Many individuals with neurological conditions have comorbid health conditions and lifestyle behaviors that negatively affect their cardiovascular fitness levels. A downward spiral ensues, leading to further decreased fitness, increased risk for cardiovascular disease, diabetes, and obesity, and reduced ability to participate in exercise or perform activities of daily living.1–4 Aerobic exercise (AE) is associated with a host of health benefits including improved exercise capacity, cognition, and quality of life, and reduced cardiovascular risk and mortality.5,6 Generally, individuals with neurological conditions respond favorably to AE, with improvements in cardiovascular fitness surpassing the changes reported following traditional rehabilitation programs.1,4,7 Clinical guidelines now recommend that cardiovascular fitness training be a part of routine neurorehabilitation and long-term management.8–12 Nevertheless, application of AE in neurological rehabilitation remains challenging, not only because of the complexity of prescribing AE to individuals with systemic cardiovascular, musculoskeletal, and cognitive limitations, but also because of limited data available on the most effective training programs.12–15
Utilization of AE in adult neurorehabilitation has not been well documented in the literature. To address this gap in evidence, we conducted a survey of Canadian physical therapists to examine current utilization patterns regarding AE in terms of utilization, screening for, and implementation of AE training. Given the burgeoning interest in evidence-based best practices in neurorehabilitation, we undertook a survey study with the intention of helping to inform future clinical recommendations and professional education opportunities that strive to optimize rehabilitation outcomes.
A cross-sectional survey of physical therapists was conducted between November 2010 and February 2011, using a self-completed Web-based survey. Approval to conduct the study was granted by the Dalhousie University Research Ethics Board.
Physical therapists were eligible to participate in the survey if they (i) were licensed to practice in Canada, (ii) were members of the Neurosciences Division of the Canadian Physiotherapy Association, (iii) had consented to receive electronic communication from Neurosciences Division, and (iv) were currently practicing in Canadian hospitals, rehabilitation centers, private clinics, community settings, or home services that provided physical therapy services for adults (ie, >17 years of age) on an inpatient or outpatient basis.
After a thorough review of the literature, guiding questions related to the purpose of the study were formulated to assist in item generation and organization. An outline was then developed of the information needed to answer the guiding questions. In designing the survey items, we ensured that (i) each item was relevant to the purpose of the study, (ii) wording of items was not leading, and (iii) time to complete the survey was less than 20 minutes. Items were drafted on the basis of 2 broad categories: (1) respondent profile (eg, sex, age, total years of practice, years of neurological practice) and (2) the use of AE in practice (eg, screening, prescription, and implementation).
The initial draft of the survey contained 26 closed-ended questions with a list of response choices. One item regarding the respondent's perception of the role of AE in neurorehabilitation was written in Likert style, which assigns a numerical value to each potential response choice. Several questions contain “other, please specify” as a response choice to ensure the most appropriate response. The only filtering question was “Do you ever prescribe aerobic exercise for your neurological patients?” The computer program was designed so that respondents who indicated “no” to that question automatically skipped specific questions related to the use of AE in practice. An expert consultation approach was used for field-testing the draft survey. Ten experienced physical therapists practicing in neurorehabilitation across practice settings (from acute care to community-based services) assessed item selection, comprehensiveness, readability, organization, presentation, and time to complete the survey. Based on written feedback received, wording was refined and 3 questions were added. The final version of the survey contained 29 questions regarding respondent profile (n = 10), screening (n = 4), prescription (n = 8), and implementation (n = 7). The survey was written at a grade level of 12.3 according to the Flesch-Kincaid Readability Test16 and took approximately 17 to 20 minutes to complete.
We used the Web-based survey tool, Opinio (www.objectplanet.com/opinio/), which has several features known to enhance response rates17: (i) respondents could stop and restart the survey at will; (ii) each survey question appeared on a separate screen, rather than requiring respondents to scroll down the page; and (iii) a percent completion bar at the bottom of the screen made respondents aware of their progress in completing the survey. In addition, Opinio disallowed a previous respondent from completing the survey a second time, thus preventing duplication of respondents.
To maximize the response rate, we used a modified Dillman approach, which entailed contacting potential respondents several times.18 A prenotice announcement of the pending survey was issued by the Neurosciences Division via e-mail to all members on their e-mail list. In the following week, the invitation letter distributed by the Neurosciences Division outlined the study's purpose, our definition of AE (ie, “AE refers to planned, structured, and repetitive physical activity performed for extended periods of time and at sufficient intensity to improve or maintain physical fitness”), rationale for conducting the survey, ethical issues (ie, voluntary participation, implication of consent by returning the survey, anonymity, and no guarantee of personal benefit), and an electronic survey link. The letter was sent prior to 9 AM to optimize the response rate and response time.19 A 2-week response deadline was requested because the majority (96.5%) of completed surveys have been reported to be returned within that interval.19 A follow-up e-mail with the survey link was sent to nonrespondents 3 weeks after the initial invitation, and a second reminder was issued 3 weeks later. The survey was made available for 3 months to receive as many responses as possible.
Frequencies were calculated on the basis of the total number of responses to each item and expressed as percentages. Questions in which “Other, please specify” was an option were analyzed by creating categories for those responses. Items with multiple responses per question (multiple-response variables) did not sum to 100%. Data generated by the single Likert question (“AE should be incorporated into treatment programs of patients with neurological conditions”) were reduced by combining “agree” and “strongly agree” responses to form an “agree” category. Similarly, the responses “disagree” and “strongly disagree” were collapsed to form a “disagree” category. The Pearson χ2 test was used to identify differences between observed and expected frequencies of responses (agree, neutral, and disagree). The Pearson product moment correlation coefficient was used to study the association between neurological conditions treated and neurological conditions for which AE was prescribed. For all analyses, an alpha level of P < 0.05 was considered significant. Data were analyzed using SPSS Statistics 17.0 (SPSS Inc, Chicago, Illinois).
The sample size targeted was based on previously published data on survey response rates. The average response rate for Web-based surveys has been reported to be 36.8%.20 For online surveys, a response rate of 40% is considered average and 50% to 60%, good to very good.21 Therefore, we chose an a priori target of 172 of 430 eligible respondents (40% response rate). We also hoped receive responses from every Canadian province and territory.
There were a total of 176 surveys returned but 16 were discarded because the respondents did not meet the inclusion criterion of currently practicing in adult neurorehabilitation in Canada. Five additional surveys were removed because of missing data, leaving 155 surveys for analysis (36% response rate). All provinces in Canada were represented, but based on the proportion of all Canadian physical therapists who practice in Ontario, Quebec, and the Prairie provinces (33%, 22%, and 20%, respectively),22 Ontario physical therapists were overrepresented and Quebec and Prairie physical therapists underrepresented. Respondents reflected current trends in physical therapy practice in Canada22 in that they were predominantly female, had obtained undergraduate education, practiced for more than 16 years, and were primarily employed in rehabilitation centers and outpatient clinics (Table 1). The majority of respondents were employed full-time with more than half of their caseload involving neurological conditions, the most common being stroke, multiple sclerosis, traumatic brain injury, and Parkinson disease.
Utilization of AE
The majority of respondents (77%) reported that they prescribed AE in their neurological practice and most (70%) reported that they prescribed AE for “every patient for whom it was deemed appropriate.” An even higher percentage (88%) agreed or strongly agreed with the statement, “Exercise aerobic should be incorporated into treatment programs of patients with neurological conditions” (χ2 = 207.9; 2 degrees of freedom; P < 0.0001). The respondents' perceived barriers to clinical implementation of AE in terms of patient safety, ability to participate in AE, resources and operations, and role of AE in neurorehabilitation are outlined in Table 2. Barriers identified by more than 50% of respondents included concerns regarding cardiac status and patients' cognitive/perceptual deficits. Only 3% perceived no barriers to the use of AE in their neurorehabilitation practice.
There was strong agreement between neurological conditions treated and neurological conditions for which AE was prescribed (R = 0.971, P < 0.000) (Table 3). The greatest discrepancy was in the case of amyotrophic lateral sclerosis; patients with this condition were treated in 22% of respondents' practices, but only 8% of respondents prescribed AE for these patients.
Screening for AE
Factors considered by the respondents when determining whether AE should be prescribed for an individual patient are listed in Table 4. The screening tools used by the respondents are outlined in Table 5. Only 3% of respondents agreed with the statement “A symptom-limited exercise stress test is essential to screen for safety for aerobic exercise to participate in aerobic exercise” and 73% agreed with the statement “Symptom-limited exercise stress tests are not available in my practice setting.”
Implementation of AE
Components of AE training programs used by the respondents and variables considered in determining initial AE intensity are summarized in Tables 6 and 7, respectively. Signs and symptoms used in monitoring patients during AE are listed in Table 8, and recommendations given to patients to promote long-term cardiovascular fitness are provided in Table 9.
The survey findings provide a “snapshot” of the current trends in the application of AE in adult neurorehabilitation by Canadian physical therapists. We undershot our targeted response rate by 4%; one province was overrepresented and 2 were underrepresented. However, because the background characteristics of the respondents were congruent with the current profile of Canadian physical therapists,22 we were reasonably confident that the sample was representative of the population of interest.
Although the majority of respondents agreed that AE should be incorporated into treatment programs of patients with neurological conditions and prescribed AE in their practice, they also identified a host of barriers to implementation. The most commonly perceived barriers centered on concerns for patient safety (particularly cardiac status) and ability to participate in AE due to noncardiac comorbidities and limitations in cognition, perception, fatigue, and emotional well-being. Indeed, fatigue and depression have been reported to be primary barriers to exercise after stroke.13 However, perceiving such limitations as barriers to AE may be problematic, given the growing evidence that, in neurological patients, AE improves cognition,23–26 fatigue,27–30 and depressive symptoms.26,31 The findings that more than one-third of respondents identified lack of motivation to exercise as a barrier and one-fifth claimed that the fitness was not a rehabilitation goal of most patients underline the need for clinicians to implement strategies to enhance motivation.32,33 A longitudinal study reported that 50% of a cohort of 400 stroke survivors demonstrated apathy that affected their rehabilitation participation and recovery.34
Other barriers to clinical use of AE in neurorehabilitation were operational in nature (eg, lack of: personnel, time, screening tools, training equipment, and carry-over across the care continuum). Potentially, these barriers could be addressed through resource reallocation and development of more efficient delivery strategies, such as group-based circuit training. Importantly, only 5% of respondents identified lack of administrative support as a barrier.
The strong agreement found between neurological conditions treated and the conditions for which AE was prescribed suggests that respondents were not selectively prescribing AE for some conditions and not others, except in the case of amyotrophic lateral sclerosis. Factors considered by the majority of respondents in determining whether AE should be prescribed were mainly patient-centered (ie, severity of neurological condition, patient goals, comorbidities, current mobility and fitness levels, fall risk). Presence of substantial impairments in these domains, however, should not necessarily preclude prescription of AE. For example, a patient with high fall risk or limited mobility could be accommodated by selecting a supportive training mode (eg, recumbent bicycle, body weight–supported treadmill walking). Similarly, AE for a patient with a very low baseline fitness level could be facilitated through gradual progression of low-intensity exercise. In the same way, operational considerations (ie, availability of personnel, treatment time, and equipment) should not be factors that unconditionally limit the use of AE for patients who would clearly benefit from the intervention.
For screening of safety and indications to participate in AE, the majority of respondents used health records, patient presentation, and/or heart rate response to low-intensity exercise. It is troubling that only 2% of respondents used an exercise stress test,35 the principal AE screening tool recommended for cardiac rehabilitation,35 and 10% indicated that they used no safety screens. Furthermore, the vast majority of respondents (97%) did not agree with the statement, “a symptom-limited exercise stress test is an essential screening tool” and 73% agreed with the statement, “Symptom-limited exercise stress tests are not available in my practice setting.” These responses are inconsistent with the recommendations of the American College of Sports Medicine (ACSM). The ACSM describes 3 risk stratification categories for screening patients for the safety of AE prescription:35 (1) Low risk are men younger than 45 years and women younger than 55 years who are asymptomatic and have 1 or less of the following risk factors–-family history of cardiac disease, cigarette smoking, hypertension, dyslipidemia, impaired fasting glucose, obesity, or a sedentary lifestyle. (2) Moderate risk are men older than 45 years and women older than 55 years with 2 or more of the previously mentioned risk factors. (3) High risk are individuals with 1 or more of the following: ischemic pain, shortness of breath, dizziness or syncope, orthopnea or paroxysmal nocturnal dyspnea, ankle edema, palpitation or tachycardias, intermittent claudication, know heart murmur, fatigue with usual activities or known cardiovascular, pulmonary, or metabolic disease.
As a screening procedure for AE, moderate-risk individuals should undergo a maximal stress test and high-risk individuals require a submaximal stress test.35 Given the older age of most people who have had a stroke and the high prevalence of vascular risk factors and comorbidities in these populations,36,37 many patients with neurological disorders would be classified as moderate- or high-risk. In fact, cardiovascular complications are leading causes of death in persons with stroke,38 MS,39 and SCI. A recent study reported that clinically relevant abnormalities were detected in 1 in 10 symptom-limited exercise stress tests performed on patients poststroke.40 Thus, the lack of use of adequate screening tools revealed in our survey data has significant systems implications.
Characteristics typical of AE programs used by the survey respondents included 11 to 20 minutes of overground/treadmill walking, cycle/arm ergometry, or active exercises in standing with supervision by a physical therapist assistant conducted 2 to 3 days per week until discharge. A systematic review concluded that exercise durations 20 minutes or more were sufficient to achieve benefits for stroke survivors.41 The ACSM recommended engaging individuals poststroke in AE 3 to 5 days per week35 whereas Gordon and colleagues12 recommended 3 to 7 days per week.
Intensity of exercise is of foremost concern in exercise prescription because it dictates the level of metabolic stress to which the participant is exposed and safeguards against adverse responses to inappropriately stressful exercise. The most frequently identified means of determining baseline AE intensity by survey respondents were observing responses to exercise, soliciting patient feedback, and/or using rating of perceived exertion and/or the Talk Test. Calculating target heart rate using percentage of predicted maximal heart rate, heart rate reserve or baseline stress test results are standard practice in cardiac rehabilitation.35,42 However, 30% or fewer of the respondents indicated the use of this approach. Given that intensity is the most critical factor in ensuring an adequate dosage to elicit a training effect43,44 and 2 cross-sectional studies concluded that the intensity of stroke rehabilitation was inadequate to induce a training effect,45,46 more consistent use of established techniques to calculate intensity is highly recommended.
Frequent heart rate monitoring and periodic blood pressure monitoring are recommended for safety and assurance of AE being performed at the planned intensity.35 Survey data indicated that the most commonly used forms of monitoring were patients' general response to exercise and rating of perceived exertion. Measuring heart rate manually or with a monitor was used for monitoring purposes by fewer than half of respondents and only 25% of respondents indicated measuring blood pressure response. Considering the aforementioned high prevalence of vascular risks in neurological population, more rigorous monitoring procedures of patients' response to AE should be instituted across neurorehabilitation settings. Preliminary evidence suggests that the benefits of AE may not be sustained in the long term because patients either stop participating in such programs or decrease their level of engagement.47 The majority of survey respondents used home exercise programs, community mall walking programs, and community-based exercise groups to promote long-term participation in AE.
The findings of our survey should be considered in light of limitations inherent in the use of a survey design. The primary limitation is the possibility of sampling bias. The response rate was somewhat lower than the anticipated rate but higher than the return rates reported in recent surveys involving Canadian physical therapists (eg, 10%,48 29.2%49). The survey was also limited to members of a voluntary group (Neuroscience Division of a national organization) whose responses to the survey questions may not have represented the views of nonmembers. Furthermore, physical therapists with a specific interest in the use of AE in neurorehabilitation may have been more inclined to respond to the survey than those less interested in the issue. If so, then our survey results may overestimate the actual use of AE in clinical practice. Finally, the underrepresentation of physical therapists practicing in Quebec may have been due, in part, to our cost-based decision not to provide a French version of the survey.
The findings of our survey raise awareness of the necessity of implementing a more evidence-based approach to screening for safety of AE, prescribing appropriate training programs and monitoring of patients' responses to AE to ensure safety and effectiveness. Trends in the data underline the importance of both entry-level and continuing education physical therapy curricular content that addresses knowledge and application of exercise physiology principles relevant to neurological populations. In addition, specific screening and exercise prescription protocols are needed to narrow the gap between evidence and practice as well as alleviate the uncertainty regarding using AE in clinical practice. The findings also have system implications in terms of ensuring that adequate personnel, time, and equipment are available to optimize neurorehabilitation outcomes.
1. Warburton DER, Eng JJ, Krassioukov A, Sproule S; the SCIRE Research Team. Cardiovascular health and exercise rehabilitation
in spinal cord injury. Top Spinal Cord Inj Rehabil. 2007;13(1):98–122.
2. Mossberg KA, Ayala D, Baker T, Heard J, Masel B. Aerobic capacity after traumatic brain injury: comparison with a nondisabled cohort. Arch Phys Med Rehabil. 2007;82:174–182.
3. MacKay-Lyons M, Howlett J. Cardiovascular adaptations to aerobic training early after stroke. Top Stroke Rehabil. 2005;12:31–44.
4. Rampello A, Franceschini M, Piepoli M, et al. Effect of aerobic training on walking capacity and maximal exercise tolerance in patients with multiple sclerosis: a randomized crossover controlled study. Phys Ther. 2007;87:545–555.
5. Garber CE, Blissmer B, Deschenes MR, et al. American College of Sports Medicine position stand. Quantity and quality of exercise for developing and maintaining cardiorespiratory, musculoskeletal, and neuromotor fitness in apparently healthy adults: guidance for prescribing exercise. Med Sci Sports Exerc. 2011;43(7):1334–1359.
6. Bean JF, Vora A, Frontera WR. Benefits of exercise for community-dwelling older adults. Arch Phys Med Rehabil. 2004; 85(suppl 3):S31–S42.
7. Rimmer JH, Wang E. Aerobic exercise training in stroke survivors. Top Stroke Rehabil. 2005;12:17–30.
8. Furie K, Kasner SE, Adams RJ, et al. Guidelines for the prevention of stroke in patients with stroke or transient ischemic attack: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2011;542(1):227–276.
9. Lindsay MP, Gubitz G, Bayley M, Hill MD, Singh S, Phillips S. Canadian Best Practice Recommendations for Stroke Care (Update 2010). Ottawa, Ontario, Canada: Canadian Stroke Network; 2010.
10. Jacobs PL, Nash MS. Exercise recommendations for individuals with spinal cord injury (Review). Sports Med. 2004;34:727–751.
11. White LJ. Exercise and multiple sclerosis. Sports Med. 2004;34(15):1077–1100.
12. Gordon NF, Gulanick M, Costa F, et al. Physical activity and exercise recommendations for stroke survivors. An American Heart Association Scientific Statement from the Council on Clinical Cardiology, Subcommittee on Exercise, Cardiac Rehabilitation
, and Prevention; the Council on Cardiovascular Nursing; the Council on Nutrition, Physical Activity, and Metabolism; and the Stroke Council. Circulation. 2004;109:2031–2041.
13. Rimmer J, Wang E, Smith D. Barriers associated with exercise and community access for individuals with stroke. J Rehabil Res Dev. 2008;45(2):315–322.
14. Brown TR, Kraft GH. Exercise and rehabilitation
for individuals with multiple sclerosis. Phys Med Rehabil Clin N Am. 2005;16:513–555.
15. Scelza WM, Kalpakjian CZ, Zemper ED, Tate DG. Perceived barriers to exercise in people with spinal cord injury. Am J Phys Med Rehabil. 2005;84:576–583.
16. Farr JN, Jenkins JJ, Paterson DG. Simplification of Flesch Reading Ease formula. J Appl Psychol. 1951;35:333–337.
17. Baruch Y, Holtom BC. Survey response rate levels and trends in organizational research. Hum Relat. 2008;61(8):1139–1160.
18. Dillman D. Mail and Internet Surveys: The Tailored Design Method. New York: John Wiley & Sons; 2000.
19. Hamilton MB. Online survey response rates and times. http://www.supersurvey.com
. Accessed July 23, 2012.
20. Sheehan K. E-mail Survey Response Rates: A Review. 2001.
22. Canadian Institute for Health Information. Physiotherapists in Canada, 2010 National and Jurisdictional Highlights and Profiles. Ottawa, Ontario, Canada: Canadian Institute for Health Information; 2011.
23. Quaney B, Boyd LA, McDowd JM, et al. Aerobic exercise improves cognition and motor function poststroke. Neurorehab Neural Repair. 2009;23(9):879–885.
24. Grealy MA, Johnson DA, Rushton SK. Improving cognitive function after brain injury: the use of exercise and virtual reality. Arch Phys Med Rehabil. 1999;80:661–667.
25. Enzinger C, Dawes H, Johansen-Berg H, et al. Brain activity changes associated with treadmill training after stroke. Stroke. 2009;40(7):2460–2467.
26. Oken BS, Kishiyama S, Zajdel D, et al. Randomized controlled trial of yoga and exercise in multiple sclerosis. Neurology. 2004;62:2058–2064.
27. Zedlitz A, Rietveld T, Geurts AC, Fasotti L. Cognitive and graded activity training can alleviate persistent fatigue after stroke: a randomized, controlled trial. Stroke. 2012;43.
28. Oncu J, Durmaz B, Karapolat H. Short-term effects of aerobic exercise on functional capacity, fatigue, and quality of life in patients with post-polio syndrome. Clin Rehabil. 2009;23:155–163.
29. McCullagh R, Fitzgerald AP, Murphy RP. Long term benefits of exercising on quality of life and fatigue in multiple sclerosis patients with mild disability: a pilot study. Clin Rehabil. 2008;22:206–214.
30. Garssen MPJ, Bussmann JBJ, Schmitz PIM, et al. Physical training and fatigue, fitness, and quality of life in Guillain-Barré syndrome and CIDP. Neurology. 2004;63:2393–2395.
31. Stuart M, Benvenuti F, Macko R, et al. Community-based adaptive physical activity program for chronic stroke: feasibility, safety, and efficacy of the Empoli Model. Neurorehab Neural Repair. 2009;23:726–734.
32. Resnick B, Michael K, Shaughnessy M, Kopunek S, Shim Nahm E, Macko RF. Motivators for treadmill exercise after stroke. Top Stroke Rehabil. 2008;15(5):494–502.
33. Sirur J, Richardson J, Wishart L, Hannan S. The role of theory in increasing adherence to prescribed exercise. Physiother Can. 2009;61:68–77.
34. Mayo NE, Fellows LK, Scott SC, Cameron J, Wood-Dauphinee S. A longitudinal view of apathy and its impact after stroke. Stroke. 2009;40:3299–3307.
35. American College of Sports Medicine. ACSM's Guidelines for Exercise Testing and Prescription. 8th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2010.
36. Olijhoek JK, van der Graaf Y, Banga J-B, et al. The metabolic syndrome is associated with advanced vascular damage in patients with coronary heart disease, stroke, peripheral arterial disease, or abdominal aortic aneurysm. Eur Heart J. 2004;25:342–348.
37. MacKay-Lyons M, MacDonald C, Howlett J. Metabolic syndrome and its components in individuals undergoing rehabilitation
after stroke. J Neurol Phys Ther. 2009;33:189–194.
38. Appelros P, Nydevik I, Viitanen M. Poor outcome after first-ever stroke: predictors for death, dependency, and recurrent stroke within the first year. Stroke. 2003;34:122–126.
39. Sadovnick AD, Eisen K, Ebers GC, Paty DW. Cause of death in patients attending multiple sclerosis clinics. Neurology. 1991;41:1193–1196.
40. Marzolini S, Oh P, McIlroy W, Brooks D. The feasibility of cardiopulmonary exercise testing for prescribing exercise to people after stroke. Stroke. 2012;43(4):1075–1081.
41. Saunders DH, Greig CA, Mead GE, Young A. Physical fitness training for stroke patients. Cochrane Database Syst Rev. 2009:(4):CD003316. DOI: 003310.001002/14651858.CD14003316.pub14651853.
42. Canadian Association of Cardiac Rehabilitation
. Canadian Guidelines for Cardiac Rehabilitation
and Cardiovascular Disease Prevention. Translating Knowledge Into Action. Winnipeg, Manitoba, Canada: Canadian Association of Cardiac Rehabilitation
43. Duscha BD, Slentz CA, Johnson JL, et al. Effects of exercise training amount and intensity on peak oxygen consumption in middle-age men and women at risk for cardiovascular disease. Chest. 2005;128:2788–2793.
44. de Groot PCE, Hjeltnes N, Heijboer AC, Stal W, Birkeland K. Effect of training intensity on physical capacity, lipid profile, and insulin sensitivity in early rehabilitation
of spinal cord injured individuals. Spinal Cord. 2003;41:673–679.
45. MacKay-Lyons M, Makrides L. Cardiovascular stress during stroke rehabilitation
: is the intensity adequate to induce a training effect? Arch Phys Med Rehabil. 2002;83:1378–1383.
46. Kuys S, Brauer SG, Ada L. Routine physiotherapy does not induce a cardiorespiratory training effect post-stroke, regardless of walking ability. Physiother Res Int. 2006;11:219–227.
47. Mead GE, Greig CA, Cunningham I, et al. Stroke: a randomized trial of exercise or relaxation. J Am Geriatr Soc. 2007;55:892–899.
48. You L, Sadler G, Majumdar SR, Burnettt D, Evans C. Physiotherapists' perceptions of their role in the rehabilitation
management of individuals with obesity. Physiother Can. 2012;64(2):168–175.
49. Chau J, Chadbourn P, Hamel R, et al. Continuing education for advanced manual and manipulative physiotherapists in Canada: a survey of perceived needs. Physiother Can. 2012;64(1):20–30.