Cardiorespiratory Fitness & Health Summary

Arm cranking (v no intervention) on cardiorespiratory fitness in people with SCI

evidence: Weak For Recommendation

Arm cranking may be provided to improve cardiorespiratory fitness in people with SCI.

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	Arm cranking (v no intervention) on cardiorespiratory fitness in people with SCI
P	People with SCI	Evidence recommendation Weak for (81%)	Weak evidence recommendation FOR Arm cranking may be provided to improve cardiorespiratory fitness in people with SCI. Clinical note: Arm cranking for cardiorespiratory fitness may not be appropriate for people with shoulder pain or overuse.
I	Arm cranking
C	No intervention	Consensus-based opinion statement No opinion statements
O	Cardiorespiratory Fitness
	SUMMARY	3 RCTs (see references)	Mean difference (95% CI): Cardiorespiratory fitness expressed as Vo2 Peak 4.7 (1.4 to 8.0) Favours arm cranking
	GRADE Very low certainty ⨁◯◯◯	Risk of bias Very serious	Inconsistency No serious	Imprecision No serious	Indirectness Serious	Publication bias Serious

ARM CRANKING ON CARDIORESPIRATORY FITNESS: GRADE Evidence to Decision
PROBLEM	No	Probably no	Probably yes	Yes		Don't know
DESIRABLE EFFECTS	Trivial	Small	Moderate	Large		Don't know
UNDESIRABLE EFFECTS	Large	Moderate	Small	Trivial		Don't know
CERTAINTY OF EVIDENCE	Very low	Low	Moderate	High		No included studies
HOW MUCH PEOPLE VALUE THE MAIN OUTCOME	Important uncertainty or variability	Possibly important uncertainty or variability	Probably no important uncertainty or variability	No important uncertainty or variability
BALANCE OF EFFECTS	Favours the Control	Probably favours the Control	Does not favour either the intervention (I) or the comparison (C)	Probably favours the I	Favours the I	Don't know
RESOURCES REQUIRED	Large costs	Moderate costs	Negligible costs and savings	Moderate savings	Large savings	Don't know
CERTAINTY OF EVIDENCE OF REQUIRED RESOURCES	Very low	Low	Moderate	High		No included studies
COST EFFECTIVENESS	Favours the comparison	Probably favours the comparison	Does not favour either the intervention or the comparison	Probably favours the intervention	Favours the intervention	No included studies
EQUITY	Reduced	Probably reduced	Probably no impact	Probably increased	Increased	Don't know
ACCEPTABILITY	No	Probably no	Probably yes	Yes		Don't know
FEASIBILITY	No	Probably no	Probably yes	Yes		Don't know

ARM CRANKING ON CARDIORESPIRATORY FITNESS: Randomised Controlled Trial Details
STUDY	COMPARISON	DOSAGE/DETAILS	PARTICIPANTS	N (Rx/C)	OUTCOME	ROB 2 PEDRo
AKKURT 2017	Arm cranking (plus usual care) V Usual care	3 days per week, 1.5 hours/week 50-70% pVO2 (A borg scale score of lightly hard-moderately hard	C7-L5 SCI	17/16	Vo2 peak	High Risk of Bias PEDro = 6/10
NIGHTINGALE 2018	Arm cranking (portable desktop ergometer) V No intervention	4 x per week for 6 weeks (moderate intensity)	Below T2 SCI	13/8	Vo2 peak	Some Concerns of Risk of Bias PEDro = 5/10
TAYLOR 1986	Arm cranking V No intervention	30 minutes, 5 x per week for 8 consecutive weeks (50rev/min)	paraplegia	5/5	Vo2 peak	High Risk of Bias PEDro = 5/10

Hand Cycling (v no intervention) on cardiorespiratory fitness in people with SCI

evidence: Weak For Recommendation

Hand cycling may be provided to improve cardiorespiratory fitness in people with SCI.

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	Hand Cycling (v no intervention) on cardiorespiratory fitness in people with SCI
P	People with SCI	Evidence recommendation Weak for (88%)	Weak evidence recommendation FOR Hand cycling may be provided to improve cardiorespiratory fitness in people with SCI. Clinical note: Hand cycling for cardiorespiratory fitness may not be appropriate for people with shoulder pain or overuse
I	Hand cycling
C	No intervention	Consensus-based opinion statement No opinion statements
O	Cardiorespiratory Fitness
	SUMMARY	1 RCT (see reference)	Mean difference (95% CI): Cardiorespiratory fitness expressed as Vo2 Peak 5.9 (3.7 to 8.1) Favours hand cycling
	GRADE Very low certainty ⨁◯◯◯	Risk of bias Serious	Inconsistency Serious	Imprecision No serious	Indirectness Serious	Publication bias Serious

HAND CYCLING ON CARDIORESPIRATORY FITNESS: GRADE Evidence to Decision
PROBLEM	No	Probably no	Probably yes	Yes		Don't know
DESIRABLE EFFECTS	Trivial	Small	Moderate	Large		Don't know
UNDESIRABLE EFFECTS	Large	Moderate	Small	Trivial		Don't know
CERTAINTY OF EVIDENCE	Very low	Low	Moderate	High		No included studies
HOW MUCH PEOPLE VALUE THE MAIN OUTCOME	Important uncertainty or variability	Possibly important uncertainty or variability	Probably no important uncertainty or variability	No important uncertainty or variability
BALANCE OF EFFECTS	Favours the Control	Probably favours the Control	Does not favour either the intervention (I) or the comparison (C)	Probably favours the I	Favours the I	Don't know
RESOURCES REQUIRED	Large costs	Moderate costs	Negligible costs and savings	Moderate savings	Large savings	Don't know
CERTAINTY OF EVIDENCE OF REQUIRED RESOURCES	Very low	Low	Moderate	High		No included studies
COST EFFECTIVENESS	Favours the comparison	Probably favours the comparison	Does not favour either the intervention or the comparison	Probably favours the intervention	Favours the intervention	No included studies
EQUITY	Reduced	Probably reduced	Probably no impact	Probably increased	Increased	Don't know
ACCEPTABILITY	No	Probably no	Probably yes	Yes		Don't know
FEASIBILITY	No	Probably no	Probably yes	Yes		Don't know

HAND CYCLING ON CARDIORESPIRATORY FITNESS: Randomised Controlled Trial Details
STUDY	COMPARISON	DOSAGE/DETAILS	PARTICIPANTS	N (Rx/C)	OUTCOME	ROB 2 PEDRo
KIM 2015	Indoor hand cycling V No intervention (usual activities)	Indoor hand bike - 60 minutes per day, 3 days per week for 6 weeks	C5-T11 SCI	8/7	Vo2 peak	Some Concerns of Risk of Bias PEDro = 5/10

Circuit training (v no intervention) on cardiorespiratory fitness in people with SCI

evidence: Weak For Recommendation

Circuit training may be provided to improve cardiorespiratory fitness in people with SCI.

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	Circuit training (v no intervention) on cardiorespiratory fitness in people with SCI
P	People with SCI	Evidence recommendation Weak for (100%)	Weak evidence recommendation FOR Circuit training may be provided to improve cardiorespiratory fitness in people with SCI.
I	Circuit training
C	No intervention	Consensus-based opinion statement No opinion statements
O	Cardiorespiratory Fitness
	SUMMARY	4 RCTs (see references)	Standardised Mean Difference (95% CI) 0.5 (0 to 0.9) Favours circuit training
	GRADE Very low certainty ⨁◯◯◯	Risk of bias Serious	Inconsistency No serious	Imprecision Very serious	Indirectness Serious	Publication bias Serious

CIRCUIT TRAINING ON CARDIORESPIRATORY FITNESS: GRADE Evidence to Decision
PROBLEM	No	Probably no	Probably yes	Yes		Don't know
DESIRABLE EFFECTS	Trivial	Small	Moderate	Large		Don't know
UNDESIRABLE EFFECTS	Large	Moderate	Small	Trivial		Don't know
CERTAINTY OF EVIDENCE	Very low	Low	Moderate	High		No included studies
HOW MUCH PEOPLE VALUE THE MAIN OUTCOME	Important uncertainty or variability	Possibly important uncertainty or variability	Probably no important uncertainty or variability	No important uncertainty or variability
BALANCE OF EFFECTS	Favours the Control	Probably favours the Control	Does not favour either the intervention (I) or the comparison (C)	Probably favours the I	Favours the I	Don't know
RESOURCES REQUIRED	Large costs	Moderate costs	Negligible costs and savings	Moderate savings	Large savings	Don't know
CERTAINTY OF EVIDENCE OF REQUIRED RESOURCES	Very low	Low	Moderate	High		No included studies
COST EFFECTIVENESS	Favours the comparison	Probably favours the comparison	Does not favour either the intervention or the comparison	Probably favours the intervention	Favours the intervention	No included studies
EQUITY	Reduced	Probably reduced	Probably no impact	Probably increased	Increased	Don't know
ACCEPTABILITY	No	Probably no	Probably yes	Yes		Don't know
FEASIBILITY	No	Probably no	Probably yes	Yes		Don't know

CIRCUIT TRAINING ON CARDIORESPIRATORY FITNESS: Randomised Controlled Trial Details
STUDY	COMPARISON	DOSAGE/DETAILS	PARTICIPANTS	N (Rx/C)	OUTCOME	ROB 2 PEDRo
BOMBARDIER 2000	Circuit training (telehealth) V No intervention	16 sessions of telehealth over 6 months	People with SCI	6/7	Vo2 Peak	Some Concerns of Risk of Bias PEDro = 6/10
HICKS 2003	Circuit training (Pushing, arm ergometry and PRE) V Sham (education)	Supervised progressive exercise 2 x weekly for 9 months. Each session 90-120 minutes	C4-L2 SCI	11/10	Power output in Watts	High Risk of Bias PEDro = 5/10
KIM 2019	Circuit training (Resistance and aerobic training) V No intervention	3 x weekly for 6 weeks. Each session was one hour	C5-T10 SCI	11/6	Vo2 Peak	Some Concerns of Risk of Bias PEDro = 6/10
MA 2019	Circuit training (Physical activity coaching including a programme) V No intervention	8 sessions, 1x week for 8 weeks. Each session was 140-180 minutes	People with SCI	14/14	Vo2 Peak	Some Concerns of Risk of Bias PEDro = 5/10

FES cycling (v no intervention) on cardiorespiratory fitness in people with SCI

consensus: Strong For Recommendation

FES cycling should be provided to improve cardiorespiratory fitness in people with SCI.

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	FES cycling (v no intervention) on cardiorespiratory fitness in people with SCI
P	People with SCI	Evidence recommendation No evidence recommendation Reason: No RCTs	Strong opinion statement FOR FES cycling should be provided to improve cardiorespiratory fitness in people with SCI.
I	FES cycling
C	No intervention	Consensus-based opinion statement Strong for (77%)
O	Cardiorespiratory Fitness

Combined arm cranking and leg cycling (plus or minus Electrical Stimulation) v no intervention to improve cardiorespiratory fitness in people with SCI

consensus: Strong For Recommendation

Combined arm cranking and leg cycling (plus or minus Electrical Stimulation) should be provided to improve cardiorespiratory fitness in people with SCI.

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	Combined arm cranking and leg cycling (plus or minus Electrical Stimulation) v no intervention to improve cardiorespiratory fitness in people with SCI
P	People with SCI	Evidence recommendation No evidence recommendation Reason: No RCTs	Strong opinion statement FOR Combined arm cranking and leg cycling (plus or minus Electrical Stimulation) should be provided to improve cardiorespiratory fitness in people with SCI
I	Combined arm cranking and leg cycling (plus or minus Electrical Stimulation)
C	No intervention	Consensus-based opinion statement Strong for (89%)
O	Cardiorespiratory Fitness

Individual or team sports (v no intervention) on cardiorespiratory fitness in people with SCI

consensus: Strong For Recommendation

Individual or team sports should be available to improve cardiorespiratory fitness in people with SCI.

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	Individual or team sports (v no intervention) on cardiorespiratory fitness in people with SCI
P	People with SCI	Evidence recommendation No evidence recommendation Reason: No RCTs	Strong opinion statement FOR Individual or team sports should be available to improve cardiorespiratory fitness in people with SCI.
I	Individual or team sports
C	No intervention	Consensus-based opinion statement Strong for (96%)
O	Cardiorespiratory Fitness

Wheelchair pushing (v no intervention) on cardiorespiratory fitness in people with SCI who are wheelchair dependent

consensus: Weak For Recommendation

Wheelchair pushing may be provided to improve cardiorespiratory fitness in people with SCI who are wheelchair dependent.

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	Wheelchair pushing (v no intervention) on cardiorespiratory fitness in people with SCI who are wheelchair dependent
P	People with SCI who are wheelchair dependent	Evidence recommendation No evidence recommendation Reason: No recommendation due to insufficient or inconclusive evidence.	Weak opinion statement FOR Wheelchair pushing may be provided to improve cardiorespiratory fitness in people with SCI who are wheelchair dependent. Clinical note: Wheelchair pushing for cardiorespiratory fitness may not be appropriate for people with shoulder pain or overuse.
I	Wheelchair pushing
C	No intervention	Consensus-based opinion statement Weak for (83%)
O	Cardiorespiratory Fitness (Vo2 peak)
	SUMMARY	1 RCT (see reference)	Mean Difference (95% CI) 0 (-0.2 to 0.1)
	GRADE Very low certainty ⨁◯◯◯	Risk of bias Serious	Inconsistency Serious	Imprecision Very serious	Indirectness Serious	Publication bias Serious

WHEELCHAIR PUSHING ON CARDIORESPIRATORY FITNESS: GRADE Evidence to Decision
PROBLEM	No	Probably no	Probably yes	Yes		Don't know
DESIRABLE EFFECTS	Trivial	Small	Moderate	Large		Don't know
UNDESIRABLE EFFECTS	Large	Moderate	Small	Trivial		Don't know
CERTAINTY OF EVIDENCE	Very low	Low	Moderate	High		No included studies
HOW MUCH PEOPLE VALUE THE MAIN OUTCOME	Important uncertainty or variability	Possibly important uncertainty or variability	Probably no important uncertainty or variability	No important uncertainty or variability
BALANCE OF EFFECTS	Favours the Control	Probably favours the Control	Does not favour either the intervention (I) or the comparison (C)	Probably favours the I	Favours the I	Don't know
RESOURCES REQUIRED	Large costs	Moderate costs	Negligible costs and savings	Moderate savings	Large savings	Don't know
CERTAINTY OF EVIDENCE OF REQUIRED RESOURCES	Very low	Low	Moderate	High		No included studies
COST EFFECTIVENESS	Favours the comparison	Probably favours the comparison	Does not favour either the intervention or the comparison	Probably favours the intervention	Favours the intervention	No included studies
EQUITY	Reduced	Probably reduced	Probably no impact	Probably increased	Increased	Don't know
ACCEPTABILITY	No	Probably no	Probably yes	Yes		Don't know
FEASIBILITY	No	Probably no	Probably yes	Yes		Don't know

WHEELCHAIR PUSHING ON CARDIORESPIRATORY FITNESS: Randomised Controlled Trial Details
STUDY	COMPARISON	DOSAGE/DETAILS	PARTICIPANTS	N (Rx/C)	OUTCOME	ROB 2 PEDRo
VAN DER SCHEER 2016	Wheelchair treadmill propulsion V No intervention	Wheelchair treadmill propulsion, twice a week (30 mins) for 16 weeks (30-40% HRR)	C4 to L5 SCI	12/13	Vo2 Peak	Some Concerns of Risk of Bias PEDro = 7

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The Australian and New Zealand Physiotherapy Guidelines for people with SCI was funded by icare NSW, National Injury Insurance Scheme Queensland, Transport Accident Commission Victoria, and Lifetime Support Authority South Australia.

Acknowledgement of Country – The Australian and New Zealand Clinical Practice Guidelines team acknowledges the Traditional Custodians of country throughout Australia and their connections to land, sea and community. We pay our respect to their Elders past and present and extend that respect to all Aboriginal and Torres Strait Islander peoples today.

Honouring Te Tiriti – Ethical approval, including Māori consultation through University of Otago, Christchurch, Te Komiti Whakarite (Canterbury District Health Board), and through Māori consultation (Counties Manukau District Health Board) was obtained for Phase 1 of the study. In developing these guidelines, we were committed to meeting our obligations under Te Tiriti and reflect the principles of tino rangatiratanga, equity, active protection, options, and partnership.