Lucas H. van der Woude

A prospective study on physical activity levels after spinal cord injury during inpatient rehabilitation and the year after discharge

OBJECTIVES To assess the change over time in the physical activity level after a spinal cord injury (SCI), to explore its determinants, and to compare the physical activity level 1 year after discharge from the rehabilitation center with the level in able-bodied persons. DESIGN Prospective cohort study. Measurements were obtained at the start of active rehabilitation, 3 months later, at discharge, 2 months after discharge, and 1 year after discharge. SETTING Rehabilitation center in The Netherlands and the participants home. PARTICIPANTS Persons (n=40) with SCI. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES The physical activity level, as indicated by the duration of dynamic activities (ie, wheelchair driving, walking, cycling, noncyclic movement) per day, and the intensity of everyday activity; both were measured with an accelerometry-based activity monitor during 2 consecutive weekdays. RESULTS Random coefficient analyses showed that the duration of dynamic activities and the intensity of everyday activity increased during inpatient rehabilitation at rates of 41% and 19%, respectively (P<.01). Shortly after discharge, there was a strong decline (33%; P<.001) in the duration of dynamic activities. One year after discharge, this decline was restored to the discharge level but was low in comparison with levels in able-bodied persons. The level of lesion and completeness of lesion were determinants of the change in the physical activity level after discharge. CONCLUSIONS The physical activity level increased during inpatient rehabilitation, but this increase did not continue after discharge, and the level 1 year after discharge was distinctly lower than the level in able-bodied persons. Subpopulations had a different change over time in the physical activity level after discharge.

Wheelchair propulsion technique and mechanical efficiency after 3 wk of practice

PURPOSE Differences in gross mechanical efficiency between experienced and inexperienced wheelchair users may be brought about by differences in propulsion technique. The purpose of this experiment was to study changes in propulsion technique (defined by force application, left-right symmetry, intercycle variability, and timing) and gross mechanical efficiency during a 3-wk wheelchair practice period in a group of novice able-bodied nonwheelchair users. METHODS Subjects were randomly divided over an experimental group (N = 10) and a control group (N = 10). The experimental group received a 3-wk wheelchair practice period (3.wk-1, i.e., 9 practice trials) on a computer-controlled wheelchair ergometer, whereas the control group only participated in trials 1 and 9. During all nine practice trials, propulsion technique variables and mechanical efficiency were measured. RESULTS No significant differences between the groups were found for force application, left-right symmetry, and intercycle variability. The push frequency and negative power deflection at the start of the push phase diminished significantly in the experimental group in contrast to the control group (P < 0.05). Work per cycle, push time, cycle time, and mechanical efficiency increased. CONCLUSION The practice period had a favorable effect on some technique variables and mechanical efficiency, which may indicate a positive effect of improved technique on mechanical efficiency. Although muscle activation and kinematic segment characteristics were not measured in the present study, they may also impact mechanical efficiency. No changes occurred over time in most force application parameters, left-right symmetry, and intercycle variability during the 3-wk practice period; however, these variables may change on another time scale.

Alternative modes of manual wheelchair ambulation : An overview

van der Woude LHV, Dallmeijer AJ, Janssen TWJ, et al: Alternative modes of manual wheelchair ambulation: An overview. Am J Phys Med Rehabil 2001;80:765–777.An estimated 90% of all wheelchairs are hand-rim propelled, a physically straining form of ambulation that can lead to repetitive strain injuries in the arms and, eventually, to secondary impairments and disability. Further disability in wheelchair-dependent individuals can lead to a sedentary lifestyle and thereby create a greater risk for cardiovascular problems. Studies on lever-propelled and crank-propelled wheelchairs have shown that these propulsion mechanisms are less straining and more efficient than hand-rim–propelled wheelchairs. This article reviews these studies and substantiates that the frequent use of these alternative propulsion mechanisms may help prevent some of the secondary impairments that are seen among today’s wheelchair-user population.

COMPLICATIONS FOLLOWING SPINAL CORD INJURY: OCCURRENCE AND RISK FACTORS IN A LONGITUDINAL STUDY DURING AND AFTER INPATIENT REHABILITATION

OBJECTIVE To assess the occurrence and risk factors for complications following spinal cord injury during and after inpatient rehabilitation. DESIGN Multicentre longitudinal study. SUBJECTS A total of 212 persons with a spinal cord injury admitted to specialized rehabilitation centres. METHODS Assessments at the start of active rehabilitation (n=212), 3 months later (n=143), at discharge (n=191) and 1 year after discharge (n=143). RESULTS Multi-level random coefficient analyses revealed that complications were common following spinal cord injury. Most subjects reported neurogenic and musculoskeletal pain, or had spasticity at each assessment. During the year after discharge, complications remained common: urinary tract infections and pressure sores affected 49% and 36% of the population, respectively. The degree of pain decreased, whereas the degree of spasticity increased significantly during inpatient rehabilitation. Overall, increased age, increased body mass index, traumatic lesion, tetraplegia, and complete lesion all increased the risk of complications. CONCLUSION Complications are common following spinal cord injury. They need specific attention after discharge from inpatient rehabilitation and within subpopulations.

Relationship between manual wheelchair skill performance and participation of persons with spinal cord injuries 1 year after discharge from inpatient rehabilitation

This cross-sectional study describes the level of manual wheelchair skill performance and participation of persons with spinal cord injuries (SCIs) 1 year after discharge from inpatient rehabilitation and tests the hypothesis that wheelchair skill performance is positively related to participation. Participants included 81 persons with SCI from eight rehabilitation centers in the Netherlands. The Wheelchair Circuit consists of eight wheelchair skills and results in three test scores: ability, performance time, and physical strain. Participation was assessed with the sum of the subscales Mobility Range and Social Behavior of the 68-Item Sickness Impact Profile (SIPSOC). SIPSOC was moderately related to the ability score (the Spearman rank correlation [rS] = -0.49), the performance time score (rS = 0.54), and the physical strain score (rS = 0.38). The regression analyses showed that, after controlling for lesion and personal characteristics, manual wheelchair skill performance is positively related to participation, with the strongest association for the performance time score. In persons with SCI who are manual wheelchair users, wheelchair skill performance is moderately associated to participation. Training of wheelchair skills has to be an important goal of rehabilitation, and persons should be stimulated to maintain their wheelchair skills after discharge from rehabilitation.

Glenohumeral Contact Forces and Muscle Forces Evaluated in Wheelchair-Related Activities of Daily Living in Able-Bodied Subjects Versus Subjects With Paraplegia and Tetraplegia

OBJECTIVE To estimate the differences in glenohumeral contact forces and shoulder muscle forces between able-bodied subjects and subjects with paraplegia and tetraplegia during wheelchair-related activities of daily living (ADLs). DESIGN Kinematics and external forces were measured during wheelchair ADLs (level propulsion, weight-relief lifting, reaching) and processed by using an inverse dynamics 3-dimensional biomechanical model. SETTING Biomechanics laboratory. PARTICIPANTS Five able-bodied subjects, 8 subjects with paraplegia, and 4 subjects with tetraplegia (N = 17). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Glenohumeral contact forces and shoulder muscle forces. RESULTS Peak contact forces were significantly higher for weight-relief lifting compared with reaching and level propulsion (P < .001). High relative muscle force of the rotator cuff was seen, apparently needed to stabilize the joint. For weight-relief lifting, total relative muscle force was significantly higher for the tetraplegia group than for the able-bodied group (P = .022). CONCLUSIONS Glenohumeral contact forces were significantly higher for weight-relief lifting and highest over the 3 tasks for the tetraplegia group. Without taking paralysis into account, more muscle force was estimated for the subjects with tetraplegia during weight-relief lifting.

A kinetic analysis of manual wheelchair propulsion during start-up on select indoor and outdoor surfaces

The objective of this study was to conduct a kinetic analysis of manual wheelchair propulsion during start-up on select indoor and outdoor surfaces. Eleven manual wheelchairs were fitted with a SMART(Wheel) and their users were asked to push on a course consisting of high- and low-pile carpet, indoor tile, interlocking concrete pavers, smooth level concrete, grass, hardwood flooring, and a sidewalk with a 5-degree grade. Peak resultant force, wheel torque, mechanical effective force, and maximum resultant force rate of rise were analyzed during start-up for each surface and normalized relative to their steady-state values on the smooth level concrete. Additional variables included peak velocity, distance traveled, and number of strokes in the first 5 s of the trial. We compared biomechanical data between surfaces using repeated-measures mixed models and paired comparisons with a Bonferroni adjustment. Applied resultant force (p = 0.0154), wheel torque (p < 0.0001), and mechanical effective force (p = 0.0047) were significantly different between surfaces. The kinetic values for grass, interlocking pavers, and ramp ascent were typically higher compared with tile, wood, smooth level concrete, and high- and low-pile carpet. Users were found to travel shorter distances up the ramp and across grass (p < 0.0025) and had a higher stroke count on the ramp (p = 0.0124). While peak velocity was not statistically different, average velocity was slower for the ramp and grass, which indicates greater wheelchair/user deceleration between strokes. The differences noted between surfaces highlight the importance of evaluating wheelchair propulsion ability over a range of surfaces.

Wheelchair skills tests: a systematic review

Objective: To describe and compare the content, feasibility, outcome parameters, and clinimetric properties of the manual wheelchair skills tests reported in the literature. Design: A systematic literature search was conducted in MEDLINE, EMBASE, PsychINFO and Current Contents. Tests were selected if they were observational tests, designed for subjects using hand-rim wheelchairs and were intended to assess wheelchair skill performance at the activity level. Results: The search resulted in 34 papers, in which 24 different wheelchair skills tests were described. The skill most frequently included was wheelchair propulsion, consecutively followed by transferring, negotiating kerbs, ascending slopes, traversing tracks, sprinting and performing a wheelie. The three most frequently used outcome parameters were task performance time, independency of task performance, and physical strain during skill performance. Sensitivity to change was evaluated in three tests, validity in 10 tests, and reliability in nine tests. Conclusions: Many tests are applied to measure wheelchair skill performance using different tasks and outcome measures. This makes it difficult to compare study results. Consensus among researchers as to which skills must be included as well as to standardization of the use of measurement instruments will reduce this problem and will additionally lead to a better insight in the quality of tests.

Duration and functional outcome of spinal cord injury rehabilitation in the Netherlands

This study describes the length of stay (LOS) and functional outcome of spinal cord injury (SCI) in the Netherlands and its determinants. Data of 157 patients from eight rehabilitation centers were available. Mean age was 40.0 years and 76.4% were traumatic injuries, 39.8% had tetraplegia, and 69.9% had a motor complete SCI. Median LOS was 240 days (interquartile range 164-322). Median motor Functional Independence Measure (FIM) scores at discharge were 37.3 for persons with complete tetraplegia and 69.7 for persons with complete paraplegia. Level and completeness of injury, bed rest because of pressure sores, and LOS were predictors of motor FIM scores. Duration of SCI rehabilitation in the Netherlands is long compared with the literature. Functional outcome appears slightly better in persons with complete tetraplegia, but not in persons with complete paraplegia when compared with data from the United States. International studies are necessary to reveal strengths and weaknesses of SCI rehabilitation systems in different countries.

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.