Transcript Experiences of an Exercise Referral Scheme from the

Experiences of an Exercise Referral
Scheme from the perspective of
people with chronic stroke:
a qualitative study
Mrs Helen Sharma
Dr Frederike van Wijck
Dr Cathy Bulley
Background
> 900,000 people living with stroke in UK1
Estimated cost to economy > £7 billion2
Personal cost3
Short-term targeted exercise interventions
improve mood4, fitness, strength, gait,
balance5, social participation6
Patient experience important
Exercise Referral Schemes and stroke??
Research Aim
To explore the experiences of an Exercise
Referral Scheme from the perspective
of people with chronic stroke
Guide scheme development
Basis for understanding exercise
behaviour after stroke
Methodology – Study Design
Qualitative
Because experiences cannot be expressed in
standardised units of measurement
Constructivist
Assuming no single ‘truth’ exists
Interpretivist
Focus on individuals’ values and meanings
Semi-structured, one-to-one interviews
Enabled individual focus and depth of data
Methodology - Sample
INCLUSION
 1° diagnosis of stroke
 Attended ERS from
Aug ‘04 to Aug ’06
EXCLUSION
 Unable to engage
with researcher
 Voice not clear on
audiotape
Examine patient records
Send recruitment letters
Signed consent form
Telephone screen
?interview feasible
Methodology - Rigour
ISSUE
Credibility
(Internal validity)
EXAMPLE ACTIONS
 Audiotape and transcribe
interviews verbatim
 Verify accuracy of interpretation via
respondent validation
Transferability
(External validity)
 Detailed description of participants
and setting
Dependability
(Reliability)
 Peer checking
Neutrality
(Objectivity)
 Reflexivity – pilot interview; field
journal
Methodology – Data Analysis
Data immersion
Coding
Reading transcripts +++
Extracting demographics, labelling
subjects, considering meaning,
questioning and exploring
relationships within text
Categories
Collections of relationships united
by central idea
Master theme
Overarching theme illustrated by
several categories
Results
Participants: n = 9
Gender: 5 male, 4 female
Age range: 37-61, mean 51
Time post-stroke: 1-4 years
Ethnicity: 5 white British, 4 black African
Affected hemisphere: 5 right, 4 left
Results
RAW DATA
ERS was understood
as a pivotal stage in
regaining
independence after
stroke
CATEGORY 1
Exercise
engagement
CATEGORY 2
Control
CATEGORY 3
Improvement
CATEGORY 4
Confidence
MASTER THEME
One small step on the
treadmill … one giant
leap towards
independence
Personal
developments in 4
key areas
contributed towards
increased
independence
Category 1 – Exercise Engagement
Attendance at ERS signalled more active
behavioural choices
Active choices were associated with
feelings of normality and independence
Data: Category 1
More active behavioural choices:
‘Before I started going [to the ERS], I wasn’t
thinking about exercise, and I wasn’t
thinking about anything, other than sit at
home, eat and watch television. When I
started, at least they gave me that ability,
they gave me that push … So thereafter, I
just cook up something in my head, go
down the stairs or go down the street.’
Category 2 - Control
There was an apparent shift in the reasons
participants gave for their physical improvement,
increased function and independence:
Pre-ERS:
At, and after ERS:
 Physiotherapist
 God
 Consultant
 Health Service
 ‘Motivation’
 ‘Willpower’
 ‘Self-determination’
Category 3 - Improvement
Improvements over time: Fitness, strength,
movement
Immediate improvements in mood
Importance of improvement to participants
was ‘getting better’ from the stroke
Getting better linked to positive feelings of
happiness and enjoyment
Data: Category 3
Mood improvement, ‘getting better’ and
positive feelings:
‘When I finish exercising and I feel so good,
so content… By the end of the day you
feel good, you know, you say ‘I feel good,
my health is coming back’ in your head.’
Category 4 - Confidence
Individuals reported increased confidence
with attendance at ERS
Attributed specifically to the influence of
the physiotherapist and the group
Confidence was associated with regaining
independence because it appeared to
carry over into situations outside ERS
Data - Category 4
Confidence and carry over:
‘I started work and I was able to start where
I left off…if I had not gone through this I
would not have had the confidence in front
of all those people. It is not the medication
that has made me better, it is the exercise’
Was it all a bed of roses?
Barriers to attending:
Gym threatening
environment – younger
participants particularly
self-conscious
Low task-specific
confidence e.g. being
able to do stairs/ get on
bus to get to gym
Discussion and Conclusion
ERS was experienced as a pivotal stage in
regaining independence after stroke
ERS is supported as a method of targeted
rehabilitation for people with chronic stroke
Service evaluation: Review outcome
measures; user views essential
Future work: Overcoming barriers to
exercise; exercise adherence; long-term
exercise participation
References
[1] DOH. National Stroke Strategy. London: Department of
Health;2007
[2] Saka RO, McGuire A, Wolfe CDA. Economic burden of stroke in
England. London: University of London; 2003
[3] Royal College of Physicians Clinical Effectiveness and Evaluation
Unit. National clinical guidelines for stroke. 2nd ed. London: Royal
College of Physicians; 2004
[4] Lai SM, Studenski S, Richards L, Perera S, Reker D Rigler S,
Duncan P. Therapeutic exercise and depressive symptoms after
stroke. J Am Geriatr Soc 2006; 54: 240-7
[5] Marigold DS, Eng JJ, Dawson AS, Ingis JT, Harris JE, Gylfadottir
S. Exercise leads to faster postural reflexes, improved balance
and mobility, and fewer falls in older persons with chronic stroke.
J Am Geriatr Soc 2005; 53: 416-23
[6] Studenski S, Duncan P, Perera S, Reker D, Lai SM, Richards L.
Daily functioning and quality of life in a randomised controlled trial
of therapeutic exercise for subacute stroke survivors. Stroke
2005; 36: 1764-70