Abstract
Background Evidence-based practice promotes patient-centered care, yet the majority of rehabilitative research fails to take patient perspectives into consideration. Qualitative research provides a unique opportunity for patients to express opinions and provide valuable insight on intervention processes.
Objective The purpose of this study was to assess the feasibility of a novel, intensive, task-specific intervention from the patient's perspective.
Design A phenomenological approach to qualitative inquiry was used.
Methods Eight individuals with chronic stroke participated in an intensive intervention, 3 hours per day for 10 consecutive days. Participants were interviewed twice regarding their impressions of the therapy, and a focus group was conducted with participants and family members. Data analysis included an analytical thematic approach.
Results Five major themes arose related to the feasibility of the intervention: (1) a manageable amount of fatigue; (2) a difficult, yet doable, level of intensity; (3) a disappointingly short therapy duration; (4) enjoyment of the intervention; and (5) muscle soreness.
Conclusions The findings suggest that participants perceived this novel and intensive, task-specific intervention as a feasible therapeutic option for individuals with chronic stroke. Despite the fatigue and muscle soreness associated with intensive rehabilitation, participants frequently reported enjoying the therapy and stated disappointment with the short duration (10 days). Future research should include a feasibility trial of longer duration, as well as a qualitative analysis of the benefits associated with the intervention.
Current literature suggests that task-specific practice and repetition play a major role in cortical reorganization and functional recovery following stroke.1–6 These basic motor learning principles have been integrated into neurological rehabilitation with success.1–6 Intensive mobility training (IMT) is a novel intervention based on concepts of motor learning theory, repetition of practice, and task-specific training, using a massed practice schedule in an effort to stimulate functional recovery of gait, balance, and mobility in individuals with chronic stroke.
Intensive mobility training applies concepts of constraint-induced movement therapy (CIMT), a therapy shown to substantially reduce the motor deficits of the more affected upper extremity of certain populations.7–10 Constraint-induced movement therapy attempts to reverse the reliance on the less affected limb by pairing 2 therapeutic components: restraint of the less affected limb and participation massed practice with the more affected limb.4 Despite the success of CIMT, these techniques are not applicable to the lower extremities, as it is not feasible to physically restrain the lower extremity.
Research indicates the benefits of CIMT may be from the massed practice component, not the restraint portion of the therapy, and, therefore, the use of CIMT components in the rehabilitation of the lower extremities has been examined without the need to physically restrain the unaffected limb.11,12 The guidelines for such an intervention promoted functional use of the affected extremity while preventing or reducing compensatory strategies, including limiting the use of assistive devices or orthoses and focusing on symmetrical movements during all tasks. An example application might include ascending stairs with a reciprocal pattern, as opposed to the compensatory step-together pattern typically seen with lower-extremity impairments. The implementation of massed practice to the lower extremities using these guidelines has been shown to significantly improve lower-extremity function and balance.5,6,12,13
Intensive mobility training uses the concepts of repetition, task-specific practice, and massed practice in an effort to elicit changes specifically in gait, balance, and mobility. In this intensive protocol, individuals participate in 3 hours of therapy a day for 10 days; rest time during the 3-hour therapy period was limited to a maximum of 30 minutes in this study. Participants are expected to spend a considerable amount of time weight bearing, in task-specific practice, in an effort to elicit changes in lower-extremity function. This protocol, as stated previously, is intensive; therefore, participant tolerance of the therapy should be taken into account.
Although the feasibility of lower-extremity massed practice has been addressed quantitatively, there are no studies assessing the feasibility of participation directly from the individuals participating in the interventions.5 Qualitatively assessing the feasibility of such an intensive intervention is necessary to gather opinions and information on perceptions of the intervention, as well as to provide valuable insight on how to modify an intervention. Most importantly, this method of gathering information captures a component of evidence-based practice—that is, patient values and preferences—directly from those participating.
Phenomenology is a qualitative method that has frequently been used in the nursing field to address research questions about nursing practice and education.14,15 This method may be used to gather information on an individual's perception of an experience. An “experience” may range from individual thoughts about living with stroke or attending the Super Bowl—either way, individuals are free to express their perceptions of the experience. This method has specific relevance to rehabilitation and, more specifically, to stroke rehabilitation.16 As Goldberg stated, “It can be argued that rehabilitation practice is rooted in patient experience and that experiential aspects, including patient perception and expectations are of ultimate importance to rehabilitation.”16(p4) A phenomenological approach offers opportunities to describe and interpret personal accounts of an experience, a vital component to the growth and success of evidence-based practice and rehabilitation for individuals with chronic stroke.
The physical therapy profession has emphasized the importance of incorporating patient preferences and priorities throughout the rehabilitation process.17 Evidence-based practice, by definition, includes patient values and preferences. Using a phenomenological approach to the observation and detailed analysis of personal perspectives of those who participate may give valuable insight on the feasibility of rehabilitative techniques, as well as highlight new questions or problems that may be addressed in future research. Therefore, the purpose of this study was to qualitatively assess the feasibility of an intensive, task-specific intervention from the perspective of those participating.
Method
Research Design
A phenomenological approach to qualitative inquiry was used to assess the participants' perspectives of the feasibility of an intensive, task-specific intervention for individuals with chronic stroke. Phenomenology acts to explore an experience (or phenomenon) from the perspective of those who participate.16,18–20 In this study, the phenomenon being explored was the feasibility of an intensive intervention, and in-depth, semistructured interviews were used to capture individual perceptions and experiences.
Role of the Researcher
During qualitative inquiry, the researcher is an integral part of the research process. This study was no different, as the primary researcher was involved with participants on a daily basis and responsible for data collection and analysis. The researcher had day-to-day interactions with participants, including daily greetings and assistance with logistical matters, and in rare instances provided the therapeutic services to the participants. As for data collection, the researcher scheduled and conducted all interviews, as well as the focus group. Data analysis was completed by both the researcher and a nonaffiliated individual in an effort to have multiple perspectives and prevent researcher bias. The nonaffiliated individual was not familiar with the therapy and had no interaction with participants, therefore eliminating potential bias during the data analysis process. Researcher biases were made apparent and monitored through reflexivity journaling completed throughout the research process, combined with occasional peer debriefings. The process of reflexivity journaling is discussed in the “Establishing Trustworthiness of the Data” section.
Participants
Prior to participation, all individuals and family members who agreed to participate in the interview process signed an informed consent document approved by the University of South Carolina Institutional Review Board. Inclusion criteria for the IMT study were: greater than 6 months poststroke, the ability to stand for minutes with or without an assistive device, the ability to walk with or without an assistive device for a minimum of 9.7 m (10 ft), and the ability to transfer (ie, from a wheelchair to a bed) with minimal assistance. Exclusion criteria for the IMT study were: the presence or diagnosis of other neurological conditions, the presence of nonhealing ulcers, resting blood pressure greater than 180/100, and various medical conditions that might place an individual at increased risk or harm.
A total of 42 individuals with chronic stroke were recruited for the larger intervention trial. For this study, a sequential sample of individuals entering the larger intervention trial was used to gather feelings and attitudes about participation in the larger trial. Participants were recruited for this study by the researcher as they began participation in the larger trial. If a participant expressed moderate to severe aphasia, he or she was not included in this study due to the nature of the research (interview); individuals with mild aphasia who were able to articulate thoughts were included in this study.
In phenomenological studies, sample sizes vary considerably, but typically are very small compared with quantitative studies.15,21,22 More data do not necessarily equate to more information, as a single experience is all that is necessary to be part of the analysis framework. In addition, qualitative research is highly labor intensive, making it time consuming and impractical to analyze large samples.23 Instead, data are collected only to the point where continued data collection does not identify new information related to the topic of interest.23 For this study, a predetermined sample size was not established prior to investigation, and data were to collected until data saturation (ie, the point at which new themes were no longer being generated with successive data collection) occurred. Following a pilot analysis of 6 participants, a sample of 8 individuals was recruited and interviewed for this study. Further recruitment was deemed unnecessary secondary to data saturation.
Intervention
Intensive mobility training was performed 3 hours per day for 10 consecutive weekdays, for a total of 30 hours. During each session, 1 hour was dedicated to gait training. For the purpose of the larger intervention trial, participants were randomized to either body-weight–supported treadmill training or traditional overground gait training. The remaining 2 hours of therapy was dedicated to balance (1 hour) and strength, range of motion (ROM), and coordination (1 hour) activities. Rest time was limited to a maximum of 30 minutes during the 3 hours of therapy. Rest time was given periodically throughout the 3 hours as performance on tasks diminished or as requested by the participant. All therapeutic activities were directed toward the affected lower-extremity limitations. Activities were marked as either balance or strength/ROM/coordination by the specific action of the affected lower extremity, and the time in activity was noted. For instance, a high-level activity may have included riding a push scooter. If the affected extremity acted as the stance limb, it would be considered as a balance activity; if the affected limb acted as the pushing limb, the activity would be considered in the strength/ROM/coordination category. This study did not include a home component; therefore, participants were not advised on specific activities to be completed after therapy.
Although the duration of the intervention and time spent in specific activities was standardized, the specific therapeutic activities were individualized according to the participant's level of function, performance, fatigue, frustration, and interest. Activities were chosen to provide a significant challenge for each individual and included functional tasks with an added level of difficulty. Such activities included overground gait training without an assistive device on various surfaces (eg, grass), sit-to-stand transfer on pliable surfaces, stair climbing using only the affected limb to ascend and descend stairs (a step-to pattern controlled by the affected limb), or balance activities on various surfaces with the incorporation of cognitive tasks. Because individual interests were taken into consideration, interventions often included hobbies or sports (ie, golf) that participants enjoyed or tasks (eg, household chores) that they expressed an interest in completing. Task difficulty was determined by allowing the participant to be successful, yet balance on the verge of failure (require some assistance) in an effort to keep the task level at a high level of difficulty. As participants improved in performance, tasks were progressed with increasing difficulty and complexity. This task progression was accomplished by altering dimensions such as increasing the time spent on a specific task, increasing height or distance at which the task was performed, or increasing the pattern complexity or speed. Participants received intermittent verbal feedback to encourage proper movement and mechanics and to acknowledge improvements in task performance.
Data Collection
Prior to data collection, a pilot study was completed on 6 individuals participating in the larger intervention trial in order to assess the integrity of the method and determine whether the information gathered during the interview process addressed the purpose of the study. The pilot study participants and the data collected in the pilot process were not included in the current analysis, as substantial changes were made to the method and interview questions.
Data collection methods involved 2 semistructured interviews and a focus group. Semistructured interviews were held with each participant after the initial 5 days of participation and following completion of the 10 days of therapy. A series of open-ended questions were asked regarding their impressions and physical tolerance of the therapy (Appendix). Participants were probed for additional information based on their initial response to the questions. For instance, if a participant stated that following therapy he or she had a difficult time moving his or her body, follow-up questions were used to clarify exactly why the individual had difficulty with body movement. Interview duration varied (10–30 minutes) according to the quantity of information participants wanted to provide. All interviews were conducted in a private setting by the primary researcher and recorded using a digital voice recorder.
Past and present participants of the larger clinical trial, as well as their caregivers or family members, were invited to attend a focus group in an effort to obtain collaborative thoughts on the feasibility of the therapy. This focus group included both participants who completed the semistructured interviews and those who did not. Family members were included to add quality descriptive information about their family member's fatigue, emotional status, and behavior throughout participation in the study. All family members participating in the focus group signed an informed consent statement prior to entering the focus group. Individuals with moderate to severe aphasia were not included in the focus group due to the nature of the research (interview). Focus groups act to contribute additional information, as the dynamic interactions among participants facilitate the generation of new ideas, issues, and perceptions related to the therapy.24 Focus group questions were pulled from the semistructured interviews and specifically addressed identical concepts of individual perceptions and physical tolerance of the therapy. The duration of the focus group was 30 minutes. The focus group was conducted by the primary researcher and recorded using a digital voice recorder.
Data Analysis
All interviews were transcribed verbatim into text format by the primary researcher. For confidentiality purposes, all transcriptions were labeled with numerical identifiers, pseudonyms were used for every participant, and all information was kept in a password-protected file.
The data were analyzed with an interpretive thematic analytical approach using qualitative analysis software (NVivo 8, QSR International Inc, Cambridge, Massachusetts).25 This method of data analysis is derived from grounded theory and phenomenological approach and is a foundational approach to qualitative analysis.25 The process includes data reduction, data display, conclusion drawing, and verification.
Reduction of the data involved repeatedly reviewing the data in an effort to organize, manage, and extrapolate the most meaningful sections of the data.25 Sections of data that provided insight on the feasibility of the therapy were highlighted. The extrapolated information was coded or indexed with shorthand labels that indicated common themes (eg, improved endurance). Because data analysis is a dynamic process that occurs throughout the data collection period, if a new theme arose during a successive interview, all previously coded transcripts were reviewed and assessed for the presence of that theme. Data reduction was conducted by the primary researcher; data coding was conducted by the primary researcher and a non–health care professional (unaffiliated with the research) to provide an alternate perspective on the transcriptions. The non–health care individual was educated on the intervention provided and trained on the coding process.
Concept maps and diagrams were used for data display to determine overlap and linkages among themes. This method allows for the condensation of codes into major themes as trends or patterns are identified in participant statements.25 For example, text initially may have been coded as “home fatigue” or as “therapy fatigue.” During data display, the aforementioned coded text may be lumped together to create a major theme “fatigue.” The themes are used to capture the essence of the experience and group text into meaningful statements.25
The final stage consisted of conclusion drawing and verification. Here the coded text and emerging themes from the data must be assessed for their credibility through the solicitation of a peer review to ensure that participant's perceptions are fully and accurately represented.25 A third analyst, a researcher in the larger clinical trial, was trained on the coding labels and themes and randomly reviewed 4 coded transcriptions to check for coding and thematic appropriateness.
Following the pilot study and the initial 3 participant interviews, no new themes or information arose with the 5 successive interviews. That is, when coding successive interviews, all information could be applied to existing themes. This occurrence is known as “data saturation”; therefore, further recruitment was deemed unnecessary.23,26
Establishing Trustworthiness of the Data
Multiple measures were taken to enhance the scientific rigor of this study, including the use of an audit trail, peer review, member checking, and maintenance of a reflexivity journal.25 An audit trail was used to document all changes to or variations in qualitative study protocol and the purpose for those changes. For instance, if a follow-up interview was conducted early due to participant availability, this information was documented, along with the reasoning, in the audit log. No major changes occurred during the study. The audit log was maintained by the researcher and reviewed by 4 individuals: 2 researchers and 2 independent individuals with knowledge of the study design. This method is used to secure the dependability of all procedures implemented throughout the research study.24 Peer review is a procedure in which colleagues review procedures and logistics in an effort to assess the dependability of the approach.24 The process of peer review was completed by a third analyst who reviewed the data for appropriateness of the coded content. Member checking, also known as “member validation,” acts to solicit feedback from participants and meet the criteria for confirmability.24 To complete the member checking process, transcriptions were mailed to all participants to allow participants to verify context of interviews and ensure accuracy of extrapolations. Lastly, a reflexivity journal is an important method to help monitor researcher bias, as the researcher is an integral part of the research process. The journal was used for the primary researcher to monitor personal judgments, perceptions, and interests that may affect the research topic, as well as state efforts to reduce or eliminate biases. The reflexivity journal was given to all other researchers involved in the study for review and comment.
Role of the Funding Source
Financial support for this study was provided by a grant from the American Heart Association (Scientist Development Grant, AHA Award #0835160N).
Results
A total of 8 individuals who participated in the intensive, task-specific therapy served as the main interviewees for this study (Table). All 8 participants participated in 2 semistructured interviews. A total of 7 individuals attended the focus group: 4 participants from the larger trial and 3 family members. Of the 4 participants from the large trial, only 2 had participated in the semistructured interviews.
Demographic and Descriptive Characteristics for the 8 Interviewees and Focus Group Attendeesa
Descriptive Data
The mean age of the interviewees was 62 years (SD=10.05), with a mean time since stroke of 21 months (SD=18.8). The majority of the participants were male, with only 1 female interviewee, as well as 1 female past participant and 2 female family members attending the focus group. Three of the 8 participants were primary wheelchair users, requiring the use of wheelchair for community mobility; 1 participant required the wheelchair for both home and community mobility. Only 2 of the 8 interviewees did not use an assistive device prior to participating in the therapy.
Themes on Feasibility
The data analysis revealed 5 major themes related to the feasibility of participating in intensive therapy (Figure): (1) a manageable amount of fatigue; (2) a difficult, but doable, level of intensity; (3) an opinion that the therapy (total days of therapy) was too short; (4) enjoyment of the therapy; and (5) mild muscle soreness. The feasibility model (Figure) displays the derived themes placed in order from greatest to least number of references.
Themes related to the feasibility of participating in the intensive intervention and the number of associated references.
Fatigue.
Fatigue was the theme most discussed by participants. References related to fatigue included experiences such as the fatigue experienced during the therapy, as well as fatigue carried over to the home environment. Some participants were surprised by the level of fatigue experienced during the therapy. Bob stated, “I got pretty tired, more tired than I thought I would.” He continued by stating, “On my right side [affected side] the muscles were tired.” The majority of comments revolved around a high, yet tolerable, level of fatigue. Charlie commented on his level of fatigue:
I'm tired—that is to be expected, but not to the point that I can't function.… I get to the point where 2½ hours in, I'm pretty well shot, but I get 2 to 2½ hours of real good work.
A common perception was that some days of therapy were very difficult and others were not. Participants discussed going home and having to nap or rest on some days, and other days being able to go about their daily routine. A number of statements were made regarding the amount of fatigue occurred early in the therapy, during the first 5 days. Frank commented:
Some of the days I was just wiped out. Other days I was able to stay up and watch TV or maybe go out to the grocery store or whatever. As my body got used to it, I wasn't as wiped out when I got home. I mean, the first 2 days I was totally wiped out.
Harold's wife, Lana stated:
Around day 3 or 4, he was just like “this is incredibly challenging.” I don't think he was going to drop out, but he was just like “I am really tired, this is a lot.” And they [trainers] told him that this was around the time when most people start to question “Am I going to make it through?” I think he had 2 trains of thought going on here. One was “I want to do it, and I'm going to do it,” but the other one was “I'm so tired, this is really more than I have done in a long time.”
Although majority of comments on fatigue revolved around a high, yet tolerable, level of fatigue, one individual commented with frustration on his fatigue due to the limited rest time. George stated, “I got very tired, and then they [trainers] tell me that I can't sit down too much because I'm using all my sitting time.”
Intensity.
Participants made various statements regarding the intensity of the therapy and how they felt their bodies handled the intense nature of the intervention. The majority of comments revolved around the therapy being difficult, yet doable. Alice described the therapy intensity as “medium or average” in difficulty. Frequently, participants made comments regarding their perception of the intensity after initiation of the therapy and how their perception changed by the end. Harold commented, “At first, I thought the length was too long, 3 hours…but by the end, I thought it was fine.” Dan made a similar statement, “Going into it, I said ‘uh oh’ after the first day. How am I going to get through 10 days of this? Never again did I think that.” Other participants discussed how they questioned their physical ability to complete the therapy, but were surprised by what they were able to accomplish. Frank stated:
I had turned into a couch potato (laugh), and I physically didn't feel like I was able to do it, but it fooled me and the way [you all] do things if your body gets tired…you take a pause or a break, and that helps.
Frank continued by stating:
I mean it's…rough, but it's enjoyable. It's not too tough that you can't put up with it.… It's tiring, yes. You hurt. The muscles you haven't used in a while start achin',…you want to quit [exerting the effort], but you can't.
Although the majority of comments experienced the therapy as difficult, but doable, one participant did suggest the therapy time be reduced. George stated:
It is very hard.… What else can I say, it's just hard.… If there would be any way of getting what you want accomplished in less time, I would do that. Three hours up on your feet after being off my feet for over 2 years is a handful.
Short therapy duration.
A common theme among participants was that the therapy duration (10 days) was too short. Participants frequently commented on how the therapy ended just as their body adjusted to the intensity. The short duration also seemed to lead to personal frustration that something that was helping them was taken away. Charlie commented:
It [the therapy] really needs to be 2 weeks, 4 weeks, 6 weeks longer to really get the most benefits out of it [be]cause right now I'm at the point where I have the endurance. I built up the endurance, and now I'm there. I'm there, let's take it to the next level, and now I [have to] go home.… It's hard work, but it's well worth it, and it's not long enough.… You're feeling really good by the end of the second week, and you can get through the 3 hours, and then, poof, it's gone.
Lana, Harold's wife, commented on how the therapy had changed their lives:
So for us [Harold and herself], those 10 days opened up an entirely new world, it was a rebirth, and so after 10 days, it's [kind of] like “Wow, I wish it were longer.” What could we have accomplished if we could have kept going?
Enjoyment of therapy.
Despite the intensity and the associated fatigue of the therapy, participants frequently commented on their level of satisfaction and enjoyment of the therapeutic experience. Jen commented, “You made it fun—working, but you made it fun. Most of it.” Frank also commented on his enjoyment of the implementation of the therapy:
I fall into a trap where if I do the same thing over and over and over, I get tired of it, and I don't want to do it anymore. And this, because it's been so many different people with so many different ideas…, you never get bored—I mean, there is always something to keep you interested.
Many participants commented on how this therapy has been different from what they have experienced in the past. Frank reported a conversation he had with a past therapist:
But…Mark, I talked to him the other night.… He was my therapist…and he was asking me…if I thought I got anything out of therapy, and I said, “Mark, I like you, but let me tell you, you all don't have anything (laugh).” I said, “If you want to see a program, you need to go and…just observe what they do.”
Despite the multitude of positive experiences related to enjoyment, one individual had quite the opposite experience secondary to fear. George stated:
It has been…very difficult and scary [be]cause I'm off balance and asked to do something that makes me more off balance. I know that I have people [trainers] all around me, hanging on to me, but still I am terrified.… It scares the hell out of me.
George went on to say:
It is the longest 3 hours I have ever spent in my life.… I could not wait for the day to be over.… I'm just tired of being scared to death.
Muscle soreness.
Participants commented on using muscles they have not used in a long time and reaching a point of muscle soreness. No statements were made regarding an intolerable level of muscle soreness or severe discomfort. Ed summed up his experience regarding muscle soreness by stating, “I mean, my legs were sore, and they were tired. But it wasn't that I was physically exhausted, just the muscles around the knees and everything, that it just caught up with me.”
Frank commented on the muscle soreness that occurs at home after a day at therapy, “Well, you get home, and you…sit around, or you sit and eat, and the muscles get tense and start aching. Muscle rub—I should have bought stock in that. It's just muscle I hadn't used in a while.”
Discussion
Numerous investigators studying task-specific practice in a massed practice setting reported their intervention as being a feasible option for an individual with chronic stroke.5,27–30 These studies, along with majority of current literature, used quantitative analyses to inform readers, reporting number of dropouts, lack of adverse events, or percentage of individuals completing the therapy in order to define the feasibility of an intervention. The quantitative reporting of results is appropriate when thinking of the operative definition of feasibility. However, when promoting evidence-based practice and patient-centered care, the opinions of participants should be taken into consideration.
Currently, no literature exists assessing the feasibility of repetitive, task-specific interventions from the participants' perspective in individuals with chronic stroke. There is an overall paucity of research investigating feasibility from the perspective of those who participate in an intervention. Researchers should routinely explore how individuals perceive their experiences during interventions, particularly novel therapies, in an effort to guide patient-centered interventions. Participant perception is of particular importance with intensive interventions, as individuals with stroke are rarely exposed to this type of therapy throughout inpatient and outpatient physical therapy.
Traditionally, in inpatient rehabilitation and outpatient physical therapy, patient rest time is excessive due to therapist time constraints, scheduling, and job demands. A recent case report observing the intensity of inpatient rehabilitation stated that a majority of rehabilitation is delivered at a low intensity, with an emphasis on seated activities.31 When observing outpatient therapeutic services, treatment time averaged only 36 minutes, with lower-extremity repetitions averaging 33 for active-exercise movements, 6 for passive exercise movements, 8 for purposeful movements, 11 for transfers, and 292 for gait.32 These findings on the intensity of services provided in inpatient and outpatient settings are consistent with those of other studies.33–35
As individuals move from generally low-intensity physical therapy experienced in inpatient or outpatient rehabilitation or no therapy following discharge from therapy to an intensive schedule, as seen in this study, the feasibility of the intervention is of concern. The novel, intensive, task-specific therapy applied in this study provides a comprehensive approach to treating people with stroke-related deficits in gait, balance, and mobility, providing a high level of activity. A massed practice approach is used, which incorporates greater time spent in activity, with little rest time—a level of intensity that the majority of individuals have not endured during prior therapeutic experiences.
In order to assess the feasibility of this study and allow participants to voice their experience, a qualitative approach was used. Due to the intensive nature of this therapy, one might expect the intensity and associated fatigue to be an issue. Participants did comment on their concerns about the intensity when initiating the therapy. Some participants questioned their ability to complete the therapy despite participation in outpatient physical therapy in the months prior to participation; family members noted the desire of their loved ones to participate, but observed hesitation due to high levels of fatigue. Although participants made multiple references to their experiences on the intensity of the rehabilitation and their feelings of fatigue, they frequently reported surprise in their ability to complete the therapy after initial feelings of concern.
Participants also stated disappointment in the short duration of the therapy (10 days), expressing their bodies had finally adjusted to the intensity. One participant was disappointed to be sent home (at the end of the intervention) when his body had just built the endurance he felt could take him to the next level. Participants and family members were left wondering what they could have accomplished if exposed to the intense therapy for a longer duration. These sentiments imply that although the therapy was difficult, they were eager to continue participation.
Muscle soreness was the last of the themes identified in this study. As mentioned in the intervention protocol, the therapy in this study was focused toward the affected lower extremity. The increase in activity for a hemiparetic lower extremity may lead to excessive muscle soreness or pain. Participants commented on how their muscles were sore, stiff, and tired; however, no comments were made reporting an intolerable level of soreness or pain. Some participants expressed pleasure with the muscle soreness, reporting they were feeling muscles they have not felt since the stroke. These types of comments lend to the idea that participants are excited that muscles are potentially “waking up” after being silent since the stroke.
Despite references to intensity, fatigue, and muscle soreness, participants expressed their enjoyment of the therapy and even labeled the intervention as fun. This was not the case, however, for one individual who experienced a great deal of fear secondary to the challenging nature of therapeutic tasks. Although fear during participation was not a common thread, the results of this study indicate that intensive therapy may be a bit much for some patients to handle.
The results of this study indicated that 7 of the 8 participants perceived the intensive approach to therapy as a feasible and enjoyable option. This finding is significant in that patients may be able to tolerate and even enjoy an intensive approach to rehabilitation. On the contrary, the results also highlight that intensive therapy is not for everyone. One individual expressed fear of falling with activities and commented with frustration on his limited ability to rest. Modified versions may be more palatable to some individuals.
The findings of this study, as well as the implementation of patient perspective through qualitative analysis, have implications for both clinical application and future research. Clinically, therapists may use this information to support the implementation of a more intensive approach to therapy. Currently, therapists might be hesitant to implement such a stringent and intensive approach to therapy, fearing harm or overexertion to patients, when in fact patients are able to tolerate increased intensity as their body adjusts to the physical demands and still enjoy the process.
Future research should be conducted to qualitatively assess the feasibility of other novel intervention studies, including those studying other neurologic populations. The addition of qualitative inquiry through the pilot process of an intervention will assist in assessing the feasibility directly from those participating, will assist in highlighting necessary modifications to existing protocols, and possibly direct future research. Most importantly, incorporating patient perspectives contributes to evidence-based practice and advocates patient-centered care.
This study presents some limitations; therefore, the application of findings to similar situations and populations should occur with some consideration. As with all qualitative research, the results of this study have limited generalizability. Instead, sampling methods were incorporated to achieve representativeness with the aim of increasing the transferability or applicability of the findings to similar populations, situations, and questions.25 Although the number of participants was small (standard for a phenomenological approach), data saturation was found, and further recruitment of participants was not necessary. As with most qualitative research, there was the potential for researcher bias, as the researcher is the one conducting the interviews and analyzing the data. In this study, multiple steps were taken to ensure the trustworthiness of the data and limit researcher bias. Lastly, there remains the possibility that participants were not comfortable reporting negative comments to the researcher (interviewer) due to the researcher's involvement in intervention implementation.
In conclusion, participants perceived a novel, intensive, task-specific intervention as a feasible therapeutic option. They reported a “difficult, but doable” level of intensity that their bodies adjusted to over the course of 10 days. Despite the level of intensity and associated fatigue and muscle soreness, the majority of the participants found the therapy enjoyable and expressed disappointment with the short duration (10 days). Clinically, this information may be used to support more intensive approaches to rehabilitation efforts. Further research should qualitatively explore the feasibility and efficacy of such interventions in other neurologic populations. Although quantitative analyses are pertinent to advancing the field of physical therapy, qualitative inquiry should play an increasing role in future research in an effort to promote evidence-based practice and patient-centered care.
Appendix.
Semistructured Interview Questions Used With Participantsa
a The questions were copied from the original semistructured interview guide. Other questions related to stroke impact and the benefits and drawbacks associated with the therapy also were asked of the interviewees.
Footnotes
All authors provided concept/idea/research design. Dr Merlo provided writing. Dr Merlo and Dr Fritz provided data collection. Dr Merlo and Dr Goodman provided data analysis. Dr Fritz provided fund procurement, facilities/equipment, and study participants. Dr Goodman, Dr McClenaghan, and Dr Fritz provided consultation (including review of manuscript before submission).
This study was approved by the University of South Carolina Institutional Review Board.
A poster presentation of this research was given at the Combined Section Meeting of the American Physical Therapy Association; February 9–12, 2011; New Orleans, Louisiana.
Financial support for this study was provided by a grant from the American Heart Association (Scientist Development Grant, AHA Award #0835160N).
- Received May 5, 2011.
- Accepted October 22, 2012.
- © 2013 American Physical Therapy Association
References
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