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 |
Methods | Outcomes |
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Active Stand Training | ||
Harkema et al. 2008; USA |
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). |
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Passive Cycling Exercise | ||
Ballaz et al. 2008; France |
Population: 17 participants with chronic paralegia (mean age 48 + 8, range 35-62), divided into experimental (n = 9) and control (n = 8) |
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Effect Sizes: Forest plot of standardized mean differences (SMD ± 95%C.I.) as calculated from pre- and post-intervention data
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Prolonged Intense Multi-Modal Exercise (IE) | ||
Harness et al. 2008; USA |
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) |
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Quad Rugby | ||
Hopman et al. 1996; The Netherlands |
Population: Participants were divided into 3 groups according to their fitness levels. All participants had a cervical SCI (C4 to C8), tetraplegia.
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. |
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Passive exercises | ||
Ter Woerds et al. 2006; Netherlands |
Population:
Treatment: Each participant successively underwent 2 interventions, passive leg movements (10 minutes) and passive cycling (20 minutes). |
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Wheelchair skills + weight training | ||
Durán et al. 2001; Colombia |
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 |
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Whole Body Vibration | ||
Yarar-Fisher et al. 2013; USA |
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 |
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General Physical Activity | ||
Totosy de Zepetnek et al. 2015; Canada |
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. |
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Effect Sizes: Forest plot of standardized mean differences (SMD ± 95%C.I.) as calculated from pre- and post-intervention data
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Ravensbergen et al. 2014; Netherlands |
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. |
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De Rossi et al. 2014; Brazil |
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 |
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Serra et al. 2014; Spain |
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) |
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Schreiber et al. 2014; Brazil Cross-sectional |
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) |
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Currie et al. 2014; Canada |
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. |
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Overground Training For Gait Rehabilitation | ||
Evans et al. 2015; USA |
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. |
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Stationary Cycling and Uphill Treadmill Walking | ||
Wouda et al. 2015; Norway |
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) |
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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.