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Why exercise in paraplegia?
  1. Michael Kjaer
  1. Sports Medicine Research Unit Bispebjerg Hospital, Building 8, 1st Floor 23 Bispebjerg Bakke DK-2400 Copenhagen NV, Denmark email: m.kjaer{at}

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    Spinal cord injury leads to two dramatic changes: not only is there loss of muscle function and a large amount of muscle, but also susceptibility to inactivity related diseases, such as obesity, insulin resistance, type II diabetes, and coronary heart disease, increases.1 Previously, one of the major problems and causes of death for people with spinal cord injuries was infection, but recently, coronary heart disease has become more prominent. The possibilities for exercise in people with spinal cord injuries are limited to either performing voluntary exercise with non-paralysed muscle groups—for example, arm exercises, especially in the paraplegic—or subjecting themselves to electrically induced exercise through stimulation of motor nerves either with surface electrodes or after implantation of electrodes.

    Whereas voluntary arm exercise can provide a certain stimulus to the cardiorespiratory system, it has recently been shown that stimulation of paralysed lower extremity muscles alone or in combination with arm cranking will not only increase energy combustion, but also activate more muscle groups and thus influence metabolic changes such as insulin resistance in a potentially better way. After the use of electrical stimulation for bladder and intestines, the possibility of stimulating paralysed muscle in a functional manner came to the fore at the beginning of the 1980s and allowed the development of a computerised bicycle (FES).2 The use of such a bicycle for functional electrical stimulation has been shown not only to improve maximal oxygen uptake and endurance of the stimulated muscles, but also to cause muscle hypertrophy and muscle fibre shift from fast twitch type 2X to 2A.3

    In addition to these effects, oxidative enzyme activity has also been shown to increase after several weeks of training.4 This occurs at a faster rate than the shift in fibre type, indicating different time patterns for the adaptation of these two systems. In addition, the collagen in muscle adapts to electrical stimulation, and it has been shown that type 4 collagen, which is predominant in the basal membrane, increases its turnover without any net increase in total amount, indicating possible reorganisation of this connective tissue.5 In addition to these effects, expression of the protein used for glucose transport (Glut4) increases with training and so does insulin stimulated glucose uptake in the muscle.6

    Finally, it has been shown that functional electrical stimulation of paralysed legs increases bone mineral content of the tibial region. In studies using FES bicycling, high frequencies were used for stimulation, and no type I fibres were observed after this training. However, stimulation with lower frequencies actually seems to produce an increase in mRNA for myosin heavy chain type I after several weeks of training.7

    In combination, the effects of functional electrical stimulation counteract the enzyme activity associated changes in people with spinal cord injuries and should thereby have a preventive effect.

    In addition to these effects, electrical stimulation of partially paralysed muscle groups such as wrist extensor and muscles in tetraplegic people has been shown to result in improved function and endurance of the affected arm allowing more daily functions to be performed than before the training programme.8

    Finally, it seems that training in people with spinal cord injuries improves their general wellbeing, temperature regulation, and sleeping patterns and reduces pressure sores, all important effects in addition to those mentioned above. It is therefore vital to encourage physical activity, including the use of electrical stimulation devices, in this group of patients in order to prevent diseases associated with physical inactivity. Such diseases not only occur in this group of people, but also reflect the general pattern in our modern inactive society. Results obtained in research on people with spinal cord injuries may therefore help to provide a basis for recommendations on exercise in the general population also.


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