BMC Public Health

BioMed Central

Research article

Open AccessStaying physically active after spinal cord injury: a qualitative
exploration of barriers and facilitators to exercise participation
Matthew Kehn*†1 and Thilo Kroll†2
Address: 1National Rehabilitation Hospital (NRH), Research Division, Washington, DC, USA and 2University of Dundee, Alliance for Self Care
Research, School of Nursing & Midwifery, Dundee, UK
Email: Matthew Kehn* - matthew.e.kehn@medstar.net; Thilo Kroll - t.kroll@dundee.ac.uk* Corresponding author †Equal contributors

Published: 1 June 2009
BMC Public Health 2009, 9:168

doi:10.1186/1471-2458-9-168

Received: 20 November 2008
Accepted: 1 June 2009This article is available from: http://www.biomedcentral.com/1471-2458/9/168© 2009 Kehn and Kroll; licensee BioMed Central Ltd.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0),
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract
Background: While enhancing physical activity has been an essential goal of public health officials,
people with physical impairments such as spinal cord injury (SCI) are more likely to live a sedentary
lifestyle. Exercise has been shown to decrease the risk for many of the secondary conditions
associated with SCI, including osteoporosis, cardiovascular disease, pressure ulcers, urinary tract
infections, diabetes and arthritis, yet this population is rarely a target for health promotion efforts.
This paper examines the self-reported exercise experiences of people with SCI using a qualitativeexploratory design.
Methods: We enrolled 26 individuals with SCI (15 self-described 'exercisers' and 11 'nonexercisers') from a non-random pool of survey responders. Semi-structured phone interviews
were conducted to record participants' experiences with exercise pre/post injury, barriers andfacilitators to being active and perceived health impact.
Results: Regardless of exercise status, all participants reported physical activity prior to injury andexpressed interest in becoming active or maintaining an active lifestyle. Participants identified a
range of both motivational and socio-environmental factors that were either facilitating or
constraining of such a lifestyle. Non-exercisers identified barriers to exercise, including a perceived
low return on physical investment, lack of accessible facilities, unaffordable equipment, no personal
assistance and fear of injury. Exercisers identified facilitators, including personal motivation,
independence, availability of accessible facilities and personal assistants, fear of healthcomplications, and weight management. Exercisers associated a greater range of specific healthbenefits with being active than non-exercisers.
Conclusion: Despite motivation and interest in being exercise active, people with SCI face many
obstacles. Removal of barriers coupled with promotion of facilitating factors, is vital for enhancing
opportunities for physical activity and reducing the risk of costly secondary conditions in thispopulation.

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Background
More than a decade ago, the United States National Institute of Health Consensus Conference on Physical Activity(1995) concluded that 'All Americans should engage inregular physical activity'[1]. Enhanced physical activity isoften identified as a key public health objective and leading health indicator and yet research has shown that,upon returning to the community after rehabilitation,
people with activity limitations, such as spinal cord injury(SCI), are less likely to be physically active when compared to the able-bodied population[2,3]. Trend data
tracking physical activity among people with disabilities
between 1997 and 2006 put forward by the U.S. Centers
for Disease Control and Prevention show that Healthy
People 2010 activity targets are largely missed as activity
rates continue to stagnate[4]. Ranking at the lower end of
the physical activity spectrum, people with SCI are at aheightened risk for ill health and costly secondary conditions [5-7]. As a group, people with disabilities rarely feature as a target for health promotion efforts[8].
Acute mortality rates for people with spinal cord injury(SCI) have declined over the past three decades[9] whileclinical attention has increasingly focused on the prevention of secondary conditions. It has been established thatpeople with SCI are highly susceptible to medical complications and secondary chronic conditions, such as pressure ulcers, urinary tract infections, diabetes,
cardiovascular disease, obesity, osteoporosis and arthritis[10-16], and that physical activity can help prevent suchconditions[17], enhance functional abilities [18-20] andincrease quality of life and social integration [20-22].
The path towards a physically active lifestyle however, isfraught with obstacles for people with disability. Several
barriers to exercise have been identified in prior studies,including accessibility, pain, costs, psychological barriers,
a lack of motivation and energy, and a lack of logisticalinformation [23-26]. Other determinants of physicalactivity identified include completeness and level of
injury[2,27], intention and perceived behavioral control[28,29], and the presence of health complications[25].
Factors working against these barriers to facilitate an exercise active lifestyle have also been identified, including
preparation during time in rehabilitation and the role ofpeer mentors[25,30]. An increase in quality of life, energy,
self-confidence and body image were reported by individuals with SCI participating in a structured exercise training
program[31] while health and fitness have been identified
as reasons for continued participation in exercise[30].
While existing research on exercise after SCI provides valuable insight towards identifying determinants, much ofthis research has been done in a controlled setting,through a structured exercise program, or in relation to

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rehabilitation discharge. Studies have used a range ofstandardized means to measure physical activity, including a structured reporting scale[24,32], a validated selfreport instrument[24,25,28], an activity monitor[2] or byproviding exercise parameters to use in self-identification(e.g. 30 minutes per day, etc.)[27,29]. In contrast, thisstudy asked participants to self-identify as 'exercisers' or'non exercisers', thus taking into account the perceived
identity of individuals as 'physically active' individuals
rather than professionally defined categories. It may be
assumed that self-definition of physical activity may
broaden the range of barriers and facilitators that could be
identified. Additionally, studies have primarily focusedon perceived benefits and barriers, with less attention on
perceived facilitators. It is unclear why some people continue to be physically active and pursue exercise opportunities after their injury while others do not. While exercise
is essential to enhancing health, the onset of a physicallydisabling condition can provide serious challenges
towards an active lifestyle. Knowledge of factors that may
enhance exercise participation after SCI is crucial, particularly in order for health professionals to adequately tailor
their support and interventions to the needs and lifestyleof their patients, thus improving upon the long-term rehabilitative process. For this reason, this paper reports on
findings from a qualitative study aimed at identifying thefactors that people with SCI living in the community perceive as affecting their level of physical activity. More specifically, the study sought to identify barriers to andfacilitators of exercise as well as any perceived links
between physical activity and secondary health conditions.

MethodThis study is based on a qualitative-exploratory design following a quantitative exploration of exercise and physicalactivity patterns.
Sampling
Twenty-six adults with spinal cord injury were recruited(15 self-reported 'exercisers' and 11 'non-exercisers'). This
sample size was deemed sufficient to explore the topicalscope addressed in this paper, and is consistent with similar studies reported in the literature[33,34].

Participants were selected from a pool of 592 nation-wide
survey participants dependent upon whether they selfidentified as an 'exerciser' or 'non-exerciser'. The survey
pool itself was non-random and consisted of self-selectedparticipants who met the following criteria:- 1 year post SCI- 18+ years of age

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BMC Public Health 2009, 9:168- Speak English- Consent to being interviewed
Researchers randomly contacted eligible participants bytelephone or email to verify eligibility, willingness to participate, status as an 'exerciser' or 'non-exerciser' and aconvenient time for the phone interview.
Semi-structured interview guide
A semi-structured interview guide was developed for indepth exploration based on core topical areas of the survey questionnaire. The guide was pilot-tested with 2 postinjury exercisers and 2 post-injury non-exercisers.

Questions focused on:• Experiences with exercise before injury

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Similarly, our definition of 'secondary conditions' wasparticipant-centred. The scope of conditions was definedby study participants.
Procedure
All participants consented to the interviews before completing the first wave of the national survey. The study
protocol, survey document, interview guide, informed
consent and HIPAA documentation forms were approvedby the MedStar Research Institute IRB in Hyattsville, MD.
Essential demographic information was obtained at thetime of the survey.

Each interview was conducted by telephone at a time convenient to participants. Interviews, conducted by an experienced interviewer, lasted between 20 and 30 minutes
and were recorded with participant consent. Audio
recordings were transcribed, and subsequently verified by
two moderators.

• Experiences with exercise after injury• Logistics of current exercise regimen• Barriers and facilitators of exercise• Perceived benefits of exercise• Perceived impact of exercise on secondary conditions• Experiences with pain management• Future plans for exercise
We adopted a pragmatic participant-centered operationalization of 'exercise'. The determination of exercise status
was based on self-reported information in the survey.
'Exercisers' were identified as those who reported being
engaged in exercise activities either at home, in a gym orin both places. 'Non-exercisers' were identified as neither
exercising at home or in a gym.
Consequently, in this paper, we will use the term 'exercise'to reflect both formalized exercise activities as well as
physical activity initiated and carried out by individuals
without the explicit intent to exercise (e.g. yard work,
wheelchair pushing, etc.). Individuals, however, musthave identified the activity as 'exercise'. This 'naturalistic'
understanding of exercise reflects the recommendation by
the Centers for Disease Control and Prevention and theAmerican College of Sports Medicine that both lowerlevel intensity activity, as well as vigorous exercise, is beneficial in reducing the risk of heart disease and enhancing
general fitness levels[35].

Data analysis
Quantitative
We conducted bi-variate, nonparametric analyses for differences in the demographic and clinical profiles between
exercisers and non-exercisers. We computed Mann-Whitney U tests for continuous data (e.g. age, duration of
injury), and χ2 tests for independent samples for categorical data. The Fisher's Exact Test was used when cell sizes
were smaller than 5.
Qualitative
We used an ethnographic approach and used a descriptive
framework provided by the interview questions[36] toguide initial coding and content analysis. All transcripts
were read by two analysts (authors of this manuscript)
independently and initial thematic categories wererecorded. Constant comparative coding[37] using TAMS
Analyser for Mac OS X generated a total set of 55 codes,
grouped as exercise type, barriers, facilitators, perceived
benefits and secondary conditions. Thematic codes werediscussed, negotiated and continuously refined between
the two authors.

Results
Participant characteristics
Table 1 contains background characteristics of the 26
study participants.

There were no statistically significant differences between
exercisers and non-exercisers with regard to age, gender,
race, education level, employment status, marital status,
injury level or completeness of injury. The only variableboth groups differed on was 'duration of injury', with
non-exercisers having a significantly longer median duration of injury. Despite the failed statistical significancePage 3 of 11(page number not for citation purposes)

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Table 1: Participant characteristics (n = 26).

Variable'Exercisers'
N = 15'Non-exercisers'
N = 11P** p < .05

Age: Median (min, max)
Sex:
FemaleMale
Ethnicity
Caucasian/White
Non-Caucasian
Education≤ 12 years> 12 years
Income< $20$20 k – $60 k$61 k – $100 k> $100 k
Working
Full/Part-time
Not working
Marital status
Married/cohabitating
Single/Living alone
Duration of injury (Years):
Median (min, max)
Injury Level
C-levelT-levelCompleteness of injury
Complete
Incomplete
Wheelchair type
Power chair
Manual chair
Does not use any chair

52 (23, 74)

46 (34, 54)

.171
.228

4 (26.7%)
11 (73.3%)

6 (54.5%)5 (45.5%)

12 (80%)3 (20%)

11 (100%)0

3 (20%)
12 (80%)3 (27.3%)
8 (72.7%)

4 (28.6%)
3 (21.4%)
7 (50%)0

3 (30%)
5 (50%)
1 (10%)
1 (10%)

6 (54.5%)
9 (60%)

5 (45.5%)
6 (54%)

9 (60%)
6 (40%)
6 (1, 32)

5 (45.5%)
6 (54.5%)
20.5 (6, 32).029**

9 (60%)
5 (33.3%)

5 (45.5%)
4 (36.4%)

.462
.999

5 (33.3%)
10 (66.7%)

6 (66.7%)
3 (33.7%)

.206
.206
.729

8 (53%)
6 (40%)
1 (7%)

5 (45%)
5 (45%)
1 (10%)

.238

.999

.456

.781

.462

between the groups in terms of reported householdincome, seven exercise-active participants indicated ahousehold income above $60,000, while only two did soin the non-exercise group. The uneven group size may
have masked group differences.
Pre-injury exercise experiences
Regardless of post-injury exercise status, most participants
reported being exercise active pre-injury. Thus, not all preinjury exercisers continued being exercise active after
injury and several pre-injury non-active participants
became active post-injury. Our finding suggests that preinjury activity levels may prove to be a poor predictor of
post-injury activity, a finding indicated elsewhere[38].

The conducted interviews revealed a wide range of factorsthat were identified as either facilitating or constraining of
an individuals' level of activity. Each factor identified as adeterrent by one group, was often inversely identified as a
facilitator by the other group, and vice versa. Understand-.819

ing these psychosocial conditions and their elasticity canbe essential to the success of promoting more active lifestyles post-injury. Often it is not one factor that facilitates
or constrains, but a cluster of overlapping and intertwined
factors, making unique each individuals experience whilethus challenging our ability to identify consistent themes.
An important distinction among the facilitating and constraining factors reported by our participants, werewhether their origin was socio-environmental or motivational. Participants identified motivation, or lack of motivation, as a major factor in the determination of their
physical activity level. We present the varied roots of participants' motivation, or potential motivation. Secondly,
participants identified socio-environmental barriers to or
facilitators of an exercise active lifestyle. We present these
exogenous factors and how they both helped or hinderedparticipants' level of physical activity.

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Motivational triggers/constraints
Both exercisers and non-exercisers identified 'motivation'
as the most critical factor to being and staying exercise
active. Just as exercisers cited motivation as a strong facilitator of their being active, non-exercisers regarded theirlack of motivation as a major constraint to an exerciseactive lifestyle. Exercisers identified a variety of 'triggers'
for their motivation while some non-exercisers suggested
potential sources of motivation.
Perceived return on investment
One of the most commonly reported barriers to exercisingamong non-exercisers was the perceived 'limited return on
investment' from aerobic exercise. The amount of timeand energy needed to reach perceived beneficial levels ofactivity were identified as too demanding or unrealistic
and failed to motivate some individuals.

'Yeah, it's just too much work for too little benefit. I've tried to
do a few things here and there but, it just takes too much time
and too much effort and I don't think the benefits out weightthe costs.' ~Non-exerciser, male, 57, injury level unknown'I find it, the exercise that I do, to be so different from the exercise I did before my injury in so many ways that it's also kindof psychologically difficult to exercise. It doesn't feel good... atall... I don't get sweaty... I don't get my heart rate up... I canfeel my legs but not that well. So, it either makes me spasm or
it like... or it just... wears me out.' ~Exerciser, male, 35, C4
incomplete
Adaptation and Outcome Expectancies
Some indicated that the activities they perceived themselves as capable of participating in, particularly modified
sports such as tennis and basketball, were not comparable
to the able-bodied version, allowing for frustration, disappointment and a disinterest in further pursuit.

'I couldn't do what I used to do. And there were a few things
that I tried to do after the accident that were so discouraging
that I quit. The main thing there was that I tried to play tennis
in a wheelchair and I hated it. It wasn't the same game. I let it
go because I couldn't stand facing it that way. I got on a horseeleven months after the accident, still in a wheelchair and it felt
so good, since I had been on horses since I was four. And I
think, I was reserving judgment because I didn't want to be disappointed the way I was with tennis.' ~Exerciser, female, 63,
C5 incomplete
Several exercising participants, however, acknowledgedthat it took time to re-adjust expectations and exercise regimens post-injury. The rehabilitation process played a critical role in re-orienting many exercising participants
towards new forms of exercise activities. It provided the
motivational as well as the practical impetus to identify,

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shape and adopt acceptable and feasible exercise regimensthat matched the individuals' lifestyle post-injury.
While there was confirmation of the importance of exercise, there was also acknowledgement that 'the way exercise happened' had to change.
'Well it [the injury]changed how I exercised. I have to do everything sitting or laying down. It didn't change the fact that I
knew that I had to keep my body fit and as young as I could.'~Exerciser, male, 52, L5 incomplete
Mental health and well-being
Several participants pointed to the perceived impact of
exercise on their psychological well-being and mental
health. Exercise was perceived as a means to prevent or
reduce depressed mood, manage stress, control pain andprovide structure and discipline. Respondents attributed
enhanced quality of life to participation in exercise.

'Mentally I feel better that I'm accomplishing something andnot just lying around. That I'm doing something good formyself.' ~Exerciser, male, 50, C7 incomplete'The exercising definitely helps control the pain'. ~Exerciser,male, 52, L5 incomplete'It just felt good, it made my body feel alive.' ~Exerciser, female,
63, C5 incomplete
Optimism or positive outlook on life appeared to be afacilitator of exercise activity. Exercise active participants
made more statements that can be characterized as 'optimistic' and as relating to a positive outlook on life. Collectively, they were much more likely to make pointed,
forward looking statements.
'I think as I get older it [exercise] will lesson the complications
I'll have in relation to my spinal cord injury. Less blood clogs,
less muscle loss and flexibility. I don't want to worry about it
later.' ~Exerciser, male, 35, T7 incomplete
Although some non-exercisers did make statements thatcan be characterized as 'positive' and 'optimistic', collectively their statements were far less frequent, less specificand would be better described as 'hopeful'.
Another motivational factor was to stay as independent as
possible and to reduce reliance on personal assistance.
'It took me a while to get into it. I was PO'd about the wholething. But I knew I had to do it. If not I would be laying aroundand having someone push me and do things for me. And I
wanted to live by myself. I didn't want a caregiver.' ~Exerciser,male, 50, C7 incomplete

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Anticipated impact on health
Exercisers and non-exercisers clearly associated various
health benefits to being physically active. While non-exercisers mostly perceived benefits in terms of general healthand well-being and in the prevention of secondary conditions, especially pressure ulcers, exercisers detailed abroader range of benefits that they attributed directly tothe exercise they were undertaking. Identification of specific exercise outcomes were a strong motivating force forcontinued exercise activity.

'There is one exercise in particular with the weights that I've
noticed...its the one where you sit and your knees are slightly
bent and your feet are on a longish paddle and what you're
doing is flexing your ankles up and down pushing the weight.
Well I put low weights and I do one foot at a time and I'll dothat to a count of 60 with each foot and after that... when I
walk, those nerves that lift my foot up feel more normal and areworking. They've been stimulated and it's easier to walk. It
doesn't last forever, it goes away but I notice it after the exercise.' ~Exerciser, female, 63, C5 incomplete'And at home also I mop the floor. Well I don't mop them, I
bucket mop them. And I do that because I have to move my legs
and I try to get my legs exercise. And I know I'm getting it
because I get some feeling... and I can feel the muscles move...'~Exerciser, male, 54, T12 incomplete
Other benefits were seen with regard to general cardiovascular and respiratory fitness. Being physically active wasalso seen as improving motor control and maintaining
physical strength.
'I can tell a difference, if I haven't done much or have been kindof lazy for a day or two I can tell a difference. I'll feel more stiff.
The more active I am, the more I move, the more I can do andthe easier it is for me.' ~Non-exerciser, female, 48, T4 complete

http://www.biomedcentral.com/1471-2458/9/168'The other reason I don't walk more then I do is because I get
nervous that with my abnormal gate I might wear out my joints
also. I often wonder if because of the abnormal way I'm moving
I'm putting abnormal stress on my joints. I think that if I wereto go faster or longer I might get into trouble a little bit. I don't
even know if I should be thinking about that, but I am.' ~Exerciser, male, 35, C4 incomplete'I still do it [exercise]. Partially out of fear. I don't want to get
any worse. I'm a young guy. I'm only 34 and hopefully I havea lot of years ahead of me and I'd like to... you know, with spinal cord injury and aging there's a lot of complications and I
want to prolong that as much as possible.' ~Exerciser, male, 35,
C4 incomplete
Exercisers reported that they were motivated to be exercise-active to maintain their health and well-being. They
were concerned about secondary conditions and weightgain as a consequence of inactivity.
'Mostly just to keep up my strength and also being in my chair
I put on quite a bit of weight and as a 24 year old girl that kindof bothers me. It's hard because you're not up walking aroundand stuff....' ~Exerciser, female, 24, C6 complete
For non-exercisers, health-related reasons, such as cardiovascular problems would provide an impetus for becoming more physically active.
'Well, if it were a matter of health. If you had to lose someweight or your blood pressure was too high. That kind of thing
maybe. ...if I gain too much weight then it might be a motivational factor. I'd have to do something to burn some calories'.
~Non-exerciser, male, 50, C4
Several participants stressed the importance of physicalactivity for weight management.

Several exercising participants reported being active tostave off the onset of secondary conditions, particularlypressure ulcers, urinary tract infections, bowel obstruction, bone loss and muscular atrophy.

'I wasn't getting the results I wanted I guess. I had lost weightat some point and felt good about it, but gained it back and felt
really bad. I was disappointed and wanted faster results to bringme back.' ~Exerciser, male, 35, T7 incomplete'You know, I think it has a lot to do with the bowel and bladder.
When I don't exercise, I become congested and I'm just out of
it. ... so I think all of that [exercising] helps me to be well all
around, but most of all with my bladder and bowel changes'.
~Exerciser, male, 54, T12 incomplete

Several participants identified their excellent physical constitution before their injury as a major factor for good
recovery. The value of maintaining health, strength, andfitness was perceived as an incentive for considering exercise post-injury.

While several exercisers used their fear of adverse healthconditions as a motivator to exercise, some non-exercisers
were constrained by a fear of causing 'damage' to oneself
as a result of exercise.

'... being in great shape before injury is a lifesaver. ...They were
saying due to the physical shape I was in... that was one of themain factors' ~Non-exerciser, male, 41, C3 complete.

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Socio-environmental resources/barriers
All participants, regardless of exercise status and motivation level recognized the impact and influence of socialand environmental factors on their level of physical activity. Non-exercisers cited various barriers that prevented
even the most motivated among them from becoming
exercise active. While exercisers were often able to identify
socio-environmental facilitators, many did so with acaveat, suggesting needs for improvement or acknowledging some level of constraint.

'They have automatic doors and a family locker room that I use
because they have a roll in shower I can transfer over to. Private
lockers and such.' ~Exerciser, male, 50, C7 incomplete

Information accessA lack of knowledge and resources were a commonly cited
obstacle towards being active. Some non-exercisers
expressed interest in being more physically active but were
unsure of where to look for tips or assistance. For thoseliving in a rural community with no local rehabilitation
facility, this may be particularly true.

'I would say, mostly because of the activities of my daily life. I'm
married. I have children. I work. And so, it's just daily activities
like everyone else would probably say. I'm very busy and that's[exercise] the least important aspect... it shouldn't be, but it is.'~Non-exerciser, female, 45, T7 complete'I have always been trying to find a really good exercise routinewith light weights for someone in a chair. They come out with
exercise videos but they don't have the balance issues that people
in chairs have to deal with. The bulkiness of the wheelchair,those kinds of things... and so I've never seen that. For me, thatwould be awesome. Just to have some kind of exercise video withsuggested cardio and strengthening activities. I can't find it,
whether it's out there, I don't know.' ~Non-exerciser, female,
45, T7 complete
Some emphasized that even their health care provider
seemed unable to supply this information.
'Yes, I would love to [be exercise active] and I want to but I
think the idea is that a lot of the doctors who I go to, who are
wonderful doctors, seem to be very knowledgeable just can't
quite find a way to point me in the right direction of what to do
and how to do it, or where to go. So I feel like my resources area barrier to my future... With my latest doctor, for the past two
years, in regards to bladder related, he would say 'you might feelbetter if you would just lose weight'. And I'm like, 'great, justtell me how I can do it.' And they're like... 'well...umm... I
don't know where to send you. Have you looked online?' And sothen I do the big online search and, like I said, there are exercise
routines out there for people who are seated but they are not specific to wheelchair sitting. And nobody in the health care world
have been able to provide me with any resources.' ~Non-exerciser, female, 45, T7 complete
Accessibility
Of those non-exercisers indicating a willingness to exercise, one identified constraint was lack of accessibility, citing a void of accessible facilities, or having to travel long
distances to reach such facilities. Some exercisers however
specifically cited accessible facilities as an important facilitator for their active lifestyle post-injury.

Several non-exercisers indicated that direct access toequipment would increase their likelihood of being
active. As with the general population, time and a busy
lifestyle can always make healthy living seem difficult toattain, and thus assigning time to be physically active
becomes an inconvenience.

Support and Personal AssistanceA lack of personal assistance was noted as a significant
barrier by participants in both subsets.

'I could probably get on a cycle machine that is motorized tomove my legs, but... I guess the main obstacle is having someone
else take up their time to help me do it. I would need at least
one or two people.' ~Non-exerciser, male, 50, C4
Even motivated exercisers with access to equipment must
cope with this particular constraint, as this participantdetails.
'Yeah, I definitely do [want to continue being active]. It's
just difficult to find someone to help is the main problem. It's
not necessarily my motivation, or not having the equipment, its
just getting the help to help me do it. I enjoy getting in mystander, it's just a pain because I can't get in it by myself.'~Exerciser, female, 25, C6 complete
Some exercisers relied heavily on the use of personal
assistance.
'I have a personal care assistant and he spends six hours a daywith me and part of that of course is bathing and so forth, but
four hours of that is exercising. I'm a tetraplegic. I can walk alittle distance. We do balance exercises; work my arms andhands. And at night, in my garage I have a hand cycle, and I
use it.' ~Exerciser, male, 70, C3 incomplete
Several non-exercisers viewed 'social support' as a factor
that could potentially allow them to become more exercise active. A few exercisers also acknowledged that the'fun' element of being active with others was something
they enjoyed and looked forward to.
'I think I would probably need to be in something more structured where I would have to go and do it with someone else. To

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really get myself to do it at this age...' ~Non-exerciser, female,
44, C5 incomplete
Affordability and Insurance Coverage
In addition to costs associated with purchasing homeequipment, participants, regardless of exercise status,
noted insurance coverage as a barrier to being active; particularly true for those using Medicare or Medicaid. Concerns most emphasized were those of coverage
limitations.

'There is one other thing I'd like to mention to you and that's
insurance. It doesn't cover a lot of equipment that would be useful, like a stand. The ability to stand will decrease your probability of getting pressure sores. Gravity alone is going to help
alone with UTIs and things like that... Insurance will normallynot cover equipment to stand. ...Braces so I can stand... insurance doesn't pay for braces' ~Non-exerciser, female, 48, T4
complete'If I have neck pain they [Medicare] might give me a week or
two of therapy but that's all. And I believe I would have been a
lot further ahead as far as mobility if I were allowed to havemore therapy.' ~Exerciser, female, 66, T7 incomplete

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cal investment required to reach the perceived degree of
benefit as unrealistic, unattainable or simply too demanding. Exercisers and non-exercisers reported similar levelsof pre-injury physical activity, suggesting a shared norm of
exercise as an essential part of life, yet the motivationneeded to comply with this standard was a point of divergence between the two groups post-injury. Finally, nonexercisers reported frustration with physical limitations
and unhappiness with existing exercise options, while
exercisers identified physical therapy and training
received in rehabilitation as major facilitators. A positive
experience with exercise options during rehabilitation
may shape the perception of behavioral control in termsof one's ability to be exercise active post-injury and lay thefoundation for exercise engagement. Participants in thisstudy, and elsewhere[25,30] identified their time in rehabilitation and physical therapy as critical for their current
level of exercise commitment, while several non-exercisers
noted a lack of support or recommendation to exercise
from their physician, a problem recorded elsewhere[26,32]. It is also worth noting that non-exercisers
had a significantly longer median duration of injury, compared to exercisers. The possibility that duration of injury
has a potentially negative effect on the intentions to exercise should be explored further.

Discussion
Our findings suggest that participants' physical activity
levels are contingent on a combination of motivationaland socio-environmental factors, varying from case tocase, and making generic exercise prescription problematic. Reported barriers and facilitators to exercise may bedifferentiated by these motivational or socio-environmental origins. All participants identified multiple factors
as having influence over their level of physical activity. In
sorting the common themes of our interviews, we recognize and emphasize the interwoven relationship between
motivational triggers/constraints and socio-environmental resources/barriers. An attempt to simplify or minimize
the potential inter-dependence of these factors would be
to distort the experiences reported. In fact, what we may
best discern from these shared experiences is that no one
factor acts as a function of an individuals' level of physicalactivity; it is instead a cluster of varying factors, with shifting degrees of severity and influence from case to case.
This paper seeks only to heighten and highlight individual
factors within this more complex context.
The Theory of Planned Behavior[39] posits that physically
active behavior is a function of intention, which is influenced by attitudes, subjective norms and perceived behavioral control. Other studies have successfully applied thistheory to the SCI population[27,28] and our findings further validate its usefulness. Exercisers' attitudes werelinked to the knowledge of the benefits of being physically
active while non-exercisers considered the level of physi-

Study participants saw multiple benefits of regular exercise in terms of maintaining physical health and preventing secondary conditions. Apart from generalcardiovascular fitness, several participants were concerned
about pressure ulcers, urinary tract infections and respiratory problems. Some perceived the threat of these conditions as a motivator for maintaining their exercise
regimen. The risk of weight gain was also a contributing
factor for several participants. The psychological benefits
that many respondents derived from their exercise engagement are consistent with findings from the literature [4043]. While these health related factors were reported as
facilitators in this study, they have been reported as benefits of exercise elsewhere[23,31]. The difference between afacilitator and a benefit is important to note. While perceived health benefits may act as a facilitator of continued
exercise, it would seem that only the anticipation of such
benefits would facilitate initial engagement.
In theoretical terms it may be argued that people who participate in regular exercise show greater 'self-determination'. Self-determination theory[44,45] posits that
individuals need to develop a sense of autonomy andcompetence, which is essential for a process of internalization and integration of health behaviors (i.e. exercise).
Autonomy implies that individuals value and prioritize
behaviors and make them integral to their life-style. Additionally, people may feel more inclined to be physically
active if they perceive themselves as confident and compe-

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tent. People who experience a greater degree of autonomy
may also be more likely to learn new behaviors and feelcompetent. In our study several exercisers acknowledgedthat their exercise routines and strategies had changed
post injury but that the reasons for being physically active
had not. It may be argued that they managed to integrate
physical activity effectively in their post-injury life and felt
competent in exploring alternative means of achieving the
expected exercise benefits. Other participants who had
been physically active before their injury however, did not
perceive these benefits (e.g. aerobic gains) and did not
make exercise an integral part of their lives post-injury.
There is some indication that individuals with long-standing exercise routines may see greater personal benefits
than external incentives (e.g. weight loss; appearance) topursue regular physical activities[46]. Another element of
the self-determination theory is 'relatedness', referring to
the quality of the patient-practitioner relationship andhow it may shape individuals' motivation to engage inbehavior change. As noted, several respondents in thisstudy felt that health professionals did not provide sufficient support and recommendations for exercise postinjury. Self-determination theory however, has not beenstudied in people with SCI. Similarly, a better understanding of psychological constructs, such as 'optimism'[47],with regard to influencing outcome expectancies related
to exercise may further complement the picture.
The identification of socio-environmental barriers, especially those focused on accessibility and disability-specificknowledge of health providers, are not unique to the
problem of exercise, and have been reported in conjunction with access to health services[26,32,48-51]. A greater
proportion of participants expressed interest in being
physically active than actually were, a finding reflected
elsewhere[24,26]. The removal of socio-environmental
barriers could prove to be one of the most effective facilitators, thus allowing a motivated individual access tochoosing an exercise active lifestyle.
It is important to emphasize that the socio-environmental
barriers identified by non-exercisers were often, in theirinverse form, factors that facilitated a physically active lifestyle for exercisers. Motivation aside, exercisers were able
to be active because of the availability of an accessible
community-based facility, or because of their capability tomaintain home equipment. Non-exercisers often
regarded the lack of such facilities and/or equipment as abarrier, a finding reflected in prior studies[26,52]. The roleof personal assistance is equally noteworthy as many exercisers, particularly those relying on home equipment wereable to do so only with the assistance of another. The
absence of such help was identified as a major constraint
by participants in both groups.

http://www.biomedcentral.com/1471-2458/9/168

Even those for whom cost was not a barrier acknowledged
its pervasive role in determining access. Facilities, personal assistance and home equipment are often available
with a financial cost; one that several exercisers admitted
at being able to meet. For those relying on insurance coverage, particularly Medicaid and Medicare, limitations ofcoverage emerged as an often impenetrable barrier, potentially denying individuals access to continuous and longterm physical activity.
More comprehensive and multi-level efforts are needed toaddress the physical health promotion needs of individuals with spinal cord injuries and other physical disabilities
as Healthy People 2010 goals are far from being met.
Limitations
The study has several limitations. Its qualitative naturedoes not necessarily allow findings to be generalized to alarger population. The selection of subgroup participants(exercise vs. non-exercise) was based on a pool of people
with SCI who had been previously included in a non-random sample. One of the principal limitations of both thelarger survey study, from which the sub-sample wasdrawn, and the resulting subsets was the limited representation of ethnic minority groups. Even though there wereno statistically significant differences between exercisers
and non-exercisers in our selected subgroup, more individuals in the exercise group had higher disposable
incomes and reported having more personal exercise
equipment and assistance. This may be a finding in itself.
Economic inequities among people with SCI may drive
differential access to exercise information and support.

Conclusion
Most people with SCI are principally motivated to engage
in exercise so to maintain health and prevent secondary
conditions. Labeling individuals simply as 'non-compliant' without a full appreciation of their motivational constraints and socio-environmental barriers to exercise is not
helpful. Successful behavior modification requires theconsideration of both these types of factors. While
improvements in providing better access to affordable
facilities and personal assistance, especially in rural communities, is essential in developing accessible, inclusive,and equitable exercise support and health promotion programs, equal consideration must be given to the uniquesocio-environmental realities faced by individuals if suchprograms are to reach their effective potential. These
broadened considerations allow clinicians and publichealth professionals to arrive at an understanding of physical activity that is not solely focused on restoring, improving or maintaining function, but enhancing general
health and wellbeing. Closing education gaps andaddressing professional 'blind-spots' among health care
professionals may additionally help abate some of the

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obstacles that currently deny motivated individuals with
SCI participation in healthy living activities.

16.

Competing interests

17.

The authors declare that they have no competing interests.
18.

Authors' contributions
TK was the principle investigator of this study andinvolved in the original protocol design. MK and TK
developed the semi-structured interview guide together.
All interviews were conducted by MK. Interview transcriptions, subsequent analysis and development of this manuscript were performed by both MK and TK. Both authors
approved this final manuscript.

19.

Acknowledgements

22.

This project was developed through the Rehabilitation and Research Training Center (RRTC) on Spinal Cord Injury: Promoting Health and Preventing
Complications through Exercise, funded by the National Institute on Disability and Rehabilitation Research (NIDRR), grant number H133B031114.

20.

21.

23.

24.

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