The Effect of a Periodized Resistance Training Program on Strength and Ambulation in an ...

70 Pages·2015·0.77 MB·English

The Effect of a Periodized Resistance Training Program on Strength and Ambulation in
an Individual with Incomplete Chronic Spinal Cord Injury

An Independent Research Report
Presented to

The Faculty of the College of Health Professions
Florida Gulf Coast University

In Partial Fulfillment
Of the Requirements for the Degree of
Doctor of Physical Therapy

By
Julie Bowditch
2015
APPROVAL SHEET

This Independent Research is submitted in partial fulfillment of
the requirements for the degree of
Doctor of Physical Therapy

____________________________
Julie Bowditch
Approved: April 2015

____________________________
Dennis Hunt, Ed.D., CSCS
Committee Chair / Advisor

____________________________
Mollie Venglar, DSC, MSPT, NCS
Committee Member

The final copy of this Independent Research has been examined by the signatories, and we find that both
the content and the form meet acceptable presentation standards of scholarly work in the above mentioned
discipline.
Acknowledgements

First and foremost, I would like to thank my committee members, Dr. Dennis Hunt and
Dr. Mollie Venglar for their unending support and thoughtful guidance throughout this
process.
Additionally, I would like to thank my parents, classmates, and peers for providing
continuous and uplifting encouragement, companionship, and assistance during this
academic adventure.
Lastly, thank you to Florida Gulf Coast University and the Department of
Rehabilitation Sciences for allowing me to conduct this research as a contribution to my
education and academic career.
Periodized Resistance Training and SCI 1

Table of Contents
Abstract ----------------------------------------------------------------------------------------- 2
Introduction ------------------------------------------------------------------------------------ 3
Spinal Cord Injury -------------------------------------------------------------------- 4
Incomplete Injuries-------------------------------------------------------------------- 5
Effects on Skeletal Muscle --------------------------------------------------------- 6
Muscle Spasticity --------------------------------------------------------------------- 7
Resistance Training & SCI-------------------------------------------------------- 9
Exercise Training Principles ------------------------------------------------------ 14
1-RM Testing -------------------------------------------------------------------------- 15
Periodization Training ---------------------------------------------------------------- 16
Periodization in SCI ----------------------------------------------------------------- 17
Methods ---------------------------------------------------------------------------------------- 20
Participant ----------------------------------------------------------------------------- 20
Study design -------------------------------------------------------------------------- 21
Data collection----------------------------------------------------------------------- 32
Results & Discussion------------------------------------------------------------------------- 34
Discussion Summary ----------------------------------------------------------------------- 56
Conclusion ------------------------------------------------------------------------------------ 60
References ----------------------------------------------------------------------------------- 61
Appendix A-------------------------------------------------------------------------------------- 65
Appendix B--------------------------------------------------------------------------------------- 66
Appendix C---------------------------------------------------------------------------------------- 67
Periodized Resistance Training and SCI 2

Abstract
Muscle atrophy is a primary health concern in individuals suffering from spinal cord
injury (SCI). This change occurs as a result of the injury and subsequent limited mobility.
The population of people with incomplete SCI appears to be increasing. Rehabilitation
and fitness professionals should strive to better understand how an individual’s
capabilities can be improved by focusing on the potential to impact and improve
functional abilities and promote wellness in this population.
PURPOSE: To understand the effect of utilizing a periodized resistance training (RT)
program in addition to a body weight supported aerobic exercise program on improving
strength, endurance, and quality of gait for a community-dwelling ambulatory individual
with a chronic incomplete SCI.
METHODS: The participant was a 38 year old male with a chronic L1 ASIA D SCI. He
completed a 12 week whole body periodized RT and flexibility program involving the
innervated muscle groups of his upper and lower extremities. The intervention included
cardiovascular endurance training once a week on a body weight supported treadmill
along with twice weekly RT sessions. The periodization model included mesocycles
involving one week of an adaptation period followed by three weeks of muscular
endurance training, four weeks of strength training, and four weeks of power training.
Outcomes measures include 1 repetition maximum testing (1RM), the 6-minute walk test
(6MWT), manual muscle testing (MMT), modified Ashworth test for spasticity, body
composition, and joint range of motion (ROM).
RESULTS: The most significant improvements were seen in 1 RM testing and 6MWT.
Upper body strength as measured by 1 RM chest press improved by 30 lbs (22%). Lower
body strength as measured by the 1RM leg press improved by 25 lbs (13%).
Improvement in the 6MWT was 107 feet or 9.7%. No other significant trends were
identified.
CONCLUSION: Strength gains through periodized RT were evident for this individual
with chronic incomplete SCI. Strength gains occurred as seen through the objective 1RM
testing measures looking at the upper and lower body as a whole. Functional
improvements in ambulation distance, endurance, and walking speed are seen in the
results of the 6MWT. Training in a periodized fashion appears to be a viable option for
further study with this population.
Periodized Resistance Training and SCI 3

Introduction
In 2013, the estimated number of people in the United States living with spinal
cord injury (SCI) was approximately 273,000 people (Spinal Cord Injury Facts 2013).
Every year there is estimated to be 40 new cases per million people in the population.
Most injuries are traumatic and happen to young people; with up to 80% of individuals
who have suffered a SCI being males. SCIs lead to a wide variety of functional
disabilities, loss of independence, loss of mobility, loss of sensation, health related
complications, and muscle atrophy below the level of the lesion. The goal of
rehabilitation for individuals with SCI is to address losses in bodily function, minimize
secondary complications, and utilize muscle groups that are still functional in order to
increase independence as much as possible and reintegrate the person back into their
community. The strengthening of muscle groups that are still functional is important in
helping a patient become as independent and functional as he/she can be and in
preventing further injury (Umphred et al 2010 ).
Resistance training (RT) is the voluntary activation of skeletal muscles against
resistance. Resistance can be in the form of using body mass, free weights, and other
modalities such as bands, springs, and manual resistance (McArdle, Katch, & Katch
2010). According to the American College of Sports Medicine (ACSM), RT improves
muscular fitness by increasing strength, endurance, and power. The health-related
benefits of RT include making activities of daily living less physiologically stressful and
managing or preventing chronic diseases. An RT program can provide these desired
benefits from just a few sessions per week (ACSM Guidelines 2010).
Periodized Resistance Training and SCI 4

The purpose of this study was to determine the effect of utilizing a periodized RT
program in addition to a body weight supported treadmill training (BWSTT) program on
strength, endurance, and quality of gait for a participant with a chronic incomplete L1
SCI.
Spinal Cord Injury
SCIs usually occur as traumatic injuries that leave healthy, active, independent
people paralyzed and dependent on others. The mechanism of injury can affect the
severity and type of the spinal cord lesion. The leading causes of SCI are motor vehicle
accidents followed by falls, violent acts, and sports injuries. Birth defects, disease, and
lack of blood flow can also cause spinal cord lesions (Umphred, Lazaro, Roller, & Burton
2013).
Clinical presentations vary depending on the extent of damage to the spinal cord
and the level of the spinal cord that is injured. A detailed physical assessment is needed
to determine which muscles have lost voluntary control and in what areas sensation has
been lost. The American Spinal Injury Association (ASIA) has developed international
standards for the classification of SCI. A SCI can be classified as complete, meaning
there is no sensory or motor function in the lowest sacral segments, or incomplete
meaning there is sensory or motor function in the lowest sacral segments (2011). The
ASIA Impairment Scale classifies injuries as complete or incomplete. The ASIA
Impairment Scale is provided in Table 1.
Periodized Resistance Training and SCI 5

Table 1. ASIA Impairment Scale
A=Complete: There is no sensory or motor function in the lowest sacral
segments (S4-S5).
B=Sensory Incomplete: Sensory but no motor function is preserved below the
neurological level and includes the S4-S5. No motor
function is preserved more than three levels below the
motor level on either side of the body.
C=Motor Incomplete: Motor function is preserved below the neurological level
and more than half of key muscles functions below the
neurological level of injury at a muscle grade less than 3.
D=Motor Incomplete: Motor function is preserved below the neurological level,
and at least half of the key muscle functions below the
neurological level of injury and have a muscle grade of
greater than or equal to 3.

The goals of rehabilitation for injuries of any of the above classifications include but are
not limited to:
• transfer training
• wheelchair training
• bowel control
• control of orthostatic hypotension
• autonomic dysreflexia management
• control of muscle spasticity
• return to living at home and in the community
Incomplete SCI
Over the past 20 years, a higher percentage of injuries are being classified as
incomplete rather than complete. In fact, more than half of new injuries occurring in the
United States are being classified as incomplete (Gregory, CM., Bowden, MG.,
Jayaraman, A., Shah, P., Behrman, A., Kautz, SA., Vandenborne, K. 2007). The life
expectancy of a person with an incomplete injury is much closer to that of an able bodied
Periodized Resistance Training and SCI 6

person than that of a person with a complete SCI. With incomplete injuries, there is a
strong potential for individuals to be able to walk again. With some muscles rendered not
functioning and others having suffered atrophy, an SCI sufferer must re-learn how to
walk. Through physical therapy with the use of BWSTT, crutches, walkers, and other
devices, many people with paraparesis regain the ability to walk. Limiting factors include
weakness, muscular endurance, fatigue, spasticity, slow gait speed, abnormal gait pattern,
and impractical energy usage. With an increasing population of people with incomplete
injuries, the discipline of physical therapy should strive to better understand how to
improve an individual’s capabilities, focusing on the potential to impact and improve
functional abilities. Evidence-based best practice research is needed to determine an
effective way to return individuals with SCI to walking and to improve the gait pattern to
as near normal as possible.
SCI Effects on Skeletal Muscle
Muscle atrophy is defined as the loss of force generating capacity due to
decreased muscle fiber size and loss of contractile proteins (Kisner& Colby 2007).
Muscles below the level of the SCI will atrophy over time. Two types of atrophy are
present with SCI: denervation and disuse. Denervation atrophy occurs when the nerve
signal to the muscle is absent. Muscles atrophy rapidly because their nerve innervation is
completely cut off. Decreased but not complete denervation of a muscle group can
decrease strength and make initial activation of the muscle difficult. Disuse atrophy is a
result of decreased motor input as well as physical inactivity due to the patient being
hospitalized, immobilized, developing contractures, or being non-weight-bearing.
Muscles that are normally weight bearing prior to the SCI are known to show greater
Periodized Resistance Training and SCI 7

disuse atrophy (Gordon & Mao 1994). For example, the average size of the quadriceps
femoris muscle in patients with SCI is 40% smaller than with able-bodied individuals
(Mahoney, et. al. 2005). Skeletal muscle cross-sectional area can decrease as much as
50% in just a few weeks after injury (Gorgey & Shepherd 2009). Decreased muscle mass
and contractile activity may also contribute to secondary health related complications.
Physical inactivity can contribute to a variety of chronic diseases such as diabetes
mellitus, cardiovascular disease, cancer, obesity, hypertension, bone disease, arthritis, and
osteoporosis (Warburton, Nicol, Bredin, 2006). Chronic SCI sufferers often lead a
sedentary lifestyle which might partially explain a decrease in muscle mass and fitness
for many (Jacobs & Nash 2004). It might also explain why there is a higher risk for
cardiovascular issues, metabolic syndromes, and obesity for those with SCI. These
individuals have much to benefit from reducing the atrophy process and even more if
they increase the mass of muscles that have become small and weak.
Muscle Spasticity in SCI
Muscle spasticity occurs as a result of damage to upper motor neurons. It is
characterized by symptoms of hypertonicity, hyperactive stretch reflexes, and involuntary
movements called clonus below the lesion (O’Sullivan & Schmitz 2007). Causes of
spasticity include decreased motor unit activation, impaired antagonist inhibition, or
impaired presynaptic inhibition of reflex pathways (Pak and Pattern 2008). Prolonged
muscle shortening can lead to contracture, joint damage, muscle damage, and pain which
restrict range of motion (ROM) and voluntary movement (Elbasiouny, S., Moroz, D.,
Bakr, M., Mushahwar, V. 2010). Muscle spasticity is a common issue in individuals with
SCI. It is a stumbling block for those who are trying to increase function and