Hostname: page-component-cd9895bd7-fscjk Total loading time: 0 Render date: 2024-12-23T18:33:24.717Z Has data issue: false hasContentIssue false

Body, Person and Environment: Why Promoting Physical Activity (PA) with Stroke Survivors Requires Holistic Thinking

Published online by Cambridge University Press:  24 March 2016

Jacqui H. Morris*
Affiliation:
Nursing, Midwifery and Allied Health Professions Research Unit, Glasgow Caledonian University, Govan Mbeki Building, Cowcaddens Road, Glasgow, G4 OBA, UK
*
Address for correspondence: Dr Jacqui Morris, Nursing, Midwifery and Allied health professions Research Unit, Glasgow Caledonian University, Buchanan House, Cowcaddens Road, Glasgow, G4 OBA, UK. E-mail: [email protected].
Get access

Abstract

The role of physical activity (PA) after stroke is increasingly recognised as important for function, fitness and wellbeing. Current evidence shows that targeted PA after stroke improves cardiovascular fitness, walking ability and muscle strength and may ameliorate depression and improve quality of life. Secondary stroke prevention and management of cardiovascular risk factors are further health benefits. Despite increasing emphasis on organised exercise classes for stroke, PA levels remain low and effects of organised exercise interventions are not maintained once programmes have finished. Barriers to PA after stroke are complex and innovative approaches to maintaining and promoting long-term engagement in activity are required. This commentary proposes that using the International Classification of Disability and Functioning (ICF) to guide thinking about PA after stroke may help us develop and apply comprehensive solutions that increase PA levels. This approach considers stroke survivors’ PA engagement in terms of Body – the physical impairments imposed by stroke; Person – the role of identity, and psychological factors on PA; and Environment – the physical and social environments that influence PA engagement. The commentary discusses how innovative solutions addressing these issues may enable stroke survivors to be better supported to lead active lifestyles.

Type
Articles
Copyright
Copyright © Australasian Society for the Study of Brain Impairment 2016 

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

Ainsworth, B.E., Haskell, W.L., Leon, A.S., Jacobs, D.R., Montoye, H.J., Sallis, J.F., & Paffenbarger, R.S. (1993). Compendium of physical activities: Classification of energy costs of human physical activities. Medicine and Science in Sports and Exercise, 25 (1), 7180.Google Scholar
Ajzen, I. (1991). The theory of planned behaviour. Organizational Behavior and Human Decision Processes, 50, 179211.Google Scholar
Andersson, A., Kamwendob, K., & Appelrosa, P. (2008). Fear of falling in stroke patients: Relationship with previous falls and functional characteristics. International Journal of Rehabilitation Research, 31 (3), 261264.Google Scholar
Bandura, A. (1986). The explanatory and predictive scope of self-efficacy theory. Journal of Social and Clinical Psychology, 4 (3), 359–73.Google Scholar
Banks, G., Bernhardt, J., Churilov, L., & Cumming, T. (2012). Exercise preferences are different after stroke. Stroke Research and Treatment Article ID 890946, 9 pages. Retrieved from http://dx.doi.org/10.1155/2012/890946.Google Scholar
Biddle, S. J. H., & Mutrie, N. (2008). Psychology of physical activity: Determinants, well-being, and interventions (2nd ed.). London: Routledge.Google Scholar
Billinger, S.A., Arena, R., Bernhardt, J., Eng, J.J., Franklin, B.A., Johnson, C.M., . . . Tang, A., on behalf of the American Heart Association Stroke Council, Council on Cardiovascular and Stroke Nursing, Council on Lifestyle and Cardiometabolic Health, Council on Epidemiology and Prevention, and Council on Clinical Cardiology (2014). Physical activity and exercise recommendations for stroke survivors: A statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 45, 25322553.Google Scholar
Billinger, S.A., Mattlage, A.E., Ashenden, A.L., Lentz, A.A., Harter, G., & Rippee, M.A. (2012). Aerobic exercise in subacute stroke improves cardiovascular health and physical performance. Journal of Neurological Physical Therapy, 36 (4), 159165.Google Scholar
Borschmann, K., Pang, M.Y., Bernhardt, J., & Iuliano-Burns, S. (2012). Stepping towards prevention of bone loss after stroke: A systematic review of the skeletal effects of physical activity after stroke. International Journal of Stroke, 7 (4), 330335.Google Scholar
Boysen, G., Krarup, L.H., Zeng, X., Oskedra, A., Ko˜rv, J., Andersen, G., . . . Truelsen, T. (2009). ExStroke pilot trial of the effect of repeated instructions to improve physical activity after ischaemic stroke: A multinational randomised controlled clinical trial. British Medical Journal, 339, 273275.Google Scholar
Butler, E., & Evenson, K. (2014). Prevalence of physical activity and sedentary behavior among stroke survivors in the United States. Topics in Stroke Rehabilitation, 21 (3), 246255.Google Scholar
Carin-Levy, G., Kendall, M., Young, A., & Mead, G. (2009). The psychosocial effects of exercise and relaxation classes for persons surviving a stroke. Canadian Journal of Occupational Therapy, 76 (2), 7380.Google Scholar
Caspersen, C.J., Powell, K.E., & Christenson, G.M. (1985). Physical activity, exercise, and physical fitness: Definitions and distinctions for health-related research. Public Health Reports, 100 (2), 126131.Google Scholar
Damush, T., Plue, L., & Bakas, T. (2007). Barriers and facilitators to exercise among stroke survivors. Rehabilitation Nursing, 32 (6), 253262.Google Scholar
Danielsson, A., Willen, C., & Sunnerhagen, K. (2012). Physical activity, ambulation, and motor impairment late after stroke. Stroke Research and Treatment. doi: 10.1155/2012/818513.Google Scholar
Deci, E.L., & Ryan, R.M. (2008). Self-determination theory: A macrotheory of human motivation, development, and health. Canadian Psychology, 49 (3), 182185.Google Scholar
Ding, M. (2012). Tai Chi for stroke rehabilitation: A focused review. American Journal of Physical Medicine and Rehabilitation, 91 (12), 10911096.Google Scholar
Douiri, A., Rudd, A.G., & Wolfe, C.D. (2013). Prevalence of poststroke cognitive impairment: South London Stroke Register 1995–2010. Stroke, 44 (1), 138145.Google Scholar
Duncan, F., Kutlubaev, M.A., Dennis, M.S., Greig, C., & Mead, G.E. (2012). Fatigue after stroke: A systematic review of associations with impaired physical fitness. International Journal of Stroke, 7 (2), 157162.Google Scholar
Ellis-Hill, C., Payne, S., & Ward, C. (2008). Using stroke to explore the life thread model: An alternative approach to understanding rehabilitation following an acquired disability. Disability and Rehabilitation, 30 (2), 150159.Google Scholar
Eng, J., & Reime, B. (2014). Exercise for depressive symptoms in stroke patients: A systematic review and meta-analysis. Clinical Rehabilitation, 28 (8), 731739.Google Scholar
English, C., Manns, P.J., Tucak, C., & Bernhardt, J. (2014). Physical activity and sedentary behaviors in people with stroke living in the community: A systematic review. Physical Therapy, 94 (2), 185196.Google Scholar
Field, M.J., Gebrauers, N., Sugavanum, T., Nicholson, S., & Mead, G. (2013). Physical activity after stroke: A systematic review and meta-analysis. ISRN Stroke, ID 464176, doi. org/10.1155/2013/464176.Google Scholar
Fulk, G.D., Reynolds, C., Mondal, S., & Deutsch, J.E. (2010). Predicting home and community walking activity in stroke survivors. Archives of Physical Medicine and Rehabilitation, 91 (10), 15821586.Google Scholar
Gebruers, N., Vanroy, C., Truijen, S., Engelborghs, S., & De Deyn, P.P. (2010). Monitoring of physical activity after stroke: a systematic review of accelerometry-based measures. Archives of Physical Medicine and Rehabilitation, 91 (2), 288297.Google Scholar
Geidl, W., Semrau, J., & Pfeifer, K. (2014). Health behaviour change theories: Contributions to an ICF based behavioural exercise therapy of individuals with chronic disease. Disability and Rehabilitation, 36 (24), 20912100.Google Scholar
Gerrits, K.H., Beltman, M.J., Koppe, P.A., Konijnenbelt, H., Elich, P.D., de Haan, A., & Janssen, T.W. (2009). Isometric muscle function of knee extensors and the relation with functional performance in patients with stroke. Archives of Physical Medicine and Rehabilitation, 90 (3), 480487.Google Scholar
Gordon, N.F., Gulanick, M., Costa, F., Fletcher, G., Franklin, B.A., Roth, E.J., & Shephard, T. (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, the council on cardiovascular nursing, the council on nutrition, physical activity, and metabolism, and the stroke council. Circulation, 109 (16), 20312041.CrossRefGoogle ScholarPubMed
Graham, R., Kremer, J., & Wheeler, G. (2008). Physical exercise and psychological well-being among people with chronic illness and disability: A grounded approach. Journal of Health Psychology, 13 (4), 447458.Google Scholar
Graven, C., Brock, K., Hill, K., & Joubert, L. (2011). Are rehabilitation and/or care coordination interventions delivered in the community effective in reducing depression, facilitation participation and improving quality of life after stroke? Disability and Rehabilitation, 33 (3), 15011520.Google Scholar
Hackam, D.G., & Spence, J.D. (2007). Combining multiple approaches for the secondary prevention of vascular events after stroke: A quantitative modeling study. Stroke, 38 (6), 18811885.Google Scholar
Hackett, M.L., & Pickles, K. (2014). Part I: frequency of depression after stroke: an updated systematic review and meta-analysis of observational studies. Int J Stroke, 9, 10171025.Google Scholar
Hill, T.R., Gjellesvik, T.I., Moen, P.M., Trhaug, T., Fimland, M.S., Helgerud, J., & Hoff, J. (2012). Maximal strength training enhances strength and functional performance in chronic stroke survivors. American Journal of Physical Medicine and Rehabilitation, 91 (5), 393400.Google Scholar
Hillen, T., Coshall, C., Tilling, K., Rudd, A.G., McGovern, R., & Wolfe, C.D. (2003). Cause of stroke recurrence is multifactorial: patterns, risk factors, and outcomes of stroke recurrence in the South London stroke register. Stroke, 34 (6), 14571463.Google Scholar
Huber, J.G., Sillick, J., & Skarakis-Doyle, E. (2010). Personal perception and personal factors: Incorporating health-related quality of life into the international classification of functioning, disability and health. Disability and Rehabilitation, 32 (23), 19551965.Google Scholar
Inatomi, Y., Yonehara, T., Omiya, S., Hashimoto, Y., Hirano, T., & Uchino, M. (2008). Aphasia during the acute phase in ischemic stroke. Cerebrovascular Disease, 25 (4), 316.Google Scholar
Ivey, F.M., Ryan, A.S., Hafer-Macko, C.E., Goldberg, A.P., & Macko, R.F (2007). Treadmill aerobic training improves glucose tolerance and indices of insulin sensitivity in disabled stroke survivors: A preliminary report. Stroke, 38 (10), 27522758.Google Scholar
Lai, S., Studenski, S., Richards, L., Perera, S., Reker, D., Rigler, S., & Duncan, P.W. (2006). Therapeutic exercise and depressive symptoms after stroke. Journal of the Americian Geriatric Society, 54 (2), 240247.Google Scholar
Laska, A., Hellblom, A., Murray, V., Kahan, T., & Von Arbin, M. (2001). Aphasia in acute stroke and relation to outcome. Journal of Internal Medicine, 249 (5), 413422.CrossRefGoogle ScholarPubMed
Lawrence, M., Kerr, S., Watson, H., Paton, G., & Ellis, G. (2010). An exploration of lifestyle beliefs and lifestyle behaviour following stroke: Findings from a focus group study of patients and family members. BMC Family Practice, 11, 97. doi: 10.1186/1471-2296-11-97.Google Scholar
Lee, B.I., Nam, H.S., Heo, J.H., & Kim, D.I. (2001). Yonsei Stroke Registry: Analysis of 1,000 patients with acute cerebral infarctions. Cerebrovascular Disease,12 (3), 145151.Google Scholar
Li, F., Fisher, K., Harmer, P., & Macaulay, E. (2005). Falls self-efficacy as a mediator for falling in an exercise intervention for older adults. Journal of Gerontology: Psychological Sciences, 60 (1), 3440.Google Scholar
Mayo, N.E., Wood-Dauphinee, S., Cote, R., Durcan, L., & Carlton, J. (2002). Activity, participation, and quality of life 6 months poststroke. Archives of Physical Medicine and Rehabilitation, 83 (8), 10351042.Google Scholar
Mead, G.E., Greig, C.A., & Cunningham, I. (2007). Stroke: A randomized trial of exercise or relaxation. Journal of the American Geriatrics Society, 55 (6), 892899.Google Scholar
Michael, K.M., Allen, J.K., & Macko, R.F. (2005). Reduced ambulatory activity after stroke: The role of balance, gait, and cardiovascular fitness. Archives of Physical Medicine and Rehabilitation, 86 (8), 15521556.Google Scholar
Michael, K.M., Allen, J.K., & Macko, R.F. (2006). Fatigue after stroke: Relationship to mobility, fitness, ambulatory activity, social support, and falls efficacy. Rehabilitation Nursing, 31 (5), 210217.Google Scholar
Michie, S., Abraham, C., Whittington, C., McAteer, J., & Gupta, S. (2009). Effective techniques in healthy eating and physical activity interventions: A meta-regression. Health Psychology, 28 (6), 690701.Google Scholar
Michie, S., van Stralen, M.M., & West, R. (2011). The behaviour change wheel: A new method for characterising and designing behaviour change interventions. Implemention Science, 6, 42. doi: 10.1186/1748-5908-6-42.CrossRefGoogle ScholarPubMed
Morris, J.H., & Williams, B. (2009). Optimising long-term participation in physical activities after stroke: Exploring new ways of working for physiotherapists. Physiotherapy, 95 (3), 227233.Google Scholar
Morris, J.H., Macgillivray, S., & Mcfarlane, S. (2014). Interventions to promote long-term participation in physical activity after stroke: A systematic review of the literature. Archives of Physical Medicine and Rehabilitation, 95 (5), 956967.Google Scholar
Morris, J.H., Oliver, T., Kroll, T., & Macgillivray, S. (2012). The importance of psychological and social factors in influencing the uptake and maintenance of physical activity after stroke: A structured review of the empirical literature. Stroke Research and Treatment. doi: 10.1155/2012/195249.Google Scholar
Morris, J.H., Oliver, T., Kroll, T., Joice, S., & Williams, B. (2015). From physical and functional to continuity with pre-stroke self and participation in valued activities: A qualitative exploration of stroke survivors’, carers’ and physiotherapists’ perceptions of physical activity after stroke. Disability and Rehabilitation, 37 (1), 6477.Google Scholar
Mudge, S., Barber, P.A., & Stott, N.S. (2009). Circuit-based rehabilitation improves gait endurance but not usual walking activity in chronic stroke: A randomized controlled trial. Archives of Physical Medicine and Rehabilitation, 90 (12), 19891996.Google Scholar
Mukherjee, D., & Patil, C. (2011). Epidemiology and the global burden of stroke. World Neurosurgery, 76 (6 Suppl), S85S90.Google Scholar
Mulligan, H., Hale, L., Whitehead, L., & Baxter, G.D. (2012). Barriers to physical activity for people with long-term neurological conditions: A review study. Adapted Physical Activity Quarterly, 29 (3), 243265.CrossRefGoogle ScholarPubMed
Nicholson, S., Donaghy, M., Johnston, M., Sniehotta, F., van Wijck, F., Johnston, D., . . . Mead, G. (2014). Qualitative theory guided analysis of stroke survivors’ perceived barriers and facilitators to PA. Disability and Rehabilitation, 36 (22), 18571868.Google Scholar
Nicholson, S., Sniehotta, F., van Wijck, F., Greig, C.A., Johnston, M., McMurdo, M., & Mead, G.E. (2013). A systematic review of perceived barriers and motivators to physical activity after stroke. International Journal of Stroke, 8 (5), 357364.Google Scholar
Pang, M.Y., Eng, J.J., Dawson, A.S., & Gylfadottir, S. (2006). The use of aerobic exercise training in improving aerobic capacity in individuals with stroke: A meta-analysis. Clinical Rehabilitation, 20 (2), 97111.Google Scholar
Parschau, L., Fleig, L., Koring, M., Lange, D., Knoll, N., Schwarzer, R., & Lippke, S. (2013). Positive experience, self-efficacy, and action control predict physical activity changes: A moderated mediation analysis. British Journal of Health Psychology, 18 (2), 395406.Google Scholar
Patterson, S., & Ross-Edwards, B. (2009). Long-term stroke survivors’ needs and perceptions of an exercise maintenance model of care. International Journal of Therapy and Rehabilitation, 16 (12), 659669.Google Scholar
Paul, L., Wyke, S., Brewster, S., Dybus, A., Rafferty, D., & Alexander, G. (2015a). Physical activity profiles and sedentary behaviour in people following stroke: A cross-sectional study. Disability and Rehabilitation. doi: 10.3109/09638288.2015.1041615.Google ScholarPubMed
Paul, L., Wyke, S., Brewster, S., Dybus, A., Rafferty, D., & Alexander, G. (2015b). Increasing PA in stroke survivors using STARFISH, an interactive mobile phone application. Scottish Stroke AHP Forum conference abstract. Retrieved from http://www.chss.org.uk/documents/2015/07/ssahp-2015-conference-starfish-pdf.pdf.Google Scholar
Rand, D., Eng, J.J., Tang, P.F., Hung, C., & Jeng, J.S. (2010). Daily physical activity and its contribution to the health-related quality of life of ambulatory individuals with chronic stroke. Health Quality of Life Outcomes, 8, 80. doi: 10.1186/1477-7525-8-80.Google Scholar
Rand, D., Eng, J.J., Tang, P.F., Jeng, J.S., & Hung, C. (2009). How active are stroke survivors?: Use of accelerometers to assess Physical Activity. Stroke, 40, 163168.Google Scholar
Ravesloot, C., Ruggeiero, C., Ipsen, C., Traci, M., Seekins, T., Boehm, M., . . . Rigles, B. (2011). Disability and health behavior change. Disability and Health Journal, 4 (1), 1923.Google Scholar
Reed, M., Harrington, R., Duggan, A., & Wood, V.A. (2010). Meeting stroke survivors’ perceived needs: A qualitative study of a community-based exercise and education scheme. Clinical Rehabilitation, 24 (1), 1625.Google Scholar
Resnick, B., Michael, K., Shaughnessy, M., Kopunek, S., Nahm, E.S., & Macko, R. F. (2008). Motivators for treadmill exercise after stroke. Topics in Stroke Rehabilitation, 15 (5), 494502.Google Scholar
Riepe, M.W., Riss, S., Bittner, D., & Huber, R. (2004). Screening for cognitive impairment in patients with acute stroke. Dement Geriatr Cogn Disord, 17, 4953.Google Scholar
Rimmer, J.H., Rauworth, A.E., Wang, E.C., Nicola, T.L., & Hill, B. (2009). A preliminary study to examine the effects of aerobic and therapeutic (nonaerobic) exercise on cardiorespiratory fitness and coronary risk reduction in stroke survivors. Archives of Physical Medicine and Rehabilitation, 90 (3), 407412.Google Scholar
Rimmer, J.H., Wang, E., & Smith, D. (2008). Barriers associated with exercise and community access for individuals with stroke. Journal of Rehabilitation Research and Development, 45 (2), 315322.Google Scholar
Robison, J., Wiles, R., & Ellis-Hill, C. (2009). Resuming previously valued activities post-stroke: Who or what helps? Disability and Rehabilitation, 31 (19), 15551566.Google Scholar
Sallis, J.F., Owen, N., & Fisher, E.B. (2008). Ecological models of health behaviour. In Glanz, K., Rimer, B.K., & Viswanith, K. (Eds.), Health behaviour and health education, theory research and practice (4th ed., pp. 465482). San Francisco: Jossey Bass.Google Scholar
Saunders, D.H., Sanderson, M., Brazzelli, M., Greig, C.A., & Mead, G.E (2013). Physical fitness training for stroke patients. Cochrane Database of Systematic Reviews. (Issue 10). Art. No.: CD003316. doi: 10.1002/14651858.CD003316.pub5.Google Scholar
Schmidt, A., Van Puymbroeck, M., Altenburger, P., Dierks, T., Miller, K., Damush, T., & Williams, L. (2012). Balance and balance self-efficacy are associated with activity and participation after stroke: A cross-sectional study in people with chronic stroke. Archives of Physical Medicine and Rehabilitation, 93 (6), 11011107.CrossRefGoogle Scholar
Scobbie, L., Dixon, D., & Wyke, S. (2011). Goal setting and action planning in the rehabilitation setting: Development of a theoretically informed practice framework. Clinical Rehabilitation, 25 (5), 468482.Google Scholar
Sharma, H., Bulley, C., & van Wijck, F.M. (2012). Experiences of an exercise referral scheme from the perspective of people with chronic stroke: A qualitative study. Physiotherapy, 98 (4), 336343.CrossRefGoogle ScholarPubMed
Shaughnessy, M., Resnick, B., & Macko, R. (2006). Testing a model of post-stroke exercise behaviour. Rehabilitation Nursing, 31 (1): 1521.Google Scholar
Simpson, L.A., Eng, J.J., & Tawashy, A.E. (2011). Exercise perceptions among stroke survivors: Barriers and facilitators to participation. International Journal of Therapy and Rehabilitation, 18 (9), 520530.Google Scholar
Sims, J., Galea, M., Taylor, N., Dodd, K., Jespersen, S., Joubert, L., & Joubert, J. (2009). Regenerate: Assessing the feasibility of a strength training program to enhance the physical and mental health of chronic post stroke patients with depression. International Journal of Geriatric Psychiatry, 24 (1), 7683.Google Scholar
Smith, A.C., Saunders, D.H., & Mead, G. (2012). Cardiorespiratory fitness after stroke: a systematic review. Int J Stroke, 7, 499510.Google Scholar
Tiedemann, A., Sherrington, C., Dean, M., Rissel, S., Lord, S., Kirkham, C., &. O'Rourke, S. (2012). Predictors of adherence to a structured exercise programme and PA participation in community dwellers after stroke. Stroke Research and Treatment. doi: 10.1155/2012/136525/.Google Scholar
Tieges, Z., Mead, G., Allerhand, M., Duncan, F., van Wijck, F., Fitzsimons, C., & Chastin, S. (2015). Sedentary behavior in the first year after stroke: A longitudinal cohort study with objective measures. Archives of Physical Medicine and Rehabilitation, 96 (1), 1523.Google Scholar
Tousignant, M., Corriveau, H., Kairy, D., Berg, K., Dubois, M.F., Gosselin, S., . . . Daggett, V. (2014). Tele-rehabilitation to promote exercise in veterans post-stroke: An observational pilot study. International Journal of Physical Medicine and Rehabilitation, 2, 200. doi: 10.4172/2329-9096.1000200.Google Scholar
van der Ploeg, H.P., van der Beek, A.J., van der Woude, L.H.V., & van Mechelen, W. (2004). Physical activity for people with a disability: A conceptual model. Sports Medicine, 34, 639649.Google Scholar
Veerbeek, J.M., Koolstra, M., Ket, J.C., van Wegen, E.E., & Kwakkel, G. (2011). Effects of augmented exercise therapy on outcome of gait and gait-related activities in the first 6 months after stroke: A meta-analysis. Stroke, 42 (11), 33113315.Google Scholar
White, J.H., Gray, K.R., Magin, P., Attia, J., Sturm, J., Carter, G., & Pollack, M. (2012). Exploring the experience of post-stroke fatigue in community dwelling stroke survivors: A prospective qualitative study. Disability and Rehabilitation, 34 (16), 13761384.Google Scholar
Wiles, R., Demain, S., Robison, J., Kileff, J., Ellis-Hill, C., & Mcpherson, K. (2008). Exercise on prescription schemes for stroke patients post-discharge from physiotherapy. Disability and Rehabilitation, 30 (26), 19661975.Google Scholar
Wolfenden, B., & Grace, M. (2012). Identity continuity in the face of biographical disruption: It's the same me. Brain Impairment, 13 (2), 203211.Google Scholar
World Health Organization (2001). International classification of functioning, disability, and health. Geneva, Switzerland: World Health Organization.Google Scholar
Wu, S., Mead, G., Macleod, M., & Chalder, T. (2015). Model of understanding fatigue after stroke. Stroke, 46 (3), 893898.Google Scholar
Zalewski, K.R., & Dvorak, L. (2011). Barriers to physical activity between adults with stroke and their care partners. Topics in Stroke Rehabilitation, 18 (Suppl 1), 666675.Google Scholar
Zedlitz, A.M., Rietveld, T.C., Geurts, A.C., & Fasotti, L. (2012). Cognitive and graded activity training can alleviate persistent fatigue after stroke: A randomized, controlled trial. Stroke, 43 (4), 10461051.Google Scholar