Physical Activity Table 1 Physical Activity and Adaptations to Muscle Morphology and Strength

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Author Year Country Score Research Design Total Sample Size	Methods	Outcome
Muscle Morphology
Carvalho et al. 2008 Brazil Downs & Black score=21 Prospective Controlled Trial N=15	Population: Traumatic SCI: Gender=All male: Mean age= 31.95±8.01 years: Mean body mass= 63.52±9.41 kg: Mean height= 176.28±5.28 cm: Mean time post-injury= 66.43±48.23 months Treatment: Gait group (n=8): Treadmill gait training at 0.5 km/h (increased according to individual’s capacity) with partial body weight support (BWS) and neuromuscular electrical stimulation (NMES) delivered by a custom built four-channel stimulator(200V at 25Hz with 300ms duration). Training was performed during 6 months, twice a week, for 20 min each session. Control group (n=7) : individuals performed only conventional physiotherapy, twice a week for 6 months without using NMES. Outcome Measures:MRI of bilateral thighs was performed in all participants, to determine the average cross sectional area (CSA) of quadriceps and mean value of gray scale. Outcomes were obtained. at baseline and at the end of treatment (6 months).	At moment of inclusion in this study, the average CSA values for the gait group and control group did not differ significantly. After 6 months, a significant increase of 15% quadriceps CSA occurred in the gait group. A 7.7% increase in gray scale value was also observed but was not statistically. In the control group, no significant change in CSA or gray scale value was found after 6 months, but a there was a noteworthy decrease in gray scale value of 11.4% .
Scremin et al. 1999 USA Downs & Black score=21 Pre-Post N=13	Population:Gender: 13 males; age (range): 24-46; level of injury (range): C5-L1; AIS: A lesion; time since injury (range): 2-19 Treatment:3 phase, FES induced, ergometry exercise program. Phase 1: quadriceps strengthening; phase 2: progressive sequential stimulation to achieve a rhythmic pedaling motion; phase 3: FES induced cycling for 30 minutes. Outcome Measures:Muscle cross-sectional area and proportion of muscle and adipose tissue measured at baseline, at the first follow-up (mean 65.4 weeks), and at second follow-up (mean 98.2 weeks)	The cross sectional area of the rectus femoris increased by 31% (p<0.001), the sartorius increased by 22% (p<0.025), the adductor magnus- hamstrings increased by 26% (p<0.001), the vastus lateralis increased by 39% (p=0.001), and the vastus medialis-intermedius increased by 31% (p=0.025). The cross-sectional area of the adductor longus and gracilis muscles did not change. The ratio of muscle to adipose tissue increased significantly in thighs and calves.
Sabatier et al. 2006 USA Downs & Black score=21 Pre-Post N=5	Population:Gender: 5 male, age (mean): 35.6; AIS: A complete; time since injury: at least 5 years (mean:13.47±6.5) Treatment:Patients underwent 18 wks of home-based neuromuscular electrical stimulation (NMES) resistance training on the quadricpes muscle group 2x week with 4 sets of 10 dynamic knee extensions against resistance while in a seated position Outcome Measures:Femoral arterial diameter resting blood flow, blood velocity, and neuromuscular fatigue. All measurements were made before training and after 8, 12, and 18 weeks of training.	Training resulted in significant increases in weight lifted and muscle mass and a 60% reduction in muscle fatigue (P=0.001). Femoral arterial diameter did not increase (P=0.70). Resting, reactive hypermic, and exercise blood flow did not appear to change with training. Quadriceps femoris muscle CSA was increased in both theighs after 18 weeks. The right thigh the mean QF CSA was significantly increased from 32.6 to 44.0 cm² (P<0.05), and the left QF was increased from 34.6 to 47.9 cm² (P<0.05) which is a 35% and 39% increase in CSA respectively.
Kern et al. 2010 Austria Downs & Black score=19 Pre-Post N=25	Population:Gender: 20 males, 5 females; age (range): 20-55; length of injury (range): 0.7-8.7 years; complete conus cauda syndrome Treatment:Muscles of patients were electrically stimulated at home by large surface area electrodes and a custom designed stimulator. Outcome Measures:Force induced by electrical stimulation, isometric knee extension torque, force measurements, area and density of quadriceps mucle and hamstring, tissue type distribution recorded before, at 1 year, and after the 2 years of training	Similar increase in muscle excitability and contractility in the both legs. Improved feasibility to elicit tetanic contractions with about ten times improvement. Myofiber size increased by 94% after 2 years of FES. Functional class improved to a level 4 for 20% of the subjects. After 2 years of home-based FES, the degenerative phase of LMN denervation was delayed or reverted.
Griffin et al. 2009 USA Downs & Black score=19 Pre-Post N=18	Population: Traumatic SCI:Gender: Male=13, Female= 5: Mean age= 40±2.4 years: Time post-injury= 11±3.1 years. Treatment:FES cycling performed on an Ergys2 automated recumbent bicycle 2–3 times per week for 10 weeks. Outcome Measures:Total body mass, lean muscle mass, AIS scores, Glucose and insulin levels, LDL.	Training week had a statistically significant effect on the ride time without manually assisted pedaling. Ride times during training weeks 5–10 were statistically greater than during week 1. Total body mass(3%) and lean muscle mass(4%) significantly increased, while, there was no significant difference in bone or adipose tissue following the 10 weeks of training Lower extremity total AIS scores and the motor and sensory components of the AIS test were all significantly higher following training Glucose and insulin levels were influenced by the time after dextrose consumption and training: levels were significantly greater at 30, 60 and 120 min after dextrose consumption compared to the baseline value at time 0. Also glucose and insulin levels at 60 and 120 min after dextrose consumption were significantly lower during the post-test values compared to the pre-test values Statistically significant reductions occurred in CRP, IL-6 and TNF-a occurred following training. LDL cholesterol, total cholesterol and triglyceride levels did not change, while HDL cholesterol fell slightly.
Carvalho et al. 2009 Brazil Downs & Black score=19 Cohort N=7	Population: Traumatic SCI: Gender=All male: Control Group(n=7); ): Mean age= 32.8±3.5 years: Mean body mass= 65.5±10.6 kg: Mean height= 176.8±8.4 cm: Mean time post-injury= 55.3± 10.6 months Treatment: Individuals performed conventional physiotherapy, twice a week without using NMES for 6 months. After 6 months, the CG was provided an additional 6 months of gait training without NMES. Outcome Measures:MRI of bilateral thighs was performed in all participants, to determine the average cross sectional area (CSA) of quadriceps. Outcomes were measured 6 months post intervention.	1 year post Carvalho et al. 2008 intervention no significant changes were observed in the quadriceps CSA in individuals receiving conventional physiotherapy.
Giangregorio et al. 2006 Canada Downs & Black score=18 Pre-Post N=14	Population:Chronic Incomplete SCI: Tetraplegic=11, Paraplegic=3; Gender: m =11, f=3; Mean age = 29 yrs; Mean time post injury – 7.7 yrs; ASIA: C = 12, B = 2. Treatment:Body weight supported treadmill training (BWSTT) program - 144 sessions, 3 x/wk. Outcome Measures:Lean body mass; Muscle cross sectional area (CSAs).	BWSTT training ↑ whole body lean mass (p<0.003). ↑ muscle CSAs in the thigh (4.9%) and lower leg (8.2%).
Willoughby et al. 2000 USA Downs & Black score=17 Pre-Post N=10	Population:Gender: 5 men, 3 women; age (range): 16.8-49.8; injury level (range): C4-T12; time since injury (range):1-9.4; AIS: A and C. Treatment:12 week exercise program using the Psycle ergometer. Training occured 2 days a week at 75% of each subject’s maximum heart rate. Outcome Measures:Thigh girth, body weight, and body mass index measured before and after training.	mRNA expression had a significant increase in expression of MHC types IIa and Iix, and significant decreases in the expression for UBI, E2, and 20S. The overall mean decrease for body weight and BMI from pretraining to post training decreases for all eight subjects1.82±4.4% and 1.40±1.3%, respectively. There was also an increase of 63.08%, 49.47%, and 61.39% that were significantly different for α-actin (t(7)=2.61 (p=0.0413), MHC type II a (t(7)=3.04 (p=0.0188), and MHC type II x (t(7)=2.51 (p=0.0405) respectively.
Heesterbeek et al. 2005 The Netherlands Downs & Black score=16 Pre-post N=10	Population:Chronic Paraplegic; Gender: m=9, f=1; Mean age= 39.3 yrs; Mean time post injury= 10.5 yrs; ASIA: A =9, C =1. Treatment: Exercise program – 4 wks, trained 8-12x in total. Each session contained a 5-min warm-up, 30-min hybrid (voluntary arm and FES-assisted leg) cycling & a 5-min cool-down. Outcome Measures:Leg Volume; Graded Hybrid Exercise Test (GHT) - peak power output (PO_peak); Power of the legs (defined by delta power); all @ baseline & 4 wks.	Leg Volume: Upper left leg: 8.3% ↑ (p=0.018) Upper right leg: 8.5% ↑ (p=0.047) Low legs did not change. PO_peak: ↑ 9.3% (p=0.015). Power of legs: did not change
Chilibeck et al. 1999 Canada Downs & Black score=14 Pre-post N=6	Population: Chronic SCI: Gender: m=5, f=1; Age range: 31-50 years; Time range post injury=3-25 yrs. Treatment: FEStraining with a leg cycle ergometer- 30 min, 3 days/wk for 8 wks. Outcome Measures: Work rate, duration & total work output/exercise per session; Muscle fibre composition & area; Capillarization.	Mean fibre area: ↑ 23% after training (p<0.05) Capillarization: capillary-to-fibre ratio ↑ 39% (p<0.05) & capillaries contacted with each fibre ↑ 29% (p<0.05). Mean work rate: ↑ from 0 to 5.1 watts (p<0.05) from baseline to 8 wks. Mean duration: continuously pedal without assistance ↑ from 4.3 min to 21.2±5.6 min after training (p<0.05). Mean total work output: ↑ from 0 to 9.2 KJ at 8 wks (p<0.05).
Crameri et al. 2002 Denmark Downs & Black score=14 Pre-post N=6	Population:Chronic complete paraplegic; Gender: m=5, f=1; Age rage= 28-43; Time range post injury=8-36 yrs. Treatment:FES leg cycle ergometry training- 30min/day, 3x/wk, for 10 wks. Outcome Measures: Incremental exercise leg test to muscle fatigue (total work output); Histological assessment; Myosin heavy chain (MHC); Citrate synthase and hexokinase.	Paralysed vastus lateralis muscle was altered with ↑ type IIA fibres, ↓ type IIX fibres ↓ MHC IIx and ↑ MHC IIa (p<0.05). Total mean fibre cross-sectional area ↑ 129%, ↑ cross-sectional area of type IIa and IIx fibres (p<0.05). Number of capillaries surrounding each fibre ↑ (p<0.05). Citrate synthase and hexokinase activity ↑ (p<0.05). Total work performed: ↑ after training (p<0.05)
Mohr et al. 1997 Denmark Downs & Black score=14 Pre-post N=10	Population: Chronic Complete SCI: Tetraplegic= 6, Paraplegic=4; Gender: m=8, f=2; Age range= 27-45 yrs; Time range post injury= 3-23 yrs. Treatment: 1 yr exercise training using an FES cycle ergometer (30 min/day, 3 days/wk). Outcome Measures: Total work output; Muscle properties; @ baseline & 1 yr.	12% ↑ in thigh muscle mass over 1 yr. Muscle atrophy found @ baseline partially improved by 1 yr. 4 fold ↑ in total work output.
Sloan et al. 1994 Australia Downs & Black score=14 Pre-post Initial N=12; Final N=9	Population: SCI: Complete=1, Incomplete=11; Gender: m=7, f=5; Age range=15-54 yrs; Time range post injury: 2 -138 mos. Treatment:Electrical stimulation induced cycling programme: 3x/wk for 3 mos, all programmes were individualized & gradual progressed to 30 min/each. Outcome Measures:Quadriceps muscle area & Thigh muscle area – cross sectional analysis (CSA); Neurological muscle charts; @ baseline & 3 mos.	Muscle size: ↑ Quadriceps CSA (p<0.05) ↑ Total thigh CSA (p<0.05) Muscle strength: ↑ Voluntary isometric strength (p<0.05) ↑ Stimulated isometric strength (p<0.05)↑ Stimulated quadriceps endurance (p<0.05) ↑ Quadriceps & biceps femoris grading (p<0.05). Cycling improvement: 9/9 ↑ cycling time by a mean of 11.7 min 8/9 ↑ cycling load by a mean of 30N. Speed=constant
Giangregorio et al. 2005 Canada Downs & Black score=13 Pre-post N=5	Population: Tetraplegic; Gender: m=2, f=3; Age range: 19-40 years; Time range post injury= 66-170 days ASIA: B=4, C=1. Treatment: Body-weight supported treadmill training (BWSTT). Initial session started at 5mins, ↑ gradually to 10-15mins in all but 1 participant during 2x/wk-training over a period of 6-8 mos. Outcome measures:Muscle cross-sectional area (CSA) done pre & post treatment; Average adherence.	↑ muscle CSAs were seen in all patients. Total body lean mass and fat mass ↑. Partial reversal of muscle atrophy was seen. Average adherence = 78%.
Crameri et al. 2004 Denmark Downs & Black score=22 Prospective controlled trial N=6	Population: Chronic complete paraplegic; Age range= 26-54yrs; Time range post injury = 3-21 yrs. Treatment: FEStraining 45 min/day, 3 days/wk, for 10 wks. One leg: dynamic cycle ergometry involved bilateral quadriceps and hamstring stimulation; Contralateral leg: isometric contractions. Outcome Measures: Muscle biopsies; Capillary-to-fibre ratio; Muscle proteins; Oxygenation.	The isometric-trained leg showed significantly larger mean improvements force, type 1 fibres, fibre cross-sectional area, capillary-to-fibre ratio, citrate synthase activity & relative oxygenation after static training, in comparison to baseline & the dynamically trained leg. These changes reflect the importance of load in the amount of adaptation to FES.
Hjeltnes et al. 1997 Norway Downs & Black score=12 Pre-post N=5	Population: Chronic Complete Tetraplegics; Gender: m=5; Mean age= 35 yrs; Mean time post injury=10.2 yrs. Treatment: 8 weeks of FES leg cycling, 7X/week. Outcome Measures:Cross sectional area (CSA) of multiple muscles.	21.3%↑ from 267cm² to 324cm²in muscle cross-sectional area for hamstrings, quadriceps, gluteus maximus & gluteus medius muscles (p<0.05).
Mahoney et al. 2005 USA Downs & Black score=11 Pre-post N=10	Population:Chronic SCI; Gender: m=, 5; Mean age=35.6 yrs; Mean time post injury=13.4 yrs. Treatment: Residence-based, resistance exercise training (RET)with thighs for 12 wks, 2d/wk for 4 sets of 10 unilateral, dynamic knee extensions. RET induced extensions via neuromuscular electric stimulation. Outcome Measures: Muscle cross sectional area (CSA) - quadriceps femoris; @ baseline & 12 wks.	Muscle CSA: 35% ↑ in right quadriceps femoris (32.6cm²@ baseline to 44.0cm² @ 12 wks) 39%↑ in left quadriceps femoris (34.6cm² @ baseline to 47.9cm² @ 12 wks) (p<0.05).
Stewart et al. 2004 Canada Downs & Black score=10 Pre-post N=9	Population: Incomplete SCI; Gender m= 8, f=1; Mean time post injury=8.1 yrs Treatment: Body weight-supported treadmill training, 3 day/wk for 6 mos. Outcome Measures: Treadmill performance;Muscle biopsy – Fibre type & Myosin heavy chain (MHC) analysis.	Muscle biopsy: ↑ mean muscle-fibre area of type I & IIa fibres (p<0.001) ↓ in mean type IIax/IIx fibres (p<0.05) ↓ IIx myosin heavy chain (p<0.05) ↑ mean type IIa fibres (p<0.01) Treadmill performance: 135% ↑ treadmill velocity (p<0.05) 55%, ↑ in session length (p<0.05) amount of externally supported weight ↓ as the result of training (p<0.05)
Strength
Needham-Shropshire et al. 1997 USA/CA PEDro=8 RCT Initial N=43; Final N=32	Population: Chronic Tetraplegic; Gender: m=31, f=3; Mean range = 18-45yrs; Mean time post injury =3yrs. Treatment: Subjects randomly assigned to one of three groups: Group 1 – received 8 wks of neuromuscular stimulation (NMS) assisted arm ergometry exercise. Group 2 – received 4 wks of NMS assisted exercise, and then 4 wks of voluntary arm crank exercise. Group 3 (control group) – voluntary exercise for 8 wks without the application on NMS. Outcome Measures:Manual muscle test.	No significant difference was found at the 4-week evaluation between Groups 1 and 2 or between Groups 2 and 3. Subjects in Group 1 had a higher proportion of muscles improving one or more muscle grades after 4 weeks of NMS cycling compared with Group 3 (p<0.003). Following the second 4 weeks of training, a significant difference was found between Groups 1 and 3 (p<0.0005) and between Groups 2 and 3 (p<0.03). No statistical difference was found between Groups1 and 2.
Glinsky et al. 2008 Australia PEDro=8 RCT Initial N= 32 Final N= 29	Population: Experimental group: Gender; M= 12, F= 3; Mean age= 37±16 years : Control group; Gender; M= 15, F= 1; Mean age= 47±20 years Treatment: Experimental group carried out a progressive resistance exercise program on one wrist 3 times a week for 8 weeks. It consisted of three sets of 10 repetition maximum of one wrist muscle group, which was increased if the participant could do more than 10 repetitions and decreased if 10 repetitions were not achieved. Control group received routine physiotherapy and occupational therapy with no progressive resistance exercises program for the wrist. Outcome Measures:Strength measured as maximal voluntary isometric torque in Nm, muscle endurance measured as fatigue resistance and participants’ perceptions about use of their hands using the Canadian Occupational Performance Measure (COPM). Measurements were taken at the beginning of the program and at end of 8 weeks.	No statistically significant evidence was found to suggest that progressive resistance exercise does or does not increase strength and/or endurance. Although, a 11% increase in mean initial muscle endurance and a 8% increase in mean initial strength was noted in the experimental group compared to the control group The activities of daily living most frequently selected by participants as part of COPM assessment were using cutlery and lifting objects such as bottles and cups. The mean effects of progressive resistance exercise on these activities were –0.3 for participants’ perceptions of performance and –0.3 for participants’ satisfaction. This indicates that the experimental group did not perceive that progressive resistance exercise improved performance of or satisfaction with their activities of daily living compared with the control group.
Hicks et al. 2003 Canada Downs & Black score=20 PEDro=5 RCT Initial N=34; Final N=24	Population:Chronic SCI; Age range= 19-65 yrs; C4-L1; Time range post injury=1-24 yrs. Treatment:Experimental group (EX) participated in progressive arm ergometry exercise training and progressive resistance training in several upper body muscle groupstwice weekly for 9 months-each session offered on alternative days lasing 90-120 minutes. Outcome Measures: Muscle strength.	Following training, EX group had 81% ↑ sub maximal arm ergometry power output (p<0.05) & 1-35% ↑ in upper body muscle strength (p<0.05). Overall 11 in the EX group (exercise adherence 82.5%) and 13 in the control group completed the study.
Jacobs et al. 2009 USA PEDro=5 RCT N=18	Population:Traumatic SCI: RT Group: Male= 6, Female= 3; Mean age= 33.7±8.0 years; Body mass= 72.3±18.3 kg: ET group: Male= 6, Female= 3; Mean age= 29.0±9.9 years; Body mass= 83.7±8.9 kg Treatment:Subjects participated in a series of testing sessions before and after a 12-wk training period. Patients were randomly assigned to two groups. The endurance training (ET) group performed 30 min of arm cranking exercise using a Saratoga arm crank device during each session at 70%–85% of HR_peak. The resistance training (RT) group performed three sets of 10 repetitions at six Hammer Strength MTS exercise stations (including horizontal press, horizontal row, overhead press, overhead pull, seated dips, and arm curls) with an intensity of ranging from 60% to 70% of 1 repetition maximum (1RM). Outcome Measures: VO_2peak, Graded exercise test (GXT) were assessed at baseline and at end of treatment (12 week).	Significant effects of both modes of training (RT and ET) in the physiological responses to peak GXT were observed. Muscular strength significantly increased for all exercise maneuvers in the RT group with no changes detected in the ET group VO_2peak values were significantly greater after RT (15.1%) and ET (11.8%). Both RT and ET study groups displayed significant increases in P_peak and P_mean. Mean power increased 8% and 5% for the RT and ET groups, respectively, with no statistically significant differences apparent between groups. RT produced significantly greater gains in P_peak (15.6%) compared with ET (2.6%). The RT group displayed significantly increased strength values ranging from 34% to 55% for the six exercise maneuvers. In contrast, the ET group did not display increases in muscular strength for any of the six exercises after 12 wk of training.
Bjerkeforrs A et al. 2006 Sweden Downs & Black score=20 Pre-Post N=20	Population: Traumatic SCI: Gender; Male= 14, Female= 6: SCI Group(n=10): M= 7, F=3; Mean age= 38±12 years; Body mass= 70.8±13.9 kg: Reference Group(n=10) ; Gender: M=7, F=3; Mean age= 35±10 years; Body mass= 76.5±12.7 kg Treatment:10-week period of kayak ergometer training using commercially available kayak ergometer (Dansprint, I Bergmann A/S, DK). Every week subjects completed 3x60 mins training session periods (30 sessions in total) of kayak ergometer training. Outcome Measures:Shoulder muscle strength	There was a main effect of kayak ergometer training with increased shoulder muscle strength (in the beginning and middle positions and independent of shoulder movement) after training in persons with SCI. There was no interaction between training, movement and angular position or between training and movement, but an interaction was observed between training and angular position. The SCI group had a lower shoulder muscle strength compared to the reference group but the difference was not statistically significant to draw conclusions.
Hartkopp et al. 2003 Denmark Downs & Black score=20 Prospective controlled trial N=18	Population:Gender:8 men, 4 women; HR: age (range): 29-55; time since injury (range): 5-38 years; level of injury: C-5/6. LR: age (range): 32-44, time since injury (range): 4-27; Treatment:Wrist extensor muscles were stimulated (30min/day X 5 days/wk X 12 wks) using either a high-resistance (Hr group) or low-resistance (Lr group) protocol. Outcome Measures:strength and endurance of contractile properties, muscle metabolism, fatigue resistance measured at baseline and 12wks	Maximum voluntary torque increased in the Hr group (P<0.05), but not the Lr group. For the Hr group the electrically stimulated peak tetanic torque increased only at 15Hz (P<0.1), and the Lr group remained unchanged. Resistance to fatigue increased (P<0.05) in both the Hr (42%) and Lr (41%). For the Hr group, the cost of contraction decreased by 38% (P<0.05) and the half-time of phosphocreatine recovery was shortened by 52% (P<0.05). Electrical stimulation of the wrist increases fatigue resistance independent of the training pattern, but only in the Hr group does increased muscle strength improve aerobic metabolism after training.
Griffin et al. 2009 USA Downs & Black score=19 Pre-Post N=18	Population: Traumatic SCI:Gender: Male=13, Female= 5: Mean age= 40±2.4 years: Time post-injury= 11±3.1 years. Treatment:FES cycling performed on an Ergys2 automated recumbent bicycle 2–3 times per week for 10 weeks. Outcome Measures:Total body mass, lean muscle mass, AIS scores, Glucose and insulin levels, LDL.	Training week had a statistically significant effect on the ride time without manually assisted pedaling. Ride times during training weeks 5–10 were statistically greater than during week 1. Total body mass(3%) and lean muscle mass(4%) significantly increased, while, there was no significant difference in bone or adipose tissue following the 10 weeks of training Lower extremity total AIS scores and the motor and sensory components of the AIS test were all significantly higher following training Glucose and insulin levels were influenced by the time after dextrose consumption and training: levels were significantly greater at 30, 60 and 120 min after dextrose consumption compared to the baseline value at time 0. Also glucose and insulin levels at 60 and 120 min after dextrose consumption were significantly lower during the post-test values compared to the pre-test values Statistically significant reductions occurred in CRP, IL-6 and TNF-a occurred following training. LDL cholesterol, total cholesterol and triglyceride levels did not change, while HDL cholesterol fell slightly.
Duran et al. 2001 Colombia Downs & Black score=16 Pre-post N=13	Population: Paraplegic; Gender: m=12. f=1; Age range= 17-38yrs; Time range post injury=2-120 mos; ASIA: A=11, B=1, C=1. Treatment:16 wk exercise program (4 wks of adaption, 1 wk of enhancement, 11 wks specific program)- 3x/wk, 120 min/session, containing mobility, coordination, strength, aerobic resistance and relaxation exercises. Outcome Measures: Max. Strength of Upper Limbs: max. Weight mobilized in one trial or number of reps on 30 secs; Progressive resistance arm crank test: 3 min warm up @ 0 watts, resistance ↑ every 2 min; done pre & post program.	Weight lifted pre-program vs. post-program: Bench press - 46% ↑, 42.7 vs. 62.5 (p=0.0001) Military press - 14% ↑, 60.0 vs. 68.3 (p=0.0002) Butterfly press- 23% ↑, 52.3 vs. 64.2 (p=0.0001). Repetitions pre-program vs. post-program: Biceps (dumbbell) - 10%↑, 26.7 vs. 29.4 (p=0.0001) Triceps (dumbbell) - 18% ↑, 35.8 vs. 42.4 (p=0.0001) Shoulder abductors- 61% ↑, 8.8 vs. 14.2 (p=0.0001) Abdominal in 1' - 33% ↑, 47.0 vs. 62.4 (p=0.009) Curl back neck - 19% ↑, 112.3 vs. 134.0 (p=0.0001) Arm Crank Test: Max. resistance ↑ from 90 watts to 110 watts post-program (p<0.001).
Nash et al. 2007 USA Downs & Black score=16 Pre-post N=7	Population: Chronic Complete Paraplegic; Gender: m=7; Age range= 39-58 yrs; Mean time post injury= 13.1 yrs. Treatment:Circuit resistance training (CRT), 45/min, 3x/wk on non-consecutive days, for 16 wks. Training consisted of low-intensity endurance activities, circuit resistance training, military press, horizontal rows, pectoralis (horizontal row), preacher curls, wide-grip latissimus pull-downs, and seated dips. Outcome Measures: Wingate Anaerobic test (power assessment); Strength testing; all @ baseline & 16 wks.	Anaerobic power: 6% ↑ in peak power (p=0.005) 8.6% ↑ average power (p=0.001). Strength: ↑ on all maneuvers from 38.6% to 59.7% (p<0.001).
Jacobs et al. 2001 USA Downs & Black score=15 Pre-post N=10	Population: Chronic Paraplegic; Gender: m=10; Mean age =39.4 yrs; Mean time post injury=7.3 yrs. Treatment: 12-wk training program – 40-45 min sessions, 3x/wk on non-consecutive days. Sessions included resistance training (weight lifting) and endurance training (arm cranking). Outcome Measures:Isoinertial strength testing; Isokinetic strength testing; @ baseline 4, 8 & 12 wks.	16.1% ↑ peak power output (p<0.05). Isoinertial strength: Mean 21,1% ↑ after 12 wks (p<0.01) Improvements noted every month. Isokinetic strength: ↑ after 12 wks for the shoulder joint internal rotation, extension, abduction, adduction & horizontal adduction (p<0.05).
Petrofsky et al. 2000 USA Downs & Black score=13 Prospective controlled trial N=90 (9/group)	Population: Paraplegic; Gender: m=90; Mean age= 24.9 yrs. Treatment: 10 wk training period – consisted of electrical stimulation of quad muscle with 10 groups examining different variations of session length, frequency of sessions and length of flexion-extension cycle used in exercise program. Outcome Measures:Isometric strength; 3 experiments were designed looking at: 1) the effect of the length of the training session on performance; 2) the number of days of training/wk on performance; 3) the effect of the length of the extension-flexion cycle on training	Length of training session: Greatest ↑ in work capacity in group training for 30min/day vs. 5 or 15 min/day (p<0.01). 30 min/day group: rate ↑of training was more rapid. Quad muscle strength was greater in 30 min/day group than others Number of days training/wk: Working out 3 days/wk benefitted more than those that worked out for 1 day/wk or 5 days/ wk. Those that worked out 3 & 5 days/wk were significantly more improved (p<0.01). 3 days/wk had greater isometric strength in the quads. Length of extension-flexion cycle: ↑training effect was assessing training by total work which would be done over the 30 min pd.
Gregory et al. 2007 USA Downs & Black score=11 Pre-post N=3	Population: Chronic SCI: 2 Tetraplegic, 1 Paraplegic; Gender: m=3; Age range= 22-61; Time range post injury= 17-27 yrs; ASIA: D=3 Treatment: 12 wks of lower extremity resistance training in combination with plyometer training (RPT) (2-3 x/wk for 30 sessions) Outcome Measures: Muscle max cross-sectional area (max-CSA) of knee extensor (KE) & plantar flexor (PF)- MRI; Peak isometric torque, time to peak torque (T20–80), torque developed in initial 220 ms of contraction (torque220) & mean rate of torque development (ARTD) -Dynamometry; Voluntary activation deficits.	Peak torque production improved following RPT in KE (M=28.9%) & PF (M=35%). ↓ T (20-80), ↑ torque (220) & ↑ mean rate of torque development in both muscle groups. PF & KE voluntary activation deficits ↓ following RPT.
Cameron et al. 1998 USA Downs & Black score=9 Pre-post N=11	Population:Chronic SCI: Gender m=10, f=1; Age range: 18-45yrs; Level of injury= C4-C7. Treatment: Testing of hybrid device, 8 wks of neuromuscular stimulation-assisted exercise with training sessions 3x/wk. Outcome Measures:Manual muscle test scores biceps, triceps, wrist flexors and extensors.	All subjects showed improvement in one or more of their manual muscle scores, with the most dramatic occurring in the triceps (mean ↑ 1.1 for L triceps, 0.7 for R triceps) Results show neuromuscular stimulation in combination with resistive exercise can be used safely and assists in the strengthening of voluntary contractions