Clients with Spinal Cord
Injury, Multiple Sclerosis,
Epilepsy, Fibromyalgia,
Lupus, and
Cerebral Palsy
Murderball
• http://www.youtube.com/watch?v=_kaT5dDiISw
Spinal Cord Injury
• Spinal Cord Injury (SCI) results
from the impairment or loss of
motor function, sensory
function, or both in the trunk or
limbs due to irreversible
damage to neural tissues within
the spinal cord
Spinal Cord Injury
• SCI may be classified as tetraplegia or
paraplegia
• Tetraplegia (Quadriplegia):
–Injury occurs between C1 and T1,
impairment of the arms, trunk, legs, and
pelvic organs
• Paraplegia:
–Injury to T2 to T12 which causes
impairment in the trunk, legs, and/or
pelvic organs.
SCI Cardiovascular Conditions
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Autonomic Dysreflexia
Postural Hypotension
Cardiac Atrophy
Congestive Heart Failure
Sudden death
Atherosclerosis
Autonomic Dysreflexia
• A sudden dangerous increase
in blood pressure
• Medical Emergency!
• If not treated promptly, it may
lead to seizures, stroke, and
even death
Autonomic Dysreflexia
• Common Causes:
–Kinked catheter (sitting on catheter)
–Overfilled bladder due to a blockage
–Bladder infection
–Inadequate bladder emptying
–Stones in the bladder
–Bladder spasms
–Skin irritations
–Pressure sores
Signs and Symptoms of Autonomic
Dysreflexia
• Hypertension
– An increase in 20
mm Hg or more in
systolic blood
pressure
• Pounding
headache
– Caused by the
elevation in blood
pressure
• Heavy sweating
• Flushed (red)
Face
• Blurry vision
• Dyspnea
(difficulty
breathing)
• Chest tightness
Autonomic Dysreflexia Treatment
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Stop ongoing activity!
Check blood pressure
Have person sit up with head elevated
Loosen clothing
Check urinary catheter for kinks and
straighten any
• Continue to monitor blood
pressure and call 911!
Postural Hypotension
• Blood pressure drops to
dangerously low levels in response
to an upright posture
• If it is not treated immediately, the
person may lose consciousness.
• Symptoms:
–Light-headedness
–Pallor (pale)
–Visual changes
Postural Hypotension Treatment
• Check blood pressure
• Recline the wheelchair
• Continue to check blood
pressure and call 911
SCI Exercise Testing and Training
• Acquire medical clearance
• Because of the high risk of
cardiovascular impairment,
maximal exercise testing
should be administered in
medical settings
SCI Exercise Concerns
• Many people with SCI cannot regulate body
temperature which can lead to hypothermia or
heat stroke
– Extreme temperatures should be avoided!
• Beware of freezer burn from cold packs or
burns from heat packs
• Maintain a constant exercise environment
• Have clients wear lose fitting clothes and
breathable materials
• Adequate hydration is necessary
SCI Exercise Induced Injuries
• Most common exercise induced injuries
occur at the shoulders, elbows, and wrist
• Incorporate exercises that will restore or
enhance balance around functional joints;
strengthen muscle groups of the
posterior shoulder and back and
stretch muscles of the anterior
shoulder and chest to reduce risk of
injuries
SCI Exercise Guidelines
• Avoid exercise two to three hours
after a meal
• Digestion can impair the ability to
shunt blood to the working muscles
during exercise creating a decrease in
cardiac output and blood flow
• The client should avoid exercise
during illness and bladder infection
SCI Aerobic Exercise Guidelines
• Intensity:
– 40-60%
• Mode:
– Arm bike, wheelchair basketball, swimming
• Duration:
– 10-20 minutes
• Frequency:
– 3 days per week or every other day is
recommended
SCI Dynamic Warm-Up Guidelines
• 3-5 repetitions of:
–Chin Tucks
–Neck Flexion/Extension
–Lateral Neck Flexion
–Neck Rotation:
•Turn chin toward left shoulder
then rotate it right
SCI Dynamic Warm-Up Guidelines
• 8-10 repetitions of:
– Trunk Rotation
– Shoulder Flexion/Extension
– Shoulder Horizontal Adduction/Abduction
– Shoulder Circles Forward and Backward
– Elbow Flexion
– Wrist Flexion/Extension
– Wrist Abduction/Adduction
– Wrist Circumduction
– Finger Flexion/Extension
SCI Resistance Training Exercise
Guidelines
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3 sets
8-12 reps for all functional muscle groups
Frequency: 2-3 days per week
Clients may also benefit from a single set
to fatigue of 8-12 reps using 8-12
exercises 2-3 days per week
• People with SCI are prone to Spasticity
(exaggerated muscle tone and reflexes)
which can impair exercise
SCI Resistance Training Exercises
• Lateral and medial shoulder rotation with tubing
or light dumbbells
• Lat pull-down
• Rows using machine, cable, or tubing
• Chest press using machine, cable, or tubing
• Front and lateral dumbbell raise
• Dumbbell biceps curl
• Triceps cable rope extension
• Dumbbell wrist curl
• Dumbbell wrist extension
Static Stretches (Cool Down)
• Hold all stretches for 30 seconds
• Upper trapezius:
– Lower the right shoulder and bend the head toward
the left shoulder
• Trunk:
– Raise the right arm over the head with the elbow by
the ear and bend the trunk to the left side
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Horizontal shoulder adduction/abduction
Scapular retraction/protraction
Shoulder medial/lateral rotation
Doorway pectoralis stretch
– Flex the elbow to 90 degrees
• Elbow flexion/extension
SCI Exercise Program
• http://www.youtube.com/watch?v=0dneU_
ZrF0E
Multiple Sclerosis (MS)
• Most commonly diagnosed
neurolgical diease in young adults
• The cause of MS remains
unknown
• Individuals who are diagnosed
with MS are typically between the
ages of 15 and 50 years
• More common in women than men
Multiple Sclerosis
• A degenerating disease of the central nervous
system (brain + spinal cord) that interferes with
the quality of movement
• An auto-immune disease in which the body’s
defensive system (macrophages) attack the
myelin sheath that covers the nerves
• Loss of myelin, which is the fatty substance
that insulates nerves, decreases the speed of
conduction and is associated with leaving areas
of scar tissue on the covering of nerve cells
(sclerosis)
Multiple Sclerosis (MS)
Multiple Sclerosis
• http://www.youtube.com/watch?v=voMQ2
6IW3Wg
Symptoms of Multiple Sclerosis (MS)
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Fatigue-primary symptom of MS
Pain
Muscle weakness
Heat sensitivity
Impaired balance and poor coordination
Muscle spasticity especially in the legs
Tremors
Blurred or double vision, eye discomfort or rapid eye
movements
• Decreased attention, memory, and concentration
• Dysphagia: difficulty swallowing
• Dysarthria: slurred speech
Multiple Sclerosis Treatments
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Education
Management of symptoms
Medication
Exercise
Multiple Sclerosis Exercise Guidelines
• Acquire medical clearance
• Exercise testing should be done
under medical supervision
• Heart rate and blood pressure must
be monitored throughout the exercise
program, and intensity might need to
be decreased. This can be due to
decreased blood pressure in
response to exercise
Multiple Sclerosis Exercise Guidelines
• Exercise may ease the symptoms of MS, but it
is important to take certain precautions:
– People with MS suffer from fatigue, muscle
spasticity, and heat sensitivity
• Optimal time of day to exercise may be
in the morning
• Fatigue may be reduced by aerobic
activity
• Muscle spasticity may be managed with a
stretching program
Multiple Sclerosis Exercise Guidelines
• Many people with MS experience a
temporary worsening of their
symptoms due to the following:
–Very hot or humid weather
–Overheating from exercise
–Sunbathing
–Fever
–Taking very hot showers or baths
Multiple Sclerosis Exercise Guidelines
• Heat Sensitivity:
– May lead to fatigue, loss of balance and visual
changes
– Create a cool environment with fans
– Air temperature should be cool
– Avoid swimming if pool temperature is too warm
– Drink water to stay hydrated
– Wear loose-fitting, light-colored breathable
clothing—dark clothes retain heat
– If exercising outdoors, try early morning or
evening hours due to overheating
MS Aerobic Endurance Exercise Guidelines
• Mode:
– Walking, swimming, aqua classes, chair
aerobics, stationary cycling
– Stationary cycling, swimming, aqua and
chair classes may be best due to leg
weakness, impaired balance, and
coordination
• Frequency: 3-4 sessions per week
• Duration:
– 10-30 minutes per day or two to three 10
minute sessions throughout the day
MS Aerobic Endurance Exercise Guidelines
• Intensity:
–40-70% of THRR with progression over
3-6 months to 50-70%
–Some people with MS demonstrate
blunted heart rate responses to
exercise- a condition in which the heart
rate does not increase with exercise
intensity due to medications. Therefore
utilize RPE scale.
• Do not exercise to fatigue!
MS and Benefits of Water Exercise
• Water reduces the effects of gravity,
and the buoyancy or weightlessness
that occurs in water
• Helps a person with weak muscles
attain a greater range of motion
• Chest-high water can provide support,
enabling persons with MS to stand
and maintain balance for exercises
with less effort than on land
MS and Benefits of Water Exercise
• The resistance that water provides
can be used for muscle
strengthening
• Water also helps reduce body
heat that can be generated by
exercise
• Water temperatures of 80° to 84°F
are usually recommended
MS Flexibility Guidelines
• People with MS experience spasticity which
leads to muscle stiffness and tightness, pain,
and decreased range of motion
• Stretching should be performed slowly
• Overstretching a neurologically weak
muscle may cause injury!
• Reps: 2-3 for each stretch
• Duration: 30-60 second hold
• Frequency: 5-6 days per week
MS Resistance Training Guidelines
• Over-exercising neurologically weak muscles may
lead to muscle spasticity, fatigue, frustration, and
discontinuation of the strength program
• Primary considerations are fatigue, safety and balance
• Be aware that balance difficulties may lead to falls and
injury
• Avoid complex skill oriented exercises!
• Resistance train on non-aerobic training days
• Avoid using dumbbells if individual has decreased
sensation
• Exercises should be performed in a seated position
when possible
• Use exercise machines
MS Resistance Training Guidelines
• A strengthening program is indicated after a
motivated client has successfully maintained an
aerobic and flexibility program
• Total body routine
• Sets: 1-2
• Reps: 6-10
• Intensity: Low-to-moderate
• Rest: 60 seconds
• Start slow and gradually increase
reps/intensity. Monitor fatigue levels!
Epilepsy
• Defined as two or more unprovoked
recurring seizures
• Seizure:
– An uncontrolled discharge of nerve cells
which may spread to other cells nearby or
throughout the entire brain. It usually lasts
only a few minutes. It may be associated with
loss of consciousness, loss of bowel and
bladder control and tremors. May also cause
aggression or other behavioral change
Epilepsy
• Acquire medical clearance
• In many people with epilepsy aerobic exercise
may contribute to improved seizure control
• However in 10% of individuals, vigorous
exercise may be a seizure precipitant
• Personal Trainers can apply the same exercise
principles for people with epilepsy as for healthy
populations
• In general there are no restrictions to
exercise (exercise and sports should be
encouraged)
Epilepsy
• It is safe to administer submaximal exercise testing to
establish cardiovascular fitness,
muscle strength and
endurance, flexibility, and body
composition
Treatment for Seizures
1. Time seizure episode
– A seizure that continues for more than 5
minutes call 911!
2. Approach calmly
3. Do not restrain client!
4. Loosen any tight clothing
5. Keep objects out of clients path!
6. Do not place anything in the client’s
mouth!
7. Allow seizure to end without
interference!
Treatment for Seizures
After seizure, check for breathing
and turn the client to his or her side
in recovery position to prevent
aspiration (entry of secretions in the
trachea or lungs)
9. Remain with the client until he or she
is fully awake
10. Alert the client’s family
8.
Treatment for Seizures
• http://www.youtube.com/watch?v=rjLD2Bp
oL1c
Fibromyalgia
• A chronic condition that affects soft
tissues-muscles, tendons and joints
• Often characterized by pain stiffness and
tenderness.
• One of the most common diseases
affecting the muscles
• Cause is unknown
• Not accompanied by tissue inflammation
so there is no deformity or body damage
Population Affected by Fibromyalgia
• Women (over 80%) between
30-50 years of age
• Rare with men, children, and older
adults
• 2% of the population in the U.S.
have Fibromyalgia
Signs and Symptoms of Fibromyalgia
• Three symptoms
commonly observed:
–Fatigue
–Soft tissue pain
–Non-restorative
sleep
• Very low pain
threshold
• Pain is widespread to
several parts of the
body
Signs and Symptoms of Fibromyalgia
• Pain in the neck, lower
back, and trapezius
• Joint swelling and
stiffness
• Depression
• Mental and/or
emotional
disturbances
• Anxiety
• Irritable Bowel
Syndrome
Fibromyalgia
• http://www.youtube.com/watch?v=cezfSAc
d9VI
How is Fibromyalgia Diagnosed?
• No definite blood or x-ray test to determine
Fibromyalgia
• Diagnosed through a physical exam and
physician looks for 11-18 “tender point” areas
• While a blood test doesn’t determine it, it is
important to have one because it rules out other
medical complications
• Difficult to diagnose because other medical
problems can mimic the symptoms
(hypothyroidism and cancer).
• It can also be associated with other diseases
such as rheumatoid arthritis.
Fibromyalgia Aerobic Endurance Training
Guidelines
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Acquire medical clearance
Aerobic training should begin very gradually
Allow for a longer warm-up (at least 10 minutes)
Start with light walking or biking for five minutes
and add two minutes every week until at least 30
minutes of continuous activity can be performed
at least three days per week
Aquatic exercise a good. Avoid water that is too
warm or cold as this can exacerbate symptoms
Allow at least 48 hrs of rest
Fibromyalgia Resistance Training Guidelines
• Strength training should not be performed until the
client can tolerate walking and stretching without
becoming exhausted
• Begin with one exercise per muscle group and
perform one set. Sometimes only a few repetitions can
be tolerated in the beginning
• Perform the exercises without weights and then
progress to resistance bands or machines that limit
eccentric movements that lengthen the muscles,
which are associated with increased muscle tears in
people with fibromyalgia
• Machines that can be utilized include hydraulic
machines and minimal weight pulley machines
Fibromyalgia Resistance Training Guidelines
• 2-3 minute rest intervals between sets is
required since the body takes longer to
replenish energy stores. This time can be used
for stretching the muscles you are working
• Work towards completing a strength training
routine two to three days per week and
increase the number of sets and reps slowly, as
tolerated.
• Free weight exercises can be introduced once
the client achieves a higher fitness level,
although this may take many months to reach.
Fibromyalgia Flexibility Guidelines
• Stretching should be done following the warm-up
and after cooling down
• Each stretch should be held 20 to 60 seconds, and
the routine should not involve getting up and down
from the floor
• The benefits of stretching include:
– Improved circulation
– Relieving pain symptoms
– Loosening tight muscles (specifically around the
neck and shoulders) that seem to be more tense
in fibromyalgia clients
Fibromyalgia Contraindications
• Client cannot progress as fast
• Allow more time to increase weight, sets
and repetitions in training programs
• Shorter, more frequent exercise sessions
are preferred over one long session
• If chronic fatigue, troubled sleeping or
headaches develop, cut back the intensity
of your workouts
Fibromyalgia Contraindications
• Avoid the following exercises:
–Shrugs
–Pull-ups
–Rowing machines
–Leg extensions
–Squats
–Cable crossover machines
• These exercises place too much
stress on tender areas
Cerebral Palsy
• http://www.youtube.com/watch?v=lFMLL6
A7K0U
Cerebral Palsy (CP)
• Non-progressive, non-contagious disorder that
affects muscle tone, movement, and motor skills
(ability to move in a coordinated and purposeful
way)
• CP is usually caused by brain damage as the
result of injury or disease at or before birth (i.e.,
premature babies, meningitis, malnutrition,
shaken baby syndrome)
• The term cerebral refers to the brain’s two
halves, or hemispheres, and palsy describes any
disorder that impairs control of body movement
Cerebral Palsy
• One of the most common congenital (existing
before birth or at birth) disorders of childhood
• About 500,000 children and adults in the United
States have the condition.
• The three types of CP are:
– Spastic cerebral palsy — causes stiffness and
movement difficulties
– Athetoid cerebral palsy — leads to involuntary
and uncontrolled movements
– Ataxic cerebral palsy — causes a disturbed sense
of balance and depth perception
Characteristics of Cerebral Palsy
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Muscle tightness
Muscle spasticity
Muscle weakness
Incoordination
Difficulty maintaining posture
Difficulty maintaining balance
Involuntary muscle movement
Difficulty with fine motor tasks:
–Writing, cutting with scissors
•
Characteristics of Cerebral Palsy
Dysphagia: difficulty swallowing
Speech impairments
Deficiencies in sensation and
perception
Impaired vision and hearing
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Seizures
Cognitive Dysfunction
Learning deficiencies
Breathing difficulties
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Management of Cerebral Palsy Symptoms
• Mostly involves managing the secondary
symptoms:
– Muscle spasticity, seizures, joint pain,
posture deformities
• Seizures occur in 60% of people with CP
• May be on anti-seizure medications, muscle
relaxants or anti-spasmodic medications
• May also be on medications that control joint
pain, posture deformities, and bladder
dysfunction
Exercise Guidelines for Cerebral Palsy
• Acquire medical clearance
• Screen for musculoskeletal
abnormalities, heart disease, and
other chronic diseases such as
diabetes, arthritis and hypertension
• Clients with CP may have tremors,
avoid using dumbbells and
barbells
Exercise Guidelines for Cerebral Palsy
• Exercise can help prevent the
weakening or deterioration of
muscles and avoid contracture,
in which muscles become fixed
in a rigid, abnormal position
CP Exercise Program Goals
• Aerobic Endurance :
–To improve the respiratory system
–Increase stamina
• Strength:
–Prevent muscle atrophy
–Prevent muscle contractures
–Prevent muscle imbalance
CP Exercise Program Goals
• Flexibility:
–To avoid muscle contracture
–To increase range of motion and
maintain joint flexibility
–To reduce tension/stress
–Increase body awareness
–Encourage/facilitate making a mind
body connection
CP Exercise Program Goals
• Coordination, balance, and core
training:
–To challenge the body’s proprioceptive
system (muscle spindles and golgi
tendon organs)
–Improve trunk stabilization
–Improve postural alignment and control
–Improve gait (walking)
–Improve weight transfer movements
Exercise Guidelines for Cerebral Palsy
• The personal trainer will need
to be creative and often modify
equipment and exercises
because of limitations client
may have
Aerobic Exercise Guidelines for Cerebral Palsy
• Moderate to vigorous intensity:
– 50-85% of VO2 or RPE of 4-6 on 0-10 scale
• Duration:
– 30 or more minutes
• Frequency:
– 4-7 days per week
• Mode:
– Elliptical, swimming, stationary bicycle, walking
• In very de-conditioned clients:
– Duration: 5-10 minutes twice per day
– Frequency: 4-7 days per week
Resistance Training Guidelines for Cerebral
Palsy
• Frequency:
– 2-3 days a week
• Volume:
– 2-3 sets
– 8-12 repetitions
• Intensity:
– 40-60%
• Focus on addressing muscle imbalances, weakness
and areas that are most susceptible to atrophy
• Some exercises will need to be modified because of
spasticity
Types of Resistance Training
• Free weights
– With caution due to tremors
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Medicine balls
Machines
Resistance bands
Sand or water filled equipment
Water
Exercise balls (air filled)
Lupus
• Lupus is a chronic inflammatory autoimmune disease
that can damage the skin, joints, and/or organs (heart,
brain, kidneys)
• Lupus can range from mild to life-threatening
• It is most common in women of childbearing age-1544
• Men and children can develop it too
• No gene or group of genes has been proven to cause
lupus
• Individuals who are Asian, African, Native American,
or Hispanic have a greater risk of developing lupus,
which may be related to genes
Lupus
• It takes some kind of environmental trigger
to set off the illness or to bring on
inflammation
• Examples include:
– Ultraviolet rays from the sun
– A cold, virus, or infection
– Emotional stress, such as a divorce, illness,
death in the family
– Surgery
– Pregnancy, or giving birth
Symptoms of Lupus
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Extreme fatigue
Fever
Headaches
Painful or swollen joints
Anemia
Edema in the feet, legs,
hands, and/or around
eyes
• Pleurisy- chest pain
during deep breathing
• Shortness of breath
• Butterfly-shaped rash
across cheeks and
nose
• Sun or light sensitivity
• Hair loss
• Anxiety
• Depression
• Memory Loss
• Raynaud’s Disease:
fingers turning white
and/or blue when cold
• Mouth nose ulcers
Lupus and Exercise
• There are no specific guidelines as to how
much exercise a person should do or
when they should do it
• Some people with lupus can exercise daily
for 30-60 minutes without a problem while
others may not be able to
• Everyone is different, so you need to
listen to your client
Lupus and Exercise
• Exercise can reduce the symptoms of Lupus, increase
endurance and strength, improve mood, and mobility
• Exercising is contraindicated during symptoms
(flares)
– Rest is necessary
• Aerobic exercise is most appropriate
– Swimming, yoga, walking, cycling, Elliptical
machine
• Isometric exercises should be performed with
caution
– Increases blood pressure
Lupus and Exercise
• Avoid outdoor exercise in the sun
because sunlight can trigger
symptoms
• Exercise daily when stiffness and pain are
the least
• Perform gentle active range of motion
(AROM) exercises in the evening to
reduce stiffness
• Modify exercise to avoid increasing joint
pain