Article Text

Exercise training programmes to improve hand-rim wheelchair propulsion capacity: PEDro systematic review update
  1. Joanna Diong1,
  2. Claire Boswell-Ruys2
  1. 1Discipline of Biomedical Science, Sydney Medical School, The University of Sydney, Lidcombe, New South Wales, Australia
  2. 2Neuroscience Research Australia, Sydney, New South Wales, Australia
  1. Correspondence to Dr Joanna Diong, Discipline of Biomedical Science, Sydney Medical School, The University of Sydney, Lidcombe, NSW 1825, Australia; joanna.diong{at}

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This section features a recent systematic review that is indexed on PEDro, the Physiotherapy Evidence Database ( PEDro is a free, web-based database of evidence relevant to physiotherapy.

▸ Zwinkels M, Verschuren O, Janssen TWJ, et al.; on behalf of the Sport-2-Stay-Fit study group. Exercise training programs to improve hand rim wheelchair propulsion capacity: a systematic review. Clin Rehabil 2014;28:847–61.


People who use a manual wheelchair as their primary mode of transport need sufficient physical fitness for wheelchair propulsion. Propulsion of a manual wheelchair often occurs over both long and short bouts of activity1 and tends to involve repetitive arm motion at high muscle forces.2 Consequently, hand-rim wheelchair propulsion presents a challenging but essential motor task for manual wheelchair users, especially those who may already be physically deconditioned. Exercise is known to improve cardiovascular fitness and strength, but the effect of exercise training on the physical ability to propel a manual wheelchair is not known.


This systematic review aimed to determine the effectiveness of different types of exercise training programmes on hand-rim wheelchair propulsion capacity.

Searches and inclusion criteria

Two databases (PubMed and EMBASE) were searched up to October 2013 and reference lists of included studies were also screened. Titles and abstracts were screened by one reviewer for eligibility. Studies were eligible if standardised and clearly described exercise training was reported, and at least one outcome on endurance or sprint wheelchair propulsion capacity was measured.


Exercise training programmes were classified into four prespecified categories: (1) aerobic exercise training, subdivided into interval and endurance exercise training; (2) anaerobic exercise training; (3) strength training and (4) mixed training. Aerobic exercise training aimed to improve cardiorespiratory function by interval exercise training (bursts of high-intensity exercise in between periods of low-intensity exercise) or endurance exercise training (repetitive, aerobic exercise at constant intensity for prolonged time period). Anaerobic exercise training involved bursts of maximal intensity work for short periods of time. Strength training involved structured, repetitive loading to increase strength, power or muscular endurance. Mixed training involved a combination of interval, endurance, aerobic and/or strength training, or training that did not conform to a specified training type.

Main outcome measures

Wheelchair propulsion capacity was measured using at least one of the following outcomes: (1) cardiorespiratory fitness (ie, aerobic capacity), (2) anaerobic capacity, (3) muscular fitness or (4) mechanical efficiency. Outcomes measured during endurance or sprint tasks were considered. Data were not pooled due to heterogeneity between studies.


Twenty-one studies were included in the review. No studies on anaerobic training were identified. The included studies represented 249 participants where 126 participants had spinal cord injury, 94 participants were able-bodied, and 29 participants had other conditions such as spina bifida, cerebral palsy or had had a traumatic injury.

Study quality was generally poor. The median PEDro score was 2 out of 10, and no studies scored more than 6 points. The included studies were conducted using a range of study designs. Only 2 of the 21 included studies were randomised controlled trials but these studies did not conceal allocation or blind participants, therapists or assessors.

Aerobic exercise: Interval training was examined in eight experimental studies (3 controlled studies and 5 case series). Interval training significantly improved endurance wheelchair propulsion capacity by 18–34% in participants with disabilities and 49–66% in able-bodied participants. Mechanical efficiency and peak oxygen uptake improved by 7–15% and 14–36%, respectively.

Aerobic exercise: Endurance training was examined in five studies (1 randomised controlled trial, 2 controlled studies and 2 case series). Endurance training improved endurance wheelchair propulsion capacity by 30–78% or improved sprint capacity by 15% and 31% in able-bodied participants in two studies. Endurance training also improved peak oxygen uptake by 10% and 94% in spinal cord-injured or able-bodied participants in two studies, and improved mechanical efficiency by 20% in able-bodied participants in one study.

Strength training was examined in two studies (1 controlled study and 1 case series). Both studies reported significant improvements in strengthening exercises that were trained. Endurance wheelchair propulsion capacity improved by 29% in participants with cerebral palsy and spina bifida in one study.

Mixed training was examined in six studies (1 randomised controlled trial, 4 case series and 1 case study). Mixed training improved endurance wheelchair propulsion demonstrated by 30% and 53% improvements in endurance time in participants with neurological conditions or spina bifida in two studies. Mixed training also improved maximal tolerated power in participants with neurological conditions or traumatic injury by 15%.


Improvements in endurance and sprint wheelchair propulsion outcomes were reported across the included studies. However, most studies were small and of low methodological quality, and so could only provide low-level evidence.

Most studies examined effects of exercise training in able-bodied participants or participants with spinal cord injury. Little is known about effects of exercise training on wheelchair propulsion capacity in other neurological or medical conditions.

Common neurological conditions such as stroke and Parkinson's disease may lead to unilateral upper limb impairments, such that manual wheelchairs requiring both upper limbs for hand-rim wheelchair propulsion might not be an appropriate mode of transport for people with these conditions.

It is difficult to make inferences about estimates of effects of interventions in the absence of between-group comparisons of outcomes and 95% CIs.

Clinical implications

Current evidence suggests aerobic exercise training, strength training and mixed training improves endurance and sprint wheelchair propulsion capacity, however, these findings need to be interpreted with caution given the methodological limitations. More well-conducted randomised controlled trials, especially in participants who do not have spinal cord injury, are needed to confirm these findings and determine the immediate and long-term benefits of exercise training on wheelchair propulsion capacity.


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  • Contributors JD selected the systematic review and wrote the first draft of the manuscript. JD and CB-R contributed to interpretation of the data and revision of the final manuscript, and are guarantors.

  • Competing interests None.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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