Table 1 .
Studies included
| Study | Study design | Intervention | Training | Location and | Participants | Lesion level | Screening or testing prior to |
|---|---|---|---|---|---|---|---|
| Downs & Black Scoring (D&B) | Protocol (session length, sessions per week, no. of weeks, intensity) | supervision | N and gender Mean age and age range (or SD) | AIS classification | training? Exclusion criteria | ||
| AAN classification | Adherence | Years post-injury | |||||
| Volitional exercise | |||||||
| Dyson-Hudson et al.13 | RCT (diet only vs. diet + exercise) D&B = 18 AAN class III | ACE | 20+ min. 3 × /week × 12 weeks, 60 rpm, 70% HRM Adherence not reported | Hospital gym, supervised | 21 males 4 females total, 10 males, 4 females in training group 42.9 ± 7.6 | C5-L2 AIS not reported 15.1 ± 8.9 years post-injury | No screening or testing. Exclusions: diabetes, CVD, cognitive impairment, “medical condition that precluded safe performance of upper limb exercise”. |
| El-Sayed and Younesian14; El-Sayed and Younesian et al.15 | Pre-post (two groups: SCI and control) | ACE | 30 min. 3 × /week × 12 weeks, 60 to 65% VO2 peak | Hospital gym, supervised | AB, n = 7; SCI, n = 5; Gender not reported | Below T-10 AIS not reported | Health history questionnaire and sub-maximal ACE monitored exercise testing pre and post |
| D&B = 14 | Adherence 100%. | SCI = 31 ± 2.9 years | Exclusions not stated | ||||
| AAN class IV | AB 32 ± 1.6 | Injury duration not reported | |||||
| McLean and Skinner16 | RCT D&B = 15 AAN class III | ACE | 20–35 min. 3 × /week × 10 weeks Adherence 100% | Laboratory, supervised | N = 15 Gender not stated Sit group 34.3± 12.1 Supine group 33.3 ± 7.0 | C5-T1 “Complete”, AIS not reported Sit group 9.3 ± 12.5 Supine group 14.1 ± 6.4 years post-injury | Approval from physician and Peak WCE exercise testing pre and post Exclusions: CVD, recurrent AD, hypotension, hypertension, use of alpha blockers, pressure sores, UTI, kidney stones, diabetes, incomplete SCI w/normal autonomic function |
| Le Foll-de Moro et al.17 | Pre–post D&B = 14 AAN class IV | WCE (interval training) | 30 min. 3 × /week × 6 weeks Adherence not reported | Hospital gym, supervised | 5 males 1 female 29 ± 14 (18–54) | T6-T12 AIS not reported 94 ± 23 days post-injury (range =73–137 days) | Maximal and submaximal WCE exercise testing pre and post Exclusions not stated |
| Bougenot et al.18 | Pre-post D&B = 14 AAN class IV | WCE (interval training) | 45 min. 3 × /week × 6 weeks Outstanding attendance (not defined) | Hospital gym, supervised | 7 males 35 ± 13 (21–55) | T6-L5 AIS A M = 12.3 (1–30) years post-injury | Maximal WCE exercise testing pre and post Exclusions not stated |
| Tordi et al.19 | Pre-post D&B = 14 AAN class IV | WCE (interval training) | 30 min. 3 × /week × 4 weeks Outstanding attendance (not defined) | Hospital gym, supervised | 5 males 27 ± 8.1 | T6-L4 AIS A “About 2 years” post-injury | Maximal WCE exercise testing pre and post, no ECG Exclusions not stated |
| Bjerkefors and Thorstensson20 | Pre-post | Kayak ergometry | 60 min. 3 × /week × 10 weeks | Clinical lab, supervised | 7 males | T3–T12 | No screening or testing |
| D&B = 18 | Adherence 100% | 3 females | AIS A, B, C | Exclusions not stated | |||
| AAN class IV | 38 ± 12 | M = 18.1 (3–26) years post-injury | |||||
| Valent et al.21 | Pre-post D&B = 18 AAN class IV | Hand cycle training | 35–45 min. 2–3 × /week × 8–12 weeks 24 sessions was goal. Adherence 19 ± 3 completed | Multiple locations (hospital gym, home setting, outdoors on track or trail) not supervised | 18 males 4 females 39 ± 12 | C5-C8 AIS A, B, C, D 10 ± 7 years post-injury | ACSM contraindications for exercise and hand cycle peak exercise test pre and post Exclusions CVD, overuse injuries of upper extremities, pressure sores, UTI, other medical conditions that did not allow performance of physical activity |
| Valent et al.22 | Controlled trial (not randomized) with matched control group D&B= 19 AAN class II | Hand cycle training | 35–45 min. 2 × /week × 9–39 weeks Adherence 87% | Hospital track, other outdoor locations. Initially supervised then no supervision | 26 males, 8 females total 13 males, 4 females in training group 46± 15 training group 45± 15 control group | 17 Paras 17 Tetras (levels not provided) AIS A/B = 22 AIS C/D = 12 5–47 weeks post-injury | Graded peak WCE test pre and post Exclusions: CVD, medical disease contraindicating exercise, serious musculoskeletal complaints |
| Mukherjee et al.23 | Pre–post D&B = 15 AAN class IV | Arm-propelled three wheeled chair | 15 min. 2 × /day × 12 weeks Adherence not reported | Outdoor setting, non-supervised | 12 males 30.5 ± 8.59 | Below T10 AIS not reported | No screening or testing Exclusions: CVD, musculoskeletal, neurological, or metabolic disorder |
| Tawashy et al.24 | Case report | Circuit training (aerobic) | 18–27 min. 3 × /week × 8 weeks | Hospital gym, supervised | 1 male | C5 | No screening or testing |
| D&B = 13 | 18/24 sessions completed | 22 years old | AIS A | Exclusions not stated | |||
| AAN class IV | 3 months post-injury | ||||||
| Duran et al.25 | Case series D&B = 20 AAN class IV | Circuit training (aerobic) | 120 min. 3 × /week × 16 weeks, THR 40–80% of max. HR Adherence 85% | Hospital gym, supervised | 12 males 1 female 26.3 ± 8.3 | T3–T12 AIS A–C M = 25 months (2 months–10 years) post-injury | ACE exercise test pre- and post-intervention Exclusions: Cardiac medications, major medical problems |
| Nash et al.26 | Pre–post D&B = 18 AAN class IV | Circuit training (resistance and aerobic) | 40–45 min. 3 ×/week × 16 weeks Adherence 94% | Hospital gym, supervised | 7 males Mn not provided (39–58) | T5-T12 AIS A, B 13.1± 6.6 years post-injury | Multi-stage graded exercise test with ECG monitoring pre and post Exclusions not stated |
| Jacobs et al.27 | Pre-post D&B = 16 AAN class IV | Circuit training (resistance) | 40–45 min 3 × /week; × 12 weeks Adherence not reported | University outpatient setting, supervised | 10 males M = 39.4± 6.0 (28–44) | T5-L1 AIS A M = 7.3± 6.0 years post-SCI (0.7–16.8) | Maximal WCE exercise test pre and post Exclusions: poor health, cardiac ischemia on ECG, shoulder joint dysfunction |
| Cooney and Walker28 | Pre–post D&B = 16 AAN class IV | Hydraulic resistance exercise (timed sets of resistance exercises w/ brief rest periods) | 30–40 min. 3 × /week × 9 weeks, 60–90% of HRM Adherence 100% | Hospital gym, supervised | 7 males, 3 females M = 28.8 (20–39) | C 5-L1 AIS not reported 2–9 years post-injury (M = 4.6 years) | ACE exercise test pre and post “Healthy”, exclusions not stated |
| Forrest et al.29 | Case report D&B = 17 AAN class IV | BWSTT | 15–25 min 3 × /week × 30 weeks 97 sessions completed | Therapy clinic; supervised, assisted | 1 male 25 | C6 AIS B 1 year post-injury | PE pre and post Exclusions: bone mineral density t-score <− 2.5 (osteoporosis) |
| Ditor et al.30 | Pre-post D&B = 15 AAN class IV | BWSTT | Up to 60 min 3 × /week × 6 months Adherence 83.6%± 9.1 | University based center, supervised, assisted | 6 males 2 females 27.6 ± 5.2 | C4-C5 AIS B = 1 AIS C = 7 9.6 ± 7.5 yrs post-injury | ECG pre and post Exclusions: CVD, musculoskeletal condition that would contraindicate exercise |
| Ditor et al.31 | Pre-post D&B = 18 AAN class IV | BWSTT | 15 min 3 × / week × 12 weeks Adherence 83.3 ± 7.6% | University based center, supervised, assisted | 4 males, 2 females (+4 dropouts, no gender information) 37.7 ± 15.4 | C4-T12 AIS A or B 7.6± 9.4 years post-injury | No screening or testing Exclusions: CVD, musculoskeletal condition that would preclude exercise |
| Protas et al.32 | Pre–post D&B = 12 AAN class IV | BWSTT | 60 min. 5 × /week × 12 weeks (Treadmill walking 20 minutes) Adherence not reported | Hospital supervised and assisted | 3 males M = 42.7 (34–48) | T8-T12 AIS C = 1 AIS D = 2 2–13 years post injury | No screening or testing Exclusions: lower extremity contracture, pressure ulcers |
| FES exercise | |||||||
| Needham-Shropshire et al. 33 | RCT with treatment control (3 groups) D&B = 15 AAN class IIII | FES-ACE | 32 min 3 × /week interval training Group 1= 8 weeks FES ACE Group 2 = 4 weeks FES ACE and 4 weeks non-FES ACE Group 3 = 8 weeks non-FES ACE Adherence not reported | Lab, supervised | N = 34 Group 1 = 11 males, 1 female Group 2 = 10 males, 1 female Group 3 = 10 males, 1 female M years group 1 = 24; group 2 = 22; group 3 = 24 | Cervical level injuries AIS not reported Group 1 = 6 years, group 2 = 9 years, group 3 = 4 years post-injury | No screening or testing Exclusions: biceps/triceps LMN dysfunction, shoulder or elbow contractures, shoulder joint subluxation, intolerance to surface FES |
| Wheeler et al.34 | Pre–post D&B = 13 AAN class IV | FES-rowing ergometry | 30 min 3 × /week × 12 weeks 70–75% of pretest peak O2 21–36 sessions completed | University based recreational activity facility; supervised | N = 6 (gender not reported) 42.5 ±17.9 (26–66) | C7-T12 ASIA A & C 13.8 ± 11.6 years post-injury | FES-row peak exercise test pre-participation Exclusions not stated |
| Duffell et al. 35 | Case series D&B = 14 AAN class IV | FES-LCE | Up to 1 hour 5 × s/week ×1 yr M completed sessions = 4.5/week | 3 research settings and 1 hospital supervised for initial sessions, then home w/o supervision | 9 males 2 females 41.8 ± 2.3 yrs | T3-T9 “Complete” 10.7± 2 yrs post injury | No screening or testing Exclusions: LMN injury Spasticity precluding pedaling Medical or psychiatric conditions Previous FES exercise |
| Frotzler et al. 36 | Prospective longitudinal cohort D&B = 18 AAN class IV | FES-LCE | 14 ± 7 weeks FES conditioning then FES cycling 10–60 mins, 3–4 × /week; then 60 mins, 5 × /week × 12 months at highest power output Adherence 76.6% | Home; not supervised; training diary only | 9 males 2 females 41.9 ± 7.5 yrs | T3-T12 AIS A 11.0 ± 7.1 years post injury | No screening or testing Exclusions: Severe spasticity Unhealed bone fxs Diseases known to affect metabolism LE contractures Previous FES exercise participation |
| Janssen and Pringle37 | Pre–post D&B = 16 AAN class IV | FES-LCE | Up to 25–30 min 2–3 × /week × 6 weeks for total =18 sessions Adherence not reported | Lab, supervised | 12 males 36 ± 16 | C4-T11 9 “motor complete”, 3 “motor incomplete” 11± 9 years post-injury | 2 Graded LCE exercise rests pre and post, screening for exercise contraindications Exclusions: Spasticity Heterotopic ossification Pressure sores Severe cardiopulmonary disease |
| Zbogar et al.38 | Pre–post D&B = 15 AAN class IV | FES-LCE | Habituation period (30 min 3 × week × 16 weeks prior to training) then 60 min 3 × /week × 12 weeks M sessions completed =29 | Rehab center, supervised | N = 4 females + N = 2 dropouts, gender not stated M = 32 (19–51) | C4-T7 AIS A-C 3–16 years post-injury | No screening or testing Exclusions: CVD Other neuro conditions Pressure ulcers Previous fragility fxs Abnormal bone formation Severe spasticity Lower extremity contractures |
| Hjeltnes et al.39 | Pre–post D&B = 13 AAN class IV | FES-LCE | 2 wk run in followed by 30 min sessions, 7 × / week × 8 weeks | Inpatients, hospital-based, supervised | N = 6 males 35 ± 3 | C5-C7 AIS A or B 10.2 ± 3.4 years post-injury | PE including x-rays, no testing pre-trial Exclusions: Osteoporosis Fxs |
| Mutton et al.40 | Pre–post D&B = 14 AAN class IV | FES-LCE | Progressive protocol, 30 min 2 × /week. Phase 1: up to 30 sessions Phase II – ∼35 sessions phase III ∼41 sessions (24–128 sessions completed) | Outpatient rehab setting, supervised | N = 11 males (phase I and II); N = 8/11 (phase III) 35.6 ±6.6 (25–46) | C5-L1 AIS A 9.7 ± 3.8 yrs post-injury | Peak and sub-maximal ACE exercise test, PE, blood chemistry, UA, chest and lower limb x-rays, 12-lead ECG pre & post Exclusions: CVD Metabolic disease Previous aerobic training |
| Mohr et al.41 | Pre–post D&B =17 AAN class IV | FES-LCE | 30 min 2–3× week × 1 year M = 2.3 sessions/week completed, adherence 75% | Research center, supervised | 8 males 2 females M = 35.3, (27–45) | C6 (6) T4 (4) AIS not specified M = 12.5 (3–23) years post injury | VO2 Max test after acclimation Exclusions: Diseases or disabilities other than SCI Previous training |
| Barstow et al.42 | Pre–post D&B = 15 AAN class IV | FES-LCE | 30 min 3 × .week × at least 24 sessions M = 2.1(.04) sessions/week completed | VA Hospital, supervised | 9 males 34.4 ±5.6 | C5-T12 AIS A 10.1± 4.1 years post-injury | PE, x-ray of spine and legs, CT legs, blood chemistry, UA, ACE ECG stress test pre–post Exclusions: Not stated |
| Hooker et al.43 | Pre–post D&B = 13 AAN class IV | FES-LCE | 30 min. 2 × /week, × 19 weeks M = 2.3 sessions/wk completed | VA Hospital Supervised | 8 males 36.0 ± 4.6 | C5–6 – T12-L1 Frankel A 9.8 ± 4.0 years post-injury | PE, blood chemistry, UA, chest, spine, and LE x-rays, 12 lead ECG, and ACE stress test with ECG monitor Exclusions not stated |
| Ragnarsson et al.44,45 | Pre–post D&B= 13 AAN class IV | FES-LCE | 12 sessions of quad strengthening (3 × /week × 4 weeks) + 36 sessions of LCE (3/week × 12 weeks). Adherence not reported | Hospital-based, supervised | 16 males, 3 females (study 1) 7 males, 4 females (study 2) M not stated (18–54) | C4-T10 11 paras 19 tetras Frankel A 0.6–17 years post-injury | LE x-rays pre Exclusions: Previous FES Abnormal LE x-ray |
| Brissot et al.46 | Pre–post D&B= 10 AAN class IV | FES-ambulation (parastep) | 20–40 min. one to two sessions/day × 4 to 12 weeks or longer M sessions = 20. | Hospital gym, supervised | 11 males, 4 females 28 ± 9 (16–47) | T3-T11, Frankel A–C M = 4.5 years post-injury (0.5–20 years) | Peak ACE exercise testing pre and post Exclusions: CVD Respiratory conditions morbid obesity Severe spasticity LE contracture Hx of Fx Severe scoliosis Skin problem at electrode site |
| Klose et al.47; Needham-Shropshire et al.48 | Pre–post D&B = 15 AAN class IV | FES-ambulation (parastep) | Incrementally increasing distances, 3 × /week × 32 sessions Adherence 100% | Therapy clinic, supervised | 13 males, 3 females 28.4± 6.6 | T4–T11 AIS A 4.0± 3.5 years post-injury | Peak ACE exercise testing pre and post. Resting ECG and PE before trial Exclusions: CVD Hx of Fxs Hx of DJD LMN injury LE contractures Severe spasticity Skin breakdown |
| Gallien et al.49 | Case series D&B = 11 AAN class IV | FES-ambulation (parastep) | 2 hours 3–5 × /week × up to 32 sessions (goal) 5–49 sessions achieved, M = 19 sessions | FES clinic, supervised | 11 males, 2 females 27± 7 (17–42) | T4-T10 AIS A 0.5–12 years post-injury | No screening or testing Exclusions: CVD Pulmonary disease LMN injury Epilepsy Skin breakdown near electrode sites |
| Field-Fote50 | Pre–post D&B = 16 AAN class IV | FES-ambulation (BWSTT) | 90 min 3 × /week × 12 weeks (36 sessions) Adherence not reported | Lab, supervised | 13 males, 6 females 31.7 ± 9.4 years | 13 tetra 6 paras AIS C 1–14.25 years post-injury | No screening or testing Exclusions not stated |
| Ferro et al.51 | Descriptive; longitudinal D&B = 10 AAN class IV | FES ambulation-(BWSTT) | 20 min 2 × /week × 6 months Adherence not reported | Lab, supervised | N = 9 Gender not specified M = 33.2 (25–46) | C4-C7 AIS A, B, D 1–10 years post-injury | No screening or testing Exclusions: Cardiac disease LMN injury Known knee injury |
| Thoumie et al.52 | Case series D&B = 12 AAN class IV | FES-ambulation (RGO) | Incrementally increasing distances, duration and frequency not specified, × 2–5 months for inpatients, 3–14 months for outpatients 21/23 completed entire program | Therapy clinic (inpatient or outpatient), supervised | 23 males, 3 females M = 31 (20–53) | Thoracic level except 1 with C8 AIS A M = 2.7, 1–12 years post-injury | No screening or testing Exclusions: LMN injury LE contracture |
AAN, American Academy of Neurology; ACE, arm cycle ergometry; AB, able-bodied; ACSM, American College of Sports Medicine; AD, autonomic dysreflexia; AIS, American Spinal Injuries Association impairment scale; BWSTT, Body weight supported treadmill training; C, cervical; CT, computed tomography; CVD, cardiovascular disease; D&B, Downs and Black scale score; DJD, degenerative joint disease, ECG, electrocardiogram; FES, functional electrical stimulation; fx: fracture; HRM, heart rate maximum; Hx, history; L, lumbar; LCE, leg cycle ergometry; LE, lower extremities; LMN, lower motor neuron; min, minutes; M, mean; MOS, months; PE, physical examination; RCT, randomized controlled trial; RGO, reciprocating gait orthoses; RPM, rotations per minute; SCI, spinal cord injury; SD, standard deviation; T, thoracic; UA, urinalysis; UTI, urinary tract infection; VO2 Max, maximal oxygen uptake; W/, with; W/O, without; WCE, wheelchair ergometry; Wk, week; Yrs, years