1. Physical Activity Maintenance and Secondary Condition Prevalence
By: Angela Monzin, BS, OTDS
November 6th, 2007

2. Sponsored by the Missouri Foundation for Health
Exercise Programs and Health Promotion for Unserved and Underserved People with Mobility Impairments
Sponsored by the Missouri Foundation for Health
MFFH fund # 40779
This project was supported by the Missouri Foundation for Health Grant. The study was conducted at the Enabling Mobility Center a collaboration between the Washington University School of Occupational Therapy and Paraquad an independent living center.

3. “Regular participation in exercise has been proven to significantly reduce the risk for several chronic diseases; yet the majority of the population [with a disability] does not exercise or maintain healthy lifestyles”
I want to start with a quote that I read while doing my literature review for my research project. The quote explains why participation in exercise is so important for all individuals, “Regular participation in exercise has been proven to significantly reduce the risk for several chronic diseases; yet the majority of the population (with a disability) does not exercise or most importantly maintain healthy lifestyles”
Froelich-Grobe & White, 2004, p640

4. Introduction: Benefits of Exercise
Reduces the risk of
dying prematurely
dying from heart disease
developing diabetes
developing high blood pressure
Reduces feelings of depression and anxiety
Helps control weight
Helps build and maintain healthy bones, muscles, and joints
Promotes psychological well-being
So a few of the benefits that the previous quote is talking about are reduces the risk of developing diabetes and high blood pressure. Reduces feelings of depression and anxiety and promotes psychological well-being.

5. Introduction: Prevalence
US Census Reports 51.2 million Americans
have some level of disability (U.S. Census Bureau, 2002)
63.1% reported Fair/Poor Health Status (U.S. Census Bureau, 2002)
53% of individuals with disabilities lack in physical activity compared to 34% of individuals without disabilities ( –A-Glance: Disability and Health: Promoting Health and Well-being of People with Disabilities 2005)
25 million people with ambulatory disability (U.S. Census Bureau, 2002)
According to the US Census Report 51.2 million Americans have some level of disability. Of those 51.2 million, 63.1% reported having a fair/poor health status. In addition, 53% of individuals lack in physical activity compared to 34% of individuals without disabilities. Out of the 51.2 million, approximately half of the individuals have an ambulatory disability which my study primary focus is on.

6. Introduction: Healthy People 2010
Chapter 6 Disability and Secondary Conditions
Goal: Promote the health of people with disabilities, prevent secondary conditions, and eliminate disparities between people with and without disabilities in the U.S. population.
6-4: Increase the proportion of adults with disabilities who participate in social activities
6-10: Increase the proportion of health and wellness and treatment programs and facilities that provide full access for people with disabilities
Healthy People 2010 has also recognized the importance of addressing health needs for individuals with disabilities. An entire chapter of Health People 2010 was devoted to Disability and Secondary Conditions. The goal of the this chapter is to promote the health of people with disabilities, prevent secondary conditions, and eliminate disparities between people with and without disabilities in the U.S. population. Two of the 13 objectives directly relate to the purpose and overall goals of my study. Objective 6.4 states to increase the proportion of adults with disabilities who participate in social activities and objective 6.10 states to increase the proportion of health and wellness and treatment programs and facilities that provide full access for people with disabilities.
U.S. Department of Health and Human Services. Healthy People nd ed., 2000

7. Background: Health Belief Change Models
Health Belief Change Theories
Trans-theoretical Model
Health Belief Model
Social Cognitive Theory
“Exercise behaviors is a complex of different behaviors” (Adams & White, 2005, p. 240)
Gaps in the literature
Do not adequately consider a person’s functioning within environment
Lack of integration among environmental factors, motivational factors, and personal health indicators
Exercise literature has also recognized the importance of exercise and maintaining the behavior. The Health behavior change literature defines healthy behavior change as the shift from risky behaviors to the initiation and maintenance of healthy behaviors and functional activities. Multiple studies have emphasized that exercise participation is heavily influenced by an individual’s motivation to participate in exercise behaviors (Kosma, Cardinal, & Rintala, 2002). The transtheoretical model, health belief model, social cognitive theory, are the most commonly used theories in the literature to explain exercise maintenance. While these theories are needed to understand the individuals motivation level for exercise, studies have attempted to use them to predict exercise outcomes of participants, but have not been successful (Adams & White, 2002). The reason being exercise is a combination of multiple factors that are complex. Motivation is not the only factor that would influence exercise participation or maintenance, the behavior is based upon multiple factors that interplay together. Since motivation though is a large part of exercise maintenance understanding the theories incorporating motivation are important because we need to motivate our clients. But the motivational literature explaining exercise lacks in the understanding that exercise behavior is influenced by numerous external factors and does not adequately consider a person’s functioning within the environment. In order to reach the maintenance phase, studies need to incorporate the environmental factors, motivational factors, and personal health indicators.
Nieuwenhuijsen, ER., Zemper, E., Miner, KR., & Epstein, M., (2006); Kosma, Cardinal, & Rintala, 2002; Adams & White, 2005.; Kosma, M, Cardinal, BJ., & Rintala, P. , 2002

8. Background: Health, Exercise & Participation
97% of adults experienced limitations in daily activities
An average of 13 secondary conditions/year
Psychological benefits include
Decreased anxiety and depression
Positive improvements in emotions, self-esteem, and self-confidence
Gaps in the literature
Exercise and the impact on participation/occupations
Understanding all the factors that enable physical activity for individuals with disabilities
Maintenance of exercise after intervention
Next the health literature has addressed the problem of sedentary activity in individuals with disabilities. In a recent study, Catherine Coyle and colleagues (Coyle et al., 2000) showed that 97% of adults with physical impairments experienced limitations in daily activities from secondary conditions and most experience an average of 13 secondary conditions within a year. The study states that secondary conditions are not only medical or physiological but psychological, social, and environmental issues as well. Individuals with disabilities can greatly benefit from physical activity since exercise has been proven to decrease, delay, or avoid the experience of secondary conditions (Cardinal et al., 2003). Regular physical exercise has been shown to increase health related physical fitness such as cardiovascular endurance, muscle strength and endurance, and flexibility. As well as psychological benefits include, decreased anxiety and depression, positive improvements in emotions, self-esteem, and self-confidence.
Several gaps still are present in the literature. Little research is done on how exercise impacts an individuals participation in daily activities from ADL to leisure. Next, little research has been done on understanding all the factors that predict physical activity. Lastly, most articles do not follow their clients after intervention has occurred to show maintenance of physical activity.
Cardinal et al., 2003; Coyle et al., 2000; Froelich-Grobe & White, 2004; Rimmer et al., 2004; Charlifue et al, 1999; Maher, et al., 1999; Kinne, et al., 1999

9. PEOP Model Diagnosis Accessibility Physical Activity Secondary
Attitudes
Secondary
Conditions
Participation
Assistance/
Support
So an exercise program developed for individuals with disabilities could aim at improving function, social participation, and quality of life; while simultaneously decreasing the prevalence of secondary conditions. As an occupational therapist we assess our clients using a model that addresses the individuals person factors, environment factors, their occupations, and performance in that occupation to results in successful participation. For physical activity, one needs to look at the individuals diagnosis (the body functions or limitations that may be present because of the diagnosis), their secondary conditions that are prevalent, and their motivation to participate in physical activity. For environment, an OT should assess the accessibility of fitness centers/community centers, the attitudes, the support or assistance they will received, and transportation availability, in order for them to perform in the occupation of physical activity so to enhance their participation and occupational performance. At the EMC this model is incorporated and was used to develop our client centered program.
Motivation
Transportation
Baum & Christiansen, 2005

10. International Classification of Functioning, Disability and Health (ICF)
The International Classification of Functioning, Disability, and Health the ICF is a framework that compliments the PEOP model very well. The ICF is not discipline specific, but allows healthcare professionals to communicate with one another using the same terminology. Similar to our PEOP model, the ICF addresses the individuals P factors (motivation level) and their body functions and health conditions (the diagnosis/secondary conditions). In addition to the individuals environmental context (accessibility, transportation, affordability). Again the ICF addresses the individual’s health needs as well as environmental factors for an end goal of participation.
World Health Organization, 2001

11. Study: Purpose and Aims
To identify key barriers and facilitators that influence exercise maintenance after participation in a 12 week exercise program and to understand the long term effects of exercise for individuals with a disability.
Aims:
To determine the common barriers and facilitators to exercise maintenance
To evaluate the long term effects of exercise on secondary conditions
To evaluate the long term effects of exercise on participation
So for my study, I wanted to understand and identify the key factors that will predict exercise maintenance after participation in a 12 week exercise program and to understand the long term effects of exercise for individuals with physical disabilities. In my study I aimed to determine the factors that will predict exercise maintenance; to evaluate the long term effects of exercise on participation; to evaluate the long term effects of exercise on secondary conditions; and to determine the common barriers and facilitators to exercise maintenance.

12. Study: Operational Definitions
Exercise Maintenance—Self Report
Have you exercised in the last 3 months?
Yes or No
Secondary Conditions—Self Report
17 conditions
Report
Participation—Self Report
PARTS/M
6 domains
Choice, satisfaction, and importance

13. Research Question 1: Barriers to Exercise
What are the main reasons for not maintaining participation in an exercise program?

14. Hypotheses 1: Exercise and Secondary Conditions
Participants who maintain exercise will continue to show positive changes with the prevalence of secondary conditions
Hypothesis 2 states that participants who did continue to exercise will continue to show positive changes with the prevalence of secondary conditions. 19 secondary conditions are asked in the survey and a few are pain, fatigue, depression, high blood pressure, osteoporosis.

15. Hypotheses 2: Exercise and Participation
Participants who maintain exercise will continue to show positive changes in participation (EQOP score)
Hypothesis three states that continued exercise will continue to show positive changes in an individuals choice, importance, and satisfaction with participation

16. Study Participants: Inclusion Criteria
All MFH Health
Education Workshop
Attendees N=139
Individuals that
DID
Exercise N=102
Individuals that
DID NOT
Exercise N=37
Individuals that
Dropped out of
Exercise N=22
The Studies inclusion criteria was: must be above the age of 18, live in Missouri, live in the community, complete the 12 week exercise program and each of the monthly surveys (baseline, 4 month, 8 month, and 12 month)
Individuals that
Completed 12
Week exercise N=80
Individuals that
Completed 12
Month survey
N=18
Did not return
Surveys or not at
12 month time
N=62

17. Study Materials: Health Information
Health Handbook 5 parts:
Part 1: Healthcare Provider Forms
Part 2: Health History
Part 3: Secondary Conditions
Part 4: Screenings & Vaccinations
Part 5: Other Important Papers

18. Study Materials: Exercise Equipment
Strengthening
Uppertone
Equalizer
Endurance
Arm/Leg Ergometer
APT
Vitaglide
MotoMed

19. Study Measures CORE questionnaire PARTS/M
Demographic Questions (age, race, education, income)
Secondary Condition Questionnaire
PARTS/M
6 domains of participation
Self-Care
Mobility
Domestic Life
Interpersonal interaction & relationships
Major Life Areas
Community, Social and Civic Life
EQOP: choice, satisfaction, and importance
Gray, Hollingsworth, Stark, & Morgan. (2006). Archives of Physical Medicine and Rehabilitation, 87(2),

20. Study Design
Study is a quasi-experimental, repeated measures design to evaluate the factors that predict exercise maintenance of people with mobility impairments.
T1 - Baseline measure
T2 – 4 month measure
T3 – 8 month measure
T4 – 12 month measure
This study is a quasi-experimental, repeated measures design to evaluate the factors that predict exercise maintenance of people with mobility impairments. Time 1 is considered baseline at the MFH health handbook seminar, Time 2 is considered 4 month this time is after the exercise intervention completion, and time 3 is at the point of which my study is looking at.

21. Study Interventions T1: MFH Health Education Workshop
Received Health Handbook
Completed initial survey (T1)
Exercise (Yes or No)
T2: After 12 Week Exercise Intervention
Minimum of 1x/week
Maximum of 3x/week
Complete 4 month survey (T2)
T3 & T4: Since Exercise Intervention
Exercise at EMC, home, or community facility
Complete the survey at
8 month (T3)
12 month (T4)

22. Results: Demographics
N= 18
Population %
Gender
Female
61.1
Age
18-44
45-64
65 and over
38.9
44.4
16.7
Race/Ethnicity
African Americans
Caucasian
Hispanic
55.6
5.5
Primary Disability
SCI CP
Arthritis/RA
Other
17.6
29.4
11.8
41.2
Primary Mobility Device
Power Wheelchair
Manual Wheelchair
Scooter
Cane , Crutch, Walker
22.2
5.6
33.3
Demographics: majority of the participants were female, majority were between the ages of 45 and 64 and Caucasian. Most participants primary diagnosis was cerebral palsy and used power wheelchairs.

23. Results: Exercise Demographics
N=18
Population %
Exercise past 3 months
Yes No
66.7
33.3
Number of time per week
None
1-2 times/week
3-4 times/week
50.0
16.7
Description of exercise
Light exercise
Moderate exercise
Vigorous exercise
No exercise
8.4
25.0
Previous exercise history of our participants: majority were already exercising before they joined the program at least 1-2 times at a moderate level meaning they breather a little hard and sweat a little.

24. Results: Research Question 1 Barriers to Exercise
Thirteen of 18 maintained exercise (23.5%)
Reasons for not exercising:
Transportation
Membership Costs
Medical Condition
3 PW users and 2 CCW

25. Results: Research Question 1 Barriers to Exercise (N=5)
0% Don’t have time
0% Facility not accessible
20% Can’t afford membership
0% Facility does not have accessible equipment
0% Can’t get assistance needed
20% Medical condition
20% No transportation to facility
20% Can’t afford transportation
0% Other reasons
Participants that did not exercise were then given 9 questions about why they were not exercising. The nine choices are: 1) don’t have time to exercise; 2) facility is not accessible; 3) can’t afford membership; 4)can’t afford special equipment; 5) facility does not have special equipment; 6) can’t get assistance needed when exercising; 7) medical condition prevents me from exercising; 8) no transportation to facility; 9) can’t afford transportation to facility. In addition participants are then offered the opportunity to qualitatively provide a different reason for not exercising. Of the 5 that did not exercise the responses were quite low.

26. Results: Hypothesis 1 – Exercise & Secondary Conditions
Blue: Continued exercising
Orange: Did not continue
Secondary Condition Prevalence Score
Hypothesis 1: Participants who maintain exercise will continue to show positive changes with the prevalence of secondary conditions? There were significant differences between T1 and T2 and T1 and T3 for both groups significant at the p< .01 level, but not significant differences between the group interactions. T1 T2 T3 T4

27. Results: Hypothesis 2 – Exercise & Participation
Trends
Participation scores improved after 12 week exercise program for both groups
Individuals that continued to exercise maintained participation scores
Individuals that did not continue in the exercise program also maintained their participation scores
Hypothesis three states participants who maintain exercise will continue to show positive changes in participation (EQOP score). Once again the EQOP score, is related to the individuals choice, satisfaction, and importance for each activity. Significant differences were found between T1 and T2 and T1 and T3 for both groups p < .01, but no significant differences between groups were found. As you can see though individuals that continued to exercise maintained their EQOP scores while those that did not declined.

28. Limitations Small ‘N’ Low return rate of surveys Study Measures
Participant Sample

29. Recommendations Assess the client Assess the community
Determine Person-Environment factors
Barriers and facilitators
Assess the community
Accessible sites
Affordable sites
Develop a client specific physical activity intervention based upon assessment

30. Study: Discussion Discussion
Still unsure of what factors predict exercise maintenance
Continuation in exercise does show maintenance in
Levels of secondary conditions prevalence
We do need to address both intrinsic and extrinsic factors
Overall, the findings show that we are still unsure of what factors predict exercise maintenance. Although the we incorporated a few variables not one of the variables were a significant indicator of maintenance. Although I hypothesized that there would be improvements with secondary conditions and participation, findings did show though that continuation in exercise does show maintenance in the number of secondary condition prevalence and satisfaction with participation. Finally, it is evident that we need to address both intrinsic (the individuals health condition, motivation) and extrinsic (accessibility, affordability) factors in order to increase exercise maintenance.

31. Future Directions
Include a measurement of motivation or exercise readiness
Larger sample size
Define exercise maintenance more specifically
Add more qualitative data

32. Thank You! Dr. Gray Dr. Holly Hollingsworth Kerri Morgan Denise Curl
EMC staff!
Jackie, Molly, & Keri fellow OTD
students
Gray Lab Research Assistants