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10 mm10,9 mm

Low-intensity wheelchair training in inactive people with

long-term spinal cord injury

Low

-inten

sity wh

eelchair train

ing

in in

active peo

ple w

ith lo

ng

-term sp

inal co

rd in

jury

Jan van

der Sch

eer

Uitnodigingvoor het bijwonen van de openbare verdediging van

het proefschrift

Low-intensity wheelchair training

in inactive people with long-term

spinal cord injury

door Jan van der Scheer

Op woensdag 18 maart 2015 om 12.45 preciesin de aula van het

Academiegebouw van de Rijksuniversiteit Groningen

Broerstraat 59712 CP Groningen

Aansluitend op de verdediging vindt er een receptie plaats, waarvoor

u ook van harte bent uitgenodigd.

Paranimfen

Ruben [email protected]

Jan [email protected]

Jan van der Scheer

Door verlamming en een rolstoelgebonden leven is het moeilijk voor mensen met een

Low-intensity wheelchair training in inactive people with long-term spinal cord injury

Jan van der Scheer

This thesis was part of research program ‘Active LifestyLe Rehabilitation Interventions in aging Spinal Cord injury’ (ALLRISC), funded by FondsNutsOhra under responsibility of ZonMw (project number 89000006). ALLRISC is embedded in the Spinal Cord Injury investigatiOn Network Netherlands (www.scionn.nl) and conducted in collaboration with the Dwarsleasie Organisatie Nederland (DON) and the Nederlands-Vlaams Dwarslaesie Genootschap. A randomized controlled trial was conducted at rehabilitation centers UMCG location Beatrixoord (Haren, the Netherlands) and Heliomare (Wijk aan Zee, the Netherlands). Pilot studies were conducted at the Center for Human Movement Sciences, University of Groningen, University Medical Center Groningen (the Netherlands) and the Faculty of Human Movement Sciences, VU University Amsterdam (the Netherlands).Ph.D. training was facilitated by research schools of Behavioural and Cognitive Neuroscience (BCN) and Research Institute SHARE.

• University of Groningen

• University Medical Center Groningen

• Hollister B.V.

• Mediq CombiCare• Lode Holding B.V.: ProCare B.V., Lode B.V. and Umaco B.V.• Double Performance

All right reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording or any information storage or retrieval system, without written permission from the author.

Low-intensity wheelchair training in inactive people with long-term spinal cord injury

Proefschrift

ter verkrijging van de graad van doctor aan deRijksuniversiteit Groningen

op gezag van de

De openbare verdediging zal plaatsvinden op

door

Jan Willem van der Scheer

geboren op 25 april 1986te Apeldoorn

PromotoresProf. dr. L.H.V. van der Woude

CopromotorDr. S. de Groot

Beoordelingscommissie

Prof. dr. Y.C. Vanlandewijck

Chapter 1 General introduction Chapter 2

level

Chapter 3

spinal cord injury

Chapter 4 Can a 15m-overground wheelchair sprint be used to assess

Chapter 5 spinal cord injury

Chapter 6 Low-intensity wheelchair exercise in inactive people with

Chapter 7 Low-intensity wheelchair training in inactive people with long-term spinal cord injury: a randomized controlled trial on propulsion technique

Chapter 8 General discussion

Appendix

duration on physical capacity

Nederlandse samenvatting

Dankwoord

About the author

6

9

21

39

59

77

95

119

137

155

171

177

183

187

Contents

(25-75th)= interquartile range

injury

bpm = beats per minute

wheelchair-push testHR = heart rateHRmax = maximal heart rateHRpeak = peak heart rate in a peak wheelchair exercise testHRR = heart rate reserve

meanVelocity-15 m = 15 m divided by stopwatch time

wheelchair exercise test

wheelchair exercise test

wheelchair sprint

based 30-s sprintPA = physical activityPara = paraplegia

List of abbreviations

PO = power output

exercise test

wheelchair sprintRC = rehabilitation center

test

submaximal wheelchair exercise test

submaximal wheelchair exercise test

VO2peak = highest 30-s mean oxygen uptake in peak wheelchair exercise test

exercise test

exercise test

Chapter 1

General introduction

1

Chapter 1

Chapter 1

10

st 1-3 -

3-6

7-9

11-16

developing inactivity-related complications as well as other secondary health compli--

20 while upper-body musculoskeletal pain is thought to result

30-33

while simultaneously reducing ---

on evidence in other popula-tions and preliminary studies

36-38

reducing secondary health complications such as up-

Figure 1. Associations assumed among an active lifestyle,

time since injury, as described for people with spinal cord injury by Van der Woude et al.27 Figure adapted.27

Chapter 1 General introduction

11

1

-

27

-

27 As such, ALLRISC is a continuation of a previous multicenter research program, which consisted of a longi-tudinal cohort study on physical capacity and strain of people with SCI during and up

Both research programs are embedded in the Dutch SCI clinical rehabilitation network.44 ALLRISC is funded by FondsNutsOHRA under responsibility of ZonMw. Program-wide outcomes of ALLRISC were formulated

Disorders, diseases: Spinal cord injury,

secondary complications, co-morbidity

Activities:

Hand- & arm functionality, basic & complex (wheelchair)

skills, ADL independence

Functions and anatomical properties:

Cardiovascular & respiratory function, musculoskeletal function, motor & sensory

functions

Participation:

Work, school, sports, family,

friends

Environmental factors:

Rehabilitation treatment, strategy, practice, (aftercare)

training

Personal factors:

Age, gender, training status, education

Health status in Spinal Cord Injury

Figure 2 -ganization applied to people with spinal cord injury.46,47 This model was used in formulating program-wide outcomes of research program ALLRISC.27 Figure reprinted.47

Chapter 1

12

-al cohort study and three randomized controlled trials (RCTs) in which self-manage-ment or exercise interventions were employed. The objective of the cross-sec-

secondary health complications in people with long-term SCI, in addition to studying the impact of these conditions on the program-wide outcomes of ALLRISC. The study consisted of an aftercare check-up in eight SCI-specialized rehabilitation centers in the Netherlands. Participants with the lowest physical activity levels were also invited for

intervention aimed at stimulating active lifestyle and teaching self-management skills in inactive people with long-term SCI. Objective of the other two RCTs was to evaluate different forms and doses of exercise in inactive people with long-term SCI.48,49 The

-creasing an active lifestyle and reducing risk of secondary health complications related to upper-body overuse and lower-body disuse.48,49 One of these interventions consisted of low-intensity wheelchair training and was the focus of this thesis.

2). In inactive or deconditioned populations, however, it is suggested that such exercise intensities may lead to low adherence, dropout and musculoskeletal injury. Further-more, it has been found that higher wheelchair exercise intensities lead to increased upper-body joint loads, which could contribute to upper-body pain of people with SCI. As a safer and more feasible alternative for inactive or deconditioned popula-

6 Low-intensity

Table 1.6,55

Exercise intensity % HRR RPE on 1-10 scale56

Low 30-40 1-3

Moderate 41-60 4-6

Vigorous 61-90 7-10


13

1Table 2.

Term

Wheelchair training

-pulsion tests, as assessed based on anaerobic work capacity,

capacity.47

Wheelchair skill performance Variety of manual wheelchair skills necessary to deal with physical barriers encountered in daily life.57,58 It can be assessed using a test battery such as the Wheelchair Circuit, which includes tests such as crossing a doorstep, propulsion on a slope, a circuit-of-eight and a 15 m-sprint.59

Force and timing parameters based on contact between hand

contact angle.60,61

However, low-intensity wheelchair training has not yet been systematically evaluated in inactive or deconditioned people with long-term SCI. Pre-liminary studies are available on low-intensity wheelchair training in able-bodied groups, novice to wheelchair propulsion (appendix).62-64 After ex-ercising for seven weeks, three times a week for

(appendix).62-64 It is also not known whether low-in-tensity wheelchair training in people with SCI leads to improved physical activity levels

Also not known are the effects of low-intensity wheelchair training on propulsion technique (table 2) in people with SCI. Changing propulsion technique has been proposed as a way to reduce joint damage that might occur during manual wheelchair propulsion in daily life.60 Favorable changes in propulsion technique, such as reduced push frequency, have been found in long-term wheelchair users performing relatively high-intensity training as well as able-bodied novices performing low-intensity wheelchair training.

A multicenter RCT was conducted in a group of physically inactive manual wheel-49

Figure 3. Wheelchair propulsion using a motor-driven treadmill.

Chapter 1

14

group was not offered any intervention. Measurements were performed in both groups

--

sion technique. Measurements and exercise took place in two SCI-specialized reha-bilitation centers (Heliomare, Wijk aan Zee and University Medical Center Groningen, location Beatrixoord, Haren, the Netherlands).

Table 3. Selection criteria in the randomized controlled trial. 49

Inclusion criteria

Aged 28-65 years

68,69

Exclusion criteria

Cardiovascular contra-indications for testing according to ACSM guidelines70

wheelchair propulsion

-

Low-intensity wheelchair training No intervention provided

No intervention provided

Exercise group

Control group

T1 T2 T3 T4Measurement

Week 0 8 16 42

Figure 4. 49


15

1

The aim of this thesis was to study the effects of low-intensity wheelchair training on

propulsion technique in physically inactive people with long-term SCI. Chapter 2

work capacity in a cohort with long-term SCI. Aim of this study was to investigate the

-

confounders in personal and lesion characteristics. Furthermore, differences were studied between participants able or not able to perform a peak wheelchair exercise test, providing insight into potential selection bias and the extent in which results could be generalized to the population with long-term SCI.

Chapter 3 is a detailed description of the design and methodology in the multi-center RCT on low-intensity wheelchair training. Working mechanisms underlying this type of training are also discussed in this chapter.

Since the multicenter RCT took place in rehabilitation centers, feasible tests were

-surement wheel to determine power output. Whether this test could be used to assess

chapter 4. Aim of the cross-sectional study in chapter 5 was to provide insight into several

SCI. For this purpose, baseline personal and lesion characteristics were described of the group that participated in the RCT, in addition to providing a description of wheel-

-

since strong associations would imply that several tests may not be necessary for as-

Chapter 6 is an evaluation of the effects of the training in the RCT on wheel-

inactive group with long-term SCI. Chapter 7 focuses on effects of the training on pro-pulsion technique.

Last, in chapter 8providing suggestions for future research and clinical implications.

Chapter 1

16

-

-

-


17

1

-

-

-

-

-

Chapter 1

18

-

-

--

-

-


19

1

Chapter 2

Disabil Rehabil. Submitted 2014

2

Chapter 2

22

N

(peak power output [POpeak] and peak oxygen uptake [VO2peak]) was assessed

N

p p

tetraplegia (p -

Chapter 2

23

21

2 participation3 Previous

(POpeak) and peak oxygen uptake (VO2peak) measured during a graded wheelchair -

5 6

9

et al.10

-et al.11

-

5 -

-

ParticipantsThis cross-sectional study among persons with long-term SCI in the Netherlands was part of the research program ‘Active LifestyLe Rehabilitation Interventions in aging

Chapter 2

24

Spinal Cord injury (ALLRISC).

dependent (hand-rim propelled or electric wheelchair) at least for longer distances

respond to an oral interview or to understand the test instructions.

Design 13 Random samples were drawn

Graded peak wheelchair exercise test

-1

Oxygen uptake and heart rate (HR) were continuously measured during the test

-1

Personal and lesion characteristics

-

15

Chapter 2

25

2-

(kg) divided by height (m2

Questionnaires

16 which requests the number

-1

-1

than the 75th -1 17 which

12 -

18 An

both upper extremities were summed to obtain an upper-extremity pain score (range: 18

StatisticsIndependent t

t- -

-

-icance was set at p

Chapter 2

26

Participants vs. non-participants

-

N

p

p p

(pscore (p p

Seventeen participants who were medically approved to participate in the peak exercise test dropped out due to equipment problems, not being able to perform the test at the selected speed, high systolic blood pressure or musculoskeletal pain at the neck and shoulder during the preceding submaximal exercise tests.

Total group N=213

Non-participants n=75

No contra-indications

n=120

Cardiovascular contra-indications

but positive medical advice n=7

Missing information

n=7

Other contra-indications

but positive medical advice n=4

Cardiovascular contra-indications

negative medical advice n=20

Using power wheelchair

n=30

Home visit, participated only in

questionnaires n=5

Other reason n=11

Not willing to participate in exercise tests

n=3

Missing information

n=6

Participants n=138

Figure 1.including reasons for non-participation among which contra-indications.

Chapter 2

27

2

Table 1. -

Outcome Participants Non-participants

N N p

138 75 0.34

138 75 0.01

m2 138 75 0.01

129 66 0.001

138 70 0.008

137 74

138 74 0.13

137 75 0.02

138 75 0.10

day-1 132 65 0.001

p based on comparison between participants and non-participants.16

Effect of time since injury and physical activity

p

VO2peak (p p

p

p

--

plegia (p -ship with POpeak in the total group (p(p

Chapter 2

28

Tab

le 2

. g

rou

p a

nd

gro

up

s w

ith

a te

trap

leg

ia a

nd

par

aple

gia

sep

arat

ely.

PO

pea

k (W

)-1

)H

Rp

eak

(bp

m)

RER

pea

k

TSI c

oh

ort

Np

Np

Np

Np

Tota

l10

-19

y48

0.24

480.

1948

0.50

480.

17

20-2

9 y

4342

4447

3230

3031

Tetr

a10

-19

y26

0.92

250.

5425

0.94

250.

28

20-2

9 y

2122

1923

1615

1516

Par

a10

-19

y22

0.04

230.

0123

0.04

230.

15

20-2

9 y

2220

2524

a15

b14

b14

14a b

Chapter 2

29

2

Tab

le 3

. in

dep

end

ent v

aria

ble

an

d le

sio

n a

nd

per

son

al c

har

acte

rist

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as c

on

fou

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ers.

Res

ult

s ar

e sh

ow

n fo

r th

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tal g

rou

p a

nd

for p

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le w

ith

a te

trap

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ia

and

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sep

arat

ely.

Tota

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Par

a

PO

pea

k (W

)-1

)P

Op

eak

(W)

-1)

PO

pea

k (W

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)

pp

pp

pp

Co

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ant

0.32

0.06

0.78

0.58

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05

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Lesi

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32-

0.02

--

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0.96

-0.

110.

18-

0.81

c-

0.03

0.01

-

a b c

Chapter 2

30

Tab

le 4

.

PO

pea

k (W

)-1

)H

Rp

eak

(bp

m)

RER

pea

k

Co

ho

rtN

pN

pN

pN

p

Tota

lA

ctiv

e91

0.02

880.

0892

0.11

940.

97

Inac

tive

2626

2426

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aA

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e52

0.01

510.

0548

0.52

530.

41

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99

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0.86

360.

9243

0.29

400.

20

Inac

tive

1717

1517

Ab

bre

viat

ion

s: s

ee ta

ble

2.

Chapter 2

31

2

Tab

le 5

. as

ind

epen

den

t va

riab

le a

nd

lesi

on

an

d p

erso

nal

ch

arac

teri

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s as

co

nfo

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der

s. R

esu

lts

are

sho

wn

for

the

tota

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up

an

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r p

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le w

ith

a t

etra

-p

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a

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pea

k (W

)-1

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(W)

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PO

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)

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020.

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26

Lesi

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Chapter 2

32

--

6 Older people might have more contra-indications

-et al 6 -

and a positive association 20

18 21 show more upper-extremity -

17

6

-1

6 When comparing 22

-

Chapter 2

33

2

in wheelchair athletes can remain stable over a 20-years period when they continue in 11 -

-

-

17 22

25 participation3 it is important to pay

et al 26

27 It is a challenge to help people

28

sports27

Limitations

29

Chapter 2

34

-

-

»-

»

»

»

»

» » » » » »

»

»

»

Chapter 2

35

2

» » » » »

»

Chapter 2

36

-

-

-

-

-

-

Chapter 2

37

2

-

-viduals with

Chapter 3

Design of a randomized-controlled trial on

low-intensity aerobic wheelchair exercise for

inactive persons with chronic spinal cord injury

Jan W. van der Scheer

Sonja de Groot

Klaas Postema

DirkJan (H.E.J.) Veeger

Lucas H.V. van der Woude

Disabil Rehabil 2013; 35: 1119-1126

3

Chapter 3

40

wheelchair users (aged 28-65y) with chronic paraplegia or tetraplegia (time since

-

Chapter 3 Design of the RCT

41

13

1

2 3

-

1 As a

9

9

-

10

12 13 prescribing moderate to vigorous aerobic intensities

--

15

Table 1.College of Sports Medicine.16

Measure of intensity Relative intensity

17-19 -17

Chapter 3

42

19

16

--

-

22 23 Although -

25

Figure 1.

aWheelchair skill performance and physical activity levels


43

13

26

-27

-

29

2 Another mechanism leading to improved propulsion technique during low-inten-

30

31

-

»

»levels);

» lead to an optimized propulsion technique; and »

32

Chapter 3

44

Participants

-

Table 2.

Inclusion criteria

Aged 28-65 years

Exclusion criteria

Cardiovascular contra-indications for testing according to the ACSM guidelines33

-cate performance of wheelchair propulsion

-34


45

13

Design

All exercise tests and training sessions will be conducted within the two rehabili--

Randomization-

Table 3. Group size and allocation ratio of the two rehabilitation centers.

RC 1 RC 2

3:2 1:2

5 or 10 3 or 6

N 25 15

N 15 5

N 10 10

Figure 2.

Low-intensity wheelchair training No intervention provided

No intervention provided

Exercise group

Control group

T1 T2 T3 T4Measurement

Week 0 8 16 42

Chapter 3

46

Table 4.

Exercise (min)

Exercise + rest (min)

Exercise blocks (N)

Rest between exercise blocks

(min)

Week 1

18 23 6 1

18 28 6 2

18 28 6 2

Week 2

24 29 6 1

24 34 6 2

24 38 8 2

Week 3-7

30 31-35 2-6 1

30 33-40 4-6 1-1.5

30 39-48 10 1-1.5

Week 8-16

30 30 1 0

30 33 4 1

30 39 10 1

A 16-week low-intensity aerobic wheelchair exercise program will be employed; partic-ipants conduct two 30-minute sessions per week on a motor-driven treadmill (center

- In some persons

37

38

21

-1 and can be lower depending


47

13

-

-

38

Outcomes

-

--

Chapter 3

48

Tab

le 5

.

Ou

tco

me

mea

sure

Inst

rum

enta

tio

nT1

T2T3

T4

35

XX

XX

35X

XX

X35

XX

XX

An

aero

bic

wo

rk c

apac

ity

15m

ove

rgro

un

d w

hee

lch

air s

pri

nt3

5X

XX

X

Iso

met

ric

stre

ng

thIs

om

etri

c w

hee

lch

air p

ush

43X

XX

X

Seco

nd

ary

ou

tco

mes

Up

per

-bo

dy

pai

n44

Qu

esti

on

nai

re o

n m

usc

ulo

skel

etal

up

per

-bo

dy

pai

n8

45

XX

XX

Up

per

-bo

dy

dis

com

fort

42X

XX

X

Sho

uld

er lo

ad46

Xa

Xa

28,4

7X

XX

X

Wh

eelc

hai

r ski

ll p

erfo

rman

ceW

hee

lch

air C

ircu

it35

XX

XX

34

Mec

han

ical

wh

eelc

hai

r od

om

eter

48

XX

XX

Sup

ple

men

tary

ou

tco

mes

Dem

og

rap

hic

s an

d

envi

ron

men

tal

XX

bX

bX

b

Lesi

on

leve

lA

SIA

ass

essm

ent

X XX

bX

bX

b


49

13

Go

nio

met

er-m

easu

red

an

gle

s o

f sh

ou

lder

, elb

ow

an

d w

rist

join

tsX

Xb

Xb

Xb

Wh

eelc

hai

r sa

tisf

acti

on

an

d

sitt

ing

co

mfo

rt49

XX

XX

Met

abo

lic h

ealt

h50

Xc

XX

51

5 2X

XX

X

Fati

gu

e53

XX

XX

Mo

od

54X

XX

X55

XX

XX

Qu

alit

y o

f life

56X

XX

X

Ind

epen

den

ce57

XX

XX

Forc

ed s

pir

om

etry

mea

sure

men

ts21

XX

XX

a b S

yste

mat

ic a

sses

smen

t, b

y re

sear

cher

an

d p

aram

edic

rese

arch

ass

ista

nt,

wh

eth

er th

ere

are

chan

ges

rela

tive

to th

e T1

mea

sure

men

t.c N

ot p

erfo

rmed

in o

rder

to re

du

ce p

arti

cip

ant b

urd

en.

Chapter 3

50

Peak and submaximal wheelchair exercise test

35

-

-

-

-

-1

58

35

15m overground wheelchair sprint

Anaerobic work capacity will be based on PO during a 15m overground wheelchair 35

-

Isometric wheelchair push

It can be seen as an isometric wheelchair push with -


51

13

Self-report questionnaires on upper-body pain

-

8 shown 60 -

Local Perceived Discomfort (LPD) scale

- similar to a protocol used to study handcycling in able-bodied

61

61 It

Figure 3. Set-up of the isometric wheelchair push used to assess isometric strength. See chapter 5 for a schematic presentation of the set-up.

Chapter 3

52

Propulsion technique

-28

2

Delft Shoulder and Elbow model

12

12

Wheelchair Circuit

-35

Physical Activity Scale for Individuals With Physical Disabilities (PASIPD)

Wheelchair odometer

Statistical analysis

62 and was based on two intervention studies: low-intensity aerobic wheelchair exercise in able-bodied persons and handcycle exercise in persons with tet-


53

1362

-

-

-

-

Chapter 3

54

-

-

-

--

-


55

13

-

-

-

-

-

-

Chapter 3

56

-

-


57

13

Chapter 4

Can a 15 m-overground wheelchair sprint be used to

Jan W. van der ScheerSonja de Groot

Riemer J.K. Vegter

Med Eng Phys 2014; 36: 432-438

4

Chapter 4

60

(PO) over a 15 m-overground wheelchair sprint test can be used to assess wheel-

-

based on stopwatch time (time and mean velocity over 15 m) and on PO (primary

-

r

2 p -1

2 p -r 2 p

It seems that outcomes based on stopwatch time over a 15 m-over-

-ed wheel can be implemented in rehabilitation practice and research settings when

Chapter 4 15 m-overground wheelchair sprint to assess anaerobic work capacity

61

14

-

6-8

-3

output outcomes over a Wingate-like sprint test in a wheelchair ergometer or roller --

Alternative tests

15-17 and as such has been implemented in rehabil-18 -

15

17

(r r 19 while others r 8

-

-20 In the

It is not yet known how PO is expressed in a 15 m-overground sprint and whether

Chapter 4

62

-

7 which resembles time needed to complete a 15 m-over-

-1

20 Able-bodied persons participated in this initial study on 15-m sprint outcomes

-25

on stopwatch time and PO over a 15 m-overground wheelchair sprint test can be used

ParticipantsN

Table 1. N

Characteristic Mean ± SD (range)

a

Fisoa

a Measured when hands were on top of the handrim.

Equipment


63

14

-

5 -

We used a custom-built stationary ergometer26 --

25 -mensions were adjusted so that it matched as closely as possible the wheelchair used

Protocol

with ergometer propulsion and learning to maintain the same relative velocity between

15-18

15

-

25 -

et al.27

Chapter 4

64

-

-1

-1

-1 or was unable to propel the wheel-

Data processing

28) and analyzed using 28

20

20

Statistics

p

r) and 2) were calculated between 15-m outcomes (time-15

p


65

14

29

-p

-

either time-15 m or P5-15m as the independent variable (step 1) and combined in step

0 1 2 3 4 5 6 7 8-100

-50

0

50

100

150

200

Time (s)

Unila

tera

l PO

(W)

PO (W)Push startPush stopPpeak-15m

P5 -15m

Pstart -15m

0 5 10 15 20 25 30-100

-50

0

50

100

150

200

Time (s)

Un

ilate

ral P

O (

W)

P5-WAnT

P30-WAnT

Figure 1.

last data point representing the start angle plus 15 m in radians.

-

-

-

263N.

Figure 2.

30s-wheelchair ergometer sprint and of the

over the 6 successive 5-s intervals of Win-

Chapter 4

66

All subjects (N-1

r and R2 that were calculated between 15-m sprint

r

2 p 2= p

between all outcomes (r p

Table 2.

N

PO outcome Unilateral PO (W) -1) -1)

38.1 ±14.0 1.8 ±0.3* 3.1 ±0.4*

46.3 ±17.0 1.0 ±0.2* 2.1 ±0.4*

228.0 ±71.6 N.A. 2.4 ±0.4

44.4 ±17.3 1.2 ±0.3 1.6 ±0.3

57.0 ±19.0 1.2 ±0.2* 1.5 ±0.3*Data in mean ±SD.

Table 3. -

N

P30-WAnT P5-WAnT

r R2 r R2

Time-15 m 0.38* 0.36*

MeanVelocity-15 ma 0.42* 0.39*

0.59** 0.56**

0.62** 0.61**

0.69** 0.61**

a Linear model without intercept


67

14

-

-

-1

-1

p

-1

p

2p

2p

2p

2p

0 1 2 3 4 5-100

-50

0

50

100

150

200

Unila

tera

l PO

(W)

Time (s)

0 1 2 3 4 5-1

0

1

2

3

Velo

city (

m/s)

Time (s)

15m sprintWAnT

15m sprintWAnT

Figure 4.

the interval of the highest successive 5-s

-gate-based 30s-wheelchair ergometer sprint

20 30 40 50 60 70 80 901.4

1.6

1.8

2

2.2

2.4

2.6

2.8

P5-WAnT (W)

Mean

Velo

city-

15m

(m/s)

Figure 3. Scatter plot of meanVelocity-15m N

line representing the linear model used to study the relationship between the outcomes over a data range than can be

15,16,19

Chapter 4

68

Table 4.

Time-15 m (s) P5-15m (W)

ß p R2 ß p R2

Step 1

Constant 120.36 24.01 7.84 7.59 0.316

15 m-outcome -10.50 3.29 0.005 0.38 0.96 0.19 0.61

Step 2

Constant 78.96 22.88 -7.01 14.95

15 m-outcome -11.53 2.64 0.001 0.88 0.20

0.70 0.21 0.005 0.63 0.26 0.22 0.265 0.63

Step 2

Constant 212.63 50.93 103.27 47.83

15 m-outcome -7.68 3.34 0.035 0.80 0.19 0.001a -1.06 0.53 0.061 0.50 -0.84 0.42 0.061 0.69

Step 2

Constant 104.77 23.63 17.04 11.13

15 m-outcome -7.50 3.43 0.044 0.81 0.23 0.002

-12.96 6.75 0.073 0.49 -6.97 6.24 0.278 0.64a Measured when hands were on top of the handrim. Abbreviations: ß 2

5-s intervals of 15 m sprint.

30 40 50 60 70-60

-50

-40

-30

-20

-10

0

10

Unilateral PO (W)

P5-1

5m -

P5-W

AnT

(W)

Figure 5. -

plotted indicating mean difference between the outcomes, while upper and lower lines indicate


69

14

over a 15 m-overground wheelchair sprint test can be used to assess wheelchair-spe-

-1 (table

-1

-

-

r

r

r

-sively starting to propel an inherently unstable wheelchair while this is not required in

-

-

in which

-

Chapter 4

70

-

-

same conclusion as based on the linear model tested in this study: stopwatch time over

r p -

-

during an interval with relatively low handrim velocities may stronger relate to

-1

r p

-


71

14

compared to P5-15m (also r

over Pstart-15m and Ppeak-15m since P5-15m is determined identically to the widely

25

a more homogeneous and well-accessible group compared to non-athletic wheelchair 25

-15

-

-

by time-15 m and P5-15m (both p

p

-ships between the tests in an able-bodied sample are similar in non-athletic wheel-

-8 and

27

We conclude that outcomes based on stopwatch time over a 15 m-overground sprint

-chair with an instrumented wheel can be implemented in rehabilitation practice and

-

Chapter 4

72

-


73

14

-

-

-

-

Chapter 4

74

-

-


75

14

Chapter 5

J Rehabil Med 2014. In press

Available ahead of print (doi: 10.2340/16501977-1934)

5

Chapter 5

78

determine: highest 5-s power output over 15-m overground sprinting (P5-15m);

th

-1

r p

P5-15m with POpeak (r p

Chapter 5

79

5

3-5 Physically inactive people -

6 -7

8-10

11-13

-

16-18

-

r

16

16

Chapter 5

80

-22

Participants-

23

22 -

conditions such as uncontrolled diabetes and thyrotoxicosis); musculoskeletal com-plaints contraindicating manual wheelchair propulsion; mental contraindications; and

Procedures and outcomes22

-

Anaerobic work capacity (15-m test)

Anaerobic work capacity was determined in a 15 m-overground sprint test in partici-25

-

Outcome was the highest mean unilateral power output over successive 5-s 25 -

ceptable given its strong association with outcomes on a Wingate-like test on a wheel-r 25

Isometric strength (isometric-push test)

81

5

13

Figure 1. 22

Peak aerobic work capacity (peak exercise test)

-

-1

-maximal treadmill propulsion; and an incremental exercise test in which the inclination

26

29

A/D converter + computer

Force transducer (1000 N)

Wall

Anchor point 1

Pulley (lightweight)

Wheelchair with participant

Push direction

Rope 1Rope 2Anchor point 2

Wheel axle

Anti-slip mat

Chapter 5

82

StatisticsDescriptive statistics were determined over the total group as well as subgroups with

(p -

p

r r

as r p

Participants

-1

Proceduresn n

n 5

-

(n=2) and peak test (n

-

occurred in POpeak (n n n

Description of outcomes

-1 -1

-

Chapter 5

83

5

Table 1.

Total Paraa Tetrab Para vs. Tetra

N n n p

Group size 29 20 9

Men / women 22 / 7 15 / 5 7 / 2 1.00

Complete / incompletea 20 / 9 15 / 5 5 / 4 0.40

AIS A / B / C / D 17 / 3 / 7 / 2 14 / 1 / 4 / 1 3 / 2 / 3 / 1 N.A.

C4-6 / C7-8 / Th1-9 / Th10-L5 5 / 4 / 13 / 7 0 / 0 / 13 / 7 5 / 4 / 0 / 0 N.A.

Married or partner / single 18 / 11 12 / 8 6 / 3 1.00

Cohabiting / not cohabiting 19 / 10 13 / 7 6 / 3 1.00

20 / 9 13 / 7 7 / 2 0.68

Low / medium / high education level

14 / 13 / 2 9 / 10 / 1 5 / 3 / 1 N.A.

b 17 / 12 9 / 11 8 / 1 0.04b 25 / 4 18 / 2 7 / 2 0.57

Mdn (25-75th) Mdn (25-75th) Mdn (25-75th)

0.30

0.80

0.372 0.56

0.80

0.69c 0.15

Statistical comparison based on Fisher’s tests and Mann-Whitney U pa 31

b

c 22 n n

Scale31th -

Chapter 5

84

Table 2. with paraplegia and tetraplegia

Total Para Tetra Para vs. Tetra

N n n p

P5-15ma (W) 23 17 6 0.02

Fisob (N) 28 19 9

POpeak (W) 28 19 9

VO2peak (L·min-1)

28 20 8 0.01

Statistical comparison based on Fisher’s tests and Mann-Whitney Ua Unilateral power outputb Bilateral force

th

Para Tetra0

10

20

30

40

50

Para Tetra0

20

40

60

80

100

Para Tetra0

0.5

1

1.5

2

2.5

Figure 2. represent a participant’s outcome. Bars represent medians of the subgroups with paraplegia and tetraplegia.

Abbreviations: see table 2.

Para Tetra0

200

400

600

800

1000

1200

85

5

p r p

exercise test (POpeak with VO2peak: r p

Table 3. r among outcomes in the total group.

POpeak VO2peak P5-15m

r r N r r N r r N

0.89** 0.77-0.95 27 0.67* 0.35-0.85 22

0.79** 0.55-0.91 22 0.50* 0.15-0.74 27

Fiso 0.64** 0.35-0.82 28 0.64** 0.35-0.82 28 0.55* 0.17-0.79 22

Figure 3. -

Abbreviations: see table 2.

0 5 10 15 20 25 30 35 40 450

10

20

30

40

50

60

70

80

90

100

P5−15m (W)

POpe

ak (W

)

ParaplegiaTetraplegia

0 200 400 600 800 1000 12000

10

20

30

40

50

60

70

80

90

100

Fiso (N)

POpe

ak (W

)

ParaplegiaTetraplegiaR

2 =0.41 (p

Chapter 5

86

Variance over

r

load in our overground-sprint test compared to the body-mass standardized load in the

P5-15m has only been determined 25 which was much higher than the groups

33

example in comparison to a study with normative values based on active as well as 13 Average

13 Isometric strength has been determined in

11 Reduced

in ADL33 -

POpeak in the subgroup with paraplegia would be

13 Average POpeak in the subgroups with

-12

28

-28 Apparent-

Chapter 5

87

5

7-10

13 -9

-13

7-10

-chair ergometer tests (r 16

-ground sprint test has been suggested to depend more on skill than the 30-s wheelchair

25

37

Chapter 5

88

18

with able-bodied people might be in coordination problems and low muscular strength 18 Low strength and coordina-

17 -

16

r -1 -1 r

-

22

38

6 since it can support mainte-1

-15

exercise test using the 15-m test or isometric-push test due to the weak correlations

Chapter 5

89

5

-22 Perhaps people with

39

--

while results in the isometric-push test might have been

-

-

25

-

-p

22

-

-

Chapter 5

90

» -

» »

»

Chapter 5

91

5

-

-

-

-

-

-

-

-

-

Chapter 5

92

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

Chapter 5

93

5

Chapter 6

Low-intensity wheelchair exercise in inactive people with long-term spinal cord injury:

physical activity levels

Jan W. van der ScheerSonja de Groot

Marga TepperWillemijn Faber

ALLRISC (group name)

PLoS one. Submitted 2014

Revised manuscript: J Rehabil Med. Under review 2015

6

Chapter 6

96

was determined as the highest 5 s-power output over 15 m-overground sprinting

uptake over two submaximal exercise blocks; and peak power output and peak oxygen

p r p r

Chapter 6

97

6

1-3 -

5-7

which are suggested to lead to reduced 10

-11 Wheelchair propulsion exercise is an accessi-

-

Low-intensity exercise using the lower

Promising results have also

17-19

-

-

-13-19

Design

and a non-exercising control group with repeated measurements in both groups at

Chapter 6

98

-

Participants

-

comprised time since

23

testing25; musculoskeletal complaints contraindicating manual wheelchair propul-sion; mental problems or progressive disease expected to lead to dropout; planning to

-

Exercise training

Chapter 6

99

6

Outcomes

Anaerobic work capacity was determined as the highest mean unilateral power output

28

-1

21

Predeter--1

Peak aerobic work capacity was determined as mean power output over the last

21

Wheelchair skill performance

--

-

Chapter 6

100

Physical activity levels

Physical activity levels were determined as distance propelled in a week in the community

--1 23

Exercise training

Absolute intensity during the exercise training was determined as mean power output -

Statisticsn Descriptive

p

-

(r nexercise * ncontrol31 A negative sign was added when the comparison

th and last training

-

Chapter 6

101

6

Participants

(table 1) and were randomly allocated to the exercise group (ngroup (n

Table 1.

Total Exercise Control Ex vs. Con

N n n p

Group size 29 14 15

Men / women 22/7 12/2 10/5 0.39a 20/9 9/5 11/4 0.70

Complete / incompletea 20/9 10/4 10/5 1.00


0.72

0.53

0.622 0.59

0.35

0.59-1 b 0.07

pa 26

b 24

23

Chapter 6

102

Preselection (N 200) Preselected from archives and invited for screening for RCT

No participation (N 171) Declined to participate1, not passing eligibility screening, no contact via mail/phone or other reason

T1 measurements and randomization (N=29)

T2 measurements Performed all or part of measurements (n=12) Did not perform any measurements (n=2)

Kidney stones (n=1) No motivation due to break-up spouse (n=1)

Week 9-16 of exercise training Completed (n=11) Did not start (n=3; see above)

Allocated to control group (n=15) Center 1 (n=7) Center 2 (n=8)

Allocated to exercise group (n=14) Center 1 (n=10) Center 2 (n=4)

Week 1-8 of exercise training Completed (n=11) Stopped after 3-5 weeks (n=3)

Kidney stones (n=1) No motivation due to break-up spouse (n=1) Lack of time due to work (n=1)

Participation (N=29) Voluntarily agreed to participate in RCT, provided written informed

consent and passed eligibility screening


Lack of time due to holiday (n=1)

T3 measurements Performed all or part of measurements (n=14)


Hospitalized due to medication issue (n=1) Severe tooth pain (n=1)

Figure 1. It was estimated that about three in four people eligible for the study declined to participate.

baseline, respectively.

Chapter 6

103

6

Exercise training

Table 2.

Total n Completed n Stopped n

Adherencea

b

Relative intensityc No Mdnc

a Attended sessions divided by 32 planned sessions.b Two participants completed 32 sessions, but their motor abilities were too limited for 30 min

c

due to an impaired autonomic nervous system.

0-10 scale.24,27

Table 3. n

Fifth sessiona 16th session Last session Friedman’s

Absolute intensity n p

11 0.005*-1 11 0.012**

Overuse symptoms

11 0.102

9 0.135a

24,31

scale assessed seven min after the session.24,27

Chapter 6

104

Outcomes at baseline (T1)-

-liable heart rate measurements in those with an impaired autonomic nervous system;

n n=8-15 in the control group

p r

p r

p r

Wheelchair skill performance

p r

(p r p r-

vidual participants indicated that only two participants in the exercise group showed a

Chapter 6

105

6

Tab

le 4

.

Exer

cise

nC

on

tro

l n

Stat

isti

cal c

om

par

iso

n

Md

n25

-75t

hn

Md

n25

-75t

hn

Up

u

aT1

47.5

10.2

-54.

514

38.4

25-5

714

94.0

0.87

N.A

.

0.3

-4.9

-4.2

110.

4-2

.5-3

.011

54.0

0.70

-0.1

1

-0.5

-7.8

-4.4

120.

1-5

.6-4

.712

69.0

0.89

-0.0

4

a-1

T11.

510.

59-1

.77

131.

140.

89-1

.61

1590

.00.

75N

.A.

-0.0

10.

08-0

.15

100.

01-0

.17-

0.07

1148

.00.

65-0

.13

-0.0

40.

23-0

.08

12-0

.08

-0.2

1-0.

0713

75.0

0.89

0.04

T114

.57.

9-24

.312

16.2

11.9

-20.

911

49.0

0.32

N.A

.

1.5

-0.7

-2.6

9-0

.1-1

.4-1

.39

27.0

0.26

0.33

2.0

0.5-

5.0

10-0

.7-2

.8-0

.210

15.0

0.01

*0.

70

T151

617

9-65

914

335

284-

538

1484

.00.

54N

.A.

-57

-87-

912

-36

-69-

-311

56.0

0.57

-0.1

5

-27

-141

-11

14-5

1-9

0--1

512

70.0

0.49

0.17

bT1

4.9

3.5-

6.1

114.

13.

4-5.

414

64.0

0.50

N.A

.

0.5

-0.8

-1.4

9-0

.2-0

.9-0

.09

23.0

0.14

0.43

0.1

-0.9

-0.6

110.

2-0

.8-0

.812

56.0

0.57

-0.1

5

bT1

5.2

3.4-

6.4

114.

63.

3-6.

314

66.0

0.57

N.A

.

0.6

-0.2

-1.8

9-0

.5-1

.4-0

.29

18.0

0.05

0.56

0.1

-0.5

-0.6

110.

0-0

.8-0

.812

65.0

1.00

0.02

b-1

T10.

700.

54-0

.83

110.

650.

52-0

.81

1576

.00.

76N

.A.

-0.0

6-0

.11-

-0.0

610

-0.0

4-0

.10-

-0.0

311

51.0

0.81

0.07

-0.0

5-0

.09-

0.06

11-0

.01

-0.1

4-0.

0713

69.0

0.91

0.03

Tabl

e co

ntin

ues

on n

ext p

age

Chapter 6

106

b-1

T10.

760.

55-0

.95

110.

6815

76.0

0.76

N.A

.

-0.0

8-0

.11-

-0.0

110

-0.0

7-0

.09-

0.13

1144

.50.

470.

19

-0.0

4-0

.10-

0.04

11-0

.06

-0.0

8-0.

0513

69.0

0.91

-0.0

3

-

Ua b

thU

32

-

blo

cks.

Tab

le 5

.

Exer

cise

nC

on

tro

l n

Stat

isti

cal c

om

par

iso

n

Md

n25

-75t

hn

Md

n25

-75t

hn

Up

u

T120

.5

14.5

-28.

314

17.6

16

.3-2

0.9

1595

.00.

56N

.A.

-0.9

-1

.6--

0.3

12-0

.1

-1.5

-0.6

1355

.00.

260.

29

-1.4

-3

.9--

0.4

140.

0

-1.3

-1.0

1346

.50.

03*

0.49

T16.

8 3.

9-8.

014

7.5

6.5-

8.0

1580

.00.

29N

.A.

0.0

0.0-

0.8

120.

0 -0

.5-0

.013

46.5

0.09

0.40

0.0

-0.1

-1.0

140.

0 0.

0-0.

013

76.5

0.49

-0.1

6

T133

25

-42

826

-2

-40

827

.00.

65N

.A.

-10

-14-

364

3 -2

0-44

611

.01.

000.

08

1 -1

0-24

61

-2

2-49

514

.01.

00-0

.07

Tab

le 4

co

nti

nu

ed.

Chapter 6

107

6

Tab

le 6

. an

d c

on

tro

l gro

up

.

Exer

cise

nC

on

tro

l n

Stat

isti

cal c

om

par

iso

n

Md

n25

-75t

hn

Md

n25

-75t

hn

Up

u

-1T1

9.0

2.7-

16.3

1015

.9

5.2-

37.0

1347

.00.

28N

.A.

1.8

-0.3

-2.6

70.

5 -5

.9-6

.69

31.0

1.00

0.02

-0.6

-4

.7-0

.08

1.6

-25.

3-8.

09

23.0

00.

24-0

.36

-1T1

6.4

1.7-

9.0

1210

.6

6.9-

17.4

1552

.00.

07N

.A.

0.6

-3.1

-11.

410

-1.4

-7

.2-5

.511

46.0

0.56

0.16

1.2

-5.8

-2.9

80.

6 -5

.4-7

.913

48.0

00.

800.

08

23

Chapter 6

108

Per

form

ance

tim

e

scor

e

T1 (s

)

T3 (s

)

T1 (s

)

T2 (s

)

Wee

kly

prop

ulsi

on

T1 (k

m)

T3 (k

m)

T1 (k

m)

T2 (k

m)

Fig

ure

3.

Wh

eelc

hai

r ski

ll p

erfo

rman

ce: p

erfo

rman

ce ti

me

of i

nd

i-vi

du

al p

arti

cip

ants

at T

1 p

lott

ed a

gai

nst

T2

and

T3.

Fig

ure

4.

par

tici

pan

ts a

t T1

plo

tted

ag

ain

st T

2 an

d T

3.

Fig

ure

2

Ab

bre

viat

ion

s: s

ee ta

ble

2.

P

Ope

ak

T1 (W

)

T3 (W

)

T1 (W

)

T2 (W

)

P5-

15m

T1 (W

)

T3 (W

)

T1 (W

)

T2 (W

)

Chapter 6

109

6

Tab

le S

1.

Exer

cise

nC

on

tro

l n

Stat

isti

cal c

om

par

iso

n

Md

n25

-75t

hn

Md

n25

-75t

hn

Up

u

aT1

43.6

10.2

-57.

311

38.4

25-5

714

73.0

0.85

N.A

.

0.2

-5.1

-4.2

100.

4-2

.5-3

.011

50.0

0.78

-0.0

9

0.2

-5.0

-5.2

100.

1-5

.6-4

.712

56.0

0.82

0.07

a-1

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Tabl

e co

ntin

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on n

ext p

age.

Chapter 6

110

b-1

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a b Tab

le S

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l n

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Chapter 6

111

6

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on

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l n

Stat

isti

cal c

om

par

iso

n

Md

n25

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111

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770.

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1576

.00.

76

0.83

0.80

-0.9

110

0.82

0.82

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811

47.0

0.61

0.86

0.83

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113

0.81

0.81

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413

81.5

0.88

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860.

79-0

.88

110.

790.

79-0

.90

1568

.00.

47

0.82

0.80

-0.8

89

0.81

0.81

-0.8

811

40.0

0.50

0.83

0.79

-0.8

712

0.83

0.83

-0.9

313

44.5

0.07

p

Chapter 6

112

Physical activity levels

Exercise training

-1

n n=6) or improved a lot (n

33

23

7

36

Chapter 6

113

6

27

37

-

38 Perhaps less change in propulsion technique occurred

--

-39

LimitationsAlthough the relatively small sample size and missing data might have limited statisti-

-

Chapter 6

114

deconditioned or inactive people might have experienced other barriers to participate

Clinical implications and future research-

13 -

Other approaches may be to gradually build up wheelchair exercise intensity over

could allow customization to higher-intensity exercise without risking upper-body

-

5-7 alternative interventions need to be developed to help prevent and improve low -

-

Chapter 6

115

6

»

» »

» »

»

»

Chapter 6

116

-

-

-

-

-

-

-

Chapter 6

117

6

-

-

-

--

-

tt

Chapter 7

Low-intensity wheelchair training in

inactive people with long-term spinal cord injury:

a randomized controlled trial on propulsion technique


Sonja de Groot

Riemer Vegter

Johanneke Hartog

Marga Tepper

Hans Slootman

ALLRISC (group name)

DirkJan (H.E.J.) Veeger


Am J Phys Med Rehabil. Submitted 2014

Revised manuscript: Am J Phys Med Rehabil 2015. In press

7

Chapter 7

120

-

-

Comparing the exercise (n=8) to the control group (n -

p r

Chapter 7 Training effects on propulsion technique

121

7

1-3 -

Factors that -

Deconditioned or inactive manual wheelchair

7 Risk reduction is considered possible through an improved propulsion technique1

to less joint damage during wheelchair propulsion1

8-10

9 -

dropout and musculoskeletal injury in deconditioned or inactive populations11 For

11

8

-

training on propulsion technique in inactive manual wheelchair users with long-term

-

8 it was hypothesized that the exercise group

Design

Chapter 7

122

-

Ethical approval

-

Participants--

Other inclusion

criteria comprised musculoskeletal complaints contraindicating wheelchair propul-

-

Procedures


123

7

--1

-5 Pa and

21

Propulsion technique

21

1 Parameters were determined

Statistics

It was estimated at n

p

correlations (r nexercise * ncontrol 23

-

Chapter 7

124

Participants

-1

Table 1.

Total Exercise Control Ex vs. Con

N n n p

Group size 29 14 15

Men / women 22/7 12/2 10/5 0.39a 20/9 9/5 11/4 0.70

Complete / incompletea 20/9 10/4 10/5 1.00

AIS A / B / C / D 17 / 3 / 7 / 2 9 / 1 / 4 / 0 8 / 2 / 3 / 2 N.A.

C4-6 / C7-8 / Th1-9 / Th10-L5 5 / 4 / 13 / 7 3 / 2 / 5 / 4 2 / 2 / 8 / 3 N.A.


0.72

0.53

0.622 0.59

0.35

0.59-1 b 0.07

c 0.87

pa 25

b 14 nc n

25

14.

Training effects on propulsion technique

125

7

Period of 26 weeks

Preselection (N 200) Preselected and invited for screening, using archives of rehabilitation centers and a SCI patient organization

No participation (N 171) Declined to participate1, not passing eligibility screening, no contact via mail/phone or other reason

Randomization (N=29) Provided written informed consent and passed eligibility screening

Allocated to exercise group (n=14) Rehabilitation center 1 (n=10) Rehabilitation center 2 (n=4)

Allocated to control group (n=15) Rehabilitation center 1 (n=7) Rehabilitation center 2 (n=8)

Week 1-8 of low-intensity wheelchair training Completed (n=11) Stopped after 3-5 weeks (n=3) Kidney stones (n=1) Lack of time due to work (n=1) Lack of motivation due to personal problems (n=1

T1 measurements Data collected (n=12) No data collected (n=2) Unable to complete 3 min (n=1) Wheelchair not suitable for instr. wheel (n=1)

T1 measurements Data collected (n=11) Technical error in data (n=3) No data collected (n=1) Wheelchair not suitable for instr. wheel (n=1)

T2 measurements Data collected (n=9) Technical error in data (n=1) No data collected (n=4) Kidney stones (n=1) Lack of motivation due to personal problems (n=1 Unable to complete 3 min (n=1) Wheelchair not suitable for instr. wheel (n=1)

Week 9-16 of low-intensity wheelchair training Completed (n=11) Did not start (see above; n=3)

T2 measurements Data collected (n=10) Technical error in data (n=2) No data collected (n=3) Bowel problems (n=1) Lack of time due to holiday (n=1) Wheelchair not suitable for instr. wheel (n=1)

T3 measurements Data collected (n=10) Technical error in data (n=1) No data collected (n=3) Lack of motivation due to spousal problems (n=1) Unable to complete 3 min (n=1) Wheelchair not suitable for instr. wheel (n=1)

T3 measurements Data collected (n=10) Technical error in data (n=2) No data collected (n=3) Hospitalized due to medication issue (n=1) Severe tooth pain (n=1) Wheelchair not suitable for instr. wheel (n=1)

T4 measurements Data collected (n=7) Technical error in data (n=2) No data collected (n=5) Lack of motivation for participation (n=3) Unable to complete 3 min (n=1) Wheelchair not suitable for instr. wheel (n=1)

T4 measurements Data collected (n=9) Technical error in data (n=3) No data collected (n=3) Pain in neck, wrist and shoulder (n=1) Pressure sore (n=1) Wheelchair not suitable for instr. wheel (n=1)

Figure 1. Details on inclusion, randomization, allocation, measurements and

declined to participate.

-surements eight, 16 and 42 weeks after baseline, respectively.

Chapter 7

126

Low-intensity wheelchair trainingn

Baseline (T1)

-

-1

-1p -

p

p

Effects of the training

-

p r p r

p r

p r -

-1p r

-1p r


127

7

Tab

le 2

.

Exer

cise

gro

up

Co

ntr

ol g

rou

pC

om

par

iso

n g

rou

ps

Md

n25

th75

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Md

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th75

thN

pU

U

-1)

Blo

ck 1

T1

5746

658

5248

648

0.80

35N

.A.

-11

-16

-48

-2-7

38

0.06

140.

56

-10

-16

-58

-3-1

02

80.

1618

0.44

-9

-15

-65

-8-1

3-1

60.

5411

0.27

Blo

ck 2

T150

4572

855

4759

81.

0032

N.A

.

-11

-16

-58

-1-3

48

0.05

130.

59

-16

-20

-48

1-7

48

0.08

150.

53

-17

-21

-13

5-3

-19

16

0.18

70.

53

Net

wo

rk p

er c

ycle

(J)

Blo

ck 1

T116

1120

.98

1716

198

0.80

29N

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0.4

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1.9

81.

4-0

.24.

28

0.80

290.

09

3.9

-0.7

6.1

82.

31.

03.

68

0.65

37-0

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5.6

-0.9

6.1

50.

7-0

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96

0.66

18-0

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Blo

ck 2

T120

1524

819

1623

81.

0032

N.A

.

-1.0

-1.7

0.5

81.

1-0

.64.

28

0.13

170.

47

1.5

-0.5

4.2

81.

0-0

.66.

08

0.88

300.

06

3.3

1.9

4.7

50.

2-3

.06.

66

0.66

18-0

.2

Tabl

e co

ntin

ues

on n

ext p

age.

Chapter 7

128

Tab

le 2

co

nti

nu

ed.

Exer

cise

gro

up

Co

ntr

ol g

rou

pC

om

par

iso

n g

rou

ps

Md

n25

th75

thN

Md

n25

th75

thN

pU

U

Co

nta

ct a

ng

le (d

egre

es)

Blo

ck 1

T1

6149

688

6259

648

0.80

29N

.A.

111

128

4-3

118

0.51

39-0

.22

152

208

1-4

68

0.13

47-0

.47

10

420

55

310

60.

5419

-0.2

7

Blo

ck 2

T162

5675

866

6470

80.

4424

N.A

.

4-1

108

3-6

108

0.72

36-0

.13

53

158

-6-7

88

0.23

44-0

.38

164

195

40

96

0.25

22-0

.47

Blo

ck 1

T19.

26.

412

89.

58.

411

80.

8029

N.A

.

-0.3

-1.3

0.8

80.

50.

02.

08

0.38

230.

28

1.5

-2.1

2.7

81.

40.

71.

88

1.00

320.

00

-0.1

-1.1

2.8

50.

1-0

.51.

86

1.00

150.

00

Blo

ck 2

T111

7.9

148

108.

513

80.

9633

N.A

.

-0.8

-1.4

-0.1

80.

6-0

.32.

08

0.06

140.

56

0.5

-1.4

2.2

81.

00.

22.

78

0.72

280.

13

1.2

-0.1

1.7

5-0

.4-2

.43.

26

0.79

17-0

.13


129

7

Pea

k fo

rce

(N)

Blo

ck 1

T1

6648

104

856

5063

80.

5139

N.A

.

-9-2

7-5

82

-36

80.

0513

0.59

0-9

88

2-3

108

0.72

280.

13

5

-13

85

-3-1

611

60.

9316

-0.0

7

Blo

ck 2

T176

5910

18

6049

738

0.16

46N

.A.

-20

-22

-15

81

07

80.

01*

70.

78

-7-1

11

81

-310

80.

1919

0.41

-4-1

65

5-4

-16

06

0.93

16-0

.07

trai

nin

g.21

-1

UU

n

* n

con

tro

l23

Chapter 7

130

8-10

exercise three times per week at relatively high intensities (high-resistance strength 9

low-intensity wheelchair exercise three times per week8 Perhaps the higher intensi-

8-10

26

0 10 20 30 40 50 60 70 80 900

10

20

30

40

50

60

70

80

90

Push frequency at T1 (push/min)

Push

freq

uenc

y at T

2 (pu

sh/m

in)

Exercise completed (n=7)Exercise stopped (n=1)Control (n=8)

0 10 20 30 40 50 60 70 80 900

10

20

30

40

50

60

70

80

90

Push frequency at T1 (push/min)

Push

freq

uenc

y at T

3 (pu

sh/m

in)

Figure 2. -


131

7

- It seems such motor

A priori -

-

-

--

Chapter 7

132

Table 3.

Responders Non-responders

n n

Group size 5 2

Men / women 4/1 2/0a 3/2 2/0

Complete / incompletea 3/2 2/0

AIS A / B / C / D 3 / 0 / 2 / 0 2 / 0 / 0 / 0

C4-6 / C7-8 / Th1-9 / Th10-L5 2 / 0 / 2 / 1 0 / 0 / 1 / 1

Mdn (25-75th) Mdn (25-75th)

2

b

c

-

that had missing data at T1, T2 or T3.

Limitations

the training (n

-

Clinical implications

training as an intervention to improve propulsion technique in inactive manual wheel-


133

7

-

-ty wheelchair training as an intervention to improve propulsion technique in inactive

-

»

»

» »

» »

»

Chapter 7

134

-

-

-

-

-

-

--


135

7

-

-

-

-

Chapter 8

General discussion

8

Chapter 8

138

1

-

-

-

10

-1

2


139

8

-2

12

13

-

while people with very -

Positive selection bias seemed more likely in the studies in this

-

-

Chapter 8

140

Low-intensity wheelchair training at a high exercise frequency

on low-intensity training19-21 Previous studies on -

19-

21

22 -

23

-

-29

-

-

Access to

-38 Continued supervision might be provided through telecommunicat-


141

8

28

Burden

39 -

29

Low-intensity wheelchair training over a long period

Training using other modalities

- Handcycling training at a moderate

28

Although improved physical activity levels were

lead to lower exercise adherence and more dropouts in inactive or deconditioned pop-23

Chapter 8

142

Programs aimed at stimulating physical activity and sports

--

2 Reha-

-

50

51

peak or mean power output over a Wingate-like 30 s-sprint test on a wheelchair


143

8

-ity could be improved by solving technical problems that occurred while using the in-

-55

-veloping low-cost methods to determine power output in an overground-wheelchair

56

--

tests may imply that peak power output is more dependent on motor coordination and 57

59

60

but such

62

Chapter 8

144

-

Lower power output implies a higher sensitivity to measurement error in mechanical Less sensitivity to measurement error will occur when using oxygen uptake

66

An adaptation in the peak graded exercise tests could be to use smaller incremental

67

69 -60


145

8

--

70

71

Further research is also recommended on selection bias in cross-sectional and lon-

Future research is recommended on alternative interventions to the low-intensity

73

-

23

Chapter 8

146

-

17

this might not always be possible

17

75 -77 but interpreting

-79

79 implying that the training protocol can be optimized based

-81

17

-


147

8

centers should be directed at psychometric properties such as sensitivity to individual 55

55

tests such as a 30-s overground wheelchair sprint59 and a six-minute wheeling test69

psychometric properties; 6) implementing the test in clinical practice; and 7) evaluat-51

-

---

-

23

: center-based exercise can 27-29 Feasibility may also be

Chapter 8

148

--

-

55

91

92 -

--

-


149

8

-

-

-

-

-

-

Chapter 8

150

-

-

-

-

-

-


151

8

-

-

-

-

-

Chapter 8

152

-

-

-


153

8

Appendix

Hand rim wheelchair training:

Effects of intensity and duration on physical capacity

Sonja de Groot


Jordi A. van der Windt

Joske Nauta

Louise J.C. van der Hijden

Linda Luigjes


Health 2013: 5: 9-16

A

Appendix

156

reserve (HRR) 70 min training group (N(N N

-

-

Appendix Wheelchair training in able-bodied people

157

A

-1 upper-body strength and cardiovascular endurance are

2

3 2

5 Van der Woude et al.2

mass involved and the discontinuous movement pattern introducing high mechanical 6 Van Drongelen and colleagues7

the persons with a spinal cord injury had shoulder musculoskeletal pain at the start -

7

-

8 7 Haskell9 was among -

10

the above-mentioned wheelchair training studies we know that all training groups (at showed an improvement in physical capacity compared to

2

den Berg et al 10

Appendix

158

ParticipantsFourteen able-bodied men who were inexperienced in wheelchair propulsion were

-

Table 1.

30%-70min n

30%-30min n

70%-30min n

p

Mean ± SD Mean ± SD Mean ± SD

23.5 ± 3.5 22.7 ± 2.0 21.9 ± 3.2 0.41

180.9 ± 10.5 183.7 ± 4.8 184.2 ± 8.3 0.57

73.0 ± 12.5 76.8 ± 4.9 71.8 ± 6.0 0.39

post-test 73.2 ± 12.0 77.0 ± 5.1 71.5 ± 6.4 0.36

Design

10 and a high-intensity short-du-2

-®


159

A

2 All post-tests were identical to the

Wheelchair ergometer tests

11

First the maximal isometric strength test was conducted to determine the maximal

output was estimated (POpeakest-I et al 12

POpeakest-I -1 -1

Sprint test

est) was determined by using the equation between Fiso and the sprint power12

P30est -1 -1

r est and an average velocity that had to -1 to prevent coordination problems12:

Fr -1) = (P30est -1 -1)

Submaximal exercise test

2 -1

estimated POpeak was calculated12

Appendix

160

POpeakest-II -1 -1

-

20 20

were recorded to calculate the power output (PO)2:

1320 ) was

calculated with the equation:

-1

Peak exercise test

-1

-

TrainingParticipants received a 7 week

were compared to groups that trained

-

the training (HRtraining) was de-Figure 1. To impose the desired power output during the training a pulley-system attaches to the instrumented wheelchair on the treadmill.


161

A

et al.

2

2

2

-1

monitored and recorded during the training to make sure that the proper training

Statistics-

20 20 20

Figure 2. Representation of temporal patterns of the training sessions for the low-intensity

Appendix

162

between the groups (interaction term group*time: p

Sprint power

(interaction term group*time: p -

Peak exercise test-

groups (interaction term group*time: p

Submaximal exercise -

showed a comparable decrease in submaximal VO2 and heart rate and an increase in


163

A

Figure 3.

40

Appendix

164

Tab

le 2

.

30

%-7

0 m

in3

0%

-30

min

70

%-3

0 m

inP

re v

s. p

ost

Gro

up

*tim

e

Mea

n ±

SD

NN

Np

p

pre

391.

0 ±

92.

914

475.

8 ±

84.

39

243.

5 ±

75.

113

0.78

0.56

po

st44

6.0

± 1

50.9

494.

8 ±

109

.028

5.8

± 8

4.7

pre

97.0

± 1

8.2

1411

4.0

± 3

3.5

910

2.7

± 1

8.9

130.

28

po

st12

6.7

± 2

7.5

148.

7 ±

29.

212

4.8

± 2

7.8

+p

re43

.7 ±

11.

914

56.5

± 1

0.7

952

.9 ±

10.

213

0.27

po

st66

.7 ±

11.

275

.6 ±

12.

679

.0 ±

15.

4

pre

1.75

± 0

.27

142.

13 ±

0.3

29

1.80

± 0

.30

130.

014

0.25

po

st1.

95 ±

0.3

32.

09 ±

0.2

82.

00 ±

0.2

8

pre

182

± 1

213

171

± 1

79

175

± 1

313

0.38

0.19

po

st17

6 ±

17

171

± 2

117

6 ±

12

+


165

A

Tab

le 3

.

30

%-7

0 m

in3

0%

-30

min

70

%-3

0 m

inP

re v

s. p

ost

Gro

up

*tim

e

Mea

n ±

SD

NN

Np

p

20p

re0.

86 ±

0.1

514

0.86

± 0

.17

90.

79 ±

0.1

413

0.44

po

st0.

68 ±

0.1

00.

69 ±

0.1

20.

67 ±

0.0

8

40p

re1.

17 ±

0.2

314

1.17

± 0

.21

91.

15 ±

0.2

013

0.43

po

st0.

92 ±

0.1

40.

95 ±

0.1

10.

98 ±

0.1

3

20p

re4.

32 ±

1.2

714

5.36

± 0

.99

96.

25 ±

1.5

913

0.30

po

st5.

65 ±

0.8

26.

27 ±

0.9

87.

36 ±

1.6

0

40p

re6.

41 ±

1.1

714

7.25

± 0

.88

98.

33 ±

1.8

013

0.88

po

st8.

32 ±

0.8

99.

00 ±

1.6

19.

85 ±

1.5

4

20p

re12

5 ±

22

1411

1 ±

19

911

1 ±

14

130.

46

po

st10

5 ±

13

97 ±

16

98 ±

10

40p

re14

3 ±

25

1412

7 ±

22

913

2 ±

17

130.

32

po

st11

4 ±

16

106

± 1

611

2 ±

12

Appendix

166

-

-al adaptations while exercise with small muscle groups may only lead to peripheral

15

the trained arm muscles but central adaptations will be less pronounced due to the -

16 17 to 18

in the above-mentioned studies was accompanied by an improvement in propulsion

2 2 10

19

20 21

an increase in VO2peak high-intensity upper-body exercise or exercise with a larger


167

A

-

21 Another study19-

als and produces changes in peak oxygen uptake that are comparable to those elicited

22

are probably due to peripheral physiological adaptations and changes in propulsion

-23

Limitations

-

our study population as such they partly mimic novice wheelchair users in early reha-

Appendix

168

-

-

-

-

-

-

-


169

A

Summary

S

Summary

172

propulsion technique in physically inactive people with long-term spinal cord injury Chapter 1 -

-

Chapter 2

-

Chapter 3

-

Summary Summary

173S

-

a 15 m-overground sprint test in a wheelchair equipped with a measurement wheel to Chapter 4 is an evaluation on whether this test can be used

-

-

Chapter 5

Chapter 6 and 7 -

-

-

Chapter 8

Summary

174

-

cross-over designs or single-case designs that include multiple baseline measurements

-

-

Summary Summary

175S


N


178

-

Hoofdstuk 1 -ming en een rolstoelgebonden leven is het moeilijk voor mensen met een dwarslaesie

-

-

-

onder andere uit een gerandomiseerd onderzoek met een controlegroep naar laag-in-

--

-

Hoofdstuk 2 presenteert een cross-sectioneel onderzoek naar de samenhang

-mers voerden een maximale inspanningstest uit in hun rolstoel om piekvermogen en

-

-

Hoofdstuk 3 is een beschr

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