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Oct 18
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Adapted Sports and Equipment

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Author: Sharon Jang | Reviewer: Courtney Pollock | Published: 18 October 2023 | Updated: ~

Key Points

  • Staying active after SCI has many benefits, but structured workouts may not be for everyone. Sports may be a good alternative to stay physically active.
  • Adapted sports (sometimes called “adaptive sports”) are sports that use modified equipment to allow individuals of all abilities to participate.
  • Participating in adapted sports is a great way to build social connections with others and to become a part of a community.
  • There are a variety of sports that can be played including cycling, court sports, winter sports, and water sports. This article introduces various adapted sports and the required equipment to partake in them.

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Why be physically active after SCI?

Staying physically active after SCI is important for your health. There is moderate to strong evidence that physical activity has many benefits after SCI including:

  • Allowing you to perform everyday activities (e.g., shopping, cooking, transferring) with more ease,
  • Improving depression and quality of life,
  • Increasing muscle strength and endurance,
  • Management of blood sugar levels,
  • Helping you to breathe with more ease,
  • Reducing pain and spasticity.

Although going to a gym is one common way to get moving, there are a variety of adapted sports that can also be played. While this article discusses a selection of adapted sports (including handcycling, court sports, winter sports, and water sports), it should be noted that almost any sport can be adapted for participation after SCI.

Refer to our article on Physical Activity for more information!

What are adapted sports?

Adapted sports are sports that can be played with equipment and approaches that are adapted to a person’s physical abilities. Many adapted sports have been altered in one of many ways to promote accessibility. Some of these adaptations include changes to the rules of a game, modifications in the equipment, or specialized equipment to allow you to partake in a sport.

Athlete Classification

There are different levels of adapted sports, ranging from recreational (or just for fun and fitness) to competition. Should you want to become competitive, classifications are used to ensure that competition is equal and fair. Classifications are used to determine which athletes should be grouped together. In adapted sports, classification is based on function (e.g., strength, how many limbs are affected by injury, range of movement, tone/spasticity). This is similar to categorizing by age, gender, or weight in able-bodied sports.

Precautions when trying new sports

While trying out new sports can be fun and exciting, skin health is an important consideration. Trialing new sports is often associated with trying new equipment. When trying new equipment, it is important to check for red marks or pressure spots on your skin including your seat and any area of the body positioned against equipment (e.g., footrest or frame). People will commonly use the cushion from their everyday chair in their sport chair when they first try a sport. However, it is important to remember that although it is the same cushion, you may be sitting in a different position (e.g., seat angle) which will change pressure and potential forces from rubbing. The best approach is like that of trialing a new wheelchair or cushion: frequently check your skin in the early days of your new sport. This means that it is best to start with shorter sessions and work your way up in time once you know that your skin can tolerate the new equipment and positions. In water sports such as kayaking, or in rainy conditions for outdoor sports, make sure to check your skin when you are done since being wet can make the skin more prone to injury.

Additionally, you may want to consider the influence of temperature (extreme hot or cold weather), as temperature regulation may be impaired with an SCI.

Refer to our article on Pressure Injuries for more information!

What types of cycling and pushing sports are there?

Handcycles are a type of bicycle that is propelled by the arms instead of the legs. There are different types of handcycles available for all levels of ability. In general, most arm-cycles have alternative handle options for those with limited hand function.

Types of arm cycles

Recumbent cycles

Recumbent arm-cycles are three wheeled bikes that are controlled with the arms while seated in a reclined position. This type of bicycle has support straps to rest the feet in while cycling.

Upright cycles

Upright cycles are similar to recumbent bikes in that the feet are on either side of the front wheel. However, the user is seated in a more upright position when using this bike.

Tandem bikes

A variety of tandem arm bikes are available. Bike models are available to allow riders to either ride beside each other, or one in front of the other. Power-assist versions are also available for those who may have some function in their legs.

Arm cycle add-ons

Instead of buying a separate wheelchair, arm-cycle add-ons are available for manual wheelchair users. These add-ons connect to the front of a manual wheelchair, lifting up the casters. This then allows an individual to propel their wheelchair via an arm cycle. Additionally, power-assist versions are available for those with less upper body strength.

Off-road wheelchairs

If you are looking to go on some trails, an off-road wheelchair may appeal to you. These wheelchairs are used for recreational riding, such as going for a hike, or going fishing. Off-road wheelchairs often have larger, knobbier tires that are meant to withstand the trail, roots, and rocks. Like the arm-cycles, off-road wheelchairs come in a variety of set ups. Some setups may look like a typical manual wheelchair, but with larger wheels. There are also ones that are controlled with push-levers (such as the mountain trike), and powered wheelchairs with more power, suspension, and agility (such as the x5 frontier, and the x8-extreme all-terrain wheelchair).

Wheelchair racing

For those who are interested in competition, wheelchair racing may be an option. Wheelchair race events range from the 100m, 200m, 400m, 800m, 1500m, and 5k distance races in track and field, to marathons. Racing wheelchairs differ from the wheelchairs and cycles listed above in that they typically have two wheels with a third one extended out in front. Ideally, race chairs should be light-weight to enhance performance. When seated, the wheelchair should fit “like a glove”, and there should be little movement in the seat. Unlike arm-cycles, the feet are bent down and kept closer to the body. In addition, specialized rubber gloves are worn to push the rims during races.

Refer to our article on Wheelchair Propulsion Assist Devices for more information!

What adapted court sports are available?

Tennis

Wheelchair tennis is played on the same court as able-bodied tennis, and with similar rules. One rule difference is that in wheelchair tennis, players are allowed two bounces instead of one, and the second bounce can be anywhere – even out of bounds. Although one can play wheelchair tennis in their day chair, tennis wheelchairs are often preferred during play. These wheelchairs are faster, lighter, more agile, and more stable. The wheels on the wheelchair are also angled (i.e., there is more camber ) to allow for more swift turning. For those with limited hand function, taping the racquet to your hand is common practice, though it can take some time to find the optimal tension for you. Therefore, people with all levels of ability can play wheelchair tennis.

Basketball

Wheelchair basketball is played on a standard basketball court. The wheelchair used for basketball is one with wheels angled to 15-20 degrees and a single rollerblade used for a caster at the back. In addition, there are many strapping options to promote stability and safety, or to hold the body in a certain position. Commonly strapped body parts include the hips, knees, feet and/or ankles. It is common for wheelchair basketball leagues to include able bodied participants at the local level of competition. This allows for more players and teams for great league play.

Rugby

Wheelchair rugby was developed specifically for people with tetraplegia and has grown to include people without SCI but with similar functional abilities (e.g., some impaired arm and hand function in addition to impaired leg function). Wheelchair rugby is played with a volleyball. The goal of the game is to carry the ball over the other team’s goal line. Unlike able-bodied rugby, wheelchair rugby is played indoors on a court. Specialized wheelchairs are used to play wheelchair rugby and can be separated into chairs for offensive players and chairs for defensive players. Offensive wheelchairs are set up for speed and mobility and are distinguished with a front bumper to prevent other chairs from hooking them. Often, offensive chairs are used by players with more function. On the other hand, defensive wheelchairs are set up with a bumper to hook and hold onto other players. Defensive chairs are often used by players with less function. Additional equipment used in rugby include straps and gloves. Straps are used on the waist (to compensate for a lack of core muscles), the thighs (to prevent them from falling to the side or from shifting side to side), and the feet (for comfort). Meanwhile, gloves work to protect the skin, add extra grip when pushing the chair, and to making throwing and catching the ball easier.

Community Voices: Byron

Byron has been playing wheelchair rugby for 17 years. He describes it as “a fast-paced sport. You get to hit things with your wheelchair, and at the same time there is a lot of strategy going on.” He enjoys the sport as he explains, “the physical benefits are a big part of why I enjoy playing wheelchair rugby. The community is amazing – it’s great because every practice is an opportunity to see a bunch of my friends.”

What adapted winter sports are available?

Alpine Skiing

Alpine skiing, also known as downhill skiing, is a sport that individuals with tetraplegia and paraplegia can partake in with the use of sit-skis. In general, sit skis have a bucket-type of seat with an adjustable seat and footrest. To create a smoother ride, sit-skis have additional features such as suspensions and a shock compression system under the seat. The seat and suspension/shock systems are all connected to either a single ski (mono-ski) or a pair of skis (bi-skis). In general, mono-skis require the user to have good upper body strength, and the ability to ski independently. Bi-skis are often used by individuals who may require some assistance. Often, bi-skis are used with an able-bodied individual who skis behind them. Skiers who use a sit-ski can use the typical chairlifts at the mountains and with experience, can access all terrains of ski areas.

Cross Country Skiing

Cross country skiing (which is a type of Nordic skiing) allows individuals with paraplegia and tetraplegia to explore snowy trails. Like the alpine skis, cross country skis consist of a bucket seat that connects to a metal frame, which clips into the skis. Cross country skiers also often use poles while skiing to propel themselves along flatter terrain. If assistance is required, an able-bodied person can help push the ski forward with their ski-pole using an adaptive add-on.

Sledge (Ice) Hockey

Sledge hockey, or para ice hockey is identical to ice hockey but is played while sitting in sledges as opposed to standing on skates.

A sledge consists of a plastic bucket-shaped seat that is connected to a metal frame. This frame is set on two adjustable skate blades, with the blades aligned on the bottom of the seat. The skate blades may be adjusted so that they are further apart for stability (good for new players) or can be moved closer together to allow for more maneuverability and speed. Straps are available to help keep the feet, knees, and hips in place. Players propel themselves in the sledge using two sticks. These sticks are dual ended: one end has a blade for handling the puck, while the other end has a metal pick in it to help players propel themselves across the ice. Typical hockey pads are used for safety during play.

What water sports are available?

Sailing

Adapted sailing is a sport that people of all abilities can participate in. Common features of adapted sailboats include handguards along the side of the boats, greater deck space due to removed masts, and customized molded seats with back support and belts that pivot. For individuals with reduced function, other available adaptations include electronic controls (such as the use of a joystick), and sip ‘n’ puff technology to steer the boat with breath. Many sailing clubs have power/mechanical lifts dockside to assist with transfers into boats.

Community Voices: Terry

Terry has been involved in adapted sailing since 1994. Terry sails a Matin 16 using sip ‘n puff technology. Sailing is special to Terry as he says he can “finally get out of my chair and be as free as the wind!” As he is unable to play court sports, sailing has provided Terry a competitive outlet.

Kayaking

Kayaks are available for people with all levels of SCI. While individuals with a lower level of injury may use non-adapted kayaks, adaptations are available for comfort and to accommodate those with limited function. Some kayaks may have custom seating with side and abdominal support. These supports are cushioned to protect the skin while kayaking. Stabilizing outriggers are available to increase stability of the boat and to reduce the chances of tipping. For those with limited arm/hand function, there are various adaptations for the paddle including:

  • A back of the hand grip, which places more paddling pressure on the arms instead of the hands.
  • Wrist cuff adaptation, which allows individuals to connect the paddle to their wrists via a cuff.

The bottom line

There are many benefits to staying physically active after SCI and there is a large variety of sports to participate in. Whether you prefer staying on land, floating on water, or being in the snow, most sports have been adapted in some way or another so that all who want to can participate! Prior to trying a sport, talk with your health providers to ensure that you are in a condition to play.

Reference list

Evidence for “Why be physically active after SCI” is based on:

Martin KA, Latimer AE, Francoeur C, Hanley H. Sustaining exercise motivation and participation among people with spinal cord injuries – Lessons learned from a 9 month intervention. Palaestra 2002;18(1):38-51.

Hicks AL, Martin KA, Ditor DS, Latimer AE, Craven C, Bugaresti J et al. Long-term exercise training in persons with spinal cord injury: effects on strength, arm ergometry performance and psychological well-being. Spinal Cord 2003;41(1):34-43.

Latimer AE, Ginis KA, Hicks AL, McCartney N. An examination of the mechanisms of exercise- induced change in psychological well-being among people with spinal cord injury. J Rehabil Res Dev 2004;41(5):643-652.

Martin Ginis KA, Latimer AE, McKechnie K, Ditor DS, Hicks AL, Bugaresti J. Using exercise to enhance subjective well-being among people with spinal cord injury: The mediating influences of stress and pain. REHABIL PSYCHOL 2003;48(3):157-164.

Latimer AE, Martin Ginis KA, Hicks AL. Buffering the effects of stress on well-being among individuals with spinal cord injury: A potential role for exercise. Therapeutic Recreation Journal 2005;39(2):131-138.

Mulroy, S. J., Thompson, L., Kemp, B., Hatchett, P. P., Newsam, C. J., Lupold, D. G., et al. (2011). Strengthening and Optimal Movements for Painful Shoulders (STOMPS) in chronic spinal cord injury: a randomized controlled trial. Physical Therapy, 91, 305—324.

Jacobs, P. L. (2009). Effects of resistance and endurance training in persons with paraplegia. Medicine & Science in Sports & Exercise, 41, 992-997.

De Groot PC, Hjeltnes N, Heijboer AC, Stal W, Birkeland K. Effect of training intensity on physical capacity, lipid profile and insulin sensitivity in early rehabilitation of spinal cord injured individuals. Spinal Cord 2003;41(12):673-679.

de Carvalho DC, Martins CL, Cardoso SD, Cliquet A. Improvement of metabolic and cardiorespiratory responses through treadmill gait training with neuromuscular electrical stimulation in quadriplegic subjects. Artif Organs 2006;30(1):56-63.

Information for “What are adapted sports” is based on:

World Para Athletes. (n.d.). What is classification? https://www.paralympic.org/athletics/classification

Information for “What types of cycling and pushing sports are there?” is based on:

World Para Athletes. (n.d.). Para-athletics explained: Wheelchair racing. https://www.paralympic.org/news/para-athletics-explained-wheelchair-racing

Chair Institute. (2019). Best off road all terrain wheelchairs for outdoors review 2020. https://chairinstitute.com/best-wheelchairs-for-outdoors/

Information for “What adapted court sports are available?” is based on:

BC Wheelchair Sports. (n.d.). Wheelchair Tennis.https://www.bcwheelchairsports.com/sites/default/files/images/BCWSA%20Wheelchair%20Tennis%20First%20Introduction%20Manual%20-%20PRINT%20%281%29.pdf

Wheelchair Basketball Canada. (2021). About the sport. https://www.wheelchairbasketball.ca/the-sport/about-the-sport/

Wheelchair Basketball Canada. (2021). Equipment. https://www.wheelchairbasketball.ca/the-sport/equipment/

Wheelchair Rugby Canada. (2018). Rules and equipment. https://wheelchairrugby.ca/rules-equipment/

Information for “What adapted winter sports are available?” is based on:

Canadian Ski Council. (2018). Skiing is for everyone! https://www.skicanada.org/ready/accessible-skiing-information/

XCSkiResorts. (2016). Nordic adaptive sit-skis bring freedom to mobility impaired persons. https://www.xcskiresorts.com/resort-features/2016/9/12/nordic-adaptive-sit-skis-bring-freedom-to-mobility-impaired-persons

BC Hockey – Saanichton, BC. (2016). Para Hockey Brochure Guide.https://www.bchockey.net/Files/Sledge%20Hockey%20Brochure.pdf

Information for “What water sports are available?” is based on:

Move United. (n.d.). Sailing. https://www.moveunitedsport.org/sport/sailing/

Disabled Sailing Association of British Columbia. (2021). Sip ‘n’ Puff Technology. https://asabc.org/sip-n-puff/

Creating Ability. (2021). Seating systems. https://www.creatingability.com/seating-systems/

Creating Ability. (2021). Paddle adaptations. https://www.creatingability.com/paddle-adaptations/

Image credits

  1. Man on Arm Erg by SCIRE Community
  2. BC Wheelchair Rugby Day 1 293©Melissa Nemeth, CC BY-SA 2.0
  3. Noun Project
  4. Noun Project
  5. Noun Project
  6. Shark ©Sunrise Medical 2021
  7. Replacement parts for Invacare Top End Handcycles ©RehabMart.com, LLC 1998-2021
  8. Van Ram Fun2Go Tandem ©Bike-On.com 2020
  9. Batec Hybrid ©Batec Mobility
  10. Invacare top end crossfire all terrain wheelchair ©Invacare Corporation 2021
  11. Top end preliminator youth racing wheelchair – custom version. ©How I Roll Sports, LLC 2018
  12. Harness Glove ©Harness Designs Wheelchair Gloves
  13. Wheelchair Tennis ©BC Wheelchair Sports
  14. Wigan Warthogs Wheelchair Basketball-2 ©Andrew Spillane, CC BY-ND 2.0
  15. Equipment ©International Wheelchair Rugby Federation 2013-2021
  16. London 2012 Paralympics Wheelchair Rugby (Murderball) ©Sum_of_Marc, CC BY-NC-ND 2.0
  17. Monique-1 Mono Ski ©Enabling Technologies 2021
  18. Dynamique Bi Ski ©Enabling Technologies 2021
  19. Woman using sit ski – photo by northeast passage ©U.S. Forest Service – Pacific Northwest Region, Public Domain Mark 1.0
  20. Sledge Hockey: Italy/Sweden ©Mariska Richters, CC BY-NC-SA 2.0
  21. Terry in Matin 16
  22. Outfitted Kayak ©Creating Ability 2021
  23. Stabilizing Outriggers ©Creating Ability 2021

 

Disclaimer: This document does not provide medical advice. This information is provided for educational purposes only. Consult a qualified health professional for further information or specific medical advice. The SCIRE Project, its partners and collaborators disclaim any liability to any party for any loss or damage by errors or omissions in this publication.
Apr 13
0

Physical Activity After Spinal Cord Injury

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Author: Sharon Jang | Reviewer: Sonja de Groot | Published: 20 April 2022 | Updated: XX October 2024

Physical activity after spinal cord injury (SCI) can provide many health benefits, as in the able-bodied population. This page covers the benefits of exercising with an SCI, precautions, and adaptations to exercising with an SCI.

Key Points

  • Exercising after an SCI can improve muscle strength, type, and size, your abilities to do things on a day-to-day basis, your well-being, and decrease risks for secondary complications.
  • There are many ways to get physically active, including sports, being active in the community, and going to the gym.
  • Many exercises and sports can be adapted for those with SCI using adaptive equipment.
  • Although rare, some secondary complications such as autonomic dysreflexia (AD), orthostatic hypotension (OH), skin breakdown, and temperature regulation, may arise.

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What are the benefits of exercise after SCI?

After SCI, there is deconditioning of muscles, bones, joints, and changes in the heart and blood vessels due to inactivity. This can lead to various secondary complications, such as heart disease, breathing complications, weakening of the bones (osteoporosis), pain, spasticity, and diabetes. Exercise has many positive changes for those with an SCI including muscle type and size, improved muscle strength, independence, well-being, and helping to prevent secondary health complications.

Muscle type, size, and strength

In the body, there are 2 main types of muscle fibers: slow twitch (type I) and fast twitch (type II). Slow twitch muscles are known as the endurance muscles, as they are able to hold a contraction for a long period of time before getting tired. For example, the muscles that are used to keep your head upright are mostly made up of slow twitch muscle fibers. Type II fibers are known for their short burst of speed or strength. They can generate more strength, but get tired really quickly. Over time with an SCI, the muscles with the endurance type (type I) tend to turn into the more fatigable type (type II). There is some moderate-weak evidence that shows that among those with limited movement in their legs, the use of functional electrical stimulation (FES) can help shift muscle fibers from being more fatigable to more endurance based.

After injury, muscles in the body slowly begin to become smaller (atrophy). However, there is moderate to weak evidence that indicates that moving your arms and legs, either passively or actively, can help build muscle up again. Two (weak evidence) studies found that amongst those with limited to no leg function, electrical stimulation (Neuromuscular electrical stimulation (NMES) or FES) can increase the size of the thigh muscles. In addition, there is weak evidence that the use of a body-weight support treadmill can also increase the size of the lower leg muscle, resulting in a partial reversal of muscle shrinking.

There is strong-moderate evidence that exercising can help individuals of any injury level improve their strength. Among those with paraplegia, there is strong evidence that strength training (i.e., doing weight training) can improve muscle strength in the arms. There is also strong evidence showing that body weight support training can improve overall muscle strength, and moderate evidence that arm cycling can help strengthen the arms and the front of the shoulder. Among those with tetraplegia, there is strong evidence that the use of FES on the arm and shoulder can improve muscle strengthening. Moreover, strong evidence suggests that neuromuscular stimulation (NMES) can improve strength among those with cervical level injuries. If you are unable to access specialized equipment, strength training with free weights or using an arm cycle can show similar benefits as well.

Activities of Daily Living

There is some moderate evidence that shows that exercising can enhance the ability to perform daily tasks by yourself. Exercising improves your fitness level (such as your strength and endurance), which can help you perform daily tasks. More specifically, tasks may become easier by reducing physical strain and a decrease in the amount of time required to do an activity.  One moderate evidence study found that doing physical therapy exercises in addition to neuromuscular stimulation enhanced participant’s ability to perform self-care (e.g., dressing, feeding, toileting) and mobility (e.g., transferring, wheelchair pushing). Other weak evidence supports these findings, as they found that exercise can help improve transferring and the ability to put on/take off clothing, wheeling and cleaning. Furthermore, increased fitness levels have also been associated with return to work.

Well-being

Some evidence suggests that exercise can help individuals improve perceptions of well-being. Well-being has been defined as how well an individual feels in their mind, their satisfaction with their health and functioning, and their overall satisfaction in life. Two aspects of well-being that are relatively well-researched are the impact of physical activity on depression and quality of life. There is weak evidence that found that all types of physical activity can help improve depressive symptoms and can improve quality of life. This relationship between physical activity and depressive symptoms and quality of life can be explained by a strong evidence study, which indicates that exercise can lead to decreased stress and pain. For example, strong evidence has shown that exercise can reduce shoulder pain, which can allow individuals to perform a greater variety of movements without consequences. The reduction in stress and pain, in turn, is thought to improve quality of life and depressive symptoms. However, many of these studies lack a control group. As a result, we are unable to determine if physical activity alone has an influence on subjective well-being.

Secondary complications

After sustaining an SCI, multiple secondary complications can occur. However, research suggests that exercise can help prevent or reduce the severity of secondary complications, including:

  • Conditions impacting the heart and blood vessels, by improving the strength of the heart and balancing out the sympathetic (fight or flight; stimulation) and parasympathetic  (relax and slowing) nervous systems,
  • Breathing complications, through strengthening the muscles required for breathing and through increasing the amounts of oxygen taken up by the body,
  • Weakened bones, by increasing bone mass density,
  • Type II diabetes, through improving the balance of blood sugar (glucose),
  • Pain, through strengthening, and
  • Spasticity, which can be reduced short term with exercising.

What are ways I can exercise after SCI?

There are many ways for you to remain physically active, even after SCI! Strength training can be done at a local community center or private gym, most often with the equipment already there. Strength training can also be done at home with free weights and exercise bands. Some equipment that can be used for strength training include free weights, exercise bands, and pulleys. For aerobic exercise, some alternatives include using an arm ergometer (arm cycle), a rowing machine (if possible), and adaptive rowers, such as the Ski-Erg.

Adaptive sports is another way to get active. There are a variety of adaptive sports, including court sports (e.g., basketball, rugby, tennis), water sports (e.g., sailing, kayaking), race sports (e.g., cycling, track and field), and winter sports (e.g., Nordic and alpine skiing).

Refer to our article on Adapted Sports & Equipment for more information!

Alternatively, specialty equipment is available to help facilitate exercise after SCI. However, this equipment is more commonly used in rehabilitation settings, as they are very expensive and additional assistance is often required. A Functional Electrical Stimulation (FES) bike can be used to simulate the legs while cycling, and has been shown improve strength and endurance. Body-weight Support Treadmills are specialized treadmills with a sling attached. This type of treadmill allows an individual to move their legs on the treadmill, while having their bodyweight supported by a sling. Some models are available to allow users to control how much of their bodyweight they feel while in the treadmill, which can alter the challenge of walking.

If going to the gym or playing sports is not your thing, there are still other ways to get active! Performing daily tasks can be hard work as well. For example, activities such as heavy gardening, going grocery shopping and carrying home groceries, doing a lot of housework such as vacuuming and cleaning the house, going for a push with family/friends are all ways of being active. However, if these are your activity of choice, you want to make sure you are pushing yourself enough to get your heart rate up and keep it up for a while.

What are the exercise guidelines?

In 2020, exercise guidelines for the SCI population were released. Currently, the starting level guidelines for fitness benefits are:

  • at least 20 minutes of moderate to vigorous intensity endurance (aerobic) exercise, 2 times per week
  • 3 sets of strength exercises for each major muscle group at a moderate to vigorous intensity, 2 times a week.

The advance level provides guidelines for additional fitness and health benefits, such as reducing your risk for diabetes. It is recommended to get at least 30 minutes of moderate to vigorous intensity aerobic exercise at least 3 times a week, in addition to the 3 sets of strength exercises twice a week.

Refer to our article on Exercise Guidelines for Adults with SCI for more information!

Another way to gauge your effort is through a Rating of Perceived Exertion (RPE). The RPE is a subjective rating scale where the individual rates how hard they feel they are working, where 0 is not working at all, and 10 is working at your absolute maximum. If someone is just starting off with exercising, starting between a 5-7 on the RPE scale is a good idea.

 

Watch SCIRE’s YouTube Video explaining how to use RPE when exercising!

Another way to evaluate how hard you are working is through using the talk test. The talk test uses your ability to carry out a conversation while performing exercise to gauge exercise intensity. According to the talk test, a moderate intensity workout is achieved when one is able to talk to someone while working out, but not being able to sing. During a vigorous intensity workout, you would only be able to say a couple of words to someone, and speaking is difficult.

How can I adapt exercises?

Watch SCIRE’s YouTube video explaining how to adapt exercises.

Going back into a gym after an SCI may be daunting given that much of the equipment may no longer be accessible. However, there are a number of ways to adapt gym equipment, including grip assistance,  transfer boards, chest straps, and using free weights and wedges. When exercising at a gym, you may require some additional assistance getting set up on pieces of equipment. If this is the case, consider going with a family member or a friend, and don’t be afraid to ask the gym attendant for help.

Adaptive grip aids include commercial gloves (left), tensor bandages (upper right) and weight lifting cuffs (bottom right).

After a high-level SCI, hand functioning may be impaired, resulting in a lack of ability to grip. To address this in a gym setting, some available options include using tensor bands, commercially available gloves, or weight-lifting cuffs. Tensor bandages can be used to wrap your hands around a handlebar. Benefits of using a tensor bandage include wide availability and low cost. Commercially available gloves, such as the Active Hands, are also available to assist with grip function on handles. These gloves provide a bit more support to the wrist and have a Velcro strap around the wrist. They also have a second Velcro that goes over the hand, which secures the hand to the handle. However, commercial gloves may not be as readily available and are usually expensive. Lastly, some individuals use weight-lifting cuffs, which are available at most gyms for use, to assist with grip function. These cuffs have a Velcro strap that goes around the wrist and a hook that can be connected to handlebars. Although commonly found in gyms, weightlifting cuffs only work for specific movements, such as pushing and pulling. In addition, they might not fit around handles of all sizes.

An abdominal binder (circled in red) being used to help keep an upright posture during rowing.

Abdominal (core) function is often impacted with an SCI, which may limit the types of activities you are able to do. One way to address this issue is through the use of a chest strap. A chest strap is a neoprene strap that comes in differing widths but is often wide enough to cover your abdominal area. The idea is to wrap the chest strap around the backrest of your wheelchair and around your torso, preventing you from falling forward if you are doing a pulling exercise. Chest straps are commonly used in various wheelchair sports as well, to provide additional support.

Refer to our article on Abdominal Binders for more information! 

When exercising in a wheelchair, you may find that the wheel lock still allows for some movement in the wheels, which may hinder an exercise. One way to address this situation is through adding additional support at the base of the wheel using wedges or free weights. Free weights can be placed behind the rear tire on both sides, or in front of the rear tire on both sides. In place, small wooden wedges (or door stoppers) can be placed under the tires on all four sides (in front and at the back) to help prevent rocking.

What should I be cautious of when exercising?

Watch SCIRE’s YouTube video explaining potential complications during exercise.

Exercise is relatively safe for individuals with SCI. However, there are some complications that, while rare, can arise.

Low blood pressure

When you first start exercising, it is common to possibly feel some nausea, or like you might pass out. This is a result of exercise-induced (exertional) hypotension, or a sudden drop in blood pressure due to exercise. One way to overcome this is to build up your exercise routine. When doing aerobic exercises, try a discontinuous approach: exercise for 2-3 minutes, then take a break. The idea is to slowly increase the length of exercising before you require a break, working your way up to 20-30 minutes of exercise. Once you are able to continuously exercise for 20-30 minutes, then you may consider increasing the resistance.

Autonomic Dysreflexia

Autonomic dysreflexia is a condition where blood pressure suddenly increases to dangerous levels. If this occurs, stop exercising. Sit up and try to lower your legs if possible, loosen any tight clothing, and move off of any high-pressure areas (e.g., sit bones, hands/wrists if you are using assistive grip). If symptoms do not go away, seek medical attention.

Refer to our article on Autonomic Dysreflexia for more information!

Temperature regulation

With a high level injury, temperature dysregulation, the body’s inability to control temperature, may be influenced. The ability to produce sweat can be compromised with higher levels of injury, resulting in an inability to cool down the body. In colder environments, it may be harder to warm up.

When exercising in hot or warmer environments, make sure you are drinking water consistently throughout your workout. Consider wearing looser clothing, and try to work out in an environment with ventilation, fans, or air conditioning. If you notice that you tend to overheat during exercise and are unable to sweat, you can also try carrying a spray bottle with you and spray your face down to cool off. When exercising in cooler environments, be mindful of your hands, arms, legs, and feet and make sure they aren’t getting too cold. Try dressing in layers so you can wear more if necessary, but also take layers off if you get warm.

Skin concerns

When exercising, it is important to be cautious of skin integrity, especially if you have no sensation. One area to be mindful of is the back when performing rocking or twisting motions. Rocking and twisting movements may cause the back to rub on the backrest of the wheelchair, creating a potential for skin breakdown. Another area to be mindful of is areas used with straps, such as the hands and sometimes the feet. For example, if using a grip aid for a longer duration of time to perform an activity, you may want to check for red spots that may have been caused by the straps. Ensure to check your skin after exercising for redness.

Refer to our article on Pressure Injuries for more information!

Overuse injuries

Overuse injuries occur when you exercise muscles that are already often used on a daily/frequent basis. An example of this is the shoulders, as it is used for pushing a wheelchair. To prevent overuse injury, make sure you have the correct posture when performing exercises. When working on the shoulder, try to consider alternatives to pushing your wheelchair as exercise, if possible. For example, the use of an arm bike could be an alternative to get around as they require less demand on your shoulders and arms. In addition, try to balance aerobic exercise and strength training in muscle groups prone to overuse injuries.

How does aging affect physical activity after SCI?

Benefits of physical activity as you age

Watch SCIRE’s video explaining to learn about ways to stay active as you age.20

It is normal as you age for the function of body systems and organs to gradually decline. People with SCI and other disabilities may find that this process starts earlier in life and has a bigger impact on daily function. Physical activity is important to keep your body and mind healthy. Physical activity can help someone aging with SCI prevent and slow down losses in function, independence, and quality of life. Small changes in muscle strength, heart health, breathing, or pain can have big impacts on the daily activities of someone with SCI. Physical activity can also be a good way to socialize if you are able to join a community group or program.

Physical activity can help keep your body healthy in many ways:

  • Improve or maintain muscle strength
  • Improve or maintain mobility
  • Improve respiratory fitness
  • Improve blood circulation
  • Reduce risk of heart health problems
  • Improve bone health and prevent osteoporosis
  • Improve your overall mood and wellbeing
  • Improve body composition (increase muscle, reduce unhealthy fat)
  • Boost the immune system
  • Improve chronic shoulder pain with strengthening and stretching
  • Reduce fatigue

Refer to the “What are the benefits of exercise after SCI?” section above for more information.

Risks and considerations

While physical activity is essential to maintaining health as you age, the impacts of aging on your body may also increase your risk for injury. These risks should be considered when doing physical activity, especially because problems like pain, fractures, pulled muscles, and strains can hinder participation.

Be aware of:

  • Pain that may be an indication of injury.
  • Increased risk of fractures due to bone loss (people with SCI are at high risk for osteoporosis).
  • Joint degeneration and injury in the shoulders and wrist (people with SCI develop overuse injury with age and have more arthritis and breakdown in the joints).
  • Skin breakdown and pressure injury from motions that cause friction during physical activity (skin becomes more thin and less elastic with age and heals more slowly from injury).

How to know when to stop

Many people with SCI live with a baseline level of pain. This can make it difficult to determine whether discomfort and pain while doing physical activity is acceptable or harmful. Expert advice includes starting small and taking note of any discomfort/pain before, during, and after physical activity.

  • If physical activity is not causing additional discomfort or pain that persists afterwards, you can maintain or make a small increase to the intensity and/or amount of physical activity.
  • If physical activity is causing additional pain that persists afterwards, consider changing the type, or reducing the intensity and/or amount of physical activity.

Adaptations

You may need to adjust your physical activity routines and methods as you age to keep it safe and accessible. Consult your physiotherapist for advice on how to safely do physical activity based on your unique abilities and barriers.

Some possible adaptations:

  • Changing the type of physical activity you do
    • Slower-paced sports
    • Less weight-bearing activities to accommodate injuries or arthritis
    • Hobbies that get you moving
  • People often get tired more quickly as they age. Start with shorter periods of less intense activity and increase gradually in small increments
  • Opportunities to do PA at home (online classes, walking the dog, gardening, etc.)
  • Opportunities in the community
    • Check with local organizations for online and in-person PA programs
  • Equipment and technology to facilitate PA
    • Lift or transfer technology to get onto workout equipment
  • Work with a trainer/coach who is knowledgeable about SCI

Can medication make you tired?

Some medications used to treat pain or spasticity may cause fatigue, reducing your motivation to be physically active. If you are concerned about the effects of your medication on energy levels, consult with your healthcare provider to see if there are opportunities to optimize your regimen.

The bottom line

Participating in physical activity after SCI can be intimidating, but it is beneficial. Being physically active can help improve your well-being and help reduce the impact of secondary complications after SCI. There are many ways to stay active after an injury, and many ways to adapt existing sports and equipment to help you get exercise. Although exercise is healthy, there are precautions to keep in mind when exercising. Overall, it is recommended that individuals with SCI stay active to promote a healthy lifestyle.

For a list of included studies, please see the Reference List. For a review of how we assess evidence at SCIRE Community and advice on making decisions, please see SCIRE Community Evidence.

Reference list

Parts of this page has been adapted from SCIRE Professional “Physical Activity” Module:

Wolfe DL, McIntyre A, Ravenek K, Martin Ginis KA, Latimer AE, Eng JJ, Hicks AL, Hsieh JTC (2013). Physical Activity and SCI. In Eng JJ, Teasell RW, Miller WC, Wolfe DL, Townson AF, Hsieh JTC, Connolly SJ, Mehta S, Sakakibara BM, editors. Spinal Cord Injury Rehabilitation Evidence. Version 4.0.
Available from: https://scireproject.com/evidence/physical-activity/

Evidence for “What are the benefits of exercise after SCI?” is based on:

Alexeeva, N., Sames, C., Jacobs, P. L., Hobday, L., DiStasio M. M., Mitchell S.A., & Calancie B. (2011). Comparsion of training methods to improve walking in persons with chronic spinal cord injury: a randomized clinical trial. The Journal of Spinal Cord Medicine, 34, 362—379.Ref 2

Andersen, J. L., Mohr, T., Biering-Sorensen, F., Galbo, H., & Kjaer, M. (1996). Myosin heavy chain isoform transformation in single fibres from m. vastus lateralis in spinal cord injured individuals: effects of long-term functional electrical stimulation (FES). Pflugers Archiv – European Journal of Physiology, 431, 513-518.

Cameron T, Broton JG, Needham-Shropshire B, Klose KJ. An upper body exercise system incorporating resistive exercise and neuromuscular electrical stimulation (NMS). J Spinal Cord Med 1998;21(1):1-6.

Chen Y, Henson S, Jackson AB, Richards JS. Obesity intervention in persons with spnal cord injury. Spinal Cord 2006;44:82-91

Chilibeck PD, Jeon J, Weiss C, Bell G, Burnham R. Histochemical changes in muscle of individuals with spinal cord injury following functional electrical stimulated exercise training. Spinal Cord 1999;37(4):264-268.

Crameri RM, Weston A, Climstein M, Davis GM, Sutton JR. Effects of electrical stimulation- induced leg training on skeletal muscle adaptability in spinal cord injury. Scand J Med Sci Sports 2002;12(5):316-322.

Crameri RM, Cooper P, Sinclair PJ, Bryant G, Weston A. Effect of load during electrical stimulation training in spinal cord injury. Muscle Nerve 2004;29(1):104-111.

de Carvalho DC, Cliquet A, Jr. Energy expenditure during rest and treadmill gait training in quadriplegic subjects. Spinal Cord 2005;43(11):658-663.

De Groot PC, Hjeltnes N, Heijboer AC, Stal W, Birkeland K. Effect of training intensity on physical capacity, lipid profile and insulin sensitivity in early rehabilitation of spinal cord injured individuals. Spinal Cord 2003;41(12):673-679.

Ditor DS, Macdonald MJ, Kamath MV, Bugaresti J, Adams M, McCartney N et al. The effects of body-weight supported treadmill training on cardiovascular regulation in individuals with motor-complete SCI. Spinal Cord 2005;43(11):664-673.

Fukuoka Y, Nakanishi R, Ueoka H, Kitano A, Takeshita K, Itoh M. Effects of wheelchair training on VO2 kinetics in the participants with spinal-cord injury. Disability & Rehabilitation Assistive Technology 2006;1:167-74.

Glinsky, J., Harvey, L., Korten, M., Drury, C., Chee, S., & Gandevia, S. C. (2008). Short-term progressive resistance exercise may not be effective at increasing wrist strength in people with tetraplegia: a randomised controlled trial. Australian Journal of Physiotherapy, 54, 103- 108.

Grimby G, Broberg C, Krotkiewska I, Krotkiewski M. Muscle fibre composition in patients with traumatic cord lesion. Scand J Rehabil Med 1976;8(1):37-42.

Hetz SP, Latimer AE, Martin Ginis KA. Activities of daily living performed by individuals with SCI: Relationships with physical fitness and leisure time physical activity. Spinal Cord 2008;47(7):550-554.

Hicks AL, Adams MM, Martin GK, Giangregorio L, Latimer A, Phillips SM et al. Long-term body- weight-supported treadmill training and subsequent follow-up in persons with chronic SCI: effects on functional walking ability and measures of subjective well-being. Spinal Cord 2005;43(5):291-298.

Jacobs, P. L. (2009). Effects of resistance and endurance training in persons with paraplegia. Medicine & Science in Sports & Exercise, 41, 992-997.

Jeon JY, Weiss CB, Steadward RD, Ryan E, Burnham RS, Bell G et al. Improved glucose tolerance and insulin sensitivity after electrical stimulation-assisted cycling in people with spinal cord injury. Spinal Cord 2002;40(3):110-117.

Klose KJ, Schmidt DL, Needham BM, Brucker BS, Green BA, Ayyar DR. Rehabilitation therapy for patients with long-term spinal cord injuries. Archives of Physical Medicine & Rehabilitation 1990;71:659-62.

Le Foll-de Moro D, Tordi N, Lonsdorfer E, Lonsdorfer J. Ventilation efficiency and pulmonary function after a wheelchair interval-training program in subjects with recent spinal cord injury. Arch Phys Med Rehabil 2005;86(8):1582-1586.

Martin Ginis KA, Latimer AE, McKechnie K, Ditor DS, Hicks AL, Bugaresti J. Using exercise to enhance subjective well-being among people with spinal cord injury: The mediating influences of stress and pain. REHABIL PSYCHOL 2003;48(3):157-164.

Millar PJ, Rakobowchuk M, Adams MM, Hicks AL, McCartney N, MacDonald MJ. Effects of short-term training on heart rate dynamics in individuals with spinal cord injury. Auton Neurosci 2009; 150: 116-21.

Mohr T, Dela F, Handberg A, Biering-Sorensen F, Galbo H, Kjaer M. Insulin action and long- term electrically induced training in individuals with spinal cord injuries. Med Sci Sports Exerc 2001;33(8):1247-1252.

Mulroy, S. J., Thompson, L., Kemp, B., Hatchett, P. P., Newsam, C. J., Lupold, D. G., et al. (2011). Strengthening and Optimal Movements for Painful Shoulders (STOMPS) in chronic spinal cord injury: a randomized controlled trial. Physical Therapy, 91, 305—324.

Needham-Shropshire BM, Broton JG, Cameron TL, Klose KJ. Improved motor function in tetraplegics following neuromuscular stimulation-assisted arm ergometry. J Spinal Cord Med 1997;20(1):49-55.

Round JM, Barr FM, Moffat B, Jones DA. Fibre areas and histochemical fibre types in the quadriceps muscle of paraplegic subjects. J Neurol Sci 1993;116(2):207-211.

Sabatier, M. J., Stoner, L., Mahoney, E. T., Black, C., Elder, C., Dudley, G. A. et al. (2006). Electrically stimulated resistance training in SCI individuals increases muscle fatigue resistance but not femoral artery size or blood flow. Spinal Cord, 44, 227-233.

Silva AC, Neder JA, Chiurciu MV, Pasqualin DC, da Silva RC, Fernandez AC et al. Effect of aerobic training on ventilatory muscle endurance of spinal cord injured men. Spinal Cord 1998;36(4):240-245.

Sutbeyaz ST, Koseoglu BF, Gokkaya NK. The combined effects of controlled breathing techniques and ventilatory and upper extremity muscle exercise on cardiopulmonary responses in patients with spinal cord injury. Int J Rehabil Res 2005;28(3):273-276.

Stewart BG, Tarnopolsky MA, Hicks AL, McCartney N, Mahoney DJ, Staron RS et al. Treadmill training-induced adaptations in muscle phenotype in persons with incomplete spinal cord injury. Muscle Nerve 2004;30(1):61-68.

Evidence for “What are the exercise guidelines?” is based on:

Martin Ginis, K. A., van der Scheer, J. W., Latimer-Cheung, A. E., Barrow, A., Bourne, C., Carruthers, P., … Goosey-Tolfrey, V. L. (2018). Evidence-based scientific exercise guidelines for adults with spinal cord injury: an update and a new guideline. Spinal Cord, 56(4), 308–321.

SCIRE. (2020, March 6). Exercise after Spinal Cord Injury: How to Begin [Video file]. Retrieved from https://www.youtube.com/watch?v=P0EWCQawRbI&list=PLi2Dc1h0G7-vn6X1ROpMEMXJK6nmzinWu&index=2

Evidence for “How can I adapt exercises?” is based on:

SCIRE. (2020, March 6). Exercise after Spinal Cord Injury: How to Adapt Equipment [Video file]. Retrieved from https://www.youtube.com/watch?v=k7vTlHzYoug&list=PLi2Dc1h0G7-vn6X1ROpMEMXJK6nmzinWu&index=4

Evidence for “What should I be cautious of when exercising?” is based on:

SCIRE. (2020, March 6). Exercise after Spinal Cord Injury: Complications to Avoid [Video file]. Retrieved from: https://www.youtube.com/watch?v=HXVaLdhsBuk&list=PLi2Dc1h0G7-vn6X1ROpMEMXJK6nmzinWu&index=3

Evidence for ” How does aging affect physical activity after SCI?” is based on:

Cerrel Bazo, H. A., Demertzis, E., & Musumeci, A. (2018). The Aging Effects in Spinal Cord Injury Rehabilitation (pp. 379–402). https://doi.org/10.1007/978-3-319-57406-6_39

Cheung, L., Chiang, J., Kaiser, A., Patterson, K. K., & Musselman, K. E. (2023). Exploring the Experiences and Perceptions of Adults With Spinal Cord Injury or Disease Aged 50 Years or Older on Participation in Sports. Topics in Spinal Cord Injury Rehabilitation, 29(4), 37–50. https://doi.org/10.46292/sci23-00028

Galea, M. P. (2012). Spinal cord injury and physical activity: preservation of the body. Spinal Cord, 50(5), 344–351. https://doi.org/10.1038/sc.2011.149

Jiang, S.-D., Dai, L.-Y., & Jiang, L.-S. (2006). Osteoporosis after spinal cord injury. Osteoporosis International, 17(2), 180–192. https://doi.org/10.1007/s00198-005-2028-8

Krause, J. S., Vines, C. L., Farley, T. L., Sniezek, J., & Coker, J. (2001). An exploratory study of pressure ulcers after spinal cord injury: Relationship to protective behaviors and risk factors. Archives of Physical Medicine and Rehabilitation, 82(1), 107–113. https://doi.org/10.1053/apmr.2001.18050

Lee, A. K. Y., Miller, W. C., Townson, A. F., & Anton, H. A. (2010). Medication use is associated with fatigue in a sample of community-living individuals who have a spinal cord injury: a chart review. Spinal Cord, 48(5), 429–433. https://doi.org/10.1038/sc.2009.145

Lundström, U., Wahman, K., Seiger, Å., Gray, D. B., Isaksson, G., & Lilja, M. (2017). Participation in activities and secondary health complications among persons aging with traumatic spinal cord injury. Spinal Cord, 55(4), 367–372. https://doi.org/10.1038/sc.2016.153

Mulroy, S. J., Thompson, L., Kemp, B., Hatchett, P. P., Newsam, C. J., Lupold, D. G., Haubert, L. L., Eberly, V., Ge, T.-T., Azen, S. P., Winstein, C. J., & Gordon, J. (2011). Strengthening and Optimal Movements for Painful Shoulders (STOMPS) in Chronic Spinal Cord Injury: A Randomized Controlled Trial. Physical Therapy, 91(3), 305–324. https://doi.org/10.2522/ptj.20100182

Paterson, D. H., Jones, G. R., & Rice, C. L. (2007). Ageing and physical activity: evidence to develop exercise recommendations for older adults. Applied Physiology, Nutrition, and Metabolism, 32(S2E), S69–S108. https://doi.org/10.1139/H07-111

Tawashy, A. E., Eng, J. J., Lin, K. H., Tang, P. F., & Hung, C. (2009). Physical activity is related to lower levels of pain, fatigue and depression in individuals with spinal-cord injury: a correlational study. Spinal Cord, 47(4), 301–306. https://doi.org/10.1038/sc.2008.120

Tomasone, J. R., Wesch, N. N., Ginis, K. A. M., & Noreau, L. (2013). Spinal Cord Injury, Physical Activity, and Quality of Life: A Systematic Review. Kinesiology Review, 2(2), 113–129. https://doi.org/10.1123/krj.2.2.113

Waters, R., & Sie, I. (2001). Upper Extremity Changes with SCI Contrasted to Common Aging in the Musculoskeletal System. Topics in Spinal Cord Injury Rehabilitation, 6(3), 61–68. https://doi.org/10.1310/7TD2-Q5CX-5WH1-FDXH

Image credits

  1. Muscle ©Servier Medical Art, CC BY 3.0
  2. Woman on FES ©SCIRE, CC BY-NC 4.0
  3. Transferring ©SCIRE, CC BY-NC 4.0
  4. Wheelchair woman disability ©codipunnett, Pixabay License
  5. Modified from: Femur, Lungs, Heart ©Servier Medical Art, CC BY 3.0, and Lightning ©FLPLF, CC BY 3.0
  6. Arm cycling ©SCIRE, CC BY-NC 4.0
  7. Sledge Hockey: Italy/Sweden ©Mariska Richters, CC BY-NC-SA 2.0
  8. Bodyweight Support Treadmill ©SCIRE, CC BY-NC 4.0
  9. RPE Scale ©SCIRE, CC BY-NC 4.0
  10. RPE thumbnail ©SCIRE, CC BY-NC 4.0
  11. Adapted Exercise Thumbnail ©SCIRE, CC BY-NC 4.0
  12. Adaptive grip aids ©SCIRE, CC BY-NC 4.0
  13. Abdominal Binder ©SCIRE, CC BY-NC 4.0
  14. Dizzy ©Berkah Icorn, CC BY 3.0
  15. Exercise Video Series ©SCIRE, CC BY-NC 4.0
  16. High blood ©Eucalyp, CC BY 3.0
  17. Hot thermometer ©Abby, DE, CC BY 3.0
  18. Modified from: Man Resting on Long Chair ©Gan Khoon Lay, CC BY 3.0
  19. Shoulder injury ©ProSymbols, US, CC BY 3.0
  20. Aging Activity Thumbnail ©SCIRE, CC BY-NC 4.0

 

Disclaimer: This document does not provide medical advice. This information is provided for educational purposes only. Consult a qualified health professional for further information or specific medical advice. The SCIRE Project, its partners and collaborators disclaim any liability to any party for any loss or damage by errors or omissions in this publication.
Mar 03
0

Manual Wheelchairs

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Author: Sharon Jang | Reviewer: Emma M. Smith | Published: 3 March 2020 | Updated: ~

Manual wheelchairs are a type of wheeled mobility device that are an important part of independent living after spinal cord injury (SCI). This page provides an overview of manual wheelchairs. SCIRE Community is not affiliated with and does not endorse any of the specific products mentioned on this page.

Key Points

  • Manual wheelchairs are typically used by people with enough movement control and strength in the arms to propel the wheelchair independently
  • A manual wheelchair consists of many different parts, most of which can be altered to suit your needs
  • Manual wheelchairs can be adjusted to prevent injury and to promote comfort
  • Multiple factors play into injuries related to manual wheelchair use, including the way you push your wheelchair, your wheelchair set up, and the surfaces you are wheeling on

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Who can use a manual wheelchair?

Manual wheelchairs are wheelchairs that are propelled by the user or pushed by another person. They do not have a battery or other power source.

For the most part, manual wheelchairs are used by people who have enough muscle control and strength in their arms to propel the wheelchair forward on their own. For people with SCI, this typically means that a person needs to at least have function of the biceps (the muscle that bends the elbow), which is intact for people with complete injuries at C5 and below. However, it can be difficult to propel a wheelchair for individuals with C5 and C6 injuries, so only some individuals with these types of injuries will be able to do so. Use of a manual wheelchair is more common in people with control of the triceps (the muscle that straightens the elbow), which is intact in people with complete injuries at C7 and below. In some cases, a manual wheelchair can be pushed by another person or propelled using the legs.

As a bridge between the more common manual and power wheelchairs, power-assist add-ons combine features of manual and power wheelchairs to provide greater assistance for those who need it. Additionally, non-powered propulsion assist add-ons may also be used to facilitate wheeling. Propulsion assist options are available for manual wheelchairs and come in several different styles. The use of powered add-ons has been reported to improve efficiency and to reduce strain on the cardiovascular system. The following article will focus on manual wheelchairs that are propelled with the arms.

Refer to our chapter on Propulsion Assist Devices for more information!

What are the components of a manual wheelchair?

A typical manual wheelchair contains a frame, seat with a backrest, footrests or footplate, two small caster wheels in the front, and two large rear wheels at the back. The rear wheels contain hand rims which are used to propel and maneuver the wheelchair. Wheel locks on the rear wheels help prevent the wheelchair from moving when it is not in use or when getting in or out of it.

There are many different styles of manual wheelchairs, most of which allow for the ability to adjust and change aspects of the set up. This can be important in the first few years that a person uses a wheelchair as a person’s skills and priorities may change. Nonetheless, it is important to try to get as lightweight and compact a wheelchair as possible while also ensuring it is safe, durable and flexible.

There are many different components of manual wheelchairs that can be customized and changed to find the best set-up for an individual. Below, we list some of the common options and changes that may be possible when setting up a manual wheelchair. In general, changes to the set-up of the manual wheelchair are a series of tradeoffs. Although changes are usually intended to achieve a desirable improvement (such as greater ease of wheeling), sometimes they need to be balanced with reduced stability and an increased risk of tipping over. Please speak to your health providers before making any major changes to your wheelchair set-up.

Frame design

Manual wheelchairs come in two basic frame designs, folding frames or rigid frames. Folding frames have a crossbar under the seat that allows the frame to fold in half. Rigid frames may also fold but in a different way, where the backrest folds down. In many manual wheelchairs, wheels can removed if they are being put in a vehicle.

Folding manual wheelchairs

Folding wheelchairs are designed to be folded vertically and take up minimal storage space. This allows for easy portability (such as fitting the wheelchair into a car). However, these wheelchairs also have many moving parts that may break down or loosen over time, and are heavier than rigid wheelchairs. Folding wheelchair often have flip up, swing away or swing in footrests so they may be used by individuals that do not use the wheelchair full time, can stand or take some steps, or by those who foot propel.

Rigid manual wheelchairs

Rigid wheelchairs tend to be lighter and more durable than folding wheelchairs, which makes them the common choice for people with complete SCI injuries. The rear tires often have to be removed to fit into a vehicle because they cannot fold inward. Some rigid manual wheelchairs can still be ordered with adjustability, which can be important if seating components change.

 

Frame materials

The majority of manual wheelchair frames are made of either aluminum or stainless steel. Ultralight and sports wheelchairs are often constructed from high performance aluminum, carbon fiber, chromium-molybdenum, nickel alloy steel, or titanium. Titanium and composites can be considerably more expensive but are more lightweight.

Seat width, depth and slope

It is important that the width, depth and slope (also known as dump) of the seat from front to back are well-fitted to the overall function and characteristics of the user. A wheelchair that is too narrow in width may cause skin problems due to rubbing, while a wheelchair that is too wide may hinder propulsion, and will interfere with the accessibility and maneuverability of the chair. A wheelchair that is too short in depth may provide insufficient support to the hips and stability to the bottom, while a wheelchair that is too long in depth may cause knee pain or a slouching posture.  In addition, an increased seat slope (i.e., one that is higher in the front than the back) makes transfers more difficult as one would need to lift up at an incline, but are better for people with a higher level of injury because this slope helps them find balance and stability to wheel.

Footrest angle and frame taper

The footplate is angled away from the frame of the chair and the post of the casters.6

When considering the footrest angle between the seat and the footplate hanger, the knee flexion range of movement and hamstring length needs to be considered as well as the visual field as the client may not be able to see their feet. For example, a greater frame angle improves wheelchair access by making the chair shorter but may make the chair more unstable in the forward direction. Some wheelchairs have a frame taper, which is the narrowing of the frame towards the front and continues down to the footplates. This improves access from the front of the wheelchair, making toilet transfers easier. However, the taper may not be compatible with the cushion and may impact the ability of the wheelchair to fold.

Rear Wheels

Spoked wheels (left) versus mag wheels (right).7,8

The rear wheels are set up with hand rims on them so that self-propelling is possible. Wheel material and the amount of air in the wheels affect how effective the wheels are in minimizing vibration or shock to prevent triggering of spasticity and to increase comfort. Wheel rims are made from a variety of materials including aircraft grade aluminum, plastic, fibreglass, reinforced nylon, titanium, carbon graphite, or steel. Types of rear wheels include: spoked wheels (made of metal, normally has more than 30 spokes), mag wheels (made out of synthetic material, less than 10 spokes), carbon-graphite mag wheels, and power assist wheels. The more spokes, the better the vibration absorption. The most common wheel size for adults is 60cm (24”) and for children it is 50cm (20”).

Tires

Airless (solid) tires tend to provide bumpier ride.9

Wheelchairs may have solid tires, foam-filled tires, or air (pneumatic) tires. Solid tires do not run the risk of popping, however, they often result in a bumpier ride. On the contrary, air tires provide a softer ride, but require regular maintenance of air pressure. A lack of air in the tires (less than 50% of the recommended PSI) makes propelling a wheelchair more difficult. It is recommended that tires be re-inflated every two months to keep the pressure above 50%. Some type of tires include: standard pneumatic tires, high pressure pneumatic tires, outdoor pneumatic tires, puncture proof tires, and solid plastic tires.

Hand rims/Push rims

Hand rims are attached to the rear wheel rim on wheelchairs that are intended for self-propulsion. This part is optional, and some users may opt not to use them. Hand rims are commonly made out of aluminum, and may be anodized or vinyl coated. Some downsides to using aluminum hand rims are that they may turn your hand black, and can become very sharp if they are damaged. Other models of hand rims have a rubber like material and assist individuals without full handgrip with their push stroke. In addition, flexible hand rims have been developed to adapt to the shape of the hand in order to reduce strain resulting from the bending action of the wrist and fingers.

Front caster wheels

The small front wheels are called caster wheels, and they help maneuver and steer the position of the wheelchair. Caster diameter, material, and position are important factors to consider that affect wheelchair balance and performance. Sizes available include 75mm (3”), 125mm (5”), 150mm (6”), 180mm (7”), 200mm (8”), and 250mm (10”). Bigger caster wheels are more stable, have a bigger turning radius, and easier to wheel over thresholds but are less maneuverable and responsive. A point of caution is that when caster wheels are trailing, a person’s weight will be more forward and may be in front of the caster wheel, which can cause tipping and is a frequent cause of falls in manual wheelchairs (see image below). Caster stem angle must always lie at right angles to the floor to ensure casters track correctly, or they may “flutter” when the wheelchair is pushed or can cause the front of the wheelchair to rise and fall during turning.

Forward casters (left) versus trailing casters (right).11

When choosing the type of caster, one should consider the most common type of surface they will be propelling on (e.g. outdoors or indoors), the desired front seat height, and the front frame angle of the wheelchair. The construction materials available for caster wheels include plastic, urethane and aluminum. Pneumatic caster tires, usually 150mm (6”)” and 200mm (8”) in diameter, have more shock absorption features making them ideal for outdoor wheeling, while 75mm (3”) and 125mm (5”) urethane caster tires are more common and are good for indoor propulsion and sport specific wheelchairs. Those who experience significant spasticity and/or discomfort when propelling wheelchairs often opt for pneumatic casters to achieve a smoother ride.

Wheel locks

Wheel locks are used on the large rear wheels for safety with transfers and when no movement is wanted. They vary in styles including push to lock, pull to lock, and scissor style locks. To decrease the force required to engage/disengage the wheel locks, extended brake levers can be applied, as they minimize the forward reach required to access the wheel locks. The type and position of the lock should be influenced by the user’s reaching ability, balance, strength, and hand function as well as the impact of wheel lock position on transfers. Some clients with good physical skills may not even require wheel locks at all.

Anti-tippers

Anti-tippers are an optional set of smaller wheels connected to a metal poles that are attached to the frame of your wheelchair 381 to 508mm (1.5 to 2″) above the ground. Anti-tippers are commonly found on rear of the chair to prevent a backwards fall, however they can also be found on the front of the wheelchair to prevent forward tipping. Anti-tippers may be especially useful for new wheelchair users, those who have recently switched to a new wheelchair, or if one’s health is declining. While they are considered a safety item, they also have drawbacks. Firstly, anti-tippers may interfere with wheelchair skills requiring you to lean backwards, such as climbing a curb or doing a wheelie. Secondly, if the anti-tippers are set too low, it may impede on going over obstacles or up hills.

What are adjustments I can make to the set-up of my wheelchair?

There are many necessary considerations for setting up a manual wheelchair properly for mobility and function. It is important to work with a knowledgeable health care professional and vendor to ensure the correct decisions are made.

These considerations may include:

Various factors can influence your ideal wheelchair set up. In this photo, some considerations include having a dog and wheeling on grass.13

  • Activities of Daily Living: It is important to think about where you need to take your chair, how close you can get to or under surfaces, reach for things, and how easily you can remove components and put them back on.
  • Mobility: You need to consider what surfaces you will wheel on (carpet, flooring, snow, rain). How the chair will move over inclines and transitions as well as in confined spaces. Is it a primary chair or just an indoor chair or a transport chair?
  • Positioning: It is important to consider your posture, comfort and interacting with people and your environment.
  • Psychosocial: You want to consider how you look and feel and how you will interact with people and your environment.
  • Transfers: You need to look at the ability to get in and out of the wheelchair safely so the height, stability, ease of moving and weight are some of the things to consider.

The three most important adjustments to have in a manual wheelchair are back angle, axle position and seat to floor height. These adjustments are important as they can have an impact on pain, wounds, or postural issues. The wheelchair set-up is essential to allow for safety and balance of the chair.

Axle Position (vertical and horizontal)

The horizontal position of the rear wheel axle can affect how much energy is required to move the wheelchair. Studies have shown that placing the rear wheel axle closer to the front of the wheelchair can make it easier to propel. However, it can also affect the stability of the wheelchair, and make the wheelchair more likely to tip backwards. This is because there is more weight behind the axle. Decisions on where to place the axle will depend on the person’s wheelchair skills. The distance between the shoulder and the axle of the rear wheel can also affect efficiency. One study showed that greater distances may result in greater energy requirements. Adding adjustable axles to manual wheelchairs can help individuals customize their wheelchairs to improve propulsion. This can lead to reduced risks of upper body injuries specifically shoulder injuries.

Backrest height and angle

The appropriate backrest height is largely a trade-off between posture, comfort and freedom of movement. A backrest is usually 406mm (16″) tall, and often does not come up any higher than your shoulder blades – any higher and it will impede your ability to push your wheelchair. Most manual wheelchairs have the ability to modify the height of the backrest (so it can be modified as function increases or decreases). A higher backrest is seen to be more comfortable, and is often used by individuals with limited trunk functioning as it provides more support. On the contrary, a shorter back rest allows for more movement of the trunk, which can be functionally useful (e.g., it will allow you to reach for objects sideways and behind you).

Using a wheelchair with backrest height that is not optimal may have negative consequences. If the backrest is too low, there will be a lack of support which may lead to postural instability. However, most often individuals are using backrests that are too high. This may result in a limited reach (and thus reduction in functional activity), pain, and a slouching posture as a result of compensating for sliding forward.

Other Adjustments

Rear wheel lateral position (space from frame) and camber

The lateral position of the rear wheel is the distance the wheel is from the wheelchair frame. This distance can affect the overall width of the wheelchair and how accessible the wheel is.

Camber relates to the rear wheels being set on an angle from their axle position, where the distance between the top of the wheels is less than at the bottom of the wheels. The angle can range from 0º up to an extreme 12º, although the average camber for day wheelchairs varies from 0º to 4º. Some wheelchair models offer adjustability in camber angles within the same chair. Stability, wheeling efficiency, and turning maneuverability can be enhanced with wheel camber, especially when moving over side slopes. In addition, the hands are better protected against trauma because the wheels touch the floor spanning a wider area than the hands have in contact with the hand rims. Too much camber can make the overall width of the wheelchair wider so assessment of the spaces and doorways needed to access is essential when deciding on camber.

Camber and Sports Wheelchairs

A large camber is often seen on sport wheelchairs, measuring up to 15º. A greater camber is of beneficial use to wheelchair sports, as it provides more lateral support to prevent tipping over to the side when turning quickly and sharply. It also helps to create turns that are smoother and sharper when in motion.

 

Footrest height and length

Proper support of the feet and legs is important to the comfort and safety of the wheelchair user. If the foot and thigh is not properly supported it may result in the leg or foot moving excessively and may result in instability, pain, and spasticity. In addition, it can create areas of pressure on the leg or the foot, ultimately leading to pressure injuries. Support can be adjusted through altering the height and length of the footrest.

The foot rest should be 1-2 inches off the ground to allow for optimal clearance. If it is too low, it may catch on door threshold and other objects, and may cause difficulties when trying to go up or down hills or slopes. Should the footrest unexpectedly hit an obstacle, there is a high risk of the user falling out of their wheelchair.

Refer to our article on Wheelchair Seating for more information on footrest set-ups

What are health concerns related to manual wheelchair use?

Using a manual wheelchair can be tough on the user’s arms and shoulders. Research has shown that 25-80% of manual wheelchair users experience injuries in their wrists, elbows, and or/shoulders. There have been multiple (weak) studies that have identified multiple factors that can be addressed in order to reduce/prevent the chances of injury:

Muscles required for propulsion

Muscles in the chest, upper back, shoulders, and arms that are used in propelling a wheelchair.17

When pushing a manual wheelchair, many muscles in the upper back, chest, shoulder, and arms are used. Pushing a manual wheelchair is not the most efficient way of getting around, as only between 2-14% of force applied by the arms goes into propelling a wheelchair, depending on the level of injury and style of propelling. The shoulder muscles are particularly strained during wheelchair propulsion as they are relatively smaller muscles that are responsible for both stabilizing the shoulder and applying force to a wheelchair to push it forward . Shoulder pain occurs in 31-73% of manual wheelchair users, and weak evidence suggests that individuals with tetraplegia experience more pain due to greater forces being applied with their arms.

 

Kinematics: the technique you use when propelling a wheelchair can impact your risk of shoulder pain/injury. For example, pushing a wheelchair at increasing speeds/intensities may contribute to the development of shoulder pain. Additional factors to be considered include the angle of your joints (i.e., the elbows, wrist) when pushing, and the angle at which you push your tires at.

Propulsion pattern: the pattern you push your wheelchair with (e.g., where do your hands go when you push and after you’re done pushing) may also have an influence on your risk of injury. Some weak evidence suggests that using the semi-circular and double-loop-over may reduce the risk of nerve injury and are the most optimal ways to push your wheelchair. Further evidence (weak) has indicated that arcing may be more efficient for short bouts of high intensity pushing (like when going uphill).

Body weight: Weak evidence suggests that having a higher body weight may be related to a higher risk of injury while propelling your wheelchair. This is due to the fact that moving a heavier body requires higher forces created by the shoulders. Body weight management is important in decreasing the amount of force created in your arms when pushing your wheelchair, and reduces the risk of injury.

Wheelchair set up: Having the rear wheels on a manual wheelchair placed in a forward axle position can help improve push rim biomechanics, reduce the amount of force put on your shoulders when propelling, and the frequency of propulsion (i.e., you do not have to push as much to go as far). Research has suggested the use of manual wheelchairs with adjustable axle positions so that the rear wheels can be optimally adjusted.

Wheeling on uneven surfaces: Some research suggests that wheeling across cross slopes (such as a driveway) can increase the forces on the arm and may lead to overuse injuries. In addition, more physiological effort  (i.e., heart rate, how much oxygen is being used, rating of perceived exertion) is required to go up slopes more than 2% incline, and more physiological and physical effort is required to go up slopes greater than 8%.

The bottom line

Manual wheelchairs are highly customizable pieces of equipment that can be tailored to your needs. In order to optimally use your wheelchair, certain adjustments to the backrest, frame, and tires can be made. Using manual wheelchairs requires upper arm function and strength. Improper set ups and techniques may lead to injuries.

It is best to discuss all treatment options with your health providers to find out which treatments are suitable for you.

For a review of how we assess evidence at SCIRE Community and advice on making decisions, please see SCIRE Community Evidence.

Reference list

Parts of this page has been adapted from SCIRE Project (Professional) “Wheeled mobility and seating equipment following spinal cord injury” Chapter:

Titus L, Moir S, Casalino A, McIntyre A, Connolly S, Mortenson B, Guilbalt L, Miles S, Trenholm K, Benton B, Regan M. (2016). Wheeled Mobility and Seating Equipment Following Spinal Cord Injury. In Eng JJ, Teasell RW, Miller WC, Wolfe DL, Townson AF, Hsieh JTC, Connolly SJ, Loh E, McIntyre A, editors. Spinal Cord Injury Rehabilitation Evidence. Version 6.0: p 1-178.

Available from: https://scireproject.com/evidence/rehabilitation-evidence/wheeled-mobility-and-seating-equipment/ 

 

Evidence for “What are the components of a manual wheelchair?” is based on:

Boninger, M., and the Model Systems Knowledge Translation Center. (2019). The manual wheelchair: What the spinal cord injury consumer needs to know. Retrieved from: https://msktc.org/sci/factsheets/wheelchairs/The-Manual-Wheelchair

Spinal outreach team and The University of Queensland School of health and rehabilitation sciences. (n.d.). Manual wheelchairs: Information resource for service providers. Retrieved from: https://www.health.qld.gov.au/__data/assets/pdf_file/0026/429911/manual-wheelchairs.pdf

Evidence for “What adjustments can I make to my manual wheelchair?” is based on:

Sprigle, S. (2014). Measure it: proper wheelchair fit is key to ensuring function while protecting skin integrity. Advanced Skin Wound Care, 27(12), 561-72.

Evidence for “What are health concerns related to manual wheelchair use?” is based on:

Arva, J., Fitzgerald, S. G., Cooper, R. A., & Boninger, M. L. (2001). Mechanical efficiency and user power requirement with a pushrim activated power assisted wheelchair. Medical Engineering and Physics, 23(10), 699–705. https://doi.org/10.1016/S1350-4533(01)00054-6

Boninger, M. L., Souza, A. L., Cooper, R. A., Fitzgerald, S. G., Koontz, A. M., & Fay, B. T. (2002). Propulsion patterns and pushrim biomechanics in manual wheelchair propulsion. Archives of Physical Medicine and Rehabilitation, 83(5), 718–723. https://doi.org/10.1053/apmr.2002.32455

Curtis, K. A., Drysdale, G. A., Lanza, R. D., Kolber, M., Vitolo, R. S., & West, R. (1999). Shoulder pain in wheelchair users with tetraplegia and paraplegia. Archives of Physical Medicine and Rehabilitation, 80(4), 453–457. https://doi.org/10.1016/S0003-9993(99)90285-X

Gil-Agudo, A., Del Ama-Espinosa, A., Pérez-Rizo, E., Pérez-Nombela, S., & Pablo Rodríguez-Rodríguez, L. (2010). Upper limb joint kinetics during manual wheelchair propulsion in patients with different levels of spinal cord injury. Journal of Biomechanics, 43(13), 2508–2515. https://doi.org/10.1016/j.jbiomech.2010.05.021

Kulig, K., Newsam, C. J., Mulroy, S. J., Rao, S., Gronley, J. K., Bontrager, E. L., & Perry, J. (2001). The effect of level of spinal cord injury on shoulder joint kinetics during manual wheelchair propulsion. Clinical Biomechanics, 16, 744–751.

Rankin, J. W., Richter, W. M., & Neptune, R. R. (2011). Individual muscle contributions to push and recovery subtasks during wheelchair propulsion. Journal of Biomechanics, 44(7), 1246–1252. https://doi.org/10.1016/j.jbiomech.2011.02.073

Richter, W. M., Rodriguez, R., Woods, K. R., & Axelson, P. W. (2007). Consequences of a Cross Slope on Wheelchair Handrim Biomechanics. Archives of Physical Medicine and Rehabilitation, 88(1), 76–80. https://doi.org/10.1016/j.apmr.2006.09.015

Image credits

  1. Kuschall wheelchair model R33 ©Tim99~commonswiki, CC BY-SA 4.0
  2. Image modified from Different kinds of handicap equipments ©brgfx, Freepik License
  3. Wheelchair ©George Hodan, CC0 1.0
  4. Wheelchair parts (main pic) ©Memasa CC BY-SA 3.0
  5. The SCIRE Community Team
  6. Modified from disabled, stroller, the disease, wheelchair, disability, wheel, transportation, medical equipment, metal, mode of transportation, CC0 1.0
  7. Wheelchair disability paraplegic injured disabled ©stevepb, Pixabay License
  8. wheelchair, old, vintage, isolated, wheel, antique, transportation, white, retro, transport, CC0 1.0
  9. The SCIRE Community Team
  10. Wheelchair disabled person with reduced mobility man ©SGENET, Pixabay License
  11. Forward versus trailing casters ©Ian Denison
  12. Modified from Black and grey wheelchair, CC0 1.0
  13. Woman, dog, pet, friend, outdoors, grass, female, person, jacket, pal, CC0 1.0
  14. Axle Position by the SCIRE Community Team
  15. Modified from Disabled people set Free Vector ©Macrovector, Freepik License
  16. Euroleague – LE Roma vs Toulouse IC-27 ©Pierre-Selim, CC BY-SA 3.0
  17. Muscles that move the humerus ©Betts et al, CC BY-SA 4.0
  18. Stylized illustration of stroke pattern classification during wheelchair propulsion ©Emily Churton and Justin WL Keogh, CC BY 2.0

 

Disclaimer: This document does not provide medical advice. This information is provided for educational purposes only. Consult a qualified health professional for further information or specific medical advice. The SCIRE Project, its partners and collaborators disclaim any liability to any party for any loss or damage by errors or omissions in this publication.
Mar 25
0

Exercise Guidelines for Adults With Spinal Cord Injury

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Download the Exercise Guidelines, currently available in 13 languages:

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Author: Dominik Zbogar | Reviewer: Kathleen Martin Ginis | Published: 25 March 2019 | Updated: 30 June 2023

Physical activity is an important consideration after spinal cord injury (SCI) and is a key factor in preventing lifestyle diseases. This page provides guidelines for physical activity following SCI.

Key Points

  • People with SCI face tremendous physical, psychosocial, and environmental barriers to physical activity. They are less active and physically deconditioned than the general population and people with other disabilities.
  • Overwhelming evidence suggests that people living with SCI can achieve health benefits from activity levels well below the generally recommended 150 min/week threshold.
  • The guidelines herein were created for adults aged 18-64 with chronic SCI (at least one year post-onset), with consideration given to the potential risks of SCI-specific adverse events including upper-body over-use injuries, skin breakdown, autonomic dysreflexia, and over-heating as well as consideration to the feasibility of these guidelines in the SCI population.

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How were the exercise guidelines developed?

A screen-capture of the first page of the journal article "Evidence-based scientific exercise guidelines for adults with SCI" from Martin-Ginis et al.A group led by Dr. Kathleen Martin Ginis at the University of British Columbia and Dr. Victoria Goosey-Tolfrey at Loughborough University, UK developed international guidelines on exercise after SCI. The process of developing these guidelines involved a systematic review of relevant literature, consensus meetings, stakeholder feedback, and a formal audit of the process.

The result was the publication of the journal article about the guidelines (available in the journal Spinal Cord via nature.com/articles/s41393-017-0017-3) and the actual guidelines titled, “Scientific Exercise Guidelines for Adults with Spinal Cord Injury” which are described next.­

What are the exercise guidelines for adults with SCI?

The exercise guidelines for adults with SCI.

For cardiorespiratory fitness and muscle strength benefits, adults with SCI should engage in:

  • At least 20 minutes of moderate to vigorous intensity aerobic exercise 2 times per week.
  • 3 sets of strength exercises for each major functioning muscle group, at a moderate to vigorous intensity, 2 times per week.

For cardiometabolic health benefits, adults with SCI are suggested to engage in:

  • At least 30 minutes of moderate to vigorous intensity aerobic exercise 3 times per week.

wheelchair sign image multiplied and stretched out

What are cardiometabolic health, cardiorespiratory fitness, and muscle strength?

Cardiometabolic health

Cardiometabolic health encompasses measures of body composition (e.g., fat mass, lean body mass) and risk factors for cardiovascular disease (e.g., high cholesterol and hypertension). Common measures to assess cardiometabolic health include a blood test to assess triglycerides and cholesterol, measuring blood pressure, and measuring height, weight, and waist circumference.

Cardiovascular fitness

Cardiovascular fitness refers to the ability of the heart and lungs to deliver oxygen to working muscles and can be assessed through a maximal graded exercise test which provides information such as peak oxygen uptake and peak power output.

Muscle strength

Muscle strength refers to the amount of force that a muscle can exert. It can be measured by lifting objects of specified weight or exerting force against a measurement tool such as a hand grip dynanometer.

The exercise guideline details

These exercise guidelines provide minimum thresholds for improving cardiorespiratory fitness and muscle strength and for improving cardiometabolic health.

orange speedometer set to lowIf you are not already exercising, it is okay to start with smaller amounts of exercise and gradually increase duration, frequency, and intensity, as a progression toward meeting the guidelines. Doing exercise below the recommended levels may or may not bring small changes in fitness or cardiometabolic health.

green speedometer set to highExceeding these exercise guidelines would be expected to yield additional cardiorespiratory fitness and muscle strength and cardiometabolic health benefits. However, there are insufficient data to comment on the risks associated with a person with SCI exceeding these guidelines.

The guidelines should be achieved above and beyond the incidental physical activity one might accumulate in the course of daily living. Adults are encouraged to participate routinely in exercise modalities and contexts that are sustainable, enjoyable, safe and reasonably achievable.

Refer to our article on Physical Activity for more information! 

These guidelines are appropriate for adults (aged 18-64) with chronic SCI (at least one year post-onset), neurological level of injury C3 and below, from traumatic or non-traumatic causes, including tetraplegia and paraplegia, irrespective of sex, race, ethnicity or socio-economic status.

The guidelines may be appropriate for individuals with a SCI less than one year post-onset, aged 65 years or older, or living with comorbid conditions. There is currently insufficient scientific evidence to draw firm conclusions about the risks and benefits of the guidelines for these individuals. These individuals should consult a health care provider prior to beginning an exercise programme.

The risks associated with these guidelines are minimal when managed in consultation with a health care professional who is knowledgeable in SCI. Individuals with a cervical or high thoracic injury should be aware of the signs and symptoms of autonomic dysreflexia during exercise.

Refer to our article on Autonomic Dysreflexia for more information! 

The bottom line

These guidelines were developed using transparent and rigorous steps that align with international best-practices for developing clinical practice guidelines. They represent an important step toward developing exercise policies and programs for people with SCI around the world.

References

Hicks, A. L., Martin Ginis, K. A., Pelletier, C. A., Ditor, D. S., Foulon, B., & Wolfe, D. L. (2011). The effects of exercise training on physical capacity, strength, body composition and functional performance among adults with spinal cord injury: a systematic review. Spinal Cord, 49(11), 1103–1127.

Martin Ginis, K. A., van der Scheer, J. W., Latimer-Cheung, A. E., Barrow, A., Bourne, C., Carruthers, P., … Goosey-Tolfrey, V. L. (2018). Evidence-based scientific exercise guidelines for adults with spinal cord injury: an update and a new guideline. Spinal Cord, 56(4), 308–321.

Hoekstra, F., McBride, C.B., Borisoff, J. et al. (2020). Translating the international scientific spinal cord injury exercise guidelines into community and clinical practice guidelines: a Canadian evidence-informed resource. Spinal Cord. https://doi.org/10.1038/s41393-019-0410-1

Images credits
  1. Flag of the Netherlands: ©Zscout370, CC BY 4.0
  2. Flag of the United Kingdom: ©Xaosflux, CC BY 4.0
  3. Flag of France: Public Domain
  4. Flag of Germany: ©Anomie, CC BY 4.0
  5. Flag of Greece: Public Domain
  6. Flag of Indonesia: Public Domain
  7. Flag of Italy: ©Anomie, CC BY 4.0
  8. Flag of Japan: Public Domain
  9. Calligraphic rendition of Farsi: By Jahongard – Own work based on: Farsi.jpg, CC BY-SA 3.0
  10. Flag of South Korea: Public Domain
  11. Flag of Spain: ©Vzb83, CC BY 4.0
  12. Flag of Sweden: ©Mr. Stradivarius, CC BY 4.0
  13. Flag of Thailand: ©Zscout370, Public Domain
  14. Modified from: Journal article screencap©Kathleen A. Martin Ginis, CC BY-NC 4.0
  15. Modified from: The scientific exercise guidelines for adults with spinal cord injury©Kathleen A. Martin Ginis, CC BY-NC 4.0
  16. Modified from: Pictogram of person in wheelchair©Kathleen A. Martin Ginis, CC BY-NC 4.0
  17. Modified from: Speedometer: ©designvector, CC BY-NC 4.0
  18. Modified from: Speedometer: ©designvector, CC BY-NC 4.0

 

Disclaimer: This document does not provide medical advice. This information is provided for educational purposes only. Consult a qualified health professional for further information or specific medical advice. The SCIRE Project, its partners and collaborators disclaim any liability to any party for any loss or damage by errors or omissions in this publication.
Jan 17
0

Supported Standing

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Author: SCIRE Community Team | Reviewer: Darryl Caves | Published: 17 January 2018 | Updated: ~

Standing with supportive equipment is a therapy option after spinal cord injury (SCI). This page outlines basic information about the use of supported standing after SCI.

Key Points

  • Passive standing using supportive equipment is a therapy option for people who do not stand as part of their everyday mobility.
  • Passive standing involves using equipment such as standing frames, tilt tables, orthoses or standing wheelchairs to support an upright position for a period of time.
  • Standing involves a change in posture that challenges the circulatory system, loads the legs, and provides different sensory stimulation.
  • Research evidence suggests that standing may improve blood pressure control and spasticity management. There is conflicting evidence about whether passive standing helps with bone density or bowel and bladder health.
  • Further research is needed to better understand the benefits of standing after SCI and how long standing should be done for to achieve those benefits.

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Why is standing used as a therapy?

Running shoes

Standing is a therapy option following SCI.1

Standing is an important part of functional movement in humans. Standing is needed for walking, and also provides a challenge to the circulatory system, bones, and muscles in ways that cannot be achieved in sitting or lying.

Passive standing (standing with support instead of by muscle activation) may have treatment benefits after SCI, even when the recovery of walking and standing abilities is unlikely. Standing may have benefits in treating health conditions associated with SCI, such as conditions involving the musculoskeletal, circulatory, breathing, bowel and bladder systems. It remains a key treatment tool used in rehabilitation.

What types of equipment are used for standing?

Supported standing involves the use of special equipment to support an upright posture. The type of equipment used depends on the person’s unique characteristics and abilities (such as the amount of muscle control in the arms, legs and trunk), the equipment that is available, and other medical concerns like joint contractures, spasticity and osteoporosis. Equipment used for standing may include a wide range of different devices such as:

Tilt tables

Illustration showing a person lying on a tilt table and secured with a band around the waist. There is an arrow showing that the tilt table is moving to an upright position.

Tilt tables can be moved from a horizontal to a vertical position.2

Tilt tables are flat surfaces that can be tilted from a horizontal position into a vertical standing position. The person is strapped securely to the table while in a horizontal lying position and the table can be tilted vertically. Tilt tables are typically the first devices that are used to work towards standing because the table can be gradually increased by degrees. This is often needed because it may take some time to tolerate being upright and maintaining a safe blood pressure. It is also a good device to test a person’s physical tolerance and safety for standing.

Standing frames

Standing frames are simple frames that have padding at the joints to support a standing position. There are many different types of standing frames. The frame needs to be fitted to the person’s unique physical abilities and body type and minimize areas of excess pressure.

Standing wheelchairs

Photograph of a person using a standing frame with cushions behind and in front of the legs to help align them. The person is resting their arms on a small desk that is attached to the frame.

Standing using a standing frame.3

Standing wheelchairs are wheelchairs that can extend from a sitting position into standing. There are many different types of standing wheelchairs, from manual devices to motorized systems. However, standing wheelchairs are expensive and not commonly available.

Body weight-supported treadmill training

Suspension body weight support systems involve a harness system that is suspended from above to support a percentage of body weight while standing. These systems are typically used while walking on a treadmill (body weight-supported treadmill training) or sometimes while walking over ground. This type of system is usually used for people with incomplete injuries that may work towards standing or stepping independently.

See our article on Body Weight Supported Treadmill Training.

Robotic exoskeletons

Robotic exoskeletons are a relatively new and emerging technology that is typically used for walking and walking training, but may also have benefits related to standing. However, this equipment is costly and not available in most settings.

Walkers, crutches or canes may be used by people with incomplete SCI and good strength in the arms who need only minimal support in standing.

Orthoses

Orthoses and braces may be used to brace the hip, knee and/or ankle joints to keep them from bending. This can help to support the person in an upright standing posture with training and rehabilitation. Orthoses and braces are typically custom-made and usually used by people with paraplegia who have good upper body strength and hip flexibility. Orthoses and braces used for standing may include:

  • Knee Ankle Foot Orthoses (KAFOs) provide support at the knee, ankle and foot.
  • Reciprocating Gait Orthoses (RGOs) are more complex orthoses that are made of a left and right KAFO that are linked together with a rigid brace at the pelvis or abdomen. The brace has hip joints that are built with an alternating stepping mechanism. When one leg is extended, the other flexes forward, providing assistance for stepping. Although normally used for walking, reciprocating gait orthoses can also be used to help support a standing position.

 


A person walking between parallel bars with FES applied to their legs and two other people supporting the feet.

FES can be applied to the leg muscles during assisted walking.4

Functional electrical stimulation

Functional electrical stimulation (FES) involves the use of electrical stimulation to activate muscles that are weak or paralyzed after an SCI during a purposeful activity. FES over the trunk or leg muscles may be used while standing with equipment for added benefits.

See our article on Functional Electrical Stimulation (FES) for more information.

Standing equipment may be expensive and sometimes requires repeated visits to healthcare facilities, which can sometimes be a barrier to regular standing. It is important for the individual to work with their health providers to find appropriate equipment that is safe and suitable.

How is standing done?

Once appropriate equipment and strategies for standing are selected with assistance from a health provider, standing is gradually introduced over time. The amount of time spent standing, the amount of load that is taken through the legs, and the final standing position will be adjusted until a suitable standing position can be maintained. During these first several sessions, health providers will monitor for any adverse effects related to the treatment.

A person walking between parallel bars with his wheelchair behind him. A heathcare provider on the side watches him.

Standing and stepping activities may be combined to optimize therapy.5

Current research findings are unable to tell us how long or how often standing should be done to have benefits. Studies have used standing for 20 to 60 minutes, three to four times per week to study the effects of this treatment. It will be different for everyone. The standing prescription will be based on the person’s unique situation.

Depending on the treatment goals, standing may also involve:

  • Adding extra weight while standing
  • Using standing together with functional electrical stimulation (FES) to activate the muscles of the legs and/or trunk
  • Weight-shifting, balance or stepping activities

Is supported standing safe?

Supported standing is considered to be a relatively safe treatment for use after SCI. However, there are some situations in which standing may not be appropriate and some possible risks. This is not a complete list; please consult a health provider for further safety information.

Standing should not be used in the following situations:

  • By people with recent broken bones (fractures) or a high risk of fractures (such as people with severe osteoporosis)
    Diagram comparing bone with normal bone mineral density to bone with osteoporosis.

    People with osteoporosis have weaker bones which can pose a risk during supported standing.6

  • Where the standing equipment places excess pressure on areas where there are injuries, sores, and wounds; or areas of skin prone to pressure injuries
  • By individuals whose limbs cannot be brought into a good standing position due to other conditions like joint contractures, spasticity, or heterotopic ossification
  • By people with medical conditions where heart rate or blood pressure are uncontrolled, such as those who are unable to stay upright without a major drop in blood pressure (severe orthostatic hypotension)
  • By people with muscle or joint injuries or other conditions that may be worsened by standing

Risks of standing may include:

  • Pressure injuries if the position and equipment used for standing creates too much pressure or shear while standing – it is essential that the equipment used for standing is appropriately fitted to prevent skin damage
  • Blood pooling in the legs may lead to feelings of light-headedness, dizziness or fainting (orthostatic hypotension)
  • Broken bones (fractures) are possible in weight-bearing positions in people with osteoporosis
  • Increased spasticity or autonomic dysreflexia in some people
  • Pain in the standing position

For more information on these topics, see our articles on Pressure Injuries, Orthrostatic Hypotension, Osteoporosis, Spasticity, and Autonomic Dysreflexia

If using electrical stimulation, the safety precautions and risks associated with use of functional electrical stimulation (FES) also apply.

Does supported standing work?

Bone health

It is not clear if standing helps to maintain or increase bone density in the legs after SCI. Current research evidence is inconclusive and further studies are needed.

Blood pressure and circulationA person taking a blood pressure reading of another person wearing a blood pressure cuff

Another proposed use of standing after SCI is to help with blood pressure control. One study provides weak evidence that standing with a harness and assistance from health providers helps to increase resting blood pressure and reduce drops in blood pressure when standing (orthostatic hypotension) in people with cervical SCI.

Spasticity

There is weak evidence that standing may help to reduce spasticity short term in people with SCI. There are also surveys that report that many people with SCI report that regular standing helped to reduce their spasticity.

Bowel problems

There is not enough evidence to determine whether standing can also improve bowel function. Further research in this area is needed.

The bottom line

Supported standing serves as a therapy option for people such as individuals with SCI as they do not normally stand as part of their everyday mobility. This therapy involves equipment such as standing frames, tilt tables, orthoses, or standing wheelchairs to support an upright position for a designated period of time. While there is research supporting the benefits of supported standing, conflicting evidence is still apparent. Further research is needed to better understand the benefits of supported standing after SCI.

For a review of how we assess evidence at SCIRE Community and advice on making decisions, please see SCIRE Community Evidence.

Reference list

Parts of this page have been adapted from the SCIRE Professional “Bone Health”, “Orthostatic Hypotension”, “Spasticity”, and “Bowel Dysfunction and Management” Modules:

Craven C, Lynch CL, Eng JJ (2014). Bone Health 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: p 1- 37.
Available from: https://scireproject.com/evidence/bone-health/

Krassioukov A, Wecht JM, Teasell RW, Eng JJ (2014). Orthostatic Hypotension 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: p. 1-26.
Available from: https://scireproject.com/evidence/orthostatic-hypotension/

Hsieh JTC, Connolly SJ, McIntyre A, Townson AF, Short C, Mills P, Vu V, Benton B, Wolfe DL (2016). Spasticity Following Spinal Cord Injury. In Eng JJ, Teasell RW, Miller WC, Wolfe DL, Townson AF, Hsieh JTC, Connolly SJ, Curt A, Mehta S, Sakakibara BM, editors. Spinal Cord Injury Rehabilitation Evidence. Version 6.0.
Available from: https://scireproject.com/evidence/spasticity/

Coggrave M, Mills P, Willms R, Eng JJ, (2014). Bowel Dysfunction and Management 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: p 1- 48.
Available from: https://scireproject.com/evidence/bowel-dysfunction-and-management/

Evidence for “Does standing work for treating the symptoms of SCI?” is based on the following studies:

Bone health

[1] Dudley-Javoroski S, Saha PK, Liang G, Li C, Gao Z, and Shields RK. High dose compressive loads attenuate bone mineral loss in humans with spinal cord injury. Osteoporos Int 2012; 23:2335-2346.

[2] Goktepe A, Tugco I, Alaca, R, Gunduz S, Nikent M. Does standing protect bone density in patients with chronic spinal cord injury? JSCM 2008;31:197-201.

[3] Needham-Shropshire BM, Broton JG, Klose KJ, Lebwohl N, Guest RS, Jacobs PL. Evaluation of a training program for persons with SCI paraplegia using the Parastep 1 ambulation system: part 3. Lack of effect on bone mineral density.  Arch Phys Med Rehabil 1997;78:799-803.

[4] Kunkel CF, Scremin AM, Eisenberg B, Garcia JF, Roberts S, Martinez S. Effect of “standing” on spasticity, contracture, and osteoporosis in paralyzed males. Arch Phys Med Rehabil 1993;74:73-78.

[5] Kaplan PE, Roden W, Gilbert E, Richards L, Goldschmidt JW. Reduction of hypercalciuria in tetraplegia after weight-bearing and strengthening exercises. Paraplegia 1981;19:289-293.

[6] Ben M, Harvey L, Denis S, et al.  Does 12 weeks of regular standing prevent loss of ankle mobility and bone mineral density in people with recent spinal cord injuries? Aust J Physiother. 2005;51:251-256.

[7] de Bruin ED, Frey-Rindova P, Herzog RE, Dietz V, Dambacher MA, Stussi E. Changes of tibia bone properties after spinal cord injury: effects of early intervention. Arch Phys Med Rehabil 1999;80:214-220.

[8] Dudley-Javoroski S, and Shields RK. Active-resisted stance modulates regional bone mineral density in humans with spinal cord injury. Journal of Spinal Cord Medicine 2013; 36: 191-199.

Blood Pressure and Circulation

[1] Harkema SJ, Ferreira CK, van den Brand RJ, Krassioukov AV. Improvements in orthostatic instability with stand locomotor training in individuals with spinal cord injury. J Neurotrauma 2008;25:1467-1475.

Spasticity

[1] Odeen I, Knutsson E. Evaluation of the effects of muscle stretch and weight load in patients with spastic paraplegia. Scand J Rehabil Med 1981;13:117-21.

[2] Bohannon R. Tilt table standing for reducing spasticity after spinal cord injury. Arch Phys Med Rehabil 1993;74:1121-2.

[3] Kunkel C, Scremin A, Eisenberg B, Garcia J, Roberts S, Martinez S. Effect of “standing” on spasticity, contracture, and osteoporosis in paralyzed males. Arch Phys Med Rehabil 1993;74:73-8.

[4] Dunn R, Walter J, Lucero Y, Weaver F, Langbein E, Fehr L, et al. Follow-up assessment of standing mobility device users. Assist Technol 1998;10:84-93.

[5] Eng JJ, Levins S, Townson A, Mah-Jones D, Bremner J, Huston G. Use of prolonged standing for individuals with spinal cord injuries. Phys Ther 2001;81:1392-9.

[6] Shields R & Dudley-Javoroski S. Monitoring standing wheelchair use after spinal cord injury: a case report. Disabil Rehabil 2005;27:142-6.

Bowel problems

[1] Hoenig H, Murphy T, Galbraith J, Zolkewitz M. Case study to evaluate a standing table for managing constipation. SCI Nursing 2001;18:74-7.

Other references

Dunn RB, Walter JS, Lucero Y, Weaver F, Langbein E, Fehr L, Johnson P, Riedy L. Follow-up assessment of standing mobility device users. Assist Technol. 1998;10(2):84-93.

Glickman LB, Geigle PR, Paleg GS. A systematic review of supported standing programs. J Pediatr Rehabil Med. 2010; 3(3),197-213.

Sadeghi M, McLvor J, Finlayson H, Sawatzky B. Static standing, dynamic standing and spasticity in individuals with spinal cord injury. Spinal Cord 2016;54:376-82.

Spinal Cord Injury Centre Physiotherapy Lead Clinicians. Clinical guideline for standing adults following spinal cord injury. 2019 Apr. Available from: https://scireproject.com/wp-content/uploads/2023/01/SCI-Standing-Clinical-Guidelines-Report-2019.pdf

Image credits

  1. 58/365 ©John Lustig, CC BY 2.0
  2. Image ©SCIRE
  3. Standing frame ©Memasa, CC BY-SA 3.0
  4. Functional Electrical Stimulation Therapy for walking ©MilosRPopovic, CC BY-SA 4.0
  5. Image ©SCIRE
  6. Modified from: oesteoporosis_eng ©go elsewhere…, CC BY-NC 2.0
  7. KRT LIFE HEALTH-BLOOD-PRESSURE PG ©Fort George G. Meade Public Affairs Office, CC BY 2.0

 

Disclaimer: This document does not provide medical advice. This information is provided for educational purposes only. Consult a qualified health professional for further information or specific medical advice. The SCIRE Project, its partners and collaborators disclaim any liability to any party for any loss or damage by errors or omissions in this publication.
Nov 29
0

Body Weight Supported Treadmill Training

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Author: SCIRE Community Team | Reviewers: Tania Lam, Shannon Sproule | Published: 29 November 2017 | Updated: ~

Body weight supported treadmill training is a therapy that can be used to support walking training after spinal cord injury (SCI). This page outlines basic information about the use of body weight supported treadmill training after SCI.

Key Points

  • Body weight supported treadmill training is a therapy modality in which part of a person’s body weight is supported while walking on a treadmill.
  • It is usually used to work on walking ability, walking speed, and fitness in people with some control of movement in their legs after SCI (usually people with incomplete SCI).
  • Research evidence supports that body weight supported treadmill training is effective to help improve walking in people with incomplete SCI. It may also have benefits for fitness, reducing spasticity, and overall wellness.
  • The relationship between body weight supported treadmill training and stepping movements after complete SCI is not well understood. Further research is needed to understand whether body weight supported treadmill training has potential treatment benefits on walking (locomotor) function for people with complete injuries.

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What is body weight supported treadmill training?

Body weight supported treadmill training is a therapy modality in which part of a person’s body weight is supported while walking on a treadmill. It is usually done using an overhead suspension system attached to a harness that supports part of a person’s body weight over a treadmill. While supported, the person walks with or without assistance from health providers on a treadmill.

Man supported with harness walks on a treadmill with a female clinician standing beside him

Man engages in body weight supported treadmill training.

Body weight supported treadmill training is usually used to work on walking in people with some control of movement in their legs after SCI (usually people with incomplete SCI).

The goals of treatment with body weight supported treadmill training may include:

To practice walking and standing

Body weight supported treadmill training is usually used to work on walking and standing skills after incomplete SCI. Because the body weight is partially supported, walking can be practiced even when a person cannot stand or walk independently. This may also allow for walking training to begin earlier after injury.

To work on walking quality and speed

Body weight supported treadmill training may be used to practice better walking patterns and prevent unwanted movement compensations that can happen during unsupported walking. It may also allow a person to safely practice walking at faster speeds. This may provide important feedback to the nervous system to help with learning.

To train fitness and health

Standing upright and walking may have benefits for cardiovascular fitness and overall health. It may also have other benefits, such as improving spasticity and feelings of wellness.

How is body weight supported treadmill training done?

Body weight supported treadmill training usually involves the use of an overhead harness and suspension system that supports the person in standing over a treadmill. There are other forms of body weight support training, such as underwater treadmills, anti-gravity treadmills and robotic assisted systems, although these are less common in standard clinical settings.

The amount of body weight that is supported will be different for each person depending on the characteristics of their SCI (such as the level of injury), the level of support provided by the health providers, and the person’s experience with the training.

Equipment

Photograph of a treadmill with handrails and equipment at the back of the treadmill supporting a harness that is placed above the treadmill.

Equipment for a suspension type system includes a treadmill, overhead suspension system, and harness1

Body weight supported treadmill training may involve the use of several different pieces of equipment, depending on the type of support provided. The most common type of harness and suspension system may involve a variety of pieces of equipment such as:

  • A harness
  • Groin and abdominal straps and padding
  • An overhead suspension system
  • A treadmill with adjustable speeds
  • A ramp up to the treadmill
  • Additional tubing or strapping
  • Parallel bars
  • Braces and orthoses

Some body weight supported treadmill training systems may also involve the use of computer systems which control the training and/or robotic systems which guide movement of the legs.

Procedures

The exact procedures depend on the type of equipment used and the person’s physical abilities. General procedures for use of a standard harness and overhead suspension system may include the following steps:

Female clinician adjusting the harness on a man sitting up out of his wheelchair

Female clinician adjusting the harness, preparing a man for the treadmill.

  • In order to ensure this treatment is safe for you, your health providers will measure your heart rate, blood pressure, and assess your risk of fractures before beginning this treatment.
  • Your health providers with help you put the harness and groin straps on in a lying or standing position. The harness is then tightened so it does not slide up when weight is supported.
  • The harness is then securely connected to the overhead suspension over the treadmill and you are lifted up using a mechanical lift to support some weight. There are usually bars on the side to hold on to for balance.
  • Once you are standing upright, your health provider will then turn on the treadmill and gradually increase the speed of the treadmill. Depending on your needs and abilities, hands-on assistance or braces may be used to help move the legs or control the trunk and pelvis.

Training usually begins with maximum body weight support at a slow speed. The amount of support is usually between 35% and 50% of body weight, but depends on your ability to stand on one leg without it buckling. As you get used to the training, the amount of support provided is reduced and the speed or time spent on the treadmill can be increased. It is important to maintain a good quality walking pattern to practice normal movement patterns.

Illustration showing a person walking on a treadmill supported by a harness around their pelvis and waist attached to an overhead suspension system. Suspension system is behind the treadmill and on the other side has an off-weighting system and a height adjustable winch. There is a healthcare provider supporting the movement of the person's legs while seated next to the treadmill.

Body weight supported treadmill training is usually done using an overhead suspension system and harness that supports the body over a treadmill. Hands-on assistance or braces may be used to help move the legs or control the trunk and pelvis.

Amount of training

Your health provider will determine how long the training will last, depending on you and your training goals, as well as the availability of equipment and staff. Body weight supported treadmill training is often done for 15 to 30 minutes two to five times per week. However, we do not know what the optimal amount of training is.

 

Additional therapies

Body weight supported treadmill training is just one of many different walking therapies for people with SCI. It is often accompanied by other forms of walking training such as:

  • Walking overground (off the treadmill) with or without an assistive device, such as a walker. This may be used to help reinforce walking after treadmill training in a form that is more realistic to everyday movement.
    A leg with two electrodes on the thigh for functional electrical stimulation execise therapy

    FES training can also strengthen muscles used for walking

  • Functional electrical stimulation (FES) can be applied to the muscles of the legs and trunk during treadmill training to stimulate muscle activity. This may help to create stronger muscle contractions in weakened muscles when walking. Special FES systems (such as foot control systems that raise the toes up with each step) may be used to help with coordination when stepping.

It is important to speak with a health provider about body weight supported treadmill training to make sure it is safe and suitable for you and to learn how to use the equipment correctly.

Refer to our article on Functional Electrical Stimulation (FES) for more information!

Are there restrictions or precautions for body weight supported treadmill training?

There are some situations in which body weight supported treadmill training may be unsafe to use. This not a complete list, speak to a health provider about whether this treatment is safe and appropriate for you.

Body weight supported treadmill training should not be used in the following situations:

  • By people with medical conditions where heart rate, blood pressure, or seizures are uncontrolled
  • By individuals who are unable to stay upright for 5-10 minutes without a major drop in blood pressure
  • By people at risk of broken bones (fractures), such as people with severe osteoporosis or recent fractures
  • By people with joint limitations (such as contractures) which limit walking, weight-bearing, or standing
  • In areas where the harness may put pressure on open wounds or areas at risk of pressure sores
  • By people using mechanical ventilation

Body weight supported treadmill training should be used with caution in the following situations:

  • When there are tubes or lines attached to the body, such as a feeding tube or indwelling catheter
  • By people with severe and uncontrolled spasticity
  • By people with blood clots or a history of blood clots
  • By people with other major medical conditions or injuries
  • By people prone to autonomic dysreflexia

What are the risks and side effects of body weight supported treadmill training?

There are some risks and side effects that should be discussed before participating in body weight supported treadmill training. This is not a complete list; ask your health providers for more detail.

Risks and side effects of body weight supported treadmill training may include:

  • Groin discomfort or pain around the harness
  • Skin irritation near where skin or clothes are shearing against the harness
  • Abdominal discomfort or difficulty breathing if the harness is too tight
  • Broken bones (fractures)
  • Muscle strain, soreness, or injuries
  • Worsening of muscle spasms
  • Autonomic dysreflexia
  • Changes in blood pressure that may cause light-headedness and dizziness

Are there other limitations to using this treatment?

In addition to the risks and side effects of body weight supported treadmill training, there are also practical limitations its use, including:

  • It is challenging to use and sometimes requires assistance from up to four people
  • The equipment and staff time needed for body weight supported treadmill training can be very costly
  • Many facilities do not have the staff or equipment to use body weight supported treadmill training in their day to day programs

Does body weight supported treadmill training improve walking after incomplete SCI?

Walking

Research studies have found that body weight supported treadmill training may help to:

  • Improve walking ability in people with chronic incomplete SCI (weak evidence)
  • Improve walking to a similar degree as walking off the treadmill at a similar intensity in people with recent incomplete SCI (moderate evidence)
  • Improve functional walking in people with incomplete SCI when used together with functional electrical stimulation (FES) of the leg muscles (moderate evidence)

Man walking while holding parallel bars

However, the benefits for walking do not appear to be unique to this type of training. Most walking strategies which involve weight-bearing (including walking overground, treadmill walking, and walking with FES) appear to be equally effective at improving walking after incomplete SCI.

Cardiovascular fitness

Several studies have looked at the effects of body weight supported treadmill training on different aspects of cardiovascular fitness after SCI. Taken altogether, these studies provide early evidence that body weight supported treadmill training helps to improve many aspects of cardiovascular fitness and health in people with complete and incomplete tetraplegia and paraplegia.

Other effects

In addition to benefits for walking and fitness, body weight supported treadmill training may also have other effects after SCI.

  • Body weight supported treadmill training may help to improve spasticity (weak evidence)
  • Body weight supported treadmill training may lead to greater life satisfaction and well-being (weak evidence)
  • Body weight supported treadmill training has been thought to improve bone density after SCI, however, early research suggests that it may not help to prevent bone loss after SCI (weak evidence).

Can body weight supported treadmill training cause stepping after complete SCI?

Although we tend to think about walking as being entirely voluntary, the ability to step and walk is actually related to both conscious and unconscious (automatic) processes. Some of the automatic walking processes are thought to be controlled within the spinal cord by networks of nerve cells known as central pattern generators or CPGs.

What are central pattern generators (CPGs)?

Central pattern generators (CPGs or spinal pattern generators) are networks of nerve cells in the spinal cord that generate rhythmic movement patterns. These networks do not require signals from the brain or sensation to keep going once they are activated.

CPGs were discovered when researchers found that animals with complete SCI demonstrated stepping movements when they were supported over a treadmill. These animals could not start the movement themselves, but once it was triggered (typically by electrical stimulation, application of certain drugs, or sensory stimulation to an area between the pubic bone and sacrum called the perineum), the stepping movements continued in a rhythmic pattern which resembled walking.

These networks of nerve connections are thought to be located within the spinal cord itself and exist to allow repetitive movements to continue without the need to think about each step.

Evidence for central pattern generators in humans with complete SCI

A diagram showing how the pathway of locomotor CPG is cut short by a complete SCI

Generation of rhythmic movement through the CPG is debatable in people with SCI2

Researchers are still unsure about whether central pattern generators can be activated after complete SCI in humans. Researchers have suggested several observations that may show evidence of central pattern generators after complete SCI in humans, including:

  • Spontaneous rhythmic movements below the level of injury;
  • Stepping-like movements when electrical stimulation is applied through an electrode implanted over the spinal cord (epidural stimulation); and
  • Rhythmic muscle contractions that can be induced through treatment with certain drugs.

However, there is debate among researchers about whether these findings really show evidence of central pattern generators or not. It is also not clear if central pattern generators are activated during body weight supported treadmill training after SCI.

Refer to our article on Epidural Stimulation for more information!

Automatic stepping is not walking

It is also important to consider that automatic stepping is not walking. Walking is much more complex, involving many other components, such as strength to support the body weight, balance to stay upright and shift weight, and sensation and voluntary control to adapt to the environment and situation. For these reasons, even if central pattern generators are activated after complete SCI, we do not know whether this will help a person regain walking ability or have any other benefits for functional walking.

Further research is needed to better understand central pattern generators after complete SCI. At this time, body weight supported treadmill training continues to be used clinically as a treatment for people with incomplete SCI who retain some movement in the legs.

The bottom line

Overall, the research evidence suggests that body weight supported treadmill training has positive effects on walking after incomplete SCI that are similar to other forms of walking training. It may also have benefits for fitness, spasticity, and wellness after SCI, although more high quality research is needed to confirm.

Body weight supported treadmill training appears to be relatively safe when used appropriately, however the equipment and support needed for this treatment may not be commonly available for regular use. If you are interested in this treatment, discuss your options with your health providers to find out if it is suitable to you.

For a review of how we assess evidence at SCIRE Community and advice on making decisions, please see SCIRE Community Evidence.

Reference list


Parts of this page have been adapted from the SCIRE Professional “Lower Limb and Walking”, “Cardiovascular Health and Exercise”, “Bone Health”, “Mental Health” and “Spasticity” modules:

 

Lam T, Wolfe DL, Domingo A, Eng JJ, Sproule S (2014). Lower Limb Rehabilitation 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: p 1-74.
Available from: https://scireproject.com/evidence/lower-limb-and-walking/

Warburton DER, Krassioukov A, Sproule S, Eng JJ (2014). 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: p 1-48.
Available from: https://scireproject.com/evidence/cardiovascular-health-and-exercise/

Craven C, Lynch CL, Eng JJ (2014). Bone Health 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: p 1-37.
Available from: https://scireproject.com/evidence/bone-health/

Orenczuk S, Mehta S, Slivinski J, Teasell RW (20140). Depression 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: p 1-35.
Available from: https://scireproject.com/evidence/mental-health/depression/

Hsieh JTC, Connolly SJ, McIntyre A, Townson AF, Short C, Mills P, Vu V, Benton B, Wolfe DL (2016). Spasticity Following Spinal Cord Injury. In Eng JJ, Teasell RW, Miller WC, Wolfe DL, Townson AF, Hsieh JTC, Connolly SJ, Curt A, Mehta S, Sakakibara BM, editors. Spinal Cord Injury Rehabilitation Evidence. Version 6.0.
Available from: https://scireproject.com/evidence/spasticity/

Evidence for “Does body weight supported treadmill training improve walking after incomplete SCI?” is based on the following studies:

Walking

[1] Behrman AL, Ardolino E, VanHiel LR, Kern M, Atkinson D, Lorenz DJ, Harkema SJ. Assessment of functional improvement without compensation reduces variability of outcome measures after human spinal cord injury. Arch Phys Med Rehabil 2012;93:1518-29.

[2] Buehner JJ, Forrest GF, Schmidt-Read M, White S, Tansey K, Basso DM. Relationship between ASIA examination and functional outcomes in the NeuroRecovery Network Locomotor Training Program. Arch Phys Med Rehabil 2012;93:1530-40.

[3] Lorenz DJ, Datta S, and Harkema SJ. Longitudinal patterns of functional recovery in patients with incomplete spinal cord injury receiving activity-based rehabilitation. Arch Phys Med Rehabil 2012;93:1541-52.

[4] Winchester P, Smith P, Foreman N, Mosby J, Pacheco F, Querry R, and Tansey K. A prediction model for determining over ground walking speed after locomotor training in persons with motor incomplete spinal cord injury. J of Spinal Cord Med 2009;32:63-71.

[5] Hicks AL, Adams MM, Martin Ginis K, Giangregorio L, Latimer A, Phillips SM, and McCartney N. Long-term body-weight-supported treadmill training and subsequent follow-up in persons with chronic SCI: effects on functional walking ability and measures of subjective well-being. Spinal Cord 2005;43:291-298.

[6] Wirz M, Zemon DH, Rupp R, Scheel A, Colombo G, Dietz V, and Hornby TG. Effectiveness of automated locomotor training in patients with chronic incomplete spinal cord injury: A multicenter trial. Arch Phys Med Rehabil 2005;86:672-680.

[7] Thomas SL, Gorassini MA. Increases in corticospinal tract function by treadmill training after incomplete spinal cord injury. J Neurophysiol 2005;94:2844-2855.

[8] Protas EJ, Holmes SA, Qureshy H, Johnson A, Lee D, and Sherwood AM. Supported treadmill ambulation training after spinal cord injury: a pilot study. Arch Phys Med Rehabil 2001;82:825-831.

[9] Wernig A, Nanassy A, and Muller S. Maintenance of locomotor abilities following Laufband (treadmill) therapy in para- and tetraplegic persons: follow-up studies. Spinal Cord 1998;36:744-749.

[10] Field-Fote EC, Roach KE. Influence of a locomotor training approach on walking speed and distance in people with chronic spinal cord injury: A randomized clinical trial. Physical Therapy 2011;91:48-60.

[11] Dobkin B, Apple D, Barbeau H, Basso M, Behrman A, Deforge D, Ditunno J, Dudley G, Elashoff R, Fugate L, Harkema S, Saulino M, and Scott M. Weight-supported treadmill vs over-ground training for walking after acute incomplete SCI. Neurology 2006;66:484-493.

[12] Hitzig SL, Craven BC, Panjwani A, Kapadia N, Giangregorio LM, Richards K, Masani K, and Popovic MR. Randomized trial of functional electrical stimulation therapy for walking in incomplete spinal cord injury: effects on quality of life and community participation. Top Spinal Cord Inj Rehabil 2013;19(4):245-58.

[13] Field-Fote EC, Lindley SD, and Sherman AL. Locomotor training approaches for individuals with spinal cord injury: a preliminary report of walking-related outcomes. J Neurol Phys Ther 2005;29:127-137.

[14] Field-Fote EC, Tepavac D. Improved intralimb coordination in people with incomplete spinal cord injury following training with body weight support and electrical stimulation. Phys Ther 2002;82:707-715.

[15] Field-Fote EC. Combined use of body weight support, functional electric stimulation, and treadmill training to improve walking ability in individuals with chronic incomplete spinal cord injury. Arch Phys Med Rehabil 2001;82:818-824.

[16] Hesse S, Werner C, and Bardeleben A. Electromechanical gait training with functional electrical stimulation: case studies in spinal cord injury. Spinal Cord 2004;42:346-352.

Cardiovascular fitness

[1] Miller PJ, Rakobowchuk M, Adams MM, Hicks AL, McCartney N, Macdonald MJ. Effects of short-term training on heart rate dynamics in individuals with spinal cord injury. Auton Neurosci 2009;150(1-2):116-21.

[2] Jack LP, Allan DB, Hunt KJ. Cardiopulmonary exercise testing during body weight supported treadmill exercise in incomplete spinal cord injury: a feasibility study. Technol Health Care 2009; 17(1):13-23.

[3] Soyupek F, Savas S, Ozturk O, Ilgun E, Bircan A, Akkaya A.E ffects of body weight supported treadmill training on cardiac and pulmonary functions in the patients with incomplete spinal cord injury. J Back Musculoskelet Rehabil 2009; 22(4):213-8.

[4] Ditor DS, Macdonald MJ, Kamath MV, Bugaresti J, Adams M, McCartney N, et al. The effects of body-weight supported treadmill training on cardiovascular regulation in individuals with motor-complete SCI. Spinal Cord 2005b;43(11):664-73.

Other effects

[1] Giangregorio LM, Hicks AL, Webber CE, Phillips SM, Craven BC, Bugaresti JM, et al. Body weight supported treadmill training in acute spinal cord injury: impact on muscle and bone. Spinal Cord 2005;43:649-657.

[2] Hicks AL, Adams MM, Martin GK, Giangregorio L, Latimer A, Phillips SM, McCartney N. Long-term body-weight-supported treadmill training and subsequent follow-up in persons with chronic SCI: Effects on functional walking ability and measures of subjective well-being. Spinal Cord 2005;43:291-8.

[3] Adams M, Hicks A. Comparison of the effects of body-weight-supported treadmill training and tilt-table standing on spasticity in individuals with chronic spinal cord injury. J Spinal Cord Med 2011;34:488-94.

Evidence for “Can body weight supported treadmill training cause stepping after complete SCI?” is based on the following studies:

[1] Minassian K, Hofstoetter US, Dzeladini F, Guertin PA, Ijspeert A. The Human Central Pattern Generator for Locomotion. Neuroscientist. 2017 Mar 1:1073858417699790. doi: 10.1177/1073858417699790. [Epub ahead of print]
[2] Kern H, McKay WB, Dimitrijevic MM, Dimitrijevic MR. Motor control in the human spinal cord and the repair of cord function. Curr Pharm Des. 2005;11:1429-1439.

[3] Dietz V, Muller R, Colombo G. Locomotor activity in spinal man: significance of afferent input from joint and load receptors. Brain. 2002;125:2626-2634.

[4] Guertin PA. Central pattern generator for locomotion: anatomical, physiological, and pathophysiological considerations. Front Neurol. 2013 Feb 8;3:183.

[5] Yang JF, Gorassini M. Spinal and brain control of human walking: implications for retraining of walking. Neuroscientist. 2006 Oct;12(5):379-89.

[6] Illis LS. Is there a central pattern generator in man? Paraplegia. 1995 May;33(5):239-40.

Other references:

Body Weight Support Treadmill Training. Summary by: Lisa Taipalus BScPT, NEO Regional Stroke Best Practice Consultant for Physiotherapy, December 2009 (updated June 2011).

Duncan PW, Sullivan KJ, Behrman AL, Azen SP, Wu SS, Nadeau SE, et al. Body-weight-supported treadmill rehabilitation after stroke. N Engl J Med 2011;364(21):2026-2036.

Senthilvelkumar T, Magimairaj H, Fletcher J, Tharion G, George J. Comparison of body weight-supported treadmill training versus body weight-supported overground training in people with incomplete tetraplegia: a pilot randomized trial. Clin Rehabil 2015; 29(1):42-49.

Morawietz C, Moffat F. Effects of locomotor training after incomplete spinal cord injury: a systematic review. Arch Phys Med Rehabil 2013;94(11):2297-2308.

Hicks AL, Ginis KA. Treadmill training after spinal cord injury: it’s not just about the walking. J Rehabil Res Dev 2008; 45(2):241-218.

Image credits:

  1. Image by SCIRE Community Team
  2. ‘Figure 1. Device for body weight support (LINAK, Silkeborg, Denmark) and treadmill (FITEX T-5050; Fitex, Gwangju, Korea) and treadmill’ from: Joon Lee B, Lee HJ, Lee, WH. The effects of intensive gait training with body weight support treadmill training on gait and balance in stroke disability patients: a randomized controlled trial. Phys Ther Rehabil Sci. 2013;2(2),104-110.
  3. Image by SCIRE Community Team
  4. Image by SCIRE Community Team
  5. Image by SCIRE Community Team
  6. Image by SCIRE Community Team
  7. ‘Figure 3 `Central’ tonic input, external train of electrical stimulation, delivered by SCS can induce stepping movements’ from: Pinter, M. M., & Dimitrijevic, M. R. (1999). Gait after spinal cord injury and the central pattern generator for locomotion. Spinal cord, 37(8), 531.

 

Disclaimer: This document does not provide medical advice. This information is provided for educational purposes only. Consult a qualified health professional for further information or specific medical advice. The SCIRE Project, its partners and collaborators disclaim any liability to any party for any loss or damage by errors or omissions in this publication.
Oct 10
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Functional Electrical Stimulation (FES)

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Author: SCIRE Community Team | Reviewer: Shannon Sproule | Published: 10 October 2017 | Updated: ~

Functional electrical stimulation is a treatment that activates muscles below the spinal cord injury (SCI) during exercise and activity. This page outlines basic information about functional electrical stimulation and its use for movement and strength after SCI.

Key Points

  • Electrical stimulation can be used to activate muscles that are weak or paralyzed after an SCI.
  • Functional electrical stimulation (FES) involves stimulating the muscles during an activity like exercise or movement.
  • FES is relatively safe and widely available treatment option for improving muscle strength and fitness after SCI.
  • Overall, the research evidence suggests that FES is most likely effective for improving muscle strength after SCI. It may also improve fitness, walking skills, bone density and other symptoms, although more high quality research is needed to confirm.

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What is "functional electrical stimulation" (FES)?

Functional electrical stimulation (FES) is a type of neuromodulation where electrical stimulation is applied to the nerves located outside the spinal cord and brain. This stimulation causes the muscles to contract and can assist with purposeful or functional movement in weak or paralyzed muscles.

FES is delivered using a variety of handheld or specialized commercial electrical therapy machines connected to electrodes that are placed on the skin’s surface. Systems are also available with implanted electrodes in the muscles, although this is very specialized and not widely available.

FES electrodes are placed on the leg muscles to be used during stationary cycling.1

Muscle stimulation is used for several reasons after SCI:

To promote movement and strength in weak or paralyzed muscles: Muscle stimulation is used early in rehabilitation to promote movement in muscles that are not moving or only producing a flicker of movement. It may promote recovery of movement function by assisting with normal movements and with repetition of movements.

To improve fitness and health: When FES is used as part of a rhythmic exercise like cycling, walking, or rowing, it can help to maintain health of the heart, lungs, and circulation. It may also help to maintain healthy bones.

To assist with functional movement activities like stepping, getting up to standing, and grasping: FES can be used to assist with purposeful movements by improving muscle contractions (for weakened muscles), mobility or range of movement as well as possibly decreasing spasticity.

To maintain muscle mass below the SCI: Regular use of FES may help to prevent muscle loss that happens when the muscles that are paralyzed are not used. Unless neurological return occurs this improvement will stop if the FES is discontinued.

To control the muscles of breathing and bladder function: This includes the use of surgically implanted diaphragmatic pacers (FES systems that create muscle contractions in the diaphragm to stimulate regular breaths) and bladder control systems (FES systems that stimulate the muscles of urination). However, this page will focus on FES used for movement and strength after SCI.

Watch our YouTube video about FES!

Other names for FES of muscles

You may hear other names for FES such as “neuromuscular electrical stimulation” (NMES) or simply “electrical stimulation” (ES). These terms are often used to refer to electrical stimulation of the muscles during more passive activities (like lying down or sitting), while ”FES” usually describes stimulation during purposeful activities like cycling or walking. However, in practice these terms are often used interchangeably to describe similar or related treatments and the goals of all are to promote strength, movement and function and decrease pain and spasticity.

There are a number of other neuromodulation techniques that are used for various purposes in SCI, including transcutaneous electrical nerve stimulation, sacral nerve stimulation, and intrathecal Baclofen, described in other SCIRE Community articles.

How is FES done?

It is important to speak with a health provider about using FES to make sure it is safe and suitable for you and to learn how to use the equipment correctly.

FES is usually applied through electrodes that are placed on the surface of the skin, although electrodes can also be implanted into the muscles. Electrodes are placed over nerves or part of the muscles below the SCI that respond well to electrical stimulation. The electrodes are then attached to an adjustable machine that generates the stimulation. Your health provider will determine the settings that are used for the treatment and how long it will last.

The electrical stimulation is then gradually turned up until the muscles begin to tense or contract. Depending on your sensation, as the machine is turned up, you may feel pins and needles or other unusual sensations, which may take some time to get used to. The aim is to create a forceful but tolerable muscle contraction.

FES is applied through electrodes on the leg muscles during assisted walking.2

If the electrical stimulation goes well, it is then combined with a movement task. This may be as simple as lifting a wrist or ankle or more complex such as cycling on a stationary bike, rowing on a rowing machine, grasping, or stepping in parallel bars or a body weight support treadmill system.

The length of each session will vary depending on the goals of the treatment. Time may be required to enable your muscles to tolerate longer sessions as the muscles may fatigue quickly. Sessions are usually done several times per week for several weeks to gain training benefits.

Your health provider will monitor your response to the treatment and inspect the skin for any redness or irritation after the treatment has ended. Once you have learned to use FES safely, you may be able to use it on your own.

How does FES work?

Our bodies naturally use electrical signals as part of the nervous system. When we move, the brain generates and sends electrical impulses along the spinal cord and nerves to tell the muscles to move.

Spinal cord injury can interrupt this pathway, preventing electrical impulses from passing through the spinal cord to reach the muscles. However, if the nerves and muscles below the injury are not damaged, they can still respond to electrical signals.

A leg with two electrodes on the thigh for functional electrical stimulation execise therapy

FES electrodes are placed over nerves or over electrically-sensitive parts of the muscles below the SCI. The specific type of electrical stimulation used with FES can trigger the nerve cells of movement (motor neurons) to send signals that cause muscle movement. An intact peripheral nerve and healthy muscle tissue are required to enable the external source of electricity to facilitate muscle contraction.

FES does not work for nerve injuries outside the spinal cord

FES can only be used for muscle weakness or paralysis caused by injuries to the spinal cord, but not injuries to the conus medullaris, cauda equina, or the nerves outside of the spinal cord. The nerve cells in these structures (called lower motor neurons) must to be intact for FES to work.

Like exercise, regular treatment with FES is usually needed to maintain the effects of the treatment. For people with complete injuries, when FES treatments are stopped, the treatment effects will usually go away over time. For people with incomplete injuries, the goal is for some carryover of strength and movement be retained after the treatment is stopped.

Are there restrictions or precautions for FES?

A cartoon pen and clipboard with check marks and x marksThere are some situations in which FES may be unsafe to use. This not a complete list, speak to a health provider about your health history and whether FES is safe for you.

FES should not be used in the following situations:

  • Near implanted medical devices like heart pacemakers
  • On areas of active cancer, or by people with bleeding disorders or other major medical conditions
  • On areas with blood clots, bleeding, damaged skin, infection, or poor circulation
  • By pregnant women
  • Electrodes should not be placed over the eyes, through the head, through the chest or abdomen, or on the front of the neck or genitals
  • By people with recent broken bones
  • By people with damage to the nerves or muscles near the area where FES is used

FES should be used with caution in the following situations:

FES is often used with the following conditions after SCI but should be monitored closely. Speak to your health provider for more information.

  • By people who have had seizures
  • By people prone to severe autonomic dysreflexia (people with cervical and thoracic injuries)
  • By people with uncontrolled spasticity
  • By people with severe osteoporosis
  • In areas where heterotopic ossification causes restricted movement
  • In areas with reduced or absent sensation (below the level of injury)
  • By people who are unable to follow instructions or provide accurate feedback

What are the risks and side effects of FES?

FES is generally well tolerated by people who can use it safely (see above for when FES may be unsafe). Serious medical complications from FES are rare. However, there are risks and side effects that should be discussed with a health provider before using FES.

More common risks and side effects of FES include:

  • Discomfort or pain
  • Skin redness or irritation
  • Nausea, light-headedness, or autonomic dysreflexia

Other less common risks and side effects of FES include:

  • Mild electrical burns near the electrodes
  • Skin breakdown near the electrodes
  • Fainting
  • Worsening of muscle spasms (spasticity)
  • Muscle and joint injuries, such as joint swelling or muscle strains
  • Broken bones
  • Mild electrical shocks (from improper use or faulty equipment)

In some cases, risks and side effects may be caused by improper use of the equipment. It is essential to learn to use the equipment from a health provider and to only use FES according to their direction and with the settings that they recommend.

For some people, side effects of FES may be stronger at first, but as their body gets used to FES with repeated treatments, their physical reactions may reduce over time.

Does FES improve strength and fitness after SCI?

Several studies have shown that FES helps to improve strength and fitness after SCI.

Strength

Cartoon of a flexed armStudies have shown that both FES arm exercise and FES cycling helps to maintain or improve strength after SCI. However, FES cycling may be more effective for maintaining strength after injury than improving strength that has already been lost. This is supported by moderate evidence from five studies.

Cardiovascular fitness

Heart with a barbellFifteen studies have looked at FES for improving many different aspects of fitness after SCI. Taken altogether, these studies provide weak evidence that FES training done at least 3 days per week for 2 months helps to improve many aspects of cardiovascular fitness after SCI.

Walking

A person walking between parallel bars with his wheelchair behind him. A heathcare provider on the side watches him.Studies show that FES improves walking speed and distance in people with both incomplete and complete SCI. Some of these studies also showed that regular use of FES carried over to improve walking even without FES. This is supported by weak evidence from eight studies.

Does FES help with other complications of SCI?

The effects of FES treatment may also help to prevent complications of SCI like pressure sores, bone loss, spasticity, and orthostatic hypotension. These benefits may accompany gains in strength or fitness related to FES treatment.

Pressure sores

A woman lifting up her buttocks off her wheelchair by straightening her armsAlthough it is commonly thought that increased muscle bulk from FES will reduce the risk of pressure sores, there are not very many studies which have looked at whether this actually happens. One study provides weak evidence that FES cycling for 2 years reduced the number of pressure ulcers that occurred after SCI. Another study showed that regular FES cycling showed a trend toward reducing seat pressures.

Bone health

Silhouette of a fractured boneResearch studies show that FES cycling does not prevent bone loss after SCI (moderate evidence from two studies). However, it may help to increase bone density that has already been lost, although the evidence for this is conflicting (based on six studies). It is not clear whether any gains in bone density last long-term or if continued FES treatment is needed for them to be maintained.

For more information on bone density, read our article about Osteoporosis.

Spasticity

It is not clear what effects FES has on spasticity after SCI. There is conflicting evidence from three studies about whether FES cycling can help to reduce spasticity after SCI.

Click here for our article on Spasticity.

Orthostatic hypotension

Three studies provide moderate evidence that FES of the legs during a single change in position reduced orthostatic hypotension. However, this only shows that FES prevents orthostatic hypotension while it is applied, and further research is needed to look at what benefits this could have to people living with SCI.

Click here for our article on Orthostatic Hypotension.

The bottom line

Overall, the research evidence suggests that FES is most likely effective for improving muscle strength after SCI. It may also have effects on fitness, walking skills, bone density, skin health, spasticity, and orthostatic hypotension, although more high quality research is needed to confirm. FES appears to be safe when used appropriately and is widely available in most rehabilitation settings. Discuss this treatment with your health providers to find out if it is a suitable treatment option for you.

For a review of how we assess evidence at SCIRE Community and advice on making decisions, please see SCIRE Community Evidence.

Reference list

Parts of this page have been adapted from the SCIRE Professional “Lower Limb”, “Upper Limb”, “Bone Health”, “Cardiovascular Health and Exercise”, “Orthostatic Hypotension”, “Pressure Ulcers”, and “Spasticity” chapters:

Lam T, Wolfe DL, Domingo A, Eng JJ, Sproule S (2014). Lower Limb Rehabilitation 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: p 1-74.
Available from: http://scireproject.com/evidence/lower-limb/

Connolly SJ, McIntyre A, Mehta, S, Foulon BL, Teasell RW. (2014). Upper Limb Rehabilitation 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: p 1-77.
Available from: http://scireproject.com/evidence/upper-limb/

Craven C, Lynch CL, Eng JJ (2014). Bone Health 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: p 1- 37.
Available from: https://scireproject.com/evidence/bone-health/

Warburton DER, Krassioukov A, Sproule S, Eng JJ (2014). 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: p. 1-48.
Available from: https://scireproject.com/evidence/cardiovascular-health-and-exercise/

Krassioukov A, Wecht JM, Teasell RW, Eng JJ (2014). Orthostatic Hypotension 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: p. 1-26.
Available from: https://scireproject.com/evidence/orthostatic-hypotension/

Hsieh J, McIntyre A, Wolfe D, Lala D, Titus L, Campbell K, Teasell R. (2014). Pressure Ulcers 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. 1-90.
Available from: https://scireproject.com/evidence/skin-integrity-and-pressure-injuries/

Hsieh JTC, Connolly SJ, McIntyre A, Townson AF, Short C, Mills P, Vu V, Benton B, Wolfe DL (2016). Spasticity Following Spinal Cord Injury. In Eng JJ, Teasell RW, Miller WC, Wolfe DL, Townson AF, Hsieh JTC, Connolly SJ, Curt A, Mehta S, Sakakibara BM, editors. Spinal Cord Injury Rehabilitation Evidence. Version 6.0.
Available from: https://scireproject.com/evidence/spasticity/

 

Evidence for “Strength” is based on the following studies:

[1] Baldi JC, Jackson RD, Moraille R, and Mysiw WJ. Muscle atrophy is prevented in patients with acute spinal cord injury using functional electrical stimulation. Spinal Cord 1998;36:463-469.

[2] Scremin AM, Kurta L, Gentili A, Wiseman B, Perell K, Kunkel C, and Scremin OU. Increasing muscle mass in spinal cord injured persons with a functional electrical stimulation exercise program. Arch Phys Med Rehabil 1999;80:1531-1536.

[3] Crameri RM, Weston A, Climstein M, Davis GM, and Sutton JR. Effects of electrical stimulation-induced leg training on skeletal muscle adaptability in spinal cord injury. Scand J Med Sci Sports 2002;12:316-322.

[4] Gerrits HL, de Haan A, Sargeant AJ, Dallmeijer A, and Hopman MT. Altered contractile properties of the quadriceps muscle in people with spinal cord injury following functional electrical stimulated cycle training. Spinal Cord 2000;38:214-223.

[5] Needham-Shropshire BM, Broton JG, Cameron TL, Klose J. Improved motor function in tetraplegics following neuromuscular stimulation-assisted arm ergometry. J Spinal Cord Med 1997;20:49-55.

[6] Cameron T, Broton JG, Needham-Shropshire B, Klose KJ. An upper body exercise system incorporating resistive exercise and neuromuscular electrical stimulation (nms). J Spinal Cord Med 1998;21:1-6.

Evidence for “Cardiovascular Fitness” based on:

[1] Berry HR, Kakebeeke TH, Donaldson N, Perret C, Hunt KJ. Energetics of paraplegic cycling: adaptation to 12 months of high volume training. Technology and Health Care 2012; 20: 73-84.

[2] Griffin L, Decker MJ, Hwang JY, Wang B, Kitchen K, Ding Z, et al. Functional electrical stimulation cycling improves body composition, metabolic and neural factors in persons with spinal cord injury. J Electromyogr Kinesiol 2009;19(4):614-22.

[3] Zbogar D, Eng JJ, Krassioukov AV, Scott JM, Esch BT, Warburton DE. The effects of functional electrical stimulation leg cycle ergometry training on arterial compliance in individuals with spinal cord injury. Spinal Cord 2008;46(11):722-6.

[4] Crameri RM, Cooper P, Sinclair PJ, Bryant G, Weston A. Effect of load during electrical stimulation training in spinal cord injury. Muscle Nerve 2004;29(1):104-11.

[5] Hjeltnes N, Aksnes AK, Birkeland KI, Johansen J, Lannem A, Wallberg-Henriksson H. Improved body composition after 8 wk of electrically stimulated leg cycling in tetraplegic patients. Am J Physiol 1997;273(3 Pt 2):R1072-9.

[6] Mohr T, Andersen JL, Biering-Sorensen F, Galbo H, Bangsbo J, Wagner A, et al. Long-term adaptation to electrically induced cycle training in severe spinal cord injured individuals. Spinal Cord 1997;35(1):1-16.

[7] Barstow TJ, Scremin AM, Mutton DL, Kunkel CF, Cagle TG, Whipp BJ. Changes in gas exchange kinetics with training in patients with spinal cord injury. Med Sci Sports Exerc 1996;28(10):1221-8.

[8] Faghri PD, Glaser RM, Figoni SF. Functional electrical stimulation leg cycle ergometer exercise: training effects on cardiorespiratory responses of spinal cord injured subjects at rest and during submaximal exercise. Arch Phys Med Rehabil 1992;73(11):1085-93.

[9] Hooker SP, Figoni SF, Rodgers MM, Glaser RM, Mathews T, Suryaprasad AG, et al. Physiologic effects of electrical stimulation leg cycle exercise training in spinal cord injured persons. Arch Phys Med Rehabil 1992;73(5):470-6.

[10] Gerrits HL, de Haan A, Sargeant AJ, van Langen H, Hopman MT. Peripheral vascular changes after electrically stimulated cycle training in people with spinal cord injury. Arch Phys Med Rehabil 2001;82(6):832-9.

[11] Ragnarsson KT, Pollack S, O’Daniel W, Jr., Edgar R, Petrofsky J, Nash MS. Clinical evaluation of computerized functional electrical stimulation after spinal cord injury: a multicenter pilot study. Arch Phys Med Rehabil 1988;69(9):672-7.

[12] Taylor JA, Picard G, Widrick JJ. Aerobic capacity with hybrid FES rowing in spinal cord injury: comparison with arms-only exercise and preliminary findings with regular training. PM R 2011;3(9):817-24.

[13] Kahn NN, Feldman SP, Bauman WA. Lower-extremity functional electrical stimulation decreases platelet aggregation and blood coagulation in persons with chronic spinal cord injury: a pilot study. J Spinal Cord Med 2010;33(2): 150-8.

[14] Hakansson NA, Hull ML. Can the efficacy of electrically stimulating pedaling using a commercially available ergometer be improved by minimizing the muscle stress-time integral? Muscle Nerve 2012; 45:393-402.

Evidence for “Walking” is based on the following studies:

[1] Thrasher TA, Flett HM, and Popovic MR. Gait training regimen for incomplete spinal cord injury using functional electrical stimulation. Spinal Cord 2006;44:357-361.

[2] Ladouceur M, and Barbeau H. Functional electrical stimulation-assisted walking for persons with incomplete spinal injuries: changes in the kinematics and physiological cost of overground walking. Scand J Rehabil Med 2000a;32:72-79.

[3] Ladouceur M, and Barbeau H. Functional electrical stimulation-assisted walking for persons with incomplete spinal injuries: longitudinal changes in maximal overground walking speed. Scand J Rehabil Med 2000b;32:28-36.

[4] Wieler M, Stein RB, Ladouceur M, Whittaker M, Smith AW, Naaman S, Barbeau H, Bugaresti J, and Aimone E. Multicenter evaluation of electrical stimulation systems for walking. Arch Phys Med Rehabil 1999;80:495-500.

[5] Klose KJ, Jacobs PL, Broton JG, Guest RS, Needham-Shropshire BM, Lebwohl N, Nash MS, and Green BA. Evaluation of a training program for persons with SCI paraplegia using the Parastep 1 ambulation system: part 1. Ambulation performance and anthropometric measures. Arch Phys Med Rehabil 1997;78:789-793.

[6] Granat MH, Ferguson AC, Andrews BJ, and Delargy M. The role of functional electrical stimulation in the rehabilitation of patients with incomplete spinal cord injury–observed benefits during gait studies. Paraplegia 1993;31:207-215.

[7] Stein RB, Belanger M, Wheeler G, Wieler M, Popovic DB, Prochazka A, and Davis LA. Electrical systems for improving locomotion after incomplete spinal cord injury: an assessment. Arch Phys Med Rehabil 1993;74:954-959.

[8] Granat M, Keating JF, Smith AC, Delargy M, and Andrews BJ. The use of functional electrical stimulation to assist gait in patients with incomplete spinal cord injury. Disabil Rehabil 1992;14:93-97.

Evidence for “Bone health” is based on the following studies:

[1] Eser P, de Bruin ED, Telley I, Lechner HE, Knecht H, Stussi E. Effect of electrical stimulation-induced cycling on bone mineral density in spinal cord-injured patients. Eur J Clin Invest 2003;33:412-419.

[2] Lai CH, Chang WHS, Chan WP, Peng CW, Shen LK, Chen JJJ, Chen SC. Effects of Functional Electrical Stimulation Cycling Exercise on Bone Mineral Density Loss in the Early Stages of Spinal Cord Injury. J Rehabil Med 2010; 42:150-154.

[3] Mohr T, Podenphant J, Biering-Sorensen F, Galbo H, Thamsborg G, Kjaer M. Increased bone mineral density after prolonged electrically induced cycle training of paralyzed limbs in spinal cord injured man. Calcif Tissue Int 1997;61:22-25.

[4] Chen SC, Lai CH, Chan WP, Huang MH, Tsai HW, Chen JJ. Increases in bone mineral density after functional electrical stimulation cycling exercises in spinal cord injured patients. Disabil Rehabil 2005;27:1337-1341.

[5] Frotzler A, Coupaud S, Perret C, Kakebeeke TH, Hunt KJ, Donaldson Nde N, Eser P. High-volume FES-cycling partially reverses bone loss in people with chronic spinal cord injury. Bone. 2008 Jul;43(1):169-76. Epub 2008 Mar 20.

[6] Pacy PJ, Hesp R, Halliday DA, Katz D, Cameron G, Reeve J. Muscle and bone in paraplegic patients, and the effect of functional electrical stimulation. Clin Sci (Lond) 1988;75:481-487.

[7]  Leeds EM, Klose J, Ganz W, Serafini A, Green BA. Bone mineral density after bicycle ergometry training. Archives of Physical Medicine and Rehabilitation 1990;71:207-9.

[8] BeDell KK, Scremin AM, Perell KL, Kunkel CF. Effects of functional electrical stimulation-induced lower extremity cycling on bone density of spinal cord-injured patients. Am J Phys Med Rehabil 1996;75:29-34.

Evidence for “Pressure Ulcers” is based on the following studies:

[1] Dolbow DR, Gorgey AS, Dolbow JD, Gater DR. Seat pressure changes after eight weeks of functional electrical stimulation cycling: a pilot study. Top Spinal Cord Inj Rehabil. 2013 Summer;19(3):222-8.

[2] Petrofsky JS. Functional electrical stimulation, a two year study. J Rehabil. 1992;58(3):29–34

Evidence for “Spasticity” is based on the following studies:

[1] Kapadia N, Masani K, Craven B, et al. A randomized trial of functional electrical stimulation for walking in incomplete spinal cord injury: Effects on walking competency. J Spinal Cord Med 2014;37:511-24.

[2] Manella K & Field-Fote E. Modulatory effects of locomotor training on extensor spasticity in individuals with motor-incomplete spinal cord injury. Restor Neurol Neurosci 2013;31:633-46.

[3] Ralston K, Harvey L, Batty J, et al. Functional electrical stimulation cycling has no clear effect on urine output, lower limb swelling, and spasticity in people with spinal cord injury: A randomised cross-over trial. J Physiother 2013;59:237-43.

[4] Kuhn D, Leichtfried V, Schobersberger W. Four weeks of functional electrical stimulated cycling after spinal cord injury: a clinical cohort study. Inter J Rehabil Res 2014;37:243-50.

[5] Mazzoleni S, Stampacchia G, Gerini A, Tombini T, Carrozza M. FES-cycling training in spinal cord injured patients. Eng Med Biol Soc 2013:5339-41.

[6] Sadowsky C, Hammond E, Strohl A, et al. Lower extremity functional electrical stimulation cycling promotes physical and functional recovery in chronic spinal cord injury. J Spinal Cord Med 2013;36:623-31.

[7] Reichenfelser W, Hackl H, Hufgard J, Kastner J, Gstaltner K, Gföhler M. Monitoring of spasticity and functional ability in individuals with incomplete spinal cord injury with a functional electrical stimulation cycling system. J Rehabil Med 2012;44:444-9.

[8] Krause P, Szecsi J, Straube A. Changes in spastic muscle tone increase in patients with spinal cord injury using functional electrical stimulation and passive leg movements. Clin Rehabil 2008;22:627-34.

[9] Mirbagheri M, Ladouceur M, Barbeau H, Kearney R. The effects of long-term FES-assisted walking on intrinsic and reflex dynamic stiffness in spastic spinal-cord-injured

[10] Granat M, Ferguson A, Andrews B, Delargy M. The role of functional electrical stimulation in the rehabilitation of patients with incomplete spinal cord injury–observed benefits during gait studies. Paraplegia 1993;31:207-15.

[11] Thoumie P, Le C, Beillot J, Dassonville J, Chevalier T, Perrouin-Verbe B et al. Restoration of functional gait in paraplegic patients with the RGO-II hybrid orthosis. A multicenter controlled study. II: Physiological evaluation. Paraplegia 1995;33:654-9.

Evidence for “Orthostatic Hypotension” is based on the following studies:

[1] Faghri PD, Yount J. Electrically induced and voluntary activation of physiologic muscle pump: a comparison between spinal cord-injured and able-bodied individuals. Clin Rehabil 2002;16:878-885.

[2] Elokda AS, Nielsen DH, Shields RK. Effect of functional neuromuscular stimulation on postural related orthostatic stress in individuals with acute spinal cord injury. J Rehabil Res Dev 2000;37:535-542.

[3] Sampson EE, Burnham RS, Andrews BJ. Functional electrical stimulation effect on orthostatic hypotension after spinal cord injury. Arch Phys Med Rehabil 2000; 81: 139-143.

Other references:

Electrophysical Agents – Contraindications And Precautions: An Evidence-Based Approach To Clinical Decision Making In Physical Therapy. Physiother Can. 2010 Fall;62(5):1-80.

Gibbons RS, Shave RE, Gall A, Andrews BJ. FES-rowing in tetraplegia: a preliminary report. Spinal Cord. 2014 Dec;52(12):880-6.

Martin R, Sadowsky C, Obst K, Meyer B, McDonald J. Functional electrical stimulation in spinal cord injury: from theory to practice. Top Spinal Cord Inj Rehabil. 2012 Winter;18(1):28-33.

Warms CA, Backus D, Rajan S, Bombardier CH, Schomer KG, Burns SP. Adverse events in cardiovascular-related training programs in people with spinal cord injury: a systematic review. J Spinal Cord Med. 2014 Nov;37(6):672-92.

Image credits

  1. E-Stim Therapy ©Rankn Jordan, CC BY-NC-SA 2.0
  2. Functional electrical stimulation ©MilosRPopovic, CC BY-SA 4.0
  3. Image by SCIRE Community Team
  4. Checklist ©lastspark,CC BY 3.0 US
  5. Muscle © Smalllike, CC BY 3.0 US
  6. cardio ©emma Mitchell, CC BY 3.0 US
  7. Image by SCIRE Team.
  8. Image by SCIRE Team.
  9. fracture ©fahmionline, CC BY 3.0 US

 

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