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-
5 m
m
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 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.
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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
-
Chapter 1 General introduction
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
-
Chapter 1 General introduction
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
-
-
-
-
Chapter 1 General introduction
17
1
-
-
-
-
-
-
Chapter 1
18
-
-
--
-
-
-
Chapter 1 General introduction
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
ics
as c
on
fou
nd
ers.
Res
ult
s ar
e sh
ow
n fo
r th
e to
tal g
rou
p a
nd
for p
eop
le w
ith
a te
trap
leg
ia
and
par
aple
gia
sep
arat
ely.
Tota
lTe
tra
Par
a
PO
pea
k (W
)-1
)P
Op
eak
(W)
-1)
PO
pea
k (W
)-1
)
pp
pp
pp
Co
nst
ant
0.32
0.06
0.78
0.58
0.00
10.
05
Lesi
on
leve
la-
Lesi
on
co
mp
lete
nes
sb0.
32-
0.02
--
-
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
Tetr
aA
ctiv
e52
0.01
510.
0548
0.52
530.
41
Inac
tive
99
99
Par
aA
ctiv
e38
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
stic
s as
co
nfo
un
der
s. R
esu
lts
are
sho
wn
for
the
tota
l gro
up
an
d fo
r p
eop
le w
ith
a t
etra
-p
leg
ia a
nd
par
aple
gia
sep
arat
ely.
Tota
lTe
tra
Par
a
PO
pea
k (W
)-1
)P
Op
eak
(W)
-1)
PO
pea
k (W
)-1
)
pp
pp
pp
Co
nst
ant
a0.
230.
650.
020.
300.
080.
26
Lesi
on
leve
lb-
--
-
Lesi
on
co
mp
lete
nes
sc-
-
--
-0.
300.
290.
93
d0.
120.
03-
0.17
--
-0.
040.
04
a16
b c d
-
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
-
Chapter 3 Design of the RCT
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
-
Chapter 3 Design of the RCT
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
-
Chapter 3 Design of the RCT
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
-
Chapter 3 Design of the RCT
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 -
-
Chapter 3 Design of the RCT
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-
-
Chapter 3 Design of the RCT
53
1362
-
-
-
-
-
Chapter 3
54
-
-
-
--
-
-
Chapter 3 Design of the RCT
55
13
-
-
-
-
-
-
-
Chapter 3
56
-
-
-
Chapter 3 Design of the RCT
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
-
Chapter 4 15 m-overground wheelchair sprint to assess anaerobic work capacity
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
-
Chapter 4 15 m-overground wheelchair sprint to assess anaerobic work capacity
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
-
Chapter 4 15 m-overground wheelchair sprint to assess anaerobic work capacity
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
-
Chapter 4 15 m-overground wheelchair sprint to assess anaerobic work capacity
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
-
-
Chapter 4 15 m-overground wheelchair sprint to assess anaerobic work capacity
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
-
-
Chapter 4 15 m-overground wheelchair sprint to assess anaerobic work capacity
73
14
-
-
-
-
-
Chapter 4
74
-
-
-
Chapter 4 15 m-overground wheelchair sprint to assess anaerobic work capacity
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
Mdn (25-75th) Mdn (25-75th) Mdn (25-75th)
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
T2 measurements Performed all or part of measurements (n=14) Did not perform any measurements (n=1)
Lack of time due to holiday (n=1)
T3 measurements Performed all or part of measurements (n=14)
T3 measurements Performed all or part of measurements (n=13) Did not perform any measurements (n=2)
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
T11.
270.
58-1
.77
111.
140.
89-1
.61
1580
.00.
91N
.A.
0.01
-0.0
5-0.
179
0.01
-0.1
7-0.
0711
40.0
0.50
0.19
0.00
-0.0
9-0.
1010
-0.0
8-0
.21-
0.07
1349
.00.
340.
25
T113
.16.
2-18
.79
16.2
11.9
-20.
911
30.0
0.15
N.A
.
1.7
0.2-
2.8
8-0
.1-1
.4-1
.39
18.0
0.09
0.50
0.8
0.5-
4.6
8-0
.7-2
.8-0
.210
15.0
0.03
*0.
63
T146
619
0-65
211
335
284-
538
1467
.00.
61N
.A.
-69
-88-
1611
-36
-69-
-311
48.0
0.44
-0.2
1
-34
-285
-29
11-5
1-9
0--1
512
58.0
0.65
0.12
bT1
4.9
3.5-
6.9
94.
13.
4-5.
414
49.0
0.40
N.A
.
0.4
-1.1
-1.4
8-0
.2-0
.9-0
.09
23.0
0.24
0.36
-1.3
-0.5
-0.5
90.
2-0
.8-0
.812
40.0
0.35
-0.2
6
bT1
5.6
3.5-
7.6
94.
63.
3-6.
314
48.0
0.37
N.A
.
0.4
-0.3
-1.7
8-0
.5-1
.4-0
.29
18.0
0.09
0.50
-0.1
-1.5
-0.3
90.
0-0
.8-0
.812
47.0
0.65
-0.1
3
b-1
T10.
660.
51-0
.79
90.
650.
52-0
.81
1564
.00.
86N
.A.
-0.0
4-0
.10-
0.07
9-0
.04
-0.1
0--0
.03
1142
.00.
600.
15
-0.0
5-0
.11-
0.05
9-0
.01
-0.1
4-0.
0713
56.0
0.90
-0.0
4
Tabl
e co
ntin
ues
on n
ext p
age.
-
Chapter 6
110
b-1
T10.
660.
54-0
.82
90.
680.
61-0
.86
1561
.00.
73N
.A.
-0.0
8-0
.11-
0.10
9-0
.07
-0.0
9-0.
1311
44.5
0.71
0.10
-0.0
2-0
.09-
0.06
9-0
.06
-0.0
8-0.
0513
51.0
0.65
-0.1
3
a b Tab
le S
2.
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
.815
.9-2
8.6
1117
.616
.3-2
0.9
1563
.00.
33N
.A.
-0.8
-1.6
--0.
211
-0.1
-1.5
-0.6
1350
.00.
230.
30
-2.3
-4.2
--0.
511
0.0
-1.3
-1.0
1332
.00.
02*
0.55
T16.
54.
0-8.
011
7.5
6.5-
8.0
1556
.00.
18N
.A.
0.0
0.0-
1.0
110.
0-0
.5-0
.013
41.5
0.08
0.42
0.0
0.0-
1.0
110.
00.
0-0.
013
45.0
0.13
0.37
T132
19-3
76
26-2
-40
822
.00.
85N
.A.
-7-1
3-N
.A.
33
-20-
446
9.0
1.00
0.00
4.4
-16-
315
1-2
2-49
512
.01.
00-0
.04
Tab
le S
1 c
on
tin
ued
.
-
Chapter 6
111
6
Tab
le S
3.
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
7.7
0.9-
14.0
815
.95.
2-37
.013
30.0
0.12
N.A
.
2.0
0.7-
3.0
60.
5-5
.9-6
.69
25.0
0.86
0.07
-0.3
-2.4
-0.0
71.
6-2
5.3-
8.0
921
.00.
30-0
.33
-1T1
7.5
3.1-
8.8
910
.66.
9-17
.415
37.0
0.07
N.A
.
0.0
-3.1
-9.5
9-1
.4-7
.2-5
.511
44.0
0.71
0.11
1.2
-4.5
-3.0
70.
6-5
.4-7
.913
43.0
0.88
0.05
Tab
le S
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
T11.
020.
90-1
.15
131.
010.
91-1
.12
1593
.00.
86
1.06
0.87
-1.1
910
1.01
0.95
-1.1
111
51.0
0.81
1.04
0.89
-1.1
012
1.02
0.89
-1.2
813
71.5
0.73
T10.
830.
80-0
.91
110.
770.
77-0
.90
1576
.00.
76
0.83
0.80
-0.9
110
0.82
0.82
-0.8
811
47.0
0.61
0.86
0.83
-0.9
113
0.81
0.81
-0.9
413
81.5
0.88
T10.
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
Jan W. van der Scheer
Sonja de Groot
Riemer Vegter
Johanneke Hartog
Marga Tepper
Hans Slootman
ALLRISC (group name)
DirkJan (H.E.J.) Veeger
Lucas H.V. van der Woude
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
-
Chapter 7 Training effects on propulsion technique
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.
Mdn (25-75th) Mdn (25-75th) Mdn (25-75th)
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
-
Chapter 7 Training effects on propulsion technique
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
thN
Md
n25
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
.A.
0.4
-1.4
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
.16
5.6
-0.9
6.1
50.
7-0
.83.
96
0.66
18-0
.20
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
-
Chapter 7 Training effects on propulsion technique
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. -
-
Chapter 7 Training effects on propulsion technique
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-
-
Chapter 7 Training effects on propulsion technique
133
7
-
-ty wheelchair training as an intervention to improve propulsion technique in inactive
-
»
»
» »
» »
»
-
Chapter 7
134
-
-
-
-
-
-
--
-
Chapter 7 Training effects on propulsion technique
135
7
-
-
-
-
-
Chapter 8
General discussion
8
-
Chapter 8
138
1
-
-
-
10
-1
2
-
Chapter 8 General discussion
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-
-
Chapter 8 General discussion
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
-
Chapter 8 General discussion
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
-
Chapter 8 General discussion
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
-
-
Chapter 8 General discussion
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 -
--
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Chapter 8 General discussion
149
8
-
-
-
-
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Chapter 8
150
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Chapter 8 General discussion
151
8
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Chapter 8
152
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Chapter 8 General discussion
153
8
-
Appendix
Hand rim wheelchair training:
Effects of intensity and duration on physical capacity
Sonja de Groot
Jan W. van der Scheer
Jordi A. van der Windt
Joske Nauta
Louise J.C. van der Hijden
Linda Luigjes
Lucas H.V. van der Woude
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
-®
-
Appendix Wheelchair training in able-bodied people
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.
-
Appendix Wheelchair training in able-bodied people
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
-
Appendix Wheelchair training in able-bodied people
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
+
-
Appendix Wheelchair training in able-bodied people
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
-
Appendix Wheelchair training in able-bodied people
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
-
-
-
-
-
-
-
-
Appendix Wheelchair training in able-bodied people
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
-
Nederlandse samenvatting
N
-
Nederlandse samenvatting
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