Open access peer-reviewed chapter - ONLINE FIRST

Role of Biokinetics Rehabilitation among Spinal Cord Injured (SCI) Patients

Written By

Adelle Jordaan, Terry Jeremy Ellapen, Mariette Swanepoel and Yvonne Paul

Submitted: December 17th, 2021Reviewed: February 9th, 2022Published: April 7th, 2022

DOI: 10.5772/intechopen.103148

IntechOpen
Spinal Cord Injury - Current Trends in Acute Management, Function Preservation and Rehabil...Edited by Luca Ricciardi

From the Edited Volume

Spinal Cord Injury - Current Trends in Acute Management, Function Preservation and Rehabilitation Protocols [Working Title]

Dr. Luca Ricciardi, Dr. Giorgio Lofrese, Dr. Andrea Perna and Ph.D. Sokol Trungu

Chapter metrics overview

16 Chapter Downloads

View Full Metrics

Abstract

Spinal cord rehabilitation is a complex and consuming pathology, requiring the skillsets of numerous experts to ensure optimal treatment. To this end, the expertise of an exercise therapist (biokineticist) can play a significant role in health maintenance, as well as in the prevention of the co-morbidities often experienced by this population (elevated risk for metabolic syndrome and coronary heart disease associated with SCI), positively improving patients’ overall quality of life. Biokinetics can furthermore help to lower cardiometabolic risks through the prescription of individualized exercise programs and by working in conjunction with other members of the patients’ health team. Physically active spinal cord injured individuals who use their wheelchairs as an exercise machine can benefit from the expertise of a biokineticist as far as these physically active spinal cord injured individuals often experience upper limb neuro-musculoskeletal overuse injuries. In so far as biokineticists are final-phase rehabilitation exercise therapists who prescribe structured physical activity to improve the physical and physiological conditioning of the patient, they are similar to other exercise therapists, such kinesiotherapists, physical therapists, or physiotherapists, and function within a multi-disciplinary rehabilitation team to improve the quality of life of a spinal cord injured individual.

Keywords

  • biokineticist
  • cardiometabolic risk
  • injury
  • spinal cord injury

1. Introduction

The unfortunate consequences of spinal injury often include paralysis, inability to stand and walk, increased cardiometabolic risks leading to metabolic syndrome, a loss of independence, social isolation, and decreased quality of life [1, 2, 3]. Spinal cord injured patients require a comprehensive multi-disciplinary team, especially during post-hospitalization [1, 2, 4]. The medical fraternity has observed that post-hospitalization, many spinal cord injured patients adopt a physically inactive lifestyle that facilitates various sedentary lifestyle pathologies commonly referred to as non-communicable diseases [5, 6]. Martin Ginis et al. and Hicks et al. encourage spinal cord injured patients to participate in habitual physical activities to combat the onset of non-communicable diseases [7, 8]. Gorgey et al. contended that prolonged sitting is a foremost risk facilitating the early onset of non-communicable diseases and premature death among those with spinal cord injuries [5]. The purpose of this chapter is to describe the role of one therapeutic profession (Biokinetics) involved with the physical and exercise rehabilitation of spinal cord injured patients in a South African context.

Advertisement

2. The genesis of the medical and therapeutic experts that intervene during the pathogenic and fortogenic healthcare paradigms of spinal cord injury

Medical treatment begins once the spinal cord injury has been identified by the medical doctors (trauma unit neuro and orthopedic surgeons), when the patient is admitted to an acute care center [9]. At the acute care center, the patient may undergo surgery, if necessary, and in-hospital stay rehabilitation. The acute stage of spinal cord injury falls with the pathogenic paradigm, which involves the illness-care dimension (treatment of the spinal cord injury which has been sustained) and/or illness-prevention dimension (the increased intrinsic risk of other prospective pathologies such as non-communicable diseases) [10]. The medical specialists managing the spinal cord injured patient during the pathogenic paradigm include trauma unit medical practitioners and nurses, neuro-surgeons, and orthopedic surgeons. Post-surgical rehabilitation therapy is offered by physiotherapists in the course of the patient’s hospital stay [10, 11]. The in-hospital physiotherapy of spinal cord injured patients concentrates on regaining motor tasks, such as optimal use of upper limbs, standing (with and without crutches), walking (if possible, with prosthetic devices), the patient being able to transfer him/herself from the bed to the wheelchair and vice versa, selecting the appropriate wheelchair based on the severity of the injury (motorized versus manual wheelchair), and gaining mobility with the wheelchair [2, 12]. The physiotherapist teaches the spinal cord injured patient both bed-bound and non-bed bound exercises to strengthen muscles and regain balance, proprioception, and kinesthesia [13]. The physiotherapy rehabilitation phase can vary from a few days to several weeks [2].

Successful recovery from a spinal cord injury depends on the severity of the injury and the treatment a patient receives in the course of each stage of the management spectrum [9]. The treatment of spinal cord injuries spans from hospitalization to surgical care, and rehabilitation (in-hospital stay and post-hospitalization) strategies [9]. A multidisciplinary medical team for spinal cord injuries usually consists of therapists, such as a physiotherapist (also known as physical therapist), occupational therapist, rehabilitation nurse, medical specialist physician, a dietician, psychologist, and biokineticist [14]. Physicians or general practitioners (GP’s) are recognized as the principal source for referral of spinal cord injured patients for participation in structured physical activity and/or leisure-time physical activity [6]. Gorgey and colleagues stated that the multi-disciplinary team that engages in the care and rehabilitation of spinal cord injured patients needs to comprehend the various benefits of physical activity as an integral part of the rehabilitation strategy [15]. Acute stage medical management of spinal cord injured patients focuses on decreasing additional neurological impairment to the spinal cord, and enhancing recovery and rehabilitation after an injury, commencing as soon as the individual is medically stable [2]. Spinal cord injury is considered to be a long-term neurological impairment, which requires the expertise of multiple healthcare professionals over a prolonged period of time to manage aspects related to this neurological condition [12, 16].

Once the acute and sub-acute treatment (which resides in the pathogenic healthcare paradigm) of spinal cord injury has been completed, the patient then enters the fortogenic healthcare paradigm. In the fortogenic healthcare paradigm, the spinal cord injured individual is considered apparently healthy, without increased risk of pathology, but is attentive to assume a physically active lifestyle to prevent the risk of illness (non-communicable diseases) and prevent a decrease in their quality of life. At this stage, the spinal cord injured patient requires the expertise of an occupational therapist and a biokineticist. The focus of the occupational therapist during spinal cord rehabilitation involves the adaption of the individual to their physical and social environments by reclaiming the abilities that help them to create a significant life [17]. Occupational therapy principally concentrates on the fundamental activities of daily living, home-based activities, and sensory, perceptual, and cognitive exercises [13]. The role of a biokineticist during spinal cord injury rehabilitation will be discussed in the subsequent sections.

Advertisement

3. What is the profession of Biokinetics?

The Health Profession Council of South Africa defines Biokinetics as a final-phase functional therapeutic health and wellness profession, concerned with improving the physical and physiological health and wellbeing of patients and apparently healthy individuals through the scientific prescription of personalized physical activity and exercise in the framework of chronic clinical and neuro-musculoskeletal pathologies and performance enhancement in both the pathogenic and fortogenic healthcare paradigms (Figure 1) [18]. Ellapen and Swanepoel contend that Biokinetics has been intermittently involved with health and wellness campaigns aimed at preventing and rehabilitating neuro-musculoskeletal injuries and non-communicable diseases. Biokinetics is an ambassador of the philosophy that exercise is medicine[10, 19, 20] and operates within the pathogenic health paradigm (illness and illness prevention healthcare dimensions) when rehabilitating patients who have sustained non-communicable diseases, as well as within the fortogenic paradigm when encouraging a physically active lifestyle as a physiological defensive mechanism to prevent the occurrence of non-communicable diseases among healthy individuals. The neuro-musculoskeletal focus of Biokinetics concentrates on final-phase functional rehabilitation involving muscle strengthening, increasing muscle endurance, cardiorespiratory conditioning, muscle extensibility, joint flexibility, proprioception, kinesthesis, and patient education [21].

Advertisement

4. How can Biokinetics improve the quality of life of a spinal cord injured person?

To appreciate the value of a biokineticist as a prominent member of the rehabilitation strategy for a spinal cord injured person, one needs to understand the consequence that physical inactivity has on their lives. It is important for health care professionals, governing bodies, rehabilitation centers, and community organizations to understand what factors constrain and promote physical activity in the SCI population, to be in a better position to support people with SCI in being physically active for life. This sub-section will describe the perils that physically inactive spinal cord injured persons may succumb too.

It is an accepted reality that spinal cord injured persons lead a limited physically active lifestyle as compared to their able-bodied counterparts and are more susceptible to the onset of non-communicable diseases [22, 23, 24]. Approximately 85% of spinal cord injured persons are physically inactive and the additional 15% reported participation in physical activity that is below the threshold where it has meaningful health benefits [25]. The objectives for incorporating a physically active lifestyle into the spinal cord injured person’s rehabilitation strategy is to avert and/or manage the onset of non-communicable diseases and improve the person’s quality of life [1]. Habitual compliance to a structured physical activity and exercise program as part of a spinal cord injured person’s rehabilitation strategy offers the following benefits: reducing the risk of cardiovascular diseases, metabolic syndrome, arthritis, osteoporosis, osteoarthritis, and urinary tract infections [26, 27].

  1. Physical activity has been identified as improving or inhibiting many of the health and well-being complications associated with SCI. For example, physical activity has been proven to reduce levels of perceived musculoskeletal and neuropathic pain [28].

  2. The upsurge of cardiovascular diseases and related co-morbidities such as diabetes mellitus, obesity, and dyslipidemia are significant concerns that are consequences of a physically inactive lifestyle and which many spinal cord injured persons contract [1]. Myers and colleagues have reported that autonomic dysfunction among physically inactive spinal cord injured individuals contributes to fluctuating blood pressure, arrhythmia, and a blunted cardiovascular response to physical activity and exercise, which hinders cardiorespiratory fitness [27].

  3. Many physically inactive spinal cord injured persons have compromised metabolic systems, resulting in a slow basal metabolic rate leading to increased body fat and obesity, increased risk lipid profiles resulting in hypertriglyceridemia, insulin resistance, and impaired glucose tolerance resulting in diabetes mellitus [29].

  4. Both strength and endurance activities contribute to improving overall functional capacity. Moreover, expiratory muscle training exercises help in improving inspiratory muscle function [30].

  5. Prolonged bed rest after a spinal cord injury facilitates muscle fiber atrophy and causes spinal cord injured persons to replace their muscle mass with fat [15]. Jiang and colleagues reported that a sedentary lifestyle is associated with osteoporosis, which increases the risk of fractures, a risk that spinal cord injured persons must safeguard against [31].

  6. Aerobic exercise helps to improve energy levels, decrease fatigue, and manage body weight. It also enhances heart and lung function and improves the body’s ability to use oxygen. Early rehabilitation improves cardiac efficiency [32].

  7. In line with the biopsychosocial model of the International Classification of Functioning Disability and Health (ICFDH), the objective of rehabilitation is to restore “the individual to the highest level of participation, and returning individuals to the life they want as far as their disability will permit” [33].

  8. Physical activity has shown improved psychological wellbeing through enabling experiences such as personal control, responsibility, and risk taking that further post-traumatic progress [34].

  9. A small portion of spinal cord injured individuals forgo a physically inactive lifestyle and are instead physically active, using their wheelchairs as an exercise apparatus [19]. These individuals experience upper limb overuse injuries, which may also curtail physical activity [19, 35]. Common overuse injuries include rotator cuff tendinitis, shoulder impingement, biceps tendinitis, ulnar neuropathy, lateral epicondylitis, carpal tunnel syndrome, and De Quervain’s tenosynovitis [36]. Will and colleagues contend that inefficient wheelchair propulsion biomechanics is the primary culprit of the aforementioned overuse injuries [37]. Van der Scheer and colleagues reported that spinal cord injured wheelchair sports activists who have poor aerobic capacities, tend to adopt inefficient wheelchair propulsion biomechanics when engaged in prolonged endurance activities causing overuse injuries [38]. Sprigle and Will et al. stated that the contributors to poor biomechanical posture among spinal cord injured wheelchair users are drooping/angulated shoulders and forward leaning [3739]. The dorsal coronal plane kinematic analyses of the angulated shoulder girdle posture are associated with rotator cuff tendinitis and shoulder impingement [40]. Ellapen and colleagues reported that the angulated shoulder girdle posture is associated with an ineffective static passive locking mechanism of the glenohumeral joint [40]. This ineffective static locking mechanism is a result of scapular depression and downward rotation because of the eccentrically lengthened trapezius and rhomboid muscles, together with a laxed superior glenohumeral capsule [41]. The inefficient kinematic angulated shoulder girdle posture creates an abnormal force-couple relationship asymmetrically elongating the trapezius and the condensing pectoralis minor in the coronal plane [41]. The concentrically contracted pectoralis minor muscles pull in the chest, producing a sunken appearance and posteriorly hyper-flexing the thoracic vertebrae, causing kyphosis. The sagittal plane kinematic analyses indicate a rounded shoulder appearance, reminiscent of pectoralis minor and serratus anterior contractures, and elongated rhomboids. The caudally orientated humeral head is medially rotated, indicating subscapularis and pectoral minor contractures [40, 41]. Collectively, the angulated shoulder appearance diminishes the impingement interval space between the coracoacromial-arch and the humeral head, diminishing the impingement interval spacing, compressing the supraspinatus, sub-acromial bursa, and biceps brachii [40, 41]. The collective biomechanic cascades of these kinematic events describe the pathomechanics of rotator cuff tendinitis, shoulder impingement, sub-acromial bursitis, and biceps tendinopathy [40, 41].

Jordaan describes a biokineticist as a specialized exercise therapist who functions in professional association with other health and medical specialists registered with the Health Professions Council of South Africa [12]. The scientifically based physical-activity prescribed rehabilitation program denotes an explicit and individual-oriented physical-training program based on the individuals’ physical condition status [19]. Final-phase rehabilitation is the point in the rehabilitation process when structured exercise and physical activity constitute the primary therapeutic modality [12]. The collaborative relationships among therapeutic practitioners and medical staff in South Africa are strained due to competition over patients and a lack of understanding and appreciation of each other’s scope of the profession. Physiotherapists have claimed that chiropractors and biokineticists encroach on their scope of the profession [42]. Booysen and colleagues have reported that despite attempts to foster interdisciplinary collaboration among South African medical staff and therapists, there is resistance [43, 44]. Ellapen and colleagues proposed that a better understanding of the scope of expertise of each of the aforementioned professions should be taught at South African universities, which will lead to an appreciation for the specific skill set that each profession offers [42, 44]. Jordaan and colleagues have advocated that medical practitioners, including nurses, physiotherapists, occupational therapists, biokineticists, nutritionists, psychologists, neurologists, or orthopedic surgeons, need to work collaboratively to provide better quality management of spinal injured patients [1]. A multi-disciplinary collaborative clinical team provides the most efficacious healthcare of spinal cord injured patients [1, 45].

A typical biokinetic rehabilitation program will include a general warm-up, progressing into a specific warm-up. Thereafter the patient will perform stretching, moving into a series of strengthening and/or aerobic exercises. The cool-down phase involves stretching of muscles and a gentle aerobic activity to return the heart rate to normal levels.

  1. The biokinetic rehabilitation program will include aerobic exercises to improve cardiorespiratory conditioning. The structured aerobic program will help to effectively mediate glucose metabolism, increase insulin sensitivity, reduce insulin resistance, and collectively prevent the onset of diabetes mellitus. Habitual aerobic exercises also reduce low-density lipoprotein cholesterol (LDL-cholesterol) and triglycerides, which collectively reduce the spinal cord injured person’s cardiometabolic risk for metabolic syndrome and coronary artery diseases.

  2. The stretching component of the biokinetic rehabilitation program will elongate shortened muscles and prevent muscle contractures. The patient will start with static stretching, moving into proprioceptive neuromuscular facilitation (PNF), and finally, dynamic stretching.

  3. Subsequently, the strengthening component of the biokinetic program will strengthen weak muscles. Collectively, the stretching and strengthening exercises will symmetrically ensure a synergistic force-couple relationship that will prevail among all active agonist-antagonist muscles.

  4. Physical rehabilitation programs should incorporate treatments designed to prevent certain complications such as frozen joints, contractures, or bedsores.

Table 1 illustrates a comprehensive rehabilitation plan for a spinal cord injured person for a six-month mesocycle as recommended by Durstine and Moore [46].

Figure 1.

Graphic illustration of the various treatment phases and clinical practitioners involved in the different healthcare paradigms in the rehabilitation of spinal cord injured persons.

Modes of physical activityIntensity, frequency, and durationClinical rehabilitation objectivesTime to achieve goal
Aerobic exercise
  • Arm ergometer

  • Wheelchair ergometer

  • Wheelchair treadmill

  • Arm cycling

  • Swimming

Duration: ranging from 20 to 60 minutes depending on person’s fitness status
Intensity: ranging from 50 to 80% of the person’s maximum heart rate (HRmax)
Frequency: 3–5 days per week
  • Increase aerobic capacity

  • Increase active muscle strength and endurance

  • Increase active muscle hypertrophy

  • Decrease body fat

  • Reduce the person’s cardiometabolic risk by reducing excessive LDL cholesterol, glucose, and triglycerides

  • Improve person’s overall functional muscle strength, endurance, and aerobic capacity for independent functionality

6 months
Muscle flexibility
  • PNF stretching facilitated by biokineticist

  • Static stretching

  • Dynamic stretching

PNF stretching: contract-relax, hold-relax, and/or slow reversal hold-relax performed by biokineticist
Static stretching: hold stretch for 20 seconds × 2 repetitions
Dynamic stretching
Stretch major muscles depending on applicability to person
  • Increase muscle extensibility

  • Increase joint range of motion

  • Avoid onset of muscle contractures

6 months
Strength
  • Resistance bands

  • Dumbbells and barbells

  • Resistance equipment if applicable to person

Intensity: 10–20 repetitions × 2 sets
Frequency: 2–4 days per week
  • Increase muscle strength and endurance

  • Recreate symmetrical force couple relationships between agonist and antagonist muscle pairings

  • Promote muscle hypertrophy

  • Increase muscle strength and endurance to promote independent functionality

  • Improve body posture

  • Improve wheelchair propulsion biomechanics

6 months

Table 1.

Comprehensive overview of a spinal cord injured patient’s rehabilitation plan for a six-month mesocycle [46].

All pictures were sourced from the internet.

Table 2 is a general biokinetic rehabilitation program targeting muscle strength and endurance and extensibility.

Table 2.

General strength rehabilitation program for spinal cord injured person.

All pictures were sourced from the internet.

Advertisement

5. Conclusion

Spinal cord injury requires a multidisciplinary team of medical and paramedical experts to ensure that the person maintains the quality of life post-injury. To this end, biokineticists, as final-phase rehabilitation exercise therapists who can help the spinal cord injured patient prevent the onset of various non-communicable diseases, are fundamental to ensuring success in the strategic approach of the team. A small proportion of spinal cord injured patients continue to live a physically active life but unfortunately succumb to various neuro-musculoskeletal overuse injuries. The intervention of a biokineticist through the prescription of preventative exercise can aid in eliminating these overuse injuries and ensuring the individual enjoys an active and healthy life.

Advertisement

Conflict of interest

None.

References

  1. 1.Jordaan A, Ellapen TJ, Swanepoel M, Paul Y. The interprofessional clinical and therapeutic team strategy to manage spinal cord injuries, Spinal Cord Injuries and Physical Therapy. United Kingdom, London: InTech Publishers; 2021
  2. 2.Harvey LA. Physiotherapy rehabilitation for people with spinal cord injuries. Journal of Physiotherapy. 2016;62:4-11
  3. 3.Sand A, Karlberg I, Kreuter M. Spinal cord injured persons’ conceptions of hospital care, rehabilitation, and a new life situation. Scandinavian Journal of Occupational Therapy. 2006;13:183-192
  4. 4.Pellatt GC. Patients, doctors, and therapists perceptions of professional roles in spinal cord injury rehabilitation: Do they agree? Journal of International Care. 2007;21(2):165-177
  5. 5.Gorgey AS. Exercise awareness and barriers after spinal cord injury. World Journal of Orthopaedics. 2014;15(3):158-162
  6. 6.Pelletier CA, Latimer-Cheung AE, Warburton DE, Hicks AL. Direct referral and physical activity counselling upon discharge from spinal cord injury rehabilitation. Spinal Cord. 2014;52:392-395
  7. 7.Martin Ginis KA, Hicks AL, Latimer AE, Warburton DER, Bourne C, Ditor DS. The development of evidence-informed physical activity guidelines for adults with spinal cord injury. Spinal Cord. 2011;49:1088-1096
  8. 8.Hicks AL, Martin Ginis KA, Pelletier CA, Ditor D, Foulon B, Wolfe DL. The effects of exercise training on physical capacity, strength, body composition and functional performance among adults with spinal cord injury: Systematic review. Spinal Cord. 2011;49:1103-1127
  9. 9.Fehlings MG, Cadotte DW, Fehlings LN. A series of systematic reviews on the treatment of acute spinal cord injury: A foundation for the best medical practice. Journal of Neurotrauma. 2011;28:1329-1333
  10. 10.Ellapen TJ, Strydom GL, Swanepoel M, Hammill H, Paul Y. Biokinetics: A south African health profession evolving from physical education and sport. In: Sports and Exercise Science. InTech Publishers; 2018
  11. 11.ACSM (American College of Sport Medicine). ACSM’s Guidelines for Exercise Testing and Prescription. 10th ed. Philadelphia: Lippincott Williams and Wilkins; 2017
  12. 12.Jordaan A. Masters physical activity prescription for the prevention of metabolic disease after spinal cord injury: A systematic review [published master’s thesis]. South Africa: North-West University; 2017
  13. 13.De Wit L, Putman K, Lincoln N, Baert I, Berman P, Beyens H, et al. Stroke rehabilitation in Europe. What do physiotherapists and occupational therapists actually do? Stroke. 2006;37:1483-1489
  14. 14.Godney J, Reinhardt JD, Haig AJ, Li J. Developing post-disaster physical rehabilitation: Role of the world health organization liaison sub-committee on rehabilitation disaster relief of the international society of physical and rehabilitation medicine. Journal of Rehabilitation Medicine. 2011;43:965-968
  15. 15.Gorgey AS, Dudley GA. Skeletal muscle atrophy and increased intramuscular fat after incomplete spinal cord injury. Spinal Cord. 2007;45:304-309
  16. 16.Mulligan H, Fjellman-Wiklund A, Hale L, Thomas D, Hager-Ross C. Promoting physical activity for people with neurological disability: Perspectives and experiences of physiotherapist. Physiotherapy Theory and Practice. 2011;27(6):399-410
  17. 17.Pillastrini P, Mugnai R, Bonfiglioli R, Curti S, Mattioli S, Maioli MG, et al. Evaluation of an occupational therapy program for patients with spinal cord injury. Spinal Cord. 2008;46:78-81.2006
  18. 18.Health Professions Council of South Africa (HPCSA). Regulations defining the scope of the profession of physiotherapy. 1976. Available from:http://www.hpcsa.co.za/Uploads/editor/UserFiles/downloads/rules_reg_constitution/scope_of_profession_of_physiotherapy.pdf[Accessed: April 19, 2016]
  19. 19.Ellapen TJ, Swanepoel M. The evolution of the profession of biokinetics. South African Journal of Research in Sport Physical Education Recreation. 2017;39(1):41-50
  20. 20.Strydom GL. Biokinetics—The development of a health profession from physical education—A historical perspective. South African Journal for Research in Sport, Physical Education and Recreation. 2005;27(2):113-131
  21. 21.BASA (Biokinetics Association of South Africa). 2021.biokineticssa.org.za
  22. 22.Motl RW, McAuley E, Snook EM. Physical activity and multiple sclerosis: A meta-analysis. Multiple Sclerosis. 2005;11:459-463
  23. 23.Rauch A, Fekre C, Cieza A, Geyh S, Meyer T. Participation in physical activity in persons with spinal cord injury: A comprehensive perspective and insights into gender differences. Disability and Health Journal. 2013;6(3):165-176
  24. 24.Kerstin W, Gabriele B, Richard L. What promotes physical activity after spinal cord injury? An interview study from a patient perspective. Disability and Rehabilitation. 2006;28(8):481-488
  25. 25.Miller LE, Herbert WG. Health and economic benefits of physical activity for patients with spinal cord injury. ClinicoEconomics and Outcomes Research. 2016;8:551-558
  26. 26.Nooijen CJ, Stam HJ, Bergen MP, Bongers-Jassen MH, Valent J, Van Langeveld S, et al. Behavioural intervention increases physical activity in people with subacute spinal cord injury: A randomised trial. Journal of Physiotherapy. 2016;62:35-41
  27. 27.Myers L, Lee M, Kiratli J. Cardiovascular disease in spinal cord injury an overview of prevalence, risk, evaluation, and management. American Journal of Physical Medicine Rehabilitation. 2007;86:1-8
  28. 28.Norrbrink C, Lindberg T, Wahman K, Bjerkefors A. Effects of an exercise programme on musculoskeletal and neuropathic pain after spinal cord injury—results from a seated double-poling ergometer study. Spinal Cord. 2012;50(6):457-461
  29. 29.Woolfe DL, Martin Ginis KA, Latimer AE, Foulon B, Eng JJ, Hsieh JTC. Physical activity following spinal cord injury. Spinal Cord Injury Rehabilitation. 2008;22:22-47
  30. 30.Eriks-Hoogland IE, de Groot S, Post MW, van der Woude LHJ. Passive shoulder range of motion impairment in spinal cord injury during and one year after rehabilitation. Journal of Rehabilitation Medicine, Official Journal of UEMS. 2009;41(6):438-444
  31. 31.Jiang SD, Dai LY, Jiang LS. Osteoporosis after spinal cord injury. Osteoporosis International. 2006;17:180-192
  32. 32.Tordi N, Mourot L, Chapuis A, Parrate B, Regnard J. Effects of a primary rehabilitation programme on arterial vascular adaptations in an individual with paraplegia. Annals of Physical Rehabilitation Medicine. 2009;52(1):66-73
  33. 33.Nunnerley J, Hay-Smith E, Dean S. Leaving a spinal unit and returning to the wider community: An interpretative phenomenological analysis. Disability and Rehabilitation. 2013;35(14):1164-1173
  34. 34.Day MC. The role of initial physical activity experiences in promoting posttraumatic growth in paralympic athletes with an acquired disability. Disability and Rehabilitation. 2013;35(24):2064-2072
  35. 35.Thompson E, Snodgrass S, Osmotherly P. Injuries, practises and perceptions of wheelchair sports participants. Physiotherapy. 2015;101(1):1515-1516
  36. 36.Apple DF, Cody R, Allen A. Overuse syndrome of the upper limb in people with spinal cord injury. In: Rehabilitation Research and Development Service: Physical Fitness: A Guide for Individuals with Spinal Cord Injury. Atlanta: Diane Publishers; 2004
  37. 37.Will K, Engsberg JR, Foreman M, Klaesner J, Birkenmeier R, Morgan K. Repetition bases training for efficient propulsion in new manual wheel chair users. Journal of Physical Medicine and Rehabilitation in Disabilities. 2015;1(1):001-009
  38. 38.Van der Scheer JW, De Groot S, Posetma K, Veerger DHE, Van der Woude LHV. Low-intensity wheel chair training in inactive people with long term spinal cord injury. American Journal of Physical Medicine and Rehabilitation. 2015;94(11):975-998
  39. 39.Sprigle S. Measure it: Proper wheelchair fit is key to ensuring function while protecting skin integrity. Advance Skin Wound Care. 2014;27(12):561-572
  40. 40.Ellapen TJ, Hammill HV, Swanepoel M, Strydom GL. The health benefits and constraints of exercise therapy for wheelchair users: A clinical commentary. African Journal of Disability. 2017;6:337a
  41. 41.Mansfield PJ, Neumann DA. Essentials of Kinesiology for the Physical Therapist Assistant. St. Louis, Missouri: Mosby, Inc.; 2015
  42. 42.Ellapen TJ, Paul Y, Swanepoel M, Strydom GL. Do biokineticists transgress on physiotherapists’ scope of profession? Evidence-based analysis of two physical rehabilitation disciplines in South Africa. African Journal for Physical Activity and Health Science. 2018;24(3):316-331
  43. 43.Booysen N, Lake J, Webb J, van Niekerk W, Schubl C. The knowledge, attitudes and perceptions of healthcare students and professionals regarding the interdisciplinary health worker team at Stellenbosch University and Tygerberg Academic Hospital. South African Journal of Clinical Nutrition. 2012;25(4):192-196. DOI: 10.1080/16070658.2012.1 1734427
  44. 44.Ellapen TJ, Swanepoel M, Qumbu BT, Strydom GL, Paul Y. Interprofessional knowledge and perceptions of physical rehabilitation practitioners towards each other in South Africa. African Journal for Health Professions Education. 2018;10(3):148-152. DOI: 10.7196/AJHPE.2018.v10i3.951
  45. 45.Marshall R, Hasnan N. Chapter 27 Team based care. In: Chhabra HS, editor. ISCoS Textbook on Comprehensive Management of Spinal Cord Injuries. International Spinal Cord Society; 2015
  46. 46.Durstine JL, Moore GE. ACSM’s Exercise Management for Persons with Chronic Diseases and Disability. 2nd ed. USA, New York: Human Kinetics; 2016

Written By

Adelle Jordaan, Terry Jeremy Ellapen, Mariette Swanepoel and Yvonne Paul

Submitted: December 17th, 2021Reviewed: February 9th, 2022Published: April 7th, 2022