• Share
  • Email
  • Embed
  • Like
  • Save
  • Private Content

Loading…

Flash Player 9 (or above) is needed to view presentations.
We have detected that you do not have it on your computer. To install it, go here.

Like this presentation? Why not share!

11 frederike van wijck et al exercise after stroke

on

  • 1,223 views

 

Statistics

Views

Total Views
1,223
Views on SlideShare
1,223
Embed Views
0

Actions

Likes
0
Downloads
22
Comments
0

0 Embeds 0

No embeds

Accessibility

Categories

Upload Details

Uploaded via as Adobe PDF

Usage Rights

© All Rights Reserved

Report content

Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
  • Full Name Full Name Comment goes here.
    Are you sure you want to
    Your message goes here
    Processing…
Post Comment
Edit your comment

    11 frederike van wijck et al exercise after stroke 11 frederike van wijck et al exercise after stroke Presentation Transcript

    • 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)
    • 2. Exercise and physical fitness training after stroke: evidence 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
    • 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.
    • Pathways into Exercise after Stroke Discharge from hospital rehabilitation Community stroke survivors Screening for absolute contraindications Referral to EAS service Complete a referral form Health care professional Pre-exercise assessment Exercise professional Exercise after stroke sessions in leisure centre 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 )
    • Carmarthenshire's Exercise Continuum Delivered by multi-qualified L4 Instructors EfS Vitality ‘Longevity Programme Mainstream GP Referral Exercise for Wellness & Scheme Healthy Ageing PSI Exercise increasing age/increased presence of limitation / reduced mobility/increasing risk Function Specific; Longevity Programme: Mobility& BE Posture Bal Fitness ‘Life’ Circuits Bone health Posture Balance & Fitness Vitality Pulse Bone Health Cardio Fusion ETM Water Based Exercise .
    • 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 group Mrs Sara Paul Ms Aisha Sohail Ms Carolyn Agnew Ms Helen Macfarlane Ms Gill Baer Dr Christine McAlpine Ms Lorraine Ayers Ms Clare McDonald Mrs Sheena Borthwick Ms Karen McGuigan Ms Wendy Beveridge Ms Hannah Macrae Mr John Brown Dr Sarah Mitchell Ms Audrey Bruce Dr Jacqui Morris Mr Cliff Collins Ms Clair Ritchie Prof Martin Dennis Mr Alan Robertson Mr Ben Gittus Mr Pat Squire Dr Carolyn Greig Ms Margaret Somerville Ms Fiona Hamilton Dr Morag Thow Ms Maddy Halliday Prof Caroline Watkins Ms Pauline Halliday Ms Fiona Wernham Dr Julie Hooper Mrs Lorraine Young Ms Heather Jarvie Prof Archie Young Mrs Anita Jefferies
    • 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 & 1997 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
    • 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 CPD Accreditation: • 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 )
    • 2010 Developments ARNI & LATERLIFE TRAINING Collaboration. Queen Margaret’s Middlesex University & University University of Edinburgh 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.
    • 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
    • Contacts Dr 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