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EXERCISE PRESCRIPTION For PERSONS With SPINAL CORD INJURY. PT 630 Cardiopulmonary Therapeutics Fall 1999.

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EXERCISE PRESCRIPTIONFor PERSONS WithSPINAL CORD INJURY

PT 630 Cardiopulmonary Therapeutics Fall 1999


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“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


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INTRODUCTION 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.”

  • 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 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.”

  • 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


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BENEFITS OF EXERCISE 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.”

  • PHYSICAL

  • PHYSIOLOGICAL

  • FUNCTIONAL

  • PSYCHOLOGICAL


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WHAT’S THE PROBLEM? 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.”

  • 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


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CYCLE OF DISABILITY 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.”


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RISK FACTORS OF SEDENTARY LIFESTYLE 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.”


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PHYSICAL FITNESS TRAINING MAY BE THE ONLY MEANS OF OVERCOMING NEGATIVE EFFECTS OF SEDENTARY LIFESTYLE


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IS THIS A ROLE FOR PT? OVERCOMING NEGATIVE EFFECTS OF SEDENTARY LIFESTYLEWHO DOES WHAT?HOW?


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MODERATE INTENSITY ENDURANCE ACTIVITY OVERCOMING NEGATIVE EFFECTS OF SEDENTARY LIFESTYLE

  • 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


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IMPORTANT TOOLS FOR EXERCISE PRESCRIPTION OVERCOMING NEGATIVE EFFECTS OF SEDENTARY LIFESTYLE

  • EDUCATION OF HEALTH CARE PROVIDERS

    • PHYSIOLOGICAL CHANGES AFTER SCI

    • RELEVANCE OF CHANGES TO EXERCISE

    • ADAPT HEALTH & FITNESS ACTIVITIES


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MOST IMPORTANT TOOL OVERCOMING NEGATIVE EFFECTS OF SEDENTARY LIFESTYLE

  • KNOWLEDGEABLE IN PROGRAMS & PROTOCALS FOR EXERCISE ACTIVITY

  • SENSE OF CREATIVITY

  • WILLINGNESS TO TRY NEW THINGS


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GOALS OVERCOMING NEGATIVE EFFECTS OF SEDENTARY LIFESTYLE

  • BENEFITS OF PHYSICAL FITNESS AND TRAINING IN SCI

  • PRACTICAL SUGGESTIONS FOR EXERCISE PRESCRIPTION


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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, Previous Exercise Experience, Functional Capacity

  • Safety Strategies for Injury Prevention

  • Adapted Equipment & Options for Home or Health Club


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ASSESSMENT of Exercise

  • NORMATIVE VALUES FOR STRENGTH ENDURANCE AND CARDIOVASCULAR ENDURANCE NOT YET ESTABLISHED IN SCI POPULATION


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CARDIORESPIRATORY of Exercise

  • 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


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QUESTIONS REMAIN of Exercise

  • WIDE RANGE OF PHYSIOLOGICAL DIFFERENCES 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 HIGHER THE LEVEL OF INJURY THE MORE LIKELY SIGNIFICANT REDUCTION IN CARDIORESPIRATORY CAPACITY


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PROGRESSIVE LOSS OF SKELETAL MUSCLE WITH EACH HIGHER LEVEL OF INJURY

DISRUPTION OF SYMPATHETIC OUTFLOW TRACTS WITH LEVELS OF INJURY ABOVE T6

WHY?


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MUSCLE PARALYSIS FACTORS OF INJURY

  • 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


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SYMPATHETIC DECENTRALIZATION OF INJURY

  • 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


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CV RESPONSE TO EXERCISE ABOVE T6 OF INJURY

  • 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


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MORE FACTORS ABOVE T6 OF INJURY

  • Impaired Shunting of Blood to Active Muscles--Early Onset of Fatigue in small muscles of arms

  • Inadequate Sweating

  • Reduced Thermoregulation

  • Increased Fatigue


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T6-T10 OF INJURY

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

CV Response to Exercise



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EXERCISE RESPONSE IN TETRAPLEGIA OF INJURY

  • 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


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EXERCISE RESPONSE IN PARAPLEGIA OF INJURY

  • 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


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CENTRAL TRAINING EFFECTS OF INJURY

Changes in HR @ 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

ADAPTATIONS TO ENDURANCE TRAINING


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Value of Peripheral Training OF INJURY

  • Improved Work Capacity & Strength

  • Everyday Activities Less Difficult

  • More Energy Reserves for Greater Independence

  • Increased Ability to Pursue More Active Lifestyle


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ASSESSMENT TOOLS OF INJURY

  • 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 PROCEDURES OF INJURY

  • Well Established for Able Bodied

  • Not for Those with Disabilities

  • ACE (Arm Crank Ergometers)

  • WCE (Wheelchair Ergometers)

  • Field Testing (12 Minute Distance Test)


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TESTING FOR TETRAS OF INJURY

  • 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


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DESIGNING PROGRAM OF INJURY

  • 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


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GUIDELINES FOR EXERCISE ACTIVITIES OF INJURY

  • ACSM Guidelines for Able Bodied

  • Absent Guidelines for SCI Population

  • Modify & Adapt from NonDisabled Guidelines For Less Muscle Mass

  • Training Principles Same

    • Overload Progression

    • Specificity Consistency


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FREQUENCY OF INJURY

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)

15-60 min

Very Deconditioned Guidelines

TYPE (MODE)

Largest MS Mass

FES+LCE (+ACE)

$20,000 FES Bike

ENJOYMENT

FITTE FACTORS



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ROM & POSTURE EXERCISES TRAINING

BREATHING EXERCISES

USE COMPUTER

PROACTIVE NUTRITIONAL PLANNING

ACTIVE ROLE IN PLANNING DAILY SCHEDULE & HIRING ATTENDANTS

PURSUIT OF MENTAL FITNESS

Intellectual, Social, Spiritual

FITNESS RECOMMENDATIONSC4 & ABOVE


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C5 TRAINING

  • 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


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C6 TRAINING

  • 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


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C7 TO T1 TRAINING

  • 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


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T2 TO T6 TRAINING

  • 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


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T7 TO T12 TRAINING

  • Include Abdominal and Back Exercises for Strength & Endurance

  • Increases in Aerobic Endurance Possible

  • Central Training Effect May Occur

  • HR + RPE for Monitoring


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L1 TO S5 TRAINING

  • 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


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SAFETY CONSIDERATIONS TRAINING

  • POSTURAL HYPOTENSION

  • AUTONOMIC DYSREFLEXIA

  • HYPERTHERMIA/HYPOTHERMIA

  • SKIN BREAKDOWN

  • OVERUSE & INJURY


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EQUIPMENT CONSIDERATIONS TRAINING

  • 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 TRAINING

  • 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 TRAINING

  • 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