Individuals with SCI tend to report poorer quality of life (QOL) than people without a disability. Leisure time physical activity (LTPA), or physical activity that one chooses to do in their spare time, improves the QOL among many populations, including persons with SCI (Tomasone et al., 2013). LTPA can influence both objective QOL (“what I have”; the congruency between one’s achievements and one’s expectations) (Dijkers, 2003) and subjective QOL (“what I think or feel about what I have”; one’s thoughts and feelings what one’s achievements meeting one’s expectations) (Dijkers, 2003) for persons with SCI. Notably, both objective and subjective QOL are dynamic and subject to change following participation in LTPA. The goal for this section is to examine if participation in LTPA is associated with objective and/or subjective QOL among persons with SCI.
Description of studies. Forty-eight (48) studies examined the relationship between LTPA and quality of life. Of the 48 included studies, 12 were RCT designs, 20 were pre-post designs and 16 were observational/correlational designs. The RCT and pre-post designs examined the impact of varied types of LTPA interventions on QOL outcomes. For example, LTPA included activities like yoga (Curtis et al., 2015; Madhusmita et al., 2019) and tai chi (Qi et al., 2018; Shem et al., 2016), upper extremity training (Mulroy et al., 2011; Nightingale et al., 2018), body weight supported treadmill training (Fundaro et al., 2018; Hicks et al., 2005; Piira et al., 2020), functional electrical stimulation (Sharif et al., 2014), exercise programs (De Oliveira et al., 2016; Sliwinski et al., 2020), and sports (skiing) (Barbin & Ninot, 2008). In addition, several interventions focused on counselling or coaching with the use of behaviour change techniques (Allin et al., 2020; Chemtob et al., 2019; Nooijen et al., 2017). The included studies were from several countries, including USA (n=16), Canada (n=12), Netherlands (n=3), Australia (n=2), France (n=2), Norway (n=2), Poland (n=2), Germany (n=1), Italy (n=1), UK (n=3), India (n=2), China (n=1), Taiwan (n=1). Notably, nearly all research has been conducted in high-income countries with very few studies from low- or middle-income countries.
Overview of objective vs. subjective QOL. In line with Dijkers (2003) model, both objective and subjective QOL are necessary for a comprehensive understanding of QOL. Initially the SCI field focused mainly on objective QOL (Noreau & Shephard, 1995), which led to a call for both objective and subjective assessments. In a subsequent review of this area, Tomasone et al. (2013) reported 67 objective QOL analyses vs. 43 subjective QOL analyses, highlighting that the field continued to focus on reporting the relationship between LTPA participation and objective QOL. However, the use of subjective QOL measures were beginning to become more prominent. In the current review, we report 38 analyses between objective QOL scale or subscales and LTPA, and 34 analyses between subjective QOL scale or subscales and LTPA. A notable difference between the studies included in Tomasone et al. (2013) and the current review on QOL is that Tomasone et al. (2013) included measures assessing pain, fatigue, anxiety or depression – these were excluded from the current review as they are included in other SCIRE sections. Regardless, over the past decade, the field has begun to place equal focus on subjective QOL and its relationship with LTPA.
The LTPA and QOL relationship. Among the 38 analyses for objective QOL, the relationship between LTPA and objective QOL was significantly positive in 28 analyses, whereas 10 analyses showed no significant relationships. No analyses showed a significant negative relationship between a measure of objective QOL and LTPA participation. Among the 34 analyses for subjective QOL, the relationship between LTPA and subjective QOL was significantly positive in 17 analyses, whereas 3 analyses showed a significant negative relationship, and 13 analyses showed no significant relationships. Overall, participation in LTPA was found to be positively associated with both objective and subjective QOL among individuals with SCI, with very few studies showing a significant negative relationship and relatively few studies showing no significant relationship between LTPA and QOL. Presumably, the increase in achievements, abilities, and opportunities that result from engaging in LTPA increase the congruency (i.e., decrease the discrepancy) between one’s achievements and expectations (increase objective QOL), and thus lead to a more positive cognitive or affective response to the level of congruency (increase subjective QOL). The relationship between LTPA and subjective QOL requires further unpacking, as the surge in analyses exploring this relationship is relatively recent and the findings remain uncertain (i.e., many studies report a non-significant relationship between LTPA and subjective QOL).
Despite the overall finding that participation in LTPA is positively associated with objective and subjective QOL among persons with SCI, some findings are also mixed. Specifically, both within a given study and across the review, the relationship between LTPA and QOL is sometimes positively significant and other times not significant. Within the same study, mixed findings are often reported between the objective and subjective QOL measures that are used. For example, both Alexeeva et al. (2011) and Bailey et al. (2020) report that the LTPA-QOL relationship is positive for objective QOL but non-significant for subjective QOL. This phenomenon likely occurs because objective and subjective QOL are two different constructs – following LTPA participation, a person with SCI may notice that their achievements are more in line with their expectations (i.e., objective QOL increases) but may not change their feelings about the congruency between their achievements and expectations (i.e., subjective QOL remains the same). Within a given study, it is also common to see two different QOL scales used to assess either objective or subjective QOL. For example, Sharif et al. (2014) used two different objective QOL measures and reported that the LTPA-QOL relationship was positively and negatively significant using two subscales of one measure (the Short Form-36) and non-significant using a second measure (the Perceived Stress Scale). It is also common for studies that used different subscales within a single QOL measure to report mixed findings. For instance, in their RCT, Mulroy et al. (2011) found that all Short Form-36 subscales except for general health and vitality improved significantly in the group that participated in exercise compared to controls. The LTPA literature typically distinguishes between global QOL (i.e., one’s overall life satisfaction or well-being) and three QOL domains: physical (i.e., pertaining to one’s physical functioning, such as health status), psychological (i.e., pertaining to both one’s emotional well-being and one’s cognitive functioning), and social (i.e., pertaining to one’s social roles and functioning, such as marital and occupational status). Differentiating between QOL domains was beyond the scope of the current chapter but readers are encouraged to refer to Tomasone et al. (2013) for a discussion about domain-specific differences in the LTPA-QOL relationship, which may account for the discrepancies between subscale findings in a given study. In addition, it is possible that participant characteristics, such as injury level and injury characteristics (Lannem et al., 2010; Manns & Chad, 1999), may influence the LTPA-QOL relationship, which may be why certain studies found insignificant relationships. Researchers should be mindful of demographic differences, as well as other potential moderators, when they consider the LTPA-QOL relationship within their studies. Finally, some of the studies may have been underpowered (due to small sample sizes) to detect significant differences in QOL following participation in LTPA. Case in point, participants in Chemtob and colleagues’ (2019) RCT did not report significant differences in life satisfaction (a measure of subjective QOL) following an 8-week behavioural counselling intervention, yet there was a medium effect size change in life satisfaction in the experimental group; a larger sample may have produced a statistically significant effect. Collectively, the mixed findings within a study point to the complexity in the conceptualization and measurement of the LTPA-QOL relationship.
Moving forward, we recommend that researchers identify which QOL measures are most responsive to the effects of LTPA, including the intervention dose (i.e., duration, frequency, length) and type of LTPA intervention (i.e., sport, exercise, yoga). Heterogeneity in intervention dose and type precluded our ability to make conclusions about the influence of these variables on the LTPA-QOL relationships for the current review, but is an avenue for future research.
Interestingly, there are connections between the variables included in this SCIRE chapter with the LTPA-QOL relationship. For example, Sweet et al. (2013) that depression (covered in section 3.1) and functional independence (covered in section 4) were statistically significant mediators of the LTPA-QOL relationship. Santino and colleagues’ (2020) analysis found that loneliness significantly mediated the relationship between LTPA and life satisfaction (i.e., subjective QOL). We recommend researchers continue to explore the mechanisms by which LTPA influences both objective and subjective QOL to further unpack the complexities in the relationship.
There is level 1a evidence from six RCTs – as well as support from two lower quality RCTs and 14 additional studies – that participation in LTPA Is effective for increasing objective QOL among persons with SCI.
There is level 1a evidence from three RCTs – as well as support from one lower quality RCT and 13 additional studies – that participation in LTPA is effective for increasing subjective QOL among persons with SCI.