Scoping reviews provide a form of knowledge synthesis that addresses an exploratory research question to map key concepts, summarize evidence, and identify gaps in research [46].

Three experts in SCI and LTPA will follow a 6-step approach: identification of the research question, identification of relevant articles, article selection, evidence extraction, synthesizing and summarizing the data, and consultation with stakeholders [47]. The review will consist of (1) a systematic search of the scientific literature (ie, electronic databases including PubMed/MEDLINE, PsycINFO, CINAHL) using key words for spinal cord injury, physical activity, mobility, and community and (2) a Google search based on the authors’ knowledge of existing programs and the abovementioned keywords. All scientific and grey literature pertinent to the objective will be considered. Findings from this scoping review will be used to design a subsequent systematic review (objective Ib) and to develop a focus group schedule (objective IIa) [48].

A systematic review will be done according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses statement guidelines (prisma-statement.org) [49,50].

Original searches will be conducted by two independent researchers using online databases (PubMed/MEDLINE, CINAHL, PsycINFO, Embase, SPORTDiscus). Reference lists of selected studies and relevant review articles will be hand searched. The search strategy and study selection criteria will be developed according to the Participant, Intervention, Comparison, and Outcomes guidelines as described in the Cochrane Handbook for Systematic Reviews [51]. Accordingly, keywords will include terms relevant to Participant (spinal cord injury, manual wheelchairs), Intervention (LTPA, physical activity, self-determination theory, social cognitive theory, behavior change), Comparison (randomized controlled trial, quasi-experimental), and Outcomes (physical activity, participation, motivation, self-efficacy). Studies that fit the Cochrane guidelines and are written in English will be included in the review.

Two reviewers will independently rate the titles, abstracts, and full texts and select articles for inclusion. If consensus is not reached regarding inclusion criteria, a third reviewer will be consulted. The same two reviewers will assess methodological quality of randomized controlled trials using the Physical Therapy Evidence Database [52] and of pre-post studies using the Quality Assessment Tool for Before-After (Pre-Post) Studies With No Control Group [53]. Relevant data (mean differences in LTPA from pre- to immediately post-intervention) will be extracted to meet the primary objective. If feasible, a meta-analysis will be conducted. To meet the secondary objective, details about the program content, delivery methods, facilitators and barriers, and other pertinent information will be extracted and organized according to the two theoretical frameworks (ie, self-determination theory [29,33] and social cognitive theory [33]) that guide this research. Findings from this review will be used to design the prototype for a new LTPA intervention and develop discussion points for the focus group schedule.

A qualitative study design will be used.

Purposive sampling will be used to recruit 10 to 15 experts (ie, individuals with SCI, health care professionals, and community partners that specialize in SCI) to participate in a focus group. Involving key stakeholders has been shown to improve intervention development and outcome selection [54]. Health care professionals will be kinesiologists, occupational therapists, and physiotherapists who have at least 5 years’ experience working with the SCI population or at least 5 years of experience with LTPA interventions for persons with SCI. Individuals with SCI will be eligible to participate if they are aged 18 years and older, live in the community, have a traumatic or nontraumatic SCI (tetraplegia or paraplegia), use a manual wheelchair as their primary means of mobility, and are one or more years post-SCI [55]. Participants will be identified through existing community partners (eg, Adaptavie, Viomax, and Spinal Cord Injury British Columbia) and clinical partners (eg, outpatient rehabilitation programs at each site) that are the knowledge users of the ALLWheel program. Institutional ethics guidelines will be followed and informed consent will be obtained.

Based on the findings from phase I, a concept version of the ALLWheel program including intervention content and smartphone apps (eg, voice calls, text messaging, videoconference, social media) will be provided to participants before the focus group. Participants will also receive an open-ended questionnaire to complete prior to the focus group where they will be asked to provide descriptive information about appropriateness of the ALLWheel intervention, suggestions for changes to content or delivery method, missing content, and potential concerns. Responses from the questionnaires will be used to guide the discussion during the focus groups. The focus group guide will be developed according to the Interview Protocol Refinement framework such that questions will align with the study objectives, questions will be organized to create an inquiry-based conversation, and the protocol will be reviewed and piloted among the research team [56]. A moderator and a research assistant will open the discussion with a brief description of results from the questionnaire and facilitate a brainstorming activity to determine potential modifications to the ALLWheel intervention protocol. Two focus groups will be conducted (each with 6 to 8 knowledge users who will be individuals with SCI, members of community groups, and clinicians) over 90 minutes and will be audiorecorded.

The Delphi method is a widely accepted and useful research approach for intervention development in the absence of sufficient evidence from experimental studies [57]. A group of experts provide insight on the topic through sequential questioning (ie, in multiple rounds) until consensus is obtained among the group [58,59]. In this way, the Delphi method will provide useful insight about an LTPA intervention that uses peers and smartphone technology for individuals with SCI who use manual wheelchairs.

The same individuals who participated in the focus groups will form an expert panel and complete the Delphi surveys.

Using an iterative process, participants will complete written questionnaires in multiple rounds to achieve consensus on the ALLWheel intervention structure and content [60]. In the first Delphi round, the ALLWheel intervention will be presented and experts will be asked to provide anonymous feedback. Details of the ALLWheel intervention will be described (eg, components to be included, useful motivational strategies, preferred program delivery methods, critical considerations) using definitive statements, and participants will rate their level of agreement or importance using Likert scales (eg, strongly agree to strongly disagree; not at all important to very important). Participants will then be asked for additional suggestions for improvement using open-ended questions. Subsequent Delphi rounds will be administered until 70% consensus is achieved [57]. The final step will consist of an expert meeting to integrate findings from the Delphi survey (eg, components to include/exclude, delivery methods preferred, critical motivation strategies) to generate a concept version of the ALLWheel program [57].

A three-site, pre-post feasibility study will be done.

A convenience sample of 12 community-dwelling individuals living with SCI will be recruited through community partners (eg, Adaptavie, Viomax, and Spinal Cord Injury British Columbia) and clinical partners (eg, outpatient rehabilitation programs at each site) that are the knowledge users of the ALLWheel program and who will be involved in the development and refinement of the program. According to Hertzog [61], 10 to 15 participants may be adequate to detect feasibility in a pilot study. Since the primary purpose of this study is to assess feasibility of the ALLWheel protocol for a future clinical trial, from a pragmatic perspective of future recruitment in a relatively small population, a smaller sample size is justifiable. Participants will be between 18 and 65 years old, live in the community, have had an SCI for 1 or more years [55], use a manual wheelchair as their primary means of mobility, be able to self-propel a manual wheelchair for at least 100 meters; not currently be meeting the physical activity recommendations [62], and be cognitively able to engage in the ALLWheel intervention (Mini-Mental State Exam score ≥25) [63]. Individuals will be excluded if they anticipate a health condition or procedure that contraindicates training, have a degenerative condition that is expected to progress quickly, or are concurrently or planning to take part in another LTPA intervention over the period of the study. Participants will be screened using the Physical Activity Readiness Questionnaire and e-PARmed-X+ [64]. Institutional ethics guidelines will be followed at each of the three sites, and participants will provide informed consent.

Preferred duration and delivery methods for the ALLWheel intervention will be explored in phase II. However, for the purposes of study planning and budgeting, the intervention length (ie, 6 months) and number of contacts with participants (ie, 14) will be based on the findings of an effective telephone-counseling intervention for improving LTPA for individuals with SCI [19]. Program sessions will be customized to individual LTPA goals, and spouses/partners may be integrated into the ALLWheel program if desired by participants. For the proposed study, a physically active peer coach who has had an SCI for at least 5 years will deliver the ALLWheel intervention. The peer coach will receive comprehensive training through a 2- to 3-day workshop administered by study investigators.

Feasibility indicators related to process, resources, management, and treatment will be collected throughout study [72]. A description of feasibility indicators, how they will be measured, and the parameters for success are described in Multimedia Appendix 1. Testers at each site will administer all outcome measures at baseline (T1), postintervention (T2), and 3 months postintervention (T3). The selected outcomes are reflective of important theoretical variables known to influence LTPA uptake, adherence, and retention. Additional outcomes may be identified during phases I and II.

The primary outcome, LTPA, will be measured objectively using actigraphy, a noninvasive method of monitoring human activity using a small and lightweight accelerometry-based activity monitor (Actigraph GT3X+, ActiGraph LLC) that can be worn on the body of the wheelchair user and on the wheelchair without impeding movement [73]. The monitor contains an accelerometer that is sensitive to motion in all directions, and data are stored in the monitor as activity counts [74]. Time between sampling units (epochs) will be set at 15 seconds, allowing the greatest sensitivity for low-intensity activity [74]. Concurrent validity and reliability have been established [75,76]. Further validation for the use of actigraphy to distinguish between low and moderate intensities of LTPA among individual manual wheelchair users, including manual wheelchair users with SCI, is available elsewhere [77].

Upon completion of all secondary outcomes (subjective self-reports) at each time point, the tester will provide participants with 2 actigraphs (one will be positioned on the rear wheel of the manual wheelchair in a waterproof enclosure; the other will be worn on the nondominant arm). Participants will be asked to wear the actigraph at all times over a 7-day period except during sleep, bathing, or swimming. Participants will record the time the actigraph was put on and taken off using a log. The tester will obtain the actigraph and log from the participant at the end of the 7-day period. Only data from the days in which the actigraphs are worn for at least 13 hours per day will be included in the analysis [78]. Data will be converted to mean activity counts per hour (ie, bouts per hour).

Secondary outcomes reflect the proposed theoretical impacts of the ALLWheel intervention (ie, the relationship between LTPA behavior) and psychological determinants of behavior change (eg, motivation, autonomy support, and satisfaction of psychological need for LTPA). The secondary outcomes will help to discern a clinically important impact of the ALLWheel intervention.

Self-reported LTPA behavior will be measured using the 7-day Leisure-Time Physical Activity Questionnaire for adults with SCI [79]. Since actigraphy may not capture the intensity of some activities (eg, weightlifting) and they cannot be worn while swimming, participants will also be asked to recall the frequency (number of bouts) and duration (minutes per bout) of light, moderate, and heavy intensity LTPA over the past 7 days. Acceptable test-retest reliability and construct validity have been documented among adults with SCI [80,81].

Motivation to participate in LTPA will be evaluated using the 15-item Treatment Self-Regulation Questionnaire [82], which is designed to measure the degree of autonomous self-regulation to participate in healthy behaviors. Reasons for engaging in or changing health behaviors are scored using a 7-point Likert scale ranging from 1 (not true at all) to 7 (very true). Three subscales assess 6 forms of motivation, including autonomous regulation (identified, integrated, and intrinsic motivations), controlled regulation (external and introjected motivations), and amotivation. The questionnaire has been validated for assessing motivation for engaging in exercise [83]. Since the purpose of this study is to assess participation in physical activity that one engages in during their free time, wording for exercise will be changed to LTPA.

Self-efficacy to overcome salient barriers to LTPA participation (eg, transportation problems, bad weather, pain, fatigue) will be assessed using a 6-item Leisure-Time Barrier Self-Efficacy Scale. The scale has been used in previous research with SCI [84-86] with evidence of high reliability and validity [84] and acceptable internal consistency [81].

Satisfaction of the psychological needs for LTPA will be assessed using the Psychological Need Satisfaction in Exercise Scale [87]. Participants are asked to rate 18 items that reflect how a person may feel during physical activity using a 6-point Likert scale. A mean score will be calculated for autonomy, competence, and relatedness.

The Wheelchair Outcome Measure is a semistructured interview that allows participants to select important wheelchair-oriented participation goals. Participants are asked to identify 2 to 5 goals and evaluate their current satisfaction with participation in each goal (on a scale from 0 to 10). Participation goals are incorporated into the intervention. The instrument demonstrates good reliability and validity in use among individuals with SCI and older adults [88,89].