HIGH-INTENSITY INTERVAL TRAINING IN PEOPLE WITH SPINAL CORD INJURY: A SYSTEMATIC REVIEW

Silva, Carlos Mariano Aguiar Ferreira da; Sá, Karina Santos Guedes de; Gorla, José Irineu; Flores, Lucinar Jupir Forner; Silva, Marília de Passos Magno e; Coswig, Victor Silveira; Silva, Anselmo de Athayde Costa e

doi:10.1590/1517-8692202430012022_0193i

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Revista Brasileira de Medicina do Esporte

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Systematic Review, Training • Rev Bras Med Esporte 30 • 2024 • https://doi.org/10.1590/1517-8692202430012022_0193i copy

HIGH-INTENSITY INTERVAL TRAINING IN PEOPLE WITH SPINAL CORD INJURY: A SYSTEMATIC REVIEW

ENTRENAMIENTO POR INTERVALOS DE ALTA INTENSIDAD EN PERSONAS CON LESIONES MEDULARES: UNA REVISIÓN SISTEMÁTICA

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Objective:

Analyze the effects of high-intensity interval training (HIIT) on cardiometabolic parameters, and cardiorespiratory fitness to compile the most used HIIT training types in adults with spinal cord injury (SCI).

Methods:

This is a systematic review of searches performed in the electronic databases PubMed / Medline, Science Direct, and Google Scholar. Studies included I) needed to apply HIIT training II) adults with SCI to analyze III) cardiometabolic aspects and cardiorespiratory fitness. Two independent reviewers selected the articles for inclusion, extracted their data, and assessed their methodological quality.

Results:

654 studies were found. Thus, 12 studies, 11 pre- and post-intervention, and one control group (CG) with 106 participants were analyzed. Pre- and post-HIITT intervention results revealed significant improvement in cardiorespiratory fitness and cardiometabolic aspects (VO₂peak, LDH, HDL, insulin resistance). In addition, GC results revealed significant improvement in cardiorespiratory fitness observed in the intervention group (HIIT) compared to the moderate-low intensity (GC) group. Seven studies used the arm ergometer as the primary exercise modality. Two studies described functional electrical stimulation (FES) performed with the arm ergometer plus electrical stimulation in the lower limbs. None reported heart rate dynamics during the study period.

Conclusion:

High-intensity interval training improves physical fitness and cardiometabolic health in adults with SCI. Evidence level II; Systematic Review of level II studies.

Keywords:
Spinal Cord Injuries; High-Intensity Interval Training; Metabolism; Physical Fitness

Question	(52)	(53)	(54)	(55)	(56)	(57)	(58)	(59)	(60)	(61)	(62)	(25)
Introduction
1. Were the objectives of the study clear?	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y
Methods
2. Was the study design appropriate for the stated objective(s)?	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y
3. Was the sample size justified?	N	N	N	N	N	N	N	N	N	N	N	N
4. Has the target/reference population been clearly defined? (Is it clear who the research was about?)	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y
5. Was the sampling frame drawn from an appropriate population base so that it closely represented the target/reference population under investigation?	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y
6. Was the selection process likely to select subjects/participants representative of the target/reference population under investigation?	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y
7. Have steps been taken to address and categorize non-responders?	ND	ND	ND	ND	ND	ND	ND	ND	ND	ND	ND	ND
8. Were the risk factors and outcome variables measured appropriately for the study objectives?	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y
9. Were the risk factors and outcome variables measured correctly using instruments/measures that have been previously tried, tested, or published?	NI	NI	NI	NI	NI	NI	NI	NI	NI	NI	NI	NI
10. Is it clear what was used to determine statistical significance and precision estimates? (e.g., p-values, CIs)	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y
11. Are the methods (including statistical methods) described sufficiently to allow their repetition?	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y
Results
12. Is the basic data adequately described?	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y
13. Does the response rate raise concerns about non-response bias?	N	N	N	N	N	N	N	N	N	N	N	N
14. If appropriate, was information about non-responders described?	NI	NI	NI	NI	NI	NI	NI	NI	NI	NI	NI	NI
15. Were the results internally consistent?	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y
16. Were the results of the analyses described in the methods presented?	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y
Discussion
17. Were the authors’ discussions and conclusions justified by the results?	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y
18. Were the limitations of the study discussed?	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y
Other
19. Were there any funding sources or conflicts of interest that might affect the authors’ interpretation of the results?	N	N	N	N	N	N	N	N	N	N	N	N
20. Was ethical approval or consent obtained from the participants?	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y

Author year	Goal	Sample	Groups	Methods training	Duration study	Frequency	Duration	Main Results Average (SD)
(de Groot et al.,²⁵25 de Groot PCE, Hjeltnes N, Heijboer AC, Stal W, Birkeland K. Effect of training intensity on physical capacity, lipid profile and insulin sensitivity in early rehabilitation of spinal cord injured individuals. Spinal Cord. 2003;41(12):673-9. 2003)	To evaluate the effect of training intensity on physical capacity, lipid profile, and insulin sensitivity in early rehabilitation of spinal cord injury (SCI) patients and to assess the correlation between peak aerobic capacity (VO₂peak) and insulin sensitivity.	6 SCI individuals.	1 - High intensity (HI; 70-80% of heart rate reserve (HRR)) 2 - Low intensity (LI; 40-50% HRR)	Arm training intervention (not specified) Repeated 3 min sessions of ACE (70-80%HRR)	8 weeks	3x week	20 min	Post-test values relative to pre-test values expressed in percent (SD). HI Group: %(SD) VO₂peak = 150 (24) Insulin sensitivity = 67 (9) TC/HDL ratio = 77 (6) Triglycerides = 69 (7) Group LI: %(SD) VO₂peak = 117 (4) Insulin sensitivity = 156 (55) TC/HDL ratio = 100 (20) Triglycerides = 95 (14)
(Tordi et al.,³³33 Tordi N, Dugue B, Klupzinski D, Rasseneur L, Rouillon JD, Lonsdorfer J. Interval training program on a wheelchair ergometer for paraplegic subjects. Spinal Cord. 2001;39(10):532-7. 2001)	It investigated the effects of a short-interval training program designed specifically for patients with spinal cord injuries.	5 Paraplegic man.	No group.	. Repeated 5-minute wheelchair ergometry sessions 50 and 80% PPO.	4 weeks	3x week	30-min	↑ VO₂peak (ml min kg/1): -Pre = 21 -Post = 24
								↑ HR peak (b min1): -Pre = 191 -Post = 183
								↑ VE peak (l min¹1 McDonald JW, Sadowsky C. Spinal-cord injury. Lancet. 2002;359(9304):417-25.): -Pre = 64 -Post = 78
								↑ O2p (ml b1): -Pre = 7.9 -Post = 9.9
(Brurok et al.,²⁶26 Brurok B, Helgerud J, Karlsen T, Leivseth G, Hoff J. Effect of aerobic high-intensity hybrid training on stroke volume and peak oxygen consumption in men with spinal cord injury. Am J Phys Med Rehabil. 2011;90(5):407-14. 2011)	To determine the effect of high-intensity interval training during combined arm cycling (ACE) exercise in individuals with spinal cord injury (SCI) and functional electrical stimulation of leg cycling (hybrid exercise), on peak systolic volume and peak oxygen consumption	6 men with SCI in stable neurological recovery (ASIA Impairment Scale grade A)	No Group	Hybrid cycling interval training. Repeated 4 min sessions of ACE + FES 85-90 %PPO.	8 weeks preceded by a 7-week control period of regular daily activity	3x week	Not reported	↑ at VO 2 peak.
								Hybrid Training VO₂pre = 1.96l/min VO₂post = 2.43l/min
								↑ SV (ml/beat) Pre= 83.2 (9.1) Post= 103.4 (17.1)
								Arm cycle training VO₂pre = 1.48L/min VO₂post = 2L/min
								FES leg cycling VO₂pre = 0.62L/min VO₂post = 0.78L/min
								↑ VE, liter/min: -Pre = 66.7 (24.4) -Post = 80.2 (29.4)
								↑ Peak HR: -Pre = 171 (12) -Post = 170 (26)
(Hasnan et al.,²⁹29 Hasnan N, Engkasan JP, Husain R, Davis GM. High-Intensity Virtual-reality Arm plus FES-leg Interval Training in Individuals with Spinal Cord Injury. Biomed Tech (Berl). 2013;58(Suppl 1). 2013)	To investigate the effect of “hybrid” high-intensity interval training (arm cycling and leg FES) in a virtual reality environment on aerobic fitness, power, lipid profiles, and glucose tolerance in people with LM.	8 individuals with SCI	No Group	Hybrid high-intensity interval training (HIT) using an arm tricycle + leg FES. Repeated 8 min sessions of ACE + FES 80-90 %HRmax.	6 weeks	2-3x week	32 min or 48 min	↑ VO₂peak mL-kg-1-min: Pre = 19.3(3.4) Post = 23.2(3.4)
		8 individuals with SCI	No Group		6 weeks	2-3x week	32 min or 48 min	Biochemical blood markers of cardiovascular risk, including total cholesterol, HDL, LDL, and oral glucose tolerance scores, remained unchanged after training, although some individuals observed modest improvements.
(Wouda et al.,²²22 Wouda MF, Lundgaard E, Becker F, Strøm V. Effects of moderate- and high-intensity aerobic training program in ambulatory subjects with incomplete spinal cord injury-a randomized controlled trial. Spinal Cord. 2018;56(10):955-63. 2018)	Investigate whether high-intensity interval training (HIIT) increases physical capacity and activity levels more than moderate-intensity training (MIT) and usual treatment.	25 men and 5 women with incomplete spinal cord injury.	MIT, HIIT and control.	The MIT group was instructed to exercise three times a week at 70% of HRmax, while the HIIT group was instructed to exercise twice a week at 85-95% of HRmax. The control group received treatment as usual.	12 weeks	3x week	35 min	↑ VO₂ peak.
								HIIT VO₂pre = 2.7 l/min VO₂post = 3 l/min
								MIT VO₂pre = 2.79l/min VO₂post = 3.23L/min
								Control VO₂pre = 2.78L/min VO₂post = 3.15L/min
(Gauthier et al.,³²32 Gauthier C, Brosseau R, Hicks AL, Gagnon DH. Feasibility, Safety, and Preliminary Effectiveness of a Home-Based Self-Managed High-Intensity Interval Training Program Offered to Long-Term Manual Wheelchair Users. Rehabil Res Pract. 2018;2018:8209360. 2018)	To investigate and compare the feasibility, safety and preliminary efficacy of high intensity interval training (HIIT) and moderate-intensity continuous training (MICT) programs in a self-managed manual wheelchair at home.	11 manual wheelchair users. Users with SCI.	HIIT and MICT	HIIT: Participants were asked to propel their wheelchair at a high and low intensity during 30 and 60 second intervals, respectively, and repeat this sequence 20 times over 30 minutes. During the 30-second high-intensity interval, participants needed to achieve an RPE between 6 and 8 (very difficult). Each high-intensity interval was followed by a low-intensity interval of 60 seconds at an RPE between 1 (very light) and 2 (light). MICT: Participants were then asked to propel their wheelchairs for 30 minutes at a constant speed, maintaining an RPE between 4 (somewhat difficult) and 5 (difficult).	6 weeks	3x week	40min	↑ in VO₂peak(ml.min)
		11 manual wheelchair users. Users with SCI.	HIIT and MICT		6 weeks	3x week	40min	HIIT Pre = 19.5(0.7) Post = 20.4(3.9) MICT Pre = 18.5 (6.8) Post = 18.9 (8.4)
(Astorino & Thum,³¹31 Astorino TA, Thum JS. Within-session responses to high-intensity interval training in spinal cord injury. Disabil Rehabil. 2018;40(4):444-9. 2018)	To examine enjoyment in response to CEX and HIIT differences in people with SCI.	9 habitually active men and women with SCI.	No Group	CEX (45%Wpico), SIT (105%Wpico), or HIIT (70%Wpico in random order.	2-3 weeks	3 sessions consisted of CEX, HIIT, or SIT, whose order was randomized. A minimum of 2 days and a maximum of 7 days apart each trial.	∼40 min	↑ VO₂peak.
								VO₂rest= 0.25-0.28 l/min.
								VO₂HIIT= 1.13l/min
								VO₂SIT= 1.02l/min.
								VO₂MCIT=0.90l/min.
(Astorino,²⁰20 Astorino TA. Hemodynamic and cardiorespiratory responses to various arm cycling regimens in men with spinal cord injury. Spinal Cord Ser Cases. 2019;5:2. 2019)	Determined hemodynamic and cardiorespiratory responses to different arm cycles in men with LM. hemodynamic responses compared to high intensity interval exercise (HIIE) and moderate-intensity continuous exercise (MICE)	5 men with LM.	MICE, HIIE and SIE	MICE: continuous cycling required at 35% PPO. HIIE consisted of repeated sessions of 60 s at 85% PPO with 120 s recovery at 10% PPO. SIE: 30 s sessions required at 115% PPO separated by 90 s recovery at 10% PPO.	1-2 weeks	5 randomized sessions	∼30min	↑ VO₂ peak.
								VO₂rest= 0.24l/min
								VO₂HIIE= 1.3(0.4) l/min
								VO₂SIE= 1.2(0.5) l/min.
								VO₂MICE=0.8(0.3) l/min
(Thum & Astorino,⁵¹51 Thum JS, Astorino TA. Greater enjoyment in two modes of high intensity interval training (hiit) compared to continuous exercise training (cex) in persons with spinal cord injury (sci). 2016;10:1-10. 2016)	Compare the changes in cardiorespiratory and metabolic variables between two regimes of interval training and moderate-intensity exercise	8 men and 1 woman with chronic LM.	No Group	MICT- 45%Wpico; HIIT- 70%Wpico; SIT- 105% Wpico.	2-3 week	The participants completed four exercise sessions in the lab. The sessions were held simultaneously between participants and were preceded by a 3-hour fast and 24-hour abstention from exercise.	MICT: 30min HIIT: 25min SIT: 25min	↑ in VO₂ peak. Effect size = 0.82
								VO₂pre= 0.25-0.28 l/min.
								VO₂post=
								HIIT= 1.13L/min
								SIT= 1.02L/min.
								MCIT=0.90L/min.
(KOONTZ,³⁰30 Koontz AM, Garfunkel CE, Crytzer TM, Anthony SJ, Nindl BC. Feasibility, acceptability, and preliminary efficacy of a handcycling high-intensity interval training program for individuals with spinal cord injury. Spinal Cord. 2021;59(1):34-43. 2021)	The objective of this study was to explore the feasibility of of a HIIT handcycling training program for wheelchair users with SCI.	7 men and 3 women with chronic SCI. 7 quadriplegics and 3 paraplegics.	No Group	The HIIT training sessions were held in the participant's home with a trainer from the study. HIIT: 90% PPO.	6 weeks	2x week	HIIT: 2x 25min. 10 hand-cycling intervals (1:1).	VO₂ peak: Average (SD)
								Baseline: 14.3 (5.0)
								Post-intervention: 14.3 (4.8)
								Peak power output (watts)
								Baseline: 60.0 (33.3)
								Post-intervention: 65.0 (38.5)
(McMillan et al.,²⁴24 McMillan DW, Maher JL, Jacobs KA, Nash MS, Bilzon JLJ. Physiological responses to moderate intensity continuous and high-intensity interval exercise in persons with paraplegia. Spinal Cord. 2021;59(1):26-33. 2021)	To test for differences in the duration and magnitude of the physiological response to the moderate isocaloric intensity continuous sessions (MICE) and high intensity interval exercise (HIIE) in people with spinal cord injury.	10 adult men with complete chronic paraplegia (T2-T10).	HIIT group and continuous moderate-intensity group (MICE)	HIIT Group: >80% VO₂peak during the work phase, with a peak intensity of ∼ 90% VO₂peak. MICE Group: 50% VO₂peak.	2 weeks	1 week.	HIIT: (80:10% POpeak 2:2 min)	MICE: Duration(min) 39.8(4.6) HRmax: 105(12) VO₂ml·kg−1min−1) 10.1(2.2) %VO₂peak 53(6.6) Energy expended (kcal): 115.9(21.8)
		10 adult men with complete chronic paraplegia (T2-T10).	HIIT group and continuous moderate-intensity group (MICE)		2 weeks	1 week.	HIIT: (80:10% POpeak 2:2 min)	HIIT Duration(min): 32.2(6.2) FCmax: 124(17) VO₂(ml·kg−1min−1): 12.6(3.1) %VO₂peak: 66.1(5.2) Energy expended (kcal): 116.6(35)

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[1] Correspondence: Carlos Mariano Aguiar Ferreira da Silva Universidade Federal do Pará, Laboratory of Adapted Physical Activity. 01, Augusto Corrêa, Guamá, Belém, PA, Brazil. 66075-110. carlosmarianoaguiar@outlook.com