Promoting Optimal Physical Exercise for Life (PROPEL): aerobic exercise and self-management early after stroke to increase daily physical activity-study protocol for a stepped-wedge randomised trial

Factors That Influence the Clinical Implementation of Aerobic Exercise in Stroke Rehabilitation: A Theory-Informed Qualitative Study

OBJECTIVE

Best practice guidelines recommend that aerobic exercise (AEx) be implemented as early as possible poststroke, yet the prescription of AEx remains limited in stroke rehabilitation settings. This study used theoretical frameworks to obtain an in-depth understanding of barriers and enablers to AEx implementation in the stroke rehabilitation setting.

METHODS

A qualitative, descriptive study was conducted. Participants were recruited from 4 stroke rehabilitation settings in Ontario, Canada, that have participated in an implementation study to provide structured AEx programming as part of standard care. Six clinician focus groups (with 19 physical therapists and 5 rehabilitation assistants) and one-to-one interviews with 7 managers and 1 physician were conducted to explore barriers and enablers to AEx implementation. The Theoretical Domains Framework and Consolidated Framework for Implementation Research informed content analysis for clinician and manager perspectives, respectively.

RESULTS

Barriers specific to resource constraints and health care system pressures, combined with patient goals, led to interventions to improve function being prioritized over AEx. Successful implementation was enabled through an interprofessional approach and team engagement in the planning and implementation process. Health care providers described concerns about patient safety, but confidence and capability for implementing AEx were enabled by education, skill development, use of exercise tests, and consultation with individuals with content expertise. Participants described the development of supportive processes that enabled AEx implementation within team workflows and shared resources.

CONCLUSION

Strategies to support implementation of AEx in stroke rehabilitation should incorporate knowledge and skills, the provision of clinical decision-making tools, access to expert consultation, the roles and social influence of the interprofessional team and formal and informal leaders, and supportive processes adapted to the local context.

IMPACT

Results from this study will inform the development of a clinical implementation toolkit to support clinical uptake of AEx in the stroke rehabilitation setting.

A systematic review of measures of adherence to physical exercise recommendations in people with stroke

OBJECTIVE:

To review methods for measuring adherence to exercise or physical activity practice recommendations in the stroke population and evaluate measurement properties of identified tools.

DATA SOURCES:

Two systematic searches were conducted in eight databases (MEDLINE, CINAHL, PsycINFO, Cochrane Library of Systematic Reviews, Sports Discus, PEDro, PubMed and EMBASE). Phase 1 was conducted to identify measures. Phase 2 was conducted to identify studies investigating properties of these measures.

REVIEW METHODS:

Phase 1 articles were selected if they were published in English, included participants with stroke, quantified adherence to exercise or physical activity recommendations, were patient or clinician reported, were defined and reproducible measures and included patients >18 years old. In phase 2, articles were included if they explored psychometric properties of the identified tools. Included articles were screened based on title/abstract and full-text review by two independent reviewers.

RESULTS:

In phase 1, seven methods of adherence measurement were identified, including logbooks ( n = 16), diaries ( n = 18), 'record of practice' ( n = 3), journals ( n = 1), surveys ( n = 2) and questionnaires ( n = 4). One measurement tool was identified, the Physical Activity Scale for Individuals with Physical Disabilities ( n = 4). In phase 2, no eligible studies were identified.

CONCLUSION:

There is not a consistent measure of adherence that is currently utilized. Diaries and logbooks are the most frequently utilized tools.

Exercise for stroke prevention

We review evidence concerning exercise for stroke prevention. Plausible biological reasons suggest that exercise would be important in preventing stroke. While definitive randomised controlled trials evaluating the impact of physical activity (PA) and exercise on preventing stroke and mortality are lacking, observational studies, small randomised controlled trials and meta-analyses have provided evidence that PA and exercise favourably modify stroke risk factors, including hypertension, dyslipidaemia, diabetes, sedentary lifestyle, obesity, excessive alcohol consumption and tobacco use. It is, therefore, important to understand the factors associated with poststroke PA/exercise and cardiorespiratory fitness. Positively associated factors include self-efficacy, social support and quality of patients' relationships with health professionals. Negatively associated factors include logistical barriers, medical comorbidities, stroke-related deficits, negative exercise beliefs, fear of falling, poststroke fatigue, arthropathy/pain and depression. Definitive research is needed to specify efficacious behavioural approaches to increase poststroke exercise. Effective techniques probably include physician endorsement of exercise programmesto patients, enhancement of patient-professional relationships, providing patients an exercise rationale, motivational interviewing, collaborative goal-setting with patients, addressing logistical concerns, social support in programsmes, structured exercise programming, individualised behavioural instruction, behavioural diary recording, reviewing behavioural consequences of exercise efforts, reinforcing successful exercise performance. Exercise programming without counselling may increase short-term activity; simple advice or information-giving is probably ineffective. Older patients or those with cognitive impairment may need increased structure, with emphasis on behaviour per se, versus self-regulation skills. We support the latest American Heart Association/American Stroke Association guidelines (2014) recommending PA and exercise for stroke prevention, and referral to behaviourally oriented programmes to improve PA and exercise.

Early robot-assisted gait retraining in non-ambulatory patients with stroke: a single blind randomized controlled trial

BACKGROUND

Restoration of walking function is a primary concern of neurorehabilitation with respect to the aspired social and vocational reintegration. To date, the best practice for improving gait early after stroke is still object of debate. On one hand, repetitive task-specific approaches with higher intensities of walking have been observed to result in greater improvements of gait after stroke. Conversely there is some evidence that conventional gait training would be more effective for facilitating walking ability after stroke.

AIM

To compare the effects of an early treatment protocol of add-on robot-assisted gait training with add-on conventional overground physiotherapy for improving locomotion in non-ambulatory adult stroke patients.

DESIGN

Single-blind randomized controlled trial.

SETTING

Neurorehabilitation hospital.

POPULATION

Seventy-four subacute patients with first-ever ischemic stroke.

METHODS

The patients were randomized into two groups. The training program consisted of forty, 2-hour sessions (including 45 minutes basic training, 45 minutes add-on training plus rest periods), 5 days a week, for 8 consecutive weeks. Patients allocated to the add-on robot-assisted gait training were treated by means of the Lokomat. Patients allocated to the add-on conventional overground gait training aimed at improving postural control during gait, body weight transfer, stability during the stance phase, free swing phase, adequate heel contact and gait pattern. Primary outcome was the modified Emory Functional Ambulation Profile. Secondary outcomes were the Rivermead Motor Index, the Mobility Milestones and the Hochzirl Walking Aids Profile.

RESULTS

No significant difference was observed between groups with regards to age (P=0.661), time from stroke onset (P=0.413) and the primary outcome (P=0.854) at baseline evaluation. As to the primary outcome, no significant differences were found between groups at the end of the study. As During the 8-week training, within-group comparisons showed significant improvements of mean modified Emory Functional Ambulation Profile in both groups (P<0.001).

CONCLUSIONS

Our results support the hypothesis that an early treatment protocol of robot-assisted gait retraining is not superior to add-on conventional gait training intervention for improving locomotion in non-ambulatory stroke patients.

CLINICAL REHABILITATION IMPACT

This study might help to better understand the role of robot-assisted gait training in early phase stroke rehabilitation.

Rating of perceived exertion with Borg scale in stroke over two common activities of the daily living

Background The Borg Scale for the rating of perceived exertion (RPE) is recommended to measure the intensity of physical exercise during stroke rehabilitation, but its reliability in activities of daily living is not explored. Objective To evaluate the correlation between the RPE using the Borg Scale (6-20) and the intensity of effort as measured by the Total Energy Expenditure per minute (TEE.min^-1) in a post-stroke population for two tasks: walking at spontaneous comfortable speed and walking up and down stairs. Methods A cross-sectional study has been conducted. Any post-stroke subjects able to walk without being helped were recruited. Subjects were asked to walk at their spontaneous comfortable walking speed for 6 min and then to walk up and down stairs with a portable gas analyzer to measure the TEE.min^-1. The RPE was evaluated by the Borg scale (6-20). The correlation between the RPE and the TEE.min^-1 for each subject's walking task and stairs task was calculated with the Pearson coefficient. Results Twenty subjects were included. TEE.min^-1 averaged at 5.6 (±1.2 kcal.min^-1) for the walking task and 9.58 (±4.3 kcal.min^-1) for the stairs task. The median RPE was 11 (min 6; max 15) for the walking task and 11 (min 6; max 16) for the stairs task. The correlation coefficient between the RPE and TEE.min^-1 was r = 0.12 (p = 0.25). Conclusion Our work has not determined a correlation between the RPE and TEE.min^-1 for two common activities of daily living in post-stroke subjects.