Sunteți pe pagina 1din 8

The psychosocial effects of exercise and relaxation classes for persons

surviving a stroke
Gail Carin-Levy I Marilyn Kendall I Archie Young I Gillian Mead

Key words
I Stroke I Exercise I Relaxation I Qualitative study I Psychosocial benefits

Mots clés
I Accident vasculaire cérébral I Exercice I Relaxation I Étude qualitative I Avantages psychosociaux

Background. This study was set up to explore unexpected findings emergent from a randomized controlled trial of exercise
versus relaxation post-stroke. Purpose. Stroke survivors’ experiences of taking part in exercise and relaxation classes were
explored. Methods. In-depth, semi-structured interviews carried out with 14 community-dwelling stroke survivors in Edinburgh.
The informants previously participated in a randomized exploratory trial of exercise versus relaxation. Findings. The classes
motivated participants to take part in other purposeful activities, to continue to practice what they had learned, and/or to attend
another class in the community. Class participation also led to an improvement of self-perceived quality of life, specifically,
improved confidence, physical ability, psychosocial functioning, and a sense of empowerment. Implications. Taking part in
either exercise or relaxation classes after stroke can contribute to improved self-perceived quality of life, improved psychosocial
functioning, and improved motivation to take an active role in the recovery process.

Description. Cette étude a été menée en vue d’examiner les résultats imprévus d’un essai contrôlé aléatoire comportant des
séances d’exercice et des séances de relaxation chez des patients ayant subi un accident vasculaire cérébral (AVC). But. Les
expériences vécues par des survivants d’un AVC ayant participé à des séances d’exercice ou à des séances de relaxation ont été
étudiées. Méthodologie. Des entrevues en profondeur semi-structurées ont été menées auprès de 14 survivants d’un AVC vivant
dans la collectivité à Edinburgh. Les informateurs avaient participé auparavant à un essai exploratoire aléatoire comportant des
séances d’exercice et des séances de relaxation. Résultats. Les séances motivaient les participants à participer à d’autres activités
significatives, à continuer de mettre en pratique ce qu’ils avaient appris ou à assister à d’autres cours dans la communauté. La
participation à ces séances a également permis aux participants d’améliorer leur perception face à leur qualité de vie, en
particulier d’améliorer leur confiance, leurs habiletés physiques et leur fonctionnement psychosocial et d’avoir un sentiment de
pouvoir sur leur vie. Conséquences. La participation à des séances d’exercice ou de relaxation à la suite d’un AVC peut contribuer
à l’amélioration de la perception de la qualité de vie, du fonctionnement psychosocial et de la motivation à participer activement
au processus de rétablissement.

n 2002, we established a randomized exploratory trial of began to emerge (Mead, 2005), which we had not anticipated

I physical fitness training versus relaxation (an “attention

control” intervention) for ambulatory stroke survivors who
had completed their stroke rehabilitation, to investigate the
and which our battery of outcome measures would not detect.
We then searched the literature using a variety of search
strategies, databases, and keyword combinations for studies
effects of physical fitness training on a battery of mainly physical exploring psychosocial benefits of either exercise or relaxation,
outcome measures (Mead et al., 2007). The trial participants but we found no published research. We identified several
were community-dwelling stroke survivors in Edinburgh. The trials of exercise training after stroke, but none had included a
intervention group was an exercise class and the control group qualitative evaluation of the participants’ experiences of taking
was a relaxation class; both took place three times per week and part in the trial. Thus, we decided to formally explore the
were 12 weeks long. An exercise instructor specializing in perceived experience of both interventions using rigorous
working with older adults led the classes. qualitative methodology.
Very soon after starting the trial, anecdotal evidence of Participant involvement in the evaluation of complex
social and psychological benefits from both interventions interventions is increasingly called for due to the advantages


to the quality and depth of the data yielded in healthcare The optimum management of anxiety after stroke is
research (Campbell et al., 2000; Oakley et al., 2006). Process uncertain. A search of the literature produced evidence of the
evaluation within complex interventions may enhance the effectiveness of non-pharmacological interventions such as
science behind the trial by increasing researchers’ relaxation in stress management (Hanley, Stirling, & Brown,
understanding of numerous factors not formally measured in 2003; Spence, Barnett, Linden, Ramsden, & Taenzer, 1999;
the trial outcome battery (Oakley et al., 2006). Timmermann, Emmelkamp, & Sandrman, 1998). In a syste-
matic review, Spence et al. found that non-pharmacological
Literature review interventions, such as relaxation, cognitive, and behavioral
Stroke is a major cause of disability and death, with an therapies, were as effective at reducing and controlling blood
estimated 150,000 people in the UK suffering a stroke each pressure as drugs in hypertensive patients who suffer from
year (The Stroke Association, 2008). A common neuropsy- stress and anxiety. Hanley et al. conducted a randomized
chiatric complication of stroke is depression; depressive controlled trial of therapeutic massage versus relaxation in
symptoms are present in at least 33% of stroke survivors stressed patients and found that both interventions were
(Hackett et al, 2005). Depression post-stroke is associated with effective at reducing stress, with no significant difference
stroke severity, physical disability, and cognitive impairment, between the intervention and control groups. More recently,
and it is likely that depression reduces the capacity and will to Dusek et al. (2008) examined the effects of stress
participate in rehabilitation (Hackett & Anderson, 2005). management, specifically, relaxation response, in hyper-
Sturm et al. (2004) present an original approach by examining tensive patients and found that relaxation techniques are
handicap (defined by the authors as “disadvantage resulting more efficient than control in maintaining healthy blood
from ill health”) in stroke survivors. They found that anxiety pressure. An extensive search of the literature yielded no
and depression may independently contribute to handicap evidence of any evaluation of relaxation in stroke survivors
post-stroke and urge clinicians to treat these mood disorders (other than the report of our own trial by Mead et al., 2007).
aggressively (Sturm et al.). Post-stroke depression has been Literature from the disciplines of psychology, sociology,
associated with certain psychological factors, namely, external and occupational therapy offer a qualitative approach to
locus of control (Thomas & Lincoln, 2006). Lower levels of explore the benefits of physical exercise and activity partici-
perceived control are associated with an increase incidence of pation in terms of self-perceived quality of life and
depression and anxiety up to six months post-stroke psychosocial functioning (Blinde & McClung, 1997; Carin-
(Morrison, Johnston, & MacWalter, 2000). In an early paper, Levy & Jones, 2007; Specht, King, Brown, & Foris., 2002;
Sinyor et al. (1986) found that feelings of helplessness resulted Taub, Blinde, & Greer, 1999). These studies provide evidence
in low mood and low internal locus of control. These findings of the benefits of such activities, highlighting a perceived
are still very relevant today. Internal locus of control and self- improvement in quality of life through the enhancement of
efficacy in stroke patients have been associated positively with psychosocial functioning (improved self confidence, positive
quality of life (measured using rating scales and derived from body image, physical competence, and an enhanced sense of
functional capacity), fewer depressive symptoms, better coping control). These studies are not stroke specific and deal with a
skills, and increased motivation (Bandura, 1997; Robinson- wide range of disabilities or impairments.
Smith, Johnston, & Allen, 2000; Sinyor et al.). Social difficulties The paucity of qualitative evaluations of exercise in
after stroke are also correlated to post-stroke depression, and stroke survivors and the scarcity of any literature on the use
they include impaired ability to relate to family, adverse of relaxation techniques post-stroke expose a real gap in
changes in lifestyle, loss of social roles, and failure to resume current knowledge. Therefore, the primary aim of this study
premorbid social activities (Hafsteinsdottir & Grypdonck, was to explore participant perspectives’ of partaking in
1997; Trigg, Wood, & Langton Hewer, 1999). A study by exercise and relaxation classes with a specific interest in the
Hartman-Maeir, Soroker, Ring, and Avni (2006), dealing effects of participation in the classes on psychological and
specifically with activity participation post-stroke, found that social functioning. A secondary aim was to identify any
stroke survivors demonstrate dissatisfaction with life one year differences between exercise and relaxation in terms of their
post-stroke due to activity limitation and participation perceived benefits and relevance to stroke survivors.
restriction (as conceptualised by ICF (World Health
Organization [WHO], 2002)). Hartman-Maeir et al. call for
the focus of rehabilitation to be not only on activities of daily Study design
living (ADL), but also on leisure activities, suggesting that this We adopted a pragmatic, qualitative program evaluation
would increase life satisfaction in this population. approach (Patton, 2002) in order to explore the participants’
Psychological and social functioning can deteriorate over the experiences of the classes.
year following the stroke despite stable neurological and
general physical function (Suenkeler et al., 2002).


Sample study due to a recent bereavement. The remaining 14

This study received ethical approval from Lothian Research transcripts were re-read and compared to the tapes to ensure
Ethics Committee. We recruited participants from accuracy of transcripts. The transcripts were entered into
community- dwelling, ambulatory stroke survivors who had QSR Nvivo (version 2.0) for thematic analysis (Miles &
taken part in a randomized trial of exercise or relaxation Huberman, 1994). The first author carried out the Initial
(Mead et al., 2007). We excluded people with significant coding of the data and organized the data into themes and
memory impairment (as recorded by the trial physicians — subthemes; the second and fourth authors then corroborated
anyone with dysphasia or confusion severe enough to prevent the themes. A discussion regarding the classification of data
giving informed consent was excluded from the main trial). into particular themes took place subsequently, giving the
Potential participants were approached at a minimum of 6 researchers the opportunity to debate the accuracy of the
months and a maximum of 18 months after the course of analysis and agree upon the emergent themes. The first
classes ended. Of the 66 trial participants, 50 met the inclusion author kept a diary exploring her own biases, thoughts, and
criteria (i.e., no memory impairment and meeting the time preconceived expectations from the data (Maso, 2003). This
frame). Of these 50, as a first round of recruitment, 25 were was used in conjunction with the interview transcripts, which
selected by randomly choosing their names from a list of trial contained annotations of the rapport between informant and
participants. This list contained a person’s name, address, and interviewer, whether the informant was forthcoming with
which class they attended in the trial. It was planned that a answers, and whether the interviewer was directive at times
second round of recruitment would be employed should new during the interview. Any interruptions or contributions
themes continue to emerge from the data. The 25 trial partic- from significant others were also noted to ensure that these
ipants were approached by letter; 24 agreed to participate. did not influence the interpretation of the data.
From these 24 people, purposeful sampling was used in order
to recruit informants who would reflect the range of partic-
ipants of the STARTER trial as a whole with regard to age, Sample
gender, and social situation (i.e., type of dwelling and whether The subjects who took part in this study came from a range
living alone. See Table 1). Potential participants were then of backgrounds. There were six participants from the exercise
contacted by telephone to arrange a time and venue for a classes and eight who took part in the relaxation classes. The
meeting with the first author. Sixteen potential participants ages of the participants range from 48-85 and the Functional
were contacted; interviews were arranged and carried out Independence Measure scores (collected as part of the main
within two weeks of contact. At this meeting, informants also trial assessment battery, Mead et al., 2007) ranged from 107-
reviewed the information sheet and gave their signed consent 124. See Table 1 for subject characteristics.
to participate in the study. Recruitment ceased after these
interview transcripts were coded, since at this point, data Key themes
saturation was reached with no new themes having been The results were categorized into the following five themes:
recorded (Fossey, Harvey, McDermont, & Davidson, 2002), enjoyment, motivation, self-perceived quality of life,
data saturation was reached. empowerment, and the long-term effects of class partici-
pation. Henceforth participants from the exercise or
Data generation relaxation classes will be referred to by E and R and their
In-depth, semi-structured interviews were used to explore participant numbers (from 1 to 8).
participants’ experiences of taking part in exercise or
relaxation classes post-stroke. The interview guide was Enjoyment of the classes
developed after reviewing the available literature and in order All informants reported high levels of enjoyment from the
to explore in depth the anecdotal comments made by trial classes. There seemed to be no difference between the groups
participants throughout the trial (Mead, 2005) (see as statements from attendees from both classes were very
Appendix). All interviews were carried out by the first author similar. Subjects reported that the classes were something to
in the participants’ homes and were audiotaped, with written look forward to during their week, and they were certain that
consent. The interviews were designed to be person- they would recommend participation in such classes to
centered, and to enable the participants to bring forward others (not necessarily other stroke survivors). The following
their own views and concerns in their own terms. captures informants’ views:
R1: [It was] a combination of everything, quite honestly.
Data analysis A combination of getting out of the house, travelling
The audiotapes were transcribed by the first and second to the venue, meeting the people, the class itself of
authors. Due to a technical fault, one interview was not course, and then the repartee on the bus on the way
transcribed and a further participant was excluded from the home, as we would talk to each other, you know?


Characteristics of sample.

Subject Age Gender Dwelling Social situation FIM Score*

E1 76 M Local authority sheltered housing Lives alone 114

E2 49 M Local authority rented flat Lives with 2 daughters 117
E3 70 M Own home Lives alone 123
E4 62 M Local authority rented flat Lives alone 115
E5 75 F Own home Lives with husband 115
E6 60 F Own home Live with husband 116
R1 85 M Local authority sheltered housing Lives alone 112
R2 79 M Local authority residential home Lives in care 109
R3 77 M Own home Lives with wife 124
R4 52 M Local authority rented flat Lives alone 107
R5 74 F Local authority sheltered housing Lives alone 124
R6 74 F Own home Lives with husband 114
R7 68 F Own home Lives alone 112
R8 71 F Local authority rented flat Lives alone 122

* Functional Independence Measure: Range of score: 18–126; a higher score denotes greater independence.

Then in the privacy of your own home, thinking back knew you were going, you had something and ... it was
on the events of the day. an afternoon’s enjoyment.
R7: To start with I thought the classes were [a bit of a E7: You felt you were living, that somebody was taking
burden], but then I started to really enjoy the class, care of you, it did make you spur on, you know, you
and get to know everyone, and there was always wouldn’t be lying saying “Oh, I can’t move,” you know
something funny, you know ... actually [most of us] ... it did motivate you.”
didn’t like to miss out on a class ... . The following comment was made by E4, who was the
E3: They [all other participants, first author] were all only participant to mention that the classes were graded to
good, every one of them. They were all super. And create an appropriate challenge to the class participants; he
they all wanted to go, and they all went to all the felt that this was one of the more important factors in
classes. And they were sorry to see it ended. Aye, I motivating him to go back to the class three times per week.
miss it ... . This participant did not feel that the exercise class had made
E1: Oh, I missed it for a while ... I enjoyed it, was a difference to his motivation to participate in other activities
something to look forward to, pick yourself up, in his own time:
tomorrow, tomorrow morning, had to get down the E4: Yes, cos it got harder and harder and that’s maybe ... why
stair, ready, speak to the [warden] before the it made you go back, to beat the thing I had to do ...
ambulance come ... I felt magic! I was very sorry it
stopped! Self-perceived quality of life
The comments participants made regarding the perceived
Effect of the classes on motivation benefits from class participation were indicative of an overall
Both classes had a positive effect on participants’ motivation, improvement in self-perceived quality of life. This is substan-
not only to attend each class of the course, but also to take tiated with comments about the effects of the classes on
part in other purposeful activities throughout the day. confidence, physical ability, and psychosocial functioning.
Participants felt the classes played a role in motivating them All informants in this study reported that taking part in the
to get up and out the house on class days. Many felt that had classes had a positive effect on their confidence, which, in
it not been for their attendance in the classes they may not turn, generated an all-round benefit on day-to-day life and
have gone out as frequently as they did. They therefore physical functioning.
gained not only from the classes themselves, but also gained E1: It helped me get in the chair you see, you know what
confidence in continuing to go out. There was no obvious I mean, eh, the exercises go up and down the chair; I
difference between the exercise and relaxation class with couldn’t do it at first and then, eh, I progressed ... I’m
regards to motivation. fair pleased with myself I can walk up the street now,
R5: It was October-November, cold months, I might not after all that time.
have gone out ... if it was a bad day you would E2: I felt myself better, and I felt stronger, and
probably not go anywhere or do anything, but you weaknesses were going that were there before ... so my


head felt better, because I was more confident in what importance of mutual support and comfort, being able to
I was doing. It [gave] me a little bit more confidence discuss their progress with others who had similar
in myself. difficulties, and the feeling that “you are not alone” (R7).
There was a clear difference in statements made by the
two groups regarding physical functioning: the exercise Empowerment: Gaining control
participants mentioned improved walking and the ability to Participants were asked whether they felt that attending the
get up from a chair, whereas the relaxation class participants classes helped them to gain more control over their lives after
mentioned the overall benefits of having a commitment that the stroke. The answers ranged from a simple “yes” or “no” to
necessitated getting out of the house. The aspects raised lengthy comments on the way the class enhanced motivation
equally by both class participants were related to an increase and confidence and enabled participants to do more for
in confidence. themselves.
R2: After a stroke you are vulnerable, and going into E2: Before it wasn’t that I was unable to do them
public places you are a little worried; there was a bit of [exercises]; it was because I couldn’t be bothered
a walk from the bus to [where the class was] and you doing them. To me that’s quite a difference.
wonder whether you will be able to do it ... but I found R4: I think it gave people more power, gave them an
I could do it ... it is hard to explain it, but that is part outlook ... oh yeah, and when you think back, you had
of getting over the stroke, because you are not going to done it for yourself.
be able to do but you have to try. There were many comments relating to post-stroke
R6: I loved it. Because when I went my speech was really treatment. Participants felt that they were “left to it” once the
quite bad at the time, and, eh, I wouldn’t speak on the rehabilitation team had finished with their treatment regime,
phone ... and I was only there a week, and I was you and they felt they now had to fend for themselves. This
know speaking to everybody, and it brought me out, highlighted an attitude of self-reliance, which seemed to be
because ...[before the classes] I hadn’t the confidence enhanced by attendance in the classes. Participants felt they were
to, em, speak outside the house…” benefiting from interacting with other people who “are making
The comments regarding psychosocial functioning the same effort as you ... we boosted each other ... ” (R7).
highlighted a clear link between the benefit of socializing and Three respondents did not feel that the classes
getting out of the house with psychological well-being. necessarily had an enhancing effect on their recovery, sense
Another clear link highlighted in the responses was between of independence, or control. These participants attribute
physical achievement and a feeling of satisfaction and their recovery to their own determination and character and
generally feeling better about oneself. This is demonstrated the support received during the rehabilitation phase. The
by a wide range of statements: “I feel better about me, as an following comments capture their views:
individual” (E2); “I know I’m on the way back to myself E8: I think by [the time I attended the class] I went back
again” (R8); and “I think that there should be more of that a to work, I was just so determined that I was going to
lot more of it [these type of classes]. This helps people with get back to what I had been doing ... and I think it’s just
their mental health... ” been a lot of mind over matter and sheer determi-
The class became a very important part of the partic- nation ... I think attitude has got a lot to do with illness.
ipants’ lives for the 12-week duration. It created a welcome R1: I can’t fault the help I had in the rehabilitation. I
social situation for participants, which was as important to really feel that it’s a little degree of independence I
them as the activity they were taking part in (both exercise have now that I didn’t have before. But without the
and relaxation): help I had at rehab I would never have achieved that,
R8: By the end of it all, they all seemed to be like a family. so I think the team work of all concerned is what
E1: We all got on well, you know, we told each other helped [rather than the classes].
jokes. R5: No, I still felt the same, I still had confidence enough
R7: I think it was nice to meet everyone, and hear other that I came out the hospital, and went out the next day
people’s opinions, and also to be told what had ... so I don’t really feel any different.
happened to them, and then you felt, oh well, that’s
something, at least you’re not alone.” Long-term effects of the classes
The perceived social benefits were similar for those who The long-term effects of the classes were explored by
lived alone or with a significant other. There was no obvious discussing whether there were any exercises that participants
difference between the exercise and relaxation class partic- continued to practice at home, whether they had learnt any
ipants in terms of their enjoyment of the social interactions. new skills from the class that they can use in their day-to-day
Most respondents felt that it was important to them that the life, and whether they attended any other form of class or
group had a common factor; they repeatedly stated the group activity after the classes had finished. Five participants


in the exercise classes continued to lead an active life, and these Our findings support the available literature on the
participants stated that they did not practice their exercises at benefits of exercise for people with physical impairments/
home. The reasons given were wide ranging: From simply not chronic diseases (Carin-Levy & Jones, 2007; Specht et al.,
being interested or lacking the time to fear of falling: 2002; Taub, Blinde, & Greer, 1999; Taylor & McGruder, 1996)
E1:”No, no, no, because you wouldn’t take [any in terms of the perceived improvement in quality of life and
exercises] at home, in case I had a fall here. enhancement of psychosocial functioning (improved
Another reason for not taking part in anything at home physical ability, self confidence, and motivation), thus
or attending a class in the community given by participant E3 demonstrating their relevance for stroke survivors also. We
was that he felt he had learnt all that there was to learn: have also found that participation in the classes had a
E3: I don’t think so. I think there is not much else, unless perceived positive effect on our informants’ internal locus of
they said there was a great new thing. control, as they felt that by attending the classes they were
Two participants from the exercise class reported the empowered to take more control over their lives and to
following when asked whether they practiced any of the become more self-reliant and confident. These benefits were
exercises at home: common to both exercise and relaxation class participants,
E5: I learnt to take bigger strides, which helps with my and they correspond with perceived benefits of activity
balance ... I also do some exercises for my arm, I do participation reported in the literature (Carin-Levy & Jones;
these every day. Specht et al.; Taub et al.; Taylor & McGruder). There is
E7: Yes, I do, I still do some of the exercises like the evidence in the literature of the importance of internal locus
stretching and of course I have this wee cycling thing of control in relation to depression and anxiety post stroke
and I do a bit every day. (Bandura, 1997; Morrison et al., 2000; Sinyor et al., 1986;
Although the relaxation classes consisted of activities Robinson-Smith, Johnston, & Allen, 2000; Thomas &
based in a chair, there was a physical component to them Lincoln, 2006). While we cannot suggest that participation in
(stretching and muscle relaxation). These participants report exercise and relaxation classes helped to prevent or control
mainly on the physical elements that they continue to low mood and anxiety, it is possible to link internal locus of
practice at home. control with a general sense of well-being and greater
R1: Well, during the 12-week course she gave us various motivation in our informants.
exercises that I still carry out to this day, which I think There were differences between the two activity groups
are beneficial. in this study; the exercise group discussed the improvements
R2:“I do mainly the exercise with my legs and sitting to their physical function as a direct result of the exercises
straight so I do that kind of thing and I learnt that they undertook in the classes, whereas the relaxation group
kind of thing with the breathing in the classes as well. identified physical benefits gained from the commitment to
R8:I still do my exercises ... turn my ankle, and when I the classes and the necessity of getting out of the house three
get up, instead of getting up and walking away, I get up times per week.
and I stand, and then I go ... I just take my time to do There is evidence of the effectiveness of stress
things now. management techniques (which include relaxation) in
reducing stress and in being of benefit to hypertensive
Discussion patients and patients at risk of developing anxiety disorders
This is the first study using rigorous in-depth qualitative (Dusek et al., 2008; Hanley et al., 2003; Spence et al., 1999;
methodology to explore the psychosocial impact of Timmermann et al., 1998). This study found that taking part
engagement in exercise and relaxation following a stroke. We in relaxation classes has a positive effect on perceived quality
found that participants perceived psychosocial benefits from of life through greater internal locus of control, improved
exercise or relaxation classes in three main areas: the effect on confidence and motivation, and improved psychosocial
motivation, improved self-perceived quality of life, and functioning. All of these may have important implications in
increased empowerment. At least some of these benefits seem controlling stress and anxiety in our informants.
to persist long after the interventions had been completed, The sample in this study was selected from a sample of
unlike some of the quantitative physical benefits, which were trial participants, all of whom met strict inclusion criteria
not sustained after the interventions had been completed (Mead et al., 2007). Hence, these data represent only a
(Mead et al., 2007). Our data suggest that the benefits may selected group of stroke survivors. More disabled stroke
have been mediated in a number of different ways, including survivors may have had different views of the effects of
participating in the intervention itself, getting out of the exercise or relaxation classes and the impact of participation
house regularly, and the resumption of social interaction by in these classes may have been different in informants with a
sharing a group activity with other stroke survivors “in the wider range of abilities and impairments.
same boat” (Mead, 2005).


We explored post-stroke participants’ views of attending Key messages
exercise and relaxation classes to find they had a perceived • According to participants of a randomized control
positive effect on motivation to recover, psychosocial trial, involvement in exercise- or relaxation-based
functioning, and confidence, thus having a positive effect on group activities had a positive effect on self-perceived
quality of life. There may be long-term effects of participation quality of life.
in such classes for this population as some of our informants
• Taking part in exercise or relaxation classes may have
reported that as a result of the class they attended they were
long-term benefits for persons surviving a stroke to
motivated to continue to practice some of the activities at explore by improving motivation to continue to
home, with some even committing to attending a similar practice at home or to attend similar classes in the
class in the community. Our findings may have important community.
implications to the post-rehabilitation phase of stroke
recovery for survivors: if such classes were offered to most
stroke survivors following their discharge from hospital, it is References
possible that the quality of life of stroke survivors might be Bandura, A. (1997). Self Efficacy. New York: W. H. Freeman.
enhanced and their motivation to take control over their own Blinde, E. M., & McClung, L. R. (1997). Enhancing the physical and
recovery might be greater. Our findings add to the body of social self through recreational activity account of individuals
knowledge on the benefits of activity participation in general, with physical disabilities. Adapted Physical Activity Quarterly,
and in the stroke population in particular. This is an 14, 327-344.
important area that may in future help shape the occupa- Campbell, M., Fitzpatrick, R., Haines, A., Kinmonth, A. L.,
tional therapy service provided to stroke survivors. Sandercock, P., Spiegelhalter, D., et al. (2000). Framework for
Clearly, there is a need to conduct further research in design and evaluation of complex interventions to improve
health. British Medical Journal, 321, 694–696.
this area: we suggest that larger numbers of informants, with
Carin-Levy, G., & Jones, D. (2007). Psychosocial aspects of scuba
the inclusion of a wider variety of abilities, including
diving for people with physical disabilities: An occupational
institution-dwelling stroke survivors, will determine whether science perspective. Canadian Journal of Occupational Therapy,
these results are applicable to the wider population of stroke 74, 6-14.
survivors. We would also suggest that further research Dusek, J. A., Hibberd, P. L., Buczynski, B., Chang, B., Dusek, K. C.,
employing a combination of methodologies examine the Johnston, J. M., et al. (2008). Stress management versus lifestyle
therapeutic value of taking part in exercise and relaxation modification on systolic hypertension and medication
training for this patient group. A randomized trial design elimination: A randomized trial. The Journal of Alternative and
using the intervention versus a social group rather than Complementary Medicine, 14, 129-138.
comparing exercise versus relaxation would assist in Fossey, E., Harvey, C., McDermont, F., & Davidson, L. (2002).
Understanding and evaluating qualitative research. Australia
exploring the value of either class. We also suggest that future
and New Zealand Journal of Psychiatry, 36, 717-732.
trials have a qualitative component to them in order to
Hackett, M. L., & Anderson, C. S. (2005). Predictors of depression
corroborate both qualitative and quantitative data effectively. after stroke. Stroke, 36, 2296-2301.
Furthermore, qualitative, longitudinal work could be Hackett, M. L., Yapa, C., Parag, V., & Anderson, C. S. (2005).
undertaken to explore the long-term effects, if any, of partic- Frequency of depression after stroke a systematic review of
ipation in such activities for this patient group. observational studies. Stroke, 36, 1330-1340.
Hafsteinsdottir, T. B., & Grypdonck, M. (1997). Being a stroke
Acknowledgements patient: A review of the literature. Journal of Advanced Nursing,
This work was undertaken while Ms Carin-Levy was a 26, 580-588.
Research Assistant in Geriatric Medicine, The University of Hanley, J., Stirling, P., & Brown, C. (2003). Randomized controlled
trial for therapeutic massage in the management of stress.
Edinburgh. We are grateful to the persons who volunteered
British Journal of General Practice, 53, 20-25.
to take part in this study; their generous contributions gave
Hartman-Maeir, A., Soroker, N., Ring, H. & Avni, N. (2007)
us a clear picture of their experiences. We are grateful to our Activities, participation and satisfaction one-year post stroke.
funders: Chief Scientist Office, Scottish Executive, which Disability and Rehabilitation, 29, 559-566.
funded STARTER, and to Moray Endowment Fund, Maso, I. (2003). Necessary subjectivity: exploiting researcher’s
University of Edinburgh, University of Edinburgh motives, passions and prejudices in pursuit of answering ‘true’
Development Fund, which funded this qualitative study. questions. In L. Finlay & B. Gough (Eds.), Reflexivity: A
practical guide for researchers in health and social sciences, p.39-
51. London: Blackwell Publishing.
Mead, G. E. (2005). Exercise or relaxation after stroke? British
Medical Journal, 330, 1337.
Mead, G. E., Greig, C. A., Cunningham, I., Lewis, S., Dinan, S.,

Saunders, D., et al. (2007). Stroke: A randomized trial of management through participation in sport and physical
exercise or relaxation. Journal of the American Geriatric Society, activity experience of male college student with physical
55, 892-899. disabilities. Human Relations, 52, 1469-1483.
Miles, M. B., & Huberman, M. (1994). Qualitative data analysis: An The Stroke Association. (2008). Facts and figures online. Retrieved
expanded sourcebook. London: Sage Publications. October 23, 2008, from:
Morrison, V., Johnston, M., & MacWalter, R. (2000). Predictors of centre/facts_amd_figures/index.html.
distress following an acute stroke: Disability, control cognitions Thomas, S. A., & Lincoln, N. B. (2006). Factors relating to depression
and satisfaction with care. Psychology and Health, 15, 395-407. after stroke. British Journal of Clinical Psychology, 45, 49-61.
Oakley, A., Strange, V., Bonell, C., Allen, E., Stephenson, J., and Timmerman, I. G. H., Emmelkamp, P. M. G., & Sanderman, R.
RIPPLE study team (2006). Process evaluation in randomized (1998) The effect of a stress management training programme
controlled trials of complex interventions. British Medical in individuals at risk in the community at large. Behaviour
Journal, 332, 413. Research and Therapy, 36, 863-875.
Patton, Q. M. (2002). Qualitative research and evaluation methods Trigg, R., Wood, V. A., & Langton Hewer, R. (1999). Social reinte-
(3rd ed.). London: Sage Publications. gration after stroke the first stages in the development of the
Robinson-Smith, G., Johnston, M. V., & Allen, J. (2000). Self-care Subjective Index of Physical and Social Outcome (SIPSO).
self-efficacy, quality of life and depression after stroke. Archives Clinical Rehabilitation, 13, 341-353.
of Physical Medicine and Rehabilitation, 81, 460-464. World Health Organization. (2001). International classification of
Sinyor, D., Amato, P., Kaloupek, D. G., Becker, R., Goldenberg, M., functioning disability and health. Geneva: Author.
& Coopersmith, H. (1986). Post stroke depression:
Relationships to functional impairment, coping strategies, and Authors
rehabilitation outcome. Stroke, 17, 1102-1107. Gail Carin-Levy, BSc (Hons), is Lecturer in Occupational Therapy,
Specht, J., King, G., Brown, E., & Foris, C. (2002). The importance of School of Social Sciences, Queen Margaret University, Queen
leisure in the lives of persons with congenital physical disabilities. Margaret University Drive, Musselburgh, East Lothian EH21
American Journal of Occupational Therapy, 56, 436-445. 6UU Scotland. Tel: +44 131 4740000. Fax: +44 131 4740001. E-
Spence, J. D., Barnett, P. A., Linden, W., Ramsden, V., & Taenzer, P. mail:
(1999). Lifestyle modifications to prevent and control Marilyn Kendall, PhD, is Research Fellow, Division of Community
hypertension. Canadian Medical Association Journal, 160 (9 Health Sciences, General Practice Section, The University of
suppl), S46-S50. Edinburgh, 20 West Richmond Street, Edinburgh, EH8 9DX,
Sturm, J. W., Donnan, G. A., Dewey, H. M., Macdonell, R. A. L., Scotland
Gilligan, A. K. & Thruft, A. G. (2004). Determinants of Archie Young, MD, FRCP, is Professor (emeritus) of Geriatric
handicap after stroke. Stroke, 35, 715-720. Medicine. Geriatric Medicine, The University of Edinburgh,
Suenkeler, I. H., Nowak, M., Misselwitz, B., Kugler, C., Schreiber, W., School of Clinical and Surgical Sciences, Chancellor’s Building,
Oertel, W. H., et al. (2002). Timecourse of health related quality Little France Crescent, Edinburgh EH16 4SB. Scotland
of life as determined 3, 6 and 12 months after stroke Gillian Mead, MD, FRCP, is Senior Lecturer in Geriatric Medicine,
relationship to neurological deficit, disability and depression. Geriatric Medicine, The University of Edinburgh, School of
Journal of Neurology, 249, 1160-1167. Clinical and Surgical Sciences, Chancellor’s Building, Little
Taub, D. E., Blinde, E. M., & Greer, K. R. (1999). Stigma France Crescent, Edinburgh EH16 4SB. Scotland.

Interview questions

• Can you please describe what was good or bad about the classes? What could have been done differently?
• What is your opinion on running classes like these?
• Now that the classes are over, do you feel that you have learnt things that will help you in the long term?
• Do you continue to practice at home or attend classes now that you have had this experience?
• What motivated you to attend the classes?
• Do you feel that attending the classes has helped or hindered the way you manage at home?
• In your opinion, do you feel your quality of life has changed as a consequence of taking part in the classes?
• Would you recommend these classes to other people? Why?
• What did you learn about yourself since attending the classes?
• Since attending the classes, do you feel any different about yourself? (aspects of control over own life)
• Can you tell me about the social side of the attendance in the classes?
• Did you like or dislike meeting new people through the class?
• Did you form relationships with the instructor or with other class participants?
• Do you go out often? Has this changed after having a stroke? Has this changed again after attending the classes?
• Free comments