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Cardiovascular Health and Exercise

Other Forms of Exercise Interventions

Various forms of exercise interventions have been used in an attempt to improve the health status of persons with SCI (Hopman et al. 1996; Duran et al. 2001; Ter Woerds et al. 2006; Ballaz et al. 2008; Harness et al. 2008). The forms of potential interventions are numerous and varied. As such, it is difficult to systematically review the literature regarding alternative forms of exercise interventions for SCI. Therefore, we have provided a brief summary of studies that have incorporated non-traditional forms of rehabilitation in SCI (Table 9). New technology has potential for physical activity, for example, Gaffurini et al. (2013) used Wii sport video games, and it showed that it had immediate effects on energy expenditure (EE), but training effects were not evaluated.

Author Year; Country
Score
Research Design
Sample Size

 Methods Outcomes
Active Stand Training

Harkema et al. 2008; USA
Pre-Post
Level 4
N = 8

 Population: 8 participants with tetraplegia or paraplegia
Treatment: Active stand training for 40 and 80 sessions.
Outcome Measures: Ability to bear weight, blood pressure and heart rate (at rest and in response to an orthostatic challenge).
  1. All participants were able to bear more weight after training.
  2. There was a significant increase in resting blood pressure in persons with tetraplegia after 80 training sessions (by 24%).
  3. Orthostatic tolerance was improved in persons with tetraplegia (i.e., orthostatic hypotension was no longer present after 80 sessions).
  4. There were no significant changes in hemodynamic parameters in persons with thoracic SCI.
Passive Cycling Exercise

Ballaz et al. 2008; France
PEDro = 6
RCT
Level 1
N = 17

Population: 17 participants with chronic paralegia (mean age 48 + 8, range 35-62), divided into experimental (n = 9) and control (n = 8)
Treatment: passive cycling exercise 6 times weekly for 6 weeks
Outcome Measures: Red blood cell velocity in the common femoral artery; Velocity index (a measure of peripheral vessel resistance) was measured before and after a 10-min session of passive cycling exercise.
  1. Before training, the resting mean blood flow velocity did not differ between groups.
  2. In the experimental group, the post-exercise mean blood flow velocity was significantly higher after training.
  3. Post-exercise velocity index was significantly lower in experimental group after training.
Effect Sizes: Forest plot of standardized mean differences (SMD ± 95%C.I.) as calculated from pre- and post-intervention data
Prolonged Intense Multi-Modal Exercise (IE)

Harness et al. 2008; USA
Prospective Controlled Trial
Level 2
N = 29

 Population: 29 SCI participants, divided into intense exercise (n=21, age 37.8 + 3.6 y, 40 + 7 months post-injury) and control (age 34.5 + 2.9 y, 97 + 23 months post-injury)
Treatment: Intense exercise group: regular participation in an individually designed exercise multi-modal program focused on regaining voluntary motor function below the level of injury for 6 months; participants in the control group dictated their own level of activity
Outcome Measures: AIS scores; Medical Research Council scale (a measure of muscle strength)
  1. The intense exercise group showed significantly greater gains for total AIS motor score compared to the control.
  2. 15 participants in the intense exercise group, compared to 0 in the control, had at least one muscle increase in strength from 0 to 1 or more on the Medical Research Council scale.
  3. 7 participants in the intense exercise group, compared to 1 in the control, had at least one muscle increase in strength from <3 to ≥3.
Quad Rugby

Hopman et al. 1996; The Netherlands
Pre-post
Level 4
N=21

 Population: Participants were divided into 3 groups according to their fitness levels. All participants had a cervical SCI (C4 to C8), tetraplegia.

  1. Trained group (T) (n=8): All males; Age: 32.7±12.7; Time since injury: 8.1±10.3; Type of injury: 4 incomplete, 4 complete
  2. Untrained group (U) (n=7): 6 males and 1 female; Age: 26.6±6.9; Time since injury: 6.6±5.2; Type of injury: All complete
  3. Sedentary group(S) (n=6): 4 males and 2 females; Age: 36.5±10.4; Time since injury: 9.1±3.9; Type of injury: All but one with complete lesion

Treatment: Untrained and trained group trained once a week and played 2 games/month for 6 months. Training consisted of endurance, sprint, and skill training. The U trained 42.2 min and T 21.3 min above 60% HRres during training.
Outcome Measures: Physiological responses to maximal and submaximal arm-cranking exercise.
  1. No significant differences were found in either absolute or relative changes in the physiological responses to arm exercise for submaximal and maximal exercise over 3 or 6 months in U, T, and S groups.
Passive exercises

Ter Woerds et al. 2006; Netherlands
Prospective controlled trial
Level 2
N=16

 Population: 

  1. SCI group: 8 males; Age: 35±8.4; Level of injury: 7 thoracic, 1 thoracic-lumbar, range T2-L1; Type of injury: 6 AIS A, 2 AIS B; Time since injury: 8.3±6.1; Hours of exercise/week: 5.7±3.9.
  2. Control group: 8 males; Age: 26±4.5; Hours of exercise/week: 4.7±2.3.

Treatment: Each participant successively underwent 2 interventions, passive leg movements (10 minutes) and passive cycling (20 minutes).
Outcomes measures: Leg blood flow, mean red blood cell velocity, diameter of common femoral artery, leg vascular resistance, mean arterial pressure, total peripheral resistance.
  1. Blood flow, vascular resistance, and blood pressure in the common femoral artery did not change during or after 2 different passive exercise interventions in the participants with SCI or the control participants.
Wheelchair skills + weight training

Durán et al. 2001; Colombia
Case series
Level 4
N=13

 Population: 12 males and 1 female; Age: 26.3±8.3; Level of injury: All thoracic, T3-T12; Time since injury: 2-120 months; Type of injury: 11 AIS A, 1 AIS B, 1 AIS C.
Treatment: The program lasted for 16 weeks, with a frequency of 3 sessions (120 minutes) per week. Mobility activities, aerobic resistance, strength, coordination, recreation, and relaxation were combined. The specific aerobic program lasted 11 weeks, including a 4-week adaptation and 1-week enhancement period. Progressively led to 40 minutes of aerobic training at 40% to 60% HR reserve.
Outcome measures: FIM (functional independence measure), arm crank exercise test, lipid levels
  1. Pre-training FIM scores mean 106±7 vs. 113±7 post-training. Highest increase occurred in mobility.
  2. Lipid profiles and average resting heart rate did not change.
  3. Maximum resistance achieved during arm exercise test increased from 90±24 watts to 110±26 watts.
  4. HR at 6 minutes after exercise test decreased from 115±19 bpm to 108±19 bpm.
Whole Body Vibration

Yarar-Fisher et al. 2013; USA
Randomized cross-over trial
Level 1
N=21

 Population: 11 males with SCI (C4-T6, ASIA- A or B) and 10 able bodied individuals
Intervention: 3 whole body vibration (WBV) exercise sessions at 30, 40, 50 Hz.
Outcome measures: Heart rate, mean arterial blood pressure (MAP), stroke volume (SV), cardiac output (CO), oxygen consumption (VO2), relative changes in oxygenated (HbMbO2), deoxygenated (HHbMb) and total (HbMbtot) heme groups
  1. No significant interactions or main effects in either group for HR, MAP, SV, and CO.
  2. Both groups demonstrated small but significant increases after WBV in VO2, [HbMbO2] and [HbMbtot] but the response was greater in the SCI group.
  3. Significant decrease in HHbMb was observed in the SCI group.
General Physical Activity

Totosy de Zepetnek et al. 2015; Canada
PEDro=4
RCT
Level 2
N=17

Population: 23 individuals with SCI from C3-T11. 12 randomly assigned to Physical Activity Guidelines (PAG) training and 11 maintained existing physical activity levels with no guidance or training intensity.
Treatment: PAG training involving at least 20 minutes of moderate-vigorous aerobic exercise and 3X10 repetitions of upper body strengthening exercise at 2 times per week for 16 weeks. The control group maintained existing physical activity levels with no guidance on training intensity.
Outcome measure: Blood biomarkers, body composition, arterial structure, arterial stiffness and function (i.e. heart rate, blood pressure, carotid pulse pressure, distensibility)
  1. There were decreases in whole body mass, whole body fat, visceral adipose tissue (VAT), and carotid distensibility in the control group. Whereas, the PAG group maintained body composition and carotid stiffness.
  2. No other interactions found for other measures of carotid artery structure, indices of regional artery stiffness or vascular function. PAG did not elicit changes in other CVD risk factors.
  3. No change in fasting insulin, leptin, adipokines, inflammatory markers, and thrombotic markers in either group
Effect Sizes: Forest plot of standardized mean differences (SMD ± 95%C.I.) as calculated from pre- and post-intervention data

Ravensbergen et al. 2014; Netherlands
Longitudinal
Level 2
N=110

 Population: 110 participants, 74% male, 36% cervical lesion, 16% high thoracic lesion, 47% low level lesion, 59% AIS-A, 41% AIS B,C,D.
Treatment: None. All underwent standard active inpatient rehabilitation
Outcome Measures: Cardiovascular variables including resting systolic (SAP) and diastolic arterial pressures (DAP), resting and peak heart rates (HR peak), were measured on 5 test occasions: start of inpatient rehab, 3 months later, at discharge and at 1 and 5 years after discharge.
  1. No significant change in the prevalence of hypotension during rehabilitation and for 5 years after discharge.
  2. No significant change over time in SAP. DAP did not change during the period of rehabilitation but increased in the first 5 years after discharge.
  3. SAP and DAP were significantly lower in those with cervical lesions compared with those with high thoracic and low level lesions.
  4. No significant change over time in HR peak. HR rest decreased significantly during inpatient rehab and decreased further from time of discharge to 5 years after discharge.  Lesion level was negatively associated with HR peak and HR rest and age was negatively associated with HR peak.
  5. No significant change in the prevalence of bradycardia over time.  Prevalence of an elevated HR improved during and after rehabilitation.

De Rossi et al. 2014; Brazil
Cross-sectional study
Level 5
N= 87

 Population: 58 SCI men (29 sedentary- SCI-S and 29 athletes SCI-A) with at least 1 year of SCI, 50 SCI participants were ASIA A and 8 were ASIA B. 29 able-bodied men (AB) acted as controls.
Treatment: None
Outcome Measures: Cumulative training time, body mass index, blood pressure, glucose, lipid fractions, C-reactive protein. Aortic root, Left ventricle and left atrial dimensions, cardiac output, mitral inflow velocity, peak early inflow velocity, peak atrial inflow velocity, peak early/atrial velocity ratio
  1. SCI-S presented similar left ventricular (LV) structural and systolic parameters but higher E/Em and lower Em/Am ratios that SCI-A and AB.
  2. Tetraplegic athletes had similar features compared with sedentary tetraplegic participants, except for higher E/Em ratio and lower Em values.
  3. Paraplegic athletes had similar features compared with sedentary paraplegic individuals, except for higher LV end-diastolic diameter, Em/Am ratio, stroke volume, lower heart rate and relative wall thickness.
  4. No correlation detected between training time and cardiac features. In paraplegic athletes, cumulative training time correlated with stroke volume, LV end-diastolic diameter, relative wall thickness, LV mass index and LV end systolic diameter.

Serra et al. 2014; Spain
Cross-sectional
Level 5
N=78

 Population: 42 paraplegic participants (T2-T12, AIS A or B) and 36 able bodied (AB) participants.
Treatment: None. Paraplegic group went about their normal physical activities (22 participants ≥ 3 hrs/week of sport vs. 20 who was active for < 3 hrs/week)
Outcome measures: Heart Rate variability (HRV)
  1. Significant differences between paraplegic and AB participants in some variables in the time domain, frequency domain, and nonlinear analyses.
  2. When power was normalized, there were no differences between the two groups.
  3. There was reduced variability in paraplegic participants who adopted a sedentary lifestyle. There was only a significant difference in detrended fluctuation in heart rate variability between the sedentary and active paraplegic groups.
  4. No differences in autonomic cardiac control between those with different levels of injury (above or below T6).

Schreiber et al. 2014; Brazil Cross-sectional
Level 5
N=42

 Population: 19 SCI men (sedentary- S-SCI) and 23 physically active men (PA-SCI) (ASIA A or B)
Treatment: None.
S-SCI did not perform sports, recreational activity or labor that required physical effort. PA-SCI comprised competing athletes regularly performing wheelchair sports for at least 1 year.
Outcome measures: Concentration of matrix metalloproteinases (MMPS) and tissue inhibitors of MMPs (TIMPs), echocardiographic parameters (i.e. LV mass, LV diastolic function)
  1. PA-SCI participants presented lower pro-MMP-2 and pro-MMP-2/TIMP-2 levels compared to S-SCI participants..
  2. No differences in structural cardiac variables and measurements of systolic function between S-SCI and PA-SCI groups.
  3. S-SCI group presented echocardiographic features of reduced LV diastolic function (lower E/A ratio and Em and higher E/Em ratio vales) in comparison with the PA-SCI group.
  4. The significant difference between the 2 groups for E/A ratio, Em, and E/Em ratio became insignificant after adjustment for pro-MMP-2 levels. (This suggests that pro-MMP-2 might play a role in LV diastolic function improvements induced by regular physical activity in SCI participants.)

Currie et al. 2014; Canada
Cross-sectional
Level 5
N= 21

 Population: 8 non-athletic men with SCI and 13 athletic men with SCI. All have tetraplegia (C4 –C8), traumatic motor complete cervical SCI for more than one year.
Treatment: None. Regular hours of physical activity for both groups
Outcome measures: Sympathetic function including palmar sympathetic skin responses (SSR) to median nerve stimulation, systolic (SPB) and diastolic blood pressure (DBP) in response to passive sit up. Peak heart rate (HR) during maximal exercise test on electrically braked arm-cycle ergometer.
  1. Compared to the athletic group, the non-athletic group exhibited lower peak HR as well as greater reductions in SPB and DPB in response to passive sit-up.
Overground Training For Gait Rehabilitation

Evans et al. 2015; USA
Pre-post
Level 4
N= 5

 Population: 4 males and 1 female; average age 42 ± 9y; chronic spinal cord injury; AIS A.
Treatment: Expired gases were collected during maximal graded exercise testing and two, 6-minute bouts of exoskeleton-assisted walking overground.
Outcome Measures: Peak oxygen consumption (V. O2peak), average oxygen consumption (V. O2avg), peak heart rate (HRpeak), walking economy, metabolic equivalent of tasks for SCI (METssci), walk speed, and walk distance.
  1. Significant differences were observed between walk-1 and walk-2 for walk speed, total walk distance, V. O2avg, and METssci
  2. Exoskeleton-assisted walking resulted in %VO2peak range of 51.5% to 63.2%.
  3. The metabolic cost of exoskeleton-assisted walking ranged from 3.5 to 4.3 METssci. -Semen collected by PVS (6 pregnancies) and EEJ.
Stationary Cycling and Uphill Treadmill Walking

Wouda et al. 2015; Norway
PEDro= 6
RCT
Level 1
N= 30

 Population: 22 males and 8 females; mean age 41y; incomplete spinal cord injury; AIS D; 4-14 y post injury
Treatment: 15 participants with incomplete SCI and 15 control participants performed sub-maximal and maximal exercise tests of both stationary cycling and uphill treadmill walking on separate days.
Outcome Measures: VO2, VCO2, respiratory exchange ratio (RER), heart rate (HR)
  1. RER was significantly higher for the SCI group during the cycle test compared to the uphill treadmill walking test.
  2. Control participants exhibited significantly higher peak VO2 during the treadmill test as compared with the cycle test.

Discussion

The evidence supporting non-traditional forms of exercise interventions in SCI is not clear. This is to be expected given the varied training methodologies that can be employed. The lack of concrete information should not however dissuade researchers from considering non-traditional rehabilitation models when for the SCI population. It is clear that novel models of exercise rehabilitation are warranted and desired in the rehabilitation of SCI. For instance, stand locomotor training has been shown to be highly effective in improving blood pressure control and orthostatic tolerance in persons with tetraplegia.

Some modalities of exercise that have been applied with success in able-bodied individuals (such as interactive video games (Warburton et al. 2007a)) or other clinical populations (e.g. interval training (Warburton et al. 2005)) may hold great promise for persons with SCI. As with early research with FES, it is essential that researchers demonstrate innovative thinking that is based upon a strong theoretical foundation. In addition, it is essential to find exercise routines and modalities that an individual can continue with in the long term. Interactive video games or circuit training might offer affordable and accessible approaches that maintain the interest of the person.

Conclusion

There is level 4 evidence (Fisher et al. 2013) that whole body vibration training increases VO2.

There is level 5 evidence (Guilherme et al. 2014; Schreiber et al. 2014) that tetraplegic and paraplegic athletes, with regular physical activity, have improved left ventricular diastolic function.

There is level 5 evidence (Currie et al. 2014) that tetraplegic athletes compared to non-athletic group have higher peak HR and lower reductions in systolic and diastolic blood pressure.

There is level 2 evidence (Totosy de Zepetnek et al. 2015) that moderate to vigorous aerobic exercise training maintained body composition and carotid stiffness in individuals with SCI. The training program had no impact on other CVD risk factors.

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