Virtual Town Hall Meeting: Exercise and Physical Activity. Presenters: Matt Elrod and Alison Lichy. Laurie: Good afternoon. I'd like to welcome you to the virtual town hall meeting on exercise and spinal cord injury. My name is Laurie Redd, and I'm with ILRU here in Houston, Texas. And today we have joining us for this webcast, Matt Elrod and Alison Lichy. Matt and Alison are both physical therapists with the National Rehab Hospital, the Center for Health and Disability Research. This webcast is sponsored by the Research and Training Center on Spinal Cord Injury, and this RTC is on promoting health and preventing complications through exercise. It's also funded by the National Institute on Disability and Rehabilitation Research, NIDRR. And ILRU is working with the National Rehab Hospital on this RTC on Spinal Cord Injury and we're handling some of the dissemination effort. This webcast will be on the benefits of exercise for a person with spinal cord injury, changes that occur in the body with exercise, the various types of exercise and their benefits, and how to get started and stick with an exercise program. What we're going to do today is Matt and Alison will present and if you have any questions that you'd like for them to answer, please E-mail them to us if you're on our webcast page, you'll see how to do that. You can mail those -- send those questions to us and then I'll ask them at the end of the session. Matt and Alison, are you ready? Matt: We are. Thank you very much. Alison: Hello, and I'm Alison Lichy as mentioned. I'm a physical therapist at NRH and today I'd like to talk about the problems with being inactive. Today we're going to be called a coach potato, being very inactive. We want to list some of the problems that are commonly seen after you've been very inactive. First of all you're going to have a low level of fitness and also you're going to show some -- your bones can become more -- they are more brittle. They are weaker, called osteoporosis. Sometimes you become more depressed, have chronic pain, long lasting, abnormal blood fats, increased insulin resistance, which is the decreased use of blood sugars that you use for energy, an increased risk for coronary heart disease, increased skin breakdown and also a decreased metabolic rate, which is the decreased efficient use of stored energy in your body. Matt: We'll talk about the exact opposite of what happens when you exercise. And that's one of the really nice things about exercise is that a lot of the problems that occur with inactivity can be reversed with any age or any type of disability. One of the major things is exercising provides more energy. It just gives you a little bit more vigor with life. It helps you to have stronger muscles. It increases your endurance, your ability to do things throughout the day and also helps prevent heart disease and that spare tire around your belly a lot of times or helps control your body weight, and one of the most important things about exercise is that it does help fight depression, getting out and moving around helps a lot with that whole aspect of life. Alison: So what is working when you're exercising in your body? Of course your muscles are doing the work, the movements. You're moving your arms and legs. Your heart is also increased its rate during exercise. It's pumping more blood and your lungs are working harder when you're exercising. They are filling up with more air and more oxygen to pump to your muscles. And your autonomic nervous system is controlling, which is considered your heart rate and your blood pressure, you're sweating. It's kind of your automatic -- your control system that's in your body. So before you have -- without a spinal cord injury, what you typically would see when you start exercising, your heart rate is going to increase and your blood pressure also is going to increase. Especially in that top number of your blood pressure. If you check your blood pressure and you have a top number and a bottom number and you'll see that top number increase. You'll have more blood flowing to your heart. You'll have more blood flowing to your lungs and to your muscles because those are all the things that are working during your exercising. You're also going to show -- you're going to start sweating and perspiring with your exercise. So those are things you're typically going to see when you exercise in an average person without a spinal cord injury. Matt: So when you start thinking about what happens if someone has a spinal cord injury, the most easy way to answer that is it depends. It totally depends on the type of injury you have and whether or not that injury is a complete injury or not. When we talk about complete injury vs. an incomplete injury, we typically use the classification system which is a national classification system used mostly with people with traumatic spinal cord injuries, and a complete injury is one where you have no feeling in the sacrum or around the anus and an incomplete injury is when you do have feeling or sensation or movement around the sacrum or the anus. So if you have a complete injury vs. an incomplete injury, that's going to affect how your body reacts to exercise and then there is a really critical area around the sixth thoracic spine, which is right around the nipple level of the body and if you have an injury above that level, as Alison mentioned a moment ago, the autonomic nervous system is going to react differently than if you have an injury below that sixth thoracic spine. So the exercise that you do is going -- and the way the body reacts to that exercise you do will definitely be different according to what that level of injury is. So let's take a little closer look. Let's think about -- although we know everything is dependent on the level of injury and the completeness of injury, let's talk a little bit about those different muscles and parts of the body and how they react to exercise. When you look at the muscles in general, what I'll do is give a couple of examples of different levels of injury and the way the body reacts to those levels of injury and then do that for a couple of the different types. When you look at the muscles -- if you have a spinal cord injury and that injury is involving the arms, to where your arms do not move completely, then you're going to have problems with blood circulation and blood movement where the muscles are not moving completely. If the muscles start -- or if the muscles do move completely, then you'll have mostly normal blood flow to those muscles that are moving completely. So if someone has a spinal cord injury that's, let's say, they have a paraplegic injury or movement of their arms completely and no movement of their legs, and let's say it's below the level of the nipple, then their arms are going to work just as they did before, and their autonomic nervous system is going to be intact. It's not going to have problems with the automatic system of the body working. So when they are exercising, they are moving, the blood is going to continue to flow in the arms, but since the legs are not moving, a lot of times the blood will pool in the legs. You'll have decreased circulation within the legs because the muscle pump, the movement of the legs is not occurring to move blood back up to the heart. So now we talk a little bit about the heart and how does the heart work when you have a spinal cord injury. Not to go into too much detail, the biggest thing to understand is you don't have the normal return of blood back to the heart when you have a spinal cord injury and you cannot move your legs that you would if you do not have a spinal cord injury and can move the legs. A lot of times when people exercise and really want to work their heart a loot, you need to do an activity that incorporates as much movement of the legs or major muscles as possible to help increase that blood flow back to the heart. And if you can't do that, then the heart is not going to work quite as hard. The autonomic nervous system, again, is what we talk about or the autonomic nervous system if you have an incomplete injury or if the injury is above the t6 level. If it's above the t6 level, then that autonomic nervous system is not going to react as normal or as it did before. The heart rate is the first thing that we'll talk about. The heart rate is typically influenced by the autonomic nervous system or the automatic nervous system. The heart rate is influenced by -- when you start exercising, your heart rate typically increases. If your heart rate is not increasing or your heart rate may not work as it normally does if you have an injury above T-6, the blood pressure also does not react as normal if your injury is above T-6. You do not have the common increase of blood pressure that was described earlier with the top number, the systolic number, and you have different ways the body reacts to that. And then sweating also is different if you have an injury above T-6 specifically and you don't always have sweating that occurs above the level of your injury as well. Alison: Let's take a look at a couple different types of exercises or activities that you can do for exercise. First of all, there is aerobic conditioning, weightlifting, balance activities, stretching and assistive type of exercises which is called functional electrical stimulation and assisted walking. Matt: With aerobic conditioning, that's specifically exercises that are at a steady state of activity that you can continue theoretically indefinitely, however, none of us are going to go out and be able to run all day or push a wheelchair all day. We need to take those breaks, but the benefits of that aerobic conditions is to improve your endurance. It improves and increases the blood flow of the heart and the muscles that are being used. It helps to move air through more parts of the lungs which of course helps prevent pneumonia which is always a good thing. It helps lower blood pressure, increases circulation of the good cholesterol. It improves your body's use of the sugars in the blood and it reduces stress. Alison: Let's take a look at weightlifting. With weightlifting you typically or any type of resistive exercise, you think a short burst of exercise at max intense or slightly below max intensity and it's not sustained for a very long time such as aerobic exercises. So we're really looking at building the strength and those muscles and typically you're working on specific muscles when you're doing the weightlifting, not an overall, you know, big body work out as you are with the aerobic exercise, including numerous muscles. You focus on a muscle or muscle group at one time. So in terms of with weightlifting you're looking at increasing the strength of the muscles and also loading on the bones, which also helps increase the strength of the bones. It improves the body's use of the sugar's in the blood, the energy that you use. And also helps you just with building the strength of your muscles and helps you perform your daily task and activities that you like to perform daily. Matt: Next let's talk about stretching and why stretching is important. Stretching helps prevent injuries: It also helps to improve your ability to move with different parts of your body to help you do different daily activities. And it also prevents you from having contractures or really tight muscles that prevent you to move. Alison: Assisted exercise -- there is different types of movement and you can sometimes have partially assisted so you assist through what you have and to the extent how much you are moving it or you are completely moving the muscle or activity or the length of any sort through the entire range of motion. There is a couple of different types that we have mentioned -- functional electrical stimulation, in which electrical stimulation is used on the muscle to stimulate the muscle for various activities, for strengthening or to relearn how to use a muscle or to assist the muscle through the range you're trying to achieve or the movement that you're trying to do, and to help build the strength of that muscle and also to help move it through the entire -- the movement. There is also assisted walking. I think there is a couple of different types of devices out on the market right now in terms of assisting with walking and supporting your weight and holding you in a pattern so that you can be assisted with a therapist with your walking and there is also robotic devices that are assisting you with the walking or the mobility of the arm to perform different tasks. Matt: So now let's think about what to do next. We talked a lot about -- a lot of kind of technical information that should help give a little bit of background to activities and to exercises and help you understand a little bit more about what the body does, but having all that information doesn't do you much good if you can't figure out the best way to use that. So let's get started with things and talk about that a little bit more. Alison: the biggest thing is to know your resources. On the website, we have listed a few different resources to help you with finding things that you're interested in doing. You know, resources to know what type of activities are out there, and assistance that you can get with different activities. Fun things, gyms, different things that you might want to know about in terms of something that might interest you to stick with and to stay with exercising. That's the biggest thing, to find something you really enjoy doing and using this resource guide will assist you with that. If you like exercising with somebody, find a friend that can do it or a family member that's going to make you stick with this program and really encourage you to keep going through it, even if they don't go with you, to talk about different ideas and to push you and to progress your exercise if you want to achieve a specific goal, and also make your goals realistic. Meet a goal that you think you can achieve that will make you stick with it and keep increasing that goal as you keep progressing with your exercise program. I always say start slow and then add on. It's always harder to go full force and then a lot of people just stop because they just did too much all at once and they are either sore, tired or doesn't fit into their daily routine. So it's always kind of start slow, build it into your daily routine. Do something that you like. You know, have a friend with you or doing anything that's going to get you motivated. Sign up for a class that makes you feel like you have to go every week because you paid for it. Keep going to these things so that you're going to stick with this exercise and make it convenient so it does fit into your daily routine. Make sure it's close to your house, something that you really want to do and really just have fun with it. That way you'll stick with it. Matt: So to get a little bit more specific about what the "it" is, it's something we call an exercise prescription. And you can think of an exercise prescription just like you think of a prescription of a medication. There is lots of different aspects of exercise that you really want to take into consideration before you start this exercise program. The first thing is to figure out the type of exercise you want to do. That's not to mean that it has to be a single type of exercise, but you need to figure out what it is that's going to work for you in your life, what type of activity, what type of exercise is going to fit in to where you live, your environment, your buddy system, your resources that you have that you can tap into. So never underestimate the type of exercise that you want to be involved in. Because if you pick something that you're not that interested in and you're doing it only because of convenience, then it's going to be a lot harder to keep up with that activity and continue that activity for a prolonged period of time and not let it be a passing fad. So once you figure out what type of activity or what activity you want to do, how often should you do it? Well, most people consider the frequency or how often you're going to perform an activity is three times a week is generally the rule of thumb of how many times to perform an activity. And when we talk about different types of activities as we discussed earlier of an aerobic activity, doing something that kind of gets your blood pumping at a middle or moderate level activity or anaerobic activity. We typically say three times a week is great for that. And you also want to think about how hard you should do that activity. And, again, it's dependent on what it is you're trying to gain with your exercise regimen. If you're trying to increase your endurance or your aerobic capacity, then, again, working at that three times a week at a moderate level somewhere on a scale from 0 to 10 of a 6 or so is how hard you want to work. But if you're trying to build muscle and get stronger, then you want to work harder than that if you're trying to get a lot of strength. If you're trying to just get some muscle tone, then again, your intensity is not going to be as high and you're not going to work as hard. Next question is how long should you do the activity for? Again, generally, when we talk about exercise, we want to talk about the aerobic conditioning and you want to do that activity three times a week, somewhat hard, not too hard, but somewhere around the moderate level, and the duration should be somewhere around 20 minutes, with a five-minute warm up, a 20 minute activity and a five-minute cool down. So you're talking about 30 minutes out of your day for duration of time. And, you know, can you do more than that? Can you do less than that? Of course. Anything is better than nothing. And more is good, but sometimes you can overdo it. So you want to be careful with how often you do your exercises. Alison: We post an example of Joe couch potato here and one thing we want to just give a typical example of a lot of people that do have questions about exercise and they are very typical of people that are not doing exercise. Joe couch potato has not exercised since his spinal cord injury five years ago. He works on a computer, which is very typical of most of us and is a father of two and enjoys being outside. And has a complete spinal cord injury at the level of C-7. So, you know, one thing to look at here is he's a father of two. So he's very busy with his children already. He enjoys being outside. So one way to incorporate both of those is to think of activities that the children may like to do that are outside that he can incorporate into and for one example is biking. And this is something that he could do with his children if they are of the age. Biking is a great exercise. It's endurance. You can do it for long spurts of exercise and you can also switch into doing short bursts. You can do relays. You can do -- to work those short bursts of exercise to really get that heart rate up very quickly. So you can really challenge yourself with different activities such as doing with the arm bike outside. Can you go up a hill to give a little bit of a challenge and kind of vary the exercise a little bit. So this is one prime example that he could do incorporated with his children. Do this quite frequently. So this is one example. Matt, do you have another example? Matt: Yeah, another thing you could do is, let's say, playing basketball or playing sporting activities like hockey or tennis even. Those are all different activities that someone who has an injury of C-7, which means they have full use of their triceps that they can participate in. You may have to have special assistance or different pieces of equipment to help you perform different activities, but regardless of your injury, there is a lot of modifications that can be made for one at that level to play tennis. So the general thing to understand is you need to make sure you've figured out the activity that fits into your life and incorporate those different things. Other things to make sure you remember when you're exercising is we listed out four items there of autonomic dysreflexia, bumps, bruises and blisters, pressure reliefs and nutrition. Autonomic dysreflexia is something that occurs with a complete injury with that nipple level of C-6 and what happens is the body's autonomic or automatic nervous system reacts inappropriately to some kind of painful stimulus or something that's going on in the body. And when you exercise, you could do something -- your foot could get caught while you're pushing the wheelchair or there may be something that you're doing that may stimulate that episode of autonomic dysreflexia. So you always have to be mindful of that and know that that is a life-threatening condition that you must address immediately and take corrective action figuring out what the problem is, fixing that and then continuing on with the activity you're doing if that is totally resolved. Your bumps, bruises and blisters you always have to keep in mind if you have problems with sensation when you're doing different sports. Let's say you play quad rugby, and a very rough sport of pushing your wheelchair around and bumping into a lot of other people. You may not have felt that your leg got pinched by another wheelchair. So after you do your activity, look at your skin, make sure that if you have a bump, bruise or a blister, that you know where it is. You're monitoring it and make sure it heals appropriately, taking appropriate actions if it does not heal appropriately by consulting a health care practitioner, and then continuing on. Pressure relieve -- just because you're going out and exercising does not mean that you can forget about those pressure reliefs. The blood flow that occurs throughout the body is still not going to occur if you're sitting in one position and no moving off of those bony prominences or prone areas for pressure sores and nutrition is also important. Make sure you stay hydrated when you exercise. Make sure you eat a balanced meal before you exercise, think about your catheterization schedule, as well, but don't forget those basic activities just because you're exercising and don't neglect them when you exercise. Alison: I also remember prevention is number one here. When you're exercising, you want to really think about what your goals are when you're exercising, what muscles or muscle groups are you focusing on to think about how do I use this muscle and what proper way do I use it to exercise. So really knowing what your focus is and how to exercise to get your maximum out of what you're doing. And this kind of feeds into being aware of shoulder problems. A lot of people overdo it sometimes and they end up with a lot of shoulder pain. So you need to be aware of how to exercise those muscles around the shoulder without damaging your shoulder. If you're doing something improper, a different technique than you really should be doing, compensating because you're weak in one area and you're overexercising one area when you should be working that one area to keep that shoulder healthy and strong. Really be aware of that because you shouldn't be having any shoulder pain with these exercises. If you are having pain, you need to back off on the weight or intensity of your exercise and think about what you're really aiming to do with these exercises and that ties into just don't overdo it. Think about what you're aiming for and progress from there and slowly progress like we talked about. Don't overdo it to start it. And again, with the outdoor activities, you need to always pay attention to the weather, just common sense there, you know. And also with the outdoor activities with the biking and the very aggressive activities, and sporting events, you know, wear a helmet, wear protective gear, shin guards, you know, be careful of these things. Once you get involved in these activities, you know, just use common sense. Matt: And the last thing to make sure you remember is if you haven't been exercising in a long time, it is always a great idea to consult your primary care physician or your therapist that you work with on a routine basis and make sure that they understand that you're doing this and can help you problem solve or think about some areas that may be of concern in your individual case because although there is a lot of similarities to individuals that have spinal cord injuries, every spinal cord injury is a little bit different and to think of all spinal cord injuries as the same can lead to some problems. So realize, again, that, you know, your individual needs of your daily life, of things to do and be involved in are going to be different and also the way your body reacts to the different types of exercises is going to be very unique according to your type of injury. So I think with that, if there are any questions, we'll be happy to take them now. Laurie: Okay, great. Thanks, Matt and Alison. Yes, we have quite a few questions that have come in. One of them says -- I'm a high level quad with little ability to move myself. Can you talk about the benefits of passive exercise and what I can recommend to my trainer or physical therapist or tell me about machines that I can use? Matt: I would start off by saying that, you know, the general questions are always difficult. Someone with a high level of quadriplegia is -- I guess it's a little relative. If we're talking about someone with a C-2 level injury or C -- anything I would say above C-5, that they have very minimum movement 6 their arms, the biggest thing that they really need to keep in mind is their pulmonary hygiene or keeping their lungs in good shape. And never discount the importance of breathing exercises, of strengthening the diaphragm which is a muscle that can be strengthen and should be strengthen and it should be worked just as other muscles can be. So, you know, if we're talking about someone with a very, very high level of injury that still has the ability to utilize their diaphragm, then let's make sure we exercise that muscle. Again, keeping in mind that you want to do this with a level of frequency, three to five times a week, making sure that you're working at a moderate pace, figuring out a resistive exercise that makes you work somewhat hard. Making sure that you don't get too short of breath when you're doing these exercises, that you have a hard time recovering from that activity. As far as passive range of motion, making sure that you're preventing contractures is key. Making sure that you can maintain proper positioning in the bed or in the wheelchair, you want to keep those things in mind to make sure that, again, you don't develop contractures and have problems there. You want the add something else, Alison? Alison: With the passive range of motion, it's always good to maintain that posture, because with good posture and stability, it helps to feed the lungs and it all works together. Matt: And just to take that a little bit further, if you have an injury to where you have the ability to strengthen your muscles around your shoulder blade, you may not have a lot of movement of your arms, but you still want to strengthen those muscles that help hold the shoulder in a proper position to prevent shoulder pain later on. So regardless of your level of spinal cord injury, there is definitely exercises to do. Laurie: Another question is how can you determine if a personal trainer is qualified? Let me read this -- how can you determine a personal trainer is not just academically qualified, but qualified experientially to deal with people with spinal cord injuries? Is there an organization we can contact for a reference or what do we need to look for in a trainer? Alison: I'm not sure of a specific organization to contact in terms of working with trainers, but it's always good to sit down and talk to the trainer. You know, saying these are my goals, this is what I want to work on. You know, asking what kind of repertoire they have with working with people with spinal cord injuries and it's always good to go back to your physical therapist. Physical therapists experienced in spinal cord injury can always set you up with an exercise program that you can learn in their gym and work on and get the technique down so can you go into the gym and do it yourself or with the assistance from a personal trainer is a very good way to do that. And start with your therapist and you can always go back to revamp your exercise program over time. You know, every month or two months, say, when you need a more challenging program and you've out grown your other program -- and also a therapist can always teach you how to progress your program that you're working on to wards your goals that you want to achieve with exercise. Matt, do you have any comments you want to add? Matt: One of the things you hear from people who are personal trainers is that they have a certification from the American Sports Trainers, that's a certification that helps people understand about exercise, how the body reacts to that under normal circumstances and as Alison alluded to, some of your other health care professions of physical therapists, occupational therapists, even your recreation therapists have more training in individuals with a spinal cord injury. But regardless of that, even if someone has that background of accreditation, the biggest question is do they truly understand spinal cord injury. Do they understand the unique aspects of a spinal cord injury, and how the body reacts to exercise in and if you have a spinal cord injury above the level of T-6 and someone doesn't mention the word autonomic dysreflexia to you or regardless of your level of injury, if they are not really concerned about your shoulders and making sure all the muscles around your shoulder is working appropriately and in an appropriate biomechanical or the appropriate rhythm or dance, if you will, then you probably aren't talking to the right person. You need to make sure that that person understands that if you have a spinal cord injury that you have to do pressure relieves and how important that is and some of those, you know, really key things that you as an individual with a spinal cord injury, you probably know an awful lot about your body. And if that person is not really clueing in to some of those specific things that you know about your body, then again, you may want to look for someone else who has more history or more practice or the past experience of dealing with individuals with spinal cord injury. Laurie: Alison, what you said earlier about a physical therapist and getting a physical therapist to help you with your routine, that's something that I did. I have a spinal cord injury, I'm a T-12, and I decided about four years ago that I wanted to become more involved or have a more structured exercise program, and so I found a physical therapist that I actually paid to help me develop my own exercise routine. And I found that to be really helpful because I was going to a gym and before I contacted him, and I was having trouble trying to figure out how to transfer on to benches safely. And I really wasn't quite sure what to do with my legs sometimes and he helped me to develop some really safe procedures for transferring and for use a bunge cord around my legs sometimes for stability and that's not something I would have known or trainers at the gym would have known. I think that's a good point. Alison: Definitely, it's knowing your resources and who to go to is key with really getting into an exercise program that you'll actually stick with. And that's a good -- very specific example. Matt: and a lot of times if you're in a rural area, you may not have the same resources that someone in a much larger area may have. Typically you have therapists in that area and they may not be experts in spinal cord injury, although speaking specifically for physical therapy, they've at least had some education in that area. Every physical therapist has training in spinal cord injury through their curriculum. It's one of the mandates that are in the programs. So they may have some initial ideas or be able to refer you to someone who has a lot more experience with individuals with spinal cord injury. Laurie: the other question has to do with cardioexercise and edema or swelling of the feet, and is there a benefit for a person with a spinal cord injury to do cardioexercise? Will that help prevent that swelling? Matt: One of the things to -- there is a couple of things to think about here. One is that if you're looking at just swelling that can sometimes occur with activity, especially if you're not able to move your lower extremities as you did before your injury. The reason why that may occur is because you don't have the pump of the legs to pump blood back up into the heart. That's more of just general blood flow. When you talk about edema, edema is more when fluid is not going through the blood vessels of the body the way that it should and it goes into the areas outside the blood vessels. And that's a little bit different than the muscle pump working. So you have to be careful when you start talking about edema and its, again, a very individualized issue. If you're having problems with blood clots and those types of things, typically within the first three months of a spinal cord injury, the blood clots are -- you have an increased risk to have blood clots. If you have blood clots or increased edema after that chronically, then that may be indicative of other problems and you need to make sure that you seek additional advice from a health care practitioner that really understands spinal cord injury and looks at the whole gamut of other causes for that edema, that swelling or the cause of blood clots. So although there may be a little bit of an increase with that type of situation with exercise, it again is something that should resolve immediately and you shouldn't notice a chronic problem. If you do, that's probably telling you there is an underlying problem that exists that exercise may be beneficial for, but again, you need just further evaluation to determine for sure if exercise will be beneficial. Laurie: Okay. Another question has to do with cardioexercise and target heart rate, and whether or not a person with a spinal cord injury should try to strive for a certain or a certain target heart rate? Alison: Well, I think it goes back to, again, when we talked about what the different types of -- you know, spinal cord injuries, again, with the T-6 level, above and below, and how the body is actually going to have a very different reaction after a spinal cord injury and so aiming for a specific heart rate I guess is not typically going to always occur. Your body doesn't always react the same way as it normally would before your spinal cord injury. So using that as a guide is not the best -- probably not the best tool to always use. For example, Matt gave a couple of examples of kind of thinking about how hard you want to be working. You know, kind of on a scale of like 1 to 10, where you want to be aiming your exercise. You want to be -- if you're going to be doing aerobic exercise -- sorry -- if you want to be doing aerobic exercise, you want to be aiming for on that scale around a 6 to feel like you're working that hard. And then also if you're doing weightlifting you want to feel like you're gaining short bursts of energy, but you're working much harder for the short bursts of energy with the muscle. So I wouldn't really recommend specifically aiming for a specific heart rate, I would think about scale, how hard am I working and try and aim for there and make sure you're not having any adverse effects for how hard you're working. You don't want to be feeling dizzy. You don't want to be feeling pain. You know, you want to -- if you're doing aerobic, a lot of times you can say you can still talk while you're doing it. You know, you can still get the words out but it's a little bit more difficult. You really feel like you're working. So, no, I wouldn't recommend a specific heart rate to aim for. Laurie: So on your scale of 6, when you talk about on a scale of 1 to 10, would 10 mean you would be out of breath? Matt: 10 is your tongue is dragging and you're really tired and 0 is your couch potato. What you'll hear a lot of time people say is taking 200 minus your age. Again, as Alison alluded to, the big problem to that is the people that are saying that are using that based off of a body of knowledge of how individuals that don't have spinal cord injuries typically react to exercise. And there hasn't been the really large case studies to help determine what's the most appropriate level of exercise for people with spinal cord injury. And, again, as Alison said, according to what your injury, if you have an injury above that T-6 area, your heart rate, you'll never get it up that high. If I'm 20 years old and I have a complete spinal cord injury at C-6, to try to get my heart rate up to 180, if I ever get it up that hard, I'm thinking that that's he something that has autonomic dysreflexia and a major problem because your heart rate -- because of the automatic nervous system not working the way it typically does should not get that high. And so it's so dependent and there is not that standardized number that you typically hear with people who don't have spinal cord injuries. Now, again, then with someone who has an injury below the T-6 level, their heart will react a little bit more normally, but still if they have different abilities to have their legs move or different major muscle pumps work, then the body again is not going to react as it did before the spinal cord injury. So you have to be really careful thinking of a target heart rate and I would also -- as Alison said -- encourage you to think more of how hard it feels like you're working. And think about those aspects of things as opposed to a specific heart rate. Now, the only other thing that you could look at is if you've had an exercise stress test or an ability to work under very closely monitored conditions to see how hard the heart works while you exercise and you max out -- in other words, you do that exercise stress test until your tongue is dragging and you're working at that 10. That will give you a pretty good idea of how high your heart rate can go. And then from there, it's easier to help give you a target heart rate to work at. So under some more specialized conditions, you can get a more realistic target heart rate to exercise, but other than that, I would suggest listening to your body. Laurie: Another question, I want to know about quad issues like no sweating and over heating while exercising and how do you prevent and detect that while you're exercising? Matt: Did you say how to present? Laurie: Prevent or detect it. Matt: The biggest thing is to think about hydration, making sure that you're staying hydrated. Again, if you have a higher level of injury, your body is not going to have the typical cooling off mechanisms, the typical ways that the body cools off which is by sweating, by becoming -- you know, a lot of times people become flush because you have increased circulation to the skin and with a spinal cord injury that's high enough, specifically someone with a complete injury that's higher, technically a quadriplegic, their body is not going to do that. So make sure you wear loose clothing. So that if it's hot outside, you're thinking about what is the better time to exercise. Should I exercise in the heat of the day? The answer is probably not because your body does not react as it did before. Again, make sure you stay hydrated appropriately, keep plenty of fluid in your body, and look at your environment. If it's really hot, that's not a smart time to exercise. Laurie: Okay. Another question is what do you think of standing wheelchairs and claims that standing will increase muscle mass and bone density? Alison: I've seen some various studies on this, but it seems a little bit more inconclusive that there really is no significant effect on bone density and muscle mass for people that do not have movements in their legs, you know, any sort of movement in their legs. It's been typically the results that we are seeing with those types of exercises. Now, ideas that do work with the standing wheelchairs -- I mean, you do get up. You do -- it's a lot of stretching on your muscles. So that is also seen as a good thing that you are stretching your muscles as you're standing. And also you can be challenging your trunk when you're in these standing wheelchairs with moving, but that's very similar as if you were sitting in your wheelchair, it's just a different type of challenge that you're putting on to your trunk and also different types of stretching that you're putting on to your legs and trunk at the same time, but in terms of building muscle and building bone, no, there hasn't been any significant increases or even maintaining muscle bone or muscle mass. Laurie: Another question has to do with pushing and overusing your shoulders and the person wants to know if there are any specific exercises for wheelchair users? And I might add to that, what about pushing a wheelchair vs. using a hand cycle? Alison: An arm exercise bike? Laurie: Yeah. Alison: You know, it kind of goes back to being aware of your shoulder, your positioning and also, you know, as we talked about earlier, it's just kind of knowing what you're doing with your exercises and how you're using it, especially in the shoulder, the shoulder joint. A lot of times people have pain because they are using their shoulder or the muscles around the shoulder that are strong, they are overusing those and the weak ones they're forgetting about and not exercising and keeping them strong. So, you know, everybody is a little bit different on what is strong and what is not. So that's really specific to the person. What muscles are weak? What is it -- is it the rhythm of the scapula that's coming up and that's pinching on their shoulder? Do they have other types of shoulder problems that are causing the pain or their overuse injury or even their posture and sitting in the chair and what type of chair they are pushing, the weight of the chair. It's very specific for each individual. I would also go back to referring to the physical therapist or occupational therapist, is their posture correct in the chair. Are they using the shoulder in the proper manner? And you know, is it with the pushing of the chair or with other activities that they are doing where they are injuring their shoulder. It's really going back to the basics and breaking down where the problem is coming in and in terms of exercise, it goes back to what's weak and what's not and also the range of your shoulder motion. You know, if you're tight in one area and you kind of end up using your shoulder in the wrong position, then if you had full flexibility of your shoulder and your trunk and your chest muscles and your back muscles. And then the second -- adding on to that with the arm bike, it's a great exercise for endurance. It's a wonderful exercise, but again you need to know how to use it properly. Positioning, how you're sitting with the machine. Make sure you're sitting close enough or far enough away and how are you positioning your trunk when you're doing this exercise? So it has to do a lot with positioning and making sure that you're doing it correctly. It's one of the big things with using the arm bike. It's a great exercise, but you need to know how to use it correctly. Matt: And one thing to add in, there are different types of pain that people may experience in their shoulder and you need to make sure that you figured out why you're having that pain. Is the pain because of your level of injury and you're having referred pain because of the level of injury? Or is the pain from biomechanical problems or that rhythm is not right and again all those things that Alison said about making sure that things are working appropriately in the right manner and that you're doing the activity the most appropriately, whether it's your transfer into your car or different things. There is a tendency to overuse your shoulder and more often than not the pain is occurring because of not using the muscles in the appropriate manner, not because of other issues. So making sure that you're using it the way you should is always the key thing to think about. Laurie: Okay. One last question. This person wrote in that they just started an exercise program. So they started lifting weights and they noticed that they're feeling pain a day or two later. Is that normal? Alison: Well, I think there is a couple of different types of pain. There can be muscle pain or there can be joint pain. Muscle pain is typical. When you start an exercise program, you are using your muscles and you are using that -- kind of how we talked earlier, that metabolic rate and that energy that is stored up in your muscles and you're using that. And when you typically start an exercise program, you sometimes can overdo it, and what you can sometimes experience is I guess lot of people talked about lactic acid build up and there is talk about that. I mean, that's not my expertise it. I'll probably throw that to Matt, but there is sometimes muscle soreness that can come with over doing your exercise a little too much. Also you've got to be aware that you didn't pull anything to injure your muscle. That's another thing that you need to be aware of. So, no, you can have some soreness a day or two afterwards, but if you're having pain, there is two different -- that's different. And also knowing if it's muscle soreness or if it's pain or joint pain or joint soreness. Those are very different. No, you shouldn't be having pain in your joint or any soreness really in your joint, but muscle soreness is typically common if you overdo your exercise when you're first starting. You can have some soreness for a couple of days, but if it's persisting past a couple of days, that is something you want to be aware of because there is probably something a little bit more going on there. So just really be aware of your body and watching how it respond to your exercise and starting slow and building into that exercise so you don't get that soreness and don't stop that exercise program or that you don't injure a muscle or tear a muscle or injure your joint by overstressing it. So those are things that, again, start slow, be knowledgeable about what exercises you're going to do and what your goals are. Matt: The only other thing I would add in -- first of all, as Alison said, if after three days an the muscle soreness is not going away, something else is going on and look at that in a little more detail. If you feel like you've sprained a muscle, you have an immediate pain while you're doing the exercise. That's not a sign of muscle soreness, that's something else is wrong. You've pulled a muscle. And there is active swelling that's causing pain or problems by tearing the muscle. And you do your typical activity or your typical ways to make that better of putting ice on that area, rest -- they call it R.I.C.E., rest, ice, compression, and elevation. So you make sure you try not to reuse that muscle that you hurt. You put ice on it and make sure you keep it nice and cool. Check your skin, make sure all that is okay as well. Try to keep compression on it again to get the swelling out and as much as you can, keep it elevated above the heart to try to get the swelling out. So make sure that pain doesn't occur immediately. The delayed onset pain is not uncommon, but again it should go away -- or definitely start going away within three days and pretty much be totally gone by day four. Laurie: Okay, great. Alison or Matt, do you have any closing comments or anything you'd like to say before we end this webcast? Alison: Thank you for having us. Matt: And to coin the phrase from Nike, just get out there and do it. It's finding the right people to help support you and find something you enjoy and just get out there and be active. There is lots of things to do. Laurie: Okay. Well, thank you. This has been very informative and I really appreciate it. I know we all do. I wanted to remind everyone that this webcast will be archived on our website at ilru.org under webcasts and there will also be a discussion forum. So if you have any questions, any follow-up questions that you'd like for Matt and Alison to answer, please send them in and they'll be posted. I also would like to acknowledge again the support for this project. It's from the Research and Training Center on Spinal Cord Injury. And there are a couple of folks that are off-site here that you can't see, one is Rob Dickehuth who is helping us out with getting this webcast on the web, and Marie Bryant who is our realtime captioner. For future webcasts that we'll be having on spinal cord injury and exercise, please check out our webcast calendar or if you're not on our E-mail list and you're not getting the invitations to this webcast, please E-mail us at ilru@ilru.org and we'll be happy to add you to the list so you'll learn about future webcasts. All right, thank you all very much. We really do appreciate it. Goodbye.