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 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…

Content 1.Introduction 2.EAS Services : a survey 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) 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 By Rehab Setting: PT/stroke nurses with assistants Leisure Setting: EP’s in collaboration with PT Charity Collaborations: EP’s, Personal Trainers PT ReferralHCP none Inc/ Exclmedical criteriavariablenone Evaluation Standard outcome measures varies; may include BP,physical performance, activity Q none Duration8-10 weeksongoing CostFreeapprox. £3 per session£0 - £2 Staff ratio1 to 71 to 51 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.

Content 1.Introduction 2.EAS Services: a survey 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 1 st session Carer/ volunteer to accompany client to 1 st 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: All UK Stroke MCNs and Cardiovascular Networks, the Stroke NGOs and the CSP,ACPIN, Skills Active & REPS were ed direct with these guidelines in November 2010

Content 1.Introduction 2.EAS Services: a survey 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

Content 1.Introduction 2.EfS Services: a survey 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 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 Reading Further detail about the topics discussed in this session can be found in section L8 of the course syllabus.