By Jo-Anne Howe and Karen Brunton, Clinical Educators-Physiotherapy, Toronto Rehab, Lecturers, University of Toronto, Department of Physical Therapy.
TIME, which stands for ‘Together in Movement and Exercise’, is a community-based exercise program for people with a range of conditions usually of neurological origin, such as stroke, MS or brain injury. The rationale for the program is to assist individuals to take steps out of the health care system and re-integrate into local, community centers after discharge from rehabilitation.
The exercise program is a circuit station design for people who have reduced community mobility and ambulate for short distances often with assistive devices. Accordingly, the program exercises emphasize task-related training (for example, walking, step-ups and sit-to-stand), balance and strengthening especially of the core and legs. TIME has been running at two community centres in Toronto since the fall of 2007 and is in pilot phase at a third site.
Why is the TIME program unique?
The interesting innovation was the development of a partnership between a rehab facility, Toronto Rehab, and a municipal organization, City of Toronto Parks, Forestry and Recreation (PFR). The unique collaboration pools the strengths and resources of the two organizations. Toronto Rehab physiotherapists
• designed the evidence-based exercise program that is safe, do-able and effective for the participants
• provide ongoing education and support for the fitness instructors and volunteers
• maintain program quality through site visits to guide and problem solve with the instructors
• established the process for screening of the participants including a physician referral and telephone screen
• modify the exercise program as best practices evolve over time.
The community partner provides:
• space for the program
• human resources, that is, the fitness instructors who lead the exercise classes as well as their hiring, scheduling and performance management
• equipment, kept to a minimum to increase the feasibility of implementing the program in local rec centres
• expertise in community programming including participant registration, safety and emergency procedures.
How does the TIME program improve access to exercise?
TIME provides a much-needed option for exercise/fitness for clients living in the community after discharge from rehabilitation. As length of stay shortens even more, many therapists and patients grow increasingly concerned about how to maintain or even extend the benefits of rehab after they return home. To counteract the cycle of deconditioning, ongoing access to physical activity and exercise are essential. The partnership between health care and community recreation builds capacity for exercise and fitness as well as community re-engagement for clients living with mobility impairments.
Keeping it safe
When the pilot was implemented in the fall of 2007, our first priority was to evaluate the safety of the program. Would it be safe for community-based fitness instructors to lead exercise classes for people with neurological conditions without the direct supervision of the health care team? The results of the pilot evaluation were that in 293 attendances, there were two near-misses: a near-fall where the participant required steadying by the caregiver and a possible hypoglycemic episode. Since then, with 9 additional sessions running
at the two sites and approximately 3400 attendances, there still have not been any adverse events. The question then arises, how is the positive safety record maintained? The contributing factors likely include:
• the commitment and skill of all PFR staff involved
• the high instructor to participant ratio (1:4) plus volunteers and caregivers
• adherence by the instructors to the carefully crafted exercise program designed by physiotherapists
• provision of ongoing education to the instructors
• the use of admission screening tools before participants enter the program
The evolution of TIME
The program is not static and we continue to modify it. For example, more participants are now accepted into the program as the circuit stations have been modified to include more group work. As well, the functional inclusion criterion of ability to walk 10 metres with or without a walking aid has been maintained throughout but the diagnostic criteria have been expanded to include individuals with mobility limitations regardless of the underlying diagnosis.
A step-by-step Toolkit based on the TIME program has been published to enable health care professionals in other regions to implement a similar community-based exercise program. Contact renaud.marie-claude@torontorehab.on.ca for more information.
Contact howe.jo-anne@torontorehab.on.ca for any questions or comments about the TIME program.
“TIME demonstrates how you can take an evidence-based exercise class and partner with a municipal organization to provide universal community-based access to a regular exercise class for people with neurological conditions who wouldn’t otherwise have opportunity.”
Nancy Salbach, Assistant Professor, University of Toronto, Department of Physical Therapy
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