EXERCISE AFTER STROKESpecialist Instructor Training Course

L7a

Referral Guidelines Part A:Overview

John Dennis/ Bex Townley

The University of Edinburgh

ContentReferral Process: an overview

1. Learning Outcomes2. Patient Pathway3. EfS Exercise Referral Service/System4. EfS Risk management: general exercise risks5. National Standards of practice:

– Referral by HCP– Self-referral

• Formalities: Referral information

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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

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Essential Reading: L7

Further detail about the topics discussedin this session can be found in sections ofthe manual:

7.1, 7.2, 7.3, 7.4

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Referral Process Overview

Patient Journey

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A&E Stroke

Unit/rehabilitation

Discharge

Community-based PA options

Exercise Referral Service

Active lifestyle

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)

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Referral Pathways

Access to specialist session or general exercisereferral session:

• Referred through medical/ AHP “circuit” (stroke consultant, SNS, physiotherapist)

• Signposted by exercise professional

• Self-referred

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EAS: Referral Process

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

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

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Modifiable risk factors for Modifiable risk factors for strokestroke

Non- modifiable Non- modifiable risk factors for risk factors for

strokestroke

   

hypertension (high blood pressure) hypertension (high blood pressure) smoking smoking heart disease heart disease high cholesterol level high cholesterol level excess alcohol intake excess alcohol intake diabetes diabetes elevated haematocrit (increase in elevated haematocrit (increase in

red blood cells) red blood cells) stress stress use of oral contraceptives use of oral contraceptives

(especially for women who smoke)(especially for women who smoke) obesityobesity sedentary lifestylesedentary lifestyle

age age sex sex race race family or individual family or individual

history of stroke or TIAhistory of stroke or TIA

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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

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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

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General Risks Associated with Exercise

Risk reduction

Scottish Intercollegiate Guidelines Network (SIGN

Guideline Cardiac Rehabilitation 2002) Clinical riskstratification 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.

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General Risks Associated with Exercise

Risk reduction

EfS course Development Team and EfS ReferenceGroup 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

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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

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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 potentialclient must obtain the acknowledgement of currentsuitability to exercise from GP in the form of areferral.

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)

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

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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

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?

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 withsufficient information prior to admitting a potentialclient to exercise.

Questions?

As an exercise professional, whatinformation do you require from thereferrer of a person with stroke? (L7b)