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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).

Table 6: Barriers to Physical Activity Participation in SCI

Author Year; Country
Score
Research Design
Total Sample Size
MethodsOutcome
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: Questionnaire

Outcome Measures: Perceived proximity to a fitness center compared to time spent participating in leisure time physical activity

1.   There was no significant association between leisure time physical activity and perceived proximity to a fitness center (p<0.1).
Kehn & Kroll 2009

USA

Downs & Black score=16

Observational (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.

1.   Non-exercisers had a significantly longer duration of injury (p<0.05). Other demographic and injury characteristics were not significantly different between exercisers and non-exercisers.

2.   Similar barriers for both groups were reported.

3.   Non-exercisers reported low return on physical investment, lack of facilities, equipment cost, fear of injury and lack of personal assistance as barriers to exercise.

4.   Facilitators reported by exercisers included motivation, availability of accessible facilities and personal assistants, weight management and fear of health complications.

Kerstin et al. 2006

Sweden

Qualitative – Multiple Case Studies

N=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 interviews

Outcome Measures: Major themes relating to the factors that promote participation in physical activity

1.            Cognitive and behavioural strategies:

·         role models

·         creating routines and goals

·         recalling previous experiences and acquiring new knowledge

·         accepting assistance

2.            Environmental solutions:

·         accessibility

·         social support

·         equipment and funding

3.            Motivation:

·         gaining and maintaining independence

·         improving physical appearance

·         becoming a role model

·         being competitive

·         establishing a self-image as physically active

·         becoming part of a social network

4.            New frames of reference:

·         learning to live with narrower physical margins

 

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 survey

Outcome Measures: The Barriers of Physical Exercise and Disability survey; The Perceived Stress Scale.

1.   73.6% wanted to be engaged in an exercise program and 79.2% thought it would be helpful. Despite this, only 45.8% were currently participating in an exercise program.

2.   Perceived Barriers:

·       37.5% health problems that caused a cessation in exercise (pain & fractures)

·       22.2% injured during exercise (strains & pulled muscles)

·       31.9% facilities (discomfort, lack of accessibility & privacy)

3.   Exercise Concerns

·       54.2% lack of motivation

·       41.7% lack of energy

·       40.3% program cost

·       36.1% lack of local exercise program knowledge

·       33.3% lack of interest

·       31.9% lack of time

4.   ↓ concerns in exercisers versus non-exercisers (p=0.016).

5.   Concerns – Tetraplegia ↑ than paraplegia:

·       health issues cause a cessation in exercise (p=0.043)

·       difficulty to engage in exercise (p=0.024)

·       health issue concerns prevented exercise (p=0.035)

6.   ↑ levels of perceived stress were related to ↑ concerns (p=0.036).

Levins et al. 2004

USA

Qualitative – Ethnography

N=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 interviews

Outcome Measures: Major themes relating to barriers and facilitators to participation in physical activity

1.             Individual influences:

·         loss of an able identity

·         redefining self; turning points

2.             Societal influences:

·         environmental and attitudinal barriers

·         material environment (structural, financial)

·         societal attitudes

 

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.

1.   Barriers

·       Accessibility – accessibility & affordability of program, transportation to program

·       Pain – soreness & stiffness

·       Psychological – depression, lack of confidence, worries & disappointment in abilities

·       Lack of information – failure of doctor to suggest exercise

2.   Benefits

·       Physical gains – ↑ muscle strength, ↑ ease of wheeling & ADLs.

·       Sense of well being – ↑ confidence and energy level

3.   Facilitators

·       ↑ accessibility

·       Personal trainers

·       Social support

4.   Recommendations

·       Self-monitoring – daily log, fitness testing

·       S.M.A.R.T. objectives (Griffin, 1998) – specific, measurable, accomplishment-oriented, realistic, time-bound

·       Safe, supervised & supportive environment

·       ↓ pain – stretching

·       ↓ transportation issues

·       Promote program

 

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.

1.   Most important barriers:

·       In current situation: store & building accessibility, physical & mental health issues.

·       After discharge: emotional distress, self-care difficulty & mental health problems.

·       ↑ importance of barriers after discharge vs. current situation.

2.   Most important facilitators:

·       In current situation: daily physical activity preparation, physical activity stimulation & social activity preparation, in rehab centre.

·       After discharge: social support (family, friends, society).

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.

  • Individuals with SCI encounter numerous impediments to physical activity participation including intrapersonal, systemic, and expertise barriers. Interventions are needed to help people with SCI manage these barriers.