Applied Ergonomics: Benoît Pierret, Kévin Desbrosses, Jean Paysant, Jean-Pierre Meyer
Applied Ergonomics: Benoît Pierret, Kévin Desbrosses, Jean Paysant, Jean-Pierre Meyer
Applied Ergonomics: Benoît Pierret, Kévin Desbrosses, Jean Paysant, Jean-Pierre Meyer
Applied Ergonomics
journal homepage: www.elsevier.com/locate/apergo
a r t i c l e i n f o a b s t r a c t
Article history: The aim of this study was to quantify cardiac, energetic and subjective strains during manual wheelchair
Received 12 November 2012 (MWC) travel on cross slopes (Cs). 25 paraplegics achieved eight 300 m propulsion tests combining 4 Cs
Accepted 7 January 2014 (0, 2, 8 and 12%) and 2 velocities (Vi ¼ 0.97 m s1, Vc “comfortable”). Heart rate and oxygen uptake were
recorded continuously. Subjective rating (RPE) was made on completion of each test. Vc exceeds Vi for all
Keywords: Cs. Cardiac and energetic strains at Vc also exceed those at Vi (p < 0.01). Mean cardiac cost (in bpm) at Vc
Wheelchair
is 34 (SD ¼ 13) bpm for a 0/2% Cs and 55 (18) bpm for a 12% Cs. Mean energetic cost (in J m1 kg1) is 1.20
Cross slope
(0.38) and 2.76 (0.97) for respectively 0/2% and 12% Cs at Vi and, at Vc 1.50 (0.43) and 3.37 (1.43) for 0/2%
Strains
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. 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.
Ó 2014 Published by Elsevier Ltd.
1. Introduction et al., 2006). Indeed, Cs causes gyratory action of the chair’s front
wheels, which generate a force that tends to pull the “subject-
In France, nearly 200,000 disabled persons use a manual wheelchair” combination to the lower side and requires users to
wheelchair (MWC) and live at home (Vignier et al., 2008). Travel- fight against this force in order to keep a straight course (Cooper,
ling difficulties are one of the determining factors in non- 1990; Van der Woude et al., 2001).
integration or occupational exclusion of persons in MWC (Lidal A 2% Cs limit is regulatory in many countries (McMillen et al.,
et al., 2007; Van Velzen et al., 2009). Environmental unsuitability 1999), but this may not always be respected. Furthermore, no
amplifies an MWC’s initial constraints and requires greater cardio- result really prompts justification of this 2% established Cs limit. In
respiratory and muscular exertion on behalf of persons in relation fact few studies have focused on MWC movements on a Cs. A recent
to their physiological capacities (Collins et al., 2012, Meyers et al., review by Cooper et al. (2011) only lists five such studies. Three
2002). Although the peak oxygen uptakes of MWC sportsmen were mainly directed towards the biomechanical aspects of
may exceed 35 ml kg1 min1 (Bhambhani, 2002; Haisma et al., wheelchair propulsion (Brubaker et al., 1986; Chesney and Axelson,
2006; Huonker et al., 1998; Van der Woude et al., 2001), these ca- 1996; Richter et al., 2007). The other two addressed the problems of
pacities are less than 20, even 15 ml kg1 min1 for many users travelling on varied surfaces, some with a Cs, experienced by
(Figoni, 1984; Haisma et al., 2006; Tahamont et al., 1986). Additional populations suffering from various pathologies (Longmuir et al.,
constraints like cross slope (Cs) which is the slope that is perpen- 2003; Kockelman et al., 2001). Only the Brubaker et al. (1986)
dicular to the direction of travel, can thus degrade MWC user social and the Kockelman et al. (2001) studies included physiological
life and state of health by increasing musculo-skeletal disorders measurements. Despite the disparity in these studies an overview
(Burnham and Steadward, 1994; Mercer et al., 2006; Van Drongelen reveals that Cs limits of between 16 and 20% for short distances
(Chesney and Axelson, 1996) and for longer journeys, a 4% Cs is
acceptable for all users and a more critical 10% limit should never be
* Corresponding author. Tel.: þ33 3 83 50 20 54; fax: þ33 3 83 50 21 85.
E-mail addresses: benoit.pierret@yahoo.fr (B. Pierret), kevin.desbrosses@inrs.fr exceeded (Kockelman et al., 2001). These values are very far from
(K. Desbrosses), jean.paysant@ugecamne.fr (J. Paysant), meyer@inrs.fr (J.-P. Meyer). the 2% regulatory limit (McMillen et al., 1999).
With a view to proposing a rationalised allowable Cs, the pre- insured physiological parameter stability (Wilmore and Costill,
sent study sets out to determine the cardio-respiratory and sub- 2004). The order of testing of the 8 conditions was random.
jective strains involved in MWC travel under real propulsion The propulsion method was free. The travelling direction con-
conditions on different Cs and at two travelling velocities for a large ditions the dominant body side in the most demanding side i.e.
number of regular MWC users. in the steeper Cs. The subjects used their own MWC. Wheel
diameter was 24 inches and tyres were inflated to a pressure of
2. Equipment and methods 8 bar.
The imposed velocity Vi (0.97 m s1), constant for the 4 Cs, was
The study was conducted in the occupational physiology labora- monitored by electroluminescent diodes fixed every 2 m along the
tory at the Institut National de Recherche et de Sécurité (INRS) jointly walls bordering the test track. The subjects adjusted the travelling
with the Institut Régional de médecine physique et de Réadaptation velocity based on delayed lighting of the diodes. The Vi and the Vc,
(IRR) both located in Nancy in the eastern part of France. chosen by the subject, were measured by timing at each lap.
Temperature and relative humidity were measured for each half-
2.1. Subjects day using a portable hygro-thermometer (RH70, OmegaÒ).
The 25 volunteer subjects were recruited from patients moni- 2.3. Measured variables
tored at the IRR, based on the following inclusion criteria: men,
paraplegic, adult and of working age (18e65 years old), travelling The measured physiological parameters were heart rate (HR in
independently and regularly in an MWC for more than 6 months. bpm), oxygen uptake (VO2 in ml kg1 min1) and carbon dioxide
Injury level was defined as “high” for injuries at or higher than the production (VCO2 in ml kg1 min1). Subjective strain was assessed
6th thoracic vertebra, and as “low” for injuries of the 7th thoracic based on the Rating of Perceived Exertion (RPE) scale (Borg, 1998).
vertebra or lower who have functional abdominal muscles. Subjects HR was measured continuously for the whole day using a cardio
have no contraindication (cardiovascular, pulmonary, muscular, frequency meter (PolarÒ, S 810 i) with a count integration time of
skin and/or developing general pathologies). They were informed 15 s. Cardiac strain parameters were: a) the HR, b) the absolute
of the study protocol and gave their written consent. The study cardiac cost (ACC in bpm), which is the difference between the
received approval from the local ethical committee. mean HR during the test and the HR when seated and at rest, c) the
relative cardiac cost (RCC in %), which expresses the percentage
2.2. Protocol 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
Two tests were performed: a test involving sub-maximal exer- RCC is determined by the ACC/HRR ratio.
tion on an arm ergocycle and a propulsion track test. The arm Respiratory parameters were recorded using a cycle-to-cycle
cranking test was conducted on a first half-day dedicated to the gas analyser telemetric system (Cosmed K4b2Ò). The respiratory
study inclusion medical examination. A second full-day was dedi- parameters processed were: a) the VO2, b) the energetic cost per
cated to the track propulsion testing. At least two rest days sepa- metre travelled and per kg weight (ECmkg in J m1 kg1) and, c)
rated the two test sessions to eliminate fatigue from the cranking the relative energetic cost (REC in %). The ECmkg is the product
test. Both tests were conducted under medical surveillance. of the oxygen cost (cVO2) by the energy equivalent of 1 L of
oxygen (k in kJ l1) divided by the velocity and the weight
2.2.1. Cranking test (P ¼ subject þ MWC weight in kg); ECmkg ¼ cVO2 k/V.P. The
The sub-maximal arm cranking test was conducted on an arm oxygen cost (cVO2 in ml kg1 min1) is the difference between the
ergocycle fitted with a magnetic induction braking system ensuring mean VO2 during the test and the VO2 at rest. The energy equiv-
power control (Upper Body Cycle, KardiomedÒ). This test allowed alent of 1 L of oxygen is calculated using the equation
to estimate the peak oxygen uptake (VO2max) of the subjects k ¼ 16.6 þ 4.6 RQ, in which the respiratory quotient (RQ) is the
through extrapolating the relationship between HR and VO2 to ratio VCO2/VO2. The REC represents the fraction of the oxygen
their HRmax (Paré et al., 1993). The test started with a 2-min, 25 W reserve involved in the exercise. REC is the ratio between the cVO2
warm-up step before continuing in 2-min steps with an increase of and the oxygen reserve (VO2R), equal to VO2maxeVO2rest
10 W per step. Pedalling frequency was 50 rotations per minute. (Wilmore and Costill, 2004).
The test was stopped when the subjects reached 85% of their Subjective strain was obtained using the RPE scale (Borg, 1998).
theoretical maximum heart rate (HRmax ¼ 220 e age in years) A global and 5 local assessments (back, shoulders, upper limbs)
(Wilmore and Costill, 2004). were asked for at the end of each track test.
Table 1
Table 2
Means, standard deviations and peak values of anthropometric and functional
Mean cardiac strains: heart rate (HR), absolute cardiac cost (ACC) and relative car-
characteristics for 25 paraplegic men and their injury level and age.
diac cost (RCC) for imposed (Vi) and comfortable (Vc) velocities at the 3 cross slopes
Mean (SD) Minimumemaximum (0/2%, 8% and 12%).
Age (year) 38.9 (9.5) 23e61 Cross HR (bpm) ACC (bpm) RCC (%)
Height (cm) 178.0 (7.7) 163e192 slope
Weight (kg) 75.3 (14.0) 57e116
(%) Vi Vc Vi Vc Vi Vc
BMI (kg m2) 23.8 (4.6) 16.5e34.6
VO2max (ml kg1 min1) 25.0 (5.5) 19.4e38.0 0/2 92.2 (14.6) 106.5 (16.4) 19.9 (5.7) 33.7 (12.9) 19 (6) 31 (11)
Injury level T3eL4 8 104.4 (14.9) 117.8 (18.2) 34.5 (14.0) 45.0 (15.0) 32 (14) 42 (16)
Injury age (years) 10.6 (7.8) 2e32 12 114.7 (19.0) 129.5 (15.9) 43.7 (18.4) 55.1 (17.8) 40 (18) 51 (16)
B. Pierret et al. / Applied Ergonomics 45 (2014) 1056e1062 1059
Table 3
Mean energetic strains: oxygen uptake (VO2), energy cost per meter and per kg
(ECmkg) and relative energetic cost (REC) for imposed (Vi) and comfortable (Vc)
velocities at the 3 cross slopes (0/2%, 8% and 12%).
Cross VO2 (ml kg1 min1) ECmkg (J m1 kg1) REC (%)
slope
% Vi Vc Vi Vc Vi Vc
0/2 8.0 (1.3) 11.2 (3.1) 1.20 (0.38) 1.50 (0.43) 16.8 (7.5) 32.0 (13.5)
8 10.8 (2.1) 13.3 (3.3) 2.11 (0.76) 2.33 (0.94) 29.6 (14.0) 42.3 (15.4)
12 11.9 (2.6) 15.7 (4.0) 2.76 (0.97) 3.37 (1.43) 37.5 (15.5) 52.4 (17.9)
Our discussion will address in succession points concerning The 25 active male subjects had a mean VO2max of 25.0 (5.5)
methodology, subject characteristics and travelling velocities ml kg1 min1, which compares with the highest data in the
before analysing the strain levels for different Cs and comparing literature for paraplegic MWC users who are not sportsmen (Van
these with data in the literature. At the end of this discussion, we der Woude et al., 2001; Bhambhani, 2002) and exceeds the most
propose a Cs limit model. frequently quoted values between 15 and 25 ml kg1 min1
(Hjeltnes, 1986; Figoni, 1984; Veeger et al., 1991). In a less active
4.1. Methodology population than that studied, Cs generated strains would un-
doubtedly be greater than those observed in the present study.
Unlike the majority of studies published to date, the results of While at Vc, the 12% Cs represents an energetic strain of 52% in the
this work are based on a large number of paraplegic subjects (25) study population (Table 3), it would represent 75% of the maximum
accustomed to travelling in an MWC. However, this subject “uni- capacity for a less active population with a VO2max of only
formity” is only partial since there is great variability between in- 20 ml kg1 min1. Cs consequences would undoubtedly be even
dividuals as shown by the standard deviations for the results more constraining for a more fragile, older and less active
displayed in Tables 2 and 3. Although this variability may be partly population.
explained by subject age, BMI, VO2max, physical activity and trav- The results reveal the surprising effects of injury level on Vc and
elling velocity, it is not totally remedied by taking into account RQ. Subjects with “high” level injuries, who have no functional
individual variables (Eqs. (1) and (2)). This testifies to the complex abdominal musculature, in fact chose a mean Vc that was signifi-
nature of MWC travel, involving unconsidered parameters, such as cantly (p < 0.05) faster (1.25 m s1) than those with “low” level
user technique and training, wheelchair adaptation, strength ca- injuries (1.18 m s1). This difference is significant for all Cs. The
pacities, efficiency variation with respect to Cs or velocity (Cooper, literature offers no explanation for this phenomenon. Maintaining
1990; Paré et al., 1993; Van der Woude et al., 2001). In the present a straighter trajectory may require users to travel faster. Lack of
study it was not possible to monitor accurately power unbalance trunk stability could also cause paraplegics with “high” level in-
between the 2 upper limbs and MWC speed and trajectories. This juries to lean more on the handrails to keep in balance, which
was due to space limitations in the experimental corridor and would also result in a higher Vc. Moreover, the trunk flexion
impossibility to equip the MWC of each subject. In consequence, amplitude should be greater for a “high” level injury (Chow et al.,
the effects of biomechanical factors of the MWC movement are not 2000). These hypotheses could not be verified in this study. Even
considered while they could explain part of the individual vari- lower RQ for “high” level injured users could be interpreted as less
ability. Our choice of 4 Cs (0, 2, 8 and 12%) was made to try to muscles involved or less respiratory difficulties for them as for the
understand this complexity, built a strain model and to take in “low” level injured users. Thus, trunk flexion could be used to
account the 2% regulatory reference slope adopted in many coun- reduce energetic and respiratory strains.
tries (McMillen et al., 1999) and the acceptable Cs of 10% The Vc is significantly different for 0% and 2% Cs, yet no other
(Kockelman et al., 2001) which explains the choice of 8 and 12% Cs result reveals a difference between travelling on the flat and over a
as upper anchor of the strain model. The Vi (0.97 m s1) is used 2% Cs. This result makes Vc a powerful strain indicator for assessing
fairly conventionally (Brubaker et al., 1986; Mukherjee and the difficulty of a travelling condition.
Samanta, 2001) and was easy to be maintained constant. The a The exertion perceived by the subjects with “low” level injuries
priori decision to perform 6 laps has been validated since it allows 3 (RPE ¼ 9.9) was higher (p < 0.001) than that perceived by subjects
stable laps from physiological and velocities point of view. with “high” level injuries (RPE ¼ 8.5), who nevertheless travelled
1060 B. Pierret et al. / Applied Ergonomics 45 (2014) 1056e1062
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