UNIT 1 Brain, Muscle and Trauma

Course Sampler

Here are the first two sides of each course Unit UNIT 1 – Brain, muscle and trauma Nervous System Structure

Classically divided into the central and peripheral nervous system:-

The peripheral system can be further divided into somatic, supplying the skin and muscles, and autonomic, supplying the viscera:-

In this course, we will be mainly concerned with the central and the somatic peripheral components. Central Nervous System - the Brain

1.2-1.5 litres (1200cc-1500cc) in volume, floating on a cushion of cerebrospinal fluid, and encased in a bony protective skull. The most active region of the body at rest, taking up 25% of blood sugar and oxygen.

The apparent complexity of brain structure can be simplified by dividing it into subsystems, reflecting its evolution:-

4 3 2 1

1. Brainstem: the spinal cord terminates into the medulla oblongata (cardiac and breathing centres) and continues forward as the brainstem. The brainstem is mainly concerned with automatic functions like breathing, acting as a relay station for motor and sensory pathways (through the pons), and contains the reticular formation, a diffuse network of neurons that regulate consciousness/sleep states. It terminates in the diencephalon, which includes the:-  thalamus - relays sensory information and contains nuclei dealing with motor planning and control  hypothalamus – controls and integrates pituitary/autonomic NS activities, such as body temperature, regulation of food/water intake, sleep patterns, circadian rhythms  epithalamus – pineal gland

2. Cerebellum: not part of the brainstem but arising from it. About one tenth of brain mass but contains 50% of the brain’s neurons. Divided into two hemispheres with a central strip (the vermis). It is crucial for smooth movements, motor learning and regulating posture and balance. The cerebellum evaluates movements as they’re being carried out and feeds back to the motor areas via the thalamus, correcting errors, smoothing and coordinating movement sequences. It acts as a timer, comparator and fine tuner, receiving sensory information from all over and inside the body, so it can modify movements in the light of the body’s position in space. The cerebellum can act in feedback and feed forward modes, and is active before movements are made. This is shown clearly in tests for cerebellar function:- Unit 2

Key fitness components

Cardio respiratory fitness This is often quite obviously poor. It is key to work and build on cardio respiratory fitness however it is vital to communicate with the patient’s GP and Phase III team and make an educated exercise prescription using the patient’s medical information.

Muscle endurance Muscle weakness and fatigue is common due to a typical sedentary lifestyle and again it is key to work on this; however again we need good communication with the patient’s GP and Phase III team.

Muscle strength, speed and power Reduction in muscle strength is common and can reduce daily functionality, however working to extremes of strength, speed and power should be avoided.

Flexibility Flexibility should be trained in the same way as for healthy individuals. If they have had a coronary artery bypass graft (CABG) then it is also beneficial to work on the pectorals due to the trauma caused during surgery.

Skill, coordination and balance Skill, coordination and balance should be trained as per the healthy individual, however watch out for a possible earlier onset of fatigue.

Exercise prescription

Cardiovascular  Intensity should be in the range of 40-80% of heart rate reserve.

 Frequency should be ≥3 days per week.

 Duration should be 20-60 minutes per session, including time for warming up and cooling down effectively.

(ACSM 2009)

Muscular Endurance and Strength

 Frequency should be 2-3 days per week.

 2-4 sets of 12-15 reps should be aimed for.

 Intensity should be between 30-40% of 1 repetition maximum for the upper body and 50-60% of 1RM for the lower body. At all times the Valsalva Maneouver must be avoided. (ACSM 2009)

Flexibility Training

 Frequency of stretching should be 2-3 days per week.

 Each stretch should be held for a minimum of 10-30 secs. Unit 3

Background

Stroke devastates lives and is a leading killer and disabler. It is the single most common cause of severe disability in the UK and the third leading cause of death. Every year, an estimated 150,000 people in the UK have a stroke. Most people who are affected are over 65, but anyone can have a stroke, including children and even babies. Around 1000 people under 30 have a stroke each year and it is the third most common cause of death in the UK. More than 250,000 people in the UK live with disabilities caused by a stroke. (Stroke Association) The World Health Organisation has defined stroke as rapidly developing clinical signs of focal (at times global) disturbance of cerebral function, lasting more than 24 hours or leading to death with no apparent cause other than that of vascular origin” (WHO 1980) stroke symptoms that last less than 24 hours are traditionally determined as transient ischaemic attack or TIA.

Therefore a person is defined as having a stroke where symptoms last longer than 24 hours and TIA where symptoms last less than 24 hours, regardless of the severity of symptoms of the stroke.

More recently stroke is referred to as a ‘brain attack’ to indicate the severity of the condition and also to separate it from heart attack.

Acute care Recent Stroke Association advertising campaigns are raising awareness of stroke using the FAST campaign

Stroke is a medical emergency. Act FAST Call 999! Stroke is a medical emergency. By calling 999 you can help someone reach hospital quickly and receive the early treatment they need.

Ambulance crews use FAST and with hospital staff can act fast to identify and diagnose a stroke quickly.

F - Facial weakness. Can the person smile? Has their mouth or eye drooped? A - Arm weakness. Can the person raise both arms? S - Speech problems. Can the person speak clearly and understand what you say? T - Time to call 999

It is still fairly common for people to confuse stroke and heart attack. You may well meet people who still think that a stroke and heart attack are the same. It’s not certain where this confusion arose but it is possibly because they have been linked together or due to the registered charity Chest, Heart and Stroke association. In Scotland and Northern Ireland they continue to be linked under the Chest, Heart and Stroke association but in England they are separate. The Stroke Association http://www.stroke.org.uk/ provides information, raises money and supports research for stroke and for heart attack it is the British Heart Foundation http://www.bhf.org.uk/ There are numerous information leaflets and resource links on the Stroke Association web site that you might find useful for your clients or the facility where you work.

Stroke – what is it and how is it diagnosed?

Our brain actions and its functions are supported by our circulatory system. The cardio-vascular system is dependent on good, patent blood flow between our heart, arteries and veins. When the circulatory system is jeopardised by a blockage or rupture in this system this can lead to a stroke or brain attack.

Arteries in the brain are known as cerebral arteries and originate from the aorta. The arteries that arise from the aorta to the brain are the carotid arteries. The carotids ascend either side of our neck before linking directly to the main cerebral arteries in the brain.

Unit 4

Background

Participation in regular physical activity provides health and social benefits. There is good evidence that this is true for people experiencing disease and disability. For people experiencing disability and lack of mobility, exercise may help reduce the risk of the associated common and serious complications associated with impaired mobility e.g. joint contractures, skin breakdown and thrombosis. People with physical disabilities have low levels of motivation and therefore have low levels of participation in physical activity. One reason for this is perhaps their fear of the complications mentioned above and their perceptions of being isolated. The treatment and rehabilitation they receive may not be adequate. Some patients receive a short course of hospital-based rehabilitation but after this is completed there may be little offered within the local community to help with further rehabilitation and help prevent deterioration or secondary complications. Access to community facilities is also sometimes limited, which can further decrease motivation.

The UK population of adults affected with neuromuscular conditions is about 25,000, but their physical activity levels are not known. A pilot study in 2005 showed a low level of general activity and a desire to increase exercise participation. (Freebody, J., et al., 2005). This is not surprising due to the fact that adults, particularly those diagnosed more than five years ago, were told that nothing could be done. Many patients, doctors and therapists still believe this to be the case. Clinical research is limited, however there are indications that adults with neuromuscular disease benefit from exercise, especially if functional and targeted. Assuming that physical activity is good, the issue remains how best to get these patients motivated to adopt this lifestyle change and to take on and adhere to a gym programme. Several specific barriers have been highlighted: a lack of appropriate fitness facilities, a lack of knowledge and disability awareness among facility staff, a lack of knowledge amongst disabled people of the benefits of exercise, physical barriers of the condition itself and lack of energy due to fatigue and decreased levels of self efficacy and negative attitudes to exercise.

One possibility is that a motivational interview may help patients to overcome these barriers. A lot of research has been done and there are many examples of motivational interviewing being used in the clinical field. Much work has been done in drug and alcohol dependency (Stein M, Charuvastra A et al, 2001), cardiac rehab, (Brodie D, Inoue A, 2004) and schizophrenia, amongst others.

Motivational interviewing is a strategy that originates out of the fields of behavioural therapy, social psychology and humanistic psychology. It uses a patient-centred approach; this allows the patient to provide the focus and the direction of the issue rather than the provider of care. This will then reduce the risk of any resistance occurring between the patients and the provider of care. The motivational approach arose from the field of substance abuse and has been effective in assisting with a number of behaviour changes (Butler, Rollnick, & Stott, 1996, Hayward, Chan, Kemp, & Youle, 1995; Miller, 1996; Miller, & Rollnick, 1991; Colby et al., 1998; Kemp et al., 1998; Pill et al., 1998; Sims, Smith, Duffy, & Hilton, 1998).

There are four basic principles in motivational interviewing, to express empathy and exploring and resolving client ambivalence (Miller et Rollnick, 2002), to develop discrepancy, to roll with resistance and finally support self- efficacy. The four principles are expanded below and are from the work of (Miller et Rollnick., 2002).

1) Express Empathy Unit 5

The referral process- Inclusion/Exclusion Criteria

Basic Medical Screening before exercise prescription.

The Physical Activity Readiness Questionnaire (PARQ) form is the first stage of screening an individual for exercise participation. There are seven standard questions on the PARQ form. These questions are designed to screen the individual’s current health status and see whether the fitness professional needs to obtain clearance from a medical professional such as a GP or consultant.

If the individual answers yes to any of the following statements whilst completing the PARQ it is recommended that a doctor’s note may need to be obtained, or at least the individual should consult their GP.

 Any form of cardiac surgery.  Any form of cardiac disease, such as, heart valve disease, heart failure or congenital heart disease.  Use of prescribed cardiac medications.  Experience of chest discomfort with exertion.  Experience of unreasonable breathlessness.  Experience and episodes of dizziness, fainting or blackouts.  Diagnosis of diabetes  Diagnosis of lung disease or asthma  Burning or cramping sensations in the lower legs on walking short distances.  A musculoskeletal problem that limits physical activity  Use of prescription medications  Pregnancy

If the individual answers yes to two or more of any of the following cardiovascular risk factors whilst completing the PARQ it is recommended that a doctor’s note may need to be obtained or at least the individual should consult their GP.

 They are male and older than 45 years  They are female and older than 55 years, have had a hysterectomy or are post menopausal.  They smoke or quit smoking within the previous 6 months  They have a resting blood pressure above 140/90 mm Hg.  They take blood pressure medication  Their cholesterol level is above 200mg/dL  Their cholesterol level is unknown  They have a close blood relative who had a heart attack or heart surgery before the age of 55 (father or brother) or age 65 (mother or sister)  They are sedentary, getting less than 30 minutes of physical activity on at least 3 days per week.  They are more than 20 pounds over weight.

AHA/ACSM Health/Fitness Facility Preparticipation screening questionnaire

Before commencing any exercise prescription the individual should obtain and give to you a signed letter from the GP. As the GPs are usually very busy and short of time it is better to have a letter already set up for the GP to sign.