Introduction

Paraplegia refers to the loss of voluntary movement and sensation in the lower half of the body. Paraplegia can significantly impact an individual’s day-to-day life, affecting their mobility, breathing, bowel control and overall quality of life. Due to the complexity of any spinal related conditions, paraplegia requires an extensive and holistic approach to treatment and management. Physical therapy has proved to be an effective and vital component in the treatment and management of paraplegia, allowing individuals to achieve improvements in their mobility, strength and overall quality of life.¹ The following article explores the most effective types of physical therapy and exercise for those with paraplegia, as well as the specific benefits each can provide. 

What is paraplegia?

Paraplegia is a term used to describe the loss of voluntary movement in the lower half of the body. It most commonly affects the mobility of the legs, feet and toes; however, it can also affect the chest and abdominal muscles. Whilst paraplegia can be a condition by itself, it is often a symptom of spinal damage caused by either an injury, disease, infection or a congenital disorder. As well as restricting mobility and function, paraplegia can also affect breathing, coughing and bowel control. The area in which the spine becomes damaged can greatly influence the severity of an individual’s paraplegia and the impact it will have on their day to day life. 

• Thoracic spine (T1-T6) - Damage nearer the top of the spinal column is likely to cause complete loss of function of the lower half of the body as well as the chest and abdominal muscles. Injuries at this level can also affect bowel control as well as deep breathing and coughing 
• Thoracic spine (T7-T12) - Damage at this level of the spine also causes complete loss of function of the lower half of the body and abdominal muscles, although the chest muscles are unaffected 
• Lumbar spine (L1-L2) - Damage at this level of the spinal column causes complete loss of function of the lower half of the body, however the chest and abdominal muscles are unaffected
• Lumbar spine/sacral Spine (L3-S5) - Damage at this level of the spinal column causes partial loss of function and sensation in the lower half of the body. Patients will likely be able to walk without assistance, altough bowel control may still be affected

The role of physical therapy in paraplegia management 

Physical therapy can be an extremely effective tool in the management and treatment of paraplegia.¹ By considering a patient's overall health, level of fitness, the level in which the spinal damage has occurred as well as their personal goals, physiotherapists and health care professionals can tailor their physical therapy programmes to each patient, increasing their effectiveness. Whilst physical therapy cannot cure paraplegia, regular exercise can help manage and even improve a patient's condition, facilitating a better quality of life and helping foster a sense of independence. Below are some of the evidence based benefits physical therapy can have on those with paraplegia.^1,2,3

• Improved mobility and function of lower body
• Improved muscular strength 
• Improved sleep 
• Improved weight control
• Reduced pain 
• Improved mental health 

Types of physical therapy for paraplegia

Incorporating different types of physical therapy into the management and treatment of paraplegia can provide patients with a wider range of health benefits than singular mode programmes. Research indicates that range of motion exercises, resistance exercise, balance and coordination drills, aerobic exercise and functional electrical stimulation are among the most effective types of physical therapy for those with paraplegia.^4,5 It is important to note that if you suffer from paraplegia, you should consult a medical professional or physiotherapist before starting an exercise programme. The type of exercises and equipment you use will differ greatly depending on their condition. 

Range of motion exercises 

Range of motion exercises are designed to help improve the flexibility and mobility available at specific joints around the body. For patients with paraplegia, the type of range of motion exercise prescribed to them will greatly depend on their condition and level of mobility. 

• In joints with little to no mobility, physiotherapists will likely prescribe the patient passive range of motion (PROM) exercises. In PROM exercises, the patient's joints are moved through their full range of motion by a medical professional or physiotherapist, rather than the patient controlling the movement
• In joints with high levels of mobility and function, active range of motion (AROM) exercises will likely be prescribed to patients. AROM exercises once again focus on moving the joint through its full range of motion. However, in this case, it is the patient that controls the movement without the assistance of a physiotherapist

For more information on the different range of motion exercises recommended to those with paraplegia, consider reviewing the examples provided by the NHS or book a consultation with a physiotherapist. 

Resistance exercises

Resistance exercises are designed to improve muscular strength or endurance by forcing targeted muscles to push or pull against an external force, for example lifting a weight or performing a push-up. In the management of paraplegia, resistance exercises will primarily serve as a tool to maintain or increase the strength of the patient's upper body, helping prevent muscular atrophy from occurring and allowing patients to more easily complete essential daily tasks such as wheelchair transfers and wheelchair walking.⁶ Examples of upper body exercises that may be included in a physical therapy plan for those with paraplegia include the following: 

• Bicep curls
• Tricep kickbacks  
• Seated lat pull-downs 
• Chest press

Balance and coordination exercises

Balance and coordination-based exercises are a vital component in physical therapy programmes for those with paraplegia. Balance-based exercises focus on improving the patient's core strength and balance. Balanced-based exercises often involve the patient performing some form of activity, for example seated marching, whilst sitting on a balance board or chair, challenging the patient to complete the task whilst maintaining their balance. Regular practice of these exercises can greatly improve a patient's balance, significantly reducing their risk of falls. Similarly, coordination-based exercise often consists of a series of repeated task-based drills that aim to improve the patient's motor skills. Drills will often begin as simple as reaching for an object, before progressing into more complex movements. Regular practice of these drills can increase an individual's control and ability to perform daily tasks, improving their sense of independence. 

Aerobic exercises

Aerobic-based exercise, also known as cardiovascular exercise, can provide a plethora of benefits for those suffering from paraplegia. Regular moderate-intensity aerobic exercise can help improve a patient’s cardiovascular health, weight control, and mental health as well as reduce the risk of several chronic health conditions like stroke and diabetes.⁷ As traditional lower-body aerobic exercises may not be possible, alternatives that utilise the upper body will likely be prescribed to patients. Examples of alternative aerobic exercises include: 

• Hand Cycling
• Swimming 
• Water aerobics
• Rowing 
• Wheelchair-based sports (e.g. basketball, rugby and tennis)     

Functional electrical stimulation (FES)

Function electrical stimulation (FES) is a physical therapy technique that uses small electrical impulses to stimulate paralysed muscles into contraction. When used in conjunction with other assistance tools, this small electrical current can allow patients to perform tasks they wouldn’t normally be able to, such as standing, moving lower limbs or grasping an object.⁸ As well as improving the function and mobility in the targeted muscle groups, research indicates that FES can help prevent muscle atrophy, improve blood circulation and decrease the amount of spasticity a patient experiences.⁹

Summary 

Paraplegia refers to the loss of voluntary movement and sensation in the lower half of the body. Whilst in some cases paraplegia can be a condition by itself, it is most commonly a symptom of spinal damage. Incorporating different types of physical activity into the management of paraplegia can be greatly beneficial, providing patients with benefits such as improved mobility and muscular strength, whilst also helping shield them from secondary conditions like diabetes, heart disease and mental health conditions. Once again, it is important to note that those with paraplegia should consult with a physiotherapist or medical professional before beginning an exercise programme, as each programme needs to be tailored and adapted for each patient for it to be effective and not cause further damage.