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Study Design: Interviews using the benefit-harm trade-off method and an online survey., Objectives: To determine the smallest worthwhile effect (SWE) of motor training on strength for people with spinal cord injury (SCI)., Setting: SCI units, Australia., Methods: Forty people with recent SCI who had participated in motor training as part of their rehabilitation program (patient participants) and 37 physiotherapists (physiotherapist participants) working in SCI were recruited. The patient participants underwent an iterative process using the benefit-harm trade-off method to determine the SWE of motor training on strength. The physiotherapist participants were given an online survey to determine the SWE for five different scenarios. Both groups considered the SWE of a physiotherapy intervention involving an additional 12 h of motor training for 10 weeks on top of usual care. They were required to estimate the smallest improvement in strength (points on the Total Motor Score of the International Standards for Neurological Classification of SCI) to justify the effort and associated costs, risks or inconveniences of the motor training., Results: The median (interquartile range) smallest improvement in strength that patient and physiotherapist participants deemed worth the effort and associated costs, risks or inconveniences of the motor training was 3 (1-5) points, and 9 (7-13) points, respectively., Conclusions: People with recent SCI are willing to devote 12 h a week for 10 weeks to motor training in addition to their usual care to gain small changes in strength. Physiotherapists wanted to see greater improvements to justify the intervention., (© 2024. The Author(s).)

Study Design: A multi-centred, single-blinded randomised controlled trial., Objectives: To determine the effect of 10,000 voluntary contractions over 8 weeks on the strength of very weak muscles in people with spinal cord injury (SCI)., Settings: Seven hospitals in Australia and Asia., Methods: One hundred and twenty people with recent SCI undergoing inpatient rehabilitation were randomised to either a Treatment or Control Group. One major muscle group from an upper or lower limb was selected if the muscle had grade 1 or grade 2 strength on a standard six-point manual muscle test. Participants allocated to the Treatment Group performed 10,000 isolated contractions of the selected muscle group, as well as usual care in 48 sessions over 8 weeks. Participants allocated to the Control Group received usual care alone. Participants were assessed at baseline and 8 weeks by a blinded assessor. The primary outcome was voluntary muscle strength on a 13-point manual muscle test. There were three secondary outcomes capturing therapists' and participants' perceptions of strength and function., Results: The mean between-group difference of voluntary strength at 8 weeks was 0.4/13 points (95% confidence interval -0.5 to 1.4) in favour of the Treatment Group. There were no notable between-group differences on any secondary outcome., Conclusion: Ten thousand isolated contractions of very weak muscles in people with SCI over 8 weeks has either no or a very small effect on voluntary strength.

Background: Obesity is associated with an increased risk of falls in older women. However, it is not certain whether factors commonly associated with obesity and falls mediate this risk., Research Question: Do lower-limb muscle quality, foot loads and postural control mediate the relationship between obesity and falls in women aged 60 years and older?, Methods: At baseline, 246 female participants underwent obesity screening (BMI≥30 kg/m²), and measurements of muscle quality (isokinetic dynamometer and dual-energy X-ray absorptiometry), foot loads (pressure platform) and postural balance (force platform). Incident falls were recorded at the end of the 18-month follow-up period via participant recall. To test whether, and to what extent, biomechanical factors mediated the relationship between obesity and falls, the Natural Indirect Effects (NIE), Natural Direct Effect (NDE) and proportion mediated were calculated using the counterfactual approach. Significance level was set at p < .05., Results: 204 participants (83 %) completed the follow-up. As expected, obesity was associated with a higher risk of being a faller (RR: 2.13, 95 % CI: 1.39-3.27). Using the counterfactual approach, only specific torque (NIE: 1.11, 95 % CI: 1.01-1.38) and flatfoot (NIE: 1.10, 95 % CI: 1.01-1.32) were significant mediators of the relationship between obesity and falls. Specific torque and flatfoot mediated 19 % and 21 % of the relationship, respectively., Significance: Lower-limb muscle quality (specific torque) and foot loads (flatfoot) mediate the relationship between obesity and falls in older women. The inclusion of muscle strengthening and podiatry interventions as part of a fall prevention program may benefit this population., Competing Interests: Declaration of Competing Interest The authors have no conflict., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Study Design: Pretest-posttest design., Objectives: To investigate mechanisms by which short-term resistance training (6 weeks) increases strength of partially paralysed muscles in people with spinal cord injury (SCI)., Setting: Community-based setting, Sydney, Australia., Participants: Ten community-dwelling people with partial paralysis of elbow flexor, elbow extensor, knee flexor or knee extensor muscles following SCI (range 5 months to 14 years since injury)., Methods: Muscle architecture and strength were assessed before and after participants underwent a six week strength-training program targeting one partially paralysed muscle group. The outcome of primary interest was physiological cross sectional area (PCSA) of the trained muscle group measured using magnetic resonance imaging (MRI) and diffusion tensor imaging (DTI). Other outcomes were changes in mean muscle fascicle length, muscle volume, pennation angle, isometric strength and muscle strength graded on a 13-point scale., Results: The mean increase in maximal isometric muscle strength was 14% (95% CI, -3 to 30%) and 1.5 points (95% CI, 0.5 to 2.5) on the 13-point manual muscle test. There was no evidence of a change in muscle architecture., Conclusion: This study is the first to examine the mechanisms by which voluntary strength training increases strength of partially paralysed muscles in people with SCI. The data suggest that strength gains produced by six weeks of strength training are not caused by changes in muscle architecture. This suggests short-term strength gains are due to increased neural drive or an increase in specific muscle tension.

Study Design: A systematic review., Objective: The aim of this review was to determine the effectiveness of physiotherapy (PT) interventions for increasing voluntary muscle strength in people with spinal cord injuries (SCI)., Methods: We included randomised controlled trials of PT interventions for people with SCI. We were interested in two comparisons: PT interventions compared with sham or no intervention, and PT interventions compared to each other. The outcome of interest was voluntary strength of muscles directly affected by SCI. All included studies were rated according to the Cochrane Risk of Bias Tool and results of similar trials were pooled using meta-analyses where possible., Results: Twenty-six trials met the inclusion criteria and provided useable data. A statistically significant between-group difference was found in four comparisons, namely, resistance training versus no intervention (standardised mean difference (SMD) = 0.64; 95% CI, 0.22-1.07; p = 0.003); resistance training combined with electrical stimulation versus no intervention (mean difference (MD) = 14 Nm; 95% CI, 1-27; p = 0.03); a package of PT interventions versus no intervention (MD = 4.8/50 points on the Lower Extremity Motor Score (LEMS); 95% CI 1.9-7.7; p = 0.01); and robotic gait training versus overground gait training (MD = 3.1/50 points on the LEMS; 95% CI, 1.3-5.0; p = 0.0008)., Conclusion: There is evidence that a small number of PT interventions increase voluntary strength in muscles directly affected by SCI.

Questions: Do interventions involving repetitive practice improve strength after stroke? Are any improvements in strength accompanied by improvements in activity?, Design: Systematic review of randomised trials with meta-analysis., Participants: Adults who have had a stroke., Intervention: Any intervention involving repetitive practice compared with no intervention or a sham intervention., Outcome Measures: The primary outcome was voluntary strength in muscles trained as part of the intervention. The secondary outcomes were measures of lower limb and upper limb activity., Results: Fifty-two studies were included. The overall SMD of repetitive practice on strength was examined by pooling post-intervention scores from 46 studies involving 1928 participants. The SMD of repetitive practice on strength when the upper and lower limb studies were combined was 0.25 (95% CI 0.16 to 0.34, I 2 =44%) in favour of repetitive practice. Twenty-four studies with a total of 912 participants investigated the effects of repetitive practice on upper limb activity after stroke. The SMD was 0.15 (95% CI 0.02 to 0.29, I 2 =50%) in favour of repetitive practice on upper limb activity. Twenty studies with a total of 952 participants investigated the effects of repetitive practice on lower limb activity after stroke. The SMD was 0.25 (95% CI 0.12 to 0.38, I 2 =36%) in favour of repetitive practice on lower limb activity., Conclusion: Interventions involving repetitive practice improve strength after stroke, and these improvements are accompanied by improvements in activity., Review Registration: PROSPERO CRD42017068658. [de Sousa DG, Harvey LA, Dorsch S, Glinsky JV (2018) Interventions involving repetitive practice improve strength after stroke: a systematic review. Journal of Physiotherapy 64: 210-221]., (Copyright © 2018 Australian Physiotherapy Association. All rights reserved.)

Question: What is the effect of adding an intensive task-specific hand-training program involving functional electrical stimulation to a combination of usual care plus three 15-minute sessions per week of one-to-one hand therapy in people with sub-acute tetraplegia?, Design: A parallel group, randomised, controlled trial. Participants were randomly assigned (1:1) via a computer-generated concealed block randomisation procedure to either a control or experimental intervention., Participants: Seventy people with C2 to T1 motor complete or incomplete tetraplegia within 6 months of injury. Participants were recruited from seven spinal units in Australia and New Zealand., Intervention: Experimental participants received intensive training for one hand. Intensive training consisted of training with an instrumented exercise workstation in conjunction with functional electrical stimulation for 1hour per day, 5 days per week for 8 weeks. Both groups received usual care and 15minutes of one-to-one hand therapy three times per week without functional electrical stimulation., Outcome Measures: The primary outcome was the modified Action Research Arm Test reflecting arm and hand function, which was assessed at the end of the intervention, that is, 11 weeks after randomisation. Secondary outcomes were measured at 11 and 26 weeks., Results: Sixty-six (94%) participants completed the post-intervention assessment and were included in the primary intention-to-treat analysis. The mean (SD) modified Action Research Arm Test score for experimental and control participants at the post-intervention assessment was 36.5 points (SD 16.0) and 33.2 points (SD 17.5), respectively, with an adjusted mean between-group difference of 0.9 points (95% CI -4.1 to 5.9)., Conclusion: Adding an intensive task-specific hand-training program involving functional electrical stimulation to a combination of usual care plus three 15-minute sessions per week of one-to-one hand therapy does not improve hand function in people with sub-acute tetraplegia., Registration: Australian and New Zealand Trial Registry ACTRN12609000695202 and ClinicalTrials.gov NCT01086930. [Harvey LA, Dunlop SA, Churilov L, Galea MP, Spinal Cord Injury Physical Activity (SCIPA) Hands On Trial Collaborators (2017) Early intensive hand rehabilitation is not more effective than usual care plus one-to-one hand therapy in people with sub-acute spinal cord injury ('Hands On'): a randomised trial. Journal of Physiotherapy 63: 197-204]., (Copyright © 2017 Australian Physiotherapy Association. Published by Elsevier B.V. All rights reserved.)

Study Design: Within-participant randomised controlled trial., Objectives: To determine whether strength training combined with usual care increases strength in partially paralysed muscles of people with recent spinal cord injury (SCI) more than usual care alone., Settings: SCI units in Australia and India., Methods: Thirty people with recent SCI undergoing inpatient rehabilitation participated in this 12-week trial. One of the following muscle groups was selected as the target muscle group for each participant: the elbow flexors, elbow extensors, knee flexors or knee extensors. The target muscle on one side of the body was randomly allocated to the experimental group and the same muscle on the other side of the body was allocated to the control group. Strength training was administered to the experimental muscle but not to the control muscle. Participants were assessed at baseline and 12 weeks later. The primary outcome was maximal isometric muscle strength, and the secondary outcomes were spasticity, fatigue and participants' perception of function and strength., Results: There were no dropouts, and participants received 98% of the training sessions. The mean (95% confidence interval (CI)) between-group difference for isometric strength was 4.3 Nm (1.9-6.8) with a clinically meaningful treatment effect of 2.7 Nm. The mean (95% CI) between-group difference for spasticity was 0.03/5 points (-0.25 to 0.32)., Conclusion: Strength training increases strength in partially paralysed muscles of people with recent SCI, although it is not clear whether the size of the treatment effect is clinically meaningful. Strength training has no deleterious effects on spasticity.

Traumatic spinal cord injury (SCI) may result in tetraplegia (motor and/or sensory nervous system impairment of the arms, trunk and legs) or paraplegia (motor and/or sensory impairment of the trunk and/or legs only). The adverse effects of SCI on health, fitness and functioning are frequently compounded by profoundly sedentary behaviour. People with paraplegia (PP) and tetraplegia (TP) have reduced exercise capacity due to paralysis/paresis and reduced exercising stroke volume. TP often further reduces exercise capacity due to lower maximum heart-rate and respiratory function. There is strong, consistent evidence that exercise can improve cardiorespiratory fitness and muscular strength in people with SCI. There is emerging evidence for a range of other exercise benefits, including reduced risk of cardio-metabolic disease, depression and shoulder pain, as well as improved respiratory function, quality-of-life and functional independence. Exercise recommendations for people with SCI are: ≥30min of moderate aerobic exercise on ≥5d/week or ≥20min of vigorous aerobic ≥3d/week; strength training on ≥2d/week, including scapula stabilisers and posterior shoulder girdle; and ≥2d/week flexibility training, including shoulder internal and external rotators. These recommendations may be aspirational for profoundly inactive clients and stratification into "beginning", "intermediate" and "advanced" will assist application of the recommendations in clinical practice. Flexibility exercise is recommended to preserve upper limb function but may not prevent contracture. For people with TP, Rating of Perceived Exertion may provide a more valid indication of exercise intensity than heart rate. The safety and effectiveness of exercise interventions can be enhanced by initial screening for autonomic dysreflexia, orthostatic hypotension, exercise-induced hypotension, thermoregulatory dysfunction, pressure sores, spasticity and pain., (Copyright © 2016 Sports Medicine Australia. Published by Elsevier Ltd. All rights reserved.)

Question: Does 4 weeks of active functional electrical stimulation (FES) cycling in addition to usual care improve mobility and strength more than usual care alone in people with a sub-acute acquired brain injury caused by stroke or trauma?, Design: Multi centre, randomised, controlled trial., Participants: Forty patients from three Sydney hospitals with recently acquired brain injury and a mean composite strength score in the affected lower limb of 7 (SD 5) out of 20 points., Intervention: Participants in the experimental group received an incremental, progressive, FES cycling program five times a week over a 4-week period. All participants received usual care., Outcome Measures: Outcome measures were taken at baseline and at 4 weeks. Primary outcomes were mobility and strength of the knee extensors of the affected lower limb. Mobility was measured with three mobility items of the Functional Independence Measure and strength was measured with a hand-held dynamometer. Secondary outcomes were strength of the knee extensors of the unaffected lower limb, strength of key muscles of the affected lower limb and spasticity of the affected plantar flexors., Results: All but one participant completed the study. The mean between-group differences for mobility and strength of the knee extensors of the affected lower limb were -0.3/21 points (95% CI -3.2 to 2.7) and 7.5 Nm (95% CI -5.1 to 20.2), where positive values favoured the experimental group. The only secondary outcome that suggested a possible treatment effect was strength of key muscles of the affected lower limb with a mean between-group difference of 3.0/20 points (95% CI 1.3 to 4.8)., Conclusion: Functional electrical stimulation cycling does not improve mobility in people with acquired brain injury and its effects on strength are unclear., Trial Registration: ACTRN12612001163897. [de Sousa DG, Harvey LA, Dorsch S, Leung J, Harris W (2016) Functional electrical stimulation cycling does not improve mobility in people with acquired brain injury and its effects on strength are unclear: a randomised controlled trial.Journal of Physiotherapy62: 203-208]., (Copyright © 2016 Australian Physiotherapy Association. Published by Elsevier B.V. All rights reserved.)

Study Design: A randomized controlled trial., Objectives: To determine the effectiveness of electrical stimulation (ES)-evoked muscle contractions superimposed on progressive resistance training (PRT) for increasing voluntary strength in the quadriceps muscles of people with spinal cord injuries (SCI)., Setting: Sydney, Australia., Methods: A total of 20 people with established SCI and neurologically induced weakness of the quadriceps muscles participated in the trial. Participants were randomized between experimental and control groups. Volunteers in the experimental group received ES superimposed on PRT to the quadriceps muscles of one leg thrice weekly for 8 weeks. Participants in the control group received no intervention. Assessments occurred at the beginning and at the end of the 8-week period. The four primary outcomes were voluntary strength (Nm) and endurance (fatigue ratio) as well as the performance and satisfaction items of the Canadian Occupational Performance Measure (COPM; points)., Results: The between-group mean differences (95% confidence interval (CI)) for voluntary strength and endurance were 14 Nm (1-27; P=0.034) and 0.1 (-0.1 to 0.3; P=0.221), respectively. The between-group median differences (95% CI) for the performance and satisfaction items of the COPM were 1.7 points (-0.2 to 3.2; P=0.103) and 1.4 points (-0.1 to 4.6; P=0.058), respectively., Conclusion: ES superimposed on PRT improves voluntary strength, although there is uncertainty about whether the size of the treatment effect is clinically important. The relative effectiveness of ES and PRT is yet to be determined.