| | A Prospective Study on Physical Activity Levels After Spinal Cord Injury During Inpatient Rehabilitation and the Year After DischargeAbstract van den Berg-Emons RJ, Bussmann JB, Haisma JA, Sluis TA, van der Woude LH, Bergen MP, Stam HJ. A prospective study on physical activity levels after spinal cord injury during inpatient rehabilitation and the year after discharge. ObjectivesTo assess the change over time in the physical activity level after a spinal cord injury (SCI), to explore its determinants, and to compare the physical activity level 1 year after discharge from the rehabilitation center with the level in able-bodied persons. DesignProspective cohort study. Measurements were obtained at the start of active rehabilitation, 3 months later, at discharge, 2 months after discharge, and 1 year after discharge. SettingRehabilitation center in The Netherlands and the participant's home. ParticipantsPersons (n=40) with SCI. InterventionsNot applicable. Main Outcome MeasuresThe physical activity level, as indicated by the duration of dynamic activities (ie, wheelchair driving, walking, cycling, noncyclic movement) per day, and the intensity of everyday activity; both were measured with an accelerometry-based activity monitor during 2 consecutive weekdays. ResultsRandom coefficient analyses showed that the duration of dynamic activities and the intensity of everyday activity increased during inpatient rehabilitation at rates of 41% and 19%, respectively (P<.01). Shortly after discharge, there was a strong decline (33%; P<.001) in the duration of dynamic activities. One year after discharge, this decline was restored to the discharge level but was low in comparison with levels in able-bodied persons. The level of lesion and completeness of lesion were determinants of the change in the physical activity level after discharge. ConclusionsThe physical activity level increased during inpatient rehabilitation, but this increase did not continue after discharge, and the level 1 year after discharge was distinctly lower than the level in able-bodied persons. Subpopulations had a different change over time in the physical activity level after discharge. BECAUSE OF LOSS OF MOTOR, sensory, and autonomic innervation below the lesion level, persons with an SCI are often restricted in their performance of everyday physical activities. As a consequence, persons with SCI are, more than the able-bodied population, at risk of developing a hypoactive lifestyle, with possible detrimental effects on physical fitness, social participation, and quality of life.1, 2, 3, 4, 5 Furthermore, a hypoactive lifestyle can increase the risk of developing secondary health problems later in life, such as cardiovascular disease and diabetes.4, 5, 6 Cardiovascular disease is one of the major causes of morbidity and mortality in persons with SCI.7, 8, 9 Despite the possible detrimental effects of a hypoactive lifestyle, few studies have objectively investigated the impact of SCI on the physical activity level.10, 11, 12, 13, 14, 15, 16 The studies that have been performed mainly have focused on physical activity levels in men or on physical activity levels in persons in inpatient or laboratory settings.11, 12, 13, 14, 15, 16 These studies suggest that activity levels in persons with SCI are lower than levels in able-bodied persons and that the treatment for these persons should be optimized so that it might lead to a more active life. However, before developing appropriate rehabilitation programs to increase the physical activity level in persons with SCI, research is needed on the change in physical activity level during the rehabilitation process in SCI. Although knowledge regarding when patients might slow down or regress during rehabilitation or whether patient subgroups differ in change in physical activity level is important for the optimalization of treatment, longitudinal studies regarding the change in physical activity level after an SCI are not available. Because of the lack of longitudinal research on the change in physical activity level after an SCI and the scarcity of objective studies on physical activity levels, we sought to objectively, and in detail in persons with an SCI; (1) determine the change in physical activity level during inpatient rehabilitation and in the year after discharge from the rehabilitation center; (2) explore the association between (the change in) physical activity level, personal characteristics (ie, age and sex), and lesion characteristics (ie, level and completeness); and (3) determine the physical activity level 1 year after discharge in comparison with the level in able-bodied persons. Methods  Design This prospective cohort study was part of a national research program.17 We collected data at 5 standardized test occasions: at the start of active inpatient rehabilitation (T1), 3 months later (T2), at discharge from inpatient rehabilitation (T3), and 2 months (T4) and 1 year (T5) after discharge. If a person was discharged within 1 month after T2, we considered the outcome at T2 the discharge outcome (no new discharge assessment was done) and included it in the analysis as such. Trained research assistants determined data according to a standardized procedure. We determined personal characteristics and physical activity level at all test occasions. For practical reasons, we did not determine lesion characteristics at T4; however, if possible, we extrapolated lesion characteristics at T4 from information obtained at T3 and T5. We defined tetraplegia as a lesion at or above the T1 segment and paraplegia as a lesion below the T1 segment. We defined a complete lesion as motor complete (ie, ASIA grade A or B).18 We defined an incomplete lesion as ASIA grade C or D. Participants From the SCI department of Rijndam Rehabilitation Center in Rotterdam, The Netherlands, we recruited persons with SCI who were in their initial inpatient rehabilitation from 2001 until 2005. Inclusion and exclusion criteria for the current study were mainly in conformity with the criteria used in the national research program; eligible persons included those aged between 18 and 65 years old, those with sufficient comprehension of the Dutch language, and those who did not have a progressive disease or a psychiatric condition that would interfere with constructive participation. Ineligible persons were those who became completely ambulatory during their inpatient period, had cardiovascular contraindications for exercise,19 and had a resting diastolic blood pressure greater than 90mm Hg or a systolic blood pressure greater than 180mm Hg. (In the national research program, maximal exercise tests were performed; the results of those tests are described elsewhere.20, 21) However, in the current study and in contrast to the national research program, we also excluded persons who were completely dependent on an electric wheelchair. We informed possible eligible persons about the study and invited them to participate within 2 weeks of admission to rehabilitation. Subjects had 1 week to consider participating, after which a physician or nurse not involved in the research program requested consent. The Medical Ethics Committee of Erasmus Medical Center approved the protocol, and all persons gave their written informed consent before participating. Forty-two (76%) of the 55 persons from the Rijndam Rehabilitation Center who participated in the national research program agreed to participate in the current study. We excluded from analysis the measurements of 2 persons because these persons became completely ambulatory during their inpatient period. Therefore, the total study sample comprised 40 persons (fig 1); these 40 persons had measurements at 1 or more test occasions. The study sample did not differ from the sample in the national research program with regard to baseline sex, age, and level and completeness of the lesion (unpaired t test; χ2 test). Eleven persons (27.5%) were partially ambulatory at some test occasion, mostly during therapy sessions; 1 person occasionally used an electric wheelchair, and 1 person became completely ambulatory after discharge from the rehabilitation center. Twenty-nine persons (72.5%) were completely dependent on a manual wheelchair. During the course of the study, 24 persons (60%) dropped out at some time point (see fig 1). At T5, measurements were successful in 16 persons. There were no significant differences (unpaired t test; χ2 test) in baseline age, sex, level and completeness of lesion, and physical activity level between persons who completed the T5 measurements and persons who dropped out at some point. Furthermore, there were several reasons we did not collect data at 1 particular test occasion: because of wearing a fixation, discharge within 3 months after submission (no measurement was performed at T2), medical complications (ie, infection, pressure ulcer), or technical problems with the measurement device. Persons had on average measurements during 3 test occasions. Measurement of Physical Activity Level We objectively measured the physical activity level by using an activity monitor (size: 15×9×3.5cm; weight: 500g).a The activity monitor is based on long-term (>24h) ambulatory monitoring of signals from body-fixed accelerometers.22 From the accelerometer signals, the duration, rate, and moment of occurrence of activities associated with mobility (the stationary activities, lying, sitting, standing; the dynamic activities walking [including climbing/descending stairs and running], cycling, manual wheelchair driving [including hand biking], general noncyclic movement) and transitions between postures can be automatically detected with a 1-second resolution. Furthermore, from each measured signal, information on the variability of the acceleration signal (motility, which is related to the intensity of body-segment movements) can be obtained.23, 24, 25, 26 Studies22, 27 in several patient groups, including persons with SCI, in which simultaneously made videotaped registrations (reference method) were compared with the outcomes of the activity monitor, have shown that the activity monitor is valid to quantify activities associated with mobility. Furthermore, the activity monitor can detect differences in physical activity level during everyday life between groups,28, 29, 30, 31 which supports its validity and applicability in clinical research. We performed measurements with the activity monitor during 2 consecutive weekdays (48-h measurement). To avoid measurement bias, we explained the principles of the activity monitor only after all measurements had been completed. All participants agreed with this procedure. We instructed the participants to continue their ordinary daily life; however, they were not allowed to swim or take a bath or shower during the 2 weekdays of testing. We used 6 ADXL202 uniaxial piezo-resistive accelerometersb (size: 1.5×1.5×1cm). We attached 1 accelerometer to each thigh and wrist and 2 accelerometers to the sternum. We connected the accelerometers to a data recorder, which the subject wore in a padded bag around the waist (fig 2). Accelerometer signals were stored digitally on a Personal Computer Memory Card International Association flash card with a sampling frequency of 32 Hz. After the measurement, we downloaded data onto a computer for analysis by the kinematic analysis part of the Vitagraph software.32,a A detailed description of the sensor configuration and the activity detection procedure has been given before.27 We disregarded short-lasting activities (<5s). To calculate the body motility, we averaged motility signals of the legs and trunk (in gravitational acceleration; 1 g=9.81 m/s2). We operationalized the physical activity level by (1) the duration of dynamic activities (composite measure consisting of the separately detected activities, manual wheelchair driving [including hand biking], walking [including running and walking stairs], cycling, general noncyclic movement) as a percentage of a 24-hour period; (2) average body motility (in gravitational acceleration), addressing average motility over a 24-hour period (representing both duration and intensity of everyday physical activity) (Because this parameter is not comparable between those who could walk and those who could not walk, we only analyzed it in persons who were completely dependent on a manual wheelchair [n=29]); and (3) mutual distribution of duration of continuous wheelchair-driving periods and walking periods (5–10s; 10–30s; 30–60s; 60–120s; 120–300s; 300–600s; >600s). We assessed this only at T5, and, consequently, it was not included in the statistical analyses of the change in physical activity level. Statistics General A probability value of less than or equal to .05 determined statistical significance. We used paired t tests (using SPSS 12.0 for Windowsc) to assess differences between the first and second 24-hour parts of the measurement with the activity monitor. Because we found no difference in the duration of dynamic activities between the first and second 24-hour parts (mean ± SD was 4.1%±3.0% and 3.9%±2.6%, respectively; P=.51), we averaged the results of the activity monitor over the 2 consecutive 24-hour periods. To evaluate the change in the outcome measures for the physical activity level, as well as the determinants, we used multilevel regression analyses (MLwiN).33, 34,d The hierarchy in this longitudinal dataset can be defined as the repeated measurement over time (level 1), which is grouped within each participant (level 2). An important advantage of this method is that it considers the dependency of repeated measurements within 1 person. Additionally, the analyses can be performed even with missing values. This offers the advantage over repeated-measurements analyses of variance that more persons can be included, which gives a more realistic representation of the group performance at each test occasion. Thus, we included persons in the analyses when measurements with the activity monitor were performed at 1 or more test occasions, and we could adequately assess the change in physical activity level with varying group composition. Change in physical activity level during and after inpatient rehabilitation We made basic multilevel regression models for the change in 2 outcome measures of the physical activity level (1 model for the change in duration of dynamic activities and 1 model for the change in average body motility). We included time in the model as a set of 4 dummy variables to measure change in physical activity (T1–T3, T2–T3, T3–T4, T3–T5) by using the physical activity level at discharge (T3) as the referent for each dummy variable. In the resultant regression equation, the intercept represented the physical activity level at discharge (T3). The regression coefficients for each time-related dummy represented the difference between the physical activity level at discharge (T3) and the physical activity level at the other test occasions. By adding the coefficients for the dummy variables to the intercept, we obtained estimates of the physical activity level at the time points T1, T2, T4, and T5. We used the size and SD of the regression coefficient to determine whether the physical activity level at discharge differed significantly from the physical activity level at the other test occasions. Relationship between (the change in) physical activity level and personal and lesion characteristics To determine whether the independent variables age, sex, level, and completeness of the lesion were related to (the change in) physical activity level, we made multivariate multilevel regression models for 2 outcome measures of the physical activity level (ie, 1 model for duration of dynamic activities and 1 model for average body motility). We alternately added the independent variables and their interaction terms with the time-related dummy variables to the basic model. Then, we selected and simultaneously added all independent variables (there was no collinearity between these variables) and the interaction terms with a considerable association (P≤.10) with the physical activity level to the basic model. We removed nonsignificant interaction terms (P>.05) and constructed a new regression model. To make a valid analysis of the relationship between an independent variable and the change in the physical activity level, we had to include all of its interaction terms, even if the relationship proved significant over only 1 time interval. Physical activity level 1 year after discharge in comparison with the level in able-bodied persons We assessed the duration of dynamic activities as a percentage of a 24-hour period in the 16 persons who completed the measurements at T5 with descriptive statistics (SPSS 12.0 for Windowsc) and compared this with the results as found in 16 matched, able-bodied subjects (unpaired t test). These able-bodied subjects were part of a large reference sample of subjects measured with the activity monitor and were matched for sex and age (±3y). Furthermore, in the persons with SCI, we assessed the mutual distribution of the duration of continuous wheelchair-driving periods and walking periods at T5. Results Table 1 presents the group sizes, means, and SDs for subject and lesion characteristics and physical activity level at the different test occasions. Change in Physical Activity Level During and After Inpatient Rehabilitation Figures 3A and 3B show the change in outcome measures of the physical activity level as estimated with the basic multilevel regression model. Outcome measures of the physical activity level increased significantly (P<.01) between the start of active inpatient rehabilitation (T1) and discharge (T3). The duration of dynamic activities increased 41% (P<.001; corresponding with an increase of 20min per 24-h period) and average body motility 19% (P=.008). Two months after discharge from the rehabilitation center (T4), the duration of dynamic activities significantly decreased (33%; P<.001) when compared with discharge (T3). Relationship Between Physical Activity Level and Personal and Lesion Characteristics Table 2 shows the association between (the change in) outcome measures of the physical activity level and the independent variables as estimated with the final multivariate multilevel regression model. The respective regression coefficients represent the difference in physical activity level associated with an increase in the independent variable of 1 unit. Age was significantly related to average body motility; an increase in age of 1 year was associated with a decrease of 7.8·10−5 g in average body motility. In persons with tetraplegia, average body motility was significantly smaller than in persons with paraplegia (.001g smaller). Sex and completeness of the lesion were not significantly related with the outcome measures of the physical activity level. Following are the differences in the change over time in physical activity level between subgroups, although the physical activity level did not change significantly: (1) the elderly showed significantly more improvement in duration of dynamic activities between T2 and T3 than the younger persons and (2) persons with paraplegia and persons with an incomplete lesion showed significantly more improvement in the duration of dynamic activities in the year after discharge than did persons with tetraplegia and persons with a complete lesion, respectively. Physical Activity Level 1 Year After Discharge in Comparison With Level in Able-Bodied Persons We calculated the duration of dynamic activities in the 16 persons who completed measurements at T5 as 3.4%±3.3% (see table 1), corresponding with 49 minutes per day. This was significantly lower (P<.001) than the mean duration of dynamic activities in matched, able-bodied subjects (9.9%±4.1%, corresponding with 143min/d). None of the persons who completed measurements at T5 had continuous wheelchair driving periods lasting more than 10 minutes; the highest duration of continuous wheelchair driving at T5 was between 120 and 300 seconds. Continuous wheelchair-driving periods lasted mostly between 5 and 10 seconds and between 10 and 30 seconds; this was the same for walking periods. Only 1 man with paraplegia (who became completely ambulatory after discharge) had continuous walking periods at T5 lasting more than 10 minutes (on average 2 periods per 24-h). Discussion Change Over Time in Physical Activity Level and Comparison With Level in Able-Bodied Persons Our study indicates that the physical activity level in persons with SCI increases during inpatient rehabilitation. We consider increases at discharge of 41% and 19% in duration of dynamic activities and average body motility, respectively, as clinically relevant. However, the increase in the physical activity level did not continue after discharge and even showed a decline in duration of dynamic activities shortly after discharge from the rehabilitation center. This decline was considerable; the level at T4 was comparable with the level at the start of active rehabilitation (T1) and may (in part) be caused by the fact that persons with SCI often do not have all their mobility aids and adaptations to their houses at discharge. One year after discharge, the duration of dynamic activities was restored to a level comparable with the one at discharge, but it was distinctly lower than levels measured in the matched able-bodied persons (3.4%±3.3% vs 9.9%±4.1%) and was also lower than levels measured with our activity monitor in persons with other chronic diseases (fig 4). Comparison of our results with the health-related guidelines as established by the Centers for Disease Control and Prevention and the American College of Sports Medicine also indicates that our participants had an unhealthy lifestyle. The guidelines recommend that all adults accumulate at least 30 minutes or more, in bouts of minimum 10-minute durations, of moderate-intensity physical activity on most, preferably all, days of the week.35, 36 One year after discharge from the rehabilitation center, the majority of our participants did not meet these guidelines. This finding of low physical activity levels in persons after SCI has been reported before.10, 11, 12, 13, 15, 16 The change over time in the duration of dynamic activities (see fig 3A) in the year after discharge seems in contrast with the change over time in average body motility (see fig 3B). Based on the change in the duration of dynamic activities between T4 and T5, one would expect a restoration of average body motility after T4. This apparent discrepancy can be explained by the fact that we included only persons who were completely dependent on a manual wheelchair in the analyses regarding average body motility. These persons did not show a restoration in duration of dynamic activities after T4. Relationship Between Physical Activity Level and Personal and Lesion Characteristics We found that age and level of the lesion were determinants of average body motility. There were no relationships between (change in) the outcome measures of the physical activity level and sex and completeness of the lesion. However, we found significant differences between persons with complete and incomplete lesions with regard to the change over time in the duration of dynamic activities 1 year after discharge. Therefore, beyond 1 year after discharge, the completeness of the lesion may be a determinant of the physical activity level. Also, Buchholz et al10 found that free-living persons with SCI (12.5±9.5y since onset) with complete lesions had lower physical activity levels than did persons with incomplete lesions. During inpatient rehabilitation, age was the only determinant of the change in physical activity level (duration of dynamic activities), which may be because of a slower recovery in older persons who may have more complications and comorbidities. After discharge, level and completeness of the lesion were determinants of the change in physical activity level (duration of dynamic activities). Persons with paraplegia and persons with an incomplete lesion showed greater improvement in the duration of dynamic activities in the year after discharge than did persons with tetraplegia and persons with complete lesions, respectively. Implications for Treatment Because of the known detrimental effects of a hypoactive lifestyle, we suggest that rehabilitation should be aimed at increasing physical activity levels in persons with SCI. Treatment should make persons more aware of the possible consequences of their low physical activity levels and should focus on stimulating persons to develop and maintain a more active lifestyle, particularly after discharge from the rehabilitation center and in persons with tetraplegia and persons with complete lesions. We may postulate that adding preventive behavioral strategies to the regular treatment may improve activity patterns after SCI. There is some evidence for the efficacy of such behavioral strategies on physical activity levels in persons with SCI and other physical disabilities.37, 38, 39 Because the physical activity level showed a (nonsignificant) deterioration after the early phase of inpatient rehabilitation (T3 vs T2) (see figs 3A, 3B), behavioral strategies preferably should start as early as possible in the rehabilitation process. To improve activity patterns throughout life, these strategies should continue to be used after discharge from the rehabilitation center. In a recent study, Vissers et al40 established barriers and facilitators to everyday physical activity in persons with SCI after discharge from the rehabilitation center. The authors reported many different barriers as mentioned by the participants and concluded that after 9 months after discharge, mental problems (eg, sad feelings) and physical problems (eg, bladder problems) were the most important barriers to physical activity. Therefore, besides behavioral strategies, which should be adjusted individually, treatment should continually focus on mental and physical problems, even long after discharge. Vissers et al40 also reported that support from family, friends, and people in the society and preparation and stimulation in the rehabilitation center with respect to an active lifestyle and social activities were the most frequently mentioned facilitators to everyday physical activity. However, before optimizing the rehabilitation of persons with SCI with respect to a more active lifestyle, to avoid overload, more knowledge is required on the change in physical strain during everyday life in these persons. It is well known that wheelchair-bound individuals with SCI have a reduced aerobic capacity,20, 41, 42, 43 which, in combination with the use of a relatively small upper-body mass, may lead to high levels of physical strain in everyday life. To our knowledge, only Janssen et al16 have studied physical strain in free-living conditions in persons with SCI. The authors found a low average strain. More research is needed on other determinants of the change in physical activity level (eg, physical capacity) than the ones studied here. Study Limitations We believe that our study sample was reasonably representative of Dutch persons with SCI. With regard to age, sex, and level and completeness of the lesion, our sample was comparable with the sample from the national research program of 205 Dutch persons with SCI.17 However, because we excluded persons who became completely ambulatory during inpatient rehabilitation and because of our inclusion criterion regarding age, our sample included (compared with some other demographic studies in Dutch persons with SCI) fewer elderly persons (those aged >60y)44, 45 and more complete lesions.44, 45, 46 Furthermore, the physical activity level in our study may have been overestimated because the tested persons represented a positive selection of all persons with SCI; they were not limited by cardiovascular or musculoskeletal complaints, they were not completely dependent on an electric wheelchair, and they were not older than 65 years of age. On the other hand, however, we excluded persons who became completely ambulatory during inpatient rehabilitation. Also, the relatively large dropout rate may have hampered the representativeness of our study sample, but there were no significant differences in baseline age, sex, level and completeness of lesion, and physical activity level between persons who completed the T5 measurements and persons who dropped out at some point. Furthermore, we used random coefficient analyses, which offer the advantage that the analyses can be performed even with missing values. Because of the relatively small study sample, particularly in view of the multivariate analyses, we had low power to show significant relationships between the independent variables and the change over time in physical activity level. However, in our opinion, multilevel regression analysis is at the moment the best available method to study our research questions. Analyses can be performed with missing values, which means that more persons can be included in the analysis, giving a more realistic representation. It has been suggested that 3 to 5 days of activity monitoring are needed to characterize an individual's habitual physical activity pattern.47 However, our aim was not to characterize habitual physical activity in SCI but to obtain insight in the change in the physical activity level in this patient group. Therefore, we believe that our monitoring during 2 consecutive weekdays is justified. Some participants experienced discomfort while wearing the activity monitor (eg, itching from the adhesive materials that attach the accelerometers and wearing the data recorder and cables was uncomfortable). However, although we aim to decrease the discomfort of wearing the activity monitor, we have no indication that wearing the activity monitor influences the physical activity level. Conclusions The physical activity level increased during inpatient rehabilitation, but this increase did not continue after discharge and the level 1 year after discharge was distinctly lower than the level in able-bodied persons. Subpopulations had a different change over time in the physical activity level after discharge. The findings suggest that rehabilitation should be aimed at increasing physical activity levels in persons with SCI, particularly after discharge from the rehabilitation center and particularly in persons with tetraplegia and persons with complete lesions. Suppliers Acknowledgments We thank Karin Postma, PT, MSc, Jan Kamberg, PT, and Rogier Broeksteeg, PT, for organizing and performing all measurements. References 1. 1Manns PJ, Chad KE. Determining the relation between quality of life, handicap, fitness, and physical activity for persons with spinal cord injury. Arch Phys Med Rehabil. 1999;80:1566–1571. Abstract |
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a Department of Rehabilitation Medicine, Erasmus Medical Center, Rotterdam, The Netherlands b Rijndam Rehabilitation Center, Rotterdam, The Netherlands c Research Institute MOVE, Institute for Fundamental & Clinical Human Movement Sciences, Faculty of Human Movement Sciences, Vrije Universiteit, Amsterdam, The Netherlands d Rehabilitation Center Amsterdam, The Netherlands  Correspondence to Rita J. van den Berg-Emons, PhD, Erasmus Medical Center, Department of Rehabilitation Medicine, PO Box 2040, 3000 CA Rotterdam, The Netherlands
Supported by the Johanna Child Fund and Child Fund Adriaanstichting (grant no. 2002/0067) and ZONmw Rehabilitation program (grant no. 1435.0003). No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit on the authors or on any organization with which the authors are associated. Reprints are not available from the author. PII: S0003-9993(08)00799-5 doi:10.1016/j.apmr.2008.04.024 © 2008 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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