Home > RNJ > 2007 > November/December > Barriers and Facilitators to Exercise Among Stroke Survivors

Barriers and Facilitators to Exercise Among Stroke Survivors
Teresa M. Damush, PhD Laurie Plue, MA Tamilyn Bakas, DNS RN Arlene Schmid, PhD OT Linda S. Williams, MD

Physical activity after stroke may prevent disability and stroke recurrence; yet, physical impairments may inhibit post-stroke exercise and subsequently limit recovery. The goal of this study was to elicit barriers to and facilitators of exercise after stroke. We conducted three focus groups and achieved content saturation from 13 stroke survivors—eight men and five women—85% of whom were African American and 15% White, with a mean age of 59 years. We coded and analyzed the transcripts from the focus groups for common themes. Participants across groups reported three barriers (physical impairments from stroke, lack of motivation, and environmental factors) and three facilitators (motivation, social support, and planned activities to fill empty schedule) to exercise after stroke. Exercise activity can provide a purpose and structure to a stroke survivor’s daily schedule, which may be interrupted after stroke. In addition, receiving social support from peers and providers, as well as offering stroke-specific exercise programming, may enhance physical activity of stroke survivors including those with disabilities. We intend to incorporate these findings into a post-stroke self-management exercise program.

Stroke is a high-volume medical condition. Stroke affects 700,000 people each year in the United States, of which 200,000 are recurrent episodes (American Heart Association, 2005). Stroke is the third leading cause of death, produces the greatest number of hospitalizations for neurological disease (Wolf et al., 1999), and is the leading cause of adult neurological, long-term disability in the United States (American Heart Association, 2005; Wolf et al., 1999). Up to 50% of stroke survivors still have some functional disability within 6 months of an ischemic stroke event (Dombovy, Basford, Whisnant, & Bergstralh, 1987). Moreover, patients who have had a stroke or a transient ischemic attack (TIA) are at risk for recurrent stroke (Hanley, 2004; Wolf et al., 1999) and death (Lai, Alter, Friday, & Sobel, 1994). More than 12% of stroke survivors will experience another stroke within a year (Lai et al.; Wolf et al.).

Managing stroke risk is often a goal of post-stroke care. Modifiable stroke risk factors include the following: atrial fibrillation, carotid artery disease, diabetes mellitus, diet, excessive alcohol consumption, high blood cholesterol, hypertension, obesity, physical inactivity, and tobacco use (Wolf et al., 1999). Most are effectively managed through a combination of lifestyle modifications and medication (American Stroke Association, 2007; Kenner & Kelley, 2005).

Although modifiable and effective at reducing the risk of stroke and other vascular events, most patients with stroke or TIA lack adequate stroke risk management control (Hajjar & Kotchen, 2003; Qureshi, Suri, Guterman, & Hopkins, 2001; Toole et al., 2004). In a recent randomized trial of high-dose folate vitamin therapy in patients with recent stroke, stroke survivors in the trial continued lifestyle practices that elevated their stroke risk (i.e., cigarette smoking, obesity, high blood pressure) (Toole et al.). Despite the knowledge of risk reduction, providers have not aggressively counseled or promoted behavioral practices for stroke prevention in the general population (Hanley, 2004).

Promoting exercise, a strategy used to lower risk for recurrent stroke (Fonarow, 2003), is often considered for stroke patients through rehabilitation and may improve functional ability (Macko et al., 2001; Weiss, Suzuki, Bean, & Fielding, 2000). However, stroke impairments may hinder exercise participation (Gordon et al., 2004). Moreover, after clinical rehabilitation is completed, exercise participation may wane. Little is known about exercise barriers and facilitators among stroke survivors.

Currently, we are aware of no systematic behavior modification program for stroke survivors to promote exercise as a self-management strategy to reduce stroke risk factors. Therefore, the purpose of this qualitative study was to elicit barriers and facilitators of exercise after stroke to inform the development of a post-stroke risk factor program.

We used the chronic care model (CCM) (Wagner, Austin, & Von Korff, 1996) as a framework to guide our inquiry of barriers and facilitators involving community resources used, the experience of the healthcare system for stroke care, patient self-management, and the delivery of care by providers. The CCM was developed in an effort to improve chronic illness management in primary care practice (Hedrick et al., 2003). This conceptual model has been widely used across diseases including depression (Damush et al., 2003), diabetes care and heart failure (Lin et al., 2000), and most recently in implementation research projects (e.g., Mental Health QUERI depression collaborative care models and influenza vaccination rates) (Evans, Legro, Weaver, & Goldstein, 2003; Glasgow et al., 2002).

The CCM posits that chronic care is provided over two entities: (1) community resources and (2) the healthcare system that provides the structure, goals, and values for the provider organization. Community resources are effective programs that fill in gaps of needed services (e.g., public awareness of stroke). The healthcare system encompasses the organization structure that supports improvement strategies and organizational change (e.g., the Veterans Health Administration [VHA]). Within these two entities are four components that support chronic care: (1) self-management support, (2) delivery system design, (3) decision support, and (4) clinical information systems. These components are interdependent and cultivate informed, activated patients practicing stroke risk factor management behaviors collaborating with prepared, proactive providers who initiate and counsel stroke risk factor management, resulting in improved patient functioning and health-related quality of life. Given that decision support and clinical information systems are provider tools, we did not query patients on these components. The focus group contents emphasized the self-management support component of the chronic care model.

Within the CCM model, exercise promotion is a salient part of patient self-management component. We reviewed barriers and facilitators of exercise participation within a social-cognitive theoretical framework for promoting self-management. Randomized controlled trials designed to increase physical activity among older adults, the age group of most stroke survivors, have often shown positive results with the incorporation of social-cognitive-theory principles (Conn, Minor, Burks, Rantz, & Pomeroy, 2003; King, 2001). Social-cognitive theory principles include personal, social, and environmental factors (Bandura, 1986).

Personal correlates, demographic and health variables, have been related to physical activity. Being a woman, overweight, or a smoker; older age (Conn et al., 2003); and having less education were factors associated with physical inactivity (Clark, 1996; King, 2001; Sternfeld, Ainsworth, & Quesenberry, 1999). Perceived poor health was another factor related to physical inactivity in older adults (Clark, 1999; Damush, Stump, Saporito, & Clark, 2001).

Among social factors, social support has been shown to correlate with physical activity in general populations (Sallis, Grossman, Pinski, Patterson, & Nader, 1987) and older adults (Orsega-Smith, Payne, & Godbey, 2003). In a recent self-report survey study of African American and rural older women, family support for physical activity was correlated with greater physical activity participation (Wilcox, Bopp, Oberrecht, Kammermann, & McElmurray, 2003). Other positive sources of social support studied among older adults were physician recommendations for physical activity (Damush, Stewart, Mills, King, & Ritter, 1999) and home-exercise support programs (Tudor-Locke et al., 2000).

Environmental factors of physical activity have recently received attention (Sallis, Kraft, & Linton, 2002). Program-related factors have not been rigorously studied as a product or service. One program factor, however, home versus group-based physical activity, has been studied. Older adults, on average, tend to prefer home-based activity with some instruction (Brownson et al., 1999) and are more likely to adhere to exercise in a home-based exercise program (King, Haskell, Taylor, Kraemer, & DeBusk, 1991). It is unknown whether older adults with chronic disease prefer professional, supervised instruction or home-based physical activity.

In another study, more than two thirds reported health symptoms (e.g., pain, fear of chest pain, and shortness of breath) and environmental reasons (e.g., weather, fear of crime) as barriers to physical activity participation among a stratified random sample of older, low-income, primary-care patients with diabetes (Clark, 1999). Most recently, Tu, Stump, Damush, and Clark (2004) found that objective measures of weather and sociodemographics of the neighborhood were barriers to adherence to a structured group-exercise program in the community.

Given that health perceptions, environmental factors, and bodily pain are barriers to older adult physical activity, and social support is a facilitator of exercise, the purpose of this study was to explore personal, social, and environmental motivators and barriers within the components of the chronic care model for stroke survivors to engage in exercise after experiencing a stroke to inform the development of a post-stroke risk factor program.


This study used focus groups (Morgan, 1993) to elicit perceived exercise barriers and facilitators of exercise among stroke survivors to inform a stroke survivor program, as the authors had previously done for patients with low back pain (Damush et al., 2002). The local Institutional Review Board at Indiana University, Indianapolis, approved the study, and we obtained written, informed consent prior to data collection. Adults who had experienced a diagnosed stroke or TIA and received care at a local community, county or Veterans Administration (VA) hospital during the past year were invited to participate in a focus group by mail. Interested persons returned our letter in a postage-paid envelope, indicating their willingness to participate. A research assistant scheduled the groups at one facility based on availability of the participants. Prior to the group commencements, but after signing informed consent, participants completed a brief demographic questionnaire. A formally trained program coordinator moderated the groups, and the co-investigators served as note takers. Each focus group lasted 2 hours in duration and was audiotaped and transcribed to ensure accuracy of the data.

Focus Group Guide

We developed a focus group to guide the leader on eliciting patient barriers and facilitators of exercise and physical activity, as well as other questions as part of a larger study on the aftermath of surviving a stroke. The focus group sessions included open-ended questions about types of physical activity engaged in and how often the participants exercised as warm-up questions to help participants think about their physical activity participation. The leader asked questions to specifically elicit barriers to exercise; strategies that helped them to exercise; support received from healthcare system, caregivers and family, peers, and community resources to promote and sustain exercise; support received specifically from providers to help them exercise; and stroke impediments that prohibited exercise. In addition, we asked questions that focused on exercise prescriptions received from rehabilitation specialists and home maintenance of such programs.


We used the session notes to catalog the principal themes that emerged and issues of both consensus and difference that transpired. The field notes and audiotapes were transcribed into computerized text. We transcribed and analyzed audiotapes of each focus group. Two investigators (Damush and Plue) independently reviewed and coded transcripts by assigning labels and codes to data segments on the transcripts. We permitted themes to emerge from the data.

In the first step in the analysis, we created a set of agreed-upon codes and a codebook that served as a template for coding of the data. The investigators used an iterative consensus-building process to generate codes. Each investigator worked independently and highlighted sections of the field notes and transcripts that illustrated a theme. In the margin of the notes or transcripts, we wrote the name of the theme, compared notes, reviewed agreements, and attempted to resolve disagreements until consensus was reached. All the authors coded a set of transcripts and participated in reaching consensus. The goal was to detect patterns within each data set that characterized potentially meaningful differences or similarities between groups, including common and useful facilitators of patient exercise self-management strategies after stroke to reduce risk for recurrent stroke and barriers to such activity. We described findings using quotes to illustrate points.



Forty stroke survivors from an existing research study were invited, and 32.5% (13) agreed to participate. Stroke survivors were originally recruited from local community, county, and veteran hospitals. We held three focus groups and achieved content saturation from 13 stroke survivors including 8 men and 5 women who were 85% (11) African American and 15% (2) White. The mean age was 59 years (SD = 12.3) and the mean level of education was 11.5 years (SD = 2.6). Time since stroke event was less than 12 months for all participants. The majority self-reported experiencing slight (n = 6) or moderate (n = 4) disability since their stroke.

Analysis of the transcribed audiotapes of the three focus groups revealed three barriers to and three facilitators of exercise among stroke survivors. We describe each barrier and facilitator, illustrated with quotations from stroke survivors.

Exercise Barriers

1. Perceived stroke impairments discourage activity engagement.

Stroke survivors reported that physical impairments experienced after the stroke prevented engagement in physical activity. Some examples from three participants included vision and walking difficulties that interfered with performing physical activities:

“My big problem is my eyes. I’ve lost my peripheral vision and I can hardly see.”

“My right arm hurts. I use it too much.”

“I find myself a little unstable at times. I still don’t have the full mobility in my foot; sometimes, I have to drag it. I’ve even got a special brace they made for me and sometimes if it gets to where I can’t support myself fully. It’s kind of an awkward thing because it doesn’t always fit in every shoe I have, but it helps to stabilize me.”

The limitations after stroke were related to participants’ fear of the consequences of exercising, which prohibited participants from engaging in physical activity. This was a common theme expressed by participants. Some examples included the following remarks by participants:

“I’m afraid of running into stuff and hurting myself.” (This comment was made by three participants.)

“I think one thing [that interferes with exercising after stroke] is fear, initially. I don’t have it [fear] anymore.”

“After I had my stroke, I was a little bit leery about exercising and bringing another [stroke] on.”

“You stop doing a lot of things (out of fear) until you see your doctor.”

Thus, perceived limitations after a stroke appeared as a barrier to engaging in exercise among survivors.

2. Lack of motivation.

Similar to the general population, stroke survivors reported that a lack of motivation, desire, or energy prevented them from exercising. The majority, 12 out of the 13 participants, endorsed this barrier. Participants made the following statements:

“That’s the hard part, to make yourself do it (exercise).”

“I can say I can go tomorrow, but when tomorrow gets here, I just lay down or sit down.”

“I know what I’m supposed to do, but I do not do it.”

Stroke survivors reported that post-stroke mood interfered with their ability to exercise.

“I was a very outgoing person before the stroke…. What the stroke did was affect me more mentally and physically. I don’t have any desire. I make myself do the things I do because they told me I had to, but it’s like I’m just like an [emotional] shell. I’m involved in a whole lot of activities, but when I go now, I just sit there. I’ve been in a lot of support groups. I used to feel people’s pain. I could cry with them. Now I just sit there. I’m emotionless. I struggle with that.”

Another survivor reported, “Since my stroke, I can’t concentrate on things like I used to.”

Many of the stroke survivors reported a lack of energy after the stroke, and this interfered with their ability to exercise. Some examples include the following statements:

“Yes, I don’t have the energy.” (Three participants stated this.)

“When I take my medicine because I’m on that depression pill, and it’s also a sleeping pill and I feel so tired.”

“I live in an apartment building, and I have a sister that lives over there, too. The women there walk all the time, and I just don’t have the energy to walk with them.”

This former quote illustrates that even when a stroke survivor has the social support to exercise, a lack of energy or motivation serves as a barrier to exercise after stroke.

3. Environmental factors.

A lack of exercise options was reported as a barrier to exercise after a stroke. Some stroke survivors perceived that there were no places for them to go for exercise. Some examples of participants’ comments include the following quotes:

“We don’t have that many places really to go. The only place I would have to go would be this YMCA.”

“There just aren’t enough meetings for us to participate in.”

Many of the stroke survivors perceived exercise as an event that was conducted in a formal or planned manner. Thus, exercise was something planned that was conducted in a facility or organization. Physical activity incorporated into daily living was not necessarily perceived as exercise. One example of this perception included the following:

“I don’t have a recommended exercise. I get out and walk around the neighborhood, go fishing, and all that sort of thing, but as far as going out every day and exercising, I don’t do that. I try to keep moving around.”

Another respondent perceived exercise as planned activity that is not maintained with age. “There are a lot of forms of exercise, but when you get to a certain stage in life, you don’t do them. You don’t ride a bike. You don’t run down the street.” These perceptions of exercise may inhibit physical activity after stroke.

Another environmental barrier to exercise was transportation. For several reasons, stroke survivors reported a lack of transportation as a barrier to exercise.

“I would have to drive, and I would have to get somebody to take me. If you can’t do something on your own, it’s pretty hard to get somebody to take you.”

“I go [to exercise] when I can when somebody can take me.”

Given the survivor’s driving limitation, a lack of public transportation system to transport the stroke survivor to an exercise facility was a common barrier reported in addition to a lack of stroke exercise programs in the community.

Exercise Facilitators

Despite the exercise barriers reported by stroke survivors, some participants reported factors that served as facilitators to exercise after stroke. The three main facilitators include finding motivation to exercise, receiving social support to exercise, and treating exercise as a specific task or work to do to facilitate performing exercise.


Stroke survivors discussed the benefits of motivators on their physical activity levels and discussed both external and internal motivators. For example, one participant discussed how his wife brought home a puppy for him to manage, and taking care of the puppy facilitated his exercise.

“I have a dog now. He makes me get up and take him out. Otherwise, I would still be in bed. He keeps me moving around.”

Other participants discussed the need for a trainer or external motivator to be active.

“To have someone come in for about an hour and put a belt around your back and say, “Now, oh, you’re doing fine. Oh, that’s good. That’s great,” and then, he leaves. It doesn’t help you a bit. You just need someone to say, “Get off your duff and move your legs.”

Moreover, stroke survivors discussed the benefits of self-motivation to exercise. Participants reported several examples illustrating this theme:

“You can do it yourself if you want to do it! I’m not saying that I am perfect as far as my exercise. There are times when I slough it off, too, because I just don’t want to do it that particular time. You don’t need someone to come in every day or every other day;”

“I just kept fighting, and I kept doing what the doctors told me.”

“I’m not going to feel like this. I’m going to beat this.”

“Either you’re going to do it [exercise] or you’re not, but don’t hold me.”

Another source of exercise motivation was seeing physical improvements after exercising. This improvement facilitated further exercise participation according to the stroke survivors. Several participants cited examples:

“One thing that motivates me more is to see improvement. When I think about where I was and what I do now is a lot different.”

“I don’t know how many of you have problems with your legs. Putting a pair of pants on, I can see the improvement there. When I first had my stroke, I had a hell of time putting on a pair of pants.”

Another participant discussed his improvement seen with the distance walked:

“I’m trying to make it [walk] four miles. If I can make it four miles, I can feel it. . . . It hurts, but after I’m done, it feels good.”

Exercise Social Support

Participants reporting receiving social support to exercise from several sources including professional support from rehabilitation services and providers, and peer support from fellow stroke survivors.

Stroke survivors mentioned the formal exercise instruction that they received from rehabilitation specialists helped them to be physically active afterward. For example, one participant mentioned, “I went to rehab, and there are a lot of things you can do as far as exercising, get a bike [sic]. They teach you how to stand somewhere and move your legs here and there. Move your body up and down against the door there.”

Another participant reported still using the equipment received from rehabilitation. “They [rehabilitation] gave me rubber bands to use, and I still use them. I use those balls in my hands. I do that every day.”

Home rehabilitation was also positively noted as a facilitator of exercise. “I still have a [therapist] come to the house. She gave me an exercise routine with my hands, and bicycle-like exercise with my legs.”

Providers were another source of support reported. Participants stated that receiving a physician recommendation to exercise provided motivation as illustrated by a participant:

“The [the doctor] said, ‘Walk more,’ and that’s what I’ve been doing since he stressed walking.”

“My circulation is better, and that was his [cardiologist’s] whole purpose [for telling me to walk], pump up the heart and make sure that it’s working properly.”

In addition to professional support, stroke survivors repeatedly reported that they would be motivated to exercise with fellow stroke survivors. Some example statements from participants include the following:

“We understand each other. You get somebody out there who’s never had a stroke; he would be bored with us. You lose part of your memory. You wouldn’t have each other dogging each other because you have the same thing.”

“Somebody who has been through virtually the same thing as we have [would motivate me to exercise].”

“One thing, if I had somebody to exercise with, go to the gym or somewhere, I would exercise more.”

“Somebody who would walk with me . . . an exercise buddy [would motivate me to exercise].”

Thus, social support from multiple sources was frequently reported as an important motivator to exercise after stroke.

Planned Activity to Fill Schedule

Stroke survivors reported that participating in an exercise program helped them to fill their empty daily schedule, which once was filled with occupational responsibilities. Having a planned activity to do helped survivors cope with their life changes after stroke. Several participants agreed that having a purpose would motivate them to participate in exercise.

“Having someplace to go [would motivate me to exercise] . . . so you don’t lie in bed all day.”

“I like to work on things … when I get up in the morning; I’ve got my mind already on what I’m supposed to be working on that day.”

Thus, the stroke survivors used exercise to fill their schedules, which had often become empty after resigning from employment due to their illness, according to participants.


Stroke survivors elicited both common barriers and facilitators of exercise similar to the general population, as well as variables specific to stroke survivors. Common barriers brought forth by participants included lack of motivation and energy to be active, as well as lack of exercise programs available in the community and lack of transportation. These barriers are commonly reported among adults (Booth, Bauman, Owen, & Gore, 1997; Cohen-Mansfield, Marx, & Guralnik, 2003). Lack of energy and lack of programs available for patients were common perceived barriers reported by patients with spinal cord injury (Scelza, Kalpakjian, Zemper, & Tate, 2005).

Common exercise facilitators identified in these focus groups of patients with stroke were also reported in the literature among older adults in general including having a purpose in life (Damush, Perkins, Mikesky, Roberts, & O’Dea, 2005), having a place to go to be physically active (Damush et al., 2005), seeing improvements and having peer support (Courneya, Plotnikoff, Hotz, & Birkett, 2000; Sallis et al., 1987), feeling self-motivated (King, 2001; Pinto et al., 2002), and receiving physician recommendations (Damush et al., 2001).

Of note, peer support was enthusiastically discussed across the focus groups. That is, participants stressed their willingness to exercise among fellow stroke survivors. Thus, stroke survivors were aware of their impediments and took refuge among those with similar experiences. These results echo those reported in another qualitative study of stroke consequences (Pound, Gompertz, & Ebrahim, 1998). They found that the loss of activities and social roles and contacts had affected the quality of life of stroke survivors and needed to be replaced. Thus, survivors may become isolated after stroke; however, a specific exercise class targeting stroke survivors may promote exercise as survivors report being comfortable around each other.

Stroke survivors identified external motivators (e.g., a pet) and rehabilitation as facilitators of exercise. Rehabilitation may be an opportunity to begin an exercise program with a therapist who may serve as coach. The rehabilitation program may be transitioned to independent exercise activity as a similar program, “Starting Again,” was successfully developed for cancer patients (Berglund, Bolund, Gustafsson, & Sjoden, 1994). Additionally, providing stroke-specific exercise classes would fulfill the exercise facilitator of having a planned activity to attend.

Equally important for promoting exercise among stroke survivors is the caregiver. In a recent study of patients with Alzheimer’s disease, caregivers were taught home exercises for their patients and to act as instructors (Teri et al., 2003). After 3 months, patients randomized to caregiver instructors reported spending more weekly minutes in physical activity and less days of restricted physical functioning. Thus, training the caregiver to coach the stroke survivor to exercise may promote physical activity.

Exercise barriers specific for stroke survivors included change in work or life status, stroke impairments (e.g., disability), fears of injury or bringing on another stroke, and lack of transportation, as many survivors were unable or unwilling to drive after the stroke. Participants reported that after the stroke, they often had to retire from work where they were once physically active on the job. Now, they were sedentary at home. These specific stroke barriers are similar to perceived barriers reported by people with spinal cord injury (Scelza et al., 2005). Fear of injury during physical activity is common among people with chronic disease. Our previous research among patients with low back pain found that fear of injury was related to less patient self-management (e.g., physical activity) (Damush et al., 2003). These patients significantly reduced their fears after participating in a patient self-management program. In addition, transportation is often a perceived barrier among disabled persons (Rimmer, 2005). In that case, home-based activities may be the most practical. However, our data suggest that stroke survivors would desire the opportunity to stay connected to their fellow stroke survivors. Therefore, technological devices such as Internet chat rooms such as those developed for patients with chronic disease (Lorig et al., 2002) or telephone conference calling may be useful to create a virtual exercise community for homebound stroke survivors and facilitate peer support for exercise.

Fatigue was mentioned as a barrier to exercise after stroke. Post-stroke fatigue is a commonly reported symptom during the following year of the acute event and is related to depression, functional limitations, and mortality (Schepers, Visser-Meily, Ketelaar, & Lindeman, 2006). Research suggests that exercise participation may decrease cancer-related fatigue (Daley et al., 2007). However, the efficacy of exercise on post-stroke fatigue is unknown. Exercise rehabilitation is not routinely offered to stroke survivors as cardiac rehabilitation is after coronary events. Treadmill training may relieve post-stroke fatigue by decreasing energy cost of gait (Colle, Bonan, Gellez Leman, Bradai, & Yelnik, 2006).


There are several limitations of this research study that should be considered. First, the participants were recruited from another research stroke study and may differ from those who did not participate. However, the study involved patients from three local hospitals that served veterans, inner-city residents with low income, and insured persons in community care. Thus, our sample represented a diverse background. Second, the participants suffered a stroke within the past year. Perceptions may differ at the time of stroke compared to years after a stroke. Third, despite the fact that we completed only three focus groups, we achieved content saturation. That is, no new themes emerged from the third and final group. Equally important to designing a program is understanding the perceptions of the participants. This study took a step in this direction.

The results of this study suggest that peer support may be an avenue for exercise promotion among stroke survivors. One existing program that incorporates stroke peer support is the American Stroke Association’s Peer Visitor Program (American Stroke Association, 2007). It is designed to train stroke survivors to become peer supporters for recent stroke patients. An exercise promotion module may be incorporated into this program. As part of our research agenda, we plan to study the implementation of such a stroke peer support program to promote exercise after stroke. In addition to the need for peer motivators, rehabilitation and external motivators were mentioned as potential facilitators of exercise after stroke. Extensions of current rehabilitation programs may include training the caregiver to serve as a coach at home for the patient, as well as including behavior change strategies during planned rehabilitation to facilitate exercise after clinical rehabilitation has ended. Viewing rehabilitation as a transition point in which to facilitate general exercise in addition to specific therapeutic activities may be an opportunity to impact stroke survivor’s general health and reduce stroke risk in addition to enhancing recovery.


Physical inactivity is a modifiable risk factor for primary and recurrent stroke; increased physical activity after stroke may not only enhance stroke recovery but also may positively affect the health-related quality of life of stroke survivors. This study has identified barriers and facilitators of exercise after stroke. To facilitate exercise after stroke, clinicians should initiate assessment of stroke survivors’ concerns and address any fears about exercise prior to discharge. Future research may incorporate these findings into planned interventions and test their effectiveness for exercise promotion and impact on quality of life. We intend to incorporate these findings into a post-stroke self-management exercise program and evaluate its efficacy on patient outcomes.


Funding for this project was provided in part by a VA VISN Collaborative Grant #0404–73 awarded to Dr. Linda Williams, and the VA Stroke QUERI Center #STR-03–168, Indianapolis, IN.

About the Authors

Teresa M. Damush, PhD, is the implementation coordinator for the VA Stroke QUERI and assistant research professor HSRD CIEBP at Roudebush VAMC, Indiana University Center for Aging Research, and Regenstrief Institute, Inc. Address correspondence to her at tdamush@iupui.edu.

Laurie Plue, MA, is the administrative coordinator for the VA Stroke QUERI Center at the Roudebush VAMC.

Tamilyn Bakas, DNS RN, is an associate professor in the Indiana University School of Nursing and affiliated scientist with IU Center for Aging Research in Indianapolis, IN.

Arlene Schmid, OT PHD, is an assistant professor at VAMC in Indianapolis, IN, Indiana University Center for Aging Research, and Indiana University School of Rehabilitation Science.

Linda S. Williams, MD, is the research coordiantor for the VA Stroke QUERI Center and chief of neurology at Roudebush VAMC and affiliated scientist with the IU Center for Aging Research.


American Heart Association. (2005). Heart disease and stroke statistics—2005 update. Dallas: Author.

American Stroke Association. (2007). Sharegivers, a Peer Visitor Program. Dallas: Author.

Bandura, A. (1986). Social foundations of thought and action: A social cognitive theory. Englewood Cliffs, NJ: Prentice Hall.

Berglund, G., Bolund, C., Gustafsson, U. L., & Sjoden, P. O. (1994). One-year follow-up of the “Starting Again” group rehabilitation programme for cancer patients. European Journal of Cancer, 12, 1744–1751.

Booth, M. L., Bauman, A., Owen, N., & Gore, C. J. (1997). Physical activity preferences, preferred sources of assistance, and perceived barriers to increased activity among physically inactive Australians. Preventive Medicine, 26, 131–137.

Brownson, R. C., Eyler, A. A., King, A. C., Shyu, Y. L., Brown, D. R., & Homan, S. M. (1999). Reliability of information on physical activity and other chronic disease risk factors among US women aged 40 years and older. American Journal of Epidemiology, 149, 379–391.

Clark, D. O. (1996). Age, socioeconomic status, and exercise self-efficacy. The Gerontologist, 36, 157–162.

Clark, D. O. (1999). Physical activity and its correlates among urban primary care patients aged 55 years or older. Journal of Gerontology: Biological Sciences, 54B, 41–48.

Cohen-Mansfield, J., Marx, M. S., & Guralnik, J. M. (2003). Motivators and barriers to exercise in an older community-dwelling population. Journal of Aging and Physical Activity, 11, 242–253.

Colle, F., Bonan, I., Gellez Leman, M. C., Bradai, N., Yelnik, A. (2006). Fatigue after stroke. Annales de Readaptation Medecine Physique, 49, 361–364.

Conn, V. S., Minor, M. A., Burks, K. J., Rantz, M. J., & Pomeroy, S. H. (2003). Integrative review of physical activity intervention research with aging adults. Journal of the American Geriatrics Society, 51, 1159–1168.

Courneya, K. S., Plotnikoff, R. C., Hotz, S. B., & Birkett, N. J. (2000). Social support and the theory of planned behavior in the exercise domain. American Journal of Health Behavior, 24, 300–308.

Daley, A. J, Crank, H., Saxton, J. M., Mutrie, N., Coleman, R., & Roalfe, A. (2007). Randomized trial of exercise therapy in women treated for breast cancer. Journal of Clinical Oncology, 25, 1713–21.

Damush, T. M., Perkins, S. M., Mikesky, A. E., Roberts, M., & O’Dea, J. (2005). Motivational factors influencing older adults diagnosed with knee osteoarthritis to join and maintain an exercise program. Journal of Aging and Physical Activity, 13, 45–60.

Damush, T. M., Stewart, A. L., Mills, K. M., King, A. C., & Ritter, P. L. (1999). Prevalence and correlates of physician recommendations to exercise among older adults. Journal of Gerontology: Medical Sciences, 54, 423–427.

Damush, T. M., Stump, T. E., Saporito, A., & Clark, D. O. (2001). Predictors of older primary care patients’ participation in a submaximal exercise test and a supervised, low-impact exercise class. Preventive Medicine, 33, 485–494.

Damush, T. M., Weinberger, M., Clark, D. O., Tierney, W. M., Rao, J. K., Perkins, S. M., et al. (2002). Acute low back pain self-management intervention for urban primary care patients: Rationale, design, and predictors of participation. Arthritis Care & Research, 47, 372–379.

Damush, T. M., Weinberger, M., Perkins, S. M., Rao, J. K., Tierney, W. M., Qi, R., et al. (2003). The long-term effects of a self-management program for inner-city primary care patients with acute low back pain. Archives of Internal Medicine, 163, 2632–2638.

Dombovy, M. L., Basford, J. R., Whisnant, J. P., & Bergstralh, E. J. (1987). Disability and use of rehabilitation services following stroke in Rochester, Minnesota, 1975–1979. Stroke, 18, 830–836.

Evans, C. T., Legro, M. W., Weaver, F. M., & Goldstein, B. (2003). Influenza vaccination among veterans with spinal cord injury: Part 1. A survey of attitudes and behavior. Journal of Spinal Cord Medicine, 26, 204–209.

Fonarow, G. C. (2003). The role of in-hospital initiation of cardiovascular protective therapies to improve treatment rates and clinical outcomes. Review of Cardiovascular Medicine, 4(Suppl. 3), S37–S46.

Glasgow, R. E., Funnell, M. M., Bonomi, A. E., Davis, C., Beckham, V., & Wagner, E. H. (2002). Self-management aspects of the improving chronic illness care breakthrough series: Implementation with diabetes and heart failure teams. Annals of Behavioral Medicine, 24, 80–87.

Gordon, N. F., Gulanick, M., Costa, F., Fletcher, G., Franklin, B. A., Roth, E. J., et al. (2004). Physical activity and exercise recommendations for stroke survivors: An American Heart Association scientific statement from the Council on Clinical Cardiology, Subcommittee on Exercise, Cardiac Rehabilitation, and Prevention; Council on Cardiovascular Nursing; Council on Nutrition, Physical Activity, and Metabolism; and Stroke Council. Stroke, 35, 1230–1240.

Hajjar, I., & Kotchen, T. A. (2003). Trends in prevalence, awareness, treatment, and control of hypertension in the United States, 1988–2000. Journal of the American Medical Association, 290, 199–206.

Hanley, D. F. (2004). The challenge of stroke prevention. Journal of the American Medical Association, 291, 621–622.

Hedrick, S. C., Chaney, E. F., Felker, B., Liu, C. F., Hasenberg, N., Heagerty, P., et al. (2003). Effectiveness of collaborative care depression treatment in Veterans’ Affairs primary care. Journal of General Internal Medicine, 18, 9–16.

Kenner, M. E., & Kelley, R. E. (2005). Update on stroke prevention. Comprehensive Therapy, 31, 113–118.

King, A. C. (2001). Interventions to promote physical activity by older adults. Journal of Gerontology: Medical Sciences, 56, 36–46.

King, A. C., Haskell, W. L., Taylor, C. B., Kraemer, H. C., & DeBusk, R. F. (1991). Group vs home-based exercise training in healthy older men and women. Journal of the American Medical Association, 266, 1535–1542.

Lai, S. M., Alter, M., Friday, G., & Sobel, E. (1994). A multifactorial analysis of risk factors for recurrence of ischemic stroke. Stroke, 25, 958–962.

Lin, E. H., Von Korff, M., Russo, J., Katon, W., Simon, G. E., Unutzer, J., et al. (2000). Can depression treatment in primary care reduce disability? A stepped care approach. Archives of Family Medicine, 9, 1052–1058.

Lorig, K. R., Laurent, D. D., Deyo, R. A., Marnell, M. E., Minor, M. A., & Ritter, P. L. (2002). Can a back pain e-mail discussion group improve health status and lower health care costs? A randomized study. Archives of Internal Medicine, 162, 792–796.

Macko, R. F., Smith, G. V., Dobrovolny, C. L., Sorkin, J. D., Goldberg, A. P., & Silver, K. H. (2001). Treadmill training improves fitness reserve in chronic stroke patients. Archives of Physical Medicine and Rehabilitation, 82, 879–884.

Morgan, D. L. (1993). Successful focus groups. Newbury Park, CA: Sage.

Orsega-Smith, E., Payne, L. L., & Godbey, G. (2003). Physical and psychosocial characteristics of older adults who participate in a community-based exercise program. Journal of Aging and Physical Activity, 11, 516–531.

Hedrick, S. C., Chaney, E. F., Felker, B., Liu, C. F., Hasenberg, N., Heagerty, P., et al. (2003). Effectiveness of collaborative care depression treatment in Veterans’ Affairs primary care. Journal of General Internal Medicine, 18, 9–16.

Kenner, M. E., & Kelley, R. E. (2005). Update on stroke prevention. Comprehensive Therapy, 31, 113–118.

King, A. C. (2001). Interventions to promote physical activity by older adults. Journal of Gerontology: Medical Sciences, 56, 36–46.

King, A. C., Haskell, W. L., Taylor, C. B., Kraemer, H. C., & DeBusk, R. F. (1991). Group vs home-based exercise training in healthy older men and women. Journal of the American Medical Association, 266, 1535–1542.

Lai, S. M., Alter, M., Friday, G., & Sobel, E. (1994). A multifactorial analysis of risk factors for recurrence of ischemic stroke. Stroke, 25, 958–962.

Lin, E. H., Von Korff, M., Russo, J., Katon, W., Simon, G. E., Unutzer, J., et al. (2000). Can depression treatment in primary care reduce disability? A stepped care approach. Archives of Family Medicine, 9, 1052–1058.

Lorig, K. R., Laurent, D. D., Deyo, R. A., Marnell, M. E., Minor, M. A., & Ritter, P. L. (2002). Can a back pain e-mail discussion group improve health status and lower health care costs? A randomized study. Archives of Internal Medicine, 162, 792–796.

Macko, R. F., Smith, G. V., Dobrovolny, C. L., Sorkin, J. D., Goldberg, A. P., & Silver, K. H. (2001). Treadmill training improves fitness reserve in chronic stroke patients. Archives of Physical Medicine and Rehabilitation, 82, 879–884.

Morgan, D. L. (1993). Successful focus groups. Newbury Park, CA: Sage.

Orsega-Smith, E., Payne, L. L., & Godbey, G. (2003). Physical and psychosocial characteristics of older adults who participate in a community-based exercise program. Journal of Aging and Physical Activity, 11, 516–531.

Pinto, B. M., Maruyama, N. C., Clark, M. M., Cruess, D. G., Park, E., & Roberts, M. (2002). Motivation to modify lifestyle risk behaviors in women treated for breast cancer. Mayo Clinic Proceedings, 77, 122–129.

Pound, P., Gompertz, P., & Ebrahim, S. (1998). A patient-centered study of the consequences of stroke. Clinical Rehabilitation, 12, 338–347.

Qureshi, A. I., Suri, M. F., Guterman, L. R., & Hopkins, L. N. (2001). Ineffective secondary prevention in survivors of cardiovascular events in the US population: Report from the Third National Health and Nutrition Examination Survey. Archives of Internal Medicine, 161, 1621–1628.

Rimmer, J. H. (2005). The conspicuous absence of people with disabilities in public fitness and recreation facilities: Lack of interest or lack of access? American Journal of Health Promotion, 19, 327–329.

Sallis, J. F., Grossman, R. M., Pinski, R. B., Patterson, T. L., & Nader, P. R. (1987). The development of scales to measure social support for diet and exercise behaviors. Preventive Medicine, 16, 825–836.

Sallis, J. F., Kraft, K., & Linton, L. S. (2002). How the environment shapes physical activity: A transdisciplinary research agenda. American Journal of Preventive Medicine, 22, 208.

Scelza, W. M., Kalpakjian, C. Z., Zemper, E. D., & Tate, D. G. (2005). Perceived barriers to exercise in people with spinal cord injury. American Journal of Physical Medicine & Rehabilitation, 84, 576–583.

Schepers V. P., Visser-Meily, A. M., Ketelaar, M., & Lindeman, E. (2006). Poststroke fatigue: Course and its relation to personal and stroke-related factors. Archives of Physical Medicine and Rehabilitation, 87, 184–188.

Sternfeld, B., Ainsworth, B., & Quesenberry, C. P. (1999). Physical activity patterns in a diverse population of women. Preventive Medicine, 28, 313–323.

Teri, L., Gibbons, L. E., McCurry, S. M., Logsdon, R. G., Buchner, D. M., Barlow, W. E., et al. (2003). Exercise plus behavioral management in patients with Alzheimer disease: A randomized controlled trial. Journal of the American Medical Association, 290, 2015–2022.

Toole, J. F., Malinow, M. R., Chambless, L. E., Spence, J. D., Pettigrew, L. C., Howard, V. J., et al. (2004). Lowering homocysteine in patients with ischemic stroke to prevent recurrent stroke, myocardial infarction, and death: The vitamin intervention for stroke prevention (VISP) randomized controlled trial. Journal of the American Medical Association, 291, 565–575.

Tu, W., Stump, T. A., Damush, T. M., & Clark, D. O. (2004). The effects of health and environment on exercise class participation in older, urban women. Journal of Aging and Physical Activity, 12, 480–496.

Tudor-Locke, C., Myers, A. M., Jacob, C. S., Jones, G., Lazowski, D. A., & Ecclestone, N. A. (2000). Development and formative evaluation of the centre for activity and aging home support exercise program for frail older adults. Journal of Aging and Physical Activity, 8, 59–75.

Wagner, E. H., Austin, B. T., & Von Korff, M. (1996). Organizing care for patients with chronic illness. Milbank Quarterly, 74, 511–544.

Weiss, A., Suzuki, T., Bean, J., & Fielding, R. A. (2000). High intensity strength training improves strength and functional performance after stroke. American Journal of Physical Medicine & Rehabilitation, 79, 369–376.

Wilcox, S., Bopp, M., Oberrecht, L., Kammermann, S. K., & McElmurray, C. T. (2003). Psychosocial and perceived environmental correlates of physical activity in rural and older African American and White women. Journal of Gerontology: Psychological Sciences, 58, P329–337.

Wolf, P. A., Clagett, G. P., Easton, J. D., Goldstein, L. B., Gorelick, P. B., Kelly-Hayes, M., et al. (1999). Preventing ischemic stroke in patients with prior stroke and transient ischemic attack: A statement for healthcare professionals from the Stroke Council of the American Heart Association. Stroke, 30, 1991–1994.