Dr Jacqui Morris

MOTIVATION AND CAPABILITY
INFLUENCES ON STROKE SURVIVORS' DECISIONS TO
ENGAGE IN PHYSICAL ACTIVITY
Dr Jacqui Morris, Professor Brian Williams, Dr Tracey Oliver, Dr Sara
Joice, Dr Thilo Kroll
1

Background
• Benefits of engagement in physical activity post-stroke now established 1-9
• Guideline recommendations for post-stroke exercise services 10-12
However....
• 58-68% of individuals with stroke undertake minimal physical activity
• Ambulatory activity levels half of non-hemiplegic adults 14
• Organised exercise classes benefits are lost at follow-up
Suggesting....
People are not managing or are choosing not to continue with physical activity
9, 15
13, 14
2

Need to understand why
• Previous qualitative studies - barriers and perceived benefits of
physical activity 16-20
• Urban environments, African Americans
• Already participating in support or exercise groups
• Unlikely to represent breadth of views and issues across range of sociodemographic
populations
3

Aim:
To explore views and experiences of stroke survivors, to
identify issues influencing physical activity participation
after rehabilitation
4

Methods
• Design: Qualitative study, in-depth interviews
• Population:
Community dwelling stroke survivors >6 months after the end of
rehabilitation
• Purposive Sampling:
• Disability (Barthel Index)
• Deprivation (Carstairs Index)
• Level of physical activity (PASIPD)
• Recruitment: NHS Fife and Tayside via stroke liaison services, NHS
rehabilitation services and exercise after stroke services
• Data analysis: Framework Approach with constant comparison to
derive conceptual themes and interpretation
5

Topic Guide
• Knowledge and beliefs about stroke and recovery
• Knowledge and beliefs about physical activity
• Beliefs and meanings relating to physical activity after
stroke
• Barriers and facilitators to physical activity
6

Sample Characteristics (n=38)
Male
Female
Gender 19 19
Age: 20-60
60-80
80+
Carstairs Deprivation Index :
Low (mean = 0)
High (high >0)
3
14
2
7
12
5
12
2
10
9
Barthel Index: High disability (=100)
Low Disability (

Physical activity after stroke
8

Motivation
Desire or intention
Do they want to do it?
9

Beliefs about stroke cause
•Few beliefs
•Lifestyle/medical
Beliefs
about cause
and
recovery
“You don’t know. I wasn’t under any stress or
anything like that...I was away at 3 o’clock in
the morning. Didn’t seem to bother me, but I
don’t know, but I don’t know how I got it. No I
don’t” Male survivor, 74
Attitudes
to activity
Motivation
“I had a brain haemorrhage, I, that was, my
type of stroke was a brain haemorrhage
‘cause by high blood pressure.” (Male, 65)
10

Stroke recovery beliefs
• Few causal beliefs, natural process, little control
• Clear causal beliefs, taking control over lifestyle for
secondary prevention and physical recovery
Beliefs
about
cause
and
recovery
“well its just a matter of rest and simple, like I
said they gave me simple exercises which I still
do a bit you know...It is because, you see, I don’t
know, when I had the stroke but I would say its
just gradual isn’t it...” (Female 73)
Attitudes
to activity
Motivation
“....I was only 52 and I thought “Oh, hey,
come on. Shake up and do something about
it, improve what you did before, improve
your fitness, improve your lifestyle”(Female
survivor 69)
11

Stroke recovery beliefs and
physical activity
• Low expectations for recovery, low control, low importance
of PA
• High expectations for recovery, high control, high
importance of PA
Beliefs
about
cause
and
recovery
“There’s no elasticity left in my leg at all now, other than me lifting
it up and down or whatever. I’ll never recover. I’ll only get
worse. All I can do is try and keep as mobile as possible. I can’t
really see exercise helping me recover from it.... (Male survivor,
68)
Attitudes
to activity
“It’s going to help me get back to a normal kind of
standard of living.” (Female survivor 52)
Motivation
12

Drivers for recovery and attitudes
to physical activity
• Few recovery drivers, low prioritisation
• Strong drivers of recovery, family, social, work,
prioritisation of PA
Drivers
for
recovery
Attitudes
to activity
Motivation
“I just let every day go by, take the day as it
comes”. (Male, 83)
Well … one of the psychological things in my brain, I, was
I need to be, get better for my wife and my family ‘cause
they need me … they do, they do em, so I, you know that
was at the back of my mind as well and I want to see my
grandchildren growing up and I want, you know I, I, that
was a real driving force for me, think of the reasons why
you want to live, or you want to do something (Male
survivor 65)
13

Physical activity after stroke
14

Capability
Translation of intentions into action
Do they think they can do it?
15

Barriers: negative effects on perceived
capability
Effects of stroke and
co-morbidities
• Physical effects
• Fatigue
• Communication
• Emotional effects/mood
• Fear – falling, recurrence
• Embarrassment
• Age, co-morbidities
Environmental Factors
• Transport availability
• Transport accessibility
• Knowledge of opportunities
• Timing
• Cost
• Weather
Perceived Capability
16

Facilitators
• Support from others
• Family:
Facilitatory
Directive
Over protective
• Other survivors
• Health professionals
“So, they know now to let me, though I stand
and struggle, just about swear and I’ll say, ‘Look
I’ll have to give up on this, I cant get this zip in
properly to zip it up.’. I try and persevere and
they know that and the family know that now
as well, the girls will say, ‘Right, we’ll leave you.
I could do this for you mum. Do you want to do
it for yourself?’ and I’ll say, ‘Look, let me try and
if I can’t manage it, I’ll ask you to do it.’”
(Female, 70)
Perceived
Capability
Support from others
“Everyone that’s up there has got something wrong with them
so you don’t feel sort of....you just don’t feel out of place
because everybody’s in the same position you know....gives
you encouragement because you think well if Neil can do that
I can do that, because he is a third my age....” (Female
survivor, 75)
17

Facilitators of activity
• Self-determination despite effects of stroke
• Overcome barriers
Motivation
Sheer bloody mindedness!...I will not be
beaten…Well, you can be so sore
sometimes. You’re in agony but you’ve
just got to keep pushing on through it.”
(Female stroke survivor, 44)
Perceived
Capability
Self- determination
“Because I want to get better and I think
that’s where the determination comes
from, the fact that you want to get better
so you do the things you’re supposed to
do in the hope that they will work.” (Male
stroke survivor, 78)
18

Experiences and self-efficacy
• Effortful, negative, undermining confidence
• Positive, contributing to recovery
Motivation
Perceived
Capability
Self-efficacy
Experiences
“I couldn’t do it and I did it all wrong and I went and
hurt myself on it. I hurt my back. So that was the end
of the Wii. It just sits there unless somebody comes to
have a game on it. I can’t do it” (Female survivor 68)
“You’re maybe just walking down the road and you think ‘Oh
that was a wee bit easier walking down there’, or rather than
take 15 minutes you realise you’ve done it in 10 minutes...you
think ‘oh I am getting better after all and then it just spurs you
on again” (Female, 43)
19

Frustration
• Dissonance between capability and motivation
There’s days I think frustration gets to you. I often
say, ‘The stroke didn’t kill me, but frustration will.’
Whoever develops a pill for frustration will make a
bloomin’ million.” (Female stroke survivor, 43)
Motivation
Perceived
Capability
“I’ve stopped going to Scottish Old time dancing
because I can’t do it properly and I used to be in a
Scottish country dance team where I did it
properly and it just frustrates me that I can’t do it
properly. The same with tap dancing....so I’ve
stopped doing that.” (Female 69)
20

Physical activity after stroke
F
r
u
s
t
r
a
t
i
o
n
21

Conclusions
• Adoption of physical activity after stroke is complex
• Decisions to be active appear to depend on stroke and recovery
beliefs and recovery drivers, influenced by motivation and
perceived pragmatic facilitators and barriers
• Beliefs about stroke cause, recovery and physical activity are
modifiable and should be targeted
• Provides a stroke specific model of interactions, may assist in
development of interventions
• Theoretically relevant behaviour change interventions should be
applied combined with pragmatic steps to address barriers
• Timing and context requires further investigation
22

References
1. Brazelli M, Saunders DH, Greig CA, Mead GE, Young A. Physical fitness training for stroke patients. Cochrane Database of
Systematic Reviews 2009, Issue 4. Art. No.: CD003316. DOI: 10.1002/14651858.CD003316.pub3.
2. Wevers L, van de Port I, Vermue M, Mead G, Kwakkel G. Effects of Task-Oriented Circuit Class Training on Walking
Competency After Stroke A Systematic Review. Stroke. 2009 Jul;40(7):2450-9.
3. Cramp MC, Greenwood RJ, Gill M, Lehmann A, Rothwell JC, Scott OM. Effectiveness of a community-based low intensity
exercise programme for ambulatory stroke survivors. Disabil Rehabil. 2010;32(3):239-47.
4. Lennon O, Carey A, Gaffnet N, Stepheenson J. A pilot randomized controlled trial to evaluate the benefit of the cardiac
rehabilitation paradigm for the non-acute ischaemic stroke population. Clinical Rehabilitation 2008; 22: 125-33
5. Rimmer J, Rauworth A, Wang E. Nicola T, Hill B A Preliminary Study to Examine the Effects of Aerobic and Therapeutic
exercise on Cardiorespiratory Fitness and Coronary Risk Reduction in Stroke Survivors. Arch Phys Med Rehabil 2009; 90:407-
12.
6. Stuart M. et al. Community-Based Adaptive Physical Activity Program for Chronic Stroke: Feasibility, Safety, and Efficacy of
the Empoli Model. Neurorehabil Neural Repair 2009; 23: 726-734
7. Yang R et al.Task-oriented progressive resistance strength training improves muscle strength and functional performance in
individuals with stroke Clinical Rehabilitation 2006; 20: 860870
8. Carin-Levy G, Kendall M, Young A, Mead G. The psychosocial effects of exercise and relaxation classes for persons surviving
a stroke. Can.J.Occup.Ther. 2009 April;76(2):73-80.
9. Mead G GC, Cunningham I, Lewis SJ, Dinan S, Fitzsimons C. A STroke: A Randomised Trial of Exercise or Relaxation
(STARTER] Journal of the American Geriatrics Society 2007;55:892-9.
10. Gordon NF. Gulanick M. Costa F. Fletcher G. Franklin BA. Roth EJ. Shephard T Physical activity and exercise
recommendations for stroke survivors. Stroke 2004 May;35(5):1230-1240.
11. Guidelines for community based exercise programs after stroke working group: Guidelines for community based exercise
programs after stroke. Endorsed by Ontario Stroke Network 2010
12. Best Practice Guidance for the Development of Exercise after Stroke Services in Community Settings . Best C., Van Wijck F,
Dinan S et al. University of Edinburgh 2010.
13. Shaughnessy M, Resnick BM, Macko RF. Testing a model of post-stroke exercise behavior. Rehabil Nurs 2006;
31:15-21
23

References
14. K. M. Michael, J. K. Allen, and R. F. MacKo, “Reduced ambulatory activity after stroke: the role of balance, gait, and cardiovascular
fitness,” Archives of Physical Medicine and Rehabilitation, vol. 86, no. 8, pp. 1552–1556, 2005.
15. Mudge S, Barber PA, Stott NS. Circuit-Based Rehabilitation Improves Gait Endurance but Not Usual Walking Activity in Chronic
Stroke: A Randomized Controlled Trial. Archives of Physical Medicine and Rehabilitation. 2009;90(12):1989-96.
16. Damush T, Plue L et al. Barriers and facilitators to exercise among stroke survivors. Rehabilitation Nursing; 32, 253
17. Rimmer JH et al 2008. Barriers associated with exercise and community access for individuals with stroke. Journal of Rehabilitation
Research and Development; 45: 315-322
18. Reed M, Harrington R, Duggan A, Wood V . Meeting stroke survivors’ preceived needs: a qualitative study of community based exercise
and education scheme. Clinical Rehabilitation 2010; 24: 16-25
19. Sharma H, Bulley C, Van Wijck F. Experiences of an exercise referral scheme from the perspective of people with chronic stroke: A
qualitative study. Physiotherapy 2012; 98: 341-348
20. Simpson LA, Eng, J, Tawshy A. Exercise perceptions among people with stroke: Barriers and facilitators to participation. International
Journal of Therapy and Rehabilitation 2011; 9: 520-530
24