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Physical Activity: Cardiovascular Health and Fitness

Other Physical Activity

Our definition of “Other Physical Activity” can be found above in Section 3.0 on Cardiorespiratory Health and Endurance.

Author Year

Country
Research Design

Score
Total Sample Size

Methods

Outcome

Behavioral Change

Montesinos-Magraner et al. (2018) (Montesinos-Magraner et al., 2018)

Spain

Observational

N=67

Population: Complete motor SCI (T2-T12). Inactive group (n=30): Mean age: 50.63yr; Gender: males=20, females=10; Mean time since injury: 15.77yr. Active group (n=37): Mean age: 43.4yr; Gender: males=31, females=6; Mean time since injury: 17.76yr.

Intervention: Participants who were full time manual wheelchair users, wore an accelerometer attached to their non-dominant wrist for a period of 1 week (actigraph model GT3X). Participants were divided into active (at least 60min moderate to vigorous physical activity per week) or inactive groups.

Outcome Measures: Physical activity levels, risk factors for metabolic syndrome.

·         The inactive group, compared to the active group, had significantly less METS (MD -0.13), and less minutes per day of light (-95.73), moderate (-22.89) and moderate-to-vigorous (-23.10) activity (all p<0.001), as well as vigorous exercise (-0.21, p=0.04).

·         There was an association between PA group and diabetes mellitus (p=0.047); active group was 7.2 times less likely to have diabetes than inactive group.

·         63% of inactive group had two or more risk factors for metabolic syndrome and 59% of active group had none or only a single risk factor.

Nooijen et al. (2017)

The Netherlands

RCT

PEDro=6

Ninitial=45; Nfinal=39

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

Control group: Mean age: 44yr; 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 coach trained in motivational interviewing, beginning 2mo before and ending 6mo after discharge from inpatient rehabilitation.

Control group: Regular rehabilitation

Outcome Measures: Physical capacity as determined during a maximal 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).

·         No significant differences in QoL and mental health were observed (p>.05)

Myers et al. (2012)
USA
Pre-Post
N=26
Population: Mean age: 56.92±5.74yr; Mean time since injury: 23.8±12.3yr.
Intervention:
Risk intervention program including frequent telephone contact and in-person visits by a dietician, physical therapist, and exercise physiologist. Very generic, nonspecific, activity advice. Participants were contacted by phone weekly during the first 6wk, then at 8wk and at 3, 4, 5, and 6mo. Following this was complete evaluations in the spinal cord injury (SCI) Center at 12, 18, and 24mo.
Outcome Measures:
Homeostasis model of assessment-insulin resistance (HOMA-IR), insulin levels, Body Mass Index (BMI), total cholesterol, high-density lipoprotein (HDL), low-density lipoprotein (LDL), and triglycerides.

·         Weight was reduced slightly at each follow-up point but was significantly lower only for the comparison between baseline and 6mo (p=0.004).

·         90 and 94% of participants exhibited reductions in insulin level, and 85 and 88% of subjects exhibited reductions in HOMA-IR at 6mo and 12mo, respectively (<0.01 for all).

·         Among lipid profiles, total cholesterol/HDL ratio was lower at the 6mo evaluation (p=0.05) and triglycerides tended to be lower at each evaluation (~10-20%).

·         No differences were observed in objective or subjective estimates of physical activity patterns at any of the measurement intervals.

Totosy de Zepetnek et al. (2015)

Canada

RCT

PEDro=4

Ninitial=23

Nfinal=17

Population: Physical Activity Guidelines (PAG) 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 either an intervention group (PAG; n=12) in which they completed supervised 60min exercise sessions, 2 times per week for 16 weeks, or a control group (n=11) in which they maintained their existing physical activity and were provided no guidance or training intensity.

Outcome Measures: Blood biomarkers (hemoglobin (HvA1c), 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-a), 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:

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

·         No change in fasting insulin, adipokines, inflammatory markers, and thrombotic markers in either group.

·         Body Composition

·         There was a group X 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).

·         No changes observed in WBL.

·         Arterial Structure and Function

·         Group X 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).

Jorgensen et al. (2019)

Sweden

Observational

N=123

Population:  Mean Age=63±9yr; Gender: Males=87, Females=36; Level of Injury: C1-L5; Severity of Injury: AIS A-C=63, D=60; Mean Time Since Injury=24±12yr.

Intervention: Not applicable. Review of data from the Swedish Aging with Spinal Cord Injury Study to assess participation in leisure time physical activity (LTPA) and cardiovascular risk factors among older adults with long-term spinal cord injury.

Outcome Measures: Physical activity recall assessment for people with SCI (PARA-SCI), body mass index (BMI), waist circumference, blood pressure, blood glucose and lipids.

·         More minutes per day of moderate-to-heavy LTPA was significantly associated with a lower BMI (p=0.001) and a lower waist circumference (p=0.009).

·         No other significant associations were found between cardiovascular risk factors and moderate-to-heavy LTPA.

·         Individuals with tetraplegia experienced significantly higher systolic blood pressure with increasing minutes per day of total LTPA (p=0.041).

·         No other significant associations were found between cardiovascular risk factors and total LTPA.

Schreiber et al. (2018)

Brazil

Observational

N=41

Population: Sedentary (S-SCI) group (n=16): Mean age: 34.0±7.6yr; Mean time since injury: 8.2±3.0yr. Physically Active (PA-SCI) group (n=25): Mean age: 30.6± 6.2yr; Mean time since injury: 9.7±4.5yr. Gender: males=41, females=0; Level of injury: C1-T1=21, T2-L5=20; Level of injury: tetraplegia=16; paraplegia=25. Level of severity: AIS A=36, AIS B=4, AIS C=1.

Intervention: No intervention provided. Subjects were classified for analysis into sedentary S-SCI and physically active PA-SCI groups.

Outcome Measures: Clinical, laboratory, carotid ultrasonography and echocardiography analysis. Plasma leptin, adiponectin and plasminogen activating inhibitor-1 (PAI-1) were determined.

·         There were no statistically significant differences in the plasmatic levels of any of the adipocytokines measured (p<0.05).

·         PA-SCI had better LV diastolic function (measured by E/Em ratio, (p=0.024) and lower carotid Intima-media thickness diameter/ratio than S-SCI (p<0.001).

·         Leptin/adiponectin ratio showed stronger correlation with BMI in PA-SCI (r=0.61; p=0.001) than in S-SCI (r=0.45; p=0.08) subjects.

·         Leptin/adiponectin ratio correlated directly with triglycerides (r=0.84, p<0.001) and low-density-lipoprotein cholesterol (r=0.53, p<0.05) in S-SCI participants, but not in PA-SCI individuals (r=0.38; p for interaction <0.05 for triglycerides and r=-0.03; p for interaction=0.08 for low-density-lipoprotein cholesterol).

Buchholz et al. (2009)

Canada

Observational

N=56

Population: Inactive group (N=28): Age: 41.1±11.4 yr; Gender: males=22, women=6; Severity of injury: tetraplegia=17, paraplegia=11; Time post injury: 16.5±10.0 yr. Active (≥25 min/day) group (N=28): Age: 42.6±13.0 yr; Gender: males=22, women=6; Severity of injury: tetraplegia=9, paraplegia=19; Time post injury: 12.6±10.2 yr.

Intervention: None.

Outcome Measures:

LTPA Physical Activity Recall Assessment for People with SCI (PARA-SCI), body mass index (BMI), %fat mass, %fat-free mass, waist circumference, fasting glucose, fasting insulin, insulin resistance, %insulin resistant.

·         Individuals in the inactive reported no leisure-time physical activity whatsoever.

·         For those in the active group, there was no significant different in minutes of mild, moderate or heavy activity between those with tetraplegia versus paraplegia.

·         The most frequently reported activities in the active group were resistance training (43%), wheeling (43%), and sports or other aerobic exercises (46%).

·         There was no significant difference between groups on %fat mass, %fat-free mass, waist circumference, fasting glucose, fasting insulin, insulin resistance.

·         BMI (p=0.0009) and %insulin resistant (p=0.03) were significantly higher in inactive than active individuals.

Nightingale et al. (2019)
UK
Cohort
N=33
Population: Mean age: 44±9yr; Gender: males=27, females=6; Level of severity: AIS: A-B=29, AIS C-D=4; Mean time since injury: 15±10 yr.
Intervention:
Participants with a SCI performed an incremental exercise protocol on an electrically braked arm-crank ergometer. Physical activity was monitored through a chest-mounted multi-sensor physical activity monitor (ActiheartTM), in which participants were required to wear the device for >80% of each 24-hour period.
Outcome Measures:
peak oxygen uptake (VO2 peak), Body Mass Index (BMI), Metabolic regulation (fasting insulin, insulin sensitivity and HOMA2-IR).

·         A lower SCI lesion was associated with; a higher BMI (p=0.03), VO2 peak (absolute, p=0.01 and relative, p=0.027) and poorer metabolic regulation (fasting insulin, p=0.009; HOMA2-IR, p=0.009 and insulin sensitivity, p=0.038).

·         Longer time since injury was correlated with higher fasting glucose concentrations (p=0.038).

·         Older age was associated with lower VO2 peak (absolute, p=0.016 and relative, p=0.001).

·         Body composition characteristics (BMI, waist and hip circumference) showed significant (p<0.04), moderate associations with parameters of metabolic regulation, lipid profiles, and inflammatory biomarkers.

Sport

Matos-Souza et al. (2016)

Brazil

Observational

N=17

 

Population:  Sports Group (n=8); Mean Age=28.3±2.5yr; Gender: Males=8, Females=0; Level of Injury: T9-C5; 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: T8-C4; 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 (6.3 ± 1.1 hr/wk) 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 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.

Hubner-Wozniak et al., (2012)

Poland

Observational

N=65

Population: Sedentary, No SCI (n=19): Mean Age=30.0±4.2yr; Gender: Males=19, Females=0. Sedentary, SCI (n=10): Mean Age=26.9±5.2yr; Gender: Males=10, Females=0; Level of Injury: C5-C7; Severity of Injury: AIS A=9, B=4. Rugby Players, No SCI (n=22): Mean Age=23±5yr; Gender: Males=22, Females=0. Rugby Players, SCI (n=14): Mean Age=30.5±5.4yr; Gender: Males=14, Females=0; Level of Injury: C5-C7; Severity of Injury: AIS A=7, B=4.

Intervention: Not applicable. Cross-sectional analysis to determine the effect of rugby training (4 – 6 hr/wk) on blood antioxidant capacity in individuals with or without SCI.

Outcome Measures: Superoxide dismutase (SOD), glutathione reductase (GR), catalase (CAT), glutathione peroxidase (GPX), total antioxidant status (TAS).

·         SOD activity was significantly greater in sedentary individuals without SCI, when compared to sedentary individuals with SCI or rugby players without SCI (p<0.05).

·         No significant between group differences were observed between sedentary or rugby players with SCI(p>0.05).

·         Resting levels of CAT and GPX were significantly greater than in active individuals versus sedentary individuals (p<0.001).

·         No significant between group differences were observed for GR activity (p>0.05).

·         Plasma TAS was greater in individuals without SCI, when compared to those without SCI (p<0.01).

Combination

Kim et al. (2019)

Korea

RCT

PEDro=6

NInitial=19, NFinal=17

Population:  Mean Age=36.8±6.9yr; 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 (60min/d, 3d/wk for 6wk) or usual care. Outcome measures were assessed at baseline and 6wk.

Outcome Measures: peak oxygen consumption, 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 average fasting insulin (p<0.05), ↓ HOMA-IR (p<0.05), improved HDL cholesterol (p<0.05), ↓ waist circumference (p<0.05), and improved muscle strength of the shoulder flexors, extensors, adductors. abductors, and elbow flexors (p<.05).

·         There were no significant differences between groups (p>0.05) on measures of: peak oxygen consumption, lean mass, body fat percentage, total cholesterol and LDL cholesterol.

Wheelchair Propulsion

Hooker & Wells (1989)

USA

Prospective Controlled Trial

N=8

Population: Low-intensity group: n = 6, 3 male, 3 female, C5-T10, age 26–36yr, 3 months to 19yr post-injury; moderate-intensity group: n = 5, 3 male, 2 female, C5-T9, age 23–30yr, 2–19yr post-injury.

Intervention: Wheelchair ergometry 20 min/d, 3 d/wk, 8wk: low-intensity (50%–60%peak HRR) and moderate intensity (70%–80% HRRpeak).

Outcome Measures: total cholesterol (TC), triglycerides, HDL, LDL.

·         No change in lipid levels in low-intensity group.

·         Significant ↑ in HDL and ↓ in triglycerides, LDL, and the TC/HDL ratio in the moderate intensity group.

Discussion

Two studies have investigated different forms of combined aerobic exercise and resistance training interventions (Kim et al. 2019; Totosy de Zepetnek et al. 2015). The strongest evidence comes from Kim et al., who demonstrated Level 1A evidence that such combined exercise, performed for 60min/d, 3d/wk improved glucose tolerance and HDL cholesterol, whereas similar exercise performed less frequently had no impact on cardiometabolic function (Totosy de Zepetnek et al. 2015). There is provisional, level 1-4 evidence from two studies that demonstrate a behaviour change coaching intervention designed to promote PA improves cholesterol, HOMA-IR, and blood lipids. Three studies have investigated the relationship between LTPA and cardiometabolic function, of which two studies found no associations between LTPA and blood lipids whereas one study found more active individuals had lower markers of inflammation and a smaller proportion of active individuals were insulin resistant. Interestingly, in the only study to assess whether following the SCI-specific physical activity guidelines improves cardiometabolic health, it was reported that the exercise group had no improvement in any marker of cardiometabolic disease. In studies comparing highly-trained wheelchair athletes with SCI against sedentary individuals with SCI, it is consistently reported that the highly-trained individuals have improved vascular function but that blood lipids and anti-oxidant status are not different between cohorts. 

Conclusion

There is level 1a evidence (Kim et al. 2019) that 6 weeks of 3d/wk aerobic and resistance training (60min/day) improves insulin resistance, glucose tolerance, and blood lipids in individuals with various levels and severities of SCI.

There is level 1a evidence (Nooijen et al. 2017) that a behavioural change intervention which promotes physical activity (8 months, 13 individual sessions) improves blood lipids in individuals with various levels and severities of SCI.

There is level 1b evidence (Totosy de Zepetnek et al. 2015) that following the SCI-specific physical activity guidelines (i.e., exercise 2d/wk) for 16 weeks does not improve insulin resistance, markers of inflammation, blood lipids or any indices of vascular structure/function.

There is level 2 evidence (Hooker & Wells 1989)that weeks or 3d/wk (20 min/day) of moderate-intensity wheelchair propulsion improves blood lipids compared to low-intensity wheelchair propulsion, in individuals with various levels and severities of SCI.

There is level 4 evidence (Myers et al. 2012) that a behavioural change intervention which promotes physical activity (6 months, weekly/monthly telephone) improves insulin resistance and blood lipids in individuals with various levels and severities of SCI.

There is level 5 evidence (Jorgensen et al. 2019) that the amount of moderate to vigorous physical activity is not associated with blood glucose or blood lipid levels in individuals with various levels and severities of SCI.

There is level 5 evidence (Schreiber et al. 2018) that physically active individuals with SCI had better cardiac and vascular function than non-active individuals, but there were no differences in plasma levels of leptin or adiponectin.

There is level 5 evidence (Buchholz et al. 2009) that physically active individuals with SCI had better insulin resistance than inactive individuals.

There is level 4 evidence (Nightingale et al. 2019) that levels of habitual physical activity are not significantly associated with insulin resistance, glucose tolerance or blood lipids, in individuals with thoracolumbar SCI.

There is level 5 evidence (Matos-Souza et al. 2016) that chronic exercise training (i.e., taking part in wheelchair sport ~6hr/wk) improves long-term (5yr follow-up) carotid vascular function but not blood lipids in individuals with various levels and severities of SCI.

There is level 5 evidence (Montesinos-Magraner et al. 2018) that a greater amount of

There is level 5 evidence (Hubner-Wozniak et al. 2012) that chronic exercise training (taking part in competitive wheelchair rugby) does not improve anti-oxidant status in individuals with various levels and severities of SCI.

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