Search

Objective: In patients with NSCLC, lymph node metastases are an important prognostic factor. Despite an accurate pre-operative work up, for optimal staging an intrapulmonary- and mediastinal lymph node dissection (LND) as part of the operation is mandatory. The aim of this study is to assess the completeness of LND in patients undergoing an intended curative resection for NSCLC in the Netherlands and to compare performance between open surgery and minimally invasive surgery (MIS)., Materials and Methods: The intraoperative LND was evaluated in 7460 patients who had undergone a lobectomy for clinically staged N0-1 NSCLC (2013-2018). The LND was considered complete, when three mediastinal (N2) lymph node stations, including station 7, were sampled or dissected, in addition to the lymph nodes from station 10 and 11. A comparison was made between open surgery and MIS., Results: Of 5154 patients, who had MIS, a sufficient intrapulmonary LND was performed in 47.9% and a sufficient mediastinal LND in 58.6%. A complete LND was performed in 31.6%. For 2306 patients who had an open resection, these numbers were 45.0%, 59.0%, and 30.6%, respectively. The overall between-hospital variation in a complete LND ranged between 0 and 72.5%., Conclusion: In the Netherlands, a complete LND of both intrapulmonary- and mediastinal lymph nodes is performed only in a minority of patients with clinically staged N0-1 NSCLC, with substantial between-hospital variation. No differences were seen between open surgery and MIS. Because of poor performance, completeness of lymph node dissection will be recorded as a mandatory performance indicator in our national audit, to improve the quality of resection., (Copyright © 2020 Elsevier Ltd, BASO ~ The Association for Cancer Surgery, and the European Society of Surgical Oncology. All rights reserved.)

Temperature passively affects biological processes involved in plant growth. Therefore, it is challenging to study the dedicated temperature signalling pathways that orchestrate thermomorphogenesis, a suite of elongation growth-based adaptations that enhance leaf-cooling capacity. We screened a chemical library for compounds that restored hypocotyl elongation in the pif4-2-deficient mutant background at warm temperature conditions in Arabidopsis thaliana to identify modulators of thermomorphogenesis. The small aromatic compound 'Heatin', containing 1-iminomethyl-2-naphthol as a pharmacophore, was selected as an enhancer of elongation growth. We show that ARABIDOPSIS ALDEHYDE OXIDASES redundantly contribute to Heatin-mediated hypocotyl elongation. Following a chemical proteomics approach, the members of the NITRILASE1-subfamily of auxin biosynthesis enzymes were identified among the molecular targets of Heatin. Our data reveal that nitrilases are involved in promotion of hypocotyl elongation in response to high temperature and Heatin-mediated hypocotyl elongation requires the NITRILASE1-subfamily members, NIT1 and NIT2. Heatin inhibits NIT1-subfamily enzymatic activity in vitro and the application of Heatin accordingly results in the accumulation of NIT1-subfamily substrate indole-3-acetonitrile in vivo. However, levels of the NIT1-subfamily product, bioactive auxin (indole-3-acetic acid), were also significantly increased. It is likely that the stimulation of hypocotyl elongation by Heatin might be independent of its observed interaction with NITRILASE1-subfamily members. However, nitrilases may contribute to the Heatin response by stimulating indole-3-acetic acid biosynthesis in an indirect way. Heatin and its functional analogues present novel chemical entities for studying auxin biology., (© 2021 The Authors. The Plant Journal published by Society for Experimental Biology and John Wiley & Sons Ltd.)

Objectives: To explore whether traditional models of cardiovascular disease (CVD) risk prediction correctly predict CVD events across a median 5.7-year follow-up period in individuals with spinal cord injury (SCI) and whether adding SCI-related characteristics (ie, lesion level) to the prediction model can improve the prognostic value., Design: Retrospective analysis of patient records., Setting: Observation at the start of active rehabilitation of participants in a multicenter cohort study, "Restoration of (Wheelchair) Mobility in SCI Rehabilitation," in the Netherlands., Participants: Patients with SCI (N=200) The patients were 74% men, aged 40±14 years, and with an American Spinal Injury Association (ASIA) impairment score of A through D. Forty percent had tetraplegia, and 69% were motor complete., Interventions: Risk profiling/not applicable., Main Outcome Measures: Survival status and cardiovascular morbidity and mortality qwere obtained from medical records. Five-year Framingham Risk Scores (FRS) and the FRS ability to predict events assessed using receiver operating characteristic (ROC) curves with corresponding areas under the curve (AUC) and 95% confidence intervals (CI). Kaplan-Meier curves and the log-rank test were used to assess the difference in clinical outcome between participants with an FRS score lower or higher than the median FRS score for the cohort. SCI-related factors associated with CVD events, ASIA impairment, motor completeness, level of injury, and sports participation before injury were explored using univariate and multivariate Cox proportional hazard regression., Results: The median 5-year FRS was 1.36%. Across a median follow-up period of 5.7 years, 39 developed a CVD event, including 10 fatalities. Although the FRS markedly underestimated the true occurrence of CVD events, the Kaplan-Meier curves and the log-rank test showed that the risk ratio for individuals with an FRS score less than the median FRS (eg, low risk) versus a score greater than the median FRS (high risk) was 3.2 (95% CI, 1.6-6.5; P=.001). Moreover, ROC with corresponding AUCs suggests acceptable accuracy of the FRS to identify individuals with increased risk for future CVD events (ROC AUC of 0.71; 95% CI, 0.62-0.82). Adding ASIA impairment (0.74; 95% CI, 0.66-0.82), motor impairment (0.74; 95% CI, 0.66-0.83), level of injury (0.72; 95% CI, 0.63-0.81), or active engagement in sport before injury (0.72; 95% CI, 0.63-0.88) to the FRS did not improve the level of discrimination., Conclusions: Our 5.7-year retrospective study reveals that cardiovascular risk factors and risk models markedly underestimate the true risk for CVD events in individuals with SCI. Nonetheless, these markers successfully distinguish between SCI individuals at high versus low risk for future CVD events. Our data may have future clinical implications, both related to (cutoff values of) CVD risk factors, but also for (earlier) prescription of (non)pharmacologic strategies against CVD in SCI individuals., (Copyright © 2020 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Locally advanced head and neck squamous cell carcinoma (LAHNSCC) treatment consists of radiotherapy (RT) alone or cisplatin-based concomitant chemoradiotherapy (CCRT). CCRT is accompanied by substantially more toxicity than RT alone. A previous retrospective cohort study found that LAHNSCC patients with tumors negative for nuclear expression of the signal transducer and activator of transcription 3 (STAT3) protein might not benefit from the addition of cisplatin to radiotherapy (RT) treatment. We set out to validate these results in a new cohort. We found that in patients with both STAT3 positive and negative tumors, disease-free survival (DFS) and overall survival (OS) did not differ significantly between treatment with cisplatin-based concomitant chemoradiotherapy (CCRT) and radiotherapy alone. Therefore, our validation study does not confirm that STAT3 is a potential biomarker to predict the effectiveness of the addition of cisplatin to RT in LAHNSCC patients., (Copyright © 2020. Published by Elsevier GmbH.)

Objectives: To investigate sports participation among individuals in the HandbikeBattle project 1.5-5.5 years after the event, the barriers and facilitators to sport participation and benefits of participating in the event., Setting: Former participants of the HandbikeBattle, a handcycling race on an Austrian mountain., Methods: Handcyclists who took part in one or more HandbikeBattle events in 2013-2017 were invited to complete a survey in December 2018. Questions were asked on benefits of participating in this event, current sport participation, and experienced barriers and facilitators regarding current sport participation., Results: Respondents (N = 96 (N = 59 with spinal cord injury (SCI) or Spina Bifida (SB)), response rate = 47%) reported benefits from this event regarding their fitness level (90%), personal development (81%), daily life activities (66%), and health (64%). Median current sport participation was 5 h/week (IQR: 3-8). Most frequently indicated personal barriers for sports participation were: lack of time (31%), disability (17%), and pain (15%). Most frequently mentioned environmental barriers were: transportation time to sport accommodation (19%), and lack of peers to do sports with (16%). Most important facilitators were motivation to improve health and/or fitness (92%), fun and/or relaxation (85%). The results for the subgroup with SCI were comparable with the results of the total group., Conclusions: Results highlight the role sports challenges can have in establishing a sustainable active life lifestyle among people with disabilities.

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.

Purpose: To develop and validate predictive models for peak power output to provide guidelines for individualized handcycling graded exercise test protocols for people with spinal cord injury (SCI); and to define reference values. Materials and methods: Power output was measured in 128 handcyclists with SCI during a synchronous handcycling exercise test. Eighty percent of the data was used to develop four linear regression models: two theoretical and two statistical models with peak power output (in W and W/kg) as dependent variable. The other 20% of the data was used to determine agreement between predicted versus measured power output. Reference values were based on percentiles for the whole group. Results: Lesion level, handcycling training hours and sex or body mass index were significant determinants of peak power output. Theoretical models ( R 2  = 42%) were superior to statistical models ( R 2 =39% for power output in W, R 2  = 30% for power output in W/kg). The intraclass correlation coefficients varied between 0.35 and 0.60, depending on the model. Absolute agreement was low. Conclusions: Both models and reference values provide insight in physical capacity of people with SCI in handcycling. However, due to the large part of unexplained variance and low absolute agreement, they should be used with caution. Implications for rehabilitationIndividualization of the graded exercise test protocol is very important to attain the true peak physical capacity in individuals with spinal cord injury.The main determinants to predict peak power output during a handcycling graded exercise test for individuals with a spinal cord injury are lesion level, handcycling training hours and sex or body mass index.The predictive models for peak power output should be used with caution and should not replace a graded exercise test.

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 ± 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., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Background: Sufficient cardiorespiratory fitness has been regarded a prerequisite for prosthetic walking. In order to improve cardiorespiratory fitness, adequate strain ought to be placed on the system during training., Objectives: To determine cardiorespiratory fitness at the start and end of inpatient rehabilitation after lower limb amputation and determine the physical strain experienced during conventional prosthetic rehabilitation., Study Design: Multicenter prospective cohort study., Methods: Cardiorespiratory fitness was assessed using a peak one-legged cycle exercise test. Physical strain was assessed during a minimum of three full rehabilitation days using heart rate recordings. Physical strain was expressed in the time per day that heart rate exceeded 40% of heart rate reserve., Results: At the start of rehabilitation, peak aerobic capacity was on average 16.9 (SD, 6.5) mL/kg/min ( n  = 33). Overall, peak aerobic capacity did not improve over the course of rehabilitation ( n  = 23, p  = 0.464). Fifty percent of the patients experienced a physical strain level that satisfies minimum criteria for maintaining cardiorespiratory fitness (>40% heart rate reserve for 30 min/day)., Conclusion: Cardiorespiratory fitness was low and did not increase during conventional prosthetic rehabilitation. On average, the physical strain during rehabilitation was insufficient to elicit potential improvements in aerobic capacity. Results stress the need for dedicated physical training modules at the individual level., Clinical Relevance: This study shows that clinicians ought to be aware of the relatively low cardiorespiratory fitness of people who have undergone lower limb amputation and that improvements during rehabilitation are not always obtained. Results stress the need for physical training modules in which intensity is imposed at the individual level.

Objective: An inadequate surgical informed consent process (SIC) may result in a medical malpractice claim or medical disciplinary board (MDB) complaint. Aim of this study was to analyse characteristics of a decade of malpractice claims and MDB decisions regarding SIC in the Netherlands., Methods: A retrospective analysis of malpractice claims and MDB decisions concerning SIC disputes in four major surgical specialties was conducted based on company data from the largest medical malpractice insurance company and two public available online MDB databases., Results: A total of 11376 malpractice claims and 661 MDB complaints were filed between 2004-2013 and 676(6%) of these claims and 69(10%) of these complaints involved an alleged deficient SIC process. A random sample of 245(37%) claims and all MDB decisions were analysed. Reasons for filing a claim or complaint were insufficient counselling or recording of SIC elements. In 20% of lawsuits and 25% of claims the case resulted in favour of the complainant., Conclusion: A substantial portion of malpractice claims and MDB decisions is related to a deficient SIC process., Practice Implications: Focusing on crucial SIC elements for patients may improve satisfaction and expectations and result in a lower risk for malpractice claims and MDB complaints., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Objectives: To observe the changes in Achilles tendon structure in novice runners, with loading prescriptions of 100% body weight compared to 20% body weight., Design: Randomised crossover., Methods: Twenty novice runners participated in two separate running bouts spaced 14days apart, one of high load at 100% body weight, and one of low load at 20% body weight. Tendon structure was measured by ultrasonographic tissue characterisation on 6 occasions; immediately prior to each run, 2 and 7days after each run., Results: The interaction effect of time and condition was not found to be significant for echotypes I-IV [Wald chi-square=2.8, d.f.=2, P=0.247; Wald chi-square=2.888, d.f.=2, P=0.236; Wald chi-square=1.385, d.f.=2, P=0.5; Wald chi-square=4.19, d.f.=2, P=0.123], respectively. A significant effect of time was found for echotypes III [Wald chi-square=6.785, d.f.=2, P=0.0.034] and IV [Wald chi-square=7.491, d.f.=2, P=0.0.024]., Conclusions: The decrease in echotypes III and IV suggest that moderate loads can be applied to the Achilles tendon without compromising tendon structure. Low to moderate loads may be beneficial in the management of Achilles tendinopathy. Further studies should focus on protocols with higher loading and/or repetitive loading in athletic populations with and without Achilles tendinopathy to assess any differences in tendon structure., (Copyright © 2017 Sports Medicine Australia. Published by Elsevier Ltd. All rights reserved.)

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., (© 2018 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Women with fibroids have a notably high hypertension risk. However, adjusted data regarding other cardiovascular disease (CVD) risk factors are scarce. In this cross-sectional study, CVD risk factors, hemodynamic parameters, and asymptomatic organ damage were analyzed between women with uterine fibroids and controls in a multi-ethnic population. In total, 104 women with self-reported fibroids and 624 controls were included. Women with fibroids had significantly higher odds to have hypertension (OR 3.4; 95% CI 2.2-5.2), diabetes (1.7; 1.0-2.9), and hypercholesterolemia (1.8; 1.1-3.2). After adjustment for confounders, only the odds ratio for hypertension was significant (1.8; 1.1-3.1). Asymptomatic organ damage occurred significantly more often in women with fibroids (66.7%; 95% CI 55.8%-77.6% vs 42.9%; 38.0-47.8 in controls), especially in the younger age group (respectively 48.5%; 31.1%-65.9% vs 22.1%; 17.0-27.2). In this study, women with fibroids had a remarkably high hypertension risk compared to controls, with more asymptomatic organ damage, in particular young women., (©2018 Wiley Periodicals, Inc.)

Ambient temperature affects plant growth and even minor changes can substantially impact crop yields. The underlying mechanisms of temperature perception and response are just beginning to emerge. Chromatin remodeling, via the eviction of the histone variant H2A.Z containing nucleosomes, is a critical component of thermal response in plants. However, the role of histone modifications remains unknown. Here, through a forward genetic screen, we identify POWERDRESS (PWR), a SANT-domain containing protein known to interact with HISTONE DEACETYLASE 9 (HDA9), as a novel factor required for thermomorphogenesis in Arabidopsis thaliana. We show that mutations in PWR impede thermomorphogenesis, exemplified by attenuated warm temperature-induced hypocotyl/petiole elongation and early flowering. We show that inhibitors of histone deacetylases diminish temperature-induced hypocotyl elongation, which demonstrates a requirement for histone deacetylation in thermomorphogenesis. We also show that elevated temperature is associated with deacetylation of H3K9 at the +1 nucleosomes of PHYTOCHROME INTERACTING FACTOR4 (PIF4) and YUCCA8 (YUC8), and that PWR is required for this response. There is global misregulation of genes in pwr mutants at elevated temperatures. Meta-analysis revealed that genes that are misregulated in pwr mutants display a significant overlap with genes that are H2A.Z-enriched in their gene bodies, and with genes that are differentially expressed in mutants of the components of the SWR1 complex that deposits H2A.Z. Our findings thus uncover a role for PWR in facilitating thermomorphogenesis and suggest a potential link between histone deacetylation and H2A.Z nucleosome dynamics in plants.

Aims: Increasing evidence indicates that the ATP-generating enzyme creatine kinase (CK) is involved in hypertension. CK rapidly regenerates ATP from creatine phosphate and ADP. Recently, it has been shown that beta-guanidinopropionic acid (GPA), a kidney-synthesized creatine analogue and competitive CK inhibitor, reduced blood pressure in spontaneously hypertensive rats. To further develop the substance as a potential blood pressure-lowering agent, we assessed the tolerability of a sub-therapeutic GPA dose in healthy men., Methods: In this active and placebo-controlled, triple-blind, single-centre trial, we recruited 24 healthy men (18-50 years old, BMI 18.5-29.9 kg m -2 ) in the Netherlands. Participants were randomized (1:1:1) to one week daily oral administration of GPA 100 mg, creatine 5 g, or matching placebo. The primary outcome was the tolerability of GPA, in an intent-to-treat analysis., Results: Twenty-four randomized participants received the allocated intervention and 23 completed the study. One participant in the placebo arm dropped out for personal reasons. GPA was well tolerated, without serious or severe adverse events. No abnormalities were reported with GPA use in clinical safety parameters, including physical examination, laboratory studies, or 12-Lead ECG. At day 8, mean plasma GPA was 213.88 (SE 0.07) in the GPA arm vs. 32.75 (0.00) nmol l -1 in the placebo arm, a mean difference of 181.13 (95% CI 26.53-335.72)., Conclusion: In this first-in-human trial, low-dose GPA was safe and well-tolerated when used during 1 week in healthy men. Subsequent studies should focus on human pharmacokinetic and pharmacodynamic assessments with different doses., (© 2017 The Authors. British Journal of Clinical Pharmacology published by John Wiley & Sons Ltd on behalf of British Pharmacological Society.)

Purpose: Recognizing the encouraging effect of challenging events, the HandbikeBattle (HBB) was created to promote exercise among wheelchair users. The purpose of this study was to reveal the effects on physical fitness and health outcomes of four-month handbike training under free-living conditions in preparation for the event., Methods: In this prospective cohort study, 59 relatively inexperienced handyclists participated in the HBB of 2013 or 2014. Incremental exercise tests were conducted, respiratory function was tested and anthropometrics were measured before and after the preparation period. Main outcome measures were peak power output (POpeak), peak oxygen uptake (VO2peak) and waist circumference, of which the changes were tested using repeated measures ANOVA. To detect possible determinants of changes in physical fitness, a linear regression analysis was conducted with personal characteristics, executed training volume and upper-extremity complaints during the training period as independent variables., Results: POpeak, VO2peak and waist circumference improved significantly with 17%, 7% and 4.1%, respectively. None of the included variables were significant determinants for the changes in POpeak found as a result of the training., Conclusion: A challenging event such as the HBB provokes training regimes among participants of sufficient load to realize substantial improvements in physical fitness and health outcomes. Implications for Rehabilitation Due to the often impaired muscle function in the lower-limbs and an inactive lifestyle, wheelchair users generally show considerably lower levels of fitness compared to able-bodied individuals. This prospective cohort study showed that four months of handbike training under free-living conditions in preparation for this event resulted in substantial improvements in physical fitness and health outcomes in wheelchair users. The creation of a challenging event such as the HandbikeBattle as part of a follow-up rehabilitation practice can therefore be a useful tool to help wheelchair users initiate or keep training to improve their physical fitness and health.

Introduction: In lower body endurance training, quantities of both moderate intensity continuous training (MICT) and high intensity interval training (HIIT) can lead to an improved physiological capacity and performance. Limited research is available regarding the endurance and muscular capacity of the upper body, and how training contributes to improvements in performance capacity is still unknown. The aim of the current study was to evaluate the effects of HIIT and MICT on the physiological capacity and handcycling performance of able-bodied men in a well-controlled laboratory setting. Methods: Twenty four recreationally active men (22 ± 2 years; 1.84 ± 0.04 m; 79 ± 10 kg) were matched on incremental handcycling pre-test performance (peakPO) and then randomly assigned to HIIT, MICT, or a non-training control group (CON, 3 × n = 8). Participants in HIIT completed 14 interval training sessions, performing 4 × 4 min intervals at 85% heart rate reserve (%HRR), and seven continuous training sessions at 55 %HRR (every 2nd training session of the week). Participants in MICT performed 21 training sessions of 30 min at 55 %HRR. After the intervention, changes in peak oxygen uptake (peakVO 2 ) and peak power output (peakPO) were compared within and between HIIT, MICT and CON. Results: The average external training load per training session did not differ between MICT and HIIT ( p = 0.713). Improvements after HIIT in peakVO 2 (22.2 ± 8.1%) and peakPO (47.1 ± 20.7%) were significantly larger compared with MICT and CON ( p < 0.001). Improvements after MICT in peakVO 2 (10.7 ± 12.9%) and peakPO (32.2 ± 8.1%) were higher compared to CON ( p < 0.001). Higher improvement after HIIT occurred despite training 22% less time than MICT. No significant changes were found in CON. Discussion: As in lower body endurance sports, HIIT proved to be very effective in improving the physiological and performance capacity of upper body exercise. Whilst physiological capacity in both training groups improved significantly compared with CON, the present study shows that peakVO 2 and peakPO improved more after HIIT than after MICT in able-bodied men. It is advised to include HIIT into training regimes of recreational and competitive handcyclists to improve the upper body endurance capacity.

Objective: To examine whether musculoskeletal shoulder pain and limitations in shoulder range of motion (ROM) at discharge from first rehabilitation are associated with activities and participation restrictions 5 years later in persons with spinal cord injury (SCI)., Design: Prospective cohort study., Setting: Eight specialized SCI rehabilitation centers., Participants: Subjects (N=138) with an SCI admitted for first rehabilitation., Interventions: Not applicable., Main Outcome Measures: Peak power output (POpeak), Wheelchair Skills Test (WST), FIM motor score, ability to transfer, Physical Activity Scale for Individuals with Physical Disabilities (PASIPD), mobility range and social behavior subscales of the Sickness Impact Profile 68 (SIPSOC), and employment status., Results: Mean age of the subjects at discharge was 39 years, 72% were men, 32% had tetraplegia, and in 65% the SCI was motor complete. At discharge, 39% reported shoulder pain and 32% had a limited shoulder ROM. In the analyses of variance, shoulder ROM limitation, but not shoulder pain, was associated with all but 1 outcome at 5 years. In the regression analyses, ROM limitations of the shoulder were negatively associated with the ability to transfer (P=.004), FIM motor scores (P<.001), and return to work (P= .027) 5 years after discharge. No significant associations were found with POpeak, WST performance time, SIPSOC, and PASIPD., Conclusions: The presence of limitations in shoulder ROM, but not shoulder pain, at discharge is associated with limitations in activities and employment status 5 years later., (Copyright © 2016 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

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 aim of the current investigation was to explore the lateral stiffness of different sports wheelchair wheels available to athletes in 'new' and 'used' conditions and to determine the effect of (a) stiffness, (b) tyre type (clincher vs. tubular) and (c) tyre orientation on the physiological and biomechanical responses to submaximal and maximal effort propulsion specific to wheelchair basketball. Eight able-bodied individuals participated in the laboratory-based testing, which took place on a wheelchair ergometer at two fixed speeds (1.1 and 2.2 m s(-1)). Outcome measures were power output and physiological demand (oxygen uptake and heart rate). Three participants with experience of over-ground sports wheelchair propulsion also performed 2 × 20 m sprints in each wheel configuration. Results revealed that wheels differed significantly in lateral stiffness with the 'new' Spinergy wheel shown to be the stiffest (678.2 ± 102.1 N mm(-1)). However the effects of stiffness on physiological demand were minimal compared to tyre type whereby tubular tyres significantly reduced the rolling resistance and power output in relation to clincher tyres. Therefore tyre type (and subsequently inflation pressure) remains the most important aspect of wheel specification for athletes to consider and monitor when configuring a sports wheelchair., (Copyright © 2015 IPEM. Published by Elsevier Ltd. All rights reserved.)

Background: Despite adequate treatment, up to 30% of treated antihypertensive patients with primary, uncomplicated hypertension remain uncontrolled. We proposed that high intracellular activity of the ATP regenerating enzyme creatine kinase (CK) increases pressor responses and hypertension risk. In line with this, we found that plasma CK activity after rest, a surrogate measure of tissue activity, is the main predictor of blood pressure levels and failure of antihypertensive therapy in the general population. In addition, the creatine analog and competitive oral creatine kinase inhibitor beta-guanidinopropionic acid effectively and safely reduced blood pressure in the spontaneously hypertensive rat. However, to our knowledge there are no human data on the safety of oral supplementation with this substance. Therefore, we will assess the tolerability of beta-guanidinopropionic acid in men, compared to creatine and placebo., Methods/design: This is a randomized, active and placebo controlled, triple blind, double dummy, single center clinical intervention trial in 24 healthy male volunteers, 18 to 50 years old, recruited in the Netherlands. The intervention consists of one week of daily oral administration of beta-guanidinopropionic acid 100 mg, creatine 5 gram, or placebo. The primary outcome is the tolerability of beta-guanidinopropionic acid as a descriptive measure, in an intent-to-treat analysis. Other outcomes include the placebo-adjusted differences with baseline in biochemical and hemodynamic parameters, including plasma markers of muscle tissue damage, urine sodium excretion, resting sitting systolic and diastolic brachial blood pressure, supine systolic and diastolic central blood pressure, pulse wave velocity and augmentation index, heart rate, cardiac contractility, cardiac output, and total peripheral resistance., Discussion: There is an unfulfilled need for new conservative options to treat resistant hypertension. This study will provide first-in-men data on creatine kinase inhibition as a potential new class of antihypertensive drugs., Trial Registration: The Netherlands National Trial Register Trialregister.nl (identifier NTR 4444) , registered 9 March 2014.

The aim of this study was to develop a more efficient (i.e. shortened) protocol for hand function capacity evaluation and to test the agreement of the protocol compared to the original protocol. 643 Healthy subjects performed tests for hand function. Agreement between two shortened protocols was compared with an existing protocol. The original protocol was performed once and the proposed shortened protocol differed in the number of trials which were reduced by statistical elimination. Agreement was determined with Intraclass Correlation Coefficients (ICC) and Limits of Agreement (LoA). Excellent ICCs (≥0.91) were observed in all proposed protocols except for the one trial purdue pegboard test protocol. For all tests of hand function, shorter protocols are valid to determine hand function. For Tip Pinch Strength testing, Palmar Pinch Strength testing and the Purdue Pegboard test, a two-trial protocol is recommended, because the LoA were considerable, which could affect decision-making with regards to hand capacity. For the Hand Grip strength test, the Key Pinch Strength test and the Complete Minnesota Dexterity Test, a one-trial protocol is recommended, because the LoA were acceptable. It was concluded that for healthy subjects, this shorter protocol is a reliable measure. Further testing of the short form hand FCE protocols should be completed on patients with disabling conditions prior to widespread use of these protocols among clinical samples., (Copyright © 2013 Elsevier Ltd and The Ergonomics Society. All rights reserved.)

Objective: To examine the relationship between wheelchair exercise capacity and life satisfaction in persons with spinal cord injury from the start of active inpatient rehabilitation up to 5 years after discharge., Design: Prospective cohort study., Subjects: Persons with spinal cord injury, aged 18-65 years, and wheelchair dependent at least for long distances., Method: Measurements at the start of active rehabilitation, after 3 months, at discharge from inpatient rehabilitation, and 1 and 5 years after discharge. A peak wheelchair exercise test was performed to record peak oxygen uptake (VO2peak) and peak power output (POpeak). Life satisfaction was measured as current life satisfaction and change of life satisfaction in comparison with life after spinal cord injury. Relationships between (changes in) exercise capacity and (changes in) life satisfaction were analyzed random coefficient analysis, corrected for possible confounders (age, gender, level of lesion, functional status, secondary impairments, pain, and sports activity) if necessary., Results: Of 225 persons included, 130 attended two or more peak exercise tests, who were include in the analyses. Mean age at start was 39 years, 75% were male, 73% had paraplegia, and 76% had a traumatic lesion. Mean POpeak increased during the study from 32.9 to 55.9 Watts, mean VO2peak from 1.02 to 1.38 l/minute, and mean life satisfaction from 5.7 to 7.8. An increase of POpeak with 10 W was associated with a 0.3-point increase of life satisfaction (P = 0.01). An increase of VO2peak with 0.1 l/minute was associated with a 0.1-point increase of life satisfaction (P = 0.049). Conclusion High(er) wheelchair exercise capacity is related to high(er) life satisfaction in spinal cord injury patients.

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., (© 2012 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

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.

Objective: Developments in assistive technology such as handcycling provide attractive possibilities to pursue a healthy lifestyle for patients with spinal cord injury. The objective of the study is to evaluate physical stress and strain of handcycling against training guidelines as defined by the American College of Sports Medicine (ACSM)., Design: Seven able-bodied males conducted an incremental peak exercise handcycling test on a treadmill. In addition, two indoor treadmill (1.3 m/second with an inclination of 0.7% and 1.0 m/second with an inclination of 4.8%) and three outdoor over ground exercise bouts were performed (1.7, 3.3, and 5.0 m/second). One individual handcycled a representative 8-km-distance outdoors., Outcome Measures: Physical stress and strain were described in terms of absolute and relative power output, oxygen uptake (VO2), gross efficiency (GE), and heart rate (HR). Also, local perceived discomfort (LPD) was determined., Results: Relative handcycling exercise intensities varied between 23.3 ± 4.2 (below the ACSM lower limit of 46%VO2peak) and 72.5 ± 15.1%VO2peak (well above the ACSM lower limit), with GE ranging from 6.0 ± 1.5% at the lower to 13.0 ± 2.6% at the higher exercise intensities. Exercise intensities were performed at 49.8 ± 4.2 to 80.1 ± 10.5%HRpeak. LPD scores were low to moderate (<27 ± 7)., Conclusion: Handcycling is relatively efficient and exercise intensities > 46%VO2peak were elicited. However, exercise load seems to be underestimated using %HRpeak. LPD was not perceived as limiting. Physiological stress and strain in able-bodied individuals appear to be comparable to individuals with a paraplegia. To understand individualize and optimize upper-body training, different training programs must be evaluated.

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., (© Georg Thieme Verlag KG Stuttgart · New York.)

The purpose of the current study was to investigate the effects of different wheel sizes, with fixed gear ratios, on maximal effort mobility performance in wheelchair athletes. 13 highly trained wheelchair basketball players, grouped by classification level, performed a battery of 3 field tests in an adjustable wheelchair with 3 different wheel sizes (0.59 m, 0.61 m and 0.65 m). Performance was assessed using the time taken to perform drills, with velocity and acceleration data also collected via a wheelchair velocometer. 20 m sprint time improved in the 0.65 m condition (5.58 ± 0.43 s, P=0.029) compared with 0.59 m (5.72 ± 0.40 s). Acceleration performance over the first 2 (P=0.299) and 3 (P=0.145) pushes was not statistically influenced by wheel size. However, the peak velocities reached were greater in the 0.65 m condition (4.77 ± 0.46 m ∙ s(-1), P=0.078, Effect Size [ES]=0.63) compared with 0.59 m (4.61 ± 0.40 m ∙ s(-1)). Impact velocity, calculated as the change in velocity from the onset of a push to the following impact peak, to define coupling performance, was also significantly improved in 0.65 m wheels (0.14 ± 0.14 m ∙ s(-1), P=0.006) than 0.59 m wheels (0.05 ± 0.10 m ∙ s(-1)). The time taken to complete the linear mobility (P=0.630) and the agility drill (P=0.505) were not affected by wheel size. Finally, no significant interactions existed between wheel size, classification and any performance measure. To conclude, larger 0.65 m wheels improved the maximal sprinting performance of highly trained wheelchair basketball players, without any negative effects on acceleration or manoeuvrability. Improvements in sprinting were attributed to a combination of the reduced drag forces experienced and improvements in coupling thought to be due to the lower angular velocities of the wheel/hand-rim when developing high wheelchair velocities in larger wheels., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: This study focuses on the relationship between overuse in association with wheelchair activities of daily living and risks for osteoarthrosis in the acromioclavicular and sternoclavicular joints. The aim is to quantify the joint moments and joint reaction forces in all three joints of the shoulder complex during wheelchair-related activities of daily living., Methods: A convenience sample of 17 subjects performed two tasks (wheelchair propulsion and weight relief lifting). Three-dimensional kinematics and kinetics were measured and position and force data were used as input for a musculoskeletal model of the arm and shoulder. Output variables of the model were the moments and the joint reaction forces on the sternoclavicular, acromioclavicular and glenohumeral joints., Findings: Moments on the sternoclavicular joint were higher than on the acromioclavicular and glenohumeral joint, but the joint reaction forces on the sternoclavicular and acromioclavicular joints were only one third of those on the glenohumeral joint (peak forces around 96N compared to 315N for wheelchair propulsion and around 330N compared to 1288N for weight relief lifting)., Interpretation: Based on the results found in this study, net joint moments are likely a better measure to describe the load on the acromioclavicular and sternoclavicular joints due to the passive stabilization. Prospective studies on wheelchair overuse injuries should also look at the acromioclavicular and sternoclavicular joints since the load of wheelchair tasks might be a risk factor for osteoarthrosis in these joints., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

Although it is likely that foveal information on treads provides important sensory cues for stair walking, it is unclear how gaze stabilization on treads contribute to gait control on stairs. The aim of this study was to determine the extent to which (i) stair walking depends on foveal information on stepped treads, (ii) fixated treads correspond to future foot landing locations, and (iii) the distance looked ahead varies with stepping distance. Gaze and foot position was monitored from six healthy young adults when they ascended and descended a 10 tread long staircase, taking the stairs one or two treads at a time. The results showed that 55-68% of the total fixation time was aimed at treads, and that tread edges were fixated more intensively during stair descent (69% of the total time spent fixating treads) than during stair ascent (48%). A substantial 28-34% of the stepped treads was never fixated and, when the staircase was taken two treads a time, approximately 35% of the fixated treads was never stepped on. Subjects fixated 3.5-4.5 treads ahead in both stepping conditions, but when the staircase was taken 2 treads a time, stepped treads were fixated shorter ahead (2.7-2.9 treads) than treads that were not stepped (3.4-4.1 treads). These results provide new insights into the visual control of stair walking, and suggest that the stabilization of gaze on treads is not used solely to guide foot placement, but may serve other purposes as well, e.g., to facilitate postural control on the staircase., (Copyright © 2011 Elsevier B.V. All rights reserved.)

Purpose: to examine the effects of rear-wheel camber on the physiological and biomechanical responses during manual wheelchair propulsion in highly trained wheelchair athletes., Methods: participants (N = 14) pushed on a motorized treadmill (2.2 m·s, 0.7% gradient) in four standardized camber conditions (15°, 18°, 20°, and 24°). Standardization was achieved by controlling seat height, the distance between top dead center of the main wheels and "toe-in toe-out" across all camber settings. Power output (PO) and cardiorespiratory measures were collected for each camber setting. Three-dimensional upper body joint kinematics were also analyzed via two high-speed video cameras (100 Hz). One-way ANOVA with repeated measures was applied to all data with statistical significance accepted when P < 0.05., Results: a significantly higher PO was observed for 24° camber (24.3 W) in relation to 15° (20.3 W) and 18° (21.3 W), and also for 20° (23.3 W) in relation to 15°. This resulted in an improvement in mechanical efficiency (ME) for both 24° (6.8%) and 20° (6.7%) compared with 15° (5.9%). However, significantly higher oxygen uptake (reduced economy) and HR responses were observed for 24° (1.04 L·min; 105 bpm) compared with 15° (0.98 L·min; 102 bpm) and 18° (0.97 L·min; 102 bpm). Also, significantly greater ranges of motion were established for shoulder flexion and elbow extension during the push phase for 24° and were likely to have contributed toward the increased oxygen cost in this setting., Conclusions: this study revealed that 20° and 24° camber improved the ME of wheelchair propulsion in highly trained wheelchair athletes, yet these increased external power requirements and reduced the economy.

By studying exercise and performance in hand-cycling in both activities of daily living and in Paralympic sport settings, new insights can be gained for rehabilitation practice, adapted physical activity, and sports. This review looks into the pros and cons of hand-cycling in both rehabilitation and optimal sports performance settings as suggested from the current-but still limited-scientific literature and experimentation. Despite the limited evidence-base and the diversity of study approaches and methodologies, this study suggests an important role for hand-cycling during and after rehabilitation, and in wheeled mobility recreation and sports. An approach that combines biomechanical, physiological, and psychosocial elements may lead to a better understanding of the benefits of hand-cycling and of the fundamentals of exercise in rehabilitation, activities of daily living, and sports.

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.

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.

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.

Objective: To evaluate whether transmural care for people with spinal cord injury living in the community has more impact on health outcomes than traditional follow-up care within the Netherlands., Design: Quasi-experiment with 12 months of follow-up., Setting: Eight Dutch rehabilitation centres., Subjects: Thirty-one patients who received transmural care in two ;experimental' rehabilitation centres were compared with a matched sample of 31 patients having received ;usual follow-up care' in six other rehabilitation centres., Intervention: The core component of the transmural care consists of a transmural nurse, who 'liaises' between former patients living in the community, primary care professionals and the rehabilitation team. The transmural care model provides activities to support patients and their family/partners and activities to promote continuity of care., Main Measures: The prevalence of pressure sores and urinary tract infections; the number and duration of re-admissions to hospital and rehabilitation centre due to pressure sores, bladder and bowel problems; and the experienced quality of follow-up care., Results: The transmural care, as implemented, did not influence the health outcomes. The prevalence of pressure sores, urinary tract infections and the number of re-admissions (due to pressure sores, bladder and bowel problems) was respectively 13, 13 and 4 in the intervention group versus 14, 15 and 6 in the usual follow-up care group. Since the transmural care had been incompletely implemented and there were methodological and practical limitations, we formulated no final conclusions regarding its effectiveness., Conclusion: Implementing the transmural care model strictly according to protocol may improve its effectiveness.

Objective: To assess the association between physical fitness and its recovery over time on the one hand, and complications and duration of phases of rehabilitation on the other., Design and Setting: Prospective cohort study at eight rehabilitation centres., Subjects: People with a spinal cord injury were assessed four times: at the start of active rehabilitation (n = 110), three months later (n = 92), at discharge (n = 137) and a year after discharge from inpatient rehabilitation (n = 91)., Main Measures: Physical fitness was defined as aerobic capacity, determined at each occasion by the peak oxygen uptake (peak Vo(2); L/min) and the peak power output (peak PO; W) during a maximal exercise test. On these occasions, spasticity, musculoskeletal and neurogenic pain were determined (1 = present; 0 = absent). During inpatient rehabilitation, complications (urinary tract infection, pulmonary infection or pressure sore) and bed rest were registered (1 = complication; 0 = no complications, and 1 = bed rest; 0 = no bed rest). Complications and bed rest occurring during the year after discharge were registered similarly., Results: Multilevel random coefficient analyses revealed associations in multivariate models (P

Objective: To describe the effects of upper body training on the physical capacity of people with a spinal cord injury., Data Sources: The databases of PubMed, CINAHL, Sport Discus and Cochrane were searched from 1970 to May 2006., Review Methods: The keywords 'spinal cord injury', 'paraplegia', 'tetraplegia' and 'quadriplegia' were used in combination with 'training'. The methodological quality of the included articles (both randomized controlled trials and controlled clinical trials) was assessed with the modified 'van Tulder et al.' checklist. Studies were described with respect to population, test design, training protocol and mode of training. The training effects on physical capacity, reflected by peak power output (PO(peak)) and oxygen uptake (VO(2peak)), were summarized., Results: Twenty-five studies were included with a mean score of 8.8 out of 17 items on the quality checklist. The methodological quality was quite low, mostly because of the absence of randomized controlled trials. Therefore no meta-analysis was possible. In the 14 articles of acceptable quality the mean (SD) increase in VO( 2peak) and PO(peak,) following a period of training, was 17.6 (11.2)% and 26.1 (15.6)%, respectively., Conclusions: Due to the overall low quality of studies it is not possible to draw definitive conclusions on training effects for different lesion groups or training modes. The results of the relatively few studies with an acceptable quality seem to support the view that upper body exercise may increase the physical capacity of people with spinal cord injury. The magnitude of improvement in PO( peak) and VO(2peak), however, varies considerably among studies.

Objective: To review the influence of physical capacity on regaining walking ability and the development of walking ability after lower limb amputation., Design: A systematic search of literature was performed. The quality of all relevant studies was evaluated according to a checklist for statistical review of general papers., Subjects: Lower limb amputees., Main Measures: Physical capacity (expressed by aerobic capacity, anaerobic capacity, muscle force, flexibility and balance) and walking ability (expressed by the walking velocity and symmetry)., Results: A total of 48 studies that complied with the inclusion criteria were selected. From these studies there is strong evidence for deterioration of two aspects of physical capacity (muscle strength and balance) and of two aspects of walking ability (walking velocity and symmetry) after lower limb amputation. Strong evidence was found for a relation between balance and walking ability., Conclusion: Strong evidence was only found for a relation between balance and walking ability. Evidence about a relation between other elements of physical capacity and walking ability was insufficient. Training of physical capacity as well as walking ability during rehabilitation following lower limb amputation should not be discouraged since several parameters have been shown to be reduced after amputation, although their relation to regaining walking ability and to the development of walking ability remains unclear.

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.

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.

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.

Objective: To investigate the consequence of task complexity on gross mechanical efficiency and propulsion technique during the learning process of hand rim wheelchair propulsion., Methods: Three groups of unimpaired subjects (N=10 each) received a 3-week wheelchair practice period (3 week(-1), nine practice trials) with different levels of complexity, i.e. propelling a stationary wheelchair ergometer, wheelchair propulsion on a motor-driven treadmill or at a circular wheelchair track. During practice trials 1 and 9, gross mechanical efficiency and propulsion technique variables (work per cycle, cycle frequency, push and cycle time, effective force) were measured., Results: Using multi-level regression analysis, no differences in the development over time in mechanical efficiency and propulsion technique could be discerned between the three conditions of task complexity. Only the percentage push time during the cycle decreased significantly more in the group that practiced on the ergometer compared to the treadmill-practice group. For all three groups a change over time was shown for cycle frequency, push time and cycle time., Discussion: Under the current experimental conditions, task complexity does not have an influence on gross mechanical efficiency and propulsion technique during the learning process of wheelchair propulsion. The 3-week practice period had a favorable practice effect on timing regardless of the task complexity.

Objective: Hand rim wheelchair propulsion is inefficient and physically straining. To evaluate the possibly advantageous role in this respect of three different prototype hand rim configurations (a rubber foam-coated cylindrical (II) hand rim and two profiled rubber foam-coated hand rims (wide and narrow: III, IV)), a group of 10 unimpaired subjects conducted four submaximal discontinuous wheelchair exercise tests on a computer-controlled wheelchair ergometer, thus allowing a comparison with a standard hand rim (chromium-plated round hand rim (I))., Methods: Apart from physiological measures (oxygen uptake, heart rate (HR), ventilation, mechanical efficiency (ME)), a subjective score for the rating of each of the hand rims was determined, as well as characteristics of the force application in the propulsion phase during each test condition. Timing parameters of the push and recovery phase were determined. Each exercise test was conducted with one of the four hand rim configurations in a counter-balanced order., Results: Analysis of variance with repeated measures (hand rim configuration, power output) revealed no significant effects (P>0.05) on any of the physiological parameters and force application characteristics for the main factor 'hand rim configuration'. Only the subjective score (scale 0-10) for rating of the hand rims proved significantly different between the round rubber (7.5+/-0.53) coated hand rim-receiving the highest score-versus the narrow rubber-coated flat profiled hand rim (5.5+/-1.72)., Discussion: In this subject group and under the selected tasks and submaximal conditions of wheelchair propulsion, the studied hand rim configurations did not introduce critical shifts in the technique of (de-)coupling and power production in the push phase. As a consequence, no systematic shifts in ME are found among the different hand rim configurations. It is suggested that the biological constraints of the task overrule the possible effects of small design variations of the different hand rim configurations within the studied subject group and under the limited test conditions. The hand rim design characteristics may however be much more critical in (1) experienced wheelchair users, (2) especially those subjects with a limited hand-arm and/or trunk function and/or (3) under much more extreme conditions of daily wheelchair ambulation (i.e. turning, stopping/starting, negotiating a slope) or during peak performance. These issues clearly require continued future research. As such, the current results can be viewed as preliminary results only.

The purpose of this study was to evaluate a technique of pushing a wheelchair at the level of the handle bars as a method for measuring rolling resistance of wheelchair-user systems under different field conditions. Under standardized conditions on a motor driven treadmill, rolling resistance was determined using a 2D strain gauge-based push technique at the level of the handle bars and a commonly used 1D strain gauge-based wheelchair drag test using an adapted push wheelchair and ISO dummy at several velocities and using different push handle heights. After verification of the method, rolling resistance of six different floor surfaces was measured with the experimental push wheelchair in a centre for rehabilitation. Using an analysis of variance for repeated measures, small but significant differences in rolling resistance were found between the drag and push tests on a motor driven treadmill. Belt velocity and push handle height significantly affected rolling resistance. In the field study in the rehabilitation centre, tiles and tarpaulin had the lowest rolling resistance, while high piled carpet had the highest values. It is concluded that the wheelchair pushing method described in this study is usable for the determination of (relative) differences in rolling resistance of different floor materials if performed under standardized conditions and procedures, such as a stable velocity (within a small range of variation), using an ISO-dummy and a constant pushing handle bar height.

The purpose of this study was to analyse adaptations in kinematics and muscle activity/co-contraction in novice able-bodied subjects during the initial phase of learning hand rim wheelchair propulsion. Nine able-bodied subjects performed three 4-min practice blocks on a wheelchair ergometer. The external power output and velocity were constant for all blocks, respectively 0.25 W x kg(-1) and 1.11 m x s(-1). Electromyography of 16 arm, shoulder, back and chest muscles and kinematics were measured. Some small changes in the segmental movement pattern were seen during the practice period. Moreover, an increase in muscle activity and co-contraction of several muscles was found over time. The hypothesis that subjects instinctively search for an optimum frequency, in which the recovery phase is related to the eigenfrequency of the arms and, therefore, the least muscle activity, could not be supported. Since co-contraction of antagonist pairs remained the same or even increased, the hypothesis that there would be a decrease in muscle co-contraction as a result of practice, was not confirmed. This study was probably too short for the novice subjects to explore this new task of wheelchair propulsion completely and reach an optimum in terms of cycle frequency and muscle activity/co-contraction.

We investigate the hypothesis that the direction of the propulsion force in manual wheelchair propulsion can be interpreted as a result of the balance between the mechanical task requirements and the driver's biomechanical possibilities. We quantify the balance at the joint level in the form of an effect-cost criterion, from which we predict the force direction that results in an optimal compromise. Kinematic and dynamic data were collected from nine habitual wheelchair users driving at four velocities (0.83, 1.11, 1.39, 1.67 m/s) and three external power levels (10, 20, 30 W). Experimental data and predictions are in good agreement in the middle and final part of the push; the effect-cost value in this region approximates the achievable maximum. Early in the push the effect-cost criterion predicts an upwards propulsion force whereas the experimental force is downwards, the difference probably being mainly attributable to the force generation dynamics of the muscles. As a result of the geometric features of large-rim manual wheelchairs, the mechanically required and biomechanically preferred force directions are not in accordance during a substantial part of the push, making even the best compromise a poor one. This may contribute to the low mechanical efficiency of manual wheelchair propulsion and the high incidence of shoulder complaints.

Aims: To examine the association between exposure to pushing/pulling at work and low back and shoulder complaints., Methods: A cross sectional questionnaire survey was carried out among 434 workers from several companies with mainly pushing/pulling tasks. From the same companies 188 workers without physically demanding tasks served as reference. The questionnaire was used to assess the exposure to pushing/pulling and other physical risk factors for low back and shoulder complaints. Mean scores at company level were used to classify groups into medium and high exposed to pushing/pulling and a reference group. Psychosocial factors at work were also assessed. Several pain related questionnaires were used to assess the 12 month prevalence of low back and shoulder complaints in three dimensions: trouble (ache, pain, discomfort), pain intensity, and disability. Prevalence rate ratios (PRs) were calculated using Cox's proportional hazards regression analysis., Results: The 12 month prevalence of low back complaints was almost equal for all three groups. The prevalence of shoulder complaints increased with an increase in exposure level. Adjusted PRs showed that the high exposed group had an increased risk for low back complaints compared to the reference group. For all dimensions of shoulder complaints a clear tendency towards a dose-response relation was observed. The high exposed group had significant PRs for shoulder complaints, ranging from 2.09 to 6.37. Generally, psychosocial factors had a confounding effect for pain intensity and disability, but not for trouble., Conclusions: For shoulder complaints a dose-response relation was observed for exposure to pushing/pulling. Low back complaints were less consistently associated with pushing/pulling. Stronger associations were observed for more severe cases of low back and shoulder complaints. It is hypothesised that work related psychosocial factors affect these associations.

Objective: Investigation of the effect of visual feedback on effective hand rim wheelchair force production and the subsequent effect on gross mechanical efficiency., Design: Ten subjects in an experimental group and 10 subjects in a control group practised three weeks (3.wk(-1), i.e., a pre-test and 8 trials) on a computer-controlled wheelchair ergometer. Every trial consisted of two blocks of 4 min at 0.15 and 0.25 W.kg(-1) at 1.11 m.s(-1). On three trials an additional block at 0.40 W.kg(-1) was performed. The experimental group practised with and the control group practised without visual feedback on the effectiveness of force production., Background: In mechanical terms, the low gross mechanical efficiency of hand rim wheelchair propulsion may be the result of ineffective force production., Methods: During all trials oxygen uptake, power output, forces and torque on the hand rims were measured., Results: In comparison with the control group, the experimental group at trial 8 had a significantly more effective force production compared to the control group (90-97% vs. 79-83%, respectively), but showed a significantly lower mechanical efficiency (5.5-8.5% vs. 5.9-9.9%, respectively)., Conclusion: Findings indicate that the most effective force production from a mechanical point of view is not necessarily the most efficient way--in terms of energy cost-- from a biological point of view and that force direction is based on an optimization of cost and effect., Relevance: Learning a more effective force production by visual feedback is not useful for increasing the mechanical efficiency of hand rim wheelchair propulsion.