Physical activity promotion to persons with spinal cord injury by health and exercise professionals: A scoping review

Abstract

Objectives:

Health and exercise professionals (HEPs) are ideal promoters and valued messengers of physical activity (PA) information among persons with spinal cord injury (SCI). However, little is known about what strategies used by HEPs increase PA behavior in persons with SCI, or what factors influence HEPs when promoting PA to persons with SCI. The purposes of this scoping review were to (1) ascertain the extent, range and nature of the literature, (2) identify strategies used by HEPs that are associated with an increase in PA behavior for persons with SCI, and (3) identify the facilitators and barriers to PA promotion by the HEPs.

Methods:

A comprehensive search was undertaken. Search terms were expanded surrounding three key terms: PA, promotion, and SCI.

Results:

Twenty-four articles representing 18 unique studies were identified. HEPs predominantly consisted of physiotherapists, occupational therapists, and leisure trainers/therapists. Most interventions were delivered by HEPs to persons with SCI in in-patient rehabilitation centres and community-based settings. Tailored exercise programs and on-going counseling support were considered essential for increasing PA behavior. HEPs’ common barriers to PA promotion were perceived lack of time, education, and training.

Conclusion:

A need to improve and sustain SCI-specific PA knowledge and education was identified if PA promotion is to become a structured and integral component of practice. This study provides valuable information for interventions to increase PA behavior among persons with SCI by improving PA promotion by HEPs.

Introduction

Persons with spinal cord injury (SCI) often face a decline in physical, psychological and social functioning, which leads to a decrease in their quality of life (QoL).1 Physical activity (PA) has been defined as “participation in all activities requiring physical exertion” (e.g. leisure-time physical activity, activities of daily living2), and has been identified as a means to alleviate or prevent many of the health and well-being complications secondary to SCI (e.g. obesity, cardiovascular disease, depression, social isolation, and infections of the skin, bladder, and/or respiratory system).3 Evidence suggests that persons with SCI who are active are more able to efficiently perform activities of daily living, and thus function independently, while also reducing the risk of developing chronic diseases that are associated with being physically inactive.4 However, the majority of persons with SCI do not meet SCI-specific PA guidelines,5 which recommend at least 20 minutes of moderate to vigorous intensity aerobic activity twice per week and strength training exercises twice per week.6 Persons with SCI frequently face multiple barriers such as lack of self-confidence, lack of knowledge about resources available, and reduced accessibility that impede leading a physically active lifestyle.7 The promotion and encouragement of PA among persons with SCI from a trusted health and exercise professional (HEP) could compensate for PA barriers and increase PA in this population,8 wherein better overall functioning, health and QoL could be observed.9

HEPs are in an ideal position to promote PA to the population at large, as well as among persons with SCI. PA promotion is broadly defined as encouragement of enabling persons with SCI to increase PA levels in order to improve overall health.10 HEPs include individuals in the health and wellness fields who maintain human health through the application of the principles and procedures of evidence-based medicine, caring, and therapy (e.g. physicians, nurses, physiotherapists, occupational therapists).11 HEPs have been identified by persons with SCI as valued and trusted messengers of PA information.12–14 However, there is a lack of PA promotion efforts among HEPs;15 for example, HEPs report low confidence and skills for promoting PA to persons with disabilities as they often lack knowledge and resources to do so.16 Therefore, it is important to understand the contexts in which positive behavioral outcomes of PA promotion by HEPs may occur.

Identifying strategies that have been previously implemented to promote PA can provide a useful framework for understanding how HEPs can facilitate PA behavior change among persons with SCI. Strategies can be defined as an approach used by HEPs to increase PA among persons with SCI (e.g. behavior change techniques, motivational interviewing).17 In addition, identifying the barriers that HEPs encounter can assist in recognizing gaps associated with the lack of PA promotion to persons with SCI. Similarly, identifying the facilitators of PA promotion among HEPs to persons with SCI (e.g. having knowledge, training, and experience with SCI and SCI PA guidelines) has the potential to guide future research and practice, and thus close the gap in HEPs’ PA promotion behavior.

Previous reviews in the field of PA promotion to persons with disabilities indicate that exercise intervention literature targeting persons with disabilities is a growing area of research. However, further investigations are needed to identify optimal strategies that scale across various disability groups. Literature supports the idea of PA promotion interventions producing positive changes in PA behavior for a variety of disabilities,18 however, literature on exercise and disability is extremely broad in scope and has limited generalizability to any specific disability group.19 As a growing number of studies show the effectiveness of behavior change strategies to increase PA in populations with neurological conditions, a review conducted by Donkers and colleagues20 suggest that there is a need for future work to highlight the most important strategies, as well as how to best implement their use into practice.

As such, the purpose of this scoping review is to identify and map the literature related to PA promotion by HEPs to persons with SCI. The specific aims are to (1) ascertain the extent, range and nature of the literature, (2) identify the strategies targeted and/or the strategies used by HEPs that are associated with an increase in PA behavior for persons with SCI, and (3) identify the facilitators and barriers to PA promotion by HEPs

Methods

The five stage Arksey and O’Malley framework was adopted for this scoping review to complement the study’s exploratory aims.21 The Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) Checklist was used to ensure all aspects of a scoping review were included.22

Stage 1–2: Identifying the research question and identifying relevant studies

The overarching purpose of this scoping review was to address the broad question: “What is known from the existing literature regarding PA promotion by HEPs to persons with SCI.” Appropriate search terms were created and expanded surrounding three key terms: physical activity, promotion, and spinal cord injury. These terms were selected based on previous research3,7 and in consultation with a university librarian to address the purpose of this study. Full search string is available in Appendix A. Due to the variation of names for HEPs across disciplines and countries, this term was excluded from the key search terms. Rather, the inclusion of HEPs was identified during screening.

The database search included CINAHL, Medline, PsycARTICLES, PsychINFO and SPORTDiscus through EBSCO HOST. The search parameters were set from 2000 onwards given interest in the research and practice fields on PA for individuals with disabilities, including SCI. The research in this field increased following Rimmer’s23 publication calling for reducing secondary conditions (e.g. obesity, hypertension, pressure sores), in order to maintain functional independence, to provide an opportunity for leisure and enjoyment, and to enhance the overall quality of life by reducing environmental barriers to good health. Reference lists of relevant papers were reviewed to identify any additional articles. In the case where an article appeared to fit the inclusion criteria, the author of the paper was contacted if it was not accessible. The authors also checked their personal libraries for any other relevant papers. The search was carried out in June 2019.

Stage 3: Study selection

Inclusion and exclusion criteria were guided by the purposes of this study. To be included, studies were required to (1) focus on PA promotion by HEPs to persons with SCI, (2) be published in a peer reviewed journal, and (3) be written in English. Studies were excluded if (1) the PA intervention was not delivered by HEPs, (2) the PA intervention was delivered by HEPs to persons with SCI, but only included information regarding the physiological outcomes of PA and did not include any information regarding the promotion of PA (e.g. a randomized controlled trial that examined changes in fitness would not be included), and (3) the publication was an editorial, commentary, conference abstract or proceeding, or a dissertation. An intervention has been defined as an act performed for, with or on behalf of a person or population whose purpose is to assess, improve, maintain, promote or modify health, functioning or health conditions,24 while strategies have been defined as mechanisms of intervention delivery.17 References from the searches were imported into the Mendeley reference manager. All duplicates were removed. Articles were screened by title then by abstract, by the first and second authors. The first and second authors screened full texts of articles that were deemed as potentially relevant based on the inclusion criteria. Discrepancies between authors were resolved through discussion and in consultation with the third author. Study protocols for randomized controlled trials (RCT) were included except where this initial study regarded a different study population (e.g.25). In addition, one study made reference to their study protocol which was under review (e.g.26), and is now published. In this instance we contacted the author and asked permission to include this paper within our scoping review as it provided deeper insight to the originally included study. Other studies were excluded where it could not be explicitly determined that the person delivering the intervention was a HEP.

Stage 4: Charting the data

A database in Google Sheets was created for data entry and management. The first author independently extracted data from all of the studies that met the inclusion criteria. The second and third authors audited the data extraction. Key information from each study was extracted using the following headings: (1) study characteristics (e.g. title, year, purpose), (2) barriers to PA promotion by HEPs, (3) facilitators to PA promotion by HEPs, (4) strategies used/HEPs’ behavior, (5) barriers to increasing PA minutes among persons with SCI, (6) facilitators for increasing PA minutes among persons with SCI, (7) and PA behavior among persons with SCI. Frequency counts were used to determine the extent, range, and nature of the literature, as well as the most common or underutilized strategies, barriers, and facilitators to PA promotion by HEPs to person with SCI.

A quality assessment of the included articles was performed following the guidelines outlined in the Mixed Methods Appraisal Tool (MMAT).27 The MMAT allows for the appraisal of several types of study methodologies and designs on a 5 point scale (0 = lower quality, 5 = higher quality), making it possible to interpret the quality assessment of all included studies on a single scale. The first author and a research assistant independently performed a quality assessment of each included article by assigning the article a score out of five based on the MMAT guidelines,27 then met to discuss any discrepancies in the assigned quality scores. Any discrepancies were discussed and coders agreed on the final quality assessment score. Included protocol or methods papers were not assigned a score, as these study types are not accounted for in the MMAT.

Stage 5: Collating, summarizing and reporting the results

In the final stage, data were summarized and reported to address the specific aims of the scoping review. In addition, a consultation exercise was undertaken with an expert panel of key stakeholders including persons with spinal cord injury, international academics and relevant charities, organizations and professional bodies. The consultation stage has been proposed as an essential component of scoping review methodology to provide valuable insights into emerging issues relating to the review and enhance opportunities for knowledge transfer.21 The expert panel were part of a wider project team and were invited to comment upon the aims and results of the study. All expert panel members provided feedback on the aims at the start of the research process and several expert panel members responded to state their agreement with the results of the study. Furthermore, expert panel members identified our interpretation of results as aligning with current issues in their respective research and practice fields. Their comments contributed to the discussion and recommendations.

Results

A total of 2261 articles were identified following the removal of duplicates. After screening for inclusion and exclusion criteria, 24 published articles representing 18 unique studies were included in the scoping review. For six of the studies, original papers were included.13,26,28–31 Please refer to the PRISMA-ScR flowchart in Fig. 1. Relevant extracted data are summarized in Table 1.

Figure 1.

PRISMA-ScR flow diagram. Diagram for the scoping review detailing the database searches, number of abstracts screened and the full texts retrieved.

Table 1 .

Summary of study findings.

Aims of the study
Aim 1: Extent, range and nature of literature		Aim 2: Strategies used to promote PA among HEPs		Aim 3: Barriers and facilitators to PA promotion among HEPs		Mixed methods appraisal tool score
Author (year) Country Purpose Study design	Participants	Strategies used	Behavioral outcome(s)	Barriers to promoting PA	Facilitators to promoting PA	(Out of 5; 0 = lowest, 5 = highest)
Arbour-Nicitopoulos et al. (2017)29 Canada To evaluate the efficacy of the SCI Get Fit Toolkit delivered online on theoretical constructs and moderate-to-vigorous PA among adults with SCI Single blind, two-group RCT	90 inactive persons with SCI	HEP N/A SCI N/A	HEP N/A SCI N/A	N/A	N/A	5
Arbour-Nicitopoulos et al. (2013)45 Canada To systematically develop an evidence-informed LTPA resource for adults with SCI Tool development using multiple methods	78 persons with SCI A multidisciplinary panel of 10 expert researchers	HEP N/A SCI N/A	HEP N/A SCI N/A	Time constraints Competing service demands to provide clients with a variety of health-related information Uncertainty regarding the optimal time to introduce the toolkit in acute practice Reaching individuals not linked to organizations that would use health care services	N/A	4
Chemtob et al. (2019)29 Canada To pilot test a tele-health intervention, grounded in self-determination theory, to enhance need satisfaction, motivation, physical activity, and quality of life among adults with SCI Tele-health intervention	22 persons with SCI 1 HEP	HEP MI to persons with SCI LTPA counseling SCI Receive one, 1-h counseling session per week, for eight weeks via an online video-chat platform	HEP N/R SCI +	N/A	Having SCI-PA education and training MI training Supplementary materials (toolbox of intervention components to aid in structuring the sessions)	4
Sweet et al. (2017)42 Canada To determine if the intervention group reports greater increases in exercise behavior, basic psychological needs, and autonomous motivation compared to the control group, to investigate group differences, to understand the impact of the intervention and to determine satisfaction with the technology and extent to which the counselor delivered the intervention as intended Protocol paper for pilot RCT	24 persons with paraplegia 1 HEP	HEP N/A SCI N/A	HEP N/A SCI N/A	N/A	N/A	N/P
Coulter et al. (2017)32 Scotland To evaluate the effectiveness and participant satisfaction of web-based physiotherapy in people with SCI Pilot RCT	Persons with SCI HEPs	HEP HEP individually tailoring exercise programs to patients needs Reviewing exercise diaries Contacting patients every two weeks Updating the program as needed SCI Receive 8 weeks of web-based physiotherapy, twice per week	HEP N/R SCI +	N/A	Having SCI-PA knowledge	3
de Oliveria et al. (2016)37 Australia and New Zealand To determine the effects of the SCIPA Com intervention on LTPA and associated outcomes among participants with spinal cord injury Quasi-experimental translational study with pre- and post-measures	64 persons with SCI HEPs	HEP Guiding clients through individual or group sessions SCI Partaking in 30–60 minute guided PA sessions with HEPs Partaking in assessments 3, 6, and 9-months post-intervention	HEP N/R SCI +	N/A	Guided training sessions Supplementary materials	4
Foulon et al. (2012)46 Canada and the United States To determine preferences of persons with SCI regarding the content and design of a physical activity guide, and to determine what health care professionals would find useful in a SCI physical activity guide Cross-sectional survey design	78 persons with SCI 80 HEPs	HEP N/A SCI N/A	HEP N/A SCI N/A	Time constraints Lack of knowledge and education Lack of confidence Lack of resources, prescription aids, and supported literature	N/A	3
Kooijmans et al. (2017)30 The Netherlands To evaluate the effectiveness of a structured self-management intervention to promote an active lifestyle in inactive persons with long-term SCI 16-week multicentre RCT self-management intervention	64 persons with SCI HEPs	HEP Providing at home visits Guiding patients through individual and group sessions during a total of 16 weeks Guidance and discussion of living a healthy, active lifestyle Additional resources SCI Partaking in a 16-week intervention program	HEP N/R SCI Ø	N/A	Having experience working with SCI MI training Supplementary materials	5
Kooijmans et al. (2013)33 The Netherlands To evaluate the effectiveness of a 16-week self-management intervention on physical activity level and self-management skills (self-efficacy, proactive coping and problem solving skills) in persons with chronic SCI Protocol paper for 16-week multicentre RCT self-management intervention	64 persons with SCI HEPs	HEP Providing an at home visit One on one time with client to understand the behavior change desires HEP individually tailoring exercise programs to patients needs Running group sessions for 6–8 persons with SCI (2.5 h) Individual sessions via telephone to monitor participants exercise Providing extra support SCI Partaking in a 16-week self-management intervention on physical activity level and self-management skills	HEP N/R SCI N/R	N/A	Having experience working with SCI Trained in MI Supplementary materials Using a manual with detailed guidance on how the intervention should be executed	N/P
Latimer-Cheung et al. (2013)40 Canada To describe two pilot interventions targeting persons with SCI who are insufficiently active but intend to be active (i.e. “intenders”) Motivational counseling and peer-mediated intervention program	Study 1: seven persons with paraplegia or tetraplegia Study 2: 11 persons with paraplegia, and HEPs Peer with paraplegia	HEP Telephone contact and counseling services that applied MI principles to persons with SCI Goal setting At home visit by CPT and a peer with paraplegia SCI Receive a single counseling session Receive a single home visit by a HEP and a peer with paraplegia	HEP N/R SCI +	N/A	Having a peer with an SCI MI training Supplementary materials SCI experience Experience with peer support groups Training in intervention delivery	5
Ma et al. (2020)26 Canada To describe the rigorous co-development process of a theory-based, PT-led PA intervention for persons with SCI and assess its feasibility to be effective and adopted in physiotherapy practice Cross-sectional survey, semi-structured interview, and RCT	26 persons with SCI 259 HEPs 13 stakeholders/experts	HEP N/A SCI N/A	HEP N/A SCI N/A	Time constraints Lack of confidence Lack of resources	Training in PA intervention content Partaking in a 1-hour education session	4
Ma et al. (2019)34 Canada To examine 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 RCT	28 persons with SCI HEPs	HEP Coaching persons with SCI SCI Receive an introductory personal training session followed by 8 weekly 15-min PA behavioral coaching sessions per week	HEP N/R SCI +	N/A	Having SCI knowledge and experience	4
Nooijen et al. (2016b)35 The Netherlands To assess the mediating effects of physical and psychosocial factors on the intervention effect on physical activity RCT	39 persons with SCI HEPs	HEP Planned, 13 face-to-face one hour sessions with patients from two months before until three months after discharge Using MI to aid in facilitation of movement among stages of the transtheoretical model of change Providing a home visit in the first month after discharge to help optimize the home and environment of the participant to undertake PA Providing additional information on request by the participant on relevant topics related to PA SCI Partaking in regular rehabilitation and performed a structured handcycle training program during the last 8 weeks of inpatient Intervention group participated in a behavioral intervention Setting an agenda	HEP N/R SCI Ø	N/A	MI training Supplementary materials	4
Nooijen et al. (2016a)31 The Netherlands To determine the effect of adding the behavioral intervention on physical activity and to determine the effects on physical capacity, health, participation and quality of life RCT	45 persons with SCI HEPs	HEP Delivering MI in addition to standard rehabilitation care SCI Receive a behavioral intervention promoting an active lifestyle after discharge in addition to regular rehabilitation	HEP N/R SCI +	N/A	MI training	4
Pelletier et al. (2014)36 Canada To evaluate the efficacy of referral from a health care professional to regular exercise combined with 16 weeks of counseling support following discharge from inpatient or outpatient SCI rehabilitation 16-week follow-up study	17 persons with SCI Trained research staff familiar with exercise in the SCI population	HEP Providing continuous open and tailored PA telephone counseling and support Follow-up phone calls to monitor patient’s LTPA levels and updating programs accordingly SCI Getting a referral for regular exercise Receive telephone counseling support to monitor adherence for the prescribed program for 16 weeks	HEP N/R SCI +	N/A	Having experience with persons with SCI	3
Salci et al. (2016)41 Canada To evaluate participants’ perceptions of the relevance/usefulness of ALLTP material/presentation, examine changes in participants’ self-efficacy to promote LTPA, identify program components associated with greater self-efficacy and, measure participants’ use of ALLTP skills and resources over the subsequent 6 months Quasi-experimental pre–post design with 6-month follow-up	Six persons with SCI Six HEPs	HEP Completed sections of ALLTP, provided feedback Promote the program resource SCI Completed sections of ALLTP, provided feedback Used the program resources to perform PA	HEP N/A SCI +	N/A	Using the program as a resource	3
Serpanou et al. (2019)48 Greece To explore PT’s perspectives about patients with incomplete post-traumatic adherence to recommended home exercises Qualitative	13 HEPs	HEP N/A SCI N/A	HEP N/A SCI N/A	Patient’s refusal to cooperate with an at home exercise program	Knowledge about the importance of PA Experience providing at home services to SCI Having experience working with SCI	5
Shirazipour et al. (2018)12 Canada To examine health care professionals’ and trainees’ initial knowledge of PAGs for adults with SCI and the general population and to determine the utility of the CMCL intervention for improving this knowledge Event-based intervention	29 HEPs 573 trainees participating in 35 CMCL presentations between 2011 and 2012	HEP N/A SCI N/A	HEP N/A SCI N/A	Single offering of intervention Little opportunity for interaction Low awareness of SCI PAGs	Attending an evidence and theory-based intervention delivered by HEPs presenters	5
Smith et al. (2015)13 Canada To examine the utility of stories as a possible tool for disseminating synthesized physical activity knowledge to adults with SCI and HEPs working with this population Ethnographic creative non-fiction	15 persons with SCI 13 peer mentors with SCI 15 HEPs	HEP Use of a story SCI Individually listening to an evidence-based story set in a rehabilitation hospital about the process of becoming physically active following SCI Reporting on personal perceptions of the story	HEP N/R SCI +	N/A	Positive comments from SCI about the stories Evidence-based Stories are realistic	5
Smith (2013)47 Canada To develop an evidence-based resource for knowing and communicating the complexities involved for both males and females in implementing and sustaining a physically active lifestyle shortly after SCI Ethnographic creative non-fiction	8 persons with SCI 8 SCI HEPs	HEP N/A SCI N/A	HEP N/A SCI N/A	N/A	N/A	N/P
Thomas et al. (2011)43 The United States To investigate changes in exercise behavior of individuals with a spinal cord injury (SCI) after interacting with knowledgeable health care professionals and receiving a tailored home program of physical activity Longitudinal study	21 persons with SCI HEPs	HEP Telephone follow-up post-intervention HEP individually tailoring exercise programs to patients needs SCI Receive brochure and DVD/videotape that explain the benefits of PA that also provides examples of appropriate exercises Enhanced intervention group also receive additional individualized instruction in an in-home physical activity program, along with a varied array of exercise supplies	HEP N/R SCI +	N/A	Knowledge about the importance of PA	4
Tomasone et al. (2017)38 Canada To explore the implementation correlates of change in LTPA intentions and behavior in the second phase of GIM Qualitative	46 persons enrolled in GIM HEP	HEP Providing clients with counseling sessions over the phone weekly for the first two months, biweekly for months 2–4, and then monthly for months 4–6 SCI Receive telephone-based counseling weekly for the first 2 months, biweekly for months 2–4, monthly for months 4–6	HEP N/R SCI +	N/A	SCI education and training Supplementary materials	5
Warms et al. (2004)39 The United States To evaluate the acceptability and feasibility of a lifestyle physical activity program for persons with spinal cord injury Nonexperimental pre-post-test design	16 persons with SCI who used a manual wheelchair as primary means of locomotion HEPs	HEP At home visits while providing MI to patients Follow-up phone calls SCI Participate in a single group pre-post-test of the “BE Active in Life Program”	HEP N/R SCI +	N/A	MI training Supplementary materials	3
Williams et al. (2018)44 United Kingdom and Ireland To explore the perceptions of PTs in SCI rehabilitation on PA for persons with SCI, and what is done to promote PA Qualitative	18 neurological PTs from SCI centres	HEP N/A SCI N/A	HEP N/A SCI N/A	Lack of formal training and education in sport and exercise (schooling) Lack of clarity within the healthcare system as to the roles and responsibilities of health care professionals in PA promotion PTs holding certain beliefs about PA (lack of skill and confidence in SCI) •Lack of sources of PA knowledge Inconsistent definition of PA between HEPs HEPs identifying barriers for SCI to increase PA	Knowledge about the importance of PA (gained through practical experience of caring for persons with SCI over time, and some of them gained this through further education such as MSc or PhD)	5

Note. ALLTP: Active Living Leaders Training Program; Behavioral outcome: increase, decrease, or no significance in PA behavior, CPT: certified personal trainer; GIM: Get in Motion; HEPs: health and exercise professionals; KT: knowledge translation; MI: motivational interviewing; LTPA: leisure time physical activity; MS: multiple sclerosis; N/A: not applicable; N/P: not performed; N/R: not reported; PA: physical activity; PAGs: physical activity guidelines; RCT: randomized control trial; SCIPA Com: Spinal Cord Injury and Physical Activity in the Community, Strategies used: the PA promotion strategies that were used in each study, +: an increase in physical activity behavior; −: a decrease in physical activity behavior; Ø: no significant difference in physical activity behavior outcome.

The Mixed Methods Appraisal Tool27 was used to assess the quality of each included article, on a scale from one to five, by two independent assessors. Quality assessment was not performed for protocol papers in which empirical research was not conducted.

Aim One: Extent, range and nature of the literature

Articles that were included were from North America, Europe, or Australia and New Zealand, with HEPs predominantly consisting of physiotherapists. Within the studies, the majority of authors classified their participants as “adults with SCI.” Articles sought to examine a variety of PA contexts through a range of study designs (i.e. randomized control trial, quasi-experimental translational study with pre- and post-measures, longitudinal study). Many studies delivered interventions by HEPs to increase PA in persons with SCI in both in-patient13,30,32–36 and community settings.29,37–43 A range of strategies were used by HEPs, or developed for use by HEPs, to promote PA behavior among persons with SCI. Of the 24 articles included, 15 discussed strategies. Six of the studies were RCTs,30–35 two of the studies were quasi-experimental study designs,37,41 and the following studies were of various study designs (e.g. follow-up study,36 ethnographic creative non-fiction,36 and longitudinal study43).

Of the 24 articles assessed for quality using the MMAT, 8 scored a 5 out of 5,12,13,28,30,38,40,44,48 8 scored a 4 out of 5,26,29,31,34,35,37,43,45 5 scored a 3 out of 5,32,36,39,41,46 and 3 were not able to be assessed as they were protocol papers and did not conduct empirical research,33,42,47 All articles were included regardless of the quality assessment score received, as excluding studies with low methodological quality is usually discouraged.27 Presentations of the scoring are reflected in Table 1.

Aim Two: Strategies used to promote PA among HEPs

The most commonly-used strategies supporting positive PA outcomes included distributing promotional materials,13,28,44 motivational interviewing (MI),29,31,39 PA counseling,29,36,38,40 tailoring programs to fit the client’s needs,26,32,33,43 and frequently following up with clients to monitor progress.36,39,43 Eight studies reported an overall increase in PA behavior among persons with SCI who participated in the studies;29,32,34,35,37–43 interventions containing tailored exercise programs, behavioral components (e.g. regular follow up with clients, delivering MI to clients) and on-going counseling support were considered essential for increasing motivation, self-efficacy and PA behavior among persons with SCI. Three studies reported a null change in PA behavior among persons with SCI after the interventions, which targeted self-efficacy and proactive coping, and providing print resources to persons with SCI.28,30,36 However, this null change was due to the delivery of the intervention. Three studies reported an increase in PA promotion among HEPs.13,37,43 Interventions containing personalized training sessions and supplementary materials were found to increase PA and were considered critical to increase PA promotion behavior because of the physical contact and built relationship between the HEP and the person with SCI. Five articles did not report on an increase or decrease in PA behavior among persons with SCI or PA promotion among HEPs as the aims of these studies were not to increase PA behavior, so this information was not reported.26,31,33,41,42,45 Seven studies reported antecedents to PA behavior change among persons with SCI and PA promotion among HEPs.12,26,40,44,46–48 None of the included articles reported a decrease in PA behavior among persons with SCI or a decrease in PA promotion among HEPs.

Aim Three: Barriers and facilitators to PA promotion among HEPs

Of the 18 studies included in the scoping review, only six articles reported perceived barriers related to the promotion of PA to persons with SCI by HEPs.12,26,44–46,48 One of the studies was an RCT,26 two of the studies were of qualitative study designs,44,48 and the remaining studies were of various study designs (e.g. cross-sectional survey design,46 event-based intervention,12 and tool development using multiple methods (i.e. questionnaires and interviews)45). Results suggest that the most common barriers to the promotion of PA included perceived lack of time,26,45,46 limited education,12,44,46 and absence of relevant resources (e.g. prescription aids) related to SCI-specific PA.26,44,46 Other barriers included lack of training and experience with persons with SCI,44,46 lack of clarity within the healthcare system as to the roles and responsibilities of health care professionals in PA promotion (i.e. who has the responsibility of PA promotion44), and low confidence in promoting PA to persons with SCI.26,46 Thirteen studies reported perceived facilitators related to the promotion of PA to persons with SCI by HEPs.12,26,29,30,32,33,35,37–40,43,44 Having knowledge and education on the importance of PA for persons with SCI,26,29,32,34,38,43,44,48 formal training,26,29,30,35,37,39,40 additional and relevant resources (e.g. booklets, intervention protocol to help structure the counseling, exercise diaries, and interactive websites)29,30,31,37–43,44 as well as practical experience working with persons with SCI,30,34,40,48 were shown to facilitate PA promotion. Participating in evidence and theory-based interventions (e.g. Theory of Deliberate Practice, and Narrative Theory) was also shown to facilitate PA promotion among HEPs.12,13,41

Discussion

The purpose of this study was to identify and explore literature related to PA promotion by HEPs for persons with SCI. Specifically, the aims of this study were threefold: (1) ascertain the extent, range and nature of the literature, (2) identify the strategies targeted and/or the strategies used by HEPs that are associated with an increase in PA behavior for persons with SCI, and (3) identify the facilitators and barriers to PA promotion by HEPs. HEPs predominantly consisted of physiotherapists, occupational therapists, and leisure trainers/therapists. Most interventions were delivered by HEPs to persons with SCI in in-patient rehabilitation centres and community-based settings. Tailored exercise programs and on-going counseling support were considered essential for increasing PA motivation, self-efficacy, and changing behavior. Frequently cited barriers to PA promotion by HEPs included perceived lack of time, education, and training, while frequently cited facilitators included knowledge about the importance of PA, formal training, and supplementary resources (e.g. booklets, intervention protocol to help structure the counseling, exercise diaries, and interactive websites).

Aim One: Extent, range and nature of the literature

A variety of study designs and methods were used, which makes it challenging to make comparisons of studies. Only nine studies used experimental study designs such as RCTs. RCTs are seen as efficient study designs as they are made to answer the questions of interest as clearly and efficiently as possible by using randomization to aim to reduce bias and to examine the cause–effect relationship between an intervention and outcome.49 Other characteristics of the studies included taking place in high income countries, specifically, North America, Europe, or Australia and New Zealand. Consequently, the findings can only be generalizable to high income countries, signifying that there might be a lack of published studies about PA promotion from HEPs across low income countries. It is of importance to note that only papers written in English were accounted for in this review, increasing the probability that studies from high income countries would be included. These findings suggest that future work should review the types of PA promotion strategies among HEPs across low income countries to further generalize findings.

Within the studies, HEPs predominantly consisted of physiotherapists, while also including occupational therapists, as well as a variety of exercise trainers and therapists. Of the included studies, definitions of HEPs ranged, but overall, were broadly defined. Subjective differences in HEP classification created a lack of consistent reporting of what types of HEPs were included in each study, thus, having to interpret the HEPs as the authors intended (e.g. exercise professionals,36 health care professionals,46 neurological physiotherapists43). Therefore, the inconsistent terminology was a challenge due to the discrepancy between definitions of HEPs across nations, as some professionals are considered HEPs only in certain countries. For example, in Canada, the term Kinesiologist is a protected term only in the Province of Ontario,50 however, the term does not exist in Europe, and therefore a Kinesiologist would not be considered a HEP in Europe. Some articles were specific to HEP classifications (e.g. only included physiotherapists), while other articles included a broad range of HEPs in their sample. Of note, broad definitions of SCI were used to classify the injuries of study participants, as only three studies specified that individuals included in their study had a paraplegic diagnosis.40,42,48 Therefore, the included studies may have had difficulties with PA promotion to persons with high level injuries (e.g. tetraplegics). Although a variety of HEPs appear able to provide PA promotion to people with SCI, future studies should outline the role and qualifications of the HEP included in the study in order to minimize discrepancies of HEPs from country to country, as well as which HEPs are successful in promoting PA and why this may be.

Aim Two: Strategies used to promote PA among HEPs

Several PA promotion strategies developed for and/or used by HEPs that were found to produce positive PA outcomes among persons with SCI included, but were not limited to: individually tailored exercise programs, regular follow up with clients, delivering MI to clients, providing counseling support to clients, providing interventions over the phone, and including at home visits for clients. Notably, these strategies are consistent with previous literature for improving PA engagement among persons with an SCI.7 By using these strategies, studies reported positive outcomes in increasing PA by persons with SCI, which provides clients with the most effective care that is available to improve client outcomes.51 The dissemination of health promotion materials through online methods provides an expansive avenue to contact a wide variety of individuals. Accordingly, the provision of health interventions through this route may improve intervention awareness and uptake. However, the strategies that produced positive outcomes were primarily delivered in person or over the phone by HEPs, as the results of this review have indicated persons with SCI prefer to receive these strategies through live contact with the HEPs.26,38,40 Further, the studies that used these strategies received high scores (i.e. 4 or 5) on the MMAT, indicating that the quality of research performed about these strategies is high. Therefore, addressing this gap between atypical avenues of dissemination (e.g. web-based) and preferred methods among targeted groups is an important consideration for future interventions.

However, none of the studies evaluated the outcomes of HEP promotion, whether the strategies used created an increase in PA promotion among HEPs, or ran interventions targeted at HEPs to increase their confidence, skills, or education in PA promotion to persons with SCI. As such, this is a limitation of the literature as a whole. Documenting strategies to increase PA promotion resulting in positive outcomes for increasing PA behavior among persons with SCI is important to guide future research and practice in this field. Future researchers should look to include these strategies when creating interventions to increase PA behavior among persons with SCI, as well as targeting interventions towards HEPs to increase PA promotion to persons with SCI. HEPs should aim to use these strategies as a mechanism to increase PA behaviors among individuals with SCI, and should learn and develop the skills to support these strategies in their daily practice.

Aim Three: Barriers and facilitators to PA promotion among HEPs

In addressing common barriers that impede HEPs’ PA promotion to persons with SCI, researchers and professionals alike can work to modify both research and practice, with the aim of reducing the significant challenges that exist in this field. The results of this review suggest the most common barriers HEPs face in facilitating PA discussion with SCI clients include a perceived lack of time,26,44,45 a lack of formal education exclusively regarding SCI,12,43,45 and lacking relevant resources related to SCI specific PAGs.26,43,45 Other notable barriers included lack of training and/or experience working with persons with SCI,43,45 as well as uncertainty regarding HEPs’ duties to promote PA among persons with SCI.43 While not discussed as frequently, lack of confidence was an additional barrier mentioned in some studies.26,45 It is important to note that persons with SCI face barriers to performing PA including intrapersonal or intrinsic barriers (e.g. lack of motivation, lack of energy, lack of interest), lack of resources (e.g. cost of an exercise program, not knowing where to exercise), and structural or environmental barriers (e.g. accessibility of facilities and knowledgeable instructors).52 Of note, the studies that reported these barriers were of high quality (three scored a five12,32,48 and two scored a four26,45 on the MMAT). Highlighted by Martin Ginis and colleagues,53 HEPs can have an impact on intrapersonal level barriers of persons with SCI in relation to PA. As HEPs are in an ideal position to promote PA, decreasing barriers faced by persons with SCI – including low levels of self-efficacy, embarrassment, and knowledge about basic exercise – may aid in increasing levels of PA. However, as HEPs commonly face the aforementioned barriers when promoting PA to persons with SCI, this may maximize the gap between increased levels of PA and person with SCI. Overall, these findings are consistent with previous literature referencing common barriers that HEPs face while promoting PA.8,55 As such, this review adds to the pool of existing literature regarding how HEPs perceive barriers to PA promotion to persons with SCI among HEPs. Addressing common barriers that HEPs face when aiming to promote PA to persons with SCI is notable because this highlights where the knowledge to action gap needs to be bridged. This review can ultimately aid in the bridging of this gap, as researchers, stakeholders, and policy makers can recognize where actions needs to be taken in order to increase PA promotion among HEPs.

While addressing barriers is critical to understanding the lack of PA promotion from HEPs to persons with SCI, understanding facilitators of behavior also provides significant insight into strategies for increasing PA promotion among HEPs. Specifically, education regarding the importance of PA for persons with SCI, as well as training to adequately promote PA to this population, is essential and consistent with previous literature.54 Additionally, practical experience with persons with SCI is a prominent facilitator discussed among HEPs for increasing PA behavior.29,30,32–34,36,38,48 Further, the provision of relevant, evidence based resources and workshops was found to facilitate discussion about PA.26,29,30,33,37–41 Identifying what elements/strategies/methods that facilitate discussions regarding PA from HEPs to persons with SCI is imperative for identifying what mechanisms are already successful, and how they can be integrated into future practice to close the knowledge to practice gap in this field. It is important to mention the medium to high quality scores for these studies: two studies scored three,34,41,42 four studies scored four,26,29,35,39 four studies scored five,30,38,43,46 and one study was not able to be assessed for quality using the MMAT, as it was a protocol paper.37 Thus, moving forward, future interventions should acknowledge these facilitators and include them in practice.

Strengths and limitations

This review has several strengths. Foremost, study findings identified gaps in the literature, specifically there are limited studies that examine the effectiveness of PA promotion outcomes, and there are a lack of SCI-specific PA education and tools that exist to aid in the promotion of PA by HEPs to persons with SCI. Second, the application of a valid scoping review framework21 provided reliable methodology to search the appropriate literature in this field. To try and gain breadth and depth of results, the inclusion of various literature across several fields/domains, while still maintaining appropriateness to the research aims, is a strength of this study. All empirical studies have undergone an assessment to appraise study quality using a reliable guideline (i.e. the MMAT).

However, this study has some notable limitations. First, several PA strategies were found to aid in increasing PA behavior; however, it is difficult to draw the conclusion regarding the effectiveness of behavior change strategy since most studies used several strategies within their PA promotion program, and did not evaluate the contribution of each strategy to the effects on PA. As such, it is not clear which strategy would be the most successful with an increase in PA behavior in any given situation. We recognize that in order to be certain about which strategy may be most effective, future studies should employ meta regression techniques to analyze the effectiveness of individual strategies. While only published literature in English was used for this review, relevant information may have been overlooked. Additionally, some studies provided an incomplete reporting of the details regarding the types of HEPs involved within the intervention. Finally, the inclusion criteria may have been too selective to account for varying terminologies for HEPs. A similar drawback may have occurred in the description of study participants. If it was not explicitly stated in the methodology that persons with SCI were part of a sample of persons with physical disabilities, the study may have been overlooked. As such, studies that did not explicitly report participant details were also excluded. Future researchers should conduct a systematic review that focuses on strategies for high and low resource environments, which includes grey literature and non-English language studies in the search.

Conclusions

Overall, findings support that providing knowledge and education, ongoing counseling support, and tailored exercise programs may produce positive PA behavioral outcomes among person with SCI. However, further research is needed to improve and sustain PA knowledge and education among HEPs if PA promotion to persons with SCI is to become a structured and integral component of HEPs’ practice.

Funding Statement

None.

Disclaimer statements

Contributors NG: Conceptualized the work; collected, analyzed and interpreted the data; drafted the work; provided final approval of the version to be published. TLW: Conceptualized the work; collected, analyzed and interpreted the data; revised the work critically for important intellectual content; provided final approval of the version to be published. JRT: Conceptualized the work; revised the work critically for important intellectual content; provided final approval of the version to be published.

Conflicts of interest The authors declare that there is no conflict of interest regarding the publication of this article.