Exercise and sports science Australia (ESSA) position statement on exercise and spinal cord injury

Abstract

Traumatic spinal cord injury (SCI) may result in tetraplegia (motor and/or sensory nervous system impairment of the arms, trunk and legs) or paraplegia (motor and/or sensory impairment of the trunk and/or legs only). The adverse effects of SCI on health, fitness and functioning are frequently compounded by profoundly sedentary behaviour. People with paraplegia (PP) and tetraplegia (TP) have reduced exercise capacity due to paralysis/paresis and reduced exercising stroke volume. TP often further reduces exercise capacity due to lower maximum heart-rate and respiratory function. There is strong, consistent evidence that exercise can improve cardiorespiratory fitness and muscular strength in people with SCI. There is emerging evidence for a range of other exercise benefits, including reduced risk of cardio-metabolic disease, depression and shoulder pain, as well as improved respiratory function, quality-of-life and functional independence. Exercise recommendations for people with SCI are: ≥30min of moderate aerobic exercise on ≥5d/week or ≥20min of vigorous aerobic ≥3d/week; strength training on ≥2d/week, including scapula stabilisers and posterior shoulder girdle; and ≥2d/week flexibility training, including shoulder internal and external rotators. These recommendations may be aspirational for profoundly inactive clients and stratification into "beginning", "intermediate" and "advanced" will assist application of the recommendations in clinical practice. Flexibility exercise is recommended to preserve upper limb function but may not prevent contracture. For people with TP, Rating of Perceived Exertion may provide a more valid indication of exercise intensity than heart rate. The safety and effectiveness of exercise interventions can be enhanced by initial screening for autonomic dysreflexia, orthostatic hypotension, exercise-induced hypotension, thermoregulatory dysfunction, pressure sores, spasticity and pain.

Results of the first interim analysis of the RAPPER II trial in patients with spinal cord injury: ambulation and functional exercise programs in the REX powered walking aid

“…In people with SCI physical activity and exercise has been shown to offer both physical and psychological benefits [9, 11]. There is good evidence to support its positive effects on cardiorespiratory fitness and muscle strength, with emerging evidence of its effect on mood, spasticity, bladder and bowel function [12]. International experts in SCI rehabilitation including the American College of Sports Medicine and the American Physical Therapy Association recommend that people with SCI undertake regular cardiovascular, endurance and strength training [9, 12–14].…”

“…There is good evidence to support its positive effects on cardiorespiratory fitness and muscle strength, with emerging evidence of its effect on mood, spasticity, bladder and bowel function [12]. International experts in SCI rehabilitation including the American College of Sports Medicine and the American Physical Therapy Association recommend that people with SCI undertake regular cardiovascular, endurance and strength training [9, 12–14]. However, identifying suitable methods, and overcoming barriers to engaging in exercise and physical activity represents a significant challenge in this population [13, 15].…”

The effects of 10,000 voluntary contractions over 8 weeks on the strength of very weak muscles in people with spinal cord injury: a randomised controlled trial

“…Progressive resistance training requires muscles to contract five to ten times against a maximal load and to the point of fatigue [14,15]. This is typically done a couple of times per training session, with training repeated 2-3 times per week [16][17][18]. While progressive resistance training appears to be effective for stronger muscles (i.e., those muscles able to actively move through full range of motion (ROM) against gravity), our work suggests that it may not be effective for weaker muscles where strength is directly affected by SCI (i.e., muscles unable to actively move through full ROM against gravity) [11,19].…”

Response to correspondence from the ESSA Statement authors

“…People living with SCI, SCI organizations, physiatrists, physiotherapists, and other stakeholders participated in the ISSEG guideline development process. Their voices were loud and clear: they do not have confidence in the World Health Organization's (WHO) [2] and ESSA's 150 min per week guideline [3] because it is neither based on SCI-specific evidence nor feasible. Stakeholders want SCIspecific guidelines [1].…”

“…The ISSEG were developed through a rigorous, systematic, and transparent process (i.e., AGREE [4]) that fully adheres to internationally accepted standards for formulating clinical practice and physical activity (PA) guidelines for the general population (e.g.,WHO) [2]. The ESSA statement was not formulated using AGREE and its authors acknowledge their "exercise recommendations…are somewhat arbitrary" (p. 112) [3].…”