Health and well being for people with disability: the role of physiotherapists in promoting physical activity.
Abstract: It is now well-known that physical activity is important to prevent or address 'lifestyle' conditions. Encouraging all individuals in our population to achieve better health via improved levels of physical activity was one of the 2008- 2011 health priorities for New Zealand. Nearly one in five people in New Zealand live with long-term sensory, physical, and/or intellectual impairment. New Zealand data indicate that individuals with disability are even less active than the general population. It appears therefore that individuals with disabling conditions are potentially less healthy than their able-bodied counterparts and more at risk of the development of lifestyle disease as a consequence of low levels of physical activity. This commentary provides an overview of the emergence of the construct of disability, and shows how disability and health are related. It then identifies the importance of physical activity for people with disability to achieve health in a holistic sense, while exploring this concept in particular for people with long- term neurological conditions. Lastly, it explores the potential role and scope of physiotherapy in promoting health for individuals with disability.

Key Words: disability, physical activity, physiotherapy, health promotion
Article Type: Report
Subject: Disabled persons (Care and treatment)
Disabled persons (Health aspects)
Physical therapy (Patient outcomes)
Physical therapy (Health aspects)
Physical therapy (Usage)
Therapeutics, Physiological (Patient outcomes)
Therapeutics, Physiological (Health aspects)
Therapeutics, Physiological (Usage)
Physical therapists (Powers and duties)
Health promotion (Methods)
Author: Mulligan, Hilda
Pub Date: 03/01/2011
Publication: Name: New Zealand Journal of Physiotherapy Publisher: New Zealand Society of Physiotherapists Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2011 New Zealand Society of Physiotherapists ISSN: 0303-7193
Issue: Date: March, 2011 Source Volume: 39 Source Issue: 1
Product: Product Code: 8043600 Physical Therapists NAICS Code: 62134 Offices of Physical, Occupational and Speech Therapists, and Audiologists SIC Code: 8049 Offices of health practitioners, not elsewhere classified
Geographic: Geographic Scope: New Zealand Geographic Code: 8NEWZ New Zealand
Accession Number: 263880338
Full Text: INTRODUCTION

Current health focus (at least in the western world) has shifted from cure and prevention of infectious diseases, to the prevention and management of conditions and diseases caused largely by our increasingly sedentary lifestyles (World Health Organisation 2006). In New Zealand, 'lifestyle' conditions such as cardio-vascular disease, diabetes and certain forms of cancer impact on overall health, not only because of physical effects, but also because of social and psychological effects (New Zealand Director-General of Health 2009; New Zealand Health Strategy 2000). It is now well-known that physical activity is important to prevent or address 'lifestyle' conditions. Being physically active produces physical and psychological effects via a substantial increase in energy expenditure from contraction of skeletal muscles (Heath and Fentem 1997; Kesaniemi et al 2001). Encouraging all individuals in our population to achieve better health via improved levels of physical activity was one of the 2008-2011 health priorities for New Zealand (New Zealand Director-General of Health 2009; New Zealand Ministry of Health 2007). The New Zealand Disability Strategy specifically encourages improved levels of physical activity for individuals with disabling conditions (New Zealand Disability Strategy 2001), thereby matching efforts to encourage physical activity for people with disability on an international basis (Durstine et al 2000; New Zealand Disability Strategy 2001; US Department of Health and Human Services 2008b; Van der Ploeg et al 2007).

According to the New Zealand 2006 census, nearly 20% of the population reports long-term sensory, physical, and/ or intellectual impairment (Statistics New Zealand 2006). Approximately half of these individuals require assistance in the form of regular help from other people or from technical aids. This number has remained stable throughout various surveys, i.e. the Disability Surveys in 1996/1997, the Household Disability Surveys in 2001 and 2006, and the Disability Surveys of Residential Facilities in 2001 and 2006 (New Zealand Director-General of Health 2009). New Zealand disability statistics mirror disability statistics in other developed countries (Australian Bureau of Statistics 2007; Statistics Canada 2001; US Department of Health and Human Services 2008a). In addition (and like other countries with indigenous populations such as Canada and Australia), New Zealand's indigenous Maori population shows higher disability statistics than the general population, with one in four adults between the ages of 45-64 years reporting disability (Statistics New Zealand 2006).

New Zealand data indicate that individuals with disability are even less active than the general population: only four out of ten people who report as disabled achieve the currently recommended levels of physical activity of 30-45 minutes of moderate physical activity on most days of the week (Statistics New Zealand 2006). Similarly, the Australian Bureau of Statistics reports that 19% of the total population has a disability, and even though people with disabilities are reported to have 7% more leisure time than able-bodied individuals, their participation rates in physical activity, as in New Zealand, are less than those of the general population (Australian Bureau of Statistics 2007). The situation in North America is reportedly even worse (US Department of Health and Human Services 2005). It was found, for example, in a large cross-sectional study (n = 4,038) conducted in the United States, that only one quarter of adults with long-term conditions who required equipment or carer support for everyday life achieved the recommended levels of physical activity for overall health (Boslaugh and Andresen 2006).

It appears therefore that individuals with disabling conditions are potentially less healthy than their able-bodied counterparts and more at risk of the development of lifestyle disease because of low levels of physical activity. This commentary will provide an overview of the emergence of the construct of disability, and show how disability and health are related. It will then identify the importance of physical activity for people with disability to achieve health in a holistic sense while exploring this concept in particular for people with long-term neurological conditions. Lastly, it will explore the potential role and scope of physiotherapy in the promotion of health for individuals with disability via recreational physical activity.

Understandings of disability and health

Our understanding of the term 'disability' and the disabling process has evolved over time. An earlier concept of disability was based on an individualistic and positivist model in which disability was due to inability to perform an activity in a normally expected manner (Murray and Lopez 1996). Disability was seen as 'inhering in the individual, and stemming from functional limitations or psychological losses' (Shakespeare 2006, p. 15). From this point of view, disability equated to a state of poor health. The World Health Organisation's (WHO) first framework for disability, the International Classification of Impairments, Disabilities, and Handicap (ICIDH), created in 1980, used this positivist understanding of disability (Gate and Niewenhuijsen 2000; World Health Organisation 2001).

In contrast, a social understanding of disability emerged during the time of political 'affirmation' for minority groups, beginning with the Black consciousness movement in the United States in the 1970's. The change in concept of disability, from an individualistic model to a social model, enabled people with life-long or long-term conditions to relate how disability arises not from individual factors, but from socially-constructed factors within the largely able-bodied environment (Shakespeare 2006). Recognition that disability and disablement can be partly socially constructed, and therefore that lack of participation in society is one of the dimensions of disablement, led to the development of the ICIDH into the ICIDH-2 (Gate and Niewenhuijsen 2000).

In 2001 the WHO adopted the International Classification of Functioning, Disability and Health (ICF) as a more suitable framework than the ICIDH-2 for human functioning and disability (Stucki et al 2007; World Health Organisation 2001). In this framework, disability is not a medical or biological dysfunction. Instead, impaired body structure and function together with activity limitations are recognised as a part of the disabling process, while personal and environmental factors may also constrain people from participating in their life activities, thereby experiencing disability (World Health Organisation 2001). With this framework, health is recognised as a holistic concept of mental, physical and social wellbeing, and not merely an absence of disease (Murray and Lopez 1996; World Health Organisation 2001).

The New Zealand Disability Strategy acknowledges that disability is experienced when individuals with impairment are disadvantaged, or have difficulty in, or are precluded from participating in their own communities, employment, recreation, or sport (New Zealand Disability Strategy 2001). The New Zealand Disability Strategy, underpinned by the New Zealand Bill of Rights Act (New Zealand Ministry of Justice 1990), the New Zealand Human Rights Act (New Zealand Parliament 1993) and the United Nations International Covenant on Civil and Political Rights (United Nations 1976), aligns to the ICF framework of disability by including impaired body structure and function, and an individual's environment, within the potential framework for disability. It acknowledges that all members of the population, including those with physical, sensory, neurological, psychiatric, or intellectual impairment, should be able to access social and physical environments without hindrance, and in this way feel welcomed and included within their own community (New Zealand Disability Strategy 2001). However, despite a strong social policy for equal opportunity for all, the New Zealand Disability Strategy also acknowledges that people with disability have less opportunity than the general population to be involved in physical activity (New Zealand Disability Strategy 2001).

Physical activity and health in the disabled population

Physical inactivity bodes poorly for individuals with disability who, besides being prone to lifestyle diseases like anyone else, are also prone to the development of secondary complications such as fatigue, physical de-conditioning, pain, increased anxiety and depression, and decreasing functional capacity (Coyle et al 2000; Kinne et al 2004; Rimmer 2001; Santiago and Coyle 2004; Seekins et al 1994). Physical inactivity therefore contributes to a spiral of complications and consequences for individuals with disability (Rimmer 2005).

More than ten years ago it was suggested that physical activity of any sort would assist in preventing secondary complications from arising, thereby improving quality of life for people with disability (Rimmer 1999). This was because of emerging evidence to suggest that physical activity carries physiological and functional benefits for people with disability (Heath and Fentem 1997; Santiago et al 1993). At that time, however, health professionals had insufficient information to gauge specific benefits and possible risks to individuals with disability associated with being physically active (Cooper et al 1999). However, we now have good evidence to demonstrate that exercise benefits individuals with long-term impairment, that the type of exercise seems not to be important, and that exercise needs to be relatively intense to be of benefit (Taylor et al 2007).

Physical activity for people with neurological conditions

People with neurological conditions make up a subset of the population with disability. The most prevalent neurological conditions are multiple sclerosis, Parkinson's disease, stroke and cerebral palsy.

Multiple sclerosis is one of the most common neurological diseases, and is characterised by a scattered loss of myelin from throughout the central nervous system. A prevalence survey supported by the Health Research Council and the New Zealand Multiple Sclerosis Society in 2006 demonstrated the prevalence in New Zealand as being 71.9 per 100,000. This prevalence is close to the estimates of prevalence in Scandinavia and the United Kingdom, where the prevalence rates in Scotland are the highest in the world at 145-193/100,000 (Pugliatti et al 2002).

Parkinson's disease is a neurodegenerative disease, with a prevalence of about 1-2% of the population over the age of 65 years, rising to 3-5% of those over 85 years (Alves et al 2008). It is therefore more common in developed countries like New Zealand, where people live longer. Prevalence of Parkinson's disease in New Zealand is estimated at 76/100,000 population (Caradoc-Davies et al 2009).

Stroke is not only the third leading cause of death in adults in the developed world, it is also a major cause of disability in adults because of its effect on neurological function. This is partly because of its high incidence (e.g. 5,200 first-ever strokes were estimated to have occurred in New Zealand in 2001), but also because, in developed countries like New Zealand, stroke mortality is falling faster than stroke incidence (Tobias et al 2007). In New Zealand, prevalence of stroke survivors is estimated at around 37,000 of the population aged over 25 years, but it is estimated that this will rise to around 45,000 by 2011 (Tobias et al 2007).

Cerebral palsy is a disorder of movement and function from damage to the central nervous system before, during, or shortly after birth. There are differences in how the incidence of cerebral palsy is measured, because of differing diagnostic approaches. Nevertheless, a large review of current literature demonstrated a world-wide incidence rate of between 2 and 2.5 per 1,000 live births, and this rate has remained static over time (Odding et al 2006).

Individuals with long-term neurological conditions who have ambulatory ability may be able to attain daily levels of physical activity that are similar to their able-bodied peers. Such individuals could undertake the recommended dose of half an hour of moderate physical activity per day in the recommended ways (American College of Sports Medicine 2006; Pate et al 1995; US Department of Health and Human Services 2008b). This may not be the case, however, for more severely impaired individuals, where ambulatory ability is affected to a greater or lesser extent.

For many individuals with neurological conditions, walking is difficult. It is not surprising, therefore, that individuals with neurological conditions have been found to be as inactive as (or even less active than) populations with other long-term conditions. For example, a systematic review of 13 studies that examined levels of physical activity in 'diseased' compared to non-diseased populations (n = 2,369), found that levels of physical activity for those with multiple sclerosis were a full standard deviation below non-diseased populations, but equal to other populations with chronic fatigue syndrome, chronic obstructive pulmonary disease, and cerebral palsy (Motl et al 2005). A different review identified the very low levels of fitness in children, adolescents, and adults with cerebral palsy. The review participants demonstrated between 20% and 60% less physical fitness than peers without disability (Rimmer 2001). A study of 312 patients with stroke found that, while 15% of the study population reported having never been physically active before stroke, this rose to 27% following stroke (Shaughnessy et al 2006).

Despite low uptake of physical activity by people with neurological conditions, many physiological and psychological benefits of being physically active have been demonstrated. Good quality research has demonstrated that: i) muscle strength can be improved in individuals with stroke and cerebral palsy by intense physical activity undertaken as resistance training in either rehabilitation or community settings (Moreland et al 2003; Ouellette et al 2004; Pang et al 2005; Teixeira-Salmela et al 1999), ii) progressive resistance training combined with aerobic conditioning produces gains in self-reported or measured functional capacity (Moreland et al 2003; Ouellette et al 2004; Pang et al 2005; Taylor et al 2004; Teixeira-Salmela et al 1999), iii) physical activity that includes balance exercises or walking training improves balance in standing, walking capacity, speed, and step-climbing ability in people with stroke (Ada et al 2003; McClellan and Ada 2004; Pang et al 2005; Teixeira-Salmela et al 1999), iv) repetitive exercises for endurance, balance, gait, and fine motor dexterity has beneficial effects on functional capacity for people with Parkinson's disease (Comella et al 1994), v) physical activity improves quality of life, cognitive function, memory, and decreases the number of symptoms experienced by individuals with traumatic brain injury (Gordon et al 1998) and vi) exercise improves symptoms of multiple sclerosis (Rietberg et al 2004).

Participation in physical activity for people with disability the potential of recreation

Unlike the general population, some individuals with disability may not be able to build incidental physical activity into everyday life activities by taking the stairs instead of the lift, or walking a few more bus stops, because of impaired mobility or decreased functional capacity. Instead, recreational physical activity is a potentially promising way to encourage people with disability to improve levels of physical activity. A large interview study of 790 individuals with physical disability published nearly 20 years ago showed that those who undertook 'leisure' exercise reported better life-satisfaction (Kinney and Coyle 1992). These findings led to the suggestion by the study's authors that therapeutic leisure exercise may be of benefit for this population. Other authors have also recommended that regular strength and fitness training in the form of recreational exercise may be a suitable way to encourage physical activity for individuals with disabling conditions (Boslaugh and Andresen 2006; Damiano 2006), because it is not only possible and enjoyable, but also produces physical and psychological benefits (Allen et al 2004; Coyle and Santiago 1995). Furthermore because it can be adapted as necessary to suit physical ability, capacity, and temperament on an individual basis, it is therefore more likely to be sustained (Durstine et al 2000).

Despite promotion of recreational physical activity, however, people with disability report a raft of barriers to being physically active. Barriers have been identified as arising from lack of physical access to recreation facilities and to equipment, from the cost of access to suitable programmes, from a range of impairments that hinder exercising in usually accepted formats, from emotional and psychological difficulties of exercising in the public domain, and from a perceived lack of knowledge of staff in recreation facilities to be able to assist those with disability to exercise safely (Froehlich et al 2002; Kehn and Kroll 2009; Motl et al 2006b; Mulligan et al 2008; Nary et al 2000; Nosek et al 2006; Rimmer et al 2005; Rimmer et al 2004; Rimmer et al 2008; Scelza et al 2005; Stroud et al 2009; Vanner et al 2008).

In addition to the barriers listed above, lack of self-efficacy for exercise has been found to be an important personal barrier to recreational exercise (Cardinal et al 2004; Motl et al 2006a; Shaughnessy et al 2006; Stroud et al 2009). Self-efficacy is the confidence and belief in one's ability to have control over events that affect one's life (Bandura 1986, p. 39). According to Bandura's Social Cognitive Theory, self-efficacy is influenced by social persuasion and support from others (Bandura 1986, 1997). There is some evidence to suggest that recreational activities can improve confidence and self-efficacy for individuals with neurological impairment. For example, a randomised controlled trial of 42 people with stroke discovered that those who undertook a programme of resistance training reported better function and less disability (thereby feeling or perceiving themselves to be more 'able'), even though there was no objective improvement in their performance-based measures of function (Ouellette et al 2004). In a different study, self-efficacy measured with the Physical Self-efficacy Scale and the Behavioural Rating Scale was found to improve in a small cohort of adults (N = 22) with disability related to traumatic brain injury, multiple sclerosis, cerebral palsy, or spinal cord injury after a twelve week horseback riding programme (Farias-Tomaszewski et al 2001). In addition to improved self-efficacy and confidence, participation in physical activity in the form of recreation or sport was shown to correlate with a higher level of perceived participation in life events--i.e. community integration (measured with the Craig Handicap and Reporting Technique) in a cohort study of 48 people with spinal cord injury (Hanson et al 2001).

Whether there is a positive relationship between physical activity and 'participation' is, however, still an emerging area of research because of lack of tools that definitively measure 'participation' (Stucki et al 2007). As an example, an experimental study failed to find an improvement in life participation on the Stroke-Adapted Sickness Impact Profile-30 score after a short physical activity programme aimed at reducing level of impairment in people who had had a stroke, even though gains were shown in walking measures (Ada et al 2003). It may be that the programme offered in this study was too short to produce perceived 'participatory' benefits, that it was not aimed at 'participation' per se, or that the measurement tool was not sensitive to measurement of 'participation'. In contrast, a study on the effects of hippotherapy (horse-riding) for 17 people with cerebral palsy across a wide age range, found perceived improved self-efficacy and self-esteem in addition to the physiological and functional level benefits of being able to walk and move better (Debuse et al 2009). Likewise, a small study of individuals with spinal cord injury who participated in scuba-diving activity reported that scuba-diving increased their confidence through meeting challenges (Carin-Levy and Jones 2007). Research therefore suggests that participation in physically active recreation can produce benefits not only of a physical nature, but also of a psycho-social nature, that this type of physical activity would encourage people to make it a lifestyle choice through improved self-efficacy, and that this would then render health benefits on an individual and holistic basis.

The role and scope of physiotherapy in the promotion of health via recreational physical activity

What then is the role of physiotherapy in promoting health via the promotion of physical activity? It is apparent that all is not well on this account. It appears that patients may not learn to expect to be physically active when living with a long-term impairment because of interactions with health professionals, including physiotherapists. For example, a number of observational studies have examined the amount of physical activity that people are engaged in during formal rehabilitation after stroke. The studies observed patients on a regular basis (e.g. every 10-30 minutes) during the day (for example from 8am to 5pm), and discovered that patients spend less than 10% of their time in rehabilitation settings actually being physically active, and spend the majority of the day (50% or more) inactive and usually alone (Ada et al 1999; Bernhardt et al 2004; De Weerdt et al 2000; Esmonde et al 1997; Lincoln et al 1989). Lack of expectation to be physically active during rehabilitation has the possible consequence that patients (and their families) then do not expect physical activity to be part of a day's schedule when living with the consequences of a longterm condition. Physiotherapists appear to be perfectly placed to encourage and facilitate their patients into physical activity because they work intensively with individuals with long-term impairment during rehabilitation. It is surprising to discover, therefore, how little physical activity occurs in rehabilitation settings where the 'seed' of expectations for being physically active could be sown.

A recent study examining the role and experiences of physiotherapists in the promotion of recreational exercise for people with neurological disability in New Zealand found that physiotherapists, despite recognising a role in the promotion and facilitation of recreational exercise for their patients, perceived a lack of acknowledgement and support for this role from health services and their health professional colleagues (Mulligan et al 2010). The researchers also identified challenges to physiotherapists being able to fully promote recreational exercise for people with disability because of issues around suitable, acceptable and accessible recreation programmes and facilities.

The World Confederation of Physical Therapists (WCPT) recognises a clear role for physiotherapists to promote health through the promotion of physical activity (World Confederation for Physical Therapy 2007). It has been suggested that exercising in a group during rehabilitation may be a suitable way of increasing the amount of physical activity performed during rehabilitation (Ada et al 2006). Group work may not only be a cost-effective way of providing therapy with stretched resources, it could also provide access to social support. Social support is one of the key features in building self-efficacy and it is self-efficacy that is purported as necessary to bring about a positive change in behaviour. It seems evident therefore that, in addition to providing social support, exercising with others may be able to instil confidence in an individual's ability as well as the expectation of being physically active. Recreational activity within a group community setting could be one method to increase levels and uptake of physical activity once patients have been discharged from the rehabilitation setting.

In conclusion, this commentary has included two main messages to physiotherapists. The first is that physiotherapists must take into account the evidence that physical activity improves the health of individuals with long-term impairment by improving physical and psycho-social well-being. The second is that physiotherapists need to investigate and trial strategies for setting up opportunities for recreational activity for individuals with disabling conditions. To do this, however, they may need to work collaboratively with their health colleagues to advocate to their local city councils, recreation providers and the general public for more inclusive access to recreational physical activity for people with disabling conditions. With such advocacy, our society may be more able to provide suitable, acceptable and user-friendly access to recreational physical activity for all members of the population, including individuals who currently experience disadvantage. If physiotherapists were to advocate and address issues around access to health promoting recreational physical activity for people with disability, then this could truly enable and promote health as a holistic concept of mental, physical and social well-being, and not merely the absence of disease.

KEY POINTS

* Individuals with disabling conditions are less physically active than their able-bodied peers.

* Individuals with disabling conditions are therefore potentially less healthy and more at risk of the development of lifestyle disease as a consequence of low levels of physical activity.

* There is a clear role and scope for physiotherapy in promoting health for individuals with disability via the promotion of physical activity.

ACKNOWLEDGEMENTS

I wish to acknowledge the Health Research Council Disability Placement Programme Award that funded my PhD studies on which this commentary was based. I also wish to acknowledge my supervisors, Professor Dave Baxter, Associate Professor Leigh Hale, Dr Lisa Whitehead, and my two advisors Emeritus Professor David Thomas and Professor Derick Wade for advice and support during my studies. Lastly, I wish to thank my colleague Heather Patterson for editing this manuscript, and friend Priscilla Beeton for providing an 'outsider's' comments on its content.

ADDRESS FOR CORRESPONDENCE

Dr Hilda Mulligan, University of Otago Christchurch, School of Physiotherapy, P O Box 4345, Christchurch, 8140. Email: Hilda.mulligan@otago.ac.nz. Phone: (03) 3640690. Fax: 9030 3640692

SOURCE OF FUNDING

This commentary arose from work completed for PhD studies supported by a New Zealand Health Research Council Disability Placement Programme Award to the author.

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Hilda Mulligan, BSc (Physiotherapy), MHSc, PhD

Lecturer, University of Otago, School of Physiotherapy Christchurch
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