Critique of two research articles

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Physiotherapy 98 (2012) 336–343

Experiences of an exercise referral scheme from the perspective of people with chronic stroke: a qualitative study

Helen Sharma a, Cathy Bulley b, Frederike M.J. van Wijck c,∗ a Physiotherapy Department, King’s College Hospital, Denmark Hill, London SE5 9RS, UK

b School of Health Sciences, Queen Margaret University, Queen Margaret University Drive, Edinburgh EH21 6UU, UK c Institute of Applied Health Research and School of Health, Glasgow Caledonian University, Cowcaddens Road, Glasgow GB4 0BA, UK

bstract

bjective To explore stroke survivors’ experiences of undertaking exercise in the context of an exercise referral scheme for people with hronic stroke. esign A qualitative design, using semi-structured interviews within a constructivist framework to explore the experiences of individ- al participants. Verbatim transcripts were thematically analysed. Rigour mechanisms included respondent validation, peer checking, and eflexivity. etting An exercise referral scheme, based at a leisure centre in South London. articipants Nine community-dwelling stroke survivors took part; 5 male and 4 female, mean age 51 years (range 37–61 years); time post troke 1–4 years, with mixed ethnic backgrounds. indings Participants described greater physical and psychological well-being following participation in the exercise referral scheme. ategories that emerged were: improved exercise engagement and confidence, more internalised perceptions of control and enhanced lifestyle, ork and social roles. Categories linked to form a master theme, labelled: ‘Exercise Referral Scheme as a catalyst for regaining independence.’

onclusions This study supports the value of exercise referral schemes in enabling people with stroke to engage in exercise. For participants

n this study, the scheme seemed influential in the process of regaining independence. 2011 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved.

eywords: Stroke; Exercise; Physical activity; Exercise referral scheme; Community

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Globally, fifteen million people suffer a stroke each year nd with five million being left permanently disabled, stroke laces a considerable burden on family, community and econ- my [1]. In England, stroke is the largest single cause of adult isability; over 900,000 people live with the consequences f stroke, with associated costs estimated at over seven bil- ion pounds per year [2]. The impact of stroke on individuals

ay include reduced independence, low mood, sensorimotor mpairment and decreased fitness.

∗ Corresponding author. Tel.: +44 0141 3318967. E-mail addresses: [email protected] (H. Sharma),

[email protected] (C. Bulley), [email protected] F.M.J. van Wijck).

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031-9406/$ – see front matter © 2011 Chartered Society of Physiotherapy. Publis oi:10.1016/j.physio.2011.05.004

Reduced physical fitness is common following stroke 3], presenting a risk for recurrent stroke, cardiac disease nd fall-related fractures [4,5], and a barrier to community e-integration [6]. With more people surviving strokes [7] nd government policies shifting health care from hospi- al towards community [8], improving physical fitness in ommunity-dwelling stroke survivors is a priority.

A growing body of evidence demonstrates that exercise, efined as structured and repetitive physical activity (PA) that s usually planned to enhance fitness [9], can improve a range f fitness parameters after stroke [10]. However, evidence lso suggests that PA must be maintained to sustain bene- ts [11]. UK national clinical guidelines recommend regular

xercise participation and aerobic training where possible, as art of a long-term strategy after stroke [12–14].

Studies of PA maintenance after stroke are scarce. One eport demonstrated immediate reductions in PA follow-

hed by Elsevier Ltd. All rights reserved.

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ng completion of an exercise programme, and return to ow levels three months later [15]. General population sur- eys have found that maintaining sufficient levels of PA s difficult [16]. To encourage ongoing exercise participa- ion among different populations, exercise referral schemes ERS) were developed in the UK [17]. However, four ran- omised controlled trials (n = 1200 in total) found a return to re-intervention exercise levels at 12-to-52 weeks after com- leting an ERS [18–23]. Reasons for this decline in exercise ehaviour are unclear, mainly due to a lack of qualitative data. xercise behaviour is complex; one review identified over 0 correlates of exercise participation in adults [24]. With he ERS model now well established, knowledge of partic- pants’ experiences with this type of service is essential to ptimise uptake and ongoing PA participation. Although the alue of patient experiences in service design and delivery is ell recognised by the UK National Health Service (NHS)

25] and government policies [26], little is known about troke survivors’ experiences of exercise in the context of n ERS.

The first qualitative study to formally explore the expe- iences of stroke survivors of an exercise intervention [27] as associated with a clinical trial [11] and found that partic-

pants had enjoyed the classes, felt empowered to take more ontrol over their recovery, and more motivated to get out f the house and undertake other activities. Most exercise articipants continued with an active lifestyle afterwards, nd felt their quality of life had increased. Another clinical rial [28] included an exploration of stroke survivors’ percep- ions of a community-based scheme combining exercise with ducation [29]. Exercise and goal setting were valued as pos- tive actions that enabled improvements in physical function nd confidence. However, these interventions were delivered ithin the context of clinical trials, and the findings may not eneralise to routine clinical practice.

To our knowledge, only one study has explored experi- nces of a community-based ERS for stroke survivors [30], nd included people with stroke, fitness instructors who an the scheme and referring physiotherapists. Four main hemes emerged: the role of the ERS in continuing rehabili- ation following physiotherapy discharge; concern regarding nstructors’ level of knowledge about stroke; low levels f supervision and interaction with instructors; and sug- ested improvements to the scheme, including closer contact etween referring physiotherapists and exercise instructors. owever, perceived impacts of the scheme on participant’s

ives were not explored, and it was not possible to isolate the xperiences of stroke survivors.

In summary, published literature on exercise after stroke ocuses primarily on physical impairments and activity limi- ations, with little information on perceptions and experiences elating to exercise and any psychosocial impacts of exer-

ise referral schemes. Therefore, the aim of this study as to explore the experiences of people in the chronic hase after stroke, who participated in a community-based, hysiotherapy-led ERS.

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ethod

tudy design

Individual experiences were explored in depth using a onstructivist qualitative approach that focuses on socially onstructed multiple realities [31]; an interpretivist per- pective that appreciates individuals’ values and meanings; nd phenomenological methodology, whereby the researcher brackets’ personal understandings when deriving meaning rom the data [32].

One-off, one-to-one semi-structured interviews enabled n individual focus and coverage of important topics with- ut limiting responses [33]. Approval was granted by the esearch and Development centre attached to the Primary are Trust that was responsible for the ERS, and by both thics committees of the lead researcher’s Higher Education nstitution and NHS employer.

ample population and recruitment

The study context was an exercise programme provided hrough an ERS based at a South London leisure centre, upervised by a chartered physiotherapist and specific to peo- le with neurological conditions. The ERS is defined in this tudy as “the referral to, and uptake of, a physiotherapist- ed exercise programme”. Individually tailored gym-based xercise took place in a group format, twice weekly, for up o three months. Participants were generally referred by a hysiotherapist at least six months after their stroke.

The study population included people with a primary diag- osis of stroke who had attended the ERS within the previous wo years, over which recall of experiences was considered ealistic. To capture varied experiences, attendance levels and RS completion were not prerequisites for selection. Poten-

ial participants were identified by the lead researcher (HS), sing NHS patient records and were sent invitation letters, nformation sheets and consent forms. Those returning con- ent forms were telephoned to screen for factors that would ender an in-depth interview unfeasible, including inability o engage in conversation, a voice potentially incomprehensi- le on audiotape, or inability to recall their ERS experiences. articipants were offered interviews at their venue of choice. t was thought unethical to undertake further measures to ncrease recruitment rate.

rocedure

The lead researcher (HS) was a female chartered phys- otherapist with 2 years’ general experience, and 3 years pecialising in neurology. She was employed at the ERS s the primary clinician, but only after participants in this

tudy had been discharged, minimising impacts from prior nowledge or relationships. Participants were aware of her ackground but the importance of their views and experiences as emphasised.

338 H. Sharma et al. / Physiotherapy 98 (2012) 336–343

Table 1 Summary of topic guide.

Topic Example question

Demographics Confirm age, time of stroke, when attended ERS Meaning of exercise to individual What do you think of when I say ‘exercise’? Past experience of exercise Before your stroke, how active were you? What sorts of things did you do? Impact of stroke on exercise behaviour How did your stroke affect the exercise that you could do? Experience before attending ERS Before you went to the ERS, what did you think it would be like? Why do you think you thought that? Experience of ERS How did you feel about exercising in this way?

Is there anything you didn’t enjoy? Why was that? Transition from ERS to independent exercising Did you have any plans to carry on exercising? How did that go? Current status Is there anything from your experience of ERS that affects your life now? Why is that? The future Do you have any future plans when it comes to exercise?

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RS: exercise referral scheme.

An interview topic guide was developed to address the tudy aims, informed by relevant literature. The questions, ummarised in Table 1, explored experiences of accepting a eferral to an exercise programme, participating, and percep- ions of any impacts. Participants’ experiences of exercise efore stroke, and their understanding of the word ‘exer- ise’ were explored. Maintenance of exercise participation fter programme completion was also addressed, based on oncerns raised by Morgan [34]. Questions were structured hronologically to aid recall, and phrasing provided scope or additional areas to emerge [35]. Only the interviewer and nterviewee were present at each interview.

A video-recorded, role-played pilot interview enabled efinement of the interview technique and further devel- pment of the topic guide. Review of this pilot interview dentified possible influences on the credibility of the partici- ants’ responses. This reflexive process continued throughout ata collection through a research diary to minimise effects iases and presuppositions [32].

ata analysis

Interviews were audiotaped and transcribed verbatim. Par- icipant verification of initial interpretation took place using nterview summaries. In-depth analysis used an iterative cod- ng process, moving towards greater levels of abstraction 36]. Text was first read and re-read by the lead researcher, nd annotated with labels that described concepts (first level hemes). Similar labels were grouped where they described elated ideas, and given another label (second level theme). urther abstraction led to the creation of categories (third

evel themes), and finally a master theme (Table 2). This as iterative, as text from all interviews was analysed. Anal- sis was considered complete when no new themes were efined and all relevant text was incorporated in a theme.

word processing package was used rather than a qualita- ive data analysis programme; while the latter is useful for

ata management, it does not perform the thinking, and can reate distance from the text [37]. A sample of themes and ontributing text units was reviewed by an experienced qual- tative researcher (CB); discussion led to consensus between

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esearchers, which enhanced dependability of the analysis 38].

esults

articipant characteristics

Of forty-one invited participants, 12 consented, three of hom could not be included: one was not contactable, one as not sufficiently fluent in English, and one could not

ecall ERS participation. Interviewed participants included our female and five male community-dwelling adults (mean ge 51; range 37–61 years), who had had a stroke one to our years previously. Four were of White English, one White rish, and four Black African ethnic origins. Interviews lasted 5–80 minutes. Six occurred in participant’s homes, one at heir workplace, and two at a hospital office.

ategories

Four categories emerged: exercise engagement (i.e. rel- vant behavioural changes); improvement (i.e. individuals’ nterpretations of physical and psychological improvements); ontrol (changing views regarding who was responsible for ncreased feelings of independence); and finally, confidence i.e. a growing sense of self-confidence in the individual’s bility to exercise). The account focuses on varied experi- nces, rather than consensus views. Pseudonyms have been sed throughout.

xercise engagement Between the stroke and ERS, participants recalled slow-

ng down and making adjustments to lifestyle, work and ocial roles. This pace-change appeared to be challenged by RS attendance, which facilitated increases in activity levels ithin sessions, and outside the ERS:

Before I started going [to the exercise referral scheme], I asn’t thinking about exercise, and I wasn’t thinking about nything, other than sit at home, eat and watch television. hen I started, at least they gave me that ability, they gave

H. Sharma et al. / Physiotherapy 98 (2012) 336–343 339

Table 2 Definitions of themes and categories.

Product of data analysis Definition Example

1st level themes An interpretation of descriptive information (age, ethnicity, etc.) and coding (labelling text according to subject); a reflection on meaning

Specific text was grouped, according to how participants viewed relationships with the physiotherapist. These were further labelled to reflect the interpretation that some text focused on the ‘personal service’ from the physiotherapist, and other text described experiences of ‘partnership’ – these were designated 1st level themes

2nd level themes Relationships between first level themes Further analysis of ‘personal service’ revealed that it was linked to participants’ observations of the personal qualities of the physiotherapist. These relationships formed 2nd level themes, e.g. ‘A personal service linked to the physiotherapist’s caring quality’

3rd level themes/categories

Collections of second level themes united by a central idea The idea of ‘confidence’ transcended many 2nd level themes and their components. ‘Confidence’ linked related ideas, including ‘the physiotherapist’, ‘the group’, ‘social situations’, ‘the rehabilitation setting’

Master theme A general pattern or overarching theme that is illustrated by “ERS as a catalyst for regaining independence”. Categories

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e that push . . . So thereafter, I just cook up something in my ead, go down the stairs or go down the street.’ [Louise]

Increased activity generated feelings of normality and ndependence:

Because when I do exercise, when I go out, it puts me back o normal. And when I see others walking, what would make e not walk? I am not disabled. The stroke has not made me isabled, so I walk.’ [Mary]

mprovement Participants identified improvements following ERS par-

icipation, predominantly in fitness, strength and movement:

If I didn’t go [to the exercise referral scheme] . . . it would ake a long time for me to be moving around . . . I gained more trength . . . [the exercise referral scheme] really helped my oving, my walking, how I am doing everything.’ [Beth]

Several participants also identified ‘immediate’ improve- ents to mood following the exercise sessions, perceived as

vidence that the stroke was ‘going away’ and that they were getting better’. Positive feelings of happiness and enjoyment ere described, and exercise became a source of pleasure in

tself:

When I finish exercising and I feel so good, so content. . . By he end of the day you feel good, you know, you say ‘I feel ood, my health is coming back’ in your head.’ [Peter]

ontrol Interestingly, participants attributed perceived improve-

ents during initial rehabilitation to external factors, such as he physiotherapist, God, the consultant, or the health service n general, and perceived themselves as dependent:

When I’d gone walking, I’d always had somebody from the ard going out with me and holding me up, or I was in the heelchair and I hated it.’ [Jim]

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were seen as personal benefits of the ERS that were connected, contributing to greater normality and independence

When recalling ERS participation, interviewees expressed he importance of their own personal qualities to successful ecovery and increasing independence, attributing improve- ents to internal factors such as motivation, willpower and

elf-determination:

The physio is something else, the exercise programme is omething else, you yourself willing to do something for your- elf, and having that willpower to proceed and progress what ou want to do is another thing.’ [Louise]

onfidence Low confidence was described as a barrier in relation to

nitial ERS attendance. Attitudinal barriers in the form of eservations about the gym environment were described, as ell as physical barriers en route from home to the leisure

entre.

My own sense of . . . my self-esteem was very low anyway, he fact that I couldn’t physically do things I used to take or granted, and I don’t particularly like that kind of macho ulture anyway. I wouldn’t want to expose myself to it. I’d ave been worried about people poking fun.’ [Tony]

Initially when I was discharged from hospital, I want to go o the gym. When I come out from my house and I look at the tairs, it’s like I want to fall over, I go back inside and shut he door.’ [Louise]

Confidence that was specifically related to exercise ncreased within the ERS, facilitated by the physiotherapist nd group dynamic:

I mean me, all I can say is that I had determination. I didn’t ave the confidence, but I had determination and they [phys- otherapists] gave me the confidence. But when I saw I could

tart to do a thing, that was it. Once I got to start doing it I ooked at my sheet and saw I did that little bit more than last eek.’ [Jim]

340 H. Sharma et al. / Physiotherapy 98 (2012) 336–343

Table 3 An overview of the master theme and contributing categories and themes.

Master theme Constituent categories and definitions Second level themes contributing to the category

‘ERS as a catalyst for regaining independence’

1a. Exercise engagement: behavioural changes regarding exercise

1ai. Links between confidence and exercise engagement

1aii. Links between physical improvement and exercise engagement 1aiii. Exercise engagement and perceived exercise restrictions or opportunities 1aiv. Reflections on the self and exercise engagement

1b. Control: participants’ changing views on who/what was responsible for them gaining independence

1bi. Links between the rehabilitation setting and perceptions of control 1bii. Varying roles of the physiotherapist 1biii. Perceptions of control and exercise behaviour 1biv. Perceptions of control and the discharge procedure

1c. Confidence: the progression of feelings of self-confidence and beliefs in exercise ability

1ci. Links between the rehabilitation setting and confidence

1cii. Links between perceptions of the physiotherapist and confidence 1ciii. Links between perceptions of the group and confidence 1civ. Links between independence, emotions and confidence 1cv. Confidence and social situations

1d. Improvement: Physical and psychological improvements and their meanings to participants

1di. Links between improvement and beliefs about the exercise programme 1dii. Links between improvement and beliefs about exercise generally

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Increased confidence also affected more general social and ccupational activities:

I was ashamed, limping all the time and using a walking tick. But when I got there, I saw people that were even older nd even younger than me and they were there for numerous easons. And these are people that say, when we finish using he gym, ‘I am going to the high street for window shopping’, nd I tag along. . . At times, I just walk into the shopping entre with confidence. . ..’ [Louise]

One participant expressed a belief that the ERS con- ributed to increased confidence, and felt able to return to ork:

I started work and I was able to start where I left off. . . nd if I had not gone through this I would not have had the onfidence. . . It is not the medication that has made me better, t is the exercise. . .’ [Peter]

aster theme

The categories emerging from the data describe a jour- ey through engagement with exercise after stroke, yielding hysical and psychological improvements, increased feelings f personal control, and raised confidence. These personal evelopments appeared to be linked in their contributions to egaining independence. Thus, the master theme that emerged

as entitled: ‘ERS as a catalyst for regaining independence’. These results are summarised in Table 3, demonstrating

he audit trail from second level themes, through categories, o the master theme.

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1diii. Links between beliefs and feelings about exercise 1div. Impacts of beliefs and feelings about exercise on exercise engagement

iscussion

ain findings

The findings from this study suggest that the ERS encour- ged participants to become more active within and outside he sessions. Participants reported physical and psycholog- cal improvements, including fitness, strength, movement,

ood and enjoyment. Locus of control appeared to shift rom predominantly external during initial rehabilitation, o more internal during the ERS. Initial barriers to exer- ise participation had to be overcome, including concerns bout getting to the venue, low self-confidence, and feelings f self-consciousness. Generic and PA-specific self efficacy ncreased, and the group format appeared to induce feelings f independence and normality.

Reduced independence is a key problem after stroke with wo thirds of people experiencing limitations in at least one ctivity of daily living five years after stroke [39]. The current tudy revealed that participants had been involved in a slow rocess of regaining independence, in which the ERS acted s a catalyst, enhancing perceptions of greater normality, onfidence and independence.

These findings contribute to the literature on exercise after troke; one systematic review highlighted the lack of research elating to effects of exercise on disability, dependence, ood, self-efficacy and locus of control [10]. The current

ndings resonate with other qualitative work, where stroke urvivors reported that exercise enhanced physical function, mpowerment and confidence [27,29]. When looking beyond

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iterature specific to stroke, the significance of ERS participa- ion was also identified by one study in an ageing population nd one in people with mental ill-health [40,41]. Recovery of lements of the self was described, as participants were said o ‘reconnect with their human potential’ [40] and ‘reclaim a ense of personhood’ [41]. This may be particularly important or stroke survivors who have experienced dramatic changes n their physical, emotional and social worlds. In the current tudy, one participant reported feeling ‘completely lost . . . he stroke took my life away from me; everything I could do, verything that meant anything to me’ [David]. Evidently, uch qualitative data deepen our understanding of the impact f exercise on the self as a whole.

All consenting participants in this study experienced pos- tive changes in their physical and psychological well-being, ome up to four years post-stroke. This supports UK national linical guidelines for stroke [12–14], which advocate the romotion of an active lifestyle where possible. The ERS rovides one strategy to this effect and further collabora- ion between physiotherapy and local health and leisure ervices is required to facilitate access to exercise after stroke 14,42–44].

mplications of findings for exercise after stroke referral chemes

Service development requires evidence of efficacy, and xisting ERSs have been criticised for using primarily mpairment-orientated outcomes (e.g. blood pressure), and eing insufficiently client-centred [18]. The current study uggests that ERS evaluation would benefit from addi- ional measures relating to mood, self-efficacy and locus of ontrol.

Low recruitment and attendance must also be addressed 34]. A survey found that the three most common barriers o exercise after stroke were programme cost, lack of trans- ortation and lack of knowledge about local exercise facilities 45]. In the current study, some participants said they were ncomfortable around able-bodied exercisers, which could e exacerbated in a gym setting where the focus is often n physical perfection. To reduce perceived barriers to exer- ise after stroke, opportunities to exercise in a peer group and olutions for environmental barriers (e.g. providing transport) hould be offered where possible, as recommended in the best ractice guidelines [44].

tudy limitations

The credibility of the data must be considered. The sam- le was small, with a low response rate, possibly due to ecruitment by mail. Although not ideal, this was approved on thical review. However, the sample was consistent with the

tudy design and aims of increased depth of insight that can e transferred to similar contexts, rather than generalisabil- ty of results [46]. Data were extensive, with 45–80 minutes f interview per participant. While data saturation through

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epeated interviews was not possible within the scope of the tudy, analytical saturation was achieved [46].

The sample was not necessarily representative of the ider stroke population, with varied demographic charac-

eristics and a low mean age, which may have affected RS uptake. Similar positive perspectives on ERS partici- ation were expressed, which may have been influenced by ocial desirability and convenience sampling. The views of hose who did not accept an invitation to the ERS were not ddressed, and future research should use purposive sam- ling to explore successful and unsuccessful experiences. It ould also be valuable to collect data relating to time since articipation and frequency of participation.

The ethnic diversity was representative of the local area 47], but in some cases, vocabulary and expression may have ffected interpretation of responses. A field diary was used in rder to reflect on possible influences during data collection nd analysis.

There were insufficient resources to provide communica- ion support, and regretfully, persons with memory impair-

ents or communication difficulties were therefore excluded, s is frequently the case. The resulting bias is acknowledged.

Five out of nine participants returned and agreed with the nterview summaries, enhancing credibility of initial inter- retation. Respondent validation of the final themes was onsidered less useful because not all themes related to the iews of every participant [48]. Although the lack of verifica- ion of four summaries limits credibility, it was not considered thical to pursue the missing summaries. On balance, the esults have credibility and were generated through a rigor- us process. The relevance of these findings to further settings ust be evaluated by the reader, using the contextual and

emographic information provided [32].

onclusions

This study aimed to explore stroke survivors’ experiences f exercise in the context of a community-based ERS. Par- icipants perceived the scheme as an important driver in he process of regaining independence, as they experienced mprovements in physical and psychological function. They lso reported a shift from an external to a more internal locus f control and improved general and exercise-specific self- fficacy, which carried over into activity outside the exercise essions. The findings from this – albeit small-scale – study upport exercise referral schemes as a method for increas- ng physical activity after stroke. However, some barriers o exercise participation also emerged, and further research s required to explore how uptake and continued exercise ngagement after stroke can be optimised.

cknowledgements

The following are gratefully acknowledged: the contri- ution of the study participants, and the assistance of Helle

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ampson (Clinical Lead Physiotherapist, Southwark Primary are Trust) with the pilot interview.

thical approval: King’s College Hospital Research Ethics ommittee (Ref. No. 06/Q0703/210) and Queen Margaret niversity, Subject Area Ethics Panel, no ref. number.

onflict of interest: The authors report that there were no onflicts of interest.

eferences

[1] Mackay J, Mensah G. Atlas of heart disease and stroke. Geneva: World Health Organisation; 2004, available at: http://www.who.int/ cardiovascular diseases/resources/atlas/en/ [accessed 2010 November 16].

[2] Saka RO, McGuire A, Wolfe CDA. Economic burden of stroke in Eng- land. London: University of London; 2003, available at: http://www. nao.org.uk/publications/0506/reducing brain damage.aspx [accessed 2010 November 16].

[3] Michael KM, Allen JK, Macko RF. Reduced ambulatory activity after stroke: the role of balance, gait and cardiovascular fitness. Arch Phys Med Rehabil 2005;86:1552–6.

[4] Roth EJ. Heart disease in patients with stroke: incidence, impact, and implications for rehabilitation. Part 1: classification and prevalence. Arch Phys Med Rehabil 1993;74:752–60.

[5] Marigold DS, Eng JJ, Dawson AS, Ingis JT, Harris JE, Gylfadottir S. Exercise leads to faster postural reflexes, improved balance and mobil- ity, and fewer falls in older persons with chronic stroke. J Am Geriatr Soc 2005;53:416–23.

[6] Mayo NE, Wood-Dauphine S, Ahmed S. Disablement following stroke. Disabil Rehabil 1999;21:258–68.

[7] Truelsen T, Piechowski-Jóźwiak B, Bonita R, Mathers C, Bogous- slavsky J, Boysen G. Stroke incidence and prevalence in Europe: a review of available data. Eur J Neurol 2006;13:581–8.

[8] Department of Health. National stroke strategy. London: Depart- ment of Health; 2007, available at: http://www.dh.gov.uk/en/ Publicationsandstatistics/Publications/PublicationsPolicyAnd Guidance/DH 081062 [accessed 2010 November 16].

[9] Caspersen CJ, Powell KE, Christenson GM. Physical activity, exer- cise and physical fitness: definitions and distinctions for health-related research. Public Health Rep 1985;100:126–30.

10] Saunders DH, Greig CA, Mead GE, Young A. Physical fitness training for stroke patients. Cochrane Database Syst Rev 2009;(4), doi:10.1002/14651858.CD003316.pub3 [Art. No.: CD003316].

11] Mead G, Greig CA, Cunningham I, Lewis SJ, Dinan S, Saunders DH, Fitzsimons C, Young A. STroke: a randomised trial of exercise or relaxation (STARTER). J Am Geriatr Soc 2007;55:892–9.

12] Royal College of Physicians. Stroke guidelines: national clinical guidelines for stroke. 3rd ed. London: Royal College of Physicians; 2008.

13] Scottish Intercollegiate Guidelines Network. SIGN guideline 108: management of patients with stroke or TIA: assessment, inves- tigation, immediate management and secondary prevention: a national clinical guideline. Edinburgh: Scottish Intercollegiate Guidelines Network; 2008, available at: http://www.sign.ac.uk/ guidelines/fulltext/108/index.html [accessed 2010 November 16].

14] Scottish Intercollegiate Guidelines Network. Guideline 118: manage- ment of patients with stroke: rehabilitation, prevention and management of complications, and discharge planning: a national clinical guide- line. Edinburgh: Scottish Intercollegiate Guidelines Network; 2010,

available at: http://www.sign.ac.uk/guidelines/fulltext/118/index.html [accessed 2010 November 16].

15] Touillet A, Guesdon H, Bosser G, Beis J-M, Paysant J. Assessment of compliance with prescribed activity by hemiplegic stroke patients

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py 98 (2012) 336–343

after an exercise programme and physical activity education. Ann Phys Rehabil Med 2010;53:250–65.

16] The Information Centre [Internet]. Statistics on obesity, physical activity and diet. UK: National Health Service; 2006, available at: http://www.ic.nhs.uk/webfiles/publications/opan06/OPAN%20bulletin %20finalv2.pdf [accessed 2010 November 16].

17] Department of Health. Exercise referral systems: a national quality assurance framework. London: Department of Health; 2001, available at: http://www.dh.gov.uk/en/Publicationsandstatistics/ Publications/PublicationsPolicyAndGuidance/DH 4009671 [accessed 2010 November 16].

18] Dugdill L, Graham RC, McNair F. Exercise referral: the public health panacea for physical activity promotion? A critical perspective of exer- cise referral schemes; their development and evaluation. Ergonomics 2005;48:1390–410.

19] Taylor AH, Doust J, Webborn N. Randomised controlled trial to exam- ine the effects of a GP exercise referral programme in Hailsham, East Sussex, on modifiable coronary heart disease risk factors. J Epidemiol Commun Health 1998;52:595–601.

20] Halbert JA, Silagy CA, Finucane PM, Withers RT, Hamdorf PA. Phys- ical activity and cardiovascular risk factors: effect of advice from an exercise specialist in Australian general practice. Med J Aust 2000;173:84–7.

21] Lamb SE, Bartlett HP, Ashley A, Bird W. Can lay-led walk- ing programmes increase physical activity in middle-aged adults? A randomised controlled trial. J Epidemiol Commun Health 2002;56:246–52.

22] Harrison RA, Roberts C, Elton PJ. Does primary care referral to an exer- cise programme increase physical activity 1 year later? A randomised controlled trial. J Public Health 2004;27:25–32.

23] Williams NH, Hendry M, France B, Lewis R, Wilkinson C. Effective- ness of exercise-referral schemes to promote physical activity in adults: systematic review. Br J Gen Pract 2007;57:979–86.

24] Trost SG, Owen N, Bauman AE, Sallis JF, Brown W. Correlates of adults’ participation in physical activity: review and update. Med Sci Sports Exerc 2002;34:1996–2001.

25] Department of Health. The expert patients programme. London: Department of Health; 2007, available at: http://webarchive. nationalarchives.gov.uk/+/www.dh.gov.uk/en/Aboutus/Ministersand DepartmentLeaders/ChiefMedicalOfficer/ProgressOnPolicy/Progress BrowsableDocument/DH 4102757 [accessed 2010 November 16].

26] The Scottish Government. Better together: Scotland’s patient expe- rience programme: patient priorities for inpatient care report no. 5/2009; 2009, available at: http://www.scotland.gov.uk/Publications/ 2009/07/08114927/0 [accessed 2010 November 16].

27] 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;76:73–80.

28] Harrington R, Taylor G, Hollinghurst S, Reed M, Kay H, Wood VA. A community-based exercise and education scheme for stroke survivors: a randomized controlled trial and economic evaluation. Clin Rehabil 2010;24:3–15.

29] Reed M, Harrington R, Duggan A, Wood VA. Meeting stroke survivors’ perceived needs: a qualitative study of a community-based exercise and education scheme. Clin Rehabil 2010;24:16–25.

30] Wiles R, Demain S, Robison J, Kileff J, Ellis-Hill C, McPherson K. Exercise on prescription schemes for stroke patients post-discharge from physiotherapy. Disabil Rehabil 2008;30:1966–75.

31] Crotty M. The foundations of social research. London: Sage Publica- tions; 1998.

32] Grbich C. Qualitative research in health. London: Sage Publications; 1999.

33] DiCicco-Bloom B, Crabtree BF. The qualitative research interview.

Med Educ 2006;40:314–21.

34] Morgan O. Approaches to increase physical activity: reviewing the evidence for exercise-referral schemes. Public Health 2005;119: 361–70.

iothera

[

[

[

[

[

[

[

[

[

[

[

[

[

H. Sharma et al. / Phys

35] Britten N. Qualitative research: qualitative interviews in medical research. BMJ 1995;311:251–3.

36] Richards L. Handling qualitative data: a practical guide. London: Sage Publications; 2005.

37] Auerbach C, Silverstein L. Qualitative data: an introduction to coding and analysis. New York: NYU Press; 2003.

38] Mays N, Pope C. Qualitative research: rigour and qualitative research. BMJ 1995;311:109–10.

39] Wilkinson PR, Wolfe CD, Warburton FG. A long-term follow-up of stroke patients. Stroke 1997;28:507–12.

40] Stathi A, McKenna J, Fox KR. The experiences of older people participating in exercise referral schemes. J R Soc Promot Health 2003;124:18–23.

41] Crone D, Smith A, Gough B. ‘I feel totally at one, totally alive

and totally happy’: a psycho-social explanation of the physical activity and mental health relationship. Health Educ Res 2005;20: 600–11.

42] Mead GE. Exercise after stroke. BMJ 2009:247–8. [

Available online at www.s

py 98 (2012) 336–343 343

43] Morris JH, Williams B. Optimising long-term participation in physical activities after stroke: exploring new ways of working for physiother- apists. Physiotherapy 2009;95:227–33.

44] Best C, van Wijck F, Dinan-Young S, Dennis J, Smith M, Fraser H, Donaghy M, Mead G. Best practice guidance for the development of exercise after stroke services in community settings. Edinburgh: Edin- burgh University; 2010, available at: http://www.exerciseafterstroke. org.uk/ [accessed 2010 November 16].

45] Rimmer JH, Wang E, Smith D. Barriers associated with exercise and community access for individuals with stroke. J Rehabil Res Dev 2008;45:315–22.

46] Krefting L. Rigor in qualitative research: the assessment of trustwor- thiness. Am J Occup Ther 1991;45:214–22.

47] Commission for Racial Equality [Internet]. London, UK; 2007, avail-

able at: http://www.cre.gov.uk/diversity/map/london/southwark.html [accessed 2007 May 11].

48] Koch T, Harrington A. Reconceptualising rigour: the case for reflexiv- ity. J Adv Nurs 1998;28:882–90.

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