Table 6.

Summary of results from randomized or quasi/non-randomized controlled trials of exercise/physical activity interventions to modify EMD risk in community-dwelling adults with chronic SCI.

Author, Year, Design	Methods	Results
Bakkum 201542 RCT Netherlands	Participants: 18 men and 1 woman, age: 28–65 years with chronic SCI (≥10 years post-injury), wheelchair dependent Intervention: Hybrid FES cycling (n=9)- 2 d/wk (18–32 min/session), 16 weeks Comparator: Hand cycling (n=10)- 2 d/wk (18–32 min/session), 16 weeks Outcomes: WC; BP via manometer; lipid and carbohydrate metabolism, and inflammatory markers via blood analysis; visceral adiposity via DXA Time-points: Baseline and 16 weeks	No statistically significant group x time interactions for WC, BP, trunk and android fat, metabolic/inflammatory markers
de Abreu 200650 Non-randomized controlled trial Brazil	Participants: 21 men, mean±SD age 32±8 yr with chronic complete tetraplegia Intervention: NMES-30–50% BWS treadmill training (n=10)- 2 times/week, 20 min/session, 24 weeks Comparator: Conventional physical therapy (n=20), 2 d/wk, 24 weeks Outcomes: Bone turnover markers via serum and urinary assay; lumbar spine, proximal femur, total femur BMD via DXA Time-points: Baseline and 24 weeks	Intervention: 82% ↑ bone formation; 67% ↓ bone resorption Control: 30% no Δ; 20% ↑ formation Changes in BMD were not related to changes in bone turnover markers
de Abreu 200852 Non-randomized controlled trial Brazil	Participants: 15 men, mean±SD age 32±8 yr with chronic complete tetraplegia (C4-C7), mean±SD DOI 66±48 months Intervention: NMES-30–50% BWSTT (n=8)-2 d/wk, 20 min/session, 24 weeks Comparator: Conventional physical therapy (n=20), 2 d/wk, 24 weeks Outcomes: Quadriceps CSA via MRI Time-points: Baseline and 24 weeks	Intervention: Quad CSA ↑15% (Δ=7.5 cm2) Control: No Δ quad CSA
de Abreu 200951 Non-randomized controlled trial Brazil	Participants: 15 men, mean±SD age 32±8 yr with chronic complete tetraplegia (C4-C7), mean±SD DOI 66±48 months Intervention: NMES-30–50% BWS treadmill training (n=8)- 2 times/week, 20 min/session, 24 weeks Comparator: Conventional physical therapy (n=20), 2 d/wk, 24 weeks; followed by 30–50% BWSTT (without NMES), 24 weeks Outcomes: Quadriceps CSA via MRI Time-points: Baseline, 6 months, 12 months (controls only)	Intervention: Quad CSA↑15% Control group 1: No Δ quad CSA Control group 2: No Δ quad CSA
Giangregorio 201237 RCT Canada	Participants: 26 men and 9 women, mean age 55±15 yr with chronic traumatic, incomplete SCI (mean±SD DOI 10±10 yr, C2-T12) Intervention: FES-BWSTT (n=17), 3 d/wk, 45 min/session for 16 weeks Comparator: Active control (n=17), tailored progressive exercise program 3 times/week, 45 min/session for 16 weeks Outcomes: Calf muscle and fat CSA via pQCT; total body, leg fat and lean mass via DXA Time-points: Baseline and 12 months	Statistically significant between-group difference for change in calf muscle CSA (MD=348 mm2)
Gorgey 201239 Pilot RCT United States	Participants: 9 adult men, age: 18–50 yr with chronic traumatic motor complete SCI (>1-yr post-injury, C5-L1), wheelchair reliant Intervention: NMES-assisted lower-extremity resistance training, 2 d/wk + diet (45% carbohydrates, 30% fat, 25% protein) (n=5) for 12 weeks Comparator: Diet (45% carbohydrates, 30% fat, 25% protein) (n=4) for 12 weeks Outcomes: Anthropometric outcomes; thigh, knee muscle CSA, thigh, trunk SAT CSA, trunk VAT CSA, intramuscular fat via MRI; total, trunk, leg fat and fat-free mass via DXA; lipid and carbohydrate metabolic markers via blood analysis Time-points: Baseline and 12 weeks	Statistically significant between-group differences for change in thigh (MD=20 cm2), knee extensor (MD=10 cm2) and flexor muscle CSA (MD=3 cm2), leg fat-free mass (MD=1 kg), leg fat mass (MD=7%), IMF (MD=16%), triglycerides (MD=67 mg/dL), C/HDL-C ratio (MD=1.1) No significant between-group differences for weight, BMI, adiposity, and body composition (whole body, trunk)
Gorgey 201338 Pilot RCT United States	Participants: 7 adult men, age: 18–50 yr with chronic traumatic motor complete SCI (>1-yr post-injury, C5-L1), wheelchair dependent Intervention: NMES-assisted lower-extremity resistance training, 2 d/wk + diet (45% carbohydrates, 30% fat, 25% protein) (n=4) for 12 weeks Comparator: Diet (45% carbohydrates, 30% fat, 25% protein) (n=3) for 12 weeks Outcomes: Thigh and trunk muscle CSA by MRI Time-points: Baseline and 12 weeks	Statistically significant between-group difference in gracilis and sartorious muscle CSA (MD=1.1 cm2) No significant between-group difference in adductor, hip flexor and back extensor muscle CSA
Kim 201545 RCT Korea	Participants: 9 men and 6 women, mean age 33±5 yr with chronic SCI (AIS A/B, 2–16 yr post-injury, C5-T11) Intervention: Indoor hand cycle ergometry (n=8), 3 d/wk, 6 weeks Comparator: Control (n=7) Outcomes: Anthropometric outcomes; body composition via BIA; lipid and carbohydrate metabolic markers via blood sample analysis Time-points: Baseline and 6 weeks	Statistically significant between-group differences for BMI (MD=0.5 kg/m2), fasting insulin (MD=3.7 µU/mL), HOMA-IR (MD=0.8)
Ordonez 201343 RCT Spain	Participants: 17 men, age: 20–35 years with chronic traumatic complete SCI below T5 (4–5 years post-injury) Intervention: Arm cycle ergometry (n=9), 3 d/wk, 35–55 min/session, 12 weeks Comparator: Control (n=8) Outcomes: Anthropometric outcomes; antioxidant, lipid and protein oxidation markers via blood sample analysis Time-points: Baseline and 12 weeks	Intervention: Antioxidant (Δ = 0.24 nmol/L), lipid peroxidation (Δ = -0.13 µmol/L) and protein oxidation markers (Δ = -0.59 nmol/mg protein), anthropometry index (Δ = -1.4) were significantly improved Control: No Δ in antioxidant and anthropometric outcomes
Rosety-Rodriguez 201444 RCT Spain	Participants: 17 men, age: 20–35 years with chronic traumatic complete SCI below T5 (4–5 years post-injury) Intervention: Arm cycle ergometry (n=9), 3 d/wk, 35–55 min/session, 12 weeks Comparator: Control (n=8) Outcomes: WC; testosterone, estradiol, luteinizing hormone, and follicular stimulating hormone via blood sample analysis Time-points: Baseline and 12 weeks	Statistically significant between-group difference in testosterone levels (MD=21.8 ng/dL) and WC (MD= 4 cm) No statistically significant between-group differences for estradiol, luteinizing hormone, and follicular stimulating hormone
Totosy de Zepetnek 201540 RCT Canada	Participants: 21 men and 2 women, mean age 41±12 years with chronic SCI (AIS A-C, mean DOI 12±10 years, C3-T11) Intervention: Physical activity guidelines training (n=12), aerobic + resistance exercise 2 d/wk, 60 min/session for 16 weeks Comparator: Active control (n=11) Outcomes: Blood pressure via manometer; Hb1ac and lipid profile via blood sample analysis; anthropometric outcomes; total body fat and lean mass, and visceral adiposity via DXA; adiponectin, leptin, and inflammatory cytokines via blood sample analysis Time-points: Baseline and 16 weeks	Statistically significant group x time interactions for whole body mass (ES=1.07) and fat mass (ES=1.00), visceral adiposity (ES=1.02) No statistically significant group x time interactions for any other outcomes

EMD= Endocrine-metabolic disease; SCI = Spinal cord injury; DOI = Duration of injury; AIS = American Spinal Injury Association impairment scale; RCT = Randomized controlled trial; MD= Mean difference of change or percentage change from baseline; ES = Effect size; NMES = Neuromuscular electrical stimulation; FES = Functional electrical stimulation; BWSTT = Body weight-supported treadmill training; BMI = Body mass index; WC = Waist circumference; VAT = Visceral adipose tissue; SAT = Subcutaneous adipose tissue; DBP = Diastolic blood pressure; IL-6 = Interleukin=6; IL-10 = Interleukin-10; CSA = Cross-sectional area; IMF = Intermuscular fat; DXA = Dual energy X-ray absorptiometry; MRI = Magnetic resonance imaging; BIA = Bioelectrical impedance analysis; HOMA-IR= Homeostatic model assessment of insulin resistance; Hb1ac = Glycated hemoglobin; AUC = Area under the curve.