Hypoactive lifestyle contributes to the development of secondary complications and lower quality of life in wheelchair users. There is a need for objective and user-friendly physical activity ...monitors for wheelchair-dependent individuals in order to increase physical activity through self-monitoring, goal setting, and feedback provision.
To determine the validity of Activ8 Activity Monitors to 1) distinguish two classes of activities: independent wheelchair propulsion from other non-propulsive wheelchair-related activities 2) distinguish five wheelchair-related classes of activities differing by the movement intensity level: sitting in a wheelchair (hands may be moving but wheelchair remains stationary), maneuvering, and normal, high speed or assisted wheelchair propulsion.
Sixteen able-bodied individuals performed sixteen various standardized 60s-activities of daily living. Each participant was equipped with a set of two Activ8 Professional Activity Monitors, one at the right forearm and one at the right wheel. Task classification by the Active8 Monitors was validated using video recordings. For the overall agreement, sensitivity and positive predictive value, outcomes above 90% are considered excellent, between 70 and 90% good, and below 70% unsatisfactory.
Division in two classes resulted in overall agreement of 82.1%, sensitivity of 77.7% and positive predictive value of 78.2%. 84.5% of total duration of all tasks was classified identically by Activ8 and based on the video material. Division in five classes resulted in overall agreement of 56.6%, sensitivity of 52.8% and positive predictive value of 51.9%. 59.8% of total duration of all tasks was classified identically by Activ8 and based on the video material.
Activ8 system proved to be suitable for distinguishing between active wheelchair propulsion and other non-propulsive wheelchair-related activities. The ability of the current system and algorithms to distinguish five various wheelchair-related activities is unsatisfactory.
Abstract
Background
Correct inhaler use depends on a complex interplay of factors, including device preparation and generating sufficient inspiratory flow. It is currently unknown which inhalation ...technique errors can be considered critical in Chronic Obstructive Pulmonary Disease (COPD) patients on Dry Powder Inhaler (DPI) maintenance therapy.
Objective
To investigate the association between inhalation technique errors and health status or exacerbations in patients with COPD. Additionally, the association between the number of errors and COPD outcomes was determined.
Methods
The PIFotal study is a cross-sectional multi-country observational study in a primary care setting, including 1434 COPD patients aged ≥ 40 years (50.1% female; mean age 69.2 yrs) using a DPI for their maintenance therapy. Inhalation technique was video recorded and scored by two independent researchers using inhaler-specific checklists. Health status was assessed with two questionnaires; the Clinical COPD Questionnaire (CCQ) and the COPD Assessment Test (CAT). The number of moderate and severe exacerbations in the past 12 months was recorded. Critical errors were identified based on their association with health status or exacerbations through multi-level prediction models adjusted for identified confounding.
Results
Errors in inhalation technique steps ‘Breathe in’, ‘Hold breath’, and ‘Breathe out calmly after inhalation’ were significantly associated with poorer CCQ and CAT outcomes and thus deemed critical. None of the errors were significantly associated with moderate exacerbations. Patients with errors ‘Preparation’, ‘Hold inhaler in correct position during inhalation’, and ‘Breathe in’ had significantly more severe exacerbations, and therefore these errors were also deemed critical. 81.3% of patients with COPD made at least one critical error. Specific combinations of errors were associated with worse outcomes. The more inhalation technique errors identified, the poorer the health status and the higher the exacerbation rate.
Conclusion
In this study, we identified multiple critical inhalation technique errors in COPD patients using DPIs each associated with poorer outcomes. Explorative analysis revealed that specific combinations of errors may be of clinical relevance, especially those related to the inhalation manoeuvre. COPD outcomes worsened with increasing error count. These results warrant further prospective longitudinal studies to establish the effect of correcting these errors on COPD control.
Trial registration
https://clinicaltrials.gov/ct2/show/NCT04532853
(31/08/2020)
The purpose of this study was to assess 1) how treadmill slope variance affected external power output (PO) and propulsion technique reliability; and 2) how PO is associated with propulsion ...technique. Eighteen individuals with spinal cord injury performed two wheelchair treadmill exercise blocks (0% and 1% treadmill slope, standardized velocity) twice on two separate days. PO, velocity, and 14 propulsion technique variables were measured. In a follow-up study, N = 29 performed wheelchair treadmill drag tests. Target and actual slope were documented and PO, intraclass correlation coefficients (ICC) and smallest detectable differences (SDD) were calculated. Within and between visits, the reliability study ICCs were perfect for velocity (1.0), weak for PO (0.33-0.46), and acceptable (>0.70) for five (0% slope) and 10 (1% slope) propulsion technique variables, resulting in SDDs of 35-196%. Measured PO explained 56-90% of the variance in key propulsion technique variables. In the follow-up, PO ICCs were weak (0.43) and SDDs high. Bias between target and actual slope appeared random. In conclusion, PO variability accounts for 50-90% of the variability in propulsion technique variables when speed and wheelchair set-up are held constant. Therefore, small differences in PO between interventions could mask the effect of the interventions on propulsion technique.
Up to 80% of wheelchair users are affected by shoulder pain. The Clinical Practice Guidelines for preservation of upper limb function following spinal cord injury suggest that using a proper ...wheelchair propulsion technique could minimize the shoulder injury risk. Yet, the exact relationship between the wheelchair propulsion technique and shoulder load is not well understood.
This study aimed to examine the changes in shoulder loading accompanying the typical changes in propulsion technique following 80 min of low-intensity wheelchair practice distributed over 3 weeks.
Seven able-bodied participants performed the pre- and the post-test and 56 min of visual feedback-based low-intensity wheelchair propulsion practice. Kinematics and kinetics of propulsion technique were recorded during the pre- and the post-test. A musculoskeletal model was used to calculate muscle force and glenohumeral reaction force.
Participants decreased push frequency (51→36 pushes/min, p = 0.04) and increased contact angle (68→94°, p = 0.02) between the pre- and the post-test. The excursion of the upper arm increased, approaching significance (297→342 mm, p = 0.06). Range of motion of the hand, trunk and shoulder remained unchanged. The mean glenohumeral reaction force per cycle decreased by 13%, approaching significance (268→232 N, p = 0.06).
Despite homogenous changes in propulsion technique, the kinematic solution to the task varied among the participants. Participants exhibited two glenohumeral reaction force distribution patterns: 1) Two individuals developed high force at the onset of the push, leading to increased peak and mean glenohumeral forces 2) Five individuals distributed the force more evenly over the cycle, lowering both peak and mean glenohumeral forces.
It has been suggested that a higher intra-individual variability benefits the motor learning of wheelchair propulsion. The present study evaluated whether feedback-induced variability on wheelchair ...propulsion technique variables would also enhance the motor learning process. Learning was operationalized as an improvement in mechanical efficiency and propulsion technique, which are thought to be closely related during the learning process.
17 Participants received visual feedback-based practice (feedback group) and 15 participants received regular practice (natural learning group). Both groups received equal practice dose of 80 min, over 3 weeks, at 0.24 W/kg at a treadmill speed of 1.11 m/s. To compare both groups the pre- and post-test were performed without feedback. The feedback group received real-time visual feedback on seven propulsion variables with instruction to manipulate the presented variable to achieve the highest possible variability (1st 4-min block) and optimize it in the prescribed direction (2nd 4-min block). To increase motor exploration the participants were unaware of the exact variable they received feedback on. Energy consumption and the propulsion technique variables with their respective coefficient of variation were calculated to evaluate the amount of intra-individual variability.
The feedback group, which practiced with higher intra-individual variability, improved the propulsion technique between pre- and post-test to the same extent as the natural learning group. Mechanical efficiency improved between pre- and post-test in the natural learning group but remained unchanged in the feedback group.
These results suggest that feedback-induced variability inhibited the improvement in mechanical efficiency. Moreover, since both groups improved propulsion technique but only the natural learning group improved mechanical efficiency, it can be concluded that the improvement in mechanical efficiency and propulsion technique do not always appear simultaneously during the motor learning process. Their relationship is most likely modified by other factors such as the amount of the intra-individual variability.
Optimal delivery of medication via dry powder inhalers, the most commonly prescribed inhaler type, is dependent on a patient achieving a minimum level of inspiratory flow during inhalation. However, ...measurement of peak inspiratory flow (PIF) against the simulated resistance of a dry powder inhaler is not frequently performed in clinical practice due to time or equipment limitations. Therefore, defining which patient characteristics are associated with lower PIF is critically important to help clinicians optimize their inhaler choice through a more personalized approach to prescribing. The objective of this scoping review was to systematically evaluate patient and disease characteristics determining PIF in patients with chronic obstructive pulmonary disease (COPD). Medline, Cochrane and Embase databases were systematically searched for relevant studies on PIF in patients with COPD published in English between January 2000 and May 2021. The quality of evidence was assessed using a modified Grading of Recommendations Assessment, Development and Evaluation checklist. Of 3382 citations retrieved, 35 publications were included in the review (nine scored as high quality, 13 as moderate, nine as low, and four as very low). Factors correlating with PIF in >70% of papers included both patient characteristics (lower PIF correlated with increased age, female gender, shorter height, decreased handgrip and inspiratory muscle strength, and certain comorbidities) and disease characteristics (lower PIF correlated with markers of lung hyperinflation, lower peak expiratory flow PEF and increased disease severity). Other factors correlating with adequate/optimal or improved PIF included education/counseling and exercise/inspiratory muscle training; impaired physical function and errors in inhalation technique/non-adherence were associated with low/suboptimal PIF. In conclusion, clinicians should measure PIF against the simulated resistance of a particular device wherever possible. However, as this often cannot be done due to lack of resources or time, the patient and disease characteristics that influence PIF, as identified in this review, can help clinicians to choose the most appropriate inhaler type for their patients.
To investigate changes in wheelchair propulsion technique and mechanical efficiency across first five weeks of active inpatient spinal cord injury rehabilitation and to compare the outcomes at ...discharge with experienced wheelchair users with spinal cord injury.
Eight individuals with recent spinal cord injury performed six weekly submaximal exercise tests. The first and last measurement additionally contained a wheelchair circuit and peak graded exercise test. Fifteen experienced individuals performed all above-mentioned tests on one occasion.
Mechanical efficiency and propulsion technique did not change during the five weeks of inpatient rehabilitation. Peak power output during peak graded test and performance time on the wheelchair circuit improved between the first and the last week. No difference in propulsion technique, peak power output, and performance time was found between the persons with a recent injury and the experienced group. Mechanical efficiency was higher after the correction for the difference in relative power output in the experienced group.
The group with a recent injury did not improve mechanical efficiency and propulsion technique over the period of active rehabilitation, despite significant improvements on the wheelchair circuit and in work capacity. The only significant difference between the groups was found in mechanical efficiency.
Implications for rehabilitation
The lack of time-dependent changes in mechanical efficiency and propulsion technique in the group with a recent spinal cord injury, combined with the lack of differences in technique, work capacity and on the wheelchair circuit between the groups, suggest that important adaptations of motor learning may happen even earlier in rehabilitation and emphasize that the group in active rehabilitation was relatively skilled.
Standardized observational analyses of handrim wheelchair propulsion abilities during early spinal cord injury rehabilitation provide detailed understanding of wheelchair technique, skill as well as wheelchair propulsion capacity.
Measurement of external power output is critical to interpretation of gross efficiency, propulsion technique, and capacity.
Wheelchair quality and body weight - next to wheelchair fitness and skill - require careful consideration both in early rehabilitation as well as in the chronic phase of spinal cord injury.
The study aimed to determine the associations of Peak Inspiratory Flow (PIF), inhalation technique and adherence with health status and exacerbations in participants with COPD using DPI maintenance ...therapy. This cross-sectional multi-country observational real-world study included COPD participants aged ≥40 years using a DPI for maintenance therapy. PIF was measured three times with the In-Check DIAL G16: (1) typical PIF at resistance of participant's inhaler, (2) maximal PIF at resistance of participant's inhaler, (3) maximal PIF at low resistance. Suboptimal PIF (sPIF) was defined as PIF lower than required for the device. Participants completed questionnaires on health status (Clinical COPD Questionnaire (CCQ)), adherence (Test of Adherence to Inhalers (TAI)) and exacerbations. Inhalation technique was assessed by standardised evaluation of video recordings. Complete data were available from 1434 participants (50.1% female, mean age 69.2 years). GOLD stage was available for 801 participants: GOLD stage I (23.6%), II (54.9%), III (17.4%) and IV (4.1%)). Of all participants, 29% had a sPIF, and 16% were shown able to generate an optimal PIF but failed to do so. sPIF was significantly associated with worse health status (0.226 (95% CI 0.107-0.346), worse units on CCQ; p = 0.001). The errors 'teeth and lips sealed around mouthpiece', 'breathe in', and 'breathe out calmly after inhalation' were related to health status. Adherence was not associated with health status. After correcting for multiple testing, no significant association was found with moderate or severe exacerbations in the last 12 months. To conclude, sPIF is associated with poorer health status. This study demonstrates the importance of PIF assessment in DPI inhalation therapy. Healthcare professionals should consider selecting appropriate inhalers in cases of sPIF.
Purpose: To assess the relationship between suboptimal Peak Inspiratory Flow (sPIF), inhalation technique errors, and nonadherence, with Healthcare Resource Utilisation (HCRU) in Chronic Obstructive ...Pulmonary Disease (COPD) patients receiving maintenance therapy via a Dry Powder Inhaler (DPI). Patients and methods: The cross-sectional, multi-country PIFotal study included 1434 COPD patients (greater than or equal to 40 years) using a DPI for maintenance therapy. PIF was measured with the In-Check DIAL G16, and sPIF was defined as a typical PIF lower than required for the device. Inhalation technique was assessed by standardised evaluation of video recordings and grouped into 10 steps. Patients completed the "Test of Adherence to Inhalers" questionnaire. HCRU was operationalised as COPD-related costs for primary healthcare, secondary healthcare, medication, and total COPD-related costs in a 1-year period. Results: Participants with sPIF had higher medication costs compared with those with optimal PIF (cost ratio CR: 1.07, 95% CI 1.01, 1.14). Multiple inhalation technique errors were associated with increased HCRU. Specifically, "insufficient inspiratory effort" with higher secondary healthcare costs (CR: 2.20, 95% CI 1.37, 3.54) and higher total COPD-related costs (CR: 1.16, 95% CI 1.03-1.31). "no breath-hold following the inhalation manoeuvre (<6 s)" with higher medication costs (CR: 1.08, 95% CI 1.02, 1.15) and total COPD-related costs (CR 1.17, 95% CI 1.07, 1.28), and "not breathing out calmly after inhalation" with higher medication costs (CR: 1.19, 95% CI 1.04, 1.37). Non-adherence was not significantly associated with HCRU. Conclusion: sPIF and inhalation technique errors were associated with higher COPD-related healthcare utilisation and costs in COPD patients on DPI maintenance therapy. Keywords: chronic obstructive pulmonary disease, Dry Powder Inhaler, health economics, cost analysis, healthcare resource utilisation
Over 1400 patients using dry powder inhalers (DPIs) to deliver COPD maintenance therapies were recruited across Europe and Australia. Their peak inspiratory flow (PIF) was measured, inhaler technique ...was observed, and adherence to treatment assessed. From relating the findings with patient health status, and thereby identifying critical errors, key clinical recommendations for primary care clinicians were determined, namely - measure PIF before prescribing a DPI to ensure inhalation manoeuvre ability is well-matched with the device. Some patients could benefit from inhalation training whereas others should have their DPI changed for one better suited to their inspiratory ability or alternatively be prescribed an active device (such as a soft mist inhaler or pressurized metered dose inhaler). Observing the inhalation technique was valuable however this misses suboptimal PIF (approaching one fourth of patients with a satisfactory observed manoeuvre had a suboptimal PIF for their DPI). Assess adherence as deliberate non-adherence can point to a mismatch between a patient and their inhaler (deliberate non-adherence was significantly associated with PIFs below the minimum for the DPI). In-person observation of inhalation technique was found to be inferior to video rating based on device-specific checklists. Where video assessments are not possible, observation training for healthcare professionals would therefore be valuable particularly to improve the ability to identify the critical errors associated with health status namely 'teeth and lips sealed around mouthpiece', 'breathe in' and 'breathing out calmly after inhalation'. However, it is recommended that observation alone should not replace PIF measurement in the DPI selection process.Trial registration: https://clinicaltrials.gov/ct2/show/NCT04532853 .
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