Augmenting exercise capacity with noninvasive ventilation in high-level spinal cord injury

High-level spinal cord injury (SCI) results in a very limited innervated skeletal muscle mass that strongly reduces exercise capacity. Our recent work showed that when adding functional electrical stimulation (FES) of the paralyzed legs (hybrid FES-exercise) to produce higher exercise capacity, peak ventilation became a limiting factor to training-induced improvement in aerobic capacity. Our assumption was that the systemic adaptations to exercise training are delimited by the maximal ventilation that can be achieved. However, herein, we present a case showing an acute increase in aerobic capacity when using noninvasive ventilatory support (NIV) during FES-rowing test in an individual who had previously experimented a plateau in his aerobic capacity for 18 mo. An 18-yr-old man with C5 SCI trained with arms-only rowing for 6 mo and subsequently trained with hybrid FES-rowing for 18 mo. Peak minute ventilation (V̇e_peak) and peak oxygen consumption (V̇o_2peak) were increased after arms-only training and increased further with 6 mo of hybrid FES-row training. Despite continued intense and frequent, hybrid FES-row training, neither V̇e_peak nor V̇o_2peak increased further over the next year (1.94 and 66.0 l/min). However, when this individual performed a FES-rowing V̇o_2peak test with the addition of NIV, V̇e_peak increased by 5 l/min, resulting in an improved V̇o_2peak (2.23 l/min, +12%). This case demonstrates that noninvasive ventilation can overcome limitations to ventilation in high-level SCI and improve aerobic capacity during hybrid FES-exercise to a level not otherwise achievable. In addition, it broadly illustrates the intimate role of pulmonary function in determining the capacity to perform exercise.