Spinal Cord Injury Exercise & STOMPS

Question 1

What is the impact of chronic sitting on individuals with complete spinal cord injury

Question 2

Define heart rate

Answer 2

• The faster the heart beats the more blood can be pumped over a particular period of time

Question 3

Define contractility

Answer 3

• Impaired contractility will reduce cardiac output however too much effort will result in fatigue sometimes leading to a complete collapse with the need to slow down substantially or even stop

Question 4

Define afterload

Answer 4

• The force against which the ventricles must act in oder to eject blood and is largely dependent on the arterial blood pressure and vascular tone

Question 5

Define preload

Answer 5

• Intrinsic property of myocardial cells is that the force of their contraction depends on the length to which they are stretched; the greater the stretch the greater the force of contraction
• Preload largely depends on the amount of ventricular filling

Question 6

Describe the relationship between tetraplegia SCI and cardiac function

Answer 6

• Chronic reduction of cardiac preload and myocardial volume, coupled with chronic hypotension leads to left ventricle atrophy (limited ability to mount a cardiac output response needed for blood pressure regulation)

Question 7

Describe the relationship between paraplegia SCI and cardiac function

Answer 7

• Normal BP, left ventricular mass, & resting cardiac output
• Elevated resting HR and depressed resting stroke volume
• Lowered stroke volume is attributed to decreased venous return from the immobile LEs accompanying loads or diminished efficiency of venous pumps or to frank venous insufficiency of the paralyzed limbs

Question 8

Peripheral vascular changes associated with SCI

Answer 8

• Blood volume & velocity of LE arterial circulation are significantly lowered after SCI
• The lowering of volume & velocity contribute to heightened thrombosis susceptibility: most often reported in those with acute & subacute SCI

Question 9

A sedentary lifestyle either imposed on, or adopted by, persons with SCI has ranked them at the lowest end of the human fitness spectrum and leads to

Answer 9

• Accelerated cardiovascular disease
• Insulin resistance
• Osteopenia
• Visceral obesity
• Immune system dysfunction
• Accelerated aging
• Pain of musculoskeletal & neuropathic origins

Question 10

Continuum of physical therapy for individuals with neurological conditions

Answer 10

• Acute care
• Inpatient rehab
• Outpatient therapy/home health PT
• Community fitness & wellness

Question 11

Exercise guidelines for SCI

Answer 11

• Cardiorespiratory & strength: 20 min of mod-vigorous intensity 2x/wk + 3 sets 2x/wk
• Cardiometabolic health: 30 min of mod-vigorous intensity 3x/wk

Question 12

Several major risk factors commonly reported in persons with SCI have been linked with their accelerated course of CVD; these include

Answer 12

• Atherogenic dyslipidemia
• Hyperinsulinemia
• Visceral obesity

Question 13

Relationship between cardiovascular disease and SCI

Answer 13

• Most frequent cause of death in those surviving more than 30 yrs after injury & those more than 60 y/o
• May have delayed diagnosis of CVD due to symptoms being masked by interruption of sensory pain fibers that normally convey warnings of cardiac ischemia & impeding cardiac damage

Question 14

Progressively higher levels of injury causes what exercise limitations

Answer 14

• Greater loss of muscle mass in those muscles that serve as prime movers and stabilizers of the trunk.
• Requires that the arms simultaneously generate propulsive forces and steady the trunk during exercise.
• Altered regulation of cardiovascular and metabolic responses to exercise

Question 15

Relationship between SCI and body composition

Answer 15

• Unique lipid profile characterized by depressed high-density lipoprotein cholesterol
• Demo greater propensity to accumulate excess body fat compared with non disabled populations
• Large additions to weekly total energy expenditure through structured exercise are required to induce meaningful reductions in body fat: essentially requires 448 min/wk of mod intensity arm crank exercise

Question 16

The lack of stimulation and disuse because of paralysis can have a profound effect on skeletal muscle below the level of injury, including

Answer 16

• Atrophy of lean mass which diminishes the tissue available for glucose disposal
• Accumulation of intramuscular fat

Question 17

Arm-crank (60-65% VO2peak, 180min/wk) in persons with chronic paraplegia improves _________ but not ____________________ sensitivity

Answer 17

• Hepatic and whole-body insulin

Question 18

Probable causes for fractures in SCI

Answer 18

• > 50% of sublesional bone is lost within the first 6 months after injury
• Sublesional bone remains permanently rarefied 7 susceptible to fracture with even trivial injury

Question 19

Risk factors for LE fragility fracture after SCI

Answer 19

• Age at Injury < 16 years
• Alcohol Intake > 5 servings/day
• Body Mass Index < 19
• Duration of SCI ≥ 10 years
• Woman
• Motor Complete (AIS A-B)
• Paraplegia
• Family history of fracture in men
• Anticonvulsant use (i.e., Tegretol, Depakote - Gabapentin – Neurontin)
• Spasticity Medication
• Opioid analgesia use (≥28 mg morphine for 3 months)
• Prior fragility fracture**
• SSRI
• PPI
• Knee region BMD below the fracture threshold

Question 20

Probable cause of thermal dysregulation in SCI

Answer 20

• Loss of vasomotor & sudomotor responses below the level of injury, altered blood flow redistribution during exercise
• Absence of sweating reflex below level of injury

Question 21

Probable cause of autonomic dysreflexia in SCI

Answer 21

• Loss of central autonomic control results in reflex adrenergic responses to noxious stimuli

Question 22

Probable causes of pressor decompensation during & after exercise in SCI

Answer 22

• Loss of sympathetic reflex responses to exercise or post exercise pooling of blood in the LEs

Question 23

What exercise has no benefit in increasing function of the UEs or for improving wheelchair propulsion

Answer 23

• Arm cranking

Question 24

What should you work on to improve wheelchair performance

Answer 24

• Increase the strength of the posterior shoulder muscles & upper back and to use wheelchair ergometry

Question 25

What is the most common location of UE pain after SCI

Answer 25

• Shoulder joint which is most commonly attributed to chronic impingement syndromes & rotator cuff tears

Question 26

What is STOMPS (strengthening and optimal movements for painful shoulders)

Answer 26

• Stretch the anterior/posterior joint capsule & surrounding musculature and the upper traps
• Endurance: shoulder elevation in scapular plane and scapular retraction for 3 sets of 15 reps
• Hypertrophy: shoulder adduction and shoulder external rotation for 3 sets of 8 reps

Question 27

STOMPS modification of transfers and raises

Answer 27

• Adjust height of transfer surfaces to make the 2 surfaces level whenever possible.
• Adjust height of transfer surfaces to lower the target surface whenever possible.
• Avoid extremes of motions or positions of the arms during transfers.
• Turn hand outward whenever possible when transferring.
• Lean trunk forward during the transfer.
• Lead with the arm experiencing shoulder pain whenever possible.
• Bring transfer surfaces as close together as possible.
• Use a sliding board for painful transfers whenever possible.
• Avoid depression raises. Use an alternate technique such as forward or side-to-side lean.
• Do keep arm/hands on the transfer surfaces rather than placing hand/arm above shoulder height or gripping overhead handles during transfers.
• Use graded height surfaces to transfer from the ground to a higher surface such as a step stool or your cushion

Question 28

Transfer techniques and forces at shoulder

Answer 28

• Head Hips with Arm Extended
• Head Hips with Arm Close
• Trunk Upright with Arm Extended

Question 29

Head hips relationship during transfers

Answer 29

• Reduces superiorly directed forces across shoulder, elbow, & wrist
• Forward flexed trunk position is ideal for engaging sternal pectorals major & latissimus doors muscles
• This may help transfer the body weight b/w the leading arm and the trailing arm with less loading of the glenohumeral joint

Question 30

STOMPS modification of wheelchair propulsion

Answer 30

• Use long, smooth strokes rather than short, frequent strokes when propelling your wheelchair.
• Allow your hand to naturally drift downward when finishing the push stroke in order to avoid a rapid change in direction of the arm.
• Avoid a rapid, forceful impact on the pushrim.
• Push off the tires to obtain better shock absorption rather than the pushrim.
• Avoid rough or uneven terrain.
• Stop and rest if you have to push over uneven terrain for a long distance.
• Avoid steep inclines whenever possible.
• If you lose your momentum when propelling up an uphill grade, stop and turn chair to the side to rest your arms before continuing.
• If your arms become tired when pushing for a long distance, stop and rest.

Question 31

What did STOMPS not significantly increase

Answer 31

• Activity participation

Question 32

Examples of circuit resistacne training for SCI

Answer 32

• Warm up -> military press -> horizontal rows -> pectoralis -> preacher curls -> wide grip latissimus pull down -> seated dips
• Push -> Pull -> Arm Crank -> Repeat

Question 33

Benefits of circuit resistance training in SCI

Answer 33

• Increased their upper extremity oxygen consumption by 29%,with accompanying upper extremity strength gains of 13% to 40%
• Lowered total and low-density lipoprotein cholesterol while increasing their high-density lipoprotein cholesterol by nearly 10%
• Significant gains in endurance, strength, and anaerobic power
• Decreased shoulder pain
• Can be replicated with theraband

Question 34

Strength training general guidelines for SCI

Answer 34

• Individuals without active movement in the legs may have impaired circulation. A proper warm-up & cool-down consisting of 5 min of light activity is important to optimize circulation & maintain a normal BP.
• Complete 8-10 reps for each exercise 3x for a total of 3 sets.
• Rest for 60-90 sec between each set.
• All exercises should be performed 2-3 days/wk on nonconsecutive days.
• Breathing is important during exercise. Individuals should be aware of breathing continuously while pushing or pulling during any resistance exercise.

Question 35

Anaerobic training exercise prescription for SCI

Answer 35

• Intensity – generally, 50% to 80% of 1RPM.
• Duration – 2-3 sets of 10 reps.
• Frequency – 2 times per week.
• Mode – weight stations, free weights, T-bands

Question 36

Aerobic training exercise prescription for SCI

Answer 36

• Intensity –Generally, 40% to 80% of heart rate reserve (HRR)
• Higher percentages will yield better training results but increases should be gradual. If a stress test was not performed, the Target HR is 20 – 30 beats above resting.
• Duration – 30 minutes of continuous aerobic exercise.
• Frequency – either 2 or 3 times per week.
• Mode—arm ergometer, wheelchair ergometer, wheelchair treadmill, free wheeling, seated aerobics, swimming, electrical stimulation leg cycle ergometry, circuit resistance training (CRT).

Question 37

Safety considerations for strength training in SCI

Answer 37

• Ensure that your wheelchair is positioned in a safe and stable place and locked while performing each exercise.
• Begin all exercises slowly to ensure stability and sufficient resistance provided by the band.
• Make sure the resistance band is securely fastened to its location, and never release a band while under tension. This can cause the band to snap back toward the user and may result in injury.
• Inspect bands and handles before every use. Check for cuts, nicks, scratches, cracks, punctures, discoloration, or anything that may indicate weakness in the band. If any flaws are discovered, discard the band immediately. Do not attempt to repair a damaged band.
• Never stretch a resistance band over 2.5 times its length.
• Exercise should be stopped immediately if the following signs or symptoms are present: light-headedness, dizziness, extreme shortness of breath, persistent chest pain, nausea, or severe headache.
• Individuals with SCI often have reduced or absent sensation. Skin must be monitored frequently to ensure that no skin damage occurs while exercising.
• The normal physiological response to exercise may be impaired after SCI. Take longer rest breaks between exercises if needed