Chapter 24
Exercise

Hardly a day goes by that we don’t hear or read something about the many benefits of regular exercise. The physical and psychological benefits of leading a fit and healthy lifestyle are well documented and widely publicized. Now that you have a spinal cord injury, it is even more critical that exercise becomes an integral part of your life. During your rehabilitation immediately following your injury, you will be exercising regularly under the guidance of skilled health professionals. Once you are discharged from the hospital, keeping exercise as a part of your daily routine is essential to maximize your abilities and overall health.

 
TYPES OF EXERCISE

There are several types of exercise that are important aspects of a well-balanced program targeted to improve fitness and function. They are:

• Muscular strength and endurance training. Strengthening enhances the ability of muscles to contract with maximal force. Endurance training increases a muscle’s ability to contract repeatedly and to resist fatigue.
• Cardiorespiratory or "aerobic" conditioning. Aerobic conditioning improves the body’s ability to use oxygen by training the heart and lungs to work more efficiently during a sustained activity.
• Stretching. Flexibility exercises help to maintain or increase the length and mobility of muscles to allow the body to move as normally as possible.

Stretching is addressed in detail in the chapter on Range of Motion. Therefore, the goal of this chapter is to discuss recommendations for muscular strength and endurance training and aerobic conditioning when you have a spinal cord injury.

 
BENEFITS OF EXERCISE

Exercise to improve muscular strength and endurance is important for a number of reasons:

• Allowing you to get from point A to point B whether you push a manual wheelchair, drive a power wheelchair with your hand or head, or have the ability to walk.
• Enabling you to move and take care of yourself as independently as possible.
• Protecting yourself from injuries.
• Supporting good upright posture.

Exercise to improve aerobic fitness is important for the following reasons:

• Improving your heart and lung function both during rest and during activity.
• Improving blood flow and oxygen delivery to muscles and skin.
• Decreasing the risk of heart disease.
• Improving the body’s ability to burn fat.
• Providing the body with more energy for daily activities.

Exercise in terms of general health also helps in many ways:

• Keeping your bones strong.
• Maintaining an ideal body weight.
• Improving control of blood sugar.
• Allowing you to participate in leisure and recreational activities you enjoy.
• Sleeping well.
• Feeling good about yourself and your body.

 
MUSCULAR STRENGTH AND ENDURANCE TRAINING

Depending on your level and classification of spinal cord injury, you will have some muscles that are within your voluntary control and some that are not. See the chapter on SCI Anatomy and Physiology. The muscles above your level of injury should not be neurologically impaired, but following your SCI they may be weak due to prolonged bedrest or inactivity. If you have a complete or sensory incomplete/motor complete injury, the muscles below your level of injury no longer work and thus they cannot be strengthened. If you have a motor incomplete SCI, some of the muscles below your level of injury work, but they are significantly weaker than normal. The goal of strengthening exercises is to encourage the muscles that you can voluntarily control to work as well as possible.

During your rehabilitation hospitalization, your physical and occupational therapists will design an exercise program to target all muscle groups that need training. Each program is tailored specifically for each person, depending on the level and extent of the spinal cord injury. For example, people who cannot move anything but their heads and necks will have a program to target the neck and breathing muscles, while people who have the ability to move all of their limbs will have extensive programs to target all muscle groups.

Whether you are completing your initial rehabilitation or have had your spinal cord injury for a while, the general recommendations for strength training are as follows:

• Address all muscle groups.
• Start with a low load and work up gradually.
• The load should allow you to complete all repetitions of the first set of 8 without struggling.
• Complete 2-3 sets of 8-12 repetitions.
• Rest for at least 1 minute between sets.
• Once you can do 3 sets of 12 easily, progress that exercise by one of the following:
  -increasing the resistance,
  -decreasing the rest between sets, or
  -adding more strengthening exercises for that muscle group.

For endurance training of a muscle or muscle group, the above recommendations apply with the following differences:

• Use a lighter resistance that allows you to complete 15-20 repetitions easily.
• Do 3-5 sets of 20-30 repetitions.
• Limit the rest between sets to less than 1 minute.

 
What is Functional Exercise?

Often the best exercises are those that are "functional" or mimic the activities that you need to do in your everyday life. Your occupational and physical therapists encourage this type of exercise because it helps you learn to coordinate your movements while improving muscle strength and endurance. One example of a functional exercise is using your finger to move small objects from one place to another, which helps to improve the use of your hand muscles for self-care activities. Another example of a functional exercise is practicing your transfers over and over using the appropriate technique so that your shoulder muscles become well trained to move your body weight. All of the skills you practice in therapy sessions have a purpose; if you are not sure why you are doing a particular exercise or activity, ask your therapist to explain.

Functional exercise is also doing all the activities that you need to do each day to take care of yourself and move around. Managing your legs for dressing, driving or pushing your wheelchair, transferring, and writing, are examples of everyday activities that help to keep you muscles working well.

 
CARDIORESPIRATORY OR AEROBIC CONDITIONING

When you hear "aerobic exercise" you may think of jogging, cycling, aerobic dance class, or other exercise activities you did before your spinal cord injury. Now that you have a spinal cord injury, you need to consider other ways to improve your cardiorespiratory system through aerobic training. Depending on your level of injury, you will have different options available to you. Some ideas are:

• Pushing a manual wheelchair
• Seated aerobics videos
• Arm ergometry
• Handcycling
• Seated rowing
• Wheelchair road racing
• Swimming
• Seated cross-country skiing
• Adaptive sports (basketball, quad rugby, tennis, etc.)

The goal of aerobic type training is to get your heart and lungs working harder than they do during your everyday activities. With consideration of SCI, the American College of Sports Medicine recommends the following for effective aerobic conditioning:

• Intensity (how hard): 50-80% of peak heart rate
• Frequency (how often): 3-5 days per week
• Duration (how long): 20-60 minutes per exercise session

 
How to Measure Heart Rate

When you are participating in an aerobic exercise program, it is important to monitor your heart rate (or pulse). If you cannot take your heart rate yourself, teach someone to do it for you. Here is how you check your heart rate:

1. Use a watch or clock that counts seconds.
2. Find your pulse with your first two fingers (not your thumb) at one of two places:
   (a) on the thumb side of your wrist with your palm up, just above the fold of your wrist
   (b) at one side of the middle of your neck, right next to your windpipe
3. Count the number of beats that you feel in a 10 second period.
4. Multiply the number of beats times 6 to get your heart rate in beats per minute.
   Example:
   20 beats felt in 10 seconds
   20 x 6 = 120 beats per minute which is the heart rate

 
Peak Heart Rate and Training Zones

In the above recommendations for cardiorespiratory training, you see that aerobic exercise requires that you work at 50-80% of peak heart rate. What does this mean? Peak heart rate is defined as:

220 minus your age.

So for a 40-year-old person, this is how to calculate appropriate intensity of exercise.

220 - 40 = 180,
which is the peak heart rate

50% of 180 = 90 beats per minute
(0.5 x 180 = 90)

80% of 180 = 144 beats per minute
(0.8 x 180 = 144)

So the training heart rate zone for a 40-year-old person would be between 90 and 144 beats per minute.

 
Rate of Perceived Exertion (RPE)

 
When to Use RPE Instead of Heart Rate to Gauge Exercise Intensity

If your spinal cord injury is at or above T6, the part of your nervous system that controls heart rate is impaired. When you exercise, your pulse does not increase the way it should, so it is difficult to get to an actual training zone based on heart rate response. Instead, it would be better to use the RPE scale and base the intensity of the exercise on how hard you feel you are working. The RPE scale can also be reliably used for injuries below T4 and is often a more convenient way to measure how hard you are working, especially if it is difficult to stop the exercise to take your pulse.

 
The Importance of Warm Up and Cool Down

You should not ask your body to start or stop an intense exercise abruptly. In order to allow the muscles, joints, and cardiovascular system to warm up and cool down properly, you should perform at least 5 minutes of low intensity exercise before progressing into your training zone and after completing a work out. Gentle stretching during the warm up and cool down periods also helps to prevent injury.

 
BASIC EXERCISE PHYSIOLOGY PRINCIPLES

The following are some general exercise concepts that you should know for muscular strength and endurance training as well as aerobic conditioning. The principles are important whether you have a new SCI or have been injured for a long time and are starting a new exercise program. These exercise "rules" apply not only to people with a disability but to anyone expecting body changes through exercise.

• Overload principle: You must exercise at an intensity that is greater than your everyday activities in order for your body to get the physiologic benefits of that exercise. The intensity of the exercise must also be progressively increased over time so that the exercise continues to be challenging. The frequency (how often), the intensity (how much), and the duration (how long) can be modified to make a given exercise a more challenging one. A general recommendation is to increase the intensity of an exercise approximately every 2 weeks.
• Specificity principle: Your body reacts to an exercise based on what that exercise is intended to do, with little carry over for other training goals. For example, lifting weights increases strength, but has little effect on cardiovascular fitness. Additionally, the best way to train for an activity is to actually do that activity. For example, if you want to improve your swimming time, you should swim a lot!
• Reversibility principle: Have you ever heard the phrase, "Use it or lose it"? Basically, the positive effects from exercise remain as long as you continue and progress in your exercise program. As soon as you stop exercising, your body will get weaker and lose all the hard work you’ve put into it. (And you lose fitness much quicker than it took to gain it!) So it’s important to remain committed to your exercise program so you don’t have to start over from scratch.

 
CRITICAL CONSIDERATIONS WHEN EXERCISING WITH AN SCI

• Skin protection: Don’t forget to do your pressure releases. Avoid staying in one position for a long time that could compromise your skin.
• Bone density: People with long-standing spinal cord injury tend to have osteoporosis, which weakens your bones. Be careful not to drop heavy weights on yourself and avoid falling during exercise activities.
• Temperature regulation: Remember that your body’s ability to regulate temperature may be impaired by your spinal cord injury. Be especially cautious when exercising in very warm or very cold environments. Dress appropriately in layers that can be added or removed and use a spray bottle of water to cool yourself when needed.
• Hydration: Be sure to drink plenty of water before, during, and after exercise. Balance your water intake with bladder management.
• Bladder and bowel: Empty your bladder or leg bag just before exercise and maintain a consistent bowel maintenance program to avoid autonomic dysreflexia and accidents during exercise.
• Body stabilization and hand supports: If your trunk muscles are paralyzed, you may need to use special straps or belts to stabilize your body while you exercise. If your hand strength is impaired, you may need to use special gloves, elastic wraps, or Velcro cuffs to secure your hands to equipment.
• Illness: If you are sick, take a break from your exercise program until you are feeling better.
• Low blood pressure: If your resting blood pressure is less than 80/50, you should wear an abdominal binder and compressive stockings while exercising. Blood pressure often drops in people with SCI when exercising, so know the symptoms of hypotension and monitor how you are feeling while you exercise.
• High blood pressure: Be aware that some types of exercise may induce autonomic dysreflexia for some people with SCI above T6. Know those symptoms, discontinue exercise if they arise, and seek medical attention as appropriate.
• Pain: Discontinue exercises that aggravate pain.

 
Medications Can Affect Exercise Tolerance

It is not uncommon to take many medications to manage spinal cord injury issues and other medical conditions. Some medications directly affect the body’s tolerance for and reaction to exercise. Be sure to check with your doctor about the medications you take and ask specifically if there are special considerations for any of your medications in relation to exercise.

 
A FEW FINAL SUGGESTIONS

• Try to choose exercise activities that you like. You are far more likely to continue a program that is fun. Consider exercising with a friend or family member to keep things enjoyable.
• Avoid overdoing it. The phrase "no pain, no gain" means that you should work hard; it does NOT mean that you should work to the point of hurting yourself. You may get some minor muscle soreness as you begin or progress an exercise program. This discomfort should resolve within a few days.
• Fitness and function are much more important than "looks". Your goal should not be to have big bulging muscles like a body builder, but rather to have a healthy and fit body that allows you to do what you need to do without fatigue and pain.
• Good nutrition is a very important aspect of your exercise training program. Refer to the chapter on Nutrition and contact your dietitian if you have specific questions.
• Ask for help. If you are unsure how to do a particular exercise or need guidance for starting a new exercise program, ask your SCI therapists to get you going in the right direction.

Regardless of your level of injury, exercise is important to keep your body as physically fit as possible. You need your muscles to be strong, your heart to be healthy, and your body to be flexible to maximize your independence. Make a commitment to yourself to keep exercise a part of your healthy lifestyle!

 
RESOURCES

Sources for discussion and advertisement of adaptive exercise equipment, seated exercise videos, and disabled sports, exercise, and recreation can be found at the websites of the following magazines and organizations.

 
Web Sites

www.palaestra.com
Palaestra is a forum of support, physical education, and recreation for people with disabilities.

 

SCI Self-Care Guide Main Page Chapter 1     SCI Anatomy & Physiology Chapter 2     Skin Care Chapter 3     Circulatory System Chapter 4     Respiratory Care Chapter 5     Range of Motion Chapter 6     Bladder Management Chapter 7     Bowel Management Chapter 8     Nutrition Chapter 9     Medications Chapter 10   Nerves, Muscles, and Bones Chapter 11   Autonomic Dysreflexia Chapter 12   Pressure Sores Chapter 13   Psychosocial Adjustment Chapter 14   Sexual Health & Rehabilitation

Chapter 15   Community Resources Chapter 16   Vocational Rehabilitation Chapter 17   Recreation Chapter 18   Driver’s Training Chapter 19   Attendant Management Chapter 20   Home Modifications Chapter 21   Approaching Discharge Chapter 22   Pain after Spinal Cord Injury Chapter 23   Substance Abuse and SCI Chapter 24   Exercise Chapter 25   Alternative Medicine Chapter 26   Equipment Chapter 27   Staying Healthy Glossary