Design of a randomized-controlled trial on low-intensity aerobic wheelchair exercise for inactive persons with chronic spinal cord injury

Purpose: To investigate effects and working mechanisms of low-intensity aerobic wheelchair exercise on fitness, (upper-body) health and active lifestyle in inactive persons with chronic spinal cord injury (SCI). Methods: A multicenter randomized-controlled trial (RCT) in 40 inactive manual wheelchair users (aged 28–65y) with chronic paraplegia or tetraplegia (time since injury >10y). Subjects will be randomly assigned to an intervention or a control group. The intervention will consist of 16 weeks (2 times per week, 30?min per session) of low-intensity aerobic handrim wheelchair exercise (30–40% HRR) on a treadmill. Repeated measurements will be performed before starting the intervention or entrance of the control group, and after week 8, 16 and 42 following the start. The primary outcome will be wheelchair-specific physical fitness. Secondary outcomes will be upper-body pain and discomfort, shoulder load, propulsion technique, wheelchair skill performance and physical activity levels. Conclusions: Results of this first RCT on low-intensity aerobic wheelchair exercise for inactive persons with chronic SCI can improve SCI-specific exercise guidelines and provide an evidence-base for an aftercare program aimed at preserving fitness, health and active lifestyle of persons aging with SCI.

Implications for Rehabilitation

• Low-intensity wheelchair aerobic exercise may be effective for improving fitness, (upper-body) health and active lifestyle of inactive persons with chronic SCI, without the high dropout rates that plague exercise programs for this population.

• Results of this study can 1) improve SCI-specific aerobic exercise guidelines and 2) provide an evidence-base for a long-term aftercare rehabilitation program for persons aging with SCI.

• As this study is embedded in Dutch rehabilitation practice, chances of knowledge transfer and implementation are high, and strengthen the Dutch SCI rehabilitation network.

     

Autonomic cardiovascular control and sports classification in Paralympic athletes with spinal cord injury

Purpose To investigate the relationship between the classification systems used in wheelchair sports and cardiovascular function in Paralympic athletes with spinal cord injury (SCI). Methods 26 wheelchair rugby (C3–C8) and 14 wheelchair basketball (T3‐L1) were assessed for their International Wheelchair Rugby and Basketball Federation sports classification. Next, athletes were assessed for resting and reflex cardiovascular and autonomic function via the change (delta) in systolic blood pressure (SBP) and heart rate (HR) in response to sit-up, and sympathetic skin responses (SSRs), respectively. Results There were no differences in supine, seated, or delta SBP and HR between different sport classes in rugby or basketball (all p?>?0.23). Athletes with autonomically complete injuries (SSR score 0‐1) exhibited a lower supine SBP, seated SBP and delta SBP compared to those with autonomically incomplete injuries (SSR score?>1; all p?2?=^?1.63, p?=?0.20). Conclusion We provide definitive evidence that sports specific classification is not related to the degree of remaining autonomic cardiovascular control in Paralympic athletes with SCI. We suggest that testing for remaining autonomic function, which is closely related to the degree of cardiovascular control, should be incorporated into sporting classification.

• Implications for Rehabilitation

• Spinal cord injury is a debilitating condition that affects the function of almost every physiological system.

• It is becoming increasingly apparent that spinal cord injury induced changes in autonomic and cardiovascular function are important determinants of sports performance in athletes with spinal cord injury.

• This study shows that the current sports classification systems used in wheelchair rugby and basketball do not accurately reflect autonomic and cardiovascular function and thus are placing some athletes at a distinct disadvantage/advantage within their respective sport.

     

Lipoproteins and free plasma catecholamines in spinal cord injured men with different injury levels

Persons with spinal cord injury (SCI) are especially prone to atherogenesis. This is partly explained by an unfavourable lipoprotein profile in these individuals. The impairment of the sympathetic nervous system, and the fact that SCI subjects are subject to extreme physical inactivity, may have an influence on their lipid profile and lipoprotein(a) concentration. We made a detailed investigation of the lipid profile as well as serum levels of adrenaline and noradrenaline in 80 men with SCI ranging from tetraplegia to low paraplegia and in 16 control subjects. The lipid profile of tetraplegics was characterized by elevated very low‐density lipoprotein cholesterol and triglyceride levels and reduced high‐density lipoprotein levels. In contrast, paraplegics had significantly higher low‐density lipoprotein and total cholesterol levels. Tetraplegics had lower and the low‐lesion paraplegics had higher adrenaline and noradrenaline levels than the high‐lesion paraplegics and the control subjects. High‐lesion SCI subjects also showed an extreme reduction in VO_2max. The lipoprotein profile was dependent on the injury level and serum catecholamine concentrations. The lower the noradrenaline values, the lower the high‐density lipoprotein cholesterol. The low‐density lipoprotein also correlated to catecholamines and particularly adrenaline values. Despite the correlation between lipoprotein(a) and adrenaline, no significant differences in lipoprotein(a) were found within SCI individuals as well as between SCI individuals and control subjects, indicating the predominantly genetic determination of lipoprotein(a) and thus the cardiovascular risk. Different serum catecholamine levels due to impairment of sympathetic nervous system and VO_2max levels were observed in SCI subjects. This was associated with a higher lipid risk profile for cardiovascular diseases; however, the risk profile is dependent on the lesion level.     

Predicting patient-specific rates of bone loss at fracture-prone sites after spinal cord injury

Purpose: People with spinal cord injury (SCI) experience bone loss and have an elevated rate of fracture in the paralysed limbs. The literature suggests an exponential time course of bone loss after SCI, but true rates may vary between patients. We propose systematic evaluation of bone status in the early stages of SCI to identify fast bone losers. Method: A case series of six patients with complete SCI were scanned using peripheral quantitative computed tomography within 5 weeks and at 4, 8 and 12 months post-injury. Bone mineral density (BMD) and bone mineral content (BMC) were measured at fracture-prone sites in the tibia and femur. Patient-specific-predictions (PSP) of expected rates of bone loss were produced by individualising published model equations according to each patient’s measured values at baseline. Wilcoxon Signed-Rank tests were used to identify changes between time-points; chi-squared tests for differences between measured and PSP values. Results: In the lower limbs, mean values decreased significantly between baseline and 8 months post-injury, by 19–31% for trabecular BMD, 21–32% for total BMD, and 9–29% for BMC. Most subjects showed no significant differences between PSP and measured values, but individuals with significantly faster rates of bone loss than predicted should be investigated further. Conclusions: There was considerable intersubject variability in rates of bone loss after SCI. Patients showing the fastest bone loss could benefit from continued follow-up and possibly treatment.

Implications for Rehabilitation

• Spinal cord injury (SCI) leads to extensive muscle paralysis, and is often accompanied by significant bone loss and increased fracture risk.

• Repeat bone scans within months of injury can be used to “red-flag” patients who are losing bone faster than predicted.

• A patient-specific approach to osteoporosis management will facilitate targeted treatment aimed at those who need it most, in SCI and other patient groups.

     

Peer support need fulfillment among adults with spinal cord injury: relationships with participation,life satisfaction and individual characteristics

Purpose: To test the hypothesis among people with spinal cord injury (SCI) that greater fulfillment of peer support needs to be associated with greater participation and life satisfaction. A secondary objective was to identify characteristics of people in great need of SCI peer support. Method: The participants consisted of a population-based sample of 1549 adults with SCI. The participants completed a survey with questions on peer support, participation, life satisfaction and provided demographic and SCI-related information. A secondary analysis of cross-sectional survey data was conducted. A set of regression analyses tested the primary purpose and a partition analysis was conducted to examine the secondary objective. Results: In regression analyses, peer support need fulfillment was positively associated with autonomous-outdoors participation (p?p?p?p?Conclusions: The results provide some evidence that SCI peer support plays an important role in promoting participation and life satisfaction. Individuals with many SCI-related unmet needs are most likely to report a need for peer support.

• Implications for Rehabilitation

• The receipt of peer support after a spinal cord injury (SCI) is positively related to aspects of social participation and life satisfaction.

• Provision of peer support can play an important role in the SCI rehabilitation process.

• Education, injury-related characteristics, and the number of other unmet needs are factors that rehabilitation professionals can use to identify those in particular need of peer support.

• Rehabilitation professionals should encourage patients who have sustained an SCI, to participate in peer support programs.

     

Mediators of disability and hope for people with spinal cord injury

Purpose: To test potential strength-based mediators of functional disability and hope in adults with spinal cord injury. Method: Two hundred and forty-two participants with spinal cord injury were recruited for this study. The mean age of participants was 44.6 years (standard deviation?=?13.2), and 66.1% were men. Participants completed a survey containing a demographic questionnaire, as well as measures of functional disability, hope, self-esteem, proactive coping, perceived social support and disability acceptance. Mediation analysis was conducted using a bootstrap test for multiple mediators. Results: Proactive coping, self-esteem and perceived social support significantly mediated the relationship between functional disability and hope, while disability acceptance did not. The combination of mediators resulted in functional disability no longer being a significant predictor of hope. Conclusions: The strength-based constructs of proactive coping, self-esteem and social support appear effective in predicting hope regardless of severity of spinal cord injury. Functional disability was no longer predictive of hope after controlling for these strength-based constructs. Disability acceptance did not significantly add to the mediation model. These results provide further evidence for strength-based interventions in rehabilitation.

• Implications for Rehabilitation

• Strength-based constructs of proactive coping, self-esteem and social support are important factors for addressing hope following spinal cord injury, regardless of level of severity.

• Rehabilitation services providers should focus efforts on supporting clients in the accurate appraisal of predictable stressors and then generate means for addressing them as a form of proactive coping.

• Rehabilitation services providers must be cautious when addressing self-esteem to focus on perceived competence and learning processes rather than self-esteem directly or through the accomplishment of goals that may not be achieved.

• Knowing that social supports are related to hope post-spinal cord injury, it is important for rehabilitation services providers to recognize potential social supports early in the rehabilitation process and involve those social supports in the rehabilitation process when possible.

     

The effects of physical activity vignettes on physical activity-related social cognitions among people with spinal cord injury

Abstract

Purpose: The purpose of this study was to explore the effectiveness of informational portrait vignettes for enhancing physical activity-related psychosocial cognitions in adults with spinal cord injury (n?=?90). Methods: Using the Health Action Process Approach (HAPA), participants were classified as being in the motivational or volitional phase of behavior change. Half of the participants were randomly allocated to read an experimental vignette, which described the physical activity behaviours, thoughts, and feelings of a character demographically similar to the reader. The remainder read a control vignette. Social cognitions were measured one-week before, and immediately after reading the vignette. Results: Analyses revealed no significant effects of the vignettes on social cognitions (p?>?0.05). Conclusions: Informational portrait vignettes describing a physically active person with SCI and targeting multiple HAPA-based social cognitions are not recommended as a physical activity promotional strategy for people with SCI. The effectiveness of other types of vignettes should be examined.

• Implications for Rehabilitation

• Until further research is completed to determine whether social comparison strategies play a meditational role in accounting for the impact of a tailored informational portrait vignette to alter leisure time physical activity among those with spinal cord injury, these types of informational intervention should not be utilized in a rehabilitation, or real-world, setting.

• Although informational portrait vignettes may not be effective in altering leisure time physical activity social cognitions among those with spinal cord injury, different types of vignettes, such as composite vignettes, should be explored.

     

The relationship between the implementation and effectiveness of a nationwide physical activity telephone counseling service for adults with spinal cord injury

Purpose: Get in Motion (GIM) is an evidence-based telephone counseling service that promotes leisure-time physical activity (LTPA) among Canadian adults with spinal cord injury (SCI). The first phase of GIM sustained intentions for, and increased participation in, LTPA; however, it is unclear how GIM led to these outcomes. The purpose of this study was to explore the implementation correlates of change in LTPA intentions and behavior in the second phase of GIM.

Methods: The frequency, duration, and content of counseling sessions were tailored to meet clients’ (N?=?46; 50.0% male; 50.0% paraplegia; 51.46 (SD 12.36) years old) needs and preferences. Intervention dose and content were monitored using Counseling Session Checklists. Clients self-reported their intentions for and actual aerobic and strength-training LTPA participation at baseline, 2-, 4-, and 6-months, and their perceptions of service quality at 6-months.

Results: The second phase of GIM effectively sustained LTPA intentions and increased time spent on moderate-to-vigorous strength-training and total LTPA. Increases in clients’ moderate-to-vigorous aerobic LTPA were significantly positively related to intervention dose, intervention content (both informational and behavioral strategies), and clients’ perceptions of service credibility.

Conclusions: This study identified intervention dose and content as key implementation variables for an LTPA telephone counseling service for adults with SCI.

• Implications for Rehabilitation

• An evidence- and theory-based telephone counseling service can effectively sustain LTPA intentions and increase LTPA behavior among adults with SCI.

• The first two months of the service are a critical period for enhancing LTPA participation and for minimizing dropouts.

• The provision of both informational and behavioral strategies is important for increasing aerobic LTPA levels among adults with SCI.

     

抗痉挛治疗对脊髓性截瘫患者肢体运动功能的影响

目的：探讨抗痉挛治疗对截瘫肢体运动功能的影响。方法：６０ 例脊髓性截瘫患者随机分为康复组和对照组。康复组以抗痉挛治疗,配合沿脊髓损伤平面针刺治疗,对照组仅用药物治疗。治疗前后进行康复评定和体感诱发电位检测。结果： 康复组截瘫肢体运动功能有较大改善和提高, 显效率和总有效率分别为６３．３％ 和９６．７％ ,对照组分别为３３．３％ 和６０％ ,有非常显著差异（Ｐ＜ ０．０１）。结论：抗痉挛治疗,是促进肢体运动功能恢复的有效方法。     

Transitional rehabilitation goals for people with spinal cord injury: looking beyond the hospital walls

Abstract

Purpose: This study aimed to identify, describe and classify the transitional rehabilitation goals of people with spinal cord injury (SCI) and map these goals to the International Classification of Functioning, Disability and Health (ICF). Method: The five most important rehabilitation goals as rated by clients were extracted from records for 220 clients of a transitional rehabilitation service for people with SCI in Australia over a 5-year period. These goals were thematically classified into domains and then mapped to the ICF framework. Goals were compared across age, gender, length of hospital stay, compensation status, level and completeness of injury. Results: A total of 1100 goals were classified into 18 different goal domains, representing most aspects of the ICF framework. Age was negatively related to vocational goals. Length of hospital stay was positively related to personal care goals but negatively related to community access and vocational goals. Goals did not differ across gender or compensation status but did differ across level and completeness of injury. Conclusions: People with SCI have a range of transitional rehabilitation goals that represent most aspects of the ICF framework. Client-centred community rehabilitation during this transition period offers continuity of care to support the realisation of these rehabilitation goals.

• Implications for Rehabilitation

• Transitional rehabilitation is a relatively new community service model in the rehabilitation literature, especially for people with spinal cord injury.

• Client-centred goal setting is integral to these types of community rehabilitation models.

• Rehabilitation goals in transitional rehabilitation are varied and map well to the International Classification of Functioning, Disability and Health (ICF) with a focus on environmental goals.

• A typology of rehabilitation goals in this setting will assist in service planning and evaluation of hospital and community rehabilitation services.

     

Sleep and physical activity: a survey of people with inflammatory arthritis and their engagement by health professionals in rheumatology in Ireland

Purpose: Sleep is important in maintaining the body’s circadian rhythm and in maintaining health. Aim was to investigate sleep and physical activity among people who have inflammatory arthritis and their engagement with Health Professionals.

Materials and methods: Members from a national charitable organisation for patients with arthritis and a national rheumatology health professionals society were invited to participate in separate cross-sectional surveys hosted on SurveyMonkey^(R)TM.

Results: Ninety people responded and report an average of 5.7 (SD 1.46) hours sleep per night. A majority (61%) report their sleep quality as bad, with 31% taking medications at least once a week to help sleep. There was a statistically significant association between longer years with symptoms, taking medication at least once a week and limited in their activities, when rating their sleep quality as bad. Twenty eight (65%) health professional’s responded with 53% discussing sleep with their patients.

Conclusions: People with inflammatory arthritis report low sleep with those having symptoms longer, taking medications regularly and having limitations with their activities, reporting poorer sleep quality. Only half of health professionals discuss sleep. More research is needed in investigating poor sleep quality, disturbances, and physical activity in order to promote health and well-being in this population.

• Implications for Rehabilitation

• People with inflammatory arthritis fall far below the National Sleep Foundations’ “sleep needs spectrum”, which is concerning as those who have reduced levels of sleep have been associated with decreased quality of life and physical function.

• Due to the importance of receiving sufficient sleep, there is a need to develop education and training for health professionals in the importance of engaging their patients in their sleep quality and disturbances.

• The effects of physical activity interventions on poor sleep need to be examined to show if it is a positive non-pharmacological treatment approach for the management of poor sleep in patients with inflammatory arthritis.

     

Satisfaction and perceptions of long-term manual wheelchair users with a spinal cord injury upon completion of a locomotor training program with an overground robotic exoskeleton

Aim: The main objectives of this study were to quantify clients’ satisfaction and perception upon completion of a locomotor training program with an overground robotic exoskeleton.

Methods: A group of 14 wheelchair users with a spinal cord injury, who finished a 6–8-week locomotor training program with the robotic exoskeleton (18 training sessions), were invited to complete a web-based electronic questionnaire. This questionnaire encompassed 41 statements organized around seven key domains: overall satisfaction related to the training program, satisfaction related to the overground robotic exoskeleton, satisfaction related to the program attributes, perceived learnability, perceived health benefits and risks and perceived motivation to engage in physical activity. Each statement was rated using a visual analogue scale ranging from “0?=?totally disagree” to “100?=?completely agree”.

Results: Overall, respondents unanimously considered themselves satisfied with the locomotor training program with the robotic exoskeleton (95.7?±?0.7%) and provided positive feedback about the robotic exoskeleton itself (82.3?±?6.9%), the attributes of the locomotor training program (84.5?±?6.9%) and their ability to learn to perform sit–stand transfers and walk with the robotic exoskeleton (79.6?±?17%). Respondents perceived some health benefits (67.9?±?16.7%) and have reported no fear of developing secondary complications or of potential risk for themselves linked to the use of the robotic exoskeleton (16.7?±?8.2%). At the end of the program, respondents felt motivated to engage in a regular physical activity program (91.3?±?0.1%).

Conclusion: This study provides new insights on satisfaction and perceptions of wheelchair users while also confirming the relevance to continue to improve such technologies, and informing the development of future clinical trials.

• Implications for Rehabilitation

• All long-term manual wheelchair users with a spinal cord injury who participated in the study are unanimously satisfied upon completion of a 6–8-week locomotor training program with the robotic exoskeleton and would recommend the program to their peers.

• All long-term manual wheelchair users with a spinal cord injury who participated in the study offered positive feedback about the robotic exoskeleton itself and feel it is easy to learn to perform sit–stand transfers and walk with the robotic exoskeleton.

• All long-term manual wheelchair users with a spinal cord injury who participated in the study predominantly perceived improvements in their overall health status, upper limb strength and endurance as well as in their sleep and psychological well-being upon completion of a 6–8-week locomotor training program with the robotic exoskeleton.

• All long-term manual wheelchair users with a spinal cord injury who participated in the study unanimously felt motivated to engage in a regular physical activity program adapted to their condition and most of them do plan to continue to participate in moderate-to-strenuous physical exercise.

• Additional research on clients’ perspectives, especially satisfaction with the overground exoskeleton and locomotor training program attributes, is needed.

     

Forgiveness and health-related outcomes among people with spinal cord injury

Purpose.?As motor vehicle accidents and violence cause the majority of spinal cord injuries (SCI) sustained in the USA and people with SCI will likely struggle with emotional issues related to the offender, the purpose of this exploratory study was to examine potential salutary effects of forgiveness among people with SCI incurred traumatically. Specifically, we hypothesized that forgiveness would have positive associations with health-related outcomes.

Method.?A community-based sample of 140 adults (19–82 years of age) with SCI completed a self-report survey regarding dispositional forgiveness of self and others, health behavior, health status, and life satisfaction. Hierarchical multiple regression analyses were employed to examine the relationships in question.

Results.?After controlling for demographic variables, forgiveness of self was significantly associated with health behavior and life satisfaction (uniquely accounting for 7% and 13% of the variance, respectively) and forgiveness of others was significantly associated with health status (uniquely accounting for 9% of the variance).

Conclusion.?Results suggest that forgiveness may play a role in the health and life satisfaction of people with traumatic SCI, with the benefit depending on the type of forgiveness offered.     

Intermittent self‐catheterization service provision: perspectives of people with spinal cord injury

Intermittent self‐catheterization (ISC) is a recommended treatment for people with a neuropathic bladder due to spinal injury. The majority of the literature to date has focused on the safety and the complication rates of ISC and use of different catheters. The aim of this paper explores the lived experience of people with spinal cord injury carrying ISC and the impact of service provision on rehabilitation. A qualitative approach was used based on grounded theory. Fifteen users (11 men and 4 women) of ISC took part in semi‐structured interviews during 2009. Ages ranged from 24 to 68 years. The sample was recruited from the regional spinal unit. Thematic analysis was used to analyse the emergent themes. The results of the core theme, the patients' journey, related to the patients' perspectives of health service provision. Incontinence was the biggest problem to impact on quality of life. Successful bladder management was considered crucial to independence. The services provided by professionals in relation to ISC impacted on the rehabilitation process and patients' journey through the care system and independence. Service provision during acute rehabilitation was excellent; however, follow‐up support was poor and failed to meet expectations. The findings of this study have potential to help professionals to identify factors in relation to the service provision important to spinal cord injured patients when learning and living with ISC. The information could be used to help those who may be resistant to ISC or have difficulty complying with the treatment and to aid with the teaching, advice giving and ongoing care.     

肠道综合物理疗法对不完全性脊髓损伤患者便秘的影响

目的：通过3种方法的对比观察肠道综合物理疗法对不完全性脊髓损伤患者便秘的影响。方法：选取符合入组条件的不完全性脊髓损伤患者30例,随机分为A、B、C 3组各10例。在常规干预的基础上,A组进行生物反馈电刺激治疗,B组进行肠道运动疗法治疗,C组进行肠道综合物理疗法（生物反馈电刺激结合肠道运动疗法）的治疗,治疗前后比较神经源性肠道功能障碍（NBD）评分量表、Wexner便秘评分量表、便秘患者生活质量量表评分（PAC-QOL）、便秘患者症状自评量表评分（PAC-SYM）、乳果糖及开塞露用量、肛门直肠测压等指标,分析评估疗效。结果：治疗4周后,3组的NBD、Wexner便秘,PAC-QOL及PAC-SYM评分均较治疗前有明显减少（P<0.01）,乳果糖及开塞露用量均较治疗前有明显减少(P<0.01),肛门收缩压较治疗前有明显增加(P<0.01),直肠容量感觉阈值较治疗前有明显减少(P<0.05),肛门静息压治疗前后差异无统计学意义;治疗后,C组各项量表评分、乳果糖及开塞露用量均较A、B组有明显减少(P<0.05),A、B组间差异无统计学意义,直肠测压各项指标3组间比较差异无统计学意义。结论：3种方法均可改善不完全脊髓损伤患者的便秘症状,肠道综合物理疗法比单独生物反馈电刺激及肠道运动疗法对不完全性脊髓损伤后便秘的改善作用更显著。