The results section is divided into two parts. Part 1 lists the identified main categories of the content and methods of PAP reported by exercise therapists. Part 2 provides a description of the associated perceived barriers and enabling factors of PAP. Table 2 and Table 3 provide an overview of the main topics of both these parts.
Table 2. Main categories of the focus-group discussion on content and methods of physical activity promotion.
(1) Explicit concept-based approaches in exercise therapy are comprised of:
- volitional support (high concept-base) vs. movement experience (low concept-base); and
- institution-specific adaptations.
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(2) The action pattern of ‘Fun and joy in exercise and physical activity’ includes:
- a diverse spectrum of exercise interventions;
- (the rediscovery of) individually tailored and enjoyable activity;
- the promotion of group experiences and activities;
- reflections on exercise experiences; and
- an effort to make rehabilitants more receptive to positive and joyful exercise experiences.
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(3) Knowledge transfer to the rehabilitants as a theory–practice combination involves:
- a central principle of reflection in the pairing of knowledge and exercise experience; and
- the demonstration of knowledge through proximity to everyday life and pictorial language.
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(4) Use of material and media for independent training and practice involves:
- the common but mostly ineffective use of materials in paper form; however,
- the search continues for modern forms of media use.
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(5) Strategies to promote personal responsibility include:
- the independent use of therapy-free time fostered by different elements;
- a reduction in consuming attitudes of rehabilitants; and
- preparation and strategies for concrete continuation at the place of residence of the rehabilitants.
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Table 3. Main categories of the focus-group discussion on the barriers to and facilitators of physical activity promotion.
(1) Individuality vs. organisational–structural conditions
- Guidelines and standards impair patient-centred care (barrier).
- A large facility may offer a wide range of different exercise therapies (facilitator), while a small facility may have a family atmosphere and potential for a significant therapist–patient to develop (facilitator).
- The changing of therapists may be quite frequent (barrier).
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(2) The role of exercise therapists
- They have empathy for the needs of rehabilitants (facilitator).
- They can be persuasive with a view to promoting PA (facilitator).
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(3) Cooperation, communication, and common messages in the interdisciplinary rehabilitation team
- Joint messages promote PA (facilitator).
- Team exchange compensates for a lack of consistency in therapists (facilitator).
- The medical dominance within therapy prescription partially impairs the suitability of exercise plans (barrier).
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(4) Expectations and previous exercise experiences of rehabilitants
- Rehabilitants expect passive interventions such as massages (barrier).
- Rehabilitants can motivate themselves based on their previous experience of exercise (facilitator).
- The older rehabilitants are less motivated (barrier).
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(5) Quantity and quality of rehabilitation aftercare services
- There is a possibility of continuing aftercare in the same facility (facilitator).
- It is important to ensure the quality of aftercare services (facilitator/barrier).
- Some aftercare actors offer follow-up contacts (facilitator).
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Main categories of content and methods of physical activity promotion
(1) Extent of explicit concept-based approaches in exercise therapy
Concept-based approaches are characterised as planned and structured procedures. This also includes the use of externally developed, standardised intervention programmes, e.g. the MoVo-Lisa-programme [29] in which different therapy hours build on each other and the individual therapy hours are described in detail in a manual.
The focus groups demonstrated that concept-based approaches with varying degrees of differentiation are used within exercise therapy. A rather differentiated concept-based approach was found in connection with the use of behavioural volitional techniques (e.g. the elaboration of action- and coping-plans), which were frequently raised in the focus-group discussions. For example, in the focus groups, orthopaedics (back pain), addiction, psychosomatics, and oncology, a motivational-volitional PAP concept from Germany, known as the ‘MoVo-LISA concept’ [29], were discussed:
There’s a good programme called MoVo-LISA, we’ve changed it a bit, adapted it to leisure in general […] Most people say, I actually want to do something, but to plan the whole thing correctly we must ask: ‘What are you doing? When will you do it? Who are you doing it with? Do you have enough options? Does it suit you? Does it fit in with your lifestyle?’ (Addiction #00:47:53-6#)
It is noticeable here that in many exercise therapy departments, specific intervention components of existing PAP programmes are used without needing to implement the entire programme. As well as this, the selected intervention components are not typically implemented as originally developed but adapted to the exercise therapists’ expertise and the structural conditions of the department.
(2) Action pattern: ‘Fun and joy in exercise and physical activity’
Across all health conditions, there was a consensus that conveying ‘fun and joy in exercise and PA’ is an important aspect of PA promotion. This was regarded as a basic prerequisite for the long-term maintenance of a physically active lifestyle by many of the focus-group participants.
Within numerous and multifaceted statements on this subject, a certain pattern was often discernible: Rehabilitation facilities try to offer a wide range of exercise and sport activities. This wide range makes it possible to effectively respond to the needs of each individual by taking existing personal preferences into account and allowing said individual to experience new PA stimuli. One exercise therapist described this connection from her point of view:
We have a relatively broad spectrum of different exercise therapies. We have 20 different sport groups […]. From archery, stick fighting, juggling, trampoline, movement meditation, etc. […] So, we have a lot of things, and in archery there are often statements like, ‘Whoa, that’s great, I want to do that at home and where can I do that?’ Not everything is for everyone, but I just have to look. And the patients must also be allowed to decide for themselves: ‘What do I enjoy? What gives me pleasure? And where can I stay consistent? Because only when I have fun with it will I stay with it in the long run.’ (Neurology #00:57:56-3#)
Another important intervention element for the action pattern of ‘fun and joy’ is the experiences found within group exercise settings. Groups play an important supportive role, thus aiding the promotion of and adherence to exercise and PA:
But when you find something in a circle of friends where you can do sports together and its fun, that’s the most sustainable thing in my eyes that you can give people. […] The long-term motivation to do exercise and stay in it is not the knowledge, […] but rather the fun in the group, the sociability, the common sports experience in the group. (Orthopaedics [back pain] #00:07:29-8#)
In order to convey fun and joy in exercise and PA, the importance of reflecting on the experience of movement was also noted. Methods to promote this reflection were discussed in the focus groups.
(3) Knowledge transfer to rehabilitants as a theory–practice combination
The two main topics of knowledge transfer are 1) knowledge about the effects of PA (i.e. effect knowledge) and 2) knowledge about the execution of PA (i.e. action knowledge) [compare 30]. A central theme in the field of knowledge transfer was the pairing of practical exercise experience with reflection. This was raised in the orthopaedics (back pain) focus group:
Only patient education, pure lecture is useless. So, we exercise therapists live from the fact that we don’t just give lectures but connect them with exercises and practice. (Orthopaedics [back pain] #00:14:33-4#)
Teachings about the knowledge of PA effects were addressed in four of the six focus groups and were related to the physical and psychological effects of PA. Exercise therapists described their use of a three-step method for outlining the short-term effects by a) targeting the possible effects of exercise; b) questioning/assessing the effects during and after the exercise; and c) reflecting on these effects in a subsequent conversation.
Linking theory with practice and reflecting on exercise experiences were two principles that were also applied to the field of imparting action knowledge. For example, methods for teaching self-directed load control (e.g. the correct independent control of the training intensity with the help of a heart rate monitor) were theoretically prepared, tested in practice, and then reflected upon in the group.
Some exercise therapists try to prepare rehabilitants for the continuation of exercise and PA after their rehabilitation. To address this, they discussed suitable exercises, physical activities, and possibilities for daily PA integration, and they provided general information as well as personal counselling to the rehabilitants. In summary, from a practitioner’s perspective, sustainable knowledge transfer is best achieved through the connection and combination of movement practice and reflection.
(4) Use of material and media for independent training and practice
The widespread use and efficiency of materials used for physical training and practice were often discussed:
But I always question how meaningful these exercise sheets are. In my experience, if patients want sheets right from day one, they forget them or throw them away. (Orthopaedics [total hip/knee replacement] #00:33:43-6#)
The most extensive discussion on this topic of material and media use took place in the orthopaedics (total hip/knee replacement) focus group:
[…] what kind of sheets do the patients get, training books, etc. and then there are also sceptical therapists who claim, ‘He takes it and throws it right into the trash can.’ So, you think about which format is the right one […]. (Neurology #00:35:07-8#)
As a solution, the need to reconsider the use of conventional print materials became increasingly visible. Moving away from paper and towards the use of more modern formats, such as smart-phone applications, photographs, video recordings of the exercises on the rehabilitants’ smartphones, or computer-aided training and exercise programmes, may be more effective.
(5) Strategies to promote personal responsibility
Strategies to promote the independent execution of exercises were frequently discussed. In one clinic, for example, the rehabilitants were required to perform independent PA and exercise during their therapy-free (leisure) time:
We make sure that the patients not only become active in the therapy programme, but also organise something movement-related themselves, become jointly active, in addition to the therapy, in their therapy-free time. […] And we’ve actually had quite good experiences with that […] they simply take more responsibility for themselves […]. (Psychosomatics #00:11:38-8#)
The exercise therapists were critical of the fact that the ‘consuming’ role of clients had to be reduced and that active, independent action had to be initiated and promoted:
We are definitely bringing the patients to the point […] where personal responsibility is much more important than just the therapeutic intervention […]. (Neurology #00:32:45-6#)
In some focus groups, it was reported that after prior instruction, rehabilitants were able to use the training rooms independently at times when there was no need for therapy.
Barriers and facilitators for implementing content and methods of physical activity promotion
The second part of the results section presents the core topics regarding the barriers to and facilitators of successful PAP. The core topics are often closely related to the main topics of part 1 of the results section.
(1) Individuality vs. organisational–structural conditions
In all focus groups, adequate organisational and structural conditions were viewed as important prerequisites for successful PAP. However, some exercise therapists stated that ‘fun and joy in exercise and physical activity’ are difficult to achieve due to several factors. One of these obstructing factors is the so called therapy standards. Therapy standards are specified by the German pension insurance for quality assurance purposes. The requirements for these standards are sometimes perceived as excessively rigid prescriptions that restrict the possibility of individually tailored therapy:
I think the main problem with these therapy specifications is that we have to report them using the KTL [Klassifikation Therapeutischer Leistungen; Translation: classification of therapeutic interventions] and the requirements that we have to meet lead to a lack of individuality. (Oncology #00:43:24-8#)
In all focus groups, the role of the clinic size was controversially discussed with regard to individuality. Small rehabilitation facilities have the advantage of close contact with rehabilitants, and the atmosphere is perceived as being more familiar. But for smaller facilities, it is often not possible to offer a wide range of exercise therapies. Large rehabilitation facilities can offer a wide range of exercise experiences to ensure that rehabilitants are more likely to have the option of making an individually tailored choice.
And the bigger a facility […] the bigger the range of exercise therapy offers. We have […] a small, familiar facility. […] After a week, I know every patient. […]. But I can’t offer as much as I can in a bigger clinic. (Orthopaedics [back pain] #00:35:04-7#)
The organisational form of the therapy was identified as a crucial factor to ensure individuality and patient-orientation. There was a broad consensus that an individual approach could be implemented in a one-on-one therapy situation. In group therapies, however, the heterogeneity of the rehabilitants and the changing composition of the (open) groups prevent an individual approach. Rehabilitants are often over- or under-challenged in groups, and this impairs a positive exercise experience. In addition, the need to attain consistency among therapists is clearly evident but not always achieved due to a lack of time, personnel resources, and planning difficulties.
So, it may be that a patient has an admission, an initial assessment by a physiotherapist. And from the next treatment on, the therapist changes. Then he has three, four, five therapists. […] the one-on-one treatment in our facility is very decimated anyway, […] simply because the capacity is not there. […] Everything in our facility is also very strongly determined by the planning department. So, the planning is above everything. […] And the therapeutic goals only play a small role. (Orthopaedics [back pain] #00:22:01-0#)
In summary, adequate organisational and structural framework conditions are seen as important prerequisites for sustainable PAP. It often seems impossible to consider the individual factors of the rehabilitants, resulting in the over- or under-training of these individuals.
(2) The role of exercise therapists
The focus groups also addressed the role of therapists in social situations within exercise therapy. The need to establish a positive and close relationship with the rehabilitants was thoroughly discussed.
Well, I have another aspect that goes beyond the content […] to give the patient the feeling that he is constantly seen. This means that, with this therapist relationship, he always has someone to whom he can turn to, but then he also has the feeling that he is perceived by what he does, how he behaves, what he shows of himself. (Psychosomatics #00:56:11-0#)
Empathy and authenticity in one’s own therapeutic practice were particularly emphasised. These characteristics were seen as facilitators in promoting a trusting and personal bond between rehabilitants and therapists.
It was also considered important for exercise therapists to be able to perceive and respond to the needs of rehabilitants. The ability to adapt the exercise therapy programme to the respective requirements of the rehabilitants was regarded as a facilitating factor. With these adaptations, the action pattern of ‘fun and joy in exercise and physical activity’ can be better served.
In a nutshell, the empathy, authenticity, and responsiveness of the therapists and their methods are considered important for PAP.
(3) Cooperation, communication, and common messages in the interdisciplinary rehabilitation team
Cooperation and transparent communication across occupational groups in the interdisciplinary rehabilitation team were deemed beneficial for PAP. Furthermore, a lively exchange of information about the rehabilitants was identified as an important factor. The importance of all therapeutic actors attaining a common and uniform language for the rehabilitants was also emphasised many times:
We have team meetings twice a week, all disciplines are there. And then, of course, it’s comparatively easy in this context to respond very individually to the patients and to find a common language. […] I have also had the experience that the patients already notice when the team of therapists works and speaks one language. (Orthopaedics [back pain] #00:06:16-4#)
In all health conditions, a hierarchical structure within the multi-professional team was seen as an obstacle to the promotion of PA. Medical dominance, lack of information, or low levels of interest among doctors in exercise therapy were described as the reasons for frequent misdirection.
Well, we have that problem over and over again. It’s simply also about the fact that doctors prescribe things, simply prescribe prescriptions and without actually knowing what we actually do in the therapies. (Oncology #00:26:19-2#)
To conclude, transparent communication and cooperation between occupational groups are crucial to attain optimal PAP. In addition to this, the exchange of information within a therapy team allows for greater consistency in the delivery of treatment plans, irrespective of any changes of therapists.
(4) Expectations and previous exercise experience of rehabilitants
Exercise therapists estimate experiences and expectations of the rehabilitants to have a great influence on the independent initiation and maintenance of PA. Our participants discuss them both as beneficial and obstructive factors. In particular, the expectation of passive therapies (e.g. massage) during rehabilitation is increasingly addressed as an obstacle of PAP in all chronic conditions. The expectation of treatment instead of attaining an active role in the rehabilitation process was discussed.
Yes, and we all know the patients who arrive and say, ‘I’ll come to the application now’ and would like to lie down somewhere and then ‘just do it’ today. And that’s very important, that you say from the beginning, ‘No, my dear patient, that’s not how it is. This is rehabilitation, not a cure. Move it!’ (Neurology #00:29:45-5#)
The self-motivation of the rehabilitants based on their previous exercise experience was perceived as a beneficial factor. Rehabilitants who had positive exercise experiences in the past were linked to pursuing more long-term activities:
We now often have patients who already have some previous sporting experience. It’s easier there, of course. They may have lost it over the years: […] they couldn’t do as many activities for themselves anymore because of family, job, and so on. But the basis is there, you can build somewhere on it. (Oncology #00:47:58-5#)
In addition to these more motivational characteristics, the age of the rehabilitants was discussed and almost exclusively addressed as a barrier. It is more difficult for older people to impart adequate physical activity for the time after rehabilitation.
Briefly summarised, the expectations of many rehabilitants to undergo therapy are mentioned as barriers to the successful promotion of PA. The age of the rehabilitants is also seen as an aggravating factor if they are older.
(5) Quantity and quality of rehabilitation aftercare services
The final core topic discusses the beneficial and impeding aspects of rehabilitation aftercare services. A sufficient number of high-quality aftercare services is considered important for a supply close to home of the rehabilitants. These aftercare services are often associated with the rehabilitation facility and regarded as a beneficial factor. The rehabilitants are already familiar with the conditions and staff of the facility, therefore eliminating any inhibitions that would otherwise limit activities in an unknown facility. One participant described this as follows:
The people who get excited come to us for the most part because they feel comfortable with us and know the processes, the therapists, the equipment. (Orthopaedics [total hip/knee replacement] #00:23:19-0#)
The existence of aftercare services at the place of residence of the rehabilitants was discussed rather controversially. Some stressed the fact that there are nationwide aftercare services already available, while some complained that the accessibility of aftercare services may be restricted depending on the place of residence of the rehabilitants.
This controversial discussion also raised scepticism regarding the quality of existing aftercare services. The question was raised as to whether the aftercare services adequately address the respective health problems of the rehabilitants. It was therefore suggested that rehabilitation facilities should provide reports on rehabilitants health status for continuing rehabilitation providers.
To sum up, an adequate number of high-quality aftercare services is essential. Services affiliated with the facility where the original treatment took place are seen as beneficial. Although a large number of aftercare services are already available, the accessibility of these facilities and thus, their effectiveness, are questioned. Furthermore, the quality of services administered at the place of residence of the rehabilitants also raises concerns and scepticism.