Introduction

The benefits of exercise after stroke described in chapter 5 should encourage stroke survivors to participate in an exercise programme to improve their health and wellbeing. Taking up exercise is an example of a health behaviour, which is a behaviour related to an individual’s health status (Ogden 2004). However, taking up a health behaviour and maintaining this in the longer term is a well-known challenge for healthy people (Dugdill et al. 2005, Williams et al. 2007), and so it is reasonable to assume that is also likely to be a challenge for stroke survivors.

For example, in the STARTER trial (Mead et al. 2007) just over half the number of eligible patients indicated that they wished to participate, and some who initially agreed changed their minds. For those who did agree to participate, class attendance was excellent during the 12-week programme (chapter 5), indicating high levels of motivation. However, at the end of the trial, when the provision of formal exercise classes ceased, some of the participants did not continue to exercise.

These findings raise some interesting questions. Why do some people choose to participate in exercise and others don’t? Why do some people who indicate a desire to participate in exercise change their minds? Why do people who participate in a programme of exercise training stop exercising once the programme has come to an end? Furthermore, since the benefits of exercise diminish when the training comes to an end (Mead et al. 2007), how can stroke survivors be encouraged to continue to be physically active beyond formal training programmes?

In this chapter, we will describe what we know about the barriers and motivators to exercising after stroke and explore theoretical concepts that describe and explain behaviour and behaviour change, in particular self-efficacy and the Transtheoretical Model (which includes stages of change). We will then explore how these concepts may apply to enhancing exercise behaviour amongst stroke survivors through techniques including motivational interviewing and goal setting. Finally, we will give exercise and health professionals some suggestions about how to use this information to help stroke survivors to start exercising and to continue exercising in the longer term.

Barriers and motivators to exercise

The evidence that shows benefits of physical fitness training for stroke survivors (chapter 5) has led to recommendations that exercise training should be provided as part of the post-stroke pathway (Best et al. 2010, Royal College of Physicians 2008, Scottish Government 2009, Scottish Intercollegiate Guidelines Network 2010). Participation in exercise may be perceived to be difficult by some stroke survivors, many of whom are sedentary (Shaughnessy et al. 2006). Sedentary behaviour patterns may arise as a direct result of the neurological effect of stroke (e.g. paresis which makes walking more difficult), or it may be that there are psychological barriers to exercise (e.g. fear of falling). Additionally, stroke survivors may not have been physically active prior to their stroke and so undertaking exercise training for the first time after a stroke may pose a considerable challenge. In addition to these personal barriers, there may be environmental barriers that reduce personal choice and impede participation. These may include inaccessible programmes, lack of community recreation facilities, transport difficulties, architectural barriers, system and policy barriers and social attitudes (Rimmer et al. 2000).

Although there are only a handful of small studies exploring barriers and motivators to exercise after stroke, these bring some important insights into the factors influencing exercise participation.

Barriers to exercise participation after stroke

One survey from North America with a group of 83 stroke survivors identified a number of barriers to exercise. The most commonly reported were: the cost of the programme (61% of respondents), lack of awareness of a fitness centre in their area (57%), no means of transportation (57%), no knowledge of how to exercise, whilst the least common barriers were lack of interest (16%), lack of time (11%) and concern that exercise would worsen their condition (1%) (Rimmer et al. 2008). Damush et al. (2007) conducted three focus groups with 13 stroke survivors recruited from an existing research study and found that the barriers preventing exercise participation were physical impairments resulting from the stroke, lack of motivation and lack of available facilities for exercise. Hammel et al. (2006), in a participatory action research study with 20 stroke survivors recruited from the community, identified both personal and environmental barriers; personal barriers related to physical and cognitive impairment including difficulty walking, fatigue and pain, motor impairments related to stroke, inattention and memory loss; environmental barriers included physical access, transportation and lack of social support. Robison et al. (2009) explored the barriers that prevented stroke survivors from returning to valued activities such as employment, domestic and social roles. Personal barriers were linked to physical and cognitive impairment, while environmental barriers included lack of adaptations to improve safety on entering or leaving the home, lack of social support and professional help.

Motivators to exercise participation after stroke

One qualitative study exploring the motivation of 29 stroke survivors, who were participating in a treadmill study (Resnick et al. 2008), highlighted the importance of personal goals (including increased ability in walking and stair climbing), physical benefits (feeling stronger, walking better and improved balance) and psychological benefits (including improvement in mood and the sense of independence). Another study demonstrated that social support from family, fellow stroke survivors and professionals facilitated exercise participation (Damush et al. 2007). Social and professional support and adaptability of the individual were also found to be helpful in resuming valued activities post stroke (Robison et al. 2009). An Australian qualitative study looked at the needs and perceptions of stroke survivors attending a 1 hour weekly exercise programme in the community. Ten stroke survivors in the chronic stage after stroke were interviewed. The findings suggest that a maintenance exercise class built confidence in participants, increased motivation and provided opportunity for both exercise participation and socialisation (Patterson and Ross-Edwards 2009).

Relevance of this knowledge to understanding exercise participation

Although the studies described above were small, and some recruited patients from existing studies (and thus there may be inherent biases), the themes that emerge from this body of evidence include:

• The importance of barriers, both personal and environmental, that influence exercise participation. Personal barriers include fear of recurrent stroke, fatigue, pain and perceived lack of time, while environmental barriers include lack of access to suitable facilities and transport. Both types of barriers need to be considered when providing Exercise after Stroke services and setting up new services.

• The importance of social support in helping the stroke survivor to exercise. Thus, exercise and health professionals involved in Exercise after Stroke services may need to consider how best to involve family members and/or carers in supporting the stroke survivor to exercise. Furthermore, exercising in a group with other stroke survivors is likely to enhance confidence and a sense of belonging; these positive experiences of exercising with other stroke survivors who were ‘in the same boat’ were also described in other studies (Carin-Levy et al. 2009, Mead 2009, Reed et al. 2010).

• Achievement of personal goals. These may include physical goals, e.g. improved walking, or return to work. Later in this chapter we will explore what we know about goal setting in stroke rehabilitation, and how to apply this to stroke survivors wishing to exercise.

Other possible influences on exercise behaviour in stroke survivors

Exercise behaviour is complex (Biddle and Mutrie 2008) and whether stroke survivors engage in exercise or not will be influenced by their attitudes to exercise. These may be long-standing beliefs or beliefs that have changed as a result of the stroke. Their attitudes are likely to be influenced to some extent by the views of family, friends and professionals.

Whether we engage in or avoid physical activity is influenced by our knowledge, beliefs and feelings about exercise. This informs our attitude towards exercise participation; if our attitude is positive, we are more likely to engage in regular physical activity. Attitude can be defined as a psychological tendency to behave in a particular way. It is hypothetical and, like other psychological constructs such as personality and motivation, not open to direct observation. Attitudes can be inferred from verbal or non-verbal responses relating to feelings, beliefs and exercise behaviours. Exercise professionals could use carefully phrased questions to gain a better insight into individual stroke survivors’ attitudes (e.g. how will exercise help you to do the things you want to do?) and confidence (self-efficacy) towards exercise participation (e.g. how confident are you that you will be able to do this exercise by yourself?).

Theoretical explanations o exercise behaviour

Numerous theories and models have been developed to try and describe, explain and predict people’s health behaviours (Connor and Norman 2005). Theories of health behaviour in general, and exercise behaviour in particular, have been applied by health and exercise psychologists as well as health promotion specialists to influence behaviour change in clinical and non-clinical populations for more than 30 years (Connor and Norman 2005). More recently, health-care professionals have used some of these theories to inform self-management interventions for people with long-term conditions (Jones 2006), for example in enhancing confidence or self-efficacy (Jones et al. 2009) and goal setting in the context of rehabilitation (Scobbie et al. 2009).

The theories introduced in this chapter have been selected for their relevance to stroke survivors as currently supported by the literature. However, because health and exercise psychology applied to stroke rehabilitation is a relatively new area of research, there are still many questions about how these theories apply to enhancing exercise behaviour after stroke.

Self-Efficacy

Self-efficacy is a psychological construct that has been defined as ‘the belief in one’s capabilities to organise and execute the course of action required to produce given attainments’ (Bandura 1997, p. 3). It is a measure of confidence and is linked to a personal sense of control. If people believe that they can take action to solve a problem, they are more likely to do so and they will be more committed to the task (Bandura 1977). Self-efficacy includes holding a personal belief about the outcome of a particular behaviour or action and also the ability to make an accurate judgement on the skills required to carry out the behaviour. Self-efficacy beliefs are linked to the degree of effort put into achieving a task and to the perseverance to continue with the task in the face of adversity (Bandura 1997).

Four sources of information have been described that both appraise and enhance self-efficacy for any particular behaviour (Bandura 1997):

1. Performance accomplishments: successful performance of the behaviour is likely to increase self-efficacy, while repeated unsuccessful performance tends to lower self-efficacy, especially if this happens early on.

2. Vicarious experience: this refers to seeing others who are in a similar situation successfully perform the behaviour and comparing one’s own performance to theirs.

3. Verbal persuasion: encouragement from others which demonstrates their belief that the person is capable of undertaking the behaviour.

4. Emotional arousal: self-efficacy in dealing with a task or situation is partially judged based on signs of stress. Reducing such symptoms and correcting their misinterpretation may enhance self-efficacy.

A recent systematic review and meta-analysis of 27 studies with 5501 healthy adults analysed interventions aimed at changing self-efficacy in the context of promoting lifestyle and recreational physical activity (Ashford et al. 2010). The findings showed that feedback in which a participant’s performance was compared to that of others was the most influential component to increase self-efficacy related to physical activity. Also, interventions that incorporated vicarious experiences were more successful in this respect than ones that did not. Interestingly, verbal persuasion alone was insufficient to increase either self-efficacy or exercise behaviour.

How do the findings from this meta-analysis compare to other research in stroke? In two studies exploring stroke survivors’ views on a community-based exercise scheme, participants commented positively on being in a stroke-specific group, which enabled them to learn from each other and compare their performance with that of others (Reed et al. 2010, Sharma et al. 2011). This suggests that stroke-specific exercise settings provide opportunities for vicarious learning, which may be instrumental in rebuilding self-efficacy. The finding that verbal encouragement alone was not sufficient echoes findings from a multinational randomised controlled trial with 314 stroke survivors; Boysen et al. (2009) found that repeated encouragement and verbal advice alone did not increase physical activity. Clearly, interventions to increase physical activity after stroke need to comprise more than just verbal support.

With the aim to increase perceived action control, Sniehotta et al. (2005) in a longitudinal study of 240 cardiac rehabilitation patients found that psychological interventions including detailed action plans, barrier-focused mental strategies and diary keeping resulted in more physical activity at follow-up, and better adherence to recommended levels of exercise intensity. Self-regulatory skills such as planning and action control also improved. The authors concluded that targeting self-regulatory skills can help post-rehabilitation cardiac patients to reduce behavioural risk factors and facilitate healthier lifestyle changes. These findings may well apply to stroke survivors, although this will require further research.

Psychological interventions for stroke survivors, based on the theory of self-efficacy, have been developed to increase confidence, facilitate recognition of personal efforts, enable goal setting and increasing exercise behaviour (Johnston et al. 2007, Jones et al. 2009, Jones and Riazi 2011, Shaughnessy and Resnick 2009). Support for the link between self-efficacy and exercise behaviour was found by Shaugnessy et al. (2006). Their survey of 312 stroke survivors found that self-efficacy and outcome expectations (i.e. beliefs that certain outcomes will be produced by personal action) were positively linked to reported exercise behaviour. Additionally, those who had exercised before their stroke were more likely to participate in regular exercise post stroke, while doctor’s recommendations influenced participation. However, taken together, these factors only explained 33% of the total variance in reported exercise behaviour, suggesting that there must be other factors that predict exercise participation after stroke.

The influence of self-efficacy on outcomes after stroke and the effectiveness of self-management strategies based on self-efficacy were examined in a systematic review by Jones and Riazi (2011). A total of 18 studies with 1418 participants investigated the influence of self-efficacy on rehabilitation outcomes, indicating that self-efficacy impacts on quality of life, mood, independence in activities of daily living, as well as aspects of physical functioning such as walking. A total of four studies with 343 participants explored the effectiveness of self-management strategies, based on self-efficacy theory. Only two randomised controlled trials were included, so the findings need to be interpreted with caution. Although there was some support for self-management strategies based on self-efficacy principles, many questions still remain, including the best way to deliver such interventions to stroke survivors (e.g. group-based or individual).

Self-efficacy is a critical determinant of self-regulation, a term described by Bandura (1986) as an individual’s evaluation of their own actions against identified expectations or desires, which allows them to modify their future behaviour. Based on this function, it will be important to establish people’s view of what they want to achieve and what they think they can achieve. For example, a stroke survivor may be motivated to exercise to improve their walking, if they perceive a discrepancy between their current abilities and what they would like to achieve. However, their motivation may be dampened if they don’t perceive themselves as being able to achieve an improvement. Motivational interviewing is one technique that exercise professionals might want to use to establish stroke survivors’ views and enhance their self-regulatory skills. This technique is described later in the chapter.