Trajectories of health-related quality of life among people with a physical disability and/or chronic disease during and after rehabilitation: a longitudinal cohort study.

PURPOSE: To identify Health-related Quality of Life (HR-QoL) trajectories in a large heterogeneous cohort of people with a physical disability and/or chronic disease during and after rehabilitation and to determine which factors before discharge are associated with longitudinal trajectory membership. METHODS: A total of 1100 people with a physical disability and/or chronic disease were included from the longitudinal cohort study Rehabilitation, Sports and Active lifestyle. All participants participated in a physical activity promotion programme in Dutch rehabilitation care. HR-QoL was assessed using the RAND-12 Health Status Inventory questionnaire at baseline (T0: 3-6 weeks before discharge) and at 14 (T1), 33 (T2) and 52 (T3) weeks after discharge from rehabilitation. A data-driven approach using Latent Class Growth Mixture modelling was used to determine HR-QoL trajectories. Multiple binomial multivariable logistic regression analyses were used to determine person-, disease- and lifestyle-related factors associated with trajectory membership. RESULTS: Three HR-QoL trajectories were identified: moderate (N = 635), high (N = 429) and recovery (N = 36). Trajectory membership was associated with person-related factors (age and body mass index), disease-related factors (perceived fatigue, perceived pain and acceptance of the disease) and one lifestyle-related factor (alcohol consumption) before discharge from rehabilitation. CONCLUSIONS: Most of the people who participated in a physical activity promotion programme obtained a relatively stable but moderate HR-QoL. The identified HR-QoL trajectories among our heterogeneous cohort are disease-overarching. Our findings suggest that people in rehabilitation may benefit from person-centred advice on management of fatigue and pain (e.g. activity pacing) and the acceptance of the disability.

Sprint performance and propulsion asymmetries on an ergometer in trained high- and low-point wheelchair rugby players.

The purpose of this study was to examine the propulsion asymmetries of wheelchair athletes while sprinting on an instrumented, dual-roller ergometer system. Eighteen experienced wheelchair rugby players (8 low point (LP) (class ≤1.5) and 10 high point (HP) (class ≥2.0)) performed a 15-second sprint in their sports wheelchair on the instrumented ergometer. Asymmetry was defined as the difference in distance and power output (PO) between left and right sides when the best side reached 28 m. Propulsion techniques were quantified based on torque and velocity data. HP players covered an average 3 m further than the LP players (P = .002) and achieved faster sprint times than LP players (6.95 ± 0.89 vs 8.03 ± 0.68 seconds, P = .005) and at the time the best player finished (5.96 seconds). Higher peak POs (667 ± 108 vs 357 ± 78 W, P = .0001) and greater peak speeds that were also evident were for HP players (4.80 ± 0.71 vs 4.09 ± 0.45 m/s, P = .011). Greater asymmetries were found in HP players for distance (1.86 ± 1.43 vs 0.70 ± 0.65 m, P = .016), absolute peak PO (P = .049), and speed (0.35 ± 0.25 vs 0.11 ± 0.10 m/s, P = .009). Although HP players had faster sprint times over 28 m (achieved by a higher PO), high standard deviations show the heterogeneity within the two groups (eg, some LP players were better than HP players). Quantification of asymmetries is important not only for classifiers but also for sports practitioners wishing to improve performance as they could be addressed through training and/or wheelchair configuration.

Effects of hybrid cycling versus handcycling on wheelchair-specific fitness and physical activity in people with long-term spinal cord injury: a 16-week randomized controlled trial.

STUDY DESIGN: This is an open randomized controlled trial. OBJECTIVE: The objective of this study was to investigate the effects of a 16-week hybrid cycle versus handcycle exercise program on fitness and physical activity in inactive people with long-term spinal cord injury (SCI). SETTING: The study was conducted in two rehabilitation centers with a specialized SCI unit. METHODS: Twenty individuals (SCI⩾8 years) were randomly assigned to a hybrid cycle (voluntary arm exercise combined with functional electrical stimulation (FES)-induced leg exercise) or a handcycle group. During 16 weeks, both groups trained twice a week for 30 min at 65-75% heart rate reserve. Outcome measures obtained before, during and after the program were fitness (peak power output, peak oxygen consumption), submaximal VO2 and heart rate (HR), resting HR, wheelchair skill performance time score) and physical activity (distance travelled in wheelchair and Physical Activity Scale for Individuals with Physical Disabilities (PASIPD) score). Changes were examined using a two-factor mixed-measures analysis of variance. RESULTS: For all fitness parameters, except for submaximal VO2, no interaction effects were found. The hybrid cycle group showed a decrease in VO2 over time in contrast to the handcycle group (P=0.045). An overall reduction in HRrest (5±2 b.p.m.; P=0.03) and overall increase in PASIPD score (6.5±2.1; P=0.002) were found after 16 weeks of training. No overall training effects were found for the other fitness and activity outcome measures. CONCLUSION: In the current study, hybrid cycling and handcycling showed similar effects on fitness and physical activity, indicating that there seem to be no additional benefits of the FES-induced leg exercise over handcycle training alone.

Effects of handrail hold and light touch on energetics, step parameters, and neuromuscular activity during walking after stroke.

BACKGROUND: Holding a handrail or using a cane may decrease the energy cost of walking in stroke survivors. However, the factors underlying this decrease have not yet been previously identified. The purpose of the current study was to fill this void by investigating the effect of physical support (through handrail hold) and/or somatosensory input (through light touch contact with a handrail) on energy cost and accompanying changes in both step parameters and neuromuscular activity. Elucidating these aspects may provide useful insights into gait recovery post stroke. METHODS: Fifteen stroke survivors participated in this study. Participants walked on a treadmill under three conditions: no handrail contact, light touch of the handrail, and firm handrail hold. During the trials we recorded oxygen consumption, center of pressure profiles, and bilateral activation of eight lower limb muscles. Effects of the three conditions on energy cost, step parameters and neuromuscular activation were compared statistically using conventional ANOVAs with repeated measures. In order to examine to which extent energy cost and step parameters/muscle activity are associated, we further employed a partial least squares regression analysis. RESULTS: Handrail hold resulted in a significant reduction in energy cost, whereas light touch contact did not. With handrail hold subjects took longer steps with smaller step width and improved step length symmetry, whereas light touch contact only resulted in a small but significant decrease in step width. The EMG analysis indicated a global drop in muscle activity, accompanied by an increased constancy in the timing of this activity, and a decreased co-activation with handrail hold, but not with light touch. The regression analysis revealed that increased stride time and length, improved step length symmetry, and decreased muscle activity were closely associated with the decreased energy cost during handrail hold. CONCLUSION: Handrail hold, but not light touch, altered step parameters and was accompanied by a global reduction in muscle activity, with improved timing constancy. This suggests that the use of a handrail allows for a more economic step pattern that requires less muscular activation without resulting in substantial neuromuscular re-organization. Handrail use may thus have beneficial effects on gait economy after stroke, which cannot be accomplished through enhanced somatosensory input alone.

The effect of crank position and backrest inclination on shoulder load and mechanical efficiency during handcycling.

Handbikes come in different models and setups, but only limited knowledge is available on the handbike-user interface. The aim of this study was to identify optimal handbike setups, assuming that in such a setup mechanical efficiency is high, while shoulder load is low. Thirteen subjects with a spinal cord injury (paraplegia) performed handcycling with different handbike setups at constant power output: four crank positions (two distances, two heights) and four backrest inclinations. The O2-consumption, kinetics, and kinematics were measured to calculate mechanical efficiency and shoulder load (glenohumeral contact force, net shoulder moments, and rotator cuff force). The analysis showed that more upright backrest positions resulted in lower shoulder load compared with the most reclined position [glenohumeral contact force (260 vs 335 N), supraspinatus (14.4% vs 18.2%), and infraspinatus force (5.4% vs 9.8%)], while there was no difference in efficiency. Except for a reduction in subscapularis force at the distant position, no differences in shoulder load or efficiency were found between crank positions. Recreational handbike users, who want to improve their physical capacity in a shoulder-friendly way, should set up their handbike with a more upright backrest position and a distant crank placement.

Hand-rim forces and gross mechanical efficiency at various frequencies of wheelchair propulsion.

To determine the effects of push frequency changes on force application, fraction of effective force (FEF) and gross efficiency (GE) during hand-rim propulsion. 8 male able-bodied participants performed five 4-min sub-maximal exercise bouts at 1.8 ms(-1); the freely chosen frequency (FCF), followed by 4 counter-balanced trials at 60, 80, 120 and 140% FCF. Kinetic data was obtained using a SMART(Wheel), measuring forces and moments. The GE was determined as the ratio of external work done and the total energy expended. Increased push frequency led to reductions in peak resultant force (P<0.05), ranging from 167 to 117 N and peak tangential force (P<0.05), ranging from 117 to 77 N. However, FEF only demonstrated a significant difference between 60% and 140% FCF (69 ± 9% and 63 ± 7, respectively; P<0.05). Work per cycle decreased significantly (P<0.05) and rate of force development increased significantly (P<0.05) with increased push frequency. GE values were significantly lower at 60%, 120% and 140% FCF than 80% and 100% FCF (P<0.05). No meaningful associations were present between FEF and GE. Under the current testing conditions, changes in push frequency are accompanied with changes in the absolute force values, albeit without changes in either the gross pattern/trend of force application or FEF. Changes in GE are not explained by different levels of force effectiveness.

Force application during handcycling and handrim wheelchair propulsion: an initial comparison.

The aim of the study was to evaluate the external applied forces, the effectiveness of force application and the net shoulder moments of handcycling in comparison with handrim wheelchair propulsion at different inclines. Ten able-bodied men performed standardized exercises on a treadmill at inclines of 1%, 2.5% and 4% with an instrumented handbike and wheelchair that measured three-dimensional propulsion forces. The results showed that during handcycling significantly lower mean forces were applied at inclines of 2.5% (P < .001) and 4% (P < .001) and significantly lower peak forces were applied at all inclines (1%: P = .014, 2.5% and 4%: P < .001). At the 2.5% incline, where power output was the same for both devices, total forces (mean over trial) of 22.8 N and 27.5 N and peak forces of 40.1 N and 106.9 N were measured for handbike and wheelchair propulsion. The force effectiveness did not differ between the devices (P = .757); however, the effectiveness did increase with higher inclines during handcycling whereas it stayed constant over all inclines for wheelchair propulsion. The resulting peak net shoulder moments were lower for handcycling compared with wheelchair propulsion at all inclines (P < .001). These results confirm the assumption that handcycling is physically less straining.

Exploring experiences of people with stroke and health professionals on post-stroke fatigue guidance: getting the right people to the right care at the right time.

PURPOSE: This focus group study aimed to explore experiences and perceptions on post-stroke fatigue guidance in Dutch rehabilitation and follow-up care among people/patients with stroke and health professionals. METHODS: Ten persons with stroke and twelve health professionals with different professions within stroke rehabilitation or follow-up care in the Netherlands were purposively sampled and included. Eight online focus group interviews were conducted. We analysed the data using reflexive thematic analysis. RESULTS: Three themes were identified. Guidance in fatigue management did not always match the needs of people/patients with stroke. Professionals were positive about the provided fatigue guidance (e.g. advice on activity pacing), but found it could be better tailored to the situation of people/patients with stroke. Professionals believe the right time for post-stroke fatigue guidance is when people/patients with stroke are motivated to change physical activity behaviour to manage fatigue - mostly several months after stroke - while people/patients with stroke preferred information on post-stroke fatigue well before discharge. Follow-up care and suggestions for improvement described that follow-up support after rehabilitation by a stroke coach is not implemented nationwide, while people/patients with stroke and professionals expressed a need for it. CONCLUSIONS: The study findings will help guide improvement of fatigue guidance in stroke rehabilitation programmes and stroke follow-up care aiming to improve physical activity, functioning, participation, and health.

We recommend fatigue guidance, including peer support, to be accessible to all people after stroke and for health professionals to pay attention to acceptance of the stroke.To improve fatigue guidance, we suggest providing information on post-stroke fatigue to people after stroke and their relatives well before discharge from stroke rehabilitation.Tailored advice on activity pacing during and after stroke rehabilitation is important to fill the current unmet need of people after stroke to manage fatigue and to gradually improve participation, physical activity behaviour and health.We recommend to health professionals working in stroke rehabilitation to tailor the rehabilitation schedule to their patients' energy level and perception of fatigue levels.

Validity of the mental health subscale of the SF-36 in persons with spinal cord injury.

STUDY DESIGN: Cross-sectional study 5 years after discharge from inpatient rehabilitation. OBJECTIVE: To examine the psychometric properties of the Mental Health subscale (MHI-5) of the 36-Item Short Form Health Survey (SF-36) in persons with spinal cord injury (SCI). SETTING: Eight Dutch rehabilitation centres with specialised SCI units. METHODS: Possible floor and ceiling effects were assessed, and Cronbach's α coefficient was calculated to assess internal consistency. Concurrent and divergent validity were assessed using Spearman correlations between the MHI-5 and measures of life satisfaction, neuroticism, vitality, general health, functional independence, participation, lesion characteristics and demographics. RESULTS: There were no floor or ceiling effects, but the total MHI-5 score was slightly skewed (-1.15). Internal consistency was good (α=0.79). Concurrent validity was shown by significant Spearman correlations between the MHI-5 and life satisfaction (0.53), neuroticism (-0.55), vitality (0.53) and general health (0.37). Divergent validity was shown by weak and, in part, non-significant correlations between the MHI-5 and functional independence (0.09), participation (-0.28) and lesion characteristics (range -0.01-0.19). CONCLUSION: The MHI-5 showed reliability and validity as a measure of mood in persons with SCI, and is a promising measurement instrument to assess mental health problems in this population.

Is manual wheelchair satisfaction related to active lifestyle and participation in people with a spinal cord injury?

STUDY DESIGN: Cross-sectional study. OBJECTIVES: To describe the satisfaction of the manual wheelchair user with hand rim wheelchair-related aspects (for example, dimensions, weight and comfort) and wheelchair service-related aspects and to determine the relationship between wheelchair users' satisfaction, personal and lesion characteristics, and active lifestyle and participation in persons with a spinal cord injury (SCI). SETTING: Eight Dutch rehabilitation centers with a specialized SCI unit. METHODS: The Dutch version of the Quebec user evaluation of satisfaction with assistive technology (D-QUEST) was filled out by 109 participants 1 year after discharge from inpatient SCI rehabilitation. Relationships between the D-QUEST scores and personal and lesion characteristics, and active lifestyle and participation (physical activity scale for individuals with physical disabilities (PASIPD), Utrecht activity list (UAL), mobility range and social behavior subscales of the SIP68 (SIPSOC)) were determined. RESULTS: A high level of satisfaction was found with wheelchair-related aspects. The participants were less satisfied with the service-related aspects. Participants with an incomplete lesion were slightly more satisfied regarding both aspects than those with a complete lesion. A higher satisfaction regarding wheelchair dimensions and a higher overall satisfaction were related to a more active lifestyle. Persons who were more satisfied with the simplicity of use of the wheelchair had a better participation score. CONCLUSION: Dutch persons with SCI are in general quite satisfied with their hand rim wheelchair. Some aspects of the wheelchair (dimensions and simplicity of use) are important to optimize as these are related to an active lifestyle and participation.

Occurrence and predictors of pressure ulcers during primary in-patient spinal cord injury rehabilitation.

STUDY DESIGN: Multicenter prospective cohort study. OBJECTIVES: To determine the occurrence and predictors for pressure ulcers in patients with spinal cord injury (SCI) during primary in-patient rehabilitation. SETTING: Eight Dutch rehabilitation centres with specialized SCI units. METHODS: The occurrence, location and stage of pressure ulcers were registered between admission and start of functional rehabilitation (called acute rehabilitation phase) and between start of functional rehabilitation and discharge. Possible risk factors for the occurrence of pressure ulcers during functional rehabilitation (personal and lesion characteristics, complications and functional independence) were measured at the start of functional rehabilitation and were entered as predictors in univariate and multivariate logistic regression analysis with pressure ulcers during functional rehabilitation as the dependent variable. RESULTS: Data for 193 patients (86%) were available. The occurrence of pressure ulcers, including stage 1, was 36.5% during acute rehabilitation phase and 39.4% during functional rehabilitation. Most pressure ulcers were located at the sacrum (43%), followed by heel (19%) and ischium (15%). The significant risk factors for pressure ulcers during functional rehabilitation were motor completeness of the lesion, tetraplegia, pressure ulcer during acute rehabilitation phase, pneumonia and/or pulmonary disease, low score on the Functional Independence Measure (FIM) self-care, continence, transfers, locomotion and total FIM motor score. Having had a pressure ulcer during acute rehabilitation phase was the strongest risk factor. CONCLUSION: The occurrence of pressure ulcers was comparable with other studies. A few significant risk factors were found, of which having had a pressure ulcer during acute rehabilitation phase being the strongest predictor.

Development and validation of prognostic models designed to predict wheelchair skills at discharge from spinal cord injury rehabilitation.

OBJECTIVE: To develop and validate a statistical model to predict wheelchair skills at discharge (t(2)) from personal and lesion characteristics and wheelchair skills at the start of spinal cord injury inpatient rehabilitation (t(1)). DESIGN: Prospective cohort study. SETTING: Eight Dutch rehabilitation centres. SUBJECTS: One hundred and forty-two patients with a spinal cord injury. MAIN MEASURES: Models were developed with the performance time and ability score at t(2) as dependent variables and t(1) scores of performance time and ability score, age, gender, body mass index, level and completeness of the lesion as independent variables. The statistical models were evaluated by comparing individual estimated scores with actual measured scores. RESULTS: The main independent variables to predict wheelchair skills at discharge were the t(1) performance time and ability score, age, gender and lesion level. The intraclass correlation coefficient between the estimated and actual ability score was 0.79 and for the performance time 0.86. However, the 95% limits of agreement and their confidence intervals were relatively wide for both ability score (-2.3 to 3.4, range 0-8) and performance time (-12.5 to 8.2, range 11-40 seconds). CONCLUSION: The prognostic models developed in this study to predict future wheelchair skills might help planning the course of rehabilitation. The models should be used with caution in daily clinical practice, but may add useful information to clinical expertise and knowledge of the individual patient.

Evaluation of the physical activity scale for individuals with physical disabilities in people with spinal cord injury.

STUDY DESIGN: Cross-sectional study. OBJECTIVES: To evaluate the physical activity scale for individuals with physical disabilities (PASIPD) in people with spinal cord injury (SCI). SETTING: Eight Dutch rehabilitation centers with a specialized SCI unit. METHODS: The PASIPD was examined by comparing group scores of people with different personal (age, gender and body mass index) and lesion characteristics (level (paraplegia/tetraplegia), completeness, time since injury (TSI)) in 139 persons with SCI 1 year after discharge from in-patient rehabilitation. Relationships between PASIPD scores and measures of activities (wheelchair skills, Utrecht Activity List, mobility range and social behavior subscales of the SIP68) and fitness (peak oxygen uptake, peak power output and muscular strength) were determined. RESULTS: Persons with tetraplegia had significantly lower PASIPD scores than those with paraplegia (P<0.02). Persons with longer TSI had lower PASIPD scores than persons with shorter TSI (P<0.03). PASIPD scores showed moderate correlations with activities (0.36-0.51, P<0.01) and weak-to-moderate correlations with fitness parameters (0.25-0.36, P<0.05). CONCLUSION: In a fairly homogeneous group of persons with SCI, 1 year after in-patient rehabilitation, the PASIPD showed weak-to-moderate relationships with activity and fitness parameters. There seems to be a limited association between self-reported activity level and fitness in people with SCI.

Technical Note: A Novel Servo-Driven Dual-Roller Handrim Wheelchair Ergometer.

The measurement of handrim wheelchair propulsion characteristics and performance in the field is complicated due to the non-stationary nature of wheelchair driving. In contrast, the laboratory provides a constrained and standardisable environment to conduct measurements and experiments. Apart from wheelchair treadmills, dynamometers or ergometers for handrim wheelchairs are often custom-made, one-of-a-kind, expensive, and sparsely documented in the research literature. To facilitate standardised and comparable lab-based measurements in research, as well as in clinical settings and adapted sports, a new wheelchair ergometer was developed. The ergometer with instrumented dual rollers allows for the performance analysis of individuals in their personal handrim wheelchair and facilitates capacity assessment, training and skill acquisition in rehabilitation or adapted sports. The ergometer contains two servomotors, one for each rear wheel roller, that allow for the simulation of translational inertia and resistive forces as encountered during wheelchair propulsion based on force input and a simple mechanical model of wheelchair propulsion. A load cell configuration for left and right roller enables the measurement of effective user-generated torque and force on the handrim and the concomitant timing patterns. Preliminary results are discussed.

Gaze direction affects walking speed when using a self-paced treadmill with a virtual reality environment.

BACKGROUND: In a previous study it was observed that participants increase their walking speed during a dual task while walking on a self-paced treadmill in a virtual reality (VR) environment (Gait Real time Analysis Interactive Lab (GRAIL)). This observation is in contrast with the limited resources hypothesis, which suggests walking speed of healthy persons to decrease when performing a cognitive dual task. AIM: The aim of the present study was therefore to determine whether the cognitive demand of the task, an aroused feeling, discrepancy in optic flow or a change in gaze direction caused participants to walk faster in this computer assisted rehabilitation environment. MATERIALS: The GRAIL included a self-paced treadmill, a motion-capture system and synchronized VR environments. METHODS: Thirteen healthy young adults (mean age 21.6 ±â€¯2.5) were included in this study. Participants walked on the self-paced treadmill while seven different intervention conditions (IC) were offered. Prior to each IC, a control condition (CC) was used to determine the natural self-selected walking speed. Walking speed during the last 30 s of each IC was compared with the walking speed during the last 30 s of the preceding CC. RESULTS: Results show that the height on which a visual task was presented in the VR environment, influenced walking speed. Participants walked faster when gaze was directed above the focus of expansion. SIGNIFICANCE: These findings contribute to a further understanding of the differences between walking in a real life environment or computer assisted rehabilitation environment. When analyzing gait on a self-paced treadmill in the future, one must be attentive where to place a visual stimulus in the VR environment.

Assessment of upper extremity muscle function in persons with tetraplegia.

The objective was to investigate the actual level of muscle function impairment in tetraplegic persons and, inextricably related to this, the possibilities to compensate function loss using new muscle coalitions. In this cross-sectional group study, 20 persons with a cervical spinal cord injury (SCI) at segmental levels C5C6 or C7C8 and 10 control persons participated. Activity from 21 upper extremity and trunk muscles was recorded during standardised gross upper extremity task performance. No substantial differences in main activation patterns were found between C7C8 and control subjects. In contrast, main activation patterns in C5C6 persons showed an absence of selectivity, which may be explained by the participants activating every controllable muscle in an attempt to perform maximally. In order to identify more intricate differences in muscle activation between control and C7C8 persons a fine motor function task may be necessary. Muscle activation patterns during arm task performance were stable in all three groups.

Mechanical efficiency and propulsion technique after 7 weeks of low-intensity wheelchair training.

BACKGROUND: To evaluate the effect of a 7-week low-intensity hand rim wheelchair training on the submaximal metabolic cost, mechanical efficiency and propulsion technique in able-bodied participants. METHODS: Participants were randomly divided over an experimental group (n=14) and a control group (n=7). The experimental group received 7 weeks wheelchair training (3 week(-1), 70 min) at a low intensity (30% of the heart rate reserve), whereas the control group did not receive training. During pre- and post-tests, submaximal exercise was performed on a stationary wheelchair ergometer at fixed levels of power output. Mechanical efficiency, oxygen uptake, heart rate, timing parameters and stroke angles were measured. Video recordings were made to determine the stroke pattern. FINDINGS: Mechanical efficiency increased and metabolic cost decreased significantly in the experimental group compared to the control group. Push time increased and cycle frequency decreased as a result of training. The stroke angle increased in the experimental group during the training period. The experimental group preferred double-looping over propulsion, while the control group mainly used single-looping over propulsion patterns during the post-test. INTERPRETATION: A low-intensity, 7-week training protocol has a beneficial effect on the mechanical efficiency and metabolic cost of wheelchair propulsion in able-bodied participants. The improved mechanical efficiency seems to be the result of changes in propulsion technique that were found.

Counselling increases physical activity behaviour nine weeks after rehabilitation.

BACKGROUND: For people with disabilities, a physically active lifestyle can reduce the risk of secondary health problems and improve overall functioning. OBJECTIVES: To determine the effects of the sport stimulation programme "rehabilitation and sports" (R&S) and R&S combined with the daily physical activity promotion programme "active after rehabilitation" (AaR) on sport participation and daily physical activity behaviour nine weeks after inpatient or outpatient rehabilitation. METHODS: Subjects in four intervention rehabilitation centres were randomised to a group receiving R&S only (n = 315) or a group receiving R&S and AaR (n = 284). Subjects in six control rehabilitation centres (n = 603) received the usual care. Most common diagnoses were stroke, neurological disorders, and back disorders. Two sport and two daily physical activity outcomes were assessed with questionnaires seven weeks before and nine weeks after the end of rehabilitation. Data were analysed by intention to treat and on treatment multilevel analyses, comparing both intervention groups with the control group. RESULTS: The R&S group showed no significant change. Intention to treat analyses of the R&S+AaR group showed significant improvements in one sport (p = 0.02) and one physical activity outcome (p = 0.03). On treatment analyses in the R&S+AaR group showed significant improvements in both sport outcomes (p<0.01 and p = 0.02) and one physical activity outcome (p<0.01). CONCLUSIONS: Only the combination of R&S and AaR had increased sports participation and daily physical activity behaviour nine weeks after the end of inpatient or outpatient rehabilitation.

Standardization of measuring power output during wheelchair propulsion on a treadmill Pitfalls in a multi-center study.

OBJECTIVE: In a multi-center study the power output of wheelchair propulsion, attained by a wheelchair drag test, differed among rehabilitation centers. The purpose of this study was to investigate what causes the differences in drag force among centers. METHODS: A set of standardized drag tests was performed while systematically varying the calibration set of the force transducer, the tester and the wheelchair. In addition, the actual calibrated velocity and slope of the treadmill were measured. RESULTS: Difference in drag force among centers was due to variation in wheelchair set-up and differences in the slopes between treadmills. The drag force was not significantly different when different testers performed the test. The belt velocity in almost all centers was lower than the manufacturer specified (assumed) velocity. CONCLUSION: The drag test appeared a robust test as far as the tester is considered. Variation in wheelchairs and differences in the actual slopes of the treadmills affected the imposed drag force. The assumed velocity of the treadmill led to an overestimation of the power output. The power output in the multi-center study should be recalculated using the measured velocities and the wheelchair set-up should be more standardized.

Glenohumeral joint loading in tetraplegia during weight relief lifting: a simulation study.

BACKGROUND: The incidence of shoulder complaints in wheelchair users is high and the etiology is poorly understood. The goal of this study was to examine the effect of lesion level and isolated triceps muscle paresis on the internal load on the shoulder by simulation. METHODS: Kinematic and kinetic profiles from four able-bodied subjects and four subjects with tetraplegia were used as input for an inverse dynamics biomechanical model. The model was modified to simulate lesion level and triceps muscle paresis. FINDINGS: The simulations resulted in a significantly higher (+56%) glenohumeral contact force (P=0.037) for tetraplegic profiles than for able-bodied profiles. The model modifications to simulate lesion level only had a minor effect (+7%) on the calculated glenohumeral contact force. More simulations were successful at lower triceps force levels for tetraplegic profiles compared to able-bodied profiles (P=0.012). The muscle forces at the simulated T1 lesion were not significantly higher in tetraplegic profiles compared to able-bodied profiles. INTERPRETATION: The glenohumeral contact force for the tetraplegic profiles is mainly higher due to different task performance. Model modifications only have a minor effect on the calculated glenohumeral contact force. For able-bodied profiles the triceps force seems to be an important factor. The high internal load at the shoulder recommends new techniques of weight relief lifting and proper training of the arm-shoulder muscles in rehabilitation.