See All Evidence Sections
Physical Activity: Cardiovascular Health and Fitness

Other Physical Activity

Other forms of activity can elicit therapeutic effects on health and/or fitness. These other forms of physical activity might be performed for a different purpose (such as sport, for the social and fun aspects, or the desire to compete), yet these activities can also benefit health and/or fitness as an unintended outcome. We categorize interventions as “other” if the activity was not restricted to a specified mode (e.g., “behavior change”, “general rehabilitation” or “multi-modal”), was sport-related, or the mode was deemed to be an uncommon form of prescribed exercise (e.g., over-ground ambulation for individuals with incomplete injuries, recumbent stepper, simulated wheelchair rolling exercise, passive leg-cycling, etc.). 

Author Year

Research Design

Total Sample Size



Behavior Change Interventions

Williams et al. (2021)






Population: Intervention Group (IG): Age=45.8±13.6yr; Gender: males=9, females=5; Level of injury: C1-T6=8, Below T6=6; Level of severity: AIS A=7, B-D=1, Not reported=6; Time since injury=14.7±13.9yr.

Control Group (CG): Age=45.6±10.5yr; Gender: males=8, females=6; Level of injury: C1-T6=9, Below T6=5; Level of severity: AIS A=6, B-D=3, Not reported=5; Time since injury=18.1±10.9yr.

Intervention: Participants were randomized to either an an 8-week behavioural physical activity intervention (n=14) or a control group (n=14).

Outcome Measures: Resting Left Ventricular (LV) Structure and Function, Posterior Wall Thickness (PWT), Blood pressure, Common Carotid Artery Intima-Media Thickness (CCA-IMT) and Pulse-Wave Velocity (PWV) were assessed with Ultrasound and Tonometry, respectively. VO2peak & POpeak were determined via a cardiopulmonary exercise test on an arm-crank ergometer.


Resting Cardiovascular Structure and Function

·         No significant group, time, or interaction effects for LV volumes, hemodynamics, or LV geometry (p>0.05 for all), despite significant improvements in VO2peak and POpeak (p<0.05).

·         For diastolic measures, only E’ (p=0.008) and A’ (p=0.025) were significantly lower at post-intervention in the IG, but not in the CG.

·         No effects for LV twist mechanics, although untwisting velocity was significantly elevated in the IG compared to the CG (p=0.014).

·         No significant change in PWT or CCA-IMT at post-intervention or between groups (p>0.05).

·         No significant effects for blood pressure.

Sub-Analysis for Level of Injury (LOI)

·         No significant changes in cardiovascular structure or function detected at post-intervention in the high-LOI group, but there were significant ↑ in LV end-diastolic internal diameter (LVID) and reductions to sphericity in the low-LOI PA group at post-intervention (p=0.027 and p=0.049, respectively).

·         No other significant effects in the low- or high-LOI groups for measures of LV mechanics, Doppler velocities, IMT, PWV, or blood pressure.

·         Both high- and low-LOI cohorts had significant group × time interactions for relative VO2peak (p=0.002 and p=0.006, respectively) and POpeak (p=0.01 for both cohorts).

·         ↑ in self-reported total PA (p=0.99) and moderate-to-vigorous PA (p=0.30) were not different between the high- and low-LOI PA cohorts.

Nooijen et al. (2017)

The Netherlands



NInitial=45; NFinal=39

Population: Intervention group: Mean age: 44 yr; Gender: males=17, females=3; Level of injury: Tetraplegia=7, Paraplegia (13); Mean time post-injury: 139 days. Control group: Mean age: 44 yr; Gender: males=16, females=3; Level of injury: Tetraplegia=6, Paraplegia=13; Mean time post-injury: 161 days

Intervention: Intervention group: A behavioral intervention promoting physical activity, involving 13 individual sessions delivered by a lifestyle coach who was trained in motivational interviewing. The intervention began 2 mo. before and ending 6 mo. after discharge from inpatient rehabilitation.

Control group: Regular rehabilitation

Outcome Measures: Physical capacity as determined during a maximal handcycle exercise test, body mass index (BMI), blood pressure, fasting lipid profile, social participation (IMPACT-S), 36-item Short Form Health Survey questionnaire (SF-36).

·         Diastolic blood pressure improved significantly 12 months after discharge (p=0.01),

·         Total cholesterol (p=0.01) and low-density lipoprotein cholesterol (p=0.05) improved significantly 12 months after discharge

·         Participation improved significantly 12 months after discharge (p<0.01).

·          There seemed to be a clinically relevant between-group difference for peak power output, BMI and general health perceptions; however, the differences between the groups were not statistically significant (p>.05).

Ambulation/Stepping Training for Individuals with Motor-Incomplete Injuries

Lotter et al. (2020)


Randomised Crossover


NInitial=17, NFinal=15

Population: Impairment-Based First Group (n=8): Mean age: 51±17yr; Gender: males=6, females=2; Level of injury: C1-C4=4; C5-C8=2 T1-T10=2; Severity of injury: Incomplete (AIS C or D)=8; Mean time since injury: 3.9±1.8yr; Task-Specific Frst Group (n=8): Mean age: 46±13yr; Gender: males=4, females=4; Level of injury: C1-C4=2; C5-C8=2 T1-T10=4; Severity of injury: Incomplete (AIS C or D)=8; Mean time since injury: 4.3±4.3yr.

Intervention: Participants performed either task-specific (upright stepping) or impairment-based training for up to 20 sessions over ≤6wks, with interventions alternated after >4wks delay. Both strategies focused on achieving higher cardiovascular intensities, with training specificity manipulated by practicing only stepping practice in variable contexts or practicing tasks targeting impairments underlying locomotor dysfunction (strengthening, balance tasks, and recumbent stepping).

Outcome measures: Primary outcome measures were fastest speed over short distances and peak treadmill speed. Secondary outcome measures were self-selected speed on the instrumented walkway with instructions to “walk at your normal, comfortable pace,” and a six minute walk test with instructions to “cover as much ground as possible”. Other outcome measures included Berg Balance Scale, 5-times sit-to-stand,

Activities-specific Balance Confidence scale, Patient-Reported Outcomes Measurement Information

System–Mobility score (version 1.2), lower extremity motor

score, VO2peak during graded exercise tests on the treadmill and peak power and VO2peak during a graded recumbent stepping test.

·         Significantly greater increases in fastest overground and treadmill walking speeds were observed following task-specific versus impairment-based training (p’s≤0.01).

·         Gains in balance confidence were observed following task-specific vs. impairment-based training (p=0.02), although incidence of falls was increased with the former protocol (3 vs. 0).

·         A significant time × training interaction was observed for changes in peak recumbent stepping power favoring impairment-based vs task-specific training, (27±45 vs −0.20±33 watts; p=0.04)

·         For secondary metabolic measures, there was a significant main effect of time only for VO2peak during treadmill exercise tests but not for recumbent stepping tests, with no significant interactions.

Wouda et al. (2018)

Population: Mean age: 41yr; Gender: males=25, females=5; Level of injury:C1-C8, T1-T12, L1-L5, S1-S5; Time since injury: 69 days.

Intervention: Participants were randomized into one of the three groups: high-intensity interval training (HIIT) group, moderate-intensity interval training (MIT) group, or a control group (treatment as usual). The HIIT program was 35min, 2x/wk; 10min warm-up at 70% of peak heart rate (HRpeak) followed by 4 × 4min intervals at an intensity of 85–95% of HRpeak interspersed with 3 × 3 min recovery periods at an intensity of 70% of HR peak. The MIT program consisted of 45min of continous walking or running (depending on their physical ability), 3x/wk at an intensity of 70% of HRpeak. Those in control group did not receive any aerobic exercise prescriptions.

Outcome measures: VO2peak, respiratory exchange ratio (RER), HRpeak, blood lactate, 6-min walking test (6MWT). Physical activity levels were assessed via the International Physical Activity Questionnaire (IPAQ).

·         VO2peak ↑ from the pre- to post on average 13±17%, 8±13%, and 10±7% in the HIIT, MIT and control groups, respectively. Similarly, the distance walked during the 6MWT ↑ on average by 18±11%, 15±16%, and 9±15%, respectively. There were no statistically significant differences in changes pre- to post-intervention between the groups, after controlling for the pre-test values in either VO2peak (ANCOVA: p=0.94) or 6MWT (p=0.58).

·         Total daily energy expenditure (TDEE) ↑ from the pre- to post-intervention on average 7±11%, 1±15%, and 5±10% in the HIIT, MIT and control groups, respectively. The MIT and control group had a ↓ daily number of steps on average −1±54% and −1±39%, while the HIIT group showed an average ↑ of 16±18%. There was no significant effect of group on the changes in physical activity levels indicated by TDEE (p=0.79) and daily number of steps (p=0.63).

DiPiro et al. (2016)



NInitial=10, NFinal=9

Population: Mean age: 57.94±9.33 yr; Gender: males=5, females=5; Level of injury: Cervical=9, Thoratic=1; Severity of injury: AIS C=1, AIS D=9; Mean time since injury: 11.1±9.6yr.

Intervention: Participants completed voluntary, progressive moderate-to-vigorous intensity exercise on a recumbent stepper (3d/wk for 6wks).

Outcome measures: Primary outcome measures: Aerobic capacity (VO2peak) and self-selected overground walking speed (OGWS). Secondary outcome measures: walking economy, 6-minute walk test, daily step counts, Walking Index

for Spinal Cord Injury, Dynamic Gait Index and Berg Balance Scale.

·         Aerobic capacity improved significantly from pre- to post-intervention (p=0.011).

·         OGWS improved significantly from pre- to post-intervention (p=0.023).

·         The percentage of VO2peak used while walking at self-selected speed improved significantly from pre- to post-intervention (p=0.03).

·         Daily step counts improved significantly from pre- to post-intervention (p=0.025).

General Sport Training Interventions

Sarro et al. (2016)



NInitial=10, NFinal=7

Population: Mean age: 26.86±5.87yr; Gender: males=10, females=0; Level of injury: C1-T1=10, T2-L5=0; Mean time since injury: 90.86±55.80mo.

Intervention: Regular wheelchair rugby training, consisting of 3-4 session/wk for 2hr/session. Training load was according to the competition schedule, following the traditional annual model divided in preparatory, competition and transition period. Training lasted 1yr.

Outcome Measures: Lung volume and tridimensional mobility of four-chest wall compartments (superior and inferior thorax, superior and inferior abdomen).

·         During quiet breathing, significant differences were found for tidal volume (p=0.04), superior thorax (p=0.04) and inferior thorax (p=0.01) mobility, representing ↑ of 16.9%, 61.3% and 83.7%, respectively.

·         During maximal breathing, significant differences and large effect sizes were found for vital capacity (p=0.01) and superior thorax (p=0.04) mobility, representing ↑ of 24.8 and 31.5%, respectively.

Matos-Souza et al. (2016)


Prospective Observational


Population: Sports Group (n=8); Mean Age=28.3±2.5yr; Gender: Males=8, Females=0; Level of Injury: C5-T9; Severity of Injury: AIS A=7, B=1; Mean Time Since Injury=5.1±1.3yr.

Control Group (No Sports; n=9); Mean Age=33.7±2.2yr; Gender: Males=9, Females=0; Level of Injury: C4-T8; Severity of Injury: AIS A=8, B=1; Mean Time Since Injury=7.6±1.5yr.

Intervention: Not applicable. Prospective observational study to determine whether involvement in adapted sports is associated with long-term changes in carotid atherosclerosis in individuals with SCI. Outcome measures were assessed at baseline and 5yr follow-up.

Outcome Measures: Cholesterol, triglycerides, c-reactive protein, blood pressure, heart rate, stroke volume, cardiac output, peripheral vascular resistance, carotid ultrasonography.

·         At follow-up the control group experienced: significant ↑ in resting heart rate (p=0.004) and no significant changes in carotid intima-media thickness or diameter (p>0.05).

·         At follow-up the sports group experienced: significant ↓ in carotid intima-media thickness (p=0.001) and diameter (p<0.001). No other variables were significantly different at follow-up.

Moreno et al. (2013)


Pre-Post and cross-sectional comparison


Population: N=15 male tetraplegic individuals with SCI divided into a control (n=7) and rugby player (n=8) group.

Control group: mean±SD age: 33±9yr; DOI: 73±53 months.

Rugby player group: mean±SD age: 26± 6 yr; DOI: 87±52 months.

Intervention: Experimental group participated in a regular 1-year wheelchair rugby training program that involved stretching, strength exercises, and cardiovascular resistance training (2-hour sessions, 3-4x per week). The control participants were only assessed once at baseline.

Outcome measures: forced vital capacity (FVC), forced expiratory volume measured during the first phase (FEV1) and maximal voluntary ventilation (MVV).

·         There was a significant ↑ in all variables after training: (mean±SD) FVC ↑ from 2.7±0.9 L to 3.0±1.0 L.

·         FEV1 ↑ from 2.5±0.9 to 2.8± 1.0 L.

·         MVV ↑ from 107±28 to 114±24 L/min.

·         No significant difference between the control group and rugby players regarding spirometric variables, except for MVV, which was higher in rugby players.

Fukuoka et al. (2006)




Population: N=8 (7M 1F); mean±SD age: 46.5±8.3yrs; AIS B; T7-L1.

Intervention: Wheelchair training program: 30 min at 50% HRR, 3x/wk, for 60 days. Outcomes were assessed before training, after 7, 15, 30 and 60 days of training

Outcome Measures: VO2peak, HR.

·         Mean VO2peak ↑ with training, became significant from 30th training day onwards (baseline = 17 ml/kg/min vs. T30 = 18 ml/kg/min).

·         Steady state HR assessed during the constant workload test (50% of VO2peak) ↓ significantly by the 7th training day and plateau from day 15 onwards (baseline HR = 123±11 bpm, day 7 = 112±11 bpm, day 15 = 109±6 bpm).

General Rehabilitation

Nooijen et al. (2012)




Population: Mean age: 42yr; Gender: 72% males; Injury: 53% tetraplegia, 72% motor-complete SCI; Mean time of inpatient rehabilitation: 7mo.

Intervention: Outcomes were assessed at 4 timpeoints : start of active rehabilitation (t1), 3 months later (t2), at discharge from inpatient rehabilitation (t3), and 1 year after discharge (t4)

Outcome measures: VO2peak, POpeak, Isometric muscle strength, Lipid profile (cholesterol, triglycerides) and physical activity level (assessed via an accelerometery-based activity monitor).

·         After correcting for confounding variables, physical activity level was significantly correlated to VO2peak and POpeak (p<0.01). An ↑ in physical activity level was associated with an ↑ in aerobic capacity.

·         With regard to lipid profile, an ↑ in activity level was correlated to a ↓ in concentration of TG (P<0.01) and to a ↓ in TC/HDL ratio (P<0.05).

·         Corrected for confounders and time, an ↑ in physical activity level of 26 min day was associated with an ↑ in 0.11 L min (ß=0.059*1.79%) in VO2peak. The same ↑ of 26 min day, corrected for confounders and time, was associated with an ↑ in POpeak of 4.06W (ß=2.27*1.79%), a ↓ in TG of 0.14 mmol (ß=0.076*1.79%) and a ↓ in TC/HDL ratio of 0.23 (ß=0.127*1.79%).

Valent et al. (2008)

The Netherlands



Population: SCI participants: C5 or lower; aged 18-65yrs. Hand cycling group: 35 participants with paraplegia, 20 with tetraplegia. Non-hand cycling group: 56 with paraplegia, 26 with tetraplegia.

Intervention: All participants followed the usual care rehabilitation program in their own rehabilitation centres, with or without regular hand cycling exercise. Study included three measurements: 1) when participants could sit in a wheelchair for three hours; 2) on discharge; 3) 1 year after discharge.

Outcome Measures: VO2peak; FVC; peak expiratory flow rate (PEFR).

·         Significant ↑ (26% in hand cycling group vs. 8% non-hand cycling group) in VO2peak in paraplegic patients, whereas tetraplegic patients showed no change.

·         No change in pulmonary function (FVC or PEFR) found in either participants with paraplegia or tetraplegia.

Grange et al. (2002)



N=14 (SCI=7)

Population: Able-bodied (n=7): Mean age: 26.6yr; Gender: males=7. SCI (n=7): Mean age: 35.2yrs; Mean time since injury: 12.3yrs; Gender: males=7; Level of injury: paraplegia; Level of severity: AIS A.

Intervention: All individuals participated in a rehabilitation program composed of 3 sessions/wk for 6wk. Each session consisted of a 45 min Square Wave Exercise Tests (SWEET). During each work bout, a 4 min period of moderate work (base level) was followed by a 1 min period of heavy work (Peak level). The maximal graded exercise tests (GXT) and the SWEET were performed before (GXT 1 and SWEET 1) and after a 6 wk training period (GXT 2 and SWEET 2).

Outcome Measures: VO2peak, maximal tolerated power (MTP), heart rate and perceived exertion (PE).

·         There was no significant difference in both groups for PE between the two GXT (p>0.05). However, a significant ↓ in the PE values (p<0.01) was observed in both groups during the SWEET 2.

·         There was no significant difference in HRmax between the two GXT, but a significant ↓ in HR (p<0.0001 for baseline HR and p<0.001 for HRpeak) was observed in SWEET 2 compared to SWEET 1.

·         The MTP and VO2peak ↑ significantly in able-bodied (p<0.0001) and paraplegic groups (p<0.05).

Multi-Modal Training

Kim et al. (2019)




NInitial=19, NFinal=17

Population:  Mean Age=36.8±6.9yrs; Gender: Males=11, Females=6; Level of Injury: L1-C4; Severity of Injury: AIS A=9, B=7, C=1; Time Since Injury ≥1yr.

Intervention: Participants were randomized to complete a combined exercise program consisting of aerobic and resistance exercises (60 min/d, 3 d/wk for 6 wk) or usual care. The exercise program consisted of the following: 25-min warm-up consisting of 5-min of joint exercises, 15-min of exercise on an arm-crank ergometer, and 5-min of stretching, followed by a 30-min exercise program (resistance training circuit and aerobic training), and a 5-min of cooldown (stretching). Circuit and aerobic exercise was performed at a moderate-to-vigorous intensity (4-8 on a Borg CR10 scale). Outcome measures were assessed at baseline and 6 wk.

Outcome Measures: VO2peak, body mass index, percent body fat, waist circumference, shoulder abduction /adduction, shoulder flexion/extension, elbow flexion/extension, fasting insulin levels and homeostasis model assessment of insulin resistance (HOMA-IR) levels.

·         Compared to usual care, the exercise program significantly: ↓ the mean fasting insulin, ↓ HOMA-IR, ↑ HDL cholesterol, ↓ waist circumference, and ↑ muscle strength of the shoulder flexors, extensors, adductors, abductors, and elbow flexors (group × time interactions P<0.05).

·         There were no significant (group × time interactions (p>0.05) on measures of: VO2peak, lean mass, body fat percentage, total cholesterol and LDL cholesterol.

Yarar-Fisher et al. (2018)




NInitial=20, NFinal=11

Population: Mean age: 46.0±7.8yrs; Gender: males=10, females=1; Level of injury: C1-T1=4, T2-L5=7; Level of severity: AIS A=3, AIS B=8; Mean time since injury: 21.8±6.3yrs.

Intervention: Isocaloric high-protein (HP) diet vs. a multi-modal exercise intervention, which consisted of upper-body resistance training (RT) in addition to neuromuscular electrical stimulation (NMES)-induced-RT for paralytic Vastus Lateralis muscle. Strength training was combined with high-intensity arm-crank exercises for improving cardiovascular endurance. Exercise training was completed 3 days/wk for 8 wk.

Outcome Measures: Dual-energy X-ray absorptiometry scan, VO2peak, and maximum voluntary upper-body strength.

·         VO2peak significantly (P<0.05) ↑ from 13.2±3.4 to 14.6±3.3 ml/kg/min.

·         Upper-body strength (arm-curl, overhead press, chest fly and lat pull down) significantly (P<0.05) ↑.

Gant et al. (2018)




Population: Mean age=31.4yrs; Gender: males=6, females=2; Time since injury: 10.5yrs; Level of injury: T2 – T10; Severity of injury: AISA A=4, B=4.

Intervention: Participants underwent three, 4-wk long multi-modal exercise conditioning and rehabilitation interventions, each separated by a one wk period of multiple body systems assessments. Each participant was in the trial for 19 continuous weeks. Outcome measurements were assessed after screening for two baseline assessments and at 4, 9, 14 and 19 wk.

Outcome Measures: Neurological motor and sensory impairment; Upper-extremity muscle strength; VO2peak; Blood pressure; cholesterol, lipids and biomarkers of glycemic control and inflammation; Clinical and electrophysiological spasticity measures; Pain history and pain-related sensory function; Self-reported function; Patient-reported global impression of change.

·         No significant differences in neurological motor and sensory impairment, blood pressure, cholesterol, lipids, biomarkers of glycemic control and inflammation, as well as chronic pain were observed (p>0.05).

·         Upper-extremity muscle strength significantly improved from baseline (p=0.001).

·         VO2peak was not significantly different from baseline (p>0.05).

·         Two participants experienced clinically significant improvements in self-reported function (p<0.05). All participants reported a perceived improvement.

Totosy de Zepetnek et al. (2015)






Population: SCI-specific Physical Activity Guidelines (PAG) for improving fitness: Age=39±11yr.; Gender: males=12, females=0; Level of injury: C3-T10; Level of severity: AIS A-B=3, C-D=9; Time since injury=15±10yr.

Control Group Age=42±13yr.; Gender: males=9, females=2; Level of injury: C1-C11; Level of severity: AIS A-B=5, C-D=6; Time since injury=9±10yr.

Intervention:  Participants were randomized to receive SCI-specific physical activity guidelines (PAG) for improving fitness or active control (CON). PAG training was 2x/wk for 16wk and involved 20min of aerobic exercise at a moderate-to-vigorous intensity (RPE 3–6 on 10-point scale) and three sets of 10 repetitions (at 50–70% 1 repetition maximum). The control group maintained existing physical activity levels with no guidance on training intensity

Outcome Measures: Blood biomarkers; glycosylated hemoglobin (HbA1c), lipids (triglycerides, total cholesterol, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, total cholesterol/high-density lipoprotein cholesterol), fasting insulin, adipokines (leptin, adiponectin), proinflammatory markers (IL-6, TNF-α), and prothrombotic markers (PAI-1), Body composition; whole body mass (WBM), leg fat (LF), body mass index (BMI), waist circumference (WC), whole-body fat (WBF), whole-body lean (WBL), and visceral adipose tissue (VAT), Arterial structure and function; Heart rate (HR) and blood pressure (BP) were monitored continuously, Carotid pulse pressure (CPP), carotid distensibility (CD), intima media thickness (IMT), lumen diameter (LD), and wall-to-lumen ratio (WLR), central and peripheral (arm, leg) pulse wave velocity (PWV), brachial (BA) and superficial femoral artery (SFA) endothelial-dependent (flow-mediated dilation [FMD]) and endothelial-independent (NTG) vasodilation.

Traditional CVD Risk Factors and Blood Biomarkers:

·         No change in HbA1c, lipids, fasting insulin, adipokines, proinflammatory markers, and thrombotic markers in either group.

Body Composition

·         There was a group × time interaction for WBM (p=0.03), WBF (p=0.04), and VAT (p=0.04).

·         Trend toward an interaction for LF (p=0.056).

·         Group × time interaction for WC (p=0.03) and BMI (p=0.02).

·         No changes observed in WBL mass.

Arterial Structure and Function

·         Group × time interaction was found for CD (p=0.05).

·         No interactions were found for other measures of carotid artery structure (CPP, IMT, WLR), indices of regional stiffness (central, arm, leg PWV), or vascular function (BA, SFA, endothelial dependent [FMD] or independent [NTG] vasodilation).

Pelletier et al. (2015)





Population: Mean age: 40.4yrs; Gender: males=21, females=2; Level of injury: C1-T11=23; Time post injury: 12.0yrs.

Intervention: Participants were randomized to receive SCI-specific physical activity guidelines (PAG) for improving fitness or active control (CON). PAG training was 2x/wk for 16wks and involved 20-min of aerobic exercise at a moderate-to-vigorous intensity (RPE 3–6 on 10-point scale) and three sets of 10 repetitions (at 50–70% 1 repetition maximum). Participants in the CON group were members in a twice weekly community exercise program geared for adults with SCI.

Outcome measures: VO2peak, Central and peripheral RPE (Borg 10- point scale), Heart rate (HR), Satisfaction with the guidelines and strength.

·         There was a significant group × time interaction for relative (p=0.01) and absolute (p=0.004) VO2peak, indicating ↑ aerobic capacity in the PAG group following training. While there was a 13.4% ↑ in POpeak in the PAG group following training, it did not reach statistical significance (p=0.059)

·         Post training, the PAG group completed a submaximal exercise test at a higher power output than the CON group (p=0.01).

·         There was a significant group × time interaction for vertical bench press (p=0.02), seated row (p=0.03) and elbow extension (p<0.01), reflective of mean strength ↑ in the PAG group of 7.3 ± 6.4 kg, 8.3 ± 6.1 kg and 22.5 ± 23.1 kg, respectively.

·         Satisfaction with both the aerobic (6.3± 0.64) and resistance (6.7± 0.5) aspects of the PAG training protocol were high (maximum score of 7). Enjoyment of the exercise program was also high (6.8± 0.4, maximum score of 7).

·         Mean score for perceived pain was 5.3 ± 1.8, with a maximum score of 7, indicating participants did not perceive an ↑ in pain or discomfort during exercise program.

Sutbeyaz et al. (2005)




Population: N=20 people with SCI (12 men, 8 women), 14 complete, 6 incomplete (T6-T12), mean age: 31.3yrs; Mean time post injury: 3.8yrs.

Intervention: Ventilatory and upper-extremity muscle exercise: 1hr, 3x/wk x 6 wks; Diaphragmatic, pursed lip breathing for 15-min; Air shifting for 5-min; voluntary isocapneic hypernea 10-min; arm-crank exercise.

Outcome measures: Spirometry and peak exercise test.

·         After training, FVC, FEV1, and vital capacity (VC), were significantly higher than the baseline values.

·         Exercise testing showed ↑ VEpeak and POpeak and a reduction in the ratio of physiological dead space to tidal volume compared to baseline values.

Hicks et al. (2003)





Population: Tetraplegia=18, Paraplegia=16; AIS A-D, C4-L1; Age range: 19–65yrs.

Intervention: Exercise: 90–120 min/d, 2d/wk, 9 mo. of arm ergometry (15–30 min, ~70% VO2peak) and circuit resistance exercise; Control group: bimonthly education session.

Outcome Measures: muscular strength, power output, HR, quality of life ratings.

·         Power output ↑ by 118% and 45% after training in the tetraplegia and paraplegia groups, respectively.

·         There were progressive ↑ in strength over the 9 months of training (range 19%–34%).

Duran et al. (2001)




Population: thoracic SCI; Mean age: 26.3yrs; Gender: males=12, females=1; Injury severity: complete ASIA A=11, ASIA B=1, ASIA C=1, incomplete=106; Time post-injury= 25mo.

Intervention: Patients participated in a 16-wk exercise program, consisting of 3 weekly 120-min sessions. Participants performed mobility, strength, coordination, aerobic resistance,

and relaxation activities during the sessions. 

Outcome Measures: Functional Independence Measure (FIM), arm-crank exercise test, wheelchair skills, maximum strength, anthropometry (body composition measurements), blood lipid levels.

·         Participants showed a significant ↑ in the average FIM score compared to baseline (p<0.001);

·         Weight lifted in the bench press exercise (46%, p<0.0001), military press (14%, p<0.0002), and butterfly press exercise (23%, p <0.0001) ↑ significantly from baseline.

·         Number of repetitions for biceps (10%, p<0.0001), triceps (18%, p<0.0001), shoulder abductors (61%, p<0.0001), abdominals (33%, p<0.009), and curl back neck exercise (19%, p<0.0001) ↑ significantly from baseline.

·         The maximum resistance achieved during the arm crank exercise test showed a significant ↑ from baseline (p<0.001),

·         Participants showed a significant ↓ in heart rate 6 minutes after the exercise test from baseline (p<0.05).

·         The time required for the wheelchair skill tests significantly ↓ in all the tasks.

·         No statistically significant changes occurred in body weight, percentage of body fat, lean body weight, cholesterol/high-density lipoprotein cholesterol ratio, or maximum heart rate (p>0.05)

Assorted Approaches to Exercise Training

Torhaug et al. (2016)


Prospective controlled trial


Population: Mean age: 44.3yrs; Gender: male=17, female=0; Level of injury: paraplegia; Level of severity: AIS A=11, AIS B=0, AIS C=1, AID D=4; Mean time since injury: 14.1yrS.

Intervention: Participants were allocated to maximal bench press strength training (MST group) or the control group. The MST group trained 3 times per week (4 sets of 4 repetitions at 85-95% bench press 1RM) for 6 wk. The control group performed no formalized exercise routine.

Outcome Measures: Work Economy (WE), VO2 and HR measurements during   during wheelchair propulsion at a submaximal workload (50W). Peak measurments were also derived during wheelchair ergometry (WCE) tests.

·         The MST group showed significantly greater improvements in WE. The mean reduction and difference in oxygen consumption between the groups during the submaximal exercise test was -2.6ml/kg/min in favour of the MST group (p=0.007).

·         At 6wks, the mean 1RM force ↑ significantly in the MST group (p=0.001) but no significant changes were seen in the control group.

·         The mean difference of peak power during WCE between groups was significantly improved for the MST group (p=0.001).

·         No significant between or within group differences were found for VO2peak, heart rate or body mass.

Lindberg et al. (2012)




Population: Mean age: 47yrs; Gender: males=8, females=5; Level of injury: T5-L=13; Time post injury: 3-35yrs.

Intervention: The intervention consisted of 3 training sessions on a seated double-poling ergometer (SDPE) per week during a 10 wk period for each participant. All training sessions were carried out in small groups coached by an instructor. A training session lasted approximately 50-min and included a warm-up, 4 interval sessions of 6–7min and a cool-down. The intervals varied between 15 s and 3-min with rests of 15 s to 1-min. Before and after the training period, aerobic and mechanical power was measured during sub-maximal and maximal double-poling exercises on the ergometer.

Outcome measures: VO2peak, ventilation, heart rate (HR), blood lactate and power output (W).

·         VO2peak uptake ↑ significantly from 1.27±0.39 before to 1.56±0.48 L/min after training. The corresponding values for ml/kg/min were significantly ↑ from 18.52±4.79) before to 22.96±6.27 after the training period.

·         There was a significant improvement in ventilation from 65.47±20.32 to 79.00±26.67) L/min.

·         Blood lactate ↑ significantly from 6.71±1.81 to 8.19±2.41 mmol/L.

·         The HRs rates noted during the maximal test were similar before and after training, mean values being 164 (range 133–183) and 167 (range 136–191) beats/min, respectively, and this difference was not significant.

·         Mean power per stroke and peak pole force (mean of left and right) ↑ significantly from 85.62±27.88 before to 98.79±32.54 W after and from 98.44±20.74 to 121.74±29.20 N, respectively.

·         At the sub-maximal workload, significantly lower mean values were observed in ventilation after the training period (before: 20.85±3.85, after: 23.85±5.79 L/min).

·         Blood lactate levels ↓ significantly from 1.41±0.84 to 1.06±0.49 mmol/L during the sub-maximal workload test.

·         There were no differences between pre- and post- training values in VO2, power output or in peak pole force at sub-maximal workload.

Ballaz et al. (2008)





Population: 17 participants with chronic paralegia (mean age 48+8yrs, range 35-62 yrs), divided into experimental (n = 9) and control (n = 8).

Intervention: passive leg-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.

·         Before training, the resting mean blood flow velocity did not differ between groups.

·         In the experimental group, the post-exercise mean blood flow velocity was significantly higher after training.

Post exercise velocity index was significantly lower in experimental group after training.

Cooney & Walker (1986)




Population: Mean age: 28.8yrs; Gender: males=7; females=3; Injury etiology: traumatic SCI=10; Level of injury: quadriplegia=5, paraplegia=5.

Intervention: Individuals trained on an Omnitron unit and performed two exercises – chest press/chest row and shoulder press/lat pull – 3 times/wk for a period of 9 wks divided into three designated stages. This series of exercises was completed in 30-40min. Outcome Measures: VO2peak and POpeak before and after hydraulic resistance training. Participants exercise electrocardiograms (ECGs) were monitored during exercise to obtain representative heart rate response to each training stage.

·         VO2peak was significantly ↑ (p<0.01). The quadriplegic and paraplegic participants demonstrated a similar training effect.

·         POpeak was significantly ↑ (p<0.01). The quadriplegic subjects showed a greater percent improvement by injury level compared to the paraplegic subjects.

·         Mean HR during stage I of the training program was generally below the intensity recommended for cardiovascular training effects. Mean HR remained elevated for 30 min of exercise and within the 60-90% maximum HR training zone during stage II. HR was elevated rapidly during stage III training.


Twenty-three studies in total have investigated the effect of other physical activity interventions on cardiorespiratory fitness, pulmonary function, or cardiovascular health outcomes. Despite the wide variability of these other physical activity interventions, the following classifications have been used in group studies: 1. Behaviour change interventions (n=2), 2. Ambulation/stepping training for individuals with motor-incomplete injuries (n=3), 3. Sport-related training interventions (n=4), 4. General rehabilitation (n=3), 5. Multi-modal interventions (n=7) and 6. Assorted approaches to exercise training (n=4).

There is mixed evidence as to whether behaviour change interventions can improve cardiorespiratory fitness or cardiovascular health outcomes in this population, which may be dependent on time since injury. One higher RCT (PEDro scores ≥6) in individuals with chronic (>1-year) SCI showed a significant improvement in aerobic capacity but no significant improvements in cardiac indices or hemodynamics (Williams et al. 2021). The authors note different responses between participants stratified by level of injury as part of a sub-group analysis, which warrants further investigation. The second higher RCT, in the sub-acute setting post-SCI, indicated clinically relevant between-group differences for peak power output, although the differences between groups were not statistically significant (also the case for VO2peak) (Nooijen et al. 2017). However, a significant intervention effect was observed for diastolic blood pressure.

The evidence regarding whether ambulation training improves cardiorespiratory fitness for individuals with motor-incomplete injuries is currently unclear. One higher-level RCT (Wouda et al. 2018) indicated no statistically significant (P = 0.94) differences in the pre-post changes between HIIT, MIT, or control groups following 12 weeks of continuous running or walking. One randomized cross-over study (Lotter et al. 2020) revealed a significant time effect (irrespective of task-specific vs. impairment-based training) for treadmill VO2peak but not recumbent stepping VO2peak and a pre-post intervention indicated that 6 weeks of ambulation type exercise can improve VO2peak (2016). Further research is required to support the efficacy of ambulation training to improve cardiorespiratory fitness, pulmonary function, or cardiovascular health outcomes in individuals with motor-incomplete SCI.

With regards to the general sport training studies, two studies investigated wheelchair rugby, one study a general level of sport conditioning, and another study a general wheelchair propulsion training program. There were no RCTs for this category of studies (3 pre-post interventions and 1 prospective observational study), which ultimately limits the strength of the evidence. This is also the case for the three general rehabilitation studies (2 observational studies and 1 pre-post intervention), which predominantly included participants with sub-acute injuries.

With regards to multi-modal exercise interventions, a variety of approaches have been tested in the literature, with interventions combining strength training, aerobic exercise, and functional electrical stimulation (to activate sublesional muscles) as part of a combined exercise program. While three lower RCTs (PEDro score < 6) indicated an improvement in aerobic capacity, the only higher RCT (Kim et al. 2019) demonstrated no significant improvement relative to the control group. An additional pre-post study indicated significant improvements in peak power with multi-modal training, however, this was with 16 weeks of exercise consisting of 3 weekly 120-minute sessions.

There is a wide degree of variability in the exercise modalities adopted for the assorted approaches to exercise training category, including simulated wheelchair rolling exercise, passive leg-cycling, seated double-poling ergometry, and strength exercises. Therefore, it is difficult to provide generalizable recommendations for this category.


There is moderate evidence (Level 1b) that behaviour change interventions can improve cardiorespiratory fitness in individuals with chronic (>1 year) SCI (Williams et al. 2021). However, there is conflicting evidence around the benefits of behaviour change interventions that are delivered in the sub-acute setting post-SCI (Nooijen et al. 2017). Further research is necessary for the sub-acute setting to inform conclusions around the efficacy of behaviour change interventions for individuals in the early stages of post-injury.

There is moderate evidence (Level 2) that multi-modal training approaches, 2-3 times per week for ≥8 weeks improve cardiorespiratory fitness in individuals with SCI (Pelletier et al. 2015; Yarar-Fisher et al. 2018). It should be noted that the length of intervention may be important as a higher RCT revealed no significant improvements in cardiorespiratory fitness following only 6 weeks of multi-modal training (Kim et al. 2019).  

There is Level 2 evidence (Totosy de Zepetnek et al. 2015) that multi-modal training improves carotid distensibility.

Weak evidence (Level 3/4) (Cooney & Walker 1986; Lindberg et al. 2012) provides early support for the efficacy of assorted approaches to exercise training but more research is needed to draw firm conclusions. However, there is moderate evidence (Level 1b) (Ballaz et al. 2008) that passive leg-cycling (performed frequently, 6 times per week for 6 weeks) may improve post-exercise blood flow velocity in the common femoral artery.

There is conflicting evidence regarding the efficacy of ambulation training to improve cardiorespiratory fitness in individuals with SCI. While Level 4 evidence (pre-post and randomized cross-over studies) may indicate early support for this exercise intervention (DiPiro et al. 2016; Lotter et al. 2020), a higher RCT indicated no significant improvements in cardiorespiratory fitness (Wouda et al. 2018). More research is needed to draw conclusions.

There is only weak evidence (Level 4) (Fukuoka et al. 2006; Matos-Souza et al. 2016; Moreno et al. 2013; Sarro et al. 2016) that sports training interventions and general rehabilitation programs can improve cardiorespiratory fitness, pulmonary function, or cardiovascular health outcomes. Further research is needed to indicate the most effective sports training programs and rehabilitation methods for this population.

Chapter Downloads
Patient Handouts
Outcome Measures
Active Clinical Trials