Physical Activity, Sedentary Behavior and Well-Being of Adults with Physical Disabilities and/or Chronic Diseases during the First Wave of the COVID-19 Pandemic: A Rapid Review

Background: People with physical disabilities and/or chronic diseases report lower levels of physical activity and well-being than the general population, which potentially is exacerbated through the COVID-19 pandemic. This study explored the international literature on physical activity, sedentary behavior and well-being in adults with physical disabilities and/or chronic diseases during the first wave of the pandemic. Method: In a rapid review, we included studies reporting on physical activity, sedentary behavior and/or well-being in adults with physical disabilities and/or chronic diseases. Four databases (Pubmed, CINAHL, PsycInfo, Embase) were searched for studies published until 30 September 2020. Results: We included twenty-nine studies involving eleven different types of disabilities or health conditions from twenty-one different countries. Twenty-six studies reported on physical activity, of which one reported an increase during the COVID-19 pandemic, four studies reported no difference, and twenty-one studies reported a decrease. Thirteen studies reported a decline in well-being. Only one study measured sedentary behavior, reporting an increase. Conclusion: Despite the variety in methods used, almost all studies reported negative impacts on physical activity and well-being in people with physical disabilities and/or chronic disease during the first wave of the pandemic. These findings highlight the importance of supporting this population, especially in times of crisis.


Introduction
In many developed countries, life expectancy has increased to over 80 years over the past century. At the same time, people have become increasingly physically inactive, leading to dramatic increases in lifestyle-related chronic diseases [1]. Recently, this was called the "global pandemic of physical inactivity" [2]. The financial burden of this physical inactivity pandemic was estimated to be USD 68 billion worldwide [3].
According to the updated World Health Organization (WHO) physical activity guidelines, all adults, including adults with disabilities or chronic diseases, should be active for 150-300 min at moderate intensity or 75-150 min at vigorous intensity aerobic per week to receive health benefits and reduce health risks [4]. Any bodily movement produced by skeletal muscles that requires energy expenditure could be classified under physical Therefore, we conducted a rapid review exploring physical activity, sedentary behavior and well-being during the first wave of the COVID-19 pandemic in people with physical disabilities and/or chronic diseases. The primary research question was: 1. What is reported in the international literature on physical activity behavior in adults with physical disabilities and/or chronic diseases during the first wave of COVID-19 pandemic? Secondary research questions were: 2.
What is reported in the international literature on sedentary behavior in adults with physical disabilities and/or chronic diseases during the first wave of the COVID-19 pandemic? 3.
What is reported in the international literature on well-being in people with physical disabilities and/or chronic diseases during the first wave of the COVID-19 pandemic?

Study Design
We conducted a rapid review because of the immediate relevance and need in the ongoing COVID-19 pandemic. A rapid review can be defined as "a form of knowledge synthesis that accelerates the process of conducting a traditional systematic review through streamlining or omitting a variety of methods to produce evidence in a resource-efficient manner" [28]. Our study methods and results were guided by and reported using the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines [29].

Search Strategy and Eligibility Criteria
Four health databases (Pubmed, CINAHL, PsycINFO, Embase) were searched for relevant studies published between 1 December 2019 and 30 September 2020. The search strategy included the following keywords: (1) terms related to COVID-19: "*COVID-19*" OR "*Sars-CoV-2*" OR "*Coronavirus*" OR "*Corona virus*" and (2) terms related to physical activity, sedentary behavior and well-being: "*Physical activity*" OR "*Sport*" OR "*Sports*" OR "*Exercise*" OR "*Exercising*" OR "*Physical training*" OR "*Physical performance*" OR "*Sedentary behavior*" OR "*Sitting activity*" OR "*Sedentary inactivity*" OR "*Well-being*" OR "*Wellness*" OR "*Wealth*" OR "*Welfare*". To capture a broad range of potentially relevant literature, we did not include terms related to the population group in our search strategy. Functions in the databases were used to search only in the titles and abstracts and to include only studies written in English. Table A1 in Appendix A outlines additional details of the search strategies for each database.
We included primary studies that reported on the impact of the COVID-19 pandemic on physical activity, sedentary behavior and/or well-being in adults with a physical disability and/or chronic diseases. To be included in this review, the study had to report primary data on changes in physical activity, sedentary behavior and/or well-being in adults with a physical disability and/or chronic disease. Studies about people without a disability or chronic disease or children/youth were excluded. We also excluded studies about people with a visual, intellectual, aural or psychological disability. Table 1 presents further details on inclusion and exclusion criteria.

Data Screening
The reference manager EndNote (EndNote X9 3.3, Clarivate Analytics, 160 Blackfriars Road, London, UK) and Excel were used to export and manage the results. The guidelines of Bramer et al. [30] were followed to remove duplicates. Title/abstract and full text screening were conducted by the first author (DB). Any uncertainties about eligibility criteria were discussed during a meeting with other team members (KH, FH, FJH), and final decisions about inclusion/exclusion were made accordingly.

Inclusion Criteria Exclusion Criteria
General - The study reports on the impact of the COVID-19 pandemic on physical activity, sedentary behavior, and/or well-being in adults (>18 years) with a physical disability and/or chronic diseases.

-
The study is about people with a physical disability and/or chronic disease. Physical disability is defined here as "an umbrella term for motor impairments, activity limitations and participation restrictions. It denotes the negative aspects of the interaction between an individual and that individual's contextual factors" [6]. - The study is about people without a disability and/or chronic disease.

-
The study is about people with a visual, hearing, intellectual and/or psychological disability.

-
The study is about children and/or youth.

-
The study compares the situation before the COVID-19 pandemic with the situation in the COVID-19 pandemic.

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The study reports on the impact of COVID-19 pandemic on physical activity, sedentary behavior AND/OR well-being. -Physical activity is defined as "any bodily movement produced by skeletal muscles that requires energy expenditure" [4]. -Sedentary behavior is defined as "any waking behavior characterized by an energy expenditure of 1.5 METs or lower while sitting, reclining or lying" [4]. -Well-being is defined as "the general term encompassing the total universe of human life domains, including physical, mental and social aspects, that make up what can be called a 'good life'" [6].

-
The study is a primary data study (e.g., cross-sectional, randomized controlled trials, observational etc.).

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The study is published between 1 December 2019 and 30 September 2020. - The study is published in English.

-
The study is published after 30 September 2020.

Data Extraction and Analyses
Data extraction was done by two team members (DB or KH) using Excel. The following data were extracted from the included studies: authors, year of publication, study design, study population, participant information (disability/ health condition, age, gender), physical activity/sedentary behavior/well-being construct, measures (e.g., questionnaire or accelerometer), key results related to the impact on physical activity/sedentary behavior/well-being during the pandemic and direction of the impact (positive, negative, no change). Aligning with our research questions, the findings on physical activity were presented separately from the findings on sedentary behavior and well-being.

Results
The search strategy resulted in a total of 2931 articles identified from the four databases. After de-duplication, a total of 1174 unique articles remained. After screening of title and abstract, a total of 53 studies remained. From these 53 studies, 29 studies were included in this review after a full-text screening. Table A2 includes a list of excluded articles during full-text screening. Figure 1 presents a flowchart of the search procedure.
ior/well-being during the pandemic and direction of the impact (p change). Aligning with our research questions, the findings on physic sented separately from the findings on sedentary behavior and well-

Sedentary Behavior and Well-Being (Secondary Research Questions)
Only one study [42] reported on changes in sedentary behavior during the first wave of the pandemic (see Table 3). This study reported that adults with type 2 Diabetes Mellitus in Spain increased sitting time during the COVID-19 pandemic compared with before the pandemic.
Thirteen of the included studies (45%) reported findings on changes in well-being during the pandemic [36][37][38][43][44][45][46][48][49][50]57,58]. These studies included 2466 individuals with nine different types of disabilities or health conditions. All thirteen studies reported a negative change in one or more constructs related to well-being of adults with physical disabilities or chronic diseases during the first wave of the COVID-19 pandemic. These findings are summarized in Table 5. Across the thirteen studies, nine different well-being constructs (anxiety, depression, loneliness, mental health, overall health, pain, quality of life, stress, well-being) were reported. Table 6 provides an overview of the well-being constructs. − Note: * Change in one or more constructs related to well-being. A negative change (−) indicates a decrease or decline in one or more well-being constructs during the COVID-19 pandemic compared with before the start of the pandemic. Well-being = WB.    [37] − Note: Change in one or more constructs related to well-being. A negative change (−) indicates a decrease or decline in one or more well-being constructs during the COVID-19 pandemic compared with before the start of the pandemic.

Discussion
This rapid review provides an overview of studies reporting on physical activity, sedentary behavior and well-being in people with physical disabilities and/or chronic diseases during the first wave of the COVID-19 pandemic. In the short time after the COVID-19 outbreak, we identified already twenty-nine studies including different types of physical disabilities and chronic diseases from twenty-two different countries on four different continents. Despite the large variation in study contexts and methodologies, almost all studies reported a negative impact on physical activity, sedentary behavior and well-being during the first wave of the COVID-19 pandemic.

Impact on Physical Activity during the COVID-19 Pandemic
Twenty-six studies reported on physical activity during the first wave of the pandemic. Almost all studies demonstrated a negative impact on the level of physical activity. This negative impact on physical activity is in accordance with a systematic review summarizing sixty-four articles on physical activity change during the first wave of COVID-19 in the general population [60]. An earlier rapid review, studying the broader impact of COVID-19 on health and participation also found a decrease of physical activity in people with neuromuscular disease and chronic pain [23]. This negative impact on physical activity can probably be explained by the many barriers regarding physical activity that people with (or without) physical disabilities may face [8]. Many of these influencing factors, such as social support, professional assistance, and availability of equipment and transportation, became less available in many countries due to lockdown restrictions, including the closing of sports facilities. It is important to note that this is a worldwide review and that lockdown restrictions varied between countries. People in some countries were obliged to stay home, while people in other countries were still able to be active outside, a finding that also came forward in the study by Washif et al. (under review) [19]. Although not studied, it is likely that the magnitude of impact of COVID-19 restrictions on physical activity, sedentary behavior and wellbeing, summarized in this rapid review, may be associated with the severity of lockdown restrictions.
Included studies in this review used a variety of methodologies (Table 3) and physical activity measures ( Table 4). The majority of the studies assessed the self-reported difference in the degree of physical activity between the situation before the pandemic compared with the situation during lockdown. Many questionnaires were investigator-developed and/or non-validated. However, the almost unanimous negative impact on physical activity during the pandemic found in this review, shows again the importance of more attention and guidance for people with physical disabilities and/or chronic diseases because it is precisely this group that can benefit a great deal from regular physical activity [5,7,61].

Impact on Sedentary Behavior during the COVID-19 Pandemic
The secondary outcome of this rapid review related to the impact of sedentary behavior during the COVID-19 pandemic. Surprisingly, sedentary behavior was measured in only one of the included studies. This one study [42] reported a negative impact of the COVID-19 pandemic on sedentary behavior [60]. A similar trend has been reported in the general population. In the same publication period, only two articles have been identified reporting on the impact of sedentary behavior in people with medical conditions [62,63]. It is worrying that sedentary behavior was studied so little during the pandemic. Work-fromhome policies that were implemented in many countries were likely to increase screen time and thus may have encouraged people to adopt sedentary behavior. Sedentary behavior is known to be a health risk independent of physical activity and therefore it is advised be studied as a separate behavior. The study by Stockwell et al. reported that the majority of the studies that measured sedentary behavior in people with medical conditions used nonvalidated questionnaires as well [60]. This might indicate that, in comparison with physical activity, it remains difficult to adequately measure sedentary behavior, especially among special populations such as people with disabilities and/or chronic diseases. Therefore, more research on (how to measure) sedentary behavior in specific populations is needed to better understand how to protect this population group against the risks of sedentary behavior, both during and after pandemics the magnitude of COVID-19.

Impact on Well-Being during the COVID-19 Pandemic
All of the identified studies in this review reporting on well-being demonstrated a negative impact on one or more constructs related to well-being during the first wave of the COVID-19 pandemic. Our findings align with other recent reviews reporting the negative impact of a variety of well-being constructs during the COVID-19 pandemic among different populations [20][21][22][23]. Interestingly, a recent review found that regular physical activity was related to lower levels of depression and anxiety in the general population during the COVID-19 pandemic [22] but that the pandemic had increased levels of depression and anxiety. Based on literature before the COVID-19 pandemic [14,15], it can be expected that regular physical activity may also be associated with positive outcomes on a variety of well-being constructs during the pandemic. This highlights again the importance of promoting physical activity in people with physical disabilities and/or chronic diseases.
Included studies in this review reported on a variety of well-being constructs using a variety of measurement tools, which is not surprising given the multidimensional character of the well-being. While there is a lack of consensus in the literature on how to define and operationalize well-being, which might partly depend on the research field and/or focus of a study [64], we used a general definition capturing both mental and physical components of well-being. This might be a contributing factor to the variety of measurement tools that was found [6]. Additionally, before COVID-19, measuring well-being was already more difficult for people with a disability compared with their peers without a disability [24,25]. The variety of measurement instruments used in the studies we included in this review made it difficult to compare their effect sizes directly. Moreover, our results clearly illustrate a negative impact on well-being of people with a physical disability and/or chronic disease during the first wave of the COVID-19 pandemic, regardless of how well-being is operationalized. This finding shows the importance of guidance and mental support, especially in times of crisis.

Scientific and Practical Implications
We were able to identify 29 studies conducted in 21 different countries and among 11 different groups of diagnosis. Another review studying changes in physical activity and sedentary behavior from before to during the pandemic lockdown amongst healthy children, adolescents and adults was able to include 66 studies [60]. Both showed decreased physical activity levels in almost all included studies, most likely indicating additional barriers for engagement in an active lifestyle. This is particularly relevant for populations with disabilities and chronic diseases who already experience substantial barriers to physical activity engagement [8,26,27]. Our rapid review is, to the best of our knowledge, the first study that has investigated and summarized physical activity, sedentary behavior and well-being in people with physical disabilities and/or chronic diseases during the first wave of the COVID-19 pandemic, establishing the need for an additional focus on vulnerable populations and physical activity stimulation. Digital technology and home-based alternatives have been mentioned as ways to provide potential support mechanisms to recreational athletes during a pandemic [18]. This could be promising to include in tailored programs to promote physical activity in persons with disabilities and/or chronic disease as well, though tailoring to their specific barriers will be needed. The results of this study show practical implications for medical support staff and policy makers. Policy makers might want to give special attention to this group, especially in times of crises.

Limitations
Some limitations need to be addressed. The first limitation concerns our search strategy. While our strategy included various terms to capture "physical activity" and "sedentary behavior" constructs, only a few terms were included to capture articles reporting on "well-being". As such, we may have missed relevant articles reporting on the impact of well-being during the pandemic, possibly impacting the rigor of this review. When specifically interested in well-being, we recommend using a more comprehensive search strategy including a variety of terms to capture the well-being construct. The second limitation concerns the quality of the studies. Many of the included studies were crosssectional studies across different setting using a variety of measurement instruments that were not validated for the population concerned, indicating that findings should be interpreted with caution. On the other hand, the fact that we were able to include already 29 studies, may highlight the urgency of studying the physical activity and well-being of people with physical disabilities and/or chronic diseases during, but perhaps also after, the pandemic. Despite these limitations, the directions of the findings (i.e., negative impact on physical activity, sedentary behavior and well-being) were consistent across almost all of the included studies. Lastly, this review focused on the impacts during the first wave of the pandemic. It is possible that there are or were other behaviors affected in subsequent waves of the COVID-19 pandemic.

Conclusions
Despite the large variation in methods of measuring physical activity and well-being, the vast majority of the included studies reported a negative impact on physical activity and well-being in adults with physical disabilities and/or chronic diseases during the first wave of the COVID-19 pandemic. Unfortunately, the impact on sedentary behavior was barely measured. The consistent findings of the negative impact during the COVID-19 pandemic that are reported in this rapid review illustrate the need to provide (additional) support and guidance to people with a physical disability and/or chronic disease to help them become and stay physically active and well during a pandemic.

Data Availability Statement:
No new data were created or analyzed in this study. Data sharing is not applicable to this article.

Acknowledgments:
The authors want to acknowledge V.R. Groot Beumer and R. Dekker for discussions on the content of this rapid review.

Conflicts of Interest:
The authors declare no conflict of interest.

Reference Exclusion Criteria
Peçanha et al. (2020) [82] Study is a review (out of study design). Quinn et al. (2020) [83] Study is an implementation study (out of study design). Rhodes et al. (2020) [84] Study is a recommendation (out of study design). Sennott et al. (2020) [85] Study is a commentary (out of study design). Speretta and Leite (2020) [86] Study is an editorial (out of study design). Tornese et al. (2020) [87] Study has a too young population (out of population). Verma et al. (2020) [88] Study has a too young population (out of population).