Feature
No.45
September 2005
 
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Exercise habits and aspects of Health - A survey of Norwegian persons with Longstanding Incomplete Spinal Cord Injuries.
Anne M. Lannem1, Nina Kahrs2, Nils Hjeltnes1 and Geir Aamodt3

1 Sunnaas Rehabilitation Hospital, Norway
2 University of Sport and Physical Education, Norway
3 Section of Biostatistics, Rikshospitalet University Hospital
 

Introduction
A large number of studies have described the benefits of physical exercise for persons with spinal cord injuries (SCI). Hjeltnes concludes in his review-article that there is no need to debate the importance of physical exercise and training for persons with SCI. An important question is, what is the best way to perform the exercise in the long term after discharge from the hospital. (Hjeltnes N, 1988).
In Norway, Hjeltnes et al. stated that physical activity had a positive influence on the respondents’ well-being in a study of 72 persons with longstanding SCI. The persons who were physically active had fewer complications from their SCI, and they had a higher level of independence regarding daily life activities (Hjeltnes N & Jansen T, 1990).
In Canada, Noreau and Shephard noticed a support in the hypotheses that physical fitness is positively related to the overall productivity of the person with SCI. Noreau et al defines productivity after Trischman as “all activities that contribute to a sense of usefulness and life satisfaction” including a person’s participation in gainful employment, education programs, community services and active leisure pursuits (Noreau L & Shephard RJ, 1992). In 1995 the same authors publish a review article concerning SCI, Exercise and Quality of Life (Noreau L & Shephard R.J, 1995b). This article states that almost all results suggest that regular exercise benefits individuals with SCI in physiological, functional (ADL) and psychological ways (higher level of self-satisfaction, stronger self-image, fewer suicidal tendencies, more independent attitude and better sense of well-being). The respondents represented in the different studies, however, do not include the whole range of individuals with SCI. Persons with incomplete injury and those not using a wheelchair are often excluded in these studies.
The cognitive requirements for walking have been studied in persons with incomplete SCI (Lajoie Y, Barbeau H, & Hamelin M, 1999). The results indicated that walking was cognitively more challenging for the study group when compared to a reference group of 10 healthy young men.
Physical exercise and training have been an important part of the rehabilitation programme in Spinal Cord Injury (SCI) since the days of Sir Ludvig Guttmann (Scruton J, 1998). Shephard emphasises the social and psychological benefits of regular physical activity in addition to the general health benefits of physical activity (Shephard RJ, 1991). However, long-term effects of adapted exercise for persons with incomplete injuries were never thoroughly described in the literature (Noreau L & Shephard R.J, 1995a). Based on this , the purpose of the study was to gain more knowledge about the differences according to perception of life satisfaction and health as experienced by physically active as opposed to physically inactive persons with longstanding incomplete SCI. In this paper the main purpose is to present exercise habits, self-reported health and quality of life in the group studied.

Methodology
The study is a cross-sectional survey, including retrospective questions giving quantitative data for analysis.
Respondents
Included in the study were persons with incomplete SCI grade Frankel D (Maynard FM et al., 1997) rehabilitated at Sunnaas Rehabilitation Hospital before 1992 and at age below 60 years at the time of injury.
Definition of activity level
Breivik et al. defines inactive persons as those who exercise every second week or less (Breivik G, Vaagbø O, 1998). Based on Breivik the present cut off between physically active and physically inactive respondents was set at 60 minutes a week.
Life satisfaction Scale
Fugl-Meyer’s and his co-workers` questionnaire was used to measure global and domain specific life satisfaction in physically active and inactive respondents regarding life as a whole (1 question) and in 8 domains of life (8 questions) (Bränholm IB, 1992).Sample characteristicsA total of 100 persons with longstanding incomplete SCI received the questionnaires. After two reminders, 72 persons (72%) returned the questionnaire. Due to wrong diagnoses, two returned questionnaires were excluded. One respondent was excluded because of senile dements. There were 69 questionnaires analysed in the present study.

Table 1
Gender distribution and age at injury in the present study, the Sunnaas SCI study and in the Stockholm SCI study.

Study groupASIA D n=69 The Sunnaas SCI study n=461 The Stockholm SCI study n=353
Sex F/M (%) 13/56(18,8/81,2) 79/351(18,4/81,6) 67/286(19/81)
Age at injury median (range) 24,5 (16-58) - 27(3-77)

The gender distribution corresponds with the Sunnaas SCI study and the Stockholm SCI study (see Table 1).

In total 35 persons (51%) were diagnosed with incomplete tetraplegia, and 33 persons (49%) were diagnosed with incomplete paraplegia. The results correspond with the results of the Stockholm SCI study(Levi R, 1996), where the distribution of incomplete tetraplegia / paraplegia were 50 % in both groups.

There was no difference between the subgroups physically active / physically inactive regarding neurological level of injury.

Statistical analysisTo study the relationship between a continuous dependent variable and a set of independent variables, linear regression analysis was used.

ResultsExercise habitsThe results from the present study group were compared to those of other studies with comparable data; statistics on exercise in the Stockholm SCI study, (Levi R, 1996) and the general Norwegian population (Breivik G & Vaagbø O, 1998). Persons with longstanding incomplete SCI in the group studied were more physically active than the general Norwegian population (72% versus 65%), and in the Stockholm SCI study 66% were physically active.
Exercise methods
The most frequent methods of exercise in the physically active group were walking 23 (46%), cycling 20 (40%), swimming 14 (28%) and strength training 13 (26%).
Functional abilities
In total 2 persons (3%) in the present study group were not able to walk at all, 5 persons (7%) could walk 10 metres or less. Before getting tired, as many as 34 persons (49%) could walk more than 700 meter.Among the physically active, 28 persons (56 %) walked outdoors without mobility aids and 14 persons (28%) used wheelchairs. Among the physically inactive, 14 persons (74%) walked outdoors without mobility aids, and only 1 person (5%) used wheelchair.
Self-reported physical fitness.
The respondents were asked to rate how satisfied they were with their physical fitness on a scale from 1 (dissatisfied) to 5 (satisfied). The persons that were physically active registered a statistically significant better self-reported physical fitness (p<0,001) than the physically inactive group.
Health problems
In total 59 persons (86%) reported health problems, 7 persons (10%) reported no health problems and 3 persons (4%) did not respond. Forty-one persons (82%) of the physically active group reported health problems, and 18 persons (95%) of the physically inactive group reported health problems. From the results given, no correlation between health problems in general and physical activity were detected.
Quality of life
Quality of life includes social activities and a scale of life satisfaction (Bränholm IB, 1992).
Contact with friends
In total, 68 (99%) reported having close friends and 48 (70 %) of the respondents had frequent contact with friends (= once a week).Feeling lonelyThe results of the study showed no association between the physically active and inactive groups and the sense of feeling lonely.
Life Satisfaction.
Statistically significant differences were found in favour of the physically active group regarding financial situation (p=0,024), leisure time (p=0,005) and partnership relations (p=0,003), see also Figure 1.

Figure 1 Mean score of global and domain specific life satisfaction in active in inactive respondents



The respondents was compared to two reference groups, adults in northern Sweden (R1) and Persons with SCI in Sweden (R2) (Fugl-Meyer AR, Bränholm I.B., & Fugl-Meyer K S, 1992). The results are presented in Table 5. The physically inactive group showed a significantly less life satisfaction than the SCI in Sweden regarding their vocational situation, financial situation and leisure time, and a significantly greater degree of life satisfaction with regard to ADL.

Table 5
Life satisfaction in the physically active and inactive groups in the
present study and in 2 reference groups, R1 = adults in Northern Sweden, R2 = Persons with SCI in Sweden
Activen=50 Inactiven=19 R1n=201 R2n=82
Life as a whole 57%(CI=45%-69%) 41%(CI=29%-53%) 69% 49%
Vocational situation 48,7%(CI=37%-60%) 25%(CI=15%-35%) 56% 45%
Financial situation 62%(CI=51%-73%) 33%(CI=22%-44%) 44% 61%
Leisure 63%(CI=52%-74%) 27,8%(CI=17%-38%) 55% 40%
Contacts 70%(CI=59%-81%) 72%(CI=61%-83%) 60% 66%
ADL 80%(CI=71%-89%) 77,8(CI=68%-88%) 94% 39%
Sexual life 38%(CI=27%-49%) 35,3%(CI=24%-47%) 63% 34%
Family life 83,3%(CI=74%-92%) 70,6%(CI=60%-81%) 82% 76%
Partnership relations 85,7%(CI=77%-94%) 53,8%(CI=42%-66%) 76% 83%


Discussion
When we are talking about persons with SCI going back to a normal life, or to live as closely as possible to normal in all aspects of life, we are dealing with the concepts of normalization and social integration in society. To specify these words it is necessary to look back and see when the words were used for the first time and in what setting. A person with a disability should have the same right to equal living conditions and the same right to make his or her own choice as those of the general population in the society. They should live with social integration in situations characterized by respect, a feeling of belonging, and being responsible for themselves. The basic requirements for security, well-being, development and stimulation should be available (Sandvin J, 1992).
In the Norwegian society, exercise and physical activities have long and strong traditions as both leisure time activities for recreation and as a tool for better health. Based on the normalisation and social integration theory, going back to “normal life” after a SCI includes participation at all the different arenas in society as well as using physical activity as a leisure-time activity. Persons who have been through a period of rehabilitation after a SCI normally have a decrease in the activity level compared to what they had before the injury due to a lower level of physical functioning. This decrease in activity leads to an increased level of high-risk behaviour with regard to health, this means that persons with a restriction in physical abilities, needs an exercise programme even more than the general able-bodied population.
The main reference group used, with regard to the comparison of exercise habits, was the general Norwegian population. In addition, comparable data from a Swedish sample of persons with SCI was available (Levi R, 1996). The analysis of the comparison of exercise habits in these groups revealed no differences in the percentage of regularly physically active persons.
The exercise methods in the present study group do not differ from the exercise methods in the general Norwegian population, except for Nordic skiing and jogging. This can easily be explained by the physical limitations found in persons with incomplete SCI. Both Nordic skiing and jogging are functionally demanding regarding strength, endurance, elasticity and coordination. For some persons with incomplete SCI these activities are too demanding, refer the range of functional abilities reported. Thus, the character of the disability can explain this small difference in the choice of exercise methods. With this exception it can be said that with regard to exercise methods, the present study group has almost returned “back to normal,” or that it has been socially integrated, according to the normalization theory.
The dependents between physical fitness and physical activity is in agreement with the theory on health and exercise, those that are physically active, achieve a better physical fitness (Nieman DC, 1998).
From the list of complications experienced in the presented study, reduced range of motion and stiffness were two of the symptoms that may have been associated with to much strain. To avoid this type of overuse, a wheelchair was recommended as a form of functional relief from overuse for many persons with incomplete spinal cord lesions even if they had relatively good walking ability. On a regular basis 28 % of the physically active group of the present study used a wheelchair outdoors as opposed to only 5 % of the physically inactive group. The odd ratio indicated that it was 7 times more likely for a person to use a wheelchair in the physically active group than in the physically inactive group.
We found a close relationship between physical activity and social activity. This could be explained in a social context by the fact that physical activity and sports are often associated with many persons exercising together in a sport club, fitness centre, or by simply going for a walk together.
Regarding feeling lonely, the presented study showed the same pattern as young persons with disabilities in Norway. The results from both these groups indicated that in the Norwegian society persons with disabilities were feeling lonely more often than the general population. An explanation might have been the discrimination that persons with disabilities often feel when participating in activities in the society (Manneråkutvalget, 2001). From this aspect there is still a long way to go “back to normal life” with social integration for persons with physical disabilities.
The results of the presented study showed a positive relationship between physical activity and global and domain specific life satisfaction. The relationship was statistically significant in favour of the physically active group regarding the domains financial situation, leisure time and partnership relations. Fugl-Meyer set a cut-off for being happy at the score 5-6 and unhappy at the score 1-4. As shown in Figure 1, the physically active group were close to the definition of happiness, and the inactive group were more clear on the unhappy side of the border. Even if the difference was not statistically significant, the difference in level of life satisfaction had a clinical value. The difference between our two groups corresponds with the study from Beitostølen (Blaasvær S & Stanghelle JK., 1999).
Compared to persons with SCI in Sweden the results indicated a similar pattern, except for ADL and leisure time activities, where the scores were significantly higher in the physically active group studied.
Practical implications
The aim of the present study was, first, to explore the exercise habits in a sample of persons with incomplete SCI and compare the results with similar results in reference groups. The second aim was to investigate potential correlation between physically active and physically inactive participants regarding self-reported health and quality of life aspects. The results indicate that the exercise habits in the study group are comparable to the exercise habits in the general Norwegian population. The physically active participants reported better physical fitness, were more socially active, and experienced a greater level of life satisfaction than those who had a more sedentary lifestyle.
Further studies are recommended to investigate the connection between health and activity level in persons with disabilities. It would also be interesting to look closer at what type, intensity, and amount of exercise that should be recommended for better health in persons with SCI. Evidence-based exercise programmes for longstanding SCI are still not to be found, even if we could assume some of the same recommendations as for the general population.
The results of the present study indicated that physical activity was an important factor regarding health and well-being for persons with incomplete SCI. The sample in this study is limited. It would be interesting to investigate some of the same aspects in a broader sample, the whole population of persons with SCI. An initiated study at Sunnaas Rehabilitation Hospital / the Norwegian University of sport and Physical Education, will look more closely into different levels of physical activity and influence on health and life satisfaction. The main question for the future will be what the best way of performing exercise is for persons with longstanding SCI in order to optimise aspects of health and life satisfaction. Important questions as “How to get more people active?” and “Which activities are most suitable?” remain also still to be answered.
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Address of Correspondance:
Anne M. Lannem
Sunnaas Rehabilitation Hospital
1450 Nesoddtangen Norway
Tlf: +47 66969278 / +47 95101005
Fax + 4766912576
E-mail: anne.lannem@sunnaas.no






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