# Exercise as it relates to Disease/Promoting functional independence and well-being through physical activity in spinal cord injury patients

This is a critique of the article "Long-Term exercise training in persons with spinal cord injury: effects on strength, arm ergometry performance and psychological well-being" by AL Hicks, KA Martin, DS Ditor, AE Latimer, C Craven, J Bugaresti and N McCartney.

## What is the background to this research?

Despite major medical advancements and improvements in life expectancy, many individuals (approximately 70%) with a spinal cord injury (SCI) suffer from secondary factors as a result of the physical disability including stress, depression, pain, quality of life, functional ability (independence) and inactivity-related chronic diseases. As rehabilitation for SCI shifts from extension of life to enhancement of it, there is a gap in the existing literature on the importance of regular and consistent long-term physical activity. While it has been proven that physical activity in individuals with a SCI is important for maintaining health and increasing independence, little research had been conducted on clinical practice guidelines for prescribing exercise, and the impact of this exercise on psychological well-being of individuals.

## Where is the research from?

The study was conducted in the Centre for Health Promotion and Rehabilitation, McMaster University in Canada. The lead author, Audrey Hicks, is a reputable scholar and professor at Department of Kinesiology, McMaster University and has over 159 research items. Dr Hicks is highly regarded for her work on exercise rehabilitation in special reference to individuals with mobility impairments resulting from either SCI or multiple sclerosis. The study was supported by a grant from the Ontario Neurotrauma Foundation which strives to provide integrated, efficient and equitable support and care for people living with SCI and acquired brain injuries.

## What kind of research was this?

The research conducted was a randomised controlled trial of exercise training, with patients being allocated to either an exercise group, or control group. Randomised controlled trials (RCTs) are deemed the gold-standard in clinical research for examining safety and efficacy of new treatments. This was an appropriate choice of methodology as RCTs are designed to be unbiased (classed as the highest level of evidence) and the structure of the study allows for clear statistical analysis between the exercising and control groups.

## What did the research involve?

Over a period of 9-months 34 participants took place in the study and were randomly allocated to an exercise group which completed twice-weekly exercise sessions lasting 90–120 minutes(n = 21) or were part of the control group (n = 13) who had access to bi-monthly information sessions. Participants comprised of both males and females aged 19–65 years that had suffered traumatic spinal cord injuries of 1–24 years in duration. The exercise sessions consisted of an aerobic portion involving arm ergometry for 15-30minutes at 70% MHR, and a resistance portion consisting of wall-pully exercises, free weights and an Equaliser-weight machine.
Assessments consisted of 1RM strength testing, arm ergometry, and a series of psychological tests testing quality of life components (stress, depression, physical self-concept, pain, perceived health and quality of life). These tests were taken at baseline, 3, 6, and 9-months post.
Study Strengths
* Gold-standard methodology design
* Examines both physiological and psychological outcome measures
* Participants assigned to exercise or control groups at a 2:1 ratio as a higher dropout was anticipated for exercising individuals (sample size needed to be sufficiently large enough for statistical analysis.)
Study Limitations
* Program completion was an issue with only 11 out of the 21 participants completing the full 9-month duration of the program
* Psychological well-being could have been influenced by the social-setting of the exercise group rather than being purely interpreted from exercise (control group did not have access to such social interactions)
* Unsure of the level of activity the control group participated in outside of the program

## What were the basic results?

The study found the following key results:
* Twice-weekly strength and endurance training results in significant increases in strength, arm ergometry performance and quality of life
* Subjects experienced decreased pain and increase physical functioning
* Positive adaptations over the 9-months allowed subjects to perform daily living tasks much easier than at baseline, resulting in greater independence

## What conclusions can we take from this research?

Overall the study provides evidence to practitioners that exercise is important in the maintenance and development of a healthy lifestyle for individuals with SCIs. This research is supported by the formulation of recent evidence-based guidelines on the type and minimum dose of exercise necessary to improve fitness and cardiometabolic health in SCI adults. A follow up study conducted by DS Ditor and accompanied by AL Hiks examined the voluntary continuation of exercise training after the original study had ended, and its subsequent implications on the patient's psychological well-being. This study found that after a significant decrease in program adherence 3-months post study, participants reported decreases in perceived quality of life, as well as increases in pain and stress.

## Practical advice

If you are an individual that has sustained a spinal cord injury, there are a number of ways you can improve both your physiological and psychological well-being
* Participate in 20 minutes of moderate to vigorous intensity aerobic exercise 2x a week
* AND 3 sets of strength exercises for each major functioning muscle group at moderate to vigorous intensity 2x a week
* Seek aid from an Exercise Physiologist or SCI-related company if you are unsure on what programs are for offer, what exercise you should be doing and how to train around possible limitations

## Further information/resources

If you are interested, listed below are some more information regarding SCI and physical activity, as well as links to companies mentioned in this review.
* The Ontario Neurotrauma Foundation https://onf.org/
* SCI Action Guidelines for Activity http://sciactioncanada.ca/docs/guidelines/spinal-cord-injury-guidelines-blue.pdf

## References

* 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Hicks A, Martin K, Ditor D, Latimer A, Craven C, Bugaresti J, et al. Long-term exercise training in persons with spinal cord injury: effects on strength, arm ergometry performance and psychological well-being. Spinal cord. 2003;41(1):34.
* 1 2 Esquenazi A, Talaty M, Packel A, Saulino M. The ReWalk powered exoskeleton to restore ambulatory function to individuals with thoracic-level motor-complete spinal cord injury. American journal of physical medicine & rehabilitation. 2012;91(11):911-21.
* 1 2 3 Ditor D, Latimer A, Ginis KM, Arbour K, McCartney N, Hicks A. Maintenance of exercise participation in individuals with spinal cord injury: effects on quality of life, stress and pain. Spinal cord. 2003;41(8):446.
* ↑ Brenes G, Dearwater S, Shapera R, LaPorte RE, Collins E. High density lipoprotein cholesterol concentrations in physically active and sedentary spinal cord injured patients. Archives of physical medicine and rehabilitation. 1986;67(7):445-50.
* ↑ Ginis KAM, Latimer-Cheung A, Corkum S, Ginis S, Anathasopoulos P, Arbour-Nicitopoulos K, et al. A case study of a community-university multidisciplinary partnership approach to increasing physical activity participation among people with spinal cord injury. Translational behavioral medicine. 2012;2(4):516-22.
* ↑ Kerstin W, Gabriele B, Richard L. What promotes physical activity after spinal cord injury? An interview study from a patient perspective. Disability and rehabilitation. 2006;28(8):481-8.
* 1 2 Nash MS, van de Ven I, van Elk N, Johnson BM. Effects of circuit resistance training on fitness attributes and upper-extremity pain in middle-aged men with paraplegia. Archives of physical medicine and rehabilitation. 2007;88(1):70-5.
* 1 2 Univeristy M. Audrey Hicks Hamilton, Ontario2019 [Available from: https://www.science.mcmaster.ca/kinesiology/component/comprofiler/userprofile/hicksal.html?Itemid=814.
* 1 2 10. ResearchGate. Audrey Hicks 2019 [Available from: https://www.researchgate.net/profile/Audrey_Hicks
* ↑ 11. Foundation ON. Neurotrauma Care Pathways: floating-point; 2019 [Available from: https://onf.org/impact/neurotrauma-care-pathways/
* ↑ 12. Kabisch M, Ruckes C, Seibert-Grafe M, Blettner M. Randomized controlled trials: part 17 of a series on evaluation of scientific publications. Deutsches Ärzteblatt International. 2011;108(39):663.
* ↑ Burns PB, Rohrich RJ, Chung KC. The levels of evidence and their role in evidence-based medicine. Plastic and reconstructive surgery. 2011;128(1):305.
* ↑ Ginis KAM, van der Scheer JW, Latimer-Cheung AE, Barrow A, Bourne C, Carruthers P, et al. Evidence-based scientific exercise guidelines for adults with spinal cord injury: an update and a new guideline. Spinal cord. 2018;56(4):308.