NSCA CPT Chapter 22 – Clients With Spinal Cord Injury, Multiple Sclerosis, Epilepsy, and Cerebral Palsy

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Chapter Objectives:

• Know the basic etiology and epidemiology of spinal cord injury, multiple sclerosis, epilepsy, and cerebral palsy.
• Know the physiological, functional, and health-related impairments caused or exacerbated by spinal cord injury, multiple sclerosis, epilepsy, and cerebral palsy.
• Understand the basic physiological response to exercise in clients with these disorders.
• Find abnormal physiological responses to exercise in clients with these disorders.
• Use the precautions for planning and implementing exercise and physical activity programs for clients with these disorders.
• Know the potential functional and health benefits of regular exercise in clients with these disorders.

Spinal Cord Injury

This injury results in the loss of motor and sensory function, potentially in the trunk or limbs, due to some irreversible damage to the neural tissues in the spinal canal.

The higher the injury level, the more extensive the resulting deficits are.

Clinical Manifestations

Common cardiovascular problems are seen in people who have chronic spinal cord injuries:

• Orthostatic hypotension
• Autonomic dysreflexia
• Impaired transmission of cardiogenic pain
• Loss of cardiac reflex acceleration
• Quadriplegic cardiac atrophy
• Atrial fibrillation
• Congestive heart failure
• Pseudo myocardial infarction
• Sudden death from an asystole
• Atherosclerosis

Relatively common showings of spinal cord injuries are through autonomic dysreflexia. This results from noxious stimuli like a distended bladder, constricted clothing, and infections that would cause heightened sympathetic nervous system functions. It is a life-threatening disorder. 

Preventing Injuries in Clients With Spinal Cord Injury

It is common to see shoulder, wrist, and elbow overuse injuries in people who have spinal cord injuries. We can prevent this through exercise programs designed to stretch the anterior and strengthen the posterior muscle groups within the shoulder girdle.

Exercise Concerns in the Spinal Cord Injury Population

Temperature Regulation

People with spinal cord injuries, especially those with high lesions, are usually unable to increase the skin blood flow in the areas of the body that are paralyzed. This impairs the ability to dissipate metabolic heat and they are thus put at a greater risk of being exposed to heat-related injuries. This would, of course, be the same for cold-related injuries, but they are less reported.

Venous Return

Spinal cord injury clients mostly have poor venous return in the seated or upright posture. This is because of lower limb venous pooling and the absence of the muscle pump feature of the skeletal muscles for venous return.

General Health Issues of Persons With Spinal Cord Injury

Several metabolic disturbances are the major risks as far as general health goes. 

There is a decrease in muscle mass, less activity by the person, and more adiposity; therefore, the risk for insulin resistance and hyperinsulinemia is greatly increased.

With tetraplegia, we see atrophy occurring in cardiac muscles more often with SCI patients.

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Exercise Testing and Training of Clients With Spinal Cord Injury

People with spinal cord injuries respond to training the same way people who do not have them do. But due to problems associated with using a wheelchair, like access to buildings, equipment, and so on, they are challenged more to achieve their activity goals.

Exercise Testing

The use of maximal exercise testing on people with spinal cord injuries is only to be done within a medical setting, by the appropriate professionals, and with physician supervision.

We commonly see the use f the arm crank ergometer for testing.

There is also a common test for the VO2 peak of a person who is tested and received from a 12-minute wheelchair propulsion distance test.

Physical Activity and Fitness Levels in Persons With Spinal Cord Injury

The sedentary lifestyle imposed by spinal cord injury is the main reason for their reduced physical activity. 

There is a great and strong relationship between the VO2 peak and upper body strength and endurance in people with spinal cord injuries. 

Forced vital capacity, the total volume of air that is forcefully exhaled, is reduced by 50% in people with high tetraplegia. 

Exercise Prescription

40 – 60% of VO2 max is recommended at the start of a program for 10 – 20 minutes 3 days per week or every other day. This is for aerobics.

For resistance training, doing 8 – 12 exercises at 40 – 70% of 1 rep max for 2 – 3 sets of 8 – 12 reps is important.

We use the standard rules for progression, specificity, and overload.

Multiple Sclerosis

Medical Management of Multiple Sclerosis

This is an autoimmune disorder occurring in genetically susceptible people. 

It is characterized by inflammation and progressive degeneration occurring in the myelin sheath of the nerves.

Early symptoms are fatigue and weakness, ipsilateral optical neuritis, gait ataxia, neurogenic bowel and bladder, and trunk and limb paresthesia. These result from axonal demyelination that leads to slowed or blocked nerve conduction. 

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This disorder typically begins in early adulthood and has a variable clinical course and prognosis.

There is no known cure. 

There are four aspects to treating multiple sclerosis:

The first is the education of the person diagnosed and the family. They must know the process, the progression, the prognosis, and how the disease is managed.

The second aspect is the management of symptoms and other secondary complications that arise.

The third aspect is managing the disease process. This involves medications, specifically for inflammation. This means the trainer needs to know all medications and also seek the medical team’s knowledge to know how they work and affect physical activity.

The fourth aspect is exercise. People who have multiple sclerosis are typically sedentary due to the added challenges. 

Exercise Testing and Training of Clients With Multiple Sclerosis

People who have multiple sclerosis often have heat intolerance.

Exercise Testing

Extreme caution is taken when testing a client with multiple sclerosis. 

It is recommended to do Submax testing instead of maximum testing.

Resistance Training

Programs typically consist of 1 set of 10 – 15 reps with 70% of 1RM. 

Aerobic Conditioning

This was not recommended for multiple sclerosis patients, but it can give the proper results when carefully designed. 

The results vary depending on the severity of the disease.

Moderate intensities are recommended.

Clients should not be exercising to exhaustion. A program is considered too extensive if the person is fatigued for more than two days following training.

Epilepsy

This is defined as 2 or more unprovoked and recurring seizures. Seizures are paroxysmal and uncontrolled electrical discharges within a part of the brain. It causes physical or mental symptoms that may not involve convulsions.

Status Epilepticus is a seizure lasting more than 30 minutes or in a series where consciousness is not restored.

For people with epilepsy, regular aerobic exercise may contribute to improved seizure control, but n 10% of people, vigorous exercise is a precipitant to seizures.

Medical Management of Seizures

This is effective in 67 – 75% of cases of epilepsy. Essentially a medication is used to control the seizures. For those that are still affected, surgery may be an option to fix it.

Exercise Testing and Training of Clients With Epilepsy

Most will have sedentary lives and thus have lower physical fitness.

But, physical activity has been shown in studies to be a contributor to better control of seizures.

A weight loss of 10 pounds can increase the bioavailability of antiseizure meds, and thus, it would increase the risk of side effects.

Cerebral Palsy

This is a term that we use to describe a group of chronic musculoskeletal deficits that cause the impairment of body movement and coordination of muscles.

This is irreversible, but therapy and rehab can focus on controlling spasticity and athetosis and improving function and neuromuscular coordination.

Medical Management of Cerebral Palsy

The treatment essentially is just managing the secondary complications of the irreversible lesion.

Seizures occur in 60% of people that have cerebral palsy.

Exercise Testing and Training of Clients With Cerebral Palsy

People with cerebral palsy can expect a systematic program of physical exercises to yield health and fitness benefits just like they would without cerebral palsy.

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