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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.

Table 7: Interventions Promoting Physical Activity Participation in SCI

Author Year; Country
Score
Research Design
Total Sample Size
MethodsOutcome
Arbour-Nicitopoulos et al. 2009

Canada

PEDRo=7

RCT

Initial N=44

Final N=38

Population: ACP condition group: Mean age: 49.00±12.93 yrs; Mean time post-injury: 18.01±14.16 yrs; Gender: 15 males=, 7 females; APO condition group: Mean age: 50.41±12.76 yrs; Mean time post-injury: 11.75±9.82yrs; Gender: 15 males, 7 females

Treatment: Participants were randomly divided into either an action planning group (APO) or action coping planning (ACP) group. Informational, instructional and other materials to assist with exercise were provided to participants prior to initiating a 10 wk program. Both groups were facilitated in completing an action plan and the ACP group also developed a coping plan intended to assist in overcoming potential barriers.

Outcome Measures: Leisure time physical activity (LTPA) participation as measured by a short version of the PARA-SCI, Intentions (2 Likert type questions), Coping self-efficacy, General barriers self-efficacy, Facility barriers self-efficacy, Scheduling self-efficacy, Health-related break from LTPA. Most measures were collected pre and post 10 wk intervention as well as mid-point (5 wks).

1.   LTPA participation was significantly greater at weeks 5 and 10 for the ACP condition in comparison with the APO condition group. The main effect for time or the time and condition interaction was not significant.

2.   No difference was found in the frequency with which participants altered their original action plans over the 10-week period between ACP and APO condition groups.

3.   Participants in the APO condition did not spontaneously form coping plans over the 10 weeks.

4.   LTPA intentions decreased for both conditions over weeks 2 to 10. No significant main effect for condition or time and condition interaction was found.

5.   A significant medium-sized effect for time for general barriers self-efficacy was observed.

6.   Confidence to schedule moderate to heavy LTPA decreased for both groups over weeks1 to 10. However, significant medium-large sized effects for condition were found for all 3 types of coping self-efficacy.

7.   Participants in the ACP condition group had greater confidence to schedule and overcome LTPA-related barriers compared to the APO condition group.

8.   The APO condition group had greater confidence to overcome facility-related barriers than did those in the ACP condition.

9.   For the intervention– coping self-efficacy relationship, the ACP condition group had greater scheduling and barrier self-efficacy, and lower facility related barriers than the APO condition group.

Latimer et al. 2006b

Canada

PEDro= 4

RCT

Initial N=54 ; Final N=37

 

 

Population: Chronic SCI; Mean age: 40.61 yrs; Gender: 16, males, 21 females; Level of injury: paraplegia (35), tetraplegia (19); Mean time post-injury: 19.34 yrs

Treatment: Intervention group: Subjects and researchers created implementation intentions over the telephone, for 30 min of physical activity 3d/wk, for 4 wks. A 4 wk calendar and daily log book was emailed to the subject. After 4 wks, implementation intentions and calendars were updated for subsequent 4 wks. Control group: Subjects were advised by an interventionalist to engage in 30 min of physical activity 3d/wk, for 4 wks. Subjects verbally recited activities they would perform, and these were put into a calendar and emailed with a daily log book. After 4 wks, verbal recitation occurred again and a new calendar and daily log was received for a subsequent 4 wks.

Outcome Measures: Intentions –  2 statements used: 1) “I will try to do at least 30 min of moderate to heavy physical activity 3d/wk over the next 4 wks” (1= definitely false; 7= definitely true);

2) “I intend to do at least 30 min of moderate to heavy physical activity 3d/wk in the forthcoming month (1=extremely unlikely; 7=extremely likely); Physical Activity: Physical Activity Recall Assessment for Individuals with SCI (PARA-SCI); Perceptions of control (perceived behavioural control, PBC; scheduling self-efficacy; barrier self-efficacy).

1.   Minutes of daily physical activity: ↑ when implementation intentions were utilized (p=0.04).

2.   The overall number of days subjects participated in ≥ 30 min of physical activity was not affected by intention implementation.

3.   The intentions-behaviour relationship was significantly stronger in the intervention group (p=0.03), as compared to the control group.

4.   Scheduling self-efficacy: ↑ at week 5 when implementation intentions were utilized (p=0.04).

5.   PBC and barrier self-efficacy did not differ between groups.

Zemper et al. 2003

USA

PEDro=4

RCT

Initial N=67; Final N=43

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

Treatment: Intervention group:  6 – 4 hr workshop sessions over 3 mo, 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); Arm crank ergometer testing; neurologic exam; Body Mass Index (BMI); all at baseline and post-study.

1.   When compared to control group, the intervention group showed statistically significant improvements in the following:

·        Health practice abilities (SAHP, p<0.05);

·       Health promoting lifestyle (HPLP- II, p<0.001);

·       Nutritional awareness and behaviour (HPLP-II subscale, p <0.05)

·       ↑ of stress management  techniques, ↓ perceived stress (HPLP-II subscale, p =.001).

2.   Secondary complications: ↓ in number, ↓ in severity, in the intervention group (p<0.001). A non-significant ↓ in depression was found.

3.   Physical Activity (HPLP-II): ↑ physical activity and improved physical fitness (p = 0.001); however, no improvement on the PADs or physical fitness measures.

Warms et al. 2004

USA

Downs & Black score=14

Pre-Post

Initial N=17; Final N=16

 

 

Population: SCI; Mean age: 43.2 yrs; Gender: 13 males, 3 females; Mean time post-injury: 14.4 yrs

Treatment: “Be Active in Life” program: included educational materials (2 pamphlets, 2 handouts), a home visit with a nurse (90 min scripted motivational interview, goal and personal action plan establishment), and follow up calls at day 4, 7, 11 & 28 (approx. 8 min each). Program lasted for 6 wks, and had a final follow-up 2 wks post-completion.

Outcome Measures: Physical activity (wrist-worn actigraph); Stage of Readiness for Change in Exercise Behaviour; Self-rated Abilities for Health Practices Scale (includes Exercise Self-efficacy subscale); Self-rated Health Scale (SRHS); Centre for Epidemiologic Studies Depression Scale (CES-D); Muscle Strength; @ baseline, 6 wk completion pt; 2 wks post-completion.

1.   Physical activity: Counts/day ↑ in 60% of subjects and self-reported activity ↑ in 69% of subjects, but both were not significant.

2.   Barriers: ↓ in overall barrier score (p=0.06) and ↓ motivational barrier score (p=0.01).

3.   Self-rated abilities: no change. Exercise self-efficacy: ↑ (p=0.01).

4.   Self-rated health: ↑ (p=0.04)

5.   Depression: no change.

6.   Muscle Strength: only upper extremity muscle strength ↑ (p=0.000).

Discussion

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.

Conclusion

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.

  • Behavioural interventions promoting physical activity in the SCI population may lead to increased levels of physical activity participation.

Table: Description of Theoretical Frameworks and Underlying Concepts re: Physical Activity

Theoretical Framework or ConceptDescription
Self-Efficacy TheorySelf-efficacy is a central construct within Social Cognitive Theory, which was developed by Alfred Bandura (1986), and suggests that the observation of others within social interactions, media or other experiences is critical for knowledge acquisition. Self-efficacy is defined as the belief in one’s ability to succeed in specific situations. In the context of interventions for increasing physical activity participation, self-efficacy is typically described as the confidence a person has in conducting the various behaviours required to engage in physical activity (e.g., overcoming barriers to participation, scheduling or in performing the specific physical activity itself). In addition to self-efficacy, other key determinants of social cognitive theory as applied to health promotion practices include knowledge of health risks and benefits, outcome expectations, health goals and associated strategies, and perceived facilitators and barriers (Bandura 2004).
Transtheoretical ModelThe transtheoretical model (TTM) is a model of health behaviour change that was developed by James Prochaska and colleagues in the late 1970’s in the area of addictive behaviours (Prochaska and Velicer 1997). More recently, the core constructs of the TTM have been employed to guide the development of interventions that seek to promote physical activity participation (Marcus and Simkin 1994). These core constructs include stages and processes of change, decisional balance and self-efficacy.
Action Phase ModelThe action phase model is a health behaviour change theory that  specifies that goal-oriented behaviour consists of various phenomena such as deliberating, planning, acting and evaluating and that these are ruled by different principles (Gollwitzer, 1993). A significant aspect of this model is the importance of mind-sets in achieving successful behaviour change. For example, various techniques may be employed to assist the person to view goal attainment in a more positive light and avoid negative thoughts that might undermine their goal pursuits (Gollwitzer and Kinney, 1989). In turn, this positive thinking is thought to yield optimistic perceptions of control over the intended outcome.
Coping Planning (as part of the Health Action Process Approach)Coping planning is a specific method that involves the pairing of anticipated barriers with self-regulatory strategies. Examples of self-regulatory strategies are self-monitoring or cognitive restructuring. By forming coping plans, persons may anticipate and develop plans to manage potential barriers that may interfere with goal attainment (Schwarzer  1992).
Implementation IntentionsImplementation intentions are action plans that specify when, where and how a goal is to be accomplished. Implementation intentions commit an individual to performing a behaviour within the situational cues (i.e., when, where, and how to act) as they are encountered (Gollwitzer, 1993). They have been identified as a useful technique that is consistent with the Action Phase Model.