• We found physical activity to be associated with improvements in walking ability, general function, balance (including fall risk), depression, sleep, activities of daily living, aerobic capacity, and female sexual function, depending on population and type of activity.
• No studies reported long-term cardiovascular or metabolic disease health outcomes.
• Evidence was also limited by heterogeneity in interventions and control groups and by small sample sizes; evidence in spinal cord injury was limited by the small number of trials.
• Evidence was lacking for many prioritized outcomes.
• Adverse effects of the interventions were inadequately reported in many studies.

Objectives. Although the health benefits of physical activity are well described for the general population, less is known about the benefits and harms of physical activity in people dependent upon, partially dependent upon, or at risk for needing a wheelchair. This systematic review summarizes the evidence for physical activity in people with multiple sclerosis, cerebral palsy, and spinal cord injury regardless of current use or nonuse of a wheelchair.

Data sources. We searched MEDLINE®, CINAHL®, PsycINFO®, Cochrane CENTRAL, Embase®, and Rehabilitation and Sports Medicine Source from 2008 through November 2020, reference lists, and clinical trial registries.

Review methods. Predefined criteria were used to select randomized controlled trials, quasiexperimental nonrandomized trials, and cohort studies that addressed the benefits and harms of observed physical activity (at least 10 sessions on 10 different days of movement using more energy than rest) in participants with multiple sclerosis, cerebral palsy, and spinal cord injury. Individual study quality (risk of bias) and the strength of bodies of evidence for key outcomes were assessed using prespecified methods. Dual review procedures were used. Effects were analyzed by etiology of impairment and physical activity modality, such as treadmill, aquatic exercises, and yoga, using qualitative, and when appropriate, quantitative synthesis using random effects meta-analyses.

Results. We included 146 randomized controlled trials, 15 quasiexperimental nonrandomized trials, and 7 cohort studies (168 studies in 197 publications). More studies enrolled participants with multiple sclerosis (44%) than other conditions, followed by cerebral palsy (38%) and spinal cord injury (18%). Most studies were rated fair quality (moderate risk of bias). The majority of the evidence was rated low strength.

• In participants with multiple sclerosis, walking ability may be improved with treadmill training and multimodal exercise regimens that include strength training; function may be improved with treadmill training, balance exercises, and motion gaming; balance is likely improved with postural control exercises (which may also reduce risk of falls) and may be improved with aquatic exercises, robot-assisted gait training, treadmill training, motion gaming, and multimodal exercises; activities of daily living may be improved with aquatic therapy; sleep may be improved with aerobic exercises; aerobic fitness may be improved with multimodal exercises; and female sexual function may be improved with aquatic exercise.
• In participants with cerebral palsy, balance may be improved with hippotherapy and motion gaming, and function may be improved with cycling, treadmill training, and hippotherapy.
• In participants with spinal cord injury, evidence suggested that activities of daily living may be improved with robot-assisted gait training.
• When randomized controlled trials were pooled across types of exercise, physical activity interventions were found to improve walking in multiple sclerosis and likely improve balance and depression in multiple sclerosis. Physical activity may improve function and aerobic fitness in people with cerebral palsy or spinal cord injury. When studies of populations with multiple sclerosis and cerebral palsy were combined, evidence indicated dance may improve function.
• Evidence on long-term health outcomes was not found for any analysis groups. For intermediate outcomes such as blood pressure, lipid profile, and blood glucose, there was insufficient evidence from which to draw conclusions. There was inadequate reporting of adverse events in many trials.

Conclusions. Physical activity was associated with improvements in walking ability, general function, balance (including fall risk), depression, sleep, activities of daily living, female sexual function, and aerobic capacity, depending on population enrolled and type of exercise utilized. No studies reported long-term cardiovascular or metabolic disease health outcomes. Future trials could alter these findings; further research is needed to examine health outcomes, and to understand the magnitude and clinical importance of benefits seen in intermediate outcomes.

Selph SS, Skelly AC, Wasson N, et al. Physical activity and the health of wheelchair users: a systematic review in multiple sclerosis, cerebral palsy, and spinal cord injury. Arch Phys Med Rehabil. 2021 Oct 12. [Epub ahead of print.] doi: 10.1016/j.apmr.2021.10.002.

Gurwitz JH, Carlozzi NE, Davison KK, et al. National Institutes of Health Pathways to Prevention Workshop: physical activity and health for wheelchair users. Arch Rehabil Res Clin Transl. 2021 Oct 17. [Epub ahead of print.] doi: 10.1016/j.arrct.2021.100163.

Selph SS, Skelly AC, Wasson N, Dettori JR, Brodt ED, Ensrud E, Elliot D, Dissinger KM, Hart E, Kantner S, Graham E, Junge M, Dana T, McDonagh M. Comparative Effectiveness Review No. 241. Physical Activity and the Health of Wheelchair Users: A Systematic Review of Evidence in Multiple Sclerosis, Cerebral Palsy, and Spinal Cord Injury. (Prepared by the Pacific Northwest Evidence-based Practice Center under Contract No. 290-2015-00009-I.) AHRQ Publication No. 21(22)-EHC017. Rockville, MD: Agency for Healthcare Research and Quality; October 2021. DOI: 10.23970/AHRQEPCCER241. Posted final reports are located on the Effective Health Care Program search page.