From Stroke to Strength

It’s not often that a personal training client’s initial screening reads “blocked cranial arteries in the left hemisphere, 1 billion destroyed brain cells, inability to speak, and paralysis and loss of feeling in both right limbs.”

Yet, with more than 800,000 people experiencing a new or recurrent stroke each year, and more strokes happening every day as the over-50 population grows (NSA 2017), trainers are increasingly likely to be assisting survivors coming out of occupational or physical rehab. In fact, because rehabilitation insurance coverage tends to be limited, personal trainers well-versed in working with stroke survivors can play a crucial role in supporting their return to independent, active and functional daily living.

Trainers need a few new skills to help stroke survivors succeed, but by and large the process is the same as helping healthy clients improve physical strength and cardiovascular conditioning. The critical difference is that stroke survivors are not just training muscle; they are using the brain’s natural ability to rewire itself (see the sidebar “Neuroplasticity and Stroke Recovery”) in order to restore movement after stroke-induced paralysis and loss of function.

A Strength and Conditioning Model for Stroke Survivors

Personal trainers and strength coaches are uniquely educated to provide important support for stroke survivors—though you may not think so given the complex mechanisms that enable stroke recovery. Trainers and coaches help people increase strength, improve cardiovascular capacity, expand mobility and optimize neuromuscular control. The goals do not change just because the client is a stroke survivor, so program design and administration will be much the same.

Trainers working with stroke survivors will need enough education and reading to understand the physical and psychological effects of stroke. Beyond that, it’s a matter of learning basic rehabilitation protocols, acquiring a few tools, and having lots of confidence and imagination.

Constructing a flexible, periodized program with exercises and movement patterns designed to strengthen weakened areas is simple. Understanding how to motivate, encourage and evaluate progress is more complex (Levine 2013; Taylor 2006).

Sample Program Design for a Stroke Survivor

The following case study describes the experience of training a 75-year-old man who had survived a severe hemorrhagic stroke. This represents one of the most challenging scenarios an exercise professional can encounter.

Assessment

The client had full paralysis (hemiparesis) in the upper arm as well as substantial paralysis and loss of feeling (hemiplegia) in the lower leg. Injury to the speech center of the brain caused difficulty speaking (expressive aphasia). Fortunately for training purposes, inability to comprehend speech (receptive aphasia) was not one of the client’s challenges. Note: For more on all these conditions, see Gillen (2011).

Before starting with a personal trainer, the stroke survivor had responded favorably to longer, quite frequent and increasingly intensive outpatient training sessions. This positive outcome aligns with conclusions of stroke-recovery research showing that sessions with a variety of therapeutic stimuli create a rich environment for recovery (EBRSR 2017).

Videos of the outpatient sessions (3 hours a day for 20 days) showed peak progress of several feet of assisted walking and a few steps of unassisted walking. The man showed some movement potential in the shoulder girdle and upper arm but no hand function.

This established the baseline training goals: Increase leg strength, arm movement and arm strength, and boost cardiovascular capacity.

Goal Setting

Each stroke survivor’s potential is unique, but a few indicators predict how much improvement is likely. Current research finds that the type, location and size of the stroke can predict certain outcomes, though metrics for recovery have moved forward with the advent of neuroplastic training (Doidge 2007 & 2016).

Though repetitive training produces neuroplastic changes, a survivor’s motivation, tenacity and time devoted to training are more critical. Without high levels of these three personal components, progress will be limited. This is where a trainer must be observant, empathetic and flexible with the training process (Levine 2013; Taylor 2006).

Reaching out to family members for background on the survivor’s personality and mentality before the stroke is key. This context can help the trainer determine how to relate effectively to the client and how to improve capacity. Motivation and tenacity are usually high in the early stages of training, because both family members and the survivor tend to be willing to devote significant time and resources to the training.

Training Structure and Administration

In our case study, the basic training plan included 1 hour 5 days a week, rising 30 minutes a day every 2–3 weeks and peaking at 3 hours per day. The trainer would adjust these parameters based on the client’s progress and stamina.

It is important to note that exercise sessions can be two to three times more difficult for a stroke survivor than they are for a traditional client, making strategic breaks critical. Survivors are trying to cover their farthest distances or lift their heaviest weights. Even seemingly low-
demand movements like getting out of bed or forming words are physically, mentally and emotionally fatiguing (Levine 2013; Taylor 2006).

Exercises, Breaks and Active Recovery

Each session started with gentle assisted stretching and easy movement of the affected areas, which often became rigid and resistant to movement, owing to involuntary contracture—a reflexive, protective muscle shortening from loss of sensation in the affected joints (Gillen 2011).

The initial exercises looked much like any training session:

• seated and standing single-leg extensions
• curls, abductions and adductions
• single-arm pulls, presses, shoulder raises and hand ball squeezes
• supine leg presses

Each leg exercise used the trainer’s hand for resistance during the desired motion.

Single-arm pushes and pulls employed similar manual resistance. Shoulder shrugs combined resistance and feedback by observing range of motion in a mirror.

The client first practiced the exercises on the unaffected side, to learn the desired range of motion, and then performed them on the affected side.

This segment lasted 20–40 minutes, with 5- to 10-minute breaks interspersed between upper- and lower-body segments. The breaks were nonactive, to keep physical and mental demands low.

A 5- to 10-minute standing and walking session at a kitchen counter followed. Hip and knee flexor and extensor stretches came first, then unresisted leg front-raises and abductions. The client also did double- and single-leg squats.

Next up, the client did forward, backward, and right and left lateral walks of 10 feet each with self-support on the counter and light support from the trainer.

The trainer assessed the client’s difficulty in doing these exercises to determine an appropriate intensity for the remainder of the session. The exercises had a goal beyond performance gains: They established a daily baseline assessment of the client’s vitality and energy, making it possible to set goals for the remaining segments.

Each day can be radically different for a stroke survivor. Minor events like getting the sniffles or contemplating an outing, combined with emotions attendant to their condition, can reduce overall capacity. The daily baseline assessment determined whether a new target goal was possible or a lighter session was needed (Taylor 2006; Levine 2013).

After a break that included mental-acuity games, the trainer conducted the main walking segment of the session. Goals here included developing independent ambulatory patterns, increasing cardiovascular capacity and improving leg strength.

Typically, the client used a walker to improve cardiovascular capacity, because this enabled him to walk for longer periods. Lightly assisted walking helped him to develop independent patterns and leg strength by stimulating use of the affected leg. The trainer assisted by placing a hand on the back of the client’s right shoulder when balance seemed tenuous.

Daily goals determined distances for each walk. Over a year and a half, the client progressed from 5 feet to 100 feet of lightly assisted walking, and from 15 feet to more than 800 feet with the walker.

Other Training Tools

Some research has found good results from therapeutic tools such as neuromuscular electronic stimulus (NMES) devices and mirror boxes, which can be used during breaks (Levine 2013).

NMES machines deliver specific electronic stimulation in 15- to 30-second intervals via two sticky pads attached to the skin along the length of a muscle. Regular use has shown promise in increasing muscle strength, retaining range of motion, increasing blood flow and reducing edema (swelling) (Levine 2013). In the case study, the trainer used an NMES device during the client’s active break periods.

A mirror box helped stimulate neuromuscular pathways in the affected arm. Here’s how this works: The unaffected hand is placed in front of a mirror on a small box, and the affected hand goes inside the box. The reflection of the unaffected hand movements creates an optical illusion that the affected hand is performing the motion. This visual connection enhances neuroplastic rewiring by stimulating the sensory connection between the affected limb and the brain (Levine 2013).

This client’s training, like that of most stroke survivors, remains ongoing. Less affected stroke survivors can often tolerate higher degrees of load with weight machines or free weights. Treadmills, unstable surfaces and agility work can be added as a client’s balance improves.

Trainers applying basic exercise and athletic development principles can help stroke survivors in many ways. The key is to absorb as much knowledge as possible. Resources that proved valuable in the case study included the books Stronger After Stroke by Peter Levine, The Brain That Changes Itself by Norman Doidge and My Stroke of Insight by Jill Bolte Taylor.

These books, along with other items on the reference list—plus trainers’ own knowledge and experience—will be helpful in developing a new area of practice.