Changes in Physical Capacity During and After Inpatient Rehabilitation in Subjects With a Spinal Cord Injury

Predicting inpatient rehabilitation length of stay for adults with traumatic spinal cord injury

INTRODUCTION

Most post-injury traumatic spinal cord injury (TSCI) care occurs in the inpatient rehabilitation setting. The inpatient rehabilitation length of stay (R-LOS) has been shown to be a significant predictor of motor function restoration in persons with TSCI. Due to the complexity, and heterogeneity of individuals with TSCI, the R-LOS is challenging to predict at admission.

PURPOSE

To identify the main predictors of R-LOS and derive an equation to estimate R-LOS in persons with TSCI.

METHODS

This is a retrospective analysis of data from adults with TSCI from The Rick Hansen Spinal Cord Injury Registry in Alberta, Canada, who received rehabilitation care between May 10, 2005, and January 28, 2020. Multiple linear regression analysis was used to determine significant relationships between R-LOS and measures of participant demographics, length of stay, impairment and injury classification, and comorbidities.

RESULTS

The analysis included 736 adults with TSCI from an eligible cohort of 1365. The median R-LOS was 65 days (IQR 39-99 days), ranging from 1 to 469 days. Multivariate linear regression analysis identified two significant predictors of R-LOS, total FIM score and the injury classification. This model was used to derive a R-LOS prediction equation, which explained 34% of the variance in R-LOS.

CONCLUSION

We developed a simple equation to predict R-LOS based on the level of impairment and total FIM scores in persons with TSCI. These data have implications for health system planning, improvement, and innovation, and provide insights to support further research into the predictors of R-LOS, identification of higher-risk individuals.

Requirements for Universally Accessible Upper-Body Exercise Equipment: The Case of People with Spinal Cord Injuries in Korea

Background

People with disabilities face considerable obstacles when exercising, which precludes them from the social and health benefits of physical activity. Especially for individuals with paraplegia with spinal cord injuries, it is necessary to maintain continuous participation in physical activity even after discharge, as it helps to maintain mobility and daily living activities through upper body strength. However, the participation rate of people with disabilities in physical activity in Korea is still low, mainly due to the lack of exercise equipment and facilities.

Objectives

The aim of this study is to identify aspects that can be improved for better accessibility to exercise equipment for individuals with paraplegia with spinal cord injuries and to reach a consensus on possible guidelines for accessible exercise equipment.

Methods

This study reviews and evaluated the usability of four existing upper-body exercise equipment for individuals with paraplegia with spinal cord injuries. To assess usability, task performance scores and time were measured, and a survey was conducted on safety and satisfaction. Based on these results, areas for improvement were identified. Through literature review, usability results, and opinions from various stakeholders, eight requirements for universal accessibility were proposed.

Results

It is necessary to consider how wheelchair users access the exercise equipment. The access method to the exercise area (facility regulations, auxiliary equipment to be provided, etc.) and placement of exercise equipment should also be considered. Information such as explanations of the exercise equipment and how to use it should be located within the wheelchair user's field of vision. Considering the participation rate in sports for people with disabilities in Korea, it is necessary to explain the exact exercise equipment and exercise method. It is also necessary to consider how wheelchair users transfer from the wheelchair to the seat of the exercise equipment. Parts that require manipulation of each exercise equipment must be within the wheelchair user's range of motion. Various supports or assistive devices that provide body support according to each piece of equipment are needed. In addition to the wheelchair's own brake, it is necessary to provide a fixing device so that the wheelchair does not move during the exercise.

Conclusion

For people with spinal cord injuries, the arm ergometer, aerobic exercise equipment, showed higher scores in performance, stability, and satisfaction compared to other exercise equipment. Among the strength exercise equipment, shoulder press had an effect on performance, seated lat pull-down had an effect on stability, and seated chest press had an effect on satisfaction. Therefore, when selecting exercise equipment, it is necessary to recommend aerobic and strength exercise equipment according to the preferences of people with spinal cord injuries. When developing strength exercise equipment, it is necessary to consider usability evaluation factors for individuals with spinal cord injury.

Post-processing Peak Oxygen Uptake Data Obtained During Cardiopulmonary Exercise Testing in Individuals With Spinal Cord Injury: A Scoping Review and Analysis of Different Post-processing Strategies

OBJECTIVES

To review the evidence regarding the most common practices adopted with cardiopulmonary exercise testing (CPET) in individuals with spinal cord injury (SCI), with the following specific aims to (1) determine the most common averaging strategies of peak oxygen uptake (V̇o2peak), (2) review the endpoint criteria adopted to determine a valid V̇o2peak, and (3) investigate the effect of averaging strategies on V̇o2peak values in a convenience sample of individuals with SCI (between the fourth cervical and sixth thoracic spinal segments).

DATA SOURCES

Searches for this scoping review were conducted in MEDLINE (PubMed), EMBASE, and Web Science.

STUDY SELECTION

Studies were included if (1) were original research on humans published in English, (2) recruited adults with traumatic and non-traumatic SCI, and (3) V̇o2peak reported and measured directly during CPET to volitional exhaustion. Full-text review identified studies published before April 2021 for inclusion.

DATA EXTRACTION

Extracted data included authors name, journal name, publication year, participant characteristics, and comprehensive information relevant to CPET.

DATA SYNTHESIS

We extracted data from a total of 197 studies involving 4860 participants. We found that more than 50% of studies adopted a 30-s averaging strategy. A wide range of endpoint criteria were used to confirm the attainment of maximal effort. In the convenience sample of individuals with SCI (n=30), the mean V̇o2peak decreased as epoch (ie, time) lengths increased. Reported V̇o2peak values differed significantly (P<.001) between averaging strategies, with epoch length explaining 56% of the variability.

CONCLUSIONS

The adoption of accepted and standardized methods for processing and analyzing CPET data are needed to ensure high-quality, reproducible research, and inform population-specific normative values for individuals with SCI.

Empowerment, Communication, and Navigating Care: The Experience of Persons With Spinal Cord Injury From Acute Hospitalization to Inpatient Rehabilitation

Background

Spinal cord injury (SCI) results in long-term functional impairments that significantly impact participation and role in the community. Newly injured persons are often reintroduced to the community with significant deficits in knowledge, including how to access and navigate community resources and supports. This warrants a better understanding of the patient experience of in-hospital care and discharge planning to ensure individuals with SCI are best supported during transitions in care and while living in the community.

Objective

To explore the lived experience of persons with acute SCI and their perceptions of care, focusing on the initial hospital experiences to inpatient rehabilitation.

Methods

A phenomenological research study was conducted using semi-structured interviews. Eligible participants had differing etiologies of SCI (including non-traumatic and traumatic SCI), were over the age of 18 at the time of initial care, and experienced acute hospital and inpatient rehabilitation at an Alberta-based institution within the last 10 years. One-on-one interviews took place between March and June 2021 over telephone or virtual platforms (Zoom). Interview transcripts, and field notes developed the text, which underwent hermeneutic analysis to develop central themes.

Results

The present study included 10 participants living with an SCI in Alberta, Canada. Most participants (80%) were male. Participants' age ranged from 24 to 69 years. The median years since initial SCI was 3 years. Interviews lasted 45–75 min. Seven participants identified as having a traumatic SCI injury and three identified as having a non-traumatic SCI. The interplay between empowerment and disempowerment emerged as the core theme, permeating participants' meanings and perceptions. Three main themes emerged from the interviews regarding the perceptions of the SCI patient experience. Each theme represents a perception central to their inpatient experience: desire to enhance functional independence to empower confidence and self-management; need for effective communication with healthcare providers to support recovery; and navigating appropriate care supports to enhance preparedness for discharge and returning home.

Conclusion

This study demonstrates the significant need to enhance education of person/family-centered SCI care, foster positive communication between care recipients and care providers, and facilitate better in-hospital access to appropriate navigation and wayfinding supports.

Comparison of the functional and cardiovascular effects of home-based versus supervised hospital circuit training exercises in male wheelchair users with chronic paraplegia

Objectives

The aim of this study was to compare the efficacy of home-based upper extremity circuit training exercises (CTEs) with supervised hospital program in male patients with traumatic complete paraplegia.

Patients and methods

Twenty men with paraplegia (mean age: 38±10.1 years; range, 30 to 43 years) between January 2007 and November 2007 were randomized into two groups. The first group had supervised hospital CTE program, whereas the second group had home-based CTE. The effects of the upper extremity CTE by using elastic bands 60 min per day, five days a week, for a total of eight weeks (70% maximal oxygen consumption [VO_2max]) were examined. The Cybex was used for the isokinetic testing of the upper extremities. The VO_2max and maximum heart rate (HR) were assessed using an arm ergometer. The Craig Handicap Report Technique Short Form (CHART-SF) was used for the evaluation of functional independence and mobility. Serum lipid profiles were measured.

Results

The mean injury duration was 7.9±2 years. The peak torque values of the upper extremities, VO_2max, maximum HR, CHART-SF physical independence and mobility scores, and serum lipid profile were all improved in both groups (p<0.05). There were no significant differences in terms of the increase in the muscle strength and serum lipid levels between the groups (p>0.05). The improvement in the VO_2max, physical independence, and mobility scores were greater in the supervised exercise group.

Conclusion

Upper extremity strength, cardiovascular endurance, and lipid profile were improved after supervised and home-based CTE in the men with paraplegia. Home-based exercise programs may be good alternatives to the hospital rehabilitation for this patient population.

Community exercise for individuals with spinal cord injury with inspiratory muscle training: A pilot study

Context/Objective: Respiratory disorders are a common cause of rehospitalization, and premature death in individuals with spinal cord injuries (SCI). Respiratory training combined with community exercise programs may be a method to reduce secondary complications in this population.Objective: The present study explores the inclusion of inspiratory muscle training (IMT) in an existing community exercise program.Design: Case series.Setting: Community.Participants: Participants (N = 6) completed the exercise program. Five were male and one was female; four reported incomplete injuries, and two reported complete injuries; four had cervical injuries, and two had thoracic injuries. The average age was 33 years (SD = 18.6) and time since injury was 7 years (SD = 4.0).Interventions: Participants completed an 8-week program, once-per-week for 4 h that included a circuit of resistance training, aerobic exercise, trunk stability, and education. IMT was completed as a home exercise program.Outcome Measures: Transfer test, T-shirt test, four-directional reach, four-directional trunk strength, weekly training diaries, and a subjective interview.Results: Twenty-eight training logs were collected. All measures improved: transfer test (mean = -14.62, SD = 7.00 s), T-shirt test (mean = -7.83, SD = 13.88 s), four-directional reach (mean = 3.75, SD = 8.06 in) and hand-held dynamometer (mean = 6.73, SD = 8.02 kg). Individuals reported a positive impact of the program.Conclusions: This pilot study demonstrated community exercise with IMT use may have positive impact on functional measures for people with SCI who are vulnerable to respiratory compromise. Continued education may increase successful health outcomes.Trial Registration: NCT03743077.

Mobile App (WHEELS) to Promote a Healthy Lifestyle in Wheelchair Users With Spinal Cord Injury or Lower Limb Amputation: Usability and Feasibility Study

BACKGROUND

Maintaining a healthy lifestyle is important for wheelchair users' well-being, as it can have a major impact on their daily functioning. Mobile health (mHealth) apps can support a healthy lifestyle; however, these apps are not necessarily suitable for wheelchair users with spinal cord injury or lower limb amputation. Therefore, a new mHealth app (WHEELS) was developed to promote a healthy lifestyle for this population.

OBJECTIVE

The objectives of this study were to develop the WHEELS mHealth app, and explore its usability, feasibility, and effectiveness.

METHODS

The WHEELS app was developed using the intervention mapping framework. Intervention goals were determined based on a needs assessment, after which behavior change strategies were selected to achieve these goals. These were applied in an app that was pretested on ease of use and satisfaction, followed by minor adjustments. Subsequently, a 12-week pre-post pilot study was performed to explore usability, feasibility, and effectiveness of the app. Participants received either a remote-guided or stand-alone intervention. Responses to semistructured interviews were analyzed using content analysis, and questionnaires (System Usability Score [SUS], and Usefulness, Satisfaction, and Ease) were administered to investigate usability and feasibility. Effectiveness was determined by measuring outcomes on physical activity, nutrition, sleep quality (Pittsburgh Sleep Quality Index), body composition, and other secondary outcomes pre and post intervention, and by calculating effect sizes (Hedges g).

RESULTS

Sixteen behavior change strategies were built into an app to change the physical activity, dietary, sleep, and relaxation behaviors of wheelchair users. Of the 21 participants included in the pilot study, 14 participants completed the study. The interviews and questionnaires showed a varied user experience. Participants scored a mean of 58.6 (SD 25.2) on the SUS questionnaire, 5.4 (SD 3.1) on ease of use, 5.2 (SD 3.1) on satisfaction, and 5.9 (3.7) on ease of learning. Positive developments in body composition were found on waist circumference (P=.02, g=0.76), fat mass percentage (P=.004, g=0.97), and fat-free mass percentage (P=.004, g=0.97). Positive trends were found in body mass (P=.09, g=0.49), BMI (P=.07, g=0.53), daily grams of fat consumed (P=.07, g=0.56), and sleep quality score (P=.06, g=0.57).

CONCLUSIONS

The WHEELS mHealth app was successfully developed. The interview outcomes and usability scores are reasonable. Although there is room for improvement, the current app showed promising results and seems feasible to deploy on a larger scale.

The Effectiveness of Active Rehabilitation Camp on Physical Performance of Disabled People Moving in Wheelchairs

(1) Background: Regular participation in physical activity (PA) prevents many medical complications and improves the physical fitness of people with spinal cord injury, and in turn improves the functional independence, psychosocial status and quality of life. The goal of Active Rehabilitation Camps (ARCs) is to use various forms of PA in order for the participants to obtain the greatest efficiency and independence in everyday life. (2) Purpose: To evaluate the improvement in physical performance of people with chronic spinal cord disabilities moving in wheelchairs taking part in the Active Rehabilitation Camp depending on (a) sex, (b) type of disability, (c) the level of injury and (d) the type of wheelchair. (3) Methods: The study included 42 wheelchair users: 28 men and 14 women aged 18-65 years (34.7 ± 14.9 years) taking part in the Active Rehabilitation Camp. Finally, the study involved 27 paraplegics, 9 tetraplegics and 6 individuals with myelomeningocele. The participants took part in four fitness tests: (1) sprint test (SP)-individual time to cover a distance of 15 m in the wheelchair; (2) slalom test (SL)-time to ride between four cones front and back; (3) basketball ball throw at a distance (BT), (4) zig-zag test (ZZ)-riding continuously for 6 min on the designated track. The tests were performed at the beginning and at the end of the ACR. Active wheelchairs were used by 32 participants, and 10 participants used the classic wheelchairs. (4) Results: Paraplegics achieved the best average results in all the tests and the best improvement in physical performance in comparison to individuals with myelomeningocele and tetraplegics. People in active wheelchairs achieved a statistically significant improvement in the results of SL and ZZ (p < 0.001). People with injury above Th-9 level of the spinal cord achieved a statistically significant improvement in the results of SP (p < 0.01), SL and ZZ (p < 0.01). People with injury below Th6 achieved a statistically significant improvement (p < 0.05) in SP, SL and ZZ. (5) Conclusions: Regular PA during the Active Rehabilitation Camp improves the physical performance of disabled people in wheelchairs, but the scale of improvement of physical performance fitness depends on the type of wheelchair used and the level and the type of injury.

Respiratory muscle training in non-athletes and athletes with spinal cord injury: A systematic review of the effects on pulmonary function, respiratory muscle strength and endurance, and cardiorespiratory fitness based on the FITT principle of exercise prescription

BACKGROUND

Respiratory muscle training (RMT) has been recommended to mitigate impacts of spinal cord injuries (SCI), but the optimal dosage in terms of the frequency, intensity, time, and type (FITT principle) to promote health in SCI individuals remains unclear.

OBJECTIVE

To discuss research related to the effects of RMT on pulmonary function, respiratory muscle strength and cardiorespiratory fitness in athletes and non-athletes with SCI, presenting the FITT principle.

METHODS

We performed a systematic review. PubMed, Lilacs, Scopus, Web of Science, PEDro, SciELO and Cochrane databases were searched between 1989 and August 2018. Participants were athletes and non-athletes with SCI.

RESULTS

4,354 studies were found, of which only 17 met the eligibility criteria. Results indicated that RMT is associated with beneficial changes in pulmonary function and respiratory muscle strength and endurance among athletes and non-athletes, whereas no effect was reported for maximal oxygen uptake. It was not possible to establish an optimal RMT dose from the FITT principle, but combined inspiratory/expiratory muscle training seems to promote greater respiratory changes than isolated IMT or EMT.

CONCLUSION

The use of RMT elicits benefits in ventilatory variables of athletes and non-athletes with SCI. However, it remains unclear which RMT type and protocol should be used to maximize benefits.

The test-retest reliability of individualized VO2peak test modalities in people with spinal cord injury undergoing rehabilitation

STUDY DESIGN

Test-retest study.

OBJECTIVE

To describe the test-retest reliability of an individualized approach for peak oxygen uptake (VO₂peak) testing in a clinical context, accommodating inpatients with heterogeneous levels of physical functioning.

SETTING

Inpatient rehabilitation.

METHOD

Test-retest on two types of devices (recumbent stepper and arm-crank ergometer) with two predefined protocols of varying load increments on each device. No participants performed all four test modalities. VO₂peak, respiratory exchange ratio (RER), peak workload, and the reason for termination were reported. Of 23 participants included, 21 completed the test-retest procedure. Participants were inpatients, ≥18 years, who sustained a spinal cord injury (SCI) within the last 12 months at the time of admission. The median age was 52 years and 74% were male. Median time since injury at the time of the first test (T1) was 5.5 months. Seventeen were classified as American Spinal Injury Association Impairment Scale D. Intraclass correlation coefficients (ICC) and Bland-Altman plots for VO₂peak was calculated to determine intra- and intertester reliability of VO₂peak.

RESULTS

Mean VO₂peak obtained at T1 was 1.91 L/min (95%CI: 1.31-2.51); 1.26 L/min and 2.69 L/min for the recumbent stepper protocols; 0.61 L/min and 1.39 L/min for the arm-crank ergometer protocols. ICC for intra- and intertester reliability was 0.997 (95%CI: 0.986-0.999) and 0.994 (95%CI: 0.978-0.998) respectively. Bland-Altman plots showed a mean difference of -0.005 (SD 0,12) for overall test-retest.

CONCLUSION

Test-retest reliability was high. Mean VO₂peak at discharge from rehabilitation was higher than previously reported and individualized test modalities seemed to yield more optimal results in a heterogenous and representative sample during rehabilitation.

Rehabilitation: mobility, exercise & sports; a critical position stand on current and future research perspectives

BACKGROUND

Human movement, rehabilitation, and allied sciences have embraced their ambitions within the cycle of "RehabMove" congresses over the past 30 years. This combination of disciplines and collaborations in the Netherlands has tried to provide answers to questions in the fields of rehabilitation and adapted sports, while simultaneously generating new questions and challenges. These research questions help us to further deepen our understanding of (impaired) human movement and functioning, with and without supportive technologies, and stress the importance of continued multidisciplinary (inter)national collaboration.

METHODS

This position stand provides answers that were conceived by the authors in a creative process underlining the preparation of the 6th RehabMove Congress.

RESULTS

The take-home message of the RehabMove2018 Congress is a plea for continued multidisciplinary research in the fields of rehabilitation and adapted sports. This should be aimed at more individualized notions of human functioning, practice, and training, but also of performance, improved supportive technology, and appropriate "human and technology asset management" at both individual and organization levels and over the lifespan.

CONCLUSIONS

With this, we anticipate to support the development of rehabilitation sciences and technology and to stimulate the use of rehabilitation notions in general health care. We also hope to help ensure a stronger embodiment of preventive and lifestyle medicine in rehabilitation practice. Indeed, general health care and rehabilitation practice require a healthy and active lifestyle management and research agenda in the context of primary, secondary, and tertiary prevention.IMPLICATIONS FOR REHABILITATIONContinued multidisciplinary (international) collaboration will stimulate the development of rehabilitation and human movement sciences.Notions from "human and technology asset management and ergonomics" are fundamental to rehabilitation practice and research.The rehabilitation concept will further merge into general health care and the quality there-off.

Improvement in Pulmonary Function with Short-term Rehabilitation Treatment in Spinal Cord Injury Patients

Cervical and upper thoracic spinal cord injury causes impairments in respiratory muscle performance, leading to variable degrees of pulmonary dysfunction and rendering deep breathing difficult for affected individuals. In this retrospective study, we investigated the effects of self-directed respiratory muscle training in this context by assessing pulmonary function relative to spinal cord injury characteristics. A total of 104 spinal cord injury patients (tetraplegia/paraplegia; 65/39, acute/subacute/chronic; 14/42/48) were admitted for short-term (4–8 weeks) in-patient clinical rehabilitation. Initial evaluation revealed a compromised pulmonary function with a percentage of predicted value of 62.0 and 57.5 in forced vital capacity in supine and forced vital capacity in sitting positions, respectively. Tetraplegic patients had more compromised pulmonary function compared with paraplegic patients. At follow-up evaluation, the percentage of predicted value of forced vital capacity in supine and sitting position improved overall on average by 11.7% and 12.7%, respectively. The peak cough flow improved by 22.7%. All assessed pulmonary function parameters improved significantly in all subgroups, with the greatest improvements found in patients with tetraplegia and subacute spinal cord injury. Therefore, short-term self-directed respiratory muscle training should be incorporated into all spinal cord injury rehabilitation regimens, especially for patients with tetraplegia and subacute spinal cord injury, as well as those with chronic spinal cord injury.

Development and validation of models to predict respiratory function in persons with long-term spinal cord injury

STUDY DESIGN

Multicenter, cross-sectional study.

OBJECTIVES

To validate previously developed respiratory function prediction models for persons with long-term spinal cord injury (SCI) and if necessary develop and validate new models.

SETTING

Ten SCI rehabilitation centers.

METHODS

Five respiratory function parameters were measured in adults with chronic, traumatic, motor complete SCI (C4-T12). First, the models published in 2012 were validated using Bland-Altman plots. Then, new models were calculated using 80% of the dataset by multiple regression analysis with the candidate predictors gender, age, height, weight, time post injury (TPI), lesion level, and smoking. In a third step, the new models were validated using the other 20% of the dataset by Bland-Altman plots.

RESULTS

In total 613 participants were included. For persons with long-term SCI, the 2012 models were poorly predictive, especially for respiratory muscle strength (R2 = 0.4). Significant predictors for all respiratory function parameters in the new models (R2 = 0.7-0.8) were lesion level, gender and weight. Small effects on single outcome parameters were observed for TPI and age whereas smoking had no effect. For the new models the mean differences between measured and predicted values for respiratory muscle strength were 4.0 ± 36.0 cm H₂O and for lung function parameters -0.5 ± 1.2 L (FVC), -0.3 ± 0.9 L (FEV1) and -0.5 ± 2.0 L/s (PEF).

CONCLUSION

We did not find better models for lung function in long-term SCI but those for respiratory muscle strength showed better accuracy.

SPONSORSHIP

The content of this publication was developed under grant from Wings for Life, grant number WFL-CH-017/14.

Overview of Systematic Reviews of Aerobic Fitness and Muscle Strength Training after Spinal Cord Injury

The number of systematic reviews on the effects of exercise on aerobic fitness and muscle strength in people with spinal cord injury (SCI) has recently increased. However, the results of some of these reviews are inconclusive or inconsistent. To strengthen recommendations, this overview was undertaken to assimilate evidence about the effectiveness of different types of physical activities, exercises, and therapeutic interventions for improving aerobic fitness and muscle strength in people with SCI. Cochrane Overview of reviews methods were adopted to undertake this overview. An online search was conducted in August 2018 on eight databases based on predefined search criteria. Potential systematic reviews were screened, selected, and assessed on methodological quality by two independent authors, and discussed and resolved with a third author, when necessary. Only systematic reviews published in the English language were included. The protocol was registered on PROSPERO. Overall, 16 systematic reviews were included (aerobic fitness, n = 10; muscle strength, n = 15). For all 16 reviews, the quality of evidence was rated as "critically low." Despite low evidence, this overview strengthens the existing guidelines for people with SCI, providing specific advice on exercise domains (types, intensities, frequency, and duration) for improving aerobic fitness and muscle strength. The evidence from this overview suggests that ergometry training with/without additional therapeutic interventions (20 min, moderate to vigorous intensity, twice weekly for 6 weeks) may improve aerobic fitness; similarly, resistance training with/without additional therapeutic interventions (three sets of 8-10 repetitions, moderate to vigorous intensity, twice weekly for 6 weeks) may improve muscle strength.

Relationship between wheelchair skills scores and peak aerobic exercise capacity of manual wheelchair users with spinal cord injury: a cross-sectional study

Purpose: Although both wheelchair skills and fitness are important and probably inter-related, the extent and nature of the relationship between them are not well understood. The objective of this study was to test the hypothesis that there are significant relationships between wheelchair skills scores and the peak exercise capacity of community-dwelling manual wheelchair users with spinal cord injury.Materials and methods: We studied 26 participants, recording Wheelchair Skills Test Questionnaire scores and peak power output from graded aerobic wheelchair exercise testing on a motorized treadmill.Results: The median Wheelchair Skills Test Questionnaire capacity, confidence, and performance scores were 83.3%, 81.5%, and 76.7% and the median peak power output was 58.2 W. On regression analysis, there were significant relationships between the total Wheelchair Skills Test Questionnaire capacity, confidence, and performance scores and peak power output (R² 0.270-0.709, odds ratios 1.043-1.150, p < 0.05).Conclusions: Significant relationships exist between the wheelchair skills capacity, confidence, and performance scores and the peak exercise capacity of community-dwelling manual wheelchair users with spinal cord injury. These findings suggest that both wheelchair skills training and exercise training may be useful during the rehabilitation of people with spinal cord injury.Implications for rehabilitationModerate positive relationships exist between wheelchair skills capacity and the peak exercise capacity of community-dwelling manual wheelchair users with spinal cord injury.Moderate positive relationships exist between wheelchair skills confidence and the peak exercise capacity of community-dwelling manual wheelchair users with spinal cord injury.Although further research is needed, these findings suggest that clinicians should address both wheelchair skills training and exercise training during the rehabilitation of people with spinal cord injury and not assume that either alone is sufficient.

Effectiveness of a Self-Management Intervention to Promote an Active Lifestyle in Persons With Long-Term Spinal Cord Injury: The HABITS Randomized Clinical Trial

BACKGROUND

Most people with long-term spinal cord injury (SCI) have a very inactive lifestyle. Higher activity levels have been associated with health benefits and enhanced quality of life. Consequently, encouraging an active lifestyle is important and behavioral interventions are needed to establish durable lifestyle changes.

OBJECTIVE

The Healthy Active Behavioral Intervention in SCI (HABITS) study was aimed to evaluate the effectiveness of a structured self-management intervention to promote an active lifestyle in inactive persons with long-term SCI.

METHODS

This assessor-blinded randomized controlled trial was conducted at 4 specialized SCI units in the Netherlands. Sixty-four individuals with long-term SCI (>10 years), wheelchair-user and physically inactive, were included. Participants were randomized to either a 16-week self-management intervention consisting of group meetings and individual counseling and a book, or to a control group that only received information about active lifestyle by one group meeting and a book. Measurements were performed at baseline, 16 weeks, and 42 weeks. Primary outcome measures were self-reported physical activity and minutes per day spent in wheelchair driving. Secondary outcomes included perceived behavioral control (exercise self-efficacy, proactive coping), stages of change concerning exercise, and attitude toward exercise.

RESULTS

Mixed models analyses adjusted for age, sex, level of SCI, time since injury, baseline body mass index, and location did not show significant differences between the intervention and control groups on the primary and secondary outcomes ( P ≥ .05).

CONCLUSIONS

A structured 16-week self-management intervention was not effective to change behavior toward a more active lifestyle and to improve perceived behavioral control, stages of change, and attitude.

Autonomic Nervous System in Paralympic Athletes with Spinal Cord Injury

Individuals sustaining a spinal cord injury (SCI) frequently suffer from sensorimotor and autonomic impairment. Damage to the autonomic nervous system results in cardiovascular, respiratory, bladder, bowel, and sexual dysfunctions, as well as temperature dysregulation. These complications not only impede quality of life, but also affect athletic performance of individuals with SCI. This article summarizes existing evidence on how damage to the spinal cord affects the autonomic nervous system and impacts the performance in athletes with SCI. Also discussed are frequently used performance-enhancing strategies, with a special focus on their legal aspect and implication on the athletes' health.

Peak oxygen uptake in Paralympic sitting sports: A systematic literature review, meta- and pooled-data analysis

Background

Peak oxygen uptake (VO_2peak) in Paralympic sitting sports athletes represents their maximal ability to deliver energy aerobically in an upper-body mode, with values being influenced by sex, disability-related physiological limitations, sport-specific demands, training status and how they are tested.

Objectives

To identify VO_2peak values in Paralympic sitting sports, examine between-sports differences and within-sports variations in VO_2peak and determine the influence of sex, age, body-mass, disability and test-mode on VO_2peak.

Design

Systematic literature review and meta-analysis.

Data sources

PubMed, CINAHL, SPORTDiscus^TM and EMBASE were systematically searched in October 2016 using relevant medical subject headings, keywords and a Boolean.

Eligibility criteria

Studies that assessed VO_2peak values in sitting sports athletes with a disability in a laboratory setting were included.

Data synthesis

Data was extracted and pooled in the different sports disciplines, weighted by the Dersimonian and Laird random effects approach. Quality of the included studies was assessed with a modified version of the Downs and Black checklist by two independent reviewers. Meta-regression and pooled-data multiple regression analyses were performed to assess the influence of sex, age, body-mass, disability, test mode and study quality on VO_2peak.

Results

Of 6542 retrieved articles, 57 studies reporting VO_2peak values in 14 different sitting sports were included in this review. VO_2peak values from 771 athletes were used in the data analysis, of which 30% participated in wheelchair basketball, 27% in wheelchair racing, 15% in wheelchair rugby and the remaining 28% in the 11 other disciplines. Fifty-six percent of the athletes had a spinal cord injury and 87% were men. Sports-discipline-averaged VO_2peak values ranged from 2.9 L∙min^-1 and 45.6 mL∙kg^-1∙min^-1 in Nordic sit skiing to 1.4 L∙min^-1 and 17.3 mL∙kg^-1∙min^-1 in shooting and 1.3 L∙min^-1 and 18.9 mL∙kg^-1∙min^-1 in wheelchair rugby. Large within-sports variation was found in sports with few included studies and corresponding low sample sizes. The meta-regression and pooled-data multiple regression analyses showed that being a man, having an amputation, not being tetraplegic, testing in a wheelchair ergometer and treadmill mode, were found to be favorable for high absolute and body-mass normalized VO_2peak values. Furthermore, high body mass was favourable for high absolute VO_2peak values and low body mass for high body-mass normalized VO_2peak values.

Conclusion

The highest VO_2peak values were found in Nordic sit skiing, an endurance sport with continuously high physical efforts, and the lowest values in shooting, a sport with low levels of displacement, and in wheelchair rugby where mainly athletes with tetraplegia compete. However, VO_2peak values need to be interpreted carefully in sports-disciplines with few included studies and large within-sports variation. Future studies should include detailed information on training status, sex, age, test mode, as well as the type and extent of disability in order to more precisely evaluate the effect of these factors on VO_2peak.

Cardiovascular Stress During Inpatient Spinal Cord Injury Rehabilitation

OBJECTIVES

(1) To measure the amount of cardiovascular stress, self-reported physical activity, and accelerometry-measured physical activity by individuals with spinal cord injury (SCI) during physical therapy (PT) and occupational therapy (OT); and (2) to investigate the relations between these measures.

DESIGN

Observational study.

SETTING

Two inpatient SCI rehabilitation centers.

PARTICIPANTS

Patients with SCI (N=87) were recruited from consecutive admissions to rehabilitation.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Heart rate was recorded by a Holter monitor, whereas physical activity was captured by self-report (Physical Activity Recall Assessment for People with SCI questionnaire) and real-time wrist accelerometry during a total of 334 PT and OT inpatient sessions. Differences between individuals with paraplegia and tetraplegia were assessed via Mann-Whitney U tests. Spearman correlations were used to explore the relation between measurements of physical activity and heart rate.

RESULTS

Time spent at a heart rate within a cardiovascular training zone (≥40% heart rate reserve) was low and did not exceed a median of 5 minutes. In contrast, individuals reported at least 60 minutes of higher-intensity time during therapy. There was a low but statistically significant correlation between all measures.

CONCLUSIONS

The cardiovascular stress incurred by individuals with SCI during inpatient PT and OT sessions is low and not sufficient to obtain a cardiovascular training effect to optimize their neurologic, cardiovascular, or musculoskeletal health; this represents a lost opportunity to maximize rehabilitation. Self-reported minutes of higher-intensity physical activity do not reflect actual time spent at a higher intensity measured objectively via a heart rate monitor.

EVALUATION OF MUSCLE STRENGTH IN MEDULLAR INJURY: A LITERATURE REVIEW

ABSTRACT Objective: To identify the tools used to evaluate muscle strength in subjects with spinal cord injury in both clinical practice and scientific research. Methods: Initially, the literature review was carried out to identify the tools used in scientific research. The search was conducted in the following databases: Virtual Health Library (VHL), Pedro, and PubMed. Studies published between 1990 and 2016 were considered and selected, depicting an evaluation of muscle strength as an endpoint or for characterization of the sample. Next, a survey was carried out with physiotherapists to identify the instruments used for evaluation in clinical practice, and the degree of satisfaction of professionals with respect to them. Results: 495 studies were found; 93 were included for qualitative evaluation. In the studies, we verified the use of manual muscle test with different graduation systems, isokinetic dynamometer, hand-held dynamometer, and manual dynamometer. In clinical practice, the manual muscle test using the motor score recommended by the American Spinal Cord Injury Association was the most used method, despite the limitations highlighted by the physiotherapists interviewed. Conclusion: In scientific research, there is great variation in the methods and tools used to evaluate muscle strength in individuals with spinal cord injury, differently from clinical practice. The tools available and currently used have important limitations, which were highlighted by the professionals interviewed. No instrument depicts direct relationship of muscle strength and functionality of the subject. There is no consensus as to the best method for assessing muscle strength in spinal cord injury, and new instruments are needed that are specific for use in this population.

Cardiac Structure and Function in Elite Para-cyclists with Spinal Cord Injury

PURPOSE

We sought to explore the association between the spinal cord injury (SCI) level on the cardiac structure and the function observed in elite para-cyclists.

METHODS

Cross-sectional echocardiographic data from 44 elite SCI hand cyclists (39.8 ± 9 yr, 68% male/32% female) stratified by the level of SCI (cervical, N = 9; T1-T5, N = 10; below T5, N = 25) and 19 non-SCI blind/visually impaired (BVI) tandem cyclists (32.4 ± 7 yr, 58% male/42% female) were analyzed before the initiation of international competition.

RESULTS

Compared with non-SCI BVI cyclists, cervical SCI para-cyclists were observed with lower indexed left ventricular (LV) mass (99.6 ± 12 vs 125 ± 20 g·m, P = 0.01), posterior wall thickness (4.5 ± 0.3 vs 5.8 ± 0.7 mm·m, P < 0.001), interventricular septal wall thickness (4.8 ± 0.5 vs 5.7 ± 0.7 mm·m; P = 0.03), and left atrial volume (21 ± 3.5 vs 28 ± 7 mL·m; P = 0.02). In multivariable analyses, cervical SCI was independently associated with decreased LV wall thickness [interventricular septum (β = -0.67, P = 0.01), posterior wall (β = -0.98, P = 0.001)], decreased LV mass (β = -21, P < 0.001), and decreased left atrial volume index (β = -6.9, P = 0.001) compared with other levels of SCI and non-SCI BVI cyclists. There were no differences in ventricular function among any of the athlete groups.

CONCLUSION

Compared with para-cyclists with lower levels of SCI, the athletes with cervical SCI demonstrate attenuated cardiac size and concentric LV hypertrophy.

Implications of altered autonomic control on sports performance in athletes with spinal cord injury

It is well known that athletes with spinal cord injury (SCI) may experience altered autonomic physiology that impacts their exercise capacity and sports performance. This is particularly relevant given the ever-increasing number of individuals with SCI who are actively engaged in sports at all levels, from community-based adaptive sports to elite Paralympic competitions. As such, the purpose of this article is to review the present literature regarding the implications of altered autonomic control on the safety and performance of athletes with SCI. A particular emphasis will be placed on the autonomic aspects of cardiovascular and thermoregulatory control in the athlete population, as well as the implications of autonomic dysreflexia in enhancing sports performance. Further research is needed to understand the autonomic factors that influence athletes with SCI in order to ensure optimal and safe sports competition. Additionally, this information is crucially relevant to the coaches, sports administrators, and team medical staff who work closely with athletes with SCI.

Effects of four-month handbike training under free-living conditions on physical fitness and health in wheelchair users

PURPOSE

Recognizing the encouraging effect of challenging events, the HandbikeBattle (HBB) was created to promote exercise among wheelchair users. The purpose of this study was to reveal the effects on physical fitness and health outcomes of four-month handbike training under free-living conditions in preparation for the event.

METHODS

In this prospective cohort study, 59 relatively inexperienced handyclists participated in the HBB of 2013 or 2014. Incremental exercise tests were conducted, respiratory function was tested and anthropometrics were measured before and after the preparation period. Main outcome measures were peak power output (POpeak), peak oxygen uptake (VO2peak) and waist circumference, of which the changes were tested using repeated measures ANOVA. To detect possible determinants of changes in physical fitness, a linear regression analysis was conducted with personal characteristics, executed training volume and upper-extremity complaints during the training period as independent variables.

RESULTS

POpeak, VO2peak and waist circumference improved significantly with 17%, 7% and 4.1%, respectively. None of the included variables were significant determinants for the changes in POpeak found as a result of the training.

CONCLUSION

A challenging event such as the HBB provokes training regimes among participants of sufficient load to realize substantial improvements in physical fitness and health outcomes. Implications for Rehabilitation Due to the often impaired muscle function in the lower-limbs and an inactive lifestyle, wheelchair users generally show considerably lower levels of fitness compared to able-bodied individuals. This prospective cohort study showed that four months of handbike training under free-living conditions in preparation for this event resulted in substantial improvements in physical fitness and health outcomes in wheelchair users. The creation of a challenging event such as the HandbikeBattle as part of a follow-up rehabilitation practice can therefore be a useful tool to help wheelchair users initiate or keep training to improve their physical fitness and health.

The effects of upper body exercise on the physical capacity of people with a spinal cord injury: a systematic review

Objective : To describe the effects of upper body training on the physical capacity of people with a spinal cord injury.

Data sources : The databases of PubMed, CINAHL, Sport Discus and Cochrane were searched from 1970 to May 2006.

Review methods : The keywords `spinal cord injury', `paraplegia', `tetraplegia' and `quadriplegia' were used in combination with `training'. The methodological quality of the included articles (both randomized controlled trials and controlled clinical trials) was assessed with the modified `van Tulder et al.' checklist. Studies were described with respect to population, test design, training protocol and mode of training. The training effects on physical capacity, reflected by peak power output (POpeak) and oxygen uptake (VO2peak), were summarized.

Results : Twenty-five studies were included with a mean score of 8.8 out of 17 items on the quality checklist. The methodological quality was quite low, mostly because of the absence of randomized controlled trials. Therefore no meta-analysis was possible. In the 14 articles of acceptable quality the mean (SD) increase in VO 2peak and POpeak, following a period of training, was 17.6 (11.2)% and 26.1 (15.6)%, respectively.

Conclusions : Due to the overall low quality of studies it is not possible to draw definitive conclusions on training effects for different lesion groups or training modes. The results of the relatively few studies with an acceptable quality seem to support the view that upper body exercise may increase the physical capacity of people with spinal cord injury. The magnitude of improvement in PO peak and VO2peak, however, varies considerably among studies.

Physical fitness in people with a spinal cord injury: the association with complications and duration of rehabilitation

Objective: To assess the association between physical fitness and its recovery over time on the one hand, and complications and duration of phases of rehabilitation on the other.

Design and setting: Prospective cohort study at eight rehabilitation centres. Subjects: People with a spinal cord injury were assessed four times: at the start of active rehabilitation (n = 110), three months later (n = 92), at discharge (n = 137) and a year after discharge from inpatient rehabilitation (n = 91).

Main measures: Physical fitness was defined as aerobic capacity, determined at each occasion by the peak oxygen uptake (peak Vo2; L/min) and the peak power output (peak PO; W) during a maximal exercise test. On these occasions, spasticity, musculoskeletal and neurogenic pain were determined (1 = present; 0 = absent). During inpatient rehabilitation, complications (urinary tract infection, pulmonary infection or pressure sore) and bed rest were registered (1 = complication; 0 = no complications, and 1 = bed rest; 0 = no bed rest). Complications and bed rest occurring during the year after discharge were registered similarly.

Results: Multilevel random coefficient analyses revealed associations in multivariate models (P ≤ 0.05). The peak oxygen uptake was negatively associated with complications after discharge. The recovery of peak power output over time was negatively associated with bed rest and spasticity. Both physical fitness and its recovery were negatively associated with the duration of active rehabilitation.

Conclusion: Results suggest that limiting complications, spasticity or bed rest may improve fitness. A longer duration of active rehabilitation is not associated with an increase in physical fitness.

Design and focus group evaluation of a bed-integrated weight measurement system for wheelchair users

Regular weight monitoring is known to help with weight management, which is an important part of maintaining a healthy, active lifestyle. Unfortunately, weight monitoring is challenging for wheelchair users because the few scales that are available are expensive and very large. Consequently, wheelchair users typically learn their weight at infrequent visits to their healthcare providers, which likely contributes to higher prevalence of obesity-related health risks among this population. In this article, we describe the design and development of the Embedded Scale, or E-Scale, which is a bed-integrated bodyweight measuring system that allows a user to measure and track their weight. The E-Scale team followed a standard product development approach to build the E-Scale prototype. Bench testing results indicate that the performance of the prototype is on par with commercially available wheelchair scales (capacity = 1,200 lbs, accuracy = 1.73 lbs, and precision = ± 0.35 lbs over one-fourth rated capacity). Institutional Review Board (IRB)-approved focus groups with 20 Veterans who use wheelchairs for mobility were conducted to gather feedback about the design, which was very positive. Development and testing results suggests the E-Scale technology is feasible and may provide a valuable tool to help wheelchair users manage their weight.

Exercise self-efficacy and the relation with physical behavior and physical capacity in wheelchair-dependent persons with subacute spinal cord injury

Background

Since physical activity and exercise levels are known to be generally low in persons with spinal cord injury (SCI), there seems to be a need for intervention. Exercise self-efficacy (ESE), the confidence persons have in their ability to be physically active and exercise, is an important and modifiable predictor of physical behavior. The goal of this study was to 1) describe ESE in persons with subacute SCI, 2) to assess ESE in subgroups based on demographic and lesion characteristics, and 3) to explore the relation between ESE and physical behavior and physical capacity.

Methods

Thirthy-seven persons with subacute SCI who are wheelchair dependent participated. Participants completed the Exercise Self-Efficacy Scale. We recorded age and lesion characteristics, measured physical behavior (physical activity, motility and sedentary day time, n = 35) with an accelerometer-based activity monitor and measured physical capacity (peak power output, n = 28 and peak oxygen uptake, n = 24) during a maximal hand-cycling test. Measurements were performed 2 months prior to discharge from inpatient rehabilitation. Mann-Whitney tests were used to test for differences between subgroups based on age and lesion characteristics and spearman correlations were used to assess the relation between ESE and physical activity and physical capacity.

Results

Persons with tetraplegia had lower ESE compared to persons with paraplegia (Z = −1.93, p = 0.05). No differences in ESE were found between subgroups based on age and motor completeness of the lesion. In persons with paraplegia, ESE was positively related to peak power output (ρ = 0.58, p = 0.02). The relation of ESE with wheeled physical activity was ρ = 0.36, p = 0.09.

Conclusions

In persons with SCI who are dependent on a manual wheelchair, lesion level when categorized as paraplegic and tetraplegic affected ESE whereas age categories and completeness categories did not. Persons with tetraplegia were found to have lower confidence with regard to physical activity and exercise indicating that this subgroup can benefit from extra attention in the promotion of physical activity and exercise. In persons with paraplegia, ESE seemed to be lower in persons with less peak power output and less daily physical activity.

Robot-assisted task-oriented upper extremity skill training in cervical spinal cord injury: a feasibility study

STUDY DESIGN

Prospective multiple case study.

OBJECTIVES

To test (1) the feasibility of haptic robot technology (Haptic Master (HM)) use to improve arm-hand function (AHF) and arm-hand skill performance (AHSP) in persons with a cervical spinal cord injury (C-SCI), (2) inventory participants' motivation and expectation to work with the robot technology used and (3) to descriptively report the results in individual cases.

SETTING

Rehabilitation Centre.

METHODS

Five C-SCI patients were trained for 6 weeks, 3 days per week, 60 min per day. Therapists filled out the Usefulness, Satisfaction and Ease-of-use questionnaire (USE). The Intrinsic Motivational Inventory (IMI) and credibility and expectancy questionnaire (CEQ) were filled out by participants. Performance at activity level was gauged using the Van Lieshout test for AHF in Tetraplegia and the Spinal Cord Independence Measure. Function level was gauged using muscle strength testing and the International Classification for Surgery of the Hand in Tetraplegia.

RESULTS

As to the feasibility of the application of haptic robot technology, the mean USE score was 65%. Mean IMI and CEQ results were 67% and 60%, respectively. Participants were motivated to train with the HM. All participants rated credibility higher than expectations regarding the improvement. In the current patients, little progress was demonstrated at the International Classification of Functioning, Disability and Health function and the activity level.

CONCLUSION

It is feasible to train C-SCI persons with the HM. Therapists report that working with the HM is easy to learn and easy to perform. Usability of the HM may be improved. Further research is needed to assess in which group of C-SCI and at which stage of rehabilitation HM training may be most beneficial.

Medical complications and falls in patients with spinal cord injury during the immediate phase after completing a rehabilitation program

BACKGROUND/OBJECTIVES

Complications and falls are crucial problems in patients with spinal cord injury (SCI). However, existing evidence on complications comes from data from hospital records over a long period of time, and falls were mostly reported retrospectively in patients with incomplete SCI. This study prospectively explored the occurrence of complications and falls, and associated factors in patients with SCI during the 6 months after discharge.

METHODS

One hundred subjects with SCI (50 wheelchair-bound (WB) and 50 ambulatory (AM) subjects) from a tertiary rehabilitation center completed the study. Every month, subjects were monitored for data on medical complications and falls. Descriptive information is provided for each group.

RESULTS

Every WB subject had complications and 14 subjects were re-hospitalized. The most frequent complications found in these subjects were neurogenic pain (36 subjects), urinary tract infection (UTI) (25 subjects), and pressure ulcers (21 subjects). In AM subjects, 38 subjects (76%) experienced complications and 3 subjects needed re-hospitalization. The most frequent complications included neurogenic pain (35 subjects) and UTI (11 subjects). Eighteen WB subjects (36%) and 27 AM subjects (54%) experienced falls. WB subjects had significantly increased odds for incidence of UTI and pressure ulcers, whereas AM subjects had significantly greater odds for falls (P < 0.05).

CONCLUSION

A number of subjects with SCI experienced complications and falls after completing a rehabilitation program. The findings add to our knowledge about complications and falls after SCI, and confirm the importance of effective strategies to minimize the occurrence of complications and falls in these individuals.

Resistive inspiratory muscle training in people with spinal cord injury during inpatient rehabilitation: a randomized controlled trial

BACKGROUND

People with spinal cord injury (SCI) may benefit from resistive inspiratory muscle training (RIMT). Current evidence is weak, and little is known about the effect on functional outcomes and long-term effects.

OBJECTIVE

The purpose of this study was to assess immediate and long-term effects of RIMT in people with SCI.

DESIGN

This was a single-blinded randomized controlled trial.

SETTING

The study was conducted at 4 specialized SCI units in the Netherlands.

PATIENTS

The study participants were 40 people with SCI (15 with motor complete tetraplegia, 16 with incomplete tetraplegia, 8 with motor complete paraplegia, and 1 with incomplete paraplegia) who had impaired pulmonary function and were admitted for initial inpatient rehabilitation.

INTERVENTION

Study participants were randomized to an RIMT group or a control group. All participants received usual rehabilitation care. In addition, participants in the intervention group performed RIMT with a threshold trainer.

MEASUREMENTS

Measurements were performed at baseline, after 8 weeks of intervention, 8 weeks later, and 1 year after discharge from inpatient rehabilitation. Primary outcome measures were: respiratory muscle function, lung volumes and flows, and perceived respiratory function. Secondary outcome measures concerned patient functioning, which included health-related quality of life, limitations in daily life due to respiratory problems, and respiratory complications.

RESULTS

During the intervention period, maximum inspiratory pressure (MIP) improved more in the RIMT group than in the control group (11.7 cm H2O, 95% confidence interval=4.3 to 19.0). At follow-up, this effect was no longer significant. No effect on other primary or secondary outcome measures was found except for an immediate effect on mental health.

LIMITATIONS

The sample size was insufficient to study effects on respiratory complications.

CONCLUSIONS

Resistive inspiratory muscle training has a positive short-term effect on inspiratory muscle function in people with SCI who have impaired pulmonary function during inpatient rehabilitation.

Longitudinal relationship between wheelchair exercise capacity and life satisfaction in patients with spinal cord injury: A cohort study in the Netherlands

OBJECTIVE

To examine the relationship between wheelchair exercise capacity and life satisfaction in persons with spinal cord injury from the start of active inpatient rehabilitation up to 5 years after discharge.

DESIGN

Prospective cohort study.

SUBJECTS

Persons with spinal cord injury, aged 18-65 years, and wheelchair dependent at least for long distances.

METHOD

Measurements at the start of active rehabilitation, after 3 months, at discharge from inpatient rehabilitation, and 1 and 5 years after discharge. A peak wheelchair exercise test was performed to record peak oxygen uptake (VO2peak) and peak power output (POpeak). Life satisfaction was measured as current life satisfaction and change of life satisfaction in comparison with life after spinal cord injury. Relationships between (changes in) exercise capacity and (changes in) life satisfaction were analyzed random coefficient analysis, corrected for possible confounders (age, gender, level of lesion, functional status, secondary impairments, pain, and sports activity) if necessary.

RESULTS

Of 225 persons included, 130 attended two or more peak exercise tests, who were include in the analyses. Mean age at start was 39 years, 75% were male, 73% had paraplegia, and 76% had a traumatic lesion. Mean POpeak increased during the study from 32.9 to 55.9 Watts, mean VO2peak from 1.02 to 1.38 l/minute, and mean life satisfaction from 5.7 to 7.8. An increase of POpeak with 10 W was associated with a 0.3-point increase of life satisfaction (P = 0.01). An increase of VO2peak with 0.1 l/minute was associated with a 0.1-point increase of life satisfaction (P = 0.049). Conclusion High(er) wheelchair exercise capacity is related to high(er) life satisfaction in spinal cord injury patients.

Patterns of changes in wheelchair exercise capacity after spinal cord injury

OBJECTIVES

(1) To identify different patterns of changes in wheelchair exercise capacity in the period between the start of active spinal cord injury (SCI) rehabilitation and 5 years after discharge; (2) to examine the pattern determinants of the change in wheelchair exercise capacity.

DESIGN

Prospective cohort study. Measurements were recorded at the start of active inpatient rehabilitation, 3 months after the start, at discharge of inpatient rehabilitation, 1 year after discharge, and 5 years after discharge.

SETTING

Eight rehabilitation centers.

PARTICIPANTS

Persons with SCI (N=130; age range, 18-65y), who were wheelchair-dependent, at least for long distances.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

Wheelchair exercise capacity: peak power output (W).

RESULTS

We found 4 different patterns of the change of peak power output (mean ± SD): (1) a pattern with high and progressive scores (33% of total study group): high progressive scores (start of rehabilitation: 49±15W to 5 years after discharge: 77±17.2W); (2) a pattern of improvement during inpatient rehabilitation and deterioration after inpatient rehabilitation (12%): progressive scores during inpatient rehabilitation with deteriorating scores after discharge (start of rehabilitation: 29±8.7W, to discharge: 60±8.4W, to 5 years after discharge: 39±13.1W); (3) a pattern with low and only slightly progressive scores (52%): low progressive scores (start of rehabilitation: 20±10.1W to 5 years after discharge: 31±15.9W); and (4) a pattern with low scores during inpatient rehabilitation and a sharp rise after discharge (3%): low inpatient scores with strong progressive scores after discharge (start of rehabilitation: 29±15.5W to 5 years after discharge: 82±10.6W). A logistic regression of factors that may distinguish between patterns with high and progressive scores and patterns with low and only slightly progressive scores revealed that older age, being a woman, having a tetraplegic lesion, and low functional status were associated with patterns with low and only slightly progressive scores. The pattern of improvement during inpatient rehabilitation and deterioration after inpatient rehabilitation showed more neuropathic pain and lower sports participation than patterns with high and progressive scores.

CONCLUSIONS

For the vast majority of patients, wheelchair exercise capacity after SCI shows a positive trend and can be described in distinct patterns that are dependent on personal, lesion, and functional characteristics.

Randomized controlled trial of a self-management intervention in persons with spinal cord injury: design of the HABITS (Healthy Active Behavioural Intervention in SCI) study

PURPOSE

To evaluate the effectiveness of a 16-week self-management intervention on physical activity level and self-management skills (self-efficacy, proactive coping and problem solving skills) in persons with chronic SCI.

METHOD AND DESIGN

Multicenter randomized controlled trial (RCT). Eighty persons with a SCI for at least 10 years and aged 18 to 65 will randomly be assigned to the intervention (self-management) or the control group (information provision). During the 16-week self-management intervention (one home-visit, five group and five individual sessions) active lifestyle will be stimulated and self-management skills will be taught. Data will be collected at baseline (T0), 16 (T1) and 42 (T2) weeks after baseline. Primary outcome measure is level of daily physical activity (self-report/objectively measured). Secondary outcome measures are self-managements skills, stage of behaviour change and attitude.

CONCLUSION

This is the first RCT on self-management in people with chronic spinal cord injury. This trial will provide knowledge on the effects of a self-management intervention on physical active lifestyle in persons with a long-term SCI.

A more active lifestyle in persons with a recent spinal cord injury benefits physical fitness and health

STUDY DESIGN

A prospective cohort study.

OBJECTIVES

To study the longitudinal relationship between objectively measured everyday physical activity level, and physical fitness and lipid profile in persons with a recent spinal cord injury (SCI).

SETTING

A rehabilitation centre in the Netherlands and the participant's home environment.

METHODS

Data of 30 persons with a recent SCI were collected at the start of active rehabilitation, 3 months later, at discharge from inpatient rehabilitation, and 1 year after discharge. Physical activity level (duration of dynamic activities as % of 24 h) was measured with an accelerometry-based activity monitor. Regarding physical fitness, peak oxygen uptake (VO(2)peak) and peak power output (POpeak) were determined with a maximal wheelchair exercise test, and upper extremity muscle strength was measured with a handheld dynamometer. Fasting blood samples were taken to determine the lipid profile.

RESULTS

An increase in physical activity level was significantly related to an increase in VO(2)peak and POpeak, and an increase in physical activity level favourably affected the lipid profile. A nonsignificant relation was found with muscle strength.

CONCLUSION

Everyday physical activity seems to have an important role in the fitness and health of persons with a recent SCI. An increase in physical activity level was associated with an increase in physical fitness and with a lower risk of cardiovascular disease.

Cardiovascular determinants of exercise capacity in the Paralympic athlete with spinal cord injury

This report briefly summarizes the cardiovascular factors that influence exercise physiology and, eventually, sports performance of athletes with a spinal cord injury (SCI). The consequences of an SCI are numerous and concern voluntary muscle function, deep and superficial sensitivity, and autonomic function to a degree determined by the level and completeness of the spinal lesion. Athletes with SCI perform with their upper body, which limits their maximal exercise capacity and puts them at a disadvantage compared with leg exercise in terms of mechanical efficiency and physiological adaptations to exercise. Studies generally find that maximal oxygen consumption and mechanical power output are inversely related to spinal lesion level. Athletes with cervical or dorsal lesions down to Th6 have limited maximal heart rates owing to a lack of sympathetic drive to the heart. Blood redistribution from body areas lacking autonomic control is impaired, thus reducing venous return and limiting cardiac stroke volume during exercise. Thermoregulatory function is affected through a lack of afferent neural feedback and limited efferent vasomotor and sudomotor control below the lesion. Strategies to support venous return and to promote body cooling potentially improve physiological responses and athletic performance, especially in individuals with high lesion levels. The latter are subject to autonomic dysreflexia, a generalized sympathetic vasoconstriction below the lesion resulting from nociceptive stimulations in insensate body regions. Acute episodes induce high blood pressure, may enhance exercise performance and must be treated as a clinical emergency. Deliberate triggering of this reflex is prohibited by the International Paralympic Committee.