Thomas W. J. Janssen

Biomechanics and physiology in active manual wheelchair propulsion.

Manual wheelchair propulsion in daily life and sports is increasingly being studied. Initially, an engineering and physiological perspective was taken. More recently a concomitant biomechanics interest is seen. Themes of biomechanical and physiological studies today are performance enhancing aspects of wheelchair use and the ergonomics of wheelchair design. Apart from the propulsion technique the focus of biomechanics research of manual wheelchair propulsion is mainly towards injury mechanisms, especially phenomena of overuse to the upper extremity. Obviously, the vehicle mechanics of wheelchairs must be included within this biological framework. Scientific research is progressing, but is still hampered by methodological limitations, such as the heterogeneity and small numbers of the population at study as well as the inconsistency of employed technologies and methodologies. There is a need for consensus regarding methodology and research strategy, and a strong need for collaboration to improve the homogeneity and size of subject groups and thus the power of the experimental results. Thus a sufficiently strong knowledge database will emerge, leading to an evidence-base of performance enhancing factors and the understanding of the risks of wheelchair sports and long-term wheelchair use. In the light of the current biomechanical and physiological knowledge of manual wheelchair propulsion there seems to be a need for the stimulation of other than hand rim propelled manual wheelchairs.

Physical strain in daily life of wheelchair users with spinal cord injuries.

Forty-three men (age 33 +/- 9 yr) with spinal cord injuries (SCI) were observed during a normal workday while heart rate was recorded continuously. Physical strain was estimated using the heart rate response expressed relative to the individual heart rate reserve (%HRR). The mean physical strain during the day for group I (C4-C8, N = 9), II (T1-T5, N = 6), III (T6-T10, N = 15), and IV (T10-L5, N = 13) was 38 +/- 8, 29 +/- 12, 22 +/- 8, and 23 +/- 5%HRR, respectively. Prolonged periods (> 15 min) of high strain (> 60%HRR) that might maintain or improve physical capacity were not identified during activities of daily life (ADL), but only during sports activities. The analysis of activity-related strain revealed that specific ADL such as making transfers, entering/leaving car, and negotiating environmental barriers, provoked high levels of strain, especially in those with quadriplegia. Periods of peak strain (> 60%HRR, < 3 min) occurred frequently, also predominantly in those with quadriplegia. It was concluded that the physical strain during ADL is related to the level of lesion and is not of a magnitude and duration that would maintain or improve physical capacity. The periods of peak strain might restrict the mobility and independence of persons with SCI, and, therefore, reduce their quality of life.

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.

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.

Intrinsic muscle strength and voluntary activation of both lower limbs and functional performance after stroke.

The objective of this study was to assess the nature of muscle weakness in both legs after stroke compared with able‐bodied control individuals and to examine whether there is a relationship between the degree of muscle weakness and coactivation of knee extensors and flexors as well as voluntary activation capacity of knee extensors of both paretic and non‐paretic legs and indices of functional performance. Maximal voluntary isometric torques of knee extensors (MVCe) and flexors (MVCf) were determined in 14 patients (bilaterally) and 12 able‐bodied controls. Simultaneous measurements were made of torque and surface EMG from agonist and antagonist muscles. Coactivation was calculated. Supramaximal triplets were evoked with electrical stimulation to estimate maximal torque capacity and degree of voluntary activation of knee extensors. MVCs, activation and coactivation parameters were correlated to scores of seven functional performance tests. MVCe, MVCf and voluntary activation were lower in paretic lower limb (PL) compared with both non‐paretic lower limb (NL) and control. Besides, all these parameters of NL were also lower than control. Electrically evoked torque capacity of knee extensors of PL was about 60% of both NL and control, which were not significantly different from each other. Strong significant correlations between strength, as well as voluntary activation, and functional performance were found. Coactivation did not correlate well with functional performance. Thus, whereas for NL activation failure can explain weakness, for PL both activation failure and reduced intrinsic torque capacity are responsible for the severe weakness. Activation capacity and muscle strength correlated strongly to functional performance, while coactivation did not.

Relationship between physical strain during standardised ADL tasks and physical capacity in men with spinal cord injuries

To describe physical strain during activities of daily living (ADL), 44 men with spinal cord injuries (C4-L5) performed a set of standardised tasks. The physical strain was defined as the highest heart rate response expressed as a percentage of the individual heart rate reserve (%HRR). The physical strain averaged over the subjects who performed all tasks (n = 24) was (mean ± SD): 20.2 ± 7.2 %HRR (washing hands), 20.4 ± 7.3 %HRR (passing a side-hung door), 28.8 ± 10.8 %HRR (transfer to a toilet), 31.2 ± 13.1 %HRR (ascending an 8 cm curb), 33.9 ± 12.0 %HRR (transfer to a shower seat), 35.1 ± 10.5 %HRR (transfer to bed), 36.4 ± 13.3 %HRR (preparing lunch), 37.1 ± 12.0 %HRR (washing up), 38.7 ± 14.9 %HRR (ascending a ramp), 39.8 ± 15.6 %HRR (transfer to a shower wheelchair), 41.4 ± 12.1 %HRR (changing sheets), and 45.9 ± 10.4 %HRR (entering a car). Physical strain could be notably high, but large variations among subjects were present. During all tasks, subjects with tetraplegia had significantly higher levels of strain than subjects with low (T6-L5) lesions. Physical strain was inversely related to parameters of physical capacity: isometric strength (r: -0.34 to -0.72), sprint power (r: —0.34 to -0.69), peak oxygen uptake (r: -0.41 to -0.81) and maximal power output (r: -0.52 to -0.82). Parameters of physical capacity were better predictors of physical strain than was the lesion level, and explained 37-71% of the variance in strain during ADL. It was also concluded that the method used in this study provides a quantitative and objective estimation of physical strain and may therefore be a useful tool to identify task difficulty during rehabilitation and to evaluate the results of task and physical training on the physical strain during ADL.

Changes in physical strain and physical capacity in men with spinal cord injuries

To determine longitudinal changes in physical capacity and physical strain during activities of daily living (ADL), 37 men with spinal cord injuries (C4/5-L5) performed an exercise test and various ADL on two occasions (T1 and T2; interval 34.5 +/- 1.5 months). Parameters of physical capacity were aerobic power (VO(2peak)) and maximal power output (PO(max)). Physical strain was estimated by the heart rate response relative to the heart rate reserve. VO(2peak) at T2 (1.75 +/- 0.55 1*min(1)) did not significantly differ from that at T1 (1.67 + 0.47 1*min(-1)). Absolute PO max improved (P < 0.05) from 64.9 +/- 25.9 (T1) to 71.7 +/- 27.2 W (T2), whereas relative PO(max) did not change. Activity level, time since injury, change in body mass, and occurrence of rehospitalization were the most important predictors of changes in physical capacity. Changes in relative VO(2peak) were related (P < 0.05) to changes in strain during transfers to the shower wheelchair (r = -0.39) and shower seat (r = -0.46), and during the curb ascent (r = -0.47). In conclusion, the hypothesized decline in physical capacity did not occur over the 3-yr period. Maintenance of physical capacity, which may in part be achieved through sport participation and improved medical care, together with avoidance of excessive body mass, may be useful to prevent high levels of strain during ADL.

Isometric strength, sprint power, and aerobic power in individuals with a spinal cord injury

This study investigated in rather specific wheelchair tests the relationships among estimates of isometric upper-body strength (Fiso), sprint power (P30), aerobic power (VO2peak), and maximal power output (POaer) in a group of 44 men (age 34 +/- 12 yr) with longstanding spinal cord injuries ranging from C4/C5 to L5. Fiso was defined as the maximum force that could be exerted on the blocked rims of a stationary wheelchair ergometer. The estimation of P30 involved the measurement of the mean power during a 30-s all-out sprint test on the same wheelchair ergometer. VO2peak and POaer were determined as the peak oxygen uptake and highest sustained power output during a discontinuous progressive maximal exercise test on a motorized treadmill, while subjects used their own daily use wheelchair. Fiso ranged from 1.5 N.kg-1 (mean of both arms) in the group with quadriplegia to 3.4 N.kg-1 in the group with lowest-lesions, and P30 ranged from 0.5 to 1.5 W.kg-1 among the subjects. VO2peak ranged from 13.6 ml.kg-1.min-1 in the group with quadriplegia to 31.3 ml.kg-1.min-1 in the group with lowest-lesions, and POaer ranged from 0.4 to 1.1 W.kg-1. Strong positive relationships (r = 0.81-0.92) were demonstrated among all variables. Regression equations among variables were calculated: P30 = 0.51 Fiso - 0.18 (R2 = 0.75); POaer = 0.34 Fiso - 0.02 (R2 = 0.66); POaer = 0.67 P30 + 0.11 (R2 = 0.81); VO2peak = 6.52 Fiso + 4.15 (R2 = 0.76); VO2peak = 12.03 P30 + 7.43 (R2 = 0.77); VO2peak = 16.81 POaer + 6.44 (R2 = 0.84).(ABSTRACT TRUNCATED AT 250 WORDS)

Coronary heart disease risk indicators, aerobic power, and physical activity in men with spinal cord injuries

OBJECTIVE To compare the lipid and (apo-)lipoprotein profile and blood pressure of men with long-standing spinal cord injuries (SCI) to those of an age-matched able-bodied (AB) population, and to assess the most important determinants of this profile and blood pressure. DESIGN A cross-sectional study of persons with chronic SCI residing in the community. SETTING Tests were performed in a university research laboratory. SUBJECTS Thirty-seven men (age 37.4 +/- 12.0 yrs) with longstanding (14.7 +/- 8.6 yrs) SCI ranging from level C4/5 to L5 volunteered to participate. Comparisons were made with published data from 3,498 AB men, age 20 to 59 yrs, from the same country. MAIN OUTCOME MEASURES Lipid and lipoprotein profile (total cholesterol [TC], high-, low-, and very low-density lipoprotein cholesterol [HDL-C, LDL-C and VLDL-C, respectively], and triglycerides [TG]), as well as aerobic power, activity level, anthropometric variables, and blood pressure. Multiple regression analyses assessed the most important determinants of the lipid and blood pressure profile. RESULTS None of the lipid variables were related to the lesion level. TC, HDL-C, and TC/HDL-C were not significantly different from the AB population. The most important determinants of TC, LDL-C, and the ratios TC/HDL and HDL-C/LDL-C were age, smoking behavior, and activity level. Aerobic power was not an important determinant of any lipid or (apo-)lipoprotein or blood pressure. CONCLUSION Men with long-standing SCI do not appear to have an essentially different coronary heart disease risk profile compared with AB persons. Modifiable risk factors such as activity level, smoking, alcohol consumption, body mass index, and adipose tissue were more important than lesion level and aerobic power in the determination of the lipid and lipoprotein profile, suggesting several potential interventions.

Effects of electric stimulation-assisted cycling training in people with chronic stroke.

OBJECTIVE To evaluate whether leg cycling training in subjects with chronic stroke can improve cycling performance, aerobic capacity, muscle strength, and functional performance and to determine if electric stimulation (ES) to the contralateral (paretic) leg during cycling has additional effects over cycling without ES. DESIGN A randomized controlled trial, with a partial double-blind design. SETTING A rehabilitation center. PARTICIPANTS Twelve stroke patients (range, 18-70 y), more than 5 months poststroke, with lower-extremity hemiparesis. INTERVENTION Subjects were randomly assigned to groups that performed cycling exercise, one with ES evoking muscle contractions and a control group with ES not evoking muscle contractions. Subjects, blinded for group assignment, trained twice a week for 6 weeks. MAIN OUTCOME MEASURES Changes in aerobic capacity and maximal power output, functional performance, and lower-limb muscle strength. RESULTS Aerobic capacity and maximal power output significantly increased by 13.8%+/-19.1% and 38.1%+/-19.8%, but muscle strength was not significantly enhanced after training. Functional performance improved (ie, scores on the Berg Balance Scale increased by 6.9%+/-5.8% (P=.000) and the six-minute walk test improved by 14.5%+/-14.1% (P=.035). There was no significant effect on the Rivermead Mobility Index (P=.165). Training-induced changes were not significantly different between the 2 groups. Changes in cycling performance and aerobic capacity were not significantly related to changes in functional performance. CONCLUSIONS This study showed that a short cycling training program on a semirecumbent cycle ergometer can markedly improve cycling performance, aerobic capacity, and functional performance of people with chronic stroke. The use of ES had no additional effects in this specific group of subjects with chronic stroke.