Clients With Spinal Cord Injury, Multiple Sclerosis, Epilepsy, and

Cerebral palsyNSCA Chapter 22

Spinal Cord Injury

• Spinal Cord Injury is the impairment or loss of motor function, sensory function, or both in the trunk or limbs due to irreversible damage to neural tissues within the spinal canal.– Quadriplegia: impairment in the arms, trunk, legs,

and pelvic organs. – Paraplegia: impairment in the trunk, legs, and

pelvic organs

Spinal Cord Injury

• Clinical manifestations– Of special importance is autonomic dysreflexia.• Signs and symptoms

– Sudden systolic BP increase of >20 to 40 mmHg– Pounding headache– Profuse sweating and flushing of skin above level of injury,

particularly the head, neck, and shoulders– Piloerection “goose bumps”– Nasal Congestion– Feelings of anxiety– Cardiac dysrhythmias

Spinal Cord Injury• Clinical manifestations

– Common precipitators of AD• Bladder distention, UTI, bladder or kidney stones• Epididymis or scrotal compression• Bowel distension or impaction• Gallstones• Gastric ulcers, gastritis, gastric or colonic irritation, appendicitis• Menstruation, vaginitis, pregnancy• Intercourse or ejaculation• DVT or pulmonary emboli• Temperature fluctuations• Pressure sores, in-grown toenail, sunburn, burn, blisters, insect bites• Constrictive clothing, shoes, appliances• Pain, fracture, other trauma• Any pain or irritating stimuli below injury level

Spinal Cord Injury

• Preventing injures in clients with SCI– Carpal tunnel syndrome is common (one study reported 23%)– Stretching the anterior shoulder musculature and strengthening

the posterior musculature can significantly reduce shoulder injury and pain

• Exercise concerns with SCI– Temperature regulation

• Trainers should try to maintain as constant of an exercise environment as possible, loose fitting clothing, and ensure access to cool water and sports drinks.

– Venous return• Supine exercise may increase the effectiveness of upper body exercise and

gradient compression hosiery may help as well to aid in venous return.

Spinal Cord Injury

• General Health Issues of persons with SCI– Insulin resistance and hyperinsulinemia• Due to relative inactivity, decreased muscle mass, and

increased adiposity– Leads to trouble with oral carbohydrate processing

– Slightly higher frequency of dyslipidemia, hypertension, and CVD

– Atrophy of cardiac muscle• Cardiac dysfunction, increased risk for congestive heart

failure

Spinal Cord Injury

• General Health Issues of persons with SCI– *An exercise session should not be started, or

should be terminated, if any of these symptoms are present, and a medical follow-up should occur as soon as possible.• Unusual shortness of breath• Excessive sweating• Fatigue• Light-headedness• Sensation of fainting and/or palpitations

Spinal Cord Injury

• Exercise Testing– Arm crank ergometer is most common mode– Maximal exercise testing of clients with SCI should be

administered ONLY in a medical setting with appropriate professional and physician supervision.

• Physical activity and fitness levels– Physically active SCI clients have greater maximal cardiac

outputs and stroke volumes, forced vital capacity is reduced by about 50% but resistive inspiratory muscle training (RIMT) may benefit a tetraplegic client.

Spinal Cord Injury

• Exercise Prescription– Initially:

• Cardiorespiratory: 40-60% of VO2max/HRR for 10-20 minutes, three days per week every other day

• Resistance: 8-12 exercises, at 40-70% of 1RM, 2-3 sets of 8-12 repetitions, with 1-2 minutes rest between sets

– Goals:• A minimum of 30 minutes or more of physical activity on most,

preferably all, days of the week.

– Warm-Up: • A gradual, progressive warm up can minimize muscle spasticity,

although frequent spasticity warrants medical follow-up for adjustment in medical therapy.

Spinal Cord Injury

• Exercise Guidelines– Resistance Training

• Enhance balance around functional joints and strengthen muscle groups of the posterior shoulder and upper back, stretch muscles of the anterior shoulder and chest

• 2-3 sets, of 8-12 repetitions, 2-3 days/week– A single set to fatigue of 8-12 exercises for 8-12 repetitions, two

to three days per week may yield benefits as well.

• Full range of motion, proper technique, avoiding the valsalva maneuver, and controlled movement

• Spasticity contraindicates resistance training

Spinal Cord Injury• Exercise Guidelines

– Flexibility• Standard guidelines with special attention to the shoulders, wrists, arms, trunk, and

lower limbs– Cardiorespiratory

• Begin at a moderate level and progress in duration, frequency, and intensity with a goal of 30 minutes four or more days a week.

• Mode: arm crank ergometer (supine may be preferred), wheel chair on treadmill or accessible sidewalks, tracks, swimming, various wheelchair sports

• Intensity: Heart rate monitoring can be problematic, but RPE is an appropriate alternative method

• Avoid exercise 2-3 hours after a meal as digestion can disrupt blood flow and distribution• Avoid exercise during an illness such as a cold or flu• Transfers from wheelchair to equipment should be minimal to reduce repetitive use

injury chances• Temperature and thermoregulation must be accounted for• Motivation and exercise adherence should be emphasized by the trainer

Multiple Sclerosis

• Multiple Sclerosis: An autoimmune disorder that occurs in genetically susceptible persons. Characterized by inflammation and progressive degeneration of the myelin sheath of the nerves.– The cause is unknown but may have a viral origin

such as Epstein-Barr virus– Typically begins in early adulthood (20-40 years)

• 80% have relapsing-remitting and 20% have chronic progressive MS.

Multiple Sclerosis

• Medical management of MS– Four aspect to treatment (scope of practice

concern)• Educate the individual and their family• Management of symptoms, such as spasms• Management of the disease process• Exercise

– Exercise and behavioral therapy– Regular stretching, resistance training, and cardiovascular

training– Mindful exercise such as Tai Chi and yoga may help

Multiple Sclerosis

• Training of Clients with MS– Heat intolerance is a prime concern

• May preclude them from participation• Use a precooling procedure (cool shower or whirlpool, cool wet

neck wraps, cool water sprays before and during exercise)

– Resistance training• 8-10 exercises, performed at 60-80% 1RM, for one to three sets,

8-15 reptitions• Progress at 50% of the rate for persons without the disorder (i.e.

increase loads every three to four weeks instead of every one to two weeks)

• Daily stretching to improve ROM and decrease spasticity

Multiple Sclerosis

• Training of Clients with MS– Aerobic conditioning

• Response to exercise can vary and must be progressed gradually in accordance with the principles of overload and progression.

• Initiate exercise at 40-50% VO2max/HRR with progression to 50-70% over three to six months

• Duration of 10-40 minutes is recommeded depending on disability level

• Progress at a rate that is 50% slower than for apparently healthy adults– Clients with MS are more prone to fatigue that can be disabling– Exercise to exhaustion in clients with MS should be avoided. Persistent

fatigue lasting more than two days should be a warning sign that an exercise program is excessive.

Multiple Sclerosis

• Exercise guidelines for clients with MS– Complex skill-oriented exercises should be avoided– The energy cost of walking may be 2 to 3 times

higher than normal for people with MS. (adjustments to workloads of 60-75% of maximal heart rate are necessary from

– Temperature sensitivity for cold or heat related injury increases.

Multiple Sclerosis

• Exercise guidelines for clients with MS– Caution should be taken with large muscle lower limb exercise,

since spasticity is dominant in hip abductor and adductors.– Sensory loss may preclude free weights because of a lack of

ability to grip the handles– Strapping may be necessary if spasticity is present– Morning may be best time for exercise– If balance is an issue, recumbent cycling is preferred over

upright cycling– Agonist/antagonist imbalances are common– Muscle weakness is the greatest in the lower limbs and trunk

Multiple Sclerosis• Exercise guidelines for clients with MS

– Neuromuscular problems such as foot drop may present in more advanced cases

– Constant reinforcement is generally needed to enhance compliance and motivation

– Exercise program adjustments may be required on a daily basis– Monitor HR before, during, and after exercise– If exercise exacerbates the MS symptoms, then exercise should be

discontinued until complete remission– Resistance training should be performed on nonendurance training days

to avoid fatigue– Resistance training should be done in the seated position initially if

balance is impaired– Flexibility training done in the seated or lying position

Table 22.4 General Exercise Session Programming Guidelines for Clients with MS

Aerobic TrainingMode(s) Stationary cycling, recumbent stepping, water aerobics, upper body ergometry, walking

Intensity Either 60% to 80% of peak HR, 40% to 60% of HRR, 50% to 70% of VO2 peak, or 40% to 60% of VO2 reserve

Duration 30 min/session, which might need initially to be accumulated in three 10-min sessions per day

Frequency 2 to 3 days per week on nonresistance training days

Resistance TrainingMode(s) Machines, free weights, resistance bands and tubing, pulleys, Pilates

Muscle Groups 8 to 10 exercises that emphasize all major muscle groups and attempt to establish balance in agonist-antagonist muscles

Intensity 8 to 15 repetitions with 60% to 80% of 1RM

Sets One or more sets per muscle group as tolerated

Rest Periods A minimum of 1 min rest between sets and exercises

Flexibility TrainingMode(s) Active range of motion, passive range of motion, yoga, tai chi

Duration Hold stretches between 30-60 s. Stretches should be held with mild to moderate tension but for a duration without discomfort

Frequency Perform gentle stretching one or two times a day

Muscle Groups All major muscle groups. The hip flexors, hamstrings, hip adductors, plantar flexors, and anterior shoulder girdle muscles should receive high priority

Epilepsy

• Epilepsy is defined as two or more unprovoked, recurring seizures– Status epilepticus is defined as a seizure lasting more

than 30 minutes or a series of seizures that occur so frequently that consciousness is not restored.

– Precipitants precede seizure episodes• Physical activity may be a precipitant to a seizure• Emotional stress, hyperventilation, menstruation, sleep

deprivation, fever, photic stimulation (visual), alcohol excess or withdrawl

Epilepsy

• Medical Management of Seizures– Exercise training in persons with epilepsy is

applicable only to the perhaps 80% of those who are well controlled either medically, surgically, or with combined therapy.

– In many persons with epilepsy, regular aerobic exercise may contribute to improved seizure control. However, in ~10% of individuals, exercise may be a seizure precipitant.

Epilepsy

• Exercise Training of Clients With Epilepsy– Be aware of the type of seizures that a client with

epilepsy has and pay attention to the client feeling an aura or signs and symptoms of an impending seizure.

– In general, there are no contraindications or restrictions to exercise in people with well-controlled epilepsy

– A weight loss of even 10 pounds can increase the bioavailability of antiseizure medications and thus increase the risk of side effects

– Ketogenic diets(low carb, higher fat, adequate protein) may be practiced by a clients with epilepsy

Epilepsy

• First Aid for Seizures– To be used during a seizure and during the postictal

state (the period immediately after the seizure).– Ten steps for First Aid for Seizures (pg. 579)

• 1. Keep client prone – lying facedown if possible• 2. Remove eyeglasses and other items that may break and

cause injury• 3. Loosen any tight clothing, particularly around the neck• 4. Do NOT restrain the client.

Epilepsy

• First Aid for Seizures– Ten steps for First Aid for Seizures (continued)

• 5. Keep objects out of clients path• 6. Do NOT place anything in the client’s mouth• 7. After the seizure, turn the client to his or her side in

recovery position to prevent aspiration• 8. Observe the client until he or she is fully awake• 9. Alert the client's physician and family• 10. The client may be able to return to exercise, but

evaluate this with the client’s physician on a case-by-case basis

Cerebral Palsy

• Cerebral Palsy is a group of chronic musculoskeletal deficits causing impaired body movement and muscle coordination.– Characterized by limitation in the ability to move,

control balance and coordination, and maintain posture due to damage to the motor areas of the brain that control muscle function and spinal reflexes.

– Irreversible condition and the focus is on controlling the spasticity and athetosis and improving function and neuromuscular coordination.

Cerebral Palsy

• Medical Management of CP– Managing the secondary complications– 60% of persons with CP suffer from seizures or

seizure tendencies– Joint pain– Hip and back deformities– Bladder and bowel dysfunction– Gastro esophageal reflux– Usually sedentary and prone to several risk factors for

CVD

Cerebral Palsy

• Exercise Training for clients with CP– Training can help improve

• Capacity to perform activities of daily life (ADL)• Sense of well-being and body image• Lessening the severity of symptoms such as spasticity and athetosis• Peak VO2, ventilatory threshold, work rates at submaximal heart

rates, range of motion, and coordination and skill of movement• Muscle strength, endurance, and hypertrophy• Skeletal bone mineral density• Ventilatory capacities in children ages 5 to 7• Higher gait velocity• Swimming ability and water orientation

Cerebral Palsy

• Exercise Training for clients with CP– All persons with CP should be screened properly for

musculoskeletal abnormalities, CVD, risk factors for atherosclerosis, diabetes, arthritis, and hypertension.

– Must obtain medical clearance before starting a moderate intensity exercise program.

– Leg or arm ergometer are the preferred testing modes for ambulatory CP persons.

– Persons with CP can expect a systematic program of physical exercise to yield health and fitness benefits similar to those obtained by persons without CP.

Cerebral Palsy

• Guidelines for Training clients with CP– Modifying equipment and exercises will allow the trainer to

be creative when working within the limitations of a client with CP

– A balanced approach of flexibility, muscle strength and endurance, and cardiorespiratory fitness is suggested

– Moderate to vigorous intensity (50-85% of VO2max or HRR, 30 minutes or more , four or more days per week should be the goal.

– Gradual progression is recommended. Begin with 5-10 minutes, twice per day, four or more days per week along with increasing physical activity in daily life

Cerebral Palsy

• Guidelines for Training clients with CP– 8-12 exercises, one to three sets of 8-12

repetitions, two to three days per week at 40-60% of maximum, although some exercises will need to be modified. No maximal loads

– Extreme caution and careful spotting should be used if using free weights with a CP client

– No valsalva maneuver, 48 hours of rest between working the same muscle groups

Cerebral Palsy

• Guidelines for Training clients with CP– Account for any muscular imbalances– Important for CP clients to warm-up for 10-15 minutes and

to stretch before exercise and to cool-down and stretch after exercise due significant joint ROM loss• Stretch all major muscle groups to the point of tension for 60 to

120 seconds each with special attention given to areas that ROM has been limited in

– Be aware of cognitive, visual, hearing, and speech difficulties

– Supervision is required at all times– Proper nutrition should be emphasized