1 Exercise and Spinal Cord Injury Presented By the RRTC on SCI. Presenter: Dr. Brad Hedrick. >> LEX: Good afternoon everyone and welcome to today's webcast. The title of the program today is Exercise and Spinal Cord Injury and this program is presented by the Rehabilitation Research and Training Center on spinal cord injury. My name is Lex Frieden and I am director here at the Independent Living Research Utilization program at TIRR, The Institute for Rehabilitation and Research in Houston. And I'll be moderating today's webcast. We have an outstanding presenter today, one that I know many of you are familiar with from his reputation and his many publications, but before I introduce him, let me give you a few housekeeping issues that we need to address during today's program. If you are using the RealPlayer, you may submit questions directly to us by clicking on the E button at the bottom right-hand corner of your screen. The E-mail button on RealPlayer will deliver the messages that you type in to us so that we can share them with our guest at the end of the narrative production and presentation here. The other possibility for submitting questions is via E-mail to webcast@i ilru.org. And finally, if you would like, you may call 2 (713)520-0232 and dial 0 for an operator if you need to research us for any reason, technical difficulties, any other issues that you have problems with during the course of the webcast. The number is available both on voice and TTY. To follow along completely with today's webcast, you may find it useful to download the PowerPoint presentation and there is also a text only file if you'd rather have that. This presentation was designed by our guest to accompany his remarks. The file is located under the handouts link at the sign-on screen for the webcast and I presume if you are listening to this, you've already been through that process. Now, let me say it's a real honor for me to introduce an acquaintance and friend of mine for a long time, somebody who I have the greatest respect and fondness for, a pioneer in the field of disability and rehabilitation, Dr. Brad Hedrick. Brad is, to me, a symbol of what people with disabilities can do if they have a goal and objective and idea in mind and a vision that will carry them forward and Brad has certainly acquired a vision which has driven his career. Currently, Brad is the director of the division of Disability Resources and Educational Services at the University of Illinois at Urbana-Champaign. Before that, Brad made many, many contributions to disability particular in the area of exercise and sport. Nobody I know has received any more accolades in the area of wheelchair basketball than Brad Hedrick. He is in fact the epitome I think of an athlete who has managed to appreciate the sport well enough to continue it well after his 3 competitive playing days are over and he's done so largely by coaching, coaching a number of championship teams, by helping athletes learn how to respect sport and use sport to grow by and he has become not only an athlete, but a noted author, educator, lecturer and an esteemed colleague in the rehabilitation academia faculty. So without further ado, I don't want to take any of Brad's time, but he will spend some time with us today discussing the various benefits of exercise for persons with spinal cord injury. There is a lot of information to cover. You have by now downloaded the PowerPoint and have access to that. It's great pleasure and, again, an honor for me to invite Dr. Brad Hedrick to provide a presentation for us today. Welcome, Brad, and thanks for being here. >> DR. HEDRICK: Thank you, Lex. I fear it's straight downhill from here after that introduction, but I certainly appreciate your very kind words. It is a pleasure to be with all of you on this webcast and to talk about a subject that has been a personal and professional interest of mine, a passion of mine actually, for 35 years. As Lex noted, I started as a participant in a wide range of wheelchair sports and then later continued as a collegiate coach and administrator in adapted sport and principally a wheelchair sport and now I get to add -- there is an old adage that those who can, play, and those who can't play, coach. And I guess I now get to add the line and those who no longer coach can be an ambassador for physical activity and sport and recreation for people with disabilities. Here at Illinois, physical activity -- I was drawn to this campus 4 because physical activity was actually a cornerstone element of the program here in the division. And it was Tim Nugent who really was responsible for that vision over six decades ago. And in noting that it wasn't just the institution's role to improve their access to the academic resources, but that there were many life skills and there were substantial issues of health and well-being that also required extracurricular programming and support, knowledge and skills that could carry them forth throughout their lives and help them -- help the students with spinal injuries maintain their vigor and productive lives for as long as possible. And so I credit with having had the vision to realize that need and to implement programming in this area long before it became cool to do it. And I think our graduates all have certainly benefited greatly over those six decades from that philosophy. With regards to the benefits of activity, just on the sort of physiological side, we know that from the research with persons without disabilities that physical activity has been shown to be an important -- to be important in preventing cardiovascular disease and reducing risk factors like high blood pressure, blood lipid cholesterol levels, particularly in elevating the HDL or good cholesterol that helps to clear plaque. The diminishing -- the susceptibility of developing insulin resistance and ultimately diabetes in diminishing obesity onset and certain types of cancer. It's been shown to have efficacy in pain management, in mood elevation and is a general -- is an efficacious way of improving our general sense of well-being, our overall quality of life. And so in some respects there seems to be the closest thing to a panacea in many respects 5 as we could identify, and yet sadly these benefits generally go largely unused by the majority of people with spinal cord injury and disease who continue to overwhelmingly adopt sedentary lifestyles. And as a result, they really do continue to experience elevated risk of a wide -- of experiencing a wide range of secondary health complications. Again, obesity I mention where some estimate that at least 60 percent of people with spinal cord injuries are overweight or obese. That spinal cord injury results in diminished bone and muscle mass and thus their body weight is comprised of a greater proportion of fat to begin with as a result of the onset of paralysis. And unfortunately for muscle burns more calories than fat, and so as a result, individuals with spinal cord injuries experience just reduced energy expenditure by some estimates 21 percent on average in reduced sort of caloric need. Now, in our programs at the college level, one of our foremost concerns is to intervene quickly and to prevent the onset of the infamous freshman 15 where kids, you know, get out of the shadow of mom and dad and living on their own and in this environment where they are left to be self-regulating, they usually do a pretty sad job and often put on 15 or 20 pounds in that first year alone. And programmatically from our standpoint we realize that it's far easier to help students keep that weight off than it is to help them lose it once they've added it because of the -- because of the reduced energy expenditure level of persons again with spinal injury and paralysis. And that really is a difficult problem. We operate a residence hall here for students with severe disabilities who need PA assistance and there 6 we're talking about individuals frequently who if they have optimized -- if they were able to optimize their strength and physical capacity, they would still likely require the assistance of others for ADL's, but when they arrive, they often still have sort of the social/psychological mindset of an 18-year-old who was accustomed prior to injury to having a 3,000-calorie balance kind of metabolism. All of a sudden they have a 1500 metabolism but they have the psyche of a typical 18-year-old in terms of calorie intake, of going to the bars and drinking beers with their coactors here. So with that kind of behave your it's critical that we intervene to help them understand the importance of not engaging in those behaviors, of understanding what their reduced metabolism means in terms of caloric consumption and then to help them understand how physical activity can help to increase their metabolic need and allow them to enjoy some of those things that they desire more without the negative impact of obesity. Due to the inactivity, again, that many demonstrate, they are at elevated risk of cardiovascular disease due again to lower levels of HDL and physical activity and again cutting caloric intake would help them reduce the risk of insulin resistance and developing diabetes which of course they are at greater risk of experiencing because of sedentary lives. I mentioned there is evidence from the National Cancer Institute of several studies that show links between physical activity and reduced risk of certain types of cancer. Osteoporosis, certainly physical activity helps to promote bone health and persons with SCID are also predisposed to contractures due to atrophy and use which can be ameliorated or abated also through physical activity regimens. 7 In terms of chronic pain, certainly all of us who work in the -- in this context know individuals with spinal injuries who experience varying degrees of chronic pain. Physical activity helps to actually stimulates endorphins to block pain impulses and in addition, I think there is just the sort of psychological distraction of physical activity that can redirect sort of awareness away from pain so it can have a dual benefit there to some extent in pain management. In mood elevation, physical activity elevates serotonin levels by stimulating the sympathetic nervous system and may then help to improve mood and psychological states. Ulcers -- pressure ulcers are very significant secondary health risks to individuals with spinal cord injury. And physical activity again helps to increase circulation that might serve to diminish the likelihood of ulcers occurring. It can improve respiratory function and diminish the onset of infections and congestion and there is some evidence that activity, at least in moderate levels, can actually enhance immune system responses. Now, it's not a linear relationship because obviously there comes a point at which training becomes so intense and so substantial that it would actually serve to undermine immune response, but at moderate levels it also has been demonstrated to have that benefit. So basically there is obviously a multitude of physiological reasons for persons with spinal cord injuries to participate in regular, moderate physical activity. And there is also, we believe, a number of benefits in terms of functional capacity in ADL's. Again, drawing from the experience we've had here at Illinois where we've been doing this for many decades, 8 that participation of students in improving their strength and endurance and motor skills through the sport programming and activity programs that we've offered have concurrently experienced improvement in their ability to perform ADL's. They also have increased again their strength and endurance sufficient time to allow them the option -- some students would come in restricted or requiring power chairs entirely have in the course of their careers developed sufficient strength and dexterity and endurance to have the option of using a manual chair when that better served their needs and interests. And that can be a tremendously beneficial outcome for students to have that option available to them. And also for those students again with -- we frequently, when we have a number of traumatic -- students with spinal injuries living at Beckwith Hall and we've had our quad rugby team and many were exclusively using power chairs and through the introduction of strength and conditioning and participation throughout their careers in rugby, again, all became proficient in the use of manual chairs, some progressed to the point that they felt it benefited them more to just use the manual chair for their every day activities because they appreciated the extra activity they were able to get from that. And all of those outcomes are really -- I think the root of those was the strength and conditioning and physical activity programming, sport programming that they participate in and access through this program. In some research with our graduates performed now I guess in 1992 by a graduate student then and doctoral student here at Illinois, the research studied all graduates from 1952 to 1992 and found that in that population 9 of students that the single greatest predictor of their physical activity later in life, regardless of their age or time in life was whether or not they had engaged in the program here at Illinois while enrolled as a student. Recent research also -- we did a study in 2002 of 93 students -- involving 93 students with spinal cord injuries who graduated between 1978 and 2002. That was actually from a sample of about 140. 43 percent of mom who have quadriplegia and we found that over 73 percent of those were employed, 91 percent had been employed in the last five years, and 81 percent of those individuals assessed their overall health to be good, very good or excellent. Interestingly, 73 percent of those respondents reported that they participated in moderate, vigorous physical activity or exercise to improve their health or fitness. Of those 44 percent participated three or more times a week, and another 27 percent participated one times per week. And so we see a clear relationship between these successful outcomes that they are experiencing upon graduation in their careers and going out and living in the community and their engagement in physical activity here and subsequent engagement in physical activity throughout the course of their lives. Physical activity also we've seen impacts self-esteem. It does so we feel improve the ability of individuals to perform ADL's independently as a result of strength and conditioning and skill improvement. And in helping individuals simply develop competence in socially valued activities, and that's true here for college students because certainly sport paralysis is something that is very significant to this population, but we found it to 10 be even more so for young people with disabilities in looking at high school youth with disabilities where it can be so significant in their development of a sense of self and a sense of self-competence that the development of skills in these socially valued activities and certainly sport is very valued in the high school context by high school peers was significant in contributing to self-esteem enhancement in youth with disabilities. And there particularly in terms of physical competence and physical self-esteem. In terms of lifestyle, physical activity really the engagement in physical activity and the benefits of activity give the individual more control over the opportunities of their lives. I've already mentioned the potential for diminishing the need for surrogates. One of the cornerstone elements of the programming we offer at Beckwith for students who need PA assistance, is certainly not that they have to become -- it's ludicrous that they would have to be totally independent. There is an appropriateness for their need for PA services, but what we want to achieve in the program is to give them the knowledge and the skills and to help them to develop to the maximum of their physical abilities in order to have control over that need. So that to the greatest extent possible their choice for PA's is one of -- that they desire. It's not one they are forced to have to make. We want to minimize the extent to which they have to default to that and physical activity programming is critical in helping us to help those students to empower themselves to be able to have the option of performing ADL's for themselves versus requiring assistance from other individuals. 11 The physical activity and the benefits of activity ultimately create greater capacity for social spontaneity that one of the things we lose to disability is that capacity to be spontaneous. And anecdotally over the decades of my career, that's been one of the messages that I've heard that I've grown to really appreciate is the opportunity again for the student who was using the power chair to have the option of using the manual chair so that when friends want to get into a vehicle and go have a pizza, they don't have to worry about where is the accessible van or I don't have access to that now. They really have greater opportunity to responsibility tain justly go and interact with their peers as a result of that. Physical activity -- it's interesting, it also improves their ability to participate in leisure. Obviously participating in certain sports and recreation requires a certain amount of physical preparation, laying the base to be able to -- in terms of physical ability, physical skill, stamina, aerobic and an aerobic capacity and just the technical skills of the activity all have to be developed as a prerequisite, but physical activity is a mechanism for them to move into leisure activity with peers and significant others so that interestingly for me now, although I'm no longer playing or coaching, I do have a 7-year-old son and my goal in going to the gym and engaging in resistance exercise and arm ergo meter is so I can go out with my son and not do soar just physical harm to myself. I'm empowering myself to be able to sustain and pursue those activities with my son. And physical activity again serves as a vehicle for greater social interaction with peers and significant others. I think one thing that it 12 really does -- and this moves also into the area of community integration -- what is one of the tenets of Tim Nugent's philosophy here is that he would often say I could not in a lifetime of lectures impress upon all of the individuals with whom I would come in contact the multitude of ways in which a spinal injury impacts an individual's life and what it really means to have a spinal injury, but he said in one 40 minute exhibition game I could communicate everything that was important about disability to people without disability. And I think that's truly -- that's true. That physical activity and certainly in adapted sport and recreation gives individuals with disabilities the opportunity to demonstrate to peers without disabilities that they are more similar than dissimilar, that it becomes a common denominator for understanding, for mutual respect so that they have -- often for the kids that are involved in our programs here, it becomes an overture to begin a conversation with peers without disabilities, that they can discuss sport and their activities in sport and they have the sense of commonality with that. And at the same time in interacting or observing the behavior of individuals involved in these sports counteracts or contradicts I think more demeaning stereotypes that exist out there about the capabilities of persons with physical disabilities. We found that physical activity can improve or increase the capacity of individuals with disabilities and the opportunity for those individuals to interact with a broader and broader network, social network. One of the major barriers -- I'm jumping here and I apologize for that, but I think one of the major barriers for people with disabilities is their sparse 13 distribution and their inaccess to individuals who have similar disabilities to this cohort of individuals can comparable disabilities who are successful, who are physically active that, they can interact with and use as role models. Certainly we see that in the school systems that in the least restrictive placement model as we distributed all the young people with disabilities throughout the school systems, they basically now can go through secondary schools never having interacted with another individual with a comparable disability. And when we consider the fact that 80 percent of what we learn is observational, that's a severe limitation to those young people that they don't have that opportunity to interact with individuals who have interests and skill to physical activity, both with and without disabilities. And so engaging I think in physical activity broadens exposure of networks to individuals who are themselves active and it helps to change the peer community in which they are interacting which is I think a very significant and important factor in whether or not individuals will adhere to exercise programs. Excuse me while I take a water break here. In terms of just common activities, strength and conditioning activities are certainly -- they cover a very broad range of endeavors. Resistance exercise has always been a cornerstone of the program here as I mentioned I think earlier that we want to increase the lean body mass of our students, their strength, their flexibility through full range of motion. We want to make sure that we are engaging them in resistance exercise that is going to improve their strength in the upper back area because pushing a wheelchair tends to increase the strength of the sort of anterior musculature of the chest, and 14 so over time when people don't engage in a well rounded strength program, we'll often see the sort of stereotypical profile of a person whose shoulders are kind very hunched forward and ultimately that -- what that tends to indicate is an imbalance in the strength that the upper back is weaker and that syndrome tends to diminish the size of the capsule in which the muscles in the shoulder have to pass and increases the susceptibility to rotator cuff impingement which is certainly when you're limited to the function of two limbs, that's a very significant impairment to have to experience and that's something I have some personal knowledge of. So it's definitely something that we have to strive to avoid in this population. The types of things that we -- the other things that we would also do is we like to use lots of free weights, if the individuals have some paralysis, upper extremities, then we will obviously use cuffs and other devices so they can manage free weights. We try to maximize to the extent that it's possible to use of free weights because it helps to reinforce kind of kinesthetic awareness of persons with spinal injury where machines don't do that. Machines can give you resistance, but you're not having to manage them in the weight and space as you are with the free weight and it helps to reinforce that awareness and balance and improve hopefully in a more holistic way to improve the functionality in those areas as well. The types of machines and equipment that we would use in that, we have a functional trainer by Cybex which basically allows you to train individuals from a chair in any range of motion and isolated motor -- and isolate the sort of motor groups that you want to focus on. Versa-Trainer is another one sort of like a Bowflex which allows the person to remain in 15 the chair to exercise. And upper body ergometers. I like these, but it does require a transfer. The one advantage it has is it allows flexion and extension in the shoulder again reinforcing not only the strength of the chest, but also the upper back. And other types of equipment, there is a number of devices, Equalizer is another one that kind of comes to mind as a machine that will accommodate both wheelchair and ambulatory, if it's an area that needs to facilitate both or the upper tone gym is unique in that it allows users to make adjustments in the weight without -- and use the equipment without hand grip strength or cuffs or assistance. That one in particularly is particularly useful for individuals who have cervical lesions. Another activity that I didn't actually put on the list, but I realized in strength and conditioning should be in there would be functional electrical stimulation. It's one that's periodically used here when the students have their equipment and we facilitate that here. It's good for individuals who don't have flaccid musculature, who can respond to external electrodes and who aren't -- but yet don't have the sensory sensitivity who can live with these electrical impulses and who don't have, say, severe contractures and limited range of motion. But it has been found to be an efficacious way to improving cardiovascular health and bone and skin health in individuals with SCI and the only concern that I've heard voiced from individuals who have been sort of long term users of this has just been they appreciate those benefits. They have on occasion espoused the concern for just when you maintain that lower extremity muscle mass and the weight of that mass, it does make them work harder in 16 locomotion and for transfers and those sorts of ADL's. Pushing, going out on a walk is obviously another option in strength and conditioning, and now there are some wonderful technologies, power assisted wheels so that persons who may be beginning a regimen who don't feel they have the ability to go out productively engage in a walk for a meaningful distance with a colleague, these wheels actually can provide supplemental power and make that kind of activity viable. Obviously there is importance to having treadmills or rollers or devices that when you rely on pushing, would allow you to move inside during inclement weather. I don't know -- living in east central Illinois that is a concern for us here that you have an inclement weather option for your exercise. And that obviously going out in the terrain, you need to be skillful in negotiating irregular terrain, sidewalks and things of that nature. Swimming is perhaps I think the best physical activity in that it doesn't involve weight bearing. It's an out of the chair experience which we all appreciate and it builds strength and endurance and cardiovascular fitness. It is very difficult logistically because it involves usually travel and changing and entering and exiting pools and often the logistics of that are seen as the barrier to engagement in that activity, but it's one that we advocate and actually offer as a therapeutic intervention focused predominantly on the students who have severe physical disabilities for whom passive range of motion is pretty much the limit of activity and we've offered therapeutic aquatics targeted at that population to try to give them an optimal health wellness physical activity experience on a regular basis, on a weekly basis. 17 Arm ergometry is another means of getting aerobic metabolism improvement as well as strength. Certainly aerobic meaning with oxygen so that it's something they could do very efficiently on a sustained basis and anaerobic meaning things they would do for short term with -- where there would be a high power requirement. And the latter is really important because a lot of things we do in wheelchair locomotion activity are actually sort of power anaerobic activities. You know, there is nothing all that aerobic about pushing on a carpet with -- a real thick carpet with a thick soft pad under it. It's a power exercise and you know I -- sort of as an anecdote here, when I started my career in athletics, I started racing in the '80's and there wasn't a media to instruct in how to push a wheelchair in track and we went to Runners World and of course all runners thought long steady distance, L. S. D., was the mechanism of choice and what we learned in wheelchair racing was that if you trained really -- if you focused your training on going long, steady distance, it made you great at racing at long steady distance which meant you didn't win very many events. And so much -- actually much of the racing strategy and the training strategy shifted so that it became much more focused on anaerobic powered capacity in wheelchair racing rather than building so much the aerobic base. But anyway, handcycling, wonderful activities. We use handcycling a lot as a cross training activity. It's a great activity because you can coact with family members, with peers with disabilities or peers without. You can go on biking treks with the local cycling club. Track and road racing, that's been a cornerstone in this program. Road racing is 18 particularly I think wonderful because from its inception it has been integrated into the road racing community nationally so that divisions are sort of self-developing in almost all road races today will include a wheelchair division. So the opportunity for interaction is pervasive. Tennis -- a wonderful sport again for interaction with people with disabilities but also with individuals who play ambulatory tennis, and up/down tennis. Sit skying -- certainly in east central Illinois where the only hill of note is an overpass on the interstate, we don't get a lot of opportunity for sit sky skiing, but again a great activity for individuals with spinal injuries who enjoy the Alpine version of that. We have cross country here and I can say that that is certainly an endeavor for the bold to want to do cross country sit skiing. Another activity that's grown particularly I think in the last decade or so is golf as particularly boomers who I think enjoyed golf experience disabilities and there is increasing interest in how to adapt that sport and make it a viable for persons with disabilities and now fortunately the ADAAG standards have included elements for fitness facilities, but also for golf courses to improve their accessibility. A wide range of team sports available for persons to participate in. The one with which I had my long standing relationship, wheelchair basketball, but also wheelchair softball, played predominantly throughout the Midwest, but I think there is an extraordinary version of the analogue sport and quad rugby which again for those who saw murder ball, you've got to experience the persona of the colorful people, many of whom are involved in the -- at the U.S. pair limbic level in the quad rugby movement, but 19 you've got to see how vigorous and extraordinary that sport is for individuals with cervical lesions. In terms of secondary injuries to avoid, obviously hypotension is a major concern with spinal cord injury and proper hydration, helping individuals change position, wearing compression stockings and abdominal binders might help to avoid the orthostatic hypertension that they may be subject to. Autonomic dysreflexia is obviously another concern for individuals who have moderately high lesions, t-6 and above and it can be life threatening and needs to be -- so individuals have to be very sensitive and aware of what the symptoms are and sort of if they have a history of this, what might be the trigger for dysreflexia. Symptoms would be diminishment of the heart rate and very high blood pressures, blurred vision, headache, sweating, flushing and a number of other things. And sadly that's probably where disability sport has had a negative influence in that we've had racers in the past with cervical lesions who would clamp off their catheters in order to get the stimulus there t chemical compounds that would elevate heart rate and then they obviously subject themselves at the same time to a bout of dysreflexia. At any rate that's something we have to be concerned with and aware of and managed. Hypothermia with individuals with sensory loss. Dehydration, many individuals with SCI when they are going to go out and get involved in training or competition, they will do opposite of what they will do. They will often dehydrate themselves so that they don't have accidents and they don't have to go to the bathroom, but then, you know, 20 they suffer the consequences of dehydration as a result. I've seen it in trips with international teams. They would often go through a planned dehydration to get on the planes to fly overseas and then when they arrived, they would almost immediately end up going to a clinic with a UTI and so we have to be educating and conscious of their need for water and to avoid the consequence of that. I mentioned earlier rotator cuff injuries which primarily we can control for with balance, strength and conditioning programming, but it's just imperative that we engage in that well rounded strength and conditioning program in order to prevent the likelihood of serious injury to the rotator cuff because it's very slow to heal once injured. Soft tissue injuries, mainly bruising, blisters, jammed fingers, things of that nature that can often occur. Pressure sores that can occur when individuals are not taking the time to make sure that the contact points with their chair, that they use appropriate cushioning and they've put barriers -- padding between body parts where there is diminished sensation and the hard surfaces of the equipment. Technology has evolved over the years and rugby was one thing that kind of I think drove some of that, and now both basketball and rugby chairs have incorporated designs of roll bars on the front that actually will protect the feet and the lower extremities from contact and so the injuries that might result later in pressure sores have been diminished substantially just by that technological change. Again, in preventing these injuries, some of the things I've already noted as I look at my time, I think one of the foremost concerns is that 21 before beginning obviously every individual needs to consult a physician. They also -- be familiar with their health history, but also with a physician who really knows spinal injury very well and hopefully have some knowledge or expertise or experience with these adapted activities. Certainly if a physician isn't available, then a physical therapist or occupational therapist, someone who understands the disability -- within the context of sports -- is very beneficial. Noting moderation is the key, and I think the first key -- the first way we ensure moderation is we set challenging but attainable goals and we identify what are the objectives that the individual has and over what course of time are we going to need to be engaged in the activity to achieve those goals. And then I think mapping that out within a die a ry. I've often told athletes that one of the most important things they will do to advantage themselves from the standpoint of performance in sport or in achieving strength and conditioning goals is to keep an exercise and diet diary. We still have very little evidence-based guidelines for prescribing exercise for this population. And so I think a lot of this it's imperative that individuals develop a plan for exercise and particularly in diet, that they would actually go through the time to keep a diet diary, to put down what they've eaten, the portion sizes, to calculate the caloric sort of intake and whether their weight is fluctuating to get an idea of what their baseline is and caloric need so they can have some control and learn to develop control over their activity and calories and their weight gain. And the neck anymore for that -- and I think helping them understand 22 also if there is an injury, to go back in time to see how they may have changed their training or their activity and that that may have somehow contributed. They perhaps didn't take the time off or rest that they should have taken and they can actually go back and assess their history and identify maybe what contributed to the injury and then change the regimen as a result. And so I really urge that one of the first things that they do is develop a plan and then to begin a diary. And I think I've probably gotten to about the end here. Lex, I should probably stop to ensure that there is some opportunity for questions. >> LEX: Brad, I mean what you've shared with us has been very, very interesting. I think a lot of people took notes. I know that you would encourage them to read further and we can go into what other resources might exist for people if they want to follow up further with this. Also I want to mention at this stage that we do have the opportunity for you to go back and review Brad's presentation in our archived transcripts. You're correct, Brad, we do have a lot of questions and as a matter of fact I've got a couple here from people have been inspired to go shopping for swimming pools after your comments. Can you tell me, actually, is it safe to acquire one of those portable pools for a person -- a wheelchair user and to try and ramp that somehow so they can use that in their own backyard? >> DR. HEDRICK: I'm not sure what a portable pool -- if we're talking about these soft side things -- if I were doing that for myself, I 23 would want to build a structure around that to ensure access because I can't imagine that the types of pools that are thin, metal gauge or certainly these soft sided pools would be sufficient. Things on the price yer side of things, the slim spas I think are kind of good compromises to full sized pools because they allow you to exercise and to swim against a current and they are efficient in terms of space and less expensive and less difficult to maintain, but they are still pricey. I'm certain those things are 20 to 30 grand. >> LEX: Are they built up for easy transfer or is that the way you install them? >> DR. HEDRICK: It's basically an installation issue. In order to install a swim spa accessibly, you'd obviously want to have it partially elevated out of ground. That would be the -- so it wouldn't be totally flush with the ground and I would -- but then also install probably a pool-side lift for that. although you do have nonmechanical transfer AIDS. There are pool side steps and things that you can add to -- depending on your functional level and what you're comfortable doing, but I think the slim spas, if they are in your price range, are good options, but for most of us, those are probably still kind of prohibitive. >> LEX: Well, you've pointed out some good issues regarding opportunities for people to find their sport, their means of exercise, their way to get engaged in physical activity and conditioning. And we have a number of questions from people, some practical, some more philosophical and esoteric. Let me ask you a couple actually that have come up that are pertinent to comments that you've made. You did mention 24 electrical stimulation as a modality and the question really is to what extent do you use electrical stimulation and to what extent would you recommend it? >> DR. HEDRICK: Well, we don't use it here as an element of our program. I think that needs -- what we have done, when students have come down -- have enrolled at the university who have gone through rehab programs where they've been using ergus machines or similar devices, what we've done is worked with their clinicians to ensure that we could establish a safe means for them to continue that exercise protocol while they are here and then we work with them to ensure that it's supervised but it's not something we're offering because it has to be medically -- the programs are developed under the direction of an attending physician and then they need to be monitored by physicians to ensure that it's being used correctly and that it's producing the benefits that are desired and not others. >> LEX: Brad, would you conclude that there are alternative ways to get the same benefit that perhaps are less risky? >> DR. HEDRICK: Well, it's difficult if you -- it's difficult to get the benefit of F. E. S. from other exercise because you can get range of motion, but you can't -- if you basically don't have functional innervation of those motor units you're not going to be able to use them. And F. E. S. is the only way I'm aware of to actually activate these paralyzed motor units and to maintain their strength and integrity and so I don't know of -- I would turn -- I'm going to ask the audience if there is something that would be alternative to that. I don't know of an activity 25 that's alternative to that, but in terms of the flexibility of cardiovascular health and fitness of all these other sort of secondary risk issues that we want to avoid, certainly I believe that there are alternatives that are beneficial and I would imagine less beneficial if not more or at least equal. >> LEX: In that regard, let me ask you another question that was forwarded to us by one of our participants and that is aerobic conditioning. Could you say a little bit more about what in fact aerobic conditioning is and what exact benefits are there for people with disabilities? >> DR. HEDRICK: Well, obviously the -- when we talk about the -- the American heart association recommendations that people engage in moderate activity at least 30 minutes a day on most days of the week, typically what they are talking about that you would exercise say a 50 -- depending on your level of fitness, 50 to 85 percent of your maximum heart rate. In our program, we would first find out -- we would put them through a stress test. We would identify what the maximum heart rate of an individual is, and usually using arm ergometer. And we would try to find a level -- incrementally -- starting low. So we may start at a heart rate of 120 and just go for 30 minutes at a heart rate of 120 and then 125 and gradually build it up until they get to a point -- usually the threshold for -- anaerobic threshold is when you can't carry on a conversation and exercise at the same time, you've probably moved from aerobic to anaerobic. And so that's sort of the line of demarkation, and I think from the 26 standpoint of just general health and fitness, the aerobic is where we want to spend most of our time in that 50 to 85 percent, depending again on your level of fitness, but the anaerobic becomes increasingly important as performance goals become important. So that the power -- the quick change of direction and powerful sprint in tennis to get to the corner to return a shot, that is not an aerobic exercise, that is something that we have to train the body through explosive interval power kind of training activities to perform efficiently. And in racing, you often travel and they draft and so in a drafting race you're riding often in the sweet spot behind someone else who is breaking the air for you and, therefore, you don't have to work very hard. And so then all of a sudden someone sprints and you have to catch up and that's anaerobic and so we've found that it's more important that people have this reserve and the ability to catch up to other individuals who are racing who are making a break, that that's the important skill and as long as they are able to catch up and stay there, their aerobic capacity is probably going to be fine for racing. I think performance is probably the key in moving to -- what are the performance objectives? Will determine how much anaerobic training you may want to do. Weight lifting is anaerobic training. >> LEX: A couple of other technical questions that came up during your comments. One regarding metabolism. Are there any easy ways for people at home to measure their metabolism and is this something that will be changing all the time for people with spinal cord injury? >> DR. HEDRICK: Well, it's a function of their level -- their 27 functional muscle mass and their lifestyle, their activity levels, if you live in a house with hard surface flooring versus carpeting can change your -- sort of how much your caloric need is throughout the day and actually I know that one of the model centers -- I think I've seen Michigan was trying to do some baselining on metabolic extendure in ADL's in people with spinal injury. We have a person here who is working to develop a means of introducing activities of daily living into the compendium of physical activity and incorporating it into surveys that are often given to individuals who don't have disabilities to estimate their caloric expenditure throughout the day. But right now there aren't any items in that that you can use to sort of estimate caloric expenditure in persons with spinal injuries. Again, my best suggestion is to develop -- is to start a food diary and I know most people say it's a real pain, but it is a labor of love. If you do this, if you will keep a me particular lust food diary and measure portions and then you can go and get the California or I estimates for that and do you over the course of a couple of weeks, then can you get a pretty good idea based on fluctuations in your weight of kind of what your base metabolism need is. And that is probably the best approach that I could suggest to anyone right now who wanted to do that. >> LEX: Okay. Here is an opinion question, and you may actually have data to base your opinion. Do you think it's tougher for women than men when they want to exercise or take part in sports? >> DR. HEDRICK: Well, certainly in terms of this population, you know, spinal cord injury is still overwhelmingly men. We all -- we still admit that for the most part the good news for women is they are smarter 28 and they tend to not do some of the things that predispose us to spinal cord injuries, but the bad news is that they have a smaller peer community I think and you know we've had women's basketball here since the '70's, but it's a struggle to sustain those teams and there has been very little growth in women's teams and since the '70's I think there is now like ten teams nationally and I think that reflects the -- some of the demographer I in disability but I think it does reflect gender bias still. I'm sure that the women that are on this webcast would agree that probably title 9 has not fulfilled its intent and certainly it hasn't even begun to fulfill an intent with women with disabilities. >> LEX: Okay. Brad, there are a couple of questions from a user of service animals, and one of the questions is have you encountered athletes or casual health nuts who use service animals? And if so, what activities do you find are convenient for them? >> DR. HEDRICK: Well, I think -- I can't imagine that there wouldn't be many activities. I think if you had -- I think running -- dogs are meant to do anaerobic activity. They are not meant to engage in aerobic running. I think my recommendation would be -- that would be something you shouldn't do with your PET is go on a long run with a dog, if it's a dog. And realizing service animal could be -- that's a pretty broad category. I guess at this point I can't imagine an activity that you -- you know, you probably couldn't do. You may have to -- you may not be able to take the service animal into that activity. If you're going to do sky diving, then that's probably something you'll have to do by yourself, but you know certainly going into gyms, going to pools and things of that 29 nature, there is protections for service animals there to ensure that people with disabilities can have their service animals and still access and use those resources. >> LEX: That's very good. I think another point that you made here in the answer to your question is that some exercises may be those that the animal may be able to participate in as well, not necessarily running, but at least walking. >> DR. HEDRICK: Oh, yeah, I think that's absolutely true. And that going -- we've got some wonderful parks around here in the community. One that has a very long accessible -- about a two mile path through prairies and it's just a great place to go in a chair and to walk a dog and to interact with the people that are out there on the path. It's just a wonderful kind of physical activity to do. >> LEX: This is a related question. In your experience, Brad, have you ever coached an athlete who used a service dog? >> DR. HEDRICK: Yes. >> LEX: And what was your experience in that regard? >> DR. HEDRICK: Well, one, the service animal basically was pretty well behaved in the gym. I coached basketball players with service animals and while the individual was involved in competition and training, that service animal was off to the side and was sort of -- I really was oblivious. I knew the animal was there. To be honest, I spent -- it required little or no of my attention and to the point that I was pretty oblivious to what it was doing. I know it wasn't on the court. So it met my main condition there that it not interfere with our training or our 30 competition. >> LEX: I understand. Brad, here is a question that -- I mean I suspect if you can answer this, you're going to be called upon to coach the next U.S. Olympic team, but what things would you recommend for a disabled athlete, what approaches would you recommend to prepare someone mentally for the challenges of physical training? >> DR. HEDRICK: Well, once again, I don't think there is a magic bullet. I think the most important thing -- to meet the challenge of training is really a matter of knowing yourself, knowing your goals and being honest with yourself about your goals. I mean -- and I would caution individuals to always be truthful with yourself about what you really want to achieve, and then honest with yourself about what it's going to take to achieve that end, and then at that juncture, you know, if you can do those two things and be honest in the identification of a goal that you legitimately desire to pursue and you are able to commit yourself to the activities that are going to be needed to have the opportunity to realize that goal, then you are to me over the hump. You know, one of the hardest things for athletes today though is again the fact that they have little access to trained knowledgeable coaches, higher education for instance still does a really lousy job of producing exercise specialists and physical education personnel who really know how to teach adapted sport and recreation, and exercise specialists who understand disability and activity and can really help individuals develop plans to achieve their goals. Those people are few and far between. We have very limited access to instructional media so if you want to go out -- I just recently had a 31 faculty at a university in Korea contact me to publish a Korean version of my basketball book. Now, I'm flat erred they want to do that, but I've got to tell you it's pretty sad when the published in 1992 is what you're going to go after in 2006 as a state of the art text. And I think that we -- barriers that are there obstructing these young people really are -- they have very limited access to even self-help content on how to organize and execute training, how to prepare for competition. They have limited access to help them with that process and some of the things again we would have talked about with more time, just the fact that the socializing agents and agencies that do that for student -- for young people and for adults without disabilities still aren't on board with people with disabilities so that we still have very limited park district programming. We still have very, very limited scholastic programming. We still have only ten institutions of higher learning in the United States that I'm aware of, that offer wheelchair sports. And so when the feeder systems are so constrained, it's very difficult to get access to the resources and the expertise to optimize your training and to pursue these goals. So I have great empathy for the folks who want to do that and it's very difficult and those are certainly areas in which we've got to see progress. >> LEX: That's good observation. Now, Brad, get your pencil out because the next question is quite technical and I'm going to read it verbatim. It is one that addresses more general issues, but it is specific to an individual. Ordinarily we wouldn't forward such a question, but because of its nature I think it eye perhaps valuable for you to hear and provide whatever advice you might. 32 >> DR. HEDRICK: Okay. >> LEX: I have had trouble developing my nutrition plan and I've had difficulty trying to determine my B. M. R. >> TED: Basal metabolic rate. >> LEX: They have me at 2214 and another one has me at 1705. That's a 509-calorie difference or an additional pound of fat a week. You mentioned a research study that reported a person with spinal cord injury needing 21 percent fewer calories. Can you talk about that? I track my diet. Do you suggest a certain micronutrient mix for an athlete. I play quad rugby. >> DR. HEDRICK: You know, this is where I have to say the limit of my expertise has been reached. I mean, normally in this situation what I would do as a coach is I would refer the individual to the nutritionist here that worked with our student athletes and to try to help resolve the concern about what is the metabolic rate. I think the most important thing is are you eating -- my wife was a dietician, so I get some of this. I can't say that I've always taken her advice, but I think the diary is what -- are you eating a well balanced diet of proteins, fats, carbohydrates with minerals and if you're getting that, if you have adequate energy for all of the activities you are doing, are you gaining weight, stable in weight, or losing weight? And, you know, that as a coach is sort of the strategy that I've employed. You obviously have been pursuing this a at a level of sophistication that I would say needs to be taken up with a nutritionist. >> LEX: And I mean I suppose finding a nutritionist who 33 understands the nuances of spinal cord injury is -- you would provide the same advice to anyone with a special need who was looking for a physician or a coach to help them and that is to basically interview those who might seek counsel from to ensure before you pose the question to them your competent in their knowledge of their baseline issues. >> DR. HEDRICK: Yeah, I think probably the biggest concern I would suggest is the person willing to work with me? Do I feel comfortable that you have the willingness to work with a person with a spinal injury in trying to determine an accurate baseline of caloric need and, you know, I think for instance I've always been comfortable here with the folks at our health center, the nutritionist who worked at the health center and generally we've done all of our assessment -- you can do laboratory assessments of caloric basal metabolic rate. We've really relied on the sort of soft text -- I rely on mechanisms that I think you can carry forward into -- throughout your life. I mean, keeping a food diary -- it's not just a food diary, it really is a training diary, an activity diary, a health diary, and people who have -- if you have secondary symptoms, if you have chronic pain, to keep the diary and to log what your one to ten level of pain this day was, and so that you can go back and look at patterns over time and associations with that. And I think -- so I see retaining that information and writing it into a log as a very robust and significant kind of tool that helps us to address a number of issues. >> LEX: Okay, Brad, we're going to cover two more questions and then I have some wrap up to do here for the benefit of the audience, we're going to move through these two questions and then have some concluding 34 remarks. The next question is can you comment more on the risks and benefits of passive exercises and perhaps reiterate your advice regarding exercise equipment that may be safe for people with spinal cord injury to use? >> DR. HEDRICK: So equipment that may be safe and what was -- I'm sorry, the first part again? >> LEX: The benefits of passive exercise. >> DR. HEDRICK: Passive exercise. I think we do lots of passive exercise even with the athletes here in terms of range of motion. So in totally relaxed modes, even assisted exercise to ensure we have good flexibility, that we are working to prevent contractures, that becomes increasingly important as we're dealing with now -- we have a very large growing group of students with disabilities that are chronic and degenerative, and frequently for that population we are almost exclusively limited to passive range of motion exercise and to -- and the therapeutic aquatic program, but those students will attest though that they find it extraordinarily beneficial, that it's probably not going -- it's not going to have the kind of impact on card oh vascular health and fitness because you're not just driving the level of activity is not sufficient to affect it. Even an arm exercise, because you're using very small muscles, you know, you can improve your central fitness, your cardiac fitness, but it's not going to be at the same level as it would be if you were using the large muscles of the lower extremities. So in passive exercise again it's even more restrictive in terms of some of those benefits, but perhaps in terms of again preventing contractures, maintaining range of motion, which 35 may also improve comfort, diminish some discomfort and pain in relation to immobility in joints and then aquatic exercise, the opportunity to be able to move very, very limited musculature in the more weightless environment of water. They are active but very limited in terms of their active nature. In terms of equipment, you know, the things that are recommended -- it really depends on what the goals are. If we're talking about -- if this is say a fitness center that says what kind of equipment should we include for people with disabilities? I think the first thing we have to do in a fitness center is make sure we have accessible routes of travel around all the equipment. I think it's important to have upper body ergometers available, put them in line with all the stair climbers and treadmills and often they don't make those available because the incidents of use is much less. And then I think generally to buy -- to invest in weight stations, resistance equipment that doesn't require lower limb stabilization. I mean, some of that equipment is -- allows for upper tore so to be used to stabilize an exercise and some of it is designed that it requires the lower limbs to be used to stabilize and obviously we don't want the latter. We want the former. And then to be able to put in, say, a multistation piece of equipment that could be used by individuals without disabilities, but the things that can be used by a person who is not going to be able to -- or doesn't wish to transfer in and out of the wheelchair, again, the one that we like the most here because it really doesn't involve any heavy weights is the Versa-Trainer because it's just using these carbon rods that you attach to 36 cables and you can change the range of motion and the motor units that you're trying to focus on. You change different exercises with minimal amount of moving in the chair in that device. And so we like that device a lot for that reason. >> LEX: Okay, you've given us lots of information and I know everybody online is grateful to you for taking the time, using what up little voice you had today, Brad and joining us for this presentation. For those of you who may have dialed in late, you're more than welcome to visit our website at www.ilru.org to look at webcasts and find the information about this webcast. You'll find eventually the whole transcript from the webcast. You can go back over Dr. Hedrick's PowerPoint slides and I'm sure if you will forward any further questions to us, we'll try to put them together in a package and send to Brad so that he might respond to you when he has time available. I want to thank Brad Hedrick for being our guest today. Again, nobody in my opinion has done more than he has to use sport to effect changing attitudes among the public about people with disabilities. Those of us with disabilities have many more abilities than we have disabilities. Some of us to choose to use those abilities to experience performance-related goals that others don't choose to use and some of us actually have talents to do that, that others of us don't have to the extent that sport can be a kind of pilot for society showing how people with disabilities can be just as active and involved and talented and skillful as anyone else, Brad has been a leader in this area and he's helped to change countless numbers of attitudes of the public about the way people with disabilities are involved 37 an participants in everyday life. We want to remind everybody that's been on the webcast that the opinions and views expressed here are strictly those of the presenter and no endorsement of any sponsoring agency should be inferred or implied. I also want to give a plug to our principal sponsor which is the Rehabilitation Research and Training Center on secondary education in spinal cord injury. This Rehabilitation Research and Training Center was established in 2003 by the National Rehabilitation Hospital in Washington, D. C. It is funded by the National Institute on Rehabilitation Research, a division of the United States Department of Education and collaborators on the NRH secondary conditions and SCI team including not only ILRU, but also the Miami School of Medicine project, the National Spinal Cord Injury Association, and Spinal Cord Injury Network. Again, thanks -- thank you, Brad, for being our guest today. >> DR. HEDRICK: My pleasure. Thanks for having me. >> LEX: And thank all of you for participating in this webcast. Please visit our website at ilru.org for more information and for a list of upcoming webcasts. Have a great afternoon. Bye-bye.