Thanda--October-08-2013.doc.docx

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Thanda-9559728

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Needs Assessment Report by Haidee Kaur Thanda

Note: The needs assessment presented here is relatively limited in scope and is only a fraction of the full program. The needs cannot fully be assessed without doing a complete detailed needs-assessment involving all stakeholders, clinicians and a variety of stroke survivor types.

Section I: About The Project

According to the Canadian Stroke Network's 2011 report on the Quality of Stroke Care in Canada, 90 per cent of individuals with mild stroke are discharged directly home from acute care. Only 37 per cent of all moderate to severe stroke cases are discharged to a rehabilitation facility. The Board of Directors (BoD) of the Jewish Rehabilitation Hospital (JRH), a general and specialized care hospital (CHSGS) that focuses on rehabilitation, is alarmed because these statistics indicate that stroke survivors are living with the consequences of stroke without receiving adequate treatment. If they do not engage in sufficient rehabilitation post stroke, they may experience decreased independence in regular activities of daily living, limited mobility and reduced participation in society. Research studies show that aggressive rehabilitation beyond the usual 6-month period increases aerobic capacity and sensorimotor function (Gordon et al., 2011). The report indicated that there are huge gaps in the delivery of rehabilitation services in all parts of Canada, that services are not well documented and that balance is the most important factor associated with the ability to perform basic mobility tasks in people with hemiparesis secondary to a stroke.

With the rising number of people surviving strokes today, the Jewish Rehabilitation Hospital recognized that there is a vital need for exercise programs designed to improve and maintain the physical fitness and quality of life for stroke survivors. The BoD of the JRH requested a 30-minute Yoga-Balance Rehabilitation program course in response to the high incidence of falls for stroke survivors. The goal of this course is to lower the incidence of falls and improve stroke survivor independence.

Summary of Research Strategy

The information collected in this report was identified and gathered through two group interviews, and a meeting with subject matter experts within the Canadian Stroke Network (CSN) and JRH. The subject matter experts included a clinician, rehabilitation nurse, physical therapist, occupational therapist, speech-language therapist, vocational therapist, mental health professional and a yoga instructor, who has had additional training in anatomy and physiology to work with people with disabilities. Two stroke survivors were also interviewed and were administered the Berg Balance Scale (BBS), a widely used clinical test of a person's static and dynamic abilities. The interviews were semi-structured and highlighted specific needs that this project will focus on. Other information was collected through an extensive literature review on post-stroke consequences and stroke rehabilitation programs developed by the National Institute of Neurological and Stroke, Canadian Stroke Network and the Balance and Mobility Clinic. This introductory module will focus on a balance and breathing technique. Other sections of the program will be designed at a later stage, which would include various yoga balance techniques.

The information contained in this report stems from three main sources:

Focus Group: Canadian Stroke Network (CSN) and Jewish Rehabilitation Hospital (JRH) subject Matter Experts (SME). This will help me gather an extensive amount of information from a variety of experts in a short period of time. I will facilitate two separate focus groups, one with the SMEs from the CSN and the other with the JRH.

Research Literature: I will leverage existing documentation to have an idea of the material stroke survivors are currently being presented with so that I have a better grasp of the situation and current resources. I will read different written documentation regarding stroke, rehabilitation programs, and implementation such as research network websites, publications program documentation

Observe: Stroke patient and rehabilitation staff and hospital facilities. The purpose of this approach of data is to have a first hand-experience of the facility resources and to see the varied processes of rehabilitation offered at the hospital.

Section II: The Request

The BoD of the JRH has requested the development of a 30-minute Yoga-Balance Rehabilitation program to help hemiparesis patients improve their balance post stroke. The BoD requested a series of 30-minute courses that cover various yoga techniques that improve physical balance with optimum thinking, nutrition, breathing, posture and support. The goal of the program is to improve balance to increase their overall independence in activities of daily living, mobility and their participation in society. This module will educate learners on the risks factors of hemiparesis and introduce a yoga breathing technique and an exercise.

The President of the JRH identified many issues that should be incorporated in the program:

●     Sections should be 30 minutes in duration, each introducing different components of yoga that contribute to physical balance

●      Program must be delivered in hospital with other stroke re-education rehabilitation training

●      Program should cover a list of symptoms that have been identified for hemiparesis

●      Yoga techniques must be easy to do and must not require specialized equipment but may use readily available equipment like chairs and walls

Business Need Underlying the Request

The business need underlying the request is to contain the expenses associated with the direct and indirect costs of falling.

According to “Nursing Best Practice Guideline Shaping the future of Nursing” (2005), fall-related injuries are a significant economic burden to the Canadian society in physician services, hospital costs, lost wages, and decreased productivity and increase of Social Security Disability Insurance (SSDI) payments. Direct health care costs relating to falls among seniors are estimated at $1 billion every year (Stevens, Corso, Finkelsteinm Miller et al., 2006). The BoD of the JRH hopes to improve balance to increase the overall independence of stroke survivors in activities of daily living, mobility and participation in society. 

Gap Between Current and Ideal Performance

The Current Situation

END RESULT: Learner does not recognize fall risk factors for stroke hemiparesis and does not implement yoga-based techniques to reduce the incidence of falls.

Mrs. Otter is a 61-year-old woman who left the JRH 3 months after her stroke. She has mild right hemiparesis, mild aphasia, and non-fluent expressive aphasia. Following her stroke, she spent several weeks in acute care and inpatient rehabilitation before being discharged to her home and diagnosed with clinical depression. She is dependent on her caregivers for basic self-care activities and mobility. She takes a combination of drugs such as antihyperglycemics and antidepressants with a shot of gin before she goes to bed to help her sleep. When Mrs. Otter gets up from bed in the morning she loses her balance and trips on her bedroom carpet. She no longer looks forward to waking up and getting out of bed because she falls frequently.

She cannot drive herself to the hospital to join the group post-rehabilitation exercise classes so she rarely does her exercises at home because she finds them repetitive and boring. When Mrs. Otter does physical activity she feels numbness in her feet and she has knee pain. This scares her so she usually doesn’t attempt to exercise and stays sedentary to avoid further complications.

The Ideal Situation

END RESULT: Learner recognizes fall risk factors for stroke hemiparesis survivors and implements yoga based techniques to help reduce the incidence of falls.

Mrs. Otter is a 61-year-old woman who left the JRH three months after her stroke. She has mild right hemiparesis, mild aphasia, and non-fluent expressive aphasia. Following her stroke, she spent several weeks in acute care and inpatient rehabilitation before being discharged to her home. She is dependent on her caregivers for basic self-care activities and mobility. Mrs. Otter is restless and has trouble falling asleep and remembers to practice the Victory breathing technique she learned in her yoga program. She practices Victory breathing in bed and falls asleep after a few minutes. When Mrs. Otter gets up from bed in the morning, she deepens her breath and brings awareness into her breathing. After a few long deep breaths, she expands her awareness into the rest of her body, even in the parts that regularly feel numb. Mrs. Otter focuses on her entire body. While maintaining whole body awareness, she slowly sits up from her sleeping position and remains seated for a few minutes. After a few moments, she slowly begins to make her way up into a standing position distributing her weight equally into both ankles. She focuses on distributing her body’s weight into both soles of her feet, and bravely maneuvers herself to the walker she placed in front of her bed. After successfully getting out of bed, she looks forward to starting her day.

She cannot drive herself to the hospital to join the group Post-Rehabilitation exercise classes on her own. She reads the Yoga-Balance for Rehabilitation frequently asked questions sheet (FAQ) that accompanied the registration form for Yoga and finds out that the para-transit can pick her up and bring her to the hospital. She goes to the exercise class and finds a community of support. She no longer feels as isolated and she is encouraged to come back the next week.

Tasks in Current Performance, Ideal Performance (see Appendix A)

Note: You will find the full list of Current and Ideal Tasks, Learning Objectives and Draft of Evaluation in the Appendices.

Tasks in Current Performance

End results: Stroke survivor engages in risky behaviour and falls frequently.

Tasks in Ideal Performance

End results: Learner recognizes fall risk factors for stroke hemiparesis survivors and implements yoga-based techniques to help reduce the incidence of falls.

Personas (Character Descriptions) of the Learners

Low maintenance learner

Jasmit is a 61-year-old man with a history of sleep apnea, and chronic low back pain who recently had a stroke that left him severely debilitated on the right side of his body. Immediately following his stroke, he spent many weeks in inpatient rehabilitation facilities before going home. Though Jasmit has a daughter who lives with him, he has a fear of falling because he has fallen at home several times. He is often left alone and deals with the limitations he faces since his daughter is both a full-time student and part-time employee at a retail store near her school. He tries to keep motivated by calling friends and fellow stroke survivors so that he feels both encouraged and supported during this transition. He recognizes that physical improvement is a process that happens over time and seeks group rehabilitative activities over individual sessions so that his budget does not feel over stretched.

Average maintenance learner

Sarah is a 29-year-old working woman, who is happily married with 2 children. She suffered from a mild stroke which limits her ability to do physical activities. In terms of her mobility, her hands tend to be very shaky and lack coordination. She has to look at her hands to be able to know where they are situated to control them. Sarah tends to tire quickly and loses focus quickly. She also has difficulty being motivated to do her exercises and remembering how to do the exercises. She feels isolated, and discouraged because her life has taken a drastic turn and she cannot relate to her previous network of friends.

High maintenance learner

Mauri is a 40-year-old man who survived a stroke, but was left severely debilitated on the right side of his body. He emigrated from India in the 80’s and has learned to be self-sufficient and independent because of his arduous experience. The stroke has caused a big shift in his perspective and been a challenge because he is not used to being dependent on medical resources and other people. Aside from his daughter, Mauri is co-habiting with his partner who is independent and has four kids. Mauri does not have any close friends and his close family members are in India.

He is afraid that he will fall and fracture or break something, and that will make him even more dependent on others. To avoid the risk of falling, he spends his days sedentary and does not practice his exercises at home. He feels stuck and disengaged because he feels like he cannot ask all the questions he would like. He is too afraid to ambulate independently without the use of assertive devices within the home because of his perpetual fear of falling. It all feels like a vicious cycle Mauri finds the process of rehabilitation challenging for a number of reasons: the exercises are repetitive and boring to practice at home and he does not see any improvements quickly. He feels defeated, stressed, and lacks motivation because he has challenges expressing himself and his physical progress is slow.

Demographics

The target population for this course is stroke patients with hemiparesis:

· Central Nervous System Disorder

· Stroke (focus on Hemiparesis)

· Other aspects of the targeted population(s) are:

· Age range of patients is adults ranging from 18-75 years of age

· Cultural background of the targeted population is North American / Western, Canadian, United States

The rate of falls varies considerably among different diagnostic groups admitted to inpatient rehabilitation. Mid-aged people with stroke and amputation, worse cognitive functions, and greater medical complexity are at a higher risk for falling (Rabadi, 2008).

Previous Knowledge: Learner will have previous stroke and rehabilitation information from their medical physician, and rehabilitation center. The information depth and resources may vary depending on what resources they have sought out in the past and present.

Influences that might affect this group of learners: Combination of comorbidities, neurological deficits and emotional barriers unique to each stroke survivor to ensure safe exercise programming.

Constraints in the Learning Environment

The effective delivery of post stroke rehabilitation requires the development of infrastructure for an integrated care system that spans acute care, acute rehabilitation, sub acute rehabilitation, outpatient services, home care, and community and transportation support services. Important developments that have been noted are the use of clinical pathways, effective information systems and communication between levels and sites of care. Barriers that limit access to post acute stroke rehabilitation include uneven distribution of resources, inadequate insurance coverage and lack of knowledge of the potential value of rehabilitation.

Characteristics of the Learners and the Environment

A primary barrier to any type of post stroke therapy is depression. The incidence of post stroke depression ranges from 18% to 68% (Gordon et al., 2011). The evaluation of physiological and emotional barriers to post stroke physical activity requires an evaluation of primary factors of stroke severity, comorbidities, and clinical deficits, as well as secondary factors of familial support, depression, post stroke fatigue, social integration and cultural issues. Professional assessment and intervention relative to primary and secondary factors are important to help prevent a cycle of diminished motivation, loss of engagement in activity, reconditioning, subsequent related acute illness (such as pneumonia) and a resultant need for temporary re-initiation of acute therapy. Therefore, the initial step to implementing an effective course regiment for post stroke patients is a medical history and physical examination to identify physiological barriers. Moreover, to facilitate optimal outcomes from an exercise-based stroke rehabilitation program, an assessment of familial support should be undertaken. In the context of defining therapy goals for the post stroke patient, it is essential that the patient’s family be integrated into the process as early as possible. Early involvement of the family unit has been noted to strongly correlated with patient adherence to therapy, better understanding between patient and caregiver of achievable outcomes and improved communication between patient and caregivers.

Constraints on the Project

Product constraints The JRH has specified the program duration of 30 minutes. We are unaware of any deadlines and no budget is stipulated at this time. The JRH may have a template for courses and also may have a style guide. This will be acquired prior to the design/development phase. A design guide is also very likely considering the institutional nature of the organization. The course may have to be delivered in the hospital rehabilitation center, so that patients can be supervised while practicing the yoga techniques.

Technical constraints There are none that have been identified.

Business constraints The project deadline is due 12 pm, Friday, December 6 2013.

Corporate culture and project history Since the hospital is a large institution, there is likely to be many administrative protocols. The training will most likely have to be translated into French as well.

Business objective

The business objective is to contain expenses that are associated with the direct and indirect costs of falling.

The BoD of the JRH hopes to improve balance to increase the overall independence of stroke survivors in activities of daily living, mobility and participation in society by reducing the incidence of falls. 

Learning objectives (see Appendix B)

Drafts of Evaluation (Level 1, 2, 3) (see Appendix C)

References

Altschuler, E. L., Wisdom, S. B., Stone, L., Foster, C., Galasko, D., Llewellyn, D. M., et al. (1999). Rehabilitation Of Hemiparesis After Stroke With A Mirror.The Lancet, 353(9169), 2035-2036.

Bastille, J., & Gill-Body, K. (2004). A Yoga-Based Exercise Program for People With Chronic Poststroke Hemiparesis.American Physical Therapy, 84(1), 33-48.

Caplan, L. R. (2006). Stroke. New York: Demos Medical Publishing.

Carliner, S. (2003) Training design basics. Baltimore, MD: ASTD press.

Gordon, N. F., Gulanick, M., Costa, F., Fletcher, G., Franklin, B., Roth, E., et al. (2004). Physical Activity And Exercise Recommendations For Stroke Survivors: An American Heart Association Scientific Statement From The Council On Clinical Cardiology, Subcommittee On Exercise, Cardiac Rehabilitation, And Prevention; The Council On Cardiovascular. Stroke,35(5), 1230-1240.

Rabadi, M. H. (2008). Re: Risk Factors For Falls During Inpatient Rehabilitation.American Journal of Physical Medicine & Rehabilitation, 87(12), 1055.

Stevens, J. A., Corso, P. S., Finkelstein, E. A., & Miller, T. R. (2006). The Costs Of Fatal And Non-fatal Falls Among Older Adults. Injury Prevention, 12(5), 290-295.

Prevention of Falls and Fall Injuries in the Older Adult. (2005, January 1). Nursing Best Practice Guideline Shaping the future of Nursing. Retrieved October 1, 2013, from rnao.ca/fr/sites/rnao-ca/files/Prevention_of_Falls_and_Fall_Injuries_in_the_Older_Adult.pdf

Muscle Weakness After Stroke Hemiparisis. (2006, January 1). National Stroke Association . Retrieved October 2, 2013, from www.stroke.org/site/DocServer/Hemiparesis.pdf

The Quality of Stroke Care in Canada Canadian Stroke Network. (2011, January 1). http://www.canadianstrokenetwork.ca. Retrieved October 1, 2013, from www.canadianstrokenetwork.ca/wp-content/uploads/2011/06/QoSC-EN1.pdf

What is paratransit? | Société de transport de Montréal. (2013, October 15). STM | Société de transport de Montréal. Retrieved October 15, 2013, from http://www.stm.info/en/paratransit/about-paratransit/what-paratransit

Woodyard, C. (2011). Exploring the therapeutic effects of yoga and its ability to increase quality of life. International Journal of Yoga, 4(2), 49–54.

Appendix A

Tasks in Current Performance

Main and Supporting Tasks

- Stroke survivor fails to identify behaviors that contribute to the chance of falling

- Stroke survivor fails to recognize the implications of depression on mental outlook

- Stroke survivor does not attempt to exercise and views rehabilitation as impossible and becomes disengaged

- Stroke survivor takes medication with alcohol (nightcaps) as a sleep aid

- Stroke survivor fails to express herself and request help with basic activities

- Stroke survivor avoids leaving his/her bed and becomes more fearful of falling

Tasks in Ideal Performance

End results: Learner recognizes fall risk factors for stroke hemiparesis survivors and implements yoga-based techniques to help reduce the incidence of falls.

Main and Supporting Tasks

· recognize fall risk factors for stroke hemiparesis survivors

· identify clinical fall risk factors for stroke hemiparesis survivors

· state comorbidity as a clinical risk factor

· state depression as a clinical risk factor

· state antidepressant medications as a clinical risk factor

· state impaired motor abilities as a clinical risk factor

· state gait balance deficits as a clinical risk factor

· state impaired cognition as a clinical risk factor

· state loss of confidence and fear of falling as a clinical risk factor

· state visual impairment as a clinical risk factor

· state the use of alcohol including nightcaps as a clinical risk factor

· describe the benefits of the yoga technique for stroke survivors

· recognize the socio-emotional benefits of group yoga

· state increases in confidence

· state decreases in feelings of perceived isolation

· state decreases in feelings of perceived sadness

· state increases in perceived independence

· recognize physical benefits of practicing yoga postures

· state improved muscle tone

· state increase of endurance

· state increase of physical balance

· state increase in cardiovascular capacity

· perform breathing technique aimed at relaxing the body and focusing the mind

· identify the relationship between breathing and the nervous system

· state that thought pattern matches the breathing pattern

· state that deep breathing relaxes the body

· perform Victory breath

· identify the parts of the body and lungs that are involved in this technique

· state chambers of the lungs, thoracic region, diaphragm

· state lower abdomen

· open the mouth wide in an “O” shape

· inhale deeply and slowly as you expand your diaphragm outwards for one mental count of one Mississippi

· exhale as you retract the abdomen slowly but forcefully for one mental count of one Mississippi. Pretend you are trying to make a window foggy with your breath

· maintain the same breathing pattern for five counts of “Mississippi”

· close the mouth fully, while maintaining the same breathing pattern

· continue breathing for forty counts of Mississippi

· perform an exercise for ankle balance

· sit on a chair

· begin Victory breath for the sequence of these exercises (explained above)

· place the soles of the feet on an even surface

· put all of your weight on your left leg

· lift your right leg up one inch off the ground

· balance your weight on your left leg for ten counts of Mississippi

· lower your right leg down

· take a break

· stop executing exercise

· close your eyes

· practice victory breath for ten counts of Mississippi

· open eyes

· repeat exercise using right leg

· lift your right leg up one inch off the ground, while putting all of your weight on your left leg

· balance your weight on your left leg for ten counts of Mississippi

· lower your right leg down

· take a break for ten counts of Mississippi

· switch feet

· balance yourself on your left leg for ten counts of Mississippi

· lift your left leg up one inch off the ground, while putting all of your weight on your right leg

· balance your weight on your right leg for ten counts of Mississippi

· lower your left leg down

· take a break

· repeat sequence exercise using the other leg

· lift your left leg up one inch off the ground, while putting all of your weight on your right leg

· balance your weight on your right leg for ten counts of Mississippi

· lower your left leg down

· take a break for ten counts of Mississippi

Appendix B

Learning objectives

Note: Unless stated otherwise, learners must perform all tasks with 100 percent accuracy, and without assistance.

· identify at least 7 of 9 clinically proven fall risk factors for stroke hemiparesis survivors

· identify clinical fall risk factors for stroke hemiparesis survivors

· state comorbidity as a clinical risk factor

· state depression as a clinical risk factor

· state antidepressant medications as a clinical risk factor

· state impaired motor abilities as a clinical risk factor

· state gait balance deficits as a clinical risk factor

· state impaired cognition as a clinical risk factor

· state loss of confidence and fear of falling as a clinical risk factor

· state visual impairment as a clinical risk factor

· state the use of alcohol including nightcaps as a clinical risk factor

· identify at least 7 of 8 benefits of the yoga technique for stroke survivors

· identify the socio-emotional benefits of group yoga

· state increases in confidence

· state decreases in feelings of perceived isolation

· state decreases in feelings of perceived sadness

· state increases in perceived independence

· identify physical benefits of practicing yoga postures

· state improved muscle tone

· state increase of endurance

· state increase of physical balance

· state increase in cardiovascular capacity

· verbally describe the procedure to perform breathing technique aimed at relaxing the body and focusing the mind

· identify the relationship between breathing and the nervous system

· state that thought pattern matches the breathing pattern

· state that deep breathing relaxes the body

· identify the parts of the body and lungs that are involved in this technique

· state chambers of the lungs, thoracic region, diaphragm

· state lower abdomen

· apply proper breathing technique in a yoga session (Victory breath)

· open the mouth wide in an “O” shape

· inhale deeply and slowly as you expand your diaphragm outwards for one mental count of one Mississippi

· exhale as you retract the abdomen slowly but forcefully for one mental count of one Mississippi. Pretend you are trying to make a window foggy with your breath

· maintain the same breathing pattern for five counts of Mississippi

· close the mouth fully, while maintaining the same breathing pattern

· continue breathing for ten counts of Mississippi

· verbally describe the procedure to perform ankle balance exercise

· sit on a chair

· begin Victory breath for the sequence of these exercises (explained above)

· place the soles of the feet on an even surface

· put all of your weight on your left leg

· lift your right leg up one inch off the ground

· balance your weight on your left leg for ten counts of Mississippi

· lower your right leg down

· take a break

· close your eyes

· practice victory breath for ten Mississippi

· open eyes

· repeat exercise using right leg

· lift your right leg up one inch off the ground, while putting all of your weight on your left leg

· balance your weight on your left leg for twenty seconds

· lower your right leg down

· take a break for ten Mississippi

· switch feet

· balance yourself on your left leg for one minute

· lift your left leg up one inch off the ground, while putting all of your weight on your right leg

· balance your weight on your right leg for twenty seconds

· lower your left leg down

· take a break for ten Mississippi

· repeat sequence exercise using the other leg.

· lift your left leg up one inch off the ground, while putting all of your weight on your right leg

· balance your weight on your right leg for ten Mississippi

· lower your left leg down

· take a break

Appendix C

Drafts of Evaluations

Sample Satisfaction Survey (Kirkpatrick Level 1)

1. Please describe this training session in one word

This training session was ____________________________________

2. Rate this training session overall

1

2

3

4

5

useless

interesting

helpful

3. Rate your knowledge of anxiety management prior to this training session

1

2

3

4

5

nothing

some

a lot

4. Rate your knowledge of anxiety management after this training session

1

2

3

4

5

nothing

some

a lot

5. Rate your likelihood of applying the skills taught in this training session to combat your anxiety

1

2

3

4

5

not likely

not sure

very likely

6. Please describe the best part of this training session

____________________________________________________________________

7. Please describe the one thing that could improve this training session

_____________________________________________________________________

* survey format adapted from Saul Carliner's “Training Design Basics” 2003 ASTD Press.

Level 2 Evaluation

Learners will be assessed on their ability to master the objectives through an observation and quiz.

· Main Objective #1: Identify clinically proven fall risk factors for stroke hemiparesis survivors in sample questions.

Question #1

Name 7 clinically proven fall risk factors for stroke hemiparesis survivors ?

ANSWER: state comorbidity as a clinical risk factor. Comorbid conditions (e.g., diabetes, pulmonary disease, and osteoporosis) have been linked to an increase risk of falling.

state depression as a clinical risk factor. In many studies, depression has been linked to an increase risk of falling.

state antidepressant medications as a clinical risk factor. The use of medications that diminish blood glucose level or blood pressure and affect central nervous system function eventually reduces the stroke patient's vigilance [or attention and leads to increased risk of falling

state impaired motor abilities as a clinical risk factor. Stoke survivors with impaired motor abilities due to weak muscles are more likely to fall than are those who have greater muscle strength.

state gait balance deficits as a clinical risk factor. Stroke survivors who have poor balance or difficulty walking are more likely to lose balance and fall.

state impaired cognition as a clinical risk factor. Stroke survivors who undergo rehabilitation often suffer from a variety of cognitive and physical deficits, placing them at high risk of falling

state loss of confidence and fear of falling as a clinical risk factor. Fear of falling and low confidence has been linked with a higher incidence of falls.

state visual impairment as a clinical risk factor. Visual acuity, contrast sensitivity, visual field, cataract, glaucoma and macular degeneration all contribute to risk of falls can lead to falls.

state the use of alcohol including nightcaps as a clinical risk factor. Drinking alcohol before bed, especially with medication can contribute to falls.

Question #2

Which of the following is not a fall risk factor for stroke hemisparesis survivors?

a) Visual impairment is a fall risk factor for stroke hemisparesis survivors.

b) Impaired motor abilities are a clinical risk factor hemisparesis survivors.

c) Gait balance deficits is a clinical risk factor hemisparesis survivors

d) Vitamin D is a clinical risk factor hemisparesis survivors.

Which of the following is not a fall risk factor for stroke hemisparesis survivors?

a) Incorrect: Visual impairment is a fall risk factor for stroke hemisparesis survivors. Visually impaired survivors with any of the following acuity and contrast sensitivity, visual field, cataract, glaucoma and macular degeneration are a risk factor.

b) Incorrect: Impaired motor abilities are a clinical risk factor hemisparesis survivors. Stroke survivors with impaired motor abilities due to weak muscles are at risk fall than are those who have greater muscle strength.

c) Incorrect: Gait balance deficits is a clinical risk factor hemisparesis survivors

d) Correct: Vitamin D is not a clinical risk factor hemisparesis survivors. There is inconclusive evidence that suggest Vitamin D supplementation is an effective intervention in lowering the risk of falls.

Question #3

Which of the following pairs is not a fall risk factor for stroke hemisparesis survivors?

a) Visual impairment and impaired motor abilities.

b) Gait balance deficits and the use of alcohol, including nightcaps

c) Coconut oil and slippers

d) Depression and comorbidities

Which of the following pairs is a fall risk factor for stroke hemisparesis survivors?

a) Incorrect: Visual impairment and impaired motor abilities. Visually impaired survivors with any of the following acuity and contrast sensitivity, visual field, cataract, glaucoma and macular degeneration are a risk factor. Stroke survivors with impaired motor abilities due to weak muscles are at risk fall than are those who have greater muscle strength.

b) Incorrect: Gait balance deficits and the use of alcohol, including nightcaps. Stroke survivors who have poor balance or difficulty walking are more likely to lose balance and fall. Drinking alcohol before bed, and with medication can contribute to falls.

c) Correct: Coconut oil and bananas. There is no evidence that suggest that coconut oil and bananas are a fall risk factor.

d) Incorrect: Depression and comorbidities. In many studies, depression and comorbidities (eg, diabetes, pulmonary disease, and osteoporosis) has been linked to an increase risk of falling.

· Main Objective #2 identify benefits of the yoga technique for stroke survivors

Question #1

· List seven benefits of practicing yoga

· Increase in confidence. The practice of yoga can help increase confidence in stroke patients and enable one to take more beneficial risks in their own rehabilitation process.

· Decrease in feelings of perceived isolation. Group yoga in rehabilitation is an experience that is shared and decreases feelings of isolation.

· Decrease in feelings of perceived sadness. Group yoga can help decrease the feelings of isolation, and sadness for stroke survivors.

· Increase in perceived independence. Yoga boosts stroke survivors’ confidence which has shown to increase their sense of independence.

· Improved muscle tone. A benefit of yoga is an increase of muscle toning because it is a strength building exercises.

· Increase of endurance. Yoga promotes endurance by exercising lung capacity during breathing techniques and yoga postures.

· Increase of physical balance. Yoga postures and breathing improves overall gait and physical balance in stroke patients.

· Increase in cardiovascular capacity. There is evidence that suggests yoga breathing and postures increase cardiovascular capacity in stroke patients.

Question #2

Which of the following is not a benefit of the yoga practice for stroke survivors?

a) increase of endurance

b) increase of physical balance

c) increase in cardiovascular capacity

d) cure paralysis

Which of the following is not a benefit of the yoga practice for stroke survivors?

a) Incorrect: increase of endurance. Yoga promotes endurance by exercising lung capacity during breathing techniques and yoga postures.

b) Incorrect: increase of physical balance. Yoga postures and breathing improves overall gait and physical balance in stroke patients.

c) Incorrect: increase in cardiovascular capacity. There is evidence that suggests yoga breathing and postures increase cardiovascular capacity in stroke patients.

d) Correct: cure paralysis. Yoga practice cannot cure paralysis but may reduce the effects of paralysis.

Question #3

Match the corresponding verb with the according yoga benefit

a) increase

1. muscle tone

b) improve

2. cardiovascular capacity

c) decrease

3. perceived isolation

d) increase

4. confidence

Answer: a4, b1, c3, d2

A4. The practice of yoga can help increase confidence in stroke patients, enabling them to take more beneficial risks in their own rehabilitation process.

B1. A benefit of yoga is an increase of muscle toning due to the strength building exercises.

C3. Group yoga in rehabilitation is a shared experience and decreases feelings of isolation.

D2. There is evidence that suggests yoga promotes cardiovascular capacity in stroke patients.

Question #4

Please circle three socio-emotional benefits of group yoga?

1) decrease in confidence.

2) decrease in feelings of perceived isolation.

3) decrease in feelings of perceived sadness

4) increase in perceived independence

1) Incorrect: decrease in confidence. Group yoga can increase confidence.

2) Correct: decrease in feelings of perceived isolation. Group yoga in rehabilitation is an experience that is shared and decreases feelings of isolation.

3) Correct: decrease in feelings of perceived sadness. Group yoga can help decrease the feelings of isolation, and sadness for stroke survivors.

4) Correct: increase in perceived independence. Yoga boosts stroke survivors’ confidence which has shown to increase their sense of independence.

· Main Objective #3 verbally describe the procedure to perform breathing technique aimed at relaxing the body and focusing the mind

Question#1

Explain what to do when you need a break during yoga?

Answer:

· stop executing exercise

· close your eyes

· practice victory breath for ten counts of Mississippi

· open eyes

Question#2

State the relationship between breathing and the nervous system

Answer:

· state that thought pattern matches the breathing pattern

· state that deep breathing relaxes the body

Question#3

State the parts of the body and lungs that are involved in this technique

Answer:

· state chambers of the lungs, thoracic region, diaphragm

· state lower abdomen

Question#4

In the following question the learners will be asked to demonstrate Victory breath. The list that follows is the rubric that will be used to observe and evaluate the learner. The evaluator should use this rubric to comment on the learner’s specific actions and to see if the learner is able to complete the exercises correctly.

Supporting Tasks

Complete Victory breath sequence

Actions

1. Open the mouth wide in an “O” shape ___Yes ___ No

2. Inhale deeply and slowly as you expand your diaphragm outwards for 1 mental count of 1 Mississippi ___Yes ___ No

3. Exhale as you retract the abdomen slowly but forcefully for 1 mental count of 1 Mississippi. Pretend you are trying to make a window foggy with your breath ___Yes ___ No

4. Maintain the same breathing pattern for 5 counts of Mississippi

___Yes ___ No

5. Close the mouth fully, while maintaining the same breathing pattern

___Yes ___ No

6. Continue breathing for ten counts of Mississippi

___Yes ___ No

· Main Objective #4 verbally describe the procedure to perform ankle balance exercise

Question#1

Explain the procedure to perform ankle balance exercise using the left leg

· sit on a chair

· begin Victory breath for the sequence of these exercises (explained above)

· place the soles of the feet on an even surface

· put all of your weight on your left leg

· lift your right leg up one inch off the ground

· balance your weight on your left leg for ten counts of Mississippi

· lower your right leg down

Question#2

In the following part of the evaluation the learners will be asked to demonstrate the balance ankle exercise.

The list that follows is the rubric that will be used to observe and evaluate the learner. The evaluator should use this rubric to comment on the learner’s specific actions and to see if the learner is able to complete the exercises correctly.

Supporting Tasks

Complete an ankles exercises

Actions

1. Demonstrate starting position to complete ankle balance exercise

___Yes ___ No

Perform the first left ankle balance exercise
___Yes ___ No

Balance for one minute ___Yes ___ No

3. Perform the first right ankle balance exercise

___Yes ___ No

Balance for one minute ___Yes ___ No

Level 3 Evaluation

In order to evaluate how well leaners have applied acquired knowledge and abilities taught in the program we will administer two tests pre, post and post intervention to the group going through the intervention and a control group (who is not doing the Yoga Balance Rehabilitation program). The tests will assess balance and depression before (pre-test) the learner is admitted to the Yoga-Balance Rehabilitation program, and post-test 3 months after the program using Berg Balance Scale (BBS). We will administer the test at three parts of the program (pre, during and post) to track the progress of the learner in the intervention and control group. The aim is to verify if the progress is indeed due to the Yoga Balance Rehabilitation program or just a result of recovering over time.

· Tests: Berg Balance Scale

Note: Some text adapted from Carliner, 2003

Berg Balance Scale

The Berg Balance Scale (BBS) was developed to measure balance among older people with impairment in balance function by assessing the performance of functional tasks. It is a valid instrument used for evaluation of the effectiveness of interventions and for quantitative descriptions of function in clinical practice and research.

Description:

14-item scale designed to measure balance of the older adult in a clinical setting.

Equipment needed: Ruler, two standard chairs (one with arm rests, one without), footstool or step, stopwatch or wristwatch, 15 ft. walkway

Completion

Time:

15-20 minutes


Scoring: A five-point scale, ranging from 0-4. “0” indicates the lowest level of function and “4” the highest level of function. Total Score = 56

Interpretation:

41-56 = low fall risk

21-40 = medium fall risk

0 –20 = high fall risk

A change of 8 points is required to reveal a genuine change in function between 2 assessments.

Appendix D

Name:

Date of Test: Control/Intervention Group:

Berg Balance Scale

1. Sit to Stand

· Instructions: “Please stand up. Try not to use your hands for support”

· Grading: Please mark the lowest category that applies


( ) 0: Needs moderate or maximal assistance to stand


( ) 1: Needs minimal assistance to stand or to stabilize

( ) 2: Able to stand using hands after several tries


( ) 3: Able to stand independently using hands

( ) 4: Able to stand with no hands and stabilize independently

2. Standing unsupported 


· Instructions: “Please stand for 2 minutes without holding onto anything”

· Grading: Please mark the lowest category that applies


( ) 0: Unable to stand 30 seconds unassisted

( ) 1: Needs several tries to stand 30 seconds unsupported

( ) 2: Able to stand 30 seconds unsupported

( ) 3: Able to stand 2 minutes without supervision


( ) 4: Able to stand safely for 2 minutes
If person is able to stand 2 minutes safely, score full points for sitting unsupported (item 3).

Proceed to item 4.

3. Sitting with back unsupported with feet on floor or on a stool 


· Instructions: “Sit with arms folded for 2 minutes”


· Grading: Please mark the lowest category that applies

( ) 0: Unable to sit without support for 10 seconds


( ) 1: Able to sit for 10 seconds


( ) 2: Able to sit for 30 seconds

( ) 3: Able to sit for 2 minutes under supervision


( ) 4: Able to sit safely and securely for 2 minutes

4.Stand to sit 


· Instructions: “Please sit down”


· Grading: Please mark the lowest category that applies

( ) 0: Needs assistance to sit


( ) 1: Sits independently but had uncontrolled descent


( ) 2: Uses back of legs against chair to control descent


( ) 3: Controls descent by using hands


( ) 4: Sits safely with minimal use of hands

4. Transfers

· Instructions: “Please move from chair to chair and back again” (Person moves one way toward a seat with armrests and one way toward a seat without armrests) Arrange chairs for pivot transfer 


· Grading: Please mark the lowest category that applies

( ) 0: Needs two people to assist or supervise to be safe


( ) 1: Needs one person to assist

( ) 2: Able to transfer with verbal cueing and/or supervision

� STM paratransit program offers door-to-door public transit service to handicapped persons (Société de transport de Montréal, 2013)