Tele-exercise in individuals with spinal cord injury: a systematic review

Introduction

The coronavirus disease 2019 (COVID-19) pandemic led to the emergence of alternative methods of delivering physical activity, including tele-exercise. Tele-exercise, defined as interventions providing remote physical training, is a form of telehealth that encompasses both synchronous and asynchronous approaches (1). Synchronous methods involve real-time services between participants and professionals through simultaneous video conferences or phone conversations. This approach offers benefits, such as enhanced accessibility and real-time feedback. Asynchronous methods, on the other hand, offer an alternative to traditional synchronous technologies, allowing communication without the need for real-time interaction and providing benefits such as flexibility in scheduling, as well as addressing administrative and financial issues (2,3).

The pandemic highlighted the vulnerability of individuals, particularly those with several neuromuscular impairments and mobility restrictions, who often experience limited access to healthcare and physical activity opportunities. This disparity aligns with the World Health Organization’s (WHO) call to strengthen the reporting of physical activity data and reduce inequalities. The WHO advocates for innovative research to develop physical activity initiatives that enable the full and effective participation of people living with disabilities, including those with spinal cord injury (SCI) (4).

Globally, over 15 million people live with SCI, a condition caused by damage to the spinal cord resulting in complete or incomplete loss of sensory and/or motor functions (5). Individuals with SCI often engage in lower levels of physical activity due to several barriers, including transportation challenges, financial constraints, limited awareness or access to adapted options, and insufficient professional guidance (6,7). However, physical activity offers numerous benefits for this population, including improved physical and emotional well-being, reduced secondary impairments, minimized disabilities, and enhanced quality of life (8,9).

In line with WHO recommendations, studies have explored using technology to assess and deliver physical activity to individuals with disabilities, demonstrating its potential to overcome barriers and achieve health benefits (10,11). Tele-exercise, specifically, has emerged as a promising intervention of regular physical activity program (12). The tele-exercise can be included as part of a tele-rehabilitation program or offered as a regular physical activity program. Regular physical activity involves engaging in exercise to improve health, fitness, and quality of life, which corroborates the WHO proposal to seek alternatives that help people with disabilities overcome barriers to adherence to regular physical activity (3,4).

Given the potential of tele-exercise as a physical activity program for individuals with SCI, this study aims to characterize research on tele-exercise interventions in this population. This characterization focuses on the approach (synchronous, asynchronous, or hybrid), platform, intervention details, duration, adherence, outcomes, and improvements. The present study followed the PRISMA reporting checklist (available at https://mhealth.amegroups.com/article/view/10.21037/mhealth-24-50/rc).

Methods

The methodology section details the organized system employed to locate, filter, and interpret the relevant literature for this review of tele-exercise intervention in individuals with SCI.

Data sources and search strategy

This study conducted a literature search using the Embase, Scopus, and PubMed databases. The search terms used were “tele-exercise” and “teleexercise”.

The term “spinal cord injury” was not included in the initial search to avoid excluding studies with diverse disability samples where SCI might be one of the diagnoses. However, the sample of each study was subsequently checked to confirm the presence or absence of individuals with SCI.

Besides, the intervention was subsequently checked to confirm if tele-exercise was a regular physical activity program.

Study selection criteria

The search was limited to English-language articles with no lower date limit and an upper publication date of April 31, 2024, coinciding with this study’s data collection period. Articles in poster or editorial format and grey literature were excluded. The decision was made to exclude gray literature and focus solely on studies published in peer-reviewed scientific journals.

Study selection process

The initial search yielded 187 articles. After removing duplications, 85 unique articles were identified. One article was excluded due to insufficient available information. Among the remaining 84 articles, 14 were deemed relevant to SCI after a full-text evaluation. Two studies were further excluded for not meeting the inclusion criteria, resulting in 12 articles considered for this review. Figure 1 illustrates the article selection process.

Figure 1 Flow diagram of studies identification and inclusion.

Data extraction

Two reviewers (B.L.R. and R.R.G.C.) independently screened the titles and abstracts of the initially retrieved articles, and then discussed them to ensure agreement. Subsequently, the reviewers assessed the full text of these articles against the pre-defined inclusion criteria (13). Data were extracted on several key parameters, including study location, number of participants, duration, type, and whether the research focused exclusively on SCI or included other populations. Additionally, information on participant characteristics (age and sex), tele-exercise devices, technology used, outcomes measured, and intervention duration was extracted.

Data items

The data items were the approach (synchronous, asynchronous, or hybrid), platform, intervention details, duration, adherence, outcomes, and improvements.

Statistical analysis

The Shapiro-Wilk normality test was used to assess the distribution of intervention duration and adherence. Adherence, being a parametric outcome, was presented as mean and standard deviation. Intervention duration, considered non-parametric, was presented as median and interquartile range (25^th and 75^th percentiles). Approach, platform, intervention, outcome, and improvement data were expressed as frequencies. Analyses were conducted using Jamovi statistical software (version 2.3, The Jamovi project, Sidney, Australia).

Results

The initial search yielded 187 articles. After duplicates were removed, 85 articles remained for title and abstract screening. Upon applying selection criteria, this was narrowed down to 12 articles (1,3,10,11,14-21) included in this review (Figure 1). These comprised seven intervention studies, three project proposals, one cross-sectional analysis, and one theoretical framework.

Table 1 details the study and participant characteristics. The studies were categorized as follows: projects (studies that did not execute an intervention); interventions (complete longitudinal studies); and theoretical frameworks (studies that analyzed existing knowledge and previously formed ideas. The studies were conducted in Brazil (n=3) (3,10,11), the United States (n=7) (14-20), and the United Kingdom (n=2) (1,21). The number of participants ranged from 4 (1) to 165 (15). All studies that reported on sex included both men and women in their samples.

Additionally, the study populations consisted exclusively of individuals with SCI, except for two studies. One study included individuals with SCI, stroke, and older adults without disabilities but with walking difficulties (11), while the other included individuals with traumatic brain injury, stroke, multiple sclerosis, SCI, spina bifida, Parkinson’s disease, or cerebral palsy (14). Eleven articles were published between January 2021 and April 2024, with one exception published in 2016.

Approach

The majority of studies (58.3%) utilized a synchronous approach (1,10,11,14,16,19,20). In contrast, 16.7% of studies used an asynchronous approach (15,21). Another 16.7% of studies combined synchronous and asynchronous components (3,18), while 8.3% used a hybrid approach, incorporating both live and independent exercise sessions (17).

Platform

Several different platforms were used for tele-exercise interventions (Table 2). Zoom teleconferencing software was used in 5 studies (41.7%) (14,16,17,19,20). Google Meets teleconferencing software and the WhatsApp messaging app were used together in 2 studies (16.7%) (3,11). Each of the following platforms was used in 1 study (8.3%): Accessercise smartphone fitness app (21), a custom wireless internet-based system (1), multiple communication channels (including the Canva program), the movement-to-music program videoconference-delivered exercise software (18), a Google Meets teleconferencing software (10), and the Spinal Cord Injury Program in Exercise website (15).

Intervention

The intervention data are shown in Table 2. For individuals with SCI, the tele-exercise interventions aimed predominantly at aerobic training (91.7%) (1,3,10,11,14-20), and muscle strength training (83.3%) (3,10,11,14-20). Balance training was the third most prevalent intervention (58.3%) (14-20), followed by mindfulness (41.7%) (14,16,17,19,20) and flexibility training (25.0%) (14,15,18). Body awareness (16) and behavior change (21) were the least prevalent interventions, representing 8.3%. The sum of all percentages exceeds 100% because some studies implemented more than one intervention.

Duration

The median (percentile 25 and 75) of the duration of intervention was 8.0 (8.0–12.0) weeks. Three studies were cross-sectional studies and did not report a duration (11,20,21).

Adherence

Only five studies reported information on adherence (Table 2). The mean (standard deviation) adherence was 67.3% (18.7). One study reported adherence separately for men and women, with rates of 56.6% and 37.4%, respectively (10). Another study showed adherence by approach, with 66.7% for synchronous and 50.0% for asynchronous tele-exercise (3).

Outcome

The main outcomes assessed in the studies were physical activity level (58.3%) (1,14-16,18-20), adherence (33.3%) (1,3,10,18), pain (25.0%) (15,16,18), and physical activity behavior (18,20,21) and quality of life (25.0%) (14-16) (Table 2). Other outcomes, each representing 16.7% of studies, included exercise self-efficacy (19,20), expectation for exercise (19,20), successful exercise recording (1,3), aerobic fitness (1,14), fatigue (15,18), and sleep (15,18). Additionally, 8.3% of studies focused on feasibility (17), mood (16), meets the SCI exercise guidelines (10), training load (3), sedentary behavior (21), subjective well-being (1), acute performance decrement (11), blood pressure (18), lower extremity function (14), social participation (14), and muscle strength (14) (Table 2).

Improvement

Nine studies assessed the improvement after tele-exercise interventions in SCI (Table 2). These studies demonstrated improvement in various variables that can be categorized in health status (blood pressure, exercise self-efficacy, subjective well-being, fatigue, mood, pain, quality of life, sleep, and social participation) (1,16,19,20), physical activity status (physical activity behavior, sedentary behavior, physical activity level, expectations for exercise) (1,16,19,21), physical capacity (aerobic fitness, acute performance decrement, lower extremity function, strength, training load) (1,11), and implementation of tele-exercise (acceptability, adherence, feasibility, and, successful exercise recording) (1,3,10,17).

Discussion

The present study aimed to characterize research on tele-exercise interventions in individuals with SCI. The most prevalent approach was synchronous (58.3%), and the most common platform utilized was teleconference software (Zoom) (48.7%). The primary intervention types focused on strength and aerobic training (75%), with a typical intervention duration of 8.0 (8.0–12.0) weeks. Adherence varied considerably (45.1% to 100.0%). The most frequently assessed outcome was physical activity level (58.3%), and tele-exercise interventions demonstrated improvements in health status, physical activity levels, physical capacity, and implementation outcomes.

Tele-exercise for individuals with SCI demonstrated a greater frequency of synchronous (58.3%) than asynchronous (16.7%) approaches. Notably, combined or hybrid approaches were also present in 16.7% of studies, similar to the frequency of purely asynchronous approaches. This finding demonstrated the potential to combine the advantages of both approaches. For example, synchronous tele-exercise offers real-life interaction with a professional, which is considered a critical component of motivation (1). On the other hand, asynchronous approaches allow opportunities for exercise data to be saved after internet disconnection and resumed once connection is restored, and additionally, the participant can set the time that is most convenient for them (1). Gomes Costa et al. (3) found that the synchronous approach presents higher values of training load, adherence, and successful exercise recording when compared to the asynchronous approach. Future studies could include hybrid and combined models in this comparison.

Regarding the platform, most studies (58.4%) utilized video conferencing software such as Google Meet and Zoom. This demonstrates the feasibility of using readily available video communication tools for telerehabilitation rather than specialized software. However, none of the studies evaluated the perception of individuals with SCI regarding the use of these tools, highlighting an important area for future research.

Aerobic and strength training were the predominant interventions, which corroborates with SCI exercise guidelines recommending these modalities for this population (22,23). In fact, one study in this review implemented a 7-month tele-exercise intervention for individuals with tetraplegia due to SCI and found that it met the moderate-intensity recommendations proposed by SCI exercise guideline (10). These data reinforce the use of tele-exercise as a viable alternative for regular physical activity and suggest that it can even meet the exercise recommendations for this population.

The duration of tele-exercise interventions varied between 6 and 30 weeks, with a median (25^th and 75^th percentile) of 8.0 (8.0–12.0) weeks. This finding highlights the flexibility in intervention duration, including longer periods, such as the 30-week intervention in one study (10). This particular study demonstrated the feasibility of a 30-week intervention not only for individuals with SCI but also for those with a greater degree of impairment, as it included participants with tetraplegia. This indicates that even individuals with significant physical limitations can participate in tele-exercise programs for extended periods.

Although only five studies reported adherence values, the mean (standard deviation) was 67.3% (18.7), which is comparable to the 85.2% (8.3) adherence rate found in a study with a face-to-face exercise program for individuals with SCI (1,3,10,17,19). However, other face-to-face studies have reported lower adherence rates (24-26). For example, in Thailand, only 14.5% of individuals with SCI met aerobic guidelines, 20.5% met strength training guidelines, and 13.5% met both aerobic and strength training SCI-specific physical activity guidelines (24). In Switzerland, 48.9% of people with SCI met the WHO recommendations on physical activity (25), and in Canada, only 12% of adults with SCI met the guidelines for physical activity (26). Another relevant finding was the sex difference in adherence, with male adherence higher than female. This finding could be explained by women feeling significantly less control over their physical activity behavior and having lower confidence to overcome barriers to physical activity than men (27). Finally, the synchronous approach was found to have greater adherence than the asynchronous approach. This finding can help professionals choose which approach to use and set realistic expectations for participant adherence.

The studies in the review presented different outcomes, most frequently assessing physical activity level (58.3%), adherence (33.3%), pain (25.0%), and physical activity behavior (25.0%). This emphasis on physical activity-related outcomes demonstrates a concern with investigating changes in exercise habits. In other words, analyzing these outcomes can help determine whether tele-exercise effectively addresses barriers to accessing physical activity for individuals with SCI, as recommended by the WHO (4). The focus on pain as an outcome may reflect a priority for ensuring participant safety and avoiding any harm during the interventions.

Finally, based on the improvements observed in this review, it can be concluded that tele-exercise in individuals with SCI demonstrated benefits across various domains, including health status, physical activity status, and physical capacity. Furthermore, it is a feasible and implementable intervention, demonstrating adherence, acceptability, and feasibility.

Study limitations

The present review did not assess the quality of the selected studies. Additionally, to understand the characteristics of the interventions, studies that were only projects or theoretical frameworks were included. Consequently, these studies did not contain information on outcomes or results. Future studies are suggested to address these limitations through a systematic review or meta-analysis format, which would allow for a more comprehensive evaluation of the effectiveness of tele-exercise interventions in individuals with SCI.

Conclusions

Tele-exercise interventions for individuals with SCI are characterized as adherent, acceptable, and feasible. They offer health status, physical activity status, and physical capacity benefits. These interventions are predominantly synchronous, often utilizing teleconference software, focusing primarily on strength and aerobic training, with a mean intervention duration of 8.0 weeks. These findings demonstrate the relevance of tele-exercise as a viable alternative to regular physical activity among individuals with SCI who face barriers to incorporating exercise into their routines.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the PRISMA reporting checklist. Available at https://mhealth.amegroups.com/article/view/10.21037/mhealth-24-50/rc

Peer Review File: Available at https://mhealth.amegroups.com/article/view/10.21037/mhealth-24-50/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://mhealth.amegroups.com/article/view/10.21037/mhealth-24-50/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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