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may also be the case in NMD. Traditionally, indivi-
duals with NMD are discouraged to exercise for fear
of overwork weakness (29). Despite accumulating
evidence for the safety of AE in a wide variety of NMD
(8, 30–32), this idea may still influence healthcare
professionals in prescribing AE in this group.
Exercise intensity is the most critical component in
ensuring an adequate dosage to elicit a training effect
(23). It is therefore important to note that our respon-
dents used several different methods to determine
target intensity. This same pattern was seen among
physical therapists in stroke rehabilitation (18, 19),
and, in line with the large support need with respect
to dosing of exercise, it probably reflects the difficul-
ties that healthcare professionals experience related
to exercise intensity prescription in NMD. Together
with the reported frequent use of unreliable methods to
determine individual target intensity in NMD, such as
those based on the (age-)predicted maximal heart rate
(33, 34), this emphasizes the need for the development
and more consistent use of methods to determine the
intensity and other FITT factors for AE in NMD.
Perceived barriers
In addition to the reported underuse, respondents iden-
tified several barriers to the application of AE in adult
neuromuscular rehabilitation. The most commonly per-
ceived barriers concern safety and patient characteristics,
including the physical inability to perform at a training
level, poor motivation, comorbidities and fatigue.
The physical inability to perform at a training level
was more often reported as a barrier to exercise by
respondents working in specialized centres compared
with those working in a primary care setting. This may
reflect the more complex cases that are usually treated
in specialized centres, and is in line with the majority
of respondents experiencing comorbidities as a barrier
in this setting. The comorbidities that respondents were
referring to in this context are unknown; these might be
directly associated with the NMD, such as cardiac in-
volvement in muscular dystrophies (35), but it may also
concern comorbidities that are unrelated to the disease.
That more than half of the respondents identified
poor patient motivation to exercise as a barrier, while
most respondents agreed that AE should be part of
treatment programmes in NMD, underlines the need
for clinicians to develop strategies to enhance moti-
vation (3, 36). Fatigue was also often reported as a
barrier. This confirms findings from previous studies
(13, 37), but contradicts the growing evidence that
physical activity and AE have beneficial effects on
fatigue in NMD (14, 38, 39), and should thus, from
this perspective, be promoted.
www.medicaljournals.se/jrm
Another interesting finding is that insufficient
knowledge about AE prescription was often reported
as a barrier, especially in the primary care setting. A
possible explanation is the low caseload; while 48% of
the respondents in specialized centres reported being
primarily engaged in neuromuscular rehabilitation, this
was the case for none of the respondents in primary
care. This highlights that attention should be given to
continuing education of physical therapists, not only in
specialized centres, but also in primary care. A model
in which care is delivered by a restricted number of
trained professionals who collaborate within regional
networks, as has proven successful in Parkinson’s
disease (40), might also be considered in NMD.
Need for support
More than three-quarters of respondents indicated
needing some kind of support to improve the appli-
cation of AE in neuromuscular rehabilitation. Most
support was required with respect to the screening
procedures and dosing of training programmes. To
our knowledge, this need for support has not yet been
reported, although it is in line with previous studies
mentioning the difficulties healthcare professionals
experience with regard to finding a balance between
improving physical fitness and preventing overburden
in NMD (15, 16). A guideline is the preferred means of
support, with evidence-based guidance on the prescrip-
tion, monitoring and evaluation of AE.
Study limitations
Although adult neuromuscular rehabilitation in the
Netherlands is organized in, and coordinated by,
specialized centres, physical therapy, including the
prescription of AE, is often provided close to home,
in a primary care setting. The generalizability of our
results might, therefore, be restricted by the relatively
low number of respondents practicing in a primary
care setting. Moreover, response bias may have occur-
red, since it is possible that physical therapists with a
specific interest in neuromuscular rehabilitation may
have been more inclined to respond to the survey than
those less interested.
Implications
These survey results emphasize the need to improve
the application of AE in current practice. The prefer-
red way to achieve this is through the development
and implementation of guidelines addressing current
evidence-based knowledge regarding AE application
in NMD. Future research should focus on improving
strategies to enhance motivation, the role of comor-