1. Clients with Spinal Cord Injury, Multiple Sclerosis, Epilepsy, Fibromyalgia, Lupus, and Cerebral Palsy

2. Murderball

4. Spinal Cord Injury
Spinal Cord Injury (SCI) results from the impairment or loss of motor function, sensory function, or both in the trunk or limbs due to irreversible damage to neural tissues within the spinal cord

5. Spinal Cord Injury SCI may be classified as tetraplegia or paraplegia
Tetraplegia (Quadriplegia):
Injury occurs between C1 and T1, impairment of the arms, trunk, legs, and pelvic organs
Paraplegia:
Injury to T2 to T12 which causes impairment in the trunk, legs, and/or pelvic organs.

6. SCI Cardiovascular Conditions
Autonomic Dysreflexia
Postural Hypotension
Cardiac Atrophy
Congestive Heart Failure
Sudden death
Atherosclerosis

7. Autonomic Dysreflexia
A sudden dangerous increase in blood pressure
Medical Emergency!
If not treated promptly, it may lead to seizures, stroke, and even death

8. Autonomic Dysreflexia
Common Causes:
Kinked catheter (sitting on catheter)
Overfilled bladder due to a blockage
Bladder infection
Inadequate bladder emptying
Stones in the bladder
Bladder spasms
Skin irritations
Pressure sores

9. Signs and Symptoms of Autonomic Dysreflexia
Hypertension
An increase in 20 mm Hg or more in systolic blood pressure
Pounding headache
Caused by the elevation in blood pressure
Heavy sweating
Flushed (red) Face
Blurry vision
Dyspnea (difficulty breathing)
Chest tightness
Hypertension and Pounding Headache are most common symptoms

10. Autonomic Dysreflexia Treatment
Stop ongoing activity!
Check blood pressure
Have person sit up with head elevated
Loosen clothing
Check urinary catheter for kinks and straighten any
Continue to monitor blood pressure and call 911!

11. Postural Hypotension
Blood pressure drops to dangerously low levels in response to an upright posture
If it is not treated immediately, the person may lose consciousness.
Symptoms:
Light-headedness
Pallor (pale)
Visual changes

12. Postural Hypotension Treatment
Check blood pressure
Recline the wheelchair
Continue to check blood pressure and call 911

13. SCI Exercise Testing and Training
Acquire medical clearance
Because of the high risk of cardiovascular impairment, maximal exercise testing should be administered in medical settings

14. SCI Exercise Concerns
Many people with SCI cannot regulate body temperature which can lead to hypothermia or heat stroke
Extreme temperatures should be avoided!
Beware of freezer burn from cold packs or burns from heat packs
Maintain a constant exercise environment
Have clients wear lose fitting clothes and breathable materials
Adequate hydration is necessary

15. SCI Exercise Induced Injuries
Most common exercise induced injuries occur at the shoulders, elbows, and wrist
Incorporate exercises that will restore or enhance balance around functional joints; strengthen muscle groups of the posterior shoulder and back and stretch muscles of the anterior shoulder and chest to reduce risk of injuries

16. SCI Exercise Guidelines
Avoid exercise two to three hours after a meal
Digestion can impair the ability to shunt blood to the working muscles during exercise creating a decrease in cardiac output and blood flow
The client should avoid exercise during illness and bladder infection

17. SCI Aerobic Exercise Guidelines
Intensity:
40-60%
Mode:
Arm bike, wheelchair basketball, swimming
Duration:
10-20 minutes
Frequency:
3 days per week or every other day is recommended

18. SCI Dynamic Warm-Up Guidelines
3-5 repetitions of:
Chin Tucks
Neck Flexion/Extension
Lateral Neck Flexion
Neck Rotation:
Turn chin toward left shoulder then rotate it right

19. SCI Dynamic Warm-Up Guidelines
8-10 repetitions of:
Trunk Rotation
Shoulder Flexion/Extension
Shoulder Horizontal Adduction/Abduction
Shoulder Circles Forward and Backward
Elbow Flexion
Wrist Flexion/Extension
Wrist Abduction/Adduction
Wrist Circumduction
Finger Flexion/Extension

20. SCI Resistance Training Exercise Guidelines
3 sets
8-12 reps for all functional muscle groups
Frequency: 2-3 days per week
Clients may also benefit from a single set to fatigue of 8-12 reps using 8-12 exercises 2-3 days per week
People with SCI are prone to Spasticity (exaggerated muscle tone and reflexes) which can impair exercise

21. SCI Resistance Training Exercises
Lateral and medial shoulder rotation with tubing or light dumbbells
Lat pull-down
Rows using machine, cable, or tubing
Chest press using machine, cable, or tubing
Front and lateral dumbbell raise
Dumbbell biceps curl
Triceps cable rope extension
Dumbbell wrist curl
Dumbbell wrist extension

22. Static Stretches (Cool Down)
Hold all stretches for 30 seconds
Upper trapezius:
Lower the right shoulder and bend the head toward the left shoulder
Trunk:
Raise the right arm over the head with the elbow by the ear and bend the trunk to the left side
Horizontal shoulder adduction/abduction
Scapular retraction/protraction
Shoulder medial/lateral rotation
Doorway pectoralis stretch
Flex the elbow to 90 degrees
Elbow flexion/extension

23. SCI Exercise Program

25. Multiple Sclerosis (MS)
Most commonly diagnosed neurolgical diease in young adults
The cause of MS remains unknown
Individuals who are diagnosed with MS are typically between the ages of 15 and 50 years
More common in women than men

26. Multiple Sclerosis
A degenerating disease of the central nervous system (brain + spinal cord) that interferes with the quality of movement
An auto-immune disease in which the body’s defensive system (macrophages) attack the myelin sheath that covers the nerves
Loss of myelin, which is the fatty substance that insulates nerves, decreases the speed of conduction and is associated with leaving areas of scar tissue on the covering of nerve cells (sclerosis)

27. Multiple Sclerosis (MS)

28. Multiple Sclerosis

30. Symptoms of Multiple Sclerosis (MS)
Fatigue-primary symptom of MS
Pain
Muscle weakness
Heat sensitivity
Impaired balance and poor coordination
Muscle spasticity especially in the legs
Tremors
Blurred or double vision, eye discomfort or rapid eye movements
Decreased attention, memory, and concentration
Dysphagia: difficulty swallowing
Dysarthria: slurred speech

32. Multiple Sclerosis Treatments
Education
Management of symptoms
Medication
Exercise

33. Multiple Sclerosis Exercise Guidelines
Acquire medical clearance
Exercise testing should be done under medical supervision
Heart rate and blood pressure must be monitored throughout the exercise program, and intensity might need to be decreased. This can be due to decreased blood pressure in response to exercise

34. Multiple Sclerosis Exercise Guidelines
Exercise may ease the symptoms of MS, but it is important to take certain precautions:
People with MS suffer from fatigue, muscle spasticity, and heat sensitivity
Optimal time of day to exercise may be in the morning
Fatigue may be reduced by aerobic activity
Muscle spasticity may be managed with a stretching program

35. Multiple Sclerosis Exercise Guidelines
Many people with MS experience a temporary worsening of their symptoms due to the following:
Very hot or humid weather
Overheating from exercise
Sunbathing
Fever
Taking very hot showers or baths

36. Multiple Sclerosis Exercise Guidelines
Heat Sensitivity:
May lead to fatigue, loss of balance and visual changes
Create a cool environment with fans
Air temperature should be cool
Avoid swimming if pool temperature is too warm
Drink water to stay hydrated
Wear loose-fitting, light-colored breathable clothing—dark clothes retain heat
If exercising outdoors, try early morning or evening hours due to overheating

37. MS Aerobic Endurance Exercise Guidelines
Mode:
Walking, swimming, aqua classes, chair aerobics, stationary cycling
Stationary cycling, swimming, aqua and chair classes may be best due to leg weakness, impaired balance, and coordination
Frequency: 3-4 sessions per week
Duration:
10-30 minutes per day or two to three 10 minute sessions throughout the day

38. MS Aerobic Endurance Exercise Guidelines
Intensity:
40-70% of THRR with progression over 3-6 months to 50-70%
Some people with MS demonstrate blunted heart rate responses to exercise- a condition in which the heart rate does not increase with exercise intensity due to medications. Therefore utilize RPE scale.
Do not exercise to fatigue!

39. MS and Benefits of Water Exercise
Water reduces the effects of gravity, and the buoyancy or weightlessness that occurs in water
Helps a person with weak muscles attain a greater range of motion
Chest-high water can provide support, enabling persons with MS to stand and maintain balance for exercises with less effort than on land

40. MS and Benefits of Water Exercise
The resistance that water provides can be used for muscle strengthening
Water also helps reduce body heat that can be generated by exercise
Water temperatures of 80° to 84°F are usually recommended

41. MS Flexibility Guidelines
People with MS experience spasticity which leads to muscle stiffness and tightness, pain, and decreased range of motion
Stretching should be performed slowly
Overstretching a neurologically weak muscle may cause injury!
Reps: 2-3 for each stretch
Duration: second hold
Frequency: 5-6 days per week

42. MS Resistance Training Guidelines
Over-exercising neurologically weak muscles may lead to muscle spasticity, fatigue, frustration, and discontinuation of the strength program
Primary considerations are fatigue, safety and balance
Be aware that balance difficulties may lead to falls and injury
Avoid complex skill oriented exercises!
Resistance train on non-aerobic training days
Avoid using dumbbells if individual has decreased sensation
Exercises should be performed in a seated position when possible
Use exercise machines

43. MS Resistance Training Guidelines
A strengthening program is indicated after a motivated client has successfully maintained an aerobic and flexibility program
Total body routine
Sets: 1-2
Reps: 6-10
Intensity: Low-to-moderate
Rest: 60 seconds
Start slow and gradually increase reps/intensity. Monitor fatigue levels!

44. Epilepsy Defined as two or more unprovoked recurring seizures Seizure:
An uncontrolled discharge of nerve cells which may spread to other cells nearby or throughout the entire brain. It usually lasts only a few minutes. It may be associated with loss of consciousness, loss of bowel and bladder control and tremors. May also cause aggression or other behavioral change

45. Epilepsy Acquire medical clearance
In many people with epilepsy aerobic exercise may contribute to improved seizure control
However in 10% of individuals, vigorous exercise may be a seizure precipitant
Personal Trainers can apply the same exercise principles for people with epilepsy as for healthy populations
In general there are no restrictions to exercise (exercise and sports should be encouraged)

46. Epilepsy
It is safe to administer sub-maximal exercise testing to establish cardiovascular fitness, muscle strength and endurance, flexibility, and body composition

47. Treatment for Seizures
Time seizure episode
A seizure that continues for more than 5 minutes call 911!
Approach calmly
Do not restrain client!
4. Loosen any tight clothing
5. Keep objects out of clients path!
6. Do not place anything in the client’s mouth!
7. Allow seizure to end without interference!

48. Treatment for Seizures
8. After seizure, check for breathing and turn the client to his or her side in recovery position to prevent aspiration (entry of secretions in the trachea or lungs)
9. Remain with the client until he or she is fully awake
10. Alert the client’s family

49. Treatment for Seizures

51. Fibromyalgia
A chronic condition that affects soft tissues-muscles, tendons and joints
Often characterized by pain stiffness and tenderness.
One of the most common diseases affecting the muscles
Cause is unknown
Not accompanied by tissue inflammation so there is no deformity or body damage

52. Population Affected by Fibromyalgia
Women (over 80%) between
30-50 years of age
Rare with men, children, and older adults
2% of the population in the U.S. have Fibromyalgia

53. Signs and Symptoms of Fibromyalgia
Three symptoms commonly observed:
Fatigue
Soft tissue pain
Non-restorative sleep
Very low pain threshold
Pain is widespread to several parts of the body

54. Signs and Symptoms of Fibromyalgia
Pain in the neck, lower back, and trapezius
Joint swelling and stiffness
Depression
Mental and/or emotional disturbances
Anxiety
Irritable Bowel Syndrome

55. Fibromyalgia

57. How is Fibromyalgia Diagnosed?
No definite blood or x-ray test to determine Fibromyalgia
Diagnosed through a physical exam and physician looks for “tender point” areas
While a blood test doesn’t determine it, it is important to have one because it rules out other medical complications
Difficult to diagnose because other medical problems can mimic the symptoms (hypothyroidism and cancer).
It can also be associated with other diseases such as rheumatoid arthritis.

58. Fibromyalgia Aerobic Endurance Training Guidelines
Acquire medical clearance
Aerobic training should begin very gradually
Allow for a longer warm-up (at least 10 minutes)
Start with light walking or biking for five minutes and add two minutes every week until at least 30 minutes of continuous activity can be performed at least three days per week
Aquatic exercise a good. Avoid water that is too warm or cold as this can exacerbate symptoms
Allow at least 48 hrs of rest

59. Fibromyalgia Resistance Training Guidelines
Strength training should not be performed until the client can tolerate walking and stretching without becoming exhausted
Begin with one exercise per muscle group and perform one set. Sometimes only a few repetitions can be tolerated in the beginning
Perform the exercises without weights and then progress to resistance bands or machines that limit eccentric movements that lengthen the muscles, which are associated with increased muscle tears in people with fibromyalgia
Machines that can be utilized include hydraulic machines and minimal weight pulley machines

60. Fibromyalgia Resistance Training Guidelines
2-3 minute rest intervals between sets is required since the body takes longer to replenish energy stores. This time can be used for stretching the muscles you are working
Work towards completing a strength training routine two to three days per week and increase the number of sets and reps slowly, as tolerated.
Free weight exercises can be introduced once the client achieves a higher fitness level, although this may take many months to reach.

61. Fibromyalgia Flexibility Guidelines
Stretching should be done following the warm-up and after cooling down
Each stretch should be held 20 to 60 seconds, and the routine should not involve getting up and down from the floor
The benefits of stretching include:
Improved circulation
Relieving pain symptoms
Loosening tight muscles (specifically around the neck and shoulders) that seem to be more tense in fibromyalgia clients

62. Fibromyalgia Contraindications
Client cannot progress as fast
Allow more time to increase weight, sets and repetitions in training programs
Shorter, more frequent exercise sessions are preferred over one long session
If chronic fatigue, troubled sleeping or headaches develop, cut back the intensity of your workouts

63. Fibromyalgia Contraindications
Avoid the following exercises:
Shrugs
Pull-ups
Rowing machines
Leg extensions
Squats
Cable crossover machines
These exercises place too much stress on tender areas

64. Cerebral Palsy

66. Cerebral Palsy (CP)
Non-progressive, non-contagious disorder that affects muscle tone, movement, and motor skills (ability to move in a coordinated and purposeful way)
CP is usually caused by brain damage as the result of injury or disease at or before birth (i.e., premature babies, meningitis, malnutrition, shaken baby syndrome)
The term cerebral refers to the brain’s two halves, or hemispheres, and palsy describes any disorder that impairs control of body movement

67. Cerebral Palsy
One of the most common congenital (existing before birth or at birth) disorders of childhood
About 500,000 children and adults in the United States have the condition.
The three types of CP are:
Spastic cerebral palsy — causes stiffness and movement difficulties
Athetoid cerebral palsy — leads to involuntary and uncontrolled movements
Ataxic cerebral palsy — causes a disturbed sense of balance and depth perception

68. Characteristics of Cerebral Palsy
Muscle tightness
Muscle spasticity
Muscle weakness
Incoordination
Difficulty maintaining posture
Difficulty maintaining balance
Involuntary muscle movement
Difficulty with fine motor tasks:
Writing, cutting with scissors

69. Characteristics of Cerebral Palsy
Dysphagia: difficulty swallowing
Speech impairments
Deficiencies in sensation and perception
Impaired vision and hearing
Seizures
Cognitive Dysfunction
Learning deficiencies
Breathing difficulties
Postural deformities

70. Management of Cerebral Palsy Symptoms
Mostly involves managing the secondary symptoms:
Muscle spasticity, seizures, joint pain, posture deformities
Seizures occur in 60% of people with CP
May be on anti-seizure medications, muscle relaxants or anti-spasmodic medications
May also be on medications that control joint pain, posture deformities, and bladder dysfunction

71. Exercise Guidelines for Cerebral Palsy
Acquire medical clearance
Screen for musculoskeletal abnormalities, heart disease, and other chronic diseases such as diabetes, arthritis and hypertension
Clients with CP may have tremors, avoid using dumbbells and barbells

72. Exercise Guidelines for Cerebral Palsy
Exercise can help prevent the weakening or deterioration of muscles and avoid contracture, in which muscles become fixed in a rigid, abnormal position

73. CP Exercise Program Goals
Aerobic Endurance :
To improve the respiratory system
Increase stamina
Strength:
Prevent muscle atrophy
Prevent muscle contractures
Prevent muscle imbalance

74. CP Exercise Program Goals
Flexibility:
To avoid muscle contracture
To increase range of motion and maintain joint flexibility
To reduce tension/stress
Increase body awareness
Encourage/facilitate making a mind body connection

75. CP Exercise Program Goals
Coordination, balance, and core training:
To challenge the body’s proprioceptive system (muscle spindles and golgi tendon organs)
Improve trunk stabilization
Improve postural alignment and control
Improve gait (walking)
Improve weight transfer movements

76. Exercise Guidelines for Cerebral Palsy
The personal trainer will need to be creative and often modify equipment and exercises because of limitations client may have

77. Aerobic Exercise Guidelines for Cerebral Palsy
Moderate to vigorous intensity:
50-85% of VO2 or RPE of 4-6 on 0-10 scale
Duration:
30 or more minutes
Frequency:
4-7 days per week
Mode:
Elliptical, swimming, stationary bicycle, walking
In very de-conditioned clients:
Duration: 5-10 minutes twice per day
Frequency: 4-7 days per week

78. Resistance Training Guidelines for Cerebral Palsy
Frequency:
2-3 days a week
Volume:
2-3 sets
8-12 repetitions
Intensity:
40-60%
Focus on addressing muscle imbalances, weakness and areas that are most susceptible to atrophy
Some exercises will need to be modified because of spasticity

79. Types of Resistance Training
Free weights
With caution due to tremors
Medicine balls
Machines
Resistance bands
Sand or water filled equipment
Water
Exercise balls (air filled)

80. Lupus
Lupus is a chronic inflammatory autoimmune disease that can damage the skin, joints, and/or organs (heart, brain, kidneys)
Lupus can range from mild to life-threatening
It is most common in women of childbearing age-15-44
Men and children can develop it too
No gene or group of genes has been proven to cause lupus
Individuals who are Asian, African, Native American, or Hispanic have a greater risk of developing lupus, which may be related to genes

81. Lupus
It takes some kind of environmental trigger to set off the illness or to bring on inflammation
Examples include:
Ultraviolet rays from the sun
A cold, virus, or infection
Emotional stress, such as a divorce, illness, death in the family
Surgery
Pregnancy, or giving birth

82. Symptoms of Lupus Extreme fatigue Fever Headaches
Painful or swollen joints
Anemia
Edema in the feet, legs, hands, and/or around eyes
Pleurisy- chest pain during deep breathing
Shortness of breath
Butterfly-shaped rash across cheeks and nose
Sun or light sensitivity
Hair loss
Anxiety
Depression
Memory Loss
Raynaud’s Disease: fingers turning white and/or blue when cold
Mouth nose ulcers

83. Lupus and Exercise
There are no specific guidelines as to how much exercise a person should do or when they should do it
Some people with lupus can exercise daily for minutes without a problem while others may not be able to
Everyone is different, so you need to listen to your client

84. Lupus and Exercise
Exercise can reduce the symptoms of Lupus, increase endurance and strength, improve mood, and mobility
Exercising is contraindicated during symptoms (flares)
Rest is necessary
Aerobic exercise is most appropriate
Swimming, yoga, walking, cycling, Elliptical machine
Isometric exercises should be performed with caution
Increases blood pressure

85. Lupus and Exercise
Avoid outdoor exercise in the sun because sunlight can trigger symptoms
Exercise daily when stiffness and pain are the least
Perform gentle active range of motion (AROM) exercises in the evening to reduce stiffness
Modify exercise to avoid increasing joint pain