Protocol for a single group, mixed methods study investigating the efficacy of photovoice to improve self-efficacy related to balance and falls for spinal cord injury.

INTRODUCTION: Many individuals living with spinal cord injury (SCI) experience falls and a fear of falling, both of which can impact participation in daily activities and quality of life. A single group, convergent mixed methods study will be conducted to examine the effects of a photovoice intervention on falls self-efficacy among individuals living with chronic SCI. Secondary objectives include examining the effects of photovoice on fear of falling, participation and quality of life and exploring participants' experiences and perceptions of the photovoice intervention through qualitative interviews. METHODS AND ANALYSIS: Adults with SCI (n=40) will be divided into groups according to their mobility status (ie, those who ambulate and those who primarily use a wheelchair). The study will be conducted virtually over three consecutive phases, totalling 30 weeks. Each group will self-report falls for 12 weeks prior to and following the intervention (phases 1 and 3, respectively). The 6-week photovoice intervention (phase 2) will be comprised of two photo assignments, two individual interviews with a researcher and a peer mentor, and four group meetings. Participants will discuss these photos at the interviews and group meetings. Standardised questionnaires of falls self-efficacy, fear of falling, participation and life satisfaction will be administered at four time points (ie, beginning of each phase and the end of phase 3). Questionnaire scores will be examined over time using repeated-measures analysis of variance. A semistructured interview will be completed at the end of phase 3 to gain feedback on the photovoice intervention. Qualitative data will be analysed using reflexive thematic analysis. ETHICS AND DISSEMINATION: Ethics approval was obtained prior to study enrolment. Findings will be shared through peer-reviewed scientific publications and participant-directed knowledge translation activities. TRIAL REGISTRATION NUMBER: NCT04864262.

Effect of Group Counseling Plus Tailored Exercise on Mobility Function in Multiple Sclerosis.

BACKGROUND: Multiple sclerosis (MS) impairs muscular function and limits individuals' ability to perform everyday activities requiring mobility. People with MS frequently exhibit mobility problems (ie, slower walking speed, shorter strides). General exercise training (eg, resistance, aerobic) provides modest physiological and walking mobility benefits. However, researchers suggest tailoring of interventions to address mobility specifically. We conducted a phase 2a pre-post intervention development study (Obesity-Related Behavioral Intervention Trials [ORBIT] intervention development model) of mobility exercise plus cognitive behavioral counseling to improve function and social cognitions known to encourage exercise. METHODS: The intervention was conducted twice per week for 8 weeks followed by 1 month of self-managed mobility exercise. Participants (N = 29; mean ± SD age = 52.24 ± 11.36 years, mean time since MS diagnosis ≥11 years) were assessed at baseline and after follow-up for mobility function, social cognitions, and intervention fidelity indicators. RESULTS: Results indicated significant improvements in a variety of valid measures of mobility function (eg, 400-m walk), self-regulatory efficacy for mobility exercise and symptom control, and fidelity measures with small to medium effect sizes. CONCLUSIONS: Positive findings suggest that the intervention seems to merit testing as a randomized pilot study following the ORBIT model.

A proof-of-concept study on the impact of a chronic pain and physical activity training workshop for exercise professionals.

OBJECTIVES: Physical activity is essential for long-term chronic pain management, yet individuals struggle to participate. Exercise professionals, including fitness instructors, and personal trainers, are preferred delivery agents for education and instruction on chronic pain, physical activity, and strategies to use adherence-promoting behavioral skills. However, exercise professionals receive no relevant training during certification or continuing education opportunities to effectively support their participants living with chronic pain. Based on the ORBIT model for early pre-efficacy phases of development and testing of new behavioral treatments, the present Phase IIa proof-of-concept study was conducted. The purpose was to examine the impacts of a newly developed chronic pain and physical activity training workshop on psychosocial outcomes among exercise professionals. Outcomes included knowledge and attitudes regarding chronic pain, attitudes and beliefs about the relationship between pain and impairment, and self-efficacy to educate and instruct participants with chronic pain. METHODS: Forty-eight exercise professionals (Mage=44.4±11.0 years) participated in a three-hour, in-person workshop that was offered at one of four different locations. Participants completed pre- and post-workshop outcome assessment surveys. RESULTS: Mixed MANOVA results comparing time (pre- versus post-workshop) by workshop location (sites 1 to 4) illustrated a significant within-subjects time effect (p<0.001). All outcomes significantly improved from pre- to post-workshop (p's<0.001), demonstrating large effect sizes (partial eta-squared values ranging from 0.45 to 0.59). CONCLUSIONS: Findings offer early phase preliminary support for the effectiveness of the chronic pain and physical activity training workshop for exercise professionals. Based on ORBIT model recommendations, findings warrant future phased testing via a pilot randomized clinical trial as well as testing for impacts that trained professionals have on activity adherence among their clients living with chronic pain. Eventual workshop adoption by exercise professional certification organizations would ensure widespread and sustainable access to qualified exercise professionals to help individuals engage in physical activity. By increasing the capacity of available exercise professionals to deliver effective support, active individuals could better manage their chronic pain and live well.

Facing Multiple Barriers to Exercise: Does Stronger Efficacy Help Individuals with Arthritis?

BACKGROUND: Research about exercise adherence amongst adults with arthritis has been largely correlational, and theoretically based causal studies are needed. We used an experimental design to test the social cognitive theory premise that high self-efficacy helps to overcome challenging barriers to action. METHODS: Exercising individuals (N = 86; female = 78%; M age = 53; BMI = 27) with differential self-regulatory efficacy for managing salient, non-disease barriers were randomly assigned to many or few barrier conditions. Individuals responded about the strength of their anticipated persistence to continue exercise, and their self-regulatory efficacy to use exercise-enabling coping strategies. RESULTS: In the many barriers condition, higher barriers-efficacy individuals expressed (a) greater persistence (Cohen's d = 0.75 [-0.029, 1.79]) and (b) more confidence in their coping solutions (Cohen's d = 0.65 [-0.30, 1.60]) than lower barriers-efficacy counterparts. CONCLUSION: Experimental support was obtained for the theoretical premise that when facing the greatest barrier challenge, individuals highest in self-regulatory efficacy still view exercise as possible. Findings suggest that identifying lower efficacy exercisers with arthritis to tailor their exercise to increase self-regulatory efficacy might also improve their adherence.

Initial validation of the exercise chronic pain acceptance questionnaire.

BACKGROUND AND AIMS: Pain acceptance, measured by the chronic pain acceptance questionnaire (CPAQ), is related to exercise adherence for those with arthritis. The CPAQ measure has 20 items comprising two subscales -- pain willingness and activities engagement about pursuing "valued daily activities" despite pain. However, exercise is not specified as a valued activity and respondents may be considering other activities raising generalizability and strength of prediction concerns. METHODS: Accordingly, a modified CPAQ solely for exercise (CPAQ-E) was developed to heighten salience to pursuit of exercise in the face of pain. An exercising sample with arthritis (N=98) completed the CPAQ-E at baseline and exercise 2 weeks later. Exploratory factor analysis of the CPAQ-E was performed using Mplus. Regression was used to predict exercise. RESULTS: Analysis revealed a two-factor, 14 item model with good psychometric properties reflecting pain willingness and activities engagement subscales (χ2=85.695, df=64, p<.037; RMSEA=.055; CFI=.967; TLI=.954). Both subscales and the total score positively predicted future weekly exercise bouts (range ps from <.05 to <.001). Activities engagement predicted future weekly exercise volume (p<.05). CONCLUSIONS: This study offers preliminary support for the factorial and predictive validity of the CPAQ-E among exercising individuals with arthritis. IMPLICATIONS: This measure could help researchers increase the specificity and sensitivity of pain acceptance responses to exercising among individuals with arthritis. A more sensitive measure might help clinicians interpret patient responses to exercise for pain self-management.

Self-Regulatory Efficacy Encourages Exercise Persistence Despite Arthritis Flare Symptoms.

BACKGROUND: The study of exercise adherence during an arthritis flare is recommended by arthritis researchers. Studies to date have been correlational. METHODS: Social cognitions of exercising individuals with arthritis who consider exercise adherence under different levels of challenge of an arthritis flare were examined using an experimental design. Exercising individuals with differential self-regulatory efficacy for managing arthritis flare symptoms (SRE-flare) were randomly assigned to conditions where flare symptoms were perceived as either many or few. Individuals in each condition responded about the strength of their anticipated persistence to continue exercise, and their self-regulatory efficacy to use coping strategies to enable exercise. RESULTS: Higher SRE-flare individuals expressed significantly (a) greater persistence (Cohen's d = 1.17) and (b) more confidence to use their flare coping solutions (Cohen's d = 1.44). CONCLUSION: Main findings were as hypothesised. When exposed to the condition with more limiting flare symptoms (i.e. greater challenge), high SRE participants were the most confident in dealing with flare symptoms and exercising. Identifying lower SRE-flare individuals less likely to persist with exercise during arthritis flares may improve tailored exercise counselling.

Predicting planned physical activity of individuals with arthritis: A self-regulatory perspective.

Few individuals with arthritis are sufficiently active. We surveyed a convenience sample of exercisers ( N = 134) to examine the utility of social cognitive theory variables, namely, self-regulatory efficacy, negative outcome expectations, and pain acceptance for predicting planned physical activity according to Weinstein's two prediction suggestions. Logistic regression revealed, after controlling for pain intensity, self-regulatory efficacy, negative outcome expectations, and pain acceptance distinguished groups achieving/not achieving planned physical activity, p < 0.001 (28% variance). A second model adding past physical activity also predicted the groups, p < 0.001 (57% variance). This is one of the first arthritis studies examining planned physical activity relative to Weinstein's recommendations.

Pain, anxiety, and negative outcome expectations for activity: do negative psychological profiles differ between the inactive and active?

OBJECTIVE: Adherence to physical activity at ≥150 minutes/week has proven to offer disease management and health-promoting benefits among adults with arthritis. While highly active people seem undaunted by arthritis pain and are differentiated from the moderately active by adherence-related psychological factors, knowledge about inactive individuals is lacking. This knowledge may identify what to change in order to help inactive people begin and maintain physical activity. The present study examined the planned, self-regulated activity of high, moderate, and inactive individuals to determine if differences existed in negative psychological factors. METHODS: Adults with a medical diagnosis of arthritis completed online measures of physical activity, perceived pain intensity, pain anxiety, and negative disease-related outcome expectations from being active. High active (n = 94), moderately active (n = 77), and inactive (n = 104) groups were identified. RESULTS: A significant multivariate analysis of covariance revealed group differences (P < 0.001). Followup analyses indicated that inactive participants had the most negative psychological profile. Inactive participants reported that negative disease-related outcomes expectancies were more distressing and likely to occur than either group of active participants and expressed greater pain intensity and pain anxiety than the highly active participants (P < 0.05 for all). CONCLUSION: Identifying differences in negative psychological factors aids in the understanding of differential adherence between activity groups and highlights possible factors to change in future intervention and research.

Examination of self-regulatory efficacy and pain among individuals challenged by arthritis flares.

PURPOSE/OBJECTIVE: Public health guidelines for physical activity (PA) for individuals with arthritis are 150 min/week. Self-regulatory efficacy to plan and schedule activity (SRE-SP) was greater for individuals meeting guidelines in studies when symptoms were usual. Extreme symptoms of a flare presumably challenge or block PA adherence. We found it surprising that the question of whether pain intensity and SRE-SP differ within the same person as a function of symptom severity (i.e., flare vs. no-flare) and PA level has not been addressed. RESEARCH METHOD/DESIGN: Participants (N = 53) reported SRE-SP and SRE to overcome arthritis barriers (SRE-AB) during the following month, average usual and flare-pain intensity, and PA volume in the past 6 months. Mixed-model ANOVAs compared those meeting or not meeting PA guidelines in both flare and no-flare conditions. RESULTS: Main effects for SRE (SP and AB) were significant for within flare/no-flare comparisons (p < .001) and for SRE-SP were significant between PA groups (p < .05). Individuals meeting PA guidelines have the advantage of greater SRE-SP to motivate adherence than those of the less active. All participants' activity was less efficacious during a flare. For pain intensity, a within-subjects flare versus no-flare effect (p < .001) confirmed that flares are perceived as more of an obstacle or challenge for engaging in PA. CONCLUSION/IMPLICATIONS: Regardless of meeting or not meeting PA guidelines, participants reported lower SRE and higher pain intensity during a flare. PA adherence during a flare may require self-regulation of PA to be active, and in particular, to be able to meet recommended guidelines, relative to symptom severity.

Do older adults' beliefs about their community mobility predict walking performance?

Among older adults, preserving community mobility (CM) is important for maintaining independent living. We explored whether perceptions of the environment and self-efficacy for CM (SE-CM) would predict walking performance for tasks reflecting CM. We hypothesized that perceptions of the environment and SE-CM would be additive predictors of walking performance on tasks reflecting the complexity of CM. Independent living older adults (N = 60) aged 64-85 completed six complex walking tasks (CWTs), SE-CM, and the environmental analysis of mobility questionnaire (EAMQ). Multiple regression analyses indicated that for each CWT, the EAMQ scales predicted walking performance (range: model R2Adj. = .078 to .139, p < .04). However, when SE-CM was added to the models, it was the sole significant predictor (p < .05). Contrary to our hypotheses, SE-CM was the best predictor in the additive models. SE-CM may be more correspondent to walking tests and thus a more sensitive predictor of CM walking performance.

Meeting physical activity recommendations: self-regulatory efficacy characterizes differential adherence during arthritis flares.

PURPOSE: Using social-cognitive theory, we examined whether adults who experienced an arthritis flare and met/did not meet the disease-specific public health recommended dose for physical activity differed in their self-regulatory efficacy beliefs, overall pain, and flare-related factors. RESEARCH METHOD/DESIGN: Adults with arthritis (N = 56; M(age) = 49.41 ± 11.56 years) participated in this prospective study. RESULTS: Multivariate analysis of variance comparing groups who met or did not meet the recommended dose (n(met) = 24, ≥ 150 minutes/week vs. n(not met) = 32, < 150 min/week) on efficacy, overall pain, and flare-related factors was significant (p < .01; η(partial)² = .28). People meeting the dose had significantly greater self-regulatory efficacy to overcome arthritis barriers (M(met dose) = 7.33 ± 1.95 vs. M(did not meet dose) = 5.74 ± 2.08, η(partial)² = .14) and to schedule/plan (M(met dose) = 7.27 ± 1.80 vs. M(did not meet dose) = 5.72 ± 1.90, η(partial)² = .15). Overall pain and flare-related factors did not differ (ps > .05). CONCLUSION/IMPLICATION: During flares, individuals with greater self-regulatory efficacy to manage disease barriers and plan their physical activity were more adherent to disease-specific public health activity recommendations. This study was the first to demonstrate differences in social cognitions that characterize adherence to recommended activity among people challenged by arthritis flares. Findings support the theoretical position that self-regulatory efficacy is related to better adherence in the face of challenging disease-related circumstances. The importance of studying individual characteristics of people who succeed in being active despite such obstacles is stressed.