individuals assess their
level of physical fitness and help them work towards a
personal fitness goal through proper exercise instruction
and personal motivation. The scope of practice for many
personal trainers is to enhance the components of fitness
for the general, healthy population. The five classic
components of fitness are muscular strength, muscular
endurance, body composition, cardiovascular endurance
and flexibility, although there are other subsets like
power and speed. The definition of healthy in this context
means an absence of a disease that would affect one’s
ability to exercise. Anyone outside that scope of practice
should be placed in a trainer’s scope after seeing a rehab
physician, an occupational therapist and a physical
therapist to see what kind of exercises they are capable
of. Trainers are required to have certifications before
beginning work in a health club or facility. Most
certifying organizations candidates need to have a high
school diploma, be certified in cardiopulmonary resusci-
tation and automatic external defibrillator and pass an
exam. The patient needs to be confident that the personal
Correspondence and reprint requests to: Lori Burkow-Heikkinen, 2222
Kingston Rd, White Lake, MI 48386, USA. [lburkow@comcast.net]
# 2009 W. S. Maney & Son Ltd Neurological Research, 2009, Volume 31, October 841
10.1179/016164109X12445505689724
trainer is experienced and has completed an internship
with the educational background and certifications
required working with these individuals. An advanced
specialized personal trainer needs to have a background
in anatomy, physiology, cardiovascular, orthopedic,
neurology and rehabilitation.
Changes in the health care system and continued
growth of the fitness industry have participated in the
need to provide advanced educational forums and
certifications for fitness professionals. Many of the
established agencies have developed standards and
guidelines for fitness professionals to use when training
patients with special needs and post-rehab concerns.
The National Commission for Certifying Agencies uses a
peer review process to establish standards and com-
pliance of the standards and serve as a resource on
quality certification. It has been suggested by the
American College of Sports Medicine that a certified
clinical exercise specialist meet the following require-
ments: a bachelor’s degree in allied health field,
minimum of 600 hours of practical experience and a
current certification as a basic life support provider. The
personal trainer needs to be acquainted with dissemi-
nating research and recent advances in the field of
medicine made for the fitness community. Many
patients having completed physical and occupational
therapy require a supervised exercise program to
maintain progress made in rehab or have been advised
by their physicians to begin an exercise program. This
type of fitness discipline will determine the level and
amount of education and training that are needed with
the extra challenges made by equipment.
EXERCISE PROGRAMMING FOR STROKE
REHABILITATION
Before working with post-rehab patients, it is imperative
that the personal trainer posses the skills and knowledge
to manage and develop fitness programs. The advanced
fitness professional should hold a bachelor’s degree in a
fitness related field or a medical fitness certification. The
IDEA Health and Fitness Association is a worldwide
organization and is a good resource for finding qualified
personal trainers for stroke rehabilitation. The following
approach presumes that rehabilitation was successfully
completed; the rehab physician and rehab team agree
that the patient no longer requires medical monitoring
[e.g. blood pressure, electrocardiography (ECG), tran-
scranial cerebral oximetry, etc.] and would benefit from
an exercise program with a certified personal trainer. An
exercise program begins when the rehab team has taken
the patient as far as they can go with the patient.
Usually, this occurs when it appears that progress has
stopped. Exercise is for life; a recommendation using a
personal trainer will greatly benefit and enhance the
patients’ functional capacities. A patient needs extra
challenges to improve muscle contractibility with the
help of professional guidance and instrumentation.
‘Before beginning a physical conditioning regime, it is
recommended that all stroke patients undergo a
complete medical history, usually the most important
part of the pre-exercise evaluation, and a physical
examination aimed at the identification of neurologicalcomplications and other medical conditions that require
special consideration or constitute a contraindication to
exercise’2. A personal trainer needs to obtain a health
history form, a signed consent from the participant, a
physicians release for exercise and a copy of patients
rehab medical records. Rehab professionals are a
valuable source of information, allowing trainers to
update a patient’s exercise program rather than starting
over. The formulation of the exercise prescription is to
minimize the potential adverse effects of exercise using
systematic movements by appropriate screening, pro-
gram design, monitoring and patient education. The role
of the personal trainer is also to challenge the patient’s
muscle capabilities, using certain equipment, in order to
get the maximum potential from the individual working.
REHABILITATION PROCESS
The purpose of the rehabilitation process is to limit the
impact of stroke related brain damage on daily life using
a multidisciplinary approach, including physical, occu-
pational, speech therapy and cognitive rehabilitation.
Based on the severity of the stroke, the patient may stay
in rehab ranging from months to years.
The goals of rehab services are to increase the
patient’s level of independent function, control any
pain and improve coordination, balance and muscle
strength. Therapy may be provided in the acute hospital
setting, a rehab hospital setting or on an outpatient basis
in either the home or clinic. An excellent means of
maintaining and possibly improving on gains made in
rehabilitation, is a supervised one-on-one fitness pro-
gram. Stroke patients are often deconditioned and
predisposed to a sedentary lifestyle that limits perfor-
mance of activities of daily living. The ability to exercise
depends on the severity of neurological involvement
and existing co-morbidities. Muscle weakness, limited
range of motion and impaired sensation may preclude
independent ambulation or the ability to exercise in a
standing position. Lack of adequate balance may
interfere with the ability to perform a sitting arm crank
or leg cycle ergometry. Weakness and/or limited range
of motion of the arm or leg may also interfere with a
person’s ability to maintain crank rates during ergome-
try. Receptive aphasia, mental confusion, and/or apraxia
may interfere with the ability to understand and follow
directions during exercise testing or training sessions2–4.
The magnitude of activity is generally related to but
not completely dependent on the level of body
impairment. ‘Other factors that influence level of
activity limitation include intrinsic motivation and
mood, adaptability and coping skill, cognition and
learning ability, and rehabilitation training by the
physical/occupational therapist’2.
FITNESS IMPROVEMENTS GOALS AND OBJECTIVES
FOR STROKE REHABILITATION
Fitness improvements goals and objectives for stroke
rehabilitation are as follows:
Role of personal trainers for stroke rehabilitation: L. Burkow-Heikkinen
842 Neurological Research, 2009, Volume 31, October
N muscle strength, endurance and coordination;
N functional capacity;
N balance and proprioception;
N active range of motion.
EQUIPMENT SECTION
Basic treadmills are equipped with speed and elevation.
As shown in Figure 1 (Matric Matrix Fitness Systems
Corp., Cottage Grove, WI, USA; Star Trac, Irvine, CA,
USA), it is equipped with a variety of programs (manual,
fitness and random hill). It also includes clock, calorie
expenditure and heart rate monitor. Recumbent exercise
bicycle is shown in Figure 1B (Life Cycle 9500HR, Life
Fitness World Headquarters, Schiller, IL, USA).
NuStep has time, steps/min and workload: METS (a
metabolic equivalent unit; a unit used to estimate the
metabolic cost of physical activity relative to resting
metabolic rate), Watts (unit of power equal to work
carried out at the rate of 1 J/s) and heart rate. It can be
adjusted for the patient’s height. It is shown in Figure 2D
(TRS4000 Nu-Step, Inc., Ann Arbor, MI, USA).
The upper body ergometer (Scifit, Tulsa, OK, USA)
model includes not only the upper body crank but also
the leg cycling (Figures 2A,B).
Choices for strength training include weight machine
(Cybex, Cybex International, Medway, MA, USA;
Figures 3–6), resistance bands/tubing (Figure 5) and free
weights (Figure 4C).
Choices of balance equipment includes agility ladder
(Figure 7), Swiss balls, foam rollers and Bosu.
STRENGTH
Resistance exercises should be prescribed to address
any muscle weakness. Training exercises should focus
on functional related activities. Exercise may use a
variety of resistance devices, such as resistance bands,
ankle weights or stability balls, all aimed at providing a
challenging, yet safe strengthening program. Individuals
with neurological impairments may have difficulty with
preparatory postural adjustments and recruiting strength
quickly enough to combat the loss of balance. Some of
the positions typically used for weight training may
need to be modified. For example, a person who has
difficulty maintaining standing balance should perform
these exercises unilaterally (side at a time) while holding
onto a bar or other stationary object or perform these
exercises from a seated position.
FLEXIBILITY
Flexibility is important for all patients especially stroke
patients. Stretches for all major muscle groups should be
performed. It has been suggested that a static method of
flexibility training be the preferred method because
there is less chance of stretching beyond the limits of the
muscle tissue. Static stretching typically involves slowly
lengthening the muscle(s) to a point of slight discomfort;
when this point is reached, the position is held for 15–
30 seconds and then repeated two or three times.
Maintaining a reasonable degree of flexibility is
necessary for efficient body movements. Being flexible
may decrease the chances of sustaining muscle injury,
improved movement function, reduce muscle tension,
enhance relaxation, improve posture and coordination
and reduce stiffness.
AEROBIC/ENDURANCE
Exercise tests of patients with stroke should be
supervised by a physician, an exercise physiologist
Figure 1: Cardiovascular/aerobic equipment for lower body. (A) Treadmill; (B) Recumbent exercise bicycle
Role of personal trainers for stroke rehabilitation: L. Burkow-Heikkinen
Neurological Research, 2009, Volume 31, October 843
Figure 2: Cardiovascular/aerobic equipment for both upper and lower body. (A) Life Fitness 950HR Elicipal trainer; (B) bicycle
ergometer; (C) Schwin Airdyne bicycle; (D) Nu step
Figure 3: Strength training: lower body. (A) Leg abduction; (B) leg abduction; (C) glute press
Role of personal trainers for stroke rehabilitation: L. Burkow-Heikkinen
844 Neurological Research, 2009, Volume 31, October
and a personal trainer. The patients should be mon-
itored with a 12-lead ECG in the acute phase. The mode
of exercise depends on the severity of neurological
involvement. Exercise training programs for individuals
with stroke should be aimed not only at increasing the
levels of physical fitness but also at reducing risk factors
such as hypertension. Theoretically, a reduction of risk
Figure 4: Equipment for upper body and lumbar spine. (A) Lumbar Spine; (B) Medicine Balls; (C) free weights
Figure 5: Resistance bands for both upper and lower body
Figure 6: Balance equipment
Figure 7: Stretching the entire body
Figure 8: Strength training the upper body
Role of personal trainers for stroke rehabilitation: L. Burkow-Heikkinen
Neurological Research, 2009, Volume 31, October 845
factors should decrease the incidence of secondary
strokes. An aerobic conditioning program can alter
several of the risk factors associated with the incidence
of stroke, including hypertension, enhanced glucose
regulation,improved blood lip profile and reduced
body fat. Aerobic training modes depend on the
individual’s ability and degree of balance impairment.
Modality choices for cardio training may include an
exercise bike, upper body ergometer or NuStep.
Treadmills may be appropriate in individuals with
minimal motor impairment who have good standing
balance and are able to ambulate independently with-
out the use of an assistive device such as a cane or
walker. Structured treadmill exercise increases gait
efficiency, so less energy is used for walking, making
the task of walking less stressful.
Over time, even a person with limited gait speed may
have the exercise intensity increased by keeping the
speed low but increasing treadmill grade. Notably,
treadmills are not advisably good exercise method for a
patient with balance problems due to the increased risk
of falls5–8.
EVALUATION
The main purpose of an evaluation is to assist the
personal trainer in improving the quality of the patient’s
activities of daily life (ADL). Upon meeting with the
personal trainer, the patient must arrive with a medical
clearance from their physician and physical/occupation
therapist. Before beginning an exercise program, the
personal trainer should implement a screening process
to identify potential concerns that could become
problems when performing exercise in a fitness setting.
The program is designed to enhance the patient’s
functional capacities through a supervised functional
exercise program. These evaluation (screening) pro-
cesses are not used to diagnosis or treat any muscular or
neuralgic conditions but, rather, to identify muscular
imbalances and weakness that can be eliminated or
reduce problems for ADLs7–9.
Components of the screening include:
N postural screen: identify gross trunk asymmetries that
potentially may cause problems when performing
exercise. View is taken from posterior, anterior, and
side view;
N range of motion (ROW): shoulders, cervical spine,
hips, knees and trunk;
N flexibility;
N balance: walking on tip toes/heals;
N strength: functional strength assessment include, wall
squat, chest press, seated row, leg extension and curl,
calf raises, hip adduction/abduction and shoulder;
N cardiovascular function: hopefully, the patients would
have had a thorough evaluation from an exercise
physiologist; otherwise, this can be a subjective
evaluation using a bike, NuStep or treadmill;
N functional activities: upper extremity: arms overhead,
hands behind back, PNF patterns; lower extremity:
ambulation, lateral step up, sit to stand, heels/toes;
lumbar: trunk flexion, seated rotation; cervical: touch
chin to chest, reach overhead.
SAMPLE PROGRAM DESIGN
The first 2 weeks will serve as an introduction to
exercise. Low intensity aerobic exercise in the fitness
setting should not exceed 30 minutes. Include active
ROM with involved extremity and possible light
resistance exercise. PNF patterns should also be intro-
duced early in the program, along with core stability
exercises.
For the next 2 weeks, the patient will continue with
exercise with increasing intensity. Patients will begin
using rubber tubing or bands for rotator cuff, posterior
should girdle and knee extension. The patient will begin
to advance cardio exercise, which may include walk-
ing, stationary biking or arm ergometer.
FITNESS PRECAUTIONS AND CRITERIA
The stroke patient may have some degree of spasticity,
flaccidity, loss of sensation and/or weakness in the
involved extremity. The personal trainer must be
cautious to assess these factors and avoid any activities
which cause the patient pain or significant discomfort.
Some general guidelines include:
N the spastic patient may have a limited range of
motion. To attempt to vigorously move this patient
into ranges that are painful without consulting, the
physical therapist is inappropriate;
N if there is a loss of sensation, care must be taken to
protect the involved extremity from possible injury of
which the patient may be unaware;
N resistance exercise should not be used with the
patient who has congestive heart failure, unstable
angina, uncontrolled arrthymias or resting blood
pressure greater than 180/105;
N proprioceptive neuromuscular facilitation activities
offer exercise patterns which can improve coordina-
tion, control, muscle strength and reduce spasticity/
flaccidity. Proprioceptive neuromuscular facilitation
is an approach to strength and flexibility developed
from basic philosophies and principles of human
anatomy and neurophysiology. The procedures and
techniques of proprioceptive neuromuscular facilita-
tion are tools by which strength and flexibility are
increased and should not be viewed as the whole
training session but only as a part of the solution for
enhancing human performance.
NEUROPLASTICITY AND THE FELDENKRAIS
METHOD
In the 1950s, Feldenkrais developed a series of exercises
in an approach to learn and find new ways of doing
tasks. The ‘plastic properties’ of the brain refers to the
ability of the brain to change and adapt. It was
Role of personal trainers for stroke rehabilitation: L. Burkow-Heikkinen
846 Neurological Research, 2009, Volume 31, October
Feldenkrais who developed a series of movement
exercises that lead the brain to self-organize and
spontaneously produce higher levels of organization
and skill. The Feldenkrais method is a unique way to
approach learning new ways of doing tasks. This
method is for all who work with their bodies to enhance
their abilities. His thoughts have been confirmed by the
use of different diagnostic techniques, including the
electroencephalography, xenon computed tomography,
functional magnetic resonance imaging, evoked poten-
tial and positron emission tomography scans. It has been
recommended that the utilization of improving the
condition of the brain requires the brain to be engaged
and focused through activity such as music, conversa-
tion, reading, television and/or through the awareness of
specific movement, including dance. The Feldenkrais
method targets the structure of the brain responsible for
producing the symptoms and signs of the problems and
‘is a form of treatment of the effect of the pathology
rather than treatment of the pathology itself’9–11.
CONCLUSION
Personal training for stroke rehabilitation patients can
provide a number of health and fitness benefits.
However, it is important for each stroke patient to follow
a proper course that adheres to specific programming and
safety guidelines as well as their specific needs and
abilities. This will allow patients to achieve the benefits of
training, while minimizing the risk of adverse events or
injury. A personal trainer needs to be resourceful and
versatile to successfully meet this challenge, and should
hold advanced certifications and experience required to
work successfully with the rehab physician, social
worker and the physical/occupational therapist.
A fitness program is designed to enhance the patient
strength, range of motion, stability, balance/coordination
and functional strength. This type of programming is
designed for the patient who has moved beyond the
acute phase of his/her stroke and can tolerate exercise in
a supervised fitness setting. It has been long recognized
that exercise is the key to long term management of
medical conditions.
ACKNOWLEDGEMENT
The help of Travis Ryder and Onyekachi Ibe for editing and picture
arrangements is acknowledged.
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Neurological Research, 2009, Volume 31, October 847