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 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 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 –OverloadProgression –SpecificityConsistency

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) – 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 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 = $ Hand Crank Cycles = $ Lightweight W/C = $

HOME EXERCISE STRENGTH –Dumbbells=$6-20 per weight, $200 set, –Cuff Weights=$6-80 per weight, set –Medicine Balls=($20-60 per ball) –Multistation Machines=$200-$1000 FLEXIBILITY –Stretch Bands, Wands, Sticks –Floor Mats=$20-500