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EXERCISE PRESCRIPTIONFor PERSONS With
SPINAL CORD INJURY
PT 630 Cardiopulmonary Therapeutics Fall 1999
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Physical activity allows me to step
away from my disability and join avital life force. In a way, exercisereconnects me with myself. It
helps me realize that Im notlimited by my physical body. Ithelps me recognize a whole inner
set of life, full of intensity,discipline and joy.
Jim McLaren, age 31, C5-6 Tetraplegia, World Record HolderTriathlete, Motivation Speaker
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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
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BACKGROUND Long Term Survival
with SCI Improving
ONCE MEDICALLY
STABLE PERSONS WITH
SCI NEED NOT BECONSIDERED
FRAGILE, IN NEEDOF PROTECTION,OR UNABLE TOEXERCISE
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BENEFITS OF EXERCISE
PHYSICAL
PHYSIOLOGICAL
FUNCTIONAL PSYCHOLOGICAL
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WHATS THE PROBLEM?
People with SCI Become Less Active AsResult of Paralysis
Promotion of Optimal Physical Fitness(as allowed by level of injury) NeglectedComponent of Health Practice for
Chronic Disability
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CYCLE OF DISABILITY
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RISK FACTORS OF
SEDENTARY LIFESTYLE
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PHYSICAL FITNESSTRAINING MAY BE THE
ONLY MEANS OFOVERCOMING NEGATIVEEFFECTS OF SEDENTARY
LIFESTYLE
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MODERATE INTENSITY
ENDURANCE ACTIVITYABLED BODIED
Short Bouts of Moderate Activity
Spread Throughout Day
30 Minutes or Longer
SCI POPULATION
NIDRR Studies Ongoing
Moderate Intensity Regular ExerciseBenefits Not Fully Defined
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IMPORTANT TOOLS FOR
EXERCISE PRESCRIPTION
EDUCATION OF HEALTH CAREPROVIDERS
PHYSIOLOGICAL CHANGES AFTER SCI
RELEVANCE OF CHANGES TO
EXERCISE
ADAPT HEALTH & FITNESS ACTIVITIES
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MOST IMPORTANT TOOL
KNOWLEDGEABLEIN PROGRAMS &
PROTOCALS FOREXERCISE ACTIVITY
SENSE OFCREATIVITY
WILLINGNESS TOTRY NEW THINGS
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GOALS
BENEFITS OF PHYSICAL FITNESS ANDTRAINING IN SCI
PRACTICAL SUGGESTIONS FOR EXERCISEPRESCRIPTION
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Physical Changes Caused by SCI That
Affect Safety & Efficacy of Exercise
Exercise Training Effects in Para &Tetraplegia
Fundamentals of Exercise Prescription
Age, Physical Characteristics, PreviousExercise Experience, Functional Capacity
Safety Strategies for Injury Prevention
Adapted Equipment & Options for Homeor Health Club
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ASSESSMENT
NORMATIVE VALUES FOR STRENGTHENDURANCE AND CARDIOVASCULAR
ENDURANCE NOT YET ESTABLISHEDIN SCI POPULATION
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CARDIORESPIRATORY
For Some, Dependent on Level ofPeripheral Muscle Endurance than on
Central Cardiorespiratory Effects Paralysis of Active Muscle Mass & Loss of
Muscle Pumping--Peripheral Return
T6 and above loss of SNS automaticreflexes for normal exercise response
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QUESTIONS REMAIN
WIDE RANGE OF PHYSIOLOGICALDIFFERENCES DEPENDING ON LEVEL
Para Vs Tetra
COMPLETENESS OF INJURY
BODY SIZE, AGE, GENDER, PHYSICAL
FITNESS BEFORE INJURY,MEDICATIONS, POSTURE
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IN GENERAL, THE HIGHERTHE LEVEL OF INJURY THEMORE LIKELY SIGNIFICANT
REDUCTION INCARDIORESPIRATORY
CAPACITY
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WHY?
PROGRESSIVE LOSSOF SKELETAL
MUSCLE WITHEACH HIGHERLEVEL OF INJURY
DISRUPTION OFSYMPATHETIC
OUTFLOW TRACTSWITH LEVELS OFINJURY ABOVE T6
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MUSCLE PARALYSIS
FACTORS LE Paralysis Limits Amount of Muscle
Available for Exercise-InducedChallenge to Heart
Small Muscles of Arms Easily Fatigued--
Peripheral Restrictions--Limit ExerciseCapacity Before Central Cardiac SystemStressed
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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 ExerciseDue to No Vagal Withdrawal
110 to 120 BPM
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CV RESPONSE TOEXERCISE ABOVE T6
VASOMOTOR PARALYSIS
PREVENTS NORMAL BLOODREDISTRIBUTION IN UPRIGHT EXERCISE--VENOUS POOLING
COMPROMISED VENOUS RETURN TOHEART
LIMITS CARDIAC PRELOAD, EXERCISE SV,EXERCISE INDUCED CO--ABILITY OF HEARTTO RESPOND TO EXERCISE REDUCED
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MORE FACTORS ABOVE T6
Impaired Shunting of Blood to ActiveMuscles--Early Onset of Fatigue in small
muscles of arms Inadequate Sweating
Reduced Thermoregulation
Increased Fatigue
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CV Response to Exercise
T6-T10
NORMALREGULATION OFCARDIACFUNCTION--NormalHeart RateResponse to
Exercise DISRUPTED
VENOUS RETURN
BELOW T10
SNS SPLANCHICINNERVATION TOABD ORGANS
PARTIAL SNSINNERVATION TOLOWER
EXTREMITIES
SOME VENOUSRETURN
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SPLANCHNICNERVES
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EXERCISE RESPONSE INTETRAPLEGIA
Unique Challenge to Aerobic Exercise &Cardiovascular Health
Studies Have Shown Training Effectswith Exercise tolerance, muscleendurance, peak VO2, peak power
output (Figoni, 1993) Physiological Training Effects Peripheral
Muscle Endurance Rather Than Central
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EXERCISE RESPONSE INPARAPLEGIA
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 VO2max in able bodied (Figoni, 1990)
Limited CO can limit oxygen to exercisingUE muscles and have less peakperformance than AB, but more than tetra
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ADAPTATIONS TO
ENDURANCE TRAINING CENTRAL TRAINING
EFFECTS
Changes in HR @Rest and SubmaxExercise, and CO
LESS PRONOUNCED
WHEN TRAININGWITH SMALL UEMUSCLES
PERIPHERALTRAINING EFFECTS
Increased O2 Use &increased bloodflow to exercisingmuscles
Mm Hypertrophy
IncreasedLocalized Strength& Endurance
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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
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TESTING FOR TETRAS
Impossible to Evaluate Central CardiacFitness 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
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DESIGNING PROGRAM
Complete Medical & Activity Profile
Basic +
OH, ROM limitations from contractures,fractures, heterotopic ossification, UEoveruse, skin problems
Self-Dressing & ADL Status
Transfers, W/C Propulsion Time up in Community, Home
Management
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GUIDELINES FOR
EXERCISE ACTIVITIESACSM Guidelines for Able Bodied
Absent Guidelines for SCI Population
Modify & Adapt from NonDisabledGuidelines For Less Muscle Mass
Training Principles Same
Overload Progression
Specificity Consistency
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FITTE FACTORS FREQUENCY
3 TO 5X/WK
Modify forAdequate Rest BtwSessions
INTENSITY
ACSM Guidelines
for THR as Guide Borgs Rate of
Perceived Exertion(RPE)
TalkSing Test
TIME (DURATION) 15-60 min
Very DeconditionedGuidelines
TYPE (MODE)
Largest MS Mass
FES+LCE (+ACE)
$20,000 FES Bike
ENJOYMENT
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TYPES OF ACTIVITIES FOR
CARDIOVASCULARTRAINING AND STRENGTHTRAINING
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C5
MANUAL W/C PROPULSION ON HARDLEVEL SURFACES FOR ENDURANCE
DELTOID, BICEPS, SCAPULARSTRENGTH 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
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C6
SCAPULAR AND LATS FOR ROTATORCUFF 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
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C7 TO T1
STRENGTH & ENDURANCE OF ALLSHOULDER 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
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T2 TO T6
UE STRENGTHENING & UPPER BACK
Emphasize pulling to balance back
muscles with strong anterior muscles dueto w/c and crutch activities
EXERCISE OUT OF CHAIR
VARIETY OF STRENGTH & ENDURANCE
Free weights, machines, handcycles, w/cruns, swimming
RPE
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T7 TO T12
Include Abdominal and Back Exercisesfor Strength & Endurance
Increases in Aerobic Endurance Possible Central Training Effect May Occur
HR + RPE for Monitoring
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L1 TO S5
Strength and Endurance as for OtherParaplegic Individuals
Involve Legs
Cycling, Swimming, Walking
Hip Flexibility for Ambulation & UprightActivities
Balance Fitness & Function to PreventOveruse & Injuries to Shld, Wrists andelbows
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SAFETY CONSIDERATIONS
POSTURAL HYPOTENSION
AUTONOMIC DYSREFLEXIA
HYPERTHERMIA/HYPOTHERMIA
SKIN BREAKDOWN
OVERUSE & INJURY
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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
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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
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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
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