The key findings that emerged from the current study include: i) the lack of education present at undergraduate level with respect to PA promotion and prescription for CF populations, ii) sources of further education sought by the majority of HCP were typically mixed and non-accredited, iii) physiotherapists were more confident in their knowledge and prescription of PA, ensuring use of the guidelines at every patient interaction, compared to other HCP who lacked sufficient knowledge and confidence, and iv) the lack of patient motivation and compliance toward PA advice were among the most common barriers to PA prescription reported by HCP.
The number of HCP who received education with respect to PA prescription for CF populations during their undergraduate degree was very low. This appears not to be specific to CF, as education focusing on PA promotion and prescription for clinical populations in general has been identified as essentially missing from the physiotherapy curriculum in Ireland (22). This is concerning, given the global movement to transition the healthcare service from primarily focusing on sickness, to a service that focusses on prevention and health promotion. The physiotherapy curriculum in Ireland is primarily focused on impairment, injury and disability, with little time devoted to PA prescription for CF and other chronic disease populations (22). This is highlighted by the fact that HCP who have graduated during the past 5 years were no more likely to have received education in relation to PA prescription for CF populations during their undergraduate degree than those that graduated 10-19 years ago.
This study has found that HCPs lack confidence in their ability to promote PA, it is a topic that is largely missing from the undergraduate curriculum, and knowledge of certain elements of the guidance could be improved. As a result, we suggest the development of a formal, standardized and structured continuing professional development programme for HCP seeking to improve their knowledge within the area of PA promotion and prescription for CF populations. In similar survey studies conducted in the UK and Germany, 100% and 87% of HCP who responded, respectively, indicated that they would benefit from additional CF-specific education, training and resources in relation to PA in CF care (23,24).
There was unanimous consensus among the HCP that the physiotherapist be identified as the lead, when prescribing PA to patients with CF. This echoes the European CF Society Standards of Care Framework, which states that the specialist CF physiotherapist should take the lead role in delivering high quality treatment, involving physical exercise training (25). Physiotherapists reported high levels of knowledge and familiarity with the current consensus guidelines, suggesting that they are confident and skilled to adopt this leadership role. Additionally, all physiotherapists reported discussing PA at every patient visit, using a combination of verbal and written PA prescription, largely based on the current consensus guidelines.
Although a significant number of other HCP reported discussing PA with CF patients as part of their professional role, there appeared to be a dearth of knowledge in relation to the appropriate PA prescription for CF populations. This is concerning, as over half of the other HCP actively sought further education to improve their knowledge regarding PA prescription in CF care. Interestingly, the other HCP were unfamiliar with the current consensus guidelines, and they tended to under-prescribe with respect to the frequency and intensity components of the FITT principle criteria. CF patients receiving this advice may not achieve an appropriate overload stimulus to maintain or improve functional capacity.
When discussing PA, other HCP used verbal advice alone, with only 5% basing their advice on the current consensus guidelines. To ensure optimal patient outcomes, it is important that all HCP within the MDT are working synchronously to effectively communicate the significance of PA to their CF patients (26). Identifying the physiotherapist as the lead for PA prescription, with other members of the MDT positively reinforcing the benefits of PA through scheduled discussions during clinic visits, will ensure that the patient receives more exposure to PA dialogue, than with the physiotherapist alone. It is evident that other HCP recognize the importance of PA prescription and deem it part of their professional role, yet currently lack the appropriate knowledge to efficiently reinforce PA promotion. This indicates the need for the development of standardized and structured CPD programmes, focusing on patient-centered, evidence-based PA promotion and prescription for CF populations, made available to all HCP working in CF care.
Although HCP are primarily motivated to prescribe PA to improve patient outcomes, they are faced with a number of barriers challenging this prescription. The most common barriers reported by HCP included a lack of compliance and motivation among CF patients to adhere to PA advice. The scarcity of PA programmes for HCP to refer patients was another significant barrier to PA prescription. The development of patient-centered, evidence-based PA programmes, underpinned by theories of behaviour change, would greatly enhance PA prescription for CF HCP. Due to HCP reporting time constraints as a barrier to PA prescription, we suggest that the expert in behaviour change within the MDT, the psychologist, should work in close collaboration with the physiotherapist to implement this.
Wearable technology has the potential to enhance patient motivation and compliance, allowing patients to be more active in their care, and to better understand how their PA behaviours can affect their health in real-time (27). The adoption of wearable technology, such as activity trackers, and mobile phone applications has the potential to promote patient engagement through personalized PA interventions. Incorporating components of e-health that are convenient and easily accessible for the patient has the potential to change how they engages with healthcare services, and reduce the burden of care and costs associated with healthcare delivery (28). Previous research suggests that the use of an internet-based program to monitor and encourage PA participation, is both feasible and acceptable among adults with CF (29).
A multifaceted approach is required to address the barriers experienced by HCP regarding PA prescription for CF populations. Investigator-developed recommendations to overcome the aforementioned barriers, and to optimize HCP prescription of PA for CF populations, include i) recognising the physiotherapist as the lead for PA prescription, with other members of the MDT positively reinforcing with appropriate PA promotion, particularly as the patient may not always attend the physiotherapist at every clinic visit, it is critical that a multidisciplinary approach is adopted to ensure regular and consistent discussions around PA are had, ii) the development of recognized, structured and standardized further education and training opportunities to enable HCP to upskill and gain confidence with respect to PA prescription for their CF patients, iii) the introduction of formal in-house educational sessions or workshops, provided by exercise specialists within CF care, to create more awareness around the importance and benefits of PA for CF populations, iv) the development of personalised and evidence-based PA programmes for HCP to refer their patients to, and v) promote the use of components of telemedicine and interventions underpinned by behaviour change theories to employ a patient-centred approach for eliciting positive and sustainable change.
There are limitations within the current study that must be considered when interpreting the results. Firstly, it is important to acknowledge the possible presence of sampling bias. Opportunistic sampling may have resulted in a sample of HCP who recognise the therapeutic impact of PA, overlooking the opinions of those who are not interested in using PA as a therapeutic modality for CF populations. There was also an over-representation of physiotherapists within the current study as a result of the survey invitation being sent to the National Physiotherapy CF Clinical Interest Group and not to other professional clinical interest groups. Also, as the nature the data is self-reported, there is a risk that social desirability bias may have occurred making the results more desirable and portraying a less realistic representation of current knowledge and practice 12,20. Clinical exercise physiologists and exercise scientists were not included in this survey as the has not yet been recognized by the Health Service Executive in Ireland.