Background: Stroke frequently leads to upper limb disability, limiting daily activities. Despite recommendations for high-intensity functional task training, many patients underutilize their affected limb, often compensating with the non-affected arm. Be- haviour Change Techniques (BCTs) may enhance physiotherapist’s ability to promote affected limb use. Objective: To identify and characterize BCTs used by physiotherapists to promote upper limb activity in stroke patients. Methods: A cross-sectional study observed 30 physiotherapists during three 1-hour treatment sessions (90 sessions total) with stroke patients exhibiting upper limb impairments. Sessions were audio/video recorded and analyzed using the Behaviour Change Technique Taxonomy v1 (BCTTv1), categorizing techniques across eight motivational domains. Descriptive statistics summarized BCT frequency and characteristics. Results: No physiotherapists used evidence-based BCTs aligned with functional task training. However, motivational techniques were common in conventional physiotherapy, with “reducing negative emotion” (34.2%), “verbal persuasion about capability” (7.5%), and “demonstration of behaviour” (6.7%) being most frequent. Sessions aver- aged 8–10 exercise repetitions, significantly below recommended levels. Conclusion: Physiotherapists frequently employ motivational strategies but lack integration with evidence-based BCTs or functional task training. Targeted training in BCT frameworks could improve upper limb rehabilitation outcomes.

• Stroke; Upper limb rehabilitation; Behaviour change techniques; Physiotherapy; Functional task training

Baniya B, Katuwal S, Rajagopalan V (2026) A Cross-Sectional Study to Verify the Behaviour Change Techniques Used by Physiotherapists in Promoting Upper Limb Activity Post-Stroke. J Neurol Disord Stroke 13(1): 1246.

Stroke is a leading cause of disability worldwide, with approximately 25.7 million survivors and 10.3 million new cases in 2013 [1]. In India, stroke prevalence ranges from 84–262 per 100,000 in rural areas to 334–424 per 100,000 in urban areas [1]. Upper limb impairment is a common consequence, affecting motor control and limiting activities like reaching and grasping. Up to 33% of stroke survivors with residual upper limb function avoid using their affected arm in daily activities [2].

The American Stroke Association recommends functional task training—repetitive, task- specific exercises—to enhance motor recovery [3,4]. However, rehabilitation sessions often fall short, with only 51% involving functional movements and an average of 32 repetitions per session, compared to 250–300 repetitions suggested by animal studies for neuroplasticity [5,6]. Low adherence to prescribed exercises, with up to 50%of stroke patients discontinuing programs within a year, further complicates recovery [7-9].

Behaviour Change Techniques (BCTs), as outlined in the Behaviour Change Technique Tax- onomy v1 (BCTTv1), provide a structured approach to influence behavior through 42 techniques across eight motivational domains (e.g., goals, emotion, reinforcement) [10]. The COM-B model (Capability, Opportunity, Motivation – Behavior) supports BCT application by identifying barriers to behavior change [11,12]. This study aimed to identify which BCTs physiotherapists use to promote upper limb activity post-stroke and to characterize their application.

Study Design

A cross-sectional observational study was conducted in hospitals and rehabilitation centers in India from January to June 2024.

Participants

Thirty physiotherapists treating stroke patients with upper limb impairments were recruited via convenience sampling. Inclusion criteria included practicing physiotherapists in clinical settings. Exclusion criteria included treating patients unable to follow commands or unwilling to participate. Ethical approval was obtained from the Institutional Review Board, and all participants provided written informed consent.

Data Collection

Each physiotherapist was observed during three 1-hour treatment sessions (90 sessions total) with stroke patients. Sessions were recorded using an 8MP audio/ video camera, with audio- only options offered to address privacy concerns. Non-disclosure agreements were signed to ensure confidentiality.

Data Analysis

Recordings were transcribed and segmented into 5-minute intervals. Two independent re- searchers coded segments using BCTTv1 to identify the presence of 42 BCTs across eight domains. Inter-rater reliability was assessed using Cohens kappa (κ = 0.82). BCT frequency, duration, and exercise type were recorded. Descriptive statistics summarized findings, and results were presented in tables.

Participant Characteristics

The sample included 30 physiotherapists (52% female, 48% male; mean age 26.5 ± 3.5 years). Most (88%) were aged 20–30 years, with an average of 3.2 years of clinical experience.

BCT Usage

No physiotherapists used evidence-based BCTs aligned with functional task training. However, all employed motivational techniques during conventional physiotherapy (e.g, resistance training, passive range of motion). Table 1 summarizes BCT frequency:

Table 1: Frequency of BCTs Used in Observed Sessions

Sessions averaged 8–10 exercise repetitions, significantly below the 250–300 recommended for neuroplasticity [6]. Interactions were face-to-face, lasting 60 minutes, five times weekly for 45 days.

This study reveals three key findings. First, none of the 30 physiotherapists used evidence- based BCTs aligned with functional task training, despite its recommendation for stroke rehabilitation [4]. This aligns with (author?) [14], who noted reliance on traditional practices over research evidence.

Second, exercise repetition was minimal (8–10 per session), consistent with (author?) [6], who reported 32 repetitions on average. This gap highlights a missed opportunity to leverage neuroplasticity through high intensity training.

Third, while motivational BCTs like “reducing negative emotion” and “verbal persuasion about capability” were common, their use was not systematic or informed by BCTTv1 or the COM-B model. This suggests a knowledge gap, as prior studies have shown structured BCTs improve rehabilitation outcomes [15].

Limitations

The study used convenience sampling, potentially limiting generalizability. The small sample size (30 physiotherapists) may not represent broader practice. Data collection faced challenges, including therapist reluctance to be recorded, mitigated by audio-only options. Future studies should include larger, diverse samples and assess patient outcomes directly.

Implications

Training programs on BCTTv1 and functional task training could bridge the gap between evidence and practice. Integrating BCTs into clinical protocols may enhance patient motivation and adherence, improving upper limb outcomes.

Physiotherapists frequently use motivational strategies but do not integrate evidence-based BCTs with functional task training. Targeted training in BCT frameworks and high-intensity rehabilitation protocols is needed to optimize stroke rehabilitation. Future research should explore barriers to BCT adoption and evaluate their impact on patient outcomes.

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