Eligibility, Enrollment, and Completion of Exercise-Based Cardiac Rehabilitation Following Stroke Rehabilitation: What Are the Barriers?

Abstract

Background People after stroke benefit from comprehensive programs for the prevention of secondary effects, including cardiac rehabilitation (CR), yet there is little understanding of eligibility for exercise and barriers to use. Objective The aim of this study was to examine eligibility for CR; enrollment, adherence, and completion; and factors affecting use. Design This was a prospective study of 116 consecutive people enrolled in a single outpatient stroke rehabilitation (OSR) program located in Toronto, Ontario, Canada. Methods Questionnaires were completed by treating physical therapists for consecutive participants receiving OSR and included reasons for CR ineligibility, reasons for declining participation, demographics, and functional level. CR eligibility criteria included the ability to walk ≥100 m (no time restriction) and the ability to exercise at home independently or with assistance. People with or without hemiplegic gait were eligible for adapted or traditional CR, respectively. Logistic regression analyses were used to examine factors associated with use indicators. Results Of 116 participants receiving OSR, 82 (70.7%) were eligible for CR; 2 became eligible later. Sixty (71.4%) enrolled in CR, and 49 (81.7%) completed CR, attending 87.1% (SD = 16.6%) of prescribed sessions. The primary reasons for ineligibility included being nonambulatory or having poor ambulation (52.9%; 18/34 patients) and having severe cognitive deficits and no home exercise support (20.6%; 7/34). Frequently cited reasons for declining CR were moving or travel out of country (17.2%; 5/29 reasons), lack of interest (13.8%; 4/29), transportation issues (10.3%; 3/29), and desiring a break from therapy (10.3%; 3/29). In a multivariate analysis, people who declined CR were more likely to be women, less compliant with OSR, and not diabetic. Compared with traditional CR, stroke-adapted CR resulted in superior attendance (66.1% [SD = 22.9%] versus 87.1% [SD = 16.6%], respectively) and completion (66.7% versus 89.7%, respectively). The primary reasons for dropping out were medical (45%) and moving (27%). Limitations Generalizability to other programs is limited, and other, unmeasured factors may have affected outcomes. Conclusions An OSR-CR partnership provided an effective continuum of care, with approximately 75% of eligible people participating and more than 80% completing. However, just over 1 of 4 eligible people declined participation; therefore, strategies should target lack of interest, transportation, women, and people without diabetes. An alternative program model is needed for people who have severe ambulatory or cognitive deficits and no home exercise support.

Inclusion of People Poststroke in Cardiac Rehabilitation Programs in Canada: A Missed Opportunity for Referral

“…Although these components have not been examined in a randomized controlled trial, a recent prospective study by our group demonstrated that collaboration between a CRP with a single SR program using the described recommendations resulted in 71% of all eligible patients poststroke being enrolled. 33 …”

“…Given the estimate that there are 182 CRPs in Canada, 37 approximately 50,000 strokes occurring in Canada annually (Heart and Stroke Foundation of Canada, 2003), and approximately 72% of patients would be eligible to participate in CR, 33 each CRP in Canada would need to accept approximately 198 stroke referrals annually. However, in the current study only 6.4% of programs that accepted stroke received > 100 to 200 patients annually after stroke.…”

“…20,[29][30][31][32] In addition, when given the opportunity, the proportion of eligible patients who have had a stroke and who enroll in CRPs (71%) is superior to that reported in patients with cardiac disease (40%) with superior completion rates (82%) than reported in the population with cardiac disease (60%-70%). 28,[32][33][34] Although current evidence supports establishing a continuum of care from SR to CRPs, it is not clear if Canada's healthcare system is adequately integrating this population into CRP facilities. To our knowledge, no study has identified the number of people poststroke who participate, the eligibility criteria, the program characteristics associated with inclusion (exploratory), or the barriers and facilitators to including people poststroke in Canadian CRPs.…”

“… 20 , 29 , 30 , 31 , 32 In addition, when given the opportunity, the proportion of eligible patients who have had a stroke and who enroll in CRPs (71%) is superior to that reported in patients with cardiac disease (40%) with superior completion rates (82%) than reported in the population with cardiac disease (60%-70%). 28 , 32 , 33 , 34 …”

Cardiac disease and stroke: Practical implications for personalised care in cardiac-stroke patients. A state of the art review supported by the Association of Cardiovascular Nursing and Allied Professions

“…Also, patients may have severe cognitive deficits which would make them ineligible for participation. 49 These factors should be considered prior to starting cardiac rehabilitation and also in the patient education and support for these patients.…”