Identifying behavioural determinants of physical activity in persistent musculoskeletal pain: a COM-B and TDF-guided qualitative study

Despite clinical recommendations supporting physical activity (PA) in the management of persistent musculoskeletal (MSK) pain, adherence remains low. Individuals report multiple barriers not addressed by public health messaging or standardised exercise interventions. This study aimed to identify behavioural determinants of PA in this population using the COM-B model and theoretical domains framework (TDF). Eighteen adults with persistent MSK pain were recruited from a specialist pain clinic and a national charity. Three focus groups were conducted and analysed using a framework approach. Data were deductively coded to the TDF and COM-B components. Nine of 14 TDF domains were relevant. Participants viewed PA as beneficial but had concerns about safety, symptom exacerbation, and emotional burden. Barriers included lack of credible guidance, stigma, and disrupted self-identity. Facilitators included psychological benefits, peer support, and personalised goal-setting. Compared to previous studies, this sample included individuals with severe long-standing pain and analysis highlighted greater emphasis on emotion, identity, and access-related barriers. Findings support tailored, theory-informed interventions addressing capability, emotional and social support, and structural barriers. While public health messaging promotes activity, adapted or co-produced interventions may be more acceptable for individuals with persistent MSK pain. The study followed COREQ guidance.