Lifestyle and behavioral interventions focusing on self-efficacy and adherence

Lifestyle behavioral interventions involved teaching people skills and strategies for increasing PA as part of daily life and may improve PA among wheelchair users. An increase in PA in a large magnitude (vector counts at wrist) were seen in wheelchair users with multiple sclerosis after receiving a three months behavioral intervention in addition to a wheelchair skills training. This intervention focused on enhancing self-efficacy, overcoming barriers, and identifying facilitators, in addition to the behavioral strategies of self-monitoring, goal setting, planning, optimizing outcome expectations (19). Weekly follow-ups were done telephonically with the participants to teach them about initiation and maintenance of PA. Another behavioral intervention with in-person individual sessions reported a significant improvement in PA and the cardiovascular outcomes of BMI, cholesterol, blood pressure, and low-density lipoproteins at one year follow up. However, these differences were not significant between the experimental and control groups. The intervention had a component of motivational interviewing, that might have increased the adherence to the intervention (25). Hence, the interventions that targeted on improving the PA self-efficacy seem to be promising for these populations. In additions some measures to improve the adherence of intervention must be incorporated into the PA interventions for better efficacy.

Contrary to the above studies, in a multisite RCT, a sixteen-week theory-based intervention that involved a home visit, 5 individual and 5 group counseling sessions and a book did not increase the self-reported PA of wheelchair users in the experimental group. The intervention focused on developing participants' active lifestyle and their self-management skills. There were no within or between-group differences in PA at four- and ten-months follow-ups. The control group had received information about active lifestyle by one group meeting and a book (23). Like other behavioral studies (19, 25), this intervention targeted PA self-efficacy, and behavioral control, however, the baseline self-efficacy in these participants was high, indicating that the intervention was not formulate based on the needs of this population. This could be explaining the ineffectiveness of this intervention on PA. In addition, this study included individuals with SCI for more than 20 years, the authors of this study believe that the long duration of their disabilities of this sample might have made their behavioral tendencies toward inactivity, thereby challenging for them to engage in the PA.

One recent study by Froehlich-Grobe et al. (2020) delivered a 12 month weight loss program to wheelchair users. The intervention was delivered in hybrid form, via telephone, and in-person. The intervention had a dietary and a PA component. The waitlist control group received the intervention after six months. Experimental group participants had a significant increase in minutes of walk and wheel time per week, and further had a significant weight loss after six months of starting the intervention. Both groups had a significant increase in self-efficacy of health behaviors (27).

Previously, Froehlich-Grobe et al. (2014) had delivered a theory-based multi-component exercise intervention to experimental and control groups (N=128). The staff support group received additional intensive staff support for exercise, while the self-guided group received minimal support. The staff support group significantly increased exercise (17 min/week) compared to the self-guided group. There was no significant difference in aerobic capacity and strength over twelve month time period (18). Although staff-assisted interventions may show greater efficacy in improving PA, the time and cost related to such interventions affect their sustainability, especially in socio-ecologically deprived communities. Therefore, in order to develop sustainable programs, it is crucial to develop cost-effective interventions, and utilize previously existing resources from communities into these programs.

Community involvement is critical for community participatory research so as to use the already existing resources and develop interventions that are need based and acceptable to a community (31); therefore, it is vital to involve community dwelling wheelchair users when developing health promotion intervention for them. The knowledge about their needs, preferences, resources, barriers and facilities of a community is critical for the development of PA interventions (32). Cole et al. (2019) conducted a feasibility study in which participants' (N=7) opinion related to the content, delivery, and self-management strategies of an evidence-based exercise intervention was assessed. Based on this information, this study developed a six months Workout on Wheels internet intervention (WoWii), which will be evaluated in the future (33). Such community-based research in which community-dwelling wheelchair users are involved in developing PA interventions is scarce. Hence, there is a critical need for such culturally sensitive PA interventions. These interventions may potentially show better acceptability, adherence, and sustainability in community settings as seen in other disciplines (34). Thereby will be more efficacious in improving wheelchair users' PA and their cardiovascular outcome.

The behavioral and lifestyle PA interventions report mixed results with regards to improvements in PA among wheelchair users. Therefore, novel lifestyle behavior programs that are tailored to the needs of these populations should be developed and tested by studies with strong methodology and larger sample sizes. The individual, interpersonal, and environmental levels factors that are found to be related to the adherence to community-based interventions (28) can be incorporated into these programs to improve consumer compliance. Studies should also examine the ecological validity and long-term sustenance of these programs in community settings. In addition, the long-term effects on cardiovascular outcomes are scarcely studied and must be focused in future research.

Wheelchair skills training programs

Wheelchair skills training programs demonstrated mixed results regarding the changes in PA of community-dwelling wheelchair users. Two RCTs delivered the wheelchair propulsion/skills training interventions to wheelchair users with SCI reported improvements in PA (14, 19). A custom-fit ultra-lightweight manual wheelchair propulsion and skills training revealed an increase in activity counts, strength and propulsion skills, and decreased fatigue of wheelchair users with multiple sclerosis (n=14) compared to the participants in the control group. The experimental group had received theory-based behavioral intervention consisting of the moderate intensity wheelchair skills training and weekly telephonic follow-ups to teach behavioral strategies for initiation and maintenance of PA. Control group participants did not receive any training (19). In contrast, a sixteen-week low-intensity wheelchair propulsion-training program did not show any significant changes in PA levels of the experimental group participants. The participants received twice a week 30-minute sessions. Also, there were no improvements in their wheelchair propulsion and PO_peak. The study indicates that low-intensity training to be insufficient to improve PA for wheelchair users with long term disabilities (21).

These studies suggest contradicting effects of wheelchair training on PA, and more studies are needed to confirm the efficacy of such interventions on PA of wheelchair users living in community settings. Van der Scheer et al. (2016) had delivered intervention to community dwelling wheelchair users in a rehabilitation setting; the barriers to access for such interventions must be focused especially in relation to availability of these resources in these underserved populations.

Exercise training programs

In a multicenter RCT, home-based moderate intensity upper body exercise intervention delivered in-person to wheelchair users with chronic SCI (n=21) showed improvements in their PA. This behavioral intervention consisted of a PA component and a dietary component; it involved 45-minute weekly sessions for six weeks. The control group received lifestyle maintenance intervention in which they were asked to maintain their routine PA behavior. The study reported moderate (d=0.62) to large (d=1.37) effect sizes for improvements in PA, cardiorespiratory fitness, and exercise self-efficacy among the intervention participants. These improvements were seen after six weeks of intervention; the study did not do any follow up to see the long-term effects (24). Since the intervention was personalized to each participant's needs and delivered in the home setting, it improved exercise self-efficacy, which is reported to be a key factor in improvements in PA (35, 36). Delivering such interventions that are accessible to the community residents overcomes the barriers of the lack of transportation, time and access. These factors resulted in low attrition (11%) and increased adherence to the intervention, which might explain the large effect size of the intervention outcomes.

Recently, hand cycling high-intensity interval training intervention delivered to the wheelchair users (n=7) showed an increase in the participants' PA. The participants received the intervention in three weekly sessions for six weeks. The participants also showed an increase in their PA heart rate (max.), training efficacy, endurance, aerobic capacity, and wheelchair propulsion skills. The study did not do any follow-ups. The intervention was tailored to each participant's pace and the study used some measure to assess and prompt the intervention adherence (14). These programs can be tested in future studies with large sample size to confirm efficacy in these populations.

Robotic exoskeleton to improve PA

An eight-week locomotor training program with EKSOTM (version 1.1) robotic exoskeleton was delivered among long-term wheelchair users (N=14) to see its effect on their PA, motivation to engage in PA and performance capability to stand transfers. The intervention consisted of 2–3 training sessions per week in which participants completed sit to stand transitions, quasi static and standing balance exercises, and walked with assistance of a rollator walker while contact-guarded by a physical therapist. The walk with assistance of rollator walker was followed by walk with robotic exoskeleton. There was a significant increase in walking speed after the completion of intervention (P<0.0001) (37). The participants provided positive feedback for the robotic exoskeleton and learning about walking capability and performance of sit-to-stand transfers. The participants' perceived an increase in their motivation to engage in leisure time PA adapted to their condition. In addition, participants also perceived positive effects of this program on their overall health, endurance, and upper limb strength (13).

Another RCT, still in the implementation phase, is planning to deliver exoskeleton assisted walking to experimental group participants (wheelchair users with SCI), in addition to standard care (N=160). The control group is receiving only standard care. The study aims to see the effect of this intervention on indoor and outdoor ambulation, body fat mass, serum lipid profile, insulin resistance, social participation, and sleep disturbance (20). The results of this study are not yet reported. These studies show varied types of locomotor training with varied duration. Therefore, making it difficult to make any conclusions about the dose and duration of the locomotor training interventions. More experimental studies are needed to see the effectiveness of locomotor training with robotic exoskeleton on the PA efficacy of community-dwelling wheelchair users. Studies should be conducted to understand the duration of each type of training and the mechanisms involved in improving PA and cardiovascular health outcomes due to robotic exoskeleton training in these populations.

Technology based interventions for changing lifestyle PA

Technology offers a way to reach the increased number of populations in less time and helps eliminate the barriers (like lack of transportation and physical therapist time) that interfere with the delivery of care services. The majority of the studies included in this review (n=6) used technology in the interventions. Use of technology (e.g., telephone calls, exercise videos delivered via web or DVD, smart phones apps.) in interventions seems to be promising for improving PA efficacy and intervention adherence among wheelchair users (16, 17, 27). Bombardier et al. (2020) adapted and delivered a multipronged diabetes prevention program to the experimental group (n=7). This intervention used the telephone calls for delivering counseling sessions and DVDs videos for delivering aerobic exercise and strength training sessions to the experimental group. The control group participants (n=8) received usual care involving advice to seek preventive care for cardio metabolic risk factors. Posttest at six months indicated though not significant, but there was an increase in experimental group participants' leisure-time PA (minutes of walk per week). There were significant improvements in their exercise self-efficacy and depression levels, also the likelihood of increase pain was significantly low in experimental group (P<0.05) (16). Coulter et al. (2017) reported an improved adherence to web-based physiotherapy intervention in the experimental group participants (n=16). The intervention was delivered for 8 weeks with two sessions per week and was tailored to each participant's individual needs. The intervention consists of strengthening, stretching, aerobic, and balance exercises as appropriate based on participants' abilities. The control group (n=8) were advised to do the self-management for their condition. The participants in experimental group had moderate effect size (d=0.40) improvements in their mobility and endurance. The study also reported improvements in PA compliance and depression in experimental group compared to control group (17). Thereby, increasing their PA performance in everyday life.

These pilot studies suggest that technology-based interventions yield improvements in PA and intervention adherence among wheelchair users, yet studies with large sample size and diverse sample in terms of severity of disability and wheelchair dependence should be conducted to help draw some concrete conclusions. For example, Best et al. (2017) has planned to deliver a 12-week Smart Phone Peer PA Counseling (SPPAC) program via phone to the experimental group participants, whereas the control group participants are supposed to receive PA guidelines only. The study aims to improve participants' autonomy to get engaged in leisure time PA as measured by Actigraph, PA self-efficacy and their motivation. The study is reported to be in implementation phase (15). Based on this study, Best et al. (2019) have developed a theory based Active Living Lifestyle Program (ALLWheel) for wheelchair users with SCI. This program is aimed to reach large number of individuals in their communities to improve their self-efficacy, motivation and autonomy, thereby improving their engagement in leisure time PA (38). The intervention is anticipated to have high participant adherence due to the benefits of technology use including flexibility in timing, independence in performing the intervention and lack of need for transportation and scheduling.

These studies have used simple technology (e.g., telephone, web delivery of home exercise videos, DVDs), which can be easily available in rural communities. However, so far, none of the RCTs that have technology-based interventions have been conducted on community dwelling wheelchair users. The use of technology could be useful to overcome the ecological barriers related to remote areas, and their sustenance in these health services deprived areas (39). Therefore, there is a need for studies with controlled designs to test efficacy of technology-based interventions to improve PA and cardio metabolic outcomes in rural dwelling wheelchair users. In addition, theory based and community partnership research should be emphasized to increase the sustenance of these programs.