Walking-adaptability therapy after stroke: results of a randomized controlled trial.

BACKGROUND: The ability to adapt walking to environmental properties and hazards, a prerequisite for safe ambulation, is often impaired in persons after stroke. RESEARCH QUESTION: The aim of this study was to compare the efficacy of two walking-adaptability interventions: a novel treadmill-based C-Mill therapy (using gait-dependent augmented reality) and the standard overground FALLS program (using physical context). We expected sustained improvements for both treatment groups combined but hypothesized better outcomes for C-Mill therapy than the FALLS program due to its expected greater amount of walking practice. METHODS: In this pre-registered single-centre parallel group randomized controlled trial, forty persons after stroke (≥ 3 months ago) with walking and/or balance deficits were randomly allocated to either 5 weeks of C-Mill therapy or the FALLS program. The primary outcome measure was the standard walking speed as determined with the 10-meter walking test (10MWT). Additionally, context-specific walking speed was assessed in environments enriched with either stationary physical context (10MWT context) or suddenly appearing visual images (Interactive Walkway obstacles). The walking-adaptability scores of those enriched walking tests served as secondary outcome measures. Furthermore, a cognitive task was added to all three assessments to evaluate dual-task performance in this context. Finally, the participants' experience and amount of walking practice were scored. The outcome measures were assessed at four test moments: pre-intervention (T0), post-intervention (T1), 5-week post-intervention retention (T2), and 1-year post-intervention follow-up (T3). RESULTS: No significant group differences were found between the interventions for the primary outcome measure standard walking speed, but we found a greater improvement in context-specific walking speed with stationary physical context of the C-Mill therapy compared to the FALLS program at the post-intervention test, which was no longer significant at retention. Both interventions were well received, but C-Mill therapy scored better on perceived increased fitness than the FALLS program. C-Mill therapy resulted in twice as many steps per session of equal duration than the FALLS program. The "change-over-time" analyses for participants of both interventions combined showed no significant improvements in the standard walking speed; however, significant improvements were found for context-specific walking speed, walking adaptability, and cognitive dual-task performance. SIGNIFICANCE: This study showed no between-group differences between the novel treadmill-based C-Mill therapy and the standard overground FALLS program with respect to the primary outcome measure standard walking speed. However, the greater amount of walking practice observed for the C-Mill group, an essential aspect of effective intervention programs after stroke, may underlie the reported increased perceived fitness and observed increased context-specific walking speed for the C-Mill group directly after the intervention. Although the "change-over-time" results for all participants combined showed no improvement in the standard walking speed, context-specific walking speed and walking adaptability showed sustained improvements after the interventions, underscoring the importance of including walking-adaptability training and assessment in rehabilitation post stroke. TRIAL REGISTRATION: The Netherlands Trial Register NTR4030 . Registered 11 June 2013.

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

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

Proprioceptively guided reaching movements in 3D space: effects of age, task complexity and handedness.

Aging is associated with impaired upper limb proprioceptive acuity, as reflected by decreased position matching accuracy with increasing task complexity and movement extent. Most studies have primarily used single-joint or planar paradigms to examine age-related changes in proprioception. It is unclear whether these changes can be generalized to more complex multi-joint movements, where additional sensory feedback may affect performance. Since age-related declines in cognitive function may impair the ability to integrate multiple sources of sensory feedback, deficits in position matching ability in older adults may persist when tasks are performed in three-dimensional space. The accuracy with which young and older participants reproduced remembered reference hand positions was assessed under different experimental conditions. Participants matched target locations located directly to the front or 45° to the side relative to the midline using the preferred and non-preferred arms. Either the same (i.e., ipsilateral matching) or the opposite (i.e., contralateral matching) arm was used to reproduce the target location. No differences in matching accuracy were found between young and older participants when matching ipsilaterally. When matching contralaterally, accuracy was worse in older participants for target locations located to the side, which may reflect age-related changes in the perception of peripersonal space. In contrast to previous studies, accuracy did not differ between the preferred and non-preferred arms in either group. These results extend previous findings demonstrating age-related impairments in proprioceptively guided arm movements when interhemispheric transfer is required.

Electromechanical abdominal massage and colonic function in individuals with a spinal cord injury and chronic bowel problems.

STUDY DESIGN: A prospective intervention of noninvasive abdominal massage using an electromechanical apparatus on bowel function in individuals with spinal cord injury (SCI). OBJECTIVES: To evaluate the effects of noninvasive abdominal massage using an electromechanical apparatus on bowel function in individuals with SCI and chronic bowel problems. This easy-to-use apparatus can be applied by the patients at home without the help of a therapist. SETTING: Homes of community-living individuals. METHODS: Twenty-one subjects with SCI were instructed to use the massage apparatus daily for 20 min during a 10-week period. Compliance, effects, side effects and user satisfaction were assessed using questionnaires. RESULTS: Fifteen subjects completed the 10-week period. Although some characteristics of defecation changed positively for some of the subjects (time to result, amount, consistency), none felt better or more confident after using the massage device. In addition, some individuals experienced negative side effects (predominantly pain or discomfort). The overall satisfaction with the device is ambiguous, with half of the group judging the device as insufficient and the other half as at least adequate. CONCLUSION: The use of an electromechanical massage device does not improve bowel function in most individuals with SCI who have chronic bowel problems. Why some subjects benefit and others do not should be investigated in future studies.

Gluteal blood flow and oxygenation during electrical stimulation-induced muscle activation versus pressure relief movements in wheelchair users with a spinal cord injury.

BACKGROUND: Prolonged high ischial tuberosities pressure (IT pressure), decreased regional blood flow (BF) and oxygenation (%SO2) are risk factors for developing pressure ulcers (PUs) in patients with spinal cord injury (SCI). Electrical stimulation (ES)-induced gluteal and hamstring muscle activation may improve pressure distribution by changing the shape of the buttocks while sitting and also increase BF and %SO2. OBJECTIVE: To compare acute effects of ES-induced gluteal and hamstring muscle activation with pressure relief movements (PRMs) on IT pressure, BF and %SO2. PARTICIPANTS AND METHODS: Twelve men with SCI performed PRMs - push-ups, bending forward and leaning sideward - and received surface ES (87±19 mA) to the gluteal and hamstring muscles while sitting in their wheelchair. Ischial tuberosities pressure was measured using a pressure mapping system; (sub)cutaneous BF and %SO2 were measured using reflection spectroscopy and laser Doppler, respectively. RESULTS: Compared with rest (156±26 mm Hg), IT pressure was significantly lower during all other conditions (push-ups 19±44; bending forward 56±33; leaning sideward 44±38; ES 67±45 mm Hg). For the whole group, all PRMs significantly augmented BF (+39 to -96%) and %SO2 (+6.0 to -7.9%-point), whereas ES-induced muscle activation did only for peak BF. In all, 63% of the participants showed an increased BF (average 52%) with ES. CONCLUSION: PRMs acutely reduced IT pressure and improved oxygenation and BF in SCI. The currently used ES method cannot replace PRMs, but it may be used additionally. ES-induced muscle activation is not as effective for acute pressure relief, but the frequency of stimulation is much higher than the performance of PRMs and can therefore be more effective in the long term.

Active LifestyLe Rehabilitation interventions in aging spinal cord injury (ALLRISC): a multicentre research program.

BACKGROUND: With today's specialized medical care, life expectancy of persons with a spinal cord injury (SCI) has considerably improved. With increasing age and time since injury, many individuals with SCI, however, show a serious inactive lifestyle, associated with deconditioning and secondary health conditions (SHCs) (e.g. pressure sores, urinary and respiratory tract infections, osteoporosis, upper-extremity pain, obesity, diabetes, cardiovascular disease) and resulting in reduced participation and quality of life (QoL). Avoiding this downward spiral, is crucial. OBJECTIVES: To understand possible deconditioning and SHCs in persons aging with a SCI in the context of active lifestyle, fitness, participation and QoL and to examine interventions that enhance active lifestyle, fitness, participation and QoL and help prevent some of the SHCs. METHODS: A multicentre multidisciplinary research program (Active LifestyLe Rehabilitation Interventions in aging Spinal Cord injury, ALLRISC) in the setting of the long-standing Dutch SCI-rehabilitation clinical research network. RESULTS: ALLRISC is a four-study research program addressing inactive lifestyle, deconditioning, and SHCs and their associations in people aging with SCI. The program consists of a cross-sectional study (n = 300) and three randomized clinical trials. All studies share a focus on fitness, active lifestyle, SHCs and deconditioning and outcome measures on these and other (participation, QoL) domains. It is hypothesized that a self-management program, low-intensity wheelchair exercise and hybrid functional electrical stimulation-supported leg and handcycling are effective interventions to enhance active life style and fitness, help to prevent some of the important SHCs in chronic SCI and improve participation and QoL. CONCLUSION: ALLRISC aims to provide evidence-based preventive components of a rehabilitation aftercare system that preserves functioning in aging persons with SCI.

Effects of electrical stimulation-induced gluteal versus gluteal and hamstring muscles activation on sitting pressure distribution in persons with a spinal cord injury.

STUDY DESIGN: Ten participants underwent two electrical stimulation (ES) protocols applied using a custom-made electrode garment with built-in electrodes. Interface pressure was measured using a force-sensitive area. In one protocol, both the gluteal and hamstring (g+h) muscles were activated, in the other gluteal (g) muscles only. OBJECTIVES: To study and compare the effects of electrically induced activation of g+h muscles versus g muscles only on sitting pressure distribution in individuals with a spinal cord injury (SCI). SETTING: Ischial tuberosities interface pressure (ITs pressure) and pressure gradient. RESULTS: In all participants, both protocols of g and g+h ES-induced activation caused a significant decrease in IT pressure. IT pressure after g+h muscles activation was reduced significantly by 34.5% compared with rest pressure, whereas a significant reduction of 10.2% after activation of g muscles only was found. Pressure gradient reduced significantly only after stimulation of g+h muscles (49.3%). g+h muscles activation showed a decrease in pressure relief (Δ IT) over time compared with g muscles only. CONCLUSION: Both protocols of surface ES-induced of g and g+h activation gave pressure relief from the ITs. Activation of both g+h muscles in SCI resulted in better IT pressure reduction in sitting individuals with a SCI than activation of g muscles only. ES might be a promising method in preventing pressure ulcers (PUs) on the ITs in people with SCI. Further research needs to show which pressure reduction is sufficient in preventing PUs.

The individual relationship between heart rate and oxygen uptake in people with a tetraplegia during exercise.

STUDY DESIGN: Descriptive study. OBJECTIVE: To examine the individual heart rate-oxygen uptake (HR-VO(2)) relationship during exercise in persons with tetraplegia (TP). SETTING: Rehabilitation Centre Heliomare, Wijk aan Zee, The Netherlands. METHODS: The HR-VO(2) relationship was determined in untrained subjects with motor complete TP (C5 or C6, n=10 and C7 or C8, n=10) during a discontinuous graded exercise hand cycle test. The mean HR and VO(2) of the final 60 s of 2-min exercise blocks were used for calculation of the individual correlation coefficient and the standard error of the estimate (SEE). RESULTS: Two subjects of the C5-C6 group were not able to complete the test. Individual Pearson's correlation coefficients (r) ranged from 0.68 to 0.97 and SEE from 2.6 to 22.4% VO(2)-Reserve (VO(2)R). The mean Pearson's r and SEE were 0.81+/-0.12 and 10.6+/-5.6% VO(2)R in the C5-C6 group and 0.91+/-0.07 and 7.0+/-3.2% VO(2)R in the C7-C8 group, respectively. Two subjects of the C5-C6 group and six subjects of the C7-C8 group attained a linear HR-VO(2) relationship with an acceptable SEE (< or =6.0%) and r (>0.90). CONCLUSIONS: The HR-VO(2) relationship appeared linear in only eight out of 18 subjects. An individual analysis of the HR-VO(2) relationship is necessary to determine whether HR can be used to quantify exercise intensity. The use of HR to prescribe training intensity should be reconsidered in persons with TP. SPONSORSHIP: This study is supported from a grant by ZON-MW.

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

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