Delivering Intensive Rehabilitation in Stroke: Factors Influencing Implementation

The evidence-base for stroke rehabilitation recommends intensive and repetitive task-specific practice, as well as aerobic exercise. However, translating these evidence-based interventions from research into clinical practice remains a major challenge. The objective of this study was to investigate factors influencing implementation of higher intensity activity in stroke rehabilitation settings.

Semistructured interviews were conducted with rehabilitation therapists from 4 sites across 2 Canadian provinces who had experience in delivering a higher intensity intervention as part of a clinical trial (DOSE). An interview guide was developed, and data were analyzed using implementation frameworks.

Fifteen therapists were interviewed before data saturation was reached. Therapists and patients generally had positive experiences regarding high-intensity interventions. However, therapists felt they would adapt the protocol to accommodate their beliefs about ensuring movement quality. The requirement for all patients to have a graded exercise test and the use of sensors (eg, heart rate monitors) gave therapists confidence to push patients harder than they normally would. Paradoxically, a system that enables routine graded exercise testing and the availability of staff and equipment contribute challenges for implementation in everyday practice.

Even therapists involved in delivering a high-intensity intervention as part of a trial wanted to adapt it for clinical practice; therefore, it is imperative that researchers are explicit regarding key intervention components and what can be adapted to help ensure implementation fidelity. Changes in therapist’s beliefs and system-level changes (staffing and resources) are likely necessary to facilitate higher intensity rehabilitation in practice.