Christof Smit

Evaluation of the physical activity scale for individuals with physical disabilities in people with spinal cord injury

Study design:Cross-sectional study.Objectives:To evaluate the physical activity scale for individuals with physical disabilities (PASIPD) in people with spinal cord injury (SCI).Setting:Eight Dutch rehabilitation centers with a specialized SCI unit.Methods:The PASIPD was examined by comparing group scores of people with different personal (age, gender and body mass index) and lesion characteristics (level (paraplegia/tetraplegia), completeness, time since injury (TSI)) in 139 persons with SCI 1 year after discharge from in-patient rehabilitation. Relationships between PASIPD scores and measures of activities (wheelchair skills, Utrecht Activity List, mobility range and social behavior subscales of the SIP68) and fitness (peak oxygen uptake, peak power output and muscular strength) were determined.Results:Persons with tetraplegia had significantly lower PASIPD scores than those with paraplegia (P<0.02). Persons with longer TSI had lower PASIPD scores than persons with shorter TSI (P<0.03). PASIPD scores showed moderate correlations with activities (0.36–0.51, P<0.01) and weak-to-moderate correlations with fitness parameters (0.25–0.36, P<0.05).Conclusion:In a fairly homogeneous group of persons with SCI, 1 year after in-patient rehabilitation, the PASIPD showed weak-to-moderate relationships with activity and fitness parameters. There seems to be a limited association between self-reported activity level and fitness in people with SCI.

The Effect of Surface Electric Stimulation of the Gluteal Muscles on the Interface Pressure in Seated People With Spinal Cord Injury

OBJECTIVE To study effects of surface electric stimulation of the gluteal muscles on the interface pressure in seated persons with spinal cord injury (SCI). DESIGN One session in which alternating and simultaneous surface electric stimulation protocols were applied in random order. SETTING Research laboratory of a rehabilitation center. PARTICIPANTS Thirteen subjects with SCI. INTERVENTION Surface electric stimulation of the gluteal muscles. MAIN OUTCOME MEASURES Interface pressure, maximum pressure, pressure spread, and pressure gradient for the stimulation measurement. Variables were compared using 2-tailed paired t tests. RESULTS Alternating and simultaneous stimulation protocol caused a significant (P<.01) decrease in interface pressure (-17+/-12 mmHg, -19+/-14 mmHg) and pressure gradient (-12+/-11 mmHg, -14+/-12 mmHg) during stimulation periods compared with rest periods. There was no significant difference in effects between the 2 protocols. CONCLUSIONS Surface electric stimulation of the gluteal muscles in persons with SCI causes a decrease in interface pressure. This might restore blood flow in compressed tissue and help prevent pressure ulcers.

Effects of electrical stimulation-induced gluteal versus gluteal and hamstring muscles activation on sitting pressure distribution in persons with a spinal cord injury.

Study design:Ten participants underwent two electrical stimulation (ES) protocols applied using a custom-made electrode garment with built-in electrodes. Interface pressure was measured using a force-sensitive area. In one protocol, both the gluteal and hamstring (g+h) muscles were activated, in the other gluteal (g) muscles only.Objectives:To study and compare the effects of electrically induced activation of g+h muscles versus g muscles only on sitting pressure distribution in individuals with a spinal cord injury (SCI).Setting:Ischial tuberosities interface pressure (ITs pressure) and pressure gradient.Results:In all participants, both protocols of g and g+h ES-induced activation caused a significant decrease in IT pressure. IT pressure after g+h muscles activation was reduced significantly by 34.5% compared with rest pressure, whereas a significant reduction of 10.2% after activation of g muscles only was found. Pressure gradient reduced significantly only after stimulation of g+h muscles (49.3%). g+h muscles activation showed a decrease in pressure relief (Δ IT) over time compared with g muscles only.Conclusion:Both protocols of surface ES-induced of g and g+h activation gave pressure relief from the ITs. Activation of both g+h muscles in SCI resulted in better IT pressure reduction in sitting individuals with a SCI than activation of g muscles only. ES might be a promising method in preventing pressure ulcers (PUs) on the ITs in people with SCI. Further research needs to show which pressure reduction is sufficient in preventing PUs.

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.

Prevention and treatment of pressure ulcers using electrical stimulation

Skin-related secondary disabilities, especially pressure ulcers, are a common problem for wheelchair users such as individuals with spinal cord injury (SCI), resulting in great discomfort and significant medical care costs. Pressure ulcers typically arise in areas of the body where prolonged pressure and shear forces are being exerted on soft tissue over bony prominences, such as the sacrum and the ischial tuberosities, inhibiting blood and oxygen supply and ultimately causing tissue ischaemia and necrosis. Individuals with SCI are at increased risk for pressure ulcers due to factors such as reduced mobility, reduced microcirculation, impaired sympathetic function, atrophy of the paralysed muscles, and a disturbed muscle pump function (also see Chap. 6). In addition, due to impaired sensation, individuals are often not aware of the necessity to relieve pressure. Although it has been shown that special cushioning systems can provide an improved redistribution of pressure, as has been reviewed in Chaps. 5 and 6, pressure ulcers still are prevalent in the SCI population. The predisposition of SCI patients with flaccid paralysis to ulcer development has been outlined in Chap. 5. It is theoretically possible that electrical stimulation (ES) and ES- induced exercise can help to reduce the risk of pressure ulcers, since they have been shown to increase muscle mass, capillary density and skin and muscle blood flow (BF). The first purpose of this chapter, therefore, is to discuss how ES can contribute to reduction of pressure ulcer risk and pressure ulcer incidence. The second purpose is to evaluate how ES can be helpful in pressure ulcer healing once preventative measures have failed.

Impact of health problems secondary to SCI one and five years after first inpatient rehabilitation

Study design:This is a multicenter prospective cohort study.Objectives:The objective of this study was to describe and compare the impact of health problems secondary to spinal cord injury (SCI) on functioning at home and on social activities at 1 and 5 years after discharge from first inpatient rehabilitation.Setting:The study was conducted in a Dutch community.Methods:Participants with SCI who use a wheelchair for everyday mobility (N=110) completed a self-report questionnaire as part of a larger cohort study including four items on extra time needed (body care, bladder and bowel regulation, ‘organization’ and transportation) and impact of 10 health problems on functioning at home and on social activities. The 10 health problems include secondary health conditions (bladder regulation, bowel regulation, decubitus, pain, spasticity, gain in body weight and edema), psychosocial problems (sexuality, having difficulty with being dependent on help from others) and handicap management.Results:Median extra time needed for self-management and transportation was not significantly higher 1 year after discharge (16 (IQR 13.5) h per week) compared with 5 years after discharge (13 (IQR 17) h per week) (P=0.925). Participants reported slightly less impact, comparing the severity sum-score (range 10–50) of the 10 health problems on functioning at home and in social activities, 5 years post discharge (20 and 17, respectively) than 1 year post discharge (21 and 18, respectively; P<0.05). Most frequently mentioned health problems were handicap management, being dependent on help from others, bladder regulation, bowel regulation, pain and sexuality.Conclusions:The impact of health problems after SCI is considerable and hardly diminishes over time. These results emphasize the need for structured long-term care for people with SCI.

Wheelchair-specific fitness of persons with a long-term spinal cord injury : cross-sectional study on effects of time since injury and physical activity level

Abstract Purpose: To study the impact of time since injury (TSI) and physical activity (PA) on fitness of persons with spinal cord injury (SCI). Method: Cross-sectional study. Persons with SCI (N = 158) in three TSI strata: 10–19, 20–29 and ≥30 years after SCI and divided in an active and inactive group. Fitness [peak power output (POpeak) and peak oxygen uptake (VO2peak)] was assessed. Results: In persons with tetraplegia, no significant relationship was found between TSI and fitness after controlling for confounders, while a higher activity level was related to a higher POpeak in this group. Active people with tetraplegia also showed less decline in POpeak with an increase in TSI compared to inactive people. In persons with paraplegia, after controlling for confounders, it was shown that TSI had a negative effect on POpeak, while PA was not significantly associated with fitness in people with paraplegia. Conclusions: In people with paraplegia, fitness was significantly lower in those with a longer TSI. Persons with a long TSI might need more attention to remain fit and PA might be an important element in that respect as shown by the results of the group with a tetraplegia. Implications for Rehabilitation Wheelchair-specific fitness seems to diminish over time after paraplegia. An active lifestyle is related to wheelchair-specific fitness in persons with tetraplegia. Prevention of long-term deconditioning is very important.

Electromechanical abdominal massage and colonic function in individuals with a spinal cord injury and chronic bowel problems

Study Design:A prospective intervention of noninvasive abdominal massage using an electromechanical apparatus on bowel function in individuals with spinal cord injury (SCI).Objectives:To evaluate the effects of noninvasive abdominal massage using an electromechanical apparatus on bowel function in individuals with SCI and chronic bowel problems. This easy-to-use apparatus can be applied by the patients at home without the help of a therapist.Setting:Homes of community-living individuals.Methods:Twenty-one subjects with SCI were instructed to use the massage apparatus daily for 20 min during a 10-week period. Compliance, effects, side effects and user satisfaction were assessed using questionnaires.Results:Fifteen subjects completed the 10-week period. Although some characteristics of defecation changed positively for some of the subjects (time to result, amount, consistency), none felt better or more confident after using the massage device. In addition, some individuals experienced negative side effects (predominantly pain or discomfort). The overall satisfaction with the device is ambiguous, with half of the group judging the device as insufficient and the other half as at least adequate.Conclusion:The use of an electromechanical massage device does not improve bowel function in most individuals with SCI who have chronic bowel problems. Why some subjects benefit and others do not should be investigated in future studies.

The Influence of Time and Adaptation on Health State Valuations in Patients With Spinal Cord Injury

Objectives: One of the explanations for the difference between health state utilities elicited from patients and the public—often provided but seldom studied—is adaptation. The influence of adaptation on utilities was investigated in patients with spinal cord injury. Methods: Interviews were held at 3 time points (T1, after admission to the rehabilitation center; T2, during active rehabilitation; T3, at least half a year after discharge). At T1, 60 patients were interviewed; 10 patients withdrew at T2 and T3. At all time points, patients were asked to value their own health and a health state description of rheumatoid arthritis on a time trade-off and a visual analogue scale. The Barthel Index, a measure of independence from help in activities of daily living, and the adjustment ladder were filled out. Main analyses were performed using mixed linear models taking the time-dependent covariates (Barthel Index and adjustment ladder) into account. Results: Time trade-off valuations for patients’ own health changed over time, even after correction for gain in independence from help in activities of daily living, F(2, 59) = 8.86, P < 0.001. This change was related to overall adaptation. Both a main effect for adaptation, F(87, 1) = 10.05; P = 0.002, and an interaction effect between adaptation and time, F(41, 1)= 4.10, P = 0.024, were seen for time trade-off valuations. Valuations given for one’s own health on the visual analogue scale did not significantly change over time, nor did the valuations for the hypothetical health state. Conclusion: Patients’ health state valuations change over time, over and above the change expected by the rehabilitation process, and this change is partly explained by adaptation. Experience with a chronic illness did not lead to change in valuations of hypothetical health states.

Prevalence of hypertension and associated risk factors in people with long-term spinal cord injury living in the Netherlands

Abstract Purpose: To describe the prevalence of hypertension and associated risk factors in people with long-term spinal cord injury (SCI) and to compare the prevalence of high blood pressure and/or the use of antihypertensive drugs with the prevalence in the Dutch general population. Method: Multicentre cross-sectional study (N = 282). Hypertension was defined as a systolic blood pressure (SBP) of ≥140 mmHg and/or a diastolic blood pressure (DBP) of ≥90 mmHg after ≥2 blood pressure measurements during ≥2 doctor visits. High blood pressure was defined as a single measurement of a SBP of ≥140 mmHg and/or a DBP of ≥90 mmHg. Results: The prevalence of hypertension was 21.5%. Significant predictors were: lesion level below C8 (T1–T6: OR =6.4, T7–L5: OR =10.1), history of hypercholesterolemia (OR =4.8), longer time since injury (OR =1.1), higher age (OR =1.1). The prevalence of high blood pressure and/or the use of antihypertensive drugs was higher in men (T1–T6 lesion: 48%; T7–L5 lesion: 57%) and women (T1–T6 lesion: 48%; T7–L5 lesion: 25%) with a SCI below C8 compared to Dutch able-bodied men (31%) and women (18%). Conclusion: High blood pressure is common in people with SCI. Screening for hypertension during annual checkups is recommended, especially in those with a SCI below C8. Implications for Rehabilitation High blood pressure is common in people with long-term SCI living in the Netherlands and its prevalence is higher in both men and women with a spinal cord lesion level below C8 compared with the age-matched Dutch general population. It is recommended to screen for hypertension during annual checkups in people with SCI, especially in those with a higher risk of developing hypertension, e.g. those with a spinal cord lesion level below C8 and an age of ≥45 years or a time since injury of ≥20 years. When a high blood pressure is measured in people with SCI, they should receive a further assessment of the blood pressure according to the available guidelines for the general population, including ambulatory 24 h-blood pressure monitoring.