Action for Rehabilitation from NeuroIogical Injury
ARNI was set up 13 years ago to attempt to ensure that there is an increasing body of
professional exercise instructors available to whom therapists (and other healthcare
professionals) can feel comfortable about referring directly. A more seamless carepathway is the ideal. The value-added of using professional exercise instructors is that the
functional retraining they are tasked to deliver seems to be a obvious way to seek to
prevent expensive long-term re-hospitalisation (due to decline after therapy or injury via
attempted risk-taking) and to „retrain‟ stroke survivors to a stage where successful
vocational rehabilitation or community integration occurs.
Evidence is still to emerge over time concerning whether utilising a rung of professional instructors in this way
can represent a significant saving nationally. But when it is considered that stroke costs the NHS and the
economy about £7 billion a year – £2.8 billion in direct costs to the NHS, £2.4 billion in informal care costs (for
example, the costs of home nursing borne by patients‟ families) and £1.8 billion in income lost to mortality and
morbidity, and benefit payments, it is clear that if using ARNI instructors can offset or delete these costs
concerned with newly discharged and longer-term community strokes even minimally, the intervention is
worthy of further investigation. The ARNI strategies are currently under evaluation by PenCHLARC (the
National Institute of Health Research's Collaboration for Leadership in Applied Health Research and Care for
the South West) and Brunel University.
A consideration for exercise trainers such as yourselves may be that the target population require, after a
therapist has finished working with them (for whatever reason) a professional physical instructor to guide them
into „retraining‟ mode. By „retrain‟, we mean to help them work on their „edges of current limitations‟, empower
them to take controlled risks leading to success… and be creative with their own recoveries. The idea is to
take stroke survivors back to (if required) a functional standard that they were left in after therapy input, and
then go further than the standard that the hospitals had the time, resources or workable strategies to deliver.
ARNI Functional Training after Stroke CPD – Conference Taster Session.
You are going to learn a few major ARNI-innovated gross-motor movement strategies
today in an ARNI FTS taster session with Dr Tom Balchin and Dr Susie Dinan-Young.
The most important of these strategies, for many stroke survivors with residual functional limitations including
paretic lower and upper body, is learning the ability to get up from the floor unaided. There are many facets to
learning how to teach this strategy effectively, but as L4 Stroke Instructors you will be aware of the difficulties
faced by survivors who are still using supports such as sticks to reduce the incidence and fear of falls, which
are common among stroke survivors (Forster and Young 1995).
Whilst in hospital, in the first six months after the stroke, and in the longer term, stroke survivors have more
falls than the general population of older people, and often with more severe consequences (Jorgensen,
Engstad et al. 2002; Batchelor, Hill et al. 2010). A majority of trainees come to ARNI not being able to get to
and up from the floor. One survey found that less than half those with stroke were able to get up after a noninjurious fall (Tinetti, Liu et al. 1993). Even if a fall does not directly cause serious injury, the inability of the
person to rise independently may lead to complications such as hypothermia, dehydration and pressure sores
if there is a long wait before help arrives (Reece and Simpson 1996). Fear of falling may lead to reduced
activity (Tinetti, Mendes de Leon et al. 1994) and restrictions to participation, so lessening the chances of
recovery from a stroke.
MARGOT (former ARNI patient):
My particular concern was that I would never be able to sit outside on the grass again so the
instructors taught me how to sit on the floor/ ground. I found this very useful as it meant that
I could look forward to the summer months and sit in the park with everyone else. It took me a little
while to learn these techniques as I had developed a phobia of being on the floor but I have seen
other people join ARNI and learn this technique almost instantaneously.
Action to reduce these fears has been recommended (Forster and Young 1995). ARNI has found a way to do
this by teaching the importance of „retraining‟ with the aim of inducing greater robusticity and action control in
limbs. „Getting to the floor‟ is termed ‘The Gatekeeper Strategy’ because once learned, fear of the floor is
lessened and patients can practice getting down to the floor and up again.
From there, hundreds of strategies and exercises for functional gain can be learned. However, fear of the
consequences of falling is one of the biggest barriers to training. Moreover, incidences of falls can be reduced
once reliance on the use of sticks is negated: this important issue will be discussed during this session.
Teaching stroke survivors to get up from the floor may help to allay their fears and those of their carers. If a
fall does occur, being able to rise independently or with a minimum of assistance may avoid “long lies” and
their consequences (Fleming and Brayne 2008) as well as give people the confidence to participate in society
knowing that they can „help themselves‟ if need be, wherever they are.
It is also clear that there are many emergency service call outs to people who have fallen and are unable to
get up, either because they are on their own or because their carer is unable to assist them. If the person who
has fallen is not injured and does not require hospitalisation then these call outs are logged as „non-conveyed‟
by the ambulance services. Even though stroke survivors may be more likely to have an injury there is still a
considerable number who are not conveyed. Providing stroke survivors with an effective technique to help
them get up from the ground independently is likely to reduce the number of non-conveyed call outs for the
ambulance service.
There is, as yet, no nationally recommended best practice / standardised approach to teaching „getting up off
the floor‟ for stroke survivors. Stroke survivors may be reluctant to get onto the floor in the first place in order
to practice the technique, particularly older people who may not have been in that position for many years
(Simpson and Salkin 1993). Clinicians may be reluctant to try to teach a technique that they perceive as
having a high risk of either injury when practicing the technique or of complete failure (meaning that the
person is left on the floor until moving and handling equipment is utilised).
These problems have led to the promotion of the backward chaining technique as the preferred method of
skill acquisition, in which each step is mastered before the next is attempted (Reece and Simpson 1996). A
retrospective study of floor-to-stand transfers among in-patient stroke survivors found that independence in
the manoeuvre was associated with independence in chair-to-floor transfers (Bohannon, Learey et al. 1995).
However, this backward chaining approach adds complexity to the technique and requires a considerable
commitment to practice each step without gaining benefit until the whole technique is mastered. Stroke
survivors report not being taught the technique, fail to recall being taught, or, do not maintain the skill once
they have finished rehabilitation.
The ARNI technique for teaching the independent floor-to-stand manoeuvre has been developed
specifically for use by a stroke survivor (Balchin 2011), providing a sequence of movements that
take into account the one-sided impairments that may be present.
There are unique features to this technique (for example a rotational element and the three point support
phase).The ARNI manual states that this technique has been used with many stroke survivors, taking
between one and ten sessions to learn. The technique is innovative, in that it enables the person to
compensate for a lack of balance. Internal video evidence has seen this process taught and mastered within 3
hours with a stroke survivor who before the intervention had difficulty performing a „getting to the ground‟
movement of any description. Subsequent video evidence showed full retention without significant prompts.
ARNI has stroke survivor‟s own accounts of being taught the ARNI technique and how this means they no
longer have to call out the paramedics to pick him up when he falls. Similarly, we have many reports of
success from ARNI instructors who have been teaching this technique to stroke survivors. Service audit data
for 24 participants attending one gym (Chaul End Stroke Facility, Luton) reported 24 ambulance calls out over
one year, these mostly occurred for one participant with a history of multiple falls. In the year after the
technique had been taught there were no call outs, with an estimated ambulance service saving of £7,200.
While the ARNI technique for teaching FTS has been used for stroke survivors, including those attending NHS
and local authority funded ARNI rehabilitation programmes it is still necessary to assess the feasibility and
potential efficacy of teaching this technique in a pre-determined subset population of stroke survivors and to
assess the safety of the technique.
Text adapted from a research study proposal written by Dr Sarah Dean & Dr Leon Poltawski and from
The Successful Stroke Survivor: A Complete Guide to Functional Recovery by Tom Balchin.
Please visit www.arni.uk.com to find out more.