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Systematic Framework to Classify the Status of Research on Spinal Cord Injury and Physical Activity
Archives of Physical Medicine and Rehabilitation journal homepage: www.archives-pmr.org Archives of Physical Medicine and Rehabilitation 2013;94:2027-31
ORIGINAL ARTICLE
Systematic Framework to Classify the Status of Research on Spinal Cord Injury and Physical Activity Mara B. Nery, MS, Simon Driver, PhD, Kerri A. Vanderbom, MA From the Department of Exercise and Sport Science, College of Public Health and Human Sciences, Oregon State University, Corvallis, OR.
Abstract Objectives: To systematically classify the physical activity research for individuals with a spinal cord injury by using the behavioral epidemiologic framework; and to identify where the physical activity research for individuals with a spinal cord injury has focused between 2000 and 2012. Design: Relevant research was identified and then categorized into 1 of 5 phases by following the coding rules of the behavioral epidemiology framework. Phase 1 studies link physical activity and health outcomes, phase 2 studies validate or develop measures of physical activity, phase 3 studies identify factors that influence behavior or examine explanatory theories of behavior, phase 4 studies evaluate interventions, and phase 5 studies disseminate health promotion programs or policies and translate research into practice. Setting: Specific keywords were identified and then searched through EBSCOhost, PubMed, and Google Scholar. Participants: Not applicable. Interventions: Not applicable. Main Outcome Measures: Not applicable. Results: One hundred and thirteen articles met the criteria. Of the articles, 55% were categorized as phase 1, 12% as phase 2, 24% as phase 3, 5% as phase 4, and 4% as phase 5. Conclusions: Most studies were categorized as phase 1, 2, or 3, which implies that this field is still in the early stages of development and research should focus on intervention development and dissemination. Archives of Physical Medicine and Rehabilitation 2013;94:2027-31 ª 2013 by the American Congress of Rehabilitation Medicine
Spinal cord injury (SCI) refers to a broad spectrum of damage to the spinal cord that results in partial or complete impairment of motor and/or sensory functions of the legs, arms, trunk, or multiple areas of the body.1 Between 236,000 and 327,000 individuals currently live with an SCI in the United States, with more than 12,000 new cases being reported each year.1 Automobile collisions are the leading cause of SCI and most commonly affect individuals from 15 to 35 years of age.1 For an average individual living with an SCI, medical costs range between $15,000 and $30,000 each year, which can add up to $500,000 to $3 million in a lifetime,1 depending on the severity of the injury. Many SCI patients suffer from complications Supported by the U.S. Department of Education, Office of Special Education (contract no. H325D100061). No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit on the authors or on any organization with which the authors are associated.
affecting their nervous, musculoskeletal, respiratory, gastrointestinal, and urogenital systems.2 People living with SCI are at a greater risk for secondary conditions, such as depression,3 obesity, osteoporosis, pressure ulcers, type II diabetes, cardiovascular disease, and urinary tract infections,4 many of which may be preventable with adequate care. It is well documented that physical activity (PA) lowers the risk of chronic diseases, such as type II diabetes, cardiovascular disease, and obesity, in able-bodied individuals.5 As research expands in the field of disability and exercise science, the benefits of PA are becoming clearer for special populations, such as individuals with SCI,6 who may experience a reduced onset of secondary conditions as a result of increased participation.7 For example, individuals with SCI experience changes in metabolism and body composition over time, which results in a decrease in lean muscle mass and bone density, as well as an increase in abdominal adiposity.8 Because of these increases in abdominal adiposity, incidence of
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2028 type II diabetes, increased cholesterol, and decreased activity, individuals with an SCI are at a much higher risk for developing metabolic syndrome, which significantly increases the risk of mortality from cardiovascular disease.8-10 In fact, this population has a higher incidence of cardiovascular disease than the general population, and its onset is decades earlier.11 However, in addition to reducing the risk of chronic disease, regular PA can reduce muscle atrophy and bone density loss, reduce the occurrence of decubitus ulcers, and help maintain cardiorespiratory fitness and mobility, which increases an individual’s independence and quality of life.7,12 The U.S. Department of Health and Human Services recommends that adults complete 150 minutes per week of moderate intensity PA,5 although only 48% of the population are regularly active.13 This number is even lower for individuals with SCI who report the lowest levels of PA among people with a disability overall,2 and report 24% less total daily energy expenditure than able-bodied individuals. There are a variety of factors that influence the PA level of individuals with an SCI, including the level of severity of the injury, degree of mobility, and subsequent barriers to activity. Barriers may include issues with accessibility, high cost, pain, and psychological barriers, such as low motivation, perceived benefits of exercise, perceived ability, and reduced self-efficacy.14 The benefits of PA in this population are vast, yet many individuals face barriers and become sedentary,15 which is why it is important to understand where researchers can best focus their efforts to facilitate the adoption and maintenance of participation. In the expanding field of exercise science and disabilities studies there is a growing need to understand where most of the research is being conducted for individuals with an SCI, and where there is a need for further inquiry. By completing this process, investigators are better positioned to conduct research in areas that have been historically less reported on, with the ultimate goal of improving the health of individuals with SCI through PA participation. The behavioral epidemiology framework described by Sallis et al16 illustrates a systematic method of categorizing current health-related research (eg, PA, nutrition, smoking cessation) that can be used to analyze the PA literature related to individuals with SCI. The framework is descriptive in nature and presents information about the status of research in the field into 1 of 5 phases. Studies categorized into phase 1 are those linking PA or exercise to health outcomes. These studies include links between behavior and health and dose-response relations with health outcomes. Studies in phase 2 validate measures of PA or the methods for measuring PA and behavior. Phase 2 also includes studies that develop and test new forms of measurement of PA. Phase 3 research includes studies identifying factors that influence behavior, and studies testing theories of behavior. Research in phase 4 includes interventions that specifically target changing PA behavior, or determinants of PA behavior, and may include randomized controlled trials. Studies in phase 5 disseminate health promotion programs or policies, and translate research into practice.16 By examining the distribution of studies that have previously been completed, researchers can shift their focus
List of abbreviations: PA physical activity SCI spinal cord injury TPB theory of planned behavior
M.B. Nery et al to phases that may be underrepresented and warrant further investigation. The phases outlined in the framework are generally sequential, building on the previous stage. For example, phase 2 studies may test the validity of a measure of behavior (eg, accelerometers), whereas phase 3 studies explore the factors that influence that behavior (eg, barriers, self-efficacy). Findings from studies in phases 1 through 3 can be used to inform intervention development, which would be classified as phase 4. When results from an intervention study provide an efficacious evidence base, findings can be disseminated into the community (phase 5). The framework can also be used to improve earlier stage research. For example, findings from studies in phase 2 that focus on the validity of a form of measurement, such as pedometers, can be used to conduct further and more accurate research in phase 1. Therefore, the purpose is to use the behavioral epidemiology framework to systematically classify studies on SCI and PA into distinct phases to better understand the current state of research in this area. The 2 major research questions posed are the following: (1) What is the current status of PA research for people with SCI? (2) What phases of PA research need further inquiry?
Method A survey of the literature was conducted by searching EBSCOhost, PubMed, and Google Scholar, using the search terms spinal cord injury, physical activity, exercise, leisure, and health promotion. The search included qualitative and quantitative studies, as well as meta-analyses and reviews published between 2000 and 2012. Articles were included that assessed PA or health promotion for populations with SCI in relation to the 5 phases of the behavioral epidemiology framework. The following coding rules were used: (1) editorials without extensive references were not included; (2) if a study fell into multiple categories, it was coded into the highest category; (3) if the study focused primarily on the measurement of PA it was coded into phase 2; (4) studies with measurements of the determinants of PA were coded into phase 3; and (5) studies that pertained to dissemination of health promotion programs were coded as phase 5.16 The research team was trained on the Sallis et al16 framework prior to coding the studies. Training involved a presentation on the article, followed by discussions and practice coding with a sample of studies to increase coding reliability among the research team. For example, from the total number of articles identified, a sample of 20 studies was randomly selected to be independently coded for reliability between 2 researchers. If the phase an article was to be coded in was questioned, the issue was resolved through discussion to reach a consensus of the group. The coders achieved 90% reliability on the sample set, which exceeded the 80% reliability minimum. The research team then completed final coding of all the identified articles, and percentages of each phase were calculated.
Results In total, 113 articles were identified, of which 55% were categorized into phase 1 (nZ62), 12% into phase 2 (nZ13), 24% into phase 3 (nZ27), 5% into phase 4 (nZ6), and 4% into phase 5 (nZ5). Most research related to SCI and PA fell into phase 1, which includes studies linking PA to health outcomes. For example, increased PA participation was linked to psychosocial www.archives-pmr.org
Epidemiologic study on physical activity and SCI benefits, such as increased self-efficacy17 and quality of life.18-22 Furthermore, studies reported a relation between increased PA and improvements in cardiovascular,19,23-27 muscular,24,28-31 and respiratory systems,23,32,33 increased bone density and decreased bone loss,34-37 lower incidence of chronic disease,38 improved motor function,28 lower levels of depression,17,20,39 and reduced pain.19,20,40 Results from phase 2 indicated that the most commonly used tool to measure PA in individuals with an SCI was the accelerometer. Other tools included heart rate monitors,41 pedometers,42,43 and accelerometers and gyrometers.41,44,45 The Physical Activity Recall Assessment for Individuals with Spinal Cord Injuries46,47 was the most frequently tested assessment, along with the Leisure Time Physical Activity Questionnaire48 and the Physical Activity Scale for Individuals with a Physical Disability.49,50 Among the phase 3 articles, the most widely used theory was the theory of planned behavior (TPB).46,51,52 The TPB links attitudes about PA and behavior to predict an individual’s intention toward being physically active.53 Other theories used were the social cognitive theory54,55 and the transtheoretical model.56,57 Studies in phase 3 also examined determinants of behavior with most articles examining barriers and facilitators to participating in PA.14,51,58-63 Very few articles were categorized into phases 4 or 5, indicating a gap in research that evaluates interventions or translates research into practice. Of the studies in phase 4, all included faceto-face health promotion programs, often in rehabilitation center settings, that examined the effects of interventions on engagement in PA,46,64-66 self-efficacy,64,65,67 goal setting,65 coping self-efficacy,64 perceived independent living status,68 empowerment,65 leisure satisfaction,46,68 and quality of life.46 All of the studies in phase 4 concluded that their interventions improved aspects of PA behavior, such as motivation, confidence, PA intention, participation, and quality of life.46,64-68
Discussion The purpose of this study was to categorize the PA and SCI literature into specific phases by using the behavioral epidemiology framework to gain a better understanding of the current status of research in this field. Articles included were published between 2000 and 2012, and were from peer-reviewed journals. From the distribution of the articles, it is clear that PA and SCI research are in the early stages of inquiry, because the focus is predominantly on phase 1 studies, which are those that link health outcomes to PA for individuals with SCI. Phase 3 consisted of the next highest concentration of research, which were studies that explore factors that influence behavior. However, there is still a need for studies that test theoretical models of health behavior on the SCI population.69 It is also apparent that there is limited research examining the efficacy of health promotion programs (phases 4 and 5). Understanding the linkages between PA and health outcomes is important to developing research in the later phases of the framework. For example, research in phase 1 allows investigators to understand dose-response relations in regards to PA, and to increase our knowledge of the benefits and risks associated with PA in the SCI population. This knowledge can then be used to guide research on increasing PA behaviors and creating meaningful interventions. www.archives-pmr.org
2029 Results from the current systematic classification suggest that there is a lack of research in phase 2, despite the importance of such studies. For example, by improving and validating existing methods and measurements of PA and behavior, and creating and testing new forms of measurement, researchers will be able to improve the accuracy of research in phases 1 and 3. Increased research into phase 2 can also help investigators integrate the most effective methods of data collection and reporting into intervention research (phase 4 studies). Phase 3 had a relatively large number of studies (24%) that explored factors that influenced PA behavior in individuals with an SCI. Behavioral theory provides a framework for creating effective health promotion programs and interventions. For example, researchers can examine the causal relations between behavioral constructs and then develop interventions to increase PA behavior, because the frameworks typically involve enhancing skills (eg, goal setting and problem-solving to increase self-efficacy) or modifying environmental conditions (eg, overcoming barriers) necessary for behavior change. In this way, theories, such as the TPB and social cognitive theory, drive practice. Phase 4 and 5 studies focus on testing interventions and disseminating health promotion programs. Health promotion programs have been shown to improve overall physical health, such as cardiovascular, respiratory, metabolic, and muscular systems, which contribute to improved performance of activities of daily living and enhanced quality of life.29 These programs have also been effective in reducing the rate of occurrence of secondary conditions.70 However, there were very few articles classified into phases 4 and 5, suggesting that the area of PA and SCI is a relatively young field and still developing.69 The importance of research into these areas is critical, because individuals with SCI typically experience poorer health than the ablebodied population, as well as secondary conditions and early mortality that could be prevented with improved interventions.69 The phase 5 studies all discussed the dissemination of recreation-based community health promotion programs. The programs consisted of engaging the participants in physical and recreation activities and having participants attend interactive seminars or education programs, which focused on health and advocacy topics and goal attainment.45,71-73 Some of the goals of the health promotion programs were to teach people how to maintain their health, decrease the occurrence of secondary conditions, and improve quality of life.70,72 It is clear that individuals with SCI could benefit enormously from further research into the implementation and dissemination of PA-based health promotion programs.
Study limitations Our use of the behavioral epidemiology framework is not without limitations. First, our systematic classification only examined articles published between 2000 and 2012. Therefore, there may be relevant articles published before 2000 that were not included. Second, relevant articles may not have been included if they were not captured in the search engines used. Third, 3 of the articles that were selected included mixed samples of disabilities in their studies. For example, 2 studies74,75 involved participants who had experienced a stroke, and 1 study76 included participants who had cerebral palsy, myelomeningocele, or acquired brain injury. Although these studies demonstrated outcomes relevant to SCI populations, they were not solely intended for SCI populations. Finally, several of the
2030 studies that were identified in our initial search examined outcomes related to physical therapy, but only those that also investigated PA outcomes were included in our review.
Conclusions Our findings illustrate that the focus of PA research for individuals with an SCI has historically been on measuring health outcomes and determinants of health behavior. These results indicate that the field is still developing because of the low representation of studies in the higher phases (phases 4 and 5). Investigators may use findings to guide future research efforts, help fill in the gaps in the body of knowledge, and improve the quality of PA research for individuals with SCI. It is well documented that PA can improve the health of individuals with an SCI, but there are a lack of health promotion programs that aim to facilitate the adoption and maintenance of participation for the population. By building on findings from phases 1 through 3, investigators can develop and implement effective health promotion programs for individuals with SCI that aim to increase PA participation and improve health.
Keywords Epidemiology; Health promotion; Motor activity; Rehabilitation; Spinal cord injuries
Corresponding author Mara B. Nery, MS, 123 Women’s Building, Oregon State University, Corvallis, OR 97331. E-mail address: mara.nery@ oregonstate.edu.
References 1. NSCISC National Spinal Cord Injury Statistical Center. NSCISC. 2012. Available at: https://www.nscisc.uab.edu/. Accessed July 25, 2012. 2. Sekhon LH, Fehlings MG. Epidemiology, demographics, and pathophysiology of acute spinal cord injury. Spine (Phila Pa 1976) 2001; 26(24 Suppl):S2-12. 3. Craig A, Tran Y, Middleton J. Psychological morbidity and spinal cord injury: a systematic review. Spinal Cord 2009;47:108-14. 4. Hitzig SL, Tomack M, Campbell KA, et al. Secondary health complications in aging Canadian spinal cord injury sample. Am J Phys Med Rehabil 2008;87:545-55. 5. Healthy People Web site. 2012. Available at http://www. healthypeople.gov/2020/default.aspx. Accessed August 7, 2012. 6. Davies DS, McColl MA. Lifestyle risks for three disease outcomes in spinal cord injury. Clin Rehabil 2002;16:96-108. 7. Buchholz AC, Ginis KA, Bray SR, et al. Greater daily leisure time physical activity is associated with lower chronic disease risk in adults with spinal cord injury. Appl Physiol Nutr Metab 2009;34:640-7. 8. Bauman WA, Spungen AM. Carbohydrate and lipid metabolism in chronic spinal cord injury. J Spinal Cord Med 2001;24:266-77. 9. Kocina P. Body composition of spinal cord injured adults. Sports Med 1997;23:48-60. 10. Jones LM, Goulding A, Gerrard DF. DEXA: a practical and accurate tool to demonstrate total and regional bone loss lean tissue loss and fat mass gain in paraplegia. Spinal Cord 1998;36:637-40. 11. Yekutiel M, Brooks ME, Ohry A, Yarom J, Carel R. The prevalence of hypertension, ischemic heart disease, and diabetes in traumatic spinal cord injured patients and amputees. Paraplegia 1989;27:58-62.
M.B. Nery et al 12. Noreau L, Shephard RJ. Spinal cord injury, exercise and quality of life. Sports Med 1995;20:226-50. 13. Kruger JK, Kohl HW, Miles IJ. Prevalence of regular physical activity among adultsdUnited States, 2001 and 2005. JAMA 2008;299:30-2. 14. Vissers MB, Sluis T, Bergen M, Stam H, Bussman H. Barriers to and facilitators of everyday physical activity in persons with spinal cord injury after discharge from the rehabilitation centre. J Rehabil Med 2008;40:461-7. 15. Jacobs PL, Nash MS. Exercise recommendations for individuals with spinal cord injury. Sports Med 2004;34:727-51. 16. Sallis JF, Owen N, Fotheringham MJ. Behavioral epidemiology: a systematic framework to classify phases of research on health promotion and disease prevention. Ann Behav Med 2000;22:294-8. 17. Kennedy P, Taylor N, Hindson L. A pilot investigation of a psychosocial activity course for people with spinal cord injuries. Psychol Health Med 2006;11:91-9. 18. Anneken V, Hanssen-Doose A, Hirschfeld S, Scheuer T, Thietje R. Influence of physical exercise on quality of life in individuals with spinal cord injury. Spinal Cord 2010;48:393-9. 19. Ditor DS, Latimer AE, Martin Ginis KA, Arbour KP, McCartney N, Hicks AL. Maintenance of exercise participation in individuals with spinal cord injury: effects on quality of life, stress and pain. Spinal Cord 2003;41:446-50. 20. Hicks AL, Martin KA, Ditor DS, Latimer AE. Long-term exercise training in persons with spinal cord injury: effects on strength, arm ergometry performance and psychological well-being. Spinal Cord 2003;41:34. 21. Lannem AM, Sørensen M, Frøslie KF, Hjeltnes N. Incomplete spinal cord injury, exercise and life satisfaction. Spinal Cord 2009;47:295-300. 22. Miki Y, Kanayama C, Nakashima S, Yamasaki M. Health-related quality of life in active persons with spinal cord injury. Jpn J Phys Fitness Sports Med 2012;61:177-82. 23. Brurok B, Helgerud J, Karlsen T, Leivseth G, Hoff J. Effect of aerobic high-intensity hybrid training on stroke volume and peak oxygen consumption in men with spinal cord injury. Am J Phys Med Rehabil 2011;90:407-14. 24. Davis GM, Hamzaid NA, Fornusek C. Cardiorespiratory, metabolic, and biomechanical responses during functional electrical stimulation leg exercise: health and fitness benefits. Artif Organs 2008;32:625-9. 25. Maggioni MA, Ferratini M, Pezzano A, et al. Heart adaptations to long-term aerobic training in paraplegic subjects: an echocardiographic study. Spinal Cord 2012;50:538-42. 26. Phillips AA, Cote AT, Warburton DE. A systematic review of exercise as a therapeutic intervention to improve arterial function in persons living with spinal cord injury. Spinal Cord 2011;49:702-14. 27. Wheeler G, Andrews B, Lederer R. Functional electric stimulatione assisted rowing: increasing cardiovascular fitness through functional electric stimulation rowing training in persons with spinal cord injury. Arch Phys Med Rehabil 2002;83:1093-9. 28. Adams MM, Hicks AL. Comparison of the effects of body-weightsupported treadmill training and tilt-table standing on spasticity in individuals with chronic spinal cord injury. J Spinal Cord Med 2011; 34:488-94. 29. Batsiou S, Trikkos O, Dafnis P, Tofas T. Exercise and individuals with spinal cord injury. Inquiries in Sport & Physical Education 2008;6:1-11. 30. Johnston TE, Modlesky CM, Betz RR, Lauer RT. Muscle changes following cycling and/or electrical stimulation in pediatric spinal cord injury. Arch Phys Med Rehabil 2011;92:1937-43. 31. Roth EJ, Stenson KW, Powley S, et al. Expiratory muscle training in spinal cord injury: a randomized controlled trial. Arch Phys Med Rehabil 2010;91:857-61. 32. Moreno MA, Zamuner AR, Paris JV, Teodori RM, Barros RM. Effects of wheelchair sports on respiratory muscle strength and thoracic mobility of individuals with spinal cord injury. Am J Phys Med Rehabil 2012;91:470-7. 33. Nooijen CF, de Groot S, Postma K, et al. A more active lifestyle in persons with a recent spinal cord injury benefits physical fitness and health. Spinal Cord 2012;50:320-3.
www.archives-pmr.org
Epidemiologic study on physical activity and SCI 34. Chain A, Koury JC, Bezerra FF. Physical activity benefits bone density and bone-related hormones in adult men with cervical spinal cord injury. Eur J Appl Physiol 2012;112:3179-86. 35. Dolbow DR, Gorgey AS, Daniels JA, Adler RA, Moore JR, Gater DR. The effects of spinal cord injury and exercise on bone mass: a literature review. NeuroRehabilitation 2011;29:261-9. 36. Giangregorio LM, Hicks AL, Webber CE, et al. Body weight supported treadmill training in acute spinal cord injury: impact on muscle and bone. Spinal Cord 2005;43:649-57. 37. Lauer RT, Smith BT, Mulcahey MJ, Betz RR, Johnston TE. Effects of cycling and/or electrical stimulation on bone mineral density in children with spinal cord injury. Spinal Cord 2011;49:917-23. 38. Fernhall B, Heffernan K, Jae SY, Hedrick B. Health implications of physical activity in individuals with spinal cord injury: a literature review. J Health Hum Serv Adm 2008;30:468-502. 39. Tawashy AE, Eng JJ, Lin KH, Tang PF, Hung C. Physical activity is related to lower levels of pain, fatigue and depression in individuals with spinal-cord injury: a correlational study. Spinal Cord 2009;47:301-6. 40. Norrbrink C, Lindberg T, Wahman K, Bjerkefors A. Effects of an exercise programme on musculoskeletal and neuropathic pain after spinal cord injury-results from a seated double-poling ergometer study. Spinal Cord 2012;50:457-61. 41. Tanhoffer RA, Tanhoffer AI, Raymond J, Hills AP, Davis GM. Comparison of methods to assess energy expenditure and physical activity in people with spinal cord injury. J Spinal Cord Med 2012;35:35-45. 42. Hiremath SV, Ding D, Farringdon J, Cooper RA. Predicting energy expenditure of manual wheelchair users with spinal cord injury using a multisensor-based activity monitor. Arch Phys Med Rehabil 2012; 93:1937-43. 43. Ishikawa S, Stevens SL, Kang M, Morgan DW. Reliability of daily step activity monitoring in adults with incomplete spinal cord injury. J Rehabil Res Dev 2011;48:1187-94. 44. Oda H, Ikemoto S, Tsunoda N, et al. Preliminary study for evaluation of daily physical activity in persons with spinal cord injury with wristwatch type equipment for classification of human activities. Jpn J Clin Sports Med 2009;17:305-14. 45. Warms CA, Belza BL, Whitney JD, Mitchell PH, Stiens SA. Lifestyle physical activity for individuals with spinal cord injury: a pilot study. Am J Health Promot 2004;18:288-91. 46. Latimer AE, Ginis KA, Arbour KP. The efficacy of an implementation intention intervention for promoting physical activity among individuals with spinal cord injury: a randomized controlled trial. Rehabil Psychol 2006;51:273-80. 47. Martin Ginis KA, Latimer AE, Hicks AL, Craven BC. Development and evaluation of an activity measure for people with spinal cord injury. Med Sci Sports Exerc 2005;37:1099-111. 48. Martin Ginis KA, Phang SH, Latimer AE, Arbour-Nicitopoulos K. Reliability and validity tests of the leisure time physical activity questionnaire for people with spinal cord injury. Arch Phys Med Rehabil 2012;93:677-82. 49. de Groot S, van der Woude LH, Niezen A, Smit CA, Post MW. Evaluation of the physical activity scale for individuals with physical disabilities in people with spinal cord injury. Spinal Cord 2010;48:542-7. 50. van den Berg-Emons RJ, L’Ortye AA, Buffart LM, et al. Validation of the physical activity scale for individuals with physical disabilities. Arch Phys Med Rehabil 2011;92:923-8. 51. Arbour-Nicitopoulos K, Martin Ginis KA, Wilson PM. Examining the individual and perceived neighborhood associations of leisuretime physical activity in persons with spinal cord injury. Ann Behav Med 2010;39:192-7. 52. Sweet SN, Ginis KA, Latimer-Cheung AE. Examining physical activity trajectories for people with spinal cord injury. Health Psychol 2012;31:728-32. 53. Ajzen I. From intentions to actions: a theory of planned behavior. In: Kuhl J, Beckman J, editors. Action-control: from cognition to behavior. Heidelberg: Springer; 1985. p 11-39. 54. Bandura A. Social foundations of thought and action: a social cognitive theory. Englewood Cliffs: Prentice-Hall; 1986.
www.archives-pmr.org
2031 55. Ginis KA, Latimer AE, Arbour-Nicitopoulos K, Bassett RL, Wolfe DL, Hanna SE. Determinants of physical activity among people with spinal cord injury: a test of social cognitive theory. Ann Behav Med 2011;42:127-33. 56. Prochaska JO, Velicer WF. The transtheoretical model of health behavior change. Am J Health Promot 1977;12:38-48. 57. Kosma M, Ellis R, Bauer JJ. Longitudinal changes in psychosocial constructs and physical activity among adults with physical disabilities. Disabil Health J 2012;5:1-8. 58. Cowan RE, Nash MS, Anderson KD. Exercise participation barrier prevalence and association with exercise participation status in individuals with spinal cord injury. Spinal Cord 2012;51:27-32. 59. Kehn M, Kroll T. Staying physically active after spinal cord injury: a qualitative exploration of barriers and facilitators to exercise participation. BMC Public Health 2009;9:1-11. 60. Levins SM, Redenbach DM, Dyck I. Individual and societal influences on participation in physical activity following spinal cord injury: a qualitative study. Phys Ther 2004;84:496-509. 61. Phang SH, Martin Ginis KA, Routhier F, Lemay V. The role of selfefficacy in the wheelchair skills-physical activity relationship among manual wheelchair users with spinal cord injury. Disabil Rehabil 2012;34:625-32. 62. Roberton T, Bucks RS, Skinner TC, Allison GT, Dunlop SA. Barriers to physical activity in individuals with spinal cord injury: a Western Australian study. Australian J Rehabil Couns 2011;17:74-88. 63. Wu SK, Williams T. Factors influencing sport participation among athletes with spinal cord injury. Med Sci Sports Exerc 2001;33:177-82. 64. Arbour-Nicitopoulos K, Ginis KA, Latimer AE. Planning, leisuretime physical activity, and coping self-efficacy in persons with spinal cord injury: a randomized controlled trial. Arch Phys Med Rehabil 2009;90:2003-11. 65. Block P, Vanner EA, Keys CB, Rimmer JH, Skeels SE. Project Shake-It-Up: using health promotion, capacity building and a disability studies framework to increase self efficacy. Disabil Rehabil 2010;32:741-54. 66. van Langeveld SA, Post MW, van Asbeck FW, et al. Contents of physical therapy, occupational therapy, and sports therapy sessions for patients with a spinal cord injury in three Dutch rehabilitation centres. Disabil Rehabil 2011;33:412-22. 67. Piatt J, Compton DM, Sara Wells M, Bennett JL. Interventions that effect active living among individuals with spinal cord injury. Ther Recreat J 2012;46:9-25. 68. Daniel A, Manigandan C. Efficacy of leisure intervention groups and their impact on quality of life among people with spinal cord injury. Int J Rehabil Res 2005;28:43-8. 69. Drum CE, Peterson JJ, Culley C, et al. Guidelines and criteria for the implementations of community-based health promotion programs for individuals with disabilities. Am J Health Promot 2009;24:93-101. 70. Sable J, Craig P, Lee D. Promoting health and wellness: a researchbased case report. Ther Recreat J 2000;34:348-61. 71. Block P, Skeels SE, Keys CB, Rimmer JH. Shake-It-Up: health promotion and capacity building for people with spinal cord injuries and related neurological disabilities. Disabil Rehabil 2005;27:185-90. 72. Sable J, Bocarro J. Transitioning back to health: participants’ perspective of project PATH. Ther Recreat J 2004;38:206-24. 73. Lagerstro¨m A, Levi R. Health promotion in spinal cord rehabilitation. Phys Ther Rev 2009;14:2-2. 74. Manns PJ, Dunstan DW, Owen N, Healy GN. Addressing the nonexercise part of the activity continuum: a more realistic and achievable approach to activity programming for adults with mobility disability. Phys Ther 2012;92:614-25. 75. Zehr EP. Evidence-based risk assessment and recommendations for physical activity clearance: stroke and spinal cord injury. Appl Physiol Nutr Metab 2011;36(Suppl 1):S214-31. 76. van den Berg-Emmons RJ, Bussman JB, Haisma JA, et al. A prospective study on physical activity levels after spinal cord injury during inpatient rehabilitation and the year after discharge. Arch Phys Med Rehabil 2008;11:2094-101.
ORIGINAL ARTICLE
Systematic Framework to Classify the Status of Research on Spinal Cord Injury and Physical Activity Mara B. Nery, MS, Simon Driver, PhD, Kerri A. Vanderbom, MA From the Department of Exercise and Sport Science, College of Public Health and Human Sciences, Oregon State University, Corvallis, OR.
Abstract Objectives: To systematically classify the physical activity research for individuals with a spinal cord injury by using the behavioral epidemiologic framework; and to identify where the physical activity research for individuals with a spinal cord injury has focused between 2000 and 2012. Design: Relevant research was identified and then categorized into 1 of 5 phases by following the coding rules of the behavioral epidemiology framework. Phase 1 studies link physical activity and health outcomes, phase 2 studies validate or develop measures of physical activity, phase 3 studies identify factors that influence behavior or examine explanatory theories of behavior, phase 4 studies evaluate interventions, and phase 5 studies disseminate health promotion programs or policies and translate research into practice. Setting: Specific keywords were identified and then searched through EBSCOhost, PubMed, and Google Scholar. Participants: Not applicable. Interventions: Not applicable. Main Outcome Measures: Not applicable. Results: One hundred and thirteen articles met the criteria. Of the articles, 55% were categorized as phase 1, 12% as phase 2, 24% as phase 3, 5% as phase 4, and 4% as phase 5. Conclusions: Most studies were categorized as phase 1, 2, or 3, which implies that this field is still in the early stages of development and research should focus on intervention development and dissemination. Archives of Physical Medicine and Rehabilitation 2013;94:2027-31 ª 2013 by the American Congress of Rehabilitation Medicine
Spinal cord injury (SCI) refers to a broad spectrum of damage to the spinal cord that results in partial or complete impairment of motor and/or sensory functions of the legs, arms, trunk, or multiple areas of the body.1 Between 236,000 and 327,000 individuals currently live with an SCI in the United States, with more than 12,000 new cases being reported each year.1 Automobile collisions are the leading cause of SCI and most commonly affect individuals from 15 to 35 years of age.1 For an average individual living with an SCI, medical costs range between $15,000 and $30,000 each year, which can add up to $500,000 to $3 million in a lifetime,1 depending on the severity of the injury. Many SCI patients suffer from complications Supported by the U.S. Department of Education, Office of Special Education (contract no. H325D100061). No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit on the authors or on any organization with which the authors are associated.
affecting their nervous, musculoskeletal, respiratory, gastrointestinal, and urogenital systems.2 People living with SCI are at a greater risk for secondary conditions, such as depression,3 obesity, osteoporosis, pressure ulcers, type II diabetes, cardiovascular disease, and urinary tract infections,4 many of which may be preventable with adequate care. It is well documented that physical activity (PA) lowers the risk of chronic diseases, such as type II diabetes, cardiovascular disease, and obesity, in able-bodied individuals.5 As research expands in the field of disability and exercise science, the benefits of PA are becoming clearer for special populations, such as individuals with SCI,6 who may experience a reduced onset of secondary conditions as a result of increased participation.7 For example, individuals with SCI experience changes in metabolism and body composition over time, which results in a decrease in lean muscle mass and bone density, as well as an increase in abdominal adiposity.8 Because of these increases in abdominal adiposity, incidence of
0003-9993/13/$36 - see front matter ª 2013 by the American Congress of Rehabilitation Medicine http://dx.doi.org/10.1016/j.apmr.2013.04.016
2028 type II diabetes, increased cholesterol, and decreased activity, individuals with an SCI are at a much higher risk for developing metabolic syndrome, which significantly increases the risk of mortality from cardiovascular disease.8-10 In fact, this population has a higher incidence of cardiovascular disease than the general population, and its onset is decades earlier.11 However, in addition to reducing the risk of chronic disease, regular PA can reduce muscle atrophy and bone density loss, reduce the occurrence of decubitus ulcers, and help maintain cardiorespiratory fitness and mobility, which increases an individual’s independence and quality of life.7,12 The U.S. Department of Health and Human Services recommends that adults complete 150 minutes per week of moderate intensity PA,5 although only 48% of the population are regularly active.13 This number is even lower for individuals with SCI who report the lowest levels of PA among people with a disability overall,2 and report 24% less total daily energy expenditure than able-bodied individuals. There are a variety of factors that influence the PA level of individuals with an SCI, including the level of severity of the injury, degree of mobility, and subsequent barriers to activity. Barriers may include issues with accessibility, high cost, pain, and psychological barriers, such as low motivation, perceived benefits of exercise, perceived ability, and reduced self-efficacy.14 The benefits of PA in this population are vast, yet many individuals face barriers and become sedentary,15 which is why it is important to understand where researchers can best focus their efforts to facilitate the adoption and maintenance of participation. In the expanding field of exercise science and disabilities studies there is a growing need to understand where most of the research is being conducted for individuals with an SCI, and where there is a need for further inquiry. By completing this process, investigators are better positioned to conduct research in areas that have been historically less reported on, with the ultimate goal of improving the health of individuals with SCI through PA participation. The behavioral epidemiology framework described by Sallis et al16 illustrates a systematic method of categorizing current health-related research (eg, PA, nutrition, smoking cessation) that can be used to analyze the PA literature related to individuals with SCI. The framework is descriptive in nature and presents information about the status of research in the field into 1 of 5 phases. Studies categorized into phase 1 are those linking PA or exercise to health outcomes. These studies include links between behavior and health and dose-response relations with health outcomes. Studies in phase 2 validate measures of PA or the methods for measuring PA and behavior. Phase 2 also includes studies that develop and test new forms of measurement of PA. Phase 3 research includes studies identifying factors that influence behavior, and studies testing theories of behavior. Research in phase 4 includes interventions that specifically target changing PA behavior, or determinants of PA behavior, and may include randomized controlled trials. Studies in phase 5 disseminate health promotion programs or policies, and translate research into practice.16 By examining the distribution of studies that have previously been completed, researchers can shift their focus
List of abbreviations: PA physical activity SCI spinal cord injury TPB theory of planned behavior
M.B. Nery et al to phases that may be underrepresented and warrant further investigation. The phases outlined in the framework are generally sequential, building on the previous stage. For example, phase 2 studies may test the validity of a measure of behavior (eg, accelerometers), whereas phase 3 studies explore the factors that influence that behavior (eg, barriers, self-efficacy). Findings from studies in phases 1 through 3 can be used to inform intervention development, which would be classified as phase 4. When results from an intervention study provide an efficacious evidence base, findings can be disseminated into the community (phase 5). The framework can also be used to improve earlier stage research. For example, findings from studies in phase 2 that focus on the validity of a form of measurement, such as pedometers, can be used to conduct further and more accurate research in phase 1. Therefore, the purpose is to use the behavioral epidemiology framework to systematically classify studies on SCI and PA into distinct phases to better understand the current state of research in this area. The 2 major research questions posed are the following: (1) What is the current status of PA research for people with SCI? (2) What phases of PA research need further inquiry?
Method A survey of the literature was conducted by searching EBSCOhost, PubMed, and Google Scholar, using the search terms spinal cord injury, physical activity, exercise, leisure, and health promotion. The search included qualitative and quantitative studies, as well as meta-analyses and reviews published between 2000 and 2012. Articles were included that assessed PA or health promotion for populations with SCI in relation to the 5 phases of the behavioral epidemiology framework. The following coding rules were used: (1) editorials without extensive references were not included; (2) if a study fell into multiple categories, it was coded into the highest category; (3) if the study focused primarily on the measurement of PA it was coded into phase 2; (4) studies with measurements of the determinants of PA were coded into phase 3; and (5) studies that pertained to dissemination of health promotion programs were coded as phase 5.16 The research team was trained on the Sallis et al16 framework prior to coding the studies. Training involved a presentation on the article, followed by discussions and practice coding with a sample of studies to increase coding reliability among the research team. For example, from the total number of articles identified, a sample of 20 studies was randomly selected to be independently coded for reliability between 2 researchers. If the phase an article was to be coded in was questioned, the issue was resolved through discussion to reach a consensus of the group. The coders achieved 90% reliability on the sample set, which exceeded the 80% reliability minimum. The research team then completed final coding of all the identified articles, and percentages of each phase were calculated.
Results In total, 113 articles were identified, of which 55% were categorized into phase 1 (nZ62), 12% into phase 2 (nZ13), 24% into phase 3 (nZ27), 5% into phase 4 (nZ6), and 4% into phase 5 (nZ5). Most research related to SCI and PA fell into phase 1, which includes studies linking PA to health outcomes. For example, increased PA participation was linked to psychosocial www.archives-pmr.org
Epidemiologic study on physical activity and SCI benefits, such as increased self-efficacy17 and quality of life.18-22 Furthermore, studies reported a relation between increased PA and improvements in cardiovascular,19,23-27 muscular,24,28-31 and respiratory systems,23,32,33 increased bone density and decreased bone loss,34-37 lower incidence of chronic disease,38 improved motor function,28 lower levels of depression,17,20,39 and reduced pain.19,20,40 Results from phase 2 indicated that the most commonly used tool to measure PA in individuals with an SCI was the accelerometer. Other tools included heart rate monitors,41 pedometers,42,43 and accelerometers and gyrometers.41,44,45 The Physical Activity Recall Assessment for Individuals with Spinal Cord Injuries46,47 was the most frequently tested assessment, along with the Leisure Time Physical Activity Questionnaire48 and the Physical Activity Scale for Individuals with a Physical Disability.49,50 Among the phase 3 articles, the most widely used theory was the theory of planned behavior (TPB).46,51,52 The TPB links attitudes about PA and behavior to predict an individual’s intention toward being physically active.53 Other theories used were the social cognitive theory54,55 and the transtheoretical model.56,57 Studies in phase 3 also examined determinants of behavior with most articles examining barriers and facilitators to participating in PA.14,51,58-63 Very few articles were categorized into phases 4 or 5, indicating a gap in research that evaluates interventions or translates research into practice. Of the studies in phase 4, all included faceto-face health promotion programs, often in rehabilitation center settings, that examined the effects of interventions on engagement in PA,46,64-66 self-efficacy,64,65,67 goal setting,65 coping self-efficacy,64 perceived independent living status,68 empowerment,65 leisure satisfaction,46,68 and quality of life.46 All of the studies in phase 4 concluded that their interventions improved aspects of PA behavior, such as motivation, confidence, PA intention, participation, and quality of life.46,64-68
Discussion The purpose of this study was to categorize the PA and SCI literature into specific phases by using the behavioral epidemiology framework to gain a better understanding of the current status of research in this field. Articles included were published between 2000 and 2012, and were from peer-reviewed journals. From the distribution of the articles, it is clear that PA and SCI research are in the early stages of inquiry, because the focus is predominantly on phase 1 studies, which are those that link health outcomes to PA for individuals with SCI. Phase 3 consisted of the next highest concentration of research, which were studies that explore factors that influence behavior. However, there is still a need for studies that test theoretical models of health behavior on the SCI population.69 It is also apparent that there is limited research examining the efficacy of health promotion programs (phases 4 and 5). Understanding the linkages between PA and health outcomes is important to developing research in the later phases of the framework. For example, research in phase 1 allows investigators to understand dose-response relations in regards to PA, and to increase our knowledge of the benefits and risks associated with PA in the SCI population. This knowledge can then be used to guide research on increasing PA behaviors and creating meaningful interventions. www.archives-pmr.org
2029 Results from the current systematic classification suggest that there is a lack of research in phase 2, despite the importance of such studies. For example, by improving and validating existing methods and measurements of PA and behavior, and creating and testing new forms of measurement, researchers will be able to improve the accuracy of research in phases 1 and 3. Increased research into phase 2 can also help investigators integrate the most effective methods of data collection and reporting into intervention research (phase 4 studies). Phase 3 had a relatively large number of studies (24%) that explored factors that influenced PA behavior in individuals with an SCI. Behavioral theory provides a framework for creating effective health promotion programs and interventions. For example, researchers can examine the causal relations between behavioral constructs and then develop interventions to increase PA behavior, because the frameworks typically involve enhancing skills (eg, goal setting and problem-solving to increase self-efficacy) or modifying environmental conditions (eg, overcoming barriers) necessary for behavior change. In this way, theories, such as the TPB and social cognitive theory, drive practice. Phase 4 and 5 studies focus on testing interventions and disseminating health promotion programs. Health promotion programs have been shown to improve overall physical health, such as cardiovascular, respiratory, metabolic, and muscular systems, which contribute to improved performance of activities of daily living and enhanced quality of life.29 These programs have also been effective in reducing the rate of occurrence of secondary conditions.70 However, there were very few articles classified into phases 4 and 5, suggesting that the area of PA and SCI is a relatively young field and still developing.69 The importance of research into these areas is critical, because individuals with SCI typically experience poorer health than the ablebodied population, as well as secondary conditions and early mortality that could be prevented with improved interventions.69 The phase 5 studies all discussed the dissemination of recreation-based community health promotion programs. The programs consisted of engaging the participants in physical and recreation activities and having participants attend interactive seminars or education programs, which focused on health and advocacy topics and goal attainment.45,71-73 Some of the goals of the health promotion programs were to teach people how to maintain their health, decrease the occurrence of secondary conditions, and improve quality of life.70,72 It is clear that individuals with SCI could benefit enormously from further research into the implementation and dissemination of PA-based health promotion programs.
Study limitations Our use of the behavioral epidemiology framework is not without limitations. First, our systematic classification only examined articles published between 2000 and 2012. Therefore, there may be relevant articles published before 2000 that were not included. Second, relevant articles may not have been included if they were not captured in the search engines used. Third, 3 of the articles that were selected included mixed samples of disabilities in their studies. For example, 2 studies74,75 involved participants who had experienced a stroke, and 1 study76 included participants who had cerebral palsy, myelomeningocele, or acquired brain injury. Although these studies demonstrated outcomes relevant to SCI populations, they were not solely intended for SCI populations. Finally, several of the
2030 studies that were identified in our initial search examined outcomes related to physical therapy, but only those that also investigated PA outcomes were included in our review.
Conclusions Our findings illustrate that the focus of PA research for individuals with an SCI has historically been on measuring health outcomes and determinants of health behavior. These results indicate that the field is still developing because of the low representation of studies in the higher phases (phases 4 and 5). Investigators may use findings to guide future research efforts, help fill in the gaps in the body of knowledge, and improve the quality of PA research for individuals with SCI. It is well documented that PA can improve the health of individuals with an SCI, but there are a lack of health promotion programs that aim to facilitate the adoption and maintenance of participation for the population. By building on findings from phases 1 through 3, investigators can develop and implement effective health promotion programs for individuals with SCI that aim to increase PA participation and improve health.
Keywords Epidemiology; Health promotion; Motor activity; Rehabilitation; Spinal cord injuries
Corresponding author Mara B. Nery, MS, 123 Women’s Building, Oregon State University, Corvallis, OR 97331. E-mail address: mara.nery@ oregonstate.edu.
References 1. NSCISC National Spinal Cord Injury Statistical Center. NSCISC. 2012. Available at: https://www.nscisc.uab.edu/. Accessed July 25, 2012. 2. Sekhon LH, Fehlings MG. Epidemiology, demographics, and pathophysiology of acute spinal cord injury. Spine (Phila Pa 1976) 2001; 26(24 Suppl):S2-12. 3. Craig A, Tran Y, Middleton J. Psychological morbidity and spinal cord injury: a systematic review. Spinal Cord 2009;47:108-14. 4. Hitzig SL, Tomack M, Campbell KA, et al. Secondary health complications in aging Canadian spinal cord injury sample. Am J Phys Med Rehabil 2008;87:545-55. 5. Healthy People Web site. 2012. Available at http://www. healthypeople.gov/2020/default.aspx. Accessed August 7, 2012. 6. Davies DS, McColl MA. Lifestyle risks for three disease outcomes in spinal cord injury. Clin Rehabil 2002;16:96-108. 7. Buchholz AC, Ginis KA, Bray SR, et al. Greater daily leisure time physical activity is associated with lower chronic disease risk in adults with spinal cord injury. Appl Physiol Nutr Metab 2009;34:640-7. 8. Bauman WA, Spungen AM. Carbohydrate and lipid metabolism in chronic spinal cord injury. J Spinal Cord Med 2001;24:266-77. 9. Kocina P. Body composition of spinal cord injured adults. Sports Med 1997;23:48-60. 10. Jones LM, Goulding A, Gerrard DF. DEXA: a practical and accurate tool to demonstrate total and regional bone loss lean tissue loss and fat mass gain in paraplegia. Spinal Cord 1998;36:637-40. 11. Yekutiel M, Brooks ME, Ohry A, Yarom J, Carel R. The prevalence of hypertension, ischemic heart disease, and diabetes in traumatic spinal cord injured patients and amputees. Paraplegia 1989;27:58-62.
M.B. Nery et al 12. Noreau L, Shephard RJ. Spinal cord injury, exercise and quality of life. Sports Med 1995;20:226-50. 13. Kruger JK, Kohl HW, Miles IJ. Prevalence of regular physical activity among adultsdUnited States, 2001 and 2005. JAMA 2008;299:30-2. 14. Vissers MB, Sluis T, Bergen M, Stam H, Bussman H. Barriers to and facilitators of everyday physical activity in persons with spinal cord injury after discharge from the rehabilitation centre. J Rehabil Med 2008;40:461-7. 15. Jacobs PL, Nash MS. Exercise recommendations for individuals with spinal cord injury. Sports Med 2004;34:727-51. 16. Sallis JF, Owen N, Fotheringham MJ. Behavioral epidemiology: a systematic framework to classify phases of research on health promotion and disease prevention. Ann Behav Med 2000;22:294-8. 17. Kennedy P, Taylor N, Hindson L. A pilot investigation of a psychosocial activity course for people with spinal cord injuries. Psychol Health Med 2006;11:91-9. 18. Anneken V, Hanssen-Doose A, Hirschfeld S, Scheuer T, Thietje R. Influence of physical exercise on quality of life in individuals with spinal cord injury. Spinal Cord 2010;48:393-9. 19. Ditor DS, Latimer AE, Martin Ginis KA, Arbour KP, McCartney N, Hicks AL. Maintenance of exercise participation in individuals with spinal cord injury: effects on quality of life, stress and pain. Spinal Cord 2003;41:446-50. 20. Hicks AL, Martin KA, Ditor DS, Latimer AE. Long-term exercise training in persons with spinal cord injury: effects on strength, arm ergometry performance and psychological well-being. Spinal Cord 2003;41:34. 21. Lannem AM, Sørensen M, Frøslie KF, Hjeltnes N. Incomplete spinal cord injury, exercise and life satisfaction. Spinal Cord 2009;47:295-300. 22. Miki Y, Kanayama C, Nakashima S, Yamasaki M. Health-related quality of life in active persons with spinal cord injury. Jpn J Phys Fitness Sports Med 2012;61:177-82. 23. Brurok B, Helgerud J, Karlsen T, Leivseth G, Hoff J. Effect of aerobic high-intensity hybrid training on stroke volume and peak oxygen consumption in men with spinal cord injury. Am J Phys Med Rehabil 2011;90:407-14. 24. Davis GM, Hamzaid NA, Fornusek C. Cardiorespiratory, metabolic, and biomechanical responses during functional electrical stimulation leg exercise: health and fitness benefits. Artif Organs 2008;32:625-9. 25. Maggioni MA, Ferratini M, Pezzano A, et al. Heart adaptations to long-term aerobic training in paraplegic subjects: an echocardiographic study. Spinal Cord 2012;50:538-42. 26. Phillips AA, Cote AT, Warburton DE. A systematic review of exercise as a therapeutic intervention to improve arterial function in persons living with spinal cord injury. Spinal Cord 2011;49:702-14. 27. Wheeler G, Andrews B, Lederer R. Functional electric stimulatione assisted rowing: increasing cardiovascular fitness through functional electric stimulation rowing training in persons with spinal cord injury. Arch Phys Med Rehabil 2002;83:1093-9. 28. Adams MM, Hicks AL. Comparison of the effects of body-weightsupported treadmill training and tilt-table standing on spasticity in individuals with chronic spinal cord injury. J Spinal Cord Med 2011; 34:488-94. 29. Batsiou S, Trikkos O, Dafnis P, Tofas T. Exercise and individuals with spinal cord injury. Inquiries in Sport & Physical Education 2008;6:1-11. 30. Johnston TE, Modlesky CM, Betz RR, Lauer RT. Muscle changes following cycling and/or electrical stimulation in pediatric spinal cord injury. Arch Phys Med Rehabil 2011;92:1937-43. 31. Roth EJ, Stenson KW, Powley S, et al. Expiratory muscle training in spinal cord injury: a randomized controlled trial. Arch Phys Med Rehabil 2010;91:857-61. 32. Moreno MA, Zamuner AR, Paris JV, Teodori RM, Barros RM. Effects of wheelchair sports on respiratory muscle strength and thoracic mobility of individuals with spinal cord injury. Am J Phys Med Rehabil 2012;91:470-7. 33. Nooijen CF, de Groot S, Postma K, et al. A more active lifestyle in persons with a recent spinal cord injury benefits physical fitness and health. Spinal Cord 2012;50:320-3.
www.archives-pmr.org
Epidemiologic study on physical activity and SCI 34. Chain A, Koury JC, Bezerra FF. Physical activity benefits bone density and bone-related hormones in adult men with cervical spinal cord injury. Eur J Appl Physiol 2012;112:3179-86. 35. Dolbow DR, Gorgey AS, Daniels JA, Adler RA, Moore JR, Gater DR. The effects of spinal cord injury and exercise on bone mass: a literature review. NeuroRehabilitation 2011;29:261-9. 36. Giangregorio LM, Hicks AL, Webber CE, et al. Body weight supported treadmill training in acute spinal cord injury: impact on muscle and bone. Spinal Cord 2005;43:649-57. 37. Lauer RT, Smith BT, Mulcahey MJ, Betz RR, Johnston TE. Effects of cycling and/or electrical stimulation on bone mineral density in children with spinal cord injury. Spinal Cord 2011;49:917-23. 38. Fernhall B, Heffernan K, Jae SY, Hedrick B. Health implications of physical activity in individuals with spinal cord injury: a literature review. J Health Hum Serv Adm 2008;30:468-502. 39. Tawashy AE, Eng JJ, Lin KH, Tang PF, Hung C. Physical activity is related to lower levels of pain, fatigue and depression in individuals with spinal-cord injury: a correlational study. Spinal Cord 2009;47:301-6. 40. Norrbrink C, Lindberg T, Wahman K, Bjerkefors A. Effects of an exercise programme on musculoskeletal and neuropathic pain after spinal cord injury-results from a seated double-poling ergometer study. Spinal Cord 2012;50:457-61. 41. Tanhoffer RA, Tanhoffer AI, Raymond J, Hills AP, Davis GM. Comparison of methods to assess energy expenditure and physical activity in people with spinal cord injury. J Spinal Cord Med 2012;35:35-45. 42. Hiremath SV, Ding D, Farringdon J, Cooper RA. Predicting energy expenditure of manual wheelchair users with spinal cord injury using a multisensor-based activity monitor. Arch Phys Med Rehabil 2012; 93:1937-43. 43. Ishikawa S, Stevens SL, Kang M, Morgan DW. Reliability of daily step activity monitoring in adults with incomplete spinal cord injury. J Rehabil Res Dev 2011;48:1187-94. 44. Oda H, Ikemoto S, Tsunoda N, et al. Preliminary study for evaluation of daily physical activity in persons with spinal cord injury with wristwatch type equipment for classification of human activities. Jpn J Clin Sports Med 2009;17:305-14. 45. Warms CA, Belza BL, Whitney JD, Mitchell PH, Stiens SA. Lifestyle physical activity for individuals with spinal cord injury: a pilot study. Am J Health Promot 2004;18:288-91. 46. Latimer AE, Ginis KA, Arbour KP. The efficacy of an implementation intention intervention for promoting physical activity among individuals with spinal cord injury: a randomized controlled trial. Rehabil Psychol 2006;51:273-80. 47. Martin Ginis KA, Latimer AE, Hicks AL, Craven BC. Development and evaluation of an activity measure for people with spinal cord injury. Med Sci Sports Exerc 2005;37:1099-111. 48. Martin Ginis KA, Phang SH, Latimer AE, Arbour-Nicitopoulos K. Reliability and validity tests of the leisure time physical activity questionnaire for people with spinal cord injury. Arch Phys Med Rehabil 2012;93:677-82. 49. de Groot S, van der Woude LH, Niezen A, Smit CA, Post MW. Evaluation of the physical activity scale for individuals with physical disabilities in people with spinal cord injury. Spinal Cord 2010;48:542-7. 50. van den Berg-Emons RJ, L’Ortye AA, Buffart LM, et al. Validation of the physical activity scale for individuals with physical disabilities. Arch Phys Med Rehabil 2011;92:923-8. 51. Arbour-Nicitopoulos K, Martin Ginis KA, Wilson PM. Examining the individual and perceived neighborhood associations of leisuretime physical activity in persons with spinal cord injury. Ann Behav Med 2010;39:192-7. 52. Sweet SN, Ginis KA, Latimer-Cheung AE. Examining physical activity trajectories for people with spinal cord injury. Health Psychol 2012;31:728-32. 53. Ajzen I. From intentions to actions: a theory of planned behavior. In: Kuhl J, Beckman J, editors. Action-control: from cognition to behavior. Heidelberg: Springer; 1985. p 11-39. 54. Bandura A. Social foundations of thought and action: a social cognitive theory. Englewood Cliffs: Prentice-Hall; 1986.
www.archives-pmr.org
2031 55. Ginis KA, Latimer AE, Arbour-Nicitopoulos K, Bassett RL, Wolfe DL, Hanna SE. Determinants of physical activity among people with spinal cord injury: a test of social cognitive theory. Ann Behav Med 2011;42:127-33. 56. Prochaska JO, Velicer WF. The transtheoretical model of health behavior change. Am J Health Promot 1977;12:38-48. 57. Kosma M, Ellis R, Bauer JJ. Longitudinal changes in psychosocial constructs and physical activity among adults with physical disabilities. Disabil Health J 2012;5:1-8. 58. Cowan RE, Nash MS, Anderson KD. Exercise participation barrier prevalence and association with exercise participation status in individuals with spinal cord injury. Spinal Cord 2012;51:27-32. 59. Kehn M, Kroll T. Staying physically active after spinal cord injury: a qualitative exploration of barriers and facilitators to exercise participation. BMC Public Health 2009;9:1-11. 60. Levins SM, Redenbach DM, Dyck I. Individual and societal influences on participation in physical activity following spinal cord injury: a qualitative study. Phys Ther 2004;84:496-509. 61. Phang SH, Martin Ginis KA, Routhier F, Lemay V. The role of selfefficacy in the wheelchair skills-physical activity relationship among manual wheelchair users with spinal cord injury. Disabil Rehabil 2012;34:625-32. 62. Roberton T, Bucks RS, Skinner TC, Allison GT, Dunlop SA. Barriers to physical activity in individuals with spinal cord injury: a Western Australian study. Australian J Rehabil Couns 2011;17:74-88. 63. Wu SK, Williams T. Factors influencing sport participation among athletes with spinal cord injury. Med Sci Sports Exerc 2001;33:177-82. 64. Arbour-Nicitopoulos K, Ginis KA, Latimer AE. Planning, leisuretime physical activity, and coping self-efficacy in persons with spinal cord injury: a randomized controlled trial. Arch Phys Med Rehabil 2009;90:2003-11. 65. Block P, Vanner EA, Keys CB, Rimmer JH, Skeels SE. Project Shake-It-Up: using health promotion, capacity building and a disability studies framework to increase self efficacy. Disabil Rehabil 2010;32:741-54. 66. van Langeveld SA, Post MW, van Asbeck FW, et al. Contents of physical therapy, occupational therapy, and sports therapy sessions for patients with a spinal cord injury in three Dutch rehabilitation centres. Disabil Rehabil 2011;33:412-22. 67. Piatt J, Compton DM, Sara Wells M, Bennett JL. Interventions that effect active living among individuals with spinal cord injury. Ther Recreat J 2012;46:9-25. 68. Daniel A, Manigandan C. Efficacy of leisure intervention groups and their impact on quality of life among people with spinal cord injury. Int J Rehabil Res 2005;28:43-8. 69. Drum CE, Peterson JJ, Culley C, et al. Guidelines and criteria for the implementations of community-based health promotion programs for individuals with disabilities. Am J Health Promot 2009;24:93-101. 70. Sable J, Craig P, Lee D. Promoting health and wellness: a researchbased case report. Ther Recreat J 2000;34:348-61. 71. Block P, Skeels SE, Keys CB, Rimmer JH. Shake-It-Up: health promotion and capacity building for people with spinal cord injuries and related neurological disabilities. Disabil Rehabil 2005;27:185-90. 72. Sable J, Bocarro J. Transitioning back to health: participants’ perspective of project PATH. Ther Recreat J 2004;38:206-24. 73. Lagerstro¨m A, Levi R. Health promotion in spinal cord rehabilitation. Phys Ther Rev 2009;14:2-2. 74. Manns PJ, Dunstan DW, Owen N, Healy GN. Addressing the nonexercise part of the activity continuum: a more realistic and achievable approach to activity programming for adults with mobility disability. Phys Ther 2012;92:614-25. 75. Zehr EP. Evidence-based risk assessment and recommendations for physical activity clearance: stroke and spinal cord injury. Appl Physiol Nutr Metab 2011;36(Suppl 1):S214-31. 76. van den Berg-Emmons RJ, Bussman JB, Haisma JA, et al. A prospective study on physical activity levels after spinal cord injury during inpatient rehabilitation and the year after discharge. Arch Phys Med Rehabil 2008;11:2094-101.