de Sonja Groot

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.

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.

Effect of wheelchair stroke pattern on mechanical efficiency.

de Groot S, Veeger HEJ, Hollander AP, van der Woude LHV: Effect of wheelchair stroke pattern on mechanical efficiency. Am J Phys Med Rehabil 2004;83:640–649. 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.

Adaptations in physiology and propulsion techniques during the initial phase of learning manual wheelchair propulsion

de Groot S, Veeger HEJ, Hollander AP, van der Woude LHV: Adaptations in physiology and propulsion techniques during the initial phase of learning manual wheelchair propulsion. Am J Phys Med Rehabil 2003;82:504–510. ObjectiveThe purpose of this study was to analyze adaptations in gross mechanical efficiency and wheelchair propulsion technique in novice able-bodied subjects during the initial phase of learning hand-rim wheelchair propulsion. DesignNine able-bodied subjects performed three 4-min practice blocks on a wheelchair ergometer. The external power output and velocity of all blocks was, respectively, 0.25 W/kg and 1.11 m/sec. Gross mechanical efficiency, force application, timing, and intercycle variability were measured. ResultsNo change in gross mechanical efficiency was found. However, a decrease in push frequency occurred, which was accompanied by an increase in work per cycle and a decrease in percentage push time. The increase in work per cycle was associated with a higher peak torque. No changes in intercycle variability were visible over time. ConclusionsThe timing variables had already changed during the initial phase of learning manual wheelchair propulsion. However, for other variables, such as force production, gross mechanical efficiency, and intercycle variability, a longer practice period might be necessary to induce a change. The effective force direction seemed to be optimized from the start of the learning process onward.

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.

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 participants 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 (VO2peak) 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 VO2peak 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.

Occurrence and predictors of pressure ulcers during primary in-patient spinal cord injury rehabilitation

Study design:Multicenter prospective cohort study.Objectives:To determine the occurrence and predictors for pressure ulcers in patients with spinal cord injury (SCI) during primary in-patient rehabilitation.Setting:Eight Dutch rehabilitation centres with specialized SCI units.Methods:The occurrence, location and stage of pressure ulcers were registered between admission and start of functional rehabilitation (called acute rehabilitation phase) and between start of functional rehabilitation and discharge. Possible risk factors for the occurrence of pressure ulcers during functional rehabilitation (personal and lesion characteristics, complications and functional independence) were measured at the start of functional rehabilitation and were entered as predictors in univariate and multivariate logistic regression analysis with pressure ulcers during functional rehabilitation as the dependent variable.Results:Data for 193 patients (86%) were available. The occurrence of pressure ulcers, including stage 1, was 36.5% during acute rehabilitation phase and 39.4% during functional rehabilitation. Most pressure ulcers were located at the sacrum (43%), followed by heel (19%) and ischium (15%). The significant risk factors for pressure ulcers during functional rehabilitation were motor completeness of the lesion, tetraplegia, pressure ulcer during acute rehabilitation phase, pneumonia and/or pulmonary disease, low score on the Functional Independence Measure (FIM) self-care, continence, transfers, locomotion and total FIM motor score. Having had a pressure ulcer during acute rehabilitation phase was the strongest risk factor.Conclusion:The occurrence of pressure ulcers was comparable with other studies. A few significant risk factors were found, of which having had a pressure ulcer during acute rehabilitation phase being the strongest predictor.

Time-courses of lung function and respiratory muscle pressure generating capacity after spinal cord injury: A prospective cohort study.

OBJECTIVE To investigate the time-courses of lung function and respiratory muscle pressure generating capacity after spinal cord injury. DESIGN Multi-centre, prospective cohort study. SUBJECTS One hundred and nine subjects with recent, motor complete spinal cord injury. METHODS Lung function and respiratory muscle pressure generating capacity were measured at first mobilization, at discharge from inpatient rehabilitation and one year after discharge. Lung function was measured in all 109 subjects, and 55 of these performed additional measurements of respiratory muscle pressure generating capacity. Trajectories of respiratory muscle function for different lesion level groups were assessed by multi-variate multi-level regression models. RESULTS Forced vital capacity, forced expiratory volume in 1 sec and maximal inspiratory muscle pressure generating capacity significantly increased during and after inpatient rehabilitation. Forced inspiratory volume in 1 sec, peak inspiratory flow, peak expiratory flow and maximal expiratory muscle pressure generating capacity increased only during inpatient rehabilitation, but not thereafter. Increasing lesion level had a negative effect on all measured lung function parameters, as well as on maximal inspiratory and expiratory muscle pressure generating capacity. CONCLUSION Respiratory function improved during inpatient rehabilitation, but only forced vital capacity, forced expiratory volume in 1 sec and maximal inspiratory muscle pressure generating capacity further improved thereafter. In particular, expiratory muscle function and subjects with tetraplegia should be screened and trained regularly.

Long-term effect of comorbidity on the course of physical functioning in patients after stroke and with multiple sclerosis.

OBJECTIVE To study the effect of comorbidity on the course of physical functioning in patients after stroke and with multiple sclerosis. SUBJECTS Patients after a first-ever supratentorial stroke (n = 198), who had been admitted for inpatient rehabilitaion, and patients with recently diagnosed multiple sclerosis (n =146). DESIGN Prospective, observational study over a period of 3 years. MEASUREMENTS Physical functioning was measured with the motor score of the Functional Independence Measure at baseline (time of diagnosis), and at 6 months, and 1 and 3 year follow-ups. Cardiovascular, respiratory, musculoskele nottal, diabetes mellitus, and other comorbidities were measured at baseline. RESULTS Patients after stroke and multiple sclerosis with comorbidity showed a significantly lower level of physical functioning over all 4 measurements. There was no difference in the course of physical functioning between patients after stroke with and without comorbidity. In patients with multiple sclerosis, a greater decrease in physical functioning over the 3-year follow-up was found in patients with comorbidity of the musculoskeletal system compared with patients without. CONCLUSION These findings indicate that similar improvements in physical functioning can be expected during rehabilitation of stroke patients with comorbidity compared with patients without these conditions. In patients with multiple sclerosis, musculoskeletal comorbidity requires further attention because of its association with a greater decrease in physical functioning.

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.