Effect of Exercise on Mental Health and Health-related Quality of Life in Adults With Spinal Cord Injury: A Systematic Review and Meta-analysis

OBJECTIVES

To determine the effect of exercise interventions on mental health and health-related quality of life (HRQoL) in individuals with SCI.

DATA SOURCES

We searched Embase, CINAHL, Medline, PsychINFO, and SPORTDiscus from inception to September 2023.

STUDY SELECTION

We included randomized controlled trials that (1) involved participants ≥18 years old with a SCI; (2) administered an exercise intervention; and (3) measured subjective well-being, psychological well-being, social well-being, and/or HRQoL as outcomes. We reported standardized means differences (d) with a 95% confidence interval (CI), assessed the risk of bias by using the Revised Cochrane Risk-of-bias Tool for Randomized Trials (RoB 2), and the certainty of the evidence using GRADE.

DATA SYNTHESIS

Nineteen studies (797 participants, mean age <65 years in every study) were included. Exercise improved overall well-being (d=0.494; 95% CI 0.268, 0.720; low certainty evidence), subjective well-being (d=0.543; 95% CI 0.270, 0.816; low certainty evidence), psychological well-being (d=0.499; 95% CI 0.193, 0.805; low certainty evidence), social well-being (d=0.452; 95% CI 0.151, 0.752; low certainty evidence), and HRQoL (d=0.323; 95% CI 0.072, 0.574; low certainty evidence). Four serious adverse events probably attributable to the interventions were reported in 3 studies.

CONCLUSIONS

Exercise interventions can improve well-being and HRQoL in adults with SCI <65 years of age. Additional research is needed to determine effectiveness in adults ≥65 years of age.

Effectiveness of a Community-Based Exercise Program for Ambulatory Individuals With Spinal Cord Injury: A Randomized Controlled Trial

OBJECTIVE

To evaluate the effectiveness of a community-based structured exercise program, compared with usual care, in enhancing physical, functional, and psychological outcomes for ambulatory individuals with spinal cord injury (SCI).

DESIGN

Randomized controlled trial comparing exercise group with usual care group.

SETTING

One university-affiliated rehabilitation hospital.

PARTICIPANTS

Fifty-seven participants with chronic SCI who could walk more than 10 m.

INTERVENTIONS

A supervised 20-session program focusing on flexibility, aerobic, and strengthening exercises was provided over 8 weeks for the exercise group, whereas the usual care group maintained their regular daily exercise routines.

MAIN OUTCOME MEASURES

Primary outcome included 6-minute walk test, and secondary outcomes assessed EuroQol-5 Dimensions 5-Level, Spinal Cord Independence Measure III, Berg Balance Scale, Timed Up and Go, grip strength, 30-second sit-to-stand test, sit and reach test, Beck Anxiety Inventory, Beck Depression Inventory, and bioelectrical impedance analysis.

RESULTS

The 51 participants were allocated to intervention (n=36) and usual care (n=15) groups, consisting of 34 males and 17 females (average age, 59.78±13.19y). The participants included 24 with cervical, 17 with thoracic, 8 with lumbar, and 2 with sacral lesions, with all participants having motor incomplete injuries. The exercise group showed significant improvement compared with the usual care group in the 6-minute walk test by 49.80 m (95% confidence interval [CI], 13.04-86.55), Berg Balance Scale scores by 3.50 (95% CI, 0.96-6.03), 30-second sit-to-stand by 2.38 (95% CI, 0.29-4.47), and sit and reach test by 3.89 cm (95% CI, 0.96-6.82). The adherence rate was remarkably high at 89.6%, suggesting the feasibility of community exercise programs for this population. However, no significant changes were observed in psychological and quality-of-life measures.

CONCLUSIONS

Community-based structured exercise programs have been shown to be both feasible and effective in improving walking capacity, balance, lower extremity strength, and flexibility in ambulatory individuals with SCI.

Activity-Based Therapy for Mobility, Function and Quality of Life after Spinal Cord Injuries-A Mixed-Methods Case Series

(1) Background: Despite inconclusive evidence on the benefits of activity-based therapies (ABTs) in people with spinal cord injuries, implementation has occurred in clinics worldwide in response to consumers' requests. We explored the clinical changes and participants' perceptions from engaging in an ABT program in the community. (2) Methods: This mixed-methods study involved a pragmatic observational multiple-baseline design and an evaluation of participants' perceptions. Fifteen participants were included. Outcome measures were balance in sitting using the Seated Reach Distance test, mobility using the Modified Rivermead Mobility Index and quality of life using the Quality of Life Index SCI version pre- and post-participation in an ABT community-based program. Linear mixed models and logistic regressions were used to analyse the effects of intervention. Semi-structured interviews explored participants' perceptions using inductive thematic analysis. (3) Results: There was an increase of 9% in the standardised reach distance (95% CI 2-16) for sitting balance, 1.33 points (95% CI: 0.81-1.85) in mobility and 1.9 points (0.17-2.1) in quality of life. Two themes emerged from the interviews: (1) reduced impact of disability and an increased sense of life as before, and (2) the program was superior to usual rehabilitation. No adverse events related to the intervention were observed. (4) Conclusion: ABT delivered in the community improved clinical outcomes in people with a chronic SCI. High levels of satisfaction with the program were reported.

Physical Activity and the Health of Wheelchair Users: A Systematic Review in Multiple Sclerosis, Cerebral Palsy, and Spinal Cord Injury

OBJECTIVE

To understand the benefits and harms of physical activity in people who may require a wheelchair with a focus on people with multiple sclerosis (MS), cerebral palsy (CP), and spinal cord injury (SCI).

DATA SOURCES

Searches were conducted in MEDLINE, Cumulative Index to Nursing and Allied Health, PsycINFO, Cochrane CENTRAL, and Embase (January 2008 through November 2020).

STUDY SELECTION

Randomized controlled trials, nonrandomized trials, and cohort studies of observed physical activity (at least 10 sessions on 10 days) in participants with MS, CP, and SCI.

DATA EXTRACTION

We conducted dual data abstraction, quality assessment, and strength of evidence. Measures of physical functioning are reported individually where sufficient data exist and grouped as "function" where data are scant.

DATA SYNTHESIS

No studies provided evidence for prevention of cardiovascular conditions, development of diabetes, or obesity. Among 168 included studies, 44% enrolled participants with MS (38% CP, 18% SCI). Studies in MS found walking ability may be improved with treadmill training and multimodal exercises; function may be improved with treadmill, balance exercises, and motion gaming; balance is likely improved with balance exercises and may be improved with aquatic exercises, robot-assisted gait training (RAGT), motion gaming, and multimodal exercises; activities of daily living (ADL), female sexual function, and spasticity may be improved with aquatic therapy; sleep may be improved with aerobic exercises and aerobic fitness with multimodal exercises. In CP, balance may be improved with hippotherapy and motion gaming; function may be improved with cycling, treadmill, and hippotherapy. In SCI, ADL may be improved with RAGT.

CONCLUSIONS

Depending on population and type of exercise, physical activity was associated with improvements in walking, function, balance, depression, sleep, ADL, spasticity, female sexual function, and aerobic capacity. Few harms of physical activity were reported in studies. Future studies are needed to address evidence gaps and to confirm findings.

Do any physiotherapy interventions increase spinal cord independence measure or functional independence measure scores in people with spinal cord injuries? A systematic review

STUDY DESIGN

Systematic review.

OBJECTIVE

To determine whether any physiotherapy interventions increase Spinal Cord Independence Measure or Functional Independence Measure scores (SCIM/FIM) in people with spinal cord injury (SCI), with the overall aim of determining whether any physiotherapy interventions need to be controlled for in studies examining the effects of novel experimental interventions on SCIM/FIM.

METHODS

A systematic review was conducted to identify all randomised controlled trials examining the effect of any physiotherapy intervention on SCIM/FIM in people with SCI. PEDro scores were used to rate risk of bias. The results of similar trials and comparisons were pooled using meta-analyses.

RESULTS

Thirty-three trials met the inclusion criteria but only 27 provided useable data. The median (IQR) PEDro score was 6.0 (4.0-7.0). A meta-analysis of four trials comparing robotic gait training with overground gait training that used a combination of FIM/SCIM indicated a pooled mean (95% CI) between-group difference of 0.38 standardised mean difference (SMD; 95% CI, 0.08-0.67). A second meta-analysis of two trials comparing upper limb training with and without functional electrical stimulation using FIM indicated a pooled (95% CI) between-group difference of 1.31 SMD (0.62-1.99). Another six trials examining a range of different physiotherapy interventions reported a statistically significant mean between-group difference on SCIM/FIM.

CONCLUSION

There is low-quality evidence to indicate that a small number of physiotherapy interventions increase SCIM/FIM. The importance of controlling for all physiotherapy interventions in studies examining the effects of novel experimental interventions on SCIM/FIM is as yet unclear.

Perspectives of people living with a spinal cord injury on activity-based therapy

PURPOSE

Activity-Based Therapy (ABT) targets recovery of function below the injury level in individuals with spinal cord injury (SCI). This qualitative study is the first to capture the perspectives of individuals with SCI on community ABT programs in Canada.

METHODS

Ten participants (6 males, aged 23.0-65.0 years, 2.5-23.0 years post-SCI) were recruited using purposive sampling, and completed semi-structured interviews. Interview questions explored benefits and challenges, facilitators and barriers to access, and motivations for participating in ABT. Themes were identified using conventional content analysis and collaboratively analyzed using the DEPICT model.

RESULTS

An overarching theme of ABT as a key part of participants' evolving and lifelong recovery process emerged. Motivations for initiating ABT included dissatisfaction with early rehabilitation, and a desire to improve function and stay active. Participants perceived that ABT contributed to neurological recovery, physical and mental health benefits, independence, and hope. Factors contributing to recovery and factors limiting accessibility and participation in ABT were identified. Participants discussed advocating for ABT, and how ABT empowered self-management.

CONCLUSIONS

ABT was perceived to play a significant role in promoting ongoing recovery and well-being in individuals with SCI. Addressing limitations in awareness and availability of ABT may improve participation in ABT programs.Implications for rehabilitationActivity-Based Therapy (ABT) targets recovery of function and sensation below the level of injury in individuals with spinal cord injury (SCI).ABT plays a key role in the evolving and lifelong recovery process of individuals with SCI.Participants reported that ABT has a positive impact on physical, functional, and psychosocial domains, leading to improved independence and quality of life.Awareness and availability of ABT remain limited, highlighting a need to further explore and address factors limiting access to this therapy.

Physiotherapy interventions for the treatment of spasticity in people with spinal cord injury: a systematic review

STUDY DESIGN

Systematic review.

OBJECTIVE

To determine the effectiveness of physiotherapy interventions for the treatment of spasticity in people with spinal cord injuries.

SETTING

Not applicable.

METHODS

A comprehensive search was undertaken to identify all randomised controlled trials of physiotherapy interventions that included an assessor-reported (objective) or participant-reported (subjective) measure of spasticity. Only trials that provided a physiotherapy intervention on more than one occasion were included. The susceptibility to bias of each trial was rated on the PEDro scale. Data were extracted to derive mean between-group differences (95% CI) for each trial.

RESULTS

Twenty-eight trials were identified but only 17 provided useable data. Seven trials compared a physiotherapy intervention to no intervention (or a sham intervention) and 10 trials compared one physiotherapy intervention to another physiotherapy intervention. The median (IQR) PEDro score of the 17 trials was 6/10 (6-8). The most commonly used assessor- and participant-reported measures of spasticity were the Ashworth scale and Spinal Cord Injury Spasticity Evaluation Tool, respectively. Only one trial demonstrated a treatment effect. This trial compared continuous passive motion of the ankle to no treatment on the Ashworth scale. The remaining 16 trials were either inconclusive or indicated that the treatment was ineffective for reducing spasticity.

CONCLUSIONS

There is no high-quality evidence to indicate that physiotherapy interventions decrease spasticity but this may reflect a lack of research on the topic. Future trials should focus on participant-reported measures of spasticity that distinguish between the immediate, short-term and long-term effects of any physiotherapy intervention.

Activity-Based Therapy in a Community Setting for Independence, Mobility, and Sitting Balance for People With Spinal Cord Injuries

INTRODUCTION

Activity-based therapy (ABT) aims to activate the neuromuscular system below the level of the spinal cord lesion and promote recovery of motor tasks through spinal reorganisation, motor learning and changes to muscles and sensory system. We investigated the effects of a multimodal ABT program on mobility, independence and sitting balance in individuals with spinal cord injury (SCI).

METHODS

Retrospective clinical data from 91 adults who independently enrolled in four community-based ABT centres in Australia were analysed. The multimodal ABT program was delivered for 3 to 12 months, one to four times per week. Assessments were undertaken every 3 months and included the Modified Rivermead Mobility Index (MRMI), Spinal Cord Independence Measure (SCIM) and seated reach distance (SRD). A linear mixed model analysis was used to determine time-based and other predictors of change.

RESULTS

There was a significant improvement after 12 months for all outcome measures, with a mean change score of 4 points in the SCIM (95% confidence interval [CI]: 2.7-5.3, d = 0.19), 2 points in the MRMI (95% CI: 1-2.3, d = 0.19) and 0.2 in the SRD (95% CI: 0.1-2.2, d = 0.52). Greater improvements occurred in the first 3 months of intervention. There were no interaction effects between time and the neurological level of injury, American Spinal Injury Association Impairment Scale classification, or duration post-injury for most outcomes.

CONCLUSIONS

A community-based ABT exercise program for people with SCI can lead to small improvements in mobility, independence and balance in sitting, with greater improvements occurring early during intervention.