1. EXERCISE AFTER STROKE Specialist Instructor Training Course L7a Referral Guidelines Part A: Overview John Dennis/ Bex Townley The University of Edinburgh

2. Content Referral Process: an overview 1. Learning Outcomes 2. Patient Pathway 3. EfS Exercise Referral Service/System 4. EfS Risk management: general exercise risks 5. National Standards of practice: –Referral by HCP –Self-referral Formalities: Referral information The University of Edinburgh

3. Learning Outcomes Describe the exercise referral pathway after stroke Identify the main risks associated with exercise after stroke Identify appropriate protocols for working with HCPs and patients within the referral process Identify the professional standards that exercise professionals must uphold when delivering within exercise referral for stroke patients The University of Edinburgh

4. Essential Reading: L7 Further detail about the topics discussed in this session can be found in sections of the manual: 7.1, 7.2, 7.3, 7.4 The University of Edinburgh

5. Referral Process Overview Patient Journey The University of Edinburgh A&EStroke Unit/rehabilitation Discharge Community-based PA options Exercise Referral Service Active lifestyle

6. Exercise Referral Services/Systems “An exercise referral scheme directs someone to a service offering an assessment, development of a tailored physical activity programme, monitoring of progress and follow-up. They involve participation by a number of professionals and may require the individual to go to an exercise facility such as a leisure centre.” National Institute for Health and Clinical Excellence (NICE) The University of Edinburgh

7. Referral Pathways Access to specialist session or general exercise referral session: Referred through medical/ AHP “circuit” (stroke consultant, SNS, physiotherapist) Signposted by exercise professional Self-referred The University of Edinburgh

8. EAS: Referral Process See page 18 Fig.2 of Best Practice Guidance for the Development of Exercise after Stroke Services in Community Settings

9. Why Refer to an EfS ERS? Evidence Based / Best Practise Protocols Risk management: safe, effective exercise Secondary stroke prevention General health improvement / risk reduction Long term improvement/ maintenance: –Aerobic fitness –Functional capabilities Social/ psychological benefits Encourages self-management of healthy lifestyle The University of Edinburgh

10. Modifiable risk factors for stroke Non- modifiable risk factors for stroke  hypertension (high blood pressure)  smoking  heart disease  high cholesterol level  excess alcohol intake  diabetes  elevated haematocrit (increase in red blood cells)  stress  use of oral contraceptives (especially for women who smoke)  obesity  sedentary lifestyle  age  sex  race  family or individual history of stroke or TIA The University of Edinburgh

11. General Risks Associated with Exercise Hazards of exercise after stroke: Musculoskeletal injury includes falls Cardiac status: up to 30-40% of stroke clients may have underlying coronary artery disease that may be ‘silent’ > sudden cardiac death 1:100,000 The University of Edinburgh

12. General Risks Associated with Exercise Risk reduction: American Heart Association: In U.S. pre-requisite to referral for exercise is Graded exercise testing with ECG (Gordon et al 2004) In GB required only for known cardiac patients. If this cannot be performed: lighter sub-optimal intensity exercise or clinical judgement by stroke consultant /cardiologist The University of Edinburgh

13. General Risks Associated with Exercise Risk reduction Scottish Intercollegiate Guidelines Network (SIGN Guideline Cardiac Rehabilitation 2002) Clinical risk stratification based on: –history and examination –resting ECG combined with a functional capacity test (e.g. shuttle walking/ or a six minute walking test) sufficient for most clients –Exercise testing and ECG: only for high-risk clients. The University of Edinburgh

14. General Risks Associated with Exercise Risk reduction EfS course Development Team and EfS Reference Group view: Treadmill exercise testing is not necessary prior to referral to exercise after stroke A functional test such as the 6 minute walk, in combination with detailed referral information, is usually sufficient The University of Edinburgh

15. Other Risk Factors Associated with Exercise Fluctuating blood sugar levels (if diabetic), fatigue etc Insufficiently cautious increments / overtraining Lack of temperature control Other pathologies e.g. osteoarthritis, PD Side effects from drugs The University of Edinburgh

16. National Standards of Practice Establish a formally agreed process for the selection, screening and referral of specific patients (DoH, 2001,p. vii) http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4009671 Medico-legal requirement: Before being eligible to participate, each potential client must obtain the acknowledgement of current suitability to exercise from GP in the form of a referral.

17. National Standards of Practice When increased physical activity is recommended by a HCP, this is distinct from a referral. When the individual is specifically referred for exercise by the HCP, responsibility for the health and wellbeing of the participant remains with the referrer. Responsibility for safe and effective management, design and delivery of the exercise programme passes to the exercise and leisure professionals. The exercise professional must not accept a person through a referral system where the patient’s HCP has declined to make a referral. (DoH, 2001, p. 11)

18. Referrer’s Knowledge A good understanding of stroke and its effects on function/ADLs Lifestyle and genetic pre-morbid risks Risks associated with: –stroke impairment –any co-morbidities –medication and its side-effects –exercise The patient’s readiness to exercise The University of Edinburgh

19. National Standards of Practice Once referrer has decided to refer a patient for exercise: information -> exercise professional Referrer responsibilities: –Identify pathology, medication and impact on safety and comfort during activity ―Stratify risk (during/ following exercise) –Educate client on early detection of important symptoms –Monitor and review progress Referrer information: section 7.4 course manual Patient consent for transfer of information

20. That’s all very well, but… In your experience: –Example of good practice? –Example where you were uncertain? –Example of poor practice? In case of uncertainty: –How did you resolve this, where did you look for information/ guidance? In case of poor practice: –what action did you take and why? –How could you prevent this from happening again?

21. Summary Exercise referral systems after stroke provide opportunity to continue the rehabilitation journey Safety first! National Quality Assurance Framework for ERS: -Referral must be provided by relevant HCP -Exercise professional must be provided with sufficient information prior to admitting a potential client to exercise.

22. Questions?

23. As an exercise professional, what information do you require from the referrer of a person with stroke? (L7b)