Dr. dr. Tirza Z. Tamin Sp.KFR (K)

Department of Physical Medicine and Rehabilitation, Cipto Mangunkusumo Hospital




Due to the sedentary lifestyle imposed by their disability, the spinal cord injury (SCI) appear to be at a greater risk for health disorders such as coronary heart disease, obesity, and diabetes. A report by Le and Prince revealed that deaths in a SCI group were 228% of the expected death in an age- and gender-matched-able-bodied control group.1 Spinal cord injury (SCI) results in personal life changes. These are often accompanied by psychological consequences that affect rehabilitation potential and the opportunity of returning to previous, familiar social life and work. In particular, higher levels of anxiety and depression were found in individuals with spinal cord injury than in able-bodied persons. Our study focused on sports activity as a possible method for improving SCI patients’ psychological status. It has been found that regular exercise confers positive health benefits on the SCI population. Several studies document objective physical and psychological gain for the spinal cord injured individual.2

The human spinal cord is a complex association of upper and lower motor neurons than that functions as a bidirectional conduit between the brain and its motor , sensory and autonomic targets. It also serves as a site for reflex integration between body sensors and their motor, sensory and autonomic targets. It also serves as a site for reflex integration between body sensors and their motor and autonomic effectors. Because spinal cord functions differ by level and structure, injury to or disease of spinal tracts results in varying types and degrees of dysfunction depending upon the specific neural structures affected.The interruption of spinal cord functions by trauma affects 10.000 Americans annualy, with an estimated 179 000 persons having survived their initial injury. Thereafter, these individuals experience unique physical, social, and phychological changes throughout their lives, including diminished ability to perform and benefit from exercise conditioning. The latter limitation is cause for concern as individuals with spinal cord injury (SCI) are usually young and physically active at the time of injury; profound physical deconditioning is common after injury and physical deconditioning contributes to multisystem medical complications, activity limitations, and accelerated aging.3



II.1 Defintion

Spinal cord injury (SCI) is a serious debilitating disorder that results in complete or artial loss of motor/sensory neuronal functions due to mechanical damage of the spinal cord.4

II.2 Etiology

The most common etiologies of SCI were automobile crashes (31.5%) and falls (25.3%), followed by gunshot wounds (10.4%), motorcycle crashes (6.8%), diving incidents (4.7%), and medical/surgical complications (4.3%). These 6 causes collectively accounted for 83.1% of total SCIs reported to the NSCID and NSSCID since 2005.5

II.3 Categories of SCI

Spinal cord injuries typically are divided into two broad functional categories: tetraplegi and paraplegia. Tetraplegia refers to complete paralysis of all four extremities and trunk, including the respiratory muscles, and result from lesions of cervical cord. Paraplegia refers to complete paralysis of all or part of the trunk and both lower extremities (Les), resulting from lesions of the thoracic or lumbar spinal cord or cauda equine.. Complete Spinal Injuries at or above T4 effexts diminished cardiac acceleration and reducing cardiac output and circulation. Complete spinal Injuries below T10 effects lower motor neuron-lower extremities and capacity for neuromuscular activation.6

II.4 Exercise for people with SCI

The effects of functional degeneration are vast and greatly reduce the overall health of paraplegics, particularly within the musculoskeletal and cardiovascular systems, thereby increasing their risk for cardiovascular disease. Recent investigations suggest that this process may be reversible through exercise training and that paraplegics respond to exercise training in essentially the same manner as the non-handicapped individual. In addition, exercise training has been reported to decrease the resorptive process of the skeleton by decreasing bone and collagen catabolism and possibly aiding in new bone formation.7

Competitive and recreational sporting opportunities for patients with disabilities have increased tremendously. One particular group of patients that has benefited from these opportunities and now participates in sports in ever-enlarging numbers is individuals with paraplegia. For the purposes of this article, paraplegia is defined as complete or incomplete paralysis in the lower extremities such that a wheelchair must be used as the primary mode of mobility. Sports participation is an indispensable method of modern rehabilitation. Especially after medical rehabilitation is completed, sports have an invaluable therapeutic value in renewing the paraplegic’s lost powers, helping coordination, and maintaining stamina. Today, individuals with paraplegia participate in all types of sports for competition, enjoyment, and to improve overall fitness. Goal of sport for people with spinal cord injury are promote good health and well-being, make daily life activities easier to perform, achieve better result in sports and competition, and achieve better result in sports and competition.8

Almost any sport in which able-bodied athletes can participate in can be modified to fit participation by individuals with paraplegia. Such common sports in Table 1.8

TABLE 1. Sport for People with Spinal Cord Injury

Training technique for people with SCI includes periodization, endurance, speed, skill, strength, and flexibility. Periodization is the technique of dividing the year into training interval. Using team sports as an example, the year is divided into a preseason, in-season, main season, and end-season. Even when training for one event, teams can use similar divisions; precompetition, initial competition, main competition, and postcompetition. Patient should implement the following five training regimens into their periodization program: endurance, speed, skill, strength, and flexibility.9

Endurance training typically focuses on training for a particular event because it involves elevating the heart rate over a prolonged period of time. A wheelchair road racer preparing for a 5K or 10K event, for example, would train that particular distance at least 3 days a week. On days when people do not do endurance training they should do interval training. This type of training stresses the cardiovascular and neuromuscular system and thus prepare the body for competition.10

Speed training is part of a well thought out periodization program. Speed training can increase reaction time, which can be a vital component related to performance and ultimately success in competition. Sprint training, in which the athlete perform short sprinting intervals, is the best method to train for speed. Athletes who participate in sports such as basketball, rugby, track and field events, swimming, and weight training will benefit from speed training. Another aspect of speed training is a technique called plyometrics. Phylometric exercise integrates strength and power into a single training session, resulting in explosiveness. Phylometric relies on an external force to store energy within the musculature. The stored energy is immediately followed by an equal and opposite reaction, using the natural elastic tendencies of the muscles to produce energy. The goal of phylometric exercises is to minimize the time the body has to recover from the external force, thereby increasing the amount of energy stored within the muscle for optimal performance.10

Skill training is also applicable to sports. Skill training in the context of this chapter essentially is equivalent to specificity training, which many athletes overlook because they think it encompasses only the competitive event itself. Athletes, however, should regularly examine and break down the mechanics of their movements. Knowledge of proper form in executing these types of movements undoubtedly can help an athlete to increased his performance. Usually, the athlete needs advice from a physical or occupational therapist or an individual who understands movement biomechanics to improve performance and efficiency.10

Strengh training techniques typically refer to resistance training which can be accomplished through the use of free or machine weights, surgical tubing, body weight exercises, manual resistance, or any other form of activity that follows basic strength training principles. The wheelchair athlete can apply exercise principles that are similar to those unimpaired athletes use, but the wheelchair athlete does have some unique characteristics. The wheelchair athlete does have some unique characteristics. The wheelchair athlete does have some unique characteristic. The wheelchair athlete with SCI depends on relatively smaller muscle group of the upper body than does the unimpaired athlete who relies on his legs to produce movement.10

Strength training can be accomplished by using free weights or machines. Resistance training should not focus solely on free weights or machines: it is best to use both methods to provide a comprehensive workout. Table 2 compares the advantages and disadvantanges of free weights versus machines. Although both machines and free weights produce strength gains, to a large extent the magnitude of gains in maximum strength as a result of resistance training depends on the similarity between the strength tests and the training exercise.10


Table 2. Free Weights VS Machine

Sets and repetitions depends on purpose of the training program, conditioning program: 3 sets with 6-15 repetitions, intens strength training (5 sets per exercise), repetitions should be reduced to 6 per set, endurance athlete: focus on lighter weights with higher repetitions (13-16), with the number of sets remaining around 3-4. Principles of spesific adaptations to imposed demands includes; progression, overload, volume, frequency, intensity, documentation, and motivation. Common training routines includes training the entire body in 1 day, dividing the body into upper and lower portions, exercising only one body part per day, three primary training days (push-pull workout).

Arm ergometer is recommended for endurance training and testing especially during the early rehabilitation period for the spinal cord injured when wheelchair driving technique has not yet been acquired. Because of the paraplegics inability to ambulate, the problems associated with determining their fitness levels have led to many investigations. Arm Cyclergometry has been the usual methode for evaluating the fitness and work capacity of paraplegics. Other investigations comparing various other methods have been performed in an attempt to find which methode is best suited for the lower limb disabled.

Electrically stimulated leg cycle (ESLC) training electrically stimulated leg cycle training in spinal cord injured individuals can increase peak VO2, muscle volume in the stimulated muscles, muscle glucose transport, the transformation from muscle fiber IIb to IIa, and bone mineral density in the proximal part of the tibial bone.

Picture 1. Arm Exercise

ESLC activates larger muscle groups than arm exercise, without any serious side-effects. Thus, ESLC is highly recommended as supplementary endurance training for SCI persons. Better compliance is achieved in patients who have been physically active before the injury, and who are realistic as to the effects of ESLC. Evidence that ESLC training leads to altered body composition in SCI has been provided. Previously magnetic resonance imaging (MRI) scans taken from electrically stimulated thigh muscles have implied that muscle hypertrophy occurs in association with training.11

Picture 2. ESLC 11


II.5 Medical Benefit of Sport for SCI People

II.5.1 Cardiovascular risk factors

Individuals with paraplegia are reported to have higher resting heart rates and lower stroke volumes while at rest and during exercise than able-bodied individuals. Additionally, persons with thoracic paraplegia have higher resting and exercise catecholamine levels than persons without SCI and persons with cervical SCI. As a result, paraplegic patients reportedly have a degree of excess cardiovascular strain, because a greater percentage of heart rate reserve is required to satisfy a given work level.12

II.5.2 Psychosocial benefits

Persons with SCI have similar psychosocial ailments as those in persons without SCI but in larger numbers. Depression and feelings of isolation are common. Limited studies have found that exercise in persons with disabilities has led to increased feelings of well-being.12

II.5.3 Shoulder and musculoskeletal injuries

Upper-extremity pain is the most common reported physical injury in persons with SCI, and the shoulder is commonly the most painful joint because it is often the end-bearer of weight and is subjected to significant repetitive strain. Rotator cuff tendinitis, frank tears, and general impingement syndrome are the most common shoulder injuries. Shoulder pain is worsened in persons with paraplegia by muscle imbalances because overly strong anterior chest and arm muscles overpower the weak posterior scapular and cervical stabilizers.12

II.5.4 Pressure Sores

Can present in amputees with improperly fitting prosthetics or in wheelchair athletes (SCI, CP, spina bifida, neuromuscular disease). Treatment involves assuring proper positioning in the wheelchair, attaining correct fit of adaptive equipment and prosthetics, performing regular pressure reliefs (eg, lifting self off seat for brief periods of 10-20 seconds throughot the day), providing appropriate cushioning, reducing skin moisture and minimizing the potential for skin shear.12

II.5.5 Thermoregulation

Hypothermia is of a special concern in the athletes with SCI. Contributing factors are the decreased muscle mass below the level of lesion, loss of vasomotor and sudomotor neural control, and possible decreased input to the hypothalamic regulatory centers. Impaired or absent sensation intensifies the risk.12

 II.5.6 Autonomic hyperreflexia

Often observed when persons with SCI are exercising under the control of an electrical current, autonomic hyperreflexia (AH) is most dangerous when it goes unrecognized. Usually limited to persons with SCI above the Tj6 level, AH occurs because the dissociated sympathetic nervous system becomes activated and is not subject to inhibitory mechanisms. Sympathetic activity is usually initiated by an offending stimulus (eg, kinked Foley catheter). If the offending stimulus is not found, blood pressure can elevate to malignant, life-threatening levels.12

II.5.7 Heterotopic Ossification

Athletes with SCI are at an increased risk for ectopic bone formation. This will usually occur in the area of major joints. Pain, increased warmth, swelling, decreased joint motion or contracture may be present in areas of heterotopic ossification.12

II.5.8. Fractures

Most athletes with SCIs develop lower-extremity osteoporosis as a result of disuse, immobility, and other factors; these individuals are at higher risk for lower-extremity long-bone (eg, femur, tibia) fractures after simple falls and minor injuries. Aggressive team sports (eg, rugby, basketball) create special risks for fracture injuries.12

II.5.9 Overuse Injuries

Quite common among athletes with paraplegia, such overuse can cause chronic pain syndromes. These include upper extremities tendonitis, bursitis, and skin maceration and breakdown.12




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