Adapted Physical Activity Quarterly, 2012, 29, 243-265

2012 Human Kinetics, Inc.

Barriers to Physical Activity for People

With Long-Term Neurological Conditions:
A Review Study
Hilda F. Mulligan, Leigh A. Hale, Lisa Whitehead,
and G. David Baxter
University of Otago, New Zealand
People with disability are insufficiently physically active for health. This study
identified the volume, quality, and findings of research that exposes environmental
and personal barriers of physical activity participation for people with neurological
conditions. CINAHL, Sport Discus, EMBASE, Medline, and AMED were systematically searched between 1999 and week one 2010 for peer reviewed studies that
fit the aim of the review. Identified barriers to physical activity participation were
categorized into the World Health Organizations ICF framework of domains. Of
the 2,061 studies uncovered in the search, 29 met inclusion criteria and 28 met
quality appraisal. Findings showed that barriers to physical activity participation
arise from personal factors that, coupled with lack of motivational support from
the environment, challenge perceptions of safety and confidence to exercise.
Keywords: barriers, physical activity, disability, neurological

People with disabilities represent 1220% of the total population (World Health
Organization, 2011). Recommendations to become more physically active to counteract lifestyle diseases (for example, heart disease, diabetes, and certain forms of
cancer) now include and specifically target people with disability (Durstine et al.,
2000; Heath & Fentem, 1997; U.S. Department of Health and Human Services,
2008). In addition to lifestyle diseases, people with disabilities are also prone to the
development of secondary conditions such as depression, pain, and deconditioning
(Marge, 2008), which develop over time but can be somewhat alleviated through
physical activity. Therefore, promoting physical activity participation for people
with disabilities is important.

Hilda Mulligan, Leigh Hale, and G. David Baxter are with the Centre for Physiotherapy Research,
School of Physiotherapy at the University of Otago, Dunedin, New Zealand. Lisa Whitehead is with
the Centre for Postgraduate Nursing Studies at the University of Otago Christchurch, New Zealand.
243

244Mulligan et al.

For some individuals with disabling conditions, mobility limitations may make
it challenging to build physical activity into everyday life activities in commonly
suggested ways (for example, by taking the stairs instead of the elevator, or by
walking a few more bus stops to work). Instead, it may be more appropriate for
people with mobility limitations to participate in recreational exercise to be more
physically active. People who live with a long-term disorder of the central nervous
system make up a subgroup of people who experience mobility limitations. Despite
such limitations, there is good evidence that planned and regular recreational exercise is of benefit to people with long-term neurological conditions (Bougenot et al.,
2003; Pang, Eng, Dawson, McKay, & Harris, 2005; Taylor, Dodd, & Larkin, 2004).
The past 2030 years have seen an attitudinal and policy change toward the
inclusion of people with disability within society. Policies, especially when supported by legislation (such as the Americans with Disabilities Act, 1990, which
provides for equitable access to services, transport, public spaces and places),
should allow people with disabling conditions to participate in recreational exercise
for their health and well-being. A large recent cross-sectional survey in the United
States of America (U.S.), however, found that only 25% of adults with disability are
meeting the recommended levels of physical activity (Boslaugh & Andresen, 2006).
In an ecological framework, physical activity participation can be conceptualized as arising from interactions of the person, the task, and their environment
(Hutzler, 2007; Hutzler & Sherrill, 2007). The World Health Organizations International Classification of Functioning, Disability and Health (ICF; World Health
Organization, 2001) provides one such ecological framework. The ICF framework
has been used to critically examine decision making for the promotion of physical
activity participation for people with disabilities (van der Ploeg, van der Beek, van
der Woude, & van Mechelen, 2004).
The purpose of this paper was to critically review current literature around
physical activity participation in populations with long-term neurological conditions. The specific objective was to assess environmental and personal barriers of
physical activity participation, using the ICF as an ecological framework. Explicit
knowledge of barriers to physical activity participation could aid health professionals, recreation providers, and planners and funders of recreational facilities to
address barriers and promote healthier lifestyles via physical activity participation
for people with neurological disability, and thereby for people with other mobility
disorders.

Method
Procedure
We searched electronic databases CINAHL, Sport Discus, EMBASE, Medline, and
AMED from 1999 to week one, January 2010. The search strategy included three
lines of search words, truncated where possible:
1. disability, cerebral palsy, multiple sclerosis, spinal cord injury, brain injury,
head injury, Parkinsons disease, stroke, cerebral vascular accident

Barriers to Physical Activity Participation 245

2. determinants, barriers, hindrances, correlates, constraints, access, influence

3. physical activity, recreation, sport, exercise, training, fitness
Limits applied were that articles were available in English and published
in peer-reviewed journals. Based on recommended guidelines (Dixon-Woods
et al., 2006), sampling at this stage used criteria that did not take into account
individual study methodology. The search inquiry was limited to studies reported
since 1999, as a window to limit findings of the review to contemporary legal
and/or social contexts for people with long-term neurological conditions. Two
researchers, working independently, screened the studies abstracts to select only
primary studies with samples of adults ( 18 years) with long-term neurological
conditions ( 6 months in duration) that reported on barriers to physical activity
participation. Physical activity participation was defined for the purposes of this
review as physical activity that is chosen to be undertaken on a planned and regular
basis, i.e., for recreation and enjoyment. Thus studies that focused on physical
activity that was performed for daily living (for example, for dressing or housework) or that was part of formal rehabilitation (for example, walking practice)
were excluded. The screening researchers did not agree about the selection of
four studies, because their abstracts provided insufficient information to ascertain
their match to our inclusion criteria regarding physical activity participation.
These four studies were therefore screened in full text. The search resulted in
2,352 articles, 291 were duplicated, 2,032 were excluded, and 29 were kept for
appraisal of study quality.

Quality Indicators
Two researchers then independently appraised the studies using the Qualitative
Appraisal Tool Checklist (Attree, 2004; Attree & Milton, 2006) for interview and
focus group studies, and the Joanna Briggs Institute (JBI) Assessment for Descriptive Studies (The Joanna Briggs Institute, 2004) for survey and questionnaire studies.
The Qualitative Appraisal Tool Checklist determines quality of the studys sampling
strategy, trustworthiness of data collection and analysis, and transferability of the
studys findings to determine an overall score of A (a study with no or few flaws),
B (some flaws), C (considerable flaws), and D (significant flaws that threaten the
validity of the whole study). The JBI Assessment appraises the quality of the study
sampling strategy, the objectivity of the studys measurements, and the quality of
the studys analysis. This tool does not have a scoring system, so for the purposes
of this review, studies appraised using this assessment were rated in a similar way
to the scoring system for the Qualitative Appraisal Tool Checklist above. Studies with scores between A and C were included in this review on the basis that
a study that scored a D would not add to the knowledge in this field. One study
(Tasiemski, Bergstrom, Savic, & Gardner, 2000) was discarded because it did not
show psychometric properties for validity and reliability of outcome measures.
Three studies were not awarded the same score during quality appraisal. These
were discussed for consensus between the appraisers, and one required discussion
among the whole research team (Figure 1).

Figure 1 A summary flowchart of the search, selection and inclusion process

246

Barriers to Physical Activity Participation 247

Data Extraction
We divided the studies into those that had samples with progressive neurological
disorders, those with nonprogressive neurological disorders, and those with mixed
samples. We extracted sample demographics, investigations, and the findings that
pertained to barriers to physical activity participation for each of the studies. These
we tabulated together with the study quality. We used the World Health Organizations (WHOs) International Classification of Functioning, Disability and Health
(ICF; World Health Organization, 2001) as a conceptual framework to categorize
barriers to physical activity participation and to combine the findings from the
range of studies included in this review, because meta-analysis was not a feasible
option, given the diversity of the study methodologies.

Results
Of the 28 studies included in the review, 21 were survey or questionnaire studies. The quality of these studies ranged from A (four studies) to B. Studies that
scored a B for quality did so because recruitment for the sample populations
was conducted by convenience sampling, via self-help groups, health service
providers, and/or the media. There were also seven interview or focus group
studies in the review, ranging in quality from A (one study), B (five studies),
and C (one study). The most frequent flaw in this group of studies was the lack
of statement or explanation of the relationship between the researchers and the
sample population. The study that was awarded a C took a reductionist approach
to the reporting of the findings instead of providing the rich detailed data usually
inherent in qualitative studies.
The majority of the studies (n = 21) were conducted in the U.S., with an additional three from Canada, one from the U.S. and Canada, one from Australia, one
from the United Kingdom, and one from the Netherlands. Overall, the 28 studies
represented a total of 3,206 participants, of whom > 80% were Caucasian, ranging in age between 1879 years. Although females and males were represented
in most study samples, four studies had female-only samples. The overall female
representation within the total sample for review was 73.7%. Overall representation
of diagnosis was multiple sclerosis (n = 1,673), spinal cord injury or spina bifida
(n = 552), stroke or traumatic brain injury (n = 519), cerebral palsy (n = 187), not
specified (n = 275; Tables 13).

Barriers to Physical Activity Participation From Impaired

Body Structure or Function
Four of the five A-grade studies identified the role of impaired body structure or
function as a barrier to physical activity participation. These studies represented
samples with both progressive conditions, i.e., multiple sclerosis (MS), and nonprogressive conditions represented in this review, i.e., cerebral palsy (CP), stroke,
traumatic brain injury (TBI), spina bifida (SB), and spinal cord injury (SCI). An
additional 15 studies of B-grade quality supported the findings of the A-grade studies. Impairments reported to limit participation in physical activity were identified
as arising either from the neurological condition itself or from secondary conditions.

248

196 participants with MS

Mean age 46 years (SD = 9.8)
88% female

196 participants with MS;

Mean age 46 years (SD = 9.8);
88% female

196 participants with MS;

Mean age 46 years (SD = 9.8);
88% female

196 participants with MS;

Mean age 46 years (SD = 9.8);
88% female

Motl
(2006a)

Motl
(2006b)

Motl
(2007)

Sample Population

Doerksen
(2007)

First
Author
(Year)

Daily step count;

Variables of MS (type, years since
diagnosis, thermo sensitivity, aids
for ambulation)

Symptoms
Self-efficacy
PA levels

Self-efficacy
Enjoyment of PA
Level of disability
PA levels
Social support

PA levels
Components of the built environment

Quality
Rating Investigations

(continued)

Increasing age
Increasing number of years since diagnosis
Use of cane/stick for ambulation
Unemployment
Relapsing-remitting type of MS

Greater number of symptoms during the past 30

days
Lack of self-efficacy

Lack of self-efficacy
Lack of enjoyment
Disability limitations
Lack of social support

Lack of shops, markets and other places within

easy walking distance
Lack of transit stop within 1015 min walking
distance from home
Lack of access to low-cost recreation facilities
such as parks, walking trails, bike paths, playgrounds.

Barriers

Table 1 Summary of Data From Studies With Samples With Progressive Neurological Conditions

249

93 participants with MS;

Mean age 50 years (SD = 10);
82% female

Stroud
(2009)

Stuifber807 participants with MS in

gen (1999) urban area (603) and rural
areas (204);
Mean age urban 47.7 years
(SD = 10.6); mean age rural
49.0 years (SD = 10.7);
80% female

292 adults with MS;

Mean age 48 years (SD =
10.3);
84% female

Sample Population

Motl
(2009)

First
Author
(Year)

Table 1 (continued)

PA levels
Functional ability and disease
severity
Exercise self-efficacy
Perceived exercise benefits and
barriers
Level of functional ability
Reported barriers to health promoting activity, including PA
Social status

PA levels
Fatigue
Depression
Pain
Self-efficacy
Functional limitations

Quality
Rating Investigations

For the urban population:

Fatigue
Impairment
Lack of time
Interferes with other responsibilities
Lack of money
For the rural population:
Fatigue
Impairment
Costs
Lack of convenient facilities
Safety concerns
(continued)

Lack of beliefs about benefits of exercise Perceived physical exertion for exercise
Lack of self-efficacy

Pain
Fatigue
Depression

Barriers

250

43 participants with MS;

Mean age 54 years (SD =
10.28);
72% female

Sample Population

Note. PAphysical activity, MSmultiple sclerosis

Vanner
(2008)

First
Author
(Year)

Table 1 (continued)

Level of impairment
Quality of life
Reported barriers to PA

Quality
Rating Investigations

Lack of self-efficacy
Decreased quality of life
Pain or health concerns
Fatigue
Sensitivity about appearance because of physical
impairments
Lack of interest and time
Fear of exacerbating symptoms
Fear of leaving home
Cost of facilities
Not knowing where to exercise
Lack of transport
Perceived lack of knowledge by facility staff
Lack of support

Barriers

251

50 participants with SCI;

Mean age 44 years (SD =
12.7);
30% female

13 participants with stroke.

Mean age 59 years (SD =
12.3)
38% female

83 participants with CP;

Mean age 47 years (SD =
10.98);
53% female

Damush
(2007)

Heller
(2002)

Sample Population

Arbour
(2009)

First
Author
(Year)
Relationship between proximity
of recreational facilities and level
of recreational activity.

Focus groups to elicit barriers and

facilitators of exercise after stroke

Caregiver attitude to perceived

benefits of PA;
Personal characteristics of individuals with CP;
Frequency of exercise

Quality
Rating Investigations

(continued)

Type of residence (i.e., nursing home cf private

home)
Caregiver attitude
Individual health status

Impairments as a consequence of the stroke:

Fear of exercising with changed functional and
physiological capacity,
Lack of suitable activity,
Lack of accessible transport.

Accessibility not shown to be a barrier, although

100% had accessible recreational facility within
15-min drive and 82% had accessible recreational
facility within 30-min wheel; only 13% used the
recreational facility.

Barriers

Table 2 Summary of Data From Studies With Samples With Nonprogressive Neurological Conditions

252

26 participants with SCI;

Mean age 52 years (range
2374);
39% female

8 participants with SCI;

Median age 42.5 years (range
2459);
38% female

83 participants with stroke;

Mean age 54 years (SD = 8.2);
70% female

Levins
(2004)

Rimmer
(2008)

Sample Population

Kehn
(2009)

First
Author
(Year)

Table 2 (continued)

Reported barriers to PA

Semistructured interviews to
explore barriers and facilitators to
PA participation

Semistructured telephone interviews

to explore barriers and facilitators
to exercise after SCI

Quality
Rating Investigations

(continued)

Lack of energy
Lack of belief in exercise for improving condition
Health concerns
Not comfortable exercising in a public place
Not knowing where to exercise
Not knowing how to exercise
Cost of recreational facility programs
Lack of (suitable) transport
Lack of support/assistance from facility staff.

Changed self-image and unknown physical ability

Not knowing what is available for exercise
Cost of programs
Lack of suitable equipment
Lack of expectations from others about being
physically active.

Increased time since injury

Fear of injury
Physical limitations hinder safe access to equipment
Perceived limited return on investment
Frustration and disappointment that modified
sports are not comparable to the able-bodied version
Lack of accessible facilities or support to access
facilities.

Barriers

253

312 participants with stroke;

Mean age 63 years;
57% female

143 participants with SCI;

Mean age 33 years (range =
1855);
8% female

Shaughnessy
(2006)

Wu (2001)

Weekly frequency of PA
Beliefs about exercise

Participation in sporting exercise

Barriers to PA reported as initial
challenges to learning a W/C
sport
Preinjury sporting history

Level of SCI
Barriers to exercising
Perceived stress in life situations

Quality
Rating Investigations

Note. denotes an interview or focus group study

CPcerebral palsy, SCIspinal cord injury, PAphysical activity, W/Cwheelchair

72 participants with SCI;

Mean age 44 years (SD =
13.0);
31% female

Sample Population

Scelza
(2005)

First
Author
(Year)

Table 2 (continued)

Difficulty getting appropriate sporting wheelchairs

Difficulty learning new skills required for the
sport
Coping with training regimes, for those who were
not active preinjury.

Fatigue
Increasing age
Lack of self-efficacy
Lack of belief about benefits of exercise
Lack of PA before stroke
Lack of information and advice on exercise from
doctor

Lack of motivation
Lack of energy
Perception that exercise is too difficult
Health problems/injury
Not knowing where to exercise
No encouragement from doctors to exercise
Lack of confidence in facility staff
Cost of exercise program

Barriers

254

15 participants with chronic

conditions, including CP, TBI,
and SCI;
Age not supplied;
53% female

16 participants with chronic

conditions, including SB, CP,
TBI, and rheumatoid arthritis;
Mean age 22.4 years (SD =
3.4);
25% female

Buffart
(2009)

Sample Population

Bedini
(2000)

First
Author
(Year)
Semistructured interviews
to elicit perceptions of stigma and
how these perceptions influence
PA participation
Focus groups to elicit barriers to
PA by young adults with childhood onset physical disability

Quality
Rating Investigations

(continued)

Lack of energy
Injury or fear of injury
Not perceiving any benefits
Feeling uncomfortable or ashamed to exercise
with able-bodied
Limited facilities to exercise for younger people,
particularly in rural areas
Lack of information and support from recreational professionals
Lack of suitable/adapted equipment
Lack of suitable transport
Costs of recreational facilities

Physical barriers (e.g., unsuitable sites for car

parks)
Perceived embarrassment by general public of
being with individuals with disability

Barriers

Table 3 Summary of Data From Studies With Samples With Progressive and Nonprogressive Neurological
Conditions

255

322 participants with physical

disability, including CP, MS,
SB, SCI, stroke, TBI, MD,
postpolio, other;
Mean age 53 years (SD =
13.9);
62% female

223 participants with physical

disability, including SCI, CP,
MS, TBI/stroke, SB, postpolio,
and other;
Mean age 45 years (SD =
10.8);
71% female

215 participants with physical

disability, including MS, SCI,
TBI, CP, stroke, MD;
Mean age 41 years (range =
1869);
100% female

Ellis
(2007)

Froelich
(2002)

Sample Population

Cardinal
(2004)

First
Author
(Year)

Table 3 (continued)

Stage of change for exercise

behavior
Self-efficacy for exercise

PA beliefs
PA levels

Reported barriers to PA

Quality
Rating Investigations

(continued)

Cost of home exercise equipment

Lack of access to knowledge and expertise for
suitable adapted exercise
Cost of fitness facilities
Lack of knowledge about where to access information about suitable equipment
Cost of fitness facility of own choice

Disability and associated symptoms

Injury or illness
PA causes pain/injury
Lack of energy
Lack of time
Lack of access to equipment, programs or support
Lack of transport
Cost

Lack of self-efficacy to exercise

Perception that the cons for exercising outweigh
the pros

Barriers

256

113 participants with substantial physical disability, including MS, SCI, stroke/TBI, CP,
postpolio, MD, other;
Mean age 47 years (SD = 1.4);
58% female

386 participants with substantial physical disability,

including
MS, stroke/TBI, CP, SCI/ SB,
postpolio, other;
Mean age 47 years (SD = 10.1);
100% female

45 participants with chronic

conditions, including CP, MS,
stroke, polio;
Mean age 43 years (range =
1880);
45 females 0 males

Nosek
(2006)

Odette
(2003)

Sample Population

Kinne
(1999)

First
Author
(Year)

Table 3 (continued)

Functional status
Exercise self-efficacy
Environmental barriers to PA

PA levels
Functional ability
Physical functioning and role
limitations
Self-efficacy

Focus groups to determine barriers to health promotion

Quality
Rating Investigations

(continued)

Limits to physical energy

Limited joint movement
Physical inaccessibility
Lack of insight and respect by the general population
Programs not meeting individual needs
Instructors who do not respect individual needs
for safety while exercising

Functional limitation s
The need for assistance with ADLs
Lack of self-efficacy for PA

Impairments
Fatigue
Lack of money
Lack of accessible facilities
Lack of information about what to do for exercise

Barriers

257

42 participants with physical

disability, 53% with SCI;

Rimmer
(2004)

50 participants with physical

disability, including MS, CP,
SB, stroke/TBI, SCI, postpolio, other;
Mean age 46 years (SD =
13.6);
50% female

Warms
(2007)

Activity limitations
Amount and intensity of PA
Interest vs. participation in PA

Levels of PA
Self-efficacy
Motivational barriers to PA
Depression
General health
Self-rated health
Pain intensity
Energy and vitality
Social support for PA

Focus groups to ascertain personal and environmental factors

that deter PA in recreation facilities.

Quality
Rating Investigations

High body mass index

Increasing age
Low self-rated health
Lack of social support
Lack of health professional education re PA

Decreased function
Decreased health
Low energy
Low interest in PA

Lack of support from family/friends to be PA

Lack of information of accessible facilities

Cost and availability of equipment

Difficult physical access

Not feeling welcome

Embarrassment at looking/behaving differently

Barriers

Note. denotes an interview or focus group study

CPcerebral palsy, MSmultiple sclerosis, SB-spina bifida, SCIspinal cord injury, TBItraumatic brain injury, PAphysical activity

170 participants with physical

disability, including CP, MS,
ataxia, TBI, stroke, SB, SCI;
Mean age 46.8 years (SD =
9.0);
100% female

Santiago
(2004)

46% female

Mean age 40.2 years (SD =

12.8);

Sample Population

First
Author
(Year)

Table 3 (continued)

258Mulligan et al.

The impairments were fatigue or lack of energy, uncoordinated movement, and/or

poor balance, poor vision, cognitive dysfunction or difficulty with concentration,
pain, depression, injury, poor general health, and being overweight (Tables 13
and Figure 2).

Barriers Arising From Activity and Participation Factors

Activity limitations due to decreased mobility and/or the need for assistance with
daily living tasks were reported in one of the A-grade and five of the B-grade studies to be associated with or perceived to lead to lower levels of physical activity.
Only three studies investigated participation barriers, reporting that people with
neurological conditions can feel embarrassed when exercising in public places
and that playing modified sports (for example, wheelchair tennis or basketball)
does not compare favorably to the able-bodied version, and hence may not provide
motivation to be physically active (Tables 13 and Figure 2).

Environmental Barriers
Three of the A-grade studies, supported by 17 other studies, identified environmental
barriers to physical activity participation. Barriers to physical activity participation
arose from both the physical environment and/or the social environment. In the
physical domain, lack of available, accessible, or affordable transport was a barrier
in five studies, in particular for those participants with higher levels of functional
limitations who need to remain in their own wheelchairs for transportation. The
cost of access to programs or facilities was a physical barrier in 10 studies and was
apparent, especially for women. Three studies identified that once inside exercise
facilities, people with disability have difficulty accessing assistance or support
because service desks may be too high for people in wheelchairs to be able to communicate easily with the staff behind the desk, equipment is not always perceived as
safe or suitable for people with limited mobility, and there can be insufficient room
between equipment for access with a wheelchair. Other important barriers included
lack of advertised information about programs, lack of suitable programs, difficulty
in procuring and affording specialized or adapted sporting or exercise equipment
(such as sports wheelchairs or home gym equipment), and lack of available training to be able to take up exercise or recreational sport that is new, or because of
altered bodily structure or function, needs to be performed in a different way to a
persons previous experience. These barriers were reported by samples both with
progressive and with nonprogressive disorders (Tables 13, and Figure 2).
Barriers reported from within the social environment included lack of expectations to be physically active and lack of support when doing so. This was reported
in one A-grade study whose participants had SCI. In particular, staff in recreational
facilities was perceived as having insufficient knowledge of the needs of people
with disabilities to be able to offer suitable assistance and support. These findings
were confirmed and extended to persons with neurological conditions other than
SCI in 13 other studies where participants identified that they had concerns for their
personal safety when staff ignored information supplied by them about their special
requirements, for example, in a swimming pool or when using exercise equipment.
Such concern was coupled with reluctance to request assistance, particularly when

259

Figure 2 Barriers to physical activity participation categorized into the International Classification of Functioning, Disability and Health framework

260Mulligan et al.

assistance is perceived to be uninformed and therefore potentially unsafe (Tables

13 and Figure 2). In addition, it was reported that healthcare professionals do not
provide sufficient encouragement and support for persons with SCI, stroke, CP,
spina bifida, and TBI to be physically active once discharged from rehabilitation
settings (Tables 23 and Figure 2).

Personal Barriers
None of the A-grade and only four other studies identified that increasing age or
unemployment were barriers to engagement in physical activity participation. In
contrast, the belief that physical activity has no positive benefits and low selfefficacy to exercise were identified as significant barriers in four A-grade and 15
other studies (Tables 13 and Figure 2). Collectively, these studies represented
males and females with progressive and nonprogressive neurological conditions.

Discussion
This review examined current literature around barriers to physical activity participation in populations with long-term neurological conditions. We found no
universal use of instruments to identify barriers to physical activity participation
in the survey and questionnaire studies. For example, a particular study may have
identified environmental barriers because it used an instrument/s that identifies
environmental factors. Therefore it would not have identified barriers from other
ICF domains, for example, personal beliefs or presence of impairments, because
it did not use a tool appropriate for revealing these types of barriers. Nevertheless,
we found a sufficient number of studies of robust quality, including studies using
qualitative methodologies, to show consistency in barriers within the domains of
the ICF framework.
We found that factors that presented as barriers to physical activity participation
for individuals with progressive disorders presented also as factors for individuals
with nonprogressive disorders. We suggest, therefore, that there are universal barriers
to physical activity participation for individuals with a range of disabling conditions.
These we have discussed below. The review identified that functional or physiological impairment makes it challenging for persons with neurological conditions
to access recreational facilities and equipment safely. These factors could result
in people feeling less in control and less confident about being physically active,
particularly when there is insufficient suitable support for them to be able to do so.
Personal beliefs were also identified as an important influence on physical
activity behavior, with the belief that physical activity has no positive benefits and
low self-efficacy to exercise found to be prominent barriers. The belief that physical
activity has little positive benefit would decrease motivation to be physically active
if, for example, the perceived difficulties in accessing suitable programs outweighed
the perceived benefits of exercising. This concept dovetails with the finding of
low self-efficacy as a barrier to physical activity participation. Self-efficacy, the
cornerstone of Banduras social cognitive theory of motivation for behavior is
defined as having the confidence that one can achieve a task. It requires belief in
ones own ability and is built through success at performing the skills required for
the situation, coupled with persuasion, support, and seeing others with whom one

Barriers to Physical Activity Participation 261

identifies performing the same challenge successfully (Bandura, 1986, 1997). We

suggest that for individuals with long-term neurological conditions, self-efficacy
could influence motivation to be physically active in that low self-efficacy could
present where changed functional or physiological capacity influences success at
performing the necessary skills to be able to exercise safely.
Negative environmental factors featured strongly as barriers to physical activity
participation in this review. This was evident even in studies that were conducted
in the U.S., where the Americans with Disabilities legislation provides for the
inclusion of people with disability within society (Americans with Disabilities Act,
1990). These findings support other authors who have identified environmental
barriers for people with disabilities in recreation facilities in the U.S. and Canada
(Arbour-Nicitopoulos & Ginis, 2011; Cardinal & Spaziani, 2003). It takes time
and resources to rebuild the physical environment and align social attitudes with
legislation such as the Americans with Disability Act. It is evident, therefore, that
despite efforts to address the inclusion of individuals with disability within society,
even via legislation, physical activity participation is still challenged by current
physical and social environments. Even where some aspects of physical access
have been addressed, for example the provision of disability car parking, people
with chronic disabling conditions have stated that these can be unsuitably placed
or are used by able-bodied people (Levins, Redenbach, & Dyck, 2004). Legislation
such as the Americans with Disabilities Act appears to be only a first step toward
the concept of inclusion. Not all of the studies in our review were conducted in
the U.S. It appears therefore that, both in the U.S. and in other countries, political
will and determination to change economic priorities is required to educate people
without disability to change social attitudes and to enable people with disability to
be represented within society in a more inclusive way.
An important barrier identified in the review was the cost of accessing suitable
participatory environments (for example, transport to or access to recreation facilities). The influence of income on physical activity participation for people with
disabling conditions other than neurological conditions has been reported elsewhere
(Boslaugh & Andresen, 2006; Rimmer, Rubin, & Braddock, 2000). Perhaps cost
presents as a universal challenge to physical activity participation for individuals
with disability, because the costs related to living with a chronic condition result in
less discretionary income to spend on opportunities to improve levels of physical
activity. This is especially pertinent given the income status of people with disability, many of whom live below the poverty line (World Health Organization, 2011).
The potential relationships between barriers arising from physical incapacity,
negative personal beliefs, an uninviting or unsafe physical environment, and lack
of social support identified in our review require further investigation. The ICF
framework of domains was developed to classify disability and function. In this
framework, the individual domains do not stand in isolation but are interrelated.
The growing body of literature demonstrating that people with neurological conditions can, if they have suitable resources and support, undertake and benefit from
physical activity programs in public settings (Carter et al., 2004; Dodd & Taylor,
2006; Roehrs & Karst, 2004; Zabriskie, 2005) suggests that limited physical capacity to exercise may not be a barrier if there is a suitable and supportive physical
and social environment in which to do so. Therefore, the potential link between
the variables could be considered as the basis for practice oriented outcomes from

262Mulligan et al.

our review, i.e., individuals with limited physical capacity should be empowered,
through training and the provision of suitable and acceptable support and access to
user-friendly environments, to build self-efficacy to choose and sustain their own
physical activity participation.
Limitations to this review have been identified. A longer time span and a search
of more databases may have uncovered more studies for inclusion, although this
was felt not particularly useful, given the large number of studies already included.
A common issue in the study methodology was the nonrandomized sampling of the
study populations; participants were volunteers, recruited most often by advertising
via self-help groups, health service providers, and/or the media. In addition, results
of this review pertain on the whole to Caucasian females in their middle aged years,
residing in the U.S. This is because of the disproportionate representation in the
overall sample of women with MS and study site. With this in mind, there could
be caution in generalizing the findings of the review to other populations in other
parts of the world. There were studies in this review, however, that included male
participants, participants with diagnoses other than MS, and studies undertaken
in countries other than the U.S. that reported similar findings. Therefore it can be
suggested that barriers identified from this review are not exclusive to the female
Caucasian population in the U.S. but that they could pertain to other individuals
with neurological disability in developed countries.
The scope of this review is very broad and included any population with
neurological disorders of the central nervous system. The authors consider that
this broad scope adds to the value of the review, because a broad scope should be
more informative for health professionals and recreation providers and planners
to work from to better promote physical activity participation for people with a
range of symptoms.

Conclusions
This review has uncovered a volume of good quality studies that investigated
and identified barriers to physical activity participation for people with a range
of long-term neurological conditions. Although the overall sample has an overrepresentation of people with MS, the findings nevertheless demonstrate that persons
with long-term neurological conditions face significant barriers to physical activity
participation and that the barriers arise from personal factors that when coupled with
lack of motivational support from within the environment, challenge perceptions
of safety and confidence to exercise. Based on social learning theory, these internal
and external factors can be linked together to explain the low rate of initiation and
adherence to physical activity for individuals with disabling conditions. Such factors
could be considered as the basis for practice oriented outcomes for the promotion of
physical activity for people with disabling conditions: people with limited physical
capacity should be empowered, through training and the provision of suitable and
acceptable support and access to user-friendly environments, to build self-efficacy
to choose and sustain their own physical activity participation.
Acknowledgments
We acknowledge Professor Derick Wades assistance in the initial planning of this review.

Barriers to Physical Activity Participation 263

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