The importance of Exercise

Spinal Cord Injury and Exercise

An individual who has sustained a spinal cord injury usually demonstrates some loss of motor function and/or sensation at and below the level of injury. The type and location of injury often dictates the severity. Partial damage to the spinal cord may result in an incomplete injury. A complete injury generally involves severe damage to the spinal cord.
There are 30 segments in the spinal cord: 8 cervical (C), 12 thoracic (T), 5 lumbar (L) and 5 sacral (S). The most vulnerable levels of injury are at the fifth through seventh cervical vertebrae, fourth through seventh thoracic vertebrae and tenth thoracic through the second lumbar vertebrae.
The most common spinal cord injuries are often sustained via a motor vehicle accident, gunshot wound, sport-related accident or fall. Non-traumatic impairments are classified as spinal cord dysfunction. Individuals with involvement of all four extremities are classified as quadriplegics. Paraplegics are those individuals with impairment of both lower extremities.

Once the spinal cord injury has been stabilized and the individual has been rehabilitated to his or her fullest potential, establishing a wellness routine can be beneficial to staying well and maintaining functional capacity. This overall approach encompasses many issues, including exercise.
Exercise programming may range from therapeutic standing to progressive resistive exercise and should be tailored to meet the unique needs of each individual. Prior to beginning an exercise program, it is important to work under the consultation of a physician who specializes in spinal cord injury. Choosing a facility with experienced personnel and adaptive equipment is also essential.

A well rounded exercise program should include components that promote fitness and help to maintain functional independence. As in any exercise program, consistency is essential. A three to four day per week commitment is necessary. Some components of the exercise program can be incorporated into a home program, while others may necessitate special equipment or supervision. Exercise participation may be limited depending on the level of function and/or adaptability of equipment. It may also be difficult to find a facility with the support and equipment necessary to carry out an effective exercise program.
Cardiovascular conditioning is essential to maintaining a healthy heart muscle and to having the endurance to meet our daily activity needs. Often people will make the mistake of trying too quickly to reach recommended intensities and duration of continuous aerobic exercise. Ways to successfully initiate cardiovascular conditioning is through circuit training and/or interval training. Again, functional ability may dictate level of participation.
Circuit training involves cycling through weight lifting and aerobic exercise. With spinal cord injured populations, a program alternating between stations of a multi-station weight machine and arm ergometer can successfully sustain heart rate and blood pressure so that an aerobic benefit can be achieved.
Interval training can be performed in various combinations of work/rest intervals. Examples of aerobic conditioning equipment adapted to spinal cord injured populations are: arm/bicycle ergometers, rowing machine and treadmills (includes those adapted for wheelchair use). Cross training, across one or all of the above-mentioned pieces of equipment, allows for a variety of muscle groups to be utilized, thus avoiding overuse injuries. It also reduces the risk of boredom by providing a more stimulating environment.

Muscular strength and endurance are also important aspects of fitness. Depending on the level and severity of injury, adaptations may be made to the design of program and equipment utilized. Developing muscular strength can be beneficial in lifting increased intensities of weight. It is also essential to maintaining balance between muscular groups, thus preventing overuse injuries. Lifting too much, too soon, should be avoided. Proper form should be emphasized, utilizing visual feedback and/or assistance from another person.
For those individuals striving to achieve gains in muscular strength, 70-75 percent of a maximal lift is utilized to perform 10-12 repetitions for 2-3 sets. It is important to lift the weight through the full range of motion, even if assistance is needed to do so. The concept of utilizing 70-75 percent allows muscles to be moderately stressed thus reducing the risk of injury.
Muscular endurance is the ability to lift mild to moderate weight many times. Functionally, it enables an individual to perform a pattern of movement for an extended duration or time. The application of muscular endurance is demonstrated when an individual with a spinal cord injury pushes his or her wheelchair. This ability to perform multiple repetitions may be especially beneficial to quadriplegics when feeding themselves with adaptive equipment.

Equipment utilized to perform strengthening can include multi-station weight machines. The "Equalizer" and "Uppertone Gym" are two such pieces adapted for individuals in wheelchairs with limited fine motor movement. Easily transportable types of equipment utilized to build and maintain muscular endurance include elastic tubing, free weights and weights with Velcro attachments for wrapping around an individual's wrists or ankles.

Range of motion is a series of exercise performed in which the joints of the extremities are moved within their capacity. Depending on the level of function total assistance or some assistance may be required. Maintaining the flexibility of individuals with spinal cord injury is important when seeking to avoid pressure sores, pain or injury. In doing so, joint contractures are prevented and the integrity of the joint maintained.

Many individuals develop muscle tightness in the shoulder, chest wrist and hip areas. These muscle groups become shortened and weak especially after sitting for extended periods of time without stretching. Muscle spasticity also plays a role in the development of tight muscle groups. It is important that proper range of motion techniques are incorporated into one's routine so that circulation to the joint and various muscle groups is maintained. Range of motion is best carried out while lying on a firm surface such as a mat table. A modified stretching program can be performed while sitting in a chair. If the available joint range is limited, gradual stretching may be achieved over several weeks of low intensity work.

The ability to move freely to and from places is often taken for granted. For the individual who has sustained a spinal cord injury, maintaining every aspect of mobility is vital to sustaining independence. Incorporating exercises designed to enhance standing or sitting balance can be beneficial; however, specific programming may vary depending on the level and severity of injury.
Balance exercise should always be performed with qualified personnel and with appropriate spotting techniques. Standing balance can be effectively carried out between two bars or rails (parallel bars) enabling an individual to hold onto them while standing. A standing frame, described as a frame, which fully supports an individual in a standing position, can also be helpful in enhancing proper posture and in strengthening muscles of the leg. Therapeutic standing is also beneficial in preventing muscle wasting (atrophy), maintaining joint integrity and in promoting circulation. Other benefits may be seen in the reduction of spasticity and in the promotion of a general sense of well being.

Establishing an effective base of support through a series of trunk balance exercises enables the spinal cord injured client to perform tasks such as pressure relief and transfers with greater ease and independence. A "Swiss Ball" can be utilized to help improve trunk balance. Sitting unsupported can also be an effective means of working trunk balance. Once again, it is important that qualified personnel are spotting this task as an individual progresses through the stages of achievement.
In every aspect of fitness, goal setting is a tool utilized to map out an effective strategy for maintaining a healthy body. It is important to set realistic goals that can be met within a reasonable period of time and effort. The motivation to sustain a consistent exercise program can be severely impacted if a goal or time frame set to achieve a goal is unattainable or unrealistic.

Some individuals may perceive themselves as able to make greater gains in their fitness levels, than physically possible. Others may have a difficult time seeing the "big picture" as to how exercise can benefit long term health. It is imperative that the goals are discussed at the beginning of an exercise program, then reinforced and/or modified along the way. Remember, "Life by the inch is a cinch. Life by the yard is hard."

Incorporating sports and recreation programs in one's routine can be instrumental in maintaining both the psychological and physical welfare of individuals. Sport participation can be utilized as an extension of fitness programming. It allows an individual to utilize enhanced physical capacities in a social setting and with other individuals of similar abilities. Today, there are many resources and organizations, which lend themselves to working with physically challenged individuals in sports and recreation programs.
As with any exercise programming, certain precautions must be adhered to. Those most specific to individuals with spinal cord injury are described below.
Autonomic Dysreflexia is a complication that occurs in spinal cord populations having sustained injuries at the 6th thoracic level and above. Generally, it is brought on by a stimulus that prior to the injury would have been recognized as uncomfortable. Due to limited communication between the injured spinal cord and brain, many individuals are unable to identify and respond to uncomfortable stimuli. As a result, blood pressure, heart rate and an overall sense of well being becomes disrupted. The changes in blood pressure and heart rate may be life threatening if not responded to appropriately. It is imperative that the signs and symptoms of autonomic dysreflexia are understood by all involved prior to beginning an exercise program.

Maintaining skin integrity can be challenging. No longer do the same warning signals of discomfort exist as they did prior to the spinal cord injury. Decreased circulation due to prolonged pressure can cause skin breakdown. Bony areas such as the hips, heels and tailbone are most vulnerable. Providing pressure relief with frequent weight shifts can maintain blood flow to areas at risk.

One major effect spinal cord injury has on circulation is that of lowered blood pressure (hypotension).
This may be of great concern during exercise participation as individuals may feel faint or dizzy. Low blood pressure, which occurs as a result of positional changes, is called orthostatic hypotension. Proper hydration, changing positions slowly and wearing compression stockings can be effective in avoiding orthostatic hypotension.
Individuals who have sustained spinal cord injury are at risk for the following conditions:
1) Joint contractures or permanent limitations of joint movement usually due to poor positioning, lack of movement and/or muscle spasticity.
2) Muscle atrophy, a shrinking or wasting of musculature due to lack of use.
3) Osteoporosis, deterioration of the bone that may occur due to decreased weight bearing, as well as factors related to the injury itself.
Decreased respiratory function can create such problems as increased risk for respiratory infections, congestion, rapid breathing and/or increased shortness of breath. Breathing exercises may be beneficial in sustaining healthy lung capacity.

Sensory deprivation or an inability to accurately discern the nature of the stimuli throughout the body at or below the level of injury is common to spinal cord injured populations. It is important that exposure to extreme temperatures be avoided and that the skin is examined regularly.

There are many facets to wellness. Staying well involves a commitment to a healthy lifestyle. Exercise is one vital component which if properly carried out can enhance the functional capacity of an individual who has sustained a spinal cord injury. It also can promote self-esteem and well being. In conjunction with an exercise program, dietary habits involving good nutrition and proper hydration are essential. It is best to consult with qualified personnel regarding dietary concerns.