Jan W. van der Scheer

Kinematic evaluation of patients with total and reverse shoulder arthroplasty during rehabilitation exercises with different loads

BACKGROUND Following shoulder arthroplasty, any well-planned rehabilitation program should include muscle strengthening. However, it is not always clear how different external loads influence shoulder kinematics in patients with shoulder prostheses. The objective of this study was to describe shoulder kinematics and determine the contribution of the scapulothoracic joint to total shoulder motion of patients with total and reverse shoulder arthroplasties and of healthy individuals during rehabilitation exercises (anteflexion and elevation in the scapular plane) using different loading conditions (without external load, 1 kg and elastic resistance). METHODS Shoulder motions were measured using an electromagnetic tracking device. A force transducer was used to record force signals during loaded conditions using elastic resistance. Statistical comparisons were made using a three-way repeated-measures analysis of variance with a Bonferroni post hoc testing. FINDINGS The scapula contributed more to movement of the arm in subjects with prostheses compared to healthy subjects. The same applies for loaded conditions (1 kg and elastic resistance) relative to unloaded tasks. For scapular internal rotation, upward rotation and posterior tilt no significant differences among groups were found during both exercises. Glenohumeral elevation angles during anteflexion were significantly higher in the total shoulder arthroplasty group compared to the reverse shoulder arthroplasty group. INTERPRETATION Differences in contribution of the scapula to total shoulder motion between patients with different types of arthroplasties were not significant. However, compared to healthy subjects, they were. Furthermore, scapular kinematics of patients with shoulder arthroplasty was influenced by implementation of external loads, but not by the type of load.

Effects of exercise on fitness and health of adults with spinal cord injury A systematic review

Objective: To synthesize and appraise research testing the effects of exercise interventions on fitness, cardiometabolic health, and bone health among adults with spinal cord injury (SCI). Methods: Electronic databases were searched (1980–2016). Included studies employed exercise interventions for a period ≥2 weeks, involved adults with acute or chronic SCI, and measured fitness (cardiorespiratory fitness, power output, or muscle strength), cardiometabolic health (body composition or cardiovascular risk factors), or bone health outcomes. Evidence was synthesized and appraised using Grading of Recommendations Assessment, Development, and Evaluation (GRADE). Results: A total of 211 studies met the inclusion criteria (22 acute, 189 chronic). For chronic SCI, GRADE confidence ratings were moderate to high for evidence showing exercise can improve all of the reviewed outcomes except bone health. For acute SCI, GRADE ratings were very low for all outcomes. For chronic SCI, there was low to moderate confidence in the evidence showing that 2–3 sessions/week of upper body aerobic exercise at a moderate to vigorous intensity for 20–40 minutes, plus upper body strength exercise (3 sets of 10 repetitions at 50%–80% 1-repetition maximum for all large muscle groups), can improve cardiorespiratory fitness, power output, and muscle strength. For chronic SCI, there was low to moderate confidence in the evidence showing that 3–5 sessions per week of upper body aerobic exercise at a moderate to vigorous intensity for 20–44 minutes can improve cardiorespiratory fitness, muscle strength, body composition, and cardiovascular risk. Conclusions: Exercise improves fitness and cardiometabolic health of adults with chronic SCI. The evidence on effective exercise types, frequencies, intensities, and durations should be used to formulate exercise guidelines for adults with SCI.

Evidence-based scientific exercise guidelines for adults with spinal cord injury: an update and a new guideline

ObjectivesTo describe the process and outcomes of using a new evidence base to develop scientific guidelines that specify the type and minimum dose of exercise necessary to improve fitness and cardiometabolic health in adults with spinal cord injury (SCI).SettingInternational.MethodsUsing Appraisal of Guidelines, Research and Evaluation (AGREE) II reporting criteria, steps included (a) determining the guidelines’ scope; (b) conducting a systematic review of relevant literature; (c) holding three consensus panel meetings (European, Canadian and International) to formulate the guidelines; (d) obtaining stakeholder feedback; and (e) process evaluation by an AGREE II consultant. Stakeholders were actively involved in steps (c) and (d).ResultsFor cardiorespiratory fitness and muscle strength benefits, adults with a SCI should engage in at least 20 min of moderate to vigorous intensity aerobic exercise 2 times per week AND 3 sets of strength exercises for each major functioning muscle group, at a moderate to vigorous intensity, 2 times per week (strong recommendation). For cardiometabolic health benefits, adults with a SCI are suggested to engage in at least 30 min of moderate to vigorous intensity aerobic exercise 3 times per week (conditional recommendation).ConclusionsThrough a systematic, rigorous, and participatory process involving international scientists and stakeholders, a new exercise guideline was formulated for cardiometabolic health benefits. A previously published SCI guideline was endorsed for achieving fitness benefits. These guidelines represent an important step toward international harmonization of exercise guidelines for adults with SCI, and a foundation for developing exercise policies and programs for people with SCI around the world.

Design of a randomized-controlled trial on low-intensity aerobic wheelchair exercise for inactive persons with chronic spinal cord injury.

Purpose: To investigate effects and working mechanisms of low-intensity aerobic wheelchair exercise on fitness, (upper-body) health and active lifestyle in inactive persons with chronic spinal cord injury (SCI). Methods: A multicenter randomized-controlled trial (RCT) in 40 inactive manual wheelchair users (aged 28–65y) with chronic paraplegia or tetraplegia (time since injury >10y). Subjects will be randomly assigned to an intervention or a control group. The intervention will consist of 16 weeks (2 times per week, 30 min per session) of low-intensity aerobic handrim wheelchair exercise (30–40% HRR) on a treadmill. Repeated measurements will be performed before starting the intervention or entrance of the control group, and after week 8, 16 and 42 following the start. The primary outcome will be wheelchair-specific physical fitness. Secondary outcomes will be upper-body pain and discomfort, shoulder load, propulsion technique, wheelchair skill performance and physical activity levels. Conclusions: Results of this first RCT on low-intensity aerobic wheelchair exercise for inactive persons with chronic SCI can improve SCI-specific exercise guidelines and provide an evidence-base for an aftercare program aimed at preserving fitness, health and active lifestyle of persons aging with SCI. Implications for Rehabilitation Low-intensity wheelchair aerobic exercise may be effective for improving fitness, (upper-body) health and active lifestyle of inactive persons with chronic SCI, without the high dropout rates that plague exercise programs for this population. Results of this study can 1) improve SCI-specific aerobic exercise guidelines and 2) provide an evidence-base for a long-term aftercare rehabilitation program for persons aging with SCI. As this study is embedded in Dutch rehabilitation practice, chances of knowledge transfer and implementation are high, and strengthen the Dutch SCI rehabilitation network.

Wheelchair-Specific Fitness of Inactive People with Long-Term Spinal Cord Injury

OBJECTIVES To describe wheelchair-specific anaerobic work capacity, isometric strength and peak aerobic work capacity of physically inactive people with long-term spinal cord injury using outcomes of tests that are feasible for use in rehabilitation centres, and to determine associations among these fitness components. DESIGN Cross-sectional study. PARTICIPANTS Manual wheelchair users with spinal cord injury for at least 10 years, who were inactive based on a norm score of a physical activity questionnaire (n = 29; 22 men; 20 with paraplegia; median age 53 years). METHODS Participants performed 3 exercise tests in their own wheelchair to determine: highest 5-s power output over 15-m overground sprinting (P5-15m); highest 3-s isometric push-force (Fiso); and peak power output (POpeak) and peak oxygen uptake (VO2peak) over a peak test. RESULTS Median (interquartile range) was in P5-15m 16.1 W (9.4-20.9); in Fiso 399 N (284-610); in POpeak 40.9 W (19.1-54.9); and in VO2peak 1.26 l/min (0.80-1.67). Correlations among outcomes of fitness components were weak (r = 0.50-0.67, p < 0.01), except for P5-15m with POpeak (r = 0.79, p < 0.001). CONCLUSION All fitness components measured in this sample were at relatively low levels, implying a specific need for interventions to improve wheelchair-specific fitness. The weak-to-moderate associations among components imply that separate tests should be used when monitoring wheelchair-specific fitness in rehabilitation centres.

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.

Can a 15m-overground wheelchair sprint be used to assess wheelchair-specific anaerobic work capacity?

OBJECTIVE To evaluate whether outcomes based on stopwatch time and power output (PO) over a 15m-overground wheelchair sprint test can be used to assess wheelchair-specific anaerobic work capacity, by studying their relationship with outcomes on a Wingate-based 30s-wheelchair ergometer sprint (WAnT). METHODS Able-bodied persons (N=19, 10 men, aged 18-26 y) performed a 15m overground sprint test in an instrumented wheelchair and a WAnT. 15m-outcomes were based on stopwatch time (time and mean velocity over 15m) and on PO (primary outcome: highest mean unilateral PO over successive 5s-intervals (P5-15m)). WAnT-outcomes were mean unilateral PO over 30s and the highest mean unilateral PO over successive 5s-intervals. Correlation coefficients (Pearsons r) and coefficients of determination (R(2)) were calculated between 15m-sprint outcomes and WAnT-outcomes. RESULTS Time over 15m (7.2s (± 1.0)) was weakly related to WAnT-outcomes (r=-0.61 and -0.60, R(2)=0.38 and 0.36, p<0.01), similar to mean velocity over 15m (2.1 m·s(-1) (± 0.3), R(2)=0.43 and 0.39, p<0.01). P5-15m (38.1W (± 14.0)) showed a moderate relationship to WAnT-outcomes (r=0.77 and 0.75, R(2)=0.59 and 0.56, p<0.001). CONCLUSIONS It seems that outcomes based on stopwatch time over a 15m-overground sprint cannot be used to assess wheelchair-specific anaerobic work capacity, in contrast to an outcome based on PO (P5-15m). The 15m-sprint with an instrumented wheel can be implemented in rehabilitation practice and research settings when WAnT equipment is not available, although care is needed when interpreting P5-15m as an outcome of anaerobic work capacity given that it seems more skill-dependent than the WAnT.

Low-Intensity Wheelchair Training in Inactive People with Long-Term Spinal Cord Injury: A Randomized Controlled Trial on Fitness, Wheelchair Skill Performance and Physical Activity Levels

OBJECTIVE To investigate the effects of low-intensity wheelchair training on wheelchair-specific fitness, wheelchair skill performance and physical activity levels in inactive people with long-term spinal cord injury. DESIGN Randomized controlled trial. PARTICIPANTS Inactive manual wheelchair users with spinal cord injury for at least 10 years (n = 29), allocated to exercise (n = 14) or no exercise. METHODS The 16-week training consisted of wheelchair treadmill-propulsion at 30-40% heart rate reserve or equi-valent in terms of rate of perceived exertion, twice a week, for 30 min per session. Wheelchair-specific fitness was determined as the highest 5-s power output over 15-m overground wheelchair sprinting (P5-15m), isometric push-force, submaximal fitness and peak aerobic work capacity. Skill was determined as performance time, ability and strain scores over a wheelchair circuit. Activity was determined using a questionnaire and an odometer. RESULTS Significant training effects appeared only in P5-15m (exercise vs control: mean +2.0 W vs -0.7 W, p = 0.017, ru=0.65). CONCLUSION The low-intensity wheelchair training appeared insufficient for substantial effects in the sample of inactive people with long-term spinal cord injury, presumably in part owing to a too-low exercise frequency. Effective yet feasible and sustainable training, as well as other physical activity programmes remain to be developed for inactive people with long-term spinal cord injury.

Low-Intensity Wheelchair Training in Inactive People with Long-Term Spinal Cord Injury: A Randomized Controlled Trial on Propulsion Technique

ObjectiveThe objective of this study was to investigate the effects of a low-intensity wheelchair training on propulsion technique in inactive people with long-term spinal cord injury. DesignParticipants in this multicenter nonblinded randomized controlled trial were inactive manual wheelchair users with spinal cord injury for at least 10 yrs (N = 29), allocated to exercise (n = 14) or no exercise. The 16-wk training consisted of wheelchair treadmill propulsion at 30%–40% heart rate reserve or equivalent in rate of perceived exertion, twice a week, 30 mins per session. Propulsion technique was assessed at baseline as well as after 8, 16, and 42 wks during two submaximal treadmill-exercise blocks using a measurement wheel attached to a participant’s own wheelchair. Changes over time between the groups were analyzed using Mann-Whitney U tests on difference scores (P < 0.05/3). ResultsData of 16 participants could be analyzed (exercise: n = 8). Significant differences between the exercise and control groups were only found in peak force after 8 wks (respective medians, −20 N vs. 1 N; P = 0.01; ru = 0.78). ConclusionsSignificant training effects on propulsion technique were not found in this group. Perhaps, substantial effects require a higher intensity or frequency. Investigating whether more effective and feasible interventions exist might help reduce the population’s risk of upper-body joint damage during daily wheelchair propulsion.

Reliability and Validity of Subjective Measures of Aerobic Intensity in Adults With Spinal Cord Injury: A Systematic Review

To systematically synthesize and appraise research regarding test‐retest reliability or criterion validity of subjective measures for assessing aerobic exercise intensity in adults with spinal cord injury (SCI).