# Barriers and facilitators to implement longstanding exercise therapy for people with rheumatoid arthritis or axial spondyloarthritis

## TL;DR

This study explores challenges and solutions for implementing long-term exercise therapy for people with rheumatoid arthritis or axial spondyloarthritis in healthcare settings.

## Contribution

The study identifies barriers and facilitators across healthcare delivery stages for implementing exercise therapy in rheumatoid arthritis and axial spondyloarthritis care.

## Key findings

- Barriers include unclear referral processes, limited access to trained physiotherapists, and financial uncertainties.
- Facilitators include strong evidence of effectiveness, clear information channels, and training for physiotherapists.
- Implementation requires a coordinated approach to improve referral systems and patient education.

## Abstract

Longstanding, personalized, supervised exercise therapy proved to be (cost)effective for people with rheumatoid arthritis (RA) or axial spondyloarthritis (axSpA) with severe functional limitations. Despite policy support, implementation in routine care is challenging. This study aimed to identify barriers and facilitators to its uptake in clinical practice.

We conducted 18 semi-structured interviews with key stakeholders (patients, rheumatologists, physiotherapists and insurers). The Consolidated Framework for Implementation Research (CFIR) guided the interviews. Interview transcripts were analyzed in Atlas.ti using direct content analysis, and findings were mapped to the CFIR domains. Barriers and facilitators were categorized across three healthcare delivery stages: (self)referral, eligibility assessment and treatment.

Barriers and facilitators were identified across all stages. Patients primarily mentioned adherence-related factors; rheumatologists focused on referral pathways; physiotherapists emphasized eligibility assessment and actual provision and insurers highlighted the extent of use and financial coverage. Cross-cutting barriers included eligibility criteria, limited access to trained physiotherapists, unclear referral processes and financial uncertainties. Facilitators included strong evidence of effectiveness, consistent messaging, clear information channels and availability of a training course for physiotherapists to deliver the longstanding exercise therapy.

Despite policy support, implementing longstanding exercise therapy can be challenging across multiple stakeholder groups and healthcare delivery stages. A coordinated, multi-stakeholder approach is essential to address barriers while utilizing facilitators. Implementation strategies must improve referral processes, clarify eligibility criteria, enhance patient education and ensure the availability of trained physiotherapists.