Physical Activity Guidelines for Spinal Cord Injury
Original Editor - Naomi O'Reilly
- 1 Introduction
- 2 Medical Considerations for Physical Activity
- 3 Background to Physical Activity Guidelines
- 4 Spinal Cord Injury Exercise Guidelines
- 5 Role of Physiotherapy in Promoting Guidelines
- 6 Resources
- 7 References
Although many people think of health in terms of illness, health is a positive concept that covers your physical, mental and social well-being (Department of Health and Children, 2000). Physical activity benefits every aspect of health. Regular physical activity reduces shows benefits for everyone including children, adolescents, adults, older adults, and people with a disability across all ethnic groups and importantly has been shown to reduce the risk of non-communicable diseases, such as Coronary Heart Disease, Type 2 Diabetes, Stroke, Cancer, Osteoporosis and Depression. 
The World Health Organisation developed Global Recommendations on Physical Activity for Health with the overall aim of providing national and regional level policy makers with guidance on the dose-response relationship between the frequency, duration, intensity, type and total amount of physical activity needed for the prevention of Non Communicable Diseases. While these guidelines were not specifically tailored to the spinal cord injury population, the WHO suggest that the recommendations could be applied to adults with disabilities with adjustment to the guidelines for each individual based on their exercise capacity and specific health risks or limitations. 
Benefits of Physical Activity
- enable the performance of everyday activities
- decrease the risk factors associated with cardiovascular complications
- Improves circulation
- helps achieve and maintain a healthy weight
- Improves health and wellbeing
- enhance participation and quality of life
- promote self esteem
- Improves energy levels
- Strengthens muscles
- Increases flexibility
- Improves mood
- Improves sleep
- Decreases pain
Barriers to Physical Activity
- lack of accessible exercise equipment
- lack of accessible venues
- costs of memberships and equipment
- lack of transportation
However, the panel also identified barriers and facilitators unique to these guidelines.
- specifying different guidelines for improving fitness and cardiometabolic health might create confusion (i.e., people may not be sure which guideline to follow), as might having guidelines that differ from what is promoted for the general population.
- use of the term ‘exercise’, as opposed to ‘physical activity’, in the guideline may constrain thinking about types of activities that people with a spinal cord injury can participate in.
- importance of improving one’s fitness might be overshadowed by launching a new cardiometabolic health guideline.
Medical Considerations for Physical ActivityIndividuals with a spinal cord injury are predisposed to medical conditions and have a higher prevalence than that of a non-spinal cord injury individual. Understanding these conditions are vital to the proper prevention, care, and return to activity for these individuals. The following briefly describes some of these considerations , though this is not an exhaustive list due to the vast anatomical and structural variances that occur within individuals with a spinal cord injury.
One of the most pressing conditions individuals with a spinal cord injury can encounter is autonomic dysreflexia. This condition is normally seen in individuals whose injury is at or above the T6 spinal level . Autonomic dysreflexia begins with a noxious stimulus below the level of the lesion and the body’s exhibits an uncontrolled sympathetic response. This is a medical emergency requiring immediate attention. Klenck and Gebke (2007) report that some athletes, regardless of the dangers, attempt to intentionally induce autonomic dysreflexia leading them to a competitive advantage because of an increase in cardiac output .
Other medical considerations for individuals with a spinal cord injury involved in physical activity include thermoregulation, pressure sores, neurogenic bladders, premature osteoporosis, peripheral nerve entrapment syndromes, and musculoskeletal injuries. Thermoregulation is decreased due to loss of the autonomic nervous system and cooling and heating mechanisms such as sweating and shivering. Losing sensation also contributes to temperature-related injury, especially during temperature and environment extremes. Individuals with a spinal cord injury require skin monitoring not only for environmental exposure, but also for areas of increased pressure. These areas include the sacrum and ischial tuberosities; sports wheelchairs that position the knees higher than the buttocks and provide a decrease in the risk of developing pressure sores. The lack of bowel and bladder control poses an increased risk for urinary track infections due to incomplete voiding, increased pressure, and catheter use.  Individuals with a spinal cord injury are also more prone to musculoskeletal co-morbidities, in particular over use injuries of the upper limb. Premature osteoporosis may be present due to decreased muscle use and demineralization while peripheral nerve entrapment in upper extremities are likely due to increased use and pressure over soft tissues from manual propulsion.
Background to Physical Activity Guidelines
While it was acknowledged that exercise is an important tool for improving wellbeing and enhancing independence for individuals with a spinal cord injury, many health and fitness professionals highlighted a lack of clear guidance on how best to prescribe physical activity for this population group. The team – collaborating with an international panel of researchers, clinicians, community organisations, adults with SCI, and knowledge translation specialists – jointly devised a set of exercise guidelines which were launched at the International Spinal Cord Society Annual Meeting in 2017.
Development of Scientific Guidelines
Translating Scientific Guidelines to Practice Guidelines
Spinal Cord Injury Exercise Guidelines
Who Do They Apply To
Men and Women aged 18 - 64 with a Chronic Traumatic or Non-Traumatic Spinal Cord Injury > 12 Months Post Onset, with a Neurological Level C3 or Lower including tetraplegia and paraplegia, irrespective of race, ethnicity or socio-economic status, who are not active above and beyond daily activities. 
While there is currently insufficient scientific evidence to draw firm conclusions about the risks and benefits of these guidelines for individuals with a Spinal Cord Injury < 12 months post-onset, aged 65 years or older, and those with co-morbid conditions, they may be appropriate following consultation with a health care provider prior to beginning an exercise program. 
What Settings Do They Apply To
The Guidelines are meant to be applicable to exercise performed in a range of settings including but not limited to; 
- rehabilitation settings
- fitness centers and
- individuals own homes
Cardiorespiratory Fitness and Muscle Strength
To improve cardiorespiratory fitness and muscle strength, adults with a spinal cord injury should engage in at least;
- 20 min of moderate to vigorous intensity aerobic exercise, 2 times per week, and
- three sets of strength exercises for each major functioning muscle group, at a moderate-vigorous intensity, 2 times per week.
This guideline affirms the 2011 Spinal Cord Injury Physical Activity Guidelines, but has also been updated to align with the evidence base by referring to ‘exercise’ rather than ‘physical activity’
Cardiometabolic disease, which includes a spectrum of conditions from insulin resistance, progressing to the metabolic syndrome, pre-diabetes, and finally to more severe conditions including Cardiovascular Disease and Type 2 Diabetes, currently poses a serious health and economic burden worldwide, with prevalence predicted to increase. Independent risk factors include prolonged sitting, lack of physical activity, poor diet, and short sleep duration, which have all become common place worldwide. 
The new guideline, states that for cardiometabolic health benefits, adults with a spinal cord injury are suggested to engage in at least;
- 30 min of moderate to vigorous intensity aerobic exercise, 3 times per week.
Role of Physiotherapy in Promoting GuidelinesPhysiotherapists have always had a close relationship with exercise, the profession was founded on the work of remedial gymnasts and the profession has a rich history of prescribing rehabilitative exercise. The global physical inactivity crisis, and the epidemic of life-style related diseases (non-communicable diseases) has created an urgent need to build on our rich history of prescribing exercise and develop our approaches for prescribing physical activity. Creating a more active population requires joined up thinking and action from many stakeholders; physiotherapists need to be active in engaging with individuals and communities.
"Physiotherapists are ideally placed to help the dissemination of these physical activity guidelines for spinal cord injury because they interact on a daily basis with patients at the start of their journey after their spinal cord injury." Dot Tussler, Physiotherapist at Stoke Mandeville Hospital
National Centre for Sport & Exercise Medicine
SCI Action Canada
Peter Harrison Centre for Disability Sport
- Fit For Life; A Guide for Adults with Spinal Cord Impairment
- Fit for Sport; A Guide for Adults with a Spinal Cord Impairment
- Physical Activity Guidelines Advisory Committee. Physical Activity Guidelines Advisory Committee Report, 2008. Washington, DC: U.S. Department of Health and Human Services, 2008.
- World Health Organization. Global recommendations on physical activity for health. World Health Organization; 2010.
- National Centre for Sport and Exercise Medicine. Peter Carruthers | The Importance of Exercise. Available from: https://youtu.be/RbJ0K75SmMM[last accessed 20/02/19]
- Klenck C., and Gebke, K. (2007). Practical management: Common medical problems in disabled athletes. Clinical Journal of Sports Medicine, 17(1), 55-60.
- National Centre for Sport and Exercise Medicine. Jan van der Scheer | How SCI Exercise Guidelines were Developed. Available from: https://youtu.be/Jd5xaBVaLv0[last accessed 20/02/19]
- National Centre for Sport and Exercise Medicine. Prof Vicky Tolfrey | Why We Need SCI-Specific Evidence. Available from: https://youtu.be/nqcbIn1XyWo[last accessed 20/02/19]
- National Centre for Sport and Exercise Medicine. Jan van der Scheer | How the Guidelines will be Translated. Available from: https://youtu.be/oEOs_0Xor-4[last accessed 20/02/19]
- Ginis KA, van der Scheer JW, Latimer-Cheung AE, Barrow A, Bourne C, Carruthers P, Bernardi M, Ditor DS, Gaudet S, de Groot S, Hayes KC. Evidence-based Scientific Exercise Guidelines for Adults with Spinal Cord Injury: An Update and a New Guideline. Spinal Cord. 2018 Apr;56(4):308.
- Vincent GE, Jay SM, Sargent C, Vandelanotte C, Ridgers ND, Ferguson SA. Improving Cardiometabolic Health with Diet, Physical Activity, and Breaking Up Sitting: What about Sleep?. Frontiers in Physiology. 2017 Nov 8;8:865.
- National Centre for Sport and Exercise Medicine. Dot Tussler | The Importance of SCI Exercise Guidelines for Physios. Available from: https://youtu.be/Giqt6jT27nU[last accessed 20/02/19]
- National Centre for Sport and Exercise Medicine. Dot Tussler | Role of Physios in helping People with SCI be Active. Available from: https://youtu.be/w6P3hQSUr-Y[last accessed 20/02/19]