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Trainer Challenge of Stroke

A stroke is an obvious turning point in most survivors’ lives. In a best-case scenario, it can be as minor as a mild concussion. At worst, it is a disabling brain injury that leaves the person incapable of caring for themselves—or even breathing on their own. In any case, stroke clients can provide a significant challenge to a trainer wanting to help them, once medical care and primary rehabilitation has plateaued. This is especially true considering the variety of experiences a survivor can have, following a stroke.

gym training, young man and his father

Exercise for Atrial Fibrillation

Here are some things to look for when working with a client with Atrial Fibrillation (A-fib).


What types of medications are they on? Calcium Channel Blockers, blood thinners (Coumadin)? These may have an effect on the intensity and type of exercise performed. You know that people who have A-fib are at increased risk for strokes, and may have hypertension and get dizzy more often. The medications – while they may help with some factors – may preclude a well-designed exercise program just because they may not tolerate some types of exercise.

What are the exercise goals? Are they wanting to tone up? Lose some weight? Get stronger? Train for a tennis match or 5K? This would help in structuring the program. The type / intensity / duration are all dependent on what the client wants. If they are just coming off surgery or a new prescription – this is important to build the foundation (which you know).


Does the doctor have any contraindications for exercise? Usually, it’s not to “overdo”, which means building up a program. I read a good article by Dr. Bill Sekula on a program for A-fib. It’s essentially a “step down, time up” program, where patients go from a few minutes of exercise a few times per day – to building up to an hour of exercise one time per day.  However, I am going to recommend more of an ITP (interval training program) that concentrates on moderate strength programs (using the 40-50% rule similar to cancer patients), so they don’t use the Valsalva maneuver while lifting, but still use a progressive resistance approach. 


Monitoring with a HR monitor, and having good hydration status are both important. Of course, you probably have them using the smart water bottle. Because of the heart dynamics and possible Coumadin Rx, the hydration is important. I assume you do a HR variability test with your client. This may be a very important test to do, as over time it may be instrumental in reducing A-fib occurrences.

I like the article by Dr. John Mandrola on the amount of exercise. He states that A-fib is completely controllable through specific lifestyle changes. He states that low inflammation exercise (high intensity endurance / triathlon, etc.) training needs to be modified, as do other lifestyle issues. I really like the discussion on inflammation, which may be one of the biggest issues in cardiac care of late. He talks about the “J curve” of exercise and that the more intense actually increases the odds ratio (OR) for sudden cardiac events and other abnormalities related to A-fib. 

I think he is on to something, and you should look into some other lifestyle aspects such as meditation and heartbeat regulation through mindful breathing and relaxation. I know that excess stress, lack of sleep and poor diet have effects on the electrical system, including SA node and conductivity. Regular relaxation may do a LOT to improve the normal sinus rhythm and reduce resting HR to a more manageable level. 

Dr. Mandrola also recommends regular monitoring of BP, keeping the use of warm exercise clothing due to peripheral circulation issues, and not overheating. 

I like the issue of ITP and progression.  I also am more of a fan of modified strength training for most clinical conditions.  I think it would work for AF because if you think of the strength of contraction during exercise (even moderate) – it will have a strong steady beat during exercise (in most cases).  

Eric Durak is President of MedHealthFit – a health care education and consulting company in Santa Barbara, CA. A 25 year veteran of the health and fitness industry, he has worked in health clubs, medical research, continuing education, and business development. Among his programs include The Cancer Fit-CARE Program, Exercise Medicine, The Insurance Reimbursement Guide, and Wellness @ Home Series for home care wellness.



  1. https://www.everydayhealth.com/hs/atrial-fibrillation-and-stroke/afib-exercise-safety-tips/
  2. https://drbillsukala.com/tips-for-safe-exercise-with-atrial-fibrillation-af-or-a-fib/
  3. http://www.drjohnm.org/2014/05/exercise-over-indulgence-and-atrial-fibrillation-seeing-the-obvious/


Trainer helping senior woman exercising with a bosu balance

Stroke Survivors Worldwide Desperately Seeking Great Care. Don’t Be a Deceiving Professional

15 Million People Suffer Stroke Each Year. There is a huge “real” need for stroke survivors to have continued physical therapy after their insurance has covered their (usually very limited) physical therapy sessions.

It’s an important time for fitness professionals to step up and gain stronger knowledge in physical rehabilitation with stroke survivors. This need is worldwide!

I know this because I have helped survivors worldwide and heard their stories of struggle. I’ve personally heard their human desire to get their bodies back to movements for everyday life. This includes things like walking, arm and hand function, balance, cognitive skills, stability, driving and much more!! Hundreds of thousands of survivors are desperately seeking proper care and guidance.

I have been asked by stroke survivors and caregivers worldwide for help. After I published my first book in 2017, The Stroke of an Artist, The Journey of a Stroke Survivor and a Fitness Trainer, I began being contacted from all over the world for help. I wanted so badly to help them all.

I also received calls and messages from personal trainers who had a survivor client. I was surprised at how some reacted. For example, one trainer, after spending an hour sharing knowledge and telling him to seek out more education beyond the one-day certification he had, responded with “So basically…” — he tried to sum up in one sentence how to train a survivor. And he had it all covered. I thought, wow, that survivor’s recovery is determined by this trainer’s ego and lack of listening skills. Most trainers I spoke with wanted a quick answer to full-body stroke recovery. They did not want to take the time needed to extend their knowledge.

I decided to begin a Stroke Recovery support group via private Facebook group page. There are almost 3000 members. It breaks my heart, but it keeps me constantly motivated to do what I can to help them and try my best to educate fitness professionals.

It is wonderful to have such a gathering from all over the world in this stroke recovery support group. It is serial and fascinating.  Everyone is so kind and supportive in the group to one another. They encourage and try to help each other so much.

Look at all the different countries our members have gathered together from: Israel, Europe, Switzerland, Australia, Canada, UK, Africa, Great Britain, Vietnam, New Zealand, Scotland, Philippines, Fiji, Ireland, Indonesia, Micronesia, Mumbai, Maharashtra, Turkey, and many States in the United States.

I know how real the urgent need is for fitness professionals to gain knowledge to help survivors get their lives back.

I decided to help get the survivors and caregivers educated since finding the professionals to help them sucked.

I then wrote my book, Stroke Recovery, What Now? When Physical Therapy Ends But Your Recovery Continues

Around this time Lisa Dougherty with the MedFit Education Foundation contacted me to be on the Education Advisory Board and write a Stroke Recovery and Exercise CEC course. I was very excited to have a platform to reach professionals to educate them to bring needed care to stroke survivors.

Fitness professionals and physical therapists must continue their education way beyond the basics of getting their original certification, license and credentials.

Hundreds of survivors have shared with me their struggles to find great care. The stories blow my mind and frustrated me tremendously.

Here is one recent story.

A 54-year-old female survivor, who lives 3 hours away from me, was so excited and filled with hope again after we met in my support group and reading my books and watching my videos. She began to get hand movement back and decided to go find a physical therapist again. She searched, asked questions and found someone who appeared and sounded like they had the knowledge and expertise to help her. She was excited, she sent me a private message and told me what the therapist said. It sounded good. This therapist spoke the neuro words.

This survivor shared in the support group how excited she was and tagged me, thanking me for helping her feel hope again. Everyone was proud of her and encouraging her. I was thrilled.

A few days ago, she sent me a message that after her 5th session with this therapist, the therapist told her that she’d never worked with a stroke survivor before and can’t help her.  She said she had gained more knowledge and recovery from me than 5 sessions with this therapist.

This upsets me so much. She deserves great care and real help. All stroke survivors do. Now she has wasted 5 insurance paid PT session and 5 co-pays. That is not okay!

I have hundreds of stories like this and some are worse.

So, to all fitness professionals and therapists…

Please don’t fake your knowledge and experience to gain a client. Don’t just talk the talk. Put the time and effort into continuing your education. Have integrity, a heart of passion and honesty in your work.

This can mean someone may walk or not walk again.

This can mean someone can hold a fork in their hand again or not.

This may mean someone can go back to work or never again.

And so much more!

In the case of the Survivor who was an artist in my first book, it meant he would paint again or not. He did paint again.

Survivors are encouraged and try to believe, never give up and don’t quit. But they need to have educated professionals they can trust to join their personal stroke recovery team.

And the fabulous 54-year-old stroke Survivor refers to me as “God’s Stroke Angel”. That makes my heart feel warm and fuzzy. ❤

I will be presenting a 4-hour “Stroke Recovery and Exercise” workshop on Thursday, February 6 from 7:30-11:30am at the Medical Fitness Tour in Irvine, CA (at UC Irvine campus). Find details at medicalfitnesstour.org/socal. Come gain a lot of knowledge to help stroke survivors gain the stroke recovery the deserve.

Fitness Specialist and Educator Tracy Markley is the Founder of Tracy’s Personal Training, Pilates & Yoga in Florence, OR. Tracy has over 2 decades experience in the fitness industry; she holds numerous specialty certifications, including many for those with medical conditions & chronic disease. She’s also studied the Brain and the neurological system, and has had great success working with seniors and special populations in stroke recovery, neurological challenges and fall prevention. Tracy also serves on the MedFit Education Foundation Advisory Board

She’s authored 3 books: “The Stroke of An Artist, The Journey of A Fitness Trainer and A Stroke Survivor” and “Tipping Toward Balance, A Fitness Trainer’s Guide to Stability and Walking” and “Stroke Recovery, What Now? When Physical Therapy Ends, But Your Recovery Continues”. Her books bring hope, knowledge and exercises to those in need, as well as sharing her knowledge and experience with other fitness professionals.

CT scan of the patient's brain and the hand of a doctor.

82-year-old Stroke Survivor & Wife Travel From New Jersey to Oregon To Train with Tracy L. Markley

Last year, I received an email from a wonderful woman who lives on the New Jersey Coast. She had read my books and wanted to know if she could fly herself and her 82-year-old stroke survivor husband to Florence Oregon, to train with me. She shard some stories of trainers refusing to work with him and those who did not have the knowledge needed. She also shared a couple stories about physical therapist not wanting to bother with using specific equipment that was needed for him. This is so disappointing. He is now almost 4 years post-stroke and she has still searched out some guidance toward a better recovery for him. It saddens me with all that she has gone through, but I am grateful that I could help, the best I know how. I made some great life time friends.

I am honored that she reached out to me.  I am still in “ahh”, by the whole experience. Often stroke survivors and their caregivers do not find the help needed to further their recovery after physical therapy ends. Unfortunately, some survivors do not even get good physical therapy in the crucial, early stages in recovery, when it is essentially needed. She shared with me some not so good experiences she and her husband had faced, like many others I have spoken with.

They arrived the last week of September 2018, and we met to train almost every day for 4 weeks. It was a productive training month for him. He made some important gains, but has much more hard work to do. I am helping them find a professional near them with the neuro and biomechanics knowledge, needed to bring him further in recovery.

She shared with me that what sold her to come see me was a handwritten note I sent to her inside of the book order she had. She ordered “The Stroke of An Artist, The Journey of A Fitness Trainer and a Stroke Survivor.”  I knew she would get more out of help with that book if I sent her my second book “Tipping Toward Balance, A Fitness Trainer’s Guide to Stability and Balance.” I included it with the other book as a gift.  I had no idea that that would lead to her and her husband taking a journey from the Jersey coast to the Oregon coast to train with me in person.  It is very special.

I have surveyed 100s of stroke survivors in the challenges they have faced finding good guidance in further recovery. Even though there are good stories, there were a much higher amount of disappointing experiences many survivors and their caregivers have faced. Some keep pushing forward and some gave up.

Gain Education to Work with Stroke Survivors

If you’re a fitness professional interested in learning how you can work with stroke survivor, Tracy is the author of a 4 hour online course with PTontheNet, Stroke Recovery and Exercise.

Article reprinted with permission from Tracy Markley. 

Fitness Specialist and Educator Tracy Markley is the Founder of Tracy’s Personal Training, Pilates & Yoga in Florence, OR. Tracy has over 2 decades experience in the fitness industry; she holds numerous specialty certifications, including many for those with medical conditions & chronic disease. She’s also studied the Brain and the neurological system, and has had great success working with seniors and special populations in stroke recovery, neurological challenges and fall prevention. Tracy also serves on the MedFit Education Foundation Advisory Board

She’s authored 3 books: “The Stroke of An Artist, The Journey of A Fitness Trainer and A Stroke Survivor” and “Tipping Toward Balance, A Fitness Trainer’s Guide to Stability and Walking” and “Stroke Recovery, What Now? When Physical Therapy Ends, But Your Recovery Continues”. Her books bring hope, knowledge and exercises to those in need, as well as sharing her knowledge and experience with other fitness professionals.

Physio assisting elderly woman during exercise with power band a

The Importance of Exercise Following A Stroke

According to the American Heart Association, 700,000 people annually in the United States suffer a stroke.(1)  The incidence of stroke is likely to continue to escalate because of an expanding population of elderly Americans; a growing epidemic of diabetes, obesity, and physical inactivity among the general population; and a greater prevalence of heart failure patients.(2)

Following a stroke, survivors will often work with Physical and Occupational Therapists to restore strength and control through exercise programs. However, most insurance companies only pay for a certain number of therapy sessions per calendar year which can leave a gap in the rehabilitation process. It’s important to continue the exercises that a physical therapist has prescribed and progress safely through an exercise program to regain strength and functional movement. This is where a certified personal trainer with experience in rehabilitative exercises can come in. A certified personal trainer can be part of the healthcare team and can design a program which is both safe and functional.  Walking, flexibility exercises, and light strength training can help a stroke survivor continue on the path of rehabilitation. Swimming is also another beneficial form of exercise if a pool is available.

Another benefit of exercise for stroke survivors is prevention of recurrent stroke or heart attack, which occurs frequently in people who have had a stroke.(3)  Reducing risk factors can decrease the incidence of recurrent strokes and coronary events. An aerobic conditioning program can enhance glucose regulation and promote decreases in body weight and fat stores, blood pressure, C-reactive protein, and levels of total blood cholesterol, serum triglycerides, and low-density lipoprotein cholesterol.(4) Exercise also increases high-density lipoprotein cholesterol and improves blood rheology, hemostatic variables, and coronary endothelial function.(5)

It is very important that a personal trainer communicate with healthcare professionals about their client after a stroke, including the physician and physical & occupational therapists to best help the client. Safety should always come first when exercising. Overexertion and pain should always be avoided. Decrease in balance, spasticity(6), memory, and fatigue is common after a stroke. Like everyone else, stroke survivors will have good days and bad days. However, modification of exercises can help after a stroke to get individuals on the path to better physical health.

Kris Pritchett Cameron is the owner of ReNu Your Life Fitness & Neuro Wellness in Cedar Rapids, Iowa and a certified personal trainer through the American Council on Exercise. Kris has dedicated over 20 years to the health and fitness of others. Kris has worked with all ages from children to the elderly, but her specialty is medical fitness and working with older adults. With a background in healthcare and physical rehabilitation, Kris has experience working with clients who have orthopedic injuries, arthritis, Multiple Sclerosis, Parkinson’s Disease, Alzheimer’s, cancer, diabetes, heart disease, osteoporosis, bariatric surgery, mental disorders, and stroke. 


  • American Heart Association. Heart Disease and Stroke Statistics-2003 Update, Dallas TX
  • Gillum RF, Sempos CT. The end of the long-term decline in stroke mortality in the United States? Stroke 1997; 28:1527-1529
  • Mol VJ, Baker CA, Activity intolerance in the geriatric stroke patient, Rehabil Nurs. 1991; 16:337-343
  • Franklin BA, Sanders W. Reducing the risk of heart disease and stroke. Physician Sports Med. 2000; 28: 19-26
  • Hambrecht R, Wolf A, Gielen S, et al. Effect of exercise on coronary endothelial function in patients with coronary artery disease. N Engl J Med. 2000; 342: 454-460
  • Spasticity is a condition where muscles are stiff and resist being stretched. It can be found throughout the body, but is common in the arms, fingers, or legs. Hope: The Stroke Recovery Guide. 2010 National Stroke Association
Personal trainer and her client with dumbbells

Metabolic Syndrome: A New Focus for Lifestyle Modification

Personal trainers have the opportunity to do more than just help people they train become more active. We need to be prepared to also help our clients implement lifestyle behavior changes related to stress, family history of coronary heart disease, obesity, smoking, high blood pressure and high cholesterol.

A look at what is called metabolic syndrome will help you understand why, even though increasing physical activity levels is the overall best thing you can do for any client, there are additional ways to guide them to a healthier lifestyle. Sometimes you may be able to help them make the changes yourself; and, sometimes you will need to refer them to another health professional like a doctor or dietitian for guidance. Either way, knowing how to help them or when to direct them to someone who is more knowledgeable than you is important. So, first let’s become familiar with the syndrome and the clinical criteria that the doctor uses to diagnose it. Your goal is then to help your clients understand and make the necessary changes so that they don’t progress to cardiovascular disease and the almost certain heart attack heart that will be the end result.

Cardiovascular disease is still the number one cause of morbidity and mortality in the United States and much of this burden of disease can be linked to poor nutrition and a dramatic increase in sedentary lifestyles, leading to overweight and obesity. This increase in weight leads to an increase in the incidence of type 2 diabetes, and blood pressure and cholesterol problems, which are all well-established cardiovascular disease risk factors. The National Cholesterol Education Program (NCEP) Adult Treatment Panel (ATP) III has updated the recommendations for the evaluation and management of adults dealing with high cholesterol, renewing its emphasis on the importance of lifestyle modifications for improving cardiovascular risk. The NCEP has coined the term “therapeutic lifestyle changes” (TLC) to reinforce both dietary intake and physical activity as crucial components of weight control and cardiovascular risk management.

As well as focusing attention on the LDL cholesterol (also called bad cholesterol) levels, the NCEP also identified metabolic syndrome as a secondary target of therapy. Metabolic syndrome (also called insulin resistance syndrome and syndrome X) is characterized by decreased tissue sensitivity to the action of insulin (pre-diabetes), resulting in a compensatory increase in insulin secretion. This metabolic disorder predisposes individuals to a cluster of abnormalities that can lead to such problems as type 2 diabetes, coronary heart disease and stroke. The prevalence of the syndrome has increased 61% in the last decade. It is crucial for medical professionals to identify patients at risk and follow these patients closely and counsel them about making lifestyle changes to lower the risk of type 2 diabetes and cardiovascular disease.

GUIDELINE: According to the NCEP, the criteria for metabolic syndrome includes at least 3 of the following 5 clinical factors

Risk factor Defining level
Abdominal obesity
Waist circumference
>40 in (>102 cm)
>35 in (>88 cm)
Fasting triglyceride level >150 mg/dL
HDL cholesterol level
<40 mg/dL
<50 mg/dL
BP >130/>85 mm Hg
or taking antihypertensive medication
Fasting glucose level >100 mg/dL or diabetes

Source: Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. Executive Summary of the Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). Bethesda, Md: National Institutes of Health; 2001. NIH publication 01-3670.

Millions of Americans at risk for metabolic syndrome can sharply lower their chances of getting this disease by adopting a healthy lifestyle (stop smoking, low-fat diet, weight loss/maintenance and increased physical activity). Without diet and exercise modifications, most patients will eventually fail and progress to type 2 diabetes within a decade and experience a heart attack about 10 years later. Experts recommend a diet reduced in saturated fats (<7%), low in cholesterol (<200 mg/day), high in fiber (20-30gm/day) and reduced in simple sugars. Weight loss of only 5-7% (less than 15 pounds) can make a big difference in health markers like cholesterol and blood pressure. A program that includes daily exercise reaching 85% of heart rate for age is reported to be of benefit too. However, any exercise is better than none, and a target of 30 minutes every other day is a reasonable level for most people.

As a fitness professional reading this, hopefully you are not asking yourself “so what?” but are instead seeing an opportunity to educate and motivate your current clients and to use your knowledge to help attract future clients. The medical community is good at diagnosing this syndrome, but not necessarily equipped to provide patients with the tools to be successful with the lifestyle changes they recommend. There exists a wonderful opportunity to build a partnership with physicians in your area. Most physicians will gladly refer patients to you for help with the all-important exercise and nutrition portion of the treatment program. In many cases, you have more knowledge in this area than the physician who has been trained in tertiary, not preventative, (i.e. most MD’s know very little about diet and exercise since this is not a focus in medical school) medicine.  Often times all that you will need to get a referral is for the doctor to be aware of your existence and to give them an easy way to get the patient to you. A short introduction letter outlining your qualifications and showing your desire to help people make lifestyle changes is a good start. A personal visit to your primary care doctor and others in your area is even better. But, be prepared to take up just a few minutes of their time to introduce yourself, your idea, and leave your letter and cards.

Tammy Petersen, MSE, is the Founder and Managing Partner for the American Academy of Health and Fitness (AAHF). She’s written a book on older adult fitness and designed corresponding training programs. SrFit Mature Adult Specialty Certification is used nationwide as the textbook for a college based course for personal trainers who wish to work with mature adults. SrFit is also the basis for a specialty certification home study course that qualifies for up to 22 hours of continuing education credit with the major personal trainer certification organizations.


  1. Centers for Disease Control and Prevention. Early release of selected estimates based on data from the January-June 2003 National Health Interview Survey. URL: cdc.gov/nchs/about/major/nhis/released200312.htm.
  2. Summary Health Statistics Tables for the U.S. Population: National Health Interview Survey, 2016 https://www.cdc.gov/nchs/nhis/SHS/tables.htm 16 Apr. 2018.
  3. Centers for Disease Control and Prevention. Prevalence of health care providers asking older adults about their physical activity levels—United States, 1998. Morbidity and Mortality Weekly Report. 51(19):412-4, 2002.
  4. Huang, Paul L. “A Comprehensive Definition for Metabolic Syndrome.” Disease Models & Mechanisms5-6 (2009): 231–237. PMC. Web. 16 Apr. 2018.
Active senior friends talking and working out in fitness club

Fitness After A Stroke

Strokes are devastating, not only physically, but mentally. They change lives, many of which are very young and active. When stroke patients are discharged from physical therapy, many are just beginning to recover physically, especially from a fitness and strength perspective. This is where the experienced Athletic Trainer, Strength Coach or Personal Trainer can make a huge difference in their quality of life.

Both physical and mental aspects must be addressed when entering a fitness program. From the physical perspective, balance, strength, flexibility, coordination and cardiovascular fitness are just some parts that may be incorporated into the fitness program. The mental aspect may be even tougher in addressing fear, complacency and motivation, to name a few.

The stroke patient can be addressed just like any other fitness client and should be. Ask them the same questions.

  • What are your goals?
  • What do you need to be able to do to obtain your goals?
  • What are your current limitations?

Active retired people, old man and woman talking and exercising in fitness gym

With these answers in mind, a professional now needs to assess where the client currently is physically by looking for strengths, weaknesses, asymmetries, flexibility issues, etc. At this point, a proper plan can be designed. Since strokes typically affect one side of the body, it is important to train each side independently. For example, step ups or isometric lunges for lower body and single arm presses or rows with a band can work each side of the upper body. The resistance or range of motion may need to be modified depending on how the client has been affected. Yes, resistance or strength training needs to be a part of the program. In an article in NeuroRehabilitation, investigators determined that targeted strength training in patients with muscle weakness due to strokes significantly increased muscle power without any negative effects on spasticity.

Considering many stroke clients are de-conditioned when they begin a fitness program, it is important to incorporate strength exercises into the sessions to improve active daily living activities such as walking through a crowd, wearing high heels or getting through a work day with less physical effort. Others may benefit by being able to start running again or getting involved with other types of sporting activities they have been missing.

Core stability and flexibility are two other aspects that need to be addressed in a program as well. The core muscles which can include the abdominal, low back and hip musculature provides a base of support for the arms and legs to work. There are a million core exercises that can utilized, but start with simple and progress to complex work. Isometric and anti-rotational core exercises like planks, planks with leg lifts or resistance band chopping exercises are a great place to start. Flexibility and mobility are also important aspects to consider and should be addressed one side at a time. Since contractions typically occur in strokes, they can limit movement and function. It is also important to send the client home with some stretching exercises to perform on their own.

The mental side of the program may be a little more trying than the physical side. Some clients may be fearful to perform certain exercises because they assume they just can’t do those things anymore, some frustrated that they can’t do what was once easy and some that have just lost motivation. It is the professional’s job to find ways to overcome these issues, whether modifying exercises or showing how they relate to their goals. Progress is the biggest component here. Showing improvement and where a client has come from and their accomplishments is the key to success. Simply reminding a client how hard an exercise used to be or what they do now without thinking that was difficult before goes a long way.

Clients recovering from a stroke are no different than any other client, they may just have different goals and different limitations that affect the way a program is put together. Developing a relationship with a client and devising programs that are specific to their needs is the key to helping former stroke patients obtain the goals they are looking for.

Chris Phillips is the owner of Compete Sports Performance and Rehab in Orange County, CA. Chris is a certified Athletic Trainer, Strength and Conditioning Specialist and Corrective Exercise Specialist.


Using Exercise for Stroke Rehabilitation

Recently we have been working very closely with several clients suffering brain injuries, severe movement dysfunction, and muscle loss caused from either accidents or strokes. The effects of these conditions can often be quite devastating and some people never regain the skills they had prior to the incident. Having said that, there are some that do recover and develop significant improvement in daily living tasks. Surprisingly, it can happen quite quickly if the right stimulus is provided. This article looks at some of the research we have been able to use and implement effectively with several clients.

“I have been getting personal training from No Regrets Personal Training for 6 months now and I have loved every minute of it! Nathan is such a patient, caring and understanding person but he still pushes you. I have definitely improved out of sight since going to training, my movement, my balance, my walking, my strength and my overall appearance have improved quite a lot and I only expect it to continue! I haven’t missed a session because I love it!” –Shannyn Moon

Shannyn is only 31 years of age and has suffered from 2 severe strokes that have left her with partial paralysis on her right side. Her goal is to be able to walk down the aisle for her wedding in her words “like a normal person”.

Interesting Stroke Facts

According to the National Stroke Association:

  • 10% of stroke survivors recover almost completely
  • 25% recover with minor impairments
  • 40% experience moderate to severe impairments that require special care
  • 10% require care in a nursing home or other long-term facility
  • 15% die shortly after the stroke
  • Approximately 14% of stroke survivors experience a second stroke in the first year following a stroke.

What Happens When You Have A Stroke?

Human Brain ECGA stroke is caused by an interruption of the flow of blood to the brain or by a rupture of blood vessels in the brain. The damaging effects of a stroke depend on what parts of the brain are affected, as well as the amount of damage. Common after affects contribute to resulting weakness on the side contra lateral to the brain injury.

In the past, exercise and more specifically strength training, with stroke victims or brain injuries has been misunderstood and at times even controversial. Most people with stroke are usually prescribed “safe” or moderate exercise programs, with more emphasis on cardio vascular exercise or using isolated exercises and stretches to treat the affected side. Typically machines are used for strengthening as they force the muscles to work in a symmetrical method that eliminates mistakes at the same time making it safer. I myself used machines when starting as a trainer as I was told that free weights are too risky and that the client would benefit from doing bilateral movement as opposed to single arm or single leg exercises. I found that this approach did not really help these clients to improve what they came to see me for in the first place which was – how to move better!

It also did not address the problem of spasticity or lack of flexibility with the affected arm or leg, which is often severely restricted in pronation and bent. Using an isolated stretch seemed to do nothing to change the actual length tension of the muscle as soon as we stopped stretching. I suspected the solution would be with the strengthening and movement approach but I needed a different model than machine training and isolated movements. What I found was that a much more integrated approach of using movement focused exercises, with more reliance on single arm and contralateral activity produced significantly better results.

Use Complex Movement Skills

I first came across the Complex Movement concept many years ago when working with sporting athletes looking to improve movement efficiency to ultimately develop improved strength and power. It just took me some time to think that I could use the same principles of teaching sports to people with injury or even just beginners. Originally I believed if I used the typical muscle approach to training this would automatically equal faster and more powerful. Yet I found anytime I used a complex task that was actually a lot lighter load, but required much more brain concentration and focus, and they were able to execute it as close to perfectly as possible, the strength gains and improvement across multiple skills, was much higher than when we focused on strength alone. This now makes up a big part of our sports program.

Over time I began applying this theory to beginners, then to injury and rehabilitation, more recently with older adults where I found this to be also true. And interestingly enough the gains were more significant with the rehab and older adults more so than the sports due to the amount of skill and strength lost.

This led me to reading hundreds of books and completing many courses in this area to develop programs and exercises with the goal of trying to improve a person’s movement efficiency. Basically we are training the neuro musculoskeletal system with our goal to get your body’s systems to work in a highly coordinated and effective fashion, so that functional tasks are completed successfully.

This aligned perfectly with our goal for rehabilitation and more specifically stroke victims because the goal of the individual who has experienced a stroke is to reach the highest possible level of independence and be as productive as possible (Just like Shannyn wanting to walk down the aisle!) The difficult and challenging part here is that the progress and recovery is so unique for each person, depending on the level of damage and paralysis. There is no one magic exercise that works every time. A method of assessing where to start and determining how each person learns best will decide how effective the program would be.

Using a reverse engineering approach with the focus being on the end result – improved human movement and function, we needed to use a way to find out what movement patterns they needed, and how good they were at completing each one. From this we could design a stepping stone approach to learning and devise plans and programs to enhance each movement pattern.

But this is where it gets very interesting and even contradictory. With the “Average Joe”, who lacks overall conditioning, we could use a more simple and isolated muscle approach to build some strength and reserve before tackling the more complex integrated movements.

For example to improve the ability to squat we could use an approach of:

  1. Hip extension progressing to
  2. A swiss ball squat against the wall to a
  3. Squat with a barbell overhead press.

jack-stroke1With the stroke or brain affected clients we had more success with starting with more complex and difficult tasks often completed in a split stance, using contralateral arm and leg movements. (See picture).

This takes advantage of how the neuromuscular system is designed to work in the first place, which is in a highly coordinated manner. The body really is a complex system made up of many chains known as slings. These slings, when they are working well, help us move efficiently, produce more force, and create more speed. However, when there is a weak link in the chain, most people don’t address the chains but rather target the muscles. Very, very rarely do muscles work in complete isolation or anywhere close to it. Some muscles contract to provide movement while some muscles contract to provide stability. This is all done at the same time. They don’t work separate to each other. In addition to this and as we have already discussed, the more co-ordinated and complex movements have a greater effect on the brain. And because the brain controls the muscles, it makes sense to try and change this!

What Is The Most Effective Ways To Learn These New Tasks?

I highly suggest reading the book Motor Learning and Performance by Richard A. Schmidt and Timothy Lee as this really helped with my program effectiveness and adapting different learning styles for each client. We knew that our purpose of conditioning was to teach your body how to train smarter and move better for life. We need to improve various abilities such as strength, balance, co-ordination and agility all relative to each other. I like to use the analogy of getting an upgrade on your computer. In the gym it is the perfect place to master these skills. Your ultimate goal should be to master every form of movement enough times that it becomes automatic! Once you learn to move properly in a gym you don’t worry about your technique when you’re playing a sport, moving something at work or even just lifting something in the garden. If you’ve done it right in the gym, and done it enough times it’s already built into the system. This is what is referred to as a Motor Engram. This is why it is so important for a new gym goer or someone recovering from injury to learn ONLY GOOD MOVEMENTS. This way it will teach the body the perfect automatic movement it needs to prevent further injury.

But What Is The Best Way To Learn?

jack-stroke2In the beginning we would intervene and guide the clients movements so that it was as close to perfect as possible. We knew that to change a movement we needed approximately 5000 perfect reps to make it automatic. But what we found more effective, was to not intervene and only help when required, and actually allow for some mistakes to be made. This would allow the problem solving nature of the brain to develop. Providing video feedback and use of mirrors became extremely effective in the client learning how to overcome the problems faster than us trying to help all the time. To the right is a video showing an example of us using video feedback to teach a client recovering from ACL surgery to stabilize better on one leg.

And with Shannyn using external nervous system stimulus to the feet to improve walking, she made more improvement than any other exercise we had ever tried. Using a bare foot approach of walking across several different surfaces to enhance the actual foot mechanics changed her movement pattern almost instantly. Her damaged foot for the first time began to dorsi flex and find its way across the uneven terrain. We got her to walk across

  1. Concrete
  2. Uneven grass
  3. Stones – this was the hardest but also the most effective

The different nerve sensations and the requirement of the foot to feel its way across the surface forced the nervous system to adapt and create better method of movement. Coupling that with video feedback for them to observe and try to change enabled us to alter their permanent way of walking faster than using standard stationary exercises we had used before.


Strength training for strokes and other accident related injuries cannot be underestimated. At times, isolated movement and muscle approach is needed and can be beneficial in adding some muscle, but a program that utilizes an integrated movement approach will produce faster and superior results. Finding creative ways to mimic and simulate daily tasks will not only significantly improve movement skills and function, but add much needed muscle improved flexibility for tight muscles that previously did not respond to stretching or releasing. Use of various learning tools such as video and external surface will also speed up the learning and enable you to complete tasks never before possible.


Nick Jack is owner of No Regrets Personal Training a Rehabilitation & Sports Training Studio located in Melbourne Australia. Having worked as a Trainer for over 10 years and has qualifications as a CHEK Exercise Coach, CHEK Golf Performance Specialist & Master Rehab Trainer and Twist Conditioning Sports Conditioning coach he specializes in working with rehabilitation and injury prevention programs. You can check out his website at www.noregretspt.com.au


Motor Learning & Performance by Richard A Schmidt
Bending The Aging Curve by Joseph Signorile
Anatomy Trains by Thomas Meyers
National Stroke Association

Healthy human health care symbol

Why do Yoga if you have Heart Disease or have had a Stroke?

Psychological stress has been shown to increase activation of the sympathetic nervous system and the hypothalamic pituitary adrenal axis. This increased activation releases adrenaline, noradrenaline, and cortisol, which lead to faster heart rate, increased cardiac output, and narrower arteries. These changes, in turn, create increased blood pressure. Activation of these systems also accelerates the progress of atherosclerosis and can lead to acute plaque rupture, which results in ischemia of the heart (angina) and coronary heart disease and stroke.