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

Capturing multiple assistive technology use and its impact in later life: lessons learned from distinct measurement approaches

PURPOSE

Assistive technology (AT) use is prevalent in older adulthood and can accommodate activity difficulties to support well-being. However, within the context of multiple activity difficulties and multiple technology use, it is unclear how to best assess their combined effects on older adults' health outcomes. This study proposed four distinct approaches to quantify multiple AT use and examined their respective impact in later life.

MATERIAL AND METHODS

Using data from the 2015 round of the National Health and Aging Trends Study (n = 6,936), we compared four indices to summarize the state of multiple AT use among the U.S. older population: binary, item-specific, cumulative, and accommodative. Separate regression analyses tested the impact of each index on older adults' well-being and restricted participation in meaningful activities.

RESULTS

In 2015, 59.9% of the respondents were identified as AT users. Among these users, 53.8% reported using two or more technologies when performing daily self-care and mobility activities. The implications of multiple AT use for health outcomes varied across the four indices. Approaches that captured elements of person-technology fit provided the most nuanced and actionable insights on the benefits of using AT to support well-being.

CONCLUSIONS

ATs were commonly adopted by older adults in everyday activities. Overall, findings suggest that there are multiple approaches to conceptualize the independent, cumulative, or balanced effects of multiple AT use. Each measurement approach has unique implications for understanding the impacts of using ATs on older adults' health outcomes.

Effect of the Assistive Technology Professional on the Provision of Mobility Assistive Equipment

OBJECTIVE

The purpose of this study was to examine factors associated with variability in satisfaction with functional mobility (as measured by the Functional Mobility Assessment [FMA]) in users of mobility devices. Our primary hypothesis was that device type and Assistive Technology Professional (ATP) involvement will be the most significant predictors of FMA score. Our secondary hypothesis was that ATP involvement is associated with use of more custom-fitted manual wheelchairs and group 3 and 4 power wheelchairs.

DESIGN

Retrospective cohort study.

SETTING

Data were collected from equipment suppliers who collaborate with clinicians to administer the FMA and associated Uniform Data Set within various settings (ie, rehabilitation clinic, school, supplier place of business).

PARTICIPANTS

A data set of 4743 cases was included in the analysis (N=4743).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

FMA questionnaire collected at baseline, client age, gender, primary diagnosis, years since disability onset, device type, device age, living situation, ATP involvement, and geographic area.

RESULTS

Ordinal logistic regression modeling showed that geographic area, device type, ATP involvement, primary diagnosis, gender, age, device age, and years since onset of disability significantly predicted the variance in FMA scores at P<.05. Device type was the most significant predictor of variance in FMA score. Involvement of an ATP had a significant effect on the type of device that participants used (χ²²⁰=1739.18, P<.001; odds ratio, 0.589; 95% confidence interval, 0.49-0.708). If an ATP was involved, there were significantly higher proportions (all P<.05) of individuals using custom-fitted manual wheelchair and high-end groups 3 and 4 power wheelchairs prescribed compared with when no ATP was involved or when involvement was uncertain.

CONCLUSIONS

The relationship between ATP involvement and functional outcome supports the concept that ATP certification recognizes demonstrated competence in analyzing the needs of consumers with disabilities and selection of appropriate mobility assistive equipment with improved functional outcomes.

Factors Influencing Incidence of Wheelchair Repairs and Consequences Among Individuals with Spinal Cord Injury

OBJECTIVE

To investigate the frequency and consequences of wheelchair repairs, looking at the relationship to usage, components, out-of-pocket costs, number of days affecting the user, and factors associated with the need for repairs or consequences.

DESIGN

Survey, cross-sectional.

SETTING

Nine spinal cord injury (SCI) Model Systems centers.

PARTICIPANTS

Wheelchair users with SCI (N=533).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Cost and incidence of wheelchair repairs and consequences and wheelchair usage within the past 6 months.

RESULTS

A total of 310 participants (56%) reported repairs, 127 (42%) of whom experienced at least 1 adverse consequence lasting a median of 5 days (interquartile range [IQR], 2-17.3 days). Repair rates were highest for the seating system, electronics, and tires. Participants were most often stranded at home or forced to use a backup chair. Median out-of-pocket costs were $150 (IQR, $50-$620). Active users, based on type of mobility and terrain, experienced more repairs and consequences than less active users. Repairs were more common among those who were Black (odds ratio [OR], 2.42) or power wheelchair (PWC) users (OR, 1.84), whereas consequences were more common among those who were Black (OR, 2.27), PWC (OR, 2.08) or power assist users (OR, 2.76), and those who had public insurance (OR, 1.70).

CONCLUSIONS

Wheelchair repairs continue to affect more than 50% of wheelchair users with significant financial and personal cost. High repair rates limited participation inside and outside of the home. Consequences lasted longer than 2 weeks for many and may be minimized by a working backup chair. Disparities exist based on participant and wheelchair factors; repairs and adverse consequences appear to hit those most vulnerable with the least financial resources. Costs may be a barrier to repair completion for some individuals. This ongoing problem of high repair rates and their associated effects requires action such as higher standards, access to quicker service, and better training of users on wheelchair maintenance and repair.

Wheelchair service provision education and training in low and lower middle income countries: a scoping review

PURPOSE

Improving access to education and training for those providing wheelchair and seating assistive technology to meet personal posture and mobility requirements, as a basic human right, is a priority. This review considers education and training available to personnel within low and lower middle income countries (LLMIC), to ascertain where gaps in knowledge exist and identify human resource education priorities.

METHOD

A scoping review, mapping out existing scientific and grey literature within the field between 1993 and 2017 was conducted. The search strategy included use of online databases, manual analogue searches and key stakeholder informant advice. A content analysis process was applied to organize the literature retrieved and extract key themes.

RESULTS

Education and training in LLMIC appears ad hoc and limited, however, there is growing recognition as to its importance, notably by the World Health Organization and nongovernmental organizations, delivering education initiatives to a number of countries, along with the development of a credentialing test. Inconsistency exists regarding personnel responsible for wheelchair provision, with no specific professional clearly recognized to oversee the system within many LLMIC.

CONCLUSIONS

Education and training is required for all stakeholders involved in wheelchair provision. Advocating for programme development to enhance personnel skills, build capacity and ensure best practice is a priority. Pilot sites, delivering and credentialing appropriate wheelchair provision education and training within context should be considered. Measuring outcomes and transferable skills should be part of education programme delivery structures. Considering a new discipline responsible for oversight of wheelchair provision should be investigated. Implications for rehabilitation Education and training is an essential step in the wheelchair provision process in the bid to obtain an appropriate wheelchair via appropriate provision services. However, it is more than education and training; its a human rights issue. Mandatory education and training needs to be a requirement for all stakeholders involved in wheelchair provision. Key wheelchair personnel need to establish their central role in this arena. The study raises awareness as to the importance of working with governments to commit to building sustainable wheelchair provision infrastructures.

Challenges in comprehensive management of spinal cord injury in India and in the Asian Spinal Cord network region: findings of a survey of experts, patients and consumers

STUDY DESIGN

Online survey.

OBJECTIVES

To understand the prevailing scenario of the comprehensive management of spinal cord injuries (SCI) in India and in the Asian Spinal Cord Network (ASCoN) region, especially with a view to document the challenges faced and its impact.

SETTING

Indian Spinal Injuries Centre.

METHODS

A questionnaire was designed which covered various aspects of SCI management. Patients, consumers (spinal injured patients discharged since at least 1 year) and experts in SCI management from different parts of India and the ASCoN region were approached to complete the survey.

RESULTS

Sixty patients, 66 consumers and 34 experts completed the survey. Difference of opinion was noticed among the three groups. Disposable Nelaton catheters were used by 57% consumers and 47% patients. For reusable catheter, 31% experts recommended processing with soap and running water and 45% recommended clean cotton cloth bag for storage. Pre-hospital care and community inclusion pose the biggest challenges in management of SCI. More than 75% of SCI faced problems of access and mobility in the community. Awareness about SCI, illiteracy and inadequate patient education are the most important factors hindering pre- and in-hospital care. Inadequate physical as well as vocational rehabilitation and financial barriers are thought to be the major factors hindering integration of spinal injured into mainstream society. Strong family support helped in rehabilitation.

CONCLUSIONS

Our study brought out that SCI in India and ASCoN region face numerous challenges that affect access to almost all aspects of comprehensive management of SCI.

Quality and Equity in Wheelchairs Used by Veterans

OBJECTIVES

To assess in Veterans with spinal cord injury (SCI) or amputated limb (AL) the following: (1) patient demographics, medical factors, cultural and psychosocial characteristic by race; (2) wheelchair quality by race; and (3) the independent associations of patient race and the other factors with wheelchair quality.

DESIGN

Cross-sectional cohort study.

SETTING

Three Department of Veterans Affairs (VA) medical centers affiliated with academic medical centers.

PARTICIPANTS

Eligible participants were Veterans with SCI or ALs (N=516); 482 of them completed the interview. Analyses were restricted to white and African American participants. Because there was no variation in wheelchair quality among AL patients (n=42), they were excluded from all but descriptive analyses, leading to a final sample size of 421.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

Wheelchair quality as defined by the Medicare Healthcare Common Procedure Coding System.

RESULTS

We found race differences in many of our variables, but not in quality for manual (odds ratio [OR]=.67; 95% confidence interval [CI], .33-1.36) or power (OR=.82; 95% CI, .51-1.34) wheelchairs. Several factors including age (OR=.96; 95% CI, .93-.99) and income (OR=3.78; 95% CI, 1.43-9.97) were associated with wheelchair quality. There were no significant associations of cultural or psychosocial factors with wheelchair quality.

CONCLUSIONS

Although there were no racial differences in wheelchair quality, we found a significant association of older age and lower income with poorer wheelchair quality among Veterans. Efforts are needed to raise awareness of such disparities among VA wheelchair providers and to take steps to eliminate these disparities in prescription practice across VA sites.

Are intensive data collection methods in pain research feasible in those with physical disability? A study in persons with chronic pain and spinal cord injury

PURPOSE

Intensive repeated measures data collection procedures, such as ecological momentary assessment (EMA) and end-of-day (EOD) diaries, are becoming more prominent in pain research. Existing data on the feasibility of such methods is encouraging; however, almost nothing is known about feasibility in clinical populations with significant physical disabilities. Research methodology feasibility is crucial to the inclusion of individuals with physical disability in pain research given the high prevalence and impact of pain in these populations. The aim of this study was to examine study compliance, protocol acceptability, and reactivity of intensive data collection methods in adults with chronic pain and spinal cord injury (SCI).

METHODS

Secondary analysis of data from a 7-day EMA and EOD diary study in a sample of 131 community dwelling adults with SCI.

RESULTS

Results showed rates of missing data ranged from 18.4 to 22.8% across measures. Participant compliance was related to time of day/presence of audible prompts, mobility aid use, race, and baseline levels of pain and pain interference, with more missing data at wake and bedtimes/no prompts, and for those who used hand-held mobility devices, identified as black/African American, and/or reported higher baseline pain and pain interference. Participants rated the study methodology as generally highly acceptable and expressed willingness to participate in similar studies of much longer duration. There was no evidence of reactivity, defined as temporal shifts in pain or pain interference ratings.

CONCLUSIONS

Overall, intensive pain data collection is feasible in persons with SCI with no evidence that the methodology impacts pain intensity or pain interference ratings.

Static Versus Dynamic Decoding Algorithms in a Non-Invasive Body-Machine Interface

In this study, we consider a non-invasive body-machine interface that captures body motions still available to people with spinal cord injury (SCI) and maps them into a set of signals for controlling a computer user interface while engaging in a sustained level of mobility and exercise. We compare the effectiveness of two decoding algorithms that transform a high-dimensional body-signal vector into a lower dimensional control vector on six subjects with high-level SCI and eight controls. One algorithm is based on a static map from current body signals to the current value of the control vector set through principal component analysis (PCA), the other on dynamic mapping a segment of body signals to the value and the temporal derivatives of the control vector set through a Kalman filter. SCI and control participants performed straighter and smoother cursor movements with the Kalman algorithm during center-out reaching, but their movements were faster and more precise when using PCA. All participants were able to use the BMI's continuous, two-dimensional control to type on a virtual keyboard and play pong, and performance with both algorithms was comparable. However, seven of eight control participants preferred PCA as their method of virtual wheelchair control. The unsupervised PCA algorithm was easier to train and seemed sufficient to achieve a higher degree of learnability and perceived ease of use.

Race and rehabilitation following spinal cord injury: equality of access for American Indians/Alaska Natives compared to other racial groups

Background

Representing 2 % of the general population, American Indians/Alaska Natives (AIs/ANs) were associated with 0.5 % (63) of the estimated 12,500 new cases of spinal cord injury (SCI) reported to the National Spinal Cord Injury Statistic Center in 2013. To date, the trend in health care disparities among AIs/ANs in the SCI community has not been examined. We sought to compare the rate of discharge to rehabilitation facilities (DRF) following traumatic SCI among adult AIs/ANs to other racial/ethnic groups for patients 15 to 64 years old.

Methods

Utilizing data from the National Trauma Data Bank (NTDB), we performed a retrospective analysis of SCI cases occurring between January 1, 2008 and December 31, 2012. SCI injuries were identified by International Classification of Diseases 9th Revision-Clinical Modification (ICD-9) codes or Abbreviated Injury Scale (AIS) scores. Injury severity was determined using the Trauma Mortality Prediction Model (TMPM) which empirically estimates each patient’s probability of death given their individual complement of injuries. A series of seven logistic regression models were used to predict DRF between racial groups.

Results

Among the 29,443 patients in our cohort, 52.4 % were discharged to rehabilitation facilities. AIs/ANs comprised 1.1 % of the population, with 63.8 % dismissed to rehabilitation. AIs/ANs were significantly younger, had a higher probability of death, had longer hospital length of stay (HLOS), and were proportionately more likely to be discharged to rehabilitation compared to non-AIs. Regression models demonstrated increased odds of DRF for AIs/ANs compared to Hispanic and Asian racial/ethnic groups.

Conclusions

American Indians/Alaska Natives who sustain SCI access rehabilitative care at a rate equitable to or greater than other races when multiple factors are taken into account. Further research is needed to assess the effect of those patient, physician, and health care system determinants as they relate to a patient’s ability to access post-trauma rehabilitative care. Recommendations include advancing the level of racial, insurance, and geographic data necessary to adequately explore disparities related to such ubiquitously life-altering conditions as SCI.

Factors predictive of type of powered mobility received by veterans with disability

Background

The goal of this observational study was to determine factors predictive of the type of powered mobility prescribed to veterans with disability.

Material/Methods

A retrospective chart review was conducted for all veterans (n=170) who received powered mobility from a designated power mobility clinic. Logistic regression analysis was used to determined factors predictive of the type of powered mobility provided.

Results

Sixty-four (38%) veterans were provided powered wheelchairs and 106 (62%) were provided powered scooters. Of the variables examined, only primary medical conditions for referral and disability severity (as measured by the 2-minute timed walk test; 2-MWT) were predictive of the types of powered mobility prescribed. Veterans who were able to walk longer distances were more likely to be prescribed powered scooters. Age, gender, race, level of education, marital and employment status, number of chronic medical conditions, and upper and lower limb muscle strength were not significant predictors.

Conclusions

This study suggests that the primary medical conditions for referral and 2-MWT can assist clinicians in the determination of the type of powered mobility to prescribe to veterans with disability.

The impact of mobility assistive technology devices on participation for individuals with disabilities

AIM

This study aims to address the gap in research and contribute to the body of knowledge on the perspectives assistive technology device users have toward their devices.

METHOD

Mixed methods were used to better understand the impact of mobility assistive technology devices (MATDs) on participation for individuals with disabilities. The Functional Mobility Assessment was administered in conjunction with two qualitative questions developed by the research team allowing participants to expound on the impact of their MATD experience. Participants were recruited online via the National Spinal Cord Injury Association website and in-person at Abilities Expo in Atlanta, Georgia, and the International Seating Symposium in Nashville, Tennessee.

RESULTS

Results are consistent with findings from prior research regarding accessibility for individuals with disabilities. Corresponding findings were found in both the quantitative and qualitative data and are categorized into several major themes: environment (indoor and outdoor), surface heights, transportation, dependence, independence, quality of life and participation.

CONCLUSION

Quantitative data from this study indicate that users of MATD are satisfied with the way in which their devices enable maneuvering indoors, while qualitative data suggest otherwise. Implications for healthcare practitioners are described and future recommendations are provided. Implications for Rehabilitation Healthcare professionals should advocate for proper mobility assistive technology devices (MATDs) for their patients in order to enable increased independence, safety and efficiency. Healthcare professionals must be cognizant of the impact of the environment and/or environmental barriers when prescribing MATD. Additional areas of interest for future research may include investigating the impact of MATD in association with date of onset of disability, according to diagnoses, or specific to length of time since acquiring the device.

Examining implicit bias of physicians who care for individuals with spinal cord injury: A pilot study and future directions

CONTEXT

Despite evidence that healthcare providers have implicit biases that can impact clinical interactions and decisions, implicit bias among physicians caring for individuals with spinal cord injury (SCI) has not been examined.

OBJECTIVE

Conduct a pilot study to examine implicit racial bias of SCI physicians and its association with functioning and wellbeing for individuals with SCI.

DESIGN

Combined data from cross-sectional surveys of individuals with SCI and their SCI physicians.

SETTING

Four national SCI Model Systems sites.

PARTICIPANTS

Individuals with SCI (N = 162) and their SCI physicians (N = 14).

OUTCOME MEASURES

SCI physicians completed online surveys measuring implicit racial (pro-white/anti-black) bias. Individuals with SCI completed questionnaires assessing mobility, physical independence, occupational functioning, social integration, self-reported health, depression, and life satisfaction. We used multilevel regression analyses to examine the associations of physician bias and outcomes of individuals with SCI.

RESULTS

Physicians had a mean bias score of 0.62 (SD = 0.35), indicating a strong pro-white/anti-black bias. Greater physician bias was associated with disability among individuals with SCI in the domain of social integration (odds ratio = 4.80, 95% confidence interval (CI) = 1.44, 16.04), as well as higher depression (B = 3.24, 95% CI = 1.06, 5.41) and lower life satisfaction (B = -4.54, 95% CI= -8.79, -0.28).

CONCLUSION

This pilot study indicates that SCI providers are susceptible to implicit racial bias and provides preliminary evidence that greater implicit racial bias of physicians is associated with poorer psychosocial health outcomes for individuals with SCI. It demonstrates the feasibility of studying implicit bias among SCI providers and provides guidance for future research on physician bias and patient outcomes.

Racial and ethnic disparities in functioning at discharge and follow-up among patients with motor complete spinal cord injury

OBJECTIVE

To examine racial and ethnic differences in self-care and mobility outcomes for persons with a motor complete, traumatic spinal cord injury (SCI) at discharge and 1-year follow-up.

DESIGN

Retrospective cohort study.

SETTING

Sixteen rehabilitation centers contributing to the Spinal Cord Injury Model Systems (SCIMS) database.

PARTICIPANTS

Adults with traumatic, motor complete SCI (N=1766; American Spinal Injury Association Impairment Scale grade A or B) enrolled in the SCIMS between 2000 and 2011. Selected cases had complete self-reported data on race and ethnicity (non-Hispanic white, non-Hispanic black, or Hispanic) and motor FIM scores assessed at inpatient rehabilitation admission, discharge, and 1-year follow-up.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Functional outcomes were measured by FIM self-care and mobility scores on a 1 to 7 FIM scale, at discharge and 1-year follow-up.

RESULTS

Multiple regression models stratified by neurologic category and adjusted for sociodemographic and injury characteristics assessed racial and ethnic group differences in FIM self-care and mobility change scores at discharge and 1-year follow-up. At discharge, non-Hispanic black participants with tetraplegia and paraplegia had significantly poorer gains in FIM self-care and mobility scores relative to non-Hispanic white and Hispanic participants. At 1-year follow-up, similar FIM self-care and mobility change scores were found across racial and ethnic groups within each neurologic category.

CONCLUSIONS

Non-Hispanic white and Hispanic participants had comparatively more improvement in self-care and mobility during inpatient rehabilitation compared with non-Hispanic black participants. At 1-year follow-up, no differences in self-care and mobility outcomes were observed across racial and ethnic groups. Additional research is needed to identify potential modifiable factors that may contribute to racially and ethnically different patterns of functional outcomes observed during inpatient rehabilitation.

Cursor control by Kalman filter with a non-invasive body-machine interface

OBJECTIVE

We describe a novel human-machine interface for the control of a two-dimensional (2D) computer cursor using four inertial measurement units (IMUs) placed on the user's upper-body.

APPROACH

A calibration paradigm where human subjects follow a cursor with their body as if they were controlling it with their shoulders generates a map between shoulder motions and cursor kinematics. This map is used in a Kalman filter to estimate the desired cursor coordinates from upper-body motions. We compared cursor control performance in a centre-out reaching task performed by subjects using different amounts of information from the IMUs to control the 2D cursor.

MAIN RESULTS

Our results indicate that taking advantage of the redundancy of the signals from the IMUs improved overall performance. Our work also demonstrates the potential of non-invasive IMU-based body-machine interface systems as an alternative or complement to brain-machine interfaces for accomplishing cursor control in 2D space.

SIGNIFICANCE

The present study may serve as a platform for people with high-tetraplegia to control assistive devices such as powered wheelchairs using a joystick.

Body machine interface: remapping motor skills after spinal cord injury

The goal of a body-machine interface (BMI) is to map the residual motor skills of the users into efficient patterns of control. The interface is subject to two processes of learning: while users practice controlling the assistive device, the interface modifies itself based on the user's residual abilities and preferences. In this study, we combined virtual reality and movement capture technologies to investigate the reorganization of movements that occurs when individuals with spinal cord injury (SCI) are allowed to use a broad spectrum of body motions to perform different tasks. Subjects, over multiple sessions, used their upper body movements to engage in exercises that required different operational functions such as controlling a keyboard for playing a videogame, driving a simulated wheelchair in a virtual reality (VR) environment, and piloting a cursor on a screen for reaching targets. In particular, we investigated the possibility of reducing the dimensionality of the control signals by finding repeatable and stable correlations of movement signals, established both by the presence of biomechanical constraints and by learned patterns of coordination. The outcomes of these investigations will provide guidance for further studies of efficient remapping of motor coordination for the control of assistive devices and are a basis for a new training paradigm in which the burden of learning is significantly removed from the impaired subjects and shifted to the devices.

Increases in wheelchair breakdowns, repairs, and adverse consequences for people with traumatic spinal cord injury

OBJECTIVE

The aims of this study were to report the current incidence of wheelchair breakdowns, repairs, and consequences and to compare current data with historical data.

DESIGN

A convenience sample survey of 723 participants with spinal cord injury who use a wheelchair for more than 40 hrs/wk treated at a Spinal Cord Injury Model Systems center was conducted.

RESULTS

Significant increases were found in the number of participants reporting repairs (7.8%) and adverse consequences (23.5%) in a 6-mo period (2006-2011) compared with historical data (2004-2006) (P < 0.001). When examining current data, minorities experienced a greater frequency and higher number of reported consequences (P = 0.03). Power wheelchair users reported a higher number of repairs and consequences than did manual wheelchair users (P < 0.001). Wheelchairs equipped with seat functions were associated with a greater frequency of adverse consequences (P = 0.01). Repairs did not vary across funding source, but individuals with wheelchairs provided by Medicare and Medicaid reported a higher frequency of consequences than did the combined group of the Department of Vocational Rehabilitation, Worker's Compensation, and the Veterans Administration (P = 0.034 and P = 0.013, respectively).

CONCLUSIONS

The incidence and consequences of repairs are increasing from what was already a very high statistic in this United States population. Further investigation into causality is required, and intervention is needed to reverse this potential trend.

Association of race, socioeconomic status, and health care access with pressure ulcers after spinal cord injury

OBJECTIVE

To assess the associations of race and socioeconomic status (SES) with pressure ulcers (PUs) after accounting for health care access among persons with spinal cord injury (SCI).

DESIGN

Cross-sectional.

SETTING

Large specialty hospital in the southeastern United States.

PARTICIPANTS

Persons with traumatic SCI who (1) had residual effects from their injury, (2) were 18 years or older at the time of the survey, and (3) were a year or more postinjury at the time of survey (N=2549).

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Outcomes were measured by a mail-in survey: having a current PU (yes vs no), having a PU in the past year with or without reduced sitting time (no PU, no reduced sitting time, month or less, ≥5wk), and having at least 1 PU surgery since SCI onset (yes vs no).

RESULTS

Of participants, 39.3% reported a PU in the past year, 19.9% had a current PU, and 21.9% reported having had surgery for a PU since their SCI onset. While race was preliminarily associated with each PU outcome, it became nonsignificant after controlling for SES and health care access. In each analysis, household income was significantly associated with PU outcomes after controlling for demographic and injury factors and remained significant after accounting for the health care access factors. Persons with lower income had higher odds of each PU outcome. Health care access was not consistently related to PU outcomes.

CONCLUSIONS

Even after accounting for health care access, household income, a measure of SES, remained significantly associated with PU outcomes after SCI; however, race became nonsignificant.

Sensory motor remapping of space in human-machine interfaces

Studies of adaptation to patterns of deterministic forces have revealed the ability of the motor control system to form and use predictive representations of the environment. These studies have also pointed out that adaptation to novel dynamics is aimed at preserving the trajectories of a controlled endpoint, either the hand of a subject or a transported object. We review some of these experiments and present more recent studies aimed at understanding how the motor system forms representations of the physical space in which actions take place. An extensive line of investigations in visual information processing has dealt with the issue of how the Euclidean properties of space are recovered from visual signals that do not appear to possess these properties. The same question is addressed here in the context of motor behavior and motor learning by observing how people remap hand gestures and body motions that control the state of an external device. We present some theoretical considerations and experimental evidence about the ability of the nervous system to create novel patterns of coordination that are consistent with the representation of extrapersonal space. We also discuss the perspective of endowing human-machine interfaces with learning algorithms that, combined with human learning, may facilitate the control of powered wheelchairs and other assistive devices.

Demographic profile of older adults using wheeled mobility devices

The purpose of this study was to determine whether the use of wheeled mobility devices differed with respect to age, gender, residential setting, and health-related factors among older adults. A total of 723 adults ageing 60 and older are representing three cohorts, from nursing homes, the Center for Assistive Technology, and the wheelchair registry from the Human Engineering Research Laboratories. Wheeled mobility devices were classified into three main groups: manual wheelchairs, power wheelchairs, and scooters. Our results found factors including age, gender, diagnosis, and living settings to be associated with differences in use of manual versus powered mobility devices. Differences in use were also noted for subtypes of manual (depot, standard, and customized) and powered (scooter, standard, and customized) mobility devices, on demographic, living arrangements, and health-related factors. Consideration of demographic, health-related, and environmental factors during the prescription process may help clinicians identify the most appropriate mobility device for the user.

Vulnerable Groups Living with Spinal Cord Injury

There is considerable variation in rehabilitation outcomes within the population of spinal cord-injured individuals across racial and socioeconomic groups. This suggests that the long-term health following spinal cord injury (SCI) is determined, at least in part, by group differences in exposure to advantages and disadvantages among persons living in the community. This article conceptualizes the nature of vulnerability and how increased vulnerability leads to disparities in SCI outcomes. Demographic, socioeconomic, and geographic determinants of adverse outcomes among vulnerable groups are discussed. Finally, a research model that outlines potential processes that elicit vulnerability following SCI and clinical implications is reviewed.

Functional reorganization of upper-body movement after spinal cord injury

Survivors of spinal cord injury need to reorganize their residual body movements for interacting with assistive devices and performing activities that used to be easy and natural. To investigate movement reorganization, we asked subjects with high-level spinal cord injury (SCI) and unimpaired subjects to control a cursor on a screen by performing upper-body motions. While this task would be normally accomplished by operating a computer mouse, here shoulder motions were mapped into the cursor position. Both the control and the SCI subjects were rapidly able to reorganize their movements and to successfully control the cursor. The majority of the subjects in both groups were successful in reducing the movements that were not effective at producing cursor motions. This is inconsistent with the hypothesis that the control system is merely concerned with the accurate acquisition of the targets and is unconcerned with motions that are not relevant to this goal. In contrast, our findings suggest that subjects can learn to reorganize coordination so as to increase the correspondence between the subspace of their upper-body motions with the plane in which the controlled cursor moves. This is effectively equivalent to constructing an inverse internal model of the map from body motions to cursor motions, established by the experiment. These results are relevant to the development of interfaces for assistive devices that optimize the use of residual voluntary control and enhance the learning process in disabled users, searching for an easily learnable map between their body motor space and control space of the device.

Quality-of-life technology for people with spinal cord injuries

Technology plays a critical role in promoting well-being, activity, and participation for individuals with spinal cord injury (SCI). As technology has improved, so has the realm of possibilities open to people with SCI. School, work, travel, and leisure activities are all facilitated by technology. Advances in materials have made wheelchairs lighter, and developments in design have made wheelchairs that fit individual needs. Software has made computer interfaces adaptive and in some case intelligent, through learning the user's behavior and optimizing its structure. As participatory action design and aware systems take greater hold, transformational change is likely to take place in the technology available to people with SCI.

A preliminary model of wheelchair service delivery

OBJECTIVE

To integrate and expand on previously published models of wheelchair service delivery, and provide a preliminary framework for developing more comprehensive, descriptive models of wheelchair service delivery for adults with spinal cord injury within the U.S. health care system.

DESIGN

Literature review and a qualitative analysis of in-depth interviews.

SETTING

Not applicable.

PARTICIPANTS

Ten academic, clinical, regulatory, and industry experts (Department of Veterans Affairs [VA] and non-VA) in wheelchair service delivery.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Interviewees were asked to discuss the full range of variables and stakeholders involved in wheelchair service delivery, and to limit their scope to the provision of primary subsequent or replacement chairs (not backup chairs) to adults within the United States.

RESULTS

Most experts we interviewed stressed that clients who require a wheelchair play a central role in the wheelchair service delivery process. Providers (including clinicians, rehabilitation engineers, and rehabilitation counselors) are also critical stakeholders. More so than in other health care settings, suppliers play an integral role in the provision of wheelchairs to clients and may significantly influence the appropriateness of the wheelchair provided. Suppliers often have a direct role in wheelchair service delivery through their interactions with the clinician and/or client. This model also identified a number of system-level factors (including facility administration and standards, policies, and regulations) that influence wheelchair service delivery and ultimately the appropriateness of the wheelchair provided.

CONCLUSIONS

We developed a detailed, descriptive model of wheelchair service delivery that integrates the delivery process and device outcomes, and includes the patient-level, provider-level, and system-level factors that may directly influence those processes and outcomes. We believe that this detailed model can help clinicians and researchers describe and consider the complexities of wheelchair service delivery. It can be used to identify factors that may be related to disparities in wheelchair service delivery and in the appropriateness of the wheelchair prescribed. Further, this model can help researchers and clinicians identify factors that may be related to disparities in wheelchair service delivery, and intervene to reduce such disparities.

[Satisfaction with technological equipment in individuals with tetraplegia following spinal cord injury]

OBJECTIVE

To measure the acquisition, use and satisfaction with high technology equipment by spinal cord injured tetraplegic subjects.

DESIGN AND SETTING

A questionnaire was mailed to 102 tetraplegic subjects who were hospitalised in the rehabilitation center of Kerpape (Ploemeur, France) between 1998 and 2004, and 59 subjects responded. The questionnaire asked about the use of telephones, computers, wheelchairs and environmental controls at home.

RESULTS

When a piece of equipment was acquired, it was very often used. Patient satisfaction with equipment was 79.3%. Home phones and mobile phones were often used with options such as hands-free devices (78 and 59% respectively). A total of 64.4% of subjects acquired a manual wheelchair and 61% a power wheelchair. The most commonly acquired options on the power wheelchairs were the powered recline (73,7%) and tilt (71,1%) systems. All options were used but all were more desired than acquired. A total of 27.1% of subjects desired a pushrim-activated power-assist wheelchair, but only 15.3% had acquired one; 695% of subjects had a computer. Communication was the first use for the computer (82.5%); 49.2% of subjects had acquired an environmental control system, but 20% desired one. The first reason for lack of acquisition was financial difficulties but also accessibility and information problems. The factor that influenced the acquisition and need for equipment was the degree of spinal cord injury. No other factor reduced patient satisfaction with equipment.

CONCLUSION

Patients were satisfied with the equipment they acquired. But their needs, especially wheelchair options and environmental control systems, were not satisfied.

Research from the Model Spinal Cord Injury Systems: findings from the current 5-year grant cycle

This issue of the Archives of Physical Medicine and Rehabilitation is dedicated to current research findings of the Model Spinal Cord Injury Systems (MSCIS) program. The MSCIS grants were established by the Rehabilitation Services Administration in the 1970s. Now administered by the National Institute on Disability and Rehabilitation Research within the Office of Special Education and Rehabilitation Services in the US Department of Education, the program has included 27 spinal cord injury centers in the United States over the years. In the current 5-year grant cycle (2000-2005), there are 16 designated regional MSCIS centers. In addition to establishing a comprehensive system of care, the grantees contribute patient data to the National Spinal Cord Injury Database (which now contains data on 30,532 subjects with follow-up of up to 30 y). In addition, the MSCIS grants enable the conduct of site-specific and collaborative research projects. To highlight the research findings of the program, the MSCIS have produced a special dissemination effort during each of the previous 5 grant cycles, with this issue of the Archives representing the latest of these endeavors. This article provides a brief history of the MSCIS program and highlights the important findings of the 17 original research articles contained in this issue.