This systematic review aimed to identify barriers and facilitators in post-stroke motor rehabilitation across patient, caregiver, and healthcare professional levels, employing the capability, opportunity, motivation, behavior (COM-B) model and the theoretical domains framework (TDF).
Materials and Methods
A systematic search of PubMed, EMBASE, Cochrane Library, Web of Science, and CINAHL, following PRISMA guidelines, covered literature until January 20, 2025. Studies reporting qualitative, quantitative, or mixed-methods data on post-stroke motor rehabilitation barriers and facilitators were included. Quality assessment utilized MMAT 2018.
Results
Analyzing 48 studies, we found that barriers to post-stroke motor rehabilitation encompassed motor impairments, cognitive issues, resource scarcity, and environmental factors, while facilitators included good physical abilities, resource accessibility, and social support. The COM-B model elucidated the dynamic interplay between capability, opportunity, and motivation, suggesting educational interventions and telerehabilitation as avenues for improvement.
Conclusion
This systematic review, guided by the COM-B model, identifies key barriers and facilitators in post-stroke motor rehabilitation. It emphasizes the importance of targeted education, improved telerehabilitation infrastructure, and robust social support systems to address multifaceted challenges.
AguiarL. T.NadeauS.Teixeira-SalmelaL. F.ReisM. T. F.PenicheP. D. C.FariaC. D. C. M. (2022). Perspectives, satisfaction, self-efficacy, and barriers to aerobic exercise reported by individuals with chronic stroke in a developing country. Disability and Rehabilitation, 44(13), 3089–3094. https://doi.org/10.1080/09638288.2020.1855260
2.
BarclayR.RipatJ.MayoN. (2015). Factors describing community ambulation after stroke: A mixed-methods study. Clinical Rehabilitation, 29(5), 509–521. https://doi.org/10.1177/0269215514546769
3.
BatesB. E.KwongP. L.XieD.ValimahomedA.RipleyD. C.KurichiJ. E.StinemanM. G. (2013). Factors influencing receipt of early rehabilitation after stroke. Archives of Physical Medicine and Rehabilitation, 94(12), 2349–2356. https://doi.org/10.1016/j.apmr.2013.07.021
4.
BhattacharjyaS.LinaresI.LanganJ.XuW.SubryanH.CavuotoL. A. (2023). Engaging in a home-based exercise program: A mixed-methods approach to identify motivators and barriers for individuals with stroke. Assistive Technology : The Official Journal of RESNA, 35(6), 487–496. https://doi.org/10.1080/10400435.2022.2151663
5.
BillingerS. A.ArenaR.BernhardtJ.EngJ. J.FranklinB. A.JohnsonC. M.MacKay-LyonsM.MackoR. F.MeadG. E.RothE. J.ShaughnessyM.TangA., & American Heart Association Stroke Council, Council on Cardiovascular and Stroke Nursing, Council on Lifestyle and Cardiometabolic Health, Council on Epidemiology and Prevention, & Council on Clinical Cardiology. (2014). Physical activity and exercise recommendations for stroke survivors: A statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 45(8), 2532–2553. https://doi.org/10.1161/STR.0000000000000022
6.
BollingerR. M.KraussM. J.SomervilleE. K.HoldenB. M.BlendenG.HollingsworthH.KelemanA. A.CarterA.McBrideT. D.BarkerA. R.YanY.StarkS. L. (2024). Rehabilitation transition program to improve community participation among stroke survivors: A randomized clinical trial. JAMA Network Open, 7(10), e2437758. https://doi.org/10.1001/jamanetworkopen.2024.37758
7.
BrounsB.MeestersJ. J. L.WentinkM. M.de KloetA. J.ArwertH. J.BoyceL. W.Vliet VlielandT. P. M.van Bodegom-VosL. (2019). Factors associated with willingness to use erehabilitation after stroke: A cross-sectional study among patients, informal caregivers and healthcare professionals. Journal of Rehabilitation Medicine, 51(9), 665–674. https://doi.org/10.2340/16501977-2586
8.
CaneJ.O’ConnorD.MichieS. (2012). Validation of the theoretical domains framework for use in behaviour change and implementation research. Implementation Science: IS, 7(1), 37. https://doi.org/10.1186/1748-5908-7-37
9.
ChoiY. A.LeeJ. S.ParkJ. H.KimY. H. (2022). Patterns of physical activity and sedentary behavior and their associated factors among nondisabled stroke survivors. Maturitas, 158(4), 10–15. https://doi.org/10.1016/j.maturitas.2021.11.009
10.
ChongW. F. W.NgL. H.HoR. M.-H.KohG. C. H.HoenigH.MatcharD. B.YapP.VenketasubramanianN.TanK. B.NingC.MenonE.ChangH. M.De SilvaD. A.LeeK. E.TanB. Y.YoungS. H. Y.NgY. S.TuT. M.AngY. H., … CheongA. (2021). Stroke rehabilitation use and caregiver psychosocial health profiles in Singapore: A latent profile transition analysis. Journal of the American Medical Directors Association, 22(11), 2350–2357.e2. https://doi.org/10.1016/j.jamda.2021.02.036
11.
ConnellL. A.KlassenT. K.JanssenJ.ThetfordC.EngJ. J. (2018). Delivering intensive rehabilitation in stroke: Factors influencing implementation. Physical Therapy, 98(4), 243–250. https://doi.org/10.1093/ptj/pzy018
12.
CsC.RjF.CN.KM.MfW. (2013). A qualitative study exploring patients’ and carers’ experiences of Early Supported Discharge services after stroke. Clinical Rehabilitation, 27(8), 750–757. https://doi.org/10.1177/0269215512474030
13.
Débora PachecoB.Guimarães CaetanoL. C.Amorim SamoraG.Sant’AnaR.Fuscaldi Teixeira-SalmelaL.ScianniA. A. (2021). Perceived barriers to exercise reported by individuals with stroke, who are able to walk in the community. Disability and Rehabilitation, 43(3), 331–337. https://doi.org/10.1080/09638288.2019.1624396
14.
FisherR. J.RussellL.Riley-BennettF.CameronT.WalkerM.SackleyC. (2023). Barriers and facilitators in providing home-based rehabilitation for stroke survivors with severe disability in the UK: An online focus group study with multidisciplinary rehabilitation teams. BMJ Open, 13(8), e071217. https://doi.org/10.1136/bmjopen-2022-071217
15.
GagnonM. A.BatchoC. S.BestK. L. (2022). A description of physical activity behaviors, barriers, and motivators in stroke survivors in Quebec. Disability and Health Journal, 15(2), 101265. https://doi.org/10.1016/j.dhjo.2021.101265
16.
GaskinsN. J.BrayE.HillJ. E.DohertyP. J.HarrisonA.ConnellL. A. (2021). Factors influencing implementation of aerobic exercise after stroke: A systematic review. Disability and Rehabilitation, 43(17), 2382–2396. https://doi.org/10.1080/09638288.2019.1704075
17.
GBD 2019 Stroke Collaborators. (2021). Global, regional, and national burden of stroke and its risk factors, 1990-2019: A systematic analysis for the Global Burden of Disease Study 2019. The Lancet. Neurology, 20(10), 795–820. https://doi.org/10.1016/S1474-4422(21)00252-0
18.
GoodwinM. V.HogervorstE.MaidmentD. W. (2024). A qualitative study assessing the barriers and facilitators to physical activity in adults with hearing loss. British Journal of Health Psychology, 29(1), 95–111. https://doi.org/10.1111/bjhp.12689
19.
HarrisA.AustinM.BlakeT. M.BirdM. L. (2019). Perceived benefits and barriers to yoga participation after stroke: A focus group approach. Complementary Therapies in Clinical Practice, 34(1), 153–156. https://doi.org/10.1016/j.ctcp.2018.11.015
20.
HongQ. N.FàbreguesS.BartlettG.BoardmanF.CargoM.DagenaisP.GagnonM.-P.GriffithsF.NicolauB.O’CathainA.RousseauM.-C.VedelI.PluyeP. (2018). The Mixed Methods Appraisal Tool (MMAT) version 2018 for information professionals and researchers. Education for Information, 34(4), 285–291. https://doi.org/10.3233/EFI-180221
21.
InnessE. L.JagroopD.AndreoliA.BayleyM.BiasinL.DanellsC.HallJ.MansfieldA.McDonaldA.NishriD.SalbachN. M.TaylorD.WongK.TangA. (2022). Factors That Influence the Clinical Implementation of Aerobic Exercise in Stroke Rehabilitation: A Theory-Informed Qualitative Study. Physical Therapy, 102(6), 1–12. https://doi.org/10.1093/ptj/pzac014
22.
JacksonS.MercerC.SingerB. J. (2018). An exploration of factors influencing physical activity levels amongst a cohort of people living in the community after stroke in the south of England. Disability and Rehabilitation, 40(4), 414–424. https://doi.org/10.1080/09638288.2016.1258437
23.
JanssenH.BirdM. L.LukerJ.McCluskeyA.BlennerhassettJ.AdaL.BernhardtJ.SprattN. J. (2022). Stroke survivors’ perceptions of the factors that influence engagement in activity outside dedicated therapy sessions in a rehabilitation unit: A qualitative study. Clinical Rehabilitation, 36(6), 822–830. https://doi.org/10.1177/02692155221087424
24.
JanssenJ.KlassenT. D.ConnellL. A.EngJ. J. (2020). Factors influencing the delivery of intensive rehabilitation in stroke: Patient perceptions versus rehabilitation therapist perceptions. Physical Therapy, 100(2), 307–316. https://doi.org/10.1093/ptj/pzz159
25.
Karadag-SaygiE.GirayE.ErenN.YolcuG.CoskunO. K.CifciliS. (2024). Barriers and facilitators to physical activity participation among community-dwelling physically inactive individuals after stroke: A qualitative exploratory study. International Journal of Rehabilitation Research. Internationale Zeitschrift Fur Rehabilitationsforschung. Revue Internationale de Recherches de Readaptation, 47(1), 34–40. https://doi.org/10.1097/MRR.0000000000000610
26.
Khoshbakht PishkhaniM.DalvandiA.EbadiA.HosseiniM. (2019). Factors affecting adherence to rehabilitation in Iranian stroke patients: A qualitative study. Journal of Vascular Nursing : Official Publication of the Society for Peripheral Vascular Nursing, 37(4), 264–271. https://doi.org/10.1016/j.jvn.2019.07.001
27.
KrishnanS.MandalaM. A.WolfS. L.HowardA.KesarT. M. (2023). Perceptions of stroke survivors regarding factors affecting adoption of technology and exergames for rehabilitation. PM and R, 15(11), 1403–1410. https://doi.org/10.1002/pmrj.12963
28.
LastN.PackhamT. L.GewurtzR. E.LettsL. J.HarrisJ. E. (2022). Exploring patient perspectives of barriers and facilitators to participating in hospital-based stroke rehabilitation. Disability and Rehabilitation, 44(16), 4201–4210. https://doi.org/10.1080/09638288.2021.1881830
29.
LinB.ZhangZ.MeiY.LiuL.PingZ. (2022). The influential factors of adherence to physical activity and exercise among community-dwelling stroke survivors: A path analysis. Journal of Clinical Nursing, 31(17–18), 2632–2643. https://doi.org/10.1111/jocn.16091
30.
LukerJ.LynchE.BernhardssonS.BennettL.BernhardtJ. (2015). Stroke Survivors’ experiences of physical rehabilitation: A systematic review of qualitative studies. Archives of Physical Medicine and Rehabilitation, 96(9), 1698–1708.e10. https://doi.org/10.1016/j.apmr.2015.03.017
31.
MahmoodA.NayakP.KokG.EnglishC.ManikandanN.SolomonJ. M. (2021). Factors influencing adherence to home-based exercises among community-dwelling stroke survivors in India: A qualitative study. European Journal of Physiotherapy, 23(1), 48–54. https://doi.org/10.1080/21679169.2019.1635641
32.
MalikA. N.TariqH.AfridiA.RathoreF. A. (2022). Technological advancements in stroke rehabilitation. JPMA. The Journal of the Pakistan Medical Association, 72(8), 1672–1674. https://doi.org/10.47391/JPMA.22-90
33.
MarcheschiE.Von KochL.Pessah-RasmussenH.ElfM. (2018). Home setting after stroke, facilitators and barriers: A systematic literature review. Health & Social Care in the Community, 26(4), e451–e459. https://doi.org/10.1111/hsc.12518
34.
McGlincheyM. P.JamesJ.McKevittC.DouiriA.McLachlanS.SackleyC. M. (2018). The effect of rehabilitation interventions on physical function and immobility-related complications in severe stroke-protocol for a systematic review. Systematic Reviews, 7(1), 197. https://doi.org/10.1186/s13643-018-0870-y
35.
McKeoughR.BlanchardC.Piccinini-VallisH. (2022). Pregnant and postpartum women’s perceptions of barriers to and enablers of physical activity during pregnancy: A qualitative systematic review. Journal of Midwifery & Women’s Health, 67(4), 448–462. https://doi.org/10.1111/jmwh.13375
36.
MeadmoreK. L.HallewellE.FreemanC.HughesA. M. (2019). Factors affecting rehabilitation and use of upper limb after stroke: Views from healthcare professionals and stroke survivors. Topics in Stroke Rehabilitation, 26(2), 94–100. https://doi.org/10.1080/10749357.2018.1544845
37.
MichieS.AtkinsL.WestR. (2014). The Behaviour Change Wheel: A Guide To Designing Interventions. Silverback Publishing.
38.
MichieS.van StralenM. M.WestR. (2011). The behaviour change wheel: A new method for characterising and designing behaviour change interventions. Implementation Science: IS, 6(1), 42. https://doi.org/10.1186/1748-5908-6-42
39.
MillerA.PohligR. T.WrightT.KimH. E.ReismanD. S. (2021). Beyond physical capacity: Factors associated with real-world walking activity after stroke. Archives of Physical Medicine and Rehabilitation, 102(10), 1880–1887.e1. https://doi.org/10.1016/j.apmr.2021.03.023
40.
NicholsonS. L.DonaghyM.JohnstonM.SniehottaF. F.van WijckF.JohnstonD.GreigC.McMurdoM. E.MeadG. (2014). A qualitative theory guided analysis of stroke survivors’ perceived barriers and facilitators to physical activity. Disability and Rehabilitation, 36(22), 1857–1868. https://doi.org/10.3109/09638288.2013.874506
41.
NingY.WangQ.DingY.ZhaoW.JiaZ.WangB. (2022). Barriers and facilitators to physical activity participation in patients with head and neck cancer: A scoping review. Supportive Care in Cancer: Official Journal of the Multinational Association of Supportive Care in Cancer, 30(6), 4591–4601. https://doi.org/10.1007/s00520-022-06812-1
42.
Nketia-KyereM.AryeeteyG. C.NonvignonJ.AikinsM. (2017). Exploring barriers to accessing physiotherapy services for stroke patients at Tema general hospital, Ghana. Archives of Physiotherapy, 7(1), 8–8. https://doi.org/10.1186/s40945-017-0037-5
43.
NoukpoS. I.TriccasL. T.BonnechèreB.AdoukonouT.FeysP.KossiO. (2023). Physical Activity Level, Barriers, and Facilitators for Exercise Engagement for Chronic Community-Dwelling Stroke Survivors in Low-Income Settings: A Cross-Sectional Study in Benin. International Journal of Environmental Research and Public Health, 20(3), 1784. https://doi.org/10.3390/ijerph20031784
44.
PoltawskiL.BoddyK.ForsterA.GoodwinV. A.PaveyA. C.DeanS. (2015). Motivators for uptake and maintenance of exercise: Perceptions of long-term stroke survivors and implications for design of exercise programmes. Disability and Rehabilitation, 37(9), 795–801. https://doi.org/10.3109/09638288.2014.946154
45.
ReicherzerL.WirzM.WieberF.GrafE. S. (2022). Facilitators and barriers to health enhancing physical activity in individuals with severe functional limitations after stroke: A qualitative study. Frontiers in Psychology, 13(1), 982302. https://doi.org/10.3389/fpsyg.2022.982302
46.
ResnickB.MichaelK.ShaughnessyM.KopunekS.NahmE. S.MackoR. F. (2008). Motivators for treadmill exercise after stroke. Topics in Stroke Rehabilitation, 15(5), 494–502. https://doi.org/2016040610101800990
47.
SaidC. M.McGinleyJ. L.SzoekeC.WorkmanB.HillK. D.WittwerJ. E.WoodwardM.LiewD.ChurilovL.BernhardtJ.MorrisM. E. (2021). Factors associated with improved walking in older people during hospital rehabilitation: Secondary analysis of a randomized controlled trial. BMC Geriatrics, 21(1), 90. https://doi.org/10.1186/s12877-021-02016-0
48.
Sánchez-SánchezM. L.Arnal-GómezA.Cortes-AmadorS.Pérez-AlendaS.CarrascoJ. J.Climent-ToledoA.Espí-LópezG. V.Ruescas-NicolauM. A. (2021). Association of barriers, fear of falling and fatigue with objectively measured physical activity and sedentary behavior in chronic stroke. Journal of Clinical Medicine, 10(6), 1–14. https://doi.org/10.3390/jcm10061320
49.
SarfoF. S.AdamuS.AwuahD.Sarfo-KantankaO.OvbiageleB. (2017). Potential role of tele-rehabilitation to address barriers to implementation of physical therapy among West African stroke survivors: A cross-sectional survey. Journal of the Neurological Sciences, 381(10), 203–208. https://doi.org/10.1016/j.jns.2017.08.3265
50.
ScorranoM.NtsieaV.MalekaD. (2018). Enablers and barriers of adherence to home exercise programmes after stroke: Caregiver perceptions. International Journal of Therapy & Rehabilitation, 25(7), 353–364. https://doi.org/10.12968/ijtr.2018.25.7.353
51.
SimpsonL. A.EngJ. J.TawashyA. E. (2011). Exercise perceptions among people with stroke: Barriers and facilitators to participation. Int J Ther Rehabil, 18(9), 520–530. https://doi.org/10.12968/ijtr.2011.18.9.520
52.
SimpsonD. B.JoseK.EnglishC.GallS. L.BreslinM.CallisayaM. L. (2022). Factors influencing sedentary time and physical activity early after stroke: A qualitative study. Disability and Rehabilitation, 44(14), 3501–3509. https://doi.org/10.1080/09638288.2020.1867656
53.
SkivingtonK.MatthewsL.SimpsonS. A.CraigP.BairdJ.BlazebyJ. M.BoydK. A.CraigN.FrenchD. P.McIntoshE.PetticrewM.Rycroft-MaloneJ.WhiteM.MooreL. (2024). A new framework for developing and evaluating complex interventions: Update of Medical Research Council guidance. International Journal of Nursing Studies, 154(6), 104705. https://doi.org/10.1016/j.ijnurstu.2024.104705
54.
SweeneyG.BarberM.KerrA. (2020). Exploration of barriers and enablers for evidence-based interventions for upper limb rehabilitation following a stroke: Use of constraint induced movement therapy and robot assisted therapy in NHS Scotland. British Journal of Occupational Therapy, 83(11), 690–700. https://doi.org/10.1177/0308022620909023
55.
TanM.LiH.WangX. (2023). Analysis of the current status of rehabilitation motivation and its influencing factors in older adults with stroke: A cross-sectional study. Frontiers in Aging Neuroscience, 15(1), 1186681. https://doi.org/10.3389/fnagi.2023.1186681
56.
TeoR.ThilarajahS.JialeL.YuF. L. F.KhimK. L. (2023). Barriers to physical activity of stroke survivors in Singapore: A face-to-face cross-sectional survey. Proceedings of Singapore Healthcare, 32(1), 20101058231184953. https://doi.org/10.1177/20101058231184953
57.
ThilarajahS.BowerK. J.PuaY. H.TanD.WilliamsG.LarikA.BokC. W.KohG.ClarkR. A. (2020). Modifiable factors associated with poststroke physical activity at discharge from rehabilitation: Prospective cohort study. Physical Therapy, 100(5), 818–828. https://doi.org/10.1093/ptj/pzaa022
58.
Thøgersen-NtoumaniC.KritzM.GrunseitA.ChauJ.AhmadiM.HoltermannA.KosterA.Tudor-LockeC.JohnsonN.SherringtonC.PaudelS.MaherC.StamatakisE. (2023). Barriers and enablers of vigorous intermittent lifestyle physical activity (VILPA) in physically inactive adults: A focus group study. The International Journal of Behavioral Nutrition and Physical Activity, 20(1), 78. https://doi.org/10.1186/s12966-023-01480-8
59.
ToleG.RaymondM. J.WilliamsG.ClarkR. A.HollandA. E. (2022). Strength training to improve walking after stroke: How physiotherapist, patient and workplace factors influence exercise prescription. Physiotherapy Theory and Practice, 38(9), 1198–1206. https://doi.org/10.1080/09593985.2020.1839986
60.
Torriani-PasinC.PalmaG. C. d. S.MakhoulM. P.AntonioB. d. A.LaraA. R. F.SilvaT. A. d.CaldeiraM. F.JuniorR. P. A.DominguesV. L.FreitasT. B. d.MochizukiL. (2021). Adherence Rate, Barriers to Attend, Safety, and Overall Experience of a Remote Physical Exercise Program During the COVID-19 Pandemic for Individuals After Stroke. Frontiers in Psychology, 12(1), 647883, https://doi.org/10.3389/fpsyg.2021.647883
61.
TyagiS.LimD. S. Y.HoW. H. H.KohY. Q.CaiV.KohG. C. H.Legido-QuigleyH. (2018). Acceptance of tele-rehabilitation by stroke patients: Perceived barriers and facilitators. Archives of Physical Medicine and Rehabilitation, 99(12), 2472–2477.e2. https://doi.org/10.1016/j.apmr.2018.04.033
62.
Van Der VeenD. J.DöppC. M. E.SiemonsmaP. C.SandenN.-V. D.De SwartM. W. G.& SteultjensB. J. M.ME. (2019). Factors influencing the implementation of home-based stroke rehabilitation: Professionals’ perspective. PLoS ONE, 14(7), e0220226. https://doi.org/10.1371/journal.pone.0220226
63.
WolfT. J.ChuhA.FloydT.McInnisK.WilliamsE. (2015). Effectiveness of occupation-based interventions to improve areas of occupation and social participation after stroke: An evidence-based review. The American Journal of Occupational Therapy: Official Publication of the American Occupational Therapy Association, 69(1), 6901180060p1–11. https://doi.org/10.5014/ajot.2015.012195
64.
ZalewskiK. R.DvorakL. (2011). Barriers to physical activity between adults with stroke and their care partners. Topics in Stroke Rehabilitation, 18(1), 666–675. https://doi.org/2016040610095600568
65.
ZhangY.QiuX.JinQ.JiC.YuanP.CuiM.ZhangJ.ChenL. (2023). Influencing factors of home exercise adherence in elderly patients with stroke: A multiperspective qualitative study. Frontiers in Psychiatry, 14(1), 1157106. https://doi.org/10.3389/fpsyt.2023.1157106
66.
ZhangL.YanT.YouL.GaoY.LiK.ZhangC. (2018). Functional activities and social participation after stroke in rural China: A qualitative study of barriers and facilitators. Clinical Rehabilitation, 32(2), 273–283. https://doi.org/10.1177/0269215517719486
67.
ZhangL.YanT.YouL.LiK. (2015). Barriers to activity and participation for stroke survivors in rural China. Archives of Physical Medicine and Rehabilitation, 96(7), 1222–1228. https://doi.org/10.1016/j.apmr.2015.01.024
68.
ZhangT.ZhaoJ.LiX.BaiY.WangB.QuY.LiB.ZhaoS.CommitteeC. S. A. S. C. G. W. (2020). Chinese Stroke Association guidelines for clinical management of cerebrovascular disorders: Executive summary and 2019 update of clinical management of stroke rehabilitation. Stroke and Vascular Neurology, 5(3), 250–259. https://doi.org/10.1136/svn-2019-000321
69.
ZhengZ.BirdS. R.LaytonJ.HydeA.MorelandA.Wong Lit WanD.StupansI. (2022). Patient engagement as a core element of translating clinical evidence into practice- application of the COM-B model behaviour change model. Disability and Rehabilitation, 45(26), 4517–4526. https://doi.org/10.1080/09638288.2022.2153935
70.
ZhouY.HuaB.ShiX.DuS.YuanJ.WangY. (2023). Exercise intention and its associated factors among persons post-stroke: A cross-sectional study. Patient Prefer Adherence, 17(1), 2535–2544. https://doi.org/10.2147/ppa.S424595
Supplementary Material
Please find the following supplemental material available below.
For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.
For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.
