11 frederike van wijck et al exercise after stroke

Commissioning Community-Based Exercise After Stroke Services

09/11/10

T

Frederike van Wijck Rebecca Townley Tom Balchin

Glasgow Caledonian University Carmarthenshire County The ARNI Trust

Content

1. Introduction

2. Evidence for Exercise After Stroke (EAS)

3. Drivers for Exercise after stroke

4. EAS services: a survey and guidelines for

best practice

5. Exercise & Fitness Training after Stroke

Level 4 Specialist Instructor Qualification

6. Research into action: EAS services in

Wales

7. ARNI Functional Training after Stroke CPD

8. Discussion

1. Introduction

Reduced physical fitness after stroke:

• Reduced muscle strength and power

• VO2 max: about 50% of age-matched controls

• Insufficient fitness to perform:

– Activities of daily living, e.g. vacuuming, shopping

– Crossing the road fast enough

• Low fitness:

– ↑ risk of further vascular events

– ↑ risks of falls

– ↓ community integration

2. Exercise and physical fitness

training after stroke: evidence

Cochrane systematic review (Saunders et al., 2009)

Questions:

• Does fitness training (i.e. cardiorespiratory and/ or

strength training) reduce death, dependence and

disability?

• What are the effects of exercise after stroke on

fitness, mobility, physical function, health status,

QoL, mood and adverse events?

STARTER exercise class (Mead et al., 2007)

Question 1:

Does fitness training reduce death, dependence

and disability?

Answer:

• Death: 1/1147 at end of intervention

• Dependence: lack of data

• Disability: majority of results not significant (but

methodological weaknesses in studies)

2. Exercise and physical fitness

training after stroke: evidence

Question 2:

What are the effects of exercise after stroke on

fitness, mobility, physical function, health status,

QoL, mood and adverse events?

Answer:

• Cardiorespiratory training involving walking:

– ↑ max. walking speed and endurance

– ↓ dependence during walking

• ↑ cardiorespiratory fitness

• Strength, health status, QoL, mood: paucity of

data

• Adverse events: rare

2. Exercise and physical fitness

training after stroke: evidence

Conclusions:

• Sufficient evidence to include walking-

based cardiorespiratory training in stroke

rehabilitation to improve aspects of

walking

• Exercise and fitness training appear to be

safe and feasible for people after stroke.

Content

1. Introduction

2. Evidence for Exercise After Stroke (EAS)

3. Drivers for Exercise after stroke

4. EAS services: a survey and guidelines for

best practice

5. Exercise & Fitness Training after Stroke

Level 4 Specialist Instructor Qualification

6. Research into action: EAS services in

Wales

7. ARNI Functional Training after Stroke CPD

8. Discussion

3. Drivers for Exercise after Stroke

- Royal College of Physicians and SIGN guidelines

108 and 118: recommendations for exercise after

stroke

- Scottish Government: policy document on CHD

and stroke care: recommendation for exercise

after stroke

- Many consultants refer stroke patients for

exercise

- Many people with stroke refer themselves for

exercise….

Content

1. Introduction

2. Evidence for Exercise After Stroke (EAS)

3. Drivers for Exercise after stroke

4. EAS services: a survey and guidelines for

best practice

5. Exercise & Fitness Training after Stroke

Level 4 Specialist Instructor Qualification

6. Research into action: EAS services in

Wales

7. ARNI Functional Training after Stroke CPD

8. Discussion

4. EAS services: a survey and

guidelines for best practice

• Where do people with stroke go for

exercise?

• What services are available?

• How are they run?

• What do they provide?

• How do we know if they are effective?

Many questions – but no answers, until…

http://exerciseafterstroke.org.uk/

Survey findings:1. There are currently 3 different stroke-specific

service models for Exercise after Stroke:

– Rehabilitation extensions

– Leisure centre services

– Charity collaborations

2. There is considerable variation in:

– Quality assurance: referral, assessment (before,

during, after)

– Qualification of exercise professionals

3. There is good work but standardisation, quality

assurance & evaluation are essential.

4. EAS services: a survey and

guidelines for best practice

1. Governance

2. Referral systems

3. Service development

4. Exercise professional training and qualification

5. Role of the exercise professional

6. Content of the exercise programme

7. Record keeping and outcome evaluation

8. Other good practice points

4. EAS services: a survey and

guidelines for best practice

1. Governance:

• Service overseen/ supported by

multidisciplinary working group:

– Local stakeholder organisations

– Service users

– Representatives from stroke Managed Clinical

Networks (Stroke MCNs).

• Service level agreement (health – leisure)

and service coordinator

4. EAS services: a survey and

guidelines for best practice

2. Referral systems:

• Robust mechanisms with appropriate and

comprehensive medical information

• Referral system in line with national quality

assurance framework for exercise referral

(DoH, 2001): client must be referred by

their GP or other pre-agreed HCP.

Screening for absolute contraindications

Referral to EAS service

Complete a referral form

Pre-exercise assessment

Exercise after stroke sessions in leisure centre

Health care

professional

Exercise

professional

Pathways into Exercise after Stroke

Discharge from hospital rehabilitation Community stroke survivors

Continue exercise after stroke sessions Mainstream exercise services

4. EAS services: a survey and

guidelines for best practice

3. Service development

• Exercise after Stroke as part of patient pathway

• Service co-ordinator/ liaison staff

• Group exercise format

• Ratio of instructors to participants

• Promoting life long participation in exercise

• Liaising with GP if required

4. EAS services: a survey and

guidelines for best practice

4. Exercise Professional Training:

Endorsed by Level 4 SkillsActive

Mapped onto National Occupational

Standards for stroke (unit D516)

Endorsed by Register for Exercise

Professionals

NB: required for insurance!

4. EAS services: a survey and

guidelines for best practice

5. Role of Exercise Professional:

• Pre-exercise assessment

• Individualised exercise programme

• Physical activity plan

• Personal exercise record

• Social support

• Referral back to health professional

4. EAS services: a survey and

guidelines for best practice

6. Content of the exercise programme:

• Preferably group format (psycho-social benefits)

• Content, duration and frequency:

– Duration: 1-hour per session

– Intensity: moderate

– Frequency: 3x per week

– High proportion of cardio-respiratory walking training

• Ongoing, i.e. not a time-limited course

4. EAS services: a survey and

guidelines for best practice

7. Record keeping and outcome evaluation

• Data protection

• At least a minimum dataset:

– Community Health Index (CHI) number

– Contact details

– Referral information

– Attendance records

– At least one outcome measure

• Adverse events

• Feedback to referrers (with consent)

4. EAS services: a survey and

guidelines for best practice

8. Other good practice points:

• Make personal contact before 1st session

• Accompany person to 1st session

• Provide transport

• Arrange in-service stroke awareness training

• Refer back for orthotics assessment if required

• Invite trainees (does not affect staff: client ratio)

Content

1. Introduction

2. Evidence for Exercise After Stroke (EAS)

3. Drivers for Exercise after stroke

4. EAS services: a survey and guidelines for

best practice

5. Exercise & Fitness Training after Stroke

Level 4 Specialist Instructor Qualification

6. Research into action: EAS services in

Wales

7. ARNI Functional Training after Stroke CPD

8. Discussion

Exercise & Fitness Training After Stroke:

L4 Specialist Instructor Training Course

EfS Course Team:

Dr. Gillian Mead, Dr. Susie Dinan-Young, Mr. John Dennis, Mrs. Sara Wicebloom, Ms. Rebecca Townley, Mr. Mark Smith,

Prof. Marie Donaghy, Dr. Frederike van Wijck

The University of Edinburgh

5. Exercise & Fitness Training after Stroke

Level 4 Specialist Instructor Qualification

• Designed by University of Edinburgh &

Queen Margaret University (QMU)

• Validated by QMU

• Double module at Scottish Higher Education

Level 2

• Endorsed by Skills Active

• Recognised by REPs at Level 4

• Aligned with CSP Curriculum Framework

5. Exercise & Fitness Training after Stroke

Level 4 Specialist Instructor Qualification

• Provided by Later Life Training

www.laterlifetraining.org.uk

• Extensive MDT led practical adaptation,

tailoring & teaching component: how to

provide exercise after stroke to groups/1-1

• Outcome measure training component

• Standardised, quality assured

• CPD 1: ARNI

• Available UK-wide

Content

1. Introduction

2. Evidence for Exercise After Stroke (EAS)

3. Drivers for Exercise after stroke

4. EAS services: a survey and guidelines for

best practice

5. Exercise & Fitness Training after Stroke

Level 4 Specialist Instructor Qualification

6. Research into action: EAS services in

Wales

7. ARNI Functional Training after Stroke CPD

8. Discussion

Carmarthenshire’s Health and Activity Team are uniquely

placed within the Leisure and Regeneration Department

Management organisation has enabled an integrated,

consistent approach to service development across all

leisure centres, and community outreach groups

Our vision - the key to increased opportunity and optimisation of

resource, is integration….where appropriate

We are developing a ‘people focussed’ exercise continuum that

ensures pathologies are matched with instructor

skills/qualifications…

And that the exercise evidence based matches

condition/pathology (quite often multi-pathology )

.

increasing age/increased presence of limitation / reduced mobility/increasing risk

Carmarthenshire's Exercise

Continuum

PSI

Vitality

GP Referral

Scheme

‘Longevity Programme

Exercise for Wellness &

Healthy Ageing

Function Specific;

Mobility& BE

Posture Bal Fitness

Bone health

Vitality Pulse

Cardio Fusion

Longevity Programme:

‘Life’ Circuits

Posture Balance & Fitness

Bone Health

ETM

Water Based Exercise

Mainstream

Exercise

EfS

Delivered by multi-qualified L4

Instructors

Summary: Exercise after Stroke

• Evidence base: exercise and fitness training after

stroke is effective

• Drivers:

– Urgent need for community-based services

– Clinical guidelines for stroke

– Government policies

– Compared to cardiac rehabilitation and falls

prevention: we need to catch up !

– One ‘gold standard’ L4 stroke specialist qualification

• Need: for more standardised services

• Implementation: Guidance and standards for best

practice

Collaborators• Dr. Gillian Mead (PI) University of Edinburgh

• Dr Catherine Best University of Edinburgh

• Mr John Dennis NHS Greater Glasgow and Clyde

• Dr Susie Dinan-Young University College London

Medical School

• Ms Hazel Fraser NHS Fife

• Professor Marie Donaghy Queen Margaret University

• Mr Mark Smith NHS Lothian

• Dr Frederike van Wijck Glasgow Caledonian University

• Professor Archie Young University of Edinburgh

Reference groupMrs Sara Paul

Ms Carolyn Agnew

Ms Gill Baer

Ms Lorraine Ayers

Mrs Sheena Borthwick

Ms Wendy Beveridge

Mr John Brown

Ms Audrey Bruce

Mr Cliff Collins

Prof Martin Dennis

Mr Ben Gittus

Dr Carolyn Greig

Ms Fiona Hamilton

Ms Maddy Halliday

Ms Pauline Halliday

Dr Julie Hooper

Ms Heather Jarvie

Mrs Anita Jefferies

Ms Aisha Sohail

Ms Helen Macfarlane

Dr Christine McAlpine

Ms Clare McDonald

Ms Karen McGuigan

Ms Hannah Macrae

Dr Sarah Mitchell

Dr Jacqui Morris

Ms Clair Ritchie

Mr Alan Robertson

Mr Pat Squire

Ms Margaret Somerville

Dr Morag Thow

Prof Caroline Watkins

Ms Fiona Wernham

Mrs Lorraine Young

Prof Archie Young

Funders and supporters

Content

1. Introduction

2. Evidence for Exercise After Stroke (EAS)

3. Drivers for Exercise after stroke

4. EAS services: a survey and guidelines for

best practice

5. Exercise & Fitness Training after Stroke

Level 4 Specialist Instructor Qualification

6. Research into action: EAS services in

Wales

7. ARNI Functional Training after Stroke CPD

8. Discussion

Supporting the Hospitals: the ARNI

UK Approach to Functional

Limitations after Stroke

Commissioning Life After Stroke Services

9thth November 2010

Considerations after discharge:

• Most, though not all, people with stroke will have very good acute and

hospital care including multidisciplinary rehabilitation but experiences vary in

the interface from Hospital to Community.

• The picture for the amount and quality of rehabilitation

after hospital is not as clear, but is certainly less than

current standards would expect.

•Strength, flexibility, balance & endurance

•Dexterity and upper limb management

•Mobility training & gait re-education-walking, stairs,

in/out bed & chair, indoor, outdoor/community issues.

•Activities of daily living (ADLs) training &

management –personal, instrumental, community

•Communication retraining

•Swallowing and eating/feeding training &

nutrition management

•Adjustment support including treatment for depression

•Cognitive & behavioural therapy

•Environmental adaptations and specialist equipment

•Transitions: life after stroke; back-to-work

•Other: vision, continence, pain, relationships & sex

1997

Who we are and what kind of intervention it is:

ARNI is an innovative approach to stroke rehabilitation that has been

developed and refined since 2001. The ARNI concept mobilises a tier of

specialist cardiac trainers to teach stroke survivors independently or in group

settings, how progressively and autonomously to recover lost strength,

balance and action control.

•The performance and personalising of set functional task-related practice

and innovation of new ones.

•The personalising of essential physical coping strategies and development of

new ones.

•The use of resistance (mostly body-weight) training techniques.

The strategic use of self-recovery programmes with the aim of self-reliance.

What is the rehabilitative stage tackled?

• Patients will have finished in-patient rehabilitation unit after transfer from an acute stroke ward. They may have attended an out-patient rehabilitation unit, at which they took part in coordinated therapy sessions.

• They are now reaching the end of formal therapy and need a home-to-community rehabilitation programme.

• They need support to develop effective self-recovery and coping strategies, and need remote monitoring.

• THIS COHORT IS HUGE.

What value does our innovation add?

• It ‘fills the void’ for stroke survivors after formal therapy finishes, for whatever reason.

• It tackles the problem of stroke survivors believing that they are being told they will not be able to walk or use their hand again (perception as terminally disabled).

• It prevents a rehabilitation turning into a decline and stroke survivors re-entering the care pathway

• It brings ‘bridges the gap’ between home and community.

• ARNI deals with about 30 enquiries per day, from stroke survivors, their loved ones, carers and others.

EVIDENCE BASED STROKE RESEARCH REVIEWS: Foley, Teasell & Bhogal (2008)

• There is strong evidence that task-specific gait training improves gait post-stroke.

• There is strong evidence that motor recovery after stroke occurs mainly through behavioral compensation rather than via processes of neural recovery alone

• There is strong evidence that rhythmic auditory stimulation, in conjunction with physical therapy, results in a significant improvement in gait.

• There is strong evidence that certain forms of balance training are associated with improved outcomes

• There is strong evidence that strength training for the lower body is beneficial in improving outcomes in hemiparetic stroke patients.

• There is moderate evidence that a program of daily stretch regimens does not prevent the development of contractures.

• There is moderate evidence that repetitive task specific training techniques improves measures of upper extremity function.

• There is strong evidence that mental practice may improve upper-extremity motor and ADL performance following stroke.

• There is strong evidence that hand splinting does not improve motor function or reduce contracture formation.

After formal therapy finishes, LITTLE of this research is forwarded to or used

by the patient, or can be understood anyway : they simply don’t know what to

do, and it is tricky/expensive to get any advice/training after PT/OT ends .

The ARNI Approach uses experientially-derived techniques for functional

training after stroke which tallies with the sum of the messages from clinical

research trials able to be included in the reviews such as EBSR.

• ARNI is a national charity which matches stroke survivors with specialist instructors and therapists who have passed the ARNI Functional Training after Stroke Accreditation.

• Instructors have been scoped for from the ranks of UK qualified cardiac instructors, most of whom own their own training businesses.

• ARNI has 65 Instructors around the UK working actively with stroke survivors, with a predicted 25 more Instructors by the end of 2010. Many cover large areas: driving up to 60 mile round trips to reach into the homes.

• It can take 6/7 months for an advanced exercise instructor to learn how to meet our interpretation of the 2007 National Stroke Strategy: delivering, reviewing and adapting a physical activity programme with patients after stroke.

• The ARNI approach contains an abundance of techniques which are designed to prime the body for this task-related practice and drive plastic changes… with the aim of conquering the functional barriers they are facing.

Sample Exercise: Getting up from the floor unaided

STEP 1 STEP 2

STEP 3 STEP 4

Supplementary adjustment STEP 5

STEP 6

2010 Research

1. @

The efficacy of methods is the focus of an application for a national multi-centre RCT (£1.79 million) evaluated by Exeter University 2011-2016.

Submitted by the Peninsula Stroke Research Network (SRN), part of the National

Institute for Health Research Clinical Research Network Coordinating Centre (NIHR CRN CC) in 2010.

2. @

A 36-week feasibility research study (£21,000) is currently underway.

– 4 Stroke groups (n=36)

– 1 lead trainer, 3 trainees

– Limitations- mild to moderate

• ARNI runs a Functional Training after Stroke CPD course (accredited by Middlesex University). This is now available mainly for therapists, MSc students and coaches &

• As CPD for exercise instructors who hold the L4 Specialist Instructor Exercise & Fitness After Stroke Training Qualification

• The system is currently being taught, on demand from (and sponsored by) several NHS Stroke Improvement services, to therapists & exercise instructors in some of the Stroke Networks – eg:

•

– 2009 - North of England Cardiovascular Network –18 trainers

– 2010 - Beds/Herts Cardiovascular Network –45 trainers

– 2010 -North and East Yorkshire and Northern Lincolnshire Cardiac and Stroke Network –20 trainers

– ARNI is also commissioned by Councils – eg.

- 2010 - Blackburn upon Darwen Council –10 trainers

The Stroke Association is sponsoring exercise instructors through the programme. ARNI also trains the Different Strokes and Headway instructors.

• The ARNI Course in Functional Training after Stroke is a 300 hr (5 days formal contact )

ARNI CPD Accreditation:

2010 DevelopmentsARNI & LATERLIFE TRAINING Collaboration.

L4 Exercise and Fitness after Stroke Qualification + Functional Training after Stroke CPD.

• Aim: to have one gold standard for the UK - one single evidence based standard and qualification for UK exercise instructors working with stroke patients. The LLT L4 course provides clinically led approaches to adapt and individually tailor exercise is endorsed by Skills Active and recognised by the Register of Exercise Professionals (REPs) at specialist clinical exercise Level 4.The ARNI course is positioned as CPD for the L4 course

• This collaboration has been formalised in order that qualified instructors are meeting the Skills Active & REPs requirements that they need to validate their professional membership and insurance when they work with stroke survivors.

Queen Margaret’s

University & University

of Edinburgh

Middlesex

University

Content

1. Introduction

2. Evidence for Exercise After Stroke (EAS)

3. Drivers for Exercise after stroke

4. EAS services: a survey and guidelines for

best practice

5. Exercise & Fitness Training after Stroke

Level 4 Specialist Instructor Qualification

6. Research into action: EAS services in

Wales

7. ARNI Functional Training after Stroke CPD

8. Discussion

ContactsDr Frederike van Wijck

Reader in Neurological Rehabilitation

Glasgow Caledonian University

Frederike.vanWijck@gcu.ac.uk

Ms Rebecca Townley

Exercise Referral Coordinator

Carmarthenshire County

RTownley@carmarthenshire.gov.uk

Dr Tom Balchin

Director, ARNI Trust

tom@arni.uk.com