| | Effects of Graduated Compression Stockings on Cardiovascular and Metabolic Responses to Exercise and Exercise Recovery in Persons With Spinal Cord InjuryAbstract Rimaud D, Calmels P, Roche F, Mongold J-J, Trudeau F, Devillard X. Effects of graduated compression stockings on cardiovascular and metabolic responses to exercise and exercise recovery in persons with spinal cord injury. ObjectiveTo investigate whether reporting blood redistribution by means of graduated elastic stockings affects exercise and postexercise responses in people with spinal cord injury (SCI). SettingPhysical medicine and rehabilitation department in France. ParticipantsFourteen men with traumatic SCI, grouped according to their level of injury. InterventionsSubjects performed 2 maximal wheelchair exercise tests 1 week apart, in random order and under a counter-balanced design. One test was done with and the other without graduated elastic stockings (21mmHg). Main Outcome MeasuresBlood lactate, blood pressure, heart rate, maximal power output, and oxygen consumption (V̇o2). ResultsPostexercise venous lactate concentration was reduced in SCI subjects with lesion levels below T6 while wearing graduated elastic stockings during both exercise and recovery (10.9±3.9mmol/L vs 12.5±4.6mmol/L, P<.05). There were no significant differences in submaximal and maximal values (heart rate, V̇o2, power output) between subjects tested with and without graduated elastic stockings. ConclusionsWearing elastic stockings affects postexercise responses by decreasing lactate concentration in well-trained, low-level paraplegic patients after a maximal exercise. The relatively low pressure generated by the stockings may not, however, influence the venous system enough to produce improved performance and cardiovascular responses. ELASTIC COMPRESSION STOCKINGS are typically used in physical medicine and rehabilitation units to support blood circulation in people with spinal cord injury (SCI).1 Dramatic adaptations occur in the central and peripheral circulatory system after SCI. For people with injuries above the level of spinal cord sympathetic nervous system outflow, these circulatory deficiencies result from sublesional vasomotor dysregulation, deconditioning of cardiac and skeletal muscles, and reduced cardiac output, explained by a smaller left ventricular chamber size and sustained venous underloading.2, 3, 4, 5, 6, 7, 8, 9, 10 Such disturbances of blood redistribution in people with SCI alter cardiovascular responses. Indeed, the absence of sympathetic vasoconstriction below the spinal cord lesion and the lack of muscle pump activity in the lower limbs culminate in venous blood pooling in the legs. As a consequence, the return of venous blood to the central circulation is reduced; evoking a limited increase of end-diastolic ventricular volume and, according to the Frank-Starling mechanism, lower stroke volume than in able-bodied subjects. This lower stroke volume may be a factor that limits cardiac output (Q) and, therefore, peak oxygen uptake (Vo2peak). Thus, people with SCI have a lower peak exercise capacity. A diminished venous return may have a role in limiting their exercise responses.3, 4, 5, 6, 7, 8, 11, 12, 13, 14, 15 In rehabilitation, compression of the lower extremity is the mainstay of therapy in patients with chronic venous insufficiency.16, 17 Elastic compression enhances venous function by reducing venous wall distension, increasing venous flow velocity, and then reducing venous stasis. Compression stockings also improve refilling rates, ejection fraction, and venous pumping, and decrease venous pressure. Finally, stockings also enhance venous function by improving coaptation of valvular cusps and reducing reflux in limbs with valve function incompetence.16, 17 In searching for techniques to prevent blood redistribution during exercise by SCI subjects, studies have examined the effects of compression therapy on physiologic responses and maximal exercise performance during arm exercise. Antigravity suits or abdominal binders were used in these studies to increase lower-body positive pressure to induce blood flow redistribution. Patients with high paraplegia and quadriplegia who are in the acute rehabilitation phase commonly wear abdominal binders to aid venous return to the heart. The binders increase intra-abdominal pressure, which helps prevent blood redistribution to the abdomen. Kerk et al18 reported, however, that abdominal binders do not alter physiologic measures in highly trained SCI athletes. People with SCI wear anti-gravity suits in an attempt to decrease venous capacitance below the lesion in order to increase end-diastolic ventricular volume and thus, stroke volume, Q, and Vo2peak. Most SCI studies have suggested that anti-gravity suits offer a central hemodynamic benefit without improving maximal performance.4, 5, 6, 8, 9 Rather than applying a constant pressure, muscle pump function may be mimicked more closely by pulsating pressure. Houtman et al9 postulated that work capacity cannot be increased with a pulsating pressure anti-gravity suit in SCI subjects. This is in contrast to the work of Pitetti et al,19 who used pulsating pressure and found both an increased Vo2peak and maximal power output (Wmax). Anti-gravity systems for lowering body positive pressure are not available for practical use, and are not possible for sports applications. Graduated elastic stockings, however, are suitable for supporting blood redistribution and improving circulatory adjustment to exercise in subjects with SCI. To our knowledge, only Hopman et al4, 6 have shown that stockings (pressure levels varying between 10 and 30mmHg) do not have any effect on cardiovascular responses during maximal or submaximal exercises. No other studies, however, have confirmed their results, and none of Hopman’s studies have evaluated the effects of compression therapy on metabolic responses during or after exercise. During intense muscle activity, large amounts of lactate and hydrogen ions (H+) are produced. Lactate accumulation, acidosis, and increased inorganic phosphate are associated with muscle fatigue and can be inhibitors to muscle contraction.20, 21, 22 Improved lactate and H+ removal has been associated with faster recovery of muscle performance.23 Adequate blood flow to the muscles will increase oxygen delivery, and at the same time, lactate and H+ will be eliminated faster. Berry and McMurray24 found that in able-bodied subjects, wearing graduated compression stockings altered the postexercise venous lactate profile. This effect was not seen in subjects wearing elastic tights.25 Chatard et al26 found that in elderly sportsmen, wearing elastic compression stockings during an 80-minute recovery period after a 5-minute maximal exercise led to a significant 2.1% increase in the performance of the following maximal exercise. This was associated with reductions in lactate and hematocrit. In this study, we introduced a new aspect in the investigation of the effect of lower-limb compression in SCI. Our main purpose was, therefore, to investigate whether supporting blood redistribution by wearing graduated elastic stockings affects the rate of decline in blood lactate after strenuous wheelchair exercise in trained SCI subjects, according to their level of injury. Of concern also were blood pressures, heart rate, Wmax, and Vo2peak responses to graduated elastic stockings during and after a maximal wheelchair exercise test. We hypothesized that the stockings could aid in the removal of metabolites, especially blood lactate, produced by the muscles. Methods  Participants Fourteen trained men with traumatic SCI participated in this study (table 1). They were divided into 2 groups according to their level of injury. The first group included high-level paraplegic subjects with lesions between T1 and T6. The second group included 9 low-level paraplegic subjects with lesions between T7 and T12. Because the lesions were between T7 and T12, cardiac sympathetic innervation was not affected, indicating a physically normal regulation of intrinsic cardiac function. Neurologic data were obtained at the time of the evaluation, using the standards of the American Spinal Injury Association.27 All subjects were at least 2 years postinjury and all underwent a medical examination, including medical history and screening questionnaire, cardiac and pulmonary auscultation, and neurologic assessment. None of the subjects had cardiovascular, pulmonary, or metabolic diseases, or took medications that might affect study results. Eight subjects were highly trained subjects who competed regularly at the national or international levels. The others participated in team sports or recreational activities. All subjects gave their informed written consent, and the local institutional ethics committee approved the study. Experimental Protocols All subjects performed 2 maximal wheelchair exercise tests, using their personal wheelchairs. One test was done with graduated elastic stockings and the other without. The tests were assigned in random order under a counter-balanced design and were conducted at the same time of the day, the same day of the week, exactly 1 week apart. All subjects ate their last meal 2 hours before the test. At least 4 hours before each test, the subjects refrained from caffeine, alcohol, and nicotine; they were asked to avoid vigorous activity for 24 hours before testing. After the subjects were set up on the wheelchair ergometer,a they rested for 15 minutes while wearing the stockings, the purpose being to stabilize the different cardiorespiratory variables. The rest was followed by a 6-minute warm-up at a constant speed (natural) with no load. The load was then increased by 10W for low-level paraplegic subjects and by 5W for high-level subjects every 2 minutes until volitional exhaustion, or until subjects could no longer maintain the required speed despite strong verbal encouragement from the examiners. The highest load that could be maintained at a constant speed for 1 minute was accepted as the Wmax. Peak Vo2 was determined as the highest V̇o2 recorded in a 30-second average. The 2 tests were performed at the same speed chosen by the patient (natural speed). The test was followed by inactive recovery; after the exercise, the subjects were instructed to rest on the wheelchair ergometer. Materials The exercise tests were performed on a wheelchair ergometer28 that has 2 parallel cylindrical rollers mounted on rotated axes linked to a frame. The system is controlled by specific software that allows the subjects to work at a predetermined speed while it records the resulting torque. The calculation of torque simultaneously takes into account the braking force really applied, the instantaneous speed of the rollers and the positive variation of speed. During the exercise, subjects can view on a control screen all the information concerning speed (so subjects can maintain the required speed), but the power output is concealed. Subjects’ personal wheelchairs were fixed to the ergometer by adjustable belts to position the wheels on the rear roller. We used Microfibers-2 tights with grip-top, graduated compression knee-length stockingsb in this study. The stockings were knitted to create the greatest amount of elastic pressure at the ankle, with decreased pressure up the leg. Pressure levels generated by the stockings varied between 21mmHg (at the ankle) and 15mmHg (at the top of the calf). They were available in small, medium, and large sizes. The size worn depended on the subject’s ankle, calf, and thigh circumferences. Measurements During the tests, V̇o2 and V̇co2 (in mL·kg−1·min−1) were measured continuously with a metabolic analyzer.c The oxygen and carbon dioxide analyzers were calibrated with a known reference gas mixture before each session. Heart rate (in beats/min) was measured continuously by Holter monitoringd at rest, during exercise, and for 15 minutes of the recovery period. We used the noninvasive and continuous arterial blood pressure monitoring by the Portapresse to collect data continuously during the 15-minute rest before exercise and during the 15-minute rest immediately after termination of the test. In this technique, the plethysmographic cuff is placed around the middle phalanx of the finger and the cuff pressure is modulated to maintain transmural pressure at an effective zero. We also monitored blood pressure with a standard sphygmomanometer as a precautionary measure so as to read without delay blood pressure values: at rest and immediately after the test. Brachial blood pressure was measured in the left arm (with the arm in front of the patient, creating a 90° angle with the torso) with subjects continuing to rest on their wheelchairs. Blood lactate concentration was measured in capillary blood (mixed capillary blood method) obtained from a fingertip. Blood samples of 20μL were taken at 3, 5, 10, and 15 minutes postexercise. They were diluted in 360μL of a hemolyzing phosphate buffer solution, and lactate concentration was quantified enzymatically by a YSI 2300 Stat Plus analyzer.f Statistical Analysis Values are given as mean ± standard deviation (SD). An independent Student t test was applied to assess the significance of differences in physical characteristics and in maximal and rest responses between the low- and high-level paraplegic groups. We used a paired t test to determine the effect of the stockings on heart rate, blood pressure, Vo2peak, and Wmax in both groups. We used 2-way analysis of variance (ANOVA) with repeated measures to compare all values when subjects did or did not wear stockings during the 15-minute recovery period or during wheelchair exercise (submaximal values). When we observed a significant F ratio, we did a post hoc analysis using the Tukey test to locate the differences. P less than .05 was set as the level of statistical significance. Results There were no significant differences in age, weight, height, activity level, or time of injury between the 2 groups (see table 1). Table 2 summarizes the resting and maximal responses to the tests for all subjects and for both groups according to the test conditions, with and without the stockings. Submaximal Exercise Because all subjects do not assume an equal number of submaximal stages, we normalized intensity of exercise as a percentage of Wmax. We found no significant differences in submaximal heart rate for either group with or without stockings. The 2-way ANOVA with repeated measures, however, showed a significant interaction effect for time and group (fig 1) (P<.01). Heart rate was higher in the high-level paraplegic subjects during submaximal exercise, but was lower than in the low-level paraplegic group at the end of the exercise, at 90% of Wmax and maximal heart rate. Maximal Exercise There were no significant differences in Vo2peak and Wmax between wearing the stockings and not wearing them. Peak Vo2 was lower in the high-level paraplegic group than in the low-level group (−34% without stockings, P<.05; −32% with, P=NS [not significant]). Wmax was significantly lower in the high-level paraplegic subjects compared with the low-level group (−38% without stockings, P<.05; −39% with, P<.05). Figure 2 shows different systolic blood pressure (SBP) responses according to conditions, injury level, and exercise. In the low-level group, there was significantly higher SBP at rest with the stockings than without them (139±24mmHg vs 126±16mmHg, P<.05), whereas in the high-level group, lower SBP at rest was recorded with stockings than without (132±20mmHg vs 141±12mmHg, P=NS). SBP was significantly lower at rest without the stockings in the low-level group than in the high-level (P<.05). Furthermore, under both conditions, SBP increased at the end of the test in the low-level group (126±16mmHg at rest to 141±38mmHg at peak exercise without stockings; 139±24mmHg to 144±40mmHg with, P=NS), whereas postexercise, SBP dropped in the high-level group even with stockings (141±12mmHg at rest to 127±21mmHg at peak exercise without the stockings; 132±20mmHg to 119±37mmHg with the stockings, P=NS) (see fig 2). Exercise Recovery Period There were no significant differences between these values evident in heart rate recovery values for the trials with and without the stockings, according to level of injury (see fig 1). In both groups and in both conditions, blood lactate levels decreased as a function of recovery, but the values were significantly lower in the high-level paraplegic group. The 2-way ANOVA for lactate disclosed a significant difference in lactate values across time and injury level (fig 3). Blood lactate values were significantly lower for the high-level group when the stockings were not worn, compared with low-level paraplegic subjects (6.5±1.3mmol/L vs 12.5±4.6mmol/L, P<.05). With graduated elastic stockings, we observed no significant differences between groups. During recovery, blood lactate concentration was lower with stockings than without in the low-level paraplegic group, with a significant difference at 3 minutes postexercise (−12%, 10.9±3.9mmol/L vs 12.5±4.6mmol/L, P<.05) (see fig 3). When the 2 groups were averaged, blood lactate concentration was lower with than without the stockings, with a significant difference at 3 minutes postexercise (−6%, 9.8±3.9mmol/L vs 10.5±4.7mmol/L, P<.05). Discussion Many wheelchair racers with SCI routinely strap their lower extremities to gain a competitive edge over fellow athletes. The objective is to reduce venous pooling, which could enhance Q and thereby improve performance.23 There is, however, no direct experimental evidence to support this practice in wheelchair racing. Our study demonstrates that wearing stockings, which are normally worn to prevent venous stasis, postoperative deep venous thrombosis, and orthostatic hypotension during postural changes, does not have any effect on submaximal values or maximal performance during maximal exercise by people with SCI. It does, however, influence metabolic responses during recovery and SBP according to one’s level of injury. Maximal Performance There is abundant information about the responses to acute exercise by people with paraplegia.4, 6, 11, 12, 13, 14, 15, 23, 29, 30, 31 In our study, V̇o2, heart rate, and Wmax values were in overall agreement with values reported in the literature, which generally indicates a relationship between lesion level and the diminution of cardiorespiratory capacity. Lower maximal values characterize high-level paraplegic subjects and may indicate greater fatigability resulting from the absence of vasomotor control in a greater sublesional area.30 SCI above T6 causes lack of control of the abdominal muscles, more reductions in available active muscle mass, and more sympathetic activity than it does in low-level SCI. Thus, peripheral and central physiologic responses to exercise are more limited in high-level than in low-level paraplegic subjects. In our experiments, the lack of improvement in exercise performance when wearing graduated elastic stockings agrees with the findings of Hopman,4, 5, 6, 8 Houtman,9 and Kerk18 and colleagues, but is in contrast to the results of Pitetti et al.19 Arm exercises performed in an anti-gravity suit have been used in an attempt to increase preload, stroke volume, and Q, thus improving oxygen transport capacity. Hopman6 reported a higher stroke volume of the heart during submaximal exercise with constant-pressure, anti-gravity suits (52mmHg), whereas maximal exercise with these suits did not improve Vo2peak or Wmax but did lower the peak heart rate by 8bpm.3, 4, 5 In the same way, Houtman9 suggested that pressure pulsating from between 35 and 70mmHg every 2 seconds fails to enhance peak performance when applied to the lower limbs and abdomen of active SCI subjects. On the other hand, Pitetti19 tested slowly changing pressure suits by alternating 2 minutes of 50mmHg pressure and 2 minutes of 75mmHg pressure, and noted increased Vo2peak and peak power. The injury levels of the study subjects could, however, explain this increase. They had lesions at a higher level (8 subjects with lesions between C5 and C7, 2 subjects with lesions between T5 and T11), resulting in a greater affect on the sympathetic innervation of the heart and splanchnic area. Hopman4, 6 demonstrated that stockings (pressure levels varying between 10 and 30mmHg) do not affect cardiovascular responses during maximal or submaximal exercises. Similarly, the relative low pressure (21mmHg) generated by stockings in our study may have been insufficient to influence the cardiovascular system during maximal exercise, and maximal performance did not increase. This result is not surprising. Maximal performance is defined by the capacity of oxygen transport and oxygen utilization, which are related to the functional capacity of the pulmonary and cardiovascular systems, muscle mitochondria, and aerobic muscle enzymes. Usually, the expected benefit of applying graduated elastic stockings is an improved central circulatory adjustment to exercise in order to improve oxygen transport capacity.4, 5, 6 In agreement with Hopman,4, 6 however, our results suggest that oxygen utilization, rather than oxygen transport capacity, is the limiting factor in Vo2peak during arm exercise by trained subjects with SCI. Thus, improving oxygen transport capacity by wearing graduated elastic stockings could not offset the mean limiting factors in Vo2peak in well-trained SCI subjects (limitation in Vo2peak located peripherally rather than centrally), and then could not improve performance. This is related to the results of Olive et al,10 who found that muscle fatigue was not significantly reduced when blood flow was enhanced at the start of exercise by SCI patients. Alternatively, and in agreement with Kerk,18 it is possible that the lack of significant improvement in Vo2peak was a result of the high level of conditioning in our subjects. Well-trained subjects may have already reached their limits of several links in the oxygen uptake process, whereas in untrained subjects, central circulatory adaptation may be the most important limitation in this process. So, it is more difficult to improve performances of trained SCI subjects than the performances of sedentary SCI patients. Indeed, Hjeltnes14 reported that a rigorous training program produced greater improvement in Vo2peak in SCI subjects who were less conditioned than those who were highly trained initially. Blood Pressure The effect of graduated elastic stockings and exercise on SBP was different in each group whether subjects were or were not wearing the stockings. In the low-level paraplegic group, SBP increased after maximal exercise (mean of 30s after the end of exercise), but in the high-level group it decreased shortly and dramatically (declining to levels below baseline resting values) after exercise. The degree of disturbance in blood redistribution depends on the level of the spinal cord lesion. In the low-level group, as in able-bodied subjects, heart rate and blood pressure rose with increasing dynamic exercise intensity. With the SCI above the major sympathetic splanchnic outflow (T6), however, sympathetic impulses to the splanchnic vascular beds and lower limbs are blocked. This interferes with regulation of blood pressure via vascular tone in lower limbs.32 The small exercise muscle mass minimizes demand and diminishes venous return; subsequently, lower stroke volume, secondary to venous pooling, and diminished venous return probably further reduce left ventricular outflow and SBP. Failure to provide an adequate SBP exacerbates poor exercising muscle perfusion and results in a hypotension response. These results, however, indicate that wearing graduated elastic stockings with a relatively low pressure (21mmHg) may not influence the venous system enough during exercise to help reduce postexercise hypotension in high-level paraplegic subjects, and does not correct SBP responses during and after maximal exercise by people with SCI. Recovery Period Although much is known about the exercise responses and training adaptation of paraplegic subjects, there is little information about their recovery from exercise. Recovery time, however, is a variable that could influence wheelchair-racing performance. The ability to recover quickly is critical if subsequent bouts of all-out activity are required, as is often so in many team sports. Physiologic mechanisms purported to be involved in recovery and postexercise responses include lactate removal. Only 1 study33 has examined excess postexercise V̇o2 and plasma lactate concentration during recovery after arm cranking in men who had a traumatic SCI, but no studies have examined the potential effect of graduated elastic stockings on recovery in this population. Our findings indicate that postexercise venous lactate concentration was reduced in SCI subjects with lesion levels below T6 (low-level paraplegic group) when they were wearing graduated elastic stockings during both exercise and recovery. The fact that there was no difference between wearing and not wearing the stockings in the high-level group may be related to the relatively low production of lactate resulting from the low muscle mass performing the exercise. Indeed, our results showed that the high-level and low-level paraplegic groups had nonsimilar maximal lactate concentrations from a maximal exercise test. During a simulated wheelchair race, according to the literature, people with paraplegia accumulate a significantly higher level of blood lactate than do subjects with quadriplegia.23, 30 The profound lactate acidosis in the low-level group can be explained by larger muscle mass and the fact that low-level paraplegic subjects sustain a higher relative intensity than do the high-level subjects (higher Wmax, P<.05). The atrophied muscles in the high-level group are not capable of sustaining a power output sufficient to produce such large amounts of lactate. Consequently, the lactate concentrations are so small in the high-level group that graduated elastic stockings cannot have a role in their removal. It is interesting that wearing graduated elastic stockings may affect blood lactate levels during recovery. Indeed, during intense muscle activity, large amounts of lactate and hydrogen ions are produced, especially in well-trained, low-level subjects.20, 23 This results in reduced muscle pH and elevated muscle lactate concentrations. Lactate production and accumulation in exercising muscle may be a cause of fatigue and can be an inhibitor to muscle contraction during high intensity work.22, 34 Its rate of removal from the blood is a function of both metabolic and circulatory dynamics.33 Indeed, lactate removal is linked to the quantity of metabolically active tissue (ie, uptake) and/or circulatory dynamics (ie, delivery to areas of removal) during recovery. It is known that people with SCI have altered physiologic responses during exercise, including different circulatory dynamics resulting from the lack of sympathetically mediated vasoconstriction and skeletal muscle pump activity below the level of the lesion.33 Thus, it could be suggested that a hypokinetic circulation, coupled with a reduction in active skeletal muscle mass in people with SCI, would alter their lactate removal. The reasons for unusually high lactate accumulation in well-trained, low-level paraplegic subjects may include the deconditioned state of paralyzed leg muscles, the preferential recruitment of type II (fast, glycolytic) muscle fibers during exercise, a diminished circulatory response to exercise due to sympathetic dysfunction, and a decreased capacity for lactate clearance. Furthermore, the lactate/H+ transport capacity is reduced in people with SCI.34 It might be expected that a decrease in the capacity to exchange lactate and H+ between muscle and blood will disturb the regulation of muscle pH associated with intense muscle contractions and thus will affect the ability to perform and recover from high-intensity exercise.34 Therefore, it is interesting to find methods or supporting techniques that could improve recovery and metabolite removal for SCI athletes involved in team sports, as well as for SCI patients in the acute rehabilitation stage who must successively endure many strenuous efforts. Decreased blood lactate concentration after exercise could appear to be of great importance in improving subsequent performance, particularly when the exercise is repeated at high intensity. Berry and McMurray24 examined the effects of elastic compression on blood lactate levels after exhaustive exercise bouts by healthy men. They hypothesized that the use of graduated elastic stockings would result in lower lactate concentrations because of the increased blood flow that occurs when the stockings are worn. Their investigation found that there were lower blood lactate levels after an exhaustive bout of short-term, high-intensity exercise when graduated elastic stockings were worn during both exercise and recovery. When graduated elastic stockings were worn during an exhaustive exercise bout and removed during recovery, however, postexercise blood lactate levels were higher. In another study, this same group25 indicated that the use of elastic tights does not significantly affect the postexercise response or circulating lactate levels in sportsmen. They assumed that the pressure exerted by tights was not high enough to augment venous return. They concluded that elastic tights reduce the diffusion of lactate from the muscle bed after exercise. Their results differ from the findings of Chatard et al,26 who concluded that wearing graduated elastic stockings during a 80-minute recovery period significantly increased subsequent performance in 63-year-old sportsmen. This was associated with reductions in lactate and hematocrit. We can suppose that in people with SCI who have circulatory deficiencies, a 21mmHg pressure exerted by graduated elastic stockings at the ankle and graduated down to 15mmHg over the calf could decrease the caliber of superficial veins and could limit the dilation of these vessels, thereby reducing the amount of both venous reflux and venous volume. Thus, our results show that graduated elastic stockings, without improvement in maximal performance, help to decrease blood lactate concentrations. One hypothesis is that graduated elastic stockings could clear lactate from the muscles and subsequently increase its oxidation. Further work is needed to obtain a satisfactory explanation. 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34. 34Pilegaard H, Mohr T, Kjaer M, Juel C. Lactate/H+ transport in skeletal muscle from spinal-cord-injured patients. Scand J Med Sci Sports. 1998;8:98–101. MEDLINE a Unité de Recherche Physiologie et Physiopathologie de l’Exercice et Handicap, Faculté de Médecine Jacques Lisfranc, Université Jean Monnet, and Service de Médecine Physique et de Réadaptation, Hôpital Bellevue, Saint Etienne, France b Gibaud S.A., Saint-Etienne, France c Département des Sciences de l’Activité Physique, Université du Québec à Trois-Rivières, Trois-Rivières, QC, Canada.  Reprint requests to Diana Rimaud, MSc, Dept of Physical Medicine and Rehabilitation, CHU Saint Etienne; Hôpital Bellevue, 42055 Saint-Etienne, Cedex 2, France
Supported by the Centre of Medical Technology (Saint-Etienne, France) and Gibaud SAS (Saint-Etienne, France). No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the author(s) or upon any organization with which the author(s) is/are associated. PII: S0003-9993(07)00232-8 doi:10.1016/j.apmr.2007.03.023 © 2007 American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved. | |
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