Definition.

The definition of exercise intensity was highly variable, including elements related to perceived fatigue (n = 4), exercise variations (n = 2), energy expenditure or heart rate variation (n = 2), exercise load (n = 1), and the number of exercise repetitions (n = 2). For example, a male PT (29 y experience, neurorehabilitation training; P1) defined intensity as, “to train, for example on a stationary bike at 80% of the maximum load during an effort……...for example training at 70% of maximum resistance…”

A 46-year-old woman (24 y experience, no neurorehabilitation training; P10) said: [intensity] a more intense cardiovascular effort! …. getting out of your wheelchair and moving around… exercises shouldn’t last too long either, because in terms of muscular fatigue, they [stroke survivors] can quickly reach their limit. So, I leave them about the same number of repetitions on the muscle strengthening exercise, balance exercise and I try to change exercises about every 5, 10 minutes”

A 38-year-old woman (7 y experience, no neurorehabilitation training; P12) defined exercise intensity as “it’s a session where the patient will be put under sufficient strain, and we’ll see him/her more or less out of breath, or the heart rate will increase significantly.”

The youngest among the PTs interviewed (28 years old, 8 y experience, no neurorehabilitation training, P6) reported that: [intensity]…I ask them to take breaks, and they do movements after. The youngest patient who is 50 years old, performs 10 repetitions…and I think it’s enough”.

Importance of intensity and knowledge of exercise intensity guidelines.

Although most surveyed PTs considered exercise intensity to be very important (n = 11, 92%), only four (33%) PTs reported being aware of guidelines. It should be noted that three of the four PTs completed neurorehabilitation training and worked in dedicated neurorehabilitation centres. «That’s it, yeah, I think it [intensity] is pretty important for their independence, their muscular recovery, their cardiorespiratory recovery... [guidelines] no, not especially, I don’t quite feel up to it.” (P6, a 28-year-old PT with 8 years of experience but without neurorehabilitation or other training). P10 (46-year-old woman, 24 y experience, no neurorehabilitation training) reported: “The way I look at [intensity], … it is important to give intensity so that patients can cope with a little more sustained effort….[exercise guidelines] Bah…… I had to redefine achievable objectives for the patient at each session, so that they wouldn’t find themselves in a situation of failure”. Another 44-year-old PT (20 y experience and neurorehabilitation training reported that intensity is very important and highly recommended: “…it’s very important because intense exercise is what’s effective, which means that patients who do intensive sessions progress faster than patients who do mobilization, so it’s... for the stroke population, I would say 180 minutes of moderate physical activity per week.” (P7). P1 and P2 (45 and 52 years old, with over 20 years’ experience, neurorehabilitation training) said intensity is important to enhance everyday life activities: “…[intensity] Ben... it’s important to cope with a more sustained effort in everyday life. So, innh, yeah, I know some HAS recommendations, but I don’t have much time for scientific reading” said P1

Criteria for screening stroke survivors prior to exercise training.

PTs reported screening stroke survivors based on their age (young people are preferred to adhere to recommended exercise intensity), stroke severity (high level of physical and motor capacity preferred), and stroke stage (chronic stage preferred to adhere to recommended exercise intensity). Spasticity, multimorbidity, cognitive impairments, medication, as well as feelings and low motivation were considered limiting factors influencing adherence to recommended exercise intensity.

PTs with additional neurorehabilitation training support more intensive sessions, depending on the stroke survivor’s age and physical abilities. A 52-year-old PT (P1, 29 y experience) pointed out that young people easily adhere to recommended exercise intensity: “Of course, there is the age criterion. but anyone can participate what counts is the evaluation.” P2 (45-year-old, 22 y experience) said he considers abilities when carrying out exercise sessions: “Ah yeah, according to their capacity… So, during the medical history, we systematically ask people whether they have any cardio-respiratory problems, and we also ask them to bring in their complementary examinations.”

Nevertheless, other PTs with no additional neurorehabilitation training were reluctant to push stroke survivors into moderate-to-vigorous intensity due to their restricted mobility, poor physical condition and low motivation. For example, a 47-year-old man (P5, 20 y experience) expressed “I don’t do all the same exercises to all the patients, we adapt according to what they can do, depending on the mobility restrictions they have”. On the other hand, they increase intensity in stroke survivors with good fitness and those in a chronic phase. A 46-year-old woman (24 y experience; P10) said: “Yes, it’s for patients with much greater motor ability…...After 6 months post-stroke, I think you can increase the exercise intensity a little more”. P8, the oldest of the respondent (41 y experience) expressed that, in addition to the person’s general condition, psychological criteria such as motivation are more important: “…Because it’s not just physiological criteria that count [to adhere to moderate-to-vigorous intensity physical activity], there are psychological and motivational criteria that count too.”

Assessment of exercise intensity, training criteria and monitoring of exercise intensity.

Three PTs (25%) claimed to perform objective assessments (e.g., submaximal tests, such as a 2 or 6 min walk test, or strength tests, such as sit-to-stand test) to determine the best exercise training zone, while 65% report using subjective assessments (stroke survivor’s state of health, pain, stroke severity, mood and motivation). None of the PTs reported performing or using an exercise stress test.

P1 (Man, 52-year-old, 29 y experience, neurorehabilitation training) highlighted the importance of an exercise test to determine the training zone. He reported using heart rate and perceived exertion to monitor exercise intensity “So, I have an exercise check-up, a customized health check-up. I do it in two ways; on treadmill or an overground test, or a resistance test…I train mostly in forms of 10 maximal resistance using a dynamometer or based on 1/10 patient’s weight…. It is always interesting to have a stress test, but it is not usually the case, it would be good to get it, as now we work based on maximal heart rate and age…. “

It seems likely that PTs with no additional neurorehabilitation training preferred subjective versus objective exercise tests. For example, a 30-year-old PT (8 y experience; P4) explained that he did not required tests for assessment or monitoring exercise intensity; “No specific test, most of my patients can’t manage a 6-minute walk test. We work on patient’s feeling to intensify exercise”. P11 who is 34 years old with 12 years’ experience follows the same approach as P4, reporting no need for a tool or test to monitor intensity during sessions: “With a tool? No, I mean, I assess it [intensity] subjectively. I see if they are tired at the end of session…to find out if my patient is feeling well, I begin with 5 minutes exercise, then 10 and try to increase progressively…” “I am obviously not assessing it, I don’t have the time. Honestly, I don’t have much time…”

Few participants (25%) agreed on objective criteria for grading and monitoring exercise intensity, such as resistance, training time or heart rate monitoring, while many PTs (66%), especially those without additional neurorehabilitation training, preferred perceptions of stroke survivors on fatigue, shortness of breath, or feeling. Perceived exertion was a commonly used method of monitoring exercise. Other indicators used, especially by PTs with additional experience included heart rate, blood oxygen saturation, blood pressure and clinical symptoms such as chest indrawing, breathlessness, dyspnea, sweating and skin coloration. The reported monitoring equipment were heart rate monitors, pulse oximeters and stopwatches. The number of repetitions and variation of exercises were the most widely used intensity grading methods.

P1, a 46-year-old man with 29 years’ experience, and P3 a 48-year-old woman with 27 years’ experience, all reported that it’s important to use objective tools for exercise monitoring. P1 said: “So, I use the Borg scale most often, heart rate monitors sometimes for heart rate, I look at breathlessness, also a stopwatch of course is sometimes necessary.” P3 stated: “We have an oxygen monitor, …. We also have a blood pressure monitor. So, we check blood oxygen saturation, heart rate and blood pressure”.

Modality of training and equipment for exercise training.

The two types of training modalities (individual or group) were equally used, and the preference for group-based sessions was influenced by time efficiencies and motivation of the stroke survivor. Aerobic training equipment were the most used, while resistance training equipment were less common. Six PTs (50%) had at least one ergometer or treadmill in their office and six PTs (50%) had strengthening equipment (in addition to aerobic training equipment).

Feasibility of implementing exercise at recommended intensity.

Five (41%) PTs reported integrating moderate-to-vigorous intensity physical exercise during outpatient sessions. “It [intensity] was moderate, I would say moderate …” said P1 (man, 52 y-old with neurorehabilitation training). P10 (46-year-old, woman, 24 y experience) reported: “… the session I did with him wasn’t intense. it was a little adapted, may be low to moderate, depending on the patient’s fatigue, condition such as infection, any kind of pain, this can hamper the session.” P5 (47 years-old, man, 20 y experience) said ““with every patient, there’s obviously physical activity of moderate-to-vigorous intensity….”

Prescription.

According to most PTs (75%), it’s the physician’s responsibility to specify the restrictions to exercise when prescribing rehabilitation sessions, but it’s up to the PT to set the training intensity. Exercise should be specified as a full detailed treatment on the prescription (minimum required intensity, frequency…). P4 (man, 30-year-old, 8 y experience) said, “When a medical doctor refers a patient to me, I expect he’s taken every precaution beforehand to make sure there’s no risk, and no, it’s not necessarily up to the physiotherapist to take that initiative”. P5 (man, 47 years old, 20 y experience) replied: “Yes, it’s up to us [to calibrate intensity]. The doctor prescribes rehabilitation sessions and then we adapt the session as we see best!”

Required skills.

All the respondents said it was important to have additional training in exercise intensity management. Only three PTs (25%) claim to have sufficient skills. One of the three PTs with additional neurorehabilitation training said “Additional training is required. This was the case for me, because it’s something I was interested in, so additional training was already a basic requirement.”

“So skilled? I’m not sure, we can always do more… knowledge is required, the intensity level of patient sessions was not covered in our basic courses, obviously not.” replied P11. Another 30-year-old PT with 8 years’ experience (P4) echoed the previous advice, saying: “Yes, finally. I miss It [additional training], yes, finally. It needs to be integrated a little more into initial training”.

Sub-theme 1: Barriers to exercise intensity.

Challenges reported in ensuring exercise intensity during rehabilitation were related to the stroke survivor, work environment and PT.

PTs expressed barriers related to the stroke survivor as follows: lack of motivation (response from 83% of surveyed PTs), severity of stroke (83%), cognitive impairment (67%), fatigue or limited physical condition (58%), subacute stroke stage (33%), presence of pain (25%), co-morbidities (1%), isolation or lack of family support (1%), and affected hemisphere (1%).

Lack of motivation.

Regardless of experience (varying from less than 10 years to more than 20 years) or additional training, PTs reported lack of motivation among stroke survivors as a major barrier to achieving the recommended exercise intensity: “Ah, it’s the motivation, the lack of motivation sometimes in some patients that makes it difficult for them to participate”, argued P1 (52-year-old, 29 y experience, neurorehabilitation training)”. P6 (28 years-old, 8 y experience, no additional training) said: “Sometimes the patient gets discouraged too....yeah, discouragement on the part of the patient, because of too much routine”.

Stroke severity and affected hemisphere.

A 46-year-old PT said «The stroke severity, level of disability? Oh yes, of course, this is a big obstacle” (P10). “When patients don’t see any motor recovery and they still have a high level of disability, they give up” said P11 (34-year-old, 12 y experience). P1, a PT with 29 years’ experience and neurorehabilitation training, added: “it’s a left hemiplegia Hein, it’s still too severe, and most of the time with cognitive problems”. Similar arguments emerged from three PTs from 8 to 27 years of experience. “Well, it depends on a lot of things, especially the stroke severity. It depends on the recovery” (P3); “Mobility restrictions, so people who can’t stand up, no physical exercise in fact” (P4); “The level of disability too. I think that the more severe the person’s hemiplegia, the more complicated it is to go for higher intensity exercise” (P6).

Cognitive impairments.

Cognitive impairments have been identified as a limiting factor to understand exercise instructions. For example, 3 PTs, including one with additional training in neurorehabilitation, all reported the impact of cognitive impairment. A 30-year-old said: “…as well, eh! cognitive limitations can be a hindrance to rehabilitation if the instructions are not properly understood or if the patient is in constant danger.” A 52-year-old with 29 years of experience with additional neurorehabilitation training highlighted: «Cognitive impairment is a major limitation”; and a 46-year-old with 24 years’ experience completed: “… patients with cognitive deficits are difficult to manage, no intensity”

Fatigue and/or limited fitness.

Fatigue was identified as an important barrier to training intensity. P11 (34-year-old PT, 12 y experience, no additional neurorehabilitation training declared; “It’s more likely that patients will get tired very quickly, that’s for sure. Fatigue happens much more quickly compared to other patients”. P2 also said that stroke survivors are too fatigued, which prevents them from pushing the intensity too far: “Too much fatigue is a limit”.

Stroke stage.

Some PTs considered that exercise in the acute and sub-acute phases may represents a great risk for stroke survivors, and therefore preferred to engage moderate-to-vigorous intensity exercise during the chronic stage. P7 (aged 45, 20 y experience and neurorehabilitation training) reported “No, it’s not the same importance. Because for me, it’s more important in the chronic stage, because there’s the secondary prevention aspect, whereas in the acute or sub-acute stage, you still waiting for recovery,...and intensity adaptation is a risk”

Other barriers raised by PTs were pain “Left hemiplegia often leads to neurological pain which can be disabling and compromise intensity work” said P1; the presence of co-morbidities “If he has any cardiac problems, I don’t do a lot of exercise’ (P5); older age “Because, on the other hand, the man who’s 80 years old, I’m not going to do any strengthening for him other than the weight of his body” (P8); and social isolation “Sometimes it’s people who live alone, so when they don’t have a social support, they’re not stimulated” (P11).

Reported barriers linked to the work environment (outpatient private services) included the limited space (66% of PTs), the session time constraint (16%), and the lack of or high cost of training equipment (treadmill, bike, 2%). “Having an adapted space that allows you to... to accommodate more severely disabled patients is a challenge” (P1); “there must be a technical facility with equipment that is both accessible and safe” (P2); “ equipment. We really need it” (P5)

Regarding barriers related to PTs, the lack of sufficient knowledge about exercise intensity, the fear of exercise training adverse effects, and limited contact with the medical doctor were the predominant barriers.

Fear of harmful effects.

A 47-year-old man with 20 years of experience reported: “Barriers include the fear of [moderate-to-vigorous intensity]. Fear of hurting patients. Well, the fear of doing too much, of forcing the patient too hard, and then either having a heart attack or something else, for example, or intensifying the pain”. P11 (34-year-old, 7 y experience, no additional training): “We avoid [increasing exercise intensity] for fear of something else happening because they’ve almost all had cardiac problems…. I wouldn’t put them in any difficulty about that”

Lack of knowledge.

Lack of knowledge about PA guidelines and exercise intensity was reported as a major barrier by 42% of the respondents. A 66-year-old physio with 41 years’ experience said “…I didn’t do any additional training related to physical exercise in stroke rehabilitation. So, my knowledge dated back to 1983. They didn’t tell us anything about intensity”. A young 30-year-old PT (8 y experience) stated: “yes, I need a refresher course, at last. I need it, yes, finally. It [additional training] needs to be integrated a little more into initial training”. Finally, a 44-year-old PT reported that intense exercise was avoided to stroke people with spasticity: “No, in my initial training, we were told that above all higher intensity exercise increased spasticity [exercise considered a contraindication], that it was very dangerous and that above all they shouldn’t get tired, that’s it. No, I didn’t do any specific training on the intensity of the sessions”

Limited contact with the medical doctor.

Some PTs (16%) reported that it is difficult to have ongoing follow-up contact with referring physicians. P5 said “yes, we’re afraid of forcing the patient too much because he could get sick, for example pain could increase...as it’s not easy to get in touch with his doctor for an opinion”.

Sub-theme 2: Facilitators to exercise intensity.

The most reported facilitators to implementing exercise at recommended intensity during outpatient private rehabilitation settings were large workspace, stroke survivor’s motivation, peer support, modality of training (group-based sessions) and continued professional education, such as additional neurorehabilitation training. “in fact, to have an adapted space that allows you to feel at ease in your workspace, to be able to welcome patients who are more disabled than a sprained ankle, or whatever; replied P1; patient’s motivation “I’d say that a patient who’s motivated, who has the desire. It’s true that we’ll be able to push him to do more intense things, said P6”; and peer support & group-based sessions “I think that the fact that patients are not alone is good for them to have other people around to talk to, to exchange ideas and to see that others are also working, P3”