# Strategies to Augment the Cardiovascular System and Acutely Enhance Exercise Performance in Individuals with Spinal Cord Injury: A Systematic Scoping Review

## TL;DR

This review explores ways to improve exercise performance in people with spinal cord injuries by enhancing cardiovascular function.

## Contribution

The study systematically identifies and compares mechanical and neuromodulatory strategies to acutely enhance exercise performance in individuals with spinal cord injury.

## Key findings

- Neuromodulatory strategies like spinal cord stimulation and functional electrical stimulation show potential for improving cardiovascular function and exercise capacity.
- Most studies focused on middle-aged males, with limited data on females and acute spinal cord injury settings.
- Inconsistent methodologies across studies make it difficult to draw definitive conclusions about specific ergogenic strategies.

## Abstract

Spinal cord injury (SCI) affects motor and autonomic functions that reduce exercise capacity. Specifically, the loss of sympathetic drive following SCI at or above the sixth thoracic segment (≥ T6) can impair cardiovascular responses to exercise. This systematic scoping review aimed to identify ergogenic strategies that may augment the cardiovascular system and acutely enhance exercise performance in individuals with SCI.

A systematic literature search was conducted using electronic databases (Medline, Embase, Web of Science) from inception to 1st April 2025. Studies were included if they met the following eligibility criteria: (1) human participants (aged ≥ 16 years); (2) any acquired SCI (traumatic, infection, cancer); (3) any sample size but must be > 80% SCI; (4) acute, single, volitional exercise sessions with cross-over design (i.e., ergogenic strategy and control sessions); (5) report a measurable exercise performance outcome, and (6) the strategy used to enhance performance must have a theoretical effect on the cardiovascular system. Data were extracted from eligible studies and charted. Hedges’ g summary effect sizes were calculated to quantify the magnitude of effects across strategies.

A total of 7266 possible articles were identified. Following a full-text review, 32 articles were included. Findings were reported by strategy, defined as either mechanical (e.g., abdominal binders, lower-body compression, passive leg exercise and supine posture) or neuromodulatory [e.g., autonomic dysreflexia (AD), functional electrical stimulation (FES), pharmaceuticals/supplements/stimulants, and spinal cord stimulation (SCS)]. The neuromodulatory strategies appeared more robust at augmenting cardiovascular and performance outcomes, particularly AD, FES, and SCS.

We examined methods to improve acute exercise performance by augmenting the cardiovascular system in individuals with SCI. The large heterogeneity across methodologies and outcome measures made it challenging to draw conclusions regarding the underlying physiological mechanisms. Consequently, providing definitive recommendations on the best strategies to enhance performance was not possible based on current literature. Future research should be conducted across all ergogenic strategies, with a careful focus on females, trained and untrained participants, and individuals who are more likely to benefit from improvements in cardiovascular output (i.e., SCI ≥ T6).

Registration This review was pre-registered on the Open Science Framework (https://osf.io/w7apu/).

The online version contains supplementary material available at 10.1186/s40798-025-00909-7.

Strategies that exploit neuromodulatory mechanisms (e.g., spinal cord stimulation, boosting via autonomic dysreflexia, and functional electrical stimulation) alter autonomic cardiovascular function and improve exercise capacity.A broad scope of testing using functional electrical stimulation has been reported, but study methodology and protocols are inconsistent across the literature making it difficult to draw conclusions for this ergogenic strategy specifically.The majority of studies recruited middle-aged males with a motor-complete, chronic spinal cord injury. Data focusing on enhancing exercise performance in females with spinal cord injury are sparse (only 6% of participants included in this review were female), as are the effects of ergogenic strategies in the acute and sub-acute spinal cord injury setting, and should therefore be a focus of future research. Further, long-term studies are needed to assess the efficacy, safety and practicality of these interventions in real-world settings.

Strategies that exploit neuromodulatory mechanisms (e.g., spinal cord stimulation, boosting via autonomic dysreflexia, and functional electrical stimulation) alter autonomic cardiovascular function and improve exercise capacity.

A broad scope of testing using functional electrical stimulation has been reported, but study methodology and protocols are inconsistent across the literature making it difficult to draw conclusions for this ergogenic strategy specifically.

The majority of studies recruited middle-aged males with a motor-complete, chronic spinal cord injury. Data focusing on enhancing exercise performance in females with spinal cord injury are sparse (only 6% of participants included in this review were female), as are the effects of ergogenic strategies in the acute and sub-acute spinal cord injury setting, and should therefore be a focus of future research. Further, long-term studies are needed to assess the efficacy, safety and practicality of these interventions in real-world settings.

The online version contains supplementary material available at 10.1186/s40798-025-00909-7.