Supporting Lifestyle and Activity Modification After a Transient Ischaemic Attack

This project, led by the Community Stroke Team, delivered a six-week education and exercise program with 12 weeks of telephone health coaching to patients in Hunter New England Local Health District (HNELHD) who had experienced a transient ischaemic attack (TIA).

Aim

To increase the time patients spend in moderate to vigorous physical activity in the first 12 months following their TIA (or non-disabling stroke).

Benefits

• Educates patients about TIA and lifestyle factors associated with an increased risk of stroke.
• Helps patients understand the signs and symptoms of a stroke, so they can get to a hospital straight away.
• Allows patients to identify their individual risk factors and then choose the ones they wish to work on improving.
• Provides a guided exercise program at a local community gym that is easily accessible both during and outside of session times.
• Helps people who have experienced TIA increase their physical activity and maintain it over the long term.

Background

A TIA describes a stroke event where someone has symptoms of a stroke that resolve within 24 hours. Symptoms may include arm weakness, loss of speech, leg weakness or a change in memory and other cognitive function. People who experience a TIA are at risk of having another cardiovascular event including a stroke¹. A large case-controlled study involving 32 countries and over 27,000 participants revealed that 90 per cent of stroke cases are attributed to lifestyle choice². Lifestyle factors which can be modified to reduce stroke risk include: having high blood pressure, having diabetes, being physically inactive, being overweight, smoking, having high levels of stress and drinking too much alcohol.

After high blood pressure, physical inactivity is the second highest modifiable risk factor attributed to stroke². Prior to the project, people who experienced a TIA in HNELHD received medical management at John Hunter Hospital. This included investigations to determine why the stroke might have occurred, medications to reduce stroke risk and general advice on making good lifestyle choices. Despite the evidence in support of behaviour change programs in increasing physical activity and reducing the risk of cardiovascular events in this patient population, there were no such programs available to TIA patients in HNELHD.

It was determined that a gym-based program was required, to:

• show patients how safely and well they could exercise outside the hospital setting
• teach them about stroke symptoms and how to tell if they were having another one
• help them manage their own cardiovascular (heart and vessel) health to reduce the risk of another stroke.

Implementation

• In-depth interviews were held with people who had experienced TIA to better understand what the program needed to include.
• A local community gym was engaged to provide the space and equipment for TIA patients to be able to exercise safely, during and outside of the sessions led by health professionals. Patients were able to access this gym 24 hours a day, seven days a week for six weeks.
• Discussions were held with the NSW Health Connecting Care Program which would deliver the health coaching.
• Discussions were held with telehealth experts in the local health district, to see how it could be incorporated into the program.
• The program involves an initial assessment, measuring participants’ stroke knowledge and risk factors. An exercise and education program is then delivered twice a week for six weeks, comprising 30 minutes of education and 60 minutes of exercise. In the final three weeks of the program, one exercise session per week is delivered via telehealth.
• Following the six-week program, the Connecting Care Program provides individually tailored health coaching fortnightly for an additional 12 weeks.
• A follow-up assessment is conducted at the completion of the health coaching to see how well they have maintained their new lifestyle changes and how this has affected their cardiovascular health.

Status

Sustained – The project has been implemented and is sustained in standard business.

Dates

Development of this project began January 2016, with the first group of patients commencing the program September 2016.  As of April 2018, five groups of patients have completed the program to date. Evaluation of the program is underway with Dr Heidi Janssen’s NSW Health Early to Mid-Career Research Fellowship, which will be completed in March 2020.

Implementation sites

• Community Aged Care Services, Greater Newcastle Sector
• Hunter New England Local Health District

Partnerships

• HNELHD Connecting Care Program
• HNELHD Telehealth
• Hunter Medical Research Institute
• Planet Fitness Gym, Lambton
• University of Newcastle

Evaluation

Three groups of participants (24 patients) joined the program between September 2016 and March 2017. Participants started the program 3-4 months after being discharged from John Hunter Hospital, with 75 per cent of participants experiencing a TIA and 25 per cent experiencing a mild stroke. The following data was collected at baseline:

• knowledge of stroke and TIA risk factors, measured via a quiz
• a six-minute walk test (6mwt), to measure endurance
• lower limb endurance (sit-to-stands)
• grip strength
• measurement of other risk factors, including blood pressure, waist to hip ratio, diet, salt intake, alcohol intake and smoking
• cognitive function, measured using the Montreal Cognitive Assessment
• mood, measured by the Depression Anxiety Stress Scale
• quality of life, measured using the EuroQol-5D
• self-perception of performance in everyday living, measured using the Canadian Occupational Performance Measure tool.

Baseline data showed that cognitive function was lower than considered normal and walking endurance was less than normal for the age of the participants. Blood pressure was higher than the target of 140/85, while waist circumference to hip circumference ratios placed almost all participants in the category of having abdominal obesity (defined by a ratio of more than or equal to 0.9 in men and more than or equal to .85 in women). One third of participants also had diabetes.

Following six weeks of twice-weekly sessions, there was a clinically meaningful improvement in endurance, with participants walking an average of 62 metres further in the 6mwt. Average blood pressure was reduced by 5[12] mmHg systolic and 3[8] mmHg diastolic, and was both clinically and statistically significant. Waist circumference to hip circumference ratio was reduced by one per cent and knowledge of TIA and stroke was improved by 15 per cent.

Participants also showed better endurance and fitness, mood and quality of life. There were reported improvements to diet, however research shows that self-reporting can be unreliable. There was no change to smoking levels. All participants were referred to Quitline for smoking cessation support.

Participants were assessed again after the 12-week Connecting Care health coaching and results showed that improvements had been maintained. While these results are exciting, it is important to take other factors into account that may have influenced the result. For example, blood pressure measurements are highly variable depending on time of day, changes in medication and changes in stress levels.

In 2016, funding for a new fellowship position to evaluate the program from a service and patient level using research methods was received. Further funding was received to collect data from a control cohort in 2017. This comparison group is comprised of people who have had a TIA or mild stroke but who are not participating in the program. The results of this non-randomised trial will be used to determine the effectiveness of the program. A new clinical service has also been established to develop referral partnerships with general practitioners and identify how to scale the program so it can be sustained across the district. Research outcomes linked to the Dr Heidi Janssen’s fellowship project will be taken at six weeks, 18 weeks and 30 weeks, to objectively measure:

• moderate to vigorous physical activity levels using an accelerometer monitor
• average blood pressure measured at home by the participant with standardised instructions
• HBA1c, cholesterol and c-reactive proteins using blood tests
• stress using cortisol levels in hair
• cognition using the recognised NIH Toolbox
• fatigue using the Fatigue Assessment Scale.

Lessons Learnt

Internet connection quality can interfere with the delivery of telehealth sessions. However, it was surprising how well participants handled telehealth consultations, given their average age was 71.

References

1. Ducrocq G, Amarenco P, Labreuche J et al. A history of stroke/transient ischemic attack indicates high risks of cardiovascular event and hemorrhagic stroke in patients with coronary artery disease. Circulation 2013;127(6):730-8.
2. O'Donnell MJ, Chin SL, Rangarajan S et al. Global and regional effects of potentially modifiable risk factors associated with acute stroke in 32 countries (INTERSTROKE): a case-control study. Lancet 2016;388(10046):761-75.

Further reading

View a presentation from the 2017 Rural Innovations Changing Healthcare Forum

Contact

Heidi Janssen
Senior Physiotherapist, Community Stroke Service
Community and Aged Care Services, Greater Newcastle Sector
Hunter New England Local Health District
Phone: 02 4042 0417
Heidi.janssen@hnehealth.nsw.gov.au