Journal of rehabilitation medicine impact factor 2014

Just two weeks of not using their legs causes young people to lose a third of their muscular strength, placing them on par with someone 40-50 years their senior, new research has found. A new study by The Center for Healthy Aging and the Department of Biomedical Sciences at the University of Copenhagen has shed fresh light on the dangers of not exercising. Many countries, including Switzerland, are confronted with increasing deficits in the health care sector.
A first cross-sectional measure of inappropriate hospital use was performed between 1 December 1994 and 28 February 1995 in a 1:2 sample of 500 patients admitted to the wards of the Department of Internal Medicine.
A more extensive search for the causes of inappropriateness through individual interviews with key informants involved in the functioning of the department and a quantitative as well as qualitative analysis of the activities performed in the department was conducted by a consulting team. These 14 processes were examined by a working group of 21 persons who either managed the Department of Internal Medicine or represented service providers (emergency room, radiology, home care, etc.).
Classification of processes of care according to their overall impact on inappropriate hospital use and their potential for improvement. The group determined that much of inappropriate hospital use was due to non-urgent admissions, which evaded triage by hospital physicians, and to unplanned admissions for elective treatments or investigations. This group identified several inefficiencies in the planning and transfer of the patient to the rehabilitation hospital. Modification of the transfer process between the wards of the Department of Internal Medicine and the rehabilitation hospital.
The intervention itself consisted of the implementation of the reorganized processes in the Department of Internal Medicine.
The main evaluation of the impact of the interventions was a before-and-after study of the proportion of inappropriate admissions and hospital days. The main analysis was a comparison of proportions of inappropriate admissions and hospitals days at baseline and at follow-up. Delays between emission of a transfer request form by an internal medicine ward and its receipt at the rehabilitation hospital, as well as delays between receipt of the request form and actual transfer, were compared before and after intervention. Only 498 admissions were included in the second appropriateness survey because information on two patients was duplicated.
The proportion of inappropriate admissions due to specific reasons did not differ between baseline and follow-up (chi-square test, P=0.2)(Table 2).
The proportion of inappropriate hospital days due to specific reasons was compared only for the days assessed by the reviewer who participated in both surveys (2736 days at baseline and 2982 days at follow-up) (Table 3). This study shows the results of a full quality improvement cycle that identified a dysfunction, attempted to correct the processes responsible for it, and evaluated the results of corrective interventions.
A substantial decrease in the number of inappropriate hospitalizations occurred after a phone line dedicated to plan elective admissions was made available to community physicians. Other studies reported interventions aimed at reducing inappropriate hospital use, such as introducing specific appropriateness criteria in patient charts [9] or providing informational feedback on appropriateness of hospital use to hospitals and physicians [10]. Finally, the sensitivity to change of the AEP, which would be its most important property for before-and-after studies remains unknown. The deceleration force between the trunk and the arm at ball impact and follow-through is up to 300 Nm.
The kinetic chain is the biomechanical system by which the body meets these inherent demands of tennis. Optimised physiology (muscle flexibility and strength and well-developed, efficient, task-specific motor patterns for muscle activation). Optimised mechanics (sequential generation of forces appropriately distributed across motions that result in the desired athletic function). Using integrated programmes of muscle activation to temporarily link multiple body segments into one functional segment (e.g. Maximising force development in the large muscles of the core and transferring it to the hand2.
Producing interactive moments at distal joints that develop more force and energy than the joint itself could develop and decrease the magnitude of the applied loads at the distal joint6. In the normally operating kinetic chain, the legs and trunk segments are the engine for force development and the stable proximal base for distal mobility.
The remaining kinetic chain segments play smaller roles in intrinsic force generation, mainly due to their smaller cross sectional area and the production of interactive moments. Efficient mechanics in the kinetic chain can be improved by decreasing the possible degrees of freedom (DOF) throughout the entire motion. The limited number of independent DOF are called nodes and represent key positions and motions in the overhead tasks2.
Tennis players with shoulder, elbow or wrist injuries have been shown to have a multitude of possible causative factors contributing to the presenting complaints of pain and decreased function, either by causing the anatomic injury or increasing the dysfunction from the injury. The examination of tennis players with shoulder symptoms should include evaluation of the proximal factors that may influence shoulder loading. The kinetic chain exam should include a screening evaluation of leg and core stability, observational evaluation for scapular dyskinesis and evaluation of various elements in the shoulder. Treatment should also involve a comprehensive approach, including restoration of all kinetic chain deficits, altered mechanics and functional joint stability. Optimal performance of the overhead throwing task requires precise mechanics that involve co-ordinated kinetic and kinematic chains to develop, transfer and regulate the forces the body needs to withstand the inherent demands of the task and to allow optimal performance. Observational analysis of the mechanics and pathomechanics using the node analysis method can be useful in highlighting areas of alteration that can be evaluated for anatomic injury or altered physiology. Researchers at the Kennedy Krieger Institute announced today the results of a pilot study demonstrating use of a virtual therapeutic sailing simulator as an important part of rehabilitation following a spinal cord injury (SCI). Published in the American Journal of Physical Medicine & Rehabilitation, findings show that using a hands-on sailing simulator over a 12-week period helped participants safely learn sailing skills in a controlled environment, ultimately improving their quality of life by gaining the ability to participate in a recreational sport. For many individuals living with paralysis, participation in recreational sports may seem impossible or even unimportant.
Study participants had chronic spinal cord injuries that occurred more than six months prior to beginning use of the Virtual Sailing VSail-Trainer, the first sailing simulator available for people with paralysis. Electronic sensors give the participant real-time feedback that matches their movements and allows them to control wind strength and water conditions.
During each session, a therapist assessed several physical and neurological indicators and compared the results to measurements taken prior to beginning the training program. All patients showed a significant positive increase in overall quality of life, including increased self-confidence and sense of accomplishment.
Following completion of the training program, all subjects were able to successfully sail and perform specific maneuvers on the water at a sailing center in Baltimore, Md.
The results of this study provide preliminary evidence that the use of the Virtual Sailing’s VSail-Training technology in a safe, controlled environment enables individuals with SCI to learn the skills required to sail on the water and can result in quality of life improvements. This pilot study involved only people with SCI; however, in principle this approach could be used with people with a wide range of injuries including loss of limbs and brain injury. SummaryThe ultimate goal of comprehensive rehabilitation in individuals with spinal cord injury (SCI) has shifted over time from an extension of their life expectancy to attainment of an optimal level of independent living and quality of life. As a baseline assessment before quality improvement interventions, the appropriateness of hospital use (admissions and hospital days) was evaluated using the Appropriateness Evaluation Protocol (AEP) in a sample of 500 patients (5665 days). Using the AEP as a criterion, the quality improvement interventions significantly reduced inappropriate hospital use due to the process of non-urgent admissions, but the reduction of inappropriate hospital days specifically attributed to the transfer to the rehabilitation hospital did not reach statistical significance.
In this context, eliminating inappropriate use of health services is one among several methods to satisfy financial constraints without compromising quality of care [1]. This approach led to the identification of 14 processes likely to generate inappropriate use of hospital services.
Their motivation consisted of attempting to reduce a waste of hospital resources, in the perspective of the introduction of a prospective payment system in Switzerland.
Both types of admissions represented patients sent to the hospital by community physicians.
As successive hospital days for the same patient are not independent observations, standard errors were estimated using methods for cluster surveys (in our study, each patient defined a cluster of hospital days) [7].
Data for this analysis were obtained from administrative files of the two treatment facilities. Type of admission and distribution of age groups differed between baseline and follow-up (Table ?). The 76 inappropriate admissions at baseline generated 938 hospital days, of which 51% (481) were inappropriate.
It is of note that the reduction in inappropriate hospital days in this sub-group was similar to the one in the whole sample (29% in 1994-1995 versus 25% in 1996-1997).
After the interventions, the proportion of inappropriate admissions sharply and significantly decreased, whereas the proportion of inappropriate hospital days decreased only a little, and not significantly. This favourable effect may be due either to more effective planning of in-hospital procedures, or to a transfer of some procedures to the outpatient sector. However, it must be recognized that a sharper reduction was unlikely, since only one discharge process was modified (i.e. Although generally successful in reducing inappropriate hospital use during the intervention periods, these studies were limited in their duration. We cannot rule out, for example, a prior trend to the reduction of in inappropriate admission and stays, or the possible existence of other concomitant changes that might have affected the results.
Firstly, we expected that the reduction of inappropriate hospital days would have been accompanied by shorter length of stay, but length of stay, if anything, increased. Even though the reliability of the AEP was satisfactory, an average kappa of 0.7 implies that 30% of the variance in AEP assessments resulted from random errors. We suggest that the AEP at least be supplemented by more specific outcome measures that directly measure the health care processes which have been modified (such as the delay between transfer request and actual transfer).
The appropriateness evaluation protocol: a technique for assessing unnecessary days of hospital care. The epidemiology of delays in a teaching hospital The development and use of a tool that detects unnecessary hospital days. Understanding the inherent demands placed on the body by the sport and how the body withstands these demands can help in evaluation, treatment and reduction of injuries.
Total arc of rotational motion (internal + external rotation) is between 160 and 180 degrees and the highest point of abduction is between 140 and 160 degrees5.
The number of strokes per match varies greatly, depending on the type of match, skill level, opponent and playing surface.
It generates the required forces and helps to regulate and modify loads seen at the joints, especially the high loads at the shoulder5.

This link develops 51 to 55% of the kinetic energy and force delivered to the hand, creates the back leg to front leg angular momentum to drive the arm forward and because of its high cross-sectional area, large mass and high moment of inertia, creates an anchor which allows centripetal motion to occur. In addition to generating force in the trunk and leg segments, kinetic chain activation through the core also generates force in the distal segments through the creation of interactive moments or forces generated at joints by the position and motion of adjacent segments. These key positions have been correlated with optimum force development and minimal applied loads and can be considered the most efficient methods of co-ordinating kinetic chain activation. It should be supplemented by a detailed examination of the areas highlighted by the symptoms or evaluation8 (Table 2). These chains have been evaluated and the basic components, called nodes, have been identified. The comprehensive kinetic chain exam can evaluate sites of kinetic chain breakage and a detailed shoulder exam can assess joint internal derangement of altered physiology that may contribute to the pathomechanics. An 8-Stage model for evaluating the tennis serve: implications for performance enhancement and injury prevention. Sequential motions of body segments in striking and throwing skills: description and explanations. Correlation of glenohumeral internal rotation deficit and total rotational motion to shoulder injuries in professional baseball pitchers. This study is one of the first to scientifically quantify the positive impact of therapeutic sailing following a spinal cord injury, including a significant increase in overall self-confidence and sense of accomplishment among participants. Albert Recio, study author and physician in the International Center for Spinal Cord Injury at Kennedy Krieger Institute. The stationary, motorized sailboat cockpit features specialized software that enables patients to navigate the boat around a virtual course in the same way as an actual sailboat in the water. Participants had no previous sailing experience and worked with the sailing simulator for one hour per week for 12 weeks. All participants completed a questionnaire at the beginning and end of the study designed to evaluate their quality of life and self-esteem. Of note, the subjects were able to participate in a sports activity with their respective family members and experienced a sense of optimism about the future. Look for the latest information to be posted on the website, with the highlights distributed Monday through Friday in the e-Newsletter. But for those who need your fix of the old Scuttlebutt, you can visit the old site, for a limited time. After World War II, the important influence of sport and exercise upon the course of rehabilitation following SCI was recognised. After modification of the two processes through a quality improvement program, inappropriate hospital use was reassessed in a sample of 498 patients (6095 days).
In an effort to reduce public expenses, the Geneva University Hospitals reduced their number of beds from 1450 to 1100 between 1994 and 1998; at the same time, the Department of Internal Medicine reduced its number of beds from 502 to 399. They ere linked to admission processes (elective admissions, semi-urgent admissions, admissions through the emergency room), specialized examinations (laboratory analyses, cardiological exams, radiological exams, endoscopies), specialized procedures (physiotherapy rehabilitation, radiotherapy), coordination with other serivices (specialized consultations, transfers between units of care), or to discharge processes (discharge towards home, home care planning, discharge to the rehabilitation hospital). Processes were rated on (I) overall impact on inappropriate hospital use and (ii) potential for improvement (Figure 1).
After involving these physicians in the search for practical solutions by means of a postal questionnaire, the working group implemented a telephone hotline. The original process (Figure 2,a) implied the intervention of at least five persons, and the transfer forms transited several times from one person to the other. A systematic 1:2 sample of admitted patients was enrolled until a sample size of 500 was reached. In contrast, distributions of the causes of inappropriateness (delay tool) differed markedly between the two reviewers, suggesting that observer bias influenced the identification of causes of inappropriateness. The design effect (ratio of true variance to navvvve variance, computed assuming independence between observations) exceeded six in both the baseline and follow-up sample, showing strong within-patient clustering.
The time requested to complete transfers before implementation of the new procedure (642 transfers between January and October 1995) was compared with data collected after implementation of the new transfer procedure (484 transfers between April and December 1996). At follow-up, inappropriate admissions (n=43) generated 540 hospital days, of which 53% (287) were inappropriate.
The proportion of inappropriate days in which delays from physicians were mentioned decreased significantly. Our goal was rather to permanently modify a standard procedure in order to minimize the need for reminders. However, since the selected processes were under full control of the Department of Internal Medicine and since the implementation of the correction was run only in the same department, we think that these potential biases did not substantially influence the results. This result is reminiscent of a previous report that inappropriate use of resources does not explain variations in resource use [11]. Such random errors may have contributed to obscure a small but real before-after difference.
The tennis serving motion is developed and regulated through a sequentially co-ordinated and task-specific kinetic chain of force development and a sequentially activated kinematic chain of body positions and motions1. Torques greater than 50 Nm are considered a significant and potentially injurious factor in loading of the upper extremity, so those inherent loads have the potential to create overload injury. At the shoulder, the interactive moment produced by trunk rotation around a vertical axis is the most important factor in generating forward arm motion and the interactive moment produced by trunk rotation around a horizontal axis from front to back is the most important factor in generating arm abduction.
The high velocities and forces seen at the shoulder are predominantly produced through kinetic chain activation.
Most models of maximum efficiency in body motions find that limiting DOF to about six to eight maximises the total force output and minimises effort and load.
There may be multiple individual variations in other parts of the kinetic chain, but these are the most basic and the ones required to be present in all motions. This type of examination can identify anatomic areas and mechanical motions that may be contributing to the symptoms and suggest areas for more detailed evaluation. This would include restoration of hip range of motion and leg strength, core stability and strength, scapular control, shoulder muscle flexibility and strength and glenohumeral rotation. Nonetheless, 5 decades later, there remains a lack of understanding of how an exercise programme can contribute to an improvement of quality of life among individuals with SCI.
The main goal of the telephone hotline was to provide community physicians with a medical respondent that would be a member of the Department of Internal Medicine, medically competent, and aware of the wards' occupancy rates. After process modification (Figure 2,b), the number of implied persons was reduced and the forms were transmitted only once to each person. As before, each admission and each hospital day were assessed using the AEP by trained abstractors.
Based on previous findings [3], possible confounders of the before-and-after comparison included patient characteristics (age, sex), and characteristics of hospital stay (appropriateness of admission, length of stay) and of hospital day (day of week, rank of each day, time remaining before discharge). The proportion of inappropriate days due to specialized consultation, as well as to transfer to a rehabilitation hospital decreased, although no significantly. Nevertheless, this process was selected because such transfers represented the third leading cause of inappropriate hospital days (important impact on appropriateness), and because the Department of Internal Medicine had a full control over its modification and could implement the modified process without the cooperation f other hospital departments (important potential for improvement). Indeed, since its opening, the telephone hotline has been increasingly used by community physicians (the number of calls received increased from 330 in 1996 to 878 in 2001). In addition, overall bed occupancy in the Department of Internal Medicine evolved from 80% during the baseline period to 83% during the follow-up period.
A possible explanation might be that some hospitalizations for investigations, which are usually short, were diverted to the ambulatory sector, thus inflating length of stay. Thus, when expected changes are small, more reliable instruments than the AEP may be necessary. Calvo, from Bossard Consulting, Barcelona, Spain for their help in the analysis of admission and transfer process. The kinematics of the tennis serve has been well described and may be broken down into phases2-4.
In junior tennis tournaments in scholastic or collegiate tennis, these numbers are larger because two to three matches may be played per day. The high muscle activations seen in the shoulder muscles are mainly directed towards co-contraction force couples to stabilise the joint. Surgery should address repairing joint structures to optimise the capability for functional stability1. In future, attention should be directed toward avoidance of secondary impairments, disabilities and handicaps. After two weeks of immobilisation, the participants bicycle-trained 3-4 times a week for six weeks, but although this helped return muscle mass, it was found that additional weight training is required to regain muscular strength. "Ita€™s interesting that inactivity causes such rapid loss of muscle mass, in fact ita€™ll take you three times the amount of time you were inactive to regain the muscle mass that youa€™ve lost,a€? said Martin Gram, PhD, another of the researchers. The baseline assessment has been published previously [2, 3]; this paper reports on the subsequent steps of the quality improvement cycle. The community physicians would therefore be able to discuss the necessity of the admission, and discuss with a colleague their views about investigation and treatment plans. The main reasons for inappropriate hospital days were determined using the delay tool [5, 6]. Adjustment for possible confounders was performed by means of logistic regression models, where standard errors were computed using robust methods that take lack of independence into account [8].
Inappropriate hospital days attributable to delays due to patients (for example a patient refusing to be transferred to another facility) increased between baseline and follow-up, but remained negligible in absolute terms.
This it is unlikely that changes in admission rates influenced inappropriate hospital use during the study period.
In addition, shorter length of stay has been shown to be poorly associated with the appropriateness of hospital use [12].
In addition, the validity of the AEP has been questioned, notably because it does not examine the appropriateness of medical procedures, such as the maintenance of an intravenous line, which can justify a day in hospital. These descriptions show how muscles can move the individual segments and show the temporal sequence of the motions.
This allows the shoulder to function in the kinetic chain primarily as a funnel, transferring the forces developed in the engine of the core to the delivery mechanism of the hand.
The World Health Organization model of disablement provides a suitable framework for addressing this issue.The most common benefits of exercise are biological in nature. The expected benefit for the community physicians was the ability to reach, at any time, a member of the hospital medical team; for the hospital physician, the telephone discussion was considered as a medical act. As each inappropriate hospital day could have several reasons for inappropriateness, we examined how many times a cause of inappropriateness was mentioned; therefore, the total number of possible causes exceeded the number of inappropriate hospital days.

The proportion of inappropriate hospital days generated by other causes remained unchanged. It should be added that in the canton, or province, of Geneva (380,000 inhabitants), there is only one large, 1100-bed community hospital, which is also the teaching University Hospital. The kinetics are not as well described but are important due to the forces and motions that are developed.
They target a reduction in secondary impairments (loss of cardiorespiratory, and muscular function, metabolic alterations and systemic dysfunctions).
Information was collected from patients' charts on the second day of their stay for appropriateness of admission, and twice a week thereafter for evaluation of hospital days.
Thus, we believe that the reorganization of the discharge process was effective, but that its effect was diluted among many other causes of days, which remained untouched. Other hospitals in the canton are private institutions, which take of patients with special insurance coverage (private insurance); thus, these institutions do not share a patient population with the Geneva University Hospitals, which means that no patient shift to or from the University Hospitals can have accounted for the changes observed during the study period. Waldvogel, Chairman of the Department of Internal Medicine, Geneva University Hospitals, for their help and support. These forces and motions are applied to all of the body segments to allow their summation, regulation and transfer throughout the segments to result in performance of the task of throwing or hitting the ball.
This in turn could minimise the development of disabilities and the appearance of such handicaps as loss of mobility, physical dependence and poor social integration.
It is also possible that improvement of selected hospitalization processes may cause or reveal inefficiencies elsewhere, such that the final proportion of inappropriate hospital days does not vary, which is what an improvement cycle is about. A lack of physical fitness for specific tasks can be a serious obstacle to autonomy following SCI.
For instance, we do not know whether the increase of inappropriate hospital days attributed to the patient was related or not to the more efficient discharge process.
Alteration in the sequential activation, mobilisation and stabilisation of the body segments commonly occurs in association with sport dysfunction; either decreased performance or injury. In a very short period of time, physical deconditioning can significantly decrease quality of life in individuals with SCI, ultimately placing them in a state of complete dependency.Quality of life is closely associated with independent living and, increasingly, it is a key outcome when measuring the success of rehabilitation. Some things have an impact, some have less impact than expected but suggest areas for future improvement. Other processes, such as scheduling diagnostic procedures or discharge processes other than to the rehabilitation hospital, were generating inappropriate hospital use.
However, since several other departments had to be involved in their modification, they were more difficult to work on. Potential for their improvement existed nevertheless, but the level of intervention had to evolve from an intra-departmental to an inter-departmental one.
Possibility of repair and of return of function after a partial or a complete division of spinal cord in man and animals. The rehabilitation of patients totally paralysed below the waist, with special reference to making them ambulatory and capable of earning their own living: an end result of 445 cases.
Subjective well-being: implications for medical rehabilitation outcomes and models of disablement. Relationship of life satisfaction to impairment, disability and handicap among persons with spinal cord injury living in the community.
Relationship between effective coping and perceived quality of life in spinal cord injured patients.
Mortality, morbidity and psychosocial outcomes of persons spinal cord injured more than 20 years ago. The arthritis impact measurement scales: further investigation of a health status instrument. Quality of life among aging spinal cord injured persons: long term rehabilitation outcomes. Quality of life after after spinal cord injury: a literature critique and meta-analysis (1983a€“1992). Prescriptive arm ergometry to optimize muscular endurance in acutely injured paraplegic patients. Comparison of physiological responses to maximal arm exercise among able-bodied, paraplegics and quadriplegics.
Physical endurance capacity, functional status and medical complications in spinal cord injured subjects with long-standing lesions. Exercise capacity of untrained spinal cord injured individuals and the relationship of peak oxygen uptake to level of injury. Relationship of impairment and functional ability to habitual activity and fitness following spinal cord injury.
Cardiorespiratory and muscular fitness in a group of individuals with SCI: a distribution according to the classification of ISMGF [abstract]. Physiological response to maximal exercise on arm cranking and wheelchair ergometer with paraplegics. Control of medical rehabilitation of para and tetraplegics by repeated evaluation of endurance capacity.
Cardiac effects of short term arm crank training in paraplegics: echocardiographic evidence. The use of functional electrical stimulation for rehabilitation of spinal cord injured patients. Lower limb endurance exercise after spinal cord injury: implications for health and functional ambulation. Physiologie responses to prolonged electrically stimulated leg-cycle exercise in the spinal cord injured. Acute hemodynamic response of spinal cord injured individuals to functional neuromuscular stimulation-induced knee extension exercise. Functional electrical stimulation leg cycle ergometer exercise: training effects on cardiorespiratory responses of spinal cord injured subjects at rest and during submaximal exercise. The effect of training on endurance and the cardiovascular responses of individuals with paraplegia during dynamic exercise induced by functional electrical stimulation. Aerobic training effect of electrically induced lower extremity exercises in spinal cord injured people. Metabolic and hemodynamic responses to concurrent voluntary arm crank and electrical stimulation leg cycle exercise in quadriplegics. Improved pulmonary function in chronic quadriplegics after pulmonary therapy and arm ergometry.
A comparative study of the muscle strength and mass of the arm flexors and extensors in paraplegic and in non paraplegic basketball players. Muscle fiber type characteristics of M deltoideus in wheelchair athletes: comparison with other trained athletes. Relationship of type of training to maximum oxygen uptake and upper limb strength in male paraplegic athletes. Physical work capacity and the effect of training on subjects with long-standing paraplegia.
Clinical evaluation of computerized functional electrical stimulation after spinal cord injury: a muticenter pilot study.
Musculoskeletal responses of spinal cord injured individuals to functional neuromuscular stimulation-induced knee extension exercise training.
Energy expenditure after spinal cord injury: an evaluation of stable rehabilitating patients. Depressed serum high density lipoprotein cholesterol levels in veterans with spinal cord injury. Coronary artery disease: metabolic risk factors and latent disease in individuals with paraplegia. The serum lipoprotein profile in veterans with paraplegia: the relationship to nutritional factors and body mass index.
High density lipoprotein cholesterol concentrations in physically active and sedentary spinal cord injured patients. Activity in the spinal cord injured patient: an epidemiologic analysis of metabolic parameters.
Effect of a vigorous walking program on body composition and carbohydrate and lipid metabolism of obese young men.
Training-induced changes in glucose regulation during prolonged exercise in persons with quadriplegia [dissertation]. Energy cost of propelling a wheelchair at various speed: cardiac responses and effect of steering accuracy.
Metabolism and pulse rate in physically handicapped when propelling a wheelchair up an incline.
Energy expenditure in patients with low-, mid-, or high thoracic paraplegia using Scott-Craig knee-anke-foot orthoses.
Relationship between physical capacity and physical strain during standardized ADL tasks in men with spinal cord injuries. Psychological adjustment to spinal cord injury: incidence of denial, depression and anxiety.
Relationship between cognitive activity and adjustment in four spinal cord injured individuals: a longitudinal investigation.
Ameta-analysis on the anxiety-reducing effects of acute and chronic exercise: outcome and mechanisms. A comparison of the psychological characteristics of male and female able-bodied and wheelchair athletes.
A comparison between the psychological profiles of wheelchair athletes, wheelchair non-athletes and able-bodied athletes. Benefits of sport and physical activity for the disabled: Implications for the individual and for society. Vocational ajustment, interests, work values and career plans of persons with spinal cord injuries.

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