Validity of the detection of wheelchair propulsion as measured with an Activity Monitor in patients with spinal cord injury

The Push Forward in Rehabilitation: Validation of a Machine Learning Method for Detection of Wheelchair Propulsion Type

Within rehabilitation, there is a great need for a simple method to monitor wheelchair use, especially whether it is active or passive. For this purpose, an existing measurement technique was extended with a method for detecting self- or attendant-pushed wheelchair propulsion. The aim of this study was to validate this new detection method by comparison with manual annotation of wheelchair use. Twenty-four amputation and stroke patients completed a semi-structured course of active and passive wheelchair use. Based on a machine learning approach, a method was developed that detected the type of movement. The machine learning method was trained based on the data of a single-wheel sensor as well as a setup using an additional sensor on the frame. The method showed high accuracy (F1 = 0.886, frame and wheel sensor) even if only a single wheel sensor was used (F1 = 0.827). The developed and validated measurement method is ideally suited to easily determine wheelchair use and the corresponding activity level of patients in rehabilitation.

Classification of Wheelchair Related Shoulder Loading Activities from Wearable Sensor Data: A Machine Learning Approach

Shoulder problems (pain and pathology) are highly prevalent in manual wheelchair users with spinal cord injury. These problems lead to limitations in activities of daily life (ADL), labor- and leisure participation, and increase the health care costs. Shoulder problems are often associated with the long-term reliance on the upper limbs, and the accompanying "shoulder load". To make an estimation of daily shoulder load, it is crucial to know which ADL are performed and how these are executed in the free-living environment (in terms of magnitude, frequency, and duration). The aim of this study was to develop and validate methodology for the classification of wheelchair related shoulder loading ADL (SL-ADL) from wearable sensor data. Ten able bodied participants equipped with five Shimmer sensors on a wheelchair and upper extremity performed eight relevant SL-ADL. Deep learning networks using bidirectional long short-term memory networks were trained on sensor data (acceleration, gyroscope signals and EMG), using video annotated activities as the target. Overall, the trained algorithm performed well, with an accuracy of 98% and specificity of 99%. When reducing the input for training the network to data from only one sensor, the overall performance decreased to around 80% for all performance measures. The use of only forearm sensor data led to a better performance than the use of the upper arm sensor data. It can be concluded that a generalizable algorithm could be trained by a deep learning network to classify wheelchair related SL-ADL from the wearable sensor data.

WISP, Wearable Inertial Sensor for Online Wheelchair Propulsion Detection

Manual wheelchair dance is an artistic recreational and sport activity for people with disabilities that is becoming more and more popular. It has been reported that a significant part of the dance is dedicated to propulsion. Furthermore, wheelchair dance professionals such as Gladys Foggea highlight the need for monitoring the quantity and timing of propulsions for assessment and learning. This study addresses these needs by proposing a wearable system based on inertial sensors capable of detecting and characterizing propulsion gestures. We called the system WISP. Within our initial configuration, three inertial sensors were placed on the hands and the back. Two machine learning classifiers were used for online bilateral recognition of basic propulsion gestures (forward, backward, and dance). Then, a conditional block was implemented to rebuild eight specific propulsion gestures. Online paradigm is intended for real-time assessment applications using sliding window method. Thus, we evaluate the accuracy of the classifiers in two configurations: “three-sensor” and “two-sensor”. Results showed that when using “two-sensor” configuration, it was possible to recognize the propulsion gestures with an accuracy of 90.28%. Finally, the system allows to quantify the propulsions and measure their timing in a manual wheelchair dance choreography, showing its possible applications in the teaching of dance.

Estimation of manual wheelchair-based activities in the free-living environment using a neural network model with inertial body-worn sensors

Shoulder pain is common in manual wheelchair (MWC) users. Overuse is thought to be a major cause, but little is known about exposure to activities of daily living (ADLs). The study goal was to develop a method to estimate three conditions in the field: (1) non-propulsion activity, (2) MWC propulsion, and (3) static time using an inertial measurement unit (IMU). Upper arm IMU data were collected as ten MWC users performed lab-based MWC-related ADLs. A neural network model was developed to classify data as non-propulsion activity, propulsion, or static, and validated for the lab-based data collection by video comparison. Six of the participants' free-living IMU data were collected and the lab-based model was applied to estimate daily non-propulsion activity, propulsion, and static time. The neural network model yielded lab-based validity measures ≥0.87 for differentiating non-propulsion activity, propulsion, and static time. A quasi-validation of one participant's field-based data yielded validity measures ≥0.66 for identifying propulsion. Participants' estimated mean daily non-propulsion activity, propulsion, and static time ranged from 158 to 409, 13 to 25, and 367 to 609 min, respectively. The preliminary results suggest the model may be able to accurately identify MWC users' field-based activities. The inclusion of field-based IMU data in the model could further improve field-based classification.

The Preliminary Criterion Validity of the Activ8 Activity Monitor to Measure Physical Activity in Youth Using a Wheelchair

PURPOSE

The aim of this study was to assess the criterion validity of the Activ8 to detect "active wheelchair use" and to distinguish 6 types of wheelchair activities using video recordings as a gold standard.

METHODS

Ten participants who use a manual wheelchair were participants in this study. Data of 2 participants were used for adapting the algorithm and data of 7 participants were used for assessing the criterion validity.

RESULTS

Criterion validity for detecting "active wheelchair use" had a relative time difference of 7.4%, agreement of 96%, sensitivity of 98.3%, and positive predictive value of 90%. Results for distinguishing 6 types of wheelchair activities had an agreement of 73%, sensitivity of 67.1%, and positive predictive value of 65.5%.

CONCLUSIONS

The Activ8 is able to detect "active wheelchair use" in youth using a manual wheelchair. Further development of the algorithm is necessary to distinguish between different types of wheelchair activities.

Measurement of self-propulsion distance of wheelchair using cycle computer excluding assistance distance by touch switch: A pilot study

Objective: Although the propulsion distance of a wheelchair is measured by some devices, measuring self-propulsion distance, excluding assistance propulsion distance by the caregiver, is difficult. This is a pilot study conducted to verify whether the propulsion distance of wheelchair users, excluding the assistance propulsion distance, can be measured using a cycle computer by attaching the touch switch.Methods: The wheelchair propulsion distance was measured using a cycle computer. We connected the touch switch and the cycle computer to the wheelchair to exclude assistance propulsion distance. We set the cycle computer to stop recording while the caregiver was touching the sensor. To confirm the propulsion distance using the cycle computer, the volunteer propelled the wheelchair on a rectangular facility with a total distance of 181 m, and the examiner confirmed the propulsion distance. The validation test to confirm the accuracy of the touch switch attached to the cycle computer was performed on a 50-m straight runway. The volunteer and caregiver propelled the wheelchair alternately by 10 m and continued until 50 m. The examiner confirmed the distance after 50-m propulsion.Results: In the 181-m rectangular facility, the propulsion distance that the volunteer propelled the wheelchair with the cycle computer was 180 m. In the 50-m straight runway, the propulsion distance was 30 m with caregiver assistance for 20 m.Conclusion: The present study showed that our modified device could measure the self-propulsion distance, excluding assistance propulsion distance in wheelchair users.

Physical activity and sedentary behaviour related to transport activity assessed with multiple body-worn accelerometers: the RECORD MultiSensor Study

OBJECTIVES

The study explored the physical activity and sedentary behaviours related to transport activity. The aim was to provide evidence to support public health and transport policies encouraging people to reach daily recommendations of physical activity.

STUDY DESIGN

The study design of this study is a cross-sectional study design.

METHODS

Between 2013 and 2015, the RECORD MultiSensor Study collected data from 155 participants using two accelerometers worn on the thigh and trunk. In addition, data were collected from Global Positioning System (GPS) receivers and a GPS-based mobility survey. Relationships between transport modes and the durations and partition patterns of physical behaviours were established at the trip stage (n = 7692) and trip levels (n = 4683) using multilevel linear models with a random effect at the individual level and taking into account temporal autocorrelation.

RESULTS

Participants travelled for a median of 1 h 45 min per day. Trip stages and trips involving walking, other active modes or public transport were associated with a lower sitting duration and a higher moderate-to-vigorous physical activity (MVPA) duration than trips with a personal motorised vehicle. Using public transport was associated with a lower number of transitions between sedentary behaviours and non-sedentary behaviours, and with a higher number of transitions between non-sedentary behaviours and MVPA than relying on a private motorised vehicle.

CONCLUSIONS

This study is the first to assess the association of transport mode with physical activity and sedentary behaviours captured with thigh- and trunk-worn accelerometers at both the trip stage and trip levels. The results demonstrate that, in addition to active transport modes, encouraging people to use public transport increases physical activity and reduces sedentary time.

The Activ8 activity monitor: Validation of posture and movement classification

Introduction

To set up and guide interventions with the aim to increase physical activity and lower sedentary behavior valid monitoring of physical behavior is essential. The aim of this study was to evaluate the validity of the single-unit Activ8 activity monitor to classify several body postures and movements.

Methods

Twelve healthy adults performed a series of activities, representative for everyday life, according to a standard protocol. Activ8 was both worn in the trouser pocket (prescribed location) and fixated to the front of the thigh. Activities were video recorded and analyzed thereafter. Postures and movements that were analyzed were lying/sitting, standing, walking, cycling, and running.

Results

The agreement between Activ8 output and video analysis was 89.7% (inter-subject range: 66.0 to 96.6%) for the pocket location and 91.9% (range 85.5 to 95.1%) for the thigh location. Sensitivity and positive predictive value scores for both locations were all above 80%, except for standing (69% or higher). Differences in classified duration of separate postures and movements were within 20% for walking, sitting and running.

Conclusion

The Activ8 is a valid instrument to quantify a defined set of body postures and movements. Because of the smaller time difference, the thigh location is preferred for research purposes.

Accelerometer assessment of physical activity in individuals with paraplegia who do and do not participate in physical exercise

OBJECTIVE

Our main goal was to measure physical activity (PA) in people with paraplegia. Secondarily, we aimed to establish the relationship between being engaged in physical exercise (PE) and reaching the recommended moderate-to-vigorous physical activity (MVPA) level. We further analyzed the effect of being engaged in PE on the PA levels.

DESIGN

Descriptive cross-sectional.

SETTING

Spanish associations for individuals with spinal cord injury.

PARTICIPANTS

Ninety-six manual wheelchair users with chronic paraplegia.

INTERVENTIONS

Participants wore a wrist accelerometer for one week.

OUTCOME MEASURES

Levels of PA and sedentary behavior. In addition, participants were classified into two groups, exercisers (EG) and non-exercisers (NEG) to analyze the effect of PE enrollment on the variables.

RESULTS

For all participants, a mean (SD) of 5,341.70 (966.4) minutes per week were spent engaged in sedentary behaviors, 2,188.99 (723.9) minutes were spent engaged in light activity, and 206.24 (180.0) minutes were spent engaged in MVPA. There was a significant relationship between PE and reaching the minimum levels of MVPA recommended [x2 (1) = 25.03, P < 0.01]. NEG showed a greater number of minutes per week for sedentary behavior [t (94) = 2.50, P < 0.05, r = 0.25]. The EG spent more than twice as much time doing MVPA than the NEG (263.8 min vs 114.3 min, respectively).

CONCLUSIONS

MVPA levels are low in manual wheelchair users who are not regular exercisers, but most of those who self-reported being regular exercisers reach the minimum levels recommended for health benefits. Sedentary behavior is a concern in this population.

Detection of body postures and movements in ambulatory adults with cerebral palsy: a novel and valid measure of physical behaviour

BACKGROUND

Accurate measurement of physical behaviour is paramount to better understand lifestyle, health, and functioning, particularly in adults with physical disability as they may be at higher risk of sedentary lifestyle and subsequent negative health consequences. This study aimed: 1) to evaluate the criterion validity of a novel and clinically applicable activity monitor (AM, Activ8), in the detection of body postures and movements in adults with spastic cerebral palsy (CP); and 2) to evaluate the extent that the AM's positioning affects validity.

METHODS

In this cross-sectional study, 14 ambulatory adults with CP [9 men; mean (SD) age, 35.4 (13.1) years] performed standardized activities while wearing three Activ8 monitors - frontolateral thigh (primary position), frontal thigh, and pant pocket - and being video recorded (criterion measure). AM activity output was compared to synchronized video recordings. Absolute (seconds) and relative [(video time-AM time)/mean time, %] time differences between methods were calculated. Relative time differences of < 10% were indicative of good validity. Comparison of AM attachment positions was completed using Spearman Rho correlation coefficients and Meng's tests.

RESULTS

Criterion validity of the AM (frontolateral thigh) was good (average relative time differences: 0.25% for sitting, 4.69% for standing, 2.46% for walking, 1.96% for upright activity, 3.19% for cycling), except for running (34.6%). Spearman Rho correlation coefficients were greater between video/frontolateral thigh position than video/frontal thigh position and video/pant pocket position for body posture and movement categories sitting, standing, walking, and upright activity (p < 0.01 for all).

CONCLUSIONS

The AM, positioned on the frontolateral thigh, demonstrated good criterion validity in ambulatory adults with CP. Though the Activ8 offers potential as an objective measure of physical activity, appropriate positioning is paramount for valid measurement.

Motor learning outcomes of handrim wheelchair propulsion during active spinal cord injury rehabilitation in comparison with experienced wheelchair users

PURPOSE

To investigate changes in wheelchair propulsion technique and mechanical efficiency across first five weeks of active inpatient spinal cord injury rehabilitation and to compare the outcomes at discharge with experienced wheelchair users with spinal cord injury.

METHODS

Eight individuals with recent spinal cord injury performed six weekly submaximal exercise tests. The first and last measurement additionally contained a wheelchair circuit and peak graded exercise test. Fifteen experienced individuals performed all above-mentioned tests on one occasion.

RESULTS

Mechanical efficiency and propulsion technique did not change during the five weeks of inpatient rehabilitation. Peak power output during peak graded test and performance time on the wheelchair circuit improved between the first and the last week. No difference in propulsion technique, peak power output, and performance time was found between the persons with a recent injury and the experienced group. Mechanical efficiency was higher after the correction for the difference in relative power output in the experienced group.

CONCLUSION

The group with a recent injury did not improve mechanical efficiency and propulsion technique over the period of active rehabilitation, despite significant improvements on the wheelchair circuit and in work capacity. The only significant difference between the groups was found in mechanical efficiency.Implications for rehabilitationThe lack of time-dependent changes in mechanical efficiency and propulsion technique in the group with a recent spinal cord injury, combined with the lack of differences in technique, work capacity and on the wheelchair circuit between the groups, suggest that important adaptations of motor learning may happen even earlier in rehabilitation and emphasize that the group in active rehabilitation was relatively skilled.Standardized observational analyses of handrim wheelchair propulsion abilities during early spinal cord injury rehabilitation provide detailed understanding of wheelchair technique, skill as well as wheelchair propulsion capacity.Measurement of external power output is critical to interpretation of gross efficiency, propulsion technique, and capacity.Wheelchair quality and body weight - next to wheelchair fitness and skill - require careful consideration both in early rehabilitation as well as in the chronic phase of spinal cord injury.

Instruments Measuring Physical Activity in Individuals Who Use a Wheelchair: A Systematic Review of Measurement Properties

OBJECTIVE

To systematically review the evidence evaluating validity or reliability of self-reported and device-based instruments, to measure physical activity (PA) in individuals who use a wheelchair, and to make recommendations for the selection of PA outcomes tools.

DATA SOURCES

PubMed, Embase, and CINAHL were systematically searched.

STUDY SELECTION

Studies reporting measurement properties of instruments to assess PA in individuals who use a wheelchair.

DATA EXTRACTION

The Consensus-Based Standards for the Selection of Health Status Measurement Instruments checklist was used to assess the methodological quality of the included studies. The measurement properties of instruments assessing PA were examined.

DATA SYNTHESIS

The search yielded 5341 records, 61 were considered relevant, 21 articles were included. A best evidence synthesis was performed on 9 studies including 4 self-reported instruments and 13 studies including 8 device-based instruments. One study evaluated both self-reported and device-based instruments. The overall methodological quality of all studies ranged from poor to excellent. Variable levels of evidence were found for both the validity and reliability for self-reported instruments and for criterion validity for device-based instruments.

CONCLUSIONS

The Physical Activity Scale for Individuals with Disabilities (PASIPD) and The Physical Activity Recall Assessment for People with Spinal Cord Injury (PARA-SCI) seem the most promising self-reported instruments for measuring the intensity of PA. Device-based instruments that can be used for measuring both the intensity and type of PA are the GENEActiv, Actigraph GT3X+, Actiheart, or the Physical Activity Monitor System (PAMS), showing moderate evidence for a positive rating of criterion validity. For measuring the type of PA, the PAMS and VitaMove are suitable, showing both good evidence for a positive rating of criterion validity.

Toward community-based wheelchair evaluation with machine learning methods

Introduction

Upper extremity pain among manual wheelchair users induces functional decline and reduces quality of life. Research has identified chronic overuse due to wheelchair propulsion as one of the factors associated with upper limb injuries. Lack of a feasible tool to track wheelchair propulsion in the community precludes testing validity of wheelchair propulsion performed in the laboratory. Recent studies have shown that wheelchair propulsion can be tracked through machine learning methods and wearable accelerometers. Better results were found in subject-specific machine learning method. To further develop this technique, we conducted a pilot study examining the feasibility of measuring wheelchair propulsion patterns.

Methods

Two participants, an experienced manual wheelchair user and an able-bodied individual, wore two accelerometers on their arms. The manual wheelchair user performed wheelchair propulsion patterns on a wheelchair roller system and overground. The able-bodied participant performed common daily activities such as cooking, cleaning, and eating.

Results

The support vector machine built from the wrist and arm acceleration of wheelchair propulsion pattern recorded on the wheelchair roller system predicted the wheelchair propulsion patterns performed overground with 99.7% accuracy. The support vector machine built from additional rotation data recorded overground predicted wheelchair propulsion patterns (F1 = 0.968).

Conclusions

These results further demonstrate the possibility of tracking wheelchair propulsion in the community.

A Novel Tool for Quantifying and Promoting Physical Activity in Youths With Typical Development and Youths Who Are Ambulatory and Have Motor Disability

BACKGROUND

Several device-based instruments have been validated in the pediatric population, but none of these are clinically applicable and provide real-time feedback on actual physical activity in terms of postures and movements. A new device (Activ8) is promising for that purpose.

OBJECTIVE

The objective was to investigate the criterion validity of the Activ8 for measuring static (sitting, standing) and dynamic (walking, bicycling, running) activities, and for separating postures and movements within basic and complex activities in children and adolescents (youths) with typical development (TD) and peers with motor disability (not typical development [NTD]).

DESIGN

This was a criterion validation study.

METHODS

Ten participants with TD (mean age [standard deviation] = 14 [2.5] years) and 10 participants with NTD (mean age = 12.9 [2.1] years) performed a standardized series of basic and daily life (complex) activities. The Activ8 measured postures and movements, while camera recording served as a reference. The outcome measures were the mean time differences between the Activ8 output and video data for the merged categories "static" and "dynamic" and for the separate postures and movements.

RESULTS

For the merged categories static and dynamic, the criterion validity was found to be excellent both in participants with TD and participants with NTD within basic activities, and was found to be good to excellent in participants with TD and moderate to good in participants with NTD within complex activities. The detection of separate postures and movements was found to be poor to excellent in both groups within complex activities.

LIMITATIONS

The sample of youths with NTD was small and limited to youths who could be considered to be at least ambulatory within a household.

CONCLUSIONS

Activ8 is a valid tool when the merged categories static and dynamic are used to interpret physical activity in daily life in both youths with TD and youths with NTD and mild motor impairment. To optimize the quantification of separate postures and movements, adjustment of the existing algorithm is required.

Physical activity in wheelchair-using youth with spina bifida: an observational study

BACKGROUND

Even though typically developing youth are already at risk for physical inactivity, youth with spina bifida may be even at higher risk as a consequence of their reduced mobility. No objective data is available for youth with spina bifida who use a manual wheelchair, so the seriousness of the problem is unknown. The purpose of this observational study was to quantify physical activity in wheelchair-using youth with spina bifida and evaluate the intensity of activities.

METHODS

Fifty-three children and adolescents (5-19 years) with spina bifida who use a manual wheelchair for daily life, long distances or sports were included. To assess time spent in several types of activities VitaMove data of 34 participants were used and were presented as time spent sedentary and time spent physically active. This was compared to reference data of typically developing youth. To assess time spent in several intensities Actiheart data of 36 participants were used. The intensities were categorized according to the American College of Sports Medicine, ranging from very light intensity to near to maximal intensity. Data of 25 participants were used to combine type of activity and intensity.

RESULTS

Children and adolescents with spina bifida who use a manual wheelchair were more sedentary (94.3% versus 78.0% per 24 h, p < 0.000) and less physically active (5.0% versus 12.2% per 24 h, p < 0.000) compared to typically developing peers. Physical activity during weekend days was worse compared to school days; 19% met the Guidelines of Physical Activity during school days and 8% during weekend days. The intensities per activity varied extensively between participants.

CONCLUSIONS

Children and adolescents with spina bifida who use a manual wheelchair are less physically active and more sedentary than typically developing youth. The physical activity levels on school days seem to be more favorable than the physical activity levels on a weekend day. The low levels of physical activity need our attention in pediatric rehabilitation practice. The different intensities during activities indicate the importance of individually tailored assessments and interventions.

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.

Validity of consumer-grade activity monitor to identify manual wheelchair propulsion in standardized activities of daily living

Background

Hypoactive lifestyle contributes to the development of secondary complications and lower quality of life in wheelchair users. There is a need for objective and user-friendly physical activity monitors for wheelchair-dependent individuals in order to increase physical activity through self-monitoring, goal setting, and feedback provision.

Objective

To determine the validity of Activ8 Activity Monitors to 1) distinguish two classes of activities: independent wheelchair propulsion from other non-propulsive wheelchair-related activities 2) distinguish five wheelchair-related classes of activities differing by the movement intensity level: sitting in a wheelchair (hands may be moving but wheelchair remains stationary), maneuvering, and normal, high speed or assisted wheelchair propulsion.

Methods

Sixteen able-bodied individuals performed sixteen various standardized 60s-activities of daily living. Each participant was equipped with a set of two Activ8 Professional Activity Monitors, one at the right forearm and one at the right wheel. Task classification by the Active8 Monitors was validated using video recordings. For the overall agreement, sensitivity and positive predictive value, outcomes above 90% are considered excellent, between 70 and 90% good, and below 70% unsatisfactory.

Results

Division in two classes resulted in overall agreement of 82.1%, sensitivity of 77.7% and positive predictive value of 78.2%. 84.5% of total duration of all tasks was classified identically by Activ8 and based on the video material. Division in five classes resulted in overall agreement of 56.6%, sensitivity of 52.8% and positive predictive value of 51.9%. 59.8% of total duration of all tasks was classified identically by Activ8 and based on the video material.

Conclusions

Activ8 system proved to be suitable for distinguishing between active wheelchair propulsion and other non-propulsive wheelchair-related activities. The ability of the current system and algorithms to distinguish five various wheelchair-related activities is unsatisfactory.

Validity of activity monitors in wheelchair users: A systematic review

Assessing physical activity (PA) in manual wheelchair users (MWUs) is challenging because of their different movement patterns in comparison to the ambulatory population. The aim of this review was to investigate the validity of portable monitors in quantifying PA in MWUs. A systematic literature search was performed. The data source was full reports of validation and evaluation studies in peer-reviewed journals and conference proceedings. Eligible articles between January 1, 1999, and September 18, 2015, were identified in three databases: PubMed, Institute of Electrical and Electronics Engineers, and Scopus. A total of 164 articles (158 from the databases and 6 from the citation/reference tracking) were identified, and 29 met the eligibility criteria. Two investigators independently extracted the characteristics from each selected article following a predetermined protocol and completed seven summary tables describing the study characteristics and key outcomes. In the identified studies, the monitors were used to assess three types of PA measures: energy cost, user movement, and wheelchair movement. The customized algorithms/monitors did not estimate energy cost in MWUs as well as the commercial monitors did in the ambulatory population; however, they showed fair accuracy in measuring both wheelchair and user movements.

Measurement of Physical Activity and Energy Expenditure in Wheelchair Users: Methods, Considerations and Future Directions

Accurately measuring physical activity and energy expenditure in persons with chronic physical disabilities who use wheelchairs is a considerable and ongoing challenge. Quantifying various free-living lifestyle behaviours in this group is at present restricted by our understanding of appropriate measurement tools and analytical techniques. This review provides a detailed evaluation of the currently available measurement tools used to predict physical activity and energy expenditure in persons who use wheelchairs. It also outlines numerous considerations specific to this population and suggests suitable future directions for the field. Of the existing three self-report methods utilised in this population, the 3-day Physical Activity Recall Assessment for People with Spinal Cord Injury (PARA-SCI) telephone interview demonstrates the best reliability and validity. However, the complexity of interview administration and potential for recall bias are notable limitations. Objective measurement tools, which overcome such considerations, have been validated using controlled laboratory protocols. These have consistently demonstrated the arm or wrist as the most suitable anatomical location to wear accelerometers. Yet, more complex data analysis methodologies may be necessary to further improve energy expenditure prediction for more intricate movements or behaviours. Multi-sensor devices that incorporate physiological signals and acceleration have recently been adapted for persons who use wheelchairs. Population specific algorithms offer considerable improvements in energy expenditure prediction accuracy. This review highlights the progress in the field and aims to encourage the wider scientific community to develop innovative solutions to accurately quantify physical activity in this population.

Data logger technologies for manual wheelchairs: A scoping review

In recent years, studies have increasingly employed data logger technologies to record objective driving and physiological characteristics of manual wheelchair users. However, the technologies used offer significant differences in characteristics, such as measured outcomes, ease of use, and level of burden. In order to identify and describe the extent of published research activity that relies on data logger technologies for manual wheelchair users, we performed a scoping review of the scientific and gray literature. Five databases were searched: Medline, Compendex, CINAHL, EMBASE, and Google Scholar. The 119 retained papers document a wide variety of logging devices and sensing technologies measuring a range of outcomes. The most commonly used technologies were accelerometers installed on the user (18.8%), odometers installed on the wheelchair (12.4%), accelerometers installed on the wheelchair (9.7%), and heart monitors (9.7%). Not surprisingly, the most reported outcomes were distance, mobility events, heart rate, speed/velocity, acceleration, and driving time. With decreasing costs and technological improvements, data loggers are likely to have future widespread clinical (and even personal) use. Future research may be needed to assess the usefulness of different outcomes and to develop methods more appropriate to wheelchair users in order to optimize the practicality of wheelchair data loggers.

Evaluation of custom energy expenditure models for SenseWear armband in manual wheelchair users

Physical activity monitors are increasingly used to help the general population lead a healthy lifestyle by keeping track of their daily physical activity (PA) and energy expenditure (EE). However, none of the commercially available activity monitors can accurately estimate PA and EE in people who use wheelchairs as their primary means of mobility. Researchers have recently developed custom EE prediction models for manual wheelchair users (MWUs) with spinal cord injuries (SCIs) based on a commercial activity monitor--the SenseWear armband. This study evaluated the performance of two custom EE prediction models, including a general model and a set of activity-specific models among 45 MWUs with SCI. The estimated EE was obtained by using the two custom models and the default manufacturer's model, and it was compared with the gold standard measured by the K4b2 portable metabolic cart. The general, activity-specific, and default models had a mean signed percent error (mean +/- standard deviation) of -2.8 +/- 26.1%, -4.8 +/- 25.4%, and -39.6 +/- 37.8%, respectively. The intraclass correlation coefficient was 0.86 (95% confidence interval [CI] = 0.82 to 0.89) for the general model, 0.83 (95% CI = 0.79 to 0.87) for the activity-specific model, and 0.62 (95% CI = 0.16 to 0.81) for the default model. The custom models for the SenseWear armband significantly improved the EE estimation accuracy for MWUs with SCI.

Multi-Day Recordings of Wearable Sensors Are Valid and Sensitive Measures of Function and Independence in Human Spinal Cord Injury

Wearable sensor assessment tools have proven to be reliable in measuring function in normal and impaired movement disorders during well-defined assessment protocols. While such assessments can provide valid and sensitive measures of upper limb activity in spinal cord injury (SCI), no assessment tool has yet been introduced into unsupervised daily recordings to complement clinical assessments during rehabilitation. The objective of this study was to measure the overall amount of upper-limb activity in subjects with acute SCI using wearable sensors and relate this to lesion characteristics, independence, and function. The overall amount of upper extremity activity counts, measures of wheeling (speed and distance), and limb-use laterality were measured in 30 in-patients with an acute cervical or thoracic SCI three months after injury. The findings were related to the international standards for neurological classification of SCI, the spinal cord independence measure, and the upper extremity motor scores of the Graded and Redefined Assessment of Strength, Sensibility, and Prehension. Overall upper extremity activity counts were successfully recorded in all patients and correlated with the neurological level of injury and independence. Clinical measures of proximal muscle strength were related to overall activity count and peak velocity of wheeling. Compared with paraplegics, tetraplegics showed significantly lower activity counts and increased limb-use laterality. This is the first cross-sectional study showing the feasibility and clinical value of sensor recordings during unsupervised daily activities in rehabilitation. The strong relationship between sensor-based measures and clinical outcomes supports the application of such technology to assess and track changes in function during rehabilitation and in clinical trials.

Objective and Self-Reported Physical Activity Measures and Their Association With Depression and Satisfaction With Life in Persons With Spinal Cord Injury

OBJECTIVE

To identify associations between objective and self-reported measures of physical activity (PA) and relationships with depression and satisfaction with life (SWL) in persons with spinal cord injury (SCI).

DESIGN

Retrospective, cross-sectional study of objectively measured wheelchair propulsion (WCP) from 2 studies in which an odometer was attached to participants' wheelchairs to record daily speed and distance. Self-reported data were collected in a separate study examining dyspnea, PA, mood, and SWL.

SETTING

Outpatient clinic in a rehabilitation center.

PARTICIPANTS

Individuals (N=86) with traumatic SCI who use a manual wheelchair.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Objective measures of PA included average daily distance and speed of WCP measured by an odometer. Self-report questionnaires included demographics, the 24-hour recall of transfers, Physical Activity Recall Assessment for People with SCI, the Patient Health Questionnaire-2 (PHQ-2) to document depressive symptoms, and the Satisfaction With Life Scale (SWLS).

RESULTS

Both objective measures of WCP, average daily distance and speed, were predicted by the combination of self-reported daily time away from home/yard and lower frequency of car transfers ([r=.367, P=.002] and [r=.434, P<.001], respectively). Daily distance of WCP was negatively correlated with depression (PHQ-2) (r=-.309, P=.004). Time in leisure PA was the only significant predictor of SWLS scores (r=.321, P=.003).

CONCLUSIONS

Short-term recall of hours away from home/yard not spent driving or riding in a vehicle is suggested as a self-report measure that is moderately related to overall WCP PA in this population. Results of this study suggest that depression is related to decreased PA and WCP activity, while SWL is related to leisure PA.

Telehealth monitor to measure physical activity and pressure relief maneuver performance in wheelchair users

This study demonstrated the feasibility of a device for monitoring pressure relief maneuvers and physical activity for wheelchair users. The device counts the number of wheel pushes based on wheelchair acceleration and measures pressure relief maneuvers using a seat sensor consisting of three force sensing resistors (FSRs). To establish the feasibility of the seat sensor for the detection of pressure relief maneuvers, 10 wheelchair users and 10 non-disabled controls completed a series of wheelchair depression raises, forward trunk leans, and lateral trunk leans. The seat sensor was placed underneath the user's seat cushion. To establish the feasibility of wheel push counting, 10 full-time wheelchair users navigated a flat 50-m outdoor track and a 100-m outdoor obstacle course during self-propulsion (e.g., wheel pushes) and during assisted-propulsion (e.g., no wheel pushes). Of the 240 performed pressure relief, 225 were properly classified by the seat sensor (accuracy: 94%, sensitivity: 96%, specificity: 80%). Sensitivity was highest for depression raises (98%) and lowest for front lean maneuvers (80%). The wheelchair activity monitor measured 2,112 pushes during the self-propulsion trials compared to 2,162 pushes measured with the instrumented push-rim (97.7%). During assisted-propulsion trials, there were 477 incorrectly identified pushes (8.0 per trial).

A behavioural intervention increases physical activity in people with subacute spinal cord injury: a randomised trial

QUESTIONS

For people with subacute spinal cord injury, does rehabilitation that is reinforced with the addition of a behavioural intervention to promote physical activity lead to a more active lifestyle than rehabilitation alone?

DESIGN

Randomised, controlled trial with concealed allocation, intention-to-treat analysis, and blinded assessors.

PARTICIPANTS

Forty-five adults with subacute spinal cord injury who were undergoing inpatient rehabilitation and were dependent on a manual wheelchair. The spinal cord injuries were characterised as: tetraplegia 33%; motor complete 62%; mean time since injury 150 days (SD 74).

INTERVENTION

All participants received regular rehabilitation, including handcycle training. Only the experimental group received a behavioural intervention promoting an active lifestyle after discharge. This intervention involved 13 individual sessions delivered by a coach who was trained in motivational interviewing; it began 2 months before and ended 6 months after discharge from inpatient rehabilitation.

OUTCOME MEASURES

The primary outcome was physical activity, which was objectively measured with an accelerometer-based activity monitor 2 months before discharge, at discharge, and 6 and 12 months after discharge from inpatient rehabilitation. The accelerometry data were analysed as total wheeled physical activity, sedentary time and motility. Self-reported physical activity was a secondary outcome.

RESULTS

The behavioural intervention significantly increased wheeled physical activity (overall between-group difference from generalised estimating equation 21minutes per day, 95% CI 8 to 35). This difference was evident 6 months after discharge (28minutes per day, 95% CI 8 to 48) and maintained at 12 months after discharge (25minutes per day, 95% CI 1 to 50). No significant intervention effect was found for sedentary time or motility. Self-reported physical activity also significantly improved.

CONCLUSION

The behavioural intervention was effective in eliciting a behavioural change toward a more active lifestyle among people with subacute spinal cord injury.

TRIAL REGISTRATION

NTR2424.

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.

Identifying physical activity type in manual wheelchair users with spinal cord injury by means of accelerometers

STUDY DESIGN

This was a cross-sectional study.

OBJECTIVES

The main objective of this study was to develop and test classification algorithms based on machine learning using accelerometers to identify the activity type performed by manual wheelchair users with spinal cord injury (SCI).

SETTING

The study was conducted in the Physical Therapy department and the Physical Education and Sports department of the University of Valencia.

METHODS

A total of 20 volunteers were asked to perform 10 physical activities, lying down, body transfers, moving items, mopping, working on a computer, watching TV, arm-ergometer exercises, passive propulsion, slow propulsion and fast propulsion, while fitted with four accelerometers placed on both wrists, chest and waist. The activities were grouped into five categories: sedentary, locomotion, housework, body transfers and moderate physical activity. Different machine learning algorithms were used to develop individual and group activity classifiers from the acceleration data for different combinations of number and position of the accelerometers.

RESULTS

We found that although the accuracy of the classifiers for individual activities was moderate (55-72%), with higher values for a greater number of accelerometers, grouped activities were correctly classified in a high percentage of cases (83.2-93.6%).

CONCLUSIONS

With only two accelerometers and the quadratic discriminant analysis algorithm we achieved a reasonably accurate group activity recognition system (>90%). Such a system with the minimum of intervention would be a valuable tool for studying physical activity in individuals with SCI.

Validation of an activity monitor for children who are partly or completely wheelchair-dependent

BACKGROUND

Children who are wheelchair-dependent are at risk for developing unfavorable physical behavior; therefore, assessment, monitoring and efforts to improve physical behavior should start early in life. VitaMove is an accelerometer-based activity monitor and can be used to detect and distinguish different categories of physical behavior, including activities performed in a wheelchair and activities using the legs. The purpose of this study was to assess the validity of the VitaMove activity monitor to quantify physical behavior in children who are partly or completely wheelchair-dependent.

METHODS

Twelve children with spina bifida (SB) or cerebral palsy (CP) (mean age, 14 ± 4 years) performed a series of wheelchair activities (wheelchair protocol) and, if possible, activities using their legs (n = 5, leg protocol). Activities were performed at their own home or school. In children who were completely wheelchair-dependent, VitaMove monitoring consisted of one accelerometer-based recorder attached to the sternum and one to each wrist. For children who were partly ambulatory, an additional recorder was attached to each thigh. Using video-recordings as a reference, primary the total duration of active behavior, including wheeled activity and leg activity, and secondary agreement, sensitivity and specificity scores were determined.

RESULTS

Detection of active behaviour with the VitaMove activity monitor showed absolute percentage errors of 6% for the wheelchair protocol and 10% for the leg protocol. For the wheelchair protocol, the mean agreement was 84%, sensitivity was 80% and specificity was 85%. For the leg protocol, the mean agreement was 83%, sensitivity was 78% and specificity was 90%. Validity scores were lower in severely affected children with CP.

CONCLUSIONS

The VitaMove activity monitor is a valid device to quantify physical behavior in children who are partly or completely wheelchair-dependent, except for severely affected children and for bicycling.

Focus on fatigue amongst young adults with spastic cerebral palsy

Background

This study aimed to assess fatigue amongst young adults with spastic cerebral palsy (CP), to determine subgroups at risk for fatigue and to explore the relationship between fatigue and cardiopulmonary fitness and daily physical activity level.

Participants

Young adults with spastic CP, Gross Motor Function Classification System (GMFCS) levels I to III, aged 16 to 24 years.

Methods

Fatigue (Fatigue Severity Scale) and self-reported daily physical activity (Physical Activity Scale for Individuals with Physical Disabilities) were assessed for 56 participants using questionnaires. Daily physical activity was objectively measured using accelerometry (Vitamove system) over 72 hours. Progressive maximal aerobic cycling was used to measure cardiopulmonary fitness.

Results

The mean Fatigue Severity Scale (FSS) score was 3.7 (SD 1.4). Forty percent of participants were fatigued, including 12.5% who were severely fatigued. Participants with bilateral CP (FSS = 4.2 (SD 1.4)) were more fatigued compared to those with unilateral CP (FSS = 3.1 (SD 1.3)) (p < 0.01). Levels of cardiopulmonary fitness (2.4 L/min (SD 0.8)) and daily physical activity (8.5% (SD 3.0)) were not significantly related to fatigue (respectively p = 0.10 and p = 0.55), although for cardiopulmonary fitness a trend was found.

Conclusions

Fatigue is already present at a relatively young age amongst adults with CP, and CP subtype is a determinant of fatigue. We did not find significant evidence for a cross-sectional relation of fatigue with cardiopulmonary fitness or daily physical activity.

Trial registration

Nederland’s trial register: NTR1785.

Detection of physical activities using a physical activity monitor system for wheelchair users

Availability of physical activity monitors for wheelchair users can potentially assist these individuals to track regular physical activity (PA), which in turn could lead to a healthier and more active lifestyle. Therefore, the aim of this study was to develop and validate algorithms for a physical activity monitoring system (PAMS) to detect wheelchair based activities. The PAMS consists of a gyroscope based wheel rotation monitor (G-WRM) and an accelerometer device (wocket) worn on the upper arm or on the wrist. A total of 45 persons with spinal cord injury took part in the study, which was performed in a structured university-based laboratory environment, a semi-structured environment at the National Veterans Wheelchair Games, and in the participants' home environments. Participants performed at least ten PAs, other than resting, taken from a list of PAs. The classification performance for the best classifiers on the testing dataset for PAMS-Arm (G-WRM and wocket on upper arm) and PAMS-Wrist (G-WRM and wocket on wrist) was 89.26% and 88.47%, respectively. The outcomes of this study indicate that multi-modal information from the PAMS can help detect various types of wheelchair-based activities in structured laboratory, semi-structured organizational, and unstructured home environments.

Valid detection of self-propelled wheelchair driving with two accelerometers

This study assessed whether self-propelled wheelchair driving can be validly detected by a new method using a set of two commonly used accelerometers.In a rehabilitation centre, 10 wheelchair-bound persons with spinal cord injury (SCI) (aged 29-63 years) performed a series of representative daily activities according to a protocol including self-propelled wheelchair driving and other activities. Two ActiGraph GT3X+ accelerometers were used; one was attached at the wrist, the other to the spokes of the wheelchair wheel. Based on the movement intensity of the two accelerometers, a custom-made algorithm in MatLab differentiated between self-propelled wheelchair driving and other activities (e.g. being pushed or arm movements not related to wheelchair driving). Video recordings were used for reference. Validity scores between the accelerometer output and the video analyses were expressed in terms of agreement, sensitivity and specificity scores.Overall agreement for the detection of self-propelled wheelchair driving was 85%; sensitivity was 88% and specificity 83%. Disagreement between accelerometer output and video analysis was largest for wheelchair driving at very low speed on a treadmill, wheelchair driving on a slope on a treadmill, and being pushed in the wheelchair whilst making excessive arm movements.Valid detection of self-propelled wheelchair driving is provided by two accelerometers and a simple algorithm. Disagreement with the video analysis was largest during three atypical daily activities.

Temporal parameters estimation for wheelchair propulsion using wearable sensors

Due to lower limb paralysis, individuals with spinal cord injury (SCI) rely on their upper limbs for mobility. The prevalence of upper extremity pain and injury is high among this population. We evaluated the performance of three triaxis accelerometers placed on the upper arm, wrist, and under the wheelchair, to estimate temporal parameters of wheelchair propulsion. Twenty-six participants with SCI were asked to push their wheelchair equipped with a SMART^Wheel. The estimated stroke number was compared with the criterion from video observations and the estimated push frequency was compared with the criterion from the SMART^Wheel. Mean absolute errors (MAE) and mean absolute percentage of error (MAPE) were calculated. Intraclass correlation coefficients and Bland-Altman plots were used to assess the agreement. Results showed reasonable accuracies especially using the accelerometer placed on the upper arm where the MAPE was 8.0% for stroke number and 12.9% for push frequency. The ICC was 0.994 for stroke number and 0.916 for push frequency. The wrist and seat accelerometer showed lower accuracy with a MAPE for the stroke number of 10.8% and 13.4% and ICC of 0.990 and 0.984, respectively. Results suggested that accelerometers could be an option for monitoring temporal parameters of wheelchair propulsion.

Inactive and sedentary lifestyles amongst ambulatory adolescents and young adults with cerebral palsy

Background

To assess physical behaviour, including physical activity and sedentary behaviour, of ambulatory adolescents and young adults with cerebral palsy (CP). We compared participant physical behaviour to that of able-bodied persons and assessed differences related to Gross Motor Functioning Classification System (GMFCS) level and CP distribution (unilateral/bilateral).

Methods

In 48 ambulatory persons aged 16 to 24 years with spastic CP and in 32 able-bodied controls, physical behaviour was objectively determined with an accelerometer-based activity monitor. Total duration, intensity and type of physical activity were assessed and sedentary time was determined (lying and sitting). Furthermore, distribution of walking bouts and sitting bouts was specified.

Results

Adolescents and young adults with CP spent 8.6% of 24 hours physically active and 79.5% sedentary, corresponding with respectively 123 minutes and 1147 minutes per 24 hours. Compared to able-bodied controls, persons with CP participated 48 minutes less in physical activities (p < 0.01) and spent 80 minutes more sedentary per 24 hours (p < 0.01). Physical behaviour was not different between persons with GMFCS level I and II and only number of short sitting bouts were significantly more prevalent in persons with bilateral CP compared to unilateral CP (p < 0.05).

Conclusions

Ambulatory adolescents and young adults with CP are less physically active and spend more time sedentary compared to able-bodied persons, suggesting that this group may be at increased risk for health problems related to less favourable physical behaviour.

Trial registration

Nederlands trial register: NTR1785

Global position sensing and step activity as outcome measures of community mobility and social interaction for an individual with a transfemoral amputation due to dysvascular disease

BACKGROUND AND PURPOSE

Community mobility of individuals following lower limb amputation is highly variable and has a great impact on their quality of life. Currently, clinical assessments of ambulatory ability and motivation influence prosthetic prescription. However, these outcome measures do not effectively quantify community mobility (ie, mobility outside of the clinic) of individuals with an amputation. Advances in global positioning systems (GPSs) and other wearable step-monitoring devices allow for objective, quantifiable measurement of community mobility. This case report will examine the combined use of a GPS unit and a step activity monitor to quantify community mobility and social interaction of an individual with transfemoral amputation due to dysvascular disease.

CASE DESCRIPTION

A 76-year-old woman with a unilateral transfemoral amputation due to vascular disease carried a commercial GPS unit and step activity monitor to quantify her community mobility and social interaction every day over a period of 1 month. The step activity monitor was affixed to her prosthesis. The patient used a wheelchair as well as her prosthesis for everyday mobility.

OUTCOME

Information from the GPS unit and step activity monitor provided quantitative details on the patient's steps taken in and out of the home, wheelchair use, prosthesis use, driving trips, and time spent on social and community trips.

DISCUSSION

This case report describes a potential clinical measurement procedure for quantifying community mobility and social interaction of an individual with lower limb amputation. Future efforts are needed to validate this measurement tool on large sample sizes and in individuals with different mobility levels. Additionally, automatization of data analysis and technological approaches to reduce compromised GPS signals may eventually lead to a practical, clinically useful tool.

The experience of using the scale of functional independence measure in individuals undergoing spinal cord injury rehabilitation in Brazil

STUDY DESIGN

Retrospective cohort.

OBJECTIVES

The aim of this study was to evaluate the correlation between the level and completeness of the injury with Functional Independence Measure (FIM) score and the validity and responsiveness of the FIM in Brazilian individuals with spinal cord injury admitted to rehabilitation.

SETTING

SARAH Network of Rehabilitation Hospitals, Brasília, Brazil.

METHODS

A total of 218 patients with spinal cord injury admitted for rehabilitation in 2006 was included in this study. The validity was assessed as the ability of the FIM to discriminate different levels of disability (cervical, thoracic and lumbar) at admission and the responsiveness was obtained by analyzing admission and discharge data for each of the three injury groups.

RESULTS

Total FIM score, motor FIM score and each of the 13 items were valid when comparing three groups and comparing groups two by two, except the items 'eating' and 'grooming' among paraplegics, and 'stairs' at cervical and thoracic levels. The scale was not responsive to the five cognitive items, 'stairs' and 'eating', among paraplegics, or 'grooming', 'bathing' and 'dressing upper body' in lumbar level patients. The patient difficulty in performing tasks can vary among populations. Therefore, the continuous evaluation process of psychometric characteristics is important to validate the use of the instrument in different contexts.

Physical activity classification utilizing SenseWear activity monitor in manual wheelchair users with spinal cord injury

STUDY DESIGN

Validation.

OBJECTIVES

The primary aim of this study was to develop and evaluate activity classification algorithms for a multisensor-based SenseWear (SW) activity monitor that can recognize wheelchair-related activities performed by manual wheelchair users (MWUs) with spinal cord injury (SCI). The secondary aim was to evaluate how the accuracy in activity classification affects the estimation of energy expenditure (EE) in MWUs with SCI.

SETTING

University-based laboratory.

METHODS

Forty-five MWUs with SCI wore a SW on their upper arm and participated in resting, wheelchair propulsion, arm-ergometery and deskwork activities. The investigators annotated the start and end of each activity trial while the SW collected multisensor data and a portable metabolic cart collected criterion EE. Three methods including linear discriminant analysis, quadratic discriminant analysis (QDA), and Naïve Bayes (NB) were used to develop classification algorithms for four activities based on the training data set from 36 subjects.

RESULTS

The classification accuracy was 96.3% for QDA and 94.8% for NB when the classification algorithms were tested on the validation data set from nine subjects. The average EE estimation errors using the activity-specific EE prediction model were 5.3±21.5% and 4.6±22.8% when the QDA and NB classification algorithms were applied, respectively, as opposed to 4.9±20.7% when 100% classification accuracy was assumed.

CONCLUSION

The high classification accuracy and low EE estimation errors suggest that the SW can be used by researchers and clinicians to classify and estimate the EE for the four activities tested in this study among MWUs with SCI.

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.

Validation of an accelerometer-based method to measure the use of manual wheelchairs

The goal of this project was to develop and validate a methodology for measuring manual wheelchair movement. The ability to study wheelchair movement is necessary across a number of clinical and research topics in rehabilitation, including the outcomes of rehabilitation interventions, the long-term effects of wheelchair propulsion on shoulder health, and improved wheelchair prescription and design. This study used a wheel-mounted accelerometer to continuously measure distance wheeled, and to continuously determine if the wheelchair is moving. Validation of the system and algorithm was tested across typical mobility-related activities of daily living, which included short slow movements with frequent starts, stops, and turns, and straight, steady state propulsion. Accuracy was found to be greater than 90% across wheelchair and wheel types (spoke and mag), propulsion techniques (manual and foot), speeds, and everyday mobility-related activities of daily living. Although a number of approaches for wheelchair monitoring are currently present in the literature, many are limited in the data they provide. The methodology presented in this paper can be applied to a variety of commercially available products that record bi-axial accelerations, and used to answer many research questions in wheeled mobility.

Addressing the nonexercise part of the activity continuum: a more realistic and achievable approach to activity programming for adults with mobility disability?

Participation in physical activity is fundamental for the maintenance of metabolic health and the prevention of major chronic diseases, particularly type 2 diabetes and cardiovascular disease. A whole-of-day approach to physical activity promotion is increasingly advocated and includes not only increasing moderate-intensity physical activity but also reducing sedentary time and increasing light-intensity activity (the "nonexercise" part of the activity continuum). This whole-of-day approach to tackling the challenge of inactivity may be particularly relevant for adults with mobility disabilities, who are among the most inactive segment of the population. Focusing on nonexercise activity by striving to reduce sedentary time and increase light-intensity activity may be a more successful place to begin to change behavior in someone with mobility disability. This article discusses what is known about the metabolic health consequences of sedentary behavior and light-intensity activity in adults with and without mobility disability. The concept of inactivity physiology is presented, along with possible applications or evidence from studies with adults with mobility disability. Mobility disability discussions and examples focus on stroke and spinal cord injury. Finally, clinical implications and future research directions related to sedentary behavior in adults with mobility disability are discussed.

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.

Wheelchair-mounted accelerometers for measurement of physical activity

PURPOSE

To evaluate the validity of a wheelchair frame-mounted accelerometer for the assessment of physical activity of wheelchair users.

METHOD

Twelve collegiate wheelchair basketball players participated in this study. The study was conducted in a modern indoor gymnasium at a university in the USA. A randomized, crossover experimental design was used to investigate accelerometer output, participant heart rate, and distance travelled. Participants performed two trials of wheeling at a combination of two different effort levels (light and moderate: Prescribed using perceived exertion) and two different modes (continuous and stop-go).

RESULTS

Accelerometer vector magnitude activity counts (VM), heart rate (HR), and distance travelled were significantly different between light and moderate effort (p < 0.01). The continuous and stop-go wheeling modes were not significantly different (p = 0.37) for VM, but were significantly different (p < 0.01) for both HR and distance. Between-trial reliability of all data collapsed for the effort and mode combinations were: VM: r = 0.85; HR: r = 0.86; and distance: r = 0.96.

CONCLUSION

A wheelchair frame-mounted accelerometer differentiated between perceptually-prescribed low and moderate effort levels and may prove to be a valid instrument in the detection of a wheelchair users' physical activity. [Box: see text].

Validation of the Physical Activity Scale for individuals with physical disabilities

OBJECTIVE

To determine the criterion validity of the Physical Activity Scale for Individuals With Physical Disabilities (PASIPD) by means of daily physical activity levels measured by using a validated accelerometry-based activity monitor in a large group of persons with a physical disability.

DESIGN

Cross-sectional.

SETTING

Participants' home environment.

PARTICIPANTS

Ambulatory and nonambulatory persons with cerebral palsy, meningomyelocele, or spinal cord injury (N=124).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Self-reported physical activity level measured by using the PASIPD, a 2-day recall questionnaire, was correlated to objectively measured physical activity level measured by using a validated accelerometry-based activity monitor.

RESULTS

Significant Spearman correlation coefficients between the PASIPD and activity monitor outcome measures ranged from .22 to .37. The PASIPD overestimated the duration of physical activity measured by using the activity monitor (mean ± SD, 3.9±2.9 vs 1.5±0.9h/d; P<.01). Significant correlation (ρ=-.74; P<.01) was found between average number of hours of physical activity per day measured by using the 2 methods and difference in hours between methods. This indicates larger overestimation for persons with higher activity levels.

CONCLUSIONS

The PASIPD correlated poorly with objective measurements using an accelerometry-based activity monitor in people with a physical disability. However, similar low correlations between objective and subjective activity measurements have been found in the general population. Users of the PASIPD should be cautious about overestimating physical activity levels.

Accelerometry-based activity spectrum in persons with chronic physical conditions

OBJECTIVES

(1) To give an overview of the impact of a variety of chronic physical conditions on accelerometry-based levels of everyday physical activity and to identify high-risk conditions; and (2) to compare these objectively assessed activity levels with the levels estimated by rehabilitation physicians.

INTERVENTIONS

Not applicable.

DESIGN

Cross-sectional study.

SETTING

Participant's home environment.

PARTICIPANTS

Patients (n=461) with 18 chronic physical (sub)conditions and able-bodied subjects (n=96).

MAIN OUTCOME MEASURES

We summarized data on the level of everyday physical activity as objectively measured with an accelerometry-based activity monitor. Thirty-one rehabilitation physicians filled in a questionnaire designed to obtain their estimates of the level of physical activity in patients with the various conditions.

RESULTS

Only 4 of the studied conditions had normal activity levels (≥90% of the able-bodied level). Persons with transtibial amputation (vascular), spinal cord injury, and myelomeningocele (wheelchair dependent) had the lowest levels of activity, less than 40% of the able-bodied level. In general, rehabilitation physicians were aware of the inactive lifestyles, but considerably underestimated the magnitude of inactivity in the high-risk conditions.

CONCLUSIONS

This is the first study to provide an objectively assessed activity spectrum in a variety of chronic physical conditions. We hope this study will increase the awareness of health professionals as to which chronic physical conditions are at increased risk for an inactive lifestyle, and will contribute to adaptation of patient management accordingly.

Learn 2 Move 16-24: effectiveness of an intervention to stimulate physical activity and improve physical fitness of adolescents and young adults with spastic cerebral palsy; a randomized controlled trial

Background

Persons with cerebral palsy (CP) are at risk for developing an inactive lifestyle and often have poor fitness levels, which may lead to secondary health complications and diminished participation and quality of life. However, persons with CP also tend not to receive structural treatment to improve physical activity and fitness in adolescence, which is precisely the period when adult physical activity patterns are established.

Methods

We aim to include 60 adolescents and young adults (16-24 years) with spastic CP. Participants will be randomly assigned to an intervention group or a control group (no treatment; current policy). The intervention will last 6 months and consist of three parts; 1) counselling on daily physical activity; 2) physical fitness training; and 3) sports advice. To evaluate the effectiveness of the intervention, all participants will be measured before, during, directly after, and at 6 months following the intervention period. Primary outcome measures will be: 1) physical activity level, which will be measured objectively with an accelerometry-based activity monitor during 72 h and subjectively with the Physical Activity Scale for Individuals with Physical Disabilities; 2) aerobic fitness, which will be measured with a maximal ramp test on a bicycle or armcrank ergometer and a 6-minute walking or wheelchair test; 3) neuromuscular fitness, which will be measured with handheld dynamometry; and 4 body composition, which will be determined by measuring body mass, height, waist circumference, fat mass and lipid profile.

Conclusions

This paper outlines the design, methodology and intervention of a multicenter randomized controlled trial (LEARN 2 MOVE 16-24) aimed at examining the effectiveness of an intervention that is intended to permanently increase physical activity levels and improve fitness levels of adolescents and young adults with CP by achieving a behavioral change toward a more active lifestyle.

Trial registration

Dutch Trial Register; NTR1785

Development and validation of a physical activity monitor for use on a wheelchair

STUDY DESIGN

Keeping physically active is important for people who mobilize using a wheelchair. However, current tools to measure physical activity in the wheelchair are either not validated or limited in their application. The purpose of this study was to develop and validate a monitoring system to measure wheelchair movement.

METHODS

The system developed consisted of a tri-axial accelerometer placed on the wheel of a wheelchair and an analysis algorithm to interpret the acceleration signals. The two accelerometer outputs in the plane of the wheel were used to calculate the angle of the wheel. From this, outcome measures of wheel revolutions, absolute angle and duration of movement were derived and the direction of movement (forwards or backwards) could be distinguished. Concurrent validity was assessed in comparison with video analysis in 14 people with spinal cord injury using their wheelchair on an indoor track and outdoor wheelchair skills course. Validity was assessed using intraclass correlation coefficients (ICC(2,1)) and Bland-Altman plots.

RESULTS

The monitoring system demonstrated excellent validity for wheel revolutions, absolute angle and duration of movement (ICC(2,1)>0.999, 0.999, 0.981, respectively) in both manual and powered wheelchairs, when the wheelchair was propelled forwards and backwards, and for movements of various durations.

CONCLUSION

This study has found this monitoring system to be an accurate and objective tool for measuring detailed information on wheelchair movement and maneuvering regardless of the propulsion technique, direction and speed.

Lifestyle, participation, and health-related quality of life in adolescents and young adults with myelomeningocele

This study aimed to describe participation and health-related quality of life (HRQoL) in adolescents and young adults with myelomeningocele and to explore their relationships with lifestyle-related factors. Fifty-one individuals with a mean age of 21 years 1 month (SD 4y 6mo) years participated (26 males, 25 females; 82% hydrocephalus, 55% wheelchair-dependent). Participation was assessed using the Life Habits Questionnaire, and HRQoL was assessed using the Medical Outcomes Study 36-item Short-form Health Survey. Physical activity was measured using an accelerometry-based activity monitor, fitness (peak oxygen uptake) was measured during a maximal exercise test, and the sum of four skin-folds was assessed to indicate body fat. Relationships were studied using logistic regression analyses. Of the participants, 63% had difficulties in daily activities and 59% in social roles. Participants perceived lower physical HRQoL than a Dutch reference population. Participants with higher levels of physical activity and fitness had fewer difficulties in participating in daily activities (odds ratio [OR]=8.8, p=0.02 and OR=29.7, p=0.02 respectively) and a higher physical HRQoL (OR=4.8, p=0.02 and OR=30.2, p=0.006 respectively), but not mental HRQoL. Body fat was not related to participation or HRQoL. In conclusion, a large proportion of individuals with myelomeningocele had difficulties in participation and perceived low physical HRQoL. Higher levels of physical activity and fitness were related to fewer difficulties in participation and higher physical HRQoL.