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As a stroke survivor, you probably heard the term ‘goal setting’ from your multi-disciplinary team who helped you in ‘the early days’. This is because goal setting is considered ‘best practice’ in clinical stroke rehabilitation and its benefits are well recognised. Let’s have a look now about how to translate this practice into something that you can do by yourself when you get home, by yourself or with collaboration from a family member or friend.,

arni stroke exercise rehabilitation goals - 5 tips - Goal setting after stroke - Stroke Exercise TrainingFirst, it is recognised that even though goal setting is embedded within community-based stroke rehabilitation given by NHS, practice does vary and is potentially sub-optimal. Further, to date, few randomised controlled trials have been completed to demonstrate that goal setting makes a unique contribution to stroke survivors’ rehabilitation outcomes.

You have received 6 weeks of community therapy, or you may have had much more, but many people after stroke feel that therapy ended much quicker than you may have liked. And if this therapy is now in the past, you will may possibly feel that it hasn’t optimally prepared you to try and haul yourself through the aftermath of stroke: ie, coping and trying to flourish as a stroke survivor, minimising multiple physical and psychological problems you may have been left with.

Unsurprisingly, a common denominator of many stroke survivors is that they believe (important to stress ‘believe’) that they have not been shown how to rehabilitate themselves effectively going forward.

Most usually understand that they need to ‘retrain’ themselves somehow, and are keen to go for it. And their supporters are keen to help them achieve their goals. But the same people hit a common wall, because they cast about in vain to find the best single way forward. It can take years for stroke survivors to exhaust presented (often very expensive) options, not realising that they had considerable power all that time to change their ‘status quo’, by planning and working out how to deliver self-set goals.

ARNI ELDERLY STROKE REHAB C 910x1024 - 5 tips - Goal setting after stroke - Stroke Exercise TrainingOften, not easy to do – but not particularly difficult either. Where does this leave ‘goals’? Will those things that the multi-disciplinary teams agreed with you to achieve in the community be the same kind of things you need to work out in the ‘real world’ and tackle as you move further away from from your time of stroke?

And how are goals supposed to be set and stuck to without that ‘negotiationary’ aspect to the process that the therapists helped you with in hospital and during  community therapy?

All reasonable questions – let’s break it down to component parts: 

Overall, most stroke survivors want to  ‘normalise and de-medicalise’ their lives again. They can set goals to do this.

Goals are things you would like to achieve. Many stroke survivors will want to restore lost function, and be able to do the things that they could do before their stroke. These are broad aims that may seem unachievable, and they may not know how to start, but defining goals can help then to break these aims down into smaller, more achievable goals.

Goal setting involves some planning and thought, but usually does not take overly long to do. It basically provides you with the steps to move from where you are now, to where you want to be. You’ll find it to be an empowering process, giving you the chance to take control of your rehabilitation.

To do this, you’re going to ‘get specific’ and ALSO ‘get broad’. Stroke survivors often have very individual hopes for the here and now, and also for the future, in terms of the goals they would like to achieve.

So. once all your therapy finishes, how do you do it? All good questions. To find out the answer, let’s get back to basics.

Where to start.

1 – Identify your goals!

When thinking about goal setting, the first thing to do is identify your goals, ask yourself ‘What do I want to achieve?’

bigstock Business Concept 111977366 300x212 - 5 tips - Goal setting after stroke - Stroke Exercise TrainingWhen setting personal goals, specificity is king. For example, just challenging yourself to “do more work” is way too vague, as you’ve got no way of tracking your progress, and no endpoint. Simply put, if your goals aren’t quantifiable, achieving success can be challenging.

SMART goals can  the answer, as you can break them down into five quantifiable factors.

Try and look at goals in this way: they should be specific, measurable, achievable, realistic/results-based/relevant and timely (SMART). These specific goals should be meaningful to you, and be a mix of highly achievable and reasonable. That said, its good to throw a few unlikely ones in to the mix, which you can do your best at achieving.

Include short-term, mid-term and longer-term goals. Rehabilitation is a journey and takes time. Your goals will reflect this.

By the way, goals that move you forward are almost ALWAYS ABOUT YOU.. DOING THINGS. Not THINGS BEING DONE UNTO YOU.

And in the meantime so much can happen or, in particular, not happen.

Let me stress that you don’t have to become fanatical to achieve success in stroke recovery. Many stroke survivors are living day to day feeling frustrated with their lot. But frustration doesn’t negate intrinsic motivation. This motivation is drive you stimulation/drive you to start, and persevere.

images 2 - 5 tips - Goal setting after stroke - Stroke Exercise TrainingHere some examples of common goals;

  • To walk indoors independently
  • To walk upstairs safely using a hand rail
  • To dress upper body independently, threading t shirt over weak arm
  • To stand to pull up trousers
  • To be able to cut a slice of bread
  • To butter toast
  • To manage independent exercise programme
  • images 300x131 - 5 tips - Goal setting after stroke - Stroke Exercise TrainingTo maintain range of movement in hand, wrist and elbow
  • To open a tablet bottle
  • To remember when to take my tablets
  • To know what my medication is for
  • To get in and out of the car safely
  • To be able to type an e-mail accurately
  • To practice golf on a driving range

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EXAMPLE: So, perhaps you would like to walk upstairs independently. Great! That might be a longer-term goal.  First you must be able to stand with support. Then, you need to be able to lift one leg and support your weight with the other leg. Then you need to move yourself up a step.  Review what you can do now and work from there.  Stepping up could be a very difficult thing to do straight away, so your short-term goals might include specific exercises, for example marching, or squats, that strengthen the muscles that you need to climb the stairs. Once you have mastered this, you could increase the repetitions, or move on to stepping up to a low step. Then increase the height of the step, or the number of steps, and so on, until you complete the longer term goal of walking up stairs independently.

Whatever your personal goal, the trick is to break it down into smaller, achievable tasks.

Big Tips from Tom

  • Be ambitious but get someone to help you regulate your ambitiousness: in practice, ‘run it past someone who knows you well”,
  • Reveal your limitations: if one of your primary goals is not to reveal your limitations for as many hours of the day as is possible, this can create an anti-risk paradigm towards your recuperation and self-training, it is highly unlikely you will do what it takes to progress.

Prioritise what you want to achieve. Hey, you don’t have to think about working out how to master everything at once… too many goals and trying to accomplish them is far too overwhelming and exhausting. Work out what you want to aim for first, and move to step 2.

2– Make a plan

TELEREHAB - 5 tips - Goal setting after stroke - Stroke Exercise TrainingOnce you have identified your goals, you can start planning for their achievement and work out how to incorporate this into your routine.

How will you measure your progress, and over what time-scale? For example, you decide to master a few smaller steps before reaching for the staircase. But, how will you know when to move onto the next challenge? You might get bored with stepping up a few steps, and run the risk of becoming disheartened or become content to just do that, losing sight of your original longer-term goal. Instead, your goal could be to step up 10 small steps after 4 weeks. This is a time-specific and measurable goal. It keeps you focused and gives you something specific to aim for.

When you can measure goals, you can appreciate your progress, and this is so motivating! Thousands of people have found this very thing out after stroke. Just what you need to keep you moving forward.

Involve family, friends and carers.  Their input is valuable, and you might want their help. They might think of things that you haven’t thought of, or provide that supportive arm, and it can helpful to get their perspective. They will be part of your journey. Time to start on that journey – move to Step 3.

3 – Do it! 

MOUNTEMBER KIERON ARNI FUNDRAISING STROKE REHAB - 5 tips - Goal setting after stroke - Stroke Exercise TrainingArmed with your planner – do your ‘retraining’, practising formally and also by simply doing activities of daily-life. Record what you’re doing. Don’t overload yourself, but make sure you challenge yourself.

A great tip for you would be: in retraining situations it is important to advance quickly toward practice of whole tasks with as much of the environment context made available as possible. For example, say, a goal of yours is to improve the action control of your paretic foot for being able to cope whilst walking outside, unsupervised and with no supports. The best retraining you can get is to ask a trainer or friend to plan a route for you to go with him or her, so that you can trial it safely and under careful supervision. You can work on leaving a stick behind or reducing the use of an AFO according to your current levels of ability.

A unifying similarity amongst successful stroke survivors is not cognitive or affective (relating to moods, feelings, and attitudes), but willingness to strive for goals deemed ‘unachievable’ for them by those around them (as worked out in your Steps 1 and 2).

CLICK PIC OF STROKE SURVIVOR DOING THE THREE PEAKS CHALLENGE WITH ONE OF OUR ARNI INSTRUCTORS, KIERON FRANKLIN FROM POOLE, WHO HAS TAKEN SOME OF HIS STROKE SURVIVORS ON THIS FOR THE LAST 2 YEARS. DONATE TO ‘MOUNTEMBER 2019‘ IF YOU’RE FEELING GENEROUS!

Tip – motivation is key – if you’re not intrinsically motivated, you’ll have no incentive to push beyond generally accepted boundaries.

4 – Review your goals regularly.

Life may take you in another direction, changing the attainability or suitability of your goals. You may be working towards them faster or slower than you anticipated, or may find that other goals have taken priority. Whatever is happening in your life, it is perfectly OK to adapt or change your goals to suit you where you are now.

Keep talking with the people close to you, try to stay positive and motivated. Also, help/guide others who are going through a similar experience, if you come into contact with them in person or online – this actually has an effect to keep YOU motivated…

5 – Identify barriers to effective goal setting, then adapt and overcome.

Barriers could include communication difficulties, cognitive impairment, fatigue, mood disorders, other health conditions and even a lack of knowledge or understanding of your problems/condition.

10411981 10205152423023069 40664990233617896 n - 5 tips - Goal setting after stroke - Stroke Exercise TrainingIf you feel you may have these, or other barriers, don’t let it stop you setting your own goals.

Take time to ensure that your goals are what you want to achieve. Try to enlist the support of positive people who will take the time to work through what you want to achieve, whether they are family or carers, or therapists/instructors. Positivity breeds positivity.

Be aware of your limitations, but almost everyone can improve and become more functional. Listen to your body and adapt your goals accordingly. You could just break them down to smaller tasks, or do them a different way.

If you are too fatigued, don’t struggle. Rest and return to the task more refreshed.

Educate yourself; there is a wealth of information available about stroke and self-help online and through books.

You can read more about goal setting in The Successful Stroke Survivor, as well as lots of innovative ways to encourage rehabilitation after stroke.

What if I need more help?

Working with a therapist or trainer can be really motivating. This collaboration combines your initiative and drive with the knowledge and experience of a professional. For example, ARNI instructors are specifically trained in methods of stroke rehabilitation and will work with you to identify goals that are functional and personal to you, and together you will strive to achieve them. Empowering you to take control of your rehabilitation.

CALL ARNI now on 0203 053 0111 or write in to receive an info pack through the post. 

ARNI STROKE CHARITY REHABIL 1 659x330 - 18 Ways to Improve Cognitive Problems after Stroke - Stroke Exercise Training

A change in cognitive ability is common after a stroke. Did you know that as many as two-thirds of stroke survivors may experience cognitive impairment as a result of their stroke.? If this is you, or you know someone who seems possibly to be going through such difficulties, here’s 18 steps you can take to try and improve cognition difficulties after stroke:

First, what is cognition?

CNX Psych 07 01 Concepts 2 - 18 Ways to Improve Cognitive Problems after Stroke - Stroke Exercise TrainingPut simply, cognition is thinking; it is the processing, organising and storing of information – an umbrella term for all of the mental processes used by your brain to carry you through the day, including perception, knowledge, problem-solving, judgement, language, and memory. The brain’s fantastic complexity means that it can collect vast amounts of information from your senses (sights, sounds, touch, etc) and combine it with stored information from your memory to create thoughts, guide physical actions, complete tasks and understand the world around you.

2019 08 21 02 07 12 300x280 - 18 Ways to Improve Cognitive Problems after Stroke - Stroke Exercise TrainingA stroke can affect the way your brain understands, organises and stores information. This brain injury can result in damage to the areas of the brain that are responsible for perception, memory, association, planning, concentration, etc. The severity and localisation of the stroke will effect the type and level of difficulties experienced by an individual, and will vary from person to person.

It can be difficult to plan and organise daily tasks. The brain is constantly working in the background, allowing us to complete a task based on prior knowledge, experience, and learned behaviour.

You don’t have to consciously think how to boil the kettle, change TV channels or put on your socks before your shoes: you just do it. But damage to the brain can result in problems with these planning and execution mechanisms.

You might not be able to think how to do a simple task, or you may get the sequence wrong (for example, shoes before socks). You might have trouble with orientation, which could include not knowing the date, day of the week, or even who you are with. Problem-solving too can become difficult. Making decisions, solving problems, understanding numbers and managing money can be a challenge.

Good cognitive function also relies on memory. The brain uses 2 types of memory to hold information, the long and short term memory. Short-term memory is the temporary store for small amounts of information. This information is kept readily available and can be recalled quickly. For example, a phone number can be remembered long enough for you to dial it. Long-term memory is where you keep your experiences, thoughts and feelings from the past and things stored here can be stored indefinitely. Memory problems could result in difficulty storing or recalling information. This could include problems remembering appointments, important dates or in the case of short term memory, what you were about to do, or what somebody just said to you.

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Problems with concentration are common. Concentration is required for effective cognitive function, as many of your thinking process require concentration. Concentration requires our brain to filter out much of the information coming in from your conscious thinking, so you are not distracted by it.

Stroke can impact on this ability because of damage to the areas of the brain responsible for this, and also because tiredness, pain and emotional problems have an effect of the ability to stay focused and concentrate. This could result in difficulties when trying to follow a television programme, or conduct a conversation with a friend. Multi-tasking too is difficult.

18 Things to try

  1. Cognitive problems are confusing and frustrating. But, there are some things you can to do help. Most improvements occur in the first 3 months after a stroke, after which they slow down, but the brain will keep creating new neural pathways after this time.
  2. arni calendar 300x150 - 18 Ways to Improve Cognitive Problems after Stroke - Stroke Exercise TrainingTo help with memory and perception problems, try using a diary, day planner, calendar or notepad. Writing down appointments and creating to-do-lists can help you to remember them.
  3. Photos and pictures can help to ‘trigger’ your memory.
  4. Check your calendar, newspaper or diary to help you remember the day and date.
  5. Make notes of important conversations.
  6. Use notes, lists  and labels around the house and help prompt you to remember. Mobile phones are a great resource. Set alarms, reminders and memos to remind you throughout the day.
  7. It is important not to overload yourself, finish one task before you start another. Plan your day and prioritise tasks.
  8. Try slowing the activity down, working through a step at a time.
  9. Keep instructions clear and short, no more than 5 or 6 words to a sentence, and only 1 or 2 instructions at a time.
  10. Paraphrasing during a conversation can help you to remember what has been said. This repeating back what they have said in your own words helps to ensure you have understood them correctly.
  11. Busy and noisy environments can make it difficult to think.
  12. Limit the number of things you have to think about at any one time, for example, turn off the TV or radio when someone is speaking to you. This should reduce distractions and help you to focus on what they are saying or follow the programme.
  13. 2019 08 21 02 15 46 300x204 - 18 Ways to Improve Cognitive Problems after Stroke - Stroke Exercise TrainingBeing in a quiet room can also help you when reading or learning something new. Reducing visual distractions may also help you to concentrate. Keeping the area around you as clutter free as possible could help you to focus.
  14. Keep to a routine, for example, dressing in the same order may help you relearn the steps.
  15. Engage in activities which help to stimulate problem solving skills. Examples include board games (connect 4, chess), crosswords, puzzles, and brain teasers. There are a variety of phone apps which can help to engage the brain.
  16. Stress and tiredness can make cognitive problems worse.
  17. Take plenty of breaks and incorporate time in your daily schedule to rest or relax. This is important to allow you to recharge and could be quiet time, meditation, engaging in a hobby or going for a walk.
  18. Exercise and listening to music may also have a positive impact on cognitive function.

Get in touch with ARNI Stroke Charity to see how we can help. We can certainly help to sign-post you to to some of the experts in cognition that we know and/or ask questions on your behalf..

 

ARNI SPASTICITY AFTER STROK 600x330 - Spasticity after Stroke: Will my Hand Get Better? - Stroke Exercise Training

Upper limb spasticity is suffered by a full 70% of the stroke population, By three months post stroke 19% of people will experience spasticity and this figure increases to 38% of people after 12 months.

Did you know that it’s one of the biggest things that survivors tell consultants, GPs, family, carers and friends that they wish they could positively alter?

Spasticity can develops months or even a year after stroke — and often may become more noticeable as recovery moves on and can have a very significant bearing on your quality of life. Let’s look at what spasticity is:

  • Spasticity - Spasticity after Stroke: Will my Hand Get Better? - Stroke Exercise TrainingMuscle stiffness;
  • Upper extremity hypertonia (excessive muscle activity);
  • Loss of fine motor control (for example small hand movements);
  • Paresis;
  • Soft tissue contracture;
  • Muscle overactivity leading to the reduced ability to relax;
  • Muscle spasms;
  • Changes in limb posture; and
  • Muscle fatigue.

Let’s see if you can grab some tips here to help you beat its limitations.

Spasticity is caused by miscommunication between your brain and your muscles. It has neural and non-neural components to it. Let’s delve deeper: knowledge is power,

Normally your muscles are in constant communication with your brain about how much tension they’re feeling, and the brain has to constantly monitor this tension to prevent tearing. Your brain continuously sends out messages telling your muscles when to contract and relax.

1st layer to spasticity:

When a stroke damages part of the brain responsible for muscle control, this communication is thrown off.

The damaged part of your brain no longer receives the messages that your muscles are trying to send, and as a result, your brain no longer tells them when to contract or relax.

So, your muscles keep themselves in a constant state of contraction in order to protect themselves.

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2nd layer to spasticity:

While your muscles are always in communication with your brain, they’re also in communication with your spinal cord.

Usually the spinal cord takes the messages from your muscles and sends them up to the brain.

But since the brain is no longer reading those messages, your affected muscles have ‘nothing to talk to’.

So, the spinal cord takes over, but it doesn’t know how to properly operate your muscles. It really only has one goal: to prevent your muscles from tearing.

In order to do that, your spinal cord sends signals to keep your muscles in a constant state of contraction (flexion), which is what causes spasticity.

For instance, your spinal cord does not want your arm flapping about and becoming liable to be damaged, hence the typical pattern of spasticity of flexed elbow, wrist, finger and thumb joints that you may see others have or have yourself.

Your spinal cord has the best intentions; to prevent your muscles from tearing. But it’s frustrating because spasticity can cause muscles in your arms or legs to tighten uncontrollably, causing pain and discomfort. Certain muscles (such as the muscles that bend your fingers) can become continuously contracted. Spasticity depends on the speed with which muscles are moved. So, the faster a passive stretch is made, the faster your resistance to it will be.

Other symptoms may include clonus (a series of rapid muscle contractions), muscle spasms, scissoring (involuntary crossing of the legs), and fixed joints.

The degree of spasticity varies from mild muscle stiffness to severe, painful, and uncontrollable spasms.

Don’t think of spasticity as all bad though: although it may cause shortening, it is keeping your flexor muscles strong. This ‘spasticity strength’ can be used functionally too, in a number of ways, particularly to help you conduct tasks. It is very difficult to achieve reduction from spasticity. There is no global answer to eradicating spasticity.

However, a very good start at progressive spasticity decline work  can be made via a mix of performing constant stretching in an effort to keep your muscles long, plus the introduction of an anti-spasticity drug if appropriate, plus a progressive task-training programme is a good start. I’ll show you a good way to do ‘task training’ below the very brief note about Botox.

botox arni stroke rehab - Spasticity after Stroke: Will my Hand Get Better? - Stroke Exercise TrainingA good example of a global (oral) medication is Baclofen (Lioresal), which relaxes your muscles by ‘turning down’ your nervous system. The downside of this is that it can also cause you to feel drowsy, confused, dizzy, weak, tired or to have a headache. Another drug, Tizanidine (Zanaflex) also helps with spasticity by stopping your muscles from spasming and it can also ease pain. Because it lasts for a short time, Tizanidine is best used only when you need it for relief or to be able to complete certain activities.

An example of a localised medication is Botulinum Toxin (Botox). It has been designed so that it can be safely injected directly into target sites to block the nerves from sending messages to the muscles, causing them to relax. The evidence shows that it decreases spasticity, but likely does not improve upper limb motor function. But still, it is worthwhile having if your consultant considers that it is appropriate that you go for assessment.

If you go for Botox, ask if the injection(s) will be guided by ultrasonography rather than by electrical stimulation or palpation. Also, it is easy for the injection to limit existing useful underlying motor movement from occurring, so care needs to be taken and a robust physical training regime must be in place before injections in order to maximise efficacy.

Further, in combination with electrical stimulation or modified constraint induced movement therapy, it is possible that you are likely to improve muscle tone in your upper limb, although advice MUST be sought from your GP and/or consultant at all times.

So, what do you do to train your contralesional hand? First, think about the huge amount of repetitions you need to do. You have to. It’s the only way I personally got my upper limb back from a pattern of spasticity to virtual ‘normality’.

Training should be done every day: and a large daily amount of task-specific work is required. Repetitions.

So, you need a ‘go-to’ set-up in order to make this easy. Advised are my two best ‘go-to’s.

Advice: Stretching precedes tasks. and allows you to access them (particularly if you cannot sustain a gap between your thumb and forefinger. Successful stretching can also increase the number of repetitions available to you. So, STRETCHING ENABLES THE TASK. It also ‘EXTENDS TIME ON TASK.’ I detail all this in the Successful Stroke Survivor manual.

Kit-wise: an all in one ‘reverse gripper’ called Neurogripper which repetitively opens the hand in a gradated manner, combined with daily use of the Task Training Board, combined of course with testing progess via your activities of daily life, is a way to push your rehab to the next stage.

RECIPE TO DO DAILY TASK TRAINING – use hand stretch device Neurogripper with a Task Training Board 

Neurogripper ARNI 225x300 - Spasticity after Stroke: Will my Hand Get Better? - Stroke Exercise Trainingred 1 ARNI task board 300x200 - Spasticity after Stroke: Will my Hand Get Better? - Stroke Exercise Training

 



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