In developing countries, spinal cord injuries (SCIs) are currently a public health concern (Jesuyajolu et al. 2023). In 2021, the World Health Organization (WHO) estimated that over 15 million people currently live with an SCI worldwide (WHO 2024). In South Africa, the incidence rate for traumatic spinal cord injury (TSCI) was estimated at 76 per million people, which was found to be one of the highest when compared to developed, Western countries (Joseph et al. 2015). Globally, adults with SCIs often lead very sedentary lifestyles, and this predisposes them to develop secondary complications and puts them at an increased risk for developing cardiovascular disease (CVD), diabetes and obesity (Cragg et al. 2013; Garcίa-Massó, Serra-Añó & Gonzalez 2015; Nooijen et al. 2015; Warms, Whitney & Belza 2008). In the previous literature, it was noticed that there is a 17% prevalence of CVD among the SCI population compared to a 5% prevalence among the non-SCI population (Cragg et al. 2013). Physical activity (PA), however, is an important modifiable factor in decreasing the risks of CVD, stroke and diabetes (Cragg et al. 2013; Garcίa-Massó et al. 2015; Nooijen et al. 2015; Warms et al. 2008).

The PA, defined as bodily movement that results in energy expenditure, can be classified in frequencies, intensities and step counts (Ainsworth et al. 2000; Park et al. 2021; Veerubhotla et al. 2020). It is well known that the lack of activity devastates health status. Physiological detriments such as pain, fatigue, slower metabolism, muscle deconditioning and atrophy are often associated with prolonged bed rest (Warms et al. 2008). They may further hinder the ability to engage and optimise one’s PA. Engaging in PA early after the injury may be a powerful and important target for rehabilitation programmes to prevent primary and secondary consequences (Soriano et al. 2022). In the Western Cape Province of South Africa, there is only one inpatient facility, offering specialised services for adults with SCIs where not all patients are admitted for care. The remaining patients are further managed at primary and/or community healthcare centres where there are currently no guidelines for the prescription of rehabilitation (Joseph et al. 2015). Furthermore, physiotherapy rehabilitation services are not available at all primary healthcare facilities, with recent inquiries indicating the availability of either physiotherapy or occupational therapy at less than 10% of the primary healthcare level in the specific setting. The continuity of care across all levels of care is suboptimal because of poor and inadequate referral processes (Conradie, Berner & Louw 2022; Louw et al. 2023). This highlights the lack of sufficient resources available for rehabilitative services for adults with SCIs and that potential innovative approaches to the engagement of PA may not be a top priority for these healthcare workers.

The WHO has recommended PA guidelines for abled-bodied individuals, as well as adults with SCIs to decrease morbidity and mortality rates (Martin Ginis et al. 2018). These guidelines are for cardiometabolic and health fitness benefits and entail approximately 30 min of moderate to vigorous exercise three times a week (Martin Ginis et al. 2018). However, in developed countries, a recent systematic review reported that 27% – 64% of participants do not engage in any PA (Stendell et al. 2024), and there is currently no evidence available in South Africa that quantifies PA in adults with TSCIs. As PA is complex, an individual’s ability to engage in PA is typically driven by the motivation to obtain health benefits by evoking behaviour change or the prescription of exercise based on need (Barron 2007; Greenman 1996; Rodrigues et al. 2023). The social cognitive theory of behaviour change has been commonly identified in the literature as driving the engagement of PA, which proposes that individuals are motivated to behave based on their intentions (Bandura 2001). However, there are several sociodemographic and injury-related factors, which may influence the ability of an individual with a TSCI to engage in PA. These include age and gender, where older males are more likely to engage in PA (Watson et al. 2022). Regarding injury characteristics, severity and time since injury also influenced PA, where complete lesions were more sedentary and participants who sustained their injuries for a longer time engaged in more PA. These factors must be considered when developing fit-for-purpose interventions to bolster PA engagement.

In developed countries, CVD has become a leading cause of death in adults with SCIs, which highlights the need to encourage a physically active lifestyle for adults with TSCI in South Africa. In addition, factors such as low-income living areas with high levels of crime and limited resources, from which a large proportion of adults with TSCI come and reside, are associated with restricted mobility, which is detrimental to long-term health and functioning for this population (Fyffe, Botticello & Myaskovsky 2011). Against the backdrop of these influencing factors, our study aimed to: (1) describe PA levels, in terms of time spent in different intensities, of community-dwelling adults with TSCI and (2) determine potential associations between demographic and injury characteristics and PA levels, that is, intensities. This information will aid in developing an understanding of how PA should be supported and augmented in the South African context.

A total of 76 participants with TSCI were included in our study, and their socio-demographic and injury characteristics, as well as functioning indices, are presented in Table 2. Most of the participants were male (n = 67, 88.2%), with a mean age of 36 years for the entire cohort. The most common cause of injury was because of assault (n = 49, 64.5%). At the time of injury, 65.8% (n = 50) reported being employed with a corresponding 15.8% (n = 12) being employed after sustaining their TSCI. The secondary complication’s mean total score was 19.18 ± 7.30, while the SCIM-SR mean score was 57.22 ± 23.41. Participants’ socio-demographic and injury features are displayed in Table 2.

Our study described the time spent in different PA intensities among adults with TSCIs living in the community. It investigated whether associations exist between demographic and injury duration characteristics and PA intensity. Our study forms the foundation for understanding how PA should be supported and tailored in a South African context.

Primarily, our study found that adults with TSCIs spent an alarming amount of time in SED and LIPA for both wheelchair users and ambulatory individuals. According to previous literature, SED is characterised as any waking activities performed while in a seated or reclined position that results in an energy expenditure of ≤ 1.5 metabolic equivalents (METs), while LIPA includes activities such as slow inside walking, household tasks requiring light effort (i.e. making the bed, sweeping the floors, dusting, eating and preparing food, hairstyling) or wheelchair propelling on tiles; that results in an energy expenditure < 3 METs (Ainsworth et al. 2000; Bates et al. 2022; Collins et al. 2010; Gibbs et al. 2015; Veerubhotla et al. 2020). The increase in SED and LIPA after an SCI corroborates with previous studies, which also found a decline in PA levels, especially for wheelchair users (Warms et al. 2008). This was seen in a study by Warms et al. (2008) that reported more than 9 h spent in bed and/or sleeping and 12 h spent in LIPA daily. Adults with SCIs, as well as healthcare providers not educated or trained in SCI management, may not understand the importance or benefits of PA and may believe that resting is necessary to conserve energy and decrease pain (Warms et al. 2008). It is, however, also evident that different activities and tasks in daily life produce different energy expenditures, which is still largely unknown to adults with SCIs and healthcare professionals alike (Ainsworth et al. 2000; Warms et al. 2008). A health promotion intervention is required to educate adults with SCIs on the type of activities that could be performed daily to induce different intensity and exertion levels, which, in turn, would benefit for them from a PA and health-enhancing perspective. These everyday and meaningful activities should be introduced and supported during inpatient rehabilitation as a means of starting with PA and exercise prescription as a crucial therapeutic target in all phases of care.

For adults with SCIs, maintaining an active lifestyle has shown to be challenging, especially once they have reintegrated back into their communities following an intensive inpatient rehabilitation (Mat Rosly et al. 2018). Efforts to increase PA participation within the SCI community are often impeded by a lack of motivation, physical impairments, institutional and policy barriers as well as a lack of accessibility (Mat Rosly et al. 2018; Paulus-Mokgachane, Visagie & Mji 2019). Generally, ambulant adults with SCI seem to be better at engaging in PA once they are home, as they can stand and walk and partake in ADLs such as house chores, self-care and move around their communities with less limitations than someone using a wheelchair (Warms et al. 2008). These findings were evident in a longitudinal study performed in the Netherlands that followed a group of participants, from inpatient rehabilitation and into the community 1-year post rehabilitation and discovered that PA levels increased from 88.7 ± 36.1 min/day to 116 ± 59.2 min/day and SED decreased from 732.4 ± 81.9 min/day to 665 ± 121.3 min/day. These findings still, however, revealed an alarming time spent in SED and LIPA (Postma et al. 2020). The increase in PA levels was related to an increase in walking mobility within the community post-discharge (Postma et al. 2020). Our study revealed similar findings where ambulatory individuals engaged in more PA, but much time spent in MVPA (18.80 min/day). Various factors could influence the decrease in activity levels seen in ambulant participants in our study, which should be taken into consideration. Factors, such as safety and gang-related violence in communities (high incidence of assault with this cohort) impacting vulnerability, infrastructure and environmental challenges, walking speed, availability of an appropriate or use of an assistive device or attitudes of community members, are possibilities for poor PA levels and increased SED within the local context (Mat Rosly et al. 2018; Paulus-Mokgachane et al. 2019; Warms et al. 2008). Thus, there is a need to understand both intrinsic and extrinsic factors related to PA levels in general, including frequency, duration and intensity.

Our study further explored whether relationships exists between demographic variables such as gender, age and time since injury, as well as time spent in different PA intensity categories. A significant finding was seen with older wheelchair users (age: 40–67 years) demonstrating more engagement in MVPA than the younger age group. The results of our study may provide a hopeful possibility that participants using wheelchairs to aid their mobility are finding ways to be more active within their home and community environments and including PA into their daily routines. However, older participants using wheelchairs depending on the severity of the injury, require more effort and may exert more energy to complete ADLs, giving the impression of higher engagement in MVPA. These findings were similarly seen in a study done by Watson et al. (2022) where older males engaged in more MVPA compared to their counterparts. South Africa’s unique SCI profile reveals that we have a predominantly younger male cohort, with majority aged between 18 and 29 years (Joseph 2017; Madasa et al. 2020; Njoki, Frantz & Mpofu 2007), and this could provide a possible reason for our cohort demonstrating lower levels of MVPA and more time spent SED. This may be suggestive of a potential barrier to PA levels within the local setting. Although our study did not look at factors associated with PA levels, previous literature has identified themes such as intrapersonal, interpersonal, policy and community levels as common perceived barriers to PA (Mat Rosly et al. 2018; Vermaak et al. 2022).

In addition, varying findings are seen in previous literature that explores time since injury and PA engagement. As with our study, it was found that adults living with more recent injuries engaged in more PA compared to chronic injuries, while other studies found increased involvement in PA for participants living with their injuries for a longer time (Mat Rosly et al. 2018; Postma et al. 2020). Even though this factor revealed a significant finding for MVPA, the time spent in MVPA was minimal and did not meet the global recommendations for PA from the WHO, which is a big concern as it is an important modifiable risk factor for CVD and potentially other health conditions. While little is known about the availability of rehabilitation services for SCIs within the communities, intensive rehabilitation is offered by a specialised unit in the Western Cape, which could account for the increased participation observed in those with more recent injuries. The PA findings in this cohort corroborate with previous studies that report alarming time spent in SED and LIPA and poor engagement in MVPA (Eitivipart et al. 2021; Mat Rosly et al. 2018). The common findings seen across literature on measuring PA levels are that adults with SCI are not meeting the recommended guidelines for PA to achieve beneficial health-enhancing outcomes. We can also conclude from these findings that this cohort does not meet recommended levels of PA.

Engaging in MVPA is known to reduce the risk of CVD, prevent or decrease the development of secondary complications and improve overall physical fitness and quality of life in adults with SCI. Therefore, promoting an active lifestyle is imperative for this population, and understanding modifiable influencing conditions would be the first step to develop novel interventions and strategies to promote PA in the future. Future studies should explore how PA and exercise behaviour evolve over the course of living with a TSCI, as well as understand how PA can be supported and made accessible at all levels of healthcare. Furthermore, healthcare professionals should be sensitised and equipped to provide information and advice on becoming and/or maintaining one’s PA levels and exercise and fitness levels once confronted with a TSCI.

Our study highlights that adults with TSCIs spent most of their time in SED and LIPA with minimal engagement in MVPA. The findings further indicated that time spent in MVPA was significantly more among adults with more recent injuries as well as older participants, demonstrating variations in subgroups, which could warrant further investigation. It is evident that adults with TSCIs are not meeting recommended PA guidelines for beneficial health outcomes. There is thus a need to investigate the determinants of PA levels to arrive at modifiable intervention targets.