Exercise

prescription in
Paraplegia
Dr. Anindya Debnath
PM&R
Contents
1. General considerations

2. Risk stratification

3. Compliance

4. Paraplegic Exercise considerations

5. Exercise Prescription

6. Gait training

7. Wheelchair Prescription
General Considerations
1. Components of prescription- exercise mode,

intensity,

duration,

frequency, and

rate of progression.

2. Appropriate warm-ups and end with a cool-down

General Considerations
3. Basic exercise goals include-

(a) Counteracting the detrimental effects of sedentary living or reduced

activity (e.g., from disease or injury), and

(b) Optimizing functional capacity within the physical limitations of

present medical conditions.
Risk Stratification
ACSM consideration-

1. Low risk: asymptomatic younger adults (men <45 years of age,

women <55 years of age)

2. Moderate risk: older individuals (men ≥45 years of age, women ≥55
years of age)

3. High-risk individuals have known cardiovascular (cardiac, peripheral

vascular, or cerebrovascular), pulmonary (COPD, asthma, ILD, or CF),
or metabolic disease (DM, thyroid disorders, renal, or liver disease).
Risk Stratification
Moderate exercise-
• 3-6 METS
• Brisk walking @ 3-4mph
• 40-60% of max oxygen
consumption

Vigorous exercise-
• >6 METS
• >60% of max oxygen consumption
Compliance
Strategic considerations to improve compliance-

1. Instilling a sense of self-involvement,

2. An understanding of exercise fundamentals, and

3. A basic idea how exercise may alleviate the patient’s condition

drastically.

Counselling-

4. Inform patients that success likely requires some discomfort, and

5. Teach patients to recognize the difference between signs of exercise

stress (e.g., increased heart rate and muscle soreness) and
symptoms of overexertion or injury.
Paraplegic exercise considerations
SCI alters exercise capacity by altering-

1. Amount of functional muscle mass

2. Autonomic nervous control of cardio acceleration

3. Redistributing blood flow

4. Limiting thermoregulation
Paraplegic exercise considerations
SCI alters exercise capacity by altering-

1. Amount of functional muscle mass:

• Aerobic exercises recruits less large muscle groups
• Alters potential adaptations
• SCI alters adaptive central cardiovascular function
• Predominant peripheral adaptation
• Recent techniques- lower body compression, FES, supine body
position with concomitant lower body exercises
Paraplegic exercise considerations
SCI alters exercise capacity by altering-

2. Autonomic deregulation:
• Loss of sympathetic cardiac innervation above T6 limit HR 110- 130
bpm

• Cervical and thoracic level injury limit regional blood flow, causing
peripheral pooling, reduced SV and CO
Paraplegic exercise considerations
SCI alters exercise capacity by altering-

2. Impaired thermoregulation:
• loss of sympathetic nervous control over vasomotor and sudomotor
responses of the insensate skin impairs thermoregulation
Paraplegic pre exercise testing
1. High paraplegics lack classical symptoms of angina

2. Screening for CAD

3. Exercise induced hypotension

Exercise prescription
Contents:

1. Diagnosis

2. Goals

3. Precautions

4. Therapies: Physical, Occupational therapy etc.

Exercise prescription
• Precautions:

a. Skin,

b. Respiratory,

c. Sensory,

d. Orthostasis,

e. Safety,

f. Risk for AD, and others as needed for the specific patient (i.e.,
bleeding if on Coumadin).
Exercise prescription-
Considerations
Exercise prescription
Modalities involved:

1. Health education

2. Physical therapy

3. Occupational therapy

4. Bedside activities

5. Vocational training and considerations

6. Psychosocial sessions and counselling

7. Peer group connections

Exercise prescription
Physical therapy can be sub divided into:

1. Therapeutic exercises

2. Active exercises

3. Functional ambulation

4. Bladder and urethral sphincter training exercises

5. Prevention of pressure sores

6. Orthostatic hypotension activities

7. Respiratory exercises

8. Wheelchair and gait training exercises

Exercise prescription-
Physical therapy:

1. Therapeutic exercise: reducing muscle tone,

maintaining or improving range of motion and

mobility,

increasing strength and coordination, and

improving comfort

A program of therapeutic exercise, including passive and active exercises,

is initiated to maintain any remaining muscle function and to restore as
much muscle activity in the affected parts as possible
Exercise prescription-
Physical therapy:

1. Therapeutic exercise:

Passive exercises should be done intensively to resolve

 Contractures,

 Muscle atrophy and

 Pain during the acute period of hospitalization in patients with complete injury.

These exercises should be done in a

 Flaccid period: at least once a day and
 Spasticity: at least 2-3 times a day in the
Exercise prescription-
Physical therapy:

2. Active exercises- 3 types:

 Stretching /flexibility exercises
 Aerobic exercises
 Strengthening exercises
Exercise prescription-
Physical therapy:

2. Active exercises- 3 types:

 Stretching /flexibility exercises: slow, sustained lengthening of the
muscle.

Usually 1-2 times a day.

Stretch as far as one can and hold the stretch for 10 secs and then ease
back.

Stretching also should be done before and after other exercises to

prevent muscle strain and soreness and to help avoid injuries.
Exercise prescription-
Physical therapy:

2. Active exercises- 3 types:

 Aerobic exercises- steady exercise using large muscle groups.

Strengthens your heart and lungs and improves your body’s ability to use
oxygen.

Reduces fatigue, increases energy levels and helps you sleep better,
control your weight, and lift spirits.

Three or four sessions per week, each lasting 15 to 60 minutes.

5-minute warm-up (including stretching) before the activity and 5 to 10

minutes of a cool down (stretching and slower activity) afterwards.
Exercise prescription-
Physical therapy:

2. Active exercises- 3 types:

 Aerobic exercises- steady exercise using large muscle groups.

Walking, stationary bicycling, water exercises and chair exercises are

excellent choices.
Exercise prescription-
Physical therapy:

2. Active exercises- 3 types:

 Strengtheningexercises- repeated muscle contractions until the
muscle becomes tired.

Increase muscle tone and improve the quality of muscles.

Strong hip and leg muscles are needed to lift the legs to walk

Strong arm muscles are needed to carry out daily functions.

Strong abdominal and back muscles help maintain correct posture

Exercise prescription-
Physical therapy:

2. Active exercises- 3 types:

 Strengthening exercises- Equipment used:

a. Empty bottles filled with water/sand,

b. Inner tube of the cycle tyre (sliced to appropriate width)

c. Dumbbells

d. TheraBand and tubes

e. Weighted cuffs and

f. Multigym
Exercise prescription-
Physical therapy:

2. Active exercises- 3 types:

 Strengthening exercises-
Exercise prescription-
Physical therapy:

2. Active exercises- 3 types:

 Strengthening exercises-
Exercise prescription-
Physical therapy:

2. Active exercises- 3 types:

 Strengthening exercises-
Exercise prescription-
Physical therapy:

2. Active exercises- 3 types:

 Strengthening exercises-
Exercise prescription-
Physical therapy:

2. Active exercises- 3 types:

 Strengthening exercises-
Exercise prescription-
Physical therapy:

2. Active exercises- 3 types:

 Strengthening exercises-
Exercise prescription-
Physical therapy:

2. Active exercises- 3 types:

 Strengthening exercises-
Exercise prescription-
Physical therapy:

2. Active exercises- 3 types:

 Strengthening exercises-
Exercise prescription-
Physical therapy:

An ideal program for a spinal cord injured person should be

 8-12 weeks of training,
 3-5 days/week comprising
5 sets of 10 repetitions with the suitable weight.

The appropriate resistance for each muscle that is to be strengthened can be

determined by calculating the 10 RM before initiating the exercise program.

10 RM (Ten Repetition Maximum) is the maximum amount of resistance that

could be lifted and lowered through the full range for exactly 10 times
without any rest in between.
Exercise prescription-
Physical therapy:

2. Functional ambulation-

Mobilization in parallel bars and stabilization of

trunk and pelvis is obligatory.

Mobilization in the parallel bars, standing and

balance training exercises should be started
and the patient could be supported by a
posterior shell.

A long and locked knee joint walking device is

utilized.

In chronic stage ambulation, walkers, crutches

and orthoses are used.
Exercise prescription-
Physical therapy:

2. Functional ambulation-

Para walker (hip guidance orthosis) is

necessary for ambulation in patients with
complete C8-T12 injury.

Robotic training is a newly applied technique.

Robotic-assisted gait training using the loco

mat system.
Exercise prescription-
Physical therapy:

3. Prevention of pressure sores-

 Lifting buttocks regularly in sitting position,
 Changing positions regularly in lying position,
 Avoiding sitting on hard surfaces by using a cushion, foam or gel,
 Routine inspection of the skin with a mirror or by
 Palpating gently the areas at risk and keeping skin dry and clean.
Exercise prescription-
Physical therapy:

4. Orthostatic hypotension-
 Tilt table- starting from 45 degrees for 30 min a day
 Sitting position on the edge of the bed 3-4 times a day
 Balance exercises should be done to maintain this position

5. Respiratory exercises-
 Proper postural drainage
 Assisted coughing
Exercise prescription-
Physical therapy:

6. Crutch muscles strengthening-

 Depressors and adductors of shoulder girdle
 Flexors of shoulder
 Extensors of elbow
 Dorsiflexors of wrist
 Flexors of fingers and thumb
 Trunk (Deep back) muscles
Exercise prescription-
Occupational therapy:
 Passive, active assisted, active ROM/exercises to bilateral UEs.
 Motor coordination skills.
 ADLprogram with adaptive equipment as needed (dressing, grooming,
feeding).
 Functional transfer training (bathroom, tub, car, etc.).
 Splinting and adaptive equipment evaluation.
 Desktop skills. Shower program.
Exercise prescription-
Occupational therapy:
 Kitchen and homemaking skills.
 Assistive technology devices, as needed.
 Wheelchair training (parts and management).
 Home evaluation.
 Family training.
 Teaching home exercise program.
Wheelchair Exercises - Stretching
Wheelchair Exercises - Streching
Wheelchair prescription-
Paraplegic wheelchair prescription considerations:

1. Type and size of wheelchair

2. Specific set-up

3. Type and size of cushion

4. Modifications- Adjustable Footrests

Elevating Leg Rests

Backrest Recline

Tilt in Space

Rigid Seat

Rigid Backrest
Preparation for returning home-
• Settled immediately after the prognosis is known and was announced
to both patients and his/her family.
• All rooms in the house must be accessible.
• Manual wheelchair access door width.
• Door handles.
• Floor should be hard and without carpet.
• Ramp at the entrance.
• Grab handles as needed in kitchen, bathroom.
Exercise prescription- Sample-T2-
T9
Physical therapy:

1. PROM to bilateral LE, with stretching of hamstrings and hip

extensors.

2. Mat activities.

3. Tilt table as tolerated. Start at 15 degrees, progress 10 degrees

every 15 min within precautions, up to 80 degrees.

4. Sitting balancing (static and dynamic).

5. Transfer training from all surfaces including mat, bed, wheelchair,

and floor.

6. Wheelchair propulsion training and management. Teach and

encourage weight shifting.
Exercise prescription- T2- T9
Physical therapy:

7. Standing table as tolerated.

8. Deep breathing exercises.

9. FES for appropriate candidates.

10. Family training.

11. Community skills.

12. Teach home exercise program.

Exercise prescription- T2- T9
Physical therapy:

7. Standing table as tolerated.

8. Deep breathing exercises.

9. FES for appropriate candidates.

10. Family training.

11. Community skills.

12. Teach home exercise program.

References
 Delisa’s Physical Medicine and rehabilitation 5E
 Braddom’s Physical Medicine and rehabilitation 4E
 Physical Medicine and rehabilitation Board Review 4E
 Journals-

 Rehabilitation
For Patients With Paraplegia-Journal of Turkish Spinal
Surgery (Impact Factor: 4.1)
 Physical Exercise for Individuals With Spinal Cord Injury: Systematic
Review Based on the International Classification of Functioning,
Disability, and Health- Journal of Sport Rehabilitation (Impact Factor:
1.9)
THANK YOU!

Source: www.physiopedia.com