1. 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

2. 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. 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

4. 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?

5. STARTER exercise class (Mead et al., 2007)

6. 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)
2. Exercise and physical fitness
training after stroke: evidence

7. 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

8. 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.

9. 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

10. 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….

11. 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

12. 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…

13. http://exerciseafterstroke.org.uk/

15. 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.

16. 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

17. 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

18. 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.

19. 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

20. 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

21. 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!

22. 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

23. 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

24. 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)

25. 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)

26. 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

27. 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

28. 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

30. 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

31. 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

32. 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 )

33. .
increasing age/increased presence of limitation / reduced mobility/increasing risk
Carmarthenshire's Exercise
Continuum
PSI
Vitality
GP Referral
Scheme
‘Longevity Programme
Exercise for Wellness &
Healthy Ageing
Function Specific;
Mobility& BE
Posture Bal Fitness
Bone health
Vitality Pulse
Cardio Fusion
Longevity Programme:
‘Life’ Circuits
Posture Balance & Fitness
Bone Health
ETM
Water Based Exercise
Mainstream
Exercise
EfS
Delivered by multi-qualified L4
Instructors

34. 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

35. 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

36. Reference group
Mrs 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

37. Funders and supporters

38. 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

39. Supporting the Hospitals: the ARNI
UK Approach to Functional
Limitations after Stroke
Commissioning Life After Stroke Services
9thth November 2010

40. 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 &
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
1997

41. 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.

42. 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.

43. 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.

44. • 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.

45. Sample Exercise: Getting up from the floor unaided
STEP 1 STEP 2
STEP 3 STEP 4

46. Supplementary adjustment STEP 5
STEP 6

47. 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

48. • 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 )
ARNI CPD Accreditation:

49. 2010 Developments
ARNI & LATERLIFE TRAINING Collaboration.
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.
Queen Margaret’s
University & University
of Edinburgh
Middlesex
University

50. 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

51. 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