Accuracy of bioelectrical impedance analysis and skinfold thickness in the assessment of body composition in people with chronic spinal cord injury.

STUDY DESIGN: Cross-sectional study. OBJECTIVES: This study: (1) investigated the accuracy of bioelectrical impedance analysis (BIA) and skinfold thickness relative to dual-energy X-ray absorptiometry (DXA) in the assessment of body composition in people with spinal cord injury (SCI), and whether sex and lesion characteristics affect the accuracy, (2) developed new prediction equations to estimate fat free mass (FFM) and percentage fat mass (FM%) in a general SCI population using BIA and skinfolds outcomes. SETTING: University, the Netherlands. METHODS: Fifty participants with SCI (19 females; median time since injury: 15 years) were tested by DXA, single-frequency BIA (SF-BIA), segmental multi-frequency BIA (segmental MF-BIA), and anthropometry (height, body mass, calf circumference, and skinfold thickness) during a visit. Personal and lesion characteristics were registered. RESULTS: Compared to DXA, SF-BIA showed the smallest mean difference in estimating FM%, but with large limits of agreement (mean difference = -2.2%; limits of agreement: -12.8 to 8.3%). BIA and skinfold thickness tended to show a better estimation of FM% in females, participants with tetraplegia, or with motor incomplete injury. New equations for predicting FFM and FM% were developed with good explained variances (FFM: R2 = 0.94; FM%: R2 = 0.66). CONCLUSIONS: None of the measurement techniques accurately estimated FM% because of the wide individual variation and, therefore, should be used with caution. The accuracy of the techniques differed in different subgroups. The newly developed equations for predicting FFM and FM% should be cross-validated in future studies.

Predicting resting energy expenditure in people with chronic spinal cord injury.

STUDY DESIGN: Cross-sectional study. OBJECTIVES: The aims of this study were (1) to validate the two recently developed SCI-specific REE equations; (2) to develop new prediction equations to predict REE in a general population with SCI. SETTING: University, the Netherlands. METHODS: Forty-eight community-dwelling men and women with SCI were recruited (age: 18-75 years, time since injury: ≥12 months). Body composition was measured by dual-energy X-ray absorptiometry (DXA), single-frequency bioelectrical impedance analysis (SF-BIA) and skinfold thickness. REE was measured by indirect calorimetry. Personal and lesion characteristics were collected. SCI-specific REE equations by Chun et al. [1] and by Nightingale and Gorgey [2] were validated. New equations for predicting REE were developed using multivariate regression analysis. RESULTS: Prediction equations by Chun et al. [1] and by Nightingale and Gorgey [2] significantly underestimated REE (Chun et al.: -11%; Nightingale and Gorgey: -11%). New equations were developed for predicting REE in the general population of people with SCI using FFM measured by SF-BIA and Goosey-Tolfrey et al. skinfold equation (R2 = 0.45-0.47; SEE = 200 kcal/day). The new equations showed proportional bias (p < 0.001) and wide limits of agreement (LoA, ±23%). CONCLUSIONS: Prediction equations by Chun et al. [1] and by Nightingale and Gorgey [2] significantly underestimated REE and showed large individual variations in a general population with SCI. The newly developed REE equations showed proportional bias and a wide LoA (±23%) which limit the predictive power and accuracy to predict REE in the general population with SCI. Alternative methods for measuring REE need to be investigated.

Shoulder kinematics and muscle activity following latissimus dorsi transfer for massive irreparable posterosuperior rotator cuff tears in shoulders with pseudoparalysis.

BACKGROUND: The aim of this study was to evaluate the thoracohumeral (TH) and glenohumeral (GH) motion with muscle activity after latissimus dorsi transfer (LDT) in a shoulder with a massive irreparable posterosuperior rotator cuff tear (MIRT) and pseudoparalysis compared with the asymptomatic contralateral shoulder (ACS). METHODS: We recruited and evaluated 13 patients after LDT in a shoulder with preoperative clinical pseudoparalysis and an MIRT on magnetic resonance imaging, with a minimum follow-up period of 1 year, and with a Hamada stage of 3 or less. Three-dimensional electromagnetic tracking was used to assess shoulder active range of motion in both the LDT shoulder and the ACS. The maximal active elevation of the shoulder (MAES) was assessed and consisted of forward flexion, scapular abduction, and abduction in the coronal plane. Maximal active internal rotation and external rotation were assessed separately. Surface electromyography (EMG) was performed to track activation of the latissimus dorsi (LD) and deltoid muscles during shoulder motion. EMG was scaled to its maximal isometric voluntary contraction recorded in specified strength tests. RESULTS: In MAES, TH motion of the LDT shoulder was not significantly different from that of the ACS (F1,12 = 1.174, P = .300) but the GH contribution was significantly lower in the LDT shoulder for all motions (F1,12 = 11.230, P = .006). External rotation was significantly greater in the ACS (26° ± 10° in LDT shoulder vs. 42° ± 11° in ACS, P < .001). The LD percentage EMG maximum showed no significant difference between the LDT shoulder and ACS during MAES (F1,11 = 0.005, P = .946). During maximal active external rotation of the shoulder, the LDT shoulder showed a higher percentage EMG maximum than the ACS (3.0% ± 2.9% for LDT shoulder vs. 1.2% ± 2.0% for ACS, P = .006). CONCLUSIONS: TH motion improved after LDT in an MIRT with pseudoparalysis and was not different from the ACS except for external rotation. However, GH motion was significantly lower after LDT than in the ACS in active-elevation range of motion. The LD was active after LDT but not more than in the ACS except for active external rotation, which we did not consider relevant as the activity did not rise above 3% EMG maximum. The favorable clinical results of LDT do not seem to be related to a change in LD activation and might be explained by its effect in preventing proximal migration of the humeral head in active elevation.

Do Handcycling Time-Trial Velocities Achieved by Para-Cycling Athletes Vary Across Handcycling Classes?

The classification system for handcycling groups athletes into five hierarchical classes, based on how much their impairment affects performance. Athletes in class H5, with the least impairments, compete in a kneeling position, while athletes in classes H1 to H4 compete in a recumbent position. This study investigated the average time-trial velocity of athletes in different classes. A total of 1,807 results from 353 athletes who competed at 20 international competitions (2014-2018) were analyzed. Multilevel regression was performed to analyze differences in average velocities between adjacent pairs of classes, while correcting for gender, age, and event distance. The average velocity of adjacent classes was significantly different (p < .01), with higher classes being faster, except for H4 and H5. However, the effect size of the differences between H3 and H4 was smaller (d = 0.12). Hence, results indicated a need for research in evaluating and developing evidence-based classification in handcycling, yielding a class structure with meaningful performance differences between adjacent classes.

The efficacy of treadmill training with and without projected visual context for improving walking ability and reducing fall incidence and fear of falling in older adults with fall-related hip fracture: a randomized controlled trial.

BACKGROUND: The ability to adjust walking to environmental context is often reduced in older adults and, partly as result of this, falls are common in this population. A treadmill with visual context projected on its belt (e.g., obstacles and targets) allows for practicing step adjustments relative to that context, while concurrently exploiting the great amount of walking practice associated with conventional treadmill training. The present study was conducted to compare the efficacy of adaptability treadmill training, conventional treadmill training and usual physical therapy in improving walking ability and reducing fear of falling and fall incidence in older adults during rehabilitation from a fall-related hip fracture. METHODS: In this parallel-group, open randomized controlled trial, seventy older adults with a recent fall-related hip fracture (83.3 ± 6.7 years, mean ± standard deviation) were recruited from inpatient rehabilitation care and block randomized to six weeks inpatient adaptability treadmill training (n = 24), conventional treadmill training (n = 23) or usual physical therapy (n = 23). Group allocation was only blind for assessors. Measures related to walking ability were assessed as the primary outcome before and after the intervention and at 4-week and 12-month follow-up. Secondary outcomes included general health, fear of falling, fall rate and proportion of fallers. RESULTS: Measures of general walking ability, general health and fear of falling improved significantly over time. Significant differences among the three intervention groups were only found for the Functional Ambulation Category and the dual-task effect on walking speed, which were in favor of respectively conventional treadmill training and adaptability treadmill training. CONCLUSIONS: Overall, adaptability treadmill training, conventional treadmill training and usual physical therapy resulted in similar effects on walking ability, fear of falling and fall incidence in older adults rehabilitating from a fall-related hip fracture. Additional post hoc subgroup analyses, with stratification for pre-fracture tolerated walking distance and executive function, revealed several intervention effects in favor of adaptability and conventional treadmill training, indicating superiority over usual physical therapy for certain subgroups. Future well-powered studies are necessary to univocally identify the characteristics of individuals who will benefit most from a particular intervention. TRIAL REGISTRATION: The Netherlands Trial Register ( NTR3222 , 3 January 2012).

Improved gait adjustments after gait adaptability training are associated with reduced attentional demands in persons with stroke.

After stroke, the ability to make step adjustments during walking is reduced and requires more attention, which may cause problems during community walking. The C-Mill is an innovative treadmill augmented with visual context (e.g., obstacles and stepping targets), which was designed specifically to practice gait adaptability. The objective of this study was to determine whether C-Mill gait adaptability training can help to improve gait adjustments and associated attentional demands. Sixteen community-ambulating persons in the chronic stage of stroke (age: 54.8 ± 10.8 years) received ten sessions of C-Mill training within 5-6 weeks. Prior to and after the intervention period, participants performed an obstacle-avoidance task with and without a secondary attention-demanding auditory Stroop task to assess their ability to make gait adjustments (i.e., obstacle-avoidance success rates) as well as the associated attentional demands (i.e., Stroop success rates, stratified for pre-crossing, crossing, and post-crossing strides). Obstacle-avoidance success rates improved after C-Mill training from 52.4 ± 16.3 % at pretest to 77.0 ± 16.4 % at posttest (p < 0.001). This improvement was accompanied by greater Stroop success rates during the obstacle-crossing stride only (pretest: 62.9 ± 24.9 %, posttest: 77.5 ± 20.4 %, p = 0.006). The observed improvements in obstacle-avoidance success rates and Stroop success rates were strongly correlated (r = 0.68, p = 0.015). The ability to make gait adjustments and the associated attentional demands can be successfully targeted in persons with stroke using C-Mill training, which suggests that its underlying assumptions regarding motor control are appropriate. This study lends support and guidance for designing a randomized controlled trial to further examine the potential of C-Mill training for improving safe community ambulation after stroke.

Effect of long-term physical activity and acute exercise on markers of systemic inflammation in persons with chronic spinal cord injury: a systematic review.

OBJECTIVE: To evaluate the effect of long-term physical activity (PA) and acute exercise on markers of systemic inflammation in persons with chronic spinal cord injury (SCI). DATA SOURCES: We searched PubMed (MEDLINE), EMBASE, Central Register of Controlled Trials, CINAHL, and PEDro, involving variations of the Medical Subject Headings: SCI, PA, exercise, and inflammation. No time or language restrictions were applied. STUDY SELECTION: Except for case reports, we included any type of study, both sexes, all ages, with SCI, resulting in the inclusion of 11 studies. PA included leisure or work activity, including exercise. DATA EXTRACTION: Two authors independently scanned titles and abstracts and read the articles included. One author extracted and the second double-checked the data. The methodological quality and evidence were rated by using the Cochrane Risk of Bias tool or the Newcastle-Ottawa Scale and the Grading of Recommendations Assessment, Development and Evaluation approach. DATA SYNTHESIS: The included studies had a high risk of bias and "very low" levels of evidence. Meta-analyses were performed (random-effects model or generic inverse variance method). The acute interleukin-6 (IL-6) response to exercise was the same for individuals with SCI and able-bodied individuals (P=.91); however, responses were higher in those with paraplegia than in those with tetraplegia (weighted mean difference, 1.19, P<.0001, and 0.25, P=.003, respectively). Compared with physically inactive people with SCI, physically active people with SCI had lower plasma C-reactive protein (CRP) levels (weighted mean difference, -0.38; P=.009). CRP concentrations were lower after the exercise intervention than before the exercise intervention (weighted mean difference, -2.76; P=.0001). CONCLUSIONS: PA and exercise may improve systemic markers of low-grade inflammation in those with SCI, particularly IL-6 and CRP. The change in IL-6 and CRP levels seems to be greater in those with paraplegia than in those with tetraplegia.

Effects of wheelchair cushions and pressure relief maneuvers on ischial interface pressure and blood flow in people with spinal cord injury.

OBJECTIVE: To investigate the effectiveness and interactions of 2 methods of pressure ulcer prevention, wheelchair cushions and pressure relief maneuvers, on interface pressure (IP) and blood flow of the buttocks. DESIGN: Within-subject repeated measures. SETTING: Rehabilitation center. PARTICIPANTS: Wheelchair users with a spinal cord injury or disorder (N=17). INTERVENTIONS: Participants performed 3 forward leans and 2 sideward leans with different degrees of lean while seated on each of 3 different wheelchair cushions. MAIN OUTCOME MEASURES: IP measured with a custom sensor and blood flow measured with laser Doppler flowmetry were collected at the ischial tuberosity. RESULTS: Pressure relief maneuvers had a significant main effect on the ischial IP (P<.001); all maneuvers except for the small frontward lean resulted in a significant reduction in IP compared with upright sitting. Blood flow significantly varied across postures (P<.001) with flow during upright sitting and small forward leans being significantly lower than during the full and intermediate leans in both the forward and sideward directions. CONCLUSIONS: The results of the study highlight the importance of positioning wheelchair users in a manner that facilitates in-seat movement. Regardless of the cushion being used, the pressure relief maneuvers resulted in very large reductions in IPs and significant increases in buttock blood flow. Only the small frontward lean was shown to be ineffective in reducing pressure or increasing blood flow. Because these pressure relief maneuvers involved postural changes that can occur during functional activities, these pressure relief maneuvers can become a part of volitional pressure relief and functional weight shifts. Therefore, clinical instruction should cover both as a means to impart sitting behaviors that may lead to better tissue health.

Metabolic rate and cardiorespiratory response during hybrid cycling versus handcycling at equal subjective exercise intensity levels in people with spinal cord injury.

OBJECTIVE: To compare the metabolic rate and cardiorespiratory response during hybrid cycling versus handcycling at equal subjective exercise intensity levels in people with spinal cord injury (SCI). DESIGN: Cross-sectional study. SETTING: Amsterdam Rehabilitation Research Centre | Reade, Amsterdam, The Netherlands. METHODS: On separate days, nine individuals with a motor complete paraplegia or tetraplegia (eight men, age 40 ± 13 years, time since injury 12 ± 10 years) performed 5-minute bouts of hybrid cycling (day 1) and handcycling (day 2) at moderate (level 3 on a 10-point rating of perceived exertion (RPE) scale) and vigorous (RPE level 6) subjective exercise intensity, while respiratory gas exchange was measured by open-circuit spirometry and heart rate was monitored using radiotelemetry. OUTCOME MEASURES: Metabolic rate (calculated with the Weir equation) and cardiorespiratory response (heart rate, oxygen pulse, and ventilation). RESULTS: Overall, the metabolic rate during hybrid cycling was 3.4 kJ (16%) higher (P = 0.006) than during handcycling. Furthermore, compared with handcycling, the overall heart rate and ventilation during hybrid cycling was 11 bpm (11%) and 5.3 l/minute (18%) higher (P = 0.004 and 0.024), respectively, while the oxygen pulse was the same (P = 0.26). CONCLUSION: Hybrid cycling induces a higher metabolic rate and cardiorespiratory response at equal RPE levels than handcycling, suggesting that hybrid cycling is more suitable for fighting obesity and increasing cardiorespiratory fitness in individuals with SCI.

The active and passive kinematic difference between primary reverse and total shoulder prostheses.

BACKGROUND: Reverse shoulder arthroplasty (RSA) and total shoulder arthroplasty (TSA) effectively decrease pain and improve clinical outcome. However, indications and biomechanical properties vary greatly. Our aim was to analyze both active and passive shoulder motion (thoracohumeral [TH], glenohumeral [GH], and scapulothoracic [ST]) and determine the kinematic differences between RSAs and TSAs. METHODS: During 3 range-of-motion (ROM) tasks (forward flexion, abduction, and axial rotation), the motion patterns of 16 RSA patients (19 shoulders), with a mean age of 69 ± 8 years (range, 58-84 years), and 17 TSA patients (20 shoulders), with a mean age of 72 ± 10 years (range, 53-87 years), were measured. The mean length of follow-up was 22 ± 10 months (range, 6-41 months) for RSA patients and 33 ± 18 months (range, 12-87 months) for TSA patients. Kinematic measurements were performed with a 3-dimensional electromagnetic tracking device. RESULTS: All patients showed better passive than active ROM. This difference was significantly larger for RSA patients than for TSA patients (TH in sagittal plane, 20° vs 8° [P = .001]; GH in sagittal plane, 16° vs 7° [P = .003]; TH in scapular plane, 15° vs 2° [P < .001]; GH in scapular plane, 12° vs 0° [P < .001]; and ST in scapular plane, 3° vs -2° [P = .032]). This finding also showed that in the scapular plane, TSA patients showed hardly any difference between active and passive ROM. Furthermore, TSA patients had 16° to 17° larger active TH motion, 15° larger active GH motion, and 8° larger active ST motion compared with RSA patients. The GH-ST ratios showed similar figures for both types of prostheses. CONCLUSION: TSA patients have larger active TH motion because in the scapular plane, they completely use the possible GH motion provided by the prosthetic design. This larger active ROM in TSA patients only applies for elevation and abduction, not for axial rotation or passive ROMs.

Occurrence of injuries and illnesses in athletes with a physical impairment; a forty-week prospective cohort study.

OBJECTIVES: Currently, the knowledge about the epidemiology of sport-related health problems of athletes with a physical impairment is limited. Therefore, this study aims to describe the prevalence, incidence and severity of sport-related health problems of athletes with a physical impairment in the Netherlands over a one sport season. DESIGN: Prospective cohort study. METHODS: Athletes (n = 99) with a physical impairment participated in this study. After completing a baseline questionnaire, athletes started a 40-week health monitoring period, during which they completed the Dutch translation of the OSTRC Questionnaire on Health Problems every week. Based on the reported information, injury and illness prevalence, incidence, weekly cumulative severity score, weekly time loss from sport and the total burden were calculated. RESULTS: A total of 368 health problems were reported by 95 athletes. These health problems consisted of 258 injuries and 110 illnesses. The average weekly prevalence of health problems was 48.0 %; for injuries 34.6 %, and illnesses 13.4 %. Differences were found when considering injury severity, with the highest severity scores for athletes with a limb deficiency. Furthermore, recreational athletes reported the highest injury severity scores, followed by athletes who competed nationally and athletes who competed internationally. CONCLUSIONS: Data from this study show a high average weekly prevalence of health problems, and differences amongst various impairment categories and sport levels when considering the severity of injuries. These results add to the knowledge regarding sport-related health problem epidemiology in this population, indicating that impairment category and sport level should be taken into account when developing injury prevention strategies.

Non-invasive spinal cord electrical stimulation for arm and hand function in chronic tetraplegia: a safety and efficacy trial.

Cervical spinal cord injury (SCI) leads to permanent impairment of arm and hand functions. Here we conducted a prospective, single-arm, multicenter, open-label, non-significant risk trial that evaluated the safety and efficacy of ARCEX Therapy to improve arm and hand functions in people with chronic SCI. ARCEX Therapy involves the delivery of externally applied electrical stimulation over the cervical spinal cord during structured rehabilitation. The primary endpoints were safety and efficacy as measured by whether the majority of participants exhibited significant improvement in both strength and functional performance in response to ARCEX Therapy compared to the end of an equivalent period of rehabilitation alone. Sixty participants completed the protocol. No serious adverse events related to ARCEX Therapy were reported, and the primary effectiveness endpoint was met. Seventy-two percent of participants demonstrated improvements greater than the minimally important difference criteria for both strength and functional domains. Secondary endpoint analysis revealed significant improvements in fingertip pinch force, hand prehension and strength, upper extremity motor and sensory abilities and self-reported increases in quality of life. These results demonstrate the safety and efficacy of ARCEX Therapy to improve hand and arm functions in people living with cervical SCI. ClinicalTrials.gov identifier: NCT04697472 .

The identification of genetic pathways involved in vascular adaptations after physical deconditioning versus exercise training in humans.

Physical inactivity and exercise training result in opposite adaptations of vascular structure. However, the molecular mechanisms behind these adaptations are not completely understood. We used a unique study design to examine both vascular characteristics of the superficial femoral artery (using ultrasound) and gene expression levels (from a muscle biopsy) in human models for physical deconditioning and exercise training. Initially, we compared able-bodied control subjects (n = 6) with spinal cord-injured individuals (n = 8) to assess the effects of long-term deconditioning. Subsequently, able-bodied control subjects underwent short-term lower limb deconditioning using 3 weeks of unilateral limb suspension. Spinal cord-injured individuals were examined before and after 6 weeks of functional electrical stimulation exercise training. Baseline femoral artery diameter and hyperaemic flow were lower after short- and long-term deconditioning and higher after exercise training, whilst intima-media thickness/lumen ratio was increased with short- and long-term deconditioning and decreased with exercise training. Regarding gene expression levels of vasculature-related genes, we found that groups of genes including the vascular endothelial growth factor pathway, transforming growth factor ß1 and extracellular matrix proteins were strongly associated with vascular adaptations in humans. This approach resulted in the identification of important genes that may be involved in vascular adaptations after physical deconditioning and exercise.

Functional gait rehabilitation in elderly people following a fall-related hip fracture using a treadmill with visual context: design of a randomized controlled trial.

BACKGROUND: Walking requires gait adjustments in order to walk safely in continually changing environments. Gait adaptability is reduced in older adults, and (near) falls, fall-related hip fractures and fear of falling are common in this population. Most falls occur due to inaccurate foot placement relative to environmental hazards, such as obstacles. The C-Mill is an innovative, instrumented treadmill on which visual context (e.g., obstacles) is projected. The C-Mill is well suited to train foot positioning relative to environmental properties while concurrently utilizing the high-intensity practice benefits associated with conventional treadmill training. The present protocol was designed to examine the efficacy of C-Mill gait adaptability treadmill training for improving walking ability and reducing fall incidence and fear of falling relative to conventional treadmill training and usual care. We hypothesize that C-Mill gait adaptability treadmill training and conventional treadmill training result in better walking ability than usual care due to the enhanced training intensity, with superior effects for C-Mill gait adaptability treadmill training on gait adaptability aspects of walking given the concurrent focus on practicing step adjustments. METHODS/DESIGN: The protocol describes a parallel group, single-blind, superiority randomized controlled trial with pre-tests, post-tests, retention-tests and follow-up. Hundred-twenty-six older adults with a recent fall-related hip fracture will be recruited from inpatient rehabilitation care and allocated to six weeks of C-Mill gait adaptability treadmill training (high-intensity, adaptive stepping), conventional treadmill training (high-intensity, repetitive stepping) or usual care physical therapy using block randomization, with allocation concealment by opaque sequentially numbered envelopes. Only data collectors are blind to group allocation. Study parameters related to walking ability will be assessed as primary outcome pre-training, post-training, after 4 weeks retention and 12 months follow-up. Secondary study parameters are measures related to fall incidence, fear of falling and general health. DISCUSSION: The study will shed light on the relative importance of adaptive versus repetitive stepping and practice intensity for effective intervention programs directed at improving walking ability and reducing fall risk and fear of falling in older adults with a recent fall-related hip fracture, which may help reduce future fall-related health-care costs.

The impact of lower-limb function on upper-limb pull and push strength in elite handcycling athletes.

This study investigated the impact of performing a closed kinetic chain with the lower limbs on isometric upper-limb pull and push strength. Sixty-two elite handcyclists were assessed with the Manual Muscle Test and allocated to groups with partial to normal (LLF) or no lower-limb (no-LLF) function. Both groups performed upper-limb strength measurements under two kinetic-chain conditions. During the closed-chain condition, the lower limbs were attached to two footrests, providing horizontal and vertical support. During the open-chain condition, the footrests were removed and the limbs were supported vertically by a horizontal plate. Repeated-measures ANOVA were conducted to investigate main effects (open vs. closed chain, LLF vs. no-LLF) and their interaction. During pull, LLF performed better (p < 0.001, +11%) by pushing against the footrests. However, this increase in pulling strength during a closed-chain condition was not observed in the no-LLF. Therefore, findings suggest an advantage for the least impaired athletes by being able to perform lower-limb closed chains during pulling. Handcyclists with LLF can maximise pulling performance by adjusting the footrests. The classification system should consider the implications of these findings on the allocation of athletes with different levels of LLF and/or on the equipment regulation.

The Effect of Mindset and Breathing Exercises on Physical and Mental Health in Persons with Spinal Cord Injury-A Pilot Feasibility Study.

This study investigated the feasibility and efficacy of mindset and breathing exercises (Wim Hof Method (WHM)) on physical and mental health in persons with spinal cord injury (SCI). Ten individuals with SCI participated in this pilot study. These ten participants followed a 4-week WHM intervention, with one weekly group session in the rehabilitation center and daily practice at home using the WHM app. An in-person exit-interview was conducted post-intervention to collect qualitative information on participants' experiences, regarding the feasibility and effects of the intervention. Furthermore, tests and questionnaires were administered pre- and post-intervention to assess physical and mental health outcomes. Adherence to the weekly in-person meetings was excellent and no adverse events occurred. Physical and mental health outcomes in this small sample size showed some pre-post differences. This pilot feasibility study provides preliminary evidence supporting the feasibility and efficacy of the WHM, including mindset and breathing exercises, on physical and mental health of people with SCI. These results warrant a randomized-controlled trial, including cold exposure, of this novel intervention in people with SCI.

Upper-Body versus Lower-Body Cooling in Individuals with Paraplegia during Arm-Crank Exercise in the Heat.

PURPOSE: For wheelchair users with a spinal cord injury, the lower body may be a more convenient cooling site than the upper body. However, it remains unknown if leg cooling reduces thermal strain in these individuals. We compared the impact of upper-body versus lower-body cooling on physiological and perceptual outcomes during submaximal arm-crank exercise under heat stress in individuals with paraplegia. METHODS: Twelve male participants with paraplegia (T4-L2, 50% complete lesion) performed a maximal exercise test in temperate conditions, and three heat stress tests (32°C, 40% relative humidity) in which they received upper-body cooling (COOL-UB), lower-body cooling (COOL-LB), or no cooling (CON) in a randomized counterbalanced order. Each heat stress test consisted of four exercise blocks of 15 min at 50% of peak power output, with 3 min of rest in between. Cooling was applied using water-perfused pads, with 14.8-m tubing in both COOL-UB and COOL-LB. RESULTS: Gastrointestinal temperature was 0.2°C (95% confidence interval (CI), 0.1°C to 0.3°C) lower during exercise in COOL-UB versus CON (37.5°C ± 0.4°C vs 37.7°C ± 0.3°C, P = 0.009), with no difference between COOL-LB and CON ( P = 1.0). Heart rate was lower in both COOL-UB (-7 bpm; 95% CI, -11 to -3 bpm; P = 0.01) and COOL-LB (-5 bpm; 95% CI, -9 to -1 bpm; P = 0.049) compared with CON. The skin temperature reduction at the cooled skin sites was larger in COOL-LB (-10.8°C ± 1.1°C) than in COOL-UB (-6.7°C ± 1.4°C, P < 0.001), which limited the cooling capacity in COOL-LB. Thermal sensation of the cooled skin sites was improved and overall thermal discomfort was lower in COOL-UB ( P = 0.01 and P = 0.04) but not in COOL-LB ( P = 0.17 and P = 0.59) compared with CON. CONCLUSIONS: Upper-body cooling more effectively reduced thermal strain than lower-body cooling in individuals with paraplegia, as it induced greater thermophysiological and perceptual benefits.

Associations between meeting exercise guidelines, physical fitness, and health in people with spinal cord injury.

PURPOSE: (1) To estimate the proportion of Dutch wheelchair users with spinal cord injury (SCI) who meet different SCI exercise guidelines; (2) to evaluate which demographic and lesion characteristics are associated with meeting these guidelines; (3) whether meeting these guidelines is associated with physical fitness and health. MATERIALS AND METHODS: Based on the PASIPD questionnaire items, participants were allocated to meeting two SCI aerobic exercise guidelines, which differ in exercise load. Differences in personal, lesion, fitness, and health characteristics between groups were tested with a one-way ANOVA. Multiple regression analyses were performed to evaluate if meeting guidelines was associated with better fitness and health. Statistical significance was accepted at p < 0.05. RESULTS: Of the 358 included participants, 63.1% met at least one aerobic exercise guideline. Being female, older age, having tetraplegia, and lower educational level were associated with a lower likelihood to meet the aerobic exercise guidelines. Meeting aerobic exercise guidelines showed a positive association with all respiratory and exercise capacity parameters. Limited associations were found between meeting exercise guidelines and health. CONCLUSIONS: Meeting exercise guidelines was associated with better respiratory functions and exercise capacity with additional fitness and some body composition benefits in higher exercise activity levels.IMPLICATIONS FOR REHABILITATIONMeeting SCI exercise guidelines are associated with better respiratory functions and exercise capacity with additional fitness and body composition benefits when higher exercising at higher activity levels, emphasizing the value and importance of regular exercise in individuals with SCI.

Sports-Related Health Problems in Para-Sports: A Systematic Review With Quality Assessment.

CONTEXT: Participation in sports is associated with a risk of sports-related health problems. For athletes with an impairment, sports-related health problems further burden an already restricted lifestyle, underlining the importance of prevention strategies in para-sports. OBJECTIVE: To provide a comprehensive overview with quality assessment of the literature on sports-related health problems, their etiology, and available preventive measures in para-sports following the steps of the Sequence of Prevention. DATA SOURCES: A literature search (in PubMed, Embase, SPORTDiscus, CINAHL and the Cochrane Library) was performed up to December 8, 2021, in collaboration with a medical information specialist. STUDY SELECTION: The search yielded 3006 articles, of which 64 met all inclusion criteria. STUDY DESIGN: Systematic review with quality assessment. LEVEL OF EVIDENCE: Level 3. DATA EXTRACTION: Two independent researchers carried out the screening process and quality assessment. One researcher extracted data, and the Sequence of Prevention categorized evidence. RESULTS: A total of 64 studies were included, of which 61 reported on the magnitude and risk factors of sports-related health problems, while only 3 reported on the effectiveness of preventive measures. Of these, 30 studies were of high quality. Most studies (84%) included elite-level athletes. The reported injury incidence varied widely between sports (0-91 per 1000 athlete days) and impairment categories (1-50 per 1000 athlete days). The same applies to illness incidence with regard to different sports (3-49 per 1000 athlete days) and impairment categories (6-14 per 1000 athlete days). CONCLUSION: This review shows the current vast range of reported sport-related health problems in para-sports. There is limited evidence concerning the severity of these sports-related health problems and inconclusive evidence on the risk factors. Lastly, the evidence regarding the development and effectiveness of preventive measures for para-athletes is sparse.

Heat preparedness and exertional heat illness in Paralympic athletes: A Tokyo 2020 survey.

Paralympic athletes may be at increased risk for exertional heat illness (EHI) due to reduced thermoregulatory ability as a consequence of their impairment. This study investigated the occurrence of heat-stress related symptoms and EHI, and the use of heat mitigation strategies in Paralympic athletes, both in relation to the Tokyo 2020 Paralympic Games and previous events. Paralympic athletes competing in Tokyo 2020 were invited to complete an online survey five weeks prior to the Paralympics and up to eight weeks after the Games. 107 athletes (30 [24-38] years, 52% female, 20 nationalities, 21 sports) completed the survey. 57% of respondents had previously experienced heat-stress related symptoms, while 9% had been medically diagnosed with EHI. In Tokyo, 21% experienced at least one heat-stress related symptom, while none reported an EHI. The most common symptom and EHI were, respectively, dizziness and dehydration. In preparation for Tokyo, 58% of respondents used a heat acclimation strategy, most commonly heat acclimatization, which was more than in preparation for previous events (45%; P = 0.007). Cooling strategies were used by 77% of athletes in Tokyo, compared to 66% during past events (P = 0.18). Cold towels and packs were used most commonly. Respondents reported no medically-diagnosed EHIs during the Tokyo 2020 Paralympic Games, despite the hot and humid conditions in the first seven days of competition. Heat acclimation and cooling strategies were used by the majority of athletes, with heat acclimation being adopted more often than for previous competitions.