Work Sample-Don

Work Sample
Anna Howery
Carroll University
Work Sample
Client Information
Medical history. The client is a 57-year-old male. In August 2008, the client selfreported that he fell out of bed in the morning and was later taken to the hospital. The client had
a dissection of the carotid artery to remove a blood clot. Client self-reports that he had 100%
blockage of his carotid and middle cerebral arteries. In August 2008, the client self-reported that
surgeons opened his carotid and middle cerebral arteries and a Greenfield filter was placed in his
vena cava. He spent 47 days in the hospital following his stroke with the initial 10 days in a
medically induced coma. In order to reduce cranium swelling, cold water was pumped through a
catheter. Prior to his stroke, the client was asymptomatic, noting no cardiac symptoms such as
unusual fatigue or shortness of breath. He also did not have known high cholesterol or high
blood pressure prior to his stroke. The clients self-reported medical history and surgical history
are presented in Table 1 and Table 2 respectively.
TABLE 1. Past medical history.
Diagnosis
Stroke
Dissected carotid artery100% blockage
of carotid and middle cerebral arteries
Date
8/9/2008
TABLE 2. Past surgical history.

Procedure
History Greenfield filter placement
Placement in vena cava
Date
8/9/2008
Special considerations. The client is currently prescribed multiple medications to assist

in managing his condition, which are shown in Table 3. Each of these medications have an
important role in helping to manage blood pressure and cholesterol levels along with managing
right foot pain. Each of these medications side effects, effect on exercise heart rate, blood
pressure and exercise capacity and possible drug and food interactions are shown in Table 3.
Drug interactions were obtained from Drugs.com (2014). The client is currently taking atenolol,
which is a beta-blocker used to treat hypertension and prevent the occurrence of a heart attack.
The client is currently taking aspirin, which is an antiplatelet drug used to reduce platelet
aggregation and decrease an individuals risk of heart attack or stroke. The client is also taking
simvastatin, which is a HMG-CoA reductase inhibitor. This medication is used lower an
individuals cholesterol level as it inhibits HMG-CoA reductase, which is necessary for the
production of cholesterol. The client is currently taking gabapentin to assist in managing his right
foot pain. Gabapentin is an anti-convulsant drug used to treat nerve pain conditions such as
neuropathy. Lastly, the client is taking vitamin B12 and Coenzyme Q10. Vitamin B12 is used to
prevent the development of vitamin B12 deficiency. Coenzyme Q10 is used to replace low levels
of ubiquinone caused by taking cholesterol-lowering medications.
TABLE 3. Current outpatient prescriptions on file.

Medication
HR, BP & EC Effect
Side Effects
Atenolol
HR: decrease
Blurred vision
25 mg
BP: decrease
Dizziness/faintness
EC: increase with
SOB
chronic administration
Unusual weakness
Aspirin
325 mg
Simvastatin
325 mg
Vitamin B12
1000 mg
Coenzyme
Q10
Gabapentin
300 mg,
3 times daily
HR: no change
BP: no change
EC: no change
HR: no change
BP: no change
EC: no change
HR: no change
BP: no change
EC: no change
HR: no change
BP: no change
EC: no change
HR: no change
BP: no change
EC: no change
Stroke
Gastrointestinal
bleeding
Dizziness
Fainting
Fast or irregular
heartbeat
None
Drug/Food Interactions
Minor interaction with
Aspirin
Moderate interaction with
foodavoid consuming
large amounts of orange
juice
Minor interaction with
Atenolol
Major interaction with food
avoid consuming
grapefruit and grapefruit
juice
Loss of appetite
Nausea
Clumsiness or
unsteadiness
Uncontrolled eye
movement
Milligram (mg), heart rate (HR), blood pressure (BP), exercise capacity (EC)
Physical exam. Results related to the clients physical exam are presented in Table 4. The
clients values for blood pressure meet pre-hypertension criteria. It should also be noted that the
client is currently prescribed a beta-blocker to assist in managing his blood pressure. The clients
heart rate is in the optimal range. Values related to his BMI meet obesity criteria. His current
waist circumference also meets obesity criteria. Upon physical examination, the client has
regular aortic, pulmonic, tricuspid and mitral valve heart sounds.
Results related to the clients modified orthostatic challenge are presented in Table 5. The
client experienced a 6-mmHg drop in systolic blood pressure and a 2-mmHg drop in diastolic
blood pressure when going from sitting to standing. The client experienced no symptoms of
dizziness or lightheadedness during the transition from sitting to standing without a significant
drop (20 mmHg in systolic BP and 10 mmHg in diastolic BP) in blood pressure. Normal
hemodynamics are indicated as the clients blood pressure increased normally while standing. As
the client has experienced right foot pain since his stroke, an ABI screening was performed to
determine the presence of PAD. PAD causes reduced blood flow to the lower limbs, which can
result in intermittent claudication. Results related to the clients ABI screening are presented in
Table 6. Results from the ABI screening indicated normal right and left ratios. Therefore, no
present findings of PAD.
TABLE 4. Physical exam.

Examination
Blood pressure
Heart rate
Height
Weight
BMI
Waist circumference
Heart sounds
Result
122/80 mmHg
60 bpm
72 in
217 lb
30.3 kg/m2 (without assistance)
44 in
Regular aortic, pulmonic, tricuspid and
mitral valve
Millimeters of mercury (mmHg), beats per minute (bpm), inches (in), pounds (lb), body mass index (BMI),
kilograms per meter squared (kg/m2)
TABLE 5. Modified orthostatic challenge.

Position
Seated blood pressure
Standing blood pressure
3 min standing blood pressure
Result
122/80 mmHg
116/78 mmHg
138/78 mmHg
Millimeters of mercury (mmHg)
TABLE 6. ABI screening.

Position
R supine arm systolic BP
L supine arm systolic BP
R supine posterior tibial systolic BP
R supine dorsalis pedis systolic BP
L supine posterior tibial systolic BP
L supine dorsalis pedis systolic BP
Right ABI ratio
Left ABI ratio
Result
118 mmHg
120 mmHg
142 mmHg
152 mmHg
146 mmHg
162 mmHg
1.27
1.35
Ankle-brachial index (ABI), right (R), left (L), blood pressure (BP), millimeters of mercury (mmHg)
Exercise history. The client self reports that he exercises at West Wood one day per
week. The client will walk one mile on the track and then perform strength-training exercises
with a stroke personal trainer for 30 minutes. The purpose of these strength-training exercises is
to improve left sided strength, as there is a presence of left-sided neglect. The client also selfreports that weather permitting, he will walk from his home to his mailbox on a daily basis. The
client estimated the distance to be half a mile there and back. During the spring, summer and fall
months, the client self-reported that he will cut down and trim trees on his property using a saw.
He will then load these branches onto his ATV. The client estimated that he will spend eight
hours a day completing these tasks. Prior to his stroke, the client had a physically demanding job
in the construction industry. Each day, he was constantly moving and lifting supplies. In addition
to his physically demanding job, the client also indicated that he enjoyed running prior to his
stroke.
Work history. The client has been retired from work for the past 6 years following his
stroke. The client owned his own construction company and would build houses. This was a very
physically demanding job that required consistent movement and lifting of supplies. Since his
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stroke, the client self-reports that he completes household chores such as yard work, gardening,
and household cleaning and cooking. He indicates that he can complete these tasks with very few
barriers following his stroke. He self-reports no specific limitations or difficultly in completing
activities of daily living. The client self-reports that he takes his time while completing tasks and
does not hurry or rush himself.
Psychosocial history. The client presents to his exercise sessions with his wife. The
client lives at home with his wife. The client self-reports that during the last month he has been
feeling in good spirits. During the past month, the client self-reports that he has experienced a
moderate amount of stress and during the past year, these stress levels have had some effect on
his health. The client self-reported that he has strong social support from friends and family and
feels at ease when discussing concerning matters with these individuals. As part of the clients
health risk assessment, he self reported that he has experienced general anxiety following his
stroke. Client self-reports that his stroke affected the hypothalamus, which causes him to have
little control over his emotions. He self-reports becoming emotionally upset regarding activities
that he completed prior to his stroke, but now are challenging to complete. This includes no
longer being able to build houses and draw pictures.
Orthopedic limitations. The client presents with right-sided foot pain from his heel to
toe that has been constant since his stroke in 2008. The client self-reports that he experiences
more right-sided foot pain while standing in place compared to walking. The pain level at worst
is a 7/10 and at least a 3/10. On average, the client usually experiences a pain level of 4-5/10.
Client self-reports that walking, moving around or lying supine assists in relieving the pain. The
client also has left-sided upper and lower extremity weakness. While walking, the client has left
leg circumduction and decreased left knee and hip flexion during left leg swing. The client also
has decreased left arm swing while walking.
Risk factor classification. Based upon criteria set by ACSM guidelines and results from
the clients latest physical exam, the client would be classified as high risk, as he has had a
stroke. According to the ACSM guidelines, the client presents with the following cardiovascular
risk factors, which are presented in Table 7 (American College of Sports Medicine, 2014, p. 27).
According to ACSM, in the absence of a CVD risk factor, due to not being available, the CVD
risk factor should be counted as a risk factor except for prediabetes. No values related to fasting
blood glucose were provided by the client.
TABLE 7. Risk factor classification.
Risk Factor
Values
Age
57 years old
Obesity
BMI: 30.3 kg/m2; WC: 44 in
Sedentary Lifestyle Exercise 3 days per week (has not been consistent for 3 months)
Hypertension
122/80 mmHg
Taking blood pressure lowering medication
Dyslipidemia
TC: 176 mg/dL LDL: 90 mg/dL HDL: 43 mg/dL
Taking lipid lowering medication
Body mass index (BMI), kilograms per meter squared (kg/m2), waist circumference (WC), inches (in), millimeters of mercury (mmHg),
milligrams per deciliter (mg/dL)
In summary, the client had a stroke from the dissected artery that was surgically repaired
using a Greenfield filter. Results from the clients physical exam indicate that he currently meets
obesity criteria based on his BMI. He is also currently taking blood pressure and lipid lowering
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medications to assist in decreasing his risk of a future stroke. The client self-reports that his
stroke has had little impact in his ability to complete activities of daily living. After thorough
review of the clients medical history, it would be recommended that he begin participation in an
aerobic exercise program. As a component of an aerobic exercise program, the client will focus
on short and long-term goal setting and achievement of his goals. Participation in an aerobic
exercise program will allow the client to work toward his goals of increasing his aerobic capacity
allowing him to achieve his goals of increased walking speed and having little to low reliance on
his cane while walking long distances. As part of the program, the client will also be provided
with client education related to secondary prevention topics such as dietary recommendations
and emotional changes after stroke. The client will be able to attend 19 sessions of aerobic
exercise two times per week. Pre and post intervention testing will be performed in order to
evaluate client outcomes.
Client Interviewing
Exercise assessment. As part of the assessment for entry into the TAC program, the
client was able to describe areas of his health and wellness in which he would like to make
changes. The client self-reported that he would like to improve his aerobic capacity allowing him
to increase his walking speed. The client would also like to have a decreased reliance on his cane
and AFO. The client currently uses the AFO only for stability. He self-reports that he does not
use his cane while moving throughout his house; he only used his cane while walking outside
(uneven surfaces) and while walking long distances (over 25 meters). While walking long
distances, he will use the cane for balance and to rest. Client self-reports that since his stroke 6
years ago, he has been experiencing right sided foot pain. He self-reports that Pain level at worst
is 7/10 at least is 3/10, average pain level of 4-5/10. Lastly, the client would like to increase his
strength on his left side.
The client self-reports that for the last 5 years, he has been exercising at West Wood one
day per week, with a stroke personal trainer. Client self-reports that he will walk 1.5 miles on
track (~30 minutes) and then will perform strength-training exercises. Lower body exercises
include the leg press and calf raises with weight. Upper body exercises include rowing, pulldowns and push-outs. Client self-reports no muscular soreness or fatigue after completing
physical activities. Client indicated that hobbies include yard work, gardening, cleaning and
cooking. Client enjoys cutting down and removing trees from his property using his ATV. Client
self-reports that the stroke has not prevented him from completing ADLs or work in the yard.
Client motivation for physical activity stems from previous employment as a construction worker
where he performed physically demanding tasks on a daily basis. Client self-reported no barriers
to exercise. Although he experiences right-sided foot pain, he is willing to push through the pain.
Client is currently prescribed Gabapentin for foot pain, but little improvement in foot pain has
occurred.
Client self-reports that he would be willing to commit 60 minutes to a home-based
exercise program on non-TAC or West Wood days. The client is willing to perform exercise with
thera-band and the stairs in his house. The client self-reports that he currently perform leg
movement (Achilles tendon) exercises while sitting in his chair watching TV. Based on the
clients self-reported health and wellness changes, the following goals were developed: These
goals included, (1) improved overground endurance and strength to increase distance walked
without cane, (2) improvements in aerobic capacity to improve walking speed, (3) maintenance
of BMI an waist circumference throughout the program.
Dietary assessment. As part of the intake interview, the client was asked to discuss his
current dietary habits. The client self-reports that he prepares that majority of the meals. Meal
preparation allows the client to be artistic. Prior to his stroke, client indicated that he enjoyed
drawing and creating art. Since his stroke, this as been challenging and therefore the client has
taken on other hobbies, such as cooking in order to utilize his artistic abilities. Client states that
he consumes breakfast each morning. Breakfast usually consists of coffee, fruit and oatmeal. For
lunch, the client consumes a can of Campbells chunky soup on a daily basis. For dinner, the
client self-reports that he will many times prepare a casserole/meat with a fruit and vegetable.
Client also, enjoys making and consuming sweets and desserts. The client self-reported that he is
not always confident in his ability to determine portion sizes, stating that he likely consumes
more than what is recommended. In order to assist the client in living a healthier lifestyle, client
education will focus on portion sizes, fruit and vegetable consumption and sodium intake.
Psychosocial assessment. The client self-reported that he experiences a moderate amount
of stress, which has had some impact on his health. Client relies on family support and support
through friends to help him through challenging and emotional times. Client self-reported that he
believes that he obtains 7-9 hours of sleep each night. He indicates that he is a restless sleeper
and only on occasion does he not feel well rested.
The client completed a Stroke-Specific Quality of Life (SS-QOL) questionnaire preexercise intervention. Results from the questionnaire are shown in Appendix A. According to
Hsueh, Jeng, Lee, Sheu and Hsieh (2011), the impact of a stroke can be devastating, leaving a
person with residual effects on physical, social, emotional and cognitive functions. In a study by
Williams, Weinberger, Harris, Clark and Biller (1999), the use of the SS-QOL questionnaire was
found to be a reliable and valid measuring device to assess quality of life in stroke clients. The
development of a quality of life questionnaire specifically for stroke survivors was important as
previous health-related quality of life questionnaires did not address questions specific to the
needs of stroke survivors. Based on the results of the clients pre-intervention SS-QOL, the client
scored 70% (171/245) in his ability to complete tasks with no trouble/help needed. The client
scored lowest in the categories of social roles, thinking and upper-extremity function. For social
roles, the client self-reports that he goes out less and is unable to complete hobbies and
recreational activities that he completed prior to his stroke. For thinking, the client experiences
difficulty concentrating and remembering things. For upper-extremity function, the client
experiences the most difficultly in using his left arm, finding it challenging to type, button a shirt
and open a jar. Post-intervention, the SS-QOL questionnaire will be completed again. It is hoped
that the client will be able to increase his QOL score by 5%, as according to Studenski et al.
(2005), improvements in physical, social and role function have been noted after participation in
a stroke rehabilitation program.
Measured physical activity assessment. As part of the pre-intervention screening, the
client wore a Metria IH1 band for seven days (1/29/15-2/5/15). The band collected baseline data
related to total calories burned, duration of physical activity, and number of steps taken and sleep
duration. Data related to client baseline information is shown in Table 8. Prior to the
intervention, it was a daily goal for the client to obtain at least 2,000 steps per day, based off of
research regarding stroke clients and recommended number of daily steps. The client was able to
average 4,773 steps per day over the seven-day collection of data. Data collected from the Metria
IH1 device indicates that the client is able to tolerate vigorous intensity activity while in his
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home environment, suggesting that the client will be able to incorporate HIIT training into his
exercise program. According to the Metria IH1 device, the client averaged about 5:50 (hrs:mins)
of sleep each night. This is below the amount of time the client estimated he slept each night (7-9
hours). As the client self-reported that he was a restless sleeper and had a significant amount of
time lying down during the seven day period, it is likely that the client could believe that he
sleeps for 7 to 9 hours each night, but is actually only sleeping for 5:50 (hrs:min).
TABLE 8. Baseline physical activity assessment.
Measure
Total
Calories burned
27,905 kcal
Physical activity
23:29 hrs:mins
Moderate intensity-20:56 hrs:mins
Vigorous intensity-02:33 hrs:mins
Steps taken
33,414 steps
Sleep duration
39:03 hrs:mins
Time lying down: 59:26 hrs:mins
Kilocalorie (kcal), hours (hrs), minutes (mins)
Secondary prevention. Since the clients stroke 6 years ago, it will be important to
discuss secondary prevention with him. Based on ACSM guidelines, the client currently meets
risk factor criteria for obesity, hypertension and dyslipidemia. In regard to blood pressure
control, the AHA recommends that all clients who meet hypertension criteria be counseled
regarding the need for lifestyle modification, including physical activity participation, sodium
reduction, and emphasis on increased consumption of fresh fruit, vegetables, and low-fat dairy
products (Smith et al., 2011). Dietary changes will assist the client in maintaining healthy blood
pressure and cholesterol values. As part of the TAC program, it will be important for the client to
maintain his current BMI values. According to Towfighi and Ovbiagele (2009) although
mortality after stroke is highest in the first month, survivors have a higher mortality risk than
individuals in the general population for several years after the stroke. In a study by Towfighi
and Ovbiagele (2009) relationships between BMI and mortality for stroke survivors was
analyzed. Results from the study found that all-cause mortality increased per kg/m2 of higher
BMI and therefore higher BMI after stroke is associated with a greater risk of all-cause mortality.
Throughout the program, the client will receive education in recommended dietary habits and
physical activity participation, which will assist him in maintaining his current BMI and reducing
his risk of all-cause mortality.
In summary, as part of the clients intake interview prior to beginning participation in the
TAC program, the client identified goals that he would like to accomplish upon completion of
the TAC program. This includes (1) improved overground endurance and strength to increase
distance walked without cane, (2) improvements in aerobic capacity to improve walking speed,
(3) maintenance of BMI and waist circumference throughout the program and (4) improvement
in stroke-related QOL questionnaire score. As part of the program, the client will wear a Metria
IH1 activity-monitoring device every 30 days to monitor daily physical activity participation and
provide the client with education related to his activity and sedentary habits. Lastly, secondary
prevention will be discussed with the client. As the client meets hypertension, obesity and
dyslipidemia criteria, information regarding sodium reduction recommended fruit and vegetable
consumption and portion control will be discussed. Education regarding weight management and
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emotional changes after stroke along will also be discussed throughout the TAC program. Upon
completion of initial client interviewing and exercise stress testing, an exercise prescription will
be designed to specifically meet the clients needs and assist the client in meeting his goals.
Exercise Prescription Considerations
As part of participation in the TAC program, the client is hoping to increase his walking
speed and have little to no reliance on his cane while walking long distances. In order to measure
client goal progress it is important that he participate in pre intervention testing. Results from
these tests will provide the exercise physiologist with beneficial information regarding the
clients current fitness level. The client had a resting ECG performed prior to his participation in
a submaximal exercise stress test. The results from this ECG are displayed in Appendix B. The
clients ECG indicates sinus bradycardia. At the time of testing, the client had a ventricular rate
of 54 bpm indicating sinus bradycardia, as it is less than 60 bpm. The clients PR intervals meet
normal (120-200 ms) criteria at 190 ms. The clients QRS complex meets normal (80-120 ms)
criteria at 96 ms. The clients QT intervals meet normal (420 ms) criteria at 414 ms. The client
had normal T waves as they were upright in I, II, and V3-V6 and inverted in aVR. Normal ST
segments were indicated at baseline. When an exercise prescription is being created,
considerations regarding his ECG will occur when determining appropriate exercise duration and
intensity levels.
Exercise test impression. On February 3, 2015, the client participated in a submaximal
exercise test using a modified NuStep protocol. Stage specific results from his test are shown in
Table 9. According to Billnger, Tseng, Kluding (2008) assessment of peak oxygen consumption
using traditional modes (treadmill and cycle ergometer) of exercise can be difficult in individuals
with stroke due to balance deficits, gait impairments or decreased coordination. Multiple
research studies have been performed validating the Modified Total-Body Recumbent Stepper
Exercise Test (mTBRS-XT) for stroke survivors (Billnger et al., 2008; Mackay-Lyons et al.,
2013). When compared to cycle ergometer test results, similar peak VO2 values were obtained
for both testing modalities. Therefore, the mTBRS-XT is a safe, feasible and valid exercise test
protocol. Due to equipment availability at the testing facility, a modified version of the mTBRSXT was used to obtain data related to peak VO2.
The client completed a submaximal exercise test, which was terminated due to time
restraints with no symptoms. Total time exercised was 12:00 minutes:seconds with a peak
workload of 2.74 METs on the modified NuStep protocol. The client obtained an age predicted
heart rate max of 48% indicating average conditioning. A blunted peak heart rate (<70% age
predicted heart rate max) occurred with exercise and recovery. This is consistent with the client
being on a beta-blocker. After completion of stage 2, with each increase in workload, the clients
heart rate increased. A normal blood pressure response occurred with exercise and recovery. The
clients electrocardiogram showed sinus tachycardia with exercise. No ST segment changes
occurred that were suggestive of ischemia. The client was able to reach a RPE level of 13
(moderate intensity). A summary of the clients submaximal exercise test results are shown in
Table 10. Results from this test will assist in developing an exercise prescription based on the
METs achieved during each stage and the clients corresponding heart rate and RPE.
Table 9. Stage specific submaximal exercise test results.

Stage
Level
S/m
W
METs
1
1
80 s/m
16 w
1.60
2
2
80 s/m
17 w
1.61
3
3
80 s/m
20 w
1.72
4
4
80 s/m
28 w
2.00
5
5
80 s/m
36 w
2.30
6
6
80 s/m
49 w
2.74
HR
64 bpm
64 bpm
67 bpm
69 bpm
71 bpm
76 bpm
BP
122/80 mmHg
124/80 mmHg
124/80 mmHg
130/80 mmHg
130/78 mmHg
132/80 mmHg
RPE
11
12
12
12
13
13
Steps per min (s/m), watts (W), heart rate (HR), blood pressure (BP), rating of perceived exertion (RPE)
TABLE 10. Summary of submaximal exercise test results.

Measure
Value
Baseline ECG
Sinus bradycardia
Rhythm
Sinus tachycardia with exercise
ST segment changes
No ST segment changes suggestive of ischemia
Peak heart rate
76 bpm, 48% predicted
Peak blood pressure
132/80 mmHg was recorded during stage 6 of exercise
Test duration
12:00 (min:sec)
Peak METs
2.74 METs
Electrocardiogram (ECG), beats per minute (bpm), millimeters of mercury (mmHg), minutes (min), seconds (sec)
Pre-exercise intervention testing. On February 5, 2015, the client participated in a 6minute walk test, which was performed by the physical therapy students. Results from the
6MWT along with results from his submaximal exercise test will be used when creating his
exercise prescription to determine appropriate exercise duration and intensity levels. Results
from the clients 6MWT are shown in Table 11. Prior to beginning the test, the client selfreported an RPE of 6 (6-20 scale). For each lap completed, data related to the clients 5-meter
gait speed was collected. Post-testing, the client self-reported an RPE of 12 (moderate intensity).
For the clients 6MWT, he was able to walk 1,054 feet in 6 minutes. The client required minimal
assistance and used his cane as needed throughout the test. According to Biljleveld-Uitman, van
de Port and Kwakkel (2013), this value is slightly below average when compared to other stroke
survivors (1285 feet). On average, the client walked 0.87 meters per second (1.9 mph).
According to Biljleveld-Uitman et al. (2013), this value is slightly below average (1.0 m/sec).
Results from this test will be beneficial in determining an appropriate exercise prescription for
the client based on his current fitness level and gait speed. This will assist in selecting
appropriate exercise duration and intensity levels.
TABLE 11. 6MWT pre-intervention results.
Lap
5 m time (sec)
0
5.84
1
5.38
2
6.04
3
5.87
4
5.56
5
6.16
6
5.35
6 Minute Walk Test (6MWT), meter (m), seconds (sec)
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Exercise Prescription
Aerobic exercise prescription. Based on results from the clients submaximal exercise
test on the NuStep, he was able to obtain a peak workload of 2.74 METs. As the client would like
to be able to increase his walking speed and walk longer distances without using his cane, it will
be recommended that the client begin participation in an aerobic exercise program. As the client
was highly active prior to his stroke, the client is motivated to try many different types of aerobic
exercise along with challenging himself through each and every exercise session. The clients
aerobic exercise prescription is shown in Table 12. Detailed exercise session results including
hemodynamic responses and RPE ratings are shown in Appendix C. Based on the length of the
TAC program, the client was able to participate in 19 aerobic exercise sessions over the course of
an 11-week period.
According to Mackay-Lyons et al. (2013) it is recommended that stroke survivors
participate in an aerobic exercise program at least 3 days per week. On other days of the week,
individuals are encouraged to participate in lighter forms of physical activity. According to
AEROBICS, for optimal gains in physical cardiorespiratory fitness, lighter physical activity,
such as brisk walking, should be encouraged on days when an individual is not participating in
structured aerobic exercise sessions. Prior to the intervention, the client exercised one day per
week at West Wood. During this session, the client will complete 1.5 miles on the walking track,
20 to 30 minutes in duration, along with the completion of strength training exercises with a
stroke personal trainer. In addition, the client will walk to his mailbox on a daily basis, which is
estimated to be half a mile of walking. As part of the TAC program, the client was provided with
basic home-exercises to complete on non-structured exercise days. The home-based exercise
program is shown in Appendix D and discussed in more detail in the home exercise prescription
section.
According to Billinger et al. (2014), stroke remains the leading cause of long-term
disability in the United States. As a result of a stroke, survivors are often deconditioned and
predisposed to a sedentary lifestyle that adversely impacts performance of activities of daily
living and may contribute to a heightened risk for recurrent stroke and other CVDs (Billinger et
el., 2014; Mackay-Lyons et al., 2013). Physical activity and exercise have been found to
positively influence multiple physical and psychosocial domains after a stroke (Billinger et al.,
2014). There is currently strong evidence linking exercise to improved cardiovascular fitness,
improved walking ability and upper-extremity muscle strength after a stroke. Therefore, there is
growing evidence to support the idea that physical activity has substantial health benefits in
improving cardiorespiratory and musculoskeletal fitness in individuals with stroke.
Recommendations provided in AEROBICS suggest that post stroke individuals should
participate in exercise at a moderate intensity level (45-60% HHR, RPE 11-13). According to
Mackay-Lyons et al. (2013), intensity of exercise is of foremost concern in exercise prescription
as it dictates the level of metabolic stress to which a participant is exposed and is the most
critical factor in ensuring an adequate dosage to elicit a training effect. In a study performed by
Rimmer, Rauworth, Wang, Nicola and Hill (2009), three different training regimens were study
to determine their impact on cardiorespiratory fitness and coronary risk reduction in stroke
survivors. Participants were placed in a constant duration group that progressed intensity 40 to
69% HHR, another group had a constant low intensity with increasing duration and the last
group participated in therapeutic exercises. Over the course of the 14-week intervention, results
of the study indicate that those in the increasing intensity group obtained more favorable effects
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on systolic and diastolic blood pressure along with total cholesterol. Results of this study
coincide with recommendations by AEROBICS in that higher intensity exercise elicits greater
improvements in cardiopulmonary fitness and greater reductions in vascular risk factors
(Mackay-Lyons et al., 2013).
Based on results from the study by Rimmer et al. (2009), it was found that increases in
intensity over the intervention period led to greater outcomes. In a similar case study by Lentz,
Mattlage, Ashenden, Rippee and Billinger (2012), a 58-year old woman had suffered an ischemic
stroke. As part of her rehabilitation process, she participated in 8-weeks of supervised exercise
using the NuStep. The intervention consisted of 3 sessions per week. During the first 4 weeks,
the participant exercised at 50-59% HHR and during the last 4 weeks, the participant exercised at
60-69% HHR. Exercise duration began at 20 minutes and was gradually increased to 30 minutes
of continuous exercise. According to Mackay-Lyons et al. (2013), aerobic exercise sessions
should be greater than 20 minutes in duration and include a 3-5 minute warm-up and cool-down.
Following the intervention, the participant showed improvements in cardiovascular measures
including: resting blood pressure, resting heart rate, VO2peak and maximum distance walked for
the 6MWT. Outcomes from this study will be applied to the current client. As the client is
currently prescribed a beta-blocker, blunted heart rate responses and blood pressure values are
observed with exercise. Therefore, RPE ratings are utilized in order to determine client tolerance
throughout a session. The client will complete continuous exercise on the NuStep, recumbent
bike and UBE. Upon intervention completion, it is a client goal to reach 30 minutes of
continuous exercise at an RPE of 12 to 13. The client began the exercise session by completing
two 10-minute bouts of continuous exercise on the NuStep. During each exercise session, the
client has been able to increase the duration and intensity of his continuous exercise sessions.
Upon completion of the intervention, the client will complete 30 minutes of continuous exercise
on the NuStep.
As research has found high intensity aerobic exercise testing to be beneficial for stroke
survivors, similar methods will be applied throughout the clients exercise program. According to
Boyne et al. (2014), HIIT training is a strategy that maximizes exercise intensity by using bursts
of concentrated effort alternated with recovery periods. In the study by Boyne et al. (2014),
within-session exercise responses were compared between three different HIIT training protocols
for individuals with chronic stroke. HIIT training was performed on the treadmill and included
30 second, 60 second and 120 second bursts of repeated activity. Each of these training sessions
were performed by each participant at least 1 week apart. Results of the study found that a
combination of 30 second and 60 second bursts of exercise led to optimal aerobic intensity,
treadmill speed and stepping repetition, leading to potentially greater improvements in aerobic
capacity and gait outcomes. Based on the current study, it was determined that the client would
participate in 1:1 and 2:1 HIIT training on the NuStep, UBE and recumbent bike. As the client is
currently taking a beta blocker, which causes a blunted heart rate and blood pressure response to
exercise, increases in intensity level will occur based on client RPE ratings. When the client does
not self-report an RPE of 13 during the high intensity interval, increase in workload (level and
cadence) will occur.
As part of the aerobic exercise prescription, gait training on the treadmill will also be
incorporated into exercise sessions. According to Eng & Tang (2007), impairments resulting
from stroke lead to persistent difficulties with walking. Due to this, improved walking ability is
one of the highest priorities for individuals living with a stroke. Gait training strategies for stroke
patients that involve the use of body weight supported treadmills have been found to be
12
beneficial (Visintin, Barbeau, Korner-Bitensky & Mayo, 1998). In a study performed by Visintin
et al. (1998), participants were assigned to one of two intervention groups. Half of the subjects
began walking at 40% BWS and gradually decreased throughout the intervention. Other
participants walked on the treadmill bearing full weight on their lower extremities (no-BWS).
Over the 6-week treatment intervention, basis of functional balance, motor recovery, overground
walking speed and overground walking endurance were assessed. Results of the study found that
in the BWS group, 79% of participants were using no weight support at the end of the
intervention. These individuals also had significant improvements in overground walking
endurance when compared to the no-BWS group. Based on this study, the client will begin at
15% BWS at a moderate pace. As the pace is increased, BWS will be increased. BWS will
gradually decrease, as the clients gait improves and his ability to walk at a faster speed occurs.
Home exercise prescription. The client was provided with an exercise behavioral
contract and home-based exercise program to participate in between March 7th through the 15th.
As part of the behavioral contract, the client agreed to walk at least 30 minutes each day. Upon
completion of exercise the client was asked to record the duration and a corresponding RPE
value. The client was also provided with 4 strength-training exercises to complete every other
day. The client was asked to record the duration and intensity of the exercises, assigning an RPE
value. The clients self-reported exercise log along with home-based strength training exercises
are provided in Appendix D. The client was unable to meet his exercise goals over the time
period. The client was only able to walk at least 30 minutes three days over the time period. The
client self-reported an average RPE of 12. The client performed resistance training 4 days over
the time period. The client self-reported an average RPE of 12 during the exercises.
Following review of the clients participation during the behavioral contract period and
based on client self-report, the client was provided with additional strength-training exercises,
along with progression of previously given exercises. It was also recommended that the client
obtain at least 4,000 steps, 4 days per week. This goal was met based on results from his Metria
IH1 activity-monitoring patch. It was also recommended that the client participate in one
moderate or vigorous intensity activity for at least 30 minutes per day. Based on client selfreport, the client was able to meet this goal due to participation in yard work and cutting and
moving trees and branches around yard for multiple days. Based on intervention progress, the
client was provided with a final home exercise prescription, which is provided in Appendix D. In
order to maintain the progress the client has made, it will be important for the client to follow the
exercise program and progress exercises as needed to further challenge himself. Aerobic training
progressions are recommended for steps per day. Additional resistance-training exercises are
provided along with a goal to participate in at least one moderate intensity physical activity each
day and at least two vigorous intensity activities each week.
Outcomes
The majority of individuals recovering from a stroke are left with residual disability or
activity limitation, which leads to a lower quality of life. According to Blasin et al. (2014), many
of these limitations are associated with reduced aerobic capacity, which is common among
people living with the effects of stroke. In addition, for individuals recovering from a stroke,
there is a high-energy cost of performing everyday activities. The combination of elevated
energy demands and low aerobic capacity leads to people with stroke working close to their
physiological limits in order to accomplish basic activities of daily living (Blasin et al., 2014)
13
TABLE 12. Client exercise prescription.

1
5
6
Day
Tues (2/10): NuStep
Warm-up: 5 min, level 2, 60 s/m
10 min interval, level 4, 80 s/m, RPE 12-13
3 min recovery, level 3 60 s/m, RPE 10-11
10 min interval, level 4, 80 s/m, RPE 12, to
tolerance
Tues (2/17): NuStep
2 min recovery, level 3, 60 s/m, RPE 10-11
5 min interval, level 5, 80 s/m, RPE 12 to
tolerance
Tues (2/24): NuStep
12 min HIIT interval, (6 x 2 min)
o 1 min, level 6, 100 s/m, RPE 12
o 1 min, level 4, 70 s/m, RPE 11-12
3 min recovery, level 4, 60 s/m, RPE 10
10 min interval, level 5, 80 s/m, RPE 12 to
tolerance
Tues (3/3): NuStep
Client did not attend session
Day
Thur (2/12): Treadmill
Warm-up: 4:30 min, 15% BWS, 1.0 mph
5:30 min interval, 15% BWS, 1.2 mph RPE 1213
2:30 min rec, 15% BWS, 0.7 mph, RPE 11
Tues (3/10) Spring break-no session

Tues (3/17): NuStep
o 1 min, level 6-7, 100 s/m, RPE 12
o 1 min, level 5, 70 s/m, RPE 11-12
8 min interval, level 5, 70 s/m, to tolerance
Tues (3/24): NuStep
Warm-up: 3 min, level 2, 70 s/m (arms only)
20 min interval, level 6, 80 s/m, RPE 12
Thur (3/12) Spring break-no session

Thur (3/19): TM
Treadmill
Warm-up: 3 min, 10% BWS, 1.0 mph
15 min interval, 10% BWS, 1.2 mph, RPE 12
14
Thur (2/19): UBE

UBE
Warm-up: 3 min, level 1, 60 rev/min
10 min HIIT (1:1), RPE: 12-13
o Workload 60, 50 rev/min: Workload 70, 60
rev/min
Thur (2/26): RB & UBE
Recumbent bike
5 min, level 3, 60 rev/min, RPE 12-13
UBE
10 min, workload 60, 60-65 rev/min, RPE: 12
Thur (3/5): NuStep
18 min interval, level 5, 80 s/m, RPE 12
1:30 min recovery, level 4 60 s/m, RPE 10
4:30 min interval, level 5, 80 s/m, RPE 12 to
tolerance
Thur (3/26): RB & UBE

Recumbent bike
10 min interval, level 3, 60 rev/min, RPE 12
UBE
12 min HIIT (1:1), RPE: 12
Level 70-85, 60-78 rev/min: Level 60, 50
rev/min
Day
8
Tues (3/31): NuStep

25 min pyramid training
o 4 min, level 5, 90 s/m
o 2 min, level 6, 90 s/m, RPE 12.5
o 1 min level 7, 100 s/m, RPE 12.5
9
Tues (4/7): RB & UBE
Recumbent bike
12 min interval, level 3, 60 rev/min, RPE
12.5
UBE
14 min HIIT (1:1), RPE: 12.5
o Level 120, 80 rev/min: Level 100, 70
10
rev/min
Tues (4/14): Treadmill
Treadmill
Warm-up: 3 min, 5% BWS, 1.0 mph
18 min interval, 5-10% BWS, 1.5 mph, RPE
13
11
Tues (4/21): 6MWT
Client did not attend due to illness
Day
Thur (4/2): 6MWT & RB
6MWT
1,122 ft
1.05 meters per second
Recumbent bike
7 min interval, level 3, 60 rev/min, RPE 12.5
Thur (4/9): NuStep

Warm-up: 2 min, level 2, 60 s/m (arms only)
Thur (4/16): NuStep

*Interval recovery time increased to
3 minutes during final 2 cycles
The client displayed signs of dehydration and
was therefore provided with education
regarding proper hydration during the
following session. The handout that was
provided is shown in Appendix E.
Thur (4/23): 6MWT
6MWT
1,210 ft
1.12 meters per second
Recent research has shown that participation in aerobic training can lead to improved
cardiovascular function, reduced neurological impairment and enhanced lower extremity
function. Higher levels of fitness have also been found to be associated with reduced risk for allcause and cardiovascular-related mortality (Tang & Eng, 2014). Also, engagement in regular
physical activity to improve fitness is an important strategy for reducing sedentary behaviors that
may otherwise compound post-stroke limitations (Tang & Eng, 2014).
Short-term goals. Prior to beginning the intervention 11 weeks ago, the client outlined
goals that he would like to achieve upon completion of the TAC program. These goals included,
(1) improved overground endurance and strength to increase distance walked without cane, (2)
improvements in aerobic capacity to improve walking speed, (3) maintenance of BMI and waist
15
circumference throughout the program and (4) improvement in stroke-related QOL questionnaire
score. Each of these goals were developed for the client in hopes that he can improve his aerobic
capacity and walking speed when performing tasks at home, in the yard and in the community.
Specific goals are outlined in Table 13. The client would like to be able to participate in these
types of activities without experiencing high levels of fatigue. It will be the clients goal to make
improvements in each of these areas in the next 11 weeks.
TABLE 13. Goal setting.
Goal
Improved overground endurance and strength
to increase distance walked without cane
Calories burned
Post-Intervention Goal
Walk 1.6 mph with 0% BWS on TM for 15
minutes
Improved aerobic capacity to improve

walking speed
1200 ft; gait speed 1.28 m/sec
Maintenance of pre-intervention BMI and

waist circumference
Maintain BMI and waist circumference
Improvement in stroke-related QOL

questionnaire score
Overall score improvement of 5%
Measured physical activity assessment. As part of the intervention, the client wore a
Metria IH1 physical activity-monitoring band every 30 days for 7 days in duration. The purpose
of the physical activity-monitoring band was to measure physical activity participation outside of
the TAC program to assist in client goal refinement along with home-based exercise
recommendations. The band collected data related to total calories burned, duration of physical
activity, number of steps taken and sleep duration. Data related to client activity-monitoring band
use throughout the intervention is shown in Table 14. At baseline, the client walked on average
4,700 steps per day. While a decrease in steps per day occurred during the second monitoring
period, the client was able to significantly increase his average steps per day during the final
activity monitoring patch period to 6,900 steps per day. Throughout the intervention, the amount
of time the client spent participating in vigorous activity significantly decreased. As the client
can tolerate vigorous exercise, as part of the clients final exercise prescription, it is
recommended that he participate in at least 15 minutes of vigorous activity 2 days per week. The
client continued to average around 6:00 (hrs:mins) of sleep each night throughout the
intervention. This is below the amount of time the client estimated he slept each night (7-9
hours).
Post-intervention testing. On April 23, 2015, the client participated in a 6-minute walk
test. Results from the 6MWT will be used to determine if improvements in aerobic capacity have
occurred due to participation in the TAC program. Prior to the intervention, the client walked
1054 ft in 6 minutes and had a gait speed of 0.87 meters per second (1.9 mph). Results from the
clients 6MWT are shown in Table 15. Prior to beginning the 6MWT, the client had a resting
heart rate of 56 bpm and a blood pressure of 114/80 mmHg. For each lap completed, data related
to the clients 5-meter gait speed was collected. Post-testing, the client had a peak heart rate of 98
bpm and a peak blood pressure of 140/82 mmHg. For the clients 6MWT, he was able to walk
16
TABLE 14. Monthly physical activity assessment.

Measure
Total
Baseline Measure (1/29/15-2/5/15)
Calories burned
27,905 kcal
Physical activity
23:29 hrs:mins
Moderate intensity: 20:56 hrs:mins
Vigorous intensity: 02:33 hrs:mins
Steps taken
33,414 steps
Sleep duration
39:03 hrs:mins
Measure 2 (2/26/15-3/5/15)
Calories burned
25,280 kcal
Physical activity
17:57 hrs:mins
Steps taken
25,062 steps
Sleep duration
52:52 hrs:mins
Measure 3 (3/26/15-3/31/15)
**Only recorded 5.5 days
Calories burned
19,280 kcal
Physical activity
17:35 hrs:mins
Steps taken
34,226
steps
Sleep duration
35:15 hrs:mins
Final Measure (4/14/15-4/21/15)
Calories burned
25,731 kcal
Physical activity
23:48 hrs:mins
Steps taken
Sleep duration
48,708 steps
41:48 hrs:mins
1,210 feet in 6 minutes. The client required minimal assistance and carried his cane throughout
the test. According to Biljleveld-Uitman et al. (2013), this value is slightly below average when
compared to other stroke survivors (1285 feet). On average, the client walked 1.12 meters per
second (2.5 mph). According to Biljleveld-Uitman et al. (2013), this value is slightly below
average (1.0 m/sec).
17
Monofilament testing. As the client self-reports right foot pain from the heel to the toe,
monofilament testing was performed to rule out the presence of neuropathy. The client scored a
6/6 on his right foot, correctly identifying the area and time when his foot was tested. The client
scored a 3/6 on his left foot. The client was unable to identify when his heel was touched. The
client also incorrectly identified the area when testing was performed on the lateral midfoot and
medial forefoot. The client wears an AFO on his left foot and self-reports that he feels phantom
sensations occasionally on his left foot. The client will present the results to his physician during
a future appointment.
TABLE 15. 6MWT pre-intervention results.
Lap
5 m time (sec)
0
4.25
1
4.60
2
4.50
3
4.41
4
4.85
5
4.20
6
4.60
7
4.30
6 Minute Walk Test (6MWT), meter (m), seconds (sec)
Goal reassessment. Over the course of the last 11 weeks, the client has been able to
increase his functional capacity and reach his intervention goals as a result of participation in the
program. A detailed discussion regarding the progression of each of the clients goals is provided
below. An executive summary regarding pre, mid and post-intervention measurements can be
found in Appendix F. The client was provided with intervention results, which are shown in
Appendix G.
6MWT. It was a client goal for improved aerobic capacity to improve walking speed. It
was a goal for the client to walk at least 1200 ft in 6 minutes with a gait speed of 1.28 m/sec.
Goal progressions were based on the Duncan et al. (2003) study, where after a 3 month
participation in a therapeutic intervention for stroke survivors which included 90 minute
sessions, walking distance improved by 15-25% based on pre-intervention values. The client was
able to reach his post-intervention goal of walking 1200 ft in 6 minutes. According to Duncan et
al. (2003), the clients value is slightly below average (1285 ft) when compared to other stroke
survivors. On average, the client walked 1.12 meters per second (2.5 mph). Compared to other
stroke survivors, this speed was slightly above average (1.0 m/sec). Over the course of the
intervention, the client was able to improve his distance walked by 156 ft. The client improved
by 13%, which is similar to the results in the Duncan et al. (2003) study (15-25% improvement).
Results indicate that the client was able to increase his aerobic capacity along with walking
speed.
Overground walking. It was a client goal for improved overground endurance and
strength to increase distance walked without using a cane. It was a client goal, which was
modified at mid-intervention to walk at 1.6 mph with 0% BWS for 15 continuous minutes. Goal
progressions were based on the Visintin et al. (1998) study, after a 6-week intervention in which
treadmill speed and duration increased, BWS decreased in 79% of participants. Post-intervention
participants trained at 0% BWS with an average walking duration of 14 minutes. Significant
improvement in overground endurance was indicated. After the clients post-intervention
18
treadmill speed was adjusted, over the course of the intervention, the client was able to slightly
increase his speed, while decreasing his percent BWS. In addition, the client was able to
significantly increase his walking duration. According to Visintin et al. (1998) study, as treadmill
speed and duration increase, %BWS should decrease. In the study, average walking duration was
14 minutes. The client was able to tolerate 18 continuous minutes, which allowed him to reach
his treadmill duration goal. The client was unable to reach the goal of walking 1.6 mph with 0%
BWS as he walked at 1.5 mph with 5-10% BWS. Results indicated that the client was able to
improve his overground endurance and strength, which allowed him to significantly increase in
walking distance without a cane.
BMI. It was a client goal to maintain his BMI and waist circumference throughout the
intervention. For the client, it was a goal, which was modified at mid-intervention (due to an
inaccurate measurement at pre-intervention) to maintain a BMI of 32.8 kg/m2 with a waist
circumference of 44 in. Goal development was based on Towfighi and Ovbiagele (2009) study in
which all cause mortality increased per kg/m2 of higher BMI. It was found that education related
to dietary habits and physical activity participation assisted in maintaining healthy BMI. As preintervention weight measurements were inaccurate, values taken at mid-intervention were used
for goal development. Based on mid-intervention testing to post-intervention testing, the clients
weight decreased by 5 pounds. His waist circumference remained consistent throughout the
intervention. As his waist circumference remained consistent, it is likely that a pre-intervention
weight was inaccurately recorded. According to a study performed by Towfighi and Ovbiagele
(2009), all cause mortality increased per kg/m2 of higher BMI. Therefore, it will be important
that the clients BMI remain consistent along with his waist circumference.
Stroke-related QOL. It was a client goal to improve his stroke related QOL questionnaire
score by 5% from pre to post-intervention. Goal development was based on Studenski et al.
(2005) study, in which participation in a stroke rehabilitation program has lead to improvements
in physical, social and role function. During pre-intervention testing, the client completed a
stroke-related QOL questionnaire. The client scored a 70%, with his lowest categories being in
social roles, thinking and UE function. During post-intervention testing, the client completed the
stroke-related QOL survey again, scoring a 71%. Lowest categories were in working, thinking
and personality. Over the course of the intervention, the client was able to obtain a 1%
improvement in his stroke-related QOL score. Significant Improvements were made in
categories of UE function and social roles. Thinking continues to be an area of difficulty for the
client. The client was unable to reach his goal of a 5% improvement, but through continued
physical activity participation, it is hoped that the client will continue to improve his QOL.
In summary, prior to beginning the TAC program, the client outlined goals that he would
like to accomplish throughout the intervention. Goals included, (1) improved overground
endurance and strength to increase distance walked without cane, (2) improvements in aerobic
capacity to improve walking speed, (3) maintenance of BMI and waist circumference throughout
the program and (4) improvement in stroke-related QOL questionnaire score. The client was able
to make progress toward each of these goals, improving his aerobic capacity, walking speed,
BMI and QOL score. These improvements have assisted the client in completing tasks for a
longer duration, which were previously fatiguing. These goals were accomplished through
participation in a structured exercise program that included home-based exercise participation. It
will be important for the client to maintain health and wellness improvements throughout the
summer, with continued physical activity participation.
19
Patient Education
According to the American Heart Association, intervention strategies should be
recommended to clients regarding modifiable cardiovascular disease risk factors. For the client,
these modifiable CVD risk factors include topics related to: fruit and vegetable consumption,
limiting salt intake, portion control and psychosocial considerations after stroke. Each of these
modifiable CVD risk factors will be discussed and suggestions will be made to the client in order
to assist in improving his overall quality of life.
Fruit and vegetable consumption. As the client currently meets obesity, hypertension
and dyslipidemia criteria according to ACSM guidelines, it would be important to discuss dietary
habits with the client. According to AACVPR (2013), it will also be important for the client to
monitor his dietary intake; monitoring the number of fruits and vegetables he is consuming each
day. It is recommended that at every meal, the client make at least half of his plate fruits and
vegetables (AACVPR, 2013). According to He, Nowson and MacGregor (2006), an increase in
the consumption of fruits and vegetables has been advocated for the prevention of stroke, other
cardiovascular diseases and some cancers. In a systematic review performed by He et al. (2006),
it was found that individuals who had less than three fruits and vegetables servings per day had
an 11% reduction in stroke compared to those who had more than 5 servings per day, having a
reduction of 26%. Therefore, these findings provide strong support for the recommendations
encouraging the public to consume more than five servings of fruits and vegetables each day.
The study also found that the protective effects of fruit and vegetables on stroke have a strong
biological basis. Fruits and vegetables are a rich source of potassium, folate, fibre and
antioxidants. Randomized control trials have shown that increasing fruit and vegetable
consumption, with a subsequent rise in 24-hour urinary potassium excretion, can ultimately lead
to reductions in blood pressure.
The client was provided with a handout, which discussed the importance and benefits of
consuming the recommended number of fruits and vegetables each day. The handout is shown in
Appendix H. This handout provided information related to the benefits of having at least 5
servings of vegetables and four servings of fruit each day. It was discussed that fruits and
vegetables contain antioxidants, potassium, fibre and folate. Each of these nutrients can assist in
reducing blood vessel damage, lowering ones blood pressure, lowering ones cholesterol and
reducing ones risk of future stroke. The handout also discussed tips for adding more vegetables
to ones diet. This included choosing vegetables rich in color, making a garden salad grow with
color, information for eating out and to savor the flavor of seasonal vegetables. In addition to this
handout, the client was provided with a four-day checklist to monitor the number of servings of
fruits and vegetables each day. Results from the checklist, which are shown in Appendix H,
indicate that the client improved his daily fruit intake, but needs continued improvement in daily
vegetable consumption. Continued education regarding the importance of vegetable consumption
will be incorporated into future client education.
Salt intake. As the client currently meets obesity and hypertension criteria according to
ACSM guidelines, it would be important to discuss dietary salt intake with the client. During the
past century, the evidence for the risks imposed on human health by excess salt consumption has
become compelling, as there is now evidence of a causal relation between habitual dietary salt
intake and hypertension (Strazzullo, DElia, Kandala & Cappuccio, 2009). According to
20
Strazzullo et al. (2009), habitual salt intake in most Western countries is close to 10 g a day. In a
meta-analysis performed by the researchers, it was determined that a 5 g per day reduction in salt
intake could lower an individuals risk of a stroke by 23% and reduce their risk of cardiovascular
disease development by 17%. In a similar study by Bibbins-Domingo et al. (2010), a reduction in
the consumption of dietary salt has been found to decrease an individuals risk of stroke and
coronary heart disease. According to the study, it was found that by reducing salt intake by 3
gm/day (1200 mg/day) resulted in 60,000-120,000 fewer cases of coronary heart disease and
32,000-66,000 fewer strokes. According to the AACVPR (2013), dietary sodium reduction,
which consists of consuming no more than 2.4 grams of sodium each day, has been found to
lower systolic blood pressure by 2-8 mmHg. Therefore, these studies and recommendations
provide strong support for the reduced salt intake recommendations encouraging individuals to
monitor daily salt intake.
The client was provided with a handout, which discussed the importance and benefits of
consuming the recommended amount of salt each day. The handout is shown in Appendix H. The
handout provided information regarding the importance of consuming salt, as our bodies need it
to function each day, but information was also provided regarding the risks associated with
consuming too much salt. Risks associated with high levels of salt intake were discussed as it can
increase an individuals risk of heart attack, stroke and other cardiovascular conditions. It was
then discussed that the American Heart Association recommends consuming no more than 1,500
mg of salt per day, which is equivalent to about 2/3 teaspoon of salt. The handout also discussed
tips for reducing sodium consumption. These included thinking fresh, or eating less highly
processed foods which likely contain high amounts of salt, adjusting ones tastes buds, gradually
cutting back on salt, consuming high levels of fruits and vegetables, which are naturally low in
sodium and choosing dairy and protein foods that are lower in sodium. In addition to this
handout, the client was provided with a short quiz regarding salt intake. This quiz provided an
opportunity to determine client understanding upon completion of the client education session.
Results from the quiz are shown in Appendix H. Based on the results, the client correctly
answered each question related to recommended daily salt intake. Therefore, the educational
handout was effective in providing the client with recommendations for salt consumption along
with providing suggestions to limit daily intake.
Portion control. As the client currently meets obesity, hypertension and dyslipidemia
criteria according to ACSM guidelines, it would be important to discuss dietary portion control
with the client. As part of these dietary recommendations, it is recommended that an individual
consume a large amount of fruits and vegetables, a moderate amount of proteins such as fish and
a low-amount of dairy products (Sofi, Abbate, Gensini & Casini, 2010). According to Estruch et
al. (2013), following these dietary recommendations could provide protection against future
development of stroke and heart attack. It was reported by Estruch et al. (2013), that by
following a diet high in fruit and vegetable intake, a moderate amount of grains and protein and a
low amount of dairy can assist in reducing an individuals risk factors for future health
complications by 30%. In addition, it was reported by Toledo et al. (2013), following a diet with
recommended portion sizes can assist in lowering an individuals blood pressure. Therefore,
these studies and recommendations provide strong support for the following recommended
portion control guidelines to assist in decreasing the presence of obesity, hypertension and
dyslipidemia.
The client was provided with a handout, which discussed the importance of building a
healthy plate during each meal. The handout is shown in Appendix H. The handout provided
21
information regarding the importance of considering the foods that are placed on ones plate.
Foods such as vegetables, fruits, whole-grains, low-fat dairy products and lean protein choices
contain essential nutrients one needs on a daily basis, without too many calories. It is also
recommended to eat some foods less often such as foods high in solid fat, added sugar and salt.
By reducing ones consumption of these foods, decreases in body weight, blood pressure values
and cholesterol values could occur. Also, preparing meals at home allows for better portion
control and knowledge regarding the preparation of the food. As part of the handout, tips for
building a healthy plate were included. These included making half of ones plate fruits and
vegetables, switching to skim or 1% milk, making at least half of ones grains whole and varying
protein choices. In addition to this handout, the client was provided with four black plates to
shade in how his meal portions were for four dinners. Results from the checklist, which are
shown in Appendix H, indicate that the client needs continued improvement with consistently
eating recommended levels of fruits and vegetables on a daily basis. In addition, protein choices
should not include additional fat such as breading.
Psychosocial considerations after stroke. As the client currently self-reported in his
health risk assessment that he sometimes suffers from anxiety along with the client becoming
emotional during the intake interview, it would be important to discuss psychosocial
considerations after a stroke with the client. According to Raju, Sarma and Pandian (2010), not
only does disability caused by stroke have massive impact on an individuals physical
functioning, but also equally devastating are the social consequences associated with stroke.
Stroke survivors many times are greatly challenged by post-stroke depression or depression
related symptoms, which can lengthen the rehabilitation and recovery time considerably (Raju et
al. 2010). According to the AACVPR (2013), signs and symptoms related to depression include,
an ongoing struggle to control mood, preoccupation with fears, loss of ability to enjoy previously
pleasurable activities and irritability or frustration. The AACVPR (2013) also provides signs and
symptoms of anxiety, which include, weakness, irritability, trembling or shaking or feelings that
things are not real. Based on these signs and symptoms for both depression and anxiety,
according to Raju et al. (2010), it is estimated that quality of life can decrease by as much as
40% after a stroke. Therefore, due to this drastic decrease in quality of life that can occur after a
stroke, it is recommended that stroke survivors be provided with education related to
psychosocial changes that are common after a stroke.
The client was provided with a handout, which discussed psychosocial and emotional
changes after a stroke. The handout is shown in Appendix H. As part of this handout, it was
discussed how emotions are difficult to control, but can be especially challenging to control after
a stroke due to the result of actual injury and chemical changes that occurred within the brain.
Throughout the handout, it is recommended that individuals acknowledge their feelings, which
can greatly assist in dealing with ones emotions. It is also discussed that after a stroke, it may be
challenging to control your emotions as one may experience rapid mood changes or crying or
laughing that does not match ones mood. The handout also provided tips to cope with changing
emotions. These included, letting yourself cope without feeling guilty about your emotions,
participation in a stroke group to discuss your feelings, participation in exercise and providing
yourself with credit for the progress that you have made. In addition to this handout, the client
was provided with a short quiz regarding depressive symptoms. This quiz provided an
opportunity to determine specific emotions that client might be experiencing throughout their
daily life. Results from the quiz are shown in Appendix H. Based on the results, the client has
experienced minimal depressive symptoms over the last 2 weeks. Over the last 2 weeks, the
22
client indicated that on several days he has felt down and had trouble falling asleep. Upon
discussion of these results, the client self-reported that he feels happiest when performing
activities that he enjoys such as exercise and manual labor in the yard. Although these activities
may be modified when compared to how he completed them prior to his stroke, the client still
self-reports that they bring happiness and excitement to his day.
23
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26
Appendix A
Stroke-Specific Quality of Life Scale
Domain
Self-care
Item
Preparing food
Eating
Getting dressed
Taking a bath or shower
Using the toilet
Vision
Seeing the TV
Trouble reaching for things due to poor eyesight
Seeing things off to one side
Language
Getting stuck, stuttering, stammering

Speaking clearly on the phone
Other people having trouble understanding what you said
Finding the word you wanted to say
Repeating yourself so others could understand you
Mobility
Walking
Losing your balance
Climbing stairs
Needing to stop and rest when walking or using a wheelchair
Standing
Getting out of a chair
Work
Doing daily work around the house

Finishing jobs
Doing the work you used to do
UB Fx
Writing or typing
Putting on socks
Buttoning buttons
Zipping a zipper
Opening a jar
Thinking
Concentration
Remembering things
Writing things down to remember them
Personality
Irritable
Inpatient with others
Personality change
Mood
Discouraged about future

Interested in other people or activities
Withdrawn from other people
Confidence in myself
Interested in food
27
Pre-Score
4
4
5
5
5
92%
5
4
2
73%
5
5
5
4
3
88%
4
4
4
3
3
5
76%
3
4
2
60%
1
5
2
2
2
48%
2
3
3
53%
3
3
3
60%
3
4
4
4
5
80%
Post-Score
5
3
4
4
4
80%
4
3
2
60%
4
4
4
4
4
80%
4
4
4
3
3
3
70%
3
3
2
53%
5
4
3
2
3
68%
2
3
3
53%
3
3
3
60%
3
5
3
4
2
68%
Stroke-Specific Quality of Life ScaleContinued

Family Role
Joining in activities just for fun with my family

Feeling like a burden to my family
Physical condition affecting family life
Social Role
Going out
Doing hobbies and recreation
See friends
Sex life
Physical condition affecting social life
Energy
Tired
Stop and rest often during the day
Too tired to do what I wanted to do
28
5
3
4
80%
2
2
2
2
2
40%
4
4
4
80%
5
3
4
80%
4
5
5
4
3
84%
4
4
4
80%
Appendix B
Resting ECG
Appendix C
Exercise Sessions
Exercise Session 1 (2/12): NuStep
Pre-exercise HR: 62 bpm
Pre-exercise BP: 116/80 mmHg
Stage
Time
Warm-up
5:00
Leve
l
2
Watts
Step/min
12 w
Interval
10:00
28 w
80 s/m
Recovery
3:00
12 w
60 s/m
Interval
10:00
28 w
80 s/m
Post-exercise HR: 63 bpm

Post-exercise BP: 134/80 mmHg
BP
HR
RPE
60 s/m
118/80 mmHg
68 bpm
11
Peak-ex BP:
126/80 mmHg
5:0070 bpm
7:3074 bpm
68 bpm
5:0012
7:3013
11
Peak-ex BP:
128/80 mmHg
5:0073 bpm
7:3074 bpm
9:0073 bpm
5:0013
7:3012
9:0012
Exercise Session 2 (2/12): Treadmill

Stage
Time
Warm-up
4:30
Interval
5:30
Recovery
2:30
MP
H
1.0
mph
Watts
%BWS
8w
15%
1.2
mph
9w
15%
0.7
mph
5w
15%

BP
Peak-ex BP:
136/80 mmHg
HR
RPE
73 bpm
11
81 bpm
12-13
72 bpm
11

Stage
Time
Warm-up
3:00
Leve
l
2
Watts
Step/min
14 w
60 s/m
Interval
15:00
30 w
80 s/m
Recovery
2:00
14 w
60 s/m
Interval
5:00
36 w
Recovery
3:00
11 w

BP
HR
RPE
81 bpm
Peak-ex BP:
136/80 mmHg
10:0081 bpm
16:0086 bpm
77 bpm
8:0012
16:0013
80 s/m
Peak-ex BP:
130/80 mmHg
5:0080 bpm
5:0012
50 s/m
Post-ex BP:
124/80 mmHg
66 bpm
Exercise Session 4 (2/19): UBE

Pre-exercise BP: was not obtained
Stage
Time
Level
Warm-up
(UBE)
3:00
HIIT
(1:1)
(UBE)
10:00
5 cycles
of HIIT
2
Workload
60:50
Cooldown
(UBE)
2:00

Watts
30w:20w
Rev/mi
n
60 r/m
BP
RPE
80 bpm
60 r/m:
50 r/m
50 r/m
HR
High-82-83 bpm
Low-76-80 bpm
Post-ex
BP: 106/60
mmHg
69 bpm
5:00-13
9:00-12

Exercise Session: NuStep
Stage
Warm-up
Time
4:00
Level
2
Watts
12
Step/min
60
BP
Interval
HIIT
(12:00)
(1:1)
6:4
65:21
90-100:70
Peak-ex BP:
132/80 mmHg
Recovery
3:00
18
70
Interval
10:00
36
80
Peak-ex BP:
126/78 mmHg
High-7778 bpm
Low-7173 bpm
72-72
bpm
78-79
bpm
Cooldown
2:00
13
60
Post-ex BP:
69 bpm

HR
64 bpm
RPE
12
12
Exercise Session 6 (2/26): Recumbent bike and UBE

Exercise Session: Recumbent bike and UBE
Stage
Time
Level
Warm-up
(RB)
3:00
40 w
Rev/mi
n
50 r/m
RB
5:00
50-60 w
60 r/m
UBE
10:00
60
32 w
Cooldown
(UBE)
1:00
55
25 w
60-65
r/m
50 r/m

Watts
BP
HR
RPE
82bpm
Peak-ex
BP: 156/74
mmHg
2:00-92 bpm
5:00-96 bpm
2:00-12
5:00-13
1:00-87 bpm
9:00-84 bpm
77 bpm
1:00-12
9:00-12

Stage
Time
Warm-up
2 min
Interval
18
min
Recovery
Interval
Cooldown
Leve
l
2
Watts
Step/min
18 w
60 s/m
38-40
w
80 s/m
1:30
min
4:30
min
18 w
60 s/m
40 w
80 s/m
3 min
BP
HR
64 bpm
Peak-ex BP:
128/80 mmHg
81-83
bpm

60 s/m
12
77 bpm
85 bpm
13 w
RPE
Post-ex BP:
118/80 mmHg
69 bpm
12

Stage
Warm-up
Time
5:00
Level
3
Watts
15 w
Step/min
60 s/m
BP
HR
Interval
HIIT
(14:00)
(1:1)
6-7:5
73 w
90 w
100 s/m:70
s/m
Peak-ex BP:
132/74 mmHg
134/76 mmHg
High- 7990 bpm
Cooldown
8:00
(armsonly 3
min)
15 w
70 s/m
Post-ex BP:
124/78 mmHg

RPE
12

Weight: 235 lb
Waist Circumference: 44 in
Exercise Session: Treadmill
Stage
Time
Speed
Warm-up
(TM)
3 min
1.0 mph
7w
%BW
S
10%
Treadmill
15 min
1.2 mph
9w
10%
Cooldown
(TM)
2 min
0.9 mph
7w
10%

Watts
BP
Peak ex BP:
132/80 mmHg
134/78 mmHg
HR
RPE
78
12
81-84 bpm
12
79

Stage
Time
Watts
Step/min
3 min
Leve
l
2
Warm-up
Arms only
15 w
70 s/m
Interval
20 min
50 w
80 s/m
Peak-ex BP:
134/80 mmHg
132/78 mmHg
82 bpm
Cooldown
2 min
13 w
60 s/m
Post-ex BP:
mmHg
66 bpm

BP
HR
RPE
67 bpm
12
Exercise Session 11 (3/26): Recumbent bike and UBE

Stage
Time
Level
Warm-up
(RB)
3 min
30 w
Rev/mi
n
60 r/m
RB
10 min
50 w
60 r/m
UBE
(1:1
HIIT)
12 min
70-85:60
24:20 w
Cooldown
(UBE)
2 min
50
16 w

Watts
BP
HR
RPE
76 bpm
12
79-82 bpm
12
60-78:
50r/m
72-75 bpm:
72 bpm
12
50 r/m
67 bpm
Peak-ex
BP: 126/80
mmHg

Stage
Warm-up
(armsonly)
Time
2 min
Pyramid
25 min
total
6 min
4 min
2 min
1 min
2 min
4 min
6 min
4
5
6
7
6
5
4
26 w
45 w
55 w
73 w
55 w
45 w
32 w
80 s/m
90 s/m
90 s/m
100 s/m
90 s/m
90 s/m
80 s/m
1 min
13 w
60 s/m
Cooldown
Level
2
Watts
13 w
Step/min
70 s/m
BP
HR
RPE
Peak-ex BP:
130/72 mmHg

68 bpm
76 bpm
77 bpm
82 bpm
79 bpm
77 bpm
75 bpm
Post-ex BP:
130/72 mmHg
12
12.5
12.5
12
Exercise Session 13 (4/2): 6MWT and Recumbent Bike

O: objective:
Exercise Session: 6MWT and RB
6 Min Walk Test
Distance walked: 1,122 ft 4 in (client required min assistance and held cane, but did not use it)
3 min HR-98 bpm
Final 6MWT BP: 140/70 mmHg
Gait speed: (5 m distance)
Lap 1: 4.66 sec
Lap 2: 4.69 sec
Lap 3: 4.75 sec
Lap 4: 4.85 sec
Lap 5: 5.41 sec
Lap 6: 4.43 sec
Lap 7: 4.53 sec
Lap 8: 4.50 sec
Client was able to walk 1,122 ft 4 in in 6 minutes. This distance is slightly below average (1285
ft) when compared to other stroke survivors. On average, the client walked 1.05 meters per
second (2.4 mph). Compared to other stroke survivors, this speed was slightly above average (1.0
m/sec). During pre-intervention testing, the client walked 1,054 ft. The client was able to
significantly improve his distance walked.
Stage
Time
Interval
7 min
Leve
l
3
Cooldown
2 min
Watts
rev/min
BP
50 w
50 r/m
Peak-ex BP:
130/78 mmHg
30 w
40 r/m
Post-ex BP:
120/80 mmHg

HR
82 bpm
RPE
12.5
Exercise Session 14 (4/7): Recumbent Bike and Upper Body Ergometer

Stage
Time
Level
Warm-up
(RB)
3 min
30 w
Rev/mi
n
50 r/m
RB
12 min
50 w
60 r/m
UBE
(1:1
HIIT)
14 min
120:100
28w:20
w
Cooldown
(UBE)
1 min

Watts
BP
HR
RPE
72 bpm
12
83 bpm
12.5
80 r/m:
60 r/m
79 bpm:
74 bpm
12.5
r/m
67 bpm
Peak-ex
BP: 138/80
mmHg

O: objective:
Stage
Time
Warm-up
(Armsonly)
Interval
2 min
Leve
l
2
30 min
2 min
Cooldown
Watts
Step/min
12 w
60 s/m
47-52
w
80 s/m
18 w
50 s/m

BP
HR
RPE
61 bpm
Peak-ex BP:
130/70 mmHg
134/70 mmHg
140/70 mmHg
Post-ex BP:
mmHg
73-86
bpm
65 bpm
12
12.5
12.75
13

Exercise Session: Treadmill
Stage
Time
Speed
Warm-up
(TM)
3 min
1.0 mph
7w
%BW
S
5%
Treadmill
18 min
1.5 mph
11 w
5-10%
Cooldown
(TM)
2 min
1.1 mph
8w
10%

Watts
BP
Peak ex BP:
142/80 mmHg
HR
RPE
75 bpm
12
81 bpm
86 bpm
77 bpm
13

O: objective:
Stage
Warm-up
(armsonly)
Interval
Time
3 min
Level
2
Watts
11 w
Step/min
70 s/m
BP
HR
HIIT
(15:00)
(2:1)
7:5
85w:45
w
100 s/m: 70
s/m
High- 7986 bpm

Recovery73-77
Cooldown
5 min
15w
60 s/m
Peak-ex BP:
128/72 mmHg
130/76 mmHg
Recovery-ex
BP: 122/70
mmHg
110/70 mmHg
Post-ex BP:
mmHg

RPE
12
13
Exercise Session 18 (4/23): 6MWT

Exercise Session: 6MWT
6 Min Walk Test
Distance walked: 1,210 ft (client required min assistance and held cane, but did not use it)
3 min HR- 84 bpm
5 min HR-93 bpm
Final 6MWT HR-98 bpm
Final 6MWT BP-140/82 mmHg
Gait speed: (5 m distance)
Lap 1: 4.25 sec
Lap 2: 4.6 sec
Lap 3: 4.5 sec
Lap 4: 4.41 sec
Lap 5: 4.85 sec
Lap 6: 4.2 sec
Lap 7: 4.6 sec
Lap 8: 4.3 sec
Client was able to walk 1,210 ft in 6 minutes. This distance is slightly below average (1285 ft)
when compared to other stroke survivors. On average, the client walked 1.12 meters per second
(2.5 mph). Compared to other stroke survivors, this speed was slightly above average (1.0
m/sec). During pre-intervention testing, the client walked 1,054 ft. During mid-intervention
testing, the client walked 1,122 ft. The client was able to significantly improve his distance
walked and reach his post-intervention goal of walking 1200 ft in 6 minutes.
Appendix D
Appendix E
1
Hydration*Before*
Exercise*
Hydration*During*
Exercise*
Hydration*Before*
Exercise*
Effectively*Using*
Hydration*for*Fitness*
Appendix F
Client Goal Progression
Goal: Improved aerobic capacity to improve walking speed
Progressions based on Duncan et al. (2003) study, after 3-month therapeutic intervention for stroke survivors, 90 minute sessions,
improved walking distance by 15-25% based on pre-intervention values.
Measurement: 6MWT distance and 5m-gait speed
Pre-Intervention Pre-intervention Mid-Intervention Mid-Intervention Post-Intervention Post-Intervention
Measurement
Goal
Measurement
Goal
Measurement
Goal Progression
Distance
1,054 ft
1200 ft
1,122 ft 4 in
1200 ft
1,210 ft
1,250 ft
(ft)
Gait Speed 0.87 m/sec
1.28 m/sec (2.8 1.05 m/sec (2.4 1.28 m/sec
1.12 m/sec (2.5 1.28 m/sec
m/sec
(1.9 mph)
mph)
mph)
(2.8 mph)
mph)
(2.8 mph)
Result: The client was able to reach his post-intervention goal of walking 1200 ft in 6 minutes. According to Duncan et al. (2003), the
clients value is slightly below average (1285 ft) when compared to other stroke survivors. On average, the client walked 1.12 meters per
second (2.5 mph). Compared to other stroke survivors, this speed was slightly above average (1.0 m/sec). Over the course of the
intervention, the client was able to improve his distance walked by 156 ft. The client improved by 13%, which is similar to the results in the
Duncan et al. (2003) study (15-25% improvement). Results indicate that the client was able to increase his aerobic capacity along with
walking speed.
Goal: Improved overground endurance and strength to increase distance walked without using cane
Progressions based on Visintin et al. (1998) study, after 6-week intervention in which treadmill speed and duration increased, BWS
decreased in 79% of participants. Post-intervention participants trained at 0% BWS with an average walking duration of 14 minutes.
Significant improvement in overground endurance was indicated.
Measurement: Treadmill walking speed on BWS Treadmill
Measurement
Goal
Measurement
Goal
Measurement
Goal Progression
Speed
1.2 mph
2.5 mph
1.2 mph
1.6 mph
1.5 mph
1.6 mph
(mph)
%BWS
15%
0%
10%
0%
5-10%
0-5%
Time
5:30
10:00
15:00
15:00
18:00
18:00
(min:sec)
Result: Based on the clients performance on the treadmill during the first session, the clients post-intervention treadmill speed was
adjusted. Over the course of the intervention, the client was able to slightly increase his speed, while decreasing his percent BWS. In
addition, the client was able to significantly increase his walking duration. According to Visintin et al. (1998) study, as treadmill speed and
duration increase, %BWS should decrease. In the study, average walking duration was 14 minutes. The client was able to tolerate 18
continuous minutes, which allowed him to reach his treadmill duration goal. The client was unable to reach the goal of walking 1.6 mph
with 0% BWS as he walked at 1.5 mph with 5-10% BWS. Results indicated that the client was able to improve his overground endurance
and strength, which allowed him to significantly increase in walking distance without a cane.
Goal: Maintain pre-intervention BMI and waist circumference
Based on Towfighi and Ovbiagele (2009) study, all cause mortality increased per kg/m 2 of higher BMI. It was found that education
related to dietary habits and physical activity participation assist in maintaining healthy BMI.
Measurement: Weight and circumference measurements
Measurement
Goal
Measurement
Goal
Measurement
Goal Progression
Weight (lb) 217 lb*
217 lb
235 lb
235 lb
230 lb
230 lb
WC (in)
44 in
44 in
44 in
44 in
44 in
44 in
BMI
30.3 kg/m2*
30.3 kg/m2
32.8 kg/m2
32.8 kg/m2
32.1 kg/m2
32.1 kg/m2
2
(kg/m )
*Pre-intervention measure was taken on carpet with a different scale, which could have affected baseline measurement.
Result: During pre-intervention testing, the clients weight was measured. This was taken on carpeting and with a scale that was only used
once throughout the intervention. Due to this, it is believed that the clients weight was inaccurately measured. Based on mid-intervention
testing to post-intervention testing values, the clients weight decreased by 5 pounds. His waist circumference remained consistent
throughout the intervention. As his waist circumference remained consistent, it is likely that a pre-intervention weight was inaccurately
recorded. According to a study performed by Towfighi and Ovbiagele (2009), all cause mortality increased per kg/m 2 of higher BMI.
Therefore, it will be important that the clients BMI remain consistent along with his waist circumference.
Goal: Improvement in stroke-related QOL questionnaire score
Based on Studenski et al. (2005) study, participation in a stroke rehabilitation program has lead to improvements in physical, social
and role function.
Measurement: Stroke-related QOL questionnaire score
Total
Average
Score (%)
Pre-Intervention
Measurement
70%
Pre-intervention
Goal
75%
Mid-Intervention
Measurement
Not measured
Mid-Intervention
Goal
75%
Post-Intervention
Measurement
71%
Post-Intervention
Goal Progression
72%
Result: During pre-intervention testing, the client completed a stroke-related QOL questionnaire. The client scored a 70%, with his lowest
categories being in social roles, thinking and UE function. During post-intervention testing, the client completed the stroke-related QOL
survey again, scoring a 71%. Lowest categories were in working, thinking and personality. Over the course of the intervention, the client
was able to obtain a 1% improvement in QOL score. The client was unable to reach his goal of a 5% improvement. According to Studenski
et al. (2005) study, participation in a stroke rehabilitation program has been found to lead to improvements in physical, social and role
function. Therefore, continued participation in exercise will assist the client in further increasing his QOL score.
Appendix G
Client Goal Outcomes
Goal: Improved aerobic capacity to improve walking speed
o Post-intervention goal of 1,200 ft in 6 minutes. Based on Duncan et al. (2003)
study, after 3-month therapeutic intervention for stroke survivors, 90-minute
sessions, improved walking distance by 15-25% based on pre-intervention values
occurred.
o Measured Results
Pre-intervention
Mid-intervention
Post-intervention
Distance (ft)
1,054 ft
1,122 ft 4 in
1,210 ft
5 m Gait Speed
0.87 m/sec (1.9 mph)
1.05 m/sec (2.4 mph)
1.12 m/sec (2.5 mph)
Overall, the client was able to significantly increase his distance walked and gait speed. The
client was able to reach his goal of walking 1200 ft in 6 minutes, as the client walked 1210 ft
in 6 minutes. The client was just short of reaching his goal of improved gait speed as he
walked at 1.12 m/sec (2.5 mph). Similar to the Duccan et al. (2003) study, after participation
in an exercise intervention for stroke survivors, the client was able to significantly improve
his aerobic capacity as a result of participation in the TAC program.
Goal: Improved overground endurance and strength to increase distance walked without
using cane
o Post-intervention goal to walk on treadmill at 1.6 mph with 0% BWS for 15
continuous minutes. Based on Visintin et al. (1998) study, after 6-week
intervention in which treadmill speed and duration increased as BWS decreased.
72% of participants began at 30-40% BWS. After 6 weeks, 79% of participants
trained at 0% BWS. Average time walking was 14 minutes. BWS group had
significant improvements in overground endurance.
o Measured Results
Speed
TM1
1.2 mph
TM2
1.2 mph
TM 3
1.5 mph
%BWS
15%
10%
5-10%
Time
5:30
15:00
18:00
Overall, the client was significantly able to increase the duration he was walking
continuously on the treadmill. The client was able to reach his goal of walking continuously
for 15 min, as the client was able to tolerate 18 min continuously. The client came close to
reaching his goal of walking at 1.6 mph with 0% BWS. Similar to the Visintin et al. (1998)
study, significant improvements in aerobic tolerance have occurred as a result of participation
in the TAC program, leading to improvements in overground walking endurance.
Goal: Maintain pre-intervention BMI and waist circumference

o Post-intervention goal to maintain pre-intervention BMI. Based on Towfighi and
Ovbiagele (2009) study, all-cause mortality increased per kg/m2 of higher BMI.
Education related to dietary habits and physical activity participation assist in
maintaining healthy BMI.
o Measured Results
Weight (lb)
WC (in)
BMI (kg/m2)
Pre-intervention
217 lb
44 in
30.3 kg/m2
Mid-intervention
235 lb
44 in
32.8 kg/m2
Post-intervention
230 lb
44 in
32.1 kg/m2
*Pre-intervention measure was taken on carpet with a different scale, which could
have affected measurement
Overall, as an accurate weight measurement was not obtained at baseline, values at mid and
post intervention were analyzed. The client was able to reach his goal of maintaining his BMI
throughout the program, as the clients BMI decreased. From mid to post-intervention
testing, the client was able to decrease his weight by 5 lb. In addition, the clients waist
circumference remained consistent throughout the program. According to Towfighi and
Ovbiagele (2009), it will be important for the client to maintain current BMI values to assist
in reducing the risk for all-cause mortality.
Goal: Improvement in stroke-related QOL questionnaire score

o Post-intervention goal to improve overall QOL average by 5%. Based on
Studenski et al. (2005) study, participation in a stroke rehabilitation program has
lead to improvements in physical, social and role function.
o Measured Results
Pre-intervention
Post-intervention
Total Average Score

70%
Overall, the client was able to slightly increase his QOL score from pre to post intervention
testing. The client was not able to reach his goal of a 5% improvement in QOL score. During
pre-intervention testing, the clients lowest categories were social roles, thinking and UE
function. During post-intervention testing, the clients lowest categories were work, thinking and
personality. According to Studenski et al. (2005) study, participation in a stroke rehabilitation
program has been found to lead to improvements in physical, social and role function. Therefore,
continued participation in exercise will assist the client in further increasing his QOL score.
Metria Physical Activity-Monitoring Results

Baseline
Final
1/29-2/5
Calories Burned
Physical Activity
Steps Taken
Sleep Duration
Sedentary Time
27,905 kcal
Total: 23:29 hr:min
Moderate: 20:56
Vigorous: 02:33
33,414 steps
39:03 hr:min
59:26 hr:min
2/26-3/5
25,280 kcal
Total: 17:57 hr:min
Moderate: 17:34
Vigorous: 0:23
25,062 steps
52:52 hr:min
69:28 hr:min
3/26-3/31
(only 5 days)
19,280 kcal
Total: 17:29 hr:min
Moderate: 16:59
Vigorous: 0:36
34,226 steps
35:15 hr:min
48:00 hr:min
4/14-4/21
25,731kcal
Total: 23:48 hr:min
Moderate: 23:18
Vigorous: 0:30
48,708 steps
41:48 hr:min
59:02 hr:min
Overall, the client was able to significantly increase his average steps per day throughout the intervention. At baseline, the client
averaged 4,800 steps per day. During post-intervention testing, the client was able to average 6,900 steps per day. The number of
calories burned remained consistent from baseline to post-intervention measurements along with total physical activity time. Sleep
duration and sedentary time reminded consistent as well.
Appendix H
Client Education
1
%Dietary%
Recommendations%
After%
Stroke%
%
!
Tips!to!Add!More!
Vegetables!to!Your!Day!
1.!Choose!vegetables!rich!in!color!
Brighten%
your%
plate%
with%
vegetables%
that%
are%
red,%
orange,%
or%
dark%
green.%
They%
are%
full%
of%
vitamins%
and%
minerals.%
Try%
acorn%
squash,%
cherry%
tomatoes,%
sweet%
potatoes,%
or%
collard%
greens.%
They%
not%
only%
taste%
great,%
but%
are%
also%
good%
for%
you,%
too.%
2.!Make!a!garden!salad!grow!
with!color!!
Brighten%
your%
salad%
by%
using%
colorful%
vegetables%
such%
as%
black%
beans,%
sliced%
red%
bell%
peppers,%
shredded%
radishes,%
chopped%
red%
cabbage,%
or%
watercress.%
Your%
salad%
will%
not%
only%
look%
good,%
but%
taste%
good,%
too.%
%
Dietary%
Recommendations%
After%
Stroke%
Have%
plenty%
of%
Fruits%
and%
vegetables%
%
You%
should%
aim%
to%
eat%
about%
five%
servings%
of%
vegetables%
and%
four%
servings%
of%
fruit%
each%
day.%
3.!While!your!out!!
Fruit%
and%
vegetables%
reduce%
your%
risk%
of%
stroke.%
If%
dinner%
is%
away%
from%
home,%
no%
This%
is%
because%
they%
contain:%
need%
to%
worry.%
When%
ordering,%
ask%
for%
an%
extra%
side%
of%
vegetables%
Antioxidantsthis%
can%
help%
reduce%
damage%
or%
side%
salad%
instead%
of%
the%
typical%
to%
blood%
vessels.%
fried%
side%
dish.%
%
Potassiumthis%
can%
help%
control%
blood%
4.!Savor!the!flavor!of!seasonal!
pressure.%
vegetables!!
Fibrethis%
can%
lower%
your%
cholesterol.%
%
Buy%
vegetables%
that%
are%
in%
season%
Folate%
(found%
in%
green%
leafy%
vegetables)
for%
maximum%
flavor%
at%
a%
lower%
this%
may%
reduce%
your%
risk%
of%
future%
stroke.%
%
cost.%
%
Healthy%
eating%
can%
reduce%
your%
risk%
of%
another%
stroke.%
Eating%
a%
diet%
low%
in%
fat%
and%
salt%
and%
high%
in%
fruits%
and%
vegetables%
reduces%
your%
risk%
factors%
for%
high%
cholesterol,%
high%
blood%
pressure,%
being%
overweight%
and%
diabetes.%
' Dietary'Recommendations'after'Stroke''
Tips%
to%
Reduce%
Your%
Sodium%
Consumption%
1.%
Think%
fresh%
Most'of'the'sodium'in'a'
Western'diet'is'found'in'
processed'food.'Eat'highly'
processed'foods'less'often'and'
in'small'portionsespecially'
bacon,'deli'meats,'soup'and'
readyJtoJeatJfood.'Fresh'foods'
are'generally'lower'in'sodium.''
'
2.%
Adjust%
your%
taste%
buds%
Cut'back'on'salt'little'by'little
and'pay'attention'to'the'natural'
tastes'of'various'foods.'Your'
taste'buds'will'adapt'to'a'lowJ
salt'diet'in'about'8'to'12'weeks.''
'
3.%
Consume%
lots%
of%
fruits%
and%
vegetables%
Eat'plenty'of'fruits'and'
vegetablesfresh'or'frozen.'
Fruits'and'vegetables'are'
naturally'low'in'sodium.'Try'to'
eat'a'fruit'and'vegetable'at'
every'meal.''
'
4.%
Choose%
dairy%
and%
protein%
foods%
that%
are%
lower%
in%
sodium%
Choose'more'fatJfree'or'lowJfat'
milk'and'yogurt'in'place'of'
cheese,'which'is'higher'in'
sodium.'Choose'fresh'beef,'
pork,'poultry'and'seafood,'
rather'than'those'with'salt'
added.'Deli'meats'and'sausages'
are'higher'in'sodium.'Choose'
unsalted'nuts'and'seeds'for'a'
healthy'snack.''
Dietary'Recommendations''
After'Stroke'
Limit&
&
Sodium'intake''
Our'bodies'require'only'a'small'amount'of'sodium'
each'day'to'function'normally.'Our'bodies'need'
sodium'for'the'function'of'our'nerves,'muscles'and'
circulatory'system.'Eating'too'much'sodium'can'
lead'to'increased'blood'pressure,'which'can'
increase'your'risk'of'heart'attack,'stroke'and'other'
cardiovascular'conditions.''
On'average,'American'adults'exceed'their'
recommended'daily'limit'of'sodium.'The'American'
Heart'Association'recommends'that'adults'limit'
their'sodium'to'less'than'1,500'mg'per'day.'Thats'
equal'to'about'2/3'teaspoon'of'salt.'Reducing'your'
sodium'intake'can'help'lower'your'blood'pressure'
and'improve'the'health'of'your'heart.''
' Dietary'Recommendations'After'Stroke''
Dietary'Recommendations''
After'Stroke'
Eat'red,'orange'and'dark'
green'vegetables'such'as'
tomatoes,'sweet'potatoes'
and'broccoli,'in'main'and'side'
dishes.'Eat'fruit,'vegetables'
or'unsalted'nuts'as'snacks
they'are'natures'original'fast'
foods.''
They'have'the'same'amount'
of'calcium'and'other'essential'
nutrients'as'whole'milk,'but'
less'fat'and'calories.''
Choose'100%'wholeM
grain'
cereals,'breads,'crackers,'rice'
and'pasta.'Check'the'
ingredients'list'on'food'
packages'to'find'wholeM
grain'
foods.''
Twice'a'week,'make'seafood'
the'protein'on'your'plate.'Eat'
beans,'which'are'a'natural'
source'of'fiber'and'protein.'
Keep'meat'and'poultry'
portions'small'and'lean.''
Before'you'eat,'think'about'what'goes'on'
your'plate.'Foods'like'vegetables,'fruits,'
whole'grains,'lowM
fat'dairy'products,'and'
lean'proteins'contain'the'nutrients'you'need'
without'too'many'calories.'Eating'some'
foods'less'often,'such'as'foods'high'in'solid'
fat,'added'sugars'and'salt'could'assist'you'in'
meeting'your'health'and'wellness'goals.'It'is'
also'important'to'eat'the'right'amount'of'
food'for'you.'By'preparing'meals'at'home,'
you'can'control'the'amount'of'food'you'are'
consuming'along'with'what'goes'into'your'
food'preparation.'Lastly,'using'a'smaller'plate'
can'assist'in'building'a'healthy'meal.'
' Emotional'Changes'After'Stroke''
Tips%
to%
cope%
with%
changing%
emotions%
1.'Tell'yourself'that'your'
feelings'arent'good'or'
bad.'Let'yourself'cope'
without'feeling'guilty'about'
your'emotions.''
2.'Find'people'who'
understand'what'you'are'
feeling.'Participation'in'a'
stroke'group'may'help.'
3.'Get'enough'exercise'and'
do'enjoyable'activities'each'
day.'''
4.'Give'yourself'credit'for'the'
progress'you'have'made.'
Celebrate'the'large'and'small'
gains.''
5.'Learn'to'talk'to'yourself'
in'a'positive'way.'Allow'
yourself'to'make'mistakes.'
6.'Ask'your'doctor'for'help.'
Ask'for'a'referral'to'a'mental'
health'specialist'for'
psychological'counseling'
and/or'medication'if'needed.''
7.'At'stroke'may'cause'you'to'
tire'more'easily.'Rest'when'
you'are'fatigued.'Make'sure'
you'get'enough'sleep.'
Sometimes'lack'of'sleep'can'
cause'emotional'changes'and'
cause'you'not'to'cope'as'well'
throughout'the'day.'''
Emotional'Changes''
After'Stroke'
Emotions'are'hard'to'control,'especially'after'a'
stroke.'Some'changes'are'a'result'of'the'actual'
injury'and'chemical'changes'to'the'brain'caused'by'
the'stroke.'Others'are'a'normal'reaction'to'the'
challenges,'fears'and'frustrations'that'one'may'feel'
trying'to'deal'with'the'effects'of'the'stroke.'Often,'
talking'about'the'effects'of'the'stroke'and'
acknowledging'these'feelings'can'assist'in'dealing'
with'these'emotions.'After'a'stroke,'you'may'
experience'rapid'mood'changes,'crying'or'laughing'
that'does'not'match'your'mood'or'crying'or'
laughing'at'unusual'times'or'that'lasts'longer'than'
seems'appropriate.'In'addition,'you'may'
experience'feelings'of'sadness,'hopelessness'or'
helplessness,'irritability'or'changes'in'eating,'
sleeping'and'thinking.'Each'of'these'are'commonly'
seen'in'individuals'after'a'stroke.'Using'the'tips'
provided'on'the'left,'it'is'important'to'address'
these'issues'as'they'could'lead'to'frustration,'
anxiety,'anger,'apathy'or'lack'of'motivation.''

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TABLE 2. Past surgical history.

Special considerations. The client is currently prescribed multiple medications to assist

TABLE 3. Current outpatient prescriptions on file.

TABLE 4. Physical exam.

TABLE 5. Modified orthostatic challenge.

Millimeters of mercury (mmHg)

TABLE 6. ABI screening.

Table 9. Stage specific submaximal exercise test results.

TABLE 10. Summary of submaximal exercise test results.

TABLE 12. Client exercise prescription.

Tues (3/10) Spring break-no session

Thur (3/12) Spring break-no session

Thur (2/19): UBE

Thur (3/26): RB & UBE

Tues (3/31): NuStep

Thur (4/9): NuStep

Thur (4/16): NuStep

Improved aerobic capacity to improve

1200 ft; gait speed 1.28 m/sec

Maintenance of pre-intervention BMI and

Maintain BMI and waist circumference

Improvement in stroke-related QOL

Overall score improvement of 5%

TABLE 14. Monthly physical activity assessment.

Getting stuck, stuttering, stammering

Doing daily work around the house

Discouraged about future

Stroke-Specific Quality of Life ScaleContinued

Joining in activities just for fun with my family

Post-exercise HR: 63 bpm

Exercise Session 2 (2/12): Treadmill

Post-exercise HR: 72 bpm

Exercise Session 3 (2/17): NuStep

Post-exercise HR: 66 bpm

Exercise Session 4 (2/19): UBE

Post-exercise HR: 69 bpm

Exercise Session 5 (2/24): NuStep

Post-exercise HR: 66 bpm

Exercise Session 6 (2/26): Recumbent bike and UBE

Post-exercise HR: 71 bpm

Exercise Session 7 (3/5): NuStep

Post-exercise HR: 69 bpm

Exercise Session 8 (3/17): NuStep

High- 7990 bpm

Post-exercise HR: 70 bpm

Exercise Session 9 (3/19): Treadmill

Post-exercise HR: 71 bpm

Exercise Session 10 (3/24): NuStep

Post-exercise HR: 66 bpm

Exercise Session 11 (3/26): Recumbent bike and UBE

Post-exercise HR: 67 bpm

Exercise Session 12 (3/31): NuStep

Post-exercise HR: 66 bpm

Exercise Session 13 (4/2): 6MWT and Recumbent Bike

Post-exercise HR: 79 bpm

Exercise Session 14 (4/7): Recumbent Bike and Upper Body Ergometer

Post-exercise HR: 67 bpm

Exercise Session 15 (4/9): NuStep

Post-exercise HR: 65 bpm

Exercise Session 16 (4/14): Treadmill

Post-exercise HR: 68 bpm