Effectiveness of Interventions to Increase Physical Activity Participation in SCI
The evidence that a large segment of the SCI population does not engage in any leisure-time physical activity whatsoever emphasizes the need for effective interventions to help people with SCI to become more physically active. In the SCI population, the majority of physical activity intervention studies are efficacy trials establishing the effects of physical activity on specific health outcomes. Few studies have examined strategies for increasing physical activity participation in this population. Thus, it is not surprising that programs and information to increase physical activity are two of the services most desired but least available to people with SCI (Hart et al. 1996; Boyd and Bardak 2004). To begin addressing this gap, this section reviews the physical activity intervention studies that include a measure of physical activity participation as a study outcome.
In the general population, three types of physical activity interventions have strong evidence of effectiveness: (1) Informational interventions that focus on delivering information to change knowledge and attitudes about the benefits of and opportunities for physical activity (e.g., a community-based media campaign), (2) Behavioural interventions that focus on teaching behavioural skills to promote physical activity participation (e.g., goal-setting), and (3) Environmental and policy interventions that focus on changing the physical environment, social networks, organizational norms and policies to enable physical activity participation (Kahn et al., 2002). Our review of physical activity interventions in the SCI population focuses solely on behavioural interventions. This narrow scope is due to the complete lack of research testing the effectiveness of informational and environmental interventions in the SCI population.
Although the sample sizes (n=12-54) are small and the research methods are limited, the findings from the four published studies promoting physical activity for individuals with SCI are encouraging. Each of the level 1 and 2 studies (Arbour-Nicitopoulos et al. 2009; Latimer et al. 2006b; Zemper et al. 2003) reported a significant increase in physical activity participation following an intervention. The level 4 study (Warms et al. 2004) indicated a promising trend in which the majority of participants increased their participation over the course of the intervention.
In addition to providing evidence thzat physical activity participation in the SCI population is amenable to change, these studies begin to provide initial insight into essential intervention elements. All four studies used an established theoretical framework to guide the intervention content. Specifically, Zemper et al. (2003) developed their intervention based on self-efficacy theory (Bandura, 1986), Warms et al. (2004) applied the transtheoretical model (Prochaska et al. 1992), Latimer et al. (2006b) used the action phase model (Gollwitzer, 1993),and Arbour-Nicitopoulos et al. (2009) employed both action planning and coping planning based on the Health Action Process Approach (Schwarzer, 1992) (See Table 9 for descriptions of these models and underlying concepts). The application of these theories in intervention development ensured that important determinants of physical activity behaviour were being targeted thus, boosting the odds of behaviour change.
From the studies by Latimer et al. (2006b) and Arbour-Nicitopoulos et al. (2009), we begin to gain an understanding of the impact of a specific intervention strategy on physical activity participation. Latimer et al. (2006b) demonstrated that assisting persons with the creation of implementation intentions is a simple and efficacious intervention technique. Arbour-Nicitopoulos et al. (2009) extended these observations by incorporating a coping planning strategy as part of systematic action planning to circumvent anticipated barriers with self-regulatory strategies. Because the studies by Zemper et al. (2003) and Warms et al. (2004) delivered multifaceted interventions including education, goal setting, and barrier management counselling, the isolated impact of each of these intervention strategies remains unknown.
There is level 1 evidence from a single RCT and supported by two low quality RCTs and by an additional level 4 study that the physical activity behaviour of individuals with SCI is amenable to change, and that theory-based interventions may be a means of generating this change.
There is level 1 evidence from a single study that indicates that coping planning as part of action planning is an effective intervention technique for promoting physical activity participation in the SCI population.
There is level 2 evidence from a single study that indicates that facilitating the formation of implementation intentions may be an effective intervention technique for promoting physical activity participation in the SCI population.
More research is needed to identify additional, specific behavioural interventions that are effective in the SCI population. Furthermore, researchers should begin to consider the impact of other types of interventions including informational and environmental interventions.