January 2022 Issue

Focus on Fitness: Exercising With Spinal Cord Injury
By Kelly Pritchett, PhD, RD, CSSD
Today’s Dietitian
Vol. 24, No. 1, P. 52

A Review of the Guidelines and How Physical Activity Can Improve Quality of Life

Approximately 296,000 individuals in the United States live with a spinal cord injury. Based on data from the National Spinal Cord Injury Statistical Center, 17,700 new cases of spinal cord injury occur in the United States every year, with motor vehicle accidents the leading cause of injury and an average rehabilitation time of 34 days. Since the 1970s, the average age of injury has increased from 29 to 43. Spinal cord injuries can lead to lifelong impairment, disability, and handicap, which can significantly impact quality of life.1

RDs who encounter clients and patients with spinal cord injury but don’t specialize in this area can gain an understanding of the types of spinal cord injuries, the causes, and the physical activity guidelines for this population that can help improve their lives.

What Is a Spinal Cord Injury?
The spine consists of 33 vertebrae that are divided into five types: cervical, thoracic, lumbar, sacral, and coccygeal. Injury to the thoracic or lumbar vertebrae leads to loss of function in the legs, trunk, muscles, and organs, which are innervated below the level of injury on the spinal cord, and is referred to as paraplegia. Quadriplegia refers to injury to the cervical vertebrae resulting in functional loss in all four extremities, with damage to the nerves leading to the head, neck, diaphragm, arms, and hands.

Furthermore, depending on the degree of motor and sensory loss, spinal cord injuries can be classified as complete or incomplete. Although highly variable among individuals, an incomplete spinal cord injury denotes neurological function below the level of injury in the spinal cord where there may be complete loss in motor function, or the function of a body part, but incomplete sensory loss (eg, touch), or vice versa. A complete spinal cord injury refers to loss of both motor and sensory function below the level of injury on the spinal cord.2

Benefits of Physical Activity
Physical deconditioning is a common consequence of spinal cord injuries given the physical, psychosocial, and environmental barriers to exercise.3 As aforementioned, the level and completeness of the injury to the spinal cord is unique to the individual and predicts mobility.4

Compared with the general population, individuals with spinal cord injury are two to four times more likely to develop obesity, diabetes, and CVD due in part to low physical activity levels and physiological changes that occur after injury.5 Therefore, physical activity is key for improving their quality of life and health. Regular physical activity can help improve energy levels, sleep, mood, blood sugar, and cholesterol; help maintain a healthy body weight; and decrease pain and risk of heart disease. However, exercise guidelines for able-bodied individuals aren’t necessarily appropriate for a spinal cord injury population.4

Exercise Guidelines
The American Congress of Rehabilitation Medicine recommends people with spinal cord injury engage in 20 to 30 minutes of moderate to vigorous aerobic activity at least two days per week for cardiorespiratory fitness benefits.5 However, more recent guidelines suggest engaging in at least 30 minutes of moderate to vigorous aerobic activity three times per week for improvements in factors that affect cardiometabolic health, such as body composition, blood lipid profiles, and vascular function.3 Activities such as arm ergometer (cranking), wheeling, aquatics, and cycling are most appropriate.5

Muscular strength and endurance are important for maintaining or improving bone density, lean body mass, resting metabolic rate, and glucose metabolism in individuals with spinal cord injury. It’s recommended to perform three sets of eight to 10 reps at a moderate to vigorous intensity, with one to two minutes of rest using free weights, weight machines, and/or resistance bands two times per week. Recommended exercises target the major functioning muscle groups and include bicep curls, tricep press, seated row, and chest fly latissimus dorsi. Furthermore, a lumbar roll or chest strap may be used for posture support and to decrease the risk of injury.3,5

Flexibility is important for maintaining range of motion and mobility. Daily stretching is recommended but with caution not to overstretch limbs where there’s impaired sensation. Special attention should be paid to the chest, shoulders, and biceps, as they may tighten after injury.5

Barriers to Exercise
Limited access, financial barriers, fear of stigma, or health-related concerns (eg, pressure ulcers, autonomic dysreflexia, or bladder management) are noted as some barriers to exercise in the spinal cord injury population. Furthermore, failure to provide an appropriate exercise routine based on an individual’s injury level can lead to decreased adherence.6 However, physical activity can provide a positive outlet. Adaptive sports programs are a fun and competitive option for individuals with spinal cord injury to become active. Check whether there are adaptive sports programs in your client’s area at challengedathletes.org/adaptive-sport-organizations.

The following strategies can help address barriers to physical activity and psychological issues that may impact the motivation to exercise3,6:

• Emphasize the importance and therapeutic benefits of exercise.
• Engage in fun activities.
• Keep track of progress.
• Schedule exercise sessions.

Before clients with spinal cord injury begin an exercise program, they’ll need to take some precautions regarding their health.

Blood Pressure
People with spinal cord injury have less sympathetic nervous system activity during exercise, which results in reduced physiological responses compared with their able-bodied counterparts.7 Those with injury levels at or above the sixth thoracic vertebrae (T6) are at risk of autonomic dysreflexia, which is a spike in blood pressure. It’s recommended they stop exercise immediately if this occurs.

Moreover, individuals may have a blunted heart rate response to exercise, so using rating of perceived exertion—a method for measuring perceived exercise intensity using an anchored scale of 6, or “no exertion,” to 20, or “maximum effort”—may be helpful for prescribing and monitoring exercise intensity. After exercise, it’s common for these individuals to experience a drop in blood pressure (or hypotension) due to decreased active musculature in the lower extremities, which can reduce circulation. Proper warm up and cool down exercises can help with circulation and blood pressure.3,5

Impaired Thermoregulation
Thermoregulation is another concern among individuals with spinal cord injury. Sweating is a normal physiological response to an increase in core temperature to help keep the body cool.8 However, reduced sweat responses below the level of injury and an impaired ability to thermoregulate during exercise has been documented in individuals with spinal cord injuries.9 To help manage core temperature and provide perceptual benefits (eg, feeling cooler), clients can combine adequate hydration (with careful attention not to overconsume fluids) and cooling strategies, such as spraying water with fans, using ice cold towels, and drinking ice slurries or cold fluids.8

Pressure Ulcers
Another issue common among individuals with spinal cord injury is skin breakdown, or pressure ulcers, due to reduced sensation. Monitoring skin and using padding with equipment can help prevent or improve skin ulcers.3,4

Low Bone Mineral Density
Those with spinal cord injury also face a risk of developing low bone mineral density (BMD), making them more prone to fractures.10,11 Because bone is strengthened by skeletal loading, individuals who become wheelchair bound due to their injury subsequently decrease weightbearing activities. Loss of BMD after injury is most rapid within the first few months and reaches a steady state after two years.12

While exercise has been shown to increase BMD in the able-bodied population, more research is needed to determine the effects of exercise on BMD in individuals with spinal cord injury. Studies conducted in para-athletes and active individuals with spinal cord injury have shown higher BMD scores in the upper extremities compared with their able-bodied counterparts.13,14 Furthermore, researchers have observed higher BMD values in body areas above the level of injury in basketball players with spinal cord injury than in sedentary individuals with spinal cord injury.13 Finally, clearance from a physician before standing or performing weight-bearing exercise is recommended if individuals haven’t stood for one year or more.5

Final Thoughts
In general, individuals with spinal cord injury should first obtain clearance from their physicians before beginning an exercise program. Exercise ideally is performed under the supervision of an exercise professional specializing in spinal cord injury management.5 Physical activity combined with lifestyle and dietary modifications should be appropriately prescribed based on the person’s level of function to improve safety, adherence, and quality of life.6 The United Spinal Association offers great resources for active individuals (adolescents and adults) with spinal cord injury at unitedspinal.org/exercise-and-spinal-cord-injury.

— Kelly Pritchett, PhD, RD, CSSD, is an associate professor in nutrition and exercise science at Central Washington University. As a board-certified specialist in sports dietetics, she has consulted with both elite and collegiate athletes as well as with active individuals. She has authored research articles for scientific journals and presented at regional and national conferences with her current research interests, including vitamin D and energy availability in athletes with spinal cord injury. In her spare time, she enjoys running and spending time with her three active boys.


1. National Spinal Cord Injury Statistical Center. Spinal cord injury facts and figures at a glance. https://www.nscisc.uab.edu/Public/Facts%20and%20Figures%20-%202018.pdf. Published 2018. Accessed September 29, 2021.

2. Nelms M, Sucher KP. Nutrition Therapy & Pathophysiology. 4th ed. Boston, MA: Cengage Learning; 2019.

3. Martin Ginis KA, van der Scheer JW, Latimer-Cheung AE, et al. Evidence-based scientific exercise guidelines for adults with spinal cord injury: an update and a new guideline. Spinal Cord. 2018;56(4):308-321.

4. Martin Ginis KA, Hicks AL, Latimer AE, et al. The development of evidence-informed physical activity guidelines for adults with spinal cord injury. Spinal Cord. 2011;49(11):1088-1096.

5. Evans N, Wingo B, Sasso E, Hicks A, Gorgey AS, Harness E. Exercise recommendations and considerations for persons with spinal cord injury. Arch Phys Med Rehabil. 2015;96(9):1749-1750.

6. Gorgey AS. Exercise awareness and barriers after spinal cord injury. World J Orthop. 2014;5(3):158-162.

7. Price M. Energy expenditure and metabolism during exercise in persons with a spinal cord injury. Sports Med. 2010;40(8):681-696.

8. Pritchett K, Broad E, Scaramella J, Baumann S. Hydration and cooling strategies for Paralympic athletes: applied focus: challenges athletes may face at the upcoming Tokyo Paralympics. Curr Nutr Rep. 2020;9(3):137-146.

9. Pritchett RC, Al-Nawaiseh AM, Pritchett KK, Nethery V, Bishop PA, Green JM. Sweat gland density and response during high-intensity exercise in athletes with spinal cord injuries. Biol Sport. 2015;32(3):249-254.

10. Bauman WA, Spungen AM. Metabolic changes in persons after spinal cord injury. Phys Med Rehabil Clin N Am. 2000;11(1):109-140.

11. Gaspar AP, Lazaretti-Castro M, Brandão CMA. Bone mineral density in spinal cord injury: an evaluation of the distal femur. J Osteoporos. 2012;2012:519754.

12. Wood DE, Dunkerley AL, Tromans AM. Results from bone mineral density scans in twenty-two complete lesion paraplegics. Spinal Cord. 2001;39(3):145-148.

13. Goktepe AS, Yilmaz B, Alaca R, Yazicioglu K, Mohur H, Gunduz S. Bone density loss after spinal cord injury: elite paraplegic basketball players vs. paraplegic sedentary persons. Am J Phys Med Rehabil. 2004;83(4):279-283.

14. Jones LM, Legge M, Goulding A. Intensive exercise may preserve bone mass of the upper limbs in spinal cord injured males but does not retard demineralisation of the lower body. Spinal Cord. 2002;40(5):230-235.