Translating the international scientific spinal cord injury exercise guidelines into community and clinical practice guidelines: a Canadian evidence-informed resource

Theory- and evidence-based best practices for physical activity counseling for adults with spinal cord injury

OBJECTIVES

This project used a systematic and integrated knowledge translation (IKT) approach to co-create theory- and evidence-based best practices for physical activity counseling for adults with spinal cord injury (SCI).

METHODS

Guided by the IKT Guiding Principles, we meaningfully engaged research users throughout this project. A systematic approach was used. An international, multidisciplinary expert panel (n = 15), including SCI researchers, counselors, and people with SCI, was established. Panel members participated in two online meetings to discuss the best practices by drawing upon new knowledge regarding counselor-client interactions, current evidence, and members' own experiences. We used concepts from key literature on SCI-specific physical activity counseling and health behavior change theories. An external group of experts completed an online survey to test the clarity, usability and appropriateness of the best practices.

RESULTS

The best practices document includes an introduction, the best practices, things to keep in mind, and a glossary. Best practices focused on how to deliver a conversation and what to discuss during a conversation. Examples include: build rapport, use a client-centred approach following the spirit of motivational interviewing, understand your client's physical activity barriers, and share the SCI physical activity guidelines. External experts (n = 25) rated the best practices on average as clear, useful, and appropriate.

CONCLUSION

We present the first systematically co-developed theory- and evidence-based best practices for SCI physical activity counseling. The implementation of the best practices will be supported by developing training modules. These new best practices can contribute to optimizing SCI physical activity counseling services across settings.

2024 Wheelchair Compendium of Physical Activities: An update of activity codes and energy expenditure values

PURPOSE

This paper presents an update of the 2011 Wheelchair Compendium of Physical Activities designed for wheelchair users and is referred to as the 2024 Wheelchair Compendium. The Wheelchair Compendium aims to curate existing knowledge of the energy expenditure for wheelchair physical activities (PAs).

METHODS

A systematic review of the published energy expenditure of PA for wheelchair users was completed between 2011 and May 2023. We added these data to the 2011 Wheelchair Compendium data that was compiled previously in a systematic review through 2011.

RESULTS

A total of 47 studies were included, and 124 different wheelchair PA reported energy expenditure values ranging from 0.8 metabolic equivalents for wheelchair users (filing papers, light effort) to 11.8 metabolic equivalents for wheelchair users (Nordic sit skiing).

CONCLUSION

In introducing the updated 2024 Wheelchair Compendium, we hope to bridge the resource gap and challenge the prevailing narratives that inadvertently exclude wheelchair users from physical fitness and health PAs.

Exercise prescription for persons with spinal cord injury: a review of physiological considerations and evidence-based guidelines

Persons with spinal cord injury (SCI) experience gains in fitness, physical and mental health from regular participation in exercise and physical activity. Due to changes in physiological function of the cardiovascular, nervous, and muscular systems, general population physical activity guidelines and traditional exercise prescription methods are not appropriate for the SCI population. Exercise guidelines specific to persons with SCI recommend progressive training beginning at 20 min of moderate to vigorous intensity aerobic exercise twice per week transitioning to 30 min three times per week, with strength training of the major muscle groups two times per week. These population-specific guidelines were designed considering the substantial barriers to physical activity for persons with SCI and can be used to frame an individual exercise prescription. Rating of perceived exertion (i.e., perceptually regulated exercise) is a practical way to indicate moderate to vigorous intensity exercise in community settings. Adapted exercise modes include arm cycle ergometry, hybrid arm-leg cycling, and recumbent elliptical equipment. Body weight-supported treadmill training and other rehabilitation modalities may improve some aspects of health and fitness for people with SCI if completed at sufficient intensity. Disability-specific community programs offer beneficial opportunities for persons with SCI to experience quality exercise opportunities but are not universally available.

Dissonance in views between healthcare professionals and adults with a spinal cord injury with their understanding and interpretation of exercise intensity for exercise prescription

Objectives

To evaluate the difference between healthcare professionals (HCPs) and adults with spinal cord injury (SCI) in Asia regarding knowledge and interpretation of 'exercise intensity' for aerobic exercise prescription.

Methods and study design

A survey was distributed to practising HCP and adults with SCI. It was completed in participants' local language on topics related to the importance of exercise frequency, intensity, time and type; methods for monitoring and terms related to exercise intensity prescription. χ² analysis was used to detect differences in HCP or those with SCI.

Results

121 HCP and 107 adults with an SCI ≥1 years (C1-L4) participated. Responses revealed 61% of all HCP ranked 'intensity' being most important whereas only 38% respondents from the SCI group ranked it as high importance (p=0.008). For those with SCI, 'frequency' was most important (61%) which was significantly higher than the 45% selected by HCPs (p=0.030). Of the 228 respondents on average only 34% believed that the terms, 'moderate' and 'vigorous' provided enough information for aerobic exercise intensity prescription. HCP most often used HR methods compared with the SCI group (90% vs 54%; p<0.01). Both groups frequently used the subjective measures of exercise intensity, for example, Ratings of Perceived Exertion (8%3 vs 76% for HCP and SCI), HCP also frequently used speed (81%) and SCI also frequently relied on 'the affect' or feelings while exercising (69%).

Conclusions

These differences must be considered when developing clinical-practice exercise guidelines and health referral educational pathways for adults with SCI in Asia.

Cultural validation and language translation of the scientific SCI exercise guidelines for use in Indonesia, Japan, Korea, and Thailand

CONTEXT

Indonesia, Japan, Korea, Thailand.

OBJECTIVE

To culturally validate and translate the Scientific Exercise Guidelines for Adults with Spinal Cord Injury (SEG-SCI) for use in four Asian countries.

DESIGN

Systematic Review.

PARTICIPANTS

N/A.

METHODS

A systematic review was conducted to identify all published English- and local-language studies conducted in Indonesia, Japan, Korea, and Thailand, testing the effects of exercise training interventions on fitness and cardiometabolic health in adults with acute or chronic SCI. Protocols and results from high-quality controlled studies were compared with the SEG-SCI. Forward and backward translation processes were used to translate the guidelines into Bahasa Indonesian, Japanese, Korean and Thai languages.

RESULTS

Fifteen studies met the review criteria. At least one study from each country implemented exercise prescriptions that met or exceeded the SEG-SCI. Two were controlled studies. In those two studies, relative to control conditions, participants in exercise conditions achieved significant improvements in fitness or cardiometabolic health outcomes only when the exercise intervention protocol met or exceeded the SEG-SCI. During the language translation processes, end-users confirmed that SEG-SCI language and terminology were clear.

CONCLUSION

Clinical researchers in Indonesia, Japan, Korea and Thailand have implemented exercise protocols that meet or exceed the SCI-SEG. Results of high-quality studies align with the SEG-SCI recommendations. Based on this evidence, we recommend that the SEG-SCI be adopted in these countries. The cultural validation and translation of the SEG-SCI is an important step towards establishing consistent SCI exercise prescriptions in research, clinical and community settings around the world.

mHealth Physical Activity Intervention for Individuals With Spinal Cord Injury: Planning and Development Processes

Background

Interventions to support physical activity participation among individuals with spinal cord injury (SCI) are required given this population’s low levels of physical activity and extensive barriers to quality physical activity experiences.

Objective

This study aimed to develop a mobile health intervention, called SCI Step Together, to improve the quantity and quality of physical activity among individuals with SCI who walk.

Methods

Our overarching methodological framework was the Person-Based approach. This included the following 4 steps: conduct primary and secondary research (step 1); design intervention objectives and features (step 2a); conduct behavioral analysis and theory (step 2b); create a logic model (step 3); and complete the SCI Step Together program content and integrated knowledge translation (IKT; step 4), which occurred throughout development. The partnership approach was informed by the SCI IKT Guiding Principles. Three end users pilot-tested the app and participated in the interviews.

Results

Step 1 identified issues to be addressed when designing intervention objectives and features (step 2a) and features were mapped onto the Behavior Change Wheel (step 2b) to determine the behavior change techniques (eg, action planning) to be included in the app. The logic model linked the mechanisms of action to self-determination theory (steps 2/3). Interviews with end users generated recommendations for the technology (eg, comparing physical activity levels with guidelines), trial (eg, emailing participants’ worksheets), and intervention content (eg, removing graded tasks; step 4).

Conclusions

Using the SCI IKT Guiding Principles to guide partner engagement and involvement ensured that design partners had shared decision-making power in intervention development. Equal decision-making power maximizes the meaningfulness of the app for end users. Future research will include testing the acceptability, feasibility, and engagement of the program. Partners will be involved throughout the research process.

Trial Registration

ClinicalTrials.gov: NCT05063617; https://clinicaltrials.gov/ct2/show/NCT05063617

Rethinking aerobic exercise intensity prescription in adults with spinal cord injury: time to end the use of "moderate to vigorous" intensity?

STUDY DESIGN

Cohort study.

OBJECTIVES

To investigate and critique different methods for aerobic exercise intensity prescription in adults with spinal cord injury (SCI).

SETTING

University laboratory in Loughborough, UK.

METHODS

Trained athletes were split into those with paraplegia (PARA; n = 47), tetraplegia (TETRA; n = 20) or alternate health condition (NON-SCI; n = 67). Participants completed a submaximal step test with 3 min stages, followed by graded exercise test to exhaustion. Handcycling, arm crank ergometry or wheelchair propulsion were performed depending on the sport of the participant. Oxygen uptake (V̇O₂), heart rate (HR), blood lactate concentration ([BLa]) and ratings of perceived exertion (RPE) on Borg's RPE scale were measured throughout. Lactate thresholds were identified according to log-V̇O₂ plotted against log-[BLa] (LT₁) and 1.5 mmol L^-1 greater than LT₁ (LT₂). These were used to demarcate moderate (<LT₁), heavy (>LT₁, < LT₂) and severe (>LT₂) exercise intensity domains.

RESULTS

Associations between percentage of peak V̇O₂ (%V̇O_2peak) and HR (%HR_peak) with RPE differed between PARA and TETRA. At LT₁ and LT₂, %V̇O_2peak and %HR_peak were significantly greater in TETRA compared to PARA and NON-SCI (P < 0.05). The variation in %V̇O_2peak and %HR_peak at lactate thresholds resulted in large variability in the domain distribution at fixed %V̇O_2peak and %HR_peak.

CONCLUSIONS

Fixed %V̇O_2peak and %HR_peak should not be used for aerobic exercise intensity prescription in adults with SCI as the method does not lead to uniform exercise intensity domain distribution.

Facilitators and barriers to clinical practice guideline-consistent supportive care at pediatric oncology institutions: a Children's Oncology Group study

Background

Clinical practice guideline (CPG)-consistent care improves patient outcomes, but CPG implementation is poor. Little is known about CPG implementation in pediatric oncology. This study aimed to understand supportive care CPG implementation facilitators and barriers at pediatric oncology National Cancer Institute (NCI) Community Oncology Research Program (NCORP) institutions.

Methods

Healthcare professionals at 26 pediatric, Children's Oncology Group-member, NCORP institutions were invited to participate in face-to-face focus groups. Serial focus groups were held until saturation of ideas was reached. Supportive care CPG implementation facilitators and barriers were solicited using nominal group technique (NGT), and implementation of specific supportive care CPG recommendations was discussed. Notes from each focus group were analyzed using a directed content analysis. The top five themes arising from an analysis of NGT items were identified, first from each focus group and then across all focus groups.

Results

Saturation of ideas was reached after seven focus groups involving 35 participants from 18 institutions. The top five facilitators of CPG implementation identified across all focus groups were organizational factors including charging teams with CPG implementation, individual factors including willingness to standardize care, user needs and values including mentorship, system factors including implementation structure, and implementation strategies including a basis in science. The top five barriers of CPG implementation identified were organizational factors including tolerance for inconsistencies, individual factors including lack of trust, system factors including administrative hurdles, user needs and values including lack of inclusivity, and professional including knowledge gaps.

Conclusions

Healthcare professionals at pediatric NCORP institutions believe that organizational factors are the most important determinants of supportive care CPG implementation. They believe that CPG-consistent supportive care is most likely to be delivered in organizations that prioritize evidence-based care, provide structure and resources to implement CPGs, and eliminate implementation barriers.

Trial registration

ClinicalTrials.gov Identifier: NCT02847130. Date of registration: July 28, 2016.

Supplementary Information

The online version contains supplementary material available at 10.1186/s43058-021-00200-2.

Implementation of the spinal cord injury exercise guidelines in the hospital and community settings: Protocol for a type II hybrid trial

STUDY DESIGN

Type II hybrid effectiveness-implementation trial protocol.

OBJECTIVES

To (1) evaluate the implementation of coordinated physical activity (PA) coaching delivered by physiotherapists and spinal cord injury (SCI) peers during the transition from in-hospital care to living in a community (implementation objective) and (2) assess the effect of coaching on PA behaviour and psychosocial predictors among people with SCI (effectiveness objective).

SETTING

Rehabilitation hospital and home/community settings in British Columbia, Canada.

METHODS

Implementation objective: PA coaches (physiotherapists and SCI peers) receive an implementation intervention including training, monitoring, feedback, and champion support. A Theoretical Domains Framework-based questionnaire is collected at baseline, post-training, 2, and 6 months follow-up and semi-structured interviews conducted at 6 months. Effectiveness objective: Using a quasi-experimental design, 55 adults with SCI are allocated to intervention (PA coaching, n = 30) or control (usual care, n = 25) groups. Participants in the intervention group are referred by physiotherapists to receive 11 SCI peer-delivered PA coaching sessions in the community. Control participants received usual care. Questionnaires assessing PA behaviour and psychosocial predictors are administered at baseline, 2-months, 6-months, and 1-year. Semi-structured interviews are conducted to assess intervention satisfaction at 6 months. Analyses include one-way (implementation objective) and two-way (effectiveness objective) repeated measures ANCOVAs for questionnaire-reported outcomes and thematic content analysis for interview data. Data are summarised using the reach effectiveness adoption implementation maintenance (RE-AIM) framework.

ETHICS AND DISSEMINATION

The University of British Columbia Clinical Research Ethics Board approved the protocol (#H19-02694), clinicaltrials.gov registration NCT04493606. Documentation of the adoption process will inform implementation in future sites.

Effects of a Tailored Physical Activity Intervention on Cardiovascular Structure and Function in Individuals With Spinal Cord Injury

Background

Spinal cord injury (SCI) leads to a loss of descending motor and sympathetic control below the level of injury (LOI), which ultimately results in chronically altered cardiovascular function and remodeling. While supervised, laboratory-based exercise training can generate cardiovascular adaptations in people with SCI, it is unknown whether behavioral community-based interventions effectively generate such adaptations for individuals with SCI.

Objective

Examine the effects of a tailored behavioral physical activity (PA) intervention on cardiac and vascular structure and function in individuals with SCI.

Methods

In this randomized controlled trial, 32 participants with SCI (18-65 years, SCI >1 year) were assigned to PA (8-week behavioral intervention) or control (CON) groups. At baseline and postintervention, measures of resting left ventricular (LV) structure and function, carotid intima-media thickness and pulse-wave velocity were assessed with ultrasound and tonometry.

Results

Twenty-eight participants completed the study (n = 14/group). Across the full study cohort there were no significant changes in indices of LV or vascular structure and function, despite notable improvements in peak power and oxygen uptake in the PA group. However, in a subanalysis for LOI, individuals in the PA group with LOIs below T6 had evidence of altered LV geometry (ie, increased LV internal diameter, reduced sphericity index and relative wall thickness; group × time P < 0.05 for all), which was not seen in individuals with higher LOIs at or above T6.

Conclusion

An 8-week behavioral PA intervention appears to promote adaptations in cardiac geometry more readily in individuals with lower level SCI than those with higher-level SCI.

A pragmatic randomized controlled trial testing the effects of the international scientific SCI exercise guidelines on SCI chronic pain: protocol for the EPIC-SCI trial

STUDY DESIGN

Protocol for a pragmatic randomized controlled trial (the Exercise guideline Promotion and Implementation in Chronic SCI [EPIC-SCI] Trial).

PRIMARY OBJECTIVES

To test if home-/community-based exercise, prescribed according to the international SCI exercise guidelines, significantly reduces chronic bodily pain in adults with SCI.

SECONDARY OBJECTIVES

To investigate: (1) the effects of exercise on musculoskeletal and neuropathic chronic pain; (2) if reduced inflammation and increased descending inhibitory control are viable pathways by which exercise reduces pain; (3) the effects of chronic pain reductions on subjective well-being; and (4) efficiency of a home-/community-based exercise intervention.

SETTING

Exercise in home-/community-based settings; assessments in university-based laboratories in British Columbia, Canada.

METHOD

Eighty-four adults with chronic SCI, reporting chronic musculoskeletal or neuropathic pain, and not meeting the current SCI exercise guidelines, will be recruited and randomized to a 6-month Exercise or Wait-List Control condition. Exercise will occur in home/community settings and will be supported through behavioral counseling. All measures will be taken at baseline, 3-months and 6-months. Analyses will consist of linear mixed effect models, multiple regression analyses and a cost-utility analysis. The economic evaluation will examine the incremental costs and health benefits generated by the intervention compared with usual care.

ETHICS AND DISSEMINATION

The University of British Columbia Clinical Research Ethics Board approved the protocol (#H19-01650). Using an integrated knowledge translation approach, stakeholders will be engaged throughout the trial and will co-create and disseminate evidence-based recommendations and messages regarding the use of exercise to manage SCI chronic pain.

From guidelines to practice: development and implementation of disability-specific physical activity guidelines

Purpose: Among people with physical disabilities, one of the most frequently-cited barriers to physical activity participation is a lack of basic information on what to do. Likewise, rehabilitation professionals often cite a lack of knowledge about what to recommend or prescribe, as their primary reason for not promoting physical activity to clients with disabilities. The development and implementation of disability-specific physical activity guidelines are important steps toward addressing informational barriers. This paper describes the reasoning behind disability-specific physical activity guidelines, the gold-standard process used to develop disability-specific guidelines for people with spinal cord injury and multiple sclerosis, and the "who, what, and how" of behavioural interventions and messaging to support people with disabilities in achieving physical activity guidelines.Materials and Methods: Not Applicable.Results: Not Applicable.Conclusions: The needs, values and preferences of people with disabilities must be taken into consideration when undertaking a disability-specific guideline development process. Guidelines can play an important role in physical activity promotion, but behavioural and other interventions are required to address the myriad physical activity barriers faced by people with disabilities.Implications for RehabilitationPeople with and without disabilities can achieve significant fitness and health benefits from activity well below the WHO's 150 minutes/week guideline.Disability-specific physical activity guidelines can alleviate informational barriers for people who want to get active and rehabilitation professionals who want to promote physical activity.Behavioural and other interventions are needed to support people's efforts to achieve physical activity guidelines.A physiotherapist-delivered intervention has shown promise for increasing physical activity in adults with a physical disability.