Linda J. Valent

Effects of Hand Cycle Training on Physical Capacity in Individuals With Tetraplegia: A Clinical Trial

Background: Regular physical activity is important for people with tetraplegia to maintain fitness but may not always be easily integrated into daily life. In many countries, hand cycling has become a serious option for daily mobility in people with tetraplegia. However, little information exists regarding the suitability of this exercise mode for this population. Objective: The purpose of this study was to evaluate the effects of a structured hand cycle training program in individuals with chronic tetraplegia. Design: Pretraining and posttraining outcome measurements of physical capacity were compared. Setting: Structured hand cycle interval training was conducted at home or in a rehabilitation center in the Netherlands. Participants: Twenty-two patients with tetraplegia (American Spinal Injury Association Impairment Scale classification A-D) at least 2 years since injury participated. Intervention: The intervention was an 8- to 12-week hand cycle interval training program. Measures: Primary outcomes of physical capacity were: peak power output (POpeak) and peak oxygen uptake (V̇o2peak), as determined in hand cycle peak exercise tests on a motor-driven treadmill. Secondary outcome measures were: peak muscle strength (force-generating capacity) of the upper extremities (as assessed by handheld dynamometry), respiratory function (forced vital capacity and peak expiratory flow) and participant-reported shoulder pain. Results: Significant improvements following a mean of 19 (SD=3) sessions of hand cycle training were found in POpeak (from 42.5 W [SD=21.9] to 50.8 W [SD=25.4]), V̇o2peak (from 1.32 L·min−1 [SD=0.40] to 1.43 L·min−1 [SD=0.43]), and mechanical efficiency, as reflected by a decrease in submaximal oxygen uptake. Except for shoulder abduction strength, no significant effects were found on the secondary outcomes. Limitations: Common health complications, such as urinary tract infections, bowel problems, and pressure sores, led to dropout and nonadherence. Conclusion: Patients with tetraplegia were able to improve their physical capacity through regular hand cycle interval training, without participant-reported shoulder-arm pain or discomfort.

The individual relationship between heart rate and oxygen uptake in people with a tetraplegia during exercise.

Study design:Descriptive study.Objective:To examine the individual heart rate–oxygen uptake (HR–VO2) relationship during exercise in persons with tetraplegia (TP).Setting:Rehabilitation Centre Heliomare, Wijk aan Zee, The Netherlands.Methods:The HR–VO2 relationship was determined in untrained subjects with motor complete TP (C5 or C6, n=10 and C7 or C8, n=10) during a discontinuous graded exercise hand cycle test. The mean HR and VO2 of the final 60 s of 2-min exercise blocks were used for calculation of the individual correlation coefficient and the standard error of the estimate (SEE).Results:Two subjects of the C5–C6 group were not able to complete the test. Individual Pearsons correlation coefficients (r) ranged from 0.68 to 0.97 and SEE from 2.6 to 22.4% VO2-Reserve (VO2R). The mean Pearsons r and SEE were 0.81±0.12 and 10.6±5.6% VO2R in the C5–C6 group and 0.91±0.07 and 7.0±3.2% VO2R in the C7–C8 group, respectively. Two subjects of the C5–C6 group and six subjects of the C7–C8 group attained a linear HR–VO2 relationship with an acceptable SEE (⩽6.0%) and r (>0.90).Conclusions:The HR–VO2 relationship appeared linear in only eight out of 18 subjects. An individual analysis of the HR–VO2 relationship is necessary to determine whether HR can be used to quantify exercise intensity. The use of HR to prescribe training intensity should be reconsidered in persons with TP.Sponsorship:This study is supported from a grant by ZON-MW.

Influence of hand cycling on physical capacity in the rehabilitation of persons with a spinal cord injury : a longitudinal cohort study

OBJECTIVE To investigate the influence of hand cycling on outcome measures of physical capacity during and after rehabilitation in persons with paraplegia and tetraplegia in The Netherlands. DESIGN A longitudinal cohort study with measurement moments at the start (t1) and end (t2) of clinical rehabilitation and 1 year after discharge (t3). Hand cycle use was assessed by means of questionnaires at t2 and t3. SETTING Eight rehabilitation centers in The Netherlands. PARTICIPANTS Subjects (N=162) with a recent spinal cord injury. INTERVENTIONS All subjects followed the regular rehabilitation program. MAIN OUTCOME MEASURES Peak oxygen uptake (Vo(2)peak) and peak power output (POpeak) determined in a handrim wheelchair peak exercise test, peak muscle strength of the upper extremities, and pulmonary function. RESULTS A significantly larger increment in Vo(2)peak, POpeak, and elbow extension strength was found in subjects with paraplegia during clinical rehabilitation. No such effect was found in subjects with tetraplegia. In the postrehabilitation period, no influence of hand cycling on any outcome measure was found in subjects with paraplegia or subjects with tetraplegia. CONCLUSIONS After correction for baseline values and confounders, regular hand cycling (once a week or more) appeared to be beneficial for improving aerobic physical capacity in persons with paraplegia during clinical rehabilitation. The small and heterogeneous study groups may have hampered the finding of positive results of hand cycling in persons with tetraplegia.

Effects of hand cycle training on wheelchair capacity during clinical rehabilitation in persons with a spinal cord injury

Purpose. To evaluate the effects of a structured hand cycle training programme on physical capacity in subjects with spinal cord injury (SCI) during clinical rehabilitation. Method. Twenty subjects with SCI who followed hand cycle training were compared with matched control subjects from a Dutch longitudinal cohort study, who received usual care. Primary outcomes of physical capacity were peak power output (POpeak), peak oxygen uptake (VO2peak) and oxygen pulse during a hand rim wheelchair test. Secondary outcome measures were isometric peak muscle strength of the upper extremities and pulmonary function. Hand cycle capacity (POpeak and VO2peak) was evaluated in the training group only. Results. Strong tendencies for improvement were found in wheelchair capacity, reflected by POpeak and oxygen pulse after additional hand cycle training. Significant effects on shoulder exo- and endo-rotation and unilateral elbow flexion strength were found but no improvements on pulmonary function. Conclusions. Additional hand cycle training during clinical rehabilitation seems to show similar or slightly favourable results on wheelchair capacity and muscle strength compared with regular care. The heterogeneous subject group and large variation in training period may explain the limited effects of additional hand cycle training on wheelchair capacity.

Hand-cycling : an active form of wheeled mobility, recreation, and sports

By studying exercise and performance in hand-cycling in both activities of daily living and in Paralympic sport settings, new insights can be gained for rehabilitation practice, adapted physical activity, and sports. This review looks into the pros and cons of hand-cycling in both rehabilitation and optimal sports performance settings as suggested from the current-but still limited-scientific literature and experimentation. Despite the limited evidence-base and the diversity of study approaches and methodologies, this study suggests an important role for hand-cycling during and after rehabilitation, and in wheeled mobility recreation and sports. An approach that combines biomechanical, physiological, and psychosocial elements may lead to a better understanding of the benefits of hand-cycling and of the fundamentals of exercise in rehabilitation, activities of daily living, and sports.

A behavioural intervention increases physical activity in people with subacute spinal cord injury: a randomised trial

QUESTIONS For people with subacute spinal cord injury, does rehabilitation that is reinforced with the addition of a behavioural intervention to promote physical activity lead to a more active lifestyle than rehabilitation alone? DESIGN Randomised, controlled trial with concealed allocation, intention-to-treat analysis, and blinded assessors. PARTICIPANTS Forty-five adults with subacute spinal cord injury who were undergoing inpatient rehabilitation and were dependent on a manual wheelchair. The spinal cord injuries were characterised as: tetraplegia 33%; motor complete 62%; mean time since injury 150 days (SD 74). INTERVENTION All participants received regular rehabilitation, including handcycle training. Only the experimental group received a behavioural intervention promoting an active lifestyle after discharge. This intervention involved 13 individual sessions delivered by a coach who was trained in motivational interviewing; it began 2 months before and ended 6 months after discharge from inpatient rehabilitation. OUTCOME MEASURES The primary outcome was physical activity, which was objectively measured with an accelerometer-based activity monitor 2 months before discharge, at discharge, and 6 and 12 months after discharge from inpatient rehabilitation. The accelerometry data were analysed as total wheeled physical activity, sedentary time and motility. Self-reported physical activity was a secondary outcome. RESULTS The behavioural intervention significantly increased wheeled physical activity (overall between-group difference from generalised estimating equation 21minutes per day, 95% CI 8 to 35). This difference was evident 6 months after discharge (28minutes per day, 95% CI 8 to 48) and maintained at 12 months after discharge (25minutes per day, 95% CI 1 to 50). No significant intervention effect was found for sedentary time or motility. Self-reported physical activity also significantly improved. CONCLUSION The behavioural intervention was effective in eliciting a behavioural change toward a more active lifestyle among people with subacute spinal cord injury. TRIAL REGISTRATION NTR2424.

Trajectories in the course of body mass index after spinal cord injury

OBJECTIVE To identify different trajectories of the course of body mass index (BMI) after spinal cord injury (SCI) and to study whether other cardiovascular risk factors (blood pressure, lipid profile) follow the same trajectories. DESIGN Multicenter prospective cohort study with measurements at the start of active rehabilitation, after 3 months, at discharge, and 1 and 5 years after discharge. SETTING Rehabilitation centers. PARTICIPANTS Persons with a recent SCI (N=204). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURE BMI trajectories. RESULTS Three BMI trajectories were identified: (1) a favorable stable BMI during and after rehabilitation (± 22-23 kg/m(2)) (54%); (2) a higher but stable BMI during inpatient rehabilitation (± 24 kg/m(2)) and an increase after discharge (up to 29 kg/m(2)) (38%); and (3) an increase in BMI during inpatient rehabilitation (from ± 23 up to 28 kg/m(2)) and leveling off after discharge (8%). Profile analyses showed that an unfavorable change in BMI was not accompanied by clear unfavorable changes in blood pressure or lipid levels. CONCLUSIONS BMI in people with SCI follows distinct trajectories. Monitoring body mass, food intake, and daily physical activity during and especially after inpatient SCI rehabilitation is important to prevent obesity and related cardiovascular risk factors.

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.

A behavioral intervention promoting physical activity in people with subacute spinal cord injury: secondary effects on health, social participation and quality of life

Objective: To assess, for people with subacute spinal cord injury, if rehabilitation that is reinforced with the addition of a behavioral intervention to promote physical activity leads to a better health, participation and quality of life. Design: Randomized controlled trial. Setting: Rehabilitation centers. Participants: A total of 39 participants analyzed (45 included), with subacute spinal cord injury in inpatient rehabilitation, dependent on a manual wheelchair (33% tetraplegia, 62% motor complete, 150 ±74 days postinjury). Intervention: A behavioral intervention promoting physical activity after discharge, involving 13 individual sessions delivered by a coach trained in motivational interviewing, beginning two months before and ending six months after discharge from inpatient rehabilitation. Main measures: Physical capacity as determined during a maximal exercise test, body mass index, blood pressure, fasting lipid profile, and social participation (IMPACT-S) and quality of life (SF-36) were determined using questionnaires. Measurements were performed two months before discharge, at discharge, and six and 12 months after discharge from inpatient rehabilitation. B represents the between-group difference. Results: Twelve months after discharge, significant intervention effects were found for diastolic blood pressure (B = –11.35 mmHg, 95% CI = –19.98 to −2.71), total cholesterol (B = –0.89 mmol/L, 95% CI = –1.59 to −0.20), low-density lipoprotein cholesterol (B = −0.63 mmol/L, 95% CI = –1.25 to −0.00) and participation (B = 9.91, 95% CI = 3.34 to 16.48). Conclusions: A behavioral intervention promoting physical activity after discharge from inpatient rehabilitation improves social participation and seems to reduce risk factors for cardiovascular disease in people with subacute spinal cord injury.

Effects of four-month handbike training under free-living conditions on physical fitness and health in wheelchair users

Abstract Purpose: Recognizing the encouraging effect of challenging events, the HandbikeBattle (HBB) was created to promote exercise among wheelchair users. The purpose of this study was to reveal the effects on physical fitness and health outcomes of four-month handbike training under free-living conditions in preparation for the event. Methods: In this prospective cohort study, 59 relatively inexperienced handyclists participated in the HBB of 2013 or 2014. Incremental exercise tests were conducted, respiratory function was tested and anthropometrics were measured before and after the preparation period. Main outcome measures were peak power output (POpeak), peak oxygen uptake (VO2peak) and waist circumference, of which the changes were tested using repeated measures ANOVA. To detect possible determinants of changes in physical fitness, a linear regression analysis was conducted with personal characteristics, executed training volume and upper-extremity complaints during the training period as independent variables. Results: POpeak, VO2peak and waist circumference improved significantly with 17%, 7% and 4.1%, respectively. None of the included variables were significant determinants for the changes in POpeak found as a result of the training. Conclusion: A challenging event such as the HBB provokes training regimes among participants of sufficient load to realize substantial improvements in physical fitness and health outcomes. Implications for Rehabilitation Due to the often impaired muscle function in the lower-limbs and an inactive lifestyle, wheelchair users generally show considerably lower levels of fitness compared to able-bodied individuals. This prospective cohort study showed that four months of handbike training under free-living conditions in preparation for this event resulted in substantial improvements in physical fitness and health outcomes in wheelchair users. The creation of a challenging event such as the HandbikeBattle as part of a follow-up rehabilitation practice can therefore be a useful tool to help wheelchair users initiate or keep training to improve their physical fitness and health.