Table of Contents
In general disabled individuals are less physically active compared with able-bodied individuals(30). Recent literature explained/ indicated the positive influence of physical activity on physical health in the entire population (31, 32). Positive effects were established of an outdoor exercise program compared with an indoor program(33, 34). Natural environments had a vitalizing effect (35) and mental well-being increased (34). The main purpose of this research was to evaluate the evolution of different physical parameters in disabled persons before, short after (one week) and 6 months after an adventurous journey.
The Influence of a First U/Turn Journey
In the short-term a positive evolution was seen for the lower limb after participating in an adventurous journey. The LP increased significantly and the KE had a positive tendency. For the upper limb, 2 significant improvements were reported, namely the SR and the VT. Lastly, the HGSL made a positive improvement at short notice.
On long-term certain improvements were the same. For the lower limb, the KE showed a positive tendency again, but no further progression was determined for the LP. The muscle force of the upper limb had again 2 significant improvements for the SR and VT. Remarkably, a significant decline was reported for the HGSR. The HGSL declined at long-term, whereby the result was lower than the starting point.
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One or 2 weeks training implies that muscles become stronger. Neural adaptations (36) and fibre muscle hypertrophy (37) arised (38, 39). Therefore the positive evolution of the strength tests in the short-term could be explained.
On the other hand, the value of contact with nature is underestimated (40). Living in a wilderness setting requires people to exercise and care for themselves or work together with a group. U/Turn focused on the ‘back to basics’ experience, whereby the participants go camping and have to build fires. This provoked an increase in confidence, grit and resilience and a gain in perceptions of body control (40, 41), which could explain the positive results on short notice.
One of the main goals of (an organisation like) U/Turn is to stimulate autonomy and independence of disabled people (24). Based on the Self-determination Theory (SDT), which particularly focused on the processes through which a person acquires the motivation for initiating new health-related behaviours and maintaining them over time. SDT argues that developing a sense of autonomy and competence are critical to the processes of integration (42). In this theory autonomously motivation, whereby an individual makes their own decisions, is important.
Environments, in this case U/Turn, may facilitate autonomous motivation and perceived competence for change by supporting participants as they are exploring resistance and barriers to change (43). This could explain the positive results in the long-term, whereby the learned adaptations are continuously used in daily life based on the autonomous motivation.
In general, a 7 day intervention is too short to introduce great influence on the dynamic balance (44) This could be the explanation of the stabilized results of the BSS, the journeys were only 7-11 days long . The same reason could explain the results of the 6MWT. Most endurance protocols described 6-12 weeks or even several months intervention before starting to see remarkable results (45).
The Added Value of a Second U/Turn Journey
A second analysis was conducted in this study, namely the added value of going on a second adventurous journey. For certain physical parameters, an additional influence was found after a second trip.
Qualitatively, a positive evolution could be noticed for the LP over the 2 journeys. An overall increase could be observed in Table 17, from the PRE test of the first journey to the POST2 test of the second journey. However when analyzing the data of the 2 trips separately, no significant differences could be reported.
Furthermore, on short-term a positive evolution could be proved for the TCST after journey 2, which was neutralized on long-term. In this case, journey 1 had no influence on the performance of the TCST.
On the contrary, a negative influence of the second journey was proved for the HGST.
A negative evolution on short-term was determined for the HGSL after journey 2. Also on long-term, a decrease could be noticed, not only for the HGSL, but also for the HGSR.
For 2 physical tests, the positive evolution after the first journey was maintained after the second journey. On short-term an increase of the KE after the first journey was established, whereafter the results stabilized after journey 2. On long-term a significant positive evolution for the SR and a positive tendency for the KE after journey 1 was noticed. Those results stabilized as well after journey 2.
Lastly a remarkable difference between the first and second journey was observed in Table 17, for the BBS. When taking a closer look to minimum values, it can be noticed that those have increased for all 3 testing moments. The changes in the walking ability could be an explanation for this extreme evolution. Participating in the first journey, one person was wheelchair bound, this changed before the second journey when she could walk independently.
Overall a second journey showed no remarkable added value for the physical parameters.
When going on an adventurous journey for the first time, the participants come into contact with a new environment, new activities, new challenges and new people. The article of Russel and Farnum (2007) stated that ‘fascination intensity is the most intense at the first exposure’ (41). This statement could explain the absence of a further evolution/improvement after a second journey, where no extremely new activities were included/added. Luckily, the achieved improvements after the first journey were maintained afterwards and during and after the second journey.
This could be clarified by 2 possible explanations. On the one hand, the most important parts of the physical therapy, given at home, were continued during the trip, which was made possible by the presence of a physiotherapist on the trip. On the other hand, an increased therapy loyalty/compliance could be at the basis of the results.
Next to that, a noteworthy negative influence in the HGST was difficult to understand/interpret. The lack of standardization of the HSGT, further elaborated in the chapter about the study limitations, could clarify this (46, 47). Furthermore during the testing moments, the researchers experienced that the HGST was the least favorite test of the participants, probably because they did not understand the purpose of the test.
However the results, obtained in the search to the added value of a second journey, were qualitatively interpreted and only conducted on 9 participants, which could conclude that further research on this topic is necessary.
Study Limitations
Three topics will be discussed in the context of the limitations of this study, namely the population, the test battery and the travel destination.
Firstly, a few critical remarks could be made about the population.
This study was conducted on a small sample size. A higher variability is noted in small sample sizes, which could affect the reliability and could lead to bias and lower generalizability (48). Only 34 participants were included in this study. In the research period of 3 years, 222 persons were tested who went on 21 adventurous trips organized by U/Turn. An enormous number of dropouts was noted. The main reason for this shortage was the absence of the participants on one of the 3 test moments. Also broken testing material or a relapse or sickness could explain the exclusion of some participants.
Furthermore, taking the missing values into account, the center measures of the most variables (namely 6 of the 8 variables) were calculated on a population even less than 34 participants.
Another population limitation is the statistical power of this study. A power analysis was conducted at the end of this study and indicated that minimally 4 times the number of the included participants would be needed to become a statistical power of 0.80. For example for the strength test VT, 208 participants would be needed for a power of 0.80. The main reason that could explain this shortage, is the heterogeneity of the population, which implied the choice of non parametric statistical analysis.
The heterogeneity of pathologies that are included in this study, could be considered as a next limitation for the topic population. In Table 2, an overview of the occurring pathologies can be found, 24 different pathologies are summed up. Taking into account that 34 participants were included, it could be noted that almost every participant had another pathology.
Obviously, each pathology has its own typical development, its own typical symptoms and its own typical associated disability/limitations. On the one hand those specific characteristics could cause low and/or high outliers for certain tests, which could influence the results of the tests. On the other hand the comparison between the participants was therefore more complicated and almost impossible. Concluding that the reliability of results of the statistical analysis was rather low.
Lastly, the characteristics of the personality of the participants could have influenced the results. They decided to go on an adventurous journey on their own initiative. Those people were probably motivated and already had social skills that made them decide to participate.
Secondly, the test battery could be an important discussion point.
The standardization of the testing protocol showed certain imperfections.
The tests were not always taken/administered by the same examiner/researcher. The assessments, especially the 6MWT and the HGSL/R, were often tested by different volunteers of the U/Turn organization. The oral instructions before and the oral motivation during the test, differed between the researchers, which could have affected the results of these assessments. Only the nRM and BBS testing were standardized. In fact, the strength testing was always examined by the same person and for the BBS, a form with general instructions and rating scale was used.
Next to that, certain shortcomings in the testing protocol could be considered. For example the TCST, the BBS, the LP and the KE, were not very meaningful for wheelchair-bound participants. Customized tests for the wheelchair-bound group could give a better insight in the evolution of their physical parameters. On adventurous journeys, wheelchair-bound people learned new functional activities, unfortunately this could not be detected with the tests in this protocol.
Another example that showed shortcomings, was the HGST. The Jamar hand held dynamometer is the most generally used and recommended instrument, as a result of its well reported reliability and variability. However variations in protocols and usage, could affect the recorded values and could make comparisons difficult. Besides, this machine may not be the most appropriate for all patient populations.
As a result of the limitations of disabled people, the grip could not be comfortable for weaker people and the used scale could be too large to detect small changes in strength. Therefore, more sensitive tools, such as the MIE digital grip analyser and the Grippit instrument could be a better alternative. Those instruments measure on a more sensitive scale, namely in Newton, resulting in the ability to discriminate better between individuals and between efforts (46, 47).
Furthermore, during the data-analysis of the 6MWT, the possible change in walking ability was not taken into account, which could have affected the statistical analysis of the 6MWT. Two participants improved in the walking ability categories. One person no longer required a walking tool and walked independently. Another person could walk with support after being wheelchair-bound. Mattering of course the measured walked distance would be smaller and could have been incorrectly interpreted as a negative evolution. However on a functional level this was an important positive evolution.
At last, a critical notice could be discussed about the interpretation of the results. A statistically significant difference could not be interpreted as clinically relevant. Therefore a search in the literature was conducted to find values for the minimal clinical difference/change, which could demonstrate clinical relevance. The minimal clinically detectable change is the smallest change in a treatment outcome that an individual patient would identify as meaningful and which would indicate a change in the patient’s management/ abilities / life.
However those values were described in the literature especially for specific pathologies and for specific tests. Even no value was defined in the literature for certain tests. Unfortunately, due to the heterogeneity of the included population, those specific values could not be applied in this study and thus/so the clinical relevance could not be determined.
Finally, a closer, more critical look into the different travel destinations could be meaningful/important.
The 6 destinations, where the participants could choose from, had different adventurous intensities, which made it difficult to compare all the data perfectly. For example the destination Spanish pyrenees had a higher physical level, compared to South Africa. For both journeys, activities such as trekking, camping and adventurous activities were mentioned on the U/Turn website.
Furthermore, even more challenging adventurous activities, such as mountain hiking, speleology, canyoning and kayaking, are part of the trip to the Spanish Pyrenees. It was noticeable that for all the destinations, a basic level was attained, where sleeping in a tent was usually the rule. The differences in intensity were therefore mainly determined by the other activities (24).
Further Research
Certain important implications for future research on this topic could be made.
The biggest difficulty in this research was the heterogeneity of the population. In future research, a selection of specific pathologies that could join the journey, would be recommended. So an analysis could be conducted per pathology.
Next to that, it would be suggested to introduce 1 standardized journey. All the participants would experience the same intensity because everyone would go to the same destination and would be involved in/ would encounter the same challenging activities.
Furthermore, an optimization of the test battery would be insurmountable. If only specific pathologies would be included to go on the adventurous journey, a specific test battery for each pathology could be set up taking into account which tests could estimate the physical parameters for that specific pathology the best. Therefore, the minimal detectable change, described in the literature, could be used to determine the clinical relevance of the results.
An example of a test that would be interesting to include in the test battery is an anaerobic exercise testing. The importance of monitoring the physical capacity in disabled people has grown. It could indicate the effectiveness of rehabilitation programmes. The article of Krops A. et al. gives an overview of the recommended protocols for anaerobic exercise testing in different categories of physically disabled people (49) .
Lastly, It could be useful to use scales, such as the Expanded Disability Status Scale (EDSS), that demonstrates the severity of the disabilities before and after the journey. The EDSS is only 1 example, which is used for patients suffering from MS. It could be interesting to use so an estimation could be made on how self-employed the person is. Eventually the status before taking part on the journey could be compared to the status after the journey (50).
Conclusion
Several positive evolutions of an adventurous journey on physical fitness are established. Only subjective evidence could be found for an eventual added value of a second journey. Indicated by the limitations, further research is necessary to objectively describe the influence of an adventurous journey, whereby a bigger sample size and adjusted test battery is recommended.
