Description #

Meet Diane.

She is 29 years old and lives with her fiancé. Diane uses a manual wheelchair full time for mobility. She has been using a wheelchair for most of life as Diane was diagnosed with spina bifida when she was born. Diane is pretty independent and has proficient wheelchair skills, however, she experiences shoulder pain from over use as she wheels to and from work every day. Diane is also concerned about developing pressure sores as is looking for strategies to avoid these painful skin conditions.

Meet Tomas.

He is 45 years old and uses a wheelchair mostly for mobility (for example, if he was going shopping Tomas would use a wheelchair to go around the mall). However, he can transfer independently and is able to stand for short periods of time. He is hoping to build up his strength and endurance to improve his overall mobility (most likely with the wheelchair- he’s not trying to get rid of it!) and reduce his fatigue (right now he feels tired all the time). Tomas has was diagnosed with MS about 7 years ago and recently he has noticed that he is relying on the use of his wheelchair more and more.

What do I need to know? #

Mobility is “the ability to move the body from one place to another or the ability to move the body or body components within space” (CSEP, 2002, p.II 2). This includes locomotor movements such as running, jumping, and skipping, and body movements including the head, neck and trunk.

A mobility aid is equipment or an assistive device that is designed to improve walking or mobility for someone with an impairment. Examples of common mobility aids are wheelchairs (power or manual), walkers, canes, or crutches. For the purpose of this resource, we will focus on wheelchairs as mobility aids, however, you are likely to encounter people with a range of impairments using a variety of mobility aids. The use of and equipment itself may change depending on the day and activity. The best thing to do is to talk about mobility aids during the consultation to gather more information from the participant.

 Things to Consider #

• Mobility aids are considered to be part of the person’s body. This is important in terms of etiquette. Do not touch or move a person’s wheelchair without asking permission first!
• Wheelchairs (or other mobility aids) provide mobility, freedom and independence for a person. They are not confined, or bound, or stuck. It’s ok to encourage the use of mobility aids (e.g. power wheelchairs or scooters) especially for those with limited mobility.
• Performing an activity independently does not require the person to do so without any support. Deciding what to do and having control over the action is key (this might mean directing support or providing instructions). Encourage individuals to use the support they need and work with them to understand how you can do this. Suggest working towards more independent movements (e.g., by increasing strength and improving flexibility), while also understanding that some movements might not be possible without support (e.g., depending on the location of SCI).
• Most people who use wheelchairs have some movement and sensation in their lower trunk and limbs. Don’t forget about lower body exercises as they might still be possible (and important!) (e.g., if person has MS, they can transfer to a recumbent bike for some low impact cardio).

Why Exercise? Why is it important? #

Exercise is important for everyone! For people who use mobility aids, the benefits of regular exercise include:

• Enhanced mood & mental well-being
• Improve quality of life
• Increase strength, flexibility & range of motion
• Improved ability to perform activities of daily living
• Decreased risk of secondary conditions
• Decrease stress/ improve stress management
• Improve posture, alignment, stability and balance

Where do I start? Getting to know Someone who uses a Mobility Aid #

Given the individual nature of how people experience disability and impairment, this section will highlight the importance of the consultation phase. Many staff are nervous about their first meeting and this section will hopefully make them feel a little more comfortable and better prepared to manage this first step.

The Consultation #

Use the consultation as an opportunity to get to know the participant. In addition to gathering medical information and fitness/ physical activity experience, you will also focus on goal setting and learning about participant preferences. In addition to discussing the exercises themselves, ask the participant about how they will get to the fitness centre, and the level of support they need (if any) to access the locker room, and prepare for exercise.

You want to support the participant to be as independent as possible. Depending on the individual, this may change over time as they become more familiar with the setting and feel more confident and capable. Some participants may choose to include task-specific training as part of their goal setting (e.g., movements to help with getting out of bed, stopping and changing directions, or wheeling more efficiently).

When someone using a wheelchair comes in for their consultation think about the following:

• They may use a wheelchair and then transfer to a chair for the consultation or they may stay in their chair
• What is the consultation space like? How accessible is it? Will the wheelchair fit through the doorway? Will there be enough space to turn around and leave the room (many consultation rooms or spaces are quite small!). You may want to consider an alternate space if you are unsure
• A wheelchair is considered part of the person- don’t try and move it or touch it without asking the person first
• Sit down so that you are eye level with the person
• Use this opportunity to build a relationship with the individual at this stage- don’t worry about saying exactly the right thing. Just be yourself. Be patient. Think about how you would like to be treated.
• Find common ground or shared interests- sports, hobbies, hometown, etc.
• It’s ok to ask about the kind of assistance they might need- for example- do they want a hand to get out of the chair? If not, let them do it themselves. Again, be patient. If this is something they are working on then you need to give them the space to do so.

Implications for Exercise #

The following safety issues are important to consider when planning and supporting exercise for people using wheelchairs

Stability

Plan ahead to ensure the wheelchair doesn’t tip over! How do you do this?

• Use a spotter the first time the participant tries a new exercise (For example, you can hold down their feet to stabilize the bottom of the wheelchair during an overhead press) (INSERST IMAGE).
• Lock the wheelchair in position before performing movement.
• You may want to turn off power chairs prior to doing the exercise.

Check out NCHPAD’s resource: Discover Accessible Fitness: A wheelchair user’s guide for using fitness equipment for great tips and suggestions to improve stability during exercise (http://incfit.org/files/Discover%20Accessible%20Fitness_FINAL.pdf)

Overloading Weight

Don’t overload the wheelchair! How do you avoid this?

• Think about the extra weight the participant is lifting in addition to their body weight
• You many want to ask the participant for the maximum capacity of their wheelchair.
• Too much stress on the wheelchair may lead to damage of the device or the individual

Assistance with Transferring

As a health club, you may want to discuss whether you will assist people with transferring from their wheelchair. Depending on the individual, transfers can range from offering a hand as the person stands on their own, to working with another person to physically perform a 2-person transfer. Different organizations may adopt different policies depending on the availability of training (if you decide to assist with transferring, proper training is strongly recommended!) and the comfort level with staff and management. There are benefits and risks associated with this decision that each club should consider – for example, how do you make a decision on a person-to-person basis? Should you have an official policy in place? What are the health risks to fitness professionals? Will you consider a weight limit for persons that are being transferred? How else can you offer assistance or support? There is no right answer to this issue- it is worth taking some time to consider how you will address it before jumping in and offering help- remember, you need to provide a safe space for both participants and staff!

Stuff you should know:

Pressure sores are caused by prolonged sitting. These can progress from slight discomfort or a small break in the skin to a full on ulcer at a risk of infection without proper attention. People who use wheelchairs are typically aware of their risk of pressure sores and may be managing one at any given time. Exercise helps to increase circulation which is good, but it also may lead to increased sweat and moisture which can make a pressure sore worse. If a participant mentions that they have a pressure sore, ask if they need anything. Remind them to shift their weight or move around every so often to decrease the pressure. This is one more reason to eat a healthy, balanced diet. Check to see how accessible your change rooms and showers are- washing after exercise and applying talc powder is a great tip. If it’s not accessible- see if there are small things you can do to make a difference.

Don’t forget:

Every person is like every other person, like some other person, and like no other person.

Monitoring Exertion & Exercise Intensity #

It’s really important that people who are new to exercise learn how to monitor and describe how they are feeling or their response to exercise. One helpful way to do this is to introduce the Rate of Perceived Exertion (RPE) scale.  The smiley face RPE Scale or the OMNI scale (see below for examples of both) may be more suitable for participants with various disabilities than the age-predicted maximal heart rate (220 – age) (Stanish & Aucoin, 2007).

In the beginning, it is also recommended that participants measure their heart rate (using wearable technology such as a heart rate monitor may make this easier!). This information will help the trainer and participant to work together to learn about how the participant perceives their exertion during exercise and may help to inform programming strategies. For example, a trainer may encourage the participant to work towards a specific level of RPE, which can be complemented with information from the HR monitor to measure exercise intensity. Monitoring HR may also be useful in the event that participants are exercising at a level beyond the recommended intensity, which may happen if the participant is very engaged in the activity or trying to make a positive impression on the trainer.

OMNI Scale

Smiley Face Relative Perceived Exertion Scale

Inclusive TIMES: Tips & Strategies for Individuals using Mobility Aids #

The tips and strategies found within the inclusive TIMES section will help you to create an environment that will support your participant’s participation in physical activity as independently as possible. It is important that you involve the participant whenever possible, along the way to ensure the program that you design will meet their needs physically, as well as emotionally and socially. Introducing a few simple strategies such as offering visual images of the participant’s program will help them to be more independent in completing their fitness programme. Ultimately, they will gain confidence and belief in their abilities (increasing self-efficacy) and experience self-determination (sense of control over their own destiny). This is key to establishing healthy habits that will be adopted for the long term.

Time #

• Schedule workouts for a time when there are typically less people in the gym (e.g., mid-morning). This will help with navigating the gym space using a wheelchair

Instruction #

• Use a menu type approach with activity cards. The participant can choose from exercises you suggested to create a personalized workout
• Provide options for completing exercises in seated or standing position (depending on individual’s wheelchair use)
• Have a chair available for you to use when demonstrating exercises from a seated position
• Clear, simple verbal cues can be used to encourage proper form
• Discover Accessible Fitness from NCPHAD is a great resource for exercises for wheelchair users

(http://incfit.org/files/Discover%20Accessible%20Fitness_FINAL.pdf)

Movement #

• Recommend strength and flexibility exercises that will focus on shoulders to ease pain and improve posture
• Use dynamic flexibility movements to warm up and static stretching to cool down (focus on tight areas such as pelvis, calves, and hip flexors)
• Recommend a gentle group exercise class such as seated yoga or tai chi that might focus on both balance and flexibility

Environment #

• Offer stabilizing equipment such as heel or wrist straps to help secure hands or feet (If your club doesn’t have any of these, there are many companies that sell them- for example, check out http://www.activehands.com/ or ask participants for suggestions!)
• Ask participant if they use a transfer board (this will help them transfer from their wheelchair to another piece of equipment)
• Remove clutter and extra equipment where possible to open up the space and improve accessibility
• Talk to the participant about the kind of equipment they would like to use (e.g., arm bikes, recumbent bike, free weights, etc.). Then brainstorm to see if there is a better way to set up the space for each workout- or think about other spaces that might work if it is difficult to navigate a small gym
• Get to know the equipment in your gym- how do the seats move? Can any or all be removed completely? Is so, could someone wheel in to use the equipment?
• Adaptive equipment such as wrist cuffs, activity cuffs, stabilizing straps, or fitness equipment such as elastic bands/ tubing, medicine balls, and ankle/wrist weights can all be useful!

Support #

• Become familiar with different ways that people might transfer independently (http://incfit.org/files/Discover%20Accessible%20Fitness_FINAL.pdf is a great resource that is specific to fitness settings!)
• Use the consultation to discuss the desired level of support for the individual (this will be individual & will be unique to each participant). Some may require support staff/family members or use assistive technology, others may not.
• Social support is vital to promote a healthy lifestyle! Introduce activities with partners to create a positive, fun & enjoyable atmosphere that is motivating
• Connect with local organizations to offer info sessions on maintaining mobility aids (e.g., how to fix broken spokes or replace a tube for the wheel on a wheelchair).
• Discuss the participant’s overall lifestyle choices (e.g., nutrition, sleep hygiene), to identify areas where they can enhance their overall health. For example, does the participant smoke? Eat healthy? Are there changes you can suggest?

References #

National Centre on Health Physical Activity and Disability (NCHPAD).  (2014). Discover Accessible Fitness: A wheelchair user’s guide for using fitness equipment.

Canadian Society for Exercise Physiology (CSEP). Canadian Physical Activity Guidelines for People with MS. Available at (Accessed 20th April 2017):

http://www.csep.ca/CMFiles/Guidelines/specialpops/CSEP_MS_PAGuidelines_adults_en.pdf

Canadian Society for Exercise Physiology (CSEP) (2002). Inclusive Fitness and Lifestyle Services for All disAbilities.

Exercise is Medicine, ‘Your Prescription for Health Series’, available at: http://exerciseismedicine.org/assets/page_documents/YPH_All.pdf [accessed 6th April 2016]

Harvard School of Public Health, ‘Healthy Eating Plate & Healthy Eating Pyramid’, available at: https://www.hsph.harvard.edu/nutritionsource/healthy-eating-plate/ [accessed 9^th May 2016]

Martin Ginis, K. A., Evans, M. B., Mortenson, W. B., & Noreau,, L. M. (2017). Broadening the conceptualization of ‘participation’ of persons with physical disabilities: A configurative review and recommendations. Archives of Physical Medicine and Rehabilitation, 98(2), 395-402. doi: 10.1016/j.apmr.2016.04.017.

Moore, G., Durstine, L., and Painter, P., eds. (2016) American College of Sports Medicine: Exercise Management for Persons with Chronic Diseases and Disabilities, 5^th Edition, Human Kinetics, Champaign

O’Connor, F., Casa, D., Davis, B., Pierre, P., Sallis, R. and Wilder, R., (2013), ACSM Sports Medicine: A Comprehensive Review, Lippincott Williams and Williams, China

Pescatello, L., Arena, R., Riebe, D., Thompson, P., eds. (2014), ACSM’s guidelines for exercise testing and prescription, 9^th Edition, Baltimore: Lippincott Williams & Wilkins

Swain, D., Brawner, C., Chambliss, H., Nagelkirk, P., Paternostro Bayles, M. and Swank, A., eds. (2014), ACSM’s Resource Manual for Guidelines for Exercise Testing and Prescription, 7^th Edition, Baltimore: Lippincott Williams & Wilkins

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