Effects of Hand Cycle Training on Physical Capacity
in Individuals With Tetraplegia: A Clinical Trial
Linda J.M. Valent, Annet J. Dallmeijer, Han Houdijk,
Hans J. Slootman, Thomas W. Janssen, Marcel W.M.
Post and Lucas H. van der Woude
PHYS THER. 2009; 89:1051-1060.
Originally published online July 30, 2009
doi: 10.2522/ptj.20080340

The online version of this article, along with updated information and services, can befound online at: http://ptjournal.apta.org/content/89/10/1051
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051.DC1.html
This article, along with others on similar topics, appears
in the following collection(s):Cardiovascular/Pulmonary System: Other
Hemiplegia/Paraplegia/Quadriplegia
Spinal Cord Injuries
Therapeutic Exercise

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Research Report

Effects of Hand Cycle Training on
Physical Capacity in Individuals With
Tetraplegia: A Clinical Trial
Linda J.M. Valent, Annet J. Dallmeijer, Han Houdijk, Hans J. Slootman,
Thomas W. Janssen, Marcel W.M. Post, Lucas H. van der Woude

Background. Regular physical activity is important for people with tetraplegia tomaintain fitness but may not always be easily integrated into daily life. In many
countries, hand cycling has become a serious option for daily mobility in people withtetraplegia. However, little information exists regarding the suitability of this exercise
mode for this population.
Objective. The purpose of this study was to evaluate the effects of a structured
hand cycle training program in individuals with chronic tetraplegia.

Design. Pretraining and posttraining outcome measurements of physical capacity
were compared.

Setting. Structured hand cycle interval training was conducted at home or in arehabilitation center in the Netherlands.

Participants. Twenty-two patients with tetraplegia (American Spinal Injury Association Impairment Scale classification A-D) at least 2 years since injury participated.
Intervention. The intervention was an 8- to 12-week hand cycle interval training
program.

Measures. Primary outcomes of physical capacity were: peak power output(POpeak) and peak oxygen uptake (V̇O2peak), as determined in hand cycle peak
exercise tests on a motor-driven treadmill. Secondary outcome measures were: peakmuscle strength (force-generating capacity) of the upper extremities (as assessed byhandheld dynamometry), respiratory function (forced vital capacity and peak expiratory flow) and participant-reported shoulder pain.

Results. Significant improvements following a mean of 19 (SD⫽3) sessions of handcycle training were found in POpeak (from 42.5 W [SD⫽21.9] to 50.8 W [SD⫽25.4]),
V̇O2peak (from 1.32 L䡠min⫺1 [SD⫽0.40] to 1.43 L䡠min⫺1 [SD⫽0.43]), and mechanicalefficiency, as reflected by a decrease in submaximal oxygen uptake. Except for shoulder
abduction strength, no significant effects were found on the secondary outcomes.
Limitations. Common health complications, such as urinary tract infections,bowel problems, and pressure sores, led to dropout and nonadherence.

Conclusion. Patients with tetraplegia were able to improve their physical capacity
through regular hand cycle interval training, without participant-reported shoulder-arm
pain or discomfort.
October 2009

L.J.M. Valent, PhD, is Occupational Therapist and Senior Researcher, Department of Researchand Development/Occupational
Therapy, Heliomare Rehabilitation
Centre, Relweg 51, 1949 EC, Wijk
aan Zee, the Netherlands. Address
all correspondence to Dr Valent at:l.valent@heliomare.nl.
A.J. Dallmeijer, PhD, is AssistantProfessor, Department of Rehabilitation Medicine, VU University
Medical Center, Amsterdam, theNetherlands.
H. Houdijk, PhD, is a staff member inthe Department of Research and Development, Heliomare Rehabilitation
Centre, and Assistant Professor, Research Institute MOVE, Institute for
Fundamental and Clinical Human
Movement Sciences, Faculty of Human Movement Sciences, VU University, Amsterdam, the Netherlands.
H.J. Slootman, MD, is a medical
doctor in the Spinal Cord Unit,
Heliomare Rehabilitation Centre.
T.W. Janssen, PhD, is Professor, Research Institute MOVE, Institute for
Fundamental and Clinical Human
Movement Sciences, Faculty of Human Movement Sciences, VU University, and Rehabilitation Center
Amsterdam,
Amsterdam,the
Netherlands.
M.W.M. Post, PhD, is Senior Researcher, De Hoogstraat Rehabilitation Centre and Rudolf Magnus
Institute for Neuroscience, University Medical Hospital Utrecht, Utrecht, the Netherlands.
L.H. van der Woude, PhD, is Professor, Research Institute MOVE,
Institute for Fundamental andClinical Human Movement Sciences, Faculty of Human Movement Sciences, VU University, andRehabilitation Center Amsterdam.
[Valent LJM, Dallmeijer AJ, Houdijk
H, et al. Effects of hand cycle training on physical capacity in individuals with tetraplegia: a clinical trial.
Phys Ther. 2009;89:1051–1060.]© 2009 American Physical Therapy
Association

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Physical Therapy f1051

Hand Cycle Training in TetraplegiaThe physical capacity of mostpeople with a cervical spinal
cord injury (SCI) is low.1 In
addition to complete or incomplete
paralysis, many other factors may
contribute to the low physical capacity of this group. People with tetraplegia often have a disturbed sympathetic nervous system that mightlead to bradycardia, orthostatic hypotension, autonomic dysreflexia,
temperature dysregulation, andsweating disturbances.2 Dependingon the location and severity of thelesion, cardiovascular responses toexercise (eg, increased blood flow toactive muscles and vasoconstriction
in relatively inactive tissues) may be
disturbed.1,2 Secondary complications such as urinary tract infections,spasms, pressure sores, and overuseinjuries in the upper extremity also
may lead to inactivity and deconditioning. Other barriers to physical activity may be intrinsic (eg, lack ofenergy or motivation) or extrinsic(eg, costs, not knowing where to exercise, accessibility of facilities,
knowledgeable instructors).3 Deconditioning eventually may lead to additional health problems such as obesity, diabetes, and cardiovascular
problems.4 Therefore, it is suggested
that a certain level of physical activity and fitness is important for people with tetraplegia in order to maintain (or even improve) functioning,participation, health, and quality oflife.5

Available With
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1052

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Physical Therapy

In contrast to arm-crank exercise,hand-rim wheelchair propulsion andhand cycling are functional modes ofregular daily mobility that are assumed to help people with tetraplegia to maintain a physically active
lifestyle. Hand-rim wheelchair propulsion, however, is highly inefficient6 and mechanically straining, often leading to upper-extremity
overuse problems.7 For people withtetraplegia, it may even be difficult toapply a well-directed force during every push.8 For them, hand cycling
may be easier to perform than handrim wheelchair propulsion. The
hands are fixed in pedals with special grips, and forces can be applied
continuously over the full 360degree cycle in both push and pullphases. In contrast, during hand-rim
wheelchair propulsion, force can beapplied in only 20% to 40% of thecycle.6 Furthermore, Dallmeijer et
al9 found a higher mechanical efficiency and peak power output(POpeak) in hand cycling comparedwith hand-rim wheelchair propulsion. According to clinical experience, people for whom hand-rim
wheelchair propulsion is too strenuous appear to be able to hand cycle
a few hundred meters after only afew practice sessions.
Only a few intervention studies areavailable on the effects of upperbody training in people with tetraplegia.10 These studies were performed with different modes of arm
exercise: arm cranking,11,12 wheelchair propulsion,13 circuit resistancetraining,14 or quad rugby.15 The ergonomics of arm cranking in thesestudies11,12 differed substantiallyfrom the ergonomics of hand cyclingin the current study (ie, asynchronous arm cranking versus synchronous hand cycling). A high positionof the crank axis (midpoint of thesternum11 or at shoulder level12) isused in arm cranking versus the low
position (just below the sternum)
used in hand cycling.

Training studies on the effects ofhand cycling in people with SCI are
even scarcer, with only one study inpeople with paraplegia16 and nostudies in people with tetraplegia. In
a recent observational study on theinfluence of hand cycling during and1 year after clinical rehabilitation, we
found clinically relevant improvements in physical capacity in patients with paraplegia during rehabilitation, but not in patients withtetraplegia, probably due to thesmall and heterogeneous groups.17
The aim of this study was to evaluate
the effects of a structured hand cycle
interval training intervention on
physical capacity in people with tetraplegia at least 2 years postinjury.
We hypothesized that a structured
hand cycle training intervention significantly improves physical work
capacity.

MethodParticipants
People with cervical SCI who had
been rehabilitated in 1 of 3 Dutch
rehabilitation centers were approached to participate. Participants
were included if they: (1) had beendischarged from clinical rehabilitation more than 1 year previously andhad a time since injury (TSI) of atleast 2 years, (2) had a motor incomplete C5–C8 lesion (American Spinal
Injury Association Impairment Scale[AIS] classification A–D),18 (3) used amanual or powered wheelchair formobility, (4) were physically activein training and outdoor mobility lessthan 2 hours a week over the past 3
months, (5) were between 18 and 65
years of age, and (6) had sufficientknowledge of the Dutch language. A
physician medically screened all participants. Exclusion criteria were: severe overuse injuries of the upper
extremities screened with a questionnaire,19 other secondary healthproblems (ie, pressure sores, bladderinfections, cardiovascular diseases,or contraindications for exercise ac-

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Hand Cycle Training in Tetraplegia
cording to American College ofSports Medicine guidelines20), or
other medical conditions that did notallow performance of physical activities. All participants signed an informed consent form.
DesignThe pretraining-posttraining design
involved a pretraining test (t1), performed 1 week before the start of the
8- to 12-week training period, and a
posttraining test (t2), performed 1
week after the end of the training
period. A subgroup performed an extra test (t0) prior to t1, and the second baseline measurements (t1)were taken for analysis to rule out
the effects of practicing.

Figure.
Add-on hand cycle system.

Peak power output and peak oxygen
uptake (V̇O2peak) during the handcycle peak exercise test were theprimary outcome measures of physical capacity. Muscle strength (forcegenerating capacity) and pulmonary
function were evaluated as secondary outcome measures.
Intervention: Hand Cycling
The add-on hand cycle. The participants used an add-on hand cycle
system* (equipped with bullhornshaped cranks and a front wheel)that was coupled to the front of theregular everyday hand-rim wheelchair. The crank pedals move synchronously with alternating flexionand extension of the arms during the360-degree cycle (Figure). In contrast to conventional straight cranks,
the wide bullhorn cranks allow positioning of the crank axis as low as
possible, slightly above the upper
legs, and, consequently, allow thepedals to move alongside the upper
legs (in the lowest position). The
hand cycle is equipped with gears
that can be changed manually or by
moving the chin forward or backward along the switches.
* Double Performance, Antwerpseweg 13–1,
Gouda, the Netherlands.

October 2009

Training protocol. Because not
all participants in the study were acquainted with hand cycling, 1 practice session a week was conductedin the 3 weeks before the test. For allparticipants, we aimed at a total of
24 training sessions within a continuous period of 8 to 12 weeks. Thoseparticipants who were using a handrim wheelchair as their primarymode of mobility were assumed to
be able to maintain a frequency of 3
training sessions a week for 8 weeks.
Those who used an electrical wheelchair were advised to train twice aweek for 12 weeks. At least 1 day ofrest was scheduled between training
days. All participants were asked tocontinue their regular physical activities and to make up for any missed
training session. Depending on theirpersonal situation, participants had
the opportunity to train in the rehabilitation center or at home and bothindoors and outdoors. To ensure
training in case of bad weather conditions, participants received indoor
bicycle roller trainers† that were adjusted for hand cycling. The durationof one training session was between†
Minoura Magturbo, 1197–1 Godo, Anpachi,
Gifu, 503-2305, Japan.

35 and 45 minutes (Appendix). During training, participants wore heart
rate (HR) monitors and were expected to train at 60% to 80% ofheart rate reserve (HRR) (peak heart
rate [HRpeak] ⫺ resting heart rate
[HRrest] [bpm]).21 Rating of perceived exertion (RPE) was monitored using the Borg 10-point scale
and was intended to range from 4 to
7, starting at the lower level in thefirst training sessions.22 Participants
were asked to keep a training diaryand to score upper-extremity pain
following a standardized protocol.19
Data from the HR monitors during
the training period were saved forfurther analysis. If serious complaintsof upper-extremity pain or illness occurred, the participants were asked tocontact the trainer/researcher before
continuation of the training.
Outcome Measures
Physical capacity. Prior to testing,participants were asked to empty
their bladder to help prevent possible bouts of autonomic dysreflexia.
Resting heart rate and resting oxygen
uptake (V̇O2rest) were monitored
during 5 minutes of quiet sitting.
Subsequently, participants were fa-

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Physical Therapy f1053

Hand Cycle Training in Tetraplegia
miliarized with the hand cycle on thetreadmill,‡ and the experimental velocity was adjusted to the ability ofthe participant, but within the rangeof 1.11 to 1.94 m䡠s⫺1 and a gear setting resulting in a cadence of approximately 60 rpm. Mean submaximal
oxygen uptake (V̇O2submax) andsubmaximal heart rate (HRsubmax)
were measured at a constant load in
the last 30 seconds of a 3-minutesubmaximal hand cycle bout. Because velocity and gear setting were
kept the same during all measurement occasions, submaximal power
output (POsubmax) was comparable
between measurements, and a lower
V̇O2submax would indicate increased mechanical efficiency.
After 3 minutes of rest, POpeak (W),V̇O2peak (mL䡠min⫺1), and HRpeak(bpm) were determined in a discontinuous graded peak exercise test
performed in the hand cycle on a
motor-driven treadmill. Exercise
bouts of 2 minutes were interspacedwith a rest period of 30 seconds.
After each exercise step, the workload was increased by adding resistance (Fadd).9 Increments of 2.00 to
5.25 W were imposed until exhaustion. The test protocol was previously described by Valent et al.21
Rolling resistance (Frol) of the individual hand cycle-user combinationon the treadmill was determined in a
drag test on the treadmill.23 The
power output (PO) was calculated
from the separately measured individual drag force (Frol [N]), Fadd (N),and treadmill belt velocity (v[m䡠s⫺1]):
PO共W兲 ⫽ 共F rol ⫹ F add 兲 ⫻ v
During the test, oxygen uptake (V̇O2)
was measured continuously with an
Oxycon Delta spirometer.§ The high‡Bonte Techniek BV, Amperestraat 25A 8013
PT, Zwolle, the Netherlands.
§
Viasys-HC, De Molen 8/10, 3994 DB,
Houten, the Netherlands.

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Physical Therapy

est average 30-second values of PO
and V̇O2 during the test were defined
as POpeak and V̇O2peak. Heart rate
was continuously monitored with an
HR monitor,㛳 and HRpeak was defined as the highest HR value recorded in a 5-second interval. Cardiovascular efficiency, reflected by theoxygen pulse (O2P [mL䡠beat⫺1]),
was calculated from V̇O2peak andHRpeak (O2P [mL䡠beat⫺1] ⫽ V̇O2peak[mL䡠min⫺1]/HRpeak [bpm]).24

on a 5-point scale (1⫽not serious,
5⫽very serious).19 We scored shoulders, elbows, and wrists separately,
but the scores for left and right sides
were summed.

Muscle strength. Arm muscle
groups (elbow flexors and extensors, shoulder exorotators and endorotators, and abductors) that scoredⱖ3 on manual muscle testing were
tested with handheld dynamometry(Microfet#), according to a standardized protocol.25 A break test was performed in which the participants
built up a peak force against a dynamometer, after which the examiner
applied a sufficiently higher resistance to break through it.26 The peakforces of the left- and right-side muscle groups were summed. Only dataof participants with a strength scorefor both left and right sides for acertain muscle group were includedin the strength analysis.

Results

Pulmonary function. To assess
training effects on pulmonary function, we measured and analyzed simple spirometric values with the Oxycon Delta spirometer. Forced vital
capacity (mL䡠min⫺1) and peak expiratory flow (mL䡠min⫺1) were recorded relative to age-, sex-, andbody weight-corrected normative
data.
Adverse Effects
Pain in the upper extremities (ie, themusculoskeletal system) was scoredbefore and after the training periodwith a self-designed questionnaire㛳Polar Electro Nederland BV, Postbus 1044,
1300 BA Almere, the Netherlands.
#
Biometrics Europe BV, Kabelstraat 11, 1322
AD Almere, the Netherlands.

Data Analysis
The change between the pretraining
and posttraining outcome measurements was examined using SPSS
version 15** with a paired, 2-tailed
Student t test (P⬍.05).

Twenty-two participants were included in this training study (Tab. 1).
Five participants were moderately
active (1.5 hours a week), and allother participants were minimally
physically active or were not physically active. Fifteen participants
completed the training period (t1–t2) and performed a pretest and a
posttest. A subgroup (participants
1–7) of these 15 participants also
performed an extra test (t0).
Seven participants dropped out during the training period due to various
reasons: problems with transportation to the training facility (participant 18), a chronic urinary tract infection (participant 19), persistentbowel problems combined withspasms (participant 20), pressure ulcers as a consequence of a fall out of
the wheelchair at home (participant21), a work-related overuse injury of
the elbow (participant 22), serious
pain as a consequence of bowel
problems (participant 17), and illness (the flu) after 3 weeks of training (participant 8).
No significant differences were
found in personal and lesion characteristics among the 7 participants
who dropped out (Tab. 1) and those
who completed the training (n⫽15):
age (X⫽43 years, SD⫽13 versus
X⫽38 years, SD⫽11); TSI (X⫽9** SPSS Inc, 233 S Wacker Dr, Chicago, IL
60606

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October 2009

October 2009

Volume 89 Number 10
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F

F

M

M

M

M

M

M

M

M

M

F

M

M

F

M

M

M

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

12

SD

17

81

110

60

77

64

84

100

63

70

71

84

80

113

77

81

117

70

88

65

58

85

86

83

Weight
(kg)

C6/T1

C5/C6

C7/C7

C8/T1

C6/C6

C5/C6

C5/C5

C5/C7

C8/C8

C8/C8

C7/C8

C5/C5

C7/C7

C7/C7

C6/C6

C6/C6

C7/C7

C6/C6

C6/C7

C6/C6

C6/C7

C6/C6

Lesion Level(Right/Left)

A

A

B

B

B

B

A

B

D

B

A

A

B

B

A

B

B

D

C

B

B

B

AIS
Classification

Hr

El

Hr

Hr

El

Hr

El

Both

Hr

Hr

Hr

El

Hr

Hr

El

Hr

El

El

Hr

Hr

Hr

El

Daily
Wheelchair

1

0

0

1

1

2

0

2

0

0

0

2

1

0

3

0

1

3

3

0

0

0

ISPS
(0–3)

0

0.5

1

0

0

0.5

0.5

1

0

1

1

1.5

1.5

1.5

0

1

0

0

1

1.5

1.5

0

Phys Act(hr/wk)

Yes

Yes

Yes

No

No

No

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

No

Yes

Yes

Yes

No

Hand
Cycle
Experience

1

8

1

10

3

4

5

0

8

12

7

8

7

6

8

8

3

8

10

8

8

8

8

10

3

19

do

do

do

do

do

do

20

24

17

19

18

13

19

24

do

24

20

20

23

23

24

17

Training Period
Sessions(wk)
Completed

21.9

42.5

17.8

16

36

28

23.7

32.0

14.0

20.6

47.1

60.6

66.6

16.0

66.8

69.6

32.0

41.9

24

14

41.8

74.3

51.8

28.8

Pre

25.4

50.9

22.0

21.0

57.6

71.7

86.0

16.0

82.7

74.2

52.4

28

16

53.8

78.5

65.0

38.8

Post

POpeak
(W)

0.40

1.32

0.90

0.61

1.32

0.80

0.94

1.12

0.75

1.08

1.69

1.40

1.73

0.91

1.50

2.20

0.82

1.10

0.91

0.95

1.21

1.60

1.60

1.12

Pre

0.43

1.43

0.81

1.12

1.39

1.66

1.87

1.04

1.72

2.00

1.15

0.84

0.95

1.57

2.02

1.93

1.38

Post

V̇O2peak(L䡠minⴚ1)2⫽slightly moderate pain, 3⫽moderate pain), Phys Act⫽physical activity (sports or outdoor manual wheelchair propulsion), do⫽dropout, pre⫽pretraining, post⫽posttraining.

a M⫽male, F⫽female, TSI⫽time since injury, AIS⫽American Spinal Injury Association Impairment Scale,18 Hr⫽hand-rim wheelchair, El⫽electric wheelchair, ISPS⫽initial shoulder pain score (1⫽minimal pain,

7

10

39

X

6

3

2

20

12

3

6

2

6

12

8

6

28

3

7

3

20

17

15

2

15

TSI
(y)

16

21

34

45

58

48

25

48

44

28

32

43

32

54

42

29

64

37

31

37

22

41

Age
(y)

51

M

M

3

22

M

M

1

2

Sex

Subject
No.

Participant Characteristics, Training Adherence, and Peak Power Output (POpeak) and Peak Oxygen Uptake (V̇O2peak) Measurementsa

Table 1.

Hand Cycle Training in Tetraplegia

Physical Therapy f1055

Hand Cycle Training in Tetraplegia
years, SD⫽7 versus X⫽10 years,SD⫽8), body mass (X⫽87.4 kg,SD⫽22.2 versus X⫽78.2 kg,SD⫽13.3), lesion level (C5 [n⫽2],
C6 [n⫽3], C7 [n⫽1], and C8 [n⫽1]versus C5 [n⫽3], C6 [n⫽6], C7[n⫽4], and C8 [n⫽2]), and AIS classification18 (A [n⫽3], B [n⫽4], C[n⫽0], and D [n⫽0]) versus A[n⫽3], B [n⫽9], C [n⫽1], and D[n⫽1]), respectively. However, thedropouts had significantly lower
baseline levels of the primary outcome measures of physical capacity
than those who completed thestudy: POpeak (X⫽26.5 W, SD⫽7.2
versus X⫽42.5 W, SD⫽21.9)(P⫽.099) and V̇O2peak (X⫽0.93
L䡠min⫺1, SD⫽0.25 versus X⫽1.32
L䡠min⫺1,SD⫽0.40)(P⫽.04),
respectively.
Five dropouts had light to moderateshoulder pain at baseline. Six participants who completed the training
period initially had light to moderateshoulder pain, and 4 of these participants appeared to have a low baseline physical capacity and only slightabsolute improvements after training(Tab. 1).
Training
Protocol. It turned out to be difficult for the participants to complete
24 training sessions within the designated period (Tab. 1). Five participants missed 5 to 7 sessions, which
was more than 20% of all sessions.
The main reasons reported were: notfeeling well because of an illness(urinary tract infection, flu), transportation problems, too busy (withwork), too tired, and no people available to help start up training. Overuse injuries were not mentioned.
The distances covered during thehand cycle training sessions increased over time and varied from 2
to 7 km. All participants who completed the training managed to train
at, on average, 60% to 80% of HRR,
with the 1- to 2-minute rest intervals
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included. During the 3- to 4-minutehand cycle intervals, the HR was between 70% and 80% of HRR. A mean
intensity of 6 (SD⫽1) on the 10-point
Borg scale was reported after the
training sessions, compared with 7(SD⫽2) after completing the peak
exercise test. Particularly those participants with a very limited active
muscle mass and a high body mass,
who already were exerting at a nearmaximal level when moving thehand cycle forward, initially had tohand cycle in a roller trainer (at alower power level). After 4 to 6
weeks of training, all participants
who completed the training wereable to train outdoors at the suggested intensity.
Adverse effects. The training wasnever stopped because of complaints of pain in the arms or shoulders, although 3 participants wereadvised on one occasion to postpone
the next training day or to train at alower intensity (or gear setting).
Comparing pretraining and posttraining pain scores, no increase inpain scores for the wrists or elbows
was found following hand cycle
training. Three participants (participants 3, 6, and 11) reported a slightly
higher shoulder pain score after
training compared with before training. All 3 participants mentioned that
this higher pain score was due tomuscle soreness as a consequence of
training too hard (with a gear settingthat was too high), which disappeared within 1 day after training.
Outcome Measures
Hand cycle capacity. Table 2 presents the results of the pretestposttest design (n⫽15). Mean peak
respiratory exchange ratio was 1.10
in both the pretest and the posttest,
suggesting that, in general, V̇O2peak
was reached. The VO2peak significantly improved, on average, 114mL䡠min⫺1 (SD⫽204) after training,which was an increase of 8.7%
(SD⫽13.9%). In addition, a signifi-

cant improvement in POpeak of 8.3
W (SD⫽5.8) was found after training, which was an increase of 20.2%(SD⫽15.0%).
No significant improvement in O2P(mean difference⫽1.3 mL䡠beat⫺1,SD⫽0.2) (P⫽.06) was seen in the
pretraining-posttraining comparison(n⫽14; Tab. 2). As expected, HRpeak (n⫽14) did not change between pretraining (X⫽128 b䡠min⫺1,
SD⫽24) and posttraining (127b䡠min⫺1, SD⫽27). A significant decrease in V̇O2submax during hand cycling of 73 mL䡠min⫺1 (SD⫽122)(X⫽8.8%, SD⫽14.6%) (P⫽.04) was
found (n⫽14; Tab. 2) at a constant
power output, indicating improved
gross mechanical efficiency during
hand cycling.
Secondary outcomes. Only shoulder abduction strength significantly
improved (X⫽5.6%, SD⫽11%);
Tab. 2). No effects of hand cycle
training were found on pulmonary
function outcome measures.

Discussion
Structured hand cycle interval training showed significant positive effects on the primary outcomes ofphysical capacity (POpeak andV̇O2peak) but not on the secondary
outcomes (muscle strength and pulmonary function).
Training
A relatively high dropout rate of approximately 30% was encounteredin the training period. The relatively
low baseline physical capacity in the
dropouts compared with participants who completed the training
period may have been a result of along history of health problems thatprevented them from maintaining
their fitness level. In general, initialshoulder pain was more prevalent in
the study dropouts. Furthermore,
people with a relatively low physicalcapacity may be in a vulnerable
health condition and thus more

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Hand Cycle Training in Tetraplegia
Table 2.
Results of Hand Cycle Training: Paired t-Test Analysis of Outcome Measures Pretraining (t1) and Posttraining (t2) (n⫽15)a

Physical CapacitynDifference (t2 ⴚ t1)

t1

t2

X (SD)X (SD)P

X (95% CI)

Hand cycle capacity
POpeak (W)15

42.5 (21.9)

50.8 (25.4)⬍.001

V̇O2peak (mL䡠min⫺1)

15

1,317 (399)

1,431 (427).05

8.3 (5.2 to 11.5)
114 (0 to 227)

V̇O2peak (mL䡠kg⫺1䡠min⫺1)

14

17.3 (5.2)

19.1 (5.7).03

1.8 (0.2 to 3.4)

O2Ppeak (mL䡠beat⫺1)

14

10.7 (2.8)

12.0 (4.0).06

1.3 (0.1 to 2.5)

VEpeak (L䡠min⫺1)

15

52.0 (17.3)

54.9 (19.2).15

2.9 (⫺1.9 to 7.0)

RERpeak15

1.10 (0.16)

1.10 (0.14).93

0.01 (⫺0.03 to 0.07)

V̇O2submax (mL䡠min⫺1)

14

834 (116)

761 (58).04⫺73 (⫺144 to ⫺3)

HRsubmax (bpm)14

92 (17)88 (18).40⫺4 (⫺13 to 5)

Extension (L⫹R) (N)8331 (99)321 (96).47⫺10 (⫺42 to 21)

Flexion (L⫹R) (N)15571 (176)

578 (177).49

7 (⫺14 to 27)

Endorotation (L⫹R) (N)12358 (130)360 (118).83

2 (⫺9 to 19)

Muscle strength (HHD)

Exorotation (L⫹R) (N)12294 (101)304 (98).10

10 (⫺2 to 22)

Abduction (L⫹R) (N)15336 (86)355 (80).05

19 (0 to 38)

FVC (L䡠min⫺1)

15

3.80 (1.24)

3.82 (1.21).80

FVC (%)

15

75.5 (15.4)

76.8 (17).45

1.2 (⫺2.1 to 4.7)

PEF (L䡠min⫺1)

15

6.52 (2.23)

6.14 (2.00).07⫺0.37 (⫺0.78 to 0.04)

PEF (%)

15

70.0 (21.3)

66,3 (18.9).27⫺3.7 (⫺8.2 to 0.8)

Pulmonary function⫺0.02 (⫺0.21 to 0.16)

a CI⫽confidence interval, POpeak⫽peak power output, V̇O peak⫽peak oxygen uptake, O P⫽peak oxygen pulse, V̇O submax⫽submaximal oxygen uptake,2
2
2

HRsubmax⫽submaximal heart rate, HRrest⫽resting heart rate, V̇O2rest⫽resting oxygen uptake, RER⫽respiratory exchange ratio, VEpeak⫽peak ventilation,
HHD⫽handheld dynamometry, L⫽left, R⫽right, FVC⫽force vital capacity, PEF⫽peak expiratory flow. For some outcome measures of hand cycle capacity,
data were missing in one (but not the same) participant due to measurement errors. Muscle strength was not available for all muscle groups (as theparticipants scored less than 3 on manual muscle testing or manual muscle testing was not feasible due to pain).

prone to developing health problems. On the other hand, healthproblems, although less severe, also
were responsible for the high nonadherence rate found in the participants in the training program. It
should be noted that health problems in both dropouts and participants who completed training were
not related to the training. It can beconcluded that untrained people
with tetraplegia are in a vulnerable
health condition27 and that healthproblems are likely to interfere with
their life and thus with their ability toperform training programs.
Protocol. From a preceding unpublished pilot project in untrained
subjects with tetraplegia, interval
October 2009training appeared to be more suitable than continuous aerobic training. Most of the participants in ourpilot project were not able to handcycle continuously for longer thanapproximately 5 to 7 minutes,
whereas several hand cycle blocks of
3 minutes, with rest intervals between blocks, were easily sustainable and without extreme muscle fatigue. Therefore, a hand cycle
interval training (and discontinuoustest) protocol was designed. The exercise intensity was within the rangeof 50% to 90% HRR, HRpeak, andPOpeak, which was imposed in previous upper-body training studies inpeople with tetraplegia.10 The broad
range in RPE scores (4 –7) as well as
HRR values (60%– 80%) accounted

for the variation in intensity common during interval training.28
It should be noted from a previous
study21 that HRR and RPE scores
have limitations for monitoring exercise intensity in people with tetraplegia. The study participants tended toscore local arm muscle fatigue instead of overall perceived exertion,
which is intended by the Borg
scale.21 In addition, HR may not always reflect exercise intensity adequately, probably due to a disturbed
sympathetic innervation (ie, of theheart, resulting in a low HRpeak29)
or other factors related to the low
physical capacity and muscle mass
involved.21

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Hand Cycle Training in Tetraplegia
Despite these limitations, however,RPE together with HRR appeared
reasonably useful in training people
with tetraplegia. The 2 methods
combined helped participants toknow their body responses to exercise and understand that HR may notalways reflect exercise intensity. For
example, study participants reported
higher-than-normal HR values (andbetter performance) during training
in the days before a bladder infection
or illness was diagnosed. This finding
suggests that symptoms of autonomic dysreflexia were present.
Adverse effects. In about 40% of
the participants, light to moderate
pain to the upper extremities was
already present before they were included in the present study. With aprevalence between 40% and70%,7,19 pain in the upper extremities, especially in the shoulder, iscommon in people with tetraplegia.
They are at higher risk for developing musculoskeletal pain as a consequence of partial paralysis of thoracohumeral muscles and imbalance inshoulder muscles.7
We noticed that 2 out of 3 participants with temporal shoulder complaints ( participants 2 and 3) were
the only individuals who were using
conventional straight cranks (with ahigh-positioned crank axis). They
were forced to move their arms further against gravity and even above
shoulder level, which may be disadvantageousfortheshouldermusculature.
Despite instructions, participantstended to cycle with higher resistance instead of higher pedal frequencies. Cycling at a high resistance potentially can overload themusculoskeletal system, but is notreflected by exercise intensity(HRR). Therefore, especially in thefirst weeks of training, supervision of
the training regimen is recommended. Moreover, for those indi1058

f

Physical Therapy

viduals with initial shoulder pain, it
is advised to incorporate an additional muscle (rotator cuff) strengthening program into the training
protocol.30
Outcome Measures
Hand cycle capacity. The primary
outcome measures in the study,
POpeak and V̇O2peak, showed significant improvements over the training period. Table 1 shows the large
interindividual differences in our
main outcomes, and clearly an improvement of 8 W after training ismore substantial for someone with abaseline value of 16 W than for someone with a baseline value of 60 W.
Moreover, it is difficult to compare
absolute gains in POpeak andV̇O2peak with the literature whendifferent test devices and protocols
have been used and with subjects
with different training statuses.10
Nevertheless, the relative gains of
20.2% in POpeak and 8.7% in
V̇O2peak in the present study were inagreement with the study by McLean
and Skinner,11 who found gains of
13.7% and 8.3%, respectively, afterarm crank exercise. In another study
on arm crank exercise in young people with tetraplegia, gains of 23.8%
in POpeak and 99% in V̇O2peak were
found.12 Dallmeijer et al15 did not
find any significant improvements in
POpeak or V̇O2peak after quad rugby
training (once a week). During clinical rehabilitation, Hjeltnes andWallberg-Henriksson31 found significant gains in POpeak but no improvements in V̇O2peak.
The question remains: How much
improvement is clinically relevant?
According to Brehm et al,32 10% is
considered to be a meaningfulchange. Applying this arbitrary cutoff in the current study, an improvement in POpeak is designated clinically relevant and the change inV̇O2peak is nearly clinically relevant.

The gains in work capacity indicate
the ability to improve fitness in people with tetraplegia. The effects ofhand cycle training probably will be
primarily local and not necessarily
central, given the extremely low
muscle mass that is actively involvedin the exercise in this population.1
The greater relative increase in
POpeak (20.2%) compared withV̇O2peak (8.7%) and the decrease inV̇O2submax indicate an improvement in gross mechanical efficiency33 (ie, effects in reduced cocontraction as part of muscle
coordination of the arms and shoulders, as well as in external force production). Another possible explanation may be an improved exercise
tolerance in the muscles.
Muscle strength. No clinically relevant improvements in muscle
strength were found after hand cycling. In general, however, the participants reported feeling stronger. A
possible explanation may be improved exercise tolerance in themuscles. This improved exercise tolerance likely results from changes inmuscle metabolism (eg, increase inmitochondria, improved glycogenstorage and synthesis) or a higher
density of capillaries, during whichless lactic acid is accumulated anddiminished muscle fatigue is experienced.34 In the current study, however, we measured isometric peakstrength and not muscle endurance.
Pulmonary function. No improvements in functional vital capacity or peak expiratory flow were
found. In the literature, however, itappears that the effects of upperbody training on pulmonary functionin people with high levels of paraplegia or tetraplegia are notuniform.10,35,36
Study Limitations
The optimal study design (ie, a randomized controlled trial) was not
feasible due to the small number ofVolume 89 Number 10
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October 2009

Hand Cycle Training in Tetraplegia
available participants. Another limitation was the variability in baseline
physical capacity among the participants. However, coalescing subgroups to reduce variability washampered by the small sample size.
The number of dropouts and thenonadherence rate were considerable, but not uncommon in training
studies in people with tetraplegia.10
Due to dropouts, the group serving
as their own controls (n⫽7) was too
small to perform statistical analysis
of a double baseline group. With 19
training sessions (instead of 24), ourparticipants trained less thanplanned. Nevertheless, a positive effect was found on physical capacity.

Conclusions andRecommendations
A successful integration of aerobic
exercise training into the daily life ofpeople with tetraplegia may be more
likely if aerobic exercise is safe, easily adjustable to a person’s low physical capacity, fun to do, motivating,
low key, and useful in daily mobility,
as well as encouraging social participation. Hand cycling may meetthese requirements. Important arean adequate ergonomic interface andan optimal range of gear ratios (orinitial use of roller trainers) to impose an adequate power output.
Hand cycling around wherever you
like and over meaningful distances
may be fun to do. After a training
period, it may be motivating to see
improvements in fitness level anddistances covered. Hand cycling(with an attachable unit) may be low
key, as no transfers have to be made,and certainly if someone can startfrom home. The hand cycle may be
useful for daily mobility in an ergonomically suitable environment.
Hand cycling with peers or together
with family members and friends
during activities such as walking, jogging, or skating may encourage social participation.

October 2009

Especially vulnerable individuals
with a low physical capacity can benefit from initial supervision by skilled
professionals who can help themovercome personal and practical barriers in daily life. Future researchshould focus on the optimization ofhand cycle training protocols (eg,training at a certain percentage of
the POpeak, in watts, which was derived from the exercise test21,37) specifically designed for people withtetraplegia.
Dr Valent, Dr Dallmeijer, Dr Slootman, Dr
Janssen, and Dr van der Woude provided
concept/idea/research design. Dr Valent, Dr
Dallmeijer, Dr Houdijk, Dr Slootman, Dr
Janssen, and Dr van der Woude provided
writing. Dr Valent provided data collection.
Dr Valent, Dr Dallmeijer, Dr Houdijk, Dr
Slootman, and Dr van der Woude provided
data analysis. Dr Dallmeijer and Dr van derWoude provided project management. Dr
Dallmeijer provided fund procurement. Dr
Houdijk and Dr van der Woude provided
facilities/equipment. Dr Houdijk provided institutional liaisons. Dr Dallmeijer, Dr Houdijk,
Dr Slootman, Dr Janssen, Dr Post, and Dr vander Woude provided consultation (including
review of manuscript before submission).
Approval for the study was obtained fromthe local medical ethics committee.
This research, in part, was presented at the
47th Annual Scientific Meeting of the International Spinal Cord Society; September 1,
2008; Durban, South Africa.
This article was received October 26, 2008,
and was accepted June 1, 2009.
DOI: 10.2522/ptj.20080340

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Appendix.
Training Protocol (12 Weeks)
Week 2

Week 3

Week 4

Week 5

Week 6

Week 7

Week 8

Week 93 min hca 3 min hc

Week 13 min hc

3 min hc

3 min hc

3 min hc

3 min hc

4 min hc

4 min hc

2 min rest 2 min rest

1.5 min rest 1.5 min rest 1.5 min rest 1 min rest 1 min rest 1.5 min rest 1.5 min rest 1 min rest 1 min rest 1 min rest

6⫻

7⫻

7⫻

8⫻

8⫻

8⫻

8⫻

7⫻

7⫻

Week 10 Week 11 Week 12
4 min hc

7⫻

4 min hc

7⫻

4 min hc

8⫻

a hc⫽hand cycling.

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October 2009

Effects of Hand Cycle Training on Physical Capacity
in Individuals With Tetraplegia: A Clinical Trial
Linda J.M. Valent, Annet J. Dallmeijer, Han Houdijk,
Hans J. Slootman, Thomas W. Janssen, Marcel W.M.
Post and Lucas H. van der Woude
PHYS THER. 2009; 89:1051-1060.
Originally published online July 30, 2009
doi: 10.2522/ptj.20080340

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