Physical Activity Guidelines for Spinal Cord Injury

Original Editor - Naomi O'Reilly based on the course by

Candice Vermaak

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Introduction

Physical activity is an essential part of a healthy lifestyle for adults with spinal cord injury. While it is acknowledged that exercise is an important tool for improving wellbeing and enhancing independence in individuals with a spinal cord injury, the existing general guidelines were found to be incomplete because they did not address cardiometabolic health and risk factors for cardiovascular diseases in this population.

The World Health Organization developed Global Recommendations on Physical Activity for Health with the overall aim of providing national and regional level policymakers with guidance on the dose-response relationship between the frequency, duration, intensity, type and the total amount of physical activity needed for the prevention of Non-Communicable Diseases. While the World Health Organization suggested that these recommendations could be applied to adults with disabilities with adjustment to the guidelines for each individual based on their exercise capacity and specific health risks or limitations, these recommendations were not specifically tailored to the spinal cord injury population.

Development of Scientific Guidelines

The guidelines for adults with spinal cord injury were developed in partnership with key stakeholders using a rigorous, systematic, participatory process, that followed the gold-standard approach for formulating clinical practice guidelines. The team, collaborating with an international panel of researchers, clinicians, community organisations, adults with a spinal cord injury, and knowledge translation specialists, jointly devised a set of exercise guidelines which were launched at the International Spinal Cord Society Annual Meeting in 2017.

Translating Scientific Guidelines to Practice Guidelines

Rigorous and systematic consumer engagement incorporating patient-public involvement is a vital part of the process of translating scientific guidelines into working guidelines understandable by those they are designed by before widespread dissemination. Engagement of key stakeholders including individuals with a spinal cord injury is necessary to determine the best way to develop and use resources helping to facilitate understanding, uptake and implementation of the guidelines.

Spinal Cord Injury Exercise Guidelines

The exercise guidelines provide minimum thresholds for achieving cardiorespiratory fitness and muscle strength and improved cardiometabolic health. It is recommended that the exercises are completed above and beyond the incidental physical activity, one might accumulate in the course of daily living. The way to fulfil the suggested guidelines is through routine participation in exercise modalities that are sustainable, enjoyable, and safe. The individuals not already exercising should start with smaller amounts of activity and gradually increase the duration, frequency and intensity, as a progression towards meeting the guidelines. At the same time, they need to recognise that exercising below the recommended levels may or may not bring small changes in cardiorespiratory fitness or cardiometabolic health.

Who Do They Apply To

Men and women aged between 18 and 64 with a chronic traumatic or non-traumatic Spinal Cord Injury over 12 months post-onset, with a neurological level C3 or lower including tetraplegia and paraplegia, irrespective of race, ethnicity or socio-economic status, who are not active above and beyond daily activities.

While there is currently insufficient scientific evidence to draw firm conclusions about the risks and benefits of these guidelines for individuals with a Spinal Cord Injury less than 12 months post-onset, aged 65 years or older, and those with co-morbid conditions, they may be appropriate following consultation with a health care provider before beginning an exercise programme.

What Settings Do They Apply To

As we know, physical activity can occur in a range of venues, indoors and outdoors, in all sorts of weather. The Spinal Cord Injury Exercise Guidelines are meant to be applicable to exercise and physical activity performed in a wide range of settings, which include but not limited to:

• Rehabilitation settings

• Fitness centers

• Individuals' own homes

Cardiorespiratory Fitness and Muscle Strength

This guideline reflects the minimum frequency, intensity, and duration of exercise involving combined upper-body aerobic plus strength exercise yielding significant improvements in fitness outcomes. It affirms the 2011 Spinal Cord Injury Physical Activity Guidelines, but has also been updated to align with the evidence base by referring to ‘exercise’ rather than ‘physical activity'. To improve cardiorespiratory fitness and muscle strength, adults with a spinal cord injury should engage in at least:

• 20 minutes of moderate to vigorous intensity aerobic exercise, 2 times per week, and

• 3 sets of strength exercises for each major functioning muscle group, at a moderate-vigorous intensity, 2 times per week

Cardiometabolic Health

Cardiometabolic disease, that includes a spectrum of conditions from insulin resistance, progressing to the metabolic syndrome, pre-diabetes, and finally to more severe conditions including Cardiovascular Disease and Type 2 Diabetes, currently poses serious health and economic burden worldwide, with prevalence predicted to increase. Independent risk factors include prolonged sitting, lack of physical activity, poor diet, and short sleep duration, which have all become commonplace worldwide.

The 2011 Spinal Cord Injury Physical Activity Guidelines have been shown to significantly improve cardiometabolic health outcomes. The new guideline states that for cardiometabolic health benefits, adults with a spinal cord injury are suggested to engage in at least

• 30 minutes of moderate to vigorous-intensity aerobic exercise, 3 times per week

Possible Barriers and Facilitators to Guidelines

The panel developing the guidelines have also identified barriers and facilitators unique to these guidelines:

• Specifying different guidelines for improving fitness and cardiometabolic health might create confusion (i.e., people may not be sure which guideline to follow), as might having guidelines that differ from what is promoted for the general population
• Use of the term ‘exercise’, as opposed to ‘physical activity’ in the guideline may constrain thinking about types of activities that people with a spinal cord injury can participate in
• Importance of improving one’s fitness might be overshadowed by launching a new cardiometabolic health guideline

Role of Physiotherapy in Promoting Guidelines

Physiotherapists have always had a close relationship with exercise as their profession was founded on the work of remedial gymnasts and has a rich history of prescribing rehabilitative exercise. The global physical inactivity crisis and the epidemic of lifestyle-related, non-communicable diseases have created an urgent need to build on our rich history of prescribing exercise and to develop our approaches for prescribing physical activity. Creating a more active population requires joined-up thinking and action from many stakeholders; physiotherapists need to be active in engaging with individuals and communities.

"Physiotherapists are ideally placed to help the dissemination of these Physical Activity Guidelines for Spinal Cord Injury because they interact daily with patients at the start of their journey after their Spinal Cord Injury." Dot Tussler, Physiotherapist at Stoke Mandeville Hospital

Meeting the Exercise Guidelines in Low-Income Countries

Barriers

Research studies on the daily life of people with SCI in low-income countries are limited. The information from the existing publications includes evidence on an increased risk of developing pressure ulcers and infections leading to premature death. A study conducted in India lists the following challenges in the management of SCI:

• Inadequate pre-hospital care
• Lack of community inclusion
• Problems with access and mobility in the community
• Poor awareness about SCI
• Illiteracy and inadequate patient education
• Inadequate physical as well as vocational rehabilitation and financial barriers.

Supportive family was the most important factor in championing the rehabilitation of a person with SCI. In another study the use of a low-cost telehealth method promoted increased function of the persons with SCI. A cross-country study comparing the situation of people with spinal cord injury in high-, middle- and low-income countries has found that the foremost barriers to achieving adequate health care were the following:

• Health care cost
• Transportation (access, availability or cost)
• Service availability (medical staff limited knowledge about SCI)

Other barriers include no access to wheelchairs or wheelchairs that are too expensive, inappropriate equipment causing pressure ulcers to develop, wheelchairs not adapted to the home environment, poor or inadequate maintenance of the equipment, no conducive home conditions, "bush toilets" in rural areas, lack of sufficient income to buy necessary devices, lack of access to public places, chronic pain issues, boredom, feeling of uselessness, negative attitude from family, friends, and neighbours. Climate was also reported as a barrier experienced by people with SCI in low-resource countries.

Health care cost is the most decisive factor in the future of the persons with SCI because if they cannot afford health care, they are excluded from the system.

Possible Solutions

• Family education
• Support provided to the family
• Regularly scheduled follow-up visits with a specialist to monitor progress
• Community outreach programmes by the multidisciplinary team to conduct home visits.

Resources

National Centre for Sport & Exercise Medicine 

• Spinal Cord Injury Exercise Guidelines

SCI Action Canada

• Physical Activity Guidelines for Adults with Spinal Cord Injury
• Vermaak C, Ferreira S, Terblanche E, Derman W. Physical activity promotion in persons with spinal cord injuries: Barriers and facilitators in low-resource communities. African Journal of Disability, 2022;11:a988.