Ask the Expert About Spinal Cord Injury and Exercise

Answers to questions submitted during August 2005. Request for more questions will be asked for in the future.

Disclaimer
“Ask the Doctor” is an informational and educational program provided by National Rehabilitation Hospital (“NRH”) to provide general information on spinal cord injury. Information posted on the “Ask the Doctor” site is provided solely for informational and educational purposes only and is not intended nor implied to be the diagnosis or treatment of a medical condition or a substitute for professional medial advice relative to your specific medical conditions. Always seek the advice of your physician or other qualified health provider prior to starting any new treatment or with any questions you may have regard.

Matt Elrod, PT, MEd, NCS
Elrod is the co-investigator on Improving Clinical Practice through Consumer-driven Education: Development of the Consumer Professional Partner Program, assisting in the development of the physical therapy curriculum and training materials for individuals with SCI. Elrod is a trained physical therapist and has over ten years experience working with individuals with SCI. He is currently the president of the DC chapter of the American Physical Therapy Association and has working relationships with the physical therapy departments at Howard, George Washington, and Marymount University.

We would like your feedback and suggestions.

Question: I am a 46-year-old woman, injured in 1999, C5-6. Since my days in rehab, both of my arms have been in the supinated position. I have wrist flexion in my left hand which I am not able to take advantage of because of the supination. I am married with two children and have a very busy lifestyle. So far, no therapist has been able to advise me the best way to strengthen my pronation muscles. And I do what I can when I can, without any supervision or expert opinion. I have been working with a cast/splint to keep the range of motion in my left arm. I wear this 1-2 hours per day. If I wear more often, combined with strengthening exercises I feel I could get back a little more of my previous life. Do you feel it is even possible to strengthen the muscle at this point? If I could just do this, I would be able to feed myself, write, maybe even paint. It is a priority for me, if I can find out how to work on it.

Currently, I use standing frame 3 times a week, arm cycle 7 times a week, FES bike 1-2 times a week, and I own the Uppertone Quad gym, which I use whenever I can. Anything you can suggest would be greatly appreciated.

Answer: First, it sounds that you are a very active and motivated individual. Keep it up. As for your question, it is difficult to predict if you can strength you pronators without examining you in person. With that being said, I will make a few assumptions that may or may not be correct about you and your injury. Since you said that you use FES, it sounds like you have a complete injury. The isolated movement of pronation is not typical for individuals with C5 or C6 level of injury; therefore it sounds like you have a zone of preservation on the left side allowing you to have movement in your left wrist flexor. In order to use the movement, you have to get your hand in a useful position. You are correct to try to work on this. If this is important to you, you should start with a visit to a spinal cord injury specialist. They would be able to test your muscles and assist with determining if the muscles are innervated and can be strengthened. This may involve manual muscle or EMG testing. If the muscle can be strengthened they can also help set up a program to maximize your strength. If the muscle does not receive the nerve message from the brain, they can help to determine if tendon transfer or electrical implantation is appropriate. The limited range of motion would have to be addressed before any of the before mentioned items could be utilized. There are much more aggressive ways to increase your ability to pronate that could be pursued. They may include serial casting, botox, or surgery. Again, a specialist in SCI should be able to help determine if this is appropriate. Good Luck.

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Question: We hear so much about shoulders joints and other structures vital to the SCI person wearing out. How does one exercise in a way to prevent the hastening of this process?

Answer: The key to prevent wearing out of your arms (degenerative changes) is having and maintaining the appropriate range of motion, the correct balance of muscles, and the use of proper body mechanics. This can be facilitated by a specialist that understands body mechanics and how the above factors can vary due to SCI level and muscle involvement.

Question: Does electrical stimulation provide an actual workout?

Answer: Yes, if you have an electrical stimulation unit that is able to provide a forceful contraction. Best results will be achieved when used with a self initiated musculature contraction.

Question: If so, what is the minimum expenditure of money necessary to acquire the equipment?

Answer: The costs for these units run between $400 and $1000.

Question: Is it possible for a C6/7 SCI to create aerobic exercise?

Answer: The American College of Sports Medicine (ACSM) defines aerobic exercise as "any activity that uses large muscle groups, can be maintained continuously, and is rhythmic in nature." The aerobic exercise capacity that most people think of when the word “aerobic” is used cannot be achieved to the same level if you do not or cannot use your legs, or arms and legs together. However, there are still cardiovascular benefits that occur when one performs continuous activities. Of note, it is now accepted that the continuous activity does not have to be performed all at once. It can be added up, say, in 10 minute increments throughout the day, to the reach a total of 30 minutes per day.

Question: My heart rate seems to stop increasing in the 90’s regardless of the expenditure of energy.

Answer: With complete SCI above the T6 neurological level, there is a disruption to normal cardiac functioning. It is typical for heart rate not to be affected (increase) to the same level as with individuals that have not sustained a SCI.

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Question: Should one pursue an exercise program if chronic central neuropathic pain is a significant issue?

Answer: YES! This may even help decrease the pain. One should remember to talk with your doctor before beginning any exercise program, start slow,, and progress the activity at a modest rate Best results will be achieved when used with a self initiated musculature contraction

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Question: I'm a 37 year old T5-6 paraplegic. I was very active in all sorts of sports up until about 2000 when arthritis in my wrist starting giving me a hard time. Since then I have slowly gained about 50 lbs. When I try to get active again my wrist hurts so bad that it takes 3 or more days to recover and in that time I take between 3 and 6 Vicodin plus another inflammatory medication per day. I need to get back into some sort of athletics to help me slim down (I have already changed my diet which helped me lose some weight). What can I do to get around the pain? Is there a workout that I can do that wouldn't stress my wrist so much? Should I just go back to doing what I used too and take the pain medication on a daily basis?

Answer: Arthritis can be a major barrier for activities and the best thing to do is to find new activities that decrease the stress on your wrist. I have three suggestions you might want to try. First try using a rigid splint. The splint may have a metal brace in it and should keep the wrist in a slightly extended position. Second, try swimming – it’s a good, low-impact exercise. Finally, try cycling. You may have to shop around to find one that has the hand cranks that help keep your wrist in a comfortable position. Keep up with the diet and good luck.

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Question: I have a C 3/4 inc. central cord injury, 12 years post. I have severe spasticity and a large, firm quad gut. I weigh 138 lbs and am 5'9".

1. Will building strength help conquer spasticity (tightness, not spasms?)
2. What exercise will help? I have some trunk control and can do sit ups with bent knees and feet on the floor.

Answer: From the limited information that was provided I would recommend a daily exercise program that starts with stretching, then focuses on strengthening, and ends with stretching. You should focus on increasing your range of motion when you stretch and use all of your available range of motion when you perform your exercise/strengthening program. You would probably benefit form working with a specialist in SCI to help determine the best program for you to determine the specific muscle you should strengthen and positions to decrease spasticity with exercise and activities.

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Question: I'm a T-11 SCI and have used a wheelchair for 38 years. I'm concerned about prevention of overuse injuries - particularly my shoulder. Are there exercises that I can do to prevent such injuries, particularly rotator cuff injuries?

Answer: The most common muscles that are overlooked are the shoulder blade stabilizers (lower trapezius, rhomboids and serratus anterior) and the small rotator cuff muscles of the shoulder. These are the muscles that help to provide the proper balance that is essential for healthy shoulders. The rotor cuff muscles are usually thought of after the injury occurs. Exercises to these muscles should be performed for endurance and not with a focus to increase strength. This means low weight and high repetitions.

Question: Will aerobic exercise help alleviate problems with edema in the feet? My feet get steadily swollen during the day (they have since I was injured). I sleep with them elevated and they are normal size in the AM. I've tried watching sodium intake but that doesn't seem to help. Any ideas would be appreciated.

Answer: Aerobic activity can decrease edema if performed in conjunction with voluntary muscular contraction or facilitated by electrical stimulation The major cause of edema in an individual with SCI’s feet is the lack of the muscles contracting and pushing fluid back up you legs. This being said you should see a SCI specialist to make sure that you do not have a more complicated cause for the edema. Once other causes are ruled out, you should try an edema support stocking. If this does not work then you may want to be fit for a custom pair of support stockings.

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Question: I am a 41 year old black woman who will be two years into my SCI (as a result of a MVA) on Oct.31, 05. I can do many task independently and have come a long way. However, I have some issues. I weighed 170 pounds at the time of injury. I am 5' 3 and was wearing a size 14.

In Dec. 2004, I received a power chair and altogether stopped using my manual chair. Since then, because that was really my main form of exercise, I have gain a considerable amount of girth in my abdominal area. My stomach was not flat initially, but now, my stomach has increased in mass. I had to increase from a size 14-16 to a size18-20.

How can I lose some weight. What types of natural supplements would help increase my metabolism? Is it true that I can not gain muscle mass in my abdomen area? If so, can I lose weight in the abdomen area and cause my stomach mass to decrease? I am no longer in physical therapy and have not done much therapy since I was released in May, 2004.

Answer: Unfortunately there is not a magic pill that increases the metabolism without running the risk of causing unwanted side effects; however, in extreme circumstances there are medical treatments that should be discussed with your physician that specializes in SCI. The best way to manage you weight and size is through diet and exercise. You should see an SCI specialist such as a physical therapist to help you start a program that is right for you. In addition, you should consult a dietitian to appropriate changes in your diet. Exercise is also a great tool to assist with decreasing and relieving stress.

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Question: Hi, my question not directly related to exercise but does affect working out. I am a T-8 Paraplegic since 1980 and have been active most of my life and during the past 5 yrs, I have been working out at the local gym. For the most part, I have never had my blood pressure tested and again, over the past 5 yrs I have had my family Dr & the Community Health Nurse check my blood pressure levels. The readings range from 120-135/90. Are these blood pressure readings normal for my disability type? My family Dr said it is high normal and not to worry & the Health Nurse was concerned. When I have
to have any procedures at the local hospital, my blood pressure readings are always 120/80/85. I realize that there are circulation issues with Para's & Quad's. Is there a need to be concerned with the higher level blood pressures, especially when I am working out or hand cycling long distances?

Answer: With your neurological innervation level, your blood pressure at rest and with exercise should not be different then before your injury. The only exception is your systolic (the top number of your BP) pressure may not increase as high as it did before your SCI.

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Question: I am a paraplegic (t-2 level) from a spinal cord injury in 1975. I have stayed active all these years, even gave birth to 2 boys and raised them. In my earlier years I was involved in many wheelchair sports but my passion is and always has been in swimming. In the past few years, I have noticed that my shoulders ache as well as my wrists so I am trying to focus on those activities that will not add to those discomforts but find very little. I will continue swimming laps but can you suggest any other activities that will keep me heart healthy? I have a hand cycle but have not been on it for awhile thinking that it may aggravate my condition.

Answer: Please refer to previous comments about sound health.

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Question: In light of "dieting fads" of the last few years, as well as general health concerns, have you looked into the potential damage of loss of muscle due to dieting and no exercise by persons with disabilities? How critical is this to persons with post polio syndrome or muscular dystrophy?

Answer: In general, it is a great concern that individuals would decrease exercise and only manage weight with diet. It is very important to incorporate a lifestyle that includes eating a healthy diet and performing regular exercise. As for how this relates to persons with post polio syndrome or muscular dystrophy, the exercise recommendations for these individuals are very different from individuals with SCI.

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Question: My significant other is 18 years post injury. He is a person with quadriplegia and his break was C 5, 6, 7. About 4 to 5 years ago he had to go to a power chair after using a manual chair for many years as his shoulders were wearing out. Since that time he has gained a significant amount of weight and now weighs 300+ pounds. He has significant break down on one ankle and foot. At one point he had a severe ulcerated sore on his bottom requiring flap graph surgery and daily hyper-baric (spelling??) chamber therapy.

What types of exercises can he be doing to burn calories? What type of diet can he follow keeping in mind his toileting program and not wanting any unexpected accidents? He cut down on eating and I think his body thought he was in starvation mode. He has purchased an ergometer specific for wheelchairs and a weight lifting tower from Sears that he can roll up to (took the bench off). He desperately wants to lose weight both for health reasons and to be able to continue to transfer in and out of bed, on and off toilet, etc.

Answer: The first concern is dieting while skin breakdown is present. I would not recommend dieting while healing a wound unless under the close supervision of a doctor/dietitian and monitoring blood laboratory values.

As for exercise, please refer to the previous comments about prevention of shoulder problems.

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Question #1: The benefit of aerobic exercise on cardiac health, improved circulation and decreasing body fat is well documented. After 15 years of living with a T4 SCI, my shoulders have "overuse syndrome". What aerobic exercise can be done without putting added stress on these joints? Weight management is difficult for any person over 40, aging with an SCI, it is increasingly difficult without effective aerobic exercise.

Answer: Please refer to the previous comments about prevention of shoulder problems.

Question #2: Can passive exercise on lower extremities increase circulation or muscle tone?

Answer: Unfortunately, passive exercise does not have much effect on circulation and muscle tone.

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Question: I am a female with a C4-5 spinal cord injury acquired in 1979 when I was 19 years old. I have good use of my biceps and deltoids but very little below those muscles. I recently started gaining weight in my stomach and hips after years of keeping my weight fairly stable. Is there any kind of exercise I can do to arrest this or is my only alternative to reduce my caloric intake?

Answer: As we increase in age, our body decreases in the efficiencies of metabolism. Thus, the only recourse is to decrease your diet or increase your activity.

Further, even if the answer is to reduce intake, are there exercises that I could do that would benefit my health despite my limited muscle availability?

You should see a SCI specialist to help you start your program. But some exercises that you may consider include strengthening (your middle and lower trapezius, rhomboids, and rotator cuff muscles) and arm ergometer. Remember to stretch.

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Question: Hello.......wonderful that you will answer our questions......thank you so much........I have cmt and post polio.....I'm getting so weak and so very tired......I would love to go to the Y and exercise.. on a bike or pool anything.....just so I can feel better and be stronger........but will I..? It frightens me that it might make me worse???

Answer: I would recommend that you be evaluated at a post polio clinic.
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Question: I'm a c-4, c-5 quad 47 years post trauma with function of my diaphragm left biceps and shoulder. What exercises do you suggest, if any? I use a power chair, lead an active life and tolerate sitting up about 13 hours a day. I'll await your response, by e-mail or the web site.

Answer: You should first see a SCI specialist to help you start your program. But some exercises that you may consider include strengthening your middle and lower trapezius, rhomboids, and rotator cuff muscles, if able. You should also exercise your diaphragm to improve respiratory function.

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Question: I have been injured for almost 30 years. Two years ago I was treated for my first but serious pressure ulcer that was in the ishial area. Before this condition, I enjoyed pushing my wheelchair for exercise. Now I am concerned about the friction that can result from distance (one mile/three times a week) pushing. What kinds of exercise can I do that won't jeopardize the health of my skin?

Answer: Start with making sure that know the cause of the pressure ulcer. Then increase your inspections of your skin as you increase your activity. Make sure that you have the correct equipment (cushion, chair…). You should start with increasing your rest breaks in order to perform more frequent pressure relief. You may want to consult your SCI specialist to help think through some options. If you feel the need to change your activity, the first thing that comes to mind is to start a swimming program. Good luck and don’t stop exercising. The activity is probably why you went 30 years without skin break down!

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Question: I am wondering if there is some kind of training material for a workshop on this subject matter that our CIL could use?

Answer: This is being worked on by National Rehabilitation Hospital Rehabilitation Research and Training Center on SCI: Promoting Health & Preventing Complications through Exercise. We expect to have some resource materials and guidelines on exercise and SCI in the coming years. Please visit our web site, and check back often for updates, at http://www.sci-health.org

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Question: What are 10 simple exercises that a person with SCI can do at home (or possibly in bed) on a daily basis that will improve their strength and/or overall well being?

Answer: Unfortunately, there is not an easy answer to this question. The exercises would depend on many different factors, such as one’s level of injury, personal resources, lifestyle, and interest in activities. Work with your doctor or an SCI specialist to come up with the exercises that are best for you.

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Question: How can CIL's start a safe exercise program for people with SCI?

Answer: Again, in the coming years we expect to have some resource materials and guidelines on exercise and SCI, based on the research and training activities of our Rehabilitation Research and Training Center on SCI. Please visit our web site, and check back often for updates, at http://www.sci-health.org

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"Ask the Doctor" is an informational and educational program provided by National Rehabilitation Hospital ("NRH") to provide general information on spinal cord injury. Information posted on the "Ask the Doctor" site is provided solely for informational and educational purposes only and is not intended nor implied to be the diagnosis or treatment of a medical condition or a substitute for professional medical advice relative to your specific medical conditions. Always seek the advice of your physician or other qualified health provider prior to starting any new treatment or with any questions you may have regarding your medical condition.