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RRDS Physical Fitness : A Guide for Individuals with Spinal Cord Injury

Kristjan T. Ragnarsson, MDDr. Lucy G. Moses ProfessorChairman, Department of Rehabilitation MedicineMt. Sinai School of Medicine, New York, NY

KRISTJAN T . RAGNARSSON, MD is the Dr . Lucy G . Moses Professor and Chairman of theDepartment of Rehabilitation Medicine of Mount Sinai School of Medicine, New York, NY.Dr. Ragnarsson joined the faculty of Mount Sinai in 1986, after 15 years at the RuskInstitute of Rehabilitation Medicine, New York University Medical Center, where he hadbeen the Project Director of the New York Spinal Cord Injury Regional System . Dr.Ragnarsson has earned an international reputation for this expertise in the rehabilitationof individuals with disorders of the central nervous system, particularly those with spinalcord injury (SCI) . He has published more than 60 articles and book chapters and madenumerous presentations in this field, locally, nationally, and internationally . He has servedon several site visit teams to funded research programs for the National Institutes ofHealth (NIH) and the Department of Veterans Affairs . He has been a principal investigatorand co-investigator on grants from NIH, the National Institute on Disability andRehabilitation Research (NIDRR), and private foundations. He was the Project Director ofthe New York TBI Model System of Care from 1987 to 1992, and is now the ProjectDirector of the Mount Sinai SCI Model System of Care . Dr. Ragnarsson has served on theBoard of numerous organizations and is currently President of the American Spinal InjuryAssociation . He has served on peer review panels for federal, state, and privateorganizations and is a member of the Spinal Cord Injury panel of the Department ofVeterans Affairs, Rehabilitation Research and Development Service Scientific MeritReview Board .

Health Maintenance And Reduction Of Disability Through Physical Exercise

by Kristjan T. 8xrnur,xon ' 8&V

The impact of regular physical activity onhealth and longevity has been debated by bothphysicians and lay persons for centuries . Theancient Greeks promoted in their culture thephilosophical concept of "a sound mind in asound body" and Hippocrates (460–377 BC),

their best known physician and father of themedical profession, indeed noted that "all partsof the body which have a function, if used inmoderation and exercised in labors in whicheach is accustomed become thereby healthy,well developed, and age more slowly, but ifunused and left idle, they become liable todisease, defective in growth and age quickly ."In contemporary terms, this view has beenexpressed as "use it or lose it." The pursuit ofphysical and mental health through physicalexercise and sports, even in times of peace,became an important part of the life of theancient Greeks . Competitive athletic eventsflourished, and of these the best known todaywould be their Olympic Games . Unfortunately,public interest in physical fitness throughexercise declined during the days of the RomanEmpire and throughout the Middle Ages,except in the military as a means to surviveand conquer in times of warfare. During thosemany centuries, health and longevity seemedto be affected more by infectious disease,natural disasters, and armed conflicts ratherthan by medical conditions related todeconditioning, aging, and sedentary lifestyle.

During the 20th century, there has been agrowing public consensus that physicalexercise is important for good health.Numerous sports facilities have been built,athletic leagues and events have beenorganized, and in the United States, thePresident's Council on Physical Fitness andSports was established . In the early part of thecentury, physical exercise and sports wereconsidered to be more for the young than for

the middle-aged or older persons, or to berecreational activities to watch or play ratherthan as a means to achieve fitness and betterhealth . During the second half of the century, itgradually became clear to the medicalprofession that there are numerous negativeaffects associated with sedentary lifestyle:prolonged bed rest during disease, andimmobilization following injury (1) . Muscleswere found to atrophy and weaken,cardiovascular function deteriorated withreduced aerobic capacity, bones lost density,endocrine function was altered, and so on . As aresult of these observations, physicians havemodified their practices and, in general, theirpatients no longer must endure long periods ofbed rest while recuperating from an illness orinjury, but are encouraged to becomephysically active as early as possible throughexercise programs of increasing intensity.

During the last quarter of a century, it hasbecome increasingly clear that physical activityand fitness are inversely associated withmorbidity and mortality from several chronicdiseases (2) . Large population studies haveshown a strong and consistent inverserelationship between physical fitness andmortality in men and women unrelated to ageand other risk factors (2) . Consequently, sportsand physical fitness are no longer consideredbeneficial just for the young and forprofessional athletes, but for middle-aged andolder individuals as well . Since scientific datademonstrating the health benefits of exerciseare relatively new and scant, the medicalprofession has been relatively slow to respondto these scientific observations and itvigorously advocates physical exercise as animportant means toward preventing illness andrestoring health . However, as individuals,physicians are generally known to pursueregular exercise for themselves in high

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RRDS Physical Fitness : A Guide for Individuals with Spinal Cord Injury

numbers while regrettably often failing torecommend this intervention for their patients.The curricula for most medical schools still

place little emphasis on teaching studentsabout the preventive and therapeutic effects ofexercise or about the principles of exerciseprescription . During the current time ofrevolutionary changes in the delivery ofhealthcare, it is interesting to note that somemanaged healthcare companies haverecognized the beneficial effects of physicalexercise and have offered discounts at physicalfitness centers and at sporting good stores totheir subscribing members . It may be

speculated that in a capitated reimbursementsystem, where the deliverers of healthcareservices carry the financial risk, healthpromotion and illness prevention programs will

play an increasingly larger role . It is thus likelythat achieving and maintaining physioul fitnessfor all constituents of such health care deliverysystems will be a major gool of their illnessand injury prevention programs.

Sports and Fitness Training for Personswith Physical Disability

As sports became a greater part of theculture in Western Societies, interest grewamong persons with physical disabilities to

actively participate in such activities . In 1944,Sir Ludwig Guttmann, MD, the founder of theNational Spinal Injuries Center at StokeMandeville Hospital in England, first introducedsporting activities as an essential part of thernodicol treatment of persons with spinal cord

injury (3) . He found these activities to haveimmense therapeutic value in restoring thedisabled person's strength, coordination, andendurance and in achieving psychologicaladjustment to the disability . His patientsparticipated in a variety of sports, includingwheelchair polo, basketball, archery, bowling,fencing, racing, field events, and weight lifting.

People with other phyairal disabilities soonfollowed suit, not only in England but in manyother countries, and organized their own sports

programs and events . Under Sir Ludwig's

leadership, the Stoke Mandeville Games for theParalyzed were first held in 1348 and grew tobe an international onnual event, which, every

fourth year, has followed the Olympic Games,in the same country if possible, andconsequently the Stoke Mandeville Gameswere renamed the Paralynnpic Games (i .e., theyrun parallel to the Olympic Games).

In the United States, the medicalprofession has paid relatively little attention to

sports as ath*repeudo intervention in diseaseand physical disability . Sports medicinefocuses more on treating the injured athletethan on the therapeutic benefits of sports.Athletes with disability have largely organizedtheir own sports programs and events andhave had special athletic gear designed andmanufactured with little support of physiciansor rehabilitation professionals . Third-partyreimbursement for athletic activities bydisabled persons has been nonexistent duringboth inpatient and outpatient rehabilitation ; as

a result, a relatively small proportion of thedisabled population has had the opportunity toparticipate regularly in sports . However,healthcare providers and third-party payershave gradually accepted the value oftherapeutic exercise supervised or delivered byprofessional physical therapists duringrehabilitation after disabling injuries anddisease. While regular aerobic exercise andfitness have been shown in numerous scientificstudies to have preventive value for differentmedical conditions, as noted above, includingcardiovascular disease (2,4–6), hypertension(7-9), non-insulin dependent diabetes mellitus

(10), colon cancer (11), osteopenia (12), obesity,and mental health problems (13), such exerciseis still not considered a reimbursable medical

expense.People with spinal cord injury (SCI) and

other forms of severe physical disability are

limited in their ability to participate in physicalexercise, both because of their physicallimitations and because of environmentalbarriers, such as, lack of transportation,appropriate athletic facilities, and the need forspecial equipment . Consequently, theircardiovascular fitness may be severelydiminished and a series of degenerativephysiological changes predictably occur thatnegatively affect the person 's health sooner or

later . According to data from the Spinal Cord

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Guest Editorials : Ragnarsson

Injury Model Systems Uniform Data Base, heartdisease now accounts for 18 .7 percent of alldeaths following spinal cord injury, rankingsecond only to respiratory conditions as thecause of death (14) . It is possible that suchheart disease and other cardiovascular causesof death following SCI may be related toimmobility . It has also been shown thatindividuals with paraplegia have a highincidence of myocardial ischemia upon cardiacstress testing with thallium 201 imaging studies

(15) . Numerous other studies have indicatedthe presence of other risk factors forcardiovascular disease in persons with SCI : riskfactors frequently related to inactivity, such as,high lipoprotein ohn/estorol concentrations (16),reduced lean body mass (17), and abnormalglucose tolerance test (18,19).

Despite such observations, health careproviders generally still do not include aerobicexercise programs in the rehabilitation or long-term follow-up of persons with SCI.Professionals in the field of rehabilitationmedicine have traditionally emphasized severalspecific forms of physical exercise for theirpatients with SCI during the rehabilitationprocess that follows the onset of the disability.Such exercises include muscle strengtheningand range of motion exercises, as well asfunctional training for self-sufficiency andmobility, but, in general, aerobic exercises,which increase endurance and have certainhealth benefits in people without disability, donot have a large role . Following rehabilitation,which usually is completed during the first yearafter injury, continued physical exercise forfitness is not emphasized . Unfortunately, mostindividuals with SCI are completely wheelchair-bound and sedentary and do not pursue anyform of regular fitness training . Relatively few,and mostly persons with paraplegia, participatein wheelchair sports and upper body training.Ordinary manual wheelchair propulsion andperformance of the activities of daily living, ingeneral, are insufficient to maintain physicalfitness, since it has been shown that activitycount and circulatory strain for persons withSCI are low compared to normal controls(20,21) . It may, therefore, be concluded thatadditional aerobic exercise—several times each

week—is needed if persons with SCI are toreach and maintain the !evel of physical fitnessthat is desirable for their health and function.

Since most people with SCI have paralysisof the largest muscles of the body (i .e ., thoseof the buttocks and lower limbs), it has beenspeculated that exercise of the non-paralyzedmuscles in the upper limbs may not be enoughto achieve a state of fitness . Aerobic exercisesthat involve the use of the upper limbs not onlymay be less effective in enhancing fitness andhealth than exercises of the lower limbs, butmay even have some drawbacks for personswith SC! . Exercise with the upper limbs clearlyinvolves smaller muscle mass and elicitssmaller phySio!o0inal response than lower limbexercise and consequently may be lesseffective in producing cardiopulmonary fitness.Additionally, persons with high-level tetraplegiamay not be physically capable of participatingin wheelchair sports or fitness training, whichrequires the use of the upper limbs . Aerobicexercise of the upper limbs may, therefore, notbe the final answer to the exercise needs ofpersons with SCI . As a result, it has beensuggested that active exercise of theirparalyzed muscles through computerizedfunctional electrical stimulation ergometry mayalso be helpful to improve the level of fitnessfor persons with SCI . Severel studies haveshown that such form of exercise may increasethe mass and strength of the stimulatedmuscles and have a modest beneficial effect oncardiovascular performance and some of therisk factors for cardiovascular disease (22).While such form of physical exercise does notreplace upper limb exercises for persons withparaplegia, it may prove to be a valuablealternative for those persons with SCI who, forsome reason, are unable to exercise using theirupper limbs.

CONCLUSION

Scientific evidence shows that physical andmental fitness may be improved throughexercise, and, by this means, health andlongevity may be improved . Clinicians,

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RRDS Physical Fitness : A Guide for Individuals with Spinal Cord injury

An archer prepares his recurve bow for practice .

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Guest Editorials : Ragnarsson

therefore, should actively advocate some formof physical exercise and pursuit of fitness forall their patients . Life-long physical exercisemay be of particular importance for personswith SCI who, by nature of their disability, areprofoundly sedentary and develop prematurelydifferent medical conditions that are oftenassociated with lack of exercise and aging.

REFERENCES

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2. Blair SN, Kohl HW, Paffenbarger RS, Clark DG,Cooper KH, Gibbons LW . Physical fitness andall-cause mortality : a perspective study ofhealthy men and women . JAMA 1989 :269 :239-401.

3. Guttmann L. Spinal cord injuries,comprehensive management and research,chapt 36, 2nd ed . Sport . Oxford : BlackwellScientific Publications, 1976:617-28.

4. Paffenbarger RS, Hyde RT, Wing AL, Hsieh CC.Physical activity all-cause mortality, andlongevity of college alumni . New Engl J Med1986:314 :605-13.

5. Sandvik L, Erikssen J, Thaulow E, Erikssen G,Mundal R, Rodahl K. Physical fitness as apredictor of mortality among healthy middle-aged Norwegian men . New Engl J Med1993:328:533-7.

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7. Dunbar CC . The anti-hypertensive effects ofexercise training . J Med 1992 :92:250-5.

8. Kelemen MH, Effron MB, Valenti SA, Stewart KJ.Exercise training combined with anti-hypertensive drug therapy: effects on lipids,blood pressure and left ventricular mass . JAMA1990:263 :2766-71.

9. Somers VK, Conway J, Johnston J, Sleight P.Effects of endurance on baroreflex sensitivityand blood pressure in borderline hypertension.Lancet 1991 :337:1363-7.

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prospective study of exercise and incidence ofdiabetes among US male physicians . JAMA1992 :268:63-7.

11. Vena JE, Graham S, Zielezny M, Swanson MK,Barnes RE, Nolan J . Lifetime occupationalexercise in colon cancer. Am J Epidemiol1985 :122 :357-65.

12. Lane NE, Bloch DA, Jones HH, Marshall WH,Wood PD, Fries JF. Long distance running, bonedensity and osteoarthritis . JAMA 1986:255:1147—51

13. Harris SS, Caspersen CJ, DeFriese GH, Estes EH.Physical activity counseling for healthy adults asa primary preventive intervention in the clinicalsetting : report for the US preventive servicestask force . JAMA 1989 :261 :3590-8.

14. DeVivo MJ, Stover SL. Long-term survival andcauses of death . In : Stover SL, DeLisa JA,Whiteneck GG, eds . Spinal cord injury : clinicaloutcomes from the model systems.Gaithersburg, MD: Aspen Publishers, 1995.

15. Bauman WA, Raza M, Spungen AM, Machac J.Cardiac stress test testing with thallium 201imaging reveal silent ischemia in individualswith paraplegia . Arch Phys Med Rehabil1994:75 :946-50.

16. Brenes G, Dearwater S, Shapera R, LaPorte RE,Collins E . High density lipoprotein cholesterolconcentrations in physically active andsedentary spinal cord injured patients. ArchPhys Med Rehabil 1986 :67:445-50.

17. Nuhlicek DNR, Spurr GO, Barboriak JJ, et al.Body composition of patients with spinal cordinjury. Euro J Clin Nutrition 1988 :42:765-73.

18. Duckworth WC, Jallepalli P, Solomon SS.Glucose tolerance in spinal cord injury . ArchPhys Med Rehabil 1983 :64:107—10.

19. Bauman WA, Spungen AM . Disorders ofcarbohydrate and lipid metabolism in veteranswith paraplegia or quadriplegia : a model ofpremature aging metabolism 1994 :43:749—56.

20. Dearwater S, LaPorte RE, Cauley JA, Brenes G.Assessment of physical activity in inactivepopulations . Med Sci Sports Exerc 1979 :17:67.

21. Hjeltnes N, Vokac Z. Circulatory strain in everyday of paraplegics. Scand J Rehabil Med1979 :11 :67.

22. Pollack SF, Axen K, Spielholz N, Levin N, HaasF, Ragnarsson KT. Aerobic training effects ofelectrically induced lower extremity exercises inspinal cord injured people . Arch Phys MedRehabil 1989 :70:214-9 .