Karin Postma

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.

Comparing Content of Therapy for People With a Spinal Cord Injury in Postacute Inpatient Rehabilitation in Australia, Norway, and the Netherlands

Background Research reports have described the contents of therapy in spinal cord injury (SCI) rehabilitation only as the total number of therapy hours. We developed the Spinal Cord Injury–Interventions Classification System (SCI-ICS) as a tool to classify therapy to improve mobility and self-care into 3 levels (body functions, basic activities, and complex activities) and 25 categories. Objective The purposes of this study were: (1) to compare specific contents and amount of therapy provided, with the aim of improving mobility and self-care for people with SCI in Australia, Norway, and the Netherlands and (2) to evaluate the use of the SCI-ICS outside the Netherlands. Design This was a prospective, descriptive study. Methods Physical therapists, occupational therapists, and sports therapists in 6 centers recorded all therapy provided to all people with a recent SCI in inpatient rehabilitation during 4 designated weeks. Each treatment session was classified using 1 or more SCI-ICS codes. Duration of each intervention was specified. Results Seventy-three therapists recorded 2,526 treatments of 79 people with SCI (Netherlands, 48; Australia, 20; Norway, 11). Most therapy time was spent on exercises (overall mean=84%) and on categories at body function and basic activity level of the SCI-ICS. Therapy time significantly differed among countries for 13 of 25 categories. Mean time in minutes per treatment (Netherlands, 28; Australia, 43; Norway, 39) and in hours per patient per week (Netherlands, 4.3; Australia, 5.8; Norway, 6.2) differed significantly. Limitations The short period and small number of patients may have influenced the results. Conclusions Therapy in inpatient SCI rehabilitation in all 3 countries focused on mobility and self-care exercises at body function and basic activity level, but differences were present in focus on the various categories and therapy time. The SCI-ICS can be used reliably to describe therapy in different countries.

Reliability of a New Classification System for Mobility and Self-Care in Spinal Cord Injury Rehabilitation: The Spinal Cord Injury-Interventions Classification System

OBJECTIVE To investigate the reliability of the Dutch version of the Spinal Cord Injury-Interventions Classification System. DESIGN Descriptive study. SETTING Three Dutch spinal cord injury facilities. PARTICIPANTS Six physical therapists, 6 occupational therapists, and 3 sports therapists. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES A 4- or 5-digit code was used to score videotaped interventions on 2 occasions in terms of level, category, and type of intervention. We examined the percentage of correctly assigned interventions (agreement between the researcher and the participants), agreement between the first and second measurements (intrarater reliability), and agreement between the therapists of the same discipline (interrater reliability). RESULTS A total of 252 interventions were assigned. The agreement between the researcher and the participants was good: the percentage of correct interventions was high at both measurements (91.7% and 94.4%). Intrarater agreement was also good (90.9%). The interrater agreement within the physical therapists and the occupational therapists was high at both occasions (mean, 92.3% and 87.0%, respectively), but lower within the sports therapists (mean, 69.3%). CONCLUSIONS The study provided first evidence for reliability of the classification system. Further research is needed to confirm these results and to test the reliability of other language versions.

Mountain time trial in handcycling: exercise intensity and predictors of race time in people with spinal cord injury

Study design:Cross-sectional analyses.Objectives:To analyze exercise intensity during a mountain time trial in handcycling and to determine predictors of race time.Setting:Eight Dutch rehabilitation centers and Austrian mountain.Methods:Forty participants with spinal cord injury (SCI; high lesion level (>T6): N=11; low lesion level (⩽T6): N=29) handcycled a 20.2-km mountain time trial. Heart rate (HR) was monitored in 17 (high: N=5, low: N=12) participants during the race to determine exercise intensity, expressed relative to the heart rate reserve (%HRR). Two weeks before the race all participants completed laboratory tests to measure anthropometrics and peak values for power output (POpeak), oxygen uptake (VO2peak) and HR.Results:Mean race time was 4 h and 1 min (s.d.: 1 h and 24 min), with no difference in race time between lesion groups. Mean exercise intensity during the race was 70±7%HRR. Exercise was mainly (73% of the race time) at a vigorous intensity (60–89%HRR), with 29% of the total time in the 80–89%HRR zone. No clear differences were found in exercise intensities between lesion groups. The strongest predictors for better race times were higher mean %HRR during race (R2=57%), lower waist circumference (R2=39%), higher POpeak (R2=39%) and VO2peak (R2=32%).Conclusion:A 20-km mountain time trial in a handcycle is intensive. Faster race times were achieved by those with a lower waist circumference, greater fitness level and ability to perform at higher average exercise intensities during the race. Level of SCI was not significantly associated with race time.

Resistive Inspiratory Muscle Training in People With Spinal Cord Injury During Inpatient Rehabilitation: A Randomized Controlled Trial

Background People with spinal cord injury (SCI) may benefit from resistive inspiratory muscle training (RIMT). Current evidence is weak, and little is known about the effect on functional outcomes and long-term effects. Objective The purpose of this study was to assess immediate and long-term effects of RIMT in people with SCI. Design This was a single-blinded randomized controlled trial. Setting The study was conducted at 4 specialized SCI units in the Netherlands. Patients The study participants were 40 people with SCI (15 with motor complete tetraplegia, 16 with incomplete tetraplegia, 8 with motor complete paraplegia, and 1 with incomplete paraplegia) who had impaired pulmonary function and were admitted for initial inpatient rehabilitation. Intervention Study participants were randomized to an RIMT group or a control group. All participants received usual rehabilitation care. In addition, participants in the intervention group performed RIMT with a threshold trainer. Measurements Measurements were performed at baseline, after 8 weeks of intervention, 8 weeks later, and 1 year after discharge from inpatient rehabilitation. Primary outcome measures were: respiratory muscle function, lung volumes and flows, and perceived respiratory function. Secondary outcome measures concerned patient functioning, which included health-related quality of life, limitations in daily life due to respiratory problems, and respiratory complications. Results During the intervention period, maximum inspiratory pressure (MIP) improved more in the RIMT group than in the control group (11.7 cm H2O, 95% confidence interval=4.3 to 19.0). At follow-up, this effect was no longer significant. No effect on other primary or secondary outcome measures was found except for an immediate effect on mental health. Limitations The sample size was insufficient to study effects on respiratory complications. Conclusions Resistive inspiratory muscle training has a positive short-term effect on inspiratory muscle function in people with SCI who have impaired pulmonary function during inpatient rehabilitation.

Impaired respiratory function and associations with health-related quality of life in people with spinal cord injury

Study design:Follow-up measurement in a multicenter prospective cohort study.Objectives:To examine the prevalence of impaired respiratory function (pulmonary function and perceived respiratory function), the incidence of respiratory infection and the associations among these parameters in people with spinal cord injury (SCI) 5 years after initial inpatient rehabilitation. Second, we assessed associations between respiratory function and health-related quality of life (HRQOL).Setting:Eight rehabilitation centers with specialized SCI units in the Netherlands.Methods:Measurements were performed 5 years after discharge of inpatient rehabilitation. Pulmonary function was determined by forced vital capacity (FVC) and perceived respiratory function by self-reported cough strength and dyspnea. HRQOL was measured using the Sickness Impact Profile 68 and the 36-item Short Form Health Survey.Results:One-hundred forty-seven people with SCI participated. Of this sample, 30.9% had impaired FVC, 35.9% poor or moderate cough strength, 18.4% dyspnea at rest and 29.0% dyspnea during activity. In the year before the measurements, 8.9% had had respiratory infection. FVC was associated with cough strength, but not with dyspnea. All respiratory function parameters were associated with social functioning, whereas other HRQOL domains were associated with dyspnea only.Conclusion:Five years after initial inpatient rehabilitation, impaired respiratory function and respiratory infection were common in people with SCI. More severely impaired respiratory function was associated with lower HRQOL.Sponsorship:The Netherlands Organisation for Health Research and Development.

People with Spinal Cord Injury in the Netherlands

EPIDEMIOLOGY OF SPINAL CORD INJURY IN THE NETHERLANDS The estimated incidence of traumatic spinal cord injury (SCI) was 14.0 per million per year in the Netherlands in 2010, or 11.7 per million per year for those surviving the acute phase. The incidence of traumatic SCI seems rather stable as an earlier study reported an estimated incidence of 10.4 per million per year surviving the acute phase in 1994. The incidence of nontraumatic SCI in the Netherlands is unknown. However, a study on characteristics of persons with SCI admitted to an SCI department for initial inpatient rehabilitation found 54.7% of persons with SCI to have a nontraumatic lesion. Therefore, we assume that the incidence of nontraumatic SCI is slightly higher than the incidence of traumatic SCI. There are no reliable figures on the prevalence of SCI in the Netherlands. Most cases of traumatic SCI admitted to acute care hospitals were falls (53%) in 2010, followed by road traffic accidents (22%) and sports (14%). Within this last category, diving (27%) and bicycling (23%) were most common. Violence applied to only 2% of cases. Reported etiologies for nontraumatic SCI admitted to specialized rehabilitation centers were vascular diseases (28%), spinal degeneration (26%), inflammation (17%), malignant tumor (17%), and benign tumor (11%). The most notable change between 1994 and 2010 was a strong increase in age at injury. The proportion of newly injured people older than 60 years was 30% in 1994 compared with 52% in 2010. This increase in age at injury was associated with a growing proportion of falls as a cause of SCI and of more people with incomplete and cervical SCI. The decreasing proportion of traumatic SCI due to traffic incidents from 31% in 1994 to 22% in 2010mirrors a decline in death and wounded people in traffic accidents in recent years in the Netherlands. The mortality rate during acute hospitalization was estimated to be 16% in 2010. In a cohort study of persons with SCI admitted to a specialized rehabilitation center who were expected to remain wheelchair dependent, the cumulative

Longitudinal association between respiratory muscle strength and cough capacity in persons with spinal cord injury:: An explorative analysis of data from a randomized controlled trial

OBJECTIVE To assess the longitudinal association between respiratory muscle strength and cough capacity in persons with recent spinal cord injury. DESIGN Longitudinal analyses. SUBJECTS Forty persons with recent spinal cord injury and impaired pulmonary function. METHODS Measurements were performed 4 weeks after the start of rehabilitation, 9 and 17 weeks after the first measurement, and one year after discharge from inpatient rehabilitation. Peak cough flow was measured with a spirometer. Maximum inspiratory and expiratory pressures (MIP and MEP), expressed in cmH2O, were measured at the mouth. RESULTS Both MIP and MEP were significantly positively associated with peak cough flow. After correction for confounders and time 10 cmH2O higher MIP was associated with a 0.32 l/s higher peak cough flow, and a 10 cmH2O higher MEP was associated with a 0.15 l/s higher peak cough flow. The association between MIP and peak cough flow was mainly based on within-subject variance. The association between MIP and peak cough flow was stronger than between MEP and peak cough flow. CONCLUSION Improvement in respiratory muscle strength is associated with improvement in cough capacity in persons with recent spinal cord injury who have impaired pulmonary function.