Stroke is one of the leading causes of neurological disability in older adults,1 and the incidence of stroke is on the rise worldwide.2 The disabling aftermath of a stroke has impacts at societal and individual levels. In 2000, the estimated economic burden of stroke in Canada alone amounted to more than $3.6 billion in physician services, hospital costs, lost wages, and decreased productivity.3 On an individual level, people poststroke experience a wide variety of physical,4 neurological,5 and cognitive impairments.6 These impairments are associated with a decline in aerobic capacity.7 Indeed, cardiovascular fitness in people poststroke is lower than age- and sex-related normative values for sedentary healthy adults.7,8 This marked deconditioning suggests that people poststroke would have difficulty completing many activities of daily living, which reduces the ability to maintain independence.9 Moreover, deconditioning leads to physical inactivity and increased risk of a repeat stroke and results in the development of secondary complications, creating a vicious cycle.1
Aerobic training (AT) following stroke has been shown to result in significant improvements in cardiovascular fitness (O2peak).10,11 Aerobic training has also been associated with improved walking endurance and speed,11,12 both of which are important poststroke outcomes and can potentially be associated with increased functional independence. Improvement in O2peak has also been reported when AT was integrated early poststroke (1 week to 6 months poststroke).13
Accordingly, the American Heart Association Scientific Statement for Physical Activity and Exercise Recommendations for Stroke Survivors supported the prescription of AT in 2004.14 Subsequently, the Aerobic Exercise Recommendations to Optimize Best Practices In Care after Stroke (AEROBICS) were published.15 These guidelines advocate that when possible, a peak effort symptom-limited exercise stress test with electrocardiography (ECG), blood pressure (BP), heart rate (HR), and rate of perceived exertion (RPE) monitoring be conducted as an important part of preparticipation screening.15 However, if a low-intensity exercise training program is planned (eg, <45% of predicted HR reserve), then a submaximal test, such as the 6-minute walk test (6MWT) or Shuttle Walk Test, is an option for individuals who are asymptomatic with no known cardiovascular disease and normal resting ECG. Furthermore, the submaximal test should demonstrate the cardiopulmonary tolerance at the planned exercise intensity.15 The guidelines also cite the American College of Sports Medicine recommendation to monitor blood glucose before, occasionally during, and after exercise in people with diabetes at risk for hypoglycemia.16 It is stressed that glucose monitoring is especially important in the initial stages of an exercise program to avoid hypoglycemic episodes.15 The guidelines also state the importance of measuring BP prior to exercise for patients with hypertension.15
Whereas guidelines advocating inclusion of structured AT for people poststroke have been published,15,17 it is unclear whether the uptake of these guidelines has been implemented as standardized practice throughout Canada at a program level. While 2 questionnaire-based studies have been previously published, they have investigated programming at an individual therapist level in Canada and in the United States.18,19 In addition, research related to implementation of AT in Canada has been limited to a study that was not restricted to people with stroke but included other neurological conditions such as traumatic brain injury, multiple sclerosis, and so forth.19 Also, no study has reported barriers to implementation of AT by those that prescribe and do not prescribe AT on either an individual level or a program level. Another gap in the literature is related to monitoring and safety issues surrounding comorbid diabetes and hypertension—common coexisting conditions in stroke. Therefore, the purpose of this study was to determine the prevalence of structured AT in public inpatient and outpatient stroke rehabilitation programs across Canada, as well as explore how these practices are operationalized and determine the barriers to implementation of AT.
This was a cross-sectional study using a Web-based questionnaire administered to public inpatient and outpatient stroke rehabilitation programs across Canada between January and May 2017. Approval from the Ethics Review Board of the University of Toronto was obtained.
For the purpose of this study, a program was eligible to participate if it self-identified as having dedicated stroke rehabilitation (this includes a dedicated stroke unit or dedicated stroke beds). Stroke rehabilitation programs provided through private clinics were excluded.
A list of health regions per province was obtained from Statistics Canada20 and contacted via telephone to determine the presence of eligible stroke rehabilitation programs in their region. Program leads were identified through the health region or by contacting the program via telephone and invited to participate. In the event that a facility provided inpatient and outpatient rehabilitation, the program lead was asked to complete separate surveys.
To enhance response-rates, a modified Dillman approach was used.21 First, a cover letter along with a link to the questionnaire was sent. One week later, a reminder letter was sent to nonresponders. Two weeks after that, a subsequent e-mail was sent to nonresponders. A total of 89 programs were successfully contacted.
Questionnaire design was based on expert knowledge and evidence from the literature in consultation with a certified market research professional.19,22–24 The Web-based questionnaire consisted of 46 items with 6 subcategories. Respondents completed questions relating to the facility, patient demographics, discharge planning, and barriers to including AT. For the purpose of this study, AT was defined as planned, structured, and repetitive exercise (excluding incidental exercise that occurs during therapy) that is progressed in duration and/or intensity with the objective of improving cardiovascular fitness. Also, AT must be continuous and for the purpose of raising HR or increasing breathing rate. Examples were provided of activities that are and are not considered AT. Aerobic assessments were those that provided information for the purpose of prescribing safe and effective exercise intensity level, including maximal/peak effort graded exercise testing (GXT), submaximal GXT, and/or 2-minute walk test (2MWT) or 6MWT.
Prior to finalization of the questionnaire, 2 physiotherapists and 2 registered kinesiologists involved in stroke rehabilitation programs participated in pilot testing to determine face and content validity and appropriate modifications were made. All material was translated to French by members of the research team.
Differences between the groups (AT inclusion vs no AT inclusion, or inpatient vs outpatient stroke rehabilitation) were assessed using independent-samples Student t tests for continuous variables and χ2 tests or Fisher exact tests for categorical variables. Normal Gaussian distributions of the data were verified by the Kolmogorov-Smirnov test. Analyses were performed in SPSS (version 20.0, SPSS, IBM Corporation, Armonk, New York).
Response Rate and Descriptive Characteristics
Despite efforts to exclude programs without a dedicated stroke unit, 17 such programs responded and thus we conducted a subanalysis of these data. Forty-six of 89 (51.7%) surveys were completed, representing 25 inpatient and 21 outpatient stroke rehabilitation programs. Response by province ranged from 42.9% to 85.7%: Nova Scotia (n = 6/7; 85.7%), Ontario (n = 26/45; 57.8%), British Columbia (n = 6/13; 46.2%), Manitoba (n = 1/2; 50%), Quebec (n = 3/7; 42.9%), Saskatchewan (n = 3/9; 33.3%), and Prince Edward Island (n = 1/3; 33.3%). While Newfoundland and Alberta were each sent 1 and 2 questionnaires, respectively, no surveys were completed. The territories were exempt as people poststroke were reportedly sent to larger provinces for rehabilitation. Programs in New Brunswick were not eligible as dedicated stroke rehabilitation was not the rehabilitation model.
Inclusion of AT
Seventy-eight percent of all programs reported including an AT component (n = 36; Table 1). Among these programs, the mean proportion of admitted people poststroke estimated to participate in AT was 68.9 ± 23.6%, with 77.8% (n = 28/36) of these programs prescribing AT to more than 50% of patients. Among all programs, AT was prescribed to more than 50% of individuals poststroke by 56% of inpatient (n = 14 of 25) and 66.7% (n = 14 of 21) of outpatient stroke rehabilitation programs. Dedicated stroke units were more likely to include AT than those without a dedicated stroke unit (P = 0.02). Inclusion of AT did not differ between inpatient and outpatient programs (P = 0.1). There was no significant difference in programs that included AT and those that did not between provinces (P = 0.3), between East and West coast (P = 0.7), or number of people following stroke admitted annually (P = 0.7). When asked to indicate which of the following options best describe reasons, if any, for excluding individuals from the AT component, all programs reported including people poststroke with up to mild physical impairment (n = 36/36; 100%), while 11.1% (n = 4/36) reported excluding those with moderate physical impairment and most (n = 27/36; 75%) reported excluding those with severe physical impairment. More than a quarter of all programs that included AT (n = 10/36; 27.8%) reported excluding those with coexisting cardiac conditions.
As shown in Table 2, the 2 most frequently cited barriers by both programs with and without an AT component were insufficient time within therapy session and insufficient time in length of stay in rehabilitation. Although lack of knowledge/skills of AT prescription for high-risk populations and lack of equipment for prescription of AT ranked as the third and fourth most cited barriers for groups that included AT, they ranked as 10th and 12th, respectively, for groups that did not provide AT. Moreover, while groups that did not include AT indicated not a goal of most patients and not an organizational/program priority as third and fourth most cited barriers, they were the eighth and thirteenth most cited, respectively, by programs that did include AT. Programs reported that inclusion of AT within the program was mainly prompted by therapists (n = 18/32; 56.3%), followed by best practice guidelines (n = 9/32; 28.1%).
Preparticipation Aerobic/Functional Assessment
Of the 36 programs that included AT, 63.9% (n = 23) reported conducting a preparticipation aerobic assessment. One respondent did not indicate type of test or measures conducted during testing; thus, the following data include responses from 22 programs. Most of the assessments reported were either 2MWT or 6MWT) with no electrocardiographic monitoring (n = 20/22; 90.9 %), followed by submaximal GXT (n = 13/22; 59.1%) and maximal/peak effort GXT (n = 7/22; 31.8%). While some programs conducted more than 1 type of assessment, 31.8% (n=7/22) conducted only a 2MWT or 6MWT and 68.2% (n = 15/22) conducted either a submaximal or maximal/peak effort GXT. Rate of perceived exertion was the most frequently reported parameter measured during the AT assessment for both submaximal GXT (n = 11/13; 84.6%) and 2MWT or 6MWT (n = 11/20; 55%) (Figure 1). For those who completed maximal/peak effort GXT aerobic assessments, HR was the most frequently reported parameter measured (n = 5/7; 71.4 %). Only 2 of the 7 programs (28.6%) reported monitoring oxygen uptake, ECG, BP, RPE, and oxygen saturation during maximal/peak effort GXT assessments as recommended by the AEROBIC guidelines. No other programs reported monitoring oxygen uptake, ECG, or oxygen saturation.
Table 3 shows exercise prescription parameters. All responding programs reported using more than 1 method to determine exercise intensity, the most common being participants' RPE (n = 31/33; 93.9%), clinician expertise/experience (n = 31/33; 93.9%), and patient-selected intensity (n = 28/33; 84.8%). Fourteen of the 23 programs (60.9%) that conducted AT assessments reported using the assessment findings to guide AT intensity. The most common AT modalities reported were overground walking and treadmill exercise (n = 32/34; 94.1% and n = 29/34; 85.3%, respectively). All responding programs reported progressing duration and intensity (n = 33), and only 69.7% of programs reported progressing frequency (n = 23/33). The majority of programs (n = 22/34; 64.7%) reported delivering AT solely on an individual basis, while 5.9% (n = 2/34) indicated using only a group-based format. A combination of both individual and group-based AT delivery was reported by 38.2% (n = 13/34).
Most responding programs (63.6%; n = 21/33) reported measuring BP during the AT session for those with hypertension and only 21.2% (n = 7/33) monitored blood glucose during the AT session for people with diabetes at risk for hypoglycemia. Of 36 programs that reported prescribing AT, 61.1% (n = 22) reported asking patients to carry out AT at home or in an unsupervised setting (35% of inpatient programs [n = 7/20] and 93.8% of outpatient programs [n = 15/16]). These programs reported that AT adherence was tracked via verbal review (n = 21/22; 95.5%), training log (n = 10/22; 45.5%), and activity tracker (n = 6/22; 27.3%). Verbal review alone was used to track adherence in 45.5% of the programs (n = 10/22).
Upon discharge, all programs reported providing at least 1 resource to participants regarding AT. The most commonly reported resource from programs with an AT component included education on the importance of continuing AT (n = 29/33, 87.9%) and instructions on how to progress AT (n = 26/33, 78.8%).
Of those programs without AT (n = 10), 50% reported providing participants with information on the importance of AT, 50% reported providing a list of recreation, fitness, or community centers with stroke-specific exercise programs, 40% reported having a discussion on how to initiate AT, and 20% reported providing information on where to purchase home exercise equipment. Only 1 program reported not providing any postdischarge information related to AT.
The AEROBICS guidelines highlight the importance and benefits of AT poststroke across the continuum of stroke recovery.15 This is the first study to examine the prevalence of AT prescription at a program level. Seventy-eight percent of programs reported including a structured AT component with an estimated mean of 68.9 ± 23.6% of admitted people poststroke participating. Overall, AT was prescribed to more than 50% of individuals poststroke by 61% of all responding programs (56% of inpatient and 66.7% of outpatient stroke rehabilitation programs). Inclusion of AT was consistent across provinces and between inpatient and outpatient programs but was more prevalent in dedicated stroke units than those without a dedicated stroke unit. The results of the current study are consistent with results of a recent survey reporting that 77% of 155 Canadian physiotherapists practicing in the area of neurorehabilitation prescribe aerobic exercise to patients.24 In the United States, AT has been reported to be prescribed to more than 50% of individuals poststroke by 55% of physical therapists (24.7% of acute care therapists and 61.3% of therapists in a nonacute clinical practice setting).18 In the current study, programs that identified as having dedicated stroke units were significantly more likely to include AT than programs without. This is of significance as people following stroke who are treated in dedicated stroke units versus those treated in general rehabilitation units are reported to have better functional outcomes with decreased mortality and disability rates.25,26 There were no other program characteristics associated with AT inclusion such as inpatient versus outpatient setting or mean number of patients admitted annually.
Challenges to Including AT in Clinical Practice
The 2 most frequently cited barriers to including AT reported by both those with and without AT were insufficient time within the therapy session and insufficient time in length of stay in rehabilitation. These barriers to AT have been previously reported by Canadian and US therapists18,19,22 but are not confined to inclusion of AT. They have also been reported as barriers to implementation of general evidence-based recommendations for inpatient stroke rehabilitation in Canada.24 In the current study, the majority of programs reported delivering aerobic exercise to patients individually as opposed to in a group setting. Incorporating AT in a group setting has been shown to be feasible for patients in the subacute stage of stroke23 and might help mitigate the barrier of time constraints within a therapy session. Different models of care may also need to be considered to promote exercise along the continuum of rehabilitation settings and recovery, for example, initiating AT in the inpatient setting and continuing training through the transition to outpatient programs in the community or through cardiac rehabilitation.27
This is the first study to identify that 2 of the top 4 barriers preventing the inclusion of AT in stroke rehabilitation programs were the perception that AT is not a goal of most patients (cited by 80%) and AT is not an organizational priority (cited by 70%). This is problematic as the benefits of AT such as improved cardiorespiratory fitness and functional goals related to activities of daily living and walking in a poststroke population have been consistently reported.10,12,13 Similarly, one-fifth of 155 Canadian physiotherapists practicing in neurorehabilitation programs reported that fitness was not a rehabilitation goal for patients.19 As suggested by Doyle and Mackay-Lyons,19 therapists need to incorporate methods to motivate people poststroke to participate in AT and provide education on the importance of participation. Currently, upon discharge most of the programs without an AT component are providing patients with some form of verbal or written information on the importance of AT or initiating an AT program. Also, 87.9% of programs that include AT are providing patients with education on the importance of continuing AT. The therapist is an important source of exercise and risk factor modification information, and future research should determine the optimal delivery method.
The third most commonly cited barrier to AT in those with an AT component was lack of knowledge/skills of AT prescription for high-risk populations. In fact, 27.8% of all programs exclude people poststroke from participating in AT due to presence of a cardiac condition. This is a barrier that has been identified previously.23,28 This may be related in part to lack of equipment for assessments, which was identified by 42.4% of programs, and lack of knowledge or skills to assess aerobic capacity for safe prescription identified by 39.4% of programs that prescribe AT. This is of clinical relevance as comorbidities such as cardiac disease are common in people poststroke.29 One study reported that more than 1 of every 10 individuals with mobility deficits poststroke developed a clinically relevant abnormality during a symptom-limited exercise test.30 Indeed, practice guidelines suggest that exercise stress testing is recommended for those with stroke and concurrent cardiac diagnoses.15 Although programs did not rank lack of information resources such as best practice guidelines and resource manuals as a significant barrier, the resources available may not provide the level of detail needed to safely and confidently prescribe AT to clinically complex populations. For example, blood glucose algorithms to guide appropriate AT assessment and prescription have not been included in stroke practice guidelines. Nor are there guidelines for prescribing exercise to people with coexisting issues such as central poststroke pain. Seventy-five percent of programs reported excluding those with severe physical impairments from AT; therefore, further exploration of the barriers to incorporating AT with this population is warranted. In a previous study, severity of impairment was not found to be a barrier to AT in stroke rehabilitation program that had access to adaptive equipment such as semirecumbent steppers.28
Similar to programs that prescribe AT, 50% of programs without AT identified both lack of knowledge/skills of AT prescription for high-risk populations and lack of knowledge or skills to assess aerobic capacity for safe prescription as a barrier to including AT. This is a striking finding and highlights an important opportunity for continued education and training in safe exercise assessment and prescription. Prout et al surveyed 16 physiotherapists from 3 inpatient programs about their perspectives on AT early after stroke.22 Therapists from the 2 sites who did not have a structured AT component reported that they did not have the opportunity or the support to pursue continuing education on AT for people poststroke.
Exercise Assessments and Prescription
Discrepancies between best practice guidelines and actual practice were identified in this study. First, only 21% of programs with an AT component reported measuring blood glucose levels during the AT session in those at risk for hypoglycemia despite American College of Sports Medicine recommendations.16 Second, only 60% of programs reported measuring BP in those with hypertension during the AT session. This may place this group at risk for adverse events. Finally, 36% of programs (n = 13/36) that include an AT component do not complete any assessment of aerobic capacity. The AEROBICS guidelines highlight the importance of exercise testing, specifically peak effort symptom-limited protocols before initiating AT.15 Of programs that included and did not include AT, 42.4% and 50%, respectively, reported lack of equipment for assessment of aerobic exercise as a barrier for including AT, thus explaining in part why peak effort symptom-limited testing is less often conducted. This is of clinical significance as a symptom-limited GXT determines an individualized training intensity and identifies ECG, BP, and other cardiac-related abnormalities.31 Submaximal testing, where maximal oxygen uptake and HR are predicted from submaximal measures, has been shown to overestimate measured O2peak8,32 and thus is not ideal but a feasible alternative.23 Also, the AEROBICS guidelines suggest that a 6MWT or the Incremental Shuttle Walk Test may be an option stating that an advantage of the 6MWT is that participants tend to walk at a constant speed at a pace near their critical power.15 In the current study, 31.8% of programs that conducted an assessment conducted only a 2MWT or 6MWT. However, we have demonstrated in a previous study that the 6MWT peak HR is not interchangeable with the target training HR that occurred at the anaerobic threshold determined by a cardiopulmonary exercise test in people with mobility deficits.33 Therefore, the utility of this test for prescribing optimal intensity is limited. Also, unless ECG is monitored during the field tests, it is not useful for prescribing a safe intensity. We suggest that future studies to develop a less resource-intensive alternative to the symptom-limited stress test for prescribing exercise are needed.
Also, although 63.9% of programs that included AT reported conducting assessments, only 60.9% of these programs used the results to prescribe intensity. In fact, the majority of programs reported using subjective measures to prescribe AT (ie, based on patient self-select intensity, RPE, clinician comfort). The AEROBICS recommendations to monitor ECG, BP, HR, and RPE during maximal/peak effort GXTs were inconsistently followed. Only 2 programs that prescribed AT (9%) measured all 4 of these parameters and only 2 programs (9%) reported measuring ECG at all. Five programs that conducted maximal/peak effort GXTs indicated that they did not monitor ECG. This finding requires further follow-up as use of ECG in maximal/peak effort GXT would be considered standard practice. It is possible that respondents misinterpreted the definition of “peak effort” test, or it is possible that some programs rely on other settings to conduct such tests but use the information to prescribe AT in stroke rehabilitation. Cardiac rehabilitation has been proposed as an effective model of care for AT following completion of traditional stroke rehabilitation.11,31,34 Partnering with cardiac rehabilitation programs or adopting a referral process from inpatient or outpatient stroke rehabilitation to outpatient cardiac rehabilitation may provide a continuum of care and help address barriers to including AT such as lack of equipment for assessment and lack of knowledge for prescribing AT for participants with cardiac conditions, diabetes, and hypertension.
Exercise prescription parameters followed by the programs that include AT closely resemble those advocated by the AEROBICS guidelines, that is, a minimum of 8 weeks of AT at least 3 days per week for a minimum 20 minutes to have a clinically meaningful training effect.15 Guidelines suggest that intensity of AT should be progressed as tolerated by the participant and monitored using HR and BP; however, these parameters were inconsistently monitored throughout AT.
While this study provides valuable information on AT in stroke rehabilitation programs, limitations exist. A comprehensive list of stroke rehabilitation programs across Canada did not exist; therefore, eligible programs may have been unintentionally excluded. Data from general rehabilitation programs that did not have designated beds or a dedicated unit for people poststroke completed the questionnaire, which was not the originally intended population for this study. Only face validity of the questionnaire was assessed and thus it is possible that questions may have been misinterpreted.
The majority of inpatient and outpatient stroke rehabilitation programs in Canada include an AT component. Dedicated stroke units appear to be better compliers to inclusion of AT. This study reveals the need for increased adherence to best practice guidelines for AT. Specifically, systematic monitoring during AT assessments and exercise training sessions to ensure patient safety and provide a more individualized prescription are needed. Improved access to exercise testing equipment as well as opportunities for therapists to pursue continuing education related to exercise assessment and prescription would be beneficial. More specific clinical guideline for safe management of patients with common comorbidities poststroke should be available as it relates to assessing exercise capacity and prescription of AT. As noted, adopting group-based AT delivery might in part address the issue of insufficient time in therapy sessions. As well, partnering with existing cardiac rehabilitation programs would aid in ensuring continuity of AT across care settings.
The authors acknowledge Emily Ho, Angela Marzolini, David Jagroop, and Sarah Munce for their help with this project.
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