NCPAD:Exercise/Fitness: Resistance Training for Persons with Physical Disabilities

Introduction

James H. Rimmer, Ph.D.

Federal officials and members of the public health community are growing concerned that as persons with disabilities age, they will have increasing difficulty performing activities of daily living (ADL) (i.e., dressing, showering) and instrumental activities of daily living (IADL) (i.e., ambulation, doing laundry, and grocery shopping) at a much earlier rate than the general population (Freedman & Martin, 1999; Sherwood, 1999). Persons with physical disabilities are often confronted with many physical challenges as a result of their functional limitations (i.e., inability to walk) and associated health conditions (i.e., spasticity, weakness, fatigue). When combined with the natural aging process, the likelihood of becoming physically dependent on others for assistance with daily activities (ADL & IADL) substantially increases (Brandt & Pope, 1997). Some experts believe that the high incidence of inactivity and poor health practices seen in persons with disabilities (Heath & Fentem; Rimmer, 1999), combined with the natural aging process and the potential loss of function from the disability itself, presents a volatile combination for those people living at or close to the "threshold" of physical dependence.

Maintaining a high level of fitness among persons with physical disabilities has even greater importance than in the general population, because a loss in strength could erode a person's ability to care for themselves, work, recreate or engage in community events (i.e., attend worship services, socialize with friends). Persons with physical disabilities would benefit greatly from participation in resistance training programs and would have a greater likelihood of maintaining their physical function and independence (Cress et al., 1999; Ferketich, Kirby, & Always, 1998; Morey, Pieper, & Cornoni-Huntley, 1998).

As persons with physical disabilities age, the interaction between the natural aging process and the disability creates a demanding physical environment. Tasks that could be accomplished in younger adulthood become major barriers in middle and later adulthood. Climbing stairs, walking with a cane or walker, carrying packages, transferring from a wheelchair to a bed, commode, chair or car, pushing a wheelchair up a ramp or over a curb cut, standing for long periods of time, become difficult or impossible tasks.

Many persons with physical disabilities are deconditioned and lack adequate muscular strength and endurance (Rimmer, 1994; Rimmer, Rubin, Braddock, & Hedman, 1999). Fitness professionals can play an important role in improving the health of persons with physical disabilities by developing resistance training programs that will assist them in maintaining adequate levels of muscular strength and endurance (Rimmer, Pitetti, & Braddock, 1996). The physical challenges that many people with disabilities are faced with on a daily basis are exacerbated by poor strength levels. If persons with physical disabilities are unable to transfer from their wheelchair to their car, or walk from their home to the bus stop or train station, they will have difficulty working and participating in social and community events. This will impose a substantial physical and psychological hardship and will reduce the person's overall quality of life (Rimmer, Braddock, & Pitetti, 1996).

Improving strength levels in persons with physical disabilities is, to some extent, even more important than in the general population. A comprehensive strength training program could provide persons with physical disabilities greater confidence in accomplishing more physically demanding tasks, and greatly improve their ability to overcome physical barriers in their environment. Strength improvements will ultimately result in greater freedom and physical independence.

This chapter will discuss resistance training guidelines for persons with physical disabilities. The first section will focus on associated conditions and general resistance training guidelines, and the last section will discuss guidelines for specific disability groups. Although the emphasis of this chapter is on five disabilities - spinal cord injury, multiple sclerosis, post-polio syndrome, cerebral palsy, and stroke - the General Guidelines section will be useful for other types of physical disabilities that have similar movement limitations (i.e., spina bifida, amputations, brain injury).

Conditions Associated with Physical Disabilities

Because of the extensive medical nature of many physical disabilities, it is important for the fitness instructor to understand the associated conditions that accommodate the disability. Since many persons with physical disabilities often have weakness or paralysis to a certain part of the body, it is important for the instructor to understand the terminology used to define movement limitations. A few of these terms are defined in Table 1.

Some physical disabilities are classified as progressive in nature. This means that the condition will worsen over time. Some forms of multiple sclerosis and postpolio syndrome are considered progressive disorders, while other conditions such as cerebral palsy and spinal cord injury are considered non-progressive. Progressive disorders will require more careful monitoring to assure that the resistance training program is not causing the condition to worsen, which is referred to as an exacerbation.
Persons with physical disabilities often exhibit asymmetrical weakness. Many individuals with cerebral palsy or stroke have hemiplegia (weakness or paralysis on the right or left side of the body), which results in significant differences in strength between the stronger side and weaker sides of the body. It is important to improve the affected side as much as possible without neglecting the non-affected side. There may be circumstances in which the nerves controlling the affected side have been partially or completely damaged. When this occurs, the magnitude of improvement in the affected muscle groups will be greatly reduced. However, if there is still some nerve innervation on the weakened side, a resistance training program should result in some measurable improvement in strength. Having hemiplegia may require active-assistive resistance exercise on the affected side while using standard exercises on the non-affected side.
Spasticity is a general term used to describe various types of rigid or hypertonic muscle tone. It results in an exaggerated contractile response to stretch. It is often seen in persons who have damage to their central nervous system such as individuals with cerebral palsy, stroke, multiple sclerosis and spinal cord injury. The condition occurs in one of three ways: (a) loss of control from the damaged portion of the brain or spinal cord; (b) hypersensitivity of nerve receptors that are no longer being supplied with control after the injury; or (c) growth of new nerve pathways (Lockette & Keys, 1994, p. 95). The amount of spasticity that a person has could be mild, moderate or severe.

Spastic muscles are very rigid and are often accompanied by a "clasped-knife" position, which refers to the arm or leg maintaining a flexed position. Some individuals will have severe spasticity, which often makes it difficult or impossible to extend the limb. Severe spasticity usually results from the muscle groups being placed in a fixed position for a significant period of time resulting in a contracture. Contractures can often be stretched except in severe cases where the muscle group is permanently shortened.

Since many individuals with physical disabilities will have some degree of spasticity (tightness), flexibility training should always be combined with resistance training. It is important for the instructor to identify the "spastic" muscle groups and develop a long-range plan to increase range of motion. If the joint has been in a "fixed" position for many years, or if the spasticity is severe, it may not be possible to fully extend the joint. The instructor should consult with a physical therapist, physician or appropriate medical professional to determine how to stretch a spastic muscle without causing injury. As with resistance training, use active-assistive stretching for certain muscle groups that are too weak (paresis) or tight (spasticity) to be moved independently. Additional guidelines for working with spasticity are noted in Table 2
Some individuals with physical disabilities develop contractures, which are shortened muscle groups and connective tissues surrounding the joint. The muscle tone is very high, which is referred to as hypertonicity. A contracture occurs when a body part (arm or leg) is placed in a flexed position over an extended period of time (weeks or months), usually resulting from spasticity. Sometimes this cannot be avoided due to the neurological involvement, while at other times it can be prevented by constantly stretching the muscle group. Contractures may be permanent or temporary depending on the severity of spasticity and the length of time that the joint has been placed in a "fixed" position. Some muscle groups with contractures may be able to obtain minimal improvements in strength, while others will be unable to benefit from a resistance training program. The fitness instructor should consult with a physical therapist or qualified health professional to determine if contractures can be strengthened. Flexibility training should always be integrated in the exercise prescription for persons who have contractures, since the primary problem is shortening of muscle fibers and connective tissues surrounding the joint.
On the other end of the spectrum are persons who have flaccid (loose) or hypotonic muscle tone. This condition is often seen in persons with postpolio syndrome and some individuals with spinal cord injury and cerebral palsy. Persons with hypotonic muscle tone may or may not have enough nerve innervation to obtain improvements in strength. If there is some nerve innervation, the hypotonic muscle groups will be very weak and will require a great amount of work.
Some individuals with neurological conditions (i.e., multiple sclerosis, post-polio syndrome) get progressively weaker as they age. This may be related to the condition or could be associated with an inactive lifestyle compounded by the aging process. Consult with the client's physician if you are concerned about a noticeable decline in strength.
At certain times in the person's life, it may be necessary to temporarily stop the training program because of an exacerbation. Exacerbations occur most often in persons with multiple sclerosis. These can occur frequently or infrequently depending on the amount of involvement. After an exacerbation, it will often be necessary to start out at a much lower resistance because of the complications that result from the exacerbation. Upon resuming activity, the fitness instructor should contact the client's physician to determine the appropriate training progression. Although the person may be unable to reach a prior level of strength before the exacerbation, it is important that the fitness instructor reassure the client that strength levels can be improved. Clients who have exacerbations should understand that they begin with a "new slate" and that the goal is to always attain the highest strength level possible.
Damage to sensory nerves occurs with many types of physical disabilities. This results in the inability to detect pressure against the skin, which, if left untreated, could result in a pressure sore (Baxter & Lockette, 1995). A pressure sore is an area of damage to the skin and underlying tissues resulting from unrelieved pressure and inadequate circulation (Constable & Pierce, 1977). Since many people with physical disabilities who wear braces or use wheelchairs have a high risk of incurring a pressure sore, it is extremely important that they frequently check all parts of their body for skin irritations that may result from a new resistive exercise or piece of equipment. These injuries often start with a small area of redness (about the size of a quarter) and then gradually get larger if untreated.
Depending on the disability, muscle groups may be functional, partially functional (paresis), or nonfunctional (paralysis). The fitness instructor will need to obtain information on which muscle groups fall into each category. There may also be some joint irregularity that needs to be considered in the exercise prescription. For example, individuals with cerebral palsy often have hip dislocations due to the strong pull of the adductor muscles. If there has been a history of hip displacement, the instructor would need to check with the client's physician to determine if modifications need to be made to the resistance training program.
It is important to keep detailed records on each client. Since there are often several associated conditions that accommodate a physical disability (i.e., spasticity, hypertension, joint pain, exacerbations, pressure sores), the fitness instructor should maintain current records and note any new medical conditions that may develop during the training program.
Progressive disorders will often result in a gradual loss of muscle mass and strength. When muscle soreness occurs in persons who have a progressive condition, it may be an indication that the overload or intensity was excessive. Although it has not been well established in the research literature, the general assumption is that this could lead to a permanent loss of strength (Lockette & Keys, 1994). Until more research is conducted, it is important for the instructor to be extremely cautious when working with individuals who have progressive disorders. Get approval and recommendations from the client's physician for the optimal training volume and specific resistance exercises that may prevent injury to the client.
Individuals who have physical disabilities must overcome the physical and psychological challenges of living with a disability. This often results in bouts of depression, which is a common association condition in persons with physical disabilities. The fitness instructor must be aware of any signs of depression and contact the client's physician or health care provider if it becomes evident that the client is struggling with this condition. Occasionally, the person may drop out of the program because of the severity of the depression.

Resistance Exercise Guidelines for Persons with Physical Disabilities

There are several factors that must be considered when prescribing resistance exercise to persons with physical disabilities. Most importantly, the resistance training program will depend on the severity of the disability and its associated conditions. Some clients will be able to train at very high intensity levels, while others will only be able to perform at minimal levels of resistance (i.e., lifting a body part against gravity). The training load (number of sets and repetitions, frequency, rest interval between sets) will also vary in persons with similar and different types of physical disabilities. For example, two individuals with multiple sclerosis may require a completely different training regimen because of the type of multiple sclerosis, length of time they have had the condition, and their age. On the contrary, two individuals with stroke and cerebral palsy may have a similar program, because they exhibit the same associated conditions (i.e, non-progressive hemiplegia, spasticity) and are at the same baseline level of strength.

A major determinant of training volume is the amount of muscle mass that is still functional. Persons with paralysis, hemiplegia, impaired motor control, or limited joint mobility have less functional muscle mass and will therefore require a lower training volume. For individuals who cannot lift the minimal weight on certain resistance machines, resistance bands or cuff weights are recommended. If bands and cuff weights are too difficult, use the person's own body weight as the initial resistance. For example, lifting an arm or leg for 5 to 10 seconds may be the initial starting point for clients with very low levels of strength.

The training load will also depend on the type of disability. In general, individuals who do not have a progressive disorder (i.e., spinal cord injury, cerebral palsy) will be able to work at higher intensity levels than persons with progressive disorders (i.e., multiple sclerosis, postpolio).

Training volume will also depend on the person's health status. For example, a person with stroke and hypertension should not perform high intensity exercise. Individuals who are seizure-prone or fatigue easily require a reduction in training volume. Many individuals with physical disabilities who have been inactive for much of their lives need only a small amount of resistance exercise during the initial stage of the program to obtain a training effect. How quickly a person is able to progress during the conditioning stage will depend on the person's health status. For individuals who start out at very low levels of strength, significant improvements can be made with very light resistance.

Modes of resistance exercise consist of three general categories: free weights, portable equipment (i.e., elastic bands, tubing), and machines. Any of these modalities is acceptable for improving strength levels except in cases where the individual is at risk for injury. For example, persons with multiple sclerosis and cerebral palsy often have impaired motor control and may have a higher risk of dropping a free weight or having an elastic band snap back too quickly. When an instructor feels that the resistance mode presents a danger to the client, the exercise routine should be either adapted (i.e, securing the weight to the hand, changing the movement) or substituted with a safer piece of equipment.

Some experts argue that free-weight exercises have greater value for persons with physical disabilities because the resistance can be tailored to resemble a functional daily activity (Lockette, 1995). Free weights also require the action of stabilizing muscles around the torso and joints while lifting and lowering the resistance, which are muscle groups that need strengthening in persons with physical disabilities in order to maintain the ability to perform ADL and IADL. However, free weights require good trunk stability and may be difficult to perform in individuals who have severe limitations in motor control and coordination.

In clients with very low strength levels, gravity-resistance exercise may be all that the person is capable of doing. Performing 8-12 repetitions of a certain movement, such as abducting an arm or extending a leg, may be a good entry point These exercises can be used with extremely weak musculature while other modes of resistance exercise can be used with stronger muscle groups. Once an individual is able to complete 8-12 reps of a gravity-resistance exercise, the person could progress to free weight, bands or machines. If a client is unable to move a limb against gravity because of extreme weakness (often seen in the late stages of multiple sclerosis or in person with high-level quadriplegia), the instructor could place the limb in a certain position (i.e., should abduction) and have the client hold the position isometrically for a few seconds or longer.

Active-Assistive exercise may be required for certain individuals who do not have enough strength to overcome the force of gravity. The instructor can assist the client in performing the movement by providing as much physical assistance as necessary to complete the repetition. At various points in the concentric phase (against gravity), the instructor may have to help the client maintain the resistance. During the eccentric phase (with gravity), the instructor controls the movement so that the weight is not lowered too quickly. In many instances, active-assistive exercise can be used with severely weak musculature while active resistance exercise (performed without assistance) can used with stronger muscle groups.

The instructor should make every effort to avoid fatigue and delayed-onset muscle soreness in individuals with physical disabilities. Although this is a common side effect of any new resistance training program, it could present a problem for persons with physical disabilities if the soreness prevents them from conducting their normal activities of daily living (ADLs). Even though a client with a physical disability may aspire to make rapid gains in strength and can train at a moderate to high intensity level, the instructor should be cautious in not overworking the muscle groups, particularly in clients with progressive disorders. Use light resistance for at least the first month of the program (30 to 50% of 1-RM) and only proceed to higher training loads if muscle soreness and fatigue are not present.

If soreness in certain muscle groups prevents the person from performing routine daily activities, the exercise should be stopped until the pain subsides. If it continues after the program resumes, the instructor may need to reduce the training volume or avoid certain exercises that incur pain or fatigue. If there are prolonged bouts of pain or soreness 24 to 48 hours after exercise, the client should consult with his or her physician to determine the cause.

Developing the greatest amount of strength in the affected muscle groups may result in a "reservoir"of strength that can be help decrease the severity of an exacerbation. Theoretically, the more muscle strength one has before an exacerbation, the more likely he or she will be able to maintain a high enough level of strength to stay above the "physical dependence" threshold. Progressive disorders (i.e., multiple sclerosis) make it very difficult to determine the success of the resistance training program. However, the general feeling among rehabilitation professionals is that improvements in strength may help delay the progression of muscle weakness and permanent disability. If an individual achieves a gain of 30 to 40 percent in strength before an exacerbation, a loss of strength may still keep the individual at a high enough level to still be able to perform ADL and IADL.

Many physical disabilities result in hand dysfunction. This may make it difficult to grasp barbells or handles on different strength machines. There are several versions of specially-designed gloves that are available commercially that will allow the person's hand to maintain contact with the resistance equipment. Gloves will also protect the hand from injury while performing resistance training routines. Participants who do not have good grip strength can use wrist cuffs or leather mitts with velcro and buckles to secure their hands to dumbbells or weight equipment. Many individuals with physical disabilities will exhibit asymmetrical weakness or will have a disproportionately greater amount of weakness to the flexor or extensor muscle groups. This will depend on where the injury site is in the brain or spinal cord and whether or not the condition is progressive in nature. It is important to evaluate individual muscle groups on both sides of the body, as well as anteriorly and posteriorly, to isolate the degree of weakness to key muscle groups.

Individuals with asymmetrical weakness will often "hike" their body toward the weaker side in order to compensate for this weakness while lifting the resistance. This could impose mild or moderate muscle strain. Make sure that the client is lifting the weight with proper form. If there is a tendency to "hike" the body, lower the resistance and emphasize good form.

Blood pressure should be monitored frequently during the early stages of the program. In some individuals with physical disabilities (i.e., stroke, SCI), hypertension or hypotension is a common problem. It is recommended that blood pressure be measured before exercise and before and after each set. Once the client adjusts to the program and there no wide fluctuations in blood pressure, it can be measured before and after each training session.

Table 1. Glossary of Common Terms Related To Limitations in Movement in Persons with Disabilities

Contracture: shortening of a muscle group and tendon usually seen in persons with spasticity.
Diplegia: involvement of all four limbs with more involvement in the lower limbs than upper limbs.
Exacerbation: flareup in which symptoms deteriorate in a particular condition
Functional Muscle Mass: muscle mass that still has nerve innervation and can be improved in a resistance training program.
Hemiplegia: involvement of both limbs on one side of the body
High Tone (Spasticity or Hypertonicity): excessive amount of tone in a muscle group.
Low Tone (Hypotonia or Flaccidity): decreased amount of tone in a muscle group.
Muscle Tone: amount of tension in a muscle group.
Paraplegia: involvement of both legs
Paresis: partial weakness to one or more limbs.
Progressive Disorder: condition that gets worse over time.
Quadriplegia (also referred to as tetraplegia): involvement of all four limbs
Remission: Symptoms stabilize or slightly improve.
Spasticity: an involuntary increase in muscle tone.

Table 2. Resistance Training Guidelines for Persons with Spasticity

Involved limbs may experience a temporary increase in tone after resistance training the affected (spastic) or non-affected side. This should dissipate soon after the exercise session is completed.
Occasionally, the person may experience muscle spasms. These are often transient and should not present a problem in resistance training routines unless they are occurring often. They can often be stopped by placing the limb (arm or leg) in an extended position.
Avoid quick movements that may increase spasticity or cause a muscle spasm. Slow, controlled movements are often best in avoiding increases in spasticity or muscle spasms.
Most experts recommend that high-intensity training be avoided in spastic muscle groups.
When training spastic muscle groups, emphasize slow and fluid movements within the person's capability. It may be impossible for some clients to move the limb in a completely smooth fashion due to high levels of spasticity.
To improve or maintain muscle balance between flexors and extensors, strengthen muscle groups that oppose the spastic muscle. For example, if the biceps have a high level of spasticity, work on strengthening the triceps.
Remember: tight muscle groups (spastic) are not necessarily strong and also need to be strengthened.

Guidelines for Wheelchair Users

1. Persons in wheelchairs often have overdeveloped anterior shoulder muscles (pectoralis major and minor, anterior deltoid) from pushing their chair (Lockette, 1995). This is usually accommodated by overstretched back musculature from chronic sitting. The fitness instructor should develop strength in the shoulder abductors, adductors, retractors, elevators and depressors, to assure greater "balance" between the anterior and posterior musculature. Since there is greater likelihood that overloading the anterior muscle groups from wheeling the chair could result in an overuse injury, it is important to not overwork these muscle groups unless they are low in strength. Pain or soreness 24 to 48 hours after activity is an indication that the joint and muscle group may have been excessively loaded.

Overuse of certain muscle groups can also cause stress fractures or cumulative trauma disorders. Manual wheelchair users are particularly prone to rotator cuff tears, lateral epicondylitis, and carpal tunnel syndrome, which result from repetitive motions to small muscle groups as a result of propelling the wheelchair (Cooper et al., 1999).

2. Transfers and seated push-ups (used to prevent pressure sores) are essential movements that should be performed several times a day. Two important muscle groups that are needed to perform these tasks are the triceps and biceps brachii. The fitness instructor should make this a primary goal of the resistance training program. Improved strength in these muscle groups is also very important for getting up from the floor. Persons with balance impairments such as cerebral palsy and multiple sclerosis have a higher incidence of falls and will occasionally have to lift themselves up from the floor.

3. Many individuals who use wheelchairs have poor trunk musculature (Rimmer, 1994). This often requires the person to wear some type of strap or harness to prevent them from falling out of the chair. The fitness instructor should evaluate upper trunk stability by having the person flex their spine while sitting in the chair and then returning to the straight-up position. If the individual has difficulty performing this task, it may be necessary for the client to wear a chest strap that attaches to the back of the wheelchair in order to maintain good trunk stability. These straps or belts can be purchased in most medical supply stores.

4. Persons who use wheelchairs will often exhibit poor sitting posture. It is important for the fitness instructor to remind the client not to slump in his or her chair. Emphasize good sitting posture while performing the resistance training program. Mirrors will often facilitate good body awareness and might assist the client in becoming more aware of his or her sitting posture. If the individual is unable to maintain good posture, it may be necessary to work with a physical therapist or physician in devising ways to improve posture. Sometimes it is necessary to facilitate improved sitting posture by having a rehabilitation engineer or assistive technology specialist design a seat cushion that supports the weak side of the body.

5. Establishing and maintaining optimal range of motion in the affected limbs is paramount. Wheelchair users often have limited range of motion from sitting in the chair for long periods of time and will therefore need a complementary flexibility program. It is important for the fitness instructor to understand the limitations in range of motion at certain joints resulting from wheelchair use (i.e., spasticity). Muscle groups that are severely shortened (contractures) may need to be strengthened using isometric exercise.

6. Some individuals with severe physical disabilities may have difficulty performing the correct breathing pattern during the resistance training program (exhaling while raising the weight and inhaling while lowering it). With certain progressive disorders such as multiple sclerosis and postpolio syndrome, breathing may worsen at various stages in the person's life. During the initial training phase, teach the client the appropriate breathing technique with little or no resistance until the person becomes accustomed to performing it correctly. Because resistance training requires a substantial increase in breathing rate and volume, diaphragmatic and pursed lip breathing is recommended for clients who have difficulty maintaining a normal breathing pattern during the exercise regimen.

7. In order to use certain pieces of equipment, the fitness instructor may have to transfer individuals who are in wheelchairs to machines or the floor. Although one-person transfers are done routinely by rehabilitation professionals, they are difficult to perform and present a high risk of injury to both the instructor and client. Whenever possible, perform a two-person wheelchair transfer. Guidelines on how to transfer clients can be found in Baxter and Lockette (1995) or Rimmer (1994). General information on wheelchair safety is listed in Table 3.

Table 3. General Safety Guidelines for Wheelchair Users

Reduce the distance between the transfer surface and the wheelchair. Removing armrests and detachable footrests will permit closer positioning to the transfer surface.
Always secure wheelchair locks (one on each side of chair). The major cause of injury to wheelchair users is being transferred to or from a wheelchair with one or both brakes unlocked.
Provide surfaces of equal height if possible. It is much more difficult lifting someone onto a surface if the height is higher than the wheelchair.
Keep a wide base of support and use legs and not back musculature to lift person.
Make sure the person knows when you are ready to transfer them.
When you are going to push a client in a wheelchair, make sure the person is prepared to move.
If you ever have to tip the wheelchair to get over an obstacle such as a curb or door threshold, never tip the wheelchair forward. This could cause the person to fall out of the chair. Always tip the chair backward onto the larger posterior wheels. Remind the client to sit back in the chair.
It is recommended that when a client needs to be transferred from their chair to the floor or a machine, it is performed by two people. One person transfers are very difficult and can result in a higher risk of injury to the client or instructor.

Resistance Training Guidelines for Spinal Cord Injury

There are approximately 250,000 to 400,000 people living in the United States with a spinal cord injury (SCI). Eighty-two percent of these injuries occur in young males in the age range of 16 to 30 years. The most common cause of SCI are motor vehicle accidents (44%), followed by acts of violence (24%) and falls (22%) (National Spinal Cord Injury Association, 1999). Persons who have sustained a SCI will lose nerve innervation to various musculature depending on where the spinal cord has been damaged. For example, if a person's injury occurs between the fifth (T5) and sixth (T6) thoracic vertebrae and is a complete lesion (some injuries result in an incomplete lesion which allows some muscle innervation), loss of function will occur from the point of injury to all nerve innervation below it. In complete lesions, the musculature has no innervation and a resistance training program will not be effective for the involved muscle groups. Instead, the emphasis should be placed on maintaining good range of motion while focusing on strengthening the muscle groups that are still functional. Table 4 provides a brief listing of the functional level at each injury site.

Resistance Training Guidelines

1. Many individuals who have sustained a spinal cord injury will require a significant increase in upper body strength in order to manage transfers, push a wheelchair, and perform activities of daily living (i.e., bathing and dressing). Pushing a wheelchair up a ramp or curb cut can be a significant physical challenge to persons with SCI who are deconditioned. The fitness instructor should have a good understanding of what muscle groups are still functional and should develop adequate amounts of strength in those muscle groups since they will be used more often to assist with transfers and performing ADL and IADL.

2. Individuals with a complete SCI will use a manual or power wheelchair to ambulate. High cervical injuries usually require a power wheelchair, while lower level injuries result in enough muscle innervation in the hands to use a manual wheelchair. However, there are some individuals who have the necessary muscle and nerve innervation to use a manual wheelchair but prefer to use a power wheelchair in order to preserve energy.

3. Persons in SCI must do everything possible to avoid pressure sores (also known as decubitis ulcers or pressure ulcers). If left untreated, pressure sores can cause tissue necrosis, which often has to be removed surgically. One way to avoid pressure sores is to perform wheelchair pushups every 15 to 20 minutes. This requires the person to lift his or her body out of the chair by grabbing the armrests and pressing up with the arms. The position should be held for 5 to 15 seconds in order to allow blood flow to the tissues that make contact with the chair (primarily the gluteals and hamstrings). Clients with injuries C6 or higher will not be able to perform this exercise independently because of damage done to the nerves controlling triceps innervation. Some clients may be able to pull one side of the body off the chair by using the biceps to grab a bar or other object located on the side of the wheelchair at approximately shoulder height. The fitness instructor should develop biceps and forearm strength to help facilitate this important movement.

4. Many persons with SCI may have a condition known as autonomic dysreflexia (AD). Individuals with SCI at the T6 level or higher have the greatest risk (National Spinal Cord Injury Association, 1999). This condition results in an excessive rise in blood pressure that could be extremely dangerous if not treated immediately (Phillips et al., 1998).AD often occurs when an individual has a distended (full) bladder. Symptoms include headache, facial flush, perspiration, and a stuffy nose. It is important for the fitness instructor to make sure that the client has voided his or her bladder before starting the program. It is also important to measure the individual's blood pressure and monitor how the person feels before each exercise session to assure that AD is not present.

Table 4. Spinal Cord Injury Location and Function of Major Muscle Groups

Cervical ₄	Retain only the scapular elevators (trapezius) and the diaphragm. Unable to use arms, trunk, or lower extremities. Individual needs a power wheelchair to ambulate and will use a mouthstick to operate the wheelchair.
Cervical ₅	Functional muscle groups include the deltoids, part of the biceps, and part of the scapular adductors (rhomboids). The innervation of these muscles allows the arm to be used for some activities. There is no control at the wrist or hand.
_{Cervical 6}	Functional muscle groups include biceps, brachioradialis, wrist extensors, and partial use of the latissimus dorsi and pectoralis muscles. There is no control at the hand.
Cervical _7-8	Use of triceps, some finger extensors, and long finger flexors. May still have some dexterity problems with the hands and fingers.
Thoracic _1-8	Has complete use of the hands. Poor trunk control because of affected abdominal muscles.
Thoracic _9-12	Good trunk control because of full use of abdominals.
Lumbar _1-3	Use of hip flexors and hip adductors.
Lumbar ₄ - Sacral ₂	Use of hamstrings. Some ankle and foot musculature may be present.

Resistance Training Guidelines for Multiple Sclerosis

Multiple sclerosis is a progressive disorder that results in a deterioration of the myelin sheath around the spinal nerves. As the disease progresses, secondary conditions may include impaired gait, genitourinary dysfunction (incontinence), and loss of movement in some or all limbs (Greenspun, Stineman, & Agri, 1987). The disease affects more women than men and is often diagnosed in the 20s and 30s (National Multiple Sclerosis Society, 1999).

Persons with multiple sclerosis may exhibit several symptoms. These include fatigue, occasionally severe enough that activities of daily living cannot be performed independently, and weakness in one or more extremities. The hands are often affected in the later stages of the disease, which makes it difficult to grasp objects.

Multiple sclerosis is characterized by periods of exacerbation and remission. An exacerbation results in the condition worsening. The individual may incur additional weakness or complete loss of function in several different muscle groups. Some individuals with multiple sclerosis have few exacerbations and little disability, while others get progressively worse. Because multiple sclerosis affects each person differently, it is difficult to make generalizations about the progression of the disease and the amount of disability that may result from it.

Resistance Training Guidelines

1. Persons with multiple sclerosis have an attenuated or absent sweating response (Mulcare, 1997). Resistance exercise that is performed in warm environments could result in early-onset fatigue and should therefore always be performed in cool environments. If the room is warm, use fans to improve air circulation. Make sure the client drinks water before, during and after the activity since dehydration can also result in higher core temperatures. Persons with multiple sclerosis would also benefit from resistance training exercises performed in a cool swimming pool (77 - 800F). The water will help maintain or lower the person's core temperature and can serve as a resistance mode at the same time. Certain commercial resistance devices are also available to help develop strength in the water.

2. Balance is often impaired in persons with multiple sclerosis, particularly as the condition progresses (Mulcare, 1997). Make sure that balance is assessed on a regular basis so that if it does decline to a point where standing exercises are difficult or dangerous, the instructor can switch to routines from a chair or provide support for standing exercise (i.e., parallel bars, holding on to a railing, leaning against a wall).

3. Tremor and incoordination may result in an inability to perform smooth movements. This could cause the movement to look somewhat "choppy." Provide as much assistance as necessary to help the client move the resistance through the full range of motion as smoothly as possible, but don't overemphasize this because they may be incapable of doing so as a result of the neurological involvement.

4. Blurred vision or double vision are often common associated conditions in persons with multiple sclerosis (Poser & Ronthal, 1991). Make sure that equipment is marked clearly. Use bright colors (yellow tape on a black weight plate) or magnets to identify where to place the pin on weight machines. Small weights and objects should not be left in the middle of the floor where a person could trip over them.

5. Persons with multiple sclerosis may need to urinate frequently during the resistance training program, particularly if there is pressure displaced on the urinary bladder. Because they are unable to sense the need to void their bladder due to the neurological involvement, accidents may occur. Make sure that the bladder is voided before exercise and intermittently during the training program, particularly if they are drinking fluids to prevent dehydration and overheating.

Resistance Training Guidelines for Postpolio Syndrome

Polio, which is sometimes referred to as poliomyelitis, is caused by an acute virus that attacks the anterior horn cells of lower motor neurons (Birk, 1997). These motor neurons are located in the front part of the spinal cord and are essential for muscle activity. The extent of motor neuron damage and the progression of the disease varies considerably in individuals with postpolio syndrome, and depends on which muscle groups were affected and how much damage was sustained during the acute stages of the disease (Nollett & Beelen, 1999).

Post-polio syndrome occurs several decades after the onset of polio. Approximately 25 percent of individuals who contracted the polio virus during the 1940s and 1950s report late-onset symptoms in their 40s and 50s (Pauls & Reed, 1996). Although polio has become quite rare in this country after the discovery of the Salk vaccine, persons who were born in the 1940s and 1950s are now in their 50s and 60s and are starting to experience significant mobility limitations. Common symptoms associated with postpolio syndrome include: (a) fatigue, generally described as a feeling of extreme exhaustion after minimal activities; (b) decreased endurance, which is manifested by the inability to sustain general activity; (c) new joint and muscle pain; (d) progressive weakness in muscles both affected by the polio and new muscle weakness; (e) respiratory insufficiency, which often requires ventilatory support; and (e) cold intolerance that contributes to muscle weakness (Jones, Speier, Canine, Owen, & Stull, 1989).

There is some debate concerning whether or not persons with postpolio syndrome should perform resistance training exercise (Birk, 1997). Since progressive weakness is a hallmark sign of postpolio syndrome in the later years, the theory is that excessive exercise can cause an accelerated loss in function. In a recent study on resistance training in persons with postpolio syndrome, Agre, Rodriquez and Franke (1997) examined the effects of a combined program of dynamic and isometric muscle strengthening exercises in 7 individuals with postpolio syndrome and concluded that muscle strength can be significantly increased without causing adverse effects on neurological function. Although there are few well-controlled studies on resistance training in persons with postpolio syndrome (Birk, 1997), most experts agree that not performing muscle strengthening exercises will result in a loss in function as the person ages.

Resistance Training Guidelines

1. Many polio survivors complain of new musculoskeletal pain as they grow older (Birk, 1997). The most common complaints are difficulty walking and stair climbing. This may be related to a progressive loss of muscle strength (Agre et al., 1997). The fitness instructor must understand that postpolio is a progressive disorder that may result in weakness as the person ages. In order to determine if a resistance training program should be maintained, reduced, or eliminated, it is important to communicate with the client's physician or other qualified health professional. The medical advisor should be able to determine if the program should be modified or stopped in a person who is complaining of pain or fatigue. High-intensity resistance exercise is not recommended for persons with postpolio syndrome since it is not known if this type of exercise can cause permanent loss of function (Birk, 1997).

2. Although resistance training should be part of an exercise program for persons with postpolio syndrome, it is extremely important to keep muscle fatigue to a minimum. Overworking affected muscle groups could result in fatigue and decreased muscle function. The development of strength in persons with postpolio syndrome must be carefully monitored to assure that the program is not compromising the person's health. The fitness instructor should monitor the client closely for any signs of pain, discomfort or fatigue resulting from the program.

3. Begin with minimal resistance and progress slowly. Stay within the client's comfort level. The more deconditioned the client is, the greater the importance on preventing fatigue by starting with very light resistance. If pain or fatigue is present, switch to cardiovascular and flexibility training until it subsides.

4. Since postpolio syndrome often results in asymmetrical muscle weakness, the fitness instructor should evaluate each limb separately. The instructor should document the training protocol and determine if any new muscle weakness is associated with other aging-related changes or the resistance training program. If there is a sudden loss of function or enhanced pain or fatigue resulting from the activity, ask the client to contact his or her physician or health provider to determine if the exercise program should be modified or discontinued.

Resistance Training Guidelines for Cerebral Palsy

Cerebral palsy is a nonprogressive disorder that results in physical impairment and causes postural and balance problems. It affects approximately 25,000 children each year (Schwartz, Engel, & Jensen, 1999). The disorder is caused by an injury to the brain before, during, or after birth. To be diagnosed with cerebral palsy, the person must have a nonprogressive lesion to the brain that causes motor dysfunction usually before the age of 3 (Schwartz et al., 1999). The injury does not result in damage to the muscles or nerves in the spinal cord, but rather, to the motor center of the brain that controls muscle function. The more severe the injury to the brain, the greater the limitation in movement and function (Gersh, 1991).

Resistance Training Guidelines

1. The strong pull of the hip adductors seen in many persons with cerebral palsy will require a resistance training program that places greater emphasis on strengthening the hip abductors. This does not necessarily mean that the hip adductors do not need to be strengthened. While the adductor muscles are often very tight due to spasticity, they may also be very weak. Therefore, both sets of muscle groups must be strengthened even though the abductors might have to receive a greater amount of work. Make sure that clients have not had a hip dislocation prior to working these muscle groups. If they have had a hip dislocation, seek advisement from their primary care physician or health provider to determine if hip exercises can be conducted safely.

2. Flexibility training is a very important part of the exercise prescription for persons with cerebral palsy because of the high level of spasticity. Resistance training programs should include nearly the same amount of attention to enhancing and/or maintaining good range of motion in the affected limbs.

3. A common type of cerebral palsy that results in weakness or paralysis to the right or left side of the body is spastic hemiplegia (A similar condition occurs in persons with stroke.). This condition will often require greater attention to developing strength on the weaker side of the body. Determining how much improvement can be made to the hemiplegic side will depend on the amount of damage that was sustained to that part of the central nervous system. If the person has complete paralysis to one side of the body, resistance training should be substituted with flexibility training.

4. Since balance is often impaired in ambulatory persons with cerebral palsy, it is important to protect clients from injury by developing safe resistance training programs that do not expose them to a high risk of injury. Some clients will be able to work on strength exercises in a standing position with physical assistance from the instructor, while others will have to perform the exercise routines from a chair. The instructor should measure the client's static and dynamic balance before developing the resistance training program to determine if standing exercises are safe.

5. In individuals who have spastic cerebral palsy, the antagonistic muscles, which directly oppose the action of the prime mover, are not inhibited. This is the result of a hyperactive stretch reflex that responds to the change in length of the muscle fibers by overreacting with a forceful contraction (Lockette & Keys, 1995). For example, during elbow flexion, the triceps are supposed to serve as the antagonists directly opposing the biceps and brachialis. When reciprocal innervation is absent, both muscles contract simultaneously causing significant movement dysfunction and jerky actions. The instructor should try to work with the client in assuring the smoothest movement possible, but should not be alarmed if there is some jerkiness during the movement phase. This is normal for persons who have this condition.

6. Certain individuals with cerebral palsy have a condition known as athetosis. This condition results in involuntary movements that occur in one or more of the person's limbs. The movements are uncontrollable and are often referred to as slow and "writhing." Facial muscles are also involved, which make the person appear to be laughing or crying. Since the movement of muscle groups is involuntary, use of free weights may not be possible because the hand may open reflexively during the weight routine. Elastic bands may also be a problem since the resistance may be difficult to control and may result in the band snapping back too quickly. Cuff weights and machines are the most appropriate modalities. Active-assistive exercise may be needed to perform the motion smoothly.

Resistance Training Guidelines for Stroke

Stroke is the third leading cause of death in the United States and affects 731,000 people annually of whom 570,000 survive (National Stroke Association, 1999). There are currently four million stroke survivors living in the United States (Gorelick et al., 1999). The newer term for stroke is brain attack. This has been adopted by the American Heart Association to denote the same level of urgency in seeking emergency medical care as a heart attack. Stroke is also referred to as a cerebrovascular accident or CVA.

Strokes occur through the interruption of the blood supply to the brain. There are generally two types of stroke. The first is called an ischemic stroke, which results from a blood clot, while the second type of stroke is called a hemorrhagic stroke, which results from a ruptured blood vessel in the brain. Either of these conditions will result in a disruption to the motor and sensory pathways that are involved in voluntary movement (Sharp & Brouwer, 1997). Approximately 83 percent of all strokes are of the ischemic type (National Stroke Association, 1999).

Aside from the emotional setback resulting from stroke, there is often complete or partial loss of muscle function on either the right (right hemiplegia) or left side (hemiplegia) of the body depending on where the injury occurs in the brain (the right brain controls the left side of the body and vice versa). The severity of stroke can vary from person to person. Some individuals who have had a mild stroke, or what is commonly referred to as a trans-ischemic attack (TIA), will often maintain full function after the injury, while others who have suffered a severe stroke, will often lose significant physical function on the right, left, or both sides of the body.

Resistance Training Guidelines

1. Blood pressure must be monitored very closely in persons with stroke. Since a common associated condition is hypertension, follow the resistance training guidelines for persons with hypertension as noted in Chapter X. It is especially important to make sure that the person's hypertension is under control before initiating the resistance training program. If blood pressure fluctuates during the first few weeks of the training program, contact the client's physician to determine how to proceed with a safe program. Under no circumstances should a person who has had a stroke and continues to have difficulty maintaining a stable blood pressure be permitted to exercise.

2. A recent paper noted that persons with stroke and hypertension can safely participate in rehabilitation therapy provided blood pressure does fluctuate widely. The investigators recommended that mean arterial pressure (MAP = diastolic pressure + 1/3 [systolic pressure - diastolic pressure]) not go above 130 mm Hg until blood pressure is under better control (Black-Schaffer, Kirsteins, & Harvey, 1999). During the early stages of the program, blood pressure should be monitored before, during and at the end of the exercise to assure that wide variations are not occurring. Once the client adjusts to the program and there are no complications, blood pressure can be taken before and after each set (Rimmer & Hedman, 1999).

3. The amount of recovery that will occur after a stroke is often a question that many stroke survivors and family members ask (American Heart Association, 1994). Most persons with stroke go through a significant recovery period during the first six months after having a stroke, while others can see significant recovery up to a year or longer (Lockette & Keys, 1994). The goal of resistance training is to maximize recovery. Since most stroke survivors will return home shortly after their injury, the fitness instructor should work closely with the client's physician or physical therapist in developing a safe and effective program.

Table 5. Summary of Resistance Training Guidelines for Persons with Physical Disabilities

Know and understand the pathology of each condition and how it may interact with a resistance training program (i.e., progressive disorders often result in increased weakness and high levels of fatigue).
Determine which muscle groups are still functional (neurological innervation) and which muscle groups are weak (paresis) or paralyzed (paralysis).
Determine the progression of resistance exercise through consultation with the client's physician, physical therapist or qualified health provider. With certain individuals, the progression may vary regularly because of exacerbations that occur throughout the person's lifetime. Periods of exacerbation may require the instructor to return to baseline or below baseline levels of strength.
Focus on muscle groups that are essential for performing ADL (i.e., shoulder abductors for combing hair and dressing) and IADL (i.e., triceps and forearm and shoulder stabilizers for wheelchair transfers).
Make sure that blood pressure and heart rate responses remain in a safe zone.
Make sure that associated conditions (i.e., autonomic dysreflexia, hypertension) are dealt with properly.
Make sure that exercise facility is accessible for wheelchair users. Guidelines can be obtained from the Americans with Disabilities Act.

Note

The information provided here is offered as a service only. The National Center on Physical Activity and Disability, University of Illinois at Chicago, the National Center on Accessibility, and the Rehabilitation Institute of Chicago do not formally recommend or endorse the equipment listed. As with any products or services, consumers should investigate and determine on their own which equipment best fits their needs and budget.

National Center on Physical Activity and Disability
http://www.ncpad.org
ncpad@uic.edu
(800) 900-8086 (voice and TTY)
(312) 355-4058 (facsimile)

Organizations

National Multiple Sclerosis Society :
New York , New York

Books

P. D. Miller (Eds.). (1995). Fitness programming and physical disability: Resistance training with stretch bands: Modifying for disability. Champaign, IL: Human Kinetics.
American College of Sports Medicine, J. Larry Durstine, Geoffrey E. Moore (Eds.). (1997). ACSM's exercise management for persons with chronic diseases and disabilities. Champaign, IL: Human Kinetics.
Edward N. Brandt (Editor), Andrew MacPherson Pope (Editor), Institute of Medicine (Editor) (Eds.). (1997). Enabling America: assessing the role of rehabilitation science and engineering. Washington, D.C: National Academy Press.
S. L. Wolf (Eds.). (1977). The total care of spinal cord injuries: Pressure sores. Boston: Little, Brown.
J. O. Holloszy (Eds.). (1997). Exercise and Sport Sciences Reviews: Physical activity among persons with disabilities--a public health perspective. Baltimore, MD: Williams & Wilkins.
P. D. Miller (Eds.). (1995). Fitness programming and physical disability: Wheelchair and transfers. Champaign, IL: Human Kinetics.
E. Geralis (Eds.). (1991). Children with cerebral palsy: What is cerebral palsy?. Washington, DC: Woodbine House.
P. D. Miller (Eds.). (1995). Fitness programming and physical disability: Resistance training: Program design. Champaign, IL: Human Kinetics.
Lockette, K.F. & Keyes, A.M. (1994). Conditioning with Physical Disabilities. Champaign, Illinois: Human Kinetics Publishers.
Pauls, J. A., & Reed, K. L. (1996). Quick reference to physical therapy. Gaithersburg, MD: Aspen Publishers, Inc.

Journals

Black-Schaffer RM, Kirsteins AE, Harvey RL. (1999). Stroke rehabilitation. 2. Co-morbidities and complications. Archives of Physical Medicine and Rehabilitation, 80(5 Suppl 1), 8-16.
Cress, M. E., Buchner, D. M., Questad, K. A., Esselman, P. C., deLateur, B. J. , Schwartz, R. S. (1999). Exercise: Effects on physical functional performance in independent older adults. Journal of Gerontological Medicine and Science, 54A(5), M242-248.
Ferketich, A. K., Kirby, T. E., Alway, S. E. (1998). Cardiovascular and muscular adaptations to combined endurance and strength training in elderly women. Acta Physiologica Scandanavica, 164(3), 259-267.
Gorelick, P. B., Sacco, R. L., Smith, D. B., Alberts, M, Mustone-Alexander, L., Rader, D., et al. (1999). Prevention of a first stroke. A review of guidelines and a multidisciplinary consensus statement from the National Stroke Association. JAMA, 281(12), 1112-1120.
Reenspun, B., Stineman, M., & Agri, R. (1987). Multiple sclerosis and rehabilitation outcome. Archives of Physical Medicine and Rehabilitation, 68(7), 434-437.
Jones, D. R., Speier, J., Canine, K., Owen, R., & Stull, G. A. (1989). Cardiorespiratory responses to aerobic training by patients with postpoliomyelitis sequelae. JAMA, 261(22), 3255-3258.
Morey MC, Pieper CF, Cornoni-Huntley J. (1998). Physical fitness and functional limitations in community-dwelling older adults. Medicine and Science in Sports and Exercise, 30, 715-723.
Nollet, F., & Beelen, A. (1999). Strength assessment in postpolio syndrome: Validity of a hand-held dynamometer in detecting change. Archives of Physical Medicine and Rehabilitation, 80(10), 1316-1323.
Phillips, W. T., Kiratli, B. J., Sarkarati, M., Weraarchakul, G., Myers, J., Franklin, B. A., et al. (1998). Effect of spinal cord injury on the heart and cardiovascular fitness. Current Problems in Cardiology, 23(11), 641-720.
Poser, C. M., Ronthal, M. (1991). Exercise and Alzheimer's disease, Parkinson's disease, and multiple sclerosis. Physician and Sportsmedicine, 19, 85-92.
Rimmer JH. (1999). Health promotion for people with disabilities: the emerging paradigm shift from disability prevention to prevention of secondary conditions. Physical Therapy, 79(5), 495-502.
Rimmer JH, Braddock D, Pitetti KH. (1996). Research on physical activity and disability: an emerging national priority. Medicine and science in sports and exercise, 28(11), 1366-1372.
Rimmer, J. H., & Hedman, G. (1998). A health promotion program for stroke survivors. Topics in Stroke Rehabilitation, 5(2), 30-44.
Schwartz, L., Engel, J. M., & Jensen, M. P. (1999). Pain in persons with cerebral palsy. Archives of Physical Medicine and Rehabilitation, 80(10), 1243-1246.
Sharp, S. A., & Brouwer, B. J. (1997). Isokinetic strength training of the hemiparetic knee: Effects on function and spasticity. Archives of Physical Medicine and Rehabilitation, 78(11), 1231-1236.
Sherwood, A. M. (1999). Aging in America. Journal of Rehabilitation Research and Development, 36(2), vii-viii.

Pamphlets

Dallas, TX. (1994). Family guide to stroke. Treatment, recovery, prevention. American Heart Association.
(1999). Spinal cord injury statistics. National Spinal Cord Injury Association.
(1999). Brain attack statistics. National Stroke Association.

This fact sheet was last updated on 12-21-2005.