Physiotherapists' perspectives on exercise prescription for fibromyalgia: a qualitative studyAbstract
Introduction: Fibromyalgia (FM) is a debilitating chronic pain syndrome. Physical exercise is recommended for treatment; however, there is low adherence to exercise, alongside high levels of kinesiophobia and catastrophiz-ing, as well as low self-efficacy, all of which facilitate sedentary behavior.
Objective: To investigate physiotherapists' perspectives on exercise prescription and to understand factors related to adherence and progress in FM cases.
Methods: This is a qualitative study involving content analysis of interviews, based on the Consolidated Criteria for Reporting Qualitative Research (COREQ) and Standards for Reporting Qualitative Research (SRQR). Interviews were conducted by a physiotherapist, involving the interviewer, the participant, and an observer. A pilot test, expert consultation, and field notes were utilized. Data analysis was performed using MAXQDA 2022 software, employing data triangulation to enhance reliability and credibility.
Results: Twenty-seven physiotherapists with clinical experience in FM were evaluated. Factors related to the clinical presentation and professional competencies influence adherence to and progress in physical therapy treatment. Individualized care and biopsychoso-cial factors were highlighted. Barriers regarding exercise were associated with the patient's clinical condition. Prescriptions are typically gradual and include muscle strengthening, aerobic exercise, Pilates, and hydrother-apy.
Conclusion: Physiotherapists' perspectives emphasize that the patient experience can be improved through physiotherapist skills, particularly active listening during treatment. Factors related to clinical condition influence patient adherence and progress during treatment. Both mixed exercise regimens and isolated modalities are prescribed during treatment.
Keywords:
Fibromyalgia; Physiotherapists; Pain; Physical exercise
Resumo
Introdução: Fibromialgia (FM) é uma síndrome de dor crôni-ca incapacitante. O exercício físico é recomendado para o tratamento, entretanto, há baixa adesão ao exercício e elevados níveis de cinesiofobia, catastrofização e baixa autoeficácia que facilitam o comportamento sedentário.
Objetivo: Investigar a visão de fisioterapeutas sobre a prescrição do exercício, bem como compreender fatores relacionados à adesão e evolução na FM. Métodos: Trata-se de um estudo qualitativo por análise do conteúdo de entrevistas baseado no Consolidated Criteria for Reporting Qualitative Research (COREQ) e Standards for Reporting Qualitative Research (SRQR). As entrevistas foram conduzidas por uma fisioterapeuta, com a participação da entrevistadora, participante e observadora. Foram realizados o teste piloto, análise de consultoria e notas de campo. A análise dos dados foi realizada no software MAXQDA 2022, utilizando o método de triangulação dos dados para aumento de confia-bilidade e credibilidade.
Resultados: Foram avaliados 27 fisio-terapeutas com experiência clínica na FM. Fatores relacionados ao quadro clínico e competências do profissional influenciam na adesão e evolução do tratamento fisioterapêutico. A individualidade do atendimento, além de fatores biopsicossociais foram descritos. Barreiras envolvendo o exercício foram associados ao quadro clínico do paciente. A prescrição comumente é feita de forma gradual e envolve exercícios de fortalecimento muscular, aeróbico, Pilates e hidroterapia.
Conclusão: A visão de fisioterapeutas ressalta que a experiência do paciente pode ser melhorada mediante as habilidades dos fisioterapeutas, especialmente envolvendo a escuta ativa no tratamento. Fatores relacionados ao quadro clínico influenciam na adesão e evolução dos pacientes durante o tratamento. Exercícios mistos e modalidades isoladas são prescritos durante o tratamento.
Palavras-chave:
Fibromialgia; Fisioterapeutas; Dor; Exercício físico
Introduction
Fibromyalgia (FM) is considered one of the most prevalent, costly, and disabling chronic pain conditions worldwide.1 FM affects approximately 2% to 4% of the general population and is diagnosed more frequently in women than in men.2 Pain is the hallmark symptom of FM and commonly coexists with a range of other symptoms, including fatigue, insomnia, cognitive dysfunction, and mental health disorders.3
The management of individuals with FM remains a challenge for healthcare professionals. To date, the most strongly recommended approach is a multimodal intervention that combines pharmacological and non-pharmacological treatments.4 Among non-pharmacological interventions, the European Alliance of Associations for Rheumatology (EULAR) strongly recommends exercise as the gold-standard intervention.5,6 Several systematic reviews7,8,9,10,11 support the recommendation of exercise for individuals with FM. Despite this, people with FM often do not adhere to physical activity recommendations because they frequently associate exercise with increased pain intensity during its performance.1
Both the initiation and maintenance of exercise in chronic pain involve self-regulatory processes in which motivational perspectives may play an important role.12 Individuals with pain may anticipate negative consequences of physical activity or exercise, such as exacerbation of pain.12,13 Exercise adherence in chronic pain conditions has been explained by different theoretical models. The fear-avoidance model suggests that fear of movement and avoidance behaviors may contribute to reduced physical activity and the persistence of di-sability.14 In addition, self-efficacy is considered one of the main predictors of exercise adherence among individuals with FM.15
Despite the importance of incorporating exercise into the treatment of individuals with FM and the fundamental role of physical therapists in promoting gradual exercise exposure, surprisingly, physical therapists' perspectives specifically on exercise and the factors that may influence adherence and clinical outcomes in individuals with FM have not been investigated. Only a few studies have specifically explored physical therapists' perspectives on FM.13,16,17 Among these, one study found that physical therapists perceive FM as a complex syndrome with uncertain diagnosis and significant psychological influences, making the management of these individuals a professional challenge.13 Other studies have examined the perspectives of physical therapists and occupational therapists regarding the care provided to individuals with FM through a questionnaire16 and investigated physical therapists' perceptions of the condition, again highlighting limited knowledge regarding the management of individuals with FM.17
Previous studies have investigated physical therapists' experiences primarily in relation to general treatment approaches and knowledge of FM, limiting conclusions specifically regarding exercise prescription and the potential barriers and facilitators associated with exercise dosage and strategies applicable to clinical practice. Accordingly, the present study seeks to enhance understanding of how physical therapists prescribe exercise for individuals with FM by providing in-depth insights that may contribute to improving therapeutic planning and strategies to promote exercise adherence.
In this context, the study was guided by the following research question: How do physical therapists prescribe exercise for individuals with FM, and which factors do they perceive as barriers and facilitators to exercise adherence and clinical outcomes? Based on this, the aim of this study was to investigate physical therapists' perspectives on exercise prescription and to understand the factors related to exercise adherence and clinical outcomes in individuals with FM.
Methods
This was a qualitative study using content analysis of interview data,18 conducted in accordance with the Consolidated Criteria for Reporting Qualitative Research (COREQ)19 and the Standards for Reporting Qualitative Research (SRQR).20 These guidelines provide standards and recommendations for qualitative research, promoting transparency and the quality of methodological reporting.
This study is part of a master's research project approved by the Human Research Ethics Committee of the Federal University of Sergipe (No. 5.531.931; CAAE: 57965922.5.0000.5546). All participants were informed about the study procedures and provided electronic informed consent by signing and informed consent form and an authorization for the use of image and voice.
Data collection was standardized, with invitations sent by email or telephone by a single researcher using a structured recruitment script for scheduling the interviews. The interviews were conducted via web conferencing using the Google Meet platform and lasted approximately 60 minutes. Participants were encouraged to respond freely, without interviewer influence, while cla-rification was provided whenever necessary.
Instruments and technologies
Structured, individual qualitative interviews were con ducted to explore physical therapists' experiences, perceptions, and beliefs regarding pain and the physiotherapeutic management of individuals with FM. The final interview guide comprised 43 questions (Supplement A), and the selected sections are described below:
Exercise prescription for individuals with FM
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Do you usually prescribe exercise for individuals with FM?
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What type of exercise have you prescribed in your clinical practice?
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What exercise dosage have you prescribed in your clinical practice?
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Have you experienced difficulties or facilitators when incorporating physical exercise into the routine of individuals with FM? Could you elaborate on this?
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What strategy do you recommend to facilitate the initiation of exercise practice in the routine of these individuals?
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What strategy do you recommend to facilitate exercise adherence in the routine of these individuals?
Adherence and clinical outcomes of individuals with FM undergoing physiotherapy treatment
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Can you identify factors that may influence treatment adherence and clinical outcomes in individuals with FM? If so, which factors? If not, why?
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What have you observed regarding self-efficacy among individuals with FM? Could you elaborate on this?
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Would you recommend any strategies to improve self-efficacy among individuals with FM?
Pilot testing of the interview and consultation analysis
The interview guide underwent pilot testing to assess its comprehensiveness, relevance, duration, and the functionality of the platform. This process was conducted by the primary researcher with two researchers experienced in qualitative studies. Additionally, the instrument was reviewed by three experts in pain and clinical research, who provided feedback through an electronic form to improve its structure and content as part of the expert review process.
Collection procedures, scheduling process, and data management
Participants received informational materials and support regarding the use of Google Meet. The interviews, which were recorded with participants’ consent, were conducted between September 2, 2022, and December 19, 2022, with only the interviewer, participant, and observer present. One participant withdrew due to health-related reasons, and no other sample losses occurred.
Interviewer characteristics and refiexivity
The interviews were conducted by a physical therapist who was a member of the Laboratory of Neuroscience Research (LAPENE) and had no previous contact with the participants. The interviewer introduced herself as a member of the research group and a graduate student, without disclosing personal objectives, in order to minimize potential influences during data collection. She was the first author of the study and had previous experience in qualitative research.
Observer characteristics, reflexivity, and field notes
The interviews included an observer from LAPENE who was trained and had no previous contact with the participants. The observer recorded field notes to help minimize potential interviewer influence.
Sampling and eligibility criteria
Participants were recruited using criterion sampling, which involves the selection of information-rich participants who meet predefined criteria. Eligible participants were physical therapists of both genders with experience in the physiotherapeutic management of fibromyal-gia. Physical therapists without an active professional registration or without clinical experience in the management of fibromyalgia were excluded.
Sampling strategy
The sample consisted of volunteers recruited through public calls on social media platforms, emails, and national physiotherapy associations and scientific societies. Interested individuals registered through an electronic form (Google Forms), providing their email address, telephone number, and information for sample characterization.
Sample size and data saturation
Recommendations suggesting an estimated sample size between 15 and 20 participants for qualitative studies were followed.21 It has been suggested that approximately 85% of concepts are identifed after 10 interviews, more than 90% after 15 interviews, more than 95% after 20 interviews, and nearly 100% after 25 interviews.19 In the present study, 100% concept representation was achieved. Data saturation was monitored throughout the data analysis process through investigator triangulation, involving more than one researcher in the identification and comparison of emerging codes and themes. Saturation was considered achieved when the final interviews did not generate new codes or relevant themes related to the study objectives.
Study participants
The sample consisted of 27 participants with experience in the clinical management of FM, with no gender restrictions, representing diversity in professional qualifications and geographic regions across Brazil.
Double transcription
After data collection, the audio recordings were subjected to double transcription using the online RESHAPE platform. Investigator 1 performed the full transcription and reviewed the content through repeated readings and active listening to the audio recordings to correct potential errors. Subsequently, Investigator 2 validated the transcripts by reviewing the material again through reading and active listening to the recordings, with the transcripts then returned to the participants.
Data processing and analysis
The subcategories were developed through the iden-tification and interpretation of elements and participants’ statements from the interviews using content analysis. The categories were previously established based on the specific objectives of the study. The categories were previously established based on the specific objectives of the study and are described in Table 1.
Interview transcripts were analyzed and coded using MAXQDA software (version 22) based on the frequency and relevance of the terms identified in the participants’ reports.
Data triangulation was used through investigator triangulation, involving two researchers in coding decisions to ensure systematic classification and the identification of common themes.22
Analyses were conducted independently and blindly, followed by peer review to ensure interpretative convergence. Triangulation enhanced the reliability and credibility of the findings, contributing to the determination of data saturation and sample size. For anonymization purposes, participants were identified bynumbers, and an audit trail was conducted through methodological review by an experienced researcher.
Results
The sample consisted of 27 physical therapists, being 77.7% female and 22.2% male, aged between 25 and 53 years (mean ± standard deviation [SD]: 37.6 ± 8.6 years), as shown in Table 2.
Participants had clinical experience in the physio-therapeutic management of FM (mean ± SD: 8.2 ± 6.5 years) and an estimated number of FM cases treated per year of 18.6 ± 31.7. Among the participants, 70.3% had not taken any undergraduate course on pain, while 77.5% had received pain-related education during postgraduate training (Table 2).
Information regarding region of practice, pain education, and professional de-velopment activities is available in Supplement B.
Exercise prescription
The first category analyzed exercise prescription in individuals with FM, including modalities, dosage, barriers, facilitators, and adherence strategies, organized into three subcategories: types and dosage of exercise, factors influencing exercise practice, and strategies to maintain adherence.
Exercise modalities and dosage
Physical therapists prescribed a variety of modalities, most commonly Pilates, aerobic exercise, muscle strengthening, and hydrotherapy. Additional interventions included stretching, mobility and breathing exercises, passive kinesiotherapy, and distraction activities (Table 3).
It was also reported that mixed exercise selection was used to assist in disease management: (...) exercises, passive kinesiotherapy combined with manual therapy, relaxation techniques, active exercises, or active kinesio-therapy both on land and in water, with active kinesio-therapy involving low resistance or low-load exercises (P1). In contrast, other participants reported the use of passive interventions in the clinical management of the disease: (...) most of the time, they are stretching exercises (P2).
The dosage of resistance exercise was primarily prescribed using the one-repetition maximum test, with 2 to 3 sets of 5 to 12 repetitions. For aerobic exercise, maximum heart rate and rating of perceived exertion were used, with light to moderate intensity, a frequency of 2 to 3 times per week, and a duration of 10 to 50 minutes. Regarding exercise dosage, the need for individualized prescription according to clinical characteristics, rating of perceived exertion, maximum heart rate, and one-repetition maximum testing was highlighted (Table 3).
(...) So, this therapeutic dosage varies considerably because there are different levels of disability. (P4)
(...) I work with resistance exercises, and the load will depend greatly on the patient. The intention is always to introduce it by starting with gradual exposure, but it varies from patient to patient. (P8)
It is possible to observe how the intensity of aerobic exercise and muscle strengthening are prescribed by some participants, as well as the distribution of sets and repetitions volume:
(...) Around 55% to 70% of the maximum heart rate, not exceeding that. (P1)
(...) Rating of perceived exertion, and perhaps a perceived exertion level from 0 to 10, around 6 or 7. (P1)
(...) It is a set of five repetitions, initially two sets, and then progressing... (P5)
Barriers and facilitators to exercise implementation
The main barriers to exercise prescription by physical therapists include pain intensity, fear of movement, catastrophizing, comorbidities, previous experiences, difficulties with engagement, and the patient's clinical condition: (...) and they do not want to do it because of their previous experiences. So, it takes around four sessions for me to help them understand that they need to engage in physical activity and that exercise is important, even if it is light. (P4)
The following participant’s report reinforces one of the psychological factors associated with FM: (...) the greatest difficulty is catastrophizing, the issue of widespread pain, and the fact that the person perceives or understands that if they perform exercises alone at home, they will experience more pain (P5).
Another difficulty faced by physical therapists in clinical practice is kinesiophobia: (...) the belief that exercise will worsen their pain, that they need to remain at rest, and that resting will improve their condition (P8).
The facilitators identified by physical therapists for exercise implementation were patient acceptability, patient commitment to treatment, professional training, patient education, and time since diagnosis of the disease (n = 2/27), with emphasis on patient commitment: (...) so, I think that this is the facilitator or the difficulty: the patient’s commitment, sometimes, to maintaining the stability of the clinical condition (P10).
Strategies to facilitate exercise implementation
Patient education and pain education, informational materials, gradual exposure to movement, supervised exercise, patient preferences, flexibility and scheduling adjustments, highlighting the educational process to improve patient adherence to exercise, were cited as phys-iotherapeutic strategies:
(...) the strategy is always education; when they understand how pain works in their bodies and how exercise can act as an analgesic, they show greater adherence. (P17)
Participants also reported strategies such as group exercises, supervised exercise, playful interventions, habit management, patient support, therapeutic alliance, multidisciplinary teams, and daily assessment. Among the participants, the importance of supervised exercise was emphasized: (...) performing an exercise with you. A guided exercise, so that they feel safe (P27).
Adherence and treatment progression
The second category analyzed factors related to adherence, self-efficacy, and clinical progression of patients with FM during physiotherapy, including modification strategies and factors influencing adherence and clinical oucomes.
Self-efficacy in patients with FM
Some participants reported that self-efficacy among patients with FM is perceived as low (n = 6/27): (...) it is usually very low, and they end up being somewhat catastrophic (P25).
The following report highlights observed variables that influence self-efficacy, such as the presence of depression: (...) it depends, it will depend on the patient, I think. It depends on the medication they are using, the level of depression they have or do not have, and whether the patient is more informed. I think it will depend on the patient’s level of understanding for them to be able to achieve this (P13).
One of the participants highlighted that self-efficacy is related to gains achieved during treatment: (...) when they are able to observe the benefts of treatment in relation to fibromyalgia, this perception becomes much easier (P18).
Self-efficacy modification strategies
The self-efficacy modification strategies reported by participants included patient education, pain education, habit management, family support, patient self-responsibility, and professional training: (...) I would positively recommend education, pain education (P1).
Some participants reported modification strategies involving the development of the therapist-patient relationship, multidisciplinary and interdisciplinary approaches, and the use of checklists. Other participants highlighted the importance of (...) setting these goals together (P3) and (...) but the responsibility lies with them. So, I think the best strategy is to make patients understand this (P21).
Factors influencing adherence and progression
Participants identified factors influencing adherence and clinical progression among patients with FM. Low adherence was associated with psychoemotional aspects, professional training, occupational and social factors, pain intensity, inadequate exercise dosage, and patients’ routines. Increased pain during treatment was highlighted as an important barrier: (...) yes, increased pain. If they come to the clinic and, in consecutive sessions, they experience significant discomfort and do not perceive improvement, then we have negative adherence to treatment (P3).
The following report reinforces the importance of an appropriate exercise dosage: (...) yes, worsening occurs when you lose control of the process and they experience increased pain due to kinesiophobia. This is a very important factor for the person to say, ‘I will not continue because I got worse’ (P6).
Finally, factors related to the professional were highlighted: (...) when the healthcare professional does not have this sensitivity, they are unable to demonstrate empathy, put themselves in the person’s position, and instead only want to show their own work, being there to serve their own ego. This greatly hinders patient engagement (P21).
Discussion
This study investigated physical therapists’ perceptions of exercise and factors related to adherence and clinical progression among patients with FM. It was observed that physical therapists’ perceptions of exercise involve challenges related to the optimal dosage, as well as factors associated with the clinical condition of the disease. Adherence and clinical progression among patients with FM were perceived as being influenced by factors involving biopsychosocial aspects and professional training.
It is well established that EULAR strongly recommends physical exercise for the treatment of FM.6 In our findings, some physical therapists reported using passive interventions in the clinical management of the condition, whereas others selected mixed exercise approaches and applied isolated modalities in their clinical practice, such as aerobic exercise and muscle strengthening. The preference for active strategies was also observed in the study by Alodiabi et al.,17 in which 49% to 81% of physical therapists recommended active physiotherapy or effective interventions, such as aerobic and strengthening exercises.
Despite the strong recommendation for the use of exercise in the treatment of FM, the optimal dosage remains unclear. In efforts to investigate exercise prescription parameters, it has been identified that, in addition to the ideal frequency, patient preferences and clinicians’ skills contribute to exercise prescription.8 Based on the participants’ reports, it is possible to observe that patient preferences and individuality are determining factors in exercise prescription by physical therapists. It has been suggested that adherence to exercise programs may be increased when exercise prescriptions are based on preferred exercise intensity, due to the inverse association between exercise intensity and adherence rates.21
In addition to individual preferences, cognitive and behavioral factors influence exercise adherence in FM, with self-efficacy highlighted as a determinant of the adoption and maintenance of health behaviors. This study demonstrated that physical therapists perceive self-efficacy among patients with FM as low. Self-efficacy can be defined as a construct referring to an individual’s belief in their ability to exert control over their behavior and environment to achieve a goal4 and may buffer the relationships between health, perceived stress, and negative life events in pain populations.23 Health professionals should focus on patients’ self-efficacy, as well as pain intensity, since self-efficacy may contribute to improving activities of daily living among individuals with chronic pain.24
In a previous study, one of the factors identified as potentially influencing physical exercise levels was when perceived barriers to becoming more active (e.g., worsening of symptoms) outweigh the potential benefits.25 The findings indicate that many patients with FM do not develop self-efficacy or change their perceptions regarding exercise, resulting in sedentary behavior, as pain associated with activity makes the recommendation to exercise paradoxical.24
In the present study, some physical therapists stated that fear of movement hinders treatment, as well as catastrophizing and coping with barriers associated with pain intensity. From this perspective, the behavioral barriers identified by participants can be understood through the fear-avoidance model, which is widely used to explain the relationship between pain, fear of movement, and disability. Fear is an anticipatory emotional response to an imminent threat.14 Avoidance behavior is an observable behavior that prevents or delays exposure to an aversive stimulus, is persistent, and generally maintains pain-related fear.14
From a treatment planning perspective, individual characteristics such as physical fitness, function, symptom severity, and goals should be considered to achieve optimal benefits and ensure long-term effects and adherence.25 In efforts to investigate exercise prescription parameters, it has been identified that, in addition to optimal dosage, patient preferences and clinicians’ skills also influence this process, highlighting the importance of gradual exposure to exercise, regardless of the modality used, as a strategy to promote engagement and therapeutic pro-gression.8 In our study, participants also highlighted phy-siotherapeutic strategies such as pain education, gradual exposure to movement, and consideration of patients’ individual preferences during exercise prescription. Especially in the context of chronic pain, clinical guidelines for the management of FM emphasize the importance of disease-related education to reduce patient anxiety and empower individuals to self-manage their symp-toms.26 Patients with FM who do not understand the mechanisms underlying chronic pain tend to experience negative emotions, which may intensify pain through descending pathways.27
In our findings, participants identified factors that facilitate adherence and clinical progression among patients with fibromyalgia. Increased pain intensity during treatment was identified as a barrier faced by physical therapists. FM pain varies significantly over time, depending on the period, season, and activities.28 Certain factors exacerbate pain, with inactivity being the most im-portant.28 The experience of persistent pain prompts a search for understanding that initially focuses on diagnosis and the identification of a treatment approach that will eliminate pain.29
In our study, inadequate exercise dosage was identi-fied as one of the factors influencing patient adherence and clinical progression during treatment. Increased pain during exercise among individuals with chronic pain is often a barrier to regular exercise, leading to a sedentary lifestyle that worsens painful conditions and makes treatment even more challenging.30 The relationship between daily pain, catastrophizing, and physical activity in patients with FM is noteworthy, indicating that catastrophizing increases acute pain during physical activity and that fear of movement may intensify this perception.31
Furthermore, relationships between patients with fibromyalgia and healthcare professionals tend to be chal-lenging.32 Mutual dissatisfaction has been observed between patients and healthcare professionals regarding FM management. In general, patients report a lack of moral support from the professionals who care for them, limited empathy, and minimal effort to provide attention, support, and understanding.32 It is known that the patient experience is positively improved when care encompasses both clinical and emotional aspects.33 Active listening, aligned with narrative knowledge, allows for a better understanding of patients’ experiences, strengthening the therapeutic relationship, promoting collaborative communication, and improving treatment adherence and outcomes.33 Similarly, professional-related factors were highlighted in our findings, emphasizing the importance of follow-up with a multidisciplinary team, physical therapists’ skills in active listening, and patient-centered support as factors that promote adherence to physiotherapy treatment for FM.
The findings of the present study may assist physical therapists in identifying barriers and facilitators related to exercise adherence among individuals with FM. Factors such as pain intensity, fear of movement, self-efficacy, gradual exposure to movement, and patient preferences were highlighted by participants and may contribute to a more individualized approach. Understanding the strategies used in clinical practice may support therapeutic planning and improve the care provided to this population. However, it is important to acknowledge that, despite the clinical experience of physical therapists in FM management, not all participants had knowledge of some topics, which may have influenced the provision of less detailed descriptions by some professionals. This finding may indicate educational aspects that should be reinforced in the development of continuing education protocols, including training for physical therapists to establish therapeutic plans that facilitate adherence to exercise protocols. Conversely, conducting interviews via web conferencing enabled the participation of a greater number of physical therapists experienced in FM from different Brazilian regions, which may have strengthened the study findings.
Conclusion
The perspective of physical therapists highlights that the patient experience can be improved through physical therapists’ skills, particularly those involving active listening during treatment. Factors related to the clinical condition and professional competencies influence patients’ adherence and clinical progression throughout treatment. Physical therapists prescribe mixed exercises and isolated modalities using gradual strategies and educational resources, emphasizing the importance of screening subjective factors related to exercise adherence, such as fear of movement, self-efficacy, individual preferences, pain-related beliefs, and perceived barriers, in the development of a more individualized and patient-centered therapeutic plan.
Supplement
Supplement A - Interview structure
Supplement B - Qualitative descriptive data of the sample
Acknowledgments
We would like to express our deepest gratitude to researchers Leandro Fukusawa and Felipe Reis for their valuable intellectual contributions, which enriched this work.
Data availability statement
The data supporting the findings of this study are openly available in Mendeley Data at https://www.doi.org/10.17632/878pky5t5p.4.
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Associate editor:
Ana Paula Cunha Loureiro
