Effects of exercise on fitness and health of adults with spinal cord injury: A systematic review

Do Exercise Programs Improve Fitness, Mobility, and Functional Capacity in Adults With Lower Limb Amputation? A Systematic Review on the Type and Minimal Dose Needed

OBJECTIVE

To answer the following questions: (1) Do physical activity (PA) and exercise improve fitness, mobility, and functional capacity among adults with lower limb amputation (LLA) and (2) What is the type and minimum dose of PA (frequency, intensity and duration) needed?

DESIGN

Systematic review.

SETTING

Outpatient intervention, outside of the prosthetic rehabilitation phase.

PARTICIPANTS

Adults with lower limb amputation living in the community.

INTERVENTION

Any physical activity or exercise intervention.

OUTCOMES AND MEASURES

Any fitness, mobility, or functional capacity indicators and measurements.

RESULTS

Twenty-three studies were included, totaling 408 adults with LLA. Studies evaluated the effect of structured PA sessions on fitness, mobility, and functional capacity. The highest evidence is for mixed exercise programs, that is, programs combining aerobic exercise with strengthening or balance exercise. There is moderate confidence that 1-3 sessions of 20-60 minutes of exercise per week improves balance, walking speed, walking endurance, and transfer ability in adults with LLA above the ankle. As for flexibility, cardiorespiratory health, lower-limb muscles strength, and functional capacity, there was low confidence that exercise improves these fitness components because of the lack of studies.

CONCLUSION

Exercise 1-3 times per week may improve balance, walking speed, walking endurance, and transfer ability in adults with LLA, especially when combining aerobic exercises with lower limb strengthening or balance exercises. There is a need for most robust studies focusing on the effect of PA on cardiorespiratory health, muscles strength, flexibility, and functional status.

Psychosocial Outcomes Associated With Types and Intensities of Physical Activity in People With Spinal Cord Injury: The Mediating Role of Self-Efficacy and Functionality

BACKGROUND

Low rates of participation and quality of life (QoL) and high rates of psychological distress are common in spinal cord injury (SCI) population. Research has supported the mediating role of self-efficacy and functionality in improving psychosocial outcomes. Furthermore, evidence supports the impact of physical activity (PA) on psychosocial variables, but little is known about the types and intensities of PA. The objective of this study was to determine whether functionality and/or general self-efficacy (GSE) mediate the relationships between the various types of PA: (1) lifestyle and (2) leisure-time physical activity (LTPA); and various intensities of PA: (1) mild, (2) moderate, and (3) heavy PA with participation, psychological distress, and perception of QoL.

METHODS

The Physical Activity Recall Assessment for SCI, and measures of functionality, GSE, participation, psychological distress, and perception of QoL were administered to 159 participants. Path analysis was performed using Jeffrey's Amazing Statistics Program.

RESULTS

GSE significantly mediated, and functionality partially significantly mediated, the relationship between LTPA and psychosocial outcomes. GSE and functionality did not mediate the relationship between lifestyle activity and psychosocial outcomes.

CONCLUSIONS

It is recommended that people with SCI perform LTPA on a regular basis to achieve psychosocial benefits. These programs should be accompanied by strategies to improve GSE.

Correlates of physical activity in ambulatory people with spinal cord injury during the first year after inpatient rehabilitation

STUDY DESIGN

Longitudinal cohort study.

OBJECTIVES

Examine the longitudinal association between mobility and level of physical activity (PA) and explore which other factors are also associated with level of PA in ambulatory people with Spinal Cord Injury (SCI) during the first-year post-inpatient rehabilitation.

SETTING

Three SCI-specialized rehabilitation centers and the Dutch community.

METHODS

Forty-seven adults with recent SCI and ambulatory function were included. All had motor incomplete lesions, 49% had tetraplegia, and the mean age was 55 ± 13 years. Duration of accelerometry-based all-day PA and self-reported level of mobility, exertion of walking, pain, fatigue, depressive mood symptoms, fear of falling, exercise self-efficacy, and attitude toward PA were measured just before discharge from inpatient rehabilitation and 6 and 12 months after discharge. All data were longitudinally analyzed using generalized estimating equations analyses. Models were corrected for age, lesion level, and time since injury.

RESULTS

Mobility was longitudinally associated with level of PA (beta: 4.5, P < 0.001, R2: 41%). In addition, lower levels of exertion of walking (beta: -5.6, P < 0.001), fear of falling (beta: -34.1, P < 0.001), and higher levels of exercise self-efficacy (beta: 2.3, P = 0.038) were associated with higher levels of PA. Exertion of walking and fear of falling were associated with level of PA independent of mobility.

CONCLUSIONS

Mobility, exertion of walking, fear of falling, and exercise self-efficacy seem to be correlates of level of PA in ambulatory people with SCI during the first year after inpatient rehabilitation. Targeting these factors using an interdisciplinary approach may enhance levels of PA in this population.

Early rehabilitation after spinal cord injury: a scoping review protocol

OBJECTIVE

The objective of this scoping review is to identify the timings and types of early rehabilitation after spinal cord injuries (SCI) that are documented in the literature, as well as identify possible research gaps in this field.

INTRODUCTION

Preclinical and clinical studies support the idea that early rehabilitation may be beneficial for patients with acute SCI. However, the timing and types of rehabilitation that should and could be used in the acute stage are still unclear. The first step towards such knowledge is to extensively review what is documented in the literature.

INCLUSION CRITERIA

This review will consider all papers focusing on early rehabilitation after SCI in adult humans or animals (<3 months post-SCI for humans and other primates and <3 weeks post-SCI for other animals). Interventions in the included papers must aim at sensorimotor or functional improvement and take place in a hospital or a rehabilitation center if they target human subjects.

METHODS

MEDLINE (PubMed), Scopus, Embase (Embase.com), PEDro, Web of Science Core Collection, CINAHL (EBSCOhost), Cochrane Database of Systematic Reviews, Cochrane CENTRAL, PROSPERO, ClinicalTrials.gov, and gray literature sources will be searched for eligible articles. This review will include published and unpublished experimental and observational studies, research protocols, conference abstracts, systematic reviews, and guidelines. No language or date limits will be applied. Two independent reviewers will perform study selection and data extraction, and the results will be presented according to the SCI type and severity.

REVIEW REGISTRATION

Open Science Framework https://osf.io/q45er.

Robotic technology (ROBERT®) to enhance muscle strength in the hip flexor muscles following spinal cord injury: a feasibility study

STUDY DESIGN

Feasibility study.

OBJECTIVE

To determine the feasibility of conducting a large trial designed to determine whether the ROBERT® can be used to increase the strength of the hip flexor muscles after spinal cord injury (SCI). The ROBERT® is a robotic device that provides assisted active movement while supporting the weight of the leg. Focus was on recruitment capability, suitability, and acceptability of the intervention and outcome measure.

SETTING

Specialised SCI centre in Denmark.

METHODS

All first-time admitted patients were screened to assess participant recruitment capability. Four people with SCI < 3 months tested a protocol consisting of 60 repetitions of hip flexion in supine conducted with the assistance of the ROBERT® three times a week for 4 weeks. Feasibility was assessed based on adherence to the protocol and completion rate and from the participants' perspectives. Maximal voluntary contraction (MVC) was accessed at baseline and four weeks.

RESULTS

The recruitment rate was 8% (7 months). The four participants completed 44 out of 48 sessions (92%). No adverse events occurred. One physiotherapist was required to set-up and supervise each session. The active exercise time varied from 7.5 to 17 min. The participants found the ROBERT® a good supplement to their usual rehabilitation. We were able to measure MVC in even very weak hip flexor muscles with a dynamometer MicroFET2 fixed to a frame.

CONCLUSION

The ROBERT® was feasible and acceptable. The participants perceived it as a supplement, not a replacement to usual physiotherapy. However, recruitment to the study was slow.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05558254. Registered 28th September 2022.

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.

High intensity functional training for people with spinal cord injury & their care partners

STUDY DESIGN

Non-randomized clinical trial.

OBJECTIVES

Examine the feasibility, physical and psychosocial effects of a high intensity functional training (HIFT) exercise program for people with spinal cord injury (pSCI) and their care partners (CPs).

SETTING

Community fitness center in a Medically Underserved Area (Fort Smith, USA.) METHODS: A single-group design with three assessment points (before the program, at midpoint (13 weeks), and post-program (25 weeks) was used to examine the effects of up to 49 HIFT sessions over 25-weeks. Sessions were 60 to 75 min in duration and adapted to the abilities of participants. Feasibility measures included recruitment, retention, attendance, safety and fidelity (exercise intensity rated via session-Rating of Perceived Exertion (RPE). Physical measures included cardiovascular endurance, anaerobic power, and muscular strength. Psychosocial measures included perceived social support for exercise, exercise self-efficacy and health-related quality of life.

RESULTS

Fourteen pSCI (7 with paraplegia and 7 with tetraplegia, 2 females) and 6 CPs (4 females) were included (median age = 60) (IQR = 15.8). Recruitment rates were 40% for pSCI and 32% for CPs. On average, participants attended 73% (22%) of exercise sessions with a median session-RPE of 5 (IQR = 1). Retention rates were 83% and 67% for pSCI and CPs, respectively. For pSCI and their CPs, large effect sizes were observed for cardiovascular endurance, anaerobic power, muscular strength, and social support for exercise.

CONCLUSIONS

For pSCI and their CPs, HIFT appears feasible and potentially leads to improvements in physical and psychosocial health for both groups.

Monitoring outcome measures for cardiometabolic disease during rehabilitation and follow-up in people with spinal cord injury

STUDY DESIGN

Controlled pragmatic intervention with follow-up.

OBJECTIVES

To describe cardiometabolic risk outcomes after a pragmatic intervention implemented into standard spinal cord injury (SCI) rehabilitation.

SETTING

Inpatient SCI rehabilitation in East-Denmark.

PARTICIPANTS

Inpatients, >18 years, having sustained a SCI within the last 12 months at admission to rehabilitation, regardless of etiology, neurological level or completeness of the lesion or mobility status.

METHODS

Patient education on health promotion was guided by evidence and included feedback on peak oxygen uptake (VO2peak) (primary outcome measure), body mass index (BMI), Dual energy X-ray absorptiometry and metabolic profile (secondary outcome measures). Paired t-tests, non-parametric tests and Analysis of Variance (ANOVA) were used for analyzes. VO2peak and BMI were compared to historical data.

RESULTS

VO2peak increased significantly from admission to discharge but did not exceed historical data despite a minimal clinical important difference. BMI decreased significantly during rehabilitation (p < 0.001) followed by a significant increase after discharge (p = 0.006). There was a trend that people with American Spinal Injury Association Impairment Scale (AIS) D SCI increased lean mass to nearly normal values. Criteria for pre-diabetes or diabetes were present in 28.5% and dyslipidemia in 45% of the participants 44.2 days after time of injury.

CONCLUSIONS

Despite improvements during rehabilitation, outcome measures were worse than recommended, and most outcome measures worsened at follow up, even in people with an AIS D SCI. Meaningful support regarding exercise and diet when tackling altered life circumstances is needed after discharge.

Socio-ecological Barriers to Leisure Time Physical Activity in Spanish Wheelchair Users With Spinal Cord Injury: Associations With Sociodemographic Characteristics and Functional Independence

OBJECTIVE

(1) To assess prevalence and severity of socio-ecological barriers to leisure time physical activity (LTPA) in a sample of adults with spinal cord injury (SCI); (2) to examine the association of these barriers with sociodemographic characteristics and functional independence (FI); and (3) to explore which socio-ecological levels of barriers might be associated with LTPA.

DESIGN

Cross-sectional study.

SETTING

Neurorehabilitation Hospital specialized in SCI.

PARTICIPANTS

207 wheelchair users with SCI living in the community who attended a comprehensive check-up (22.7% women, 47.5±10.7 mean age; N=207).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The short version of the Barriers to Physical Activity Questionnaire for People with Mobility Impairments was used to measure socio-ecological barriers to LTPA. The Spinal Cord Independence Measure III was used to measure FI. The Physical Activity Recall Assessment for People with SCI was used to quantify LTPA. Several multiple linear regression models were computed to examine the associations between socio-ecological barriers and sociodemographic factors, LTPA and FI.

RESULTS

A high prevalence of barriers to LTPA was found. Seven of these barriers (2 intrapersonal, 3 organizational, and 2 community) were present for >60% of the participants. Intrapersonal and organizational barriers had a higher effect on participants with lower FI and women. Interpersonal barriers were higher for older participants and with lower FI, while community barriers were higher for unemployed participants. Finally, intrapersonal and interpersonal barriers were negatively associated with LTPA, and FI revealed as a moderator of the intrapersonal barriers-LTPA relation.

CONCLUSIONS

Given their high prevalence and their association with LTPA, the development of interventions targeting socio-ecological barriers to LTPA in people with SCI becomes crucial. The associations of these barriers with FI and sociodemographic characteristics should also be considered for these interventions to be as specific and effective as possible.

Multidimensionality of leisure-time physical activity behaviour in adults with spinal cord injury: implications for measurement

The Physical Activity Recall Assessment for People with SCI (PARA-SCI) has demonstrated the best test-retest reliability and validity of self-report measures of leisure-time physical activity (LTPA) for adults with SCI. However, the absence of internal consistency reliability data has been raised as a concern. Internal consistency is relevant only for unidimensional measures. In other populations, LTPA is known to be a multidimensional construct, evaluated with multidimensional measures. We tested for unidimensionality through secondary analysis of PARA-SCI data (n = 703). Cronbach's α was 0.227. Principal components analysis showed two components/dimensions ('Moderate and Heavy Intensity LTPA' and 'Mild Intensity LTPA') explained 73% of the variance. Binary logic crosstabulation produced no discernible patterns of behavioural interrelatedness across LTPA intensities. Together, these data demonstrate the multidimensionality of LTPA and the PARA-SCI is not unidimensional. Internal consistency should not be a criterion for evaluating LTPA questionnaires for use in studies of people with SCI.

Association between individual wheelchair skills and fitness in community-dwelling manual wheelchair users with spinal cord injuries

PURPOSE

Wheelchair skills are a key component to promotion of community participation among persons with spinal cord injury (SCI). The objective of this secondary analysis was to examine the association between individual wheelchair skills from the Wheelchair Skills Test Questionnaire (WST-Q) and fitness among community-dwelling adults with SCI.

MATERIALS AND METHODS

Twenty-six adults were recruited to complete the WST-Q and a standard graded aerobic wheelchair exercise test on a motorized treadmill for assessing peak power output (POpeak).

RESULTS

Spearman Rho rank-order correlation (ρ) analyses indicated statistically significant correlations between POpeak and six basic (ρ = 0.41-0.57), eight intermediate (ρ = 0.44-0.59), and nine advanced (ρ = 0.42-0.80) WST-Q skill scores. After controlling for sex and injury level (Partial Spearman Rho rank order) significant correlations persisted for four advanced skills (i.e., descends high curb, turns in place in wheelie position, descends steep incline in wheelie position, descends high curb in wheelie position; ρ = 0.46-0.59) and one additional skill (i.e., ascends high curb ρ = 0.51).

CONCLUSIONS

More advanced wheelchair skills are significantly associated with fitness in persons with SCI. The directionality of the skills-fitness relationship, specifically whether wheelchair skills facilitate greater fitness or fitness is a prerequisite for certain wheelchair skills needs to be determined in future, larger studies. However, results from this study provide a comprehensive list of wheelchair skills that are associated with fitness that can be directly applied to guide further research and practice promoting community participation among persons with SCI.Implications for RehabilitationSignificant positive associations exist between advanced wheelchair skills (i.e., descends high curb, turns in place in wheelie position, descends steep incline in wheelie position, descends high curb in wheelie position and ascends high curb) and fitness in manual wheelchair users with spinal cord injury (SCI).This study provides a list of skills associated with fitness to guide clinical practice and areas for further rehabilitation research assessing the directionality of the relationship between fitness and wheelchair skills.

The Association Between Physical Activity and Health Care Risk Management in Individuals With Disabilities

Despite the increasing economic burden of people with disabilities (PWDs) over time, the impact of physical activity on PWDs in the Republic of Korea (ROK) remains relatively unexplored. Thus, we examined the association between physical activity and disease risk, health care utilization, and expenditures for PWDs in the ROK. We considered gender differences across eight diseases using the National Health Insurance (NHI) panel data from 2013 to 2019. The sample consisted of PWDs who underwent regular medical check-ups and were aged 40 years and above, aligning with the NHI's health screening program targeting beneficiaries in this age range. The final sample included 281 142 healthy PWDs. Among them, 44.1% (n = 124 061) engaged in physical activity, while the remaining 45.9% (n = 157 081) did not participate in any physical activity. The results show a negative association between physical activity and the incidence of various diseases among both genders. Health care utilization exhibited gender and disease-based variations, with men and women demonstrating higher utilization rates in the absence of physical activity. Health care expenditures also differed based on gender and disease, as men and women displayed higher costs in the absence of physical activity. Consequently, public policymakers should establish tailored activity programs for PWDs, adhering to activity guidelines designed for this population.

The Clinical Relevance of Autonomic Dysfunction, Cerebral Hemodynamics, and Sleep Interactions in Individuals Living With SCI

A myriad of physiological impairments is seen in individuals after a spinal cord injury (SCI). These include altered autonomic function, cerebral hemodynamics, and sleep. These physiological systems are interconnected and likely insidiously interact leading to secondary complications. These impairments negatively influence quality of life. A comprehensive review of these systems, and their interplay, may improve clinical treatment and the rehabilitation plan of individuals living with SCI. Thus, these physiological measures should receive more clinical consideration. This special communication introduces the under investigated autonomic dysfunction, cerebral hemodynamics, and sleep disorders in people with SCI to stakeholders involved in SCI rehabilitation. We also discuss the linkage between autonomic dysfunction, cerebral hemodynamics, and sleep disorders and some secondary outcomes are discussed. Recent evidence is synthesized to make clinical recommendations on the assessment and potential management of important autonomic, cerebral hemodynamics, and sleep-related dysfunction in people with SCI. Finally, a few recommendations for clinicians and researchers are provided.

Experiences of Participants with Spinal Cord Injury at an Active Rehabilitation Camp

This study explored the physical, social, and psychological benefits of an active rehabilitation (AR) camp as experienced by participants with spinal cord injury (SCI), and perceived fitness and mastery of being physically active six months after the camp. The study used a mixed-method design with pre- (n = 23), post- (n = 23), and follow-up questionnaires (n = 18) and individual interviews (n = 8). Fuzzy qualitative comparative analysis (fsQCA) was used to analyze the quantitative data and qualitative content analysis was used to analyze the qualitative data. Results showed that benefits were mainly experienced in the social and psychological domains. As for the physical domain, younger and more recently injured persons with tetraplegia reported more benefits. Six months after the camp, being in the preparation stage of change and being somewhat physically active were necessary and sufficient conditions for experiencing mastery of physical activity regardless of injury type, but only persons with paraplegia experienced fitness benefits. Qualitative data shed further light on the perceived benefits of the camp. The knowledge gained from this study might help practitioners to tailor interventions to individual needs and researchers to ask questions that take into consideration the complexity of active rehabilitation and changes in physical activity behavior for people with SCI.

Estimation of peak oxygen consumption in individuals with spinal cord injury patients using multiple linear regression analysis: a preliminary study

PURPOSE

This study aims to develop a regression model to estimate peak oxygen consumption (VO2peak) in individuals with spinal cord injury (SCI) by employing different variables.

METHODS

In this study, 34 participants were divided into two groups: 19 with cervical injury (CI) and 15 with thoracic injury (TI). Key measurements included VO2peak and related factors such as age, height, weight, body mass index (BMI), fat-free mass, body fat percentage, limb and trunk circumferences, spinal cord independence (SCIM III), Korean activities of daily living (K-ADL), and respiratory functions (forced vital capacity (FVC), peak expiratory flow (PEF), and maximum voluntary ventilation (MVV)). Statistical analyses were conducted using forward selection regression to examine the relationships between these variables.

RESULTS

Height, calf circumference, SCIM III score, and PEF were key variables in all patients with SCI (TSCI). For patients with CI, the key variables were height, calf circumference, and MVV, whereas for patients with TI, the key variable was calf circumference. The average explanatory powers of the VO2peak regression model for TSCI were 70.3% (R2) and 66.2% (adjusted R2), with an average standard error of estimate (SEE) of 2.94 ml/kg/min. The average explanatory power for patients with CI was 71.7% (R2) and 66.1% (adjusted R2), with an average SEE of 1.88 ml/kg/min. The average explanatory power for patients with TI was 55.9% (R2) and 52.5% (adjusted R2), with an average SEE of 3.41 ml/kg/min. There was no significant difference between the VO2peak measured and predicted VO2peak for each type of injury.

CONCLUSION

The regression model for estimating VO2peak in SCI patients in this preliminary study is as follows: TSCI=39.684-0.144×(Height)-0.513×(Calf)+0.136×(SCIM III)+1.187×(PEF), CI=38.842-0 .158×(Height) - 0.371×(Calf)+0.093×(MVV), TI=42.325-0.813×(Calf).

Exercise prescription for persons with spinal cord injury: a review of physiological considerations and evidence-based guidelines

Persons with spinal cord injury (SCI) experience gains in fitness, physical and mental health from regular participation in exercise and physical activity. Due to changes in physiological function of the cardiovascular, nervous, and muscular systems, general population physical activity guidelines and traditional exercise prescription methods are not appropriate for the SCI population. Exercise guidelines specific to persons with SCI recommend progressive training beginning at 20 min of moderate to vigorous intensity aerobic exercise twice per week transitioning to 30 min three times per week, with strength training of the major muscle groups two times per week. These population-specific guidelines were designed considering the substantial barriers to physical activity for persons with SCI and can be used to frame an individual exercise prescription. Rating of perceived exertion (i.e., perceptually regulated exercise) is a practical way to indicate moderate to vigorous intensity exercise in community settings. Adapted exercise modes include arm cycle ergometry, hybrid arm-leg cycling, and recumbent elliptical equipment. Body weight-supported treadmill training and other rehabilitation modalities may improve some aspects of health and fitness for people with SCI if completed at sufficient intensity. Disability-specific community programs offer beneficial opportunities for persons with SCI to experience quality exercise opportunities but are not universally available.

Exercise and aerobic capacity in individuals with spinal cord injury: A systematic review with meta-analysis and meta-regression

BACKGROUND

A low level of cardiorespiratory fitness [CRF; defined as peak oxygen uptake ([Formula: see text]O2peak) or peak power output (PPO)] is a widely reported consequence of spinal cord injury (SCI) and a major risk factor associated with chronic disease. However, CRF can be modified by exercise. This systematic review with meta-analysis and meta-regression aimed to assess whether certain SCI characteristics and/or specific exercise considerations are moderators of changes in CRF.

METHODS AND FINDINGS

Databases (MEDLINE, EMBASE, CENTRAL, and Web of Science) were searched from inception to March 2023. A primary meta-analysis was conducted including randomised controlled trials (RCTs; exercise interventions lasting >2 weeks relative to control groups). A secondary meta-analysis pooled independent exercise interventions >2 weeks from longitudinal pre-post and RCT studies to explore whether subgroup differences in injury characteristics and/or exercise intervention parameters explained CRF changes. Further analyses included cohort, cross-sectional, and observational study designs. Outcome measures of interest were absolute (A[Formula: see text]O2peak) or relative [Formula: see text]O2peak (R[Formula: see text]O2peak), and/or PPO. Bias/quality was assessed via The Cochrane Risk of Bias 2 and the National Institute of Health Quality Assessment Tools. Certainty of the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Random effects models were used in all meta-analyses and meta-regressions. Of 21,020 identified records, 120 studies comprising 29 RCTs, 67 pre-post studies, 11 cohort, 7 cross-sectional, and 6 observational studies were included. The primary meta-analysis revealed significant improvements in A[Formula: see text]O2peak [0.16 (0.07, 0.25) L/min], R[Formula: see text]O2peak [2.9 (1.8, 3.9) mL/kg/min], and PPO [9 (5, 14) W] with exercise, relative to controls (p < 0.001). Ninety-six studies (117 independent exercise interventions comprising 1,331 adults with SCI) were included in the secondary, pooled meta-analysis which demonstrated significant increases in A[Formula: see text]O2peak [0.22 (0.17, 0.26) L/min], R[Formula: see text]O2peak [2.8 (2.2, 3.3) mL/kg/min], and PPO [11 (9, 13) W] (p < 0.001) following exercise interventions. There were subgroup differences for R[Formula: see text]O2peak based on exercise modality (p = 0.002) and intervention length (p = 0.01), but there were no differences for A[Formula: see text]O2peak. There were subgroup differences (p ≤ 0.018) for PPO based on time since injury, neurological level of injury, exercise modality, and frequency. The meta-regression found that studies with a higher mean age of participants were associated with smaller changes in A[Formula: see text]O2peak and R[Formula: see text]O2peak (p < 0.10). GRADE indicated a moderate level of certainty in the estimated effect for R[Formula: see text]O2peak, but low levels for A[Formula: see text]O2peak and PPO. This review may be limited by the small number of RCTs, which prevented a subgroup analysis within this specific study design.

CONCLUSIONS

Our primary meta-analysis confirms that performing exercise >2 weeks results in significant improvements to A[Formula: see text]O2peak, R[Formula: see text]O2peak, and PPO in individuals with SCI. The pooled meta-analysis subgroup comparisons identified that exercise interventions lasting up to 12 weeks yield the greatest change in R[Formula: see text]O2peak. Upper-body aerobic exercise and resistance training also appear the most effective at improving R[Formula: see text]O2peak and PPO. Furthermore, acutely injured, individuals with paraplegia, exercising for ≥3 sessions/week will likely experience the greatest change in PPO. Ageing seemingly diminishes the adaptive CRF responses to exercise training in individuals with SCI.

REGISTRATION

PROSPERO: CRD42018104342.

Effects of Functional Electrical Stimulation Cycling Combined With Arm Cranking Exercise on Cardiorespiratory Fitness in People With Central Nervous System Disorders: A Systematic Review and Meta-analysis

OBJECTIVE

To examine the evidence regarding the potential of hybrid functional electrical stimulation (FES) cycling for improving cardiorespiratory fitness for people with a mobility disability related to a central nervous system (CNS) disorder.

DATA SOURCES

Nine electronic databases: MEDLINE, EMBASE, Web of Science, CINAHL, PsycInfo, SPORTDiscus, Pedro, Cochrane, and Scopus, were searched from inception until October 2022.

STUDY SELECTION

Search terms included multiple sclerosis, spinal cord injury (SCI), stroke, Parkinson's disease, cerebral palsy, synonyms of FES cycling, arm crank ergometry (ACE) or hybrid exercise, and V̇o2. All experimental studies, including randomized controlled trials that included an outcome measure related to peak or sub-maximal V̇o2 were eligible.

DATA EXTRACTION

From a total of 280 articles, 13 were studies included. The Downs and Black Checklist was used to assess study quality. Random effects (Hedges' g) meta-analyses were undertaken to determine whether there were differences in V̇o2peak during acute bouts of hybrid FES cycling vs other modes of exercise and changes resulting from longitudinal training.

DATA SYNTHESIS

During acute bouts of exercise, hybrid FES cycling was moderately more effective than ACE (effect size [ES] of 0.59 (95% CI 0.15-1.02, P=.008) in increasing V̇o2peak from rest. There was a large effect on the increase of V̇o2peak from rest for hybrid FES cycling compared with FES cycling (ES of 2.36 [95% CI 0.83-3.40, P=.003]). Longitudinal training with hybrid FES cycling showed a significant improvement in V̇o2peak from pre to post intervention with a large, pooled ES of 0.83 (95% CI 0.24-1.41, P=.006).

CONCLUSIONS

Hybrid FES cycling produced higher V̇o2peak compared with ACE or FES cycling during acute bouts of exercise. Hybrid FES cycling can improve cardiorespiratory fitness in people with SCI. Additionally, there is emerging evidence that hybrid FES cycling might increase aerobic fitness in people with mobility disability related to CNS disorders.

Effectiveness of the "Evidence-Based Scientific Exercise Guidelines" in Increasing Cardiorespiratory Fitness, Cardiometabolic Health, and Muscle Strength in Acute Spinal Cord Injury Rehabilitation: A Systematic Review

Objective

To determine the effect of exercise and physical activity interventions that meet current guideline recommendations on cardiorespiratory fitness, cardiometabolic health, and muscle strength in adults in the acute stage (<1 year post onset) of spinal cord injury (SCI) rehabilitation.

Data Sources

Six electronic databases (PubMed, CINAHL, SPORTDiscus, Google Scholar, National Institute Clinical Excellence, World Health Organization) were searched (January 2016-March 2022) to extend a previously published review.

Study Selection

Included studies implemented exercise interventions in the acute stage of SCI rehabilitation participants which met the exercise guidelines and measured cardiorespiratory fitness, cardiometabolic health, and strength outcomes.

Data Extraction

Titles and abstracts were screened against eligibility criteria and duplicates removed using EndNote X8. Full texts were independently assessed and results presented in a Preferred Reporting Items for Systematic Reviews and Meta-Analyses flowchart. Data extraction was completed on included studies by 2 reviewers (L.R. and V.B.) using a modified Cochrane Group form.

Data Synthesis

Data were synthesized, appraised using the Modified Downs & Black checklist and presented in narrative and tabular format. This review was registered on PROSPERO (Register ID:CRD42021249441). Of the 1255 studies, 4 were included, featuring 108 total participants <1-year post-SCI. Functional electrical stimulation cycle ergometry reduced muscle atrophy after 3 months training and increased lean body mass after 6 months. Resistance training increased muscle peak torque, perceived muscle strength and function. Aerobic exercise interventions did not increase cardiorespiratory fitness.

Conclusions

Interventions meeting the exercise guidelines did not increase cardiorespiratory fitness but were shown to improve cardiometabolic health and perceived muscle strength and function in adults in the acute stage of SCI rehabilitation. Further empirical research using standardized outcome measures are required to explore the effectiveness of aerobic exercise and strengthening interventions in acute stage of SCI rehabilitation to support the development of exercise guidelines.

Examining long-term motivational and behavioral outcomes of two physical activity interventions

OBJECTIVE

To examine possible impacts of two theory-based interventions - "Enhancing quality of life through exercise: A tele-rehabilitation approach (TEQ) and Active Living Lifestyles for individuals with SCI who use Wheelchair (ALLWheel)" - 12-18 months post-intervention on the satisfaction of psychological needs and motivation for leisure-time physical activity (LTPA), LTPA participation, and participation experience.

DESIGN

A mixed-methods follow-up study.

SETTING

Community.

PARTICIPANTS

Sixteen TEQ and six ALLWheel participants completed questionnaires and a semi-structured interview, 12-18 months after completing the interventions.

INTERVENTION

TEQ intervention participants received a weekly LTPA counseling session with a trained kinesiologist through videoconferencing for 8 weeks. ALLWheel participants interacted with a peer mentor who provided LTPA counseling using smartphones for 10 weeks.

OUTCOME MEASURES

The Psychological Need Satisfaction in Exercise, and the Treatment Self-Regulation Questionnaire were used as primary outcome measures. The LTPA barrier self-efficacy scale, the Measure of Experiential Aspects of Participation, and the 7-day LTPA Questionnaire for Adults with SCI were used as secondary outcome measures. A coding framework was created and deductive thematic analyses were used to analyze the qualitative data.

RESULTS

Medium to large effects were found for autonomous motivation (TEQ), competence (TEQ and ALLWheel), and barrier self-efficacy (TEQ and ALLWheel). LTPA remained higher for the TEQ intervention group compared to the control group at follow-up, while an increase in moderate-to-vigorous LTPA was found in ALLWheel participants.

CONCLUSION

Community-based tele-rehabilitation and virtual rehabilitation approaches, informed by theory, may assist adults with SCI in implementing LTPA over the long term.

Motor and autonomic concomitant health improvements with neuromodulation and exercise (MACHINE) training: a randomised controlled trial in individuals with spinal cord injury

INTRODUCTION

Motor and autonomic dysfunctions are widespread among people with spinal cord injury (SCI), leading to poor health and reduced quality of life. Exercise interventions, such as locomotor training (LT), can promote sensorimotor and autonomic recovery post SCI. Recently, breakthroughs in SCI research have reported beneficial effects of electrical spinal cord stimulation (SCS) on motor and autonomic functions. Despite literature supporting the independent benefits of transcutaneous SCS (TSCS) and LT, the effect of pairing TSCS with LT is unknown. These therapies are non-invasive, customisable and have the potential to simultaneously benefit both sensorimotor and autonomic functions. The aim of this study is to assess the effects of LT paired with TSCS in people with chronic SCI on outcomes of sensorimotor and autonomic function.

METHODS AND ANALYSIS

Twelve eligible participants with chronic (>1 year) motor-complete SCI, at or above the sixth thoracic segment, will be enrolled in this single-blinded, randomised sham-controlled trial. Participants will undergo mapping for optimisation of stimulation parameters and baseline assessments of motor and autonomic functions. Participants will then be randomly assigned to either LT+TSCS or LT+Sham stimulation for 12 weeks, after which postintervention assessments will be performed to determine the effect of TSCS on motor and autonomic functions. The primary outcome of interest is attempted voluntary muscle activation using surface electromyography. The secondary outcomes relate to sensorimotor function, cardiovascular function, pelvic organ function and health-related quality of life. Statistical analysis will be performed using two-way repeated measures Analysis of variance (ANOVAs) or Kruskal-Wallis and Cohen's effect sizes.

ETHICS AND DISSEMINATION

This study has been approved after full ethical review by the University of British Columbia's Research Ethics Board. The stimulator used in this trial has received Investigation Testing Authorisation from Health Canada. Trial results will be disseminated through peer-reviewed publications, conference presentations and seminars.

TRIAL REGISTRATION NUMBER

NCT04726059.

Effects of behaviour change interventions on physical activity in people with spinal cord injury: A systematic review and meta-analysis

OBJECTIVES

This review investigated the effectiveness of behaviour-change interventions to improve physical activity (PA) participation in individuals with a spinal cord injury. Additionally, the review sought to analyse the change in PA behaviour that might be expected by utilising behaviour change in PA interventions and what specific intervention characteristics, application of behaviour change theories, and behaviour change techniques are most efficacious.

METHODS

The protocol was prospectively registered on PROSPERO: CRD42021252744, and the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines were followed in this review. Eight databases were comprehensively searched using a well-defined strategy developed in collaboration with an academic liaison librarian. Randomised, non-randomised controlled, and non-controlled studies were included in this review; however, controlled and non-controlled studies were analysed separately. Studies were included if participants were older than 16 years and had an SCI of any cause, level or severity, regardless of the time since injury. The behaviour change technique taxonomy version 1 was used to code the intervention characteristics for behaviour modification. The combined effects across studies were pooled in a meta-analysis, and the risk of bias was assessed using the Cochrane Risk of Bias 2 tool.

RESULTS

The search retrieved 10,155 titles and abstracts. After duplicate removal and screening against the eligibility criteria, 23 studies were included. The overall effect estimate of the change in PA participation in the controlled trials post-intervention was medium (d = 0.50, 95% CI = 0.31-0.70) in favour of behaviour-targeted interventions. The mean difference in PA volume between pre- and post-intervention was an increase of 22 minutes per week (95% CI = 5.96-38.90). Interventions that provided practical support (d = 0.81, 95% CI = 0.46-1.16), which were individualised (d = 0.62, 95% CI = 0.34-0.90) and that utilised monitoring (d = 0.59, 95% CI = 0.34-0.83) had a greater effect on change to PA than those that were group-based and did not utilise those specific techniques.

CONCLUSIONS

Interventions that target behaviour change to increase PA in people with SCI appear effective. Utilising behaviour change frameworks and specific behaviour change techniques augments PA uptake and levels, and interventions aimed at improving PA in people with SCI should incorporate a behaviour modification component. More research is needed on the isolated effect of intervention structure parameters and specific behaviour change techniques.

Optimization of Protocols Using Neuromuscular Electrical Stimulation for Paralyzed Lower-Limb Muscles to Increase Energy Expenditure in People With Spinal Cord Injury

OBJECTIVE

The aim of this study was to evaluate whether using surface neuromuscular electrical stimulation (NMES) for paralyzed lower-limb muscles results in an increase in energy expenditure and whether the number of activated muscles and duty cycle affect the potential increase.

DESIGN

This was a cross-sectional study.

RESULTS

Energy expenditure during all NMES protocols was significantly higher than the condition without NMES (1.2 ± 0.2 kcal/min), with the highest increase (+51%; +0.7 kcal/min, 95% confidence interval, 0.3-1.2) for the protocol with more muscles activated and the duty cycle with a shorter rest period. A significant decrease in muscle contraction size during NMES was found with a longer stimulation time, more muscles activated, or the duty cycle with a shorter rest period.

CONCLUSION

Using NMES for paralyzed lower-limb muscles can significantly increase energy expenditure compared with sitting without NMES, with the highest increase for the protocol with more muscles activated and the duty cycle with a shorter rest period. Muscle fatigue occurred significantly with the more intense NMES protocols, which might cause a lower energy expenditure in a longer protocol. Future studies should further optimize the NMES parameters and investigate the long-term effects of NMES on weight management in people with SCI.

Application of Vagus Nerve Stimulation in Spinal Cord Injury Rehabilitation

Spinal cord injury (SCI) is a prevalent devastating condition causing significant morbidity and mortality, especially in developing countries. The pathophysiology of SCI involves ischemia, neuroinflammation, cell death, and scar formation. Due to the lack of definitive therapy for SCI, interventions mainly focus on rehabilitation to reduce deterioration and improve the patient's quality of life. Currently, rehabilitative exercises and neuromodulation methods such as functional electrical stimulation, epidural electrical stimulation, and transcutaneous electrical nerve stimulation are being tested in patients with SCI. Other spinal stimulation techniques are being developed and tested in animal models. However, often these methods require complex surgical procedures and solely focus on motor function. Vagus nerve stimulation (VNS) is currently used in patients with epilepsy, depression, and migraine and is being investigated for its application in other disorders. In animal models of SCI, VNS significantly improved locomotor function by ameliorating inflammation and improving plasticity, suggesting its use in human subjects. SCI patients also suffer from nonmotor complications, including pain, gastrointestinal dysfunction, cardiovascular disorders, and chronic conditions such as obesity and diabetes. VNS has shown promising results in alleviating these conditions in non-SCI patients, which makes it a possible therapeutic option in SCI patients.

Prediction of leg muscle activities from arm muscle activities in arm and leg cycling

Functional electrical stimulation (FES) driven leg cycling is usually controlled by previously established stimulation patterns. We investigated the potential utilization of a particular computational method for controlling electrical stimulation of lower limb muscles by real-time electromyography (EMG) signals of arm muscles during hybrid arm and leg cycling. In hybrid arm and leg cycling, arm cranking is performed voluntarily, while leg cycling is driven by FES. In this study, we investigate arm and leg cycling movements of able-bodied persons when both arm and leg cycling is performed voluntarily without FES. We present a neural network-based model in which the input of the neural network is given by a time series of upper limb muscle activities (EMG), and the output provides potential lower limb muscle activities. The particular neural network was a nonlinear autoregressive exogen (NARX) neural network. The measured EMG signals of the lower limb muscles were compared to the signals that were predicted by the neural network. The neural network was trained with data recorded from four participants. Our preliminary results show notable differences between the predicted and the experimentally measured lower limb muscle activities. The prediction was good only for 60% of the movement time. We conclude that-while including arm cycling in the movement-simpler control modalities or further consideration of applying machine-learning techniques has to be taken into account to improve voluntary upper limb-controlled FES assisted leg cycling.

Effectiveness of robotic-assisted gait training on cardiopulmonary fitness and exercise capacity for incomplete spinal cord injury: A systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

To determine the effects of robotic-assisted gait training on cardiopulmonary fitness and exercise capacity for people with incomplete spinal cord injury.

METHODS

PubMed, Embase, Web of Science, PEDro, CENTRAL and CINAHL were searched from inception until September 4, 2022. Randomized controlled trials that evaluated the effects of robotic-assisted gait training on cardiopulmonary fitness and exercise capacity for individuals with incomplete spinal cord injury were selected. Mean differences (MD) with 95% confidence interval (CI) were calculated. The methodological quality was evaluated by the Cochrane Risk of Bias 2.0 tool. Subgroup analyses were conducted according to the time since injury.

RESULTS

In total 19 studies involving 770 patients were eligible for analysis. Individuals with acute incomplete spinal cord injury in robotic-assisted gait training groups showed significantly greater improvements in 6-minute walking test (MD 53.32; 95% CI 33.49 to 73.15; P < 0.001), lower extremity motor scale (MD 5.22; 95% CI 3.63 to 6.80; P < 0.001) and walking index for spinal cord injury II (MD 3.18; 95% CI 1.34 to 5.02; P < 0.001). Robotic-assisted gait training improved peak oxygen consumption to a greater degree for chronic incomplete spinal cord injury patients (MD 4.90; 95% CI 0.96 to 8.84; P = 0.01).

CONCLUSION

Robot-assisted gait training may be a feasible and effective intervention in terms of cardiopulmonary fitness and exercise capacity for individuals with incomplete spinal cord injury.

Physical Activity and Health of Koreans with Spinal Cord Injury during COVID-19

Objectives: The primary purpose of this study was to explore the mediating roles of resilience and physical activity (PA) levels on the subjective health of people with spinal cord injury(SCI) during the COVID-19 pandemic.Methods: A total of 201 Koreans with SCI completed a survey between February and April 2021. The questionnaire measured participants' PA levels before and during the COVID-19 pandemic, resilience, and subjective health assessment. The data were analyzed using SPSS, and PROCESS macro (Model 6) was used to determine the dual mediation effects. Results: PA levels before COVID-19 positively affected resilience and PA levels during COVID-19, and resilience positively affected PA levels during COVID-19 and subjective health. PA levels during COVID-19 had a positive influence on subjective health. Moreover, resilience and PA levels during COVID-19 were independent mediators of the relationship between PA levels before COVID-19 and subjective health. PA levels before COVID-19 indirectly affected subjective health through a dual-mediated pathway of resilience and PA levels during COVID-19. Conclusion: We suggest that it is necessary to promote regular PA for people with physical disabilities to enhance resilience, and thus, maintain a healthy life even during a public health crisis.

Feasibility study of high-intensity interval training to reduce cardiometabolic disease risks in individuals with acute spinal cord injury

INTRODUCTION

Individuals ageing with spinal cord injury (SCI) experience an accelerated trajectory of diseases and disorders, such as cardiovascular disease and diabetes, that resemble those experienced with ageing alone. Currently, an evidence-based approach toward managing this problem does not exist and therefore the purpose of this study is to determine the feasibility of conducting a high-intensity exercise intervention in individuals with acute (<6 months postinjury) SCI to improve cardiometabolic health.

METHODS AND ANALYSIS

We will conduct a single-centre, two parallel-arm, randomised feasibility study of a high-intensity interval training (HIIT) intervention in individuals with acute SCI. We will enrol 40 individuals (20 intervention, 20 control) with acute SCI attending inpatient rehabilitation at Salisbury District Hospital. Participants will be randomly allocated to the intervention group (HIIT) or control group for 18 weeks. Both groups will participate in standard care throughout the duration of the study. The HIIT group only will also perform supervised HIIT exercise on an arm cycle ergometer three times per week. Over the course of the intervention, most participants will be discharged from the hospital, and at this time, an arm cycle ergometer will be installed in their home and the intervention will transition into outpatient care. We will assess cardiorespiratory fitness, glycaemic control, lipid profile and body habitus as well as qualitative assessments of acceptability at weeks 0, 9 and 18 with the primary outcome being the feasibility of a full Randomised Controlled Trial (RCT).

ETHICS AND DISSEMINATION

This study will inform a longer-term, definitive, multicentre RCT to establish the impact of this exercise intervention in maintaining the cardiometabolic health of patients during the acute phase following SCI. Results will be disseminated in different formats including peer-reviewed journal articles, conference presentations and internet media, to a wide audience including clinicians, researchers and individuals with SCI.

TRIAL REGISTRATION NUMBER

ISRCTN57514022.

Effects of a 12-week, seated, virtual, home-based tele-exercise programme compared with a prerecorded video-based exercise programme in people with chronic neurological impairments: protocol for a randomised controlled trial

INTRODUCTION

Exercise is vital to staying well and preventing secondary complications in people with chronic neurological impairments (CNI). Appropriate exercise is often inaccessible to this population. The purpose of the study is to investigate the effects of a seated, virtual exercise programme on heart rate, recovery, fatigue, pain, motivation, enjoyment and quality of life in people with CNI.

METHODS AND ANALYSIS

Individuals with CNI will be screened for eligibility, and 60 participants will be randomised 1:1 into either a live or prerecorded group. There is no geographical limitation to where participants reside, since participation is virtual. The study will be coordinated by one site in White Plains, New York, USA. The live group will exercise with an instructor via Zoom while the prerecorded group will exercise at their chosen time using prerecorded videos, 3×/week for 12 weeks.

PRIMARY OUTCOME MEASURES

change in heart rate during exercise/recovery.

SECONDARY OUTCOME MEASURES

fatigue, motivation, level of pain and exertion, physical well-being, enjoyment of physical activity, motivation and quality of life. Outcomes will be assessed at baseline, midpoint, end of study and 1-month poststudy. Adverse events, medication changes and physical activity will be tracked throughout. Within-group and between-group comparisons will be performed by using analysis of covariance and regression.

ETHICS AND DISSEMINATION

BRANY IRB approval: 22 September 2020, protocol #20-08-388-512. All participants will provide written informed consent. Results will be disseminated through presentations, publications and ClinicalTrials.gov.

TRIAL REGISTRATION NUMBER

NCT04564495.

Dissonance in views between healthcare professionals and adults with a spinal cord injury with their understanding and interpretation of exercise intensity for exercise prescription

Objectives

To evaluate the difference between healthcare professionals (HCPs) and adults with spinal cord injury (SCI) in Asia regarding knowledge and interpretation of 'exercise intensity' for aerobic exercise prescription.

Methods and study design

A survey was distributed to practising HCP and adults with SCI. It was completed in participants' local language on topics related to the importance of exercise frequency, intensity, time and type; methods for monitoring and terms related to exercise intensity prescription. χ² analysis was used to detect differences in HCP or those with SCI.

Results

121 HCP and 107 adults with an SCI ≥1 years (C1-L4) participated. Responses revealed 61% of all HCP ranked 'intensity' being most important whereas only 38% respondents from the SCI group ranked it as high importance (p=0.008). For those with SCI, 'frequency' was most important (61%) which was significantly higher than the 45% selected by HCPs (p=0.030). Of the 228 respondents on average only 34% believed that the terms, 'moderate' and 'vigorous' provided enough information for aerobic exercise intensity prescription. HCP most often used HR methods compared with the SCI group (90% vs 54%; p<0.01). Both groups frequently used the subjective measures of exercise intensity, for example, Ratings of Perceived Exertion (8%3 vs 76% for HCP and SCI), HCP also frequently used speed (81%) and SCI also frequently relied on 'the affect' or feelings while exercising (69%).

Conclusions

These differences must be considered when developing clinical-practice exercise guidelines and health referral educational pathways for adults with SCI in Asia.

Physical activity promotion to persons with spinal cord injury by health and exercise professionals: A scoping review

OBJECTIVES

Health and exercise professionals (HEPs) are ideal promoters and valued messengers of physical activity (PA) information among persons with spinal cord injury (SCI). However, little is known about what strategies used by HEPs increase PA behavior in persons with SCI, or what factors influence HEPs when promoting PA to persons with SCI. The purposes of this scoping review were to (1) ascertain the extent, range and nature of the literature, (2) identify strategies used by HEPs that are associated with an increase in PA behavior for persons with SCI, and (3) identify the facilitators and barriers to PA promotion by the HEPs.

METHODS

A comprehensive search was undertaken. Search terms were expanded surrounding three key terms: PA, promotion, and SCI.

RESULTS

Twenty-four articles representing 18 unique studies were identified. HEPs predominantly consisted of physiotherapists, occupational therapists, and leisure trainers/therapists. Most interventions were delivered by HEPs to persons with SCI in in-patient rehabilitation centres and community-based settings. Tailored exercise programs and on-going counseling support were considered essential for increasing PA behavior. HEPs' common barriers to PA promotion were perceived lack of time, education, and training.

CONCLUSION

A need to improve and sustain SCI-specific PA knowledge and education was identified if PA promotion is to become a structured and integral component of practice. This study provides valuable information for interventions to increase PA behavior among persons with SCI by improving PA promotion by HEPs.

Leisure-Time Physical Activity in People With Spinal Cord Injury-Predictors of Exercise Guideline Adherence

Objectives: This study described leisure-time physical activity (LTPA) for people in Australia with spinal cord injury (SCI) and whether certain sociodemographic and psychosocial variables might be associated with LTPA uptake and guidelines adherence. Methods: The Physical Activity Scale for Individuals with a Physical Disability was used to measure the intensity and volume of LTPA of 1,579 individuals with SCI. Summary statistics were calculated for LTPA guidelines adherence. Analyses included regression modelling. Results: Of the 1,579 participants, 58% performed LTPA and 13% adhered to recommended guidelines for weekly LTPA. There was an association with being an "exerciser" based on the time since injury (OR = 1.02 [95% 1.01-1.03]), a traumatic injury (OR = 1.53 [95% CI 1.13-2.08]) and a higher self-rating of health (OR = 1.10 [95% CI 0.95-1.27]). Where LTPA guidelines were met, adherence was most related to a traumatic injury (OR = 1.75 [95% CI 1.02-3.02]) and being unemployed (OR = 1.53 [95% CI 1.03-2.25]). Conclusion: Of those who performed LTPA with SCI, one in four met population-specific LTPA guidelines. Sociodemographic variables were moderately associated with being an "exerciser" or LTPA "guideline-adherent."

Systemic inflammation after spinal cord injury: A review of biological evidence, related health risks, and potential therapies

Individuals with chronic traumatic spinal cord injury (SCI) develop progressive multi-system health problems that result in clinical illness and disability. Systemic inflammation is associated with many of the common medical complications and acquired diseases that accompany chronic SCI, suggesting that it contributes to a number of comorbid pathological conditions. However, many of the mechanisms that promote persistent systemic inflammation and its consequences remain ill-defined. This review describes the significant biological factors that contribute to systemic inflammation, major organ systems affected, health risks, and the potential treatment strategies. We aim to highlight the need for a better understanding of inflammatory processes, and to establish appropriate strategies to address inflammation in SCI.

Feasibility of an Upper Limb Strength Training Program in Persons with Spinal Cord Injury during Primary Rehabilitation-An Uncontrolled Interventional Study

Data concerning the outcomes of standardized strength-training programs in people with acute spinal cord injury (SCI) are scarce. The present study evaluated the feasibility and effects of a clinic-internal strength-training concept in people with paraplegia during the course of primary rehabilitation. For this purpose, participants followed a 10-12 week standardized supervised strength-training program (30 training sessions) during primary rehabilitation. At the beginning, 5-6 weeks and 10-12 weeks later, maximal strength based on indirect one-repetition maximum (1RM) measurements for two specific exercises (triceps press; horizontal rowing pull) was determined. Twelve out of 17 participants successfully completed the study. Maximal weights for 1RM significantly increased over the 10-12 week training program for the triceps press (+30%; p = 0.018) and the horizontal rowing pull (+41%; p = 0.008). Training compliance was 95%. Reasons for study exclusion were urgent surgery (n = 2), cardio-respiratory complications (n = 1), shoulder pain (n = 1) and a training compliance of less than 50% (n = 1). In conclusion, a supervised and standardized strength-training program during primary rehabilitation of people with paraplegia is feasible and leads to significant increases in maximal strength. Although study participants showed a high training compliance, factors such as medical complications may impede the proper implementation of a strength-training concept into daily clinical practice.

Cultural validation and language translation of the scientific SCI exercise guidelines for use in Indonesia, Japan, Korea, and Thailand

CONTEXT

Indonesia, Japan, Korea, Thailand.

OBJECTIVE

To culturally validate and translate the Scientific Exercise Guidelines for Adults with Spinal Cord Injury (SEG-SCI) for use in four Asian countries.

DESIGN

Systematic Review.

PARTICIPANTS

N/A.

METHODS

A systematic review was conducted to identify all published English- and local-language studies conducted in Indonesia, Japan, Korea, and Thailand, testing the effects of exercise training interventions on fitness and cardiometabolic health in adults with acute or chronic SCI. Protocols and results from high-quality controlled studies were compared with the SEG-SCI. Forward and backward translation processes were used to translate the guidelines into Bahasa Indonesian, Japanese, Korean and Thai languages.

RESULTS

Fifteen studies met the review criteria. At least one study from each country implemented exercise prescriptions that met or exceeded the SEG-SCI. Two were controlled studies. In those two studies, relative to control conditions, participants in exercise conditions achieved significant improvements in fitness or cardiometabolic health outcomes only when the exercise intervention protocol met or exceeded the SEG-SCI. During the language translation processes, end-users confirmed that SEG-SCI language and terminology were clear.

CONCLUSION

Clinical researchers in Indonesia, Japan, Korea and Thailand have implemented exercise protocols that meet or exceed the SCI-SEG. Results of high-quality studies align with the SEG-SCI recommendations. Based on this evidence, we recommend that the SEG-SCI be adopted in these countries. The cultural validation and translation of the SEG-SCI is an important step towards establishing consistent SCI exercise prescriptions in research, clinical and community settings around the world.

Cardiovascular and cerebrovascular responses to urodynamics testing after spinal cord injury: The influence of autonomic injury

Autonomic dysfunction is a prominent concern following spinal cord injury (SCI). In particular, autonomic dysreflexia (AD; paroxysmal hypertension and concurrent bradycardia in response to sensory stimuli below the level of injury) is common in autonomically-complete injuries at or above T6. AD is currently defined as a >20 mmHg increase in systolic arterial pressure (SAP) from baseline, without heart rate (HR) criteria. Urodynamics testing (UDS) is performed routinely after SCI to monitor urological sequelae, often provoking AD. We, therefore, aimed to assess the cardiovascular and cerebrovascular responses to UDS and their association with autonomic injury in individuals with chronic (>1 year) SCI. Following blood draw (plasma norepinephrine [NE]), continuous SAP, HR, and middle cerebral artery blood flow velocity (MCAv) were recorded at baseline (10-minute supine), during standard clinical UDS, and recovery (10-minute supine) (n = 22, age 41.1 ± 2 years, 15 male). Low frequency variability in systolic arterial pressure (LF SAP; a marker of sympathetic modulation of blood pressure) and cerebral resistance were determined. High-level injury (≥T6) with blunted/absent LF SAP (<1.0 mmHg²) and/or low plasma NE (<0.56 nmol•L⁻¹) indicated autonomically-complete injury. Known electrocardiographic markers of atrial (p-wave duration variability) and ventricular arrhythmia (T-peak–T-end variability) were evaluated at baseline and during UDS. Nine participants were determined as autonomically-complete, yet 20 participants had increased SAP >20 mmHg during UDS. Qualitative autonomic assessment did not discriminate autonomic injury. Maximum SAP was higher in autonomically-complete injuries (207.1 ± 2.3 mmHg) than autonomically-incomplete injuries (165.9 ± 5.3 mmHg) during UDS (p < 0.001). HR during UDS was reduced compared to baseline (p = 0.056) and recovery (p = 0.048) only in autonomically-complete lesions. MCAv was not different between groups or phases (all p > 0.05). Cerebrovascular resistance index was increased during UDS in autonomically-complete injuries compared to baseline (p < 0.001) and recovery (p < 0.001) reflecting intact cerebral autoregulation. Risk for both atrial and ventricular arrhythmia increased during UDS compared to baseline (p < 0.05), particularly in autonomically-complete injuries (p < 0.05). UDS is recommended yearly in chronic SCI but is associated with profound AD and an increased risk of arrhythmia, highlighting the need for continued monitoring during UDS. Our data also highlight the need for HR criteria in the definition of AD and the need for quantitative consideration of autonomic function after SCI.

The effects of active upper-limb versus passive lower-limb exercise on quality of life among individuals with motor-complete spinal cord injury

STUDY DESIGN

Multi-centre randomized clinical trial.

OBJECTIVES

(1) compare the effects of arm-cycle ergometry (ACET) and body weight supported treadmill training (BWSTT) on quality of life (QOL) and intermediary variables in individuals with spinal cord injury (SCI); (2) examine correlations between baseline measures, and changes in physical activity, QOL, and intermediaries.

SETTING

Hospital-based research institutes (Vancouver, Toronto) and University-based exercise program (Hamilton).

METHODS

35 participants with motor-complete SCI above T6 completed baseline assessments of physical activity, life satisfaction, independence, autonomy, positive and negative affect, and pain. Twenty-eight participants were randomized to 72 sessions of ACET (n = 14) or BWSTT (n = 14) with measures repeated following 36 sessions, 72 sessions, and 6-months post-intervention.

RESULTS

Neither intervention significantly impacted QOL. Pain was reduced in ACET compared to BWSTT (interaction effect p = 0.022) and was significantly less at 72 sessions vs. baseline in the ACET group (p = 0.009). At baseline, QOL was positively correlated with independence, autonomy, and positive affect and negatively correlated with negative affect (all p < 0.05). Following BWSTT, changes in moderate-vigorous physical activity correlated with changes in QOL (r = 0.87, p = 0.010). Following ACET, changes in autonomy and independence were positively correlated with changes in QOL (both r > 0.64, p < 0.048).

CONCLUSIONS

Contrary to previous studies, there was no benefit of either intervention on measures of QOL. The social context of exercise may be important for improving QOL. However, individuals may benefit more from active (ACET) than passive (BWSTT) exercise modalities through reduced pain. Exercise interventions that improve autonomy and independence may lead to improvements in QOL.

Impact of COVID-19 on the self-reported physical activity of people with complete thoracic spinal cord injury full-time manual wheelchair users

CONTEXT

The emergence of COVID-19 caused a new public health crisis, leading to major changes in daily life routines, often including physical activity (PA) levels. The main goal of this study was to analyze the differences in self-reported physical activity of people with complete spinal cord injuries between the time prior to the COVID-19 lockdown and the lockdown period itself.

METHODS

A sample of 20 participants with complete thoracic spinal cord injuries completed the Physical Activity Scale for Individuals with Physical Disabilities before and during the COVID-19 lockdown.

RESULTS

The results showed differences between the pre-lockdown and lockdown measurements in total self-reported PA (z=-3.92; P<0.001; d=1.28), recreational PA (z=-3.92; P<0.001; d=1.18) and occupational PA (z=-2.03; P=0.042; d=0.55). Nevertheless, no differences were found in housework PA between the two time periods. Furthermore, the results showed differences in total minutes (z=-3.92; P<0.001; d=1.75), minutes spent on recreational activities (z=-3.82; P<0.001; d=1.56) and minutes spent on occupational activities (z=-2.032; P=0.042; d=0.55) of moderate/vigorous intensity.

CONCLUSIONS

Individuals with thoracic spinal cord injuries who were full-time manual wheelchair users displayed lower levels of PA during the pandemic than in the pre-pandemic period. The results suggest that the prohibition and restrictions on carrying out recreational and/or occupational activities are the main reasons for this inactivity. Physical activity promotion strategies should be implemented within this population to lessen the effects of this physical inactivity stemming from the COVID-19 pandemic.

The impact of sport participation for individuals with spinal cord injury: A scoping review

BACKGROUND: Spinal cord injury (SCI) leads to various physical, psychological, and social challenges. Sport is a holistic physical activity that may target these challenges. No literature systematically summarizes the overall impact of sport participation for those with SCI. OBJECTIVE: To comprehensively report the findings of quantitative studies investigating the impact of sport on the physical, psychological, and social health of individuals with SCI. METHODS: Six databases were searched: APA PsycInfo, CINAHL, Embase, Emcare, Ovid Medline, and PubMed (non-Medline). Studies were included if (a) participants were adults with SCI for ≥12 months, (b) outcomes resulting from ≥3 months of sport participation were investigated, (c) sport occurred in the community setting, and (d) comparisons of sport and non-sport conditions were analyzed. Details regarding study characteristics, participants, sport(s), and outcomes were extracted. Methodological quality was assessed using the Modified Downs and Black checklist. RESULTS: Forty-nine studies were included. Study quality ranged from poor to moderate. Sport participation showed favourable results for outcomes including function, quality of life, and community integration. Mixed results were found for outcomes including cardiac function, depressive symptoms, and employment. No significant associations were found for postural control, resilience, and education. CONCLUSIONS: The review findings suggest sport may be a promising intervention for addressing some challenges associated with SCI.

A Scoping Review of the Characteristics of Activity-based Therapy Interventions Across the Continuum of Care for People Living With Spinal Cord Injury or Disease

Objective

To identify the characteristics of activity-based therapy (ABT) that individuals with spinal cord injury and disease (SCI/D) participate in across the continuum of care.

Data Sources

A search of 8 databases was conducted from inception to 4 March 2020: Medline, CINAHL, Embase, Emcare, PEDro, APA PsycINFO, Cochrane Database of Systematic Reviews, and the CENTRAL. The search strategy used terms identifying the population (SCI/D) and concept (ABT).

Study Selection

Original studies involving individuals with SCI/D ≥16 years of age participating in ABT interventions for >1 session were included in the review. The Joanna Briggs Institute guidelines for scoping reviews were followed. The initial search produced 2306 records. Title, abstract, and full-text screening by 2 independent reviewers yielded 140 articles.

Data Extraction

Data extraction was conducted by 3 independent reviewers and charted according to key themes. Data fields included participant demographics, ABT interventions, exercises, parameters, technology, and setting. Data synthesis included frequency counts and descriptive analysis of key themes.

Data Synthesis

Eighty percent of participants were male. Eighty-seven percent of studies included individuals with tetraplegia (26% exclusive). Fifty-six percent of studies occurred in a research lab. Fifty-four percent of studies were single modality interventions encompassing the whole body (71%). Sixteen main types of ABT exercises were identified. The most common were treadmill training (59%), muscle strengthening (36%), and overground walking (33%). Electrical stimulation (50%) and virtual reality (6%) were used in combination with an ABT exercise. Eighty-four types of parameters were identified. Six were general intervention parameters and 78 were specific to the type of ABT exercise. Sixteen main categories of technology were reported. The most common were motorized treadmills (47%) and transcutaneous electrical stimulation (44%).

Conclusions

The characteristics of ABT are diverse in scope. The results will inform the content to include in tools that track ABT participation and performance.

Association between weekly exercise minutes and resting IL-6 in adults with chronic spinal cord injury: findings from the fracture risk after spinal cord injury exercise study

STUDY DESIGN

Cross-sectional study.

OBJECTIVE

To assess associations between weekly aerobic exercise minutes and resting interleukin-6 (IL-6), C-reactive protein (CRP), or leptin levels in adults with chronic spinal cord injury (SCI).

SETTING

Three hundred and forty-four community-dwelling men and women with SCI duration of > 1 year.

METHODS

CRP, IL-6, and leptin levels were quantified by ultra-sensitive enzyme-linked immunoassay. Smoking, medication use, comorbidities, and aerobic exercise minutes per week were assessed by self-reported questionnaire. Body composition was determined by whole-body dual-energy X-ray absorptiometry. Generalized linear models were used to assess associations.

RESULTS

In multivariable modeling, resting IL-6 levels were 0.001 pg/mL lower for every 1 min of weekly aerobic exercise. IL-6 levels increased with increasing android-to-gynoid fat ratio, in active/ever smokers compared to never smokers, and in individuals with skin pressure injuries compared to those without. IL-6 levels were lower in active ibuprofen users compared to nonusers. We found no association between weekly exercise minutes and CRP or leptin when designing similar models.

CONCLUSIONS

Increasing aerobic exercise minutes is associated with lower IL-6 levels in adults with chronic SCI when considering body composition, smoking, skin pressure injuries, and ibuprofen use. CRP and leptin did not demonstrate an association with exercise when considering the similar variables. The use of these biomarkers in assessing the therapeutic value of future exercise-related interventions will be paramount for meaningful health improvement among those with SCI. Although a large, prospective dataset, this cross-sectional study cannot assign causation. Future prospective studies are needed to confirm these findings.

Adaptive Sports in Spinal Cord Injury: a Systematic Review

Purpose of Review

Recent Findings

Summary

Cardiometabolic risk profiling during spinal cord injury rehabilitation: A longitudinal analysis from Swiss Spinal Cord Injury cohort (SwiSCI)

BACKGROUND

Early screening is important in individuals with spinal cord injury (SCI) as they were deemed high-risk for cardiometabolic diseases. Few studies explored changes in cardiometabolic risk profile in the early phase of the injury. Thus, it remains unclear how early the cardiometabolic status deteriorates after injury.

OBJECTIVE

We determined the longitudinal changes in the cardiometabolic risk profile and examined the association between injury characteristics and cardiometabolic status in subacute SCI.

SETTING

Multicenter Swiss Spinal Cord Injury Cohort.

PARTICIPANTS

Adults with traumatic SCI without history of cardiovascular disease or type 2 diabetes.

MAIN OUTCOME MEASURES

Blood pressure (BP), lipid profile, fasting glucose, waist circumference (WC), weight, body mass index (BMI) and Framingham risk score (FRS) were compared across time and according to the injury characteristics.

RESULTS

We analyzed the data of 258 individuals with traumatic SCI (110 tetraplegia and 148 paraplegia, 122 motor complete and 136 incomplete). The median age was 50 years (IQR 32-60), with 76.36% (n=197) of the population being male. The median rehabilitation duration was 5.5 months (IQR 3.2-7.1). At admission to rehabilitation, fully-adjusted linear regression models showed higher baseline weight (β 0.06, 95% CI 0.005, 0.11), systolic BP (β 0.05, 95% CI 0.008, 0.09), diastolic BP (β 0.05 95% CI 0.004, 0.10), and triglycerides (β 0.27 95% CI 0.13, 0.42) in paraplegia than tetraplegia. Systolic BP, diastolic BP, HDL-C were higher in incomplete than complete injury. In our main analysis, we observed an increase in cholesterol and HDL-C and lipid ratio when comparing the beginning and end of rehabilitation. Individuals with paraplegia had a higher increase in BMI than tetraplegia, while no differences in other cardiometabolic risk factors were detected when comparing motor incomplete and complete injury. Trajectories of each participant showed that the majority of individuals with SCI decreased FRS score at follow-up compared to baseline and no significant changes in prevalence of cardiometabolic syndrome were observed. At discharge, one-third of study participants were classified as moderate to high risk of CVD, 64% were overweight, and 39.45% had cardiometabolic syndrome.

CONCLUSION

We observed a modest improvement in lipid profile and FRS during the first inpatient rehabilitation hospitalization. Injury characteristics, such as level and completeness, were not associated with changes in cardiometabolic risk factors in the subacute phase of the injury. Despite this, a significant proportion of study participants remained at risk of cardiometabolic disease at discharge, suggesting that early cardiometabolic preventive strategies may be initiated as early as during the first inpatient rehabilitation hospitalization. This article is protected by copyright. All rights reserved.

A multimodality intervention to improve musculoskeletal health, function, metabolism, and well-being in spinal cord injury: study protocol for the FIT-SCI randomized controlled trial

BACKGROUND

A spinal cord injury (SCI) is a devastating, life-changing event that has profoundly deleterious effects on an individual's health and well-being. Dysregulation of neuromuscular, cardiometabolic, and endocrine organ systems following an SCI contribute to excess morbidity, mortality and a poor quality of life. As no effective treatments currently exist for SCI, the development of novel strategies to improve the functional and health status of individuals living with SCI are much needed. To address this knowledge gap, the current study will determine whether a Home-Based Multimodality Functional Recovery and Metabolic Health Enhancement Program that consists of functional electrical stimulation of the lower extremity during leg cycling (FES-LC) plus arm ergometry (AE) administered using behavioral motivational strategies, and testosterone therapy, is more efficacious than FES-LC plus AE and placebo in improving aerobic capacity, musculoskeletal health, function, metabolism, and wellbeing in SCI.

METHODS

This single-site, randomized, placebo-controlled, parallel group trial will enroll 88 community-dwelling men and women, 19 to 70 years of age, with cervical and thoracic level of SCI, ASIA Impairment Scale grade: A, B, C, or D, 6 months or later after an SCI. Participants randomized to the multimodality intervention will undergo 16 weeks of home-based FES-LC and AE training plus testosterone undecanoate. Testosterone undecanoate injections will be administered by study staff in clinic or by a visiting nurse in the participant's home. The control group will receive 16 weeks of home-based FES-LC and AE exercise plus placebo injections. The primary outcome of this trial is peak aerobic capacity, measured during an incremental exercise testing protocol. Secondary outcomes include whole body and regional lean and adipose tissue mass; muscle strength and power; insulin sensitivity, lipids, and inflammatory markers; SCI functional index and wellbeing (mood, anxiety, pain, life satisfaction and depressive symptoms); and safety.

DISCUSSION

We anticipate that a multimodality intervention that simultaneously addresses multiple physiological impairments in SCI will result in increased aerobic capacity and greater improvements in other musculoskeletal, metabolic, functional and patient-reported outcomes compared to the control intervention. The findings of this study will have important implications for improving the care of people living with an SCI.

TRIAL REGISTRATION

ClinicalTrials.gov :  ( NCT03576001 ). Prospectively registered: July 3, 2018.

Wheelchair-modified ergometer rowing exercise in individuals with spinal cord injury: a feasibility, acceptability, and preliminary efficacy study

STUDY DESIGN

Exploratory clinical investigation.

OBJECTIVES

To assess the feasibility, acceptability, and preliminary efficacy of upper-body rowing exercise adapted to wheelchair users with spinal cord injury (SCI).

SETTING

University exercise laboratory.

METHODS

Eight individuals with SCI exercised on a rowing ergometer modified for wheelchair users (REMW), three times weekly, for up to 30 min per session. Participants completed feasibility and acceptability questionnaire (1-5 Likert scale), and the Wheelchair Users Shoulder Pain Index (WUSPI) before and after six weeks of exercise. Average power output (PO_AVG), distance rowed, percent peak heart rate (%HR_peak), and rating of perceived exertion (RPE) (6-20 scale) were monitored throughout the 18 exercise sessions and analyzed to evaluate preliminary efficacy of the exercise modality.

RESULTS

All eight participants completed the study (97% adherence). Participants rated the exercise high on the feasibility and acceptability scale; median (interquartile range) = 5.0 (4.0-5.0), where higher numbers indicated greater feasibility. Shoulder pain was reduced by 21% yet not significantly different from baseline (p = 0.899). Physiological measures (%HR_peak = 80-83%; RPE = 15.0-16.0) indicated a high cardiovascular training load. From week 1 to week 6, PO_AVG and distance rowed increased by 37 and 36%, respectively (both p ≤ 0.001).

CONCLUSIONS

Data from six weeks of exercise on the REMW suggests that upper-body rowing is a feasible and acceptable exercise modality for wheelchair users with SCI. Session data on %HR_peak, RPE, and shoulder pain indicate that REMW evoked moderate to vigorous intensity exercise without exacerbation of shoulder pain. Future research is required to quantify potential training-induced changes in cardiorespiratory fitness.

Advanced Equipment Development and Clinical Application in Neurorehabilitation for Spinal Cord Injury: Historical Perspectives and Future Directions

Partial to complete paralysis following spinal cord injury (SCI) causes deterioration in health and has severe effects on the ability to perform activities of daily living. Following the discovery of neural plasticity, neurorehabilitation therapies have emerged that aim to reconstruct the motor circuit of the damaged spinal cord. Functional electrical stimulation (FES) has been incorporated into devices that reconstruct purposeful motions in the upper and lower limbs, the most recent of which do not require percutaneous electrode placement surgery and thus enable early rehabilitation after injury. FES-based devices have shown promising results for improving upper limb movement, including gripping and finger function, and for lower limb function such as the ability to stand and walk. FES has also been employed in hybrid cycling and rowing to increase total body fitness. Training using rehabilitation robots is advantageous in terms of consistency of quality and quantity of movements and is particularly applicable to walking training. Initiation of motor reconstruction at the early stage following SCI is likely to advance rapidly in the future, with the combined use of technologies such as regenerative medicine, brain machine interfaces, and rehabilitation robots with FES showing great promise.

Effectiveness and feasibility of the workout on wheels internet intervention (WOWii) for individuals with spinal cord injury: a randomized controlled trial

Study design

Randomized-controlled trial (RCT) with immediate intervention (IMM) and wait-list control (WLC) groups; WLC participants received the intervention during delivery to subsequent cohorts.

Objectives

Investigate the effectiveness and feasibility of a virtually-delivered exercise intervention.

Setting

Home and community.

Methods

A total of 168 middle-aged (49.6 [12.3] years old) men (57%) and women (43%) who lived an average 15.5 (12.3) years with spinal cord injury (SCI) participated. The 16-week program provides users (a) website access with exercise information, resources, and 16 skill-building modules; (b) virtual 60-minute, group-based weekly meetings; and (c) a starter package of exercise equipment. Primary outcomes included subjective physical activity (IPAQ) and objective exercise (Polar A300 wrist-based activity monitor and H7 heart rate strap). Secondary outcomes included fitness indices during a maximal arm crank test, plus self-reported exercise barriers, exercise self-efficacy, and goal-directed thinking.

Results

RCT results indicate significant between group differences in participants’ self-reported weekly time spent in vigorous-intensity PA and goal directed thinking but not for fitness changes. Data combined for IMM and WLC participants from Polar monitoring show participants performed 150 min per week of aerobic exercise plus reported significantly greater time spent in moderate-PA, vigorous-PA, self-efficacy for exercise and nutrition, goal directed thinking, and exercise barriers. Oxygen uptake (V̇O₂ peak) and power output (watts max) were the only physiologic measures to demonstrate significant change, with a moderate effect size.

Conclusion

This virtually-delivered program offers a promising approach to increase exercise among those with SCI and may help participants perceive fewer motivational barriers and greater self-efficacy.

Protocols aiming to increase muscle mass in persons with motor complete spinal cord injury: a systematic review

PURPOSE

The purpose of this review was to compare all intervention modalities aimed at increasing skeletal muscle mass (SMM) in the paralysed limbs of persons with chronic (>1-year post-injury), motor complete spinal cord injury (SCI).

MATERIALS AND METHODS

A systematic review of EMBASE, MEDLINE, Scopus, and SPORTDiscus databases was conducted from inception until December 2021. Published intervention studies aimed to increase SMM (measured by magnetic resonance imaging, computed tomography, ultrasound, muscle biopsy, or lean soft tissue mass by dual X-ray absorptiometry) in the paralysed limbs of adults (>18 years) with SCI were included.

RESULTS

Fifty articles were included that, overall, demonstrated a high risk of bias. Studies were categorised into six groups: neuromuscular electrical stimulation (NMES) with and without external resistance, functional electrical stimulation cycling, walking- and standing-based interventions, pharmacological treatments, and studies that compared or combined intervention modalities. Resistance training (RT) using NMES on the quadriceps produced the largest and most consistent increases in SMM of all intervention modalities.

CONCLUSIONS

Current evidence suggests that clinical practise aiming to increase SMM in the paralysed limbs of persons with motor complete SCI should perform NMES-RT. However, more high-quality randomised control trials are needed to determine how training variables, such as exercise volume and intensity, can be optimised for increasing SMM. Implications for rehabilitationPersons with spinal cord injury (SCI) experience severe reductions in skeletal muscle mass (SMM) post-injury, which may exacerbate their risk of obesity and metabolic disease.Out of all exercise and non-exercise-based interventions, this systematic review shows that neuromuscular electrical stimulation-based resistance training demonstrates the most robust and consistent evidence for increasing skeletal muscle mass in the paralysed limbs of adults with motor complete spinal cord injury.The findings from this review can be used to inform evidence-based practise for exercise practitioners, as well as direct future research focused on increasing muscle mass in this population.

Physical activity and cardiometabolic risk factors in individuals with spinal cord injury: a systematic review and meta-analysis

Physical inactivity in individuals with spinal cord injury (SCI) has been suggested to be an important determinant of increased cardiometabolic disease (CMD) risk. However, it remains unclear whether physically active SCI individuals as compared to inactive or less active individuals have truly better cardiometabolic risk profile. We aimed to systematically review and quantify the association between engagement in regular physical activity and/or exercise interventions and CMD risk factors in individuals with SCI. Four medical databases were searched and studies were included if they were clinical trials or observational studies conducted in adult individuals with SCI and provided information of interest. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was applied to rate the certainty of evidence. Of 5816 unique citations, 11 randomized clinical trials, 3 non-randomized trial and 32 cross-sectional studies comprising more than 5500 SCI individuals were included in the systematic review. In meta-analysis of RCTs and based on evidence of moderate certainty, physical activity in comparison to control intervention was associated with: (i) better glucose homeostasis profile [WMD of glucose, insulin and Assessment of Insulin Resistance (HOMA-IR) were - 3.26 mg/dl (95% CI - 5.12 to - 1.39), - 3.19 μU/ml (95% CI - 3.96 to - 2.43)] and - 0.47 (95% CI - 0.60 to - 0.35), respectively], and (ii) improved cardiorespiratory fitness [WMD of relative and absolute oxygen uptake relative (VO2) were 4.53 ml/kg/min (95% CI 3.11, 5.96) and 0.26 L/min (95% CI 0.21, 0.32) respectively]. No differences were observed in blood pressure, heart rate and lipids (based on evidence of low/moderate certainty). In meta-analysis of cross-sectional studies and based on the evidence of very low to low certainty, glucose [WMD - 3.25 mg/dl (95% CI - 5.36, - 1.14)], insulin [- 2.12 μU/ml (95% CI - 4.21 to - 0.03)] and total cholesterol [WMD - 6.72 mg/dl (95% CI - 13.09, - 0.34)] were lower and HDL [WMD 3.86 mg/dl (95% CI 0.66, 7.05)] and catalase [0.07 UgHb-1 (95% CI 0.03, 0.11)] were higher in physically active SCI individuals in comparison to reference groups. Based on limited number of cross-sectional studies, better parameters of systolic and diastolic cardiac function and lower carotid intima media thickness were found in physically active groups. Methodologically sound clinical trials and prospective observational studies are required to further elaborate the impact of different physical activity prescriptions alone or in combination with other life-style interventions on CMD risk factors in SCI individuals.