The effectiveness and satisfaction of web-based physiotherapy in people with spinal cord injury: a pilot randomised controlled trial

Study Design: Pilot randomised controlled trial. Objectives: The aims of this study were to evaluate the effectiveness and participant satisfaction of web-based physiotherapy for people with Spinal Cord Injury (SCI). Setting: Community patients of a national spinal injury unit in a university teaching hospital, Scotland, UK. Methods: Twenty-four participants were recruited and randomised to receive eight weeks of web-based physiotherapy (intervention), twice per week, or usual care (control). Individual exercise programmes were prescribed based upon participant’s abilities. The intervention was delivered via a website (www.webbasedphysio.com) and monitored and progressed remotely by the physiotherapist. Results: Participants logged on to the website an average of 1.4±0.8 times per week. Between-group differences, although not significant were more pronounced for the 6 minute walk test. Participants were positive about using web-based physiotherapy and stated they would be happy to use it again and would recommend it to others. Overall it was rated as either good or excellent. Conclusions: Web-based physiotherapy was feasible and acceptable for people with SCI. Participants achieved good compliance with the intervention, rated the programme highly and beneficial for health and well-being at various states post injury. The results of this study warrant further work with a more homogenous sample

Metabolic and electromechanical investigation during individual stimulated muscle exertion and volitional systemic adapted physical activity

Il nostro lavoro ha analizzato vari possibili aspetti che sono essenziali per definire programmi di attivit\ue0 fisica adattata; ci sono molti strumenti che permettono di effettuare varie tipologie di valutazione e ovviamente non tutti possono essere considerati. Il primo studio intendeva fornire un metodo innovativo ed obiettivo per misurare il grado di fornitura / prelievo di ossigeno nel singolo muscolo durante esercizio controllato da una stimolazione incrementale del pool di unit\ue0 motorie, attraverso una stimolazione elettrica che fosse indipendente dalla motivazione e dal controllo centrale dei soggetti testati. Successivamente ci si \ue8 spostati da una valutazione locale ad una globale, studiando diverse tipologie di attivit\ue0 motoria adattata in un contesto riabilitativo. Nel secondo e nel quarto studio abbiamo trattato due diversi tipi di attivit\ue0 fisica adattata per persone affette da lesione midollare. In particolare la spesa energetica e gli adattamenti metabolici durante un'attivit\ue0 che simulava delle discipline sportive mediante una consolle per videogiochi e durante attivit\ue0 di handbike su un ergometro progettato in modo specifico. Nel terzo studio \ue8 stato invece analizzato un tipico trattamento riabilitativo per pazienti affetti da ictus; il trattamento consisteva nel cammino in sospensione con scarico del peso corporeo su uno specifico nastro trasportatore. In questo studio abbiamo indagato l'influenza della percentuale di scarico del peso corporeo e della velocit\ue0 del treadmill sulla spesa energetica e sul reclutamento muscolare dei muscoli responsabili del cammino. Riassumendo i quattro studi erano: 1. Differenza tra fornitura e prelievo di ossigeno durante stimolazione elettrica incrementale nel muscolo tibiale anteriore. 2. Spesa energetica in attivit\ue0 fisica durante videogioco in soggetti affetti da lesione midollare. 3. Indice di costo fisiologico e reclutamento muscolare durante cammino in sospensione al nastro trasportatore in soggetti sani e soggetti affetti da ictus. 4. Valutazione metabolica di atleti disabili durante attivit\ue0 fisica con un ergometro specificatamente progettato: risultati preliminari. Le conclusioni di ogni studio sono state: 1. Il nostro lavoro ha fornito uno strumento relativamente semplice per valutare obiettivamente il bilancio tra ossigeno fornito e prelevato, indipendentemente dalla motivazione del soggetto, nel muscolo scheletrico umano a vari livelli di forza prodotta. In particolare il sistema ha mostrato che, pi\uf9 alto era la concentrazione di O2Hb, migliore era la risposta del microcircolo nell'evitare che vi fosse una grossa differenza tra O2 fornita e prelevata. Inoltre, pi\uf9 il muscolo era affaticabile, pi\uf9 elevato era la differenza tra O2 fornito e prelevato. Questo fattore pu\uf2 essere relativo al livello di inadeguatezza del microcircolo a soddisfare l'aumentata richiesta di O2 via via che il livello di contrazione aumentava, nel quale sempre pi\uf9 emoglobina ossigenata doveva essere convertita in deossigenata. Questo sistema pu\uf2 essere usato per stimare la cinetica degli adattamenti aerobici durante I transienti dell'aumentata richiesta metabolica nei muscoli affetti da specifiche miopatie o in seguito a protocolli riabilitativi, di trattamento e/o programmi di allenamento. 2. Questo lavoro suggerisce che nei oggetti affetti da lesione midollare, la pratica di attivit\ue0 fisica con videogame che simulino sport reali, induce un incremento significativo dei parametri cardiopolmonari e metabolici. Gli adattamenti funzionali correlati, specialmente per la simulazione del pugilato, possono essere considerati come uno stimolo aerobico per promuovere la salute. Inoltre l'incremento di spesa energetica pu\uf2 giocare un ruolo importante nel computo calorico giornaliero quando i soggetti cercano di controllare i loro peso. 3. Il cammino in sospensione al nastro trasportatore per soggetti sani o soggetti con esiti di ictus, permette ai pazienti di avere delle sessioni di allenamento pi\uf9 lunghe ed efficaci con un inferiore indice di costo fisiologico. Questo parametro e il consumo di ossigeno, sono fortemente correlati e di conseguenza, l'indice di costo fisiologico pu\uf2 essere usato in un ambiente clinico in maniera economica, senza particolari strumentazioni, in modo da poter confrontare due o pi\uf9 soggetti. Il significato del miglior rapporto tra reclutamento elettrico dei muscoli degli arti inferiori e indice di costo fisiologico deve essere approfondito. Uno studio longitudinale potrebbe essere utile per verificare che la combinazione di riduzione del peso corporeo e velocit\ue0 del nastro trasportatore sia la pi\uf9 favorevole per consentire un allenamento muscolare ed aerobico adeguati a ri-allenare pazienti con esiti di ictus. 4. I dati preliminari confermano che l'ergometro handbike, appositamente progettato pu\uf2 aiutare a controllare l'intensit\ue0 dell'esercizio praticato. Una integrazione di successo di allenamenti aerobici in protocolli riabilitativi per soggetti affetti da lesione midollare pu\uf2 essere pi\uf9 semplice se l'esercizio \ue8 sicuro, facilmente adattabile a soggetti con scarsa capacit\ue0 fisica, divertente, motivante e utile per l'attivit\ue0 di mobilit\ue0 quotidiana. La pratica dell'hanbike soddisfa questi requisiti. Gli accorgimenti pi\uf9 importanti di questo ergometro sono un'adeguata ed ergonomica interfaccia ed un sistema di controllo preciso ed affidabile della potenza prodotta dal soggetto. Inoltre, un sistema che pu\uf2 essere usato sia per valutare che per allenare, pu\uf2 essere uno strumento molto utile nell'aiutare gli operatori dell'attivit\ue0 fisica adattata a pianificare specifici programmi di attivit\ue0 fisica. Ulteriori studi saranno necessari su un gruppo di individui simile, ma pi\uf9 numeroso.Our research has analysed various possible aspects that are essential to define custom programs of Adapted Physical Activity; there are many tools that allow performing various types of assessments and obviously not everyone could be considered. Therefore the first study was aimed to provide a novel objective method to measure the degree of individual muscle oxygen supply/uptake balance during exertion through a controlled incremental activation of the motor unit (MU) pool through neuromuscular electrical stimulation (NMES) that is independent from motivation and central control of tested subjects. This tool could be applied to estimate the kinetics of aerobic adaptation to increasing metabolic demand in muscles affected by myopathies or subjected to rehabilitation or training programmes. Afterwards we have moved from local to global measures, studying different kinds of APA in a rehabilitation setting. In second and fourth study we treat two different special leisure time physical activities for SCI subjects. In particular, energy expenditure and metabolic adaptation during activity promoting video games (APVG) and during handbike exercise on a specific designed ergometer. At the end, in the research, we investigated a typical post stroke rehabilitation treatment, such as BWS, studying the influence of body weight reduction and walking speed on energy expenditure and lower limb muscles recruitment. Summarizing the four studies were: 1. Oxygen supply/uptake mismatch during incremental stimulation of human tibialis anterior. 2. Energy expenditure of activity-promoting video games in spinal cord injured subjects. 3. Physiological Cost Index and Muscular Recruitment during Body Weight Support Treadmill Training in Healthy and Stroke Patients 4. Metabolic evaluation of the disabled athlete during handcycling on a specific designed ergometer: preliminary results Conclusions of the four studies were: 1. Our work provided a relatively simple tool for the objective functional evaluation of the O2 supply/uptake balance, independent of subject motivation, in a single skeletal muscle in humans at increasing levels of output force. In particular its sensitivity showed that the higher the O2Hb concentration at rest, the better is the specific behaviour of the microvascular network response, with incremental stimulation, in limiting O2M. Indeed, Fig. 2.3 clearly shows that the higher the fatigability of the stimulated muscle, the higher the O2M area. This fact may be related to the degree of inadequacy of the microcirculation to match the increased O2 demand from one level of the evoked contractions to the next, more intense, level with more O2Hb to be deoxygenated to HHb. This tool could be applied to estimate the kinetics of aerobic adaptation during transients of increasing metabolic demand in muscles affected by specific myopathies or the effects of particular rehabilitation protocols, treatments and/or training programmes. 2. This work suggests that in spinal cord injured subjects APVG practice induces sizeable increases of cardiopulmonary and metabolic parameters. The related functional adaptations, especially for boxing, may be considered an aerobic training stimulus to promote health. Furthermore, the energy expenditure increase may play a role in total energy balance computation when subject weight control is sought for. 3. Body weight support treadmill training in healthy or post stroke subjects is well tolerated. This practice enables post stroke patients to have longer and more effective training session with a lower physiological cost index. This last and VO2 are strongly correlated so, the PCI can be evaluated inexpensively in a clinical setting, to get exercise capacity on treadmill and compare two or more patients. The best EMGTOT / PCI value significance requires further analysis. A longitudinal study will be suitable to check if the suggested combination of speed and BWR will be the most favourable to reach a valuable muscular and aerobic training stimuli to retain post stroke patient. 4. These preliminary results introduced a new instrumented handbike which will help to control handcycling intensity. A successful integration of aerobic exercise training into rehabilitation protocol of people with Spinal Cord Injury may be more likely if aerobic exercise is safe, easily adjustable to a low physical capacity subject, fun to do, motivating, and useful in daily mobility. Handbike practice may meet these requirements. Important features of this ergometer are an adequate ergonomic interface and an optimal system to impose a precise power exertion. A system that allows training and testing with the same device, may be a useful tools in helping Adapted Physical Activity operators to plan specific physical activity programs. Further studies need to be conducted with similar but larger populations

Oxygen supply/uptake mismatch during incremental stimulation of the human tibialis anterior.

Background: Local oxygen supply/uptake mismatch (O2M) of active muscles may be influenced by the effectiveness of microvascular adaptations to metabolic demand. The aim of this work was to provide a novel, objective method to measure O2M through incremental stimulation. Methods: The tibialis anterior of 20 subjects was electrically stimulated at the main motor point. The stimulation protocol involved five single twitches at maximal stimulus amplitude (Vmax = full motor unit recruitment) and five 90-s steps with increasing amplitude and frequency of the intermittent stimulation. Changes in force, oxygenated Hb (O2Hb) and deoxygenated Hb (HHb) were recorded. Contraction time (CT) of single twitches, fatigue index (FI) and O2M were calculated. Results: F-statistics identified two groups of muscles, one with FI 0.69 (group R, less fatiguable). Group R showed significantly lower CT, higher basal O2Hb, lower ΔHHb and lower O2M with respect to group F. Conclusion: On the basis of the rela- tionship between O2M and FI, the proposed method distinguished two different functional capacities of human TA muscles. This tool could be applied to estimate the kinetics of aerobic adaptation to increasing metabolic demand in muscles affected by myopathies or subjected to rehabilitation or training programmes

Transcutaneous neuromuscular electrical stimulation: influence of electrode positioning and stimulus amplitude settings on muscle response.

The aim of the study was to investigate the influence of two different transcutaneous neuromuscular electrical stimulation procedures on evoked muscle torque and local tissue oxygenation. In the first one (MP mode), the cathode was facing the muscle main motor point and stimulus amplitude was set to the level eliciting the maximal myoelectrical activation according to the amplitude of the evoked electromyogram (EMG); in the second one (RC mode), the electrodes were positioned following common reference charts for electrode placement while stimulus amplitude was set according to subject tolerance. Tibialis Anterior (TA) and Vastus Lateralis (VL) muscles of 10 subjects (28.4 ± 8.2 years) were tested in specific dynamometers to measure the evoked isometric torque. The EMG and near-infrared spectroscopy probes were placed on muscle belly to detect the electrical activity and local metabolic modifications of the stimulated muscle, respectively. The stimulation protocol consisted of a gradually increasing frequency ramp from 2 to 50 Hz in 7.5 s. Compared to RC mode, in MP mode the contractile parameters (peak twitch, tetanic torque, area under the torque build-up) and the metabolic solicitation (oxygen consumption and hyperemia due to metabolites accumulation) resulted significantly higher for both TA and VL muscles. MP mode resulted also to be more comfortable for the subjects. Based on the assumption that proper mechanical and metabolic stimuli are necessary to induce muscle strengthening, our results witness the importance of an optimized, i.e., comfortable and effective, stimulation to promote the aforementioned muscle adaptive modifications

Transcutaneous neuromuscular electrical stimulation : influence of electrode positioning and stimulus amplitude settings on muscle response

The aim of the study was to investigate the influence of two different transcutaneous neuromuscular electrical stimulation procedures on evoked muscle torque and local tissue oxygenation. In the first one (MP mode), the cathode was facing the muscle main motor point and stimulus amplitude was set to the level eliciting the maximal myoelectrical activation according to the amplitude of the evoked electromyogram (EMG); in the second one (RC mode), the electrodes were positioned following common reference charts for electrode placement while stimulus amplitude was set according to subject tolerance. Tibialis Anterior (TA) and Vastus Lateralis (VL) muscles of 10 subjects (28.4\ua0\ub1\ua08.2\ua0years) were tested in specific dynamometers to measure the evoked isometric torque. The EMG and near-infrared spectroscopy probes were placed on muscle belly to detect the electrical activity and local metabolic modifications of the stimulated muscle, respectively. The stimulation protocol consisted of a gradually increasing frequency ramp from 2 to 50\ua0Hz in 7.5\ua0s. Compared to RC mode, in MP mode the contractile parameters (peak twitch, tetanic torque, area under the torque build-up) and the metabolic solicitation (oxygen consumption and hyperemia due to metabolites accumulation) resulted significantly higher for both TA and VL muscles. MP mode resulted also to be more comfortable for the subjects. Based on the assumption that proper mechanical and metabolic stimuli are necessary to induce muscle strengthening, our results witness the importance of an optimized, i.e., comfortable and effective, stimulation to promote the aforementioned muscle adaptive modifications

Electromyogram and force fluctuation during different linearly varying isometric motor tasks.

The purpose of this work was to verify if deviation from the mirror-like behaviour of the motor units activation strategy (MUAS) and de-activation strategy (MUDS) and the degree of the error of the motor control system, during consecutive linearly increasing-decreasing isometric tension tasks, depend on the maximum reached tension and/or on the rate of tension changes. In 12 male subjects the surface EMG and force produced by the first dorsal interosseus activity were recorded during two (a and b) trapezoid isometric contractions with different plateau (a: 50\% maximal voluntary contraction (MVC) and b: 100\% MVC) and rate of tension changes (a: 6.7\% MVC/s and b: 13.3\% MVC/s) during up-going (UGR) and down-going (DGR) ramps. Ten steps (ST) 6s long at 5, 10, 20, 30, 40, 50, 60, 70, 80 and 90\% MVC were also recorded. The root mean square (RMS) and mean frequency (MF) from EMG and the relative error of actual force output with respect to the target (\% ERR) were computed. The EMG-RMS/\% MVC and EMG-MF/\% MVC relationships were not overlapped when the ST and DGR as well as the UGR and DGR data were compared. The \% ERR/\% MVC relationships during a and b contractions differed from ST data only below 20\% MVC. It can be concluded that MUAS and MUDS are not mirroring one each other because MU recruitment or de-recruitment threshold may be influenced by the maximum effort and by the \% MVC/s of UGR and DGR. The role of MUs mechanical and/or central nervous system hysteresis on force decrement control is discussed

Electromyogram and force fluctuation during different linearly varying isometric motor tasks.

The purpose of this work was to verify if deviation from the mirror-like behaviour of the motor units activation strategy (MUAS) and de-activation strategy (MUDS) and the degree of the error of the motor control system, during consecutive linearly increasing-decreasing isometric tension tasks, depend on the maximum reached tension and/or on the rate of tension changes. In 12 male subjects the surface EMG and force produced by the first dorsal interosseus activity were recorded during two (a and b) trapezoid isometric contractions with different plateau (a: 50% maximal voluntary contraction (MVC) and b: 100% MVC) and rate of tension changes (a: 6.7% MVC/s and b: 13.3% MVC/s) during up-going (UGR) and down-going (DGR) ramps. Ten steps (ST) 6s long at 5, 10, 20, 30, 40, 50, 60, 70, 80 and 90% MVC were also recorded. The root mean square (RMS) and mean frequency (MF) from EMG and the relative error of actual force output with respect to the target (% ERR) were computed. The EMG-RMS/% MVC and EMG-MF/% MVC relationships were not overlapped when the ST and DGR as well as the UGR and DGR data were compared. The % ERR/% MVC relationships during a and b contractions differed from ST data only below 20% MVC. It can be concluded that MUAS and MUDS are not mirroring one each other because MU recruitment or de-recruitment threshold may be influenced by the maximum effort and by the % MVC/s of UGR and DGR. The role of MUs mechanical and/or central nervous system hysteresis on force decrement control is discussed

Instrumentation of a handbike for biomechanical measurements

This study presents the project of an instrumentation system that, applied on a handbike, allows the measurements of biomechanical parameters as cranking speed, exerted forces on the handles and output power. Similar devices exist only based on normal bikes: they're called “ergometers”, but nothing exists strictly dedicated to handbike