6. Pas de moyens de transport accessibles

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7. Pas de moyens financiers

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8. Pas de raisons de sortir

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16. Circulation sur les trottoirs. Sept difficultés rencontrées sur les trottoirs ou à proximité ont été identifiées. Evaluez sur une échelle de 0 à 10 la gène occasionnée par chacune de ces difficultés lors de vos déplacements (0 : aucune influence ; 10 : influence maximale).

1. Largeur du trottoir

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2. Hauteur du trottoir / absence de bateaux

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3. Pente

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4. Dévers

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5. Revêtement du sol (pavés, graviers, trous...)

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6. Obstacles fixes (poteaux, parcmètres...)

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7. Obstacles mobiles (deux roues, voitures...)

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17. Commentaires. Si vous avez des commentaires, n'hésitez pas à m'en faire part.

Merci pour le temps consacré à ce questionnaire
Annexe 2. Courrier joint au questionnaire (étude 1)

PIERRET Benoît
Institut National de Recherche et de Sécurité
Laboratoire de Physiologie du Travail
Avenue de Bourgogne, BP n°27
54501 Vandoeuvre cedex
Tél.: 03-83-50-85-46
E-mail : benoit.pierret@inrs.fr

<figure><img src="image_322.png" /></figure>

Nancy, le 26 mars 2008

**Objet** : Etude sur les déplacements des personnes en fauteuil roulant

Madame, Mademoiselle, Monsieur,

Etudiant en Doctorat à la Faculté de Médecine de Nancy, je m'intéresse à l'insertion professionnelle des personnes en fauteuil roulant, étant moi-même paraplégique. Mon travail est co-dirigé par les médecins du Centre de Réadaptation de Lay Saint-Christophe - Institut Régional de Réadaptation et par le Dr Meyer de l'INRS.

Conscient des difficultés de locomotion des personnes à mobilité réduite, j'ai souhaité orienter ma thèse sur les déplacements des personnes en fauteuil roulant.

Avant de mener des études plus précises dans le cadre de mon travail de thèse, il est nécessaire que je connaisse, de la façon la plus complète possible, l'ensemble des difficultés que peuvent rencontrer les personnes en fauteuil roulant.

L'objectif de ce questionnaire est de **connaître** et de **prendre en considération votre avis !**

**Votre collaboration est donc essentielle** au bon déroulement de ce projet.

Le questionnaire est bien sûr anonyme. Pour vous faciliter son renvoi, une enveloppe affranchie et libellée à mes coordonnées est jointe à ce courrier.

Pour celles et ceux qui préfèrent compléter ce questionnaire à partir de leur ordinateur, une version informatique est disponible sur la page suivante : http://pierretbenoit1.free.fr

Merci de consacrer quelques minutes pour y répondre...

Comptant sur votre coopération et restant à votre entière disposition pour toute information complémentaire, veuillez agréer, Madame, Mademoiselle, Monsieur, l'expression de mes salutations respectueuses.

Dr L. Le Chapelain
Pr J. Paysant

<figure><img src="image_323.png" /></figure>

Dr JP. Meyer
B. Pierret

<figure><img src="image_324.png" /></figure>
# Annexe 3. Lettre d'information destinée au sujet (étude 2)

## LETTRE D'INFORMATION AU SUJET

Lisez attentivement cette notice et posez toutes les questions qui vous sembleront utiles.
Vous pourrez alors décider si vous voulez participer ou non à cette recherche.

### Effets du dévers sur les performances fonctionnelles
de salariés en fauteuil roulant manuel

**Nom du promoteur:** Institut Régional de Médecine Physique et de Réadaptation (Pr. Paysant)

**Adresse du promoteur:** 75 Boulevard Lobau - CS 34209
54042 Nancy Cedex

**Lieu d'expérimentation :** Institut National de Recherche et de Sécurité – Centre de Lorraine
Laboratoire de Physiologie du Travail
Rue du Morvan – CS 60027
54519 Vandoeuvre Cedex

(Contact : Benoit Pierret, mail : benoit.pierret@inrs.fr, tél : 03 83 50 85 46)

Madame, Mademoiselle, Monsieur,

Monsieur Benoit Pierret, associé au Professeur Jean Paysant et au Docteur Jean-Pierre Meyer (médecin investigateur), vous propose de participer à une étude qui a pour objectif d'évaluer l'influence du dévers sur les personnes en fauteuil roulant manuel afin de mettre en évidence les difficultés émanant de cette contrainte. Le dévers étant une inclinaison du terrain, perpendiculaire au sens de circulation piétonne, qui pose problème aux usagers de fauteuil roulant.

Les tests auront lieu au centre de Lorraine de l'INRS à Vandoeuvre-les-Nancy, au sein du laboratoire de Physiologie du Travail. La réalisation de ces tests requiert votre présence pendant une journée et demie. Ces tests présentent peu de risque, cependant le risque de chute ne peut pas être exclu. Afin de le limiter, les sujets seront accompagnés par un expérimentateur à pied.

- Au cours de la première demi-journée, vous passerez un examen médical avant d'effectuer un test mesurant vos capacités cardio-respiratoires. Ce test, précédé d'un interrogatoire, permettra de contrôler si vous présentez une éventuelle contre-indication à cette expérimentation.

- Lors de la seconde journée, 2 jours plus tard au minimum et selon vos disponibilités, vous réaliserez un test qui consiste à vous déplacer avec votre fauteuil sur une surface plane ou en dévers. Ce test sera effectué sur une piste. Vous devrez parcourir 300 mètres à votre vitesse (vitesse de confort) et 300 mètres à vitesse imposée (3,5 km.h⁻¹) pour 4 inclinaisons de piste différentes (0, 2, 8 et 12 %). Au total, vous parcourrez 2400 mètres (300 „mètres” x 2 „vitesses” x 4 „inclinaisons”). Après chaque parcours de 300 m, vous disposerez d'une période de repos. Votre fréquence cardiaque sera enregistrée en continu sur l'ensemble de la journée. Pendant les tests, pour mesurer votre dépense énergétique, vous respirerez à travers un masque qui permet de recueillir les échanges respiratoires. Votre activité musculaire sera recueillie au moyen d'électrodes collées sur votre peau en regard des muscles investigués. A la fin de chaque parcours, vous évaluerez le degré de pénibilité de l'effort que vous avez réalisé à l'aide d'une échelle d'évaluation subjective de l'astreinte physique (échelle de Borg).
Votre affiliation à un régime de sécurité sociale sera vérifiée. Vous percevrez une indemnité en compensation des contraintes subies, selon le tarif horaire en vigueur à l'INRS.

L'ensemble des informations recueillies sont confidentielles, couvertes par le secret médical. Après l'expérimentation votre participation sera enregistrée dans le fichier national des personnes qui se prêtent à des recherches biomédicales sans bénéfice individuel direct. Vous aurez la possibilité de vérifier l'exactitude et de rectifier les données informatisées vous concernant dans ce fichier, auprès du titulaire de l'autorisation de lieu de recherche (Mr. Berthet, responsable du département Homme au Travail à l'INRS) ou du Ministère chargé de la santé. Ces données sont détruites au terme d'un délai défini dans le Code de Santé Publique (R.1124-7). Conformément à la loi Huriet, un contrat d'assurance a été souscrit par le promoteur. Enfin, le fait de participer à cette expérimentation impose que vous ne soyez soumis à aucune expérimentation autre dans la période des 10 jours qui précèdent la première demi-journée expérimentale et la deuxième journée expérimentale. A l'issue de cette étude, vous serez informé des résultats globaux de la recherche en en faisant la demande au médecin investigateur principal, le Professeur Jean Paysant, par e-mail : paysant@irr.u-nancy.fr. Ce protocole a reçu un avis favorable de la part du Comité de Protection des Personnes (CPP EST-III) et de l'Autorité compétente (Agence Française de Sécurité Sanitaire des Produits de Santé).

Vous pourrez quitter l'étude à tout moment si vous le souhaitez. N'hésitez pas à nous questionner, nous répondrons jusqu'à satisfaction de votre curiosité. Si vous rencontrez des problèmes (musculaires, cardio-respiratoires ou autres), pendant ou après l'expérimentation, vous pourrez contacter le médecin investigateur, le Docteur Jean-Pierre Meyer, au 03.83.50.20.54. ou par e-mail : meyer@inrs.fr. Nous sommes à votre disposition pour que vous abordiez cette étude le plus sereinement possible.
Annexe 4. Formulaire de consentement destiné au sujet (étude 2)

FORMULAIRE DE CONSENTEMENT

Effets du dévers sur les performances fonctionnelles
de salariés en fauteuil roulant manuel

Etude promue par l'Institut Régional de Médecine Physique et de Réadaptation (Prof J. Paysant) et menée au laboratoire de physiologie du travail de l'Institut National de Recherche et de Sécurité (B. Pierret, Dr J-P. Meyer)

Les détails de cette étude sont fournis dans la lettre d'informations qui vous a été remise.

Lisez le attentivement et posez toutes les questions qui vous sembleront utiles.

Si vous acceptez de participer à cette étude, veuillez compléter le formulaire ci-dessous.

Nom, Prénom et adresse :

Je soussigné Monsieur.................................................... (nom complet en lettres capitales) déclare avoir pris connaissance du document d'information sur la recherche biomédicale, en être possesseur, et avoir compris le but et les modalités de cette étude.

J'ai bien compris qu'il s'agit d'une étude sans bénéfice individuel direct.

Si j'accepte d'y participer, ma participation sera enregistrée dans le fichier national des personnes se prêtant à des recherches biomédicales sans bénéfice individuel direct. J'aurai la possibilité de vérifier, auprès du titulaire de l'autorisation du lieu de recherche (Mr M. Berthet) ou du Ministère chargé de la santé, l'exactitude des données me concernant, et la destruction de ces données au terme d'un délai défini dans le Code de Santé Publique (R.1124-7). Je ne pourrai participer à aucune autre recherche sans bénéfice individuel direct pendant la période qui couvre les 10 jours précédant ma première expérimentation et le jour de la dernière expérimentation.

J'ai été informé qu'un contrat d'assurance avait été souscrit par le promoteur de la recherche.

J'ai également été informé que le Comité de Protection des Personnes (CPP EST III) a rendu
un avis favorable pour la réalisation de cette étude.

A l'issue de la recherche, je serai informé des résultats globaux de cette recherche.

En conséquence, je donne mon consentement pour participer à cette recherche dans les conditions précisées dans le formulaire d'information.

Je demeure libre de quitter l'étude à tout moment.

<table><tr><td>Date :</td><td>Date :</td></tr><tr><td>SIGNATURE DU SUJET</td><td>SIGNATURE DE L'INVESTIGATEUR</td></tr></table>

Fait en 3 exemplaires dont 1 sera conservé par l'investigateur, 1 remis au sujet, 1 conservé par
le promoteur.
Annexe 5. Avis du Comité de Protection des Personnes (CPP) Est III (étude 2)

COMITÉ de PROTECTION des PERSONNES EST-III

Hôpital de Brabois. Rue du Morvan - 54511 VANDŒUVRE-LES-NANCY Cedex

Téléphone : 03 83 15 43 24 - Télécopie : 03.59.62.06.02 - Courriel : cppest.3@chu-nancy.fr

Nancy, le jeudi 9 juillet 2009

Monsieur le Pr Paysant
Institut Régional de Réadaptation
75 bd Lobau
54 042 NANCY cedex

Projet de recherche enregistré
sous les références
N° : 2009-A00447-50
N° CPP : 09.06.03

Monsieur et Cher Confrère,

Je vous prie de bien vouloir trouver ci-joint l'avis du Comité concernant les modifications apportées au protocole intitulé :

Effets du dévers sur les performances fonctionnelles de salariés en fauteuil roulant manuel.

Veuillez agréer, Monsieur et Cher Confrère, l'assurance de ma sincère considération.

Le Président

<figure><img src="image_325.png" /></figure>
COMITÉ de PROTECTION des PERSONNES EST-III

Hôpital de Brabois. Rue du Morvan - 54511 VANDŒUVRE-LES-NANCY Cedex

Téléphone : 03 83 15 43 24 - Télécopie : 03.59 62.06.02 - Courriel : cppest.3@chu-nancy.fr

Projet de recherche enregistré
sous les références
N° : 2009-A00447-50
N° CPP : 09.06.03

Le Comité a été saisi le 16 juin 2009 par Monsieur le Professeur Paysant, investigateur principal de l'étude représentant l'Institut Régional de Réadaptation de Nancy, promoteur, pour l'examen des modifications apportées au protocole intitulé :

Effets du dévers sur les performances fonctionnelles de salariés en fauteuil roulant manuel.

Le Comité a examiné ces modifications lors de sa séance du 07 juillet 2009 suite à une première lecture le 02 juin 2009. Ont participé aux délibérations :

- les membres du Collège n° 1 : M. le Docteur Peton (Titulaire, cat. 1), M. le Docteur Lamaze (Suppléant, cat. 1), Mr le Docteur Robert (Titulaire, qualifiée en raison de sa compétence en matière de biostatistique), M. le Docteur Fenot (Titulaire, cat. 2), Mme Picaut (Titulaire, cat. 3), Mme Léonard (Titulaire, cat.4), Mr le Dr Beau (Titulaire, cat.1)

- les membres du Collège n° 2 : Mme Boutet (Suppléante, cat. 5), Mme Batt (Titulaire, cat.7), Mr le Pr Ducrocq (Suppléant, cat. 5), M. Vidal (Titulaire, cat. 9), Mr Pilon (Titulaire, cat.9), Mr Vouaux (Titulaire, cat. 8), Mme Claudot (Titulaire, cat.8), Mr Vauthier (Suppléant, cat.8), Mme François (Suppléante, cat.5), Mme List (Suppléante, cat. 6), Mme Blondelet (Titulaire, cat. 6)

Le Comité a adopté la délibération suivante : AVIS FAVORABLE pour :

- Le protocole : version 2 du 11 juin 2009

- Le résumé : version 2 du 11 juin 2009

- Le document additionnel : version 2 du 11 juin 2009

- La note d'information : version 2 du 11 juin 2009

- Le formulaire de consentement : version 2 du 11 juin 2009

Nancy, le jeudi 9 juillet 2009

Le Président

<figure><img src="image_326.png" /></figure>

Docteur P. PETON
Annexe 6. Avis de l'agence française de sécurité sanitaire des produits de santé
(AFSSAPS) (étude 2)

Fax émis par : 33155873642

AFSSAPS U.E.C.

22-07-09 17:46

Pg: 1/1

<figure><img src="image_327.png" /></figure>

Agence française de sécurité sanitaire
des produits de santé

AUTORISATION D'ESSAI CLINIQUE NE PORTANT
PAS SUR UN PRODUIT DE SANTE (ESSAI-HPS)

Nombre de pages : 1

(Incluant la page de garde)

Envoi par Télécopie

Date : 22 JULI 2009

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Titre Effets du dévers sur les performances fonctionnelles de salariés en fauteuil roulant manuel (FRM)

Promoteur Institut Régional de médecine physique et de Réadaptation (IRR)

Réf. CPP

Réf. Promoteur IRR-INRS 2009-1

N° ID RCB

2009-A00447-50

Réf. Afssaps

B90866-60

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AFSSAPS / DEMED / Département de révaluation des essais cliniques et des médicaments à statut particulier

Unité essais cliniques médicaments et hors produits de santé

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tél : 33 (0) 1 55 87 36 41 / Fax : 33 (0) 1 55 87 36 42

Destinataire (demandeur : nom / société / tél.)

Pr. Jean PAYSANT

Institut Régional de médecine physique et de
Réadaptation

03 83 52 67 50

Fax 03 83 52 67 79

CPP destinataire en copie

Est III (Nancy)

Fax 03.83.15.43.05

Code 24

Vu le code de la santé publique et notamment ses articles L. 1123-8, R. 1123-32 et vu le dossier de demande d'autorisation d'essai clinique adressé à l'Agence française de sécurité sanitaire des produits de santé (Afssaps),

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décision.

Toutefois, conformément à l'article R. 1123-33 du code de la santé publique, la présente autorisation devient caduque
si la recherche n'a pas débuté dans un délai d'un an.

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Dr C. BELORGEY BISMUT
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et des Médicaments à Statut Particulier

22 JULI 2009

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Annexe 7. Formulaire de l'examen médical (étude 2)

CERTIFICAT DE VISITE MEDICALE

Expérimentation relative à :

Effets du dévers sur les performances fonctionnelles
de salariés en fauteuil roulant manuel

Je soussigné, ...................................., docteur en médecine, certifie
avoir examiné ce jour Melle, Mme, M .................................... qui ne
présente pas de contre-indication à l'exposition aux conditions de l'étude précitée.

L'expérimentation se déroule au Laboratoire de Physiologie du Travail
Rue du morvan, CS 60027, 54519 Vandoeuvre Cedex

Vandoeuvre, le ....................

Signature
## 2ème visite (1 journée)

Date : ....../....../ 2010

Température matin (°C) : ....................................

Hygrométrie matin (%) : ....................................

Température après-midi (°C) : ....................................

Hygrométrie après-midi (%) : ....................................

### Tests de force maximale

<table><thead><tr><th rowspan="2"></th><th colspan="2">Côté droit</th><th colspan="2">Côté gauche</th></tr><tr><th>essai 1</th><th>essai 2</th><th>essai 1</th><th>essai 2</th></tr></thead><tbody><tr><td>Extenseur radial du carpe</td><td></td><td></td><td></td><td></td></tr><tr><td>Biceps</td><td></td><td></td><td></td><td></td></tr><tr><td>Triceps</td><td></td><td></td><td></td><td></td></tr><tr><td>Deltoïde antérieur</td><td></td><td></td><td></td><td></td></tr><tr><td>Deltoïde postérieur</td><td></td><td></td><td></td><td></td></tr><tr><td>Trapèze</td><td></td><td></td><td></td><td></td></tr><tr><td>Grand pectoral</td><td></td><td></td><td></td><td></td></tr><tr><td>Grand dorsal</td><td></td><td></td><td></td><td></td></tr></tbody></table>

### Fmax : 'triceps' du bras sollicité (avant chaque dévers)

<table><tr><td></td><td>D2</td><td>D3</td><td>D4</td><td>D5</td><td>D6</td><td>D7</td><td>D8</td></tr><tr><td>Essai 1</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Essai 2</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr></table>

### Tests sur piste

Ordre et horaires de passage (0, 2, 8 ou 12 pour les dévers ; VL : vitesse libre ; VI : vitesse imposée)

<table><tr><td>1 : ............../............</td><td>2 : ............../............</td><td>3 : ............../............</td><td>4 : ............../............</td></tr><tr><td>5 : ............../............</td><td>6 : ............../............</td><td>7 : ............../............</td><td>8 : ............../............</td></tr></table>

### Vitesse de déplacement libre

<table><thead><tr><th rowspan="2"></th><th rowspan="2"></th><th colspan="4">Dévers (%)</th></tr><tr><th>0</th><th>2</th><th>8</th><th>12</th></tr></thead><tbody><tr><td rowspan="5">Perception de l'effort (échelle RPE de Borg)</td><td>Avant-bras-Main D</td><td></td><td></td><td></td><td></td></tr><tr><td>Avant-bras-Main G</td><td></td><td></td><td></td><td></td></tr><tr><td>Bras-Epaule D</td><td></td><td></td><td></td><td></td></tr><tr><td>Bras-Epaule G</td><td></td><td></td><td></td><td></td></tr><tr><td>Dos</td><td></td><td></td><td></td><td></td></tr><tr><td></td><td>Général</td><td></td><td></td><td></td><td></td></tr></tbody></table>
• Vitesse de déplacement imposée : 0,97 m.s⁻¹

<table><thead><tr><th rowspan="2"></th><th rowspan="2"></th><th colspan="4">Dévers (%)</th></tr><tr><th>0</th><th>2</th><th>8</th><th>12</th></tr></thead><tbody><tr><td rowspan="6">Perception de l'effort<br>(échelle RPE de Borg)</td><td>Avant-bras-Main D</td><td></td><td></td><td></td><td></td></tr><tr><td>Avant-bras-Main G</td><td></td><td></td><td></td><td></td></tr><tr><td>Bras-Epaule D</td><td></td><td></td><td></td><td></td></tr><tr><td>Bras-Epaule G</td><td></td><td></td><td></td><td></td></tr><tr><td>Dos</td><td></td><td></td><td></td><td></td></tr><tr><td>Général</td><td></td><td></td><td></td><td></td></tr></tbody></table>

→ Remarques

Sujet

Nous
VIII. Liste des publications et des communications
Revues internationales à comité de lecture

Pierret B<sup>a,b,c</sup>, Desbrosses K<sup>a</sup>, Paysant J<sup>b</sup>, Meyer JP<sup>a</sup>. Cardio-respiratory and subjective strains sustained by paraplegics subjects when travelling on a cross slope in a manual wheelchair. Appl Ergon (Soumis).

Pierret B, Desbrosses K, Paysant J, Meyer JP. Cross slope travelling in a wheelchair and paraplegics strains. Arch Phys Med Rehabil (Prochainement soumis).

Pierret B, Desbrosses K, Paysant J, Meyer JP. Muscular strains of wheelchair travelling on a cross slope. J Electromyogr Kinesiol (Prochainement soumis).

Pierret B, Desbrosses K, Paysant J, Meyer JP. Submaximal cranking test of paraplegics subjects. Arch Phys Med Rehabil (Prochainement soumis).

Conférences nationales à comité de lecture

Pierret B, Desbrosses K, Meyer JP, Paysant J. Effets du dévers sur les astreintes cardio-respiratoires de sujets paraplégiques en fauteuil roulant manuel. 27<sup>ème</sup> congrès de la société française de médecine physique et de réadaptation (SOFMER). Toulouse. 2012.

Pierret B, Desbrosses K, Meyer JP, Paysant J. Astreintes du dévers chez une population de sujets paraplégiques en fauteuil roulant manuel : analyse EMG. 27<sup>ème</sup> congrès de la société française de médecine physique et de réadaptation (SOFMER). Toulouse. 2012.

Pierret B, Meyer JP, Paysant J. Les déplacements chez une population de sujets paraplégiques. 24<sup>ème</sup> congrès de la société française de médecine physique et de réadaptation (SOFMER). Lyon. 2009.

<footnote><sup>a</sup> Institut National de Recherche et de Sécurité (INRS)</footnote>

<footnote><sup>b</sup> Institut Régional de médecine physique et de Réadaptation (IRR)</footnote>

<footnote><sup>c</sup> Centre de Ressources, d'Expertise et de Performance Sportives (CREPS) de Lorraine</footnote>
## Article soumis à ‘Applied Ergonomics’

# Cardio-respiratory and subjective strains sustained by paraplegic subjects, when travelling on a cross slope in a Manual Wheelchair (MWC)

Benoît Pierret<sup>a,b,c</sup>, Kévin Desbrosses<sup>a</sup>, Jean Paysant<sup>b</sup>, Jean-Pierre Meyer<sup>a</sup>.

### Corresponding author:

Jean-Pierre Meyer
INRS, 1 rue du Morvan, 54519,
Vandœuvre-lès-Nancy, France

Tél : 03.83.50.20.54
meyer@inrs.fr

Fax : 03.83.50.21.85

### Highlights:

- Strains of MWC displacements increase significantly and linearly with cross slope

- Subjective evaluation of paraplegics underestimate strains and can induce over exertion

- Injury level is a strong determinant of displacement strains and strategy

- Measures and models show that a 2% cross slope can be an efficient limit for the less fit MWC users

<footnote><sup>a</sup> Institut National de Recherche et de Sécurité, Vandœuvre-lès-Nancy cedex, 54519, 1 rue du Morvan, CS 60027, France. (kevin.desbrosses@inrs.fr; meyer@inrs.fr)</footnote>

<footnote><sup>b</sup> Institut Régional de médecine physique et de Réadaptation, Nancy cedex, 54042, 75 boulevard Lobau, CS 34209, France. (jean.paysant@ugecamne.fr)</footnote>

<footnote><sup>c</sup> Centre de Ressources, d'Expertise et de Performance Sportives, Essey-lès-Nancy, 54271, 1 avenue Foch, BP 30020, France. (benoit.pierret@yahoo.fr)</footnote>
**Abstract**

**Aim.** Quantify cardiac, energetic and subjective strains during manual wheelchair (MWC) travel on cross slopes (Cs).

**Methods.** 25 paraplegics achieved height 300 m propulsion tests combining 4 Cs (0, 2, 8 and 12%) and 2 velocities (Vi = 0.97 m.s⁻¹, Vc "comfortable"). Heart rate and oxygen uptake were recorded continuously. Subjective rating (RPE) was made on completion of each test.

**Results.** Cardiac, energetic and subjective strains are the same (p>0.5) for 0% and 2% Cs. Vc exceeds Vi for all Cs. Cardiac and energetic strains at Vc also exceed those at Vi (p<0.01). Mean cardiac cost (in bpm) at Vc is 34 (SD = 13) bpm for a 0/2% and 55 (18) bpm for a 12% Cs. Mean energetic cost (in J.m⁻¹.kg⁻¹) is 1.20 (0.38) and 2.76 (0.97) for 0/2% and 12% Cs at Vi and, at Vc, 1.50 (0.43) and 3.37 (1.43) for 0/2% and 12% Cs respectively. Subjective rating was considered as moderate for a 12% Cs. MWC users with high level injuries travel faster as those with low level injuries.

**Conclusion.** Strain increase is linear for Cs from 0% to 12%. The results suggest that 2% Cs is generally acceptable, while 8% would be a critical threshold.

Keywords: Wheelchair, Cross Slope, Strains.
# 1. Introduction

In France, nearly 200,000 disabled persons use a manual wheelchair (MWC) and live at home (Vignier et al., 2008). Travelling difficulties are one of the determining factors in non-integration or occupational exclusion of persons in MWC (Lidal et al., 2007; Van Velzen et al., 2009). Environmental unsuitability amplifies a MWC's initial constraints and requires greater cardio-respiratory and muscular exertion on behalf of persons in relation to their physiological capacities (Collins et al., 2010; Hurd et al., 2008; Meyers et al., 2002). Although the peak oxygen uptakes of MWC sportsmen may exceed 35 $ml.kg^{-1}.min^{-1}$ (Bhambhani, 2002; Haisma et al., 2006; Huonker et al., 1998; Van der Woude et al., 2001), these capacities are less than 20, even $15 \cdot ml.kg^{-1}.min^{-1}$ for many users (Figoni, 1984; Haisma et al., 2006; Tahamont et al., 1986). Additional constraints like cross slope can thus degrade MWC user social life and state of health by increasing musculo-skeletal disorders (Burnham et al., 1994; Mercer et al., 2006; Van Drongelen et al., 2006). A 2% cross slope limit is regulatory in many countries (McMillen et al., 1999), but this may not always be respected. Furthermore, no result really prompts justification of this 2% established cross slope limit.

Cross slope causes gyratory action of the chair's front wheels, which generate a force that tends to pull the "subject-wheelchair" combination to the lower side and requires users to fight against this force in order to keep a straight course (Cooper, 1990; Van der Woude et al., 2001). However, few studies have focused on MWC movements on a cross slope. A recent review by Cooper et al. (2011) only lists five such studies. Three were mainly directed towards the biomechanical aspects of wheelchair propulsion (Brubaker et al., 1986; Chesney and Axelson, 1996; Richter et al., 2007). The other two addressed the problems of travelling on varied surfaces, some with a cross slope, experienced by populations suffering from various pathologies (Longmuir et al., 2003; Kockelman et al., 2001). Only the Brubaker et al. (1986) and the Kockelman et al. (2001) studies included physiological measurements. Despite the disparity in these studies an overview reveals that cross slope limits of between 16 and 20% for short distances (Chesney and Axelson, 1996) and for longer journeys, a 4% cross slope is acceptable for all users and a more critical 10% limit should never be exceeded (Kockelman et al., 2001). These values are very far from the 2% regulatory limit (McMillen et al., 1999).

With a view to proposing a rationalised allowable cross slope, the present study sets out to determine the cardio-respiratory and subjective strains involved in MWC travel under real
propulsion conditions on different cross slopes and at two travelling velocities for a large number of regular MWC users.

## 2. Equipment and Methods

The study was conducted in the occupational physiology laboratory at the Institut National de Recherche et de Sécurité (INRS) jointly with the Institut Régional de médecine physique et de Réadaptation (IRR) both located in Nancy in the eastern part of France.

### 2.1. Subjects

The 25 volunteer subjects were recruited from patients monitored at the IRR, based on the following inclusion criteria: men, paraplegic, adult and of working age (18-65 years old), travelling independently and regularly in a MWC for more than 6 months. Injury level was defined as “high” for injuries at or higher than the 6th thoracic vertebra, and as “low” for injuries of the 7th thoracic vertebra or lower who have functional abdominal muscles. Subjects have no contraindication (cardiovascular, pulmonary, muscular, skin and/or developing general pathologies). They were informed of the study protocol and gave their written consent. The study received approval from the local ethical committee.

### 2.2. Protocol

Two tests were performed: a test involving sub-maximal exertion on an arm erg-cycle and a propulsion track test. The arm cranking test was conducted on a first half-day dedicated to the study inclusion medical examination. A second full-day was dedicated to the track propulsion testing. At least two rest days separated the two test sessions to eliminate fatigue from the cranking test. Both tests were conducted under medical surveillance.

a) The sub-maximal arm cranking test was conducted on an arm erg-cycle fitted with a magnetic induction braking system ensuring power control (Upper Body Cycle, Kardiomed®). This test allowed to estimate the peak oxygen uptake (VO₂max) of the subjects through extrapolating the relationship between HR and VO₂ to their HRmax (Glaser et al., 1980; Paré et al., 1993). The test started with a 2-minute, 25 W warm-up step before continuing in 2-minute steps with an increase of 10 W per step. Pedalling frequency was 50 rotations per minute. The test was stopped when the subjects reached 85% of their theoretical maximum heart rate (HRmax = 220 - age in years) (Wilmore and Costill, 2004).
b) The propulsion test was performed on a 50 m long test track specially designed for the study. Two opposite straights were each 24 m long and the subjects travelled back and forth on these. The track was 1.2 m wide in compliance with wheelchair route minimum width. The wooden track was covered with surfacing material (Tarasafe super, Gerflor®) with a dynamic friction coefficient of 0.4 (ua) close to that of an average asphalt pavement (0.38 ua). The track cross slope was mechanically adjusted and checked using an electronic level (Laser Cross Liner Novipro, Bosch®).

The subjects were submitted to 8 experimental conditions combining 4 cross slopes (0, 2, 8 and 12%) and 2 velocities: one imposed ($V_i$ = 0.97 m.s⁻¹), the other so-called “comfortable” ($V_c$), chosen by the subjects themselves. Under each of the 8 conditions, the subjects undertook 6 laps (300 m) around the track; this distance insured physiological parameter stability (Wilmore and Costill, 2004). The order of testing of the 8 conditions was random. The propulsion method was free. The travelling direction conditions the dominant body side in the most demanding side i.e. in the steeper cross slope. The subjects used their own MWC. Wheel diameter was 24 inches and tyres were inflated to a pressure of 8 bar.

The imposed velocity $V_i$ (0.97 m.s⁻¹), constant for the 4 cross slope, was monitored by electroluminescent diodes fixed every 2 meters along the walls bordering the test track. The subjects adjusted the travelling velocity based on delayed lighting of the diodes. The $V_i$ and the $V_c$, chosen by the subject, were measured by timing at each lap. Temperature and relative humidity were measured for each half-day using a portable hygro-thermometer (RH70, Omega®).

## 2.3. Measured variables

The measured physiological parameters were heart rate (HR in bpm), oxygen uptake ($VO_2$ in ml.kg⁻¹.min⁻¹) and carbon dioxide production ($VCO_2$ in ml.kg⁻¹.min⁻¹). Subjective strain was assessed based on the Rating of Perceived Exertion (RPE) scale (Borg, 1998).

a) HR was measured continuously for the whole day using a cardio frequency meter (Polar®, S 810 i) with a count integration time of 15 s. Cardiac strain parameters were: a) the HR, b) the absolute cardiac cost (ACC in bpm), which is the difference between the mean HR during the test and the HR when seated and at rest, c) the relative cardiac cost (RCC in %), which expresses the percentage strain of the HR reserve (HRR), which is the difference between the subject's HRmax and his HR at rest (Wilmore and Costill, 2004). The RCC is determined by the ACC/HRR ratio.
b) Respiratory parameters were recorded using a cycle-to-cycle gas analyser telemetric system (Cosmed K4b²®). The respiratory parameters processed were: a) the VO₂, b) the energetic cost per metre travelled and per kg weight (ECmkg in J.m⁻¹.kg⁻¹) and, c) the relative energetic cost (REC in %). The ECmkg is the product of the oxygen cost (cVO₂) by the energy equivalent of one litre of oxygen (k in kJ.l⁻¹) divided by the velocity and the weight (P = subject+MWC weight in kg); ECmkg = cVO₂.k/V.P. The oxygen cost (cVO₂ in ml.kg⁻¹.min⁻¹) is the difference between the mean VO₂ during the test and the VO₂ at rest. The energy equivalent of 1 litre of oxygen is calculated using the equation k = 16.6+4.6 RQ, in which the respiratory quotient (RQ) is the ratio VCO₂/VO₂. The REC represents the fraction of the oxygen reserve involved in the exercise. REC is the ratio between the cVO₂ and the oxygen reserve (VO₂R), equal to VO₂max-VO₂rest (Wilmore and Costill, 2004).

c) Subjective strain was obtained using the RPE (Borg, 1998) scale. A global and 5 local assessments (back, shoulders, upper limbs) were asked for at the end of each track test.

## 2.4. Statistical analysis

Results are expressed by their mean and standard deviation (SD) shown in brackets for the 25 subjects. Student t tests on the paired samples allow us to analyse the effects of cross slope on: travelling velocity (Vi and Vc), HR, VO₂ and subjective strains. Distribution normality was checked and achieved by variable transform if needed. Three-factor variance analyses (ANOVA) with correction for co-variable effects qualify the effects of cross slope, velocity and injury level on the cardiac, energetic and subjective strains. Simple and multiple regression models based on the least square method were used to establish the relationships between the different variables. A 5% significance threshold was retained (p<0.05). Statistical analyses were conducted using Statgraphics® Centurion XVI software.

## 3. Results

### 3.1. Subject characteristics

Table 1 displays the means, SD and peak values of age, height, weight, body mass index (BMI) and the injury age and level for the 25 subjects.

**Table 1 about here**
The MWC mean weight was 14.6 (2.1) kg and ¾ of the subjects had been using a wheelchair for over 4 years. No Table 1 characteristic is significantly different (p>0.1) in relation to the injury's "low" or "high" level. In particular, the 15 subjects with "low" level injuries display a VO₂max of 25.6 (6.0) ml.kg⁻¹.min⁻¹ and a HR at rest of 71.3 (3.1) bpm that are not statistically different (p>0.15) to those of the 10 subjects with "high" level injuries, who display a VO₂max of 24.0 (4.8) ml.kg⁻¹.min⁻¹ and a HR at rest of 73.8 (3.7) bpm. The mean VO₂ at rest is 4.1 (0.9) ml.kg⁻¹.min⁻¹ and is not significantly altered by the injury level either.

## 3.2. Experimental conditions

- The sub-maximal exertion and track tests were conducted under conditions of thermal comfort; air temperature and relative humidity mean values were 20.5 (1.7) °C and 42 (14) %. Cross slope checking showed that cross slope values were slightly, but systematically, higher than their theoretical values. The mean error was 0.4% and never exceeded 0.8%.

- The imposed velocity $V_i$ (0.97 m.s⁻¹) effective mean value was 0.95 (0.03) m.s⁻¹ and is the same at the 4 cross slopes (p>0.5). The mean “comfortable” velocity $V_c$ was 1.26 (0.25) m.s⁻¹. $V_c$ was stable from the second lap onwards under each cross slope condition. It decreased significantly ($F_{3.1169}=57; p<0.001$) when the cross slope increased: 1.41 (0.25) on the flat, 1.33 (0.21) for 2%, 1.21 (0.19) for 8% and 1.10 (0.24) m.s⁻¹ for 12% cross slopes. $V_c$ is significantly related to the subject VO₂max (t=3.7; p<0.001). For an increase of 5 ml.kg⁻¹.min⁻¹ in VO₂max, $V_c$ increases by 0.08 m.s⁻¹. Surprisingly, the $V_c$ of subjects with “high” level injuries (1.25 m.s⁻¹) is significantly higher (p<0.05) than that of subjects with “low” level injuries (1.18 m.s⁻¹). The mean total test times were 5.28 (0.18) minutes at $V_i$ and comprised between 3.65 (0.6) minutes for 0% slopes and 4.85 (1.45) minutes for 12% slopes at $V_c$. Total test time (p<0.05) and $V_c$ (p<0.01) are significantly different between 0 and 2% cross slopes. Among the 25 subjects, 5 were incapable of undertaking the last lap under all the experimental conditions. From the third to the sixth lap, there was no significant difference neither HR ($F_{3.753}<0.1; p>0.9$) nor VO₂ ($F_{3.773}=0.6; p>0.6$). Moreover, for the 0 and 2% cross slope conditions, there was no significant difference in both HR and VO₂ ($F_{1.592}<0.6; p>0.4$). These observations led us to process only the data for laps 3, 4 and 5 and to group the results of the physiological strains at 0 and 2% cross slopes denoted 0/2%.
### 3. 3. Measured strains

#### a. Cardiac strains

The HR, ACC and RCC shown in Table 2 are all significantly altered by the velocity conditions (F>95; p<0.001) and, for each velocity, by the 3 different cross slopes (F>92; p<0.001).

**Table 2 about here**

The ACC is related to the cross slope (Cs in %) and the real travelling velocity (V in m.s⁻¹) as follows:
$$ACC = -7.1 + 2.3 Cs + 28.1 V \qquad \text{Equation 1}$$
$$n = 568; r² = 0.44$$

In Equation 1, the individual effects of Cs and V are significant (p<0.001). The ACC is increased by individual factors increase, such as user weight (p<0.001), age (p<0.001), injury age (p<0.001) and VO₂max decrease (p<0.001).

#### b. Energetic strains

The VO₂, ECmkg and REC values presented in Table 3 are all significantly modified by the velocity conditions (F₁.₅₇ >20; p<0.005) and by the cross slopes (F₂.₅₇₀>108; p<0.001) for each velocity.

**Table 3 about here**

The oxygen uptake (VO₂ in ml.kg⁻¹.min⁻¹) is related to the cross slope (Cs in %) and the real travelling velocity (V in m.s⁻¹) as follows:

$$VO_2 = -4.0 + 0.46 Cs + 7.4 V \qquad \text{Equation 2}$$
$$n = 583; r^2 = 0.52$$

In Equation 2, the individual effects of Cs and V are significant (p<0.001). The energetic strain increases when individual factors, such as age (p<0.001) and BMI (p<0.001) increase or when physical activity (p<0.001), injury level (p<0.01) or VO₂max (p<0.001) decrease.

The mean respiratory quotient (RQ) are significantly different for the three cross slopes studied (F₂.₅₇₀=23; p<0.001). For the 12% cross slope, the RQ at Vc (0.98) is significantly (p<0.01) higher than at Vi (0.93). Additionally, for the 0/2% cross slope, the RQ does not change when laps are performed, while it increases regularly and significantly (p<0.01) for
the 8% and 12% cross slopes. The RQ of half the subjects exceeds 1 at the end of the test at Vc on the 12% cross slope. The mean RQ of the subjects with a "low" level injury (0.92) is significantly (p<0.02) higher than that of the subjects with a "high" level injury (0.89) and neither the cross slope nor the velocity alters this difference.

### c. Subjective strains

The subjective rating results remain unaltered by the velocity (p>0.4), but the cross slope increases significantly the subject rating (p<0.001). The mean estimation is 7.8 (1.8) for the 0/2%, 9.9 (2.6) for the 8% and 11.9 (3.4) for the 12% cross slope, equivalent to very light, light and moderate on the Borg scale respectively. The RPE increases with BMI ($F_{1,199}=5.5$; p<0.02). It is significantly (p<0.001) higher (RPE = 9.9 (0.6)) for subjects with "low" level injuries than for those with "high" level injuries, who rated RPE as 8.5 (0.7). Finally, the cross slope is only perceived at 8% and at 12%. The ratio of dominant to non dominant side local RPE (shoulder + arm) remains 1 for the 0% and 2% cross slopes (p>0.3) and becomes significantly (p<0.01) greater than 1 from the 8% cross slope upwards. However, at 2% cross slope RPE of "low" level injured is significantly (p<0.005) higher than that of "high" level injured; 8.5 (0.5) vs 7.0 (0.6).

### d. Strains variations

Figure 1 illustrates the variations in the 3 strains (cardiac, energetic and subjective) at 2 velocities and 4 cross slopes studied.

**Figure 1 about here**

Results in figure 1 reveal a virtually linear variation in strains for cross slopes between 0/2% and 12%. This illustrates the fact that, under the conditions of this study, the linear models representing Equations 1 and 2 are not improved by non-linear modelling.

### 4. Discussion

Our discussion will address in succession points concerning methodology, subject characteristics and travelling velocities before analysing the strain levels for different cross slopes and comparing these with data in the literature. At the end of this discussion, we propose a cross slope limit model.
## 4.1. Methodology

Unlike the majority of studies published to date, the results of this work are based on a large number of paraplegic subjects (25) accustomed to travelling in a MWC. However, this subject "uniformity" is only partial since there is great variability between individuals as shown by the standard deviations for the results displayed in Tables 2 and 3. Although this variability may be partly explained by subject age, BMI, VO2max, physical activity and travelling velocity, it is not totally remedied by taking into account individual variables (Equations 1 and 2). This testifies to the complex nature of MWC travel, involving unconsidered parameters, such as user technique and training, wheelchair adaptation, strength capacities, efficiency variation with respect to cross slope or velocity (Cooper, 1990, Paré et al., 1993; Van der Woude et al., 2001). Our choice of 4 cross slopes (0, 2, 8 and 12%) was made to try to understand this complexity, built a strain model and to take in account the 2% regulatory reference slope adopted in many countries (McMillen et al., 1999) and the acceptable cross slope of 10% (Kockelman et al., 2001) which explains the choice of 8 and 12% cross slopes as upper anchor of the strain model. The Vi (0.97 m.s⁻¹) is used fairly conventionally (Brubacker et al., 1986; Mukherjee and Samanta, 2001) and was easy to be maintained constant. The a priori decision to perform 6 laps has been validated since it allows 3 stable laps from physiological and velocities point of view.

## 4.2 Subjects characteristics

The 25 active male subjects had a mean VO2max of 25.0 (5.5) ml.kg⁻¹.min⁻¹, which compares with the highest data in the literature for paraplegic MWC users who are not sportsmen (Bhambhani, 2002; Coutts et al., 1983; Van der Woude et al., 2001) and exceeds the most frequently quoted values between 15 and 25 ml.kg⁻¹.min⁻¹ (Figoni, 1984; Hjeltnes, 1986; Veeger et al., 1991). In a less active population than that studied, cross slope generated strains would undoubtedly be greater than those observed in the present study. While at Vc, the 12% cross slope represents an energetic strain of 52% in the study population (Table 3), it would represent 75% of the maximum capacity for a less active population with a VO2max of only 20 ml.kg⁻¹.min⁻¹. Cross slope consequences would undoubtedly be even more constraining for a more fragile, older and less active population.

The results reveal the surprising effects of injury level on Vc and RQ. Subjects with "high" level injuries, who have no functional abdominal musculature, in fact chose a mean Vc that was significantly (p<0.05) faster (1.25 m.s⁻¹) than those with "low" level injuries (1.18 m.s⁻¹). This difference is significant for all cross slopes. The literature offers no explanation for this
phenomenon. Maintaining a straighter trajectory may require users to travel faster. Lack of trunk stability could also cause paraplegics with “high” level injuries to lean more on the handrails to keep in balance, which would also result in a higher Vc. Moreover, the trunk flexion amplitude should be greater for a “high” level injury (Chow et al., 2000). These hypotheses could not be verified in this study. Even lower RQ for "high" level injured users could be interpreted as less muscles involved or less respiratory difficulties for them as for the "low" level injured users. Thus, trunk flexion could be used to reduce energetic and respiratory strains.

The Vc is significantly different for 0% and 2% cross slopes, yet no other result reveals a difference between travelling on the flat and over a 2% cross slope. This result makes Vc a powerful strain indicator for assessing the difficulty of a travelling condition.

The exertion perceived by the subjects with “low” level injuries (RPE = 9.9) was higher (p<0.001) than that perceived by subjects with “high” level injuries (RPE = 8.5), who nevertheless travelled faster without significantly different energetic (p>0.5) or cardiac (p>0.3) strains. The day-to-day life of a paraplegic with a “high” level injury is more trying and complex than that of a paraplegic with a “low” level injury. The former could sustain a higher difficulty set-point, which would allow him to confront more easily an identical constraint and have a more positive perception of the laboratory situation than the user with a "low" level injury. Furthermore, depending on the experimental condition, a “high” injury level does not always cause significant alteration in capacities (Vanlandewijck et al., 2011). These factors, which have not been demonstrated in this study, could explain the exertion perception differences in relation to injury level.

## 4.3. Physiological strains

Between the situation at Vi with a 0/2% cross slope and at Vc with a 12% cross slope, the mean cardiac strains are multiplied by 2.5 (Table 2) and the energetic strains by 3 (Table 3). More precisely, the 0 to 12% cross slope multiplies the strains by 2 and the change from Vi to Vc multiplies them by 1.5. Except for the 12% cross slope, the subjects’ HR and VO₂ strains remain moderate. For comparison, the cardiac strains in this study are significantly lower than those measured on a flat surface at similar velocities: 127 bpm (Mukherjee and Samanta, 2001). The values of HR, ACC and RCC measured at Vc for a given cross slope condition are very close the values measured for the higher cross slope condition at Vi. As an example, the ACC at Vc for a 0/2% cross slope is 33.7 (12.9) bpm and is 34.5 (14.0) bpm at Vi for an 8% cross slope. Thus, it is important to inform MWC users that their velocity is a major strain
factor and must be adapted to the environment. The relative energetic cost is equivalent to the relative cardiac cost (Tables 2 and 3). The energetic cost per meter (ECm) is related to the travelling velocity. Under the 0/2% cross slope condition, ECm is 93 J.m⁻¹ at the imposed velocity Vi (0.95 m.s⁻¹). This result echoes the Brubaker et al. (1986) study, in which ECm was found to be 97 J.m⁻¹ for a 0% cross slope at a similar travelling velocity.

Subjective strains, at the opposite of the objective ones are not significantly different in relation to the travelling velocity on the same cross slope. Choosing a so-called “comfortable” velocity causes the subjects to sustain an increase in cardio-respiratory strain, which is not subjectively perceived. Velocity control would appear to minimise the perceived exertion, but may expose the subject to a risk of overload in terms of physiological strains.

### 4.4. Comparison with literature data

Studies that have focused on cross slope have not addressed the physiological aspect or have, but based on a few subjects. To validate the data provided by this study, we can compare them with physiological cost data for flat ground. Table 4 consolidates the ACC, cVO₂ and ECmkg values with respect to travelling velocity on the flat. The studies retained were conducted on a minimum of 9 subjects and involved measuring the HR and/or VO₂.

**Table 4 about here**

Results in Table 4 seem to be poorly comparable. However, from these results it is possible to compute a very significant relationship between energetic cost and velocity which is:

$$cVO_2 = 7.5 V \quad (r^2 = 0.92; p<0.001)$$

This relationship shows that the results of the present study are strongly in accordance with the other ones in Table 4. Furthermore, mean ECmkg is equal to 1.54 (0.3) and is not related to velocity (p>0.3). Thus, the observed differences in table 4 can probably be related to subject fitness or travelling conditions or MWC technology.

Hildebrandt et al. (1970) study, conducted on a widely varied population, suggests equivalents in watts (W) of travelling on flat ground in a MWC (18 kg + 70 kg subject) at velocities of 0.3 m.s⁻¹ (2 W), 0.55 m.s⁻¹ (4 W), 0.8 m.s⁻¹ (6.5 W) and 1.1 m.s⁻¹ (11 W), i.e. an equivalent of 8.7 and 16 W at Vi and Vc respectively. For these authors, the efficiency on the flat lies between 5% and 8%. In this study, the mean energetic cost of travelling on flat ground is 100 W at Vi and 182 W at Vc, i.e. an efficiency of 8.7% for both velocities, which
corresponds to a normal result in view of MWC progress, along with the capacities of our study subjects (Van der Woude et al., 1988).

Finally, a number of studies (Van der Woude et al., 1989; Van der Woude et al., 2001; Voigt and Bahn, 1969) have enabled relationships between ACC (bpm) and VO₂ (ml.kg⁻¹.min⁻¹) with respect to velocity (V in m.s⁻¹) and slope (S in %) to be derived in the form: ACC = 31.4 V + 12.1 S and VO₂ = 10.1 V + 3.8 S. Based on these relationships, 1% slope increases the ACC by 12 bpm and the VO₂ by 3.8 ml.kg⁻¹.min⁻¹. From the results of the present study (Equations 1 and 2) Cs will be 8.3%, based on the energetic cost, and 5.3%, based on the cardiac cost, to reach the strains at 1% slope. These results do not agree with the data provided by Chesney and Axelson (1996), who considered that a 1% slope induces a power equivalent to a 3% cross slope, in other words a cost that is 2 times higher than that extrapolated from the results of this study. The differences between Chesney and Axelson (1996), Richter et al. (2007), Van der Woude et al. (1989) results and ours explain that cardio-respiratory strains cannot be compared to physical strains, at least when propelling a MWC. Using only the later to model strains can involve large and dangerous errors. MWC literature focuses, above all, on the technical and biomechanical data for improving exertion efficiency (Gorce and Louis, 2012; Van der Woude et al., 2001) and on the maximum capacities of sportsmen in MWCs (Huonker et al., 1998; Paré et al., 1993; Van der Woude et al., 2001; Veeger et al., 1991). The main aim of MWC studies conducted between 1975 and 1995 was to improve wheelchairs by taking advantage of the wheelchair sports boom (Cooper, 1990). During this period, Boston (USA) and Oita (Japan) marathon winning times dropped from over 2.5 hours to less than 1.5 hours. This progress was made possible by improving the technical and technological characteristics of wheelchairs (weight, stabilities, wheels, propulsion, etc.) and adopting efficiency optimising postures (Van der Woude et al., 2001). This explains why physiological data have been so little measured on large numbers of habitual MWC users since research directed towards technical and mechanical data effectively revealed much more refined improvements than physiological data (Van der Woude et al., 2001). The significant effect of a 2% cross slope on Vc supports this idea, even though it does not alter the strains.

## 4.5. Strain model

Observation of the data illustrated in Figure 1 shows that the relationship between cross slope and both physiological costs can be considered linear (Chesney and Axelson, 1996;
Kockelman et al., 2001). If all variables are otherwise constant, the mean cross slope (Cs in %) cost can be quantified using the following equations:

$$cVO_2 = 4.6 + 0.4 Cs \qquad n = 583; r = 0.51$$

$$ACC = 25.6 + 2.0 Cs \qquad n = 568; r = 0.54$$

If we consider that a 50%-of-maximum strain can be easily maintained for several hundred meters (long term) and that a 75%-of-maximum strain can be maintained for several tens of meters (short term), we can establish long- and short-term cross slope limits based on the 2 physiological costs (Monod and Kapitaniak, 2009). For energetic cost ($VO_2rest = 4.1 \text{ ml.kg}^{-1}\text{.min}^{-1}$) users with a $VO_2max$ of $15 \text{ ml.kg}^{-1}\text{.min}^{-1}$ can travel on a 2% cross slope for several hundred of meters and can travel several tens of meters on a 8% cross slope. If their $VO_2max$ is $20 \text{ ml.kg}^{-1}\text{.min}^{-1}$, which is undoubtedly the most common among these wheelchair users, they can confront a 19% short-term cross slope, potentially causing a major risk of imbalance. On the other hand, they will be capable of travelling over no more than an 8% cross slope in the long term. For subjects with a $VO_2max$ of $25 \text{ ml.kg}^{-1}\text{.min}^{-1}$, there is no short-term limitation and the long term one (15%) is risky. For higher $VO_2max$ values, cross slope limitation is no longer rational. The cardiac strains of the subjects in this study were too low to be able to derive a credible limiting model based on HR since no cross slope limit was less than 12%. However, if an ACC of 30 bpm would be a cardiac cost limit (Monod and Kapitaniak, 2009), this would only be respected if the cross slope was less than 2%.

## 5. Conclusion

The results of this study show that a 2% cross slope was indistinguishable from flat ground in terms of cardio-respiratory and subjective strains. The results also indicate that the physiological strain increases linearly with cross slope. Under these conditions, 8% cross slopes are subjectively sensitive, they impose noteworthy physiological costs and they do not allow the RQ to stabilise. The 12% cross slopes are unachievable for some users and should therefore be prohibited. These limits enable to remain well below 50% of the functional capacities of the subjects taking part in this study. These conclusions cannot be generalised to all MWC users. Thus, for users with low cardio-respiratory capacities, a model derived from the results of this study shows that the 2% cross slope limit is a good basis, allowing all users to travel. In practice, an environment in which there are no 8% cross slopes and there is a trend for compliance with the regulatory limit of 2% should encourage a great majority of people in MWCs to travel. These conditions allow acquisition of independence, conservation
of functional capacities and promotion of health. Furthermore, they would favour integration
of employees in MWCs.

Acknowledgements

Authors wish to thank the subjects of the study for their interest and willful involvement and
Mrs Bruno Corazzini, Gérard Didry, Jean-Charles Guelin and Olivier Remy for their technical
help during the experiments.

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## Figures and tables

### Tables' captions

Table 1. Means, standard deviations and peak values of anthropometric and functional characteristics for 25 paraplegic men and their injury level and age.

Table 2. Mean cardiac strains: heart rate (HR), absolute cardiac cost (ACC) and relative cardiac cost (RCC) for imposed (Vi) and comfortable (Vc) velocities conditions at the 3 cross slopes (0/2%, 8% and 12%).

Table 3. Mean energy strains: oxygen uptake ($VO_2$), energy cost per meter and per kg (ECmkg) and relative energy cost (REC) for imposed (Vi) and comfortable (Vc) velocities conditions at the 3 cross slopes (0/2%, 8% and 12%).

Table 4. Comparison of physiological strains when travelling in a manual wheelchair on flat ground with date in the literature. For each study, we give the number of subjects, the travelling velocity and the cardiac (ACC in bpm), oxygen ($cVO_2$ in $ml.kg^{-1}.min^{-1}$) and energy costs per meter and per kg of subject weight (ECmkg in $J.m^{-1}.kg^{-1}$).
Figure caption

Figure 1. Mean strains and standard deviations for the 4 cross slopes and 2 travelling velocities. Absolute cardiac cost (ACC in bpm, rectangles), oxygen cost (cVO₂ = VO₂-VO₂rest in ml.kg⁻¹.min⁻¹, circles) and subjective strain (RPE, arbitrary unit, triangles). Full forms are for Vi (0.97 m.s⁻¹) and empty ones for Vc. Regression lines of § 4.5 equations are plotted to simplify reading.
<table><caption>Table 1</caption><thead><tr><th></th><th>Mean (SD)</th><th>Minimum - Maximum</th></tr></thead><tbody><tr><td>Age (year)</td><td>38.9 (9.5)</td><td>23 - 61</td></tr><tr><td>Height (cm)</td><td>178.0 (7.7)</td><td>163 - 192</td></tr><tr><td>Weight (kg)</td><td>75.3 (14.0)</td><td>57 - 116</td></tr><tr><td>BMI (kg.m<sup>-2</sup>)</td><td>23.8 (4.6)</td><td>16.5 - 34.6</td></tr><tr><td>VO<sub>2</sub>max (ml.kg<sup>-1</sup>.min<sup>-1</sup>)</td><td>25.0 (5.5)</td><td>19.4 - 38.0</td></tr><tr><td>Injury level</td><td></td><td>T3 - L4</td></tr><tr><td>Injury age (years)</td><td>10.6 (7.8)</td><td>2 - 32</td></tr></tbody></table>
<table><caption>Table 2</caption><thead><tr><th rowspan="2">Cross slope (%)</th><th colspan="2">HR (bpm)</th><th colspan="2">ACC (bpm)</th><th colspan="2">RCC (%)</th></tr><tr><th>Vi</th><th>Vc</th><th>Vi</th><th>Vc</th><th>Vi</th><th>Vc</th></tr></thead><tbody><tr><td>0/2</td><td>92.2 (14.6)</td><td>106.5 (16.4)</td><td>19.9 (5.7)</td><td>33.7 (12.9)</td><td>19 (6)</td><td>31 (11)</td></tr><tr><td>8</td><td>104.4 (14.9)</td><td>117.8 (18.2)</td><td>34.5 (14.0)</td><td>45.0 (15.0)</td><td>32 (14)</td><td>42 (16)</td></tr><tr><td>12</td><td>114.7 (19.0)</td><td>129.5 (15.9)</td><td>43.7 (18.4)</td><td>55.1 (17.8)</td><td>40 (18)</td><td>51 (16)</td></tr></tbody></table>
<table><caption>Table 3</caption><thead><tr><th rowspan="2">Cross slope (%)</th><th colspan="2">VO<sub>2</sub> (ml.kg<sup>-1</sup>.min<sup>-1</sup>)</th><th colspan="2">ECmkg (J.m<sup>-1</sup>.kg<sup>-1</sup>)</th><th colspan="2">REC (%)</th></tr><tr><th>Vi</th><th>Vc</th><th>Vi</th><th>Vc</th><th>Vi</th><th>Vc</th></tr></thead><tbody><tr><td>0/2</td><td>8.0 (1.3)</td><td>11.2 (3.1)</td><td>1.20 (0.38)</td><td>1.50 (0.43)</td><td>16.8 (7.5)</td><td>32.0 (13.5)</td></tr><tr><td>8</td><td>10.8 (2.1)</td><td>13.3 (3.3)</td><td>2.11 (0.76)</td><td>2.33 (0.94)</td><td>29.6 (14.0)</td><td>42.3 (15.4)</td></tr><tr><td>12</td><td>11.9 (2.6)</td><td>15.7 (4.0)</td><td>2.76 (0.97)</td><td>3.37 (1.43)</td><td>37.5 (15.5)</td><td>52.4 (17.9)</td></tr></tbody></table>
<table><caption>Table 4</caption><thead><tr><th></th><th>Number of subjects</th><th>Velocity (m.s<sup>-1</sup>)</th><th>ACC (bpm)</th><th>cVO<sub>2</sub> (ml.kg<sup>-1</sup>.min<sup>-1</sup>)</th><th>ECmkg (J.m<sup>-1</sup>.kg<sup>-1</sup>)</th></tr></thead><tbody><tr><td>This study</td><td>25</td><td>0.95<br>1.41</td><td>19.9<br>33.7</td><td>8.0<br>11.2</td><td>1.2<br>1.5</td></tr><tr><td>Hadj Yahmed and Charpentier, 1990*</td><td>12</td><td>0.83<br>1.66</td><td>28<br>47</td><td>8.2<br>13.7</td><td>1.2<br>1.0</td></tr><tr><td>Mukherjee and Samanta, 2001</td><td>17</td><td>0.95<br>1.12</td><td>47.7<br>14.6</td><td>7.6<br>9.1</td><td>1.6<br>1.9</td></tr><tr><td>Hilbers and White, 1987</td><td>9</td><td>1.59<br>2.18<br>2.92</td><td>20.4<br>34.4<br>47.4</td><td>11.3<br>14.4<br>24.1</td><td>1.7<br>1.6<br>2.0</td></tr><tr><td>Beeckmann et al, 1999</td><td>44</td><td>1.24</td><td></td><td>7.6</td><td>1.7</td></tr></tbody></table>

<footnote>* Hadj Yahmed and Charpentier results obtained for a 1% slope.</footnote>
<figure><img src="image_328.png" /><figcaption>Figure 1</figcaption></figure>
Résumé

**Introduction.** Les capacités et les possibilités de déplacement en fauteuil roulant manuel (FRM) sont déterminantes pour l’intégration sociale et professionnelle des usagers.

**Objectifs.** Approfondir la connaissance des contraintes de déplacement en FRM à travers 2 études. La 1ère pour identifier les habitudes et préciser les difficultés des usagers ; la 2ème, induite par les résultats de la 1ère, pour évaluer les effets du dévers, encore méconnus, sur les astreintes cardiaques, énergétiques, musculaires et subjectives.

**Méthodes.** La 1ère étude a été menée par questionnaire complété par 118 sujets paraplégiques en FRM. La 2ème étude, en laboratoire avec 25 hommes paraplégiques, comporte 2 tests : un test d'effort sur ergocycle à bras et un test de propulsion de 300 m et 8 conditions combinant 4 dévers (0, 2, 8 et 12 %) et 2 vitesses (0,97 m.s⁻¹ et une vitesse choisie "de confort").

**Résultats.** La 1ère étude révèle un environnement peu adapté, avec des moyens de transport et des bâtiments souvent inaccessibles sans aide, et des gènes limitant les sorties des usagers parmi lesquelles figure le dévers. La 2ème étude indique des astreintes cardiaques, énergétiques et musculaires significativement modifiées par le dévers et par la vitesse (p < 0,01). L'astreinte subjective n'est pas modifiée par la vitesse. Des différences entre 0 et 2 % sont faibles mais existent. Un dévers de 12 % est difficilement réalisable. Les équilibres des activités musculaires changent dès 2 % de dévers. Le niveau lésionnel modifie de façon très importante les stratégies de déplacements et les niveaux d'astreintes mesurées ou perçues.

**Discussion-Conclusion.** Les effets du dévers sont perceptibles dès 2 % et sont nets et délétères à 8 %. Ce travail permet de proposer de façon plus argumentée un modèle d'astreintes qui conforte le seuil de dévers fixé réglementairement à 2 % permettant à la grande majorité des usagers de FRM de se déplacer de façon autonome et de rester actifs.

**Mots clés** : Paraplégiques - Fauteuil roulant manuel - Dévers - Environnement - Astreintes

Abstract

**Introduction.** Displacement capacities and possibilities in manual wheelchair (MWC) are strong determinants of social and occupational integration of MWC users.

**Objectives.** Improve the knowledge of the strains involved by displacement in MWC through 2 studies; the first one to identify habits and difficulties of MWC users. The second one, induced by the results of the first one, has assessed the poorly known cardiac, energetic, muscular and subjective strains of the displacement of MWC users on a cross slope.

**Methods.** The first study was a survey answered by 118 paraplegics habitual MWC users. The second one, a laboratory study conducted with 25 paraplegic men, includes 2 tests: a sub maximal arm-cranking test and a 300 m propulsion test with 8 conditions combining 4 cross slope (0, 2, 8 and 12%) and 2 velocities (0,97 m.s⁻¹ and a "comfortable" chosen one).

**Results.** The first study shows an adverse environment, with many places unreachable without help and disturbances, like cross slope, which hinders users' displacements. The second study demonstrates the increases of cardiac, energetic, muscular and subjective strains with cross slope. Differencies between 0 and 2% cross slopes are low but quantified. Displacement on a 12% cross slope is very difficult. The balance of muscles activities is changing at 2% cross slope. The injury level makes deep changes in the displacements strategies and in as well perceived as measured strain levels.

**Discussion-Conclusion.** Effects of cross slope are perceived for as low as 2% and onwards values. They are high and deleterious at 8%. This work allows to construct a model of cross slope strains which confirms that the regulatory 2% cross slope limit is well chosen because it allows most MWC users to move without help and remain active.

**Keywords:** Paraplegics - Manual wheelchair - Cross slope - Environment - Strains