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Physical Activity Participation

Tools to Support Physical Activity Dissemination and Implementation

Knowledge translation is the broad umbrella term that aims to address the ‘know-do’ gap and move research findings into the hands of those for whom the research is intended (Straus et al. 2013). Within the scope of knowledge translation, dissemination is the active process of making knowledge users aware of evidence (Straus et al. 2013). Implementation practice and science are the use and study of strategies to support putting evidence into practice, respectively (Straus et al. 2013).

There is a growing body of physical activity intervention literature for people with SCI (see Section 3.2). How to best support translation (e.g., dissemination or implementation) of those interventions to non-research settings is an identified gap in improving physical activity participation in this population (Giouridis et al. 2021). A recent scoping review of studies examining physical activity promotion by health and exercise professionals for people with SCI reported that SCI-specific resources and training are needed to help address the ‘know-do’ gap in this field (Giouridis et al. 2021). High-quality physical activity resources are available from sources like SCI Action Canada and the SCI Physical Activity Guidelines to support health care professionals and people with SCI to participate in physical activity. The present review aims to pull from recent research directly evaluating evidence-informed tools and strategies to support the dissemination and implementation of physical activity in clinical and community settings. Specifically, the included tools and strategies are designed to support physical activity promotion amongst providers or physical activity participation among people with SCI.

Author

Year

Country

Research Design

Score

Total Sample Size

Methods

Outcome

Ma et al. (2020)

(Part 1)

Canada

Observational

N=300

Phase 1: Systematic reviews and meta-analysis.

No Intervention: Two systematic reviews and a meta-analysis (provided the evidence base for the PA intervention). A mix of SCI-specific and general physical disability evidence was used.

 

Phase 2: Key informant interviews with people with SCI (N=26)

Population: Age range=31-64 yr, Level of injury=C5-L2; Time post injury= 1.2–43.0 yr.

Intervention: Open-ended questions were administered to understand participants’ experiences or recommendations for strategies that were or were not helpful for engaging in PA from their physiotherapists.

 

Phase 3: National survey of physiotherapists (N=239)

Intervention:  A national survey was employed to assess: (a) whether physiotherapists wanted an intervention to promote PA to clients with SCI; (b) physiotherapists’ intervention needs and barriers to promoting PA; and (c) their intervention delivery preferences.

Phase 4: Expert panel meeting (N=10)

 

Phase 4

Population: People with SCI (paraplegia and tetraplegia, n = 5), inpatient, outpatient, and private practice physiotherapists (n = 5), a physiatrist, and behaviour change researchers (n = 2).

Intervention: The panel experts discussed and identified the most relevant results from Phases 1 to 3, highlighted missing information, and developed strategies for disseminating the PA intervention.

Outcome Measures: A modified theoretical domains framework (TDF) measure was used to evaluate implementation determinants (i.e., barriers identified in Phase 3 such as knowledge, confidence, and resources).

1.        Optimal intervention delivery should be tailored and include (1) education on safety, PA guidelines, and behaviour change techniques, (2) referral to other peers, local programs, and health professionals, and (3) adapted exercise prescriptions.

Ma et al. (2020)

(Part 2)

Canada

RCT

PEDro=4

N= 20

Phase 5: PA intervention content evaluation—randomized controlled trial of intervention training and implementation determinants among physiotherapists (N=20)

Population: Gender: Females=16, Males=4; Mean Years of Practice=16.6 yr.

Interventions: Intervention Group (n=10): physiotherapists were trained in the PA intervention content in a 1 h, individual education session delivered virtually. Participants were also provided with an electronic copy of the developed PA intervention which included a 50-page toolkit outlining intervention strategies and the SCI exercise guidelines at the end of the training; Control Group (n=10): Waitlist (no intervention).

Outcome Measures: A modified affordability, practicability, effectiveness, acceptability, safety, and equity (APEASE)-criteria measure was implemented to assess participants’ perceptions on the feasibility of implementing the PA intervention in the physiotherapist setting; a test was administered comprised of 20 true or false questions to assess knowledge of SCI-specific PA information (e.g., exercise safety considerations, exercise guidelines and effective-behaviour change techniques). A modified theoretical domains framework (TDF) measure was used to evaluate implementation determinants.

1.    Following intervention implementation training, physiotherapists in the intervention group demonstrated stronger tested and perceived knowledge, skills, resources, and confidence for promoting PA to people with SCI, compared to physiotherapists in the control group (p< 0.05).

Tomasone et al. (2018)

Canada

Pre-Post

Ninitial=46

Nfinal=25

Population: Age=51.46±12.36yr.; Gender: males=23, females=22, not reported=1; Level of injury: paraplegia=23, tetraplegia=21, not reported=2; Time since injury=17.00±17.59yr.

Intervention: Participants completed informational/behavioural phone call counselling sessions to explore the implementation correlates of change in leisure time physical activity (LTPA) intentions and behavior in the second phase of Get In Motion (GIM).

Outcome Measures: LTPA Intentions, LTPA Behaviours, Counselling Session Checklist, Client Reflection.

2.      The means for all measures of implementation dose and content were greater between baseline to 2 months than 2 to 6 months (p≤0.02).

3.      Informational strategies were discussed significantly more times than behavioral strategies between 2 and 6 months (p<0.001).

4.     Changes in aerobic MVPA between baseline to 6 months were significantly related to total session duration, total number of sessions, and the number of times that informational and behavioral strategies were discussed over the 6-month period (p<0.05).

5.      Measures of intervention dose and content were also significantly positively related (p<0.01).

6.      Clients’ ratings of credibility were significantly related to changes in aerobic MVPA, as well as total session duration, total number of sessions, and number of times behavioral strategies were discussed (p<0.05).

7.      Clients’ perception of the personal importance of the content discussed during counseling sessions was significantly related to total session duration, total number of sessions, and number of times behavioral strategies were discussed over the 6-month service (p<0.01).

Salci et al. (2016)

Canada

Pre-Post

N=12

Population: Individuals with SCI=6, Exercise trainers for SCI=6; Age: 20+yr; Gender: males=8, females=4.

Intervention: Participants engaged in an online program (Active Living Leaders Training Program) and received a handbook covering leisure time physical activity (LTPA) knowledge, transformational leadership skills and practice interactions. Assessments at baseline, post-program and follow-up survey 6mo later.

Outcome Measures: Self-efficacy measure.

1.   Self-efficacy to speak about LTPA did not significantly differ between time points, nor did self-efficacy to encourage LTPA.

2. Of those that completed follow-up (n=9), 8 had spoken to someone with a disability about LTPA since completing the program and 7 had shared one of the resources.

Gainforth et al. (2015)

Canada

Pre-Post

N=13

Population: Mean age: 52.77±9.16yr; Mean time since injury: 18.46±14.51yr; Gender: males=7, females=6; Level of injury: tetraplegia=7.

Intervention: Individuals attended a 4hr brief action planning (BAP) workshop, which began with a 1hr didactic presentation about BAP followed by 3hr of practice with feedback/instruction as well as audio recordings of a peer with SCI using BAP to promote physical activity to a mentee. Measures were taken at baseline, immediately post-training, and 1mo follow up.

Outcome Measures: Leisure Time Physical Activity Questionnaire for

People with Spinal Cord Injury (LTPAQ-SCI), Motivational Interviewing Treatment Integrity scale, Likert scale, Theory of planned behavior questionnaire.

1.   BAP and motivational interviewing competence significantly increased after training (p<0.05).

2. Training satisfaction was very positive with all means falling above the scale midpoint.

3. Perceived behavioral control to use BAP increased from baseline to post (p<0.05), but was not maintained at follow up (p>0.05).

Discussion

Although currently a small body of literature, these studies represent the evolution of SCI physical activity interventions shifting into clinical and community settings. These findings show that the co-creation of material and integration of behaviour change techniques supports both people with SCI (see section 3.2) and their health care professionals (e.g., demonstration, practice, and feedback, as shown in Gainforth et al. (2015)), are key features of implementation. Implementation factors such as increased intervention dose, the use of both informational and behavioural strategies, and clients’ perceptions of service credibility may improve physical activity counselling session effectiveness on physical activity behaviour (Tomasone, Arbour-Nicitopoulos et al. 2018). Future research and initiatives are needed to inform how to best support end-users in the uptake and delivery of material.

Five evidence-informed tools to support physical activity intervention dissemination and implementation were identified in the search. Active Living Leaders is an online physical activity mentorship training program designed to be delivered by peers or people who may be in contact with adults with SCI (Salci et al. 2016). Get In Motion is a free physical activity coaching service delivered over the phone for people with physical disabilities, including SCI (Tomasone, Arbour-Nicitopoulos et al. 2018). The Canadian SCI Physical Activity Guidelines and the Scientific Exercise Guidelines for Adults with SCI are knowledge translation tools developed to share the findings of the international scientific SCI exercise guidelines (Goosey-Tolfrey et al. 2018; Hoekstra et al. 2020; Martin Ginis et al. 2018). The use of the guidelines is currently being assessed in conjunction with behavioural interventions in a randomized controlled trial of the effects of exercise on chronic pain (Martin Ginis et al. 2020). The Canadian SCI Physical Activity Guidelines are also undergoing evaluation in a type II hybrid implementation-effectiveness trial assessing the uptake of physical activity coaching among hospital physiotherapists and SCI peers and the impact of this coaching on physical activity participation among people with SCI (Ma et al. 2022)

The ProACTIVE SCI Toolkit was developed to support physiotherapists to promote and prescribe physical activity to clients with SCI. Its use in conjunction with a behavioural intervention has demonstrated significant, medium- to large-sized effects on physical activity, cardiorespiratory fitness, and psychosocial predictors of physical activity among people with SCI when administered in the research setting (Ma et al. 2019). Its effectiveness in the hospital and community setting is currently undergoing evaluation in the above-described Type II hybrid-implementation effectiveness trial (Ma et al. 2022). Importantly, all of the tools described in this section were developed in collaboration with an expert panel of SCI researchers and stakeholders. The latter 3 tools were developed using an adapted version of the Appraisal of Guidelines, Research, and Evaluation (AGREE)- II instrument, supporting the rigour and transparency of their development process (Brouwers et al. 2016).

Though not within the scope of the present review, it is important to note the limitation of tools and resources alone to affect physical activity promotion and participation behaviour. While resources (e.g., informational interventions) may improve theory-based determinants of behaviour, additional strategies are likely needed to optimize physical activity behaviour (Michie et al., 2008). These tools should be paired with i) behavioural strategies (described in section 3.2), ii) the use of implementation theories in development and evaluation (examples used in the SCI literature include the Knowledge to Action Framework, the Reach, Effectiveness, Adoption, Implementation, Maintenance [RE-AIM] framework, and Quality Implementation Framework (Esmail et al. 2020; Glasgow & Estabrooks 2018; Graham et al. 2006; Ma et al. 2022; Meyers et al. 2012; Sweet et al. 2017; Tomasone, Arbour-Nicitopoulos et al. 2018), and iii) adopted in collaboration with stakeholders to understand needs, adaptations, and factors that affect the use of these tools in the local context  (Graham et al. 2006) for SCI-specific guiding principles for involving research users throughout the research process, i.e.,  integrated knowledge translation, see (Gainforth et al. 2021).

Conclusion

There is level 1b evidence from one RCT that a knowledge translation tool supported by a behavioural intervention can improve physical activity behaviour among people with SCI. 

There is level 4 evidence from one pre-post study that demonstration, practice, and feedback are important behaviour change techniques to include when training interventionists to deliver PA strategies.

There is level 4 evidence from one pre-post study that intervention dose, the use of both informational and behavioural strategies, and clients’ perceptions of service credibility are important physical activity session implementation factors.

Addressing physical activity behaviour for people with SCI needs to extend beyond passive education. While resources such as guidelines and toolkits help summarize available physical activity evidence, integrating behaviour change techniques at both the participant (i.e., individual with SCI) and the health professional level are needed to support increasing physical activity behaviour in non-research settings.

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