How to keep fit when you are in a wheelchair

Wheelchair users have reported how important it is stay fit and strong (1), and there is a wealth of information available online to help (2)

There are many reasons for using a wheelchair (3), and your fitness routine must accommodate your particular needs and preferences. Safety is key. An assessment from a professional, such as a registered Physiotherapist, is a good way to get the program that works for you and keeps you safe.  

Here are some ideas to get you started. Remember, if you’re new to exercise, go slowly. Add to your routine in increments that allow your body to adjust.

1.     Cardiorespiratory fitness.

The simplest way to work on cardio fitness for manual chair users is to push yourself around in your chair. Find some uncluttered space and use your arms and legs together if possible. Add a notch of challenge to this by increasing speed (make sure you’re in a traffic-free, flat area).

Other options are to use a seated bike (for arms or legs), rowing machine or elliptical that you can access from a wheelchair. Build up your time gradually, and stretch afterwards.

And there’s the wide world of wheelchair sports to explore and enjoy, sports like basketball, netball, tennis, table tennis, badminton, hockey, and sledge hockey (4)

2.     Strengthening.

If you use a manual wheelchair, shoulder and arm strength is very important, as overuse injuries of these areas are common.

Use resistance and/ or repetitions to build up strength (weights or resistance bands).

Examples of arm/upper back and neck exercises that can be performed in a wheelchair are:

·      Just wheeling yourself around will strengthen your back, arms and shoulders.

·      Biceps curls. Take a weight in your hand and bend your elbow, then slowly straighten.

·      Arm raises overhead (overhead press) with a weight. Bend your elbows so that your hands are next to your shoulders. Raise your arms above your head. Return to the starting position slowly.

·      If you can’t lift your arms overhead, you could try putting your hands on the wheelchair arms and lifting yourself up a few centimeters. This strengthens your back and triceps.

·      Chest press. Holding a band wrapped around your back and under your arms, reach forwards so that the band is stretching as you straighten your elbows.

·      Sit tall with a chin tuck and squeeze your shoulder-blades together, keeping your shoulders down. This helps with posture.

There are many more exercises that can be completed for leg and core strengthening, and they should be adapted to your abilities. Check out (1) for more information, exercises and routines.

3.     Flexibility.

Stretching is important as it’s easy to tighten up sitting in one position.

Ideally you would do some stretches out of the wheelchair. For example, lying on your back or your tummy will open the hips and stretch the back. Lying on your back, putting your feet together and allowing the knees to come apart will also open the hips.

Some examples of stretching in sitting are:

a.     Biceps. Stretch your arm horizontally behind you until you feel biceps stretching gently.

b.     Triceps. Put your right hand on your left elbow and stretch your bent arm overhead, then swap arms.

c.     Chest. Open up your chest by taking both arms (at 90 degrees or lower) behind you until you feel a gentle stretch across the chest.

d.     Upper back. Clasp your hands together and reach forwards with your arms at 90 degrees. You should feel a gentle stretch in between your shoulder-blades.

Sometimes stretching before exercise is needed if you are stiff. Always stretch after working out and stretch often whilst in your chair. Hold stretches for 30-60 secs or as your therapist recommends.

4.     Balance. If safe, you could work on sitting balance by sitting tall and forward from the back of the chair, trying not to assist with your arms. Try moving side to side while upright. Check out this video (5): it shows working on balance in your chair using a cushion. If you are able to stand then this should be incorporated safely into your program.

5.     Functional activities. This might include working on moving around in the chair indoors or outdoors. It may include standing at a kitchen counter with your wheelchair safely behind you, with the brakes on. If you are able to get outside check out the links below for wheelchair accessible trails in Toronto. (6)

Happy Exercising!

R. Sian Owen PT

Registered Physiotherapist

(1)  Exercise in a wheelchair

 https://www.shape.com/lifestyle/mind-and-body/people-dont-know-about-staying-fit-wheelchair

https://www.womenshealthmag.com/uk/fitness/workouts/g37402259/wheelchair-workouts/

(2) For seniors

https://frontiermgmt.com/blog/5-great-exercises-for-seniors-in-wheelchairs/

https://agerrtc.washington.edu/sites/agerrtc/files/files/Aging_Exercise.pdf

(2) General

https://www.nhs.uk/live-well/exercise/exercise-guidelines/wheelchair-users-fitness-advice/

(3)

https://www.physio-pedia.com/Wheelchair_Users

(4) Sports

https://onpara.ca/

https://mobilitydeck.com/wheelchair-sport/

https://torontoaccessiblesports.ca/

https://bowlscanada.com/en/programs-resources/para-bowls/

Sports wheelchair loans: https://onpara.ca/getting-started-in-para/wheelchair-rentals/

(5) Balance

 https://www.youtube.com/watch?v=rbhDHOi6hTM

(6) Additional information

Toronto and Region Conservation Authority accessibility information

https://trca.ca/about/accessibility-trca-facilities/

Wheelchair accessible park trails in Toronto

https://www.alltrails.com/canada/ontario/toronto/ada

Balance.

How do we achieve balance?

Balance occurs when our centre of gravity is within our base of support. Our base of support includes every point of contact we make with a supporting surface. For example, this is made up by our feet when we’re upright, and our buttocks and upper legs when we’re seated.  If our centre of gravity moves too far beyond our base of support, we will stumble or fall unless we can correct our posture quickly. Balance declines with age, and the risk of falling increases, so it is important to include balance work in our exercise routines.

What systems are involved?

1.     Sensation/proprioception: we need to be able to judge where we are in space so we can keep within our base of support (or to correct if we are moving outside of it). We learn a lot about where our limbs and bodies are in space simply through touch, but also through a kind of sixth sense that evolves from neurons in our muscles, tendons and joints communicating with our brains about body movement and position.

2.     Vestibular system: this is based in our inner ear and gives us constant feedback on how to maintain balance, including postural corrections needed to avoid falling.

3.     Visual system: our eyes add to the information already received by 1 and 2.

Note that to be able to maintain our balance using these systems we need strength in our lower extremities and core, and flexibility to be able to move our body back into a balanced position.

Balance is often divided into:

1.     Static Balance: this is the ability to maintain postural stability in a fixed position, such as standing.

2.     Dynamic Balance: this is the ability to maintain postural stability when some part of the body is moving, such as in walking.

Can exercise improve our balance?

YES! Not only do we need strength and flexibility, we need to challenge the systems that help us balance (see systems involved above.) The easiest way to do this is to incorporate balance exercises into our daily routine.

What exercises can I do?

This depends on your ability. If you prefer a group setting you could try Tai Chi, yoga or a balance class at your level.

If you have any medical conditions that affect your balance, such as Parkinson’s disease or stroke, I recommend you discuss with your MD and see a professional, such as a Physiotherapist, who can assess your needs and provide you with a tailored program.  

Here are some exercises to try - remember safety is key! Use a wall or sturdy chair for support or have someone stand nearby. Stand tall and maintain good posture throughout the exercises. For #5 below, ensure you maintain a good chin tuck and have core muscles activated.

1.     Weight shifts. Stand with your feet hip width apart. Gently shift your weight to the right and lift the left leg off the floor. Hold for up to 30 seconds and try the right side.

2.     Standing on one leg. Put your hands on your hips. Lift your left leg off the floor and bend your knee back.  Gradually increase the time/repetitions. To increase the challenge try reaching out your left foot to the side, forwards or backwards or keep moving it.  

3.     Walk heel to toe for 10 steps. Use a wall for support as needed.

4.     Try walking sideways 5 steps each way.

5.     Bird Dog. For a much bigger challenge, if you are able to get down to the floor and back up again easily, and your knees are ok in this position, try 4 point kneeling (on hands and knees) on a yoga mat or soft rug, activate your abdominal muscles and then lift your left arm and right leg straight out. Balance in this position for 5 seconds and switch to the other side. This is a great core work-out that also targets your balance skills. As you progress, you can increase the time you spend balancing in this way.

If you can do exercises 1-4 safely, try incorporating them into your day. For example, can you stand on one leg while cleaning your teeth? Or working at the sink in your kitchen? (not while you’re cooking something though!) Can you walk heel to toe around your home or office?

See the links below for more balance exercises and tips:

https://www.mayoclinic.org/healthy-lifestyle/fitness/multimedia/balance-exercises/sls-20076853

https://www.nhs.uk/live-well/exercise/strength-and-flexibility-exercises/balance-exercises/

R. Sian Owen PT

Registered Physiotherapist

Safety Is Key When Using Walkers.

Walkers vary in size, design and detail. There is evidence that while walkers do encourage mobility and independence, walker users are at higher risk of falls than non-walker users (Physiopedia), so safety is key.

The references below contain excellent information about walkers, which I won’t repeat here. The Physiopedia article is particularly thorough, with information on walker types, factors involved in walker prescription, usage and correct maintenance.  

I will make two strong recommendations.

No matter what your reason for buying a walker, it is crucial to get properly assessed by a PT or OT with experience in this area.  There are many factors involved in choosing the right walker for your needs, and PTs and OTs have the skills to help you decide. In addition, the Government of Ontario’s Assistive Devices Program (ADP) helps fund the purchase of medical assistive devices, including walkers. To apply for this assistance you must work with an ADP-registered PT or OT. The Government of Ontario ADP website below provides a list of ADP registered therapists in your area. You can also ask your vendor if they have links with ADP registered therapists.

And finally, try the walker out before you buy. If you’re buying online make sure you can return the walker easily and free of charge.

R. Sian Owen

Registered Physiotherapist

References/Further Reading

1.     Physiopedia- excellent article on different walker types. Includes important information about paradoxical increased risk of falls in walker users, and reported benefits of increased mobility and independence.

https://www.physio-pedia.com/Walkers#:~:text=A%20walker%20is%20a%20walking,mobility%20or%20lower%20extremity%20impairment.

2.     ADP -Government of Ontario program to help finance medical equipment including aids to mobility. Must apply and be assessed by an ADP-certified therapist (PT or OT).

https://www.ontario.ca/page/mobility-aids

3.     Mayo Clinic – good detail on different walker types and safe use.

https://www.mayoclinic.org/healthy-lifestyle/healthy-aging/multimedia/walker/sls-20076469

4.     Medline (National Library of Medicine USA) – focus is on safe use. Links to other helpful articles.

https://medlineplus.gov/ency/patientinstructions/000342.htm

Vendors

This is as incomplete list of vendors in the Toronto area.  (Vendors included in this list are for your convenience, and do not represent a recommendation by Sian Owen Physiotherapy.)

LifeCare Mobility (authorized ADP vendor)

https://www.lifecaremobility.ca/wheeled-walkers-rollators-toronto/

HME (Home Medical Equipment)

https://www.hmemobility.com/walkers/

Vital Mobility - Bariatric Walkers

https://www.vitalmobility.ca/Products/Walkers/Bariatric-Walkers.php

InMotion Services

https://inmotionservices.ca/collections/walkers

Silver Cross

https://silvercrossstores.com/walkers-rollators/

Wellwise (Shoppers)

https://shop.wellwise.ca/search?type=product&options%5Bprefix%5D=last&options%5Bunavailable_products%5D=last&q=walkers&pf_t_category=category%3ARollators+%26+Walkers

Starkmans

https://starkmans.com/catalogsearch/result/?q=walkers

Med + Medical Equipment Distribution

https://www.medplushealth.ca/product-category/walkers-rollators/

Sources of additional financial help

Wellwise (Shoppers) Sources of additional financial help for assistive devices, mobility devices and home modifications.

https://shop.wellwise.ca/pages/funding-assistance

What mattress should I buy?

All the literature points to the fact that there is no one “correct” mattress out there. Mattresses come in different sizes, designs, firmness, and fill material. Some claim to be organic, although it seems that they can do this if only one part of the mattress uses organic material. And mattresses are only one part of the equation for sleep: the correct pillow is very important. See my blog October 2022 by clicking HERE.

Some key points we found in our reading:

·      Detailed independent analysis may be a helpful starting point. (1)

·      A deep dive into mattress testing published by an Italian academic study suggests some benefit to a medium firm mattress for people with low back pain. (2)

·      What firmness, fill type or design is right for you is personal. Some people will consider a “firm” mattress too firm, some consider them not firm enough.

·      You should lie on a new mattress for at least 20 mins before deciding to buy. Change position. Feel for pain points, numbness, tingling, any kind of discomfort. Your spine should be supported so it is in neutral alignment. That means that when you’re on your back there should be a small curve in your low back which is fully supported by the mattress. When on your side your spine should be straight and feel completely supported.

·      Although it’s always better to shop in person, you may prefer to buy online: check the reviews, ask friends/family about their mattresses.  

·      As with pillows, the mattress shop/website should offer you a good return policy- some allow you to keep the mattress for 100 days. They should collect the returned mattress for free and provide a full refund. (We asked about the wasteful impact of this in one store and were told by an employee that returned mattresses do not go to landfill -they are used in their stores to allow customers to try them out).

·      High prices don’t necessarily mean better comfort and durability for you.

·      Mattresses should be replaced when they start to cause you discomfort, increased allergy symptoms, or become shapeless. A general estimate (from websites reviewed) is every 6-10 years.

Good resources for further reading/viewing

1.     “Consumer Reports” provides a free overview and general buying guide. Must pay to join and see all details, though.

https://www.consumerreports.org/home-garden/mattresses/buying-guide/?EXTKEY=SG72H00&ds_rl=1247060&gclid=Cj0KCQjwhsmaBhCvARIsAIbEbH7jTBZ7lgO4iiVyyMatBO98LsHRiUvlYc_zLyJtq3hmvvBxXB5goRMaAtPAEALw_wcB&gclsrc=aw.ds

2.     National Library of Medicine (Pubmed) meta-analysis of over 30 articles on what type of mattress helps reduce back pain and improve sleep quality

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8655046/

3.     New York Times- Wire Cutter review of several mattresses. Contains good general information about mattress buying. Wire Cutter independently reviews products but will receive a commission if products are bought through their links. Seems thorough and helpful, but delivery to Canada doesn’t seem to be an option, so you would have to search for the mattress you like via its own website. Read the “About Us” on the site if you’re not sure.

https://www.nytimes.com/wirecutter/guides/buying-a-mattress/

R. Sian Owen PT

Registered Physiotherapist

5 Ways To Keep Your Bones Healthy And Reduce The Risk Of Osteoporosis

1.     DO regular weight bearing exercise such as walking, hiking, jogging, climbing stairs, tennis, and dancing. Note: if you already have osteoporosis, you should consult your doctor or physiotherapist to make sure which exercise is safe for you.

2.     DO strengthen your body, particularly your core and hips; Progressive resistance training is recommended for bone quality along with regular weight bearing exercise. (1) (2)

3.     DO take in calcium and vitamin D, preferably in your diet, or as a supplement if recommended by your doctor.

4.     DO get enough quality sleep. This allows your body to replenish and repair itself.

5.     DO limit alcohol and tobacco.

A physiotherapist with expertise in this area can assess you and provide a comprehensive exercise program tailored to your needs, whether you have osteopenia, osteoporosis or just want to reduce the risk.

Look out for my next blog for more detail about exercise for healthy bones.

 R. Sian Owen PT

(1) Howe T, Shea B, Dawson L, et al. Exercise for preventing and treating osteoporosis in postmenopausal women. Cochrane Database Syst Rev. 2011;(7):CD000333. doi:10.1002/14651858.CD000333.pub2.www. cochranelibrary.com.

(2) 2010 clinical practice guidelines for the diagnosis and management of osteoporosis in Canada:summary Alexandra Papaioannou, Suzanne Morin, Angela M. Cheung, Stephanie Atkinson, Jacques P. Brown, Sidney Feldman, David A. Hanley, Anthony Hodsman, Sophie A. Jamal, Stephanie M. Kaiser, Brent Kvern, Kerry Siminoski, William D. Leslie and ; for the Scientific Advisory Council of Osteoporosis Canada CMAJ November 23, 2010 182 (17) 1864-1873; DOI: https://doi.org/10.1503/cmaj.10077

Physiotherapy in the management of Persistent Post Concussion Symptoms Part 2

Post traumatic headaches - how can physio help?

What is a post-traumatic headache?

It is a headache which can occur following any brain injury, and is one of the most common complaints following a mild traumatic brain injury. (Ref 1-4)

Often the headache will resolve quickly following the original injury, but in some clients the headache persists. If it continues beyond 3 months, it is termed chronic.

What types of post traumatic headaches are there?

There are many causes and types of headaches and it is important to have a reliable diagnosis, so that the appropriate treatment can be determined.

The Ontario Neurotrauma Foundation has identified four common types in adults following a mild traumatic brain injury:

1.     Migraine without aura

2.     Frequent episodic tension-type headache

3.     Primary stabbing headache

4.     Occipital neuralgia

Headaches may be made up of more than one of these types.

You can get more detailed information here:  http://braininjuryguidelines.org/concussion/

It’s important to note that headaches can also be caused by medication over-use. These are called rebound headaches. Your doctor will assess whether medication is the possible cause and develop a plan with you to deal with the problem.

What can physio do to help?

Once an assessment has been completed, your physiotherapist can help by advising, guiding and treating the following areas:

1.     Pain, by using modalities such as heat, ice, acupuncture, manual therapy or Integrative Manual Therapy as needed.

2.     Head and neck posture.

3.     Stretches for the neck and upper body.

4.     Strengthening for the neck and upper body when appropriate.

5.     Cardiorespiratory exercise. Some headaches are aggravated by exercise. Your physiotherapist will guide you to the most appropriate program for you.

6.     All exercise must be performed in a graduated way so that there are minimal injuries, and you are successful in getting the benefits from your program.

R. Sian Owen PT

Registered Physiotherapist

1.Gladstone J. From psychoneurosis to ICHD-2: an overview of the state of the art in post-traumatic headache. Headache. 2009;49(7):1097-1111.

2. Dikmen S, Machamer J, Fann JR, Temkin NR. Rates of symptom reporting following traumatic brain injury. J Int Neuropsychol Soc. 2010;16(3):401-411.

3. Lew HL, Lin PH, Fuh JL, Wang SJ, Clark DJ, Walker WC. Characteristics and treatment of headache after traumatic brain injury: a focused review. Am J Phys Med Rehabil. 2006;85(7):619-627.

4. Lew HL, Poole JH, Guillory SB, Salerno RM, Leskin G, Sigford B. Persistent problems after traumatic brain injury: The need for long-term follow-up and coordinated care. J Rehabil Res Dev. 2006;43(2):vii-x.

Physiotherapy in the Management of Post Concussion Syndrome (Persistent Post Concussion Symptoms)

I just got back from a most informative and exciting course on Post Concussion Syndrome with Jacquie van Ierssel PT, a physiotherapist who has developed “R2P”, a systematic and evidence- based approach to identify causes of concussion symptoms and create a treatment plan. It was great to see how much physiotherapy can do to help. Thank you Jacquie!

I want to share some of my learning with you, and in the next few blogs I plan to do just that.

First of all:

What is post concussion syndrome, or persistent post concussion symptoms as it is now being called?

Up to 15% of people with concussion may have persistent symptoms. The Ontario Neurotrauma Foundation guidelines recommend a referral for a specialized assessment if symptoms persist at one month post injury. (1)

The diagnosis is based on symptoms (see below) and your Doctor may use diagnostic criteria from the World Health Organisation and/or the Diagnostic and Statistical Manual of Mental Disorders. Because symptoms can be the same as in a variety of other conditions, obtaining the correct diagnosis can be difficult.

The following are common symptoms: (from Willer and Leddy (2))

Physical: headache, nausea, vomiting, blurred or double vision, seeing stars or lights, balance problems, dizziness,sensitivity to light or noise, tinnitus.

Behavioural or emotional: drowsiness, fatigue or lethargy, irritability, depression, anxiety, sleeping more than usual, difficulty falling asleep. 

Cognitive: feeling “slowed down”, feeling “in a fog” or “dazed”, difficulty concentrating, difficulty remembering. 

Symptoms do vary.  Some people experience three or four while others may be dealing with more, and they can persist for months and even years.

What happens in treatment?

Education is a key component. Treatment will focus on addressing the physical/cognitive/psychological challenges arising from the concussion.  A team approach works best for managing persistent post concussion symptoms.

What can the physiotherapist do to help?

The physiotherapist can help treat post traumatic headaches, dizziness and poor balance (vestibular problems), fatigue, and vision (ocular motor). After an in-depth assessment the physiotherapist can provide a program specifically designed to address your problems. Appropriate exercises will help to improve sleep and mood, as well providing physical benefits such as increased strength, better balance and posture and improved exercise tolerance. The physiotherapist will also work with other healthcare providers as needed.

I will go into more detail about treatment in my next blog.

(1) onf.org/documents/guidelines-for-concussion-mtbi-persistent-symptoms-second-edition

(2) https://www.ncbi.nlm.nih.gov/pubmed/16901381

R. Sian Owen PT

Registered Physiotherapist

How To Climb Stairs Safely With A Cane

This can be tricky if you don't know how! 

First, make sure your cane is adjusted to the correct height. Ask your physio to do this. If you don't have access to a physio, look at my blog entitled "how to get your cane height right."

The general rule for stair climbing is put the good leg up first when going up, and put the affected leg first when going down. 

With a rail

Facing forwards, put the cane in the opposite hand to to rail.

Going up

1. Take the first step up with the good leg. Leave the cane on the step with your affected leg. (Unless your physio asks you to do this differently). Take weight through the cane and rail when stepping up with your good leg. 

2. Then move the cane followed by the affected leg.

Going down

1. Hold the rail. Put your cane down first, then your affected leg. 

2. Step down with the good leg.

What happens if you don't have a rail? 

If your physio tells you that you are ok with just one cane, (you could use 2 for more support on steps with no rail), then:

Keep the cane in the hand opposite your affected leg, as you would for normal walking and follow the general rule for stairs. 

Put your good leg up first when going up, and your cane then affected leg down first when going down. 

This link has some nice pictures to make everything clear.

http://www.hamiltonhealthsciences.ca/documents/Patient%20Education/SafeStairClimbingCane-th.pdf

R. Sian Owen PT

Registered Phystiotherapist

How To Get Your Cane Height Right

Here are a few tips if you don't have access to a physiotherapist to do this for you.

Why is it important to have your cane at the appropriate height? 

It is easy to alter your posture to accommodate a cane at the wrong height, and then very easy to cause other injuries because of this poor posture/alignment. 

How do I measure? 

I think the easiest way to measure the height is to use the wrist crease. You will find this on the inside of your wrist. Stand and relax your arm by your side. Adjust your cane height vertically to the ground from the wrist crease. 

Check that your elbow remains slightly bent (about 15◦) and is not fully straight when you apply weight. 

How do I adjust an aluminum cane? 

Most will have an anti-rattle collar. Unscrew this, then press in the push button and adjust the height. Once you have the correct height, remember to tighten the anti-rattle collar. 

Watch out for my video on this, coming in 2017! 

R. Sian Owen

Registered Physiotherapist

Working from home during Covid-19.

Many of us are having to work from home in the current environment. Often workplaces are set up ergonomically so that we can reduce injuries such as repetitive strain, but are our homes?

Here are a few suggestions to help reduce the stress on your body.

1.Work set up.

• If you have an adjustable chair make sure it’s set up for your body: your hips and knees should be at approximately 90 degrees.

• The back of the chair should be vertical. Support your lumbar spine (‘the small of your back’) with a small cushion or rolled up towel. Adjust the size of the cushion if it is not comfortable or you have pain.

• The height of the desk/table you work at should allow you to rest your elbows without slouching, and keep your shoulders relaxed (not raised).

• Use books or boxes (whatever works) to adjust your screen to eye height.

2. Posture
Think about your posture in general but start with your head posture because your head leads the way.

• Your head weighs about 10lbs and perches on top of your spine. Working at a computer or talking on the phone, it’s very easy to bring your head into a position that will put stress on your neck and back muscles, and ultimately affect your whole body. This is called a “head forwards” posture, where your chin sticks out and your neck muscles start to work too hard to hold the weight.

• Avoid this by checking your head posture frequently: set a timer on your computer for every 30 minutes or so and do a head check. This exercise will help:

  • Keeping your eyes level, gradually lengthen your neck upwards as you tuck your chin in gently.

  • Bring your shoulder blades down and back towards your spine.

  • Hold for 5 secs. Repeat often.

  • Do not push through pain and stop if you have any.

You will need a modified program if you have had an accident and/or you have a neck condition such as arthritis.

See my blog Text Neck April 2019 for more details.

http://icanmove.com/blog/2019/4/15/text-neck-what-is-it-and-what-can-i-do-to-reduce-the-problem

R. Sian Owen PT

Registered Physiotherapist