Introduction to Spinal Cord Injury

Spinal cord injury (SCI) is a complete or partial lesion to the spinal cord. The result of SCI is functional loss (sensory motor and autonomic dysfunction); severity depends on the level and completeness of the lesion. The physical ability of persons with SCI is classified according to the amount of function retained. Common categories are paraplegia (SCI affecting level T2 and below, trunk and lower extremities involved) and quadriplegia/tetraplegia (SCI affecting level T1 or above, all four extremities and trunk involved).

Importance of Exercise

Individuals with spinal cord injuries can experience several benefits from regular exercise, which may include:

• Prevents secondary conditions such as cardiovascular disease, diabetes, pressure sores, carpal tunnel syndrome, chronic obstructive pulmonary disease, hypertension, urinary tract infections, and respiratory disease.
• Prevents deconditioning and obesity
• Provides psychological and/or recreational benefits
• Can help ease the effort involved in activities of daily living (ADLs)

Best Exercises for Persons with SCI

Some exercises provide greater benefit for persons with SCI than other. These include:

• Aerobic exercise to maintain cardiovascular health and prevent secondary conditions
• Strength training to maintain and improve the ability to perform activities of daily living and mobility, to aid in transfers, and to prevent injury through muscular balance
• Flexibility training to improve range of motion and reduce spasticity

Important Considerations When Exercising

• Incontinence (flaccid or neurogenic bowel/bladder) – Individuals with lesions above the sacral level experience a loss of control with their bowel or bladder.
  KEY: Monitor urinary cycle, be sure to empty your bowel and bladder before starting exercise.
• Spasticity – This condition is characterized by high muscle tone and hyperactive stretch reflexes. It typically occurs in the muscles below the site of injury and is exacerbated by exposure to cold air, urinary tract infections and physical exercise.
  KEY: You should stretch spastic muscle groups often. When you are at home you should extend your legs as often as possible.
• Autonomic Dysreflexia – A sudden rise in blood pressure resulting from an exaggerated autonomic nervous system response to noxious stimuli below the level of injury, usually due to bladder/bowel overdistension or blocked catheter. Symptoms include profuse sweating, sudden elevation in blood pressure, flushing, shivering, headache, and nausea.
  KEY: Get rid of noxious stimuli if possible or seek medical attention immediately when it occurs.
• Orthostatic hypotension – A drop in blood pressure (greater than 20 mmHg for systolic blood pressure and greater than 10 mmHg for diastolic blood pressure). It occurs in upright postures, especially moving from supine to upright sitting/standing/head-up tilt. Symptoms include nausea, dizziness and light-headedness.
  KEY: Monitor blood pressure throughout exercise, avoid quick movements, perform orthostatic training (if available), maintain proper hydration, and use compression stockings and an abdominal binder. If orthostatic hypotension occurs, lie in a supine position with your feet elevated. Sometimes holding your breath while changing positions can help reduce the chance of orthostatic hypotension taking place.
• Thermoregulation – Irregular body temperatures are often experienced by individuals with SCI.
  KEY: Wear appropriate clothing, drink plenty of fluids and take precautions in certain environments; in warm environments, a fan and water spray will aid in cooling, and in cold environments, wear extra layers.
• Pressure sores (decubitus ulcers) – Damage to the skin or underlying tissue caused by prolonged sitting, using old wheelchair cushions, sitting on hard surfaces, shear forces or as a result of a fall.
  KEY: Check skin regularly and perform wheelchair push-ups or pressure releases often. (See strength training section for protocol.)
• Transfers – Be sure to follow appropriate guidelines.
• Balance – Use straps or other physical assistance to hold the trunk in position during upright exercise.

Cardiovascular Training Guidelines

The American College of Sports Medicine (ACSM) recommends performing 20 to 60 minutes of continuous aerobic exercise or multiple sessions of short duration (approximately 10 minutes) for three to five sessions per week. For individuals just starting an exercise program, a circuit training program is effective.

Aerobic exercise can be monitored using an individual’s maximal heart rate (MHR) or rating of perceived exertion (RPE). MHR for individuals with SCI may be lower than for individuals without SCI while RPE should provide an accurate measure. See NCHPAD’s general exercise factsheet for more information.

Quadriplegia

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MHR typically does not exceed 100 to 125 bpm, and training intensity should be between 50% and 70% maximal heart rate. Therefore, an average target heart rate (THR) falls between 65 and 91 bpm.

Arm ergometry is a preferred type of exercise training for individuals with quadriplegia. Be sure the wheelchair is locked, the hands are secured to the equipment (straps can be used for stability and balance) and the ergometer is in a fixed position. Other forms of aerobic exercise may include pushing their chair or a track chair, handcycling, and NuStep machines.

The following video shows individuals with quadriplegia engaging in aerobic exercise:  https://www.youtube.com/watch?v=1CdwOe-5OaA&list=TLqFcbekj165s

Paraplegia

The MHR of individuals with a lesion T1 to T6 is suppressed; however, for lesions below T6, the MHR is closer to the age-predicted maximum. Training intensity should not go above 70%.

Types of cardiovascular training that benefit individuals with paraplegia are wheelchair ergometry, upper-body calisthenics, rowing machine, recumbent steppers, handcyling, sports such as basketball, track, swimming, quad rugby, and functional electrical stimulation-leg cycle ergometer (FES-LCE).

The following video features individuals with paraplegia engaging in aerobic activity:  https://www.youtube.com/watch?v=-1y3oly6V4Y

Strength Training Guidelines

The following guidelines should be followed by individuals with SCI as they engage in a strength training exercise program:

• Training sessions should be held three days per week.
• Refrain from training the same muscle groups on consecutive days.
• Upper-body pushing and pressing exercises (bench press, overhead press) will help transfers and wheeling, while pulling/rowing exercises will help prevent shoulder overuse injuries and improve sitting posture.
• If you do not transfer weight regularly, perform wheelchair push-ups every 10 to 30 minutes and hold for 30 to 60 seconds. When doing wheelchair push-ups, be sure to bend the elbows slightly.
• Use straps or a partner for stabilization and balance.
• Vary exercises to reduce over-use injuries and emphasize muscle groups that are still functional.

Types of strength training that benefit individuals with SCI are free weights, weight machines (e.g., Nautilus), medicine ball, wall pulley, cable columns, and theraband.

Flexibility Training Guidelines

Flexibility training is important to prevent contractures (permanently shortened muscles), particularly in the hip area. Paralyzed muscles should be passively stretched by an exercise specialist; specifically, the hamstrings, adductors, hip flexors, plantar flexors, and lumbar extensors.

Types of flexibility training are:

• Passive and active resistance
• Theraband
• Standing in a standing frame (if not medically contraindicated)

Important Safety Considerations

• Get physician consent.
• Regularly monitor blood pressure, heart rate, RPE, and symptoms.
• Stop exercising if you feel pain or discomfort.
• Don’t exercise if you are ill (i.e., cold, flu, bladder infection, pressure ulcer, unusual spasticity).
• Check medications and their effect on exercise tolerance.
• Extended periods of inactivity may cause osteoporosis.

Special thanks to Dr. Steven Figoni and Bridget Collins.