the effect of a periodized resistance training program on

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


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.


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).


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.


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


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


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


independence. The severity, duration, and frequency of spasticity varies from individual

to individual. It can be triggered by both internal and external stimuli. The symptoms of

spasticity are managed pharmacologically with neurologic antispastic agents. Examples

of common antispastic agents are baclofen, diazepam, and dantrolene (Umphred et al.

2010). To avoid negative side effects of oral baclofen, individuals frequently use an

intrathecal baclofen pump which is surgically inserted under the skin. This pump delivers

the pharmacological effect directly to the spinal cord. The amount of medication

delivered can be adjusted to the individual’s needs by a physician. However, this type of

treatment is not always completely successful at alleviating the symptoms of spasticity

and additionally, a tolerance to the drug can be developed causing the individual to

require adjustments for increased levels of baclofen delivery. Surgical procedures are also

utilized to deliver relief of symptoms including a myotomy (i.e. cutting of the muscle) or

neurectomy (i.e. cutting of the nerve) (O’Sullivan & Schmitz 2007). A drawback to both

of these procedures is that they render the body less able to contract that muscle.

Therapeutic interventions known to benefit and treat muscle spasticity include

prolonged stretching, cryotherapy, weight-bearing exercise, and aquatic therapy

(Umphred et al. 2010). Passive stretching is a mechanism of increasing muscle length,

reducing and preventing contracture, maintaining and increasing ROM, and reducing

muscle tone (Elbasiouny, S., et al 2010). Stretching addresses the biomechanical issues

involved in spasticity that medications do not. Evidence-based duration of stretching

exercises recommended for all individuals is at least 30 seconds (Baechle & Earle 2008).


Resistance Training and SCI

It is well established that RT can induce muscle hypertrophy in able-bodied

individuals (Seyness, Boer, Narici 2007). Muscle performance in the areas of strength,

endurance, and power has also been shown to improve with RT (Kisner & Colby 2012).

This type of training maintains or increases strength of musculoskeletal tissues, increases

bone density, decreases stress on joints, decreases risk of injury, and has positive effects

on body composition (Kisner & Colby 2012). The ACSM (2010) guidelines recommend

RT for all individuals, including clinical populations such as those with SCI. Although

special considerations might need to be followed, the benefits of RT can extend to the

SCI’s population.

Researchers have examined various aspects of RT for subjects with chronic SCI.

Gorgey and Shepherd (2009) completed a lower extremity RT program along with

neuromuscular electrical stimulation (NMES). Since the nerve connection between the

brain and the muscles is partially or completely cut off as a result of SCI, NMES was

utilized to induce muscle contraction in order to strengthen the muscle. The use of a

NMES unit allowed for training of muscles that were entirely denervated to participate in

RT. In Gorgey and Shepherd’s (2009) case report, a patient with a complete C5-C6 injury

(ASIA A) underwent RT using NMES to evoke contractions in his knee extensors. The

subject participated in seated RT for his knee extensors, specifically the vastus lateralis,

twice weekly for twelve weeks. Initially the resistance was the weight of the patient’s leg.

Ankle weights were added and intensity increased when the subject was able to perform 4

sets of 10 repetitions. The results of the case study were measured by the patient’s ability

to lift ankle weights as well as T1 weighted magnetic resonance imaging to measure


changes in size and cross sectional area of the knee extensors and surrounding

musculature. The researchers concluded that the NMES RT resulted in substantial

increases in muscle hypertrophy (Gorgey& Shepherd 2009).

A similar study examined the increases in skeletal muscle size as evaluated by

MRI after seated knee extension RT was performed twice a week for twelve weeks

(Mahoney et al. 2005). Mahoney et al. (2005), focused more on NMES of the rectus

femoris muscle in five long term SCI sufferers. They concluded that even years after

initial injury, increases in skeletal muscle were remarkable with RT. Increases of up to

37% in muscle cross-sectional area (CSA) were found. These authors performed similar

RT studies on able-bodied and sedentary populations with fewer positive results. In one

of those studies on able-bodied and sedentary populations, subjects performed voluntary

knee extension and reported only 5-10% increases in CSA after 12 weeks. The sedentary

individuals in their study performed knee extension voluntarily and with NMES and

showed gains of only 4%hypertrophy and 10% in CSA. Their conclusions suggest that

the atrophy of muscles in subjects with SCI allowed for greater improvements during RT

program (Mahoney et al 2005).

Improvement in locomotor recovery for individuals with chronic motor

incomplete SCI has also been demonstrated with the use of RT. A study completed in

2010 combined a RT program with a BWSTT program for locomotion to determine the

effects on walking speed, endurance, and balance in an elderly person with a chronic

incomplete SCI (Gorgey, AS., Poarch, H., Miller, J., Castillo, T., & Gaiter, DR. 2010).

The hypothesis for the study was that utilizing a combination of two types of treatment

would stimulate adaptations in both the neuromuscular system and the musculoskeletal


system. A drawback of their study was that it involved only one subject who participated

in a program using the treadmill twice a week alternating with twice a week RT program

over a period of 10 weeks. The RT program had a similar design utilized in previous

studies that used a seated knee extension and ankle weights and progressed to 4 sets of 10

repetitions. Outcomes measures for the study included the Berg Balance scale, the

Walking Index for SCI, Functional Independence Measure (FIM), Functional Locomotor

Assessment, and walking speed and duration. Results from the single subject case study

showed that the subject’s body weight and BMI decreased during the training period. The

following increases were also attributed to RT:

• Berg balance score

• FIM level

• Walking speed

• Walking distance (initially increased but decreased when the patient progressed

from using a standard walker to bilateral crutches for ambulation.)

The exercise program also helped the patient to progress to where he was no longer

wheelchair dependent. The author’s concluded that the combination of locomotor training

using BWSTT and RT was effective and efficient at improving walking in a patient over

the age of 60 with chronic SCI. The researchers believed that the combination of the two

interventions was more beneficial because BWSTT alone does not provide the needed

benefits of muscle hypertrophy, diminishing muscle fatigue, and improving bone density

that RT offers (Gorgey et al 2010).

Gregory et al. (2007) examined the effects of RT on locomotor speed and muscle

function in three ambulatory individuals with chronic incomplete SCI. The twelve week


study incorporated RT and plyometric training three times weekly. The RT was

performed using selectorized equipment included

• leg press

• knee extension and flexion

• hip extension and flexion

• ankle plantar flexion

Plyometric training included jump exercises in the supine position. The subjects were

tested before and after the twelve week program using MRI to determine muscle CSA of

the knee extensors and plantarflexor groups. These muscle groups were selected based on

their roles in locomotion. These muscle groups were also tested using a Biodex isokinetic

dynamometer to assess strength, peak torque production, time to peak torque, and

average torque development. Gregory et al. (2007) examined and reported voluntary

activation deficits observed in the tested muscle groups before training. The subjects

were also pre and post tested using the GaitRite™ system to determine maximal and self-

selected gait speed changes. GaitRite™ is also able to measure gait pattern. Results of the

study showed that the training program resulted in significant increases in torque and

muscle strength. Increases in strength were considered a result of increased muscle CSA

and an increased ability of the subject to voluntarily initiate contractions in affected

skeletal muscles. Both maximum and self-selected gait speeds demonstrated an increase

by 30%. Increased step lengths as well as improved symmetry during gait cycle were also

reported. Results of this study also suggest that RT can facilitate neuromuscular

improvements as well as strength improvements in those with chronic incomplete SCI.

However, Gregory et al. (2007) stated that few studies have attempted to examine the


relationship between lower extremity strength and gait in persons after incomplete SCI.

More research in this very important and expanding area is needed to determine what

interventions are most effective at making improvements in locomotion, increasing

independence and to normalize gait in this population.

A study performed by Jayaraman, Thompson, Rymer, and Hornby (2013) more

recently compared maximal-intensity RT to conventional RT in individuals with an

incomplete SCI to determine and compare the effects. Five individuals with chronic

incomplete SCI were tested before and after a four week program for either maximal-

intensity RT or conventional progressive RT. Effects were measured through the 6-

minute walk test, Berg Balance Scale, and peak isometric torque for strength of lower

extremity muscles. The results of this short 4-week study showed that not only are there

strength increases with short durations of training, but that conventional progressive RT

is not always associated with the greatest functional and strength gains. Maximal-

intensity training for a short duration demonstrated more strength gains as indicated by

greater peak isometric torque. The individuals who participated in this study also had

chronic injuries and had been discharged from therapy many years prior to participation

in this study indicating that strength gains are possible long after a SCI occurs.

Furthermore, this study showed a trend for decreased spasticity of lower extremity

muscles following maximal intensity RT as measured by the modified Ashworth scale.

Muscle weakness is reported to cause pain and dysfunction with aging in persons

with disability due to SCI (Jacobs & Nash 2004). Although more is known about the

effects of endurance and cardiovascular training for people with chronic SCI, current

evidence supports the benefits of increased strength, muscle size, and muscle CSA from


RT in this population. Improved torque production and gait speed for locomotor recovery

after incomplete SCI has been shown with the use of RT (Gregory et al 2007). The use of

RT with BWSTT has also been effective in enhancing walking in people with SCI

(Gorgey et al 2010).

Exercise Training Principles

Mcardle, Katch, and Katch (2010) outline general exercise training principles

needed to affect structural and functional adaptations to improve performance. The first

and most important principle greatly applies to the concepts behind RT. This principle,

called the overload principle, says that the load placed on the body must be greater than

what it is accustomed to in order to elicit a training response. The body will adapt and

accommodate to be more efficient at handling that specific load.

The ACSM (2010) provides recommendations for exercise prescription for

muscular fitness for all adults who are untrained or not formally trained. An important

part of any exercise training program should be RT which can produce benefits of

strength, endurance, and power (ACSM 2010). Frequency of RT is suggested to be two

or three days per week per muscle group with at least forty-eight hours of recovery time

between sessions. The overall intensity of each exercise is oftentimes based off

percentages of an individual’s one-repetition maximum (1-RM).

According to the National Strength and Conditioning Association (NSCA),

intensity and volume of exercise are chosen based on the primary training goal (Baechle

& Earl 2008). Better outcomes are achieved when a training program focuses on one

training outcome at a time. Common training goals include hypertrophy, muscle

endurance, strength, and power. The training goal should dictate the number of sets,


repetitions, intensity, and amount of recovery time. The amount of recovery time is

directly related to the intensity of training and the goal of training. The greater the

intensity of RT, the longer the recovery period between sets might be. The NSCA

recommends a RT frequency of two to three times a week for a beginner and increased

frequency for intermediate or advanced trainees. In regards to exercise order, the NSCA

recommends that beginning level individuals alternate between upper and lower

extremity exercises if being performed in the same training session. This method reduces

training time and is especially favorable for untrained individuals to decrease stress and

fatigue on muscle groups.

ACSM’s Guidelines for Exercise Testing and Prescription (2010) also outlines

guidelines for exercise testing and prescription for special populations including those

with SCI. They recommend taking into consideration the individual’s capabilities and

effects of the injury, when applying the exercise prescription guidelines for specific

populations. However, at this time there are no specific considerations for the assessment

of muscular strength. The guidelines do advise that a functional assessment is essential in

order to adapt the exercise equipment and program to the individual’s needs. The ACSM

also places an emphasis on stretching and strengthening being performed together to

prevent contracture and promote joint health.

1RM Testing

A 1-repetition maximum (1RM) is the greatest amount of weight that an

individual is able to lift with proper form for one repetition and then is too fatigued to

successfully complete another repetition (Baechle & Earle 2008). A repetition maximum

is the greatest weight able to be lifted for a given number of repetitions with maximal


effort. The 1RM is used as a tool to predict appropriate submaximal loads and repetitions

for the purpose of focusing on one specific training goal in RT exercise. The 1RM can be

directly assessed or estimated from the results of a multiple-RM test. Estimating training

intensity from a submaximal multiple-RM test is less accurate than assigning weight

based on percentages of the directly tested 1RM (Baechle & Earle 2008). Furthermore,

utilizing multiple high-repetition tests involved in multiple-RM testing session increases

fatigue which can decrease the accuracy of a test. The 1RM testing protocol outlined by

the NSCA is provided in Appendix C. Exercises used for the 1RM test should involve

multiple joints and larger core muscle groups. These exercises are better equipped to lift

high intensity weight and are less prone to injury. For this reason, the participant in this

study performed 1RM testing with only the chest press and leg press.

Periodization Training

Periodization is an approach to RT that includes planned variations in exercise

over a period of time. This type of training was first developed for athletes who were

looking for a way to maximize training in the off season and to afford peak performance

at a desired point in time (Turner 2011). Most periodized training programs are separated

into periods of time, or phases, with each phase being geared towards a different goal

related to muscular fitness. Phases are also referred to as mesocycles and microcycles and

can range in length by months, weeks, or even days depending on the program.

Appropriate changes in sets, repetitions, exercises, recovery time, or frequency can be

adjusted to meet the specific goal of that phase. Common goals for a particular mesocycle

include increases in overall muscular fitness, endurance, strength, hypertrophy, or power.

The manipulation of variables helps to optimize strength gains, prevent overtraining,


prevent joint or muscle damage, and promote psychological interest while challenging the

neuromuscular and musculoskeletal systems to adapt to be efficient at varying capacities

for optimal sport performance (Kraemer & Fleck 2007). Classic periodization RT begins

with high volume, low intensity resistance activities and progresses to low volume, high

intensity activities. Periodization can also begin with generalized strengthening exercises

and progress to more sport specific or competition specific exercises. Studies have

indicated that periodization results in greater strength and power gains than non-

periodized training programs for both men and women of various ages and training

backgrounds (Kell 2011). Rhea and Alderman (2004) conducted a meta-analysis study

comparing periodized and non-periodized training programs. The researchers concluded

that men and women of all ages and training backgrounds would develop greater strength

gains from a periodized training program than from a non-periodized training program

(Rhea & Alderman 2004).

Periodized Training in SCI

There is little research existing using periodization training with diverse

populations, and none found to have been performed with a SCI population. This study

examined whether a whole body periodized RT approach is effective in improving

strength for an individual with chronic incomplete SCI who is ambulatory. By

periodizing the training program, it was hypothesized that optimal muscular fitness (i.e.

strength) gains will be achieved, overtraining will not occur, and participant interest will

be maintained just as in the general population.

In addition, many periodization programs begin with an adaptation phase. An

adaptation phase is a short period of time where the intensity and volume of exercise are


intentionally kept at a low to medium level. Referred to as the anatomical adaptation

phase, the goal of this phase is to prevent injury by getting the muscles and connective

tissue accustomed to movements for more intense exercise later in the periodized

program (Bompa & Carrera 2005). Physiologically, tendons, joints, and ligaments begin

to be strengthened, muscles learn the neuromuscular movement patterns needed for

strength training, and muscular fitness begins to be challenged during the anatomical

adaptation phase (Bompa & Carerra 2005). This phase was considered of great

importance in this study because the participant had little prior experience with RT.

This study involved three mesocycles, each with a specific goal, number of sets,

number of repetitions, intensity, and recovery time. This study began in the classical

manner with a focus on muscular fitness and high volume, low intensity resistance

activities. Muscular fitness is defined as the ability to perform many repetitions at a set

weight for longer periods of time (Baechle& Earle 2008). A lower intensity of resistance

will allow for more repetitions to be completed. Four sets of fifteen repetitions at 50% of

the 1RM were completed with short rest periods of 30 seconds.

The next mesocycle focused on increasing muscular strength. Since this phase

was only four weeks long in this program, it was not expected to produce strength gains

due to hypertrophy. Strength gains during this phase were anticipated as a result of neural

adaptations and increased motor unit recruitment (Schoenfeld 2010). Force production is

under neural control which determines the nerves and motor units that will induce muscle

contraction (Baechle & Earle 2008). Force production is higher if more motor units are

recruited and if they are recruited at a faster rate. Therefore, strength increases in the first

few weeks of training are a result of the increasing neurologic control producing better


muscle recruitment and force for contractions. The use of the Bod PodTM as an outcomes

measurement in determining body composition was used to assist in determining if any

increases in muscle mass were achieved. For the strength phase, three sets of eight to

twelve repetitions were utilized at an intensity of 80% of 1RM. A two to three minute rest

period between exercises was also used.

The third and final phase of this study was three weeks long and included a

paradigm with the goal of increasing power. Training for power helps an individual to be

better prepared to handle explosive movements. Power is defined as a relationship

between force and velocity (Baechle& Earle 2008). As a result, the two components are

related and cannot function independently of each other in terms of power. Within the

literature, there exists considerable controversy related to how to best achieve adaptations

in power. Studies have shown effectiveness for high intensity (>80 or 90% 1RM) power

training as high intensities are known for their benefit in increasing muscle mass and

cross-sectional area (CSA). The key component for producing high maximum strength

and power is CSA (Hartmann, H., Bob, A., Wirth, K., Schmidtbleicher, D. (2009).

However, other studies have found that to increase power output, individuals should train

at the maximum combination of velocity and intensity in order to produce the maximum

mechanical power. But, according to the “Power = Force x Velocity” equation, as

velocity increases, the amount of force that a muscle is able to generate decreases.

Therefore, maximum mechanical power would only be achieved when an individual lifts

moderate to low intensities (30-45% of 1RM) that allow for greater velocity of movement

(Kawamori, N., Haff, G. 2004). Power increases in this present case were attributed to the

contribution of neuromuscular factors and increased rate of force development (RFD).


Since increases in muscle size and CSA are not expected within a study of this short

duration, parameters for the power phase involved low to moderate intensity exercise at a

high velocity of movement. The program variable; exercise for this present study was not

manipulated and the same exercises on selectorized equipment were used for the duration

of each mesocyle.

Methods

Participant

The participant in this study has chronic motor incomplete L1 paraparesis from a

SCI sustained 9 years ago. His injury is classified as ASIA D by the American Spinal

Cord Injury Association. He currently ambulates independently with the assistance of

bilateral canes, bilateral dorsiflexion-assist ankle cuffs, and a Bioness©L300 device on

his right leg designed to electrically assist with ankle dorsiflexion during ambulation. He

was recruited based on his participation in a prior study at Florida Gulf Coast University.

In order to complete the former study, he was deemed medically stable and was

medically cleared for exercise. This study was designed as a continuation and

modification of the previous study and had a primary objective of enhancing muscular

fitness. The prior study involved participation in a BWSTT program twice weekly for

eight weeks, followed by four weeks of no intervention, followed by eight more weeks of

the same BWSTT program twice weekly. The initial study examined elements of

cardiovascular fitness training, effects of training on ambulation, and effects of detraining

after discontinuing exercise. The participant was chosen based on his injury, high level of

physical ability, motivation, and interest in continuing to participate in an associated

study. The participant’s right distal lower extremity was affected most by the SCI. Since


active movement in the ankle is almost absent and lacks innervation more than other

muscle groups, strengthening of the ankle complex by itself was not specifically

addressed by this exercise program.

Study Design

This was a quantitative quasi-experimental case study examining the effects of

adding a periodized RT program along with a flexibility program to an existing BWSTT

protocol to an individual’s exercise routine. The participant completed a whole body

periodized RT and flexibility program of the innervated muscle groups of his upper and

lower extremities. The intervention program included a BWSTT routine that was reduced

from twice weekly to once weekly from the previous study and added a twice weekly RT

program.

The periodized program began with a one week adaptation period which included

the participant’s preliminary strength testing. After the adaptation period the participant

performed three weeks of RT focusing on the goal of improving muscular fitness and

endurance, followed by four weeks of RT to increase strength, and then four weeks of RT

with the goal of making power gains. The weekly BWSTT remained consistent

throughout the twelve week exercise program. The variables for the 12 week exercise

program including exercise volume, intensity, duration, and recovery time were

manipulated as depicted in Table 2:


Table 2. Periodization Mesocycles

Length of

Cycle

Sets Repetitions Recovery

Time

Between

Exercises

Intensity

(% 1-RM)

Muscular

Endurance

3 weeks 3 12-15 30 seconds 50% 1-RM

Strength 4 weeks 3 6-8 2-3 minutes 80% 1-RM

Power 4 weeks 3 3-5 2-3 minutes 45% 1-RM

Within a mesocycle, the daily loads were altered in order to remain within the

parameters of the mesocycle. As the individual became able to complete more repetitions,

weight was increased to maintain the repetitions at the desired number. A method called

the 2-for-2 Rule was implemented as a basis of increasing the individual’s training loads

(Baechle & Earle 2010). This method states that if the individual can perform two or

more repetitions above the desired amount for a given exercise on two separate

consecutive workouts, the individual’s load should be increased. Baechle and Earle

(2008) recommend weight increases of 2-2.5 pounds for upper body and 5-10 pounds for

lower body in less trained individuals and 5-10 pounds for upper body and 10-15 pounds

for lower body in more trained individuals.

The individual was instructed and cued in proper weight lifting techniques. These

techniques are outlined by Baechle and Earle (2012) and include:

• Proper body positioning (see below for details of each exercise). Proper body

positioning includes keeping a relaxed head and neck with spine in proper

alignment. When feet are on the ground they are shoulder width apart with toes

pointed forward, and knees bent at 90 degrees where appropriate. Proper


positioning as a starting point is essential to support the weight being lifted and to

prevent injury.

• Movement pattern: The individual was instructed to move through the full ROM

possible in order to improve strength at all lengths of the muscle.

• Lifting Speed: This refers to the speed of the movement during the exercise. The

individual was instructed to perform slow and controlled motions for the

development of control and to prevent injury. An appropriate verbal cue utilized

in this program was to allow two seconds for the initial push (or pull) during the

concentric phase, and four seconds for the return to original position, or eccentric

phase of the exercise. The exception to this rule occurs during the power phase,

where increased speed of movement is an important component of the mesocycle

and of power.

• Breathing Pattern: The individual was instructed to exhale upon concentric

motion, and to exhale through the sticking point, followed by inhalation during

the eccentric portion of the movement.

Each training session was completed on selectorized equipment. Slight adaptations and

modifications were made to the exercise program as the study progressed to

accommodate the patient’s deficits, promote proper positioning, and to further

individualize the exercise program to the needs of the subject. Modifications were made

based on feedback from the subject, outcomes, and observation. The following exercises

were included in the program in the given order. Changes that were made to the

positioning are noted.


• CybexTM Chest Press- The individual assumed a seated position with feet on the

ground. The machine was adjusted so that the individual’s upper chest was just

above the machine handles. Handles were grasped with overhand grip. Handles

were pushed straight forward until arms were extended.

• CybexTM Leg Press- The individual assumed a seated position on the machine

with a padded back. The individual’s legs were elevated in front of him with

knees bent at ninety degrees, hips bent, and feet against a metal plate. The

individual pushed his hips and knees into extension against the metal plate to

complete the exercise. The individual then slowly returned to the original

position.

This exercise was modified after the second week of training. The individual’s

high adductor muscle tone caused by the SCI pulled his knees together for the

duration of the exercise. A soft pool buoy was placed between the individual’s

knees to place his knees the appropriate distance apart and in the optimal position

to exert force for this exercise. As this method was not yet discovered during the

pre test 1RM assessment of lower body strength, it was not implemented in the

post testing 1RM assessment of lower body strength.

• CybexTM Lat Pull-down- The individual assumed a seated position with feet on

the ground. The individual’s knees were held in place with an adjustable pad. The

subject reached overhead to hold onto a weighted overhead bar. The individual

pulled the bar towards his chest while leaning slightly backward. The individual

then slowly returned to the original position.


• CybexTM Supine Leg Curls-The individual assumed a seated position with legs off

the ground and knees bent. A weighted pad was placed across the back of the

individual’s ankles and the individual bent his knees as much as possible to

complete the exercise. The individual then slowly returned to the original

position.

The individual was initially unable to complete concentric supine leg curls

independently. He was given assistance with the concentric portion of this

exercise but was able to independently perform the eccentric portion throughout

the duration of the study.

• MagnumTM Shoulder Press- The individual assumed a seated position with feet on

the ground. The machine was adjusted so that the machine handles were at

shoulder level on either side of the subject. Handles were grasped with overhand

grip. Handles were pushed upward until arms were extended.

• CybexTM Leg extension- The individual assumed a seated position slightly

reclined with legs off the ground and knees bent. A weighted pad was placed

across the individual’s ankles and the individual extended his knees till they were

straight out to complete the exercise. The individual then slowly returned to the

original position.

• CybexTM Arm (Bicep) Curls- The individual assumed a seated position with feet

on the ground. The individual’s arms rested on a pad with elbows lined up with

the axis of the machine. The individual held the handles and bent at the elbows

while his arms stayed in contact with the pad.


• NautilusTM Hip Abduction- The individual assumed a seated position with back

supported. His legs and feet were elevated off the ground and rested on machine

handles. Weighted pads rested on his outer thigh. The individual pushed the pads

outward as much as possible, and then returned slowly to his original position.

• CybexTM Arm Extension- The individual assumed a seated position with feet on

the ground. The individual’s arms rested on a pad with elbows lined up with the

axis of the machine. The individual held handles and extended the elbows while

arms stayed in contact with the pad. The individual then slowly returned to the

original position.

• CybexTM Back Extension-The individual placed his feet in foot rests while sitting

on a pad. A resisted pad rested against the individual’s back. The individual’s

back was slightly bent forward and he extended his back against the resisted pad

as far as possible. The individual then slowly returned to his original position.

This was another exercise in which the participant’s high adductor muscle tone

posed a problem with proper positioning. At the beginning of the second

mesocycle the pool buoy was also introduced in this exercise as a positioning tool

placed between the individual’s knees to assist in maintaining proper positioning

for the duration of the exercise.

• Supine Abdominal Curls- The individual laid on a mat with hips and knees bent at

90 degree angles. The legs were supported on the seat of a chair. The individual

rested his arms on the mat while flexing his abdominals to lift his upper body

towards the ceiling, and then slowly returned to the original position.


Upper and lower extremity exercises were alternated within each individual training

session to hopefully minimize stress and fatigue in muscle groups. In addition to

performing RT the subject performed the following flexibility exercises:

• Thomas Hip Flexor Stretch (Figure 1): The individual sat at the edge of a mat

table and pulled one knee towards his chest as he lied down backwards. The

stretch should be felt in the hip flexor muscles that are on the anterior portion of

the leg hanging off the table.

Image provided by AthleticAdvisor.com (2009)

Figure 1. Thomas Hip Flexor Stretch

• Ober Stretch (for abductors and iliotibial band)(Figure 2): The individual laid on a

mat table on his side with the bottom leg bend upward while the back leg

remained straight and was allowed to drop downwards toward the table. The

stretch affected the abductors that run down the length of the outer thigh.

This stretch was omitted after the endurance phase as the participant reported no

stretch felt and no benefit from the exercise. The individual demonstrated

significant tightness of the adductors throughout the study, it was determined that

the abductors were not in need of lengthening or stretching.


Image provided by Stretching-Exercises-Guide (2013)

Figure 2. Ober Stretch

• Standing Calf Stretch (Figure 3): The individual stood with one foot in front of

the other leaning against a wall with both hands. The front leg was bent while the

back leg remained straight with the heel remaining on the ground.

This stretch was modified for the final phase of the program. As time went on, the

individual felt less stretch from this position. It was modified so that he stepped

on a slanted board to place the ankle in a more dorsiflexed position for greater

lengthening of the gastroc/soleus complex.

Image provided by Top End Sports (2015)

Figure 3. Standing Calf Stretch

• Sit and Reach Stretch (Figure 4): The individual sat on a mat with legs extended

and leaned towards one side, then the other while reaching towards his toes as

much as possible. The knees were kept straight.


This stretch was modified during the strength phase. A towel was used to wrap

around the foot to allow him to pull himself closer towards the foot and place the

hamstring in a more lengthened position.

Image provided by Edinformatics (1999)

Figure 4. Sit and Reach Stretch

At the beginning of the power phase it was eliminated altogether and a separate

manual hamstring stretch was used in its place (Figure 5). This provided a

progression of the flexibility exercise and was a more comfortable and effective

stretch for the participant.

Image provided by TeachPE.com (2015)

Figure 5. Manual Hamstring Stretch

• Adductor stretch (Butterfly Stretch) (Figure 6): The individual sat on a mat and

pulled his feet towards his body with his arms. The knees were bent, while the

heels touched each other until a stretch was felt in the inner thigh.


Image provided by Physiohub (2010)

Figure 6. Adductor Stretch

• Supine Cross-body Gluteal stretch (Figure 7): The individual laid down on a mat

and pulled one knee towards his opposite shoulder with his arms. This was

repeated on both sides.

Image provided by My Physical Therapy Coach (2014)

Figure 7. Supine Cross-body Gluteal Stretch

• Cross body shoulder stretch (Figure 8): The individual extended one arm across

the front of his body and held it in place with the opposite hand until a stretch was

felt across the back of the arm. This was repeated with both sides.

Image provided by Top End Sports (2015)

Figure 8. Cross Body Shoulder Stretch


• Overhead Triceps Stretch (Figure 9): The individual bent one elbow behind his

head and pulled posteriorly with the opposite hand until a stretch was felt across

the bottom of the arm. This was repeated on both sides.

Image provided by SuperSets (2013)

Figure 9. Overhead Triceps Stretch

This stretch was modified going into the strength phase of the program. The

individual placed one arm overhead and the other behind the back and was given

a towel to hold within each hand as shown in Figure 10. By pulling the towel with

the lower hand the triceps stretch within the upper hand is increased.

Image provided by All About Tennis (2015)

Figure 10. Modified Overhead Triceps Stretch

• Standing Corner Pectoralis Stretch (Figure 11): The individual stood in a doorway

with arms extended out to both sides. He then leaned in towards the open

doorway until a stretch was felt across the chest.


Image provided by Abbott center for Neuromuscular Therapy (2009)

Figure 11. Standing Pectoralis Stretch

Data Collection

Results are quantified by a comparison of preliminary and post testing outcomes

measures including:

• Manual Muscle testing: Manual muscle testing is a basic test for an individual’s

general strength in muscles and muscle groups. It takes into consideration a

muscle groups abilities against the force of gravity and against the force of

manual resistance provided by a clinician. A muscle or muscle group is isolated

and tested for its ability to move through its ROM against gravity, and then for its

ability to hold its position against resistance within the mid-ROM. The standard

grading system of 0-5 for manual muscle testing was used. An outline of the

grading system given by O’Sullivan and Schmitz (2007) is provided in the

Appendix A.

• 1-RM Testing (as described previously)

• Modified Ashworth Scale for muscle spasticity: This is a non-functional measure

of muscle tone based on motions to affect a response to a stretch reflex. The

grading scale measures the severity of muscle tone in response to the stretching

of a muscle. The grading scale for the modified Ashworth scale outlined by

O’Sullivan and Schmitz (2007) is provided Appendix B. It should be noted that


the participant in this study received Baclofen through an intrathecal pump for

the duration of the study. The dosage and delivery of this medication was kept

consistent and was not altered in any way at any point during the 12 week study.

• Joint range of motion of the lower extremities via goniometry: This is an

objective measure of an individual’s flexibility and ability to move a single joint

through a ROM.

• 6-minute walk test: The 6-minute walk test is both a speed and endurance test

that measures the distance a person is able to walk for 6 minutes independently.

• Body composition analysis as measured by Bod Pod©: The Bod Pod is a device

that measures an individual’s body composition through the use of air

displacement. The test requires an individual to sit inside a closed vessel for a

few minutes with minimal movement while the device records data.


Results & Discussion

Manual Muscle Testing

Manual muscle testing (MMT) has been used in clinical practice since 1912 as a

clinical means to assess and grade muscle strength based on gravity and manually applied

resistance (O’Sullivan 2007). Using this type of assessment, muscles are graded on their

ability to move through a full available ROM, move against gravity, and move against

manual resistance on a scale from zero to five. The ability to move a muscle group

against gravity is indicative of the ability to ambulate. Baseline measures of strength of

the lower extremities as measured by MMT are presented in Table 3.

Table 3. Baseline Manual Muscle Assessment

Left Right

Hip Flexors 3+ 2-

Hip Abductors 2+ 2

Knee Flexors 3 1+

Knee Extensors 4+ 4+

Ankle Dorsiflexors 4+ 0

Ankle Plantarflexors 4+ 1

Except for the hip abductors, all of the muscles in the left lower extremity were graded at

3 or more and showed the ability to move through full ROM against gravity. However,

on the right side, only one muscle group was graded above a 3 (knee extensors). The

participant had no active muscle contraction in the right ankle dorsiflexors and only trace

palpable muscle contraction in the right ankle plantarflexors. Overall, strength was

greater in the left lower extremity than the right. This difference would be expected as the

participant’s right lower extremity was more affected by the SCI.

Post-testing MMT assessments of the lower extremities are shown in Table 4.

During post-testing all of the muscle groups in the left lower extremity scored at a 3 or


higher. The right lower extremity was assessed as having only one muscle group that was

graded at 3 or above. The participant continues to have no active muscle contraction in

the right ankle dorsiflexors and only trace palpable muscle contraction in the right ankle

plantarflexors.

Table 4. Post Testing Manual Muscle Assessment

Left Right

Hip Flexors 4 2

Hip Abductors 3+ 2-

Knee Flexors 3 1+

Knee Extensors 5 5


Ankle Plantarflexors 4+ 1

A comprehensive view of the changes in muscle strength, measured by MMT, are

shown in Table 5. MMT showed minimal increases in strength for primarily the left

lower extremity. Greater strength gains in the left extremity are attributed to the patient’s

injury having had a more detrimental effect on muscle innervations in his right. The

nature of the injury is such that the neural connection between the brain and motor units

is disrupted. If the number of motor units to a particular muscle is limited, then strength

gains have been shown to be limited as well. Hip abduction on the left side increased

from a grade of 2+ to a grade of 3+. This increase is clinically significant as this muscle

group went from being unable to lift the limb against gravitational forces to now being

able to produce enough force to counteract gravity.


Table 5.Changes in Muscle Strength

∆ ∆

Left Right

Hip Flexors + +

Hip Abductors + -

Knee Flexors 0 0

Knee Extensors + +

Ankle Dorsiflexors - 0

Ankle Plantarflexors 0 0 + : Increase in spasticity after 12 weeks

- : Decrease in spasticity after 12 weeks

0 : No change in spasticity

MMT grades were summed into a single score for each extremity before and after

the exercise program. Changes in summative scores are displayed in Figure 1. While a

trend exists in strength increases, overall changes were not significant.

Figure 12. Manual Muscle Testing Summative Scores

A study by Yang et al. examined the predictive nature of volitional muscle

strength, as measured by lower extremity MMT, on walking speed following locomotor

training in individuals with chronic incomplete SCI (2011). Their results showed that

greater initial MMT scores correlated with greater increases in gait speed following

locomotor training. However, improvements in walking speed were not correlated with

improvements in lower extremity MMT scores following training. This suggests that

41

12

44

13

0

10

20

30

40

50

Manual Muscle Testing

Pre Post Pre Post

Left Right


improvements in gait speed following locomotor training are related to modified muscle

activation patterns rather than improvements in strength. These findings correlate to the

findings in the current study, where the participant made improvements in gait speed, but

did not show equal improvement in.

1RM Testing

Studies examining strength training in the SCI population are becoming more

prominent but are still sparse compared with other populations. Functional and clinical

outcomes measures are more commonly utilized within studies of the SCI population

rather than 1RM assessments. There exists very limited research on 1RM testing in the

SCI population. There is also limited normative data available to be used for statistical

comparison.

Table 6. Normative Data for 1RM Bench Press

Data provided by the Cooper Institute for Aerobics Research, The Physical

Fitness Specialist Manual. Author: Dallas, TX. 2005

Percentile rankings Men age 30-39

Weight Ratios

90 (well above average) 1.24

80 1.12

70 (above average) 1.04

60 0.98

50 (average) 0.93

40 0.88

30 (below average) 0.83

20 0.73

10 (well below average) 0.71


Table 7. Normative Data for 1RM Leg Strength

Percentile Men age 30-39

Weight ratios

90 2.07

80 1.93

70 1.85

60 1.77

50 1.71

40 1.65

30 1.59

20 1.52

10 1.43 Data provided by the American College of Sports Medicine (ACSM)

As previously stated, the majority of exercise professionals consider the 1RM test

the gold standard for measuring both upper and lower body strength. Based on this

rational, 1RM tests were utilized as the primary measure of upper and lower body

strength within this study. Normative data of the general population for the selectorized

bench press and leg press are provided in Table 6 and Table 7, respectively (Heyward

2006). Normative data that is specific to the actual Cybex chest press machine, used

within this study, does not seem to exist. Normative data from the Cooper Institute for

Aerobics Research (CIAR) was utilized for comparison of the current study’s use of a

selectorized bench press. The normative data used from the CIAR was compiled from

protocols that utilized a Universal Dynamic Variable Resistance Bench Press (ExRx.net).

Relative strength measures for both the upper and lower body at baseline for this

case study are presented in Table 8. Initially, the participant had a 1RM of 135 pounds for

the chest press. When assessed for lower body strength, his 1RM for the leg press was

195 pounds. In order to make a comparison using the normative data, relative strength

was calculated using the following equation:


Table 8. Baseline 1RM Assessment Results Preliminary

Testing

Relative Strength Normative Data Ratio

for age 30-39

Chest Press 135 0.77 ~20th percentile

Leg Press 195 1.11 <10 percentile

Relative Strength= weight pushed in pounds/body weight in pounds

The participant’s calculated relative strength for chest press and bench press were 0.77

and 1.11 respectively. This placed him near the 20th percentile for upper body strength.

His lower body relative strength was determined to be below the lowest ranking for men

of his age. With the subject completing a 12 week periodized RT program, upper body

strength gains were expected. In addition, because some increases in strength were noted

during lower body assessment, indicating motor innervation, there still existed the

potential for strength gains for the lower body after the 12 week periodized RT program.

After completing the 12 week periodized RT program, the participant had a

maximum chest press of 165 pounds and a maximum leg press of 220 pounds as shown

in Table 9. When compared to normative selectorized bench press data, the subject’s

upper body strength improved to 0.93 which is the 50th percentile and equates to a

relative strength index for an average person of his age and size. The relative strength

index for the leg press was 1.25, although clinically improved, the score still indicated

that it was well below average when compared to the ACSM normative weight ratios.

Table 9. Post Testing 1 RM Assessment Results Post

Testing

Relative Strength Normative Data Weight Ratio

for age 30-39

Chest Press 165 0.93 50th percentile

Leg Press 220 1.25 <10 percentile


Results of both the pre and post assessments for upper and lower body strength,

respectively are depicted in Table 10. As can be observed, strength gains were evidenced

for both upper and lower body strength. The upper body strength test (i.e. chest press)

indicated an increase of 30 pounds, or a 22.2% increase from baseline. The lower body

strength assessment (i.e. leg press) showed an increase of 25 pounds, or a 12.8% increase

in lower body strength from the initial assessment.

Table 10. Changes in 1 RM PreTest Post Testing ∆

(Pounds)

Chest Press 135 165 +30

Leg Press 195 220 +25

Changes in strength are shown in Table 11 and compared to the results from two

other RT studies. These studies were selected because the participants were men, and

each study utilized a 12 week RT intervention. Each study also used 1RM testing as a

measure of upper and lower body strength. Additionally, Gentil et al. was selected

because participants were untrained similar to the participant’s training status in the

current study. The Miranda et al. study was selected because the RT intervention utilized

a periodized paradigm.

Table 11. Comparison to Research Present Study

% change

Miranda et al. (2011)

periodized

trained subjects

Gentil et al. (2010)

not periodized

untrained subjects

Chest Press 22.2% 15% (bench press) 10.5% (bench press)

Leg Press 12.8% 10% 17.5%

Gentil et al. (2010) also manipulated the training variable of rest/recovery

between sets in the study population of young untrained men. The group of participants


were divided into two groups with 16 subjects in the long work rest ratio group and 18

subjects in the short work rest ratio group. Both groups performed 12 weeks of whole

body RT with variations between the duration of set rest intervals. They utilized 1RM

testing on the bench press and leg press to determine both strength and changes in

strength. The results shown in Table 11 for both upper and lower body strength were

significant (p < 0.05) for the study population.

Miranda et al (2011) utilized a 12 week periodized training approach and included

the bench press and leg press as strength outcomes measures. Their study, however, had

resistance trained men participating in either a linear or daily undulating periodization

model. The linear periodization model was designed off of a traditional approach similar

to the one used in the current study, where mesocycles lasted four weeks with RT

increasing from lower intensity to higher intensity, as determined by percentage of 1RM,

at the completion of each four week period. However, in the daily undulating model, the

intensity was modified for every individual training session so that three different

intensities were occurring within the same mesocycle. At the conclusion of their study,

the authors indicated that the strength measures for the bench press and the leg press for

both groups showed a significant (no p value provided) change (see Table 11). These

changes can be compared to the increases of 22.5% on the chest press and 12.8% on the

leg press in the present study.

Spasticity Assessment

The Modified Ashworth Scale (MAS) is the most commonly used tool amongst

clinicians for measuring spastic hypertonia (Umphred 2013). Levels of muscle spasticity

of the lower extremities were measured using the MAS performed manually by a licensed

physical therapist (PT). Pre-training levels of muscle spasticity as measured on the MAS


are shown in Table 12. Spasticity was absent in the left and right hip flexors, knee

flexors, and ankle plantarflexors. Hip extensors and hip adductors measured equally on

the right and the left at 1+ and 2 respectively. The right side demonstrated greater

spasticity in the knee extensors and ankle dorsiflexors with the knee extensors measuring

1 on the left and 1+ on the right. The ankle dorsiflexors measuring 1+ on the left and 2 on

the right. The greatest level of muscle spasticity was found in both hip adductors and the

right ankle dorsiflexors at a measurement of 2 on the scale defined as a more marked

increase in muscle tone through most of the ROM, but affected part(s) easily moved.

Table 12. Baseline Spasticity Assessment

Left Right

Hip Flexors 0 0

Hip Extensors 1+ 1+

Hip Adductors 2 2

Knee Flexors 0 0

Knee Extensors 1 1+


Ankle Plantarflexors 0 0

Post-training levels of muscle spasticity are shown in Table 13. Spasticity was

absent in the hip flexors, knee extensors, ankle dorsiflexors, and ankle plantarflexors on

both sides. In the hip extensors, spasticity was greater on the right at a measurement of 2

than on the left at a measurement of 1. In the hip adductors, spasticity was greater on the

left at a measurement of 2 than on the right at a level of 1. Both knee flexors were a 1+ on

the scale.


Table 13. Post Testing Spasticity Assessment

Left Right

Hip Flexors 0 0

Hip Extensors 1 2

Hip Adductors 2 1

Knee Flexors 1+ 1+

Knee Extensors 0 0

Ankle Dorsiflexors 0 0

Ankle Plantarflexors 0 0

As stated earlier, prolonged stretching is an intervention known to assist in

decreasing and managing spasticity in those with SCI. Furthermore, strengthening

exercise does not increase spasticity, but instead shows a trend in decreasing spasticity

(Jayaraman, Thompson, Rymer, and Hornby 2013). The levels of spasticity after

participating in the combined aerobic and RT periodized program were anticipated to

either stay the same or possibly decline (Table 14). As predicted, the general trend for the

muscle groups measured to either remain the same or to decrease in muscle spasticity was

found. All the muscle groups tested except for the right hip extensors and both knee

flexor groups demonstrated either no change or a decrease in muscle spasticity. The

change in the knee extensors and ankle dorsiflexors on both sides is clinically significant

as they went from having a detectable level of muscle spasticity to measuring at no

detectable increase in muscle tone. Inversely, muscle spasticity was absent in the knee

flexors prior to the study, but was present after. The increase in muscle spasticity in both

knee flexors might be a result of improved motor unit activation brought on by RT. This

muscle group initially was not strong enough to complete a full concentric movement

against resistance consistently enough to finish a set. Therefore, it was the muscle group

that required the most exercise modification. This particular modification included

training the muscle group with eccentric movements for the duration of the 12 weeks.


The nature of this modification could have also been stressful enough to contribute to the

small increase in spasticity that was observed. If RT had continued for a longer period of

time, the training principle of adaptation might have become applicable and the muscles

would have had time to adapt to the stimulus thus causing the spasticity to reduce back to

previous levels.

Table 14. Changes in Muscle Spasticity

∆ ∆

Left Right

Hip Flexors 0 0

Hip Extensors - +

Hip Adductors 0 -

Knee Flexors + +

Knee Extensors - -

Ankle Dorsiflexors - -

Ankle Plantarflexors 0 0 + : Increase in spasticity after 12 weeks

- : Decrease in spasticity after 12 weeks

0 : No change in spasticity

MAS for both pre and post tests were summed into a single value and are

presented in Figure 13. An overall trend for a decrease in muscle spasticity is evident in

both the right and left lower extremity. As is evident, the right lower extremity had

greater spasticity initially than the left. This is consistent with the greater damage on the

right side of the body from the participant’s SCI, a lower level of strength in the right

lower extremity as measured by MMT, and the use of an electrical stimulation device on

the right dorsiflexors for assisted ambulation.


Figure 13. Effects of training on Spasticity

Gorgey et al (2011) examined the effects of two weeks of BWSTT on two

participants with incomplete SCI. Muscle spasticity was measured by using a Biodex

Isokinetic Dynamometer to measure maximum voluntary contraction, passive torque, and

index of spasticity at various degrees of knee extension. Although in the Gorgey et al

study, the MAS was not used to measure spasticity, they suggested that just two weeks of

locomotor training can reduce the spasticity of knee extensors in individuals with

incomplete SCI.

A study performed by Adams and Hicks compared the effects of single session

versus multiple session treatments of BWSTT as well as tilt-table standing on spasticity

in individuals with chronic SCI. They concluded that there was no evidence of change in

muscle tone following 4 weeks of either intervention. The study went on to state that they

believed the lack of change could be due to limitations of the MAS or ineffectiveness of

the intervention.

A review of the literature reveals that while the effect of aerobic training on

muscle spasticity in individuals with SCI has been investigated, the effect of RT on

muscle spasticity in this population has not. Muscle spasticity is also a health concern in


individuals who suffer from chronic stroke. A review by Pak and Patten examined the

effects of strengthening in individuals following stroke. Their theory is that weakness

contributes to spasticity. Therefore, providing strengthening interventions would not

increase the level of spasticity. They reviewed 11 clinical studies, several of which used

the MAS as an outcomes measure. They concluded that none of the clinical studies they

reviewed reported increased spasticity or hypertonia after a course of strengthening

interventions.

It is important to note that although the test has been shown to have good

intrarater reliability (0.84) and good interrater reliability (0.83), the test itself does not

provide the ability to detect small changes in tone.

Joint Range of Motion

Range of motion was assessed to determine if the exercise program had an effect

on flexibility. Range of motion was assessed via goniometry prior to the exercise

program. Joint ROM can be limited by muscle spasticity, muscle length, connective

tissue extensibility, muscle mass, and improper joint articulation. In addition, active joint

ROM can be limited due to absent or decreased activation or strength of the muscle and

the inability support the movement of the limb. Baseline assessments of passive and

active range of motion in the lower extremities are shown in Table 15 and Table 16

respectively. A box marked with ‘-‘ indicates that there was no active movement of that

muscle group. Due to the nature of his injury, the participant would be expected to have

less active range of motion in his right side rather than his left.


Table 15. Baseline Passive Range of Table 16. Baseline Active Range of Motion

Motion

Left Right

Hip Flexion 126 121

Hip Abduction 21 22

Hip Adduction 20 10

Knee Flexion 151 141

Knee Extension 0 0

Ankle Dorsiflexion +3 3

Ankle

Plantarflexion

45 48

Table 17. Post Testing Passive ROM Table 18. Post Testing Active ROM

Left Right

Hip Flexion 96 115

Hip Abduction 21 20

Hip Adduction 14 17

Knee Flexion 135 137

Knee Extension 0 -7

Ankle

Dorsiflexion

10 18

Ankle

Plantarflexion

22 25

With the inclusion of flexibility exercises into the current study, increases in joint

range of motion were expected in the lower extremities. In addition, RT of the lower

extremities was expected to have a positive impact on active joint range of motion since

strength is a key factor in this assessment. Post-training measurements are shown for

passive and active ROM in Table 17 and Table 18. Changes in passive and active range

of motion over the 12 week period are shown in Table 19 and Table 20. Passive hip

flexion decreased in both hips, but significant active ROM improvements were seen on

the left side only. Knee flexion also showed decreases in passive ROM on both sides, but

increases in active ROM on both sides. This could be associated with an increase in

muscle spasticity of the knee flexors on both sides from 0 to 1+. Noticeable decreases in

Left Right

Hip Flexion 8 61

Hip Abduction 12 10

Hip Adduction 12 6

Knee Flexion 120 58

Knee Extension 0 0

Ankle Dorsiflexion -14 -

Ankle

Plantarflexion

45 28

Left Right

Hip Flexion 87 40

Hip Abduction 13 11

Hip Adduction 10 4

Knee Flexion 124 75

Knee Extension -5 -2

Ankle Dorsiflexion 2 -

Ankle

Plantarflexion

17 -


active ROM of the ankle dorsiflexors are also noted. The data shows no significant trends

for either passive or active range of motion. No additional correlations exist between

changes in range of motion when compared with changes in MAS levels of spasticity or

strength changes as measured by manual muscle testing.

Table 19. Changes in Passive ROM Table 20. Changes in Active ROM

Left Right

Hip Flexion -30 -6

Hip Abduction 0 -2

Hip Adduction -6 +7

Knee Flexion -16 -4

Knee Extension 0 -7

Ankle Dorsiflexion +7 +15

Ankle

Plantarflexion

-23 -23

Results from the 6 minute walk test

The 6MWT test was performed as a measurement of gait speed and endurance.

Heart rate was recorded prior to the test and at 1 minute intervals of walking. RPE was

reported just before and immediately after the test by the participant. Values collected at

the beginning of the BWSTT only exercise phase completed immediately prior to this

study (labeled initial) are shown in Table 21. Data collected prior to (PRE) and following

the current study (POST) are also listed in Table 21.

Table 21. Six Minute Walk Test Data

Date Resting Measures

RPE

before/

after

HR (bpm) during test:

Minutes 2-6

HR BP SpO2 2 3 4 5 6

Initial 5/6/13 72 124/84 98 10 14 138 152 158 158 162

Pre 9/25/13 78 128/86 98 10 12 146 155 154 155 158

Post 12/23/13 84 128/86 98 10 12 144 148 149 152 152

When vitals are taken throughout the test, the 6MWT can be used clinically as a

test of the cardiovascular system. The systemic response seen during the 6MWT

Left Right

Hip Flexion +79 -21

Hip Abduction +1 +1

Hip Adduction -2 -2

Knee Flexion +4 +17

Knee Extension -2 -2

Ankle Dorsiflexion +16 -

Ankle

Plantarflexion

-28 -28


however, will be less than that of for example a VO2 test on a treadmill or cycle

ergometer that steadily increases in difficulty (Umphred 2013). During the 6MWT, speed

is not regulated and subjects tend to walk at a close to constant speed and reach steady

state heart rate within a few minutes of the test. The 6MWT does not provide enough

information to provide a holistic indication of the level of cardiopulmonary fitness, but

does present an idea of the body’s response to exercise. In clinical situations, the 6MWT

is considered a better index of quality of life (QoL) and of the patient’s ability to perform

daily activities than is a measure of peak oxygen uptake (VO2peak) (ATS statement 2001).

Resting HR measures taken prior to testing are shown in Table 21. As can be

observed, resting HR is reported to have increased from 72 bpm to 78 bpm during the

previous study and from 78 to 84 during the current study. Resting HR is expected to

decrease with aerobic endurance training such as that performed on the body weight

supported treadmill (Baechle & Earl 2008). It is believed that these numbers increased

due to factors involving the participant’s amount of activity prior to testing, time of day

of testing, measurement error, caffeine intake, or patient familiarity and expectations for

the test. An error of the current study is that the duration of time the participant spent

‘resting’ after ambulating into the building prior to collecting resting measures was not

closely monitored or objectively measured.

Table 22. Vitals

Resting HR

(bpm)

HR range during test

(bpm)

Intensity range

Initial 72 138-162 60-81%

Pre 78 146-158 65-77%

Post 84 144-152 61-69%


In order to measure cardiovascular intensity of the participant during the 6-minute

walk test, the HR ranges measured during the test were used to calculate the percent of

heart rate reserve. Heart rate reserve is directly correlated to functional capacity and can

be calculated by subtracting the resting heart rate from the maximum heart rate. The

Karvonen formula is used to determine the percentage of heart rate reserve or functional

capacity. The Karvonen formula is as follows

220 − �� = max �� − �� = ℎ�� + �� = ��

The percent ranges of aerobic capacity during the test as calculated by the Karvonen

method are listed in Table 22. The data shows that initially, the participant reached 81%

of heart rate reserve which decreased to only 77% after aerobic BWSTT. After the 12

week RT program, the participant reached a maximum of only 69% of his calculated

functional capacity. This indicates a functional improvement in the cardiovascular

system, as it became more efficient and required fewer heart beats to send oxygen rich

blood to working muscles in order to complete a greater amount of work (increased

distance). Chetta et al (2006) outlines reference values based off a study of 100 healthy

Caucasians ages 20-50 performing the 6MWT. They recorded HR every ten seconds for

the duration of the test to calculate and determine the average percentage of maximal

predicted HR. However, maximal predicted heart rate for their study was calculated

based on a different method and used the following formula:

210 − 0.66 � �� = max ��

Results suggested that the participants only reached 67±10% of their predicted HRmax.

This has significant implications for the current study. When compared to healthy


individuals without SCI, the participant went from a pre-test measure at 81% HRmax to

being within the Chetta et al. study range at 69%.

The distance for the 6MWT was measured in laps of 75’ increments. This

distance was selected by convenience based on the space available during testing

procedures. Ambulation distance, speed, and changes for each 6MWT are listed in Table

23. The initial ambulation distance was 856 feet. In comparison, the average 6-minute

walk distance for healthy individuals is 571±90 m (1,873 ± 295 feet) (Casanova, C. et al.

2011). According to Umphred (2013), the reference equation used to calculate the

predicted total distance for healthy men is as follows.

"��#� = $2.11� ��ℎ��#�% − �5.78 � )�� − $2.29 � +��ℎ��,��% + 667

This equation uses height, weight, and age to predict maximum ambulation distance and

is therefore a more individualized prediction measure. At a height of 182.9 cm, a weight

of 79.6 kg, and age 38, the participant’s predicted total distance was 650m or 2,132 feet.

Although this equation does not take into account any possible physical limitations or

disabilities such as SCI which affects individuals across a wide spectrum of severity,

leaving many unable to ambulate, currently there does not appear in the literature any

such equation or standardization for SCI. As hypothesized, due to the participant’s SCI

and reliance on bilateral canes the distance traveled was significantly lower than what

would be expected of a healthy individual performing the same type of 6MWT.

Table 23. 6MWT changes

Date Total

Distance

walked (feet)

∆ (feet)

Speed

(feet/s) ∆ (feet/s)

Initial 5/6/13 856 2.38

Pre 9/25/13 1103 +247 3.06 +0.68

Post 12/23/13 1210 +354 3.36 +0.98


With aerobic BWSTT, the participant’s gait speed and endurance were expected

to improve. At the start of the current study, ambulation distance was found to be 1103

ft., demonstrating a change of 247 ft., a 28% increase resulting from the phase of

BWSTT. The participant showed functional gains in ambulation distance and speed after

the addition of the periodized RT program in achieving a distance of 1210 ft at the post

testing. This distance represented a change of 107 feet, or a 9.7% increase after

completing 12 weeks of combined RT and BWSTT. Overall, the subject was able to

demonstrate an increase in distance ambulated by 354 ft (42% increase).

A study by Harkema, Schmidt-Read, Lorenz, Edgerton, and Behrman (2012)

showed that individuals with long term chronic SCIs showed fewer improvements in the

6MWT following intensive locomotor training than those whose injuries occurred more

recently. However, they discovered that significant improvements could be made

regardless of how far removed the individuals were from their SCI. They noted that

individuals whose SCI was greater than three years prior to intervention showed gains of

24±43m (78.7 ± 141.0 ft.) whereas individuals whose SCI had occurred only 1-3 years

before intervention demonstrated improvement of 44±71m (144.3 ±232.9 ft). But,

Harkema et al stated that both resulted in significant gains (p<.001). The results of the

current case study are also similar to the study by Jayaraman et al. (2013) that was

previously mentioned and showed statistically significant changes (p = 0.03) of 12.19 ±

8.29m (or 42 ± 27.2 feet) on the 6MWT with a four week RT program in participants

with chronic SCI.

One major issue that was found in the literature is that there appears to be very

little research utilizing a 12 week period in people with SCI on the 6MWT. A study that


combined treadmill and strength training for chronic stroke rehabilitation over a 12 week

period considered a change in 6MWT distance of 35m (114.8 ft) to be statistically

significant, which correlates with the increase of 107 ft in this study (Al-Jarrah, M.,

Shaheen, S., Harries, N., Kissani, N., Molteni, F. 2014).

Musselman (2009) suggests that the minimal clinically important difference for

the 6MWT distance in the SCI population has not been determined and is not known. He

also stated that the clinically relevant difference for the 10-meter walk test is a change in

speed of 0.05 m/s (0.16 ft/s) for community dwelling individuals with SCI. For the

6MWT, a speed increase of 0.30 ft/s was evidenced after RT which would be similar to

what was observed with the present case study. Musselman noted that the results

represented a clinically important improvement. In the current case study, the participant

achieved a speed of 3.36 ft/s which was an improvement from his initial speed of 2.38

ft/s. The increase of 0.98 ft/s over the course of both studies suggests that it was clinically

relevant. A meta-analysis by Bohannan and Andrews determined that normal walking

speed for healthy males age 30-39 is 1.43 m/s (4.69 ft/s) (2011). The studies used to

calculate this speed used distances of 30 meters or less to determine “normal” walking

speed. Therefore these numbers do not take into account any decreases in speed that

would be seen using a longer distance, a test involving turning, or longer duration test

such as the 6MWT.

Body Composition

Body composition data was obtained from the Bod PodTM utilizing the Siri

density-model are found in Table 24. Body composition was measured, to assess the

potential of any increase or decrease in fat free mass or fat mass. As stated previously, it


was expected that there would not be a significant change in percent fat free mass. In

part, because it was determined during baseline testing that the participant had 17.3%

body fat which categorizes him as ‘good’ according to ACSM standards for body

composition of men aged 30-39 (ACSM 2010) and any change would require more

energy expenditure than what was predicted for the intervention.

Table 24. Body Composition Assessment Results

Oct 2 Dec 23

% Fat 17.3% 18.2%

% Fat Free Mass 82.7% 81.8%

Fat Mass 30.299 lb 32.169 lb

Fat Free Mass 145.205 lb 144.515 lb

Body Mass 175.505 lb 176.685 lb

Energy Expenditure (RMR) 1755 kcal/day 1750 kcal/day

During post testing, the participant was found to have a percent fat mass of 18.2

and a percent of fat free body mass 82.7% to 81.8%. Both indicated a very small change

from the preliminary body composition data. These changes did not change the overall

body composition category found initially.

Mesocycles

According to Baechle and Earle (2008), work is defined as the product of force

and distance. In order to quantify the amount of mechanical work performed during daily

training session within each mesocycle, load-volume units were calculated. Load-volume

is directly related to work and is calculated by multiplying the weight lifted by the

number or repetitions accomplished on the given day. The values of each exercise are

summed into a single value. Daily load-volumes for each day of each phase are shown in

Figures 14, 15, and 16. Each phase shows a positive correlation between time elapsed and

the load-volume units the participant could lift in a single day. The participant’s


continued ability to increase daily work output demonstrates improvements in the ability

to meet metabolic demands. It also shows that adaptations were being made toward the

goals of endurance, strength, and power, respectively, through the parameters of each

mesocycle.

Figure 14. Load-Volume Totals for the Endurance Phase in Pounds

Figure 15. Load-Volume Totals for the Strength Phase in Pounds

The load-volume units for the strength phase appear less consistent than the

graphs for the other two mesocycles. Because of an equipment malfunction the

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participant was unable to complete an exercise, which resulted in a lower training for that

day. If the participant had been able to complete this exercise at the same workload that

he did in previous sessions the positive plots in the graph would most likely have

continued.

Figure 16. Load-Volume Totals for the Endurance Phase

Discussion Summary

The participant was present for all scheduled RT days except for one which he

missed due to personal reasons unrelated to the exercise program or his physical health.

His motivation and compliance were contributing factors to the outcomes of this study.

He had no reports of muscle soreness or abnormal effects of the periodized RT and

flexibility program. The greatest improvements with the implementation of the presented

program were seen in 1 RM testing and 6MWT.

Strength gains occurred as observed by results of the 1RM testing measures for

both the upper and lower body. Increases were seen in both the chest press and the leg

press. Results of the 1RM assessments have evidenced that the training principles of

overload, progression, and specificity are applicable and effective to the population of

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Power Phase Load-Volume


people who have suffered an SCI. Furthermore, these training principles apply to not only

unaffected muscle groups (in this case the upper body), but to those partially affected as

well (in this case the lower body).

The percent increases in strength evidenced by increased 1RM assessments

however were not reflected in MMT grades. Assessments using 1RM tests examine upper

and lower extremities as a whole, while MMT examines a single group of muscles at a

time. MMT also offers the ability to compare between left and right extremities. While

there are benefits to both assessments of strength, perhaps this study reflects the

limitations of the MMT system and its inability to measure the functional abilities of the

body and strength as a whole. Assessments of 1RM reflect both functional movements

and muscle activation patterns. The importance of using appropriate assessments to

determine functional strength and movement should not be minimized.

The load-volume graphs indicate that strength gains were being made not only

within each mesocycle, but almost on a daily basis. Each mesocycle proved to be

physiologically beneficial. These graphs reveal that not only are the three presented

paradignms with variables of sets, reps, recovery time, volume, and intensity effective as

a whole, but they are effective individually with this population as well. It is important to

note that the participant was successful at achieving the goal of each paradigm through

various recovery times due to the fact that those with SCI are often assumed to have

cardiovascular complications. Decreased circulation and inability to sweat can affect rest

and recover, however as shown by this study, principles of rest and recovery in

periodization were still effective for this participant with SCI. Furthermore, the use of

eccentric only exercises on machines for which the participant could not complete


concentric movements also proved to be successful at improving strength and load-

volume. The use of eccentric strengthening in the population of people with SCI with

weaker, less functional, and more acute injuries for the improvement of strength,

improvement of function, and prevention of secondary complications needs to be

explored further.

Greater strength increases were observed in the participants upper extremities

which were unaffected by the SCI. Anecdotally upper body strength was believed to have

actually increased since the onset of the SCI secondary to use of canes and compensation

for weakness in the lower extremities. As stated earlier, SCIs affect strength and

coordination by damaging motor unit connections. Fewer numbers of functioning motor

units might have prevented the increases in strength one might normally observe in the

lower extremities of a healthy individual that is participating in a periodized RT program.

However, strength increases were still evidenced in the lower extremities despite the

impaired neuromuscular connection.

High levels of muscle spasticity affecting the hip adductors quickly became

obvious as one of the participant’s primary limiting factors in his gait, exercise program,

and daily life. For this reason strengthening of the adductors was not implemented into

the program. Stretching of the hip abductors was also eliminated. To help counteract the

effects of muscle spasticity, the RT and flexibility program focused on strengthening the

hip abductors and stretching the hip adductors.

The participant’s fat free body mass decrease from 145.205lbs to 144.515lbs

suggests that skeletal muscle hypertrophy did not occur. A possible explanation to these

atypical findings might suggest that the length and/or dose of the mesocycles along with


the overall duration of the study might not have been sufficient to effect such

morphological changes. In addition, the participant had transitioned from an initial study

that required him to perform aerobic exercise twice a week to the RT program which only

required him to perform aerobic exercise once a week along with the RT. The overall

decrease in aerobic exercise training volume might have also resulted in the small

increase in body fat.

While no significant trends occurred within joint ROM and muscle spasticity

within this study, more research is needed to determine the effects of periodized RT and

flexibility training in individuals with chronic incomplete SCI. Training for specific

aspects of muscle fitness such as endurance, strength, and power have clinical relevance

in the rehabilitation world and coincide with the known benefits of periodization in the

athletic population. In addition, activities of daily living require greater affluence in one

or more of these areas to maintain independence. For example, walking is a muscle

endurance activity and an individual who needs improvement with ambulation would

benefit greatly from training in a fashion that applies the goals of muscular endurance. In

the same fashion, aspects of daily life that include standing and lifting require elements of

strength and power. Individuals who lack these abilities should receive appropriate

exercise training with the appropriate variables adjusted accordingly to achieve the

desired goals of strength and power (muscular fitness).

Inconsistencies could be related to the participant’s diet, amount of sleep, or

amount of physical activity performed prior to training on a given day. This study

recognizes the importance of a participant’s nutrition to his exercise goals and outcomes.

More research is needed that can take advantage of this growing population to determine


the potential benefits of this type of training that has largely been used in only training

athletes.

Conclusion

Muscular fitness gains through the use of a periodized RT program were evident

for this individual that exhibited chronic incomplete SCI. Both upper and lower body

strength gains occurred as evidenced by standardized 1RM assessments. Functional

improvements were also found in ambulation distance, endurance, and walking speed as

evidenced by the results of the 6MWT. The case study individual experienced three

different mesocycles or phases of periodized RT. These cycles varied training loads,

repetitions, lifting speeds, and rest periods to focus on the specific goals of muscular

endurance, strength, and power. Training in a periodized fashion appears to be a viable

option for this population and suggests that needed study in this area is warranted.


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Appendix A

Manual Muscle Testing Grades

Grades Criteria

5 Normal Full available ROM, against gravity,

strong manual resistance

4+ Good plus Full available ROM, against gravity,

nearly strong manual resistance

4 Good Full available ROM, against gravity,

moderate manual resistance

4- Good minus Full available ROM, against gravity

nearly moderate manual resistance

3+ Fair plus Full available ROM, against gravity,

slight manual resistance

3 Fair Full available ROM, against gravity, no

resistance

3- Fair minus At least 50% of ROM, against gravity, no

resistance

2+ Poor plus Full available ROM, gravity minimized,

slight manual resistance

2 Poor Full available ROM, gravity minimized,

no resistance

2- Poor minus At least 50% ROM, gravity minimized, no

resistance

1+ Trace plus Minimal observable motion (less than

50% ROM), gravity minimized, no

resistance

1 Trace No observable motion, palpable muscle

contraction, no resistance

0 zero No observable or palpable muscle

contraction

Data provided by O’Sullivan & Schmitz (2007). Physical Rehabilitation 5th edition.

Philadelphia, PA: F.A. Davis Company 2007


Appendix B

Modified Ashworth Spasticity Scale

Grade Description

0 No increase in muscle tone

1 Slight increase in muscle tone, manifested by a catch and release or by

minimal resistance at the end of the ROM when the affected part(s) is

moved in flexion or extension

1+ Slight increase in muscle tone, manifested by a catch, followed by

minimal resistance throughout the remainder (less than half) of the

ROM

2 More marked increase in muscle tone through most of the ROM, but

affected part(s) easily moved

3 Considerable increase in muscle tone, passive movement difficult

4 Affected part(s) rigid in flexion or extension

Data provided by O’Sullivan & Schmitz (2007). Physical Rehabilitation 5th edition.

Philadelphia, PA: F.A. Davis Company 2007


Appendix C

1-RM Testing Protocol

1. Instruct the athlete to warm up with a light resistance that easily allows 5 to 10

repetitions

2. Provide a 1-minute rest period

3. Estimate a warm-up load that will allow the athlete to complete three to five

repetitions by adding:

• 10-20 pounds or 5% to 10% for upper body exercise or

• 30-40 pounds or 10% to 20% for lower body exercise.

4. Provide a 2-minute rest period

5. Estimate a conservative, near-maximal load that will allow the athlete to complete

two to three repetitions by adding:



6. Provide a 2-to 4-minute rest period

7. Make a load increase:



8. Instruct the athlete to attempt a 1-RM

9. If the athlete was successful, provide a 2-to 4-minute rest period and go back to

step 7.

If the athlete failed, provide a 2- to 4-minute rest period, then decrease the load by

subtracting:



AND then go back to step 8

Continue increasing or decreasing the load until the athlete can complete one repetition

with proper exercise technique. Ideally, the athlete’s 1-RM will be measured within three

to five testing sets.

Data provided by Baechle & Earle (3rd edition). (2008). Essentials of Strength Training and Conditioning: National

Strength and Conditioning Association. Champaign, IL: Human Kinetics

the effect of a periodized resistance training program on

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