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Effects of a 6-Week Indoor Hand-Bike Exercise Program on Health and

Fitness Levels in People With Spinal Cord Injury: A Randomized Controlled
Trial Study

Article  in  Archives of physical medicine and rehabilitation · August 2015

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Archives of Physical Medicine and Rehabilitation 2015;96:2033-40

ORIGINAL RESEARCH

Effects of a 6-Week Indoor Hand-Bike Exercise Program

on Health and Fitness Levels in People With Spinal Cord
Injury: A Randomized Controlled Trial Study
Dong-Il Kim, PhD,a,* Hyelim Lee, BSc,b Bum-Suk Lee, MD, PhD,c Jongbae Kim, PhD,d
Justin Y. Jeon, PhDa,*
From the aDepartment of Sport and Leisure Studies, Yonsei University, Seoul; bDepartment of Rehabilitative and Assistive Technology, The
Korea National Rehabilitation Research Institute, Seoul; cDepartment of Rehabilitation Medicine, National Rehabilitation Hospital, Seoul; and
d
Department of Occupational Therapy, Yonsei University, Wonju, Kangwondo, Korea.
*D.-I. Kim and Jeon contributed equally to this work.

Abstract
Objective: To investigate the effects of a 6-week indoor hand-bike exercise program on fasting insulin and homeostasis model assessment of
insulin resistance (HOMA-IR) levels and physical fitness in people with spinal cord injury (SCI).
Design: Randomized controlled trial.
Setting: National rehabilitation center (outpatient).
Participants: Participants with SCI (NZ15; exercise group: nZ8, control group: nZ7).
Interventions: This study involved 60-minute exercise sessions on an indoor hand-bike. Participants in the exercise group exercised 3 times per
week for 6 weeks.
Main Outcome Measures: Health parameters (body mass index [BMI], waist circumference, percent body fat, insulin level, and HOMA-IR level)
and fitness outcomes (peak oxygen consumption [VO2peak], shoulder abduction and adduction, shoulder flexion and extension, and elbow flexion
and extension).
Results: Participation in a 6-week exercise program using an indoor hand-bike significantly decreased BMI (baseline: 22.03.7m/kg2 vs
postintervention: 21.73.5m/kg2, PZ.028), fasting insulin (baseline: 5.42.9mU/mL vs postintervention: 3.41.5mU/mL, PZ.036), and
HOMA-IR (baseline: 1.00.6 vs postintervention: 0.60.3, PZ.03) levels compared with those in the control group. Furthermore, this training
program significantly increased VO2peak and strength in shoulder abduction, adduction, flexion, and extension and elbow flexion and extension
compared with those in the control group.
Conclusions: Exercise using an indoor hand-bike appears to be an effective modality to improve body composition, fasting insulin, and
HOMA-IR levels and fitness in people with an SCI.
Archives of Physical Medicine and Rehabilitation 2015;96:2033-40
ª 2015 by the American Congress of Rehabilitation Medicine

People with spinal cord injury (SCI) have 3 to 5 times higher risk
of developing type 2 diabetes,1 and cardiovascular disease is one
of the major causes of morbidity and mortality in patients with
SCI.2,3 Mortality rates of people with SCI were elevated 47%
compared with the U.S. general population.4 Contributing factors
for the increased mortality in people with SCI included diabetes
Supported by the National Rehabilitation Research Institute (grant no. NRC-2013-03-024).
Disclosures: none.
(relative risk, 2.62; 95% confidence interval, 1.19e5.77), heart
disease (relative risk, 3.66; 95% confidence interval, 1.77e7.78),
reduced pulmonary function, and smoking.
Aerobic exercise is known to improve type 2 diabetes,5 car-
diometabolic profile,6 and cardiopulmonary and muscular
strength7 in people with SCI. In particular, previous studies have
demonstrated that exercise with functional electrical stimulation
(FES) devices (eg, FES-assisted cycling and rowing) improved
insulin resistance and glucose tolerance in people with SCI.5,8-10
However, FES devices are only available to a small number of

0003-9993/15/$36 - see front matter ª 2015 by the American Congress of Rehabilitation Medicine
http://dx.doi.org/10.1016/j.apmr.2015.07.010
2034
people with SCI because of their limited accessibility and use of
their upper body for exercise.
People with SCI typically exercise with arm ergometers or
wheelchairs. These exercise modalities involve a repetitive pushing
motion with the upper body (shoulder and elbow extension) and
often result in overuse injuries of the shoulder or elbow.11 Because
people with SCI rely on their upper body for most daily activities,
an upper-body injury can have a significant detrimental impact on
their quality of lives. Therefore, it is important to develop an ex-
ercise modality that involves both pushing and pulling motions
(shoulder extension and elbow flexion). Furthermore, people with
SCI above level C6-7 often experience loss of elbow extension,
which typically results in a functional deficit in their upper body.
Therefore, shoulder injuries are more common in people with high-
level SCI because their shoulders are forced to compensate for the
lack of elbow extension.12-14 Exercise devices that involve elbow
extension and shoulder flexion and elbow flexion and shoulder
extension could be ideal for people with high-level SCI. The
development of an exercise device that enables users to perform
both forward and backward rotating motions, including both arms
together or alternating each arm, would be beneficial for people
with SCI. Furthermore, if the device can be connected to an in-
formation system (eg, active video game), it would be ideal to in-
crease participants’ interest and motivation.15
We recently developed an indoor hand-bike that allows both for-
ward and backward pedaling and is equipped with a tablet personal
computer and associated gaming software. The purpose of the present
study was to determine the effect of 6 weeks of exercise with this
hand-bike on fasting insulin, cardiometabolic profile, and musculo-
skeletal and cardiopulmonary fitness levels in people with SCI.
Methods
Study design and participants
This study is a randomized controlled trial of 15 people with SCI
(exercise group: nZ8, control group: nZ7) who met our inclusion
criteria. Randomization of people with SCI was performed on a
1:1 ratio to either the exercise or control group using a computer-
generated random number sequence (Research Randomizera). All
participants in the study were classified as American Spinal Injury
Association grades A and B (T5-11). The mean age of the subjects
was 33.15.4 years, and the mean body mass index (BMI) was
21.43.2kg/m2.
Inclusion criteria were as follows: (1) SCI for >6 months, (2)
between 18 and 65 years of age, and (3) had not exercised regu-
larly during the 6 months preceding this study. The exclusion
criteria were as follows: (1) cardiovascular disease (including all
diseases that involve the heart or blood vessels), (2) uncontrolled
type 2 diabetes, (3) uncontrolled hypertension, (4) pressure ulcers,
or (5) orthopedic problems. The current study was approved by the
institutional review board (NRC-2013-03-024). Participant
List of abbreviations:
BMI body mass index
FES functional electrical stimulation
HOMA-IR homeostasis model assessment of insulin resistance
RPE rating of perceived exertion
SCI spinal cord injury
VO2peak peak oxygen consumption
D.-I. Kim et al
characteristics are shown in tables 1 and 2. Moreover, participant
recruitment procedures are summarized in figure 1.
Development of an indoor hand-bike
The indoor hand-bike equipped with an information technology
system consisted of a hand-bike body, wheelchair platform, indoor
roller trainer, and 3 built-in devices: speedometer, motion sensor,
and friction-induced resistor (fig 2).
A hand and cycle software application (Hycle) (fig 3) was
developed for the bike. The Hycle program consists of a record,
customizable settings (distance, intensity, speed, and time), game
mode, training mode, and description of the exercise. Real-time
information regarding speed, time, distance, and heart rate is
presented on a display monitor, and total distance traveled can be
visualized using a variety of themes.
Exercise program
Participants exercised with the indoor hand-bike equipped with
Hcycle 60min/d, 3d/wk, for 6 weeks at the national rehabilitation
center of Korea under the supervision of an exercise trainer. Each
daily exercise session consisted of an 8-minute warm-up, 44 mi-
nutes of training on the hand-bike (6 sets of 6-min intervals with
60s of rest between each interval), and an 8-minute cool down.
During the training sessions, participants maintained a heart rate
of at least 70% of their maximum,16,17 as measured by an SHC-U7
heart monitor.b Exercise intensity was calculated based on resis-
tance and revolutions per minute and was gradually increased on a
weekly basis using the Borg rating of perceived exertion (RPE) to
ensure the safety of the participants18 (1e2wk: RPE 5 or 70% of
maximum heart rate17; 2e4wk: RPE 6 or 75% of maximum heart
rate; 4e6wk: RPE 7 or 80% of maximum heart rate). A detailed
description of the exercise program is shown in table 3.
Participants in the control group were instructed to continue
with their usual activities. At the end of the study, these participants
received exercise handouts and results of their blood lipid profile
and fitness tests (muscle strength and cardiopulmonary fitness).
Measurements
Upper-body muscle strength
All measurements were conducted at baseline and within 2 days
after the completion of the 6-week exercise programs. To measure
upper-body strength, a handheld dynamometerc was used as previ-
ously described.19 Briefly, shoulder flexor and extensor strength
were measured in the supine position, with the shoulder and elbow
flexed at 90 , the arm in a neutral rotation, and the dynamometer
placed proximal to the humeral epicondyle. The strength of the
shoulder abductors and adductors was then measured by placing the
dynamometer proximal to the elbow, with the elbow fully extended
and the shoulder abducted 45 while the patient remained supine.
Elbow flexor (sitting position) and extensor strength (supine posi-
tion) were measured with the shoulder adducted from the trunk in a
supine and sitting position and with the elbow flexed to 90 .
Cardiopulmonary fitness
All participants underwent maximal graded exercise tests ac-
cording to the ramp protocol. The criteria for peak oxygen con-
sumption (VO2peak) were as follows: achievement of oxygen
consumption plateau despite increased exercise intensity; R>1.15;
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Indoor hand-bike and information technology system 2035

Table 1 Participant characteristics

Age Height Weight BMI Waist Duration Level of ASIA
No. Sex (y) (cm) (kg) (kg/m2) (cm) (y) Injury Grade*
1 Male 22 180 59 18.2 72 2 C7 A
2 Male 28 165 57 20.9 74 2 T11 B
3 Male 34 181 82 25 98 3 C6 B
4 Male 27 170 63 21.8 92 9 C6 A
5 Female 36 160 74 28.9 109 9 C7 A
6 Male 32 174 67 22 90.5 8 C6 A
7 Female 39 168 48 17 76 5 T6 B
8 Male 34 176 69 22.2 95.5 2 C5 A
9 Female 33 166 51 18.5 77 10 C6 B
10 Female 34 160 50 19.5 74 6 C7 A
11 Female 36 160 45 17.6 75 3 C6 B
12 Female 31 165 62 22.8 78 4 C6 B
13 Male 31 183 68 20.3 84.5 11 C6 A
14 Male 46 187 90 25.7 100 16 C5 B
15 Male 34 183 72 21.5 84 8 C6 B
NOTE. Duration is the time interval between the onset of stroke and exercise training.
Abbreviation: ASIA, American Spinal Injury Association.
* Grade A includes complete injury (no motor or sensory function is preserved in sacral segments S4-5); grade B includes incomplete injury (sensory
function but no motor function is preserved below the neurologic level and extends through sacral segments S4-5); and grade C includes incomplete injury
(motor function is preserved below the neurologic level, and more than half of the key muscles below the neurologic level have a muscle grade <3).

peak heart rate (200 beats/min minus chronologic age17) achieved;

Table 2 Baseline demographic, fitness, and blood profiles of or RPE grade of 19 or 20.20,21 If at least 2 of the criteria were met,
participants by group assignment it was assumed that VO2peak had been reached. If none of these
Exercise Group Control Group criteria were met, the test was considered an early termination. If
Variables (nZ8) (nZ7) P the subject was unable to maintain a given work rate for >15
seconds at each stage or if a subject wished to terminate the ex-
Duration (y) 5.03.2 8.24.4 .10
amination, the exercise examination was discontinued. Respira-
Age (y) 31.55.5 35.05.1 .44
tory gas data were measured in real-time breath-by-breath analysis
Height (cm) 171.87.3 172.011.8 .95
and then analyzed at 5-second intervals to calculate the mean and
Weight (kg) 64.810.5 62.515.6 .64
peak values of each variance. A portable K4b2 gas analyzerd was
BMI (m/kg2) 22.03.7 20.82.76 .56
used to measure VO2peak.
Lean mass (kg) 20.25.0 19.06.4 .56
Body fat (%) 39.013.7 40.66.8 .35
Anthropometric measurement
WC (cm) 88.313.1 81.79.0 .52
Body weight was measured to the nearest 0.1kg on a scale adapted
Fitness
for use with wheelchairs, and height was measured to the nearest
VO2peak (mL$kg 1$min 1) 16.87.2 15.23.4 .72
millimeter in a supine position with legs outstretched and feet in
EF (N) 123.358.9 152.835.1 .13
dorsiflexion. Measurements of waist circumference were taken to
EE (N) 34.046.0 18.018.3 .39
the nearest millimeter in a supine position using a Gullick II tape
SAB (N) 96.857.7 106.427.2 .35
measuree at the midpoint between the inferior portion of the lateral
SAD (N) 104.763.5 92.734.7 .81
rib cage and the iliac crest.22 Body composition was measured
SF (N) 111.265.6 105.230.5 >.99
using bioelectrical impedance (Inbody S20f) when participants
SE (N) 98.763.0 132.829.2 .20
were in the supine position. Bioelectrical impedance analysis has
Blood profiles
been previously validated against dual-energy x-ray absorptiom-
Glucose (mg/dL) 78.68.3 88.710.8 .06
etry, and the 2 techniques exhibit a correlation coefficient >0.9 in
TC (mg/dL) 176.235.7 183.121.4 .56
both able-bodied persons23,24 and people with SCI.25
TG (mg/dL) 103.042.0 96.449.2 .60
HDL-C (mg/dL) 42.411.5 45.17.04 .13
Biochemical analyses
LDL-C (mg/dL) 113.125.9 118.723.9 .72
A blood sample and the levels of glucose metabolismerelated
Insulin (mU/mL) 5.42.9 4.92.9 .73
variables, including fasting glucose (ADVIA 1650g) and fasting
HOMA-IR 1.00.6 1.10.8 .89
insulin (Rocheh), were collected from each patient after a 12-hour
NOTE. Values are presented as mean  SD or as otherwise indicated. fast. Insulin resistance was estimated using the homeostasis
Duration is the time since spinal cord injury. model assessment of insulin resistance (HOMA-IR) index (insulin
Abbreviations: EE, elbow extension; EF, elbow flexion; HDL-C, high- [mIU/mL]  fasting glucose [mmol/L]/22.5).26 Lipid metabolite
density lipoprotein; LDL-C, low-density lipoprotein; SAB, shoulder
indices, including total cholesterol, triglycerides, high-density li-
abduction; SAD, shoulder adduction; SE, shoulder extension; SF, shoulder
flexion; TC, total cholesterol; TG, triglyceride; WC, waist circumference.
poprotein cholesterol, and low-density lipoprotein cholesterol
levels, were measured using an ADVIA 1650 chemistry system.

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2036 D.-I. Kim et al

Fig 1 Consolidated Standards of Reporting Trials flowchart diagram of study participation.

Statistical analysis
PASW statistics 18i was used for all statistical analyses. Descriptive
statistics were used to evaluate baseline characteristics. The normality
of distribution was verified with the Shapiro-Wilk test. Pre- and
posttraining differences within each study group were analyzed using
paired t tests for normally distributed variables and Wilcoxon signed-
rank tests for nonnormally distributed variables. In addition, inde-
pendent sample t tests were used to compare the changes in each study
group from baseline to the 6-week endpoint for normally distributed

Fig 2 Pictures of the indoor hand-bike equipped with the information technology system.

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Indoor hand-bike and information technology system 2037

Fig 3 Exercise training applications. (A) Main, (B) control and intensity, (C) game mode, and (D) training mode.

variables, and Wilcoxon rank-sum tests were used for nonnormally
distributed variables. Furthermore, we also performed 2-way
repeated-measures analysis of variance (timegroup) and analysis
of covariance as the sensitivity analyses. The results of the 2-way
analysis of variance and analysis of covariance are shown in
supplemental table S1 (available online only at http://www.archives-
pmr.org/). The P values <.05 were considered significant.
Results
Participant characteristics at baseline
All 15 participants with SCI in the range of C5 to T11 completed
this trial. The intervention consisted of a total of 18 exercise
sessions on an indoor hand-bike equipped with an information
technology system. Participant characteristics are presented in
tables 1 and 2. The mean participant age was 33.15.4 years, and
the mean BMI was 21.43.2kg/m2.
Effects of exercise on health (body composition,
insulin, and HOMA-IR)
Waist circumference (baseline: 88.313.1cm vs post-
intervention: 85.612.2cm, PZ.011) and BMI reduced signif-
icantly more in the exercise group than the control group (mean
difference in waist circumference vs control, 3.4cm, PZ.002;
mean difference in BMI vs control, 0.5kg/m2, PZ.007).
Baseline to postintervention fasting insulin level (PZ.009) and
HOMA-IR level (PZ.008) decreased significantly in the exer-
cise group compared with the control group (mean difference in
fasting insulin vs control, 3.7mU/mL; PZ.009; mean differ-
ence in HOMA-IR vs control, 0.8; PZ.008). Insulin, HOMA-
IR, and high-density lipoprotein cholesterol values in each
group after the 6-week training intervention are shown in
table 4. The exercise group exhibited significantly lower insulin
(baseline: 5.42.9mU/mL vs postintervention: 3.41.5mU/mL,
PZ.017) and HOMA-IR (baseline: 1.00.6 vs post-
intervention: 0.60.3, PZ.012) levels after the exercise

Table 3 Description of the exercise program

Characteristics Components Details Duration
Exercise program Warm-up (1) IHIS with the exercise application (game mode), 1 set 8 min
(2) 90s of rest
Exercise (3) IHIS with the exercise application (training mode) 44 min
6 sets of forward 3 min and backward 3 min, 60s
of rest between intervals
(4) 90 seconds of rest
Cool-down (5) IHIS with the exercise application (game mode), 1 set 8 min
Weeks Borg Scale Intensity
Exercise intensity 1e2wk Borg scale (RPE) 5 or max HR 70% Moderate
2e4wk Borg scale (RPE) 6 or max HR 75% Moderate
4e6wk Borg scale (RPE) 7 or max HR 80% Vigorous
NOTE. Exercise frequency: 3 times per wk for 60 min (Monday, Wednesday, Friday for 6wk). The exercise group was supervised by certifıed trainers who
regularly monitored and controlled exercise intensity.
Abbreviations: HR, heart rate; IHIS, indoor hand-bike equipped with an information technology system; max, maximum.

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2038 D.-I. Kim et al

Table 4 Changes in body composition, fitness, insulin, and HOMA-IR

Exercise Group (nZ8) Control Group (nZ7)
Variables Pre Post DPostePre Pre Post DPostePre DP
Body composition
BMI (m/kg2) 22.03.7 21.73.5* 0.20.2 20.82.7 21.12.7 0.30.4 <.01
Lean mass (kg) 20.25.0 21.74.9 1.53.5 19.06.4 19.46.3 0.30.9 .39
Body fat (%) 39.013.7 35.511.8 3.57.2 40.66.8 40.56.4 0.11.9 .23
WC (cm) 88.313.1 85.612.2* 2.61.7 81.79.0 82.68.7 0.81.6 <.01
Fitness
VO2peak (mL$kg 1$min 1) 16.87.2 21.29.1* 4.43.1 15.23.4 13.73.4* 1.50.7 <.01
EF (N) 123.358.9 177.173.2* 53.839.9 152.835.1 148.735.0* 4.05.1 <.01
EE (N) 34.046.0 44.459.8* 10.414.6 18.018.3 17.217.5 0.81.1 <.01
SAB (N) 96.857.7 134.665.7* 37.825.7 106.427.2 100.925.1 5.47.0 <.01
SAD (N) 104.763.5 142.382.5* 37.525.0 92.734.7 90.237.0 2.55.6 <.01
SF (N) 111.265.6 142.874.6* 31.520.1 105.230.5 102.929.2 2.25.1 <.01
SE (N) 98.763.0 139.673.5* 40.917.8 132.829.2 128.725.8 4.04.9 <.01
Insulin and HOMA-IR
Glucose (mg/dL) 78.68.3 77.07.7 1.64.4 88.710.8 89.412.8 0.77.0 .32
TC (mg/dL) 176.235.7 177.235.8 1.022.1 183.121.4 179.529.6 3.513.5 .81
TG (mg/dL) 103.042.0 102.129.3 0.836.3 96.449.2 85.422.3 11.045.4 .95
HDL-C (mg/dL) 42.411.5 46.112.3* 3.63.2 45.17.0 44.75.8 0.35.9 .29
LDL-C (mg/dL) 113.125.9 110.728.8 2.418.6 118.723.9 117.725.0 1.010.2 >.99
Insulin (mU/mL) 5.42.9 3.41.5* 2.02.2 4.92.9 6.74.5 1.72.5 <.01
HOMA-IR 1.00.6 0.60.3* 0.40.4 1.10.8 1.61.3 0.40.7 <.01
NOTE. Values are presented as mean  SD or as otherwise indicated.
Abbreviations: EE, elbow extension; EF, elbow flexion; HDL-C, high-density lipoprotein; LDL-C, low-density lipoprotein; Post, 6 weeks after training; Pre,
before training; SAB, shoulder abduction; SAD, shoulder adduction; SE, shoulder extension; SF, shoulder flexion; TC, total cholesterol; TG, triglyceride;
WC, waist circumference.
* Significantly different from the Pre value (P<.05).

training period compared with baseline. Furthermore, high- Discussion

density lipoprotein cholesterol level (baseline: 42.411.5mg/
dL vs postintervention: 46.112.3mg/dL, PZ.012) increased
significantly after training. No significant changes in glucose,
total cholesterol, triglycerides, or low-density lipoprotein
cholesterol levels were observed in the exercise group. As
sensitivity analyses, 2-way analysis of variance and analysis of
covariance were performed, and results from these analyses
were the same as our primary analysis (see supplemental
table S1).
Effects of exercise on fitness (upper-body muscle
strength and VO2peak)
Upper-body muscle strength in terms of shoulder flexion (mean
difference vs control, 33.7N; PZ.002), extension (mean dif-
ference vs control, 44.9N; PZ.002), abduction (mean difference
vs control, 43.2N; PZ.001), and adduction (mean difference vs
control, 40N; PZ.003) and elbow flexion (mean difference vs
control, 57.8N; PZ.001) and extension (mean difference vs
control, 11.2N; PZ.001) increased significantly in the exercise
group compared with the control group. In addition, VO2peak
(baseline: 16.87.2mL$kg 1$min 1 vs postintervention:
21.29.1mL$kg 1$min 1, PZ.012) increased significantly in the
exercise group compared with the control group (mean difference vs
control, 2.9mL$kg 1$min 1; PZ.001). As sensitivity analyses,
2-way analysis of variance and analysis of covariance were
performed, and results from these analyses were the same as
our primary analysis (see supplemental table S1).
This study tested the effects of an exercise program using an indoor
hand-bike equipped with an information technology system on in-
sulin resistance, cardiometabolic profiles, and cardiopulmonary and
muscular skeletal fitness in participants with SCI. Furthermore, 6
weeks of training with an indoor hand-bike equipped with an in-
formation technology system resulted in significantly reduced BMI,
waist circumference, and insulin and HOMA-IR levels.
In this study, we observed a 7.4% increase in average lean
mass and a 9% decrease in average percent body fat in the exer-
cise group after 6 weeks of training. People with SCI suffer from
sarcopenia in paralyzed limbs and increased adiposity because
of decreased physical activity. Reduced muscle mass and
increased fat mass are associated with increased insulin resistance,
risk of type 2 diabetes, and cardiovascular disease; as a result,
people with SCI suffer significantly increased prevalence of type
2 diabetes and cardiovascular diseases.1-4 Therefore, significant
increase in muscle mass and reduced fat mass only after 6 weeks
of exercise in our study is of importance.
Indeed, fasting insulin and HOMA-IR levels were reduced by
37% and 40%, respectively. Consistent with these results, a pre-
vious study found that exercise and physical activity had benefi-
cial effects on insulin sensitivity in both healthy subjects and
subjects with glucose intolerance.27 Other studies have also re-
ported significant improvements in glucose tolerance, insulin
sensitivity, and lipid profile after FES rowing and FES
cycling.5,28,29 Knowing that people with SCI have increased risk
of metabolic disorders, significant reduction in fasting insulin, and
insulin resistance after exercise training with a hand-bike may

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Indoor hand-bike and information technology system
suggest that in addition to other exercise modalities, exercise with
a hand-bike is one of the effective exercise modalities to improve
metabolic profiles.
In addition to improvement in body composition and metabolic
profiles after exercise training in our study, participants in the
exercise group showed a significant increase in upper-body
strength. The exercise performed in our study involved both for-
ward and backward pedaling of a hand-bike; therefore, the
strength of the muscle groups involved with both forward and
backward pedaling improved significantly. There was a 41.4%,
43.6%, and 39% increase in muscle strength in shoulder exten-
sion, elbow flexion, and shoulder abduction, respectively. In
addition, there was a 28.3%, 30.6%, and 35.8% increase in muscle
strength in shoulder flexion, elbow extension, and shoulder
adduction, respectively. Many people with SCI suffer from
shoulder pain caused by glenohumeral instability and shoulder
impingement syndrome.30 Previous studies have also found that
increased fitness is associated with reduced shoulder pain.31,32
Nash et al31 reported an increase in upper-body strength after
exercise training ranging from 38.6% to 59.7%. Shoulder pain
scores as measured by the Wheelchair User Shoulder Pain Index
also decreased from 31.924.8 at baseline to 5.75.9 (PZ.008)
after training in people with paraplegia.31 Training with FES
rowing,33 a cycle ergometer,10,34 and an arm ergometer35 or hand
cycle36 has been shown to significantly increase muscle strength in
people with SCI. In this study, we observed significantly increased
muscle strength (shoulder flexors, extensors, abductors, and ad-
ductors and elbow flexors and extensors) after 6 weeks of training.
This increased muscle strength is hypothesized to improve scap-
ular stability and strength, which are important aspects in pre-
venting shoulder overuse injuries.13,32,37
Previous studies have reported significantly improved
VO2peak and cardiopulmonary fitness after FES rowing,8 FES
cycling,38 and arm ergometer training.39 In the current study,
VO2peak increased by 26.2% in the exercise group. In accor-
dance with this result, Jeon et al8 observed a 7.9% increase in
average VO2peak of participants with SCI after 12 weeks of FES
rowing. In addition, Kim et al33 found an increase in VO2peak of
12.8% after 6 weeks of FES rowing in individuals with SCI.
Finally, Valent et al36 observed a 19.8% increase in average
VO2peak in participants with SCI after 3 months of hand cycle
training. The significant improvement in oxygen consumption
observed in the present study is an important finding because
cardiopulmonary fitness is a vital predictor of cardiovascular
disease mortality in adults.40
To understand the use experience of the hand-bike with an
information technology system, we have performed a satis-
faction survey (supplemental table S2, available online only at
http://www.archives-pmr.org/). The satisfaction survey from
participants’ experience in indoor hand-bike with an infor-
mation technology system showed that participants thought
that their exercise experiences were satisfied, their exercise
experiences were convenient, and they were willing to
participate in this exercise in the future. Knowing that
compliance to the exercise program was 100% in this study,
we can speculate that the information technology system may
positively influence the motivation of participants to exercise.
Knowing from previous studies in nondisabled populations,
which reported increased motivation, participation, and dura-
tion of training when the training was implemented with an
active video game,41,42 the information technology system in
our study, which allowed participants to exercise with a game
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2039
mode, might have increased the interest and motivation
to exercise.
Study limitations
The limitation of this study is the relatively small number of
participants. Despite this limitation, we successfully tested the
efficacy of an exercise program using an indoor hand-bike
equipped with an information technology system on body
composition, VO2peak, upper-body extremity strength, insulin
level, and HOMA-IR level in participants with SCI.
Conclusions
A 6-week exercise program using an indoor hand-bike equipped
with an information technology system exercise program appears
to be an effective exercise modality for increasing upper-
extremity muscle strength and VO2peak and decreasing insulin
and HOMA-IR levels.
Suppliers
a. Research Randomizer; Social Psychology Network. Available
at: www.randomizer.org.
b. SHC-U7; Solmitech.
c. Handheld dynamometer; J-tech Medical Industries.
d. K4b2; COSMED.
e. Gullick II; Country Technology.
f. Inbody S20; Biospace.
g. ADVIA 1650; Siemens.
h. Roche Cobas; Roche Diagnostics.
i. PASW statistics 18; SPSS.
Keywords
Exercise; Insulin; Muscle strength; Rehabilitation; Spinal cord
injuries
Corresponding author
Jongbae Kim, PhD, Yonseidae-gil, Wonju, Department of
Occupational Therapy, Yonsei University, Kangwondo, Korea,
220-710. E-mail address: jongbae@yonsei.ac.kr.
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Indoor hand-bike and information technology system 2040.e1

Supplemental Table S1 Changes in health (body composition, insulin, and HOMA-IR) and fitness

Variables Group Pre Post Group Time GroupTime ANCOVA P

Body composition
BMI (m/kg2) Exercise group 22.03.7 21.73.5 .61 .95 .01 .01
Control group 20.82.7 21.12.7
Lean mass (kg) Exercise group 20.25.0 21.74.9 .54 .21 .41 .36
Control group 19.06.4 19.46.3
Body fat (%) Exercise group 39.013.7 35.511.8 .53 .22 .24 .16
Control group 40.66.8 40.56.4
WC (cm) Exercise group 88.313.1 85.612.2 .41 .06 <.01 <.01
Control group 81.79.0 82.68.7
Fitness
VO2peak (mL$kg 1$min 1) Exercise group 16.87.2 21.29.1 .19 .03 <.01 <.01
Control group 15.23.4 13.73.4
EF (N) Exercise group 123.358.9 177.173.2 .98 <.01 <.01 <.01
Control group 152.835.1 148.735.0
EE (N) Exercise group 34.046.0 44.459.8 .32 .09 .04 .03
Control group 18.018.3 17.217.5
SAB (N) Exercise group 96.857.7 134.665.7 .63 <.01 <.01 <.01
Control group 106.427.2 100.925.1
SAD (N) Exercise group 104.763.5 142.382.5 .31 <.01 <.01 <.01
Control group 92.734.7 90.237.0
SF (N) Exercise group 111.265.6 142.874.6 .43 <.01 <.01 <.01
Control group 105.230.5 102.929.2
SE (N) Exercise group 98.763.0 139.673.5 .68 <.01 <.01 <.01
Control group 132.829.2 128.725.8
Insulin and HOMA-IR
Glucose (mg/dL) Exercise group 78.68.3 77.07.7 .04 .76 .44 .37
Control group 88.710.8 89.412.8
TC (mg/dL) Exercise group 176.235.7 177.235.8 .77 .79 .64 .69
Control group 183.121.4 179.529.6
TG (mg/dL) Exercise group 103.042.0 102.129.3 .48 .58 .63 .26
Control group 96.449.2 85.422.3
HDL-C (mg/dL) Exercise group 42.411.5 46.112.3 .89 .19 .12 .16
Control group 45.17.0 44.75.8
LDL-C (mg/dL) Exercise group 113.125.9 110.728.8 .63 .66 .85 .80
Control group 118.723.9 117.725.0
Insulin (mU/mL) Exercise group 5.42.9 3.41.5 .36 .84 <.01 .01
Control group 4.92.9 6.74.5
HOMA-IR Exercise group 1.00.6 0.60.3 .25 .84 .01 .01
Control group 1.10.8 1.61.3
NOTE. Values are presented as mean  SD or as otherwise indicated.
Abbreviations: ANCOVA, analysis of covariance; EE, elbow extension; EF, elbow flexion; HDL-C, high-density lipoprotein; LDL-C, low-density lipoprotein;
Post, 6 weeks after training; Pre, before training; SAB, shoulder abduction; SAD, shoulder adduction; SE, shoulder extension; SF, shoulder flexion; TC,
total cholesterol; TG, triglyceride; WC, waist circumference.

Supplemental Table S2 Satisfaction for indoor hand-bike

equipped with the information technology system

Exercise Group
Attitude (nZ8)
Interesting 4.00.5
Convenient 4.00.5
Willing to continue exercise with this device 4.60.5
NOTE. Values are presented as mean  SD. Maximum score is 5 (5-point
Likert scale).

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