What can be learnt from occupational therapists practising in the Netherlands who address sports in practice? A qualitative study

Participation in sports or physical activity improves physical and mental health, enhances quality of life; and supports social inclusion according to the meta synthesis review from Soundy et al. (2015). Sports include “activities involving physical exertion and skill in which an individual or team competes against another or others for entertainment” (Oxford Learners Dictionary, 2026a, 2026b). Related concepts such as physical activity, physical exercise and physical fitness all describe movement and are often used interchangeably (Caspersen et al., 1985). Physical activity contains all daily activities ranging from sports to conditioning and household activities. Exercise on the other hand, is the planned and structured subset of physical activity that has the final or intermediate objective to improve or maintain physical fitness. Whilst physical fitness contains a set of attributes that are health- or skill-related (Caspersen et al., 1985).

In occupational therapy, sports or physical exercise are categorised as leisure activities, according to the scoping review from Costalonga et al. (2020). In occupational therapy practice for adults, leisure can be seen as a means to other therapeutic goals, rather than an end in itself (Chen and Chippendale, 2018). In their opinion paper Chen and Chippendale (2018) argue that this view fails to acknowledge that leisure activities are meaningful, unique and significantly affect an individual’s health and well-being. The Universal Declaration of Human Rights recognises the right to participate in leisure (OHCHR, 2018) and limited access, especially for marginalised groups, can be viewed as occupational injustice (Townsend, 2012).

Beyond physical development, sports foster psychosocial development by allowing people to be part of a community (Holt et al., 2017). For both healthy individuals and people with mental illness, sports participation provides meaning, identity and a feeling of belonging (Soundy et al., 2015). A systematic review among older adults indicates that health is both a motivator and a barrier to sports participation, as poor physical health limits sports participation, while regular activity enhances it (Jenkin et al., 2017).

According to the World Health Organisation guideline on physical activity and sedentary behaviour (2020), sports is a form of physical activity and can be part of recreation and leisure. The guideline recommends that children and adolescents should engage 60 min per day of moderate to vigorous-intensity aerobic physical activity, as well as activities that strengthen muscle and bone for at least three days a week. For adults and older adults the guideline recommends 150–300 min of moderate-intensity or 75–150 min of vigorous-intensity aerobic physical activity per week; or a combination of the two, alongside muscle-strengthening activities on two or more days a week. In addition, to prevent falls older adults should additionally perform multicomponent balance-focused activities three or more days a week. These recommendations also apply to individuals living with chronic conditions (WHO, 2020).

The implementation of national physical activity policies increased across Europe between 2015 and 2021. However, data from 23 indicators of the European Union Health-Enhancing Physical Activity Monitoring Framework showed that no significant change in levels of sufficient physical activity was found between 2013 and 2022. Therefore, the physical activity policies in the European Union do not seem to impact the intended goal of increasing physical activity (Whiting et al., 2025).

The Dutch Government’s national physical activity guidelines (Gezondheidsraad, 2017) promotes and monitors physical activity and sports participation. However, by 2022, just 44% of adults and only 29% of those aged 75 and older met the standards (CBS, 2023). Meanwhile, a Dutch cross-sectional study showed that an adapted after-school sport program for youth with chronic illness or physical disabilities improves self-confidence, health and overall quality of life (Lankhorst et al., 2021).

Occupational therapists (OTs) acknowledge that physical and mental well-being is enhanced through participation in chosen occupations and environments (AOTA, 2020b). In occupational science, this understanding of the connection between occupation and overall health is deepened by studying people’s everyday occupations (Hocking, 2020).

Costalonga et al. (2020)’s scoping review, examining sport as a leisure occupation, identified a few studies addressing sports participation from an occupational science perspective (e.g. Mynard et al., 2009; Ratcliff et al., 2002; Rogers et al., 2014). These studies primarily focused on experiences of a singular sport, such as football, surfing, tai chi or judo. However, only Ratcliff’s et al.’s (2002) study explicitly connected experiences with physical occupation, martial arts and circus performance to the occupational science framework, emphasising the importance of studying occupations from a holistic mind-body perspective.

Occupational therapy literature reflects diverse approaches to sport. Kalb et al. (2020) advised early OT involvement to help people with MS develop a lifestyle physical activity plan by addressing barriers and facilitators for participation. De Lima and De Jesus Alves (2020) highlighted OTs’ role in monitoring para-athletes’ satisfaction with assistive technology devices. Other studies examined the effectiveness of an occupational therapy program after a sports-related concussion (Li, 2023) or the feasibility of sports-based interventions, such as ocean therapy (Rogers et al., 2014). National occupational therapy guidelines, including Parkinson’s disease associate sport with leisure activities and describe sport as a potentially meaningful occupation in practice (Ergotherapie Nederland, 2020). Specifically, the multi-disciplinary guideline on Parkinson’s disease recommends that physiotherapists, exercise therapists and OTs should map the physical activities for people with Parkinson’s, educate patients regarding the risks of inactivity and Parkinson’s-specific benefits of exercise/being active, as well as the benefits of exercise/being active for overall health. The guideline recommends that OTs specifically should stimulate and evaluate behavioural change towards physical activities, using tools such as the Activity Weighting Scale, adjusting activities, activity pattern and/or physical environment to optimise the activity level (ParkinsonNet, 2025).

Despite the benefits of sports participation, people with disabilities, chronic illnesses or living in poverty still face barriers to participation. This suggests a potential role for OTs in enabling and promoting sports participation by broadening their range of practice and tackling social and occupational inequalities which may include inaccessible environments, stigma, policies and restrictions on personal autonomy (Frier et al., 2017).

The literature shows the benefits of sports participation to health and well-being and the role OTs can play in facilitating sports participation to improve health and address occupational injustices. However, this area of practice is underexplored, particularly in the Netherlands. Therefore, this study explored the experiences of OTs practising in the Netherlands with sports participation as an intervention or a goal in therapy and to understand influences on these experiences.

This qualitative research study adopted a critical realist methodology (Danermark et al., 2019) with semi-structured interviews to investigate OTs’ experiences of sports participation as an intervention or goal in the Netherlands. The critical realist paradigm has a realist ontology, which understands that the real world exists outside of anyone’s perception of it. However, critical realism’s epistemology acknowledges that people’s perspectives of a shared reality may vary from person to person, as perceptions are influenced by aspects such as personal beliefs, values, identity and socioeconomic background (Danermark et al., 2019). Realist ontology allows researchers to seek explanation. However, its relativist epistemology demands that this task is approached with caution. Therefore, this study drew on Healy and Perry’s (2000) criteria for qualitative realist research to support its validity and reliability.

This research was conducted as part of the first author’s master’s degree for qualified OTs. She became interested in sports in occupational therapy practice a few years after sustaining a sports injury in 2019. During her recovery and return to work, different professionals supported her, but she and other professionals did not recognise the need for guidance in sports participation. The first author understands that she brings her personal and professional background and beliefs to this study. To acknowledge this, she kept a reflexive journal in which she examined how her background affected her. The content in this journal has been part of discussions with peers and during supervision (Holmes, 2020). To further enhance trustworthiness, the researcher discussed findings (member checking) with one participant to support the results’ credibility (Braun and Clarke, 2013). The first author acknowledges that her personal experience could be considered a form of bias as it certainly influenced the choice of topic and it is likely she is more sensitised to parallels to her own experience. However, the authors hopes that a combination of transparency with regard to this acknowledgement and the measures of reflexivity and rigour have resulted in a trustworthy analysis that makes a significant contribution to occupational therapy knowledge.

Six participants were recruited by purposive sampling (Braun and Clarke, 2013). Inclusion criteria were OTs:

• currently/recently working within the Dutch healthcare system;

• educated in the Netherlands; and

• with professional experiences of sports participation in occupational therapy.

People with whom the first author had a close personal or professional relationship with were excluded. Recruitment was completed by circulating an invitation through the researcher’s professional networks.

Data were gathered by the first author in five online and one face-to-face semi-structured individual interviews of 45–60 min using an interview protocol based on the key aspects of the literature review. A selection of the main interview questions is shown in the interview protocol in Table 1. Conversations were recorded using a voice recorder on a mobile phone or through Microsoft Teams software. Data were transferred anonymously to an encrypted folder in OneDrive within 24 h after the interview.

The first author transcribed and analysed the data using MAXQDA (VERBI Software, 2024). Transcribing and coding were done in Dutch, the original language of the participants and the researcher. The first author listened to the recordings between two to four times each. During this process, she familiarised herself with the data by highlighting and taking notes of potentially interesting topics in the transcripts. After this, codes and patterns related to the research question were identified. Later, when coding interviews four, five and six, the first author became more selective about what data to code and latent codes were also used (Braun and Clarke, 2013). In the next phase, the first author grouped codes and looked for overarching themes. The first themes were discussed and translated into English with the help of a Dutch peer student and later on, they were discussed with the third author, whose first language is English. Through discussion, themes were revisited and revised a number of times. Table 2 presents an example of the coding process. In line with the critical realist methodology, themes were thus developed using a combination of inductive and deductive thematic analysis, with the deductive analysis drawing on themes suggested by the literature review. A combination of both inductive and deductive analysis was chosen because, from a critical realist standpoint, themes that are considered inductive are informed by deductive elements, such as professional-, practice-, personal experience and the literature review conducted at the start of a study (Danermark et al., 2019). The final draft and key findings were discussed among all authors.

Ethical approval was obtained from Amsterdam University of Applied Sciences, January 24th, 2024, reference HVA-539. Written informed consent was obtained from all participants. All data were anonymised.

Themes derived from the data and were congruent with both inductive and deductive analysis.

Table 3 shows participants’ work setting and frequency of encountering sport-related cases. All six participants, with professional experience varying from 1 up to 34 years, had an affinity for sports and regularly engaged in sports such as soccer, cycling, running, athletics, weightlifting or bouldering. Participants worked in mainly physical health care settings by which improving mental health issues were usually the secondary objective. As data on gender was not collected, gender neutral Pseudonyms were assigned to participants to enhance readability. Participants described how sports were meaningful occupations for them. They considered that sports were occupations that gave them positive energy and contributed to their physical and mental health. Table 4 provides an overview of the themes and subthemes.

No specialist sports interventions which OTs use specifically for clients with sport-related goals were reported. Instead, more general practice tools were deployed. Sports participation was sometimes a primary objective, but more often was a means to achieve a broader therapeutic goal, like returning to work or staying fit for activities of daily living (ADL) activities after a head injury. A commonly used intervention was reported to be education about energy conservation. This involved explaining the importance of engaging in meaningful occupations and the benefits and risks associated with increased activity levels and with the specific sports related to the client’s health condition.

Other frequently used interventions included graded activity, graded exposure, traffic light model, creating support splints, advising on posture for specific sports equipment or during sports activities like boxing to prevent injury, breathwork and pacing techniques. To make interventions meaningful and occupation-focused Luca combined functional exercises with daily occupations:

Although Luca’s clinic provided a room to simulate playing wheelchair tennis. In this scenario they were using the resources they had to support sports participation. Similarly, the other participants were able to work with the tools they have, suggesting that OTs in this study were ready and equipped to address sport-related goals in practice.

Nevertheless, both Ellis and Lee expressed a desire to innovate and develop their expertise and knowledge in sport and underpinning sciences:

Despite Ellis’ and Lee’s affinity with various sports, from which they implement experience into occupational therapy practice, expressed a need for tools to support their ability to provide education to clients in relation to the physiological value of sports on recovery and wellbeing.

Participants found themselves exploring clients’ motivations to engage in occupations that improve their physical and mental health by addressing fears and beliefs that might affects progress. Depending on a client’s character, clients were advised to slow down to prevent overexertion or encouraged to prevent under exertion. Participants, including Bo, described having a coaching role, encouraging clients to identify solutions and letting them define how to build up their occupations, fostering a sense of autonomy and empowerment. Overall, participants used a client-centred approach to support people’s sports-related goals, integrating various methods and educational strategies to enhance physical and mental well-being:

Bo helped the client become more conscious of what aspects of badminton were enjoyable, generalising these aspects to a different setting and exploring their beliefs and assumptions about modified badminton. This created insights for Bo’s client of how their clients’ beliefs had been preventing her from enjoying a meaningful occupation. She then provided evidence that her motivational impact had enduring effects:

According to participants, OTs have a role in working with clients with sports-related goals despite the existence of other professionals in this field. This role may encompass long-term recovery from sports injuries rather than short-term, where in acute care for instance, physiotherapy may be more appropriate. The value of occupational therapy in long-term recovery from sports injuries was located, beyond functional levels, in occupational and participation realms. However, Luca sometimes adopted a more interdisciplinary hand therapy approach using physiotherapy type interventions and postponing occupational therapy interventions to accommodate client’s needs:

Although, Luca’s physiotherapist colleague educated clients about the value of occupational therapy and often referred new clients to Luca, roles in their hand therapy practice were blurred by putting the client’s interest first.

Most participants associated sports with exertion, exercise, increasing heart rate and being physically active to improve their physical and mental health. Participants acknowledged that physical activity or physical exercise could accomplish that, too. During treatment, participants experienced that a client’s definition of sports often also included aspects of physical activity or physical exercise:

Although the definition of sports sometimes varied from the clients’ definition, participants verified very clearly what a client understood by sports and stuck with the client’s interpretation as guidance for client-centred therapy. Besides, the English definition of sports is similar in Dutch but at the same time “sports” is used as a noun to say someone is “working out” or “being physically active”. Those two meanings can be related to the competitive aspects of sports, but also to participants associations like exertion, increasing heart rate and being active to improve health. This could partly explain the fine line between sports and physical activity.

Furthermore, participants noticed a difference between sports and sports participation in practice by asking what aspects of sports were meaningful for a client. Meaningful aspects could involve doing sports or sport-related activities with friends, joining a running event, visiting a sports club and watching sports in real life or on television. Differentiating between sports and sports participation helped set realistic and meaningful goals to motivate the client:

It could be understood from this, that visiting a sports club and watching others play sports enables social participation in which one becomes or stays a member of a community and creates a sense of belonging.

Generally, participants noted that sports became less important to clients when health issues deteriorated and with older age. Despite that, sports were addressed in all reported settings, though their frequency and intensity varied. Therapy goals in acute hospital care typically focus on ADL and mobility. In other settings, goals often include ADL, return to work, social activities or sports participation, demonstrating varied priorities. Examples were provided of how sports appear in acute healthcare settings or cases with older adults.

Robin discussed with their clients how to return to sports after discharge despite the acute health care setting. And Sam guided a woman of 82 in primary care to resume tennis after a cerebral vascular accident that led to hemianopia:

OTs’ incorporation of sports in their practice was influenced by their personal affinity and experiences. Robin discussed with a colleague whether they address sports in the hospital. The colleague did not address sports, arguing that it was more important for people to dress and cook independently first. Robin realised that the colleague was less interested in sports personally than themselves. Robin had also seen the benefits of focusing on regular walking and improving condition of their father-in-law whilst recovering from cerebral haemorrhage:

In addition, positive stories of clients’ use of sports alongside OT’s educational studies encouraged participants to reflect on their practice and shaped participants’ vision of sports and occupational therapy.

Participants explained that sports are usually seen as leisure activities by both themselves and their clients. Although sports can be part of treatment in each setting, it is often not the client’s priority. Furthermore, the time clients had to do what “they like to do” varied from person to person. This amount of time was influenced by many factors, such as age, health status, family, work and financial situation. For example, the daily occupations of one man with muscular dystrophy were affected by his health state:

This theme illustrates the awareness created by negotiating, prioritising and adjusting when discussing the distribution of daily occupations with an OT.

This study explored the experiences of OTs practising in the Netherlands with sports participation as an intervention or a goal in occupational therapy and aimed to understand what affected these experiences. Some of the findings are discussed in relation to the four dimensions of occupation – doing, being, becoming and belonging as described by Hitch et al. (2014). This framework is effectively used in occupational therapy and occupational science research to explore and analyse people’s participation in occupations and it’s impacts on their lives. The results highlight how personal, contextual and systemic factors interact in therapists’ decisions, offering a critical perspective on the role of occupational therapy in the context of sports.

As shown in the findings participants associated sports with exertion, movement, energy and benefits for physical and mental health. Their experiences align with doing – being active and productive in a way that is visible and recognisable to others (Hitch et al., 2014). The doing of sports can provide routine and purpose and a sense of identity, reinforcing its therapeutic value (Soundy et al., 2015).

Furthermore, sports were described as a shared experience, fostering belonging. Watching, playing, attending events or discussing sports together created connection and inclusion, particularly in group settings. These experiences support the idea that belonging is tied to the interpersonal relationships that occupations involve (Hitch et al., 2014).

As indicated in the findings reveal several factors as to why, when and by whom sports are prioritised and deprioritised. Firstly, factors external to the therapist, such as the client’s health condition and setting (e.g. acute care vs rehabilitation) often dictated priority. Participants noted that sports were deprioritised when clients faced pressing physiological or safety needs, for example, after being recently admitted to a hospital. This practice may reflect an implicit application of Maslow (1970)’s hierarchy, where higher-level needs such as belongingness, esteem and self-actualisation are deferred until lower needs are met, such as Sam’s client. However, the study findings suggest that for some clients, such a rigid application of Maslow may overlook the potential motivating power of seemingly higher-level needs, which may serve to encourage and enable the client to address more basic needs. Not addressing certain occupations in acute care may also be affected by the service’s priority to discharge clients when they can because of fiscal limitations (Britton et al., 2015) rather than service philosophy.

Secondly, internal factors, such as personal values and experiences of OTs, also played a role. OTs with an affinity for sports or professional experiences made them more aware of sports’ role in clients’ recoveries and more likely to integrate it, while colleagues with less affinity tended to overlook it. Having less affinity with an occupation could be a form of bias if an OT is unaware when they do not address for that reason. According to Meidert et al. (2023), health professionals can have prejudices towards clients due to their gender, race or other factors without their conscious knowledge. These unconscious confirmation biases, also known as implicit biases, are described as involuntary associations or attitudes that affect our perceptions and, therefore, our behaviours, decision-making and interactions in an unconscious manner. This reflects how implicit biases can shape clinical reasoning. While such bias differs from those of race or gender, it still challenges the OT principle of equality (AOTA, 2020a). Notably, most studies on implicit bias concern physicians or nurses (Meidert et al., 2023). Further research is needed to understand how this occurs in occupational therapy. Another internal factor is how the affinity for sports could lead to therapists transferring knowledge and experiences from private life to a professional context or vice-versa to help a client overcome barriers in practice. This process of comprehending oneself, including beliefs, values and biases, to create effective relationships with clients is called the therapeutic use of self (Taylor, 2020). Thirdly, participants noted that sports were also deprioritised by clients and themselves because people were more likely to choose the activities they must do over the ones they like to do. Participants often associated activities they like to do with leisure. Despite its contribution to health and well-being, the value of leisure is often minimised. Leisure, defined as “time that is spent doing what you enjoy when you are not working or studying” (Oxford Learners Dictionary, 2026a, 2026b), implies that people participate autonomously and have choices in their daily occupations – a condition that constitutes a privilege. For example, in 3.3 Bo’s client with muscular dystrophy said having no choice but to quit all his hobbies due to lack of energy and is nowadays only able to work, eat and sleep. Asserting this privilege as a fundamental principle of a worldwide profession is a considerable assumption rooted in a Western ideology (Murthi and Hammell, 2021). Existing research has shown that opportunities for occupational choice are unevenly distributed globally, as various external factors – such as poverty, racism, environmental challenges, political instability or conflict – can significantly restrict individuals’ ability to choose their occupations (Frier et al., 2017; Galvaan, 2012).

This theme illustrated the interventions OTs use to address sport-related issues, the role OTs take and foresee in this field of practice and what development needs they have. Participants acknowledged they are working with the tools that we have as OTs since there are no specialist interventions developed for sport-related goals. In Luca’s example in 1.1 working with the tools we have included working with an occupation-focused approach. Adopting an occupation-based approach appeared to send a stronger message of commitment to occupational therapy’s unique perspective, emphasising the core importance of meaningful occupation.

Coaching, exploring motivation and adapting occupations were key roles adopted by participants to support occupational engagement, such as when the client was supported to consider modified badminton. The client’s process aligns with the dimension of becoming, which involves a process of personal change and development. Becoming is not solely about progress; it also encompasses the capacity to maintain agency and manage oneself amid changing abilities. For example, for individuals with chronic pain, learning to manage symptoms effectively facilitated their process of becoming (Hitch et al., 2014). This subtheme is also related to being, the dimension that refers to being true to oneself and that people are required to engage in self-reflection. This helps individuals to understand their experiences and identity. The being dimension emerged when participants explored clients’ perceptions of- and motivations towards sports occupation and noticed how these varied from their own, highlighting the need for a client-centred approach in occupational therapy (Fieldhouse and Fedden, 2009).

As shown in the findings, OTs can support clients with long-term recovery from sports injuries because OTs look beyond functional levels towards occupational and participation levels. However, one participant noted that working in sport-related domains sometimes blurred professional boundaries, especially with physiotherapists, which sometimes led to postponing occupational therapy. This confirms concerns raised by Molineux (2011) that OTs must clearly articulate what they do and do not do when entering a new or emerging field and convey the core philosophies of their profession, ensuring that meaningful occupation remains their central focus of practice and research.

This study provides insights into the experiences of OTs practising in the Netherlands who adress sports participation as an intervention or a goal in therapy and into what affected these experiences. The findings affirm the usefulness of the framework about the four dimensions of occupation “Doing, being, becoming and belonging.” (Hitch et al., 2014) as a lens for both practice and analysis. Furthermore, the findings in 1.1 show how an occupation-focused is currently used in practice. Adopting an occupation-based approach appeared to send a stronger message of commitment to occupational therapy’s unique perspective, emphasising the core importance of meaningful occupation. In addition, occupation-based performance analysis offers an ecologically valid method for evaluating the quality of a person’s occupational performance, not just the outcome (Fisher, 2014). Future research should include client perspectives and explore the sport-related occupational therapy practice in different international and policy contexts. Clarifying the scope and value of OT in interdisciplinary teams may strengthen its presence in the evolving field of sport and occupational participation.

To judge the quality of this study, Healy and Perry’s (2000) criteria for realist research were adopted. One of the strengths of this study was the recruitment of six participants with sport-related professional experience from a variety of settings, despite sports and occupational therapy being an underexplored area. Secondly, Healy and Perry’s (2000) contingent validity asks researchers to show “generative mechanisms and the contexts that make them contingent.” (p123). This is demonstrated the analysis and discussion by a transparent explanation of the findings that is grounded in the data, notably with attention to the personal factors and context-related influences. However, as a result of the recruitment process, a potential limitation of this study is that all participants had a strong affinity for sports themselves. This suggests caution when assuming that other OTs with similar professional experience but less affinity with sports would produce similar data. There were also no OTs represented from mental health settings, in which the literature review often refers to as a setting in which sport is used in practice. Another criterion concerns epistemology; the use and acknowledgement of multiple perceptions of participants and peer researchers. The use of supervision, peer researchers and member-checking helped the researcher meet this criterion (Healy and Perry, 2000). Although the researcher aimed to focus on sports as a distinct concept, it was clear that some participants and their clients at times included concepts of physical exercise and physical activity as “sports”. To adhere to the principle of acknowledging different perceptions of a shared reality these differing interpretations were included in the findings.

This study explored the experiences of OTs practising in the Netherlands who address sports participation as an intervention or a goal in therapy and explained what affected these experiences. This study illustrated OTs’ supporting role in enabling sports and sports participation for their clients, suggesting an added value to the field of sports due to OT’s occupation-centred approach and holistic view of how to integrate sports and sports participation into someone’s daily life to improve health and wellbeing. Finally, this study gave an explanation of reasons why sports are prioritised or deprioritised by clients, workplace characteristics and practitioners’ values and professional experiences. This poses important questions for the occupational therapy profession about the ways and extent to which sport as an occupation is consistently considered. Especially, since physical activity policies in the European Union, including recommendations of active leisure and sports activities, do not seem to impact the intended goal of increasing physical activity (Whiting et al., 2025). Further research is necessary to improve our approach and explore what innovations benefit OTs practising in this field.

The authors would like to thank the participants for sharing their experiences and contributing to this research.

This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.