Strength training for people with disabilities

June 04, 2021

Aided by medical and surgical advances, new developments in adaptive equipment and the Americans with Disabilities Act (ADA) mandates, the number of people with disabilities now engaging in organized physical activities and competitive sports within the U.S. is rising.

According to Mayo Clinic physiatrist Edward R. Laskowski, M.D., today's competitive athletes with disabilities are performing at a very high level and have reached some impressive milestones. Dr. Laskowski is the former co-director of Sports Medicine at Mayo Clinic's campus in Rochester, Minnesota, and has served as a member of the President's Council on Physical Fitness, Sports and Nutrition under Presidents George W. Bush and Barack Obama. Dr. Laskowski has authored peer-reviewed journal articles on strength training and conditioning in athletes with disabilities, and his 1992 publication in The American Journal of Sports Medicine on snow skiing injuries in the physically disabled population provided the impetus and data that enabled many ski areas to open their doors to adaptive skiing.

Becoming an elite competitive athlete may not be a realistic goal for every patient. But Dr. Laskowski notes that there's a large body of research demonstrating that individuals with disabilities who engage in some form of regular physical activity can experience significant and lasting positive impacts on their cardiovascular, musculoskeletal and psychosocial health.

Key considerations when designing a strength program for patients with disabilities

Engaging in some form of strength training can help patients develop the strength and coordination needed for a new activity, and it can help improve performance and prevent injuries in patients who are already engaged in some form of activity or sport.

There are a few categories of patients for whom strength training may not be appropriate. "People who have severe muscular dystrophy and those with active inflammatory myopathies, severe spasticity, or severe coordination or strength deficits may not be able to engage in typical strength training exercises," explains Dr. Laskowski.

For many other types of disabilities, however, the benefits associated with strength training are well documented. "Most individuals with neuromuscular disease, for instance, can benefit from engaging in some form of strength training," says Dr. Laskowski.

A basic strength program typically begins with developing muscle endurance through low weight and higher repetitions. Optimal form and technique are paramount to ensure maximum benefit and protection from injury. A single set of a strength exercise performed to muscle fatigue can provide almost all the same benefits as multiple sets. Dr. Laskowski offers these basic guidelines and suggestions to help keep patients with disabilities safe when engaging in strength training:

  • Ensure that spasticity and primitive reflex patterns do not interfere with exercise performance. In patients with spasticity, Dr. Laskowski explains that the patient should work on strengthening antagonist muscle groups, the muscle groups that oppose the muscles responsible for spasticity.
  • Strive for balance in muscle groups. Creating a program that helps patients work toward achieving muscle balance can also help address overuse and injuries to muscles that stem from a lack of balance. Individuals who use a wheelchair should strive for strength in the posterior shoulder and scapular stabilizer groups with the goal of producing a balanced shoulder force couple to protect the rotator cuff.
  • Focus on proper positioning, using straps as needed. "Proper technique, as well as balanced, stable and secure positioning are critical," says Dr. Laskowski. "Poor alignment can increase muscle tone and trigger primitive reflexes, particularly for patients with cerebral palsy or traumatic brain injury, or for those recovering from a stroke. Patients with cerebral palsy should attempt to maintain neutral head position and prevent neck flexion."
  • Straps can also help patients, including those with spasticity, maintain stable posture and limit maladaptive response patterns. An elastic binder or chest strap can help patients maintain trunk stability and diminish the stimulus for extensor spasm response. Below-knee strapping can help with adductor spasticity. Patients who use straps during strength training should be monitored closely for skin breakdown.
  • Use wrap-around weights and other adaptive equipment. Weights that can be wrapped around limbs and secured with fabric closures can be effective, particularly for amputees or patients with poor distal extremity (especially hand) function. Patients can also use manual resistance and tubing that allows them to exercise in multiple planes and diagonal spiral patterns.
  • Incorporate stretching for spasticity reduction and injury prophylaxis. "Because suboptimal flexibility can hinder positioning and increase the risk of pressure sores, performing stretching exercises is important. It can help with spasticity reduction and injury prophylaxis," says Dr. Laskowski. "Keep in mind that some patients with disabilities may need assistance to perform stretches."

Special considerations for patients with spinal cord injuries

When developing strength programs for patients with spinal cord injuries, Dr. Laskowski says there are additional adaptations that providers can consider. Some patients may need assistance with transfers and positioning on equipment, and some may require a spotter when using free weights. Correct positioning (with straps if needed) is key, with the goal of avoiding shear to the skin. Protecting insensate skin from pressure and cold temperatures are other priorities to keep in mind.

Patients with spinal cord injuries should avoid the Valsalva maneuver or breath-holding as these can affect blood pressure adversely and may cause incontinence. If their injuries are above T6 they should also be monitored closely for autonomic dysreflexia. Because they can be poikilothermic, patients with spinal cord injuries may also need to have the room temperature adjusted using fans or air conditioning.

For more information

Laskowski ER, et al. Snow skiing injuries in physically disabled skiers. The American Journal of Sports Medicine. 1992;20:553.