Topic of the Month - SCI and Exercise

Topic of the Month: Exercise and Spinal Cord Injury

Physical Fitness has been well documented for the able- bodied population for many years. Physical fitness has also shown to be important for persons with SCI. However, there are many factors that limit the ability for a person with SCI to exercise. Disruptions of the autonomic nervous system, motor dysfunction and secondary complications can all limit the exercise tolerance of persons with SCI. Research by such authors as Figoni, Hooker, Gass, Camp, Glaser, Nash, Davis, Shepherd, etc have shown the many benefits of physical fitness for persons with SCI.

The National Spinal Cord Injury Database estimates that roughly 11,000 people sustain a spinal cord injury (SCI) each year. The mean age at the time of injury is 32.1 years with over half of the persons between the ages of 16 and 25 years old. The average life expectancy after injury is between 46 years for persons with paraplegia and 27 years for persons with high-level tetraplegia. The leading causes of death are respiratory disease (20.4%) and heart disease (18.7%). Heart disease is the leading cause of death in persons with paraplegia and second for persons with tetraplegia (Stover, 1995).

There are many forms of exercise programs that one can initiate in the clinic. Arm crank ergometers, wheelchair ergometers, various circuit training methods, strength training, FES, body weight supported ambulation are just a few documented forms of exercise training for persons with SCI.

The questions the SCI SIG posed were:

What testing methods are you using successfully in the clinics?

It is challenging to objectively measure aerobic capacity in most PT settings. There are many options and varying degrees of measuring aerobic capacity for persons with spinal cord injury. If cost is a factor, there is research on various field test (Vanderthommen-2002, and Franklin-1990) that can be performed that only require a stopwatch and a measured off area. These tests are not as precise as other, more expensive options, but give a baseline for comparison.
The next least expensive option that is available in most clinics is the arm crank ergometer. One can use an existing LE ergometer and mount it on a table, or utilize and arm crank ergometer that already exists in your clinic. VO2 can be calculated based on the resistance achieved (Knutson 1973). In additions wheelchair treadmill protocol can calculate VO2 without the use of a metabolic cart. (Hartung, 1993)
The above references will assist in calculating a baseline metabolic VO2 that you can compare the effectiveness of any training. For monitoring heart rate, the clinician must be careful in measuring HR responses for persons with injury levels above T5. The Borg Scale of Perceived Exertion has been widely used for this population. Also, the clinician must be aware of exercise hypotension with this population and should be measuring BP prior to, during and post exercise.
There was some discussion regarding submaximal exercise testing for persons following a stroke. Since this discussion was off the topic of SCI exercise, this discussion will not be presented here. However, you can read this discussion on the List Serve dated 1/22/04.

What mode, frequency, intensity and duration of activity in the SCI population have you all had the greatest "success" with?

Modes Utilized
- Arm crank ergometer
- Wheelchair ergometer
- Circuit Training
- FES
- Treadmill training
- Weight lifting
- Other
- Aerobic exercise (swimming, road racing etc)

Frequency, intensity and duration were not discussed specifically, However the studies in this area indicated the following:
- Frequency 2-5x/week
- Duration: 20 minutes - 120 minutes
- Intensity: HR 40% - 85% of Max HR Borg rate of perceived exertion 13-15.
What evidence-based fitness programs have you instituted in your clinics (inpatient and outpatient)?

Group therapy for stretching/strengthening exercises
Exercise videos have been trailed, but no evidence to date to suggest the success of these programs.
An entire fitness/exercise facility built to service inpatient and outpatient clients with disabilities.

What programs have you used for the prevention of over-use injuries?
Proper stretching/strengthening programs to stretch anterior shoulder musculature and strengthening programs for the posterior shoulder musculative. (Hicks, 2003;Jacobs, 2001;Nash 2002)

References

Davis GM. Exercise capacity of individuals with paraplegia. Med Sci Sports Exerc.1993; 25(4): 423-432.
DavisGM, Plyley MJ, Shepherd RJ.Gains of cardiorespiratory fitness with arm-crank training in spinally disabled men. Can J Sport Sci. 1991; 16:64-72
Figoni SP. Perspectives on cardiovascular fitness and spinal cord injury. J Am Paraplegia Soc.1990; 13:63-71.
Franklin BA, Swantek KI, Grais SL, Johnstone KS, Gordon S, Timmis GC. Field test estimation of maximal oxygen consumption in wheelchair users. Arch Phys Med Rehabil. 1990;71:574-578.
Gass EM, Harvey LA, Gass GC. Maximal physiological responses during arm cranking and treadmill wheelchair propulsion in T4-T6 paraplegic men. Paraplegia 1995; 33:267-270.
Gass GC, Camp EM. The maximum physiological responses during incremental wheelchair and arm cranking exercise in male paraplegics. Med Sci Sports Exerc. 1984; 16:355-359.
Glaser RM, Sawka MN, Brune MF, Wilde WS. Physiological responses to maximal effort wheelchair and arm crank ergometry. J Appl Physiol. 1980; 48: 1060-1064.
Hartung GH, Lally DA, Blanco RJ. Comparison of treadmill exercise testing protocols for wheelchair users. Eur J Appl Physiol. 1993; 66(4): 362-365.
Hicks Al, Martin KA, Ditor DS, Latimer AE, Craven C, Bugaresti J, McCartney N. Long term exercise training in persons with spinal cord injury: effects on strengt, arm ergometry performance and psychological well being. Spinal Cord. 2003; 41:34-43
Hooker SP, Wells CL. Aerobic power of competitive paraplegic road racers. Paraplegia. 1990; 30:428-436
Hooker SP, Wells Cl. Effect of low and moderate intensity training in spinal cord injured persons. Med Sci Sports Exerc. 1989; 21:18-22.

Hooker SP, Figoni SF, Rodgers MM, Glaser RM, Mathews T, Suryaprasad AG, Gupta SC. Physiological effects of electric stimulation leg cycle exercise training in spinal cord injured person. Arch Phys Med Rehabil. 1992; 73:470-476.
Jacobs PL, Nash MS, Rusinowski JW. Circuit training provides cardiorespiratory and strength benefits in persons with paraplegia. Med Sci in Sports Exerc. 2001; 33(5): 711-717.
Knutson E, Lewenhaupt-Olsson E, Thorsen OM. Physical work capacity and physical conditioning in paraplegic patients. Paraplegia. 1973; 11:205-216.
Nash MS, Jacobs PL, Woods JM, Clark JE, Pray TA, Pumarejo AE. Acomparison of 2 circuit exercise training techniques for eliciting matched metabolic responses in persons with paraplegia. Arch Phys Med Rehabil. 2002; 83: 201-209.
Nash MS. Exercise reconditioning of the heart and peripheral circulation after spinal cord injury. Top Spinal Cord Inj Rehabil. 1998; 3(3): 1-15.
National Spinal Cord Injury Database: Facts and Figures at a Glance, May 2001. www.spinalcord.uab.edu
Stover SL, DeLisa JA, Whiteneck GG. Spinal Cord Injury Clinical Outcomes From the Model Systems. Aspen Publication. Gaithersburg, MD, 1995.
Vanderthommen M. Multistage field test of wheelchair users for evaluation of fitness and prediction for peak oxygen uptake. Journal of Rehab Research and Development. 2002; 39(6): 655-692.