journal of orthopaedic & sports physical therapy | volume 44 | number 6 | june 2014 | 415

[ research report ]

The importance of regular physical activity in personal health promotion is well documented in the literature.18,23,25,46 People with physical capacity and emotional commitment to meet the recommended level of moderate-intensity physical activity, 30

to 60 minutes most days of the week,26 can reduce disease risk and mortality, help maintain body weight, and improve overall health.24,34

Strategies to increase physical activity to create healthy and safe communities, reduce or eliminate health disparities, in-tegrate prevention, and assist individuals in making healthy lifestyle choices have been developed.24,47 In fact, physical ac-tivity guidelines are recognized in the National Prevention and Health Promo-tion Strategy as an attribute of a robust economy, and these guidelines meet the prevention focus of the Affordable Care Act of 2010.24,27 However, despite the above, people in general, and older adults in particular, fail to meet physical activity recommendations.43

Promoting others to engage in and to maintain a physically active lifestyle is challenging, and, unfortunately, interven-tions designed to motivate older adults to adopt active lifestyles have had lim-ited success.39,44 Behavior change can be particularly difficult for those discharged from rehabilitation, given the physical and psychosocial impact that an injury or an illness may have on an individual.48 Physically inactive older adults may have lower expectations from a physical activ-ity program, perceive more barriers, and require a more personalized interven-tion to successfully modify activity.8 In addition, self-efficacy for exercise, or the

TT STUDY DESIGN: Cross-sectional study.

TT OBJECTIVE: To describe readiness for change and barriers to physical activity in older adults and to contrast perceptions of physical therapists and patients using the Barriers to Being Active Quiz.

TT BACKGROUND: Regular physical activity is vital to recovery after discharge from physical therapy. Physical therapists are positioned to support change in physical activity habits for those transi-tioning to home care. Understanding of readiness for change and barriers to physical activity could optimize recovery.

TT METHODS: Thirteen physical therapists enrolled in the study and invited patients who met the inclusion criteria to enroll (79 patients enrolled). The physical therapists provided the ICD-9 code, the physical therapist diagnosis, and completed the Barriers to Being Active Quiz as they perceived their patients would. The enrolled patients provided demographics and filled out the Satisfaction With Life Scale, the stages-of-change scale for physical activity, and the Barriers to Be-ing Active Quiz.

TT RESULTS: Patients were predominantly in

the early stages of readiness for change. Both patients and physical therapists identified lack of willpower as the primary barrier to physical activity. Patients identified lack of willpower and social influence as critical barriers more often than physical therapists, whereas physical therapists identified fear of injury and lack of time more often than their patients did. Differences between physical therapists and their patients were noted for fear of injury (z = 2.66, P = .008) and lack of time (z = 3.46, P = .001). The stage of change for physical activity impacted perception of social influence (χ2 = 9.64, P<.05), lack of willpower (χ2 = 21.91, P<.01), and lack of skill (χ2 = 12.46, P<.05). Women ranked fear of injury higher than men did (χ2 = 6.76, P<.01).

TT CONCLUSION: Understanding readiness for change in and barriers to physical activ-ity may allow physical therapists to better tailor intervention strategies to impact physical activity behavior change. J Orthop Sports Phys Ther 2014;44(6):415-424. Epub 25 April 2014. doi:10.2519/jospt.2014.5171

TT KEY WORDS: aging/geriatrics, physical activity, physical therapy

1Doctor of Physical Therapy Program, University of Wisconsin-Milwaukee, Milwaukee, WI. 2Department of Kinesiology, University of Wisconsin-Milwaukee, Milwaukee, WI. This project was supported in part by a grant to Dr Zalewski by the Wisconsin Physical Therapy Association, Lynn Phillippi Geriatric Advocacy Grant Fund. The authors certify that they have no affiliations with or financial involvement in any organization or entity with a direct financial interest in the subject matter or materials discussed in the article. Address correspondence to Dr Kathryn Zalewski, University of Wisconsin-Milwaukee, Doctor of Physical Therapy Program, PO Box 413, Pavilion 360, Milwaukee, WI 53213. E-mail: zalewski@uwm.edu T Copyright ©2014 Journal of Orthopaedic & Sports Physical Therapy®

KATHRYN ZALEWSKI, PT, PhD1 • CARLYNN ALT, PT, PhD1 • MONNA ARVINEN-BARROW, PhD, CPsychol2

Identifying Barriers to Remaining Physically Active After Rehabilitation:

Differences in Perception Between Physical Therapists and Older Adult Patients

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[ research report ]internal belief that one is able to be suc-cessful in the exercise prescribed, is an important factor in adherence to physi-cal activity interventions.32

One of the fundamental tenets to consider when planning, designing, and implementing strategies to promote physical activity is the individual’s readi-ness to engage in such behaviors.31 The existing literature proposes that an in-dividual’s readiness for change can best be assessed using the transtheoretical model (TTM) of behavior change, which posits that, when contemplating behavior change, an individual progresses through 5 stages: precontemplation (no inten-tion to change), contemplation (think-ing about change), preparation (making small changes to prepare for change), ac-tion (actively engaging in new behaviors), and maintenance (continuing to engage in new behaviors regularly).31 Typically, when considering change, individuals engage in the cognitive and behavioral processes of change,31 during which they also evaluate the possible costs and ben-efits (ie, decisional balance) of engaging in such change. These processes are also influenced by individuals’ perceived con-fidence (ie, self-efficacy) in engaging in such activities (for more details on the TTM, please visit http://www.prochange.com/transtheoretical-model-of-behav-ior-change).2

In addition to the constructs out-lined in the TTM, it is likely that when contemplating behavior change, an indi-vidual will also consider possible barriers to change, as these can have a significant impact on how a person thinks, feels, and subsequently behaves in a given sit-uation. These barriers to becoming and remaining physically active are typically categorized as either internal or external. Internal barriers, those attributed to the persons themselves, include knowledge of the benefits of activity, motivation, willpower, exercise beliefs, self-efficacy, and internal drive.49 External barriers, those attributed to social and environ-mental-related factors, include access to resources such as safe exercise envi-

ronments, transportation, disposable income, and exercise partners. Both in-ternal and external barriers have been identified as real challenges to physical activity participation for persons with conditions managed by physical thera-pists, including osteoarthritis,29 chronic pain,1,21 low back pain,16,19 and stroke.36,45

There is limited research on inter-ventions to change internal barriers to physical activity, and fostering long-term change in physical activity participation has had only partial success. For exam-ple, education on the benefits of physical activity, counseling to support change, referral to exercise groups, and self-efficacy training have all been found to improve short-term physical activity par-ticipation but not to support long-term change.3,4,10,12,13,17,33 Though this picture may seem bleak, one way of increasing the likelihood of successful activity in-terventions during physical therapy is to strengthen the relationship between the clinician and the patient. A strong, trusting, and respectful bond between the therapist and the patient may ensure individualized, stage-matched interven-tions that lead to progression through the stages of the TTM and eventually result in long-term change in physical activity behavior.42 As physical therapists often serve as the connection between the formalized health care system and self-managed physical activity programs, physical therapists are uniquely situated to identify physical activity readiness, cat-egorize barriers to physical activity, and develop stage-appropriate interventions that promote healthy behaviors.

Despite the importance of under-standing the barriers to behavior change and of providing a readily accessible mea-sure of the barriers to physical activity, to date, there is no published research in-vestigating barriers to physical activity among older adults following discharge from rehabilitation. The Barriers to Be-ing Active Quiz5 (BBAQ) is a self-report measure designed to assist older adults in identifying barriers to increasing physical activity participation. Though the BBAQ

may be useful in helping older adults to identify the primary barriers to becom-ing more physically active, due to lim-ited psychometric testing, the utility of the BBAQ in physical therapy practice is poorly understood. Research of other ex-isting tools that assess barriers to activity is also limited, and those tools were de-veloped for a targeted clinical population with little to no validation across clinical diagnoses.14,22,29,35

The aim of this study was to explore the readiness for change and barriers to physical activity participation in older adult patients when they were discharged from physical therapy care. The 3 goals of the study were (1) to explore the util-ity of the BBAQ as an evaluative tool to help identify barriers to physical activ-ity in older adults, (2) to describe readi-ness for change in physical activity upon discharge from rehabilitation in older adults, and (3) to explore physical thera-pists’ perceptions and patients’ report of barriers to remaining physically active.

METHODS

Participants

Two groups of participants were recruited for this study: physical therapists and their patients, who

were being discharged from physical therapy care. The physical therapists were recruited from a random sample of names from a list of members of the Wisconsin Physical Therapy Association. Eligibility criteria of physical therapists participating in the study included (a) a minimum workload of 30 hours per week in clinical practice and (b) a regular workload that included treating individu-als 65 and older who were discharged to their home or community. Once enrolled in the study, the physical therapist invited the next 15 patients who met inclusion criteria and were to be discharged from physical therapy care to participate. In-clusion criteria for patients included (1) age 65 or older and (2) being discharged from physical therapy care to a living en-vironment other than skilled nursing.

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Measures and ProceduresOn the last day of the episode of care, the physical therapist provided the patients with a packet of information to complete at home. Patients were asked to complete a demographic form, the Satisfaction With Life Scale (SWLS), the stages-of-change scale for physical activity, and the BBAQ. The SWLS is a self-reported global measure of life satisfaction that has been shown to be reliable in older adults.7,9 Physical activity participation predicts approximately 18% of the vari-ance in SWLS scores.28 The stages-of-change scale for physical activity is a self-reported tool anchored in the TTM that has been used to evaluate stages of change in people becoming more physi-cally active.20

Despite its widespread public avail-ability, only one publication has used the BBAQ.38 We chose the BBAQ as a mea-sure to explore barriers because of its ease of use and convenience. The BBAQ is a publicly available measure that tar-gets a large segment of the population. It is easy to administer and is anchored in modifiers to activity participation (eg, internal and external barriers) rather than a description of body systems, which may be limited due to the primary medical condition. Responses are aggre-gated into 7 subscale scores that identify 5 internal barriers (lack of time, lack of energy, lack of willpower, fear of injury, and lack of skill) and 2 external barriers (social influence and lack of resources). Each barrier subscale is weighted us-ing 3 questions that are rated on a scale from 0 to 3 and summed to provide a total score (maximum barrier score of 9). Barriers that receive a total score of 5 or greater are considered “critical” barriers.

Physical therapists were asked to provide the ICD-9 code for the referring diagnosis, the physical therapy diag-nosis, and any modifying conditions in the plan of care. In addition, they were asked to complete the BBAQ as they per-ceived the patient would. The physical therapists were instructed not to discuss

the BBAQ with their patients prior to completion.

The physical therapists and patients completed the surveys at the time of discharge from physical therapy, and returned the surveys to the authors in a self-addressed stamped envelope coded to match the physical therapist’s response with that of the patient. Both physical therapists and patients provided informed consent to participate. Physical therapists were consented by one of the authors in person; patient consent was implied with the return of survey instru-ments. A modified informed consent was included in the survey instrument packet provided to patients. For their participa-tion, patients received a small gift card

to a convenience store/pharmacy once surveys were returned. The project was approved by the University of Wisconsin-Milwaukee Institutional Review Board for Human Subjects Protection.

Data AnalysisReliability analyses of the full BBAQ and individual subscales were completed using a Cronbach alpha on the patient data only (ie, physical therapist ratings of the patient were not used in the reli-ability analysis). An exploratory prin-cipal-components factor analysis with varimax rotation was used to affirm the constructs proposed by the BBAQ scoring form. Descriptive statistics (means and percentages) were calculated to evalu-

TABLE 1 Descriptive Characteristics of Patients*

*The physical therapist–patient comparison sample is a subset of the overall sample and represents those patients for whom therapists also submitted packets.†Missing data may result in total percentages in any category being below 100%.

Indicator† Patients Only (n = 79)Physical Therapist–Patient

Comparison Sample (n = 66)

Mean SD age, y 73.9 8.0 74.9 7.1

Sex, %

Male 49.4 45.5

Female 40.5 45.5

Living environment, %

Home 91.1 93.9

Apartment 7.6 4.5

Assisted living 0 0

Other 1.3 1.5

Lives alone, % yes 12.7 12.2

Works outside the home, % yes 89.9 88.9

Satisfaction With Life Scale, %

Very highly satisfied 39.2 39.4

Highly satisfied 40.5 37.9

Average satisfaction 5.1 6.1

Slightly below average 2.5 1.5

Dissatisfied 7.6 7.6

Extremely dissatisfied 3.8 4.5

Readiness for change in physical activity, %

Precontemplation 46.8 48.5

Contemplation 21.5 24.2

Preparation 19.0 13.6

Action 3.8 4.5

Maintenance 7.6 6.1

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418 | june 2014 | volume 44 | number 6 | journal of orthopaedic & sports physical therapy

[ research report ]ate readiness for change. A priori sample estimates suggested that correlations of 0.4 or greater could be estimated from a sample of 62 pairs of data.6 Relation-ships between therapists and patients were evaluated using a Spearman rho. Differences between therapists’ and pa-tients’ ratings of barriers were compared using the Wilcoxon signed-rank test. The effects of sex, living environment, em-ployment, SWLS score, and score on the stages-of-change scale for physical activ-ity were evaluated using the k-sample median test for ordinal data. All statistics were calculated using SPSS Version 21.0 (SPSS Inc, Chicago, IL).

RESULTS

Participants

Of the 15 physical therapists re-cruited to participate in the study, 13 returned surveys. The therapists

provided information on 88 patients, and 79 patients returned survey pack-ets. Complete data sets (physical thera-pist and patient-matched surveys) were received from 66 pairs. Of the 13 physi-cal therapists who returned surveys, 12 were private practitioners in freestand-ing outpatient practices and 1 practiced in a skilled nursing facility with a reha-bilitation unit. Descriptive data for the patients are provided in TABLE 1. A de-scription of the patient ICD-9 classifica-tions is provided in TABLE 2. The majority of the patients received treatment for musculoskeletal conditions.

Utility of the BBAQ for Use in Older AdultsExploratory principal-component analy-sis with varimax rotation suggested that the BBAQ would be appropriate for use in this sample. Initial factorability of the 21 BBAQ items demonstrated that interitem correlations were 0.3 or better on most items. Item number 21 (exer-cise facilities at work) was considered a possible outlier but was retained in the analysis. The Kaiser-Meyer-Olkin mea-sure of sampling adequacy was 0.86, and

the Bartlett test of sphericity was signifi-cant (χ2

210 = 878.17, P<.01). The commu-nalities of the factored items were all above 0.3.

In this sample of 79 patients, the BBAQ was highly reliable (α = .92; 21 items). Internal consistency for the 7 subscales was moderate to strong: lack of time (α = .85), social influence (α = .67), lack of energy (α = .73), lack of willpower (α = .85), fear of injury (α = .73), lack of skill (α = .67), and lack of resources (α = .43). Two items in the lack-of-resources subscale reflect access to outdoor recre-ational supports and questions about sup-ports in the work environment that might not have been meaningful to this sample of older adults and might have resulted in a lower internal consistency than other subscales. These numbers are consistent with the findings of the only other study known to have used the BBAQ.38 The fi-nal factor structure did not exactly repli-cate the proposed structure of the BBAQ; however, because of the high reliability and strong internal consistency of the 7 subscales, the authors chose to continue to explore the BBAQ results using the

recommended scoring and predefined barriers.

Readiness for Change in Physical Activity in Older AdultsMost of the participants in the study were classified in the precontemplation or con-templation stages of readiness for change in physical activity (TABLE 1). There were no differences in distribution between all patient respondents and those patients in physical therapist–patient pairs.

Perceived Barriers at Discharge From RehabilitationPatient Self-Reporting of Barriers Pa-tients ranked lack of willpower as the primary barrier to remaining active after discharge from physical therapy (FIGURE

1). Person-related variables appeared to influence barrier perception. Fear of inju-ry was ranked as a more significant barri-er by women, scoring 3 out of 9, whereas men ranked it as a minor barrier, scoring 1 out of 9 (χ2 = 6.76, P<.01). Additionally, fear of injury was ranked higher by those living in apartments (rank, 3) or assisted living or other environments (rank, 4)

TABLE 2Primary ICD-9 Codes of Patients

as Reported by the Physical Therapist

Abbreviation: ICD-9, International Classification of Diseases, Ninth Revision.

ICD-9 Code Description n (%)

043 Human immunodeficiency virus infection causing other specified conditions 5 (6.4)

386 Vertiginous syndromes and other disorders of the vestibular system 1 (1.3)

438.2 Hemiplegia/hemiparesis 1 (1.3)

715 Osteoarthrosis and allied disorders 7 (8.8)

719 Other unspecified disorders of joint 19 (24.4)

721 Spondylosis and allied disorders 2 (2.6)

722 Intervertebral disc disorders 3 (3.8)

723 Other disorders of cervical region 5 (6.4)

724 Other and unspecified disorders of back 19 (24.4)

726 Peripheral enthesopathies and allied symptoms 4 (5.1)

728 Disorders of muscle, ligament, and fascia 2 (2.6)

729 Other disorders of soft tissue 2 (2.6)

781 Symptoms involving nervous and musculoskeletal systems 3 (3.8)

813 Fracture of radius and ulna 1 (1.3)

831 Dislocation of shoulder 1 (1.3)

840 Sprains and strains of shoulder and upper arm 2 (2.6)

846 Sprains and strains of sacroiliac region 1 (1.3)

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than by those living at home (rank, 1) (χ2 = 6.64, P<.05). Employment outside the home, satisfaction with life, and whether the patient lived with someone else did not impact ranking of barriers.

The stage of readiness for change in physical activity influenced perception of some barriers, including social influence (χ2 = 9.64, P<.05), lack of willpower (χ2 = 21.91, P<.01), and lack of skill (χ2 = 12.46, P<.05). There was no effect of stage of change on the barriers of lack of time, lack of energy, fear of injury, or lack of resources.Comparison of Physical Therapist Per-ceptions and Patient-Reported Barriers The responses of the physical therapists and those of their patients on the BBAQ subscales were weak to moderately cor-related (TABLE 3). Spearman rho analy-sis found that lack of time had the best agreement between physical therapists and their patients (rs66 = 0.47, P<.01), followed by fear of injury (rs66 = 0.34, P<.01). Lack of willpower was reported

as the highest ranked barrier by both physical therapists and patients (FIGURE

2). Therapists perceived lack of time and social influence as the next 2 highest-ranked barriers, and patients reported social influence and lack of skill as the next highest-ranked barriers. The Wil-coxon signed-rank test indicated differ-ences between physical therapists and patients on fear of injury (z = 2.66, P = .008) and lack of time (z = 3.46, P = .001). No other differences were found.

Although total scores on individual barriers in the BBAQ are important, they only tell a portion of the story. Scoring of the BBAQ encourages a review of barriers that score above 5 and identifies these as critical barriers that should be attended to in order to improve physical activity participation.5 FIGURE 2 presents the per-centage of respondents who ranked a bar-rier as critical. Patients identified lack of willpower and social influence as critical barriers much more often than physical therapists did, whereas physical thera-

pists identified fear of injury and lack of time as critical barriers more often than patients did.

Sex, satisfaction with life, and whether the patient lived with someone else had no impact on the physical therapist-pa-tient difference score in the barrier rank-ings. There was an impact of readiness for change, but only on the barrier of social influence. For those in the precon-templation or contemplation stage, phys-ical therapists generally ranked social influence as a larger barrier than their patients ranked it, and for those in the actively changing behavior stage, physi-cal therapists ranked social influence as a smaller barrier than their patients did (χ2 = 9.95, P<.05).

DISCUSSION

The purpose of this study was (1) to explore the utility of the BBAQ as an evaluative tool to help iden-

tify barriers to physical activity in older adults, (2) to describe readiness for change in physical activity upon discharge from rehabilitation in older adults, and (3) to examine the perceptions of patient barriers to activity reported by physical therapists and their older adult patients at the point of discharge from an episode of direct care.

Utility of the BBAQ for Use in Older AdultsOur results did not exactly replicate the factors proposed by the BBAQ; how-ever, the analysis did demonstrate that the BBAQ has good internal consistency and that the conceptual understanding of internal barriers (eg, willpower) and ex-ternal barriers (eg, resources, time) con-tinues to be a meaningful classification. Given that the psychometric properties of the BBAQ have not been well described and that the sample size in this study did not allow for replication, these results are preliminary, and further investigation is warranted. Due to a lack of other instru-ments available to assist older adults in identifying barriers to physical activity

Lack of resources

Lack of skill

Fear of injury

Lack of willpower

Lack of energy

Social influence

Lack of time

0 50 100 150 200 250 300

Barr

iers

to B

eing

Act

ive

Sum of Rankings

10697

151148

151 *P = .008

*P = .001

90

214250

12487

167150

207120

Physical therapist Patient

FIGURE 1. Sum of rankings of barriers on the Barriers to Being Active Quiz, by physical therapist and patient.

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[ research report ]

that are independent of diagnosis, the BBAQ may be considered a cautious first approach to facilitating therapist-patient discussions about perceived bar-riers to change in physical activity after discharge.

Readiness for Change in Physical Activity in Older AdultsThe majority of patients in this study were found to be in the precontemplative, con-templative, or preparation stage of readi-ness for change. Although we know of no studies that explored the distribution of readiness for change as a primary goal, the distribution found in this sample appears consistent with much of the literature examining readiness for change and ex-ercise in general,42 and is consistent with self-reported physical activity behaviors in older adults.43 As stage-specific interven-tions appear to have success at advancing participants through stages of readiness for change in physical activity, therapists are encouraged to develop interventions for patients in the precontemplation and contemplation stages of change. Most of these interventions are relatively simple and include direct conversation about ex-ercise and behavior change.

Perceived Barriers to Physical Activity at DischargePhysical therapists and patients identi-fied lack of willpower as the primary bar-

rier to changing physical activity. In the context of wider literature on inactivity, this is not unexpected. People who are physically inactive are likely to be in the early stages of behavior change and per-ceive exercise differently than those who are active. Additionally, in this study, pa-

tients in the early stages of readiness for change noted lack of willpower and social influence as the most common barriers to physical activity, which is consistent with previous findings on barriers in the early stages of change for physical activity behavior.37

TABLE 3Spearman Correlations Between Patient Self-Report

and Physical Therapist Perception on the BBAQ Subscales

Abbreviation: BBAQ, Barriers to Being Active Quiz.*P<.01.†P<.05.

Patients’ Self-Report Lack of Time Social Influence Lack of Energy Lack of Willpower Fear of Injury Lack of Skill Lack of Resources

Lack of time 0.473* 0.338* 0.293† 0.263† 0.162 0.238 0.258†

Social influence 0.192 0.147 0.127 0.202 0.219 0.166 0.046

Lack of energy 0.387* 0.293† 0.277† 0.281† 0.304† 0.338† 0.180

Lack of willpower 0.221 0.357* 0.231 0.269† 0.246 0.228 0.097

Fear of injury 0.202 0.239 0.189 0.227 0.342* 0.182 0.060

Lack of skill 0.159 0.227 0.127 0.225 0.284† 0.297† 0.213

Lack of resources 0.270 0.307† 0.353† 0.249 0.334† 0.413* 0.191

Physical Therapist Perception

Lack of resources

Lack of skill

Fear of injury

Lack of willpower

Lack of energy

Social influence

Lack of times

0 5 10 15 20 25 30 35 40

Barr

iers

to B

eing

Act

ive

Percent of Respondents

10697

151148

15190

214250

12487

167150

207120

Physical therapist Patient

FIGURE 2. Percent of physical therapist and patient ratings of barriers considered important (ranking greater than 5) to address to improve activity participation.

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Knowing that willpower is seen as a critical barrier for physical activity by both physical therapists and patients alike, and that social influence can sup-port change,8,30 it is important that physi-cal therapists, being a primary source of social influence, develop interventions that address these issues as a critical component of their practice. By becom-ing attuned to patients’ personal goals and the environment, factors that are critical in influencing willpower, physical

therapists can create interventions that add to depersonalized consciousness-raising approaches (print materials), dis-cussions of exercise benefits, classes, and media campaigns, all of which have been found to assist in promoting forward motion through the staging process but, for the most part, have failed to promote long-term change.3,4,10,12,13,17,33 We know that taking multiple approaches over a long period of involvement (6 months or more) promotes lasting change.42 As such,

building a physical therapist–patient re-lationship that may serve as a permanent framework for change is critical. The con-cept of “discharge” should be changed to one of continued care, with the goal of supporting lasting change and ultimately reducing health care expenditure.

There was an apparent disconnect between some of the critical barriers perceived by the physical therapists and reported by the patients. Therapists ap-peared to overestimate the role of lack

Self-E�cacyConfidence in own abilities to both make and maintain change in situations that can tempt the person to relapse and return to old, unhealthy behavior.

Processes of Change in Physical ActivityTen thinking and doing processes: consciousness raising, dramatic relief, self–re-evaluation, environmental re-evaluation, social liberation, self-liberation, helping relationships, counterconditioning, reinforcement management, and stimulus control

Decisional BalanceThe process in which the benefits (ie, the pros) and costs (ie, the cons) of the contemplated change are evaluated.

PrecontemplationNot thinking about change

MaintenanceEngaging in regular physical activity for at least 6 months

ContemplationThinking about change

ActionEngaging in regular physical activity

PreparationMaking small changes, such as taking the steps instead of the elevator, and occasional physical activity sessions

Stages of Change in Physical Activity

Barriers to Physical ActivityInternal and external factors that are seen as influencing the change- making process, a�ecting the processes of change, decisional balance, and/or self-e�cacy.

Contextual Factors

Personal Factors Environmental Factors

FIGURE 3. Transtheoretical model of stages of change in physical activity, including the role of barriers to physical activity.

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[ research report ]of time and fear of injury, and, although not statistically significant, they underes-timated the role of social influence and lack of skill in the process of becoming/remaining physically active. It may be that the interventions physical thera-pists are currently promoting to increase postrehabilitation physical activity are not appropriately matched to the individ-ual stage of readiness and therefore may not meet the needs of patients. If physi-cal therapists are providing active home exercise programs for patients in the pre-contemplative or contemplative stage of change, there should be no surprise by lack of adherence to those programs. Un-derestimating barriers of social influence and lack of skill may mean that physical therapists do not realize the significance of their own role (or the role of patients’ significant others) in behavior change, resulting in interventions that may be perceived as too difficult to adhere to.

It is also possible that physical thera-pists overestimate the lack-of-time barri-er, given that the majority of participants in this study reported working outside of the home. In addition, women and those living in environments other than the home identified fear of injury as a barrier to physical activity. Thus far, no literature that we are aware of suggests that older adult women have a greater fear of injury than their older adult male counterparts. As the sample is representative of both genders and is relatively high function-ing, the fear of injury associated with sex is unexplained. Fear of injury with exer-cise has been noted in older adults with health limitations,15,41 and it is possible that we are observing this relationship rather than the effect of sex alone. As this sample is biased toward the home envi-ronment, we believe the influence of fear of injury associated with living environ-ment should be interpreted with the most extreme caution. Living environment may be a proxy variable for health status, but, without a measure of physical health, this relationship is exploratory at best.

This study only explored percep-tions of barriers at discharge from an

episode of care, assuming to capture the self-management phase of recovery. It would be interesting to examine whether change in perception of barriers to physi-cal activity occurs within the episode of care, and whether the physical therapists are effective at directly addressing inter-nal and external barriers as a function of the treatment process. Given that ap-proximately 8% of all physical therapy episodes of care for older adults (older than 65) in outpatient practices are for treatment of musculoskeletal conditions and are 1 treatment in length,11 and given our finding of readiness for change in this sample, we continue to believe that a model of continued episodic care is critical.

Study LimitationsThe original premise of this work was that, because physical therapists are po-sitioned to support change (especially for patients in the precontemplative or contemplative stage of readiness for change), intentional treatment of barri-ers to change may facilitate early prob-lem solving and strategy building to support lasting change after discharge. When originally conceived, the lack of tools to assess barriers to change in physical activity and a lack of under-standing of the status of patients in the change process after discharge from physical therapy posed a challenge. As a result, this became an exploratory study designed to examine a tool (the BBAQ), to describe stage of change in a specific sample, and to study differences in phys-ical therapist perception and patient report of barriers to change. However, due to the lack of psychometric proper-ties for the BBAQ and the small sample size, and as this study examined both the psychometric properties of the BBAQ as a tool and the product of that tool, the results should be considered preliminary and interpreted with caution. It is pos-sible that the barriers identified by the patients in this sample could have been a proxy for low levels of self-efficacy in exercise, which is known to be more

of a challenge for older adults.40 Given that patients report both internal and external barriers to physical activity on the BBAQ, barriers to physical activity should be considered as an important adjunct to the TTM model of physical activity (FIGURE 3).

The BBAQ is not a tool customized for a sample of people with known barri-ers to activity participation. Indeed, this study is the first known study to explore psychometric properties of the BBAQ. The BBAQ does appear to have strong internal consistency, suggesting that it may capture meaningful information about activity barriers. However, with-out validity and reliability data in this population, the full utility of the BBAQ cannot be described. In the absence of other tools validated for clinical practice, the BBAQ does provide a starting point for meaningful discussions with patients and/or referrals.

CONCLUSION

Use of the BBAQ and assessing stage of readiness for change in physical activity during the reha-

bilitation process may help therapists de-velop better stage-specific interventions, thus improving rehabilitation outcomes long after discharge. t

KEY POINTSFINDINGS: Physical therapists and their patients in the early stages of behavior change agree that willpower is a primary barrier to sustained change in physical activity.IMPLICATIONS: Because physical therapists have opportunity to impact behavior change, assessment of barriers to physi-cal activity should be a part of physical therapy care. The BBAQ may provide one opportunity to facilitate discussion and/or referral, optimizing potential for behavior change.CAUTION: Data evaluating the BBAQ as a tool are emerging. Additional informa-tion is needed to evaluate overall utility of this assessment.

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ACKNOWLEDGEMENTS: A portion of this work was presented by Carlynn Alt at the 2012 National Wellness Conference, Stevens Point, WI.

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[ research report ]

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