La rimodulazione delle esenzioni esistenti (negative scope)

3.3.1. Choosing a suitable Tai Chi instructor

As discussed above, choosing which style of Tai Chi to use for stroke survivors needs careful consideration. However, finding a Tai Chi instructor specialising in the desired style may not be possible due to a lack of instructors in the area. Previous studies have not explained why they used a certain Tai Chi style. Therefore, it may be that previous studies used a certain Tai Chi style because it was the only one available, or it was convenient. Taylor-Piliae et al.

(2014a) acknowledged that Yang style is the most popular one practised in the West, suggesting it may have been the only option. Thus, one advantage of using Yang style among western studies is the ability to compare results across studies.

The Tai Chi instructor at the researcher’s gym who specialised in Yang style was approached. The researcher designed the TCAS programme before approaching the instructor, so that he could see what was desired from the study. The instructor then

offered his expert advice without diverting from the research question. This first draft of the exercises designed for TCAS can be found in Appendix 3.

It has become clear from the above discussion that self-efficacy, transport issues and significant others may play an essential role in adherence, attendance and retention of participants. Taylor-Piliae et al. (2011) suggest that a charismatic Tai Chi instructor is essential in maintaining adherence to their Tai Chi programme for stroke survivors.

According to Yang et al. (2014), Tai Chi instructors include qualitative components such as imagination, philosophy, encouragement and the Tai Chi principles which may make or break the success of the Tai Chi programme. Therefore, utilising one Tai Chi instructor may help participants talk about issues regarding adherence, attendance and retention, so that

the researcher and instructor can work through these issues to avoid participants dropping out of the study.

3.3.2. Designing appropriate exercises for stroke survivors with varying levels of impairment

There are numerous things to weave into the designing of a Tai Chi programme for stroke survivors. This section will discuss things to consider, such as the safety of participants, ways to improve attendance and adherence, and communication. Justification for the

inclusion of each exercise in both the class and home practice shall also be discussed. It will be made clear which exercises were initially included by the researcher and how the final version of the TCAS programme was developed following collaboration with the Tai Chi instructor. A number of pertinent aspects related to safety, attendance/retention and communication were considered during the development of TCAS:

1) What is in place for fatigued participants?

2) Is there a need for special clothing?

3) What can be done to maximise attendance and adherence?

4) Which exercises should be included?

5) How long and frequent should Tai Chi classes be?

6) Are these exercises to be included the most appropriate?

7) Should the programme include a ‘warm up’ or ‘cool down’?

8) Why is each exercise included in the study?

9) What exercises would be better suited for home practice?

10) What should be included and omitted from the home practice DVD and booklet?

11) How long should home practice be?

3.3.3. Ensuring the safety of participants

Safety of stroke survivors whilst taking part in exercise is important to consider, particularly because this population is at high-risk of falls. Aspects of safety to consider are fatigue, ratio of instructors per participants, clothing and footwear. This section will discuss concerns regarding safety and how they were addressed.

Stroke survivors experience fatigue, so they are encouraged to not only rest as part of the programme’s schedule, but to also rest whenever needed. As well as placing chairs near participants during exercises in the TCAS, study chairs were laid out along the length of the sports hall where participants were stepping, so they could have intervals of rest whenever they required. Whilst resting, participants were able to observe other participants practising their movements.

Stroke survivors who are assessed as being at risk of falling require supervision during the intervention. Therefore, it is important that there are enough people to monitor the

participants during the intervention. Previous studies have used small groups. For example, Au-Yeung et al. (2009) used a class of between two and five participants, and Taylor-Piliae and Coull (2011) used a class of a maximum of six participants. The safest ratio of

instructor versus participant was sought from a local physiotherapist to be implemented in the TCAS study. The physiotherapist advised an instructor/participant ratio of two

supervisors per twelve participants to ensure the safety of participants.

Clothing is important when practising Tai Chi because if unsuitable clothing is worn, the full range of movement required may not be possible. Additionally, not being able to move easily may result in loss of balance because participants have adopted an incorrect movement or position. There is no specific Tai Chi clothing, but most Tai Chi instructors agree that casual clothing is ideal for Tai Chi (Docherty, 2014). Therefore, loose clothing is recommended for the TCAS programme so that participants may move freely: participants do not need to purchase any clothing specifically for Tai Chi and should be able to find suitable clothing in their wardrobe.

As well as clothing, suitable footwear is also important for practising Tai Chi safely.

Shoes chosen by many older people may increase their risk of falling, by impairing their ability to walk and keep their balance (Ramstrand, Theusen, Nielsen, Brandborg & Rusaw, 2010). Therefore, participants of the TCAS study were encouraged to wear shoes as suggested above.

In line with an emergency procedure by Taylor-Piliae et al. (2014a), an emergency

procedure for TCAS was verbally agreed between the researcher, hospital matron and ward staff. The emergency buzzer available in the sports hall could not be used because this would encourage ward staff to leave their patients. Therefore, a trained nurse would be present during the classes who would be qualified to deal with medical urgencies, such as falls. Should an adverse event happen, the incident would be dealt with as an out-of-hospital situation, where the participant would be treated by the researcher or taken to the Emergency Room.

A sense of safety among participants is important for the maintenance of attendance, adherence and retention. However, safety is not the only factor for ensuring the

continuation of the exercise programme. Other factors involved include catching up after participants fail to attend, not being able to get to the venue, participants’ feelings of not being able to do it, and feeling isolated. This section will discuss each of these points related to attendance, adherence and retention.

3.3.4. Designing exercises which stroke survivors can easily remember Participants may miss classes due to outpatient follow-up appointments and family

commitments. Being unable to attend certain classes, may make participants feel Tai Chi is not worth pursuing because they may forget what they have already learned or may not be able to catch up. Participants of TCAS join a rolling programme. By its nature, a rolling programme includes participants who are more ‘advanced’. The TCAS programme has, therefore, being designed to be flexible so that participants may drop in and out of classes without impeding on their progression. Participants may catch up easily because exercises are repeated in each class, to a point where participants become familiar with them.

Repetition of exercises not only increases familiarity but also helps to practice each

movement with greater accuracy. This accuracy in practising exercises enables participants to move onto more challenging exercises. Thus, feeling able to re-join a class at any time without difficulty may increase adherence.

3.3.5. Involving significant others

None of the Tai Chi studies involving stroke survivors in Chapter 2 mentioned the inclusion of significant others. Brooks, McCluskey, King & Burton (2013) suggest that the inclusion of significant others should be considered carefully when designing rehabilitation programmes.

For example, the authors showed that significant others may support optimal functioning in people with back pain. It may be that significant others (spouse, partners, close family members) may support stroke survivors’ attendance and adherence to Tai Chi. For this to occur, it is important that significant others do not perceive stroke disability as an obstacle to recovery, otherwise significant others may have a negative impact on attending Tai Chi classes. It is thought that self-management strategies are most effective when involving significant others, especially with more burden placed on healthcare due to the current ageing population; being involved in the recovery process may enable significant others to be able to encourage optimal functioning (McCluskey, de Vries, Reneman, Brooks &

Brouwer, 2015). In terms of the TCAS study, participants’ significant others may, therefore, become involved in the Tai Chi classes, enabling them to help participants with the home practice component of the intervention, thereby increasing adherence.

Significant others may provide a solution for transport issues if stroke survivors are unable to drive. It is known that lack of transportation is a barrier to exercise participation for stroke survivors (Taylor-Piliae, Boros & Coull, 2014b). However, adherence of significant others is required for this to be possible. Barriers which may cause a problem for significant others is the accessibility of parking. Using a hospital as the venue means high parking costs with limited availability of parking spaces. Additionally, significant others may find timing an issue because hospital car parks require payment by the hour, which may result in participants leaving classes early to avoid the payment of an extra hour.

3.3.6. Communication difficulties

Communication difficulties due to stroke may have a significant impact on participating in a Tai Chi exercise programme. Improved communication may develop through camaraderie.

To enable camaraderie in the TCAS study, refreshments were made available with time to socialise at the end of each class. This also encouraged participants to share plans regarding missing sessions due to appointments or holidays within a comfortable setting.

Communication is also important during the intervention (Taylor-Piliae et al., 2014b).

Impaired memory may prolong the mastery of exercises due to recall difficulties. Similarly, impaired comprehension may prolong the mastery of exercises due to an inability to

understand instructions. These difficulties in communication may lead to a lack of self-efficacy which may encourage the participant to drop out. Therefore, it is essential that the researcher and Tai Chi instructor possess effective communication skills. Excellent two-way communication skills are required for the correct adoption of each exercise. Clear instruction from the Tai Chi instructor on how to practise each exercise is required, with minimal word prompts. Where certain postures may be complex to describe in simple terms, analogies, common in Tai Chi classes, were used. For example, the concept of ‘central alignment’, the instructor may use commonly used analogies such as, “imagine there is a thread attached to the top of your head, connected to the sky, keeping you aligned” and “imagine there is a thread all the way down from your head, down the centre of your body, and is rooted firmly in the ground.” Participants will also be given time and encouragement to ask questions at any time.