Article Text

Movement Foundations. The perceived impact of a digital rehabilitation tool for returning to fitness following a period of illness, including COVID-19 infection: a qualitative study
  1. David Salman1,2,3,
  2. Peter Le Feuvre1,4,
  3. Oliver Hill1,5,
  4. Dean Conway1,5,
  5. Simon Taylor6,
  6. Shruti Turner1,
  7. Jonathan Korgaonkar2,
  8. Shehan Hettiaratchy7,
  9. Alison H McGregor1
  1. 1MSk Lab, Faculty of Medicine, Imperial College London, London, UK
  2. 2Emergency Medicine—Sport and Exercise Medicine, Imperial College Healthcare NHS Trust, London, UK
  3. 3Department of Primary Care and Public Health, Imperial College London, London, UK
  4. 4Royal Centre for Defence Medicine (RCDM), John Radcliffe Hospital, Oxford, UK
  5. 5Defence Medical Rehabilitation Centre (DMRC), Stanford Hall, Loughborough, UK
  6. 6Suite 2C, Brosnan House, Rehab Guru, Potters Bar, UK
  7. 7Department of Surgery and Cancer, Imperial College London, London, UK
  1. Correspondence to Dr David Salman; d.salman11{at}


Digital interventions can increase physical activity (PA) levels in adults. However, the COVID-19 pandemic highlighted the complexities faced when guiding people to start or return to PA following illness or inactivity. A digital tool, Movement Foundations, was developed to provide remote guidance on building strength and capacity across functional movement patterns, with graduated progression based on user responses and input. This qualitative study aimed to explore the perceived impacts of using the tool. Nine participants aged over 35 years from the healthcare and academic healthcare sectors were recruited to use it and were subsequently interviewed. Thematic analysis identified three themes falling under the overarching concept of ‘Capability, Opportunity and Motivation—Behaviour (COM-B) Plus’, encompassing: skills and capacity for movement; opportunities, motivations and barriers for movement; and a personalised, safe space in which to develop. Participants felt that the digital tool increased their capacity and confidence in movement and positively impacted their daily activities. External factors such as illness and stress clouded perceptions of the impacts of PA. Time, work pressures and needing equipment were still considered significant barriers to PA. Still, participants appreciated the flexibility and non-prescriptive nature of the tool and felt that it helped movement to become opportunistic and habitual. Increased capacity for PA and feeling the subsequent physical and mental effects positively influenced motivation. Structure and guidance, with graduated progress, were seen as protective. Guided self-reflection helped participants understand their capacity and limitations with regard to movement and promoted motivation. Although acquiring technical skills to guide movement may be important for those recovering from illness, participants found that a structure promoting individualised guidance, graduated progression and guided self-reflection were important motivational factors for continuing use. Digital interventions should consider these aspects when seeking to promote habitual PA.

  • Physical activity
  • Behaviour
  • Illness
  • Rehabilitation

Data availability statement

Data are available upon reasonable request. Transcriptions with deidentified participant data may be made available on reasonable request to

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:

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  • Digital interventions can increase physical activity (PA) levels in the short-term. Still, there are specific complexities when guiding people to start or restart PA following illness or inactivity.


  • A user-guided graduated digital tool that responds to daily interactions with participants helps with skills acquisition for movement. More importantly, increased capacity for movement and guided self-reflection positively increased motivation for PA.


  • Digital interventions should consider individualised guidance, graduated progression and guided self-reflection when promoting PA, particularly when aimed at individuals returning from illness or inactivity.

Background and rationale

Physical inactivity is a major risk factor for non-communicable diseases and mortality.1 Before the COVID-19 pandemic, approximately a third of adults were not active enough for good health as defined by UK Chief Medical Officer (CMO) or WHO guidelines.2–6 During the COVID-19 pandemic, physical activity (PA) in adults decreased7; particularly in those with chronic health conditions,8 and in those who were socially isolated, shielding or lonely,9 risking further inactivity and deconditioning.10

There is no comprehensive framework to support or guide individuals wishing to start or return to PA following illness or prolonged inactivity. Traditional ‘return to play’ strategies guiding the resumption of PA were inadequate to meet the challenges posed by COVID-19 and its sequelae11; where a significant proportion of people reported postexertional symptoms as part of a Long COVID spectrum of disease, highlighting the challenges of unpredictable activity tolerance. People described conflicting advice on returning to PA following COVID-19,12 demonstrating the need for clear guidance that is individualised, sensitive and provides people with tools for self-monitoring and signposting for further support where necessary.

Digital tools have shown promise in encouraging the uptake of PA.13 A digital rehabilitation tool for potential use in primary care was developed to support people wishing to return to PA after illness or inactivity,14 and tested by clinical and academic staff. This qualitative research was designed to capture the perceived impact and usability of such a tool following a period of illness, including COVID-19.


Design of the digital tool (web app)

The Movement Foundations digital tool (web app) was developed between February and November 2021. The team consisted of medical professionals (DS and JK), exercise rehabilitation instructors (OH and DC), academic physiotherapists (AM and PLF) and Rehab Guru Software (a platform used by clinicians to support rehabilitation guidance) application designer (STaylor). The tool consisted of exercises based on functional movement patterns, with a graduated progression in volume (number of sessions per week and the number of repetitions of exercises) and intensity/load (relative difficulty of exercise repetition) (figure 1). Participants were entered onto a starting level based on an algorithm adjusted for the number of sit-to-stand (STS) repetitions over 1 min and the perceived degree of effort this required (Borg Category Ratio (CR)10 Scale). Participants with STS between 0 and 35 and Borg CR10 above 7, or STS 35–39 and Borg CR10 above 8 were signposted to seek medical advice before continuing. Levels of exercise were phased: each phase lasted 1-2 weeks and contained a variable number of sessions. For each phase, participants were able to choose exercises ranging in difficulty across functional movement pattern domains, empowering them to titrate exercise intensity as they felt necessary. When participants logged individual exercise sessions, they were asked to rate their perceived effort and subjective assessment of adherence to the exercises (how much they could do of what they intended).

Figure 1

Representative screens from the digital tool showing sit-to-stand (STS) assessment, exercise selection screens, daily ‘check-in’ questionnaires and summary progress screens.

Participants were asked to complete daily questionnaires on fatigue, sleep, muscle soreness and emotional stress, based on Hooper and Mckinnon scoring criteria.15 An additional domain of recovery was added to account for postexertional symptoms or deterioration. Participants were asked if they had new or recurring symptoms of their illness and were signposted to seek medical advice. At the end of each phase, scores from the daily questionnaires, perceived effort and degree of subjective and objective adherence to the sessions were combined by an algorithm to generate options for the participant. These included progressing to the next phase, consolidating the previous phase, regressing a phase and signposting for further medical advice. A resource hub provided participants with information on deconditioning, PA following illness, functional movement patterns, Long COVID, planning sessions, rest and recovery, fatigue, sleep and muscle soreness.

Study design

A thematic analytical approach was used, underpinned by subtle realist and interpretivist ontological and epistemological paradigms. This approach acknowledges that reality is understood through individual and socially constructed meanings and that the researchers’ understanding impacts the research process and findings.16

Recruitment and data collection

Healthcare and academic healthcare staff who met eligibility criteria (box 1) were opportunistically recruited from Imperial College Healthcare NHS Trust and Imperial College London email chains and WhatsApp groups from November 2021 to July 2022. Eligibility criteria were expanded to increase recruitment from March 2022 from a minimum age of 40 to 35 years. Recruitment continued until the research team were confident that data saturation was achieved. Data collection and analysis took place concurrently, with analytical data saturation considered at the point when no new codes were identified during analysis.17

Box 1

Eligibility criteria

Inclusion criteria

  • 35–60 years old

  • Able to give informed consent

  • At least 28 days asymptomatic post illness, including presumed or confirmed COVID-19 (no cough/fever/anosmia)

  • MRC dyspnoea scale 1: (‘Not troubled by breathlessness except on strenuous exercise’); 2: (‘Short of breath when hurrying on a level or when walking up a slight hill’); or 3: (‘Walks slower than most people on the level, stops after a mile or so, or stops after 15 min walking at own pace’)

  • Able to stand from sitting

  • Able to climb a flight of stairs

  • Imperial College or NHS Trust staff

Exclusion criteria

  • Pregnant/6 weeks postpartum

  • Admitted to hospital with COVID-19 at any point

  • Disease/disability that requires ongoing hospital treatment (stable disease or disease in remission, for example, diabetes/HIV requiring regular follow-up is exempt)

  • Chest pain at rest or on exertion

  • MRC dyspnoea scale 4: ‘I stop for breath after walking about 100 yards or after a few minutes on level ground’ or 5: ‘I am too breathless to leave the house, or I am breathless when dressing.’

  • Ongoing, or relapsing and remitting, symptoms suggestive of Long COVID, including excessive lethargy, postexertional symptoms or impaired recovery following exertion

  • If using an oxygen saturation probe and are aware of desaturation (≥3%) associated with exercise or exertion

  • MRC, Medical Research Council; NHS, National Health Service.

On entry, all participants were asked to input age, gender, occupation, level of previous PA and whether their illness was COVID-19, in which case time since the illness was noted (online supplemental file 1). Approximately 3 weeks following entry into the study, participants were invited for semistructured interviews. These were conducted remotely using Microsoft Teams by a male researcher (DS) with a second (female) interviewer (STurner) present for the initial interviews to ensure standardisation. Interviews were based on perceptions of: entry to the web app; exercise suggestions provided; the relevance of the daily questions; the feedback provided to the participant; the progression through the phases; engagement and interface with the web app; fitness levels and well-being; and whether the participant would recommend the digital tool to others (online supplemental file 2). Interviews lasted approximately 30 min and were recorded, pseudoanonymised and transcribed verbatim.

Supplemental material

Supplemental material

Data analysis

Transcripts were managed using NVivo V.10.18 Two authors (DS and STurner) independently coded two transcripts initially and agreed on a coding strategy. Themes and concepts from the data were developed using the principles outlined in Braun and Clarke’s six-step process.19 This included: familiarisation with the data, involving repeat listening and reading of interviews and transcripts respectively and checking for accuracy; generating initial codes; and developing, reviewing, defining and naming themes. Although an inductive approach was taken to coding in as much as possible, the research team approached the data with the Capability, Opportunity and Motivation—Behaviour (COM-B) model as a broad framework.20 Coding and analysis were independently verified by AM and PLF.

Patient and public involvement

Participant and public involvement (PPI) groups were convened to outline the strategy and web app design. PPI participants were of a mix of ages and gender, and all had personal experience of COVID-19 infection or physical fitness rehabilitation following illness or inactivity. Comments and suggestions from meetings contributed to adjustments made in the interface of the digital tool and the study design. Key themes, codes and illustrative quotes were then discussed with PPI members to verify codes further.


Participant characteristics

Out of 22 participants who expressed interest in the study, 9 completed participation. Eleven did not complete the initial consent process and two started the study but could not complete it due to unrelated illnesses. Data saturation was observed following eight participants and confirmed following the ninth interview when recruitment ceased. Ages ranged from 42 to 59 years, with a median (IQR) of 50 (12) years. Four out of the nine participants had COVID-19: two in the previous 2 months and two between 2 and 6 months prior. A further two participants (‘F’ and ‘H’) had a recent non-COVID-19 illness. Three of the participants demonstrated baseline PA levels below CMO guideline amounts. Baseline STS scores for participants ranged from 25 to 54 per min, with a median (IQR) of 28 (5) repetitions. Borg CR10 scores for baseline STS assessments ranged from 2 to 7, with a median (IQR) of 3 (2) (table 1).

Table 1

Participant characteristics

Qualitative findings

Coded data were initially sorted into subthemes and then clustered to form three key themes: (1) skills and capacity for movement, (2) opportunities, motivations and barriers for movement and (3) a personalised, safe space in which to develop (table 2). From this thematic structure, a broad overarching concept was identified as ‘COM-B Plus’.

Table 2

Subthemes, themes and over-arching concept

Codes were not exclusive to specific subthemes. Codes, subthemes and themes are shown in online supplemental file 3. The themes are described below with direct quotes from participants.

Supplemental material

Skills and capacity for movement

Participants described how the digital tool contributed to their movement vocabulary and capacity. ‘A’ discussed how the tool provided access to exercises that he would not have necessarily done otherwise and ‘I’ explained how this breadth impacted her physical literacy, or understanding of movement, and its impact on her body:

I think the exercises in general makes you a lot more aware of what you're exercising, you know, which muscles and things like that. So that was quite good feedback. And also, because it made you realise what parts of your body you might need to work more on.

The tool provided instruction to increase confidence with movement. ‘F’ talked about how this allowed her to ‘reclaim (her) ability to move’ and take control and direct her body. ‘B’ discussed how it was useful to be able to check, even if it was a simple exercise, that his form was correct ‘Am I doing that the way it’s supposed to be done?’, and ‘H’ felt that adding the tool to her routine helped remind her about posture and core strength.

There was a perception that this breadth of exercises encouraged participants to engage a different and broader range of muscle groups. ‘A’ talked about how he felt an effect from this and ‘B’ described how this was particularly welcome in the post-COVID-19 period. ‘I’ felt that there were some exercises that were not ‘captured’ elsewhere, such as for the back. The digital tool prompted participants towards different movement patterns from those they routinely used. For example, ‘B’ discussed how this tool focused on tone and strength, and ‘G’ explained that he had previously held an inclination towards aerobic activity, as opposed to strengthening exercises, but without any reason or rationale. ‘H’ commented on how the ‘general workout’ was a positive experience rather than just being focused on a specific body area.

This breadth also contributed to an increase in their capacity. ‘G’ explained how he felt engagement with the tool meant that he was using his rowing machine more. Participants also discussed the impact that even the short duration of participation had on activities of daily living. ‘B’ felt that the exercises might have helped with his capacity to walk up the escalators at a train station, and ‘H’ felt that the exercises, and STS movements in particular, helped with her ability to climb stairs. This was related to general perceptions of the relationship between moving more and ageing, and the role of interventions. ‘F’ discussed how increased movement and PA meant that she felt she was moving with less inhibition, particularly compared with people of her age, for whom standing up ‘always seems to be accompanied by an oooph (laughter)’.

‘G’ discussed his perceptions of the impacts of PA on longevity, highlighting the relevance of this tool in the context of ageing and bereavements:

I know it’s coming and I just want to try and make sure that I'm doing everything I can to be in as good a position as possible when it comes along. So it’s partly a self-preservation strategy, partly it’s because I want to be around for as long as possible for my kids.

Opportunities, motivations and barriers to movement

This theme describes how participants perceived the factors that helped enable or obstruct movement with regard to the digital tool. The impact of illness and fatigue was prominent but perhaps contrary to what was anticipated. ‘B’ felt that the broad range of movement, without feeling the need to push himself, helped reduce fatigue. ‘I’ discussed how her experiences of fatigue following COVID-19 meant that she was apprehensive about starting the digital tool, but despite some surprise about how tiring the exercises made her feel, she was happy and motivated to continue using it.

The relationship between the impact of external factors, such as illness, with how people felt following PA and exercise was confusing, particularly when answering the daily questions posed by the tool. ‘D’ felt that the question about aching muscles did not take into account her joint pain, and ‘B’, ‘H’ and ‘I’ discussed how extraneous factors, such as having a cold, the time of day, and daily stress, all clouded this relationship.

Time and work pressures were seen as barriers to participating in PA and were not necessarily overcome by the digital tool. ‘D’ discussed how trying to fit time to be physically active around a busy schedule was stressful. ‘C’ discussed the scenario of getting home, doing house chores and then feeling exhausted when she found time for herself. However, ‘D’ felt the digital tool was not prescriptive about timing and provided flexibility for people to organise their PA schedule themselves, allowing for ‘crazy days’. ‘G’ felt that it helped him define time for scheduled PA around the hectic pressures of family and work life and that this had the potential to become habitual. Scheduling was felt to be important for habit formation. For example, ‘A’ referred to the need to schedule a time to do the exercises on a calendar as being particularly important, and ‘E’ felt that an automated notification system would help her incorporate brief PA into her daily life and around meetings. ‘A’ reflected that it did not take long to complete an individual session: approximately 20–25 min, which was feasible.

There was a perception that the tool allowed for opportunistic bouts of PA: ‘E’ described the beneficial impact of being able to incorporate the exercises into a day at the office rather than sitting at her desk for prolonged periods. ‘H’ discussed how not requiring any special equipment meant that she could do her exercises anywhere, such as when travelling for work.

There were certain barriers to use, such as the equipment specified. ‘E’ and ‘D’ reflected on the need for tins, or a suitable step, impeding their capacity to schedule the exercises, such as when at work. Having space available was also perceived as a barrier and a potential issue for inclusivity. ‘G’ felt that his arm span meant that finding enough wall space for some of the exercises was difficult.

Related to the previous theme, there was a positive cycle of increased capacity to move that then increased motivation:

So, I think it’s as you do more, you’re able to do more, and then you want to do more, and it becomes less of a chore to go upstairs and get the thing you just left in your bedroom because you’ve got brain fog, but you just go, “Oh, right, okay, I’ll go back up three flights of stairs to get my glasses again,” and you don’t mind. (‘F’).

‘C’ and ‘I’ described how feeling the impact in their muscles, or stiffness the following day, motivated them to continue, and ‘B’ reflected on the beneficial impact on his mental health, which was motivating:

[…] it was mentally uplifting to do this broader set of exercises and realise that actually, they were good things to do, if you see what I mean, that it was helping me use muscles that I wasn’t really using or even trying to avoid using.

A personalised, safe space in which to develop

‘B’ described how having a structure and guidance within the tool gave him ‘permission’ to not push himself too hard when exercising. He discussed how this ‘carefully guided situation’ reduced the stress he associated with exercise, as he felt less risk of pushing himself too far and getting ‘into more of a downward spiral again’. Participants reflected that the pressure to push themselves could come from external sources as well and that the digital tool reduced this. ‘E’ felt that there was no pressure to complete all sessions and that the tool made it clear that she could progress at her own pace, which was a positive feature for her. Similarly, ‘H’ discussed how the tool gave her the information she needed but did not force her into doing anything. ‘B’ stated:

None of us are used to stopping ourselves pushing ourselves harder, you know, or having a structure that keeps ourselves back, […] that terrible phrase no pain no gain […] so, you know, having that structure that says, “No, no, hang on, just stay back, just, you know, do these,” […]… I would recommend it. (laughs).

Participants also described the protective effects of the structure of the digital tool. ‘C’ discussed how she felt the graduated progress in intensity was very helpful and easy to follow. ‘B’ felt that the structure was useful for allocating dedicated time to the exercises and feeling he had achieved something. ‘F’ described how the phased nature of the tool, and the structured guidance, would be useful for people with chronic conditions who are not physically active. The intensity of exercises was seen as gentle and graded. ‘B’ described it as a ‘steadying hand’ on the rate of return to PA, ‘F’ regarded the increase in the difficulty of exercises as ‘surreptitious’, and ‘D’ described how she noticed the gradual increase in intensity and felt that it was positive so she could continue. ‘I’ reflected that the graded approach, feedback and daily guided self-reflection aspects would be valuable for friends and family who were not physically active. ‘H’ felt that the tool gave her the ‘chance’ to introduce movement and PA, rather than it feeling ‘invasive’. However, she felt that this might not be enough when the discipline to do movement activities were lacking. The tool and the initial assessment part were described as ‘non-judgemental’ by ‘I’.

Participants reported a positive impact on their state of mind from PA in general and not specifically from the tool;

it definitely makes me feel better. […] So I actually look forward to it because I feel like I’m doing something good for myself, and I don’t know if it’s that that makes me feel better or it’s the actual exercises that are making me feel better, but it’s definitely positive (‘H’).

‘G’ described feeling better knowing he was doing some exercise and feeling improvements. He also described feeling more positive and fewer negative emotions as a result of being physically active. ‘A’ felt this motivated him to continue using it, and as a reason to recommend it to others.

Using the tool prompted a reflective approach which contributed to increasing physical literacy and helped participants understand their current capacity and limitations. ‘F’ explained that the daily questionnaires were helpful for checking in with herself to reflect on how she was feeling, which was something she wouldn’t normally do. Similarly, ‘I’ explained that the feedback provided a realistic understanding of how much activity she actually did rather than the idealised perception she might have otherwise held. ‘D’ similarly reflected that the initial assessment gave her a realistic appraisal of how fit she might actually be, but this motivated her to use the digital tool.

Finally, participants valued that the tool felt individualised for their level of physical fitness in some respects. ‘A’ appreciated that the tool contained guidance relevant for someone of his demographic background, and ‘D’ explained:

I think for all the bog-standard, even a nervous person, it would make you feel reassured that it was tailored to you and not to superman next door.

However, some felt the tool was not individualised enough. ‘H’ felt that the digital tool felt quite ‘general’ rather than specific to her. Moreover, some participants felt empowered to tailor advice to their own circumstances. ‘B’ felt that he could eventually do more than what was guided within the digital tool, and ‘D’ felt she could ignore guidance to take some time to recover, as she felt her poor sleep was unrelated to the exercises. ‘I’ discussed how she thought it useful that she could tailor less intense exercises for her upper body but more intense exercises for her lower body, which was stronger, and she appreciated this flexibility.


Transcripts were further coded for positive and negative attitudes. How attitudinal codes intersected with each of these subthemes was examined to identify features of the digital tool which contributed positively or negatively to interaction with participants, and their exercise experiences, highlighting areas for future development (table 3). Positive attitudes outweighed negative ones for most subthemes, including physical literacy (21 positive/4 negative); pressure, motivations and incentives (31 positive/8 negative); and self-reflection (24 positive/7 negative). Negative attitudes were more prevalent when participants discussed the impact of external factors on health and well-being (2 positive/18 negative). Key actions from this exercise included: improvements in design; the use of prompts and notifications; adjusting user feedback to capture a more general reflection of health status; and providing a wider range of suggestions for non-specialist equipment to increase the accessibility of the exercises.

Table 3

Attitudinal coding for subthemes


Key findings

Themes were developed under an over-arching concept of ‘COM-B Plus’. This refers to the behaviour change framework of capability (skills and capacity for movement), opportunity and motivation (opportunities, motivations and barriers for movement)20; with additional aspects of guidance, structure and permission not to push oneself too hard (a personalised, safe space in which to develop), that participants felt enabled a protective and beneficial effect.

Capacity to be physically active

This study falls within the broader context of poor adherence to PA guidelines in the UK and the additional complexities and challenges of supporting individuals returning to or starting PA following illness or prolonged inactivity. Current interventions for PA in UK healthcare are based on education. This is despite limited knowledge of CMO guidance and low confidence among practitioners in delivering exercise guidance,21 and a small effect that likely wanes over time.22 Moreover, practitioners point towards the need for more individualised approaches for PA guidance that use resources effectively.21 Interventions to increase knowledge on how and why to engage in PA may not be enough.

In a prospective study of the predictive validity of the COM-B model for PA,23 24 ‘capability’ was defined almost exclusively by psychological aspects, such as self-monitoring, habits and action planning, and was itself a motivating factor. Knowledge itself did not contribute, emphasising that capability for PA might be more about the capacity to control and apply habits rather than knowing how to do something. However, participants in our study did highlight the benefit of skills acquisition related to safe PA and expanding a vocabulary of movement. These aspects might therefore be important in subgroups with specific needs, such as those recovering from illness, and less so for generic PA guidance. In their study of the validity of the COM-B model for PA, Howlett et al identified that habits and autonomous actions increased PA via the motivational impacts on self-identity.23 Our participants discussed the relationship between the impacts of PA, such as on mental health, reclaiming control over what one can or cannot do, feeling stiffness the following day, or seeing self-monitoring scores, and subsequent increased motivation to be physically active. Therefore, reflecting on the impacts from a pattern of PA that is becoming habitual can feed into a cycle of increasing PA, and guided self-reflection might be an important motivating tool.

This concept of physical literacy, a subtheme, encapsulates the domains of motivation, confidence, physical competence and knowledge and understanding with regard to PA and has generally been applied to children and younger adults.25 26 However, it has not been robustly defined, and a national UK consultation to develop a shared definition, led by Sport England, is underway to address this.27 Initial findings suggest that people regard affective elements of a relationship with physical movements, such as motivation, self-perception of competence and enjoyment, more than technical, physical skills when considering physical literacy. A framework for physical literacy for older adults proposed that confidence in movement, and perceived self-efficacy, are important elements.25 This indicates that, although interventions might consider technical movement skills in the capability domain, it is the self-efficacy, self-perception and confidence from habitual use that translate into increased PA and movement rather than simply knowing how to do an exercise. Therefore, when seeking to engage those unfamiliar with PA or recovering from illness, digital tools should consider adopting individualised, non-judgemental approaches with graduated progression and guided self-reflection, as reported by participants in this study.

Digital tools and habitual PA

Digital tools have the potential to increase PA in adults,28 based on the ubiquity of smartphone devices and the capacity to provide cost-effective and wide-reaching guidance. However, little is known about their long-term impacts. For example, PA coaching using smartphones effectively increased step counts in adults in a US study. Still, it demonstrated decreasing interaction from users, with only a small number completing their assigned interventions.29 Generally, impacts of digital PA tools are measured at less than a year in adults and older adults.13 28 Therefore, concepts of physical literacy are likely to be important to translate the short-term impacts of digital interventions into meaningful longer-term habitual activity. This work suggests that a COM-B Plus model, based on guided self-reflection and graduated progression, might be of value for future digital interventions with longer-term follow-up.


There are limitations to the generalisability of our findings. First, less than half of those who expressed interest in the study participated. This is concerning given that NHS staff, targeted for recruitment, have a 46% higher rate of absence than other sectors and high costs of retirement from ill health.30 Therefore, it is likely that digital tools such as this cannot overcome initial barriers to PA and that the participants in this study, overwhelmingly from the academic sector, had fewer barriers to being physically active than others. Second, it is also possible that respondents were more digitally and health literate than the general population, coming from clinical, research and management domains. This might affect the impacts of tools such as this when disseminated more widely. Future development of this work must focus on ensuring inclusivity when using digital approaches.31 Finally, this study recruited opportunistically, and the diversity of participants in socioeconomic status is unclear. Again, this will likely impact usability and interaction with digital tools, demonstrating the importance of ensuring inclusivity in future research to evaluate this approach.


Accounts describing users’ experience of a digital tool designed to support people returning to PA after a period of illness or inactivity clustered around three themes: skills and capacity; opportunities, motivations and barriers; and personalised, safe spaces. These were encapsulated under the overarching framework of COM-B Plus. Safe and graduated progression and self-reflection were important elements which increased motivation beyond simple learning of technical skills for movement. These self-efficacy components of physical literacy are important considerations for digital PA tools that promote PA following illness or inactivity.

Data availability statement

Data are available upon reasonable request. Transcriptions with deidentified participant data may be made available on reasonable request to

Ethics statements

Patient consent for publication

Ethics approval

This study involves human participants. This research was approved by the Imperial College Research Governance and Integrity Team (RGIT) (12 August 2021; 21IC6693). All participants were required to provide informed consent before taking part in the study. Data collected as a part of this study are anonymised and kept strictly confidential in accordance with the UK General Data Protection Regulations (2016). Participants gave informed consent to participate in the study before taking part. Copies of this study will be disseminated to all PPIE and study participants.


We are grateful to those who contributed to all the PPI engagement for their time and kind advice. We are also grateful to Dr Dane Vishnubala and Dr Enrica Papi for their contributions to the early stages of conception of this project, and to the Imperial Health Charity for their support.


Supplementary materials


  • Twitter @drdavidsalman

  • Contributors AM, PLF and SH conceptualised the development of the digital tool and the study. OH and DC developed the exercise content of the digital tool and contributed to the overall development and outlook. STaylor (Rehab Guru) developed the software platform and contributed to the development and outlook of the digital tool. DS, AM, PLF and SH guided the development of the digital tool together with OH, DC and STaylor. JK and DS guided clinical input and safeguarding with regards exercise following illness and COVID-19 infection and progression permutations. DS, STurner, PLF and AM developed the pilot study and recruited participants. DS and STurner conducted qualitative interviews and coded the transcripts. DS analysed the data, and all members of the research team contributed to refinement of themes. AM reviewed transcripts and supervised the study. All authors contributed to the drafting, writing and editing of the manuscript. DS is the guarantor.

  • Funding Work towards this article was supported by Imperial Health Charity Innovate funding (grant reference number II2021_7). DS is also supported by an Imperial College and National Institute of Health Research (NIHR) Post-Doctoral, Post-CCT research fellowship. STurner was supported by SCARFREE fellowship. The views expressed in this publication are those of the authors and not necessarily those of Imperial College London, the Defence Medical Rehabilitation Services, Imperial College Healthcare NHS Trust or Rehab Guru. Imperial College London is the sponsor for this study and has no influence on the direction or content of the work.

  • Competing interests None declared.

  • Patient and public involvement statement Participant and public involvement (PPI) groups were convened to outline the strategy and outlook of the web app design. Participants were of a mix of ages and gender, and all had personal experience of COVID-19 infection and/or Long COVID, or of physical fitness rehabilitation following illness. Comments and suggestions made from the initial meetings contributed to adjustments made in the interface of the digital tool, wording of participant-facing literature, and in the study design. Key themes, codes and illustrative codes were then discussed with members of the PPI groups to further verify and refine codes.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • © Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.