Woman holding an x-ray image of the leg and ankle bones in front of her.

SCI Workout Consideration #5 – Bone Loss

Having weak and brittle bones due to a loss of bone mass can be a significant risk factor for injury during exercise. In general, weak bones are:

  • More susceptible to fractures from forces generated on them during physical activity.  
  • More likely to break as a result of accidents during exercise, such as slipping and falling or injury from a piece of equipment.  Even minor accidents, such as twisting your leg can result in a broken bone.

What Issues Are Posed With SCI? 

Bone loss can impact anyone, however, individuals with SCI are affected at much higher rates than the general population. In fact, it is estimated that 80% of individuals with chronic SCI have bone loss significant enough to be diagnosed with osteopenia or osteoporosis and decreases in bone density of 30% to 40% in the legs is typical after SCI.

Most of the bone loss occurs below the level of injury; therefore, individuals with quadriplegia experience the greatest overall bone loss. Individuals with paraplegia also experience significant bone loss in the lower extremities but maintain bone density in the upper body.

The primary reason for bone loss after SCI is due to the lack of mechanical stress on the bones below the level of injury. This is because every time we move, and even when we are standing still, our muscles are working to support us. When a muscle contracts, it places a mechanical stress on the bone it is attached to and the body responds to the stress by creating more bone. When the muscle can’t contract, the bone-building process ceases and bone mass is gradually decreased over time.

Other factors that contribute to the loss of bone mass in individuals with SCI include:

  • Hormonal changes
  • Changes in metabolism and blood pH
  • Poor blood flow to the limbs
  • Altered gas and nutrient exchange at the bone.

How to Reduce Risk When Exercising

You can significantly reduce your risk of fractures during exercise by always taking the following steps:

  • Exercise in a safe environment. Since accidents are a common cause of fractures, the best way to avoid them is through prevention. This means exercising in a safe environment.  
  • Make sure that your training environment is safe and free from obstacles that may cause a fall.
  • Learn safe transfer techniques to minimize the possibility of injury while transferring from your wheelchair to equipment and back again.
  • Use straps or other adaptive devices to make sure that your trunk is properly supported on equipment and ensure that you can maintain your balance throughout the exercise.
  • Take the time to properly position and secure your wheelchair prior to each exercise.
  • Use appropriate equipment. For example, if you have limited hand function, using cuff weights or weights with straps will allow you to safely perform exercises without the risk of dropping the weight on yourself.  
  • Avoid movements with a high fracture risk. Some movements put excessive stress on the bones, which can lead to fractures.  

To avoid fractures, always:

  • Perform all movements in a slow, controlled manner and always within your range of motion.
  • Avoid movements that put excessive stress on the bones.  Movements to avoid include:
    • Twisting (especially twisting with a weight or other load)
    • Extensive flexion or extension
    • Overstretching can put significant stress on the bones, causing fractures. When performing assisted stretches (i.e. stretches with a partner), make sure your partner avoids extreme tension.

Finally, remember to always check your body after each workout for any signs of fracture, including swelling, redness, and bruising.

Next Up…

#6 Muscle & Joint Issues

Further Reading 

Osteoporosis and Fractures in Persons with SCI:  What, Why, and How to Manage


The top of a man's bare feet on a wood plank floor.

SCI Workout Consideration #4 – Skin Breakdown

Anyone participating in physical activity can expect to experience skin irritations and injuries, such as cuts, scrapes, and bruises, at one time or another.  For most people, these issues are unpleasant and annoying; however, skin breakdown and irritation can be a potentially serious condition for exercisers with SCI.

What Issues Are Posed With SCI? 

In general, the loss of sensation below the level of SCI can make it difficult to realize when skin breakdown occurs. You may not be able to feel when you have a new cut or sore.

Increased friction on the skin from physical activity can lead to skin breakdown. When moving, friction occurs during skin on skin contact and from contact with clothing and equipment. Friction can also occur on areas of the body in contact with prosthetics, assistive devices, and adaptive equipment.

It’s important to note that skin breakdown experienced below the level of SCI injury can put you at serious risk for developing Autonomic Dysreflexia (AD).

There are a number of types of skin breakdown that individuals with SCI need to be aware of when exercising:

Pressure sores, or pressure ulcers, are areas of skin that are damaged due to a lack of blood flow to the area. These lesions are caused when pressure is applied to the skin and not relieved on a regular basis. They can occur from:

  • Sitting or lying in one position for too long
  • Sitting or lying on hard surfaces
  • Improperly fitting prosthetics and adaptive equipment
  • A buildup of moisture on the skin

Untreated pressure sores will gradually worsen and can cause serious complications.

Blisters are raised areas of skin filled with fluid or blood.  Blisters result from friction on the skin when it repeatedly rubs against the body, clothing, or equipment.

Abrasions, or scrapes, are caused when the skin is scraped away when rubbed up against a rough surface.

Lacerations, or cuts, are the result of the skin being cut or torn open.

How to Reduce Risk When Exercising 

To prevent pressure sores:

  • Stay well hydrated. Make sure to drink water before, during, and after exercise.
  • Avoid sitting on hard surfaces and use a well-padded wheelchair cushion whenever possible.
  • Wear clothing that is well-fitting, moisture-wicking, and appropriate for the activity/exercise.
  • Consider taping or padding areas that are prone to skin breakdowns, such as feet and heels.
  • Make sure all prosthetics and adaptive equipment are properly fitted.
  • Perform pressure reliefs, such as wheelchair push-ups, every 20 minutes.
  • Change position on a regular basis.
  • Secure yourself to equipment to reduce friction.

To prevent blisters, abrasions, and lacerations:

  • Use talcum powder, petroleum jelly, or another type of skin lubricant to reduce friction.
  • Make sure all prosthetics and adaptive equipment are properly fitted.
  • Wear gloves to protect the hands.  
  • Use plastic wheel-guard covers on wheelchairs.
  • Use caution when transferring on and off equipment.

Remember: always check your body during and after your workout for new sites of skin breakdown and pay close attention to areas that are more prone to skin breakdown, such as the hips, sacrum, feet, and heels.

Next Up…

#5 Bone Loss

Further Reading 

NCHPAD – Overuse Injuries in Wheelchair Users

Human Kinetics – Medical Conditions in Athletes With Spinal-Cord Injuries

Exercise After Spinal Cord Injury

Close up of a smartwatch displaying the heart rate monitoring function.

SCI Workout Consideration #3 – Heart Rate

An increase in heart rate is a normal and typical response to exercise. Your heart rate will increase with exercise intensity until it reaches a maximum heart rate based on a number of factors (including age and gender); however, the magnitude of the heart rate response during exercise can vary significantly among individuals with and without SCI.

What Issues Are Posed With SCI? 

Your heart rate response to exercise is directly related to the level of the spinal cord injury.

T7 Injury or Below: Individuals with SCI at T7 or below, typically display heart rate responses similar to individuals without SCI.

Paraplegia: The maximum predicted heart rate for individuals with paraplegia is suppressed. Current guidelines from NCHPAD recommend keeping exercise intensity at or below 70% of your maximum heart rate.

Quadriplegia: The maximum predicted heart rate for individuals with quadriplegia is 100 to 125 bpm. Current guidelines from NCHPAD recommend keeping exercise intensity between 50-70% of your maximum heart rate.

How to Reduce Risk When Exercising 

The most effective way to make sure that you are training in a safe range based upon your injury is by monitoring your heart rate during exercise using an electronic heart rate monitor or by taking your pulse.

The rate of perceived exertion (RPE) scale is another way to gauge if you are working at an appropriate level of intensity. The RPE scale can be used alone or in conjunction with heart rate monitoring and is based upon how hard you feel you are working, on a scale from 7 (Easy) to 20 (Very, Very Hard).  The goal is to exercise at an intensity of about a 10-14, depending on your level of SCI.

Next Up…

#4 Skin Breakdown

Further Reading 

Get Moving: Exercise and SCI

NCHPAD – Spinal Cord Injuries

Close up of a blood pressure cuff and stethoscope.

SCI Workout Consideration #2 – Blood Pressure

Blood pressure (BP) is another factor that is directly affected by exercise.  As with temperature, your body has a series of automatic mechanisms that work to keep your blood pressure in a safe range during and after exercise.  

What Issues Are Posed With SCI? 

Spinal cord injury, however, affects your body’s autonomic responses and its ability to regulate blood pressure.  There are two conditions that individuals with a SCI need to be aware of during exercise – orthostatic hypotension and autonomic dysreflexia (AD).  

Orthostatic Hypotension 

Orthostatic hypotension is a drop in blood pressure when in an upright position.

Orthostatic hypotension occurs most frequently when:

  • Changing from a lying position to a sitting position,
  • Changing from a sitting position to a standing position, or
  • Sitting or standing for long periods of time.

It occurs in these positions because blood pools in the legs. Furthermore, loss of nervous system control and muscle function in the lower body and trunk (typically associated with SCI) make it difficult for the body to pump blood from the legs to the brain.


Symptoms of orthostatic hypotension include:

  • Dizziness
  • Lightheadedness
  • Nausea
  • Fainting

If you experience any of these symptoms, lay on your back with your feet elevated until your symptoms go away.

How to Reduce Risk When Exercising 

To reduce the risk of orthostatic hypotension when exercising you can:

  • Gradually increase the pace and intensity of exercise to avoid sudden drops in blood pressure.
  • Get up slowly. Avoid quickly moving from lying to sitting or from sitting to standing.
  • Stay well hydrated before, during, and after exercise.
  • Wear an abdominal binder and/or compression stockings to help move blood from the legs and trunk to the brain.
  • Compression garments increase blood flow to the brain by increasing pressure in the trunk and lower extremities and “pushing” the blood towards the head.

Autonomic Dysreflexia (AD)

Autonomic Dysreflexia (AD), or autonomic hyperreflexia, is an extremely dangerous condition that results in very high blood pressures (up to 190 – 250 mm Hg systolic and 130 – 150 mm Hg diastolic) and is caused by an irritating stimulus, such as a full bladder, urinary tract infection, or pressure sore, below the level of injury. Individuals with a complete SCI at T6 or higher are most susceptible to AD since these individuals lack sensation in the lower extremities.

When irritation occurs below the level of SCI, the body reflexively responds by causing spasms and narrowing blood vessels, resulting in a rise in blood pressure. The body attempts to send signals to the brain about the increase in blood pressure; however, these signals are carried only as far as the spinal cord lesion and stop before reaching the brain.

Since the SCI lesion interrupts communication between the lower body and brain, the brain is unable to detect and respond to the increase in blood pressure. Unless treated, the blood pressure will continue to rise until it reaches potentially fatal levels.


Symptoms of Autonomic Dysreflexia include:

  • High blood pressure (hypertension)
  • Profuse sweating
  • Headache
  • Nausea
  • Goosebumps
  • Shortness of breath

How to Reduce Risk When Exercising 

To reduce the risk of autonomic dysreflexia when exercising:

Do not exercise if you:

  • Have a urinary tract, kidney, or other infection.
  • Have a known injury (e.g. broken bone) or wound (e.g. pressure sore) below the level of SCI.
  • Are constipated.

Prior to your exercise session, always:

  • Examine your body below the level of SCI for signs of injury or other potential irritants. Look for things such as pressure sores, bruises, blisters, and ingrown toenails.
  • Empty your bladder and bowels.
  • Make sure your urinary catheter is unobstructed and working properly.

If you begin experiencing any symptoms of AD during your workout, immediately:

  • Stop exercising.
  • Determine the source of the irritant and remove it, if possible.
  • Sit upright to reduce blood pressure.
  • Loosen any tight clothing.

If your symptoms do not get better right away after taking these steps, contact emergency medical services!  Remember, AD is a very serious condition and getting medical care as soon as possible could be the difference between life and death.

Next Up…

#3 Heart Rate

Further Reading 

Complications of Spinal Cord Injury: Orthostatic Hypotension

Factsheet: Autonomic Dysreflexia

Woman out in the hot sun, sweating and drinking water to stay cool.

SCI Workout Consideration #1 – Thermoregulation

Maintaining a safe and consistent core body temperature is critical for our bodies to function properly. In general, the human body is very effective at maintaining a safe internal temperature because it has a series of involuntary mechanisms to regulate temperature.  

For example, if your body temperature rises too high, the body attempts to cool itself by sweating and dilating blood vessels (vasodilation). If your body temperature drops too low, the body attempts to warm itself by constricting blood vessels (vasoconstriction), increasing metabolism, and shivering. These processes of regulating and maintaining a stable core temperature are called thermoregulation.  

As we exercise, our bodies respond to a variety of internal and external factors that impact our core body temperature. The temperature of the external environment, the heat generated by the working muscles, and increased respiratory functions all put stress on our thermoregulatory processes.  

Most of the time, our natural heating and cooling systems are up to the task and our body stays in a safe temperature range; however, certain circumstances, such as exercising in extreme temperatures or certain medical conditions, can result in your body’s natural heating and cooling systems to become “overloaded”. In fact, if your body temperature rises too high (hyperthermia), or drops too low (hypothermia) you can experience consequences such as cardiac arrest, brain damage, and death.

What Issues Are Posed With SCI? 

If you have a spinal cord injury, you are particularly susceptible to hyperthermia and hypothermia during exercise.

A person with a SCI has limited autonomic control (i.e. control of involuntary bodily functions) below the level of injury. Since temperature regulation is controlled by involuntary mechanisms, the mechanisms that your body relies on to regulate temperature, such as sweating dilation/constriction of the blood vessels, and shivering do not occur or are limited. This might also limit the ability to perceive changes in body temperature as well as an individual without SCI, putting you at additional risk for injury.


Symptoms of hyperthermia (overheating) include:

Symptoms of hypothermia (low body temperature) include:

  • Shivering
  • Slurred speech or mumbling
  • Slow, shallow breathing
  • Weak pulse
  • Clumsiness or lack of coordination
  • Drowsiness or very low energy
  • Confusion or memory loss
  • Loss of consciousness

How to Reduce Risk When Exercising 

There are several steps that you can take before, during, and after exercise that can help maintain a safe body temperature throughout your workout.

To reduce the risk of hyperthermia (overheating):

  • Stay well hydrated. Make sure you drink water before, during, and after exercise.
  • Wear lightweight clothing designed for use in warm-weather activities.
  • Dress in layers so you can remove clothing as needed.
  • In extreme heat and humidity conditions, exercise indoors.
  • Make use of fans and air conditioning.
  • Use a cold towel or spray bottle to help you stay cool during exercise.

To reduce the risk of hypothermia (low body temperature):

  • Stay well hydrated. Make sure you drink water before, during, and after exercise.
  • Refrain from exercising in the extreme cold.
  • If you do exercise in the cold, dress in layers and bring extra clothing.
  • Remember that the extremities (such as your arms, hands, feet, and legs) lose heat quickly.  Make sure to protect your extremities with appropriate apparel such as gloves and warm socks.  

Next Up…

#2 Blood Pressure

Further Reading 

Hypothermia: Causes, Symptoms, and Treatment

Understanding Heat-Related Illness – Symptoms

Man using a wheelchair doing a dumbbell curl with a spot from his trainer.

The Top 6 Considerations for a Safe and Effective SCI Workout – Introduction

September is Spinal Cord Injury (SCI) Awareness month.  As the month comes to a close, we will focus on the importance of exercise for individuals with SCI and take a look at 6 common conditions to be aware of when exercising to stay safe during your workout.

Benefits of Exercise with SCI

To many individuals with a SCI, the thought of exercising can seem overwhelming and downright scary.  Although exercising with SCI does pose its challenges, regular exercise is very important for the overall health and well-being of these individuals.  Of course, exercise provides numerous benefits to both physical and mental health and offers the additional benefit of improving independence and the ability to perform day-to-day activities.

Research in the SCI population has shown that exercise improves:

  • Respiration (breathing)
  • Muscle strength
  • Circulation
  • Immune system function
  • Body composition
  • Self-esteem
  • Mood
  • Independence and ability to perform activities of daily living (ADL’s)

Likewise, exercise also helps prevent:

  • Urinary tract infections
  • Respiratory infections
  • Loss of muscle mass
  • Obesity

And finally, exercise reduces:

  • Depression
  • Anxiety
  • Constipation
  • The risk for diabetes
  • The risk for heart disease

Fortunately, most individuals with SCI can exercise safely, as long as they are familiar with a few common conditions.

Our Top 6 Considerations When Exercising with SCI

Being aware of a few common conditions associated with SCI that can impact exercise will help you take the necessary steps to minimize your risk so that you can exercise safely.

Staying Safe When Exercising with SCI Infographic
Click on the Image to View Larger

Here are our top 6 considerations when exercising with SCI:

#1  Thermoregulation

#2  Blood Pressure

#3  Heart Rate

#4  Skin Breakdown

#5  Bone Loss

#6  Muscles & Joints

Each day over the next week, we will take a look at one of these 6 common conditions associated with SCI.  We will see how they can impact exercise and outline the steps that you can take to minimize risk and make exercise both enjoyable and safe.

Remember, exercising with SCI doesn’t have to be intimidating or scary, and the benefits of exercise are well-worth the investment!

Next Up…

#1 Thermoregulation