Participation in community-based activities of daily living: Comparison of a pushrim-activated,power-assisted wheelchair and a power wheelchair

Purpose. The purpose of this study was to evaluate pushrim-activated, power-assisted wheelchair (PPW) performance among dual-users in their natural environment to determine whether the PPW would serve as a satisfactory alternative to a power wheelchair for community-based activities.

Methods. A concurrent mixed methods research design using a cross-over trial was used. The outcome measures used were number of hours reported using the different wheelchairs, Quebec User Evaluation of Satisfaction with assistive Technology (QUEST), Functioning Everyday with a Wheelchair (FEW), Psychosocial Impact of Assistive Devices Scale (PIADS) and Canadian Occupational Performance Measure (COPM).

Results. The number of hours spent participating in self-identified activities was not significantly different. Only the Self-Esteem subscale of the PIADS identified a statistically significant difference between the PPW and power wheelchair conditions (p = 0.016). A clinically important difference for Performance and Satisfaction was suggested by the COPM, in favour of the power wheelchair.

Conclusions. Additional knowledge was gained about the benefits of PPW technology. Participants were able to continue participating independently in their self-identified community activities using the PPW, and identified comparable ratings of satisfaction and performance with the PPW and the power wheelchair. For some individuals requiring power mobility, the PPW may provide an alternative to the power wheelchair.     

Investigating the Efficacy of Web-Based Transfer Training on Independent Wheelchair Transfers Through Randomized Controlled Trials

Objectives

To determine the efficacy of a web-based transfer training module at improving transfer technique across 3 groups: web-based training, in-person training (current standard of practice), and a waitlist control group (WLCG); and secondarily, to determine subject factors that can be used to predict improvements in transfer ability after training.

Rates and Predictors of Manual and Powered Wheelchair Use for Persons With Stroke: A Retrospective Study in a Canadian Rehabilitation Center

Mountain AD, Kirby RL, MacLeod DA, Thompson K. Rates and predictors of manual and powered wheelchair use for persons with stroke: a retrospective study in a Canadian rehabilitation center.

Objectives

To determine the rates of manual and powered wheelchair use at discharge for people with stroke admitted to a rehabilitation center and to determine whether any predictors of wheelchair use at discharge could be identified.

Design

Retrospective cohort study.

Setting

Rehabilitation center.

Participants

Consecutive former inpatients (N=100) with a primary diagnosis of stroke, a sample of convenience.

Interventions

None.

Main Outcome Measures

We reviewed the inpatient health records to determine the rates of wheelchair use at discharge and to record some readily available demographic and clinical data that might serve as predictors of wheelchair use.

Results

At discharge, 40 people (40%) were using manual wheelchairs, 1 person (1%) was using a powered wheelchair, and 59 (59%) were not using a wheelchair. Of the patients who were walkers on admission (ie, walking FIM scores of 6 or 7), none (0%) used wheelchairs at discharge. Of those with nonwalking FIM scores (1-5) on admission, 56% were using wheelchairs at discharge. Multivariate analyses revealed that the adjusted odds ratios of using a wheelchair (manual or powered) were 3.33 (95% confidence interval [CI], 1.33-8.33) for those with left-hemisphere versus right-hemisphere strokes (P=.010), .94 (CI, .91-.96) for each point rise in the total raw FIM score on admission (P<.0001), and 19.46 (CI, 6.33-59.81) if the total admission FIM score was less than 80 versus greater than or equal to 80 (P<.0001).

Conclusions

On discharge from our rehabilitation center, 40% of people with stroke were using manual wheelchairs and 1% powered wheelchairs. People who were not walking on admission, those with left-hemisphere strokes, and those with lower total admission FIM scores were more likely to use a wheelchair. These findings may permit clinicians to predict wheelchair use better early in the rehabilitation process, when it can affect rehabilitation planning.     

Life-Space Mobility of Middle-Aged and Older Adults at Various Stages of Usage of Power Mobility Devices

Auger C, Demers L, Gélinas I, Miller WC, Jutai JW, Noreau L. Life-space mobility of middle-aged and older adults at various stages of usage of power mobility devices.

Objective

To examine whether the impact of power mobility devices (PMDs) varies as a function of stage of usage and to explore key factors associated with greater life-space mobility for middle-aged and older adults.

Design

Multicohort study with respondents grouped as a function of stage of PMD usage (reference group with mobility impairments, n=42; initial users, 1-6mo, n=35; long-term users, 12-18mo, n=39). Cohorts were compared with respect to life-space mobility in a continuum of environments ranging from home to outside town, using analysis of variance and chi-square tests. Baseline personal, assistive device, intervention, and environmental factors associated with life-space mobility were explored with age-adjusted linear regression models.

Setting

Four Canadian rehabilitation centers.

Participants

Random sample of middle-aged and older adults (N=116; 50-89y) living in the community or residential care.

Intervention

Procurement of a powered wheelchair or scooter.

Main Outcome Measure

Life-Space Assessment composite score.

Results

Cohort comparisons showed higher frequency of outings for PMD users in the neighborhood (P<.001) and around home (P<.05) and significantly greater Life-Space Assessment composite scores for initial and long-term users than for the reference group (P<.05). Factors such as sex, the nature of activities, and device type explained variances in Life-Space Assessment composite score ranging from 15.9% to 18.0% (P<.006).

Conclusions

Life-space mobility increases after PMD use and remains stable across the stages of initial and long-term use. To appreciate the impact of PMDs, clinicians should consider the environment and a combination of personal and device factors that are associated with the range of life-space mobility in the first 18 months after procurement.     

Effect of Respiration on the Static Rear Stability of Wheelchairs

Kirby RL, Heimrath O, Stewart A, Smith C, MacLeod DA. Effect of respiration on the static rear stability of wheelchairs.

Objective

To test the hypothesis that the static rear stability of an occupied wheelchair is greater during full inspiration than expiration.

Design

Within-subject comparisons.

Setting

Rehabilitation center.

Participants

Able-bodied participants (N=10).

Intervention

None.

Main Outcome Measures

We measured the static rear stability (brakes unlocked) of an occupied wheelchair on a test platform according to International Organization for Standardization standards. We also used the Exhalation Threshold Test. The Exhalation Threshold Test was positive if, having been positioned at the maximum degree of platform tilt needed to maintain stability during full inspiration, the wheelchair tipped backward when the participant exhaled.

Results

The mean static rear stability values at full inspiration and expiration ± SD were 16.5°±2.3° and 16.1°±2.4°, with a mean difference of .46°±.24° (3%; P=.002). The Exhalation Threshold Test was positive in 19 (95%) of 20 trials.

Conclusions

Respiration has a slight but statistically significant effect on the rear stability of occupied wheelchairs, with greater stability at full inspiration. This has potential clinical implications for stability testing and the training of wheelchair skills, but further study is needed.     

Effects of single-variable biofeedback on wheelchair handrim biomechanics

Richter WM, Kwarciak AM, Guo L, Turner JT. Effects of single-variable biofeedback on wheelchair handrim biomechanics.

Objective

To determine the effects of single-variable biofeedback on select wheelchair propulsion variables.

Design

Within-subject comparisons.

Setting

Biomechanics laboratory.

Participants

Manual wheelchair users (N=31).

Interventions

Biofeedback on braking moment, cadence, contact angle, peak force, push distance, and smoothness were presented on a large monitor during propulsion on a motor-driven treadmill. For each variable, subjects were asked to make a maximum improvement, as well as a targeted 10% improvement for cadence, contact angle, peak force, and push distance.

Main Outcome Measures

Relative differences (%) in each variable between the normal propulsion trial and the biofeedback trials.

Results

Subjects were able to interpret and respond to the biofeedback successfully. For the maximum change conditions, significant improvements were made to all variables except smoothness, with individual improvements of 11% in peak force, 31% in contact angle, 44% in braking moment, 64% in cadence, and 255% in push distance. For the 10% target conditions, improvements were achieved to within 1% for all variables except peak force, which was a difficult variable for most subjects to control. Cross-variable interactions were found for most variables, particularly during the maximum change conditions. Minimizing cadence led to a 154% increase in peak force, suggesting the need for multi-variable feedback if multiple training objectives, such as reducing cadence and peak force simultaneously, are desired. While subjects were unable to significantly change smoothness, efforts to push more smoothly led to improvements across most outcome variables.

Conclusions

Biofeedback can be used to improve specific aspects of wheelchair propulsion. Cadence, contact angle, and push distance are well controlled by wheelchair users, and may be useful for clinical propulsion training. Clinicians should be aware of and comfortable with any cross-variable effects resulting from single-variable biofeedback training.     

Manual Wheelchair-Handling Skills by Caregivers Using New and Conventional Rear Anti-Tip Devices: A Randomized Controlled Trial

Kirby RL, Walker R, Smith C, Best K, MacLeod DA, Thompson K. Manual wheelchair-handling skills by caregivers using new and conventional rear anti-tip devices: a randomized controlled trial.

Objective

To test the hypothesis that, in comparison with caregivers handling manual wheelchairs equipped with conventional rear anti-tip devices (C-RADs), those using a new design (Arc-RADs) perform relevant wheelchair skills better and as safely.

Design

Randomized controlled trial.

Setting

Rehabilitation center.

Participants

Caregivers (n=16) and the wheelchair users (n=16) for whom they cared.

Intervention

Participants were trained in wheelchair-handling skills for an average of 54 minutes each.

Main Outcome Measures

Total percentage score on a set of 20 rear anti-tip device- and caregiver-relevant skills from the Wheelchair Skills Test, version 3.2, administered a minimum of 3 days after training.

Results

For the C-RAD and Arc-RAD groups, the mean ± SD Wheelchair Skills Test scores were 40%±0% and 98.8%±3.5%, respectively (P<.001). Skills that required the wheelchair to be tipped back extensively (eg, for ascending a 15cm curb) accounted for the differences between the groups. There were no adverse effects in either group.

Conclusions

The Arc-RAD design allows significantly better caregiver wheelchair-handling skills than the conventional design, without compromising safety.     

Shoulder magnetic resonance imaging abnormalities, wheelchair propulsion, and gender

OBJECTIVE: To investigate the relationship between pushrim forces and the progression of shoulder injuries in manual wheelchair users. DESIGN: Longitudinal case series. SETTING: Biomechanics laboratory and magnetic resonance imaging (MRI) facility at a Veterans Health Administration medical center and university hospital, respectively. PARTICIPANTS: Fourteen individuals with spinal cord injury (8 men, 6 women) who used manual wheelchairs. INTERVENTION: Subjects propelled their own wheelchairs on a dynamometer at 0.9 and 1.8m/s. Bilateral biomechanical data were obtained by using force and moment sensing pushrims at time 1. Bilateral shoulder MR images were also completed on 2 occasions, at time 1 and, approximately 2 years later, at time 2. MAIN OUTCOME MEASURES: The peak pushrim forces in a pushrim coordinate system were calculated, weight normalized and averaged over 5 strokes (presented as % body weight). MRI abnormalities were graded by using a summated scale. Differences between scores between times 1 and 2 were calculated. RESULTS: Subjects were divided into 2 groups based on change in MRI score. Seven subjects were in the group with worsening scores (MRI+; mean, 8.14 points; range, 5-16), and 7 were in the group with improving or unchanging scores (MRI-; mean, -1.00 point; range, -5 to 1). There was no significant difference between groups with respect to age, body mass index, or years from injury. There were significantly more women in the MRI+ group (6 women, 1 man) than in the MRI- group (7 men) (P=.001). The MRI+ group used significantly greater weight-normalized radial force, or force directed toward the axle at time 1, to propel their wheelchairs at each speed (P<.01): MRI+ at 0.9m/s (mean radial force +/- standard deviation, 5.2%+/-1.0%) and MRI- at 0.9m/s (mean radial force, 3.2%+/-1.7%) (P=.028); and MRI+ at 1.8m/s (mean radial force, 6.6%+/-1.2%) (P=.023) and MRI- at 1.8m/s (mean radial force, 4.1%+/-2.2%). In a separate analysis, women were found to propel with a significantly higher radial force. A logistic regression found a significant relationship between radial force at time 1 and increased risk of progression of MRI findings over time. CONCLUSION: Individuals who propel with a greater percentage of force directed toward the axle were at increased risk of progression of MRI findings over time. Most people in this group were women. Clinicians should instruct wheelchair users in effective propulsion techniques and should pay particular attention to women who use wheelchairs. Reducing forces during wheelchair propulsion may minimize the likelihood of developing shoulder injuries.     

Manual wheelchair propulsion on ramp slopes encountered when boarding public transit buses

Abstract

Objective: To compare the kinetics of manual wheelchair (MWC) propulsion on ramps of varying slopes that may be encountered when accessing large accessible transit vehicles (LATVs).

Design: Observational study.

Setting: Biomechanics research laboratory.

Participants: A convenience sample of able-bodied adults (n?=?7) having no propulsion experience propelled a MWC on ramps of slope 3.5°, 9.5° and 15°.

Interventions: Not applicable.

Main outcome measures: Resultant (F_res), radial (F_r) and tangential (F_t) forces applied to the wheelchair pushrim, rate of rise of resultant force (ROR), peak power output (P), temporal characteristics and thigh to trunk angle were analyzed across three ramp slopes.

Results: Pushrim forces and power output significantly increased with increasing slope, with peak F_res more than doubling from 107?N on a 3.5° slope to 230?N on a 15° slope. ROR was 1.76 times higher at 9.5° and 2.47 times higher at 15° compared to a 3.5° slope. Minimum thigh to trunk angle decreased sharply from 80° (3.5° slope) to 50° (9.5° slope) and then to 30° (15° slope) as ramp slope increased.

Conclusions: Ascending bus ramps require greater power and pushrim force on steeper ramp slopes, presenting a potential barrier to transportation accessibility. Given this finding, it is imperative that bus operators minimize ramp slope to assure MWC users are able to access LATVs.

• Implications for Rehabilitation

• Although transit bus ramps are intended to provide wheelchair access to public transportation, limitations in MWC user physical strength and function may prevent safe access.

• Transit bus ramp slopes encountered during ingress can present a challenge to MWC users given power output and pushrim force requirements to ascend the ramp.

• MWC users and therapists should be aware of ramp slopes that may be encountered when boarding transit buses; wheelchair training should incorporate skills needed to ascend transit bus ramps.