Promoting Physical Activity in Persons with Subacute Spinal Cord Injury

Carla Nooijen, MSc (Researcher)
Rita van den Berg-Emons, PhD (Project leader)
Henk Stam, MD, PhD
Michael Bergen, MD, PhD
Tebbe Sluis, MD
Marcel Post, PhD
Linda Valent, PhD

On October 14, 2015 Carla Nooijen will defend her dissertation entitled: Promoting Physical Activity in Persons with Subacute Spinal Cord Injury

SUMMARY

Persons with spinal cord injury (SCI) in inpatient rehabilitation are physically active during therapy sessions. However, after discharge from inpatient rehabilitation, daily physical activity levels are known to decline to a level that is severely low compared to the general population and also low compared to persons with other chronic diseases. More physical activity in persons with SCI has been found to reduce the risk of cardiovascular disease, prevent or reduce secondary conditions, and improve physical fitness and quality of life. During the first months after SCI, persons establish a new routine and therefore this period might be critical to introduce and encourage new habits that incorporate physical activity. The current thesis focuses on the promotion of physical activity in persons with subacute SCI.

The main objective of this thesis was to evaluate the added value of a behavioral intervention, on top of regular rehabilitation and handcycle training, on physical activity in persons with subacute SCI. Additionally, the intervention effects on secondary outcomes as health, participation and quality of life were studied and working mechanisms of the behavioral intervention evaluated. For further insight on the promotion of physical activity in persons with subacute SCI we additionally explored handcycle training feasibility during inpatient rehabilitation. Furthermore, baseline levels of exercise self-efficacy and fatigue were described and relations with demographic- and lesion characteristics were assessed.

The introductory Chapter 1 describes background information concerning SCI, secondary conditions, physical capacity, physical activity, and interventions to promote physical activity. A short description of Act-Active and the Umbrella project is provided. The chapter concludes with the aims and outline of this thesis.

Chapter 2 describes the longitudinal relation between objectively measured physical activity, and physical fitness and lipid profile in persons with subacute SCI. An increase in physical activity level was significantly related to an increase in physical capacity as measured during a maximal exercise test. Furthermore, an increase in physical activity level favorably impacted lipid profile. The results indicate that a more active lifestyle decreases the risk of cardiovascular disease for persons with subacute SCI.

The study described in chapter 3 estimates the prevalence of fatigue in persons with subacute SCI. Fatigue was prevalent in 31% of the participants, compared to 18% in the general population. Those with incomplete lesions seem to be at higher risk for fatigue. Furthermore, lower aerobic capacity tended to be related to more fatigue. It was concluded that fatigue is of concern in persons with subacute SCI, and because fatigue is known to persist among persons with SCI, interventions reducing fatigue seem necessary.

Chapter 4 describes the psychometric properties of the Dutch version of the exercise self-efficacy scale. The results support the use of the questionnaire as a reliable and valid measure for exercise self-efficacy. In chapter 5 this questionnaire was used to describe exercise self-efficacy and to assess subgroup differences in persons with subacute SCI. Persons with tetraplegia were found to have lower exercise self-efficacy, indicating that this subgroup might benefit from extra attention in promoting physical activity.

In chapter 6 feasibility and physical capacity results of handcycle training during inpatient rehabilitation are described. Overall, handcycle training during inpatient rehabilitation in persons with SCI was feasible except for training frequency. Persons with complete lesions demonstrated lower training feasibility. Most participants were satisfied with the handcycle training. Since the improvements in physical capacity were larger than those known to occur in persons with paraplegia receiving only regular rehabilitation, the results suggest that the addition of handcycle training may result in larger increases in physical capacity compared to regular rehabilitation only.

Chapters 7 to 9 describe the added value of a behavioral intervention promoting an active lifestyle after discharge from inpatient rehabilitation, on top of regular rehabilitation and handcycle training, in persons with subacute SCI. Chapter 7 describes the primary results on objectively measured physical activity. The behavioral intervention was effective in eliciting a behavioral change toward a more active lifestyle among persons with subacute SCI. Addition of the behavioral intervention resulted in 50% more wheeled physical activity half year after discharge from inpatient rehabilitation as well as continuation of the more active lifestyle up to one year after discharge. In chapter 8 the added value of the behavioral intervention on health, participation and quality of life is described. The addition of the behavioral intervention resulted in a more favorable lipid profile, lower diastolic blood pressure and higher participation one year after discharge from inpatient rehabilitation. Furthermore, there seemed to be an intervention effect on peak oxygen uptake and BMI. Perceptions of general health seemed to be lower after the intervention, while other domains of health-related quality of life did not seem to be affected by the behavioral intervention. As described in chapter 9, there was not one factor found to be a strong mediator but multiple parameters partly explained the effect of the behavioral intervention on physical activity. Pro-active coping, exercise self-efficacy, pain disability and helplessness are important concepts in interventions promoting physical activity in persons with subacute SCI. Based on all results of the randomized controlled trial we advise to add a behavioral intervention, on top of handcycle training, to regular rehabilitation.

Finally, chapter 10 contains the general discussion of this thesis. This chapter describes the main findings, results interpretation and literature perspective. Methodological considerations are addressed. Furthermore, the chapter describes clinical implications and directions and recommendations for future research.

Read more about this project and the other SCI projects in Rotterdam in the newsletter of January 2012.

Publications

A more active lifestyle in persons with a recent spinal cord injury benefits physical fitness and health. Nooijen CFJ, de Groot S, Postma K, Bergen MP, Stam HJ, Bussmann JBJ, van den Berg-Emons HJG. Spinal Cord. 2012; 50(4): 320-3.
Exercise self-efficacy in persons with spinal cord injury: Psychometric properties of the Dutch translation of the Exercise Self-Efficacy Scale. Nooijen CF, Post MW, Spijkerman DC, Bergen MP, Stam HJ, van den Berg-Emons RJ. J Rehabil Med. 2013; 45(4): 347-50.
Feasibility of handcycle training during inpatient rehabilitation in persons with spinal cord injury. Nooijen CF, van den Brand IL, Ter Horst P, Wynants M, Valent LJ, Stam HJ, van den Berg-Emons RJ, Act-Active research group. Arch Phys Med Rehabil. 2015. Accepted.
Fatigue in persons with subacute spinal cord injury who are dependent on a manual wheelchair. Nooijen CF, Vogels S, Bongers-Janssen HM, Bergen MP, Stam HJ, van den Berg-Emons HJ, Act-Active Research Group. Spinal Cord 2015. Accepted.