With the aging of the baby boomer population and their accompanying burden of disease, future disability rates are expected to increase. This paper summarizes the state of the evidence regarding physical activity and aging for individuals with mobility disability and proposes a healthy aging research agenda for this population. Using a previously published framework, we present evidence in order to compile research recommendations in four areas focusing on older adults with mobility disability: (1) prevalence of physical activity, (2) health benefits of physical activity, (3) correlates of physical activity participation, and, (4) promising physical activity intervention strategies. Overall, findings show a dearth of research examining physical activity health benefits, correlates (demographic, psychological, social, and built environment), and interventions among persons aging with mobility disability. Further research is warranted.
Disability rates are expected to increase with the aging of the baby boomer population [
Although much physical activity research has focused on older adults who are free of disability and illness, the need still exists for a healthy aging research agenda specific to older adults with mobility disability for tertiary prevention purposes. Promoting healthy aging among people who already have mobility disabilities has been neglected. People with mobility disabilities may benefit from living in accordance with a healthy aging model that includes “the development and maintenance of optimal physical, mental, and social well-being and function” [
Prohaska et al. [ surveillance data on the prevalence of physical activity among older adults with mobility disability, overview of the health benefits of physical activity and the consequences of sedentary behavior in older adults with mobility disability, correlates and determinants of physical activity participation among older adults with mobility disability, promising intervention approaches for promoting physical activity in older populations with mobility disability.
While there are many categories of disability including mobility, sensory, intellectual, cognitive, or emotional disabilities [
The International Classification of Function (ICF) framework broadly defines health conditions that can lead to body functions and structure, activity, and participation alterations as “diseases, disorders, injuries, aging, and congenital anomaly” [
Regardless of the etiology, there is a need to address physical activity promotion for those with any type of condition that leads to mobility disability. We include in this review both persons aging with specific disabling conditions, such as MS, and those with more general conditions (e.g., frailty or decreased ability to walk due to arthritis or diabetes) that result in mobility disabilities. Although we focus on persons with mobility disability, where data are lacking or when definitions are unclear, we will discuss research in the broader populations of persons with any type of disability.
To shape a research agenda on physical activity among persons aging with mobility disabilities, we conducted a scoping review. A scoping review was selected instead of a systematic review because the purpose of our investigation was to summarize research on a broad topic area and identify research gaps in an area that has not been reviewed before [
Measuring the prevalence of physical activity among those with mobility disability presents several difficulties. Definitions and criteria for mobility disability are based on various indicators. People can self-identify as having a mobility disability, they may have a diagnosable condition that causes mobility disability, or they may have specific activity limitations which are considered to be related to mobility disability [
Regarding the prevalence of physical activity in persons aging with mobility disability, little is known about their physical activity patterns, and no specific population based information exists on the percent of people with mobility disability who meet the physical activity guidelines. Instead, there are data sources describing rates of physical activity among the general population with any type of disability. The 2008 Physical Activity Guidelines recommend that persons with disabilities meet the same guidelines as for healthy adults or do as much as they are able and avoid being inactive [
Another way of viewing discrepancies in physical activity levels between those with and without chronic conditions is through Tudor-Locke’s review of expected pedometer steps/day for persons with chronic illnesses and disabilities [
Understanding physical activity patterns in individuals with mobility disability is complicated by the frequent use of single time point estimates. For example, research has shown that during inpatient rehabilitation, duration of dynamic activities increases over time, but shortly after discharge this decreases. In one study of SCI inpatients, activity duration decreased by 33% postdischarge [
Another difficulty in tracking physical activity among persons with mobility disability, whether for surveillance or in research trials, is the lack of validated measures for assessing physical activity in persons with mobility disability. It is important to use measures that capture lower intensity activities, which may be more common among persons aging with mobility disability, that include the use of assistive devices to ambulate and that can be administered in a variety of formats (e.g., interviewer administered by phone) [
In the rehabilitation medicine literature, rather than measuring the physical activities that a person engages in, it is more common to assess ability to independently perform activities of daily living and measures of more distal outcomes such as community integration. The problem is that even if someone is able to do an activity (e.g., walk 1/4 mile), this does not mean that they regularly do that activity (e.g., they may spend a half-hour walking each day or they may never spend time walking). Future opportunities that would enhance a rehabilitation medicine-public health collaboration could include measures that assess both functional capacity and ability, as well as regular physical activity that individuals regularly undertake. Dimensions of physical activity should include the types, duration, frequency, and intensity of the physical activities in which people with disabilities engage [
Objective measures of physical activity, such as pedometers and accelerometers, can detect all types of activity. However, these monitors are typically worn on the waist and were developed to measure lower extremity movement so may miss activities done by persons in wheelchairs, including upper body activity or users of assistive devices [
Research supports the use of waist-worn accelerometers in populations with MS [
Activity and participation have also been assessed in persons with disability using newer technologies. The Participation and Activity Measurement System integrates self-reported data with wheel revolution counters, seat sensors, and GPS to capture activity data for people using wheelchairs [
Additional research on the measurement of physical activity for populations aging with mobility disability is needed on several fronts. One is that it is imperative to include measures of physical activity in studies of persons aging with mobility disabilities. Another is that determining the best objective and self-reported measures of physical activity for individuals aging with mobility disability will be important. Integrating measures of functioning and physical activity could be an improved measurement approach. Further examination of the equations used to derive energy expenditure for persons aging with mobility disability is also needed. The use of newer technologies, such as GPS and home sensors, to examine physical activity patterns holds promise.
Improving physical activity in an aging population helps to prevent mobility disability. Much of the research conducted in this area excludes those that already have mobility disability [
Generally, the health benefits of an active lifestyle among persons with disabilities appear to be similar to populations without disability. Research conducted on individuals with disability has shown physical activity to positively affect hypertension, manage cardiovascular disease and osteoarthritis, and reduce spasticity [
Due to a lack of studies, evidence is limited that physical activity improves healthy weight and metabolic health among persons with mobility disabilities. There is some evidence that physical activity improves weight and metabolic factors among persons with SCI [
Research conducted on individuals with disability has shown physical activity to increase overall fitness and prevent functional decline [
Research conducted on individuals with disability has shown physical activity to improve quality of life and reduce depression [
Research shows that exercise interventions can improve cognitive functioning among people with existing mild cognitive impairment [
The committee report from the 2008 Physical Activity Guidelines [
An understudied area of concern is the health effects of prolonged sedentary behavior in persons aging with mobility disabilities. Even when adults meet physical activity guidelines, sitting for prolonged periods can compromise metabolic health. Television time, even after adjustment for physical activity, is independently associated with increased risk for obesity, type 2 diabetes, CVD mortality, and all-cause mortality [
Overall, there is a dearth of research on the health benefits of physical activity among persons aging with mobility disabilities. Larger studies, focusing on specific diseases (e.g., MS) and cross-cutting conditions (e.g., mobility disability related to cardiovascular disease, diabetes, etc.), can better elucidate the health benefits of physical activity. Additionally, more focus on the health effects of light intensity activities [
Few cross-cutting studies address correlates of physical activity among people aging with mobility disability. We discuss the studies that have examined the demographic, physical health, psychological, social, and built environment variables that are correlated with physical activity among various groups with mobility disability.
Sociodemographic correlates of physical activity have been understudied among persons with disabilities. Younger age has been related to less physical activity among people with SCI [
Common health-related correlates include pain and fatigue for those with SCI (shoulder pain; [
There are several common psychological correlates of exercise. Higher self-efficacy has been related to higher physical activity among people with SCI [
Social isolation has been shown to be a barrier to physical activity among persons with stroke [
The ICF framework states that the environmental context includes products and technology, natural environment and human-made changes, support and relationships, attitudes, and services, systems, and policies [
Research on built environment features shows that having access to public transportation is important for promoting recreational physical activity among those with physical disabilities [
There are few studies that measure both the environmental context for physical activity and physical activity levels among persons with disabilities. Few detailed self-reported measures of the built environment are validated for use among those with disabilities. Some have related environmental features to participation, activity ability, and quality of life among persons with SCI [
One methodologic issue in these studies is that many built environment features (e.g., walkability, transit access, nearby destinations) are expected to more highly relate to active transport (e.g., walking or wheeling to get to useful destinations like stores or a bank) rather than the more commonly studied recreational physical activity (e.g., walking or wheeling for leisure) [
Environmental avoidance can also affect mobility among persons aging with disabilities [
More research is needed describing individual, psychological, social, and built environment correlates of physical activity among persons aging with mobility disability. Perhaps one reason for the dearth of research in these areas relates to the focus of medical rehabilitation on remediation of physical impairments and regaining the ability to carry out activities of daily living, a focus that is largely driven by insurance reimbursement. Outcomes measurement in rehabilitation has reached beyond measuring impairment and disability to encompass environmental determinants of societal participation. However, it is telling that measures of environmental factors within rehabilitation, such as the Craig Hospital Inventory of Environmental Factors, have not been widely used [
While research on physical activity is increasing among populations with disability, particularly those with MS, there are many cross-cutting conditions (e.g., mobility disability) and specific conditions (e.g., spinal cord injury) that are understudied in terms of physical activity correlates and determinants. Correlates of physical activity among persons with mobility disability may include a combination of general barriers faced by the general population (e.g., lack of time) and barriers specific to the condition or disability (e.g., arthritis-related pain). Among those with the various disabilities described, common correlates include pain, fatigue, depression, and self-efficacy. Some research suggests that mental health and built environment variables are related to physical activity but more data are needed, and interventions will need to target these barriers.
Interventions can target individuals, either one-on-one or in group settings, to promote changes. Another intervention approach, however, is to change the built environment and create policies to make healthy choices, including active living, the default option (e.g., walking to the store rather than driving there) [
Maximizing mobility in older adults has been the focus of multiple intervention projects. Much of the focus has been on preventing mobility disability in otherwise healthy older adults (e.g., [
The research that has been done among older adults with chronic disease or low fitness has indicated that multicomponent programs (including endurance, strength, flexibility, and balance) focusing on physical activity only (versus multiple behavior targets such as activity, nutrition, and medication), building exercise slowly over time, and using behavior change principles (e.g., social support, health contracts, self-monitoring, goal-setting) help promote physical activity [
Rimmer and colleagues conducted a review of exercise interventions specifically for individuals under age 65 with physical and cognitive disability [
It can be difficult to evaluate whether exercise interventions result in increases in exercise. Motl’s review of studies on MS and physical activity showed the largest effect sizes were for studies with supervised exercise and shorter duration programs [
Barriers to activity can be much higher than for populations without disabilities, stemming from both increased internal struggles (e.g., motivation, pain, depression) and environmental constraints (e.g., lack of access to exercise facilities). Strategies to improve self-efficacy for continuing to exercise as well as self-efficacy to overcome barriers to exercise (symptoms, social environment, and physical environment) may merit specific attention in trials to promote physical activity in people with MS and other mobility disabilities [
Pacing of activity may be important to promoting physical activity among persons aging with mobility disability. Brawley et al. noted that in one large intervention for knee osteoarthritis, those who exercised more often but for shorter durations per session had less pain and better ADL performance than those who did more exercise [
An important issue is assuring older participants of the safety of exercise. Older adults or those with mobility disability may not believe that exercise is safe for them or they may not consider activities they can do (e.g., slow walking with an assistive device) a valid form of exercise [
Evidence-based physical activity programs do exist for some populations of adults aging with mobility disability. The EnhanceFitness program, for example, has been offered to adults over age 65 in community-based settings, and many participants have chronic illnesses that make them susceptible to disability [
The Chronic Disease Self-Management Program is an empirically supported program teaching self-confidence to manage chronic conditions for those with hypertension, arthritis, heart disease, stroke, lung disease, and diabetes [
Some studies have sought to provide cognitive-behavioral self-regulation skills to aid participants’ transitions from rehabilitation to independent lifestyle activity [
Notably, while Internet-based and technology-based interventions are becoming increasingly popular to use among many populations [
In sum, based on evidence with older and less active populations and those with general disabilities, programs for those with mobility disability will likely need to target multiple components. To address risk of falls, lifestyle physical activity interventions may not be enough and specific exercises to improve strength and balance may be needed. In this case, structured, community-based exercise programs are needed for people aging with various types of mobility disability. However, issues such as pain, fatigue, and depression may make it more difficult to engage persons with mobility disability in such programs. Therefore, promoting low-intensity, unstructured, lifestyle activity, although underutilized, may be a viable strategy among individuals with mobility disability coping with barriers to moderate to vigorous activities. Researchers need to focus on participation in community-based programs as well as lifestyle activity changes and decreased sedentary behavior.
Intervention approaches to physical activity recommended by the
Longitudinal evidence shows that street conditions affect mobility more among persons with mobility disability than those with mild or no physical impairments [
Another relevant neighborhood characteristic relates to safety and neighborhood deprivation. Lang et al. [
Beyond neighborhood-level environmental considerations, home environments can either support or hinder mobility [
Some studies have used interventions that combine cognitive behavioral approaches and address the environment. Cognitive-behavioral strategies, finding supportive environmental solutions, exploring motivation postinjury, and capturing new frames of reference were found to help promote physical activity after SCI in a qualitative study [
With the advent of the Americans with Disabilities Act (ADA), newer construction and retrofitting of older construction can lead to improved mobility in public buildings and spaces but has yet to reach our private homes. The opportunity to use universal design (UD) features in the design of homes as well as communities will be increasingly important as the population ages. UD features are intended to be accessible, attractive, and acceptable to everyone [
The Environmental Protection Agency (Building Healthy Communities for Active Aging [
Because states depend on funding from the federal government to support these programs, securing policies that provide investment at the federal level should be a target. Promising policy avenues that could lead to improved federal funding include the emphasis on prevention and wellness in the 2010 Patient Protection and Affordable Care Act. There will be opportunities for grants to provide funding for programs that deliver evidence-based services. As part of healthcare reform, Medicare and Medicaid beneficiaries will be incentivized to complete behavior modification programs. Promoting dissemination of physical activity programs targeting people with disabilities and those that use Medicare and Medicaid should be an important objective for these funds.
There are increasingly more technical assistance opportunities available targeting cross-sector groups related to environmental and policy change for mobility. One such initiative is the Environmental and Policy Change for Healthy Aging [
Overall, there are few physical activity interventions from which to draw conclusions on the most effective ways to promote activity among persons aging with mobility disability. It is likely that the best approaches to promoting physical activity will use an intervention framework that incorporates both the physiologic process involved in disability, psychosocial barriers (e.g., self-efficacy), as well as the role of the environment. Several frameworks are available to guide intervention approaches. A widely used model in physical activity and public health research is the ecological model, which promotes intervention at the intrapersonal (biological/psychological), interpersonal/cultural, physical environment, and policy levels of change (i.e., multilevel approaches) [
There are many models of disability which are also important to consider including the the biopsycho-ecological paradigm [
Regardless of the model used, the built environment appears to be an important barrier to mobility and physical activity in persons with mobility disability. Thus, interventions will need to address built environment influences. Making changes to the built environment, by retrofitting and encouraging policies that use UD for new developments, is a promising approach to helping people stay active as they age with a mobility disability.
The population of individuals aging with mobility disability is increasing and current research on physical activity to promote health and reduce secondary conditions is limited. In this review, we provide several recommendations that will help build a research agenda targeting physical activity promotion among persons aging with mobility disabilities (see Table
Recommendations for research priorities related to promoting physical activity for adults aging with mobility disabilities.
Topic Area | Recommendations |
---|---|
(1) Prevalence of physical activity among older populations with mobility disability | (i) Define mobility disability and employ standard definition across sectors and research studies. Include specific categories of disability (e.g., mobility disability, sensory disability) in surveillance |
(2) Health benefits of physical activity and consequences of sedentary behavior in older adults with mobility disability | (i) Conduct research on ways physical activity benefits persons with mobility disabilities as they age, including larger samples, more rigorous methods, and prospective studies |
(3) Correlates and determinants of physical activity participation among older adults with mobility disability | (i) Expand studies on the correlates of physical activity participation in this population to include demographic, societal, mental health, and built environment variables |
(4) Interventions to promote physical activity in older populations with mobility disability | (i) Develop and test interventions that use multilevel approaches (which aim to target individual, interpersonal, and built environment factors) to promote physical activity among persons with mobility disability |
Evidence shows that physical activity levels among persons with mobility disability are lower than the general population though information on subgroups of disability type is lacking. Improved surveillance system assessment of various disability types as well as improved measures of self-reported and objective physical activity assessment will help researchers better understand patterns of physical activity among those aging with mobility disability. Several new technologies can help guide measurement and understanding of physical activity and mobility patterns, including GPS and sensor technology.
Evidence illustrates that even among those with disabilities, physical activity can reduce secondary chronic conditions, reduce pain, and improve physical function [
There are several special concerns for a research agenda targeting persons aging with mobility disabilities that cross-cut each of the four areas covered here. One issue is that there is a lack of clear prevalence and trend data on physical activity patterns in this population, making it difficult to fully understand the scope of the problem, identify relevant correlates, and develop effective interventions. Healthy People 2020 contains an objective related to including identification of people with disabilities in datasets [
Another problem is that clear physical activity objectives and guidelines are lacking for persons aging with mobility disability. Such specific guidelines can be useful for tracking physical activity patterns and developing intervention targets which could include provider-based recommendations. Due to a lack of research focus on those aging with mobility disability, determining adequate doses and types of physical activity necessary to confer health benefits has not been possible. One promising step forward is that Healthy People 2020 includes a physical activity objective for older adults with reduced physical or cognitive function [
A theme observed in the research described here is that community-based exercise programs targeting persons with various types of mobility disability are lacking. There is evidence that rehabilitation programs may effectively increase physical activity levels among participants, but once the programs end, levels decline. It would be helpful for rehabilitation practitioners to refer their discharged patients to relevant community-based physical activity programs, but these programs are not widely available, with the possible exception of those for persons with arthritis. However, even these empirically validated programs are underused. Research can help improve our understanding of what program characteristics will be effective in promoting physical activity for persons aging with mobility disability. More knowledge is needed regarding preferred settings for doing exercise (e.g., home, general group, or group of persons with the same impairments), modes of exercise (alone or with others), and types of exercise (e.g., walking, chair-based aerobic). Physical activity programs and interventions will need to include safeguards that address the fluctuations in activity due to illness or other setbacks. Other under-examined intervention targets relevant to promoting physically active lifestyles include reducing sedentary behaviors such as television watching.
An additional research difficulty is that physical activity research on people with mobility disability has often been discipline and disease specific [
The importance of the built environment, both in the neighborhood and the home environment, as a barrier to activity among persons aging with mobility disabilities is clear and needs to be further elucidated and measures of these constructs are needed. Employing ADA standards and UD principles will be important so that an aging society can find acceptable housing and communities that allow them to stay active as they become unable to drive. Healthy People 2020 targets both persons with disabilities and older adults as important populations that need supportive built environments [
In sum, there is a dearth of research on promoting physical activity among persons aging with mobility disability. Due to a population that is aging with more disease and disability [
B. Belza is partially funded by the Prevention Research Centers Program of the Centers for Disease Control and Prevention through a cooperative agreement with the Universifty of Washington Health Promotion Research Center, cooperative agreement #U48DP001911. C. H. Bombardier has funding from the Northwest Regional Spinal Cord Injury System, Grant H133N060033, the National Institute on Disability and Rehabilitation Research, Office of Special Education and Rehabilitative Services, US Department of Education. D. E. Rosenberg is funded by the NIH Kirschstein NRSA Award, Grant 2T32HD007424-19.