Does Aerobic Exercise Benefit Persons with Tetraplegia ...

Does Aerobic Exercise Benefit Persons with Tetraplegia from

Spinal Cord Injury?

Stephen F. Figoni, PhD, RKT

Exercise Physiologist and Kinesiotherapist

Spinal Cord Injury/Disorders Center

VA Long Beach Healthcare System, Long Beach, CA

Objectives

1. Describe how levels/completeness of spinal cord injury (SCI) limit muscular, cardiovascular, pulmonary and autonomic function and aerobic/cardiovascular exercise capacity.

2. List five documented benefits of aerobic exercise for persons with tetraplegia from SCI.

3. Write an aerobic exercise prescription and document exercise training progress for a person with SCI tetraplegia.

• van den Berg-Emons et al. (2010): SCI population is 40% below “normal” physical activity compared to able-bodied population, directly measured by accelerometry (not questionnaire.

BACKGROUND: Physical Inactivity and SCI

• 26% of Americans with a disability are physically inactive, compared to 13% of those without disability. (https://www.dosomething.org)

Figoni & Chen (2015): • review of 178 SCI Veteran outpatients referred to

Kinesiotherapy for exercise • 59% tetraplegia/paresis. AIS A-D. 94% M. Md age 66.

SCI and CVD Risk

Condition Prevalence Dyslipidemia 72% Obesity (BMI >25 kg/m2) 67% Hypertension 62% (Pre)diabetes 46% Cardiovascular disease 28%

Groah et al. (2001): Tetraplegia (>25 yr post-SCI) associated with 16% ↑ CVD risk and 400% ↑ stroke risk vs. non-SCI ABs.

Co-morbidities Sooner… Later… • Physical inactivity, Deconditioning • ↓ % lean mass, ↑ % fat mass • Obesity (mean BMI >22-25 kg/m2) • Prediabetes • Dyslipidemia • Hypertension, Autonomic dysreflexia • Orthostatic/exercise hypotension • Anxiety/Depression • Urinary tract infection • Restrictive lung disease, Pneumonia • Osteopenia, Heterotopic bone • Spasticity, Joint contracture, Pressure ulcer • Deep venous thrombosis, Pulmonary

embolism • Chronic (musculoskeletal/neuropathic)

pain • Bladder/bowel incontinence

Metabolic syndrome: Diabetes, CVD, PAD, Stroke Chronic renal insufficiency Hemodialysis Respiratory failure Sepsis Pathological fractures Frequent hospitalizations

Downward Spiral SCI

Disability

↑ Inactivity

↑ Deconditioning

↑ Secondary conditions

↑ Morbidity & Mortality

↓ Quality of Life

↓ Functional Independence

Anatomy and

Physiology

7

C1-8

T1

Q: How can a person with 4 paralyzed limbs exercise? A: …depends on intact residual functions

9

C1-8

T1

Tetraplegia (literally, paralysis in 4 limbs)

complete impairment of motor, sensory and sympathetic autonomic function in arms, trunk, legs, and pelvic organs,...

resulting from injury/disease to cervical spinal cord segments (C1-8) or highest thoracic segment (T1)

--- 13.3% of all SCI

10

C1-8

T1

Tetraparesis (literally, muscle weakness in 4 limbs)

incomplete impairment of motor, sensory and sympathetic autonomic function in arms, trunk, legs, and pelvic organs,…resulting from injury/disease to cervical spinal cord segments (C1-8) or highest thoracic segment (T1) ---

45% of all SCI: 3x as many as tetraplegic!

Intact Residual Functions (depending on level/completeness of SCI)

1. Diaphragm (inspiration)

2. Some proximal upper-extremity innervation/ sensation from muscles, joints, and skin (myo/dermatomes)

3. Respiratory/thoracic muscle pump (↑ venous return)

4. Cranial nerve functions, including vagus

(baroreflex: ↑BP ↓HR, v.v.)

5. Intrinsic tone of arteries/veins (↑BP)

Intact Residual Functions (depending on level/completeness of SCI

6. Renin-angiotensin system: ↓BP or low Na+2

↑ renin by kidney & angiotensin in blood ↑ Na+2 retention in kidney ↑BP

7. Vagal withdrawal during exercise ↑HR

8. Frank-Starling mechanism: ↑ heart filling (LV EDV) ↑SV

9. Local metabolism in muscles

Myotomes and Dermatomes

Myotome: group of muscles innervated

by 1 spinal nerve root

Dermotome: area of skin innervated

by 1 spinal nerve root

Muscles Root Muscles Root

Neck flexors/extensors C1-61

Quadriceps L2-4

Diaphragm C3-5 Iliopsoas L3-4

Biceps brachii, Deltoids, Shoulder ext. rotators

C5-61 Hip adductors & abductors

L4-S1

Tibialis anterior L4-5 Triceps, Wrist extensors C6-81

Hamstrings, Toe extensors

L4-S1 Wrist flexors C6-T11

Finger extensors C7-81 Peroneals, Posterior tibial, Toe flexors

L5-S1 Finger flexors C7-T1

Thenar-Hypothenar, Interossei

C8-T1 Gastroc-soleus L5-S2

Gluteus maximus S1-2 Abdominals T6-L1 Rectal sphincter S3-4

Myotomes

Anterior Posterior

Dermatomes

Autonomic Nervous System

T1-4

T4-12 T1-S3

T5-9

Impairments

Neurological lesion level and completeness of SCI determine residual function and degree of impairment.

1. Sensorimotor Function: a. normal above lesion b. impaired at lesion (flaccid paralysis) c. impaired below lesion (spastic paralysis)

d. skeletal muscle pump

T11 C3

Impairments

2. Autonomic Dysfunction:

a. sympathetic autonomic decentralization and dysfunction (↓ control of CV system) b. occasional dysreflexia and bradycardia c. ↓ cardiac sympathetic stimulation (vagal dominance, ↓ peak HR & BP, orthostatic and exercise hypotension ) d. ↓ catecholamines from adrenal medullae (↓ myocardial contractility, ↓ shunting of blood to muscle and skin) e. ↓ sweating & thermoregulation

Impairments

2. Autonomic Dysfunction, continued:

f. ↓ venous distensibility & capacity, ↑ venous flow resistance

IMPAIRED VENOUS RETURN,

CARDIAC OUTPUT, AND O2 DELIVERY

20

Exercise Impairments

1. ↓ ability to perform large-muscle-group aerobic exercise voluntarily (without FES)

2. Spasticity decreases usefulness of some partially innervated muscles, e.g., legs (below level of SCI).

3. ↓ ability to stimulate/control CV system to support blood flow and metabolism

EVIDENCE OF

BENEFIT

Warburton DER, Krassioukov A, Sproule S, Eng JJ. Cardiovascular health and exercise following spinal cord injury. In: Eng JJ, Teasell RW, Miller WC, Wolfe DL, Townson AF, Hsieh JTC, Connolly SJ, Noonan VK, Loh E, McIntyre A, editors. Spinal Cord Injury Rehabilitation Evidence. Version 5.0. Vancouver, BC, Canada: 2014;1- 48.

https://www.scireproject.com/book/export/html/7

Systematic Reviews PEDro Scale: Physiotherapy Evidence Database Used in PT world to rate the strength of the experimental design of individual studies of treatment efficacy

Verhagen et al. (1998) http://www.pedro.org.au/english

http://www.pedro.org.au/english



PEDro Scale: Physiotherapy Evidence Database Yes 1

No 0

1 Eligibility criteria were specified.

2 Subjects were randomly allocated to groups. In crossover study, subjects were randomly allocated in order in which treatments were received.

3 Allocation was concealed.

4 Groups were similar at baseline re: most important prognostic indicators.

5 Blinding of all subjects

6 Blinding of all therapists who administered therapy

7 Blinding of all assessors who measured at least one key outcome

8 Measures of at least one key outcome were obtained from more than 85% of the subjects initially allocated to groups.

9 All subjects for whom outcome measures were available received the treatment or control condition as allocated or, where this was not the case, data for at least one key outcome were analysed by “intention to tx”.

10 Results of between-group statistical comparisons are reported for at least one key outcome.

11 Study provides both point measures and measures of variability for at least one key outcome.

TOTAL SCORE:

To Evaluate Strength of Experimental Design of Individual Studies:

Methods of Systematic Review: 5 Levels of Evidence

Level Research Design Description

1a Randomized Controlled Trial (RCT)

>1 higher RCT, PEDro score ≥ 6. Includes within-subjects comparison with random-ized conditions and cross-over designs

1b RCT 1 higher RCT, PEDro score ≥ 6

2

RCT Lower RCT, PEDro score < 6

Prospective controlled trial

Prospective controlled trial (not randomized)

Cohort Prospective longitudinal study using ≥2 similar groups with 1 exposed to a particular condition

3 Case control Retrospective study comparing conditions, including historical controls

Methods of Systematic Review: 5 Levels of Evidence

Level Research Design Description

4

Pre-post Prospective trial with baseline measure, intervention, and post-test using 1 group

Post-test Prospective post-test with ≥2 groups (intervention followed by posttest and no re-test or baseline measurement), 1 group

Case Series Retrospective study usually collecting variables from a chart review

5

Observational Study using cross-sectional analysis to interpret relations Expert opinion without explicit critical appraisal, or based on physiology, biomechanics or "first principles"

Clinical Consensus

Case Report Pre-post or case series involving 1 subject

Types of Health Outcomes (Benefits)

1. Fitness (power, VO2peak, strength) 2. Function (mobility, activity, etc.) 3. CVD risk factors 4. Morbidity/mortality 5. Psychology/mental health

Types of Aerobic Exercise

1. Voluntary arm/leg exercise 2. FES leg cycle ergometry 3. Hybrid voluntary arm + FES leg exercise

a. Exercise Testing (Peak Physiologic Responses)

and b. Exercise Training Adaptations

1. Voluntary Arm/Leg Exercise

• is highest flow rate of O2 uptake attained during “maximal-effort” exercise.

• is gold standard of aerobic/cardiorespiratory fitness.

• is measured as L/min (absolute rate), or mL/kg/min (relative to bodymass)

• depends on integrated ability of cardiovascular and pulmonary systems to deliver O2 and muscle metabolism to utilize/consume O2

• limited primarily by size of active muscle mass, peak cardiac output and blood flow in active muscles, hemoglobin in blood, and ability of cells to extract O2

. VO2peak

32

O2 and CO2 Transport Pathway

O2

CO2

Heart &

Blood

Airways & Lungs Muscle

33

Acknowledgement

My research was funded by the

Rehabilitation R&D Service,

U.S. Dept. of Veterans Affairs.

http://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwie8eXZx-rOAhVHyWMKHdJtAt0QjRwIBw&url=http://resumesempak.dvrlists.com/resume-photos.html&psig=AFQjCNFcMhp6aRMNv5-hG85Q2uZVRRP5Eg&ust=1472695308751736

Best Arm Exercise Testing Studies (Note variability.)

N Level AIS Trained/

Untrained

Male/ Female

Van Loan et al., 1987 13 C5-8 ? T, U M, F

Figoni, 1987 11 C6-7 A U M

Lasko-McCarthey et al., 1991

22 C5-8 A-C U M

Morrison et al., 1997 24 C6-8 A-B U M, F

Figoni et al., 1999 11 C5-8 A-D U M, F

Janssen et al., 2002 50 C4-8 --- T, U M

Simmons et al., 2014 60 C3-8 A-D U M, F

Total: 191

Summary of Peak Responses During Upright Arm Exercise from Previous 7 Studies

Male Female

N Mean N Mean Power (W) 191 25.5 6 16.7

VO2 (L/min) 191 0.77 8 0.68

VO2 (mL/kg/min) 191 10.5 8 9.37

METs (1 MET = 2.7 mL/kg/min) 191 3.9 8 3.5

Cardiac output (L/min) 34 5.96 --- ---

Stroke volume (mL/b) 34 51 --- ---

HR (bpm) 81 117 --- ---

BP (mmHg) 11 97/60 --- ---

Best Arm Exercise Training Studies (Note variability.)

N Level AIS Training

McLean et al., 1995 14 C5-T1 A-B Arm-crank,

3x/wk, 10 wk

Hjeltnes et al., 1998 10 C6-8 A-B Arm-crank + w/c,

3x/wk, 16 wk

Hicks et al., 2003 11 C4-8 A-D Arm-crank + PRE,

2x/wk, 37 wk

Valent et al., 2008 22 C5-8 A-D Handcycle,

2x/wk, 10 wk

Total: 57

Summary of Exercise Training Responses from Previous 4 Studies (N=11-54)

N Pre Post Δ Δ%

Power (W) 54 30 40 +10 +33

VO2 (L/min) 43 1.05 1.12 +0.07 +9

VO2 (mL/kg/min) 43 16.3 17.7 +1.4 +9

METs (1 MET = 2.7 mL/kg/min) 43 4.6 5.1 +0.5 +9

Cardiac output (L/min) 11 7.2 6.2 -1.0 -14

Stroke volume (mL/b) 11 74 73 -1 -1

HR (bpm) 21 110 119 +9 +8

No evidence that aerobic exercise training improves central cardiovascular functions (CO, SV, HR, SBP).

Quad Rugby (W/C Exercise) Training

Currie et al. (2016): • Design: 1 group, post (descriptive) N=8 tetraplegic male Paralympic quad rugby athletes (“trained”). Mean age 34. C5-7. AIS A-B.

• Results of resting echo cardiography: - normal diastolic function

- low CO, SV, HR, BP (systolic function) due to low volume-loading & pressure-loading (myocardial deconditioning)

Gorla et al. (2016): • Design: 1 group, pre/post N=13 tetraplegic men. Mean age 27. Levels? AIS A-C. • Training: Mean 8 mo W/C rugby training • Results: 13% ↓ fat mass

7% ↑ arm bone mineral content 11% ↑ arm fat-free (muscle) mass

Quad Rugby (W/C Exercise) Training

CVD Risk (Lipids)

Dallmeijer et al. (1997): • Design: Between-group comparison n=11 “active” (sport >6 mo) vs. n=13 “sedentary” tetra men. C5-8, AIS A-D. • Results: Active tetras: 16% ↑ HDL. NS Δ in other lipids (NS 46% ↓ triglycerides) Low N and statistical power.

2. FES LEG EXERCISE application of electrical currents through skin electrodes to induce muscle contractions by an external controller, thereby bypassing CNS, to…

activate sufficiently large muscle mass

elicit substantial acute physiological responses

induce aerobic training adaptations

result in health benefits

skin

Muscle Stimulation with Surface Electrode

nerve

muscle

Types of FES Exercise 1. FES leg cycle ergometry (FES-LCE)

2. “Hybrid exercise”:

= combined FES-LCE + voluntary arm exercise

a . FES-LCE + arm-cranking

b. FES + rowing

c. FES-assisted gait (treadmill)

FES-LCE

TAI, REGYS & ERGYS

REHAMOVE

RTC300 STIMMASTER

RECK MOTOMED

Compared to voluntary arm exercise, FES-LCE: • activates larger lower-body muscle mass, especially

for tetraplegics

• low peak power (9 W) due to low efficiency (recruits large fast-twitch motor units)

• elicits similar VO2 peak in paraplegia and higher VO2peak in tetraplegia (0.7 L/min)---similar to arm-cranking at 25 W or walking at 2 mph (2.5-3 METs)

• elicits higher peak cardiac output and stroke volume (higher cardiac volume-loading),

perhaps due to activation of peripheral venous muscle pump

FES-LCE

Hamzaid & Davis (2009): Earlier Systematic Review

Insufficient evidence to document health/fitness benefits of FES exercise for persons with

SCI (NOT SPECIFICALLY TETRAPLEGIA)

• Lack of consistency of approach (varying experimental designs, FES instrumentation;

frequency, intensity, & duration of training programs)

• Small group sample sizes (N=5-10, younger males)

• Lack of randomization and control

FES-LCE

5 years later....Warburton et al. (2014) identified: • 1 longitudinal study (Berry et al. 2012)

• 1 post study (Hakansson et al. 2012)

• 14 pre-post studies (Ragnarsson et al. 1988, Faghri et al. 1992, Hooker et al. 1992, Barstow et al. 1996, Hjeltnes et al. 1997, Mohr et al. 1997, Gerrits et al. 2001, Hopman et al. 2002, Crameri et al. 2004, Berry et al. 2008, Janssen & Pringle 2008, Zbogar et al. 2008, Griffin et al. 2009, Kahn et al. 2010)

…that examined the effects of FES-LCE training on cardiovascular fitness and/or health, and…

FES-LCE

• 1 prospective cohort study (Carty et al. 2012), and • 11 pre-post studies

(Jacobs et al. 1997, Nash et al. 1997, Solomonow et al. 1997, Wheeler et al. 2002, de Groot et al. 2005, Sabatier et al. 2006, Stoner et al. 2007, Berry et al. 2008, Jeon et al. 2010, Taylor et al. 2011, Ryan et al. 2013)

…that examined effects of other FES-assisted training programs on cardiovascular fitness and/or health in

persons with SCI (NOT SPECIFICALLY TETRAPLEGIA).

FES-LCE

Warburton et al. (2014):

Level 4 evidence from multiple pre-post studies that FES-LCE training:

1. increases peak power output and VO2 20-40%

2. improves cardiac function during rest and exercise.

3. decreases vascular resistance and increases muscle blood flow at rest and during exercise

4. decreases platelet aggregation and blood coagulation.

5. Overall, improves musculoskeletal fitness, oxidative potential of muscle, exercise tolerance, and cardiovascular fitness when performed at least 3 days/week for 2 months.

FES-LCE

Hamzaid & Davis (2009) systematic review:

1 RCT and 2 pre-post controlled studies on muscle morphology/histochemistry:

Baldi et al. (1998): • 3 mo. training prevented gluteal muscle atrophy vs. control. • 6 mo. training induced hypertrophy of gluteal lean body mass vs. control.

Skold et al. (2002), & Demchak et al. (2005): • FES-LCE training increased leg muscle volume & cross-sectional

area vs. control

• FES-LCE training promotes peripheral muscle health and fitness. • Unknown role in metabolic health or preventing pressure ulcers

FES-LCE

Nash et al. (1991): • Design: Pre/post, no controls N=8 tetraplegic men, C5-6, AIS A • Training: 1 mo FES knee extension PRE + 6 mo FES-LCE • Results: 35% ↑ LV mass 18-20% ↑ septal wall thickness • Conclusion: LV volume- and pressure-loading during

FES exercise “reversal” of LV atrophy

LV

FES-LCE

Nash et al. (1996): • Design: n=10 FES-LCE trained vs. n=10 sedentary

tetraplegic men. C5-7. AIS A-B. Mean age 27. • Training: 0.4 – 7.0 yr • Measurements: supine resting Doppler blood flow

responses to common femoral artery (CFA) occlusion test

• Results: 15% ↑ peak systolic velocity (faster flow) 30% ↑ CFA x-sectional area (wider artery) 51% ↑ CFA inflow volume

FES-LCE

Sadowsky et al (2013): • Design: retrospective/x-sectional, non-random (bias?)

n=25 SCI (13 tetra) training group vs. n=20 SCI “standard of care” controls (15 tetra). C5-7. AIS A-C. Mean age 36. 84% M. • Training: FES-LCE. 45-60 min, 3x/wk, mean 29 wk (3-

168 mo, mean 29 mo) + other undefined activities (“activity-based restorative therapy,” ABRT), a major confounder. Usually includes strength/endurance training, standing, BWSTT, FES, etc.

FES-LCE

Sadowsky et al (2013): continued • Results: 17% ↑ ASIA sensory & motor scores 23% ↑ ASIA motor scores 36% ↑ quadriceps mass, 44% ↓ fat mass 30/35% ↑ quad/ham strength ↓ quadriceps spasticity and baclofen use ↑ FIM transfer, bowel, & bladder scores SF-36: ↑ physical functioning and ↓ role limitations due to physical problems ↓ total cholesterol, LDL, triglycerides ↑ BUN and creatinine (renal function) Unknown if changes are due to FES-LCE or other activities

FES-LCE

Dolbow et al. (2013): • Design: 1 group, pre/post, no controls. N=11 SCI vets

(9 tetra, 82%). C4-7. AIS A-C. Mean age 40 yr. • Training: home-based FES-LCE. Restorative Therapies

RT300. 40-60 min x 3x/wk x 8 wk. • Results: WHOQOL-BREF questionnaire

• 12% ↑ physical QOL (physical health, work capacity, comfort) • 9% ↑ environmental QOL (physical safety, freedom, comfort in home) • No significant changes in psychosocial items

FES-LCE

= concurrent FES leg + voluntary arm exercise

a . FES-LCE + arm-cranking b. FES + rowing c. FES-assisted gait

Objective: increase active muscle mass to enable greater cute metabolic and cardiovascular responses, training adaptations, and health benefits

3. HYBRID EXERCISE

Types of Hybrid Exercise a. FES-LCE + arm-cranking

Types of Hybrid Exercise b. FES leg + rowing

Types of Hybrid Exercise c. FES-assisted gait

Warburton et al. (2014) identified:

• 7 pre-post studies (Krauss et al. 1993, Figoni et al. 1996, Gurney et al. 1998, Thijssen et al. 2005, Thijssen et al. 2006, de Carvalho et al. 2006, Brurok et al. 2011)

…that examined effects of hybrid (FES-LCE + arm) training on cardiovascular fitness in persons with SCI, not specifically tetraplegia.

Hybrid Exercise

Figoni et al., 1996 (Tetra Only)

•Design: 1 group, pre/post •N=14 tetraplegic SCI (10 M, 2 F) Mean age 35. Mean 6 yr post-SCI. Levels C5-T1. AIS A-B. •Training: upright hybrid arm + FES leg cycle ergometry, 3x/wk x 15 wk, 83% adherence

Figoni et al., 1996 (continued)

Results: ● ↑ peak power, VO2, METs, and a-vO2 by 18% ● No Δ peak CO, SV, HR, SBP (central CV function)

Power W

VO2 mL/kg/min

a-vO2 (vol.%)

METs CO

L/min

SV mL/b

SBP mmHg

HR bpm

Pre 40 17.1 17.6 6.3 7.26 56 83 131

Post 47 20.2 20.8 7.5 7.24 54 84 134

Δ +7 3.1 3.2 1.2 -0.02 -2 +1 3

%Δ +18 +18 +18 +18 <-1 -4 +1 +2

Warburton et al. (2014): strength of evidence

1. Level 4 evidence that hybrid exercise increases peak power output and O2 uptake in SCI.

2. Level 4 evidence that FES-LCE training may be effective in improving exercise cardiac function in SCI.

3. Level 2 evidence (de Carvalho et al. 2006) that FES gait training increases peak metabolic and cardiorespiratory responses in persons with tetraplegia.

Hybrid Exercise

Warburton et al. (2014) conclusion:

• Interventions that involve FES training at least 3 days/week for 2 months may improve muscular endurance, oxidative metabolism, exercise tolerance, and cardiovascular fitness in SCI.

Hybrid Exercise

Metabolic and Cardiovascular Risk Factors

in SCI


• Level 1b evidence from 1 RCT (de Groot et al. 2003)

and 5 Level 4 studies (Chilibeck et al. 1999, Mohr et al. 2001,

Jeon et al. 2002, Griffin et al. 2009, Jeon et al. 2010)

that both arm-cranking, FES-LCE, and FES-rowing training improve glucose homeostasis:

(↓ insulin sensitivity, ↓ insulin resistance, and/or improved glucose tolerance).

• Level 4 evidence from multiple pre-post studies that improvements in glucose homeostasis are clinically significant for prevention and/or treatment of DM-II.

Glucose Homeostasis in SCI


• A minimum of 30 min. moderate intensity training on 3 days/ week is required to achieve and/or maintain the benefits from exercise training.

Glucose Homeostasis in SCI

Cardiovascular Disease Risk Factor Mngt in SCI 1. Cardiovascular Fitness:

Parameter Level 4 Evidence (References) Increased peak exercise tolerance

Pollack et al. 1989, Hooker et al. 1992, Barstow et al. 1996, Mohr et al. 1997, Wheeler et al. 2002, Thijssen et al. 2005

Increased VO2peak Pollack et al. 1989, Hooker et al. 1992, Barstow et al. 1996, Hjeltnes et al. 1997, Mohr et al. 1997, Wheeler et al. 2002, Thijssen et al. 2005

Increased peak cardiac output Hooker et al. 1992

Reduced submax exercise HR Faghri et al. 1992

Increased peak stroke volume Faghri et al. 1992

Decreased peak total peripheral vascular resistance

Faghri et al. 1992

Increased peak power output Faghri et al. 1992, Hooker et al. 1992, Thijssen et al. 2005

Increased peak oxidative metabolic cellular adaptations

Andersen et al. 1996, Mohr et al. 1997, Crameri et al. 2002, Crameri et al. 2004

Risk factor Level 4 Evidence (References) Decreased LDL cholesterol

Solomonow et al. 1997 Decreased total cholesterol

Cardiovascular Disease Risk Factor Mngt in SCI 2. Lipid Profile:

• Optimal training program for changes in lipid lipoprotein profile remains to be determined.

• Aerobic exercise intensity of 70% of HRreserve on most days of week appears to be good general recommendation for improving lipid lipoprotein profile.

• Preliminary Level 4 data also indicate that FES training (3 hr/wk for 14 weeks) may improve lipid lipoprotein profiles.

• No evidence of effects of FES/hybrid exercise on hypertension or obesity.

GENERAL PHYSICAL ACTIVITY GUIDELINES

FOR SCI

(NOT SPECIFICALLY FOR TETRAPLEGIA)

Physical Activity Guidelines for SCI (SCI Action Canada, 2011)

For important (evidence-based) fitness benefits, adults with SCI should engage in: • At least 20 minutes of moderate-to-vigorous

intensity aerobic activity 2x/wk, AND

• Strength training exercises 2x/wk: 3 sets x 8-10 reps each exercise for each major muscle group.

Physical Activity Guidelines for SCI http://sciactioncanada.ca/guidelines/

Aerobic Activity Strength Training Activity

Frequency 2x/wk 2x/wk

Volume Gradually aerobic activity to ≥20 min/session

8-10 reps/exercise. Work up to 3 sets x 8-10 reps/exercise

Intensity moderate (somewhat hard) to vigorous (hard)

8-10-RM on last set. Rest 1-2 min. between sets.

Type UEs: wheeling, arm cycling, sports LEs: BWSTT, cycling, FES-LCE Whole Body: recumbent stepper, arm+leg cycling, rowing, water exercise, hybrid exercise

Free weights (barbells, dumbbells, cuff weights) Elastic resistance bands/tubing Cable pulleys Weight machines Electrical stimulation

Individually tailored prescription to improve physical performance, functional fitness and health

Exercise Prescription (ExRx)

ExRx Individualized ExRx is based on: • Medical history • Current medical/functional status • Medications • Current level of fitness • Activity history • Age • Motivation • Goals • Availability/accessibility of equipment

and facilities

ExRx

“FIT Principles” (ACSM’s Guidelines…, 2014):

1. Frequency: how often (x/week) 2. Intensity: how hard (HR, PO, RPE) 3. Time: duration or how long (min./bout or session) 4. Type: mode of exercise 5. Volume: amount (min./session or week) 6. Progression: advancement, ↑ in FIT above

ExRx “FIT Principles” continued:

• Precautions: limits for specific signs/symptoms e.g., limits to HR, BP, HR x SBP, O2sat%, symptoms (dysrhythmia, chest pain, dyspnea, dizziness, nausea, pallor, anxiety, pain), falls, infectious disease

• Monitoring: close observation, recording and reporting of s/s above o Intended and side-effects of exercise and

meds during rest, exercise and recovery

1. Frequency: How often? “How many days/wk are you available?”

•Beginners: 2x/wk, nonconsecutive days (establish exercise tolerance, ↑ as tolerated) • Intermediate/Advanced: 3-6x/wk (full recovery between workouts, avoid overtraining)

2. Intensity: How hard? Absolute or relative?

Absolute: • VO2 (L/min, mL/kg/min, METs) • Power output (W) • Heart rate (bpm) Relative: • % peak VO2, PO, HR, or RPE

• % VO2, PO, HR, or RPE reserve

Intensity

Issues: • Minimal effective training intensity

• Karvonen Formula: % HR reserve

• % Peak Power Output

• Rating of Perceived Exertion (RPE)

Minimal Effective Training Intensity (METI) for Non-SCI

Swain & Franklin (2002): METI to ↑ VO2max for “lower fit” people is 30% VO2reserve.

Batacan et al. (2015): Light-intensity physical activity (20-39% VO2peak) is ineffective for improving CVD risk factors in physically inactive adults with medical conditions (non-SCI).

We do not know METI for improving health/fitness in tetraplegia with very small active muscle mass.

ACSM Recommendation #1:

HR ex – HR rest

HR peak – HR rest

• 40-60% HR reserve: beginners/cardiac rehab • 70-90% HR reserve: athletes

Problems: need HRM/ECG telemetry, max GXT, and linear HR-VO2 relationship

Intensity for General Non-SCI Population

x 100 % HR reserve =

40

60

80

100

120

140

0.0 0.2 0.4 0.6 0.8 1.0 1.2

HR

(b

pm

)

VO2 (L/min)

HR-VO2 Relationship in Tetraplegia (N=50) (Figoni et al., 2014a)

Use % HR reserve only if HR-VO2 relationship is linear and stable.

Sometimes imperfect, depending on CV stability (dysreflexia, hypotension, etc.)

Test and retest HR vs. VO2 or PO relationship

Stabilize medications, vascular support (binder, support hose), (de)hydration, bowel/bladder program, infection, posture (upright vs. reclined), environmental temp.

Alternative #1: % Peak Power Output

• Begin: 40-60% ?

• Intermed./Adv.: 70-90% ?

Problem: need ergometer, max GXT to start, and repeat max GXTs to progress

Intensity for General Non-SCI

Alternative #2: ACSM Recommendation #2:

Subjective Rating of Perceive Exertion (RPE):

• RPE = 3-6 on 0-10 scale • RPE = 12-16 on 6-20 scale

RPE is default if lack of equipment.

Intensity for General Non-SCI

Borg RPE Scales

0 Nothing at all

(just noticeable) 1 2 Weak (light) 3 Moderate 4 5 Strong (heavy) 6 7 Very strong 8 9 10 Extremely strong

(almost maximal) • Maximal

6 7 Very very light 8 9 Very light 10 11 Fairly light 12 13 Somewhat hard 14 15 Hard 16 17 Very hard 18 19 Very very hard 20

3. Time: duration or how long?

• Depends on exercise tolerance/ symptoms and muscular endurance: o 1-10 min/bout o 10-40 min/session

• Multiple bouts if limited by muscular fatigue

4. Type: mode of exercise

Voluntary arm/leg exercise wheeling, wheelchair sports, arm-cranking, handcycling, rowing, recumbent stepping (e.g., NuStep), arm+leg cycling (e.g., SciFit), SkiErg, aquatics, BWSTT

FES exercise FES-LCE

Hybrid exercise arm-cranking + FES-LCE, rowing + FES-LCE, BWSTT with FES

4. Type: mode of exercise

• For aerobic/CV fitness, select mode that activates largest muscle mass possible, e.g., arm+leg or hybrid.

• With sympathetic impairment, beware of hypotension and use recumbent posture if possible.

5. Volume: amount (min/session or week)

• e.g., weekly volume in min/wk = min/bout

x bouts/session x sessions/wk • monthly, annually…

6. Progression: advancement, ↑ in FIT above

• ↑ training volume (frequency, intensity, time)

• ↓ rest periods • Advanced/specialized: periodization • Physical activity goals:

1. ≥150 min/wk (avg 21 min/day) moderate (3-6 MET) physical activity

2. increasing to ≥300 min/wk moderate-to-vigorous (43 min/day)

New ExRx for SCI

Figoni SF. In: ACSM's Guidelines for Exercise Testing and Prescription. 10th ed., in press.

1. Aerobic Exercise

Frequency ≥2 sessions/wk

Intensity Beginners: 40-60% HR reserve Intermediate/Advanced: 70-90% HR reserve

Time Initially bouts of 5-10 min moderate intensity alternated with 5-min active recovery periods

Type Maximize active muscle mass: voluntary arm+leg ergometry, hybrid exercise (combined FES-LCE + voluntary arm-cranking, rowing, BWSTT), recumbent stepping (NuStep), arm+leg cycling (SciFit), arm-cranking, wheelchair ergometry/rollers), wheeling, handcycling, sports (tennis, basketball, rugby)

New ExRx for SCI (Figoni, in press)

1. Aerobic Exercise, continued

Progression As exercise tolerance ↑, ↑ frequency to 3-5x/wk, ↑ exercise bout duration to 20-40 min, and ↓/eliminate rest periods. Athletes can progress to 75–90% HR reserve for 60+ min, 3-5x/wk.

Goals • aerobic/cardiorespiratory fitness • prevention of deconditioning • wellness (weight management, glucose homeostasis, lower cardiovascular risk) • fitness for functional independence (wheelchair mobility, transfers, activities of daily living) • performance (success in adaptive sports and recreational activities)

Write Aerobic ExRx (Case Study)

Introduction: 53 yo male, C7 SCI tetraplegia, AIS A x 5 yr, independent in manual wheelchair.

Subjective: c/o arm muscle fatigue during ADLs. “Overweight, out of shape”. Goals: “Do ADLs without exhaustion. Lose weight.”

Objective: 5’10”, 190 lb., BMI = 27.3 (>25 kg/m2) & waist circumference = 40 in. (>37 in.) Obesity. HbA1c = 6.2% Prediabetes. Sedentary. No formal exercise, only ADLs.

1. Does person perform planned structured physical activity ≥30 min/day, at moderate intensity, ≥3 days/wk, ≥3 mo? No (“inactive”)

2. Is person asymptomatic? Yes (see next)

3. Does person have known CV, metabolic, or renal disease? Yes (obesity, prediabetes) • After medical clearance (exam, GXT), light-to-

moderate exercise is recommended, and gradually progress as tolerated according to ACSM guidelines.

Preparticipation Screening

Rule Out Major Signs/Symptoms • Angina at chest, neck, jaw, arms • Dyspnea on exertion • Dizziness or syncope • Orthopnea or paroxysmal nocturnal dyspnea • Ankle edema • Palpitations or tachycardia • Intermittent claudication • Known heart murmur • Unusual fatigue or dyspnea with usual activities

Write Aerobic ExRx

Frequency Beginner: 2x/wk

Intensity ?

Time Type Volume Progression

Intensity: % HR reserve

• No HR peak prediction equations for SCI tetra • Need GXT, using exercise mode of choice:

1. Measure HR rest 2. Measure HR peak 3. Calculate Target HR Range for

safe & effective moderate-intensity aerobic training (beginners)

= 40-60% of HR reserve

Example Data from GXT:

HR rest = 60 bpm HR peak = 120 bpm HR reserve = HR peak – HR rest = 120 - 60 = 60 bpm Target HR Range = 40-60% HR reserve 40% HR reserve = (0.40 x 60) + 60 = 84 bpm

60% HR reserve = (0.60 x 60) + 60 = 96 bpm Target HR Range = 84-96 bpm

Intensity: % HR reserve

Example Data From GXT without HR:

PO peak = 30 W 40% PO peak = 0.4 x 30 = 12 W 60% PO peak = 0.6 x 30 = 18 W 40-60% PO peak = 12–18 W

Intensity: Power Output Peak

0 Nothing at all

(just noticeable) 1 2 Weak (light) 3 Moderate 4 5 Strong (heavy) 6 7 Very strong 8 9 10 Extremely strong

(almost maximal) • Maximal

Intensity: RPE

6 7 very very light 8 9 very light 10 11 fairly light 12 13 somewhat hard 14 15 hard 16 17 very hard 18 19 very very hard 20

Beginner Aerobic ExRx Frequency 2-3x/wk

Intensity 40-60% HR reserve = 84-96 bpm Time 5-10-min bouts, alternated with 5 min active recovery

Type Hybrid exercise, FES-LCE, Arm-crank or Wheelchair

Volume/wk = Frequency x Intensity x Time = Wk 1: 2x/wk x 85 bpm x 20 min/x = 3400 bmin/wk

Progression Wk 2: 2x/wk x 88 bpm x 25 min/x = 4400 bmin/wk

Wk 3: 3x/wk x 91 bpm x 30 min/x = 8190 bmin/wk



Document Training Progress Using HR reserve

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Intensity 40-60% Power Output = 12–18 W Time 5-10-min bouts, alternated with 5 min active recovery


Volume/wk = Frequency x Intensity x Time: Wk 1: 2x/wk x 12 W x 20 min/x = 480 Wmin/wk

Progression Wk 2: 2x/wk x 14 W x 25 min/x = 700 Wmin/wk

Wk 3: 3x/wk x 16 W x 30 min/x = 1440 Wmin/wk



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Document Training Progress Using Power Output (W)


Intensity RPE = “light-to-moderate” = 2-4 on 0-10 scale, or 10-13 on 6-20 scale

Time 5-10-min bouts, alternated with 5 min active recovery


Volume/wk = Frequency x Intensity x Time: Wk 1: 2x/wk x 2 x 20 min/x = 80 min/wk

Progression Wk 2: 2x/wk x 3 x 25 min/x = 150 min/wk

Wk 3: 3x/wk x 3 x 30 min/x = 270 min/wk



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Document Training Progress Using 0-10 RPE scale

To Optimize Exercise Tolerance

Prevent orthostatic and exercise hypotension 1. supine/recumbent posture, elevate legs 2. hydration 3. compression (abdominal binder, support stockings) 4. cool environment (spray) 5. midodrine? 6. Monitor BP during breaks.

Q: Does aerobic exercise benefit persons with SCI tetraplegia? A: Probably….but less for C5-6 or if <3 METs, and more for C7-T1 if >3 METs ● very little strong research evidence on tetras, especially women & elders ● small sample sizes ● mixed levels & completeness of SCI ● varied training interventions (modes, training durations) ● mostly physiological outcomes ● few health/functional/psychosocial outcomes

Difficulties of Clinical or Research Exercise Training

• Relatively few healthy participants available (need for multi-site cooperative studies)

• Need large samples for multi-group studies

• SCI tetraplegia/paresis population is physically/ functionally heterogeneous.

• Susceptibility to secondary health conditions (interrupting training), difficult to comply with strict research protocols

• Exercise intolerance

• Few accessible exercise facilities in community

Thank you!

Q & A

• Anderson TJ. Nitric oxide, atherosclerosis and the clinical relevance of endothelial dysfunction. Heart Fail Rev. 2003;8:71-86.

• Berry HR et al. Cardiorespiratory and power adaptations to stimulated cycle training in paraplegia. Med Sci Sports Exerc. 2008; 40:1573-80.

• Baldi JC et al. Muscle atrophy is prevented in patients with acute spinal cord injury using functional electrical stimulation. Spinal Cord. 1998;36:463-9.

• Barstow TJ et al. Changes in gas exchange kinetics with training in patients with spinal cord injury. Med Sci Sports Exerc. 1996;28:1221-8.

• Batacan RB Jr et al. Effects of light intensity activity on CVD risk factors: a systematic review of intervention studies. Biomed Res Int. 2015:596367. doi: 10.1155/2015/596367.

• Borg G. Borg's Perceived Exertion and Pain Scales. Champaign: Human Kinetics, 1998. • Brurok B et al. Effect of aerobic high-intensity hybrid training on stroke volume and

peak oxygen consumption in men with spinal cord injury. Am J Phys Med Rehabil. 2011;90:407-14.

• Chilibeck PD et al. Functional electrical stimulation exercise increases GLUT-1 and GLUT-4 in paralyzed skeletal muscle. Metabolism. 1999;48:1409-13.

• Collins EG et al. Energy cost of physical activities in persons with spinal cord injury. Med Sci Sports Exerc. 2010;42:691-700.

• Crameri RM et al. Effects of electrical stimulation-induced leg training on skeletal muscle adaptability in spinal cord injury. Scand J Med Sci Sports. 2002;12:316-22.

• Crameri RM et al. Effect of load during electrical stimulation training in spinal cord injury. Muscle Nerve. 2004;29:104-11.

References

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References • Mohr T et al. Long-term adaptation to electrically induced cycle training in severe

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References

Appendix: Exercise METs (Collins et al. 2010)

Physical Activity/Exercise METs

Complete C5-8 Complete T1-8 Complete T9-L4 arm-cranking 16 W 2.6 2.8 3.0 arm-cranking 32 W 3.5 3.6 3.7 arm-cranking 48 W 4.4 4.1 4.4 arm-cranking 64 W 4.0 4.8 5.0 arm-cranking 80 W 5.0 5.3 6.1 arm-cranking 96 W 6.0 6.3 7.6 wheelchair basketball 6.0 7.7 8.0 shooting baskets 3.0 3.9 4.4 wheeling on tile 2.3 2.8 2.7 wheeling on carpet 3.0 3.1 3.0 wheeling outside 2.8 3.0 4.2 wheeling on grass 4.0 5.0 5.5 weight training 2.2 3.0 3.4 handcycling 5 mph 4.0 5.0 5.8 handcycling 10 mph 8.0 9.0 9.7 handcycling all-out 7.0 15.0 16.2 vacuuming 3.0 3.3 4.1 Yellow: 3-6 METs Pink: >6 METs

Physical Activity/Exercise METs

Incomplete C5-8 Incomplete T1-8 Incomplete T9-L4 arm-cranking 16 W 2.9 2.9 --- arm-cranking 32 W 3.4 3.4 3.8 arm-cranking 48 W 4.2 4.2 4.6 arm-cranking 64 W 4.9 5.0 5.7 arm-cranking 80 W 5.0 --- 6.5 wheelchair basketball 5.0 6.0 6.6 wheeling on tile 2.8 2.3 3.3 wheeling on carpet 2.8 4.3 3.4 wheeling outside 3.6 4.2 4.2 wheeling on grass 4.4 5.0 6.2 weight training 3.0 3.0 3.0 handcycling 5 mph 4.0 5.0 5.8 handcycling 10 mph --- --- 9.7 handcycling all-out --- --- 16.2 vacuuming 2.4 2.8 2.7

Yellow: Moderate, 3-6 METs Pink: Vigorous, >6 METs

Appendix: Exercise METs (Collins et al. 2010)

Does Aerobic Exercise Benefit Persons with Tetraplegia ...

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