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Resistance Training Recommendations for Individuals With Neuromuscular Disabilities

J. P. Barfield
Endicott College
D. C. Cobler
Emory & Henry College
Daniel Pratt
Tennessee Tech University
Laurie Malone
Lakeshore Foundation

In 2008, the Physical Activity Guidelines for Americans (U.S. Department of Health and Human Services, 2008) recommended that resistance training be included in a general exercise prescription to improve the health of adults with or without disabilities. Specific to adults with disabilities, these guidelines recommended two or more days per week of moderate- to high- intensity resistance training with accommodations to match one’s functional capabilities. This general recommendation was clarified by the American College of Sports Medicine (ACSM) position stand to specify the intensity and type of resistance training needed to improve health and reduce disease risk (Garber et al., 2011). Important for persons with disabilities, especially those with neuromuscular involvement, the resistance training prescription recommended in the Physical Activity Guidelines and the ACSM position stand has been shown to result in meaningful health outcomes including improved blood pressure, cardiovascular function, completion of daily activities, body composition, glucose uptake, and, perhaps most important to the target audience, motor function (Garber et al., 2011; National Center on Physical Activity and Disability, 2012; Stone, Stone, & Sands, 2007; U.S. Department of Health and Human Services, 2008). The following section of this article describes the components of the general resistance training prescription appropriate for persons with disabilities outlined in the Physical Activity Guidelines for Americans and ACSM position stand.

General Resistance Training Prescriptionand Associated Benefits

Resistance training includes any type of resistance to muscular contraction and includes activity incorporating body-resistance exercise, circuit training, free weights, plyometrics, resistance bands, or weight machines (Stone et al., 2007). A resistance training prescription is typically called a training program and is designed to achieve specific outcomes in muscular strength, power, endurance, or some combination of the three called muscular fitness. In general, a resistance training prescription or program includes manipulation of key training variables including exercise choice, exercise frequency, exercise intensity, exercise order, number of repetitions, number of sets, and rest periods between sets (Kraemer & Fleck, 2007). These prescription or program components are manipulated to target specific muscular fitness adaptations and are described in detail in Table 1. The general resistance training prescription intended to maximize health and reduce disease risk in healthy adults, including those with disabilities, is reported in Table 2. Although this resistance program is effective for persons with disabilities, there are unique program modifications that are needed for persons with certain neuromuscular limitations.

Table 1
Components of a Resistance Training Program

Component Description
Exercise choice Exercise choices indicate the decision to select free weights over machine weights or multiple-joint exercises over single-joint exercises. These decisions are made to provide the best exercise option for an individual’s personal goals within the confines of functional limitations.
Exercise frequency Frequency reflects the number of days per week that resistance training is recommended.
Exercise intensity Exercise intensity is perhaps the most poorly prescribed component of a resistance training program. Intensity can be prescribed as a percentage of the maximum lift (% of 1-RM) or can be prescribed as the number of repetitions to failure (repetition maximum or RM).
Exercise order Exercise order emphasizes the sequence of training and dictates which exercises should be completed first: large muscle groups prior to small muscle groups, multi-joint exercises prior to single-joint, or priority exercises before secondary exercises. Exercise order can also be used to rest muscle groups by alternating exercises from upper to lower body or alternating exercises after each set.
Number of repetitions Exercise repetitions (reps) are influenced by exercise intensity. The lower the intensity, the greater number of reps that can be completed. In general, 1 to 6 repetitions are prescribed to improve muscular power and strength, whereas greater than 15 are needed to improve muscular endurance.
Number of sets The number of sets will dictate strength and functional benefits. Although multiple sets of exercise are advantageous for trained persons wanting to improve muscular fitness, there are times when single set recommendations are used to target specific functional goals for persons with a variety of functional abilities.
Rest periods between sets Rest periods reflect the amount of time needed between sets for one’s body to restore sufficient energy levels. One minute or less is needed between sets for endurance training, whereas 3 to 5 minutes between sets are needed for recovery during strength and power training.
Note. These descriptions are based on the work of Baechle, Earle, & Wathen, 2008, and Kraemer & Fleck, 2007.

It is important to recognize that the general prescription reported in Table 2 is appropriate for varying types of neuromuscular disabilities including multiple sclerosis, post-polio syndrome, and Parkinson’s disease. Unfortunately, voluntary motor limitations in other neuromuscular conditions dictate that modifications be made for specific populations. For example, ataxia, muscle weakness, paralysis, and spasticity require changes to exercise choice, exercise intensity, and exercise order to meet the motor capabilities of persons with cerebral palsy, stroke, and spinal cord injury. Progressive muscle loss associated with muscular dystrophy also dictates that exercise intensity be adjusted to reduce risk of functional declines in this population. Despite limited research to establish recommendations for persons with traumatic brain injury, there is empirical support for resistance training modifications needed to improve motor function in persons with cerebral palsy, muscular dystrophy, spinal cord injury, and stroke. Therefore, the following section addresses appropriate program modifications of the general resistance prescription and associated disability-specific benefits for these populations. The audience is also reminded that resistance training is only one component of an overall exercise prescription that should include aerobic and flexibility training as well.

Table 2
General Resistance Training Prescription for Persons With Disabilities

Prescription Component Reccomendation
Exercise choice Choice of free weights (e.g., dumbbells) or machine weights
Exercise frequency 2 to 3 days per week
Exercise intensity 8 to 12 RM or 60 to 80% of 1-RM
Exercise order Larger muscle group exercises should be completed prior to small muscle group exercises. Multi-joint exercises should be completed prior to single-joint exercises.
Number of repetitions 8 to 12
Number of sets 2 to 4 sets although 1 set is sufficient for novice exercisers
Rest periods between sets 2 to 3 minutes
Note. This prescription is the general resistance training recommendation to improve health and reduce disease risk reported in the Physical Activity Guidelines for Americans and ACSM position stand.

Resistance Training for Persons With Neuromuscular Disabilities

Individuals With Cerebral Palsy (CP)
Resistance training program. Few definitive resistance training prescriptions or programs have been proposed for persons with CP for two reasons. One, CP includes a group of disorders with varying manifestations and levels of functional ability, making one general recommendation difficult (Damiano, Alter, & Chambers, 2009; Laskin, 2009). Additionally, the majority of research studies on research training outcomes have been conducted on children and adolescents with CP rather than adults, making a general adult recommendation speculative (Rimmer, 2012a). Regardless, a general resistance training prescription is appropriate for persons with CP with two distinct modifications. One, exercise choice needs to be determined based on function. Despite the desire to use free weights, individuals with CP may have difficulty with multi-joint open chain exercises. Free weight exercises typically require dynamic or static balance during execution and persons with CP, depending on level and intensity of involvement, may not have the balance required for such movements. Therefore, single-joint open chain exercises are a prudent starting point for persons with CP (Verschuren et al., 2011). Additionally, exercise intensity needs to be guided by functional capability rather than the general 8–12 RM recommendation. Persons with CP may demonstrate reduced exercise efficiency and higher submaximal work rates than the general population; therefore, exercise intensity should be prescribed “as tolerated” or to fatigue (Damiano, Arnold, Steele, & Delp, 2010; Laskin, 2009). Whereas the general ACSM recommendation calls for a minimum intensity of 8–12 RM or 60 to 80% of 1-RM, persons with CP may have to progress to this intensity from a much lower starting point. Spasticity during exercise may also influence the prescription in this population. The summary of these prescription modifications are reported in Table 3.

Resistance training benefits. In addition to the general benefits of resistance training (e.g., reduced risk of chronic disease and improved bone/joint health), disability-specific benefits include improved functional ability, improved quality of life, and potentially decreased spasticity in adults with CP (Allen, Dodd, Taylor, McBurney, & Larkin, 2004; McBurney, Taylor, Dodd, & Graham, 2003). Collectively, these outcomes are important for independence and completion of activities of daily living. Although research on strength training outcomes is still emerging, positive benefits to resistance prescription is important because this mode of exercise was previously contraindicated for persons with CP (Damiano et al., 2010).

Table 3
Unique Program Considerations for Neuromuscular Populations

Population Unique Prescription Component Rationale for Distinction
Cerebral Palsy Excercise Choice Weight machines, rather than free weights, may be necessary for individuals whose spasticity, athetosis, or ataxia interfere with dynamic or static balance.
  Excercise Intensity Decreased work efficiency and greater submaximal work expenditure require some individuals to start an intensity that can completed in 8 to 12 repetitions rather than the general intensity recommendation (60% of 1-RM).
Muscular Dystrophy Excercise Choice Eccentric exercise, or exercises that emphasize the lengthening of the muscle, should be avoided in persons with dystrophinopathies (e.g., Duchenne muscular dystrophy).
  Excercise Intensity Low-intensity exercise (< 40% 1-RM) should be used by persons with dystrophinopathies.
Spinal Cord Injury Excercise Order Overuse injuries are a major training consideration. Integrating resistance training into traditional aerobic training (i.e., circuit training) reduces the continuous movement stress of wheelchair pushing on the shoulder joint and enhances muscular endurance needed for everyday functioning.
Stroke Excercise Choice Resistance bands and weight machines may be prudent starting points for persons post-stroke until sufficient balance and/or strength is gained to support free weight exercise.
  Excercise Intensity Resistance band laxity and weakness caused by stroke can limit exercise intensity (< 40% 1-RM). The general exercise intensity recommended by ACSM may not be achievable for all persons post-stroke.

Individuals With Muscular Dystrophy
Resistance training program. The primary modification to the general resistance training prescription for persons with muscular dystrophy is specific to exercise intensity. Low intensity exercise, or resistance loads < 40% of 1-RM, is recommended for persons with dystrophinopathies (i.e., Duchenne or Becker muscular dystrophy). Low-intensity resistance exercise may maximize slow-twitch fiber characteristics that are important to muscular endurance and are less susceptible to condition-related muscle deterioration (Ansved, 2003). For individuals with dystrophies that progress more slowly (e.g., facioscapulohumeral), higher intensities can be incorporated into resistance prescriptions (Tarnopolsky, 2009). Exercise choice must also be considered for this population. Because of the ramifications of exercise-induced damage in persons with dystrophinopathies, both high-intensity and eccentric exercise should be avoided in this population because of the potential to damage muscle tissue excessively (Ansved, 2003; de Groot, Geurts, Jansen, & van Alfen, 2010).

Resistance training benefits. Although the potential to maximize muscle function and delay condition-related regression seems possible, few empirical studies on resistance training effectiveness have been conducted in persons with muscular dystrophy. Initial empirical findings indicate that the benefits to muscular fitness and improved function may be meaningful in adults with slow-progressing dystrophies (Tarnopolsky, 2009). However, the benefits of including resistance training as a method of slowing muscle loss due to dystrophinopathies have not yet been established (deGroot et al., 2010; Voet et al., 2010). Therefore, resistance training in adults seems prudent, but additional research on various types of dystrophies is needed.

Individuals With Spinal Cord Injury (SCI)
Resistance training program. The primary modification needed for persons with SCI centers around exercise order (Table 3). Rather than completing all sets before moving to a different exercise, this population should complete circuit training. Circuit training is a series of resistance exercises performed at 40 to 60% of the 1-RM with less than 15 to 30 seconds rest between exercises (Fleck & Kraemer, 2007). This exercise order has been used extensively in programs for persons with SCI and typically has included three circuits of approximately six resistance exercises separated by two minutes of aerobic exercise (Jacobs, Nash, & Rusinowski, 2001). Aerobic training usually implies arm ergometry, handcycling, or wheelchair pushing within circuit training for persons with SCI. For individuals wanting to pursue a traditional resistance training program, Figoni (2009) has recommended a general prescription consistent with the Physical Activity Guidelines for Americans (U.S. Department of Health and Human Services, 2008) and ACSM position stand.

Resistance training benefits. A primary benefit of resistance training for persons with paraplegia is improved aerobic fitness. As noted by Jacobs (2009), 12 weeks of resistance training improved peak aerobic fitness by 15% among persons with paraplegia compared to 12% by endurance training. When combined with circuit training, resistance exercise resulted in aerobic fitness improvements of 30% over the same time period and similar injury level (Jacobs et al., 2001). Better aerobic gains from resistance training compared to endurance training are distinct from the general population and reveal the importance of resistance training to independent living. In essence, persons with SCI do not have the metabolic capacity to reach high aerobic training loads and the improved muscular endurance in the arms and shoulders yields higher aerobic power output. Additionally, resistance exercise is an excellent training alternative to continuous aerobic training modes because overuse injuries are problematic in this population and variation is needed to reduce risk of musculoskeletal injuries (Steadward, 1998).

Resistance training also contributes to important secondary disease prevention. Resistance training, when included in a circuit program, has yielded improvement in lipid profiles, providing important protection from cardiovascular risk factors common to persons with SCI (Jacobs & Nash, 2004). In addition to the benefits in persons with paraplegia, resistance training also yields similar improvement in muscular strength and endurance among persons with tetraplegia (Turbanski & Schmidtbleicher, 2010). Improvement in muscular fitness helps to slow typical age-related declines in function, thereby enhancing independence and reducing risk of inactivity. Although most often used in rehabilitation settings, resistance training clearly has many avenues in which to improve quality of life for persons with SCI.  

Individuals With Stroke
Resistance training program. A primary modification to the general resistance program for persons post-stroke includes exercise choice. An important outcome of resistance training post-stroke is the recovery of functional ability such as walking (Langhammer & Lindmark, 2012; Palmer-McLean & Harbst, 2009). Therefore, exercise choice is dictated by target muscle groups that will enhance daily activities. Whereas the general resistance prescription targets whole-body exercise, persons post-stroke should train affected areas such as a particular side of the body (e.g., left hemiplegia) or muscle group (e.g., knee extensors). Because of weakness or potential paralysis associated with stroke, exercise choice should also be recommended based on dynamic and static balance and strength. For persons with major involvement, exercise bands or weight machines (Harris & Eng, 2010; Patel & Rao, 2011) may be more appropriate than free weight exercises. Affected balance and weakness also dictate exercise intensity. Whereas high-intensity exercise is certainly appropriate for this population (85 to 95% 1-RM; Hill et al., 2012), light-intensity exercise (< 40% 1-RM) might be required due severity movement limitation following stroke (Palmer-McLean & Harbst, 2009).

Resistance training benefits. Perhaps the most significant benefit to strength training for stroke patients is the role it can play in restoring walking efficiency. Evidence suggests that resistance exercise can improve overall strength, which in turn may enhance walking competency in individuals post-stroke (Scanni, Teixeris-Salmela, & Ada, 2010). This outcome is not surprising considering that resistance training has been shown to improve functional ability in a variety of areas in persons post stroke including grip strength, lower body strength, upper body function, and walking time (Harris & Eng, 2010; Hill et al., 2012; Jurkiewicz & Marzolini, 2011; Palmer-McLean & Harbst, 2009). It is important to note, however, that resistance training effects on stroke-related impairment are not indefinite. There is evidence to suggest that functional improvement from resistance training, or therapy in general, may occur up to 6 months or a year before hitting a plateau (Langhammer & Lindmark, 2012). Fortunately, muscular fitness improvement achieved during this span can be maintained ,which is important to overall functional ability and prevention of fitness decline (Flansbjer, Lexell, & Brogardh, 2012).

General Neuromuscular Considerations
Rimmer (2012b) described several considerations that a programmer may also want to consider when developing programs or leading exercise for persons with neuromuscular disabilities. One, spasticity affects many persons with CP, SCI, and stroke, and muscle groups opposite spastic regions should always be included in a prescription. For example, if the biceps brachii muscle is spastic, the triceps should be targeted in the resistance program. Additionally, individuals with muscle weakness may use improper form during resistance exercise to compensate. Proper technique should always be addressed to prevent muscle injury, and machine weights may help to facilitate better technique in persons with balance or strength limitations. Finally, asymmetrical muscle weakness in these particular neuromuscular disabilities may dictate distinct prescription for an affected side or muscle group compared to a non-affected side or body region (e.g., stroke). Therefore, programmers may need to provide two separate prescriptions (one for the affected regions and one for the non-affected regions).

Resistance Training Resources for Persons With Neuromuscular Disabilities

Three important resources should be recognized by exercise programmers. The first, the National Center on Physical Activity and Disability, provides thorough discussions of neuromuscular-specific training benefits and programs (www.ncpad.org). Information provided by this center reflects recent research and summarizes best practices in training, equipment choices, and novel exercise techniques. The Center is a model online resource that has disability-specific information for persons wanting to become more active or improve their lifestyle through physical activity.

Additionally, there are two national disability sport organizations that provide resistance training resources for participants. Blaze Sports (www.blazesports.org) serves individuals with physical disabilities and is a primary sport and recreation provider to persons with CP. For competitive athletes, Blaze publishes a variety of coaching and training resources, including a strength and conditioning manual for track and field athletes through the Certified Disability Sport Specialist program (www.blazesports.org/resources/professional-development). Outside elite competition, Blaze provides resources for recreational participants including a lifetime physical activity guide for community users. Although this guide does not address resistance training programs, it does provide many beneficial ideas for incorporating exercise into one’s lifestyle (www.blazesports.org/resources/technical-assistance). Wheelchair and Ambulatory Sports USA (http://www.wsusa.org) also serves persons with physical disabilities and provides many opportunities for persons with SCI. This organization provides online training videos for competitive track athletes as well as coaching education at community and national levels. However, this organization does not offer specific resistance training guides aimed to maximize health benefits. This dichotomy is typical for the majority of disability sport organizations as resistance training guidelines for community users are not included in resources for U.S. Deaf Sports, Disabled Sports USA, Dwarf Athletic Association, or the U. S. Association of Blind Athletes. Because only 15% of adults with disabilities engage in, and therefore benefit from, weekly resistance training, there is a clear opportunity for these organizations to increase the percentage of persons with disabilities who benefit from resistance training (U.S. Department of Health and Human Services, 2010).

Conclusion

Incorporating resistance training into one’s lifestyle has many important benefits for persons with disabilities including reduced risk of chronic disease and improved functional ability. The Physical Activity Guidelines for Americans and the ACSM position stand articulate a general resistance training prescription that is appropriate for individuals with and without disabilities (Table 2). However, altered voluntary movement associated with several neuromuscular disabilities requires modification of specific program variables. The current article addressed unique exercise choice, intensity, and order considerations for persons with cerebral palsy, muscular dystrophy, spinal cord injury, and stroke.

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