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Arm crank exercise increases V[O.sub.2] peak and reduces body fat mass in older adult with chronic paraplegia.


Physical deconditioning following spinal cord injury (SCI) increases the risk of developing cardiovascular disease, obesity, metabolic syndrome, insulin resistance, osteoporosis, and reduced functional mobility (5,16,17).

Due to paralysis, people with SCI have limited options concerning exercise programs. Arm-crank exercise, hand-rim wheelchair propulsion, and hand cycling are generally used for endurance training, while resistance exercises are used for upper body strength training (19). Neuromuscular electrical stimulation to paralyzed muscles can be used to exercise paretic muscles, but is typically clinically based due to the cost involved with home use (18).

For individuals with SCI the importance of regular physical activity becomes even greater with the added effects of aging (20). Cardiovascular disease represents the most frequent cause of death among individuals with SCI greater than 60 years of age and those surviving SCI by 30 years or more (1,21). Groah and colleagues (11) have shown that in addition to advanced age, increased levels of severity of SCI also increase the risk of coronary artery disease.

There is a lack of research concerning the effects of regular exercise on older adults with SCI. There is also a lack of research concerning the effects of exercise on body composition of those with SCI. Therefore, it is important to investigate the role of physical activity on general fitness and body composition in those with SCI, especially spinal cord injured older adults. The purpose of this case study was to investigate the effects of sixteen weeks of arm crank activity on oxygen consumption and body composition of a geriatric gentleman with chronic paraplegia.


General design. Prior to beginning the study the participant received medical clearance from his VA SCI Physician. The participant also reviewed and signed a VA Human Subjects Research Consent form. The institutional review board of the participating VA Medical Center approved the study.

Training consisted of 60 minutes of arm crank activity including a ten minute warm-up and cool-down period five times per week. Pre- and post-exercise program testing was performed to evaluate the effects on V[O.sub.2] peak and body composition.

Participant description. The participant was a 62-year-old male with T8-9 (T8 right sensory and motor) (T9 left sensory and motor), ASIA A paraplegia resulting from the excision of a spinal mass 11 years prior to the study. Prior to the start of the exercise program the participant's weight was 79.4 kg and his height was 167.4 cm. The participant was classified as modified independent in transfers, bed mobility, and wheelchair mobility via a manual wheelchair (Table 1 & 2). Other medical problems associated with this participant included neurogenic bowel and bladder, osteoarthritis of the right wrist and right shoulder, leg spasms, neuropathic pain, chronic back pain, hypertension controlled by medication, and hypercholesterolemia. At the time of the study the participant lived with his spouse in a wheelchair accessible home and drove an automobile with hand controls. The participant had not been involved in physical exercise other than performing activities of daily living for at least one year prior to the study.

Exercise training. Training was performed at the Richmond (Virginia) VA Medical Center SCI Exercise Physiology Laboratory and consisted of arm crank exercise five times per week for sixteen weeks on an upper body ergometer (Monarch Rehab Trainer 881E). Each session began with a ten-minute warm-up, followed by forty minutes of training exercise, and finished with a ten minute cool-down. The workload was adjusted as the participant tolerated. This resulted in a gradual increased of workload from 20 to 40 watts during the sixteen-week period. The participant was encouraged to maintain an exercise rate of 50 revolutions per minute. Warm-up and cooldown periods consisted of arm cycling without resistance.

Graded exercise test. Maximal graded exercise testing using a Lode arm crank ergometer (Groningen, The Netherlands) was performed before and after the sixteen weeks of exercise. A TrueMax 2400 computerized metabolic measurement system (ParvoMedics, Salt Lake, UT) was used to determine V[O.sub.2] peak during the graded exercise tests. The participant was tested in his own wheelchair. Leg wraps, abdominal binder, and protective gloves were utilized during testing. A warm up period with the initial resistance of 36 watts and a pace of 50 revolutions per minute lasted for two minutes. This was followed by subsequent two-minute stages of twelve-watt increments until exhaustion according to American College of Sports Medicine Guidelines for Exercise Testing (8).

Body composition. Body composition was determined using a four-compartment model (water, protein, fat, minerals) before and after the sixteen-week exercise program. Body density or fat free mass was measured by hydrostatic weighing in a therapeutic pool. Underwater weight was measured at residual lung volume for five trials with the three heaviest weights being averaged together. Body density was determined from underwater weight using the standard equation of Goldman and Buskirk (1961). Gastrointestinal gases were assumed to be 100 ml. In tank residual lung volume was measured using an oxygen dilution technique. Total body water was measured by deuterium dilution at a general clinical research clinic. Total body bone mineral was measured by a DXA scan (GE Lunar Prodigy Advance, GE Healthcare, Madison, WI) in an SCI research body composition clinic. After the three fat free mass compartments were determined (protein, mineral and water), they were used to predict the fourth compartment (fat weight).


After performing arm crank exercise five times per week for sixteen weeks this participant improved his performance on the graded exercise test and achieved positive changes in body composition. Metabolic testing during graded arm cycling showed an improvement in V[O.sub.2] peak from 13.3 ml/kg/min during the pre exercise program testing to 16.2 ml/kg/min during the post exercise program testing. This was an improvement of 2.9 ml/kg/min or 17.9%.

Total body weight, BMI, and fat mass decreased from 79.4 kg to 76.4 kg, 28.1 to 27.1 and 28.05 to 25.26 kg, respectively. Lean mass decreased but was negligible at 0.12 kg (51.06 kg to 50.94 kg) or 0.2% and bone mineral density (BMD) remained unchanged at 1.118 g/[cm.sup.2]. Likewise total body water content was essentially unchanged 32.4 liters pre exercise program and 32.9 liters post exercise program.


Although V[O.sub.2] peak and peak power output are reduced in people with SCI, various forms of upper extremity exercise have shown benefits related to maximum oxygen uptake, muscle endurance and muscle strength (3,4,6,12). Central cardiovascular adaptations to exercise training such as increased maximal stroke volume or cardiac output have not been documented to date. However, improvements in peak power and V[O.sub.2] peak probably due to peripheral adaptations have been documented (7). Jacobs et al. (14) reported 30% increases in V[O.sub.2] peak and up to 30 % increases in muscle strength in individuals with complete paraplegia after twelve weeks of circuit training. More recently, Jacobs (15) reported an 11.8% and a 15.1% increase in V[O.sub.2] peak measures after twelve weeks of arm crank and resistance training activities respectively. As the amount of information on the effects of physical activity on muscle strength and endurance for the general SCI population has grown, information concerning these effects on older individuals with SCI remains limited.

Body composition changes after SCI include muscle wasting, fat accumulation, a rapid loss of bone mineral within the first eighteen months of injury, and a reduction in total body water due to the decrease in muscle mass (9). Hjeltnes et al. (13) demonstrated an increase in lean body mass and a concomitant decrease in whole body fat on individuals with chronic complete tetraplegia after daily electric stimulation cycling for eight weeks. Regular physical activity is considered a major component of weight loss programs and the maintenance of muscle and bone mass for those with SCI. However, there is a paucity of research concerning the effects of exercise on older adults with SCI.

The results of this case study support the theory that regular volitional physical activity can induce positive changes on a geriatric gentleman with chronic paraplegia. An important aspect of general physical fitness is the ability to utilize greater amounts of oxygen (V[O.sub.2] peak) during physical work. By increasing general physical fitness the results of this study indicate that regular physical activity may play a positive role in the maintenance of an independent lifestyle for older adults with paraplegia.

Likewise, another important aspect of health and the prevention of diseases such as cardiovascular disease, diabetes and metabolic syndrome is the maintenance of a healthy lean mass to fat mass ratio. By reducing fat mass and essentially maintaining muscle mass during the sixteen-week exercise program it can be suggested that physical activity may play a positive role in reducing risk factors associated with secondary diseases that accompany SCI and aging.

There are currently general exercise guidelines for those with SCI (10, refer to Table 3), however there is a need for updated guidelines that are more specific to level of injury. Collins and associates (2) determined that 1 MET of energy expenditure for spinal cord injured adults during various physical activities was equivalent to 2.7 mL x [kg.sup.-1] x [min.sup.-1] compared to 3.5 mL x [kg.sup.-1] x [min.sup.-1] for nondisabled adults. By using the value for nondisabled adults for those with SCI, researchers may underestimate the difficulty of a particular activity in a person with SCI. To assist with estimation of energy expenditure of those with SCI, Collins and associates developed a foundation for a compendium of energy expenditure with regard to physical activities for persons with SCI. Further research is needed to expend the compendium.

The authors recognize that it is difficult to ascertain cause and effect with only one subject and no controls. Thus recommendations for future study include larger study groups and controls for confounding variables such as diet and outside exercise. The authors also recommend the inclusion of resistance exercise, electrical stimulation to paretic extremities, and a focus on older adults with SCI.


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Dolbow, David R. (a), Miller, Joshua (a), Harnish, Chris (a), Poarch, Hunter (a), Gorgey, Ashraf (a), and Gater, David R. (a,b)

(a) Spinal Cord Injury and Disorders Center, McGuire VAMC, Richmond, VA, USA (b) Department of Physical Medicine and Rehabilitation, Virginia Commonwealth University, Richmond, VA, USA


David Dolbow

1784 W. Northfield Blvd, #291

Murfreesboro, TN 37129

615-513-0279 (Cell), 615-893-1360 x3915 (Work)
Table 1. Functional Independence Measure Scoring

Score               Independence/Assistance Level

7                   Complete Independence
6                   Modified Independence (Uses Assistive Device)
5                   Requires Supervision
4                   Requires Minimal Assistance (client 75%+)
3                   Requires Moderate Assistance (client 50%+)
2                   Requires Maximal Assistance (client 25%+)
1                   Requires Total Assistance (client 0%+)

Table 2. FIM Scores Prior to Exercise Program.

ADL Activity   Score   Mobility/Locomotion    Score

Eating           7     Bed Transfers            6
Grooming         7     Chair/WC Transfers       6
Bathing          6     Toilet Transfers         6
Dressing-UB      7     Tub/Shower Transfers     6
Dressing-LB      7     Wheelchair               6
Toileting        6     Stairs                   1

Self Care              Mobility/Locomotion
Total:          40     Total:                  31

ADL=Activities of Daily Living, UB=Upper Body, LB=Lower

* FIM scores documented by a physical therapist during
evaluation prior to the study. * No post study FIM scores

Table 3. SCI General Exercise Guidelines

             Cardiovascular         Resistance
             exercises              exercises

Frequency    3-7 days per week      2-3 days per week

Intensity    11-14 PRE or 60-90%    1-3 sets, 8-12 reps,
             peak HR                60-75% of 1RM

Duration     20-60 minutes          30-60 minutes

Adapted from: Gater, D. R., Jr Spinal Cord Injury. In: Ehrman,
J. K., Gordon, P. M., Visich, P. S., Keteyian, S. J. (Ed.) Clinical
Exercise Physiology. 1st ed. Human Kinetics Inc. Champaign,
IL. 2003; 503-526.

RPE = rating of perceived exertion; RM = repetition maximum
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Title Annotation:Clinical Applications
Author:Dolbow, David R.; Miller, Joshua; Harnish, Chris; Poarch, Hunter; Gorgey, Ashraf; Gater, David R.
Publication:Clinical Kinesiology: Journal of the American Kinesiotherapy Association
Article Type:Case study
Geographic Code:1USA
Date:Dec 22, 2010
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