by Mark Boyland, PT, DPT, CSCS
The joy of training allows for many populations of people to be able to exercise and as trainers and strength coaches we need to be aware of individual differences between some of these unique populations. There are some considerations to make prior to training a client with a spinal cord injury however they fall into the same targets set by the ACSM and AHA for exercise targets: 75 minutes of vigorous aerobic activity or 150 minutes of moderate aerobic activity per week or some combination of these with the exercise sessions spread throughout the week. Strength training and stretching should also be performed multiple days per week focusing on total body strengthening/stretching. While there are more significant considerations to be made in regards to creating a fitness plan for your client with a spinal cord injury these plans should be specific to their current presentation and their goals.
At this time there are about 300,000 people in the United States with a spinal cord injury, or approximately 10% of the current US population, meaning there is a good chance for a potential client with a spinal cord injury could come through your door trying to maintain or improve their health and wellness. Considerations for these clients include: partial/incomplete injury, level of the client’s injury, paraplegia/tetraplegia, overuse injuries, autonomic dysreflexia, and current medications. Considerations for you and your gym are temperature/humidity control and accessibility in regards to parking, accessing the gym from the outside, as well as being able to navigate between equipment at your gym while using a wheelchair or other assistive device.
Regarding your client’s specific considerations in regards to their injury: a complete spinal cord injury is one that results in a total loss of sensation and motor activity including the lowest sacral nerve levels. An incomplete spinal cord injury is where there is still partial sensation or motor activity below the level of injury. Most spinal cord injuries results in tetraplegia with 59.5% of spinal cord injuries being considered tetraplegic and only about 40% of injuries being considered paraplegic. About two-thirds of spinal cord injuries are a result of vehicular accidents or falls. Another consideration is the level of the patient’s injury and their ASIA score. The ASIA score describes the amount of sensation/motor function available to the patient based on their injury level. There are online resources to explore each level and what motions/sensations are preserved based on the patient’s level of injury. An additional consideration is your client’s medications. Your client may be on several medications that are directly related to their injury and other non spinal cord injury related conditions so be sure to review their medications, the intended effects, side effects, and red flags prior to beginning working with your client. While this article and blog are meant to cover the basics of working with clients with spinal cord injuries it cannot be an exhaustive review especially when considering medications. Commonly spinal cord injury patients may be placed on medication for pain management, tricyclic drugs, antispasmodics, bladder control, and autonomic dysreflexia. Common side effects of medications across these classes include but not limited to: drowsiness, dizziness, fatigue, sedation, and weakness which could lead to generally reduced exercise tolerance and balance.
Client and gym/training center considerations include being aware that due to the loss of neurological control beyond the level of injury there can be negative reactions that your client may experience while training with you. These include your client overheating due to a loss of the ability to sweat below the level of their injury so a gym that is excessively hot/humid can cause a negative reaction. Make sure to monitor your client’s status while training with them to avoid overheating and monitor the ambient temperature/humidity of your training facility. Another serious reaction is Autonomic Dysreflexia. Autonomic Dysreflexia is a reaction to a noxious stimulus which can result in: abnormal systolic blood pressure elevation of greater than 20 mmHg, pounding headache, flushing above the level of the injury, increased heart rate, and can also be asymptomatic. Autonomic Dysreflexia can also be asymptomatic and can become life threatening quickly. Common causes for Autonomic Dysreflexia include muscle spasms, pressure sores, bladder/bowel distension, lower extremity injuries (broken bones). One of the most common causes is due to a kinked catheter which results in an inability to empty the bladder resulting in a back up of urine in the bladder.
Having gone past the major considerations clients with spinal cord injuries coming to you are similar to clients without a spinal cord injury. Their training to should be specific to their needs/goals and with what they are capable of doing. Initially clients with spinal cord injuries may only be able to tolerate 1 or 2 sessions of aerobic/resistance training per week using an arm crank ergometer, Nustep, or wheel chair treadmill for aerobic conditioning. For a beginner resistance training program the use of household items such as can is advised, however you can also use dumbbells, elastic bands/tubes, wrist weights. As your client progresses they can advance their resistance training with use of machine-based resistance training, dumbbells, and medicine balls. You can progress your clients to multiple training sessions per week progressively increasing the duration/intensity to match the recommendations by the ACSM/AHA however you must consider that your clients may be reliant on their upper extremities for most of their daily activities and training. This increased use of their upper extremities to manage their daily life can result in overuse injuries so exercise programming to avoid overuse injuries is important.
Training clients with a spinal cord injury can be initially intimidating but so are most things that you are not familiar with. You can familiarize yourself with the levels of impairment present depending on the level of the injury, the ASIA scale, and reach out to your client’s Doctor’s and Therapists to form a relationship with them early on to help your client as a team. Keep your clients safe, don’t be afraid to ask questions, and always look to learn more.
For more details you can read the full article at the NSCA
Aerobic and Resistance Training for Individuals with Spinal Cord Injuries
Joshua M Miller, DHSc, CSCS, ACSM-EP
Department of Kinesiology and Nutrition, University of Illinois-Chicago, Chicago, Illinois
1. Following a spinal cord injury, if there is some feeling or activity lower than the injury site, this is called a(n) ____________ injury.
2. How many people in the United States are likely living with a spinal cord injury at this moment?
c. Nearly 300,000
3. Which of the following is the most accurate representation of the amount of spinal cord injuries that result in paralysis of the lower body?
b. Less than 1/2
4. Which of the following recommendations for training is true for both paraplegics and tetraplegics?
c. 75 minutes per week of vigorous aerobic activity
5. Thermoregulation is a major environmental concern in those with a spinal cord injury due to _______________.
c. The inability to sweat below the level of the injury
6. Which of the following would be considered an advanced resistance training method for those with a spinal cord injury?
b. Dumbbells and resistance machines
7. Acute changes in systolic blood pressure during exercise can be an issue in those with spinal cord injuries and it is primarily due to _____________.
a. The lack of communication between the nerves and brain below the injury site
8. A common site of overuse injury related to locomotion in those with spinal cord injuries is __________.
c. The shoulder
9. A frequent side effect of medication on exercise in clients with spinal cord injuries is ____________.
b. A reduction in exercise capacity
10. A frequent potential adverse effect of pain and antispasmodic medication is __________.