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Exercise Recommendations and Considerations for Persons With Spinal Cord Injury

      Increasing activity and exercise is essential for health and quality of life for people living with spinal cord injury (SCI). Obesity, cardiovascular disease, and diabetes are 2 to 4 times higher for people with SCI compared to the general population. This is due, in part, to low levels of activity, limited access and opportunities to participate in exercise, as well as changes in muscle and heart function that are common after injury. Exercise is necessary to improve fitness and reduce long-term health complications after SCI. Below are exercise recommendations for improving cardiovascular health, muscular strength and endurance, and flexibility for people with SCI.

      Exercise Guidelines

      It is important to note that anyone with SCI should first seek medical advice to ensure that it is safe to begin an exercise program, especially for those who have not exercised in the past 6 months. The following exercise recommendations can be used to build fitness. The balance of intensity and duration of activity should be gradually adjusted over time based on level of conditioning, preferably under the guidance of a clinician or exercise professional specializing in SCI management.
      Tabled 1
      Cardiovascular Health
      These cardiovascular and muscular strength/endurance recommendations are adapted with permission from SCI Action Canada (www.sciactioncanada.ca/guidelines accessed August, 2014).
      Muscle Strength and Endurance
      These cardiovascular and muscular strength/endurance recommendations are adapted with permission from SCI Action Canada (www.sciactioncanada.ca/guidelines accessed August, 2014).
      Flexibility and Range of Motion
      FrequencyMinimum 2 days/weekMinimum 2 days/weekDaily
      IntensityModerate to vigorous
      Moderate intensity: somewhat hard but can be sustained for long periods without experiencing excessive fatigue; Vigorous intensity: very hard, close to maximum and cannot be sustained for long without experiencing excessive fatigue.
      8–10 repetitions30–60 seconds/stretch; gentle , slow, pain free
      Duration20–30 minutes/session3 sets; 1–2 minutes rest between sets (30–60 minutes total)2 sets; 5–15 minutes
      ActivitiesWheeling, arm cycle, sports, recumbent stepper, aquatics, cycling, circuit training, functional electrical stimulationFree weights, elastic resistance bands, cable pulleys, weight machines, functional electrical stimulationStanding in standing frame (if medically cleared); passive and active static stretching
      These cardiovascular and muscular strength/endurance recommendations are adapted with permission from SCI Action Canada (www.sciactioncanada.ca/guidelines accessed August, 2014).
      Moderate intensity: somewhat hard but can be sustained for long periods without experiencing excessive fatigue; Vigorous intensity: very hard, close to maximum and cannot be sustained for long without experiencing excessive fatigue.
      Cardiovascular Health – Cardiovascular health, as a predictor of disease risk, has significant implications for those with SCI. Cardiovascular fitness has generated greater attention from both the clinical and research communities because poor cardiovascular fitness has been directly linked to the presence of secondary health conditions, including cardiovascular disease and cardiometabolic syndrome, in the SCI population. It can be affected by a number of factors including level of injury, severity of injury, degree of physical deconditioning, and extent of autonomic nervous system impairment. Participation in a variety of activities can be used to improve cardiovascular health, some of which have been listed in the table above; however, any sustained physical activity can be of benefit as long as it meets the requirements for time and intensity.
      Muscular Strength and Endurance – Muscle strength refers to the ability of a muscle or muscle group to generate maximal force. Muscle endurance refers to the ability of a muscle or muscle group to produce force over multiple repetitions. These are important components of fitness and play a vital role in improving or maintaining bone mineral density, muscle mass, resting metabolic rate, force and power production, muscle and tendon health, and glucose metabolism.
      Individuals with SCI rely heavily on their shoulder and arm muscles for mobility and for performing activities of daily living. Resistance training programs should be comprehensive, but an emphasis should be placed on improving strength and endurance of the muscles supporting the scapulae (shoulder blades) and posterior shoulders.
      Any muscle that can be voluntarily activated has the potential to benefit from resistance training exercise. However, the following exercises can have direct positive impact on the major muscles required for common daily activities: Bicep Curl, Triceps Press, Shoulder Press, Latissimus Pull-Down, Chest Fly, and Seated Row. For individuals with diminished trunk and shoulder stability and strength, external support such as a lumbar roll or a chest strap can be added to improve posture and reduce the risk of injury while exercising.
      Flexibility and Range of Motion – Flexibility and adequate joint range of motion are essential to maintaining mobility and decreasing the risk of injury. Extra attention should be directed toward stretching the chest, shoulders, and biceps, as these muscles are likely to be used extensively for mobility and may tighten after SCI. Lower body stretching should also be included, but caution should be taken not to overstretch limbs where impaired sensation exists, as this may lead to overstretching and excessive stress on joint structures. Specific muscles to be stretched should be based on individual needs and can be identified with the help of a trained clinician or exercise professional.

      Exercise Participation Safety Considerations

      The following list summarizes several major considerations for ensuring safe and effective exercise participation for persons with SCI:
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      Disclaimer

      This information is not intended to replace the advice from a medical professional. Individuals with SCI should consult their health care provider before participating in an exercise program.

      Authorship

      Exercise Recommendations and Considerations for Persons With Spinal Cord Injury was developed by Nicholas Evans, MHS; Brooks Wingo, PhD; Elizabeth Sasso, DPT; Audrey Hicks, PhD; Ashraf S. Gorgey, MPT, PhD; and Eric Harness, BS; and supported by the ACRM SCI-ISIG Fitness and Wellness Task Force and its members. This Information/Education Page may be reproduced for noncommercial use for health care and exercise professionals to share with clients, patients, and their caregivers. Any other reproduction is subject to approval by the Publisher.

      Linked Article

      • Correction
        Archives of Physical Medicine and RehabilitationVol. 97Issue 6
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          In the article “Exercise Recommendations and Considerations for Persons With Spinal Cord Injury” (Evans et al, Arch Phys Med Rehabil 2015;96:1749-50), these cardiovascular and muscular strength/endurance recommendations are a modified version of the Physical Activity Guidelines for Adults with Spinal Cord Injury developed and published by Martin Ginis KA, Hicks AL, Latimer AE, et al. The development of evidence-informed physical activity guidelines for adults with spinal cord injury. Spinal Cord 2011;49:1088-96.
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      • Sedentary Behavior in People With Spinal Cord Injury
        Archives of Physical Medicine and RehabilitationVol. 97Issue 1
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          With great interest we read the articles by Totosy de Zepetnek,1 Evans,2 and colleagues related to physical activity and exercise recommendations for people with spinal cord injury (SCI). Both articles focus on the necessity of exercise and physical activity to reduce (cardio)vascular health complications after SCI. We fully share this objective. However, we would like to raise an important issue.
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