Poor specificity of National Early Warning Score (NEWS) in spinal cord injuries (SCI) population: a retrospective cohort study.

STUDY DESIGN: Retrospective chart audit. OBJECTIVES: The National Early Warning Score (NEWS) is based on seven physiological parameters which can be altered in some individuals with spinal cord injuries (SCI). The aim was to start the development of adapted NEWS suitable for SCI population. The objective was to determine the SBP NEWS specificity based on neurological level of injury (NLI) and completeness of injury. SETTING: Tertiary centre in the UK. METHODS: Adult patients admitted for the first time to the National Spinal Injuries Centre between 1 January 2015 and 31 December 2016 were included if they were >6 months post injury. Data were extracted retrospectively including the last ten consecutive BP and heart rate readings before discharge. Data were analysed based on different AIS grades, completeness of injury and NLI. RESULTS: One hundred and ninety one patients were admitted in 2015 and 2016 and 142 patients were included in the primary analysis. The mean SBP ranged between 92 and 151 mmHg. Patients with the NLI of T6 and above (≥T6) motor complete lesions had a significantly lower SBP than motor incomplete lesions. The specificity of the SBP NEWS was 35.3% in ≥T6 motor complete individuals versus 80.3% in ≥T6 motor incomplete individuals. CONCLUSION: The baseline BP is significantly lower in the ≥T6 motor complete SCI individuals (>6 months post injury) resulting in a very low specificity of 35.3% to SBP NEWS, which could lead to mismatch between clinical deterioration and NEWS resulting in lack of timely clinical response.

Thermoregulatory Responses during Competitive Wheelchair Rugby Match Play.

The purpose of this study was to determine whether a player's physical impairment or activity profile was related to the amount of thermal strain experienced during wheelchair rugby match play. 17 elite wheelchair rugby players played a competitive match, whilst activity profiles, measures of core and skin temperature, heart rate and perceptual responses were taken. Players were divided into 2 groups depending on their physical impairment: players with a cervical spinal cord injury, (n=10) or non-spinal related physical impairment (n=7). Total distance was lower (4 842±324 vs. 5 541±316 m, p<0.01, ES=2.2) and mean speed slower (1.13±0.11 vs. 1.27±0.11 m∙s-1, p<0.03, ES=1.3) in players with a spinal cord injury. Yet, the change in core temperature (1.6±0.4 vs. 0.7±0.3°C, p<0.01, ES=2.5) was significantly greater in players with a spinal cord injury. In conclusion, players with a spinal cord injury were under greater thermal strain during wheelchair rugby match play, as a result of their reduced heat loss capacity, due to their physical impairment and not because of their activity profile.

Wheelchair satisfaction and recommended improvements of manual wheelchairs in the UK.

PURPOSE OF THE ARTICLE: The aim of this study was to determine user satisfaction with manual wheelchairs in the United Kingdom and to determine areas that could be improved to help drive future design and development. MATERIALS AND METHODS: Manual wheelchair users, aged 18-65 years old living in the United Kingdom, were invited, to complete an online cross-sectional questionnaire. The link to the questionnaire was distributed using a range of methods to charities, organisations and wheelchair user groups via invitation by email and social media. Responses were gathered from 122 respondents and analysed using descriptive statistics, cross-tabulation and content analysis. RESULTS: Respondents felt comfort (39.3%), weight (35.4%), manoeuvrability (34.3%) and durability (30.7%) were the most important features of a wheelchair. Seventy percent of respondents that were "not at all satisfied" with their current wheelchair were fitted by the National Health Service (NHS, X2 = 42.39, p < 0.001). Ninety percent of respondents who were "not at all satisfied" with their current wheelchair experienced issues with comfort (X2 = 17.82, p = 0.001). Sixty percent who were "not satisfied at all" with their wheelchair had not chosen their wheelchair (X2 = 25.15, p < 0.001). CONCLUSION: Wheelchair satisfaction was largely determined by comfort, location of the users' wheelchair fitting (for example the NHS) and users choosing their own wheelchair. Future wheelchair designs should utilise a user centred and inclusive design approach to cater for a wider range of individual needs and requirements.

Manual wheelchair users in the UK are more likely to be satisfied with their wheelchair if they were fitted by a service other than the National Health Service (NHS), chose their own wheelchair and experience no issues with comfort.Wheelchair fittings should account for individual differences and requirements as no model or size can cater for all users. This may help increase wheelchair satisfaction and comfort for the user.Manufacturers should consider more inclusive designs to cater for a wider range of users, for example accommodating female users at different stages throughout their lifetime.

Integrated fan cooling of the lower back for wheelchair users.

Introduction: A large proportion of a wheelchair user's body is in contact with their wheelchair. Integrated fan cooling systems fitted to a wheelchair's backrest aim to alleviate the build-up of heat at the skin-chair interface. The aim of this pilot study was to evaluate the effectiveness of an integrated fan cooling system at cooling the user during daily pushing activity. Methods: Eight male able-bodied participants completed two conditions, with (FAN) and without (CON) fan cooling, pushing for four 15 min blocks. The fan was turned on (highest setting) at the end of block 1 (FAN), whilst in CON the fan remained off. Skin temperature was measured over the back and chest throughout alongside heart rate and perceptual responses (rating of perceived exertion, thermal sensation, thermal comfort, wetness sensation) at the end of each 15 min block. Results: Wetness sensation and lower back skin temperature were lower in FAN (both p < 0.02), with the difference in lower back skin temperature between the two conditions being 2.20°C at the end of block 4. Conclusion: The integrated fan cooling system provided significant cooling to the lower back without affecting any other physiological or perceptual response, besides wetness sensation.

A Reappraisal of Ventilatory Thresholds in Wheelchair Athletes With a Spinal Cord Injury: Do They Really Exist?

The ventilatory threshold (VT) separates low- from moderate-intensity exercise, the respiratory compensation point (RCP) moderate- from high-intensity exercise. Both concepts assume breakpoints in respiratory data. However, the objective determination of the VT and RCP using breakpoint models during upper-body modality exercise in wheelchair athletes with spinal cord injury (SCI) has received little attention. Therefore, the aim of this study was to compare the fit of breakpoint models (i.e., two linear regression lines) with continuous no-breakpoint models (i.e., exponential curve/second-order polynomial) to respiratory data obtained during a graded wheelchair exercise test to exhaustion. These fits were compared employing adjusted R2, and blocked bootstrapping was used to derive estimates of a median and 95% confidence intervals (CI). V̇O2-V̇CO2 and V̇E/V̇O2-time data were assessed for the determination of the VT, and V̇CO2-V̇E and V̇E/V̇CO2-time data for the determination of the RCP. Data of 9 wheelchair athletes with tetraplegia and 8 with paraplegia were evaluated. On an overall group-level, there was an overlap in the adjusted R2 median ± 95% CI between the breakpoint and the no-breakpoint models for determining the VT (V̇O2-V̇CO2: 0.991 ± 0.003 vs. 0.990 ± 0.003; V̇E/V̇O2-time: 0.792 ± 0.101 vs. 0.782 ± 0.104, respectively) and RCP (V̇E-V̇CO2: 0.984 ± 0.004 vs. 0.984 ± 0.004; V̇E/V̇CO2-time: 0.729 ± 0.064 vs. 0.691 ± 0.063, respectively), indicating similar model fit. We offer two lines of reasoning: (1) breakpoints in these respiratory data exist but are too subtle to result in a significant difference in adjusted R2 between the investigated breakpoint and no-breakpoint models; (2) breakpoints do not exist, as has been argued previously.

Heat-related issues and practical applications for Paralympic athletes at Tokyo 2020.

International sporting competitions, including the Paralympic Games, are increasingly being held in hot and/or humid environmental conditions. Thus, a greater emphasis is being placed on preparing athletes for the potentially challenging environmental conditions of the host cities, such as the upcoming Games in Tokyo in 2020. However, evidence-based practices are limited for the impairment groups that are eligible to compete in Paralympic sport. This review aims to provide an overview of heat-related issues for Paralympic athletes alongside current recommendations to reduce thermal strain and technological advancements in the lead up to the Tokyo 2020 Paralympic Games. When competing in challenging environmental conditions, a number of factors may contribute to an athlete's predisposition to heightened thermal strain. These include the characteristics of the sport itself (type, intensity, duration, modality, and environmental conditions), the complexity and severity of the impairment and classification of the athlete. For heat vulnerable Paralympic athletes, strategies such as the implementation of cooling methods and heat acclimation can be used to combat the increase in heat strain. At an organizational level, regulations and specific heat policies should be considered for several Paralympic sports. Both the utilization of individual strategies and specific heat health policies should be employed to ensure that Paralympics athletes' health and sporting performance are not negatively affected during the competition in the heat at the Tokyo 2020 Paralympic Games.

Effects of cooling before and during simulated match play on thermoregulatory responses of athletes with tetraplegia.

OBJECTIVES: Athletes with high level spinal cord injuries (tetraplegia) are under greater thermal strain during exercise than the able-bodied. The purpose of this study was to investigate the effectiveness of pre-cooling using an ice vest and the combination of pre-cooling and cooling during play using water sprays in athletes with tetraplegia. DESIGN: Counter-balanced, cross-over design. METHODS: Eight wheelchair rugby players with tetraplegia completed a 60min intermittent sprint protocol (ISP) on a wheelchair ergometer in 20.2°C±0.2°C and 33.0%±3.1% relative humidity. The ISP was conducted on three occasions; no cooling (NC), pre-cooling with an ice vest (P) and pre-cooling with an ice vest and water sprays between quarters (PW). Gastrointestinal (Tgi) temperature, mean skin temperature (Tsk) and perceptual responses were measured throughout. RESULTS: At the end of pre-cooling, the change in Tgi was not significantly different between conditions (P>0.05) but the change in Tsk was significantly greater in P and PW compared to NC (P<0.001). The change in Tgi over the ISP was significantly lower in PW and P compared to NC (P<0.05), whilst the change in Tsk was lower in PW compared to P and NC (P<0.05). Cooling had no effect on performance or perceptual responses (P>0.05). CONCLUSIONS: Water spraying between quarters combined with pre-cooling using an ice vest lowers thermal strain to a greater degree than pre-cooling only in athletes with tetraplegia, but has no effect on simulated wheelchair rugby performance or perceptual responses.

Cooling athletes with a spinal cord injury.

Cooling strategies that help prevent a reduction in exercise capacity whilst exercising in the heat have received considerable research interest over the past 3 decades, especially in the lead up to a relatively hot Olympic and Paralympic Games. Progressing into the next Olympic/Paralympic cycle, the host, Rio de Janeiro, could again present an environmental challenge for competing athletes. Despite the interest and vast array of research into cooling strategies for the able-bodied athlete, less is known regarding the application of these cooling strategies in the thermoregulatory impaired spinal cord injured (SCI) athletic population. Individuals with a spinal cord injury (SCI) have a reduced afferent input to the thermoregulatory centre and a loss of both sweating capacity and vasomotor control below the level of the spinal cord lesion. The magnitude of this thermoregulatory impairment is proportional to the level of the lesion. For instance, individuals with high-level lesions (tetraplegia) are at a greater risk of heat illness than individuals with lower-level lesions (paraplegia) at a given exercise intensity. Therefore, cooling strategies may be highly beneficial in this population group, even in moderate ambient conditions (~21 °C). This review was undertaken to examine the scientific literature that addresses the application of cooling strategies in individuals with an SCI. Each method is discussed in regards to the practical issues associated with the method and the potential underlying mechanism. For instance, site-specific cooling would be more suitable for an athlete with an SCI than whole body water immersion, due to the practical difficulties of administering this method in this population group. From the studies reviewed, wearing an ice vest during intermittent sprint exercise has been shown to decrease thermal strain and improve performance. These garments have also been shown to be effective during exercise in the able-bodied. Drawing on additional findings from the able-bodied literature, the combination of methods used prior to and during exercise and/or during rest periods/half-time may increase the effectiveness of a strategy. However, due to the paucity of research involving athletes with an SCI, it is difficult to establish an optimal cooling strategy. Future studies are needed to ensure that research outcomes can be translated into meaningful performance enhancements by investigating cooling strategies under the constraints of actual competition. Cooling strategies that meet the demands of intermittent wheelchair sports need to be identified, with particular attention to the logistics of the sport.

Thermoregulation during intermittent exercise in athletes with a spinal-cord injury.

PURPOSE: Individuals with a spinal-cord injury have impaired thermoregulatory control due to a loss of sudomotor and vasomotor effectors below the lesion level. Thus, individuals with high-level lesions (tetraplegia) possess greater thermoregulatory impairment than individuals with lower-level lesions (paraplegia). Previous research has not reflected the intermittent nature and modality of wheelchair court sports or replicated typical environmental temperatures. Hence, the purpose of this study was to investigate the thermoregulatory responses of athletes with tetraplegia and paraplegia during an intermittent-sprint protocol (ISP) and recovery in cool conditions. METHODS: Sixteen wheelchair athletes, 8 with tetraplegia (TP, body mass 65.2±4.4 kg) and 8 with paraplegia (body mass 68.1±12.3 kg), completed a 60-min ISP in 20.6°C±0.1°C, 39.6%±0.8% relative humidity on a wheelchair ergometer, followed by 15 min of passive recovery. Core temperature (Tcore) and mean (Tsk) and individual skin temperatures were measured throughout. RESULTS: Similar external work (P=.70, ES=0.20) yet a greater Tcore (P<.05, ES=2.27) and Tsk (P<.05, ES=1.50) response was demonstrated by TP during the ISP. CONCLUSIONS: Despite similar external work, a marked increase in Tcore in TP during exercise and recovery signifies that thermoregulatory differences between the groups were predominantly due to differences in heat loss. Further increases in thermal strain were not prevented by the active and passive recovery between maximal-effort bouts of the ISP, as Tcore continually increased throughout the protocol in TP.

Salivary immunoglobulin A and upper respiratory symptoms during 5 months of training in elite tetraplegic athletes.

PURPOSE: Altered autonomic innervation in tetraplegic individuals has been shown to depress certain immune parameters at rest and alter exercise-related salivary immunoglobulin A (sIgA) responses. The purpose of this study was to examine resting sIgA responses as a function of training load and episodes of upper respiratory symptoms (URS) in elite tetraplegic athletes. METHODS: Resting saliva samples were obtained from 14 tetraplegic athletes at 12 predefined time points over 5 months and analyzed for sIgA. Occurrence of self-reported URS and training load was recorded throughout the study's duration. Regression analyses were performed to investigate the relationship between sIgA responses and training load. Furthermore, the relationships between sIgA responses and URS occurrence were examined. RESULTS: sIgA secretion rate was negatively correlated with training load (P=.04), which only accounted for 8% of the variance. No significant relationships were found between sIgA responses and subsequent URS occurrence. Finally, sIgA responses did not differ between athletes with and without recorded URS during the study period. CONCLUSIONS: In line with findings in able-bodied athletes, negative relationships between sIgA secretion rate and training load were found in tetraplegic athletes. This may explain some of the higher infection risk in wheelchair athletes with a high training load, which has been previously observed in paraplegic athletes. However, the nonsignificant relationship between sIgA responses and URS occurrence brings into question the use of sIgA as a prognostic tool for the early detection of URS episodes in the studied population.