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 Im 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

WHATS 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

PERIPHERAL TRAINING EFFECTS

Increased O2 Use & increased blood flow to exercising muscles Mm Hypertrophy Increased Localized Strength & Endurance

LESS PRONOUNCED WHEN TRAINING WITH SMALL UE MUSCLES

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 Specificity Progression Consistency

FITTE FACTORS
FREQUENCY
3 TO 5X/WK Modify for Adequate Rest Btw Sessions

TIME (DURATION)
15-60 min Very Deconditioned Guidelines

INTENSITY
ACSM Guidelines for THR as Guide Borgs Rate of Perceived Exertion (RPE) TalkSing Test

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
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