Facilitators of and Barriers to Physical Activity Promotion among Physical Therapists who Treat Clients with Neurological Conditions: A Qualitative Study Informed by the Theoretical Domains Framework

Authors

Affiliations

Winston Kennedy

Northeastern University

Carol Curtin

UMass Chan Medical School

Jafrā D. Thomas

UMass Chan Medical School

April Bowling

Merrimack College

Abstract

Healthcare provider communications about physical activity (PA) lead to meaningful and sustained increases in PA, but physical therapists (PTs) do not consistently promote PA for clients with neurological conditions (NC). The purpose of this qualitative study was to understand factors that could support implementation strategies related to PTs promoting PA for clients with NC. The Theoretical Domains Framework (TDF) was used to develop a semi-structured interview guide. One-on-one online interviews were conducted in 2022 with 10 physical therapists licensed to practice in the United States whose caseloads include clients with NC. Responses were first sorted into a priori factors derived from previous research (TDF codebook), then reappraised to ensure other factors were not overlooked (inductive analysis). Responses about facilitators corresponded to three factors: Personal (e.g., sense of responsibility, personal connections to community opportunities); Professional (e.g., a specific PT course on PA promotion); and Client-related (e.g., highly motivated). Barriers corresponded to two factors: Professional (e.g., limited continuing education, lack of guidance/communication from PT-associations), and Client-related (e.g., lack of low-cost/free services to offer, provider safety concerns). There are opportunities for PTs to increase PA promotion when treating clients with NC, as outlined in PT education. PTs should also utilize and advocate for community-based partnerships and expand education/resources from PT associations beyond traditional communication channels.

Keywords

health promotion, implementation, disability health

NoteAuthor Note

Conflict of Interest: The authors have no conflict of interest to disclose.

Financial Support: This work was funded under the Department of Education no. H325D160023.

Correspondence: Correspondence concerning this article should be addressed to Winston Kennedy, Bouve College of Health Sciences, Northeastern University, 360 Huntington Ave, 301R Robinson Hall, Boston, MA 02115. Email: wi.kennedy@northeastern.edu

Physical therapists (PTs) are health professionals who may be able to include physical activity (PA) promotion for people with neurological conditions (NC); however, it is well documented that PTs do not consistently engage in PA promotion behaviors as part of their clinical practice (Kennedy et al. 2023; Rethorn et al. 2021). Including PA promotion in clinical practice is not a novel recommendation but instead is an evidence-based strategy. One scoping review found that PA promotion by clinical providers had a small-to-moderate positive effect on increasing clients’ PA levels (Sanchez et al. 2015). PA promotion in clinical settings has also been shown to be effective for children and adults with chronic disabilities, including those with NC (Ross et al. 2021; van der Ploeg et al. 2007).

Many people with disabilities have greater difficulty participating in various types of health-promoting behaviors like PA engagement, social activities, and accessing preventative care, which contribute to health disparities that promote people with disabilities being at increased risk for secondary health conditions (Rimmer et al. 2014). Specifically, youth and adults with disabilities have higher rates of secondary health conditions like pain, fatigue, depression, and obesity (Havercamp and Scott 2015; Kinne et al. 2004; Rimmer et al. 2011), and report lower rates of participation in health promoting activities that are intended to change behaviors like physical activity engagement (Carroll et al. 2014; Rimmer 2012; Rimmer et al. 2014). This is important for people with NC because they may either identify as being disabled or may be identified as disabled by a healthcare professional. Barriers to participating in health promotion initiatives include lack of staff or professionals who understand how to support people with disabilities in their programs, and negative perceptions and attitude among health professionals that support the idea that people with disabilities need ‘specialized’ services and support that are independent of and separated from the general public (Anderson et al. 2017; Ginis et al. 2016). Given that PA is a major health indicator for people with NC for functional recovery and is a mechanism of preventive care for secondary conditions, it is also vital to provide PA promotion for people with NC.

The limited implementation of evidence-based practice behaviors, such as PA promotion, in healthcare is common. To encourage better adoption of evidence-based practices, it is important to identify key factors associated with PA promotion among PTs (French et al. 2012; Grol and Grimshaw 2003). The Theoretical Domains Framework (TDF), developed in implementation science, aims to facilitate behavior change among health professionals (Cane et al. 2012). The TDF has been used to assess how often PTs promote PA for clients with and without NC. Kennedy et al. (2023) used a TDF-informed survey to explore PA promotion practices among PTs treating clients with NC, finding that although most PTs viewed PA promotion as part of their scope of practice, their actual promotion behaviors were inconsistent. Similarly, Rethorn et al. (2021) surveyed outpatient PTs and identified knowledge, skills, environmental context, and social influences as key TDF domains linked to attitudes and practices related to PA promotion. However, these quantitative studies did not thoroughly explore the detailed barriers and facilitators PTs face, especially when serving clients with NC. More recently, the TDF was used to identify strategies to support the implementation of guidelines for the physical therapy management of people with spinal cord injuries using qualitative methods (Tranter et al. 2025). The barriers to implementing the guidelines identified by PTs were a lack of knowledge and skills, a lack of resources, and challenges associated with working within large organizations. Facilitators of the uptake of care guidelines included education, skills training, awareness, and two-way communication between patient and therapist. These findings are on par with barrier and facilitator research on PA promotion in clinical care (Tranter et al. 2025). However, the context is different because of the management of acute health risks for individuals who have an acute spinal cord injury, compared to those with chronic NC who are engaging in general PA. The aforementioned study is an example of how qualitative inquiry using the TDF can provide a rich, contextual understanding of implementation challenges and opportunities that quantitative surveys cannot capture.

Much of the PA promotion literature involving PTs has focused on implementation with populations without disabilities. Barriers to PA promotion in clinical practice for the general population include time, provider reimbursement, training, provider self-efficacy, healthcare system support, and knowledge of community resources (Lobelo et al. 2018). When considering PT specifically, additional barriers include: perceived lack of interest or awareness on the part of clients, the public, and other healthcare professionals that PT can provide PA promotion services (Kearns et al. 2014; Taukobong et al. 2014; Verhagen and Engbers 2008); limited capacity to implement evidenced-based practice (Dzewaltowski et al. 2004; Eccles et al. 2005; Grimshaw et al. 2012); lack of participation of PT in health promotion research, policy, and action initiatives; and payment systems that do not emphasize wellness through PA promotion (Dean 2009).

While the existing literature enumerates potential barriers to PA promotion experienced by PTs, qualitative research exploring PT perception of barriers and facilitators is lacking. This is especially true in the context of services provided to clients with NC, given that most of the research has focused on clients without a chronic disability. The purpose of the present study was to gain insight into PTs’ perceived barriers and facilitators to promoting PA when serving clients with NC. The findings of this study should provide a focus for future implementation strategies to increase PTs’ likelihood of promoting PA when serving clients with NC.

Methods

This study was approved by the Institutional Review Board at Oregon State University in 2022 (the primary investigator’s prior institution). The first author conducted all interviews.

Participants

Purposive sampling was used to recruit licensed PTs who worked with clients with NC in the US. The sampling occurred from the pool of PTs who participated in another study (N = 76) (Kennedy et al. 2023). As per best practices for theory-informed qualitative research, we attempted to recruit participants until theme saturation was achieved (Francis et al. 2010). Data saturation was considered achieved when no new information emerged from three consecutive interviews, resulting in 10 interviews (after the 7th interview). Demographic data are shown in Table 1.

Table 1: Participant Demographics

Characteristics	N (10)
Gender
Male	2
Female	8
Average age, years (range)	44 (30–72)
Average experience, years (range)	18 (3–49)
Race/Ethnicity
White (non-Hispanic/Latinx)	7
Asian	2
Other	1
Highest Level of Education
Academic doctorate (DSc, EdD, PhD, etc.)	1
Bachelor’s	2
Clinical doctorate (DPT, tDPT, etc.)	6
Master’s	1
Practice Setting
Home health	1
Commercial PT (5 or more locations) OP	1
Private Practice (PT-owned) OP	4
Neurological OP	2
Hospital-based OP	2
Patient Age Range
<18	4
18–64	5
≥65	1

Measures

A semi-structured interview guide was developed based on a review of the TDF literature (Cane et al. 2012). To ensure quality and understandability, questions in the interview guide were reviewed by health promotion experts and PTs who were not part of this study. The expert review process involved interviews with three experts to assess the clarity, comprehension, and relevance of the questions to the research aims (Kallio et al. 2016). Updates to the interview guide were made based on the expert’s feedback. The interview guide is shown in Table 4.

Data Analysis

Interviews were conducted and recorded via Zoom^TM (Archibald et al. 2019). Transcripts were downloaded, transcribed, cleaned, and read. Analysis of the transcriptions used a pragmatic approach that combined applicable evidence-based qualitative strategies (Ramanadhan et al. 2021). Thematic analysis was then used as the analytic strategy to represent the data through qualitative description (Sandelowski 2000). Transcriptions were initially coded deductively using a TDF-based codebook (Atkins et al. 2017). Data were then re-analyzed inductively to ensure that important factors were not lost during the deductive data analysis (Fereday and Muir-Cochrane 2006). The data were divided into facilitator and barrier categories to both align with and extend prior research on health professionals promoting health for their clients. All transcripts were analyzed by the first author (primary investigator) and then independently reviewed by the fourth author, ensuring a rigorous and trustworthy analysis. A third reviewer was available to resolve any discrepancies if necessary.

Results

Identified trends were categorized into three groups of facilitators that facilitate PTs’ implementation of PA promotion: personal, professional, and client-related. Two categories of barriers were identified: professional and client-related. Personal facilitators for PTs were related to participants’ sense of self and to how that supported the promotion of PA. Professional facilitators for PTs include factors that support PA promotion through PT training and professional practice. Client-related facilitators were client characteristics that PTs believed facilitated their ability to promote PA as part of their service to a client. See Table 2 for identified trends and examples. Professional barriers for PTs stemmed from factors in PT training and practice that made it harder to engage in PA promotion. Client-related barriers for PTs were client-specific factors (e.g., environmental resources, perceived risk of injury). See Table 3 for identified trends and examples.

Discussion

The present study sought to understand how PTs perceived and experienced barriers to and facilitators of PA promotion when treating clients with NC based on the TDF. Facilitators and barriers for PTs to increase uptake in PA promotion in clinical practice that were identified may be able to inform implementation practices that can increase the uptake of including PA promotion by PTs who treat clients with NC.

Several personal facilitator factors were identified that may be understood through the lens of public service motivation (PSM). PSM refers to an individual’s motivation to serve the public interest, encompassing beliefs, values, and attitudes that go beyond self-interest to concern the interests of a larger community (Perry and Wise 1990). Importantly, research has shown that individuals with high levels of PSM are more likely to engage in behaviors that serve the public good, including health promotion activities in healthcare settings (Roh et al. 2016). This suggests that PSM may function as an important antecedent to PA promotion behaviors among PTs, particularly when serving populations with heightened health needs such as clients with NC. While PSM was originally conceptualized as specific to public-sector employment, research suggests that PSM manifests across sectors when professionals perform similar public-serving tasks (Andersen et al. 2011).

The personal facilitators identified in the current study appear to be manifestations of PSM dimensions that may increase the likelihood of PTs engaging in PA promotion for clients with NC. Participants’ sense of responsibility to learn about PA promotion and their confidence in promoting PA align with the commitment-to-public-interest dimension of PSM, suggesting that PTs who feel a duty to serve the broader health needs of people with NC may be more inclined to incorporate PA promotion into their practice. Similarly, participants’ reports of personal enjoyment and satisfaction from promoting PA reflect the compassion dimension of PSM, indicating that the intrinsic reward from helping clients with NC improve their health through PA may motivate continued engagement in these promotion behaviors. This interpretation is supported by a recent systematic review, which found that health professionals with strong PSM are more likely to choose and remain in positions that allow frequent contact and interaction with patients (Fernandes et al. 2022). The review further identified that altruistic PSM-related factors (desire to help patients, recognition of one’s contribution to public health) sustain engagement in public service activities. This suggests that PTs who demonstrate high PSM, particularly in the compassion and public-interest dimensions, may be more likely to overcome barriers to PA promotion and to persist in PA promotion despite systemic challenges. Understanding that these personal facilitators are linked to PSM provides a theoretical foundation for implementation strategies related to strengthening PTs’ sense of public service mission and their connection to the health outcomes of people with NC.

Among the multiple professional facilitator factors identified, having community connections for NC-specific resources indicates the impact community engagement can have on health professional practice. Participants speaking saliently of this professional facilitator was surprising, given its absence from PT education. Further, prior research suggests PTs are resistant to referring clients with NC to community-based PA programs (Williams et al. 2018). When drilling down into why PTs may resist referring clients to community-based programs, Williams et al. (2018) found that PTs were concerned programs would promote unrealistic expectations or would be run unsafely. An implementation strategy suggested by our findings for increasing referrals to community-based PA promotion programs is for PTs to partner with community programs. Most participants in our study were connected to a community PA opportunity for individuals with chronic disabilities. This community PA involvement was a salient professional facilitator, meaning they may have seen it as an extension of their practice to reduce barriers to PA and support clients in engaging in safe forms of exercise and active recreation.

Within the professional facilitator category, participants reported that their PT education included relevant content on people with disabilities and that they had participated in continuing education relevant to PA promotion for clients with NC. This suggests that these PTs may have a better understanding of how to promote PA for their clients with NC; however, this warrants further investigation. Although this may not be true for all PT training curricula, there is a shift to include more content on people with disabilities (Garrand et al. 2018; Robey et al. 2013; Sharp and Herrman 2021; Whalen Smith et al. 2024). Further, participants reported that their job helped them promote PA, that they worked at a hospital with community programs specifically focused on exercise, and that the organization in which a PT works has the potential to assist PTs in promoting PA. This is not a surprising finding because supportive environments are conducive to health professionals’ satisfaction, which may, in turn, support their work performance (Sumathi et al. 2015). It can be assumed that organizational support reduces the burden on the sole PT to promote PA, which may make it more likely that the PT will engage in the behavior.

Several professional barriers were identified. Acknowledging these barriers provides an opportunity to implement strategies to reduce them. Pivotal professional barrier factors included a lack of knowledge regarding PA guidelines and a lack of engagement with content on PA promotion for people with disabilities. The lack of understanding of the PA guidelines and their application to individuals with NC was a barrier, consistent with other studies examining PT knowledge of PA guidelines (Lowe et al. 2017; Rethorn et al. 2021). While PTs are trained in exercise prescription, their training focuses on rehabilitation rather than recreational activity for general health. While there is a call for PTs to support their clients with NC by promoting PA (Quinn and Morgan 2017), a lack of general knowledge of sport and exercise may hinder PA engagement among clients with NC (Williams et al. 2018). If PTs were better educated on the PA guidelines, PA promotion may become more regular and consistent. Prior research has shown that PT curriculum is being updated to include health promotion strategies (Bodner et al. 2013; Magnusson et al. 2020). How this content is applied, and the effect it has on PA promotion practices, remains to be seen. There have been calls to increase disability-related content in PT training as well; however, large-scale curricular changes are difficult to implement (Garrand et al. 2018).

In the current study, participants reported client-related barriers such as low motivation, client safety, and client finances, and noted that some client factors (such as low motivation) make PTs feel less confident and effective at promoting PA. Some PTs who work with clients with NC have been shown to perceive that their clients’ lack of motivation to engage in PA is fixed and that they cannot promote behavior change (Morris et al. 2015; Williams et al. 2018), which is in line with the broader healthcare perspective of promoting behavior change in people who are perceived to have low motivation to engage in PA (Huijg et al. 2015). PTs, like other health professionals, need to be able to address their clients’ motivation specifically, even when it is perceived to be low (Yap and Davis 2008). Perceived low motivation, whether due to a bias on the part of the health professional or as stated by the client, can be addressed.

There have been calls for PTs to enhance their skills in behavior change through motivational interviewing to address patient motivation and adherence (McDevitt et al. 2024; Pignataro and Huddleston 2015). It has been shown that motivational interviewing can promote behavior change. A 2011 systematic review and meta-analysis found that motivational interviewing was associated with a greater reduction in body mass compared to controls when promoting weight loss with overweight and/or obese clients (Armstrong et al. 2011). Further, a 2016 study suggested that motivational interviewing can improve health-promoting behaviors in clients with multiple sclerosis (Dashti et al. 2016). Additionally, other behavior change frameworks, such as the Health Belief Model (Rosenstock et al. 1988) and Social Cognitive Theory (Bandura 1986), can support PTs in addressing perceived low motivation by focusing on self-efficacy, outcome expectations, and barriers to PA engagement (Sweet et al. 2012). PTs can benefit from enhanced education and training to recognize and promote self-esteem, self-efficacy, and positive self-talk in their clients. Addressing perceived low motivation, whether due to a health professional bias or, as the client stated, requires targeted education in evidence-based behavior change techniques such as goal-setting, action planning, and social support development (Michaelsen and Esch 2023).

This study was not without limitations. PTs included in the study varied in the extent to which they worked with NC. Due to a low response rate, we broadened the criteria to include PTs who work with NC in any capacity. This precludes determining whether the facilitators of and barriers to PA promotion depended on PTs’ caseloads. Due to the recruitment method, the current study lacks external validity. Despite these limitations, this study yields important data on this topic.

Conclusions

This study used the TDF to investigate the barriers to and facilitators of PA promotion by PTs for their clients with NC, to understand why PTs are not consistently promoting PA and to consider implementation strategies to shift this trend. Several barriers and facilitators emerged from this study that are specific to PTs promoting PA for clients with NC, prompting a discussion of strategies to promote facilitators and reduce barriers. The PT profession may benefit from including health promotion and community engagement curricular content, both in student training and in post-professional education. Future research should examine specific implementation strategies to address identified barriers, including enhanced training in behavior change techniques, development of community-clinical partnerships, and organizational supports for PA promotion practices.

License

This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.

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Appendix

Table 2: Facilitators

Table 2: Facilitators

Facilitator	Factor	Exemplar Quotes
Personal	High motivation and confidence in promoting PA for patients with NC	“I have no problem [confidence in promoting PA]. I kind of figured the neuromuscular disorder is just another challenge that they have to meet.” [P4]
Personal	A sense of responsibility to learn about PA promotion	“It would be just kind of on my own trying my best to kind of keep up.” [P1]
Personal	A desire to model PA behaviors	“If I’m providing a guideline or recommending that somebody become more physically active and I don’t do it myself, I feel I’m not practicing what I’m preaching.” [P6]
Personal	Personal enjoyment/satisfaction promoting PA	“It’s very satisfying when you can motivate somebody to do it… I think that can be very rewarding personally.” [P10]
Professional	Connections to community PA opportunities	“I have an in at the university. My husband is the disability accommodation director… Also, there’s Special Olympics teams here.” [P8]
Professional	Availability of continuing education	“I took some courses related to physical activity and prevention of obesity for people with disabilities… I really loved them.” [P3]
Professional	PT education had relevant disability content	“I think that it was probably separated out into a class related to disability studies and a little bit more of the awareness of assistive devices.” [P7]
Professional	Job setting/environment facilitates PA promotion	“The job location that I have right now participates in silver sneakers… I like the fact that our facility is open and available to encourage patients to come back.” [P4]
Client-Related	Highly motivated	“Some people are very enthusiastic about kind of taking care of their lives… when they’re motivated to do it, that is encouraging.” [P1]

Table 3: Barriers

Table 3: Barriers

Barrier	Factor	Exemplar Quotes
Professional	Lack of specific knowledge on PA guidelines	“I don’t know of it [PA guidelines] and it’s probably crap.” [P5]
Professional	Lack of content on PA promotion for people with disabilities in PT training	“I don’t think that that was considered [PA promotion for people with disabilities]… I don’t think that at that time physical activity was kind of considered a part of it.” [P1]
Professional	Lack of continuing education resources on PA promotion	“I’ve attended courses at CSM that are related to health promotion… I don’t know that I’ve attended any specific courses about health promotion [for people with disabilities] though.” [P10]
Professional	Time	“If I had more ability to have more time with my patients, that would help me, but, you know, limited time… time would be nice.” [P6]
Professional	Cost as a barrier to learn about PA promotion	“I mean most PTs who halfway like their job would take a continuing education course every weekend, but I don’t always have $600.” [P5]
Professional	Lack of organizational support and guidelines	“I think we’re not given like a lot of guidelines on what that [PA promotion] should be… that’s up to our just own discretion as a therapist.” [P2]
Professional	Billing/insurance	“Payment barriers would be big part of it… a push for productivity… to make sure we bill the maximum number of units.” [P4]
Client-Related	Low patient motivation	“There are people who don’t want to do it [PA]. They don’t like the way they feel when they move. And that becomes very challenging.” [P7]
Client-Related	Patient safety	“Do I have people around me who can help… Am I safe? Where am I going to do my workouts?… So, I think there’s another layer [which is] safety.” [P8]
Client-Related	Financial and insurance resources	“I don’t think I would bring up a ton of activities to parents if I knew they cost money. I try to only tell them things that are free.” [P2]

Table 4: Semi-Structured Interview Guide

Table 4: Semi-Structured Interview Guide Informed by the TDF

Construct	Definition	Question	Prompts
Knowledge	An awareness of the existence of something.	What is your current understanding of health-promoting physical activity guidelines?	What is your current understanding of how they should be modified for individuals with NMD?
Skills	An ability or proficiency acquired through practice.	What were the courses you took in PT school that focused on health enhancing PA promotion for people with disabilities?	Have you pursued any continuing education in this area?
Social/Professional Role and Identity	A coherent set of behaviors and displayed personal qualities.	What role do you think PTs should play in health enhancing PA promotion for individuals with NMD?
Beliefs about Capabilities	Acceptance of the truth about an ability a person can put to constructive use.	How confident do you feel in promoting health enhancing PA for individuals with NMD?	Give examples of PA promotion types you are confident in.
Optimism	The confidence that things will happen for the best.	How effective do you think your health enhancing PA promotion efforts are?	Are there things you can do better?
Beliefs about Consequences	Acceptance of the truth about outcomes of a behavior.	What are some of the benefits of health-enhancing PA for folks with mobility disabilities?
Intentions	A conscious decision to perform a behavior.	What influences your decision to promote health enhancing PA to patients with NMD?
Goals	Mental representations of outcomes an individual wants to achieve.	Do you believe the health enhancing PA guidelines are a good goal for individuals with NMD?
Innovation	Characteristics that discourage or encourage development of skills.	What are some facilitators that might make it easier to promote health enhancing PA?	What are barriers facing PTs?
Socio-political Context	Characteristics of the socio-political context.	What are financial facilitators or barriers to including PA promotion in sessions?	Can you bill for this?
Organization	Characteristics of the organization.	In what ways does your job setting encourage you to promote health enhancing PA?	Are there employer barriers?
Patient	Characteristics of the patient.	What patient characteristics may deter you from promoting PA?	What patient characteristics may facilitate PA promotion?
Innovation Strategy	Characteristics of the innovation strategy.	What are facilitators to learning more about health enhancing PA promotion?	What are barriers?
Social Influences	Interpersonal processes that can cause individuals to change their behaviors.	What are things your colleagues do to promote PA for individuals with NMD?	What do you think APTA could do better?
Positive Emotion (Motivation)	A complex positive reaction pattern.	What benefits do you get from promoting health enhancing PA for individuals with NMD?
Negative Emotions	A complex negative reaction pattern.	What are some drawbacks or frustrations to promoting health enhancing PA?
Behavioral Regulation	Anything aimed at managing or changing actions.	Is PA a regular part of your life?	Do you find it important to meet physical activity guidelines?
Nature of the Behaviors	The aggregate of all responses in any situation.	How hard is it to include health enhancing PA promotion alongside your treatment plan?
Knowledge/Environment	Awareness of resources available to implement behavior.	Are you aware of any resources or facilities that help individuals with NMD engage in PA?
Motivation	The individual’s level of wanting to engage in the behavior.	How motivated are you to promote health enhancing PA for individuals with NMD?	Do you experience competing priorities for your time?