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June 2003


Healing on Wheels

By Bonita J. Sawatzky, PhD; Heather M. Macdonald, MSc; and Nicola Valentine, BSc, OT


Researchers in Vancouver tracked kids’ results via the Web as they participated in activities such as basketball.

It is well accepted that exercise is an important factor in overall health and fitness across all populations. However, paraplegics are known to be at greater risk for cardiovascular disease than the normal population due to a decrease in active muscle mass.1 It is suggested that through regular exercise focusing on increasing both aerobic capacity and muscle strength, wheelchair users could improve cardiovascular function.

Inactive wheelchair users are also at an increased risk for osteoporosis.2 A lack of weight-bearing activity leads to demineralization of the skeleton, especially in the lower extremities. For wheelchair users, this fact is of great importance as the weaker bones are more susceptible to spontaneous fractures that could occur during simple transfers.1,2 Unfortunately, for some children, such as those with spina bifida, access to adapted athletic programs is limited because of availability of such programs, transportation issues, limited facilities, and cost. With the increased demand on public school systems, adapted physical education programs are disappearing. It should be a goal of physicians, health care teams, and educators to emphasize the importance of regular physical activity for disabled children.

Weight gain is one of the greatest concerns of physicians caring for the pediatric disabled. Not only does an increase in body fat lead to a greater chance of ischemic heart disease, hypertension, and diabetes, but it also affects the psychological well-being of the patient. Overweight wheelchair users may adopt a dependent and passive lifestyle as reliance on family members for transferring and wheelchair pushing increases.3 A lowered self-concept and a tendency for depression to occur are also concerns, especially with adolescents with whom body image and peer acceptance are a main focus. Physical activity has been shown to relieve these tendencies in many disabled populations and in fact reverse the effects in a positive direction.1,3 If we propose to increase the level of activity of individuals using wheelchairs, the questions are: how can we achieve this goal and how much activity is required?

GETTING ONLINE

To address the method of how to implement an exercise program to a large geographic population of wheelchair users, we chose the online approach, using a 4-month, Web-based exercise program. We implemented a study using children with spina bifida who attend our tertiary hospital clinic. This project included a group of children (ages 8-18 years) who were primary wheelchair users (using them more than 50% of the time). The geographic distribution of the children was varied, with some participants living in the Vancouver area and others living in far-reaching northern British Columbia communities, driving up to 20 to 25 hours through mountainous and often snowy terrain to the clinics.

During a clinic visit, each child had a bicycle odometer attached to their wheelchair to measure their wheeling distance. For those who were not coming to a clinic appointment, the odometer was sent to their homes with instructions on how to mount it to the wheelchair. During the first week, the participants were instructed to continue with their usual activities. During week 2, they were contacted by phone or email to find out how far they had wheeled. A distance goal for the 4 months was then decided upon with the researcher and subject (with input from parent and/or therapist or their physical education teacher). The children were encouraged to wheel independently whenever possible, and this was also discussed with the parents. Each subject was given an access account to our secured Web site designed specifically for this project.

On the site, the child could enter their weekly distance and view their progress toward the distance goal. For those children who were involved in nonwheeling activities, sport equivalent distances could be entered (ie, 30-min swim = 3 km). The interactive site also provided ideas for wheeling activities that could help increase the distance traveled. During the 4 months, the project coordinator regularly emailed the participants to encourage activity, as well to problem-solve any hardware difficulties. After the 4 months in the Web-based exercise program, the same measures were repeated. The total distance was recorded on the follow-up visit or phone call, which served as a check for honesty on the self-report into the site.

CHECKING STATS

To assess how well such a program worked and how exercise improved wheeling in these children, we measured the effects of exercise, specifically looking at wheeling efficiency in addition to other measures. Wheeling efficiency or energy cost can be measured as the amount of oxygen consumed per unit of body mass per unit of distance traveled (mL/kg/m). This is a well-accepted measurement in gait analysis to study the effect of assistive devices such as orthotics, crutches, and prostheses, as well as surgical interventions in children and adults with cerebral palsy, paraplegia, or amputations.4-8 Heart rate can also be used to assess energy expenditure during walking and wheeling, such as the energy efficiency index (EEI), or physiological cost index (PCI).9 Heart rate has been shown to be a reliable predictor of energy efficiency during walking5,6,10,11 with correlations reported between 0.78 and 0.90. Sawatzky et al showed the relationship between oxygen consumption and heart rate (r=0.83) during wheelchair propulsion of 10 adult subjects with traumatic paraplegia (T6 or below).12 Other measures in this present study were: Body Mass Index (BMI), level of physical activity and strength using the Canada Fitness Survey13,14 and self-esteem using the validated Piers-Harris self-concept scale.15 The physical activities reported were categorized as daily, weekly, monthly, and none.


Bonita J. Sawatzky, PhD

FITNESS FEEDBACK

Similar to walking, the goal of manual wheelchair propulsion is to move forward through space with the least mechanical and physical energy expenditure.16 One needs adequate upper body strength, flexibility, and coordination, as well as stable pelvic and trunk seating position. From the preassessment with 38 children, strength was the biggest contributor to wheeling efficiency with body composition being the next major factor (r=0.59; P<0.0005; r=0.41; P<.05). The amount of physical activity played a large role in the person’s strength, self-esteem, and body composition (P<.05).

Prior to the exercise program, children who participated in activities such as wheelchair basketball, tennis, or swimming on a regular basis demonstrated a lower energy expenditure than children who lead more sedentary lifestyles (P<.05). This observation is of particular importance for the general health of this population, and for the prevention of secondary disabilities.

The 13 individuals who participated in the exercise program showed an overall trend toward improvement in wheeling efficiency and strength (P<.10). This was a limited intervention as the children came from a wide geographic region with variable resources for sports or exercise facilities. The odometer allowed the child to see their progress in terms of distance. Some children did laps in their school gyms, while others, who normally were driven to school, wheeled themselves or had their parents drop them off at a shopping mall to do laps. The children enjoyed the immediate feedback given to them by looking at their odometer to see how far and fast they were going. They also had great fun telling the project coordinator who was monitoring their progress by email what activities they were doing—even when it had nothing to do with exercise (ie, first dates, going to movies). The average distance achieved in 4 months was 476 km.

A WEB-BASED FUTURE

Despite the small numbers of participants in the exercise program, the results showed a trend toward improved wheeling efficiency of children with spina bifida. This type of exercise program and monitoring system shows promise. More subjects and a longer exercise period may show more improvement. In addition, a Web-based program like ours could be used for other issues such as a weight management program by recording monthly weights or other health variables. As it is difficult to follow patients who live in large geographic areas, a Web program may be the way of the future to keep a closer link with high-risk patients. It should be noted, however, that a project coordinator was an invaluable, personal link to the participants of the study, helping to make it successful.

We would like to thank the families and clinicians of the Spina Bifida Clinic at BC’s Children’s Hospital for their participation and financial support.

Bonita J. Sawatzky, PhD, is assistant professor, Department of Orthopaedics, University of British Columbia, and research director for the Division of Paediatric Orthopaedics at BC’s Children’s Hospital, Vancouver. Heather M. Macdonald, MSc, is a PhD student in Human Kinetics, University of British Columbia; and Nicola Valentine, BSc, OT, is an occupational therapist for the Meningomyelocele Clinic at BC’s Children’s Hospital.

REFERENCES
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  2. Quan A, Adams R, Ekmark E, Baum M. Bone mineral density in children with myelomeningocele. Pediatrics. 199:102: 34-39
  3. Beekman CE, Miller-Porter L, Schoneberger M. Energy cost of propulsion in standard and ultralight wheelchairs in people with spinal cord injuries. Phys Ther. 1999;79:146-58.
  4. Shephard RJ. Benefits of sport and physical activity for the disabled: implications for the individual and for society. Scand J Rehab Med. 1991;23:51-59.
  5. Corry IS, Duffy CM, Cosgrove AP, Graham HK. Measurement of oxygen consumption in disabled children by the Cosmed K2 portable telemetry system. Dev Med Child Neurol. 1996;38:585-589.
  6. Duffy C, Hill A, Graham H. The influence of flexed knee gait on the energy cost of walking in children. Dev Med Child Neurol. 1997;39:234-239.
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  8. Williams L, Anderson A, Campbell J, Thomas L, Feiwell E, Walker J. Energy cost of walking and wheelchair propulsion by children with myelodysplasia: comparison with normal children. Dev Med Child Neurol. 1993;25:617-624.
  9. Rose J, Gamble JG, Medeiros J, Burgos A, Haskell WL. Energy cost of walking in normal children and in those with cerebral palsy: comparison of heart rate and oxygen uptake. J Pediatr Orthop. 1989;9:276-9.
  10. Duffy CM, Hill AE, Cosgrove AP, Corr IS, Graham HK. Energy consumption in children with spina bifida and cerebral palsy. Dev Med Child Neurol. 1996;38:238-243.
  11. Findley TW, Agre JC. Ambulation in the adolescent with spina bifida. II. Energy expenditure of mobility. Arch Phys Med Rehabil. 1988;69:855-861.
  12. Sawatzky BJ, Denison I, Miller W. Correlation of oxygen consumption and heart during wheelchair propulsion in paraplegia. Presented at: 19th International Seating Symposium; February 27-March 1, 2003; Orlando, Fla.
  13. Health Canada. The Canadian Physical Activity, Fitness & Lifestyle Appraisal. Ottawa. Canadian Society for Exercise Physiology; 1996.
  14. Russel SJ, Craig Cl. Physical Activity and Lifestyles in Canada: 1981-1995. (Appendix F). Ottowa: Canada Fitness and Lifestyle Research Institute; 1995.
  15. Piers EV. Piers-Harris Children’s Self-Concept Scale. Revised Manual. Los Angeles: WPS; 1984.
  16. Waters RL, Mulroy S. The energy expenditure of normal and pathologic gait. Gait and Posture. 1999;9:207-231.

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