Cardiopulmonary Exercise Testing in Stroke Rehabilitation: Benefits and Clinical Utility Perceived by Physiotherapists and Individuals with Stroke (2025)

Abstract

Purpose: The purpose of this study was to understand the perceived benefits and clinical utility of cardiopulmonary exercise testing (CPET) from the perspectives of physiotherapists and patients and to explore the factors that influence adopting CPET in a stroke rehabilitation setting. Method: A qualitative descriptive study was conducted. Physiotherapists (n=6) participated in a focus group to discuss the use of CPET in practice. Patients (n=8) who had completed CPET during stroke rehabilitation participated in a semi-structured interview to explore their experiences. Thematic analysis was performed. Results: CPET increased the physiotherapists’ confidence in prescribing exercise, especially for medically complex patients. Ongoing medical management early post-stroke was a barrier to referral. Physiotherapists expressed decreased confidence in interpreting test results. Consultation with local experts facilitated the use of CPET. Patients described how CPET increased their confidence to participate in exercise. They desired more information before and after CPET to better understand the purpose and results and their relation to their rehabilitation goals. Conclusions: Both physiotherapists and patients described the benefit of having CPET available to support them as they participated in exercise in a stroke rehabilitation setting. Physiotherapists would benefit from having educational tools to support their interpretation and application of test results, and patients would benefit from improved communication and education to support their understanding of the relevance of CPET to their rehabilitation goals. Future research should explore these findings in other stroke rehabilitation settings.

Key Words: exercise, focus groups, interview, stroke

Strong evidence supports the benefits of aerobic exercise (AE) after stroke.¹ After stroke, individuals often present with cardiovascular fitness levels that are insufficient to meet the metabolic requirements of independent living.² Early exercise training may improve the aerobic capacity necessary to support their functional recovery;³ indeed, findings from a meta-analysis demonstrated that during the subacute stages of recovery, structured AE could improve aerobic capacity and endurance for individuals with stroke.⁴ Accordingly, best practice guidelines recommend that health care professionals screen individuals for aerobic training as soon after stroke as they are medically stable.⁵

A symptom-limited exercise stress test using an electrocardiogram (ECG) is recommended before prescribing aerobic training post-stroke.⁵ A submaximal exercise test can be used if the planned intensity of the exercise is light to moderate (e.g., <50% predicted heart rate reserve [HRR]).⁵ However, many individuals with stroke have comorbid cardiovascular disease.⁶ Moreover, such conservative endpoints may not be of sufficient intensity to yield an optimal exercise prescription as individuals progress in their recovery. Many of the known benefits of AE after stroke have been achieved during training at higher intensities (e.g., 40%–80% HRR).⁴ A model of care that includes symptom-limited exercise testing during stroke rehabilitation may inform and support early access to AE, yet such testing is not standard practice in stroke rehabilitation settings.^7–9

Our institution implemented a clinic that enabled access to cardiopulmonary exercise testing (CPET) in a stroke rehabilitation setting. CPET provides information that can be used for exercise prescription,¹⁰ including indices of respiratory gas exchange (oxygen uptake, carbon dioxide output, and minute ventilation) and heart rate (HR) and ratings of perceived exertion, while blood pressure and a 12-lead ECG are monitored. The test is discontinued if an individual reaches maximum oxygen consumption or peak volitional effort or develops adverse clinical signs or symptoms. Understanding end users’ experiences is important to understand how best to support the clinical uptake of new practices.¹¹ Understanding physiotherapists’ perspectives could inform how future models of care are implemented and how CPET is used in rehabilitation. Understanding the experiences of individuals with stroke could improve how CPET is used to better meet their needs. The purpose of this study was, therefore, to explore the perspectives and experiences of physiotherapists who had referred patients for CPET and of individuals with stroke who had completed CPET during stroke rehabilitation in a large academic urban center. The primary objective was to understand the perceived clinical benefits, if any, and utility of CPET from the perspectives of the physiotherapists and the individuals attending stroke rehabilitation. The secondary objective was to understand the facilitators and barriers that may influence the use of CPET in stroke rehabilitation.

Methods

Design

A qualitative descriptive methodology was used to obtain an in-depth understanding of the participants’ experiences.^12,13 We conducted a focus group with physiotherapists and face-to-face interviews with individuals with stroke. Both modes of data collection were semi-structured. This research received institutional ethics approvals, and all participants provided informed consent.

Setting

The Toronto Rehabilitation Institute – University Health Network has implemented a once-a-month, on-site clinic that makes symptom-limited CPET available to patients attending neurorehabilitation. The CPET clinic is a partnership between the hospital’s stroke and cardiac rehabilitation programmes. Patients are referred by their primary physiotherapist, and CPET is administered by a physiotherapist affiliated with the clinic and a cardiopulmonary exercise technician, under the supervision of a physician. CPET is conducted on an upright cycle or recumbent stepper.^10,14 The test results are provided to the referring physiotherapist to inform an exercise prescription, which considers HR at the ventilatory anaerobic threshold (VAT), as a percentage of oxygen uptake during peak exercise or HRR; exercise-induced abnormalities; and participant perceived exertion. The clinic physiotherapists and cardiac rehabilitation staff provide initial education and ongoing patient-specific consultation to assist the referring physiotherapists in interpreting the test.

Participants

We recruited 6 of the 8 physiotherapists employed in the stroke rehabilitation service. All had extensive experience working with stroke patients (3–36 y) and had referred multiple individuals for CPET (see Table 1). We recruited a convenience sample of 8 patients (aged >18 y) who had diagnosed stroke and the cognitive or communicative ability to provide informed consent and participate in a 60-minute interview, determined by best clinical judgment. To be eligible, patients had to have completed CPET during their rehabilitation, a minimum of 1 week before the interview. Between January and June 2018, 21 individuals were referred for CPET. Nine did not meet the inclusion criteria (5 did not have a stroke diagnosis, 2 had limiting cognitive impairment, and 2 were not English speaking). Of the 12 eligible patients, we recruited 8 (5 men and 3 women, aged 23–83 years) (see Table 2). The primary therapists were blinded to the patients’ involvement in the interview.

Table 1.

Physiotherapist Characteristics (n=6)

Characteristic	No. of participants*
Age, y
30–39	3
40–49	1
50–59	0
60–69	2
Sex
Female	5
Male	1
Stroke rehabilitation experience, y, median (range, min-max)	14 (3–36)
Setting
Inpatient	4
Outpatient	2
CPET referrals
Inpatient
3–5	3
6–10	1
11–20	0
>20	0
Outpatient
3–5	0
6–10	0
11–20	0
>20	2

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Unless otherwise specified.

CPET=cardiopulmonary exercise testing.

Table 2.

Characteristics of Individuals Living with Stroke (n=8)

Characteristic	No. of participants*
Age, y, median (range, min-max)	47.1 (24–83)
Sex
Male	5
Female	3
Setting
Inpatient	1
Outpatient	7
Time between CPET and interview, d, median (range, min-max)	13(5–43)
Walking status
Independent, no aid	4
Independent with aid	2
Assistance required	2
Highest education^†
< High school diploma	1
High school diploma	1
College	2
University (undergraduate)	1
University (graduate)	2

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Unless otherwise specified.

^{^†}

Missing data for 1 participant.

Data collection

We held a focus group with the physiotherapist participants and interviews with the patient participants. We asked the physiotherapists a set of clinical profile questions so that we could collect information to characterize them. We collected information about the patients through self-report before the interviews; therefore, it did not include specific measures of stroke severity or cognitive or motor impairment. Self-reported walking status was obtained. Physiotherapist focus group and patient interview guides were developed, consisting of open-ended questions with probes (reproduced in online Appendices 1 and 2). The focus group questions explored the physiotherapists’ experiences in referring patients to the clinic, the perceived benefit or clinical utility (if any) of CPET, the challenges and facilitators of using the CPET results in practice, and suggested improvements for future implementation.

The patient interview questions explored their experiences during CPET, their understanding of the purpose of the test, any perceived benefit to their care, the perceived challenges of participating, and future recommendations. The focus groups and interviews were digitally audio recorded and transcribed verbatim. The interviewers also took detailed field notes after each focus group or interview to summarize the major points. Physical therapy graduate students served as focus group (AS, CM, and JM) and interview (VB and CL) facilitators; all had received extensive education on interviewing, stroke, and aerobic exercise. To ensure reliability, VB and CL administered all the patient interviews together, either leading them or taking field notes and asking clarifying questions.

Data analysis

To ensure the rigor of the coding process and the trustworthiness of the data, team members (excluding SM and ELI) reviewed the transcribed interviews for accuracy. Braun and Clarke’s step-by-step thematic analysis approach was used for data analysis.¹⁵ We familiarized ourselves with the interview and focus group data by reviewing the verbatim transcriptions. We used colour coding to identify major themes and ideas in the first four transcripts and then used repeated comparative analysis to develop descriptive codes. SM and ELI, who were involved in developing the clinic, did not participate in this early analysis.

We also developed code books to support consistent coding of the transcribed focus groups and interviews. They included a table of major codes and sub-codes, the definitions of the codes, and the importance or relevance of a code to the study purpose. Members of the research team used these code books to independently code the data using line-by-line coding. Similar codes were clustered to identify themes, and quotes from the coded segments were used to support the emerging themes. Regular debriefing sessions with all members of the research team allowed us to triangulate similar and different interpretations of the data.

Results

Three main themes emerged from the interviews with the therapists: (1) the clinical utility and benefits of CPET in stroke rehabilitation; (2) the challenges of using CPET in stroke rehabilitation for ongoing patient medical management and physiotherapists’ confidence in interpreting the results; and (3) having access to local clinical expertise to support the use of CPET. Two main themes were developed from the patient interviews: (1) increased confidence to participate in AE and (2) the need for therapists to improve their communication with their patients so that they could better understand the purpose and results of the CPET. A final theme that emerged from both groups was their recommendations for future developments in stroke rehabilitation. (See Figure 1.)

Cardiopulmonary Exercise Testing in Stroke Rehabilitation: Benefits and Clinical Utility Perceived by Physiotherapists and Individuals with Stroke (1)

Physiotherapists’ perspectives

Utility and benefits

Physiotherapists reported that CPET informed the exercise that they prescribed for patients at lower levels of ability and with increased medical complexity. It also enhanced their confidence in prescribing exercise at an appropriate intensity early post-stroke to achieve the intended health benefits.

It gives you the confidence to treat them earlier at a level that’s appropriate for them…. If you can get them on a programme and refer them to a fitness group then we know that they are being able to be trained a lot earlier. (Physiotherapist 1, outpatient)

The physiotherapists also described how early access to CPET results could facilitate a patient’s participation in AE along the rehabilitation continuum. Inpatient physiotherapists referred their patients for CPET so that they would have the results ready for use by the outpatient physiotherapists

I would refer toward the end of somebody’s [inpatient] stay … but before their outpatient stay, just to help facilitate the next stage of the continuum in terms of aerobic exercise. (Physiotherapist 3, inpatient)

Physiotherapists also described sharing CPET results to inform the care their patients would receive when they were discharged to other rehabilitation settings that did not have access to such testing. They also shared the results with their patients to promote them exercising independently after discharge.

I like the idea that the prescription can be ultimately shared in the community as well … I think it’s important to the concept of ongoing participation outside the hospital setting so they know how they can [use their prescription] in their daily life. (Physiotherapist 5, inpatient)

Challenges with using cardiopulmonary exercise testing in stroke rehabilitation

The physiotherapists reported that ongoing patient medical management and access to the health information required for screening posed barriers to referring for CPET for both in-patients and outpatients who were being admitted earlier post-stroke and with limited lengths of stay.

There’s a lot of juggling medications and [blood pressure] fluctuations, and often it takes weeks to get that right and so we just have to wait … it ends up being something that is beneficial at the end of their inpatient stay or during their outpatient stay. (Physiotherapist 2, inpatient)
With one of our outpatient programmes … they’re coming in super acutely, so they could be 1, 2, or 3 weeks post-stroke, and we don’t have the investigations done … don’t have the results … to see if there’s any abnormality we need to be aware of, so that can prevent us from moving further. (Physiotherapist 1, outpatient)

Most physiotherapists described not having a lot of confidence in the independent interpretation of the test results, specifically the VAT. They also described the challenges of prescribing the appropriate intensity of AE.

Honestly the graphs and how to make sense of it…. My confidence is nil in terms of interpreting it … heart rate I can use that no problem, but at times it’s the graphs that give us the most difficulty to make sense of. (Physiotherapist 1, outpatient)
I’m confident I know the person can exercise within these levels, [but] I’m not entirely confident that I’m prescribing them in the exact place they should be exercising, so sometimes it’s a big range. (Physiotherapist 3, inpatient)

Access to local clinical experts

Having access to clinical expertise facilitated the use of CPET. Physicians were considered important for giving physiotherapists support with patient screening and providing guidance for patient management if an abnormality was found. The physiotherapists also identified the consultation provided by the clinic physiotherapists and the cardiac rehabilitation staff as being important facilitators of applying CPET in a clinical setting.

Patients’ perspectives

Increased confidence to participate in aerobic exercise

Although no patients described the test as not being beneficial, some were not able to describe how they had benefited or how their rehabilitation had changed post-test. However, other patients said that their confidence had increased as well as their participation in exercise. In addition, these patients described having a newfound knowledge of the safe range of exercise intensity based on their CPET results.

I am more confident about the rehab that I am going through here now given that I had that stress test…. Before I was just really anxious. (Patient 6)
I learned a lot from the results. For example, I have a recumbent bike at home … I do every morning for an hour every day, but now I know like how fast to go and how hard to work myself and what heart rate to maintain to get the proper exercise. (Patient 4)

Need for improved communication to understand the purpose and results of cardiopulmonary exercise testing

Patients described not fully understanding the purpose of the test and its relationship to their therapy or rehabilitation goals.

Pre-test: Although some patients expressed a general understanding of the purpose of the test, they thought that the link among the test results, accomplishing their goals, and plans of care was not well explained.

I didn’t know what it was for, to be honest … then I came to understand when I started the fitness programme that it was to measure my heart rate … to make sure they monitored it and [it] stayed within a certain range … for safety precaution…. That is about as far as I understood the reason for the whole CPET machine. (Patient 3)
Yeah, so initially I was a little confused because my physio was kind of like, “We want to get you on this cardio thing,” and I was like, “Well cardio is not the problem. My problem is that I can’t walk.” (Patient 1)

Post-test: Patients expressed a desire for more information about their test results from the CPET clinic team immediately after the test and from their physical therapists in subsequent therapy sessions.

My only concern was that I wanted to know what the results were and I wish they would be like, I wish someone would give me a quick summary or like or a response on how I did or something…. It would have been nice if someone said, “OK, … you pushed yourself and we notice that your heart is healthy, we noticed no problems with your heart.” (Patient 4)

Recommendations for improving the current cardiopulmonary exercise testing model

Both study groups made recommendations to improve the use of CPET in rehabilitation. Physiotherapists recommended improving their training to increase their understanding of how to interpret the results and apply them to therapy.

Let’s go through a case…. Like is there some sort of template? That would make it a lot easier [to interpret the results and put] it into function. So for bikes for example, a programme of where would [the patient with stroke] start and how to progress [the patient] within a few weeks and some guidelines and practice tools … like that along with in-services would be helpful. (Physiotherapist 1, outpatient)

The physiotherapists also suggested that referral processes could be improved by timely access to patient health information and by physicians conducting routine screening. Alternatively, they suggested a flagging system at admission or throughout rehabilitation to identify patients who were candidates for CPET.

The patients recommended improving patient education so that they could receive more information about the nature and purpose of the test in advance.

I think like a couple of days prior to the test, I think explaining the test more in detail would definitely help ’cause … when I was told about the test in detail it was like a couple of minutes before the test. (Patient 4)

The patients also recommended that they receive a more thorough review and explanation of their test results. This would inform their exercise in the home and community.

It would be nice if there was a written report of some sort … that I could just take with me … just to explain to me what they are basing their conclusions off of. (Patient 6)
A copy of what I’m supposed to be doing for my own activities outside of this place…. I’m not going to accomplish everything in 2 weeks …. So I want to know what my future will be and how I can prevent myself from having another stroke. (Patient 2)

In addition, the limited availability of the CPET clinic restricts when patients are able to complete the test; both the physiotherapists and the patients recommended more frequent scheduling.

Discussion

Previous research has highlighted the importance of AE in stroke rehabilitation, and best practice guidelines recommend using the results of a symptom-limited exercise test to guide safe, optimal exercise prescription.⁵ To our knowledge, this study is the first to explore the perspectives and experiences of physiotherapists and individuals with stroke who have experience with CPET in stroke rehabilitation. Physiotherapists described having more confidence in prescribing exercise at this stage of recovery, and patients expressed more confidence in participating in it. However, the physiotherapists identified several barriers to prescribing exercise resulting from ongoing patient medical management, and they lacked confidence in interpreting and prescribing independent tests. The patients described not fully understanding the purpose of the test or its relationship to their rehabilitation goals.

The perspectives of the physiotherapists sampled in this study appear to differ from views previously reported.⁸ In a national survey, only 3% of Canadian physiotherapists practising in adult neurorehabilitation thought that exercise testing was essential to facilitate aerobic exercise, but the majority of respondents did not have these tests available in their setting.⁷ The views expressed in our study may be related to physiotherapists’ experience with CPET in clinical practice. The physiotherapists in our study stated that access to CPET helped them feel more confident in prescribing AE that was safe and at an appropriate intensity, especially for patients with a more medically complex condition. Survey studies have revealed that a primary barrier to physiotherapists implementing AE is concern about the risk of cardiovascular disease (CVD).^7,8,16 Those with stroke and CVD are often excluded from AE programming.^8,17 Therefore, providing access to CPET in stroke rehabilitation may be a strategy to overcome known barriers and provide earlier access to AE for those with stroke and CVD who could benefit  from it.

The therapists also used CPET to give their patients guidelines for participating in safe, independent exercise. Some patients said that completing CPET had increased their confidence to exercise and their desire to participate. When shared with and properly understood by patients, the results of CPET may help to build their confidence to exercise. Exercise self-efficacy is an important predictor of exercise behaviour.^18–20

However, physiotherapists described challenges with CPET when patient medical management was ongoing and screening information was not yet available. In response, they considered AE as running along a continuum whereby the CPET results in one setting could be used for care in the next rehabilitation or community setting. More routine screening and referral processes and more frequent CPET scheduling might facilitate access when patients are medically capable of participating. This, in turn, might help patients realize the benefits of CPET and AE in supporting their rehabilitation goals.

The therapists also stated that certain aspects of the test results were difficult to interpret and apply in a functional way – for example, interpreting the measures of gas exchange provided with CPET results. Future work should explore physiotherapists’ need for knowledge and skill in interpreting CPET results for prescribing exercise and should develop optimal educational strategies to address this gap (e.g., guidelines, case-based studies, references for clinical interpretation).

Whereas most literature has explored physiotherapists’ role in implementing AE after stroke,^7,9 the present results suggest that physicians played a key role in screening and interpreting CPET findings. In addition, having access to staff with clinical expertise for consultation facilitated physiotherapists’ use and application of CPET in patient care. An interprofessional approach may be necessary to achieve success in other stroke rehabilitation settings.

Patients described not fully understanding the purpose of the test or its relationship to their rehabilitation goals. It has previously been suggested that patients are often unable to correctly identify their treatment plans despite their health care provider’s belief that they are providing sufficient education.²¹ Patients described wanting more information in advance of being tested. Effective communication is achieved when patients are given enough time with health care providers to discuss the details of their medical procedures.²² Educational strategies that include motivational interviewing, with a specific focus on an individual patient’s needs and concerns, may also encourage patients to adhere to exercise.²³

In our study, the majority of patients were aged younger than 50 years. The younger participants appeared to have a better understanding of the purpose of CPET than their older counterparts. Sherlock and Brownie also found that patients’ understanding of their proposed medical procedures was poor, especially among older patients.²²

Moreover, it became apparent during our interviews that a few patients had residual cognitive or communicative impairments. Although the degree of impairment did not preclude them from participating and sharing their perspectives, it may have influenced their understanding of CPET or their ability to fully discuss how their results could be used in their rehabilitation. Patients voiced concerns related to the inadequate provision, timing, and format of information related to CPET, which is similar to information barriers identified in other research with people with stroke.²⁴ Patients would benefit from being given more information about the purpose and process of CPET and enough time to adequately discuss it with their physiotherapists before participating. Educational processes and materials should be developed for patients (considering timing, content, format, and method of delivery) to ensure that they understand the purpose of the test, the test results, their exercise prescription, and how it supports their rehabilitation goals.

Patients’ understanding may also have been influenced by the level of experience of the referring physiotherapists in interpreting and applying the results of CPET. As indicated in Table 1, outpatient physiotherapists referred patients more often than inpatient physiotherapists. Svavarsdóttir and colleagues found that expert health professionals were able to provide more effective and understandable patient education than novel health professionals in cardiac care.²⁵ Improved physiotherapist education may help increase physiotherapists’ confidence in explaining test results, which in turn may facilitate patient understanding.

This study had two limitations. First, it may not be generalizable to other institutions, given the different models of care and access to resources among stroke rehabilitation programmes. Another factor that may limit generalizability was our small sample size of individuals with stroke and physiotherapists as well as the young median age of the patients. Finally, in some cases, insufficient time may have elapsed between use of CPET and interviews of patients for them to realize the impact of the exercise test on their therapy and rehabilitation goals.

Conclusion

When access to CPET was made available in a stroke rehabilitation setting, both the physiotherapists and the patients recognized its benefit in supporting the patients’ participation in exercise. However, physiotherapists would benefit from having educational tools that supported them in interpreting and applying the CPET results in practice. Patients would benefit from well-designed educational processes and materials to ensure that they adequately understand the test process, test results, and their relevance to their rehabilitation goals. Future research is required to explore the barriers to and facilitators of using CPET in other stroke rehabilitation settings. Future studies should also compare patients who received CPET with those who did not to explore whether the perceived clinical benefit of CPET correlates to an actual change in patients’ exercise outcomes.

Key Messages

What is already known on this topic

There is strong evidence for the benefits of participating in AE after stroke. Exercise stress testing with electrocardiogram monitoring is a recommended method for screening patients before they participate and determining the target exercise intensity. However, few physiotherapists in stroke rehabilitation settings have access to such testing.

What this study adds

When access to cardiopulmonary exercise testing (CPET) was made available in a stroke rehabilitation setting, the physiotherapists were more confident in prescribing, and the patients were more confident in participating in, aerobic exercise. To support the clinical implementation of CPET, physiotherapists would benefit from having educational tools that support how they interpret and apply CPET results in practice. Patients would benefit from enhanced communication and education to ensure that they adequately understand the test process, the test results, and their relevance to their rehabilitation goals.

Supplementary Material

Appendix 1

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Appendix 2

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Appendix 1

Click here for additional data file.^{(401KB, pdf)}

Appendix 2

Click here for additional data file.^{(402.1KB, pdf)}