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Systematic Reviews

Barriers and Facilitators to Aerobic Exercise Implementation in Stroke Rehabilitation: A Scoping Review

Moncion, Kevin MSc; Biasin, Louis PT; Jagroop, David MHSc; Bayley, Mark MD; Danells, Cynthia PT; Mansfield, Avril PhD; Salbach, Nancy M. PT, PhD; Inness, Elizabeth PT, PhD; Tang, Ada PT, PhD

Author Information
Journal of Neurologic Physical Therapy: July 2020 - Volume 44 - Issue 3 - p 179-187
doi: 10.1097/NPT.0000000000000318

Abstract

INTRODUCTION

Stroke is a leading cause of neurological disability worldwide.1 Most individuals with stroke live sedentary lifestyles,2 have limited aerobic capacity,3 and do not engage in adequate levels of physical activity.4 As a result, individuals in the chronic phase of stroke recovery often reach their maximum aerobic capacity when performing activities of daily living.5 Strong evidence supports the benefits of aerobic exercise after stroke,6 including improvements in aerobic and walking capacity.7 In fact, aerobic exercise is key to neuroplastic recovery8 and functional independence after stroke7 and may also facilitate engagement in physical activities after rehabilitation,9 which could potentially stem the detrimental cycle of inactivity. Therefore, rehabilitation that incorporates aerobic exercise is recommended after stroke.10

Clinicians endorse the importance of including aerobic exercise within professional practice11–13; however, access to aerobic exercise interventions within stroke rehabilitation remains limited and inconsistent.11,12,14,15 Earlier reports have cited barriers to aerobic exercise implementation in stroke rehabilitation across hospital, outpatient clinics, community, and home settings. These barriers include a lack of resources (eg, exercise testing equipment for establishing exercise parameters) and screening tools (eg, risk stratification for appropriateness of exercise),11 as well as gaps in knowledge and skills in aerobic exercise prescription.11 However, a complex interaction of patient-clinician characteristics and practice setting–related barriers likely contributes to inconsistencies in aerobic exercise implementation among individuals with stroke.

Identifying barriers to implementation is an important first step in knowledge inquiry that can inform development of interventions designed to change clinical practice16; however, these barriers also need to be mapped to theoretical constructs in order to provide a strong foundation for intervention development.17 The Theoretical Domains Framework (TDF) is a commonly used framework to identify and classify the barriers and facilitators of health care professional behavior related to implementation of evidence-based practice.18 The TDF consists of 14 domains: knowledge; skills; memory, attention, and decision processes; behavioral regulation; social/professional role and identity; beliefs about capabilities; optimism; beliefs about consequences; intentions; goals; reinforcement; emotions; environmental context and resources; and social influences.18 Theory-driven analyses using the TDF can help interpret the barriers and facilitators that affect the implementation of aerobic exercise interventions in individuals with stroke and, in turn, can be used to develop behavior change19 strategies to support uptake of aerobic exercise in clinical practice. Such an analysis has yet to be conducted in the context of aerobic exercise implementation in stroke rehabilitation settings.

Therefore, the purpose of this systematic scoping review was to identify and describe the barriers and facilitators to aerobic exercise implementation, as reported by health care professionals, in adults post-stroke.

METHODS

This review followed a 5-stage methodological framework proposed by Arksey and O'Malley,20 with consideration given to suggestions from Levac et al21 for scoping reviews. In brief, stage 1 involved identifying a research question. Stages 2 and 3 involved searching and identifying relevant studies. Stages 4 and 5 involved qualitative synthesis, including data extraction and collating study data. Therefore, this scoping review is descriptive in nature20 and does not provide a quantitative synthesis.21 The scoping review protocol and search strategy were established prior to the conduct of the review. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews22 guided the reporting of this study, and the checklist is provided in Appendix 2 (see Supplemental Digital Content 3, available at: http://links.lww.com/JNPT/A314, PRISMA Checklist).

Data Sources and Search Strategy

A literature search was conducted in 6 electronic databases, MEDLINE, EMBASE, Web of Science, CINAHL, PsycINFO, and AMED Allied and Complementary Medicine, indexing literature from inception to October 16, 2019. The search strategy used key words related to stroke, aerobic exercise, barriers, and facilitators and was developed in collaboration with a research librarian (see Appendix 1, Supplemental Digital Content 2, http://links.lww.com/JNPT/A313, Sample Search Strategy for EMBASE). Searches were restricted to articles with studies conducted on humans and published in English. Two authors (K.M. and L.B.) independently conducted title and abstract screening, full-text evaluation, and data extraction. Both authors (K.M. and L.B.) were trained by independently screening a predetermined set of 150 abstracts during abstract screening, 5 full-text articles during full-text evaluation, and 1 full-text article during data extraction. After each training stage, both authors deliberated, compared results, and resolved any discrepancies to ensure the screening criteria and data extraction sheets were clear and that they were consistently applied. A third reviewer (A.T.) was consulted to resolve any conflicts during title and abstract screening and full-text evaluation. Reference lists of included articles and potentially relevant systematic reviews were also hand-searched to identify any additional potentially relevant literature that could be included for review. Rayyan online software (https://rayyan.qcri.org/) was used throughout the title and abstract screening process.23

Eligibility Criteria

Studies were included in this review if they included any health care professional or administrator who (i) implemented aerobic exercise, defined as any structured or planned aerobic exercise programs, in individuals with stroke in any setting, and (ii) reported barriers or facilitators to implementing aerobic exercise. We included primary research studies that explicitly examined and reported the barriers and facilitators to aerobic exercise implementation. As per recommendations from Levac et al21 to balance between feasibility, breadth, and comprehensiveness, we opted not to search for gray literature as we felt that the majority of data pertaining to our research question would be answered within primary studies.

In this review, a barrier was defined as “a circumstance or obstacle that keeps people or things apart and/or prevents communication or progress”24 whereas a facilitator was defined as “a person or thing that makes something possible.”25 Studies were excluded if they were not primary research studies (eg, gray literature, literature and systematic reviews, editorials, theses, poster or conference abstracts or presentations, opinion pieces, or news stories).

Data Extraction and Analysis

Two authors (K.M. and L.B.) independently extracted the data from eligible studies using a data extraction spreadsheet with a predetermined content field. The data extraction spreadsheet was piloted by both authors and refined prior to extraction. Data were extracted on the basis of guidance for conducting systematic scoping reviews26 and consisted of lead author, year of publication, study outcome(s), study population, and sample characteristics (ie, sex, age, and clinical practice setting, where applicable). Because of the varying definitions of aerobic exercise implementation (eg, implementation, utilization, inclusion) and aerobic exercise prescription (eg, prescription, dosing, assessment) in the included studies, study outcomes were simplified to aerobic exercise implementation and prescription, respectively. Any barriers or facilitators identified in each article were extracted and classified using existing definitions and constructs of the 14 TDF domains.27 Identified TDF domains were then narratively summarized and where relevant specific barriers and/or facilitators were expressed using study-reported frequencies and percentages (eg, the number of respondents reporting a barrier/facilitator out of the total respondents).

Quality Assessment

The methodological quality of the included studies was evaluated independently by the 2 authors (K.M. and A.M.) using the Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies.28 The quality assessment tool assesses the internal validity and risk of bias for each study. The overall study quality was rated as “good” (eg, low risk of bias and valid results), fair (eg, susceptible to bias, may compromise validity of results), or “poor” (eg, high risk of bias, results considered invalid).28

RESULTS

Study Selection

Overall, 7675 articles were screened for eligibility. Thirty-two articles were included for full-text examination, of which 28 were excluded as they did not meet our eligibility criteria. Therefore, 4 articles were included in this scoping review (Figure).

Figure.
Figure.:
Flowchart of the study selection process.

Study Characteristics

Descriptive study characteristics of the 4 included studies are shown in Table 1. All 4 studies were quantitative cross-sectional survey studies. Three studies were conducted in Canada,11,14,15 and one was conducted in the United States.12 Three studies were conducted with physical therapists working primarily with individuals with stroke.12,14,15 One study was conducted with physical therapists working with individuals with stroke and other neurological conditions but was eligible to be included in this review as a majority of physical therapists in the sample (n = 128/155; 83%) prescribed aerobic exercise to individuals with stroke.11 In 2 studies, the majority of physical therapists practiced in inpatient settings,14,15 while the practice settings varied and included outpatient, inpatient, community, and acute care hospital settings in the other 2 studies.11,12 Studies were published between 2013 and 2018.

Table 1. - Descriptive Characteristics of the Included Studies
Included Study Study Characteristics Study Outcome(s)
Boyne et al12 N = 568 PT surveys analyzed (n = 407 women; 72%)
Practice setting: Outpatient (44%), acute care (18%), home (15%), extended care (14%), and inpatient (9%)
Location: United States
Data source: Cross-sectional Web-based survey
  1. AE implementation

  2. AE prescription

  3. AE screening

  4. AE safety considerations

Doyle and MacKay-Lyons11 N = 155 PT surveys analyzed (n = 130 women; 90%)
Practice setting: Rehabilitation center (34%), outpatient (28%), community/home (21%), stroke unit (13%), general hospital ward (8%)a
Location: Canada
Data source: Cross-sectional Web-based survey
  1. AE implementation

  2. AE prescription

  3. AE screening

Nathoo et al14 N = 33 physical therapy programs analyzed
Practice setting: Inpatient (54%), outpatient (46%)
Location: Canada
Data source: Cross-sectional Web-based survey
  1. AE implementation

  2. AE prescription

  3. AE screening

Prout et al15 N = 16 PTs (n = 13 women; 81%)
Practice setting: Inpatient (100%)
Location: Canada
Data source: Written in-person survey
  1. AE implementation

  2. AE prescription

Abbreviations: AE, aerobic exercise; PT, physical therapist.
aIndicates multiple response variable.

Barriers and Facilitators to Aerobic Exercise Implementation in Stroke Rehabilitation Settings

The identified barriers and facilitators to implementing aerobic exercise, classified using the TDF, are presented in Table 2. Across the 4 studies, 7 of the 14 domains were identified as barriers while 5 of the 14 domains were identified as facilitators to the implementation of aerobic exercise in stroke rehabilitation settings.

Table 2. - Identified Barriers and Facilitators Using the Theoretical Domains Framework
TDF Domains Barriers Facilitators
1. Knowledge Unfamiliar with the American Heart Association Physical Activity and Exercise Recommendations for Stroke Survivors or American College of Sports Medicine Guidelines for Exercise Testing and Prescription11,12
Lack of knowledge for safe AE prescription for high-risk populations11,14
Lack of knowledge to assess aerobic capacity11,14
Using exercise and safety precautions (ECG, risk stratification from the American Heart Association or the American College of Sports Medicine) to screen for safety before prescribing AE11,14
Knowledge to use objective measures to monitor and prescribe AE11,12,15
2. Skills Lack of skills for AE prescription in high-risk populations11,12
Lack of skills to assess aerobic capacity for safe prescription11,12
Using objective measures (eg, heart rate, ratings of perceived exertion, blood pressure, ECG, O2 saturation, exercise stress test) to monitor and prescribe AE11,12,15
3. Professional role and identity AE not part of routine practice11,12
AE interferes with other therapy schedules14
AE is low on treatment priority list and not an organization or program priority11,14
AE is an important aspect of PT practice15 and should be incorporated into practice and treatment11,12
4. Beliefs about capabilities Uncertainty regarding prescribing proper exercise intensity12 PTs interested and willing to learn or improve skills that are necessary to incorporate AE into routine practice14
Confidence about all aspects of AE prescription for individuals with stroke12
5. Optimism Not identified in any study Not identified in any study
6. Beliefs about consequences Concern over patients' cardiac, cognitive, and functional impairments and safe AE11,12,15 Not identified in any study
7. Reinforcement Not identified in any study Not identified in any study
8. Intentions Not identified in any study Not identified in any study
9. Goals AE not a rehabilitation goal of most patients11,12 Not identified in any study
10. Memory, attention, and decision processes Not identified in any study Not identified in any study
11. Environmental context and resources Lack of access to exercise equipment11,12,14,15 and safety monitoring equipment (eg, ECG)11,14,15
Lack of screening tools to ensure patient safety and to assess the need for AE training11,14,15
Lack of staff to support and/or supervise AE11,15 and lack of time11,12,15 and space14,15 for AE implementation
Insufficient length of stay in rehabilitation12,14
Lack of support for continuing education15
Access to training on AE prescription11,14,15
Availability of support staff and training equipment11
12. Social influences Not identified in any study Not identified in any study
13. Emotions Not identified in any study Not identified in any study
14. Behavioral regulation Not identified in any study Not identified in any study
Abbreviations: AE, aerobic exercise; ECG, electrocardiogram; PTs, physical therapists.

Knowledge and Skills

The domains of “knowledge” and “skills” were identified as both barriers and facilitators to aerobic exercise implementation. Some physical therapists reported that they did not possess sufficient knowledge or skills for safe aerobic exercise prescription and assessment of aerobic capacity.11,14 Studies reported that 19% (n = 23/120)11 to 55% (n = 255/462)12 of physical therapists were unfamiliar with the American College of Sports Medicine Guidelines for Exercise Testing and Prescription29 and 85% (n = 391/462) reported that they were unfamiliar with the American Heart Association Physical Activity and Exercise Recommendations for Stroke Survivors.12 Three studies reported that physical therapists used objective measures such as heart rate, ratings of perceived exertion (RPE), blood pressure, electrocardiography, oxygen saturation levels, and exercise stress test results to safely monitor aerobic exercise.11,12,15 Electrocardiogram-monitored exercise was infrequent (≤12%),12 and submaximal and/or symptom-limited exercise test results were rarely (n = 2/120; 2%)11 or infrequently used (≤20%) across practice settings (eg, outpatient, home health, extended care, inpatient, and acute care).12 The most common variables used to prescribe aerobic exercise included using subjective general patient presentation (n = 367/386; 96%),12 symptoms or RPE (n = 280/386; 73%),12 heart rate response to low-intensity exercise (n = 66/120; 66%),11 predicted maximal heart rate (n = 202/386; 52%),12 talk test (n = 198/386; 51%),12 resting blood pressure (n = 55/120; 46%),11 and blood pressure response to low-intensity exercise (n = 46/120; 38%).11

Professional Role and Identity

“Professional role and identity” was also identified as both a barrier and a facilitator to aerobic implementation. Two studies11,12 reported that aerobic exercise was not part of routine physical therapist practice (n = 10/155; 15%),11 and 2 studies reported that aerobic exercise interfered with other therapy schedules and was low on treatment priority (n = 30/130; 19%11 to n = 8/33; 24%14) in stroke rehabilitation programs. In contrast, 94% (n = 15/16) of physical therapists reported that aerobic exercise is an important aspect of physical therapist practice15 while 70% (n = 84/120) of physical therapists believe that aerobic exercise should be incorporated into practice and treatment.11

Beliefs About Capabilities

One study reported barriers relating to the domain of “beliefs about capabilities,” and 2 studies reported facilitators in this domain. Physical therapists expressed uncertainty regarding prescribing proper exercise intensity for individuals with stroke.12 Light-intensity exercise (RPE ≤11) was the most commonly prescribed intensity reported by acute care (n = 22/49; 45%) and outpatient (n = 77/177; 44%) physical therapists, due to patient safety concerns or limited availability of exercise testing or electrocardiogram monitoring.12 Moderate intensity (RPE 11-13) was more commonly prescribed in home (n = 34/55; 62%) and inpatient settings (n = 23/46; 50%), while vigorous intensity (RPE ≥14) was rarely prescribed (≤2%) across all practice settings.12 One study reported that 100% (n = 16/16) of physical therapists were interested and willing to learn or improve skills that are necessary to incorporate aerobic exercise into routine practice.15 Another study found that 72% (n = 346/480) of physical therapists were able to prescribe aerobic exercise for every individual with stroke and that 39% (n = 161/416) were confident in all aspects of aerobic exercise prescription.12

Beliefs About Consequences

Three studies identified barriers related to the TDF domain “beliefs about consequences,” where physical therapists reported concerns over patients' cardiac, cognitive, functional status, and physical impairments as barriers for safe implementation of aerobic exercise.11,12,15 In one study, 59% (n = 92/155) of physical therapists reported concerns over a patient's cardiac status.11 In acute and non–acute care settings, physical therapists commonly reported perceived patient-related barriers such as a limited ability to exercise at the adequate training level (≤82%) and cognitive/perceptual impairments (≤68%).12 Balance impairments (n = 56/81; 69%) were commonly reported barriers in acute care settings, while lack of motivation (≤57%) was commonly reported barriers in non–acute care settings.12 No studies reported facilitators regarding the “beliefs about consequences” domain.

Goals

In 2 studies, 21% (n = 33/155)11 and 39% (n = 13/33)14 of physical therapists reported that aerobic exercise was not a rehabilitation goal for most individuals with stroke. However, 69% (n = 83/120) of physical therapists reported that an individual's rehabilitation goal should be considered before determining whether aerobic exercise should be prescribed for an individual patient.14 No studies reported facilitators to improve the goals of individuals with stroke.

Environmental Context and Resources

All studies identified barriers related to the “environmental context and resources” domain. Physical therapists reported lack of access to exercise equipment suitable for people with stroke (eg, recumbent steppers or bikes)11,12,14,15 and equipment for safety monitoring (eg, electrocardiography).11,14,15 One study identified that almost all (95%-98%) of physical therapists working across multiple practice settings did not have access to exercise electrocardiographic equipment for their patients with stroke.12 In addition, physical therapists in all studies identified that screening tools to assess the need for aerobic exercise intervention and to ensure patient safety were not readily available.11,12,14,15 For example, in one study, very few (n = 7/398; 2%) physical therapists had access to exercise stress testing results for their patients with stroke.12 Another study reported that 34% (n = 52/120) of physical therapists lacked the time and staff to supervise aerobic exercise and 30% (n = 46/120) of physical therapists lacked information resources for safe prescription.14 In contrast, one study identified that having access to training on aerobic exercise prescription was a facilitator for aerobic exercise implementation.15 One study identified that availability of support staff to supervise (n = 60/120; 50%) and available treatment time (n = 54/120; 45%) would facilitate aerobic exercise implementation. Similarly, available training equipment (n = 54/120; 45%) and results of an exercise test (n = 30/120; 25%) have been reported to be important resources to consider before determining whether aerobic exercise should be prescribed for a patient.11

Quality Assessment

Table 3 provides a summary of results of the quality assessment using the Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies.28 Two studies14,15 were given a rating of “good” and the other 2 studies11,12 were rated as “fair.” Justification of sample size and power description was not reported in 3 studies.12,14,15 Two studies had participation rates of less than 50% for eligible participants (4%12 and 36%11). One study did not have a clearly stated research question or objective.11

Table 3. - Results of the Quality Assessment
Assessment Criteria Boyne et al12 Doyle and MacKay-Lyons11 Nathoo et al14 Prout et al15
1. Was the research question or objective in this paper clearly stated? Yes No Yes Yes
2. Was the study population clearly specified and defined? Yes Yes Yes Yes
3. Was the participation rate of eligible persons at least 50%? No No Yes Yes
4. Were all the subjects selected or recruited from the same or similar populations? Were inclusion and exclusion criteria for being in the study prespecified and applied uniformly to all participants? Yes Yes Yes Yes
5. Was a sample size justification, power description, or variance and effect estimate provided? No Yes No No
6. For the analyses in this paper, was the exposure(s) of interest measured prior to the outcome(s) being measured? NA NA NA NA
7. Was the time frame sufficient so that one could reasonably expect to see an association between exposure and outcome if it existed? NA NA NA NA
8. For exposures that can vary in amount or level, did the study examine different levels of the exposure as related to the outcome (eg, categories of exposure, or exposure measured as continuous variable)? NA NA NA NA
9. Were the exposure measures (independent variables) clearly defined, valid, reliable, and implemented consistently across all study participants? NA NA NA NA
10. Was the exposure(s) assessed more than once over time? NA NA NA NA
11. Were the outcome measures (dependent variables) clearly defined, valid, reliable, and implemented consistently across all study participants? Yes Yes Yes Yes
12. Were the outcome assessors blinded to the exposure status of participants? NA NA NA NA
13. Was loss to follow-up after baseline 20% or less? NA NA NA NA
14. Were key potential confounding variables measured and adjusted statistically for their impact on the relationship between exposure(s) and outcome(s)? NA NA NA NA
Overall quality rating (Good, Fair, or Poor) Fair Fair Good Good
Abbreviation: NA, not applicable.

DISCUSSION

Physical therapists working with individuals with stroke report a range of barriers and facilitators to implementing aerobic exercise into their practice. “Environmental context and resources” was the most frequently identified TDF domain, where barriers related to lack of access to screening tools, exercise, and safety monitoring equipment were commonly reported.11,12,14,15 Barriers and facilitators related to the TDF domains of “knowledge,” “skills,” “professional role and identity,” “beliefs about capabilities,” “beliefs about consequences,” and “goals” were less frequently reported in the literature. Knowledge, skills, and beliefs held by physical therapists have been shown to be primary influences on the successful implementation of evidence-based practice across a broad range of settings.30–32 Indeed, previous research conducted with physical therapists in a range of practice settings including oncology, neurological, musculoskeletal, cardiac, and respiratory physical therapy has also reported that a lack of knowledge and skills can lead to uncertainty in prescribing safe and appropriate exercise intensities.33 Given the complex medical history34 and the high prevalence of cardiovascular comorbidities in most people with stroke,5,35 it is important for health care professionals to possess the requisite knowledge and skills to safely prescribe aerobic exercise at appropriate levels of intensity.10,13

Despite possessing the knowledge and skills for aerobic exercise prescription and monitoring of low-intensity exercise (ie, exercises performed at RPE ≤11),11 physical therapists have expressed a lack of belief in their capabilities to prescribe aerobic exercise12 and have concerns over their patients' health status (eg, cardiac, cognitive, functional impairments)11 affecting their ability to participate in higher-intensity aerobic exercise.11,12,15 Most stroke rehabilitation programs (75%) have reported that they exclude individuals with severe physical impairments from structured aerobic training, and more than a quarter of all programs (28%) report excluding individuals with coexisting cardiac conditions.14 Higher-functioning participants are thus often prioritized for aerobic exercise.6 Clinical practice guidelines have been developed to help reduce some of the barriers regarding preparticipation screening and prescription for aerobic exercise in individuals post-stroke.10,13 However, participants with comorbidities are commonly excluded from stroke exercise trials,36 which are often used to generate evidence to guide clinical practice. There remains a paucity of evidence to inform clinical practice for safe aerobic exercise among individuals with a broad range of abilities at sufficiently high intensities to benefit cardiovascular and functional health.10,13 Future research is needed to establish safety and feasibility of aerobic exercise among individuals with stroke with greater levels of disability or more complex health histories and to explore how to optimally support health care professionals who may face challenges in aerobic exercise implementation.

Resources at the organizational level can also affect the implementation of evidence-based practice.31,32 Lack of equipment, space, time, and support staff has been frequently cited as a barrier to the implementation of evidence-based practice in stroke rehabilitation and across physical therapy settings.31,32 In corroboration with these previous findings, studies in the current review reported a lack of exercise equipment,11,12,14,15 time,11,12,15 space,14,15 and support staff11,15 for comprehensive cardiopulmonary exercise assessments. As a result, physical therapists report the use of subjective measures to prescribe aerobic exercise,14 highlighting a discrepancy between clinical practice and best practice recommendations to use objective measures (eg, exercise stress testing) to assess and prescribe aerobic exercise to people with stroke.10,13 This knowledge-practice gap is similar to those identified in other areas of stroke rehabilitation, where the lack of resources is a barrier to implementation of best practice guidelines.37,38

We also found that a small proportion of physical therapists (n = 30/130; 19%)11 and programs (n = 8/33; 24%)14 identified that aerobic exercise was a lower priority for treatment. This may be a product of the many demands on therapist resources; therapists perceiving that they have limited knowledge of how to screen, assess, prescribe, and progress aerobic exercise; and limited access to exercise equipment and resources to accommodate patients with complex clinical presentations or health histories. It may be that the lack of institutional resources to support aerobic exercise, such as screening tools, or exercise and safety monitoring equipment, reinforces the notion that aerobic exercise is not a part of therapists' routine practice. Indeed, among physical therapists who offered structured aerobic exercise programs reported that aerobic exercise was an important aspect of their practice, but therapists working in settings without structured aerobic exercise programs did not view aerobic exercise as a priority.15 Therefore, implementation interventions that target organizational leaders and encourage institutional support for structured aerobic exercise programs may be an important factor in promoting use of aerobic exercise as an important aspect of physical therapy practice.

We also identified a number of facilitators to physical therapists' implementation of aerobic exercise in a stroke rehabilitation setting, mapped to 5 TDF domains: “knowledge,” “skills,” “professional role and identity,” “beliefs about capabilities,” and “environmental context and resources.” Receiving educational training related to aerobic exercise prescription15 and possessing the knowledge and skills to screen, monitor, and interpret responses to exercise (eg, electrocardiography, heart rate, blood pressure, oxygen saturation, and exercise stress tests)11,14 were key facilitators to the implementation of aerobic exercise in stroke rehabilitation settings. Foster and colleagues33 similarly reported that continued professional education and hands-on experience in electrocardiography interpretation and criteria for exercise termination could facilitate the implementation of aerobic exercise into a range of clinical practice settings. Of note, physical therapists in stroke rehabilitation14,15 and other settings33 have reported interest in gaining knowledge and improving in skills that are necessary to implement aerobic exercise into practice, provided that they also have access to training programs15 and resources such as support staff and treatment time to support this practice.11 Therefore, strategies to support future implementation of aerobic exercise into stroke rehabilitation practice should include educational components regarding exercise prescription and safety monitoring using electrocardiography14 and cardiovascular risk screening.11,12,15

A strength of this review is the application of the TDF as a theoretical framework to classify the barriers and facilitators that impact the implementation of aerobic exercise in stroke rehabilitation settings. The TDF is a valid framework to identify challenges in knowledge implementation,27 and it has been previously used to design a complex intervention to improve acute low back pain management in primary care.39 Seven TDF domains (optimism; reinforcement; intentions; memory, attention, and decision processes; social influences; emotions; and behavioral regulation) were not identified in the present review as barriers or facilitators to aerobic exercise implementation. It is unknown whether these domains are not applicable or relevant, or simply have yet been identified, since the questionnaires may not have been designed to capture the extent of these items. Future research may use different study designs (eg, qualitative methods) to explore the breadth of TDF domains and include other health care professional and administrator experiences and perspectives on implementing aerobic exercise in various practice settings. This would provide additional insight into and an in-depth understanding of factors associated with aerobic exercise implementation and can inform the development of behavior change interventions and strategies to minimize the barriers and optimize the facilitators.

We acknowledge that all the studies included in this review were conducted in North America and most (3/4) in Canada. Barriers and facilitators to implementing aerobic exercise identified in the present review may not apply to different stroke rehabilitation settings in other countries and societal contexts. Interestingly, we also noted that despite the broad eligibility criteria employed in our search to consider perspectives of all stroke rehabilitation health care professionals who may implement aerobic exercise, all of the studies included in this review examined the barriers and facilitators to aerobic exercise implementation from the perspectives of physical therapists alone. Future research should explore the barriers and facilitators to implementation from the perspectives of other stakeholders, including other professional disciplines, health care administrators, and patients.

The studies included in this review contained some methodological limitations that can be improved in future work. Two of 4 studies were rated as “fair” quality11,12 related to lack of sample size justification and low enrollment of eligible participants, which limits our confidence in their findings. This review was also not without its own limitations. The search strategy was limited to 6 databases, and we only considered articles published in English language.

However, we are confident that our search strategy, developed in collaboration with a research librarian, and hand-searching of potentially relevant articles yielded a comprehensive breadth and depth coverage20,21 of the available literature (n = 12 129 articles) regarding the barriers and facilitators to aerobic exercise implementation in stroke rehabilitation.

CONCLUSIONS

This study describes the nature and extent of barriers and facilitators to aerobic exercise implementation in stroke rehabilitation settings and maps these items to the TDF framework. Findings from this study will help bridge the knowledge-practice gap by providing guidance to researchers and clinician-scientists to design theory-informed implementation interventions tailored to the needs of stroke health care professionals. These findings provide a foundation to improve aerobic exercise implementation in stroke rehabilitation settings.

REFERENCES

1. Feigin VL, Krishnamurthi RV, Theadom AM, et al. Global, regional, and national burden of neurological disorders during 1990-2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet Neurol. 2017;16(11):877–897. doi:10.1016/S1474-4422(17)30299-5.
2. English C, Healy GN, Coates A, Lewis L, Olds T, Bernhardt J. Sitting and activity time in people with stroke. Phys Ther. 2016;96(2):193–201. doi:10.2522/ptj.20140522.
3. Smith AC, Saunders DH, Mead G. Cardiorespiratory fitness after stroke: a systematic review. Int J Stroke. 2012;7(6):499–510. doi:10.1111/j.1747-4949.2012.00791.x.
4. Field MJ, Gebruers N, Shanmuga Sundaram T, Nicholson S, Mead G. Physical activity after stroke: a systematic review and meta-analysis. ISRN Stroke. 2013;2013:1–13. doi:10.1155/2013/464176.
5. Ivey FM, Macko RF, Ryan AS, Hafer-Macko CE. Cardiovascular health and fitness after stroke. Top Stroke Rehabil. 2005;12(1):1–16. doi:10.1310/geeu-yruy-vj72-lear.
6. Saunders D, Sanderson M, Hayes S, et al. Physical fitness training for stroke patients. Cochrane Database Syst Rev. 2016;(3):CD003316. doi:10.1002/14651858.CD003316.pub6. www.cochranelibrary.com. Accessed October 16, 2019.
7. Stoller O, de Bruin ED, Knols RH, Hunt KJ. Effects of cardiovascular exercise early after stroke: systematic review and meta-analysis. BMC Neurol. 2012;12(45):1–16. doi:10.1111/j.1467-7660.2008.00514.x.
8. Ploughman M, Kelly LP. Four birds with one stone? Reparative, neuroplastic, cardiorespiratory, and metabolic benefits of aerobic exercise poststroke. Curr Opin Neurol. 2016;29(6):684–692. doi:10.1097/WCO.0000000000000383.
9. Mansfield A, Knorr S, Poon V, et al. Promoting optimal physical exercise for life: an exercise and self-management program to encourage participation in physical activity after discharge from stroke rehabilitation—a feasibility study. Stroke Res Treat. 2016;2016:9476541. doi:10.1155/2016/9476541.
10. Billinger SA, Arena R, Bernhardt J, et al. Physical activity and exercise recommendations for stroke survivors. Stroke. 2014;45(8):2532–2553. doi:10.1161/STR.0000000000000022.
11. Doyle L, MacKay-Lyons M. Utilization of aerobic exercise in adult neurological rehabilitation by physical therapists in Canada. J Neurol Phys Ther. 2013;37(1):20–26. doi:10.1097/NPT.0b013e318282975c.
12. Boyne P, Billinger S, MacKay-Lyons M, Barney B, Khoury J, Dunning K. Aerobic exercise prescription in stroke rehabilitation: a Web-based survey of United States physical therapists. J Neurol Phys Ther. 2017;41(2):119–128.
13. MacKay-Lyons M, Billinger S, Eng J, et al. Aerobic exercise recommendations to optimize best practice in care after stroke. https://www.strokengine.ca/wp-content/uploads/2019/03/AEROBICS-2019-last-revised-March.pdf. Published 2019. Accessed October 16, 2019.
14. Nathoo C, Buren S, El-Haddad R, et al. Aerobic training in Canadian stroke rehabilitation programs. J Neurol Phys Ther. 2018;42(4):248–255. doi:10.1097/NPT.0000000000000237.
15. Prout EC, Mansfield A, McIlroy WE, Brooks D. Physiotherapists' perspectives on aerobic exercise early after stroke: a preliminary study. Physiother Theory Pract. 2016;32(6):452–460. http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=med8&NEWS=N&AN=27459027. Accessed October 16, 2019.
16. Graham ID, Logan J, Harrison MB, et al. Lost in knowledge translation: time for a map? J Contin Educ Health Prof. 2006;26(1):13–24. doi:10.1002/chp.47.
17. Weatherson KA, Gainforth HL, Jung ME. A theoretical analysis of the barriers and facilitators to the implementation of school-based physical activity policies in Canada: a mixed methods scoping review. Implement Sci. 2017;12(1):41. doi:10.1186/s13012-017-0570-3.
18. Atkins L, Francis J, Islam R, et al. A guide to using the Theoretical Domains Framework of behaviour change to investigate implementation problems. Implement Sci. 2017;12(1):77. doi:10.1186/s13012-017-0605-9.
19. Michie S, Johnston M, Francis J, Hardeman W, Eccles M. From theory to intervention: mapping theoretically derived behavioural determinants to behaviour change techniques. Appl Psychol. 2008;57(4):660–680. doi:10.1111/j.1464-0597.2008.00341.x.
20. Arksey H, O'Malley L. Scoping studies: towards a methodological framework. Int J Soc Res Methodol Theory Pract. 2005;8(1):19–32. doi:10.1080/1364557032000119616.
21. Levac D, Colquhoun H, O'Brien KK. Scoping studies: advancing the methodology. Implement Sci. 2010;5:69. doi:10.1186/1748-5908-5-69.
22. Liberati A, Altman DG, Tetzlaff J, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. J Clin Epidemiol. 2009;62(10):e1–e34. doi:10.1016/j.jclinepi.2009.06.006.
23. Ouzzani M, Hammady H, Fedorowicz Z, Elmagarmid A. Rayyan—a Web and mobile app for systematic reviews. Syst Rev. 2016;5(1):210. doi:10.1186/s13643-016-0384-4.
24. Barrier. https://www.lexico.com/en/definition/barrier. Accessed October 11, 2019.
25. Facilitator. https://www.lexico.com/en/definition/facilitator. Accessed October 11, 2019.
26. Peters MD, Godfrey CM, Khalil H, Mcinerney P, Parker D, Soares CB. Guidance for conducting systematic scoping reviews. Int J Evid Based Healthc. 2015;13(3):141–146. doi:10.1097/XEB.0000000000000050.
27. Cane J, O'Connor D, Michie S. Validation of the Theoretical Domains Framework for use in behaviour change and implementation research. Implement Sci. 2012;7:37.
28. National Institutes of Health. Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. Bethesda, MD: National Heart Lung and Blood Institute. https://www.nhlbi.nih.gov/health-topics/study-quality-assessment-tools. Accessed February 10, 2020.
29. Riebe D, Ehrman J, Liguori G, Magal M. ACSM's Guidelines for Exercise Testing and Prescription. Indianapolis, IN: American College of Sports Medicine; 2017.
30. Jette DU, Bacon K, Batty C, et al. Evidence-based practice: beliefs, attitudes, knowledge, and behaviors of physical therapists. Phys Ther. 2003;83(9):786–805. doi:10.1093/ptj/83.9.786.
31. Salbach NM, Jaglal SB, Korner-Bitensky N, Rappolt S, Davis D. Practitioner and organizational barriers to evidence-based practice of physical therapists for people with stroke. Phys Ther. 2007;87(10):1284–1303. doi:10.2522/ptj.20070040.
32. da Silva TM, da Cunha Menezes Costa L, Garcia AN, Costa LO. What do physical therapists think about evidence-based practice? A systematic review. Man Ther. 2015;20(3):388–401. doi:10.1016/j.math.2014.10.009.
33. Foster E, Fraser J, Inness EL, et al. Examining physiotherapist use of structured aerobic exercise testing to decrease barriers to aerobic exercise. Int J Phys Ther. 2019;35(8):787–796. doi:10.1080/09593985.2018.1457110.
34. Ovbiagele B, Nguyen-Huynh MN. Stroke epidemiology: advancing our understanding of disease mechanism and therapy. Neurotherapeutics. 2011;8(3):319–329. doi:10.1007/s13311-011-0053-1.
35. Roth EJ. Heart disease in patients with stroke: incidence, impact, and implications for rehabilitation, part 1: classification and prevalence. Arch Phys Med Rehabil. 1993;74(7):752–760. http://www.ncbi.nlm.nih.gov/pubmed/8328899. Accessed October 16, 2019.
36. Nelson MLA, McKellar KA, Yi J, et al. Stroke rehabilitation evidence and comorbidity: a systematic scoping review of randomized controlled trials. Top Stroke Rehabil. 2017;24(5):374–380. doi:10.1080/10749357.2017.1282412.
37. Bayley MT, Hurdowar A, Richards CL, et al. Barriers to implementation of stroke rehabilitation evidence: findings from a multi-site pilot project. Disabil Rehabil. 2012;34(19):1633–1638. doi:10.3109/09638288.2012.656790.
38. McCluskey A, Vratsistas-Curto A, Schurr K. Barriers and enablers to implementing multiple stroke guideline recommendations: a qualitative study. BMC Health Serv Res. 2013;13:1–13. doi:10.1186/1472-6963-13-323.
39. French SD, Green SE, O'Connor DA, et al. Developing theory-informed behaviour change interventions to implement evidence into practice: a systematic approach using the Theoretical Domains Framework. Implement Sci. 2012;7:38. doi:10.1186/1748-5908-7-38.
Keywords:

aerobic exercise; evidence-based practice; knowledge translation; rehabilitation

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