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Physical Activity: Cardiovascular Health and Fitness

Arm Cycle Ergometry (ACE) Training

Our definition of arm cycle ergometry (ACE) can be found above in Section 3.0 on Cardiorespiratory Health and Endurance.

Author Year

Research Design

Total Sample Size



Nightingale et al. (2017)
Population: Mean age: 47±8yr; Gender: males=15, females=6; Level of injury: C1-T5=12, T6-L5=9; Level of severity: AIS: A-B=18, AIS C-D=3; Mean time since injury: 17±5yr.
Participants were randomized into either a 6wk prescribed home-based exercise intervention (INT) or control group (CON). Participants allocated to the exercise group completed 4, 45min moderate-intensity (60-65% peak oxygen uptake (VO2peak)) arm-crank exercise sessions/wk.
Outcome Measures:
Physical activity energy expenditure, Body composition, Metabolic regulation, VO2peak, power output, Homeostasis Model Assessment of Insulin Resistance (HOMA2-IR), Fasting serum concentrations, and Adipose tissue gene expression (ATGL).

·         The moderate-intensity upper-body exercise INT group significantly ↑ physical activity energy expenditure and minutes spent performing moderate-to-vigorous intensity physical activity relative to the CON group (p<0.01).

·         Body mass significantly ↓ from baseline to follow-up when all participants were considered (p<0.05). The absolute change was not different between the two groups (p=0.6).

·         The INT group significantly ↑ (p<0.001) VO2peak and peak power output, whereas these outcomes remained unchanged in the CON group.

·         Changes in fasting serum insulin concentrations and the HOMA2-IR were different between the two groups (p<0.044). The INT group significantly ↓ fasting serum insulin concentrations and HOMA2-IR (p<0.035), whereas these outcomes were unchanged in the CON group.

·         ATGL was down-regulated over the course of six weeks (p=0.038).

Kim et al. (2015)





Population: 15 participants (9 males, 6 females) with SCI (ASIA-A &B, C5-T11). Mean age was 33 and all participants had SCI for more than 6 months. 8 participants allocated to the hand-bike exercise group, 7 participants to the control group.

Intervention: Participants exercised with the indoor-hand bike for 60min/day, 3 days/week, for 6 weeks under supervision of an exercise trainer. Participants maintained a heart rate of 70% of theirmaximum. Exercise intensity was gradually ↑ on a weekly basis using the Borg rating of perceived exertion (RPE level 5 to 7). The control group continued with usual activities.

Outcome Measures: Body mass index (BMI), waist circumference, percent body fat, insulin level, homeostasis model assessment of insulin resistance (HOMA-IR) level, upper body muscle strength (using a dynamometer), V02 peak, lipid metabolite indices (including cholesterol, triglycerides, high & low density lipoprotein cholesterol levels.

·         Post-intervention, the exercise group showed significant ↓ in BMI, waist circumference, fasting insulin and HOMA-IR levels compared with the control group.

·         The exercise group exhibited significantly lower insulin and HOMA-0R levels, and ↑ in high density lipoprotein cholesterol after the exercise training period compared with baseline levels.

·         The exercise group also showed significant ↑ in V02peak and upper body strength compared with the control group following intervention.

·         No change in glucose, total cholesterol, triglycerides, or low-density lipoprotein were observed in the exercise group.

Bakkum et al. (2015)





Population: 19 participants (18 males, 1 female, C2-L2) with SCI for more than 10 years.

Intervention: Participants were randomized to the hybrid or hand cycle group. 9 participants on hybrid cycle and 10 participants on hand cycle during 32 individual training sessions within a period of 16 weeks. The duration of each training session ↑ from 18 to 32 minutes during the program.

Outcome Measures: Metabolic syndrome (waist circumference, systolic/diastolic blood pressure, high density lipoprotein cholesterol, triglycerides, and insulin resistance), inflammatory status (C-reactive protein, interleukin -6 & -10), and visceral adiposity (trunk and android fat).

·         For all metabolic components, inflammatory markers, and visceral adiposity, there were no differences over time between the 2 training groups.

·         Overall reductions were found for waist circumference, diastolic blood pressure, insulin resistance, CRP, IL-6, trunk and android fat percentage.

Rosety-Rodriguez et al. (2014)





Population: Experimental group: Mean age: 29.6±3.6yr; Time post injury: 54.8±3.4mo. Control group: Mean age: 30.2±3.8yr; Mean time since injury: 55.7±3.6mo. Gender: males=17, females=0; Level of injury: T2-L5=17.

Intervention: 12wk arm cranking exercise program for 3 sessions/wk. Each training session consisted of warm-up (10-15min), arm crank (20-30min; increasing 2min and 30sec every 3wk) at a moderate work intensity of 50% to 65% of heart rate reserve (starting at 50% and increasing 5% every 3wk), and cool-down (5-10min). Control participants completed assessments but did not take part in a training program. The control group consisted of individuals matched for age, sex, and injury level.

Outcome Measures:  Plasma levels of leptin, adiponectin, plasminogen activator inhibitor-1 (PAI-1), TNF-a, IL-6,maximum oxygen consumption [VO2peak], anthropometric index [AI], waist circumference [WC], and body mass index [BMI].


·         Leptin, TNF-a and IL-6 levels were significantly ↑ in the exercise group (p<0.05) when compared to the control after the exercise intervention.

·         VO2peak was significantly ↑ in the intervention group (p=0.031). Body composition was improved as the AI (p=0.042) and WC (p=0.046) were significantly reduced at the end of the training program.

·         No significant change was observed in BMI after exercise (p=0.72)

·         All other measures were not significantly different between the two groups (p>0.05)

Ordonez et al. (2013)





Population: Intervention group (n=9): mean (SD) age: 29.6(3.6)yr; Gender: males=9, females=0; mean (SD) DOI = 54.8(3.4) mo. Control group (n=8): mean (SD) age: 30.2(3.8)yr; Gender: males=8, females=0; mean (SD) DOI = 55.7(3.6)mo; At or below the fifth thoracic level (T5)

Intervention: Intervention group performed a 12-week arm-cranking exercise program, 3 sessions/wk, consisting of warming-up (10-15min) followed by a main part in arm-crank (20-30min [increasing 2 min and 30s every 3 wk]) at a moderate work intensity of 50% to 65% of the HR reserve and by a cooling-down period.

Outcome Measures: Plasmid levels of total antioxidant status, erythrocyte glutathione peroxidase activity malondialdehyde and carbonyl group levels, physical fitness and body composition

·         When compared with baseline results, VO2peak was significantly ↑ in the intervention group.

·         Both total antioxidant status and erythrocyte glutathione peroxidase activity were significantly ↑ at the end of the training program.

·         Plasmatic levels of malondialdehyde and carbonyl groups were significantly reduced following training.

Horiuchi & Okita, (2017)
Population: Mean age: 38±10yr; Gender: males=9, females=0; Level of injury: T8-L1=9; Level of severity: AIS A=7, AIS B=2; Mean time since injury: 16±7.1yr.
Individuals with a SCI)performed 2, 30min sets of arm-cranking exercises with a 10min resting interval between them, 4 days/wk for 10wk at an intensity of 50~70% heart rate reserve (HRR).
Outcome Measures:
Isometricmaximum handgrip (HG), strength, body mass (BM), waist circumference (WC), aerobic capacity (peak VO2), plasminogen activator inhibitor 1 (PAI-1), systolic blood pressure (SBP), glucose metabolism, and lipid profiles (triglycerides (TG), high-density lipoprotein (HDL) cholesterol).

·         Maximum WC, BM, VO2peak, SBP, TG, and PAI-1 significantly improved with the 10-week arm-cranking exercise training (p<0.05).

·         WC, BM, SBP, TG, and PAI-1 ↓, and peak VO2 ↑ after training (p<0.05, respectively).

·         After the 10-week detraining phase, WC, BM, VO2peak, SBP, TG, and PAI-1 accurately recovered with statistical differences between post-training and detraining (p<0.05).

·         Spearman rank order analysis revealed that changes in PAI-1 were related to changes in peak VO2, BM, WC, TG, and HDL cholesterol.

·         Multiple linear regression analysis revealed that WC was the most sensitive factor for predicting changes in PAI-1 (p=0.038).

Gorgey et al. (2016)


Prospective Controlled Trial


Population: Gender: males=11, females=0; Level of injury: C1-T1=3, T2-L5=8; Level of severity: AIS A=8, AIS B=3, AIS C=0. Exercise group: Mean age: 40.5±7yr; Mean time since injury: 13.3±9.3yr. Control group: Mean age: 35±7.5yr; Mean time since injury: 4.7±4yr.

Intervention: Exercise group (n=6) received either: arm cycling ergometry (ACE), (n=3) or Functional electrical stimulation (FES), (n=3). ACE was performed two to three times a week for 16 weeks with ten-minute warm-up, forty minutes of training, and with a ten-minute cool down. The workload was adjusted as the participant tolerated from 20 to 40 watts to maintain a peak HR at 75% of theirmaximum HR. The participant was encouraged to maintain an exercise rate of 50 revolutions per minute. FES cycling (n=3) was performed with bilateral stimulation of the quadriceps, hamstrings, and gluteal muscles. Muscles were stimulated sequentially at 60 Hz with current amplitude (140 mA) necessary to complete 40min of cycling at a cadence of 50 revolutions per min (RPM) with progressively greater resistance over the course of training. Each session included 10min of passive warm-up and cool down. Controls (n=5) did not receive any exercise intervention.

Outcome Measures: Anthropomorphic measurements, body composition, Basal Metabolic Rate (BMR) and blood lipid profiles for cholesterol, high-, low-density lipoproteins, triglycerides.

·         In a within group comparison there were significant ↑ in only thigh circumference; 48.5±8 to 52.6±10cm, p<0.05 for the exercise group. Measurements for waist, calf, and hip were all non significant.

·         In a between group comparison 2.5yr after the intervention, this thigh circumference was significantly larger in the exercise group.

·         Lean Mass (LM) ↑ by 8.4% and reverted back by 5.4% following 2.5yr of washout period. Whole body LM significantly ↓ at the follow-up visit compared to both the baseline visit (p=0.015) and the post-intervention visit (p=0.054) in the exercise group, with no changes in the control group.

·         Blood lipid profiles were all non significant in both within group comparison and between group comparison at 2.5yr follow up.

El-Sayed et al. (2005)




Population: 5 SCI, lesion below T10, age 32yr; 7 AB controls, age 31yr.

Intervention: Arm ergometry, 30 min/d (60%–65%VO2peak), 3 d/wk, 12 wks.

Outcome Measures: VO2peak, peak HR, peak workload, total cholesterol (TC), triglycerides, HDL.

·         Training improved HDL but did not alter TC or triglycerides.

Graham et al. (2019)




NInitial=9, NFinal=7

Population: Gender: males=6, females=1; Mean time since injury: >3 yr. Intervention group: Mean age: 49.4±13yr; Level of injury: C6=1, C8=1, T8=1, L1=1; Level of severity: AIS A=1, B=3. Control group: Mean age: 51.3±1.2yr; Level of injury: C7=1, T6=1, T8=1, T12-L1=1; Level of severity: AIS A=1, B=1, D=1.

Intervention: Subjects were randomly allocated to either the intervention group or the control group. The intervention group participated in high-intensity interval training (HIIT), whereas the control group performed moderate-intensity training (MIT). Both groups performed training on an arm ergometer. The intervention group trained for 20min (30s x 4 repeats; 4 min rest 2 sessions per week), 2x/wk, whereas the control group trained for 30 min continuous exercise, 3x/wk. Both groups trained for 6wk. Assessments were taken at baseline, and post-intervention

Outcome Measures: fat mass, lean mass, percent body fat, percent arm fat, percent leg fat, blood pressure, resting energy expenditure, oral glucose tolerance test, quantitative insulin sensitivity check index (QUICKI), blood lipids, strength assessment, peak oxygen uptake, peak power on ergometer, OGTT, HOMA-IR

·         There were no significant differences between groups for body composition related metrics.

·         There was a significant interaction effect for arm fat percentage (p=0.043) showing MIT had a lower arm fat percentage.

·         There was a significant effect of time on QUICKI, muscle strength in the chest press (0.035) and latissimus pulldowns (p=-0.021) exercises. Additionally, there was a significant interaction effect for chest press in favour of MIT.

·         No significant changes in blood lipids or HOMA-IR.

de Groot et al. (2003)





Population: 4 male, 2 female, C5-L1, AIS A (n = 1), B (n = 1), and C (n = 4), age 36yr, 116 d post-injury.

Intervention: Randomized to low-intensity (50%–60% HRR) or high-intensity (70%–80% HRR) arm ergometry, 20 min/d, 3 d/wk, 8 wks.

Outcome Measures: VO2peak, insulin sensitivity, blood glucose.

·         There was a significant difference in insulin sensitivity between groups, with a non-significant decline in the high-intensity group and a significant improvement in the low-intensity group with training.

·         A positive correlation between VO2peak and insulin sensitivity (r = 0.68, p = 0.02).


Ten studies have investigated the effect of arm-crank exercise on metabolic health. There is level 1a evidence arising from five studies (4 RCTs, 1 pre/post) that arm-crank exercise 2-3 times per week for 6-12 weeks improves insulin resistance. With respect to the effect of arm-crank exercise on lipids, the evidence is less clear. One RCT and one prospective controlled trial found that arm-crank exercise does not impact blood lipids, whereas an additional prospective control trial and one pre-post trial found arm exercise improves blood lipids as defined by increased HDL and/or reduced triglycerides. Since there appear to be no consistent differences in participant demographics, exercise intensity, or exercise duration across studies future research in this area is needed.


There is level 1a evidence (Rosety-Rodriguez et al. 2014) that 12 weeks of arm-crank exercise (20-45 min/day, 50-65% heart rate reserve) improves metabolic/immune function in those with mid-to-low thoracic SCI.

There is level 1a evidence (Ordonez et al. 2013) that 12 weeks of arm-crank exercise (20-45 min/day, 50-65% heart rate reserve) improves metabolic function in those with low thoracic SCI.

There is level 1a evidence (De Groot et al. 2003) that 8 weeks of 3d/k arm exercise at a low intensity (50-60% heart rate reserve), but not high intensity (70-80% heart rate reserve), improves insulin sensitivity.

There is level 1b evidence (Graham et al. 2019) that both 6 weeks of both HIIT (30s x 4 repeats; 4 min rest 2 sessions per week) and MICT (30 min continuous exercise, 3x/wk) are both effective in reducing QUICKI, but not HOMA-IR or blood lipids.

There is level 1b evidence (Nightingale et al. 2017) that 6 weeks of 4d/wk arm crank exercise (45min/day, 60-65% VO2peak) improves markers of insulin resistance in individuals with various levels and severities of SCI.

There is level 1b evidence (Kim et al. 2015) that 6 weeks of 3d/wk hand-bike exercise (60 min/day, 70% peak heart rate) improves markers of glucose tolerance and blood lipids in individuals with various levels and severities of SCI.

There is level 1b evidence (Bakkum et al. 2015) that 16 weeks of hand-bike exercise (18-32 min/day) improves markers of inflammation and immune function, but not metabolic function in individuals with various levels and severities of SCI.

There is level 2 evidence (Gorgey & Lawrence 2016) that 16 weeks of 2-3d/wk arm-crank exercise (40min/day, 75% peak heart rate) improves thigh lean mass but not blood lipids in individuals with various levels and severities of SCI.

There is level 4 evidence (Horiuchi & Okita 2017) that 10 weeks of 4d/wk arm-crank exercise (2 x 30min/day, 50-70% heart rate reserve) improves metabolic fuction in those with low-thoracic/lumbar SCI.

There is level 4 evidence (El-Sayed & Younesian 2005) that 12 weeks of 3d/wk arm-crank exercise (30 min/day, 60%–65%VO2peak) improves metabolic function in those with low-thoracic SCI.

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