Conclusions

Gillian Mead, Frederike van Wijck

This book has focused on physical fitness after stroke, which is often considerably reduced, and exercise and fitness training after stroke. The first part of the book has described the effects of stroke, how stroke is treated, and the long-term consequences of stroke that can interfere with daily life. Some stroke survivors will make a good recovery, whilst for others, life will never be the same again. John Brown has described his own personal journey of recovery from stroke – much of what he has written will resonate with other stroke survivors and those involved in their care. John’s contribution to this book is unique as he has so clearly expressed how exercise training can contribute to ongoing recovery after stroke, long after usual stroke care has been completed.

Most stroke survivors will need hospital care, delivered by a multidisciplinary team of health professionals. Acute stroke care has improved substantially over the past few years, and so attention is now turning to how to mitigate the longer term effects of stroke and improve quality of life. There is increasing recognition that the inactivity that often follows (and sometimes precedes) stroke can have profound effects on aerobic fitness, muscle strength, power and endurance. This book has highlighted the extent to which physical fitness tends to be impaired after stroke, and the impact this may have on function, activities of daily living and independence. This evidence clearly indicates that, to facilitate recovery from stroke, attention must be paid to the low levels of physical fitness throughout the stroke survivor’s journey.

There is now a strong evidence base that demonstrates that physical fitness training after stroke including aerobic training leads to improvements in physical function – at least for ambulatory stroke survivors. Research on stroke survivors’ experiences with community-based exercise groups also suggests that they can benefit in terms of physical and psychological wellbeing and confidence. Although data are currently lacking to make firm recommendations with respect to the ‘FITT’ principles (frequency, intensity, time/duration and type of exercise) and further research is required to establish the effects of training on disability, there is sufficient evidence to incorporate fitness training into the rehabilitation of stroke survivors. This book has focused on how to deliver evidence-based exercise and fitness training to stroke survivors after they have been discharged from hospital.

We have explained, in detail, our recommendations for the referral of stroke survivors to exercise, highlighting the importance of safety. Thorough and detailed risk assessment prior to exercise is essential. Communication between referring health care professionals and the professionals delivering exercise and fitness training is a requirement for a safe and seamless transition into exercise and fitness training after stroke. We then moved on to the process of designing exercise programmes for stroke survivors, emphasising the need to adapt the principles and variables of exercise programming to the stroke population in general, as well as tailor the training to the individual, taking into account their personal goals and unique constellation of post-stroke problems, possibly in addition to co-morbidities. The specialist skills and competencies involved in adapting and tailoring exercise to stroke survivors require an extensive working knowledge of stroke and its medical and rehabilitation interventions (including drugs and their possible side effects) as well as co-morbidities. The cycle of designing and delivering exercise is completed by outcome assessment, in which the importance of relevance and scientific robustness has been underlined.

We have emphasised throughout this book that our vision is to enable more people after stroke to be more physically active. This requires that exercise professionals fully engage individual stroke survivors in their physical activity programme. Communication skills come into play – and are particularly important when working with people with speech and language impairments – when listening to what individuals wish to achieve, what motivates them and what they see as barriers to becoming more physically active. Motivational interviewing may enable individuals to make decisions about changing their exercise behaviour, while goal setting can be used to identify more specific targets. The ultimate aim is to enable stroke survivors to enjoy a more physically active lifestyle in a way that is safe and meets their personal needs and goals.

We have concluded the book with recommendations on how to develop existing or set up new community-based Exercise after Stroke services, informed by current best-practice guidelines. We have highlighted the importance of teamwork, a sound referral system, exercise professional training and qualification, and evidence-based and person-centred practice.

Exercise after stroke is a topic area that is expanding rapidly, with more and more stroke services seeking to link with leisure services to develop pathways into exercise after stroke. Exercise after stroke is also an exciting area for further research as well as developments in practice and education.

This book is intended as a stepping stone for further developments in the field. It will need to be reviewed as new research emerges, and experience with delivering and participating in exercise and fitness training after stroke – and other forms of physical activity – accumulates. Meanwhile, we are confident that exercise and fitness training after stroke has the potential to make a real contribution to the quality of life of stroke survivors.

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