Development and evaluation of an activity measure for people with spinal cord injury

Socio-ecological Barriers to Leisure Time Physical Activity in Spanish Wheelchair Users With Spinal Cord Injury: Associations With Sociodemographic Characteristics and Functional Independence

OBJECTIVE

(1) To assess prevalence and severity of socio-ecological barriers to leisure time physical activity (LTPA) in a sample of adults with spinal cord injury (SCI); (2) to examine the association of these barriers with sociodemographic characteristics and functional independence (FI); and (3) to explore which socio-ecological levels of barriers might be associated with LTPA.

DESIGN

Cross-sectional study.

SETTING

Neurorehabilitation Hospital specialized in SCI.

PARTICIPANTS

207 wheelchair users with SCI living in the community who attended a comprehensive check-up (22.7% women, 47.5±10.7 mean age; N=207).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The short version of the Barriers to Physical Activity Questionnaire for People with Mobility Impairments was used to measure socio-ecological barriers to LTPA. The Spinal Cord Independence Measure III was used to measure FI. The Physical Activity Recall Assessment for People with SCI was used to quantify LTPA. Several multiple linear regression models were computed to examine the associations between socio-ecological barriers and sociodemographic factors, LTPA and FI.

RESULTS

A high prevalence of barriers to LTPA was found. Seven of these barriers (2 intrapersonal, 3 organizational, and 2 community) were present for >60% of the participants. Intrapersonal and organizational barriers had a higher effect on participants with lower FI and women. Interpersonal barriers were higher for older participants and with lower FI, while community barriers were higher for unemployed participants. Finally, intrapersonal and interpersonal barriers were negatively associated with LTPA, and FI revealed as a moderator of the intrapersonal barriers-LTPA relation.

CONCLUSIONS

Given their high prevalence and their association with LTPA, the development of interventions targeting socio-ecological barriers to LTPA in people with SCI becomes crucial. The associations of these barriers with FI and sociodemographic characteristics should also be considered for these interventions to be as specific and effective as possible.

Leisure time physical activity in middle-aged and older adults aging with long-term spinal cord injury: Changes over six years

BACKGROUND

Regular leisure time physical activity (LTPA) has beneficial health effects in people with spinal cord injury (SCI). Yet, participation in LTPA is low, and little is known about changes many years after injury.

OBJECTIVES

To determine changes in LTPA in middle-aged and older adults with long-term SCI over six years, investigate associations with gender, age, injury characteristics and changes in secondary health conditions and activity limitations, and investigate factors related to being physically active or sedentary.

METHODS

Part of the Swedish Aging with Spinal Cord Injury Study (SASCIS). LTPA was assessed twice over a six-year period with the Physical Activity Recall Assessment for people with Spinal Cord Injury (n = 75; 32% women, mean age 67 years, mean time since injury 31 years, injury levels C1-L3, AIS A-D). Changes were assessed with paired t-tests, McNemar test and Wilcoxon signed-rank test, associations with multivariable regression and group comparisons with Mann-Whitney U test and Chi Square test.

RESULTS

On group level participation in LTPA did not change, but the variability was substantial on individual level. There were no significant associations between changes in LTPA and the investigated variables. Among sedentary participants, higher level and severity of injury were overrepresented and the activity limitations were greater.

CONCLUSIONS

Our findings indicate stability in LTPA over time, but with a large individual variation. In many participants LTPA was insufficient to reach positive health effects. Promoting participation in LTPA is therefore an important part of the long-term management of middle-aged and older adults aging with long-term SCI.

Psychosocial Outcomes Associated With Types and Intensities of Physical Activity in People With Spinal Cord Injury: The Mediating Role of Self-Efficacy and Functionality

BACKGROUND

Low rates of participation and quality of life (QoL) and high rates of psychological distress are common in spinal cord injury (SCI) population. Research has supported the mediating role of self-efficacy and functionality in improving psychosocial outcomes. Furthermore, evidence supports the impact of physical activity (PA) on psychosocial variables, but little is known about the types and intensities of PA. The objective of this study was to determine whether functionality and/or general self-efficacy (GSE) mediate the relationships between the various types of PA: (1) lifestyle and (2) leisure-time physical activity (LTPA); and various intensities of PA: (1) mild, (2) moderate, and (3) heavy PA with participation, psychological distress, and perception of QoL.

METHODS

The Physical Activity Recall Assessment for SCI, and measures of functionality, GSE, participation, psychological distress, and perception of QoL were administered to 159 participants. Path analysis was performed using Jeffrey's Amazing Statistics Program.

RESULTS

GSE significantly mediated, and functionality partially significantly mediated, the relationship between LTPA and psychosocial outcomes. GSE and functionality did not mediate the relationship between lifestyle activity and psychosocial outcomes.

CONCLUSIONS

It is recommended that people with SCI perform LTPA on a regular basis to achieve psychosocial benefits. These programs should be accompanied by strategies to improve GSE.

Multidimensionality of leisure-time physical activity behaviour in adults with spinal cord injury: implications for measurement

The Physical Activity Recall Assessment for People with SCI (PARA-SCI) has demonstrated the best test-retest reliability and validity of self-report measures of leisure-time physical activity (LTPA) for adults with SCI. However, the absence of internal consistency reliability data has been raised as a concern. Internal consistency is relevant only for unidimensional measures. In other populations, LTPA is known to be a multidimensional construct, evaluated with multidimensional measures. We tested for unidimensionality through secondary analysis of PARA-SCI data (n = 703). Cronbach's α was 0.227. Principal components analysis showed two components/dimensions ('Moderate and Heavy Intensity LTPA' and 'Mild Intensity LTPA') explained 73% of the variance. Binary logic crosstabulation produced no discernible patterns of behavioural interrelatedness across LTPA intensities. Together, these data demonstrate the multidimensionality of LTPA and the PARA-SCI is not unidimensional. Internal consistency should not be a criterion for evaluating LTPA questionnaires for use in studies of people with SCI.

Cross-Cultural Adaptation and Validation of the Arabic Version of the Physical Activity Scale for Individuals with Physical Disabilities in Saudi Arabia (PASIPD-AR)

This study aimed to cross-culturally adapt and validate the Arabic version of the Physical Activity Scale for Individuals with Physical Disabilities (PASIPD) with Saudi Arabian participants. The study encompassed four distinct stages: (i) translation and subsequent back-translation; (ii) a preliminary assessment aimed at evaluating the quality of the translated scale; (iii) an assessment of the reliability of the measures employed; and (iv) a comprehensive examination of the validity of the measures. A sample of Saudi Arabian participants with physical disabilities (N = 206) took part, ranging in age from 18 to 70 years old, with an average age of 39.56 years and a standard deviation of 12.16. The findings obtained from the reliability tests indicated a notable level of internal consistency and stability. Experts and confirmatory factor analysis were employed to establish the face, content, and construct validity. The findings of the assessment of the Arabic version of PASIPD demonstrated a satisfactory degree of reliability and validity, rendering it suitable for implementation within the Saudi Arabian setting.

Exercise and aerobic capacity in individuals with spinal cord injury: A systematic review with meta-analysis and meta-regression

BACKGROUND

A low level of cardiorespiratory fitness [CRF; defined as peak oxygen uptake ([Formula: see text]O2peak) or peak power output (PPO)] is a widely reported consequence of spinal cord injury (SCI) and a major risk factor associated with chronic disease. However, CRF can be modified by exercise. This systematic review with meta-analysis and meta-regression aimed to assess whether certain SCI characteristics and/or specific exercise considerations are moderators of changes in CRF.

METHODS AND FINDINGS

Databases (MEDLINE, EMBASE, CENTRAL, and Web of Science) were searched from inception to March 2023. A primary meta-analysis was conducted including randomised controlled trials (RCTs; exercise interventions lasting >2 weeks relative to control groups). A secondary meta-analysis pooled independent exercise interventions >2 weeks from longitudinal pre-post and RCT studies to explore whether subgroup differences in injury characteristics and/or exercise intervention parameters explained CRF changes. Further analyses included cohort, cross-sectional, and observational study designs. Outcome measures of interest were absolute (A[Formula: see text]O2peak) or relative [Formula: see text]O2peak (R[Formula: see text]O2peak), and/or PPO. Bias/quality was assessed via The Cochrane Risk of Bias 2 and the National Institute of Health Quality Assessment Tools. Certainty of the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Random effects models were used in all meta-analyses and meta-regressions. Of 21,020 identified records, 120 studies comprising 29 RCTs, 67 pre-post studies, 11 cohort, 7 cross-sectional, and 6 observational studies were included. The primary meta-analysis revealed significant improvements in A[Formula: see text]O2peak [0.16 (0.07, 0.25) L/min], R[Formula: see text]O2peak [2.9 (1.8, 3.9) mL/kg/min], and PPO [9 (5, 14) W] with exercise, relative to controls (p < 0.001). Ninety-six studies (117 independent exercise interventions comprising 1,331 adults with SCI) were included in the secondary, pooled meta-analysis which demonstrated significant increases in A[Formula: see text]O2peak [0.22 (0.17, 0.26) L/min], R[Formula: see text]O2peak [2.8 (2.2, 3.3) mL/kg/min], and PPO [11 (9, 13) W] (p < 0.001) following exercise interventions. There were subgroup differences for R[Formula: see text]O2peak based on exercise modality (p = 0.002) and intervention length (p = 0.01), but there were no differences for A[Formula: see text]O2peak. There were subgroup differences (p ≤ 0.018) for PPO based on time since injury, neurological level of injury, exercise modality, and frequency. The meta-regression found that studies with a higher mean age of participants were associated with smaller changes in A[Formula: see text]O2peak and R[Formula: see text]O2peak (p < 0.10). GRADE indicated a moderate level of certainty in the estimated effect for R[Formula: see text]O2peak, but low levels for A[Formula: see text]O2peak and PPO. This review may be limited by the small number of RCTs, which prevented a subgroup analysis within this specific study design.

CONCLUSIONS

Our primary meta-analysis confirms that performing exercise >2 weeks results in significant improvements to A[Formula: see text]O2peak, R[Formula: see text]O2peak, and PPO in individuals with SCI. The pooled meta-analysis subgroup comparisons identified that exercise interventions lasting up to 12 weeks yield the greatest change in R[Formula: see text]O2peak. Upper-body aerobic exercise and resistance training also appear the most effective at improving R[Formula: see text]O2peak and PPO. Furthermore, acutely injured, individuals with paraplegia, exercising for ≥3 sessions/week will likely experience the greatest change in PPO. Ageing seemingly diminishes the adaptive CRF responses to exercise training in individuals with SCI.

REGISTRATION

PROSPERO: CRD42018104342.

Are Malaysians Exercising? A Psychometric Analysis of Their Physical Activity Habits, Physical Literacy and Exercise Participation Rates among Adults with and without Disability

BACKGROUND

Physical activity levels of adults worldwide have reported a rising trend in sedentarism. This study's main objective is to analyze and understand the current tendency in this field and in physical literacy among Malaysian adults in order to improve physical performance.

METHODS

The sample from which the data were collected corresponded to 352 Malaysian participants (N = 176 non-disabled, N = 176 physical disability) using The Physical Activity Scale for Individuals with Physical Disabilities questionnaire.

RESULTS

Four factors were extracted, consisting of leisure activities, home maintenance, household chores, and career. The group with physical disability reported higher physical activity levels (14.30 MET h/day) compared to non-disabled (12.77 MET h/day), performing higher in leisure activities and light exercise. The compliance rate to health-beneficial exercise was 12.8% and was significantly higher among those with physical disability. Self-reported physical activity level correlated moderately well to overall MET performed p < 0.000, (r = 0.57). Only 2.8% of the respondents were aware of the recommendations outlined by health guidelines.

CONCLUSION

The results indicated that the population surveyed was moderately active but had low compliance to exercise habits as recommended by international health guidelines. Non-participation in prescribed exercises was linked to higher education, urban dwellers, and higher income. The study also highlighted very low physical literacy among respondents in health recommended exercise guidelines.

Robotic locomotor training for spasticity, pain, and quality of life in individuals with chronic SCI: A pilot randomized controlled trial

Objective

The prevention and treatment of secondary complications is a key priority for people with spinal cord injury and a fundamental goal of rehabilitation. Activity-based Training (ABT) and Robotic Locomotor Training (RLT) demonstrate promising results for reducing secondary complications associated with SCI. However, there is a need for increased evidence through randomized controlled trials. Therefore, we aimed to investigate the effect of RLT and ABT interventions on pain, spasticity, and quality of life in individuals with spinal cord injuries.

Methods

Participants with chronic motor incomplete tetraplegia (n = 16) were recruited. Each intervention involved 60-minute sessions, 3× per week, over 24-weeks. RLT involved walking in an Ekso GT exoskeleton. ABT involved a combination of resistance, cardiovascular and weight-bearing exercise. Outcomes of interest included the Modified Ashworth Scale, the International SCI Pain Basic Data Set Version 2, and the International SCI Quality of Life Basic Data Set.

Results

Neither intervention altered symptoms of spasticity. Pain intensity increased from pre-post intervention for both groups, with a mean increase of 1.55 [-0.82, 3.92] (p = 0.03) and 1.56 [-0.43, 3.55] (p = 0.02) points for the RLT and ABT group, respectively. The ABT group had an increase in pain interference scores of 100%, 50%, and 109% for the daily activity, mood, and sleep domain, respectively. The RLT group had an increase in pain interference scores of 86% and 69% for the daily activity and mood domain respectively, but no change in the sleep domain. The RLT group had increased perceptions of quality of life with changes of 2.37 [0.32, 4.41], 2.00 [0.43, 3.56] and 0.25 [-1.63, 2.13] points, p = 0.03, for the general, physical, and psychological domains, respectively. The ABT group had increased perceptions of general, physical and psychological quality of life with changes of 0.75 [-1.38, 2.88], 0.62 [-1.83, 3.07] and 0.63 [-1.87, 3.13] points, respectively.

Conclusions

Despite increased pain ratings and no change in symptoms of spasticity, there was an increase in perceived quality of life for both groups over 24-weeks. This dichotomy warrants additional investigation in future large-scale randomized controlled trials.

Home-based exergaming training effects for two individuals with spinal cord injury: A case report

INTRODUCTION

Exergaming is a type of serious game that requires active bodily movements for video gameplay. This game-based exercise is gaining interest as a form of leisure activity of moderate-vigorous dose intensity.

OBJECTIVE

This case report sought to assess the effects of exergaming training (i.e. Move Boxing, Move Tennis, and Move Gladiator Duel) on aerobic capacity, feasibility, enjoyment and motivation in two individuals with spinal cord injury (SCI).

CASE DESCRIPTIONS

Two males with SCI at the level of L4 and T10, aged 32 and 39, respectively, underwent home-based exergaming training sessions over a period of 12-18 weeks, conducted within moderate-vigorous intensity training zones for health improvements as recommended by health guidelines. Their peak oxygen consumption (VO₂), physical activity levels and perceived enjoyment were evaluated before, during and after the completion of the training.

OUTCOMES

Participant peak VO₂ improved (effect size g = 2.7) from their baseline values (Participant A: 16.0 ± 0.7 mL/kg/min to 41.7 ± 8.1 mL/kg/min; Participant B: 13.5 ± 0.8 mL/kg/min to 32.7 ± 5.2 mL/kg/min), with an increase in overall weekly physical activity levels. Both participants maintained a relatively high level of enjoyment scores throughout their training period (mean: 31.9 ± 3.2, p = .56, 95% CI 0.22-1.0).

CONCLUSION

A home-based exergaming training program improved aerobic capacity and level of physical activity, while maintaining adherence to the exercise within a relatively high perception of enjoyment for these two participants. The relatively high enjoyment scores maintained throughout the duration of the exergaming training period suggested its feasibility as a home-based exercise program and perceived as enjoyable by these individuals.

Assessing physical activity and health-related quality of life in individuals with spinal cord injury: a national survey in Thailand

PURPOSE

This study sought to; (i) investigate the proportion of Thai individuals with spinal cord injury (Thai-SCI) who met SCI-specific physical activity (PA) guidelines, (ii) describe PA and health-related quality of life (HRQOL) of Thai-SCI across different sociodemographic strata, and, (iii) measure the variance in HRQOL associated with the intensity and volume of leisure-time physical activities (LTPA).

METHODS

Two surveys, measuring PA and HRQOL, were used in this study. Descriptive analysis, parametric and non-parametric tests for comparing two or more groups were used to analyse the data. The relationship between PA levels and HRQOL scores was investigated using Spearman's correlation coefficients. All statistical significance level in this study were set to alpha < 0.05.

RESULTS

From the 200 participants, 14.5% met aerobic, 20.5% met strength training and 13.5% met both aerobic and strength training SCI-specific PA guidelines. Sedentary Thai-SCI accounted for 49% of the study sample. Thai-SCI spent 132.0 ± 254.3 (mean ± SD) minutes per week on moderate-to-heavy intensity LTPA. Average Physical and Mental Component Summary (PCS and MCS scores) of Thai-SCI were 42.3 ± 7.6 and 49.3 ± 8.4 (mean ± SD), respectively. Increases in average LTPA of moderate-to-heavy intensities were weakly correlated with increases in PCS scores and its sub-domains (r = 0.1-0.3, n = 200, all p < 0.05).

CONCLUSION

The average time spent on moderate-to-heavy intensity ADLs and LTPA were below SCI-specific PA guidelines and the WHO global recommendations for PA. The proportion of Thai-SCI who were sedentary was high, suggesting immediate action and implementation of strategies to promote PA for Thai-SCI.IMPLICATIONS FOR REHABILITATIONThe proportion of Thai people with spinal cord injury with a sedentary lifestyle was high.Healthcare providers in Thailand must engage to a greater degree in health-related physical activity promotion to effectively deliver physical activity and exercise knowledge to their clients with spinal cord injury.Likely, structured programs of physical activity and exercise deployed by healthcare professionals with the appropriate knowledge and skills might reverse the current trend to sedentary lifestyle in this population.Interventions to improve participation in physical activity and health-related quality of life should be tailored to the individual needs of Thai individuals with a spinal cord injury and might be better delivered seperately.

Effects of a low-carbohydrate/high-protein diet on metabolic health in individuals with chronic spinal cord injury: An exploratory analysis of results from a randomized controlled trial

We explored the impact of a low-carbohydrate/high-protein diet (LC/HP, ~30% energy from protein, 40% energy from carbohydrate) on indices of metabolic function and body composition in individuals with chronic spinal cord injury (SCI). Adults with SCI (≥3 years post-injury, C4-L2, AIS A-D) and insulin resistance or pre-diabetes were randomly assigned to an 8-week iso-caloric LC/HP diet group (n = 11) or control group (n = 14). All LC/HP meals were delivered weekly to participants' homes, and participants in the control group consumed their habitual diet. Each participant underwent an oral glucose tolerance test (OGTT) to assess glucose tolerance, insulin, area under the curve (AUC) for glucose and insulin, Matsuda Index, glucose-stimulated insulin secretion (GSIS), disposition index, and hepatic insulin extraction (HIE). Fasting blood lipid and inflammation were assessed, and body composition was estimated using dual-energy x-ray absorptiometry. A linear mixed model was used to evaluate the main effect of diet, time, and their interaction. Compared to the control group, participants in the LC/HP group had reduced total body fat mass (LC/HP: -5.9%, Control: 0.7%), visceral fat mass (LC/HP: -16.2%, Control: 5.2%), total- (LC/HP: -20.1, Control: 3.7 mg/dl), and LDL-cholesterol (LC/HP: -13.9, Control: 3.1 mg/dl) (pdiet*time  < 0.05 for all). Regardless of group, AUCinsulin and peak insulin during the OGTT decreased, and HIE increased over time (ptime  < 0.05). A trend for diet*time interaction was observed for glucoseOGTT120min (LC/HP: -20.7, Control: 3.0 mg/dl, pdiet*time  = 0.09) and peak C-peptide (LC/HP: -2.1, Control: 0.0 ng/ml, pdiet*time  = 0.07). HDL-cholesterol, lean body mass, Matsuda Index, fasting glucose, insulin, insulinOGTT120min , AUCglucose , pancreatic beta cell function (GSIS, disposition index), and inflammation (C-reactive protein, IL-6, IL-8, IL-10, TNF-α) did not change over time. In conclusion, our results suggest that individuals with SCI and insulin resistance may adopt an LC/HP diet to improve body composition and lipid profiles. Its impact on glucose metabolism and inflammation remains inconclusive and warrants future investigations.

Association between weekly exercise minutes and resting IL-6 in adults with chronic spinal cord injury: findings from the fracture risk after spinal cord injury exercise study

STUDY DESIGN

Cross-sectional study.

OBJECTIVE

To assess associations between weekly aerobic exercise minutes and resting interleukin-6 (IL-6), C-reactive protein (CRP), or leptin levels in adults with chronic spinal cord injury (SCI).

SETTING

Three hundred and forty-four community-dwelling men and women with SCI duration of > 1 year.

METHODS

CRP, IL-6, and leptin levels were quantified by ultra-sensitive enzyme-linked immunoassay. Smoking, medication use, comorbidities, and aerobic exercise minutes per week were assessed by self-reported questionnaire. Body composition was determined by whole-body dual-energy X-ray absorptiometry. Generalized linear models were used to assess associations.

RESULTS

In multivariable modeling, resting IL-6 levels were 0.001 pg/mL lower for every 1 min of weekly aerobic exercise. IL-6 levels increased with increasing android-to-gynoid fat ratio, in active/ever smokers compared to never smokers, and in individuals with skin pressure injuries compared to those without. IL-6 levels were lower in active ibuprofen users compared to nonusers. We found no association between weekly exercise minutes and CRP or leptin when designing similar models.

CONCLUSIONS

Increasing aerobic exercise minutes is associated with lower IL-6 levels in adults with chronic SCI when considering body composition, smoking, skin pressure injuries, and ibuprofen use. CRP and leptin did not demonstrate an association with exercise when considering the similar variables. The use of these biomarkers in assessing the therapeutic value of future exercise-related interventions will be paramount for meaningful health improvement among those with SCI. Although a large, prospective dataset, this cross-sectional study cannot assign causation. Future prospective studies are needed to confirm these findings.

Physical Activity and Public Health among People with Disabilities: Research Gaps and Recommendations

Physical activity has become an integral component of public health systems modeling the public health core functions of assessment, policy development, and assurance. However, people with disabilities have often not been included in public health efforts to assess, develop policies, or evaluate the impact of physical activity interventions to promote health and prevent disease among people with disabilities. Addressing the core function of assessment, current physical activity epidemiology, and surveillance among people with disabilities across the globe highlights the paucity of surveillance systems that include physical activity estimates among people with disabilities. The status of valid and reliable physical activity measures among people with condition-specific disabilities is explored, including self-report measures along with wearable devices, and deficiencies in measurement of physical activity. The core functions of policy development and assurance are described in the context of community-based intervention strategies to promote physical activity among people with disabilities. The identification of research gaps in health behavior change, policy, and environmental approaches to promoting physical activity among people with disabilities is explored, along with recommendations based on the principles of inclusive and engaged research partnerships between investigators and the members of the disability community.

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

Level of injury is an independent determining factor of gut dysbiosis in people with chronic spinal cord injury: A cross-sectional study

STUDY DESIGN

A cross-sectional study.

OBJECTIVE

To investigate the correlations between gut microbiota and metabolic parameters in people with different levels of chronic spinal cord injury (SCI).

SETTING

An SCI-specialized rehabilitation facility in a university hospital.

METHODS

Forty-three participants with chronic SCI were recruited. Blood samples of each participant were collected for analysis of metabolic parameters. Feces were collected after the bowel opening method the patient routinely uses to evaluate fecal bacterial microbiota using quantitative RT-PCR. Body composition was examined using dual-energy x-ray absorptiometry (DEXA). Data were analyzed to evaluate the correlations between gut microbiota and other parameters.

RESULTS

Of the 43 participants, 31 people (72.1%) were paraplegic and 12 people (27.9%) tetraplegic. Thirty-two people (74.4%) were diagnosed with obesity using the percentage of body fat (% body fat) criteria. The mean (SD) ratio of Firmicutes:Bacteroides (F/B), which represents the degree of gut dysbiosis, was 18.3 (2.45). Using stepwise multivariable linear regression analysis, both having tetraplegia and being diagnosed with obesity from % body fat evaluated by DEXA were independent positively-correlating factors of F/B (p < 0.001 and p = 0.001, respectively), indicating more severe gut dysbiosis in people with tetraplegia than paraplegia.

CONCLUSION

In people with chronic SCI, having tetraplegia and being diagnosed with obesity from % body fat evaluated by DEXA are independent positive-correlating factors of gut dysbiosis. These results indicate a significant association between gut microbiota and the characteristics of SCI as well as metabolic parameters.

Effectiveness and feasibility of the workout on wheels internet intervention (WOWii) for individuals with spinal cord injury: a randomized controlled trial

Study design

Randomized-controlled trial (RCT) with immediate intervention (IMM) and wait-list control (WLC) groups; WLC participants received the intervention during delivery to subsequent cohorts.

Objectives

Investigate the effectiveness and feasibility of a virtually-delivered exercise intervention.

Setting

Home and community.

Methods

A total of 168 middle-aged (49.6 [12.3] years old) men (57%) and women (43%) who lived an average 15.5 (12.3) years with spinal cord injury (SCI) participated. The 16-week program provides users (a) website access with exercise information, resources, and 16 skill-building modules; (b) virtual 60-minute, group-based weekly meetings; and (c) a starter package of exercise equipment. Primary outcomes included subjective physical activity (IPAQ) and objective exercise (Polar A300 wrist-based activity monitor and H7 heart rate strap). Secondary outcomes included fitness indices during a maximal arm crank test, plus self-reported exercise barriers, exercise self-efficacy, and goal-directed thinking.

Results

RCT results indicate significant between group differences in participants’ self-reported weekly time spent in vigorous-intensity PA and goal directed thinking but not for fitness changes. Data combined for IMM and WLC participants from Polar monitoring show participants performed 150 min per week of aerobic exercise plus reported significantly greater time spent in moderate-PA, vigorous-PA, self-efficacy for exercise and nutrition, goal directed thinking, and exercise barriers. Oxygen uptake (V̇O₂ peak) and power output (watts max) were the only physiologic measures to demonstrate significant change, with a moderate effect size.

Conclusion

This virtually-delivered program offers a promising approach to increase exercise among those with SCI and may help participants perceive fewer motivational barriers and greater self-efficacy.

A national survey of physical activity after spinal cord injury

Physical activity is a powerful modifiable risk factor for disease and mortality. Physical activity levels in people with spinal cord injury (SCI) have not been quantified relative to uninjured individuals in a large population-based sample. We aimed to quantify and compare physical activity in people with and without SCI, and to examine the associations between physical activity, lifestyle, and socioeconomic factors. The 2010 Canadian Community Health Survey (n > 57,000) was used, which includes three measures that assess physical activity levels (i.e., leisure time activity frequency, leisure time activity intensity, and transportation time activity intensity). Bivariable and multivariable logistic regressions were performed and odds ratios (ORs) with corresponding 95% confidence intervals (CIs) were estimated. The odds of physical activity in people with SCI were 0.43 (95% CI 0.3–0.61), 0.53 (95% CI 0.36–0.75), and 0.42 (95% CI 0.28–0.61), across the three measures of physical activity, respectively. These differences persisted after adjustment for lifestyle, comorbidities, and socioeconomic factors. Physical activity is reduced in the SCI population compared with the general population. This knowledge is important to direct future research and guide the allocation of health care resources.

Trans-Spinal Electrical Stimulation Therapy for Functional Rehabilitation after Spinal Cord Injury: Review

Spinal cord injury (SCI) is one of the most debilitating injuries in the world. Complications after SCI, such as respiratory issues, bowel/bladder incontinency, pressure ulcers, autonomic dysreflexia, spasticity, pain, etc., lead to immense suffering, a remarkable reduction in life expectancy, and even premature death. Traditional rehabilitations for people with SCI are often insignificant or ineffective due to the severity and complexity of the injury. However, the recent development of noninvasive electrical neuromodulation treatments to the spinal cord have shed a ray of hope for these individuals to regain some of their lost functions, a reduction in secondary complications, and an improvement in their life quality. For this review, 250 articles were screened and about 150 were included to summarize the two most promising noninvasive spinal cord electrical stimulation methods of SCI rehabilitation treatment, namely, trans-spinal direct current stimulation (tsDCS) and trans-spinal pulsed current stimulation (tsPCS). Both treatments have demonstrated good success in not only improving the sensorimotor function, but also autonomic functions. Due to the noninvasive nature and lower costs of these treatments, in the coming years, we expect these treatments to be integrated into regular rehabilitation therapies worldwide.

Management of Acute Traumatic Spinal Cord Injury: A Review of the Literature

Traumatic spinal cord injury (TSCI) is a debilitating disease that poses significant functional and economic burden on both the individual and societal levels. Prognosis is dependent on the extent of the spinal injury and the severity of neurological dysfunction. If not treated rapidly, patients with TSCI can suffer further secondary damage and experience escalating disability and complications. It is important to quickly assess the patient to identify the location and severity of injury to make a decision to pursue a surgical and/or conservative management. However, there are many conditions that factor into the management of TSCI patients, ranging from the initial presentation of the patient to long-term care for optimal recovery. Here, we provide a comprehensive review of the etiologies of spinal cord injury and the complications that may arise, and present an algorithm to aid in the management of TSCI.

Measurement Performance of Activity Measurements with Newer Generation of Apple Watch in Wheelchair Users with Spinal Cord Injury

Background  The level of physical activity (PA) of people with spinal cord injury (SCI) has an impact on long-term complications. Currently, PA is mostly assessed by interviews. Wearable activity trackers are promising tools to objectively measure PA under everyday conditions. The only off-the-shelf, wearable activity tracker with specific measures for wheelchair users is the Apple Watch.

Objectives  This study analyzes the measurement performance of Apple Watch Series 4 for wheelchair users and compares it with an earlier generation of the device.

Methods  Fifteen participants with subacute SCI during their first in-patient phase followed a test course using their wheelchair. The number of wheelchair pushes was counted manually by visual inspection and with the Apple Watch. Difference between the Apple Watch and the rater was analyzed with mean absolute percent error (MAPE) and a Bland–Altman plot. To compare the measurement error of Series 4 and an older generation of the device a t -test was calculated using data for Series 1 from a former study.

Results  The average of differences was 12.33 pushes ( n  = 15), whereas participants pushed the wheelchair 138.4 times on average (range 86–271 pushes). The range of difference and the Bland–Altman plot indicate an overestimation by Apple Watch. MAPE is 9.20% and the t -test, testing for an effect of Series 4 on the percentage of error compared with Series 1, was significant with p  < 0.05.

Conclusion  Series 4 shows a significant improvement in measurement performance compared with Series 1. Series 4 can be considered as a promising data source to capture the number of wheelchair pushes on even grounds. Future research should analyze the long-term measurement performance during everyday conditions of Series 4.

Predicting physical activity intensity using raw accelerometer signals in manual wheelchair users with spinal cord injury

STUDY DESIGN

Cross-sectional validation study.

OBJECTIVES

The performance of previously published physical activity (PA) intensity cutoff thresholds based on proprietary ActiGraph counts for manual wheelchair users (MWUs) with spinal cord injury (SCI) was initially evaluated using an out-of-sample dataset of 60 individuals with SCI. Two types of PA intensity classification models based on raw accelerometer signals were developed and evaluated.

SETTING

Research institutions in Pittsburgh PA, Birmingham AL, and Bronx NY.

METHODS

Data were collected from 60 MWUs with SCI who followed a structured activity protocol while wearing an ActiGraph activity monitor on their dominant wrist and portable metabolic cart which measured criterion PA intensity. Data was used to assess published models as well as develop and assess custom models using recall, specificity, precision, as well as normalized Mathew's correlation coefficient (nMCC).

RESULTS

All the models performed well for predicting sedentary vs non-sedentary activity, yielding an nMCC of 0.87-0.90. However, all models demonstrated inadequate performance for predicting moderate to vigorous PA (MVPA) with an nMCC of 0.76-0.82.

CONCLUSIONS

The mean absolute deviation (MAD) cutoff threshold yielded the best performance for predicting sedentary vs non-sedentary PA and may be used for tracking daily sedentary activity. None of the models displayed strong performance for MVPA vs non-MVPA. Future studies should investigate combining physiological measures with accelerometry to yield better prediction accuracies for MVPA.

Physical activity recall assessment for people with spinal cord injury: Thai translation and cross-cultural adaptation

PURPOSE

This research sought to translate and culturally adapt the content of the original Physical Activity Recall Assessment for People with Spinal Cord Injury (PARA-SCI) into the Thai language and to assess its inter- and intra-rater reliability.

METHODS

This study was divided into two parts; (i) translation and cross-cultural adaptation, using a six-step guideline-based translation-validation process and (ii) reliability assessment of the translated survey tool using intraclass correlation coefficients (ICCs), Bland-Altman plots and one-way ANOVA analyses.

RESULTS

The Thai-PARA-SCI was successfully developed. The results revealed an excellent inter-rater reliability (ICC = 0.99, 95% CI range from 0.959-0.999) and the Bland-Altman plots showed little difference in times spent engaged physical activity. Intra-rater reliability results were affected inadvertently by testing across an unusual period, demonstrating poor to moderate scores (ICC ranged from 0.05-0.69, 95% CI ranged from -0.067-0.830) with the Bland-Altman plots showing very different ranges of time spent on physical activity.

CONCLUSION

This study achieved its aims of culturally and systematically translating the English PARA-SCI interview script into the Thai version with excellent scores for inter-rater reliability and was proven to be understandable by prospective users (Thai-PT) and participants (Thai-SCI).Implications for RehabilitationA robust cross-cultural translation and adaptation of the Physical Activity Recall Assessment for people with Spinal Cord Injury (PARA-SCI) into the Thai context has been undertaken, providing an effective exemplar for converting patient reported health outcome measures between languages of different root origins.When using the PARA-SCI as a pre- and post-intervention outcomes survey, clinicians should ensure that the timing of interview administration does not coincide with any unintended alterations in work-life balance, to ensure that the data are representative of the habitual physical activity levels performed by participants in their daily lives.Due to the possibility that physical activity levels could vary day-by-day or week-to-week, using the same day measurement findings may be a more reliable way to deploy the PARA-SCI than repeated assessments week(s) apart.

Robotic Locomotor Training Leads to Cardiovascular Changes in Individuals With Incomplete Spinal Cord Injury Over a 24-Week Rehabilitation Period: A Randomized Controlled Pilot Study

OBJECTIVE

To describe the effect of robotic locomotor training (RLT) and activity-based training (ABT) on cardiovascular indices during various physiological positions in individuals with spinal cord injury.

DESIGN

Randomized controlled pilot study.

SETTING

Private practice: Therapy & Beyond Centre - Walking with Brandon Foundation, Sports Science Institute of South Africa, Cape Town, South Africa.

PARTICIPANTS

Participants with chronic traumatic motor incomplete tetraplegia (N=16) who resided in the Western Cape, South Africa.

INTERVENTION

Robotic locomotor training (Ekso GT) and activity-based training over a 24-week intervention.

MAIN OUTCOME MEASURES

Brachial and ankle blood pressure, heart rate, heart rate variability, and cardiovascular efficiency during 4 physiological positions.

RESULTS

No differences between groups or over time were evident in resting systolic and diastolic blood pressure, ankle systolic pressure, ankle brachial pressure index, and heart rate variability. Standing heart rate at 24 weeks was significantly higher in the ABT group (95.58±12.61 beats/min) compared with the RLT group (75.14±14.96 beats/min) (P=.05). In the RLT group, no significant changes in heart rate variability (standard deviation R-R interval and root mean square of successive differences) was found between the standing and 6-minute walk test physiological positions throughout the intervention. Cardiovascular efficiency in the RLT group during the 6-minute walk test improved from 11.1±2.6 at baseline to 7.5±2.8 beats per meter walked at 6 weeks and was maintained from 6 to 24 weeks.

CONCLUSIONS

Large effect sizes and significant differences between groups found in this pilot study support the clinical effectiveness of RLT and ABT for changing cardiovascular indices as early as 6 weeks and up to 24 weeks of rehabilitation. RLT may be more effective than ABT in improving cardiac responses to orthostatic stress. Based on heart rate variability metrics, the stimulus of standing has comparable effects to RLT on the parasympathetic nervous system. Cardiovascular efficiency of exoskeleton walking improved, particularly over the first 6 weeks. Both the RLT and ABT interventions were limited in their effect on brachial and ankle blood pressure. A randomized controlled trial with a larger sample size is warranted to further examine these findings.

Factors associated with leisure-time physical activity participation among individuals with spinal cord injury who ambulate

PURPOSE

The purpose of this study was to employ the theoretical domains framework (TDF) to identify behaviour change factors related to leisure-time physical activity (LTPA) in spinal cord injury (SCI) ambulators.

METHODS

A cross-sectional design was employed. Among 43 SCI ambulators, the TDF behaviour change factors were assessed, along with the duration, types, and intensities of LTPA performed over the previous week.

RESULTS

The TDF behaviour change factors identified as barriers to LTPA included: knowledge, beliefs about capabilities, coping planning, and goal conflict. Approximately 71.81 mins/day (SD = 75.41) was spent doing LTPA. Participants reported aerobic and resistance training activities, along with several other types of LTPA (e.g., rock climbing). Coping planning, action planning, goal conflict, and skills explained significant variance in time spent on LTPA (R²_adjusted = 0.259, p < 0.01), but only action planning uniquely predicted LTPA.

CONCLUSIONS

Greater use of coping and action planning, lower levels of goal conflict and stronger skills were associated with greater participation in LTPA. These factors will be targeted for a future LTPA-enhancing intervention for SCI ambulators, informed by behaviour change theory. SCI ambulators participate in a surprisingly wide range of LTPA. Rehabilitation specialists can use this list to suggest activities for patients with SCI who ambulate.IMPLICATIONS FOR REHABILITATIONBarriers to leisure-time physical activity for individuals with spinal cord injury (SCI) who ambulate include lack of knowledge, weak beliefs about capabilities, lack of coping planning, and high goal conflict.Physical activity interventions for individuals with SCI who ambulate should include action and coping planning, goal conflict, and skills.Physical activity interventions should be created systematically using behaviour change theory and involvement of stakeholders throughout the development process.Practitioners can promote skills training in adapted activities like gardening, cycling, and rock-climbing for ambulators with SCI.

Development of community participation indicators to advance the quality of spinal cord injury rehabilitation: SCI-High Project

Community participation following spinal cord injury/disease (SCI/D) can be challenging due to associated primary impairments and secondary health conditions as well as difficulties navigating both the built and social-emotional environment. To improve the quality of SCI/D rehabilitation care to optimize community participation, the SCI-High Project developed a set of structure, process and outcome indicators for adults with SCI/D in the first 18 months after rehabilitation admission.

A pan-Canadian Working Group of diverse stakeholders: (1) defined the community participation construct; (2) conducted a systematic review of available outcomes and their psychometric properties; (3) constructed a Driver diagram summarizing available evidence associated with community participation; and (4) prepared a process map. Facilitated meetings allowed selection and review of a set of structure, process and outcome indicators.

The structure indicator is the proportion of SCI/D rehabilitation programs with availability of transition living setting/independent living unit. The process indicators are the proportion of SCI/D rehabilitation inpatients who experienced: (a) a therapeutic community outing prior to rehabilitation discharge; and, (b) those who received a pass to go home for the weekend. The intermediary and final outcome measures are the Moorong Self-Efficacy Scale and the Reintegration to Normal Living Index.

The proposed indicators have the potential to inform whether inpatient rehabilitation for persons with SCI/D can improve self-efficacy and lead to high levels of community participation post-rehabilitation discharge.

Construct validation of the leisure time physical activity questionnaire for people with SCI (LTPAQ-SCI)

STUDY DESIGN

Cross-sectional construct validation study.

OBJECTIVES

To test the construct validity of the Leisure Time Physical Activity Questionnaire for People with Spinal Cord Injury (LTPAQ-SCI) by examining associations between the scale responses and cardiorespiratory fitness (CRF) in a sample of adults living with spinal cord injury (SCI).

SETTING

Three university-based laboratories in Canada.

METHODS

Participants were 39 adults (74% male; M age: 42 ± 11 years) with SCI who completed the LTPAQ-SCI and a graded exercise test to volitional exhaustion using an arm-crank ergometer. One-tailed Pearson's correlation coefficients were computed to examine the association between the LTPAQ-SCI measures of mild-, moderate-, heavy-intensity and total minutes per week of LTPA and CRF (peak volume of oxygen consumption [V̇O_2peak] and peak power output [PO_peak]).

RESULTS

Minutes per week of mild-, moderate- and heavy-intensity LTPA and total LTPA were all positively correlated with V̇O_2peak. The correlation between minutes per week of mild intensity LTPA and V̇O_2peak was small-medium (r = 0.231, p = 0.079) while all other correlations were medium-large (rs ranged from 0.276 to 0.443, ps < 0.05). Correlations between the LTPAQ-SCI variables and PO_peak were also positive but small (rs ranged from 0.087 to 0.193, ps > 0.05), except for a medium-sized correlation between heavy-intensity LTPA and PO_peak (r = 0.294, p = 0.035).

CONCLUSIONS

People with SCI who report higher levels of LTPA on the LTPAQ-SCI also demonstrate greater levels of CRF, with stronger associations between moderate- and heavy-intensity LTPA and CRF than between mild-intensity LTPA and CRF. These results provide further support for the construct validity of the LTPAQ-SCI as a measure of LTPA among people with SCI.

Leisure time physical activity in persons with spinal cord injury across the seasons

OBJECTIVES

The main goal of this study was to assess the level of leisure-time physical activity (LTPA) and its differentiation across the seasons among persons with spinal cord injury (SCI). The additional aim was to determine whether socio-demographical, injury, and seasonal factors are determinants of LTPA.

METHODS

This study included 51 adults with SCI, who completed the LTPA questionnaire for persons with SCI during a calendar year in the middle of four seasons, and demographic questionnaire. A multiple regression analysis was used to examine the role of socio-demographical, injury, and seasonal variables, as determinants of LTPA.

RESULTS

The levels of LTPA were differentiated throughout the seasons. Three models containing variables related to LTPA were created. All models were significant, for mild LTPA (F = 10.01, r ² = 0.21), moderate LTPA (F = 5.24, r ² = 0.9), and heavy LTPA (F = 7.09, r ² = 0.6). Age at the time of study, lack of employment, tetraplegia, and shorter time since injury were significantly, negatively associated with LTPA.

CONCLUSION

LTPA in persons with SCI differs significantly in relation to the seasons throughout a year. The season of the year should be considered in future studies and interventions on LTPA in adults with SCI.

Estimation of Physical Activity Intensity in Spinal Cord Injury Using a Wrist-Worn ActiGraph Monitor

OBJECTIVES

To derive accelerometer count thresholds for classifying time spent in sedentary, light intensity, and moderate-to-vigorous physical activity (MVPA) in manual wheelchair users (MWUs) with spinal cord injury (SCI).

DESIGN

Participants completed 18 activities of daily living and exercises for 10 minutes each with a 3-minute break between activities while wearing a COSMED K4b2 portable metabolic cart and an ActiGraph activity monitor on the dominant wrist. A linear regression was computed between the wrist acceleration vector magnitude and SCI metabolic equivalent of task (MET) for 80% of the participants to obtain thresholds for classifying different activity intensities, and the obtained thresholds were tested for accuracy on the remaining 20% of participants. This cross-validation process was iterated for 1000 times to evaluate the stability of the thresholds on data corresponding to different proportions of sedentary, light intensity, and MVPA. MET values of 1.5 or lower were classified as sedentary behavior, MET values between 1.5 and 3 were classified as light intensity, and MET values of 3 or higher were classified as MVPA. The final thresholds were then validated on an out-of-sample independent dataset.

PARTICIPANTS

MWUs (N=17) with SCI in the out-of-sample validation data set.

INTERVENTIONS

Not applicable.

SETTING

Research lab, community MAIN OUTCOME MEASURES: Accelerometer thresholds to classify sedentary, light intensity, and MVPA were obtained and their accuracy tested using cross-validation and an out-of-sample dataset.

RESULTS

The threshold between sedentary and light intensity was 2057 counts-per-minute, and the threshold between light intensity and MVPA was 11,551 counts per minute. Based on the out-of-sample validation, the obtained thresholds had an overall accuracy of 85.6%, with a sensitivity and specificity of 95.3% and 97.4% for sedentary behavior, 87.8% and 84.5% for light intensity, 68.5% and 96.3% for MVPA, respectively.

CONCLUSION

Accelerometer-based thresholds can be used to accurately identify sedentary behavior. However, thresholds may not provide accurate estimations of MVPA throughout the day when participants engage in more resistance-based activities.

The Effects of a Patient and Provider Co-Developed, Behavioral Physical Activity Intervention on Physical Activity, Psychosocial Predictors, and Fitness in Individuals with Spinal Cord Injury: A Randomized Controlled Trial

BACKGROUND

Physical activity (PA) interventions in people with spinal cord injury (SCI) have been limited by a shortage of (1) evidence for sufficient increases in unsupervised PA to improve aerobic fitness and (2) stakeholder involvement in intervention design.

OBJECTIVES

This study examined the effects of a theory-based PA intervention, developed in collaboration with nearly 300 stakeholders, on PA levels, aerobic fitness, and psychosocial predictors of PA among individuals with SCI.

METHODS

A randomized controlled trial (RCT) was conducted with 28 men and women with chronic SCI (age 45.0 ± 11.5 years, years post-injury 16.4 ± 12.4). Participants randomized to the intervention group (n = 14) received an introductory personal training session followed by eight weekly 15-min PA behavioral coaching sessions per week. PA was assessed using self-report and accelerometers. Aerobic fitness and psychosocial predictors of exercise were evaluated using an incremental exercise test and survey methods, respectively.

RESULTS

At post-intervention, controlling for baseline, the intervention group showed fivefold greater self-reported moderate to vigorous physical activity [mean difference 247.9 min/day; 95% confidence interval (CI) 92.8-403.1; p = 0.026, d = 1.04], 17% greater accelerometer-measured PA (mean difference 3.9 × 10⁵ vector magnitude counts; 95% CI 1.1 × 10⁴-7.7 × 10⁵; p = 0.014, d = 0.31), and 19% higher peak oxygen uptake (VO_2Peak; mean difference 0.23 L/min; 95% CI 0.12-0.33; p < 0.001, d = 0.54) compared with the control group. Mean values of psychosocial predictors of PA were also significantly improved in the intervention group compared with controls.

CONCLUSION

To our knowledge, this co-created behavioral intervention produced the largest effect size to date for change in self-reported PA in an RCT involving people with physical disability. This is also the first RCT in people with SCI to demonstrate that a behavioral intervention can sufficiently increase unsupervised PA to improve aerobic fitness.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03111030, 12 April 2017, https://clinicaltrials.gov/ct2/show/NCT03111030?term=NCT03111030&rank=1 .

Use of actigraphy to measure real-world physical activities in manual wheelchair users

Introduction

The benefits of physical activity for manual wheelchair users are well-known. The purpose of this study was to validate actigraphy to objectively measure physical activity intensity among manual wheelchair users.

Method

An experimental design was used. Adult manual wheelchair users wore a GT3X actigraph on their non-dominant arm while completing eight physical activities of low (reading), moderate (propelling -- flat) and high (propelling -- steep ramp) intensity. Heart rate and rating of perceived exertion were collected at the end of each physical activity. Distribution of data were examined and used to determine the type of repeated measures (parametric vs. non-parametric). A categorical principal component analysis was performed to determine the amount of variability explained by actigraphy, heart rate and rating of perceived exertion. Activity count cut-points were estimated using bootstrapping methods.

Results

Twenty-eight manual wheelchair users completed the study. Actigraphy, heart rate and rating of perceived exertion co-varied as physical activity intensity changed. Activity counts for low-intensity and medium-intensity physical activities were estimated to be 0 to 45 and 45 to 100 activity counts per second, respectively. Activity counts' ranges for high-intensity physical activities were not clear.

Conclusion

Combining actigraphy and rating of perceived exertion could be an easy and reliable method to measure the intensity of real-world activities. Further research is needed confirm cut-points for physical activity intensity.

Accelerometer assessment of physical activity in individuals with paraplegia who do and do not participate in physical exercise

OBJECTIVE

Our main goal was to measure physical activity (PA) in people with paraplegia. Secondarily, we aimed to establish the relationship between being engaged in physical exercise (PE) and reaching the recommended moderate-to-vigorous physical activity (MVPA) level. We further analyzed the effect of being engaged in PE on the PA levels.

DESIGN

Descriptive cross-sectional.

SETTING

Spanish associations for individuals with spinal cord injury.

PARTICIPANTS

Ninety-six manual wheelchair users with chronic paraplegia.

INTERVENTIONS

Participants wore a wrist accelerometer for one week.

OUTCOME MEASURES

Levels of PA and sedentary behavior. In addition, participants were classified into two groups, exercisers (EG) and non-exercisers (NEG) to analyze the effect of PE enrollment on the variables.

RESULTS

For all participants, a mean (SD) of 5,341.70 (966.4) minutes per week were spent engaged in sedentary behaviors, 2,188.99 (723.9) minutes were spent engaged in light activity, and 206.24 (180.0) minutes were spent engaged in MVPA. There was a significant relationship between PE and reaching the minimum levels of MVPA recommended [x2 (1) = 25.03, P < 0.01]. NEG showed a greater number of minutes per week for sedentary behavior [t (94) = 2.50, P < 0.05, r = 0.25]. The EG spent more than twice as much time doing MVPA than the NEG (263.8 min vs 114.3 min, respectively).

CONCLUSIONS

MVPA levels are low in manual wheelchair users who are not regular exercisers, but most of those who self-reported being regular exercisers reach the minimum levels recommended for health benefits. Sedentary behavior is a concern in this population.

The effects of an individualized health-risk report intervention on changes in perceived inactivity-related disease risk in adults with cerebral palsy

BACKGROUND

To explore the effect of an individualized health-risk report intervention on changes in perceived disease risk in adults with cerebral palsy (CP).

HYPOTHESES

1. Perceived disease risk from those at risk for heart disease, obesity, and/or diabetes will be greater compared to those not at risk following receipt of health-risk information; 2. There will be a positive relationship between risk measures of inactivity-related diseases and post-intervention perceived disease risk; and increases in perceived disease risk will predict increases in physical activity (PA).

METHODS

An individualized health-risk report was delivered to each participant. Three brief telephone interviews were conducted over two weeks to measure perceptions of disease risk and PA. Two-way repeated measures ANOVA and regression analyses were performed to address the study objectives.

RESULTS

Thirty-one adults with CP (Gross Motor Function Classification System level I-V; age, 33.7 ± 13.1y) completed the study. The health-risk report did not change the perceived risk of any inactivity-related disease. We found significant main effects for hypertension (p = 0.02; 95% CI [-1.1, -0.5]) on perceived risk of heart disease, and for waist circumference (p < 0.01; 95% CI [-1.3, -0.3]) and BMI (p < 0.01; 95% CI [-1.3, -0.3]) on perceived risk of obesity. PA did not change following the intervention.

CONCLUSIONS

An individualized health-risk report intervention did not change perceived risk of inactivity-related disease or change PA behaviour. Blood pressure, waist circumference and BMI were salient measures of health that affected perceived disease risk in adults with CP; these health variables should be assessed and managed through clinical encounters.

Instruments Measuring Physical Activity in Individuals Who Use a Wheelchair: A Systematic Review of Measurement Properties

OBJECTIVE

To systematically review the evidence evaluating validity or reliability of self-reported and device-based instruments, to measure physical activity (PA) in individuals who use a wheelchair, and to make recommendations for the selection of PA outcomes tools.

DATA SOURCES

PubMed, Embase, and CINAHL were systematically searched.

STUDY SELECTION

Studies reporting measurement properties of instruments to assess PA in individuals who use a wheelchair.

DATA EXTRACTION

The Consensus-Based Standards for the Selection of Health Status Measurement Instruments checklist was used to assess the methodological quality of the included studies. The measurement properties of instruments assessing PA were examined.

DATA SYNTHESIS

The search yielded 5341 records, 61 were considered relevant, 21 articles were included. A best evidence synthesis was performed on 9 studies including 4 self-reported instruments and 13 studies including 8 device-based instruments. One study evaluated both self-reported and device-based instruments. The overall methodological quality of all studies ranged from poor to excellent. Variable levels of evidence were found for both the validity and reliability for self-reported instruments and for criterion validity for device-based instruments.

CONCLUSIONS

The Physical Activity Scale for Individuals with Disabilities (PASIPD) and The Physical Activity Recall Assessment for People with Spinal Cord Injury (PARA-SCI) seem the most promising self-reported instruments for measuring the intensity of PA. Device-based instruments that can be used for measuring both the intensity and type of PA are the GENEActiv, Actigraph GT3X+, Actiheart, or the Physical Activity Monitor System (PAMS), showing moderate evidence for a positive rating of criterion validity. For measuring the type of PA, the PAMS and VitaMove are suitable, showing both good evidence for a positive rating of criterion validity.

Development of Cardiometabolic Health indicators to advance the quality of spinal cord injury rehabilitation: SCI-High Project

Context: Spinal cord injury or disease (SCI/D) leads to unchanged low-density lipoprotein and cholesterol, very low high-density lipoprotein a form of dyslipidemia and physical inactivity which combine to increase risk of morbidity and mortality from cardiometabolic disease. Herein, we describe the selection of structure, process and outcome indicators for adults in the first 18 months post-SCI/D rehabilitation admission. Methods: A Pan-Canadian Cardiometabolic Health Working Group was formed to develop a construct definition. Cardiometabolic risk factors were summarized in a Driver diagram. Release of the Paralyzed Veterans of America "Identification and Management of Cardiometabolic Risk after Spinal Cord Injury" and the International Scientific Exercise Guidelines: "Evidence-based scientific exercise guidelines for adults with spinal cord injury", informed the group's focus on prevention strategies to advance this Domain of rehabilitation admission. Results: The structure indicator identifies during rehabilitation the presence of appropriate time and resources for physical exercise prescription. Process indicators are lipid profile assessment at rehabilitation admission and documented exercise prescriptions prior to discharge. The outcome indicators track patient's knowledge retention regarding exercise prescription at discharge, current exercise adherence and lipid status 18 months after rehabilitation discharge. Conclusion: Routine national implementation of these indicators at the specified time points will enhance efforts to detect dyslipidemia and assure routine participation in endurance exercise. These indicators align with international initiatives to improve cardiometabolic health through interventions targeting modifiable risk factors specifically endurance exercising and optimal lipid profiles, crucial to augmenting cardiometabolic health after SCI/D.

Utilizing a low-carbohydrate/high-protein diet to improve metabolic health in individuals with spinal cord injury (DISH): study protocol for a randomized controlled trial

Background

Metabolic disorders (e.g., impaired glucose tolerance, insulin resistance, and type 2 diabetes) are more prevalent in people with spinal cord injury (SCI) than able-bodied individuals. Dietary modification is a more cost-effective treatment option than pharmacological therapies for reducing the risk of metabolic dysfunction. Lowering carbohydrate, increasing protein, and maintaining a proper dietary fat intake are expected to induce favorable adaptations in glucose control, body fat distribution, and the composition of the gut microbiome. However, dietary modification has not been rigorously investigated in people with SCI. The purpose of this study is to determine if an 8-week low-carbohydrate/high-protein (LC/HP) dietary intervention will show improvements in clinically important metrics of metabolic function, body composition, the composition of gut bacteria, and quality of life.

Methods/design

We intend to recruit 100 participants with chronic traumatic SCI (3 years postinjury, C5–L2, American Spinal Injury Association impairment scale A–D, and aged 18–65 years) and insulin resistance, impaired glucose tolerance or untreated type 2 diabetes and randomly assign them to an 8-week LC/HP dietary intervention group or a control group. The daily LC/HP dietary intervention includes ~ 30% total energy as protein (1.6 g/kg per day) with a carbohydrate-to-protein ratio < 1.5 and fat intake set at ~ 30% of the total energy intake. The control group does not receive any dietary intervention and are continuing with their regular daily diets. Glucose tolerance, insulin sensitivity, β-cell function, body composition, gut microbiome composition, and quality of life measures are assessed at week 1, before starting the LC/HP dietary intervention, and at week 8, after completion of the LC/HP dietary intervention.

Discussion

New information derived from this project will result in the development of a low-cost, simple, self-administered LC/HP dietary intervention for improving metabolic function in individuals with chronic SCI, improved understanding of the composition of gut bacteria in SCI, and how a LC/HP dietary intervention alters gut bacteria composition. In addition, this project will improve our understanding of the relationship between metabolic function and quality of life in individuals with long-standing SCI.

Trial registration

ClinicalTrials.gov, NCT03207841. Registered on 5 June 2017.

Electronic supplementary material

The online version of this article (10.1186/s13063-019-3520-3) contains supplementary material, which is available to authorized users.

Perceptually regulated training does not influence the differentiated RPE response following 16-weeks of aerobic exercise in adults with spinal cord injury

This study investigated the effect of prolonged familiarisation with ratings of perceived exertion (RPE) on the peripheral (RPE_P) and central (RPE_C) RPE responses to moderate-vigorous exercise in adults with spinal cord injury (SCI). RPE_P and RPE_C characterise the exertion of the working musculature and cardiorespiratory systems, respectively. Nineteen participants (age, 41.4 ± 11.4 years; peak oxygen uptake, 19.2 ± 7.2 mL·kg^-1·min^-1) with chronic SCI were randomly assigned to RPE-guided (n = 11; EXP) or active control (n = 8; CON) groups. EXP performed 16-weeks of RPE-guided, supervised aerobic training for 20 min, twice weekly, at RPE 3-6 (Category-Ratio 10 scale). CON had access to the same exercise equipment but received no specific advice on their exercise-training regime. Participants completed a graded exercise test, using an arm crank ergometer at pre- and post-training to determine peak oxygen uptake, with RPE_P and RPE_C recorded every minute throughout tests. Sixteen weeks training did not improve peak oxygen uptake. RPE decreased post-training at 50% (p = 0.02) and 70% peak oxygen uptake (p = 0.03), though there was no effect of group at either intensity (p = 0.54, 0.42, respectively). At 70% peak oxygen uptake, RPE_P was greater than RPE_C (4.2 ± 1.7 vs 3.4 ± 1.8, p < 0.005). Training with RPE-guidance for 16 weeks had no additional effect on the differentiated RPE responses to moderate-vigorous exercise in adults with SCI. Novelty In adults with SCI, differentiated RPE responses were not different between those who did, and did not, perform 16 weeks of RPE-guided training. This challenges whether familiarisation with RPE is necessary to be an effective regulator of exercise intensity in this population.

Long-term recording of electromyographic activity from multiple muscles to monitor physical activity of participants with or without a neurological disorder

Various portable monitors have been used to quantify physical activity but most rely on detecting limb movement with a sensor rather than measuring muscle activity. Our first goal was to design and validate a portable system for recording surface electromyographic activity (EMG) from eight muscles over 24 h. The modular system includes: (1) preamplifiers that filter and amplify signals; (2) a preprocessor unit for further filtering and amplification, signal offset and power supply modification; (3) a data-logger for analog-to-digital conversion; a flash memory card for data storage and (4) a rechargeable battery. The equipment samples EMG at 1000 Hz, has a resolution of 2.6 μV and records signals up to 10 mV. The built-in analog filters create a bandwidth appropriate for surface EMG. Our second aim was to test the system biologically by recording EMG from able-bodied and spinal cord injured participants. Modifications were made to electrodes for remote preamplifier placement, and to the battery connection after pilot testing. Thereafter, 31 consecutive 24-h EMG recordings were successful. Both the engineering and biological validation of this system establishes it as a valuable tool for measuring physical activity from different muscles in real-world environments whether individuals have an intact or damaged nervous system.

Malaysian adaptation of the physical activity scale for individuals with physical disabilities in individuals with spinal cord injury

Purpose: The Physical Activity Scale for Individuals with Physical Disabilities questionnaire provides an assessment of physical activity after spinal cord injury. This study sought to adapt, with cultural competence, the English questionnaire and translate it into Bahasa Malaysia, including evaluation of content and face validity, internal consistency and test-retest reliability, and completion of a factor analysis in order to validate the Malaysian version.Materials and methods: A total of 250 participants completed the questionnaire that was distributed via email, postal mail, the internet, physically and by word of mouth. Sixty-eight respondents were re-contacted to complete the questionnaire again.Results: The adapted PASIPD demonstrated adequate internal consistency Cronbach's α = 0.68 and acceptable test-retest reliability, intraclass correlation = 0.87. Factor analysis extracted four main dimensions for physical activity; factor 1 (heavy housework, home repair, lawn work and gardening), factor 2 (sports and recreation), factor 3 (light housework and caring for another person) and factor 4 (leisure and occupational activities) that accounted for 64% of the physical activities' total variance.Conclusion: The Malaysian-adapted English and translated Bahasa Malaysia versions of the questionnaires intended to measure physical activity levels in individuals with spinal cord injury, demonstrated good to acceptable validity and reliability. However, some individual items revealed weak reliability measures. Further work is needed to validate the questionnaire's criterion validity against other physical activity measures.Implications for rehabilitationThe Malaysian adaptation of the Physical Activity Scale for Individuals with Physical Disabilities questionnaire provided preliminary support for its use since it has demonstrated adequate construct validity and reliability.The Malaysian adaptation of the Physical Activity Scale for Individuals with Physical Disabilities questionnaire can quantify the physical activity level of community-dwelling individuals with spinal cord injury, whilst deriving descriptive information on their physical activities.Deploying the Physical Activity Scale for Individuals with Physical Disabilities questionnaire to a spinal cord injury population in Malaysia may provide the first data on activities of daily living in an Asian developing country.

Associations between leisure time physical activity and cardiovascular risk factors among older adults with long-term spinal cord injury

STUDY DESIGN

This is a cross-sectional study.

OBJECTIVES

To describe the association between cardiovascular risk factors (body mass index (BMI), waist circumference (WC), blood pressure, blood glucose and lipids) and leisure time physical activity (LTPA) in older adults with long-term spinal cord injury (SCI).

SETTING

Community settings, southern Sweden.

METHODS

Data from the baseline data collection of the Swedish Aging with Spinal Cord Injury Study (SASCIS) (n = 123, 71% men, injury levels C1-L5, American Spinal Injury Association Impairment Scale A-D, mean age 63 years, mean time since injury 24 years). Data were collected through home interviews, assessments and blood samples. The Physical Activity Recall Assessment for People with SCI was used to assess LTPA. Associations were investigated using multivariable linear regression analyses adjusted for age, gender, level and severity of injury, cause of injury, time since injury and tobacco use.

RESULTS

More minutes per day of moderate-to-heavy LTPA were significantly associated with a lower BMI (Beta = -0.31; p = 0.001) and a lower WC (Beta = -0.24; p = 0.009). More minutes per day of total LTPA (mild intensity or greater) were associated with a higher systolic blood pressure (Beta = 0.27; p = 0.041) among participants with tetraplegia. No other significant associations between the cardiovascular risk factors and total LTPA were found.

CONCLUSION

Participation in daily LTPA is associated with better cardiovascular health with regard to BMI and WC in older adults with long-term SCI. Further studies are needed to establish the specific amount of activity needed to obtain positive health effects in this group and the directional causality of the associations.

SPONSORSHIP

Not applicable.

Participation in moderate-to-vigorous leisure time physical activity is related to decreased visceral adipose tissue in adults with spinal cord injury

Increased visceral adiposity places individuals with chronic spinal cord injury (SCI) at increased risk of cardiometabolic disease. The purpose of this study was to identify if people with chronic SCI who participate in any moderate- to vigorous-intensity leisure time physical activity (LTPA) have lower visceral adipose tissue (VAT) area compared with those who report none. Participants included 136 adult men (n = 100) and women (n = 36) with chronic (mean (±SD) 15.6 ± 11.3 years post-injury) tetraplegia (n = 66) or paraplegia (n = 70) recruited from a tertiary rehabilitation hospital. VAT area was assessed via whole-body dual-energy X-ray absorptiometry using a Hologic densitometer and the manufacturer's body composition software. Moderate-to-vigorous LTPA was assessed using the Leisure Time Physical Activity Questionnaire for People with SCI (LTPAQ-SCI) or the Physical Activity Recall Assessment for People with SCI (PARA-SCI). Summary scores were dichotomized into any or no participation in moderate-to-vigorous LTPA to best represent the intensity described in current population-specific physical-activity guidelines. Data were analyzed using univariate and multiple regression analyses to identify the determinants of VAT. Overall, the model explained 67% of the variance in VAT area and included time post-injury, age-at-injury, android/gynoid ratio, waist circumference, and moderate-to-vigorous LTPA. Participation in any moderate-to-vigorous LTPA was significantly (95% confidence interval: -34.71 to -2.61, p = 0.02) associated with VAT after controlling for injury-related and body-composition correlates. Moderate-to-vigorous LTPA appears to be related to lower VAT area, suggesting potential for LTPA to reduce cardiometabolic disease risk among individuals with chronic SCI.

Cardiovascular Stress During Inpatient Spinal Cord Injury Rehabilitation

OBJECTIVES

(1) To measure the amount of cardiovascular stress, self-reported physical activity, and accelerometry-measured physical activity by individuals with spinal cord injury (SCI) during physical therapy (PT) and occupational therapy (OT); and (2) to investigate the relations between these measures.

DESIGN

Observational study.

SETTING

Two inpatient SCI rehabilitation centers.

PARTICIPANTS

Patients with SCI (N=87) were recruited from consecutive admissions to rehabilitation.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Heart rate was recorded by a Holter monitor, whereas physical activity was captured by self-report (Physical Activity Recall Assessment for People with SCI questionnaire) and real-time wrist accelerometry during a total of 334 PT and OT inpatient sessions. Differences between individuals with paraplegia and tetraplegia were assessed via Mann-Whitney U tests. Spearman correlations were used to explore the relation between measurements of physical activity and heart rate.

RESULTS

Time spent at a heart rate within a cardiovascular training zone (≥40% heart rate reserve) was low and did not exceed a median of 5 minutes. In contrast, individuals reported at least 60 minutes of higher-intensity time during therapy. There was a low but statistically significant correlation between all measures.

CONCLUSIONS

The cardiovascular stress incurred by individuals with SCI during inpatient PT and OT sessions is low and not sufficient to obtain a cardiovascular training effect to optimize their neurologic, cardiovascular, or musculoskeletal health; this represents a lost opportunity to maximize rehabilitation. Self-reported minutes of higher-intensity physical activity do not reflect actual time spent at a higher intensity measured objectively via a heart rate monitor.

Measurement of Physical Activity and Energy Expenditure in Wheelchair Users: Methods, Considerations and Future Directions

Accurately measuring physical activity and energy expenditure in persons with chronic physical disabilities who use wheelchairs is a considerable and ongoing challenge. Quantifying various free-living lifestyle behaviours in this group is at present restricted by our understanding of appropriate measurement tools and analytical techniques. This review provides a detailed evaluation of the currently available measurement tools used to predict physical activity and energy expenditure in persons who use wheelchairs. It also outlines numerous considerations specific to this population and suggests suitable future directions for the field. Of the existing three self-report methods utilised in this population, the 3-day Physical Activity Recall Assessment for People with Spinal Cord Injury (PARA-SCI) telephone interview demonstrates the best reliability and validity. However, the complexity of interview administration and potential for recall bias are notable limitations. Objective measurement tools, which overcome such considerations, have been validated using controlled laboratory protocols. These have consistently demonstrated the arm or wrist as the most suitable anatomical location to wear accelerometers. Yet, more complex data analysis methodologies may be necessary to further improve energy expenditure prediction for more intricate movements or behaviours. Multi-sensor devices that incorporate physiological signals and acceleration have recently been adapted for persons who use wheelchairs. Population specific algorithms offer considerable improvements in energy expenditure prediction accuracy. This review highlights the progress in the field and aims to encourage the wider scientific community to develop innovative solutions to accurately quantify physical activity in this population.

Leisure time physical activity among older adults with long-term spinal cord injury

STUDY DESIGN

Cross-sectional.

OBJECTIVES

To describe participation in leisure time physical activity (LTPA) (amount, intensity and type) among older adults with long-term spinal cord injury (SCI), and to investigate the associations with sociodemographics, injury characteristics and secondary health conditions (SHCs).

SETTING

Home settings in southern Sweden.

METHODS

Data from the Swedish Aging with Spinal Cord Injury Study (SASCIS). The physical activity recall assessment for people with SCI was used to assess LTPA among 84 men and 35 women (mean age 63.5 years, mean time since injury 24 years, injury levels C1-L5, American Spinal Injury Association Impairment Scale A-D). Associations were analyzed statistically using hierarchical multivariable regression.

RESULTS

Twenty-nine percent reported no LTPA, whereas 53% performed moderate-to-heavy intensity LTPA. The mean minutes per day of total LTPA was 34.7 (±41.5, median 15, range 0-171.7) and of moderate-to-heavy LTPA 22.5 (±35.1, median 5.0, range 0-140.0). The most frequently performed activities were walking and wheeling. Sociodemographics, injury characteristics and SHCs (bowel-related and bladder-related problems, spasticity and pain) explained 10.6% and 13.4%, respectively, of the variance in total and moderate-to-heavy LTPA. Age and wheelchair use were significantly, negatively associated with total LTPA. Women, wheelchair users and employed participants performed significantly less moderate-to-heavy LTPA than men, those using walking devices/no mobility device and unemployed participants.

CONCLUSION

Many older adults with long-term SCI do not reach the amount or intensity of LTPA needed to achieve fitness benefits. Research is needed on how to increase LTPA and to identify modifiable factors that could enhance their participation.