EXERCISE PRESCRIPTIONFor 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

• 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

• 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 Progression– Specificity 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 RECOMMENDATIONSC4 & 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

• 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

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