The content of this chapter is based on a survey of existing Exercise after Stroke services in Scotland (Best et al. 2011) which – to our knowledge – is currently the most detailed source of information on models of service design for Exercise after Stroke in the UK. Other relevant international publications will also be discussed, including a survey of fitness facilities in Canada (Fullerton et al. 2008).

Existing models of community exercise after stroke services

Our research, which included contact with Exercise after Stroke service providers in the UK (Best et al. 2011), and a review of the international exercise after stroke literature, showed that there are several means by which stroke survivors access exercise:

Each of these options will be discussed in more detail below.

Exercise referral schemes

Exercise referral schemes (also known as physical activity referral schemes or exercise on prescription) are multi-agency services whereby general practitioners (primary care physicians) or other nominated health-care professionals can refer patients for an individually tailored programme of exercise, designed by a suitably qualified exercise professional (Department of Health 2001).

Exercise referral is designed to combat the high levels of physical inactivity and sedentary behaviour within the population as a whole. People referred to exercise referral schemes are those who need more than just advice or recommendation from a health-care professional in order to become more active, e.g. motivational support and a programme of exercise that has been tailored to their needs and preferences.

Exercise referral schemes are a structured link between health and leisure services which ensures that:

• The exercise professional has appropriate qualifications and resources

• The exercise professional receives adequate medical referral information

• The participant has been risk-assessed for exercise by the health professional prior to referral.

In 2001 the UK Department of Health published a quality assurance system for exercise referral schemes to ensure these standards of service delivery.

Exercise referral schemes are organised locally and therefore have different characteristics (e.g. referral pathways, inclusion criteria), depending on local circumstances. For this reason, exercise referral schemes in the UK vary greatly in terms of:

• Their target groups: these can be defined as sedentary individuals, the economically deprived, people with existing health conditions or people at identified risk of future health problems.

• The length of the intervention.

• The location: this includes local leisure centres, swimming pools, or the outdoors.

• The type of intervention: this could be individual gym programmes, group exercise, or walking groups.

• The amount of follow up: that is, whether participants who do not attend a session are contacted to ascertain the reason for non-attendance and/or whether outcome measures are recorded.

We have anecdotal reports that stroke survivors are successfully using these services and achieving good outcomes. It is estimated that around 400–500 stroke survivors per year access the Live Active exercise referral scheme run in the NHS Greater Glasgow and Clyde area of the UK (Forsyth 2009).

Generic exercise referrals schemes (i.e. not targeted at stroke survivors) exist across the world, including Scandinavia (e.g. Leijon et al. 2009) and Europe (e.g. Schmidt et al. 2008), while the principle of referral for exercise is also well developed in the United States (American College of Sports Medicine 2010).

The positive aspects of using exercise referral schemes for stroke survivors are that exercise referral is a highly individualised process where each participant will have a personal activity programme tailored to their preferred mode of exercise, with attention given to individual barriers and motivators to becoming more active. Another positive factor is that generic exercise referral schemes can achieve good community penetration: a recent survey found that 70% of general practitioners in Scotland had access to a generic exercise referral scheme (Jepson et al. 2010).

There are some limitations, however, in using exercise referral as a model for Exercise after Stroke, which pertain to:

• Exercise professional qualifications. Most exercise professionals employed on exercise referral schemes in the UK have a general qualification (in the UK a Register of Exercise Professionals Level 3 qualification) rather than an advanced exercise qualification specific to stroke (in the UK a Register of Exercise Professionals Level 4 qualification). The majority of exercise professionals in exercise referral schemes, therefore, do not have the specialist qualifications required to work with people who have had a stroke. In a qualitative study of stroke survivors, physiotherapists and exercise professionals involved in an exercise referral scheme in the south of England, appropriate knowledge of stroke amongst exercise professionals was considered important by stroke survivors (Wiles et al. 2008), and there were concerns from physiotherapists that, due to the limited knowledge of exercise professionals about stroke, only the least physically impaired patients could be referred to the service.

• The emphasis on individual exercise. Most exercise referral schemes do not include group exercise sessions. Therefore, stroke survivors may miss the social aspects of exercising in a group with other people in a similar situation. The element of social support from fellow exercise participants has been reported to be highly valued in studies of experiences of Exercise after Stroke (e.g. Carin-Levy et al. 2009, Reed et al. 2010, Sharma et al. 2011), as described in chapter 6.

• Time-limited nature of exercise referral schemes. Exercise referral schemes work mainly on an individual basis and therefore capacity issues mean they are often time-limited. Some stroke survivors may not be able to move on to independent or mainstream exercise, so they would either have to continue with one-to-one support indefinitely, which is not cost-effective, or the individual may not be able to continue in structured exercise.

Cardiac rehabilitation

Cardiac rehabilitation is ‘the process by which patients with cardiac disease, in partnership with a multidisciplinary team of health professionals, are encouraged and supported to achieve and maintain optimal physical and psychosocial health’ (Scottish Intercollegiate Guideline Network Guideline 2002, p. 1).

Cardiac rehabilitation programmes for patients with cardiac disease include supported exercise and lifestyle advice. The process of cardiac rehabilitation is divided into four phases that begin in acute hospital care, and end in long-term maintenance of exercise and healthy lifestyle, in the community. An important component of cardiac rehabilitation is the exercise intervention and this has been shown to have considerable health benefits independent of other aspects of the programme (Jolliffe et al. 2001). Overall, the evidence of the effectiveness of cardiac rehabilitation in improving outcomes for people with cardiac problems is very strong. Cardiac rehabilitation programmes are widespread across the UK and the rest of the developed nations and, although access to long-term maintenance exercise classes in the community is limited in some areas, cardiac rehabilitation community exercise sessions are far more widespread than Exercise after Stroke groups at present.

Adapted cardiac rehabilitation

Tang and colleagues working in Canada argued against developing new community Exercise after Stroke services, suggesting instead that cardiac rehabilitation should be adapted to include stroke survivors (Tang et al. 2009). The arguments for this are as follows:

• There is considerable co-morbidity between stroke and heart disease. It has been estimated that up to 75% of stroke survivors have co-morbid heart disease (Roth 1993) and the two conditions have considerable overlap in modifiable risk factors.

• Cardiac rehabilitation services are already well established, and there are well-developed referral pathways from the health service.

However, in a survey of cardiac rehabilitation services in the Ontario area of Canada, only about 5% of participants in these classes were stroke survivors, even though 60% of cardiac rehabilitation services accepted stroke survivors (Tang et al. 2009). Tang et al. (2010) compared the outcomes of users who had primary stroke diagnosis and cardiac diagnoses, or primary cardiac and stroke, or just a cardiac diagnosis: all three groups had similar benefits from a cardiac rehabilitation programme in improving peak oxygen capacity.

There are two ways in which the cardiac rehabilitation model could be utilised to develop Exercise after Stroke services:

1. By including stroke survivors in existing cardiac rehabilitation services as described above; however, stroke-specific adaptations should be in place, as described in chapter 10.

2. By using cardiac rehabilitation exercise classes as a template, i.e. designing a stroke-specific service based on the phased model of cardiac rehabilitation.

Where cardiac rehabilitation is used as a template for stroke-specific services, there are two key elements of cardiac rehabilitation that could be transferred. The first is that cardiac rehabilitation begins during inpatient stay and the first exposure to exercise is in a clinical environment, supervised by a health-care professional. When the cardiac patient then starts to exercise in the community, they know the duration and intensity of exercise that they can tolerate and will have learnt about their body’s response to exercise. The second element is that cardiac rehabilitation includes lifestyle advice and more holistic rehabilitation interventions. Exercise after Stroke services run by several health services in Scotland have taken on some elements of the cardiac rehabilitation model. Although their exercise programmes were specifically adapted for stroke survivors and tailored to the individual, the systems approaches were similar to cardiac rehabilitation in that they:

• Were conducted in a rehabilitation setting

• Were run by health-care professionals (physiotherapists, nurses and assistants)

• Included an educational component

• Were time limited

• Acted as a risk assessment or transition to exercise in community venues.

In this way, these services were very similar to phase 3 cardiac rehabilitation which has ‘historically taken the form of a structured exercise programme in a hospital setting with educational and psychological support and advice on risk factors’ (Scottish Intercollegiate Guidelines Network Guideline 57. 2002, p. 1).

It is a very parsimonious solution to replicate models from other health service programmes that have already been implemented effectively. However, we need further research evidence about whether the education component is independently effective in improving outcomes for stroke survivors. Harrington et al. (2010) conducted a randomised controlled trial of a community-based exercise and education intervention for stroke survivors. Their parallel qualitative study (Reed et al. 2010) indicated that participants did not find all of the education sessions useful.

Aerobic training is already recommended as part of rehabilitation for stroke in UK clinical guidelines (Royal College of Physicians 2008) so it would seem that joining up inpatient and community-exercise programmes to an integrated patient pathway would seem an optimum model for future service development (this will be further discussed at the end of the chapter).

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