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Article

Perspectives of Healthcare Professionals and People with a Spinal Cord Injury on Resistance Exercise Intensity in Japan, Indonesia, Korea and Thailand

by
Kyung Su Jung
1,*,
Chayaporn Chotiyarnwong
2,
Martha Kurnia Kusumawardani
3,4,
Seung-Hyun Yoon
5,
Pojchong Chotiyarnwong
6,
Inggar Narasinta
3,4,
Damayanti Tinduh
3,4,
Ken Kouda
7 and
Fumihiro Tajima
8
1
Medical Center for Health Promotion and Sports Science, Wakayama Medical University, Wakayama 640-8033, Japan
2
Department of Rehabilitation Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand
3
Department of Physical Medicine and Rehabilitation, Faculty of Medicine, Universitas Airlangga, Surabaya 60131, Indonesia
4
Dr. Soetomo General Academic Hospital, Surabaya 60286, Indonesia
5
Department of Physical Medicine and Rehabilitation, Ajou University School of Medicine, Suwon 16499, Republic of Korea
6
Department of Orthopaedic Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand
7
Department of Rehabilitation Medicine, Wakayama Medical University, Wakayama 641-8509, Japan
8
Chuzan Hospital, Okinawa 904-2151, Japan
*
Author to whom correspondence should be addressed.
Disabilities 2024, 4(4), 770-780; https://doi.org/10.3390/disabilities4040047
Submission received: 11 July 2024 / Revised: 19 September 2024 / Accepted: 27 September 2024 / Published: 2 October 2024
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Abstract

(1) Background: This study aims to investigate differences in the perspectives of healthcare professionals (HCPs) and adults with spinal cord injury (SCI) on resistance exercise intensity in Asian countries in association with knowledge translation (KT). Also, it verifies the appropriateness of the conventional indicators for resistance exercise intensity in an Asian context. (2) Methods: 121 certified HCPs and 107 adults with SCI participated in a survey conducted in Indonesian, Japanese, Korean and Thai languages. The survey asked what principles are important for prescribing resistance exercise, and if ‘moderate’ and ‘vigorous’ were appropriate terms for indicating an intensity level. Perspective differences were examined between both groups and, further, between countries from a psychosocial perspective. (3) Results: Of the HCPs, 92% perceived that resistance exercise intensity was far more important than frequency, time or type of exercise while frequency (61%) followed by intensity (58%) was perceived as important by respondents with SCI. Only Japanese respondents with SCI agreed with the HCPs’ perception of intensity. Both HCPs and respondents with SCI showed unfavorable responses to the usage of ‘moderate’ and ‘vigorous’ for describing resistance exercise intensity, especially Japanese HCPs and respondents with SCI from Indonesia. (4) Conclusions: Our findings suggest that non-HCPs must improve their perceptions of exercise intensity. Our findings also suggest the need for more explicit and user-friendly terms or expressions indicating the level of intensity in a local (Asian) context.

1. Introduction

Adults with spinal cord injury (SCI) should be encouraged to participate in physical activities including aerobic exercise [1,2,3] to benefit physical health, including reducing the risk of chronic disease and improving body functional independence, social reintegration and psychological health [4,5]. For these benefits, most studies have focused on aerobic exercise for people with SCI but resistance exercise is also regarded as a crucial type of training to improve muscle strength, endurance, power output and muscle mass [1,6]. It improves fitness and metabolic health, too [1,2].
Various systematic reviews and meta-analyses examining the benefits of exercise for persons with SCI [7,8,9] have shown the limited coverage of the benefits of exercise. The 2011 SCI Exercise Guidelines also excluded cardiometabolic health due to insufficient high-quality evidence [1,10]. Accordingly, an international multidisciplinary team undertook a systematic review to develop evidence-based exercise guidelines for adults with SCI, helping to improving cardiorespiratory fitness, muscle strength and cardiometabolic health [2,11]. As exercise prescriptions are composed of four FITT principles (Frequency, Intensity, Time and Type) [12], and are the “dose” of exercise given to people with SCI [2], the FITT principles are the key information elements of exercise guidelines [12].
The Scientific Exercise Guidelines for Adults with Spinal Cord Injury (SEG-SCI) describe the minimum dose of aerobic and resistance exercises for those aged 18–64 with chronic SCI of level C3 and below [13,14]. This guideline provides the minimum frequency, intensity and duration of exercise involving combined upper-body aerobic plus strength exercise, yielding significant improvements in fitness outcomes. The resistance exercise recommendations are that “3 sets of strength exercises for each major functioning muscle group should be conducted at a moderate to vigorous intensity, 2 times per week” to improve muscle strength [11]. The guidelines include frequency, intensity and duration without type and, specifically, stress the intensity of excise by specifying the level of moderate to vigorous intensity [11].
International guidelines have been adopted in some European countries and Canada [15]. Four Asian countries (Indonesia, Japan, Korea and Thailand) collaborated on the cultural validation of the SEG-SCI by conducting systematic review including local and international publications written either in their local languages or in English [16]. The selected publications confirmed the validity of the SEG-SCI. The SEG-SCI was then translated into Bahasa Indonesian, Japanese, Korean and Thai languages [16] to be disseminated to healthcare professionals (HCPs) and people living with SCI in these countries.
However, the review revealed several limitations, including inconsistency in the exercise prescriptions used across studies and countries [16]. This led us to conduct a survey to reveal any different views across countries on aerobic exercise prescriptions. Regarding the SEG-SCI recommend minimum thresholds for aerobic and resistance intensity exercises [13], a sample of HCPs and people with SCI in Asia were surveyed about their perceptions of the relative importance of the four FITT principles [17]. For aerobic exercise, we discovered that among HCPs, the most important principle was intensity but among the SCI group, the most important principle was frequency [17]. When also asked if the exercise intensity was appropriately described by the terms ‘moderate’ or ‘vigorous’, both groups shared a similar negative view on this [17]. Additionally, irrespective of the group, only 34% of the total respondents agreed that these terms provided enough information for aerobic exercise intensity prescription [17].
Resistance exercise, on the other hand, is discussed using the concept of knowledge translation to understand whether the importance of intensity has been effectively conveyed to end-users by HCPs in Asian countries, as the SEG-SCI emphasizes the importance of exercise intensity ranging from moderate to vigorous. Knowledge translation (KT) is defined as “a dynamic and iterative process that includes synthesis, dissemination, exchange and ethically sound application of knowledge to improve the health, provide more effective health services and products and strengthen the health care system” [18]. Given that Asian HCPs and patients with SCI were the target subjects, KT in this context is considered a good parameter to identify how KT occurs between HCPs and patients with SCI.
A good example of KT, for instance, is a rehabilitation program called PROr (physiatrist and registered therapist operating acute rehabilitation) [19,20,21,22] introduced by the Wakayama Medical University (WMU) Rehabilitation Center, Japan. This program aims at high-intensity exercise and high-frequency mobilization [19], and has encouraged the patients (end-users) to be more vigorously involved in high-intensity rehabilitation activities and to understand the importance of high-intensity exercise. The American College of Sports Medicine (ACSM) also outlines that exercise intensity is regarded as the most crucial element and continues to stress the benefits of moderate-to-vigorous-intensity physical activity along with relevant prescriptive considerations [23].
Thus, our study focuses on analyzing perceptions about intensity from a psychosocial perspective, rather than a physiological perspective, since we aim to understand if the nature of intensity is perceived as important, and how KT affects the end-users’ perception of resistance exercise intensity prescription in four Asian countries. It also examines if the exercise intensity is well delivered using the terms ‘moderate’ and ‘vigorous’ in Asian contexts, too.

2. Materials and Methods

Participants: A cross-sectional design and survey were employed in Indonesia, Japan, Korea and Thailand. In order to compare the development of KT in the Asian context, this study mainly surveyed four major university rehabilitation centers based in the four Asian countries, such as the Universitas Airlangga in Indonesia, Ajou University in Korea, and Siriraj Hospital of Mahidol University in Thailand, along with the WMU in Japan. The academic level and the size of the hospital were major considerations in the selection of participating universities. The School of Medicine at the Universitas Airlangga is ranked as the second best university in Indonesia, and Siriraj Hospital is part of Mahidol University, which is ranked as the top medical institution. Ajou University rehabilitates a large number of patients with SCI, since the Hospital accommodates the largest trauma center in the region near Seoul. Subsequently, HCPs specializing in SCI healthcare and adults with SCI (aged 18 or higher with traumatic or non-traumatic SCI and one year post-onset) were recruited from the above centers and participated anonymously in the survey. A convenience sampling method was also adopted as respondents with SCI were selected by the institutions where the HCPs were affiliated or employed.
Questionnaire: Unlike the questionnaire for aerobic exercise, which was designed for a physiological analysis [17], the resistance exercise questionnaire was simplified for analysis from a psychosocial perspective and was translated into the local languages. Apart from personal information (e.g., age, occupation, impairment), it was divided into two categories: the first included (1) a question ranking the perceived importance of FITT for resistance exercise, and (2) multiple-choice questions using a 5-point Likert scale asking about the frequency of considering a target intensity to discuss how KT has occurred in different cultural contexts. On the other hand, the second category involved topics such as if the terms ‘moderate’ and ‘vigorous’ were appropriate and provided enough information about resistance exercise intensity using multiple-choice questions using a 5-point Likert scale.
Procedure: The same procedure as that of the previous paper was applied in terms of its design and use of a questionnaire and the translation process for each country [17]. The procedures adhered to the ethical standards of the respective committees in each country and the 2008 Declaration of Helsinki. The respondents were required to provide informed consent forms prior to completion of the questionnaire. The data were analyzed by χ2 analysis using the Statistical Package for the Social Sciences V.26 software (SPSS). Significance was determined at p < 0.05.

3. Results

Demographics: 228 responses were collected in Indonesia, Japan, Korea and Thailand, including 121 certified HCPs (mean age 39 ± 9 years, 23–61) and 107 adults with SCI (mean age 46 ± 13 years, 20–74); ≥1 year ranging C1–L4) [17]. On average, participants who were physiotherapists (49%), physiatrists (30%), occupational therapists (18%) and nurses (3%) had 12 ± 10 years of experience of rehabilitative treatment. The respondents with SCI had an average of 15 ± 12 years post-onset after a thoracic injury (50.5%), cervical injury (29%) or lumbar injury (14%) along with a 6.5% unknown injury level, and there were 43% complete injury, 52% incomplete injury and 5% unspecified [17].

3.1. Perception of Resistance Exercise Intensity

HCPs and adults with SCI were found to have different perceptions of the FITT principles including frequency, intensity and time in relation to resistance exercise (p < 0.001), whereas the perception of type appeared to be relatively similar (p = 0.002) (Table 1). Of the three principles, intensity showed the greatest difference between the two groups, with a total of 92% of HCPs (rank1 + rank2) placing a significant emphasis on intensity. Frequency was revealed as a top priority by the majority of the SCI group in Asia with 61% ranking it as the number 1 or 2 priority (Table 1). However, nearly 58% of adults with SCI also considered intensity to be important.
When asked how often a target intensity was considered (Table 2), there was a big difference between both groups (p < 0.001).
While the Asian HCPs had unified views, with the greatest importance on intensity (Figure 1a), the SCI groups did not rank intensity as the top priority except for the Japanese SCI group, whose emphasis on resistance exercise intensity reached 78% (Figure 1b).
Accordingly, only in Japan did both HCPs and adults with SCI consider a target intensity to be a high priority for resistance exercises (Figure 2).

3.2. Appropriateness of Exercise Intensity Terms ‘Moderate’ and ‘Vigorous’ for Strength Training

There were no different views on using the terms ‘moderate’ and ‘vigorous’ between groups (p = 0.839, p = 0.801, respectively) (Figure 3).
Both groups also similarly agreed that the terms were somewhat inappropriate when asked if these terms provide enough information regarding resistance exercise intensity (p = 0.899, p = 0.615, respectively) (Figure 4).
Japanese HCPs and adults with SCI from Indonesia had the lowest number of respondents who believed the terms were ‘extremely’ or ‘very’ appropriate (Figure 5).

4. Discussion

4.1. Perception of Resistance Exercise Intensity in Asia

We conducted a survey to understand perceptions of the importance of intensity and appropriateness of the terminology from a psychosocial perspective. We discovered that HCPs believed intensity was the top priority for resistance exercise while the SCI group did not place as much importance on intensity (Table 1). In fact, when asked how often a target intensity was considered, 84% of HCPs ‘always’ or ‘often’ considered intensity compared to only 52% of the SCI group (Table 2).
Studies have shown that aerobic exercise improves cardiorespiratory fitness in adults with SCI and that moderate and vigorous exercise is more effective than light-intensity exercise [1,2,24]. Intensity is an important element to prevent cardiometabolic disease [25,26,27,28] and further, vigorous intensity is better than moderate intensity [29,30]. Promoting resistance exercise is also beneficial to cardiovascular fitness [31], power output [32] and muscular strength [32]. One study found maximal-intensity resistance training resulted in an increase in strength in comparison to conventional training [33]. In general, moderate–vigorous-intensity exercise benefits the improvement of cardiorespiratory fitness [34] and the reduction in the risk of mortality and morbidity [35,36]. Therefore, it is important for HCPs to prescribe moderate- and vigorous-intensity exercise and for people with SCI to understand and carry out this prescription.
Our study revealed that HCPs acknowledged the importance of intensity for resistance exercise while people with SCI did not. Similar results were found in our companion paper on aerobic exercise, as the majority of HCPs regarded intensity as the most important aspect for prescribing aerobic exercise while the SCI group largely ranked frequency as the most important element [17]. However, more respondents with SCI appeared to focus on resistance exercise intensity (58%) than aerobic exercise intensity (38%).
Interestingly, only Japanese respondents with SCI (78%) ranked intensity as the most important element for resistance exercise (Figure 2). As we applied convenience sampling, all Japanese respondents had experienced a rehabilitation program called PROr [19] offered by the Wakayama Medical University (WMU) Rehabilitation Center. This experience can possibly explain why Japanese HCPs and respondents with SCI both highly evaluated the importance of intensity for resistance exercise. It likely also explains why the largest number of Japanese SCI and HCPs ‘always’ considered a target intensity for resistance exercises.
In Thailand, nearly half of respondents with SCI ranked type of exercise as the most important element for resistance exercise, while HCPs chose intensity. This result may be due to patient education programs and also SCI exercise guidelines mostly classifying exercise into two major groups: aerobic for cardiovascular health and resistance exercise for muscle strength [37]. On the other hand, standard exercise guidelines for HCPs are the American College of Sports Medicine (ACSM) guidelines, for which exercise intensity is considered as the most important of the primary variables [23,38].
In our companion paper, there was a hypothesis that people with SCI might have had a lack of knowledge on and understanding of the concept of exercise intensity and the physiological consequences of SCI [17]. A knowledge translation gap exists between evidence and implementation [39,40] and the gap in exercise prescription knowledge is broadly apparent in people with SCI [41]. What we supposed from this study was that HCPs should be able to carry out the knowledge translation. For instance, those living with SCI who have ever experienced the intensity-focused rehabilitation program in Japan can be made aware of how important exercise intensity is. Only a few Indonesian participants with SCI set a target intensity during resistance exercises while 77% of Indonesian HCPs favorably did (p < 0.001) (Figure 2). We can suppose that the HCPs in Indonesia can play a key role in narrowing the gap in knowledge. That said, our finding supports our assumption that HCPs’ KT could improve the perception of exercise intensity in the SCI population.

4.2. Appropriateness of Exercise Intensity Prescriptions ‘Moderate’ and ‘Vigorous’

Building on the results of our first report from the survey [17], the present study found that the HCP and the SCI groups both similarly showed that ‘moderate’ and ‘vigorous’ were unlikely to be appropriate (p = 0.839, p = 0.801 respectively). When the international SCI Exercise Guidelines were introduced to Asian countries, an issue was the language barrier, as Asia is not an English-speaking continent and the guidelines were developed in English. To produce a high-quality version of translated guidelines, those who were rich in rehabilitation knowledge or were language professionals joined the translation process [16]. In this process, a question was naturally brought up on the appropriateness of terms ‘moderate’ and ‘vigorous’.
When again asked if these terms ‘completely’ or ‘mostly’ provide enough information regarding resistance exercise intensity, both groups similarly agreed but the response of HCPs was slightly more positive than that of the SCI group (Figure 4). On the contrary, adults with SCI showed more positive attitudes towards aerobic exercise prescription [17], as reported in the companion paper.
When breaking down the data across countries, both groups in Japan were relatively disapproving of these terms for aerobic exercise intensity [17] and were the same for resistance exercise intensity. As noted earlier, Japanese respondents with SCI and HCPs both highly evaluated exercise intensity in that WMU PROr has facilitated adults with SCI to be aware of the importance of exercise intensity, but both groups assessed these terms as relatively inappropriate. Thus, we hypothesize that moderate and vigorous should be substituted by more understandable or conveyable terminology in the Japanese context.
Interestingly, Indonesian HCPs were highly comfortable with these terms while the SCI group was not. We assumed that the Indonesian language has a good translation and that this was probably the case for the matter of knowledge translation, too. Communication between HCPs and people with SCI would also influence the understanding of exercise intensity in SCI [42]. Also, HCPs have lower confidence for physical activity counseling and prescribe exercise in their regular clinical practice [43]. If the Indonesians with SCI were actively instructed by their HCPs, knowledge translation would occur, and in turn, their perception of exercise intensity would be improved and exercise prescription would become familiar. Jung et al. [17] implied that “the term intensity is operationally more difficult to define compared with frequency and duration” (p. 5). Accordingly, if there are gaps between both groups, this would suggest that people with SCI and HCPs need more appropriate resources/information to explain/understand the prescription of intensity.
There is another possibility in that the use of the RPE (Rating of Perceived Exercise, or the Borg scale) was mostly acceptable for non-HCPs due to different levels of exposure to medical knowledge and environments [17] and, thus, it might be necessary to find more appropriate and familiar terminology or words to convey a level of exercise intensity by using the RPE, if possible.

5. Implications of the Findings

The survey results revealed two issues: the knowledge translation of exercise intensity and an end-user friendly prescription. Considering the knowledge translation gap, this problem is not unique to people with SCI, and there is also a problem for the general population because there are many different definitions of moderate-to-vigorous and different ways of monitoring it [44]. Also, as people with SCI are more familiar with the RPE scale, the RPE scale might attain a clearer perception of resistance exercise intensity for individuals with SCI, which enables individuals with SCI to apply the guidelines to their daily life activities and exercises. This implies that the international SCI exercise guidelines should be more informative and locally customized for delivery in a different medical or social context.

6. Conclusions

Exercise intensity has widely been emphasized for resistance exercises by healthcare professionals, along with aerobic exercise, yet individuals with SCI have challenges in living up to exercise intensity recommendations. By facilitating an intensity-focused rehabilitative program with a user-friendly scale, successful knowledge translation can effectively occur between HCPs and individuals with SCI. This enables the SCI population to be aware of the importance of exercise intensity and, thus, improve their fitness, health and physical function.

Author Contributions

Conceptualization, K.S.J. and C.C.; methodology, K.S.J., C.C., D.T. and S.-H.Y.; software, K.S.J. and P.C.; validation, M.K.K., C.C. and S.-H.Y.; formal analysis, K.S.J. and C.C.; investigation, I.N.; resources, K.S.J., C.C., S.-H.Y., M.K.K. and I.N.; data curation, K.S.J. and P.C.; writing—original draft preparation, K.S.J.; writing—review and editing, K.S.J. and C.C.; visualization, K.S.J. and P.C.; supervision, F.T.; project administration, F.T. and K.K.; funding acquisition, K.S.J., K.K. and F.T. All authors have read and agreed to the published version of the manuscript.

Funding

This research was funded by Joint Usage/Research Center of Sport for Persons with Impairments authorized by the Ministry of Education, Culture, Sports, Science and Technology at Wakayama Medical University, Japan, grant number SP2020-01.

Institutional Review Board Statement

The study was conducted in accordance with the Declaration of Helsinki, and approved by the Institutional Review Board (or Ethics Committee) of Universitas Airlangga, Indonesia (0318/LOE/301.1.2/I/2021, 30 January 2021); Wakayama Medical University, Japan (3109, 3 March 2021); Siriraj Hospital, Mahidol University, Thailand (SIRB Protocol No. 036/2564(IRB2), COA No. Si 093/2021, 2 February 2021) and Ajou University Hospital, Korea (AJOUIRB-SUR-2021-051, 16 March 2021).

Informed Consent Statement

Written informed consent was obtained by all subjects involved in the study.

Data Availability Statement

The data presented in this study are available on request from the corresponding author due to privacy/ethical restrictions.

Acknowledgments

K.A. Martin Ginis provided advice on the statistical analyses and preparation of the manuscript.

Conflicts of Interest

The authors declare no conflicts of interest.

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Figure 1. The question was “rank these aspects in order of importance when conducting RESISTANCE exercise”: (a) HCP respondents in each nation’s categorization; (b) respondents with SCI in each nation’s categorization.
Figure 1. The question was “rank these aspects in order of importance when conducting RESISTANCE exercise”: (a) HCP respondents in each nation’s categorization; (b) respondents with SCI in each nation’s categorization.
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Figure 2. How often a target intensity is considered during resistance exercise in each Asian nation.
Figure 2. How often a target intensity is considered during resistance exercise in each Asian nation.
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Figure 3. How appropriate the terms ‘moderate’ and ‘vigorous’ are in resistance exercise.
Figure 3. How appropriate the terms ‘moderate’ and ‘vigorous’ are in resistance exercise.
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Figure 4. Whether the terms ‘moderate’ and ‘vigorous’ provide enough information in Asian nations.
Figure 4. Whether the terms ‘moderate’ and ‘vigorous’ provide enough information in Asian nations.
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Figure 5. How appropriate the terms ‘moderate’ and ‘vigorous’ are in resistance exercise in each Asian country.
Figure 5. How appropriate the terms ‘moderate’ and ‘vigorous’ are in resistance exercise in each Asian country.
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Table 1. The ranking of the four aspects in order of importance when conducting resistance exercise in the four Asian nations (count (per cent %)).
Table 1. The ranking of the four aspects in order of importance when conducting resistance exercise in the four Asian nations (count (per cent %)).
ParameterRankResistance Exercise
Adults with SCIHCPs(x2)
p-Value
Frequency129 (30)12 (10)p < 0.001
230 (31)30 (25)
322 (23)41 (35)
416 (16)36 (30)
Intensity126 (27)75 (63)p < 0.001
229 (31)35 (29)
327 (28)3 (2)
413 (14)7 (6)
Time (duration)116 (17)5 (4)p < 0.001
226 (27)16 (13)
328 (30)51 (43)
425 (26)48 (40)
Type126 (27)28 (23)p = 0.002
212 (13)39 (33)
318 (19)25 (21)
439 (41)28 (23)
Table 2. How often a target intensity is considered during resistance exercise in the four Asian nations? (count (per cent %)).
Table 2. How often a target intensity is considered during resistance exercise in the four Asian nations? (count (per cent %)).
How OftenResistance Exercise
Adults with SCIHCPs
Never11 (10)1 (1)
Rarely11 (10)2 (2)
Sometimes30 (28)16 (13)
Often31 (29)48 (40)
Always24 (23)54 (44)
(x2) p valuep < 0.001
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Jung, K.S.; Chotiyarnwong, C.; Kusumawardani, M.K.; Yoon, S.-H.; Chotiyarnwong, P.; Narasinta, I.; Tinduh, D.; Kouda, K.; Tajima, F. Perspectives of Healthcare Professionals and People with a Spinal Cord Injury on Resistance Exercise Intensity in Japan, Indonesia, Korea and Thailand. Disabilities 2024, 4, 770-780. https://doi.org/10.3390/disabilities4040047

AMA Style

Jung KS, Chotiyarnwong C, Kusumawardani MK, Yoon S-H, Chotiyarnwong P, Narasinta I, Tinduh D, Kouda K, Tajima F. Perspectives of Healthcare Professionals and People with a Spinal Cord Injury on Resistance Exercise Intensity in Japan, Indonesia, Korea and Thailand. Disabilities. 2024; 4(4):770-780. https://doi.org/10.3390/disabilities4040047

Chicago/Turabian Style

Jung, Kyung Su, Chayaporn Chotiyarnwong, Martha Kurnia Kusumawardani, Seung-Hyun Yoon, Pojchong Chotiyarnwong, Inggar Narasinta, Damayanti Tinduh, Ken Kouda, and Fumihiro Tajima. 2024. "Perspectives of Healthcare Professionals and People with a Spinal Cord Injury on Resistance Exercise Intensity in Japan, Indonesia, Korea and Thailand" Disabilities 4, no. 4: 770-780. https://doi.org/10.3390/disabilities4040047

APA Style

Jung, K. S., Chotiyarnwong, C., Kusumawardani, M. K., Yoon, S.-H., Chotiyarnwong, P., Narasinta, I., Tinduh, D., Kouda, K., & Tajima, F. (2024). Perspectives of Healthcare Professionals and People with a Spinal Cord Injury on Resistance Exercise Intensity in Japan, Indonesia, Korea and Thailand. Disabilities, 4(4), 770-780. https://doi.org/10.3390/disabilities4040047

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