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The purpose of this study was to characterize push characteristics and force requirements of left (TL) and right (TR) turnings compared with straight-line (SL) propulsion between men and women. Twenty able-bodied subjects (10 men; 10 women, age: 26 ± 5 years, height: 1.68 ± 0.07 m, body mass: 64.2 ± 8.4 kg) received a 12-min familiarization trial of multiple turns around a rectangular course. Subsequently, they performed three tasks in a random order: SL, TR and TL. A Smartwheel was mounted at the right wheel of a standard wheelchair to measure forces and timing parameters of the inner hand during TR or the outer hand during TL. A repeated measure analysis of variance was used to detect the difference across tasks and groups (P < 0.05). In the turning manoeuvres, adjustments were made in the approach, turning and depart phase. Speed of TR and TL was lower compared with SL (P < 0.05). TR was accomplished by retarding speed, initiated in the approach phase, accompanied by increasing braking force of the inner hand (11.2 times higher compared with SL) and changing push characteristics (higher frequency) of the outer hand during the turning phase. In TL, peak force and most timing parameters were similar to SL, except the approach phase (lower peak force for TL). Differences in speed and peak force requirements were found between genders (P < 0.05). It can be concluded that that turning manoeuvres require unique execution of force requirements and push characteristics, which needs further study and need to be taken into consideration in the effort to preserve upper limb function. Sex differences in force and push characteristics exist during turning. This is the first study addressing turning biomechanics in wheelchair propulsion.

PURPOSE: The purpose of this study was to evaluate how activity pacing relates to physical activity and health-related quality of life over a one year period in a sample of adults with multiple sclerosis. METHODS: 68 adults with multiple sclerosis (mean age= 42 ± 11 years) filled in questionnaires on their active engagement in pacing decisions and perceived difficulty in preventing overactivity (5-point Activity Pacing and 2-point Risk of Overactivity Questionnaire), fatigue (7-point Fatigue Severity Scale), physical activity (adapted Short Questionnaire to Assess Health-Enhancing Physical Activity) and health-related quality of life (RAND-12 Health Survey) post rehabilitation and at one year follow up, as part of the Rehabilitation, Sports and Active lifestyle study (a nationwide multi-centre program aimed at stimulating and promoting an active lifestyle in rehabilitation in the Netherlands). Multilevel modelling was used to analyse the associations between activity pacing, fatigue, physical activity and health-related quality of life. RESULTS: No associations were found between activity pacing and physical activity (β = -0.21; p > 0.05), and between activity pacing and health-related quality of life (β = -0.10; p > 0.05) at long-term. Fatigue was negatively related to health-related quality of life (β = -0.35; p < 0.001). Perceived risk of overactivity moderated the association between fatigue and health-related quality of life (β = -0.13; p = 0.039). CONCLUSIONS: These findings suggest that persons who experience decreases in health-related quality of life with increased fatigue, are more likely to be engaging in ‘overactive’ behaviour. The lack of associations between activity pacing and physical activity, and between activity pacing and health-related quality of life suggests there is no clear strategy among persons with MS that is successful in improving physical activity and quality of life either in short or long-term when no interventions are introduced.

Neurological disorders such as stroke and (incomplete) spinal cord injury (SCI) usually lead to difficulties in performing locomotor activities, such as walking or climbing stairs. Therefore, an important part of rehabilitation programs is aimed at restoration of gait function. To improve walking ability it seems important to include task-specific repetitive training with focus on higher intensities of walking practice. These concepts have lead to the development of various automated electromechanical gait-training devices, such as the Lokomat, which assist walking practice. Although it is claimed that such devices may be highly beneficial owing to the intense practice possible in non-ambulatory patients, scientific evidence which could justify their relatively high cost is scarce. Recently, within our research institute in collaboration with the Rehabilitation Centre Amsterdam, we have started a randomized controlled clinical trial investigating the effectiveness of Lokomat-training in patients after stroke and SCI on gait performance, quality of life and neuromuscular and cardiovascular properties. This lecture will give an overview on the existing literature concerning the efficacy of electromechanical assisted training for walking and the concepts which would favor the use of these devices will be discussed. In addition, developments and preliminary results from our study will be presented and discussed.

Purpose: To identify a possible relationship between chronic Post-Stroke Shoulder Pain (PSSP), scapular resting pose and shoulder proprioception. Methods: A total of 21 inpatients with stroke and 10 healthy control subjects were included and kinematics and proprioception of both shoulders were measured. Results: The contralateral (i.e. paretic) shoulder of patients with PSSP showed more scapular lateral rotation and larger errors on proprioception tests compared to both patients without PSSP and control subjects. Additionally, the contralateral shoulder of patients with deteriorated proprioception showed more scapular lateral rotation compared to control subjects whereas their ipsilateral (i.e. unaffected) shoulder showed more scapular lateral rotation when compared to both control subjects and patients with good proprioception. Conclusions: A clear relation between affected shoulder kinematics, affected proprioception and PSSP was found. In determining the risk of developing PSSP, attention should be paid to a patients shoulder proprioception and kinematics. If both are altered after stroke, this could worsen the initial pathology or cause secondary pathologies and thus initiate a vicious circle of repetitive soft tissue damage leading to chronic PSSP. Additionally, more attention should be paid to the ipsilateralshoulder since it could be used in determining the risk of developing PSSP in the contralateral shoulder.

The aim of the present study was to examine the muscle activity of patients with stroke during robotic walking. In the robotic walking condition (RWC), subjects (n=10) walked in a robotic walking device with minimal support and a walking speed of 2.2 km/h. In the overground walking condition (OWC), subjects walked without any assistance on their preferred walking speed. The results showed significant differences between conditions in individual phases of the gait cycle. Thereby, a significant lower EMG amplitude was found in the RWC compared to the OWC. Furthermore, significant interaction effects were found indicating a higher activity of the paretic semitendinosus and gastrocnemius muscle during the RWC compared to the OWC, supporting the use of robot treadmill training after stroke.

Purpose: To study the energy expenditure needed for balance control of stroke patients during upright standing, and to determine the relationship between energy expenditure and measures of balance control and muscle activity. Methods: Ten stroke patients and twelve healthy controls performed four upright standing tasks; one without and three with balance perturbations. Energy expenditure was assessed using a pulmonary gas measurement system. Conventional and dynamic balance measures were calculated from center of pressure time series, obtained with a force plate. Muscle activity of the ankle plantar flexors and dorsal flexors was measured using electromyography. Results: On average, energy expenditure during standing was 125% higher in stroke patients. Challenging balance caused a significant increase in energy expenditure (21-52%) for both groups, but no significant interaction (group x condition) was found. Balance control was impaired and muscle activity was higher in stroke patients in all standing conditions. Significant, though moderate to low, correlations were found between energy expenditure and measures of balance control and muscle activity. Conclusion: This study shows that the increased effort for maintaining balance can have a clinically relevant effect on energy expenditure of stroke patients. Besides balance control, other factors responsible for the increased energy expenditure during upright standing in stroke patients should be explored.

To evaluate the reliability and validity of the extended Wheelchair Circuit fifteen dependent subjects with Spinal Cord Injuries performed the extended Wheelchair Circuit two times with 9.3 ± 11.3 days between the trials. Test-retest reliability and validity were calculated for the three outcome measures: ability score, the performance time score and the physical strain score. Validity was assessed by analyzing the scores of the Wheelchair Circuit on age, lesion level and completeness of the lesion. The intraclass correlation coefficients of the Wheelchair Circuit were 0.94 for ability score, 0.99 for performance time score and 0.82 for physical strain score at confidence level p

Neurological disorders such as stroke and (incomplete) spinal cord injury (SCI) usually lead to difficulties in performing locomotor activities, such as walking or climbing stairs. Therefore, an important part of rehabilitation programs is aimed at restoration of gait function. To improve walking ability it seems important to include task-specific repetitive training with focus on higher intensities of walking practice. These concepts have lead to the development of various automated electromechanical gait-training devices, such as the Lokomat, which assist walking practice. Although it is claimed that such devices may be highly beneficial owing to the intense practice possible in non-ambulatory patients, scientific evidence which could justify their relatively high cost is scarce. Recently, within our research institute in collaboration with the Rehabilitation Centre Amsterdam, we have started a randomized controlled clinical trial investigating the effectiveness of Lokomat-training in patients after stroke and SCI on gait performance, quality of life and neuromuscular and cardiovascular properties. This lecture will give an overview on the existing literature concerning the efficacy of electromechanical assisted training for walking and the concepts which would favor the use of these devices will be discussed. In addition, developments and preliminary results from our study will be presented and discussed.

The purpose of this study was to evaluate the implementation of standardized physical and functional tests to individually monitor patients with a spinal cord injury (SCI) in 8 rehabilitation centers and to analyze enablers and barriers of the implementation process. A prospective effect- and process evaluation was performed. Team members responded to mailed questionnaires at the start (n=115) and end (n=82) of the one-year implementation period. Furthermore, a questionnaire was administered to managers (n=8), coordinators (n=8) and 32 persons with SCI in 4 centers. Outcome of the effect evaluation was the phase of implementation of standardized testing in each center. The process evaluation analyzed enablers and barriers of the implementation process. After a year of implementation, half of the centers shifted to higher implementation phases. None of the centers was classified in the highest phase. Enablers were the positive attitude of the team members regarding standardized testing and an encouraging local coordinator. Most important barrier was lack of time to implement standardized testing. It can be concluded that there is a large support for implementing standardized tests to monitor functioning of patients with SCI. During a year a positive shift was visible in the extent of implementation. Successful implementation of patient monitoring requires substantial amounts of time and effort of the rehabilitation centers involved.

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