Upper-limb biomechanical analysis of wheelchair transfer techniques in two toilet configurations

Reliability of home-based remote and self-assessment of transfers using the Transfer Assessment Instrument among wheelchair users with spinal cord injury

STUDY DESIGN

Cross-sectional study.

OBJECTIVE

To evaluate the reliability of home-based remote and self-assessment of transfer quality using the Transfer Assessment Instrument (TAI) among wheelchair users with spinal cord injury (SCI).

SETTING

Participant's home environment.

METHODS

Eighteen wheelchair users with SCI transferred from their wheelchair to a surface of their choice (bed, sofa, or bench) in their homes. During a live video conference, the transfer was recorded and evaluated live using the TAI (rater 1). Participants completed a self-assessment of their transfer using the TAI- questionnaire (TAI-Q). Two additional raters (raters 2 & 3) completed asynchronous assessments by watching recorded videos. Interrater reliability was assessed using Intraclass Coefficient Correlations (ICC) to compare rater 1 with the average of raters 2 & 3 and TAI-Q. Intrarater reliability was assessed by rater 1 completing another TAI by watching the recorded videos after a 4-week delay. Assessments were compared using paired sample t-tests and level of agreement between TAI scores was evaluated using Bland-Altman plots.

RESULTS

Moderate to good interrater and good intrarater reliability were found for the total TAI score with ICCs: 0.57-0.90 and 0.90, respectively. Moderate to good intrarater and interrater reliability were found for all TAI subscores (ICC: 0.60-0.94) except for interrater reliability of flight/landing which was poor (ICC: 0.20). Bland-Altman plots indicate no systematic bias related to the measurement of error.

CONCLUSIONS

The TAI is a reliable outcome measure for assessing the wheelchair and body setup phases of home-based transfers remotely and through self-assessment among individuals with SCI.

Automating the Clinical Assessment of Independent Wheelchair Sitting Pivot Transfer Techniques

Background

Using proper transfer technique can help to reduce forces and prevent secondary injuries. However, current assessment tools rely on the ability to subjectively identify harmful movement patterns.

Objectives

The purpose of the study was to determine the accuracy of using a low-cost markerless motion capture camera and machine learning methods to evaluate the quality of independent wheelchair sitting pivot transfers. We hypothesized that the algorithms would be able to discern proper (low risk) and improper (high risk) wheelchair transfer techniques in accordance with component items on the Transfer Assessment Instrument (TAI).

Methods

Transfer motions of 91 full-time wheelchair users were recorded and used to develop machine learning classifiers that could be used to discern proper from improper technique. The data were labeled using the TAI item scores. Eleven out of 18 TAI items were evaluated by the classifiers. Motion variables from the Kinect were inputted as the features. Random forests and k-nearest neighbors algorithms were chosen as the classifiers. Eighty percent of the data were used for model training and hyperparameter turning. The validation process was performed using 20% of the data as the test set.

Results

The area under the receiver operating characteristic curve of the test set for each item was over 0.79. After adjusting the decision threshold, the precisions of the models were over 0.87, and the model accuracies were over 71%.

Conclusion

The results show promise for the objective assessment of the transfer technique using a low cost camera and machine learning classifiers.

Effectiveness of a Web-Based Direct-to-User Transfer Training Program: A Randomized Controlled Trial

OBJECTIVE

To determine the effectiveness of a web-based, direct-to-user transfer training program in improving transfer quality and maintaining improvements for up to 1 month after training as compared with a control group.

DESIGN

Randomized controlled trial with participants randomized to an immediate intervention group (IIG) or waitlist control group (WLCG) that received the training after a 6-month delay.

SETTING

Wherever the participants accessed the web-based training, likely the home environment.

PARTICIPANTS

Convenience sample of full-time wheelchair users (N=72; IIG, n=34; WLCG, n=38 for between-group analysis, n=48 for combined within-group analysis) with spinal cord injury or disorder who were able to independently perform a lateral scoot transfer.

INTERVENTIONS

Self-paced, web-based transfer training module.

MAIN OUTCOME MEASURES

Transfer Assessment Instrument Questionnaire (TAI-Q) score at baseline, 1 month, and 6 months postbaseline (WLCG only), immediately posttraining, and 1 month posttraining. The TAI-Q is an 18-item self-assessment that covers several aspects of a quality transfer.

RESULTS

The IIG significantly increased particpants' baseline TAI-Q score from 6.91±0.98 to 7.79±1.12 (P<.001) by 1 month posttraining. The WLCG also increased from baseline to the 1-month postbaseline assessment (from 6.52±1.13 to 7.00±1.09; P=.014), potentially from learning effects secondary to self-assessment with the TAI-Q. The extent of change over time did not differ significantly between the IIG and WLCG from baseline to 1 month (P=.169). However, significant improvements in TAI-Q scores were still evident after the training for the WLCG (P<.001). Those with a lower pretraining TAI-Q score and more shoulder pain were most likely to benefit from the training.

CONCLUSIONS

Repeated TAI-Q self-assessments likely contributed to improved transfer quality, with web-based training having an additive effect. Wheelchair users are likely to benefit from transfer training and self-assessment of transfer quality in their home environments. This has the potential to decrease injury risk while avoiding barriers to in-person training.

Intra- and Interrater Reliability of Remote Assessment of Transfers by Wheelchair Users Using the Transfer Assessment Instrument (Version 4.0)

OBJECTIVE

To evaluate the reliability, standard error of measurement, minimum detectable change, and item-level consistency of the Transfer Assessment Instrument (TAI) version 4.0 when used to evaluate transfer quality remotely.

DESIGN

Participants transferred from their wheelchair to a mat table (transfer 1), repeated this after a 10-minute delay to assess intrarater reliability (transfer 2), and repeated this 1-2 days later to assess test-retest reliability (transfer 3). Each transfer was scored in person by 4 raters and asynchronously by a remote clinician rater.

SETTING

2017 National Veterans Wheelchair Games.

PARTICIPANTS

Convenience sample of 44 full-time wheelchair users (N=44).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

TAI total score, subscores (wheelchair setup, body setup, flight/landing), and item scores (15 items).

RESULTS

Moderate to excellent reliability was found when scoring remotely for TAI total and subscores for intrarater (intraclass correlation coefficient (ICC(3,1)=0.687-0.854), test-retest (ICC(3,1)=0.695-0.836), and interrater reliability (ICC(3,5)=0.746-0.962). Remote rater total score and flight/landing subscore were greater (indicating higher transfer quality) compared to the average in-person raters (P=.021 and P=.005, respectively). There were no differences between transfers 1-3 in remote rater scores. Item-level percentage agreement between the remote rater and in-person exceeded the 75% cutoff for clinical utility for all items.

CONCLUSIONS

The TAI is a reliable outcome measure for assessing transfer technique remotely.

Concurrent Validity and Reliability of the Transfer Assessment Instrument Questionnaire as a Self-Assessment Measure

Objectives

To evaluate the psychometric properties of the Transfer Assessment Instrument Questionnaire (TAI-Q), a self-assessment measure to evaluate transfer quality compared with clinician-reported measures.

Design

Participants self-assessed transfers from their wheelchair to a mat table using the TAI-Q. For session 1, participants self-assessed their transfer both before and after reviewing a video of themselves completing the transfer (session 1). Self-assessment was completed for another transfer after a 10-minute delay (session 2, intrarater reliability) and after a 1- to 2-day delay (session 3, test-retest reliability). Self-assessment was compared with a criterion standard of an experienced clinician scoring the same transfers with the Transfer Assessment Instrument (TAI) version 4.0 (concurrent validity).

Setting

2017 National Veterans Wheelchair Games.

Participants

Convenience sample of full-time wheelchair users (N=44).

Interventions

Not applicable.

Main Outcome Measures

TAI-Q and TAI.

Results

After video review of their transfer, acceptable levels of reliability were demonstrated for total TAI-Q score for intrarater (intraclass correlation [ICC], 0.627) and test-retest reliability (ICC, 0.705). Moderate to acceptable concurrent validity was demonstrated with the TAI (ICC, 0.554-0.740). Participants tended to underestimate the quality of their transfer (reported more deficient items) compared with the TAI. However, this deficit decreased and reliability improved from pre-video review to post-video review and from session 1 to session 2. The minimum detectable change indicated that a change of 1.63 to 2.21 in the TAI-Q total score is needed to detect a significant difference in transfer skills.

Conclusions

When paired with video review, the TAI-Q demonstrates moderate to acceptable levels of reliability and validity for the total score. Self-assessment was completed quickly (<5min) and could help to potentially screen for deficiencies in transfer quality and opportunities for intervention.

Does the setting matter? Observing wheelchair transfers across different environmental conditions

The setting in which wheelchair transfers are performed can affect the difficulty and the risks associated with completion. This article presents results from an observational study involving 13 wheelchair users performing independent transfers across four settings. The aim is to understand how the environment affects how different types of independent transfers are performed. Descriptive analysis was performed alongside an objective assessment using the Transfer Assessment Instrument (TAI). The perceived difficulty reported after each transfer was also collected. Two participants exhibited radically different transferring techniques in different scenarios. Additionally, the transferring scenario was found to significantly affect the perceived difficulty of sitting transfers (toilet 2.17 ±.88; bed 1.47 ±.65, p =.001; car 1.63 ±.82, p =.012) and standing transfers (car 3.5 ±.71; bed 1 ± 0, p =.03; toilet 1 ± 0, p =.03), and the TAI score attributed to sitting pivot with use of a transfer board (couch 4.3 ±.88; bed 6.93 ± 1.29, p =.022; car 7.13 ± 1.32, p =.018). Overall, environmental constraints can lead to major technique changes and, more often, to different positioning of hands and feet which could impact the transfer's biomechanics.

Kinematic analysis of motor learning in upper limb body-powered bypass prosthesis training

Motor learning and compensatory movement are important aspects of prosthesis training yet relatively little quantitative evidence supports our current understanding of how motor control and compensation develop in the novel body-powered prosthesis user. The goal of this study is to assess these aspects of prosthesis training through functional, kinematic, and kinetic analyses using a within-subject paradigm compared across two training time points. The joints evaluated include the left and right shoulders, torso, and right elbow. Six abled-bodied subjects (age 27 ± 3) using a body-powered bypass prosthesis completed the Jebsen-Taylor Hand Function Test and the targeted Box and Blocks Test after five training sessions and again after ten sessions. Significant differences in movement parameters included reduced times to complete tasks, reduced normalized jerk for most joints and tasks, and more variable changes in efficiency and compensation parameters for individual tasks and joints measured as range of motion, maximum angle, and average moment. Normalized jerk, joint specific path length, range of motion, maximum angle, and average moment are presented for the first time in this unique training context and for this specific device type. These findings quantitatively describe numerous aspects of motor learning and control in able-bodied subjects that may be useful in guiding future rehabilitation and training of body-powered prosthesis users.

Accessibility facilitators and barriers affecting independent wheelchair transfers in the community

PURPOSE

The purpose of this study is to identify facilitators and barriers to wheelchair transfers in the community and to identify specific places and surfaces in the community where increasing transfer accessibility could enable greater participation.

METHODS

This study enrolled 112 wheeled mobility device users who completed a survey describing barriers to independent transfers. Descriptive statistics (means, standard deviations, and percentages) were used to report the survey results.

RESULTS

The majority of subjects (≥50% of the sample) who were impacted by the following features found them to be helpful while transferring: presence of transfer aids, presence of grab bars, large enough transfer surface size, storage space for a wheeled mobility device (WMD), large amounts of space and clearance for legs and feet, soft surfaces, and enough space next to the transfer surface. Ninety percent (90.5%) felt their participation was limited when surfaces higher than their WMD were encountered. Participants also reported feeling limited in their participation due to lack of transfer accessibility at a variety of community destinations, including medical facilities (35.1%), modes of transportation (38.5-52.1%), pools and hot tubs (45.4%), dressing rooms (50.0%), amusement parks (49.1%), and boating areas (52.1%).

CONCLUSION

Improving accessibility for independent transfers in the community may support greater participation and lead to a better quality of life. Study findings provide insight into changes that would make the built environment more accessible and safer for wheelchair users who independently transfer.Implications for rehabilitationTransferring independently is one of the most physically demanding tasks for wheelchair users, and physical and environmental factors may affect transferability in the community.Identifying environmental facilitators and barriers to transfers may improve accessibility for wheelchair users, allowing for greater community participation, reduced risk of falls and injuries, and improvements to quality of life.

A Systematic Methodology to Analyze the Impact of Hand-Rim Wheelchair Propulsion on the Upper Limb

Manual wheelchair propulsion results in physical demand of the upper limb extremities that, because of its repetitive nature, can lead to chronic pathologies on spinal cord injury patients. The aim of this study was to design and test a methodology to compare kinematic and kinetic variables of the upper limb joints when propelling different wheelchairs. Moreover, this methodology was used to analyze the differences that may exist between paraplegic and tetraplegic patients when propelling two different wheelchairs. Five adults with paraplegia and five adults with tetraplegia performed several propulsion tests. Participants propelled two different wheelchairs for three minutes at 0.833 m/s (3 km/h) with one minute break between the tests. Kinematic and kinetic variables of the upper limb as well as variables with respect to the propulsion style were recorded. Important differences in the kinetic and kinematic variables of the joints of the upper limb were found when comparing paraplegic and tetraplegic patients. Nevertheless, this difference depends on the wheelchair used. As expected, in all tests, the shoulder shows to be the most impacted joint.