EXERCISE AND FITNESS TRAINING

AFTER STROKE:

Physical Activity & Health Specialist

Exercise Instructor Training Course

CANDIDATE
SUMMATIVE
ASSESSMENT PACK

Later Life Training  August 2010 1

 CONTENTS
Contents Page
Assessment overview and timeline 3
Introduction 4
1.0 Theory and Applied Theory 6
1.1 Theory Paper: Written Examination 6
Specifications 6
Sample questions 6
Sample answers 7
1.2 Coursework – Case Study and Session Plan 9
Content of the coursework 9
Length, format and presentation of the coursework 10
Students with special educational needs 10
Presentation of the coursework 10
Referencing 11
Penalties for exceeding word limit and late submission 11
Academic dishonesty and plagiarism 12
Criteria for awarding marks 12
Case Study 2 Details 13
Example Coursework Case Study feedback form 17
Session plan template 19

2.0 The Practice 21

Content of the practical assessment 21
Format of the practical assessment 21
2.1 Practical Group Assessment 22
2.2 Individual exercise delivery and outcome measure Assessment 22
Risk Assessment + Health and Safety Information for EfS 22
assessment
Criteria for awarding marks 24
Cardiopulmonary Resuscitation 24
Practical Assessment Menu 25
Health and Safety Venue Assessment Checklist 27
Environmental / Exercise/ Client Based Risk Assessment 28
Medium or High Level Risk Continuation Assessment 29
Practical Assessment Observation Checklist 30
Interpretation of marking Criteria 32
Candidate Assessment Record 37
Assessor Feedback Sheet 40
Self-evaluation Form 41
Outcome Measures Protocols 43

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ASSESSMENT OVERVIEW

Component Day of Course Details

One 2-hour written Day 6 You will sit the Theory paper on the
examination morning of Day 6
One 1500-word case Day 6 Submit one hard copy of the Case Study 2
study coursework based and Session Plan to the Assessors on Day
on Case Study 2, which 6. This will be sent to the LLT Office and
should include a full ONE will be marked within 3 weeks of Day 6.
hour session plan
demonstrating
progression at week 7-8.
One 30-minute practical Day 6 You will deliver the allocated exercises of
assessment for a group your practical EfS session to a group of
of EfS participants, your peers, adapting and tailoring for a
based on Case Study 2 range of specified impairments, on the
and a range of specified afternoon of Day 6.
impairments. Also one The allocated exercises will comprise:
strength exercise - TWO warm up exercises,
delivered one to one and - TWO circuit exercises,
one outcome measure - TWO strength exercises
conducted with an - one delivered to a group
individual participant. - one delivered one to one
- ONE cool down stretch
You will also conduct ONE outcome
measure with an individual
(NB. You can present a draft of your final Case Study on Day 5 of the course to receive formative
feedback from your course tutor.)

You will be informed of your final course assessment mark within one month of Day 6. This will
be in the form of a Candidate Assessment Record, Coursework Case Study Feedback, a Practical
Observation Checklist and Assessors Feedback Sheets (examples given later). In order to receive
your Qualification Certificate you must hold a valid CPR Certificate. Refer also to page 24.

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INTRODUCTION:

This 20-credit course has been validated through Queen Margaret University (QMU) at Level 8 of the
Scottish Credit and Qualifications Framework. This is equivalent to a BSc(Hons) module at Level 2.
The assessment consists of two components:

1. The Theory and Applied Theory

The theory and applied theory part of the EfS Assessment comprises 40% of the overall course
module mark. It comprises two parts:
1.1 ONE 2 -hour Written Examination, comprising short answer questions, combined with:
1.2 ONE piece of 1500-word Case Study coursework based on a clinical video case study,
including ONE Session Plan, developed for the delivery of a 1 hour EfS session based on
the Case Study (above) and EfS participants with specified impairments.

2. The Practice
The EfS practice assessment comprises 60% of the overall course module mark. It comprises two
parts:
2.1 ONE Group 30 minute Practical Examination, combined with:
2.2 ONE Strength exercise delivered to, and ONE outcome measure conducted with, an
individual participant.

Further information on each component of the assessment can be found later in this Summative
Assessment Manual.

In order to pass this assessment, candidates will have to demonstrate that they have achieved the
following learning outcomes (Skills Active Stroke Standards) associated with this module:

1. Demonstrate effective communication skills (in particular effective teaching skills)

2. Follow the required protocols for gathering and reporting information
3. Follow required Health and Safety protocols
4. Plan a safe, effective and appropriate intervention
5. Deliver, tailor to individuals and teach a safe, effective and appropriate intervention
6. Demonstrate competency in relevant assessment procedures, risk management and
an understanding of professional boundaries

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 7. Deliver appropriate client/ patient support
8. Demonstrate an awareness of patient/client confidentiality
9. Demonstrate an appropriate level of knowledge of:
a. Government policy and published national guidelines for the prevention and
management of Stroke.
b. Relevant medico-legal requirements.
10. Demonstrate an appropriate level of theoretical knowledge and understanding of the
subject of stroke.
11. Demonstrate a sufficient level of theoretical knowledge and understanding of exercise
prescription and progressive programming and ability to apply this safely and effectively in
practice with people (groups and individuals) who have had a stroke.
12. Demonstrate a sufficient level of knowledge and understanding of exercise behaviour and
an ability to apply this effectively in practice with people who have had a stroke
13. Demonstrate an awareness of the need for engaging in reflective practice and life-long
learning.

In cases where a student refers on any part of the EfS Course Assessment, the student shall
normally be reassessed in the failed component only. If you have any questions about assessment
and cannot find the answer in this document, please contact the LLT Office or speak to your
course tutor.

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1 THEORY AND APPLIED THEORY

1.1 THEORY PAPER: WRITTEN EXAMINATION

Specifications

The written exam will have a duration of 2 hours, preceded by 5 minutes reading time. The exam
will consist of 20 questions, 15 of which are short answer questions and 5 are multiple choice
questions on medication. The exam is designed to test your knowledge and understanding of all
the theory discussed during the course, i.e.:
• Stroke
• Treatment after stroke
• Physical fitness after stroke: theory and evidence
• Physical fitness after stroke: guidelines for practice including health and safety, referral,
ethics and professional standards.

A useful source for exam questions are the directed learning questions in your “Tutorial, Self
Assessment and Distance Learning Pack”.

Sample questions
1. What is the difference between the two main types of stroke? (5 marks)

2. A 84 year old lady who had had a lacunar ischaemic stroke was referred for exercise. She
had a past history of asthma. She mentioned that she was dizzy when she stood up. Which
of her drugs are most likely to be the cause? (2 marks)
a) Salbutamol inhaler
b) digoxin
c) lisinopril (an angiotensin converting enzyme inhibitor)
d) aspirin
e) simvastatin

3. The multidisciplinary team involved in stroke rehabilitation often involves a speech and
language therapist (SLT). List five important aspects that characterise the role of the SLT in
this context. (5 marks)

4. With respect to the STARTER trial: what is the rationale for including the “Sit to stand”
exercise? (5 marks)

5. Exercise instructors need to undertake a specific risk assessment for people exercising after
stroke. Describe two stroke-specific impairments and explain, in detail, what action you
would undertake to reduce the risk associated with each of these impairments. (20 marks)

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Sample answers

1. Answer: Ischaemic strokes are due to a blockage of the blood supply to part of the brain
whereas haemorrhagic strokes are due to bleeding in the brain

2. Correct answer is c)

3. The answer should include any five of the following (1 mark per point):
• Assessment and diagnosis
• Provision of information and support
• Individualised SLT therapy programme to maximise function
• Strategies to compensate for the communication impairment
• Facilitate access to information
• Advice and training (of others) to facilitate interaction
• Assessment for and provision of alternative and augmentative methods of
communication
• Referral to support groups / other professional support
• Liaison with others

4. Answer could include:

• Sit to stand is an important functional activity, undertaken many times during waking
hours (1 mark)
• The ability to move from sit to stand safely and without assistance is a prerequisite for
independence (1 mark)
• Stroke often impairs balance and leg extensor power. (2 marks)
• Practising sit to stand is an effective way to target these impairments in a task-specific
manner. (1 mark)

5. The answer should include two of the risks listed in the syllabus with the indicated action
explained, e.g.:
• Symptom: Abnormal Tone (1 mark)
• Description: Altered tone is an “ Abnormal response to stimuli resulting in alteration in
muscle function” i.e. the muscles affected by the stroke may behave differently from

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 normal and the muscles may then work in the wrong sequences and with the wrong
forces or the wrong timing. (4 marks)
• Suggested action: Where there is an adverse response (e.g. an unresolved change in the
patient’s baseline tone status and/or their degree on movement control), the exercise
should be temporarily discontinued by changing the activity and engaging the patient in
an active recovery activity (e.g. interspersing marching, or walking during step
endurance training or stretching or mobility during resistance training may be effective
in preventing or resolving these problems). (5 marks)

THE PASS MARK FOR THE THEORY WRITTEN ASSESSMENT IS 50%

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1.2 COURSEWORK – CASE STUDY AND SESSION PLAN

Content of the coursework:

Carefully read the case study information presented on page 13 and refer to the video-based
information on Case Study 2 on the EfS Student Webpage.

1. From the information provided about Mr. R, identify the impairments and activity
limitations. Select one impairment and one activity limitation and explain, in detail, how
each of these might impact on Mr. R’s ability to exercise.

2. Before Mr. R. is allowed to commence his exercise programme, indicate which other
information you require from Mr. R’s GP, who referred him for exercise.

3. Having obtained the required information from his GP, Mr. R has now been enrolled in your
exercise programme. Explain the possible impact of Mr. R’s co-morbidities and medications
on his abilities to exercise. Which symptoms will you need to monitor especially?

4. Mr. R experiences a degree of executive dysfunction. This first manifests itself in your initial
session, where he expresses some goals that are clearly unrealistic (i.e. “I want to be able to
walk to the gym instead of taking the bus” - he lives 1 mile away from the gym). Detail
which measures you will put in place to help Mr. R achieve his personal goals through his
exercise programme and explain your rationale.

5. In relation to the impairment and activity limitation identified in question 1, explain how you
will reduce the risks associated with each of these two problems in your exercise
programme.

6. In order to be able to evaluate the effectiveness of the exercise programme for Mr. R, Select
two different assessment tools that you might use for his outcome measures, and provide a
clear rationale for selecting each of your tools.

7. Based on the specific case information, as well as the relevant evidence and national
guidelines on exercise after stroke, complete a ONE HOUR session plan for week 7-8,
following the STARTER plan (issued in class). Design appropriately adapted exercises with
tailoring strategies/approaches to meet Mr R’s needs and specific impairments, based on

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 the literature and guideline recommendations (including the EfS manual). Provide a clear
rationale for choosing each of the exercises.

Please bring your completed case study coursework to Day 6 of the course. You should also bring
your completed session plan to your practical assessment, as you will be expected to teach
elements of this. Your handed in coursework will not be returned to you so please keep a copy.

Length, format and presentation of the coursework

The Case Study coursework should be no more than 1500 words. The word limit for the coursework
does not include: text in tables, boxes, references or appendices (but note that these elements must
be used in an appropriate manner). Please refer to the Information on coursework submission for
information about special educational needs and support (below), criteria for awarding marks (page
12), referencing and submission (page 11), as well as penalties for exceeding the word limit and late
submission (page 11) and plagiarism (page 12). Please note that presentation quality and clarity of
presentation will be considered in the award of marks (see below).

Your session plan has no word count but must be an appropriate length. A session plan template
can be found on page 19, for you to photocopy and use. Alternatively an electronic session plan
(word document) can be downloaded from the EfS Student Webpage on the LLT website. Your
plans can be completed with neat hand-writing (but must be in INK) or word-processed and each
page of the plan needs to be signed and dated.

Students with Special Educational Needs

Students with special needs that may affect their performance should discuss their circumstances
with the LLT Office or the Course Tutor prior to submission. Whenever possible, your needs will be
addressed to ensure it is possible for anonymous marking to take place.

Presentation of Course Work

All students need to follow the guidelines below:
• The work must be neatly hand-written in INK or word-processed
• Text must be double spaced
• All pages must be numbered
• Word count on the Case Study must be stated (see below for penalties on exceeding the
word limit)

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Referencing
Students are advised to use the Harvard Referencing system, for which guidance can be found on
the QMU Library website: http://www.qmu.ac.uk/lb/IFS_Harvard.htm

Penalties for Exceeding Word Limits and Late Submission of Coursework

This course is accredited by Queen Margaret University, Edinburgh. Therefore the following rules
apply to candidates handing in coursework on the EfS Course. The relevant QMU assessment
regulations are included below: -

20.1 A piece of written work which exceeds the specified word limit by 10% or more will receive a
maximum mark of 40% for undergraduate or 50% for postgraduate programmes.
20.2 In each piece of written work where a word limit is identified, students are required to include and
clearly state the total number of words used. The number of words counted should include all the
text, references and quotations used in the text, but should exclude abstracts, supplements to the
text, diagrams, appendices, reference lists and bibliographies.

In addition, extracts from the LLT EfS terms and conditions state that:

13. Deferral during the course – if candidates wish to defer the course assessments (Theory Paper, Case Study
and Practical Assessment) there will be an administration charge of £50. Once candidates have signed the
assessment sign-up form on DAY 3 of the course, failure to attend the assessments (‘late deferral’) will
result in a maximum re-assessment fee of £140. Late deferred assessment costs are £35 for the Theory
Paper, £35 for the Case Study, £25 for the Session Plan (where the Practical teaching was passed) and £70
for the Practical Assessment. Late deferrals of all assessments with a Med 3 Certificate received by LLT and
related to the assessment date, will incur an administration charge of £50 only and the place will be
transferred to a future course. No refunds will be given if course assessments are not taken. An invoice for
late deferral costs will be sent to the Individual or Host/Funder, as appropriate, as soon as transfer course
and dates are agreed, and must be paid before the assessment dates.
14. Assessment referrals – a referral of any part of the assessments will result in a re-assessment. The re-
assessment costs are £35 for the Theory Paper, £35 for the Case Study, £25 for the Session Plan (where the
Practical teaching was passed) and £70 for the Practical Assessment. A maximum of three referrals on an
assessment is permitted before having to re-take the full course at full course cost. An invoice for referral
costs will be sent to the Individual or Host/Funder, as appropriate, as soon as transfer course and dates are
agreed and must be paid before the assessment dates. Non attendance at the arranged re-assessment of
the referred Assessments will not generate the refund of re-assessment costs and will be subject to the
same Med 3 Certificates requirements as covered in items 14 above.

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15. Deferrals and Referrals must be taken within twelve months of the original course assessment date and
may result in candidates having to travel to another course venue elsewhere in the country which may
involve transport and/or accommodation costs. It is the candidate’s responsibility to book their
referral/deferral dates within this time period. All course dates and venues can be found on the LLT
website – www.laterlifetraining.co.uk . If deferrals or referrals are not taken or not passed within twelve
months of the original assessment date, an Attendance Certificate will be issued. Once an Attendance
Certificate is issued, the individual cannot sit assessments at a future course without re-taking the full
course at full course cost.

Academic Dishonesty and Plagiarism

This course is accredited by Queen Margaret University, Edinburgh. Therefore the following rules
apply to candidates handing in coursework on the EfS Course. The relevant QMU assessment
regulations are included below: -

24.1.1 This institution’s degrees and other academic awards are given in recognition of the candidate’s
achievement. Plagiarism is therefore, together with other forms of academic dishonesty such as
personation, falsification of data, computer and calculation fraud, examination room cheating and
bribery, considered an act of academic fraud and is an offence against University discipline.
24.1.2 Plagiarism is defined as follows:
The presentation by an individual of another person’s ideas or work (in any medium, published or
unpublished) as though they were his or her own.
24.1.3 In the following circumstances academic collusion represents a form of plagiarism:
Academic collusion is deemed to be unacceptable where it involves the unauthorised and
unattributed collaboration of students or others work resulting in plagiarism, which is against
University discipline.
24.1.5 QMU has a policy to use the TurnItIn UK plagiarism detection system, or other equivalent systems, to
help students avoid plagiarism and improve improve their scholarship skills.

Criteria for awarding marks

The criteria for awarding marks are detailed in the Example Coursework Case Study Feedback Form
on page 17. Note that your session plan and your rationale for each of the elements, based on
individual participant needs, relevant guidelines and evidence, is the most important section of the
coursework.

THE PASS MARK FOR THE CASE STUDY COURSEWORK IS 50%.

THE SESSION PLAN IS MARKED AS PASS OR REFER.

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CASE STUDY 2 DETAILS

Personal details:
Name: Mr. R
Address: provided (but omitted from case study for data protection reasons)
DOB: provided (but omitted from case study for data protection reasons). Age: 55 years.
Telephone number: provided (but omitted from case study for data protection reasons)
GP Details: all details provided (but omitted from case study for data protection reasons)

Current health problems:

• Cardiac history: quiet heart murmur
• Respiratory history: no symptoms
• Other neurological conditions: no symptoms
• Osteoarthritis and Rheumatoid Arthritis: mild osteoarthritis in low lumbar spine
• Fracture history: none
• Joint replacement: none
• Osteoporosis: no symptoms
• Diabetes: no symptoms
• Epilepsy: no seizures over the previous 5 years
• Hearing impairment: none
• Hypertension
• High cholesterol

Prior to the stroke, Mr. R was a heavy smoker. Mr. R still occasionally smokes and has a generally
low alcohol intake per week (i.e. 1 pint of beer on Friday-Sunday).

Current medication :
o Tramadol 150 mg qds
o Perindopril 4mg od
o Simvastatin 80mg od
o Aspirin 75 mg od
o Bendroflumethiazide 2.5 mg od
o Fluoxetine 20mg od
o Diazepam 2mg prn
o Dipyridamole SR 200mg bd

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Stroke history
Mr R had his CVA 8 years ago; an ischaemic (R) TACS (Total Anterior Circulation Stroke) affecting the
left side of his body. Tests showed the stroke was not caused by any cardiac condition or embolic
type event. Carotid Dopplers showed no significant carotid stenosis and the echocardiogram was
normal. Following thrombolysis, Mr. R was treated in a stroke unit and had an extensive
rehabilitation programme, however the start of upper limb rehabilitation was delayed due to
shoulder pain. This was probably caused by early inappropriate management of a vulnerable
shoulder and a lack of awareness on Mr. R’s behalf of his upper limb position at that stage of his
recovery. As a result, Mr. R’s glenohumeral (shoulder) joint became subluxed by 1.5 cm. Eight years
after the acute event, he still remains with residual impairments of the following:

Affected upper limb:

• increased tone and reduced active movement, with a reduction of external shoulder
rotation and elbow extension.
• pain upon shoulder flexion/ abduction of more than 80 degrees
• moderate return of active movement to shoulder flexors and internal rotators, as well as
elbow flexors and extensors
• tendency to use a flexor tonal pattern to obtain a grab hold of objects. There is little
voluntary control of selective movement once hypertonus is “switched on”.
• during strenuous activity, the biceps brachii often contracts, pulling the affected hand up
against the chest.
• wrist tends to be positioned in radial deviation and flexion
• in rest, the tip of the fingers end near the palm of the hand.
• Mr. R is currently receiving phenol injections to reduce the activity in his biceps, wrist and
finger flexors

Affected lower limb

• lower limb is affected by increased tone, particularly in the quadriceps, hamstrings
and lateral glutei.
• weakness in all lower limb flexors - except plantar flexors
• contracture of the L calf muscles
• some active selective movement at hip and knee, but none at the ankle.
• knee/ ankle control is achieved by use of an ankle-foot orthosis (splint). Mr. R has
two of these; one gives the most efficient gait, but is difficult to get on/ off, while

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 the second is easier to put on/ off with one hand, but slightly compromises the gait
pattern. Mr. R uses the latter for attending the gym where he requires to change
independently.

Gait
• hip and pelvis on the affected side are externally rotated
• full knee extension is limited at the end of the swing phase of gait, prior to heel strike.
• during mid to end stance phase, the affected leg is still externally rotated but the knee has
the tendency to hyperextend.

Cognitive/ perceptual functions

• there is a degree of executive dysfunction, which manifests itself in Mr. R being overly
ambitious at times. He demonstrates poor planning and time management skills and has a
low frustration tolerance. His concentration is limited to approximately 5 mins. per activity.
During complex/ lengthy activities, he easily becomes disorganised and requires prompting
to get back on track.
• when tired/ stressed, his visuo-spatial awareness is slightly reduced (L)
• receptive speech processing speed is reduced, but remains functional during 1:1
communication

Pain control
• increased tone in general is an issue which is associated with chronic pain affecting his L hip,
thigh and shoulder regions as well as restricting range of movement at these joints.

Social History
Mr R was previously self-employed in a variety of jobs, ranging from garage foreman to supermarket
agent, but has been unable to return to work after his stroke. He admitted having a generally poor
diet with little regular exercise prior to his stroke, mainly because of irregular hours and the
frequently changing locations of his job. Since his stroke, Mr. R has moved with his wife from a two-
storey house to a bungalow. This has an extensive garden, which he loves tending. However, this
has a variety of surface areas, including a few steps which he currently has difficulty negotiating.
Mr. R is planning to grow a range of fruit and vegetables this summer which he hopes to harvest by
himself. Mr. R manages to get himself up, showered and dressed each morning, but requires approx
1 hour to achieve this. He has a Modified Barthel Index score of 94/100. Mr. R is now regularly

Later Life Training  August 2010 15

attending a gym-based programme, has learned how to drive again and can walk up to 1 mile. He is
highly motivated, but admits being frustrated at times, especially concerning the lack of return of
movement in his upper limb.

Further information
In his referral letter to you, the GP provides the following additional information: Mr. R is highly
motivated to exercise, but admits experiencing frustration at times - especially concerning the lack
of return of function in his upper limb; prior to the stroke, Mr. R was left hand dominant. The GP
feels that exercise may be of benefit to Mr. R to increase his general level of fitness, lower his level
of cholesterol and blood pressure and enable him to reduce his medication for these conditions.
According to the GP, Mr. R specifically wants to improve his arm function to make it easier to engage
in the gardening activities that he enjoys. He would also like to improve his balance and leg strength
so he can manage getting on/ off the ground easier when kneeling to manage his flower beds. The
GP emphasises the need for adequate supervision, especially given the degree of Mr. R’s executive
dysfunction.

Video footage of this case study will be available on the EfS Student webpage. You will be
able to watch these clips as often as you like.

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Example Coursework Case Study Feedback Form
Candidate Name: EfS Course Name: Date:

Assessor Name: EfS Course Code Result:

PASS

Criteria Excellent Very Average Satisfactory Fail

Good
1. Knowledge of information required from referrer:
correct and complete

2. Co-morbidities/ medication:
a. Knowledge and understanding of impact on
exercise: correct and sufficiently detailed

b. Knowledge about symptoms: correct.
3. Assessment tools:
a. Knowledge and understanding: correct and
sufficiently detailed

b. Based on sound rationale
4. Applied knowledge about stroke-related
impairments and activity limitations: correct and

sufficiently detailed
5. Risk management: appropriate and effective

6. Session plan - warm up (1):
a. Appropriate
b. Clearly described

c. Based on sound rationale
7. Session plan - warm up (2):
a. Appropriate
b. Clearly described

a. Based on sound rationale
8. Session plan – circuit (1):
a. Appropriate
b. Clearly described

c. Based on sound rationale
9. Session plan – circuit (2):
a. Appropriate
b. Clearly described

c. Based on sound rationale
10. Session plan – strength:
a. Appropriate
b. Clearly described

c. Based on sound rationale
11. Session plan – cool down:
a. Appropriate
b. Clearly described

c. Based on sound rationale
Very Good Satisfactory Poor
12. Fluent grammatical writing style

13. Correct English Usage (including spelling)

14 Referencing (use of literature)

Comments: You need to concentrate on clearly describing adaptations to your strength exercise, although based on
sound rationale you need to demonstrate that you can adapt for activity limitations. Otherwise a good session plan
based on sound rationale.
Assessor Signature: S Dinan-Young

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Notes:

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Later Life Training  August 2010 20
2.0 THE PRACTICE

Content of the practical assessment

This component of the assessment is based on the same coursework, detailed for Part I.2 (ie .the
ONE hour individual programme designed for Case Study 2). Here, however the programme is
delivered in the context of a group session for EfS participants with a range of specified
impairments. The emphasis is on the competencies of adapting, tailoring and teaching exercise (see
2.1 and 2.2 on pg 22) and on the application/administration of the outcome measure (2.2 on pg 22).

You will need to bring along the 1 hour Session Plan you have created for your Case Study 2, based
on week 7-8 of the STARTER programme (see Section 1.2)

The practical assessment consists of a demonstration of your exercise and teaching technique and
approaches. This, includes the need to demonstrate your ability to adapt and tailor your proposed
session plan for the range of designated impairments modelled by your peers (ie. the individual
participants in the session). These competencies and will be marked against the Summative Practical
Observation Checklist (pages 30-31) –against strict criteria (pages 32-36). Your assessor will provide
you with written feedback based on these criteria (page 40).

On Day 6 of the course, you will be asked to draw tickets from a hat to indicate the specific
exercises you will be required to teach and which outcome measure you are required to
apply/administer. You will then be given 10 minutes to prepare and set up any equipment for the
whole of the practical assessment, including the outcome measure. Further details on pages 25-26.

Format of the practical assessment

Each candidate will have 30 minutes for the practical assessment.
Each candidate will be required to teach a group (Section 2.1) as well as an individual (Section 2.2)
on a one-to-one basis (see pages 25-26)

Following your session you will be expected to complete a Self Evaluation based your own thoughts
about your performance as a specialist instructor on this occasion and how this correlates with the
feedback gained from the group (see pages 41-42).

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2.1 ONE Group 30 minute Practical Examination
You will introduce and teach allocated exercises comprising:
• TWO exercises from the Warm Up;
• TWO aerobic endurance circuit exercises, including transitions;
• ONE Strength exercises and
• ONE Cool Down Stretch.

You will be teaching a group (your peers on the course). Your peers will have badges with specified
impairments clearly visible. You must tailor and adapt the exercises to meet their needs.

2.2 ONE Strength exercise delivered and tailored to, and ONE outcome
measure conducted with, an individual participant.
Following straight on from your group practical assessment, you will then be asked to teach the
second strength exercise you have been allocated, this time to an individual participant. Then you
will be asked to demonstrate and conduct ONE outcome measure (pages 43-45) with that individual
participant.

Risk Assessment + Health and Safety Information for EfS assessment

You will need to complete a Health & Safety/Risk Assessment for the session. Guidance and advice
on completing this is provided (see pages 27-29).

Why Risk Assess?

There are both legal and moral obligations to carrying out an assessment of exercise-related risk*
prior to participation, particularly where the exercise is supervised., as well as possible cost
implications if an assessment is not completed, sufficient or current. Once completed, the risk
assessment should be periodically reviewed to ensure it is still up to date with the patient’s health
and fitness status and relevant to your organisation.

*(ie. of an adverse event during or following exercise)

What does a risk assessment need to be?

It must be suitable and sufficient for the activity/ environment work is happening.

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These are not defined in regulation, but in practical terms mean:
- The risk of assessment should identify the risks arising from, or connected to work.
- The level of detail in the risk assessment should be proportionate to the risk.
- Once the risks are assessed, insignificant risks can usually be ignored.
- The level of risk arising from the work activity will determine the intensity of the risk
assessment.

What are Hazards?

Hazards can come in a variety of forms:
- Physical – Mechanical, Electrical, Noise, Lighting, others
- Biological - Allergies, Health Status, Medications
- Chemical – Dust, Fumes, Corrosives
- Ergonomic – Unsuitable equipment, poor working posture

Identifying Hazards can help determine the level of risk by asking ‘What If…?’ scenario questions
surrounding the environment/ activity
- Personal Observation - Workforce Consultation
- Previous Experience - External Advice

Questions you should ask to determine risk are:

- Who might be harmed and how
- The Likelihood of risk
- The Severity of risk

Ways to reduce the Likelihood and or Severity of risk could be

- Hard Control measures – Protective devices, Housekeeping, activity layout.
- Soft Control measures – Procedures, Culture, Campaigns / Posters, training/Induction

Methods of preventing an occurrence or controlling risk could include:

- Elimination of something or activity
- Substitution of something or activity
- Engineering controls (modifying /safeguarding machinery)
- Administrative control such as procedures, supervision of those working

Welfare Arrangements such as rest and toilet breaks.

Hydration and privacy.

Later Life Training  August 2010 23

Calculating and Stratifying Risk
To determine what risks require further action through the above methods you can calculate risk
through rating Likelihood and Severity on a scale of 1-5
Likelihood = 1 unlikely 2 may happen 3 Likely 4 Very Likely 5 Certain
Severity = 1 Minor (1st Aid) 2 Minor (treatment off site) 3 Injury over 3 days
4 Major injury (RIDDOR reportable) 5 Death
Risk Rating = Likelihood x Severity

If the Risk Rating is between 1-4 = Low Risk = Existing control measure must be maintained
If the risk Rating is between 5-10 = Medium Risk = Action required soon to control. Interim
measure may be necessary in short term
If the risk rating is between 12-25 = High Risk = Action required urgently to control. Further
resources may be required.

You should complete the Health and Safety Venue Assessment Checklist (page 27), the
Environmental / Exercise/ Client Based Risk Assessment (page 28) and, if your risk rating is either
medium or high risk please complete the Medium / High Risk Continuation Assessment (Page 29).

Criteria for Awarding Marks

The Assessor will assess your competence on set criteria. They will complete an Assessment
Observation Checklist (pages 30-31) and given written feedback (page 40) based on set criteria
(pages 32-26). The Assessor will then complete a Candidate Assessment Record (page 37).

ALL COMPONENTS OF THE PRACTICAL ASSESSMENT (TEACHING, OUTCOME

MEASURE AND SELF-EVALUATION ARE MARKED AS PASS OR REFER.

Cardiopulmonary resuscitation (CPR)

You must present a valid CPR certificate to the Assessor on Day 6. If you do not hold a valid CPR
Certificate, a ‘refer’ will be recorded on your Candidate Assessment Record and you should post this
into the LLT Office as soon as possible. You will not be issued a L4 Exercise and Fitness Training
Specialist Instructor Qualification or Certificate until a valid CPR Certificate is registered with the LLT
Office.

Later Life Training  August 2010 24

 PRACTICAL ASSESSMENT MENU
[Level: Weeks 7-8 of the 12 week STARTER programme ]
EXERCISE AND FITNESS TRAINING AFTER STROKE
SPECIALIST INSTRUCTOR TRAINING COURSE

1. WARM UP
You will be required to teach only TWO elements from the warm up component (ie ONE Circulation
exercise and ONE Mobility exercises) but the other warn up exercises should be included in your
session plan

1a WARM UP: circulation exercise: gentle 'pulse raiser' i.e. low level marching on the spot/ side
stepping
1b1 WARM UP: mobility: shoulders (standing with 1 person seated)
1b2 WARM UP: mobility: lateral spinal flexion (trunk side bend)(standing with 1 seated)
1b3 WARM UP: mobility: spinal rotation (trunk twist)(standing with 1 person seated)
1b4 WARM UP: mobility: ankle flexion and extension(standing with 1 person seated)
1c1 WARM UP: stretches: calf (standing with 1 person seated)
1c2 WARM UP: stretches: hamstrings (all seated)
1c3 WARM UP: stretches: pectorals (all seated)
1c4 WARM UP: stretches: triceps (all seated)
1c5 WARM UP: stretches: latissimus (standing with 1 person seated)

2. TRAINING/ AEROBIC ENDURANCE: CIRCUIT

You will be required to teach TWO elements from the circuit component. Introduce’ TWO specified
circuit exercises IN FULL to the whole group prior to the commencement of the circuit. (ie.
demonstrate and group practice with you correcting, adapting tailoring, being interactive and ;in
control’ of the circuit. Your session plan should have all the exercises below for approximately one
revolution of the circuit.

2a TRAINING/ CIRCUIT: bike

2b TRAINING/ CIRCUIT: ball lift and lower
2c TRAINING/ CIRCUIT: walk
2d TRAINING/ CIRCUIT: wall press
2e TRAINING/ CIRCUIT: step-up

Later Life Training  August 2010 25

2f TRAINING/ CIRCUIT: hand-to-knee
2g TRAINING/ CIRCUIT: sit to stand: endurance (rhythmical, steady pace)

3. STRENGTH TRAINING :UNISON

You will be required to teach TWO elements from the strength component, one to a group and one
to an individual. Your session plan should include all exercises.

3a STRENGTH TRAINING: pole lift/ lower

3b STRENGTH TRAINING: triceps extension (triceps press) with resistance
3c STRENGTH TRAINING: upper back strengthener ("backward row") with resistance
3d STRENGTH TRAINING: sit to stand (slower pace for strength)

4. COOL DOWN
You will be required to teach ONE flexibility stretch from the cool down component but all elements
of the cool down should be included in your session plan.

4a COOL DOWN: circulation exercise: gentle 'pulse lowerer' i.e. low level marching on the spot.
4b1 COOL DOWN: stretches: calf (standing)
4b2 COOL DOWN: stretches: pectorals (seated)
4c3 COOL DOWN: stretches: hamstrings(seated)
4b4 COOL DOWN: stretches: triceps (seated)
4b5 COOL DOWN: stretches: latissimus (seated OR standing)

OUTCOME MEASURES
You will be required to demonstrate and conduct ONE of the following outcome measures.

5a 10 meter walk test

5b Timed Up and Go
5c Visual Analogue Scale

Later Life Training  August 2010 26

Health and Safety Venue Assessment for L4 Exercise after Stroke Session
Venue Information and contacts
Venue Name Date of Assessment / Review date

Contact Person / Details for Venue Person(s) writing assessment

Address of Venue

Client Information
Maximum number within class Any known special requirements of client group i.e. NO YES
Are support Staff required Medical/Overall Risk Stratification /Behavioural (if yes please indicate action below)
First Aid and Fire
Location of First Aid Kit Fire Exits

First Aider on call during class Fire Fighting equipment locations

Location of Telephone Fire Assembly point

Venue specific procedure for 1st Aid Venue Specific procedure for Fire

Site Information
Location / Distance of toilets Wheelchair access

Car Parking Information Hearing aid loop?

Equipment Used: Safety Points.

Equipment Name Hazards or Risks Associated Controls in place to reduce risk Likelihood (L) x Severity (S) = Risk (R) Risk Rate
L S =R H/M/L

L S =R H/M/L

L S =R H/M/L

L S =R H/M/L

L S =R H/M/L

Later Life Training  August 2010 27

EfS Environmental / Exercise/ Client Based Risk Assessment
Potential Risk Hazards or Risks Associated Controls in place to reduce risk Likelihood (L) x Severity (S) = Risk (R) Risk Rate
Ceiling Height L S =R H/M/L

Floor L S =R H/M/L

Obstacles L S =R H/M/L

Temperature / Ventilation L S =R H/M/L

Equipment L S =R H/M/L

Access to venue (i.e. car loading etc) L S =R H/M/L

Privacy / Protection issues L S =R H/M/L

Exercise / Skill Choices L S =R H/M/L

Health/ Suitability of Clients L S =R H/M/L

Lighting/Distractions L S =R H/M/L

Other L S =R H/M/L

Later Life Training  August 2010 28

Medium or High Level Risk Continuation Assessment for L4 Exercise After Stroke Session

Name of Risk Original Risk Rating Further Action taken to reduce risk rating Revised Risk Rating
Likelihood (L) x Severity (S) = Risk (R) Level
L S =R H/M/L

L S =R H/M/L

L S =R H/M/L

L S =R H/M/L

L S =R H/M/L

L S =R H/M/L

L S =R H/M/L

L S =R H/M/L

L S =R H/M/L

L S =R H/M/L

L S =R H/M/L

L S =R H/M/L

L S =R H/M/L

L S =R H/M/L

L S =R H/M/L

Source: St John Ambulance Issue 3 (2007). Level 2 Certificate in Risk Assessment Booklet. BSC Awards.

Later Life Training  August 2010 29

 L4 EXERCISE AFTER STROKE SPECIALIST INSTRUCTOR SESSION
PRACTICAL ASSESSMENT OBSERVATION CHECKLIST (FULL DETAIL)
Candidate Name: Date:
Assessors Name:
The Candidate must demonstrate competence in the following essential criteria.
(1) PLANNING – The candidate produced a plan that:
P1. Included a health and safety information sheet relevant to the needs of
participants and exercise after stroke identifying specific environmental and
equipment factors to ensure safety during the session
P2. Produced a plan that was appropriate to the needs of a range of participants after
stroke
P3. Selected safe and effective exercises appropriate to the component and to fitness
training after stroke (including warm-up and cool-down)
P4. Provided specific, relevant teaching points for each exercise in order to provide a
safe and effective session of exercise after stroke
P5. Included adaptations and/or alternative exercises and individual tailoring
strategies for each exercise in each component which enable stroke survivors to
participate safely and effectively in all exercises and components
P6. Contained exercises that reflect current good practice and current evidence based
guidelines for exercise after stroke
4) ENDING THE SESSION AND GAINING FEEDBACK - The candidate:
F1. Gained constructive feedback about strengths and gaps in meeting the assessment
criteria from participants at the end of the session
KEY: P / √ = PASS = PASS WITH COMMENT Q = QUESTION
Later Life Training  August 2010
Course name :
Course code:
(2) PREPARING – With relevance to ethical practice the candidate:
P7. Wore attire appropriate to leading a session for stroke survivors and
to allow effective demonstrations.
P8. Set out equipment for the evidence-based programme and
demonstrated correct lifting technique with adaptations and individual
tailoring approaches appropriate for stroke survivors.
P9. Welcomed (formed a general impression of each participant) and
made them feel at ease in a manner which promotes confidence
in,concern for and effective communication with stroke survivors.
P10. Implemented appropriate verbal screening and adapted language
and communication skills to meet the needs of exercise after stroke
participants
P11. Gave guidance to individuals relevant to information gathered in a
sensitive and appropriate way taking into account the specific
communication needs of exercise after stroke participants
P12. Advised the participants of the purpose of the session relating to the
benefits of exercise and possible contraindications & reasons for stopping
an exercise with reference to fitness after stroke
(5) EVALUATING – The candidate evaluated correctly in terms of:
E1. Their application of the standard outcome measure
E2. Their own teaching skills
E3. Their delivery of contents of the session (safety and effectiveness)
E4.The feedback received from participants
R = REFER (3) TEACHING is overleaf
30
 CIRCILATION
Warm Up

MOBILITY
Warm Up

Aerobic 1
Circuit

Aerobic 2
Circuit

(group)
Strength

stretch
Cool down

(1:1)
Strength

Measure
Outcome

Result
Overall
Practical Assessment. Success in 7 out of 8 sections is required to pass
(3) TEACHING – The candidate:

T1. Appropriately arranged the group, individuals and resources to allow for safe and effective exercise taking into account the needs of stroke
participants and individual functional ability/comprehension/communication etc
T2 Delivered safe and effective exercises appropriate to the component and in accordance with the evidence-based exercise programme and
rationale for fitness training after stroke
T3. Demonstrated and performed adapted exercises (with alternatives and tailored therapy led approaches for individuals) with correct
technique (posture, stable base, positioning, alignment, grip, movement quality /control) using appropriate visual and verbal cues and
information to account for the needs of stroke survivors and individual functional ability/comprehension/communication
T4. Gave effective and appropriate visual and verbal cues and instructions eg. adjusting pace of speech, language, volume and clarity of
instructions appropriate for a diverse range of communication challenges experienced by stroke survivors
T5. Explained the purpose of the exercises, relating them to activities of daily living & benefits for fitness after stroke and tailoring information in
an appropriate way for individuals with specific stroke related needs
T6. Provided specific teaching points and demonstrated use of therapy led approaches to stroke specific adaptations for all exercises to enhance
technique, safety and effectiveness (especially with relevance to inattention, memory loss and fatigue)
T7. Selected the appropriate intensity for the exercises (speed/level of effort) whilst monitoring and adjusting intensity for each individual,
tailoring to meet the needs of participants with stroke specific limitations
T8. Engaged participants in order to encourage, motivate and promote confidence and adapted communication skills (visual and verbal cues) to
meet the needs of each individual with relation to their specific physical and sensory impairments
T9. Offered alternatives to allow for different levels of ability and tailored exercises for individuals by responding to feedback from participants
and offer appropriate alternatives as well as offering stroke specific adaptations and progressions to the group as a whole
T10. Reinforced relevant teaching points at regular intervals recognising the need to adapt language and approaches for stroke survivors to
enhance performance (especially with relevance to inattention, memory loss and fatigue)
T11. Changed teaching position to improve observation and enhance communication to accommodate the stroke specific needs of each
participant
T12. Demonstrated the use of observation and effective correction which was appropriate and sensitive, respecting individuals dignity and
ability, to ensure the most effective performance considering the stroke specific needs of each participant
T13.Provided safe transitions and took measures to reduce the risk of falls through excellent group management skills between exercises and
session components (including use of equipment) and between exercises ensuring instructions are tailored to stroke specific conditions
T14. Asked questions and encouraged interactive communication, to check or clarify understanding in a way to engage and receive quality
feedback to ascertain that understanding has taken place (with respect to disarthia, dysphasia, cognition and sensory impairments)
T15. Spoke clearly, audibly and at an appropriate pace by adapting pitch/tone/timing and language with respect to disarthia, dysphasia,
cognition and sensory impairments
T16. Adapted exercises to meet the specific needs of stroke survivors. Delivered stroke specific adaptations to the group and offered tailoring
and alternatives to individuals (i.e. promoting external rotation at shoulder, stance positioning with AFO, unaffected side focus on shuttle
walk, bilateral assistive support on upper limbs with altered tone, postural stability strategies during knee raises)
T17. Demonstrated best practice to guide participants in preventing/managing adverse effects of exercise by observing and individual correction
to ensure movement patterns remain in optimum ranges without adverse affects (i.e. triggers that exercises may be too intense leading to
adverse tonal changes in affected limbs/posture)

Later Life Training  August 2010 31

 L4 EXERCISE AND FITNESS TRAINING AFTER STROKE SPECIALIST INSTRUCTOR
OBSERVATION CHECKLIST - INTERPRETATION OF MARKING CRITERIA
(1) PLANNING –
The candidate produced a plan that:
P1. Included a health and safety
information sheet relevant to the
needs of participants and exercise
after stroke identifying specific
environmental and equipment
factors to ensure safety during the
session
P2. Produced a plan that was
appropriate to the needs of
participants after stroke
P3. Selected safe and effective
exercises appropriate to the
component and fitness after stroke
(including warm-up and cool-down)
P4. Provided specific, relevant
teaching points for each exercise in
order to provide a safe and effective
session of exercise after stroke
P5.Included alternative exercises
and tailoring of each component
which enable stroke survivors to
participate safely and effectively in
all exercises and components
P6. Contained exercises that reflect
current good practice and current
guidelines for exercise after stroke
Later Life Training  August 2010
• Clearly showed they had considered all aspects of health and safety to reduce risk by providing a written health
and safety information sheet which included a risk assessment for the venue and participants. Covering issues
concerning equipment, environment and the needs of the group. Identifying they had considered emergency
procedures and first aid issues with particular attention to the needs of stroke survivors.
• Provided a plan using exercises from the stroke after exercise programme (STARTER) with particular attention to
the evidence base and the specific adaptations for stroke survivors.
• Provided a plan selecting exercises from the STARTER programme, and demonstrated mastery of the therapy
led approaches to individual tailoring
• Ensuring that each component is effective and appropriate for the needs of stroke survivors (eg appropriate
content and intensity for fitness gains in EfS including appropriate number of reps/sets and timings tailoring for
individual needs where appropriate)
• Provided teaching points for all exercises with particular attention to stroke specific adaptations (eg outward
rotation with shoulder extension to reduce/prevent increased tone) ensuring that teaching points are specific to
the exercise.
• Teaching points given where prioritized and specific to the exercise.
• Provided alternatives to allow for individual fitness levels and ability to ensure the exercise is safe and effective
for all participants with consideration for issued concerning hemi-inattention, AFO splints and acemetrical
movement patterns
• Provided a plan that included components and exercises that reflect current guidelines/good practice (ie
included an appropriate warm up and cool down) with appropriate timings/intensity/reps for stroke survivors.
32
(2) PREPARING –
With relevance to ethical practice the candidate:
P7. Wore attire appropriate to leading a
session for stroke survivors and allowed
effective demonstrations.
P8. Set out equipment and demonstrated
correct lifting technique with adaptations
appropriate for stroke survivors.
P9. Welcomed the participants and made
them feel at ease in a manor which
promotes confidence and effective
communication with stroke survivors.
P10. Implemented appropriate verbal
screening and adapted language and
communication skills to meet the needs of
participants and exercise after stroke
P11. Gave guidance to individuals relevant
to information gathered in a sensitive and
appropriate way taking into account the
specific communication needs of
participants & exercise after stroke
P12. Advised the participants of the purpose
of the session relating to the benefits of
exercise and possible contraindications &
reasons for stopping an exercise with
reference to fitness after stroke
Later Life Training  August 2010
• Clothing was appropriate for leading an exercise after stroke session
• Appearance and image considered in order to promote confidence with participants and allow for effective
demonstrations
• Clothing was clean and presentable and appropriate
• Footwear was supportive and secured (fastened)
• Unless required for specific reasons, headgear was not worn
• If baggy/loose clothing was worn, coping strategies must be used to demonstrate correct joint alignment and
technique.
• Gum was disposed of prior to the session
• Ensured the exercise area and equipment was set up appropriately in order to lead a safe and effective session by
arranging equipment to suit the needs of stroke survivors to ensure the group and individuals can access all
equipment safely and use effectively. Taking into account stance positioning with AFO, bilateral assistive support on
upper limbs with altered tone and postural stability strategies etc)
• Was a positive roll model and used correct lifting technique when setting up equipment and demonstrated
adaptations appropriate for stroke survivors.
• Established a rapport with the group at the start of the session in a positive manor which encouraged interaction
with participants
• Was appropriate to the needs of individuals using language which promotes confidence and effective
communication with stroke survivors
• Encouraged participants to give details of anything that could affect their ability to perform any of the exercises by
asking questions discreetly/appropriately
• Adapted language and communication skills to meet the needs of participants and exercise after stroke to ensure
participants understand the need for relevance and feel at ease in providing information
• Responded appropriately to feedback gained (P10) and gave appropriate advice in a sensitive and appropriate way
taking into account the specific communication needs of participants & exercise after stroke.
• Gave a brief outline of the session stating the purpose of each component explaining why participants may wish to
rest or provide alternatives.
• Provided opportunity for the group to ask questions
33
Practical Assessment: Success in 7 out of 8 sections of the session is required to pass.
(3) TEACHING - The candidate:
T1. Appropriately arranged the group,
individual and resources to allow for safe
and effective exercise taking into account
the needs of stroke participants and
individual functional
ability/comprehension/communication
T2 Delivered safe and effective exercises
appropriate to the component and in
accordance with the evidence- based
exercise programme and rationale for
fitness training after stroke
T3. Demonstrated and performed adapted
exercises (with alternatives and tailored,
therapy lead approaches for individuals)
with correct technique (posture, stable
base ,positioning, grip, movement
quality/control) using appropriate visual
and verbal cues and information to account
for the needs of stroke survivors and
individual functional ability/comprehension
/communication
T4. Gave effective and appropriate visual
and verbal cues and instructions eg
adjusting the pace of speech, language,
volume and clarity of instructions
appropriate for a diverse range of
communication challenges experienced by
stroke survivors
T5. Explained the purpose of the exercises,
relating them to activities of daily living &
benefits for fitness after stroke and
tailoring information in an appropriate way
for individuals with specific stroke related
needs
Later Life Training  August 2010
• Demonstrated adapted planning for EfS, with consideration given to the lay out of the exercise area relating to the environment and
potential challenges and impairments of stroke survivors participating in an exercise class (ie inattention, tonal changes, fatigue and
comprehension/understanding and risk of falls/communication)
• Demonstrated adapted planning for EfS, with consideration given to room lay out and access of equipment used in the exercise class
(e.g. participants with hemi-inattention or left sided weakness are positioned appropriately within the group to reduce challenges and
risks associated with equipment)
• Delivered the adapted exercises from the STARTER programme and demonstrated mastery of exercise technique and of the therapy led
strategies and approaches to individual tailoring (by adapting the angle of the limb/pace of exercise or transition/ levels of intensity etc
and by coaching individual exercise technique whilst considering the safety and effectiveness of adaptations offered)
• Delivered safe and effective components of the STARTER programme; including appropriate number of reps/sets/durations,
demonstrating appropriate intensity and progressions for each participant without compromising the safety of the group
• Delivered technically correct, and concise demonstrations at appropriate pace and optimum teaching positions (i.e. considered
appropriate teaching position and the amount of information given adapted for individual stroke survivors within the group)
• Considered appropriateness of instructions and teaching position for stroke specific conditions (ie inattention, tonal changes, fatigue and
comprehension/understanding and risk of falls)
• Demonstrated excellent verbal communication skills, adjusting pace, language, volume. clarity and reinforcement of instructions
appropriate for a diverse range of communication deficits/challenges experienced by stroke survivors
• Visual cues are clear and appropriate considering; teaching position, group dynamic and individual requirements (i.e. transitions and
directional changes are reinforced with clear visual cues and are given at appropriate times to ensure safety and enjoyment)
• Is able to articulate clear set up instructions for each exercise, and management of transitions from one exercise to another and offer
appropriate advice for stroke specific conditions (ie inattention, tonal changes, fatigue and comprehension/understanding and risk of
falls) to ensure safe & effective participation.
• Benefits and purpose of exercises given and related these to the individuals within the group (eg related to stroke specific goals and
benefits of fitness after stroke to specific individualized activities of daily living and reduction in health related risk factors such as
cardiovascular disease, falls and fractures)
34
T6. Provided specific teaching points and
demonstrated use of therapy led approaches to
stroke specific adaptations for all exercises to
enhance technique, safety and effectiveness
(especially with relevance to inattention, memory
loss and fatigue)
T7. Selected the appropriate intensity for the exercises
(speed/level of effort) whilst monitoring and
adjusting intensity for each individual, tailoring to
meet the needs of participants with stroke specific
limitations
T8. Engaged participants in order to encourage,
motivate and promote confidence and adapted
communication skills (visual and verbal cues) to
meet the needs of each individual with relation to
their specific physical and sensory impairments
T9. Offered alternatives to allow for different levels of
ability and tailored exercises for individuals by
responding to feedback from participants and offer
appropriate alternatives as well as offering stroke
specific adaptations and progressions to the group
as a whole
T10. Reinforced relevant teaching points at regular
intervals recognizing the need to adapt language
and approaches for stroke survivors to enhance
performance (especially with relevance to
inattention, memory loss and fatigue)
T11. Changed teaching position to improve observation
and enhance communication to accommodate the
stroke specific needs of each participant
T12. Demonstrated the use of observation and effective
correction which was appropriate and sensitive,
respecting individuals dignity and ability, to ensure
the most effective performance considering the
stroke specific needs of each participant
Later Life Training  August 2010
• Provided specific teaching points for each exercise related to each individuals ability to perform any given exercise/movement
• Demonstrated use of therapy led approaches to stroke specific adaptations (e.g. outward rotation with shoulder extension,
accommodating AFO’s, wrist splints and users of FES)
• Delivered effective instructions to enable participants to maintain optimum posture in seated, standing and during movement (in relation
to stroke specific communication challenges and physical function inability and postural stability challenges)
• Offered purposeful rationale for the content of the STARTER programme with relation to IADL’s and fitness after stroke (i.e. pole lift, balls
raise, wall press)
• Exercises are demonstrated/performed and recommended at a speed/ pace to encourage optimum technique for effectiveness, and safety
(to be effective in reducing risk factors including cardiovascular disease, falls and fractures)
• Monitored and adjusted intensity for each individual, tailoring to meet the needs of participants with stroke specific limitations (i.e.
considering implications of AFO’s, wrist splints and use of FES)
• Demonstrates effective group management skills and control of specific exercises (whilst still managing tailoring to the needs of individuals
with specific needs).
• Provided the group with positive and specific feedback based on group and individual performance.
• Adapted communication skills (visual and verbal cues) to meet the needs of each individual with relation to their specific physical and
sensory impairments (including changes in muscle tone, inattention. neglect or challenges with postural stability)
• Obtained constructive feed back from participants in order to offer specific adaptations and tailoring.
• Used appropriate language to motivate and promote confidence i.e. recognizing achievement and level of effort, use of praise)
• Offered effective alternatives to allow for individual fitness levels and ability (eg Candidate needs to respond to feedback from participants
and offer appropriate alternatives as well as offering adaptations and progressions to the group as a whole)
• Demonstrated understanding of the requirement for regular reinforcement/reminders of specific teaching points for the group, and any
participant identified as requiring increased need for reinforcement (i.e. especially participants with neglect/inattention) using a variety of
visual and verbal instructions tailored to the specific needs of the group.
• Adapted teaching position to accommodate the stroke specific needs of each participant (i.e. considering visual impairments and those
with altered body schema) and ensure full observation without compromising safety (ie those with balance/mobility issues) or
effectiveness (eg change in position improved communication whilst maintaining group control)
• Demonstrated effective observation and appropriate individual corrected technique in a sensitive way, respecting individuals dignity and
ability to ensure the best/most effective performance of each exercise by all participants (taking into account stroke specific conditions eg.
visual impairments, those with altered body schema AFO’s, wrist splints and use of FES)
35
T13. Provided safe transitions and • Applied group management and organizational skills (visual, verbal) to safely direct and move a group of stroke survivor participants around an exercise
took measures to reduce the risk of area/class through; allowing sufficient time for transitions in relations to delivery of instructions; identified individuals who may need additional
falls through excellent group guidance/instruction/supervision throughout transitions
management skills between • Communicated with individuals in an appropriate and sensitive way, respecting individuals dignity and ability without compromising safety.
exercises and session components • Instructions and timing is adapted taking into account levels of ability and understanding of individual needs.
(including use of equipment) and • Use of equipment and instruction for use is tailored to stroke specific conditions (i.e. safe and correct mount/dismount on cycle)
between exercises ensuring • Selected safe approaches to all exercise stations (i.e. unaffected side able to access support options, sit to stand, step ups etc)
instructions are tailored to stroke • Provided individual supervision needs without compromising safety of the group
specific conditions • Demonstrated awareness of group needs at all times and delivered appropriate tailoring of transfers where required
T14. Asked questions and encouraged • Asked bespoke questions to individuals in a way to engage them, receive quality feedback, and to ascertain that understanding has taken place (with
interactive communication, to check or respect to disarthia, dysphasia, cognition and sensory impairments)
clarify understanding in a way to engage • Facilitated group encouragement and motivation through appropriate questioning using language and visual cues to enhance understanding.
and receive quality feedback to ascertain • Positively encouraged two way communication in order to continually assess and monitor responses to exercise, anxiety fatigue or confusion.
that understanding has taken place (with
respect to disarthia, dysphasia, cognition
and sensory impairments)
T15. Spoke clearly, audibly and at an • Delivered clear and audible instructions when communicating with the whole group. Adapting pitch/tone/timing and language when giving individual
appropriate pace by adapting feedback or adaptations (i.e. delivered in an appropriate and sensitive way, respecting individuals dignity and ability without compromising safety).
pitch/tone/timing and language with
respect to disarthia, dysphasia,
cognition and sensory impairments
T16. Adapted exercises to meet the specific • Applied problem solving skills and therapy led approaches to tailoring to the specific needs of stroke survivors individual needs (i.e. AFO’s, flaccid upper
needs of stroke survivors. Delivered stroke limb, high/low tone, inattention) and ability at appropriate times delivered in an appropriate and sensitive way, respecting individuals dignity and ability
specific adaptations to the group and without compromising effectiveness and safety
offered tailoring
and alternatives to individuals
(i.e.promoting external rotation at
shoulder, stance positioning with AFO,
unaffected side focus on shuttle walk,
bilateral assistive support on upper
limbs with altered tone, postural stability
strategies during knee raises)
T17. Demonstrated best practice to • Asked individual questions in order to ascertain/monitor intensity of all exercises
guide participants in • Demonstrated observation and individual correction to ensure movement patterns remain in optimum ranges without adverse affects (i.e. triggers that
preventing/managing adverse exercises may be too intense leading to adverse tonal changes in affected limbs/posture or confusion/fatigue)
effects of exercise by observing and • Set out clear ‘Stop Signs’ at class introduction (i.e. when to stop exercising) which where reinforced throughout the component
individual correction to ensure
movement patterns remain in optimum
ranges without adverse affects (i.e.
triggers that exercises may be too
intense leading to adverse tonal
changes in affected limbs/posture)

Later Life Training  August 2010 36

 CANDIDATE ASSESSMENT RECORD FOR L4 EfS SPECIALIST INSTRUCTOR SESSION

Candidate Name: Course Name and Code:

Chief Assessors Name: Date:

Summary of Assessment Date of Evidence & Summary of Candidates Action Plan for L4 Exercise and Assessors signature
Assessment Outcome (Delete Assessment Assessment Fitness Training after Stroke Qualification
as appropriate) Method
TRAINING PROVIDER:
APA WRITTEN
CERTIFICATE NUMBER:
CPR
DEFER Awarding date: Renewal date:

THEORY PAPER PASS WRITTEN %

(1.1)
REFER

CASE STUDY PASS WRITTEN %

(1.2)
REFER

PLANNING PASS WRITTEN

(1.2) QUESTION
REFER

TEACHING PASS OBSERVATION

(2.1 & 2.2) QUESTION
REFER

OUTCOME PASS OBSERVATION

MEASURE QUESTION
(2.2) REFER

EVALUATION PASS WRITTEN

(2.0)
REFER

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 L4 EXERCISE AFTER STROKE SPECIALIST INSTRUCTOR TRAINING COURSE - ASSESSOR’S
FEEDBACK SHEET

Candidate Name: ___________________________ Date: __/__/__ Page:__

Assessors Name: Assessors Signature:

Criterion
No.

Later Life Training  August 2010 40

 CANDIDATE SELF EVALUATION FOR L4 SPECIALIST INSTRUCTOR EXERCISE AND
FITNESS TRAINING AFTER STROKE SESSION

Candidate Name: Candidate Signature:

PEER FEEDBACK
After teaching my session, I received the following feedback from the
Participants (ie. my peers):

SELF EVALUATION ~
Comments on your thoughts of how your teaching met the Specialist EfS Instructor assessment
criteria

Later Life Training  August 2010 41

ACTION PLAN
List the improvements/changes you feel you need to action to improve your future EfS
teaching:

Assessor comments on how the candidate’s evaluation correlated with their teaching and
with participant feedback/Action plan

Assessor Name: Assessor Signature:

Internal Verifier Signature: Date:

Later Life Training  August 2010 42

 EfS OUTCOME MEASURES

In the assessment, students will be asked to undertake one of the following THREE outcome measures in
a one-to-one setting:
- 10 meter walk test or
- Visual Analogue Scale or
- Timed Up and Go.

10 METER WALK TEST

Introduction:
There are a number of different timed walking tests, which typically measure the time taken to cover a
set distance, or the distance covered in a set period of time (Wade, 1992). Commonly used variations
are the 6 minute walk test and the 10 meter walk test.

Protocol:
Set up a 10 m walkway, e.g. two lines, perpendicular to the direction of travel, and at a distance of 10m
apart. The participant is asked to walk at their preferred speed, using any aid needed (including personal
support, Wade, 1992). The participant starts 2m before the starting line and finishes 2 m over the
finishing line. Time is started as the leading foot first crosses the starting line and ends as the leading
foot first crosses the finishing line, respectively. If possible, the average of 3 tests should be taken, after
a practice trial.

References
SCHEFFER TM, HACKER TA, MOLLINGER L (2002). Age- and Gender-Related Test Performance in Community-
Dwelling Elderly People: Six-Minute Walk Test, Berg Balance Scale, Timed Up & Go Test, and Gait Speeds.
Physical Therapy 82 (2): 128-137.
WADE DT (1992) Measurement in Neurological Rehabilitation, Oxford, Oxford University Press.
WILLENHEIMER R, ERHARDT L (2000) Value of 6-min-walk test for assessment of severity and prognosis of heart
failure The Lancet 355 (9203): 515 -516.

Later Life Training  August 2010 43

VISUAL ANALOGUE SCALE
__________________________________________________________________________________

Introduction:
Visual Analogue Scales are used widely in health care settings to obtain a measure of a patient’s
perception of a health issue. There is a considerable body of research on the properties of the VAS.
“Pain” is probably the most widely assessed issue, but other examples include overall well-being and
function. Students may assess any issue, provided this is relevant to the participant in an exercise after
stroke setting. Examples discussed in class included: fatigue, confidence in a particular exercise, pain,
mood. The student must be specific in their statement, and the anchors must reflect extreme ends of
the spectrum pertaining to the construct being measured (e.g. no confidence at all/ extremely
confident). Students should check that the participant understands the statement, and how the VAS
works, since people with stroke may have difficulty understanding the tool (Price et al., 1999).
A VAS can be horizontal or vertical. For working with people with stroke, vertical VAS is less prone to
error than horizontal VAS (Price et al., 1999).

Protocol
The participant should be seated at a table.
Students are given a blank sheet of A4 paper, a pen and a ruler and are asked to construct a VAS at the
assessment.
The VAS comprises a line of 10 cm long without any numbers or subdivisions.
Each end of the line is anchored with an extreme statement reflecting the issue being measured, e.g.
“zero represents no pain whatsoever and 10 represents the worst possible pain”.
The assessor explains the VAS to the participant and clearly explains what the anchors stand for.
The VAS should then be offered to the participant, with the participant’s midline aligned with the
midline of the paper. The vertical VAS should be drawn in the middle of the paper (this is to avoid any
boas due to hemi-inattention, neglect or visual impairment).
The participant is then asked to mark the line at a position that indicates their current perception of the
issue being measured.
The location of this mark is then measured in millimetres from the lower end.

References
PRICE CIM, CURLESS RH, RODGERS H (1999) Can Stroke Patients Use Visual Analogue Scales? Stroke 30: 1357-
1361.

Later Life Training  August 2010 44

TIMED UP & GO

Introduction:
The Timed Up & Go was designed to assess basic mobility skills in frail elderly people, living in the
community. It is based on the Get-Up and Go test by Mathias et al. (1986), which was originally scored
on an observational scale. Time taken to perform the test is simple to measure and improves the
robustness of the results.

Protocol:
“The timed "Up & Go" measures, in seconds, the time taken by an individual to stand up from a standard
arm chair (approximate seat height of 46 cm), walk a distance of 3 meters, turn, walk back to the chair,
and sit down again. The subject wears his regular footwear and uses his customary walking aid (none,
cane, or walker). No physical assistance is given. He starts with his back against the chair, his arms
resting on the chair's arms, and his walking aid at hand. He is instructed that, on the word "go," he is to
get up and walk at a comfortable and safe pace to a line on the
floor 3 meters away, turn, return to the chair, and sit down again. The subject walks through the test
once before being timed in order to become familiar with the test. Either a wrist-watch with a second
hand or a stop-watch can be used to time the performance..” (Podsiadlo & Richardson, 1991, p. 142).

References
PODSIADLO D & RICHARDSON S (1991). The Timed "Up & Go": A Test of Basic Functional Mobility for Frail Elderly
Persons. Journal of the American Geriatric Society 39: 142-148.
SHUMWAY-COOK, A., BRAUER, S., & WOOLLACOTT, M. (2000). Predicting the probability for falls in community-
dwelling older adults using the timed up & go test. Physical Therapy, 80(9): 896-903.

Later Life Training  August 2010 45

Notes:

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