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Physical Activity Psychosocial

Quality of Life

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.

Author Year
Research Design PEDro Score Total Sample Size



Alexeeva et al. 2011

Population: 35 individuals- 30 males and 5 females; chronic SCI; 8 AIS C and 27 AIS D; level of injury: C2-T10. meanage= 38.5y; median years post injury= 4y

Intervention: Patients participated in a 13-week training program, with three 1hr sessions per week. The PT group is a structured rehab program individualized for each participant. The TRK group consisted of body weight supported ambulation on a fixed track. The TM group involved body weight supported ambulation on a treadmill.

Outcome Measures: Quality-of-life survey (incorporated a subset of items from two existing questionnaires: Satisfaction with Abilities and Well-Being Scale [SAWS] and the SF-36 Short-Form Health Survey [SF-36]).

Subjective QOL
1. Immediately following the training program, 28 out of the 35 study participants (i.e. 80%) reported better satisfaction with abilities and well-being (SAWS).
2. The degree of score improvement (where a lower value reflects higher satisfaction) was roughly constant across training groups, and the overall effect across groups was significant (p=0.03).
3. These improvements were retained at the 1-month follow-up evaluation (p>0.05).

Objective QOL
1. No other significant between- or within-group differences on QOL measures were observed following training (p>0.05).

Bailey et al. 2020
RCT Crossover
NInitial=18, NFinal=14

Population: Mean age: 51±9yr; Gender: males=6, females=8; Injury etiology: traumatic=11, non-traumatic=3; Level of injury: T6-12=8, L1-5=5, Post-polio syndrome=1; Level of severity: complete=4, incomplete=10.

Intervention: Individuals were allocated to 2, 5.5hr experimental conditions in random order. One condition was uninterrupted sedentary time (SED) where individuals remained seated and sedentary throughout in a wheelchair. The other condition was sedentary time interrupted with physical activity breaks (SED-ACT) where individuals performed physical activity for 2 min every 20 min at ~70 rpm using the Lode Angio arm ergometer with fifteen breaks. Sedentary behaviours included reading, writing, using a laptop computer or a tablet. Standardized breakfast and lunch meals were consumed during each condition. Questionnaires were completed before and after each experimental condition.

Outcome Measures: National Well-being Measurement, Warwick Edinburgh Mental Well-Being Scale, Schwarzer and Renner Physical Exercise Self-Efficacy Scale

Objective QOL
1. Positive affect was significantly higher in SED-ACT than SED (P=0.001).

Subjective QOL
1. There were no significant differences between conditions for score on the National Well-being Measurement, and the Warwick Edinburgh Mental Well-Being Scale (p>0.05).

Chemtob et al. 2019

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: Life Satisfaction Questionnaire-11 (LSQ-11), Meaning Questionnaire (MQ).

Subjective QOL
1. The intervention group reported slightly greater levels in LSQ-11 scores at 6 weeks and moderately greater levels in LSQ-11 scores at 10 weeks.
2. The intervention group reported greater scores in the MQ 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: Subjective Quality of Life Scale.

Subjective QOL
1. In the experimental group, there were significant improvements in QOL scores (p=0.001).
2. No significant changes in QOL scores were observed for the control group from baseline to post-intervention (p>0.05).

Latimer et al. 2005 Canada
Secondary analysis of RCT (Hicks et al., 2003)

Population: Exercise Group (n=13): Mean age: 37.54yr; Gender: males=9, females=4; Level of injury: paraplegia=6, tetraplegia=7; Level of severity: incomplete=8, complete=5; Mean time since injury: 9.23yr; Control Group (n=10): Mean age: 43.30yr; Gender: males=8, females=2; Level of injury: paraplegia=6, tetraplegia=4; Level of severity: incomplete=5, complete=5; Mean time since injury: 15.70yr.

Intervention: Experimental group participated in a progressive exercise training program twice weekly for 9mo on alternative day’s 90-120 min starting with warm up, upper extremity stretching, and 15 to 30 min of aerobic training. As the rate of perceived exertion decreased, workload was increased. Some resistance training took place.

Outcome Measures: Perceived Stress Scale (PSS), Centre for Epidemiological Studies Depression Scale (CES-D), seven items from the 11-item Perceived Quality of Life Scale (PQOL).

Objective & Subjective QOL Interaction
1. At baseline, there was a strong positive relationship between stress and depression for both conditions (p<0.05).

2. At six months, the stress-depression association was no longer significant for the exercise group (p > .05).
3. The strong stress-depression relationship demonstrated at baseline was maintained across the three- and six-month measurement points for the control group (p<0.05).
4. At baseline, there was a strong negative relationship between stress and perceived quality of life for both conditions (p < .05).
5. At three- and six-month, the stress-perceived quality of life relationship was no longer significant for participants in the exercise condition (p>0.05).
6. The stress-perceived quality of life relationship remained significant across all three time points for the control condition (p<0.05).

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: Medically-Based Emotional Distress Scale (MEDS); Quality of Life Index Spinal Cord Injury – Version III (SCI-QOL index)

Objective QOL
1. Participants showed significant improvements in MEDS (p<0.001) compared to the control group.

Subjective QOL
1. Participants showed significant improvements in SCI-QOL Index (p<0.001) compared to the control group.

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

Population: SCI; Intervention Group: Mean age: 47yr; Gender: males31; 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: 36-Item Short-Form Health Survey (SF-36), Subjective Quality of Life Scale (SQOL).

Objective QOL

1. All SF-36 subscales, except for general health and vitality, improved significantly for the exercise/movement optimization group (p<0.05), and showed no change for the attention control group. 2. Both groups maintained their levels from post-intervention to 4 weeks follow-up with no group x time interactions effects.

Subjective QOL

1. Overall SQOL scores increased significantly following the intervention for the exercise/movement optimization group (p=0.04), but were unchanged for the attention control group post intervention.

Nightingale et al. 2018

Population: Mean age=47±8yr; Gender: males=15, females=6; Time since injury: 16±11yr; Level of injury: T4 and below; Severity of injury: not reported.

Intervention: Participants were randomly assigned to a home-based moderate-intensity upper-body exercise intervention (n=13) or a lifestyle maintenance control group (n=8) for 6 weeks. Outcome measures were assessed at baseline and follow-up.

Outcome Measures: Physical and mental component scores (PCS and MCS)

Objective QOL
1. The exercise intervention group significantly improved PCS and MCS (p=0.017) outcomes in relation to controls.

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 days. 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: 36-item Short Form Health Survey questionnaire (SF-36).

Objective QOL
1. No significant differences in QOL were observed (p>0.05).

Piira et al. 2020
Norway Secondary Analysis of Two RCTs combined PEDro=7
NInitial=44, NFinal=37

Population: Chronic motor incomplete SCI; Intervention Group (n=16): Mean age: 50yr; Gender: males=10, females=6; Level of injury: cervical=7, thoracic=6, lumber=3; Injury severity: AIS C=4, AIS D=12; Cause of injury: traumatic: n=10, non-traumatic: n=6; Mean time post-injury: 14.6yr. Control Group (n=21): Mean age: 49yr; Gender: males=13, females=8; Level of injury: cervical=10, thoracic=10, lumbar=1; Injury severity: AIS C (n=8), AIS D (n=13); Cause of injury: traumatic: n=11, non-traumatic: n=10; Mean time post-injury: 11.1yr.

Intervention: Data of this study was combined from two independent single-blinded RCTs. Intervention Group: Intervention consisted of 60 training days of BWSLT, either with manual or robotic assistance 60–90min per day, 3–5 days per wk over 6mo. Participants were suspended in a body-weight support system with treadmills (Study 1) or the Lokomat gait training robot (Study 2). A physical therapist supervised three to five staff members (Study 1) or controlled the robotic device (Study 2)
Control Group: usual care.

Outcome Measures: 36-Item Short-Form Health Status Survey (SF-36)

Objective QOL
1. Health related quality of life (HRQOL) did not improve significantly in the intervention group compared to the control group (SF-36; p>0.05).

Qi et al. 2018

Population: Intervention Group: Mean age: 38.3yr; Gender: males=15, females=5; Injury severity: ASIA A=7, ASIA B=2, ASIA C=3, ASIA D=8; Time post-injury: 5.61mo. Control Group: Mean age: 43.05yr; Gender: males=16, females=4; Level of injury: ASIA A=8, ASIA B=2, ASIA C=2, ASIA D=8; Time post-injury: 5.11mo.

Intervention: In addition to normal rehabilitation intervention, participants in the intervention group received wheelchair Tai Chi (WCTC) training (two 30min sessions/d, 5d/wk for 6wk. The program consisted of three parts:
● A 5-min warm-up session
● WCTC movements that encompassed 16 easy-to-learn and easy-to-perform forms
● A 5-min cool-down session.
Control Group: Normal rehabilitation intervention only.

Outcome Measures: short version of the World Health Organization’s Quality of Life Instrument (WHOQOL-BREF).

Objective QOL
1. Compared with the control group, the psychological domain of QOL improved significantly in the WCTC group (time by group interaction, p<0.05).

Zemper et al. 2003
NInitial=67, NFinal=43

Population: SCI: Mean age: 47yr (range 22-80); Gender: males=30, females=13; Level of injury: paraplegia (18), tetraplegia (17), ambulatory (8); Mean time post-injury: 14yr (range 1-49)

Intervention: Intervention group: 6 – 4hr workshop sessions over 3mo, which included lifestyle management, physical activity, nutrition, preventing secondary conditions, 3 individual coaching sessions, and 2 follow-up calls within 4 mos. after workshop. Control group: no intervention.

Outcome Measures: Health Promoting Lifestyle Profile II; Secondary Conditions Scale; Self-rated Abilities for Health Practices scale (SAHP); Perceived Stress Scale; Physical activities with disabilities (PADS); all at baseline and post-study.

Objective QOL
1. When compared to control group, the intervention group showed statistically significant improvements in the following:
• Health promoting lifestyle (HPLP- II, p<0.001);
• Stress management techniques, perceived stress (HPLP-II subscale, p=0.001).

Chen et al. 2009

Population: SCI; Mean age: 48.2yr; Gender: males=14, females=16; Level of injury: ASIA C and D at the spinal segments L1 to S2.

Intervention: The experimental group underwent therapy with a virtual-reality-based exercise bike. Participants were asked to sit comfortably on the exercise bike and then to pedal at their preferred speed for as long as they could. The control group underwent the therapy without virtual-reality equipment.

Outcome Measures: Activation–Deactivation Adjective Check List (AD-ACL)

Objective QOL
1. The experimental group showed significantly better scores on AD-ACL calmness (p=0.042) and tension (p=0.036) compared to the control group following the intervention.

Daniel et al. 2005

Population: Patients with paraplegia; Experimental Group: Mean age: 33.40yr; Gender: males=21, females=4; Time post injury: <3mo=4, >3mo=21. Control Group: Mean age: 37.24yr; Gender: males=18, females=7; Time post injury:<3mo=17, >3mo=8.

Intervention: The experimental group participated in 1 h-long leisure group sessions 3x/wk; the control group did not participate in intervention sessions.

Outcome Measures: World Health Organization Quality of Life Scale – Brief (WHO QOL – BREF), Leisure Satisfaction Scale (LSS).

Objective QOL
1. Significant improvements were observed in all domains of quality of life in the experimental group compared to the control group (p<0.01), except for social relationships.

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: Rosenberg Self-Esteem Scale (RSS), World Health Organization Quality of Life Scale – BREF (WHOQOL-BREF).

Objective QOL
1. Participants’ overall quality of life improved significantly from baseline (p<0.05).
Subjective QOL
2. Participants showed a significant improvement in self-esteem compared to baseline (p<0.001).

Alajam et al. 2020
NInitial=15, NFinal=11

Population: SCI; Mean age= 38±10yr; Gender: males=8, females=3; Level of injury: T3-L1; Mean time post-injury: 8.72±10.40yr.

Intervention: Participants received walking training, 3 sessions/wk for 8wk. Participants were trained on a treadmill using a novel assistive gait training device consisting of a thigh brace attached to a pulley cable designed to assist with leg flexion.

Outcome Measure: Short form-36 Health Survey (SF-36).

Objective QOL
1. The overall score of SF-36 significantly increased after training (p<0.01).

Allin et al. 2020

Population: Age=43±8yr.; Gender: males=4, females=7; Level of injury: paraplegia=5, tetraplegia=3, not reported=3; Level of severity: Not reported; Time since injury=20±12yr.

Intervention: Participants took part in a self-paced, six-session self-management program guided by a trained peer health coach. The program lasted between 35-88 days with a total of 6 coaching sessions.

Outcome Measures: Spinal Cord Injury Quality of Life Resilience Scale [SCI-QOL-R])

Subjective QOL
1. SCI-QOL-R score improved and trended towards significance (p=0.08).

Barbin & Ninot. 2008

Population: SCI; Mean age: 32.1yr; Gender: males=7, females=3; Level of injury: cervical=3, lumber=2, thoracic=5; Mean time post-injury: 5.1yr.

Intervention: Participants took part in a 1-wk adapted skiing program. The skiing program was a group activity including 30 participants (10 participants with spinal cord injury and 20 specialized physical educators) over a period of 5 days, 5 h/day.

Outcome Measures: Physical Self Inventory.

Objective QOL
1. After the skiing program, participants demonstrated significant improvements in global self-esteem (p=0.007), physical self-worth (p<0.001) and three subdomains (physical condition: p=0.008; sport competence: p=0.004; attractive body: p=0.001)
2. The physical strength dimension of the Physical Self-Esteem inventory did not change significantly from pre-skiing to post-skiing.

Bochkezanian et al. 2018

Population: Individuals with chronic SCI; Mean age: 41.2yr; Gender: males=4, females=1; Injury severity: AIS A=2, AIS B =2, AIS D=1; Mean time post-injury: 3.2yr.

Intervention: Participants completed five 10-repetition sets of high-intensity knee extension NMES strength training sessions for 12wk in both quadricep muscles.

Outcome Measures: QOL index SCI version III.

Subjective QOL
1. QOL showed a near-significant improvement in the health and functioning domain (p=0.07)

Chen et al. 2006

Population: Mean age: 43.8yr; Gender: males=9, females=7; Level of injury: tetraplegia=25%, paraplegia=75%; Severity of injury: ASIA A=56%, ASIA C=19%, ASIA D=25%; Cause of injury: traumatic=93.75%, non-traumatic=6.25%.

Intervention: 12wk of a weight management program (e.g., nutrition, exercise, behaviour modification training) + 1-30-min exercise session/wk for 6wk.

Outcome Measures: General Well-Being Schedule.

Objective QOL
1. Although there were small increases in general well-being schedule scores from baseline to 12 weeks and baseline to 24 weeks, they did not reach statistical significance (p=0.12).

Curtis et al. 2015

Population: Mean age=48.4±15yr; Gender: males=1, females=10; Time since injury=157.4±191.8mo; Level of injury: complete=3, incomplete=6; unknown=1, not reported=1; Severity of injury: tetraplegia=2, paraplegia=6, unknown=1, not reported=2.

Intervention: Participants took part in an 8-wk modified yoga program with assessments taken at baseline and post-intervention.

Outcome Measures: Positive and Negative Affect Scale (PANAS)

Subjective QOL
1. No significant differences between baseline and exit scores for the PANAS (p>0.05).

Ditor et al. 2003

Population: Mean age: 43.3yr; Gender: males=5, females=2; Time post injury: 3-23yr.

Intervention: Patients who previously took part in a 9mo exercise training program were given 3mo (2 sessions/wk) of continued supervised exercise training in a laboratory setting.

Outcome Measures: 11-item Perceived Quality of Life Scale (PQOL) with four additional SCI-relevant items, Perceived Stress Scale (PSS).

Objective QOL
1. At 3-month follow-up, a trend was found for increased stress (p=0.12).

Subjective QOL
1. At 3-month follow-up, a decrease in PQOL was found (p<0.05).

Effing et al. 2006
The Netherlands

Population: Chronic incomplete SCI; Age (range): 45-51yr; Gender: 3 males; Severity of injury: AISA C (75%), ASIA D (25%); Time post-injury (range): 29-168mo.

Intervention: Body weight supported treadmill training 5d/wk for 30 min/session for 12wk personalized to physical abilities.

Outcome Measures: Schedule for the Evaluation of Individual Quality of Life (SEIQOL). Collected at baseline, 6wk – treatment, 12wk – wash-out, 6wk – follow-up, 6 mo.

Subjective QOL

1. Participant 1:
• Showed significant improvement in perceived QOL during the intervention phase (P<0.05)
• Perceived QOL did not change significantly between the baseline and the wash-out phase or after the follow-up (P>0.05)

2. Participant 2:
● Judged his QOL as unchanged during the intervention phase (P>0.05), and diminished during the wash-out phase (P<0.05).
● At the end of the follow-up, the subject’s perception of his QOL had improved, reaching the baseline level.

3. Participant 3

● During the baseline, intervention, and wash-out phases, participant 3 judged his QOL as not changed (P>0.05) but as improved after the follow-up.

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: Psychosocial Impact of Assistive Device (PIADS)

Subjective QOL
1. PIADS total and subscale scores significantly improved for all participants from pre- to post-intervention (p<0.01; no between-group differences were observed (p>0.05).

Hicks et al. 2005

Population: Chronic incomplete SCI: N=14; Tetraplegic=11, Paraplegic=3; Gender: males=11, females=3; Age range=20-53yr; Mean time post injury=7.4yr; ASIA: B=2, C=12.

Intervention: Body weight supported treadmill training (BWSTT) – up to 45 min, 3x/week, 144 sessions (12mo).

Outcome Measures: Satisfaction with Life Scale (SWLS), SF-36

Objective QOL
1. Increased physical function satisfaction (p<0.05) after BWSTT.

Subjective QOL
1. Increased life satisfactio

Kennedy et al. 2006
United Kingdom

Population: Gender: males=30, females=5; Age: 18-61yr, Level of injury: paraplegia=20, tetraplegia=15.

Intervention: ‘Back-Up Trust’ sports participation program: 1wk participation in single or multi-activity course in an integrated, residential environment. Activities include skiing, horseback riding, waterskiing, canoeing, rappelling and gliding. Questionnaires were completed at baseline and end of 1wk activity courses

Outcome Measures: Life Satisfaction Questionnaire (LSQ)

Subjective QoL
1. A significant difference was demonstrated for life satisfaction as a whole (Z = 2.40, p=.016) and satisfaction with leisure between the start and end of the course (Z=2.69, p=.007).

Protas et al. 2001

Population: 3 males; age 34-48yr; Participant diagnosis was AIS C and D; T8-T12 lesion level; 2-13yr post-injury.

Intervention: BWSTT: 20 min, 5x/wk, for 12 wks.

Outcome measures: Center Positive and Negative Affect Schedule (PANAS), Life Satisfaction Index—A (LSIA)

Subjective QOL
1. Life satisfaction, and positive and negative affect did not change significantly for these 3 participants during training (ps>0.05).

Radomski et al. 2011
NInital=13, NFinal=10

Population: Median age: 33yr; Gender: males=6, females=4; Median time post injury:8.5yr.

Intervention: Participants completed a 12wk exercise and education program, which involved individualized diet and exercise recommendations, once weekly group nutrition and exercise education classes, and twice weekly exercise sessions (group and individual).

Outcome Measures: General Well-Being Schedule

Objective QOL
1. General well-being increased from a median of 72.0 to 85.5 (P = .059), a pre-post change to positive well-being.

Semerjian et al. 2005

Population: Mean age: 34yr; Gender: males=8 males, females=4; Level of injury: Tetraplegia=7, Paraplegia=5; Time post injury: 1-30yr.

Intervention: 10wk individualized exercise program, 2d/wk, using the Bowflex Versatrainer, the Active-Passive Trainer, the EasyStand 6000 Glider, and the Body Weight Support System treadmill trainer (BWST).

Outcome Measures: Quality of Life Index-Spinal Cord Injury Version III (QLI-SCI III) – 4 subscales: Health & Functioning, Psychological, Social & Economic and Family; the Body Satisfaction Questionnaire (BSQ); Semi-structured interview; Field notes taken during each session; Questionnaires done pre & post intervention, interview done post intervention.

Subjective QOL
1. QOL:
● The overall QOL (p<0.001), as well as the Health and Functioning (p<0.001), Psychological (p<0.05), and Social and Economic (p<0.05) subscales improved significantly post-intervention.
● No significant changes in the Family subscale scores were observed.
2. Body Satisfaction:
● Perceived body functioning (p<0.001) and body attractiveness (p<0.05) increased significantly post intervention.

Sharif et al. 2014

Population: Gender: males=3, females=3; Level of injury C5 to L4; All AIS D; mean age= 60.5 ± 13.2yr; Mean time post injury: 9.3 ± 12.0yr.

Intervention: The exercise protocol consisted of 12wk of FES-ambulation, with the RT600 (Restorative Therapies, Baltimore, MD), at a frequency of 3x/wk.

Outcome Measures: HRQOL was assessed via the Short Form-36, Perceived Stress Scale (PSS)

Objective QOL
1. Participants showed a decrease in the Short Form-36 pain score and an increase in the overall mental health score.
2. However, no significant changes were detected in perceived stress.

Shem et al. 2016
NInitial=26, NFinal=10

Population: SCI; Mean age: 49.8±13.0yr; Gender: males=14, females=12; Level of injury: tetraplegic=16, Level of injury: paraplegic=6, unknown=4, Mean time post-injury: 25.1yr.

Intervention: Participants completed a 12-week seated Tai Chi course consisting of weekly sessions (one 90-min session/wk).

Outcome Measures: emotional sense of well-being (EWB), mental distraction (MD), physical sense of well-being (PWB), and sense of spiritual connection (SC,)

Objective QOL
1. No significant between-group differences in the outcome measures were observed.

Sliwinski et al. 2020
USA Secondary Analysis
NInitial=22; NFinal=18

Population: Level of injury: C2-L5 (cervical injury=52%, thoracic injury=37%, lumbar injury=10%); Mean time post injury: 8.6yr.

Intervention: An 8-week community exercise program (one 4 hr session/wk) that includes a four-station circuit of resistance exercises, aerobic conditioning, trunk stability, and health education.

Outcome Measures: Life Satisfaction Questionnaire-9 (LiSAT-9).

Subjective QOL
1. QOL improved significantly after the intervention (p<0.001).

Anneken et al. 2010

Population: Mean age: 41.7 ± 12.7yrs; Gender: 219 males, 58 females; Level of injury: Paraplegia (78.3%); Severity of injury: Complete (62.9%); Cause of injury: traumatic (79%), non-traumatic (21%);

No Intervention: Questionnaire

Outcome Measures: QOL Feedback

Objective QOL
1. The most prominent differences between the physically active and physically inactive individuals occurred in the single scales of physical domain (physical capacity in everyday life, physical activity, and mobility); all p<0.001.
In the single scales of the psychological domain, prominent differences were found in remedial exercises, energy, and self-confidence; all p<0.001.

Bassett & Ginis 2009

Population: Mean age: 42yr; Gender: Males=50; Level of injury: paraplegia=25, tetraplegia=25; Level of severity: AIS A=20, AIS B-D=30; Time since injury: ≥1yr.

No Intervention: Participants reported their functional and appearance body image, perceived body image on quality of life (QOL), and leisure-time physical activity performed over the previous 3 days.

Outcome Measures: Body image: The Adult Body Satisfaction Questionnaire (ABSQ), perception of body image on quality of life (QOL): 7-point scale, leisure time physical activity: Physical Activity Recall Assessment for People with SCI (PARA-SCI)

Subjective QOL
1. Linear regression found a significant LTPA x body image impact on QOL (p<0.05).
• Among individuals who reported a negative effect of body image on QOL, those who engaged in LTPA were less satisfied with their physical function than those who did not.
• Those who did not perceive their body image to negatively impact QOL, there was generally no difference in functional body image between those who engaged in LTPA and those who did not.

Dallmeijer and van der Woude 2001 The Netherlands Observational N=37

Population: Mean age: 36.5yr; Gender: males=37, females=0; Level of injury: high tetraplegia (motor complete; C5 ± C6, n=10), low tetraplegia (motor complete, C6/7 ± C8, n=9), motor incomplete tetraplegia (n=7), paraplegia (n=11); Mean time since injury: 4.3yr.

No Intervention: Participants performed a maximal wheelchair exercise test in the laboratory and were asked to fill out the SIP68 questionnaire.

Outcome Measures: Short version of the Sickness Impact Profile (SIP68), including a physical (SOM), psychological (PSY) and social subscore (SOC). Endurance capacity (maximal power output (POmax) and peak oxygen uptake (VO2peak).

Objective QOL
1. Total SIP68-score and SOM were significantly different between lesion groups, showing higher values in the high- and low-tetraplegia group (p<0.05).
2. There were no differences between lesion groups for PSY and SOC subscores (ps>0.05).
3. Significant negative correlations were found for VO2peak and POmax with SIP68 and SOM and SOC (ps<0.05), indicating that a higher endurance capacity was associated with a better functional status; no significant relationship was found with PSY (p>0.05).
4. After correction for lesion level, 22% of the variance of SIP68, 8% of the variance of SOM, and 30% of the variance of SOC was explained by POmax or VO2peak (P<0.001).

Garshick et al. 2016

Population: SCI: with Dyspnea: Mean age: 45.0±16.2yr; Gender: males=87; females=17; Median time since injury: 10.0yr; cervical motor complete and AIS C=13, high thoracic motor complete and AIS C=27, other motor complete and AIS C=27, AIS D=32. Without Dyspnea: Mean age: 44.9±15.2yr; Gender: males=206; females=37; Median time since injury: 9.0yr; cervical motor complete and AIS C=38, high thoracic motor complete and AIS C=41, other motor complete and AIS C=105, AIS D=52.

No Intervention: Participants filled out a questionnaire survey by interview (89%) or self-completed (11%).

Outcome Measures: Satisfaction with life scale (SWLS), Physical Activity Recall Assessment for People with SCI.

Subjective QOL.
1. Using a multivariate model adjusting for covariates, it was found that there was a significant linear trend between greater SWLS and more time spent away from home (p=0.0002), as well as participation in sports (p=0.010).

Gernigon et al. 2015

Population: Participants (n=10): Mean age: 33.8±19.8yr; Gender: males=7, females=3; Level of injury: paraplegia=7, tetraplegia=3. Non-participants (n=8): Mean age: 40.5±15.4yr; Gender: males=6, females=2; paraplegia=2, tetraplegia=6.

No Intervention: Individuals were assigned in either the participants group or the non-participants group depending on whether they engaged or not in Adapted Physical Activity (APA) programs.

Outcome Measures: Approach and
Avoidance Questionnaire for Sport and Physical Education (AAQSPE), Physical Self-Perception Profile (PSPP).

Subjective QOL
1. Non-participants had significantly lower scores of physical self-worth than participants (p<0.05).
2. There was no significant between-group difference in perceived physical condition, physical strength, body attractiveness, sport competence, and global self-esteem (p>0.05).

Greenwood et al. 1990

Population: Tennis Group: Mean age: 32.60yr; Gender: males=77, females=10; Time since injury: ≥2yr; Nontennis Group: Mean age: 35.40yr; Gender: males=32, females=8; Time since injury: ≥2yr.

No Intervention: Questionnaires. The tennis participants were recruited from the 7 Southwest National Wheelchair Tennis Championships. The nontennis group participants had the physical capabilities necessary to compete in wheelchair tennis but were not actively involved in an exercise program or a competitive sport.

Outcome Measures: Two self-efficacy scales assessing participants’ self-efficacy expectations toward playing tennis and performing daily wheelchair mobility task, Profile of Mood States (POMS).

Objective QOL
1. The tennis group showed significantly better scores on all six POMS measures (i.e., tension, depression, vigor, fatigue, confusion, anger), compared to the nontennis group (ps<0.001)..
2. For the wheelchair nontennis participants, wheelchair mobility self-efficacy significantly correlated with each of the POMS subscales except for depression (ps<0.001).

Lannem et al. 2010

Population: AIS A-B (n=47): Mean age: 48yr; Gender: males=41, females=6; Level of injury: Tetraplegia=13, Paraplegia=34; Mean time since injury: 29yr. AIS D (n=69): Mean age: 48yr; Gender: males=56, females=13; Level of injury: Tetraplegia=35, Paraplegia=34; Mean time since injury: 18yr.

No intervention: Participants completed a questionnaire pertaining to exercise status and exercise-related self-perceptions. Aerobic work capacity was tested using an arm ergometer for those with motor complete SCI. For those with incomplete SCI either arm or leg cranking was used. Participants who exercised at least once per week were categorized as “exercisers”.

Outcome Measures: Self-Perception in Exercise Questionnaire (SPEQ)

Subjective QOL
1. Exercisers with complete and incomplete SCI showed significant differences in SPEQ mastery compared to non-exercising participants (p=0.002 and p=0.012, respectively). Exercisers with complete lesions reported more positive exercise mastery and those with incomplete lesions reported more negative exercise mastery than non-exercising participants.
2. SPEQ fitness was significantly higher for exercisers with complete (p=0.016) and incomplete (p=0.004) SCI compared to similar non-exercisers.
3. For incomplete injury, exercise status (p=0.04) and exercise hours per week (p=0.007) contributed negatively to the variance in SPEQ mastery.

Loy et al. 2003 USA Observational N=178

Population: Mean age: 43.6yr; Gender: males=73.7%, females=26.3%; Level of injury: paraplegia=56.1%, tetraplegia=43.9%; Level of severity: incomplete=69.1%, complete=30.9%; Mean time since injury: 9.6yrs.

No Interventions: Questionnaire.

Outcome Measures: Recreation and Health Survey (RHS)- assessed general participant information, injury information, leisure activities over the last year, leisure identity, perceived freedom, favorite leisure activities, leisure and coping with SCI, social support, health beliefs, subjective well-being, and depression.

Objective QOL
1. The model proposed that: (a) leisure engagement has a direct influence on the adjustment of individuals with SCI and (b) leisure engagement has an indirect influence on adjustment to SCI through the promotion of social support.
2. Results from structural equation modeling confirmed that the leisure and SCI adjustment model was an “acceptable” fit to data; however, leisure engagement explained only 13% of the variance in the adjustment to SCI construct and 5% of the variance in the social support construct.
3. Diversity and intensity were significantly associated with depression, subjective well-being, and perceived health (p<0.05).
4. Frequency was significant associated with subjective well-being (p<0.05), and perceived health (p<0.01).

Manns & Chad 1999

Population: Mean Age=30.1±9.8yr; Gender: Males=20, Females=3; Level of Injury: Quadriplegic=17, Paraplegic=21; Severity of Injury=complete; Time Since Injury=2-30yr.

No Intervention: Cross sectional analysis to determine the relationships among fitness, physical activity, subjective quality of life and handicap in individuals with SCI.

Outcome Measures: Fitness level, leisure time exercise questionnaire, Quality of Life Profile: Physical and Sensory Disabilities Version, Craig Handicap Assessment Reporting Technique (CHART).

Subjective QOL
1. There was no correlation between subjective quality of life scores and fitness/physical activity in individuals with paraplegia or quadriplegia (p>0.05).

Mulroy et al. 2016 Canada Observational N=86

Population: Mean age: 37.4±16.2yr; Gender: males=77, females=9; Mean time since injury: 11.1±7.5yr.

No Intervention: Analysis of those with traumatic SCI who use a manual wheelchair. Participants were telephoned and asked to recall their activities during an interview based on the Physical Activity Recall Assessment.

Outcome Measures: Wheelchair propulsion (WCP), Leisure-time physical activity (LTPA), Wheelchair usage, Patient Health Questionnaire-2 (PHQ-2), Satisfaction with Life Scale (SWLS).

Subjective QOL
1. On average, participants felt slightly satisfied with life, with a mean score of 23.3±6.4 on the SWLS.
2. LTPA was the only significant predictor of SWLS (r=.321, P=. 003); persons who reported more LTPA also reported higher SWL

Paulsen et al. 1990

Population: Athletes (n=26): Mean age: 26.9yr; Gender: males=26, females=0: Level of injury: unknown; Level of severity: unknown; Time since injury: ≥2yr; Nonathletes (n=28): Mean age: 26.1yr; Gender: males=28, females=0; Level of injury: unknown; Level of severity: unknown; Time since injury: ≥2yr

No Intervention: Questionnaire.

Outcome Measures: Profile of Mood States (POMS; six subscales: Anger, Confusion, Depression, Fatigue, Tension, and Vigor)

Objective QOL
1. No significant between-group differences on other POMS subscales were found (ps>0.05).

Santino et al. 2020

Population: Age: <55yr=54, >55yr=116; Gender: males=136, females=34; I Injury: Incomplete paraplegia=40, Complete paraplegia=40, Incomplete tetraplegia=58, Complete tetraplegia=30, missing=2; Time since injury: <10yr=48, 10+yr=122.

No Intervention: Participants completed various measures during a telephone interview.

Outcome Measures: Leisure Time Physical Activity Questionnaire for People with Spinal Cord Injury, UCLA Loneliness Scale, Life Satisfaction Questionnaire (LSQ).

Subjective QOL
1. 31.2% of the participants scored 6 or higher on the UCLA Loneliness Scale indicating feeling lonely at least some of the time.
2. Significant correlations were found between leisure time physical activity (LTPA) and life satisfaction (p=0.02), LTPA and loneliness (p=0.05), and loneliness and life satisfaction (p<0.001).

3. Loneliness significantly mediated the relationship between LTPA and life satisfaction.
4. Loneliness significantly and negatively related to LTPA (p=0.04) and life satisfaction significantly and negatively related to loneliness (p<0.001).

Stevens et al. 2008
NInitial=73 NFinal=62

Population: Mean age: 35±10yr; Gender: males=32, females=30; Level of injury: Tetraplegia=23, Paraplegia=39; Level of severity: Complete=38, Incomplete=24, Mean time since injury: 9±9yr.

No Intervention: Cross sectional study to examine relationship of physical activity and quality of life.

Outcome Measures: The Quality of Well-Being Scale (QWB).

Objective QOL
1. Pearson product correlation coefficient analysis showed a strong positive association between level of physical activity and quality of life (p<0.05), indicating that participants who reported higher levels of physical activity had greater QOL.
2. More than half (56%) of the variation in quality of life was explained by differences in physical activity level.

Tasiemski and Brewer 2011

Population: Mean age: 35.93yr; Gender: males=861, females=173; I Level of injury: paraplegia: 49.8%, tetraplegia: 50.2%; Mean time since injury: 9.78yr.

No Intervention: Questionnaire.

Outcome Measures: Sport participation (i.e., hours of sport participation per week before and after injury, sport discipline practiced before and after injury, opportunities to practice one’s favorite sport after injury, reasons for sport participation after injury, barriers to sport participation after injury, best sport results after injury, and years of sport participation after injury), involvement in nonsport recreational activities before and after SCI, Athletic Identity Measurement Scale (AIMS), Life Satisfaction Questionnaire (LiSat-9), Hospital Anxiety and Depression Scale (HADS).

Subjective QOL
1. Being able to practice one’s favorite sport after SCI was associated with higher levels of life satisfaction (p<0.001).
2. Team sport participants reported better life satisfaction (p<0.01), than individual sport participants did.

Tasiemski et al. 2005

Population: Mean age: 48.1yr; Gender: males=798, females=198; Level of injury: tetraplegia A=216, tetraplegia B=65, tetraplegia C=61, paraplegia A=535, paraplegia B=38, paraplegia C=70. Mean time since injury: 19.5yr.

No Intervention: Questionnaire.

Outcome Measures: Sports Participation Questionnaire, life satisfaction questionnaire (LSQ), Hospital Anxiety and Depression Scale (HADS).

Subjective QOL
1. Participants who were involved in sports or physical recreation demonstrated higher general life satisfaction, compared to those not participating in physical activities (p<0.001).


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.

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