| | Effects of Circuit Resistance Training on Fitness Attributes and Upper-Extremity Pain in Middle-Aged Men With ParaplegiaAbstract Nash MS, van de Ven I, van Elk N, Johnson BM. Effects of circuit resistance training on fitness attributes and upper-extremity pain in middle-aged men with paraplegia. ObjectiveTo examine the effects of circuit resistance exercise (CRT) training on muscle strength, endurance, anaerobic power, and shoulder pain in middle-aged men with paraplegia. SettingAcademic medical center. ParticipantsSeven men (age range, 39−58y) with motor-complete paraplegia from T5 to T12 and confirmed shoulder pain occurring during daily activities. InterventionsNot applicable. Main Outcome MeasuresSubjects underwent a 4-month CRT program using alternating resistance maneuvers and high-speed, low-resistance arm exercise. One-repetition maximal force was measured before training and monthly thereafter. Pretraining and posttraining peak oxygen uptake (Vo2peak) was measured by graded arm testing. Anaerobic power was measured before and after training using a 30-second Wingate Anaerobic Test. Shoulder pain was self-evaluated by an index validated for people with spinal cord injury (Wheelchair Users Shoulder Pain Index [WUSPI]). ResultsStrength increases ranging from 38.6% to 59.7% were observed for all maneuvers (P range, .005−.008). Vo2peak increased after training by 10.4% (P=.01), and peak and average anaerobic power increased by 6% (P=.001) and 8.6% (P=.005), respectively. WUSPI scores ± standard deviation were lowered from 31.9±24.8 to 5.7±5.9 (P=.008), with 3 of 7 subjects reporting complete resolution of shoulder pain. ConclusionsCRT improves muscle strength, endurance, and anaerobic power of middle-aged men with paraplegia while significantly reducing their shoulder pain. THERE IS WIDESPREAD AGREEMENT that people with spinal cord injuries (SCIs) should adopt habitual exercise as part of a healthy lifestyle to the extent that their abilities permit.1, 2, 3, 4 This need is supported by an early assessment that ranked people with chronic SCI at the lowest end of the fitness continuum5 and a more recent observation that their sedentary profiles and poor levels of fitness have remained unchanged.6 Nearly 25% of young people with paraplegia have fitness levels that compromise performance of essential daily activities,7 and although those with paraplegia have far greater capacities for activity and more extensive choices for exercise participation than people with tetraplegia, they are only marginally more fit.8 No evidence suggests that the fitness levels for those with SCI will improve without a committed effort on their parts to increase daily physical activity. Various impediments to successful exercise conditioning exist for those with SCI, among them aging and pain. Although SCI remains a trauma that is primarily sustained by young people, population aging for those with SCI has been widely noted over the past 2 decades.9, 10, 11, 12, 13, 14 Of the 179,000 people in the United States who live with SCI, 40% are now 45 years or older, and 1 in 4 has lived 20 or more years with disability.9 Aging with disabilities obviously imposes changing abilities, including those caused by cumulative stress effects from wheelchair propulsion and repetitive upper-extremity weight bearing.15, 16, 17, 18 The aging of people with SCI and common reports of pain are special concerns for those who wish to comply with exercise recommendations of their health professionals. Although the upper extremities are widely used to perform exercise by persons with SCI, they are structurally and functionally ill-suited for the propulsion and weight-bearing functions required to satisfy daily living.19, 20 They are thus susceptible to chronic deterioration, overuse injury, and pain,16, 17, 21, 22 making exercise selection and prescription critical if activities are to provide benefit and not cause harm. Both nociceptive and neuropathic pain are highly prevalent after SCI.23, 24 Upper-limb pain is the most common symptom of physical dysfunction reported by those with SCI,16, 25 and the shoulder the most common site.26 It is also the location for commonly experienced rotator cuff dysfunction and tears and impingement.27, 28 A large segment of the paralyzed population lives with pain in the shoulders, arms, and wrists, with complaints reported in 35%21 to 73%16 of people with chronic paraplegia. These figures cause special concern because the onset of pain occurs earlier than is observed in people without disability and because pain from muscle and joint overuse worsens with passing time and advancing age.20 Upper-limb pain must be prevented if function is to be enhanced by exercise and incipient disability avoided. Although a single cause for shoulder pain has not been identified, many studies attribute pain to deterioration and injury resulting from insufficient shoulder strength, range, and muscle endurance.29, 30, 31, 32 Pain that accompanies wheelchair locomotion and other wheelchair activities interferes with functional performance including upper-extremity weight bearing for transfers, high-resistance muscular activity in the extremes of limb range, wheelchair propulsion up inclines, and frequent overhead activity.32, 33 Wheelchair propulsion and transfers requiring shoulder girdle depression cause the most pain and increase the intensity of existing pain more than other daily activities. As many as half of people with SCI experience significant shoulder pain intensified by wheelchair propulsion and body transfers,15 which are activities critical to activity and health maintenance. The severity of upper-limb pain increases during common transfer activities and increases as time after injury lengthens,25 although exercises focusing on the posterior shoulder and upper back appear to lessen the pain.31 Because deficiencies and imbalances in upper-extremity strength contribute to upper-limb pain in those with SCI29, 34 we previously examined the benefits of a circuit resistant training (CRT) program in young, healthy men with paraplegia.35 CRT is an exercise program consisting of multiple resistance activities with short periods of interposed endurance exercise.36 The cardiorespiratory and strength benefits of CRT have been reported in several studies of people without disability and exceed those observed after conventional resistance training.36, 37, 38 Noteworthy in our earlier training of subjects with SCI were gains in both cardiorespiratory endurance and strength that were greater than had been previously reported after training with an arm crank or wheelchair ergometer. However, subjects trained in this study were relatively young and without significant upper-limb pain. As such, study participants may not have realistically reflected population characteristics of those who are older and living with pain. Because strengthening of the upper limbs has recently been recommended by consensus guidelines,39 we examined the effects of an identical CRT protocol on muscle strength, endurance, and anaerobic power in middle-aged men with paraplegia having moderate shoulder pain during daily activities. The purpose of this study was to test the hypotheses that CRT improves upper-limb endurance, strength, and anaerobic power in middle-aged people with chronic paraplegia while reducing shoulder pain experienced during the performance of daily activities. Methods  Participants Seven healthy men between 39 and 58 years old with motor-complete (American Spinal Injury Association grades A or B) paraplegia averaging ± standard deviation 13.1±6.6 years at the T5 to T12 levels volunteered to undergo 16 weeks of CRT. These subjects were selected because people with these injury levels exhibit competent and relatively homogenous chronotropic responses to physical activity.32 Study participants were recruited from a pool of volunteers who reported mild to moderate upper-limb pain during the performance of daily activities and used a manual wheelchair for locomotion. All subjects had been physically inactive for at least 6 months before entry into the study. Signed informed consent was obtained from all subjects before the start of the study. This study was approved by the University of Miami Medical Sciences Subcommittee for the Protection of Human Subjects. Upper-limb endurance was operationalized as the primary study outcome. To obtain an estimate of the effect size we might expect for the variables in our sample, we relied on the results of an identical training algorithm tested in younger people with paraplegia.35 Considering that the results of that study produced a 29% increase in peak oxygen uptake (Vo2peak), we estimated that an overall sample of 7 subjects would result in a power of approximately .96 at the α equal to .01 level of significance. Therefore, our enrolled sample size was considered sufficient to achieve statistically significant differences in Vo2peak after training. Fitness Testing Endurance testing To screen for contraindications to exercise training and to test the hypothesis that subjects undergoing CRT experienced an endurance training effect, subjects underwent peak cardiorespiratory testing at baseline and after study week 16. A peak, multistage, graded exercise test was performed with a calibrated hydraulically braked upper-arm ergometera as previously described.26 The initial exercise workload of 400kpm at 60rpm for 3 minutes was followed by 3-minute stages, each increasing in 100-kpm increments until fatigue. Responses to exercise were continuously monitored via open-circuit spirometry and 12-lead electrocardiography (Vmax229b with integrated electrocardiographic monitoring). Exercise termination points were consistent with the Guidelines for Exercise Testing and Training, 7th Edition,40 of the American College of Sports Medicine. Peak work was defined as volitional exhaustion, inability to maintain targeted workload, or the point at which increasing workload failed to further increase of Vo2. Anaerobic power testing The Wingate Anaerobic Test was used to assess anaerobic power before and after training.7, 41 Subjects propelled a table-mounted Monark 834e ergometerc for 30 seconds at maximal speed against a constant force, with flywheel velocity assessed by an Optosensor 2000.d The constant resistance for each subject was set at 3.5% of his or her body mass, as recommended.42 Data for 2 variables were obtained: (1) peak power, defined as the highest average mechanical power measured during any 5-second period, and (2) mean power, the average power sustained during the 30-second test period. Data were expressed as the average of repeated tests with 30 minutes of rest between efforts. Strength testing Upper-extremity dynamic strength was assessed before the start of the program and every 4 weeks thereafter. Testing was performed on a Helms Equalizer 1000 multistation exercisere using the following maneuvers: overhead press, horizontal row, vertical butterfly, biceps curl, latissimus pull down (either to the chest or the neck), and dips. Subjects were instructed to perform 8 repetitions of each maneuver, with each repetition lasting 6 seconds (3s concentric, 3s eccentric). If 8 repetitions were completed in a controlled fashion the weight was increased and the exercise repeated. Incremental increases in weight were provided until 8 controlled repetitions could not be completed. The 1-repetition maximum (1-RM) was calculated using the Mayhew regression equation43 as we have previously reported44: where Wt is the resistance used in the last set where more than 3 repetitions but less than 8 repetitions were completed and reps equals the number of repetitions completed in the last set of testing. Pain Assessment Subjects self-administered the Wheelchair Users Shoulder Pain Index (WUSPI),45 a 15-item self-report instrument that measures shoulder pain during transfers, wheelchair mobility, self-care, and general activities. This rating was performed before and after training. The WUPSI is a valid and reliable measure of shoulder pain causing limitation of function for people who use wheelchairs for locomotion. The index has high internal consistency (Cronbach α=.98) and high levels of reliability between 2 consecutive administrations. These characteristics support its use for multiple administrations over time. The WUSPI was scored using a visual analog scale according to the methods of Curtis et al,45 with scores ranging from 0 to 10 for each of the 15 items. Individual item scores were summed for the total index score ranging from 0 to 150. The WUSPI index items include transfers (bed to wheelchair, car to wheelchair, tub and/or shower to wheelchair, load wheelchair in car), wheelchair mobility (more than 10 minutes in duration, ramp/uneven), self-care (lift object from overhead, put on pants, put on t-shirt, put on button-down shirt, wash back), and general activities (work and/or school activities, driving, household chores, sleeping). Circuit Resistance Training Subjects underwent CRT 3 times weekly on nonconsecutive days for 16 weeks. Each session lasted approximately 40 to 45 minutes and included resistance training (weight lifting) and high-speed, low-intensity endurance activities (arm cranking) with interposed periods of incomplete recovery (ie, heart rate not falling to baseline). The following full-range, bilateral resistance maneuvers were performed on an Equalizer 7000 multistation exercise systeme: (1) military press, (2) horizontal rows, (3) pectoralis (horizontal row), (4) preacher curls (elbow flexion), (5) wide grip latissimus pull-down, and (6) seated dips. Each training session was preceded by a 2-minute arm ergometry warm-up with a Saratoga Cycle.f Subjects executed 1 set of 10 repetitions (6-s movement; 3-s concentric [lifting]; 3-s eccentric [lowering]) for 2 of the resistance maneuvers, which were performed in pairs and were followed by 2 minutes of arm ergometry without applied resistance. Two more resistance pairs and arm ergometry then followed. The last 2 (of 6) resistance maneuvers were then performed, accompanied by 2 more minutes of arm ergometry. A circuit consisted of 3 such cycles performed without interruption and with rest between maneuvers limited to the 10 seconds needed to change stations. Resistive loads for training during weeks 1 and 2 were 50% of the 1-RM values calculated during the initial isoinertial strength testing. These loads were increased to 55% and 60% of the 1-RM during training weeks 3 and 4, respectively. The 1-RM for each maneuver was recomputed during the last training session every 4 weeks, which adjusted for training effects. Data Analysis Data examining study outcomes were analyzed by a series of univariate single-factor analysis of variance, with time as the single factor. The criterion for significance was set at P less than or equal to .01. Results Subject-Reported Pain Subject-reported pain scores reflect significant reduction of shoulder pain during daily activities (fig 2). WUSPI scores decreased from 31.8±23.5 to 5.0±7.7 (P=.008). Of the 7 study participants, 3 reported either complete or near-complete resolution of shoulder pain after training. Discussion The key finding of the study is that middle-aged men who underwent 16 weeks of CRT increased their endurance, strength, and anaerobic power while decreasing their self-reported shoulder pain. We have previously reported that CRT performed by younger men with paraplegia enhanced both muscle strength and cardiorespiratory endurance35 and in a separate study significantly reduced their lipid-related cardiovascular disease risk.44 One of the anecdotal observations communicated by participants in earlier studies was a reduction of shoulder pain during daily activities, which prompted us to pursue more objective assessment using a shoulder pain instrument validated in this population. The average gain in peak work capacity in the study was 10.4%, which was less than 29.7% gain reported in the CRT program for younger participants but still comparable to studies that have used arm ergometry alone as a training mode over a similar training period. The gains in strength, however, were greater than those reported in other studies, with increases ranging from 35.7% on wide-grip latissimus pull down to 57.9% for horizontal row. Although strength and endurance are commonly used as the primary outcomes of training studies, little emphasis has been placed on anaerobic power for those with SCI.42 In our view all of these fitness elements are important, because strength is used during the performance of daily activities such as transfers and lifting tasks46 and physical endurance is needed for steady-state wheelchair propulsion and as a fitness-associated countermeasure to the accelerated vascular disease widely reported in the population.47, 48 Anaerobic endurance is a validated fitness measure in those with SCI42 that best serves short-duration, high-intensity activities such as wheelchair propulsion up inclines. Recent evidence also confirms a positive effect of strength on both anaerobic power and endurance in people with paraplegia,49 suggesting an interrelation between fitness attributes that satisfies all conditioning needs. No other single training mode has provided all 3 fitness benefits for those with SCI. To the contrary, very little training crossover has been reported for those with SCI who undergo exercise conditioning. Despite the importance for both upper-extremity strengthening and achieving better strength balances after SCI, very few studies have examined strength acquisition through targeted training. This is surprising for 2 reasons. First, the American College of Sports Medicine urges the inclusion of resistance training in adult exercise conditioning programs.50, 51 In these recommendations resistance training is identified as the most effective method for maintaining and increasing lean body mass and improving both muscular strength and endurance. The recommendations further cite an increasing body of evidence suggesting that resistance training may significantly improve many health factors associated with the prevention of chronic diseases.50 Second, strength acquisition and balance have been recommended for preserving upper-limb function in the recent clinical practice guidelines of the Consortium for Spinal Cord Medicine.39 This study is not the first to test resistance protocols or the benefits of strength training in people with SCI, but to our knowledge it is the first to report all fitness attributes and pain treatment in a single conditioning plan. Nilsson et al52 were the first to describe a program of upper-limb strengthening consisting of interval arm ergometry followed by progressive resistance activities. Significant improvements in triceps muscle strength were reported, which allowed those with incomplete SCI to better ambulate while using crutches. Cooney and Walker41 trained subjects on hydraulic resistance equipment using multiple sets at 2 exercise stations and controlled rest periods of 40 to 100 seconds between sets. Improvements in cardiorespiratory capacity of 28.1% and power output of 36.7% as assessed by arm ergometry testing were observed after the 9-week training program, although no strength-related outcomes were reported. Unlike other CRT programs in which station changes were made rapidly, several wheelchair transfers were required to perform the exercises, because the equipment used was not adapted for wheelchair use. Hicks et al53 reported increased strength and arm power output after 9 months of twice-weekly arm ergometry and resistance training accompanied by reduced shoulder pain reported on 2 items contained in the 36-Item Short-Form Health Survey, although anaerobic power was not measured, their subjects were younger than those in the current study, and strength gains (19%−34%) were not as robust as those reported in the current study (39%−60%). Further, the training sessions were conducted over 90- to 120-minute intervals, which are 2 to 3 times longer than the 43 minutes required to execute the CRT protocol. Notwithstanding, the study by Hicks reported an important link between fitness and life quality that we did not measure. Curtis et al31 reported significant lowering of WUSPI scores in 42 people with SCI after 6 months of anterior shoulder stretching and posterior shoulder strengthening with elastic bands. Reductions in performance-corrected WUSPI scores of 12.1 points were noted by Curtis31 but were larger in the current study, possibly because subjects began training with higher average pain ratings. Inspection of the WUSPI subscales failed to identify a sole benefit for the reduction of pain, although the data and subject reports favored diminished discomfort during wheelchair propulsion up inclines. Noteworthy is the similarity that the 2 protocols emphasized stretching of the anterior chest accompanied by strengthening of the shoulder joint complex and mobilization of the scapulothoracic articulation. These techniques have been noted to prevent or reduce shoulder joint pain in wheelchair users.31 The training-induced reductions of shoulder pain noted by Hicks53 and Curtis31 are also remarkable for their association between fitness and reduction of shoulder pain.22, 54 The study findings are delimited by the small study group. To reduce the likelihood of committing an alpha (type I) error, the probability criterion for all testing was lowered to the .01 level. As shown by the power analysis for this study, effect sizes for this type of training are large and the benefits of training in deconditioned people are robust—whether participants have a disability or not. In the current instance the study subjects were recreationally active but not involved in structured exercise, suggesting that percentage gains in fitness could be greater in a significantly deconditioned cohort. The study conclusions are further delimited by the lack of a control group design, although the study was conducted over a relatively short training period in a group that was fairly homogeneous at baseline. We are unaware of an instance in which significant gains in fitness attributes or spontaneous resolution of musculoskeletal pain accompanies chronic sedentary behavior, suggesting that significant benefits were a true reflection of the training activity. In contrast with other training studies53, 54 that used a longer conditioning period, the current findings indicate that fitness can be acquired over a relatively short period, which may provide an incentive for exercise participation in deconditioned people with paraplegia. Conclusions Exercise conditioning with CRT rapidly improves the muscle strength, endurance, and anaerobic power of middle-aged men with paraplegia while significantly reducing shoulder pain. Training with CRT enhances multiple fitness attributes, which provides an economy of training that is superior to either endurance or resistance training alone. Supplier Acknowledgment We acknowledge the important methodologic contributions of John E. Lewis, PhD. References 1. 1Nash MS. Cardiovascular fitness after spinal cord injuries. In: Lin V editors. Spinal cord medicine. New York: Demos; 2002;p. 637–646. 2. 2Nash MS. Exercise reconditioning of the heart and peripheral circulation after spinal cord injury. Top Spinal Cord Inj Rehabil. 1997;3:1–15. 3. 3Kjaer M. Why exercise in paraplegia?. Br J Sports Med. 2000;34:322–323. MEDLINE |
CrossRef
4. 4van der Ploeg HP, van der Beek AJ, van der Woude LH, van Mechelen W. Physical activity for people with a disability: a conceptual model. Sports Med. 2004;34:639–649. MEDLINE |
CrossRef
5. 5LaPorte RE, Adams LL, Savage DD, Brenes G, Dearwater S, Cook T. The spectrum of physical activity, cardiovascular disease and health: an epidemiologic perspective. Am J Epidemiol. 1984;120:507–517. MEDLINE 6. 6Bracken MB, Shepard MJ, Collins WF, et al. A randomized, controlled trial of methylprednisolone or naloxone in the treatment of acute spinal-cord injury (Results of the Second National Acute Spinal Cord Injury Study). N Engl J Med. 1990;322:1405–1411. MEDLINE 7. 7Noreau L, Shephard RJ, Simard C, Pare G, Pomerleau P. Relationship of impairment and functional ability to habitual activity and fitness following spinal cord injury. Int J Rehabil Res. 1993;16:265–275. MEDLINE 8. 8Bostom AG, Toner MM, McArdle WD, Montelione T, Brown CD, Stein RA. Lipid and lipoprotein profiles relate to peak aerobic power in spinal cord injured men. Med Sci Sports Exerc. 1991;23:409–414. MEDLINE 9. 9Gerhart KA, Bergstrom E, Charlifue SW, Menter RR, Whiteneck GG. Long-term spinal cord injury: functional changes over time. Arch Phys Med Rehabil. 1993;74:1030–1034. MEDLINE |
CrossRef
10. 10Ohry A, Shemesh Y, Rozin R. Are chronic spinal cord injured patients (SCIP) prone to premature aging?. Med Hypotheses. 1983;11:467–469. MEDLINE |
CrossRef
11. 11Capoor J, Stein AB. Aging with spinal cord injury. Phys Med Rehabil Clin N Am. 2005;16:129–161. Full Text |
Full-Text PDF (360 KB)
|
CrossRef
12. 12Charlifue S, Lammertse DP, Adkins RH. Aging with spinal cord injury: changes in selected health indices and life satisfaction. Arch Phys Med Rehabil. 2004;85:1848–1853. Abstract | Full Text |
Full-Text PDF (89 KB)
|
CrossRef
13. 13Liem NR, McColl MA, King W, Smith KM. Aging with a spinal cord injury: factors associated with the need for more help with activities of daily living. Arch Phys Med Rehabil. 2004;85:1567–1577. Abstract | Full Text |
Full-Text PDF (175 KB)
|
CrossRef
14. 14Adkins RH. Research and interpretation perspectives on aging related physical morbidity with spinal cord injury and brief review of systems. NeuroRehabilitation. 2004;19:3–13. MEDLINE 15. 15Nichols PJ, Norman PA, Ennis JR. Wheelchair user’s shoulder? (Shoulder pain in patients with spinal cord lesions). Scand J Rehabil Med. 1979;11:29–32. MEDLINE 16. 16Subbarao JV, Klopfstein J, Turpin R. Prevalence and impact of wrist and shoulder pain in patients with spinal cord injury. J Spinal Cord Med. 1995;18:9–13. MEDLINE 17. 17Boninger ML, Towers JD, Cooper RA, Dicianno BE, Munin MC. Shoulder imaging abnormalities in individuals with paraplegia. J Rehabil Res Dev. 2001;38:401–408. MEDLINE 18. 18Corfman TA, Cooper RA, Boninger ML, Koontz AM, Fitzgerald SG. Range of motion and stroke frequency differences between manual wheelchair propulsion and pushrim-activated power-assisted wheelchair propulsion. J Spinal Cord Med. 2003;26:135–140. MEDLINE 19. 19Bayley JC, Cochran TP, Sledge CB. The weight-bearing shoulder (The impingement syndrome in paraplegics). J Bone Joint Surg Am. 1987;69:676–678. MEDLINE 20. 20Gellman H, Sie I, Waters RL. Late complications of the weight-bearing upper extremity in the paraplegic patient. Clin Orthop Relat Res. 1988;(233):132–135. 21. 21Silfverskiold J, Waters RL. Shoulder pain and functional disability in spinal cord injury patients. Clin Orthop Relat Res. 1991;(272):141–145. 22. 22Fullerton HD, Borckardt JJ, Alfano AP. Shoulder pain: a comparison of wheelchair athletes and nonathletic wheelchair users. Med Sci Sports Exerc. 2003;35:1958–1961. MEDLINE |
CrossRef
23. 23Levi R, Hultling C, Nash MS, Seiger A. The Stockholm spinal cord injury study: 1. Medical problems in a regional SCI population. Paraplegia. 1995;33:308–315. MEDLINE 24. 24Widerstrom-Noga EG, Turk DC. Exacerbation of chronic pain following spinal cord injury. J Neurotrauma. 2004;21:1384–1395. MEDLINE 25. 25Sie IH, Waters RL, Adkins RH, Gellman H. Upper extremity pain in the postrehabilitation spinal cord injured patient. Arch Phys Med Rehabil. 1992;73:44–48. MEDLINE 26. 26Pentland W, McColl MA, Rosenthal C. The effect of aging and duration of disability on long term health outcomes following spinal cord injury. Paraplegia. 1995;33:367–373. MEDLINE 27. 27Burnham R, Martin T, Stein R, Bell G, MacLean I, Steadward R. Skeletal muscle fibre type transformation following spinal cord injury. Spinal Cord. 1997;35:86–91. MEDLINE 28. 28Lal S. Premature degenerative shoulder changes in spinal cord injury patients. Spinal Cord. 1998;36:186–189. MEDLINE 29. 29Burnham RS, May L, Nelson E, Steadward R, Reid DC. Shoulder pain in wheelchair athletes (The role of muscle imbalance). Am J Sports Med. 1993;21:238–242. MEDLINE |
CrossRef
30. 30Curtis KA, Drysdale GA, Lanza RD, Kolber M, Vitolo RS, West R. Shoulder pain in wheelchair users with tetraplegia and paraplegia. Arch Phys Med Rehabil. 1999;80:453–457. Abstract |
Full-Text PDF (752 KB)
|
CrossRef
31. 31Curtis KA, Tyner TM, Zachary L, et al. Effect of a standard exercise protocol on shoulder pain in long-term wheelchair users. Spinal Cord. 1999;37:421–429. MEDLINE 32. 32Pentland WE, Twomey LT. Upper limb function in persons with long term paraplegia and implications for independence: Part I. Paraplegia. 1994;32:211–218. MEDLINE 33. 33Pentland WE, Twomey LT. The weight-bearing upper extremity in women with long term paraplegia. Paraplegia. 1991;29:521–530. MEDLINE 34. 34Ballinger DA, Rintala DH, Hart KA. The relation of shoulder pain and range-of-motion problems to functional limitations, disability, and perceived health of men with spinal cord injury: a multifaceted longitudinal study. Arch Phys Med Rehabil. 2000;81:1575–1581. Abstract | Full Text |
Full-Text PDF (72 KB)
|
CrossRef
35. 35Jacobs PL, Nash MS, Rusinowski JW. Circuit training provides cardiorespiratory and strength benefits in persons with paraplegia. Med Sci Sports Exerc. 2001;33:711–717. MEDLINE 36. 36Gettman LR, Ayres JJ, Pollock ML, Jackson A. The effect of circuit weight training on strength, cardiorespiratory function, and body composition of adult men. Med Sci Sports. 1978;10:171–176. MEDLINE 37. 37Eriksson J, Taimela S, Eriksson K, Parviainen S, Peltonen J, Kujala U. Resistance training in the treatment of non-insulin-dependent diabetes mellitus. Int J Sports Med. 1997;18:242–246. MEDLINE |
CrossRef
38. 38Eriksson J, Tuominen J, Valle T, et al. Aerobic endurance exercise or circuit-type resistance training for individuals with impaired glucose tolerance?. Horm Metab Res. 1998;30:37–41. MEDLINE |
CrossRef
39. 39Preservation of upper limb function following spinal cord injury: a clinical practice guideline for health care professionals (Paralyzed Veterans of America Consortium for Spinal Cord Medicine). J Spinal Cord Med. 2005;28:434–464. MEDLINE 40. 40In: Whaley MH editors. Guidelines for exercise testing and training. 7th ed.. Philadelphia: Lippincott Williams & Wilkins; 2005;. 41. 41Cooney MM, Walker JB. Hydraulic resistance exercise benefits cardiovascular fitness of spinal cord injured. Med Sci Sports Exerc. 1986;18:522–525. MEDLINE 42. 42Jacobs PL, Mahoney ET, Johnson B. Reliability of arm Wingate Anaerobic Testing in persons with complete paraplegia. J Spinal Cord Med. 2003;26:141–144. MEDLINE 43. 43Mayhew JL, Ball TE, Bowen JC. Relative muscular endurance performance as a predictor of bench press strength in college men and women. Sports Med Training Rehabil. 1992;3:195–201. 44. 44Nash MS, Jacobs PL, Mendez AJ, Goldberg RB. Circuit resistance training improves the atherogenic lipid profiles of persons with chronic paraplegia. J Spinal Cord Med. 2001;24:2–9. MEDLINE 45. 45Curtis KA, Roach KE, Applegate EB, et al. Reliability and validity of the Wheelchair User’s Shoulder Pain Index (WUSPI). Paraplegia. 1995;33:595–601. MEDLINE 46. 46Janssen TW, van Oers CA, Hollander AP, Veeger HE, van der Woude LH. Isometric strength, sprint power, and aerobic power in individuals with a spinal cord injury. Med Sci Sports Exerc. 1993;25:863–870. MEDLINE |
CrossRef
47. 47Bauman WA, Spungen AM, Raza M, et al. Coronary artery disease: metabolic risk factors and latent disease in individuals with paraplegia. Mt Sinai J Med. 1992;59:163–168. MEDLINE 48. 48Bauman WA, Spungen AM. Metabolic changes in persons after spinal cord injury. Phys Med Rehabil Clin N Am. 2000;11:109–140. MEDLINE 49. 49Zoeller RF, Riechman SE, Dabayebeh IM, Goss FL, Robertson RJ, Jacobs PL. Relation between muscular strength and cardiorespiratory fitness in people with thoracic-level paraplegia. Arch Phys Med Rehabil. 2005;86:1441–1446. Abstract | Full Text |
Full-Text PDF (109 KB)
|
CrossRef
50. 50Hass CJ, Feigenbaum MS, Franklin BA. Prescription of resistance training for healthy populations. Sports Med. 2001;31:953–964. MEDLINE |
CrossRef
51. 51American College of Sports Medicine Position Stand. The recommended quantity and quality of exercise for developing and maintaining cardiorespiratory and muscular fitness, and flexibility in healthy adults. Med Sci Sports Exerc. 1998;30:975–991. MEDLINE |
CrossRef
52. 52Nilsson S, Staff PH, Pruett ED. Physical work capacity and the effect of training on subjects with long-standing paraplegia. Scand J Rehabil Med. 1975;7:51–56. MEDLINE 53. 53Hicks AL, Martin KA, Ditor DS, et al. Long-term exercise training in persons with spinal cord injury: effects on strength, arm ergometry performance and psychological well-being. Spinal Cord. 2003;41:34–43. MEDLINE |
CrossRef
54. 54Ditor DS, Latimer AE, Ginis KA, Arbour KP, McCartney N, Hicks AL. Maintenance of exercise participation in individuals with spinal cord injury: effects on quality of life, stress and pain. Spinal Cord. 2003;41:446–450. MEDLINE |
CrossRef
a Department of Neurological Surgery, Miller School of Medicine, University of Miami, Miami, FL b Department of Miami Project to Cure Paralysis, Miller School of Medicine, University of Miami, Miami, FL c Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands.  Reprint requests to Mark S. Nash, PhD, Dept of Neurological Surgery, 1095 NW 14th Ter, R-48, Miami, FL 33136.
Supported by the Miami Project to Cure Paralysis. No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the author(s) or upon any organization with which the author(s) is/are associated. PII: S0003-9993(06)01371-2 doi:10.1016/j.apmr.2006.10.003 © 2007 American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved. | |
|
FULL TEXT
01371-2/journalimage?img=PIIS0003999306013712.gr1.lrg.gif&fig=fig1&kwhquery=&issn=0003-9993&ishighres=false&allhighres=false&free=yes','journalimage');)
01371-2/journalimage?img=PIIS0003999306013712.gr2.lrg.gif&fig=fig2&kwhquery=&issn=0003-9993&ishighres=false&allhighres=false&free=yes','journalimage');)