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EXERCISE PRESCRIPTION For PERSONS With SPINAL CORD INJURY

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

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EXERCISE PRESCRIPTION For PERSONS With SPINAL CORD INJURY

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  1. EXERCISE PRESCRIPTIONFor PERSONS WithSPINAL CORD INJURY PT 630 Cardiopulmonary Therapeutics Fall 1999

  2. “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

  3. 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

  4. 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

  5. BENEFITS OF EXERCISE • PHYSICAL • PHYSIOLOGICAL • FUNCTIONAL • PSYCHOLOGICAL

  6. 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

  7. CYCLE OF DISABILITY

  8. RISK FACTORS OF SEDENTARY LIFESTYLE

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

  10. IS THIS A ROLE FOR PT?WHO DOES WHAT?HOW?

  11. 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

  12. IMPORTANT TOOLS FOR EXERCISE PRESCRIPTION • EDUCATION OF HEALTH CARE PROVIDERS • PHYSIOLOGICAL CHANGES AFTER SCI • RELEVANCE OF CHANGES TO EXERCISE • ADAPT HEALTH & FITNESS ACTIVITIES

  13. MOST IMPORTANT TOOL • KNOWLEDGEABLE IN PROGRAMS & PROTOCALS FOR EXERCISE ACTIVITY • SENSE OF CREATIVITY • WILLINGNESS TO TRY NEW THINGS

  14. GOALS • BENEFITS OF PHYSICAL FITNESS AND TRAINING IN SCI • PRACTICAL SUGGESTIONS FOR EXERCISE PRESCRIPTION

  15. 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

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

  17. 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

  18. 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

  19. IN GENERAL, THE HIGHER THE LEVEL OF INJURY THE MORE LIKELY SIGNIFICANT REDUCTION IN CARDIORESPIRATORY CAPACITY

  20. PROGRESSIVE LOSS OF SKELETAL MUSCLE WITH EACH HIGHER LEVEL OF INJURY DISRUPTION OF SYMPATHETIC OUTFLOW TRACTS WITH LEVELS OF INJURY ABOVE T6 WHY?

  21. 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

  22. 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

  23. 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

  24. 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

  25. 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 CV Response to Exercise

  26. SPLANCHNIC NERVES

  27. 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

  28. 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

  29. CENTRAL TRAINING EFFECTS 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

  30. 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

  31. 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

  32. 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)

  33. 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

  34. 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

  35. 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 • Overload Progression • Specificity Consistency

  36. 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) 15-60 min Very Deconditioned Guidelines TYPE (MODE) Largest MS Mass FES+LCE (+ACE) $20,000 FES Bike ENJOYMENT FITTE FACTORS

  37. TYPES OF ACTIVITIES FOR CARDIOVASCULAR TRAINING AND STRENGTH TRAINING

  38. 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 FITNESS RECOMMENDATIONSC4 & ABOVE

  39. 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

  40. 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

  41. 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

  42. 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

  43. 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

  44. 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

  45. SAFETY CONSIDERATIONS • POSTURAL HYPOTENSION • AUTONOMIC DYSREFLEXIA • HYPERTHERMIA/HYPOTHERMIA • SKIN BREAKDOWN • OVERUSE & INJURY

  46. 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

  47. 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

  48. 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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