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Background: Two randomized trials comparing longstanding personalized, active exercise therapy delivered by trained physiotherapists to usual care in people with Rheumatoid arthritis (RA) and Axial Spondyloarthritis (axSpA) with severe functional limitations demonstrated its significant effects on physical function and quality of life after 12 months [1, 2]. Although implementation on the national level was endorsed by the responsible national healthcare organizations, implementing this intervention into routine practice is likely to be challenging. Identifying the factors influencing implementation is crucial for the development of a tailored implementations strategy that will ensure sustained accessibility and accurate delivery of the intervention.
Objectives: To identify key facilitators and barriers for the national implementation of longstanding, personalized exercise therapy for people with RA and axSpA with severe functional limitations.
Methods: Between December 2023 and June 2024, a qualitative study using 18 semi-structured, in-depth interviews was employed. As the implementation involves multiple levels, from individual patients and healthcare providers to organizational structures and the broader healthcare system, key informants playing a role in the referral, the eligibility assessment, the delivery of the intervention, training and registration of providers and/or reimbursement were invited to participate (6 people with RA/axSpA, 5 rheumatologists, 5 exercise/physiotherapists, and 2 health insurers). Recruitment was done through the national organizations representing the various stakeholders. The Consolidated Framework for Implementation Research (CFIR) informed the development of the interview topic guide, coding, and data analysis [ref]. The topic guide included open-ended questions and was pilot-tested. All interviews were done by one of the researchers (AI). The transcribed audio recordings were manually coded and findings were categorized according to three key phases in healthcare delivery: referral to exercise therapy services, assessment of patient eligibility, and the provision and participation/adherence to treatment. Transcripts were analyzed by two researchers (AI, AN) using Atlas.ti. Three independent researchers (AI, LvB, AN) reflected upon, compared, and discussed the coding framework.
Results: For the referral to longstanding, personalized, active exercise therapy we identified the following facilitators: strong communication and collaboration between healthcare providers and patients, ensuring clear explanations of benefits, eligibility criteria, and addressing concerns about longstanding exercise therapy. The identified barriers included: unclear eligibility criteria, limited knowledge about the effectiveness of the longstanding exercise therapy, lack of awareness where to locate qualified therapists, and time constraints during patient consults. For the patient eligibility assessment respondents reported that open communication with patients, including shared decision-making and active listening, can help identify those who are motivated and likely to adhere to longstanding exercise programs. Identified barriers were: unclear eligibility criteria, discrepancies between patients’ perceived limitations and objective assessments, patient complexity, unclear insurance coverage, potential out of pocket costs for the patient, access to specialized physiotherapists, and a lack of effective communication and coordination between involved healthcare professionals. For the use and provision respondents indicated that tailored exercise programs that are accessible and convenient can improve patient adherence, and that access to continuing education and adequate resources facilitates therapists’ ability to provide longstanding exercise therapy. Furthermore, they reported that motivated patients who understand their condition and actively participate in their care are more likely to benefit from longstanding exercise therapy. The identified barriers included concerns about the limited availability and proximity of longstanding exercise therapy due to a shortage of qualified exercise therapists. Additionally, restricted insurance coverage caused confusion among healthcare providers and patients which causes a barrier to.
Conclusion: This study highlights the multifaceted nature of implementing longstanding, personalized exercise therapy. Our findings underscore the need for increased awareness and education, clearer referral pathways, improved access to qualified therapists, and strategies to address cost concerns and support patient motivation. By addressing these challenges, we can ensure that longstanding, personalized exercise therapy becomes a standard part of care, ultimately improving the quality of life for these patients.
REFERENCES: [1] Teuwen M.H.T., et al. Annals of the Rheumatic Diseases, 2024. 83(4): p. 437.
[2] van Wissen, M.A., et al. Physiotherapy Research International, 2022. 27(1): p. e1933.
Acknowledgements: NIL.
Disclosure of Interests: None declared.
© The Authors 2025. This abstract is an open access article published in Annals of Rheumatic Diseases under the CC BY-NC-ND license (