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How to rate your exercise intensity:

People with SCI usually cannot use heart rate as a measure of exercise intensity. In the absence of a standardized scale for the SCI population, a good way to gauge workout intensity is to pay attention to what your body tells you about how hard you are working; this is called "perceived exertion."

Rating exertion on a 0 to 10 scale-where 0 = no intensity,

2 = light intensity, 3 = moderate intensity, 5 = heavy or hard intensity, and 10 = very, very high intensity-has been shown to be a valid and reliable indicator of exercise intensity.[ 4 ]

Inactive people should begin with light intensity activity and gradually increase to moderate intensity. More fit folks can safely work in the 4 to 6 (high intensity) range.


Fitness after SCI: How to Get Started

We all know physical activity is important for good health. This is as true for people with SCI as it is for the general population. But the barriers to getting exercise and staying fit are especially challenging for those with SCI .

Because moving about is difficult for people with SCI, they can easily fall into a "cycle of deconditioning" (Figure 1), whereby inactivity causes changes in the body that make it even harder to move about and be active, and this further dampens the motivation to be active.[ 1 ] The process of losing fitness may begin with the sudden changes in muscular function caused by SCI, but it is perpetuated and aggravated by lack of physical activity. Furthermore, long-term inactivity produces harmful effects on body function and structures: slowing bowel motility; weakening bones, joints, and muscles; and causing the heart and lungs to work harder.

cycle of deconditioning
Figure 1.

Effects of Physical Activity

Research has shown that regular physical activity decreases the risk of heart disease, diabetes, high blood pressure and colon cancer; reduces depression and anxiety; helps control weight; and helps build and maintain healthy bones, muscles and joints.

In the SCI population, physical activity results in improved breathing ability; greater muscle strength and stamina; improved blood circulation; decreased body fat; more normal levels of fats (lipids) in the blood; improved self-esteem; decreased depression; improved immune system function; decreased risk of diabetes; slowing of bone loss, and better bowel function.

Physical activity also has been shown to help prevent common secondary conditions related to SCI, such as urinary tract infections, pressure sores, respiratory infections and constipation. These problems are more common in people who are inactive, and people with SCI who are most active (athletes) have fewer of these problems than those who are less active.[ 2 ]

There are some physiological responses to exercise that are unique to SCI. People with an injury at T-4 or above are less able to increase heart rate and control blood pressure while exercising, and blood in the legs does not return to the heart and lungs as easily. As a result, the positive cardiac effects are not as strong as they are in people who have more autonomic nervous system control.

SCI may cause changes in the sympathetic nervous system that can keep blood pressure low during very hard exercise. This low blood pressure may not be noticed and returns to normal after exercise ends. Such exercise responses need not prevent low to moderate level activity, but those wanting to do more strenuous continuous exercise (such as marathon wheeling or handcycling) should consult with a physical therapist or physician knowledgeable about SCI to get specific advice about how to minimize light-headedness or other problems related to low blood pressure or heart rate.

Lifestyle Physical Activity-A Practical Approach to Exercise

Deciding to become more active raises many questions: What do I need to do to get fit? What will help me become more active? What things might get in the way? The answers may surprise you and help you take the first step toward increasing your activity levels.

In recent years health researchers have shown that fitness (defined as the physiological improvements that result from activity) can be achieved without embarking on a formal exercise program. Called "lifestyle physical activity," this approach includes any movement of the body that is produced by the muscles and uses energy.

While "exercise" is often a planned, structured, repetitive activity that may require knowing specific movements or skills, lifestyle physical activity can occur anywhere and be a part of whatever you are doing. One example is doing household chores that involve torso or arm movement, especially with the arms above the level of the heart. Adding "wheeling" time to your day is another way to increase activity.

Physical activity can range in intensity from low to high (see sidebar: How to rate your exercise intensity ). Low or moderate intensity activity is the best way to become active because it helps build confidence and reduces the chance of injury. Moderate activity produces the same health benefits as high intensity activity, and it does not have to be done all at once to be beneficial. Studies have shown that three 10-minute sessions of activity worked into the course of a day may have the same health benefits as longer sessions. People who begin physical activity with this approach (moderate intensity, short sessions) are more likely to adopt activity as a habit and may choose to pursue more vigorous activity (like exercise or sports) at a later time, often because they feel better and have more energy.

The "lifestyle" approach to increasing physical activity was recently tested in a research study that included 16 people with SCI (C6 level or below) who were not regular exercisers.[ 3 ] The nurse researcher helped participants develop a personal plan for becoming more active based on preferences, schedules, opportunities, motivators, and barriers to becoming active.

After six weeks on their personalized programs, 60% of participants significantly increased their level of activity (recorded with an activity monitor). They had significant increases in upper extremity muscle strength and improvements in self-rated health, confidence, and motivation to exercise. Participants reported that the lifestyle physical activity approach was easy to do and did not interfere with other activities.

Study participants chose an interesting assortment of activities that fit their schedules: using exercise tubing while doing something inactive (watching television or taking a break from computer work); lifting weights or doing stretching exercises to break up an inactive period; increasing wheelchair wheeling time by mall wheeling, parking farther from a destination, or doing a lap during downtime at a youth sporting event. Some chose traditional exercise (exercise videos, upper extremity ergometry, mat exercises, bed push-ups, wheelchair arm "dips," using a standing table or a walker), sports (skiing, target shooting, swimming), or lifestyle activities (housework, gardening, arm movements during television, painting), or a combination of these. Those who had been the most inactive increased their activity levels by spending more time out of bed. While this study did not examine weight loss or cardiac fitness, it did demonstrate that the lifestyle activity approach is a feasible way to increase physical activity and exercise in people who have significant barriers to improving their physical fitness.

-Catherine Warms, PhD RN, ARNP,
CRRN, UW School of Nursing, and Cynthia Salzman, MHA, UW Rehabilitation Medicine

Getting Started


1. Washburn, R.A. & Figoni, S.F. (1999). High density lipoprotein cholesterol in individuals with spinal cord injury: The potential role of physical activity. Spinal Cord , 37, 685-695.

2. Stotts, K.M. (1986). Health maintenance: Paraplegic athletes and nonathletes. Archives of Physical Medicine and Rehabilitation , 67, 109-114.

3. Warms CA, Belza BL, Whitney JD, Mitchell PH, Stiens SA. (2004). Lifestyle physical activity for individuals with spinal cord injury: A pilot study. American Journal of Health Promotion . 18(4):288-291.

4. Borg, G. (1998). Borg's Perceived Exertion and Pain Scales. Champaign, IL: Human Kinetics.

Web Resources:

The National Center on Physical Activity and Disability ( www.ncpad.org ) is a one-stop information center concerned with physical activity and disability, and offers resources, links, discussion forums, exercise guidelines, and more.