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Snyder L, Goods PS, Peeling P, Binnie M, Peiffer JJ, Balloch A, Scott BR. Physical Characteristics and Competition Demands of Elite Wheelchair Basketball. Strength Cond J 2023. [DOI: 10.1519/ssc.0000000000000779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2023]
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Effects of trunk muscle activation on trunk stability, arm power, blood pressure and performance in wheelchair rugby players with a spinal cord injury. J Spinal Cord Med 2022; 45:605-613. [PMID: 33166206 PMCID: PMC9246102 DOI: 10.1080/10790268.2020.1830249] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Objective: In wheelchair rugby (WR) athletes with tetraplegia, wheelchair performance may be impaired due to (partial) loss of innervation of upper extremity and trunk muscles, and low blood pressure (BP). The objective was to assess the effects of electrical stimulation (ES)-induced co-contraction of trunk muscles on trunk stability, arm force/power, BP, and WR performance.Design: Cross-sectional study.Setting: Rehabilitation research laboratory and WR court.Participants: Eleven WR athletes with tetraplegia.Interventions: ES was applied to the rectus abdominis, obliquus externus abdominis and erector spinae muscles. For every test, the ES condition was compared to the non-ES condition.Outcome measures: Stability was assessed with reaching tasks, arm force/power with an isokinetic test on a dynamometer, BP during an ES protocol and WR skill performance with the USA Wheelchair Rugby Skill Assessment.Results: Overall reaching distance (ES 14.6 ± 7.5 cm, non-ES 13.4 ± 8.2 cm), and BP showed a significant increase with ES. Arm force (ES 154 ± 106 N, non-ES 148 ± 102 N) and power (ES 37 ± 26 W, non-ES 36 ± 25 W), and WR skills were not significantly improved.Conclusion: ES-induced trunk muscle activation positively affects trunk stability and BP, but not arm force/power. No effects were found in WR skill performance, probably due to abdominal strapping. More research is needed to assess different ES (training) protocols and longitudinal effects.
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Fossey MPM, Balthazaar SJT, Squair JW, Williams AM, Poormasjedi-Meibod MS, Nightingale TE, Erskine E, Hayes B, Ahmadian M, Jackson GS, Hunter DV, Currie KD, Tsang TSM, Walter M, Little JP, Ramer MS, Krassioukov AV, West CR. Spinal cord injury impairs cardiac function due to impaired bulbospinal sympathetic control. Nat Commun 2022; 13:1382. [PMID: 35296681 PMCID: PMC8927412 DOI: 10.1038/s41467-022-29066-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 02/20/2022] [Indexed: 02/08/2023] Open
Abstract
Spinal cord injury chronically alters cardiac structure and function and is associated with increased odds for cardiovascular disease. Here, we investigate the cardiac consequences of spinal cord injury on the acute-to-chronic continuum, and the contribution of altered bulbospinal sympathetic control to the decline in cardiac function following spinal cord injury. By combining experimental rat models of spinal cord injury with prospective clinical studies, we demonstrate that spinal cord injury causes a rapid and sustained reduction in left ventricular contractile function that precedes structural changes. In rodents, we experimentally demonstrate that this decline in left ventricular contractile function following spinal cord injury is underpinned by interrupted bulbospinal sympathetic control. In humans, we find that activation of the sympathetic circuitry below the level of spinal cord injury causes an immediate increase in systolic function. Our findings highlight the importance for early interventions to mitigate the cardiac functional decline following spinal cord injury. By combining experimental models with prospective clinical studies, the authors show that spinal cord injury causes a rapid reduction in cardiac function that precedes structural changes, and that the loss of descending sympathetic control is the major cause of reduced cardiac function following spinal cord injury.
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Affiliation(s)
- Mary P M Fossey
- International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, BC, Canada.,Experimental Medicine, Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Shane J T Balthazaar
- International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, BC, Canada.,Experimental Medicine, Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Jordan W Squair
- International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, BC, Canada
| | - Alexandra M Williams
- International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, BC, Canada.,Department of Cellular and Physiological Sciences, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | | | - Tom E Nightingale
- International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, BC, Canada.,School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, Birmingham, UK.,Centre for Trauma Sciences Research, University of Birmingham, Edgabaston, Birmingham, UK
| | - Erin Erskine
- International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, BC, Canada.,Department of Cellular and Physiological Sciences, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Brian Hayes
- International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, BC, Canada
| | - Mehdi Ahmadian
- International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, BC, Canada.,School of Kinesiology, Faculty of Education, University of British Columbia, Vancouver, BC, Canada
| | - Garett S Jackson
- Faculty of Health and Social Development, University of British Columbia, Kelowna, BC, Canada
| | - Diana V Hunter
- International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, BC, Canada
| | - Katharine D Currie
- International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, BC, Canada
| | - Teresa S M Tsang
- Division of Cardiology, University of British Columbia, Vancouver General and University of British Columbia Hospital Echocardiography Department, Vancouver, BC, Canada
| | - Matthias Walter
- International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, BC, Canada.,Department of Urology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Jonathan P Little
- School of Health and Exercise Sciences, University of British Columbia, Kelowna, BC, Canada
| | - Matt S Ramer
- International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, BC, Canada.,Department of Zoology, Faculty of Science, University of British Columbia, Vancouver, BC, Canada
| | - Andrei V Krassioukov
- International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, BC, Canada. .,Experimental Medicine, Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada. .,Division of Physical Medicine and Rehabilitation, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada. .,GF Strong Rehabilitation Centre, Vancouver Coastal Health, Vancouver, BC, Canada.
| | - Christopher R West
- International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, BC, Canada. .,Department of Cellular and Physiological Sciences, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada.
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4
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Hoevenaars D, Yocarini IE, Paraschiakos S, Holla JFM, de Groot S, Kraaij W, Janssen TWJ. Accuracy of Heart Rate Measurement by the Fitbit Charge 2 During Wheelchair Activities in People With Spinal Cord Injury: Instrument Validation Study. JMIR Rehabil Assist Technol 2022; 9:e27637. [PMID: 35044306 PMCID: PMC8811691 DOI: 10.2196/27637] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 11/12/2021] [Accepted: 11/30/2021] [Indexed: 12/12/2022] Open
Abstract
Background Heart rate (HR) is an important and commonly measured physiological parameter in wearables. HR is often measured at the wrist with the photoplethysmography (PPG) technique, which determines HR based on blood volume changes, and is therefore influenced by blood pressure. In individuals with spinal cord injury (SCI), blood pressure control is often altered and could therefore influence HR accuracy measured by the PPG technique. Objective The objective of this study is to investigate the HR accuracy measured with the PPG technique with a Fitbit Charge 2 (Fitbit Inc) in wheelchair users with SCI, how the activity intensity affects the HR accuracy, and whether this HR accuracy is affected by lesion level. Methods The HR of participants with (38/48, 79%) and without (10/48, 21%) SCI was measured during 11 wheelchair activities and a 30-minute strength exercise block. In addition, a 5-minute seated rest period was measured in people with SCI. HR was measured with a Fitbit Charge 2, which was compared with the HR measured by a Polar H7 HR monitor used as a reference device. Participants were grouped into 4 groups—the no SCI group and based on lesion level into the <T5 (midthoracic and lower) group, T5-T1 (high-thoracic) group, and >T1 (cervical) group. Mean absolute percentage error (MAPE) and concordance correlation coefficient were determined for each group for each activity type, that is, rest, wheelchair activities, and strength exercise. Results With an overall MAPEall lesions of 12.99%, the accuracy fell below the standard acceptable MAPE of –10% to +10% with a moderate agreement (concordance correlation coefficient=0.577). The HR accuracy of Fitbit Charge 2 seems to be reduced in those with cervical lesion level in all activities (MAPEno SCI=8.09%; MAPE<T5=11.16%; MAPET1−T5=10.5%; and MAPE>T1=20.43%). The accuracy of the Fitbit Charge 2 decreased with increasing intensity in all lesions (MAPErest=6.5%, MAPEactivity=12.97%, and MAPEstrength=14.2%). Conclusions HR measured with the PPG technique showed lower accuracy in people with SCI than in those without SCI. The accuracy was just above the acceptable level in people with paraplegia, whereas in people with tetraplegia, a worse accuracy was found. The accuracy seemed to worsen with increasing intensities. Therefore, high-intensity HR data, especially in people with cervical lesions, should be used with caution.
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Affiliation(s)
- Dirk Hoevenaars
- Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam, Netherlands.,Amsterdam Rehabilitation Research Center, Reade, Amsterdam, Netherlands
| | - Iris E Yocarini
- Leiden Institute of Advanced Computer Science, Leiden University, Leiden, Netherlands
| | - Stylianos Paraschiakos
- Leiden Institute of Advanced Computer Science, Leiden University, Leiden, Netherlands.,Molecular Epidemiology, Department of Biomedical Data Science, Leiden University Medical Center, Leiden, Netherlands
| | - Jasmijn F M Holla
- Amsterdam Rehabilitation Research Center, Reade, Amsterdam, Netherlands.,Faculty of Health, Sports and Social Work, Inholland University of Applied Sciences, Haarlem, Netherlands.,Center for Adapted Sports, Amsterdam Institute of Sport Science, Amsterdam, Netherlands
| | - Sonja de Groot
- Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam, Netherlands.,Amsterdam Rehabilitation Research Center, Reade, Amsterdam, Netherlands.,Center for Adapted Sports, Amsterdam Institute of Sport Science, Amsterdam, Netherlands
| | - Wessel Kraaij
- Leiden Institute of Advanced Computer Science, Leiden University, Leiden, Netherlands
| | - Thomas W J Janssen
- Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam, Netherlands.,Amsterdam Rehabilitation Research Center, Reade, Amsterdam, Netherlands.,Center for Adapted Sports, Amsterdam Institute of Sport Science, Amsterdam, Netherlands
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5
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McMillan DW, Astorino TA, Correa MA, Nash MS, Gater DR. Virtual Strategies for the Broad Delivery of High Intensity Exercise in Persons With Spinal Cord Injury: Ongoing Studies and Considerations for Implementation. Front Sports Act Living 2021; 3:703816. [PMID: 34423292 PMCID: PMC8377288 DOI: 10.3389/fspor.2021.703816] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 07/08/2021] [Indexed: 11/13/2022] Open
Abstract
Spinal cord injury (SCI) results in a multitude of metabolic co-morbidities that can be managed by exercise. As in the non-injured population, manipulation of exercise intensity likely allows for fruitful optimization of exercise interventions targeting metabolic health in persons with SCI. In this population, interventions employing circuit resistance training (CRT) exhibit significant improvements in outcomes including cardiorespiratory fitness, muscular strength, and blood lipids, and recent exploration of high intensity interval training (HIIT) suggests the potential of this strategy to enhance health and fitness. However, the neurological consequences of SCI result in safety considerations and constrain exercise approaches, resulting in the need for specialized exercise practitioners. Furthermore, transportation challenges, inaccessibility of exercise facilities, and other barriers limit the translation of high intensity “real world” exercise strategies. Delivering exercise via online (“virtual”) platforms overcomes certain access barriers while allowing for broad distribution of high intensity exercise despite the limited number of population-specific exercise specialists. In this review, we initially discuss the need for “real world” high intensity exercise strategies in persons with SCI. We then consider the advantages and logistics of using virtual platforms to broadly deliver high intensity exercise in this population. Safety and risk mitigation are considered first followed by identifying strategies and technologies for delivery and monitoring of virtual high intensity exercise. Throughout the review, we discuss approaches from previous and ongoing trials and conclude by giving considerations for future efforts in this area.
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Affiliation(s)
- David W McMillan
- Christine E. Lynn Rehabilitation Center for the Miami Project to Cure Paralysis, UHealth/Jackson Memorial, Miami, FL, United States.,Department of Physical Medicine & Rehabilitation, University of Miami Leonard M. Miller School of Medicine, Miami, FL, United States
| | - Todd A Astorino
- Department of Kinesiology, California State University San Marcos, San Marcos, CA, United States
| | - Michael A Correa
- Christine E. Lynn Rehabilitation Center for the Miami Project to Cure Paralysis, UHealth/Jackson Memorial, Miami, FL, United States
| | - Mark S Nash
- Christine E. Lynn Rehabilitation Center for the Miami Project to Cure Paralysis, UHealth/Jackson Memorial, Miami, FL, United States.,Department of Physical Medicine & Rehabilitation, University of Miami Leonard M. Miller School of Medicine, Miami, FL, United States.,Department of Neurological Surgery, University of Miami Leonard M. Miller School of Medicine, Miami, FL, United States
| | - David R Gater
- Christine E. Lynn Rehabilitation Center for the Miami Project to Cure Paralysis, UHealth/Jackson Memorial, Miami, FL, United States.,Department of Physical Medicine & Rehabilitation, University of Miami Leonard M. Miller School of Medicine, Miami, FL, United States
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Krassioukov A, Linsenmeyer TA, Beck LA, Elliott S, Gorman P, Kirshblum S, Vogel L, Wecht J, Clay S. [Formula: see text] [Formula: see text] [Formula: see text] [Formula: see text]Evaluation and Management of Autonomic Dysreflexia and Other Autonomic Dysfunctions: Preventing the Highs and Lows. J Spinal Cord Med 2021; 44:631-683. [PMID: 34270391 PMCID: PMC8288133 DOI: 10.1080/10790268.2021.1925058] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Affiliation(s)
- Andrei Krassioukov
- University of British Columbia, Vancouver, British Columbia, BC
- International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, British Columbia, BC, Canada
| | - Todd A Linsenmeyer
- Kessler Institute for Rehabilitation, West Orange, NJ
- Rutgers University Medical School, Newark, NJ
| | | | - Stacy Elliott
- University of British Columbia, Vancouver, British Columbia, BC
| | | | - Steven Kirshblum
- Kessler Institute for Rehabilitation, West Orange, NJ
- Rutgers University Medical School, Newark, NJ
| | | | - Jill Wecht
- Icahn School of Medicine at Mt Sinai, New York, NY
| | - Sarah Clay
- Richard L. Roudebush VA Medical Center, Indianapolis, IN
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Krassioukov A, Linsenmeyer TA, Beck LA, Elliott S, Gorman P, Kirshblum S, Vogel L, Wecht J, Clay S. Evaluation and Management of Autonomic Dysreflexia and Other Autonomic Dysfunctions: Preventing the Highs and Lows: Management of Blood Pressure, Sweating, and Temperature Dysfunction. Top Spinal Cord Inj Rehabil 2021; 27:225-290. [PMID: 34108837 PMCID: PMC8152175 DOI: 10.46292/sci2702-225] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
| | | | | | - Stacy Elliott
- University of British Columbia, Vancouver, British Columbia, CA
| | | | | | | | - Jill Wecht
- Icahn School of Medicine at Mt Sinai, New York, NY
| | - Sarah Clay
- Richard L. Roudebush VA Medical Center, Indianapolis, IN
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Thompson WR, Vanlandewijck YC. Perspectives on research conducted at the Paralympic Games. Disabil Rehabil 2020; 43:3503-3514. [DOI: 10.1080/09638288.2020.1849427] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- Walter R. Thompson
- College of Education & Human Development, Georgia State University, Atlanta, GA, USA
| | - Yves C. Vanlandewijck
- Department of Rehabilitation Sciences, KU Leuven, Leuven, Belgium
- Swedish School of Sport and Health Sciences (GIH), Stockholm, Sweden
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Hansen RK, Samani A, Laessoe U, Handberg A, Larsen RG. Effect of wheelchair-modified rowing exercise on cardiometabolic risk factors in spinal cord injured wheelchair users: protocol for a randomised controlled trial. BMJ Open 2020; 10:e040727. [PMID: 33067301 PMCID: PMC7569950 DOI: 10.1136/bmjopen-2020-040727] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 09/09/2020] [Accepted: 09/15/2020] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Cardiovascular and metabolic diseases are a growing concern for individuals with spinal cord injury (SCI). Physical inactivity contributes to cardiometabolic morbidity and mortality in the SCI population. However, previous studies have shown mixed results regarding the effects of exercise on cardiometabolic risk factors in individuals with SCI. This discrepancy could be influenced by insufficient exercise stimuli. Recent guidelines recommend 30 min of moderate-to-vigorous intensity aerobic exercise, three times per week, for improvement in cardiometabolic health in individuals with SCI. However, to date, no studies have implemented an exercise intervention matching the new recommendations to examine the effects on cardiometabolic risk factors. Therefore, the primary objective of this study is to determine the effects of 12 weeks of wheelchair user-modified upper-body rowing exercise on both traditional (constituents of the metabolic syndrome) and novel (eg, vascular structure and function) cardiometabolic risk factors in manual wheelchair users with SCI. METHODS AND ANALYSIS A randomised controlled trial will compare 12 weeks of upper-body rowing exercise, 30 min three times per week, with a control group continuing their normal lifestyle. Outcome measurements will be performed immediately before (baseline), after 6 weeks (halfway), 12 weeks of training (post) and 6 months after the termination of the intervention period (follow-up). Outcomes will include inflammatory (eg, C reactive protein) and metabolic biomarkers determined from venous blood (with serum fasting insulin as primary outcome), body composition, arterial blood pressure, cardiorespiratory fitness level, brachial artery vascular structure and function and autonomic nervous system function. ETHICS AND DISSEMINATION This trial is reported to the Danish Data Protection Agency (J.nr. 2019-899/10-0406) and approved by the Committees on Health Research Ethics in The North Denmark Region on 12 December 2019 (J.nr. N-20190053). The principal investigator will collect written informed consent from all participants prior to inclusion. Irrespective of study outcomes, the results will be submitted to peer-reviewed scientific journals for publication. TRIAL REGISTRATION NUMBER NCT04390087.
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Affiliation(s)
- Rasmus Kopp Hansen
- Sport Sciences - Performance and Technology, Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
- Department of Research and Development, University College of Northern Jutland (UCN), Aalborg, Denmark
| | - Afshin Samani
- Sport Sciences - Performance and Technology, Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - Uffe Laessoe
- Department of Research and Development, University College of Northern Jutland (UCN), Aalborg, Denmark
- Physical Therapy Department, University College of Northern Jutland (UCN), Aalborg, Denmark
| | - Aase Handberg
- Department of Clinical Biochemistry, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Ryan Godsk Larsen
- Sport Sciences - Performance and Technology, Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
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Abstract
OBJECTIVE To examine differences in heart rate (HR) responses during international wheelchair rugby competition between athletes with and without a cervical spinal cord injury (SCI) and across standardized sport classifications. DESIGN Observational study. SETTING The 2015 Parapan American Games wheelchair rugby competition. PARTICIPANTS Forty-three male athletes (31 ± 8 years) with a cervical SCI (n = 32) or tetraequivalent impairment (non-SCI, n = 11). MAIN OUTCOME MEASURES Average and peak HR (HRavg and HRpeak, respectively). To characterize HR responses in accordance with an athletes' International Wheelchair Rugby Federation (IWRF) classification, we separated athletes into 3 groups: group I (IWRF classification 0.5-1.5, n = 15); group II (IWRF classification 2.0, n = 15); and group III (IWRF classification 2.5-3.5, n = 13). RESULTS Athletes with SCI had lower HRavg (111 ± 14 bpm vs 155 ± 13 bpm) and HRpeak (133 ± 12 bpm vs 178 ± 13 bpm) compared with non-SCI (both P < 0.001). Average HR was higher in group III than in I (136 ± 25 bpm vs 115 ± 20 bpm, P = 0.045); however, SCI athletes showed no difference in HRavg or HRpeak between groups. Within group III, SCI athletes had lower HRavg (115 ± 6 bpm vs 160 ± 8 bpm) and HRpeak (135 ± 11 bpm vs 183 ± 11 bpm) than non-SCI athletes (both P < 0.001). CONCLUSIONS This study is the first to demonstrate attenuated HR responses during competition in SCI compared with non-SCI athletes, likely due to injury to spinal autonomic pathways. Among athletes with SCI, IWRF classification was not related to differences in HR. Specific assessment of autonomic function after SCI may be able to predict HR during competition and consideration of autonomic impairments may improve the classification process.
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11
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Onushko T, Mahtani GB, Brazg G, Hornby TG, Schmit BD. Exercise-Induced Alterations in Sympathetic-Somatomotor Coupling in Incomplete Spinal Cord Injury. J Neurotrauma 2019; 36:2688-2697. [PMID: 30696387 DOI: 10.1089/neu.2018.5719] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The aim of this study was to understand how high- and low-intensity locomotor training (LT) affects sympathetic-somatomotor (SS) coupling in people with incomplete spinal cord injury (SCI). Proper coupling between sympathetic and somatomotor systems allows controlled regulation of cardiovascular responses to exercise. In people with SCI, altered connectivity between descending pathways and spinal segments impairs sympathetic and somatomotor coordination, which may have deleterious effects during exercise and limit rehabilitation outcomes. We postulated that high-intensity LT, which repeatedly engages SS systems, would alter SS coupling. Thirteen individuals (50 ± 7.2 years) with motor incomplete spinal cord injuries (American Spinal Injury Association Impairment Scale C or D; injury level >T6) participated in a locomotor treadmill training program. Patients were randomized into either a high-intensity (high-LT; 70-85% of maximum predicted heart rate; n = 6) group or a low-intensity (low-LT; 50-65% of maximum predicted heart rate; n = 7) group and completed up to 20 LT training sessions over 4-6 weeks, 3-5 days/week. Before and after taining, we tested SS coupling by eliciting reflexive sympathetic activity through a cold stimulation, noxious stimulation, and a mental math task while we measured tendon reflexes, blood pressure, and heart rate. Participants who completed high- versus low-LT exhibited significant decreases in reflex torques during triggered sympathetic activity (cold: -83 vs. 13%, p < 0.01; pain: -65 vs. 54%, p < 0.05; mental math: -43 vs. 41%; p < 0.05). Mean arterial pressure responses to sympathetic stimuli were slightly higher following high- versus low-LT (cold: 30 vs. -1.5%; pain: 6 vs. -12%; mental math: 5 vs. 7%), although differences were not statistically significant. These results suggest that high-LT may be advantageous to low-LT to improve SS coupling in people with incomplete SCI.
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Affiliation(s)
- Tanya Onushko
- Department of Biomedical Engineering, Marquette University, Milwaukee, Wisconsin
| | - Gordhan B Mahtani
- Department of Orthopaedic Surgery, Stanford University, Stanford, California
| | | | - T George Hornby
- Department of Physical Medicine and Rehabilitation, Indiana University School of Medicine, Indianapolis, Indiana
| | - Brian D Schmit
- Department of Biomedical Engineering, Marquette University, Milwaukee, Wisconsin
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12
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Williams AM, Gee CM, Voss C, West CR. Cardiac consequences of spinal cord injury: systematic review and meta-analysis. Heart 2018; 105:217-225. [PMID: 30262456 DOI: 10.1136/heartjnl-2018-313585] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2018] [Revised: 08/23/2018] [Accepted: 08/25/2018] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE Conduct a meta-analysis to determine the impact of traumatic spinal cord injury (SCI) on echocardiographic measurements of left ventricular (LV) structure and function. METHODS MEDLINE and Embase were used for primary searches of studies reporting LV echocardiographic data in individuals with SCI. Of 378 unique citations, 36 relevant full-text articles were retrieved, and data from 27 studies were extracted for meta-analyses. Literature searches, article screening and data extraction were completed by two independent reviewers and compared for agreement. Primary analyses compared echocardiographic indices between individuals with SCI and able-bodied individuals, using a random effects model. RESULTS Data are reported as pooled effect estimates (95% CI). Data from 22 articles (474 participants) were included in the primary meta-analysis. Compared with able-bodied individuals, individuals with SCI had reductions to LV stroke volume of 11.8 mL (95% CI -17.8 to -5.9, p<0.001), end-diastolic volume of 19.6 mL (95% CI -27.2 to -11.9, p<0.001) and LV massindex of -7.7 g/m2 (95% CI -11.6 to -3.8, p<0.001), but ejection fraction was not different between the groups (95% CI -2.6% to 0.6%, p=0.236). Individuals with SCI also had altered indices of diastolic function, specifically a lowered ratio of early-to-late filling velocities (p=0.039), and augmented ratio of early diastolic flow-to-tissue velocities (p=0.021). CONCLUSIONS Individuals with SCI have smaller LV volumes and mass, and altered systolic and diastolic function. While this meta-analysis demonstrates important alterations to echocardiographic measures of cardiac structure and function at rest, future work should consider the impacts of SCI on the heart's capacity or 'reserve' to respond to physiological challenges. PROSPERO REGISTRATION NUMBER CRD42017072333.
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Affiliation(s)
- Alexandra Mackenzie Williams
- International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, British Columbia, Canada.,Department of Cellular and Physiological Sciences, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Cameron Marshall Gee
- International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, British Columbia, Canada.,Faculty of Education, School of Kinesiology, Vancouver, British Columbia, Canada
| | - Christine Voss
- Department of Pediatrics, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Christopher Roy West
- International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, British Columbia, Canada.,Department of Cellular and Physiological Sciences, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
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Walter M, Krassioukov AV. Autonomic Nervous System in Paralympic Athletes with Spinal Cord Injury. Phys Med Rehabil Clin N Am 2018; 29:245-266. [PMID: 29627087 DOI: 10.1016/j.pmr.2018.01.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
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.
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Affiliation(s)
- Matthias Walter
- Faculty of Medicine, International Collaboration on Repair Discoveries (ICORD), University of British Columbia, 818 West 10th Avenue, Vancouver, British Columbia V5Z 1M9, Canada
| | - Andrei V Krassioukov
- Division of Physical Medicine and Rehabilitation, Department of Medicine, International Collaboration on Repair Discoveries (ICORD), Blusson Spinal Cord Centre, University of British Columbia, GF Strong Rehabilitation Centre, Vancouver Coastal Health, 818 West 10th Avenue, Vancouver, British Columbia V5Z 1M9, Canada.
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Baumgart JK, Brurok B, Sandbakk Ø. Peak oxygen uptake in Paralympic sitting sports: A systematic literature review, meta- and pooled-data analysis. PLoS One 2018; 13:e0192903. [PMID: 29474386 PMCID: PMC5825058 DOI: 10.1371/journal.pone.0192903] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Accepted: 01/12/2018] [Indexed: 11/30/2022] Open
Abstract
Background Peak oxygen uptake (VO2peak) 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 VO2peak values in Paralympic sitting sports, examine between-sports differences and within-sports variations in VO2peak and determine the influence of sex, age, body-mass, disability and test-mode on VO2peak. Design Systematic literature review and meta-analysis. Data sources PubMed, CINAHL, SPORTDiscusTM and EMBASE were systematically searched in October 2016 using relevant medical subject headings, keywords and a Boolean. Eligibility criteria Studies that assessed VO2peak 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 VO2peak. Results Of 6542 retrieved articles, 57 studies reporting VO2peak values in 14 different sitting sports were included in this review. VO2peak 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 VO2peak 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 VO2peak values. Furthermore, high body mass was favourable for high absolute VO2peak values and low body mass for high body-mass normalized VO2peak values. Conclusion The highest VO2peak 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, VO2peak 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 VO2peak.
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Affiliation(s)
- Julia Kathrin Baumgart
- Centre for Elite Sports Research, Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Science, Norwegian University of Science and Technology, Trondheim, Norway
- * E-mail:
| | - Berit Brurok
- Centre for Elite Sports Research, Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Science, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Physical Medicine and Rehabilitation, St. Olav’s University Hospital, Trondheim, Norway
| | - Øyvind Sandbakk
- Centre for Elite Sports Research, Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Science, Norwegian University of Science and Technology, Trondheim, Norway
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Escalona MJ, Brosseau R, Vermette M, Comtois AS, Duclos C, Aubertin-Leheudre M, Gagnon DH. Cardiorespiratory demand and rate of perceived exertion during overground walking with a robotic exoskeleton in long-term manual wheelchair users with chronic spinal cord injury: A cross-sectional study. Ann Phys Rehabil Med 2018; 61:215-223. [PMID: 29371106 DOI: 10.1016/j.rehab.2017.12.008] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Revised: 12/18/2017] [Accepted: 12/19/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND Many wheelchair users adopt a sedentary lifestyle, which results in progressive physical deconditioning with increased risk of musculoskeletal, cardiovascular and endocrine/metabolic morbidity and mortality. Engaging in a walking program with an overground robotic exoskeleton may be an effective strategy for mitigating these potential negative health consequences and optimizing fitness in this population. However, additional research is warranted to inform the development of adapted physical activity programs incorporating this technology. OBJECTIVES To determine cardiorespiratory demands during sitting, standing and overground walking with a robotic exoskeleton and to verify whether such overground walking results in at least moderate-intensity physical exercise. METHODS We enrolled 13 long-term wheelchair users with complete motor spinal cord injury in a walking program with an overground robotic exoskeleton. Cardiorespiratory measures and rate of perceived exertion (RPE) were recorded by using a portable gas analyzer system during sitting, standing and four 10m walking tasks with the robotic exoskeleton. Each participant also performed an arm crank ergometer test to determine maximal cardiorespiratory ability (i.e., peak heart rate and O2 uptake [HRpeak, VO2peak]). RESULTS Cardiorespiratory measures increased by a range of 9%-35% from sitting to standing and further increased by 22%-52% from standing to walking with the robotic exoskeleton. During walking, median oxygen cost (O2Walking), relative HR (%HRpeak), relative O2 consumption (%VO2peak) and respiratory exchange ratio (RER) reached 0.29mL/kg/m, 82.9%, 41.8% and 0.9, respectively, whereas median RPE reached 3.2/10. O2Walking was moderately influenced by total number of sessions and steps taken with the robotic exoskeleton since the start of the walking program. CONCLUSION Overground walking with the robotic exoskeleton over a short distance allowed wheelchair users to achieve a moderate-intensity level of exercise. Hence, an overground locomotor training program with a robotic exoskeleton may have cardiorespiratory health benefits in the population studied.
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Affiliation(s)
- Manuel J Escalona
- School of rehabilitation, Université de Montréal, Montreal, QC, Canada; Pathokinesiology laboratory, Centre for interdisciplinary research in rehabilitation of greater Montreal, Centre intégré universitaire de santé et services sociaux du Centre-Sud-de-l'Île-de-Montréal, 6300, avenue Darlington, Montreal, QC, H3S 2J4 Canada
| | - Rachel Brosseau
- School of rehabilitation, Université de Montréal, Montreal, QC, Canada; Montreal Heart Institute, QC, Canada
| | - Martin Vermette
- Pathokinesiology laboratory, Centre for interdisciplinary research in rehabilitation of greater Montreal, Centre intégré universitaire de santé et services sociaux du Centre-Sud-de-l'Île-de-Montréal, 6300, avenue Darlington, Montreal, QC, H3S 2J4 Canada
| | - Alain Steve Comtois
- Department of exercice sciences , Faculty of sciences, Université du Québec à Montréal ( UQÀM), QC, Canada
| | - Cyril Duclos
- School of rehabilitation, Université de Montréal, Montreal, QC, Canada; Pathokinesiology laboratory, Centre for interdisciplinary research in rehabilitation of greater Montreal, Centre intégré universitaire de santé et services sociaux du Centre-Sud-de-l'Île-de-Montréal, 6300, avenue Darlington, Montreal, QC, H3S 2J4 Canada
| | - Mylène Aubertin-Leheudre
- Department of exercice sciences , Faculty of sciences, Université du Québec à Montréal ( UQÀM), QC, Canada
| | - Dany H Gagnon
- School of rehabilitation, Université de Montréal, Montreal, QC, Canada; Pathokinesiology laboratory, Centre for interdisciplinary research in rehabilitation of greater Montreal, Centre intégré universitaire de santé et services sociaux du Centre-Sud-de-l'Île-de-Montréal, 6300, avenue Darlington, Montreal, QC, H3S 2J4 Canada.
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A 20×20m repeated sprint field test replicates the demands of wheelchair rugby. J Sci Med Sport 2018; 21:753-757. [PMID: 29373205 DOI: 10.1016/j.jsams.2017.12.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2017] [Revised: 12/05/2017] [Accepted: 12/08/2017] [Indexed: 11/23/2022]
Abstract
OBJECTIVES To assess the physiological responses to, and the agreement between, a 20×20m repeated sprint field test and wheelchair rugby game play, as well as the reliability of the test. DESIGN Cross-sectional and longitudinal. METHODS Heart rate (HR), blood lactate ([La-]B), and ratings of perceived exertion (RPE) were collected in nineteen elite wheelchair rugby athletes before, during, and after a 20×20m repeated sprint field test and game play. Times to complete 5, 10, and 20m during the field test were also collected. RESULTS Peak HR and peak [La-]B were positively correlated during the field test (r=0.470, p=0.043), as were peak HR and peak speed (r=0.493, p=0.031), and peak [La-]B and peak speed (r=0.559, p=0.013). During game play, peak [La-]B was correlated with peak RPE (rho=0.703, p=0.001). Intra-class correlations (ICCs) between the field test and game play were significant for peak HR (ICC=0.922, p<0.001) and peak [La-]B (ICC=0.845, p<0.001). Bland-Altman analysis revealed good agreement between HR and [La-]B obtained during the field test and game play and excellent between-day reliability of the 20×20m sprint test. CONCLUSIONS The physiological demands of a 20×20m repeated sprint field test are similar to those of elite wheelchair rugby game play and the test is highly reliable. This simple to implement field test may be useful as a component of team selection and in assessing the effectiveness of training interventions or monitoring athletes across training phases.
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Abstract
Over the past 10 years, our team has attended numerous Paralympic games and International Paralympic Committee (IPC)-sanctioned events where we have accumulated the largest data set to date from elite athletes with spinal cord injury (SCI). This empirical evidence has allowed us to address critical questions related to health and athletic performance in these incredibly medically complex individuals. Namely, does autonomic function influence performance? Can we account for this with the present sport classification? How can we prevent the doping practice of self-inducing life-threatening episodes of hypertension to improve performance (termed "boosting")? How does extremely high participation in routine upper-body wheelchair exercise impact cardiovascular and cerebrovascular disease risk? Is it possible to improve the sport classification to level the playing field between athletes with and without autonomic dysfunction? Herein, we will narratively address these questions, and provide our perspective on future directions and recommendations moving forward. Our extensive clinical experience and comprehensive dataset suggest preserved autonomic function is critical for elite performance. We will explore how an easy-to-execute test may be able to predict which individuals are most likely to develop autonomic dysfunctions that may negatively affect their health and performance. We also will evaluate the possibility that a level playing field may be even more difficult to establish than once thought, considering the importance of not only voluntary movement to performance, but also autonomic function. Finally, we also will discuss new changes in screening guidelines at Rio to assess the occurrence of boosting, which is a banned practice by the IPC.
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Affiliation(s)
- Aaron A Phillips
- 1 International Collaboration on Repair Discoveries, University of British Columbia , Vancouver, British Columbia, Canada
| | - Jordan W Squair
- 1 International Collaboration on Repair Discoveries, University of British Columbia , Vancouver, British Columbia, Canada .,2 MD/PhD Training Program, University of British Columbia , Vancouver, British Columbia, Canada
| | - Andrei V Krassioukov
- 1 International Collaboration on Repair Discoveries, University of British Columbia , Vancouver, British Columbia, Canada .,3 Department of Medicine, University of British Columbia , Vancouver, British Columbia, Canada .,4 GF Strong Rehabilitation Centre, Vancouver Health Authority, University of British Columbia , Vancouver, British Columbia, Canada
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Challenging cardiac function post-spinal cord injury with dobutamine. Auton Neurosci 2016; 209:19-24. [PMID: 28065654 DOI: 10.1016/j.autneu.2016.12.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Revised: 09/28/2016] [Accepted: 12/13/2016] [Indexed: 12/29/2022]
Abstract
There is general consensus that spinal cord injuries (SCI) above T6 result in altered sympathetic control of the heart, which negatively influences cardiac structure and function. To by-pass disrupted circuitry and investigate cardiac responses under enhanced sympathetic activity we utilized dobutamine (DOB) stress echocardiography. Animals were divided into a T2, 25g-cm contusive SCI (SCI) or an uninjured control (CON) group. Echocardiography was performed pre-SCI and at 1, 2 and 6weeks post-SCI. Increasing doses of DOB (5, 10 & 20μg/min/kg) were infused intravenously pre-SCI and at 1 and 6weeks post-SCI. Parasternal-short axis images were used to compare group differences in systolic function and track changes in response to SCI and DOB over time. One week post-SCI, stroke volume (SV), end diastolic volume (EDV), cardiac output (CO) and ejection fraction (EF) were all reduced compared to CON and these deficits persisted to 6weeks. We also found an increase in collagen deposition at 6weeks post SCI. Pre-SCI, DOB elicited a decrease in EDV and increases in CO, EF and HR but not SV. At 6weeks following SCI, in addition to increases in CO, EF and HR, DOB also induced increases in SV. This is the first report, to our knowledge, of DOB responses in a contusive SCI model with persistent cardiac impairments. The return of CO to pre-SCI levels and the substantial increase in SV at low DOB dosages shows that impaired descending control of the heart is directly contributing to reduced resting SV after SCI.
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Milner K, da Silva R, Patel D, Salau S. How do we measure up? A comparison of lifestyle-related health risk factors among sampled employees in South African and UK companies. Glob Health Promot 2016; 25:73-81. [PMID: 27406821 DOI: 10.1177/1757975916656346] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The need to address the growing prevalence of non-communicable diseases through changing the lifestyle behaviours that contribute to them has become a global priority. Settings-based health promotion strategies such as workplace health promotion programmes are growing in an attempt to start meeting this need. In order for settings-based health promotion programmes to be successful, they need to be based on the specific risk profiles of the population for whom they are designed. Workplace health promotion programmes are becoming popular in South Africa, but there are currently few data available about the health risks and lifestyle behaviours of the South African employed population. In order to obtain such data and reward workplace health promotion initiatives, Discovery Health initiated healthy company campaigns in South Africa and the UK. These campaigns took the form of a competition to assess the healthiest companies in each country. Through these campaigns, an extensive data set was collected encompassing UK and South African employees' lifestyle behaviours and health risks. In this article, we used these data to compare self-reported physical activity levels, self-reported fruit and vegetable consumption, calculated BMI, self-reported smoking, mental health indicators, and health screening status of the UK and South African employee samples. We found significant differences across all measures, with the exception of self-reported fruit and vegetable consumption. The findings emphasise the importance of using local data to tailor workplace health promotion programmes for the population for which the programmes have been designed.
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Affiliation(s)
- Karen Milner
- 1. University of the Witwatersrand, Johannesburg, South Africa
| | | | | | - Sulaiman Salau
- 1. University of the Witwatersrand, Johannesburg, South Africa
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Currie KD, West CR, Hubli M, Gee CM, Krassioukov AV. Peak heart rates and sympathetic function in tetraplegic nonathletes and athletes. Med Sci Sports Exerc 2016; 47:1259-64. [PMID: 25211366 DOI: 10.1249/mss.0000000000000514] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
PURPOSE To examine differences in peak heart rate (HR) and measures of sympathetic function between nonathletes and athletes with chronic, motor-complete, cervical spinal cord injury (SCI). METHODS Eight nonathletic men with SCI (C4-C7; age 47 ± 9 yr, with injury duration of 16 ± 9 yr) and 13 athletic men with SCI (C5-C8; age 37 ± 8 yr, with injury duration of 16 ± 6 yr) participated in the study. Measures of sympathetic function included palmar sympathetic skin responses (SSR) to median nerve stimulation, and systolic (SBP) and diastolic (DBP) blood pressure responses to a passive sit-up test. Peak HR responses were assessed during a maximal exercise test. RESULTS Compared to the athletic group, the nonathletic group exhibited lower peak HR (102 ± 34 vs 161 ± 20 bpm, P < 0.001) and average SSR scores (0.13 ± 0.35 vs 2.41 ± 1.97, P = 0.008), along with greater reductions in SBP and DBP in response to passive sit-up (SBP: -22 ± 10 vs -9 ± 12 mm Hg, P = 0.019; DBP: -18 ± 8 mm Hg vs -4 ± 9 mm Hg, P = 0.003). On the basis of the criteria for orthostatic hypotension (OH) (drop in SBP ≥ 20 mm Hg or DBP ≥ 10 mm Hg), 88% and 23% of nonathletes and athletes had OH. CONCLUSIONS Attenuated peak HR in nonathletic individuals with tetraplegia may be secondary to impairments in sympathetic function including absent SSR and OH. Furthermore, the degree of preserved sympathetic function documented in tetraplegic athletes may suggest a predisposition to engage in high-performance sports. Collectively, our findings provide novel insight into the importance of the sympathetic nervous system for exercise performance.
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Affiliation(s)
- Katharine D Currie
- 1International Collaboration on Repair Discoveries, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, CANADA; 2Division of Physical Medicine and Rehabilitation, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, CANADA; 3G. F. Strong Rehabilitation Centre, Vancouver, British Columbia, CANADA
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21
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West CR, Leicht CA, Goosey-Tolfrey VL, Romer LM. Perspective: Does Laboratory-Based Maximal Incremental Exercise Testing Elicit Maximum Physiological Responses in Highly-Trained Athletes with Cervical Spinal Cord Injury? Front Physiol 2016; 6:419. [PMID: 26834642 PMCID: PMC4712301 DOI: 10.3389/fphys.2015.00419] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2015] [Accepted: 12/21/2015] [Indexed: 11/20/2022] Open
Abstract
The physiological assessment of highly-trained athletes is a cornerstone of many scientific support programs. In the present article, we provide original data followed by our perspective on the topic of laboratory-based incremental exercise testing in elite athletes with cervical spinal cord injury. We retrospectively reviewed our data on Great Britain Wheelchair Rugby athletes collected during the last two Paralympic cycles. We extracted and compared peak cardiometabolic (heart rate and blood lactate) responses between a standard laboratory-based incremental exercise test on a treadmill and two different maximal field tests (4 min and 40 min maximal push). In the nine athletes studied, both field tests elicited higher peak responses than the laboratory-based test. The present data imply that laboratory-based incremental protocols preclude the attainment of true peak cardiometabolic responses. This may be due to the different locomotor patterns required to sustain wheelchair propulsion during treadmill exercise or that maximal incremental treadmill protocols only require individuals to exercise at or near maximal exhaustion for a relatively short period of time. We acknowledge that both field- and laboratory-based testing have respective merits and pitfalls and suggest that the choice of test be dictated by the question at hand: if true peak responses are required then field-based testing is warranted, whereas laboratory-based testing may be more appropriate for obtaining cardiometabolic responses across a range of standardized exercise intensities.
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Affiliation(s)
- Christopher R West
- International Collaboration on Repair Discoveries, University of British ColumbiaVancouver, BC, Canada; School of Kinesiology, University of British ColumbiaVancouver, BC, Canada; Centre for Sports Medicine and Human Performance, Brunel University LondonLondon, UK
| | - Christof A Leicht
- School of Sport, Exercise and Health Sciences, The Peter Harrison Centre for Disability Sport, Loughborough University Loughborough, UK
| | - Victoria L Goosey-Tolfrey
- School of Sport, Exercise and Health Sciences, The Peter Harrison Centre for Disability Sport, Loughborough University Loughborough, UK
| | - Lee M Romer
- Centre for Sports Medicine and Human Performance, Brunel University London London, UK
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The effect of FES-rowing training on cardiac structure and function: pilot studies in people with spinal cord injury. Spinal Cord 2016; 54:822-829. [PMID: 26754476 DOI: 10.1038/sc.2015.228] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2015] [Revised: 09/27/2015] [Accepted: 11/30/2015] [Indexed: 01/19/2023]
Abstract
STUDY DESIGN Two studies were conducted: Study-1 was cross-sectional; and Study-2 a longitudinal repeated measures design. OBJECTIVES To examine the influence of functional electrical stimulation (FES) rowing training on cardiac structure and function in people with spinal cord injury (SCI). SETTING A university sports science department and home-based FES-training. METHODS Fourteen participants with C4-T10 SCI (American Spinal Injury Association Impairment Scale A or B) were recruited for the studies. Cardiac structure and function, and peak: oxygen uptake ([Vdot ]O2peak), power output (POpeak) and heart rate (HRpeak), were compared between two FES-untrained groups (male n=3, female n=3) and an FES-trained group (male n=3) in Study-1 and longitudinally assessed in an FES-naive group (male n=1, female n=4) in Study-2. Main outcome measures left ventricular-dimensions, volumes, mass, diastolic and systolic function, and [Vdot ]O2peak, POpeak and HRpeak. In Study-2, in addition to peak values, the [Vdot ]O2 sustainable over 30 min and the related PO and HR were also assessed. RESULTS Sedentary participants with chronic SCI had cardiac structure and function at the lower limits of non-SCI normal ranges. Individuals with chronic SCI who habitually FES-row have cardiac structure and function that more closely resemble non-SCI populations. A programme of FES-rowing training improved cardiac structure and function in previously FES-naive people. CONCLUSION FES-rowing training appears to be an effective stimulus for positive cardiac remodelling in people with SCI. Further work, with greater participant numbers, should investigate the impact of FES-rowing training on cardiac health in SCI. SPONSORSHIP We thank the INSPIRE Foundation, UK, for funding these studies.
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West CR, Krassioukov AV. Autonomic cardiovascular control and sports classification in Paralympic athletes with spinal cord injury. Disabil Rehabil 2016; 39:127-134. [DOI: 10.3109/09638288.2015.1118161] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Christopher R. West
- International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, BC, Canada
| | - Andrei V. Krassioukov
- International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, BC, Canada
- Department of Medicine, Division of Physical Medicine and Rehabilitation, University of British Columbia, Vancouver, BC, Canada
- G. F. Strong Rehab Centre, Vancouver, BC, Canada
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Omar VC, Rafael D, Vinicius C, Alexandre B. Complete factorial design experiment for 3D load cell instrumented crank validation. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2015; 2015:3655-3658. [PMID: 26737085 DOI: 10.1109/embc.2015.7319185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Developing of instrumentation systems for sport medicine is a promising area, that's why this research evaluates the design of a new instrumented crank arm prototype for a race bicycle projecting an experiment for indoor - outdoor comparison. This study investigated the viability of an instrumentation 3D load cell for force measurement crank, implementing a design of experiment. A Complete factorial design experiment was developed for data validation, with an Analysis of Variance (ANOVA) throwing significant results for controlled factors with response variables rms, mean and variance. A software routine allowed to obtained system variables metrics for Symmetry and Cadence analysis, which came out from Effective force bilateral comparing and speed computation. Characterization allowed achieving calibration curves that were used for data conversion in force projection channels with a linearity error of 0.29% (perpendicular), 0.55% (parallel) and 0.10% (lateral). Interactions of factors resulted significant mainly for indoor tests in symmetry and cadence was significant in interactions generally for outdoor tests. Implemented system was able to generate Effective Force graph for 3D plot symmetry analysis, torque and power symmetry for specialist's analysis.
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West CR, Popok D, Crawford MA, Krassioukov AV. Characterizing the Temporal Development of Cardiovascular Dysfunction in Response to Spinal Cord Injury. J Neurotrauma 2015; 32:922-30. [DOI: 10.1089/neu.2014.3722] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Affiliation(s)
- Christopher R. West
- International Collaboration on Repair Discoveries (ICORD), Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - David Popok
- International Collaboration on Repair Discoveries (ICORD), Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Mark A. Crawford
- International Collaboration on Repair Discoveries (ICORD), Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Andrei V. Krassioukov
- International Collaboration on Repair Discoveries (ICORD), Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Department of Medicine, Division of Physical Medicine and Rehabilitation, University of British Columbia, Vancouver, British Columbia, Canada
- GF Strong Rehabilitation Centre, Vancouver Health Authority, Vancouver, British Columbia, Canada
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Boosting in Elite Athletes with Spinal Cord Injury: A Critical Review of Physiology and Testing Procedures. Sports Med 2015; 45:1133-42. [DOI: 10.1007/s40279-015-0340-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Krassioukov A, West C. The role of autonomic function on sport performance in athletes with spinal cord injury. PM R 2015; 6:S58-65. [PMID: 25134753 DOI: 10.1016/j.pmrj.2014.05.023] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2014] [Revised: 05/05/2014] [Accepted: 05/21/2014] [Indexed: 11/17/2022]
Abstract
Devastating paralysis, autonomic dysfunction, and abnormal cardiovascular control present significant hemodynamic challenges to individuals with spinal cord injury (SCI), especially during exercise. In general, resting arterial pressure after SCI is lower than with able-bodied individuals and is commonly associated with persistent orthostatic intolerance along with transient episodes of life-threatening hypertension, known as "autonomic dysreflexia." During exercise, the loss of central and reflexive cardiovascular control attenuates maximal heart rate and impairs blood pressure regulation and blood redistribution, which ultimately reduces venous return, stroke volume, and cardiac output. Thermoregulation also is severely compromised in high-lesion SCI, a problem that is compounded when competing in hot and humid conditions. There is some evidence that enhancing venous return via lower body positive pressure or abdominal binding improves exercise performance, as do cooling strategies. Athletes with SCI also have been documented to self-induce autonomic dysreflexia before competition with a view of increasing blood pressure and improving their performance, a technique known as "boosting." For health safety reasons, boosting is officially banned by the International Paralympics Committee. This article addresses the complex issue of how the autonomic nervous system affects sports performance in athletes with SCI, with a specific focus on the potential debilitating effects of deranged cardiovascular control.
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Affiliation(s)
- Andrei Krassioukov
- International Collaboration on Repair Discoveries, Division of Physical Medicine and Rehabilitation, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada; GF Strong Rehabilitation Centre, Vancouver Coastal Health, Vancouver, British Columbia, Canada∗; International Collaboration on Repair Discoveries, Division of Physical Medicine and Rehabilitation, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada(†).
| | - Christopher West
- International Collaboration on Repair Discoveries, Division of Physical Medicine and Rehabilitation, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada; GF Strong Rehabilitation Centre, Vancouver Coastal Health, Vancouver, British Columbia, Canada∗
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How reliable are sympathetic skin responses in subjects with spinal cord injury? Clin Auton Res 2015; 25:117-24. [DOI: 10.1007/s10286-015-0276-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2014] [Accepted: 11/20/2014] [Indexed: 11/26/2022]
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FES-rowing in tetraplegia: a preliminary report. Spinal Cord 2014; 52:880-6. [PMID: 25266698 DOI: 10.1038/sc.2014.159] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2014] [Revised: 08/01/2014] [Accepted: 08/12/2014] [Indexed: 11/08/2022]
Abstract
STUDY DESIGN A training intervention study using functional electrical stimulation-rowing (FES-R) in a group of eight individuals with tetraplegia. OBJECTIVES To assess the feasibility of a structured progressive FES-R training programme in people with tetraplegia, and to explore the number and type of FES-training sessions required to enable continuous FES-R for 30 min. SETTING A fully integrated sports centre, elite rowing training centre and university sport science department. METHODS Eight participants with chronic complete and incomplete tetraplegia (C4 to C7, American Spinal Injury Association Impairment Scale A, B and C) who had not previously used any form of FES-assisted exercise, participated in the study. Participants completed a progressive FES-assisted training programme building to three continuous 30-min FES-R sessions per week at 60-80% of their predetermined peak power output. Thereafter, rowing performance was monitored for 12 months. MAIN OUTCOME MEASURES number and type of FES-training sessions required before achieving 30-min continuous FES-R, and FES-R average power output (POav) pre and post 12 months training. Participant feedback of perceived benefits was also documented. RESULTS All participants were able to continuously FES-row for 30 min after completing 13±7 FES-R training sessions. Each individual POav during 30 min FES-R increased over 12 months FES-training. FES-R was found safe and well tolerated in this group of individuals with tetraplegia. CONCLUSION Individuals with tetraplegia are able to engage in a progressive programme of FES-R training. Future research examining FES-R training as an adjunctive therapy in people with tetraplegia is warranted.
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West CR, Wong SC, Krassioukov AV. Autonomic cardiovascular control in Paralympic athletes with spinal cord injury. Med Sci Sports Exerc 2014; 46:60-8. [PMID: 23739527 DOI: 10.1249/mss.0b013e31829e46f3] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Disruption of autonomic control after spinal cord injury (SCI) results in life-threatening cardiovascular dysfunctions and impaired endurance performance; hence, an improved ability to recognize those at risk of autonomic disturbances is of critical clinical and sporting importance. PURPOSE The objective of this study is to assess the effect of neurological level, along with motor, sensory, and autonomic completeness of injury, on cardiovascular control in Paralympic athletes with SCI. METHODS Fifty-two highly trained male Paralympic athletes (age, 34.8 ± 7.1 yr) from 14 countries with chronic SCI (C2-L2) completed three experimental trials. During trial 1, motor and sensory functions were assessed according to the American Spinal Injury Association Impairment Scale. During trial 2, autonomic function was assessed via sympathetic skin responses (SSR). During trial 3, cardiovascular control was assessed via the beat-by-beat blood pressure response to orthostatic challenge. RESULTS Athletes with cervical SCI exhibited the lowest seated blood pressure and the most severe orthostatic hypotension (P < 0.025). There were no differences in cardiovascular function between athletes with different American Spinal Injury Association Impairment Scale grades (P > 0.96). Conversely, those with the lowest SSR scores exhibited the lowest seated blood pressure and the most severe orthostatic hypotension (P < 0.002). Linear regression demonstrated that the combined model of neurological level and autonomic completeness of SCI explained the most variance in all blood pressure indices. CONCLUSION We demonstrate for the first time that neurological level and SSR score provide the optimal combination of assessments to identify those at risk of abnormal cardiovascular control. We advocate the use of autonomic testing in the clinical and sporting classification of SCI athletes.
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Affiliation(s)
- Christopher R West
- 1International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, BC, CANADA; 2Division of Physical Medicine and Rehabilitation, Department of Medicine, University of British Columbia, Vancouver, BC, CANADA; and 3GF Strong Rehabilitation Centre, Vancouver, BC, CANADA
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West CR, Gee CM, Voss C, Hubli M, Currie KD, Schmid J, Krassioukov AV. Cardiovascular control, autonomic function, and elite endurance performance in spinal cord injury. Scand J Med Sci Sports 2014; 25:476-85. [DOI: 10.1111/sms.12308] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/16/2014] [Indexed: 12/17/2022]
Affiliation(s)
- C. R. West
- International Collaboration on Repair Discoveries (ICORD); Faculty of Medicine; University of British Columbia; Vancouver British Columbia Canada
| | - C. M. Gee
- International Collaboration on Repair Discoveries (ICORD); Faculty of Medicine; University of British Columbia; Vancouver British Columbia Canada
| | - C. Voss
- Centre for Hip Health and Mobility; Faculty of Medicine; University of British Columbia; Vancouver British Columbia Canada
| | - M. Hubli
- International Collaboration on Repair Discoveries (ICORD); Faculty of Medicine; University of British Columbia; Vancouver British Columbia Canada
| | - K. D. Currie
- International Collaboration on Repair Discoveries (ICORD); Faculty of Medicine; University of British Columbia; Vancouver British Columbia Canada
| | - J. Schmid
- Paracycling Classification; International Cycling Union; Aigle Switzerland
| | - A. V. Krassioukov
- International Collaboration on Repair Discoveries (ICORD); Faculty of Medicine; University of British Columbia; Vancouver British Columbia Canada
- Division of Physical Medicine and Rehabilitation; Faculty of Medicine; University of British Columbia; Vancouver British Columbia Canada
- GF Strong Rehabilitation Centre; Vancouver Health Authority; Vancouver British Columbia Canada
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Berger MJ, Hubli M, Krassioukov AV. Sympathetic skin responses and autonomic dysfunction in spinal cord injury. J Neurotrauma 2014; 31:1531-9. [PMID: 24874269 DOI: 10.1089/neu.2014.3373] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
Sympathetic skin responses (SSRs), a measure of sympathetic cholinergic sudomotor function, have been used in the assessment of autonomic dysfunction in patients with spinal cord injury (SCI). This review highlights the basic mechanisms underlying SSRs as well as their application to the SCI population. We address the utility of SSRs in assessing autonomic function, the relationship between autonomic and sensorimotor impairment, and the association between SSRs and the sequelae of autonomic dysfunction in SCI, particularly autonomic dysreflexia and orthostatic hypotension. Overall, SSRs are a rapid, convenient and non-invasive method illustrating that the severity of autonomic impairment can be independent from sensorimotor impairment. We suggest that SSRs be used in conjunction with other validated autonomic tests in order to predict or document autonomic dysfunction in SCI.
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Affiliation(s)
- Michael J Berger
- 1 Division of Physical Medicine and Rehabilitation, University of British Columbia , Vancouver
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West CR, Goosey-Tolfrey VL, Campbell IG, Romer LM. Effect of abdominal binding on respiratory mechanics during exercise in athletes with cervical spinal cord injury. J Appl Physiol (1985) 2014; 117:36-45. [PMID: 24855136 PMCID: PMC4458640 DOI: 10.1152/japplphysiol.00218.2014] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2014] [Accepted: 05/15/2014] [Indexed: 11/25/2022] Open
Abstract
We asked whether elastic binding of the abdomen influences respiratory mechanics during wheelchair propulsion in athletes with cervical spinal cord injury (SCI). Eight Paralympic wheelchair rugby players with motor-complete SCI (C5-C7) performed submaximal and maximal incremental exercise tests on a treadmill, both with and without abdominal binding. Measurements included pulmonary function, pressure-derived indices of respiratory mechanics, operating lung volumes, tidal flow-volume data, gas exchange, blood lactate, and symptoms. Residual volume and functional residual capacity were reduced with binding (77 ± 18 and 81 ± 11% of unbound, P < 0.05), vital capacity was increased (114 ± 9%, P < 0.05), whereas total lung capacity was relatively well preserved (99 ± 5%). During exercise, binding introduced a passive increase in transdiaphragmatic pressure, due primarily to an increase in gastric pressure. Active pressures during inspiration were similar across conditions. A sudden, sustained rise in operating lung volumes was evident in the unbound condition, and these volumes were shifted downward with binding. Expiratory flow limitation did not occur in any subject and there was substantial reserve to increase flow and volume in both conditions. V̇o2 was elevated with binding during the final stages of exercise (8-12%, P < 0.05), whereas blood lactate concentration was reduced (16-19%, P < 0.05). V̇o2/heart rate slopes were less steep with binding (62 ± 35 vs. 47 ± 24 ml/beat, P < 0.05). Ventilation, symptoms, and work rates were similar across conditions. The results suggest that abdominal binding shifts tidal breathing to lower lung volumes without influencing flow limitation, symptoms, or exercise tolerance. Changes in respiratory mechanics with binding may benefit O2 transport capacity by an improvement in central circulatory function.
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Affiliation(s)
- Christopher R West
- Centre for Sports Medicine and Human Performance, Brunel University, United Kingdom; and
| | - Victoria L Goosey-Tolfrey
- School of Sport, Exercise & Health Sciences, The Peter Harrison Centre for Disability Sport, Loughborough University, United Kingdom
| | - Ian G Campbell
- Centre for Sports Medicine and Human Performance, Brunel University, United Kingdom; and
| | - Lee M Romer
- Centre for Sports Medicine and Human Performance, Brunel University, United Kingdom; and
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Using Reactive Hyperemia to Assess the Efficacy of Local Cooling on Reducing Sacral Skin Ischemia Under Surface Pressure in People With Spinal Cord Injury: A Preliminary Report. Arch Phys Med Rehabil 2013; 94:1982-9. [DOI: 10.1016/j.apmr.2013.03.022] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2012] [Revised: 02/18/2013] [Accepted: 03/25/2013] [Indexed: 11/21/2022]
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West CR, AlYahya A, Laher I, Krassioukov A. Peripheral vascular function in spinal cord injury: a systematic review. Spinal Cord 2012. [DOI: 10.1038/sc.2012.136] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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