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Research Reports |
CE Beekman, PT, is Clinical Manager, Spinal Injury and Pediatric Services, Physical Therapy Department, Rancho Los Amigos Medical Center, 7601 E Imperial Hwy, Downey, CA 90242. Address all correspondence to Ms Beekman
L Miller-Porter, PT, is Clinical Manager, Adult Orthopedic and Outpatient Services, Physical Therapy Department, Rancho Los Amigos Medical Center
M Schoneberger, PT, is Physical Therapist, Santa Barbara Visiting Nurses Association, Santa Barbara, Calif. She was Physical Therapy Instructor, Spinal Injury Service, Rancho Los Amigos Medical Center, when the study was conducted
Submitted December 26, 1997;
Accepted October 8, 1998
 | Abstract |
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o2 mL/kg/m) were compared by wheelchair, group, and over time, using a Bonferroni correction. Results. In the ultralight wheelchair, speed and distance traveled were greater for both subjects with paraplegia and subjects with tetraplegia, whereas o2 was less only for subjects with paraplegia. Subjects with paraplegia propelled faster and farther than did subjects with tetraplegia. Conclusion and Discussion. The ultralight wheelchair improved the efficiency of propulsion in the tested subjects. Subjects with tetraplegia, especially at the C6 level, are limited in their ability to propel a wheelchair.
Key Words: Energy cost • Paraplegia • Spinal cord injury • Tetraplegia • Wheelchair
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Most commonly, the alternative mode of mobility chosen is a wheelchair (WC). More than half of the 183,000 to 230,000 people with SCI in the United States4 are nonambulatory and are presumed to use WCs. Wheelchair propulsion (WCP) is more efficient than walking for people with extensive paralysis,5–8 but less efficient than normal walking. The inefficiency of WCP is due, in part, to the small muscle mass of the arms and the biomechanical disadvantages of using handrims to propel the WC.9 In people with SCI, other factors such as impaired sympathetic vascular responses,10–12 respiratory compromise,12 and trunk instability13 further impair the effectiveness of WCP. Because of the relative efficiency of WCP for people with SCI and the large number of people with SCI in WCs, considerable efforts have been made to identify the WC models, components, and propulsion techniques that maximize the efficiency of WCP.11,14–21
Energy cost studies have been used to compare the efficiency of different WCs and to document the demands of WCP in subjects with various impairments. Researchers have compared WCP using arm cranks and handrims,9,11,17,18 front and rear location of the large wheels,20 various surfaces,18,22,23 different starting techniques,24 standard and sports or lightweight WCs,14,15 and various speeds of WCP.21 Other researchers have investigated the kinematics of WCP16,25 and muscle activity during WCP.26–28 Investigations of maximal aerobic capacity in subjects with SCI12,29,30 have added further information about physiological responses during WCP.
Limitations exist in a number of these studies. One limitation is the use of a constant, preestablished speed, rather than a self-selected speed.11,14,21 A self-selected speed is thought to better reflect demands during daily propulsion, when the patient is able to change his or her energy output to one that is most efficient31 for him or her. Another limitation is the use of subjects who do not have an impairment affecting their ability to propel a WC.11,17,20 Subjects without impairment have a more stable sitting position13 and are unable to mimic the postures that must be assumed by people with tetraplegia or paraplegia to maximize stability and muscular output. Although some research comparing lightweight and standard WCs has been published,14,15 additional studies are needed to corroborate those findings and to investigate other variables of WCP. Aspects of WCP that we believed warranted further study were the effects of level of injury, use of a self-selected speed, and data collection during a longer bout of WCP than had been used by previous researchers.
The purpose of our study was to determine the energy cost of WCP in people with SCI, comparing ultralight wheelchairs (UWCs) with standard wheelchairs (SWCs), people with different levels of injury, and changes over a 20-minute trial.
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Subjects propelled each WC for 20 minutes around a level outdoor track, 60.5 m in circumference. The UWC was a 43.2-cm (17-in) Everest and Jennings (E&J) Lightning,* with 12.7-cm (5-in) casters and a 3-degree rear wheel camber. The Lightning had a rigid frame and no armrests and weighed 12.2 kg (27 lb). Its seat back height was not adjustable. A WC with a rigid frame was selected over a WC with a folding frame because the treating therapists believed, based on their experience, that the subjects would have more efficient WCP in a rigid chair. The E&J Lightning was one of the few rigid-frame WCs available when the study was initiated. The SWC the subjects used was either a 40.6- or 45.7-cm-wide (16- or 18-in-wide) E&J Premier,* with 20.3-cm (8-in) casters and vertical rear wheels. The 40.6-cm SWC weighed 20 kg (44 lb), and the 45.7-cm SWC weighed 22.2 kg (49 lb). Both the UWC and the SWCs had 61-cm (24-in) rear wheels with pneumatic tires, which were maintained at 60 psi. Rubber tubing was spirally wrapped around the handrims of the chairs for subjects with C6 tetraplegia to help maintain hand contact. Each subject sat on a pressure-relieving cushion, which, in most cases, was of 10.2-cm (4-in) foam with a cutout for the ischial tuberosities. Each subject transferred to the selected WC, and the footrests were adjusted. A soft cloth strap was secured around the chest of subjects with C6 tetraplegia. The strap was loose enough to allow arm movement and some trunk movement, but tight enough to prevent excessive forward excursion of the trunk.
Test equipment was fitted to each subject, and he or she was given 3 to 5 minutes to become familiar with breathing into the mouthpiece and propelling while wearing the apparatus. After a 3-minute rest, baseline resting data for oxygen uptake were recorded for 2 minutes.
Each subject propelled around the track at a self-selected speed for 20 minutes in either a clockwise or counter-clockwise direction. The direction of travel allowed the subject's stronger or dominant arm to be to the outside of the track. Expired air samples were collected without interrupting propulsion for 2 minutes at minutes 3 through 5 and for 1 minute at minutes 9 through 10, 14 through 15, and 19 through 20. The distance traveled was recorded during each period. Total distance traveled during 20 minutes or the maximum time pushed was determined by counting the number of laps completed.
The oxygen consumed by subjects was measured using a modified Douglas bag technique.33 The inner diameter of the 2-way respiratory valve was 40 mm. A thermistor sensitive to change in the temperature of inspired and expired air was placed in the airway just beyond the mouthpiece and was used to monitor respiratory rate. Heart rate was measured using bipolar surface electrodes placed over the manubrium and the left seventh intercostal space. Heart rate and respiratory rate were transmitted to a strip chart recorder by a battery-powered FM-FM telemetry system.
Telemetry eliminated the need for wires or cables that might impede normal WCP. Airway valves, hoses, and the telemetry system were supported by a lightweight shoulder harness. A frame of polyvinyl tubing, which weighed 1.02 kg (2.25 lb), extended behind the chair to support the 5-way valve and the 5 air collection bags (Fig. 1). Oxygen content of the expired air was measured using a paramagnetic oxygen analyzer. Carbon dioxide content was determined with an infrared analyzer.
The analyzer was calibrated daily prior to each test to gases of known content. A dry gas flowmeter was used to determine expired air volume. All volumes were corrected to standard values for temperature, pressure, and water vapor (body temperature, pressure, saturated units). Vital capacity was measured using a Breon Laboratories model 2400 spirometer.
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o2 mL/kg/m). The oxygen consumed over a given period of time (o2 mL/kg/min) has not been shown to differentiate among groups during WCP when a self-selected speed is used5 and therefore was not analyzed. Means and standard deviations were calculated for descriptive data and the energy cost variables. Comparative analyses were done by condition (WC), by group (SCI level), and over time (4 data collection periods) using a mixed-design analysis of variance (ANOVA), with 1 between-group factor (the 4 groups) and 2 within-group factors (WC and time). To help identify sources of differences, 2 x 4 (WC x time) ANOVAs for repeated measures were performed. Data were analyzed using a Crunch interactive statistical software package.|| When the computer program could not analyze data from subjects with missing data, mean group values were substituted for the missing data. This substitution was made for 2 subjects who did not complete the fourth data collection period and for 3 other subjects during one data collection period due to technical difficulties. Scheffé post hoc tests were used to determine significant comparisons. Because of the presumed interrelationship of the dependent variables, the number of variables studied was limited to the 3 identified above. In addition, the level of significance (alpha level) was lowered from .05 to .0167, using a Bonferroni correction for 3 dependent variables.35
The purpose of the Bonferroni correction is to compensate for the probability of a Type I error, which is increased when multiple interdependent variables are statistically analyzed. Type I errors occur when the null hypothesis is erroneously rejected. This erroneous rejection of the null hypothesis means that differences have been statistically identified, when they do not actually exist. Ottenbacher's35 discussion of problems associated with analyzing multiple dependent variables in rehabilitation research forms the rationale for the statistical procedures used in this study. Methods for dealing with the problems of multiplicity (multiple interrelated dependent variables) include lowering the significance level, using multivariate statistical procedures, and applying appropriate post hoc tests. We were able to adopt the recommendation for the use of post hoc comparisons, but we were unable to perform multivariate analyses with the Crunch statistical program. We, therefore, chose to decrease the alpha level by using the Bonferroni correction. It is calculated by dividing the chosen alpha by the number of dependent variables. In our case, an alpha of .05 was divided by 3, which resulted in a revised alpha level of .0167.
Because of the small group sizes, subjects with C6 and C7–8 tetraplegia were combined and described as being in the "primary group with tetraplegia." The subjects with T2–8 and T10–L1 paraplegia were combined and described as the "primary group with paraplegia." The purpose of this combination of subjects was to increase the sample size and, thus, the statistical power. Power is the probability of correctly rejecting the null hypothesis. Beta, or the probability of a Type II error, is 1–power. A Type II error occurs when the null hypothesis is erroneously accepted. This erroneous acceptance of the null hypothesis means that differences have not been statistically identified, when they actually exist. Power is affected by sample size, the size of the effect being detected, and the chosen probability value.
A power analysis was performed, using the PASS computer program,# with a large effect size (ie, .4) and P=.05 (Tab. 3). A power of .8 or .85 is considered adequate to reduce the probability of a Type II error. When the subjects with C6 tetraplegia and the subjects with C7–8 tetraplegia were analyzed separately, the power was low (ie, .67 and .74, respectively). When the 2 groups were combined as primary group with tetraplegia, a power of .86, which is in the desired range, was achieved. Additional mixed-design ANOVAs were performed using tetraplegia and paraplegia as the between-group factors.
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o2 mL/kg/m as dependent variables. This section is organized so that data for the 3 dependent variables are presented for each of the independent variables. All subjects completed the first 3 data collection periods in both WCs. Two subjects failed to complete the final data collection period, 1 subject with C6 tetraplegia in the UWC and 1 subject with T2–8 paraplegia in the SWC.
Comparison by Wheelchair
Total distance traveled (in meters).
The mean distance propelled in 20 minutes in the UWC was greatest for the subjects with T2–8 paraplegia (1,517.48 m, P <.0000) and the subjects with T10–L1 paraplegia (1,557.72 m, P=.0030) (Tab. 4, Fig. 2). It was also greater for subjects in the primary group with tetraplegia (958.65 m, P=.0132) (Fig. 3), but not for the subjects with C6 tetraplegia (807.8 m) or the subjects with C7–8 tetraplegia (1,090.7 m) when analyzed separately.
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O2 mL/kg/m).o2 mL/kg/m was less in the UWC than in the SWC only for subjects with T2–8 paraplegia (0.13 versus 0.16 mL/kg/m, P<.0000) and subjects with T10–L1 paraplegia (0.13 versus 0.15 mL/kg/m, P=.009) (Tab. 6).
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Speed (in meters per minute).
Speed was less for the subjects in the primary group with tetraplegia (47.4 m/min) than for the subjects in the primary group with paraplegia (74.5 m/min), independent of WC or time (P <.0000) (Tab. 5).
Oxygen cost per distance traveled (O2 mL/kg/m).
The oxygen cost was greater for the subjects with C6 tetraplegia (0.19 mL/kg/m) than for the subjects in all other groups, independent of WC or time (C6>C7–8 [0.15 mL/kg/m], P=.0066; C6>T2–8 [0.15 mL/kg/ m],P=.0007; C6>T10–L1 [0.14 mL/kg/m], P=.0002) (Tab. 6).
Comparison Over Time
Total distance traveled (in meters).
Distance traveled was analyzed for each trial, but not for each data collection period.
Speed (in meters per minute).
Speed increased over the 4 data collection periods for all groups except for the subjects with C6 tetraplegia, independent of the type of WC used (Fig. 3). Subjects with C7–8 tetraplegia had greater speeds during the last 2 periods (53.70 and 55.02 m/min) compared with the first 2 periods (50.43 and 52.72 m/min). Subjects with T2–8 and T10–L1 paraplegia had greater speeds during only the last period (75.21 and 78.44 m/min) compared with the first period (70.54 and 75.35 m/min). When the WC used was taken into account, the increase in speed over time in the UWC was different only for the subjects with T2–8 paraplegia (P=.0003). For the primary group with tetraplegia, speed, independent of WC, was less for the first period (45.04 m/min) than for the 3 subsequent periods (47.44, 48.23, and 48.91 m/min) (P <.0000).
Oxygen cost per distance traveled (O2 mL/kg/m).
No change over time in oxygen cost was noted for any group (Fig. 4).
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| Discussion |
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Subjects with tetraplegia.
The UWC was superior to the SWC for distance traveled and speed for the subjects with C6 and C7–8 tetraplegia only when they were combined into the primary group with tetraplegia. Parziale,15 in contrast, found no difference between the distance traveled in the UWC and the distance traveled in the SWC during a 4–minute trial, a finding that might have been related to his small sample size or the short period of time his subjects propelled the WC, as compared with our subjects. He did, however, find the UWC to be superior to the SWC during a sprint push.15 None of our groups with tetraplegia (ie, subjects with C6 tetraplegia, subjects with C7–8 tetraplegia, and primary group with tetraplegia) demonstrated a greater energy efficiency (decreased o2 mL/kg/m) in the UWC.
A number of WC-related factors could account for the relative efficiency of the UWC compared with the SWC. These factors include the geometry and stiffness of the frame19; rolling,19,36 air,19 and bearing19,37 resistance; wheel stiffness19; push ring size38; static stability36; foreaft and vertical location of the seat36,37; and wheel camber.37 The effect of the WC weight on efficiency is unclear. One view is that WC weight has little effect on efficiency when propulsion is on level ground.36 Another view is that a WC of lighter weight is easier to push and, therefore, more energy-efficient.37 Weight seems unlikely to be the sole factor accounting for the increased efficiency of one WC over another, based on the limited studies available. In one study,16 for example, the addition of 5- to 10-kg weights to low-weight WC systems did not change wheeling kinematics, at least during the short distances used.16 Specific WC features that might account for the efficiency of the UWC were not studied.
A UWC is not appropriate for all people with SCI, but it can be considered for most people who use WCs. The UWCs are available in both folding and rigid models, with each model having advantages over the other. A rigid UWC, which is the type of UWC used in our study, is considered by many clinicians to be more durable and more efficient to push. The folding UWC is thought to be easier for some people to put into a car because it is more compact and, unlike the rigid WC, does not require removal of the wheels for transport. Rigid WCs are frequently ordered with a lower back height and no armrests, which could compromise sitting posture in some people. The WC does not need to have those components, however, as numerous options are available. Rigid WCs can be adjusted to assist with balance and accessories can be added to produce very effective seating systems, even for people with tetraplegia. Folding UWCs, as well as currently available SWCs, are typically lighter in weight and easier to push than the SWCs used in our study.
Comparison by Group
We chose 4 groups based on level of injury to represent varying functional capabilities. The 2 groups with paraplegia differed from each other in the extent of trunk and intercostal muscle innervation. Subjects with T10–L1 paraplegia had complete or almost complete innervation of the trunk and intercostal muscles, whereas subjects with higher thoracic lesions (ie, subjects with T2–8 paraplegia) had few of these muscles innervated. Subjects with paraplegia lacked motor control of their lower-extremity musculature. Both groups with paraplegia also had normal hand function, but neither of the groups with tetraplegia did. The primary muscle groups that differentiated the subjects with C6 tetraplegia from the subjects with C7–8 tetraplegia were the triceps muscles, the latissimus dorsi muscle, the sternal portion of the pectoralis major muscle (which was not innervated in the subjects with C6 tetraplegia), and the serratus anterior muscle (which was weak in the subjects with C6 tetraplegia).
Primary group with paraplegia.
Subjects with paraplegia benefited more from use of the UWC, although they moved farther and faster than subjects with tetraplegia independent of the WC used. In either WC, subjects with paraplegia could maintain speeds of almost 70 to 80 m/min, which is very close to the normal walking speed of 80 m/min for similar distances.2,5,6 These WC speeds are similar to those identified by Lerner-Frankel et al39 as being necessary for "community" ambulation.
In contrast to Waters and Lunsford,5 who found differences in speed between subjects with high- and low-level paraplegia, our subjects with paraplegia, like those of Newsam et al,23 were not different from each other. The discrepancy between our finding and that of Waters and Lunsford5 may be related to the time postinjury when testing occurred, which was earlier in our study. The importance of time following injury was demonstrated by Yakura et al,40 who found that gait variables and walking energy cost improved in the year following initial rehabilitation for SCI. In both our study and the study by Waters and Lunsford,5 oxygen cost per distance traveled (o2 mL/kg/m) was equivalent for people with both high- and low-level paraplegia.
Primary group with tetraplegia.
Subjects with tetraplegia exhibited lower speeds, less total distance traveled, and higher oxygen cost than did subjects with paraplegia. Newsam et al23 found similar differences for cycle distance and speed on carpet between subjects with tetraplegia and those with paraplegia. They also found, as we did, that subjects with C6 and C7 injuries were functionally similar to each other and that subjects with high- and low-level paraplegia were similar.
The subjects with C6 tetraplegia were least efficient of all the groups, as demonstrated by their higher oxygen cost in both the SWC and the UWC and their inability to increase their distance traveled. They were 25% slower than the subjects with C7–8 tetraplegia, 46% slower than the subjects with T2–8 paraplegia, and 48% slower than the subjects with T10–L1 paraplegia, even when using the UWC. The WCP speed of the subjects with C6 tetraplegia was only about half as great (41 m/min) as the normal walking speed. Using the criteria established by Lerner-Frankel et al39 for community ambulation, our subjects with C6 tetraplegia would be categorized as having only marginal community mobility in their WCs because of their slow speeds and the risks to safety that their slowness would impose. Newsam et al23 concluded similarly that most people with C6 tetraplegia are functioning near their maximum capability and demonstrate even more difficulty with community environments, such as ramps and carpeting, than they do with level propulsion on smooth surfaces.
Although configuration of the WC will influence the way the subject propels the WC, subject-related factors have an even greater effect on the efficiency of WCP. People with tetraplegia have limited upper-extremity force production, restricted handgrip strength, poor trunk balance, and small respiratory reserves. They also have lower tidal volumes, vital capacities, and peak heart rates than do subjects with paraplegia,12 and their maximal oxygen uptake during WC ergometry is less.29
The extent of weakness in the upper-extremity musculature of people with tetraplegia has probably been under-estimated. According to international classification standards,32 key muscle groups that distinguish neurological levels of injury need only have a manual muscle test (MMT) grade of Fair (3/5), provided that more rostral muscles test as 5/5 on the numerical scale. Only limited forces can be generated, however, by muscles with an MMT grade of Fair. Upper-extremity weakness in people with tetraplegia has been confirmed by Powers et al,41 especially in the medial (internal) rotators, where subjects with tetraplegia were able to generate only 38% as much force as as that generated by subjects without impairment. The sternal portion of the pectoralis major muscle, a medial rotator of the shoulder, is not innervated in a person with C6 tetraplegia and is weak in someone with a C7-level injury. This muscle has been shown to produce high-intensity electyromyographic activity in subjects with paraplegia during the push phase of WCP and is responsible for providing the primary propulsive force.27 Weakness or absence of motor control of this muscle affects the ability of most people with tetraplegia to generate effective propulsive forces27,28 and results in increased intensity26,28 and duration28 of activity in other shoulder muscles to substitute for the lost function.
The changes in speed and total distance traveled by subjects in the primary group with tetraplegia were small, although statistically significant. Given the very limited ability of these subjects to physically and physiologically meet the demands of WCP, however, even small benefits, in our opinion, are likely to be of clinical importance. The clinical importance of using the UWC may also relate to factors that we did not investigate. For our study, subjects propelled only on a level, paved surface. This environment did not replicate the variety of conditions that would be encountered during daily living because energy efficiency, speed, and distance traveled in a given period of time are not the only variables that might be altered by using an UWC. Other factors such as demands on the shoulder musculature that can lead to pain42,43 might be positively influenced by use of UWCs. The beneficial effect of UWC use by people with tetraplegia might also be enhanced by attention to seat position, wheel size, and other features that have been shown to affect the efficiency of WCP,19,36 but were not examined in our study.
A number of factors contribute to differences in responses between people with tetraplegia and people with paraplegia. All of these factors are related to the additional motor control that people with paraplegia gain by sparing of lower segments of the spinal cord. People with paraplegia have use of additional upper-extremity muscles, increased force production in those muscles, and more trunk and shoulder muscle stability. Although subjects with paraplegia do not perform as well as control subjects,12,13,26 Powers et al41 found that the torque of tested upper-extremity muscles in subjects with paraplegia was not different than that of control subjects, except in medial rotation, which was 65% of normal. In individuals with SCI, the trunk muscles are important in allowing a greater forward lean, which permits them to apply a greater force to the WC handrim.25 In addition, activity of the intercostal and abdominal muscles, when present, improves respiratory function. Finally, people with injuries below T6 have normal sympathetic activity, which improves cardiac output and the vascular response to activity.29
Comparison Over Time
Speed increased over the 20-minute period for all groups, independent of the WC used, except for the subjects with C6 injuries. The subjects with C7–8 tetraplegia had different speeds between the first and last 2 periods. The subjects with paraplegia had different speeds only between the first and last periods. The change in speed over time was a reflection, in part, of the time to achieve a physiologic steady state and, in part, of the effort to put the WC into motion initially. This commencement of movement would be more difficult for people with tetraplegia with a smaller upper-extremity muscle mass and particularly difficult for people with C6 tetraplegia who lack elbow extensor force production, which is thought to be important in initiating a WC start.15,24
Limitations
We identified the following limitations of our study. Subjects were more familiar with the SWC than the UWC, despite practice trials with the UWC. An SWC was used daily for mobility around the hospital, and some subjects had never propelled a UWC before the study. Seat-to-wheel position, wheel camber, and other factors that might influence WC efficiency were not adjusted for each subject in the UWC. These adjustments were not possible for the SWC. Many more UWCs are now available. It is possible that the results would be different, especially for the subjects with tetraplegia, if the study were replicated with other UWCs. The study was carried out somewhat early in the period following injury. Although subjects had been participating in structured endurance and strengthening activities, they were relatively untrained. Because either training programs30 or daily activities40 can improve force production,30 maximum aerobic power,30 speed,40 and oxygen cost per meter traveled,40 the performances of the subjects, particularly those with tetraplegia, would probably have been better if more time had elapsed since injury or the subjects had been more highly trained.
Use of the Bonferroni correction increases the possibility of a Type II error, while correspondingly decreasing the possibility of a Type I error.35 Type II errors might have occurred in this study, particularly with data obtained from the subjects with C6 and C7–8 tetraplegia. For example, changes in speed over time in the subjects with C6 tetraplegia (P=.0173), differences in speed between the 2 WCs for the subjects with C7–8 tetraplegia (P=.0351), and differences in distance traveled for the subjects with C7–8 tetraplegia (P=.023) would have been significant at the .05 level, but not at the more stringent .0167 level used. The small sample sizes for the subjects with C6 and C7–8 tetraplegia necessitated combining them to increase the statistical power, which may have resulted in masking differences that might exist between the 2 groups.
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o2 mL/kg/m) achieved. The use of UWCs instead of SWCs for people with C6 and C7–8 tetraplegia is also supported by our data, although the changes were not as great as for the subjects with paraplegia. Oxygen cost (o2 mL/kg/m) was not different between the 2 WCs for subjects with tetraplegia. People with tetraplegia have less efficient WCP than do people with paraplegia. All subjects with tetraplegia, especially the subjects with C6 injuries, were extremely inefficient in WCP and were so limited by weakness that no method of manual propulsion was efficient.
A 5-minute data collection period can be used to determine both 5-minute and 20-minute speeds for people with C6 tetraplegia because no change in speed was seen between the first and last data collection periods. For people with injuries at other levels, however, a shorter (5-minute) test of speed will not be as accurate as a 20-minute test in determining speed.
Future studies should be aimed at determining additional benefits of the UWC not investigated in our study and WC features that affect efficiency of propulsion. Other UWCs not on the market at the time of this study should also be evaluated.
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This research was supported in part by a grant from Everest and Jennings, through the Foundation for Physical Therapy Inc.
The study protocol was approved by the Institutional Review Board of Rancho Los Amigos Medical Center.
Preliminary results of this research were presented at the Annual Conference of the American Physical Therapy Association (APTA), June 11-15, 1989, Nashville, Tenn; at the Annual Conference of the California Chapter of APTA, October 21-25, 1987, Palm Springs, Calif; and at the Combined Sections Meeting of APTA, February 1-4, 1990, New Orleans, La.
* Everest and Jennings Co, 1100 Corporate Square Dr, St Louis, MO 63132. 
Biosentry Telemetry Inc, 20720 Earl St, Torrance, CA 90503.
Sensormedics Corp, 16305 State College Blvd, Anaheim, CA 93806.
Breon Laboratories Inc, Park Ave, New York, NY 10016.
|| Crunch Software Corp, 2966 Diamond St, #292, San Francisco, CA 94131.
# NCSS, 329 N 1000 E, Kaysville, UT 84037.
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o2.
Adapted Physical Activity Quarterly.1988; 5:130–139.
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