Physiotherapists' role in physical activity promotion: Qualitative reflections of patients and providers.

Connecting patients with community-based recreation programs 2 carries the potential to: (a) provide effective options for individuals with disabilities to be physically active, and (b) be a valuable setting for social participation for people with disabilities. Yet, we still know little about the strategies used by therapists to connect patients with these programs (e.g., Lowe, Gee, et al., 2018 ). Furthermore, existing studies in this domain (e.g., Shannon, Legg and Pritchard-Wiart, 2021 ; Williams, Smith, and Papathomas, 2018 ) have yet to integrate perspectives from patients with disabilities. To bridge this gap in knowledge, we examined the collection of interpersonal and practical strategies used by physiotherapists to foster physically active lifestyles, through the experiences of physiotherapists as well as individuals with disabilities. The purpose for this research was to examine strategies to promote physical activity in physiotherapy, and to capture patients’ reflections on the integration of community-based programs as a resource within these strategies. We sought participation from physiotherapists along with patients to capture insights into how the presence or absence of therapist efforts to foster connections with community programs extended into patients’ lives, relative to at-home exercises and clinical activities.

We adopted critical realism as an epistemological stance that values the personal experiences and contexts of each participant. While being a form of empirical realism that accepts that there are certain stable factors contributing to reality, critical realists recognize that individuals’ experiences shape how they interpret and respond to reality ( Modell, 2009 ). One example of how we put these approaches into action was our use of triangulation to incorporate experiences of physiotherapists, as well as persons with disabilities. Applying triangulation in a critical realist analysis meant that we focused on heterogeneity in individuals’ experiences with physiotherapy and sought to explore areas of difference across participants. We also designed interview questions to focus participants toward their own stories (e.g., “Can you think back to a time during physiotherapy when…”) to prompt reflection on personal experiences in therapy. While adopting a critical realist orientation, we aligned with recent research and international frameworks that characterize inherently personal experiences of disability. In contrast to historical perspectives that defined disability according to the restrictions imposed by one’s physical function or by society, researchers and practitioners in physical activity and rehabilitation are increasingly adopting holistic models that consider the many factors that shape how disability is experienced. As one example, the World Health Organization’s International Classification of Functioning, Disability, and Health ( ICF, 2001 ) is a biopsychosocial model that recognizes the multidimensionality of the factors related to health and disability. The ICF recognizes function and disability as a part of the human condition that is composed of body structure, activity, participation, environmental factors, and personal factors – where disabilities are understood to be shaped through personal experiences and narratives ( Kostanjsek, 2011 ). Aligning with the need to recognize personal experiences, we purposefully recruited participants carrying diverse perspectives of both disability and of health promotion (i.e., therapists and patients; privately and publicly funded roles) and sought to respect unique perspectives. This orientation was also shaped by the positionality of the research team. Beyond our identities as Caucasian and as able-bodied researchers, we identify as researcher-practitioners and educators engaged directly in the profession of physiotherapy (i.e., MF and JC), as well as health psychology researchers focused on physical activity (i.e., CS and MBE). We also entered as advocates. For instance, the lead author is a doctoral-level physiotherapy student who advocates for physical activity programs and has partnered with local stakeholders to develop a community recreation program with individuals with disabilities. We therefore entered this research with a view of physiotherapists as providers with the resources to address physical activity inequities faced by individuals with disabilities. Having professional experiences in the field, we also recognized the demands that can limit therapists’ capacity to promote health. We sought individuals with physical disabilities and chronic conditions along with physiotherapists practicing in outpatient clinics in North America to describe experiences and perspectives regarding physical activity promotion. Our strategies to recruit participants included: advertisement on an online portal for clinical research participation at an academic institution, connecting with leaders of physiotherapy clinics in North America, and through snowball sampling (i.e., encouraging participants to share information about the study with others who may be interested). Potential participants were prompted to contact the lead researcher to arrange a time for an interview. Although we placed few inclusion criteria related to participation, it is important to highlight that we sought: (a) physiotherapists who identified as having actively treated patients with chronic physical disabilities in an outpatient setting (i.e., treating four or more persons with chronic disabilities or mobility impairments each month), and (b) participants with disabilities who had attended physiotherapy for treatment of their disability in the previous year. As a maximum variation strategy (Smith and Sparkes, 2014) we sought participants with experiences in several contexts (e.g., geriatric, pediatric, orthopedic, and neurological clinics) and from countries with differing health care systems (e.g., United States, primarily privately funded healthcare; Canada, primarily publicly funded health sector). Complete inclusion and exclusion criteria are provided in online supplemental materials . Physiotherapist participants included nine individuals (five female, four male; 89% White; six American and three Canadian) who were between 35 and 57 years of age ( M = 44.9 years, median = 49) and had 10 to 28 years of experience in the field ( M = 19.5 years, median = 22). The sample also included eight American individuals with a chronic condition or physical disability between 21 and 67 years old ( M = 50.5 years, median=57.5; 63% Caucasian; 50% female) who that their condition or disability impaired their mobility. Detailed descriptions of each participant are available in Tables 1 and 2 . After gaining approval from the lead author’s human research ethics committee, interview guides were piloted before beginning data collection. The lead researcher met with three physiotherapists informally for feedback on the research goals of the project and construct potential interview questions. Following this, the lead researcher conducted mock interviews with two additional physiotherapists and two individuals with disabilities – seeking feedback regarding question and interview design that ultimately produced the final interview guide. During one-on-one interview sessions, the lead researcher first reviewed the consent form and restated the nature of the project before guiding discussions with participants using a semi-structured guide. Interview guides for both physiotherapists and individuals with disabilities are available in the online supplemental materials and focused on experiences with physical activity promotion during therapy interactions – as the person promoting activity or as the patient experiencing these strategies. Participants were also directed to consider the extent to which community programming was discussed as a potential context for physical activity away from the clinical setting. Interviews nevertheless included unique questions for each stakeholder type. Interviews with therapists focused on the strategies employed when promoting physical activity (e.g., “Tell me about a time when you discussed physical activity with patients as a way to keep them active after therapy.”). Questions for those with a disability were framed to understand their experiences and the extent to which they felt their expectations were met (e.g., “In what ways, if any, did your physiotherapist educate you about how to be physically active in your daily life?”). All interviews were audio-recorded and transcribed, with interview duration lasting a maximum of 46 minutes, with an average length of 33 minutes. Thematic analysis (recently described as reflective thematic analysis; Braun and Clarke, 2019 ) was chosen because the research team was interested in constructing patterns and themes that were both shared and differing across therapists and those with disabilities. Our thematic analysis was guided by Braun and Clarke’s (2006) framework, which includes steps to familiarize oneself with the data, generate initial codes, search for themes, review and define themes, as well as producing the final report. The first author led analyses and integrated the remainder of the authorship team as critical friends throughout the analysis process. The initial three stages of familiarization were targeted throughout the interview process by memoing ( Birks, Chapman, and Francis, 2008 ) and by developing a thematic map ( Braun and Clarke, 2006 ). First, the lead author completed journal entries after completing each interview that highlighted any key insights to track similarities and differences across participants. Second, the lead researcher created whiteboard figures with preliminary themes and the anticipated associations between them. Separate figures were maintained for interviews with physiotherapists as well as those with disabilities and were subsequently compared to identify tensions across interviews with therapists and patients and to enhance reflexivity. After completing the process above with all interviews, we then defined themes. The lead researcher began by tagging interview responses with preliminary codes that reflected the meaning of a given statement or section of an interview. The lead author then distilled these codes into more substantial themes, using the preliminary themes developed in the familiarization stage as guidance. Interviews with both physiotherapists and individuals with disabilities were coded simultaneously, rather than conducting separate thematic analyses. We constructed common themes spanning all participant groups and were sensitive to cases where participants held competing or contrasting insights. The rigor of this study should be considered in light of our critical realist orientation. Indeed, even though many criteria may help inform what it means to conduct a ‘good’ qualitative investigation (see Tracy, 2010 ), the criteria related to study quality should be grounded in the context of a given investigation. Our critical realist orientation meant that it was especially important to present a description that credibly and vividly presents participants’ stories and experiences, while also producing a significant contribution to existing literature. See Table 3 for examples of how these criteria were evident in the current investigation.

Participants shared a spectrum of personal experiences that depicted both ideal perspectives toward promotion of physical activity during therapy along with experiences that challenged key assumptions about promoting activity. Therapists defined physical activity promotion in terms of three general types of activities: Efforts to explain the benefits of active lifestyles, efforts to prescribe or prompt patients to engage in certain activities or exercises inside or outside of the clinic, and efforts to encourage physical activities outside of the clinical context. These efforts to promote activity ranged from initial consultations through to the conclusion of therapy and were predominately focused upon regaining function to complete activities of daily living (as opposed to promoting wellbeing). Physiotherapists spanning several specialties (i.e., orthopedic, neurology, and pediatric) valued physical activity promotion, but noted that they had few resources to help them promote activity. Persons with disabilities interviewed were predominately an inactive sample, with three participants reporting regular physical activity behavior and ongoing involvement in community recreation programs. These participants reported similar physical activity promotion strategies as those described by therapists but also struggled to follow-through on recommendations independently once they completed therapy. We identified three themes common to each of the two groups (i.e., physiotherapists and persons with a disability). The first theme emphasizes individualization as a characteristic of optimal physical activity promotion, which was perceived as critical for adherence and as a satisfying component of therapy. Other themes build upon this goal of individualization by highlighting the challenges of therapists in actively engaging with their community (second theme) and identifying options in the community for physical activity (third theme). Therapists described individualization as the process of “meeting the patient where they are at” and developing tactics to promote activity that best suit each individual. Both therapist and patient participants described many strategies employed by therapists to individualize their treatment for patients. These strategies included listening to the patient, gaining trust, learning what the patient enjoys and incorporating it into treatment, treating the individual not the disease, educating patients about resources available to be physically active, focusing on the patients’ goals, and being flexible. This was summarized sufficiently by PT-01 who described his own personal experiences as a patient in similar situations: “You [know] as a patient, when the practitioner is actually listening and paying attention to what you’re saying and taking that into consideration […]. So, my biggest advice is to really truly listen [to the patient] and take in all that they’re telling you about their personal lives – their whole lives – and really factoring that into how you tailor their treatment plan, education and their discharge plan for continued physical activity.” PT-01 explained that therapists need to be fully invested in each patient and in identified their individual goals, to ensure patients can maintain mobility after therapy. As indicated above, one strategy to individualize the process was to center activities around each patient’s interests. The value of individualization is captured by PT-03: “One of the most important questions to me is [saying to your patient] ‘You have this problem that you are here for. But what is it interrupting in your life? What do you like to do that this is stopping you from doing?’ […] Once we find that out, then I’m sort of looking at that as: ‘Okay, this is something we want to incorporate into the program to get this person excited, and when we are trying to work physical activity into their routine we will use it as motivator.’ We have bowlers at times or, you know, golfers. I’ve had chefs. And your rehab program and way you promote activity should be geared somehow toward whatever they’re trying to get back to, as an individual.” This participant continued to explain how he leverages the patient’s interest to increase their “buy in”; using physical activity is a means to continue the other lifestyle activities they enjoy. Individualization was also valued by patients and was described as a critical contributor to experiences with both physical activity promotion and the general experience in physiotherapy. Several participants shared stories where they felt negative experiences were a result of a lack of options or a general disinterest in provided options. Most patient participants expressed only receiving a home-based exercise program with minimal encouragement to attend a local gym or program. PWD-01, used the analogy of a processing plant to describe the feeling about the lack of personalization in a clinic: “They [the therapist] treated you just like a piece of meat going through their conveyor belt or whatever, so we stopped going”. When considering individualization, several negative patient experiences were described in circumstances where they lacked autonomy and independence, evident when patients felt excluded from shaping their physical activity experiences and goals in therapy. One example of this was described by PWD-04 with an incomplete spinal cord lesion with aspirations of independently walking again. He felt that physiotherapy was discouraging because therapists’ goals were more conservative and weren’t something that he valued. To avoid negative patient experiences related to autonomy, PT-05 recommended using motivational interviewing to set attainable goals; explaining that: “[Therapists at my clinic] are not trained in motivational interviewing. But we use those techniques to try to help the patients come to reasonable goals themselves, and help them calibrate about you know, what reasonable goals are, identifying barriers, and facilitators to those goals. Then we help them come to their own conclusions about why being physically active is important to them.” This participant described how her patients were more invested in maintaining physical activity behavior when they felt autonomous and could contribute to decision-making. Despite therapists acknowledging their expertise regarding physical activity promotion and maintenance, only three mentioned community engagement beyond their clinical role. Therapists who had successfully engaged within the community explained that the additional time spent engaging with the community allowed them to give a patient more physical activity options. Physiotherapists in both the United States and Canada reported limited local community programs for people with disabilities, regardless of their country of origin, and few therapists spoke of instances where they addressed the lack of community-based programs available for their patients (e.g., creating their own program). Nevertheless, there were numerous stories of experiences being conduits to existing programs and sharing information with patients. As a further example, two physiotherapists described community outreach that they had conducted to promote awareness of physical therapy and program adaptations for individuals with disabilities. Efforts to connect patients with programs and educating existing programs were evident in the explanation by PT-07 from Canada treating patients with spinal cord injuries: “Part of my job [as a physiotherapist] is going to different community centers to learn about the opportunities [available for individuals with chronic conditions]. Luckily we have an annual wellness conference where representatives from most community recreation centers will be present.” PT-07 continued to explain that he would also lead educational seminars about physiotherapy services provided, biomechanics to avoid injury, or other health and wellness discussions: “When I see a need [for education about how to work with individuals with disabilities], I will set up a day where I will hold a training seminar to help educate staff on how to better serve the patients I am referring to their center. This way I can confidently make referrals [to the community recreation centers] knowing that my patients will likely have a more positive experience.” This therapist explained the importance of training individuals within local community programs to have a positive impact on the experiences of his former patients within the programs. He described how this minimal time investment would increase the available programs that he can confidently refer an individual to for physical activity outside of the home and clinic. One barrier to successful physical activity promotion was the lack of follow-up after therapy was completed. This issue was addressed by physiotherapists and individuals with disabilities both in Canada and the US. Whereas few therapists engaged in patient follow-up, two therapists did follow-up to make modifications to home exercise programs, as well as inform the patient of any new opportunities to be active. PT-06, who works with persons with neurological disorders, communicated with patients following the end of treatment to maintain mobility: “We look to see if there’s any changes in their mobility, increased falls and increase in the difficulty of doing activities of daily living. [We look for] any red flags. We also get to see how the options we gave patients are working, what we need to do better. Or those check-ins can be even simple things where it’s just a matter of them needing to come in and you know, have to have a tune up on their exercise program.” Those patients who had heard from their therapists following discharge explained how they had a greater motivation to stay active. PWD-05 explained how he continued to be physically active in the gym connected to the clinic where he had completed therapy. This proximity meant that he was checked on by therapists regularly: “[At my clinic, there is] a level of concern and caring that’s there, and that really means something. […] Every one of them touched my life and convinced me that they were personally invested in my long-term well-being, so I need to do my part” Physiotherapists all identified the social benefits of engaging in community recreation programs including increased self-confidence, self-esteem, and peer support. Therapists did not, however, actively refer or discuss these programs with their patients. One explanation for this was because their community lacked critical resources and recreation infrastructure to give patients a positive experience. In other words, therapists felt that the recreation centers within their communities were not suited to accommodate the needs of their patients. Emphasizing how important a patient’s experiences can be to their prolonged engagement of physical activity, PT-01 told a story of one of her previous patient who stopped participating in karate and Boy Scouts because his peers were bullying him for his disability – disengaging him from the programs to which he had access. Perceived barriers such as transportation or financial barriers were another reason that therapists were leery of promoting community programs. Eight of the nine therapists stressed home exercise programs to focus on physical activity promotion as a result, even though participants recognized the shortcomings of doing so (e.g., poor adherence to activities). Three therapists nevertheless did provide examples of discussing available programs with patients. Furthermore, one therapist described introducing patients to activities within the clinical setting that could be accessed in the community – activities that were already delivered by community programs, and that could be adapted even if there were no existing adapted programs in place (e.g. dance, yoga, and karate). Another therapist emphasized the importance of creating long-term physical activity options within the clinic through programs where former patients continue coming to the clinic to exercise independently using equipment for a minimal fee. Although participants with disabilities described similar limitations to the link to programs in the clinical setting, three patients described having shared opportunities to join groups within the community through referral from their therapist. These participants described the positive impact that peer mentorship experienced in programs had on their ability to be physically active, one even becoming an advocate for individuals with disabilities in his community. PWD-04 detailed how he relied on an adaptive kayaking group for veterans for social and financial support: “It has really helped me even though I am not a veteran. It’s kind of like a support group when we go. We tell our story and help each other with issues and listen to each other. […] It also helped me learn of grants [for sport equipment]. People start talking and just tell us that we can get grants for certain things like they have for adaptive bicycles, for adaptive golf equipment, and all-terrain wheelchairs for outdoor activities.” In this case, the individual’s therapist connected him with a local kayaking group for veterans with disabilities after hearing about what interested the participant. Even though he had never served in the military, the therapist put him in contact with the group because they were one of the only groups in his area working with individuals with disabilities. The participant explained that he was readily accepted into the group and how the group donated a kayak to him, in addition to educating him about ways to get additional funding for equipment. Although other participants described involvement in community programs, this was nevertheless the only participant who shared this experience as being prompted by therapy experiences. Seven therapists stressed the need to become more creative regarding the ways in which physical activity is prescribed to patients and how barriers are addressed. One strategy to overcome the lack of community programs was to plan physiotherapy activities to be implemented out-of-clinic. Another recommendation was to use activity-tracking devices (e.g., Fitbits) to construct friendly competitions between patients. Finally, another therapist described integrating university students and interns, whose role was to provide assistance at patients’ homes or local gyms following therapy. Whereas the core themes were informed by responses from both therapists and patients, we also identified cases where stories diverged when comparing those told within each participant group (i.e., physiotherapists’ stories compared to persons with disabilities). One tension underpinned the main justification for physical activity promotion within physiotherapy. All persons with disabilities perceived their therapist’s role as an expert in physical activity who could help them integrate physical activity into their lives to the extent that it had been prior to their disability or condition. Whereas four therapists held a similar view, the prevailing perspective shared by the other five therapists was more constrained to therapeutic goals of reducing pain, regaining range of motion, and optimizing mobility. PT-05 reflected on therapeutic goals when indicating that they often prioritized health promotion because of their resource limitations: “It is not always practical to spend a large amount of time focused on [integrating physical activity into patients’ daily lives] when insurance only covers physical therapy for so long. You have so much else to do like getting range of motion back, reducing pain, and other therapeutic goals that directly relate back to what [physiotherapists] are assessed on now.” This tension describes the challenge faced by physiotherapists when balancing their resources as well as the core indices upon which they are judged. Another tension involved the extent to which strategies were individualized and embedded in the community. This tension was evident particularly in relation to home-based individual exercise programs. Whereas seven of the nine therapists described independent home exercise programs as a strategy to individualize physical activity prescriptions, six of the eight participants with disabilities felt unengaged with the home programs that were provided to them. PWD-07 described how a therapist had prescribed a home exercise program to him using generic handouts given to every patient with his condition: “The home exercises that they gave me were a copied list of exercises that everyone with lower back pain got. [The handout] was titled “Lower back pain HEP”. I am assuming that everyone that said they had low back pain got this, so no they did not individualize it. […] They did not give me anything I liked to do.” A third tension related to perspectives of barriers to physical activity promotion. Six of the nine therapists explained that they commonly did not promote community recreation and sports programs due to transportation and financial barriers they perceived their patients to have. In contrast, patients expressed that they failed to be active due to a lack of interest in physical activity options provided and three patient participants felt that their therapists’ lack of knowledge limited their ability to be active. This was brought to light in the experiences of one person who described being told by his therapist that few programs were suited for him within his region – out of frustration, he personally reached out to local community centers and located several interesting local recreation options. Compared to contrasts between patient and therapist interviews, the international sample provided a chance to contrast responses from therapists in the United States and Canada. Whereas themes were shared by participants in each context, one difference related to time available with patients – which dictated the degree to which outside physical activity programs were relied upon. Physiotherapists working with clients relying on the public sector in the Canadian context described seeing patients (at most) one-time per week following discharge from the hospital. Those working with patients who held private insurance in Canada and the United States, in contrast, saw patients two to three times per week once discharged to the community. By virtue of their limited access to participants, therapists within the public sector describe a larger responsibility on the patient to be active as well as the therapist to individualize a program. That is, patients in the community are more self-reliant with resources in the community to be active. Therapists who saw their patients less frequently focused on how the success of their activity promotion efforts were constrained by patients’ willingness and interest in physical activity. PT-08 was a specific participant who had worked in both the public and private healthcare sectors in Canada and reflected on the need to leverage community-based programs: “[Community recreation programs] are definitely more relied upon in the public health sector because I maybe see someone one time a week. But it can be hard to find options interesting to the patient because of the additional barriers.” Several of the additional barriers that she described included how programs in the community lacked adaptable equipment or staff that were trained to properly assist patients with disabilities.

The purpose of this study was to explore experiences with physical activity promotion within physiotherapy, with a focus on integration of community-based recreation programs. Our study examined strategies to promote physical activity in therapy, taking a broader perspective to examine promotion to patients with any physical disability with an interest in community-based programs. Participants provided insights regarding the value of individualized programs with a variety of options to promote physical activity in physiotherapy. This study also showcased the importance of patient autonomy and described the opportunities for participants to have optimal experiences (e.g., peer mentorship) when connected with the ‘right’ community programs. Whereas physiotherapists and patients did describe efforts to integrate community programming through strategies such as referring patients to programs, patient participants shared negative experiences with referrals and described how health promotion rarely involved learning about community recreation programs. We reflect on how these findings align with existing research and implications for how applied health providers can contribute to physical activity promotion. This research built from previous qualitative research that revealed tensions between (a) physiotherapists’ recognition of possessing a role within physical activity promotion, alongside (b) limited integration strategies within therapy to promote lifelong physical activity (e.g., Shannon, Legg, and Pritchard, 2021 ; Williams, Smith, and Papathomas 2018 ). Participants’ attitudes also aligned closely with quantitative evidence that activities like exercise prescription are within the scope of practice for physiotherapists ( Lowe et al., 2017 ) and are an important topic in education ( Bodner et al., 2013 ). When reflecting on connections with community programs, however, participants also reported barriers that resemble past interview-based studies with physiotherapists within neurological rehabilitation ( Williams Smith, and Papathomas, 2018 ) and pediatric settings ( Shannon et al., 2021 ). Barriers to implementation also resemble those from survey studies reporting that physiotherapists infrequently use strategies to enable lifestyle physical activity (e.g., identifying sources of support for patients; Lowe et al., 2017 ). This represents a disconnect between the education and positive attitudes of therapists toward roles in health promotion, against narrowed roles that therapists may adopt within the clinic and community. Therapist and patient stories differed regarding how they interpreted the outcomes of physical activity promotion. Whereas some physiotherapists focused on how they can help participants gain mobility and function throughout therapy and physical activity, patient participants talked about physical activity after therapy in relation to their quality of life. Participants’ perspective of physical activity with a disability adopted a holistic lens relating to their sense of self and their perception of autonomy in focusing therapy and movement activities toward goals that held meaning for them. These findings align with commentary leveraging models like the ICF to prioritize patient-centered tools within rehabilitation settings ( Harty, Griesel, and VanderMerwe, 2011 ). Whereas patients who participated in this study rarely encountered this holistic approach in their treatment during therapy, the current research also uncovered powerful stories about experiences in community programs. This was evident when participants described how they sought community programs as support groups. Indeed, it is well established that the relationships formed in support groups for individuals with mobility-impairing conditions like spinal cord injury, stroke, and chronic pain can produce peer mentorship experiences that enhance recovery time, emotional states, and functional motor skill development ( Chemtob, et al., 2018 ; Glass, Matchar, Belyea, and Feussner, 1993 ; Subramaniam, Stewart, and Smith, 1999 ). Shirazipour and Latimer-Cheung (2020) recently described how rehabilitation is leveraged to promote long-term physical activity engagement in parasport within a group of disabled veterans. In their study Shirazipour and Latimer-Cheung (2020) showcased how group therapy is used to provide support to patients as they build a sense of belongingness, later progressing into more long-term parasport opportunities that allowed them to engage in a challenging environment. The current findings integrated participants from both the United States and Canada and therefore provided opportunities to contrast experiences across countries that adopt unique healthcare models. Whereas Canada employs a healthcare model that is both regulated and funded by the public purse, the United States’ medical system involves a combination of sources of funding and regulation (e.g., privately funded insurance alongside government health programs) and 68% of the population is supported through private insurance through employers ( Cacace and Schmid, 2008 ). We identified commonalities across these contexts. American and Canadian physiotherapists both perceived limited access to programs in the community. Even when programming was available, they perceived that these programs were costly and challenging to attend through accessible transportation. This finding highlights how barriers may often extend past the national healthcare environment or relevant policies and instead emerge in relation to features of clinical environments and the regional community. The current study nevertheless identified one key tension across international settings involving a distinction between public and private healthcare. We observed that physiotherapists from publicly funded contexts in Canada felt that it was part of their role to engage directly with community-based programs and to work with patients to plan meaningful physical activity into their daily routine. This was not expressed by their American physiotherapist counterparts. We anticipate that this difference might be explained by the relatively limited time that patients spend ‘in clinic’ in publicly funded environments – making community programs a more coveted resource. This contrast is not inherently a ‘national’ level issue, because: (a) this experience was not shared with Canadian physiotherapists in private settings, and (b) physiotherapists in the US may also work within comparable settings that are institutional or public settings (e.g., Veteran’s Affairs; see Morey et al., 2018 ). Nevertheless, this contrast across healthcare sectors reveals how the distribution of resources to which therapists have access can shape the necessity to engage with the recreation community. These unanticipated findings when contrasting public and private settings raise questions related to advocacy in rehabilitation: what degree of community engagement falls within one’s scope of practice, and should this differ between public and private contexts? This is a difficult question to answer when considering that these findings emerged when contrasting distinct healthcare systems. For instance, insights from participants in this study may not represent those of practitioners and patients in all settings across each healthcare system. Smith (2018) clarified this challenge when describing how sampling approaches and epistemological stances mean that probabilistic generalizability is ill-suited to qualitative research. Smith (2018) nevertheless describes how qualitative studies may generalize in other ways, such as through transferability (i.e., do physiotherapists see these findings applying to their own context?), naturalistic generalizability (i.e., do the findings resonate with patients?), or analytical generalizability (i.e., can we contrast these findings against policy or theory?). Therefore, these findings could transfer toward policy or practice uniquely in each healthcare context. Therapists in publicly funded contexts relied on community programs and shared experiences regarding lack of resources or recognition for these efforts. It might therefore be crucial to consider resources available for therapists in publicly funded systems, along with how scope of practice and assessment in these settings might account for this role. Transferring these findings into privately funded settings or others with greater intensity and duration of patient contact, it may be crucial to examine pathways toward the inclusion of community-based programs throughout the course of therapy (e.g., physical activity and peer support programs). For clinicians, this research carries practical implications related to: (a) pathways for fostering a link between physiotherapy and community programming, and (b) commentary relating to scope of practice and professional identity. Regarding links in the community, practitioners can learn from physiotherapist participants’ stories about conducting outreach with community programs to share information about working with participants who have mobility impairments. Therapists can use some tactics described by participants in this study like creating wellness programs within their clinics or educating pre-existing community programs. Some potential strategies might even fall farther from traditional scopes of practice, such as creating online support groups, pursuing financial support for programs (e.g., seeking recreational grants), leading educational initiatives around adaptive physical activity, or advocating for recreation resources (e.g., advocating for accessible transportation). The examples of patients finding social support through their physical activity groups within this study also highlights the broader rehabilitative goals of physiotherapy. By promoting community programming, therapists might be able to address the need to promote physical activity alongside holistic goals for patients to access social support and participate in the community. The findings also carry implications for policymakers, educators, and researchers. This discussion around community programs underpins ongoing commentary pertaining to the historical and current scope of practice for physiotherapists as well as the professional identities fostered around roles within patients’ lives. The increasing body of evidence around patient experience and emergence of patient-centered practices (i.e., ICF model) have led to calls for physiotherapists to (re)evaluate their role around physical activity (e.g., Lowe, Gee, et al., 2018 ). The National Physiotherapy Advisory Group in Canada, for instance, have also more generally called for therapists to be leaders and advocates for patients. Results from the current interviews nevertheless seem to communicate that these shifts have outpaced some education and development of therapists. Therapists who develop skills and identities focused on their role intervening with individual patients in the context of a clinic are faced with ambiguity when learning how to adopt roles advocating for broader societal changes to address physical inactivity. As such, the current study reveals a need for policymakers, educators, and researchers to question how dominant approaches to physiotherapy fit alongside emerging approaches and potential tools to engage communities. Limitations of the study are important to acknowledge. One limitation focuses on potential strategies to enrich the descriptions of participants. Our interviews were conducted with therapist and patient participants outside of the clinical setting, meaning that we did not have any ‘matched pairs’. The true spirit of triangulation within a given context would emerge to a greater extent through future interviews that capture experiences from both individuals in the same therapeutic relationship, while also being conducted in a clinical setting and involving observation of therapy sessions. Along with a lack of Canadian patient perspectives within the studying the patient group, a further limitation relates to our capacity to understand successful pathways (i.e., way by which an individual is introduced to community-based recreation programs) from physiotherapy into community-based recreation due to the limited number of patients that engaged in community programs. This is perhaps a pattern that extends to therapy more generally for individuals with disabilities, and fails to unpack individual experiences that ‘mastered’ the jump from therapy to lifelong physical activity. This study’s limited capacity to explore pathways from physiotherapy into community programs is the most critical next step in future research. Past research has identified physiotherapy as a viable pathway into community sport and has revealed how therapists recognize the importance of community physical activity programs specifically related to pediatric patients (e.g., Shirazipour and Latimer-Cheung, 2020 ; Shannon et al., 2021 ). Researchers need to further investigate the role that community-based recreation programs can play within physiotherapy practice to promote physical activity and how physiotherapists can play an active role in increasing the access patients have to access these programs. To do so, research should be done to further integrate patient perspectives when considering physical activity promotion and identify interventions or tools for therapists to integrate existing community programming to effective promotion of active movement for patients with chronic disabilities. Researchers should also investigate how therapists can adopt a more direct role in advocacy and leadership through community engagement.

Numerous existing studies have documented the strategies that physiotherapists use to emphasize the value of physical activity among patients and, when appropriate, prescribe moderate exercise ( Lowe, Gee, et al., 2018 ; Lowe, Littlewood, and McLean, 2018 ; Shirley, Van Der Ploeg, and Bauman, 2010 ; Williams, Smith, and Papathomas 2018 ). Research reflecting on the health-promoting roles of physiotherapists has focused on therapists’ perceptions of their roles, patient education, self-efficacy, and attitudes toward physical activity and has demonstrated a tendency for positive attitudes toward activity and an acceptance of this role ( Fleig, Lippke, Pomp and Schwarzer, 2011 ; Taal, Rasker, Seydel, Wiegman, 1993 ). A consistent observation from this literature focused on those who deliver therapy to people with physical disabilities is that physiotherapists tend to value their physical activity promotion role while experiencing ambiguity in recognizing precisely what their role is or how they can practically enable physical activity (e.g., Ma et al., 2020 ; Williams, Smith, and Papathomas 2018 ). Compared to physical activity promotion or exercise prescription outlined above, physiotherapists may also directly link patients with programs that deliver opportunities for physical activity in community contexts, or directly develop a professional role supporting current programs in the community. This more ‘active’ role blends the role of physiotherapists as leaders in health promotion and as advocates as embodied in the guidelines and policies of major organizations like the APTA and National Physiotherapy Advisory Group (ATPA House of Delegates, 2019; National Physiotherapy Advisory Group, 2017 ). Preliminary evidence regarding this role has indicated that a relative minority of physiotherapists regularly engage in tactics to connect patients with sources of physical activity that would continue following therapy ( Lowe, Gee, et al., 2018 ). Shannon, Legg and Pritchard-Wiart (2021) invited physiotherapists who work with pediatric patients in the United States to complete an online survey ( n = 116) as well as a focus group interview ( n = 10) examining beliefs about community-based physical activity programs. Whereas 69% of those surveyed by Shannon and colleagues (2021) recognized that promotion of community programs was one of their primary roles, few therapists reported integrating links to community programs into their practices; ascribing this limited integration to their own barriers (e.g., low knowledge of community programs; little time with patients) and barriers faced by patients (e.g., costly programs; poor staff training in community programs). Researchers have nevertheless documented physiotherapists’ efforts to promote community programs to patients with disabilities. Some therapists interviewed by Williams, Smith and Papathomas (2018) reported strategies to promote community programs, including: (a) encouraging patients to attend available physical activity programs outside of structured sessions, (b) prescribing independent exercise programs, or (c) sharing knowledge about specific programs that may suit patients’ interests. Also as documented by Shannon and colleagues (2021) , one therapist created their own dance class for patients and several other therapists described taking their patients out of the clinic to visit community centers. The role of physiotherapy as a ‘pathway’ into community programs is especially well-established in research examining the experiences of military veterans where rehabilitation is often closely bound to recreational and competitive parasport programs that deliver opportunities for social participation and physical activity. For instance, Shirazipour and Latimer-Cheung (2020) identified physiotherapy as a primary pathway through which military veterans discovered community sport – including programs that are adaptive (i.e., organized for individuals with disabilities), along with existing programs that are not explicitly adaptive are nevertheless inclusive of individuals with varying abilities.