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The effects of upper extremity progressive resistance and endurance exercises in patients with spinal cord injury Article in Journal of Back and Musculoskeletal Rehabilitation · March 2014 DOI: 10.3233/BMR-140462 · Source: PubMed
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Journal of Back and Musculoskeletal Rehabilitation 27 (2014) 419–426 DOI 10.3233/BMR-140462 IOS Press
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The effects of upper extremity progressive resistance and endurance exercises in patients with spinal cord injury Gulseren Dosta , Deniz Dulgeroglub,∗ , Adem Yildirima and Nese Ozgirginc a
Department of Physical Medicine and Rehabilitation, Faculty of Medicine, Adiyaman University, Adiyaman, Turkey b Diskapi Yildirim Beyazit Education and Research Hospital, Department of Physical Medicine and Rehabilitation, Ankara, Turkey c Ankara Physical Medicine and Rehabilitation Education and Research Hospital, Ankara, Turkey
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Abstract. BACKGROUND AND OBJECTIVES: Exercises aiming to strengthen the upper extremities are recommended to increase activities of daily living (ADLs) in patients with spinal cord injury (SCI). The aim of this study was to compare the effects of upper extremity progressive resistance exercises (PRE) and endurance exercises (EE) performed with an arm ergometer in patients with paraplegia due to SCI. MATERIALS AND METHODS: A total of 19 SCI patients were included in the study, and randomly divided into two groups. The first group performed PRE while the second group performed arm EE. The functional independence measurement (FIM) was used on each patient at the beginning and at the end of the study. The elbow flexion and extension muscle strengths of each patient were determined with the computerized isokinetic dynamometer at the beginning and end of the study. RESULTS: Post-training increased the FIM scores in both PRE (p = 0.005) and EE groups (p = 0.008). There were increases in the extension peak torque (PT) and total work (TW) at 180◦ /sec and 60◦ /sec angular velocity in the PRE group compared to the EE group (all p < 0.05). CONCLUSION: There were improvement in post-training muscle strength values in both the PRE (found to be more effective) and EE groups. LEVEL OF EVIDENCE: Randomized trial (Level I).
1. Introduction
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Keywords: Spinal cord injury, progressive resistance exercise, endurance exercise, isokinetic dynamometer
Paraplegic patients require certain muscular strength for their basic activities of daily living (ADLs), such as transfer into a wheelchair [1]. Arms must be strong enough for self-care activities, activities at ∗ Corresponding author: Deniz Dulgeroglu, Diskapi Yildirim Beyazit Education and Research Hospital, Department of Physical Medicine and Rehabilitation, Dicle cad. No:81/17 06840 Ankara, Turkey. Tel.: +90 312 5962993; Fax: +90 312 3181881; E-mail:
[email protected].
work, household chores, transfer activities and ambulation activities [2,3]. If the upper extremity (UE) is not strong enough, pressure ulcers associated with prolonged sitting in the wheelchair may develop, if the patient does not perform push-ups frequently. Upper extremity (UE) progressive resistance exercises (PRE) and endurance exercises (EE) are known to be useful for spinal cord injury (SCI) patients. However, there is not a particular consensus on the type, intensity and frequency of these exercises. Guidelines for endurance and strength training in SCI are limited [4]. In paraplegic patients, PRE and ergometer EE may be
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G. Dost et al. / The effects of upper extremity progressive resistance and endurance exercises
recommended for ADLs alongside a conventional rehabilitation program, in order to improve UE muscle strength [5]. During the performance of ADLs, tasks such as transfers and lifting are also effective [6,7]. Endurance is required to control the wheelchair for an extended period of time without reducing the speed. Improved endurance reduces the risk of cardiovascular disease in patients with SCI [8]. However, the literature contains only a limited number of studies dealing with resistance training in relevant patients [5,6]. Very few studies have examined strength acquisition through targeted training [9]. Therefore, the aim of this study was to compare the effects of UE PRE and EE in patients with SCI.
2. Materials and methods
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The study included a total of 19 male SCI patients aged between 16–51 years, who underwent an inpatient rehabilitation program at the Ankara Physical Medicine and Rehabilitation Education and Research Hospital between January 2007 and August 2007. Participants were randomly assigned to either the PRE (n = 10) or the EE group (n = 9). A signed informed consent was obtained from all subjects prior to the initiation of the study. The study protocol was approved by the Local Ethics Committee of the hospital. Paraplegic patients with spinal stability who did not have any cardio-respiratory or orthopedic complications were included in the study. Age, gender, height, weight, body mass index (BMI), dominant side, etiological factors of the SCI, history of the injury, lesion levels, disease duration, American Spinal Injury Association (ASIA) scale, and ECG and PA chest-x-rays were recorded at baseline for all patients. The functional independence measurement (FIM) was used in all patients at the beginning and end of the study [10]. Upper arm circumferences of the patients were measured at 10 cm proximal to the olecranon before and after exercise, and were recorded in cm. A conventional rehabilitation program was applied to the patients for a period of five weeks in the form of daily 90-minute sessions, five days a week. The SCI rehabilitation program included upper extremity exercises, strengthening exercises for body muscles, mobilizations, standing exercises, practice of ADLs, and basic training exercises for the wheelchair and transfers [3]. The PRE group performed UE isotonic strengthening exercises at the mechanical exercise station for five weeks, 45 minutes per day. The constant repetition sta-
tion activities included exercises on eight different machines (Jimsa Fitness LineTM ) for strengthening elbow flexors, extensors, abductors, adductors, pectoral muscles, and latissimi dorsi muscles. Delorme’s strengthening program was used for the patients, performing 10 repetitions in each set. The weight for the first set was 50% of the 10 repetition maximum (RM), for the second set 75% of the 10 RM, and for the third set it was 100% of the 10 RM [12]. Patients lifted 5 kg in the first set, 7.5 kg in the second set, and 10 kg in the third set. In the first three sets, arms, shoulders, and elbows were at 90 degrees flexion and hands grasped the iron bar over the head, pulling it downwards. In the second three sets, hands gripped the sides of the iron bar, and were then joined in front of the chest, and shoulders performed internal rotation and adduction exercises. A one-minute rest was allowed between the sets for each muscle group [13]. The EE group was included in an arm EE program by calculating 50% to 70% of the work value (Watt), determined for each patient as a result of a 30minute cardiopulmonary exercise test. [14]. A Monark ergometer (Monark Rehab Trainer 881, Quinton Instruments, Burlington, Ont.) was operated at a cadence of 80 revs/min. The exercise subjects visited the exercise hall every day for five weeks, and were assigned to high intensity exercises with 70% of the maximum heart rate in sessions of 45 minutes [2]. The isokinetic analysis of the bilateral elbow flexor and extensor muscles, and concentric muscle power was performed with the computerized isokinetic dynamometer (Biodex Corp, Shirley, New York). Biodex Advantage Software procedure manual (Version 3.2) was used. Calibration was performed on every test before the investigations. The patient to be tested was placed on the test chair. The dynamometer axis was elevated to the same level as the elbow. The subjects held the grip in the neutral position (in the middle position of forearm supination-pronation). The range of motion was determined separately for the two sides, and the maximum joint range of motion without body rotation was measured (0◦ –150◦). All test measurements were performed by the same physiatrist in either group. The isokinetic evaluation of elbow flexors and extensors was performed in both groups, first at 60◦ /sec and then at 180◦/sec angular velocities. A trial consisting of two repetitions was first performed at both velocities. The subjects were asked not to indulge in maximum effort during the trials. They were then asked to use maximum effort and perform five repetitions at 60◦ /sec velocity and then at 180◦ /sec velocity after a 10s rest.
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Table 1 Demographic and clinical features of the patients
Level
T5-T10 T11-L4
Etiology
Traumatic Firearm injury
ASIA
A C D Cauda equina
∗p
PRE group 10 (Male) 30.0 ± 9.4 447.9 ± 523.1 168.8 ± 7.7 63.3 ± 10.6 22.0 ± 2.1 7/3
EE group 9 (Male) 29.7 ± 10.7 249.5 ± 248.8 174.4 ± 7.7 65.6 ± 9.5 21.5 ± 3.0 4/5
6 4
6 3
7 3
9 0
7 3
4 3 1 1
0.838 0.514 0.086 0.511 0.870
< 0.05: statistically significant; PRE: Progressive resistive exercise, EE: Ergometer Exercise.
2.1. Statistical analysis
training, the EE group had FIM averages of 73.78 ± 15.09 pre-training, and 94.56 ± 9.67 post-training. There was not any significant difference between the groups with respect to pre-training FIM scores (p = 0.066). Post-training FIM score increases in both the PRE and EE groups were statistically significant (p = 0.005 and p = 0.008, respectively). No difference was found between the PRE and EE groups with respect to the increase in FIM scores (p < 0.211). The average post-training arm circumference difference in arm circumference was 0.62 cm for the PRE group and 0.61 cm for the EE group (p = 0.933).
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The same procedure was repeated in the other UE after a five-minute rest. The peak torque (PT) and total work (TW) parameters for elbow flexion and extension were recorded at 60◦ /sec and 180◦ /sec angular velocities during the isokinetic test, and administered pretraining and post-training to all patients.
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Data were analyzed using SPSS 15 software. The Mann-Whitney U-test was used to analyze the difference between the PRE group and the EE group. The Wilcoxon signed-rank test was used to analyze the differences in pre-training, post-training, total work, and peak torque values within a group. P values < 0.05 were considered statistically significant.
3. Results
p value
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Number of patients Age (years) Disease duration (days) Height (cm) Weight (kg) BMI (Kg/m2 ) Complete/Incomplete
The mean age (30.0 ± 9.5 years) of the PRE group was not different from the mean age (29.78 ± 10.77 years) of the EE group. Similarly, there were no significant differences in disease duration and BMI between the groups. The dominant hand in all patients was the right hand. Neurological levels of the patients were T5L4 according to ASIA [11]. Patients with a lesion level of T5-T10 (inclusive) were included in the upper lesion level group and those with lesion at T11-L4 (inclusive) were included in the lower lesion level group with no difference regarding patient numbers between the groups (Table 1). While the average FIM for the PRE group was 87.55 ± 9.37 for pre-training and 103.03 ± 8.79 post-
4. Isokinetic muscle strength values Pre-training and post-training TW and PT values at 180◦/sec and 60◦ /sec angular velocities for the PRE group are presented in Table 2 and these values for the EE group are presented in Table 3. There was no significant difference in pre-training values between the groups (p > 0.05). When pre-training and post-training values of extension and flexion TW and PT at 180◦/sec and 60◦ /sec angular velocities were compared in the PRE group, there was a significant increase in the post-training values (p < 0.05) (Table 2). When pre-training and post-training values of extension and flexion TW and PT at 180◦/sec and 60◦ /sec angular velocities were compared in the EE group, there was a significant increase in the post-training values (p < 0.05) (Table 3). When PRE and EE groups were compared for extension and flexion TW and PT at 180◦/sec and 60◦ /sec
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G. Dost et al. / The effects of upper extremity progressive resistance and endurance exercises Table 2 Pre- and post-training isokinetic parameters in progressive resistive exercise group
PRE group (N = 10)
TW (Joule)
Left
180◦ /sec 60◦ /sec 180◦ /sec 60◦ /sec
PT (Nm)
Left
180◦ /sec 60◦ /sec
Right
180◦ /sec 60◦ /sec
∗p
Post-training Mean ± SD 230.0 ± 19.3 308.0 ± 15.8 149.6 ± 9.2 218.5 ± 12.2
Wilcoxon sign test p value 0.005∗ 0.005∗ 0.005∗ 0.005∗
Ext. Flex. Ext. Flex.
162.0 ± 14.0 261.7 ± 26.9 124.9 ± 12.6 217.2 ± 24.1
234.6 ± 17.5 372.6 ± 31.4 151.8 ± 11.4 458.4 ± 69.5
0.005∗ 0.005∗ 0.005∗ 0.005∗
Ext. Flex. Ext. Flex.
15.4 ± 1.4 19.2 ± 1.4 16.9 ± 1.6 20.1 ± 1.5
19.2 ± 1.6 23.7 ± 1.2 21.4 ± 1.3 24.3 ± 1.4
0.005∗ 0.005∗ 0.005∗ 0.005∗
Ext. Flex. Ext. Flex.
16.1 ± 1.4 19.2 ± 1.4 17.8 ± 1.8 24.1 ± 2.7
19.6 ± 1.5 23.7 ± 1.2 21.7 ± 1.6 51.0 ± 7.7
0.005∗ 0.005∗ 0.005∗ 0.005∗
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Right
Ext. Flex. Ext. Flex.
Pre-training Mean ± SD 185.2 ± 16.8 249,5 ± 18.0 118.2 ± 11.5 180.6 ± 13.9
< 0.05: statistically significant; SD: Standard deviation, PT: Peak Torque (Nm), TW: Total Work (Joule), 180◦ /sec and 60◦ /sec: Angular velocities, Ext: Extension, Flex: Flexion, PRE: Progressive resistive exercise. Table 3 Pre- and post-training isokinetic parameters in the endurance exercise group TW (Joule)
Left
180◦ /sec
60◦ /sec
Right
180◦ /sec
60◦ /sec
PT (Nm)
Ext. Flex. Ext. Flex.
Pre-training 180.0 ± 15.7 237.6 ± 17.5 111.8 ± 10.4 172.5 ± 8.5
Post-training 206.7 ± 20.6 293.7 ± 15.2 129.7 ± 9.8 209.8 ± 9.4
p value 0,008∗ 0.008∗ 0.008∗ 0.008∗
Ext. Flex. Ext. Flex.
157.0 ± 14.3 252.5 ± 14.1 118.5 ± 9.3 226.3 ± 9.1
215.0 ± 19.3 361.2 ± 23.6 139.3 ± 9.8 454.3 ± 43.6
0.008∗ 0.008∗ 0.008∗ 0.008∗
Ext. Flex. Ext. Flex.
15.0 ± 1.3 18.3 ± 1.3 16.0 ± 1.5 19.2 ± 0.9
17.2 ± 1.7 22.6 ± 1.2 18.5 ± 1.4 23.3 ± 0.9
0.008∗ 0.008∗ 0.008∗ 0.008∗
Ext. Flex. Ext. Flex.
15.7 ± 1.4 19.4 ± 1.1 16.9 ± 1.3 25.3 ± 1.1
17.9 ± 1.6 24.1 ± 1.6 19.9 ± 1.4 52.6 ± 3.0
0.008∗ 0.008∗ 0.008∗ 0.008∗
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EE Group (N = 9)
Left
180◦ /sec 60◦ /sec
Right
180◦ /sec
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60◦ /sec
∗ P
