Effect of kayak ergometer training on trunk control, independence and the cardiovascular condition in individuals with a spinal cord injury

doi:10.21203/rs.3.rs-4877104/v1

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Effect of kayak ergometer training on trunk control, independence and the cardiovascular condition in individuals with a spinal cord injury

https://doi.org/10.21203/rs.3.rs-4877104/v1

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Study Design. One of the main objectives in spinal cord injury (SCI) rehabilitation programs is the improvement of trunk control to achieve independence, to prevent complications and, in specific cases, to walk.

Objective. To determine the effect of kayak ergometer training in trunk control, cardiovascular condition and independence in individuals with a spinal cord injury.

Setting. National Institute of Rehabilitation in Mexico City.

Methods. Randomized clinical trial double blinded study. Individuals with SCI of any etiology, with a neurologic level of C8 and below, with three months to one year since injury were included. The subjects were randomized to a control group with neuro proprioceptive facilitation exercises focused in trunk control and to an experimental group with kayak ergometer training. Both groups received 5 weekly sessions for 6 weeks.

Results. 18 individuals for each training group concluded the 6-week sessions, with an age of 29.33 ± 7.78 SD. 72.2% were men with complete injuries (77.8%), and the majority had lower thoracic injuries (58.4%). At the final measurements, the kayak ergometer group showed significant improvement in trunk control (p=0.032), maximum oxygen uptake ((p<0.001) and in metabolic equivalents (p=0.002) compared to the conventional therapy group.

Conclusions. Kayak ergometer training is superior to conventional exercise (to improve trunk control and cardiovascular function in individuals with SCI.

Health sciences/Health care/Therapeutics/Rehabilitation

Health sciences/Neurology/Neurological disorders/Spinal cord diseases

Spinal Cord Injury

trunk control

kayak ergometer

cardiovascular condition

Spinal Cord Injury (SCI) is a disturbance of the spinal cord that modifies not only muscular strength and sensitivity, but that also generates a change in all the systems of the organism(1, 2). Damage to the ascending and descending tracts of the spinal cord consequently gives rise to a disturbance in the postural control system(3). It is known that an effective postural control is extremely important for standing and walking(4), as well as to provide support for voluntary movements (5, 6). Alterations in posture depend on the grade and level of the injury; thus, persons with complete, thoracic, or cervical lesions have poor trunk control. Due to this, SCI individuals are limited in many movements that are necessary to perform activities of daily living (ADL) (7, 8). Therefore, part of the objectives of rehabilitation in individuals with an SCI includes improving trunk control to achieve independence in ADL, prevent serious complications such as pressure ulcers and neuromuscular deformities and, in specific cases, be able to walk (6–10).

On the other hand, patients with SCI tend to engage in a sedentary lifestyle that, added to the alterations in the autonomic nervous system due to the injury, exposes individuals with a SCI to a greater risk of developing chronic-degenerative conditions, such as metabolic syndrome and cardiovascular diseases, which are, at present, the main cause of death in these persons (11).

Thus, after the immediate rehabilitation, it is necessary to maintain and improve the functional capacity obtained during this process. Therefore, it is important to find training activities to challenge upper body stabilization and sitting balance, without exposing them to overuse injuries (12–14).

Kayak training appears to meet these criteria, as it involves most of the upper musculature, presents high metabolic demands, and imposes strict requirements for the balance control system, due to continuous compensation of the disturbances of the upper part of the body caused by movement (14). It was previously demonstrated that open-sea kayak training could be implemented in a group of paraplegic individuals and that this is accompanied by improvements in strength and sitting balance (15).

Due to the difficulty in controlling and adjusting the time and challenge level of the balance experienced by participants at subacute stages, it is necessary to use a kayak ergometer, in such a way that the balance demand m can be adjusted individually and according to this progressively increases the treatment advances. In this regard, Bjerkefors and Thorstensson demonstrated that kayak ergometer training in a group of persons with SCI is accompanied by an improvement in shoulder muscle strength and in various functional wheelchair tests that demand trunk stabilization and balance control (6, 16, 17).

These studies were able to demonstrate the positive effect of kayak training in patients with SCI. However, these studies included small populations (10 and 12 individuals), with chronic stage injuries, and the effects on trunk control were not evaluated using a scale validated in this population, nor the effects of training on cardiovascular function and functional independence.

To date, the effect of kayak ergometer training has not, to our knowledge, been studied in individuals with SCI in terms of trunk control with tools validated for persons with SCI, regarding the cardiovascular condition, functional independence, and quality of life, thus generating the need to carry out the present study that pretends to determine the effect of kayak ergometer training in patients with SCI on functionality, trunk control, cardiovascular condition, and quality of life.

Study design

Randomized controlled clinical trial blinded to the evaluator and to the person performing the data analysis.

Description of the population:

Inclusion criteria

Male and female patients were included, over 18 years old, who had a clinical diagnosis of a SCI of any American Spinal Injury Association Impairment Scale (AIS) grade and with a NLI under C8 (who were able to carry the oar), with any injury etiology, and between 3 months and 1 year after injury, who signed a letter of informed consent.

Elimination criterion

Participants whose assessments were incomplete, had non-assistance of 20% or more at training sessions, or acquired a new cardiovascular, orthopedic, or neurological pathology that impeded training.

Exclusion criteria

Individuals with another neurological diagnosis, visual, hearing or mental impairment, or with an orthopedic, metabolic, or cardiovascular condition that could impede carrying out the training.

Procedure.

After signing a consent letter, medical personnel trained in the evaluation and management of SCI obtained the individuals’ clinical and demographic variables.

Description of variables

Demographic variables included age and sex. Other clinical variables included any AIS grade, NLI defined as most caudal segment of the cord with intact sensation and antigravity muscle function strength, and time since injury defined as time in days from the SCI at the moment of applying the clinical tests for the descriptive analysis. Regarding the outcome measures, trunk control test (TCT) was performed in the physical therapy area to establish adequate and inadequate trunk control (cut-off of 13 points), the spinal cord independence measure III (SCIM-III) was used to assess independence; to measure life satisfaction we used the life satisfaction questionnaire (LiSAT-9); and for cardiovascular condition we measured metabolic equivalents (METs) and maximum oxygen uptake (Vo2max).

Randomization

Two training groups were formed with patients who attended the out-patient consultation service or were hospitalized at the SCI Service who met the inclusion and exclusion criteria. Assignment to the control group or to the experimental group was carried out randomly using sealed envelopes:

Group A. Control group, with conventional therapy to improve trunk control (proprioceptive neurofacilitation exercises focused on trunk control), 30 minutes five times weekly for 6 weeks.

Group B. Experimental group, with kayak training, 30 minutes five times weekly for 6 weeks.

Training description

Conventional therapy and kayak training were led by a single person with an undergraduate degree in physical therapy trained in proprioceptive neurofacilitation techniques and in kayak ergometer training, and with experience in the management of patients with SCI.

Kayak ergometer training included a 3-minute warm-up (Preload), training (load) of 3–5 medium-to-high intensity intervals of 2–4 minutes in duration, pauses of between 1 and 2 minutes between active phases, and 2 minutes cool down (post-load), for a total of 30 minutes of training.

STATISTICAL ANALYSIS

Statistical analysis was performed using of the SPSS/PC ver. 17 statistical software program. The results were considered statistically significant for p < 0.05. Descriptive statistics were performed with frequencies for qualitative variables and with mean and standard deviation (SD) for quantitative variables. To determine differences between groups, analysis of covariance was carried out.

A total of 40 patients were recruited, of which 20 were assigned to the kayak training group and 20 to the conventional therapy group. 2 patients from each group were eliminated for not completing at least 80% of the training sessions.

The average age of the subjects was 29.33 ± 7.78 SD with a range between 18 and 50. Most of the subjects were men (72.2%). In relation to the SCI, the majority had complete injuries (77.8%), followed by AIS B (19.4%) and D (2.8%) injuries, and the majority had lower thoracic injuries (58.4%). No baseline differences were found between the groups in relation to the characteristics of the SCI, sex or age, as seen in Table 1. The differences in the outcome measures between the groups are shown in Table 2.

Table 1

Baseline characteristics between groups
Variable	Control group	Kayak	p
Sex (men)	55.56%	88.89%	0.066
AIS A	66.67%	88.89%	0.076
NLI (lower thoracic)	62.5%	66.5%	0.657
Time of evolution	3	6	0.199
Age	31.72	28.21	0.295
AIS: ASIA impairment scale ; NLI: Neurologic Level of Injury

Table 2. Outcome measures between the groups

Variable

Baseline

Final

TCT

Kayak

Control

13.5

15.28

0.209

21.3

18.3

0.032

SCIM-III

Kayak

Control

46.56

51.56

0.006

53.18

58.94

0.47

LiSAT-9

Kayak

Control

36.83

35.94

0.446

45.65

43.37

0.353

METs (ml/kg/min)

Kayak

Control

6.5

4.7

0.06

8.2

5.6

0.002

Vo2max

Kayak

Control

23.1

17.3

0.322

30.8

20.6

<0.001

TCT: trunk control test; SCIM-III: Spinal Cord Independence Measure version III; Life Satisfaction Questionnaire (LiSAT-9); METs: metabolic rate; Vo2max: Maximum oxygen uptake.

In baseline functional independence there was a statistically significant difference, however, in the final score the difference was equal, which may suggest that the improvement in functionality in the kayak group improved until they reached the control group scores.

Our study supports the proposed hypothesis regarding improvement in trunk control and cardiovascular function.

Previous studies with a kayak ergometer, such as Bjerkefors and collaborators study, reported improvement in sitting, reaching, transfers and propulsion tests, however, they did not perform any resistance test. Grigorenko and collaborators carried out a study of kayaking in the open sea, in which they found non-significant changes in the center of gravity and speed, and subjective improvement in quality of life and balance while sitting. In our study we objectively assess and report trunk control, cardiovascular condition, functional independence, and life satisfaction (5, 6). In a study carried out by Garshick and collaborators, obtained results that suggest that a great part of mortality in chronic SCI is related to potentially treatable factors, such as the recognition and treatment of cardiovascular diseases, diabetes and lung disease, along with smoking cessation. In this way, mortality in chronic SCI can be substantially reduced. They also analyzed causes of death after SCI and identified that the main cause of death in individuals with thoracic SCI was due to lung diseases (pneumonia, airway obstruction, pleural injury and unspecified respiratory complications), contributing to 20% of the deaths. In patients with thoracic SCI, In patients with thoracic SCI, the main cause of death was due to cardiovascular diseases (heart failure, atrial fibrillation, atherosclerosis, ischemic heart disease, ventricular tachycardia, cerebral vascular disease, cardiomyopathy, abdominal aneurysm and pulmonary hypertension), contributing to 40.5% of deaths (12). Ginis and collaborators mention in the exercise guidelines for SCI patients, that to obtain benefits in terms of cardiorespiratory resistance and muscle strength, they must perform at least 20 minutes of aerobic exercise of moderate to vigorous intensity, 2 times a week; and 3 sets of strength exercises for each muscle group, of moderate to vigorous intensity, 2 times per week (13). Cragg and collaborators demonstrated in 2013 that individuals with SCI have a risk 2 to 3 times higher of suffering cerebral vascular disease and heart disease than the population without disabilities; and, identified smoking, diabetes mellitus, systemic arterial hypertension and obesity as related risk factors. In patients with SCI, altered blood pressure manifested as orthostatic hypotension or extreme hypertension documented during autonomic dysreflexia episodes. Theses researchers have speculated that blood pressure instability could result in vascular injury, and therefore increase the risk for vascular disease after SCI (14). It has been estimated that the risk of coronary artery disease and stroke is up to 3 times higher after SCI than in the general population, so implementing cardiovascular exercise in patients with SCI is relevant. For every MET gained, cardiovascular risk decreases by 13% (15). The ACMS (American College of Sports Medicine) guidelines recommend, regarding the assessment and prescription of aerobic exercise in patients with SCI, to carry out a stress test with arm crank or wheelchair treadmill ergometry, starting at 0W, with increments of 10 to 25 W per stage. To perform the exercise, they recommend starting with moderate intensity 40–59% of the RHR (heart rate reserve), progressing to vigorous intensity 60–90% of RHR, with 5–10-minute series alternating with 5 minutes of active recovery for at least 20 minutes, gradually increasing the time until 30–44 minutes per session is reached, 3 to 5 days per week, with a total of 90–150 minutes of exercise per week (11).

The WHO (World Health Organization) recommends at least 75 to 150 minutes of aerobic exercise per week with moderate to vigorous intensity in adults with disabilities. Physical inactivity is one of the main risk factors for mortality for non-transmissible diseases. Inactive people have 20–30% higher risk of death compared to people who are active enough. Regular physical activity improves muscular and cardiorespiratory fitness; improves bone health, reduces the risk of hypertension, coronary disease, stroke, diabetes, and many types of cancer (including breast and colon cancer); it also reduces the incidence of depression, helps to maintain a healthy body weight, reduces the risk of falls, and hip or vertebral fractures (17).

According to previous studies, intervention with therapeutic exercise should be used to reduce cardiovascular risk in patients with SCI. In our study we implemented 150 hours of cardiovascular exercise per week, finding satisfactory results in terms of cardiovascular condition, in addition to trunk control improvement.

LIMITATIONS

Among the limitations of the research are the lack of consideration of blood pressure, heart rate variability and recovery of heart rate after 1 and 3 minutes of rest, these data that are planned to be taken in the future by continuing with the research, as well as comparing kayaking with other type of aerobic exercise, and long-term follow-up of patients to assess the persistence of changes, adherence to aerobic exercise and decrease in cardiovascular complications.

Kayak ergometer training is superior to conventional exercise (proprioceptive neurofacilitation) to improve trunk control and cardiovascular function in individuals with SCI.

There is a tendency to also achieve a greater improvement in life satisfaction in the kayak group, however, this was not statistically significant, probably due to the size of the sample.

Spinal Cord Injury (SCI)

Trunk Control Test (TCT)

Activities of Daily Living (ADL)

Spinal Cord Independence Measure version III (SCIM-III)

Neurologic Level of Injury (NLI)

AIS (ASIA impairment scale)

Life Satisfaction Questionnaire (LiSAT-9)

Metabolic equivalents (METs)

Maximum oxygen uptake (Vo2max)

Standard deviation (SD)

AUTHOR CONTRIBUTIONS:

Author initials	Contribution
MARB	Recruiting and clinical evaluation Article writing and revision Interpretation of results Article Writing
JQF	Protocol design Statistical Analysis Interpretation of results Article Writing and revision
FMPR	Recruiting and clinical evaluation Article revision
WMTS	Recruiting and clinical evaluation Article revision
ABO	Recruiting and clinical evaluation Article writing and revision
VBR	Protocol design Data acquisition Kayak ergometer calibration
IQU	Protocol design Data acquisition
AIPSP	Data acquisition Kayak ergometer calibration
PJVA	Protocol design Data acquisition
RGG	Conventional therapy Kayak ergometer training
CECC	Recruiting and clinical evaluation Article writing and revision

FUNDING:

The project was financed by CONACYT-SALUD-2015-02-261647

ETHICAL APPROVAL:

The study has been approved by the local institutional review board, with the study ID number: 74/15.

Clinical trials: NCT03531164.

COMPETING INTERESTS

The authors declare no competing interests.

ADDITIONAL INFORMATION

Correspondence and requests for materials should be addressed to Jimena Quinzaños-Fresnedo

DATA AVAILABILITY STATEMENT:

The data generated or analyzed during this study are available from the corresponding author on reasonable request.

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There is no duality of interest

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Effect of kayak ergometer training on trunk control, independence and the cardiovascular condition in individuals with a spinal cord injury

Status:

Version 1

Abstract

INTRODUCTION

METHODS

Description of the population:

Description of variables

Randomization

Training description

STATISTICAL ANALYSIS

RESULTS

DISCUSSION

LIMITATIONS

CONCLUSION

Abbreviations

Declarations

References

Additional Declarations

Status:

Version 1