Factors Influencing the Delivery of Intensive Rehabilitation in Stroke: Patient Perceptions Versus Rehabilitation Therapist Perceptions

Abstract

Background

Despite increasing evidence regarding the benefit of intensive task-specific practice and aerobic exercise in stroke rehabilitation, implementation remains difficult. The factors influencing implementation have been explored from therapists’ perspectives; however, despite an increased emphasis on patient involvement in research, patients’ perceptions have not yet been investigated.

Objective

The study aimed to investigate factors influencing implementation of higher intensity activity in people with stroke and to compare this with therapists’ perspectives.

Design

The design was a cross-sectional qualitative study.

Methods

The study used semistructured interviews with people with stroke who were part of a randomized clinical trial, the Determining Optimal post-Stroke Exercise study, which delivered a higher intensity intervention. An interview guide was developed and data analyzed using implementation frameworks. Factors emerging from interviews with people with stroke were compared and contrasted with factors perceived by rehabilitation therapists.

Results

Ten people with stroke were interviewed before data saturation was reached. Participants had a positive attitude regarding working hard and were satisfied with the graded exercise test, high intensity intervention, and the feedback-monitoring devices. Therapists and patients had contrasting perceptions about their beliefs regarding intensive exercise and the content of the intervention, with therapists more focused on the methods and patients more focused on the personal interactions stemming from the therapeutic relationship.

Conclusions

People with stroke perceived no barriers regarding the implementation of higher intensity rehabilitation in practice and were positive towards working at more intense levels. Contrastingly, from the therapists’ perspective, therapists’ beliefs about quality of movement and issues around staffing and resources were perceived to be barriers. In addition, therapists and people with stroke perceived the contents of the intervention differently, highlighting the importance of involving patients and clinicians in the development and evaluation of rehabilitation interventions.

Intensive rehabilitation, including increased repetitions and aerobic exercise, is advised for people after a stroke.^1–6 However, implementation of intensive rehabilitation within inpatient stroke rehabilitation is still lacking.^1,7–9 A survey among American physical therapists highlighted the fact that physical therapists see the benefit of higher aerobic exercise in the stroke population; however, current recommendations for levels of intensity were not reached.¹⁰ Identified barriers to reaching these were related to the cardiac status of the patient and lack of staff and time.¹¹ In addition, within North America, the graded exercise test was underused as a screening tool.^10,11

A recent multi-site, randomized clinical trial, Determining Optimal Post-Stroke Exercise (DOSE), assessed the feasibility of implementing intensive, task-specific, physical therapy during inpatient rehabilitation.^12,13 Patients received either standard care or a 1 or 2- times 1-hour intensive exercise program each weekday for 4 weeks. The graded exercise test was used as a screening tool, and a heart rate monitor (Alpha Mio heart rate monitor wrist watch, MioGlobal, Vancouver, BC, Canada) and step counters (Fitbit One, Fitbit Inc, San Francisco, CA, USA; StepWatch Activity Monitor, modus health, Washington, DC, USA) were worn to provide patient feedback and monitor progression. This study provided a unique opportunity to explore the perceptions of therapists and patients toward intensive therapy.

From a recent qualitative investigation,¹⁴ 15 therapists involved in the DOSE trial believed the emphasis of the intervention on the quantity rather than quality of movement was a barrier to implementing intensive rehabilitation in everyday clinical practice. In addition, system-level factors (ie, staffing, access to the graded exercise test and monitoring equipment) also impeded implementation.

Patient perceptions towards intensive therapy have not yet been explored, to our knowledge. This is surprising because from ethical¹⁵ and methodological viewpoints,¹⁶ the patient perspective should be central to the development of new treatments. Patients’ beliefs about intensive therapy, safety, and respecting their choice are important¹⁵ when designing and trialing clinical complex interventions.¹⁶

Therefore, this study aimed to explore the factors influencing implementation of a high-intensity intervention from a patient perspective. In addition, it compared the found factors between the patients and previously published perspectives of rehabilitation therapists delivering the therapy.¹⁴

Methods

Study Design

This qualitative study was embedded in a constructivist paradigm. This meant that we believed that every individual, including patients and their therapists, attached a different meaning to events happening in their environment.¹⁷ By asking open-ended semistructured questions to patients and therapists involved in the DOSE trial and being open to the social context, these different views could be exposed. Patients who had completed the DOSE intervention were interviewed and transcripts were analyzed. The resulting factors were then compared with those of previous DOSE rehabilitation therapists.¹⁴ Semistructured interviews are a widely used form of qualitative interviewing, utilizing a topic guide that provides a framework for directed, though flexible, open-ended questions.^18–21 The Standards for Reporting Qualitative Research: A Synthesis of Recommendations was used.²²

Participant Selection

Participants in the DOSE trial were adults admitted to inpatient rehabilitation within the first 10 weeks post-stroke with hemiparesis in the lower extremity, able to ambulate for at least 5 m with up to 1 person maximum assist, and able to understand and follow directions (ClinicalTrials.gov Identifier: NCT01915368). Additional information on inclusion and exclusion criteria of the DOSE protocol can be found in Klassen et al, 2019.¹³

For this interview study, we sought participants who were randomized in the 1 or 2- times 1-hour intensive exercise program of the DOSE trial between January 2017 and June 2018 to minimize recall bias but also to obtain perspectives from people at various time points after discharge in case their perspectives changed. The lead investigator of the DOSE trial only contacted these individuals by email if they had previously consented to being part of further research studies. The email included an information sheet explaining the study and a consent form. Twenty potential participants were in the DOSE trial within the set timeframe. Eight of these potential participants were not approached as they could not be reached with the provided contact numbers (n = 4) or had language (n = 2) and cognitive barriers (n = 2) that excluded them from conducting a phone interview. Therefore, 12 participants were approached and 10 accepted. Those who wanted to participate and provided informed consent were put in contact with the researchers (J.J. and L.C.), who were independent of the DOSE trial and conducted the telephone interview.

The comparator therapists were physical therapists and rehabilitation assistants who had experience with delivering the DOSE intervention. The lead investigator of the DOSE study (T.K.) identified, invited, and consented the rehabilitation therapists before 1 researcher (L.C.) conducted the telephone interviews. The perceptions of these therapists towards intensive therapy have been published.¹⁴

Data Collection

The interview guide was based on the interview guide developed for rehabilitation therapists in the DOSE study¹⁴ and the underlying implementation frameworks: Normalization Process Theory²³ and the Consolidated Framework for Implementation Research (CFIR)²⁴ (see Supplemental Appendix, available at: https://academic.oup.com/ptj). Both the Normalization Process Theory and the CFIR were developed to understand the factors that influence the implementation of an intervention in a clinical setting,²⁵ such as the DOSE intervention. The interview guide was reviewed and piloted by 2 researchers with qualitative and physical therapy experience, 1 DOSE therapist, and 2 patients from the DOSE trial who fell outside the inclusion criteria of the study.

The interviews were conducted by J.J. and L.C. via telephone and Skype. Participants were informed that the conversation would be recorded and that the interviewer was not part of the DOSE research team, giving participants the opportunity to provide an honest perspective. Criticisms were welcomed. The reason for the interview was explained, and the recorder was switched on before the participants were asked about their own perceptions and experiences of being involved in the trial. Interviews lasted on average 34 minutes (range 17–46 minutes). All participants provided written informed consent and received a $50 (CDN) honorarium to compensate them for their time. Interviews were digitally recorded and transcribed verbatim to enable in-depth analysis.

Researcher Characteristics and Reflexivity

The first interviewer was a physical therapy researcher in musculoskeletal and neurological disorders (J.J.). The second interviewer was a physical therapist and clinician-scientist with substantial clinical and research experience in stroke rehabilitation (L.C.). Because of previous publications and experiences, both interviewers were aware of potential factors influencing implementation arising from a therapist’ perspective but were less aware from a patient perspective.

Data Analysis

All participants were given a participant code, and their interviews were transcribed and imported into NVivo 12. Content analysis was used, with the CFIR as the coding framework. The CFIR provides a menu of constructs that have been associated with effective implementation and includes the following domains: individuals (eg, people with stroke), intervention (eg, DOSE intervention protocol), inner setting (eg, stroke rehabilitation settings), and outer setting (eg, outside the inner setting). Each domain can be divided into different items, which can be found online (https://cfirguide.org/constructs/). The first and second author coded the first 2 transcripts using the CFIR framework. Free codes arising inductively from the data were added throughout the coding period in case topics were covered that did not fit into the CFIR framework. The 2 authors compared their coding, reviewed differences, and agreed on codes. This was done to ensure that similar decisions were made about how to interpret the framework in the context of a patient perspective. After this, the remaining transcripts were coded by both authors and checked for accuracy. Finally, the 2 authors met again to compare and discuss their codes and then decided on their final codes. Findings are presented according to the CFIR domain, together with supporting quotes. Participants are identified by their participant code.

Findings from this study were then compared and contrasted against the findings of the rehabilitation therapists¹⁴ in each domain of the CFIR framework. Discussion between authors took place to ensure that interpretation of the framework was consistent.

Results

Participant Characteristics

Ten people, 5 females and 5 males, with an average age of 58.7 (SD 5.6) years, were interviewed between April and July 2018. Ongoing analysis by 2 researchers determined that data saturation was reached after 10 participants. Participants were recruited from 5 different sites across Canada. Although the sites were all in major metropolitan cities (Vancouver, Calgary, Winnipeg), several participants were from rural towns outside of these large cities. Median time at interview was 5.5 months (range 1–16 months) since stroke and 3.5 months (range 3–18 months) since completing the DOSE intervention. No physical tests were conducted at the time of the interview; however, participants’ 5-m-walk test scores at the start of the DOSE trial ranged from 0.15 to 0.86 m/s. Seven participants exercised 2 × 1 h/d in the study, 3 of them 1 × 1 h/d. More detail is displayed in Table 1.

Table 1.

Demographic Information of Participants^a

Participant No.	Gender	Center	Trial Arm	Age at Interview (Years)	Time Since Stroke (Months)	Time Since End of DOSE Trial (Months)
DP1	Male	1	2 × 1 hour	57	4	2
DP2	Male	2	2 × 1 hour	61	5	3
DP3	Male	2	2 × 1 hour	60	9	7
DP4	Female	3	2 × 1 hour	64	12	10
DP5	Female	3	2 × 1 hour	58	5	3
DP6	Female	4	2 × 1 hour	63	6	4
DP7	Male	1	1 × 1 hour	58	5	3
DP8	Female	4	2 × 1 hour	44	9	8
DP9	Male	4	1 × 1 hour	61	3	1
DP10	Female	5	1 × 1 hour	61	18	16

^aDP = DOSE patient = ***; DOSE = Determining Optimal post-Stroke Exercise.

Factors Influencing Implementation for People With Stroke

CFIR and free codes are listed in Table 2. Aspects related to the characteristics of the individuals and the intervention were mentioned most frequently. Three free codes were found: “exercise history” was placed in the domain of characteristics of the individuals, while “content of intervention” was placed under the characteristics of the intervention. The free code “family” was placed under the outer setting characteristics of the CFIR. Findings within the CFIR domains are explained in more detail below.

Table 2.

Therapists’ and Patients’ Perceptions of Factors Influencing Implementation of a High-Intensity Intervention (DOSE)^a

CFIR
	Therapists	Patients
Characteristics of individuals
Knowledge and beliefs	DOSE fits better with some people’s belief system than others due to conflict with quality of movement vs quantity of movement. Some people’s beliefs changed once they had trialed the intervention	Belief that extra exercise is beneficial. Limited expectations prior to study involvement. Limited concerns about it being too much/working too hard: actually positive about intensity/doing more
Self-efficacy	Therapists gained confidence to “push people harder” due to: The graded exercise test making them confident patients had the “all clear,” seeing patients able to work harder, and using heart rate monitors and step counters as objective measures	Patients tended to be able to work hard and work out routines/support strategies that worked for them
Individual stage of change	Most individuals were in the preparation or contemplation stage of change. Some recognized their practice had already changed. Others still felt they would “step back” to their everyday clinical practice
Other personal attributes	Most therapists had some previous exposure to research and were keen to be involved. Two participants felt obliged to take part in the trial	Exercise and lifestyle history. Most people active/open to exercise
Intervention characteristics
Evidence strength and quality	Practical experience of using the intervention tended to outweigh publications. Some mention of the importance of having underpinning research	Personal experience rather than academic evidence
Relative advantage	Graded exercise test gave therapists the advantage of knowing they could push the patient harder	Comparison between patients while on stroke rehab unit helped reinforce positive beliefs. Participants in the 1-h/d exercise group did not see a relative advantage
Adaptability	Research protocol needs to be adaptable for clinical reality (eg, more focus on upper limb/education for some patients). Therapists thought “pre-gait” activities were essential, though recognized doing this first may reduce intensity.
Complexity	Graded exercise test and heart rate monitoring enabled therapists to push patients harder than they normally would have (more radical). Need for a graded exercise test and equipment make intervention more difficult to implement. Frequency and duration of sessions were considered difficult to implement outside of study	Graded exercise tests accepted and not an issue. Feedback devices seen as helpful to monitor outcome but problematic when unreliable. Patients felt they were able to have structure in their day to fit in extra sessions
Design quality and packaging	Therapists liked the structure and detail of manual and paperwork, particularly tips and ideas. Structured format helped support different therapists treating the same patients.
Content of intervention	Treadmill—walking—exercise test	Walking Positive effect of therapists More time with therapists
Inner setting
Structural characteristics	Concerns regarding staffing to enable the duration of therapy outside of the study. Shift required in how therapists prioritize treatment and buy-in from all therapists and managers when scheduling to allow for longer sessions.
Networks and communication	Communication important to ensure treatment schedules work to allow for longer sessions
Culture	Recognition that these therapists worked in research intensive departments
Readiness for implementation	Leadership engagement recognized as important to support resources required
Available resources	Need for graded exercise test, and ideally equipment (HR monitors, step counters, treadmills, harnesses)
Characteristics of individuals
Knowledge and beliefs	DOSE fits better with some people’s belief system than others due to conflict with quality of movement vs quantity of movement. Some people’s beliefs changed once they had trialed the intervention	Belief that extra exercise is beneficial. Limited expectations prior to study involvement. Limited concerns about it being too much/working too hard: actually positive about intensity/doing more
Outer setting
Patient needs and resources	Recognition that this type of intervention will not be suitable for all (especially elderly with comorbidities). Patients generally liked high intensity and felt they accomplished something. Therapists were surprised how hard patients worked and tolerated intensive regime
External policies and guidelines	The Canadian guidelines for stroke state a graded exercise test should be undertaken, which poses a challenge for implementation
Family influence		Family generally supportive (both practical and emotional) during rehabilitation On-going influence

^aCFIR = Consolidated Framework for Implementation Research; DOSE = Determining Optimal post-Stroke Exercise.

Characteristics of the Individuals

Patients’ knowledge and beliefs about exercise and the importance of rehabilitation were commonly stated as factors influencing engagement with the high-intensity intervention. Overall, patients saw the benefit of being involved in intensive exercises with limited prior expectations of rehabilitation.

Exercise History

Most people had been involved in exercise or were active before their stroke.

DP02: I’ll go to the gym usually maybe about twice a week, just to do some cardio only for about 20 minutes. I did a lot of sprint training and then I usually walk about 2 hours a day.

DP03: I’d ride my bike a lot. My job entails a lot of walking. So you might be walking up 6 stories and down, walking all over the job sites and stuff. It wasn’t a sedentary lifestyle but I was not an athlete. I did not go to the gym or anything like that. Just your typical overweight middle-aged guy.

Knowledge and Beliefs

Because of the unexpected nature of having a stroke, participants did not have any preconceived ideas about what the rehabilitation should look like.

DP01: I wasn’t expecting to have a stroke so I had not really thought about it.

However, all participants believed that additional or more intense exercise would be beneficial.

DP08: When I got to the DOSE program: more, do more, and I think that’s a lot better, doing more.

Self-Efficacy: (Positive) Attitude Towards Working Hard

All patients who participated in the intensive exercises twice a day were positive about intensive rehabilitation, despite it being daunting in the beginning.

DP02: Oh. Well, I was really happy to get extra therapy to begin with, you know. And when I was pretty—laughs—it was pretty physically daunting to be honest with you because as a stroke patient, you know, you do not have much endurance.... And so by the end of the day I was just beat.

Intervention Characteristics

Factors regarding evidence strength, relative advantage, and complexity were the 3 most extracted concepts of the intervention characteristics. One free theme placed under the intervention characteristics was the content of the intervention.

Evidence Strength and Quality

Participants mainly talked about their personal experience of being in the DOSE study and how this had given them the evidence that the intensive intervention worked. No one talked about research evidence.

DP03: … if I had not had that DOSE program, I think I would be healing perfectly well, but not nearly at this rate. I do not think I would be where I am now if I did not have that DOSE program and that physio—intense physio at the beginning.

Relative Advantage

Overall, most participants saw the advantage of taking part when they compared themselves with other patients in the hospital.

DP04: I was walking. …yes, I was using the walker but I was walking. I could steady myself, I was playing basketball! I was bowling! And then I watched the other people around me not doing much of anything … … And after I got out, because I had to go back to the doctor there, I would still see some of the same people, and I thought, “Oh, that’s really too bad, you should’ve said yes.” I did not say it out loud but that’s what I was thinking.

DP07: I was only aware of 1 person in the DOSE study when I got there and he was very active and he was recovering very rapidly, much more rapidly than the other patients that were around, and that was kind of an indicator to me that it might be worth doing this if I could get some similar type of recovery, it would be worth a try.

However, 2 of the 3 patients who were involved in exercises once a day felt they could have done more and did not see the advantage of being included in the DOSE study.

DP09: I could have been pushed harder…. probably could have been walking more, even more.

Complexity

The graded exercise test and the feedback devices, together with practical issues of incorporating all the sessions in 1 day, were the main codes in this theme.

Participants were able to fit the additional exercise session into their routine.

DP02: No, it was pretty much straightforward. I seemed to understand what was going on, and there was a certain routine. We tried to get in half an hour of walking every session, try to aim for an hour a day, which was good, you know. So, no, it was straightforward.

There was a mixed reaction towards the graded exercise test. During the test some participants indicated that it was difficult.

DP02: Okay, that was the first time I had pushed my heart over a month. And it just about killed me—laughs—because I was on the bicycle I was going “Oh my God”, and course, you know like, what do you expect for a person who’s had a stroke, it’s gonna be difficult. But we had a doctor there supervise the test. So it was kinda good to push myself but it was hard, as you can imagine. If you just take anybody off the street and just put them on a bed have them lay down for 3 weeks and say, “okay, get up and start moving.” It’s gonna be hard no matter what.

Other participants indicated they were happy the graded exercise test was included as it empowered them to work hard in the exercise sessions.

DP05: Oh! That was kind of cool. There’s an exercise bike and—it was actually good for me because …, it actually gave me confidence because you know, they were there monitoring me and I was getting to push myself. Whereas until then, I felt like everyone was trying to coddle me so much, and all of a sudden it was like, “here, get on the bike and go!” And it was really, I think empowering.

The importance of feedback-monitoring devices (heart rate monitor and step counter) varied, with some participants not really able to remember what devices were used and others commenting the feedback was a good motivator.

DP06: You could see the progress everyday if they were recording how many steps you have taken or how, you know, where your heart beat has gotten during that session or how much you were in the target zone for how long. And so it was rewarding seeing progress.

Content of the Intervention

The therapeutic aims of the DOSE intervention protocol were to progress patients towards 30 to 60 minutes of continuous walking activities in an aerobic zone (≥ 40% heart rate reserve) and complete > 2000 steps within a 60-minute therapy session. When asked more specifically about the training goals of the DOSE study, most participants were not aware of their optimal heart rate levels despite being prompted about this. Only some participants knew there was a certain level set for their heart rate.

DP01: Uh well, I believe we had a goal to have my heart rate …. not really intense but a certain amount of intensity to help recover the abilities.

Interestingly, the patients in this study talked most about the interaction between the therapists and themselves. For them, the intervention was a way to receive more exercise time with their therapists, who they perceived to be their coach and motivator. Without exception, the participants developed a positive relationship with the therapist team.

DP05: I had an opportunity and I had a lot of people to help me with it. Like I had someone with me 2 hours a day.

DP07: And they know a little bit about you more than just—you build a relationship that’s deeper than purely a clinical one. That helps a lot, especially for me during the recovery process, you—stroke tends to remove some of your feelings of humanity, if that means anything and you feel less of a person, and part of the rebuilding is coming to terms with the changes that you are going through, accepting that some of them will to some degree and other be permanent, and having people around you that you feel actually care helps in during the recovery and helps you start regaining a sense of being a worthwhile person again, if that makes sense. And the, all of the therapists I worked with during the program were exceptionally good. They were wonderful people. It’s presumptuous but I would like to consider them friends.

Inner Setting

There was very limited insight into the culture of the hospital setting and the structural characteristics.

Outer Setting

None of the participants raised issues regarding external policies and guidelines. Patients did mention their support network, including family and friends, during the intervention and after they had been discharged from the rehabilitation hospital.

When asked how family and friends supported patients during their stay, 1 participant answered.

DP09: Just encouraging me to be involved and to do my best.

Other family members needed to come around to the idea of intense therapy as illustrated by a quote from DP04.

DP04: I do not think at first that my sisters thought it was a good thing, only because they know I will push myself to the point, as they came around, they saw that I was really being monitored, I wasn’t being pushed, and if I was pushing myself they would temper me back, say, “Okay, you don’t have to go gung-ho like that.”—laughs—I had boundaries.

This patient also mentioned that a good support network was needed once you were discharged from the rehabilitation hospital.

DP04: I had a really good support system because I scared everybody.—laughs—I had a good friend, … and he did not let me sulk—none of that. So my scheduling—he would send me a text, “Okay, you have to go the gym this, this, and this day.” And I’ll say, “No, I don’t want to.” “Hey, either you call the bus or I’ll come get you.”—laughs—So, that was my scheduling. You just have to have a good support system. Do not talk yourself out of exercise.

Comparing and Contrasting Views of Patients and Therapists

The perceptions of the patients and the therapists involved in the DOSE study are displayed in Table 2. People with stroke and their rehabilitation therapists both seemed to base their beliefs of the effectiveness of the intense therapy on the practical and personal experiences rather than academic evidence. Despite both groups perceiving intensive rehabilitation to be beneficial, the rehabilitation therapists were more reserved in their opinion by their previous education around quality of movement, which conflicted with the protocol’s focus on quantity. In addition, both the rehabilitation therapists and the people with stroke found the graded exercise test to be helpful and empowering in guiding the progression of the intervention. However, therapists found structural aspects at system level, such as staffing and access to the graded exercise test, to be barriers for further implementation.

Interestingly, the patients and the therapists perceived the intervention completely differently. Patients thought it consisted of having additional time with their therapists, who they saw as their coaches to get them through this difficult time. Conversely, the therapists described the intervention in mechanistic terms, such as levels of intensity and number of steps in each training session.

Discussion

Patients were facilitated to undertake intensive exercise by a number of factors, including their positive belief toward intensive exercise, the positive therapeutic relationships they developed, and their belief that they would experience improvements if they worked hard. Other less prominent facilitators included the use of the graded exercise test and feedback devices.

Patients seemed to perceive fewer barriers to being involved in intensive therapy than their rehabilitation therapists, as therapists were more influenced by their previous education around quality of movement, which conflicted with the focus on the quantity of activity. The patients did not have any preconceived ideas about what the rehabilitation should contain and were overall content with the intervention. However, 2 of the 3 patients who were randomly assigned to the 1-h/d arm of the trial mentioned that they were happy to be pushed harder.

Patients based their beliefs about the effectiveness of the intervention on practical and personal experiences rather than academic evidence. Similarly, despite the evidence around this topic being available in the literature,^1,2 therapists also relied on their own experiences when discussing the effectiveness of the intensive therapy when interviewed in an earlier study. Negative attitudes towards research, poor research literacy, and insufficient time have been identified as factors that hinder implementation.^26–29 In addition, it is important to acknowledge the clinical expertise clinicians possess as an influencing factor for implementation.

The graded exercise test used in this study was perceived to be beneficial and empowering for people with stroke and their therapists alike. The results of the graded exercise test provided the therapists with additional confidence to push people with stroke harder during exercise, without major safety issues, while the confidence of people with stroke lay in the feedback they received from their monitoring devices. However, practical issues surrounding the graded exercise test, such as access to the test and the professionals, remain barriers in the implementation of this test in clinical practice.

Patients in this study perceived the higher intensity rehabilitation intervention to consist of having additional time with their therapists, who they viewed as their coaches helping them get through this difficult time. Peiris et al also found that patients perceived their relationship with physical therapists was more important than the content of the therapy.³⁰ Others have found that support from qualified personnel to exercise is a facilitating factor for participating in exercise.^31,32 Contrastingly, the therapists described the intervention in mechanistic levels, such as 1 or 2 sessions of 1 h/d of aerobic exercise within task-specific walking activities, focusing on upright gait-related activities in an aerobic zone, and the inclusion of the graded exercise test, heart rate monitor, and step counters. Future research could investigate possible ways of capturing patients’ viewpoints when developing and trialing new interventions. For example, standard intervention frameworks such as the TIDier checklist³³ do not acknowledge the establishment of a therapeutic relationship between a patient and clinician, and yet patients in our study felt this was the most important benefit. The lack of focus on therapeutic relationships has implications when investigating fidelity within trials, as possible aspects may be lost when up-scaling interventions if they are not clearly defined as part of the intervention in the first place.

The CFIR framework has been developed to explore implementation of health innovations into practice. Although this worked very well for the therapist participants in a previous study,¹⁴ the framework did not fit as well from a patient perspective. Inner and outer setting characteristics were not well defined from a patient perspective. For example, it was unclear whether a patient’s family viewpoint was included in the inner setting or outer setting. With the current increased focus of involving patients in the research process, more emphasis needs to be placed on capturing the patients’ perspective when discussing implementation issues.³⁴

Limitations

There is a chance of selection bias in the sample recruited. People with stroke who were positive about exercise and who had positive experiences in the trial might have stepped forward to be interviewed. The analysis showed that participants had been active prior to their stroke; however, their exercise history showed that only some were very active prior to having a stroke, indicating there was a mixed level of people recruited to this study. The time between completing the trial and the time of the interview might have caused some levels of recollection bias; however, different time points were selected purposefully to incorporate reflections over time.

Conclusions

Patients’ perceptions about intensive therapy were different than their therapists. Patients perceived the benefits of intensive therapy to result from the therapeutic relationship in guiding and motivating them along their recovery journey, whereas therapists perceived the therapy in terms of the units of exercise delivered. Given the contrasting perceptions, it is important to consider both patient and therapist views when developing rehabilitation interventions.

Author Contributions and Acknowledgments

Concept/idea/research design: J. Janssen, T.D. Klassen,L.A. Connell, J.J. Eng

Writing: J. Janssen, T.D. Klassen, L.A. Connell, J.J. Eng

Data collection: J. Janssen, L.A. Connell

Data analysis: J. Janssen, L.A. Connell

Project management: J. Janssen, T.D. Klassen, L.A. Connell

Fund procurement: L.A. Connell, J.J. Eng

Providing participants: T.D. Klassen, J.J. Eng

The authors acknowledge the patients involved in the DOSE study who talked openly about their experiences of being involved in high-intensity interventions. We also thank Chelsea Chua for her assistance with the transcriptions.

Ethics Approval

Study ethics approval was obtained from both the University of British Columbia Behavioural Research Ethics Board (H16–02449) and the UCLan Science, Technology, Engineering, Medicine and Health Board (STEMH 560).

Funding

This study was supported by the Canada Research Chair Program, Canadian Institutes of Health Research (FDN 143340 operating grant to J.J. Eng and Doctoral Award to T.D. Klassen), and Heart and Stroke Canadian Partnership for Stroke Recovery.

The funders played no role in the design, conduct, or reporting of this study.

Clinical Trial Registration

The Determining Optimal post-Stroke Exercise (DOSE) trial (some of whose participants took part in this qualitative study) was registered at ClinicalTrials.gov (NCT01915368).

Disclosures

The authors completed the ICMJE Form for Disclosure of Potential Conflicts of Interest and reported no conflicts of interest.