Iranian Rehabilitation Journal, Vol. 11, No. 18, October 2013
Original Article

Effects of Upper Limb Exercises on Physical Capacity and Heart
Function in Quadriplegics
Kanupriya Arora
ISIC Institute of Rehabilitation Sciences, New Delhi

Majumi Mohamad Noohu1
Centre for Physiotherapy and Rehabilitation Sciences, Jamia Millia Islamia, New Delhi

Introduction: Wheelchairs are the prime mobility aid of persons with spinal cord injuries. Manual
wheelchair propulsion puts a lot of demand on the cardiopulmonary as well as the skeletal system. The
main purpose of the study was to compare the effects of both arm ergometry training and progressive
resistance exercise training of upper limbs on resting heart rate and distance covered during wheelchair
propulsion in paraplegics.
Method: A convenience sample of 30 male subjects took were randomly assigned to two groups.
Participants were spinal cord injured patients recruited from the Indian Spinal Injuries Centre, New Delhi.
Each group consisted of 15 subjects. Group 1 received arm ergometry training and group 2 received
progressive resistance exercise training. The resting heart rate and distance covered during wheelchair
propulsion in a 3 minutes task of the wheelchair circuit was measured before and after 4 weeks oftraining.
Results: The post intervention resting heart rate and distance covered during wheelchair propulsion after
4 weeks between the two groups showed significant differences. In group 1, resting heart rate was
77.53±3.52 beats/min and in group 2 resting heart rate was 82.33±3.69 beats/min (mean±SD). In group 1,
the distance covered during wheelchair propulsion was 305.19±17.21 meters and in group 2 it was
250.71+20.59 meters.
Conclusion: The arm ergometry training may be a better choice of exercise for improving the
cardiovascular and functional aspect of spinal cord injury patients who are dependent on wheelchairs formobility.
Keywords: Paraplegia, wheelchair, endurance, ergometry, functional independence.
Submitted: 15may2013
Accepted: 20september2013

Introduction
Wheelchairs are important in achieving independent
mobility as approximately 82% of persons withspinal cord injury (SCI) depend on the wheelchairfor their mobility purposes [1]. Manual wheelchair
propulsion is a straining form of ambulation, bothfor the cardiopulmonary as well as the skeletal
system. Manual wheelchair propulsion is based on
the use of upper extremities which are usuallycapable of producing less force than the lower limbs
with less mechanical efficiency [2].
The normal daily locomotor patterns of wheelchairdependent individuals are insufficient to maintain or
improve fitness levels. The lack of adequate fitnesslevels is a major concern in individuals who havelower body disablement. Therefore an upper limb

exercise is important to maintain adequate levels offitness in spinal cord injured persons using awheelchair. Moreover, it is important to attempt toestablish training models that serve the needs of
persons confined to the wheelchair [3]. The conceptof exercise specificity however suggests that use ofan exercise mode which resembles wheelchair
activity may be advantageous. So recently arm
ergometry and wheelchair ergometry have shown tosimulate actual wheelchair locomotion and are usedas the bases of exercise tests to evaluate fitness forwheelchair activity [4]. It’s been reported that
resting heart rate is generally higher in those withlesions below T5 than in the uninjured population[5].

1- All correspondances to: Majumi Mohamad Noohu, Email:<mnoohu@jmi.ac.in>

Iranian Rehabilitation Journal

25

Arm ergometry is an electronic arm bicycle used forexercises of the upper limbs. It is similar to the leg
bicycle with two pedals which can be propelled bysubjects while in a seated position. It is the mostreliable and valid exercise mode for clinical andfunctional evaluation of exercise performance andfor optimal prescription of individualized exercise
training programs in SCI individuals [4, 6].
Progressive resistance exercises in physical therapy(PRE) provide a practical application of the overload
principle and form the basis of most resistancetraining programs [7].
Dicarlo documented the effects of arm ergometry
training on wheelchair propulsion in individuals
with quadriplegia [8]. S.Nilsson and P.H Staff haveshown a significant increase in the maximal oxygen
uptake and maximal dynamic strength andendurance in 12 paraplegics who had undergone 7
weeks of intensive training [6]. Studies showing thephysiological responses with an arm crank andwheelchair ergometry in SCI are well documented[9,10,11]. Studies have also shown the effects ofstrength training on wheelchair users [11,12].In thisstudy there are not many studies that have compared
the effects of arm ergometry training and strength
training on resting heart rate and wheelchair
propulsion in paraplegics.
Therefore, the main purpose of this study was tocompare the effects of both arm ergometry training
and progressive resistance exercise training of upper
limbs on resting heart rate and distance covered
during wheelchair propulsion in paraplegics.
Methods
A convenience sample of 30 male subjects was
randomly assigned to two groups through the lottery
method. The study was of pretest post-test
experimental design. Participants were spinal cord
injured patients recruited from a sub-specialty centre
for treating spinal cord injuries in New Delhi. Eachgroup consisted of 15 subjects. Group 1 received
arm ergometry training. Group 2 received
Progressive resistance exercise training. To avoid
selection bias the following conditions wereobserved: the level of injury was T6-T12, patientswere aged between 20-40 years, a minimum spinal
cord independence measure score (SCIM) of 80, allparticipants should have been wheelchair users who
could propel the wheelchair for at least 3 minutes,
and patients should’ve been undergoing a regularrehabilitation program with no participation in any
other endurance training program. The study was26

approved by the research and ethics committee of
the institute affiliated with the hospital.
The Standard active wheelchair and its dimensions
are of: 16 inches length, 16 inches seat width, 16
inches height, standard measuring tape, standardized
weighing machine for wheel chair dependent, pulse
oximeter, Reck Motomed arm cycle ergometer andfree weights of different kilograms were theinstruments used. An informed consent was takenfrom all the subjects and detailed explanation of theprocedure was given. The patient’s Demographic
data and neurological details were collected.
Preliminary measurements were taken prior to thebeginning of the study which included body weightand spinal cord independence measure score.
The resting heart rate was measured using pulse
oximeter in the morning in fasting state. The
subjects were asked to relax for five minutes. The
pulse oximeter probe was then attached to thepatient’s middle finger. The graphical display of theheart rate was noted. The pre-training distancecovered during wheelchair propulsion in the 3
minutes task of the wheelchair circuit was measured.
Subjects were seated on a standard wheelchair andwere instructed to propel the wheelchair from thestarting position marked on the 200 meter track withmarkings of 100 and 200 meters for 3 minutes [1].
Subjects were instructed to begin on a signal and tocontinue wheeling on a track until the stop sign wasgiven. Subjects were free to determine theirindividual strategy for optimal performance. A 4week protocol was carried out for both groups.
Interval arm ergometer training program was carriedout for group 1 subjects and Delorm’s & Watkins
protocol was followed for group 2 subjects [13].
The training mode was arm pedaling on an
ergometer on a schedule of 3 times a week with 2
sets for 4 weeks. Training was closely supervisedand daily logs were maintained for both workload
and training heart rate. The starting phase of theexercise session included 5 minutes of warm up
which provided stretching or arm pedaling on an
ergometer. The arm pedaling was done on theergometer at 50 rpm during the first week; at 50 rpm
for 15 minutes plus an additional 5 minutes at 60rpm in the second week, then at 50 rpm for 15
minutes at 60 rpm in the third week, then at 60 rpm
with an additional 15 minutes at 60 rpm in the fourthweek. The resistance load was kept constant at 0.5
kg. A rest period of 5 minutes in-between sets wasgiven. At the end of each session 5 minutes of cool
down was also included for group 1. Group 2Vol. 11, No. 18, October. 2013

subjects were made to relax and were well
positioned according to the muscle group to betested against gravity. 10 Repetition maximum (10RM) was calculated for each muscle individually.
Subjects were given different weights for particular
muscles to be tested. So the maximum weight which
was lifted for a complete range of motion for 10
times was considered as the 10 RM. Rest period wasprovided in-between [7]. Caution was taken to begin
the training session on the following day of
calculating the 10 RM. The muscles which were
tested and trained included anterior and posteriordeltoid, infraspinatus, pectoralis major, middle
trapezius, biceps, triceps and wrist extensors. All
these muscles were trained in their standardized
position against gravity. Training sessions included
3 sets of exercises for multiple muscle groups; each
set consisting of 10 repetitions with 3 minute rests
in-between. The first set required one half of 10 RM,
the second set used 3/4th the 10 RM, and the final set
used 10 RM of maximum weight. The training
sessions were held 3 times a week. After the end ofeach week, 10 RM was again calculated and thesame training procedure was followed for eachmuscle with the new 10 RM.
After 4 weeks of training, the resting heart rate
(beats per minute) and distance covered during
wheelchair propulsion (meters) were recorded. Posttraining resting heart rate was measured in themorning after 4 weeks using pulse oximeter for both
the groups. The distance covered during 3 minutesof wheelchair propulsion was measured using thewheelchair circuit test on a 200 meter track.
Data Analysis The data was managed on an Excel
spread sheet and was analyzed using SPSS software.

A significance level of P≤0.05 was used. T-tests
were used to find the differences between the effects
of arm ergometry training and progressive resistance
exercise training of upper limbs on resting heart rateand distance covered during wheelchair propulsion
in paraplegics. Paired t-test was used for analysis
within the group.
Results
Group 1 consisted of paraplegic patients with thefollowing particulars; age: 30.6±5.31 years(mean±SD); duration of injury: 329.80±54.82 days;
weight: 60.33±4.95 kg; SCIM score: 85.20±1.65.
The patients in group 2 had the following
particulars; age: 30.46±4.79 years; duration of
injury: 329.26±55.94 days; weight: 60.66±4.77 kg;
SCIM score: 85.
Analysis of data indicates that there were no
significant differences in pre-test values of restingheart rate and distance covered during wheelchair
propulsion between the two groups. The pre-testvalue of heart rate in group 1 was 84.13±2.87
beats/min and in group 2 was 84.53±3.50 beats/min.
Pre-test values for distance covered during wheelchair
propulsion in group 1 and group 2 were 238.41±16.19
and 238.02±19.85 meters. Comparison of postintervention resting heart rate between the two groups
showed significant differences; being 77.53±3.52
beats/min in group 1 and 82.33±3.69 beats/min ingroup 2. Comparison of post-test distance covered
during wheelchair propulsion between the two groups
showed a significant difference; being 305.19±17.21
meters in group 1 and 250.71+20.59 meters in group
2 table (1).

Table 1: Comparison of pre-training and post-training resting heart rate and distance covered during wheelchair
propulsion between the two groups
Variable
Pre-Training Resting Heart rate
(beats/min)Post-Training Resting Heart rate
(beats/min)
Pre-Training Distance Covered inWheelchair Propulsion (m)Post-Training Distance Covered inWheelchair Propulsion (m)Group 1N=15(mean+SD)

Group 2
N=15(mean+SD)tp84.13 + 2.8

84.53 +3.5

.342

0.735

77.53 + 3.52

82.33 + 3.69

3.64

0.001

238.41+ 16.19

238 +0.02 19.85

0.06

0.953

305.19 + 17.21

250 + 20.59

7.86

0.001

comparison of pre and post intervention scores ofresting heart rate and distance covered during
wheelchair propulsion within the two groups showed
Iranian Rehabilitation Journalsignificant differences too. In group 1, the restingheart rate was 84.13±2.87 beats/min (mean±SD) at
day 0, and 77.53±3.52 beats/min at the end of the 4th

27week. In group 2, the resting heart rate was
84.53±3.50 beats/min at day 0 and 82.33±3.69
beats/min at the end of the 4th week. In group 1, thedistance covered during wheelchair propulsion was
238.41±16.19 meters at day 0, and 305.19±17.21

meters at the end of the 4th week. In group 2 thesame measure was 238.02±19.85 meters at day 0,
and 250.71±20.59 meters at the end of the 4th week
table (2).

Table 2: Comparison of pre-training and post-training resting heart rate and distance covered during wheelchair
propulsion within the two groups
VariableGroup

Resting Heartrate(beats/min)

Group 1N=15Group 2N=15Group 1
N=15Distance
Covered inWheelchair
Propulsion(m)Group 2
N=15Pre-training(mean+SD)

Post training(mean+SD)tp84.13 + 2.8

77.53 + 3.52

21.60

0.001

84.53 +3.5

82.33 + 3.69

5.01

0.001

238.41+ 16.19

250 + 20.59

16.73

0.001

238+.02 19.85

305.19 + 17.21

16.73

0.001

Discussion
Significant improvements were seen between the twogroups in resting heart rate after 4 distances covered by
the subjects in favor of group 1 subject. Possible
explanations for the reduction in post-training heart
rate values and increased distance covered by subjects
can be central as well as peripheral adaptations of the
body. Peripheral adaptations result in improvement ofoxidative metabolic capacity, oxygen extraction andincreased muscle blood flow, whereas central
adaptation results in enhanced cardiac output andstroke volume with a compensatory decrease insympathetic stimulation and alteration in the central
nervous system and adaptation in the trained muscle.
Central cardiac improvement after exercise results inincreased volume loading and reduced heart rate
because of a decreased sympathetic drive withdecreased levels of epinephrine and nor epinephrine[14].
On comparing mean percentage decrease in restingheart rate after 4 weeks, there were significant
differences between the two groups. Group 1 showed
greater improvement with mean decreases in restingheart rate of 7.05%, versus group 2, where a mean
decrease of 2.6% was observed after 4 weeks. There
were also significant differences between the twogroups on comparing the distance covered during
wheelchair propulsion. Group 1 showed greater
improvement with a mean increase of 28.00% in the
distance covered, versus group 2, where a mean
increase of 5.33% was observed after 4 weeks.
These results are in agreement with a previous study
showing improvement in cardiopulmonary functions

28

in parallel with an increase in wheelchair propulsion
endurance in quadriplegics [8]. This study also
reported that subjects exercising on an arm
ergometer were able to work more efficiently. Thechanges in cardiovascular functional status might
have contributed to the differences seen in group 1.
Another factor might be the exercise specificity
which helped improve the function. The arm
ergometry training simulates more of a functional
activity as compared to strength training that only
consists of lifting and lowering of free weights.
Moreover, wheel chair propulsion is an activity
which demands cardiovascular endurance rather thanmuscle strength alone.
The results obtained from this study suggest that arm
ergometry training may be used to improvefunctional independence in spinal cord injured
subjects who are using wheelchairs. Future studies
can be carried out to assess torque or force
production ability during wheelchair propulsion.
Furthermore, subjects should be tested for otherwheelchair skills with arm ergometry training.
Conclusions
This study showed significant changes in heart rate
and an increase in distance covered during
wheelchair propulsion after 4 weeks of training withthe arm ergometry protocol as compared to theprogressive resistance training program. Thus,
training programs well codified and adapted to eachsubject must be systematically considered inparaplegics’ rehabilitation program to increase
fitness and its components among these individuals.
Vol. 11, No. 18, October. 2013

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