Exercise and SecondaryExercise and SecondaryExercise and Secondary Exercise and Secondary Conditions among Adults with Conditions among Adults with

Spinal Cord InjurySpinal Cord InjuryPeiPei--Shu Ho, Ph.D.Shu Ho, Ph.D.11; Matthew Kehn, B.A. ; Matthew Kehn, B.A. 11; ; Melinda Neri, B.A. Melinda Neri, B.A. 11; Thilo Kroll, Ph.D. ; Thilo Kroll, Ph.D. 1,21,2

11National Rehabilitation Hospital Washington DCNational Rehabilitation Hospital Washington DC11National Rehabilitation Hospital, Washington, DC National Rehabilitation Hospital, Washington, DC 22 University of Dundee, ScotlandUniversity of Dundee, Scotland

ASIA/ISC S A l M tiASIA/ISC S A l M ti

11

ASIA/ISCoS Annual MeetingASIA/ISCoS Annual MeetingJune 27, 2006, Boston, MAJune 27, 2006, Boston, MA

AcknowledgementsAcknowledgementsAcknowledgementsAcknowledgementsFunding agencyFunding agencyFunding agency Funding agency –– National Institute on Disability & Rehabilitation National Institute on Disability & Rehabilitation

Research (NIDRR)Research (NIDRR)CollaboratorsCollaborators–– National Spinal Cord Injury AssociationNational Spinal Cord Injury Associationp j yp j y–– Midwest Center for Health Services & Policy Midwest Center for Health Services & Policy

Research/VAResearch/VA–– Independent Living Research UtilizationIndependent Living Research Utilization

Study participantsStudy participants

22

BackgroundBackgroundBackgroundBackground

People with disabilities in general arePeople with disabilities in general arePeople with disabilities, in general, are People with disabilities, in general, are less likely to be physically active as less likely to be physically active as compared to people without disabilitiescompared to people without disabilitiescompared to people without disabilities compared to people without disabilities (Heath & Fentem, 1997)(Heath & Fentem, 1997)

The majority of adults with physical The majority of adults with physical j y p yj y p ydisabilities live a sedentary lifestyle disabilities live a sedentary lifestyle (Amosun, Mutimura, & Frantz, 2005; Ebrahim, Wannamethee, Whincup, (Amosun, Mutimura, & Frantz, 2005; Ebrahim, Wannamethee, Whincup, Walker Shaper 2000; Hofoss 2004)Walker Shaper 2000; Hofoss 2004)Walker, Shaper, 2000; Hofoss, 2004)Walker, Shaper, 2000; Hofoss, 2004)

33

BackgroundBackgroundBackgroundBackgroundReasons for physical inactivity:Reasons for physical inactivity:Reasons for physical inactivity:Reasons for physical inactivity:–– mobility limitations mobility limitations –– lack of transportationlack of transportationlack of transportation lack of transportation –– poor accessibility of fitness facilities, health poor accessibility of fitness facilities, health

clubs, & equipment clubs, & equipment –– informationinformation--related barriers (e.g., not knowing related barriers (e.g., not knowing

where to exercise) where to exercise) l k f ( t f th il k f ( t f th i–– lack of resources (e.g., cost of the exercise lack of resources (e.g., cost of the exercise program) program)

Ref: Rimmer, et al., 2005; Rimmer, et al., 2004; Rimmer, et al., 2000; Stuifbergen & Roberts, 1997; Washburn & Ref: Rimmer, et al., 2005; Rimmer, et al., 2004; Rimmer, et al., 2000; Stuifbergen & Roberts, 1997; Washburn & Hedrick 1997Hedrick 1997

44

Hedrick, 1997Hedrick, 1997

BackgroundBackgroundBackgroundBackgroundPeople with SCI are at risk for a variety of People with SCI are at risk for a variety of p yp ysecondary conditions resulting from the secondary conditions resulting from the sedentary lifestyle often associated with sedentary lifestyle often associated with disabilitydisabilitydisabilitydisability (Case, 2004; Sable & Gravink, 1999).(Case, 2004; Sable & Gravink, 1999).

Consequences of secondary conditionsConsequences of secondary conditions–– Increasing health care costsIncreasing health care costs

The annual cost of treating pressure sores alone was estimated at The annual cost of treating pressure sores alone was estimated at $1.2 billion $1.2 billion (Byrne & Salzberg, 1996).(Byrne & Salzberg, 1996).

–– Loss of productivity (time missed from work or school)Loss of productivity (time missed from work or school)–– Delayed community reintegration Delayed community reintegration –– Reduced quality of lifeReduced quality of life (Lucke 1999)(Lucke 1999)

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Reduced quality of lifeReduced quality of life (Lucke, 1999)(Lucke, 1999)

Research QuestionsResearch QuestionsResearch QuestionsResearch Questions

Of adults with SCI are there significantOf adults with SCI are there significantOf adults with SCI, are there significant Of adults with SCI, are there significant differences in the incidence of secondary differences in the incidence of secondary conditions between exercisers and nonconditions between exercisers and non--conditions between exercisers and nonconditions between exercisers and nonexercisers? exercisers? How does exercise contribute to theHow does exercise contribute to theHow does exercise contribute to the How does exercise contribute to the decreased risks of secondary conditions in decreased risks of secondary conditions in adults with SCI?adults with SCI?adults with SCI? adults with SCI?

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MethodsMethodsMethodsMethodsCrossCross--sectional designsectional designCrossCross sectional designsectional designSelfSelf--reported mail surveyreported mail surveyAdults (Adults (≥≥18 years old) with a SCI for at18 years old) with a SCI for atAdults (Adults (≥≥18 years old) with a SCI for at 18 years old) with a SCI for at least 1 year, living in U.S.least 1 year, living in U.S.Snowball samplingSnowball samplingSnowball samplingSnowball samplingAnalysisAnalysis

DescriptiveDescriptive–– DescriptiveDescriptive–– Independent tIndependent t--test & chitest & chi--square statisticssquare statistics

Multiple logistic regressionMultiple logistic regression

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–– Multiple logistic regressionMultiple logistic regression

Sample CharacteristicsSample Characteristics (n=355)(n=355)Sample Characteristics Sample Characteristics (n=355)(n=355)

MaleMale 59 4%59 4%MaleMale 59.4%59.4%

Hispanic originHispanic origin 5.15.1

White raceWhite race 87 987 9White raceWhite race 87.987.9

Married/living with a partnerMarried/living with a partner 50.750.7

Some college/college graduatesSome college/college graduates 49 049 0Some college/college graduatesSome college/college graduates 49.049.0

Average age (year)Average age (year) 46.4 46.4 12.612.6

Average age at injury (year)Average age at injury (year) 31 631 6 14 214 2Average age at injury (year)Average age at injury (year) 31.6 31.6 14.214.2

Average years since injury Average years since injury 15.7 15.7 12.012.0

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Sample CharacteristicsSample Characteristics (Cont )(Cont )Sample Characteristics Sample Characteristics (Cont.)(Cont.)

Injury levelInjury levelj yj y–– CervicalCervical 46.8%46.8%–– ThoracicThoracic 40.040.0–– LumbarLumbar 7.67.6–– SacralSacral 0.30.3–– UnknownUnknown 5 35 3UnknownUnknown 5.35.3

Incomplete SCIIncomplete SCI 53.2 53.2 Wheelchair usersWheelchair users 86.886.8Wheelchair usersWheelchair users 86.886.8–– Power Power 34.734.7–– ManualManual 65.365.3

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Functional ConditionsFunctional ConditionsFunctional ConditionsFunctional ConditionsNeed help with … ‘all the time’Need help with … ‘all the time’

100

%

60

80

28.7 26.2 25.1 28.240

5.9 5.1

0

20

/showeringDressing

Eatingf chair & bed

t/commodeide the home

1010

Bathing/showDress Eat

Getting in/out of cha

Using toilet/com

Getting around inside t

Functional ConditionsFunctional Conditions (Cont )(Cont )Functional Conditions Functional Conditions (Cont.)(Cont.)

Need help with ‘all the timeNeed help with ‘all the time‘‘Need help with … all the timeNeed help with … all the time

100%

53.260

80

19 7

53.2

24.540

60

19.7 16.37.9

3.10

20

1111

0Preparing own

mealsShopping for

personal itemsManaging

moneyUsing

telephoneDoing heavywork aroundthe house

Doing lightwork aroundthe house

Top Five Chronic ConditionsTop Five Chronic ConditionsTop Five Chronic ConditionsTop Five Chronic Conditions%

80

100

42.840

60

30.4 26.822.0 19.7

20

40

0Incontinence Depression Osteoporosis Arthritis High

cholesterol

1212

Exercise ActivitiesExercise ActivitiesExercise ActivitiesExercise Activities%

80

100

19 2

40.028.740

60

19.212.1

0

20

Exercise at Exercise at Exercise No exerciseExercise athome &

outside ofhome

Exercise athome only

Exerciseoutside ofhome only

No exercise

1313

Physical/Exercise ActivitiesPhysical/Exercise ActivitiesPhysical/Exercise ActivitiesPhysical/Exercise Activities

Aerobic activitiesAerobic activitiesAerobic activitiesAerobic activities–– Arm/hand/leg cycling, walking/wheeling Arm/hand/leg cycling, walking/wheeling

around, aerobic exercise, swimming/pool around, aerobic exercise, swimming/pool therapytherapy

Strengthening activitiesStrengthening activities–– Weight lifting, resistance trainingWeight lifting, resistance trainingFlexibility activitiesFlexibility activities–– Stretching, standing (with walker/braces), Stretching, standing (with walker/braces),

rang of motion (legs/arms)rang of motion (legs/arms)

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Major Reasons for not Major Reasons for not ExercisingExercising

Reasons for not exercising at homeReasons for not exercising at homeReasons for not exercising at homeReasons for not exercising at home–– Accessibility (lack of money, equipment, personal Accessibility (lack of money, equipment, personal

help, & time) help, & time) –– Physical conditions (pain, functional limitations, Physical conditions (pain, functional limitations,

fatigue, lack of motivation or energy)fatigue, lack of motivation or energy)Other choices (gardening wheeling physicalOther choices (gardening wheeling physical–– Other choices (gardening, wheeling, physical Other choices (gardening, wheeling, physical activities, exercising in gyms or schools) activities, exercising in gyms or schools)

Reasons for not exercising outside the homeReasons for not exercising outside the homeReasons for not exercising outside the homeReasons for not exercising outside the home–– Accessibility (cost, inconvenience, transportation, Accessibility (cost, inconvenience, transportation,

equipment, facility)equipment, facility)

1515

Are there significant differences in the incidence Are there significant differences in the incidence of secondary conditions between exercisers andof secondary conditions between exercisers andof secondary conditions between exercisers and of secondary conditions between exercisers and

nonnon--exercisers?exercisers?%

80

100

Exerciser Non-exerciser%

56.1

68.6

46.160

80

6 3 7.9

32

13.7 15.720

40

6.3 7.9

0Bladder/kidney

stones*Respiratoryinfection*

UTI* Skin breakdown*

1616

* p ≤ 0.05*** p ≤ 0.001

Secondary Conditions & Exercise by Secondary Conditions & Exercise by S it L lS it L lSeverity LevelSeverity Level

Exerciser Non-exerciser%

80

100%

With complete SCI (n=134) With incomplete SCI (n=189)

50.3

70.0

50.060

80

29.532.7

20.0 20.0

40

15.9

6.0 8.7

0

20

D i * Bl dd /Kid R i t UTI* Ski

1717

Depression* Bladder/Kidneystones**

Respiratoryinfection*

UTI* Skinbreakdown**

*p ≤ 0.05** ≤ p 0.01

How does exercise contribute to the decreased How does exercise contribute to the decreased i k f d diti ?i k f d diti ?risks of secondary conditions?risks of secondary conditions?

NonNon--exercisers had exercisers had increased risks of …increased risks of …–– Bladder or kidney stones Bladder or kidney stones

OR=2 923 (p=0 008;OR=2 923 (p=0 008;10

OR

OR=2.923 (p=0.008;OR=2.923 (p=0.008;95% CI: 1.31595% CI: 1.315--6.498)6.498)

–– Skin breakdown Skin breakdown OR 2 013 ( 0 007OR 2 013 ( 0 007 2.9234

6

8

OR= 2.013 (p=0.007; OR= 2.013 (p=0.007; 95% CI: 1.21495% CI: 1.214--3.337)3.337)

–– Respiratory infection Respiratory infection

2.9232.013 2.345

0

2

Bladder/kidney Skin Respiratoryp yp yOR=2.345 (p=0.028; OR=2.345 (p=0.028; 95% CI: 1.09795% CI: 1.097--5.014)5.014)

stones Breakdown infection

1818* Controlling for gender, race, education, age at injury, completeness & level of injury, exercise frequency/duration

ConclusionsConclusionsConclusionsConclusionsIncidence of secondary conditions is significantly Incidence of secondary conditions is significantly y g yy g ylower in exercisers than in nonlower in exercisers than in non--exercisers exercisers among adults with SCI, particularly for those with among adults with SCI, particularly for those with incomplete SCIincomplete SCIincomplete SCIincomplete SCIExercise is associated with the decreased risks Exercise is associated with the decreased risks of secondary conditions in adults with SCIof secondary conditions in adults with SCIof secondary conditions in adults with SCI of secondary conditions in adults with SCI regardless of their socioregardless of their socio--demographics, injury demographics, injury level/severity, & frequency/duration of exercise level/severity, & frequency/duration of exercise

ti ititi itiactivitiesactivitiesAccessibility is the common barrier for adults Accessibility is the common barrier for adults with SCI to engage in various types of exerciseswith SCI to engage in various types of exercises

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with SCI to engage in various types of exercises with SCI to engage in various types of exercises

ImplicationsImplicationsImplicationsImplicationsAdults with SCI can benefit greatly by Adults with SCI can benefit greatly by g y yg y yparticipating in exercise activities, but those participating in exercise activities, but those benefits can be enhanced by benefits can be enhanced by

i ibilii ibili l d b il d b i–– removing accessibilityremoving accessibility--related barriersrelated barriers–– providing structured exercise activities that providing structured exercise activities that

are appropriate for their physical capacityare appropriate for their physical capacityare appropriate for their physical capacityare appropriate for their physical capacityLongitudinal data are needed Longitudinal data are needed –– to ascertain the causal relationship betweento ascertain the causal relationship between–– to ascertain the causal relationship between to ascertain the causal relationship between

exercise & secondary conditionsexercise & secondary conditions

2020

ImplicationsImplications (Cont )(Cont )Implications Implications (Cont.)(Cont.)

The relationship between exercise & secondaryThe relationship between exercise & secondaryThe relationship between exercise & secondary The relationship between exercise & secondary conditions among adults with complete SCI can conditions among adults with complete SCI can be further studied using a larger/representative be further studied using a larger/representative sample & longitudinal datasample & longitudinal data

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