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.     

Maneuverability and usability analysis of three knee-extension propelled wheelchairs

PURPOSE: The purpose of this study was to evaluate the maneuverability and usability of three knee-extension propelled wheelchairs. METHOD: The maneuverability of the knee-extension propelled wheelchairs was determined in a controlled test representing five standard wheelchair activities. The usability of the wheelchairs was evaluated in a field test with elderly residents of an extended care facility in Salt Lake City. RESULTS: The results indicate that the wheelchair designs using a swinging (four-bar linkage) or sliding belt mechanism are preferred to a sliding plate design. CONCLUSIONS: The use of knee-extension propelled wheelchairs is a feasible alternative to hand propelled wheelchairs. Further development and research is needed to address power requirements, maneuverability, and entrance/egress from the chairs.     

Maneuverability and usability analysis of three knee-extension propelled wheelchairs

Purpose : The purpose of this study was to evaluate the maneuverability and usability of three knee-extension propelled wheelchairs.

Method : The maneuverability of the knee-extension propelled wheelchairs was determined in a controlled test representing five standard wheelchair activities. The usability of the wheelchairs was evaluated in a field test with elderly residents of an extended care facility in Salt Lake City.

Results : The results indicate that the wheelchair designs using a swinging (four-bar linkage) or sliding belt mechanism are preferred to a sliding plate design.

Conclusions : The use of knee-extension propelled wheelchairs is a feasible alternative to hand propelled wheelchairs. Further development and research is needed to address power requirements, maneuverability, and entrance/egress from the chairs.     

Mechanical effects of rear-wheel camber on wheelchairs

Giving the rear wheels of manually propelled wheelchairs negative camber (by angling them such that the bottoms of the wheels are farther apart than the tops) has become increasingly popular, especially among active users. This study's purpose was to evaluate how changing camber affects a wheelchair's mechanics and the extent of these changes. Using a representative wheelchair occupied by an anthropomorphic dummy, we altered the camber from +15 degrees to -15 degrees and measured the effects on nine selected variables. In addition to increasing the wheelchair's track width, negative camber increases the wheelchair's wheelbase and decreases the height of the frame. With negative camber, the center of gravity (CG) of the occupied wheelchair moves backwards. Negative camber causes a backwards tilt of the frame which, in turn, causes toe-out of the rear wheels, a positive caster-inclination angle and an increase in the caster-trail distance. It is apparent that a change in one component of a wheelchair can affect many others, which should be taken into consideration and, where appropriate, compensated for when changing the camber of the wheelchair.     

Mechanical Effects of Rear-Wheel Camber on Wheelchairs

Giving the rear wheels of manually propelled wheelchairs negative camber (by angling them such that the bottoms of the wheels are farther apart than the tops) has become increasingly popular, especially among active users. This study's purpose was to evaluate how changing camber affects a wheelchair's mechanics and the extent of these changes. Using a representative wheelchair occupied by an anthropomorphic dummy, we altered the camber from +15° to ?15° and measured the effects on nine selected variables. In addition to increasing the wheelchair's track width, negative camber increases the wheelchair's wheelbase and decreases the height of the frame. With negative camber, the center of gravity (CG) of the occupied wheelchair moves backwards. Negative camber causes a backwards tilt of the frame which, in turn, causes toe-out of the rear wheels, a positive caster-inclination angle and an increase in the caster-trail distance. It is apparent that a change in one component of a wheelchair can affect many others, which should be taken into consideration and, where appropriate, compensated for when changing the camber of the wheelchair.     

An observational study of powered wheelchair provision in Italy

Powered wheelchairs are complex and expensive assistive devices that must be selected and configured on the basis of individual user needs, lifestyle, motivation, driving ability, and environment. Providing agencies often require evidence that their financial investment will lead to a successful outcome. The authors surveyed a sample of 79 users who had obtained powered wheelchairs from a Regional Health Service in Italy in the period 2008–2013. Follow-up interviews were conducted at the users’ homes in order to collect information about wheelchair use, and its effectiveness, usefulness, and economic impact. The instruments used in the interviews included an introductory questionnaire, QUEST (Quebec User Evaluation of Satisfaction with Assistive Technology), PIADS (Psychosocial Impact of Assistive Devices Scale), FABS/M (Facilitators and Barriers Survey/Mobility), and SCAI (Siva Cost Analysis Instrument). The results indicated positive outcomes, especially in relation to user satisfaction and psychosocial impact. A number of barriers were identified in various settings that sometimes restrict user mobility, and suggest corrective actions. The provision of a powered wheelchair generated considerable savings in social costs for most users: an average of about $38,000 per person over a projected 5-year period was estimated by comparing the cost of the intervention with that of non-intervention.     

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.

     

Issues in maintenance and repairs of wheelchairs: A pilot study

In this pilot study, we assessed wheelchair durability and its effect on user satisfaction. Specifically, we examined the characteristics of the participants' wheelchairs, the types of maintenance and repairs completed, and whether the participants' satisfaction was affected by problems with their wheelchairs. A convenience sample of 130 participants who used wheelchairs as their primary means of mobility was recruited. Participants completed a questionnaire about their wheelchairs, the maintenance and repair history, and their satisfaction levels. Results showed that 26% of the participants had completed a wheelchair repair in the past 6 months, 16% had completed general maintenance, and 27% had completed tire repairs. Neither hours of wheelchair use nor wheelchair age affected repair or maintenance frequency. Participants were generally satisfied with their wheelchairs. Better understanding of wheelchair maintenance and repair issues will guide improvements in wheelchair design and enhance the community participation of individuals who use wheelchairs.     

Relationships Between Wheelchair Services Received and Wheelchair User Outcomes in Less-Resourced Settings: A Cross-Sectional Survey in Kenya and the Philippines

ObjectiveTo explore the relationships between wheelchair services received during wheelchair provision and positive outcomes for users of wheelchairs.DesignSecondary analysis of cross-sectional data.SettingUrban and periurban communities in Kenya and the Philippines.ParticipantsAdult basic manual wheelchair users (N=852), about half of whom reported having received some wheelchair services with the provision of their current wheelchairs.InterventionsNot applicable.Main Outcome MeasuresParticipants completed a survey that included questions related to demographic, clinical, and wheelchair characteristics. The survey also included questions about the past receipt of 13 wheelchair services and 4 positive outcomes for users of wheelchairs. The relationships between individual services received and positive outcomes were assessed using logistic regression analyses. In addition to assessing individual services and outcomes, we analyzed a composite service score (the total number of services received) and a composite outcome score (≥3 positive outcomes).ResultsThe top 3 individual services from the perspective of relationships with the composite outcome score were “provider did training” (P=.0009), “provider assessed wheelchair fit while user propelled the wheelchair” (P=.002), and “peer group training received” (P=.033). The composite service score was significantly related to “daily wheelchair use” (P<.0001), “outdoor unassisted wheelchair use” (P<.0001), “high performance of activities of daily living” (P=.046) and the composite outcome score (P=.005), but not to the “absence of serious falls” (P=.73).ConclusionsThe receipt of wheelchair services is associated with positive outcomes for users of wheelchairs, but such relationships do not exist for all services and outcomes. These findings are highly relevant to ongoing efforts to optimize wheelchair service delivery.     

Driving characteristics of electric-powered wheelchair users: how far, fast, and often do people drive?

OBJECTIVES: To determine the driving characteristics of electric-powered wheelchair users during unrestricted community activities and to compare the activity levels among an active group and a group of regular users. DESIGN: Multisite engineering evaluation of electric-powered wheelchair driving activity during unrestricted community mobility. SETTING: Data were collected in the communities of Pittsburgh, PA, and the National Veterans Wheelchair Games (NVWG) in San Antonio, TX. PARTICIPANTS: Seventeen people participated, all of whom used electric-powered wheelchairs as their primary means of mobility. INTERVENTION: Each subject was asked standarized questions about self and wheelchair use. Data logger and sensor installed on wheelchair. Data downloaded from logger. MAIN OUTCOME MEASURES: Speed, distance traveled, and the time that each subject's personal wheelchair was being driven were recorded for 24hr/d over approximately 5 days for each subject by using a custom-built data logger. RESULTS: The NVWG group traveled faster than the Pittsburgh group, but this difference was only statistically significant on the first day. The NVWG group was more likely to travel longer than the Pittsburgh group with significant differences seen in day 4 (P = .03) and day 5 (P = .05). Total distance traveled during the 5-day period and average distance traveled per day were also significantly different between the groups (P = .02 for both 5-day distance and daily distance), with the NVWG group traveling longer (17,164 +/- 8708m) when compared with the Pittsburgh group (8335 +/- 7074m) over the 5-day period. Both distance traveled and speed increased during afternoon and evening hours. The maximum distance traveled by any subject for each hour across the 2 groups was used to create the theoretic maximum distance day, which resulted in 7970m of driving. CONCLUSION: Drivers of electric-powered wheelchairs are most active during the afternoon and evening hours. Over the 5-day period of this study, there was little variation in the speed or distance driven per day. The subjects participating in the NVWG were more active than their counterparts during a typical week at home. The maximum theoretic distance that a wheelchair user in our group would travel is less than 8km. The range of current electric-powered wheelchairs appears adequate, if not generous, for the subjects in our study.     

Energy cost of propulsion in standard and ultralight wheelchairs in people with spinal cord injuries

BACKGROUND AND PURPOSE: Wheelchair- and subject-related factors influence the efficiency of wheelchair propulsion. The purpose of this study was to compare wheelchair propulsion in ultralight and standard wheelchairs in people with different levels of spinal cord injury. SUBJECTS: Seventy-four subjects (mean age=26.2 years, SD=7.14, range=17-50) with spinal cord injury resulting in motor loss (30 with tetraplegia and 44 with paraplegia) were studied. METHOD: Each subject propelled standard and ultralight wheelchairs around an outdoor track at self-selected speeds, while data were collected at 4 predetermined intervals. Speed, distance traveled, and oxygen cost (VO2 mL/kg/m) were compared by wheelchair, group, and over time, using a Bonferroni correction. RESULTS: In the ultralight wheelchair, speed and distance traveled were greater for both subjects with paraplegia and subjects with tetraplegia, whereas VO2 was less only for subjects with paraplegia. Subjects with paraplegia propelled faster and farther than did subjects with tetraplegia. CONCLUSION AND DISCUSSION: The ultralight wheelchair improved the efficiency of propulsion in the tested subjects. Subjects with tetraplegia, especially at the C6 level, are limited in their ability to propel a wheelchair.     

Changing chairs: anticipating problems in prescribing wheelchairs

Purpose: This article presents a framework for prescribing, ordering, and adapting a new wheelchair, focusing on individual, environmental and wheelchair factors that must be taken into consideration to ensure optimal function. Method: A review and analysis was conducted of all factors relevant to the transition to a new wheelchair. Without appropriate planning and implementation, this transition can result in unnecessary expenses, duplication of effort, and possibly even injury to the user and abandonment of the wheelchair. Results: Recommendations are provided to manufacturers, therapists, technicians, users, insurers and physicians, who must work together throughout this process. To the extent feasible, the authors suggest that major changes from the previous wheelchair should be avoided, particularly for people with substantial functional limitations. Therapists and technicians must measure the user accurately, and anticipate those factors that can impede a smooth transition. Insurers and other payors must recognize that changing wheelchairs will often require substantial professional assistance, including several fittings to adjust the new chair to the needs of the user. Conclusion: Additional research and case reporting on outcomes of adjusting to a new wheelchair appear warranted.     

Controllability and physiological evaluation of three unilaterally-propelled wheelchairs for patients with hemiplegia.

OBJECTIVE: To evaluate the controllability of, and physiological responses to, 2 newly designed unilaterally-propelled wheelchairs for patients with hemiplegia. DESIGN: Within-subject comparison. SUBJECTS: A total of 15 patients after stroke were recruited from the rehabilitation centre of Chung Shan Medical University, Taichung, Taiwan. METHODS: Two newly designed wheelchairs (an ankle-propelled wheelchair and a knee-propelled wheelchair) were compared with a commercially available 2-hand-rim propelled wheelchair. Patients propelled the 3 wheelchairs along an oval pathway. Videotapes were made for analysis. The following parameters: total propulsion time, deviation frequency, deviation percentage, physiological cost index (VO2) and rating of perceived exertion were measured and compared. RESULTS: The knee-propelled wheelchair gave the best results for controllability, cardiopulmonary and perceived exertion. However, the gear ratio of this wheelchair's force transmission was fixed, and some patients felt that its propulsion was heavy when starting off. CONCLUSION: The knee-propelled wheelchair showed good controllability and physiological responses for hemiplegic patients. If some details were improved, it would suitable for use by patients with hemiplegia.     

Effect of a pushrim-activated power-assist wheelchair on the functional capabilities of persons with tetraplegia

OBJECTIVES: To test the differences between a pushrim-activated power-assisted wheelchair (PAPAW) and a traditional manual wheelchair while performing common driving activities and to assess their relative merits for people with tetraplegia. DESIGN: Repeated measures. SETTING: An activities of daily living (ADL) laboratory within a rehabilitation research center. PARTICIPANTS: Fifteen full-time manual wheelchair users with tetraplegia due to a spinal cord injury. INTERVENTIONS: Participants propelled both their own manual wheelchairs and a PAPAW 3 times over an ADL course. The order in which the 2 different wheelchairs were presented to the participants was randomized. MAIN OUTCOME MEASURES: Each participant's heart rate was monitored throughout testing by a digital, wireless heart-rate monitor. Time to complete the course was recorded, and participants were surveyed with a visual analog scale after the first, third, fourth, and sixth trials to determine the ease of completing each obstacle and their ergonomic preferences between the 2 wheelchairs. Participants also were observed throughout the trials to determine how much assistance they needed to complete each obstacle course. RESULTS: After using a Bonferroni adjustment, 4 obstacles (carpet, dimple strips, up a ramp, up a curb cut) were rated as being significantly easier ( P <.001) to complete when using the PAPAW. Participants also showed a significant decrease in mean heart rate throughout all 3 trials ( P =.015, P =.001, P =.003, respectively) when using a PAPAW. The amount of assistance needed by participants, the responses to ergonomic questions, and the overall time to complete the ADL course did not differ significantly between the 2 wheelchairs. CONCLUSIONS: For subjects with tetraplegia, PAPAWs have the potential to improve functional capabilities during certain ADLs, especially when propelling up ramps, over uneven surfaces, and over thick carpet.     

User assessment of manual wheelchair ride comfort and ergonomics

OBJECTIVE: To examine wheelchair-user perceived ride comfort during propulsion and to compare the ride comfort of ultralight and lightweight manual wheelchairs. An ultralight wheelchair is defined as having a high degree of adjustability, whereas a lightweight wheelchair has minimal adjustability. DESIGN AND PARTICIPANTS: Repeated measures design of a sample of 30 community-dwelling manual wheelchair users evaluating 7 different manual wheelchairs over an activities of daily living course. SETTING: A rehabilitation engineering center. MAIN OUTCOME MEASURES: Subject ratings of perceived ride comfort and basic ergonomics while propelling over the activities of daily living course. Ratings were recorded for each wheelchair on individual tasks and for the course overall. RESULTS: The Invacare Action XT wheelchair was ranked best for both ride comfort and basic ergonomics. The ride-comfort scores (p < .05) and wheelchair ergonomics ratings (p < .05) for the ultralight wheelchair group were significantly different from those for lightweight wheelchair group. CONCLUSION: There are differences in perceived ride comfort and basic ergonomics between the designs of the wheelchairs (lightweight vs ultralight). Subjects perceived that ultralight wheelchairs were more comfortable and had better basic ergonomics than lightweight wheelchairs.     

Changing chairs: anticipating problems in prescribing wheelchairs

Purpose: This article presents a framework for prescribing, ordering, and adapting a new wheelchair, focusing on individual, environmental and wheelchair factors that must be taken into consideration to ensure optimal function. Method: A review and analysis was conducted of all factors relevant to the transition to a new wheelchair. Without appropriate planning and implementation, this transition can result in unnecessary expenses, duplication of effort, and possibly even injury to the user and abandonment of the wheelchair. Results: Recommendations are provided to manufacturers, therapists, technicians, users, insurers and physicians, who must work together throughout this process. To the extent feasible, the authors suggest that major changes from the previous wheelchair should be avoided, particularly for people with substantial functional limitations. Therapists and technicians must measure the user accurately, and anticipate those factors that can impede a smooth transition. Insurers and other payors must recognize that changing wheelchairs will often require substantial professional assistance, including several fittings to adjust the new chair to the needs of the user. Conclusion: Additional research and case reporting on outcomes of adjusting to a new wheelchair appear warranted.     

Occupant Restraint Preferences of Individuals Traveling in Motor Vehicles While Seated in Their Wheelchairs

A survey among 127 wheelchair users was conducted to characterize wheelchair occupant restraint usage patterns, restraint deficiencies, user characteristics, and essential wheelchair occupant restraint design parameters for when individuals travel in motor vehicles while seated in their wheelchairs. Survey respondents value independent travel and seem generally interested in the use of an occupant restraint system that is attached to the wheelchair frame and that can be used independently by the wheelchair user without caregiver or vehicle driver assistance. Results of the survey further indicate that despite the relatively high percentage of respondents who are attempting to travel safely (78.8%), almost half of these wheelchair users have experienced injury or compromised wheelchair balance while traveling in motor vehicles.     

Wheelchair propulsion biomechanics and wheelers' quality of life: an exploratory review

PURPOSE. To provide an overview of associations between wheelchair propulsion biomechanics for both everyday and racing wheelchairs, wheeling-related upper limb injuries, and quality of life of manual wheelchair users through a synthesis of the available information. METHODS. A search of publications was carried out in PubMed and SportsDiscus databases. Studies on wheelchair propulsion biomechanics, upper limb injuries associated with wheelchair propulsion and quality of life of wheelchair users were identified. Relevant articles cited in identified articles but not cited in PubMed or SportsDiscus were also included. RESULTS. Wheelchair sports participation has positive impact on quality of life and research in racing wheelchair biomechanics can indirectly promote the visibility of wheelchair sports. The impact of pushrim-activated power-assisted wheelchairs (a hybrid between manual and battery-powered wheelchairs) and geared manual wheels on wheelers' everyday life were discussed. CONCLUSIONS. The study of wheelchair propulsion biomechanics focuses on how a wheelchair user imparts power to the wheels to achieve mobility and the accumulated knowledge can help to improve wheelchair users' mobility, reduce physical stress associated with wheelchair propulsion, and as a result, enhance quality of life.     

Usability testing of multimodal feedback interface and simulated collision-avoidance power wheelchair for long-term-care home residents with cognitive impairments

Many older adults in long-term-care homes have complex physical and cognitive impairments and have difficulty propelling manual wheelchairs. Power wheelchair use is restricted owing to safety concerns. Power wheelchairs with collision-avoidance features are being developed to enable safe and independent mobility; however, a paucity of information exists on interface features to help users navigate away from obstacles. We developed a system combining an interface with auditory, visual, and haptic feedback and a simulated collision-avoidance power wheelchair. This device allowed the investigator to stop movement of the power wheelchair when users approached obstacles and to deliver feedback to help them navigate. Five long-term-care home residents with mild or moderate cognitive impairments evaluated device usability, which included effectiveness, efficiency, and user satisfaction. Each resident used the device for six 1 h sessions. Observations, feedback interviews, and outcome questionnaires were completed during and after the sessions. We found the device effective in enabling residents to achieve basic driving tasks and self-identified indoor mobility goals. Furthermore, residents perceived workload to be low and were satisfied with the device. Residents also felt that the feedback was useful to help them navigate away from obstacles.     

Older people's use of powered wheelchairs for activity and participation.

OBJECTIVE: The aims of this study were to investigate outcomes of older people's use of powered wheelchairs and risk factors for negative outcomes. DESIGN: The study was a cross-sectional interview-study including 111 powered wheelchair users over 65 years of age. RESULTS: All participants used their powered wheelchair in the summer; nearly all users regarded it as important and found that it gave them independence. The wheelchair made activity and participation possible for the users. The most frequent activity in the summer was going for a ride, and in the winter it was shopping. However, some could not use the wheelchair for visits, and supplementary travel modes are called for. Users who could not walk at all or who could not transfer without assistance were more likely not to be able to carry out prioritized activities. Furthermore, other risk factors for negative outcomes and need for further research were identified. CONCLUSION: The use of powered wheelchairs is a relevant societal intervention in relation to older people with limited walking ability in order to make activity and participation possible. It is likely that a larger proportion of older people could benefit from this intervention, in particular if current practices are improved taking activity and participation outcomes into consideration.