Physical Activity Promotion for People with Spinal Cord Injury

Introduction[edit | edit source]

It is crucial for people with spinal cord injury (SCI) to be physically active to maintain health and avoid co-morbidities. However, after hospital discharge, individuals with spinal cord injury are relatively inactive, with up to 50% being completely sedentary.[1] The role of rehabilitation as a community re-integration strategy is to enable the individual to achieve "the highest possible level of participation" and to return to a "life they want as far as their disability will allow".[1][2] 

Promoting Physical Activity[edit | edit source]

Physical activity promotion is an important part of the education that forms SCI rehabilitation. Unfortunately, persons with SCI perceive many barriers to physical activity including time, energy, motivation, lack of knowledge about what to do and where to exercise.[1] A study conducted on 73 individuals with SCI from Quebec, Canada has shown that as much as 43% of participants reported 0 minutes of activities. Another study looked at the physical activity of 277 people with SCI and found that 48% of them did not participate in any form of physical activity.[3]

One empirical study investigated physiotherapists’ beliefs about physical activity for people with SCI and the physiotherapists' actions with regards to physical activity promotion during rehabilitation and in the community. The authors found that physiotherapists value the importance of physical activity for people with SCI, but that physical activity promotion is mostly absent within the UK and Ireland SCI rehabilitation settings. Its promotion was found to be inconsistent, and the following reasons were given:[1]

  1. Inadequate training regarding physical activity and SCI
  2. Uncertainty about the role of the physiotherapist within the multidisciplinary team to promote physical activity
  3. Lack of resources within rehabilitation settings and the community
  4. A physiotherapist's beliefs cannot change the behaviour of individuals, like their motivation to exercise
  5. Physiotherapists should also reflect on their own opinions and biases towards what constitutes a good life and well-being to avoid reflecting their beliefs onto the patient[1]

Community Integration Post-Hospital Discharge[edit | edit source]

In the rehabilitation of individuals with spinal cord injury, hope plays a significant role in the way people adjust to their lives and participate in the activities that bring them closer to achieving their goals. However, if health or environmental difficulties continue to affect persons with SCI, their ability to self-motivate and to seek activities can be seriously challenged.[4] This is why access to health services and community support is so important in assisting with meeting physical activity guidelines recommended for people with SCI.[3]

Preparation for Discharge to Home and Community[edit | edit source]

The patient's perspective of readiness for hospital discharge after spinal cord injury consists of four attributes: personal status, coping ability, knowledge and expectation for support. Secondary health conditions and coping ability are personal barriers restricting full community integration for people with SCI. Social and environmental barriers can lead to isolation and delay in other forms of community reintegration, such as work and leisure activities.[7]

Health and Personal Barriers to Community Integration[edit | edit source]

Spinal cord injury can directly or indirectly lead to the development of secondary health conditions, often requiring medical intervention and rehospitalisation. Urinary tract infections and pressure ulcers are among the health problems necessitating admission to the hospital. Others include respiratory system and gastrointestinal complications.[8] Strong health barriers to community reintegration include the following: pain, neurogenic bladder, spasticity, contracture and sleep problems. In addition, inappropriate or a lack of equipment and equipment failure can reduce community participation for individuals with SCI.[9]

Persons with spinal cord injury often report feelings of isolation and loneliness post-hospital discharge. This can contrast significantly with the friendship they experience from fellow patients during the hospital stay.

Social and Environmental Barriers to Community Integration[edit | edit source]

Lack of psychological support and peoples' reactions to spinal cord injury hugely affect their adjustment to new life.[10] Environmental and social factors are considered to be critical for participation in physical activity among individuals with spinal cord injury,[11] including:

  • Societal attitudes accepting and integrating individuals with spinal cord injury
  • Government policies offering opportunities to return to education or employment
  • Disability-friendly public transportation
  • Facilities with easy access for wheelchair users
  • Access to public spaces, including parks, beaches, streets and roads[9]
  • Adaptations for persons with limited mobility provided by assistive technologies
  • Accessible housing facilities that decrease dependency on caregivers[12]
  • Financial independence[9]

"Rehabilitation practitioners should not only consider how the community supports people with SCI but also consider how rehabilitation programmes change the community".[11]

Group Activity[edit | edit source]

The focus of physical activity is to offer a wide range of activities.[1] If sport is the main focus, it might encourage the athletically inclined, but it discourages the individual who does not desire to do sport or is physically or financially unable to participate. It can also discourage the individual who dislikes sport, but who is interested in other activities like resistance or aerobic training.

Group activity for individuals with spinal cord injury can be run in the form of a strengthening programme, aerobic training or circuit training.


Risk Factors[edit | edit source]

The following are risk factors that one must consider when instructing on or participating in physical activity. Along with this knowledge, learning how to manage these risk factors is necessary to ensure the safety of all in attendance.

Thermoregulation[edit | edit source]

A higher level of spinal cord injury (i.e. T6 and above) will more likely lead to problems with body temperature regulation. It can occur after the spinal cord injury and lasts a lifetime.

The autonomic nervous system controls thermoregulation where the descending pathway of the sympathetic system is responsible for maintaining body homeostasis in response to the changes in the environment. Both functions are affected by the spinal cord injury.[14]

When temperature dysregulation occurs, the following symptoms are experienced by persons with a spinal cord injury:

  • Sweating above the level of injury with minimal to no sweating below the level of injury
  • Hyperthermia as a result of exercising
  • Fever with no infection
  • High or low body temperature in response to the environment temperature

Skin Problems[edit | edit source]

Skin breakdowns can appear as a consequence of faulty postures and positions while performing physical activities. These injuries are very serious and can lead to secondary complications.

Pressure sores or decubitus ulcers occur when pressure is applied over a bony prominence for a period of time. They can also occur due to shear forces exerted on the skin during certain movements like turning, twisting, or scooting.

Skin problems are preventable when the following actions are taken:[15]

  • Reduction of the number of hours sitting
  • Maintaining proper posture while exercising
  • Using appropriate equipment, which includes ensuring that the equipment is a suitable weight and height
  • Having a properly adjusted wheelchair with proper cushion, back and armrests

Autonomic Dysreflexia[edit | edit source]

Autonomic dysreflexia (AD) is characterised by paroxysmal hypertension in response to a non-specific stimulus below the level of the lesion. The triggering stimulus for autonomic dysreflexia can be:

  • Somatic pain
  • Faecal impaction
  • Abdominal distention

AD can be present in the acute and chronic stage of the spinal cord injury and it can produce debilitating symptoms, including:

  • Pounding headache
  • Anxiety
  • Blurred vision
  • Sweating

In more serious situations it can cause cerebral haemorrhage, pulmonary oedema, or seizures.[16]

Orthostatic Hypotension[edit | edit source]

"Orthostatic hypotension (OH) is typically accepted as a decrease in systolic blood pressure of 20mmHg or more, or a reduction in diastolic blood pressure of 10mmHg or more, upon changing body position from a supine position to an upright posture, regardless of the presence of symptoms".[17] The symptoms can be present for years after a spinal cord injury and they can get worse with time.

The typical presentation of OH includes :[18]

  • Dizziness,
  • Lightheadedness
  • Syncopal events

Overuse Injuries[edit | edit source]

Individuals with a spinal cord injury often complain of shoulder pain as a result of overuse injury. When neglected it can last many years and lead to more serious problems. The cause of the pain is typically multifactorial, but it is most likely due to:

Impingement syndrome is consistent with compression or pinching of the rotator cuff muscle tendon that can cause micro-tears in the tendon. If the problem continues, further damage to the tendons can occur, which can cause pain and an inability to use the shoulder.

Treatment options depend on the cause of the problem and the level of damage within the shoulder structures. The proposed interventions are:[19]

  • Rest
  • Equipment modification
  • Environment modification
  • Postural and movement modification
  • Therapeutic exercises
  • Tendon injection
  • Tendon surgical repair[19]

Watch this video for detailed information on the complications mentioned above:


Activity Type[edit | edit source]

Circuit training programme[edit | edit source]

"Circuit training consists of a consecutive series of timed exercises performed one after the other with varying amounts of rest between each exercise".[21]


Yoga class[edit | edit source]

Yoga is a form of exercise. It includes two basic components, posture and breathing, and consists of flexibility exercises, strengthening exercises and breathing exercises.


Strengthening programme[edit | edit source]

The focus of strengthening exercises is to increase the strength of targeted muscles or groups of muscles. It affects muscle power, endurance and muscle mass.[24]


Aerobic activities[edit | edit source]

Aerobic or endurance exercises are the basis for cardiovascular conditioning. During aerobic exercises, the heart rate and breathing should increase in response to performed activities. Examples include arm cycling, elliptical training, swimming, and dancing.

Teams[edit | edit source]

Physiotherapists[edit | edit source]

Physiotherapists demonstrating supportive attitudes are important motivators for individuals with spinal cord injury to engage in physical activity. Such an attitude gives them a feeling of autonomy, hope and encouragement. Engaging physiotherapists with disabilities to conduct physical activity classes can positively engage participants and change the stereotype that people with disabilities are always patients.[26]

Training of the trainers (ToT)[edit | edit source]

When specialised personnel resources are limited, the use of trained volunteers can be very cost-effective. In addition, a study by Lim et al.[27] shows that interventions provided by volunteers are likely to be more sustainable, break down communication barriers, and provide positive role modelling. It is also important that volunteer-led physical activity programmes are safe, and that there are no reports of serious adverse events.[27]

The training of the trainer model (ToT) can be utilised for group activity programmes as it has the potential to develop local educators and enhance the sustainability of the programmes.[28] The goal of a ToT intervention is to train volunteers or physical activity group participants to become instructors who can carry on the task of leading the activity, responding to questions and reinforcing the learning.[29] The trainers can be successful only when enough time and detailed instructions are provided during training. In the CDC guidelines[29] for the Training of the Trainers Model, the following elements are considered when designing a training schedule:

  • Pre-assessment of the skills and interests of the potential trainers
  • Development of the learning manual
  • The choice of topics to be delivered
  • Skills practice and feedback
  • Action plan and follow-up support[29]

The eligibility criteria for the trainers include:

  • Being engaged and flexible
  • Having an interest or advanced skills in training
  • Completing the entire training programme

Additional Resources[edit | edit source]

  1. YouTube.Adaptive Yoga Class for People with Spinal Cord Injuries, 2021
  2. YouTube.Shepherd Center Workout Routine for People with Spinal Cord Injury, 2015

References[edit | edit source]

  1. 1.0 1.1 1.2 1.3 1.4 1.5 Williams TL, Smith B, Papathomas A. Physical activity promotion for people with spinal cord injury: physiotherapists’ beliefs and actions. Disability and rehabilitation. 2018 Jan 2;40(1):52-61.
  2. Nunnerley JL, Hay-Smith EJ, Dean SG. Leaving a spinal unit and returning to the wider community: an interpretative phenomenological analysis. Disability and Rehabilitation. 2013 Jul 1;35(14):1164-73.
  3. 3.0 3.1 Rocchi M, Routhier F, Latimer-Cheung A et al. Are adults with spinal cord injury meeting the spinal cord injury-specific physical activity guidelines? A look at a sample from a Canadian province. Spinal Cord 2017; 55: 454–459.
  4. Dorsett P, Geraghty T, Sinnott A et al. Hope, coping and psychosocial adjustment after spinal cord injury. Spinal Cord Ser Cases 3, 2017;17046
  5. W Cape biokineticist throws a lifeline to spinal cord injury patients. Available from:[last accessed 21/11/2021]
  6. Mandela Monday: Adapted Physical Activity Community Groups. Available from: [last accessed 22/11/2021]
  7. Nunnerley JL, Hay-Smith EJ, Dean SG. Leaving a spinal unit and returning to the wider community: an interpretative phenomenological analysis. Disabil Rehabil. 2013 Jul;35(14):1164-73.
  8. Du Plessis M, McGaffin CR, Molepo T, Oelofse R, Van Zyl S, Mashola MK. Perceived readiness for hospital discharge: Patients with spinal cord injury versus physiotherapists. S Afr J Physiother. 2018;74(1):437.
  9. 9.0 9.1 9.2 Kashif M, Jones S, Darain H, Iram H, Raqib A, Butt AA. Factors influencing the community integration of patients following traumatic spinal cord injury: a systematic review. J Pak Med Assoc. 2019 Sep;69(9):1337-1343.
  10. Dickson A, Ward R, O'Brien G, Allan D, O'Carroll R. Difficulties adjusting to post-discharge life following a spinal cord injury: an interpretative phenomenological analysis. Psychol Health Med. 2011 Aug;16(4):463-74.
  11. 11.0 11.1 Chang FH, Liu CH, Hung HP. An in-depth understanding of the impact of the environment on participation among people with spinal cord injury. Disabil Rehabil. 2018 Sep;40(18):2192-2199.
  12. Ahmed N, Quadir MM, Rahman MA, Alamgir H. Community integration and life satisfaction among individuals with spinal cord injury living in the community after receiving institutional care in Bangladesh. Disabil Rehabil. 2018 May;40(9):1033-1040.
  13. Exercise and Spinal Cord injury. 2011 Available from:[last accessed 22/11/2021]
  14. Grossmann F, Flueck JL, Perret C, Meeusen R, Roelands B. The Thermoregulatory and Thermal Responses of Individuals With a Spinal Cord Injury During Exercise, Acclimation and by Using Cooling Strategies-A Systematic Review. Front Physiol. 2021 Apr 1;12:636997.
  15. Hsieh J, Benton B, Titus L, Gabison S, McIntyre A, Wolfe D, Teasell R. Skin integrity and pressure injuries following spinal cord injury. Spinal cord injury rehabilitation evidence. Vancouver, BC: Spinal Cord Injury Research Evidence (SCIRE) Professional Project. 2020:1-23.
  16. Rabchevsky AG, Kitzman PH. Latest approaches for the treatment of spasticity and autonomic dysreflexia in chronic spinal cord injury. Neurotherapeutics. 2011 Apr;8(2):274-82.
  17. Consensus statement on the definition of orthostatic hypotension, pure autonomic failure, and multiple system atrophy. The Consensus Committee of the American Autonomic Society and the American Academy of Neurology. Neurology. 1996 May;46(5):1470.
  18. Claydon VE, Steeves JD, Krassioukov A. Orthostatic hypotension following spinal cord injury: understanding clinical pathophysiology. Spinal cord. 2006 Jun;44(6):341-51.
  19. 19.0 19.1 Van Straaten MG, Cloud BA, Zhao KD, Fortune E, Morrow MMB. Maintaining Shoulder Health After Spinal Cord Injury: A Guide to Understanding Treatments for Shoulder Pain. Arch Phys Med Rehabil. 2017 May;98(5):1061-1063.
  20. Exercise After Spinal Cord Injury: Complications to Avoid. Available from: [last accessed 22/11/2021]
  21. Walker B. What is Circuit Training and Examples of Circuit Training Workouts? Stretch Coach 2020. Available at:[last accessed 23/11/2021]
  22. Spinal Cord Injury Fitness Integrated Training (Rumah Aafiyah, Malaysia) 2020. Available from:[last accessed 22/11/2021]
  23. Spinal Cord Injury Patients Share Thoughts on Yoga and More, 2021. Available from:[last accessed 22/11/2021]
  24. Bennie JA, Shakespear-Druery J, De Cocker K. Muscle-strengthening Exercise Epidemiology: a New Frontier in Chronic Disease Prevention. Sports Med-Open 2020; 6 (40).
  25. Exercise After Spinal Cord Injury: How to Adapt Equipment. Available from:[last accessed 22/11/2021]
  26. International perspective on Spinal Cord Injury. Chapter 6. Attitudes, relationships and adjustment. WHO 2013: 121-137.
  27. 27.0 27.1 Lim SER, Cox NJ, Tan QY et al. Volunteer-led physical activity interventions to improve health outcomes for community-dwelling older people: a systematic review. Aging Clin Exp Res 2021;33:843–853.
  28. Mormina M, Pinder S. A conceptual framework for the training of trainers (ToT) interventions in global health. Global Health 2018;14(100).
  29. 29.0 29.1 29.2 CDC. Understanding the Training of Trainers Model. Available at: [last accessed 22/11/2021]