Demographic and socioeconomic factors associated with disparity in wheelchair customizability among people with traumatic spinal cord injury

OBJECTIVES: To determine if a standard of care for wheelchair provision exists within the participating centers and if there is disparity in wheelchair customizability among the study sample. DESIGN: Convenience sample survey. SETTING: Thirteen Model Spinal Cord Injury Systems that provide comprehensive rehabilitation for people with traumatic spinal cord injury (SCI) and that are part of the national database funded through the US Department of Education. PARTICIPANTS: A total of 412 people with SCI who use wheelchairs over 40 hours a week. INTERVENTION: Survey information was obtained from subjects via telephone and in-person interviews and from the national database. Collected information included age, race, education, level of injury, and wheelchair funding source. MAIN OUTCOME MEASURES: Number and type (manual or power) of wheelchairs. Wheelchair customizability as defined by design features (eg, adjustable axle position, programmable controls). RESULTS: Ninety-seven percent of manual wheelchair users and 54% of power wheelchair users had customizable wheelchairs. No power wheelchair user received a wheelchair without programmable controls. Minorities with low socioeconomic backgrounds (low income, Medicaid/Medicare recipients, less educated) were more likely to have standard manual and standard programmable power wheelchairs. Older subjects were also more likely to have standard programmable power wheelchairs. CONCLUSIONS: The standard of care for manual wheelchair users with SCI is a lightweight and customizable wheelchair. The standard of care for power wheelchairs users has programmable controls. Unfortunately, socioeconomically disadvantaged people were less likely to receive customizable wheelchairs.     

The longitudinal relation between physical capacity and wheelchair skill performance during inpatient rehabilitation of people with spinal cord injury

OBJECTIVE: To study the longitudinal relation between physical capacity and wheelchair skill performance in subjects with spinal cord injury (SCI) during rehabilitation. DESIGN: Observational prospective cohort study. Measurements were taken 3 times during subjects' rehabilitation. SETTING: Eight rehabilitation centers in the Netherlands. PARTICIPANTS: Ninety-seven subjects with SCI. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Parameters of physical capacity were upper-extremity muscle strength (manual muscle test [MMT] sum score), peak oxygen uptake, and peak power output (POpeak). The Wheelchair Circuit consists of 8 wheelchair skills and results in 3 test scores: ability, performance time, and physical strain. RESULTS: POpeak was related to all 3 scores of the Wheelchair Circuit, and the MMT sum score was related to the ability score and the performance time score. The results indicate that (1) subjects with higher values of POpeak and/or the MMT sum score had better scores on the Wheelchair Circuit than subjects with lower values and (2) when a subject increased his/her POpeak and/or MMT sum score, this was associated with better wheelchair skill scores. CONCLUSIONS: There is a significant longitudinal relation between wheelchair skill performance and POpeak and MMT sum score during the rehabilitation of people with SCI. To optimize wheelchair skill performance, attention should be directed toward manual wheelchair exercise training and strength training of the upper body.     

Investigation of factors associated with manual wheelchair mobility in persons with spinal cord injury

Oyster ML, Karmarkar AM, Patrick M, Read MS, Nicolini L, Boninger ML. Investigation of factors associated with manual wheelchair mobility in persons with spinal cord injury.

Objective

To quantify wheelchair mobility of persons with a spinal cord injury (SCI), and to assess the relationship between wheelchair mobility and demographics, type of manual wheelchair, and participation.

Design

Cross-sectional study.

Setting

Six Model Spinal Cord Injury Systems.

Participants

People (N=132) with SCI who use a manual wheelchair as their primary means of mobility.

Interventions

Not applicable.

Main Outcome Measures

Wheelchair-related mobility characteristics measured by a data-logging device, and community participation measured by the short form of the Craig Handicap Assessment Recording Technique (CHART).

Results

Age was found to be significantly (r=–.225, P<.01) related to average speed traveled per day. Whites were found to travel significantly further (P<.01) and accumulate more minutes per day (P<.01) compared with minorities. Participants who were employed traveled significantly further (P<.01), faster (P<.01), and for more minutes per day (P<.01) compared with those who were not employed. A moderate relationship (r=.245–.390) was found between wheelchair mobility data and CHART total score.

Conclusions

Results suggest a need for future investigation of the factors that influence wheelchair mobility and community participation of persons with SCI. Findings indicate the efficacy of a quantitative method to track wheelchair mobility in community settings, which could serve as a way of identifying community participation for persons with SCI and possibly uncovering additional aspects of participation.     

Course of gross mechanical efficiency in handrim wheelchair propulsion during rehabilitation of people with spinal cord injury: a prospective cohort study

OBJECTIVE: To investigate the course of mechanical efficiency of handrim wheelchair propulsion during rehabilitation of subjects with (in)complete paraplegia and tetraplegia. DESIGN: Subjects were tested at the start of active rehabilitation (t1), 3 months later (t2), and when discharged from inpatient rehabilitation (t3). They performed two 3-minute submaximal treadmill exercise blocks in a wheelchair. SETTING: Eight rehabilitation centers in the Netherlands. PARTICIPANTS: Ninety-two people with (in)complete paraplegia and tetraplegia. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Mechanical efficiency values were calculated for each block. The course of mechanical efficiency was investigated using test occasions (t1 -t3), completeness and level (paraplegia or tetraplegia) of the lesion, and power output as independent variables in a multilevel regression analysis. RESULTS: Mechanical efficiency significantly increased between t1 and t2 only. After adding level and completeness of the lesion and their interactions with time to the model, block 2 showed that subjects with paraplegia had a significantly higher mechanical efficiency than subjects with tetraplegia. Subjects with tetraplegia improved more between t1 and t2 . Differences in mechanical efficiency between subjects with paraplegia and tetraplegia could not be explained by differences in absolute and relative power output levels. CONCLUSIONS: Results showed a significant improvement in mechanical efficiency during the first 3 months of active rehabilitation. Subjects with paraplegia showed a higher mechanical efficiency than did subjects with tetraplegia, whereas the latter showed more improvement between t1 and t2 .     

Periodically relieving ischial sitting load to decrease the risk of pressure ulcers

OBJECTIVE: To investigate the relieving effect on interface pressure of an alternate sitting protocol involving a sitting posture that reduces ischial support. DESIGN: Repeated measures in 2 protocols on 3 groups of subjects. SETTING: Laboratory. PARTICIPANTS: Twenty able-bodied persons, 20 persons with paraplegia, and 20 persons with tetraplegia. INTERVENTIONS: Two 1-hour protocols were used: alternate and normal plus pushup. In the alternate protocol, sitting posture was alternated every 10 minutes between normal (sitting upright with ischial support) and with partially removed ischial support (WO-BPS) postures; in the normal plus pushup protocol, sitting was in normal posture with pushups (lifting the subject off the seat) performed every 20 minutes. MAIN OUTCOME MEASURE: Interface pressure on seat and backrest. RESULTS: In WO-BPS posture, the concentrated interface pressure observed around the ischia in normal posture was significantly repositioned to the thighs. By cyclically repositioning the interface pressure, the alternate protocol was superior to the normal plus pushup protocol in terms of a significantly lower average interface pressure over the buttocks. CONCLUSIONS: A sitting protocol periodically reducing the ischial support helps lower the sitting load on the buttocks, especially the area close to ischial tuberosities.     

Subject- and injury-related factors influencing the course of manual wheelchair skill performance during initial inpatient rehabilitation of persons with spinal cord injury

OBJECTIVES: To study changes in wheelchair skills in subjects with spinal cord injury (SCI) during rehabilitation; to determine whether changes in wheelchair skill performance are related to the subject, lesion characteristics, secondary complications, and upper extremity pain; and to investigate if wheelchair skill performance at discharge can be predicted from these features. DESIGN: Longitudinal. Subjects performed the Wheelchair Circuit 3 times during rehabilitation: at admission (t1), 3 months later (t2), and at discharge (t3). SETTING: Eight rehabilitation centers in the Netherlands. PARTICIPANTS: One hundred twenty-one subjects with SCI. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The Wheelchair Circuit consists of 8 wheelchair skills and results in 3 test scores: ability, performance time, and physical strain. RESULTS: All the scores of the Wheelchair Circuit improved significantly between t1 and t2, and between t2 and t3. The scores were related to age and lesion level, whereas changes in scores were related to age, sex, lesion level, and secondary complications. The variables age, body mass index, sex, lesion level, motor completeness, and secondary complications contributed significantly to the prediction of the scores at t3. CONCLUSIONS: Wheelchair skill performance improved during rehabilitation. Personal and lesion characteristics are most important for improving wheelchair skill performance and predicting wheelchair skill performance.     

The effect of surface electric stimulation of the gluteal muscles on the interface pressure in seated people with spinal cord injury

van Londen A, Herwegh M, van der Zee CH, Daffertshofer A, Smit CA, Niezen A, Janssen TW. The effect of surface electric stimulation of the gluteal muscles on the interface pressure in seated people with spinal cord injury.

Objective

To study effects of surface electric stimulation of the gluteal muscles on the interface pressure in seated persons with spinal cord injury (SCI).

Design

One session in which alternating and simultaneous surface electric stimulation protocols were applied in random order.

Setting

Research laboratory of a rehabilitation center.

Participants

Thirteen subjects with SCI.

Intervention

Surface electric stimulation of the gluteal muscles.

Main Outcome Measures

Interface pressure, maximum pressure, pressure spread, and pressure gradient for the stimulation measurement. Variables were compared using 2-tailed paired t tests.

Results

Alternating and simultaneous stimulation protocol caused a significant (P<.01) decrease in interface pressure (-17±12mmHg, -19±14mmHg) and pressure gradient (-12±11mmHg, -14±12mmHg) during stimulation periods compared with rest periods. There was no significant difference in effects between the 2 protocols.

Conclusions

Surface electric stimulation of the gluteal muscles in persons with SCI causes a decrease in interface pressure. This might restore blood flow in compressed tissue and help prevent pressure ulcers.     

Wavelet analysis of skin blood oscillations in persons with spinal cord injury and able-bodied subjects

OBJECTIVE: To assess the blood oscillations in the skin over the ischial tuberosity (high-risk area for pressure ulcer) using spectral analysis of laser Doppler flowmetry signals based on wavelet transform. DESIGN: Wavelet analysis of skin blood oscillations in persons with spinal cord injury (SCI) and able-bodied subjects. SETTING: Seating and body support interface laboratory. PARTICIPANTS: Ten men were recruited for this study, of whom 5 were able-bodied subjects (age, 31.2+/-3.3 y) and 5 were persons with SCI (age, 37.2+/-7.3 y). INTERVENTIONS: External pressure of 16.0 kPa (120 mmHg) was applied to the ischial tuberosity via 1 specifically designed pneumatic indentor. The loading duration was 30 minutes. MAIN OUTCOME MEASURES: Skin blood flow was monitored for 10 minutes prior to loading and 20 minutes after the prescribed loading period. With spectral analysis based on wavelet transform, 5 frequency intervals were identified (.01-.02, .02-.06, .06-.15, .15-.40, .40-2.0 Hz) corresponding to endothelial related metabolic, neurogenic, myogenic, respiratory, and cardiac activities, respectively. RESULTS: The relative amplitude of the metabolic component for persons with SCI was significantly lower (F=5.26, P=.032) during the resting conditions as compared with able-bodied subjects. During the postloading period, the response of oscillatory activities was evidently lower in the skin over the ischial tuberosity for persons with SCI when compared with able-bodied subjects. In addition, the relative amplitude of the neurogenic component (.02-.06 Hz) during postloading was significantly lower for persons with SCI (F=5.44, P=.029). CONCLUSIONS: These findings suggest that the contributions of endothelial related metabolic and neurogenic activities to the blood perfusion regulation become relatively less for persons with SCI during the resting and postloading periods, respectively.     

Pressure ulcer prevalence in people with spinal cord injury: age-period-duration effects

OBJECTIVE: To examine age-period-duration patterns of the prevalence of pressure ulcers in community-residing people with spinal cord injury (SCI). DESIGN: Multicenter cohort study. SETTING: Nine Model Spinal Cord Injury Systems throughout the United States. PARTICIPANTS: People with SCI (N=3361) injured between 1986 and 1995 and followed up thereafter on a yearly basis through 2002. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Physician-confirmed pressure ulcers of stage II or greater at the follow-up visits. RESULTS: The multivariable generalized estimating equations model showed a significant trend toward increasing pressure ulcer prevalence in the recent years (1994-2002 vs 1984-1993: odds ratio=1.4; 95% confidence interval, 1.2-1.6) not explained by aging, years since injury, or demographic and clinical factors. The risk of pressure ulcers appeared to be steady during the first 10 years and increased 15 years postinjury. Pressure ulcers were more common among the elderly, men, African Americans, singles, subjects with education less than high school, unemployed, subjects with complete injury, and subjects with history of pressure ulcers, rehospitalization, nursing home stay, and other medical conditions. Injury cause and level had no significant effect. CONCLUSIONS: These results highlight the need for research into factors that contribute to the increasing pressure ulcer prevalence.     

Shoulder ultrasound abnormalities, physical examination findings, and pain in manual wheelchair users with spinal cord injury

Brose SW, Boninger ML, Fullerton B, McCann T, Collinger JL, Impink BG, Dyson-Hudson TA. Shoulder ultrasound abnormalities, physical examination findings, and pain in manual wheelchair users with spinal cord injury.

Objectives

To investigate the presence of ultrasound (US) abnormalities in manual wheelchair users with spinal cord injury (SCI) using a quantitative Ultrasound Shoulder Pathology Rating Scale (USPRS). To investigate physical examination (PE) findings using a quantitative Physical Examination of the Shoulder Scale (PESS), and to obtain data about pain and other subject characteristics such as age, years with SCI, and weight.

Design

Case series.

Setting

National Veterans' Wheelchair Games 2005 and 2006.

Participants

Volunteer sample of manual wheelchair users with SCI participating in the National Veterans' Wheelchair Games.

Interventions

Not applicable.

Main Outcome Measures

Presence of relationships between US findings, PE findings, pain, and subject characteristics.

Results

The USPRS correlated with age, duration of SCI, and weight (all P<.01), and showed a positive trend with the total Wheelchair User's Shoulder Pain Index (WUSPI) score (r=.258, P=.073). Several US findings related to presence of PE findings for specific structures. The PESS score correlated with the WUSPI (r=.679, P<.001) and duration of SCI (P<.05). The presence of untreated shoulder pain that curtailed activity was noted in 24.5% of subjects, and this was related to increased WUSPI scores (P=.002).

Conclusions

PE and US abnormalities are common in manual wheelchair users with SCI. The USPRS and PESS demonstrated evidence for external validity and hold promise as research tools. Untreated shoulder pain is common in manual wheelchair users with SCI, and further investigation of this pain is indicated.     

Assessing the influence of wheelchair technology on perception of participation in spinal cord injury

OBJECTIVE: To investigate factors related to the wheelchair, impairment, and environment that affect perception of participation of persons with spinal cord injury (SCI) in activities performed in 3 settings: in the home, in the community, and during transportation. DESIGN: Cross-sectional study. SETTING: Research centers and a specialized assistive technology (AT) clinic in Pittsburgh (Pitt). Research centers and community-based rehabilitation technology suppliers in Saint Louis (SL). PARTICIPANTS: Seventy wheelchair users with SCI. INTERVENTIONS: Subjects from Pitt and SL completed a written survey of AT usage in daily activities. MAIN OUTCOME MEASURES: Subjects were asked 5 questions within each setting (home, community, transportation) related to their perceived reason for functional limitations. RESULTS: The wheelchair was the most commonly cited factor limiting participation, followed by physical impairment and physical environment. Twenty-one percent of subjects with paraplegia reported pain as a limiting factor for their transportation use, significantly more (P=.047) than subjects with tetraplegia (3%). A trend (P=.099) was seen toward a higher percentage of subjects with tetraplegia (tetraplegia, 7%; paraplegia, 3%) reporting lack of equipment as a limiting factor for use of transportation. Differences were also seen across sites. CONCLUSIONS: The wheelchair was the most commonly cited limiting factor, followed by physical impairment and physical environment. The wheelchair is the most important mobility device used by persons with SCI and the one that users most associate with barriers.     

Effects of spinal cord injury level on the activity of shoulder muscles during wheelchair propulsion: an electromyographic study

OBJECTIVE: To determine the influence of spinal cord injury (SCI) level on shoulder muscle function during wheelchair propulsion. DESIGN: Fine-wire electromyographic activity of 11 muscles was recorded during wheelchair propulsion. SETTING: Biomechanics research laboratory. PARTICIPANTS: Convenience sample of 69 men, in 4 groups by SCI level (low paraplegia, n=17; high paraplegia, n=19; C7-8 tetraplegia, n=16; C6 tetraplegia, n=17). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Timing of muscle activity onset, cessation, and duration, and time of peak intensity for each functional group were compared with 1-way analysis of variance. Median electromyographic intensity was also compared. RESULTS: Two functional synergies were observed: push (anterior deltoid, pectoralis major, supraspinatus, infraspinatus, serratus anterior, biceps) and recovery (middle and posterior deltoid, supraspinatus, subscapularis, middle trapezius, triceps). Push phase activity began in late recovery and ceased in early to late push. Recovery phase muscles functioned from late push to late recovery. Recruitment patterns for the groups with paraplegia were remarkably similar. For subjects with tetraplegia, pectoralis major activity was significantly prolonged compared with subjects with paraplegia (P<.05). Subscapularis activity shifted from a recovery pattern in subjects with paraplegia to a push pattern in persons with tetraplegia. CONCLUSIONS: Level of SCI significantly affected the shoulder muscle recruitment patterns during wheelchair propulsion. Differences in rotator cuff and pectoralis major function require specific considerations in rehabilitation program design.     

The Wheelchair Circuit: Construct validity and responsiveness of a test to assess manual wheelchair mobility in persons with spinal cord injury

OBJECTIVE: To assess the validity and responsiveness of the Wheelchair Circuit, a test to assess manual wheelchair mobility in persons with spinal cord injury (SCI). DESIGN: Longitudinal. Subjects performed the Wheelchair Circuit at the start (T1) and at the end (T3) of inpatient functional rehabilitation. Construct validity and responsiveness were assessed. SETTING: Eight rehabilitation centers in the Netherlands. PARTICIPANTS: Seventy-four subjects with SCI admitted for inpatient rehabilitation. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The Wheelchair Circuit consists of 8 wheelchair skills and results in 3 test scores: ability, performance time, and physical strain. The construct validity of the Wheelchair Circuit was assessed by testing whether the test scores were significantly related to the subjects' functional status, physical capacity, lesion level, motor completeness of the lesion, and age. To prove the test's responsiveness, it was assessed whether the test scores had significantly improved between T1 and T3. RESULTS: For construct validity, 4 of the 5 hypotheses were confirmed. For test responsiveness, all 3 test scores had significantly improved during rehabilitation, and the standardized response mean values ranged from 0.6 to 0.9. CONCLUSIONS: The Wheelchair Circuit is a valid and responsive instrument with which to measure manual wheelchair mobility in subjects with SCI.     

Comparative study of pressure distribution at the user-cushion interface with different cushions in a population with spinal cord injury

Background

Few studies have offered comparative information on the mechanical characteristics of different wheelchair seat cushions. The objective of the present study was to compare the benefits of the wheelchair seat cushions most frequently used in a population of patients with spinal cord injury in terms of pressure distribution and contact surface at the user-cushion interface.

Methods

Each one of 48 patients with spinal cord injury was seated in his or her own wheelchair on the four models of cushions analyzed (low-profile air, high-profile air, dual-compartment air, and gel and firm foam), which were presented in randomized order. The pressure distribution readings and support surface area of the user-cushion interface were obtained with a matrix of piezocapacitive sensors.

Findings

The dual-compartment air cushion yielded lower readings for all pressure parameters analyzed (P_max, P_mean, P_sd, and P_isch) than the other three cushion models (P < 0.05). The best surface parameter results (S_tot, S > 60 and %S > 60) also were obtained with the dual-compartment air cushion (P < 0.05).

Interpretation

In the sample analyzed, the dual-compartment air cushion was the cushion with the best pressure distribution and largest contact surface of the user-cushion interface compared to the other three cushions studied.     

Power-assisted wheels ease energy costs and perceptual responses to wheelchair propulsion in persons with shoulder pain and spinal cord injury

Nash MS, Koppens D, van Haaren M, Sherman AL, Lippiatt JP, Lewis JE. Power-assisted wheels ease energy costs and perceptual responses to wheelchair propulsion in persons with shoulder pain and spinal cord injury.

Objective

Test effects of pushrim-activated power-assisted wheelchairs (PAPAWs) on the energetics and perceptual responses to steady-state and intensity-graded wheelchair propulsion in persons with paraplegia and tetraplegia having chronic shoulder pain.

Design

Test, retest with a control condition.

Setting

Academic medical center.

Participants

Subjects (N=18) aged 19 to 70 years with chronic, motor-complete paraplegia and tetraplegia having confirmed shoulder pain.

Interventions

Study participants underwent testing on 4 randomized nonconsecutive days during either 6 minutes of steady-state or 12 minutes of intensity-graded wheelchair propulsion on stationary rollers. Participants used their own manual wheelchair and either their customary wheels or power-assist wheels attached with an axle bracket.

Main Outcome Measures

Oxygen consumption (V?o₂, L/min), distance (m), energy cost (L/m), and ratings of perceived exertion (RPE; Borg Categorical 6-20 Scale) were measured during propulsion.

Results

Significant main effects of testing were observed for V?o₂, heart rate, and RPE in both subject groups. Distances propelled were significantly increased in both groups across both tests and in each of their 2-minute exercise stages.

Conclusions

Use of PAPAWs by persons with paraplegia and tetraplegia having shoulder pain significantly lowers energy cost responses and perceived exertion compared with manual wheelchair propulsion while significantly increasing the distanced propelled.     

The timed manual wheelchair slalom test: a reliable and accurate performance-based outcome measure for individuals with spinal cord injury

Gagnon D, Décary S, Charbonneau M-F. The timed manual wheelchair slalom test: a reliable and accurate performance-based outcome measure for individuals with spinal cord injury.

Objectives

To describe the timed manual wheelchair slalom test (MWST) and to quantify its test-retest reliability, standard error of measurement, and minimum detectable change (MDC).

Design

Repeated-measures design.

Setting

Pathokinesiology laboratory.

Participants

Manual wheelchair users (N=15) with spinal cord injury (SCI) (vertebral levels, C6 to T12; American Spinal Injury Association Impairment Scale: A, B, or C) participated in this study. Participants were 40.7±12.6 years of age, measured 1.77±.08m in height, weighed 79.6±23.9kg, and had been using a manual wheelchair as their primary mode of mobility for 5.9±7.5 years.

Interventions

Participants propelled their own wheelchair at a self-selected maximum velocity along a slalom trajectory (linear length, 18m) defined by 7 cones aligned in a straight line and set 3m, 2m, and 1m apart from one another. Three trials (T=3) of the MWST were performed on 2 separate visits (V=2) 6.3±5.4 days apart. The generalizability theory was used to determine the reliability, standard error of measurement, and MDC and to propose testing protocols for the MWST.

Main Outcome Measure

The time needed to complete the MWST expressed in seconds.

Results

All participants successfully completed the MWST. No adverse effect was reported. The time required to complete the MWST at visits 1 and 2 was 16.8±4.4 and 16.5±4.3 seconds, respectively. The reliability coefficient (φ=.981) and accuracy (standard error of measurement=3.47%, MDC=8.097%) were high when the time required for a participant to perform 3 MWST trials during a single visit (T=3, V=1) was averaged.

Conclusions

The timed MWST is a safe, reliable, and accurate performance-based outcome measure that can be administered easily and quickly in individuals with SCI who rely on a manually propelled wheelchair for mobility.     

Preventing recurrent pressure ulcers in veterans with spinal cord injury: impact of a structured education and follow-up intervention

Rintala DH, Garber SL, Friedman JD, Holmes SA. Preventing recurrent pressure ulcers in veterans with spinal cord injury: impact of a structured education and follow-up intervention.

Objective

To test the hypothesis that enhanced education and structured follow-up after pressure ulcer surgery will result in fewer recurrences.

Design

Randomized controlled trial.

Setting

Veterans Affairs medical center.

Participants

Forty-nine veteran men with spinal cord injury or dysfunction were approached on admission for pressure ulcer surgery. Five never had surgery, 2 refused to participate, and one withdrew. Forty-one were randomized into 3 groups. Three participants' ulcers did not heal, so follow-up could not begin.

Interventions

Group 1 received individualized pressure ulcer education and monthly structured telephone follow-up (n=20); group 2 received monthly mail or telephone follow-up without educational content (n=11); and group 3 received quarterly mail or telephone follow-up without educational content (n=10). Follow-up continued until recurrence, death, or 24 months.

Main Outcome Measure

Time to pressure ulcer recurrence.

Results

Group 1 had a longer average time to ulcer recurrence or end of study than groups 2 and 3 (19.6mo, 10.1mo, 10.3mo; P=.002) and had a smaller rate of recurrence (33%, 60%, 90%; P=.007). Survival analysis confirmed these findings (P=.009).

Conclusions

Individualized education and structured monthly contacts may be effective in reducing the frequency of or delaying pressure ulcer recurrence after surgical repair of an ulcer.     

Adapted manual wheelchair circuit: test-retest reliability and discriminative validity in persons with spinal cord injury

Cowan RE, Nash MS, de Groot S, van der Woude LH. Adapted manual wheelchair circuit: test-retest reliability and discriminative validity in persons with spinal cord injury.

Objective

To assess the test-retest reliability and discriminative validity of a 14-item manual wheelchair circuit adapted from previous research (AMWC).

Design

Two AMWC trials per subject completed within 15 days.

Setting

Two clinical research and 3 rehabilitation centers.

Participants

Convenience sample of individuals with spinal cord injury (N=50) from centers in the United States (n=38) and the Netherlands (n=12). Mean age ± SD was 46±13 years, and mean injury duration ± SD was 12±11 years. Fifteen had cervical injuries, and 42 were men.

Interventions

An existing 8-task manual wheelchair circuit was modified to remove the need for a wheelchair treadmill and expanded to 14 tasks to attenuate floor and ceiling effects: 5 original tasks—figure-of-8, .012-m doorstep crossing, .10-m platform, 15-m sprint, and making a level transfer; 3 modified tasks—3% and 6% ramp, and 3-minute overground wheeling; and 6 new tasks—.04-m doorstep crossing, propelling over artificial grass, opening/closing a door, 3% side slope, holding a wheelie for 10 seconds, and propelling in a wheelie.

Main Outcome Measures

Reliability of the primary outcomes, sum ability score (sum of all tasks; 0–14 [no.]) and sum performance time (figure-of-8 + sprint + grass; 0–360 [s]), was determined by intraclass correlation coefficients (ICCs) for the whole sample and paraplegia (PP) and tetraplegia (TP) subsets. Independent t tests compared PP and TP trial 1 sum ability score and sum performance time.

Results

Sum ability and sum performance time ICCs exceeded .90 for the full sample and the PP/TP subsets. Sum ability was higher for PP than TP (PP, 12.9±1.2; TP, 9.8±2.8; P<.00), and sum performance times were lower for PP than TP (20.0±4.0s vs 32.0±1.97s, P<.00).

Conclusions

AMWC primary outcomes, sum ability score and sum performance time, are reliable and discriminate between TP and PP.     

Pelvic movement and interface pressure distribution during manual wheelchair propulsion

OBJECTIVE: To investigate the movement of the ischial tuberosities and the redistribution of interface pressure during manual wheelchair propulsion. DESIGN: Measurement of ischial tuberosity positions and comparison with corresponding position of the zones of peak pressure by using independent samples t tests. Analysis of variance was used to compare peak and average pressures under static and dynamic conditions. SETTING: Human locomotion laboratory. PARTICIPANTS: Ten subjects with spinal cord injury (SCI) and 10 individuals with no disabilities. INTERVENTIONS: Manual wheelchair propulsion on a stationary wheelchair ergometer at the subject's maximum propulsion speed. MAIN OUTCOME MEASURES: Seat interface pressure and the 3-dimensional position of the pelvis were measured with a pressure mat and an optical motion analysis system. RESULTS: During wheelchair sprinting, the ischia were located at 19.2+/-11.7 mm behind the corresponding peak pressure locations. The anteroposterior rocking of the pelvis was 11.2 degrees and 5.2 degrees for the normal and SCI group, respectively. The average interface pressure over the ischial tuberosity area was lower under dynamic conditions. It was also observed in the SCI group that there was a concentration of high-pressure gradients around the peak pressure areas of the buttock during dynamic propulsion. CONCLUSION: Peak pressure locations did not concur exactly with the ischial tuberosities during propulsion. The movements of the ischial bone and the cyclic loading imposed on the tissue underneath the ischial tuberosities during dynamic conditions may have implications for the etiology of decubitus ulcers.