Wheelchair users and exercise

Magnus from Malmo, Sweden asks:

How do people in wheelchairs exercise?

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This sounds like a very simple question but the answer is probably more complicated than most people would expect.
The first major factor is whether the person usually uses a manual wheelchair or a power wheelchair. This is important because quite often (but not always), the person's ability level determines the type of wheelchair he/she uses. For example, if your spinal cord was damaged at the cervical (neck) area, you may have movement in the arms but perhaps impaired or little movement in the fingers or wrists – this person is more likely to use a power wheelchair to get around town than a manual one.

It is obvious why this makes a difference. Someone in a wheelchair that they have to push up a hill him/herself would get more exercise than someone who simply pushes a lever to do the same thing. That is why when I push myself up a hill, I have a 50% chance of someone mentioning something like, "You must have good cardio" or "You must have strong arms."

Does that mean people who use power wheelchairs cannot exercise? Of course not.

Notice how I said earlier that people with impaired hand/arm function may need a power wheelchair to "get around town." I said that on purpose because it is not the same as needing a power wheelchair to "get around." People with impaired hand/arm function may be able to use a manual wheelchair under certain situations that do not require racking up the miles, such as getting around the house or the neighborhood – or in sports.

Ah, sports. This is a topic that will be gaining momentum this summer as the Paralympic Games in London approach. Many able-bodied sports have been adapted over the years, providing an outlet for people with various disabilities to exercise. As the Paralympics show, some of them turn their exercise into actual athletic competitions.

There are also weight room exercises that wheelchair users can take advantage of. The recent TV series Push Girls shows several scenes of working out with weights. There are also adaptive weight rooms out there specially designed for wheelchair users.

These are also in addition to exercises that you might see in rehabilitation centers and therapy, which can give you quite the workout – many things that are taught in those places require a LOT of core strength (especially important if one does not have full use of his/her lower- to mid-body muscles).

Of course, this is all nice and everything but the hard truth sometimes is that it is not always affordable to take advantage of sports programs or exercise rooms. This is where the unfortunate stereotype of "using a wheelchair because you are fat" comes in.

If you cannot use all of your muscles vital for "normal" exercise (such as walking) and cannot afford exercise programs, it is much more likely that you will become overweight. When you become overweight, you may start having difficulties pushing your own chair (if you use a manual wheelchair). This may lead to shoulder injuries, which becomes a secondary obstacle to pushing your own chair and you may require a power wheelchair. When you use a power wheelchair, you're exercising even less and may get more overweight.

As you can see, it's a slippery slope and one that is difficult to escape from once it starts.

Another factor that may lead to that slippery slope may include prescription drugs, particularly steroids (which some people may need to get enough strength for some functions such as breathing). Steroids can make someone gain weight, which leads to the same situation. This is why I am not a fan of the stereotype of the "fat person using a wheelchair because he/she is fat" – often there is a reason for that and it would have nothing to do with one's eating habits.

As a manual wheelchair user, that is why I try to get as much exercise as possible, whether it be a casual stroll through the neighborhood or playing sports. I know some people with more limited hand/arm function who try to do the same if they can. Unfortunately there is still no simple solution that works for everyone but it is quite important to do what we can to stay in shape.

Prolonged wheelchair sitting and how to combat the effects

Recently there was an article in the Vancouver Province newspaper about a study revealing that how too much sitting is linked to shortened lives. Obviously for those who rely on wheelchairs for mobility, this is a concern. So on Twitter...

BFWriter from Vancouver, British Columbia asks:

If too much sitting is linked to shortened lifespans, then what can wheelchair users do about it?

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This is a very good question and it can vary from person to person. I have very good use of my upper body so most of my answers will be based on that. However, there are those who do not; I will try my best to address as much as I can.

When someone relies almost exclusively on a wheelchair for mobility, his/her body often undergo some changes, including (but not limited to):

• reduced bone density (or osteoporosis)
  
• reduced/atrophied muscles
  
• skin breakdown (such as pressure sores, a.k.a. "bed sores")
  
• spasticity/spasms
  
• changes in blood pressure and blood flow
  
• cardiovascular conditions
  
• contractures and joint problems
  

Some of these are for spinal cord injuries or paralysis, but I want to focus on wheelchair use in general (regardless of the type of condition someone has).

One of the most common tools used to combat the complications of prolonged sitting is the standing frame. There are several types, but basically they look like this.

An example of a standing frame.

To use one, the person simply transfers from a wheelchair to the stander and perhaps get strapped in (if there are straps). Once properly positioned, there will be a hydraulic pump that raises the person up. This video demonstrates:

However, not all standing frames can move around like that one. Most of them remain stationary. They are not meant to be a mobility device, but rather a device used to force someone's body to stand if he/she is unable to stand independently.

What this does is increase weight-bearing. By doing so, it maintains bone density (the bones are being used), it forces some muscles to do something new (which helps prevent atrophy), it allows the body to be in a new position (which can help with spasticity) and can also force the heart to pump quicker (due to more work needed to keep blood flowing in an upright standing position).

Other benefits can include reducing pressure on parts of the body usually involved in sitting (reducing the incidence of pressure sores), preventing scoliosis (by forcing someone to stand up straight and not slouch), aiding in bladder and bowel control (for those with spinal cord injury or paralysis, by using gravity and "stretching out" the areas involved) and psychological improvement (no more being short and always looking UP to things/people).

While this is all good, some people may have problems with standing frames. I remember when I had to stand for the first time since acquiring my disability, I nearly passed out because I was unprepared for the sudden change in blood pressure. Some people may still have this problem years later; light-headedness and slight dizziness can occur, which may prevent some people from using a standing frame too often.

There are also wheelchairs that can elevate someone to a more upright position. Some wheelchairs can help someone stand up partially, and others can stand completely.

Wheelchair with partial elevation.

Wheelchair with complete elevation.

While they have some of the same benefits as standing frames, the obvious drawback to these wheelchairs is practicality. They weigh a lot more than the aluminum and titanium wheelchairs that are often used, which can result in an increase of shoulder muscle injuries, and they can be difficult to transport for wheelchair users who drive cars, especially cars without wheelchair lifts or ramps.

These are the equipment-related options that can be used. However, can something be done without needing to use expensive equipment? Certainly.

One of the best ways to combat the complications of sitting is to go to the pool. This can be in the form of pool therapy or a casual swim. Being in the water puts more pressure on bones and muscles to fight water resistance; simply having to breathe harder in the water is proof enough of that.

I find that even with limited movement and sensation in my lower body, I can still take advantage of the water for weight bearing. At the shallow end, the water has a peculiar ability to support my weight yet allow me to "stand" with some weight on my legs; it is almost 50% standing on my own and 50% supporting my weight. The water also puts pressure on my muscles; since I have some movement, that can be used to try to increase strength. This can actually prove to be a bigger benefit than using standing frames!

Another thing I do is stretching on a yoga mat. Stretching muscles is important because those mobility problems are prone to contractures (shortening of muscle due to lack of use, resulting in reduced joint mobility). In addition, I have some joint pain in places where I have sensation and I suspect that for places where I lack sensation, it might be the same story. In general, I can independently stretch my lower body relatively well; if I want to "go the extra mile," I would require some assistance, but those with good use of their upper bodies should be able to stretch well.

There is another option that is not as widely used as standing frames, standing wheelchairs, swimming or stretching. That is functional electrical stimulation (FES). Basically, it involves electrodes that are attached to muscles that are paralyzed and small electric currents are used to activate and perhaps reprogram those muscles.

I am not an expert on FES, nor do I use it. From what I can find out, it is not right for everyone (which may be why it was never suggested to me). It does not repair spinal cord damage but rather it attempts to recover specific muscular functions. From what I can tell, it does not directly address the issues on the list that I put together at the beginning of this post.

Also, from what I can find, if someone is unable to stand, FES is unlikely to change that; however, if someone is already able to stand, FES can help with how the muscles move. In other words, it does not necessarily help someone achieve the ability to stand if the person does not already have that ability.

In the occasional cases where it does help someone achieve walking ability, one still needs 6-8 times more energy than able-bodied people to walk with FES. It is not practical walking (it cannot be sustained for a long period of time) and hence the person will still likely spend the vast majority of his/her time in a wheelchair.

(I may be wrong about this; I'm simply going by what I can find through some research. Unfortunately the studies out there are not very unified.)

This has been a long and somewhat complex post. I am sure there are other things that wheelchair users do to help with standing or increasing the time spent outside the wheelchair; these are just a few of the ways to do it.