Workplace social support, mental health and work functioning among young workers

Background

Young adults with a history of mental health problems (MHPs) report lower work functioning (WF) compared to their peers without a history of MHPs. The identification of modifiable, protective workplace factors, such as workplace social support, is needed to increase WF.We examined the moderating role of workplace social support from supervisors and co-workers in the prospective association between MHP trajectories from childhood to young adulthood and WF among young adults.

Methods

The most recent 2019/2020 data of N = 861 young workers, participating in the 18-year follow-up Dutch TRAILS (TRacking Adolescents’ Individual Lives Survey) cohort study, was used. MHP trajectories for internalising and externalising problems included measurements at ages 11, 13, 16, 19, 22 and 26. Supervisor and co-worker social support were measured at age 29. WF was assessed at age 29. Logistic regression analyses were conducted to examine the moderating role of workplace social support in the association between MHP trajectories and WF.

Results

Four trajectories were identified for both internalising and externalising problems. Young adults with high-stable MHP trajectories reported more often low WF (ORs 3.73 (95% CI 2.28-6.12) and 2.88 (1.78-4.65) for internalising and externalising problems respectively) than those with low-stable trajectories. Higher supervisor and co-worker social support were associated with a lower odds for low work functioning (adjusted ORs ranging from 0.67 (0.54-0.83) to 0.84 (0.71-1.00)). No moderating effect of workplace social support was found for the association between MHP trajectories and WF.

Conclusions

Both supervisor and co-worker support were shown to be important for all young workers, regardless their history of mental health problems. Occupational health professionals should create awareness among employers and employees that workplace social support is beneficial for young adults’ work functioning.

Key messages

• Both supervisor and co-worker social support are important for all young workers’ work functioning, regardless of their history of mental health problems.

• Creating awareness of the impact of workplace social support on young adults’ work functioning among employers and employees should be a priority area for occupational health practice and policy.

Abstract P1-15-20: DIetary REstriction as an adjunct to neoadjuvant ChemoTherapy for HER2-negative breast cancer: Final results from the DIRECT trial (BOOG 2013-04)

Background:

Short term fasting (STF) protects from toxicity, while enhancing the efficacy of chemotherapy in cancer bearing mice and is a promising strategy to enhance the efficacy and tolerability of chemotherapy in humans. A specifically designed low calorie, low amino acid substitution diet (“Fasting Mimicking Diet”, FMD) has similar effects in vivo during chemotherapy as STF. The DIRECT trial evaluates the impact of FMD on toxicity and efficacy of neoadjuvant chemotherapy in women with HER2-negative early breast cancer.

Patients and methods:

Eligible patients had histologically confirmed, HER2-negative, stage II/III early breast cancer, adequate bone marrow, liver and renal function, BMI > 19kg/m2 and absence of diabetes mellitus. Women receiving 8 neo-adjuvant AC-T courses (adriamycin/cyclophosphamide - docetaxel) or 6 FEC-T courses (5-fluorouracil, epirubicin and cyclophosphamide - docetaxel); day 1, q 3 weeks, were randomized to receive FMD or regular diet for 3 days prior to and at the day of chemotherapy and 3 days prior to surgery. The FMD group received no dexamethasone during the AC or FEC courses. The primary endpoint of the phase II part was feasibility and grade III/IV toxicity and of the phase III pathological complete response (pCR) rate. Additionally, in a side study increase in DNA damage in lymphocytes before and three hours after chemotherapy was compared between the 2 arms.

Results

From February 2014 to January 2018 131 patients from 11 participating Dutch centers were randomized, whereof 100 received AC-T and 31 received FEC-T. Sixty-six of the patients received FMD. Compliance to the diet was low as 32% fasted at least half of the cycles and 24% of patients fasted during all of cycles. The main reasons of non-compliance were food aversion induced by chemotherapy and the taste of the diet. Intention to treat grade III/IV toxicity was not significantly different between the standard arm (67,2%) and in the FMD arm (79,4%), although the majority of the toxicities in the FMD arm were assessed in patients that did not complete the FMD diet preceding the measurements. The total overall pCR rate was 12,8%, lower than assumed in the sample size calculation and would therefore need minimally a doubling in patient numbers to be able to reach the expected pCR difference between both arms. Due to the poor compliance, slow accrual rate and low overall pCR rate the DIRECT study terminated after completion of the phase II part. Subgroup analysis will be presented at SABCS. In a side study, DNA damage after chemotherapy was significantly less increased in lymphocytes in the FMD group as compared to the control group (p=0.043).

Conclusion

The effect of STF on toxicity and efficacy of chemotherapy was not established due to poor compliance, however STF by FMD reduced a transient increase in chemotherapy induced DNA damage. Close monitoring of patients by nutritionists with expertise in low calorie diets as well as diets with a more variable taste are probably needed to successfully examine the impact on adverse effects and tumor biology.

Citation Format: de Groot S, Lugtenberg RT, Welters MJ, Ehsan I, Vreeswijk MP, Smit VT, de Graaf H, Heijns JB, Portielje JE, van de Wouw AJ, Imholz AL, Kessels LW, Vrijaldenhoven S, Baars A, Meershoek-Klein Kranenbarg E, Duijm-de Carpentier M, van Leeuwen-Stok E, Putter H, Longo VD, van der Hoeven JJ, Nortier JW, Pijl H, Kroep JR. DIetary REstriction as an adjunct to neoadjuvant ChemoTherapy for HER2-negative breast cancer: Final results from the DIRECT trial (BOOG 2013-04) [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P1-15-20.

Is Fitbit Charge 2 a feasible instrument to monitor daily physical activity and handbike training in persons with spinal cord injury? A pilot study

Study design

It is a longitudinal pilot study.

Objectives

To investigate the feasibility of a low-cost and widely used fitness tracker with step count and heart rate data to monitor daily physical activity in wheelchair users with spinal cord injury (SCI).

Setting

Dutch community.

Methods

Six participants with SCI who were in training for a handbike event were recruited. They were asked to wear a Fitbit Charge 2^® 24 h a day for at least 2 weeks and were questioned about the utility and user-friendliness of this device.

Results

Five out of six participants managed to wear the device nonstop for 2 weeks, and continued to wear the device after this initial period. Most participants were enthusiastic about the direct feedback provided by the tracker and reported the data to be accurate. Data collected during more than 2 months of three participants and during 8 months on one of them showed the possibility of detecting training days and observing interpersonal and intrapersonal variation in daily physical activity level.

Conclusions

A commercially available, low-cost, self-monitoring multi-sensor wrist device or a fitness tracker like the Fitbit Charge 2^® can be a promising instrument to monitor daily activity levels among wheelchair users with SCI. The free commercial dashboard and log data clearly show trends of variations in physical activity and increases in heart rate, which are of value to both researchers and clinicians interested in identifying training schedules of wheelchair athletes.

Health-related quality of life and its determinants in patients with metastatic renal cell carcinoma

PURPOSE

Based on improvements of progression-free survival (PFS), new agents for metastatic renal cell carcinoma (mRCC) have been approved. It is assumed that one of the benefits is a delay in health-related quality of life (HRQoL) deterioration as a result of a delay in progression of disease. However, little data are available supporting this relationship. This study aims to provide insight into the most important determinants of HRQoL (including progression of disease) of patients with mRCC.

METHODS

A patient registry (PERCEPTION) was created to evaluate treatment of patients with (m)RCC in the Netherlands. HRQoL was measured, using the EORTC QLQ-C30 and EQ-5D-5L, every 3 months in the first year of participation in the study, and every 6 months in the second year. Participation started as soon as possible following a diagnosis of (m)RCC. Random effects models were used to study associations between HRQoL and patient and disease characteristics, symptoms and treatment.

RESULTS

Eighty-seven patients with mRCC completed 304 questionnaires. The average EORTC QLQ-C30 global health status was 69 (SD, 19) before progression and 61 (SD, 22) after progression of disease. Similarly, the average EQ-5D utility was 0.75 (SD, 0.19) before progression and 0.66 (SD, 0.30) after progression of disease. The presence of fatigue, pain, dyspnoea, and the application of radiotherapy were associated with significantly lower EQ-5D utilities.

CONCLUSIONS

Key drivers for reduced HRQoL in mRCC are disease symptoms. Since symptoms increase with progression of disease, targeted therapies that increase PFS are expected to postpone reductions in HRQoL in mRCC.

A Comparison of Methods for the Estimation of Body Composition in Highly Trained Wheelchair Games Players

The purpose of this study was to assess the agreement in body composition measurements of wheelchair athletes using skinfolds, bio-impedance analysis (BIA) and air displacement plethysmography (ADP) relative to dual-energy X-ray absorptiometry (DXA). A secondary objective was to develop new skinfold prediction equations to estimate %fat for this sample. 30 wheelchair games players were recruited and the body composition outcomes of BIA, ADP, and skinfolds were compared to the DXA outcomes by a paired-samples t-test (systematic bias), intraclass correlation (ICC, relative agreement) and Bland-Altman plots (absolute agreement). Regression models to predict the %fat as measured by DXA by the sum of skinfolds or BIA were calculated. Results showed that the predictions of %fat when using BIA, ADP or skinfolds systematically underestimated the %fat mass as measured by the DXA. All ICC values, except for the measurement of fat (kg) by ADP (ICC=0.702), were below 0.7. New prediction models found the ∑7 skinfolds and calf circumference as the best model to predict %fat (R(2)=0.84). In conclusion, BIA, ADP and existing skinfolds equations should be used with caution when estimating %fat of wheelchair athletes with substantial body asymmetry, lower body muscular atrophy and upper body muscular development.

Abstract P3-07-54: Insulin-like growth factor 1 receptor expression and polymorphism are associated with response to neoadjuvant chemotherapy in breast cancer patients: Results from the NEOZOTAC trial (BOOG 2010-01)

Background

The insulin-like growth factor 1 (IGF-1) pathway is involved in cell growth, proliferation and cell cycle progression and associated with tumor genesis and therapy resistance. This study aims to elucidate whether variation in the IGF-1 pathway is predictive for pathologic response in early breast cancer (BC) patients taking part in the phase III NEOZOTAC trial, randomizing between 6 cycles of neoadjuvant TAC chemotherapy with or without zoledronic acid.

Method

Formalin-fixed paraffin-embedded (FFPE) tissue samples of pre-chemotherapy biopsies and operation specimens were collected for analysis of IGF-1 receptor (IGF-1R) expression using IHC (n=216) and for analysis of 8 candidate SNPs in genes of the IGF-1 pathway (n=184) using OpenArray® RealTime PCR. Optionally, blood samples were collected immediately before chemotherapy for determination of glucose, insulin, IGF-1, IGF-2 and IGF-BP3. Associations with patient and tumor characteristics and chemotherapy response according to Miller and Payne (MP) pathologic response were performed using chi square and logistic regression analyses.

Results

High IGF-1R expression was associated with estrogen receptor expression (P=0.001). During chemotherapy, a significant number of the tumors (47.2%) showed a decrease in IGF-1R expression, while in a small number of the tumors an upregulation was seen (15.1%). IGF-1R expression before treatment was not associated with pathological response, however absence of IGF-1R expression after treatment was associated with a better response in multivariate analyses (P=0.012) and patients with a decrease in expression during treatment showed a better response to chemotherapy as well (P=0.008). Moreover, the variant T allele of 3129G>T in IGF-1R (rs2016347) was associated with a better pathological response in multivariate analyses (P=0.032). In addition, high glucose and insulin levels were associated with positive lymph node status before chemotherapy in multivariate analysis (P=0.019) and (P=0.031), respectively.

Conclusion

Neoadjuvant chemotherapy induced changes in the IGF-1R expression in most of the tumors. Absence or diminished expression of IGF-1R after treatment was associated with a better pathological response. Additionally, we found a SNP (rs2016347) in IGF-1R as a potential predictive marker for chemotherapy efficacy in BC patients treated with TAC. These findings may help to select patients who might benefit from (co-)treatment with an IGF-1 pathway inhibitor.

Citation Format: de Groot S, Charehbili A, van Laarhoven HWM, Mooyaart AL, Dekker-Ensink NG, van de Ven S, Janssen LGM, Swen JJ, Smit VTHBM, Heijns JB, Kessels LW, van der Straaten RJHM, Bhringer S, Gelderblom AJ, van der Hoeven JJM, Guchelaar HJ, Pijl H, Kroep JR. Insulin-like growth factor 1 receptor expression and polymorphism are associated with response to neoadjuvant chemotherapy in breast cancer patients: Results from the NEOZOTAC trial (BOOG 2010-01). [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P3-07-54.

Exploratory analysis of candidate germline gene polymorphisms in breast cancer patients treated with neoadjuvant anthracycline-containing chemotherapy and associations with febrile neutropenia

AIM

SNPs may be associated with (side) effects of chemotherapy and may be useful as biomarkers to predict febrile neutropenia.

PATIENTS & METHODS

187 DNA samples extracted from formalin-fixed paraffin-embedded tissue from patients with stage II/III HER2-negative breast cancer were genotyped.

RESULTS

Candidate SNPs were selected and explored for association with febrile neutropenia and/or pathological complete response. TT genotype of 388 C>T in FGFR4 (rs351855) had a tendency toward higher incidence of febrile neutropenia during neoadjuvant chemotherapy, compared with the CT (p = 0.383) genotype and compared with the CC genotype (p = 0.068).

CONCLUSION

The TT genotype of 388 C>T FGFR4 may be related to incidence of febrile neutropenia during neoadjuvant TAC (docetaxel, doxorubicin, cyclophosphamide) chemotherapy and is possibly useful as a patient-related risk factor when assessing febrile neutropenia risk. Original submitted 23 January 2015; Revision submitted 26 May 2015.

Abstract P3-06-50: Thyroid function is associated with the response to neoadjuvant chemotherapy in breast cancer patients: Results from the NEOZOTAC trial on behalf of the Dutch Breast Cancer Research Group (BOOG 2010-01)

Background: Thyroid hormones, regulators of metabolism and development in healthy tissue, stimulate tumor growth in vitro and are associated with breast cancer risk. We investigated the effect of chemotherapy on thyroid function and the extent to which it can predict the pathological response in patients with HER2 negative stage II/III breast cancer taking part in the NEOZOTAC phase III trial, randomizing between 6 cycles of neoadjuvant TAC chemotherapy with or without additional zoledronic acid. Moreover, we examined the impact of thyroid function on chemotherapy toxicity.

Methods: Serum samples of 38 of the 105 patients who participated in the side study of the NEOZOTAC trial were available for analyses. Serum free thyroxin (fT4) and thyroid stimulating hormone (TSH) levels were measured at baseline and compared with fT4 and TSH levels before the 2nd and 6th chemotherapy cycle. FT4 and TSH levels were also compared between subjects with and without pathological complete response (pCR). The relation between toxicity, per side effect of any CTC grade, and the variation in fT4 and TSH levels during chemotherapy was tested.

Results: Serum samples at baseline, before the 2nd chemotherapy cycle and at end of treatment were available for 31, 30 and 21 patients, respectively. In the total population, the mean baseline fT4 level was 16,0pmol/L and the mean TSH level 1,11mU/L. There were no differences between subjects solely treated with TAC chemotherapy and subjects treated with zoledronic acid as an adjunct to TAC with respect to the mean fT4 and TSH at each time point. Baseline TSH levels tended to be higher in patients who achieved pCR (p=0.035 univariate analysis and p=0.074 multivariate analysis) (Table 1). During 6 cycles of chemotherapy, fT4 levels decreased (p<0.000) and TSH levels increased significantly (p=0.019). Interestingly, the decrease of fT4 was significantly greater in patients without nausea, vomiting or sensory neuropathy, than in patients with those side effects (p=0.037, p=0.043 and p=0.050 respectively).

CharacteristicUnivariate analysisMultivariate analysis OR95%CIP valueOR95%CIP valueN stage: N0 vs. N+0.330.03-3.640.368T stage: <5cm vs. >5cm0.330.03-3.630.333ER receptor: Pos vs. Neg2.560.20-33.10.473fT40.780.43-1.420.4170.660.33-1.290.581TSH3.241.09-9.700.03517.30.76-3910.074Table 1. Univariate and multivariate logistic regression models of baseline characteristics and TSH and fT4 predictive of pCR.

Conclusion: TSH levels at baseline were higher in breast cancer patients with pCR. Chemotherapy blunts thyroid function, and a large decline of fT4 was associated with less side effects. These data suggest that thyroid hormones may interact with chemotherapy to modulate treatment (side-) effects in patients with breast cancer.

Citation Format: S de Groot, A Charehbili, L GM Janssen, E M Dijkgraaf, V THBM Smit, L W Kessels, A van Bochove, H WM van Laarhoven, E Meershoek-Klein Kranenbarg, A E van Leeuwen-Stok, G J Liefers, C JH van de Velde, J WR Nortier, J JM van der Hoeven, H Pijl, J R Kroep. Thyroid function is associated with the response to neoadjuvant chemotherapy in breast cancer patients: Results from the NEOZOTAC trial on behalf of the Dutch Breast Cancer Research Group (BOOG 2010-01) [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P3-06-50.

Hair follicle bulge cultures yield class III β-tubulin-positive melanoglial cells

Class III β-tubulin (TUBB3)-positive cells from the hair follicle bulge are thought to be neuronal cells derived from a local neural crest stem cell. However, TUBB3 has recently been shown to be expressed in the melanocytic lineage. To evaluate the neural-crest-associated immunophenotype of TUBB3-positive cells from hair follicle bulge explants, we dissected hair follicle bulges out from mouse whisker pads and cultured for 1 month and assessed outgrowing cells by means of immunocytochemistry using the biomarkers TUBB3, nestin, NGFR, SOX9, TYRP1 and laminin. Large amounts of TUBB3-positive cells could be cultured that co-expressed nestin, NGFR, SOX9 and, to a lesser degree, TYRP1, matching a melanoglial phenotype. In addition, a small population of TUBB3-negative but laminin-positive cells was found, which presumably are of glial origin. It can be concluded that cells of melanoglial origin can easily be obtained from hair follicle bulge explants. These cells may be of use in experimental animal or human disease and wound healing models. Notably, the TUBB3-positive cells are of melanoglial rather than neuronal origin.

Abstract P4-16-12: CARE: A pilot study of the effects of short-term fasting on tolerance to (neo) adjuvant chemotherapy in breast cancer patients

Background:

Preclinical evidence shows that short-term fasting (STS) protects normal cells and makes cancer cells more vulnerable to chemotherapy. This pilot study examines the feasibility and the effects of STS on tolerance to chemotherapy in patients with breast cancer.

Patients and methods:

Eligible patients had histologically confirmed, HER2-negative, early stage breast cancer and adequate bone marrow, liver and renal function. Women receiving (neo) adjuvant TAC courses (docetaxel/adriamycin/cyclophosphamide; day 1, q 3 weeks with G-CSF support at day 2) were randomized to fast 24 hours before and 24 hours after start of chemotherapy or to eat according to the guideline for healthy nutrition. The primary endpoint of the study was to compare neutrophil count after therapy. Secondary endpoints were side effects of chemotherapy, other hematologic counts and chemotherapy-induced DNA damage in leukocytes.

Results:

A total of 13 patients were included of which 7 patients fasted for 48 hours around the chemotherapy infusion (arm A) and 6 patients had a normal diet according to healthy nutrition guidelines (arm B). The median age was 52 years versus 53 years, BMI was 25.5 kg/m2 versus 22.9 kg/m2 and stage III was 43% versus 17% of patients in arms A and B, respectively. Patients were generally motivated to fast and the fasting was well tolerated. Plasma glucose levels were significant lower in fasting patients compared to controls. However, other metabolic parameters showed no significant difference. Fasting did not result in significant differences in neutrophil count or side effects of chemotherapy. Hemoglobin levels and erythrocyte counts after therapy were significantly higher in patients who fasted. Leukocytes of the patients which were isolated at various time points during therapy will soon be analysed for chemotherapy-induced DNA damage and presented at San Antonio.

Conclusion:

This is the first study evaluating the feasibility of 48 hours STS and its impact on side effects of chemotherapy in a homogeneous group of cancer patients. STS was well tolerated and had a beneficial effect on hemoglobin level, but not on experienced side effects. DNA analysis will follow. Larger studies are required to produce more insight into the possible benefits of STS during chemotherapy.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P4-16-12.

Abstract OT3-1-03: DIRECT: A phase II/III randomized trial with dietary restriction as an adjunct to neoadjuvant chemotherapy for HER2-negative breast cancer

Background:

Preclinical evidence shows that short-term fasting protects normal cells, while cancer cells are sensitized to chemotherapy. Furthermore, a specifically designed very low calorie, low amino acid substitution diet (“Fasting Mimicking Diet”, FMD) has similar effects on chemotherapy as short-term fasting. This trial evaluates the impact of FMD on tolerance to and efficacy of neoadjuvant chemotherapy in women with HER2-negative early breast cancer.

Trial design:

DIRECT is a Dutch, randomized, open-label multicenter phase II/III trial. Women receiving neoadjuvant TAC courses (docetaxel/adriamycin/cyclophosphamide; day 1, q 3 weeks with G-CSF support at day 2) will be randomized with or without FMD for 3 days prior to and the day of chemotherapy and 3 days prior to surgery.

Eligibility criteria:

Eligible women are WHO 0-2, age ≥18 years, HER2-negative, stage II or III breast cancer and adequate bone marrow, liver and renal function, BMI > 19kg/m2 and absence of diabetes mellitus.

Study endpoints:

The primary endpoints are grade III/IV toxicity (phase II) and the pathologic complete response rate (pCR) (phase III). Secondary endpoints are grade I/II toxicity, metabolic and inflammatory response to chemotherapy, DNA damage, apoptosis, immunology and nutrient sensing pathways in the tumor, biomarkers as single nucleotide polymorphisms, Ki67 and tumor stroma/ratio, patient's quality of life and (disease free) survival. Optional side studies include chemotherapy-induced DNA damage and nutrient sensing pathways in leukocytes and proteomics.

Statistical Methods:

Using a 5% significance level based on the two-sided Fisher's exact test with a power of 80%, 128 patients (64/arm) will be enrolled to show a 50% decrease of grade III/IV adverse events in the experimental arm (phase II) and 250 patients (125/arm) are needed to show an improvement of the pCR rate from 18% to 36% (phase III).

Target accrual:

Recruitment will start in September 2013. The expected end of accrual of 250 patients from multiple centers in the Netherlands will be the last quarter of 2015.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr OT3-1-03.

Arm hand skilled performance in persons with a cervical spinal cord injury--long-term follow-up

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

To assess development of arm hand skilled performance (AHSP) during and after in-patient rehabilitation in persons with cervical spinal cord injury (CSCI) and to determine factors that influence the outcome.

SETTING

Eight rehabilitation centres in the Netherlands with specialised spinal cord injury departments.

METHODS

AHSP was assessed using the Van Lieshout test (VLT) in persons admitted with recent CSCI. Assessment was carried out at the beginning (t1), after 3 months (t2), at the end (t3) of in-patient rehabilitation, and 1 and 5 years thereafter (t4, t5). Multilevel regression analysis was performed to determine development of AHSP and associations between AHSP and age, gender, motor completeness, lesion level (high or low CSCI), motor scores of upper extremity (MSUE), and pain in the tested arm.

RESULTS

Fifty-five participants were included with mean age 38 years (range 18–64). There were 73% male, 80% had high CSCI (C3–C6) and 69% had motor complete lesion. Scores of VLT improved significantly during in-patient rehabilitation (mean: t1=25; t3=33) (P=0.005), scores remained unchanged at 1 year (t4=32) and 5 years (t5=32) (P=0.903) after in-patient rehabilitation. Motor completeness, MSUE and pain were significantly related to the VLT score (P<0.001, P<0.001, P=0.015, respectively). Age, gender and lesion level had no significant relationship.

CONCLUSION

AHSP improved during in-patient rehabilitation. It was then stable during the next 5 years after discharge. Persons with an incomplete lesion, high MSUE and no pain in the tested arm perform best on the VLT.

Gluteal blood flow and oxygenation during electrical stimulation-induced muscle activation versus pressure relief movements in wheelchair users with a spinal cord injury

BACKGROUND

Prolonged high ischial tuberosities pressure (IT pressure), decreased regional blood flow (BF) and oxygenation (%SO2) are risk factors for developing pressure ulcers (PUs) in patients with spinal cord injury (SCI). Electrical stimulation (ES)-induced gluteal and hamstring muscle activation may improve pressure distribution by changing the shape of the buttocks while sitting and also increase BF and %SO2.

OBJECTIVE

To compare acute effects of ES-induced gluteal and hamstring muscle activation with pressure relief movements (PRMs) on IT pressure, BF and %SO2.

PARTICIPANTS AND METHODS

Twelve men with SCI performed PRMs - push-ups, bending forward and leaning sideward - and received surface ES (87±19 mA) to the gluteal and hamstring muscles while sitting in their wheelchair. Ischial tuberosities pressure was measured using a pressure mapping system; (sub)cutaneous BF and %SO2 were measured using reflection spectroscopy and laser Doppler, respectively.

RESULTS

Compared with rest (156±26 mm Hg), IT pressure was significantly lower during all other conditions (push-ups 19±44; bending forward 56±33; leaning sideward 44±38; ES 67±45 mm Hg). For the whole group, all PRMs significantly augmented BF (+39 to -96%) and %SO2 (+6.0 to -7.9%-point), whereas ES-induced muscle activation did only for peak BF. In all, 63% of the participants showed an increased BF (average 52%) with ES.

CONCLUSION

PRMs acutely reduced IT pressure and improved oxygenation and BF in SCI. The currently used ES method cannot replace PRMs, but it may be used additionally. ES-induced muscle activation is not as effective for acute pressure relief, but the frequency of stimulation is much higher than the performance of PRMs and can therefore be more effective in the long term.

Longitudinal association between lifestyle and coronary heart disease risk factors among individuals with spinal cord injury

OBJECTIVE

To investigate: (1) the course of coronary heart disease risk factors (lipid profiles and body mass index (BMI)) in the first five years after discharge from inpatient spinal cord injury (SCI) rehabilitation and (2) the association between lifestyle (physical activity, self-care related to fitness, smoking, alcohol, body mass and low-fat diet) and coronary heart disease risk factors during that period.

DESIGN

Prospective cohort study.

PARTICIPANTS/METHODS

Individuals with SCI (N=130). Total cholesterol (TC), high-density lipoprotein (HDL), low-density lipoprotein (LDL), triglycerides (TG) and BMI were determined at discharge from inpatient rehabilitation and 1 and 5 years after discharge. Using multilevel regression models, the effects of lifestyle (drinking alcohol, smoking, active lifestyle and self-care) on the lipid profiles and BMI were determined.

RESULTS

After correction for lesion and personal characteristics, no changes in lipid profiles in the five years after discharge were seen, whereas the BMI increased significantly with 1.8 kg m(-2). A high percentage was at risk of cardiovascular disease due to high BMI (63-75%) or HDL (66-95%). The individuals who indicated to maintain their fitness level as good as possible and the individuals with a low BMI showed better lipid profiles. Individuals with a more active lifestyle showed higher HDL levels. Individuals who avoid smoking showed a 1.5 kg m(-2) higher BMI.

CONCLUSION

Lipid profiles seem to stabilize in the years after discharge from inpatient SCI rehabilitation, whereas the BMI increased. Lifestyle factors associated with a favorable lipid profile and BMI could be identified.

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

PURPOSE

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

METHOD AND DESIGN

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

CONCLUSION

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

Active LifestyLe Rehabilitation interventions in aging spinal cord injury (ALLRISC): a multicentre research program

BACKGROUND

With today's specialized medical care, life expectancy of persons with a spinal cord injury (SCI) has considerably improved. With increasing age and time since injury, many individuals with SCI, however, show a serious inactive lifestyle, associated with deconditioning and secondary health conditions (SHCs) (e.g. pressure sores, urinary and respiratory tract infections, osteoporosis, upper-extremity pain, obesity, diabetes, cardiovascular disease) and resulting in reduced participation and quality of life (QoL). Avoiding this downward spiral, is crucial.

OBJECTIVES

To understand possible deconditioning and SHCs in persons aging with a SCI in the context of active lifestyle, fitness, participation and QoL and to examine interventions that enhance active lifestyle, fitness, participation and QoL and help prevent some of the SHCs.

METHODS

A multicentre multidisciplinary research program (Active LifestyLe Rehabilitation Interventions in aging Spinal Cord injury, ALLRISC) in the setting of the long-standing Dutch SCI-rehabilitation clinical research network.

RESULTS

ALLRISC is a four-study research program addressing inactive lifestyle, deconditioning, and SHCs and their associations in people aging with SCI. The program consists of a cross-sectional study (n = 300) and three randomized clinical trials. All studies share a focus on fitness, active lifestyle, SHCs and deconditioning and outcome measures on these and other (participation, QoL) domains. It is hypothesized that a self-management program, low-intensity wheelchair exercise and hybrid functional electrical stimulation-supported leg and handcycling are effective interventions to enhance active life style and fitness, help to prevent some of the important SHCs in chronic SCI and improve participation and QoL.

CONCLUSION

ALLRISC aims to provide evidence-based preventive components of a rehabilitation aftercare system that preserves functioning in aging persons with SCI.

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

STUDY DESIGN

A prospective cohort study.

OBJECTIVES

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

SETTING

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

METHODS

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

RESULTS

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

CONCLUSION

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

Development and validation of prognostic models designed to predict wheelchair skills at discharge from spinal cord injury rehabilitation

Objective: To develop and validate a statistical model to predict wheelchair skills at discharge (t 2) from personal and lesion characteristics and wheelchair skills at the start of spinal cord injury inpatient rehabilitation (t1).

Design: Prospective cohort study

Setting: Eight Dutch rehabilitation centres.

Subjects: One hundred and forty-two patients with a spinal cord injury.

Main measures: Models were developed with the performance time and ability score at t2 as dependent variables and t1 scores of performance time and ability score, age, gender, body mass index, level and completeness of the lesion as independent variables. The statistical models were evaluated by comparing individual estimated scores with actual measured scores.

Results: The main independent variables to predict wheelchair skills at discharge were the t1 performance time and ability score, age, gender and lesion level. The intraclass correlation coefficient between the estimated and actual ability score was 0.79 and for the performance time 0.86. However, the 95% limits of agreement and their confidence intervals were relatively wide for both ability score (—2.3 to 3.4, range 0—8) and performance time (—12.5 to 8.2, range 11—40 seconds).

Conclusion: The prognostic models developed in this study to predict future wheelchair skills might help planning the course of rehabilitation. The models should be used with caution in daily clinical practice, but may add useful information to clinical expertise and knowledge of the individual patient.

Relationships between driving simulator performance and driving test results

This article is considered relevant because: 1) car driving is an everyday and safety-critical task; 2) simulators are used to an increasing extent for driver training (related topics: training, virtual reality, human-machine interaction); 3) the article addresses relationships between performance in the simulator and driving test results--a relevant topic for those involved in driver training and the virtual reality industries; 4) this article provides new insights about individual differences in young drivers' behaviour. Simulators are being used to an increasing extent for driver training, allowing for the possibility of collecting objective data on driver proficiency under standardised conditions. However, relatively little is known about how learner drivers' simulator measures relate to on-road driving. This study proposes a theoretical framework that quantifies driver proficiency in terms of speed of task execution, violations and errors. This study investigated the relationships between these three measures of learner drivers' (n=804) proficiency during initial simulation-based training and the result of the driving test on the road, occurring an average of 6 months later. A higher chance of passing the driving test the first time was associated with making fewer steering errors on the simulator and could be predicted in regression analysis with a correlation of 0.18. Additionally, in accordance with the theoretical framework, a shorter duration of on-road training corresponded with faster task execution, fewer violations and fewer steering errors (predictive correlation 0.45). It is recommended that researchers conduct more large-scale studies into the reliability and validity of simulator measures and on-road driving tests.

The longitudinal relationship between lipid profile and physical capacity in persons with a recent spinal cord injury

STUDY DESIGN

A multicenter prospective cohort study.

OBJECTIVE

To determine the longitudinal relationship between physical capacity and lipid profile in persons with spinal cord injury (SCI) during and 1 year after rehabilitation.

SETTING

Eight Dutch rehabilitation centers with a specialized SCI unit.

METHODS

A total of 206 subjects with SCI (78 with tetraplegia) participated. The longitudinal relationship between lipid profiles (total cholesterol (TC), high- (HDL) and low-density lipoprotein (LDL) and triglycerides (TG) and physical capacity (peak power output (POpeak), peak oxygen uptake (VO2peak), and muscle strength) was investigated during inpatient SCI rehabilitation (start, 3 months later, discharge) and 1 year after discharge. A correction was made for the possible confounding variables age, body mass index, gender, time since injury, lesion level and completeness.

RESULTS

HDL and the ratios LDL/HDL and TC/HDL showed a significant and favorable relationship with VO2peak, POpeak and muscle strength. TG was positively related to POpeak and muscle strength.

CONCLUSIONS

More favorable lipid profiles were seen in people with a higher physical capacity after correction for personal and lesion characteristics. Therefore, improving the physical capacity by being active during daily life or in sport may further improve the lipid profile and thus reduce the risk for coronary heart disease.

Mechanical Efficiency and Wheelchair Performance during and after Spinal Cord Injury Rehabilitation

The purpose of the present study was to investigate whether mechanical efficiency (ME) relates to wheelchair propulsion capacity and wheelchair performance tasks during and after rehabilitation of people with a spinal cord injury (SCI). Eighty participants with a SCI were tested during rehabilitation (3 x) and 1 year after discharge. Two 3-minute submaximal exercise blocks, a maximal wheelchair exercise test, and four wheelchair performance tasks were performed. ME, peak power output (PO (peak)), the sum of the performance times of a 15-m sprint and figure-of-eight, and the heart rate reserve (%HRR) during 10 s of wheelchair propulsion on a 3 % and 6 % slope were calculated. The relationship between ME and PO (peak), %HRR and performance time was tested with a multilevel regression analysis. ME showed a significant relationship with PO (peak) (p </= 0.002). A 1 % higher ME related to a 1.6 - 2.2 W higher PO (peak). ME of exercise block 2 was related to the sum of the performance times of a 15-m sprint and figure-of-eight; the tests were performed faster by participants with a higher ME. No relationship was found between ME and %HRR during wheelchair propulsion on a slope. ME showed a significant effect on wheelchair propulsion capacity and wheelchair performance time during and 1 yr after SCI rehabilitation although the isolated effect of ME is small.

[Restless legs due to ingestion of 'light' beverages containing saccharine. Results of an N-of-1 trial]

To determine whether there was a connection between the complaint of restless legs and the ingestion of artificial sweeteners in a patient with these symptoms after drinking certain 'light' beverages, a randomised, double-blind, placebo-controlled N-of-1 trial with a crossover design was used. During a period of 48 days, the patient took 4 capsules per day containing either 150 mg of cyclamate, 22.5 mg of saccharine, both sweeteners, or placebo on two successive days. Between each of these 2-day periods there was a 2-day rest period during which no capsules were taken. The hospital pharmacist had prepared the capsules and determined the sequence of the 2-day periods on a random basis. The patient did not know which capsules he was taking. Every day on arising, starting 3 weeks before the trial period, the patient noted the intensity and duration of the symptoms in the late evening and previous night. For this notation he used an 11-point scale, from 0 (= no restless legs) to 10 (= almost total inability to sleep because of restless legs). A score of 1-3 corresponded to mild symptoms that had no effect on the patient's sleep; at a score of 4-6 his sleep was disturbed and at a score of 7-10 the patient hardly slept at all. The patient had symptoms more often while using saccharine or the combination of saccharine and cyclamate than when taking the placebo (4 and 4 versus 2 of the 6 nights); moreover, the average score was then statistically significantly higher (5.2 and 5.8 versus 3-3). It was concluded that there was a connection between the patient's complaints of restless legs and the use of saccharine, but not the use of cyclamate.

[Restless legs due to ingestion of 'light' beverages containing saccharine; results of an N-of-1 trial]

OBJECTIVE

To determine whether there was a connection between the complaint of restless legs and the ingestion of artificial sweeteners in a patient with these symptoms after drinking certain 'light' beverages.

DESIGN

Randomised, double-blind, placebo-controlled N-of-1 trial with a cross-over design.

METHOD

During a period of 48 days, the patient took 4 capsules per day containing either 150 mg of cyclamate, 22.5 mg of saccharine, both sweeteners, or placebo on two successive days. Between each of these 2-day periods there was a 2-day rest period during which no capsules were taken. The hospital pharmacist had prepared the capsules and determined the sequence of the 2-day periods on a random basis. The patient did not know which capsules he was taking. Every day on arising, starting 3 weeks before the trial period, the patient noted the intensity and duration of the symptoms in the late evening and previous night. For this notation he used an 11-point scale, from 0 (= no restless legs) to 10 (= almost total inability to sleep because of restless legs).

RESULTS

A score of 1-3 corresponded to mild symptoms that had no effect on the patient's sleep; at a score of 4-6 his sleep was disturbed and at a score of 7-10 the patient hardly slept at all. The patient had symptoms more often while using saccharine or the combination of saccharine and cyclamate than when taking the placebo (4 and 4 versus 2 ofthe 6 nights); moreover, the average score was then statistically significantly higher (5.2 and 5.8 versus 3.3).

CONCLUSION

There was a connection between the patient's complaints of restless legs and the use of saccharine, but not the use of cyclamate.

Standardization of measuring power output during wheelchair propulsion on a treadmill

OBJECTIVE

In a multi-center study the power output of wheelchair propulsion, attained by a wheelchair drag test, differed among rehabilitation centers. The purpose of this study was to investigate what causes the differences in drag force among centers.

METHODS

A set of standardized drag tests was performed while systematically varying the calibration set of the force transducer, the tester and the wheelchair. In addition, the actual calibrated velocity and slope of the treadmill were measured.

RESULTS

Difference in drag force among centers was due to variation in wheelchair set-up and differences in the slopes between treadmills. The drag force was not significantly different when different testers performed the test. The belt velocity in almost all centers was lower than the manufacturer specified (assumed) velocity.

CONCLUSION

The drag test appeared a robust test as far as the tester is considered. Variation in wheelchairs and differences in the actual slopes of the treadmills affected the imposed drag force. The assumed velocity of the treadmill led to an overestimation of the power output. The power output in the multi-center study should be recalculated using the measured velocities and the wheelchair set-up should be more standardized.

Demographics of the Dutch multicenter prospective cohort study 'Restoration of mobility in spinal cord injury rehabilitation'

STUDY DESIGN

A multicenter prospective cohort study.

OBJECTIVE

To compare the demographic data of the included population with other studied spinal cord injury (SCI) populations in the international literature.

SETTING

Eight Dutch rehabilitation centers with a specialized SCI unit.

METHODS

A total of 205 individuals with SCI participated in this study. Information about personal, lesion and rehabilitation characteristics were collected at the beginning of active rehabilitation by means of a questionnaire.

RESULTS

The research group mainly consisted of men (74%), of individuals with a paraplegia (59%), and had a complete lesion (68%). The SCI was mainly caused by a trauma (75%), principally due to a traffic accident (42%). The length of clinical rehabilitation varied between 2 months and more than a year, which seemed to be dependent on the lesion characteristics and related comorbidity.

CONCLUSIONS

The personal and lesion characteristics of the subjects of the multi-center study were comparable to data of other studies, although fewer older subjects and subjects with an incomplete lesion were included due to the inclusion criteria 'age' and 'wheelchair-dependent'. The length of stay in rehabilitation centers in The Netherlands was longer compared to Denmark but much longer than in eg Australia and the USA.

Upper extremity musculoskeletal pain during and after rehabilitation in wheelchair-using persons with a spinal cord injury

STUDY DESIGN

Prospective cohort study.

OBJECTIVES

To study upper extremity musculoskeletal pain during and after rehabilitation in wheelchair-using subjects with a spinal cord injury (SCI) and its relation with lesion characteristics, muscle strength and functional outcome.

SETTING

Eight rehabilitation centers with an SCI unit in the Netherlands.

METHODS

Using a questionnaire, number, frequency and seriousness of musculoskeletal pain complaints of the upper extremity were measured. A pain score for the wrist, elbow and shoulder joints was calculated by multiplying the seriousness by the frequency of pain complaints. An overall score was obtained by adding the scores of the three joints of both upper extremities. Muscle strength was determined by manual muscle testing. The motor score of the functional independence measure provided a functional outcome. All outcomes were obtained at four test occasions during and 1 year after rehabilitation.

RESULTS

Upper extremity pain and shoulder pain decreased over time (30%) during the latter part of in-patient rehabilitation (P<0.001). Subjects with tetraplegia (TP) showed more musculoskeletal pain than subjects with paraplegia (PP) (P<0.001). Upper extremity pain and shoulder pain were significantly inversely related to functional outcome (P<0.001). Muscle strength was significantly inversely related to shoulder pain (P<0.001). Musculoskeletal pain at the beginning of rehabilitation and BMI were strong predictors for pain 1 year after in-patient rehabilitation (P<0.001).

CONCLUSIONS

Subjects with TP are at a higher risk for upper extremity musculoskeletal pain and for shoulder pain than subjects with PP. Higher muscle strength and higher functional outcome are related to fewer upper extremity complaints.

Influence of task complexity on mechanical efficiency and propulsion technique during learning of hand rim wheelchair propulsion

OBJECTIVE

To investigate the consequence of task complexity on gross mechanical efficiency and propulsion technique during the learning process of hand rim wheelchair propulsion.

METHODS

Three groups of unimpaired subjects (N=10 each) received a 3-week wheelchair practice period (3 week(-1), nine practice trials) with different levels of complexity, i.e. propelling a stationary wheelchair ergometer, wheelchair propulsion on a motor-driven treadmill or at a circular wheelchair track. During practice trials 1 and 9, gross mechanical efficiency and propulsion technique variables (work per cycle, cycle frequency, push and cycle time, effective force) were measured.

RESULTS

Using multi-level regression analysis, no differences in the development over time in mechanical efficiency and propulsion technique could be discerned between the three conditions of task complexity. Only the percentage push time during the cycle decreased significantly more in the group that practiced on the ergometer compared to the treadmill-practice group. For all three groups a change over time was shown for cycle frequency, push time and cycle time.

DISCUSSION

Under the current experimental conditions, task complexity does not have an influence on gross mechanical efficiency and propulsion technique during the learning process of wheelchair propulsion. The 3-week practice period had a favorable practice effect on timing regardless of the task complexity.

Effect of Wheelchair Stroke Pattern on Mechanical Efficiency

OBJECTIVE

To investigate the effect of different wheelchair stroke patterns on efficiency and propulsion technique (force application and timing).

DESIGN

Inexperienced, able-bodied subjects were randomly divided into two velocity groups (1.11 m/sec [n = 13] and 1.39 m/sec [n = 11]). An external (medium) load was set at 0.23 N/kg. Subjects performed four 4-min exercise blocks on a wheelchair ergometer. The first block was performed with a freely chosen movement pattern of the hand. Thereafter, the pumping, semicircular, or single-looping over propulsion pattern were performed in a counterbalanced order. Gross mechanical efficiency and propulsion technique variables were measured with Oxycon Alpha and an instrumented wheelchair ergometer.

RESULTS

A significant difference was found for mechanical efficiency, with pumping showing the highest efficiency and semicircular the lowest efficiency, regardless of velocity. Timing variables and negative power deflections before and after the push phase showed significant differences between the stroke patterns.

CONCLUSIONS

Pumping is the energetically most efficient stroke pattern in contrast to the semicircular pattern in this subject group. Propulsion technique could not explain the difference in efficiency.