EXERCISE PRESCRIPTION
For PERSONS With
SPINAL CORD INJURY
PT 630 Cardiopulmonary Therapeutics Fall 1999
“Physical activity allows me to step
away from my disability and join a
vital life force. In a way, exercise
reconnects me with myself. It
helps me realize that I’m not
limited by my physical body. It
helps me recognize a whole inner
set of life, full of intensity,
discipline and joy.”
Jim McLaren, age 31, C5-6 Tetraplegia, World Record Holder
Triathlete, Motivation Speaker
INTRODUCTION
• Additional Demands of Physical Disability
– Greater Need for Maximizing Physical
Function
• Physical Fitness Important for SCI
– Enhances Functional Ability
– Promotes Better Quality of Life
– Improvement in Physiologic Systems
– Functional Adaptations & Improved ADL
BACKGROUND
• Long Term Survival
with SCI Improving
• ONCE MEDICALLY
STABLE
– PERSONS WITH
SCI NEED NOT BE
CONSIDERED
FRAGILE, IN NEED
OF PROTECTION,
OR UNABLE TO
EXERCISE
BENEFITS OF EXERCISE
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•
•
•
PHYSICAL
PHYSIOLOGICAL
FUNCTIONAL
PSYCHOLOGICAL
WHAT’S THE PROBLEM?
• People with SCI Become Less Active As
Result of Paralysis
• Promotion of Optimal Physical Fitness
(as allowed by level of injury) Neglected
Component of Health Practice for
Chronic Disability
CYCLE OF DISABILITY
RISK FACTORS OF
SEDENTARY LIFESTYLE
PHYSICAL FITNESS
TRAINING MAY BE THE
ONLY MEANS OF
OVERCOMING NEGATIVE
EFFECTS OF SEDENTARY
LIFESTYLE
IS THIS A ROLE FOR PT?
WHO DOES WHAT?
HOW?
MODERATE INTENSITY
ENDURANCE ACTIVITY
• ABLED BODIED
– Short Bouts of Moderate Activity
– Spread Throughout Day
– 30 Minutes or Longer
• SCI POPULATION
– NIDRR Studies Ongoing
– Moderate Intensity Regular Exercise
Benefits Not Fully Defined
IMPORTANT TOOLS FOR
EXERCISE PRESCRIPTION
• EDUCATION OF HEALTH CARE
PROVIDERS
– PHYSIOLOGICAL CHANGES AFTER SCI
– RELEVANCE OF CHANGES TO
EXERCISE
– ADAPT HEALTH & FITNESS ACTIVITIES
MOST IMPORTANT TOOL
• KNOWLEDGEABLE
IN PROGRAMS &
PROTOCALS FOR
EXERCISE ACTIVITY
• SENSE OF
CREATIVITY
• WILLINGNESS TO
TRY NEW THINGS
GOALS
• BENEFITS OF PHYSICAL FITNESS AND
TRAINING IN SCI
• PRACTICAL SUGGESTIONS FOR EXERCISE
PRESCRIPTION
• Physical Changes Caused by SCI That
Affect Safety & Efficacy of Exercise
• Exercise Training Effects in Para &
Tetraplegia
• Fundamentals of Exercise Prescription
– Age, Physical Characteristics, Previous
Exercise Experience, Functional Capacity
• Safety Strategies for Injury Prevention
• Adapted Equipment & Options for Home
or Health Club
ASSESSMENT
• NORMATIVE VALUES FOR STRENGTH
ENDURANCE AND CARDIOVASCULAR
ENDURANCE NOT YET ESTABLISHED IN
SCI POPULATION
CARDIORESPIRATORY
• For Some, Dependent on Level of
Peripheral Muscle Endurance than on
Central Cardiorespiratory Effects
– Paralysis of Active Muscle Mass & Loss of
Muscle Pumping--Peripheral Return
– T6 and above loss of SNS automatic
reflexes for normal exercise response
QUESTIONS REMAIN
• WIDE RANGE OF PHYSIOLOGICAL
DIFFERENCES DEPENDING ON LEVEL
– Para Vs Tetra
• COMPLETENESS OF INJURY
• BODY SIZE, AGE, GENDER, PHYSICAL
FITNESS BEFORE INJURY,
MEDICATIONS, POSTURE
IN GENERAL, THE HIGHER
THE LEVEL OF INJURY THE
MORE LIKELY SIGNIFICANT
REDUCTION IN
CARDIORESPIRATORY
CAPACITY
WHY?
• PROGRESSIVE LOSS
OF SKELETAL
MUSCLE WITH
EACH HIGHER
LEVEL OF INJURY
• DISRUPTION OF
SYMPATHETIC
OUTFLOW TRACTS
WITH LEVELS OF
INJURY ABOVE T6
MUSCLE PARALYSIS
FACTORS
• LE Paralysis Limits Amount of Muscle
Available for Exercise-Induced
Challenge to Heart
• Small Muscles of Arms Easily Fatigued-Peripheral Restrictions--Limit Exercise
Capacity Before Central Cardiac System
Stressed
SYMPATHETIC
DECENTRALIZATION
• Unopposed PNS via Vagal Nerve
– Limits Cardiac Output
– Cardio Acceleration
– Shunting of Blood from Inactive to Active
Muscle
• Blunting of HR Response to Exercise
Due to No Vagal Withdrawal
– 110 to 120 BPM
CV RESPONSE TO
EXERCISE ABOVE T6
• VASOMOTOR PARALYSIS
– PREVENTS NORMAL BLOOD
REDISTRIBUTION IN UPRIGHT EXERCISE-VENOUS POOLING
• COMPROMISED VENOUS RETURN TO
HEART
– LIMITS CARDIAC PRELOAD, EXERCISE SV,
EXERCISE INDUCED CO--ABILITY OF HEART
TO RESPOND TO EXERCISE REDUCED
MORE FACTORS ABOVE T6
• Impaired Shunting of Blood to Active
Muscles--Early Onset of Fatigue in small
muscles of arms
• Inadequate Sweating
• Reduced Thermoregulation
• Increased Fatigue
CV Response to Exercise
• T6-T10
– NORMAL
REGULATION OF
CARDIAC
FUNCTION--Normal
Heart Rate
Response to
Exercise
– DISRUPTED
VENOUS RETURN
• BELOW T10
– SNS SPLANCHIC
INNERVATION TO
ABD ORGANS
– PARTIAL SNS
INNERVATION TO
LOWER
EXTREMITIES
– SOME VENOUS
RETURN
SPLANCHNIC
NERVES
EXERCISE RESPONSE IN
TETRAPLEGIA
• Unique Challenge to Aerobic Exercise &
Cardiovascular Health
• Studies Have Shown Training Effects
with Exercise tolerance, muscle
endurance, peak VO2, peak power
output (Figoni, 1993)
• Physiological Training Effects Peripheral
– Muscle Endurance Rather Than Central
EXERCISE RESPONSE IN
PARAPLEGIA
• Less ANS Disruption
– Normal Heart Rate Response to Exercise
• More Available Muscle Mass
– May Still Have Venous Pooling &
Decreased CO & SV for same level of VO2
max in able bodied (Figoni, 1990)
– Limited CO can limit oxygen to exercising
UE muscles and have less peak
performance than AB, but more than tetra
ADAPTATIONS TO
ENDURANCE TRAINING
• CENTRAL TRAINING
EFFECTS
– Changes in HR @
Rest and Submax
Exercise, and CO
• LESS PRONOUNCED
WHEN TRAINING
WITH SMALL UE
MUSCLES
• PERIPHERAL
TRAINING EFFECTS
– Increased O2 Use &
increased blood
flow to exercising
muscles
– Mm Hypertrophy
– Increased
Localized Strength
& Endurance
Value of Peripheral Training
• Improved Work Capacity &
Strength
• Everyday Activities Less
Difficult
• More Energy Reserves for
Greater Independence
• Increased Ability to Pursue
More Active Lifestyle
ASSESSMENT TOOLS
• Vary Widely in Complexity & Practicality
• GOAL OF ASSESSMENT
– Level of Fitness--Max & Submax Testing
– Identify Cardiorespiratory Problems (OH)
– Determine wheelchair propulsion capacity
– Comparative Data Over Time
TESTING PROCEDURES
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Well Established for Able Bodied
Not for Those with Disabilities
ACE (Arm Crank Ergometers)
WCE (Wheelchair Ergometers)
Field Testing (12 Minute Distance Test)
TESTING FOR TETRAS
• Impossible to Evaluate Central Cardiac
Fitness Because Small Muscles do not
Adequately Stress Heart
• Measure Peak Exercise Capacity of
Other Physiological Support Systems
• Glaser (1988) & Figoni (1990, 1993)
– Extensive Testing on Voluntary Arm
Exercise in Tetraplegia
DESIGNING PROGRAM
• Complete Medical & Activity Profile
– Basic +
– OH, ROM limitations from contractures,
fractures, heterotopic ossification, UE
overuse, skin problems
– Self-Dressing & ADL Status
– Transfers, W/C Propulsion
– Time up in Community, Home
Management
GUIDELINES FOR
EXERCISE ACTIVITIES
• ACSM Guidelines for Able Bodied
• Absent Guidelines for SCI Population
• Modify & Adapt from NonDisabled
Guidelines For Less Muscle Mass
• Training Principles Same
– Overload
– Specificity
Progression
Consistency
FITTE FACTORS
• FREQUENCY
– 3 TO 5X/WK
– Modify for
Adequate Rest Btw
Sessions
• INTENSITY
– ACSM Guidelines
for THR as Guide
– Borg’s Rate of
Perceived Exertion
(RPE)
– TalkSing Test
• TIME (DURATION)
– 15-60 min
– Very Deconditioned
Guidelines
• TYPE (MODE)
– Largest MS Mass
– FES+LCE (+ACE)
– $20,000 FES Bike
• ENJOYMENT
TYPES OF ACTIVITIES FOR
CARDIOVASCULAR
TRAINING AND STRENGTH
TRAINING
FITNESS RECOMMENDATIONS
C4 & ABOVE
• ROM & POSTURE
EXERCISES
• BREATHING
EXERCISES
• USE COMPUTER
• PROACTIVE
NUTRITIONAL
PLANNING
• ACTIVE ROLE IN
PLANNING DAILY
SCHEDULE &
HIRING
ATTENDANTS
• PURSUIT OF
MENTAL FITNESS
– Intellectual, Social,
Spiritual
C5
• MANUAL W/C PROPULSION ON HARD
LEVEL SURFACES FOR ENDURANCE
• DELTOID, BICEPS, SCAPULAR
STRENGTH WITH SET UP
– LOW WEIGHTS, HIGH REPS
• ACE WITH ADAPTED HAND GRIPS
– Trunk & Chest Strapping
• CHEST FLEXIBILITY, GOOD POSTURE
• REGULAR PASSIVE STANDING
– DECREASE SPASTICITY, STRETCHING
C6
• SCAPULAR AND LATS FOR ROTATOR
CUFF AND SCAPULAR STABILITY
– Prevent Rounded Shld Posture & Shld
Impingement
• ENDURANCE W/C ACTIVITIES
– Runs, ACE, Hand Bikes -hand adapt, chest
& trunk stability (Use RPE)
• FLEXIBILITY OF SHLDS, BACK,NECK
• REGULAR STANDING IN FRAME
C7 TO T1
• STRENGTH & ENDURANCE OF ALL
SHOULDER GIRDLE MUSCLES FOR
TRANSFERS, W/C MOBILITY, DRIVING
• ENDURANCE THROUGH W/C PUSHING,
ACE, HANDCYCLING
– Adapted Gloves or cuffs as needed
– Trunk or chest strapping as needed
– RPE
T2 TO T6
• UE STRENGTHENING & UPPER BACK
– Emphasize pulling to balance back
muscles with strong anterior muscles due
to w/c and crutch activities
• EXERCISE OUT OF CHAIR
• VARIETY OF STRENGTH & ENDURANCE
– Free weights, machines, handcycles, w/c
runs, swimming
– RPE
T7 TO T12
• Include Abdominal and Back Exercises
for Strength & Endurance
• Increases in Aerobic Endurance Possible
• Central Training Effect May Occur
• HR + RPE for Monitoring
L1 TO S5
• Strength and Endurance as for Other
Paraplegic Individuals
– Involve Legs
– Cycling, Swimming, Walking
• Hip Flexibility for Ambulation & Upright
Activities
• Balance Fitness & Function to Prevent
Overuse & Injuries to Shld, Wrists and
elbows
SAFETY CONSIDERATIONS
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POSTURAL HYPOTENSION
AUTONOMIC DYSREFLEXIA
HYPERTHERMIA/HYPOTHERMIA
SKIN BREAKDOWN
OVERUSE & INJURY
EQUIPMENT
CONSIDERATIONS
• FACILITY CONCERNS
• SCI “User Friendly”
– Allow for Independence of User
– Safety
– Padding on Benches and Seats
– Gloves & Handwraps
– Lifts or Ramps for Pools
HOME EXERCISE
• Transportation, Lack of Facilities
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AEROBIC EQUIPMENT
Videotapes (seated aerobics) = $10
Table top ACE = $200-500
Hand Crank Cycles = $1500-2500
Lightweight W/C = $1500-2000
HOME EXERCISE
• STRENGTH
– Dumbbells=$6-20 per weight, $200 set,
– Cuff Weights=$6-80 per weight, 90-200 set
– Medicine Balls=($20-60 per ball)
– Multistation Machines=$200-$1000
• FLEXIBILITY
– Stretch Bands, Wands, Sticks
– Floor Mats=$20-500