Ejercicio Físico y Osteoartristis

European Journal of Physical and Rehabilitation Medicine
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Motives for physical exercise participation as a basis for

the development of patient-oriented exercise interventions
in osteoarthritis: A cross-sectional study
Inga KRAUSS, Uwe KATZMAREK, Monika RIEGER, Gorden SUDECK
European Journal of Physical and Rehabilitation Medicine 2017 Feb 17

DOI: 10.23736/S1973-9087.17.04482-3
Article type: Original Article
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Motives for physical exercise participation as a basis for the development of patient-
oriented exercise interventions in osteoarthritis: A cross-sectional study
Inga Krauss1*, Uwe Katzmarek1, Monika A. Rieger2,3, Gorden Sudeck4
Institutions:
1
University Hospital of Tübingen, Medical Clinic, Department of Sports Medicine
2
University Hospital of Tübingen, Institute of Occupational and Social Medicine and Health
Services Research
3
Coordination Centre, Core Facility for Health Services Research, Faculty of Medicine,
Eberhard Karls University of Tübingen, Wilhelmstraße 27, 72074 Tübingen, Germany

4
University of Tübingen, Institute of Sports Science
Notes
Data of this manuscript have been presented at two national congresses:
(1) Congress of the German Association of Sports Science (Deutsche Vereinigung
Sportwissenschaft dvs)
Krauß I, Katzmarek U, Rieger MA, Sudeck G. Motivbasierte Konzeptionen der Sporttherapie bei
Arthrose. Sportwissenschaft grenzenlos?! In: Schriftenreihe der Deutschen Vereinigung für
Sportwissenschaft 2013;230:157. 21. Sportwissenschaftlicher Hochschultag der dvs vom 25.-
27.9.2013 in Konstanz, Germany.
(2) German Congress for health services research
Krauß I, Katzmarek U, Sudeck G. Personenorientierte, sporttherapeutische Interventionsmaßnahmen
bei Osteoarthrose. Dtsch med Wochenschr 2012;137:A185. 11. Deutscher Kongress für
Versorgungsforschung vom 27.-29.9.2012 in Dresden, Germany.
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Acknowledgments
The present study was conducted as part of the Young Investigator Program of the Network
for Health Services Research Baden-Württemberg, funded by the Ministry for Science,
Research and Art in cooperation with the Ministry for Work, Social Order, Families, Women
and the Elderly of Baden-Württemberg.
We also want to thank Mrs. Christine Emrich (Coordination Unit for Health Service Research
of the University of Tübingen) for her support in content-related and organizational
questions; Dr. Martina Michaelis (FFAS - Freiburger Forschungsstelle Arbeits- und
Sozialmedizin and Institute of Occupational and Social Medicine and Health Services
Research, Tübingen) for the data from the Public Use File of the GEDA 2009 database; and
the Centre for Evaluation and Quality Management of the University of Tübingen for support
in scanner-based questionnaire processing (EvaSys, Electric Paper).
The work of the Institute of Occupational and Social Medicine and Health Services Research
Tübingen is supported by an unrestricted grant from the Employers’ Association of the Metal
and Electric Industry Baden-Württemberg (Südwestmetall).
Declaration of interest
The authors have no declarations of interest to report.
Name, address, e-mail of the corresponding author.
Prof. Dr. Inga Krauss
Medical Clinic, Department of Sports Medicine
University of Tübingen
Hoppe-Seyler-Strasse 6
72076 Tübingen, Germany
Tel. +49 7071 2986486, Fax +49 7071 29 5162
inga.krauss@med.uni-tuebingen.de
Abstract
BACKGROUND: Physical exercises are effective in the treatment of osteoarthritis (OA).
There is consensus that exercise interventions should take into account the patient’s
preferences and needs in order to improve compliance to exercise regimes. One important
personal factor is the patient’s motivation for physical exercise. Health improvement is a
relevant motive for exercise participation. Accordingly, exercise interventions primarily
focus on health related needs such as strengthening and pain reduction. However exercising
provides further many-faceted incentives that may foster exercise adherence. AIM: The
present study aimed to characterize target groups for person-tailored exercise interventions in
OA according to the International Classification of Functioning and Disability and Health
(ICF). Target groups should be classified by similar individual exercise participation motive
profiles and further described by their disease-related symptoms, limitations and
psychological determinants of exercise behavior. DESIGN: Observational study via self-
administered questionnaires. SETTING: Community. POPULATION: 292 adults with
hip/knee OA living independently of assistance. METHODS: Participants completed the
Bernese Motive and Goal Inventory in Leisure and Health Sports (BMZI), the Hannover
Functional Ability Questionnaire for Osteoarthritis, the WOMAC-Index (pain/stiffness), the
General Self-efficacy Scale and a questionnaire on perceived barriers to exercise
participation. The BMZI-scales served as active variables for cluster analysis (Ward’s
method), other scales were used as passive variables to further describe the identified
clusters. RESULTS: Four clusters were defined using five exercise participation motives:
health, body/appearance, aesthetics, nature, and contact. Based on the identified motive
profiles the target groups are labelled health-focused sports people; sporty, nature-oriented
individualists; functionalists primarily motivated by maintaining or improving health through
exercise; and nature-oriented, health-conscious exercisers. CONCLUSION: This study
contributes to the development of person-oriented exercise recommendations with a special
regard to motives for exercise participation. This study delineates four phenotypes with
distinctive profiles of facilitators and barriers to exercise behavior. Key aspects of person-
oriented exercise interventions could be defined according to each phenotype. CLINICAL
REHABILITATION IMPACT: Incentives related to physical exercise such as enjoyment,
contact, or natural environment may encourage compliance to an exercise intervention. Goal
setting in the context of OA rehabilitation should therefore not only refer to health-oriented
reasons but also reconsider individual motives for exercise participation.
Keywords
Osteoarthritis, Exercise, Patient-oriented therapy, ICF
Introduction
Osteoarthritis (OA) is the most prevalent musculoskeletal disease and has a health burden for
people living in industrialized countries almost as large as that of respiratory or digestive
disorders 1. The knee and hip are the large joints most commonly affected by this disease 2.
Patients with OA suffer from pain and experience limitation of activities and participation 3.
There is evidence for the efficacy of joint-related exercise programs with respect to pain
reduction and increase of functioning in people with knee and hip OA 4-6. Thus, strengthening
and aerobic exercise is strongly recommended as a first-line, conservative treatment option

3;5;7
. In addition to this general recommendation, the literature highlights the need for tailored,
individualized exercise interventions 3;5;6;8. They should be based on informed, shared

3;9
decision-making that takes into account each person’s preferences and needs .
The International Classification of Functioning, Disability and Health (ICF) is a suitable
framework to enable development of a comprehensive patient-oriented exercise intervention
that incorporates a broad range of health status factors 10. According to the ICF, a health
condition such as OA may impact on a person’s functioning at three levels: in relation to body
functions and structures, at an activity level, and at the level of participation in society. There
is an interdependence between the health condition and environmental and personal context
factors 11.
One personal factor that is particularly relevant for sustainable effects of an intervention is
the patient’s motivation for exercise participation 12. Explicitly formulated motives are a main
source of patient’s motivation. Explicit motives correspond to goals that are defined as
internal representations of desired states that patients want to achieve through exercise 13. An
up-to-date synthesis of literature summarizes findings of previous studies on facilitators for
participation in physical exercises in patients with hip and knee OA. Results of this synthesis
reveal that motives for exercise participation among patients with hip and knee OA frequently
refer to positive outcome expectations such as health benefits, taking control of disability,
ease of symptoms, and others 14. It therefore seems reasonable that exercise interventions in
osteoarthritis should focus on health related needs of the patients such as strengthening, pain
reduction and weight reduction 15. Addressing the patient’s preferences is then mainly related
to the exercise delivery mode (e.g. home-based), the type of exercise (e.g. strengthening) and
the exercise medium (e.g. land-based) 3;15;16. Further recommendations such as “treatment of
hip and/or knee OA should be individualized according to the wishes and expectations of the
individual” remain rather general.
If health benefits are the only individual source for exercise motivation, compliance to an
exercise regime may be hindered. Deferral of physical benefits induced by exercise can be
accompanied by delay of gratification and may, therefore, negatively affect exercise
participation. Another important reason for not adhering to an exercise regime is a decline in
pressure to continue with exercise if physical improvements result in relief of disease-related
symptoms. Patients may no longer perceive a need for health-related exercise and stop
participating 17. However, physical exercises provide opportunities to achieve further many-
faceted individual goals in addition to the objective of improving health. In this regard, social
interaction and enjoyment of exercise have been described as important facilitators of
exercise behavior as well 14. Other obvious reasons to engage in exercise such as recovery,
distraction, aesthetic movements, competition or outdoor experience are rarely mentioned in
literature 18;19.
Consideration of a wide range of individual exercise motives is a rather novel approach in the
development of exercise programs 20. The beneficial effects of incorporating additional
motives for exercise participation into an exercise regime appear to be promising in fostering
physical exercise behavior in OA patients. Such approach may be more beneficial when it is
combined with other relevant personal factors to account for a comprehensive individualized
approach. For example, self-efficacy and perceived barriers to exercise are both recognized as
determinants of exercise participation 10. Additionally, the patients’ physical status has to be
considered when developing a tailored exercise intervention as it may limit the exercise
tolerance of the individual. Physical status is primarily associated with disease-related pain as
well as limitations in physical functioning and participation in activities of daily living.
Taking account all of the above facts, the aim of the present cross-sectional survey study was
to characterize target groups for exercise interventions in patients with hip and knee OA that
consider an individually tailored approach aligned with the ICF framework. Target groups
should be characterized by similar profiles of individual exercise participation motives
identified using cluster analysis. Additionally, patients in each of these clusters should be
described by their disease-related symptoms and limitations in physical functioning, as well
as their psychological prerequisites for exercise behavior (self-efficacy and perceived barriers
to exercise).
Methods
Study design
The present study was a cross-sectional study conducted in Baden-Württemberg, Germany.
Data from patients with knee and/or hip OA were collected using self-administered, paper-
based questionnaires. The questionnaires were distributed through outpatient clinics, medical
doctors, and personal contacts (n = 392); health exhibitions (n = 213); local newspaper
advertisements (n = 65); subjects of previous studies (n = 44); and at an open house at the
study institute (n = 43). Questionnaires were disseminated from February to November 2012.
Ethical approval was obtained from the Ethics Committee of the university hospital.
Participants
To be included in the study, participants had to be at least 18 years of age with no upper age
limit. They further must have a positive, lifetime prevalence of one- or both-sided OA at the
knee and/or hip joint. OA was defined according to the German Federal State health reporting
system criteria 21. Patients were asked to affirm the following two questions for lifetime
prevalence of OA:
1. “Have you ever visited a doctor because of complaints in the hip and/or knee joint?”
2. “If yes, did a medical doctor ever ascertain OA or a degenerative disorder at your knee
and/or hip joint?”
Measures
We used scales or subscales of several established questionnaires. Exercise participation
motives were recorded using the Bernese Motive and Goal Inventory in Leisure and Health
Sports (“Berner Motiv- and Zielinventar,” BMZI) 18. This is an inventory specifically
designed for people in middle and later adulthood. It allows an individual diagnosis of motive
profiles for exercise participation in the fields of leisure and health sports. The BMZI
comprises 28 items, with response options on a 5-point Likert scale (a score of 5 represents
explicit agreement with the mentioned motive, while a score of 1 indicates disregard of the
mentioned motive). The BMZI contains eight domains of exercise motives: contact,
competition/performance, distraction/stress regulation, body/appearance, fitness, health,
activation/enjoyment, and aesthetics. Its psychometric properties has been proved to be good
18
. According to a preceding version of the BMZI, the instrument was complemented by a
scale with two items related to outdoor experience 19. Item examples as well as internal
consistencies of each of the nine domains for the given sample are depicted in Table 1
(Cronbachs’ alpha).
Disease-related symptoms and activity limitations were measured with the Hannover
Functional Ability Questionnaire for Osteoarthritis (“Funktionsfragebogen Hannover für
10
Arthrosepatienten,” FFbH-OA) 22, along with the pain (5 items) and stiffness (2 items)
subscales of the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC)
numeric rating scale (NRS) 3.1 23. The FFbH-OA uses a percentage scale of 0–100, with
100% indicating maximum functional capacity. Each WOMAC scale ranges from 0 to 10,
with 0 indicating no pain or stiffness and 10 indicating maximum constraint on the given
scale.
General self-efficacy (GSE) was measured with the German version of the General Self-
Efficacy Scale, with responses on a 4-point Likert scale (ranging from “not right” to
“definitely right”). This scale comprises 10 items, with each item referring to successful
coping and implying an internal-stable attribution of success. The total scores for the scale
range from 10 to 40, with 40 indicating maximum self-efficacy 24. Chronbach’s alpha for the
given sample was α=0.89. Exercise-related self-efficacy (ESE) was measured using three
items referring to the confidence to be able to initiate, to maintain, and to resume regular
exercise behavior 25. The response format was a 4-point Likert scale with total scores from 3
to 12 points. Cronbach’s alpha for the given sample was α=0.89.
Perceived barriers to physical exercise were quantified using a 15-item questionnaire
exploring why physical exercises could not be conducted regularly 26. Responses were given
on a 7-point Likert scale (from “fully true” to “not true at all”). The 15 items included four
subscales: lack of motivation for physical exercise (5 items, α=0.86), lack of time (4 items,
α=0.86), body-related uncertainty (4 items, α=0.81), and social context (2 items, α=0.57).
Each subscale ranges from 0 to 6 with the value 0 indicating no perceived barriers.
In addition, a background information questionnaire was administered to obtain information
on participants’ OA diagnosis, co-morbidity, subjective health status, previous surgeries, and
socio-demographic data.
11
Data analysis - overview
Returned completed questionnaires were scanned and data were electronically processed into
a text file (EvaSys, Electric Paper, Lüneburg, Germany). Queries were generated
electronically and subsequently edited by the investigator; plausibility checks of the complete
data table were conducted at random.
The cluster analytic approach to define groups of patients with distinct profiles of exercise
participation motives comprises several steps of data preparations and analyses. Firstly, we
determined which of the BMZI scales were considered as active cluster variables. This was
done by comparing the basic characteristics of each scale as well as by conducting several
cluster analysis with different subscale combinations as input variables using Ward’s method.
Secondly, we determined the number of clusters for the final cluster analysis, again using
Ward’s method. Thirdly, we used an optimization procedure (quick cluster method) to
optimize the cluster assignment of single individuals. For these three steps of data analyses,
we applied a set of formal and content-related criteria that are presented in Table II in order
to maximize the conformability of the cluster analytical procedures 27.To improve
comprehensibility of the iterative and explorative procedure for interested readers, further
details on these three steps are given below. Fourthly, we were able to characterize the final
distinct profiles of exercise participation motives that represent the main results of our study
report. Finally, we further characterized the defined clusters by means of the passive cluster
variable that comprises the measures of physical functioning, self-efficacy, perceived barriers
to exercise participation as well as socio-demographic characteristics.
Between-cluster differences in both active and passive variables were tested using a one-way
ANOVA for metric data and chi-square tests for categorical data, with cluster membership as
the independent variable and the descriptive variables as dependent variables (crit = 0.05).
Statistically significant between-group differences were further analyzed using the post-hoc-
12
test Tukey’s (Honestly Significant Difference) for metric data, and comparison of
standardized residuals for categorical chi square tests (crit = 0.05). Statistical analyses were
conducted with SPSS Version 20 (IBM SPSS Statistics for Windows, Version 20.0. Armonk,
NY: IBM Corp.).
Detailed data analysis: Determination of active cluster variables
Descriptive data for all BMZI scales are presented in Table I. Reduction of active cluster
variables was rationalized according to formal and content-related criteria (Table II).
According to criterion 1 (score distribution), criterion 2 (discriminant information), and
criterion 3 (practical relevance), the motives fitness and competition/performance were
discarded from further analysis.
Insert Tables I and II about here
For further stepwise reduction of active cluster variables, we used a standardizing procedure
to allow comparison of different cluster solutions. This procedure was chosen to align with a
previous research project on person-oriented exercise interventions, and be comparable with
procedures used in person-oriented research 20;28. An intra-individual standardization with the
seven identified motives (contact, distraction/stress regulation, body/appearance, health,
activation/enjoyment, aesthetics, and nature) was conducted to allow inter-individual
comparison on the basis of the intra-individual weighting of motives by each subject 20. For
this reason, data were prepared in four steps: (a) Calculation of the respective mean values of
each of the seven motives for each participant (individual means for each motive on the basis
of underlying items); (b) calculation of the overall mean of the seven individual means for
each participant (mean level of individual motive means); (c) calculation of the standard
deviation of all individual means for each participant; and (d) z-standardization of each
individual motive by dividing the difference of (a) and (b) by (c). A mean individual
13
weighting of a given motive, therefore, had an intra-individual standardized z-value of 0.
Deviations from the mean were expressed in units of the individual standard deviations (SD)
of the seven underlying motives.
An iterative procedure was then used to define the final active cluster variables. In each
analysis, the single-linkage method for clustering was conducted as a first step to control
extreme individual motive profiles. Subsequently, Ward’s method (Euclidean distance) was
used to cluster motive profiles. The final active variables and the final number of clusters
were rationalized with the complementing criteria according to goodness of fit (formal
criteria) and content-related criteria (Table II). In particular, these are the criterion 4
(between-cluster heterogeneity), criterion 5 (cluster-specific importance), and criterion 6
(within-cluster homogeneity). The motives activation/enjoyment and distraction/stress
regulation were excluded after consideration of these criteria 4 to 6.
Concerning criterion 4 (between-cluster heterogeneity), one-way ANOVA showed
statistically significant between-group effects for clusters for each of the remaining five
motives (p < 0.001). However, the proportion of variance explained by the motive health in
comparison to the other motives was limited (eta = 0.09 (health) vs. eta = 0.40 − 0.58 (other
motives)). Despite the limited discriminative power of this motive, we decided to retain it as
it showed the highest mean values indicating the particular relevance of this motive for
exercise participation (see Table I and Table II, No5). It has also face validity for the setting
of exercise therapy in OA (criterion 3: practical relevance) and it is comparable to the motive
fitness which was rejected according to criterion 2 (discriminant information) in favor of the
motive health.
Because of these preparatory analyses, the main cluster analysis (Ward’s method, Euclidian
distance) was based on the following five BMZI subscales: health, body/appearance,
aesthetics, nature, and contact (see Table II).
14
Detailed data analysis: Determination of the final cluster number
The final number of clusters was derived according to criteria 7–10 (Table II). Criteria 7
(dendrogram) and criteria 8 (scree plot) recommended a final number of 4 or 6 clusters.
When considering criteria 9 (feasible number of clusters) and criteria 10 (cluster size) 27, four
clusters were finally defined as the cluster solution representing individual motive profiles for
exercise participation. The number of participants in each cluster after Ward’s method was
applied ranged from 48 to 113 participants.
Detailed data analysis: Optimization procedure
In the last step of the cluster analytical procedures, the final Ward cluster solution was
optimized using a non-hierarchical method (quick cluster). Therefore, the cluster centers from
the prior analysis were used as initial seed points. This method allows the reassignment of
objects into clusters; if, in the course of assigning objects, an object became closer to a cluster
that was not the cluster to which it was currently assigned, the optimizing procedure switched
the object to the more similar (closer) cluster 29. The resulting clusters showed higher internal
(within-cluster) homogeneity and higher external (between-cluster) heterogeneity 30.
Table III presents the mean and SD for each motive in the four final clusters after this
optimization procedure (n = 60–80). The overall percentage of subjects that were identically
classified in a given cluster was “good” (84.6%;; κ = 0,792). Within each cluster, the identical
classifications ranged from “satisfying” (69%) to “very good” (98.3%).
Insert Table III about here
Calculation of within-cluster SD related to overall SD for a given motive was used to
quantify the degree of within-cluster homogeneity (criterion 6, Table II). A ratio larger than1
(F > 1) indicated a larger within-cluster deviation compared with the deviation of the
15
respective motives over all subjects. These limits were only touched or exceeded for the
motive health in cluster 4 and the motive nature in cluster 1 (Table III, bold). All other
indices were between F = 0.52 and 0.85.
Results
Characterization of recruitment and study sample
In total, 757 questionnaires were disseminated, of which 291 were completely returned. This
gave a response rate of 38%. 279 participants could be included in the data analysis (Figure
1).
Insert Figure 1 about here
Most of patients were recruited in the region of the study institution. Further characteristics
of the study sample are displayed in Table IV (column 1).
Characterization of clusters: motive profiles
Each of the four clusters represented a distinct exercise participation motive profile based on
different BMZI domains. Characteristics of motive profiles were primarily described using
the standardized z-values of the underlying motives (Figure 2). Raw data without a
normalization procedure were used to cross-check the standardized findings. The description
of motives also reverted to the items underlying the motives to illustrate the specific topics.
Insert Figure 2 about here
The four clusters with different exercise participation motive profiles were further specified
according to socio-demographic characteristics, physical functioning, degree of OA-related
impairment, perceived barriers to exercise participation, and self-efficacy (Table IV). These
16
specifications were not only related to statistically significant differences but also in a
descriptive manner.
Insert Table IV about here
The motive health appeared to be a predominant motive for the majority of participants
across all motive profiles (Figure 2). Characteristics of all other motives varied between
clusters and were able to be further distinguished in the particular motive profiles.
Motive profile 1 (health-focused sportperson: n = 60; 22%)
Predominant motives for this cluster were health and aesthetics, the latter being related to
enjoyment of exercise, or visual and kinesthetic perception of exercise and movement.
Additionally, this cluster was the only one that highlighted social contact as a potential
motive for exercise participation (mean > 3 on a scale from 1-5 in the raw data). Weight
management and appearance were of minor relevance for participants in this cluster.
Participants in this cluster tended to be older and the proportion of retired people was higher
than in clusters 2 and 3. The group also had a higher proportion of females. Despite their
advanced age, participants indicated little physical impairment and most reported an average
or above-average subjective health status.
Motive profile 2 (sporty nature-oriented individualists: n = 77; 28%)
Activities involving the natural environment, health, and enjoyment of exercise (motives
nature, health, and aesthetics) were found to be preferences of participants in cluster 2.
Although standardized values for the motive body/appearance were only average, its
respective raw data indicate that this motive with the underlying items weight management
and improvement of physical appearance was more relevant for these participants than for
17
those in clusters 1 and 4. The motive contact was disregarded as being relevant for this group
following comparison with the parameter values of all other motives.
Both males and females were represented in cluster 2. Although not statistically significant,
participants in this cluster had above-average education levels. They also had superior
general and exercise-related self-efficacy, and were able to accomplish their goals on their
own.
Motive profile 3 (the Functionalist: n = 62; 22%)
This motive profile reflects purposive people predominantly interested in preserving or
rebuilding health through exercise. For this cluster, weight management and appearance
(motive body/appearance) were further factors influencing participation in exercise, whereas
the motives aesthetics, nature, and contact were of less importance.
Patients in this group reported below average subjective judgments of health status, and had
the worst scores on physical functioning of all clusters for pain and stiffness. These between-
cluster differences reached statistical significance in comparison with cluster 4.
Exercise related self-efficacy in this cluster was sub-standard, and they also reported many
barriers that impacted on physical activities, including fear of increasing the load on the
affected joints and the corresponding increase in pain, lack of time, difficulties in motivating
themselves to exercise, limited confidence in their own body, or a social environment that
obstructed participation in periodic exercise.
Motive profile 4 (nature and health-conscious exercisers: n = 80; 29%)
Nature and health were the distinct motives for cluster 4, and enjoyment of exercise
(aesthetics) was underrepresented.
18
The scores of participants in this group indicated that they experienced a lack of motivation
to participate in physical exercise.
Discussion
Person-oriented therapy
The efficacy of exercise for hip and knee OA has been demonstrated in a number of studies,
and international guidelines recommend exercise as a core element in OA treatment 3-6;31;32.
However, the literature clearly identifies a need for further research related to individualized
therapies 3;6;8. Individualization should be based on informed, shared decision-making that
takes into account that person’s preferences and needs 3;9. In so doing patients are more likely
to comply with therapeutic interventions which has been shown to be a predictor for efficacy
of physical exercise 9;33.
The person-oriented therapy approach reflects body functioning, activity, and personal factors
according to the bio-psycho-social ICF framework 10;11.
The uniqueness of this study is to emphasize the consideration of motive profiles as potential
facilitators of exercise participation 9;34. In this regard, the BMZI seems to be a valuable tool
as it delineates numerous incentives induced via physical activity aside of health-related
exercise reasons. This instrument was already used in a previous investigation conducted in
leisure and health sports in a university setting. That study examined the influence of motive-
based tailoring of exercise regimes based on acute affective responses to the exercise activity
18;20
. The results indicated that explicit motives and goals had a moderating influence, and the
authors concluded that their findings suggested a systematic consideration of explicit motives
and goals in the planning of exercise programs 35. We therefore transferred this approach to
patients with hip or knee OA. Despite the given focus on individual motives for exercise
participation, disease-specific as well as exercise related barriers were also considered to
19
account for the complexity of exercise behavior in people with OA. The definition of
distinctive motive profiles in the underlying population by cluster analysis was the first step
for a person-oriented exercise regime. We further described our results using variables that
influenced the components of specific exercise programs. This allowed us to identify general
recommendations for four different programs targeted to four specific subgroups of people
with hip and knee OA. Examples to transfer study results into every day routine are outlined
in the following. Contents take into account the authors personal knowledge on effectiveness
of exercise interventions in OA from the professional perspective of a physician, sports
scientist and physiotherapist. The expertise was nurtured by literature research, own research
activities as well as several years of practical experience in the treatment of patients with hip
and knee OA.
Exercise recommendations for motive profiles
Recommendations for motive profile 1: Health-focused sportperson
The characteristics underlying this motive profile mean that functional exercises should be
implemented to increase physical health. The exercises should also include aesthetic activities
for older patients with OA that are not high-impact. An exercise program for patients with
OA with this motive profile could, therefore, incorporate elements of activities such as Tai
Chi that involve fluent, smooth movements which benefit muscle strength, coordination, and
postural control without placing high loads on the body 36.
Recommendations for motive profile 2: Sporty nature-oriented individualists
For patients in this motive profile, individual outdoor activities with cyclic loading that
prohibit high joint-loading have face validity for a positive impact on physiognomy and
weight. An exercise that meets these requirements and may be appropriate for this group is
20
cycling. In addition, the exercise regimes developed for people in this group should
implement strength and coordination training, which can be incorporated into aerobic
training. Instruction for these types of exercises can be delivered through leaflets/booklets
that could also contain additional information on OA, disease-specific management in
everyday life, and an exercise log to document progress. This will allow people given this
kind of exercise regime to a self-directed training and thus accounting for their good values in
self-efficacy.
Recommendations for motive profile 3: The Functionalist
Exercises for people with this motive profile should primarily be purposive, and aimed at
maintaining or improving health and regulating weight. This group is likely to benefit from a
well-structured, functionally oriented training program with the following exercise types:
training of strength, coordination, and flexibility will increase physical functioning in the
activities of daily life, aerobic exercises will improve body composition. Patients in this
group may have difficulties in initiating and maintaining physical exercise due to their low
exercise self-efficacy. As a consequence, health behavior change should be supported by
health professionals and exercise should be supervised on a regular basis. In addition, as
people in this group tend not to place emphasis on social contact and frequently have limited
confidence in their own abilities, individual exercises should be favored over group lessons.
A clearly defined home exercise program that has both aerobic and strengthening elements
should also be included in the regime. To increase self-efficacy in implementing and
maintaining physical exercises, patients in this group may also benefit from information on
10;37
exercise self-regulation and an exercise log to document progress . To manage the
barriers to exercise, it may be helpful to include the person’s partner or other support person
in a counseling session at the beginning of the training program to assist scheduling of
21
exercise lessons. The recommendations for this group include elements of an exercise
program for hip OA that has been previously evaluated 4;38;39.
Recommendations for motive profile 4: Nature and health-conscious exercisers
People in this motive profile tend to have an affinity for nature, and will benefit from an
exercise program that incorporates outdoor activities that can be conducted in groups or
alone. Although people in this profile may not specifically seek social contact through
exercise activities, group dynamics can be useful to increase motivation to initiate and
maintain physical exercises 37. Training sessions could include low-impact aerobic exercises
such as cycling or Nordic walking, and involve intermittent stationary strengthening and
flexibility exercises for hip and knee joints as well as balance tasks in standing and walking.
This type of exercise program can use natural environmental conditions to create exercise
stations.
Study limitations
Exercise recommendations
The aforementioned exercise recommendations present examples of application for the
depicted motive profiles for exercise participation. They reflect an individual opinion that
was not standardized by a systematic procedure to achieve consensus. This remains a
limitation of the study.
Outcome measures
Some outcome measures used in this study are not available in English. This may
compromise external validity of the results. From our perspective this argument can be
refuted for the most part. The BMZI is the central element of this research project to ask for
22
motives for exercise participation in health sports. Relevant facilitators of exercise such as
being outdoor, health benefits, enjoyment, socializing etc. have already been described for
persons with osteoarthritis and knee pain 34;40. However, to the authors’ knowledge there is no
other validated reputed questionnaire to quantify individual motives for exercise participation
with a German translation.
The FFbH-OA was chosen over the WOMAC physical function scale because of its extensive
use in Germany in the context of rehabilitation and because of its more specific time and task
related definition of activities of daily living in comparison to the WOMAC Index. According
to their similar psychometric properties, both instruments can be used broadly equivalent 41.
The General Self efficacy scale is a validated scale that was developed by Schwarzer and
Jerusalem 24. It is available in several languages. The exercise efficacy scale with three items
has already been used in previous investigations 42 and showed very good internal
consistency in our study. We foresaw using a more comprehensive questionnaire for exercise
related self-efficacy to limit the total length of the questionnaire.
Perceived barriers to initiating and sustaining engagement in physical activities were
quantified with a scale including many items that have been described as relevant in
literature. Examples are lack of time, laziness, lack of family support, availability of exercise
classes, perceived ability to exercise, concern over exercise induced pain and wear and tear,
and lack of enjoyment 9;34;40. Aside from the subscale social context, all other scales
demonstrated very good values for internal consistency. However no English translation for
this questionnaire is available. This remains a limitation of the study.
Data analysis
Cluster analysis is an explorative procedure and is dependent on the investigators’ criteria for
defining active variables and determining the final cluster number. In the context of our
23
study, several formal and content-related criteria were defined to illustrate the decision
criteria (Table II). The external validity of the defined clusters was also supported by the
discriminative power of the passive variables used to further differentiate the clusters (Table
IV). Measures of all sections of the questionnaire showed plausible and statistically
significant between-cluster differences. This allowed motive profiles to be characterized to
show a patient-oriented perspective related to motives for exercise participation as well as to
relevant elements of OA (i.e., pain and functioning) and determinants of exercise behavior
(i.e., self-efficacy and barriers).
The stability of the analysis has been demonstrated by the reclassification of participants in
the context of the cluster analysis optimization procedure. In our study, the rate of
reassignment to the previous cluster was 85%; a value considered to be good and comparable
to previous investigations 20. However, reassignment rates differed between clusters, with fair
rates for cluster 4 (69%) and very good rates for clusters 2 and 3 (98%). The homogeneity
indices of the clusters were also comparable to results of previous studies that used the BMZI
with respect to within-cluster SD for a given motive versus overall SD of that motive 20. Our
findings showed that for cluster 1, the motive nature had a larger within-cluster SD compared
with the SD of the motive nature for all participants. For the motive health in cluster 4,
within-cluster heterogeneity was equal to between-cluster heterogeneity. Aside from these
two exceptions the homogeneity was satisfying.
External validity of the study sample
In terms of the extent to which our results can be expected to be representative of the target
group, the intended area of application is the population of patients with hip and/or knee OA.
Data are representative for gender aspects: the male to female ratio of participants was 44%
to 56%; a ratio similar to the prevalence of OA in Baden-Württemberg (37% to 63%). Our
study sample is not representative of all patients with OA with regard to other
24
sociodemographic data such as age, region of residence and proportion of foreigners: The
mean age of all study participants was 62 years, and there were no relevant sex-related age
differences. Study data were not representative of age-related OA prevalence: Males and
females of 50–59 years of age were overrepresented in comparison with the basic population
of patients with OA in Baden-Württemberg 43. The regional distribution of participants was
not representative of the wider German population, as most of patients were recruited in the
region of the study institution. However, the community sizes used as an indication for rural
versus urban living environments were similar for the study sample and the general
population 44. Of the study population, 95% were born in Germany and 98% were German
citizens. The proportion of foreigners was considerably lower than the proportion of
participants from Baden-Württemberg, with a foreigner rate of 12% 45.
According to mean values of the WOMAC scores and the FFbH-OA, results of this study
refer to PA patients with moderate limitations in pain and functioning.
Conclusion and Perspectives
The present study aimed to identify target groups as an initial point for patient-oriented
exercise interventions for people with knee and hip OA. Our approach explicitly used
intrinsic incentives related to physical exercise such as aesthetics of movement, social
contact, or the natural environment, to encourage the initiation and maintenance of an
exercise intervention in the treatment of OA. Results of the study delineate phenotypes
defined by cluster analysis and further description, which are comprehensible and
meaningful. The phenotypes were subsequently used to define key aspects of different
patient-oriented exercise interventions, each considering a distinctive profile of motives for
exercise participation. The chosen sample represents patients with OA eligible for exercise
therapy. Therefore, our results present significant insights stimulating the development of
25
person-oriented exercise interventions in this population group. They address health
professionals to rethink goal setting in the context of exercise interventions and may also help
patients to comply with this first-line treatment. This will encourage development and
implementation of person-oriented, effective exercise regimes. Further research is required to
evaluate whether the described phenotypes are stable across different populations with regard
to disease progression, age, socio-demographic data and exercise related experience. It is of
further interest, if a person-oriented therapy focusing on individual motives for physical
exercise participation increase compliance to therapy and as a consequence its effectiveness.
Both outcomes should therefore be investigated in controlled studies that compare
individualized with standardized exercise programs.
26
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30
Titles of Tables
Table I. Raw data scale characteristics: Distribution and internal consistency.
Table II. Criteria for definition of active cluster variables and the number of clusters.
Table III. Quick cluster optimization of BMZI1 motives: F values ≥1 in bold numbers, calculated as
ratio of cluster SD/Overall SD.
Table IV. Characteristics of the overall data set (total) and each of the four clusters 1-4.
Titles of Figures
Figure 1. Study flow chart.
Figure 2. Motive profiles of clusters 1–4 based on z-standardized means of BMZI domains; high
values indicate a high individual weighting of a given motive, zero indicates an average weighting,
and a low value indicates a low individual weighting.
1
Bernese Motive and Goal Inventory in Leisure and Health Sports
SD: standard deviation
Table I. Raw data scale characteristics: Distribution and internal consistency.
Item examples1
Scale Items n MV SD Skewness Kurtosis 
Why do you exercise (or might exercise)?
 To maintain a good physical condition.
Fitness 3 285 4.32 0.90 −1.77 3.12 0.91
 To be physically fit.
 To compete with others.
Competition/performance  To achieve my exercise goals. 4 280 1.64 0.82 1.30 1.00 0.79
 Especially for enjoyment of body

Activation/enjoyment movements. 3 283 3.64 1.06 −0.72 −0.08 0.78
To replenish new energy.
 To release stress.
Distraction/stress regulation  To distract from others problems. 4 280 2.47 1.19 0.42 −0.81 0.87
 To improve my health status.

Health  Especially because of health reasons. 4 287 4.24 0.85 −1.47 2.30 0.86
 To regulate weight.
Body/appearance  Because of my body shape. 3 279 3.17 1.30 −0.19 −1.11 0.87
 For enjoyment of aesthetic movements in

Aesthetics 2 287 3.03 1.32 −0.06 −1.18 0.76
exercise.
Nature  To exercise in the nature. 2 286 3.56 1.34 −0.59 −0.85 0.87
 To do sociable activity with others.
Contact  To meet friends and acquaintances. 5 280 2.56 1.15 0.20 −0.90 0.91
MV: mean value; SD: standard deviation; : standardized Cronbach’s alpha; 1 The items have been originally used in German language and were translated into English by the
authors.
Table II. Criteria for definition of active cluster variables and the number of clusters. + criterion met by variable; - criterion not met by variable
Discarded variables Active cluster variables
No. Type1 Criterion for definition of active cluster variables
Fitness
Competition
performance
Activation
enjoyment
Distraction
stress regulation
Health
Body
appearance
Aesthetics
Nature
Contact
Score distribution. Analysis of mean, SD, and histograms of all score values as indices for mean values and between-
subject heterogeneity of the answering behavior. Low (1–2) and high (4–5) score values were defined as negative
1 F selection criterion. High SD as an expression for answering heterogeneity was a positive selection criterion. A - - - + - + + + +
heterogenic distribution of values was favored for selection in contrast to a large SD caused by few extreme values.
Assessment of skewness, kurtosis, and normality of the distribution of BMZI scale values.
Discriminant information. Assessment of raw scale correlation coefficients for each motive. In cases of high
2 F correlations (r > 0.6) only one motive should be used as an active variable for the subsequent cluster analysis to - + - + + + + + +
avoid redundant discriminatory power of active variables.
Practical relevance. Assessment of the practical relevance of each scale (motive) by answering the following
questions: Is it possible to easily implement the given motive in the conception of health-related exercise programs
3 C - - + + + + + + +
for subjects with OA? Are motives redundant and, therefore, interchangeable in terms of their realization into an
exercise program?
Between-cluster heterogeneity. Rating of the between-cluster center difference of each active variable (statistical
4 F - - - + + + +
significance and eta for between-group effects).
Cluster-specific importance. Rating of the cluster-specific mean of each active variable in comparison to the overall
5 C cluster mean. Positive differences were prioritized as they indicated explicit confirmation of the given active + - + + + - +
variable.
Within-cluster homogeneity. Rating of within-cluster SD in comparison to overall cluster SD for each active variable.
6 F + + - + + - +
F = >1 was set as a criterion for within-cluster heterogeneity.
No. Type Criterion for determination of the number of clusters
Visual inspection of the dendrogram for interpretation of the distance between merged clusters and the intergroup
7 F
dissimilarity between the two daughters.
8 F Visual inspection of the scree plot (imaging of the cumulative sum of errors in relation to the number of clusters).
Feasible number of clusters in terms of their content-related interpretability, parsimony, and translation into practice
9 C
because too many different motive profiles cannot be addressed in daily routine.
A cluster size of >10% was adopted to allow for the representativeness of final clusters for the underlying
10 F
population.
1
Formal (F) and content-related (C) criteria. SD: standard deviation
Table III. Quick cluster optimization of BMZI1 motives: F values ≥1 in bold numbers, calculated as ratio of cluster SD/Overall SD.
Quick Cluster Method

zBMZI_health zBMZI_body/appearance zBMZI_aesthetics zBMZI_nature zBMZI_contact
Cluster number
Cluster 1 Mean 0.95 −1.02 0.45 −0.14 0.03
n = 60 SD 0.53 0.67 0.66 0.80 0.62
Cluster 2 Mean 0.69 −0.03 0.33 0.70 −1.42
n = 77 SD 0.50 0.68 0.49 0.42 0.45
Cluster 3 Mean 1.32 0.92 −0.57 −0.41 −0.73
n = 62 SD 0.52 0.57 0.55 0.60 0.40
Cluster 4 Mean 0.86 −0.24 −0.93 0.95 −0.31
n = 80 SD 0.73 0.75 0.52 0.43 0.66
Overall Mean 0.93 −0.09 −0.21 0.35 −0.64
n = 279 SD 0.62 0.93 0.81 0.80 0.77
1
Bernese Motive and Goal Inventory in Leisure and Health Sports
SD: standard deviation
Table IV. Characteristics of the overall data set (total) and each of the four clusters 1-4.
Cluster Total 1 2 3 4 p value1

Sociodemographic characteristics
Number of subjects 279 60 77 62 80 279
Females 156 72%a 55%b 48%b 51%b p = 0.042
Age (years)2 62.1 (10.9) 67 (11.4)a 59 (10.0)b 60 (10.6)b 63 (10.2)a,b p < 0.001
a b
BMI (kg/m ) 26.9 (5.4) (11.4)
26 (6.9) (10.0)
27 (4.8) 28 (5.6) 27 (4.3) p = 0.249
Use of medication — yes? 66% 68% 64% 73% 63% p = 0.641
Are there complaints that can worsen with exercise — yes? 61% 57% 64% 71% 55% p = 0.116
Retired — yes? 51 % 72%a 38%b 43%b 53%b p =0.029
Educational Background (% for High school, p-value overall) 32% 34.5% 33.8% 28.8% 29.5% p = 0.029
0.907
Professional qualification (% for apprenticeship, p-value overall) 57% 55% 55% 54% 62% p = 0.414
Living in partnership — yes? 76% 67% 75% 82% 79% p = 0.208
Children at home — yes? 27% 20% 33% 33% 24% p = 0.253
Subjective health status (% for below average, p-value overall) 11% 3%a 8%a,b 23%b 9%a,b p = 0.008
Physical functioning
WOMAC3 Subscale Stiffness (0=best, 10=worst) 3.1 (2.6) 3.1 (2.5)a,b 3.2 (2.5)a,b 3.8 (3.0)b 2.5 (2.2)a p = 0.036
WOMAC2 Subscale Pain (0=best, 10=worst) 2.8 (2.3) 2.6 (2.2)a,b 3.1 (2.5)a 3.2 (2.6)a 2.2 (1.9)b p = 0.049
FFBH-OA4 (0=worst, 100=best) 83.5 (18.1) 83.2 (17.4) 83.3 (20.0) 81.1 (19.5) 86.0 (15.5) p = 0.454
Self-efficacy
General self-efficacy (10=worst, 40=best) 30.6 (4.6) 30.4 (4.8)a 32.2 (4.0)b 30.2 (4.0)a 29.4 (5.0)a p = 0.001
Exercise-related self-efficacy (3=worst, 12=best) 9.9 (2.2) 9.6 (2.4)a,c 10.6 (1.6)b 9.2 (2.3)a 9.8 (2.2)c p = 0.002
Perceived barriers to exercise participation
Social context hampering exercise participation (0= not at all; 6=absolutely) 1.8 (2.0) 1.6 (1.9)a 1.5 (1.7)a 2.6 (2.4)b 1.8 (1.9)a p = 0.009
Uncertainty with respect to body/appearance (0= not at all; 6=absolutely) 1.9 (2.0) 1.6 (1.7)a 1.5 (1.8)a 2.6 (2.5)b 1.8 (1.7)a p = 0.003
Lack of motivation (0= not at all; 6=absolutely) 2.0 (2.0) 1.4 (1.5)a 1.3 (1.3)a 3.3 (2.5)b 2.3 (2.0)c p < 0.001
Time issues (0= not at all; 6=absolutely) 2.1 (2.1) 1.7 (1.6)a 2.1 (2.1)a 2.9 (2.2)b 2.1 (2.1)a p = 0.011
1Between-cluster effects (alpha = 0.05). a, b Groups showing significant differences denoted with different letters.
2
Mean (SD)
3 Western Ontario and McMaster Universities Osteoarthritis Index
4 Hannover Functional Ability Questionnaire for Osteoarthritis

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European Journal of Physical and Rehabilitation Medicine

EDIZIONI MINERVA MEDICA

Motives for physical exercise participation as a basis for

European Journal of Physical and Rehabilitation Medicine 2017 Feb 17

Article type: Original Article

© 2017 EDIZIONI MINERVA MEDICA

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oriented exercise interventions in osteoarthritis: A cross-sectional study

Inga Krauss1*, Uwe Katzmarek1, Monika A. Rieger2,3, Gorden Sudeck4

Eberhard Karls University of Tübingen, Wilhelmstraße 27, 72074 Tübingen, Germany

Data of this manuscript have been presented at two national congresses:

(1) Congress of the German Association of Sports Science (Deutsche Vereinigung

Arthrose. Sportwissenschaft grenzenlos?! In: Schriftenreihe der Deutschen Vereinigung für

Sportwissenschaft 2013;230:157. 21. Sportwissenschaftlicher Hochschultag der dvs vom 25.-

27.9.2013 in Konstanz, Germany.

(2) German Congress for health services research

Krauß I, Katzmarek U, Sudeck G. Personenorientierte, sporttherapeutische Interventionsmaßnahmen

Versorgungsforschung vom 27.-29.9.2012 in Dresden, Germany.

and the Elderly of Baden-Württemberg.

of the University of Tübingen) for her support in content-related and organizational

questions; Dr. Martina Michaelis (FFAS - Freiburger Forschungsstelle Arbeits- und

in scanner-based questionnaire processing (EvaSys, Electric Paper).

and Electric Industry Baden-Württemberg (Südwestmetall).

The authors have no declarations of interest to report.

Name, address, e-mail of the corresponding author.

Prof. Dr. Inga Krauss

Medical Clinic, Department of Sports Medicine

72076 Tübingen, Germany

Tel. +49 7071 2986486, Fax +49 7071 29 5162

BACKGROUND: Physical exercises are effective in the treatment of osteoarthritis (OA).

relevant motive for exercise participation. Accordingly, exercise interventions primarily

OA according to the International Classification of Functioning and Disability and Health

profiles and further described by their disease-related symptoms, limitations and

psychological determinants of exercise behavior. DESIGN: Observational study via self-

administered questionnaires. SETTING: Community. POPULATION: 292 adults with

hip/knee OA living independently of assistance. METHODS: Participants completed the

Functional Ability Questionnaire for Osteoarthritis, the WOMAC-Index (pain/stiffness), the

General Self-efficacy Scale and a questionnaire on perceived barriers to exercise

individualists; functionalists primarily motivated by maintaining or improving health through

exercise; and nature-oriented, health-conscious exercisers. CONCLUSION: This study

contributes to the development of person-oriented exercise recommendations with a special

oriented exercise interventions could be defined according to each phenotype. CLINICAL

REHABILITATION IMPACT: Incentives related to physical exercise such as enjoyment,

contact, or natural environment may encourage compliance to an exercise intervention. Goal

reasons but also reconsider individual motives for exercise participation.

Osteoarthritis, Exercise, Patient-oriented therapy, ICF

people living in industrialized countries almost as large as that of respiratory or digestive

and aerobic exercise is strongly recommended as a first-line, conservative treatment option

individualized exercise interventions 3;5;6;8. They should be based on informed, shared

The International Classification of Functioning, Disability and Health (ICF) is a suitable

framework to enable development of a comprehensive patient-oriented exercise intervention

up-to-date synthesis of literature summarizes findings of previous studies on facilitators for

individual” remain rather general.

accompanied by delay of gratification and may, therefore, negatively affect exercise

pressure to continue with exercise if physical improvements result in relief of disease-related

interaction and enjoyment of exercise have been described as important facilitators of

distraction, aesthetic movements, competition or outdoor experience are rarely mentioned in

development of exercise programs 20. The beneficial effects of incorporating additional

well as limitations in physical functioning and participation in activities of daily living.

should be characterized by similar profiles of individual exercise participation motives

described by their disease-related symptoms and limitations in physical functioning, as well

The present study was a cross-sectional study conducted in Baden-Württemberg, Germany.