L11 Exercise and fitness training

after stroke

Service implementation and evaluation:how it works in practice

Dr. Catherine Best, Dr. Frederike van Wijck, John Dennis, Dr Susie Dinan-Young & Rebecca Townley

Content

1. Introduction

2. EAS Services : a survey

3. 2010 Guidelines for best practice

4. Professional requirements

5. EAS Service Model

6. Summary

1. Introduction – what ?

Evidence of the need for Exercise and fitness training

after stroke (EAS) services

- Research: exercise can be beneficial after stroke

- Royal College of Physicians: recommendations for exercise after stroke

- English & Scottish Government: policy documents on exercise after stroke

- Many medical & AHP refer stroke patients for exercise

- Many people after stroke self refer for exercise….

1. Introduction – who ?EAS service professionals & stakeholders

- National : the Public Health Depts of the 4 countries- The Regional Health Authorities- PCTs/GP Consortia/Community Health Partnerships etc- Commissioners- Stroke Management Clinical Networks (Stroke MCN)- Stroke secondary & primary medical & AHP professionals ( refers) &

researchers (evaluation)- ER Co-ordinators & exercise professionals- Stroke participants/patients

- ….

1.Introduction-Where? What? How?

EAS services : some questions

• Where do people with stroke go for exercise?

• What kind of exercise services are available?

• How do they run?

• What do they provide?

• How do we know if they are effective? Safe?

• How do we know if the exercise professionals are qualified?

Many questions – but no satisfactory answers, until…

Content1. Introduction

2. EAS Services : a survey

3. 2010 Guidelines for best practice

4. Professional requirements

5. EAS Service Model

6. Summary

2. EAS services in Scotland: a survey

Scotland-wide scoping exercise:Aims: • To identify content and structure of EAS

services in Scotland• To identify and disseminate best practice

Methods:• Internet survey• Interviews with selected services( 2010 Best, Mead, van Wijck, Smith, Dennis, Dinan-Young, Fraser, Donaghy)

2. EAS services in Scotland: a survey

Results : ( findings)

1. 14 stroke-specific with an aerobic component:

Rehabilitation extensions; to aid transition to community exercise (3)

Leisure centre services ; to encourage PA in community (3)

Charity collaborations; respond to members requests (8)

2. Significant variation in content, FITT, qualifications, training and experience, referral criteria and process

Led ByRehab Setting:

PT/stroke nurses with assistants

Leisure Setting: EP’s in collaboration

with PT

Charity Collaborations:EP’s, Personal Trainers

PT

Referral HCP HCP none

Inc/ Excl medical criteria variable none

Evaluation Standard outcomemeasures

varies; may include BP,physical

performance, activity Q

none

Duration 8-10 weeks ongoing ongoing

Cost Free approx. £3 per session £0 - £2

Staff ratio 1 to 7 1 to 5 1 to 10

Other exercise and physical activity options • ARNI Trust: Functional training after stroke (L4 CPD & AHP)

• + NON stroke specific– ***Mutipathology exercise classes**– Cardiac rehabilitation– Disability swimming groups and disability sports groups– Generic exercise referral schemes– Extend, class diamonds (exercise for older people)– Personal trainers

• Without aerobic evidence for stroke – Chair-based exercise in stroke charity support group

meetings– Pilates, yoga, tai chi etc.

Content1. Introduction

2. EAS Services: a survey.

3. 2010 Guidelines for best practice

4. EAS Service model

5. Professional requirements

6. Summary

3. EAS: Guidelines for Best Practice

Key guidelines for EAS service providers:• Governance• Preparation and risk assessment for exercise• Referral systems and procedures• Pre-exercise assessment and ongoing review• Specialist Exercise Professional training• Content, frequency and duration • Record keeping

3. EAS: Guidelines for best practice

Other good practice points:• EP to make personal contact before 1st session• Carer/ volunteer to accompany client to 1st

session• EAS service to:

– Provide transport as appropriate– Arrange in-service staff ‘stroke awareness’ training– Refer back for Orthotics etc assessment if required– Invite trainee EPs/ HCPs (does not affect staff: client ratio)

3. EAS: Guidelines for best practice

Available to download from:

http://exerciseafterstroke.org.uk/

All UK Stroke MCNs and Cardiovascular Networks, the Stroke NGOs and the CSP,ACPIN, Skills Active & REPS were emailed direct with

these guidelines in November 2010

Content1. Introduction

2. EAS Services: a survey.

3. 2010 Guidelines for best practice

4. Professional requirements

5. EAS Service model

6. Summary

4. EAS : Professional requirements

Whatever the country ( England, Scotland, Wales, Ireland ) & type of Ex Referral service model, there are a number of ethical and professional standards that all Exercise Professionals must adhere to when working with all patient populations.

•See Section 8.10 in course syllabus

4. EAS : Professional requirements

3. National Skills Active Physical Activity Standards for People after Stroke (Unit D561):

• Design and agree a physical activity programme with people after stroke

• Deliver, review, adapt and tailor a physical activity programme with people after stroke

This Exercise after Stroke course is based on these

National Occupational Stroke Instructor Standards

Content1. Introduction

2. EfS Services: a survey.

3. 2010 Guidelines for best practice

4. Professional requirements

5. EAS Service Model

6. Summary

5. EAS: Referral Process

• See page 18 Fig.2 of Best Practice Guidance for the Development of Exercise after Stroke Services in Community Settings

5. EAS: Service Model Management

• See page 13 Fig.1 of Best Practice Guidance for the Development of Exercise after Stroke Services in Community Settings

5. EAS: Local Service Model

Content

1. Introduction

2. EAS Services: a survey.

3. 2010 Guidelines for best practice

4. Professional requirements

5. EAS Service Model

6. Summary

5. EAS Service Implementation: Summary

• EAS is a relatively new and fast developing area

• Three different service models UK wide

• Suggested guidelines for best practice for EAS services (incl. methods for service evaluation)

• Single professional, ethical and medico-legal standards for EAS ExP – wherever the patient lives!

Essential ReadingFurther detail about the topics discussed in this

session can be found in section L8 of the

course syllabus.