Physical Activity and Quality of Life among Adults with Paraplegia in Odisha , India

Objectives: The complete rehabilitation of patients with spinal cord injuries (SCI) comprises both physical and psychosocial factors. This study therefore aimed to assess physical activity and quality of life (QOL) among paraplegic patients with SCI in Odisha, India. Methods: This cross-sectional prospective study was conducted between March 2010 and December 2013. All paraplegic patients treated at the Swami Vivekanand National Institute of Rehabilitation Training & Research in Odisha, India, during the study period who met the inclusion criteria were invited to participate in the study (n = 364). Structured face-to-face interviews were held with participants and QOL and physical activity were assessed using the abbreviated World Health Organization QOL instrument and the Physical Activity Scale for Individuals with Physical Disabilities, respectively. Results: A total of 84 people participated in the study (response rate: 23.1%). The mean age was 32.54 ± 10.75 years and 90.5% of the participants were male. Participants had a low mean metabolic equivalent score (18.18 ± 10.68 hours/day). Additionally, low mean scores were noted for the physical health, psychological well-being, social relationships and environment QOL domains (49.76 ± 18.74, 48.57 ± 17.04, 57.88 ± 17.04 and 49.85 ± 17.77, respectively). There was a strong positive association between levels of physical activity and all QOL domains (P <0.050). Physical activity and employment status were significant predictors of all QOL domains (P <0.001). Conclusion: Low physical activity levels and QOL were noted among the paraplegic subjects. Interventions promoting physical activity and employment may help to improve QOL among this patient group.


Physical Activity and Quality of Life among Adults
with Paraplegia in Odisha, India

*Shankar Ganesh and Chittaranjan Mishra
Advances in Knowledge -Low physical activity levels and quality of life (QOL) were noted among the studied individuals with spinal cord injuries (SCI) in Odisha, India.
-The study found a strong positive association between physical activity and all domains of QOL.Furthermore, physical activity and employment status were significant predictors of all QOL domains.
Application to Patient Care -The identification of variables affecting QOL is necessary to inform rehabilitation protocols for patients with SCI.Rehabilitation measures should address emotional, social and cognitive factors as well as physical rehabilitation in order to achieve better QOL for these patients.
A dvances in the medical management of spinal cord injuries (SCI) have reduced the severity of this disability and increased patient longevity. 1Following the completion of inpatient rehabilitation, most patients with SCI are discharged and are expected to resume their lives and find ways of coping with their disability. 2However, health and wellbeing are best understood in terms of a combination of biological, psychological and social factors.As certain disabilities are permanent, including those associated with SCI, there is a need to identify factors affecting well-being which can be influenced by the rehabilitation team.Traditional health indicators provide a measure of the impact of disease but do not assess quality of life (QOL) in the context of an individual's culture, value systems, goals, expectations, standards and concerns. 3Wilson et al. stated that QOL should be routinely assessed among individuals with SCI along with neurological and functional outcomes. 4ubjective QOL is considered by some researchers to be the only relevant measure of QOL among individuals with SCI as it reflects their own perception of their well-being. 5The inclusion of QOL assessments in healthcare will promote a holistic treatment approach and encourage healthcare professionals to account for the personal perceptions and values of their patients.Hence, the evaluation of QOL is a crucial issue for future national health planning.
Very few studies have evaluated the QOL of SCI patients in India, where the estimated SCI prevalence is 236 per million. 6Gupta et al. found that patients with neurological illnesses, including SCI, reported impaired QOL in all domains of life; moreover, the social relationships domain of QOL was noted to adversely affect functional abilities. 7Singh et al. reported that gender, employment, mobility, autonomy, partner relations and social adjustment were associated with fair-to-good QOL scores among individuals with SCI in northern India. 8Tasiemski et al. compared life satisfaction and life values among SCI-affected individuals living in India, Vietnam and Sri Lanka; no significant relationships were observed between these variables. 9In an international cross-sectional study, Geyh et al. examined the QOL of SCI patients across six countries using five satisfaction items from the World Health Organization QOL (WHOQOL) assessment. 10The results indicated inter-country QOL differences that could not be explained by differences in demographic or lesion-related characteristics; future research in this area was hence recommended. 10s little is known about the subjective differences in QOL among SCI patients with different backgrounds, this study aimed to determine physical activity levels and QOL among SCI patients in Odisha, India, and identify relationships between demographic/clinical data, physical activity levels and QOL.

Methods
This cross-sectional study was conducted between March 2010 and December 2013 at the Swami Vivekanand National Institute of Rehabilitation Training & Research in Odisha.During this period, a total of 364 paraplegic in-or outpatients with SCI of at least one year's duration were invited to participate in the study.As physical function, independence and physical well-being is known to affect the QOL of quadriplegic patients to a greater extent than paraplegic patients, the study was limited to patients with paraplegia. 11Patients with thoracic and lumbar injuries and without mental health problems or medication usage that might affect their decisionmaking skills were included.The exclusion criteria included patients with traumatic brain injuryassociated SCI, brachial plexus injuries and/or fractures of the extremities and systemic medical diseases that would restrict physical activity.Individuals who met these criteria were invited to participate in the study.Data were collected using surveys in combination with interviews to ensure uniformity in the research process.
Each subject participated in a structured faceto-face interview which lasted an average of 45 minutes.The interviews were conducted in Oriya, the regional dialect spoken in Odisha.All questions were translated from English to Oriya by two translators using back-translation methods.Interviews were conducted by one researcher while another monitored the proceedings.Demographic data and information on QOL and physical activity was collected during the interviews using questionnaires.The questionnaires were filled out by the researcher who conducted the interviews due to the lack of reading literacy amongst some of the participants.At the end of each interview, the interviewee was given the opportunity to clarify any doubts or ask questions.
A custom-made Oriya-language survey with closeended questions was used to collect demographic data from participants, including age, gender, time since injury, marital status, level of education and employment status.For the purpose of the study, participants were categorised into age groups of fiveyear intervals.Education level was recorded on a scale from 1-4 (1 = no education, 2 = primary education, 3 = secondary education and 4 = university-level education).The employment and marital statuses of the participants before and after their injury were also noted.For statistical analysis, only post-injury values were considered.Paraplegia was classified as either complete (categories A and B) or incomplete (categories C and D) according to the American Spinal Injury Association Impairment Scale (AIS). 12hysical activity levels were measured using the Physical Activity Scale for Individuals with Physical Disabilities (PASIPD), which assesses the long-term effects of SCI on the health, functional ability and independence of persons with SCI. 13 This scale has been found to have good test-retest reliability and criterion validity.14 Participants' QOL was assessed using the abbreviated version of the WHOQOL assessment (WHOQOL-BREF). 3 This international crossculturally comparable instrument measures QOL across four domains: physical health (pain/discomfort, energy/fatigue and sleep/rest), psychological wellbeing (body image/appearance, negative feelings, positive feelings, self-esteem and thinking/learning/ memory/concentration), social relationships (person-al relationships, social support and sexual activity) and environment (financial resources, freedom/physical safety/security, accessibility/quality of health/social care, home environment, opportunities for acquiring new information/skills, participation in/opportunities for recreation/leisure activities, physical environment e.g.pollution/noise/traffic/climate and transport).3 The WHOQOL-BREF assessment is currently the most accepted and established instrument to assess QOL among individuals with SCI. 15 The instrument has shown good differentiation, content validity and testretest reliability.3 Based on an individual's responses to the questionnaire, QOL is scored between zero (poor QOL) and 100 (high QOL).In addition, domain scores correlate at approximately 0.9 with those of the full version of the WHOQOL instrument.3 Data were analysed using the Statistical Package for the Social Sciences (SPSS), Version 16 (IBM Corp., Chicago, Illinois, USA). A earson product-moment correlation coefficient analysis was used to identify relationships between QOL and physical activity, time since injury, age, gender, marital status, employment status, paraplegia severity and educational level.A multiple linear regression analysis with backward elimination was used to determine the significance of eight predictors (age, gender, education level, paraplegia severity, time since injury, employment status, physical activity and marital status) of QOL.For all analyses, a P value of <0.050 was considered significant.
Ethical approval for this study was granted from the Ethics Committee of the Swami Vivekanand National Institute of Rehabilitation Training & Research.Participation in the study was voluntary and informed consent was obtained from each participant.Due to the sensitive nature of the study, all participants were provided with the telephone number of the institute's clinical psychologist for counselling services.

Results
A total of 84 individuals with SCI participated in the study (response rate: 23.1%).Of these, there were 76 men (90.5%) and eight women (9.5%).The mean age was 32.54 ± 10.75 years (range: 15-60 years old).All of the participants used mechanical wheelchairs daily, were independent and needed no nursing.The post-injury employment rate of the participants was 7.1% and the average time since the onset of their injuries was 26.73 ± 23.94 months.The descriptive characteristics of the participants are reported in Table 1.
Participants reported a mean metabolic equivalent score of 18.18 ± 10.68 hours/day out of a possible There was a strong association between levels of physical activity and the physical health (r = 0.819; P <0.050), psychological well-being (r = 0.776; P <0.050), social relationships (r = 0.706; P <0.050) and environment (r = 0.627; P <0.050) domains of QOL [Figure 1].A weak correlation was found between employment status and the physical health (r = 0.262; P <0.050), psychological well-being (r = 0.277; P <0.050) and environment (r = 0.332; P <0.050) domains of QOL.No correlation was found between employment status and the social relationship domain (r = 0.144; P >0.050).There were moderate and weak associations between the time since injury and the physical health (r = 0.456; P <0.050) and psychological well-being (r = 0.277; P <0.050) domains of QOL, respectively.However, there was no significant relationship between the time since injury and the social relationships and environment domains.Paraplegia severity according to AIS scores was significantly related to all domains of QOL (r = 0.300; P <0.050).No association was found between QOL and age, gender, marital status or educational level [Table 2].
According to the multiple regression analysis, none of the predictors of QOL exceeded Bonferroniadjusted critical values [Table 3].Time since injury  *Physical activity was assessed using the Physical Activity Scale for Individuals with Physical Disabilities. 13 Quality of life (QOL) was assessed using the abbreviated version of the World Health Organization QOL measure.20  for the physical health, psychological well-being, social relationships and environment domains, respectively. 17statistically significant and strong positive association between physical activity and all domains  13 of QOL was observed among the studied sample of SCI patients.The mean metabolic equivalent score of the participants was suggestive of a low level of physical activity among SCI patients in Odisha, indicating that patients were physically active for fewer hours per day and fewer days per week than highly-active individuals with physical disabilities (36.34 ± 15.28). 18Another study found that higher PASIPD scores (22.5 ± 14.8) were reported by individuals with physical disabilities who rated their level of physical activity as active/extremely active. 13Stevens et al. also demonstrated reduced physical activity among individuals with SCI. 19Low physical activity has been found to correlate strongly with QOL in patients with SCI. 20Previous studies have found that people with disabilities are less likely to engage in physically active lifestyles than those without disabilities. 21,22easons for the low levels of physical activity among participants in the current study were beyond the scope of this study.However, architectural barriers (i.e. a lack of transportation facilities or wheelchairaccessible environments), societal attitudes, climate, logistical issues (i.e.problems with wheelchairs), loss of motor function and a lack of knowledge about how to engage in physical activity may play decisive roles, along with psychological factors.Employment status was found to be a strong predictor of all domains of QOL in the current study.Critically, participants had a very low postinjury employment rate.Unemployment and low income may result in financial difficulties, which is an important factor affecting the QOL of those with SCI. 23Financial hardships may also be associated with emotional problems. 24Harrison et al. found that only 8% of 222 SCI patients were employed following their injuries. 25Another study showed a considerable drop in employment rates after SCI. 26 These studies indicated that unemployment rates were 10-fold higher among SCI patients compared with the general population. 25,26Access to place of work, employer attitudes and patients' beliefs in their own abilities may influence the decision to resume employment following SCI. 26Singh et al. found that employment status was associated with a higher QOL among those with SCI living in India. 8Chapin et al. reported that SCI patients who had been successfully rehabilitated and were employed had a significantly higher QOL in all four domains. 27n the current study, physical activity and employment status were found to strongly predict scores in the physical health domain of QOL.Reduced physical activity among individuals with SCI may be related to changes in metabolism. 28Among paraplegic individuals, 25% have a maximum oxygen consumption of 15 mL/kg/minute; the normal range is 34-61 mL/kg/minute for males and 30-42 mL/kg/ minute for females. 29This reduced maximum oxygen consumption is inadequate to meet the requirements of independent living. 29Furthermore, the total caloric intake per day for individuals with SCI is lower than that of the general population. 28These factors may result in increased fatigue during work-related or daily living activities.
Several studies have shown no relationship between the time since injury and QOL among individuals with SCI. 30,31In contrast, the current study identified a strong predictive relationship between the time since injury and the physical health domain of QOL.This could be attributed to a gradual reduction in pain and improvement in function over time.In a crosssectional study, Saadat et al. compared the healthrelated QOL of veterans and non-veterans with SCI in Iran and noted that better health-related QOL was associated with a longer period of time since the injury. 32u et al. found a significant difference between patients with complete and incomplete paraplegia with regards to the environment domain of QOL. 33owever, the results of the current study indicated that the severity of paraplegia significantly predicted and was associated with the psychological wellbeing domain of QOL.The researchers hypothesise that this finding is a result of low self-esteem and negative feelings related to a lack of control over the environment due to the severity of the disability.Selfefficacy and self-esteem have been found to correlate highly with participation and contribute to a better understanding of functioning, disability and health in those with SCI. 34Access to the environment has been shown to be related to neurological status, with the environment more accessible to individuals with mild impairment than to those with severe impairment. 35n the current study, marital status was a significant predictor of the social relationships domain of QOL.Married subjects may have been less satisfied with their lives, more anxious about their sex lives and felt pressured by their inability to function normally in the household.Reasons for not wanting or not having the courage to be sexually intimate may be related to physical problems, low sexual desire, low self-esteem and feelings of being unattractive. 36he findings of this study indicate that rehabilitation should aim to improve QOL among individuals with SCI.This may be done by facilitating shared clinical decision-making to help individuals with SCI to achieve their preferences, adjust to their disability, improve their interpersonal relationships and reintegrate within the community.The development of interventions and programmes to increase levels of

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Activity and Quality of Life among Adults with Paraplegia in Odisha, India e56 | SQU Medical Journal, February 2016, Volume 16, Issue 1

Figure
Figure 1A-D: Scatter plots showing the relationship between physical activity* and (A) physical health, (B) psychological well-being, (C) social relationships and (D) environment domains of quality of life † among individuals with spinal cord injuries in Odisha, India (N = 84).

Table 1 :
Demographic characteristics of individuals with spinal cord injuries in Odisha, India (N = 84) 12araplegia was classified as either complete (categories A and B) or incomplete (categories C and D) according to the American SpinalInjury Association Impairment Scale.12199.5 hours/day, suggesting that patients were physically active for a few hours during the day and a few days during the week.In the physical health, psychological well-being, social relationships and environment QOL domains, participants had mean scores of 49.76 ± 18.74, 48.57± 17.04, 57.88 ± 17.04 and 49.85 ± 17.77, respectively.

Table 2 :
Correlations between quality of life* and demographic characteristics and physical activity † among individuals with spinal cord injuries in Odisha, India (N = 84) 13QOL = quality of life.*QOL was assessed using the abbreviated version of the World Health Organization QOL measure.3†Physicalactivity was assessed using the Physical Activity Scale for Individuals with Physical Disabilities.13‡Paraplegia was classified as either complete (categories A and B) or incomplete (categories C and D) according to the American Spinal Injury Association Impairment Scale. 12 P <0.001.¶ P <0.050.

Table 3 :
Multiple regression analysis of variables predicting quality of life domains* among individuals with spinal cord injuries in Odisha, India (N = 84)