An exploration of adherence to intensive exercise in stroke survivors

Author: Tamina Levy

Levy, Tamina, 2021 An exploration of adherence to intensive exercise in stroke survivors, Flinders University, College of Medicine and Public Health

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Stoke is the third most common cause of death in Australia and a leading cause of disability worldwide. One of the most common deficits following stroke is hemiparesis, and consequently, a key goal of stroke rehabilitation is to restore movement impairments and associated functions. Loss of movement in the upper limb, and subsequent reduced functional use, can severely impact quality of life after stroke.

Stroke guidelines recommend large amounts of practice to potentiate motor recovery, however, in practice, providing higher doses of therapy is challenging and evidence has shown there may be low adherence to participation in higher intensity therapies. As formal rehabilitation delivered by a hospital team is typically finished within the first six months following stroke, stroke survivors must be provided with ongoing exercise programs and recommendations to continue with after discharge from rehabilitation. To complete the necessary amount of practice to maximise recovery, adherence to these programs needs to be high.

Understanding factors that influence adherence to intensive exercise programs in stroke survivors could assist health professionals to develop tailored programs that promote large amounts of practice. Factors known to influence exercise adherence in stroke survivors include the level of social support, self-efficacy, knowledge about the benefits of exercise, and support of health professionals. Health professionals have some knowledge about potential barriers to adherence to the home exercise programs they prescribe. However, there is a lack of depth in this understanding when applied to intensive programs, as well as a lack of research exploring strategies that can be implemented to minimise the impact of specific barriers.

Measurement of adherence to exercise programs can take various forms and there is no acknowledged gold standard. It is important to use a method of measurement that is valid in the specific population; that is, the tool measures what it is supposed to measure. Measurement of adherence can be challenging as there are many parameters to consider including dose, timing, and quality. Methods of measurement specific to stroke have included logbooks and other methods of self-report, wearable sensors, and questionnaires. However, to date, there remains uncertainty amongst health professionals as to which method of monitoring adherence is optimal.

This thesis explores exercise adherence in stroke survivors, including methods of measuring exercise adherence after stroke, and barriers and enablers to adherence to intensive programs. The thesis begins with a literature review and the aims of the thesis are detailed. The first study, described in Chapter 2, is a systematic review of methods of measurement of adherence in stroke survivors. The purpose is to identify approaches to measurement that may be utilised throughout other chapters and to provide recommendations for health professionals and researchers regarding methods of measurement. Next, Chapter 3 details a feasibility study that explores the use of technology (a tablet computer) as a method of monitoring exercise adherence in a group of stroke survivors who had participated in an intensive home-based exercise program. This study evaluated how much exercise participants did and what factors influenced the amount of practice. Chapter 4 describes a single-case series which extended the exploration of technology use to determine if the addition of a tablet computer increased adherence to an intensive home exercise program in ten stroke survivors. Chapter 5 describes a qualitative descriptive study that explored the experiences of, and barriers and enablers to, adherence to intensive exercise programs following stroke. In Chapter 6, an implementation-effectiveness study is described where the candidate developed, implemented, and evaluated an exercise-based group for stroke survivors and their carers on an inpatient ward. The group aimed to engage carers in rehabilitation and to increase adherence to exercise of the stroke survivor, including when they were discharged from inpatient care. Chapter 7 outlines how a behaviour change model can be used to analyse barriers to adherence and develop strategies to address these. Practical implications of the research are presented in the form of a guide developed by the candidate from a synthesis of this analysis, which aims to provide health professionals with an evidence-based approach to the prescription of home exercise programs for stroke survivors. The thesis concludes with Chapter 8; a reiteration of the research aims and work completed. Strengths, limitations, and key outcomes are discussed.

Keywords: stroke, exercise, adherence

Subject: Public Health thesis

Thesis type: Doctor of Philosophy
Completed: 2021
School: College of Medicine and Public Health
Supervisor: Professor Maria Crotty