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Astorino et al. Neuroimmunol Neuroinflammation 2020;7:40-50 I http://dx.doi.org/10.20517/2347-8659.2019.11 Page 47

Our results show no change in bodily pain, which may be due to the fact that many participants reported
no or minimal pain at baseline. This finding opposes previous results; for example, in individuals with
[29]
chronic SCI, 12 weeks of FES-ambulation training reduced bodily pain , similar to findings seen in
[4]
response to nine months of resistance/aerobic training . In persons with paraplegia, four months of circuit
[50]
training reduced shoulder pain, which was consequent with increased total body strength . In addition, a
[51]
single bout of locomotor training may reduce pain perception in persons with incomplete SCI . However,
[5]
findings from one study demonstrated no change in pain after nine months of aerobic and resistance
training, which was seen as a positive response considering that non-exercising controls showed greater
pain. Baseline pain was also associated with change in BSS-A, and our participants’ change in pain was a
[3]
significant predictor of change in PQOL, which supports previous findings . As pain is related to exercise
[54]
[53]
adherence [3,52] , mobility , and onset of depressive symptoms , rehabilitation and fitness professionals
should consider this outcome when treating persons with SCI who have elevated pain.
In the present study, we used the Center for Epidemiological Studies Depression scale to assess potential
[55]
changes in depression in response to ABT. It is evident that scores above 16 may identify individuals at
risk for clinical depression. Although our participants’ scores declined by two units from baseline to six
months, this change was not significant. Our heterogeneous sample may have been too small to detect
changes in depression considering that greater than 40 participants may be needed for adequate statistical
[55]
power . Moreover, examination of change in depression with between-subjects factors equal to injury
severity, duration, completeness, and volume of training did not reveal any differences between groups.
[4]
In another study , fewer depressive symptoms were noted after nine months of exercise training in
individuals with SCI compared to non-exercising controls, although their baseline score did not indicate
clinical depression and, in addition, the value did not increase from pre- to post-training.

Our data do not support the efficacy of ABT to improve body composition measured via DXA, as whole body
and regional %BF increased and there was no change in FFM [Table 3]. However, the observed increase
in %BF is minimal and may not be clinically meaningful in regards to enhancing risk of comorbidities
associated with SCI. In contrast, decreased FM and increased FFM occurred [17,19] when long-term FES is
performed by persons with acute as well as chronic paraplegia and tetraplegia. There are a few explanations
for the lack of change in body composition in response to ABT. First, our ABT regime required more
core and upper-body resistance training than exposure to FES, which may minimize potential for muscle
[40]
hypertrophy. Second, energy expenditure of ABT is lower than other exercise modes , which may be
insufficient to induce negative energy balance and thus weight or fat loss. In the present study, 56% of
participants were less than or equal to 1 year post-injury, during which there is a considerable loss in FFM
[56]
and rise in FM , and it could be that our minimal changes are a result of continued changes in body
composition that were not slowed by our intervention. Third, despite wide use of DXA to assess body
composition [16,57] and data showing DXA-derived increases in FFM and/or decreases in regional body fat
in SCI in response to electrical stimulation training [19,58] , its ability to detect small changes in FM or FFM
after exercise training is less than magnetic resonance imaging. It is plausible that DXA should only be
used in studies when relatively robust changes in energy balance and/or body composition are expected,
such as those using high-volume FES-based exercise or manipulation of both exercise and dietary intake
to improve health status in this population. Fourth, individual variability in these responses occurred, as
FFM declined in persons with complete injury and was unchanged in men and women with incomplete
injury. Overall, by itself ABT does not seem to induce significant changes in body composition, especially
in persons with acute injury.

Our study had a few limitations. We used a convenience sample composed of individuals who were already
completing ABT at the facility. A non-exercising control group was not recruited, thus we are uncertain
if the changes seen in this study are truly due to exercise training. Participants differed in injury duration,