Stroke is a leading cause of disability, affecting around 60,000 people every year in Australia [
Understanding and incorporating an individual’s exercise preferences into a program can help to increase motivation to exercise [
Long-term engagement of stroke survivors in exercise programs may reduce further stroke and enhance recovery [
The lack of previous research in this area made it difficult to formulate hypotheses. We predicted that stroke patients will have different exercise preferences to controls, given the wide range of physical and emotional impacts of stroke. For the same reason, we hypothesised that variability in exercise preferences will be higher within the stroke group than the control group. Finally, we hypothesised that exercise preferences will be associated with current activity levels, quality of life, and psychological wellbeing.
Stroke survivors and healthy older people living in the community were eligible for recruitment, providing they were at least 18 years old and were able to communicate in English. Stroke participants must have had a completed stroke (not TIA) not less than 6 months and not more than 4 years previously. Participants for the stroke group were recruited through the Stroke Association of Victoria and affiliated Stroke Support Groups and the National Stroke Research Institute register of people interested in participating in further research. Controls included partners of participating stroke survivors, people from community groups across Victoria, and colleagues’ family members and friends.
Potential participants were contacted by the researcher (G. Banks) or a stroke network coordinator and briefed about the study. All participants gave written informed consent prior to participation. Procedure was the same for stroke survivors and controls. The assessment tools were completed in 1 of 3 ways: (a) mailed out to the participant with attached instructions, (b) completed by the participant in the presence of the researcher, or (c) read to the participant with their verbal responses recorded verbatim by the researcher. Participants were instructed to fill in the questionnaires as honestly and accurately as possible and assistance was only given to clarify questions. All study procedures and assessment tools were approved by the La Trobe University Faculty of Health Sciences Ethics Committee.
The primary outcome for this study was exercise preference, as indicated by the Exercise Preference Questionnaire (EPQ). Secondary outcome measures, detailed below, included the Human Activity Profile (HAP), the Assessment of Quality of Life (AQoL) scale, and the Irritability, Depression, and Anxiety (IDA) scale. Background information on age, gender, marital status, living arrangements, and type of stroke and side affected (if applicable) was also collected.
The questionnaires used to probe exercise preference in older adults [
Factor 1 “group” | I like to exercise alone |
I like to exercise with family or friends | |
I like to exercise with other people of similar age | |
I like to exercise in a community group | |
Factor 2 “structure” | I like to do the same activity each time I exercise |
I like my exercise sessions to be planned (e.g., water aerobics class) | |
I like to have written instructions for my exercises | |
I like to make exercise part of my daily activities (e.g., walk to shops) | |
Factor 3 “independence” | I like someone showing me what to do when I exercise |
I like someone else to organise my exercise sessions | |
I like the flexibility of organising my own exercise sessions | |
Factor 4 “location” | I like to exercise at a gym |
I like to exercise at a community fitness centre | |
I like to exercise at a rehabilitation centre | |
I like to exercise at home | |
I like to exercise outdoors | |
Factor 5 “exertion” | I like to feel tired after an exercise session |
I like to do gentle exercise | |
I like to work hard in an exercise session |
Section 3 had three open questions enabling the participant to specify what they liked and disliked about exercise, and what stopped them from exercising. The last two questions asked participants to identify favoured types of exercise, first by listing three favourites (with no prompts) and then selecting most to least favourite of 10 exercise options (walking, water aerobics, golf, swimming, weight training, bowls, yoga, pilates, cycling, and gym).
The HAP is a measure of activity that includes 94 activity items that require increasing energy expenditure [
The IDA includes four subscales, but was primarily used to assess anxiety and depression levels. Of the 18 self-report items, five assess depression, five assess anxiety, and the other eight assess irritability. Higher scores represent greater mood disorder. The IDA has been validated [
The AQoL is a utility-based scale that assesses health-related quality of life across five dimensions: independent living, social relationships, illness, physical senses, and psychological wellbeing [
To analyse differences in exercise preference between stroke survivors and controls on these factors, we first removed the 3 stroke-specific items. Second, in cases where questions reflected opposing views, for example, “I like to exercise alone” and “I like to exercise in a group,” the anchor for the score of one question was reversed (from zero to 100). So if a score of 30 was recorded by the participant on this question, the final score for analysis was 70. This allowed us to determine an average agreement score for each factor, which was the sum of all scores for each question related to that factor divided by the number of questions within the factor. This was the score used for analysis for each factor. A single overall exercise preference score was also generated, termed a “vector,” by combining all five factors together.
Although we proposed the five
A coding tree was created for responses to the three open-ended questions (liked and disliked aspects of exercise and limitations to exercise). All responses were then coded independently by two reviewers (G. Banks and J. Bernhardt), and responses were tallied for each group.
For each of the five
For the data-driven approach, the first step was a factor analysis of data from all relevant items in Section
To determine the variability in preferences across the two groups, standard deviations for each
Pearson correlations were computed to establish whether there were associations between exercise preferences, current activity levels, quality of life and anxiety, and depression. Descriptive statistics were used to summarise responses to the open questions in Section
The demographic characteristics of the 23 stroke survivors and 41 controls are outlined in Table
Participant characteristics.
Characteristic | Stroke ( | Control ( |
---|---|---|
Male | 15 (65) | 27 (66) |
Age— | 63.4 (14.7), 36–86 | 60.7 (13.5), 34–87 |
Married | 15 (65) | 34 (83) |
Living arrangements | ||
Home alone | 6 (26) | 4 (10) |
Home with others | 16 (70) | 37 (90) |
Hostel | 1 (4) | 0 (0) |
Side affected by stroke | ||
Left | 16 (69) | n/a |
Right | 5 (22) | n/a |
Other | 2 (9) | n/a |
Months since stroke— | 22.1 (13.6), 6–47 | n/a |
*
Stroke survivors had different exercise preferences to controls on 4 of the 5 factors (Figure
Mean scores for stroke and control groups on each of the 5
With the factors combined into a single vector, the stroke and control groups were significantly different on the total combined score (
Principal components analysis yielded 6 factors with eigenvalues >1, and these factors together accounted for 67% of the variance. Factor 1 alone accounted for 24%, factor 2 for 12%, and factor 3 for 11%. Cronbach’s alpha was 0.75, indicating good internal consistency of the scale. The pattern matrix is presented in Table
Factor analysis loadings used to derive the 6 data-driven factors.
1 | 2 | 3 | 4 | 5 | 6 | |
---|---|---|---|---|---|---|
I prefer to exercise in the morning | .699 | |||||
I like to have written instructions for my exercise | .624 | |||||
I like to do the same activity each time I exercise | .609 | |||||
I like to do gentle exercise | .600 | |||||
I like to exercise at home | .530 | |||||
I like someone showing me what to do when I exercise | .506 | |||||
I like my exercise sessions to be planned | .506 | |||||
I like to exercise at a rehabilitation centre | .821 | |||||
I like to exercise at a gym | .727 | |||||
I like to exercise at a community fitness centre | .587 | |||||
I like the flexibility of organising my own exercise sessions | −.835 | |||||
I like to exercise in a community group | .663 | |||||
I like someone else to organise my exercise session | .562 | |||||
I like to exercise outdoors | .808 | |||||
I like to make exercise part of my daily activities | .780 | |||||
I like to exercise with other people of similar age | .526 | |||||
I like to exercise alone | −.506 | .517 | ||||
I feel I am able to participate in an exercise program | .800 | |||||
I like to exercise | .644 | |||||
I like to work hard in an exercise session | .643 | |||||
I like to feel tired after an exercise session | .819 | |||||
I like to exercise with family or friends | .508 |
Data-driven factor labels.
Factor | Label | Exercise preferences |
---|---|---|
1 | Routine, unadventurous | Planned, instructed, gentle, at home, prefer AM |
2 | Gym-goer | Rehab centre, gym, fitness centre, not alone |
3 | Follower | Not organising, community group, someone else to organise |
4 | Flexible | Outdoors, part of daily life, with similar-aged people, alone |
5 | Active | Able to exercise, like to exercise, like to work hard |
6 | Strenuous, social | Like to feel tired, with family of friends |
When the two groups were compared on the weighted factor scores, it was found that stroke survivors had different exercise preferences to controls on 2 of the 6 factors. Stroke survivors had greater preference for routine/“unadventurous” exercise (
The error bars in Figure
Using the 5
More stroke survivors than controls were currently participating in an organised exercise program (48% versus 29%). Stroke survivors and controls were similar in the aspects of exercise they reported liking, focusing on the health benefits, improvements to fitness and strength, and how good it makes one feel. There were group differences in dislikes and barriers, however, with stroke survivors reporting pain and tiredness whereas controls reported issues with not having enough time and motivation (see Table
Likes, dislikes, and limitations to exercise for stroke survivors and controls.
Stroke | Control | |||
---|---|---|---|---|
Top 5 likes | 1- Improves mobility | 5 (22) | 1- Improves fitness and strength | 19 (46) |
2- Is healthy | 4 (17) | 2- Makes you feel better | 17 (41) | |
3- Improves fitness and strength | 4 (17) | 3- Is healthy | 5 (12) | |
4- Makes you feel better | 4 (17) | 4- Makes you flexible | 3 (7) | |
5- Improves the effects of stroke | 4 (17) | 5- Makes you feel happy | 3 (7) | |
Top 3 dislikes | 1- Nothing | 9 (39) | 1- Nothing | 11 (27) |
2- Tiredness | 5 (22) | 2- Time it takes | 7 (17) | |
3- Pain | 3 (13) | 3- Hard to fit in | 4 (10) | |
Top 5 limitations | 1- Nothing | 5 (22) | 1- No time | 11 (27) |
2- Being tired | 4 (17) | 2- Motivation | 6 (15) | |
3- Laziness | 3 (13) | 3- Nothing | 5 (12) | |
4- Weather | 2 (9) | 4- Injuries | 5 (12) | |
5- Illness | 2 (9) | 5- Laziness | 4 (10) |
NB: most participants gave multiple responses.
The notable finding from this study was that stroke survivors have different exercise preferences to people of the same age who have not had stroke. These preference differences were evident irrespective of whether the EPQ’s factor structure was defined
First we will discuss group differences on the 5
A similar picture emerged from data-driven factor analysis. Factor 1 (“routine-unadventurous”) corresponded with the
Our findings in stroke do have similarities to those identified in cardiac patients, who were found to place more importance on being part of group exercise and having individualised attention from professionals than controls [
Correlational analyses using the
Responses to the open questions were informative. Both stroke and control groups liked exercise because it is healthy, improves fitness and strength, makes one feel good, and keeps the mind active. The two groups diverged, however, when it came to dislikes. Stroke survivors indicated that they did not like exercise because it can cause them pain and make them tired. A susceptibility to fatigue and tiredness is common after stroke, making previously routine activities tiring [
Understanding exercise preferences is important when organising an exercise or rehabilitation program. This preliminary study gives an insight into the exercise preferences of stroke survivors and their interaction with current activity levels, psychological wellbeing and quality of life. The next step will be to refine the Exercise Preference Questionnaire, adding or removing items where necessary, to ensure that it captures the most relevant information without becoming unwieldy.
This questionnaire is about what kinds of exercise you like and don’t like.
Your answers will help us understand more about the best kinds of exercise programs for people after a stroke.
Please answer honestly—all information collected is confidential.
The questionnaire shouldn’t take more than 10 minutes—thank you for your time.
Do you currently participate in an organised exercise program?
Yes
How long have you participated in this program for?
Less than 1 month
More than 6 months
What does this program include? Tick all that apply.
Walking
Swimming
Other
Please indicate how much you agree with each of the following statements:
Don’t agree at all (0%)—Totally agree (100%) I like to exercise I feel I am able to participate in an exercise program I prefer to exercise in the morning I like to exercise at a gym I like to exercise alone I like to do the same activity each time I exercise I like someone showing me what to do when I exercise I like to exercise at a community fitness centre I like to feel tired after an exercise session I like to exercise with family or friends I like my exercise sessions to be planned (e.g., water aerobics class) I like someone else to organise my exercise sessions I like to exercise at a rehabilitation centre I like to do gentle exercise I like to exercise with other people of similar age I like to have written instructions for my exercise I like the flexibility of organising my own exercise sessions I like to exercise at home I think exercise will help prevent further stroke I like to work hard in an exercise session I like to exercise with other people who have had a stroke I like to make exercise part of my daily activities (e.g., walk to shops) I like to exercise outdoors I like to exercise in a community group I worry that exercise might cause another stroke What do you like about exercise? ………………………………… What don’t you like about exercise? ………………………………… What stops you from exercising? ………………………………… List your three favourite types of exercise ………………………………… Number the following forms of exercise from 1–10 with 1 being your favourite and 10 being your least favourite form of exercise: Walking Swimming Yoga THE END—Thank you very much.
The authors thank all stroke survivors and controls for devoting their time and effort to participating. G. Banks was supported by an honours grant from the National Stroke Foundation.