Research Report

Physical Activity Promotion in the

Physical Therapy Setting: Perspectives
From Practitioners and Students

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Debra Shirley, Hidde P. van der Ploeg, Adrian E. Bauman
D. Shirley, PT, PhD, FACP, is
Coordinator of Musculoskeletal
Background. Physical inactivity is a major risk factor for chronic disease. Primary Physiotherapy, Discipline of Phys-
health care practitioners are well placed to promote a physically active lifestyle. The iotherapy, Faculty of Health Sci-
perceptions and practice of physical therapists on their role in physical activity ences, University of Sydney, Syd-
promotion are not well known. ney, New South Wales, Australia.

H.P. van der Ploeg, PhD, is Senior

Objective. The objective of this study was to determine the knowledge, confi- Research Fellow, Cluster for Phys-
dence, role perception, barriers, feasibility, and counseling practice of physical ical Activity and Health, Sydney
therapists and physical therapist students regarding the promotion of nontreatment School of Public Health, University
of Sydney, Level 2, Medical Foun-
physical activity for better health.
dation Building (K25), Sydney,
New South Wales 2006, Australia.
Design. A cross-sectional survey was conducted. Address all correspondence to Dr
van der Ploeg at: hiddep@health.
Methods. In 2008, 321 (54%) of a random sample of all physical therapists usyd.edu.au.
registered in New South Wales, Australia, responded to a survey on their knowledge, A.E. Bauman, PhD, FAFPHM, is
confidence, role perception, barriers, feasibility, and counseling practice with regard Sesquicentenary Professor of Pub-
to promoting a physically active lifestyles to their patients. Physical therapist students lic Health (Behavioral Epidemiol-
(n⫽279) completed the same survey but without the questions on barriers and ogy and Health Promotion), Clus-
ter for Physical Activity and
counseling practice. Health, Sydney School of Public
Health, University of Sydney.
Results. Physical therapists and physical therapist students consider that it is part
[Shirley D, van der Ploeg HP, Bau-
of their role to give their patients nontreatment physical activity advice. Overall, they man AE. Physical activity promo-
reported having adequate knowledge and skills to undertake this role. Incorporating tion in the physical therapy
advice into normal consultations is deemed the most feasible form of lifestyle physical setting: perspectives from practi-
activity promotion in physical therapist practice. tioners and students. Phys Ther.
2010;90:1311–1322.]
Limitations. The cross-sectional nature of this study makes it difficult to deter- © 2010 American Physical Therapy
mine cause and effect relationships. Some selection bias may have occurred, as the Association
physical therapists who completed the questionnaires may have been those most
interested in physical activity promotion.

Conclusions. Physical therapist practice appears to be an excellent avenue for

promoting a physically active lifestyle and could potentially play an important public
health role.

Post a Rapid Response to

this article at:
ptjournal.apta.org

September 2010 Volume 90 Number 9 Physical Therapy f 1311

Physical Activity Promotion in Physical Therapy
P
hysical activity is accepted
worldwide as a public health
priority. A physically active life-
style has been shown to significantly
reduce the risk of developing cardio-
vascular disease, obesity, type 2 dia-
betes mellitus, several forms of can-
cer, and depression.1– 4 Regular
physical activity decreases all-cause
mortality risk by 20% to 30% com-
pared with insufficient activity.5
Most of these effects on all-cause
mortality can be assigned to the pos-
itive effects of physical activity on
cardiovascular disease and cancer,
the leading causes of mortality and
morbidity in the Western world.
This epidemiological evidence has
been synthesized into recommended
levels of physical activity for meta-
bolic health and cardiovascular dis-
ease prevention by the American
College of Sport Medicine and the
American Heart Association. The rec-
ommendation states that adults
should be active 5 days per week and
have at least 30 minutes of moderate-
intensity activity daily.1,3 Recom-
mended levels of physical activity for
cardiovascular health can comprise
all types of regular activity, such as
structured exercise, active commut-
ing, incidental activity and active liv-
ing, and active sports and recreation.
Only half of all Australian adults meet
these physical activity recommenda-
tions,6 which means the other half is
at increased risk of developing car-
diovascular disease, diabetes, obe-
sity, several forms of cancer, and a
range of other chronic diseases. In
the United States, physical inactivity
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1312 f Physical Therapy Volume 90
is an even more widespread public
health problem, with only a quarter
of adults meeting the national phys-
ical activity recommendations.7 The
public health challenge is to develop
approaches that reach large numbers
of people with evidence-based pri-
mary prevention strategies.
Primary health care practitioners are
ideally positioned to promote physi-
cal activity as a health promotion
measure. Many patients in primary
care have health problems that could
be prevented by a physically active
lifestyle.8 For the past decade, there
has been a focus on using primary
care physicians to promote physical
activity. Strategies implemented by
primary care physicians have demon-
strated mixed success,9 –12 with most
programs showing modest effect
sizes and only in the short term.13 It
has been suggested that a reasonable
approach for primary care physi-
cians to adopt is to undertake brief
interventions with inactive patients
who have health conditions that
could be reduced by physical activity
participation.13 However, the main
barriers to health promotion identi-
fied by primary care physicians are
perceived lack of training, beliefs
that they are unable to change health
habits, time constraints, and lack of
confidence.14,15 Although campaigns
about the importance of physical ac-
tivity have improved knowledge
among primary care physicians, this
knowledge has not translated into
counseling more patients in physical
activity.8,16
Physical therapists are primary care
practitioners who are thought to
have great potential for physical ac-
tivity promotion.17 They prescribe
exercise for a wide range of condi-
tions (mostly musculoskeletal) re-
quiring rehabilitation. Currently,
physical therapy is mainly a tertiary
prevention discipline, even though
physical therapists are equipped
with the ideal skills and potential to
Number 9
act in a primary prevention role. In
the United States, a survey of physi-
cal therapists indicated that increas-
ing physical activity was the most
frequent area of focus for health pro-
motion behavior.18 The physical
therapists’ confidence in prescribing
nontreatment physical activity pro-
grams is the best predictor of
whether physical activity is pre-
scribed.18 Although it is believed that
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physical therapists should be in-
volved in physical activity promo-
tion,17 the views of individual physi-
cal therapists about their potential
role in physical activity promotion
are not well known. Thus, the feasi-
bility and acceptability of physical
activity promotion in the physical
therapy setting need to be ex-
plored.19 The aim of this study was
to determine the knowledge, confi-
dence, role perception, barriers, fea-
sibility, and counseling practice of
physical therapists and physical ther-
apist students regarding the promo-
tion of nontreatment physical activ-
ity for better health.
Method
In June 2008, study survey question-
naires were mailed to a random sam-
ple of 602 physical therapists. This
sample size was based on our earlier
work on primary care physicians,8
because no data were available for
physical therapists on the researched
outcomes that would have justified
a proper sample size calculation with-
out making ungrounded assumptions.
The random sample was drawn from
all physical therapists in New South
Wales, Australia, who were members
of the Australian Physiotherapy Asso-
ciation. At the time of the survey,
there were 6,585 registered physical
therapists in New South Wales.20 To
maximize the response rate, the orig-
inal sample was sent a reminder to
complete the survey questionnaire
if they had not returned it after 2
months. Three different groups of
physical therapist students from the
University of Sydney were surveyed
September 2010

at the end of a lecture. First-year
(n⫽161) and fourth-year (n⫽136)
students enrolled in the Bachelor of
Applied Science in Physiotherapy
degree program and first-year stu-
dents (n⫽59) from the Masters of
Physiotherapy degree program were
invited to complete the survey. All
survey responses were entered by
the same person into a preset data
entry system, and approximately 10%
were randomly checked by one of
the other researchers for entry mis-
takes, which showed good data entry
quality.
Survey Design
The survey questionnaire was
adapted from a previous survey ques-
tionnaire used in a study of primary
care physicians8 that was designed
based on focus groups with primary
care physicians and initial pilot test-
ing.21 The adaptations made to the
questionnaire were minor and only
aimed to make the questionnaire rel-
evant for physical therapists. The
survey questionnaire, presented in
the Appendix, covered the following
topics: knowledge about the amount
of physical activity required for
health benefits in adults (4 items),
perception of the role of physical
therapists in physical activity promo-
tion (2 items), confidence in promot-
ing physical activity (3 items), barri-
ers to physical activity promotion (6
items), and feasibility of different
physical activity promotion strate-
gies (4 items). All items were scored
on a 5-point Likert scale. Physical
therapists also were asked about the
number of patients they had encour-
aged in the previous month to lead a
more physically active lifestyle. Fi-
nally, general demographic data
were recorded, and participants
were asked how they would rate
their own physical activity levels
compared with those of other Aus-
tralians of the same sex and age on a
5-point scale (ranging from “much
more active” to “much less active”),
which has been shown to reliably
September 2010
Physical Activity Promotion in Physical Therapy
Table 1.
Personal Characteristics of the Physical Therapist Participants and of All Physical
Therapists Registered in New South Wales, Australia
Variable
Female, n (%)
Age (y), n (%)
⬍35
35–44
45–54
ⱖ55
Private practice, n (%)
Years in practice, mean (SD)
No. of patients treated per week, mean (SD)
Hours worked per week, mean (SD)
a
NA⫽not available.
determine relative proportions of ac-
tive and inactive people.22 The phys-
ical therapist student survey was sim-
ilar to the physical therapist survey
but did not include the items on
physical activity promotion practice
and barriers.
Data Analysis
The responses to the questions on
knowledge, role perception, confi-
dence, feasibility, and barriers were
dichotomized by combining the 2
“agree” options and combining the
“neutral” with the 2 “disagree” op-
tions. The question on numbers of
patients counseled about physical
activity each month was dichoto-
mized at 10 or more per month and
fewer than 10 per month, because
this division resulted in 2 groups of
almost equal size and thus optimized
statistical power for the analysis.
Descriptive analysis was used to pro-
vide a basic quantitative description
of the data set. The personal charac-
teristics of all physical therapists reg-
istered in New South Wales were re-
ported to give an indication of how
representative our physical therapist
sample was.20 Inferential compari-
Volume 90
All Physical
Therapists in New
Study Sample South Wales
(nⴝ319) (nⴝ6,585)20
233 (73) 4,863 (74)
133 (42) 2,536 (38)
94 (29) 1,821 (28)
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69 (22) 1,454 (22)
22 (7) 774 (12)
182 (57) 3,753 (57)
14 (11) NAa
50 (26) NA
34 (11) 33 (NA)
sons were made on knowledge, con-
fidence, role perception, barriers,
feasibility, and counseling practice
of physical activity among groups us-
ing multiple logistic regression anal-
yses. The logistic regression analyses
were used to calculate odds ratios
(ORs) to compare physical therapists
who encouraged 10 or more patients
per month to become more active
with those who encouraged fewer
than 10 patients per month to be-
come more active. Similarly, ORs
were calculated using logistic regres-
sion to compare the physical thera-
pists, the fourth-year bachelor’s de-
gree students, and the first-year
master’s degree students with the
first-year bachelor’s degree students.
All logistic regression analyses were
checked for possible confounding
among groups from participants’
sex, years in practice, hours worked
per week, and number of patients
treated per week. Possible con-
founders were added to the regres-
sion model; variables that changed
the OR by at least 10% were identi-
fied as confounders and were cor-
rected for in the final analysis. The
logistic regression analyses were re-
peated to stratify for physical thera-
Number 9 Physical Therapy f 1313
Physical Activity Promotion in Physical Therapy
pists working in the public and pri-
vate health care sectors. All analyses
were performed in SPSS version 17.*
Role of the Funding Source
The project was financed through an
Australian Government National
Health and Medical Research Coun-
cil program grant (#301200) held by
Dr Bauman.
Results
A total of 319 physical therapists
(54%) and 279 (78%) students com-
pleted the survey. The personal char-
acteristics of the participating phys-
ical therapists are described in Table
1, which also describes the personal
characteristics of all physical thera-
pists registered in New South Wales.
The proportion of female respon-
dents was greater in the physical
therapist group (73%) compared
with the student groups, which had
a more even distribution of female to
male respondents (58% female year 1
bachelor’s degree students, 68% fe-
male year 4 bachelor’s degree stu-
dents, and 52% female master’s de-
gree students). The majority of
physical therapists and students con-
sidered themselves more physically
active than other Australians of their
same sex and age (Tabs. 2 and 3).
More than half of the physical thera-
pists (54%) reported that they en-
couraged 10 or more patients each
month to lead a more physically ac-
tive lifestyle (beyond therapeutic ex-
ercises). Table 2 presents the knowl-
edge, role perception, confidence,
barriers, and feasibility of physical
activity promotion for physical ther-
apists who encouraged 10 or more
patients per month to become more
active and those who encouraged
fewer than 10 patients per month to
become more active. There were no
major differences between the phys-
ical therapists who gave physical ac-
* SPSS Inc, 233 S Wacker Dr, Chicago, IL
60606.
1314 f Physical Therapy Volume 90
tivity advice more frequently and
those who gave less advice with re-
gard to their knowledge of the phys-
ical activity message. However, only
one third of the respondents could
name the national physical activity
recommendation for Australian
adults. In both groups, almost all
physical therapists thought it should
be part of their role to give their
patients physical activity advice.
Physical therapists who gave more
patients physical activity advice
were more likely to feel confident in
suggesting specific physical activity
programs. They also were less likely
to identify lack of time or the per-
ception that it would not change the
patient’s behavior as barriers to pro-
moting a physically active lifestyle in
their patients. Overall, physical ther-
apists generally did not identify
many barriers to promoting physical
activity to their patients. Almost all
physical therapists thought it would
be feasible to incorporate brief phys-
ical activity counseling into regular
treatment sessions. Separate one-on-
one and group physical activity con-
sultations were thought to be less
feasible, although almost two thirds
of the physical therapists who gave
physical activity advice more fre-
quently still thought these were fea-
sible avenues for physical activity
promotion. Ninety percent of physi-
cal therapists also thought it would
be feasible to distribute physical ac-
tivity promotion resources.
Physical therapists working in the
public and private health care sec-
tors showed similar responses to the
survey (data not shown). However,
physical therapists in private prac-
tice were less likely to report that
physical activity promotion would
not change the patients’ behavior
(OR⫽0.38, P⬍.01). Compared with
the public sector, private practice
physical therapists more frequently
identified usual treatment consulta-
tions (OR⫽3.76, P⬍.01) or separate
one-on-one sessions (OR⫽1.99,
Number 9
P⬍.01) as feasible avenues for phys-
ical activity promotion, whereas
group sessions were thought to be
less suitable (OR⫽0.55, P⫽.01).
Table 3 shows the results of the com-
parison of physical therapist stu-
dents and practicing physical thera-
pists with regard to knowledge, role
perception, confidence, and feasibil-
ity of physical activity promotion.
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Knowledge of the public health
physical activity message showed a
gradual improvement from the first-
year bachelor’s degree students on-
ward. Almost all respondents agreed
that promoting a physically active
lifestyle is part of the role of a phys-
ical therapist, and as students
progress toward being graduate
physical therapists, their confidence
in promoting physical activity
grows. The most feasible method of
promoting physical activity seems to
be incorporating brief counseling
into a normal consultation, with pro-
vision of resources as the next most
feasible method.
Discussion
The current study indicates that
physical therapists and physical ther-
apist students believe that physical
activity prescription for health pro-
motion should be part of their role
and that they would be confident in
this role. Integrating brief counseling
into usual treatment sessions was
thought to be the most feasible form
of physical activity promotion in
physical therapist practice, followed
by the distribution of resources such
as brochures.
The results of our study are compa-
rable to the attitudes of Australian
primary care physicians who com-
pleted a similar survey that indicated
98% believed physical activity pro-
motion was part of the physician’s
role.16 However, the surveyed physi-
cians felt less confident in giving
physical activity advice than the cur-
rent sample of physical therapists,
September 2010
 Physical Activity Promotion in Physical Therapy

Table 2.
Physical Therapists’ Knowledge, Role Perception, Confidence, Barriers, and Feasibility of Physical Activity Promotiona

Odds Ratio (95% CI) for

Counseled <10 Counseled >10 Physical Therapists Who
Patients/Month Patients/Month Counseled >10 Patients/Month
Variable (nⴝ140), n Agree (%) (nⴝ165), n Agree (%) Compared With <10b

Knowledge of PA message

Taking the stairs at work and generally being 80 (58) 83 (51) 0.70 (0.44–1.13)
more active each day is enough PA to
improve health

Half an hour of walking on most days is all the 77 (56) 100 (61) 1.40 (0.87–2.26)

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exercise that is needed for good health

Exercise that is good for health must make you 35 (25) 45 (27) 1.12 (0.66–1.91)
puff and pant

Several short walks of 10 minutes each on 99 (71) 132 (80) 1.83 (1.05–3.17)c
most days is better than one round of golf
per week for good health

Physical therapist’s role

Discussing the benefits of a physically active 132 (94) 160 (97) 1.69 (0.53–5.39)
lifestyle with patients is part of the physical
therapist’s role

Suggesting to patients ways to increase daily 130 (93) 161 (98) 3.07 (0.92–10.25)
PA is part of the physical therapist’s role

Physical therapists should be physically active 127 (91) 158 (96) 2.58 (0.97–6.85)
to act as a role model for their patients

Confidence in giving PA message

I would feel confident in giving general advice 134 (96) 160 (97) 1.28 (0.37–4.38)
to patients on a physically active lifestyle

I would feel confident in suggesting specific PA 121 (87) 156 (96) 2.48 (1.03–5.99)c
programs for my patients

Barriers to PA promotion

Lack of time 47 (34) 25 (15) 0.32 (0.18–0.57)c

Lack of counseling skills 11 (8) 0 (0)

Lack of remuneration for promoting PA 12 (9) 15 (9) 0.85 (0.37–1.96)

Lack of interest in promoting PA 2 (1) 1 (1)

Feeling it would not change the patient’s 28 (20) 9 (6) 0.25 (0.11–0.56)c
behavior
Feeling it would not be beneficial for the 3 (2) 1 (1)
patient

Feasibility of PA promotion strategies

Brief counseling integrated into regular 122 (88) 158 (97) 3.65 (1.29–10.31)c
consultations

Separate one-on-one consultations 46 (33) 102 (63) 3.25 (1.98–5.32)c

Group sessions 67 (48) 98 (60) 1.69 (1.05–2.72)c

Distribution of resources (eg, brochures) 124 (89) 147 (90) 1.14 (0.53–2.45)

Physical therapist’s PA level

How physically active do you think you are 103 (74) 137 (83) 1.67 (0.94–2.98)
currently compared with other Australians of
your sex and age? (agree⫽more active)

Are you aware of the physical activity 46 (35) 56 (34) 1.09 (0.66–1.79)
guidelines
a
CI⫽confidence interval, PA⫽physical activity.
b
Adjusted for participants’ sex and years in physical therapist practice.
c
P⬍.05.

September 2010 Volume 90 Number 9 Physical Therapy f 1315

Physical Activity Promotion in Physical Therapy

Table 3.
Comparison of Physical Therapist Students and Practicing Physical Therapists With Regard to Knowledge, Role Perception,
Confidence, and Feasibility of Physical Activity Promotiona
Group (Students or n Agree Odds Ratio
Variable Physical Therapists) (%) (95% CI)b

Knowledge of PA message

Taking the stairs at work and generally being more active each day is enough PA BSc, year 1c 33 (36) 1.00
to improve health BSc, year 4d 48 (38) 1.10 (0.63–1.93)
MP, year 1e 22 (44) 1.38 (0.71–2.70)
PTf 167 (53) 1.95 (1.20–3.16)g

Half an hour of walking on most days is all the exercise that is needed for good BSc, year 1 26 (28) 1.00

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health BSc, year 4 48 (38) 1.53 (0.86–2.75)
MP, year 1 29 (48) 2.48 (1.25–4.92)g
PT 187 (59) 3.64 (2.08–5.77)g

Exercise that is good for health must make you puff and pant BSc, year 1 31 (34) 1.00
BSc, year 4 35 (28) 0.82 (0.45–1.47)
MP, year 1 22 (37) 1.14 (0.57–2.26)
PT 85 (27) 0.77 (0.47–1.27)

Several short walks of 10 minutes each on most days is better than one round of BSc, year 1 57 (63) 1.00
golf per week for good health BSc, year 4 86 (69) 1.28 (0.73–2.27)
MP, year 1 41 (67) 1.19 (0.60–2.37)
PT 244 (77) 1.96 (1.19–3.24)g

Physical therapist’s role

Discussing the benefits of a physically active lifestyle with patients is part of the BSc, year 1 84 (91) 1.00
physical therapist’s role BSc, year 4 119 (94) 1.61 (0.56–4.63)
MP, year 1 57 (93) 1.80 (0.46–7.07)
PT 305 (96) 2.11 (0.85–5.24)

Suggesting to patients ways to increase daily PA is part of the physical therapist’s BSc, year 1 75 (82) 1.00
role BSc, year 4 119 (94) 3.61 (1.42–9.23)g
MP, year 1 55 (90) 2.33 (0.80–6.74)
PT 305 (96) 4.73 (2.19–10.19)g
Physical therapists should be physically active to act as a role model for their BSc, year 1 88 (96) 1.00
patients BSc, year 4 115 (91) 0.46 (0.14–1.51)
MP, year 1 52 (85) 0.26 (0.08–0.88)g
PT 298 (93) 0.63 (0.21–1.91)

I would encourage most my patients to have a physically active lifestyle if I were BSc, year 1 89 (97) 1.00
in physical therapist practice BSc, year 4 116 (92) 0.50 (0.05–4.95)
MP year 1 60 (98) 2.19 (0.02–1.56)
PT NA NA

Confidence in giving PA message

I would feel confident in giving general advice to patients on a physically active BSc, year 1 80 (87) 1.00
lifestyle BSc, year 4 110 (87) 1.16 (0.51–2.64)
MP, year 1 58 (95) 4.23 (0.91–19.69)
PT 308 (97) 4.64 (1.95–11.01)g

I would feel confident in suggesting specific PA programs for my patients BSc, year 1 62 (67) 1.00
BSc, year 4 102 (81) 2.28 (1.20–4.30)g
MP, year 1 57 (93) 9.09 (2.62–31.51)g
PT 290 (91) 5.54 (3.05–10.06)g

(Continued)

with about 22% fewer physicians
feeling confident in giving specific
physical activity advice.16 This find-
ing gives physical therapists an ad-
vantage over other primary care
practitioners in successfully integrat-
ing lifestyle physical activity promo-
tion into practice. Furthermore, our
findings showed that the surveyed
physical therapists identified few
barriers to promoting an active life-
style, whereas a number of those same
barriers are known to frequently pre-
vent physicians from promoting phys-
ical activity, especially lack of time,
absence of reimbursements, and lim-
ited counseling skills.8,23,24 In con-
trast, physical therapists have exten-
sive training in exercise prescription
for treatment purposes and at present
mainly operate in a tertiary prevention
capacity. Our results support the ear-
lier notion that physical therapists are
underutilized for promoting a physi-
cally active lifestyle and appear to be
well placed to play an important pub-
lic health role.17,25

1316 f Physical Therapy Volume 90 Number 9 September 2010

 Physical Activity Promotion in Physical Therapy

Table 3.
Continued

Group (Students or n Agree Odds Ratio

Variable Physical Therapists) (%) (95% CI)b
Feasibility of PA promotion strategies

Brief counseling integrated into regular consultations BSc, year 1 59 (65) 1.00
BSc, year 4 92 (73) 1.60 (0.88–2.89)
MP, year 1 53 (87) 3.48 (1.47–8.24)g
PT 293 (93) 7.15 (3.88–13.17)g

Separate one-on-one consultations BSc, year 1 50 (55) 1.00

BSc, year 4 55 (44) 0.65 (0.37–1.12)

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MP, year 1 19 (31) 0.35 (0.17–0.69)g
PT 157 (50) 0.83 (0.52–1.34)

Group sessions BSc, year 1 60 (66) 1.00

BSc, year 4 105 (83) 2.72 (1.43–5.20)g
MP, year 1 36 (59) 0.72 (0.37–1.41)
PT 174 (55) 0.65 (0.40–1.05)

Distribution of resources (such as brochures) BSc, year 1 62 (68) 1.00

BSc, year 4 108 (86) 2.74 (1.41–5.35)g
MP, year 1 49 (80) 2.09 (0.95–4.60)
PT 282 (89) 3.84 (2.17–6.80)g

PA level

How physically active do you think you are currently compared with other BSc, year 1 55 (60) 1.00
Australians of your sex and age? (agree⫽more active) BSc, year 4 66 (53) 0.81 (0.46–1.41)
MP, year 1 43 (71) 1.47 (0.73–2.98)
PT 248 (77) 2.59 (1.56–4.30)g
a
CI⫽confidence interval, PA⫽physical activity, BSc⫽Bachelor of Applied Science in Physiotherapy degree program, MP⫽Master of Physiotherapy degree
program, PT⫽physical therapist.
b
Adjusted for participants’ sex.
c
n⫽92 in BSc program, year 1 (⫽reference category).
d
n⫽127 in BSc program, year 4.
e
n⫽59 in MP program, year 1.
f
n⫽319 of the surveyed physical therapists.
g
P⬍.05.

Although the role of physical thera-
pists as promoters of a physically ac-
tive lifestyle has received only lim-
ited attention in the literature, this
role is believed to be appropriate for
these primary care practitioners.18,25,26
In 3 US states, when physical thera-
pists’ perceptions of health promo-
tion behaviors were surveyed, it was
apparent that 54% believed physical
therapists were involved in promo-
tion of health and fitness.18 In Swe-
den, an audit of the amount of phys-
ical activity prescription by various
health care professionals indicated
that physical therapists provided the
highest number of physical activity
referrals, with physicians providing
the lowest.26 The most common rea-
sons for physical activity prescription
were musculoskeletal conditions,
obesity, diabetes, and high blood
pressure, although it was not clear
how frequently physical therapists
prescribed physical activity for con-
ditions other than musculoskeletal
conditions. People receiving physi-
cal activity lifestyle advice in a phys-
ical therapy outpatient department
in Australia were more likely to in-
crease their average weekly physical
activity by 60 minutes compared
with a control group.25 However,
this was the only significant differ-
ence evident between the groups in
the average weekly physical activity
measures in this controlled inter-
vention trial. The authors stated that
the capacity of physical therapists to
promote physical activity for non-
therapeutic purposes could be fur-
ther improved, but that the physical
therapy setting was a feasible avenue
for promoting an active lifestyle.
Physical therapists who already gave
more patients physical activity life-
style advice also appeared to have
somewhat greater knowledge about
physical activity promotion. This re-
sult is similar to that for physicians;
those who attended relevant work-
shops were more likely to give phys-
ical activity advice.8 Physical thera-
pists who gave more patients
physical activity advice also were
slightly more confident and reported
fewer barriers to promoting physical
activity in their practice. Because of
the cross-sectional nature of our
study, cause and effect are difficult
to determine. Thus, it remains un-
clear whether the physical thera-
pists’ better knowledge and confi-
dence and lower perceived barriers
enabled them to integrate physical
activity promotion more easily into

September 2010 Volume 90 Number 9 Physical Therapy f 1317

Physical Activity Promotion in Physical Therapy
their daily practice, or whether these
factors improved because they had
already incorporated physical activity
promotion more into their routine
care. Physical therapists’ awareness
of the physical activity guidelines
was not correlated with the number
of patients counseled, on average,
and was surprisingly low, with just
one third aware of the national phys-
ical activity guidelines.
Physical therapists indicated that
separate, one-on-one consultations
are less feasible for physical activity
promotion, and incorporating non-
treatment physical activity advice
into normal consultations is deemed
feasible by almost all physical thera-
pists. Previous intervention work in
the rehabilitation setting has shown
that a physical activity counselor can
effectively improve patients’ daily
physical activity levels in a series of
one-on-one counseling sessions.27,28
In light of our findings, integrating a
similar intervention into physical
therapist practice might be feasible if
the physical therapist would give a
brief physical activity promotion in-
tervention during or following the
treatment sessions that the patients
receive for their initial health condi-
tion. This strategy would use the
physical therapist’s knowledge and
skills in exercise prescription, while
simplifying the logistics of the inter-
vention and making the intervention
more convenient for the patient.
Such an intervention strategy also
would lower the costs, as the physi-
cal activity advice would be built
into existing consultation time for
another condition, and would make
good use of clinical contact time, as
well as build on the patient-therapist
relationship. As treatment by a phys-
ical therapist usually is spread out over
several sessions over a number of
weeks, this duration will allow time
for the provision of sequential physical
activity advice that has previously
been shown to be important for effec-
tive physical activity promotion.27,28
1318 f Physical Therapy Volume 90
Comparison among the groups of
students revealed some interesting
differences that may be accounted
for by their different backgrounds, as
well as their increasing knowledge
acquired through their studies. The
bachelor’s degree students were pri-
marily high school graduates en-
rolled in their first degree program,
whereas the master’s degree stu-
dents all had a bachelor’s degree in a
major such as exercise and sport sci-
ences or human movement science.
Many of the master’s degree students
had held jobs in gymnasium environ-
ments or as personal trainers, where
their primary role was to assist peo-
ple with exercise training. Our re-
sults showed that the further the stu-
dents had advanced through their
studies, the more likely they were to
have perceptions similar to those of
the practicing physical therapists.
This finding suggests that the stu-
dents were learning about the possi-
bilities of promoting nontreatment
physical activity through physical
therapist practice during their cur-
rent physical therapy curriculum.
However, it also has been suggested
that the capacity of Australian phys-
ical therapists to give their patients
physical activity advice for nontreat-
ment purposes could be improved
further and could possibly be better
embedded in the physical therapy
curriculum.25 Furthermore, the cur-
rent study only surveyed students
from one university, so it is possible
that students from universities with
somewhat different curricula would
have answered these questions
differently.
The main limitations of this study are
the cross-sectional nature of the
study and the potential selection bias
of study recruitment. Although our
survey had a higher response rate
(54%) than a similar survey of pri-
mary care physicians (40%),16 only
just over half of the invited, ran-
domly sampled physical therapists
Number 9
responded to the survey. Physical
therapists who chose to participate
may have been those who are more
interested in physical activity and
health promotion in general. Thus,
our results might have overestimated
the perceived role, confidence, and
feasibility of promoting a physically
active lifestyle in physical therapist
practice. However, comparison of
the personal characteristics of our
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sample with those of all physical
therapists registered in New South
Wales (Tab. 1) suggests that our
study sample was representative for
the physical therapy workforce in
New South Wales for at least these
personal characteristics. Finally, the
study sample size might have been
insufficient to detect significant dif-
ferences among groups for some of
the variables that were studied.
Conclusion
This study highlights the previously
untapped potential for physical ther-
apists to give nontreatment physical
activity advice during regular treat-
ment. Physical therapists, current
and future, recognize this as one of
their roles and are confident in their
ability to promote lifestyle physical
activity. They perceive few barriers
to promoting physical activity and
believe that integrating brief coun-
seling into usual treatment sessions
is the most feasible form of physical
activity promotion in physical thera-
pist practice. The results of this
study highlight the need to further
explore the possibilities to integrate
lifestyle physical activity promotion
into physical therapist practice to de-
termine its potential important role
in public health.
All authors provided concept/idea/research
design, writing, and consultation (including
review of manuscript before submission). Dr
Shirley and Dr van der Ploeg provided data
collection and analysis. Dr van der Ploeg and
Dr Bauman provided project management.
Dr Shirley provided participants. Dr Bauman
provided facilities/equipment and institu-
tional liaisons. The authors thank the Austra-
September 2010

lian Physiotherapy Association for help with
the distribution of the study survey
questionnaires.
The study was approved by the Human Re-
search Ethics Committee of the University of
Sydney.
The project was financed through an Austra-
lian Government National Health and Med-
ical Research Council program grant
(#301200) held by Dr Bauman.
This article was submitted November 16,
2009, and was accepted May 15, 2010.
DOI: 10.2522/ptj.20090383
References
1 Bauman AE. Updating the evidence that
physical activity is good for health: an ep-
idemiological review 2000 –2003. J Sci
Med Sport. 2004;7(suppl 1):6 –19.
2 Garrett NA, Brasure M, Schmitz KH, et al.
Physical inactivity: direct cost to a health
plan. Am J Prev Med. 2004;27:304 –309.
3 Haskell WL, Lee I, Pate RR, et al. Physical
activity and public health: updated recom-
mendations for adults from the American
College of Sport Medicine and the Ameri-
can Heart Association. Med Sci Sports Ex-
erc. 2007;39:1423–1434.
4 Mathers CD, Vos ET, Stevenson CE, Begg
SJ. The Australian Burden of Disease Study:
measuring the loss of health from diseases,
injuries and risk factors. Med J Aust. 2000;
172:592–596.
5 Lee IM, Skerrett PJ. Physical activity and
all-cause mortality: what is the dose-
response relation? Med Sci Sports Exerc.
2001;33(suppl 6):S459 –S471.
6 Chau J, Smith BJ, Bauman A, et al. Recent
trends in physical activity in New South
Wales. Is the tide of inactivity turning?
Aust N Z J Public Health. 2008;32:82– 85.
7 Brownson RC, Boehmer TK, Luke DA. De-
clining rates of physical activity in the
United States: what are the contributors?
Annu Rev Public Health. 2005;26:421– 443.
September 2010
Physical Activity Promotion in Physical Therapy
8 van der Ploeg HP, Smith BJ, Stubbs T, et al.
Physical activity promotion: Are GPs get-
ting the message? Aust Fam Physician.
2007;36:871– 874.
9 Eaton CB, Menard LM. A systematic review
of physical activity promotion in primary
care office settings. Br J Sports Med. 1998;
32:11–16.
10 Hillsdon M, Thorogood M, White I, Foster
C. Advising people to take more exercise
is ineffective: a randomized controlled
trial of physical activity promotion in pri-
mary care. Int J Epidemiol. 2002;31:808 –
815.
11 Lawlor DA, Hanratty B. The effect of phys-
ical activity advice given in routine pri-
mary care consultations: a systematic re-
view. J Public Health Med. 2001;23:219 –
226.
12 Marshall AL. Booth ML. Bauman AE. Pro-
moting physical activity in Australian gen-
eral practices: a randomised trial of health
promotion advice versus hypertension
management. Patient Educ Couns. 2005;
56:283–290.
13 Smith BJ, Merom D, Harris P, Bauman AE.
Do Primary Care Interventions to Pro-
mote Physical Activity Work? Report
CPAH 03– 0002. Melbourne, Australia: Na-
tional Institute of Clinical Studies; 2002.
14 Bauman A, Mant A, Middleton, et al. Do
general practitioners promote health? A
needs assessment. Med J Aust. 1989;151:
262–269.
15 Pinto BM, Goldstein MG, Marcus BH. Ac-
tivity counseling by primary care physi-
cians. Prev Med. 1998;27:506 –513.
16 Buffart LM, van der Ploeg HP, Smith BJ,
et al. General practitioners’ perceptions
and practice of physical activity counsel-
ling: changes over the past 10 years. Br J
Sports Med. 2009;43:1149 –1153.
17 Verhagen E, Engbers L. The physical ther-
apist’s role in physical activity promotion.
Br J Sports Med. 2009;43:99 –101.
18 Rea BL, Hopp Marshak H, Neish C, Davis
N. The role of health promotion in physi-
cal therapy in California, New York, and
Tennessee. Phys Ther. 2004;84:510 –523.
Volume 90
19 Harris P, Smith BJ. Beliefs, Attitudes and
Practices Among GPs in Relation to the
Promotion of Physical Activity in Gen-
eral Practice: A Qualitative Study. Report
CPAH 03– 0003. Melbourne, Australia: The
National Institute of Clinical Studies; 2003.
20 Profile of the Physiotherapists Workforce
in NSW. Sydney, Australia: New South
Wales Department of Health; 2009.
21 Mark A, Miners A, Bauman, Wallner F. Il-
lawarra Physical Activity Project. Wol-
longong, Australia: University of Wollon-
gong; 1999.
22 Slater CH, Green LW, Vernon SW, Keith
Downloaded from https://academic.oup.com/ptj/article-abstract/90/9/1311/2738092 by guest on 26 July 2019
VM. Problems in estimating the preva-
lence of physical activity from national sur-
veys. Prev Med. 1987;16:107–118.
23 Bull FC, Schipper EC, Jamrozik K,
Blanksby BA. Beliefs and behaviour of gen-
eral practitioners regarding promotion of
physical activity. Aust J Public Health.
1995;19:300 –304.
24 Eakin EG, Smith BJ, Bauman AE. Evaluating
the population health impact of physical
activity interventions in primary care: are
we asking the right questions? J Phys Ac-
tivity Health. 2005;2:197–215.
25 Sheedy J, Smith B, Bauman A, et al. A con-
trolled trial of behavioural education to
promote exercise among physiotherapy
outpatients. Aust J Physiother. 2000;46:
281–289.
26 Leijon ME, Bendtsen P, Nilsen P, et al.
Physical activity referrals in Swedish pri-
mary care: prescriber and patient charac-
teristics, reasons for prescriptions, and
prescribed activities. BMC Health Serv
Res. 2008;8:201.
27 van der Ploeg HP, Streppel KR, Van der
Beek AJ, et al. Counselling increases phys-
ical activity behaviour nine weeks after
rehabilitation. Br J Sports Med. 2006;40:
223–229.
28 van der Ploeg HP, Streppel KR, Van der
Beek AJ, et al. Successfully increasing
physical activity behaviour after rehabilita-
tion. Am J Health Promot. 2007;
21:153–159.
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Physical Activity Promotion in Physical Therapy

Appendix.
Questionnaire for Physical Therapistsa

Physical Activity in Physical Therapist Practice

Physical Activity: includes any activity from a low intensity level, such as walking, to a high intensity level, such as
playing a competitive sport.
1. How often did you encourage your patients to have a more physically active lifestyle (beyond therapeutic exercise)
in the last month? (please tick one)
E Never E Often, perhaps 6 –9 patients
E Rarely, only 1 or 2 patients E More often, 10 or more patients

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E Sometimes, perhaps 3–5 patients

2. To what extent do you agree or disagree with the following statements: (circle only one for each statement)

Strongly Not Strongly

Agree Agree Sure Disagree Disagree

a. Taking the stairs at work and generally 1 2 3 4 5

being more active each day is enough
physical activity to improve health

b. Half an hour of walking on most days 1 2 3 4 5

is all the exercise that is needed for
good health

c. Exercise that is good for health must 1 2 3 4 5

make you puff and pant

d. Several short walks of 10 minutes each 1 2 3 4 5

on most days is better than one round
of golf per week for good health

e. Discussing the benefits of a physically 1 2 3 4 5

active lifestyle with patients is part of
the physical therapist’s role

f. Suggesting to patients ways to 1 2 3 4 5

increase daily physical activity is
part of the physical therapist’s role

g. I feel confident in giving general 1 2 3 4 5

advice to patients on a physically
active lifestyle

h. I feel confident in suggesting specific 1 2 3 4 5

physical activity programs for my
patients

i. Physical therapists should be physically 1 2 3 4 5

active to act as a role model for their
patients

(Continued)

1320 f Physical Therapy Volume 90 Number 9 September 2010

 Physical Activity Promotion in Physical Therapy

Appendix.
Continued

3. How often does the following prevent you from promoting a physically active lifestyle in your patients (beyond
therapeutic exercise)? (circle only one for each statement)
Very
Never Rarely Sometimes Often Often
a. Lack of time 1 2 3 4 5
b. Lack of counseling skills 1 2 3 4 5
c. Lack of remuneration for 1 2 3 4 5
promoting physical activity

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d. Lack of interest in 1 2 3 4 5
promoting physical activity
e. Feeling it would not change 1 2 3 4 5
the patient’s behavior
f. Feeling it would not be 1 2 3 4 5
beneficial for the patient
g. Other:______________ 1 2 3 4 5

4. What kinds of physical activity promotion (beyond therapeutic exercise) would be feasible for you to deliver to
your patients? (circle only one for each statement)
Not
Highly Somewhat Not Really Totally
Feasible Feasible Sure Feasible Unfeasible

a. Brief counseling integrated 1 2 3 4 5

into your regular consultations
b. Separate one-on-one consultations 1 2 3 4 5

c. Group sessions 1 2 3 4 5

d. Distribution of resources 1 2 3 4 5
(eg, brochures)

5. Some general questions about your practice:

a. Average number of patients _________
you see each week:
b. Your number of years in _________
practice:
c. Your sex: E Female E Male
d. Your age in years: E ⬍35 E 35– 44 E 45–54 E ⬎54
e. Usual number of hours _________
worked each week:
f. The postal code where you _________
work:
g. In what area of physical E Musculoskeletal E Cardiopulmonary
therapy do you practice? E Neurological E Pediatrics
(please tick as many as are E Geriatrics E Occupational health and safety
applicable)
h. In what kind of practice do E Private practice
you work? E Community
E Public hospital (Continued)

September 2010 Volume 90 Number 9 Physical Therapy f 1321

Physical Activity Promotion in Physical Therapy

Appendix.
Continued

6. a. Are you aware of the National Physical Activity E E

Recommendation for Australian Adults? Yes No

b. If yes, please describe the National Physical Activity Recommendation for Australian Adults here.

__________________________________________________________________________________________________

__________________________________________________________________________________________________

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7. Finally, about your own physical activity: How physically active do you think you are currently compared with
other Australians of your sex and age? (please tick one)

E Much more active E Slightly more active E About the same E Slightly less active E Much less active

a
The questionnaire may not be used or reproduced without written permission from the authors, except when referenced appropriately for noncommercial
scientific purposes.

1322 f Physical Therapy Volume 90 Number 9 September 2010