Perceptions and experiences of health professionals when supporting adults with stroke to engage in physical activity
A. Pepar A , N. Mahendran
A B * , E. Preston A and R. Keegan A
A
B
Abstract
Understanding health professional perceptions and experiences when supporting post-stroke physical activity may assist with development of strategies targeting low physical activity observed in this group. The aims of this study were to explore health professionals’ perceptions and experiences of post-stroke physical activity, the barriers they experience and potential facilitators when supporting people with stroke to be active.
Ten focus groups were conducted with 57 health professionals (physiotherapists, occupational therapists, nurses, exercise physiologists, psychologists and sports scientists) and allied health students. Data were analysed via inductive thematic analysis.
Health professionals were reluctant to recommend moderate intensity physical activity. Barriers included: (1) post-stroke barriers being varied and individual; (2) resources being under pressure and (3) physical activity goals falling through the cracks. Suggested facilitators included: (1) clearly defined roles, processes and environments which encourage activity; (2) funding for more staff; (3) improving health professional skills and confidence and (4) using internal motivation and social supports after stroke.
Post-stroke physical activity is a complex goal. Varied and individual barriers require tailored solutions. Health professionals report insufficient time, resources and skills to address these individual barriers as well as limited pathways to access physical activity support. Resource-efficient interventions and care models that allow routine strategies targeting post-stroke physical activity are required.
Keywords: barriers, facilitators, health personnel, perspective, physical activity, qualitative research, secondary prevention, stroke.
Introduction
Physical activity is generally low in volume, frequency and intensity, with high levels of sedentary behaviour across all phases of post-stroke recovery (Bernhardt et al. 2004; Mahendran et al. 2016a; Fini et al. 2017). Clinical guidelines recommend that people with stroke complete a minimum of 30-min of moderate intensity physical activity most days of the week (Kleindorfer et al. 2021; Stroke Foundation 2022) and reduce time in sedentary behaviours (Kleindorfer et al. 2021; Stroke Foundation 2022). Despite these recommendations, and evidence that physical activity is safe (Johnson et al. 2020; Saunders et al. 2020; Kleindorfer et al. 2021) and beneficial after stroke (Turan et al. 2017; Kleindorfer et al. 2021), many remain inactive.
Health professionals are important facilitators of post-stroke physical activity (Nicholson et al. 2013; Morris et al. 2014; Moore et al. 2018) and their support is highly valued by adults living with stroke (Nicholson et al. 2013). While many health professional-led interventions are effective in increasing post-stroke physical activity (Morris et al. 2014; Moore et al. 2018), people with stroke also report being discouraged by health professionals to engage in physical activity due to concerns such as safety (Luker et al. 2015; Morris et al. 2015; Ezeugwu et al. 2017). Many of these concerns may be related to long-standing cultures, processes and perspectives within health systems, such as the perceived importance of bedrest in hospital, and prioritising clinical care and safety to ensure efficient discharge and falls prevention (Alsop et al. 2023). Nevertheless, recent guidelines (Kleindorfer et al. 2021) and routine audits of care (Stroke Foundation 2022) highlight that inclusion of physical activity interventions is an essential component of routine post-stroke care.
These perceptions of health professionals may contribute to the low physical activity observed in people with stroke (Luker et al. 2015). Only one study has explored the perspectives of physiotherapists on physical activity after stroke (Morris et al. 2015). Nonetheless, other health disciplines also play a role in improving physical activity after stroke, as barriers are varied, complex and individual to each person, and not only physical in nature (Nicholson et al. 2013). Thus, it is important to explore the perspectives of all members of the multidisciplinary team across the care continuum. Further, exploring the experiences and perspectives of health professionals with varied years of experience may provide additional insights to guide system-level solutions and translation efforts targeting post-stroke physical activity. For example, experiences of novice health professionals (such as new graduates and final year health students) as they embed the latest evidence into practice could inform solutions that tackle existing cultures, processes and structures that do not encourage physical activity. Thus, this study aimed to explore the perceptions and experiences of health professionals of physical activity after stroke, and the barriers and facilitators they face when supporting engagement in post-stroke physical activity.
Materials and methods
Ten focus groups were conducted with health professionals and final year health students in Australia. These health professionals and final year health students were practising in university health clinics, hospitals, community rehabilitation centres and private community gyms. Institutional ethics approval was obtained from the University of Canberra (HREC 18-03), and all participants provided written informed consent.
Participants
Participants were included if they were: (a) a health professional who had experience working with people after stroke or (b) a health student in the final year of their degree who had completed their full-time neurological rehabilitation clinical placement. These criteria ensured breadth of experience. Health students were recruited as they were identified as individuals that would have a fresh perspective on implementing the most current evidence and guidelines regarding physical activity into existing practices, cultures and systems. A convenience sample was recruited via professional networks, flyers and social media advertisements. Medical practitioners, physiotherapists, occupational therapists, exercise physiologists, psychologists, speech pathologists, dietitians, nurses and nurse practitioners were invited to participate. Final year health students were recruited via professional clinical educator networks and flyers in student-led clinics. Interested health professionals and students contacted the research team via email or phone. There were no additional exclusion criteria.
Procedure
Participants attended a 1-h, in-person, discipline-specific focus group, to encourage discipline-specific perspectives. A target of 6–12 health professionals per group was set to promote group discussions (Krueger 2000). Focus groups were facilitated by an experienced female member of the research team (N. M.) and supported by another female member (A. P.). All focus groups were audio and video recorded, except for one, which was only audio recorded at the request of participants. Field notes were taken by both facilitators of the focus group and cross-checked with video recordings for accuracy. Participants also provided demographic information including qualifications, years of clinical experience and time working with people after stroke.
Participants were provided with a definition of physical activity as ‘any bodily movement produced by skeletal muscles that required energy expenditure’ (Caspersen et al. 1985, p. 126), as well as the current guidelines for physical activity after stroke (Stroke Foundation 2022). This introduction was followed by the focus group questions. Questions were developed by the research team based on insights from the team’s earlier work in post-stroke physical activity and secondary prevention with: adults with stroke, health professionals, researchers and allied health students (Mahendran et al. 2016a, 2020; Howes et al. 2020; Dudley et al. 2022; Alsop et al. 2023). Qualitative studies identified through a systematic review of the literature were also used to guide question design and gaps that needed further exploration (PROSPERO ID: CRD42018100446). Questions were developed to be open ended, to encourage participants to reflect on their own experiences and identify roles, perceptions, barriers and facilitators themselves. These questions were checked for clarity and alignment to intended meaning by two adults from a non-clinical or stroke background and three health professionals unrelated to the study (including one experienced qualitative health researcher). Any new insights obtained during focus groups or preliminary analyses were further explored in subsequent groups. Participants were asked to reflect on physical activity, inclusive of sedentary behaviour and light, moderate and high-intensity activity accumulated across the day, rather than a single therapy session or recovery of independence in activities of daily living. The final focus group questions are provided in Fig. 1.
Data analysis
Audio recordings of each focus group were transcribed verbatim via a professional external to the study. Every transcript was audited against video recordings and notes to confirm the transcripts were an accurate representation of the data recorded and to document non-verbal communication.
Thematic analysis via inductive approach, and guided by grounded theory (Braun and Clarke 2006; Bradley et al. 2007; Weed 2009), was used to analyse raw data, using nVivo 11 (QSR International, Doncaster) (Tong et al. 2007). Two researchers (A. P., N. M.) independently coded each word or phrase, which were then categorised into sub-themes and higher order themes. Identified themes were then discussed to ensure consensus regarding final themes. A third researcher (R. K.) independently reviewed transcripts to confirm themes were an accurate representation of the raw data. All themes were confirmed as an accurate representation of the raw data. Member checking (Guba 1981; Guest et al. 2006) was completed by emailing a final summary of themes to a small sample of 12 health professionals: six involved in the focus groups and six who were not. Members included one nurse, three physiotherapists, two occupational therapists and six final year allied health students. Participants in the member-checking process were asked to provide feedback on the synthesised data (themes, sub-themes and summary notes under each), to confirm if these accurately reflected their experiences and if anything had been missed. Feedback was incorporated into the final results.
Results
Participant demographics
Fifty-seven participants including physiotherapists, occupational therapists, nurses, exercise physiologists, psychologists and final year health students participated across 10 focus groups. Sufficient medical practitioners and dieticians could not be recruited to make up a focus group. Data saturation was reached, with no new themes identified across the last three groups (Guest et al. 2006). Participants reflected on their experiences from health settings across Australia, including the Australian Capital Territory, New South Wales and Queensland. Participant demographics are presented in Table 1.
| Characteristic | n (%) | |
|---|---|---|
| Sex (n, % male) | 17 (30) | |
| Age (years) | ||
| 18–24 | 16 (28) | |
| 25–34 | 23 (40) | |
| 35–44 | 11 (19) | |
| 45–54 | 2 (4) | |
| 55–64 | 1 (2) | |
| Not provided | 4 (7) | |
| Highest qualification | ||
| Currently completing clinical degree | 20 (35) | |
| Diploma | 1 (2) | |
| Advanced diploma | 1 (2) | |
| Bachelor degree | 19 (33) | |
| Masters degree | 15 (26) | |
| Postgraduate doctorate | 1 (2) | |
| Experience working with people after stroke | ||
| <6 months | 23 (40) | |
| 6 months – <2 years | 10 (18) | |
| 2–5 years | 10 (18) | |
| 5–10 years | 4 (7) | |
| >10 years | 9 (16) | |
| Not provided | 1 (2) | |
| Discipline | ||
| Physiotherapist | 15 (26) | |
| Occupational therapist | 9 (16) | |
| Nurse | 6 (11) | |
| Exercise physiologist | 4 (7) | |
| Psychologist | 2 (4) | |
| Sports scientist | 1 (2) | |
| Health student | 20 (35) | |
| Clinical setting | ||
| Acute stroke unit | 9 (16) | |
| Inpatient rehabilitation | 26 (46) | |
| Community public | 2 (4) | |
| Community private | 20 (35) | |
Focus group themes
Nine hours and 57 min of audio recordings (10 focus groups ranging from 47 to 78 min in duration) were transcribed into 146 pages of text. A summary of the coding with counts of quotes, sub-themes, mid-level themes and higher order themes is provided in Table 2. Similar themes emerged out of health professional and allied health student groups. Health professionals reported not prioritising physical activity as part of routine post-stroke care, and that they were reluctant to recommend moderate intensity physical activity. They proposed a multidisciplinary approach to support. Barriers to supporting adults with stroke engage in physical activity included: (1) post-stroke barriers being varied and individual; (2) resources being under pressure and (3) physical activity goals falling through the cracks. Suggested facilitators to supporting adults with stroke engage in physical activity included: (1) roles, processes and environments which encourage activity; (2) funding for more staff; (3) improving health professional skills and confidence and (4) using internal motivation and social supports after stroke.
| Higher order theme | Quotes | Sub-themes | Mid-level themes | |
|---|---|---|---|---|
| Perceptions of physical activity | 57 | 7 | 2 | |
| Roles | 66 | 7 | 2 | |
| Many varied and individual barriers | 213 | 40 | 2 | |
| Public resources under pressure | 101 | 40 | 11 | |
| Poor knowledge, access and continuum of care leading to physical activity goals falling through the cracks | 121 | 16 | 5 | |
| Funding more staff | 12 | 2 | 1 | |
| Health professionals roles and responsibilities, health processes and facilities which encourage activity | 166 | 35 | 12 | |
| Improving health professionals skills and confidence to provide tailored, creative strategies | 136 | 20 | 7 | |
| Internal motivation and social support facilitates physical actvity after stroke | 45 | 7 | 3 | |
| Total | 917 | 174 | 45 |
Most health professionals reported physical activity was not an appropriate or prioritised goal for many people early after stroke.
I haven’t often prescribed non-specific exercise as a therapy itself. [Physiotherapist, inpatient rehabilitation]
Specifically, moderate intensity physical activity was identified as inappropriate for most people with stroke across all settings. Incidental activity and breaking up sitting time were considered more appropriate activity goals than moderate intensity activity.
This individual, 30 min [moderate intensity activity] would be very ambitious. [Exercise physiologist, private community setting]
What counts as moderate? Are we talking based on heart rate? I think we’re pretty well placed to do health promotion and have these discussions, instead of talking specifically about physical activity and those guidelines [moderate intensity activity guidelines]. I think currently I’m doing more about changing positions and don’t have prolonged… sedentary [behaviour]… [Physiotherapist, acute setting]
Physical activity was perceived as inappropriate, or low priority, due to the severity of physical impairments and low pre-morbid physical activity levels. Further, health professionals needed to prioritise recovery of essential activities, independence, function and participation over physical activity. The achievement of physical activity recommendations was often not a goal of structured rehabilitation.
… it’d be working on that sitting balance with the physio or starting some upper limb therapy with the goal that it’ll enable them to walk or to be able to dress or cook a meal or whatever. There’ll always be a bigger goal… physical function needs to be there before we can do that [physical activity]. [Physiotherapist, acute setting]
In those with severe impairments, and uncertain prognosis, some participants believed that discussing physical activity may give people false hope or be upsetting.
You don’t want to upset people… if something [physical activity] is so unachievable, there’s no point. [Nurse, acute setting]
Many health professionals considered achieving premorbid levels of mobility a key precursor for physical activity.
If you don’t get their function back to a certain level… [physical activity] is unlikely to be a conversation you’re having. [Physiotherapist, acute setting]
Allied health students were aware of the benefits of physical activity after stroke, and considered it a part of holistic care. Nevertheless, students reported being educated on new prioritisation tools during orientation activities and thus de-prioritised physical activity in hospital.
It was very structured system P1 [priority 1], P2 [priority 2], P3 [priority 3]. If you didn’t hit the mark, they just don’t get seen… On orientation, we get sat down, and this is an example of the ward sheet, this is the prioritising tool, and this is how we would prioritise this patient. [Physiotherapy student, acute setting]
Students also felt the pressure to discharge patients quickly from hospital. This perception led to allied health students adopting existing practices and feeling that they could not be as holistic as they wanted to be.
I think you learn early on, one of my supervisors said to me… if you try to do the best for every single person, you will fall to pieces as a person. You just won’t be able to make it through the day. When he said that to me, I thought, that is horrendous. Because I think you go into this degree thinking, I want to save the world, I want to help these people, but particularly in a hospital setting, you learn very quickly it’s all about budget. Resources. The amount of patients you can see in a day. You don’t have the time to be as holistic as you’d like. You don’t have the time to be addressing other factors, other than, can you walk to the bathroom? Discharge. [Physiotherapy student, acute setting]
All health professionals recognised they had a role in increasing physical activity, but identified the lack of a clear leader. All groups agreed that discussions about physical activity should be initiated by the medical team.
If there’s a neurologist that comes in wearing a white coat, the patient and the family are going to listen to what he or she has to offer [more] than a senior physio. [Nurse, acute setting]
As a result of no clear roles or leader, many people with stroke were discharged having received no information, guidance or support for physical activity.
I guess it [physical activity] doesn’t always get initiated by anyone… For a lot of patients you never have that conversation. We don’t bring it up, they don’t bring it up. [The] team might not ever cover that at all. [Physiotherapist, inpatient rehabilitation]
Participants recommended a model of supporting physical activity led by the medical team – meaning that stroke and rehabilitation consultants initiate the discussion of physical activity during hospital admission, and then general practitioners following discharge. The medical team would provide medical clearance, advice and encouragement to people with stroke to engage in physical activities. Physiotherapists and occupational therapists could then design specific programs. Exercise physiologists could supervise the programs. Nurses, support workers and carers could support implementation of physical activity throughout the day.
I honestly think it has to be multidisciplinary, and the physios bang on about it at the gym, the [nurse clinical care coordinator] and I hand out information and talk about it again, but hopefully we can get one of the bosses [neurologists] to spruce the same message, and I think a multipronged attack is the best way. [Nurse, acute setting]
Three main barriers were identified, including: (1) many varied and individual barriers for people after stroke; (2) public resources being under pressure and (3) poor knowledge, access and continuum of care leading to physical activity goals ‘falling through the cracks’.
Health professionals reported that the barriers preventing people with stroke engaging in physical activity were varied and individual. They included a range of post-stroke impairments, psychological barriers, low motivation, medical co-morbidities and poor social support. These varied and individual barriers made addressing physical activity difficult. Physical impairments such as hemiparesis and loss of balance made movement very challenging, especially after severe stroke. These impairments made physical activity guidelines difficult to achieve.
Physical activity, with a person who has 0 out of 5 strength and has no sitting balance? [Physiotherapist, community private]
Fatigue and cognitive impairments were reported as barriers to people with stroke to initiate movement, concentrate, understand and remember instructions, and communicate. This affected their ability to commence and maintain physical activity.
If there’s cognitive impairment on top of that then they might have difficulties remembering what they were told in rehab. [Neuropsychologist, community private]
People with stroke whose impairments did not improve in the subacute phase were discharged into residential aged care. In these cases, health professionals working in inpatient and community settings reported regular physical activity was not feasible, and thus they did not prioritise it.
[Discharge destination] that’s a big factor, how much allied health support can they get out of a nursing home? [Nurse, acute setting]
Psychological barriers, including fear, depression and the adjustment to life after stroke inhibited physical activity. Early falls further decreased confidence and motivation for activity.
She [recounting story of person with stroke] was on the parallel bars and she’s had a very bad fall. Therefore, she completely lost confidence in movement, in ability, and she lost confidence in other people around her… she withdrew from any rehabilitation… she was already feeling distressed and feeling that loss of persona, loss of self, loss of confidence, just dealing with everything going on, then the fall was sort of the last straw for her. She just kind of went, no, I need to protect myself and I can’t be put in this situation. [Exercise physiologist, community private]
Health professionals reported that people with stroke, and their carers, were often afraid moving would cause further harm.
‘If I do anything, it’s going to make me have another stroke. It’s going to get worse.’ [Physiotherapist quoting a patient, community private]
Health professionals reported that many people with stroke had to adjust to changes following stroke, with emotional adjustments particularly difficult for those who were previously active or younger in age. Difficulty adjusting to post-stroke life led to social withdrawal and depression, which created further barriers to physical activity.
[One stroke survivor] who had significant facial weakness. She was a very glamorous woman. Getting out and about, accessing the community, there was a lot of shame and grief and loss associated with the changes in her physical appearance. [Neuropsychologist, community public and private]
Health professionals reported difficulties with motivating people with stroke to engage in physical activity, as many had not engaged in physical activity before their stroke.
‘I didn’t do any exercise beforehand, what’s going to make me want to do exercise now?’ [Nurse quoting a patient, acute setting]
Additional barriers were perceived to exist for people with stroke who had medical co-morbidities such as uncontrolled hypertension or blood glucose, and atrial fibrillation. These considerations had a negative impact on a stroke survivor’s motivation and prioritisation of physical activity.
… when people come in with their first stroke, [the doctors] don’t know what’s caused the stroke. [The stroke survivor] might get a new diagnosis of atrial fibrillation, or their blood pressure was poorly controlled so [the doctors] are mucking around with their anti-hypertensives and things… this will impact the [physical activity] message. [Physiotherapist, inpatient rehabilitation]
Health professionals identified that a lack of adequate social support impacted their decision to encourage post-stroke physical activity.
If you have a… stroke patient with an 80-year-old fragile wife, you’re not going to get them to do anything because they won’t be able to help pick them up if they fall. [Student physiotherapist, community public]
All health professionals working in public health settings reported being ‘under pressure’, with no support available for people with stroke to achieve physical activity guidelines. This perception was not reported by private practitioners, who managed people with stroke with access to private funding. Within public settings, however, (1) limited bed space; (2) time pressures on staff; (3) long wait times for rehabilitation; (4) discharge pressures; (5) competing clinical priorities and (6) ward layouts that did not enable physical activity often resulted in missed opportunities for incidental and planned physical activity. Insufficient bed space in rehabilitation wards meant many people appropriate for stroke rehabilitation were discharged without rehabilitation and thus did not access time and therapy to work towards physical activity goals.
… let’s be honest, if we had more beds [in rehabilitation], they might be suitable for a trial [of rehabilitation] but we can’t give them that trial. [Nurse, acute setting]
Further, due to limited bed spaces, people with stroke had limited time in inpatient rehabilitation to show ‘progress’ in recovery of lost activities. If progress was not achieved quickly, patients were discharged, resulting in these supports for physical activity no longer being available.
… we have this set of internal norms about when discharge happens… They’re [people with stroke] not 100%, we know. But they probably won’t get 100%. They’re not making gains as we see it, so it’s time for discharge. [Psychologist, community private]
Health professionals working within public community-based rehabilitation reported that, due to resource constraints, people with stroke were only accepted for community-based rehabilitation if they had a ‘rehabilitation goal’ targeting ‘essential activities’ such as returning to independent walking or employment.
… in the community [therapists] have their hands tied in taking referrals without a specific goal. So those [people with stroke] who don’t like class[es] and don’t have functional goals, they’re… on their own. [Physiotherapist, inpatient rehabilitation]
People who were offered inpatient rehabilitation, sometimes had a long wait in the acute setting, where allied health professionals often had insufficient time to facilitate physical activity. Instead, therapists typically saw people with stroke once per day, due to the number of patients scheduled each day. Nurses had competing clinical priorities such as feeding, hygiene and medication management, limiting their capacity to support physical activity.
There are limited beds and lots of people. There was all kinds of people coming in, I would classify it as chaos. It was busy. If this guy was functional, and he’s able to, he’s independent and we think he can do a 100-metre walk, that’s not classified for [inpatient rehabilitation]. He doesn’t have the resources to go to some other outpatient [service]… We didn’t have the time to discuss those issues [physical activity]. It was, yep, you’re functional, these are your options, if you can do it, you’re discharged. [Physiotherapy student, inpatient rehabilitation setting]
Within the hospital setting, long waits for rehabilitation and the need to prioritise patient safety, meant physical activity was not facilitated. People with stroke required medical and physiotherapy clearance to mobilise around the ward. Those requiring assistance in transferring were often hoisted, as this method was faster and safer for health professionals and patients, leading to missed opportunities for incidental activity.
One of my patients, he could always walk day one. He was that good. It was just a bit of argy-bargy, is he going to fall at night or not. Are the nurses comfortable with him walking? [Physiotherapy student, acute setting]
Ward design and gym location also impacted physical activity. In one acute ward, the gym was a long way from the patient’s bed, resulting in people with stroke being so exhausted by the journey that they had insufficient energy to engage in physical activity once arriving there.
By the time you’ve lifted them, put them in a [wheel]chair… got down to the gym they’re like ‘no I don’t want to do it’ because they’re too tired. [Occupational therapist, inpatient rehabilitation]
Health professionals reported a lack of knowledge, skills and confidence when advising people with stroke-related impairments about physical activity, and a lack of clarity on where or who to refer to for physical activity support after discharge meant opportunities for activity were missed.
… another barrier I would say to physical activity in the acute phase is staff knowledge or education or awareness of how important it is. And maybe there is a dissection between, well, I work [in the Acute Stroke Unit], but rehab can deal with that. [Nurse, acute setting]
Health professionals reported that many opportunities for physical activity were missed across the post-stroke continuum. They reported individuals often did not continue with hospital-based advice and exercises after going home and felt abandoned by the health system.
… a flurry of activity when you’re in hospital, and then you have your rehab services when you get out. And then it’s nothing. [Neuropsychologist, inpatient, community and private practice]
Health professionals felt that stroke survivors and carers feared physical activity would cause falls and increase risk of recurrent stroke, and they believed that people with stroke found physical activity difficult, or uninteresting, without follow-up from a health professional. Without health professionals supporting or driving engagement in physical activity, adults with stroke continued to avoid moderate and vigorous activities.
Most of the time it’s not a conscious thing… they’ll just… do something else or… avoid that activity entirely because it’s uncomfortable. [Exercise physiologist, community private]
Further, health professionals believed that few patients valued physical activity sufficiently to self-fund these activities.
… like an exercise physiologist at [service name]. Which would be cheaper than going privately, but again, taking into account some of the patients we’ve seen in terms of mobility and ability to get there, but also cost of the service. It is something they will need to see value in. [Physiotherapist, acute setting]
The few community-based classes appropriate for people with stroke were often over-attended, resulting in people with stroke receiving limited health professionals support in these classes.
There’s about 20 people coming in… Trying to juggle and make sure everyone is getting appropriate care jumping on the equipment, making sure they’re actually completing their program… feeling comfortable, safe, technique is appropriate. [Exercise physiologist, community private]
Health professionals provided suggestions for facilitators for health professionals to support people to engage in physical activity after stroke. These included: (1) health professional roles, health processes and facilities that encourage activity; (2) funding for more staff; (3) improving skills and confidence of health professionals to provide tailored, creative strategies and (4) using internal motivation and social support for people with stroke.
To facilitate physical activity after stroke, health professionals reported that their roles, responsibilities, goals and incentives needed updating to include supporting stroke survivors to achieve physical activity outcomes.
We need to measure patient steps rather than patient falls. [Physiotherapist, community private]
Participants suggested a case manager, such as the general practitioner, be given responsibility for providing continued physical activity support to facilitate physical activity after stroke.
Consistent [physical activity] check-ups… for a lifetime. [Exercise physiologist, community private]
Processes such as strong communication across and within services – to ensure physical activity advice was consistent and repeated, and changes in mobility status were implemented quickly – were recommended. This was believed to improve engagement in physical activity and increase incidental activity on the ward. Discharge processes that included plans for physical activity and referrals to accessible community services are needed to facilitate people with stroke to consider these goals and be supported as they returned home.
With the neurology team, that’d be the perfect time to bring it up. We have a little sheet that gets filled out that could easily be a tick box on that. [Physiotherapist, inpatient rehabilitation]
The setup of facilities – such as having centrally located staff to allow supervision of activity on the ward, and the gym being located near patient and communal dining rooms – were perceived to encourage physical activity.
One of our solutions for this patient who can’t be left alone in her room. Oh, that’s fine, just take her to the nurse’s station. There’s always people there. Anyone was just doing incidental activity, because there was always someone around. [Physiotherapy student, inpatient rehabilitation]
Funding for more staff was believed to enable higher staff-to-patient ratios to support physical activity early, especially for those with severe impairments, as well as allowing more time to build self-efficacy and capacity for physical activity after stroke.
Professional supervision for longer periods of time where they can actually get… improvement. [Physiotherapy student, community rehabilitation]
More time also allowed therapists to undertake reassessments against physical activity goals. During these reassessments, health professionals believed they could celebrate physical activity ‘wins’, and thus improve motivation and confidence of people with stroke to complete physical activity.
Sometimes you actually have to demonstrate to them that they have some capacity before they’re even willing to… try. I’ve got the vision that they might be able to walk around the block. They’re like, ‘forget it, I fall down the front steps’. You’ve got to… give them success… And helping them in seeing ‘if you can do that much in 2 weeks, maybe it’s possible we can do that bigger task in 8 weeks’. [Physiotherapist, community private]
Investment in education for health professionals on clinical guidelines and strategies to increase physical activity was proposed as a strategy to build health professionals’ confidence and skills in developing tailored plans that targeted physical activity. Specifically, public health professionals reported they required training in new technologies (e.g. measurement tools for physical activity, robotics) and support to build their behaviour change skills to assist people with stroke to embed physical activity into their lives. Many private practitioners working within the community felt they already used these skills effectively.
Exercise isn’t just about focussing on deficits or making bits of you that don’t work to work better, that phase [12 months post-stroke] is kind of over. It’s actually about finding a way to enjoy yourself and making parts of your body move well… if none of that is an option, I think as physios we have an obligation to explore. There’s a lot of technology around. [Physiotherapist, private practice]
Health professionals reported that patients who were motivated proactively sought medical clearance, specific advice and advocated for access to support for physical activity. As a result, health professionals were more likely to discuss physical activity goals with these patients.
There was a 42-year-old who came in a few months ago. Newly diagnosed with atrial fibrillation, and she ran marathons prior to this. She wanted to get back to it, she kept asking me. I ended up getting the cardiology team to actually write something down in the medical notes. [Physiotherapist, acute setting]
Social support was also highlighted by health professionals as a facilitator of physical activity. Carers who understood the importance of physical activity, were observed to be encouraging and to positively impact physical activity. Peer exercise groups were identified as facilitators of physical activity.
It’s about them actually seeing the future… actually seeing other people… a couple steps ahead… So they can actually see [their progress]. [Sports scientist, community private]
Discussion
This study presents the perspectives and experiences of health professionals on supporting people with stroke to increase physical activity. Health professionals did not perceive that guidelines on moderate intensity physical activity were safe or feasible for all people with stroke, and identified that no one was currently responsible for physical activity in post-stroke care. Post-stroke physical activity is a complex goal, and the barriers faced by people with stroke are many, varied and individual. Health professionals are, thus, faced with the challenge of trying to identify and target each of these barriers, while also prioritising independence and medical management for safe discharge, within a short timeframe and with limited resources. Further, as many individuals with stroke have often not engaged in physical activity before their stroke, health professionals are also required to change well-established behaviours, in which they have little confidence. There is growing evidence supporting the benefits of physical activity for health and recovery after stroke (Turan et al. 2017), as well as the inclusion of physical activity in stroke clinical guidelines (Kleindorfer et al. 2021; Stroke Foundation 2022). As such, resource-efficient modifications to current healthcare culture, processes and environments are needed to ensure physical activity is included in routine post-stroke care.
Health professionals in the current study believed that moderate intensity physical activity was not feasible or safe for people with acute or subacute stroke. The need to prioritise functional independence and apprehension of medical complications such as overexertion (Haussmann et al. 2018), recurrent stroke and falls (Morris et al. 2014) is similar to views of health professionals working with other vulnerable populations and adults in hospital (Parry et al. 2017; Haussmann et al. 2018; Alsop et al. 2023). Nevertheless, as people with stroke only have access to stroke health services across the acute and subacute phases (Lynch et al. 2019), not addressing physical activity during this time will likely result in it not being addressed at all. This will increase risk of recurrent stroke and cardiovascular events (Turan et al. 2017). Strategies exist to improve safety during moderate intensity physical activity, such as obtaining medical clearance, exercise testing (Johnson et al. 2020), monitoring of perceived exertion, and heart rate, blood pressure or – in acute and vulnerable patients – continuous ECG monitoring (MacKay-Lyons et al. 2020). If the resources to implement these strategies are unavailable, other physical activity goals, such as increasing incidental activities across the day or breaking up sedentary behaviours with low intensity activity, should be considered. These activity behaviours have also demonstrated health benefits after stroke (English et al. 2018; Kleindorfer et al. 2021) and thus could be a feasible option to consider as part of physical activity goal setting.
All discipline groups proposed a multidisciplinary model where medical practitioners initiated and led the discussion, allied health professionals developed physical activity programs, and nurses and carers supervised physical activity. This recommendation was offered because health professionals believed that medical practitioner advice would be adhered to by patients, and thus lead to successful change in behaviours. Further, it was perceived that by medical practitioners initiating discussions and planning with adults with stroke and treating teams, concerns around safety, such as medical complications when commencing physical activity programs, could be eliminated. Medical practitioners report having some knowledge and confidence in providing general verbal advice on physical activity (Hébert et al. 2012; Woodhead et al. 2023). Similar to the current sample, however, most medical practitioners report lacking skills in providing specific and tailored intervention to improve physical activity (Woodhead et al. 2023) and being time poor within current scheduling practices to allocate time to have effective physical activity conversations (Woodhead et al. 2023). Another challenge is limited structures that enable medical practitioners to refer individuals across disciplines and settings for tailored physical activity support (Leemrijse et al. 2015). This pattern is also observed in broader secondary prevention initiatives in post-stroke management, such as referral to cardiac rehabilitation services from acute and rehabilitation services (Howes et al. 2020; Dudley et al. 2022). Future work should explore the role and scope of team members in multidisciplinary models of support for post-stroke physical activity, as well as referral options across each discipline and setting (e.g. acute hospital versus primary care) to enable this multidisciplinary approach to meet the specific needs of adults with stroke.
Increasing physical activity after stroke is a complex goal. There are many individual barriers that impact the stroke survivor directly. Health professionals need to identify, address and overcome each barrier while changing behaviour and facilitating patient motivation to engage in healthy long-term physical activity. Health professionals in the current study perceived this process took time that was not available within public health systems. Also, due to the complex and individual nature of factors affecting someone with stroke to engage in physical activity, it is unlikely that one evidence-based physical activity intervention will suit all individuals. Regardless, health professionals in the current study were able to identify most of the individual barriers to physical activity reported by stroke survivors (Nicholson et al. 2013). The current sample were also using creative strategies to help people with stroke successfully achieve rehabilitation goals, despite resource limitations, and their perceived lack of education and skills. Thus, education and training of health professionals should include resource-efficient tools that can complement existing therapies, such as behaviour change strategies, technology and adaptive devices (Lynch et al. 2018) while also improving health professional capacity and confidence to adapt interventions to individual patients. Education about physical activity guidelines alone will not be sufficient to ensure adherence (Morris et al. 2014). Instead, education and training targeting capacity and self-efficacy of health professionals (Crisford et al. 2018) in implementing tailored strategies to assist adults with stroke achieve physical activity guidelines will be required.
Many health professionals reported that they were more likely to discuss physical activity with stroke survivors who were motivated, engaged in physical activity before their stroke, had mild impairments and were younger, as these patients were also more likely to have physical activity as a goal of rehabilitation. Older age, low pre-stroke activity, poor walking capacity and executive function impairments are predictors of lower physical activity across the subacute phase after stroke (Mahendran et al. 2020). This could be due to this group not having physical activity goals discussed (as highlighted in the current study), or because this group need more assistance with commencing physical activity and achieving recommendations (Nicholson et al. 2013). Motivation to engage in physical activity could be improved with the use of devices like commercial accelerometers (Lynch et al. 2018) or tailored, structured aerobic exercise programs, which are delivered face-to-face and complemented with behaviour change strategies (Moore et al. 2018). To improve commencement of physical activity after stroke, routine management of physical activity with all individuals, regardless of age, motivation, impairment severity or pre-stroke activities and roles will be essential. Models such as blanket referrals to secondary prevention programs, which also address physical activity, are followed in other cardiovascular populations. This model may be a potential option for people with stroke (Howes et al. 2020).
Resource-efficient solutions which enable routine post-stroke physical activity management are required to be feasible in current resource-limited health systems. Further, factors such as long wait times in acute wards for inpatient rehabilitation, poor access to inpatient and community-based rehabilitation, early discharge home from acute stroke units and delayed start of community-based rehabilitation means that strategies for physical activity are required across all settings to ensure it is not missed. Resource efficient solutions could include: (1) routine device-based measurement (e.g. accelerometers) of physical activity to encouraging awareness of low activity (Mahendran et al. 2016b; Moore et al. 2018) and achievement of physical activity goals during rehabilitation (Connell et al. 2016); (2) enriched environments to maximise opportunities for activity (Rosbergen et al. 2017); (3) community-based rehabilitation programs targeting physical activity (Morris et al. 2014; Moore et al. 2018) and (4) checklists including physical activity and secondary prevention plans to guide discharge planning in each setting. Future research exploring interventions targeting physical activity should also consider resource-efficient options that target self-efficacy of both health professionals and people with stroke, as this will likely lead to long-term maintenance of physical activity behaviours (Espernberger et al. 2021).
Limitations and strengths
While purposive sampling to recruit participants from a range of health disciplines was attempted, a sample of convenience was used. As no new themes were apparent in the last three focus groups, data collection was ceased after 10 groups. Medical practitioners and dietitians were not represented in the current study, however, there was representation of all other health disciplines involved in post-stroke care. The McMasters quality guidelines (Letts et al. 2007) and the consolidated criteria for reporting qualitative studies (Tong et al. 2007) guided the design and reporting of this study to ensure minimal bias and generalisability of the findings. The grounded theory requirements of theoretical sampling, theoretical sensitivity and saturation were not achieved in full (Weed 2009), although the pursuit of these considerations supported the collection of quality data. The focus groups were held at times of convenience for the participants and researchers, not allowing for data analysis between all data collection episodes. Thus, theoretical sampling was not iterative. This limitation has been mitigated by member checking of final results.
Conclusions
Post-stroke physical activity is a complex goal, and often not prioritised in stroke care. Health professionals identify many varied and individual barriers that affect people with stroke. They also report insufficient time, resources and skills to address these individual barriers, while changing well-established attitudes and behaviours and prioritising rehabilitation strategies targeting independence. Improving resources available to health professionals, as well as their self-efficacy and skills in delivering tailored physical activity intervention may assist in improving physical activity after stroke. Future research should also consider resource-efficient interventions and models of care that could complement current practice to ensure that physical activity can be a routine inclusion into current practice after stroke.
Data availability
The data that support the findings of this study are available from the corresponding author (NM) upon reasonable request.
Ethics standard
The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008.
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