Abstract
Background
Exercise rehabilitation has been advocated for clinically stable stroke survivors for the past 15 years and is promoted in most international evidence based practice guidelines (Intercollegiate Stroke Working Party, 2012; Miller et al., 2010; Stroke Foundation of New Zealand and New Zealand Guidelines Group, 2010), including the American Heart and Stroke Association’s, “Physical Activity and Exercise Recommendations for Stroke Survivors” (Billinger et al., 2014).
A number of systematic reviews of exercise rehabilitation interventions suggest that more intensive training is likely to result in better outcomes than less intensive training (Langhorne, Coupar, & Pollock, 2009; Mehrholz, Pohl, & Elsner, 2014; Veerbeek et al., 2014). However, there is some confusion regarding the difference between dose and intensity in the rehabilitation literature (Bowden, Woodbury, & Duncan, 2013; Lohse, Lang, & Boyd, 2014; Page, Schmid, & Harris, 2012). Dose refers to the amount of exercise rehabilitation and is usually quantified in time, while intensity refers to the amount of effort or rate of work undertaken and may be quantified with regard to cardiovascular load, metabolic cost, muscle loading or task difficulty (Billinger, Boyne, Coughenour, Dunning, & Mattlage, 2015; Page et al., 2012).
Current clinical practice guidelines recommend that in clinically stable stroke survivors exercise rehabilitation be undertaken at moderate to high intensities. For example, strength training should be undertaken at 50–80% of capacity (1-Repetition Maximum), whilst aerobic training is frequently prescribed at a perceived exertion of ‘somewhat hard’ to ‘hard’ (Billinger et al., 2015; Boyne et al., 2015). Despite evidence and recommendations, observational studies of clinical practice indicate that uptake of exercise rehabilitation is poor (DeJong, Horn et al., 2004; Gassaway, Horn et al., 2005; McNaughton, DeJong et al., 2005; De Wit, Putman et al., 2006). Furthermore, during rehabilitation, people with stroke frequently do not work at moderate to high intensities (Johnston, Mudge, Kersten, & Jones, 2013; Kaur, English, & Hillier, 2012; MacKay-Lyons & Makrides, 2002; Polese, Scianni, Kuys, Ada, & Teixeira-Salmela, 2014; West & Bernhardt, 2012). Unpacking the barriers to implementation of evidence based interventions into clinical practice is an essential component of translating research into practice (Bayley et al., 2012).
One of the most significant challenges to any rehabilitation programme, regardless of its scientific merit, is whether participants perceive it to be acceptable, beneficial to them, and whether the programme is tailored in such a way to allow individuals to engage (Page et al., 2012; Siegert, McPherson, & Dean, 2005). One frequently cited barrier to implementing evidence based practice guidelines is patient tolerance to the recommended intervention (Bayley et al., 2012; Signal, 2014). This may be a substantial barrier to implementing moderate to high intensity exercise rehabilitation. The objective of this study was to ascertain the acceptability of high intensity exercise rehabilitation for people with stroke and to explore factors which influenced engagement in a twelve week exercise rehabilitationprogramme.
Method
This qualitative descriptive study was nested in a mixed methods randomised, controlled, single blind pilot trial (RCT) investigating high intensity exercise rehabilitation interventions in people with stroke. Ethical approval for the study was received from the NZ Health and Disability Ethics Committee-Northern X (NTX10/07/069)
Participants
Participants were recruited to the pilot RCT from hospital stroke clinics, neurological physiotherapy clinics, the Stroke Foundation and through local media advertising. They were aged over 18 years, had experienced a single disabling stroke at least 3 months prior, were able to walk 10 m and had a gait speed of between 0.05 to 1.3 m/s at entry to the study. All participants of the pilot RCT who had participated in moderate to high intensity group based exercise rehabilitation (n = 14) consented to post intervention interviews. The exercise rehabilitation involved strength and/or task-specific training aimed at improving locomotor function, undertaken three times per week for twelve weeks under the supervision of a physiotherapist. Exercise intensity was individually prescribed and after a familiarisation period, intensity was progressed from moderate to high over the twelveweeks.
Data collection
Data was collected using semi-structured interviews (Sandelowski, 2000). The initial interview guide was developed by the primary researcher (NSi) in consultation with the wider research team. Interviews focused on the acceptability of the exercise rehabilitation intervention, the barriers and facilitators to engagement and the participant’s experience of exercising at a high intensity. A semi-structured approach was selected to allow flexibility in response to the person being interviewed and the interview context (Sandelowski, 2000). The interviewers (NK and SM) were independent from other aspects of the pilot RCT and experienced in interviewing people with neurological pathologies. Participants were invited to include family members in the interview. Interviews lasted between 20 and 45 minutes and were audio-recorded and transcribed.
Data analysis
The intent of data analysis was to provide a rich description of participants’ experiences and opinions, rather than an interpretation. However, it is acknowledged that description is never completely free from interpretation (Sandelowski, 2000) and is always influenced by the epistemological background of the researcher. The researcher (NSi) who conducted the analysis is a physiotherapist who was not involved in the exercise rehabilitation delivery. The audio recordings were listened to repeatedly, and then interview transcripts read. Initial coding was manually applied to sentences or phrases. Subsequently, transcripts were imported into NVivo 10 software (QSR International, USA) and re-coded. Comparison between the initial manual coding and the electronic coding was then undertaken. To gain an understanding of the relationships between codes, a number of strategies were utilised. These included constant comparison within and across codes and data sources, and the use of memos to record details of the codes and keep track of initial impressions about the data and hypothesised interactions between codes. Where relevant, codes were then grouped into themes and negative case analysis was used to identify data that was contradictory or dissonant with the proposed theme; this was an iterative process. Two coded transcripts were sent to a second researcher (KM) to ensure consistency of interpretation, and two meetings were held to discuss the interpretation of the data with the aim of reaching consensus on thematic development. Different iterations of the theme map were discussed and revised with the wider research team to ensure the suggested relationships between themes were consistent with the agreed interpretation of data. For the purposes of data representation, illustrative quotes were selected that corroborated the data and these are presented with pseudonyms.
Results
Participant characteristics
Ninety seven people were screened for eligibility to participate in the pilot RCT; 47% did not meet the inclusion criteria, 15% had a medical condition which contraindicated moderate to high intensity exercise and 19% were unwilling to participate. The demographic and clinical characteristics of the participants are presented in Table 1.
Interview findings
Thirteen of the fourteen participants interviewed expressed strongly positive views about the intervention. One participant, who discontinued the intervention at week 5, expressed negative views. Six key themes were drawn from the data. These were making progress, sourcing motivation, working hard, the people, fit with me and fit with my life. The following section discusses each theme in detail.
Theme 1: Making progress
The identification of positive outcomes in response to the intervention appeared to be a powerful modifier of participants’ perceptions of the intervention and their ability to continue to engage. However, making progress, and being able to see that progress, was not confined to improvements in physical function. Four subthemes describe the breadth of the theme.
Experiencing success. The ability to achieve and progress in aspects of the intervention itself was an important marker of success for many participants, with many participants describing specific gains they made during the intervention.
I know I was getting to the stage where I could push and lift more – that was good. (Rebecca, Age 73)
I couldn’t go down on my knees and by the end I could actually go down on my knees, sit down on my bottom, stretch my legs and do the reverse and get up again, you know, which is a big thing for me. (Tania, Age 51)
Identifying gains. Participants identified a range of gains in impairment, including cardiovascular fitness, endurance, strength, range of motion, muscle tone, communication ability and mental alertness. Thirteen participants described gains in aspects of walking, including speed, endurance, safety, aesthetics, dual tasking and the use of aids.
Before I started the programme when I walked, I would limp. And now I don’t, I just walk. (Carolyn, Age 50)
Many participants described gains at a participatory level. Participation gains included taking on roles within and beyond the home, and engaging in sporting, leisure and social activities. For example, one participant described how her young niece had her first sleepover at the participant’s house,
Whereas before, no she didn’t really stay with us because they (the participant’s sister and brother-in-law) knew that ... it would be difficult for me ... she’s running up and down like the wind, you know. And for me to follow her, well see now it’s no problem, I can get up and down those stairs just as almost as fast as she can now. So it really has made a difference. (Lee-Ann, Age 68)
Gains from the programme also appeared to have an effect on the participants’ personal relationships. For example, one participant described how gains in her endurance had influenced her ability to socialise with her friends;
I used to have to say to people after half an hour, oh gosh, you know, I really need to go and lie down now because this is all too much. But now I can actually now sit and do a full visit, a proper visit, you know. And with many people talking around me and I just so you know it feels so much more back normal. (Tania, Age 51)
Becoming confident. Participants also reported gains in confidence; many participants talked specifically about increasing their confidence in relation to balance and walking.
Well I think it’s given me a bit more confidence because I’d lost it ... .I think it’s given me back a bit more confidence than I did before because at one time I was sort of jittery going anywhere, you know ... this has given me a bit more confidence and I’m doing things now I didn’t think I could do. (May, Age 90)
Seeing possibilities for the future. For some participants, the intervention appeared to highlight potential capacity and future possibilities.
Yeah, I feel more confident using the walking stick and I’m looking forward to the time when I can dispense with the walking stick. (Brian, Age 73)
Before the programme I really, I was thinking that I really have to start working on myself and I accept that I am now a disabled person, you know, and I don’t feel that anymore. I now just think well there’s some things I can’t do but, you know, if I keep trying then I will be able to do them. Let’s just keep going, even if it takes five years, even if it takes 11 years. (Tania, Age 51)
Experiencing success with the intervention and the identification of gains which extended beyond activity to participation and confidence appeared strongly related to intervention acceptability and engagement. The positive influence of these gains was also powerful when reinforced by others, including family, friends and acquaintances, other group members and the physiotherapist and therapy assistant.
Theme 2: Sourcing motivation
All participants referred to different sources of motivation that encouraged and helped them sustain their engagement with the programme. These sources were divided between self-motivation and other sources of motivation.
Self-motivation. A strong theme, identified by the majority of participants, was the importance of self-motivation. Self-motivation and determination were discussed with reference to the individual and by those offering opinions about what was necessary for others to successfully engage.
Interviewer: [...] what has helped you take part in it?
Carolyn: I think it’s my self-determination ...
Interviewer: And what do you think has helped you achieve those goals?
Carolyn: Hard work. And a hundred percent commitment from me. (Carolyn, Age 50)
Key thing is, you know, getting your mind stuck to what you’re doing to improve your health and turning up when you’re needed, you know, on the day ... The things got harder like there’s a couple there that couldn’t take it but I wasn’t going to let that, you know, stop me because I had a goal and you don’t give up half way. You’ve got to go all the way if you know where you, what the outcome is. (Jonathon, Age 56)
Other sources of motivation. The participants also derived motivation from other sources, including family, having an altruistic view towards research and other members of the group.
And I said to my son, “I don’t really want to go because it’s going to interrupt”. However he said, “Well, it could benefit someone else”. I said, “Okay I’ll do it”. (Rebecca, Age 73)
The power of the group as a source of motivation and the role of the physiotherapist as motivators are discussed in greater depth below in the section The People. However, whilst external motivational factors appeared to be important to engagement with the intervention, participants appeared to place more emphasis on self-motivation. Those who described high levels of self-motivation and self-determination also described the intervention very positively.
Theme 3: Working hard
The requirement to work at a high intensity during the intervention did not appear to negatively influence the acceptability of the intervention. Instead, many participants talked of valuing how the intensity of Physical and mental effort forced them to focus and work hard, and linked this to their sense of success with the programme. Some participants identified a direct link between hard work and reward, No pain-No gain, and some commented on the hard work being repetitive, requiring an attitude of Slogging it out.
Physical and mental effort. Thirteen of the fourteen participants described the intensity of the interventions as hard, describing the high level of physical and cognitive effort required to participate. Participants reported fatigue in response to the programme. The level of effort and consequent fatigue was often referenced to changes in intensity of the intervention as the programme progressed.
Yeah, I put, I mean the pushing the various weights and things, that was so hard. I was sweating straight away, you know, that was, you put maximum effort in once you got, particularly when we got to the point where we had to do things fast. (Jeff, Age 70)
I thought the intensity was really good because it made you focus. (Lee-Ann, Age 68)
The level of effort required and fatigue were accepted as normal responses to high intensity exercise by the participants and did not appear to negatively influence the acceptability of the intervention.
And sometimes even towards the end I would be still tired the next day but I’m ready to get it all over again the following day. (Tania, Age 51)
No pain-no gain. Many participants linked how hard they worked during the intervention to the gains they made and their sense of achievement.
I mean, no pain no gain isn’t it, you know, so um no well what I put in no, it was benefiting me, you know. Like, I mean, the more I put in, the more benefits I was getting out of it. You can cheat or you can do it properly so I opted for the, you know, the latter, do it properly. (Jonathon,Age 56)
And I started in it just got harder and harder as the time went on but actually I started being, feeling that I wanted it to be harder, you know ... they really did challenge me and I loved it. Honestly I did yeah. I was excited about coming ... . (Tania, Age 51)
Participants found some of the exercises challenging. This engendered a sense of frustration but once an exercise was mastered, participants described a strong sense of success. Frustration with individual exercises did not seem to influence their overall engagement.
No, my least favourite exercise was the rubber bands moving it sideways ... Oh that was difficult too. Um couldn’t stretch as far as I wanted to with it. Actually that one annoyed me. I mean, I don’t think it should be taken out or anything like that and you did it each week. You can’t like them all. (Jeff, Age 70)
Slogging it out. Four participants commented on the repetitive nature of the programme. Two spoke negatively about this, citing a lack of variety, particularly in the latter weeks of the programme.
Maybe they could set us or people with different machines. As well as what we did. Still do what we did but have more variety ... It would um make it a little, a little less of a pain in the arse for us. (Carolyn, Age 50)
In contrast, two participants spoke about the repetitive nature of the training as a positive factor as it facilitated a recognition of progress.
And also like the, it was repetitive but a repetition might normally be a bit boring but it wasn’t. You could feel yourself getting better as you, as you repeated the exercises. (Brian, Age 73)
Theme 4: The people
The role of people involved in the intervention, including the other participants and the staff, is closely linked to the theme Sourcing motivation. However, broader concepts of caring, belonging and camaraderie are encapsulated within this theme. The two subthemes highlight how the group of other participants and the physiotherapists acted as external sources of motivation.
The group. The majority of participants referred to the group positively, describing a sense of belonging, camaraderie and caring.
I feel it was almost like a family in the end, you know, with 12 weeks of five people, although we didn’t have time to talk, you got to know them and it was a really nice feel ... but the others in a group it was a nice feel, kind of friendly and encouraging and interesting to see them and how they were doing. (Sonia, Age 81)
I looked forward to coming to the sessions each time and it gave me a feeling of belonging, that’s what it amounted to ... Oh I felt, I felt that somebody, this course, that somebody cared. (Mark, Age 81)
Participants also felt a strong sense of obligation to the group; their individual level of effort was reflective of the group.
... I feel if I didn’t I would let down the team. (Carolyn, Age 50)
The group provided an external source of motivation for many, with some participants describing an active process of supporting one another to work hard.
Well actually it was quite good in a group because we all helped each other, we all looked after each other – “you can do it, you can do it”. (Jonathon, Age 56)
The group also provided a sense of competition, with some participants making reference to competing with other members of their group during classes.
Yeah and also I think seeing other people you think, “Mm if people can do that, well I can do that”, or “Don’t want you to do better than me”. (Sonia, Age 81)
However, for one participant the competition between other members of the group and himself was viewed negatively.
I got worried at the finish that I wasn’t going to keep up with the others in what weights they were shifting. (Thomas, Age 92)
The physiotherapists. Participants viewed the role of the physiotherapists and therapy assistants positively; valuing the therapists’ clinical expertise, the care and attention they provided, their ability to motivate and help the participants to maintain focus during the training and their belief in the participants’ capacity to be successful.
They weren’t bullies. That’s the first thing but they had a way of getting you to do things without stand over methods. Yeah they pushed me and but being firm and if I try to be super silly or anything like that they soon caught on to it, you know, and just brought me back to earth ... They observed when you had finished a machine so there was no sort of having a little daydream because they were on to you. (Mark, Age 81)
The people involved, including the other participants and the physiotherapy staff seemed to be a powerful promoter of engagement.
Theme 5: Fit with me
All the participants discussed the suitability of the intervention for themselves and for others. They described how well the interventions met their needs and goals, and factors they considered might impact the effectiveness of the intervention or a person’s ability to engage. A number of participants described the intervention as being suitable for everyone, not just those with stroke, but to otherwise healthy individuals.
Different strokes. One participant described how she would have benefited more from the programme had she received it early after her stroke. Another participant also thought the time since stroke would be an important factor for others. Severity of stroke was mentioned by one participant as a potential factor which would limit others’ engagement with the programme.
Well I wouldn’t recommend it to anyone that, that’s, you know, you know, they’ve done all they can and, you know, and they’re bedridden and all that ... (Jonathon, Age 56)
Although, the same participant went on to say,
Even if you were crippled or something you’d probably get that 2%, 1% difference and that’s enough. (Jonathon, Age 56)
In contrast, when discussing the influence of severity of stroke on the ability to participate in the intervention another participant said,
... the people that are doing, taking the course, seemed to know our strengths and they regulated according to our strengths so even if it’s, you know, somebody who’s a lot weaker, you know, they would accordingly do, you know, a low intensity for them than they would for somebody who was a lot stronger. (Lee-Ann, Age 68)
None of the participants who were more severely affected by their stroke identified their level of disability as a limiting factor for engagement.
Meeting my needs. The degree to which the intervention met an individual’s needs was also important. This related to the content of the exercise programme and the context in which it was carried out. For example, those with co-morbidities such as back pain and osteoarthritis described how the intervention had to be modified to meet their needs. The fact that the intervention focused only on the lower limbs and locomotion was a concern for those with upper limb disability, whilst two participants described how the outpatient based nature of the intervention combined with a limited social support network meant that they had difficulty translating gains in function into their home environments.
Being older. Two participants in their nineties spoke about the effect of their age on the suitability of the programme for them; with age appearing to impact both acceptability and the expectation of a highly positive outcome.
Well fitness is hard thing to answer because I’m now 92. So I’ve got to expect deterioration in my body ... I think the fact that I’m still getting about at this age. It hasn’t done me any harm ... Nobody can foresee when they’re going ... No because of my age I won’t plan ahead extensively. (Thomas, Age 92)
My kind of exercise. Some participants described their previous experience of exercise and the type of exercise they enjoyed doing and related it to their enjoyment of the intervention, which was positive in some cases;
Well I enjoy, I always have enjoyed kind of gym and I’ve always been a going, you know, doing things ... never still. So I enjoyed this activity. (Sonia, Age 81)
And negative in others, in particular for this woman who withdrew from the intervention after five weeks;
Rebecca: Well I hate the gym to start with. I’m a walker, I’m a tramper.
Interviewer: Right so are you saying that strength training is sort of not appealing to you?
Rebecca: Well no, never was ... No I hate the gym. ... I’m an outdoors person ... I can’t say I don’t like it, I just, it’s just not me. (Rebecca, Age 73)
A key influence of intervention acceptability seemed to be the extent to which the intervention suited an individual; the less relevant the individual perceived the intervention to their specific needs and desires the more challenging ongoing engagement was.
Theme 6: Fit with my life
The ease with which exercise three times a week for an hour was integrated into their lives was discussed by the majority of participants. They also described the effect of unexpected and expected life events on participation.
My schedule. For some participants, the exercise programme was hard to accommodate in to their weekly schedule. However, the disruption appeared to be strongly influenced by how important they perceived the intervention to be to them, and how much value they placed on it.
You’re never going to find the exact perfect time. It wasn’t convenient for me; it was 11 to 1, 11 to 12 or 11.30 to 12.30 I think, yeah. That wasn’t convenient for my work because I’d go to work and then I’d have to come here ... I do it, I adjust my personal life to live around it. (Jeff, Age 70)
Routine. The routine and commitment was also described in a positive light, as a method of prioritising exercise and rehabilitation, which might not otherwise happen if they were exercising independently or in their own homes. The intervention also provided structure and purpose to some participants’ days, which was valued;
I just think just having to be here, you know ... Oh the discipline of just coming here, you know ... Yeah, structured yeah, yeah. Yeah it’s been good for me. (John, Age 63)
Life’s challenges. The influence of unexpected life events on the ability to engage with the intervention and the consequent acceptability appeared to vary among participants. For example, one participant who had a hospital admission for an unrelated medical problem was very challenged by the effect of that life stressor and the disruptions it caused to his life. The burden of this event alongside the commitments of the intervention appeared to be overwhelming. In contrast, another participant who experienced exacerbations of his osteoarthritis in response to the intervention and had to seek medical advice was less challenged by these events.
What makes it easier. Participants identified other factors which had facilitated their engagement in the intervention. These included the provision of transportation, the location of the venue, accessibility of parking, the availability of amenities such as the onsite café, and administrative and family support.
Discussion
This research presents novel findings with respect to the acceptability of, and engagement in, high intensity exercise rehabilitation following stroke. The relative acceptability of, and ongoing engagement in, this high intensity exercise rehabilitation intervention, appeared to be mediated by a number of broad and inter-related factors, including making progress, sourcing motivation, working hard, the people, and the fit with the individual and their life. One of the most notable findings of this research is that high intensity exercise was very acceptable to a diverse group of people with stroke in terms of age, ethnicity, time since stroke and level of disability. Importantly, participants also perceived that high intensity exercise is suitable for a broad range of people with stroke, highlighting that the intensity of the exercise was tailored to the individual and therefore catered for a wide range of physical abilities. The responsiveness of the context and content of the intervention to an individual’s needs and desires points to the importance meeting the diverse needs of the patient cohort when designing group based exercise rehabilitation programmes, particularly with respect to co-morbidity, aging and social situation.
Participants described the high level of physical and cognitive effort required to engage in high intensity exercise, and they reported fatigue in response to the programme. Low energy and fatigue have been identified as potential barriers to physical activity following stroke (Damush, Plue, Bakas, Schmid, & Williams., 2007; Rimmer, Wang, & Smith, 2008) and concerns about patient tolerance to rehabilitation is often cited as a barrier to implementation of rehabilitation interventions (Bayley et al., 2012). However, in this study the intensive nature of the exercise and the experience of fatigue in response to exercise were not considered a barrier to continued engagement. It is possible that participants became aware of a reduction in fatigue and an increase in capacity as the programme progressed. In many cases, the intervention appeared to highlight to participants a capacity for activity they had previously been unaware of, seemingly increasing self-efficacy. These findings are important as they suggest that in the context of a well-constructed, carefully progressed exercise rehabilitation programme higher intensity exercise may in fact promote ongoing engagement.
All of the participants referred to different sources of motivation which encouraged their initial engagement with the programme and then supported their continued participation. The value of motivators, both internal and external, feature strongly in the literature describing barriers and facilitators to engagement in physical activity following stroke (Damush et al., 2007; Patterson & Ross-Edwards, 2009; Resnick et al., 2008; Rimmer et al., 2008). In the current study, whilst external motivational factors were relevant to the acceptability of the intervention, participant’s reflections emphasised the importance of self-motivation as being a critical factor for continued participation. Indeed, those who described high levels of self-motivation and self-determination were more likely to view the intervention positively. In contrast, participants who appeared more reliant on external motivators found the intervention less acceptable and had difficulty sustaining engagement over the intervention period. Consistent with this finding, Siegert and Taylor (2004) have argued that a central tenet of self-determination theory relevant to rehabilitation is the notion that intrinsic goals are a more powerful motivator than externally imposedgoals.
There has been much debate in the literature regarding the role of motivation in rehabilitation engagement and outcome. Similar to the views of the participants in this study, clinicians report motivation to be a key determinant of rehabilitation outcome and routinely make judgements regarding their patient’s level of motivation (Maclean, Pound, Wolfe, & Rudd, 2002). However, motivation is multidimensional, and is influenced by the effects of the pathology and resultant impairments, psychological adjustment and personality (Lequerica & Kortte, 2010; Maclean & Pound, 2000; Siegert, McPherson, & Taylor, 2004). As such, there is risk in viewing motivation as solely driven from within. Practitioner behaviour and the strategies they adopt have been argued to play a potentially crucial role as a source of motivation (Kayes et al., 2015). Motivation may be fostered by using strategies which enable the individual to see meaning in rehabilitation. For example, education about the benefits of exercise rehabilitation in relation to the things that matter most to the patient and personalised goal setting which explicitly connects concrete rehabilitation tasks to higher level goals (Gill & Sullivan, 2011; Shaughnessy & Resnick, 2009; Shaughnessy, Resnick, & Macko, 2006; Siegert & Taylor, 2004). Furthermore, a focus on self-regulatory skill development may be important given the role that the physical, cognitive, emotional and behavioural impairments inherent to stroke play in limiting ones self-regulatory capacity and motivation (Siegert & Taylor, 2004). Future research exploring the efficacy of strategies to support behaviour change and facilitate engagement in exercise rehabilitation following stroke is warranted.
In the current study, where participants reflected on barriers and facilitators to ongoing engagement in a high intensity exercise programme, the experience of gains in response to the intervention appeared to be a critical factor in promoting engagement. Importantly, all participants identified gains in response to the intervention across the domains of impairment, activity, participation and self-efficacy. Identification of gains in participation and self-efficacy seemed particularly influential. In this case being able to clearly identify the specific benefits of the intervention for themselves promoted ongoing engagement for participants, suggesting the experience of success and the identification of gains is a potentially potent tool in supporting ongoing engagement (Lequerica & Kortte, 2010). This finding has two clinical implications. Firstly, research evidence suggests more intensive training results in better outcomes than less intensive training, and this study indicates that gains experienced in response to more intensive training promote engagement. Therefore, therapists should reconsider the assumption that high intensity training acts as a barrier to engagement as this is not supported by the current study. A second clinical implication of this study is that engagement may be fostered by explicitly identifying and celebrating gains made in the course of exercise rehabilitation. One example of how this could be enacted in clinical practice is, actively seeking opportunities to celebrate successes and gains as a group. Measures of success could be improvement at the impairment, activity or participation levels and could include feedback from family, friends and peers in relation toprogress.
Participants described the importance of the other people in promoting engagement. The other group members acted as a source of obligation, inspiration, and support. Exercising with a group of people is described as a potentially powerful facilitator of exercise activity in people following stroke (Damush et al., 2007; Patterson & Ross-Edwards, 2009). The data from the current study, indicated a strong and positive group dynamic developed quickly within most groups despite considerable diversity in the group. This was a surprising finding as the interviews also indicated that the structure of the exercise rehabilitation did not allow much time for social interaction. Consequently strategies which explicitly promote positive social interactions may be warranted when developing group based exercise programmes (Morris, Oliver, Kroll, & Macgillivray, 2012).
One potential limitation of this study is that half of potentially eligible participants did not want to engage in research investigating high intensity exercise rehabilitation. Whilst it was not possible to explore why potential participants were unwilling to take part in the study, previous research has emphasized that multiple factors including the perception that exercise will not make a difference following stroke, acts as a barrier to initial engagement in exercise rehabilitation (Damush et al., 2007; Patterson & Ross-Edwards, 2009; Resnick et al., 2008; Rimmer et al., 2008). Given that higher intensity exercise rehabilitation promotes engagement, exposure to intensive exercise rehabilitation during inpatient rehabilitation could promote ongoing engagement in exercise rehabilitation and physical activity following discharge. This hypothesis requires further investigation.
Conclusion
The majority of the participants appraised very highly the acceptability of a high intensity group-based exercise programme. Intervention acceptability varied with the extent to which the intervention design met the needs of the individual and fit with their lifestyle. Making good gains in response to the intervention acted to promote intervention acceptability and engagement, particularly when those gains extended beyond activity to participation and self-efficacy. Sourcing motivation also seemed to be an important factor, with self-motivation being a key element. Importantly participants did not view exercise intensity as a barrier to engagement. This may be because they experienced a reduction of fatigue and increase in energy and capacity as the programme progressed, the intervention highlighted a capacity for activity which participants had previously been unaware of, or that participants viewed that any negative symptoms in response to exercise were outweighed by positive benefits. The findings of this study provide a basis for challenging assumptions about the acceptability and consequent engagement in high-intensity exercise programmes for people after stroke, and how practitioners might facilitate a greater uptake of effective strategies for engagement in exercise rehabilitation.
Conflict of interest
The authors have no conflict of interest to report.