Evidence-based scientific exercise guidelines for adults with spinal cord injury: an update and a new guideline

The Impact of Sub-maximal Exercise on Neuropathic Pain, Inflammation, and Affect Among Adults With Spinal Cord Injury: A Pilot Study

Introduction: Persons with spinal cord injury (SCI) often report high levels of neuropathic pain (NP) and poor well-being, which may result from increased inflammation. This study examined the impact of sub-maximal aerobic exercise on NP, inflammation and psychological affect among adults with SCI. Methods: Eight active adults with tetraplegia (n-4, AIS A-C) and paraplegia (n = 4, AIS A-C) performed 30-min of arm-crank aerobic exercise and reported their ratings of perceived exertion (RPE) each minute. Measures of NP, affect, and inflammatory cytokines (IL-6, IL-10, IL-1ra, TNF-α) were taken pre-(T0), immediately post-(T1), and 90-min post-exercise (T2). Results: NP decreased between T0 and T1 for tetraplegics (-60%, d = 0.47; CI = -0.32, 2.02) and paraplegics (-16%, d = 0.15; CI = -0.30, 0.90). Correlations between change in cytokines and change in NP were medium-to large for tetraplegics (rs ranged from -0.820 to 0.965) and paraplegics (rs ranged from -0.598 to 0.833). However, the pattern of correlations between change in cytokines and affect was inconsistent between groups. Lower baseline levels of IL-1ra predicted greater decreases in NP immediately post-exercise (r = 0.83, p = 0.01). Conclusion: Sub-maximal exercise can positively impact NP for some persons with SCI. Further experimental research should identify the optimal exercise intensity to reduce NP for persons with SCI, in addition to understanding biomarkers which may predict changes in NP. Clinical Trial Registration: www.ClinicalTrials.gov, identifier NCT03955523.

A qualitative interview study on how people with incomplete spinal cord injury experience high-intensity walking exercise

STUDY DESIGN

Qualitative, in-depth research interviews.

OBJECTIVE

To provide new insight into how people with a recent incomplete spinal cord injury (SCI) experience high-intensity walking exercise after discharge from subacute inpatient rehabilitation.

SETTING

Informants for this interview study participated in a previous randomized controlled trial (RCT) that was conducted at Sunnaas Rehabilitation Hospital, Norway.

METHODS

Four individual face-to-face interviews were conducted with the participants in natural setting. The interviews were analyzed through systematic text condensation and discussed in the context of experiences of bodily changes.

RESULTS

Four themes emerged that described positive but also challenging bodily experiences related to performing high-intensity walking exercise: "Expectations and motivation"-reasons for participating, "Challenging bodily changes"-impacts on walking ability, "Adaptation strategies"-achieving the high-intensity target level, and "Integrating exercise into a new daily life"-combining participation, new body and new life.

CONCLUSIONS

This study indicates the importance of participating in a specific exercise program at discharge from subacute inpatient rehabilitation for ambulant people with SCI. However, high-intensity walking exercise may be too demanding to perform during this time period. The insights from the study provide new knowledge that can contribute to improving clinical rehabilitation practice.

Effects of repetitive transcranial magnetic stimulation on recovery in lower limb muscle strength and gait function following spinal cord injury: a randomized controlled trial

Study design

Randomized sham-controlled clinical trial.

Objectives

The objective of this study is to investigate the effects of repetitive transcranial magnetic stimulation (rTMS) compared to sham stimulation, on the development of lower limb muscle strength and gait function during rehabilitation of spinal cord injury (SCI).

Setting

SCI rehabilitation hospital in Viborg, Denmark.

Methods

Twenty individuals with SCI were randomized to receive rTMS (REAL, n = 11) or sham stimulation (SHAM, n = 9) and usual care for 4 weeks. rTMS (20 Hz, 1800 pulses per session) or sham stimulation was delivered over leg M1 Monday–Friday before lower limb resistance training or physical therapy. Lower limb maximal muscle strength (MVC) and gait function were assessed pre- and post intervention. Lower extremity motor score (LEMS) was assessed at admission and at discharge.

Results

One individual dropped out due to seizure. More prominent increases in total leg (effect size (ES): 0.40), knee flexor (ES: 0.29), and knee extensor MVC (ES: 0.34) were observed in REAL compared to SHAM; however, repeated-measures ANOVA revealed no clear main effects for any outcome measure (treatment p > 0.15, treatment × time p > 0.76, time p > 0.23). LEMS improved significantly for REAL at discharge, but not for SHAM, and REAL demonstrated greater improvement in LEMS than SHAM (p < 0.02). Similar improvements in gait performance were observed between groups.

Conclusions

High-frequency rTMS may increase long-term training-induced recovery of lower limb muscle strength following SCI. The effect on short-term recovery is unclear. Four weeks of rTMS, when delivered in conjunction with resistance training, has no effect on recovery of gait function, indicating a task-specific training effect.

Health Promotion and Wellness in Neurologic Physical Therapy: Strategies to Advance Practice

BACKGROUND AND PURPOSE

Neurologic physical therapy (PT) can assist people with neurologic conditions and injuries to optimize their health and well-being by addressing barriers at the individual, relationship, community, and societal levels. The purpose of this special interest article is to provide consensus-driven strategies to address barriers to implementing health promotion and wellness (HPW)-related neurologic PT practice.

SUMMARY OF KEY POINTS

Environmental scan, literature review, and expert input were used to determine barriers and develop strategies. Barriers include lack of time; low knowledge, self-efficacy, and awareness; client complexity; and lack of HPW resources; as well as concerns regarding payment and scope of practice. Four key strategies emerged: (1) develop and disseminate a consensus-based scope of practice for HPW in neurologic PT; (2) increase knowledge of resources related to HPW; (3) promote delivery models for HPW-related neurologic PT; and (4) encourage advocacy, community building and partnership along the continuum of care.

RECOMMENDATIONS FOR CLINICAL PRACTICE

Clinicians should practice to their full scope of HPW-related PT practice. This includes optimizing movement, including physical activity and fitness, as well as reinforcing the importance of healthy sleep, nutrition, stress, and smoking cessation. These activities address primary, secondary, and tertiary prevention. Clinicians are encouraged to report their experiences with HPW-focused delivery models and outcomes. Additional research is needed to understand the full impact of HPW on PT practice (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A364).

Effects of Exercise Mode on Postprandial Metabolism in Humans with Chronic Paraplegia

PURPOSE

The purpose of this study was to assess the acute effects of exercise mode and intensity on postprandial macronutrient metabolism.

METHODS

Ten healthy men age 39 ± 10 yr with chronic paraplegia (13.2 ± 8.8 yr, ASIA A-C) completed three isocaloric bouts of upper-body exercise and a resting control. After an overnight fast, participants completed circuit resistance exercise (CRE) first and the following conditions in a randomized order, separated by >48 h: i) control (CON), ~45-min seated rest; ii) moderate-intensity continuous exercise (MICE), ~40-min arm cranking at a resistance equivalent to ~30% peak power output (PPO); and iii) high-intensity interval exercise (HIIE), ~30 min arm cranking with resistance alternating every 2 min between 10% PPO and 70% PPO. After each condition, participants completed a mixed-meal tolerance test consisting of a 2510-kJ liquid meal (35% fat, 50% carbohydrate, 15% protein). Blood and expired gas samples were collected at baseline and regular intervals for 150 min after a meal.

RESULTS

An interaction (P < 0.001) was observed, with rates of lipid oxidation elevated above CON in HIIE until 60 min after a meal and in CRE at all postprandial time points up to 150 min after a meal. Postprandial blood glycerol was greater in MICE (P = 0.020) and CRE (P = 0.001) compared with CON. Furthermore, nonesterified fatty acid area under the curve had a moderate-to-strong effect in CRE versus MICE and HIIE (Cohen's d = -0.76 and -0.50, respectively).

CONCLUSIONS

In persons with paraplegia, high-intensity exercise increased postprandial energy expenditure independent of the energy cost of exercise. Furthermore, exercise combining resistance and endurance modes (CRE) showed the greater effect on postprandial lipid oxidation.

Community exercise for individuals with spinal cord injury with inspiratory muscle training: A pilot study

Context/Objective: Respiratory disorders are a common cause of rehospitalization, and premature death in individuals with spinal cord injuries (SCI). Respiratory training combined with community exercise programs may be a method to reduce secondary complications in this population.Objective: The present study explores the inclusion of inspiratory muscle training (IMT) in an existing community exercise program.Design: Case series.Setting: Community.Participants: Participants (N = 6) completed the exercise program. Five were male and one was female; four reported incomplete injuries, and two reported complete injuries; four had cervical injuries, and two had thoracic injuries. The average age was 33 years (SD = 18.6) and time since injury was 7 years (SD = 4.0).Interventions: Participants completed an 8-week program, once-per-week for 4 h that included a circuit of resistance training, aerobic exercise, trunk stability, and education. IMT was completed as a home exercise program.Outcome Measures: Transfer test, T-shirt test, four-directional reach, four-directional trunk strength, weekly training diaries, and a subjective interview.Results: Twenty-eight training logs were collected. All measures improved: transfer test (mean = -14.62, SD = 7.00 s), T-shirt test (mean = -7.83, SD = 13.88 s), four-directional reach (mean = 3.75, SD = 8.06 in) and hand-held dynamometer (mean = 6.73, SD = 8.02 kg). Individuals reported a positive impact of the program.Conclusions: This pilot study demonstrated community exercise with IMT use may have positive impact on functional measures for people with SCI who are vulnerable to respiratory compromise. Continued education may increase successful health outcomes.Trial Registration: NCT03743077.

Effects of functional electrical stimulation on muscle health after spinal cord injury

Spinal cord injury is a devastating condition interrupting voluntary movement and motor control. In response to unloading, skeletal muscle undergoes numerous adaptations, including rapid and profound atrophy, intramuscular fat accumulation, impaired muscular glucose metabolism and decreased force generation and muscle performance. Functional electrical stimulation (FES) involves electrically stimulating affected muscles to contract in a coordinated manner to create a functional movement or task. Effects of FES-cycling, rowing and resistance training on muscle health are described here. Briefly, FES-cycling and resistance training may slow muscle atrophy or facilitate muscle hypertrophy, and all modalities benefit muscle composition and performance to some extent. These interventions show promise as future rehabilitative tools after spinal cord injury.

The ability of heart rate or perceived exertion to predict oxygen uptake varies across exercise modes in persons with tetraplegia

STUDY DESIGN

Descriptive study.

OBJECTIVES

To examine grouped and intra-individual relationships between 1) exercise intensity and heart rate (EI-HR); 2) EI and oxygen uptake (EI-VO₂); 3) VO₂ and HR (VO₂-HR); and 4) perceived exertion and VO₂ (PE-VO₂) in persons with tetraplegia (C4/5-C8) during different modes of exercise.

SETTING

Community in Winnipeg, Canada.

METHODS

Participants exercised at 3 graded intensities during arm ergometry (ERG), wheeling indoors on cement (MWC), or hand-cycling outdoors (HC). EI (Watts, km/hr) and VO₂, HR and PE were recorded.

RESULTS

22 persons completed ERG, 14/22 also completed MWC and 5/22 completed ERG, MWC and HC. Regression analysis of grouped data showed a significant relationship between EI-VO₂ but not for EI-HR or HR-VO₂. Intra-individual analyses showed a strong correlation (r or ρ > 0.7) for VO₂-HR for 16/22 during ERG. In the participants completing multiple exercise modes, a strong VO₂-HR relationship was present in 12/14 in ERG, but in only 6/14 in MWC. The 5 persons exercising with all 3 modes had a strong HR-VO₂ relationship in 5/5 for ERG, 2/5 in MWC and 1/5 in HC. A strong relationship for PE-VO₂ was observed in a higher proportion of participants (versus HR-VO₂) during MWC (9/14) and HC (2/4).

CONCLUSION

Within the same individual, the HR-VO₂ relationship varies across modes, despite exercising over similar ranges of steady-state VO₂. HR appears less able to predict VO₂ compared to PE. Based on these new findings, systematic investigation of the HR-VO₂ relationship across modes of exercise in tetraplegia is warranted.

Mobile App (WHEELS) to Promote a Healthy Lifestyle in Wheelchair Users With Spinal Cord Injury or Lower Limb Amputation: Usability and Feasibility Study

BACKGROUND

Maintaining a healthy lifestyle is important for wheelchair users' well-being, as it can have a major impact on their daily functioning. Mobile health (mHealth) apps can support a healthy lifestyle; however, these apps are not necessarily suitable for wheelchair users with spinal cord injury or lower limb amputation. Therefore, a new mHealth app (WHEELS) was developed to promote a healthy lifestyle for this population.

OBJECTIVE

The objectives of this study were to develop the WHEELS mHealth app, and explore its usability, feasibility, and effectiveness.

METHODS

The WHEELS app was developed using the intervention mapping framework. Intervention goals were determined based on a needs assessment, after which behavior change strategies were selected to achieve these goals. These were applied in an app that was pretested on ease of use and satisfaction, followed by minor adjustments. Subsequently, a 12-week pre-post pilot study was performed to explore usability, feasibility, and effectiveness of the app. Participants received either a remote-guided or stand-alone intervention. Responses to semistructured interviews were analyzed using content analysis, and questionnaires (System Usability Score [SUS], and Usefulness, Satisfaction, and Ease) were administered to investigate usability and feasibility. Effectiveness was determined by measuring outcomes on physical activity, nutrition, sleep quality (Pittsburgh Sleep Quality Index), body composition, and other secondary outcomes pre and post intervention, and by calculating effect sizes (Hedges g).

RESULTS

Sixteen behavior change strategies were built into an app to change the physical activity, dietary, sleep, and relaxation behaviors of wheelchair users. Of the 21 participants included in the pilot study, 14 participants completed the study. The interviews and questionnaires showed a varied user experience. Participants scored a mean of 58.6 (SD 25.2) on the SUS questionnaire, 5.4 (SD 3.1) on ease of use, 5.2 (SD 3.1) on satisfaction, and 5.9 (3.7) on ease of learning. Positive developments in body composition were found on waist circumference (P=.02, g=0.76), fat mass percentage (P=.004, g=0.97), and fat-free mass percentage (P=.004, g=0.97). Positive trends were found in body mass (P=.09, g=0.49), BMI (P=.07, g=0.53), daily grams of fat consumed (P=.07, g=0.56), and sleep quality score (P=.06, g=0.57).

CONCLUSIONS

The WHEELS mHealth app was successfully developed. The interview outcomes and usability scores are reasonable. Although there is room for improvement, the current app showed promising results and seems feasible to deploy on a larger scale.

Virtual Strategies for the Broad Delivery of High Intensity Exercise in Persons With Spinal Cord Injury: Ongoing Studies and Considerations for Implementation

Spinal cord injury (SCI) results in a multitude of metabolic co-morbidities that can be managed by exercise. As in the non-injured population, manipulation of exercise intensity likely allows for fruitful optimization of exercise interventions targeting metabolic health in persons with SCI. In this population, interventions employing circuit resistance training (CRT) exhibit significant improvements in outcomes including cardiorespiratory fitness, muscular strength, and blood lipids, and recent exploration of high intensity interval training (HIIT) suggests the potential of this strategy to enhance health and fitness. However, the neurological consequences of SCI result in safety considerations and constrain exercise approaches, resulting in the need for specialized exercise practitioners. Furthermore, transportation challenges, inaccessibility of exercise facilities, and other barriers limit the translation of high intensity "real world" exercise strategies. Delivering exercise via online ("virtual") platforms overcomes certain access barriers while allowing for broad distribution of high intensity exercise despite the limited number of population-specific exercise specialists. In this review, we initially discuss the need for "real world" high intensity exercise strategies in persons with SCI. We then consider the advantages and logistics of using virtual platforms to broadly deliver high intensity exercise in this population. Safety and risk mitigation are considered first followed by identifying strategies and technologies for delivery and monitoring of virtual high intensity exercise. Throughout the review, we discuss approaches from previous and ongoing trials and conclude by giving considerations for future efforts in this area.

Participation of people living with disabilities in physical activity: a global perspective

Approximately 1·5 billion people worldwide live with a physical, mental, sensory, or intellectual disability, about 80% of which are in low-income and middle-income countries. This Series paper provides a global overview of the prevalence, benefits, and promotion policies for physical activity for people living with disabilities (PLWD). PLWD are 16-62% less likely to meet physical activity guidelines and are at higher risk of serious health problems related to inactivity than people without disabilities. Meta-analyses have shown that physical activity has beneficial effects on cardiovascular fitness (average standardised mean difference [SMD] 0·69 [95% CI 0·31-1·01]), musculoskeletal fitness (0·59 [0·31-0·87]), cardiometabolic risk factors (0·39 [0·04-0·75]), and brain and mental health outcomes (0·47 [0·21-0·73]). These meta-analyses also show that health benefits can be achieved even with less than 150 min of physical activity per week, and suggest that some physical activity is better than none. Meta-analyses of interventions to increase physical activity for PLWD have reported effect sizes ranging from SMD 0·29 (95% CI 0·17-0·41, k=10) to 1·00 (0·46-1·53, k=10). There is increasing awareness among policy makers of the needs of PLWD for full participation in physical activity. Physical activity action plans worldwide must be adequately resourced, monitored, and enforced to truly advance the fundamental rights of PLWD to fully participate in physical activity.

Cardiorespiratory Responses to 10 Weeks of Exoskeleton-Assisted Overground Walking Training in Chronic Nonambulatory Patients with Spinal Cord Injury

Exercise intensity of exoskeleton-assisted walking in patients with spinal cord injury (SCI) has been reported as moderate. However, the cardiorespiratory responses to long-term exoskeleton-assisted walking have not been sufficiently investigated. We investigated the cardiorespiratory responses to 10 weeks of exoskeleton-assisted walking training in patients with SCI. Chronic nonambulatory patients with SCI were recruited from an outpatient clinic. Walking training with an exoskeleton was conducted three times per week for 10 weeks. Oxygen consumption and heart rate (HR) were measured during a 6-min walking test at pre-, mid-, and post-training. Exercise intensity was determined according to the metabolic equivalent of tasks (METs) for SCI and HR relative to the HR reserve (%HRR). Walking efficiency was calculated as oxygen consumption divided by walking speed. The exercise intensity according to the METs (both peak and average) corresponded to moderate physical activity and did not change after training. The %HRR demonstrated a moderate (peak %HRR) and light (average %HRR) exercise intensity level, and the average %HRR significantly decreased at post-training compared with mid-training (31.6 ± 8.9% to 24.3 ± 7.3%, p = 0.013). Walking efficiency progressively improved after training. Walking with an exoskeleton for 10 weeks may affect the cardiorespiratory system in chronic patients with SCI.

Physical activity and sedentary behavior in people with spinal cord injury: Mitigation strategies during COVID-19 on behalf of ACSM-EIM and HL-PIVOT

People with spinal cord injury (SCI) face unique challenges during the COVID-19 pandemic, including greater risk of poor COVID-19-related outcomes, increased social isolation, and restricted access to important services. Furthermore, COVID-19 related restrictions have decreased already low levels of physical activity (PA) in this population. Therefore, the purpose of this commentary is to: 1) address the impact of COVID-19 on PA and sedentary behavior (SB) in people with SCI; 2) provide potential SB reduction strategies to guide future research; and 3) provide recommendations to increase PA and reduce SB on behalf of the American College of Sports Medicine Exercise is Medicine (ACSM-EIM) and Healthy Living for Pandemic Event Protection (HL-PIVOT) using a social-ecological model targeting the individual-, social environment-, physical environment-, and policy-level determinants of behavior in people with SCI.

The effectiveness of vigorous training on cardiorespiratory fitness in persons with spinal cord injury: a systematic review and meta-analysis

DESIGN

Systematic review and meta-analysis.

BACKGROUND AND PURPOSE

Traditional forms of upper-body moderate intensity exercise consistently provide little cardiovascular benefits for persons with spinal cord injury (PwSCI). Explorations of new training methods are vital to improve cardiovascular fitness among PwSCI. This study sought to evaluate the effectiveness of vigorous training on cardiorespiratory fitness in PwSCI.

METHODS

Database search through PubMed, Web of Science, Scopus, SportDiscus, and Cumulative Index of Nursing and Allied Health Literature (CINAHL) was conducted from the databases' inception to November 2020 to identify relevant exercise studies with PwSCI. Two independent reviewers screened articles for inclusion. Data were extracted from included studies and methodological quality evaluated.

RESULTS

Sixteen trials (eight pre-post trials and eight controlled trials [CTs]) with a total of 145 participants were analyzed. Results from pre-post studies revealed significant improvements in cardiorespiratory fitness following high-intensity interval training (HIIT) (Peak Oxygen Uptake [VO_2peak], standardized mean difference [SMD] = 0.81; 95% CI 0.23-1.39; P < 0.01 and Peak Power Output [PPO], SMD = 0.91; 95% CI 0.32-1.5; P < 0.01) and circuit resistance training (CRT) (VO_2peak, MD = 0.38; 95% CI 0.19-0.57; P < 0.01 and PPO, MD = 20.17; 95% CI 8.26-32.08; P < 0.01). Meta-analysis of CTs did not demonstrate significant improvements in cardiorespiratory fitness following vigorous training interventions in comparison to lower intensity training interventions.

CONCLUSION

Evidence from HIIT and CRT interventions suggest benefits for cardiovascular functions; however, vigorous training was not more beneficial than other forms of endurance training. More CTs are needed to better understand the effectiveness of vigorous training on cardiorespiratory fitness in PwSCI.

Predicting Cardiometabolic Risk From Visceral Abdominal Adiposity in Persons With Chronic Spinal Cord Injury

Persons with spinal cord injury (SCI) have increased adiposity that may predispose to cardiovascular disease compared to those who are able-bodied (AB). The purpose of this study was to determine the relationships between dual energy X-ray absorptiometry (DXA)-derived visceral adipose tissue (VAT) and biomarkers of lipid metabolism and insulin resistance in persons with chronic SCI. A prospective observational study in participants with chronic SCI and age- and gender-matched AB controls. The study was conducted at a Department of Veterans Affairs Medical Center and Private Rehabilitation Hospital. The quantification of DXA-derived VAT volume (VAT_vol) and blood-derived markers of lipid and carbohydrate metabolism were determined in 100 SCI and 51 AB men. The VAT_vol was acquired from a total body DXA scan and analyzed using iDXA enCore CoreScan software (GE Lunar). Blood samples were collected for the serum lipid profile and plasma and glucose concentrations, with the latter two values used to calculate a measure of insulin resistance. In the SCI and AB groups, VAT% was significantly correlated with most cardiometabolic biomarkers. The results of the binary logistic regression analysis revealed that participants who had a VAT_vol above the cutoff value of 1630 cm³ were 3.1-, 4.8-, 5.6-, 19.2-, and 16.7-times more likely to have high serum triglycerides (R²_N= 0.09, p = 0.014), low serum high density lipoprotein cholesterol (R²_N = 0.16, p < 0.001), HOMA2-IR (R²_N = 0.18, p < 0.001), metabolic syndrome (R²_N = 0.25, p < 0.001), and a 10-yr Framingham Risk Score ≥ 10% (R²_N = 0.16, p = 0.001), respectively, when compared to participants below this VAT_vol cutoff value. Our findings reveal that persons with chronic SCI have a higher VAT_vol than that of AB controls, and VAT_vol correlates directly with biomarkers of lipid and carbohydrate metabolism that are strong predictors of cardiometabolic disorders.

Functional electrical stimulation cycling exercise after spinal cord injury: a systematic review of health and fitness-related outcomes

OBJECTIVES

The objective of this review was to summarize and appraise evidence on functional electrical stimulation (FES) cycling exercise after spinal cord injury (SCI), in order to inform the development of evidence-based clinical practice guidelines.

METHODS

PubMed, the Cochrane Central Register of Controlled Trials, EMBASE, SPORTDiscus, and CINAHL were searched up to April 2021 to identify FES cycling exercise intervention studies including adults with SCI. In order to capture the widest array of evidence available, any outcome measure employed in such studies was considered eligible. Two independent reviewers conducted study eligibility screening, data extraction, and quality appraisal using Cochranes' Risk of Bias or Downs and Black tools. Each study was designated as a Level 1, 2, 3 or 4 study, dependent on study design and quality appraisal scores. The certainty of the evidence for each outcome was assessed using GRADE ratings ('High', 'Moderate', 'Low', or 'Very low').

RESULTS

Ninety-two studies met the eligibility criteria, comprising 999 adults with SCI representing all age, sex, time since injury, lesion level and lesion completeness strata. For muscle health (e.g., muscle mass, fiber type composition), significant improvements were found in 3 out of 4 Level 1-2 studies, and 27 out of 32 Level 3-4 studies (GRADE rating: 'High'). Although lacking Level 1-2 studies, significant improvements were also found in nearly all of 35 Level 3-4 studies on power output and aerobic fitness (e.g., peak power and oxygen uptake during an FES cycling test) (GRADE ratings: 'Low').

CONCLUSION

Current evidence indicates that FES cycling exercise improves lower-body muscle health of adults with SCI, and may increase power output and aerobic fitness. The evidence summarized and appraised in this review can inform the development of the first international, evidence-based clinical practice guidelines for the use of FES cycling exercise in clinical and community settings of adults with SCI. Registration review protocol: CRD42018108940 (PROSPERO).

The effects of a high-fat/high-carbohydrate meal on leukocyte populations in adults with chronic spinal cord injury

STUDY DESIGN

Secondary analysis of aggregated case series data.

OBJECTIVES

To examine the effects of a high-fat/high-carbohydrate meal on leukocyte populations in adults with a chronic SCI.

SETTING

University-based laboratories in British Columbia, Canada.

METHODS

Ten individuals (M = 9) with a traumatic SCI (>1-year post-injury; M = 15.5 years; n = 2 sensory complete, n = 7 motor complete) participated in this study. Participants arrived fasted (≥12 h) prior to both the control (quiet sitting, no food/drink) and experimental meal conditions (high-fat/high-carb meal: 880 kcal, 52 g fat, 73 g carbohydrates, 29 g protein). Blood samples were taken in the fasted state and at 120-min post-meal/baseline in both conditions. Immune cell counts were assessed using multi-color flow cytometry.

RESULTS

A significant time × condition interaction effect was seen in CD3+, CD4+, and CD8+ T cells as well as CD56+ and CD3+/CD56+ natural killer (NK) cells (p < 0.05). CD14+/CD16+ monocytes and CD19+ B cells approached a significant time × condition interaction (p < 0.07). A main effect of time was observed in CD19+ B cells (p < 0.05). Cell counts for T-lymphocytes and NK cells followed the general trend of an increase in the control condition from baseline to 120-min with no change observed following the experimental meal condition.

CONCLUSIONS

Following the HFHC meal, immune cells did not show the same general increase observed following the control condition. Future research is needed to determine if there are any potential consequences of these immune cell responses in immunosuppressed populations and if other factors (e.g., diurnal variation) might influence immune cell response.

Development of priorities for a Canadian strategy to advance activity-based therapies after spinal cord injury

Study Design

Participatory design.

Objectives

Activity-based therapies (ABT) have physical and psychosocial benefits for individuals with spinal cord injury (SCI). A Canadian ABT summit was held to: (1) identify methods used in stroke rehabilitation that may be appropriate for SCI; (2) understand the current state of ABT activities in Canada; and (3) identify priorities for ABT research and care for the next five years.

Setting

Stakeholder-engaged meeting at a tertiary rehabilitation hospital.

Methods

Thirty-nine stakeholders, including individuals with SCI, frontline clinicians, healthcare administrators, researchers, funders and health policy experts, attended. Two participants were note-takers. Priority identification occurred through input from stakeholder groups, followed by individual voting. Conventional content analysis was used to synthesize the information in the meeting notes.

Results

The strengths of ABT in stroke rehabilitation included clear and clinically feasible definitions, measurements and interventions, and recognized requirements for implementation (e.g. behavior change, partnerships). Knowledge gaps concerning ABT activities in Canada were identified for acute and community settings, non-traumatic populations, and the interventions, equipment and standardized measures (i.e. upper limb, activity levels) used. Five priorities for ABT across the continuum of care were identified: (1) Identify current ABT activities; (2) Create a network to facilitate dialog; (3) Track engagement in ABT activities; (4) Develop and implement best practice recommendations; and (5) Study optimal timing, methods, and dose of ABT. Working groups were formed to address priorities 1–3.

Conclusions

The priorities will guide SCI research and care activities in Canada over the next five years.

Sponsorship

Praxis Spinal Cord Institute.

Aerobic fitness is a potential crucial factor in protecting paralympic athletes with locomotor impairments from atherosclerotic cardiovascular risk

Purpose

To test the hypothesis that aerobic fitness is inversely related to the risk of atherosclerotic cardiovascular disease (ACVD) in athletes with locomotor impairments deriving from health conditions, such as spinal cord injury (SCI), lower limb amputation, cerebral palsy, poliomyelitis, and other health conditions different from the previous ones.

Methods

A total of 68 male athletes who competed in either summer or winter Paralympic games were divided in two health conditions groups (35 with SCI, mean age 37.2 ± 8.0 years, and 33 with different health conditions, mean age 37.8 ± 9.9 years) and in four sport type groups (skill, power, intermittent—mixed metabolism—and endurance). They were evaluated through anthropometric and blood pressure measurements, laboratory blood tests, and graded cardiopulmonary maximal arm cranking exercise test, with oxygen uptake peak (VO2peak) measurement. Cardiovascular risk profile was assessed in each athlete.

Results

The prevalence of ACVD-risk factors in the overall population was 20.6% for hypertension; 47% and 55.9% for high values of total and LDL cholesterol, respectively; 22.1% for reduce glucose tolerance; and 8.8% for obesity. No difference was found between athletes with and without SCI, while the prevalence of obesity was significantly higher in those practicing skill sports (22.7%, p = 0.035), which was the sport type group with Paralympic athletes with the lowest VO2peak (22.5 ± 5.70 ml kg−1 min−1). VO2peak was lower in athletes with SCI than those with different health conditions (28.6 ± 10.0 vs 33.6 ± 8.9 ml kg−1 min−1p = 0.03), and in those with 3–4 risk factors (19.09 ± 5.34 ml kg−1 min−1) than those with 2 risk factors (27.1 ± 5.50 ml kg−1 min−1), 1 risk factor (31.6 ± 8.55 ml kg−1 min−1), or none (36.4 ± 8.76 ml kg−1 min−1) (p < 0.001).

Conclusions

The present study suggests that having higher VO2peak seems to offer greater protection against ACVD in individuals with a locomotor impairment. Prescribing physical exercise at an intensity similar to that of endurance and intermittent sports should become a fundamental tool to promote health among people with a locomotor impairment.

Mechanisms of exercise as a preventative measure to muscle wasting

Skeletal muscle is the most abundant tissue in healthy individuals and it has important roles in health beyond voluntary movement. The overall mass and energy requirements of skeletal muscle require it to be metabolically active and flexible to multiple energy substrates. The tissue has evolved to be largely load dependent and it readily adapts in a number of positive ways to repetitive overload, such as various forms of exercise training. However, unloading from extended bed rest and/or metabolic derangements in response to trauma, acute illness, or severe pathology, commonly results in rapid muscle wasting. Decline in muscle mass contributes to multimorbidity, reduces function, and exerts a substantial, negative impact on the quality of life. The principal mechanisms controlling muscle mass have been well described and these cellular processes are intricately regulated by exercise. Accordingly, exercise has shown great promise and efficacy in preventing or slowing muscle wasting through changes in molecular physiology, organelle function, cell signaling pathways, and epigenetic regulation. In this review, we focus on the role of exercise in altering the molecular landscape of skeletal muscle in a manner that improves or maintains its health and function in the presence of unloading or disease.epigenetics; exercise; muscle wasting; resistance training; skeletal muscle.

Exercise-Induced Plasticity in Signaling Pathways Involved in Motor Recovery after Spinal Cord Injury

Spinal cord injury (SCI) leads to numerous chronic and debilitating functional deficits that greatly affect quality of life. While many pharmacological interventions have been explored, the current unsurpassed therapy for most SCI sequalae is exercise. Exercise has an expansive influence on peripheral health and function, and by activating the relevant neural pathways, exercise also ameliorates numerous disorders of the central nervous system (CNS). While the exact mechanisms by which this occurs are still being delineated, major strides have been made in the past decade to understand the molecular underpinnings of this essential treatment. Exercise rapidly and prominently affects dendritic sprouting, synaptic connections, neurotransmitter production and regulation, and ionic homeostasis, with recent literature implicating an exercise-induced increase in neurotrophins as the cornerstone that binds many of these effects together. The field encompasses vast complexity, and as the data accumulate, disentangling these molecular pathways and how they interact will facilitate the optimization of intervention strategies and improve quality of life for individuals affected by SCI. This review describes the known molecular effects of exercise and how they alter the CNS to pacify the injury environment, increase neuronal survival and regeneration, restore normal neural excitability, create new functional circuits, and ultimately improve motor function following SCI.

A Single Bout of Upper-Body Exercise Has No Effect on Postprandial Metabolism in Persons with Chronic Paraplegia

PURPOSE

The acute effects of a single bout of upper-body exercise on postprandial metabolism in persons with spinal cord injury are currently not well understood. The primary aim of this study was to evaluate the effects of a single bout of upper-body high-intensity interval exercise (HIIE) and moderate-intensity continuous exercise (MICE) in comparison with a no-exercise control (REST) condition on postprandial metabolic responses in persons with chronic paraplegia.

METHODS

Ten participants (eight males, two females; age, 49 ± 10 yr; time since injury, 22 ± 13 yr) with chronic paraplegia took part in a randomized crossover study, consisting of three trials: HIIE (8 × 60 s at 70% peak power output [PPEAK]), MICE (25 min at 45% PPEAK), and REST, at least 3 d apart. Exercise was performed in the fasted state, and participants consumed a mixed-macronutrient liquid meal 1-h postexercise. Venous blood and expired gas samples were collected at regular intervals for 6-h postmeal consumption.

RESULTS

There were no significant differences in postprandial incremental area under the curve for triglycerides (P = 0.59) or glucose (P = 0.56) between conditions. Insulin incremental area under the curve tended to be lower after MICE (135 ± 85 nmol·L-1 per 360 min) compared with REST (162 ± 93 nmol·L-1 per 360 min), but this did not reach statistical significance (P = 0.06, d = 0.30). Participants reported a greater fondness (P = 0.04) and preference for HIIE over MICE.

CONCLUSIONS

After an overnight fast, a single bout of upper-body exercise before eating has no effect on postprandial metabolism in persons with chronic paraplegia, irrespective of exercise intensity. This suggests that alternative exercise strategies may be required to stimulate postprandial substrate oxidation for this population.

Meeting Proceedings for SCI 2020: Launching a Decade of Disruption in Spinal Cord Injury Research

The spinal cord injury (SCI) research community has experienced great advances in discovery research, technology development, and promising clinical interventions in the past decade. To build upon these advances and maximize the benefit to persons with SCI, the National Institutes of Health (NIH) hosted a conference February 12-13, 2019 titled "SCI 2020: Launching a Decade of Disruption in Spinal Cord Injury Research." The purpose of the conference was to bring together a broad range of stakeholders, including researchers, clinicians and healthcare professionals, persons with SCI, industry partners, regulators, and funding agency representatives to break down existing communication silos. Invited speakers were asked to summarize the state of the science, assess areas of technological and community readiness, and build collaborations that could change the trajectory of research and clinical options for people with SCI. In this report, we summarize the state of the science in each of five key domains and identify the gaps in the scientific literature that need to be addressed to move the field forward.

Narrative Review of Clinical Practice Guidelines for Rehabilitation of People With Spinal Cord Injury: 2010-2020

ABSTRACT

Clinical practice guidelines provide reliable, vetted, and critical information to bring research to practice. Some medical specialties (e.g., physical medicine and rehabilitation) provide multidomain treatment for various conditions. This presents challenges because physical medicine and rehabilitation is a small specialty, a diverse patient base in terms sociodemographics and diagnosis, treatments are difficult to standardize, and rehabilitation research is underfunded. We wished to identify quality and applicability of clinical practice guidelines and searched "Spinal Cord Injury AND Clinical Practice Guidelines AND Rehabilitation" and vetting process.Three hundred fifty-nine articles were identified of which 58 met all criteria for full-text review of which 13 were included in the final selection. Additional publications were accessed from a nondatabase search. Five articles addressed postacute care, community treatment. Nine articles had no recorded vetting process but addressed rehabilitation as an outcome and were included separately. Many of the clinical practice guidelines were developed without evidence from randomized controlled trials, one had input from stakeholders, and some are out of date and do not address important aspects of changes in demographics of the affected population and the use of newer technologies such as sensors and robotics and devices. Identification of these gaps may help stimulate treatment that is clinically relevant, accessible, and current.

Role of exercise on visceral adiposity after spinal cord injury: a cardiometabolic risk factor

PURPOSE

Visceral adipose tissue (VAT) is associated with cardiometabolic disease risk in able-bodied (AB) populations. However, the underlying mechanisms of VAT-induced disease risk are unknown in persons with spinal cord injury (SCI). Potential mechanisms of VAT-induced cardiometabolic dysfunction in persons with SCI include systemic inflammation, liver adiposity, mitochondrial dysfunction, and anabolic deficiency. Moreover, how exercise interventions impact these mechanisms associated with VAT-induced cardiometabolic dysfunction are still being explored.

METHODS

A search for relevant scientific literature about the effects of exercise on VAT and cardiometabolic health was conducted on the PubMed database. Literature from reference lists was also included when appropriate.

RESULTS

Both aerobic and resistance exercise training beneficially impact health and VAT mass via improving mitochondrial function, glucose effectiveness, and inflammatory signaling in SCI and AB populations. Specifically, aerobic exercise appears to also modulate cellular senescence in AB populations and animal models, while resistance exercise seems to augment anabolic signaling in persons with SCI.

CONCLUSIONS

The current evidence supports regular engagement in exercise to reduce VAT mass and the adverse effects on cardiometabolic health in persons with SCI. Future research is needed to further elucidate the precise mechanisms by which VAT negatively impacts health following SCI. This will likely facilitate the development of rehabilitation protocols that target VAT reduction in persons with SCI.

Physical activity recall assessment for people with spinal cord injury: Thai translation and cross-cultural adaptation

PURPOSE

This research sought to translate and culturally adapt the content of the original Physical Activity Recall Assessment for People with Spinal Cord Injury (PARA-SCI) into the Thai language and to assess its inter- and intra-rater reliability.

METHODS

This study was divided into two parts; (i) translation and cross-cultural adaptation, using a six-step guideline-based translation-validation process and (ii) reliability assessment of the translated survey tool using intraclass correlation coefficients (ICCs), Bland-Altman plots and one-way ANOVA analyses.

RESULTS

The Thai-PARA-SCI was successfully developed. The results revealed an excellent inter-rater reliability (ICC = 0.99, 95% CI range from 0.959-0.999) and the Bland-Altman plots showed little difference in times spent engaged physical activity. Intra-rater reliability results were affected inadvertently by testing across an unusual period, demonstrating poor to moderate scores (ICC ranged from 0.05-0.69, 95% CI ranged from -0.067-0.830) with the Bland-Altman plots showing very different ranges of time spent on physical activity.

CONCLUSION

This study achieved its aims of culturally and systematically translating the English PARA-SCI interview script into the Thai version with excellent scores for inter-rater reliability and was proven to be understandable by prospective users (Thai-PT) and participants (Thai-SCI).Implications for RehabilitationA robust cross-cultural translation and adaptation of the Physical Activity Recall Assessment for people with Spinal Cord Injury (PARA-SCI) into the Thai context has been undertaken, providing an effective exemplar for converting patient reported health outcome measures between languages of different root origins.When using the PARA-SCI as a pre- and post-intervention outcomes survey, clinicians should ensure that the timing of interview administration does not coincide with any unintended alterations in work-life balance, to ensure that the data are representative of the habitual physical activity levels performed by participants in their daily lives.Due to the possibility that physical activity levels could vary day-by-day or week-to-week, using the same day measurement findings may be a more reliable way to deploy the PARA-SCI than repeated assessments week(s) apart.

Exploring exercise participation and the usability of the adaptive rower and arm crank ergometer through wheelchair users' perspectives

PURPOSE

Arm crank ergometry and adaptive rowing are existing exercise options for wheelchairs users, but not commonly available. This study was conducted to explore exercise participation of wheelchair users, as well as the usability of the adaptive rowing ergometer (aROW) and arm crank ergometer (ACE).

METHODS

This mixed-methods study used a concurrent triangulation design. Following completion of both exercise sessions (5 min each), participants (n = 14) with spinal cord injury/disease (SCI/D) completed the System Usability Scale (SUS), and a semi-structured interview. Participants were asked about the use of both exercise modalities, and general exercise participation. SUS data were analyzed using a paired sample t-test and qualitative data were analyzed through conventional content analysis.

RESULTS

Wheelchair users exercised for improved physical and mental health, as well as for functional independence, and community participation; however, lack of accessible equipment was a prominent barrier. Both the aROW and ACE have high usability, but the aROW was perceived as more enjoyable and effective for cardiovascular exercise.

CONCLUSIONS

The implementation of the aROW into community gyms has the potential to help close the existing gap in inclusive equipment and may help people with disabilities to be more fully included in their community and lead healthier lives.Implications for rehabilitationWheelchair users perceive exercise as a meaningful activity that enhances physical health and risk of disease, functional independence, community participation, and overall social and emotional health.The adapted rowing machine was perceived as highly usable and was felt to be more enjoyable and effective for cardiovascular exercise compared to traditional arm crank ergometers.The adaptive rower provides an additional accessible equipment option for wheelchair users to obtain effective cardiovascular exercise.More available equipment may increase community participation and promote inclusion for wheelchair users.

Rethinking the clinical management of volumetric muscle loss in patients with spinal cord injury: Synergy among nutritional supplementation, pharmacotherapy, and rehabilitation

Spinal cord injury (SCI) is a condition defining the damage of the spinal cord that leads to musculoskeletal sequelae, including volumetric muscle loss (VML) in a significant proportion of patients. VML occurring after SCI is responsible for delayed recovery, with detrimental consequences in terms of functional outcomes and additional alterations of the muscle tissue. The treatment of muscle alterations in these patients usually relies on nutritional supplementation. However, rehabilitation therapy has a well-recognized role in improving muscle mass and function, even in subjects affected by SCI. Furthermore, novel medical therapies have been recently investigated, with positive results. In this scoping review, we portray the state-of-the-art treatment of muscle modifications after SCI, focusing on the multidisciplinary and multidimensional management of these patients.

Different Relationships Between Steps and Movements and Healthy Biomarkers in People With and Without Disability

BACKGROUND

Physical activity benefits have been extensively studied. However, the public health guidelines seem unclear about the relationships between steps and movements with healthy biomarkers for people with (PWD) and without disabilities (PWOD), respectively. While public health guidelines illustrate types of exercise (eg, running, swimming), it is equally important to provide data-driven recommended amounts of daily steps or movements to achieve health biomarkers and further promote a physically active lifestyle.

METHODS

Data from the National Health and Nutrition Examination Survey 2003-2006 were used. The authors conducted sensitivity, specificity, and receiver-operating-characteristic curve analyses regarding cut points from ActiGraph 7164 of daily steps and movements for health biomarkers (eg, body mass index, cholesterol) in PWD (2178 participants) and PWOD (4414 participants). The authors also examined the dose relationships of steps, movements, and healthy biomarkers in each group.

RESULTS

The authors found significant differences in the cut points of daily steps and movement for health biomarkers in PWD and PWOD. For daily steps, cut points of PWD were ranged from 3222 to 8311 (area under the receiver-operating-characteristic curve [AUC] range = 0.52-0.93) significantly lower than PWOD's daily steps (range = 5455-14,272; AUC = 0.58-0.87). For daily movement, cut points of PWD were ranged from 115,451 to 430,324 (AUC = 0.53-0.91) significantly lower than the PWOD's daily movements (range = 215,288-282,307; AUC = 0.60-0.88). The authors found strong but different dose relationships of many biomarkers in each group.

CONCLUSIONS

PWD need fewer daily steps or movement counts to achieve health biomarkers than PWOD. The authors provided data-driven, condition-specific recommendations on promoting a physically active lifestyle.

A Primary Care Provider's Guide to Shoulder Pain After Spinal Cord Injury

Shoulder pain is a common occurrence after spinal cord injury (SCI) and can have significant negative effects on health and function as many individuals with SCI are reliant on their upper extremities for mobility and self-care activities. Shoulder pain after SCI can be caused by acute injury or chronic pathology, but it is most often related to overuse injuries of the rotator cuff. Both acute strain and chronic overuse shoulder injuries in persons with SCI typically result from increased weight bearing on the upper extremities during transfers, weight-relief raises, and wheelchair propulsion, which are often performed in poor postural alignment owing to strength deficits. This article discusses management of patients with SCI who present with shoulder pain from the perspective of primary care physicians including evaluation and diagnostic procedures, interventions appropriate for both acute and chronic shoulder pain, and strategies for prevention.

Substrate metabolism during recovery from circuit resistance exercise in persons with spinal cord injury

INTRODUCTION

Whole body energy expenditure and lipid oxidation (Lox) are upregulated during and after exercise. Persons with spinal cord injury (SCI) generally have a blunted ability to utilize fat during exercise, but it is unknown if their substrate partitioning is affected during recovery from exercise.

PURPOSE

To determine the effect of a single session of upper body circuit resistance exercise (CRE) on energy expenditure and Lox during exercise recovery in persons with and without SCI.

METHODS

Twenty four persons (3 groups; 7 male and 1 female per group) without paralysis (neurologically intact; N) or with chronic (≥ 1 yr) paraplegia (P) or tetraplegia (T) participated. Energy expenditure and substrate partitioning were assessed via indirect calorimetry before, during, and three times after (up to 120 min after) a single session of CRE, or time-matched seated control (CON).

RESULTS

During CRE, all groups experienced a similar relative increase in oxygen consumption (49 ± 13, 55 ± 11, and 48 ± 15% VO_2peak for N, P, and T, respectively). The Post_0-120 energy expenditure was greater following CRE vs. CON (P < 0.01) and independent of injury characteristics (10.6, 22.6, and 14.3% higher than CON for N, P, and T; P = 0.21). The absolute increase in Lox above CON during recovery was similar for N, P, and T (5.74 ± 2.81, 6.62 ± 3.10, and 4.50 ± 3.91 g, respectively; P = 0.45).

CONCLUSIONS

Energy expenditure and lipid utilization was increased similarly following circuit exercise in persons without and with spinal cord injury in a manner independent of level of injury.

Effects of robotic-assisted gait training on the central vascular health of individuals with spinal cord injury: A pilot study

Objective: To investigate the effect of a short-term, robotic-assisted (exoskeleton) gait training (RGT) program on central and peripheral hemodynamic measures in patients with spinal cord injury (SCI).Design: Parallel group, non-randomized trial with before (baseline) and after (follow-up) assessments.Setting: Single-center, community-based neuro-physiotherapy practice.Participants: Twelve individuals with SCI (ASI A to C).Interventions: Participants completed either a 5-day RGT program plus physiotherapy (n = 6), or a usual care physiotherapy only program (control group; n = 6). The RGT program consisted of daily 60-min physiotherapy and 90-min of RGT. Outcome measures were measured before and after the rehabilitation program.Main outcome measure(s): The primary outcome measure was arterial wave reflection (Augmentation index [AIx]), with central and peripheral blood pressures also reported. Data are presented as mean (SD) and effect sizes (partial eta squared; η2p).Results: There was a significant reduction in AIx (30 ± 18-21 ± 15%; η2p=0.75) and mean arterial pressure (89 ± 11-82 ± 10 mmHg; η2p=0.47) following completion of the RGT program (both P < 0.05). There were no changes in these measures for the control group. Although not significantly different, medium to large effects were observed in favor of RGT for all other central and peripheral measures (η2p=0.06-0.21), except for heart rate and pulse pressure (η2p<0.04).Conclusions: RGT using an exoskeleton is a promising therapy for improving cardiovascular health in patients with SCI. Specifically, this study indicates decreased arterial wave reflection and supports the need for larger randomized controlled trials.Trial Registration: Clinical trials Registry (https://clinicaltrials.gov/; NCT03611803).

Effect of high-intensity interval training on cardiometabolic component risks in persons with paraplegia: Protocol for a randomized controlled trial

Individuals with a spinal cord injury (SCI) are at an increased risk of developing cardiovascular disease and present with a multitude of elevated cardiometabolic component risks. Although upper-body exercise appears an effective strategy to improve some of these outcomes, the effectiveness of high-intensity interval training (HIIT) has yet to be determined for this population. Therefore, a randomized controlled trial will be conducted to determine the effectiveness of a 6 week home-based upper-body HIIT intervention on biomarkers of cardiometabolic health in persons with spinal cord injury, in comparison to a control (CON) group. We will recruit 40 individuals with chronic (>1 year post-injury) paraplegia (spinal cord lesion between the second thoracic and second lumbar vertebrae), aged between 18 and 65 years. After baseline testing, participants will be assigned randomly, using a 2:1 allocation, to the home-based exercise intervention (HIIT, n = 26) or control group (CON, n = 14). The HIIT intervention will consist of 30 min of arm crank-based HIIT (60 s intervals at 80-90% peak heart rate) four times per week. Participants in the CON group will be asked to maintain their habitual diet and physical activity patterns over the study period. Baseline and follow-up assessments will be made for determination of body composition, postprandial glycaemic control, fasting blood lipids and systemic inflammation, aerobic capacity, physical activity and energy intake, resting metabolic rate, resting blood pressure, and subjective measures of health and well-being. ClinicalTrials.gov, ID: NCT04397250. Registered on 21 May 2020.

Intensity of usual care physical therapy during inpatient rehabilitation for people with neurologic diagnoses

BACKGROUND

Early, intense rehabilitation is essential to promote recovery after stroke, spinal cord injury (SCI), and traumatic brain injury (TBI). However, intensity of usual care rehabilitation interventions during inpatient rehabilitation are poorly characterized.

OBJECTIVE

To describe the intensity of usual care rehabilitation interventions completed during the subacute phase of recovery from neurologic injury.

DESIGN

Observational.

SETTING

Inpatient rehabilitation facility.

INTERVENTIONS

Twenty-two usual care physical therapy interventions were grouped into six categories: gait (four activities), functional (two), strengthening (four), aerobic (six), balance (four), and wheelchair (two).

PATIENTS

Patients admitted to inpatient rehabilitation with a primary diagnosis of stroke, SCI or TBI within 6 months of injury.

MAIN OUTCOME MEASURE(S)

Cardiovascular intensity (physiological and perceived) was recorded during rehabilitation activity sessions. Physiological intensity was assessed by heart rate reserve (HRR) via a Polar A370 Fitness Watch and characterized as very light (<30%), light (30-39%), moderate (40-59%), vigorous (60-89%), and near maximal (≥90%). Perceived intensity was assessed using the Rating of Perceived Exertion scale.

RESULTS

Patients (stroke n = 16 [number of activity sessions = 388/average session duration = 15.1 min]; SCI n = 15 [299/27.3 min]; TBI n = 15 [340/13.4 min]) participated. For patients with stroke, moderate-to-vigorous HRR was attained between 42% (aerobic exercise) to 55% (wheelchair propulsion) of activity sessions. For patients with SCI, moderate-to-vigorous HRR was attained between 29% (strength training) to 46% (gait training) of activity sessions. For patients with TBI, moderate-to-vigorous HRR was attained between 29% (balance activities) to 47% (gait training) of activity sessions. Associations between HRR and rate of perceived exertion were very weak across stroke (r = 0.12), SCI (r = 0.18), and TBI (r = 0.27).

CONCLUSIONS

Patients with stroke, SCI, and TBI undergoing inpatient rehabilitation achieve moderate-to-vigorous intensity during some usual care activities such as gait training. Patient perception of intensity was dissimilar to physiological response.

Clinical Benefits and System Design of FES-Rowing Exercise for Rehabilitation of Individuals with Spinal Cord Injury: A Systematic Review

OBJECTIVE

To comprehensively and critically appraise the clinical benefits and engineering designs of functional electrical stimulation (FES)-rowing for management of individuals with spinal cord injury (SCI).

DATA SOURCES

Electronic database searches were conducted in Cumulative Index to Nursing & Allied Health Literature, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Excerpta Medica database, Emcare, Medline, PubMed, Scopus, and Web of Science databases from inception to May 12, 2020.

STUDY SELECTION

Search terms used were synonyms of "spinal cord injury" for Population and "Electric Stimulation (Therapy)/ and rowing" for Intervention. Two reviewers independently assessed articles based on the following inclusion criteria: recruited individuals with SCI; had aerobic FES-rowing exercise as study intervention; reported cardiovascular, muscular, bone mineral density, or metabolic outcomes; and examined engineering design of FES-rowing systems. Of the 256 titles that were retrieved in the primary search, 24 were included in this study.

DATA EXTRACTION

Study characteristics, quality, participants' characteristics, test descriptions, and results were independently extracted by 2 reviewers. The quality of studies was assessed with the Downs and Black checklist.

DATA SYNTHESIS

Comparison of peak oxygen consumption (V̇_o2peak) rates showed that V̇_o2peak during FES-rowing was significantly higher than arm-only exercise; FES-rowing training improved V̇_o2peak by 11.2% on average (95% confidence interval, 7.25-15.1), with a 4.1% (95% confidence interval, 2.23-5.97) increase in V̇_o2peak per month of training. FES-rowing training reduced bone density loss with increased time postinjury. The rowing ergometer used in 2 studies provided motor assistance during rowing. Studies preferred manual stimulation control (n=20) over automatic (n=4).

CONCLUSIONS

Our results suggest FES-rowing is a viable exercise for individuals with SCI that can improve cardiovascular performance and reduce bone density loss. Further randomized controlled trials are needed to better understand the optimal set-up for FES-rowing that maximizes the rehabilitation outcomes.

Assessing the quality of seven clinical practice guidelines from four professional regulatory bodies in Quebec: What's the verdict?

RATIONALE, AIMS, AND OBJECTIVES

Clinical practice guidelines (CPGs) have become a common feature in the health and social care fields, as they promote evidence-based practice and aim to improve quality of care and patient outcome. However, the benefits of the recommendations reported in CPGs are only as good as the quality of the CPGs themselves. Indeed, rigorous development and strategies for reporting are significant precursors to successful implementation of the recommendations that are proposed. Unfortunately, research has demonstrated that there is much variability in their level of quality. Furthermore, the quality of many CPGs has yet to be examined. The aim of the present study was to assess the quality of seven CPGs from four Quebec professional regulatory bodies pertaining to clinical evaluations in the fields of medicine, psychoeducation, psychotherapy, and social work.

METHODS

The seven Quebec CPGs were assessed by four trained appraisers using the Appraisal of Guidelines for Research and Evaluation II guideline evaluation tool.

RESULTS

Results suggest that while some quality criteria were met, most were not, denoting that these CPGs are of sub-optimal quality.

CONCLUSION

Our findings highlight that there is still a lot to be done in order to improve the rigour and transparency with which scientific evidence is assessed and applied when developing CPGs. Impacts regarding the implementation of these CPGs are discussed in light of their use in clinical practice.

Recommended Musculoskeletal and Sports Medicine Curriculum for Internal Medicine Residency Training

ABSTRACT

Patients present to primary care physicians with musculoskeletal complaints more often than they do for upper respiratory infections, hypertension, or diabetes. Despite this, instruction in musculoskeletal medicine for internal medicine residents represents less than 1% of their total didactic and clinical education time. We recognize the immense breadth of knowledge and skill required to train residents in the practice of internal medicine. This curriculum guideline defines a recommended training strategy, and supplies relevant resources, to improve musculoskeletal education among internal medicine residents to optimize patient care. This curriculum guideline was created by internists who are sports medicine specialists. Sports medicine physicians promote overall health and well-being while providing expertise in acute and chronic musculoskeletal conditions, as well as how disease affects exercise and using exercise as medicine for people with chronic disease.

Evaluation of the quality of published SCI clinical practice guidelines using the AGREE II instrument: Results from Can-SCIP expert panel

INTRODUCTION

Spinal cord injury (SCI) is a complex condition with substantial adverse personal, social and economic impacts necessitating evidence-based inter-professional care. To date, limited studies have assessed the quality of clinical practice guidelines (CPGs) within SCI. The aim of this study is to evaluate the quality of the development process and methodological rigour of published SCI CPGs across the care continuum from pre-hospital to community-based care.

METHODS

Electronic health databases and indexes were searched to identify English or French language CPGs within SCI published within the last nine years with specific evidence-based recommendations applicable to the Canadian health care setting. Eligible CPGs were evaluated using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument.

RESULTS

A total of forty-one CPGs that met the inclusion criteria were appraised by at least four raters. There was high variability in quality. Twenty-seven CPGs achieved a good rigour of development domain score of >70%. Other standardized mean domain scores were scope and purpose (85.32%), stakeholder involvement (65.03%), clarity of presentation (84.81%), applicability (55.55%) and editorial independence (75.83%). The agreement between appraisers (intraclass correlation coefficient) was high (intraclass correlation coefficient > 0.80).

CONCLUSION

There is a paucity of CPGs that address community-based specialized rehabilitation and community reintegration. Furthermore, many CPGs only focus on a single impairment at one time point in the care continuum. As SCI is a complex condition that results in multimorbidity and requires health monitoring and intervention across the lifespan, a rigorously developed CPG that addresses high-quality, interprofessional comprehensive care is needed.

Exercise Interventions Targeting Obesity in Persons With Spinal Cord Injury

Spinal cord injury (SCI) results in an array of cardiometabolic complications, with obesity being the most common component risk of cardiometabolic disease (CMD) in this population. Recent Consortium for Spinal Cord Medicine Clinical Practice Guidelines for CMD in SCI recommend physical exercise as a primary treatment strategy for the management of CMD in SCI. However, the high prevalence of obesity in SCI and the pleiotropic nature of this body habitus warrant strategies for tailoring exercise to specifically target obesity. In general, exercise for obesity management should aim primarily to induce a negative energy balance and secondarily to increase the use of fat as a fuel source. In persons with SCI, reductions in the muscle mass that can be recruited during activity limit the capacity for exercise to induce a calorie deficit. Furthermore, the available musculature exhibits a decreased oxidative capacity, limiting the utilization of fat during exercise. These constraints must be considered when designing exercise interventions for obesity management in SCI. Certain forms of exercise have a greater therapeutic potential in this population partly due to impacts on metabolism during recovery from exercise and at rest. In this article, we propose that exercise for obesity in SCI should target large muscle groups and aim to induce hypertrophy to increase total energy expenditure response to training. Furthermore, although carbohydrate reliance will be high during activity, certain forms of exercise might induce meaningful postexercise shifts in the use of fat as a fuel. General activity in this population is important for many components of health, but low energy cost of daily activities and limitations in upper body volitional exercise mean that exercise interventions targeting utilization and hypertrophy of large muscle groups will likely be required for obesity management.

Comparison of two Borg exertion scales for monitoring exercise intensity in able-bodied participants, and those with paraplegia and tetraplegia

STUDY DESIGN

Cross-sectional cohort study.

OBJECTIVES

To compare ratings of perceived exertion (RPE) on Borg's 6-20 RPE scale and Category Ratio 10 (CR10) in able-bodied (AB) participants during upper and lower body exercise, and recreationally active participants with paraplegia (PARA) and athletes with tetraplegia (TETRA) during upper body exercise only.

SETTING

University and rehabilitation centre-based laboratories in UK and Netherlands.

METHODS

Twenty-four participants were equally split between AB, PARA, and TETRA. AB performed maximal tests using cycle (AB-CYC) and handcycle (AB-HC) ergometry. PARA and TETRA performed maximal handcycle and wheelchair propulsion tests, respectively. Oxygen uptake (V̇O₂) and blood lactate concentration were monitored throughout. RPE was rated each stage on Borg's RPE scale and CR10. Thresholds were identified according to log-V̇O₂ plotted against log-blood lactate (LT₁), and 1.5 mmol L^-1 greater than LT₁ (LT₂).

RESULTS

RPE from both scales were best fit against each other using a quadratic model, with high goodness of fit between scales that was independent of exercise mode and participant group (range R²: 0.965-0.970, P < 0.005). Though percentage peak V̇O₂ was significantly greater in TETRA (P < 0.005), there was no difference in RPE at LT₁ or LT₂ between groups on Borg's RPE scale or CR10.

CONCLUSION

Strong association between Borg's RPE scale and CR10 suggests they can be used interchangeably. RPE at lactate thresholds were independent of mode of exercise and level of spinal cord injury. However, inter-individual variation precludes from making firm recommendations about using RPE for prescribing homogenous exercise intensity.

Development of the Canadian Spinal Cord Injury Best Practice (Can-SCIP) Guideline: Methods and overview

INTRODUCTION

Spinal cord injury (SCI) is a life-altering injury that leads to a complex constellation of changes in an individual's sensory, motor, and autonomic function which is largely determined by the level and severity of cord impairment. Available SCI-specific clinical practice guidelines (CPG) address specific impairments, health conditions or a segment of the care continuum, however, fail to address all the important clinical questions arising throughout an individual's care journey. To address this gap, an interprofessional panel of experts in SCI convened to develop the Canadian Spinal Cord Injury Best Practice (Can-SCIP) Guideline. This article provides an overview of the methods underpinning the Can-SCIP Guideline process.

METHODS

The Can-SCIP Guideline was developed using the Guidelines Adaptation Cycle. A comprehensive search for existing SCI-specific CPGs was conducted. The quality of eligible CPGs was evaluated using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument. An expert panel (n = 52) convened, and groups of relevant experts met to review and recommend adoption or refinement of existing recommendations or develop new recommendations based on evidence from systematic reviews conducted by the Spinal Cord Injury Research Evidence (SCIRE) team. The expert panel voted to approve selected recommendations using an online survey tool.

RESULTS

The Can-SCIP Guideline includes 585 total recommendations from 41 guidelines, 96 recommendations that pertain to the Components of the Ideal SCI Care System section, and 489 recommendations that pertain to the Management of Secondary Health Conditions section. Most recommendations (n = 281, 48%) were adopted from existing guidelines without revision, 215 (36.8%) recommendations were revised for application in a Canadian context, and 89 recommendations (15.2%) were created de novo.

CONCLUSION

The Can-SCIP Guideline is the first living comprehensive guideline for adults with SCI in Canada across the care continuum.

Effects of 16-Form Wheelchair Tai Chi on the Autonomic Nervous System among Patients with Spinal Cord Injury

Objective

This study aims to investigate the effects of 16-form Wheelchair Tai Chi (WCTC16) on the autonomic nervous system among patients with spinal cord injury (SCI).

Methods

Twenty patients with chronic complete thoracic SCI were recruited. Equivital life monitoring system was used to record and analyze heart rate variability (HRV) of patients for five minutes before and after five consecutive sets of WCTC16, respectively. The analysis of HRV in the time domain included RR intervals, the standard deviation of all normal RR intervals (SDNN), and the root mean square of the differences between adjacent NN intervals (RMSSD). The analysis of HRV in the frequency domain included total power (TP), which could be divided into very-low-frequency area (VLFP), low-frequency area (LFP), and high-frequency area (HFP). The LF/HF ratio as well as the normalized units of LFP (LFPnu) and HFP (HFPnu) reflected the sympathovagal balance.

Results

There was no significant difference in RR interval, SDNN, RMSSD, TP, HEP, VLFP, and LFP of SCI patients before and after WCTC16 exercise (P > 0.05). LFPnu and HF peak decreased, while HFPnu and LF/HF increased in SCI patients after WCTC16 exercise. The differences were statistically significant (P < 0.001).

Conclusion

WCTC16 can enhance vagal activity and decrease sympathetic activity so that patients with chronic complete thoracic SCI can achieve the balanced sympathovagal tone.

Physiological responses during active video games in spinal cord injury: a preliminary study

Objectives: Investigate the physiological responses to active video games (AVG) in individuals with spinal cord injury by comparing oxygen consumption (VO₂) and heart rate (HR) during an AVG session and at the ventilatory thresholds (i.e., anaerobic threshold and respiratory compensation point); and by calculating the session energy expenditure (EE).Method: Eight paraplegic individuals with spinal cord injury underwent cardiopulmonary exercise tests in an arm cycle ergometer to determine ventilatory thresholds. Then, they underwent three experimental sessions: two of AVG (4 sets of 3 min of Tennis and 4 min of Boxing) and one control (watching a movie). HR and VO₂ were continuously measured, and the total energy expenditure was calculated from it.Results: HR and VO₂ were similar in both AVG sessions and higher than in the control session (p < .05). Mean HR and VO₂ in Tennis and Boxing were, respectively, 100 ± 7 and 114 ± 9 bpm and 7.9 ± 1.2 and 10.3 ± 1.4 ml.kg^-1.min^-1.HR and VO₂ during both games did not differ significantly from the anaerobic threshold (121 ± 2 bpm and 10.6 ± 1.0 ml.kg^-1.min^-1, p > .05). Mean energy expenditure during the AVG sessions was 2.4 METS, while the total was 136 kcal.Conclusion: The AVG generated an aerobic stimulus equivalent to the anaerobic threshold that increased basal metabolism 2.6 times, characterizing a low-intensity aerobic exercise.

Serum CCL21 as a Potential Biomarker for Cognitive Impairment in Spinal Cord Injury

Objective

Cognitive impairment is considered to be an important complication of spinal cord injury (SCI), but its underlying mechanism remains unclear. The purpose of this study is to explore whether serum CCL21 can be used as a potential biomarker of cognitive impairment in SCI.

Methods

In Neck-Shoulder and Lumbocrural Pain Hospital, Shandong First Medical University & Shandong Academy of Medical Sciences, hospitalized or treated acute SCI patients were included in the study as the SCI group (SCI). At the same time, a normal control group (NC) matching the age and sex of the SCI group was recruited in the outpatient clinic. Once the two groups were enrolled, their demographics and clinical characteristics were collected immediately. Enzyme-linked immunosorbent assay (ELISA) was used to detect serum CCL21 levels within 24 hours of admission. Three months later, the Montreal Cognitive Assessment (MoCA) was used to test the cognitive function of the population.

Results

A total of 84 SCI patients and 49 NC populations were eligible for inclusion in the study. There was no significant statistical difference in the demographics and clinical characteristics (age, gender, BMI, TG, LDL-C, FBG, SBP, and DBP) between the two groups (p > 0.05). Compared with the NC group, the SCI group had a higher serum CCL21 level (p < 0.001) and a lower MoCA score (p < 0.001). Serum CCL21 level in SCI was negatively correlated with MoCA score (p = 0.023). Multivariable analyses showed that serum CCL21 level is an independent prognostic factor of cognitive impairment in SCI.

Conclusions

MoCA score has a linear relationship with serum CCL21 quartile, and SCI cognitive function has a negative correlation with serum CCL21. Serum CCL21 is an independent risk factor for cognitive impairment after SCI.

Oxygen Uptake During Exoskeletal-Assisted Walking in Persons With Paraplegia

OBJECTIVE

To determine the cardiometabolic demands associated with exoskeletal-assisted walking (EAW) in persons with paraplegia. This study will further examine if training in the device for 60 sessions modifies cost of transport (CT).

DESIGN

Prospective cohort study. Measurements over the course of a 60-session training program, approximately 20 sessions apart.

SETTING

James J. Peters Bronx Veterans Affairs Medical Center, Center for the Medical Consequences of Spinal Cord Injury Research Center.

PARTICIPANTS

The participants' demographics (N=5) were 37-61 years old, body mass index (calculated as weight in kilograms divided by height in meters squared) of 22.7-28.6, level of injury from T1-T11, and 2-14 years since injury.

INTERVENTIONS

Powered EAW.

MAIN OUTCOME MEASURES

Oxygen consumption per unit time (V˙O₂, mL/min/kg), velocity (m/min), cost of transport (V˙O₂/velocity), and rating of perceived exertion (RPE).

RESULTS

With training: EAW velocity significantly improved (Pre: 51±51m; 0.14±0.14m/s vs Post: 99±42m; 0.28±0.12m/s, P=.023), RPE significantly decreased (Pre: 13±6 vs Post: 7±4, P=.001), V˙O₂ significantly improved (Pre: 9.76±1.23 mL/kg/m vs Post: 12.73±2.30 mL/kg/m, P=.04), and CT was reduced from the early to the later stages of training (3.66±5.2 vs 0.87±0.85 mL/kg/m).

CONCLUSIONS

The current study suggests that EAW training improves oxygen uptake efficiency and walking velocities, with a lower perception of exertion.