developments in exercise after stroke

Developments in Exercise after StrokeLater Life Training Conference

11/09/11

Frederike van Wijck PhD MCSP FHEA

Reader in Neurological Rehabilitation

Glasgow Caledonian 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. Summary and Next Steps

1. Introduction

In the UK:

• Every year, 150,000 people have a stroke

• Stroke: 3rd most common cause of death

• Stroke: most common cause of severe

disability

• More than 250,000 people live with stroke-

related disabilities

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

0

5

10

15

20

25

30

1 10 100 1000 10000

Time since stroke (days)

Maxim

um

oxyg

en

up

take

(m

l.kg

-1.m

in-1

)

Bathing or feeding

Food shopping

or washing dishes

Sitting quietly

Walking 3 miles/h

Independence

Saunders & Greig (in Mead and van Wijck 2011)

Saunders & Greig (in Mead and van Wijck 2011)

Content

1. Introduction




best practice




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?

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)


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


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.


Qualitative studies

’Before I started going [to the exercise

referral scheme], I wasn’t thinking about

exercise, and I wasn’t thinking about

anything, other than sit at home, eat and

watch television. When I started, at least

they gave me that ability, they gave me

that push … So thereafter, I just cook up

something in my head, go down the stairs

or go down the street.’ [Louise]


Qualitative studies

’When I finish exercising and I feel so good,

so content… By the end of the day you

feel good, you know, you say ‘I feel good,

my health is coming back’ in your head.’

[Peter]

(Sharma, Bulley, van Wijck 2011)

Content

1. Introduction




best practice




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




best practice




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.



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



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



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



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. 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!



5. Role of Exercise Professional:

• Pre-exercise assessment

• Individualised exercise programme

• Physical activity plan

• Personal exercise record

• Social support

• Referral back to health professional



6. Content of the 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



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)



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)

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

Content

1. Introduction




best practice






• 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

• Endorsed by UK Forum for Stroke Training

• Run by LLT



• 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




best practice




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

Next questions

• Physical activity for non-ambulant stroke survivors

• Effects of physical activity on mood and fatigue

• Barriers and motivators to exercise after stroke

• Maintaining physical activity in the long term...

Thank you

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

Selected references

• Best C, van Wijck F, Dinan-Young S et al. (2010). Best practice

guidance for the development of Exercise after Stroke services in

community settings. Edinburgh: Edinburgh University. [Online]

Available at: http://www.exerciseafterstroke.org.uk/ [Accessed

08/09/11]

• Mead G, Greig CA, Cunningham I et al. STroke: A Randomised Trial

of Exercise or Relaxation (STARTER) J Am Ger Soc, 2007;55:892-

899.

• Saunders DH, Greig CA, Mead GE et al. Physical fitness training for

stroke patients. Cochrane Database of Systematic Reviews Issue

2009;4, DOI: 10.1002/14651858.CD003316

• Sharma H, Bulley C, van Wijck F (2011). Experiences of an exercise

referral scheme from the perspective of people with chronic stroke: a

qualitative study. Physiotherapy,

doi.org/10.1016/j.physio.2011.05.004

developments in exercise after stroke

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