Effects of Physical Activity on Participation-related Outcomes

In this chapter, we are operationalizing the concept of (community/social) participation as involvement in life situations, in line with the World Health Organization’s International Classification of Functioning, Disability, and Health (ICF) (WHO, 2001). These life situations are often tied to “activities”, another dimension of the ICF. Participation in these life situations and activities can then range between daily activities (e.g., preparing a meal) to leisure and social activities (e.g., meeting with friends). The evaluations/ratings of participation can be conceptualized as person-perceived participation (e.g., a person’s own judgement of their level of participation in an activity) or society-perceived participation (e.g., a person’s participation ability is judged against a social standard of “normal” participation) (Noreau et al., 2005). This section examines the evidence on the relationship between LTPA and participation in daily and social activities from studies that have assessed person-perceived or society-perceived participation. We do not explicitly separate the type of participation but rather provide an overview of the LTPA-participation relationship.

Author Year
Country Research Design PEDro Score Total Sample Size



Chemtob et al. 2019
PEDro=9 N(start)=24

Population: Age=51.64±12.13yr.; Gender: males=16, females=8; Level of injury: paraplegia=24, quadriplegia=0; Level of severity: Not reported; Time since injury=15.45±12.85yr.

Intervention: Participants were randomized to either an intervention group which received one, 1-hour counselling session per week for 8 weeks via online video chat, or a control group who continued their regular routine.

Outcome Measures: Patient-Perceived Participation in Daily Activities

1. The intervention group reported greater scores in the Patient-Perceived Participation in Daily Activities than the control group.

Kemp et al. 2011

Population: individuals with SCI paraplegia who were also experiencing shoulder pain; Mean age: 45yr; Gender: not reported; Level of injury: Mean time post-injury: 20.1yr.

Intervention: Participants were randomized to either an exercise treatment or a control group. Participants in the treatment group participated in a 12wk, at-home, exercise and movement optimization program designed to strengthen shoulder muscles and modify movements related to upper extremity weight bearing.

Outcome Measures: Wheelchair User’s Shoulder Pain Index (WUSPI), Social Interaction Inventory (SII)

1. In the experimental group, significant improvements in SII scores (p=0.03).
2. No significant changes on SII were observed for the control group from baseline to post-intervention (p>0.05).
3. A significant interaction between WUSPI and SII scores was found in the experimental group from baseline to post-intervention (p<0.001), suggesting that decreases in shoulder pain was associated with increases in social participation.

Madhusmita et al. 2019

Population: SCI; Integrated Yoga and Physiotherapy (IYP) Group: Mean age: 33.97yr; Gender: males=54, females=8; Level of injury: incomplete, (AIS)-C and (AIS)-D; Time since injury: >6mo
Control Group: Mean age: 32.84yr; Gender: males=53, females=9; incomplete, (AIS)-C and (AIS)-D; Time post-injury: >6mo

Intervention: Participants in the IYP group received 75 min (6 days/wk) of an integrated yoga intervention for 1 mo. The control group received physiotherapy only. Physiotherapy session for both groups lasted for 60min/day and 6 days/wk for 1mo

Outcome Measures: Spinal Cord
Injury Independence Measure (SCIM).

1. The IYP group showed a significant improvement in SCIM compared to the control group (p<0.001).

Mulroy et al. 2011
NInital=80, NFinal=52

Population: SCI; Intervention Group: Mean age: 47yr; Gender: males= 31; females=9; Level of injury: Paraplegia=40; Injury severity: AIS A=25, AIS B=9, AIS C=3, AIS D=1, Unknown=2; Mean time post-injury: 17.9yr. Control Group: Mean age: 47yr; Gender: males=26, females=14; Level of injury: Paraplegia=40; Injury severity: AIS A=25, AIS B=5, AIS C=5, AIS D=1, Uknown=4; Mean time post injury: 22.3yr.

Intervention: Participants were randomly allocated to either the exercise/movement optimization group or the attention control group. The exercise/movement optimization intervention consisted of a 12-wk home-based program of shoulder strengthening and stretching exercises, along with recommendations on how to optimize the movement technique of transfers, raises, and wheelchair propulsion. The attention control group viewed a 1-h educational video. Outcome measures were assessed at baseline, at the end of the 12-week intervention, and at 4 weeks after the end of the intervention.

Outcome Measures: Social Interaction Inventory (SII)

1. Community activity, as measured with the SII, showed a significant greater increase for the exercise/movement optimization group than for the attention control group (p<0.03).
2. Improvements in community activity levels over were maintained at the 4-week follow-up assessment.

Nooijen et al. 2017
The Netherlands
NInitial=45; NFinal=39

Population: Intervention group: Mean age: 44yr; Gender: males=17, females=3; Level of injury: Tetraplegia=7, Paraplegia (13); Mean time post-injury: 139 d. Control group: Mean age: 44yr; Gender: males=16, females=3; Level of injury: Tetraplegia=6, Paraplegia=13; Mean time post injury: 161 days.

Intervention: Intervention group: A behavioral intervention promoting physical activity, involving 13 individual sessions delivered by a coach trained in motivational interviewing, beginning 2mo before and ending 6mo after discharge from inpatient rehabilitation.
Control group: Regular rehabilitation.

Outcome Measures: social participation (IMPACT-S)

1. Participation improved significantly 12 months after discharge (p<0.01).

de Oliveira et al. 2016

Population: Inactive Group: Mean age: 48.9yr, Gender: males=51%, females=49%, Level of injury: C5-C8, A: 21.5%, C5-C8, B or C: 30%, T1–S4 to S5, A: 21.5%, T1–S4 to S5, B or C: 27%; Injury etiology: traumatic: 73%, non-traumatic: 27%; Mean time post injury:9yr
Active group: Mean age=48.2yr; Gender: males=89%, females=11%; Level of injury: C5-C8, A: 11%, C5-C8, B or C: 30%, T1–S4 to S5, A: 37%, T1–S4 to S5, B or C: 22%; Injury etiology: traumatic: 93%, non-traumatic: 7%; Mean time post injury: 10yr.

Intervention: Participants took part in the Spinal Cord Injury and Physical Activity in the Community (SCIPA Com), which involved supervised physical activity programs 2x/wk for 30-60min for 8-12wk.

Outcome Measures: Patient-Specific Functional Scale (SFS)

1. Participants showed a significant improvement in functional goal achievement compared to baseline (p<0.001).

Fundaro et al. 2018

Population: SCI: n=21; Parkinson’s Disease (PD): n=10; Stroke Event: n=8; Age range: 33 to 79yr; Gender: males=27, females=12; Level of injury (SCI): paraplegia (n=4), paraparesis (n=11), quadriplegia (n=1) quadriparesis (n=5).

Intervention: Participants underwent robot gait training with Lokomat. The training period lasted for 4wk, with 30min session carried out 3x/wk.

Outcome Measures: Functional Independence Measure (FIM).

1. All patients showed significant improvements in FIM scale.

McVeigh et al. 2009 Canada Observational N=90

Population: Age range: 16+yr; Gender: males=71, females=19; Level of injury: C5-L5; Level of severity: AIS A=37, AIS B-D=43; Mean time since injury: ≥1yr.

No Intervention: Prospective study to determine whether community integration and/or quality of life (QOL) among people with chronic spinal cord injury (SCI) are superior among sport participants versus non-sport participants.

Outcome Measures: Community Integration Questionnaire (CIQ), Reintegration to Normal Living Index (RNL).

1. Both CIQ and RNL total mean scores were higher among sport participants versus non-sport participants (p<0.05).
2. The home and social subscales of the CIQ showed the largest difference in mean subscale scores between the sport (t(88)=3.27, p=0.02) and non-sport (t(88)=4.42, p=0.00) groups, with the sport group demonstrating the higher scores.

Sweet et al. 2013

Population: Age=45.68±14.05yr; Gender: males=298, females=95; Level of injury: paraplegia=190, tetraplegia=194; Level of severity: ASIA A=254, ASIA B/C/D=134; Time since injury=13.51±10.35yr.

No Intervention: Using a prospective design, this study examined potential intermediary constructs linking LTPA and QOL in people with SCI. Drawing from previous literature, a longitudinal structural equation model was developed and tested to determine if depression, functional independence, social integration/participation, and self-efficacy mediate the LTPA–QOL relationship.

Outcome Measures: Functional Independence Measure (FIM), Social integration subscale of the Craig Handicap Assessment and Reporting Technique Short-Form (CHART-SF).

1. LTPA at baseline significantly and positively predicted 6-month FIM scores.
2. Functional independence (FIM) scores were statistically significant mediators of the LTPA-QOL relationship.
3. Social integration/participation (CHART-SF) did not mediate the LTPA-QOL relationship.


Description of studies. Compared to the other sub-sections within this chapter, fewer studies have examined the relationship between LTPA and participation-related outcomes. From these 9 studies, five were randomized controlled trials, one prospective controlled trial, two observational, and one pre-post study. The included studies were from different countries, including Canada (n = 3), USA (n=2), Netherlands (n=1), Australia (n=1), Italy (n=1), and India (n=1). The majority of studies have been conducted in high-income countries, limiting our knowledge of this relationship in low- or middle-income countries.

The LTPA and participation-related outcomes relationship. Across all studies, LTPA had a positive relationship with participation in daily and social activities, meaning that greater LTPA is related to greater participation. These promising results remain limited by the small number of studies, thus requiring further research. Another important limitation of this research is that most studies examine participation as a single, overall concept. Participation includes a number of independent activities that range from self-care to social activities. Currently, we have little knowledge on the relationship between LTPA and specific types of participation activities. For instance, McVeigh et al. (2009) demonstrated differences on home and social subscales among individuals who participated in sports or not. In another sample of individuals with physical disabilities, Sweet et al. (2021) found that individuals participating in a community-based LTPA program increased participation in family-based activities (e.g., preparing dinner) but not autonomous outdoor activities (e.g., moving outside the home). Future research could examine the relationship between types of LTPA and specific participation activities (or at least specific grouping of activities; e.g., self-care, social) to help optimize the design of LTPA interventions aimed to promote participation.

Moreover, the interventions reported varied from home-based, to person-centered, to supervised LTPA programs. This variability combined with the limited number of studies makes it impossible to conclude how to best intervene to improve participation. Further, these studies were primarily LTPA promotion studies where participation was not the primary outcome, but one of many secondary/tertiary outcomes. Effects could be stronger if the physical activities that are chosen are directly targeted or explicitly aimed to enhance specific participation activities. For example, Mulroy et al. (2011) and Kemp et al. (2011) provided a home-based program to optimize shoulder strength for shoulder-based activities (e.g., transfers, propulsion). Despite not finding effects on wheelchair propulsion speed and LTPA, Kemp et al. (2011) reported significant differences for participation in community activities and preparatory activities and, to a lesser extent, social activities. Interestingly, Kemp et al. (2011) noted that changes were mostly associated with community activities and preparatory subscale. These studies provide an initial example for future LTPA interventions aimed to specifically increase participation in daily and social activities.

Although it was beyond the scope of this section to compare and contrast measures and results of person-perceived or society-perceived participation, it may be an important next step in understanding the role of LTPA on participation. For example, do LTPA interventions (or types of interventions) differently impact person- vs society-perceived participation? Such an exploration could help identify which participation-related outcome measure may be most sensitive to (types of) LTPA.

In conclusion, there is a promising and positive association between LTPA and participation in daily and social activities. Excellent opportunities to investigate new avenues and conduct additional research to strengthen the current conclusions remain.


There is level 1a evidence from three RCTs – as well as support from two lower quality RCTs, one prospective control trial, one pre-post study – that physical activity-based interventions are effective for increasing participation in daily and social activities among persons with SCI.