The analysis resulted in six main categories and 21 subcategories, presented in Table 2. The exercise with person-centred guidance was experienced as a feasible opportunity to start exercising. The transition to independent exercise was further influenced by a positive experience of exercise, contextual factors, developing knowledge and thinking, finding one’s way and managing barriers for exercise.
A feasible opportunity to adopt exercise
Person-centred introduction, advancement and adjustments made the exercise feasible
When the participants described the development of their exercise routine they talked about how the routine was formed based on their individual abilities, needs and wishes. The person-centred introduction, starting at low intensity with careful progression, was described as enabling their adoption of exercise, despite limitations related to consequences of their disease, such as joint prostheses, cardiovascular disease, or other reasons for low physical capacity. Some participants described how the low intensity introduction was restraining, but that they came to understand the purpose of a light start. The progression of the exercise was also described as positive as it demonstrated increased capacity.
“I got to exercise based on what I could manage, you could say. But anyhow, I got… when I had gotten started, the opportunity to try different things, so to say. It wasn’t just for me to do certain things, but I could add or try what worked for me, and that felt good for me. I thought that was good.” -C.
A new experience of exercise
In contrast to the experience of exercise as manageable, several participants described how previous attempts to exercise at gym facilities had failed to succeed due to lack of introduction or structure. The exercise was also described as being at higher intensity than in their previous experiences.
“I have tried, many years ago, but I thought it was really tough with those machines because you never got to learn. Because they left; they showed you ‘it works like this’ and then you were alone the next time.” –L.
A fortunate opportunity to start exercising
The participants described themselves as fortunate to have been invited to exercise. The invitation gave them a push to start exercising. Some described the opportunity to participate in moderate- to high-intensity exercise with person-centered guidance as the answer to a personal need. It was also considered interesting to see if any effects would occur.
“I had very poor function in my leg muscles and all. It was necessary…this [the exercise]… I’m so happy they called because I would never have gotten to it myself. So it was pure… it was just like a gift from heaven. I’m very happy about it.” –H.
Exercise feasible despite negative elements
Some participants mentioned that exercising could be tough or boring, but yet they wanted to, and managed to, carry out the intervention and sustain independent exercise afterwards.
“I can’t say that it’s super fun to exercise at all times [laughter]. I would maybe rather do something else. But afterwards, I feel so much better.”–B.
Experiencing positive effects of exercise
Positive effects manifested both physically and mentally
Positive effects on body function were experienced by the participants, both physically and mentally. Improved strength, aerobic capacity, mobility, sleep, energy, and mood were described.
“I have become stronger both physically and mentally. Both in getting out meeting people, and feeling that the body works. It means a lot. It does.” -E.
Experiencing positive effects and well-being related to exercise was perceived as increasing motivation for continued, independent exercise.
Positive effects manifested in everyday life
The participants also described experiencing positive effects in everyday life, and activities were made possible or became easier. Effects of exercise were also acknowledged by family members and friends.
“When we started here… I couldn’t walk down a stair. But after 5–6 weeks… at home where I live there are five steps to the front door. One day I was in a hurry, and just went straight out. So I wondered ‘What did I do?’ I had to go back and do it again. [Laughter] I could walk down a stair!” –E.
A positive, fun and healthy experience
The participants described positive experiences of participating in exercise and the exercise was perceived as fun. Adopting exercise also led to a more positive feeling of other parts of life and a feeling of health.
“I think it’s fun. It’s… it gives a kick for life when you think it’s fun. So that’s really important, to have a positive view on life. So it… It feels good.” –F.
Contextual factors affect the experience of exercise
Guidance as a security and a driving force
The participants perceived the physiotherapist leading the exercise as a security. The presence and competence of the physiotherapist ensured the quality of the performed exercise, and there were always opportunities to ask questions and receive help. The physiotherapist also acknowledged the individual and met individual needs and wishes.
“I think that the physiotherapist was very supportive and encouraging, and pushing at the same time. She told me how it should be and what I should try… and it felt safe. That’s how I would describe the physiotherapist. I felt that she had the situation in her hand in some way.” -A.
However, a few participants said that they were not in need of all the support offered by the physiotherapist during the intervention, or that the need for support was reduced with time.
The physiotherapist was described as a driving force as she pushed the participants to deal with the strain of heavy exercise. The presence of the physiotherapist also gave a feeling of control that prevented deviation from the protocol.
The possibilities and inadequacies of a loosely connected group
The participants expressed very different experiences of being part of a group. For some, participating in a group was a positive, social experience that contributed to motivation for exercise and encouraged harder work. That the group members shared the same diagnosis and were approximately the same age was described as positive.
“And we talked about everything except diseases and problems. We talked about good food, good wine… possible acquaintances, mutual acquaintances and that sort of stuff. But we didn’t talk about diseases, our group that was here. It was great… we just noted when someone new came: ‘So you’re also… rheumatic.’ And that was that.” -E.
Others did not experience any connectedness to a group at all, which was a drawback for some and a benefit for others depending on differing social needs and longings.
“I thought it was quite good, that you didn’t need to adjust to anyone, someone who doesn’t keep up or so. If you’re a group where everybody is supposed do the same thing at the same time, and there is someone, or it might be yourself, who don’t keep up. That’s not particularly fun. That’s why I thought it was quite good that you could exercise on your own.” –D.
The facilities influence the experience
There was a wide range of experiences of the gym facilities among the participants. Some found the facilities to be a negative experience mostly due to music volume and location. Others appreciated the facilities and struggled to find a similar alternative. A nearby geographic location was seen as a strength when choosing a facility. Other important factors were the cost, the equipment of the facility, the air quality, and the environment of the facility.
“The question is if I should keep going to [the intervention gym]. I have to go by car since there is a distance. Or should I find another gym? At [the intervention gym] there were space and there were always people, it was clean and tidy, lockers and so, clean and tidy in the showers and it felt great. I have visited another gym and I can’t imagine going there, it felt… no. So that matters, at least to me, how it looks at the gym.” –C.
Developing knowledge and thinking
Learning about exercise
Through the person-centred guidance the participants described gaining knowledge about exercise management and aerobic and resistance exercise at high intensity. This new knowledge was used to adjust their independent exercise routines, both when resuming exercise after a break and when in need of increased exercise loads.
“Since the exercise was new for me it was even more important to learn the movements. And when I came to [a gym facility near home] there were the same machines and the movements were still the same.” -P.
New thoughts about exercise and oneself
The participants described how their thoughts about exercise changed due to the performed exercise. Some stated that their views on intensity and the need for regularity of exercise had changed. Some stated that they had learned that exercise was not dangerous despite pain and disease. They also recognised that they were capable of more than they first thought.
“Now I know that I can exercise just as much as everyone else. I don’t need to be afraid to go to the gym and I can just leave out certain things if I realise that I can’t handle them.” -N.
Some also described how the onset of exercise also brought other personal changes, such as a higher priority of one self or smoking cessation.
The gym as a new arena
The participants described how they overcame a previous sense of resistance towards the gym environment. However, someone still described the gym as not for them after the moderate- to high-intensity exercise with person-centred guidance. The process of becoming familiar with a new facility was by some participants described as taking some time and by others as being unproblematic.
“…it’s very fun now to be a person that knows what it means to exercise, and suddenly I meet lots of friends that also exercise. Yes, you feel that you are part of a contemporary movement, a contemporary phenomenon.” -N.
Finding one’s way
Fitting exercise into everyday life
The participants described strategies and important factors for fitting exercise into their everyday life, both during the intervention and during the follow up period. For a limited time a more extensive expenditure of time was reasonable but to incorporate exercise in the long term two times a week was described as reasonable. However, both one and three times was also mentioned as reasonable for some and some mentioned that as a pensioner there is time for exercise.
“You have to have a life outside this as well. So I thought this was perfect. And it took about one… one and a half hour. That was just right. I think that she [the physiotherapist] had figured that out just right.” -L.
The flexible time for exercising facilitated the development of a personal arrangement for exercise, since the preferences differed among individuals. Some described that the development of exercise routines formed habits and created a need for exercise. Everyday walks and other types of exercise were also described as part of a new routine.
Several of the participants described a wish and a need for seasonality of exercising. The seasonality could be related to a wish for exercising outdoors in the summer and for a change of routines related to summer homes and gardening.
Making the protocol your own
The participants described the process of making the exercise protocol ‘their own’ and adopting it as a personal routine. The descriptions of the practicalities in forming their own protocol varied from strictly adhering to the initial exercise protocol, to finding their own programme by adding other kinds of exercise activities to their weekly routine. The participants also described how they modified the protocol in terms of repetitions and sets at the gym.
“I had planned to quit exercising after this, but I did the tests before, and after five months, and my results were apparently really good, according to the doctor. So I thought ‘I be damned if I quit’, so I kept exercising. I exercised at the gym until my membership ended, then I went swimming, and later I started to run with my dog, up to five times a week.” -K.
Transition to independent exercise
Many of the participants perceived that the step to independent exercise was unproblematic, because they could stick to established routines from the intervention. Someone described that it helped to already be familiar with the facilities. Someone speculated that it would have been easier to continue at a new facility if you were accompanied by a friend. However, a few participants described how they did not manage to go through with the step to independent exercise and stopped exercising.
“It was no problem, no problem at all, I just kept going. So it… it was no problem at all, it went well.” –C.
Using tools for motivation
Different tools for increasing motivation for exercise were described. The exercise diary used during the intervention period was described as a helpful tool that several participants continued to use independently. At the same time, the diary was described as unappreciated by others who were not motivated to keep a diary during or after the initial period. A social element helped several participants keep motivation as they perceived it as meaningful to meet friends or acquaintances at the gym. Another important motivational factor for some was having long term goals related to everyday life.
“My goal is to do what I can myself to influence my possibilities to stay in my current home for another 20 years, and take care of myself. I want to be able to carry my wine bags on Fridays for example, and grocery bags. I’m happy to accept help if someone drops by but I want to be able to do it. That’s what motivates me, I would say.” -A.
Access to support
The participants described various ways of receiving support for exercise during the follow up period. Some had positive experiences from continued coaching, through for example professional introduction at a new facility or through appointments with personal trainers. Some sought help from a physiotherapist in the healthcare system. Some participants considered the possibility to get help but had not used that possibility yet and some had not seen a need for further coaching.
Some participants also described missing the continuous contact with the physiotherapist in their independent exercise. Telephone calls from the physiotherapist during the follow-up period instilled a sense of being cared for, and was perceived as support for continued independent exercise. The phone calls also provided a feeling of being supervised, which increased motivation for independent exercise. Some described the feeling of being controlled as unwanted and declined follow-up phone calls.
“She [the physiotherapist] asked if we wanted to [be phoned]. And I said ‘that’s good’ because then you still have some… motivation and so, to not quit immediately.” -J.
Managing barriers for exercise
Facing barriers for exercise
Reduced physical health, ranging from light infections to chronic diseases and hospitalisation, was perceived as a barrier for exercise. Other barriers were reduced motivation without coaching, economic factors, poor sleep, and competing activities. However, some participants perceived no barriers during the follow up period.
“It wasn’t a conscious strategy of mine, to refrain from exercise. That’s not it. It’s rather the body talking, or my health status talking. I can’t. I would’ve liked to go there anyway, but I can’t.” -D.
Various strategies to overcome barriers
The participants also described their strategies to overcome barriers. These could be mental strategies, such as keeping to the routines; physical strategies, such as using orthoses; and social strategies, such as contacting a trainer.
“I was furious. Totally furious. I was… I thought I was doing so well. And the foot was swollen, I couldn’t get my shoes on, I couldn’t walk and I couldn’t do anything. But then I thought ‘now I just have to accept this’. Even my husband said that if I hadn’t been exercising he wouldn’t have wanted to be at home with me, since then I wouldn’t have managed at all. And I thought ‘Maybe I could do a little exercise.’ And I did exercise with my arms and hands. Otherwise I would have been sitting there longer.” -B.
The importance of determination
Participants who had encountered barriers talked about a strive to get back to exercise, and having more or less detailed plans. Others also described the importance of being determined to exercise to be able to overcome barriers.
“I could do it all. But the thing is…. You can’t do it if you don’t want to. Many times when the will is lacking, you have to tell yourself that you can do it. And then you can and in the end it’s easy.” -F.