Physical Activity and Perceived Barriers In Individuals With Spinal Cord Injury In Saudi Arabia: A Cross-Sectional Study

Summary

Individuals with spinal cord injury in Saudi Arabia completed a pilot cross-sectional assessment of physical activity (PASIPD-AR), awareness of physical activity recommendations, and perceived barriers and facilitators. Participants reported low physical activity levels and limited awareness of recommendations, with lack of suitable facilities commonly identified as a barrier to participation.

Abstract

Spinal cord injury (SCI) impairs physical function and quality of life (QoL), and physical activity is important for health maintenance; however, participation may be influenced by multiple barriers. This cross-sectional study (May–September 2024) recruited 50 individuals with SCI in Saudi Arabia using convenience sampling via outpatient clinics and online distribution. Data were collected through structured interviews or self-administered surveys using identical questionnaires, including demographics, lesion characteristics, physical activity levels using the Arabic Physical Activity Scale for Individuals with Physical Disabilities (PASIPD-AR), awareness of physical activity recommendations, and perceived barriers and facilitators. Descriptive analyses were performed. The PASIPD score was 12.94 (4.48–26.86) MET-hr/day (median [IQR]) and 17.25 ± 15.35 MET-hr/day (mean ± SD). Awareness of recommendations was reported by 32% of participants, while 10% and 4% correctly identified aerobic and strength recommendations, respectively. The most frequently reported barrier was lack of suitable facilities (42%), and the most commonly reported facilitator was maintaining a healthy body (74%). Individuals with SCI in Saudi Arabia reported lower PASIPD scores compared with previous studies and limited awareness of recommendations, alongside commonly reported environmental and informational barriers.

Introduction

Spinal cord injury (SCI) is a life-altering condition that can significantly impair physical functioning and diminish overall quality of life (QoL)¹. Individuals with SCI often experience a range of debilitating consequences, including partial or complete paralysis, sensory loss, and dysfunction of the bladder and bowel systems². These impairments can severely limit an individual’s ability to participate in physical activity and maintain an active lifestyle^3,4. A recent systematic review reported global incidence estimates for SCI overall and, in separate analyses, for traumatic and non-traumatic SCI⁵. Reported pooled incidence estimates included 23.77 per million for SCI overall, 26.48 per million for traumatic SCI, and 17.93 per million for non-traumatic SCI⁵. Unfortunately, data on the prevalence and incidence of SCI in Saudi Arabia remain limited. However, a recent review has outlined the epidemiological characteristics of traumatic SCI (TSCI), emphasizing factors such as age, gender, and causes of injury⁶.

Physical activity is widely recognized as a critical component of health and well-being, particularly for individuals with disabilities such as SCI³. Engaging in regular physical activity can yield numerous health benefits, including improved cardiovascular fitness, increased muscle strength, enhanced endurance, and improved mobility⁴. Additionally, physical activity plays an essential role in preventing secondary health complications commonly associated with SCI, such as cardiovascular disease, obesity, and osteoporosis⁷. Beyond physical benefits, regular exercise has been shown to positively impact mental health by reducing symptoms of depression, anxiety, and stress, while also promoting self-esteem, social integration, and overall life satisfaction⁸.

Despite these benefits, individuals with SCI often face substantial barriers to physical activity participation. These include physical limitations such as muscle weakness and spasms, inadequate access to adaptive facilities and equipment, transportation challenges, and a lack of tailored exercise programs⁹. Social and psychological factors, including low motivation, lack of support, and limited awareness of available resources, further hinder their ability to lead active lifestyles. Conversely, several facilitators may support engagement in physical activity, including access to adapted fitness centers, specialized exercise programs, peer support networks, and professional guidance from healthcare providers¹⁰.

Recent research indicates that individuals with SCI are generally less physically active than the general population; for instance, approximately half of individuals with SCI report little to no leisure-time physical activity¹¹. Global recommendations on physical activity for health for adults living with disabilities, including individuals with SCI, were published by the World Health Organization in 2020¹². These guidelines recommend at least 150–300 minutes of moderate-intensity aerobic physical activity, or 75–150 minutes of vigorous-intensity aerobic physical activity, or an equivalent combination of moderate- and vigorous-intensity activity throughout the week for substantial health benefits. Additionally, adults living with disability should perform muscle-strengthening activities at moderate or greater intensity involving all major muscle groups on two or more days per week¹². However, it remains unclear how well these recommendations are known or followed in Saudi Arabia. There is a notable lack of data on physical activity among individuals with SCI in Saudi Arabia, reflecting a broader gap in disability-related research in the country^13,14. To date, limited evidence has quantified physical activity levels or exercise participation among individuals with SCI in this population, highlighting an important knowledge gap¹⁵. This paucity of information may partly reflect a historical emphasis on disability from a medical perspective (focusing on acute care and impairment) rather than a community health perspective¹⁴. Additionally, environmental barriers in Saudi Arabia, such as limited access to public spaces and wheelchair-accessible exercise facilities, may contribute to reduced physical activity levels¹⁴. While physical activity is known to be vital for health after SCI, limited evidence exists regarding activity patterns, barriers, and facilitators among individuals with SCI in Saudi Arabia, underscoring the need for research in this area.

Therefore, this study aimed to assess knowledge and awareness of physical activity guidelines, quantify physical activity levels, and identify perceived barriers and facilitators to physical activity participation among individuals with SCI in Saudi Arabia.

Protocol

Ethical approval was obtained from the Ministry of Health, General Directorate of Health Affairs, Al-Qassim Region, Saudi Arabia (Approval No.: 607/45/14477). All procedures were conducted in accordance with institutional ethical standards. Informed consent was obtained from all participants prior to data collection. Participation was voluntary, and responses were kept confidential. The research tools used in the protocol are listed in the Table of Materials.

1. Study design and participants

The study utilized a cross-sectional design conducted from May to September 2024. Data were collected using either a clinic-based, interviewer-administered structured interview or an online self-administered survey platform. In both modes, participants completed identical questionnaire items in the same order. To minimize duplicate entries, participants were asked whether they had previously completed the survey; online responses were restricted to one submission per device or account where possible, and clinic participants were not provided access to the online survey after enrollment. Convenience sampling was used to recruit participants through social media and outpatient clinics. This study was designed as a pilot study; therefore, a formal a priori power calculation was not performed. A target sample size of approximately 50 participants was set to evaluate study feasibility and generate preliminary estimates relevant to the study aims.

Inclusion criteria were diagnosis of SCI, age ≥18 years, and current residence in Saudi Arabia. Individuals with concurrent brain injuries or severe polytrauma, as well as those with other disabling neurological or medical conditions (e.g., stroke, Parkinson’s disease, or Alzheimer’s disease), were excluded.

2. Data collection form

Demographic and lesion-related data were collected. Participants also completed measures assessing knowledge and awareness of physical activity guidelines, physical activity level, and perceived barriers to and facilitators of physical activity participation.

3. Demographic and lesion characteristics

Demographic variables included age, sex, smoking status, marital status, employment status, education level, height, and weight. Lesion-related variables included time since injury, injury etiology (traumatic or non-traumatic), injury completeness (complete or incomplete), neurological presentation (paraplegia or tetraplegia), and use of mobility aids (manual wheelchair, powered wheelchair, crutches, walker, orthotic braces, or none). All variables were collected via self-report during the survey or interview. Participants were permitted to select more than one mobility aid.

4. Knowledge and awareness of physical activity guideline

Knowledge and awareness of physical activity recommendations were assessed using a brief set of questions. Participants were first asked whether they had ever read or heard about physical activity recommendations (yes/no). All participants were then asked to report the recommended weekly amount of aerobic physical activity and the recommended frequency of strength-training exercise per week for adults living with disabilities. Responses were scored as correct or incorrect using operational criteria derived from World Health Organization recommendations, defined as at least 150 minutes per week of moderate-to-vigorous intensity aerobic activity and strength training involving major muscle groups at least twice per week¹².

5. Physical activity scale for individuals with physical disabilities

The Physical Activity Scale for Individuals with Physical Disabilities (PASIPD) was developed to assess physical activity levels in individuals with disabilities for epidemiologic studies on health and function¹⁶. This scale adapts the earlier validated Physical Activity Scale for the Elderly (PASE)¹⁶ through qualitative interviews with individuals with disabilities and rehabilitation professionals, ensuring its relevance and comprehensibility. The final version of PASIPD includes 13 items categorized into leisure (6), household (6), and occupational (1) activities, with respondents indicating the frequency of participation and the average daily duration. Scoring involves multiplying the average hours for each activity by associated metabolic equivalent (MET) values, yielding a maximum possible score of 199.5 MET-hr/day. Total scores are expressed in metabolic equivalent task hours per day (MET-hr/day). For descriptive purposes, PASIPD items were summarized into four scales and measured in MET-hr/day. These scales include (1) home repair, lawn, and garden activities; (2) housework; (3) sport and recreational activities; and (4) occupational and transportation activities. The PASIPD scale has been translated into Arabic and validated¹⁷. The PASIPD instrument and scoring instructions are provided in Supplementary File 1.

6. Perceived barriers and facilitators of physical activity

Perceived barriers to and facilitators of physical activity were assessed using a checklist of 12 items for each category. Participants were asked to select all items that applied to them. Items were adapted from prior studies, including 10 items reported by Matheri and Frantz (2009)¹⁸ and two additional items identified from subsequent studies^19,20. The checklist was administered in Arabic, translated by a bilingual researcher, and reviewed by two rehabilitation clinicians for clarity and content validity.

7. Data analysis

Descriptive statistics were used to summarize knowledge and awareness, physical activity levels, and perceived barriers and facilitators among participants. Data were analyzed using SPSS Statistics (version 29). Only participants who completed the survey or interview were included in the analysis. Results are reported as mean ± standard deviation (SD) for continuous variables and counts (n) and percentages (%) for categorical variables. Figures were generated using a spreadsheet program.

Results

A total of 50 participants with SCI were included in the study. The mean age was 41 ± 10.9 years; most participants were male (82%) and non-smokers (66%). Employment status varied, with 38% employed full-time and 24% retired, and just over half were married (52%). The mean height was 167.4 ± 10.5 cm, and the mean weight was 72.36 ± 15.7 kg. Educational attainment was predominantly secondary school or higher.

Regarding lesion characteristics, injury duration was broadly distributed, with most p...

Discussion

This study found low PASIPD scores among individuals with SCI in Saudi Arabia. This is consistent with a prior study that reported a mean PASIPD score of 17.8 ± 18.6 MET-hr/day among individuals with SCI²¹. In the present study, the mean PASIPD score was 17.25 ± 15.35 MET-hr/day, which is lower than values reported in some previous studies of people with disabilities and individuals with SCI. For example, the original PASIPD development study reported a mean of 20.2 ± 14.5 MET-hr/da...

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
Google Forms (survey distribution platform)	Google LLC (Alphabet Inc.)	N/A	Used to distribute the survey and collect responses online. https://forms.google.com/
IBM SPSS Statistics (Version 29)	IBM Corp., Armonk, NY, USA	N/A	Used for statistical analyses.
Microsoft Excel (Microsoft 365)	Microsoft Corporation, Redmond, WA, USA	N/A	Used for data management and preparation of figures.
Physical Activity Scale for Individuals with Physical Disabilities, Arabic version (PASIPD-AR)	Washburn et al.16 (instrument developers); Arabic version validated by Alhumaid et al.17	N/A	Questionnaire used to assess self-reported physical activity and compute MET-hours/day domain and total scores. Original instrument: Washburn RA, Zhu W, McAuley E, Frogley M, Figoni SF. The physical activity scale for individuals with physical disabilities: development and evaluation. Arch Phys Med Rehabil. 2002;83(2):193–200. Arabic adaptation/validation: Alhumaid MM, Said MA, Adnan Y, Khoo S. Cross-Cultural Adaptation and Validation of the Arabic Version of the Physical Activity Scale for Individuals with Physical Disabilities in Saudi Arabia (PASIPD-AR). MDPI; 2024:179.