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

PAUL R. MEYER, Jft, MD, MM, COL . USAR \no

1954 graduate of Virginia Military Institute, a 1958

graduate of Tulane Medical School, and hecompleted his other residency training at CharityHospital, New Orleans, LA, in 1963 . Uponcompletion of this training Dr . Meyer entered activeduty, U .S. Army, where he remained until August1965. Dr. Meyer immediately joined the OrthopaedicSurgical Faculty at Tulane Medical School,remaining there until his departure for Viet Nam inMarch 1867. Dr. Meyer returned in September 1967to join the faculty at Northwestern University, wherehe has remained for the past 27 years . Since joiningthe faculty, Dr . Meyer has ascended through all ofthe academic ranks to the rank of Full Professor ofOrthopaedic Surgery (1977 to present).

Dr. Meyer is a founding father in thedevelopment of trauma centers in the United States.He founded the first (and still largest, U .S .) AcuteSpine Trauma Center in Chicago . The latter activity,since its founding in 1972, has been under thesponsorship of the National Institute on DisabilityRehabilitation Research.

Dr. Meyer has extensive experience ; he isinternationally acclaimed in the area of surgery ofspine trauma and in the development of spinetrauma centers. He is the author of a surgical textbook on spine trauma and of more than 50 scientificpapers, and has served as a technical advisor inspine trauma centers and surgery to governmentsaround the world . His latest participation was inbehalf of the Government of the United ArabEmirates (Nov ., 1993>.

Dr. Meyer continues to serve in the activeUnited States Army Reserve, at the rank of fullColonel . Besides his presence in Viet Nam in 1987 'he has served in El Salvador as liaison between theU .S. Army Surgeon General's Office and the Chiefof Staff of the El Salvadorian Army (1985) ; as aParatrooper, in Africa with a special forces unit(Kenya 1989) ; and was activated and served ascompany Chief of Orthopaedic Surgery in the U .S.Army Hospital in Landstuhl, Germany during DesertStorm . Dr . (Col .) Meyer serves as ReserveOrthopaedic Consultant to both the U .S . ArmySurgeon General and the U.S . Army AeromedicalCenter, Ft . Rucker, Alabama . He is a member of theSpinal Cord Injury panel of the Department ofVeterans Affairs, Rehabilitation Research andDevelopment Service Scientific Merit Review Boardand the recipient of numerous civilian and militaryawards .

Paul R. Meyer ' Jr . ' MD, MMProfessor of Orthopaedic SurgeryNorthwestern University, Chicago, IL

GUEST EDITORIALS

Health Benefits Derived by a Person with Paraplegia who is Involved in SportsorWhy Sports are Important in the Life of the Person with Paraplegiaby Paul R . Meyer, Jr., MD, MM

Much has been written about thealterations in organ system physiologicalfunction associated with spinal cordneurological trauma . While these alterationsare of immediate concern, there areconcurrently present and of equal importance,unseen, scientifically immeasurable and oftenunrecognized, devastating psychologicalchanges that have the power to influence andnegatively affect every organ system'sphysiological recovery . Accepting thissupposition assists in crystallizing thepsychological importance of sports in the life ofa spinal cord injured person.

To note a few of the metabolic changesone might anticipate with the onset ofneurological injury and paraplegia, theyinclude : alterations in cardiorespiratory systemoutput, decrease in oxygen transport capacity,an altered vasomotor regulation system withpoor venous return, a reduction in muscularstrength and endurance, a decreased ability tomaintain good physiological and psychologicaladaptation, pooling of blood in paralyzedregions, a reduction of cardiac preloading andperformance, extensive muscular and vasculardeficiency, a reduced blood volume, and arelatively small heart volume . Because thesedisabilities are the result of nervous systeminjury, it becomes readily apparent that somemechanism should be found to ameliorate oralter these deleterious physiological factors.

During the International Year for Personswith Disability (1981), much attention wasplaced on the importance of fitness in thelower limb disabled wheelchair-confinedindividual . In the process, muscle strength andendurance received much less attention than

did the cardiorespiratory systems, in spite oftheir importance in the performance ofactivities of daily living . Also neglected werethe effects of psychological correlates upon thewhole conditioning process . Recognizing thatfitness in the disabled is poor, and that theeveryday propulsion of a wheelchair is not aneffective means of providing or maintainingcardiorespiratory conditioning, othermechanisms have been sought . Research inthis area has demonstrated that forearmpedaling and arm cranking exercises, alongwith upper limb weights are each effectivecardiac output enhancers . It would appear thatthe effectiveness of these activities is throughan alteration in the oxygen transport capacityto active muscles due to changes in vasomotorregulation below the level of the lesion (1).

In the same vein, due to the presence oflimited physical activity in the individual withdisabilities, there results a pooling of blood inthe paralyzed lower limbs . This effects areduction in "cardiac preloading" (2) . "Intrained paraplegics, as well as competitiveparaplegic athletes, both displayed to the sameextent . . .a conspicuously poorer cardiovascularcapacity in relation to able-bodied individuals ."The reason: a poor venous return, a reducedblood volume, and a smaller heart volumesecondary to extensive muscular and vasculardeficiencies. It is well-recognized thatindividuals with spinal cord paralytic lesionshave a greatly reduced activity level, oftenproducing additional associated medicalcomplications. This combination results in apatient's involuntary "isolation" (3) . Together,these result in a higher incidence ofcardiovascular disease than seen in the general

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

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Guest Editorials : Meyer

population . In a group of adults with lowerlimb disability, by means of increasing theexercise load, the frequency of training, theload range and ergometric stimulus 'density,'there has been noted a real increase instamina, strength, and coordinated abilities (4),which suggests that gains in performancemight follow active arm crank exercising (2).

Confirming the above is a study thatsought to predict leisure time exercise behavioramong a similar group of persons with lowerlimb disabilities . The variables observed andmeasured included : habit, education, disabilitytype,fitneao /evm[ and an "nxmroisefn//om+up . "

The most important variable found wasintention . Two important factors requiringconsideration are: the cause of the individual'sdisability and the strength of the individual'sexercise habit . Both greatly influence exercisebehavior (5).

It is well-recognized that individuals withspinal cord lesions frequently have presentseveral "active" variables . They include : agreatly reduced activity level, multipleadditional medical complications, involuntary"isolation," and a high incidence ofcardiovascular disease . Also present is the factthat normal daily activities for a person withparaplegia or quadriplegia are insufficient tomaintain "a satisfactory level of physicalfitness" (3).

Individuals with paraplegia are at great riskfor the development of heart disease becauseof "low-HDL-cholesterol ." Exercise has beenidentified as an important means of "elevatingHDL cholesterol ." Thus, "Iong-term coronaryrisk factors have been greatly reducedfollowing a marked increase in the HDLcholesterol level" (6) . Therefore, a long-termmethod of managing this disability is theincorporation of strenuous exercise (such asswimming) into the lifestyle of the person withparaplegia . There is also good evidence thatexercise training is very effective in decreasingthe resorptive process of the skeleton bydecreasing bone and collagen catabolism,aiding in new bone formation (7).

A finding in sports medicine is that"continuous training must take place with

relatively high intensity" in order to produce aneffective circulatory response . To accomplishthis, "stamina training" of skeletal musclesmust ensure that the capacity reserves ofskeletal muscle are developed (4).

All of the aforementioned activities seemto indicate that active participation in "sports"serves as an effective means of achieving andmaintaining good physiological andpayoho/ogioal adaptation to neurological injuryresulting in wheelchair living (8) . An additionalaim of rehabilitation (and sports participation)is to increase the active participation in dailylife activities of persons with physicaldisabilities.

REFERENCES

1. Joh!JLGandnoontogneM ' PuuteneG.etaiCardiac output during exercise in paraplegicsubjects . Eur J App! Physiol 1991 :63(4) :256—60.

2. Davis GM, Plyley MJ, Shepard RJ . Gains ofcardiorespiratory fitness with arm-crank trainingin spinally disabled men . Can J Sport Sci199116(1) :64—72.

3. Eriksson P . Lofstrom L, Ekblom B . Aerobic powerduring maximal exercise in untrained and welltreinod persons with quadriplegia and paraplegia.SoandJ Rehabil Med 1988 :20(4)1 41—7.

4. Koch I, Schlegel M ' PirmvitzA' Jaoohke B,Schlegel K . Objectification of the training effect ofsports therapy for wheelchair users . !ntJ RehabilRes 1983 :64(4):439—48 (published in German).

5. Godin G, Colantonio A, Davis GM, Shepard RJ,Simard C . Prediction of leisure time exercisebehavior among a group of lower-limb disabledadults . J Clin Psychol 1986 :42(2) :272-9.

6. Sorg RJ . HDL-cholesterol : exercise formula.Results of long-term (6 year) strenuousswimming exercise in a middle-aged male withparap!egio .J OrthopSporio PhyaThar1993 :17(4)1 95—9.

7. Cowell LL, SquirouVVG ' Raven PB . Benefits ofaerobic exercise for the paraplegic : a briefreview. MedSciSports Exeoo 1986:18(5) :501—8.

8. Davis GM, Shepard RJ ' Jeckoon RW. Cardio-naopiratoryfitn*au and muscular strength in thelower-limb disabled . Can J App/ Sport Sci1981 :6(4)1 59—65 .