Feasibility of integrating survivors of stroke into cardiac rehabilitation: A mixed methods pilot study

Abstract

Background Survivors of stroke are often deconditioned and have limited opportunities for exercise post-rehabilitation. Cardiac Rehabilitation (CR), a structured exercise program offered post-cardiac event in the United States (U.S.), may provide an opportunity for continued exercise. The purpose of this study was to examine the feasibility of integrating survivors of stroke into an existing, hospital-based CR program through an assessment of (1) recruitment, uptake and retention, (2) adherence and fidelity, (3) acceptability and (4) safety. Methods A mixed methods design combined a single group, pre-post design, pilot feasibility study with an imbedded qualitative inquiry. Survivors of stroke were recruited into a standard 12-week, 36 visit CR program. Results Fifty-three survivors were referred, 29 started and 24 completed the program. Program uptake rate was 55% and completion rate was 83%. Eleven completers and one non-completer participated in the qualitative interviews. Program completers attended an average of 25.25 (SD 5.82) sessions with an average of 38.93 (SD 5.64) exercise minutes per session while reaching targeted rate of perceived exertion levels. Qualitative themes included perceived benefits of an individualized program in a group setting, positive interactions with qualified staff, opportunities for socialization, and regular monitoring and staff attentiveness promoting feelings of safety. Conclusions Survivors of stroke were able to meet Medicare standard dosage (frequency and session duration) and rate of perceived intensity goals, and perceived the program as needed regardless of their mobility limitations or previous exercise experience. Primary challenges included managing referrals and uptake. Results support feasibility and benefit for survivors to integrate into U.S. CR programs.

Perspectives and Experiences of Cardiac Rehabilitation after Stroke—A Qualitative Study

“…Overall, participants in this study identified that the cardiac rehabilitation programme helped them to make risk-reducing lifestyle changes in categories that included dietary changes, smoking cessation, mindfulness, and physical activity levels, similar to previous quantitative and qualitative findings where knowledge of risk-factor reduction was reinforced and/or learned in CR-based secondary prevention programmes [ 22 , 23 , 25 , 28 , 48 ]. Access to healthcare professionals for ongoing exercise and secondary prevention is a recurrent theme in the stroke literature [ 49 , 50 ], and cardiac rehabilitation may prove an important bridge to independent self-management of physical activity for secondary prevention after stroke.…”

“…Exercise and lifestyle-based interventions modelled on cardiac rehabilitation (CR) have been proposed for physical conditioning to improve habitual PA for survivors of stroke and to reduce lifestyle risk factors after stroke [ 19 ]. CR is a proven and established secondary prevention programme in coronary heart disease [ 20 , 21 ], and results from across Europe and North America suggest that CR is not only feasible to provide after stroke, but it is a safe, effective, and integrated approach for risk-factor reduction and to improve cardiorespiratory fitness [ 4 , 22 , 23 , 24 , 25 ]. Notably, stroke participants are reported to make similar improvements to cardiac patients during CR in cardiorespiratory fitness; risk-factor reduction; and physiological markers, including lipid profiles and blood pressure [ 24 ].…”

“…Despite promising findings for CR as a stroke secondary prevention programme, suboptimal (55–57%) uptake rates and dropout rates of more than double that of cardiac counterparts are reported for people with stroke when referred to cardiac rehabilitation [ 24 , 25 ]. Higher uptake rates (71%) are reported in individuals who already attend outpatient stroke rehabilitation [ 26 , 27 ], where the barriers recorded included lack of interest and transportation issues [ 26 ].…”

“…While it is clear that CR may benefit stroke secondary prevention, it is not clear why individuals attending cardiac rehabilitation do not engage as well with risk-factor-reduction education and why those already attending stroke services are more likely to participate in CR. The experiences of individuals after stroke who participated in cardiac rehabilitation are reported in two qualitative studies associated with clinical trials of CR [ 25 , 28 ]. While some feasibility aspects of the CR intervention were addressed [ 25 ], results failed to provide insights into the educational and support components of the programme and could not address participants’ experiences of being referred to a cardiac rehabilitation programme during their routine stroke care pathway.…”

“…The experiences of individuals after stroke who participated in cardiac rehabilitation are reported in two qualitative studies associated with clinical trials of CR [ 25 , 28 ]. While some feasibility aspects of the CR intervention were addressed [ 25 ], results failed to provide insights into the educational and support components of the programme and could not address participants’ experiences of being referred to a cardiac rehabilitation programme during their routine stroke care pathway. Therefore, the aims of this study are translational in nature and explore, using moderated focus-group discussions, stroke participants’ perceptions of referral to and participation in cardiac rehabilitation following discharge from stroke services during routine stroke care.…”