The psychosocial effects of exercise and relaxation classes for persons

surviving a stroke
Gail Carin-Levy I Marilyn Kendall I Archie Young I Gillian Mead

Key words
I Stroke I Exercise I Relaxation I Qualitative study I Psychosocial benefits

Mots clés
I Accident vasculaire cérébral I Exercice I Relaxation I Étude qualitative I Avantages psychosociaux

Abstract
Background. This study was set up to explore unexpected findings emergent from a randomized controlled trial of exercise
versus relaxation post-stroke. Purpose. Stroke survivors’ experiences of taking part in exercise and relaxation classes were
explored. Methods. In-depth, semi-structured interviews carried out with 14 community-dwelling stroke survivors in Edinburgh.
The informants previously participated in a randomized exploratory trial of exercise versus relaxation. Findings. The classes
motivated participants to take part in other purposeful activities, to continue to practice what they had learned, and/or to attend
another class in the community. Class participation also led to an improvement of self-perceived quality of life, specifically,
improved confidence, physical ability, psychosocial functioning, and a sense of empowerment. Implications. Taking part in
either exercise or relaxation classes after stroke can contribute to improved self-perceived quality of life, improved psychosocial
functioning, and improved motivation to take an active role in the recovery process.

Résumé
Description. Cette étude a été menée en vue d’examiner les résultats imprévus d’un essai contrôlé aléatoire comportant des
séances d’exercice et des séances de relaxation chez des patients ayant subi un accident vasculaire cérébral (AVC). But. Les
expériences vécues par des survivants d’un AVC ayant participé à des séances d’exercice ou à des séances de relaxation ont été
étudiées. Méthodologie. Des entrevues en profondeur semi-structurées ont été menées auprès de 14 survivants d’un AVC vivant
dans la collectivité à Edinburgh. Les informateurs avaient participé auparavant à un essai exploratoire aléatoire comportant des
séances d’exercice et des séances de relaxation. Résultats. Les séances motivaient les participants à participer à d’autres activités
significatives, à continuer de mettre en pratique ce qu’ils avaient appris ou à assister à d’autres cours dans la communauté. La
participation à ces séances a également permis aux participants d’améliorer leur perception face à leur qualité de vie, en
particulier d’améliorer leur confiance, leurs habiletés physiques et leur fonctionnement psychosocial et d’avoir un sentiment de
pouvoir sur leur vie. Conséquences. La participation à des séances d’exercice ou de relaxation à la suite d’un AVC peut contribuer
à l’amélioration de la perception de la qualité de vie, du fonctionnement psychosocial et de la motivation à participer activement
au processus de rétablissement.

n 2002, we established a randomized exploratory trial of began to emerge (Mead, 2005), which we had not anticipated

I physical fitness training versus relaxation (an “attention

control” intervention) for ambulatory stroke survivors who
had completed their stroke rehabilitation, to investigate the
effects of physical fitness training on a battery of mainly physical
outcome measures (Mead et al., 2007). The trial participants
were community-dwelling stroke survivors in Edinburgh. The
intervention group was an exercise class and the control group
was a relaxation class; both took place three times per week and
were 12 weeks long. An exercise instructor specializing in
working with older adults led the classes.
Very soon after starting the trial, anecdotal evidence of
social and psychological benefits from both interventions
and which our battery of outcome measures would not detect.
We then searched the literature using a variety of search
strategies, databases, and keyword combinations for studies
exploring psychosocial benefits of either exercise or relaxation,
but we found no published research. We identified several
trials of exercise training after stroke, but none had included a
qualitative evaluation of the participants’ experiences of taking
part in the trial. Thus, we decided to formally explore the
perceived experience of both interventions using rigorous
qualitative methodology.
Participant involvement in the evaluation of complex
interventions is increasingly called for due to the advantages

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 CARIN-LEVY ET AL.
to the quality and depth of the data yielded in healthcare
research (Campbell et al., 2000; Oakley et al., 2006). Process
evaluation within complex interventions may enhance the
science behind the trial by increasing researchers’
understanding of numerous factors not formally measured in
the trial outcome battery (Oakley et al., 2006).
Literature review
Stroke is a major cause of disability and death, with an
estimated 150,000 people in the UK suffering a stroke each
year (The Stroke Association, 2008). A common neuropsy-
chiatric complication of stroke is depression; depressive
symptoms are present in at least 33% of stroke survivors
(Hackett et al, 2005). Depression post-stroke is associated with
stroke severity, physical disability, and cognitive impairment,
and it is likely that depression reduces the capacity and will to
participate in rehabilitation (Hackett & Anderson, 2005).
Sturm et al. (2004) present an original approach by examining
handicap (defined by the authors as “disadvantage resulting
from ill health”) in stroke survivors. They found that anxiety
and depression may independently contribute to handicap
post-stroke and urge clinicians to treat these mood disorders
aggressively (Sturm et al.). Post-stroke depression has been
associated with certain psychological factors, namely, external
locus of control (Thomas & Lincoln, 2006). Lower levels of
perceived control are associated with an increase incidence of
depression and anxiety up to six months post-stroke
(Morrison, Johnston, & MacWalter, 2000). In an early paper,
Sinyor et al. (1986) found that feelings of helplessness resulted
in low mood and low internal locus of control. These findings
are still very relevant today. Internal locus of control and self-
efficacy in stroke patients have been associated positively with
quality of life (measured using rating scales and derived from
functional capacity), fewer depressive symptoms, better coping
skills, and increased motivation (Bandura, 1997; Robinson-
Smith, Johnston, & Allen, 2000; Sinyor et al.). Social difficulties
after stroke are also correlated to post-stroke depression, and
they include impaired ability to relate to family, adverse
changes in lifestyle, loss of social roles, and failure to resume
premorbid social activities (Hafsteinsdottir & Grypdonck,
1997; Trigg, Wood, & Langton Hewer, 1999). A study by
Hartman-Maeir, Soroker, Ring, and Avni (2006), dealing
specifically with activity participation post-stroke, found that
stroke survivors demonstrate dissatisfaction with life one year
post-stroke due to activity limitation and participation
restriction (as conceptualised by ICF (World Health
Organization [WHO], 2002)). Hartman-Maeir et al. call for
the focus of rehabilitation to be not only on activities of daily
living (ADL), but also on leisure activities, suggesting that this
would increase life satisfaction in this population.
Psychological and social functioning can deteriorate over the
year following the stroke despite stable neurological and
general physical function (Suenkeler et al., 2002).
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The optimum management of anxiety after stroke is
uncertain. A search of the literature produced evidence of the
effectiveness of non-pharmacological interventions such as
relaxation in stress management (Hanley, Stirling, & Brown,
2003; Spence, Barnett, Linden, Ramsden, & Taenzer, 1999;
Timmermann, Emmelkamp, & Sandrman, 1998). In a syste-
matic review, Spence et al. found that non-pharmacological
interventions, such as relaxation, cognitive, and behavioral
therapies, were as effective at reducing and controlling blood
pressure as drugs in hypertensive patients who suffer from
stress and anxiety. Hanley et al. conducted a randomized
controlled trial of therapeutic massage versus relaxation in
stressed patients and found that both interventions were
effective at reducing stress, with no significant difference
between the intervention and control groups. More recently,
Dusek et al. (2008) examined the effects of stress
management, specifically, relaxation response, in hyper-
tensive patients and found that relaxation techniques are
more efficient than control in maintaining healthy blood
pressure. An extensive search of the literature yielded no
evidence of any evaluation of relaxation in stroke survivors
(other than the report of our own trial by Mead et al., 2007).
Literature from the disciplines of psychology, sociology,
and occupational therapy offer a qualitative approach to
explore the benefits of physical exercise and activity partici-
pation in terms of self-perceived quality of life and
psychosocial functioning (Blinde & McClung, 1997; Carin-
Levy & Jones, 2007; Specht, King, Brown, & Foris., 2002;
Taub, Blinde, & Greer, 1999). These studies provide evidence
of the benefits of such activities, highlighting a perceived
improvement in quality of life through the enhancement of
psychosocial functioning (improved self confidence, positive
body image, physical competence, and an enhanced sense of
control). These studies are not stroke specific and deal with a
wide range of disabilities or impairments.
The paucity of qualitative evaluations of exercise in
stroke survivors and the scarcity of any literature on the use
of relaxation techniques post-stroke expose a real gap in
current knowledge. Therefore, the primary aim of this study
was to explore participant perspectives’ of partaking in
exercise and relaxation classes with a specific interest in the
effects of participation in the classes on psychological and
social functioning. A secondary aim was to identify any
differences between exercise and relaxation in terms of their
perceived benefits and relevance to stroke survivors.
Methods
Study design
We adopted a pragmatic, qualitative program evaluation
approach (Patton, 2002) in order to explore the participants’
experiences of the classes.
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Sample
This study received ethical approval from Lothian Research
Ethics Committee. We recruited participants from
community- dwelling, ambulatory stroke survivors who had
taken part in a randomized trial of exercise or relaxation
(Mead et al., 2007). We excluded people with significant
memory impairment (as recorded by the trial physicians —
anyone with dysphasia or confusion severe enough to prevent
giving informed consent was excluded from the main trial).
Potential participants were approached at a minimum of 6
months and a maximum of 18 months after the course of
classes ended. Of the 66 trial participants, 50 met the inclusion
criteria (i.e., no memory impairment and meeting the time
frame). Of these 50, as a first round of recruitment, 25 were
selected by randomly choosing their names from a list of trial
participants. This list contained a person’s name, address, and
which class they attended in the trial. It was planned that a
second round of recruitment would be employed should new
themes continue to emerge from the data. The 25 trial partic-
ipants were approached by letter; 24 agreed to participate.
From these 24 people, purposeful sampling was used in order
to recruit informants who would reflect the range of partic-
ipants of the STARTER trial as a whole with regard to age,
gender, and social situation (i.e., type of dwelling and whether
living alone. See Table 1). Potential participants were then
contacted by telephone to arrange a time and venue for a
meeting with the first author. Sixteen potential participants
were contacted; interviews were arranged and carried out
within two weeks of contact. At this meeting, informants also
reviewed the information sheet and gave their signed consent
to participate in the study. Recruitment ceased after these
interview transcripts were coded, since at this point, data
saturation was reached with no new themes having been
recorded (Fossey, Harvey, McDermont, & Davidson, 2002),
data saturation was reached.
Data generation
In-depth, semi-structured interviews were used to explore
participants’ experiences of taking part in exercise or
relaxation classes post-stroke. The interview guide was
developed after reviewing the available literature and in order
to explore in depth the anecdotal comments made by trial
participants throughout the trial (Mead, 2005) (see
Appendix). All interviews were carried out by the first author
in the participants’ homes and were audiotaped, with written
consent. The interviews were designed to be person-
centered, and to enable the participants to bring forward
their own views and concerns in their own terms.
Data analysis
The audiotapes were transcribed by the first and second
authors. Due to a technical fault, one interview was not
transcribed and a further participant was excluded from the
© CAOT PUBLICATIONS ACE VOLUME 76
CARIN-LEVY ET AL.
study due to a recent bereavement. The remaining 14
transcripts were re-read and compared to the tapes to ensure
accuracy of transcripts. The transcripts were entered into
QSR Nvivo (version 2.0) for thematic analysis (Miles &
Huberman, 1994). The first author carried out the Initial
coding of the data and organized the data into themes and
subthemes; the second and fourth authors then corroborated
the themes. A discussion regarding the classification of data
into particular themes took place subsequently, giving the
researchers the opportunity to debate the accuracy of the
analysis and agree upon the emergent themes. The first
author kept a diary exploring her own biases, thoughts, and
preconceived expectations from the data (Maso, 2003). This
was used in conjunction with the interview transcripts, which
contained annotations of the rapport between informant and
interviewer, whether the informant was forthcoming with
answers, and whether the interviewer was directive at times
during the interview. Any interruptions or contributions
from significant others were also noted to ensure that these
did not influence the interpretation of the data.
Findings
Sample
The subjects who took part in this study came from a range
of backgrounds. There were six participants from the exercise
classes and eight who took part in the relaxation classes. The
ages of the participants range from 48-85 and the Functional
Independence Measure scores (collected as part of the main
trial assessment battery, Mead et al., 2007) ranged from 107-
124. See Table 1 for subject characteristics.
Key themes
The results were categorized into the following five themes:
enjoyment, motivation, self-perceived quality of life,
empowerment, and the long-term effects of class partici-
pation. Henceforth participants from the exercise or
relaxation classes will be referred to by E and R and their
participant numbers (from 1 to 8).
Enjoyment of the classes
All informants reported high levels of enjoyment from the
classes. There seemed to be no difference between the groups
as statements from attendees from both classes were very
similar. Subjects reported that the classes were something to
look forward to during their week, and they were certain that
they would recommend participation in such classes to
others (not necessarily other stroke survivors). The following
captures informants’ views:
R1: [It was] a combination of everything, quite honestly.
A combination of getting out of the house, travelling
to the venue, meeting the people, the class itself of
course, and then the repartee on the bus on the way
home, as we would talk to each other, you know?
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TABLE 1
Characteristics of sample.

Subject Age Gender Dwelling Social situation FIM Score*

E1 76 M Local authority sheltered housing Lives alone 114

E2 49 M Local authority rented flat Lives with 2 daughters 117
E3 70 M Own home Lives alone 123
E4 62 M Local authority rented flat Lives alone 115
E5 75 F Own home Lives with husband 115
E6 60 F Own home Live with husband 116
R1 85 M Local authority sheltered housing Lives alone 112
R2 79 M Local authority residential home Lives in care 109
R3 77 M Own home Lives with wife 124
R4 52 M Local authority rented flat Lives alone 107
R5 74 F Local authority sheltered housing Lives alone 124
R6 74 F Own home Lives with husband 114
R7 68 F Own home Lives alone 112
R8 71 F Local authority rented flat Lives alone 122

* Functional Independence Measure: Range of score: 18–126; a higher score denotes greater independence.

Then in the privacy of your own home, thinking back
on the events of the day.
R7: To start with I thought the classes were [a bit of a
burden], but then I started to really enjoy the class,
and get to know everyone, and there was always
something funny, you know ... actually [most of us]
didn’t like to miss out on a class ... .
E3: They [all other participants, first author] were all
good, every one of them. They were all super. And
they all wanted to go, and they all went to all the
classes. And they were sorry to see it ended. Aye, I
miss it ... .
E1: Oh, I missed it for a while ... I enjoyed it, was
something to look forward to, pick yourself up,
tomorrow, tomorrow morning, had to get down the
stair, ready, speak to the [warden] before the
ambulance come ... I felt magic! I was very sorry it
stopped!
Effect of the classes on motivation
Both classes had a positive effect on participants’ motivation,
not only to attend each class of the course, but also to take
part in other purposeful activities throughout the day.
Participants felt the classes played a role in motivating them
to get up and out the house on class days. Many felt that had
it not been for their attendance in the classes they may not
have gone out as frequently as they did. They therefore
gained not only from the classes themselves, but also gained
confidence in continuing to go out. There was no obvious
difference between the exercise and relaxation class with
regards to motivation.
R5: It was October-November, cold months, I might not
have gone out ... if it was a bad day you would
probably not go anywhere or do anything, but you
knew you were going, you had something and ... it was
an afternoon’s enjoyment.
E7: You felt you were living, that somebody was taking
care of you, it did make you spur on, you know, you
wouldn’t be lying saying “Oh, I can’t move,” you know
... it did motivate you.”
The following comment was made by E4, who was the
only participant to mention that the classes were graded to
create an appropriate challenge to the class participants; he
felt that this was one of the more important factors in
motivating him to go back to the class three times per week.
This participant did not feel that the exercise class had made
a difference to his motivation to participate in other activities
in his own time:
E4: Yes, cos it got harder and harder and that’s maybe ... why
it made you go back, to beat the thing I had to do ...
Self-perceived quality of life
The comments participants made regarding the perceived
benefits from class participation were indicative of an overall
improvement in self-perceived quality of life. This is substan-
tiated with comments about the effects of the classes on
confidence, physical ability, and psychosocial functioning.
All informants in this study reported that taking part in the
classes had a positive effect on their confidence, which, in
turn, generated an all-round benefit on day-to-day life and
physical functioning.
E1: It helped me get in the chair you see, you know what
I mean, eh, the exercises go up and down the chair; I
couldn’t do it at first and then, eh, I progressed ... I’m
fair pleased with myself I can walk up the street now,
after all that time.
E2: I felt myself better, and I felt stronger, and
weaknesses were going that were there before ... so my

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head felt better, because I was more confident in what
I was doing. It [gave] me a little bit more confidence
in myself.
There was a clear difference in statements made by the
two groups regarding physical functioning: the exercise
participants mentioned improved walking and the ability to
get up from a chair, whereas the relaxation class participants
mentioned the overall benefits of having a commitment that
necessitated getting out of the house. The aspects raised
equally by both class participants were related to an increase
in confidence.
R2: After a stroke you are vulnerable, and going into
public places you are a little worried; there was a bit of
a walk from the bus to [where the class was] and you
wonder whether you will be able to do it ... but I found
I could do it ... it is hard to explain it, but that is part
of getting over the stroke, because you are not going to
be able to do but you have to try.
R6: I loved it. Because when I went my speech was really
quite bad at the time, and, eh, I wouldn’t speak on the
phone ... and I was only there a week, and I was you
know speaking to everybody, and it brought me out,
because ...[before the classes] I hadn’t the confidence
to, em, speak outside the house…”
The comments regarding psychosocial functioning
highlighted a clear link between the benefit of socializing and
getting out of the house with psychological well-being.
Another clear link highlighted in the responses was between
physical achievement and a feeling of satisfaction and
generally feeling better about oneself. This is demonstrated
by a wide range of statements: “I feel better about me, as an
individual” (E2); “I know I’m on the way back to myself
again” (R8); and “I think that there should be more of that a
lot more of it [these type of classes]. This helps people with
their mental health... ”
The class became a very important part of the partic-
ipants’ lives for the 12-week duration. It created a welcome
social situation for participants, which was as important to
them as the activity they were taking part in (both exercise
and relaxation):
R8: By the end of it all, they all seemed to be like a family.
E1: We all got on well, you know, we told each other
jokes.
R7: I think it was nice to meet everyone, and hear other
people’s opinions, and also to be told what had
happened to them, and then you felt, oh well, that’s
something, at least you’re not alone.”
The perceived social benefits were similar for those who
lived alone or with a significant other. There was no obvious
difference between the exercise and relaxation class partic-
ipants in terms of their enjoyment of the social interactions.
Most respondents felt that it was important to them that the
group had a common factor; they repeatedly stated the
© CAOT PUBLICATIONS ACE VOLUME 76 I NUMBER
CARIN-LEVY ET AL.
importance of mutual support and comfort, being able to
discuss their progress with others who had similar
difficulties, and the feeling that “you are not alone” (R7).
Empowerment: Gaining control
Participants were asked whether they felt that attending the
classes helped them to gain more control over their lives after
the stroke. The answers ranged from a simple “yes” or “no” to
lengthy comments on the way the class enhanced motivation
and confidence and enabled participants to do more for
themselves.
E2: Before it wasn’t that I was unable to do them
[exercises]; it was because I couldn’t be bothered
doing them. To me that’s quite a difference.
R4: I think it gave people more power, gave them an
outlook ... oh yeah, and when you think back, you had
done it for yourself.
There were many comments relating to post-stroke
treatment. Participants felt that they were “left to it” once the
rehabilitation team had finished with their treatment regime,
and they felt they now had to fend for themselves. This
highlighted an attitude of self-reliance, which seemed to be
enhanced by attendance in the classes. Participants felt they were
benefiting from interacting with other people who “are making
the same effort as you ... we boosted each other ... ” (R7).
Three respondents did not feel that the classes
necessarily had an enhancing effect on their recovery, sense
of independence, or control. These participants attribute
their recovery to their own determination and character and
the support received during the rehabilitation phase. The
following comments capture their views:
E8: I think by [the time I attended the class] I went back
to work, I was just so determined that I was going to
get back to what I had been doing ... and I think it’s just
been a lot of mind over matter and sheer determi-
nation ... I think attitude has got a lot to do with illness.
R1: I can’t fault the help I had in the rehabilitation. I
really feel that it’s a little degree of independence I
have now that I didn’t have before. But without the
help I had at rehab I would never have achieved that,
so I think the team work of all concerned is what
helped [rather than the classes].
R5: No, I still felt the same, I still had confidence enough
that I came out the hospital, and went out the next day
... so I don’t really feel any different.
Long-term effects of the classes
The long-term effects of the classes were explored by
discussing whether there were any exercises that participants
continued to practice at home, whether they had learnt any
new skills from the class that they can use in their day-to-day
life, and whether they attended any other form of class or
group activity after the classes had finished. Five participants
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 CARIN-LEVY ET AL.
in the exercise classes continued to lead an active life, and these
participants stated that they did not practice their exercises at
home. The reasons given were wide ranging: From simply not
being interested or lacking the time to fear of falling:
E1:”No, no, no, because you wouldn’t take [any
exercises] at home, in case I had a fall here.
Another reason for not taking part in anything at home
or attending a class in the community given by participant E3
was that he felt he had learnt all that there was to learn:
E3: I don’t think so. I think there is not much else, unless
they said there was a great new thing.
Two participants from the exercise class reported the
following when asked whether they practiced any of the
exercises at home:
E5: I learnt to take bigger strides, which helps with my
balance ... I also do some exercises for my arm, I do
these every day.
E7: Yes, I do, I still do some of the exercises like the
stretching and of course I have this wee cycling thing
and I do a bit every day.
Although the relaxation classes consisted of activities
based in a chair, there was a physical component to them
(stretching and muscle relaxation). These participants report
mainly on the physical elements that they continue to
practice at home.
R1: Well, during the 12-week course she gave us various
exercises that I still carry out to this day, which I think
are beneficial.
R2:“I do mainly the exercise with my legs and sitting
straight so I do that kind of thing and I learnt that
kind of thing with the breathing in the classes as well.
R8:I still do my exercises ... turn my ankle, and when I
get up, instead of getting up and walking away, I get up
and I stand, and then I go ... I just take my time to do
things now.
Discussion
This is the first study using rigorous in-depth qualitative
methodology to explore the psychosocial impact of
engagement in exercise and relaxation following a stroke. We
found that participants perceived psychosocial benefits from
exercise or relaxation classes in three main areas: the effect on
motivation, improved self-perceived quality of life, and
increased empowerment. At least some of these benefits seem
to persist long after the interventions had been completed,
unlike some of the quantitative physical benefits, which were
not sustained after the interventions had been completed
(Mead et al., 2007). Our data suggest that the benefits may
have been mediated in a number of different ways, including
participating in the intervention itself, getting out of the
house regularly, and the resumption of social interaction by
sharing a group activity with other stroke survivors “in the
same boat” (Mead, 2005).
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Our findings support the available literature on the
benefits of exercise for people with physical impairments/
chronic diseases (Carin-Levy & Jones, 2007; Specht et al.,
2002; Taub, Blinde, & Greer, 1999; Taylor & McGruder, 1996)
in terms of the perceived improvement in quality of life and
enhancement of psychosocial functioning (improved
physical ability, self confidence, and motivation), thus
demonstrating their relevance for stroke survivors also. We
have also found that participation in the classes had a
perceived positive effect on our informants’ internal locus of
control, as they felt that by attending the classes they were
empowered to take more control over their lives and to
become more self-reliant and confident. These benefits were
common to both exercise and relaxation class participants,
and they correspond with perceived benefits of activity
participation reported in the literature (Carin-Levy & Jones;
Specht et al.; Taub et al.; Taylor & McGruder). There is
evidence in the literature of the importance of internal locus
of control in relation to depression and anxiety post stroke
(Bandura, 1997; Morrison et al., 2000; Sinyor et al., 1986;
Robinson-Smith, Johnston, & Allen, 2000; Thomas &
Lincoln, 2006). While we cannot suggest that participation in
exercise and relaxation classes helped to prevent or control
low mood and anxiety, it is possible to link internal locus of
control with a general sense of well-being and greater
motivation in our informants.
There were differences between the two activity groups
in this study; the exercise group discussed the improvements
to their physical function as a direct result of the exercises
they undertook in the classes, whereas the relaxation group
identified physical benefits gained from the commitment to
the classes and the necessity of getting out of the house three
times per week.
There is evidence of the effectiveness of stress
management techniques (which include relaxation) in
reducing stress and in being of benefit to hypertensive
patients and patients at risk of developing anxiety disorders
(Dusek et al., 2008; Hanley et al., 2003; Spence et al., 1999;
Timmermann et al., 1998). This study found that taking part
in relaxation classes has a positive effect on perceived quality
of life through greater internal locus of control, improved
confidence and motivation, and improved psychosocial
functioning. All of these may have important implications in
controlling stress and anxiety in our informants.
The sample in this study was selected from a sample of
trial participants, all of whom met strict inclusion criteria
(Mead et al., 2007). Hence, these data represent only a
selected group of stroke survivors. More disabled stroke
survivors may have had different views of the effects of
exercise or relaxation classes and the impact of participation
in these classes may have been different in informants with a
wider range of abilities and impairments.
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Conclusion
We explored post-stroke participants’ views of attending
exercise and relaxation classes to find they had a perceived
positive effect on motivation to recover, psychosocial
functioning, and confidence, thus having a positive effect on
quality of life. There may be long-term effects of participation
in such classes for this population as some of our informants
reported that as a result of the class they attended they were
motivated to continue to practice some of the activities at
home, with some even committing to attending a similar
class in the community. Our findings may have important
implications to the post-rehabilitation phase of stroke
recovery for survivors: if such classes were offered to most
stroke survivors following their discharge from hospital, it is
possible that the quality of life of stroke survivors might be
enhanced and their motivation to take control over their own
recovery might be greater. Our findings add to the body of
knowledge on the benefits of activity participation in general,
and in the stroke population in particular. This is an
important area that may in future help shape the occupa-
tional therapy service provided to stroke survivors.
Clearly, there is a need to conduct further research in
this area: we suggest that larger numbers of informants, with
the inclusion of a wider variety of abilities, including
institution-dwelling stroke survivors, will determine whether
these results are applicable to the wider population of stroke
survivors. We would also suggest that further research
employing a combination of methodologies examine the
therapeutic value of taking part in exercise and relaxation
training for this patient group. A randomized trial design
using the intervention versus a social group rather than
comparing exercise versus relaxation would assist in
exploring the value of either class. We also suggest that future
trials have a qualitative component to them in order to
corroborate both qualitative and quantitative data effectively.
Furthermore, qualitative, longitudinal work could be
undertaken to explore the long-term effects, if any, of partic-
ipation in such activities for this patient group.
Acknowledgements
This work was undertaken while Ms Carin-Levy was a
Research Assistant in Geriatric Medicine, The University of
Edinburgh. We are grateful to the persons who volunteered
to take part in this study; their generous contributions gave
us a clear picture of their experiences. We are grateful to our
funders: Chief Scientist Office, Scottish Executive, which
funded STARTER, and to Moray Endowment Fund,
University of Edinburgh, University of Edinburgh
Development Fund, which funded this qualitative study.
© CAOT PUBLICATIONS ACE VOLUME 76
CARIN-LEVY ET AL.
Key messages
• According to participants of a randomized control
trial, involvement in exercise- or relaxation-based
group activities had a positive effect on self-perceived
quality of life.
• Taking part in exercise or relaxation classes may have
long-term benefits for persons surviving a stroke to
explore by improving motivation to continue to
practice at home or to attend similar classes in the
community.
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Authors
Gail Carin-Levy, BSc (Hons), is Lecturer in Occupational Therapy,
School of Social Sciences, Queen Margaret University, Queen
Margaret University Drive, Musselburgh, East Lothian EH21
6UU Scotland. Tel: +44 131 4740000. Fax: +44 131 4740001. E-
mail: GCarin-Levy@qmu.ac.uk
Marilyn Kendall, PhD, is Research Fellow, Division of Community
Health Sciences, General Practice Section, The University of
Edinburgh, 20 West Richmond Street, Edinburgh, EH8 9DX,
Scotland
Archie Young, MD, FRCP, is Professor (emeritus) of Geriatric
Medicine. Geriatric Medicine, The University of Edinburgh,
School of Clinical and Surgical Sciences, Chancellor’s Building,
Little France Crescent, Edinburgh EH16 4SB. Scotland
Gillian Mead, MD, FRCP, is Senior Lecturer in Geriatric Medicine,
Geriatric Medicine, The University of Edinburgh, School of
Clinical and Surgical Sciences, Chancellor’s Building, Little
France Crescent, Edinburgh EH16 4SB. Scotland.

APPENDIX
Interview questions

• Can you please describe what was good or bad about the classes? What could have been done differently?
• What is your opinion on running classes like these?
• Now that the classes are over, do you feel that you have learnt things that will help you in the long term?
• Do you continue to practice at home or attend classes now that you have had this experience?
• What motivated you to attend the classes?
• Do you feel that attending the classes has helped or hindered the way you manage at home?
• In your opinion, do you feel your quality of life has changed as a consequence of taking part in the classes?
• Would you recommend these classes to other people? Why?
• What did you learn about yourself since attending the classes?
• Since attending the classes, do you feel any different about yourself? (aspects of control over own life)
• Can you tell me about the social side of the attendance in the classes?
• Did you like or dislike meeting new people through the class?
• Did you form relationships with the instructor or with other class participants?
• Do you go out often? Has this changed after having a stroke? Has this changed again after attending the classes?
• Free comments

80 AVRIL 2009 I REVUE CANADIENNE D’ERGOTHÉRAPIE I NUMÉRO 2 I VOLUME 76 © CAOT PUBLICATIONS ACE