Self-Management to Promote Physical Activity after

Discharge from Inpatient Stroke Rehabilitation 1

Al-Hussein Bin Talal University

Princess Aisha Bint Al-Hussein College for Nursing and Health Sciences

Nursing Department – Master Program

Acute Care Nursing for Adult- theory II

Term paper
Self-Management to Promote Physical Activity after Discharge from Inpatient Stroke
Rehabilitation
Prepared by:
Maysa’a Al-hilalat & Salsabeel Al-Salameen
Supervised by:
Dr. Lubna Dwerij.
Self-Management to Promote Physical Activity after
Discharge from Inpatient Stroke Rehabilitation 2

Introduction

Stroke survivors have a threefold increased risk of having a second cardiovascular incident

compared to the general population (Sen et al., 2009). Many researchers indicates that physical

activity has a preventive effect against stroke (Howard & McDonnell, 2015), that it can reduce

cardiovascular risk factors in patients who have had a stroke (D’Isabella, Shkredova, Richardson,

& Tang, 2017), and that not getting enough physical activity increases the risk of recurrent stroke

(Towfighi et al., 2017). Generally speaking, the degree of physical activity conducted by stroke

survivors who live in the community is low (Després, 2016). Also, maintaining a high level of

physical activity after a stroke is difficult, presumably because of the poor cardiorespiratory

fitness which will alter the physical activity (Agustiyaningsih, Marta, & Mashfufa, 2020).

Fitness, poor walking ability, and a low sense of self-efficacy are also factors to consider (Regan

et al., 2021).

Exercise can help patients regain your aerobic fitness after a stroke (Mansfield et al., 2016).

Patients with stroke who are physically active report higher levels of satisfaction with their lives

and better quality of life than those who are not physically active. Physical activity, particularly

aerobic exercise, is known to improve cardiovascular health and is recommended for secondary

stroke prevention (Billinger et al., 2014). Importantly, aerobic exercise has been shown to be

beneficial even in the early stages of stroke, and it may be easily included into everyday

rehabilitation. However, because the length of stay in stroke rehabilitation is generally brief,

continued exercise after release is required to retain the benefits obtained throughout the

rehabilitation period. Participants in supervised exercise programs such as modified cardiac

Self-Management to Promote Physical Activity after
Discharge from Inpatient Stroke Rehabilitation 3

rehabilitation who have had a chronic stroke may benefit from referral to other programs that

assist them to develop or maintain aerobic fitness (Howes, Mahenderan, & Freene, 2020).

Referral to such a program, on the other hand, does not imply that a person will enroll (enrollment

rates average 42 %) or actively participate in its activities (38 % of people who enroll in cardiac

rehabilitation attend less than half of the exercise sessions) (Grace et al., 2016). Furthermore,

engagement in such initiatives is not sustainable over an extended period of time. For this reason,

participation in self-directed physical activity is essential for long-term fitness maintenance.

Individuals who have suffered a stroke, on the other hand, are regularly found to be less active

than their age-matched counterparts. Individuals who have suffered a stroke are forced to give

up more than half of the physical activities they were involved in before their stroke. Following

discharge from rehabilitation, physical activity levels begin to fall. Individuals with stroke who

live in their communities and are mobile often walk less than 4,200 steps (Phusuttatam,

Saengsuwan, & Kittipanya-ngam, 2019; Tudor-Locke et al., 2011). When heart rate monitors

were used to evaluate the cardiovascular challenge of daily physical activity, none of the

participants with a stroke reached the guidelines for frequency, intensity, and duration of physical

activity (Field, et al., 2013), according to the findings of one study. For these reasons, even when

persons who have suffered a stroke are physically active, the intensity of the exercise is not

sufficient to cause any changes in physical fitness. Because of the chronic inactivity experienced

by this group, any increases in aerobic fitness acquired during rehabilitation are quickly lost

following discharge (Fan & Jia, 2020). Therefore, techniques for promoting long-term uptake of

self-directed exercise after stroke are needed to be developed. Following the completion of

formal therapy, interventions to encourage longer-term self-directed exercise after stroke have

been predominantly targeted at patients who have returned to their homes after completing formal
Self-Management to Promote Physical Activity after
Discharge from Inpatient Stroke Rehabilitation 4

rehabilitation (Moore et al., 2018). Targeted fitness programming during rehabilitation may

provide an opportunity not only to boost aerobic capacity, but also to shape long-term self-

directed physical activity behavior once the patient returns to the community. Increasing exercise

self-efficacy before discharge from rehabilitation has been shown to predict exercise behavior

after stroke (Espernberger, Fini, & Peiris, 2021), and it is possible that increasing exercise self-

efficacy prior to discharge from rehabilitation could influence long-term exercise behavior.

Self-management reflects a person’s responsibility for the daily conduct of healthy behaviors that

may mitigate a disease or disability. Self-efficacy, the confidence in one’s capabilities to develop

and meet planned goals, increases as self-management proceeds successfully.

The purpose of this study is to detect the feasibility of self-management program that can improve

the physical activity after discharge from inpatient stroke rehabilitation.

Literature review

DePaul et al. )2020) investigated Inpatient Rehabilitation for Independent Mobility-Related

Physical Activity (IMPACT) is a coach-assisted intervention that uses self-management strategies

to empower patients to engage in additional autonomous walking-related activities following a

stroke, both during and following inpatient rehabilitation. This program, the Independent Mobility-

related Physical Activity, was implemented with a convenience sample of ten persons in an

inpatient stroke rehabilitation unit using a pre-intervention/post-intervention paradigm. The

researchers found that, all participants were able to identify a personal objective, negotiate a

practice plan for autonomous walking-related activities, and partially or entirely stick to that plan,

regardless of their prior experience. Patients completed an average of 36 minutes of practice each
Self-Management to Promote Physical Activity after
Discharge from Inpatient Stroke Rehabilitation 5

day outside of supervised physiotherapy sessions, with practice taking place on both weekdays

and weekends. All patients stated that the IMPACT program assisted them in increasing their

activity level, and they stated that they would continue to engage in walking-related activities after

the coaching period ended.

Brauer et al. (2018) conducted a protocol for a randomized controlled trial encompassing 128

stroke survivors undergoing rehabilitation via treadmill training and self-management (IMPACT),

they found that improving stroke survivors’ walking ability and cardiorespiratory fitness is likely

to increase their levels of physical activity. Additionally, self-management results in maintained

high levels of physical activity, this should translate into increased involvement and a higher

quality of life for all participants.

Mansfield et al. (2016) adopted self-management program, PROPEL, during stroke therapy to

encourage the continuation of physical activity beyond discharge. The purpose of this study was

to determine the feasibility of doing a bigger study to examine the effect of this program on

involvement in self-directed physical exercise among college students.

Caetano, et al. (2021) conducted that self-management program appears to be feasible in a middle-

income country and has the potential to increase physical activity levels in sedentary individuals

with mild disability after stroke.

Jones & Riazi (2011) concluded that, in general, there is some evidence of the influence of self-

efficacy on outcomes post stroke and some support for stroke specific self-management

interventions.

Ezeugwu & Manns (2017) conducted a cross-sectional cohort study on 30 patients with ischemic

or hemorrhagic stroke who were discharged from an inpatient stroke rehabilitation hospital

between 2-4 weeks. The extent of disability was determined using the Chedoke–McMaster Stroke
Self-Management to Promote Physical Activity after
Discharge from Inpatient Stroke Rehabilitation 6

Assessment (CMSA) scale, which varied from 1 to 7, with 1 indicating no active movement and 7

suggesting normal movement. They discovered that persons who have had a stroke sleep for longer

periods of time than usual, spend almost three-quarters of their waking hours in sedentary

behaviors, and walk very little after stroke recovery.

Kanai et al. (2017) evaluated the effectiveness of promoting physical activity by enhancing self-

efficacy in hospitalized patients with mild ischemic stroke who could walk without assistance were

recruited. They suggested that enhancing the self-efficacy of the patients will increase physical

activity during the interventions. The results provide new strategies for the promotion of physical

activity in these types of hospitalized patients. Twenty-two patients were included and physical

activity during the intervention was higher than that at the baseline measurement.

in the Arab community, Nazzal et al. (2001) used the modified Barthel index to collect data from

80 hemiplegic patients with completed stroke and identify specific local characteristics that

adversely affect outcomes by a neurologist, physiatrist, and physiotherapist on admission and

release. The index has shown to be completely acceptable and simple to implement in our

community, as well as a means of providing input to our national organizations. The rehabilitation

team quickly learned how to use it and reproduce the data it collected. The rehabilitation goals

were met by a decrease in the number of people with more severe MBI scores and an increase in

the number of people with less severe MBI scores .

Stein et al. (2021) developed a stroke rehabilitation guideline in the United States to be applicable

in the health care systems. These guidelines had been reviewed by a working group of stroke

rehabilitation experts based on the AHA/ASA “Guidelines for Adult Stroke Rehabilitation and

Recovery”. One of the most important strokes rehabilitation guideline recommendations was
Self-Management to Promote Physical Activity after
Discharge from Inpatient Stroke Rehabilitation 7

participation should do exercise or physical activity at home or in the community. And these

recommendations identified to be suitable for creating performance measures.

Espernberger et al. (2021) investigated the personal and social factors that perceived to influence

physical activity levels in stroke survivors. A comprehensive review of 1269 publications were

conducted. Physical activity levels in the general older population have been proven to be

influenced by social connections, support, and relationships. Social activities and support, pre-

stroke identity, self-efficacy levels, and completion of activities that were meaningful to stroke

patients all influenced physical activity levels in stroke survivors.

Agustiyaningsih et al. (2020) adopted an observational study design with a case-control technique

to examine the physical activity of patients following a stroke event. The international physical

activity questionnaire was used to measure the physical activity. Most physical activity among

stroke victims was minor, according to the findings (68.3 percent.). As a result, they advised

continuing to engage in physical exercise to lower the risk of stroke recurrence.

The advancements and problems in stroke rehabilitation were discussed by Stinear et al. (2020).

In most trials, they found that participants' motor performance improved, but to a similar level in

both the intervention and control groups. These results could be due to a lack of further benefit

from the interventions examined, or they could be due to the numerous problems of organizing

and conducting large stroke rehabilitation trials. New approaches to patient selection, control

treatments, and endpoint assessments are among the strategies for increasing trial quality. Even

though stroke rehabilitation research is constantly striving for better trials, interventions, and

outcomes, rehabilitation approaches continue to aid patients in regaining independence following

a stroke.
Self-Management to Promote Physical Activity after
Discharge from Inpatient Stroke Rehabilitation 8

Conclusion

As a result of self-management training, participants in clinical trials may experience increased

compliance, improved outcomes by engaging participants beyond the time of formal practice,

and the ability to carry over training from one trial to another. Self-management training may

support earlier home discharge after stroke, more daily practice at home during formal and post

rehabilitation care, and increased compliance in clinical trials. A goal and reality will be revealed

by feedback from frequent interim assessments regarding progress, made possible by wireless

worn sensors and instrumented workout gear. This will allow for timely discussion and guidance

about how to close the gap between goal and reality. However, if clinicians are to maximize self-

efficacy for rehabilitation in order to further diminish impairments and disabilities and increase

the participation of disabled people, a broader spectrum of behavioral techniques may need to be

incorporated into trials and daily care in a standardized manner.

A significant health issue that has a large personal and communal cost has the potential to reduce

impairment and burden of care in people who have it, according to the researchers. Heart, stroke,

and vascular illnesses are together one of the most common causes of premature mortality and

disability in the industrialized world, accounting for one-third of all deaths and disabilities. More

than 75% of persons who have a stroke have coronary heart disease, and they are 2–3 times more

likely than the general population to be admitted to the hospital with coronary heart disease and

heart failure, which leads to high health-care expenses. Inactivity is an established risk factor for

coronary heart disease, and low levels of physical activity are a contributing factor. People who

have suffered a stroke have reduced levels of physical activity. Numerous studies have

demonstrated that stroke survivors can improve their fitness and, as a result, their physical
Self-Management to Promote Physical Activity after
Discharge from Inpatient Stroke Rehabilitation 9

activity in the short term by utilizing self-management programs. The self-management

component of the intervention is also expected to result in the maintenance of high levels of

physical activity over the long term, so enhancing quality of life and lowering the load on others.

Given the large demographic shift occurring in industrialized countries, which includes a

significant increase in the elderly population, this research has the potential to make a significant

evidence-based contribution to the promotion of healthy ageing.

Recommendation

In Jordan, small-vessel occlusion was the most frequent stroke etiology and large artery

atherosclerosis was associated with the highest residual disability. As well, current smoking

status, and age above 50 appeared to be the strongest predictors of prognosis. Therefore, there is

a need to improve walking ability and cardiorespiratory fitness. Long-term follow-up should be

included in future research to see if the benefits of improving self-management to increase

physical health persist over time. In addition, wirelessly worn sensors and instrumented workout

gear are being used to expose the results of frequent interim assessments regarding progress.
Self-Management to Promote Physical Activity after
Discharge from Inpatient Stroke Rehabilitation 10

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