Scoping review of dual-task interference in individuals with intellectual disability

Dual-task paradigms can provide insights on the structures and mechanisms underlying information processing and hold diagnostic, prognostic, and rehabilitative value for populations with cognitive deficits such as in individuals with intellectual disability (ID). In this paradigm, two tasks are performed separately (single-task context) and concurrently (dual-task context). The change in performance from single- to dual-task context represents dual-task interference. Findings from dual-task studies have been largely inconsistent on whether individuals with ID present with dual-task-specific deficits. The current review aimed to map the published literature on dual-task methods and pattern of dual-task interference in individuals with ID. A scoping review based on Arksey and O'Malley's five-stage methodological framework was performed. Seventeen electronic databases and registries were searched to identify relevant studies, including gray literature. Charted data from included studies were analyzed quantitatively and qualitatively. PRISMA guidelines informed the reporting of this review. Twenty-two studies involving 1,102 participants (656 with ID and 446 without ID) met the review's inclusion criteria. Participants in the included studies were heterogeneous in sex, age (range 3-59 years), etiology and ID severity. Included studies characterized their ID-sample in different ways, most commonly using intelligence quotient (IQ) scores. Other measures of intellectual function (e.g., mental age, ID severity, verbal and/or visuospatial ability scores) were also used, either solely or in combination with IQ. Methods of dual-task testing varied across studies, particularly in relation to dual-task combinations, equation of single-task performance between groups, measurement and reporting of dual-task performance for each single-task, and task priority instructions. Thematic content of the included studies were: (1) structural interference to dual-tasking; (2) etiology-based differences in dual-tasking; (3) gait and balance dual-task performance; (4) testing executive function using dual-task paradigms; and (5) training effect on dual-task performance. Although the evidence consistently supported the intact dual-tasking ability of individuals with ID, the pattern of dual-task interference was inconsistent. Likewise, the evidence was inconclusive regarding dual-task deficit specific to individuals with ID because of heterogeneity in dual-task study designs among included studies.

The Underlying Mechanisms of Sports Injuries in Paralympic Goalball: A Mixed-Method Study

OBJECTIVE

Data from the Paralympic Games indicate a fluctuating injury incidence in the Paralympic sport goalball, but the mechanisms behind have not been explored. The aims of this study are to (1) quantitatively analyze goalball injuries reported in the London 2012 and Rio 2016 Paralympic Games, (2) qualitatively explain the differences between both games, and (3) qualitatively assess general injury mechanisms and prevention opportunities of injuries in Goalball.

DESIGN

This is a mixed-method study. Injury incidence rates were analyzed from data collected during the 2012 and 2016 Paralympic Games. Then, semistructured interviews of games participants qualitatively explored injury mechanisms and prevention opportunities.

RESULTS

A reduction of injuries occurred from 2012 (incidence rate, 19.5; 95% confidence interval, 12.5-26.5) to 2016 (incidence rate: 5.6; 95% confidence interval, 1.7-9.5). In both games, acute traumatic injuries were most common. Female athletes reported higher rate of injuries compared with males ( P = 0.05). Qualitative data revealed that causes of injuries were collisions, overuse, and poor physical conditioning. The differences between the two games were explained by equipment, environment, and preparations.

CONCLUSIONS

The result from this study indicates that injuries in goalball are multifactorial. Ultimately, the mixed-method data from this study can help the sports context develop prevention measures.

Physical activity, fear avoidance beliefs and level of disability in a multi-ethnic female population with chronic low back pain in Suriname: A population-based study

BACKGROUND

Chronic low back pain (CLBP) is an important cause for reduced daily physical activity (PA) and loss of quality of life, especially in women. In Suriname, a middle-income country in South America, the relationship between PA and CLBP is still unknown.

AIMS

To assess the level of PA in women with CLBP of different ethnicity, and to identify whether fear avoidance beliefs (FAB), disability, co-occurring musculoskeletal pain sites and various sociodemographic and lifestyle factors were associated with self-reported PA.

METHODS

A cross-sectional community-based house-to-house survey was conducted between April 2016 and July 2017. The survey followed the Community Oriented Program for Control of Rheumatic Diseases methodology. Selection criteria were being female of Asian-Surinamese, African-Surinamese or of Mixed ethnicity and aged 18 or older, living in an urban area, and reporting CLBP. Data was collected on PA, FAB, disability, co-occurring musculoskeletal pain sites, CLBP intensity and sociodemographic and lifestyle factors.

RESULTS

Urban adult women with current CLBP (N = 210) were selected. Nearly 57% of the population met the WHO recommendation on PA, with work-related PA as the largest contributor to total self-reported PA. Most women showed low FAB scores (FABQ-Work ≤34 (96.2%) and FABQ-PA ≤14 (57.6%)) and low disability levels (Oswestry Disability Index ≤20 (62.4%)). An inverse association between total PA and FABQ-Work (OR = 0.132, CI: 0.023; 0.750) was found. In contrast, total PA had a significant, positive association with disability (OR = 2.154, CI: 1.044; 4.447) and workload (OR = 2.224, CI: 1.561; 3.167). All other variables showed no association with total PA.

CONCLUSION

This was the first study in Suriname reporting that 43.3% of urban adult women with CLBP were physically inactive. Total self-reported PA is influenced by FABQ-Work, average to heavy workload and moderate to severe disability. In this study, PA-Work was the major contributor to total PA. Therefore, future longitudinal studies should evaluate different types and aspects of PA in relation to CLBP management.

Athletes with intellectual disability: The effects of cognitive deficits and sports practice on bipedal standing balance

BACKGROUND

Athletes with intellectual disability represent a unique population who experiences the contrasting effects of cognitive deficits and benefits of sports on balance. This study investigated the combined impact of intellectual disability and sport practice on balance.

METHOD

Center-of-pressure excursion in bipedal stance of 2 disability (with and without intellectual disability) × 2 sport practice (athlete and novice) participant groups was measured in several balance conditions.

RESULTS

Sport practice exerted no significant effect on any of the center-of-pressure measures used. In contrast, intellectual disability's effects on balance, which were most apparent in challenging balance conditions, were significant (p < .05) and had large effect sizes (η_p ²  > 0.13).

CONCLUSION

The negative effects of cognitive deficits on the balance of young adults with intellectual disability underscore the need for effective interventions. Although findings did not support sports' balance-remediating potential, the value of sport participation for individuals with intellectual disability cannot be fully dismissed just yet.

Low back pain prevalence, beliefs and treatment-seeking behaviour in multi-ethnic Suriname

Objectives

The aims were to determine, for the first time, the prevalence of low back pain (LBP) in urban and rural communities and to assess back beliefs and treatment-seeking behaviour in Suriname, a multi-ethnic country in the Caribbean community.

Methods

A cross-sectional community-based survey using the Community Oriented Program for the Control of Rheumatic Diseases methodology was performed between April 2016 and July 2017. Information was collected on LBP prevalence and LBP-related treatment seeking, beliefs about LBP [Back Beliefs Questionnaire (BBQ)], level of disability (Oswestry Disability Index) and the risk of developing persistent disabling pain (Start Back Screening Tool).

Results

A total of 541 out of 2902 individuals reported current acute or chronic LBP. It was more prevalent in urban (20.2%) than in rural (13.7%) communities, especially in females and older adults (>55 years of age). Individuals from rural areas [median BBQ = 18.00 (14.00-22.00)] had significantly more negative beliefs than the urban population [median BBQ = 25.00 (19.00-31.00); P < 0.001]. Maroons displayed more negative beliefs than Creole (P = 0.040), Hindustani (P < 0.001), Javanese (P < 0.001) and mixed ethnicity (P < 0.001) groups. At least 75% of the LBP population sought care, especially from a western health-care practitioner. Seeking treatment and having a higher risk of developing persistent disabling pain was significantly associated with more disability (P < 0.001). Age ≥45 years (P < 0.001), Indigenous ethnicity (P < 0.05) and functional disability (P < 0.001) were factors influencing treatment seeking.

Conclusion

Low back pain is a prevalent health problem in the Surinamese urban community, especially in older adults and among females. Most individuals experiencing LBP visited a western health-care practitioner and had more negative beliefs compared with other communities.

Steering Does Affect Biophysical Responses in Asynchronous, but Not Synchronous Submaximal Handcycle Ergometry in Able-Bodied Men

Real-life daily handcycling requires combined propulsion and steering to control the front wheel. Today, the handcycle cranks are mostly mounted synchronously unlike the early handcycle generations. Alternatively, arm cycle ergometers do not require steering and the cranks are mostly positioned asynchronously. The current study aims to evaluate the effects of combining propulsion and steering requirements on synchronous and asynchronous submaximal handcycle ergometry. We hypothesize that asynchronous handcycling with steering results in the mechanically least efficient condition, due to compensation for unwanted rotations that are not seen in synchronous handcycling, regardless of steering. Sixteen able-bodied male novices volunteered in this lab-based experiment. The set-up consisted of a handcycle ergometer with 3D force sensors at each crank that also allows “natural” steering. Four submaximal steady-state (60 rpm, ~35 W) exercise conditions were presented in a counterbalanced order: synchronous with a fixed steering axis, synchronous with steering, asynchronous with a fixed axis and asynchronous with steering. All participants practiced 3 × 4 mins with 30 mins rest in between every condition. Finally, they did handcycle for 4 mins in each of the four conditions, interspaced with 10 mins rest, while metabolic outcomes, kinetics and kinematics of the ergometer were recorded. The additional steering component did not influence velocity, torque and power production during synchronous handcycling and therefore resulted in an equal metabolically efficient handcycling configuration compared to the fixed condition. Contrarily, asynchronous handcycling with steering requirements showed a reduced mechanical efficiency, as velocity around the steering axis increased and torque and power production were less effective. Based on the torque production around the crank and steering axes, neuromuscular compensation strategies seem necessary to prevent steering movements in the asynchronous mode. To practice or test real-life daily synchronous handcycling, a synchronous crank set-up of the ergometer is advised, as exercise performance in terms of mechanical efficiency, metabolic strain, and torque production is independent of steering requirements in that mode. Asynchronous handcycling or arm ergometry demands a different handcycle technique in terms of torque production and results in higher metabolic responses than synchronous handcycling, making it unsuitable for testing.

Cognitive-motor multitasking in athletes with and without intellectual impairment

PURPOSE

We investigated cognitive-motor multitasking in 29 top athletes with intellectual impairment (II) recruited during the European Championship Games organized by Virtus (World Intellectual Impairment Sports) and 29 control (CT) athletes matched for age, sex, sports practiced, and lifetime accumulated practice hours.

METHODS

Participants performed a cognitive task that required recognizing previously displayed visual objects among distractors. The motor task required maintaining a stable upright posture balancing on a rocking board placed atop a force plate which assessed center-of-pressure (COP) movement. Both tasks were performed separately (with participants seated for the cognitive single task) and concurrently under dual-task conditions, wherein participants memorized objects while balancing. We analyzed recognition accuracy, COP path length, and sample entropy of the COP trajectory as a measure for automaticity of postural control.

RESULTS

As expected, CT-athletes outperformed II-athletes in the cognitive task but the two groups have comparable performance in the postural task under single- and dual-task conditions. When multitasking, CT-athletes switched to more automatic postural control and maintained their postural sway at single-task levels. II-athletes prioritized balance thereby successfully keeping COP excursion comparable to single-task conditions. However, this came with pronounced costs for memory performance, which was unaffected by multitasking in CT-athletes.

CONCLUSION

The adaptive capacity observed in control athletes was not at the disposal of II-athletes who revealed pronounced sensitivities to multitasking interference. This sensitivity obviously was not compensated for by either athletic competence or potential transfer of athletic skill to domain-general cognitive functions.

"Fairness, Technology and the Ethics of Paralympic Sport Classification"

Fairness in sport is a widely shared meritocratic norm. Its application is usually restricted to equality of opportunity to compete for victory. Paralympic sports lay down a further challenge in that equality of opportunity must be shaped by considerations of fairness, evidenced by the development of discrete competition categories to construct fair and meaningful contests. In this article we extend these philosophical ideas to consider how Fair Equality of Opportunity might operate in the context of Paralympic sports classification. We articulate three conceptions of fairness relevant to these sports: (i) background fairness; (ii) procedural fairness; and (iii) stakes fairness. We critically review the International Paralympic Committee's Policy on Sport Equipment in relation to the first two conceptions and argue that greater clarification, theorization and rule modification is required if physical prowess, as opposed to equipment technology, is to be assured as the dominant determinant of Paralympic athletic success.Bullet points: Fair equality of opportunity in sport is applied to disability or Paralympic sportConceptual and ethical review of IPC sport equipment policyGreater theorization and rule modification required to preserve the principle that physical prowess as opposed to equipment technology is the dominant determinat of athletic success.

Evaluating objective measures of impairment to trunk strength and control for cross-country sit skiing

In Paralympic cross-country sit skiing, athlete classification is performed by an expert panel, so it may be affected by subjectivity. An evidence-based classification is required, in which objective measures of impairment must be identified. The purposes of this study were: (i) to evaluate the reliability of 5 trunk strength measures and 18 trunk control measures developed for the purposes of classification; (ii) to rank the objective measures, according to the largest effects on performance. Using a new testing device, 14 elite sit-skiers performed two upright seated press tests and one simulated poling test to evaluate trunk strength. They were also subjected to unpredictable balance perturbations to measure trunk control. Tests were repeated on two separate days and test–retest reliability of trunk strength and trunk control measures was evaluated. A cluster analysis was run and correlation was evaluated, including all strength and control measures, to identify the measures that contributed most to clustering participants. Intraclass correlations coefficients (ICC) were 0.71 < ICC < 0.98 and 0.83 < ICC < 0.99 for upright seated press and perturbations, respectively. Cluster analysis identified three clusters with relevance for strength and balance control measures. For strength, in upright seated press peak anterior pushing force without backrest (effect size = 0.77) and ratio of peak anterior pushing force without and with backrest (effect size = 0.72) were significant. For balance control measures, trunk range of motion in forward (effect size = 0.81) and backward (effect size = 0.75) perturbations also contributed. High correlations (− 0.76 < r < − 0.53) were found between strength and control measures. The new testing device, protocol, and the cluster analysis show promising results in assessing impairment of trunk strength and control to empower an evidence-based classification.

Challenges and opportunities in wheelchair basketball classification- A Delphi study

The International Paralympic Committee (IPC) mandates Paralympic Sports to develop evidence-based classification systems that allocate athletes into 'classes' according to the impact of their impairment on sport-specific performance. In wheelchair-basketball, a panel of classifiers assesses athlete's performance through observation. One key barrier to evidence-based classification is the absence of defined eligible impairments, including clear guidelines on how to assess them and their impact on wheelchair basketball performance. This study aims to reach expert consensus on issues specific to wheelchair basketball that can benefit from evidence-based classification. It offers recommendations for refining the classification manual, thus improving adherence to the IPC classification code. A three-round Delphi study was conducted with 29 experts in wheelchair basketball. The experts agreed with the new definition for the aim of wheelchair basketball classification, which is in line with the IPC code. Cases identified as having the highest risk for disagreement between classifiers included classifying players with upper limb deficiency or with impaired coordination. The panel failed to agree on changing the classification procedures and on defining the eligible impairment list. This study identifies issues specific to wheelchair basketball classification to be addressed in future research. Additional discussions need to take place to promote further resolution.

Conceptual model of sport-specific classification for para-athletes with intellectual impairment

The present paper describes the conceptual basis of evidence-based classification of para-athletes with intellectual impairment (II). An extensive description of the theoretical and conceptual foundation of the system as currently conceived is provided, as are examples of its applications in the three sports included in the Paralympic programme for II-athletes in 2020 (i.e., athletics, swimming and table tennis). Evidence-based classification for II-athletes is driven by two central questions: i. How can intellectual impairment be substantiated in a valid and reliable way, and ii. Does intellectual impairment limit optimal sport proficiency? Evolution of the system and current best practice for addressing these questions are described, and suggestions for future research and development are provided. Challenges of understanding and assessing a complex (multifaceted and intersectional) impairment in the context of sport also are considered.

Reliability of center of pressure excursion as a measure of postural control in bipedal stance of individuals with intellectual disability: A pilot study

The high prevalence of postural instability in individuals with intellectual disability (ID) warrants the need for reliable and practical postural control assessments. Stabilometry is a postural control assessment that has been widely used for clinical populations. However, the scant systematic knowledge about the reliability of stabilometric protocols for adults with ID renders results questionable and limits its value for clinicians and researchers. The study's purpose was to develop a stabilometric protocol for adults with and without ID based on optimal combinations of shortest necessary trial durations and the least number of trial repetitions that guarantee sufficient reliability. Participants performed six trials of bipedal standing in 2 vision (eyes open vs eyes closed) x 2 surface (solid vs compliant) conditions on a force platform. Several parameters were calculated from the first 10-, 20-, and 30-s interval of every center-of-pressure (COP) trial data. For different trial durations, we identified the number of trials that yielded acceptable relative (intraclass correlation coefficient ≥ 0.70) and absolute (standard error of measurement < 20%) reliability using the Spearman-Brown prophecy formula. To determine the optimal combination of trial duration and number of repetition for each COP parameter, we implemented a two-step process: 1) identify the largest number of repetition for each of the three trial durations and then 2) select the trial duration with the lowest number of repetition. For both ID- and non-ID groups, we observed a trend whereby shorter trial durations required more repetitions and vice versa. The phase plane and ellipse area were the most and least reliable center-of-pressure parameter, respectively. To achieve acceptable reliability, four 30-s trials of each experimental condition appeared to be optimal for testing participants with and without ID alike. The results of this research can inform stabilometric test protocols of future postural control studies of adults with ID.

Effect of Sildenafil Citrate on Exercise Capacity in Athletes With Spinal Cord Injury

PURPOSE

Ingestion of sildenafil citrate has performance-enhancing effects at high altitudes above 3800 m in able-bodied individuals. It is unknown whether it can improve the performance of athletes with spinal cord injury (SCI) at moderate altitudes (<2200 m), relevant to Paralympic competitions. As most men with SCI suffer from erectile dysfunction of neurologic origin and use sildenafil on a regular basis, it seems important to study the impact of sildenafil on exercise capacity. The outcome of this study is also relevant to the antidoping community.

METHODS

Twenty-seven healthy male wheelchair athletes with a motor-complete SCI participated in this prospective double-blind, randomized, placebo-controlled study. The participants performed arm cranking exercise to exhaustion at sea level and moderate altitude (2200 m) after ingestion of 50 mg sildenafil citrate or a placebo. Peak power output, peak oxygen uptake, peak heart rate, rating of perceived exertion, oxygen saturation, and lactate concentrations at exhaustion were measured.

RESULTS

Friedman analysis showed that peak power output at sea level was significantly higher (P = .004) under placebo treatment (median [minimum; maximum]: 120 W [35; 170]) compared with sildenafil (115 W [40; 165]). Blood oxygen saturation under sildenafil treatment at sea level (98% [81; 100]) was significantly higher (P = .006) compared with sildenafil treatment at moderate altitude (94% [85; 100]). All other parameters revealed no impact of sildenafil or altitude.

CONCLUSIONS

In this study, the ingestion of sildenafil citrate in athletes with SCI demonstrated no positive effects on peak arm-cranking-exercise capacity compared with placebo either at sea level or at moderate altitude.

Prevalence of musculoskeletal complaints in urban communities in multi-ethnic Suriname: a cross-sectional study with the COPCORD methodology (stage 1, phase 1 and 2)

INTRODUCTION/OBJECTIVES

Musculoskeletal complaints (MSCs) are a major burden worldwide. In Suriname, a South American developing country, the epidemiology of MSCs and its related disorders is still unknown. Therefore, a cross-sectional survey was carried out to determine prevalence and risk factors of MSCs in urban areas of Suriname.

METHODS

This is the first Community Oriented Program for the Control of Rheumatic Diseases survey in a Caribbean Community. Trained interviewers collecting self-reported data conducted this house-to-house community-based survey. Data was analyzed using SPSS version 23 and Stata version 14.1.

RESULTS

The prevalence of MSCs was 62.1% with a higher prevalence rate among women compared with men (resp. 64.3% vs. 58.6%) (Odds ratio = 1.185; p ≤ 0.05). The most decisive self-reported variables associated with MSCs were older age (defined as ≥ 45 years) and moderate to heavy physical workload. The prevalence of MSCs was also associated with women, low educational level, smoking, alcohol use, high-intensity physical activity level, and body mass index (≥ 25 kg/m²). The highest prevalence of MSCs was found among African descendants (Maroons (68.8%) and Creoles (68.0%)), followed by the Indigenous (65.0%) and Asian descendants (Hindustani (64.3%) and Javanese (49.5%)). Most persons with MSCs (75.7%) reported multisite complaints with lower back, knee, and shoulder being the most frequently reported sites. In our study population, MSCs were not considered disabling (mean Health Assessment Questionnaire Disability Index score of 0.23).

CONCLUSIONS

The prevalence of MSCs in this urban multi-ethnic Surinamese community is high; therefore, future research is needed to further explore the burden of MSCs in Suriname.Key Points• Musculoskeletal complaints are highly prevalent in different ethnic groups in an urban Surinamese community; almost two-thirds of the population reported MSCs with the highest prevalence rate among women and African descendants.• The most decisive self-reported variables associated with MSCs were older age (defined as ≥ 45 years) and moderate to heavy physical workload. Gender, educational level, smoking, alcohol use, high-intensity physical activity, and body mass index were also significantly associated with musculoskeletal complaints.

Balance Perturbations as a Measurement Tool for Trunk Impairment in Cross-Country Sit Skiing

In cross-country sit-skiing, the trunk plays a crucial role in propulsion generation and balance maintenance. Trunk stability is evaluated by automatic responses to unpredictable perturbations; however, electromyography is challenging. The aim of this study was to identify a measure to group sit-skiers according to their ability to control the trunk. Seated in their competitive sit-ski, 10 male and 5 female Paralympic sit-skiers received 6 forward and 6 backward unpredictable perturbations in random order. k-means clustered trunk position at rest, delay to invert the trunk motion, and trunk range of motion significantly into 2 groups. In conclusion, unpredictable perturbations might quantify trunk impairment and may become an important tool in the development of an evidence-based classification system for cross-country sit-skiers.

Cluster analysis of novel isometric strength measures produces a valid and evidence-based classification structure for wheelchair track racing

Background

The Para athletics wheelchair-racing classification system employs best practice to ensure that classes comprise athletes whose impairments cause a comparable degree of activity limitation. However, decision-making is largely subjective and scientific evidence which reduces this subjectivity is required.

Aim

To evaluate whether isometric strength tests were valid for the purposes of classifying wheelchair racers and whether cluster analysis of the strength measures produced a valid classification structure.

Methods

Thirty-two international level, male wheelchair racers from classes T51–54 completed six isometric strength tests evaluating elbow extensors, shoulder flexors, trunk flexors and forearm pronators and two wheelchair performance tests–Top-Speed (0–15 m) and Top-Speed (absolute). Strength tests significantly correlated with wheelchair performance were included in a cluster analysis and the validity of the resulting clusters was assessed.

Results

All six strength tests correlated with performance (r=0.54–0.88). Cluster analysis yielded four clusters with reasonable overall structure (mean silhouette coefficient=0.58) and large intercluster strength differences. Six athletes (19%) were allocated to clusters that did not align with their current class. While the mean wheelchair racing performance of the resulting clusters was unequivocally hierarchical, the mean performance of current classes was not, with no difference between current classes T53 and T54.

Conclusions

Cluster analysis of isometric strength tests produced classes comprising athletes who experienced a similar degree of activity limitation. The strength tests reported can provide the basis for a new, more transparent, less subjective wheelchair racing classification system, pending replication of these findings in a larger, representative sample. This paper also provides guidance for development of evidence-based systems in other Para sports.

Does a cycling program combined with education and followed by coaching promote physical activity in subacute stroke patients? A randomized controlled trial

BACKGROUND

To investigate the effects of a three month active cycling program followed by coaching on physical activity in subacute stroke patients.

METHODS

Patients (n = 59; mean age =65.4 ± 10.3) aged ≤80 years with first stroke and able to cycle at 50 revolutions/minute enrolled 3-10 weeks post stroke. Patients were randomly allocated to three month active cycling group (n = 33) or to a control group (n = 26), 3 x 30 minutes training/week. Afterwards, the active cycling group was randomized into a coaching (n = 15) versus non-coaching group (n = 16) for nine months. Physical activity was measured by objective and self-reported measures, which were taken before/after the active cycling program and during six and 12 months, except the Baecke-questionnaire, which was used at baseline and 12 months.

RESULTS

A significant difference was found in Baecke/sport (95% confidence interval: 0.06, 2.24; p = 0.039) between the active cycling group and the control group, in patients with severe motor function deficits at baseline. Patients in the control group performed significant less sports at 12 months (mean Baecke/sport_baseline =3.07 ± 1.21, mean Baecke/sport_12months = 1.43 ± 0.98; p = 0.01). Furthermore, all groups showed significant changes over time in all measures at three months (except: Physical Activity Scale for Individuals with Physical Disabilities, diary/Mets*minutes-moderate) and 12 month and additionally in a subgroup with severe motor function deficits (except diary Mets*minutes-sedentary).

CONCLUSION

When active cycling combined with education is used in subacute patients with severe motor function deficits, more sport participation might be observed after one year. No other significant group differences were found over time. In all groups, however, patients showed significant improvement over time in physical activity measures. Future work is needed to explore the most effective coaching approach after an aerobic training program. Implications for Rehabilitation The active cycling program combined with education is applicable in subacute stroke patients as it required little stand-by assistance due to chip cards, the intensity was gradually built and the involvement of caregivers in the educational sessions. This training approach also revealed applicable in severely impaired stroke patients and might facilitate sport participation on the long-term. This randomized controlled study aims to quantify physical activity after stroke by using a combination of objective and self-report measures, which revealed detailed information about different aspects of physical activity levels. There is a need for coaching approaches that facilitate aerobic exercise after ending a supervised program. A coaching approach needs to guide patients in adopting aerobic exercise as a part of a lifestyle change and needs to be less time consuming.

Effectiveness of Active Cycling in Subacute Stroke Rehabilitation: A Randomized Controlled Trial

OBJECTIVE

To examine the effects of 3 months of aerobic training (AT) followed by coaching on aerobic capacity, strength, and gait speed after subacute stroke.

DESIGN

Randomized controlled trial.

SETTING

Inpatient rehabilitation center.

PARTICIPANTS

Patients (N=59; mean age ± SD, 65.4±10.3y; 21 women (36%); Barthel Index ≤50 in 64% of patients) with first stroke and able to cycle at 50 revolutions/min were enrolled in the study 3 to 10 weeks after stroke onset.

INTERVENTIONS

Patients were randomly allocated to a 3-month active cycling group (ACG, n=33) and education, or to a control group (CG, n=26). Afterward, patients in the ACG were randomly assigned either to a coaching (n=15) or to a noncoaching group (n=16) for 9 months.

MAIN OUTCOME MEASURES

Aerobic capacity, isometric knee extension strength, and gait ability and speed were measured before and after intervention and during follow-up at 6 and 12 months.

RESULTS

A nonsignificant difference was found in workload (Watt_peak) (P=.078) between ACG and CG after 3 months. Furthermore, after 3 months of cycling and after 9 months of coaching, all groups showed significant changes over time (P≤.027) in peak oxygen consumption, Watt_peak, leg strength, and gait speed. Also, significant changes over time (P<.001) were found in the ACG and the CG in patients with walking inability at baseline.

CONCLUSIONS

No significant differences between training groups were found over time. Although our study did not have objective exercise data from the training device during follow-up, the 3-month active cycling (AC) program combined with education sessions seemed an applicable method in subacute stroke rehabilitation. New long-term AT interventions should focus on coaching approaches to facilitate training after a supervised AC program.

Pacing Profiles in Competitive Track Races: Regulation of Exercise Intensity Is Related to Cognitive Ability

Pacing has been defined as the goal-directed regulation of exercise intensity over an exercise bout, in which athletes need to decide how and when to invest their energy. The purpose of this study was to explore if the regulation of exercise intensity during competitive track races is different between runners with and without intellectual impairment, which is characterized by significant limitations in intellectual functioning (IQ ≤ 75) and adaptive behavioral deficits, diagnosed before the age of 18. The samples included elite runners with intellectual impairment (N = 36) and a comparison group of world class runners without impairment (N = 39), of which 47 were 400 m runners (all male) and 28 were 1500 m-runners (15 male and 13 female). Pacing was analyzed by means of 100 m split times (for 400 m races) and 200 m split times (for 1500 m races). Based on the split times, the average velocity was calculated for four segments of the races. Velocity fluctuations were defined as the differences in velocity between consecutive race segments. A mixed model ANOVA revealed significant differences in pacing profiles between runners with and without intellectual impairment (p < 0.05). Maximal velocity of elite 400 m runners with intellectual impairment in the first race segment (7.9 ± 0.3 m/s) was well below the top-velocity reached by world level 400 m runners without intellectual impairment (8.9 ± 0.2 m/s), and their overall pace was slower (F = 120.7, p < 0.05). In addition, both groups followed a different pacing profile and inter-individual differences in pacing profiles were larger, with differences most pronounced for 1500 m races. Whereas, male 1500 m-runners without intellectual impairment reached a high velocity in the first 100 m (7.2 ± 0.1 m/s), slowly decelerated in the second race segment (−0.6 ± 0.1 m/s), and finished with an end sprint (+0.9 ± 0.1 m/s); the 1500 m runners with intellectual impairment started slower (6.1 ± 0.3 m/s), accelerated in the second segment (+0.2 ± 0.7 m/s), and then slowly decreased until the finish (F = 6.8, p < 0.05). Our findings support the hypothesis that runners with intellectual impairment have difficulties to efficiently self-regulate their exercise intensity. Their limited cognitive resources may constrain the successful integration of appropriate pacing strategies during competitive races.

Physical activity in chronic home-living and sub-acute hospitalized stroke patients using objective and self-reported measures

BACKGROUND

Despite confirmed reduced physical activity (PA) after stroke in various stages of recovery, the type of activities stroke patients executed and the time spent at different activity levels have not been sufficiently verified with stroke-validated assessment tools.

DESIGN

Observational study.

OBJECTIVE

To determine PA of sub-acute stroke patients hospitalized in a rehabilitation centre (HOS) compared to chronic home-living stroke patients (HOM) using objective and self-reported measures during 2 weekdays and 1 weekend day.

METHODS

Fifteen HOS and 15 HOM patients wore a Sense Wear Pro 2 accelerometer (METs*minutes/24 h) and a knee-worn pedometer Yamax Digi Walker SW 200 (steps) and filled in a coded activity diary (kcal/24 h; METs*minutes/24 h) during three consecutive days.

RESULTS

In HOM significantly more steps (stepstotal HOM = 18722.6 ± 10063.6; stepstotal HOS = 7097.8 ± 5850.5) and higher energy expenditure (EE) levels (EEtotal HOM = 7759.34 ± 2243.04; EEtotal HOS = 5860.15 ± 1412.78) were measured. In this group less moderate activity (≥3-6 ≤ METs) was performed on a weekday (pday1 = 0.006; pday2 = 0.027) and in total (p = 0.037). Few therapy hours (physical, occupational and speech therapy, and psychological support) were provided in HOM compared to HOS (p < 0.001). Vigorous activities were only seen in HOM. In both groups few patients executed sport activities.

CONCLUSIONS

In HOM significantly more steps were performed and higher EE values were measured. However, participation in moderate activities and time spent on therapy were less in HOM. Evaluating PA with quantitative measures is feasible in both chronic home-living and sub-acute hospitalized patients with stroke.

Is a coded physical activity diary valid for assessing physical activity level and energy expenditure in stroke patients?

Objectives

to determine the concurrent validity of a physical activity diary for measuring physical activity level and total energy expenditure in hospitalized stroke patients.

Method

Sixteen stroke patients kept coded activity diaries and wore SenseWear Pro2 multi-sensor activity monitors during daytime hours for one day. A researcher observed the patients and completed a diary. Data from the patients' diaries were compared with observed and measured data to determine total activity (METs*minutes), activity level and total energy expenditure.

Results

Spearman correlations between the patients' and researchers' diaries revealed a high correlation for total METs*minutes (r_s = 0.75, p<0.01) for sedentary (r_s = 0.74,p<0.01) and moderate activities (r_s = 0.71,p<0.01) and a very high correlation (r_s = 0.92, p<0.01) for the total energy expenditure. Comparisons between the patients' diaries and activity monitor data revealed a low correlation (r_s 0.29) for total METs*minutes and energy expenditure.

Conclusion

Coded self-monitoring activity diaries appear feasible as a low-tech alternative to labor-intensive observational diaries for determining sedentary, moderate, and total physical activity and for quantifying energy expenditure in hospitalized stroke patients. Given the poor correlation with objective measurements of physical activity, however, further research is needed to validate its use against a gold-standard measure of physical activity intensity and energy expenditure.

Novel strength test battery to permit evidence-based paralympic classification

Ordinal-scale strength assessment methods currently used in Paralympic athletics classification prevent the development of evidence-based classification systems. This study evaluated a battery of 7, ratio-scale, isometric tests with the aim of facilitating the development of evidence-based methods of classification. This study aimed to report sex-specific normal performance ranges, evaluate test-retest reliability, and evaluate the relationship between the measures and body mass.Body mass and strength measures were obtained from 118 participants-63 males and 55 females-ages 23.2 years ± 3.7 (mean ± SD). Seventeen participants completed the battery twice to evaluate test-retest reliability. The body mass-strength relationship was evaluated using Pearson correlations and allometric exponents.Conventional patterns of force production were observed. Reliability was acceptable (mean intraclass correlation = 0.85). Eight measures had moderate significant correlations with body size (r = 0.30-61). Allometric exponents were higher in males than in females (mean 0.99 vs 0.30).Results indicate that this comprehensive and parsimonious battery is an important methodological advance because it has psychometric properties critical for the development of evidence-based classification. Measures were interrelated with body size, indicating further research is required to determine whether raw measures require normalization in order to be validly applied in classification.

Tactical proficiency among table tennis players with and without intellectual disabilities

The effect of intellectual impairment on sports performance has received limited attention by researchers. As a contribution to closing this gap, the purpose of the present investigation was to examine the differences in tactical proficiency between table tennis players with and without intellectual disabilities (ID). These groups were matched for training-volume and experience and consisted of 41 male (age = 27±8) and 30 female (age= 28±8) elite players with ID and a reference group of 12 male (age= 24±12) and 5 female (age= 20±9) players without ID. In two different test settings - one a World Championship and the other a training camp - the players in each group performed 60 semi-standardised rallies against the same opponent. Players were told that 12 sets of five identical services would be delivered, and their goal was to return the service with the intention of 'winning the point'. The test results were validated for this study, to compute tactical proficiency scores (maximal score of eight points) for each player. A two-way Analysis of Variance (ANOVA) revealed significantly lower proficiency scores for players with ID than for those without ID. Repeated-measures ANOVA revealed that within each series of five rallies, starting with identical services, all participants were able to significantly improve their tactical proficiency gradually, but players without ID scored 4.3±0.5 from the first ball on, and while athletes with ID only 3.3±0.7 after five balls. The results of this study indicate that ID is associated with decreased tactical proficiency in table tennis.

Evolution of cardiorespiratory fitness after stroke: a 1-year follow-up study. Influence of prestroke patients' characteristics and stroke-related factors

OBJECTIVES

To examine changes in cardiorespiratory fitness over the first year poststroke and explore the effect of prestroke patients' characteristics and stroke-related factors on this evolution.

DESIGN

Descriptive, longitudinal study with repeated measures of exercise capacity at 3, 6, and 12 months poststroke.

SETTING

Rehabilitation center and exercise testing laboratory.

PARTICIPANTS

Consecutive sample of patients with stroke (N=33; mean age ± SD, 59.0±11.3 y).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Peak oxygen consumption (VO(2)peak) and oxygen uptake efficiency slope (OUES) were determined during a symptom-limited graded cycle ergometer test at 3, 6, and 12 months poststroke. Age, sex, premorbid physical activity level, clinical history (smoking, diabetes mellitus, chronic pulmonary diseases, cardiovascular diseases, overweight, and hypertension), stroke type and area, side of lesion, and assessments of stroke severity were evaluated at intake.

RESULTS

Mean VO(2)peak ± SD was 18.1±6.6 mL·kg(-1)·min(-1), 19.8±8.0 mL·kg(-1)·min(-1), and 19.7±8.4 mL·kg(-1)·min(-1) at 3, 6, and 12 months poststroke. Values for OUES were 1575.3±638.3, 1710.7±710.3, and 1687.2±777.5, respectively. Mixed models showed no significant difference over time for VO(2)peak (P=.10), nor for the logarithm of OUES (P=.09). Stroke survivors at risk of deconditioning were premorbidly less active at work or in sport activities, diabetic, or initially more severely impaired. Combination of factors revealed that older patients with stroke and diabetes were less likely to improve on VO(2)peak and that older, women, diabetic nonsmokers improved less on log OUES.

CONCLUSIONS

Cardiorespiratory fitness was reduced from 3 to 12 months poststroke and on average did not significantly change over time. Further studies should elucidate methods of increasing cardiorespiratory fitness during stay in the rehabilitation center and how community-based aerobic exercise training postrehabilitation can be organized.

Are patients 1 year post-stroke active enough to improve their physical health?

PURPOSE

This study aimed to quantify physical activity one year post-stroke--by means of a multifaceted approach combining absolute, relative, and self-reported measures of physical activity (PA)--and to investigate their mutual associations. The determinants of PA were explored.

METHOD

Daily PA was measured in 16 mildly disabled stroke patients (median RMA-GF score of 12 (IQR = 10-12.5)) using a heart rate monitor, a pedometer, the Baecke Physical Activity Questionnaire and the Physical Activity Scale for individuals with physical disabilities. Potential determinants were age, gender, functional mobility, peak exercise capacity, mood, participation and hours of daylight.

RESULTS

On average, stroke participants had a good baseline level of activity (44 ± 39 min/day spent moderate active, 6428 ± 4117 steps/day), but only three (19%) performed more than 10,000 steps/day, required for health benefits. Functional mobility, cardiorespiratory fitness, mood and participation were related to the total daily steps, but not to the time spent in moderate intense activities. Discrepancies between absolute (frequency and duration) and relative (intensity) measures of PA exist regarding the achieved quantity and its potential determinants.

CONCLUSIONS

It is not only important to be active, but to be active enough to improve health. Health recommendation for stroke survivors to perform moderate intense PA needs to be translated into a pedometer-based step goal.

Determinants of shuttle run performance in the prediction of peak VO2 in wheelchair users

PURPOSE

The purpose of this study was to determine the impact of ergonomic and environmental variations on indoor shuttle run (SR) performance in wheelchair sportsmen.

METHODS

Eleven experienced male wheelchair sportsmen performed three 25-m SRs in random order with varying turning capacity (TC) and mechanical resistance (MR): condition NN where participants used their sports wheelchair on a tartan surface, condition RN with increased MR, and condition RD with limited TC. Metabolic data were continuously recorded using a portable K4b(2) system.

RESULTS

Friedman ANOVA with Wilcoxon a posteriori testing indicated similar VO(2peak) values in all three tests. SR performance, however, was significantly different across the three test conditions (NN: 536.18 +/-119.09 s; RN: 488.82+/-119.84 s; RD: 404.91+/-88.41 s). SR performance contributed for 28% of the explained variance of the measured VO(2peak). The addition of TC or MR or both increased the explained variance to 32, 38 and 41%, respectively.

CONCLUSIONS

These findings demonstrate a significant impact of variations in floor surface and wheelchair-user interface on SR performance. The findings also suggest that strong reservations have to be made regarding the validity of a SR test, as predictor of VO(2peak) in a wheelchair user population.

Cardiorespiratory responses during arm ergometry, functional electrical stimulation cycling, and two hybrid exercise conditions in spinal cord injured

PURPOSE

The purpose of this study was to compare peak functional aerobic power (VO2 peak) across four different types of exercise: arm crank ergometry (ACE), functional electrical stimulation (FES) cycling, and two hybrid exercise conditions: FES cycling combined with ACE and FES rowing using a newly developed rowing device (ROWSTIM).

METHODS

Five participants (C7-T12), four male paraplegics with neurologically complete spinal cord injury (SCI), and one male with neurologically incomplete SCI, underwent a progressive maximal peak oxygen exercise test to ascertain peak physical work capacity during arm cranking, FES cycling, FES cycling combined with arm cranking and FES rowing. ariables were significantly lower for FES cycling versus ACE, FES cycling combined with ACE and FES rowing measures (P < 0.05). However there were no significant differences between ACE, FES cycling combined with ACE and FES rowing.

CONCLUSIONS

Preliminary results suggest that the ROWSTIM is as effective an exercise device or training tool for persons with SCI as ACE or combined FES-cycling and ACE, and more effective than FES-cycling. A larger sample size and further technological developments of the ROWSTIM are needed to demonstrate the efficacy of rowing over other hybrid exercise modalities and ACE.

Consistency of within-cycle torque distribution pattern in hand cycling

This investigation studied the consistency of the within-cycle torque pattern in hand cycling (1) in subsequent cycles, (2) between different individuals, (3) between different power output levels, and (4) with respect to fatigue. Ten nondisabled male participants performed a progressive peak arm crank ergometry test; a number of 5-minute submaximal tests at 10, 20, 30, and 40 W; and one 15-minute submaximal test at 80% to 90% of their peak heart rate. A hand cycle unit attached to a computerized motor allowed for power output adjustments and registered position and torque. Variation coefficients were calculated and averaged for evaluation of the pattern consistency. Values were 2.7% to 3.9% for subsequent cycles, 3.2% to 5.3% between participants, 2.8% between different power output levels, and 3.1% with respect to fatigue. These results indicate a consistent within-cycle torque distribution pattern for subsequent cycles that is minimally influenced by factors such as power output and fatigue.

Respiratory muscle training in persons with spinal cord injury: a systematic review

The purpose of this paper was to review the effectiveness of respiratory muscle training (RMT) on respiratory muscle strength and endurance, pulmonary function, quality of life, respiratory complications and exercise performance in persons with spinal cord injury. A MEDLINE (National Library of Medicine, Bethesda, MD, USA) database was used for selection of the literature (from 1980 to November 2004), and relevant references from peer-reviewed articles were retrieved as well. Studies investigating the effects of RMT (i.e. resistive breathing weight lifting or normocapnic hyperpnea) in persons with spinal cord injury were selected. Two independent reviewers investigated controlled studies for methodological quality by using a modification of the framework for methodological quality. Methodological quality ranged between 15 and 29 (maximal feasible score=40). Twenty-three papers were retrieved and six controlled trials were kept for further analysis. A meta-analysis and calculation of effect-size of each individual study and weighted summary effect-size was intended. However, unreported data and heterogeneity in outcome variables did not allow performing a meta-analysis. From the systematic review it is concluded that RMT tended to improve expiratory muscle strength, vital capacity and residual volume. Insufficient data was available to make conclusions concerning the effects on inspiratory muscle strength, respiratory muscle endurance, quality of life, exercise performance and respiratory complications.

Influence of Crank Rate in Hand Cycling

PURPOSE

The purpose of this study was to determine gross mechanical efficiency (ME) at different power output (PO) levels of synchronous hand cycling and to evaluate the influence of increasing PO by changing crank rate or resistance in wheelchair users with experience in hand cycling.

METHODS

Nine male participants with spinal cord injury randomly performed three maximal incremental hand cycling tests using a computer controlled cycle ergometer. Each test started at a PO level of 50 W with increments of 10 W. In the velocity protocol, PO was increased via crank rate while resistance was constant (VEL). In the resistance protocol PO was increased via resistance while crank rate was constant (RES). In the freely chosen frequency protocol, the participants could freely select their crank rate while resistance was automatically adjusted to obtain the desired PO (FCF).

RESULTS

Peak physiological responses were similar in all three tests, whereas PO max was lower in VEL compared with RES and FCF. Similar values for gross ME were found in both RES and FCF protocols, although systematically higher and increasing crank rates were adopted throughout FCF. Nevertheless, differences in gross ME at comparable relative (RES > VEL at 60 and 80% of PO range: 14.09 and 14.40% vs 13.02 and 13.11%, respectively) and absolute (RES, FCF > VEL at 90 W: 14.47, 14.47, and 13.43%, respectively) PO levels were demonstrated.

CONCLUSION

These results suggest that during synchronous hand cycling the freely chosen crank rate is not necessarily the most economical, that high crank rates result in a lower ME at a given PO and that freely chosen crank rates increase with increasing PO levels.

Wheelchair propulsion biomechanics: implications for wheelchair sports

The aim of this article is to provide the reader with a state-of-the-art review on biomechanics in hand rim wheelchair propulsion, with special attention to sport-specific implications. Biomechanical studies in wheelchair sports mainly aim at optimising sport performance or preventing sport injuries. The sports performance optimisation question has been approached from an ergonomic, as well as a skill proficiency perspective. Sports medical issues have been addressed in wheelchair sports mainly because of the extremely high prevalence of repetitive strain injuries such as shoulder impingement and carpal tunnel syndrome. Sports performance as well as sports medical reflections are made throughout the review. Insight in the underlying musculoskeletal mechanisms of hand rim wheelchair propulsion has been achieved through a combination of experimental data collection under realistic conditions, with a more fundamental mathematical modelling approach. Through a synchronised analysis of the movement pattern, force generation pattern and muscular activity pattern, insight has been gained in the hand rim wheelchair propulsion dynamics of people with a disability, varying in level of physical activity and functional potential. The limiting environment of a laboratory, however, has hampered the drawing of sound conclusions. Through mathematical modelling, simulation and optimisation (minimising injury and maximising performance), insight in the underlying musculoskeletal mechanisms during wheelchair propulsion is sought. The surplus value of inverse and forward dynamic simulation of hand rim stroke dynamics is addressed. Implications for hand rim wheelchair sports are discussed. Wheelchair racing, basketball and rugby were chosen because of the significance and differences in sport-specific movement dynamics. Conclusions can easily be transferred to other wheelchair sports where movement dynamics are fundamental.

Cutaneous vascular response and thermoregulation in individuals with paraplegia during sustained arm-cranking exercise

This study investigated whether a 60-minute arm-cranking exercise at 50% of the individual maximal power output would increase lower limb skin blood flow (laser Doppler flowmetry) in individuals with high-level (T5-T9; n = 6) and low-level paraplegia (T10-T12; n = 6), compared to 6 able-bodied controls. Significant (P < 0.05) group by time interactions (two-way repeated measures ANOVA) were found for leg cutaneous vascular conductance, leg skin temperature and esophageal temperature. Cutaneous vascular conductance increased to a peak of approximately 180% of pre-exercise rest in both paraplegic groups and to -436% in the control group, with differences after 15, 30, 45 and 60 minutes of exercise. Leg skin temperature increased by approximately 0.3 C in individuals with paraplegia and decreased by approximately 2.0 C in able-bodied. Esophageal temperature increases at the end of exercise were higher in individuals with paraplegia (approximately 0.9 C) than in able-bodied subjects (approximately 0.5 C). Heart rate was higher in the paraplegic groups than in able-bodied, whilst stroke volume and cardiac output were not different (impedance cardiography). The data suggest that lesion level had no influence on the results. These findings indicate that there is no excessive shunting of blood to the skin of the lower limbs of individuals with paraplegia during sustained exercise.

Central and peripheral haemodynamics in individuals with paraplegia during light and heavy exercise

The purpose of this study was to analyse lower leg skin blood flow (laser Doppler flowmetry) in five individuals with high-level paraplegia (T5-T9), six participants with low-level paraplegia (T10-T12) and six able-bodied controls during 3-minute light and heavy arm-cranking exercises (approximately 15% and 80% peak power output, respectively). Throughout light exercise, cutaneous vasoconstriction was shown for the control group (-20%), but not the low-level (+62%) or the high-level paraplegic group (+33%). During heavy exercise, vasoconstriction was initially found for controls followed by an increase in skin blood flow during the last 2 minutes, whereas the participants with paraplegia demonstrated skin blood flow increases. Skin blood flow responses were not related to lesion level. Metabolic parameters were not different among the three groups, but heart rates for participants with paraplegia were higher during heavy exercise than in controls. These results suggest impaired sympathetic vasoconstriction in individuals with paraplegia during exercise.

Blood distribution adaptations in paraplegics during posture changes: peripheral and central reflex responses

The veno-arteriolar reflex (VAR) in spinal-cord-injured subjects (SCI) has been attributed little interest, although it might contribute substantially to their blood redistribution. This peripheral reflex response, which is based on an axon reflex, consists of a reduction in limb blood flow following an increase in venal transmural pressure. The purpose of the present investigation was to assess the peripheral and central cardiovascular adaptations of paraplegics with high (HP) and low (LP) spinal lesions to subsequent, passive posture changes involving leg dependency and upright sitting, and to compare them to able-bodied (AB) subjects. Lower-limb cutaneous vascular conductance (CVC) was evaluated from skin blood flow measurements (laser Doppler flowmetry) taken from the dorsal foot, and from ankle blood pressure. Cardiac stroke volume, heart rate and myocardial performance were assessed using impedance cardiography and brachial blood pressure. During leg dependency, a significant vasoconstriction was noted in all three groups. The initial decrease in CVC was higher in HP (-76.82%) than in AB (-45.82%), the values for LP (-67.08%) lying in between these two (significant group x time interaction: F = 2.832; P = 0.042). There were no differences for parameters of central hemodynamics. No between-group differences were noted in any parameter tested during upright sitting. CVC remained at a similar low level as compared to leg dependency, stroke volume decreased, heart rate and blood pressure increased, and myocardial performance remained constant. The present results suggest that paraplegics have a peripheral VAR in their paralyzed lower limbs, and that this contributes to their cardiovascular stability.