Interventions to Promote Physical Activity
Given the low rates of physical activity participation, as well as the multi-level barriers and facilitators to physical activity participation, among persons with SCI, the need for effective physical activity-enhancing interventions is urgent. The physical activity intervention literature in SCI has expanded substantially in the last decade. More research groups have begun to test interventions to promote physical activity participation among persons with SCI. This section reviews physical activity intervention studies that include a physical activity-related psychosocial variable and/or a measure of physical activity participation as study outcomes.
In the general population, three types of physical activity interventions have strong evidence of effectiveness: (1) Informational interventions that focus on delivering information to change knowledge and attitudes about the benefits of and opportunities for physical activity (e.g., a community-based media campaign, informational pamphlets), (2) Behavioural interventions that focus on teaching behavioural skills to promote physical activity participation (e.g., goal-setting, planning), and (3) Environmental and policy interventions that focus on changing the physical environment, social networks, organizational norms and policies to enable physical activity participation (Kahn et al. 2002). This section reviews informational (Table 4) and behavioural (Table 5) physical activity interventions given the lack of research on environmental interventions in the SCI population.
Discussion
Over the past decade, there has been a burgeoning amount of research exploring informational and behavioural interventions to increase leisure-time physical activity psychosocial variables and behaviour among persons with SCI. All interventions have been developed and evaluated in high-income countries including Canada, the United States, the Netherlands and Australia. Future intervention research is required to test the efficacy of physical activity-enhancing interventions for persons with SCI in low- and middle-income countries.
Recognizing the importance of offering evidence-based information about p (Williams et al. 2017), informational strategies (e.g., offering information about the benefits of physical activity or risks of physical inactivity, examples of exercises that can be performed) are sometimes used independently in interventions. Of the two interventions that used informational-only strategies, one RCT (Bassett-Gunter et al. 2013) showed positive changes, whereas one RCT (Foulon & Ginis 2013) demonstrated no change, in physical activity-related psychosocial variables. Changes in physical activity participation were not assessed in either study.
Most intervention studies used behavioural strategies. Of the 22 studies that used behavioural strategies, six RCTs (Arbour-Nicitopoulos, Ginis et al. 2009; Arbour-Nicitopoulos et al. 2017; Chemtob et al. 2019; Latimer et al. 2006; Ma et al. 2019; Zemper et al. 2003) and four pre-post studies (Brawley et al. 2013; Jeske et al. 2020; Latimer-Cheung et al. 2013; Warms et al. 2004) highlighted increases in physical activity-related psychosocial variables, whereas two RCTs (Kooijmans et al. 2017; Nooijen et al. 2016) and three pre-post studies (Latimer-Cheung et al. 2013; Pelletier et al. 2014; Tomasone, Arbour-Nicitopoulos et al. 2018) demonstrated no change in physical activity-related psychosocial variables.
Eight RCTs (Arbour-Nicitopoulos, Ginis et al. 2009; Arbour-Nicitopoulos et al. 2017; Chemtob et al. 2019; Latimer et al. 2006; Ma et al. 2019; Thomas et al. 2011; Wise et al. 2009; Zemper et al. 2003), one prospective controlled trial (De Oliveira et al. 2016), and five pre-post studies (Brawley et al. 2013; Hiremath et al. 2019; Jeske et al. 2020; Latimer-Cheung et al. 2013; Tomasone, Arbour-Nicitopoulos et al. 2018) reported changes in physical activity participation following the intervention. One RCT (Kooijmans et al. 2017) and three pre-post studies (Arbour-Nicitopoulos et al. 2014; Dolbow et al. 2012; Warms et al. 2004) reported no change in physical activity behaviour following the intervention. Of note, four interventions combined both informational and behavioural strategies (Arbour-Nicitopoulos et al. 2017; Latimer-Cheung et al. 2013; Tomasone, Arbour-Nicitopoulos et al. 2018; Wise et al. 2009). Also noteworthy is that behavioural strategies were implemented with varying degrees of intensity, from offering information about how to engage in behavioural strategies (Arbour-Nicitopoulos et al. 2014) to having one-on-one tailored interventionist support for engaging in behavioural strategies (Tomasone, Arbour-Nicitopoulos et al. 2018).
The use of multiple strategies across behavioural interventions makes it challenging to tease apart the isolated impact of individual intervention strategies. However, in a review that extracted behaviour change techniques (or “active ingredients” of behavioral interventions) (Michie et al. 2013) used in physical activity interventions for persons with SCI (Tomasone, Flood et al. 2018), the following strategies were associated with positive LTPA outcomes and can be considered in future interventions that aim to increase physical activity-related psychosocial variables and/or behaviour: goal setting (i.e., setting a level of physical activity to be achieved), problem-solving (i.e., analysis of factors influencing physical activity behaviour and selecting strategies that overcome barriers and/or increase facilitators to participation), action planning (i.e., setting a detailed plan of what, when, where and how physical activity will be performed) and social support (i.e., providing non-contingent praise and/or emotional support for the performance of the behaviour) (Michie et al. 2013).
The use of theory has been encouraged for SCI physical activity research (Best et al. 2017). Many of the included studies used an established theoretical framework to guide intervention content, intervention evaluation, and/or interpret findings. The included studies reported using theories and/or theoretical constructs from the Health Action Process Approach Model (Schwarzer et al. 2011), the Theory of Planned Behaviour (Ajzen 1991), the Transtheoretical Model (Marcus & Simkin 1994), Self-Efficacy Theory (Bandura 2004), and Self-Determination Theory (Ryan & Deci 2017). A theory is an abstract set of interrelated concepts, definitions and relationships that can predict or explain how certain phenomena, events or behaviour occur (Glanz & Bishop 2010). When considering theory use, it is important to consider how theories can be used in intervention studies. Theory can be used to (1) guide the design of the intervention (i.e., select intervention strategies that will target a theory’s constructs); (2) explore mediators or moderators of the behaviour or effects of the intervention; or (3) offer a post hoc/retrospective explanation of study findings (i.e., the theory has been introduced once the intervention is executed) (Davies et al. 2010). Studies may also vary in the degree to which theory is employed; that is, intervention studies may (1) be explicitly theory-based, wherein the intervention and evaluation of the intervention are based on a named theory, and the study offers a direct test of one or more hypotheses deduced from a named theory (i.e., to determine whether the intervention findings can be explained by the theoretical base); (2) have some conceptual basis in a theory, wherein theory is employed in the design of the intervention or evaluation, but tests of hypotheses deduced from theory are not conducted; or (3) use or examine some theoretical constructs from a theory without use of the entire theory (Davies et al. 2010). However, theory use varies in physical activity interventions for persons with SCI to date; some studies included in this chapter were explicitly theory-based whereas others did not use theory (or offered a poor reporting of theory). When theories are explicitly used to develop an intervention, it is more likely that important determinants of physical activity behaviour are targeted in the intervention, which should hypothetically increase intervention effectiveness (Glanz & Bishop 2010). Future intervention research should consider the extent to which theory is used in intervention design and evaluation if we want to fully grasp the impact of theory in physical activity-enhancing interventions in the SCI community.
While it is encouraging that theory use is expanding in this field, theory use alone cannot fully account for the effectiveness and maintenance of physical activity interventions. Other intervention features, such as intervention tailoring, dose, delivery mode, and provider, can also influence intervention effectiveness (Tomasone, Flood et al. 2018). For example, support from health and fitness professionals has been touted as important for enhancing physical activity participation among persons with SCI (Giouridis et al. 2021; Williams et al. 2017). Among included studies, the integration of health and fitness professionals was seen in different delivery formats. Several interventions included coach-counselling as a component and the counselling was delivered by a health or fitness professional (Arbour-Nicitopoulos et al. 2014; Chemtob et al. 2019; Ma et al. 2019; Nooijen et al. 2016; Tomasone, Arbour-Nicitopoulos et al. 2018; Zemper et al. 2003); or a trained peer (Latimer-Cheung et al. 2013). Of note, two interventions utilized a group-mediated cognitive behavioural intervention that was delivered by a health and fitness professional but harnessed the power of group-based sessions (Brawley et al. 2013; Jeske et al. 2020). Several interventions included structured and supervised physical activity programs where persons with SCI would exercise with supervision from a health or fitness professional (De Oliveira et al. 2016; Kooijmans et al. 2017; Pelletier et al. 2014). Other interventions offered home-based physical activity support by a health and fitness professional (Dolbow et al. 2012; Thomas et al. 2011; Warms et al. 2004; Wise et al. 2009) and one study included both a health and fitness professional along with a peer (Latimer-Cheung et al. 2013). Variety in intervention tailoring, dose and delivery mode was also evident. Researchers are encouraged to explore these additional aspects of intervention design and fully report all intervention details, not just strategies employed in interventions so that future syntheses can make recommendations. Using reporting guidelines, such as the TIDieR checklist (Hoffmann et al. 2014) will facilitate complete reporting of intervention descriptions.
Finally, the synthesis of the included interventions points to several additional areas for future research. One intervention aimed to enhance physical activity behaviour alongside other health behaviours among persons with SCI (Zemper et al. 2003). The utility of multiple behaviour change interventions among persons with SCI remains unknown and is a fruitful avenue for future research. While most behavioural interventions integrated behavioural strategies, few if any studies were explicit about providing training to participants with SCI about independent use of the strategies for self-management of physical activity beyond the intervention period. Future interventions should seek to train participants in how to use behavioural strategies (e.g., goal setting, action planning) without guidance from interventionists, with a goal to foster long-term behaviour change. Finally, and stemming from this point, is that most included studies examined the impact of interventions immediately following the intervention period, and most interventions occur over a relatively short period. Given physical activity behaviour requires sustained effort over a person’s lifetime, interventionists need to consider designing interventions that foster long-term change in psychosocial variables and physical activity participation. Extending intervention studies by including a follow-up period would begin to establish this needed evidence base.
Conclusion
There is level 1b evidence from one RCT that informational interventions are effective for increasing physical activity-related psychosocial variables among persons with SCI.
There is level 1a evidence from three RCTs, as well as support from three lower quality RCTs and four additional studies, that behavioural interventions are effective for increasing physical activity-related psychosocial variables among persons with SCI.
There is level 1a evidence from four RCTs, as well as support from four lower quality RCTs, one prospective controlled trial, and five additional studies, that behavioural interventions are effective for increasing physical activity behaviour among persons with SCI.
Future research should seek to fully employ behavioural theory throughout intervention design and evaluation, conduct a process evaluation to consider additional intervention components that influence effectiveness (e.g., dose, tailoring, delivery mode, provider), and design interventions that foster and evaluate long-term changes in LTPA psychosocial variables and participation.
