Muscle enzyme adaptation to training and tapering-off in spinal-cord-injured humans

Rehabilitation interventions to modify endocrine-metabolic disease risk in individuals with chronic spinal cord injury living in the community (RIISC): A systematic search and review of prospective cohort and case-control studies

CONTEXT

Endocrine-metabolic disease (EMD) is associated with functional disability, social isolation, hospitalization and even death in individuals living with a chronic spinal cord injury (SCI). There is currently very low-quality evidence that rehabilitation interventions can reduce EMD risk during chronic SCI. Non-randomized trials and alternative study designs are excluded from traditional knowledge synthesis.

OBJECTIVE

To characterize evidence from level 3-4 studies evaluating rehabilitation interventions for their effectiveness to improve EMD risk in community-dwelling adults with chronic SCI.

METHODS

Systematic searches of MEDLINE PubMed, EMBASE Ovid, CINAHL, Cochrane Database of Systematic Reviews, and PsychInfo were completed. All longitudinal trials, prospective cohort, case-control studies, and case series evaluating the effectiveness of rehabilitation/therapeutic interventions to modify/associate with EMD outcomes in adults with chronic SCI were eligible. Two authors independently selected studies and abstracted data. Mean changes from baseline were reported for EMD outcomes. The Downs and Black Checklist was used to rate evidence quality.

RESULTS

Of 489 articles identified, 44 articles (N = 842) were eligible for inclusion. Individual studies reported statistically significant effects of electrical stimulation-assisted training on lower-extremity bone outcomes, and the combined effects of exercise and dietary interventions to improve body composition and cardiometabolic biomarkers (lipid profiles, glucose regulation). In contrast, there were also reports of no clinically important changes in EMD outcomes, suggesting lower quality evidence (study bias, inconsistent findings).

CONCLUSION

Longitudinal multicentre pragmatic studies involving longer-term exercise and dietary intervention and follow-up periods are needed to fully understand the impact of these rehabilitation approaches to mitigate EMD risk. Our broad evaluation of prospective cohort and case-control studies provides new perspectives on alternative study designs, a multi-impairment paradigm approach of studying EMD outcomes, and knowledge gaps related to SCI rehabilitation.

3D synchrotron imaging of muscle tissues at different atrophic stages in stroke and spinal cord injury: a proof-of-concept study

Synchrotron X-ray computed tomography (SXCT) allows 3D imaging of tissue with a very large field of view and an excellent micron resolution and enables the investigation of muscle fiber atrophy in 3D. The study aimed to explore the 3D micro-architecture of healthy skeletal muscle fibers and muscle fibers at different stages of atrophy (stroke sample = muscle atrophy; spinal cord injury (SCI) sample = severe muscle atrophy). Three muscle samples: a healthy control sample; a stroke sample (atrophic sample), and an SCI sample (severe atrophic sample) were imaged using SXCT, and muscle fiber populations were segmented and quantified for microarchitecture and morphology differences. The volume fraction of muscle fibers was 74.7%, 70.2%, and 35.3% in the healthy, stroke (atrophic), and SCI (severe atrophic) muscle fiber population samples respectively. In the SCI (severe atrophic sample), 3D image analysis revealed fiber splitting and fiber swelling. In the stroke sample (atrophic sample) muscle fiber buckling was observed but was only visible in the 3D analysis. 3D muscle fiber population analysis revealed new insights into the different stages of muscle fiber atrophy not to be observed nor quantified with a 2D histological analysis including fiber buckling, loss of fibers and fiber splitting.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

A Comparison of FES and SCS for Neuroplastic Recovery After SCI: Historical Perspectives and Future Directions

There is increasing evidence that neuroplastic changes can occur even years after spinal cord injury, leading to reduced disability and better health which should reduce the cost of healthcare. In motor-incomplete spinal cord injury, recovery of leg function may occur if repetitive training causes afferent input to the lumbar spinal cord. The afferent input may be due to activity-based therapy without electrical stimulation but we present evidence that it is faster with electrical stimulation. This may be spinal cord stimulation or peripheral nerve stimulation. Recovery is faster if the stimulation is phasic and that the patient is trying to use their legs during the training. All the published studies are small, so all conclusions are provisional, but it appears that patients with more disability (AIS A and B) may need to continue using stimulation and for them, an implanted stimulator is likely to be convenient. Patients with less disability (AIS C and D) may make useful recovery and improve their quality of life from a course of therapy. This might be locomotion therapy but we argue that cycling with electrical stimulation, which uses biofeedback to encourage descending drive, causes rapid recovery and might be used with little supervision at home, making it much less expensive. Such an electrical therapy followed by conventional physiotherapy might be affordable for the many people living with chronic SCI. To put this in perspective, we present some information about what treatments are funded in the UK and the US.

Skeletal muscle hypertrophy and attenuation of cardio-metabolic risk factors (SHARC) using functional electrical stimulation-lower extremity cycling in persons with spinal cord injury: study protocol for a randomized clinical trial

Background

Persons with spinal cord injury (SCI) are at heightened risks of developing unfavorable cardiometabolic consequences due to physical inactivity. Functional electrical stimulation (FES) and surface neuromuscular electrical stimulation (NMES)-resistance training (RT) have emerged as effective rehabilitation methods that can exercise muscles below the level of injury and attenuate cardio-metabolic risk factors. Our aims are to determine the impact of 12 weeks of NMES + 12 weeks of FES-lower extremity cycling (LEC) compared to 12 weeks of passive movement + 12 weeks of FES-LEC on: (1) oxygen uptake (VO₂), insulin sensitivity, and glucose disposal in adults with SCI; (2) skeletal muscle size, intramuscular fat (IMF), and visceral adipose tissue (VAT); and (3) protein expression of energy metabolism, protein molecules involved in insulin signaling, muscle hypertrophy, and oxygen uptake and electron transport chain (ETC) activities.

Methods/Design

Forty-eight persons aged 18–65 years with chronic (> 1 year) SCI/D (AIS A-C) at the C5-L2 levels, equally sub-grouped by cervical or sub-cervical injury levels and time since injury, will be randomized into either the NMES + FES group or Passive + FES (control group). The NMES + FES group will undergo 12 weeks of evoked RT using twice-weekly NMES and ankle weights followed by twice-weekly progressive FES-LEC for an additional 12 weeks. The control group will undergo 12 weeks of passive movement followed by 12 weeks of progressive FES-LEC. Measurements will be performed at baseline (B; week 0), post-intervention 1 (P1; week 13), and post-intervention 2 (P2; week 25), and will include: VO₂ measurements, insulin sensitivity, and glucose effectiveness using intravenous glucose tolerance test; magnetic resonance imaging to measure muscle, IMF, and VAT areas; muscle biopsy to measure protein expression and intracellular signaling; and mitochondrial ETC function.

Discussion

Training through NMES + RT may evoke muscle hypertrophy and positively impact oxygen uptake, insulin sensitivity, and glucose effectiveness. This may result in beneficial outcomes on metabolic activity, body composition profile, mitochondrial ETC, and intracellular signaling related to insulin action and muscle hypertrophy. In the future, NMES-RT may be added to FES-LEC to improve the workloads achieved in the rehabilitation of persons with SCI and further decrease muscle wasting and cardio-metabolic risks.

Trial registration

ClinicalTrials.gov, NCT02660073. Registered on 21 Jan 2016.

Skeletal muscle mitochondrial mass is linked to lipid and metabolic profile in individuals with spinal cord injury

PURPOSE

Changes in metabolism and body composition after spinal cord injury (SCI) predispose individuals to obesity, type II diabetes, and cardiovascular disease. A link between lean mass and skeletal muscle mitochondrial mass has been reported but it is unknown how skeletal muscle mitochondrial mass and activity impact metabolic health. This study examined the relationship between skeletal muscle mitochondrial mass, activity and metabolic profile in individuals with chronic SCI.

METHODS

Twenty-two men with motor complete SCI participated in the study. Citrate synthase (CS) and complex III (CIII) activity was measured in vastus lateralis biopsies. Metabolic profile was assessed by intravenous glucose tolerance test, basal metabolic rate (BMR), maximum oxygen uptake (VO₂ peak) and blood lipid profile.

RESULTS

Skeletal muscle CS activity was negatively related to the cholesterol:high density lipoprotein cholesterol (HDL-C) ratio and triglycerides (r = -0.60, p = 0.009; r = -0.64, p = 0.004, respectively). CS activity was positively related to insulin sensitivity and BMR (r = 0.67, p = 0.006; r = 0.64, p = 0.005, respectively). Similar relationships were found for CIII and metabolic profile, but not CIII normalized to CS. Many of the relationships between CS and metabolism remained significant when age, level of injury, or time since injury were accounted for. They also remained significant when CS activity was normalized to total lean mass.

CONCLUSIONS

These results suggest that an increase in skeletal muscle mitochondrial mass is associated with improved metabolic health independent of age, level of injury, or time since injury in individuals with chronic SCI. This highlights the importance of maintaining and improving mitochondrial health in individuals with SCI.

Functional electrical stimulation: cardiorespiratory adaptations and applications for training in paraplegia

Regular exercise can be broadly beneficial to health and quality of life in humans with spinal cord injury (SCI). However, exercises must meet certain criteria, such as the intensity and muscle mass involved, to induce significant benefits. SCI patients can have difficulty achieving these exercise requirements since the paralysed muscles cannot contribute to overall oxygen consumption. One solution is functional electrical stimulation (FES) and, more importantly, hybrid training that combines volitional arm and electrically controlled contractions of the lower limb muscles. However, it might be rather complicated for therapists to use FES because of the wide variety of protocols that can be employed, such as stimulation parameters or movements induced. Moreover, although the short-term physiological and psychological responses during different types of FES exercises have been extensively reported, there are fewer data regarding the long-term effects of FES. Therefore, the purpose of this brief review is to provide a critical appraisal and synthesis of the literature on the use of FES for exercise in paraplegic individuals. After a short introduction underlying the importance of exercise for SCI patients, the main applications and effects of FES are reviewed and discussed. Major findings reveal an increased physiological demand during FES hybrid exercises as compared with arms only exercises. In addition, when repeated within a training period, FES exercises showed beneficial effects on muscle characteristics, force output, exercise capacity, bone mineral density and cardiovascular parameters. In conclusion, there appears to be promising evidence of beneficial effects of FES training, and particularly FES hybrid training, for paraplegic individuals.

Effects of circuit resistance training and timely protein supplementation on exercise-induced fat oxidation in tetraplegic adults

BACKGROUND

Substrate utilization during exercise in persons with spinal cord injury (SCI) remains poorly defined.

PURPOSE

To investigate effects of circuit resistance training (CRT) and timing of protein supplementation (PS) on fuel utilization in persons with tetraplegia.

METHODS

Eleven individuals with chronic tetraplegia underwent 6 months of CRT 3 times weekly. Five randomly assigned participants received immediate PS (iPS) administered in split doses prior to and following all exercise sessions. Other participants consumed a matched dose of PS that was delayed until 24 hours post-exercise (dPS). Participants underwent a maximal graded exercise test (GXT) to volitional exhaustion at 4 conditioning time points: 3 months before (-3mo), at the beginning of (0mo), 3 months into (3mo), and 6 months following (6mo) the CRT conditioning program. Respiratory measures were continuously obtained throughout the GXT via open-circuit spirometry. Fuel utilization and energy expenditure were computed from the respiratory data.

RESULTS

The differences in changes in substrate utilization between the PS groups were not significant as determined by the interaction of PS group and conditioning time point, F (3, 27) = 2.32, P = .098, η(2) P = .205. Maximal absolute fat oxidation did not change significantly from 0 to 6mo (mean difference, 0.014 ± 0.031 g/min; P = .170), and fat oxidation remained low never exceeding an average of 0.10 ± 0.09 g/min for any given exercise intensity.

CONCLUSION

Maximum fat utilization during exercise and fat utilization at matched exercise intensities were not increased in persons with tetraplegia, independent of PS, and levels of fat oxidation remained low after training.

In vivo (31)P NMR spectroscopy assessment of skeletal muscle bioenergetics after spinal cord contusion in rats

PURPOSE

Muscle paralysis after spinal cord injury leads to muscle atrophy, enhanced muscle fatigue, and increased energy demands for functional activities. Phosphorus magnetic resonance spectroscopy ((31)P-MRS) offers a unique non-invasive alternative of measuring energy metabolism in skeletal muscle and is especially suitable for longitudinal investigations. We determined the impact of spinal cord contusion on in vivo muscle bioenergetics of the rat hind limb muscle using (31)P-MRS.

METHODS

A moderate spinal cord contusion injury (cSCI) was induced at the T8-T10 thoracic spinal segments. (31)P-MRS measurements were performed weekly in the rat hind limb muscles for 3 weeks. Spectra were acquired in a Bruker 11 T/470 MHz spectrometer using a 31P surface coil. The sciatic nerve was electrically stimulated by subcutaneous needle electrodes. Spectra were acquired at rest (5 min), during stimulation (6 min), and recovery (20 min). Phosphocreatine (PCr) depletion rates and the pseudo first-order rate constant for PCr recovery (k PCr) were determined. The maximal rate of PCr resynthesis, the in vivo maximum oxidative capacity (V max) and oxidative adenosine triphosphate (ATP) synthesis rate (Q max) were subsequently calculated.

RESULTS

One week after cSCI, there was a decline in the resting total creatine of the paralyzed muscle. There was a significant reduction (~24 %) in k PCr measures of the paralyzed muscle, maximum in vivo mitochondrial capacity (V max) and the maximum oxidative ATP synthesis rate (Q max) at 1 week post-cSCI. During exercise, the PCr depletion rates in the paralyzed muscle one week after injury were rapid and to a greater extent than in a healthy muscle.

CONCLUSIONS

Using in vivo MRS assessments, we reveal an acute oxidative metabolic defect in the paralyzed hind limb muscle. These altered muscle bioenergetics might contribute to the host of motor dysfunctions seen after cSCI.

Case report: endurance electrical stimulation training improves skeletal muscle oxidative capacity in chronic spinal cord injury

OBJECTIVE

To describe the use of a novel neuromuscular electrical stimulation (NMES) endurance exercise protocol and its effects on skeletal muscle oxidative capacity.

DESIGN

Case report, pre/post intervention.

SETTING

University-based trial.

PARTICIPANT

A 39-year-old man who suffered a motor complete spinal cord injury (C5-6, ASIA Impairment Scale grade A).

INTERVENTION

Twenty-four weeks of endurance NMES that consisted of progressive increases in the twitch frequency, duration of sessions, and sessions per week.

MAIN OUTCOME MEASURE

Mitochondrial capacity was measured, in vivo, as the rate of recovery of muscle oxygen consumption using near-infrared spectroscopy.

RESULTS

The rate of recovery of muscle oxygen consumption increased approximately 3-fold from 0.52 to 1.43, 1.46, and 1.40/min measured on 3 separate occasions during week 12 of training, and 1.57/min after 24 weeks of NMES endurance training.

CONCLUSION

The findings of this study suggest that NMES endurance training using twitches can increase mitochondrial capacity to comparable levels measured in nonparalyzed muscles of sedentary able-bodied controls.

Electrically induced resistance training in individuals with motor complete spinal cord injury

OBJECTIVE

To examine the effects of 16 weeks of electrically induced resistance training on insulin resistance and glucose tolerance, and changes in muscle size, composition, and metabolism in paralyzed muscle.

DESIGN

Pre-post intervention.

SETTING

University-based trial.

PARTICIPANTS

Participants (N=14; 11 men and 3 women) with chronic (>2y post spinal cord injury), motor complete spinal cord injury.

INTERVENTION

Home-based electrically induced resistance exercise training twice weekly for 16 weeks.

MAIN OUTCOME MEASURES

Plasma glucose and insulin throughout a standard clinical oral glucose tolerance test, thigh muscle and fat mass via dual-energy x-ray absorptiometry, quadriceps and hamstrings muscle size and composition via magnetic resonance imaging, and muscle oxidative metabolism using phosphorus magnetic resonance spectroscopy.

RESULTS

Muscle mass increased in all participants (mean ± SD, 39%±27%; range, 5%-84%). The mean change ± SD in intramuscular fat was 3%±22%. Phosphocreatine mean recovery time constants ± SD were 102±24 and 77±18 seconds before and after electrical stimulation-induced resistance training, respectively (P<.05). There was no improvement in fasting blood glucose levels, homeostatic model assessment calculated insulin resistance, 2-hour insulin, or 2-hour glucose.

CONCLUSIONS

Sixteen weeks of electrical stimulation-induced resistance training increased muscle mass, but did not reduce intramuscular fat. Similarly, factors associated with insulin resistance or glucose tolerance did not improve with training. We did find a 25% improvement in mitochondrial function, as measured by phosphocreatine recovery rates. Larger improvements in mitochondrial function may translate into improved glucose tolerance and insulin resistance.

Metabolic responses to 4 different body weight-supported locomotor training approaches in persons with incomplete spinal cord injury

OBJECTIVE

To describe metabolic responses accompanying 4 different locomotor training (LT) approaches.

DESIGN

Single-blind, randomized controlled trial.

SETTING

Rehabilitation research laboratory, academic medical center.

PARTICIPANTS

Individuals (N=62) with minimal walking function due to chronic motor-incomplete spinal cord injury.

INTERVENTION

Participants trained 5 days/week for 12 weeks. Groups were treadmill-based LT with manual assistance (TM), transcutaneous electrical stimulation (TS), and a driven gait orthosis (DGO) and overground (OG) LT with electrical stimulation.

MAIN OUTCOME MEASURES

Oxygen uptake (V˙o2), walking velocity and economy, and substrate utilization during subject-selected "slow," "moderate," and "maximal" walking speeds.

RESULTS

V˙o2 did not increase from pretraining to posttraining for DGO (.00 ± .18L/min, P=.923). Increases in the other groups depended on walking speed, ranging from .01 ± .18 m/s (P=.860) for TM (slow speed) to .20 ± .29 m/s (P=.017) for TS (maximal speed). All groups increased velocity but to varying degrees (DGO, .01 ± .18 Ln[m/s], P=.829; TM, .07 ± .29 Ln[m/s], P=.371; TS, .33 ± .45 Ln[m/s], P=.013; OG, .52 ±.61 Ln[m/s], P=.007). Changes in walking economy were marginal for DGO and TM (.01 ± .20 Ln[L/m], P=.926, and .00 ± .42 Ln[L/m], P=.981) but significant for TS and OG (.26 ± .33 Ln[L/m], P=.014, and .44 ± .62 Ln[L/m], P=.025). Many participants reached respiratory exchange ratios ≥ 1 at any speed, rendering it impossible to statistically discern differences in substrate utilization. However, after training, fewer participants reached this ceiling for each speed (slow: 9 vs 6, n=32; moderate: 12 vs 8, n=29; and maximal 15 vs 13, n=28).

CONCLUSIONS

DGO and TM walking training was less effective in increasing V˙o2 and velocity across participant-selected walking speeds, while TS and OG training was more effective in improving these parameters and also walking economy. Therefore, the latter 2 approaches hold greater promise for improving clinically relevant outcomes such as enhanced endurance, functionality, or in-home/community ambulation.

Muscle after spinal cord injury

The morphological and contractile changes of muscles below the level of the lesion after spinal cord injury (SCI) are dramatic. In humans with SCI, a fiber-type transformation away from type I begins 4-7 months post-SCI and reaches a new steady state with predominantly fast glycolytic IIX fibers years after the injury. There is a progressive drop in the proportion of slow myosin heavy chain (MHC) isoform fibers and a rise in the proportion of fibers that coexpress both the fast and slow MHC isoforms. The oxidative enzymatic activity starts to decline after the first few months post-SCI. Muscles from individuals with chronic SCI show less resistance to fatigue, and the speed-related contractile properties change, becoming faster. These findings are also present in animals. Future studies should longitudinally examine changes in muscles from early SCI until steady state is reached in order to determine optimal training protocols for maintaining skeletal muscle after paralysis.

Muscle and bone plasticity after spinal cord injury: review of adaptations to disuse and to electrical muscle stimulation

The paralyzed musculoskeletal system retains a remarkable degree of plasticity after spinal cord injury (SCI). In response to reduced activity, muscle atrophies and shifts toward a fast-fatigable phenotype arising from numerous changes in histochemistry and metabolic enzymes. The loss of routine gravitational and muscular loads removes a critical stimulus for maintenance of bone mineral density (BMD), precipitating neurogenic osteoporosis in paralyzed limbs. The primary adaptations of bone to reduced use are demineralization of epiphyses and thinning of the diaphyseal cortical wall. Electrical stimulation of paralyzed muscle markedly reduces deleterious post-SCI adaptations. Recent studies demonstrate that physiological levels of electrically induced muscular loading hold promise for preventing post-SCI BMD decline. Rehabilitation specialists will be challenged to develop strategies to prevent or reverse musculoskeletal deterioration in anticipation of a future cure for SCI. Quantifying the precise dose of stress needed to efficiently induce a therapeutic effect on bone will be paramount to the advancement of rehabilitation strategies.

Oxygen consumption during functional electrical stimulation-assisted exercise in persons with spinal cord injury: implications for fitness and health

A lesion in the spinal cord leads in most cases to a significant reduction in active muscle mass, whereby the paralysed muscles cannot contribute to oxygen consumption (VO2) during exercise. Consequently, persons with spinal cord injury (SCI) can only achieve high VO2 values by excessively stressing the upper body musculature, which might increase the risk of musculoskeletal overuse injury. Alternatively, the muscle mass involved may be increased by using functional electrical stimulation (FES). FES-assisted cycling, FES-cycling combined with arm cranking (FES-hybrid exercise) and FES-rowing have all been suggested as candidates for cardiovascular training in SCI. In this article, we review the levels of VO2 (peak [VO2peak] and sub-peak [VO2sub-peak]) that have been reported for SCI subjects using these FES exercise modalities. A systematic literature search in MEDLINE, EMBASE, AMED, CINAHL, SportDiscus and the authors' own files revealed 35 studies that reported on 499 observations of VO2 levels achieved during FES-exercise in SCI. The results show that VO2peak during FES-rowing (1.98 L/min, n = 17; 24.1 mL/kg/min, n = 11) and FES-hybrid exercise (1.78 L/min, n = 67; 26.5 mL/kg/min, n = 35) is considerably higher than during FES-cycling (1.05 L/min, n = 264; 14.3 mL/kg/min, n = 171). VO2sub-peak values during FES-hybrid exercise were higher than during FES-cycling. FES-exercise training can produce large increases in VO2peak; the included studies report average increases of +11% after FES-rowing training, +12% after FES-hybrid exercise training and +28% after FES-cycling training. This review shows that VO2 during FES-rowing or FES-hybrid exercise is considerably higher than during FES-cycling. These observations are confirmed by a limited number of direct comparisons; larger studies to test the differences in effectiveness of the various types of FES-exercise as cardiovascular exercise are needed. The results to date suggest that FES-rowing and FES-hybrid are more suited for high-intensity, high-volume exercise training than FES-cycling. In able-bodied people, such exercise programmes have shown to result in superior health and fitness benefits. Future research should examine whether similar high-intensity and high-volume exercise programmes also give persons with SCI superior fitness and health benefits. This kind of research is very timely given the high incidence of physical inactivity-related health conditions in the aging SCI population.

Skeletal muscle changes after hemiparetic stroke and potential beneficial effects of exercise intervention strategies

Stroke is the leading cause of disability in the United States. New evidence reveals significant structural and metabolic changes in skeletal muscle after stroke. Muscle alterations include gross atrophy and shift to fast myosin heavy chain in the hemiparetic (contralateral) leg muscle; both are related to gait deficit severity. The underlying molecular mechanisms of this atrophy and muscle phenotype shift are not known. Inflammatory markers are also present in contralateral leg muscle after stroke. Individuals with stroke have a high prevalence of insulin resistance and diabetes. Skeletal muscle is a major site for insulin-glucose metabolism. Increasing evidence suggests that inflammatory pathway activation and oxidative injury could lead to wasting, altered function, and impaired insulin action in skeletal muscle. The health benefits of exercise in disabled populations have now been recognized. Aerobic exercise improves fitness, strength, and ambulatory performance in subjects with chronic stroke. Therapeutic exercise may modify or reverse skeletal muscle abnormalities.

Gene expression of myogenic factors and phenotype-specific markers in electrically stimulated muscle of paraplegics

The transcription factors myogenin and MyoD have been suggested to be involved in maintaining slow and fast muscle-fiber phenotypes, respectively, in rodents. Whether this is also the case in human muscle is unknown. To test this, 4 wk of chronic, low-frequency electrical stimulation training of the tibialis anterior muscle of paraplegic subjects were used to evoke a fast-to-slow transformation in muscle phenotype. It was hypothesized that this would result from an upregulation of myogenin and a downregulation of MyoD. The training evoked the expected mRNA increase for slow fiber-specific markers myosin heavy chain I and 3-hydroxyacyl-CoA dehydrogenase A, whereas an mRNA decrease was seen for fast fiber-specific markers myosin heavy chain IIx and glycerol phosphate dehydrogenase. Although the slow fiber-specific markers citrate synthase and muscle fatty acid binding protein did not display a significant increase in mRNA, they did tend to increase. As hypothesized, myogenin mRNA was upregulated. However, contrary to the hypothesis, MyoD mRNA also increased, although later than myogenin. The mRNA levels of the other myogenic regulatory factor family members, myogenic factor 5 and myogenic regulatory factor 4, and the myocyte enhancer factor (MEF) family members, MEF-2A and MEF-2C, did not change. The results indicate that myogenin is indeed involved in the regulation of the slow oxidative phenotype in human skeletal muscle fibers, whereas MyoD appears to have a more complex regulatory function.

Body-weight-support treadmill training improves blood glucose regulation in persons with incomplete spinal cord injury

The impact of a 6-mo body-weight-supported treadmill training program on glucose homeostasis and muscle metabolic characteristics was investigated. Nine individuals (31 ± 3 yr, 8.1 ± 2.5 yr postinjury; means ± SE) with incomplete spinal cord injury trained three times weekly for a total of 6 mo. Training session duration and intensity (velocity) increased by 54 ± 10% ( P < 0.01) and 135 ± 20%, respectively. Muscle biopsies and a modified glucose tolerance test (100 g glucose with [U-13C]glucose) were performed before (Pre) and after training (Post). Training resulted in a reduction in area under the curve of glucose × time (−15 ± 4%) and insulin × time (−33 ± 8%; both P < 0.05). Oxidation of exogenous (ingested) glucose increased as a result of training (Pre = 4.4 ± 0.7 g/h, Post = 7.4 ± 0.6 g/h; P < 0.05), as did oxidation of endogenous (liver) glucose (Pre = 3.8 ± 0.3 g/h, Post = 5.2 ± 0.3 g/h; P < 0.05). Training resulted in increased muscle glycogen (80 ± 23%; P < 0.05) and GLUT-4 content and hexokinase II enzyme activity (126 ± 34 and 49 ± 4%, respectively, both P < 0.01). Resting muscle phosphocreatine content also increased after training (Pre = 62.1 ± 4.3, Post = 78.7 ± 3.8, both mmol/kg dry wt and P < 0.05). Six months of thrice-weekly body-weight-supported treadmill training in persons with an incomplete spinal cord injury improved blood glucose regulation by increasing oxidation and storage of an oral glucose load. Increases in the capacity for transport and phosphorylation glucose in skeletal muscle likely play a role in these adaptations.

Effect of load during electrical stimulation training in spinal cord injury

Electrical stimulation training is known to alter skeletal muscle characteristics after a spinal cord injury, but the effect of load on optimizing the training protocol has not been fully investigated. This study investigated two electrical-stimulation training regimes with different loads on intramuscular parameters of the paralyzed lower limbs. Six paraplegic individuals with a spinal cord injury underwent electrical stimulation training (45 min daily for 3 days per week for 10 weeks). One leg was trained statically with load, and the contralateral leg was trained dynamically with minimal load. Isometric force assessed with 35-HZ stimuli increased significantly in both legs from baseline, with the static-trained leg also being significantly higher than the dynamic-trained leg. The vastus lateralis muscle of the statically trained leg showed a significant increase in type I fibers, fiber cross-sectional area, capillary-to-fiber ratio, and citrate synthase activity when compared to both baseline and the dynamically trained leg. Relative oxygenation of the vastus lateralis muscle as determined by near infrared spectroscopy was also significantly greater after static training. This study indicates that the load that is applied to paralyzed muscle during an electrical stimulation training program is an important factor in determining the amount of muscle adaptation that can be achieved.

Treadmill training-induced adaptations in muscle phenotype in persons with incomplete spinal cord injury

Body weight-supported treadmill (BWST) training has been shown to improve ambulatory capacity in persons with a spinal cord injury (SCI); however, the effect that BWST training has on skeletal muscle phenotype is unknown. We aimed to determine whether 6 months (three sessions/week) of BWST training in neurologically stable persons with a traumatic spinal cord injury (ASIA C) alters skeletal muscle phenotype, ambulatory capacity, and blood lipid profile. Externally supported body weight decreased, and walking velocity and duration of the training sessions increased (all P < 0.05) as a result of training. Muscle biopsies revealed increases in the mean muscle-fiber area of type I and IIa fibers. Training induced a reduction in type IIax/IIx fibers, as well as a decrease in IIX myosin heavy chain, and an increase in type IIa fibers. Maximal citrate synthase and 3-hydroxy-acyl-CoA dehydrogenase activity also increased following training. BWST training brought about reductions in plasma total (-11%) and low-density lipoprotein (-13%) cholesterol. We conclude that, in patients with a spinal cord injury, BWST training is able to induce an increase in muscle fiber size and bring about increases in muscle oxidative capacity. In addition, BWST training can bring about improvements in ambulatory capacity and antiatherogenic changes in blood lipid profile.

Effects of electrical stimulation-induced leg training on skeletal muscle adaptability in spinal cord injury

Neuromuscular electrical stimulation has grown in popularity as a therapeutic device for training and an ambulation aid to human paralyzed muscle. Despite its current clinical use, few studies have attempted to concurrently investigate the functional and intramuscular adaptations which occur after electrical stimulation training. Six individuals with a spinal cord injury performed 10 weeks of electrical stimulation leg cycle training (30 min d(-1), 3 d week(-1)). The paralyzed vastus lateralis muscle showed significant alterations in skeletal muscle characteristics after the training, indicated by an improvement in total work output (52-112 kJ; P < 0.05), an increase in fiber cross-sectional area (18 to 41 x 10(2) microm(2); P < 0.05), a reduction in the percentage of type IIX fibers (75% to 12%; P < 0.05), a decrease in myosin heavy chain IIx (68% to 44%; P < 0.05), an increase in capillary density (2-3.5 capillaries around fiber; P < 0.05) and increases in activity levels of citrate synthase (7-16 mU mg(-1) protein) and hexokinase (1.2-2.4 mU mg(-1) protein). This study showed that 10 weeks of electrical stimulation training of human paralyzed muscle induces concurrent improvements in functional capacity and oxidative metabolism.