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Physical activity promotion in physiotherapy practice: a systematic scoping review of a decade of literature
  1. Anna Lowe1,
  2. Melanie Gee2,
  3. Sionnadh McLean3,
  4. Chris Littlewood4,5,
  5. Carolyn Lindsay3,
  6. Simon Everett6
  1. 1Sheffield Hallam University, Sheffield, UK
  2. 2Centre for Health and Social Care Research, Sheffield Hallam University, Sheffield, UK
  3. 3Health and Wellbeing, Sheffield Hallam University, Sheffield, UK
  4. 4School of Health and Related Research, University of Sheffield, Sheffield, UK
  5. 5Research Institute for Primary Care & Health Sciences, Keele University, Staffordshire, UK
  6. 6Physiotherapy Department, Nottinghamshire Healthcare NHS Foundation Trust, Sheffield, UK
  1. Correspondence to Anna Lowe, Sheffield Hallam University, Sheffield S10-2BP, UK; a.lowe{at}shu.ac.uk

Abstract

Background The health benefits of physical activity (PA) have been extensively documented. Globally PA levels are low with only a small proportion of the population reaching recommended levels. Insufficient PA is seen as a major public health problem with high cost to society. Physiotherapists work with people to manage long-term conditions and are well placed to deliver individual interventions to increase PA. Despite this, little is known about the evidence that exists in this field.

Methods This scoping review comprises a comprehensive search of key databases using predetermined search terms. This is supplemented with a parallel search that incorporated novel social media strands. In line with current guidance, a robust screening process took place using agreed inclusion and exclusion criteria.

Results 31 studies met the inclusion criteria. The number of studies published annually increased over the decade. Ireland and USA yielded the largest number of publications with only 1 study from the UK. The target populations included physiotherapists and service users from a range of clinical populations. The studies were mainly quantitative and observational in design with a predominance of studies that scoped attitudes, perceptions, barriers and current practice.

Conclusions This reconnaissance has shown the state of the evidence to be sparse and disparate. However, the sharp rise in published work in recent years is encouraging. The predominance of scoping studies and the clear social, economic and political drivers for change in this area highlights a need for more pragmatic, interventional studies that can inform clinical practice.

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Background

The positive effects of physical activity (PA) on physical and mental health,1 ,2 health-related quality of life,3 and healthy ageing4 have been extensively documented. Many of the leading causes of ill health could be prevented if more inactive people were to become active.5

Insufficient PA is seen as a major public health problem, which puts a high demand on society due to the high costs it generates.1 In developed countries physical inactivity (PI) accounts for 1.5–3.0% of total direct healthcare costs.6 In the UK in 2006–2007, PI cost the National Health Service (NHS) an estimated £0.9 billion.7

PA is described as any body movement produced by the skeletal muscles that results in a substantial increase over resting energy expenditure.8 PI is described as doing no or very little PA at work, at home, for transport or during discretionary time and not reaching PA guidelines deemed necessary to benefit public health.9

In 2010, the WHO published global recommendations on PA for health.5 These were followed, in 2011, by UK guidelines for participation in PA across the life course.10 Despite the well-reported health and economic benefits of PA, levels of participation are low. Globally in 2010, around 23% of adults aged 18+ years were insufficiently physically active.5 In the UK, fewer than 40% of men and fewer than 30% of women met the recommended PA guidelines across England, Scotland, Wales and Northern Ireland.11

In order to increase PA worldwide, it has been identified that a systems approach is required that focuses on populations and the complex interactions among the correlates of PI, rather than solely on a behavioural science approach focusing on individuals.12

Healthcare is part of this system and within healthcare there is a need for organisational, environmental and individual approaches promoting PA. Current UK guidance recommends that behaviour change is promoted by all health and social care professionals who have contact with the general public.13 It has been identified that opportunities exist to promote the benefits of healthy lifestyles (including increasing PA) through routine contacts that people have with health services, by engaging individuals in conversations which support them in the steps they wish to take towards a healthier lifestyle.14

However, despite these aspirations, it has been suggested that there is little evidence that PA is being comprehensively promoted in healthcare settings.15 The barriers to increasing health promotion and preventative care in healthcare settings are consistent across professional groups and include lack of time, perceived lack of knowledge, lack of confidence and lack of organisational support.16–18

It has been suggested that physiotherapists have a professional and ethical responsibility to ensure that health promotion opportunities are maximally exploited.19 ,20 The opportunities are significant with physiotherapy outpatient contacts numbering three million in 2012 in the UK alone.21 However, little is known about the extent to which physiotherapists embed PA promotion in routine/usual care. This type of PA promotion has been termed ‘non-treatment’ PA promotion, highlighting that PA is unlikely to be the main focus of the contact but acknowledging that the contact represents an opportunity for PA behaviour change.22

To date, published reviews in this field have focussed on:

  1. Programmes commissioned with the primary aim of increasing PA (as opposed to integration of PA promotion into existing healthcare infrastructure). Orrow et al23 concluded that promotion of PA to sedentary adults recruited in primary care significantly increased self-reported PA levels at 12 months.

  2. Other healthcare professionals. A recent global review of PA counselling in primary care included studies involving physicians, counsellors, exercise professionals, health visitors, nurses, activity coaches; none of the included studies involved physiotherapists.24

  3. Broader prevention themes of which PA is a subtheme. In a narrative synthesis of the literature related to allied health professionals (including physiotherapy) and health promotion, Needles et al25 concluded that interventions were focused on individuals with identified ‘target’ pre-existing conditions rather than approaches that identify risk factors. In 2012, Frerichs et al26 published a systematic review of the literature exploring whether physical therapists can effectively counsel patients for lifestyle-related health conditions, the seven studies included the provision of additional PA interventions as well as PA promotion integrated into usual practice. The authors concluded that health counselling delivered by a physical therapist has the potential to be effective, at least in the short term. Finally Taukobong et al27 performed a systematic review of the literature related to health promotion and physiotherapy (of which PA was a component) identifying a lack of PA promotion in the educational literature.

To summarise, despite the compelling rationale for promoting PA and the opportunities that physiotherapy practice presents, little is known about the extent to which PI is addressed in current physiotherapy practice.

The overarching aim of the review is to identify and map literature related to PA promotion in physiotherapy practice. Specific aims were to:

  1. Ascertain the extent of the literature that explicitly relates to PA promotion in physiotherapy practice.

  2. Explore the key characteristics of the body of evidence.

Methods

Design

This review uses the scoping review design described by Peters et al28 and is further informed by additional relevant guidance.29–31 Scoping reviews are indicated when the nature and extent of the available evidence is unknown and they have been increasingly used in response to demand for effective and timely summaries of primary research.28

Search methods

The search strategy was developed by principle investigator (AL) and information scientist (MG).

The strategy was deliberately narrow, with the aim of retrieving articles that explicitly mention physiotherapy and PA (and synonymous terms) in the title or abstract. Appropriate search terms were identified from relevant literature known to the author and from exploring the National Library of Medicine Medical Subject Headings. See table 1 for the search parameters.

Table 1

Search parameters

Table 2

Summary of included studies (full details of data extraction can be seen in online supplementary table 3)

The search was carried out in December 2015 and the database date parameters were set from 2005 to 2015. Search terms were combined using Boolean logic and used to perform searches of key databases (MEDLINE, CINAHL complete, PsychINFO, Web of Science, Cochrane Central Register for Controlled Trials, Applied Social Sciences Index and Abstracts (ASSIA)).

A parallel search was also carried out, this included using key search terms in Google; the top 100 results were scanned for relevance. The allied health professions research network CHAIN was used to circulate a request for information and an abbreviated message was circulated on Twitter. The reference lists of included articles were checked, publications of particular relevance were hand searched and publication lists of key authors were manually checked for relevant articles.

Screening

The references from the above search strands were imported into Refworks reference management software and all duplicates were removed. AL read all the titles and excluded overtly irrelevant articles. All three reviewers then conducted a small pilot test of the inclusion/exclusion criteria; this was an iterative process that required several amendments before an agreement was reached. All potentially eligible abstracts were then reviewed independently by CL and SE who applied the inclusion/exclusion criteria, AL arbitrated in the event of disagreement. In line with the aim of identifying articles explicitly relating to physiotherapy and PA screening and data extraction were from the abstracts only.

Inclusion and exclusion criteria

Studies that met the following criteria were included in the review:

  1. Studies focussed on the physiotherapy workforce (physiotherapists, assistants, students) or physiotherapy service users.

  2. Interventions were related to PA promotion in a physiotherapy context. Articles were excluded if they pertained only to specific, targeted or ‘therapeutic’ exercise.

  3. Studies were available in English; studies were excluded if the abstract was not available in English.

  4. Primary research of any design. Secondary research, including reviews were excluded but relevant studies from these reviews were included if they met the criteria. Editorials and commentaries were excluded.

  5. Published 2005 onwards. This date was chosen because it corresponds with increased global interest in PA following the adoption by WHO of the global strategy on diet, PA and health.32 It also allowed for mapping of a full decade of activity.

Search outcome

Articles that met the above criteria were included in the review. The process of identification, screening, eligibility and inclusion has been documented in accordance with PRISMA guidance and is represented in figure 1.33

Figure 1

Flow chart of the study selection process.

Quality appraisal

In line with current guidance, as this is a preliminary reconnaissance, quality appraisal was not considered necessary to achieve the aims of the study.28

Data extraction

A database in Microsoft Excel was created for data entry and management; it was developed iteratively. When consensus was reached on database design, CL and SE extracted data from all studies independently. Data were extracted from abstracts only as this was deemed sufficient to gain the required information based on the pilot exercise and with reference to other similar reviews.34 ,35

Collation and synthesis

The data extraction spreadsheets were collated by AL. All studies meeting the inclusion criteria were summarised numerically in the first instance. This included the overall number of studies, year of publication, geographical location of study, study design, aims and study populations used, which can be seen in table 3.

Results

A total of 2050 records were identified through the searches. Following the screening process, 31 records met the study inclusion criteria, these are summarised in table 2. Reasons for exclusion are listed in figure 1.

Year of publication

Figure 2 shows the results by year of publication. It demonstrates a steady increase from 2008 onwards with more than 50% (n=17) of the studies published in 2014 and 2015.

Figure 2

Year of publication of records.

Figure 3

Study type by research design.

Geographic location

Ireland and USA have produced the largest volume of the literature with five studies each per country. This is followed by Australia which yielded four studies; there were also three international studies where data collection occurred in more than one country. Only one study from the UK met the inclusion criteria.

Populations

The focus populations in the included studies were physiotherapists, students, associate/support works, service users and a number of literature-based educational studies. Several of the included studies focussed on more than one population.

The service users included in the studies were from a variety of clinical groups including musculoskeletal, older adults, stroke, general adults, cerebral palsy, and children with obesity, multiple sclerosis, autistic spectrum disorder and long-term neurological conditions.

Study design

The design of the included studies was categorised according to a research design framework by Littlewood and May.66 All included studies were primary research as per the inclusion criteria. The most frequently employed design was quantitative, observational studies, followed by mixed-methods and qualitative studies. The smallest category was quantitative interventional studies.

Focus/theme of the studies

The included studies fell broadly into five categories:

  1. Scoping of barriers, current practice, knowledge and attitudes. This included scoping of physiotherapists and/or service users (n=17).

  2. Identifying the need for PA promotion (n=1).

  3. Development or evaluation of a specific PA promotion initiative (n=2).

  4. Educational studies (n=3).

  5. PA promotion intervention (n=8).

Discussion

The key aims of this review were to identify and map the body of literature related to physiotherapy and PA promotion. To the best of our knowledge, this is the most up to date published review of existing literature that explicitly relates to PA promotion in physiotherapy practice thus providing an important springboard for discussion and research.

This study returned 31 studies globally from the previous decade; it is important to recognise that this is not a large body of the literature. This could be due to the way in which PA promotion is recorded in the research literature; it may be ‘packaged’ as part of a broader ‘health promotion’ or ‘making every contact count’ approach, for example, and may therefore not have been returned in the search. It was the intention of this research to identify articles in which there was explicit reference to physiotherapy and PA either in the title or abstract. The vast majority of studies were excluded because of a lack of specific reference to physiotherapy. It is also important to note that some studies were excluded despite having a physiotherapy and PA component. Reasons for this include (1) usual physiotherapy being compared with a non-physiotherapy PA intervention (2) PA approaches were developed with physiotherapists involved but were not explicitly labelled as physiotherapy. The above points raise questions for the physiotherapy profession about the terminology used and the visibility of PA promotion within professional practice.

The search strategy incorporated novel social media strands; although the additional strands did not yield any included studies, they highlighted a number of relevant protocols and helped develop international networks. The impact of this is hard to measure but Twitter impressions can be used as a guideline for reach within the Twitter community. Basic analytics on the original tweet show that it was retweeted 21 times and had 8388 ‘impressions’ (ie, was seen by 8388 Twitter users). This suggests that incorporation of Twitter may be a useful, cheap and accessible means of increasing the reach of a search.

The overall trend shows an increase in research outputs over time; this is consistent with the increased awareness of the impact of PI globally and the corresponding increase in focus on PA in public health policy, and consequently, as a research priority. The overall volume of the literature, however, remains small and the geographical location of the studies shows that large areas of the global physiotherapy community were not represented.

Fewer than half of the included studies focussed on service users, with most focussing on physiotherapists; this may be indicative of an immature field of research or may be a reflection of the fact that accessing healthcare professionals for research purposes can be quicker and more straightforward than accessing service users.

In terms of the aims of the included studies, over half of all included studies focussed on scoping, which may suggest that there is an appetite for development in this area and a rationale for further interventional research. Only eight interventional studies were identified, these included testing the acceptability of PA interventions62 and the effectiveness of specific physiotherapy-related PA promotion programmes.38–40 ,43 ,44 ,48 ,56 This includes examples of projects that have been developed specifically with the purpose of increasing PA in a specific population, (eg, a physiotherapy-led service for obese children56) and examples of existing physiotherapy services that have evolved to incorporate effective PA promotion interventions.43 Both are important and viable future research strands.

One notable study focussed on highlighting the need for PA promotion (and other lifestyle interventions) among physiotherapy service users by quantifying the prevalence of comorbidities among inactive musculoskeletal service users.46 This Australian study provides an important rationale for physiotherapy action in this area suggesting that:Interventions in ambulatory hospital clinics for people with musculoskeletal disorders primarily focus on their presenting musculoskeletal complaint with cursory attention given to lifestyle risk factors; including physical inactivity. This missed opportunity is likely to have both personal costs for patients and economic costs from downstream healthcare utilisation.

Only two studies described the development of physiotherapy/PA interventions and both were community partnerships.37 ,42 This highlights an important area for future research; it is essential that physiotherapy PA promotion interventions dovetail with community services and meet the needs of local populations. Without this any benefit from physiotherapy interventions is likely to be short lived.

Three studies focussed on pre-registration physiotherapy education.36 ,50 ,53 None of the educational literature focuses on postregistration education highlighting a gap concerned with the educational needs of the current workforce.

Despite the small volume of identified research, these studies add to the body of literature around barriers to change, and provide examples of physiotherapy-led PA promotion initiatives and examples whereby PA promotion is integrated into existing practice.

Physiotherapists are part of the multiagency workforce required to influence system-wide PA change. It is essential that physiotherapists recognise their potential contribution, particularly in relation to using PA as a way of reducing and managing long-term health conditions.21 Access to this growing and increasingly costly population of people with long-term conditions should be viewed as a significant health promotion opportunity. To have impact, physiotherapists need to be equipped to capitalise on these opportunities at scale. This requires recognition of PA promotion opportunities, knowledge skills and confidence to deliver PA promotion that is acceptable and effective in a PT context and robust recording and evaluation processes.

Strengths and limitations

This comprehensive and systematic scoping review followed good practice guidance and robust, clearly reported methods.

Novel, social media strands were incorporated into the search strategy to increase the reach of the search.

The aim of identifying and mapping the literature that explicitly relates to PA promotion and physiotherapy meant that the focus of the search was relatively narrow and information was extracted from titles and abstracts only.

Conclusion

This is the most up to date scoping review that identifies, collates and maps the literature on physiotherapy and PA promotion. The review shows an increasing research interest in physiotherapy and PA although it remains an immature field of research. This review highlights an appetite for engagement in this area; this should be cultivated to increase the impact on PI through individual approaches. In addition to individual approaches highlighted in this review, there is scope for physiotherapists to be involved in more systems-based approaches including promoting healthy environments, healthy workforces and creating connections with community assets. This would enable physiotherapists to promote PA on a much larger scale and thus increase their impact on PI.

What are the findings?

  • Research in the area of physiotherapy and PA promotion has increased significantly in the past few years.

  • More interventional studies are needed to understand the best way for PA promotion to be effectively integrated into practice in a way that is acceptable and effective.

  • Educational research in this field focuses on pre-registration curricula. The educational needs of the current workforce warrant further investigation.

How might it impact on clinical practice in the future?

  • Despite the guidance that physiotherapists should promote PA in routine clinical practice yet there is insufficient evidence to identify the best approaches.

  • As this field of research grows Physiotherapists should be supported to deliver PA interventions that are based on the best available evidence.

View Abstract

Footnotes

  • Twitter Follow Anna Lowe @annalowephysio

  • Contributors AL, MG, SE and CL were involved in the process as described in the manuscript. SM and CL oversaw the entire research process and ensured ethical governance as doctoral supervisors. All authors contributed to the development of the manuscript for publication.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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