Disability and Health Journal 1 (2008) 7e13
www.disabilityandhealthjnl.com
Research Articles
People with mobility impairments: Physical activity
and quality of participation
Angela Crawford, M.S.O.T./S., Holly H. Hollingsworth, Ph.D.,
Kerri Morgan, M.S.O.T., O.T.R./L., David B. Gray, Ph.D.*
Program in Occupational Therapy and Department of Neurology, Washington University, School of Medicine, St. Louis, MO 63108, USA
Abstract
Background: We sought to describe the characteristics of physical activity levels, health, community integration, and social participation of people with mobility impairments.
Methods: Based on responses to a participation survey, respondents, located primarily in the Midwestern United States, were divided
into 3 physical activity groups: high, low, and inactive. We chose a purposeful sample of 604 people with mobility limitations who had
a diagnosis of spinal cord injury, multiple sclerosis, cerebral palsy, stroke, or poliomyelitis. The Participation Survey/Mobility (PARTS/
M) was used to measure participation in 6 domains and 20 different activities, the Physical Activity and Health Status (SF-36) was used
to measure health and quality of life, and the Reintegration to Normal Living Index (RNL) was used to measure integration into the
community.
Results: People with mobility impairments who were identified as having a high level of physical activity reported greater participation,
better health, and a higher level of reintegration to normal community living compared with participants who described their physical activity level as low or inactive.
Conclusion: Positive health status and superior community participation were found in a high physical activity group compared with
low active or inactive groups of people with mobility impairments and limitations. Ó 2008 Elsevier Inc. All rights reserved.
Keywords: Physical activity; Disability; Community Participation; Health
Despite proven benefits in health and quality of life associated with moderate daily exercise, over half of Americans currently do not participate in regular physical activity
[1]. Furthermore, Americans with disabilities are less likely
to engage in physical activity than those without disabilities, yet have greater need to promote health and prevent
disease [2,3]. An estimated 13% to 20% of the Western
world’s population has 1 or more disabilities, and 56% of
this population does not participate in physical activity
compared with 36% of the able-bodied population [3,4].
According to the U.S. Department of Health and Human
Services (USDHHS) Centers for Disease Control and Prevention (CDC), appropriately high levels of physical activity can be achieved in 1 of 2 ways. The first is through
engagement in 30 minutes of moderately intense activity
5 days a week, resulting in a small increase in heart rate
and burning 3.5 to 7 calories per minute. The second is
by performing 20 minutes of vigorous activity 3 days
* Corresponding author: 4444 Forest Park, St. Louis, MO 63108. Fax:
314-286-1601.
E-mail address: grayda@wustl.edu (D.B. Gray).
1936-6574/08/$ e see front matter Ó 2008 Elsevier Inc. All rights reserved.
doi:10.1016/j.dhjo.2007.11.004
a week, resulting in a large increase in heart rate and burning more than 7 calories a minute. These gains can be accomplished through activities such as house cleaning or
yard work, as well as through traditional exercise and active
recreation. Two additional classifications are used to characterize lower levels of physical activity. Insufficient physical activity is defined as engaging in more than 10 total
minutes per week of moderate or vigorous intensity activities but less than the recommended level of activity previously defined. Inactivity is described as engaging in less
than 10 total minutes per week of moderate or vigorous intensity lifestyle activities. These operational definitions are
based on those used by the American Heart Association
[5,6].
Many studies have documented a variety of health benefits that result from increased physical activity. Moderate
to high levels of physical activity have been demonstrated
to increase strength, stamina, fitness, mobility, coordination, endurance, posture, weight control, immune function,
cardiopulmonary function, and circulation for people with
disabilities [7-11]. In addition, the psychological benefits
of moderate levels of physical activity include a better
8
A. Crawford et al. / Disability and Health Journal 1 (2008) 7e13
acceptance of disability, a more independent attitude, enhanced mood, greater sense of life control, and fewer suicidal tendencies due to decreased depression and anxiety
[7-9,12-14]. Overall, health benefits due to moderate to
high levels of physical activity include a decrease in secondary conditions and the need for medical care, as well
as an increase in functional independence, energy, and
physical capacity [13,15-18]. Subjectively, people who participate in physical activity report having a greater self image and level of self-satisfaction, increased feelings of wellbeing, and improved self-esteem, perceived health, body
image, and self-resilience [9,11,19-21].
Although relationships between activity level and both
the physical and psychological health status have been examined for people with disabilities [2,21-24], the participation in major life activities by people with mobility
impairments who are inactive, somewhat active, or highly
active has not been studied. The International Classification
of Functioning, Disability, and Health (ICF) defined participation as involvement in some area of human life [26]. In
2003, Perenboom and Chorus [27] reviewed 11 instruments
that have been reported to measure participation as defined
by the ICF. Many existing measures are based on the concept of handicap as described in the 1980 version of the International Classification of Impairment, Disability, and
Handicap [28]. Perenboom and Chorus assert that these
measures are inadequate to assess the ICF concept of full
participation. The term involvement, used by the ICF to define participation, allows for the expansion of the concept
of participation beyond the frequency of doing activities
or being limited in doing activities. Gray et al. [25] used
the ICF concept of full participation as a basis for developing a measure of participation called the Participation Survey/Mobility (PARTS/M). The PARTS/M includes 6 of the
9 major life activities encompassed in the ICF. In addition
to the temporal component of participation, the PARTS/M
provides information on how individuals evaluate their participation, the influence of several health-related conditions
on their participation, and the type and amount of support
they use when they participate.
The purpose of this study was to describe levels of physical activity and participation in major life activities as
measured by the PARTS/M, health status as measured by
the Physical Activity and Health Status (SF-36) Physical
and Mental Health Summary Scales, and return to normal
community life as measured by the Reintegration to Normal Living Index (RNL).
blocks. Inclusion criteria required that participants live in
the community, have no history of mental illness, are able
to give informed consent, and are over the age of 18.
Non-English speakers, persons who did not use a mobility
device or have difficulty walking 3 blocks, and persons who
lived in institutions were excluded from the study. Participants were recruited from across the United States with
the assistance of disability organizations, independent living centers, and support groups. All phases of this project
were approved by the Washington University Human Subjects Committee.
Instruments
The PARTS/M is a self-report survey instrument designed to measure the participation of persons with mobility impairments in major life activities [25]. Six domains
and 20 different activities are included in the PARTS/M
(Table 1). Four components of participation (temporal,
evaluative, health-related, and supportive) are included in
each activity. Temporal questions focus on frequency of,
and time spent participating in, an activity. Evaluative items
are on choice, satisfaction, and importance of participating
in a particular activity. Health-related questions ask if an
activity is limited by illness, physical impairment, pain, fatigue, or another condition. Finally, the level of personal
and/or environmental supports needed to perform an activity is solicited. Participation scores may be calculated for
all 20 activities, the 6 domains, the 4 components, and an
overall total. The internal consistency and stability of the
PARTS/M are moderate to high [25].
The SF-36 consists of 8 subscales measuring physical
and mental health with established reliability and validity
for the general population [29]. Scores for each subscale
range from 0 to 100; higher scores indicate better health
Table 1
Activities and Domains of the PARTS/M
Domain
Activity
Self-care
Dressing
Bathing
Bowel care
Bladder care
Meals
Move inside home
Leave home
Take vacations
Work inside home
Exterior maintenance
Parenting
Intimacy
Employment
Volunteering
Money management
Community
Religious
Socializing
Leisure
Active recreation
Mobility
Domestic life
Interpersonal interactions and relationships
Major life areas
Methods
Participants
This study consisted of a purposeful sample of people
with lower limb impairments who reported using a mobility
device or having difficulty walking a distance of 3 city
Community, social, and civic life
A. Crawford et al. / Disability and Health Journal 1 (2008) 7e13
status, except for the pain subscale, where low scores indicate that pain impedes doing activities. For this study, only
7 of the 8 subscales of the SF-36 were analyzed. The Physical Functioning (PF) subscale was excluded because these
items ask questions about walking, lifting, climbing, and
bending; these activities may not be possible for some
people with mobility impairments [30].
The RNL is an 11-item instrument that assesses personal
satisfaction with community integration and performance
of everyday occupations [31]. High levels of satisfaction
with community integration are indicated by high scores.
This index is a valid measure of community integration
for people living with chronic health conditions such as
mobility impairments [32].
9
Data analysis
Chi square tests were used to relate physical activity
level with the demographic groups of race, level of education, gender, diagnostic group, annual income, type of primary mobility device utilized, and employment. A 1-way
analysis of variance (ANOVA) was performed to compare
the level of physical activity with participant age and the
participation across the 6 participation domains. An ANOVA was used to examine relationships between physical
activity groups and the subscales of the SF-36 and questions on the RNL. If results were significant at the .05 level,
then Scheffé post-hoc tests were performed to analyze pairwise differences.
Procedures
Results
The PARTS/M, SF-36, RNL and demographic questionnaires were completed by 604 people with mobility impairments. The USDHHS-recommended amounts of physical
activity were used to guide the formation of 3 physical activity groups: high active, low active, and inactive. These
physical activity level groups were based on responses to
questions regarding (1) frequency and duration of exercise
inside the home, (2) frequency and duration of exercise outside of the home, and (3) frequency of participation in active recreation outside of the home (Table 2). Active
recreation included activities such as swimming, golfing,
playing basketball, skiing, racing, bowling, camping, going
on nature trails, or other activities.
Table 2
Criteria for Exercise and Recreational Activity Groups
Activity
High active group
Exercise inside or
outside of home
Active recreation event
Frequency
More than 2 exercise
sessions per week
One event more than
2 times a week or
Active recreation events At least 2 events once
or twice a week
Low active group
Exercise inside or
One or 2 exercise
outside of home
sessions per week
Exercise inside or
At least 2 exercise
outside of home
sessions per week
Active recreation event One event once or
twice per week; or
Active recreation events At least 2 events, once
or twice a month
Inactive active group*
Exercise inside or
One to 2 exercise
outside of home
sessions per week
Exercise inside or
Rarely or never exercise
outside of home
Active recreation event One to 2 times per
month; or
Active recreation event Never
Duration
Over 30 minutes
Over 30 minutes
Under 30 minutes
Under 30 minutes
* Includes those who responded ‘‘don’t know’’ or ‘‘not applicable.’’
Demographics
The sample included 604 participants with lower limb
impairments hindering their abilities to walk (Table 3).
The distribution of device use by study participants was
as follows: cane, crutch, walker (37%); power wheelchair
(17%); manual wheelchair (14%); scooter users (15%);
and those who reported having difficulty walking 3 or 4 city
blocks but did not use a mobility device of any kind (17%).
The sample included polio survivors (28%), stroke survivors (13%), individuals with a spinal cord injury (SCI)
(23%), multiple sclerosis (MS) (21%), and cerebral palsy
(CP) (15%).
The responses to the PARTS/M questions on exercise
and active recreation were used to create 3 physical activity
groups: 39% (n 5 236) in high active, 34% (n 5 203) in
low active, and 27% (n 5 165) in inactive. Significant differences were found for levels of physical activity when examined for diagnoses ( p 5 .001), gender ( p 5 .003), and
age ( p ! .001). Those with CP and SCI were significantly
more active than those who had MS or had survived a
stroke or polio. More females were in low and inactive
groups. The average age of those in the high active and
low active groups was lower than the age of those in the
inactive group.
Physical activity and participation measured
by the PARTS/M
An ANOVA was used to examine the relationship between physical activity level and the 4 participation components of each of the 6 domains measured by the PARTS/M.
A Scheffé post-hoc test revealed pairwise differences
within each participation component (Table 4).
Table 4 provides information on activity group differences. The frequency of participation (temporal) in the mobility domain and in the community, social, and civic life
domain was significantly higher for those people in the high
active group compared with the less active groups ( p ! .01
A. Crawford et al. / Disability and Health Journal 1 (2008) 7e13
10
Table 3
Demographics of the Sample
Table 4
Mean Scores of PARTS/M Components by Physical Activity Level
Characteristic
Total
High active
Low active
Inactive
Domains and components
N
Percent of sample
Gender
Female
Male
Mean age (y)
Race
White/Caucasian
Black/African American
Other
No response
Annual income
!$10,000
$10,000 to !$25,000
$25,000 to !$50,000
$50,000 to $75,000
O$75,000
No response
Highest level of education
None to Grade 8
Grade 9-11
Grade 12 or GED
College 1-3 y
College >4 y
No response
Employment
Employed
Not employed
No response
Diagnostic group
SCI
MS
CP
Polio
Stroke
No response
Primary mobility device
Cane, crutch, walker
Power wheelchair
Manual wheelchair
Scooter
None
604
100
236
39
203
34
165
27
Self-care domain
Temporal
50.13
49.04
Evaluative
51.17 a*
49.87
Health related
49.15
50.18
Supportive
49.38
50.09
Total self-care domain
50.84
50.23
Mobility domain
Temporal
53.39 a, b**
49.11
Evaluative
51.75 a**
49.77
Health related
49.36
50.03
Supportive
49.07
49.51
Total mobility domain
51.78 a**, b**
50.36
Domestic life domain
Temporal
50.88
49.92
Evaluative
51.42 a**
50.33 c*
Health related
49.05
50.45
Supportive
48.37
50.08
Total domestic life
51.76 a**, b*
50.07
domain
Interpersonal interactions and relationships domain
Temporal
49.57
50.73
Evaluative
51.06
49.37
Health related
50.74
50.89
Supportive
48.63
50.76
Total interpersonal
48.54 b*
48.93
interactions and
relationships domain
Major life areas domain
Temporal
50.34
48.83
Evaluative
50.67
50.11
Health related
49.25
50.84
Supportive
49.50
50.39
Total major life
50.92
49.42
areas domain
Community, social, and civic life domain
Temporal
54.13 a**, b**
49.74
Evaluative
52.07 a**
50.04 c*
Health related
49.19
50.66
Supportive
49.10
49.90
Total community,
52.94 a, b*
49.80
social, and civic
life domain
Total participation score
51.98 a**
49.80
57.5
42.5
55.4
55
45
52
51
48
49.6
68
32
50.8
88
10
2
00
89
8
3
0
87
12
1
1
89
9
1
20
30
24
14
13
0
15
20
23
11
15
16
16
29
20
12
10
14
21
28
20
14
7
10
4
4
30
27
35
0
3
4
25
29
36
3
3
4
28
26
38
1
7
4
36
25
26
2
27
73
0
29
69
2
27
71
2
20
75
5
23
21
15
28
13
25
20
20
22
14
27
19
15
28
11
17
23
7
37
16
37
17
14
15
17
38
15
14
15
18
36
17
14
14
19
36
17
14
18
15
GED, general educational development diploma.
for each comparison). People in the high active group evaluated their participation as having higher choice and satisfaction in the self-care domain ( p ! .05), the mobility
domain ( p ! .01), the domestic life domain ( p ! .01),
and the community, social, and civic life domain
( p ! .01). The health-related domain, which assessed the
influence of pain, fatigue, illness, and impairment upon participation, showed no group differences. The support used
to participate (personal assistance and special equipment)
was higher for the inactive group in the mobility and domestic life domains ( p ! .05 and p ! .01, respectively).
The total mobility domain scores for the high active group
were larger than the low active group ( p ! .01) and the inactive group ( p ! .01). For the total domestic life domain,
the high active group had a larger mean value than the low
High active
Low active
Inactive
50.99
48.49
50.99
50.77
48.53
48.40
47.79
50.88
51.94 d*
47.01
48.84
47.56
50.80
52.22 d**
47.40
49.72
49.25
49.96
51.02
49.22
50.96
48.90
50.03
50.23
49.40
44.41
46.99
50.35
51.50
46.10
47.40
All values are T-scores.
a 5 high active O inactive.
b 5 high active O low active.
c 5 low active O inactive.
d 5 inactive O high active.
e 5 inactive O low active.
* p ! .05.
** p ! .01.
active group ( p ! .05) and the inactive group ( p ! .01).
The total participation score for all domains was significantly higher for the high active group compared to the inactive group ( p ! .05).
Physical Activity and Health Status (SF-36)
The scores of the 3 physical activity groups on the 7 subscales of the SF-36 were compared using an ANOVA. The
A. Crawford et al. / Disability and Health Journal 1 (2008) 7e13
7 subscales were role physical, mental health, role emotional, social functioning, vitality, general health, and
bodily pain. The results of the analysis showed significant
differences ( p ! .05) for physical activity groups for the
social functioning, vitality, general health, and bodily pain
subscales (Table 5). In addition, Scheffé post-hoc tests were
conducted to analyze pairwise differences within each
subscale. In the social functioning subscale, the inactive
group was significantly lower than the high active group
( p ! .01). For the vitality subscale, the inactive group
mean score was significantly lower than both the low active
group and the high active group ( p ! .01). The general
health subscale scores were lower for the inactive and
low active groups than the high active group ( p ! .05). Finally, the inactive group mean for bodily pain was significantly lower than the low active group ( p ! .05) and
high active group ( p ! .01). The low scores of the inactive
group on the pain subscale signify that pain hinders the
performance of activities.
Physical activity and reintegration to normal living
An ANOVA was used to examine the differences between physical activity level and each of the 11 questions
contained in the RNL. Scheffé post-hoc tests were conducted to determine pairwise differences within these specific questions (Table 6). The high active group took more
trips out of town and had a higher level of satisfaction with
assistance provided for self-care (e.g., dressing, eating) than
the inactive group ( p ! .01 for each comparison). Participants in the low active group spent more days participating
in enjoyable work than those who were in the inactive
group ( p ! .05). Members of the high active group scored
Table 5
Mean Scores (Percentiles) for Self-Reported Health (SF-36) by Physical
Activity Level
SF-36 subscale
High active
Physical functioning
Role physical
Mental health
Role emotional
Social functioning
Vitality
General health
Bodily pain
.
49.5
74.7
79.8
74.2
49.1
62.5
60.1
Low active
.
(21)
42.7
(39)
73.7
(57)
72.3
(34) a**
69.8
(29) a**
45.1
(29) a**, b* 55.7
(21)
55.7
Inactive
.
(18)
36.7 (17)
(39)
70.0 (32)
(41)
71.4 (39)
(30)
63.0 (23)
(23) c** 35.1 (14)
(18)
51.3 (15)
(21)
49.7 (14) d**, e*
Physical functioning subscale was not analyzed because questions were
not applicable to the sample. Higher scores on the bodily pain subscale indicate less pain or limitations due to pain. Higher scores on the other scales
indicate responses in the positive direction: more social functioning, higher
vitality, and better general health.
a 5 high active O inactive.
b 5 high active O low active.
c 5 low active O inactive.
d 5 inactive ! high active.
e 5 inactive ! low active.
* p ! .05.
** p ! .01.
11
Table 6
Mean Scores of Reintegration to Normal Living Index (RNL) by Physical
Activity Level
Question
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
I move around in my living quarters
I move around in my community
I am able to take trips out of town
I am comfortable with how myself;
care needs are met
I spend most days in work that is
important to me
I am able to participate in
recreational activities
I participate in social activities
I assume a role in my family which
meets my needs
I am comfortable with my personal
relationships
I am comfortable when I am in the
company of others
I can deal with life events as they
happen
High
active
Low
active
Inactive
8.83
7.64
7.31 a**
8.64 a**
8.62
7.40
6.92
8.50
8.37
6.92
6.16
7.91
7.01
7.18 c*
6.29
7.79 a*
7.53
7.03
7.96 a**
7.86
7.84 c*
7.80
7.01
7.64
8.35
8.18
8.18
8.44
8.15
8.06
8.43
8.24
8.06
Values are based on a 1-to-10 scale.
a 5 high active O inactive.
b 5 high active O low active.
c 5 low active O inactive.
d 5 inactive O high active.
e 5 inactive O low active.
* p ! .05.
** p ! .01.
higher than the low active for recreational activities
( p ! .05). The high active group participated more in social activities than the inactive group ( p ! .01). The low
active group participated more in social activities than the
inactive group ( p ! .01).
Discussion
This study used 3 instruments to investigate different aspects of the lives of people with mobility impairments who
were grouped by their level of activity in exercise and recreation. The PARTS/M survey results indicate that people
who often engage in physical activity participate in other
major life activities more frequently than those who are less
physically active. These findings are similar to Hanson
et al. [17], who found that individuals with disabilities
who participate in sports also demonstrate high levels of
community participation. When asked to evaluate the quality of their participation, people in the higher active groups
reported greater choice, satisfaction, and importance in major life activities and self-care domain activities than the inactive group members. The high active group described
having more choices and satisfaction and using less support
when participating in mobility and domestic life activities
than did the low active and inactive groups. The interpersonal interactions and relationships domain of the
PARTS/M showed a higher total participation score for
the high active and low active groups than for the inactive
12
A. Crawford et al. / Disability and Health Journal 1 (2008) 7e13
group. No group differences were found in the major life
areas domain. Participants in the high active group participated in the community, social, and civic life activities
more frequently than both the low active and inactive
groups. The total PARTS/M participation score for the high
active group was significantly greater than the inactive
group, which confirms the hypothesis that people who are
classified as highly active in exercise and active recreation
report higher levels of participation in others major life
activities.
Diagnostic group differences in reported activity level
may be due to age. The majority of participants with SCI
and CP were in the 31- to 40-year age group, while those
who were stroke or polio survivors were in the 51- to
60-year age range. An ANOVA showed that those who reported high and low physical activity levels were significantly younger than those who reported being inactive
( p ! .01). Females with mobility impairments reported
engaging in less physical activity than males with similar
mobility impairments.
The SF-36 was used to examine group differences in the
general health status of the 3 activity groups. Compared
with the low activity groups, people in the high active
group report higher SF-36 scores on social functioning, vitality, and general health subscales. The inactive group
scored lower on the pain subscale than the high active
and low active groups, indicating that this group experienced severe and very limiting pain. These findings support
the assertion made in Healthy People 2010 that physical activity of people with mobility impairments and health status
are related [3].
Both the PARTS/M and RNL measures found that members of the high active group took more out-of-town trips,
did more of their own self-care, were more likely to be employed, and participated more frequently in recreational
and social activities than did people in the low active and
inactive groups.
and does not reflect a national random sample of the total
population of people living with mobility impairments,
which limits the generalization of these findings.
Conclusion
Individuals with mobility impairments who report a high
level of physical activity evaluate participation in social activities higher than those who are less physically active.
These relatively high active individuals describe their
health status as better than those in the low and inactive
groups. Several indicators of positive integration into normal community living were found more frequently in the
high active group. These results need to be examined for
causal relationships to discover if community-based health
and wellness interventions have a salutary influence on the
quality of participation of those receiving the intervention.
The findings of our study strongly suggest that measures of
health status need to be supplemented by measures of
community participation. Use of multiple measures could
extend outcome measurement beyond clinical settings to
environments where people live. Providing community
based programs that focus on increasing the level of physical activity of people with mobility impairments and
limitations may improve their health and community
participation, which are important goals for the rehabilitation industry, for individuals with disabilities, and for our
society.
Acknowledgments
This work was supported by the Centers for Disease
Control and Prevention (grant R04/CCR714134), The Missouri Department of Public Health Contract (grant
C003019001), and the National Center on Medical Rehabilitation Research (grant R21HD04585501).
Study limitations
The 3 physical activity level groups were formed retrospectively using criteria applied to data collected about subjectively reported levels of exercise and active recreation.
Thus, causal relationships among health, activity level,
and social participation cannot be made. A majority of
the significant differences in participation were reported
for comparisons of the high active and inactive groups,
which may mean that differences in physical activity level
may only be associated with participation differences for
the most active and least active people with mobility impairments. Differences among activity groups using the
PARTS/M were not always confirmed when the RNL was
used. For example, differences in self-care for the 3 activity
level groups were found when the RNL was used but not
when the PARTS/M was used. Finally, the sample was
a purposive group of people with mobility impairments
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