Barriers To Physical Activity Participation in the SCI Population
The inactive lifestyle of individuals with SCI is a serious functional and health liability. Consequently, developing effective interventions to promote physical activity should be a research and public health priority (Rimmer 1999). In order to tailor interventions to the needs of individuals with SCI it is necessary to understand the factors affecting their participation in physical activity.
Among adult populations of persons with disabilities, frequently cited barriers impeding participation include: intrapersonal barriers (i.e., personal factors such as health concerns, motivation, and knowledge), systemic barriers (i.e., obstacles such as program costs and accessibility resulting from infrastructure and policy preventing participation or access), attitudinal barriers (i.e, stigma and negative stereotypes held by persons who are not impaired), and expertise barriers (i.e., gaps in practitioners’ knowledge and skill to effectively prescribe and supervise physical activity for adults with a disability). The objective of this section is to examine the prominence of these barriers specifically in the SCI population. Indeed, barriers are a critical factor affecting participation in the SCI population (Latimer et al. 2004). For example, among a group of individuals with SCI exercising at an adapted exercise facility, participation rates were lowest among people experiencing more physical symptoms related to their injury (i.e., intrapersonal barriers; Ditor et al. 2003).
| Author Year; Country Score Research Design Total Sample Size |
Methods | Outcome |
|---|---|---|
| Arbour et al. 2009
Canada Observational N=50 |
Population: Mean age: 43.5±12.7 yrs; Gender: 35 males, 15 females; Mean time post-injury: 13.8±10.4 yrs; Severity of injury: complete (15), incomplete (35); Wheelchair users: 52% manual Treatment: QuestionnaireOutcome Measures: Perceived proximity to a fitness center compared to time spent participating in leisure time physical activity |
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| Kehn & Kroll 2009 USADowns & Black score=16Observational (Mixed Methods)N=26 |
Population: Mean age (range): 23-74 yrs; Gender: 16 males, 10 females; Level of injury: Tetraplegia (14), Paraplegia (9); Severity of injury: complete (11), incomplete (9); Time post-injury (range): 1-32 yrs Treatment: Semi-structured interview guide was developed to explore core areas such as experiences with exercise before and after injury, logistics of current exercise regimen, barriers and facilitators of exercise, perceived benefits of exercise, perceived impact of exercise on secondary conditions. Each interview lasted between 20 and 30 min. Analysis was conducted on patients who were exercisers vs. non-exercisers.Outcome Measures: Patients’ experiences with exercise pre/post injury, barriers and facilitators to being active and perceived health impact measured after phone interview. |
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| Kerstin et al. 2006 SwedenQualitative – Multiple Case StudiesN=16 |
Population: Mean age: 36.0±10.6 yrs (range 21-61); Gender: 12 males, 4 females; Mean time post-injury: 8.6±9.8 yrs (range 2-41); Severity of injury: tetraplegia (8), paraplegia (8) Treatment: In-person and telephone semi-structured interviewsOutcome Measures: Major themes relating to the factors that promote participation in physical activity |
|
| Scelza et al. 2005
USA Downs & Black score=14 Observational N=72 |
Population: Mean age: 44.1 yrs; Gender: 50 males, 22 females; Severity of injury: paraplegia – complete (36%), incomplete 11%); tetraplegia – complete (19%), incomplete (17%), ambulatory (17%); Mean time post-injury= 13.1 yrs Treatment: Cross-sectional surveyOutcome Measures: The Barriers of Physical Exercise and Disability survey; The Perceived Stress Scale. |
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| Levins et al. 2004 USAQualitative – EthnographyN=8 |
Population: Mean age: 42 yrs; Gender: 5 males, 3 females; Level of injury: T1-low thoracic levels; Mean time post-injury: 25.6 yrs; Treatment: Semi-structured interviewsOutcome Measures: Major themes relating to barriers and facilitators to participation in physical activity |
|
| Martin et al. 2002
Canada Downs & Black score=11 Observational N=15 |
Population: Group 1 (N=4); Mean age: 40 yrs (males), 19 yrs (females)-; Gender: 3 males, 1 female; Group 2 (N=6); Mean age: 38.5 yrs (males), 44 yrs (females); Gender: 4 males, 2 females; Group 3 (N=5); Mean age: 49.5 yrs (males), unknown (female); Gender: 4 males, 1 female.
Treatment: Groups 1 & 2 were involved in an ongoing exercise program study. Group 3 was not in the study, but activity levels ranged from sedentary to regular. Each group engaged in a 1 hr focus session (open dialogue & discussion). Outcome Measures: Responses to open ended questions concerning exercise barriers, benefits and suggestions. |
|
| Vissers et al. 2008
Netherlands Downs & Black score=11 Observational N=32 |
Population: Mean age: 45 yrs; Gender: 24 males, 8 females, Severity of injury: tetraplegia (12), paraplegia (20); Mean time post-injury: 103.5 mo; Years post-discharge 82.6 mo
Treatment: Semi-structured interview. Outcome Measures: Response to retrospective & cross-sectional questions. 10 topic areas: subject & lesion characteristics, daily physical activity, attitude towards an active lifestyle, social activities, health, quality of life, coping, care requirements, other factors. |
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Discussion
This series of seven observational (level 5) studies provide an indication of frequently encountered barriers and facilitators affecting physical activity participation in the SCI population (Arbour et al, 2009; Kehn and Kroll 2009; Kerstin et al., 2006; Levins et al. 2004; Martin et al. 2002; Scelza et al. 2005; Vissers et al. 2008). Although all types of barriers as described above (i.e., intrapersonal, systemic, attitudinal, expertise, and societal) were cited as obstacles to physical activity participation, intrapersonal, systemic, expertise, and societal barriers were the most prominent and consistent. Arbour et al. (2009) did not find that proximity to a fitness center was related to the amount of time subjects spent in leisure time physical activity. Further research should determine which of these barriers are most influential and modifiable. In turn, practitioners and researchers should direct their efforts towards developing interventions to alleviate these key barriers.
One level 5 qualitative study (Kerstin et al. 2006) reported on factors that promote participation in physical activity among people with spinal cord injuries. The authors reported that four major themes were uncovered from the interviews as facilitators of physical activity participation: cognitive-behavioural strategies (e.g., accepting and becoming role models); environmental solutions (e.g., adequate social support); motivation (e.g., being competitive); new frames of reference (i.e., living within a narrower physical margin).
Interestingly, two of the studies suggest that the physical activity barriers that people with SCI encounter vary depending on lesion level and time post-injury. People with tetraplegia reported being more concerned about health conditions preventing exercise and exercise being too difficult than individuals with paraplegia (Scelza et al. 2005). Moreover, participants in the study by Vissers et al. (2008) indicated that they encountered more barriers to participation such as a need for more information and opportunity to participate in sport soon after discharge compared to later. Together these findings suggest that strategies for overcoming barriers to physical activity participation may be most effective when they are individualized to suit specific needs.
Conclusion
There is level 5 evidence from seven studies to suggest that individuals with SCI encounter a variety of factors that impede physical activity participation. Among these factors, the most frequently cited barriers include: (a) intrapersonal barriers such as perceived limited return on investment, health concerns and a lack of motivation, energy and time, (b) systemic barriers such as a lack of accessible facilities or unavailability of personal assistants, transportation difficulties, and program costs, and (c) expertise barriers such as a lack of knowledge about physical activity prescription and client referral processes.
A single level 5 study reported four areas that could promote participation in physical activity: cognitive-behavioural strategies, environmental solutions, motivation and new frames of reference.
Interventions are needed to help alleviate these obstacles. Further research must determine the most influential and modifiable barriers that would be optimal targets for intervention.
