Biomedical subjects

L H van der Woude

Publications and source records attributed to L H van der Woude.

At least 19 recordsLinked to original sources

PubMed2001

Contractile speed and fatigue of adductor pollicis muscle in multiple sclerosis.

The purpose of the study was to investigate differences in contractile speed, force, and fatigability of the adductor pollicis muscle between 12 patients with multiple sclerosis (MS) and 8 sedentary control subjects matched for age and gender. There were no differences between the patients with MS and control subjects with respect to the percentage of maximal muscle force that could be recruited during voluntary effort (95.5 +/- 3.9% and 98.2 +/- 2.0%, respectively, P = 0.10), the stimulation frequency/force and force/velocity relationships, the rates of force development and relaxation, fatigue resistance, and the recovery rate of adductor pollicis muscle. However, previous results from the same group of MS patients showed that quadriceps femoris muscle force and resistance to fatigue were reduced. Therefore, our data support the clinical experience that, in patients with MS, lower limb muscle function is more or earlier affected than upper limb muscle function.

Adult↗

PubMed2001

Biomechanics and physiology in active manual wheelchair propulsion.

Manual wheelchair propulsion in daily life and sports is increasingly being studied. Initially, an engineering and physiological perspective was taken. More recently a concomitant biomechanics interest is seen. Themes of biomechanical and physiological studies today are performance enhancing aspects of wheelchair use and the ergonomics of wheelchair design. Apart from the propulsion technique the focus of biomechanics research of manual wheelchair propulsion is mainly towards injury mechanisms, especially phenomena of overuse to the upper extremity. Obviously, the vehicle mechanics of wheelchairs must be included within this biological framework. Scientific research is progressing, but is still hampered by methodological limitations, such as the heterogeneity and small numbers of the population at study as well as the inconsistency of employed technologies and methodologies. There is a need for consensus regarding methodology and research strategy, and a strong need for collaboration to improve the homogeneity and size of subject groups and thus the power of the experimental results. Thus a sufficiently strong knowledge database will emerge, leading to an evidence-base of performance enhancing factors and the understanding of the risks of wheelchair sports and long-term wheelchair use. In the light of the current biomechanical and physiological knowledge of manual wheelchair propulsion there seems to be a need for the stimulation of other than hand rim propelled manual wheelchairs.

Aerobiosis↗

PubMed2001

Health related functional status in men with spinal cord injury: relationship with lesion level and endurance capacity.

STUDY DESIGN: Cross-sectional study. OBJECTIVES: To determine the relationship of health related functional status with lesion level and endurance capacity in persons with spinal cord injury (SCI). METHODS: Thirty-seven men with SCI were divided in four lesion groups: high tetraplegia (motor complete; C5-C6, n=10), low tetraplegia (motor complete, C6/7-C8, n=9), motor incomplete tetraplegia (n=7), and paraplegia (n=11). Health related functional status was measured with the short version of the Sickness Impact Profile (SIP68), including a physical (SOM), psychological (PSY) and social subscore (SOC). Endurance capacity, defined as maximal power output (PO(max)) and peak oxygen uptake (VO(2peak)), was measured in a maximal exercise test on a wheelchair ergometer. RESULTS: Total SIP68-score and SOM were significantly different between lesion groups, showing higher values in the high- and low-tetraplegia group. There were no differences between lesion groups for PSY and SOC subscores. VO(2peak) and PO(max) were significantly higher in the paraplegia group, compared to the high and low tetraplegia groups. VO(2peak) was also higher in the motor incomplete versus other tetraplegia groups. Significant Spearman correlation coefficients were found for VO(2peak) and PO(max) with SIP68 and SOM (ranging from -0.68 to -0.79) and SOC (ranging from -0.39 to -0.51). No significant relationship was found with PSY. Hierarchical regression analysis showed that after correction for lesion level, 22% of the variance of SIP68, 8% of the variance of SOM, and 30% of the variance of SOC was explained by PO(max) or VO(2peak). CONCLUSIONS: Results indicate that there is an evident relationship between the physical dimensions of health related functional status and lesion level, but not for the psychological and social dimensions. After controlling for lesion level a significant amount of the variance of health related functional status can be explained by endurance capacity parameters. Although no causal relationships can be established in this cross-sectional study, these results suggest that functional status may be improved by increasing the endurance capacity.

Adolescent↗

PubMed2001

Alternative modes of manual wheelchair ambulation: an overview.

An estimated 90% of all wheelchairs are hand-rim propelled, a physically straining form of ambulation that can lead to repetitive strain injuries in the arms and, eventually, to secondary impairments and disability. Further disability in wheelchair-dependent individuals can lead to a sedentary lifestyle and thereby create a greater risk for cardiovascular problems. Studies on lever-propelled and crank-propelled wheelchairs have shown that these propulsion mechanisms are less straining and more efficient than hand-rim-propelled wheelchairs. This article reviews these studies and substantiates that the frequent use of these alternative propulsion mechanisms may help prevent some of the secondary impairments that are seen among today's wheelchair-user population.

Cumulative Trauma Disorders↗

PubMed2001

The internal consistency and validity of the Self-Assessment Parkinson's Disease Disability Scale.

OBJECTIVE: To test the consistency and validity of the Self-assessment Parkinson's Disease Disability Scale in patients with Parkinson's disease living at home. DESIGN: Patients with Parkinson's disease responded to a set of questionnaires. In addition, an observation of the performance of daily activities was carried out on a subgroup. SETTING AND SUBJECTS: Patients with Parkinson's disease living at home (n = 142). MEASURES: The Self-assessment Parkinson's Disease Disability Scale (SPDDS), the Hoehn & Yahr Rating Scale (H&Y), and the Sickness Impact Profile (SIP68). The observation concerned nine activities that correspond to items of the SPDDS questionnaire. RESULTS: Internal consistency of the SPDDS was very high (Cronbach's alpha = 0.97; reliability rho = 0.97). The items of the SPDDS are hierarchical (Loevinger's H = 0.64): patients had least difficulty with 'washing' and 'brushing teeth' and most difficulty with 'turning in bed', 'travelling by public transport' and 'writing a letter'. Validity of the SPDDS was good: the relationship between the SPDDS questionnaire and the H&Y rating scale, the SIP68 and the results of the observation was strong and significant. CONCLUSION: The SPDDS is a unidimensional instrument measuring disabilities in Parkinson's disease patients living at home.

Activities of Daily Living↗

PubMed2000

Measuring physical strain during ambulation with accelerometry.

PURPOSE: To study the feasibility of ambulatory accelerometry in the evaluation of physical strain in walking at different speeds and different levels of economy. METHODS: Twelve able-bodied subjects performed a walking test on a treadmill with increasing walking speed. After a 6-wk period, these measurements were repeated, with an additional test of perturbed walking. Motility (the intensity of body segment movements, measured with accelerometry), heart rate, and oxygen uptake were simultaneously recorded. Feasibility was determined by comparing motility with percentage heart rate reserve (%HRR), using oxygen uptake (VO2) as reference. The relation with oxygen uptake, the sensitivity to change when walking speed increased and gait was perturbed, and intrasubject and intersubject variability were studied. RESULTS: Walking with increasing walking speed resulted in a higher pooled r2 value (0.91) and a lower residual standard deviation (1.44 mL x kg(-1) x min(-1)) for the motility-VO2 relation than for the %HRR-VO2 relation (0.84 and 1.92 mL x kg(-1) x min(-1), respectively). Furthermore, the motility-VO2 relation for this part of the protocol showed lowest interindividual differences. The sensitivity to changes due to an increase in walking speed, and the test-retest reliability were the highest for motility. Walking with a brace resulted in a lower pooled r2 value for the motility-VO2 relation than for the %HRR-VO2 relation (0.31 and 0.67, respectively); the sensitivity to changes due to walking with a brace was lower for motility than for %HRR. CONCLUSION: Compared with heart rate, accelerometry allows accurate measurement with little error in any able-bodied individual, without the need for individual calibration. The response of motility to changes and differences in economy in patients requires further study.

Acceleration↗

PubMed2000

Influence of muscle temperature on the contractile properties of the quadriceps muscle in humans with spinal cord injury.

Low muscle temperature in paralysed muscles of individuals with spinal cord injury may affect the contractile properties of these muscles. The present study was therefore undertaken to assess the effects of increased muscle temperature on the isometric contractile properties of electrically stimulated paralysed quadriceps muscles. When muscle temperature at a depth of 3 cm was increased from approximately 32 degrees C to approximately 36 degrees C by ultra-short-wave application, the half-relaxation time shortened and low-frequency force responses became less fused, but the maximal rate of increase in force remained unchanged. Heating had no effect upon either force decline or slowing of relaxation during fatiguing contractions. The force-frequency relationship of the paralysed quadriceps muscle was shifted to the right after the muscle was heated. Despite this shift, however, the relationship still resembled that in muscles of non-paralysed individuals, probably due to the unexplained high twitch forces. These results indicate that reduced muscle temperature in spinal-cord-injured individuals may lead to an underestimation of the changes in contractile properties in terms of relaxation rate or the degree of fusion with low-frequency stimulation. In addition, the force-frequency relationship of paralysed muscles does not accurately reflect the magnitude of these changes, even when the muscle is heated, and should therefore be treated with caution.

Adult↗

PubMed1999

Changes in lipid, lipoprotein and apolipoprotein profiles in persons with spinal cord injuries during the first 2 years post-injury.

OBJECTIVE: To investigate changes in lipid, lipoprotein and apolipoprotein profiles in persons with spinal cord injury (SCI) during the first 2 years post-injury, and to determine whether changes in risk profiles were associated with sport activity and/or changes in physical capacity parameters. DESIGN: Risk profiles and physical capacity were investigated in 19 subjects with recent SCI during rehabilitation (t1) and +/- 1 year after discharge from rehabilitation (t2). MAIN OUTCOME MEASURES: Changes in total plasma cholesterol (TC), high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), triglycerides (TG), apolipoprotein-A1 (ApoA1), apolipoprotein-B (ApoB) concentrations, the ratios TC/HDL-C, LDL-C/HDL-C, ApoA1/ApoB and HDL-C/ApoA1, and physical capacity (maximal isometric strength, sprint power output, maximal power output, aerobic power). RESULTS: Risk profile parameters changed towards more favorable values at t2, except for HDL-C (P=0.06), TG and HDL-C/ApoA1. Sport activity and changes of the physical capacity were the most important determinants of changes in lipid and (apo)lipoprotein profiles, showing more favorable values with larger increases of the physical capacity and in persons who were physically active. CONCLUSION: Results show that the lipid and (apo)lipoprotein profiles improve in persons with SCI during the first 2 years post-injury, and that improving the physical capacity or being physically active can improve the lipid and (apo)lipoprotein profiles.

Adult↗

PubMed1999

Physical work capacity after 7 wk of wheelchair training: effect of intensity in able-bodied subjects.

PURPOSE: The purpose of this study was to study the effects of a 7-wk wheelchair training program on physical work capacity in able-bodied subjects. Effects of training intensities of 50 and 70% heart rate (HR) reserve (HRR) were studied for different subject groups. METHODS: Twenty-seven able-bodied male subjects participated in this study. They were randomly divided into a control group (N = 8), a 50%-intensity group (N = 9), and a 70%-intensity group (N = 10). The 50%- and the 70%-intensity groups received a 7-wk wheelchair training program: three times a week, one-half hour wheelchair exercise on a motor driven treadmill at an average intensity of 50 and 70% of the HRR, respectively. Before and after the training period, parameters for physical work capacity (maximal isometric strength (Fiso), sprint power (P30), maximal power output (POmax) and peak oxygen uptake (VO2peak)), and submaximal performance (mechanical efficiency, HR) at 20 and 40% of the estimated POmax (ME20, ME40; HR20, HR40) were obtained during tests on a stationary wheelchair ergometer. RESULTS: A two-factor ANOVA for repeated measures on the within-subjects factor "pre-post tests," the between-subject factor training (50% and 70% training vs control) and the interaction term showed that the 50%-intensity group significantly increased on P30 and POmax compared with the control group. The 70% intensity group significantly increased on P30, POmax and VO2peak compared with the control group (P < 0.05). The 70% group did not show significantly higher increases in P30 and POmax over training than the 50% intensity. No significant effects were found for the Fiso and the parameters at submaximal PO. CONCLUSIONS: The wheelchair training at both intensities can have favorable effects on maximal physical work capacity in able-bodied subjects, and possibly also on mechanical efficiency at submaximal power output. Effects are seen in parameters for both aerobic and anaerobic work capacities. Although training at 70% intensity was more effective than the 50% intensity, training at 50% HRR may initially be more appropriate in untrained individuals, such as novice wheelchair users at the start of their rehabilitation, to prevent fatigue and enhance motivation.

Adult↗

PubMed1999

Physical performance in persons with spinal cord injuries after discharge from rehabilitation.

PURPOSE: The purpose of this study was to investigate changes in physical capacity and performance of activities of daily living (ADL) during the postrehabilitation period of persons with spinal cord injuries and to determine the factors explaining the changes in physical capacity. METHODS: Nine subjects with tetraplegia and 11 subjects with paraplegia were measured at time of discharge from rehabilitation (t1) and on average 1.2 yr later (t2). Physical capacity was measured as maximal isometric strength (F(iso)), sprint power output (P30), maximal power output (POmax), and peak oxygen uptake (VO2peak). Physical strain and performance time were measured during standardized ADL (ascending ramp, passing door, making transfer, washing hands). RESULTS: P30 and POmax showed a significant increase at t2, whereas F(iso) and VO2peak remained unchanged. Sport activity was the most important independent variable explaining relative changes in P30 and POmax, showing on average larger values in active subjects. Other independent variables that were significantly related to changes in physical capacity were the occurrence of illness and having a tetraplegia (negatively associated with changes in P30 and VO2peak), and incompleteness of the lesion and an increased body mass (positively associated with changes in F(iso)). Increase in physical capacity was found to coincide with decrease of the physical strain and performance time of ADL, reflected in significant negative correlation coefficients for some tasks. CONCLUSIONS: It is concluded that physical capacity and performance of ADL improved or remained constant during the first year after rehabilitation and that sport participation is associated with improvements in physical capacity. Results of this study underline the importance of being physically active during the period after rehabilitation of persons with spinal cord injuries.

Activities of Daily Living↗

PubMed1999

Physical performance during rehabilitation in persons with spinal cord injuries.

PURPOSE: The objective of the present study was to evaluate the effect of rehabilitation on physical capacity, mechanical efficiency of manual wheelchair propulsion, and performance of standardized activities of daily living (ADL). METHODS: Nineteen recently injured subjects with spinal cord injuries were tested on a wheelchair ergometer (maximal isometric strength, sprint and maximal power output, and peak oxygen uptake) and during standardized ADL (physical strain and performance time) at the beginning (t1) and at the end (t2) of the active rehabilitation period. RESULTS: Paired Student t-tests showed significant increases for maximal isometric strength (24%, P < 0.01), sprint power output (l7%, P < 0.001) and maximal power output (38%, P < 0.001). Peak oxygen uptake showed no statistically significant improvement (11%, P = 0.06). Mechanical efficiency of submaximal wheelchair exercise was significantly higher at t2 (9.0%) compared to t1 (7.9%, P < 0.01). No significant differences were found for physical strain during ADL, except for passing a door (P < 0.05). Performance time showed a significant decrease for most tasks. CONCLUSIONS: The results of this study show considerable improvements in physical capacity and mechanical efficiency of manual wheelchair propulsion during rehabilitation, and a concomitant lower performance time during standardized ADL. The higher mechanical efficiency and the decrease in performance time during standardized ADL suggest improvement in wheelchair propulsion technique.

Activities of Daily Living↗

PubMed1998

Pushing and pulling in relation to musculoskeletal disorders: a review of risk factors.

The objective was to review the literature on risk factors for musculoskeletal disorders related to pushing and pulling. The risk factors have been described and evaluated from four perspectives: epidemiology, psychophysics, physiology, and biomechanics. Epidemiological studies have shown, based on cross-sectional data, that pushing and pulling is associated with low back pain. Evidence with respect to complaints of other parts of the musculoskeletal system is lacking. Risk factors have been found to influence the maximum (acceptable) push or pull forces as well as the physiological and mechanical strain on the human body. The risk factors have been divided into: (a) work situation, such as distance, frequency, handle height, and cart weight, (b) actual working method and posture/movement/exerted forces, such as foot distance and velocity, and (c) worker's characteristics, such as body weight. Longitudinal epidemiological studies are needed to relate pushing and pulling to musculoskeletal disorders.

Arm Injuries↗

PubMed1998

Wrist motion in handrim wheelchair propulsion.

Prevalence rates of carpal tunnel syndrome (CTS) in the wheelchair user population are high. One of the possible causes of CTS in this population is the movement pattern of the wrist during handrim wheelchair propulsion, which could include large wrist joint angles and wrist/finger flexor activity. Combined with the repetitive character of the movement, this could, in time, be detrimental to the soft tissue of the wrist. To study peak wrist joint angles and their relationship with wrist- and finger-flexor activity, a three-dimensional (3-D) analysis of wrist movement during the push phase was performed. Nine subjects (five nonimpaired controls, four wheelchair users) propelled a handrim wheelchair on a treadmill at three different velocities (0.83, 1.11, and 1.39 m/s) and three slopes (1, 2, and 3%), while the surface EMGs of the wrist- and finger-flexor group were recorded. Average peak wrist joint angles during the push phase were: ulnar deviation, -24 +/- 11 degrees; radial deviation, 13 +/- 12 degrees; flexion, -14 +/- 18 degrees; and extension, 34 +/- 16 degrees. The values for ulnar and radial deviation were close to normal values for maximal range of motion (ROM) found in the literature. Peak extension was approximately 50% of ROM. The peak angles, which occurred with concurrent activity of the wrist flexors, were: ulnar deviation, -22 +/- 11 degrees; radial deviation, 13 +/- 10 degrees; flexion, -16 +/- 15 degrees; and extension, 32 +/- 16 degrees. The large deviation and extension angles, especially those recorded simultaneously with wrist flexor activity, are serious risk factors for CTS. This finding may help explain the high rates of CTS in the wheelchair user population.

Adult↗

PubMed1997

Coronary heart disease risk indicators, aerobic power, and physical activity in men with spinal cord injuries.

OBJECTIVE: To compare the lipid and (apo-)lipoprotein profile and blood pressure of men with long-standing spinal cord injuries (SCI) to those of an age-matched able-bodied (AB) population, and to assess the most important determinants of this profile and blood pressure. DESIGN: A cross-sectional study of persons with chronic SCI residing in the community. SETTING: Tests were performed in a university research laboratory. SUBJECTS: Thirty-seven men (age 37.4 +/- 12.0 yrs) with longstanding (14.7 +/- 8.6 yrs) SCI ranging from level C4/5 to L5 volunteered to participate. Comparisons were made with published data from 3,498 AB men, age 20 to 59 yrs, from the same country. MAIN OUTCOME MEASURES: Lipid and lipoprotein profile (total cholesterol [TC], high-, low-, and very low-density lipoprotein cholesterol [HDL-C, LDL-C and VLDL-C, respectively], and triglycerides [TG]), as well as aerobic power, activity level, anthropometric variables, and blood pressure. Multiple regression analyses assessed the most important determinants of the lipid and blood pressure profile. RESULTS: None of the lipid variables were related to the lesion level. TC, HDL-C, and TC/HDL-C were not significantly different from the AB population. The most important determinants of TC, LDL-C, and the ratios TC/HDL and HDL-C/LDL-C were age, smoking behavior, and activity level. Aerobic power was not an important determinant of any lipid or (apo-)lipoprotein or blood pressure. CONCLUSION: Men with long-standing SCI do not appear to have an essentially different coronary heart disease risk profile compared with AB persons. Modifiable risk factors such as activity level, smoking, alcohol consumption, body mass index, and adipose tissue were more important than lesion level and aerobic power in the determination of the lipid and lipoprotein profile, suggesting several potential interventions.

Adult↗

PubMed1997

Lipid, lipoprotein, and apolipoprotein profiles in active and sedentary men with tetraplegia.

OBJECTIVE: To investigate whether the risk profile of coronary heart disease (CHD) is more favorable in physically active men with tetraplegia compared with sedentary men with tetraplegia. DESIGN: Using a cross-sectional design, the lipid and (apo)lipoprotein concentrations of 11 active and 13 sedentary men with tetraplegia were compared. Regression analysis was applied to investigate the influence of subject characteristics and behavioral factors on the risk profile of CHD. MAIN OUTCOME MEASURES: Total plasma cholesterol (TC), high-density lipoprotein cholesterol (HDL-C), triglycerides, apolipoprotein-A1 (ApoA1), and apolipoprotein-B (ApoB) concentrations were determined. Low-density lipoprotein cholesterol (LDL-C) and the ratios TC/HDL-C, LDL-C/HDL-C, ApoA1/ApoB, and HDL-C/ApoA1 were calculated. RESULTS: A significantly higher HDL-C and ApoA1/ApoB and lower TC/HDL-C were found in the active group. Age and body mass index were important determinants of the lipids and (apo)lipoproteins. Sport activity was the only significant determinant of HDL-C. CONCLUSIONS: Results suggest a positive influence of sport activity on HDL-C in men with tetraplegia, which may reduce the risk of CHD.

Activities of Daily Living↗

PubMed1997

Respiratory muscle strength and endurance in individuals with tetraplegia.

The purpose of this study was to assess the strength and endurance capacity of the respiratory muscles in individuals with tetraplegia and to compare these properties to those in able-bodied subjects. In addition, the relationship between respiratory muscle properties and respiratory function, ie, ventilation and gas exchange, was examined. Fifteen individuals with tetraplegia (TP) and 15 able-bodied controls (AB) participated in this study. Respiratory muscle strength was assessed by measuring static inspiratory (Pi-max) and expiratory (Pe-max) mouth pressure, whereas inspiratory endurance capacity (Pendu) was determined using an incremental ventilatory threshold loading test. Results were significantly lower in TP compared to AB: Pi-max (5.9 vs 8.4 kPa), Pre-max (5.6 vs 12.3 kPa), Pendu (2.7 vs 6.9 kPa), vital capacity (3.1 vs 5.5 l) and rest oxygen uptake (0.21 vs 0.29 ml/min) and significant correlations were found between the respiratory muscle properties and the respiratory function. Of note is the fact that the ratio Pendu/Pi-max was significantly lower in TP (0.49) compared to AB (0.82). This implies that the capacity to generate pressure during the endurance test was not fully used in TP, probably due to an early onset of muscle fatigue and an altered force-length relationship of the diaphragm muscle. Results of this study demonstrate a limited ability in individuals with tetraplegia to ventilate.

Adult↗

PubMed1997

Mechanical advantage in wheelchair lever propulsion: effect on physical strain and efficiency.

In this experimental study on a prototype lever-propelled wheelchair, the effect of a range of mechanical advantages (MA) on physical strain, oxygen uptake, energy cost, mechanical efficiency, stroke frequency and perceived exertion was examined. Nine out of 10 male nonwheelchair users successfully performed five submaximal tests on a motor-driven treadmill in a prototype bi-manual asynchronous lever-propelled tricycle. Each test contained the same protocol, but made use of one of the five different MAs. In every test the inclination level increased by 1% every third minute, starting on 0% up to 3%. The velocity was kept constant at 0.97 m.s-1. Variables measured included oxygen uptake, minute ventilation, respiratory exchange ratio, heart rate, and stroke frequency. Analysis for repeated measures was conducted on the main factors slope and MA and their interaction. Additional analysis include a multiple regression analysis. All statistics were conducted with a p < 0.05 level of significance. MA had a significant effect (p < 0.05) on oxygen uptake, energy cost, mechanical efficiency, and stroke frequency. These results suggest that the implementation of a range of MAs on a lever-propelled wheelchair may accommodate different external conditions (slope, climatic, surface conditions, sports, and recreational conditions) and different user groups more readily. This may improve the social radius of action and freedom of mobility of individuals confined to wheelchairs.

Adult↗

PubMed1997

Effect of training on physical capacity and physical strain in persons with tetraplegia.

The effects of quad rugby training on physical capacity and physical strain during standardized activities of daily living were investigated in 9 trained (A) and 5 untrained quad rugby players (B), and 7 inactive persons with tetraplegia (C) at 0, 3 and 6 months after the start of a quad rugby training program (1.5h.wk[-1]). Physical capacity was measured as maximal isometric strength, peak power output (POpeak) and peak oxygen uptake (VO2peak) on a stationary wheelchair ergometer. Physical strain was expressed as a percentage of heart-rate reserve. No measurable training effects could be observed for POpeak, VO2peak and physical strain. A significant rise in maximal isometric strength was found in group B after 3 and 6 months of training, whereas no significant changes were found in groups A and C. The results suggest that a higher training frequency and/or intensity may be needed to gain significant training effects for POpeak and VO2peak.

Activities of Daily Living↗