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Given the motor loss of the lower limbs following injury, upper extremity exercise is a logical choice for improving cardiovascular fitness and health. However, improving cardiovascular function can be challenging using the smaller mass of the arms especially when muscle fatigue can often occur before exercise training targets are met. From our search, we found five RCTs, two high quality (de Groot et al. 2003, Ordonez et al. 2013), and three lower quality trials (Davis et al. 1987, Davis et al. 1991, Hicks et al. 2003), two prospective controlled (Hooker and Wells 1989, Hjeltnes and Wallberg-Henriksson 1998), a case report (Tordi et al. 2009), a case-controlled investigation (Jae et al. 2008), one cohort study (Valent et al. 2008), and 20 pre-post studies.

Given the large number of studies that have looked at upper extremity exercise, we have tabled only those studies that included a control group consisting of participants with SCI (Table 5).

Table 5 : Effects of Upper Extremity Training on Cardiovascular Fitness and Health

Author, Year;

Country

Score

Research Design

Sample Size

MethodsOutcomes
Arm Ergometry
 

 

 

 

 

 

 

 

 

Ordonez et al. 2013;

Italy

PEDro=8

RCT

Level 1

N=17

Population: N=17 male participants with complete SCI at or below the fifth thoracic level (T5); Participants were randomly allocated to the intervention (n=9) or control (n=8) group. Intervention group: mean (SD) age: 29.6(3.6) yr; mean (SD) DOI = 54.8(3.4) months. Control group: mean (SD) age: 30.2(3.8) yr; mean (SD) DOI = 55.7(3.6) months.

Treatment: 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

1.  When compared with baseline results, VO2peak was significantly increased in the intervention group.

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

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

 

Effect Sizes: Forest plot of standardized mean differences (SMD ± 95%C.I.) as calculated from pre- and post-intervention data
de Groot et al. 2003;

The Netherlands

PEDro = 7

RCT

Level 1

N = 6

 

Population: 4 male, 2 female, C5-L1, AIS  A (n = 1), B (n = 1), C (n = 4), age 36 yrs.

Treatment: Interval training (3-min exercise: 2-min rest), 1hr/d, 3d/wk, 8 wks. Randomized to low intensity (50%–60% HRR) or high intensity (70%–80% HRR).

Outcome Measures: VO2peak, maximal power output.

1.  Greater changes in VO2peak in the high-intensity (59%) versus low- intensity group (17%).
Davis et al. 1991;

Canada

PEDro = 4

RCT

Level 2

N = 24

 

Population: 8 spina bifida, 16 traumatic, age 17–42 yrs.

Treatment: Random assignment to (a) control or 1 of 3 arm ergometry programs 2 d/wk, 24 wks: (1) high-intensity long duration (40 min at 70% VO2peak), (2) high-intensity short duration (20 min at 70% VO2peak), and (3) low-intensity short duration (20 min at 50% VO2peak) training.
Outcome Measures: Cardiac output, HR, VO2peak, power output, stroke volume.

 

1.  Training increased VO2peak in the 3 arm ergometry groups (~21%).

2.  There were increases in submaximal stroke volume and cardiac output in the high-intensity long and the low- intensity long training groups.

3.  The low-intensity short duration training and control groups exhibited small non-significant decreases in stroke volume.

Davis et al. 1987;

Canada

PEDro = 4

RCT

Level 2

N = 14

Population: Sedentary SCI (n = 9 exercise group, n = 5 control group), age 20–39 yrs.

Treatment: Arm ergometry, 50%–70% VO2peak, 20–40 min/d, 3d/wk, 16 wks.

Outcome Measures: BP, HR, power output, VO2peak, resting left ventricular dimensions, cardiac function.

 

1.  Significant improvement in VO2peak (31%) and HR (-9.5%) with training.

2.  During isometric handgrip exercise, decreased rate-pressure product (HR*BP) (20%) and increased stroke volume (12%–16%).

Effect Sizes: Forest plot of standardized mean differences (SMD ± 95%C.I.) as calculated from pre- and post-intervention data
Hjeltnes and Wallberg-Henriksson, 1998;

Norway

Prospective controlled trial

Level 2

N = 27

Population: Exercise group: 10 tetraplegia, C6-8, 7 AIS  A & 3 AIS  B; Control: 10 paraplegia, T7-11, all AIS  A.

Treatment: Exercise group: standard rehabilitation + arm ergometry, 30min/d, 3d/wk, 12–16 wks; Control: standard rehabilitation.
Outcome Measures: power output, cardiac function, HR, VO2, systolic blood pressure, lactate levels, muscular strength, ability to perform activities of daily living.

 

1.  Persons with tetraplegia increased peak workload (45%) with no change in VO2peak.

2.  Peak workload (45.5%) and VO2peak (27.7) increased significantly in persons with paraplegia.

3.  No change in peak HR, systolic BP, submaximal exercise stroke volume, or cardiac output in either SCI group.

Milia et al.

2014

Italy

Cohort study

Level 2

N=9

Population: 9 SCI individuals (2 females, 7 males, mean age of 41) with clinically complete spinal lesions (T4-L1)

 

Treatment:

One year of exercise training for 3 to 5 hours per week of arm cranking against a workload corresponding to 60% of maximal workload (Wmax).

 

Outcome measures: Hemodynamic variables including maximum values of work rate (Wmax), heart rate (HR max), oxygen update (Vo2 max), carbon dioxide production (VCO2 max), respiratory exchange ratio (RER max), pulmonary ventilation (VE max), ventricular filling rate (VFR), end diastolic volume (EDV), mean blood pressure (MBP)

1.      After one-year of training, patients reached higher levels in Wmax and VO2 max expressed both in absolute and relative terms.

2.      The HR, MBP and EDV responses were significantly increased after one-year training.

3.       There were no differences in stroke volume, absolute cardiac output value or VFR absolute values due to training.

 

 

 

Jae et al. 2008;

South Korea

Case Control

Level 3

N = 52

(28 SCI, 24 AB)

Population: 28 physically active (trained) competitive wheelchair athletes (below T6). The able-bodied controls (n = 24) were recreationally active age-matched controls.

Outcome Measures: Measures of arterial structure and function: Common carotid artery intima–media thickness, arterial compliance and b stiffness, and aortic augmentation index (applanation tonometry of radial artery- to capture arterial efficiency)

1. No difference in any of the arterial function indices between groups.
West et al.

2014

Canada

Cross-sectional

Level 5

N=23

Population: 23 elite male paracyclists with SCI (11 with cervical SCI, 12 with thoracic, C3-T8, mean age of 41) at the 2013 Paracycling World Championship

 

Treatment: None

 

Outcome measures: Heart rate (HR), systolic blood pressure (SBP) and diastolic blood pressure (DBP)

1.      No difference in supine SPB and DBP between the thoracic SCI and cervical SCI group.

2.      Seated SBP was lower in cervical SCI than the thoracic SCI group.

3.      No difference in maximum heart rate for cervical compared to thoracic SCI groups. The average HR was lower in thoracic SCI compared cervical SCI group.

4.      Maximum and average HR also tended to be higher in cervical autonomic incomplete compared to autonomic complete.

5.      No difference in HR between thoracic autonomic complete vs. incomplete SCI.

Mixed arm and other exercise
Hicks et al. 2003;

Canada

PEDro = 5

RCT

Level 2

N = 23

Population: 18 tetraplegia and 16 paraplegia, AIS  A-D, C4-L1, ages 19–65 yrs.

Treatment: Exercise: 90–120 min/d, 2d/wk, 9 months of arm ergometry (15–30 min, ~70%VO2max) and circuit resistance exercise; Control group: bimonthly education session.

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

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

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

Effect Sizes: Forest plot of standardized mean differences (SMD ± 95%C.I.) as calculated from pre- and post-intervention data
Wheelchair ergometry
Hooker and Wells 1989;

USA

Prospective controlled trial

Level 2

N = 8

Population: Low-intensity group n = 6, C5-T7; moderate-intensity group n = 5, C5-T9.

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

Outcome Measures: HR, power output, blood lactate, VO2max, Rating of Perceived Exertion (RPE), lipid profiles.

1.  The moderate-intensity group had significantly lower post-training submaximal HR, lactate, and RPE but no changes in oxygen consumption.

2.  70% maximal HRR appears to be the beneficial training threshold.

Hand-crank Cycling
Kim et al.

2015

Korea

PEDro=5

RCT

Level 2

N = 15

 

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.

 

Treatment: 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 their maximum. Exercise intensity was gradually increased 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.

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

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

3.      The exercise group also showed significant increases in V02 peak and upper body strength compared with the control group following intervention.

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

Effect Sizes: Forest plot of standardized mean differences (SMD ± 95%C.I.) as calculated from pre- and post-intervention data
Valent et al. 2008

The Netherlands

Cohort

Level 2

N = 162

Population: Acute SCI participants, level of injury C5 or lower, divided into participants with paraplegia and tetraplegia , and further divided hand–cycling (HC) and non-hand cycling (non-HC) groups according to their rehabilitation protocols; data for 137 participants were available for the clinical rehabilitation period, and 131 for the post-rehabilitation period, 106 were available for both periods, and 162 different participants were tested in total

Treatment: Hand cycling

Outcome Measures: Power output; oxygen uptake (VO2peak); elbow extension strength; measured upon start of active rehabilitation, on discharge, and 1 year after discharge

1.    During clinical rehabilitation, a significantly larger increment in peak power output and VO2peak was found in participants with paraplegia.

2.    On average, peak power output increased 6.2W more in HC compared to non-HC participants with paraplegia.

3.    Compared with baseline, VO2peak increased by 29% in HC paraplegics, compared to 8% in the non-HC group.

4.    Elbow extension strength increased significantly in the HC compared to the non-HC participants with paraplegia.

5.    In contrast to the participants with paraplegia, there was no significant difference between HC and non-HC during rehabilitation for participants with tetraplegia.

6.    In the post-rehabilitation period, there was no significant difference between HC and non-HC groups.

Nooijen et al.

2015

Netherlands

Pre-Post

Level 4

N=30

Population: 30 SCI individuals, 20 paraplegia, 10 tetraplegia, 12 incomplete lesion, 18 complete lesion

 

Treatment: Structured hand cycle interval training program during the last 8 weeks of inpatient rehab. Training was more than 2 times per week at intended intensity of Borg score of 4 to 7 on a 10-point scale.

 

Outcome Measures: Peak power output and VO2peak

1.Peak power output and VO2 peak improved significantly after the training period.

 

Hubli et al.

2014

Canada

Cross-sectional

Level 5

N=20

Population: 20 individuals with motor-complete chronic SCI (C2-T5, 2-29 years post-injury, AIS-A or B). 10 of these individuals were elite hand-cyclists and 10 were sex matched to sedentary individuals with SCI.

 

Treatment: None

 

Outcome measures: Aortic Pulse Wave Velocity (PWV), discrete brachial blood pressure, heart rate

 

1.      No differences in systolic blood pressure, diastolic blood pressure, mean arterial pressure, and heart rate when resting supine between athletes and non-athletes.

2.      Aortic PWV was significantly lower in athletes compared with non-athletes.

Discussion

The reported improvements in aerobic capacity after aerobic arm training in SCI are approximately 20%–30%; however, it is not uncommon for improvements in excess of 50% (DiCarlo 1988). The majority of aerobic training investigations have evaluated the effectiveness of moderate (40%–59% heart rate reserve (HRR) or 55%–69% of maximum HR) to vigorous (60%–84% HRR or 70%–89% of maximum HR) intensity exercise. These studies have used arm ergometry, wheelchair ergometry, and swimming-based interventions. Based on the current level of literature, it appears that moderate intensity exercise performed 20–60 minutes per day for at least three days/week for a minimum of six weeks is effective for improving cardiovascular fitness and exercise tolerance in persons with SCI (Level 1b evidence based on two high-quality RCT’s (Ordonez et al. 2013; de Groot et al. 2003) and several lower quality RCTs). Therefore, the general recommendations provided by many international agencies (i.e., 150 min of moderate-to-vigorous physical activity (Tremblay et al. 2011) are appropriate for improving the cardiovascular fitness of persons with SCI. However, these recommendations are not optimal as significant changes in aerobic fitness may occur at volumes of exercise well below international recommendations designed for apparently healthy individuals (Ginis et al. 2011). It is also important to note that training intensities may need to be established using a rating of perceived exertion (e.g., RPE) (rather than objective measures of heart rate) in individuals with SCI-induced autonomic denervation of the heart.

 

Figure 5 – Borg Perceived Exertion Scale (15 point) and Modified Perceived Exertion Scale (10 point). Reprinted with permission from CDC and @Gunnar Borg.

Figure 5 – Borg Perceived Exertion Scale (15 point) and Modified Perceived Exertion Scale (10 point). Reprinted with permission from CDC and @Gunnar Borg.

An exercise intensity threshold of 70% maximal HR reserve has been advocated for the attainment of training benefits when exercising for the standard 20 minute duration (Hooker and Wells 1989, Tordi et al. 2001, Bizzarini et al. 2005). It is also apparent that improvements in exercise capacity and functional status may occur after training without significant changes in VO2peak, particularly in persons with tetraplegia (Hjeltnes and Wallberg-Henriksson 1998).

Questions remain regarding the primary mechanisms for improvements in aerobic fitness after training. It is unclear whether central (heart and lung) or peripheral (skeletal muscle) adaptations are of key importance. Enhancements have been observed in peripheral muscle function. For instance, investigators have shown intrinsic cellular adaptations in the paralyzed muscle that facilitate oxidative metabolism following BWSTT (Stewart et al. 2004). Only limited investigations, however, have shown an improvement in cardiac function after upper extremity aerobic exercise training (Davis et al. 1987). It could therefore be argued that peripheral adaptations are of primary importance to the improvement in aerobic capacity after this type of aerobic exercise aerobic exercise. However, this statement is somewhat misleading as the majority of studies have not directly evaluated cardiac output during maximal/peak exercise. This is owing to the fact that the assessment of maximal cardiac output during exercise is one of the most difficult procedures in clinical exercise physiology (Warburton et al. 1999a, 1999b). When exercise measures of cardiac function have been taken, improvements in central function have been observed (Davis et al. 1987). Further research examining the primary mechanism(s) of importance for the improved cardiovascular fitness and exercise capacity seen in persons with SCI after aerobic exercise training is warranted. It is also important to highlight that it is often difficult for patients to attain VO2max during exercise. Moreover, the submaximal prediction of VO2peak (based on the heart rate response to exercise) is limited owing to the potential impairment in the sympathetic drive to the heart in many persons with SCI. Furthermore, it is often difficult to determine whether the changes in VO2peak/VO2max seen after training are related to changes in musculosketelal fitness rather than changes in cardiovascular fitness.

[su_spoiler title=”Effect Size Forest Plots of RCTs with Available Data” style=”fancy”][su_row]Click on the image to enlarge[/su_row]

[su_lightbox type=”image” src=”/wp-content/uploads/Forest_Cardio_Kim_2015-1.gif”][image_with_animation image_url=”/wp-content/uploads/Forest_Cardio_Kim_2015-1.gif” alt=”Effect size SMD forest plot for Kim et al. 2015, Hand Bike Exercise”][/su_lightbox]
[su_lightbox type=”image” src=”/wp-content/uploads/Forest_Cardio_Ordonez_2013.gif”][image_with_animation image_url=”/wp-content/uploads/Forest_Cardio_Ordonez_2013.gif” alt=”Effect size SMD forest plot for Ordonez et al. 2013, arm crank exercise, arm ergometry”][/su_lightbox]

[su_lightbox type=”image” src=”/wp-content/uploads/Forest_Cardio_Davis_1987.gif”][image_with_animation image_url=”/wp-content/uploads/Forest_Cardio_Davis_1987.gif” alt=”Effect size SMD forest plot for Davis et al. 1987, arm crank exercise, arm ergometry”][/su_lightbox]

[su_lightbox type=”image” src=”/wp-content/uploads/Forest_Cardio_Hicks_2003.gif”][image_with_animation image_url=”/wp-content/uploads/Forest_Cardio_Hicks_2003.gif” alt=”Effect size SMD forest plot for Hicks et al. 2003, long term physical exercise”][/su_lightbox]
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Less is known about the effects of resistance training on cardiovascular fitness. However, the incorporation of resistance training into the treatment of SCI appears to be essential. In fact, muscle weakness and dysfunction are key determinants of pain and functional status in persons with SCI. Previous studies have revealed improvements in maximum aerobic power (Cooney and Walker 1986, Jacobs et al. 2001), exercise tolerance (Jacobs et al. 2001), and musculoskeletal fitness (Jacobs et al. 2001) after resistance training (e.g. circuit training).

As reviewed systematically by Phillips et al. (2011) two papers have evaluated the effects of upper body (arm) exercise on arterial function in SCI (Jae et al. 2008; Tordi et al. 2009). Jae et al. (2008) revealed that there were no significant differences in intima-media thickness, compliance, and beta stiffness index (a measure of arterial elasticity) of the common carotid artery between 28 competitive SCI athletes and 24 age-matched recreationally active able-bodied controls. Tordi and colleagues (2009) revealed (in a case study) that there was an improvement in aortic pulse wave velocity (central aortic stiffness) following six weeks of upper body training (30 min/session, 3 sessions/wk).

Conclusion

There is level 1b (Ordonez et al. 2013) and Level 2 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 1b evidence (de Groot et al. 2003) that vigorous intensity (70%–80% HR reserve) exercise leads to greater improvements in aerobic capacity than moderate intensity (50-60% HR reserve) exercise.

There is level 2 evidence (Milia et al. 2014) that arm cranking against a workload corresponding to 60% of WMax (performed 3-5 hours/day for one year) increases WMax and VO2 max.

There is level 2 evidence (Hjeltnes and Wallberg-Henriksson 1998) that hand cycling exercise increases the power output, oxygen consumption, and muscle strength in individuals with paraplegia, but not tetraplegia during active rehabilitation. Conversely, there is level 4 evidence (Valent et al. 2008) that hand cycling increases power output and oxygen consumption in individuals with tetraplegia. Further research is clearly warranted. Further research is clearly warranted. There is also level 4 evidence (Nooijien et al. 2015) that hand cycling interval training program increases peak power output and peak VO2 in individuals with paraplegia and tetraplegia.

There is level 3 evidence (Jae et al. 2008) that upper body strength exercise training can improve arterial structure and function in those with SCI.

There is level 5 evidence (Hubli et al. 2014) that aortic pulse wave velocity is significantly lower in athletes (hand cyclists) compared to sedentary individuals with SCI.

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.

  • Individuals with tetraplegia and paraplegia can improve their cardiovascular fitness and physical work capacity through aerobic arm cycling exercise training which is of moderate intensity, performed 20-60 min day, at least three times per week for a minimum of six to eight weeks.
  • Resistance training at a moderate intensity at least two days per week also appears to be appropriate for the rehabilitation of persons with SCI. It remains to be determined the optimal exercise intervention for improving cardiovascular fitness.