Effects of Arm-Crank Exercise on Fitness and Health in Adults With Chronic Spinal Cord Injury: A Systematic Review

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.

Impact of upper-body ergometer rowing exercise on aerobic fitness and cardiometabolic disease risk in individuals with spinal cord injury: A 6-month follow-up study

Objective: We recently demonstrated that upper-body rowing exercise (UBROW) improved aerobic fitness in individuals with spinal cord injury (SCI), with no effect on traditional cardiometabolic risk factors. Here, we tested the hypothesis that the exercise-induced increase in aerobic fitness was maintained at 6-month (6M) follow-up.Design: Six-month follow-up.Setting: University/hospital.Participants: Seventeen wheelchair-dependent participants with SCI.Interventions: 12-week of exercise training (UBROW) or control (CON).Outcome Measures: Aerobic fitness (POpeak and V̇O2peak), body composition, blood pressure, and blood biomarkers of cardiometabolic risk were assessed at 6M follow-up and compared to baseline (BL) and immediately post-intervention (12-week). Minutes of mild, moderate, and heavy intensity leisure time physical activity (LTPA) were assessed by self-report.Results: Fourteen participants returned at 6M follow-up (CON, n = 6; UBROW, n = 8). In UBROW, POpeak (median (Q1-Q3)) increased from BL (70 W (37-84)) to 12-week (77 W (58-109), P = 0.01) and 6M follow-up (81 W (51-96), P = 0.01), with no difference between 12-week and 6M follow-up (P = 0.21). Similarly, V̇O2peak increased from BL (15.4 ml/kg/min (10.5-19.4)) to 12-week (16.6 ml/kg/min (12.8-21.3), P = 0.01) with no difference between 12-week and 6M follow-up (16.3 ml/kg/min (12.9-19.7), P = 0.74). No differences were found in CON for either POpeak (P = 0.22) or V̇O2peak (P = 0.27). There were no changes over time in traditional cardiometabolic risk factors or for minutes of different LTPA intensities.Conclusion: We demonstrate that improvements in aerobic fitness are maintained for at least six months after completion of a 12-week exercise intervention, supporting the use of periodic exercise interventions to boost aerobic fitness level in individuals with SCI.Trial registration: ClinicalTrials.gov identifier: NCT04390087..

Effects of exercise on autonomic cardiovascular control in individuals with chronic, motor-complete spinal cord injury: an exploratory randomised clinical trial

STUDY DESIGN

Secondary analysis of a clinical trial.

OBJECTIVE

To assess the impact of 6 months of arm cycle ergometry training (ACET), or body weight-supported treadmill training (BWSTT), on autonomic cardiovascular responses to a laboratory sit-up test (SUT) in individuals with chronic (≥1-year post-injury) spinal cord injury (SCI).

SETTING

Tertiary Rehabilitation Centre, Vancouver, Canada.

METHODS

Sixteen individuals with motor-complete (American Spinal Injury Association Impairment Scale A-B) SCI between the fourth cervical and sixth thoracic spinal cord segments, aged 39 ± 11 years, were assessed. Participants were randomized to receive 72 sessions of moderate-to-vigorous intensity ACET (n = 8) or passive BWSTT (n = 8). Changes in mean arterial pressure (finger plethysmography), hemodynamics (Modelflow® method), and heart rate/heart rate variability (HR/HRV; electrocardiography) were measured in response to a  SUT before and after 6 months of exercise training. Spontaneous cardiovagal baroreflex sensitivity (cvBRS) was assessed using the sequence method.

RESULTS

Neither ACET nor BWSTT impacted hemodynamic responses to SUT or the incidence of orthostatic hypotension (all P > 0.36). ACET increased HR (P < 0.01, ηp2 = 0.34) and high frequency (HF) power HRV responses (P < 0.01, ηp2 = 0.42) to SUT following 6 months of training while BWSTT did not. Consistent with this, cvBRS improved (P < 0.05, ηp2 = 0.16) only following ACET. Improvements in cvBRS were correlated with both the HR (r = 0.726, P < 0.0001) and HF power (r = -0.484, P < 0.01) responses to SUT.

CONCLUSION

Six months of ACET, but not BWSTT, improved cardiovagal baroreflex control of HR but had no effect on BP responses to SUT in individuals with chronic, motor-complete SCI.

SPONSORSHIP

Canadian Institutes of Health Research (CIHR) CLINICAL TRIAL REGISTRATION: NCT01718977.

Community-Based Exercise Programs Post Spinal Cord Injury Hospitalization: A Pilot Study for a Randomized, Multicenter, Double-Blind Controlled Setting

This study explores the effectiveness of community-based exercise programs for individuals with spinal cord injury (SCI) following hospital discharge. Given the rising incidence of SCI, particularly in South Korea, and the associated long-term disabilities, the necessity for comprehensive post-discharge rehabilitation is paramount. The study focuses on a pilot randomized multicenter double-blind controlled trial, targeting SCI patients who have completed inpatient rehabilitation and are living in the community. The primary aim is to evaluate the impact of structured exercise programs on physical fitness, functional capacity, and overall recovery. The research introduces the SpinalFit program, a community-based intervention designed to enhance muscle strength, cardiopulmonary endurance, and mobility through a combination of aerobic and resistance training. This program addresses the critical need for safe and effective rehabilitation options outside the hospital setting, utilizing circuit training with resistance bands and body-weight exercises tailored to each participant's capacity. The study also investigates barriers to physical activity in the community for SCI patients and the potential role of community exercise centers in bridging this gap. Preliminary findings from this pilot trial are expected to provide valuable insights into optimizing exercise regimens for SCI patients, informing future large-scale studies and contributing to improved post-discharge rehabilitation strategies.

Efficacy of arm crank ergometry on individuals with spinal cord injury: A systematic review of randomized controlled trials

OBJECTIVES

To investigate the efficacy of arm crank ergometry (ACE) on physical, psychological, and quality of life outcomes in individuals with spinal cord injury (SCI).

LITERATURE SURVEY

A comprehensive search was conducted on PubMed, Scopus, MEDLINE, Physiotherapy Evidence Database (PEDro), Web of Science, REHABDATA, and Embase from inception until July 2023.

METHODOLOGY

Studies were included if the sample was composed of individuals with SCI, the intervention followed an ACE intervention, and the study was a randomized controlled trial including at least one outcome measure evaluating physical, psychological, or quality of life. The PEDro scale was used to assess the methodological quality of the included studies. The meta-analysis was not feasible due to the heterogeneity in the treatment protocols and outcome measures among the selected studies.

SYNTHESIS

Of 1013 articles, seven studies (n = 200), with 16% of participants being female, were included in this review. The scores on the PEDro scale ranged from 6 to 8, with a median score of 7. There were variations in treatment protocols and outcome measures, resulting in heterogeneous findings. The effects of the ACE interventions on physical, psychological, and quality of life outcomes showed inconsistency.

CONCLUSIONS

ACE training proves to be a suitable and safe intervention for individuals with traumatic SCI. Nevertheless, the existing evidence concerning its effects on physical, psychological, and quality of life outcomes in individuals with SCI is limited. Further trials are required to investigate the effects of various ACE training protocols on SCI populations.

Physiological and perceptual responses to acute arm cranking with blood flow restriction

INTRODUCTION

Lower-body aerobic exercise with blood flow restriction (BFR) offers a unique approach for stimulating improvements in muscular function and aerobic capacity. While there are more than 40 reports documenting acute and chronic responses to lower-body aerobic exercise with BFR, responses to upper-body aerobic exercise with BFR are not clearly established.

PURPOSE

We evaluated acute physiological and perceptual responses to arm cranking with and without BFR.

METHODS

Participants (N = 10) completed 4 arm cranking (6 × 2 min exercise, 1 min recovery) conditions: low-intensity at 40%VO2peak (LI), low-intensity at 40%VO2peak with BFR at 50% of arterial occlusion pressure (BFR50), low-intensity at 40%VO2peak with BFR at 70% of arterial occlusion pressure (BFR70), and high-intensity at 80%VO2peak (HI) while tissue oxygenation, cardiorespiratory, and perceptual responses were assessed.

RESULTS

During exercise, tissue saturation for BFR50 (54 ± 6%), BFR70 (55 ± 6%), and HI (54 ± 8%) decreased compared to LI (61 ± 5%, all P < 0.01) and changes in deoxyhemoglobin for BFR50 (11 ± 4), BFR70 (15 ± 6), and HI (16 ± 10) increased compared to LI (4 ± 2, all P < 0.01). During recovery intervals, tissue saturation for BFR50 and BFR70 decreased further and deoxyhemoglobin for BFR50 and BFR70 increased further (all P < 0.04). Heart rate for BFR70 and HI increased by 9 ± 9 and 50 ± 15b/min, respectively, compared to LI (both P < 0.02). BFR50 (8 ± 2, 1.0 ± 1.0) and BFR70 (10 ± 2, 2.1 ± 1.4) elicited greater arm-specific perceived exertion (6-20 scale) and pain (0-10 scale) compared to LI (7 ± 1, 0.2 ± 0.5, all P < 0.05) and pain for BFR70 did not differ from HI (1.7 ± 1.9).

CONCLUSION

Arm cranking with BFR decreased tissue saturation and increased deoxyhemoglobin without causing excessive cardiorespiratory strain and pain.

Home-based arm cycling exercise improves trunk control in persons with incomplete spinal cord injury: an observational study

Arm cycling is used for cardiorespiratory rehabilitation but its therapeutic effects on the neural control of the trunk after spinal cord injury (SCI) remain unclear. We investigated the effects of single session of arm cycling on corticospinal excitability, and the feasibility of home-based arm cycling exercise training on volitional control of the erector spinae (ES) in individuals with incomplete SCI. Using transcranial magnetic stimulation, we assessed motor evoked potentials (MEPs) in the ES before and after 30 min of arm cycling in 15 individuals with SCI and 15 able-bodied controls (Experiment 1). Both groups showed increased ES MEP size after the arm cycling. The participants with SCI subsequently underwent a 6-week home-based arm cycling exercise training (Experiment 2). MEP amplitudes and activity of the ES, and movements of the trunk during reaching, self-initiated rapid shoulder flexion, and predicted external perturbation tasks were measured. After the training, individuals with SCI reached further and improved trajectory of the trunk during the rapid shoulder flexion task, accompanied by increased ES activity and MEP amplitudes. Exercise adherence was excellent. We demonstrate preserved corticospinal drive after a single arm cycling session and the effects of home-based arm cycling exercise training on trunk function in individuals with SCI.

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.