Rehabilitation in spinal cord injury: Exercise and testing for cardiorespiratory endurance and musculoskeletal fitness

Abbreviations

SCI

spinal cord injury

PwSCI

persons with a spinal cord injury

VO _2peak

peak volume of oxygen consumption

VO _2max

maximal volume of oxygen consumption

ACE

arm crank ergometer

1-RM

one repetition maximum

WMS

WheelMill System

6-MAT

6-minute arm test

6MPT

6-minute push test

RPE

rate of perceived exertion

ASIA

The American Spinal Injury Association Impairment Scale

PO

power output

W

watts

RM

repetition maximum

ROM

range of motion

RER

respiratory exchange ratio

Introduction

Persons with a spinal cord injury (PwSCI) are at increased risk of leading less active lifestyles as compared to the general population. Spinal cord injury (SCI) results in declines in physical capacity and an increased risk of secondary health conditions. Specifically, PwSCI are three times more likely to have one or more chronic diseases such as heart disease, stroke, diabetes, cancer, or obesity compared to persons without disabilities ( ; ). SCIs often result in various physiological alterations affecting multiple body systems, including blunted hemodynamics, altered sympathetic innervation, altered glycemic control, reduced active muscle mass, deteriorated circulatory vessels below level of injury, and impaired arterial compliance and function ( ). These pathophysiological alterations amplify the risk and prevalence of cardiovascular and metabolic diseases in PwSCI. PwSCI are also at an increased risk of negative mood states including depression and anxiety ( ). An approach to managing the potential physiological and psychological implications of an SCI is engaging in physical activity or exercise.

Exercise and persons with a spinal cord injury

The typical daily routine of PwSCI does not stress the cardiorespiratory system enough to produce positive health-related changes; therefore, participation in regular exercise is needed to enhance physical capacity and to reduce the likelihood of secondary complications ( ; ). Similar to the general population, regular exercise is critical to reducing the risk of developing chronic health conditions and has positive effects on the physiological health and psychological well-being of PwSCI ( ; ). Participation in exercise is also connected to more established social networks and greater participation in life activities ( ; ). Increased cardiorespiratory fitness in PwSCI promotes not only improved functional independence, but also improved cardiovascular and metabolic health ( ).

Exercise and spinal cord injury considerations

PwSCI may experience secondary health conditions that are important to take into consideration when engaging in exercise. Bone loss and osteoporosis are complications that may occur following an SCI and can lead to an increased risk of fractures, which can have further negative consequences on health and functioning ( ). Upper extremity pain and chronic overuse injuries, particularly in the shoulder joints of PwSCI, are commonly associated with wheelchair self-propulsion and transfers ( ). Due to the direct effects of an SCI, PwSCI often lack normal protective sensation below the level of their injury. This lack of sensation combined with the reduced mobility associated with an SCI can result in the development of pressure ulcers ( ). Having an understanding of these possible secondary conditions is important when exercising. Proper biomechanical positioning when exercising, reducing the number of transfers onto exercise equipment, and implementing a regular shoulder strengthening exercise program targeted at the rotator cuff are among the actions that can be taken to prevent or delay these secondary conditions from impacting the exercise routine of a PwSCI.

Exercise recommendations for persons with spinal cord injury

Basic programming guidelines for exercise and physical activity are set forth by organizations including the American College of Sports Medicine’s Guidelines for Exercise Testing and Prescription (2020) and the Physical Activity Guidelines for Adults with Chronic Health Conditions and Adults with Disabilities from the . The U.S. Department of Health and Human Services recommends at least 150 minutes per week of moderate-intensity aerobic activity or 75 minutes per week of vigorous-intensity aerobic activity for adults with chronic conditions or disabilities, as well as muscle strengthening activities of moderate or greater intensity, 2 or more days a week. Diagnosis-specific guidelines exist for PwSCI and recommend shorter durations of weekly exercise time. For example, to gain cardiometabolic health and fitness and muscle strength benefits, the International Exercise Guidelines for PwSCI recommend that a PwSCI should engage in at least 20 to 30 min of moderate-to-vigorous-intensity aerobic exercise two to three times per week and three sets of strength exercises for each major functioning muscle group, at a moderate-to-vigorous intensity, two times per week ( ).

Barriers to exercise

Despite the widely recognized health benefits of regular exercise, PwSCI report lower levels of exercise compared to the general population ( ; ; ). Because of decreased sympathetic innervation, muscle atrophy, and decreased cardiac reserves, it is difficult for PwSCI to achieve intensity levels necessary to make health-related changes without proper support ( ; ). PwSCI face numerous challenges to participating in exercise, including personal (e.g., lack of motivation and self-efficacy) and environmental (e.g., transportation, access to proper equipment) barriers ( ). Unlike the surplus of fitness centers and equipment available for the general population, there is a considerable lack of accessible equipment, support, and professional guidance for PwSCI ( ; ). In addition, PwSCI do not always have access to the information needed to monitor their progress. Accurate and reliable measures are important so that physical activity levels of PwSCI can be assessed, recommendations can be made to better inform development of exercise programs, and PwSCI can independently track their exercise and take ownership of their health.

Importance of exercise testing

An important aspect of supporting PwSCI to successfully engage, initiate, and maintain exercise is the ability to have reliable information to inform and develop individualized programs and track change. Whether a person is an elite athlete training for the Paralympics or a newly injured PwSCI, having information to guide programs and help people achieve their goals is crucial. The following will discuss different types of testing, testing protocols, considerations for PwSCI, and equipment and adaptations.

Exercise testing for persons with a spinal cord injury

Physical fitness is the ability to perform activities of daily living, leisure activities, and other occupations without excessive fatigue. Physical fitness testing, also known as exercise testing, is important to conduct to determine a baseline fitness level, identify strengths and areas of improvement, and establish realistic goals for individuals. Comprehensive testing best informs exercise professionals to design and implement appropriate, client-centered exercise prescriptions. Follow-up testing results can also be performed and compared to baseline data to evaluate progress during and/or following a prescribed exercise program ( ). Accurate and reliable assessments are important so that exercise and fitness levels can be evaluated, recommendations can be made to better inform development of exercise programs, and PwSCI can independently track their exercise and take ownership of their health.

Exercise testing can include a number of different components; however, the two most common are cardiorespiratory endurance, also known as functional capacity, and musculoskeletal fitness testing. Musculoskeletal fitness is comprised of two components, muscle strength and muscle endurance ( ; ).

General considerations for exercise testing for people with spinal cord injury

PwSCI may experience a myriad of multi-system physiological alterations as a result of their injury ( ). For these reasons, specific considerations and precautions are recommended when conducting exercise testing with PwSCI. Exercise testing participants should obtain physician approval and signed release prior to initiation of testing. Testers should be well trained in the testing protocol, procedures, and equipment, and also familiar with potentially dangerous conditions associated with SCI, such as autonomic dysreflexia. Testing participants should be supervised and closely monitored throughout the duration of the testing session. Ambient temperature of the testing environment should be comfortable for the participant, keeping in mind persons with a cervical level injury may not be able to control their temperature by sweating and may need a fan blowing on them or cooler room temperatures. Devices such as heart rate monitors and/or other wearable sensors should be worn by testing participants for accurate monitoring of participant status. Vitals and pain level should be taken prior to initiation of testing to ensure that the session can safely proceed. The testing session should be terminated if any of the following distressful issues occur: abnormal heart rate or blood pressure, presence of a bladder infection, presence of a pressure ulcer, unusual spasticity, or autonomic dysreflexia. Testers should also determine a pain threshold at which to terminate testing; recommended thresholds may vary; however, terminating testing if reported pain is ≥ 6 out of 10 has been acceptable ( ).

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