Summary

There is level 2 evidence from a single study with support from several level 4 studies that an appropriately-configured program of functional electrical stimulation of lower limb muscle in persons with SCI produces muscle adaptations such as increasing individual muscle fibre and overall muscle size and may result in the prevention and/or recovery of muscle atrophy.

There is level 2 evidence from a single study with support from several level 4 studies that an appropriately-configured program of functional electrical stimulation of lower limb muscles in persons with SCI results in an increase in muscle fibre types with more aerobic (endurance) capabilities, (most notably a shift in type IIx to type IIa muscle fibres).

There is level 1 evidence from a single RCT with support from a single level 4 study that functional electrical stimulation-assisted upper limb cycle ergometry is capable of producing significant increases in upper limb muscle strength in persons with tetraplegia.

There is level 2 evidence from a single RCT that voluntary upper limb cycle ergometry is capable of producing significant increases in upper limb muscle strength in triceps, biceps and anterior deltoids in persons with SCI.

There is level 1 evidence from two RCTs that voluntary upper limb resistance exercise is effective in increasing upper limb muscle strength in persons with paraplegia.

There is conflicting level 1 evidence across two RCTs that electrical stimulation-assisted resistance training of paretic wrist extensors or flexors increases strength and fatigue resistance in persons with tetraplegia.

There is level 1 evidence from a single RCT that body-weight supported fixed track or treadmill training can increase muscle strength in persons with SCI. There is also level 4 evidence from three studies that suggests that body-weight supported treadmill training in persons with SCI produces muscle adaptations of increasing individual muscle fibre size and overall muscle size and may result in the prevention and/or recovery of muscle atrophy.

There is level 2 evidence from a prospective controlled trial and level 4 evidence from several pre-post studies that circuit resistance training and other forms of resistance training combined with other approaches may increase upper limb muscle strength in triceps, biceps and anterior deltoids in persons with tetraplegia and/or paraplegia.

There is level 2 evidence from a low quality RCT that either 16 weeks of physical exercise therapy alone or a combination of 2, 8 week blocks of physical exercise therapy, neuromuscular stimulation or EMG biofeedback may enhance self-care and mobility scores.

There is level 2 evidence from a single prospective, controlled trial that a twice weekly swimming program conducted over 4 months immediately following rehabilitation discharge may enhance motor FIM scores. This finding of exercise-related enhancement of functional outcomes is generally supported by 6 additional level 4 studies that employ different modes of physical activity associated with either increases to overall FIM scores or improved performance of ADLs.

Prospective, controlled trials are required to better determine the relationship of physical activity programming and functional benefits. There is no evidence for a relationship between specific program parameters (e.g., mode, intensity, frequency, duration) that might be necessary to achieve particular benefits.

Based on level 1 and 2 evidence from 6 studies, exercise is an effective intervention for improving two aspects of SWB; quality of life and depressive symptomatology. For the most part, the level 4 and 5 evidence also supports this conclusion.

Emerging data from these studies suggest that changes in stress and pain may be the mechanisms underlying the effects of exercise on quality of life and depression. Further research is needed to examine other aspects of SWB in relation to physical activity.

There is level 4 evidence (Ditor et al. 2005a) that body-weight supported treadmill training (BWSTT) improves cardiac autonomic balance in persons with incomplete tetraplegia.

There is level 4 evidence (de Carvalho and Cliquet 2005) that BWSTT can lead to improvements in cardiac autonomic balance in a subset of individuals with motor-complete SCI who respond to ambulation with moderate-to-large increases in heart rate. Level 4 evidence (Ditor et al. 2005b) indicates that BWSTT can improve arterial compliance in individuals with motor-complete SCI.

There is level 2 evidence (de Carvalho et al. 2006) that neuromuscular electrical stimulation gait training can increase metabolic and cardiorespiratory responses in persons with complete tetraplegia.

There is level 1 evidence (Davis et al. 1987) that moderate intensity aerobic arm training (performed 20–60 min/day, three days/week for at least 6-8 weeks) is effective in improving the aerobic capacity and exercise tolerance of persons with SCI.

There is level 1 evidence (De Groot et al. 2003) that vigorous intensity (70–80% heart rate reserve) exercise leads to greater improvements in aerobic capacity than moderate intensity (50-60% heart rate reserve) exercise.

The relative importance of changes in cardiac function and the ability to extract oxygen at the periphery in persons with SCI after aerobic training remains to be determined.

There is level 4 evidence from pre-post studies that FES training performed for a minimum of three days per week for two months can be effective for improving musculoskeletal fitness, the oxidative potential of muscle, exercise tolerance, and cardiovascular fitness.

There is level 4 evidence that FES training is effective in improving exercise cardiac function in persons with SCI.

Based on the changes observed in VO2max and findings from able-bodied individuals a consensus (level 5; Expert Opinion) was derived stating that aerobic training is effective in improving the ability to extract oxygen at the periphery in persons with SCI.

There is level 1 (De Groot et al. 2003) and level 4 (Chilibeck et al. 1999; Mohr et al. 2001; Jeon et al. 2002) evidence that both aerobic and FES training (approximately 20–30 min/day, three days/week for eight weeks or more) are effective in improving glucose homeostasis in persons with SCI.

There is level 4 evidence that the changes in glucose homeostasis after aerobic or FES training are clinically significant for the prevention and/or treatment of type 2 diabetes.

There is level 1 evidence (De Groot et al. 2003) to suggest that aerobic exercise training programs (performed at a moderate to vigorous intensity 20-30 min/day, 3 days per week for 8 weeks) are effective in improving the lipid lipoprotein profiles of persons with SCI.

Preliminary evidence (level 4; Solomonow et al. 1997) also indicates that FES training (3 hours/week, for 14 weeks) may improve lipid lipoprotein profiles in SCI.

There is level 2 evidence (based on 1 prospective controlled trial) (de Carvalho et al. 2006) and level 4 evidence (based on 4 pre-post studies) (Silva et al. 1998; Sutbeyaz et al., 2005; Le Foll-de-Moro et al. 2005; Fukuoka et al. 2006) to support exercise training as an intervention that might improve resting and exercising respiratory function in people with SCI.

There is level 4 evidence based on several studies to support inspiratory muscle training as an intervention that might decrease dyspnea and improve inspiratory muscle function in some people with SCI.

There is level 1 evidence (from one RCT) (Warden et al. 2001) that short-term (6 weeks) ultrasound is not effective for treating bone loss after SCI.

There is level 2 evidence (from 1 non-randomized prospective controlled trial) (Shields et al. 2006) that ES reduced the decline in BMD in the leg.

There is level 2 evidence (from 1 non-randomized prospective controlled trial) (Eser et al. 2003) that FES-cycling did not improve or maintain bone at the tibial midshaft in the acute phase.

There is level 4 evidence (from 1 pre-post study) (Giangregorio et al. 2005) that walking and level 1 evidence (from 1 RCT) (Ben et al. 2005) that standing in the acute phase did not differ from immobilization for bone loss at the tibia.

There is level 2 evidence (from 1 prospective controlled trial) (Bélanger et al. 2000) that electrical stimulation either increased or maintained BMD over the stimulated areas.

There is level 4 evidence (from 1 pre-post study) (Chen et al. 2005) that 6 months of FES cycle ergometry increased regional lower extremity BMD over areas stimulated.

There is inconclusive evidence for Reciprocating Gait Orthosis, long leg braces, passive standing or self-reported physical activity as a treatment for low bone mass

There is level 1 evidence from a single RCT (Martin Ginis et al. 2003) that a regular exercise program significantly reduces post-SCI pain.

There is level 2 evidence (from one RCT and one PCT) that a shoulder exercise protocol reduces the intensity of shoulder pain post-SCI.

There is level 4 evidence that the MAGIC wheels 2-gear wheelchair results in less shoulder pain.

There is level 1 evidence from a single study that passive ankle movements may not reduce lower limb muscle spasticity in persons with initial mild spasticity.

There is level 2 evidence from a single study supported by level 4 evidence from another study that hippotherapy may reduce lower limb muscle spasticity immediately following an individual session.

There is limited level 1 evidence from a single study that a combination of a 6 week course of neural facilitation techniques (Bobath, Rood and Brunnstrom approaches) and Baclofen may reduce lower limb muscle spasticity with a concomitant increase in ADL independence. More research is needed to determine the relative contributions of these therapies.

There is level 4 evidence from a single study that rhythmic, passive movements may result in a short-term reduction in spasticity.

There is level 4 evidence from a single study that externally applied forces or passive muscle stretch (applied in assisted standing programs) may result in short-term reduction in spasticity. This is supported by individual case studies and anecdotal reports from survey-based research.

There is level 2 evidence from a single study (Kesiktas et al. 2004) that hydrotherapy is effective in producing a short-term reduction in spasticity.

There is level 2 evidence from a single study that single bouts of FES-assisted cycling ergometry and similar passive cycling movements are effective in reducing spasticity over the short-term with FES more effective than passive movement.

There is level 4 evidence from three studies (Granat et al. 1993;Thoumie et al. 1995; Mirbagheri et al. 2002) that a program of FES-assisted walking acts to reduce ankle spasticity in the short-term (i.e., <24 hours).

There is no evidence describing the length and time course of the treatment effect related to spasticity for hydrotherapy or FES-assisted walking.

There is level 2 evidence from a single study and supported by two additional pre-post trials that a 45 day period of 3/week 30 minute aerobic exercise sessions (arm cycle ergometry) is equally effective as L-dopa in reducing night-time periodic limb movements in persons with complete paraplegia.

There is tremendous variability in the number of minutes of daily LTPA reported by persons with SCI.

There is level 5 evidence from two large-sample studies and one small-sample study from different countries (i.e., Canada and UK) that approximately 50% of persons with SCI devote some time per week to sports, exercise, and other forms of LTPA.

There is level 5 evidence from a single study that a person with SCI participates in some form of LPTA for an average of about an hour per day (median ~ 30 minutes) when considering only the approximately 50% of people with SCI who are not inactive.

There is level 5 evidence from a single study that when physical activity is defined in terms of sports participation, the majority of people with SCI are considered inactive.

There is level 5 evidence from a single study that indicates that most daily physical activity is accumulated in the form of activities of daily living when physical activity is defined in terms of participation in any activity that requires physical exertion.

There is tremendous variability in the number of minutes of daily LTPA reported by persons with SCI. There is level 5 evidence from two studies that, although many report no activity whatsoever, there is a minority that devotes several hours per week to sports, exercise, and other forms of LTPA.

There is level 5 evidence from seven studies to suggest that individuals with SCI encounter a variety of factors that impede physical activity participation. Among these factors, the most frequently cited barriers include: (a) intrapersonal barriers such as perceived limited return on investment, health concerns and a lack of motivation, energy and time, (b) systemic barriers such as a lack of accessible facilities or unavailability of personal assistants, transportation difficulties, and program costs, and (c) expertise barriers such as a lack of knowledge about physical activity prescription and client referral processes.

A single level 5 study reported four areas that could promote participation in physical activity: cognitive-behavioural strategies, environmental solutions, motivation and new frames of reference. Interventions are needed to help alleviate these obstacles. Further research must determine the most influential and modifiable barriers that would be optimal targets for intervention.

There is level 1 evidence from a single RCT and supported by two low quality RCTs and by an additional level 4 study that the physical activity behaviour of individuals with SCI is amenable to change, and that theory-based interventions may be a means of generating this change.

There is level 1 evidence from a single study that indicates that coping planning as part of action planning is an effective intervention technique for promoting physical activity participation in the SCI population.

There is level 2 evidence from a single study that indicates that facilitating the formation of implementation intentions may be an effective intervention technique for promoting physical activity participation in the SCI population.