1. Physical Therapy Considerations with Spinal Cord Injuries
Jordan Rosenberger
Cleveland State University DPT Student
Edwin Shaw Rehabilitation Hospital In-service
Thursday, October 10, 2017

2. Why Exercise? The Benefits 1
People who have Spinal Cord Injuries also experience:
Decreased exercise capacity
Decreased stroke volume
Decreased max heart rate
Decreased respiratory function
Evidence shows exercise can have positive effects on:
Cardiorespiratory fitness
Muscular strength
Decreased risk of cardiometabolic disease
Decreased risk of depression
Decreased shoulder pain
Improved respiratory function
Improved Quality of Life
Improved functional independence

3. How Much Exercise? Physical Activity Guidelines for SCI 2, 3
Released in 2011
Recommends > 20 minutes of Moderate to Vigorous Intensity Aerobic Exercise 2x/week (40 minutes total)
A randomized control trial has shown that adhering to these guidelines for 16 weeks was clinically insufficient to produce meaningful changes in biomarkers of cardiovascular disease
Intervention included: minute sessions broken down into:
20 minutes Moderate-Vigorous Aerobic Activity (RPE 3-6 on 10 point scale)
3 x 10 reps (at 50-70% 1 RPM) Strengthening to Major Upper Body Muscle Groups
Results showed this regime of activity did NOT produce a change in fasting insulin, body composition and arterial structure and function (including carotid artery structure, regional artery stiffness and vascular function)

4. How Much Exercise? – Newer Recommendations 1
Journal of Science and Medicine in Sport released a position statement in recommending:
> 30 minutes of MODERATE aerobic exercise >5 days/week (150 minutes total) OR
> 20 minutes of VIGOROUS aerobic exercise > 3 days/week (60 minutes total)
> 2 days/week of strength training including scapula stabilizers and posterior shoulder girdle musculature
> 2 days/week flexibility training including shoulder IR and ER
*These recommendations were created for a patient able to use a hand-rim propelled wheelchair, but notes that the information is still relevant for more and less severely impacted SCI.
Additionally, the Statement focuses on exercise with VOLUNTARILY activated muscles vs. Functional Electrical Stimulation and Body Weight Supported Treadmill Training

5. Why Increase the Intensity? 2
Patient’s with SCI are likely restricted to using smaller, upper body skeletal muscles for aerobic activity (ex: arm ergometer, manual wheelchair propulsion) vs. a generally healthy person who is able to adhere to exercise guidelines using LE/Whole body activities (walking, running, cycling)
This results in smaller active muscle mass added to blunted hemodynamic responses that occur with SCI  decreased absolute capacity for physical exercise
SOOO….at the same relative intensity, the absolute energy expenditure, cardiovascular strain and metabolic demand will be LOWER in a person using primarily UE musculature
Patients with SCI are likely to suffer from Overuse Injuries associated with the UE, so it may not be feasible to increase the TIME spent performing aerobic exercise
Patients with SCI also tend to have compromised venous return, producing blunted cardiac output which can lead to EARLY onset muscular fatigue (which could also limit the TIME spent performing aerobic exercise)

6. Proposed Training Model to Increase Intensity – HIIT 2, 4
HIIT = High Intensity Interval Training
Operationally defined: exercise performed above the intensity that elicits the maximal lactate steady state (~80-85% VO2 Max)
Exercise at this level cannot be maintained for long durations, so must be broken with periods of low intensity resting recovery
Hypothesized Benefits of HIIT
Improved VO2 Max
Reduced insulin sensitivity
Body composition changes
Patient reports more enjoyable workout with HIIT type workout
Limitations
Stronger evidence needs to be collected with HIIT and the SCI population

7. Aerobic Exercise Considerations 1, 5
Modes: Rhythmic Contraction/Relaxation of Largest available muscle groups
W/C propulsion, Hand Cycling, Swimming if appropriate
Intensity Measures: RPE Scale may be most appropriate with SCI Population due to decreased max heart rate levels and decreased thermoregulatory systems
Moderate Intensity : on Borg RPE Scale
Vigorous Intensity: on Borg RPE Scale
2014 study shows that using a hybrid cycle (pictured to the right, with passive movement of the legs) lead to significantly higher metabolic rates, heart rate and ventilation than handcycling alone at equal RPE levels
Can be concluded that hybrid cycling is more suitable for fighting obesity and increasing cardiorespiratory fitness in the SCI population
Methods: Warm up, Cycle at Moderate RPE Level, Rest, Cycle at Vigorous RPE, Cool down

8. Strength Training Considerations 1
Incorporate major muscle groups
If possible, 4-5 Upper Limb Exercises
3 sets of 8-12 reps, 2-3 minute recovery between sets
Moderate Intensity (60-70% 1RM, on Borg RPE Scale)
Strengthening should be in PAIN FREE movements when possible
If pain is pre-existing, should be monitored. If pain is exacerbated, exercise should be discontinued
AVOID:
Shoulder IR with 90* ABD (Impingement position)
IR with overhead ROM

9. Flexibility/Stretching Considerations 1
Address major muscle groups including neck, upper limbs, trunk and lower limbs
Focus areas: IR/ER Shoulder, Chest, Anterior Shoulders
Static Stretch for secs each, for 60 secs each muscle group
Ex: 2 x 30 sec or 4 x 15 sec
Static stretching should be done at point in ROM where there is feeling of tightness/slight discomfort
Lower Limb stretching in Long term wheelchair users should be conducted cautiously due to increased incidence of sub-lesional osteopenia/osteoporosis
Thumb/Finger flexors of patients with Tenodesis grip should NOT be stretched

10. Classifying Patients to Progress Appropriately 1
Recommended to place patients into 1 of the following categories:
Beginner: not currently completing recommended exercise volume, and based on safe progression will not achieve recommendations in the next 3 months
Likely a lot of patients will fall in this category
Modest increases in activity (5 min MODERATE exercise/day) can reduce disease risk
Intermediate: not currently completing recommended exercise volume, but could safely progress to achieve recommendations in next 3 months
Will lead to a broad spectrum of significant health benefits
Advanced: meeting or exceeding recommended exercise volume for good health
Because of high level of exercise, must be aware of clinical practice guidelines for preservation/optimal UE Function with SCI population

11. Barriers with SCI Population – Shoulder Pain 6, 7, 8
Pain results from general wheelchair locomotion (including inclines/declines), upper extremity weight bearing for transfers and frequent overhead activity
Daily Exercise Program found to significantly decrease intensity of shoulder pain that interferes with functional activity in wheelchair users:
1. Scapular Retraction with Thera-band (3 x 15)
2. Shoulder External Rotation with Thera-band at side (3 x 15)
3. Shoulder Adduction with Thera-band (3 x 15)
4. Pec Stretch 5 x sec
5. Bicep Stretch 5 x sec
EMG studies show that during a sit-pivot transfer, the highest muscular activations/greatest demands were in:
Sternal pec major of the leading arm
Infraspinatus
Supraspinatus
Reduced strength also recorded in above muscles in patients with impingement
Reduced strength in humeral head depressors (lower rotator cuff and ADD) contributed to development of rotator cuff pathology by providing inadequate depression of humeral head during WB activities

12. What Should I Expect My SCI Patient to Functionally be able to Achieve?
See chart handout
Can assist in creating functional goals and d/c planning as needed

13. Summary
Research is showing that patient’s with SCI may benefit from increased TIME or INTENSITY of aerobic activity for cardiometabolic effects
Improve strength of humeral head depressors (Lower Rotator Cuff, Adductors) to decrease rotator cuff pathology during UE WB activities
As always, more research is required to determine the different physical and physiological changes that occur with changes in the amount/type of exercise with the SCI population

14. https://www. google. com/search

15. References
1. Tweedy S, Beckman E, Vanlandewijck Y, et al. Exercise and sports science Australia (ESSA) position statement on exercise and spinal cord injury. Journal Of Science & Medicine In Sport [serial online]. February 2017;20(2): Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed October 7, 2017.
2. Nightingale T, Metcalfe R, Vollaard N, Bilzon J. Exercise Guidelines to Promote Cardiometabolic Health in Spinal Cord Injured Humans: Time to Raise the Intensity?. Archives Of Physical Medicine & Rehabilitation [serial online]. August 2017;98(8): Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed October 7, 2017.
3. de Zepetnek JO, Pelletier CA, Hicks AL, MacDonald MJ. Following the physical activity guidelines for adults with spinal cord injury for16 weeks does not improve vascular health: a randomized controlled trial. Arch Phys Med Rehabil 2015;96:
4. Astorino TA, Thum JS. Interval training elicits higher enjoyment versus moderate exercise in persons with spinal cord injury. J Spinal Cord Med 2016 Nov 3 [Epub ahead of print].
5. Bakkum A, de Groot S, Onderwater M, de Jong J, Janssen T. Metabolic rate and cardiorespiratory response during hybrid cycling versus handcycling at equal subjective exercise intensity levels in people with spinal cord injury. Journal Of Spinal Cord Medicine [serial online]. November 2014;37(6): Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed October 9, 2017.
6. Jacobs P, Nash M. Exercise Recommendations for Individuals with Spinal Cord Injury. Sports Medicine [serial online]. August 2004;34(11): Available from: Academic Search Complete, Ipswich, MA. Accessed October 8,
7. Curtis K, Tyner T, Pacillas B, et al. Effect of a standard exercise protocol on shoulder pain in long-term wheelchair users. Spinal Cord [serial online]. June 1999;37(6):421. Available from: Academic Search Complete, Ipswich, MA. Accessed October 11, 2017.
8. Sara J. Mulroy, Patricia Hatchett, Valerie J. Eberly, Lisa Lighthall Haubert, Sandy Conners, Philip S. Requejo; Shoulder Strength and Physical Activity Predictors of Shoulder Pain in People With Paraplegia From Spinal Injury: Prospective Cohort Study, Physical Therapy, Volume 95, Issue 7, 1 July 2015, Pages 1027–1038,