Research

A study of perceived
facilitators to physical activity
in neurological conditions Charlotte Elsworth is
Researcher, Movement
Science Group, School
C Elsworth, H Dawes, C Sackley, A Soundy, K Howells, D Wade, D Hilton-Jones, J Freebody, H Izadi of Life Sciences, Oxford
Brookes University; School
of Population Sciences,
Aims: The study aimed to determine the opinions of individuals with neurological conditions on University of Birmingham;
factors facilitating their physical activity participation. Rivermead Research
Group, Oxford Centre for
Methods: Four condition-specific focus groups (muscular dystrophy, multiple sclerosis, motor neurone Enablement;
disease and Parkinson’s disease) were run with a total of 24 people. Themes that emerged were used Helen Dawes is Research
Physiotherapist and Senior
to create an eight-item self-completed questionnaire, which explored barriers to participation, preferred Lecturer in Exercise
activities and support networks. A cross-sectional survey was then conducted using this questionnaire Physiology, Movement
Science Group, School
with individuals with a range of neurological conditions. of Life Sciences, Oxford
Findings: Three themes categories emerged from the focus groups: ‘opinions of physical activity’, Brookes University;
Rivermead Research
‘barriers to physical activity’, and ‘factors that would encourage increased physical activity Group, Oxford Centre for
involvement’. Of the 115 distributed questionnaires, 80 (70%) responses were received. Swimming, Enablement; Catherine
Sackley is Professor of
stretching and walking were the three most popular activities. The most common barriers were Physiotherapy, School
embarrassment, perceived lack of condition-specific knowledge of the fitness professionals about of Population Sciences,
University of Birmingham;
neurological disease and the impact of that on exercise advice. Facilitators were use of specific group- Andrew Soundy is
based exercise sessions and the presence of specifically trained staff. Lecturer in Sports Science,
School of Health Sciences,
Conclusions: People with neurological conditions enjoy participating in physical activity but reported University of Birmingham;
several barriers that prevent their participation in exercise. Respondents identified barriers and Ken Howells is Principle
Lecturer in Anatomy,
facilitators in functional, psychological and environmental domains. It is important that health- Movement Science
care professionals and fitness professionals identify and remove these barriers to promote greater Group, School of Life
Sciences, Oxford Brookes
participation in exercise among people with neurological conditions. University;
Key words: n Neurological n physical activity n exercise n participation Derick Wade is Professor
of Neurological
Submitted 17 July 2008, sent back for revisions 10 October; accepted for publication following double-blind peer review 2 December 2008 Rehabilitation, Oxford
Centre for Enablement,
Windmill Road, Oxford,

E
OX3 7LD;
vidence suggests that adults with physical studies indicate low levels of general activity despite David Hilton-Jones is
disabilities have low levels of participation a desire to increase exercise participation (Kersten et Consultant Neurologist,
in leisure time physical activities (Kosma al, 2002; Dawes et al, 2006). Department of Clinical
Neurology, University
et al, 2004; Rimmer et al, 2004a; Rimmer
of Oxford, Radcliffe
et al, 2005). The reduced activity that occurs as a Barriers to physical activity Infirmary;
result of chronic disease or disability can in turn lead Therapeutic exercises such as treadmill walking Jane Freebody is
to a cycle of secondary deconditioning, with impair- (Pohl et al, 2002), muscle strengthening (Weiss et al, Physiotherapist,
ments causing physical deterioration and further sub- 2000) and functional exercises (Duncan et al, 1998) Department of Clinical
Neurology, University
sequent reductions in activity (Durstine et al, 2000). have been shown to improve mobility in individuals
of Oxford, Radcliffe
There are many health concerns that can affect the with neurological conditions and can be delivered Infirmary; and
general population if they lead a sedentary lifestyle, effectively in the home or the community (Ada et Hooshang Izadi is Senior
and these same health concerns may be more serious al, 2003). In spite of growing evidence that regular Lecturer, Department of
for those with disabilities (Hicks et al, 2003; Rimmer, exercise may provide health and social benefits for Mathematical Sciences,
Oxford Brookes University,
2005). We do not know specifically how active the people with neurological (Singh, 2002; Allen et al,
UK
UK population of over 900 000 adults affected with 2004; Santiago and Coyle, 2004, Brennan Ramirez
neurological conditions are (Department of Health et al, 2006; Crizzle and Newhouse, 2006) and neu- Correspondence to:
(DH), 2005a). However, findings from exploratory romuscular disease (Singh, 2002; van der Kooi et al, C Elsworth

International Journal of Therapy and Rehabilitation, January 2009, Vol 16, No 1 17

 Research
2005), it is apparent that there are barriers to partici-
pation (Rimmer et al, 2004b; Rimmer et al, 2008).
Evidence from individuals with disabilities and
long-term neurological conditions suggests there are
many important factors, such as physical support,
cost, transportation and access, that limit access to
community leisure facilities (Kersten et al, 2002;
Rimmer et al, 2005). These also include (Kosma et
al, 2004; Rimmer et al, 2005):
n A lack of disability awareness among fitness
professionals
n Limited condition-specific knowledge among
health professionals on appropriate exercises and
the benefits of exercise for people with disabilities
n Decreased self-efficacy and negative attitudes to
exercise of people with disabilities
n Barriers of the health condition itself
n A general lack of energy.
Lees et al (2005) found the most significant barriers
to exercise among older adults to be fear of falling,
inertia, negative affect and time constraints.
AIMS
In older adults motivation and confidence to exer-
cise has been shown to be low if they are required
to participate in physical activity unsupported, i.e.
without physical assistance (Cromwell and Adams,
2006). There is evidence that exercise support sys-
tems are beneficial for individuals after stroke and
can facilitate outdoor mobility (Logan et al, 2004).
However, there is limited evidence regarding posi-
tive facilitators to support exercise participation in
the community for individuals with neurological
conditions. This study aimed to investigate the opin-
ions of individuals with progressive neurological
disorders on exercise, and explore the possible bar-
riers to and facilitators for enabling participation in
physical activity within community facilities such as
leisure centres.
METHODS
Support groups for people with progressive neu-
rological conditions in Oxfordshire, UK were con-
tacted by post and phone and asked to invite their
members to contribute in one focus group to dis-
cuss physical activity. There was no upper age limit
and people with any level of functional ability were
included. Ethical approval was gained from the local
University Research Ethics Committee. Four focus
groups took place between November 2004 and
April 2005. Written consent was obtained before
the focus group meetings were conducted. The focus
group discussions were conducted in condition-spe-
cific groups; this was deemed important owing to
the very specific nature of each condition.
18 International Journal of Therapy and Rehabilitation, January 2009, Vol 16, No 1
All focus group discussions were held in a con-
ference room at Oxford Brookes University. Focus
groups were coordinated by three members of the
research group (CE, HD and AD) who attended
each focus group discussion. At the beginning
of each focus group session, group coordinators
explained that the purpose of the study was to dis-
cuss issues relating to perceived barriers and facili-
tators to taking part in physical activity. Groups also
discussed current levels of activity and difficulties
in changing behaviour.
Notes taken by the three researchers during focus
group sessions were analysed using a note-based
approach. Independent note analysis by the research-
ers provided identification of major themes. The
analysis took the form of categorical content analy-
sis (Lieblich et al, 1998) that is, statements gener-
ated from the focus groups were noted then grouped
by categories or themes. To establish trustworthi-
ness and establish consensus authors (CE, AS, HD)
compared, reviewed and constituted agreement. The
authors have experience with qualitative research and
neurological physiotherapy.
Following the analysis, a questionnaire was devel-
oped using the themes that emerged. The question-
naire was to be self-completed, and consisted of
eight questions. The questions covered topics such
as: necessary support, barriers to participation and
average time spent participating in physical activity.
The initial version of the questionnaire was piloted
among the focus group participants to further verify
that the questions truly addressed the focus group
participants thoughts. The questionnaires were dis-
tributed to members of the various support groups
either at group meetings or by post. Individuals
completed the questionnaire by themselves or with
the help of a carer.
FINDINGS
Focus groups
Formal consent to take part in a group discussion
was given by 24 individuals (mean age=54 years;
standard deviation (SD)=25 years). The condition-
specific focus groups comprised the following:
n Muscular dystrophy (MD): n=5
n Multiple sclerosis (MS): n=7
n Motor neurone disease (MND): n=6
n Parkinson’s disease (PD) n=6.
All participants had partners who acted as carers
and 22 individuals brought them to the focus group.
However, this study did not report the views and
opinions of the carers.
Three themes emerged from the focus group dis-
cussions: perception of the barriers to and enjoyment
of physical activity; disease-specific consideration,
and confidence in health professionals.
Perception, barriers and enjoyment
of physical activity
Of the 24 individuals who participated, all agreed
that physical activity was a positive experience that
had the potential to make them ‘feel better’. The
most frequent physical activities identified as being
beneficial and enjoyable were swimming, stretching
and walking. These activities were discussed across
all conditions. The participants also wanted the
choice of activities that they enjoy, which sometimes
included other activities such as ballroom dancing.
However, feelings of inertia and lack of motivation
were expressed by 19 of the 24 participants as major
reasons for their reluctance to exercise.
The reasons for participating in physical activity
varied, but in all four focus groups, individuals felt
that exercise was an effective way of preventing phys-
ical deterioration. For example, an individual with
MS stated: ‘exercise helps us to focus on the positive
aspects of our mobility’. This opinion was reiterated
consistently across all the focus groups and appeared
to be an important incentive to participation.
The facilities and environment were identified
as a barrier to physical activity. Individuals in all
four groups expressed the view that fitness facili-
ties are inherently inaccessible; citing access routes,
doorways being too narrow for wheelchairs to pass
through and a lack of lifts as contributory factors.
Individuals also highlighted several safety issues
such as wet floors in changing rooms, poorly main-
tained equipment and unsuitable hoists in pool
areas. Further practical problems included the costs
of membership fees and transport were highlighted
as barriers, particularly for those who do not work.
These barriers to exercise were highlighted in all
condition groups. In addition to this there are limited
services provided through primary health-care serv-
ices and the NHS. This meant short-term gains, but
poor long-term prospects. For example, an individual
with MD stated that
‘I enjoy swimming, but I am concerned
about the rationale, I only get 6 to 8 weeks
hydro and that’s it, then we’re out’.
Individuals recalled previous negative experiences
associated with fitness centres. These memories
acted to prevent their attendance, as an individual
with MD stated:
‘I would have fear of doing something
if I had not done it for a while…as I
would not be sure if [I] would judge it
right…like when I went swimming...I was
so self conscious in the changing room
and this was scary and really affected my
confidence.’
Fear and worry was associated with adapting to
the new environment; the unknown location and sur-
roundings, the new equipment and different people
International Journal of Therapy and Rehabilitation, January 2009, Vol 16, No 1
all contributed to this. Individuals needed reassurance
that their needs would be met and that staff would be
sensitive to and knowledgeable about their condition.
This need was highlighted particularly in those users
who had a negative experience previously. An indi-
vidual with PD recalled a specific incident:
‘I really enjoyed the treadmill, but when I
fell over on it, there was no one there to
help me’
There was also fear of not performing the exercise
‘correctly’ and that this would be embarrassing for
individuals. The memory of falls, and lack of confi-
dence in their ability were also mentioned as sources
of concern. Individuals wanted a supported environ-
ment that could allay these concerns. All individuals
agreed that the social aspect of exercise was impor-
tant and that attending exercise sessions with others
enhanced the feeling of ‘normality’. The idea of a
group for people in similar situations was generally
perceived as positive.
Disease-specific considerations
Disease progression and feelings of hope were found
to be important factors that influenced participants’
motivation and feelings towards physical activity.
Participants identified a specific need to consider the
physical problems associated with each disease and
its responsiveness to change. Disease considerations
influenced some participants’ faith in exercise. An
individual with MD illustrated this:
‘they don’t understand how fatigue is part
of my condition’
Table 1 identifies the disease-specific barriers
mentioned for all the conditions identified.
Table 1.
Disease-specific considerations for participation in physical activity
Disease Barriers that concern individuals
Motor neurone n Walking is hard; individuals feel their legs need to be conditioned
disease n Fatigue
n Incontinence
n Fear of falling
n Exercise becomes less safe owing to progression of disease
n Can easily do too much, resulting in aches, physical and mental
fatigue. Cramps occur regardless of activity levels
n Unpredictable nature of the disease
Multiple sclerosis n Warmer environments cause over heating
n Over stretching
n Accessibility to the toilet
Parkinson’s n Difficulty moving about in public spaces e.g. swimming pool
disease n Medication affects timing of exercise sessions and coordination
and consideration is needed as to when it should be taken.
n Swimming pools temperature is too cold and individuals
cannot move fast enough to get warm
n Losing balance
Muscular n Fatigue or ‘overdoing’ an activity
dystrophy n Fear of adverse event in a new environment
19
 Research
Some individuals with PD preferred medication
to exercise as they felt that ‘exercise can’t cure me’.
Also an individual with MND indicated that exercise
is not proven to be helpful therefore it may be point-
less in ‘influencing our health state’.
Confidence in health professionals
All of the focus group participants agreed that staff
in fitness facilities would benefit from some training
to help them understand the specific neurological
conditions and which exercises would benefit them.
Individuals stressed the importance of fitness profes-
sionals having easier access to information regarding
their condition. It was also considered important that
fitness professionals are made more aware of how to
access this information. Many individuals reported
a lack of confidence in the fitness staff with regards
to their knowledge of the condition and what exer-
cises were appropriate for them. An individual with
MND identified that the rarity of the disease meant
that people, including general practitioners, did not
always understand. An individual with MD stated:
‘I want a trainer to be familiar with [my]
condition and confident to deal with me.
[I’m] fed up with constantly having to
explain everything.’
Individuals with MS suggested that support from
a specialist neuro-physiotherapist would help the
exercise sessions and make them feel more confi-
dent. Eighteen participants stated that they would
only feel comfortable with some form of physi-
otherapy support. Additionally, it was reported that
support from health-care professionals is integral
to assisting with the transition from rehabilitation
settings (such as hospitals) to community settings
(such as leisure centres), and this would reduce the
reluctance to participate.
Additionally, it was made clear by focus group
participants that gym/fitness instructors needed to be
aware of various other important aspects regarding
neurological conditions, such as lifting and handling
issues for individuals with MD. Individuals with
conditions such as these are extremely capable of
managing their own conditions, and it is clear that fit-
ness professionals must strive to develop participant
autonomy alongside all aspects of their knowledge
surrounding these conditions. An individual with MD
stated that having to ask for help was horrible:
‘At first I had no confidence in the new
machines; I want the instructor to be
familiar with the condition and confident
to deal with me’.
Participants preferred to have someone in these
community settings who they already knew as their
point of contact, and would often request this. An
individual with MD stated:
‘I like to have a point of contact, [I] feel
20 International Journal of Therapy and Rehabilitation, January 2009, Vol 16, No 1
safer if I know someone there and I would
be scared to turn up cold’.
Individuals with MS stated that they like to find
exercise centres, such as leisure centres and com-
munity based gyms, through the MS society—a UK
MS charity—because they trust it.
Questionnaire
A total of 115 questionnaires were distributed and
80 (70%) were completed. Age of respondents in
years ranged from 42 to 68, 55±13 (mean±SD) and
48 (60%) were women. Table 2 gives a summary of
the questionnaire findings. Respondents had the fol-
lowing diagnoses:
n MS: n=27 (33.75%)
n MD: n=30 (37.5%)
n PD: n=13 (16.25%)
n ‘Other’ (stroke or MND): n=10 (12.5%)
All respondents provided estimates of the time spent
exercising during a typical week, ranging from 32
to 140 minutes a week. Sixteen (20%) individuals
reported not participating in any physical activity
at all. Those that did report exercising did so for
108±76 minutes a week (mean±SD).
The number of occasions people exercised during
the week varied; with 16 respondents (20%) report-
ing ‘not at all’, 37 (46%) reporting one to three
occasions and 29 (36%) reporting more than four
occasions. Of the 64 who reported exercising, 40
estimated the length of time spent on each occasion
to be 15–30 minutes, 12 spent 45 minutes exercising
and the remainder an hour or longer.
When asked to rank their favourite exercise
activities, most respondents prioritized walking
and swimming, followed by stretching and exer-
cise classes. Respondents were happy to access
these activities in the usual way; at gyms, leisure
or community centres, or to practice at home.
Half of the respondents reported the main bar-
riers to physical activity participation were: staff
lack of knowledge of neurological disability, staff
lack of knowledge of suitable exercises for their
condition and feelings of embarrassment. One
third of respondents cited concerns over cost,
suitability of the environment, time constraints
and lack of personal care support. Half of the
respondents wanted to exercise with people either
with their condition or another disability. Only six
people wanted to exercise exclusively with able-
bodied individuals.
The final question asked who the individuals
would like to support them while they were exercis-
ing; 43 of the 80 respondents would prefer a physi-
otherapist, 25 would like a specially trained fitness
professional who had support from a physiothera-
pist, nine preferred a fitness professional and eight
a trained carer.
 Table 2.
Condition-specific exercise involvement

Other
(Stroke and
Multiple Muscular Parkinson’s motor neurone All
sclerosis dystrophy disease disease) conditions
No of completed 27 30 13 10 80
questionnaires
Average time 106 60.5 121 105 87.6
exercising per
week (minutes)
No of individuals 2 9 1 4 16
reporting no exercise
Favourite three Swimming Swimming Walking Walking Walking
activities reported Group exercise class Walking Stretching Stretching Swimming
Stretching Stretching Swimming Swimming Stretching

DISCUSSION However, within the focus groups, fears and wor-

Opinions on physical activity
Individuals with progressive neurological condi-
tions indicated that they enjoyed participating in a
range of activities including walking, swimming and
group exercises, and that they would like to access
these activities in a number of different community
settings. When considering the delivery of exercise,
it is noteworthy that the majority of respondents pre-
fer to exercise in a group of people with the same or
other disabilities, with relatively few indicating they
would like to exercise alone. The majority of indi-
viduals indicated they would prefer to exercise with
the support of health and fitness professionals with
expertise relevant to their condition.
A report by the The Gary Jelen Sports Foundation
(1999) indicated that people with disabilities would
like to exercise in an environment available to able-
bodied individuals. However, this study found that
only six individuals with neurological conditions
would like to exercise alongside able-bodied individ-
uals. It would appear that people with neurological
conditions may have specific requirements. In order
to optimize participation, these findings should be
considered when implementing community exercise
programmes. Clients’ participation barriers should
be assessed on an individual basis and their con-
cerns and preferences addressed when delivering a
programme involving physical activity. The findings
also support the need to examine opinions in a range
of conditions. It is plausible that change is possible
with time and support.
Barriers and concerns
As expected, the study highlighted previously
described barriers to exercise, such as high costs,
poor access, inappropriate facilities and equip-
ment (Rimmer et al, 2000; Rimmer et al, 2004a).
ries about participation were raised and in sup-
port of this observation, the most common barrier
to participation in questionnaire responses was
that of embarrassment. This finding has not been
reported in other neurological conditions and may
link with the strongly reported desire to exercise
among individuals with such disabilities. Other
issues highlighted by the focus groups and not pre-
viously reported were the concerns of individuals
regarding a perceived lack of knowledge of fitness
professionals on their condition and of suitable safe
exercises. In support of this finding, when asked
who would be preferred in a supporting role, most
respondents in the questionnaire indicated that they
would prefer to exercise with physiotherapy sup-
port, followed by the less costly option of a fitness
professional supported by a physiotherapist.
Facilitators
Becoming or remaining active for individuals with
disabilities can be a daunting step and their anxiety
about being able to participate or use equipment
at a ‘regular’ fitness centre (Steadward, 1998) was
evident in this study. Many people with a disability
lack the confidence, both in themselves and in fit-
ness professionals (Steadward, 1998), to participate
in physical activities. Knowledgeable support has
previously been highlighted as an important deter-
minant of physical activity participation in people
with arthritis (Der Ananian et al, 2006). The value
of the patients’ knowledge for managing their own
condition was clearly evident in the current study
and identified in UK government publications (DH,
2001; 2005b). The patient’s knowledge needs to be
taken into account by fitness staff and documented in
a way that it can be recalled. Staff need to be aware
of any specific conditions and exercise response
before meeting a patient to give them confidence in

International Journal of Therapy and Rehabilitation, January 2009, Vol 16, No 1 21

 Research
prescription and aid trust in the relationship.
The wide range of activities that individuals would
like to participate in, indicated that a degree of flex-
ibility is required in supporting physical activity par-
ticipation. Certainly when considering long-term
adherence to programmes enjoyment is key and a
wide choice of supported activities has been associ-
ated with better adherence to physical activity (Der
Ananian et al, 2006). When discussing the issue of
support this can be broken down into three areas;
emotional, physical and informational. This study
found support requirements spanned all three areas,
but emotional issues such as embarrassment and
informational issues relating to knowledge of pro-
fessionals were highlighted as particular concerns.
Limitations
There are several limitations to this study, prima-
rily related to the small size of the groups involved
and non-random selection of participants in both the
focus groups and questionnaire survey. Geographical
and socio-economic factors need to be considered
when making generalizations. However, the emo-
tional factors highlighted would be expected across
all groups and certainly require further investigation.
Many of the findings regarding physical and knowl-
edge barriers mirror earlier studies in other disabled
populations, which offers support to the strength of
these results. It is important to note that barriers iden-
tified by individuals in this study were perceived and
not objectively measured. The current sample were
relatively inactive compared to healthy populations,
with mean weekly activity levels of 108 minutes
compared with 300 minutes for healthy middle aged
women (Guthrie, 2002). Levels were comparable
with those of older people whose activity levels have
been reported to be between 119 and 161 minutes
Key points
n This focus group and questionnaire study aimed to determine the opinions
of individuals with neurological conditions in the community, in the UK, on
factors facilitating their physical activity participation.
n Individuals with neurological conditions wish to participate in a range of activities
that they enjoy in a community setting, and prefer to exercise with the support
of health and fitness professionals with expertise relevant to their condition.
n A general preference to exercising in groups of individuals with similar
disabilities, rather than with able-bodied individuals, was evident.
n Emotional issues such as embarrassment and informational issues relating
to knowledge of professionals were highlighted as particular concerns that
may act as barriers to participation.
n These findings should be considered when implementing community
exercise programmes.
22 International Journal of Therapy and Rehabilitation, January 2009, Vol 16, No 1
a week (Davis and Fox, 2006). Further studies may
examine the gap between perception of barriers and
attitudes, and the reality of the effect these percep-
tions actually have on physical activity participation.
Conclusions
This focus group and questionnaire study explored
the opinions of individuals with neurological
conditions in the community, in the UK, on fac-
tors facilitating their physical activity participation.
Individuals with neurological conditions expressed a
desire to participate in a range of activities that they
enjoy within a community setting. They also indi-
cated they would prefer to exercise with the support
of health and fitness professionals with expertise
relevant to their condition. However, findings indi-
cated that these individuals may prefer to exercise in
groups of individuals with similar disabilities rather
than directly with able-bodied individuals.
This study has highlighted some barriers not pre-
viously reported which may be specific for neuro-
logical conditions. If these barriers are addressed by
simple practical solutions, exercise delivery within
current community facilities could be enhanced.
Despite acknowledging there are barriers that need
to be recognized, individuals considered exercising
in a range of community settings. Given that pre-
vious findings suggest that exercise may be more
effective when delivered in a community setting
than in a medical setting (Ansved, 2003; Logan et al,
2004), this is encouraging. The pursuit of exercise
provision within the wide range of facilities availa-
ble in the community is an attractive option. Further
work is needed to evaluate if the implementation
of such changes as improved fitness professional
knowledge, increased physical support, assistance
with cost issues can increase participation and make
available health benefits that are regularly accessible
for the general population. IJTR
Conflict of interest: none
The authors would like to express their thanks to those indi-
viduals who gave up their time to participate in this study,
and to the support groups who aided in the recruitment of
participants.
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COMMENTARies

How to promote participation
in physical activity in chronic
neurological conditions?
Despite increasing evidence for
the benefits of physical activities,
it has been shown that people
with chronic diseases perform
too little physical activity to main-
tain their physical capacity. This
qualitative study is interesting,
since it has given us more insight
into the facilitators and barri-
ers for participation in physical
activity from the perspective of
the individuals with progressive
neurological conditions.
The study identified barriers for
participation at four different lev-
els as classified by Grol (1997):
n The individual with a chronic
disease: their health state,
preferences, experiences,
fears and worries
n The health-care professionals
and fitness staff: their knowl-
edge and understanding of
the health conditions and
appropriate exercises
n The facilities and environ-
ment: accessibility, equipment
and transport
n Primary health care services:
intervention duration and
costs of membership fees.
At all levels, various interven-
tions can be linked to the barri-
ers in order to promote partici-
pation in physical activity. Some
barriers, such as limited inter-
vention duration or the costs
of membership fees, may be
overcome with a more generic
approach towards reimburse-
ment policies of health-care
insurers and governments. For
the barriers at the level of the
individual, we agree with the
authors that a client-centered
approach is recommended in
which the barriers are assessed
and addressed on an individual
basis. A study by Logan et al
(2004), which successfully iden-
tified and addressed barriers to
outdoor mobility after stroke,
is an example of the efficacy of
a client-centered approach. In
such an approach, the client is
the expert regarding his experi-
ences and preferences regard-
ing physical activity, and the
therapist has knowledge and
experience regarding the appro-
priateness of intervention strate-
gies for a specific condition. The
goals for physical activity and
the intervention strategies are
negotiated by means of shared
decision making.
If we look at adherence to
physical activity as implemen-
tation of best practice for an
individual, the implementation
model by Grol and Grimshaw
(2003) may be useful as a theo-
retical framework. The first step

International Journal of Therapy and Rehabilitation, January 2009, Vol 16, No 1 23

 Research
in their model deals with the
development of a change pro-
posal, in this case the physical
activity. Most clinicians will recog-
nize that advice to participate in
physical activity should be tailor-
made to be successful. But how
can we tailor physical activity
to optimize adherence? Rogers
(1995) described five properties
of successful innovations:
n Relative advantage: the
experience of an immediate
positive effect
n Compatibility: fitting in a
person’s daily routine
n Complexity: the easier, the
better
n Triability: being able to try
out and personally adjust an
intervention programme
n Observability: showing active
involvement, leading to
social approval.
The tailoring of physical activity
should be done in a continu-
ous feedback loop, identifying
obstacles and adjusting the pro-
gramme accordingly.
The question is whether
physical activity in a fitness cen-
This article emphasizes the
importance of people with disa-
bilities having community-based,
disability-specific exercise oppor-
tunities. It stresses the need to
educate health and fitness pro-
fessionals and to make commu-
nity fitness centres more acces-
sible. The article also mentions
participants’ sense of embar-
rassment or self-consciousness
when exercising in community
settings. Participants expressed a
desire to exercise together with
other people with disabilities.
Supplemental to educating
health and fitness profession-
als, it is important to educate
people with disabilities them-
selves about the many types
of community-based adaptive
exercise opportunities available.
Most participants in this study
mention walking, swimming,
group exercise and stretching.
As many people with neurologi-
24
tre is the optimal intervention
for all people with chronic neu-
rologic disorders? In our opin-
ion, there are many other types
of physical activity (e.g. Nordic
walking, swimming, cycling or
hand biking) which should be
considered. In order to promote
adherence to physical activity it
is important to look at the bar-
riers to participation, but also
at the change proposal, i.e. the
type of physical activity. From an
occupational therapy perspec-
tive, it is worth finding out how
physical activity can become a
meaningful occupation for a
person (Pierce, 2001). This infor-
mation can be gathered when
asking the person about their
previous experiences and the
context of these experiences;
including the spatial (physical
environment), temporal (day,
time, duration) and sociocul-
tural context. The results from
the focus groups provided us
with examples, such as ‘the
importance of the social aspect
of exercise’ or ‘the engagement
in ballroom dancing’ or ‘having
cal conditions do not engage in
an intensive rehabilitation expe-
rience available to those who
acquired a traumatic injury, such
as spinal cord or traumatic brain
injury, it is quite likely that they
have not been exposed to infor-
mation about other less well-
known exercise options, such as
handcycling, wheelchair basket-
ball, sailing, sledge hockey and
kite flying. Information about
these activities can be found
through local and international
organizations such as Disabled
Sports USA (http://www.dsusa.
org/links-drsr-links.html) and
the International Organizations
of Sport for the Disabled
(http://www.paralympic.org/
release/Main_Sections_Menu/
IPC/Organization/General_
Assembly/IOSDs/) or through
informational websites such as
the National Center on Physical
Activity and Disability (www.
International Journal of Therapy and Rehabilitation, January 2009, Vol 16, No 1
someone there that they know’
or ‘the support from a special-
ist physiotherapist which made
someone feel more confident’.
This brings us to the level
of the health-care professionals
and their lack of knowledge of
the specific health conditions
and appropriate exercises. How
can this barrier be addressed?
We suggest that generic advice
to participate in physical activi-
ties is replaced by tailor-made
advice by so-called specialist
services (Hill and Phillips, 2006;
Cup et al, 2007), as it is impos-
sible for all physiotherapists and
fitness instructors in primary
care to have knowledge of and
experience with all chronic neu-
rological conditions.
Our challenge for the future
is to bridge the gaps between
the evidence and daily practice;
filling holes of knowledge and
methodically implementing new
knowledge gained.
Cup EH, Pieterse AJ, Knuijt S et al (2007)
Referral of patients with neuromuscular
disease to occupational therapy, physi-
cal therapy and speech therapy: usual
ncpad.org) and Project Shake-It-
Up (www.projectshakeitup.org).
Depending on the geographi-
cal location, organizations that
support recreation for people
with disabilities may or may not
be available in a local com-
munity. However, if people are
unaware of the existence of
certain types of activities, how
can they advocate for making
these recreational opportunities
available? How many people
have simply assumed, as did one
of our Project Shake-It-Up par-
ticipants with multiple sclerosis,
that activities such as cycling,
sailing, and skiing were barred
to them?
Everyone deserves the right to
engage in exercise activities that
are not just health promoting,
but also fun and engaging. Not
only that, but obviously different
people will prefer different sorts
of activities. To engage larger
practice versus multidisciplinary advice.
Disabil Rehabil 29(9): 717–26
Grol R (1997) Personal paper. Beliefs and
evidence in changing clinical practice.
BMJ 315(7105): 418–21
Grol R, Grimshaw J (2003) From best evi-
dence to best practice: effective imple-
mentation of change in patients’ care.
Lancet 362(9391): 1225–30
Hill ME, Phillips MF (2006) Service provision for
adults with long-term disability: a review of
services for adults with chronic neuromus-
cular conditions in the United Kingdom.
Neuromuscular Disord 16(2): 107–12
Logan PA, Gladman JR, Avery A, Walker MF,
Dyas J, Groom L (2004) Randomised con-
trolled trial of an occupational therapy
intervention to increase outdoor mobility
after stroke. BMJ 329(7479): 1372–5
Pierce D (2001) Untangling occupation and
activity. Am J Occup Ther 55(2): 138–46
Rogers EM (1995) Lessons for guidelines
from the diffusion of innovations. Jt
Comm J Qual Improv 21(7): 324–8
Edith Cup OT MSc
Rehabilitation/Occupational
Therapy;
Allan Pieterse PT
Rehabilitation/Physical Therapy,
Radboud University Nijmegen
Medical Centre,
The Netherlands
numbers of people with dis-
abilities in exercise, it is essential
to provide a greater variety of
affordable, accessible and fun
exercise opportunities in the
community. Health-care and fit-
ness professionals can educate
people with disabilities about
the wide variety of exercise and
recreation options available to
them. People with disabilities
can also provide peer support
and mentoring for each other,
as well as advocate in their
local communities for increased
options.
Pamela Block PhD
Clinical Associate Professor,
Occupational Therapy Program,
SUNY Stony Brook,
HSC - SHTM (ECC),
Stony Brook, NY 11794-8206,
USA
Pamela.Block@stonybrook.edu
www.projectshakeitup.org