Exploring the implementation potential of physical activity assessment and prescription tools in physical therapy practice: A mixed-method study

Abstract

Background:

Despite the benefits of physical activity (PA), especially related to aging, physical therapists do not perform regular PA prescriptions secondary to various barriers, including lack of tools. Therefore, we developed the Inventory of Physical Activity Barriers (IPAB).

Objective:

Explore potential solutions that could address the current lack of PA prescription among United States-based physical therapists treating patients 50 years and older.

Method:

A convergent parallel mixed-method design consisting of focus groups and self-report questionnaires. Descriptive statistics were used for all quantitative variables. Focus groups were thematically coded.

Results:

The 26 participants had 8.6 years (SD= 6.4) of clinical experience, 88.4% (n= 23) reported they regularly have PA conversations with patients, 65.4% (n=17) regularly assess PA levels, and 19.2% (n=5) regularly provide PA prescriptions. We identified three themes: 1) opportunities and challenges related to PA prescriptions; 2) lack of standardization in PA assessments and interventions; and 3) implementation potential for innovative solutions that address the current informal PA assessments and interventions.

Conclusion:

Physical therapists are amenable to incorporating innovative solutions that support physical activity prescription behavior. Therefore, we recommend the continued development and implementation of PA assessment and prescription tools.

INTRODUCTION

According to the 2016 Centers for Disease Control report, 27.5% of adults above the age of 50 and 35.3% above the age of 75 reported no leisure-time physical activity (PA) (Watson et al., 2016). Insufficient PA levels can lead to an increased risk of poor quality of life, morbidity, and mortality (Carlson, Adams, Yang, and Fulton, 2018; De Souto Barreto, 2015; Ding et al., 2016; Lee et al., 2012). The health consequences of insufficient PA levels are even more detrimental in aging adults undergoing age-related changes, such as decreased strength, balance, and endurance (Sakuma and Yamaguchi, 2012). Consequently, regular participation in PA is critical for older adults (Paterson, Jones, and Rice, 2007). Due to physical therapists’ expertise related to the aging process and PA as well as their primary care provider status, physical therapists are in an ideal position to address the insufficient levels of PA among adults 50 years and older (Bezner, 2015; Rea, Hopp, Neish, and Davis, 2004). Although physical therapists acknowledge the importance of PA, most of them do not implement PA prescriptions in addition to therapeutic exercises (Bezner, 2015; Dean, 2009a; Dean, 2009b; Freburger et al., 2009; Morris and Jenkins, 2018; Mulligan et al., 2011).

Most solutions and implementation interventions that can address the lack of PA prescriptions are complex (Bezner, 2015; Rea, Hopp, Neish, and Davis, 2004). As lack of tools is a PA prescription barrier (Abaraogu, Edeonuh, and Frantz, 2016; Barton et al., 2021; Lowe, Littlewood, and McLean, 2018) a potentially less complex solution maybe to develop clinically feasible PA assessment and prescription tools. The need for PA assessment tools and associated toolkits is further emphasized by Zalewski, Alt, and Arvinen-Barrow (2014) who identified that physical therapists currently do not accurately estimate older adults’ PA participation barriers nor effectively incorporate solutions for the barriers. Therefore, we developed the Inventory of Physical Activity Barriers (IPAB) (Wingood, Gell, Peters, and Hutchins, 2021; Wingood et al., 2021) and are currently developing a PA toolkit that will provide step-by-step guidance for addressing insufficient levels of PA among patients 50 years and older. The IPAB is a valid and reliable 27-item scale that is based on the social-ecological model (Wingood, Gell, Peters, and Hutchins, 2021; Wingood et al., 2021). Using the IPAB physical therapists can evaluate PA participation barriers experienced by patients 50 years and older (Wingood, Gell, Peters, and Hutchins, 2021; Wingood et al., 2021). The results can be used to develop solutions to the identified PA participation barriers.

Before implementing the newly developed IPAB it is essential to explore its implementation potential (Bowen et al., 2009; Proctor et al., 2011). Thus, the overarching goal of this study was to explore the recently developed IPAB’s potential of addressing the current lack of PA prescription among United States (US)-based physical therapists treating patients 50 years and older. Sub-aims of this study included: 1) examine factors that impact the assessments and prescriptions of PA among patients 50 years and older; and 2) explore participants’ interest in a PA toolkit. The insight gained from this study will help guide the development of 1) future implementation studies to increase assessments of PA levels and barriers to PA via tools such as the IPAB; and 2) a PA toolkit.

METHODS

Study Design

A convergent parallel mixed-method design was used for this study. As developing PA tools, implementing PA tools, and changing clinical practice require complex integration of information and behavior, it is important to use both quantitative and qualitative data to achieve the overarching purpose of the study (Green et al., 2015). The quantitative data provides insight into: 1) factors that impact physical therapists’ PA assessments and prescriptions for patients 50 years and older; and 2) physical therapists’ perceived potential feasibility, appropriateness, and acceptability of the IPAB. While the qualitative data explored: 1) factors that impact physical therapists’ PA assessment and prescription; 2) how physical therapists envision using the IPAB; and 3) physical therapists’ perceptions and suggestions regarding a PA toolkit. As the focus of this study was to explore the recently developed IPAB’s potential of addressing the current lack of PA prescription among US based physical therapists, the qualitative data was the core of the analyses and the quantitative data was supplemental. Thus, our Morse Mixed Method nomenclature is QUAL+quan (Guest, Namey, and Chen, 2020). Secondary to the focus of this study starting with examining a problem related to PA assessments and prescriptions and ending with a potential solution that informs future practice, the study’s philosophical underpinning was pragmatism (Kelly and Cordeiro, 2020). Pragmatism is an overarching philosophical orientation that is influenced by the longing to contribute valuable and actionable knowledge that is anchored in participants’ experiences (Kelly and Cordeiro, 2020).

The University’s Internal Review Board (IRB) approved the study. All participants completed the IRB-approved consenting process before participating. The qualitative and quantitative data were collected within the same week, analyzed separately, and then interpreted together (Fetters, Curry, and Creswell, 2013; O’Cathain, Murphy, and Nicholl, 2007). For a visual representation of the study design see Figure 1.

Figure 1.

Convergent Parallel Mixed-Method Design

Participants and Recruitment

Participants were licensed physical therapists with at least one year of clinical experience in an outpatient physical therapy setting. Physical therapists were excluded if they did not treat patients 50 years and older. Participants were recruited using flyers, list-serves, e-mails, and social media. Recruitment materials included information about eligibility criteria, what is involved, compensation, and a link to the survey. The survey was administered using REDCap (Vanderbilt University, Nashville, TN) a secure survey platform. The first part of the survey was an IRB-approved consent form, which provided potential participants with additional detail. At the end of the survey, participants were asked to provide an e-mail address which was used to schedule the focus group sessions.

Data Sources

Quantitative Data

Online Survey 1 (Pre-Focus Group Questionnaire)

The primary purpose of the first online questionnaire was to identify factors that impact physical therapists’ PA assessments and prescriptions of adults 50 years and older. Physical therapists answered questions regarding their level of experience, knowledge, confidence in PA prescription, and perception of PA prescription barriers. The items on the questionnaire were based on previous publications related to PA prescription among physical therapists (Lowe, Littlewood, and McLean, 2018; Lowe, Littlewood, McLean, and Kilner, 2017; Mouton, Mugnier, Demoulin, and Cloes, 2014; Shirley, Van der Ploeg, and Bauman, 2010).

Online Survey 2 (Post-Focus Group Questionnaire)

The purpose of the second online questionnaire was to explore physical therapists’ perceptions related to the IPAB’s implementation potential and the IPAB’s potential of addressing the PA participation barriers asked about during the first online survey. The questions related to the IPAB’s implementation potential were based on valid and reliable measures used to explore an intervention’s potential for successful implementation, including Acceptability of Intervention Measure, Intervention Appropriateness Measure, and Feasibility of Intervention Measure (Weiner et al., 2017). In accordance with the recommended use of these validated measures the questionnaires were modified to specify the implementation potential of the IPAB (Weiner et al., 2017).

Qualitative Data

The purpose of the qualitative data was to explore the factors that impact PA assessment and prescription, how participants envision using the IPAB and PA toolkit, and what they would want included in the PA toolkit (Gibbs, 1997). The exploratory nature of the study’s purpose made it suitable for the use of focus groups. Focus groups are useful for exploratory objectives because they gather input on one topic from several different perspectives (Gibbs, 1997). Our focus groups were conducted using a discussion guide. The discussion guide provided the focus group moderator with questions, probes, and cues (Wong, 2008). The guide had the following format: 1) an opening to promote conversation; 2) introduction of the topic; 3) transition to key questions; 4) key questions related to study purpose; and 5) ending question that brings closure (Kreuger, 1997; Wong, 2008). See the Supplemental File for a copy of the interview guide.

Focus Group Procedures

Using the pre-focus group questionnaire’s item related to PA prescription, physical therapists were stratified into the following three focus groups: 1) prescribing PA “a lot” or “all the time” (n=5); 2) prescribing PA “sometimes” (n=6); and 3) prescribing PA “rarely” or “never” (n=2). By stratifying the physical therapists into homogenous focus groups, the participants within each group were more likely to develop group cohesion, a key component for maximizing the amount of information shared by focus group participants (Palinkas et al., 2015). As it is important to gather input from all perspectives, at least one focus group for each stratified group of participants was completed. This sampling strategy was also guided by pragmatism as gaining perspectives from physical therapists with different experiences of assessing and prescribing PA results in uncovering a range of perspectives, a critical component of pragmatism (Kelly and Cordeiro, 2020).

The focus groups consisted of 45–55 minute Zoom meetings (Zoom, San Jose, CA) (Kite and Phongsavan, 2017) held between July and December 2020 and moderated by MW. Halfway through the focus group sessions the original 40-item IPAB was introduced (Wingood et al., 2021). Participants were given approximately 10 minutes to review the IPAB before discussing it. At the end of each focus group, the moderator and a secondary interviewer (NG or DP) completed a debriefing session that addressed any challenges identified during the focus group, such as questions that required follow-up or probing questions (Curtis and Redmond, 2007).

After the initial three focus groups saturation was not met, resulting in an additional fourth focus group. The fourth focus group was comprised of participants who stated that they prescribe PA “sometimes” (n=13). Data saturation was met after the fourth focus group when no new codes or information emerged (Halcomb et al., 2007). After the focus groups, participants completed the post-focus group questionnaire.

Analysis

Quantitative Analysis

Data were managed using SPSS-Version 27 (IBM, Armonk, NY). We calculated descriptive statistics including means, standard deviations, and frequencies for all items on the pre and post-focus group questionnaires.

Qualitative Analysis

Data across the four focus groups was aggregated for analysis to obtain divergent and varied perceptions on factors that impact PA assessment and prescription and their opinions about the IPAB and PA toolkit. Data were managed using NVivo 12 (QSR International, Burlington, MA) and MAXQDA (VERBI GmbH, Berlin, Germany). To become immersed in the data and ensure familiarity, the coders (MW and JV) read the transcripts four times. Each coder initially coded all four transcripts independently and then met to discuss the emerging themes and reach a consensus on codes. A second round of coding was completed using the agreed-upon codes. After finalizing the coding, the codes were grouped into broader categories or themes. An agreed-upon summary matrix for each theme was outlined, including subthemes and quotes. These inductive and deductive data analyses are supported by pragmatism, which embraces a reflexive and flexible approach to data analyses (Kelly and Cordeiro, 2020). Using both inductive and deductive analysis also allows for the combination of the post-positivism view of using deductive reasoning with the constructivism emphasis on inductive reasoning (Kaushik and Walsh, 2019).

Qualitative Standards for Rigor

Ensuring rigor in qualitative research means assessing the study’s dependability, credibility, transferability, consistency, and confirmability (Anderson, 2010). Methods used to ensure rigor included: 1) using a question guide to run the focus group; 2) completing debriefing sessions at the end of each focus group; 3) recording the interviews and transcribing them word by word; 4) maintaining a clear trail of data by creating tables for each step of the coding process; 5) in-depth description of the qualitative themes; 6) comparing the qualitative and quantitative data (data triangulation); and 7) using self-reflective strategies such as debriefing with the research team, using systematic tables for data collection, and having multiple coders (Anderson, 2010; Patton, 1999). To further enhance the rigor of the study, we followed the Standards for Reporting Qualitative Research.

Integration of the Data

A deeper understanding of the data was obtained by merging the quantitative and qualitative data and examining them for common concepts (Green et al., 2015). Common concepts were further examined to identify if the data confirmed or disconfirmed each other. The data that confirmed each other was than examined to identify if the quantitative and qualitative data expanded on each other. For example, during the first online survey participants were asked about PA prescription barriers, and during the focus groups participants verbalized multiple barriers that they encounter during clinical practice. The data regarding PA barriers was then compared and examined to identify if the findings confirm or disconfirm each other. As they confirmed each other, further examination about how the qualitative data expanded on the quantitative data was conducted (Green et al., 2015). Through data integration, we can emphasize the connectedness of knowledge, experience, and the potential of action, a key principle of pragmatic epistemology (Kelly and Cordeiro, 2020).

RESULTS

Participant Characteristics

The 26 participants had a mean age of 33.6 years (SD=6.2) with a median years of clinical experience of 7.3 [interquartile range (IQR= 5.0–11.0)]. The majority reported having PA conversations “a lot” or “all the time” (88.4%), assessed PA levels “a lot” or “all the time” (65.4%), and provided PA prescription “sometimes” or less (82.7%). On the PA knowledge assessment, physical therapists answered 66.0% of the PA knowledge questions correctly. Within the components of the assessment 11.5% (n=3) could define PA; 19.2% (n=5) knew the PA recommendations for older adults; 84.6% (n=22) knew what the acronym for frequency, intensity, time, and type (FITT) was; 76.9% (n= 20) could list at least four PA benefits; and 69.2% (n= 18) knew at least three acute physiological changes that occur during PA. See Table 1 for additional participant characteristics.

Table 1.

Participant Characteristics

Variable
Age, mean years (SD)	33.6 (6.2)
Experience as a physical therapist, median (IQR)	7.3 (5.0–11.0)
Working in outpatient physical therapy, median (IQR)	5.0 (1.4–8.0)
Certified clinical specialists, n (%)	15 (57.7)
Caseload of patients 50 years and older, median % (IQR)	70.0 (60.0–88.8)
PA knowledge score range 0–100%, mean score (SD)	66.4 (16.0)
PA conversation, n (%)
A lot-all the time	23 (88.4)
Sometimes	3 (11.5)
Not at all-rarely	0 (0.0)
Assess PA, n (%)
A lot-all the time	17 (65.4)
Sometimes	8 (30.8)
Not at all-rarely	1 (3.8)
PA prescription, n (%)
A lot-all the time	5 (19.2)
Sometimes	11 (42.3)
Not at all-rarely	10 (38.4)
Address lack of PA, n (%)
A lot-all the time	11 (41.3)
Sometimes	14 (53.8)
Not at all-rarely	1 (3.8)
PA plan post-DC, n (%)
A lot-all the time	6 (23.0)
Sometimes	12 (46.2)
Not at all-rarely	8 (30.8)
Importance of asking about PA, n (%)
Very-extremely	15 (57.8)
Somewhat	9 (34.6)
Not at all-minimally	2 (7.6)
Importance of providing a PA prescription, n (%)
Very-extremely	24 (92.3)
Somewhat	2 (7.7)
Not at all-minimally	0 (0.0)
Burden of asking about PA, n (%)
Large-extreme	2 (7.7)
Moderate	7 (26.9)
None-minimal	17 (65.4)
Burden of providing a PA Prescription, n (%)
Large-extreme	2 (7.7)
Somewhat	15 (57.7)
None-minimal	9 (34.6)
Top Barriers, n (%)
Patient preference of not doing PA	23 (88.5)
Other treatment priorities	19 (73.1)
Lack of time	14 (53.9)
Lack of tools	12 (46.1)
Patient won’t change	11 (42.3)

DC= discharge; IQR= interquartile range; n= number; PA=physical activity, SD= standard deviation;

Qualitative Data

The qualitative data revealed three primary themes: 1) opportunities and challenges related to PA prescriptions; 2) lack of standardization in PA assessments and interventions; and 3) implementation potential for innovative solutions that address the current informal PA assessments and interventions. The sub-themes that emerged from within the larger themes are described below.

Opportunities and Challenges Related to Physical Activity Prescriptions

Nearly all participants verbalized the importance of PA, but acknowledged challenges such as lack of knowledge or confidence related to patients’ medical or physical complexity, increasing patients’ PA levels, and lack of treatment time prohibit the ability to prioritize PA. This clinical challenge was highlighted by PT11 who stated:

“I know it is important, I know it is necessary…I think that sometimes our interest. I just want to say lack of time. But that is an excuse, just focusing more on the immediate needs somebody is coming to see me for.”

The qualitative data about opportunities and challenges led to two sub-themes: 1) patient-related opportunities and challenges of prescribing PA; and 2) physical therapy-related opportunities and challenges of prescribing PA.

Patient-Related Opportunities and Challenges of Prescribing Physical Activity

The participants discussed their knowledge about the importance of performing the recommended amount of PA. They tied the importance of PA to patients’ general health and the patients’ reason for receiving physical therapy services. The importance was summarized by PT6 who stated:

“there is a large amount of research and evidence that talks about improved quality of life, decreased mortality and morbidity.”

The conversation about PA’s importance and value was followed by discussing the many challenges physical therapists face related to patients’ PA participation barriers and their knowledge and skills related to addressing the patients’ barriers. Identified patient barriers included pain, interests in PA, motivation to participate in PA, mental health, cognition, access, experience, medical history, and support systems. The impact of the patients’ barriers was mentioned by PT10, who said:

“sometimes I won’t prescribe physical activity because of the beliefs of the patient or the barriers they come up with.”

Physical Therapy-Related Opportunities and Challenges of Prescribing Physical Activity

A challenge of prescribing PA verbalized by numerous participants is prioritizing patients’ primary reason for coming to physical therapy, meaning the International Classification of Disease (ICD) code attached to the patients’ plan of care. The struggle between wanting to address the lack of PA and addressing the primary reason for coming to physical therapy is highlighted by PT11 who said:

“Physical activity is one of the secondary things that I need to get to… But it’s sometimes kind of pushed to the side, to the secondary level of importance compared to the condition that they are coming to see me for.”

Multiple physical therapists stated that part of the issue related to prioritization is the current reimbursement system, as highlighted by PT6:

“Insurance will not pay for you to spend a whole lot of time on something that’s not the primary problem.”

Due to the perception of being unable to implement PA prescriptions, many physical therapists turn to community PA programs. The value of community PA programs is mentioned by PT6 who said:

“I think one of the most important things for me for physical activity is the use of my community resources.”

However, many physical therapists felt that the availability of PA programs is lacking.

The conversations about the current barriers of prescribing PA shifted to conversations about the opportunities within the physical therapy profession. The opportunities were summarized well by PT4 who stated:

“Physical therapists have such a strong role in helping clients improve their physical activity, especially older adults… our clinical expertise are what is the top-notch of service that they should be receiving for that insight of what is appropriate physical activity.”

The discussion about opportunities to prescribe PA came with concerns about the current skills and knowledge physical therapists have regarding behavior change. This point was highlighted by PT8 who stated:

“I don’t even know if PTs have the appropriate training to really [pause] we have the training to prescribe the exercise, but do we know how to address the barriers?”

Lack of Standardization in Physical Activity Assessments and Interventions

Participants shared that part of the reasons why PA prescriptions do not occur regularly are the lack of tools and guidance. Multiple participants verbalized that they just do not have the tools or resources they need to assess and address insufficient levels of physical activity. A challenge that arises with not having appropriate tools is the lack of standardization, resulting in the inability to identify a primary method of assessing and addressing PA participation barriers. Subsequently, the participants’ verbalization related to lack of standardization led to two sub-themes: 1) informal PA assessments; and 2) informal PA interventions.

Informal Physical Activity Assessments

During the focus group, participants verbalized using the following PA assessment methods: 1) observations; 2) outcome measures such as gait speed and 6-minute walk test; 3) unvalidated questionnaires; and 4) informal conversations or subjective questions. An example of an informal conversation was described by PT3:

“I don’t have a formal way, but certainly just asking people if they are not currently participating in an exercise program of any sort. Is it part of their goals? Why do they think they cannot participate?”

Informal Physical Activity Interventions

During the focus group physical therapists indicated that they felt a lack of structure, skills, or resources to address PA. For example PT10 stated:

“I don’t have a structure of how to prescribe physical activity, how we’re going to take steps to get patients more active. I know I do it, but it’s unorganized. And that means I’m not consistent.”

The usefulness of a formal step-by-step approach was highlighted by PT2, who stated that it would be helpful to have:

“something that’s very, you know, boom, boom, boom…to help guide that conversation.”

Participants also verbalized interest in having tools that provide them with the following: 1) information about community resources; 2) easy ways to assess metabolic equivalent (MET) levels of activities; 3) individualized PA programs that would be based on clinical outcome measures, such as gait speed and 6-minute walk test, and patients’ needs and interests; and 4) a feasible method of monitoring patients’ PA levels and progress towards goals. Several physical therapists verbalized the interest in having the material in a mobile application format. All focus groups agreed that having an algorithm or step-by-step guide for addressing PA among patients 50 years and older would be beneficial.

Implementation Potential for Innovative Solutions that Address the Current Informal Physical Activity Assessments and Interventions

A vital component of addressing the PA prescription gap includes implementing innovative solutions that are appropriate, acceptable, feasible, and adoptable (Baumann, Morshed, Tabak, and Proctor, 2018; Bowen et al., 2009; Proctor et al., 2011). We defined an appropriate solution as a solution that is perceived to be relevant and fits into current practice standards (Bowen et al., 2009). An acceptable solution is a suitable, satisfying, and attractive solution (Bowen et al., 2009). Solutions are perceived as feasible if they can be used in the clinic (Bowen et al., 2009). An adoptable solution is one that will be used (Bowen et al., 2009).

Appropriate

Participants indicated that the IPAB would provide them with a systematic and comprehensive method for asking about patient PA participation barriers. The IPAB’s appropriateness was highlighted by PT11 who stated:

“I like it a lot. I think it hit on probably the most common things I’ve come across.”

Participants also felt that having a PA toolkit that provides step-by-step guidance would be appropriate, particularly for students, newly licensed physical therapists, or those who do not have much experience prescribing PA. In addition to being appropriate within the physical therapy profession, participants also felt that these tools could promote an interprofessional approach that addresses patients’ lack of PA. The appropriateness of an interprofessional approach was emphasized by PT21 who stated:

“I love the idea to give it to primary care and then have an algorithm to figure out where they need to go to, whether it could be silver sneakers or a physical therapist.”

Participants also felt that it would be appropriate to have both the IPAB and PA toolkit in an interactive format were patients and healthcare providers could communicate using a phone application or an online platform. The participants envisioned that within the interactive format, healthcare providers would see the patients’ real-time PA data and determine if individualized PA intervention may be needed. The value of an interactive IPAB and PA toolkit was mentioned by PT3 who stated:

“I love an algorithm. I think that would be cool. I think it would be cool for this interactive tool to be for both the clinician and the patient.”

Acceptable

Participants identified that they were satisfied and attracted to both the IPAB and the concept of a PA toolkit. The participating physical therapists felt that both tools are needed and would improve discharge planning. Participants also had multiple recommendations for improving the IPAB and PA toolkits acceptability, including: 1) validating the IPAB; 2) categorizing the IPAB items into smaller factors or sub-scales; 3) ensuring patients can complete the IPAB on their own time; and 4) having it link to an electronic health record. Per PT 15:

“I like the idea they can take it home and do it in their own time…and I like the category idea, like if it’s an environment issue versus maybe a personal choice or priorities, maybe we can just categorize them.”

The acceptability of linking it to an electronic health record was highlighted by PT22 who said:

“I also would love an app version that can be sent or be in the waiting room or be via a link to a website where people will answer those questions and then the top reasons for not performing physical activity just auto-populate into an electronic health record.”

Feasible

The feasibility of using the IPAB in the clinic had heterogeneous responses. Some worried that it was too long, and some felt that it was as long as other commonly administered outpatient questionnaires, such as the Disabilities of the Arm, Shoulder, and Hand (DASH). No matter what opinions participants had, each feasibility discussion ended with a statement such as the one provided by PT1:

“Unfortunately, in healthcare, if anything is going to be used, it has to be quick and simple and easy. And so I think that it was excellent, but maybe a little long.”

Another barrier that appeared to have heterogeneous responses was related to reimbursement and payment. According to PT20:

“we determine that patients are functionally improving and no longer have the complaint that they came in for and now they said that they want to become more physically active. Are payers going to pay for that? Probably not.”

Several physical therapists rebutted the reimbursement barrier by providing solutions such as describing the purpose of the PA interventions (e.g. decreasing fall risk or reducing dependence on caregivers) or tying it into current treatment approaches (e.g. patient education or therapeutic exercise).

Participants felt that feasibility would increase if PA assessment and prescriptions tools were implemented in an electronic application format. The participants felt that an application could be: 1) downloaded by patients who could complete the assessments prior to their physical therapy visit; 2) used to provide patients with basic PA education, resulting in extra time for more in-depth PA conversations in the clinic; and 3) provide physical therapists with an output of the assessment, which would increase the feasibility of assessing and addressing lack of PA.

Adoptable

Physical therapists verbalized that they would implement the tool, especially if it were validated. Many felt that the IPAB would help start a conversation about PA, such as indicated by PT13, who stated:

“You can introduce that during your treatment, like, hey, did you happen to go through any of the information that the app/questionnaire was telling you about? Let’s talk about your biggest barriers and how we can kind of try and problem solve them.”

Quantitative Data

The quantitative data was used to provide insight into the qualitative themes and triangulate the data. More specifically, the pre-focus questionnaire results presented in Table 1 provided insight into the first two themes, and the post-focus questionnaire results presented in Table 2 provided more insight into the last theme. Below we present the quantitative data relative to each qualitative theme.

Table 2.

Potential for the IPAB to be Appropriate, Acceptable, and Feasible

Item	N (%)
The IPAB meets my approval
Agree-completely agree	25 (96.1)
Neither agree/disagree	0 (0.0)
Disagree-completely disagree	1 (3.8)
The IPAB is appealing to me
Agree-completely agree	23 (88.5)
Neither agree/disagree	3 (11.5)
Disagree-completely disagree	0 (0.0)
I like the IPAB
Agree-completely agree	23 (88.50)
Neither agree/disagree	3 (11.5)
Disagree-completely disagree	0 (0.0)
I welcome the IPAB
Agree-completely agree	23 (88.5)
Neither agree/disagree	3 (11.5)
Disagree-completely disagree	0 (0.0)
The IPAB seems fitting
Agree- completely agree	23 (88.5)
Neither agree/disagree	3 (11.5)
Disagree-completely disagree	0 (0.0)
The IPAB seems suitable
Agree-completely agree	23 (88.5)
Neither agree/disagree	3 (11.5)
Disagree-completely disagree	0 (0.0)
The IPAB seems easy to use
Agree-completely agree	19 (73.1)
Neither agree/disagree	5 (19.2)
Disagree-completely disagree	2 (7.7)
The IPAB seems like a good match
Agree-completely agree	21 (80.8)
Neither agree/disagree	5 (19.2)
Disagree-completely disagree	0 (0.0)
The IPAB seems implementable
Agree-completely agree	20 (76.9)
Neither agree/disagree	3 (11.5)
Disagree-completely disagree	3 (11.5)
The IPAB seems possible
Agree-completely agree	22 (84.7)
Neither agree/disagree	3 (11.5)
Disagree-completely disagree	1 (3.8)
The IPAB seems doable
Agree-completely agree	22 (84.7)
Neither agree/disagree	3 (11.5)
Disagree-completely disagree	1 (3.8)
The IPAB seems applicable
Agree-completely agree	24 (92.3)
Neither agree/disagree	2 (7.7)
Disagree-completely disagree	0 (0.0)
I would recommend the IPAB to colleague(s)
Agree-completely agree	20 (77.0)
Neither agree/disagree	6 (23.1)
Disagree-completely disagree	0 (0.0)
Top Barriers addressed by IPAB
Lack of time	24 (92.3)
Lack of tools	16 (61.5)
Lack of guidance	15 (57.7)
Lack of knowledge	15 (57.7)
Patient’s preferences of not doing physical activity	15 (57.7)

IPAB= Inventory of Physical Activity Barriers; n=number of participants

Opportunities and Challenges Related to Physical Activity Prescriptions

The quantitative data identified that 92.3% of participants identify prescribing PA to patients 50 years and older as “very” or “extremely” important, but only 19.2% provided a prescription “a lot” or “all the time.” The top barriers to providing PA prescriptions could be a reason for this discrepancy. Among our participants, the top barriers were the physical therapists’ perception related to the patients’ preferences for not doing PA (88.5%; n=23), treatment prioritization (73.1%; n=19), lack of time (53.9%; n=14), and lack of tools (46.1%; n=12).

Lack of Standardization in Physical Activity Assessments and Interventions

According to the quantitative data, almost half (41.3%) address the lack of PA “a lot” or “all the time,” but formal or standardized PA prescriptions are only given by 19.2% of participants “a lot” or “all the time.” Thus, other methods besides providing a PA prescription are used to address lack of PA.

Implementation Potential for Innovative Solutions that Address the Current Informal Physical Activity Assessments and Interventions

As the majority (84–96%) of participants identified the IPAB as appropriate, applicable, suitable for clinical practice, and doable in day-to-day clinical practice, the IPAB’s implementation potential is supported. Furthermore, the data identified 89–96% of the participants approve and/or like the IPAB. See Table 2 for additional information.

Integration of Qualitative and Quantitative Data

The integration of qualitative and quantitative data was based on the themes discovered during the qualitative analyses. The qualitative and quantitative data confirmed and expanded on each other across the three themes. More specifically, the importance of PA prescription, challenges of PA prescription, lack of standardized interventions, and the IPAB’s implementation potential was illustrated through both the qualitative and quantitative data. For assessments of PA, our quantitative data illustrated that 65% of participants assess PA levels, yet our focus group data highlighted informal assessments that occur on irregular basis; thus, due to the ambiguity of the information provided, it is difficult to determine data confirmation or disconfirmation for this content area. See Table 3 for a joint display of data that was confirmative and expanded on each other.

Table 3.

Joint Display of Confirmatory Qualitative and Quantitative Data

	Qualitative Data	Quantitative Data
Opportunities and Challenges Related to Physical Activity Prescriptions
Importance of PA Prescription	“We’re talking about extending people’s lives and quality of their life. It’s very important.” PT12	92.3% identify prescribing PA to patients 50 years and older as “very” or “extremely” important.
Challenges of PA prescription	“I don’t feel very comfortable helping patient change their behavior and start being active. I don’t feel like I’m that successful with it and that makes it harder for me to continue doing it.” PT1	Top barriers: 1) Patient preferences for not doing PA (88.5%; n= 23); 2) Treatment prioritization (73.1%; n= 19); 3) Lack of time (53.9%; n= 14); 4) Lack of tools (46.1%; n= 12)
Lack of Standardization in Physical Activity Assessments and Interventions
Interventions	“I would maybe throw in a handout with local gyms or some activities that would be good for them, but I really do not spend time specifically going over that piece.” PT18	Formal PA prescription was provided by19.2% of participants “a lot” or “all the time.” But, 41.3% addressed the lack of PA “a lot” or “all the time.”
Implementation Potential for Innovative Solutions that Address the Current Informal Physical Activity Assessments and Interventions
Appropriate	“I think I could see a huge use for this, especially when patients are nearing the end of their course as a continuation and an adjunct.” PT16	92.3% of found the IPAB applicable; 88.5% identified it as suitable and fitting.
Acceptable	“I think your ideas are good and very much needed.”PT6	96.1% approve of the IPAB; 88.5% liked the IPAB
Feasible	“It seems very helpful. It can start a conversation, such as ‘Let’s talk about your biggest barriers…” PT21	84.7% think the IPAB is doable in clinical practice.

IPAB= Inventory of Physical Activity Barriers; n=number of participants; PA= physical activity; PT= physical therapist

DISCUSSION

Our quantitative and qualitative findings highlight the importance of our study. The quantitative data illustrates that about half of our participants perceive the lack of PA assessment and prescription tools as a PA prescription barrier. Our qualitative data expanded on this finding, elucidating lack of standardization in PA assessments and interventions as a major theme. The lack of standardized tools may explain why participants could not identify a primary method of assessing and addressing PA participation barriers, why PA assessments and prescriptions occur inconsistently, and why PA assessment and prescriptions lack organization. Fortunately compared to the other PA prescription barriers perceived by our participants (e.g. their patients’ preferences of not doing PA and lack of time) potential solutions to address lack of tools are less complex (Ellen et al., 2014).

The need for PA assessment and prescription tools was further emphasized by the participants’ statements regarding the benefits of PA assessment and prescription tools, such as providing physical therapists with guidance on how to organize their patient encounters. The participants felt that PA-related tools were particularly useful for physical therapists who lack experience promoting or prescribing PA. Participants also thought that the IPAB could help address the following PA prescription barriers: 1) lack of time; 2) lack of guidance; and 3) lack of knowledge. The need to have standardized tools and guidance is supported by Mathieson, Grande, and Luker (2019) who identified that having a method to organize and structure clinical decisions can address barriers associated with lack of time, knowledge, and skills.

Vadiveloo et al. (2020) findings further supported the use of tools to address implementation barriers. The authors findings identified that easy-to-use clinical tools integrated into electronic health records that incorporate algorithms for referrals or treatment strategies could address the lack of time barrier. The use of algorithms and the incorporation of PA assessment and prescription tools into electronic health records is supported by our participants. Our participants also recommended that the PA assessment and prescription tools have a patient-physical therapist interface, where patients can enter their data and physical therapists can provide both automatic or individualized feedback or recommendations. Therefore, we plan to incorporate PA assessment strategies into an interactive PA toolkit application that provides step-by-step guidance on addressing patients’ lack of PA. Additionally, we hope to connect this future application to electronic health records.

Another concern related to the lack of standardized tools is clinicians’ current use of PA assessment methods, including observations, unvalidated questionnaires, and informal conversations. Using these unstandardized assessment strategies can result in the following difficulties: 1) justifying clinical-decision making; 2) identifying the need to address insufficient levels of PA; 3) writing measurable and specific goals; 4) identifying if the PA promotion or prescription assisted the patient with increasing their PA levels; 5) identifying the need for alternative solutions to address insufficient levels of PA; and 6) documenting the need for a PA-related plan of care (Copeland, 2009; Jette et al., 2009; Lyman and Hidaka, 2016; Michener, 2011). Furthermore, patient-reported outcome measures, such as the IPAB, captures the patients’ opinion regarding what impacts their ability to participate in PA, an important component of “patient-centered” outcomes (Kyte et al., 2015).

Recently we developed the IPAB as a potential solution to help address this lack of standardized PA assessment tools (Wingood, Gell, Peters, and Hutchins, 2021; Wingood et al., 2021). Before implementing the IPAB, it is essential to explore implementation potential by examining the tool administrators’ perceptions (Bowen et al., 2009; Proctor et al., 2011). According to the participants in the current study, the IPAB is appropriate, needed, acceptable, feasible, and adoptable. The participants’ primary concern about the IPAB was regarding its length which at the time of the focus group was 40 items (Wingood, Wingood, Gell, Peters, and Hutchins, 2021). Concerns regarding lack of time and burdening patients with too many questions led to the decision to decrease the number of items on the IPAB. Using a validation study that incorporated factor analyses, we identified eight factors or categories and have decreased the 40-item IPAB to 27 items (Wingood et al., 2021). In addition to examining implementation potential, we gathered feedback regarding: 1) how the IPAB can be further improved to address PA prescription barriers; and 2) what tools or resources would be beneficial to support physical therapists with assessing and prescribing PA and thus should be incorporated into the PA toolkit. Participants had no direct feedback on the IPAB but did regarding a PA toolkit. Participants recommended that the PA toolkit include additional methodologies or guidance on monitoring patient PA levels and utilizing community programs, other healthcare providers, or exercise experts. These recommendations can be applied to future implementation studies that aim to address PA assessment and prescription barriers among physical therapists (Saldana, 2014).

The findings from this study are encouraging regarding the implementation potential of the IPAB and clinician interest in a PA toolkit. The implementation potential can be further improved by incorporating feedback provided by the participants of this study. This feedback may also help develop other tools or toolkits that address current clinical gaps. For example our participants highlighted the importance of integrating tools and toolkits into electronic health records. However, before these results are used to develop, refine, or implement tools or toolkits, study limitations must be considered. The primary limitation is that this study is a pre-implementation study wherein the participants did not have the opportunity to implement the IPAB in clinical practice. Additionally, the participants only theorized the potential use of a PA toolkit as it has not been developed. Thus, they may not have considered the day-to-day barriers that physical therapists may encounter when implementing the IPAB or PA toolkit in daily practice. A methodological study limitation is related to the size of the third focus group (i.e. participants self-identifying as prescribing PA “rarely” or “never”). Initially eight people agreed to participate in the online focus group yet only two participants showed up despite reminder e-mails. Another study limitation is that the focus group approach may have biased participants based on peer statements related to the tools’ appropriateness, acceptability, feasibility, and adoption. Therefore, further exploration via an implementation study is necessary to examine the potential impact of tools, such as the IPAB.

CONCLUSION

Our findings highlight the value of developing and implementing PA assessment and intervention tools such as the IPAB. These tools may provide physical therapists with a method to organize and structure clinical decisions. Therefore, we hypothesize that PA assessment and prescription tools can address barriers associated with lack of time, knowledge, and skills. Further exploration via an implementation study is necessary to examine the potential impact of tools, such as the IPAB, that address PA assessment and prescription barriers.