Understanding and measuring powered wheelchair mobility and manoeuvrability. Part I. Reach in confined spaces

Purpose. To determine: (1) what wheelchair manoeuvrability factors are important and (2) the effects of powered wheelchair design on the ability to reach in a confined space.

Method. The relative importance of five aspects of wheelchair manoeuvrability was determined through a survey of users of wheelchairs (N = 52) and health care professionals and others (N = 89). A single young, non-disabled subject undertook repeated trials of reach distance on to a counter at the end of a corridor whose width could be adjusted by moving Styrofoam walls.

Results. Reaching, moving in confined spaces and avoiding collisions were more important than speed and avoiding the need to drive backwards. The rear wheel drive powered wheelchair was found to allow the greatest reach when driving backwards into the space and the wheelchair which moved in a sideways direction allowed greatest reach in the narrowest corridor.

Conclusions. The survey concluded that manoeuvring in small spaces and reaching without collisions were important. The powered wheelchair with sideways capability afforded the greatest reach in confined spaces except when the rear wheel drive chair was driven in backwards. The survey respondents did not place a high priority on avoiding backwards driving but some people find this difficult to do safely.     

The manual wheelchair wheelie: A review of our current understanding of an important motor skill

Purpose.?To review the current understanding of the manual wheelchair wheelie.

Method.?Review of the literature.

Results.?A rear wheelchair wheelie occurs when the front wheels, ordinarily in contact with the support surface, are intentionally caused, by means of a transient or sustainable rear pitch, to lift from the surface while the rear wheels remain on the surface. Pitch control (partial or full) is the foundation of many wheelchair skills (e.g., negotiating thresholds, potholes, curbs, steep inclines and gravel). Yet, most wheelchair users never learn to perform this valuable skill. Wheelie capability is affected by the characteristics of the clinician, the wheelchair user, the wheelchair and the environment. Although our understanding of wheelie biomechanics and training methods is evolving, much remains to be learned. Three recent wheelchair developments have wheelie-related implications: a new type of rear anti-tip device (Arc-RAD) that permits wheelie-like function, pushrim-activated power-assisted wheelchairs (PAPAWs) that make wheelie-dependent skills more dangerous and difficult, and a powered wheelchair that has robotic wheelie capabilities (the IBOT).

Conclusions.?Improvements in our understanding of the nature of wheelies, formalization of training protocols and innovations in wheelchair design hold promise for improved activities and participation by wheelchair users.     

Mobility-related participation and user satisfaction: Construct validity in the context of powered wheelchair use

Purpose.?The aim of this study was to investigate the constructs of mobility-related participation and user satisfaction, two important outcome dimensions within praxis and research on mobility device interventions.

Method.?To fulfill this aim, validity and reliability of a 12-item scale on mobility-related participation and a 10-item scale on user satisfaction were examined in the context of older people's powered wheelchair use (n?=?111). Rasch analysis and correlation analysis were applied.

Results.?Construct validity of both scales was confirmed. The reliability of the user satisfaction scale was good, while the mobility-related participation scale was not optimal in discriminating between persons with a high degree of mobility-related participation. It was demonstrated that mobility-related participation and user satisfaction are separate, not related constructs.

Conclusions.?It can be concluded that the investigated mobility-related participation and user satisfaction constructs appear to be valid. Since the two constructs are not related and both yield important information, both dimensions should be evaluated in outcomes research and praxis targeting powered wheelchair interventions. Reliability problems of the mobility-related participation scale indicate the complexity of this construct. The results have been instrumental in the development of a new scale for measuring mobility-related participation ‘The NOMO 1.0’.     

Electric-powered indoor/outdoor wheelchairs (EPIOCs): users' views of influence on family,friends and carers

Purpose.?This study explored the effects of electric-powered indoor/outdoor wheelchair (EPIOC) provision to users on their family and carers.

Method.?EPIOC users receiving their chairs between February and November 2002 (N?=?74) were invited to participate in a telephone questionnaire/interview, and 64 agreed. This study examined the responses to the question ‘Has the use of your EPIOC affected your family or friends in any way?’ and related comments. Interviews were analysed using a qualitative framework approach to identify emergent themes. In addition, the proportion of individuals raising issues related to each theme was determined. Participants were interviewed 10–19 (mean?=?14.3) months after chair delivery.

Results.?The following themes emerged: reduced physical burden on family/friends and increased independence and freedom. However, an EPIOC does not eliminate other practical problems particularly during transportation and negotiating kerbs and slopes. Users also reported anxiety/worry in relationship to EPIOC use, e.g., weather conditions, personal safety (muggings), use of ramps and kerbs.

Conclusion.?There are considerable benefits to families and carers associated with powered wheelchair use. A reduction in the physical demand for pushing and increased freedom were identified. These benefits appear to outweigh the residual practical difficulties and worries.     

The experiences of using an anti-collision power wheelchair for three long-term care home residents with mild cognitive impairment

Purpose.?Presented are three case analyses of long-term care home residents with cognitive impairment who tested an anti-collision power wheelchair. We discuss technology design and research implications for this population.

Method.?Case studies involved 371?h of participant observation and 7?h of open-ended interview with residents (n?=?3), family members (n?=?3) and clinical staff (n?=?11). Thematic analysis generated themes related to technological, psychological and social aspects of residents' inclination and disinclination towards power mobility use.

Results.?Themes examined the discordance between others' and residents' reports of anti-collision power wheelchair use; a facet of response bias; unanticipated implications for independence and dependence; and implications of device design for self-presentation.

Conclusions.?Technology alone is insufficient to help residents to fully benefit from the autonomy that a wheelchair intervention can provide: close attention is required to the social and organisational factors of institutional life. For technology to be acceptable, the design must meet the functional and aesthetic needs of users. Considerations in the design of future power wheelchairs for residents with cognitive impairment include capabilities to drive on uneven surfaces, effort-reducing driving modes, improved user interface usability, and acceptable driving speed, size and appearance.     

Evaluation of manual wheelchairs by individuals with spinal cord injuries

Purpose.?The aim of this study was to investigate how adults with spinal cord injury assess their satisfaction regarding various aspects and use of their manual wheelchair.

Method.?The Quebec User Evaluation of Satisfaction with Assistive Technology (QUEST 2.0) together with seven additional questions was sent to 205 adults with SCI.

Results.?One hundred and twenty-four responses were available. The QUEST 2.0 showed a high level of satisfaction with manual wheelchair properties. However, the respondents were less satisfied with the services offered. Ease of use and comfort were identified as most important. Eighty-nine percent of the respondents rated their level of satisfaction as ‘quite satisfied’ or ‘very satisfied’ in ease of using a manual wheelchair compared with 68% of the respondents that were ‘quite satisfied’ or ‘very satisfied’ with the level of comfort. A greater satisfaction of ease in propulsion indoors compared with sitting comfort in various activities was found.

Conclusions.?A discrepancy was shown between users not being as satisfied with comfort in sitting in various activities as opposed to satisfaction with propulsion. This indicates the need for increased knowledge and developments concerning individual solutions, incorporating comfort as well as ease of use of a manual wheelchair.     

Effects of hand cycle training on wheelchair capacity during clinical rehabilitation in persons with a spinal cord injury

Purpose.?To evaluate the effects of a structured hand cycle training programme on physical capacity in subjects with spinal cord injury (SCI) during clinical rehabilitation.

Method.?Twenty subjects with SCI who followed hand cycle training were compared with matched control subjects from a Dutch longitudinal cohort study, who received usual care.

Primary outcomes of physical capacity were peak power output (PO_peak), peak oxygen uptake (VO_2peak) and oxygen pulse during a hand rim wheelchair test. Secondary outcome measures were isometric peak muscle strength of the upper extremities and pulmonary function. Hand cycle capacity (PO_peak and VO_2peak) was evaluated in the training group only.

Results.?Strong tendencies for improvement were found in wheelchair capacity, reflected by PO_peak and oxygen pulse after additional hand cycle training. Significant effects on shoulder exo- and endo-rotation and unilateral elbow flexion strength were found but no improvements on pulmonary function.

Conclusions.?Additional hand cycle training during clinical rehabilitation seems to show similar or slightly favourable results on wheelchair capacity and muscle strength compared with regular care. The heterogeneous subject group and large variation in training period may explain the limited effects of additional hand cycle training on wheelchair capacity.     

Manual wheelchair propulsion pattern use by people with multiple sclerosis

Purpose.?To determine the most commonly used manual wheelchair propulsion pattern by people with multiple sclerosis (MS) and to assess which factors influence the preference.

Method.?Sixty manual wheelchair users with MS from an MS outpatient rehabilitation centre in Northern Italy were assessed on upper limb range of motion and trunk stability to determine if these factors or demographic, disease or wheelchair use history, influenced the choice of wheelchair propulsion pattern.

Results.?Fifty-four (90%) subjects used the arcing propulsion pattern, the least efficient pattern as reported in the literature. Sixteen (26.7%) subjects had impaired trunk stability and 38 (63.3%) subjects demonstrated some deficit on either extremity for active range flexion–extension. Twenty (33%) subjects had no deficits on active range flexion–extension and had normal trunk control. Upper limb range of motion and trunk stability were not significant in determining the preference for propulsion pattern (p?=?1.05 and 0.38, respectively). Demographic and disease factors and wheelchair use history were also not significant in determining propulsion pattern.

Conclusions.?The person with MS uses the least efficient pattern overall, requiring frequent repetition, although a smaller range of movement. This may be an energy conservation technique that helps in managing fatigue.     

Use of orthoses and orthopaedic technical devices in proximal spinal muscular atrophy. Results of survey in 194 SMA patients

Purpose.?The purpose of this study is to determine the use of orthopaedic and assistive devices for Spinal muscular atrophy (SMA) patients, following a survey of 194 patients.

Method.?The use of wheelchairs, corsets and orthoses was evaluated in 194 SMA patients whose mean age was 12.6 (SD 7.2, 0.7–41.1). There were 14 patients with SMA type Ib (age range 1.7–36.9), 133 with type II (age range 0.7–37.7), 42 with type IIIa (age range 3.2–41.1) and 5 with type IIIb (age range 8.0–20.0).

Results.?One hundred and sixteen patients (60%) had powered and 29 patients (15%) manual wheelchairs. Nineteen patients (10%) used long leg orthoses. Ten patients (5%) used swivel walkers and 26 (13%) had standing frames. Twenty-six patients (13%) received lower leg orthoses because of foot deformities. Eight patients (4%) used night splints for the lower limbs. One hundred and fifteen patients (59%) were fitted with corsets because of progressive scoliosis.

Conclusion.?This is the first study about the provision of orthopaedic and assistive devices in a large group of SMA patients. Following the results of this survey we can optimise the strategy of providing orthoses and assistive devices for SMA patients and better adapt them to the patient's individual needs.     

A review of manual wheelchairs

Purpose: To review the scientific literature published in the last 14 years on the different types of manual wheelchairs. Method: A systematic review of the literature was conducted to find the recent research on manual wheelchairs. Results: The findings of 77 references on pushrim-propelled wheelchairs, crank-propelled wheelchairs, lever-propelled wheelchairs, geared manual wheelchairs and pushrim-activated power-assist wheelchairs are reported. Conclusion: The pushrim-propelled wheelchair is light, easy to steer and has good indoor manoeuvrability but is very inefficient and causes serious upper body overloading so that long-term use leads to steadily deteriorating capability for the user and ultimately a transition to a powered chair. Whilst the latter is less physically demanding, the sedentary lifestyle and decreasing muscle use lead to several secondary health problems. Crank- and lever-propelled wheelchairs and geared pushrim wheelchairs are more efficient and less demanding and may improve the quality of life of the user by expanding the range of accessible environments, reducing upper body pain, increasing independence and avoiding or delaying the ‘debilitating cycle’. However, wheelchairs with these alternative modes of propulsion are often heavier, wider and/or longer and are less easy to steer, brake and fold than the pushrim wheelchair.

• Implications for rehabilitation

• Pushrim-propelled wheelchairs are difficult to drive on outdoor paths (grass and gravel/sand surfaces) and ramps so that users are confined to restricted environments and have limited participation in everyday activities.

• The repetitive strain imposed on the upper body by pushrim propulsion leads to very high prevalence of shoulder and wrist pain in manual wheelchair users.

• Crank-propelled and lever-propelled wheelchairs are more efficient and less straining than pushrim propelled wheelchairs, allowing users to access more challenging environments, prolong independence and improve the quality of life.

     

A critical review of powered mobility assessment and training for children

Purpose.?Assessment and training of young children using powered mobility tends to be based on expert opinion although research in this area has recently been completed. This review critiques available research and discusses the studies in relation to theory and expert opinion.

Method.?A literature review was completed to identify research regarding powered mobility training for children with developmental disabilities. Two recent qualitative studies were identified and their models and assessment tools were compared and discussed with recommendations for clinical practice and research.

Results.?The focus of the two studies is on a continuum of learning, the reciprocal relationship of trainer and trainee, and impact of the social and attitudinal environment on powered mobility skill development. The assessment tools and training protocols are backed up by motor learning principles and expert opinion. Further research is required to incorporate the tools into clinical practice and to examine additional psychometric properties.

Conclusions.?Rather than focusing on readiness skills or pass/fail tests, clinicians should explore early mobility options for clients at the beginning of the continuum of learning, reflect on how they relate to and impact on their clients' learning, and set up the environment to facilitate independent learning and exploration.     

Contents of physical therapy,occupational therapy,and sports therapy sessions for patients with a spinal cord injury in three Dutch rehabilitation centres

Purpose.?To describe the contents of interventions to improve self-care and mobility for patients with spinal cord injury (SCI) in early post-acute rehabilitation, using the Spinal Cord Injury-Interventions Classification System (SCI-ICS), and to compare these interventions between rehabilitation centres. The SCI-ICS describes therapy to improve self-care and mobility at three levels of functioning and consists of 25 categories with a total of 139 different interventions.

Methods.?Fifty-three physical therapists, occupational therapists and sports therapists of three Dutch SCI rehabilitation centres recorded interventions with the SCI-ICS for patients with SCI in early post-acute rehabilitation for four consecutive weeks.

Results.?Therapists recorded 1640 treatment sessions of 48 patients with a SCI. The mean number of treatment sessions per patient per week (8.9 overall) differed between centres (p?<?0.05), unlike the mean therapy time in minutes per patient per week (259 overall). Highest frequencies for individual categories were found for ‘Muscle Power’, ‘Walking’, and ‘Hand rim wheelchair propulsion’.

Conclusions.?We described the specific contents of therapy of patients with a SCI in three Dutch rehabilitation centres. The largest proportion of time was spent on interventions to improve muscle power, walking, and hand rim wheelchair propulsion.     

Effects of dance on balance and gait in severe Parkinson disease: A case study

Purpose.?Dance may improve functional mobility in individuals with mild-to-moderate Parkinson disease (PD), yet dance effects in severe PD remain unexamined. This study's purpose was to evaluate the feasibility and effects of partnered tango classes on balance, endurance and quality of life in an individual with severe PD.

Design.?Over 10 weeks, the participant attended 20, 1-h tango classes for individuals with PD. Balance, walking, and quality of life were evaluated before and after the intervention and at a 1-month follow-up in this single case design. Caregiver burden was also assessed at all time points.

Results.?The participant improved on the Berg Balance Scale, 6-min walk test, and functional reach. He reported increased balance confidence and improved quality of life as measured by the Parkinson Disease Questionnaire-39 summary index. Gains were maintained at the 1-month follow-up. Caregiver burden increased from baseline immediately post-intervention and at follow-up.

Conclusion.?Twenty partnered tango lessons improved balance, endurance, balance confidence, and quality of life in a participant with severe PD. This is the first report of the use of dance as rehabilitation for an individual with advanced disease who primarily used a wheelchair for transportation.     

The M3S-based electric wheelchair for the people with disabilities in Taiwan

Purpose.?This study aims to establish an electronic wheelchair system in Taiwan that conforms to multiple master–multiple slave (M3S) standards. The proposed system could enhance the safety and convenience of people with disabilities.

Material and method.?The M3S-based head-controlled electric wheelchair consists of three parts: (A) the input device, (B) the output device, and (C) the safety device. Head movement can be used as the input control to cause the tilting device to produce a corresponding level of analog voltage (backward & forward/left & right) which is then transmitted to the analogy/digital conversion module to control the output device (wheelchair's motor). Ten subjects with C5 uncompleted spinal cord injury were recruited in the clinical assessment. They were randomly assigned into groups A and B. In the group A, the subjects were assigned to operate the head-controlled wheelchair system with M3S standard before operating the head-controlled wheelchair system without M3S standard. In the group B, the subjects were assigned to operate the head-controlled wheelchair system without M3S standard before operating the head-controlled wheelchair system with M3S standard. Two subjects in the group B drop off due to their personal reasons.

Results.?The time cost for group A in completing tasks 1, 2, and 3 with the M3S and without the M3S were insignificant (p > 0.05). The time cost for completing in group B was insignificant (p > 0.05). Thus, the wheelchair operating time is depended on the proficiency of the subjects, not the M3S standard added.

Discussions and conclusions.?The time cost for subjects to operate the wheelchair was determined by their proficiency, not the M3S standard control added to the system. However, the M3S-based system did realize the safety mechanism and complex auxiliary tools with and without the plug-in and play function.     

Effects of 4-weeks of asynchronous hand-rim wheelchair practice on mechanical efficiency and timing

Purpose.?To investigate the consequence on gross mechanical efficiency (GE), arm frequency and sub-maximal performance, of paced and unpaced practice during asynchronous hand-rim wheelchair propulsion.

Methods.?Twenty-five able-bodied participants performed five, 4-min exercise bouts at 1.7?m/s, at the freely chosen frequency (FCF) and four paced arm frequencies of 60, 80, 120 and 140% FCF. GE, arm frequency and measures of sub-maximal performance were determined. Participants were assigned to an unpaced (FCF, N?=?9), paced (80% FCF, N?=?8) or control (CON, N?=?8) no practice group. The FCF and 80% FCF groups received 4-weeks (unpaced and paced, respectively) propulsion practice (three sessions·per wk, four 4?min/trials; 33–35?W) at 1.7?m/s on a wheelchair ergometer. Following practice, the pre-testing protocol was repeated.

Results.?Mean GE showed a relative increase in both experimental groups (21 and 17%; FCF and 80% FCF respectively; p?=?0.001) compared to no change in CON (?1.5%). The FCF arm frequency decreased in both experimental groups (p?=?0.001), with larger changes evident following FCF practice.

Conclusion.?Four weeks of unpaced or paced practice had a beneficial effect on GE. This improvement seems to be associated with a reduction in arm frequency.     

The perceived benefits and barriers to exercise participation in persons with multiple sclerosis

Purpose.?The purpose of this study was to examine the perceived benefits and barriers to exercise participation in persons with multiple sclerosis (MS).

Method.?A cross-sectional postal survey comprised of 93 adults with MS was conducted. Participants completed the Exercise Benefits and Barriers Scale (EBBS), Spinal Cord Injury Exercise Self-Efficacy Scale (EXSE), Multiple Sclerosis Impact Scale, Disease Steps Scale and International Physical Activity Questionnaire.

Results.?Forty-three percent of the participants were classified as exercising individuals (EX group) as compared with non-exercising individuals (non-EX group). Participants in the EX group reported significantly higher scores on the EBBS and EXSE. Items related to physical performance and personal accomplishment were cited as the greatest perceived benefits to exercise participation and those items related to physical exertion as the greatest perceived barriers to both the EX and non-EX groups.

Conclusion.?When compared with previous studies conducted in the general population, the participants in the present study reported different perceived barriers to exercise participation. Furthermore, awareness of the benefits of physical activity is not sufficient to promote exercise participation in persons with MS. Perceived exercise self-efficacy is shown to play an important role in promoting exercise participation in persons with MS.     

Physical capacity after 7 weeks of low-intensity wheelchair training

Purpose.?To simulate the effect of low-intensity exercise in early rehabilitation, we investigated the effect of a 7-week low-intensity norm duration hand rim wheelchair training on the physical capacity in untrained able-bodied individuals.

Method.?Twenty-five able-bodied participants were randomly assigned to an experimental and control group: 10 participants exercised 7 weeks, three times a week at 30% heart rate reserve (HRR) for 30?min (experimental group). The control group consisted of 15 participants who did not receive training. Physical capacity (maximal isometric strength, sprint power, peak power output and peak oxygen uptake) and submaximal performance [heart rate (HR), oxygen uptake (VO₂), mechanical efficiency (ME)] were assessed pre- and post-training. The levels of upper-body discomfort were determined with the use of a Local Perceived Discomfort scale.

Results.?Compared to the control group the experimental group significantly improved on sprint power (+31.2%), peak aerobic power output (+34%), submaximal HR, VO₂ and ME (+16.9%). The participants did not experience high levels of local discomfort in the upper body during the training.

Conclusions.?Low-intensity norm duration hand rim wheelchair training which significantly improved peak aerobic and sprint power output, efficiency and physical strain in able-bodied untrained individuals. Training at 30% HRR (3?×?/week, 30?min/session) may be appropriate in untrained individuals, such as novice wheelchair users at the start of their rehabilitation, to prevent early fatigue and overuse and enhance motivation.     

Reliability and the measurement of activity limitations (ADLs) for children with special health care needs (CSHCN) living in the community

Purpose.?Meeting the personal care challenges of children with special health care needs (CSHCN) living in the community demands a reliable assessment of their abilities to perform activities of daily living (ADLs). This research investigates factors affecting the inter-rater reliability of functional assessments of CSHCN conducted in the home.

Methods.?Dual-standardised assessments were conducted with 236 community-dwelling CSHCN seeking or receiving Medicaid Personal Care Services (PCS) in a single state in USA.

Results.?Analyses revealed that assessments of CSHCN with the greatest or least amount of activity limitations exhibited the greatest agreement. The greatest disagreement occurred when assessors faced children with moderate to moderately severe activity limitations. Specific ADLs, where the greatest and least agreements occurred, varied by the level of the child's overall activity limitation.

Conclusions.?These results imply that the most serious challenges to the reliability of home-based assessment of ADLs among CSHCN occur in cases of children with moderate or moderately severe activity limitations.