RESNA Position on the Application of Tilt, Recline, and Elevating Legrests for Wheelchairs

An Automated Electronic System in a Motorized Wheelchair for Telemonitoring: Mixed Methods Study Based on Internet of Things

BACKGROUND

Wheelchair positioning systems can prevent postural deficits and pressure injuries. However, a more effective professional follow-up is needed to assess and monitor positioning according to the specificities and clinical conditions of each user.

OBJECTIVE

This study aims to present the concept of an electronic system embedded in a motorized wheelchair, based on the Internet of Things (IoT), for automated positioning as part of a study on wheelchairs and telemonitoring.

METHODS

We conducted a mixed methods study with a user-centered design approach, interviews with 16 wheelchair users and 66 professionals for the development of system functions, and a formative assessment of 5 participants with descriptive analysis to design system concepts.

RESULTS

We presented a new wheelchair system with hardware and software components developed based on coparticipation with singular components in an IoT architecture. In an IoT solution, the incorporation of sensors from the inertial measurement unit was crucial. These sensors were vital for offering alternative methods to monitor and control the tilt and recline functions of a wheelchair. This monitoring and control could be achieved autonomously through a smartphone app. In addition, this capability addressed the requirements of real users.

CONCLUSIONS

The technologies presented in this system can benefit telemonitoring and favor real feedback, allowing quality provision of health services to wheelchair users. User-centered development favored development with specific functions to meet the real demands of users. We emphasize the importance of future studies on the correlation between diagnoses and the use of the system in a real environment to help professionals in treatment.

Identification of wheelchair seating criteria in adults with neuromuscular diseases: A Delphi study

BACKGROUND

Adults with neuromuscular diseases like spinal muscular atrophy or Duchenne muscular dystrophy require full-time use of a wheelchair (WC) and perform all activities of daily living in a sitting position. Optimal configuration of the WC and seating system is essential to maintain the health and quality of life of users. However, few recommendations for configuration exist. The aim of this study was to identify and select 10 WC seating criteria that ensure an optimal sitting posture for health and quality of life.

METHODS

A four round Delphi method was used to collect the opinions of WC users and health professionals (HP), separately. First, the HP were asked if they believed that different criteria would apply to each disease. Then the HP and SMA II and DMD WC user experts responded to electronic surveys in 4 rounds.

RESULTS

Overall, 74 experts took part: 31 HP, 21 WC users with SMA II and 22 WC users with DMD. In total, 52% of HP believed that different criteria would apply to each disease. Ten criteria were identified by the HP for SMA II and 10 for DMD. Of the 40 criteria selected, 30 (75%) were common to each panel. Six topics were similar across panels: comfort, access to the joystick, prevention of pain, stability, pressure management and power seat functions. However, power seat functions did not reach consensus between HP and WC users (30-33% of agreement for HP and 93-100% for the WC user panels, p < 0.001).

CONCLUSION

Adults with SMA II and DMD had similar WC seating needs. Therefore, the same recommendations can be applied to these groups. Further research is necessary to understand the impact of cost on the prescription of power seat functions by health professionals.

Measure It: Proper Wheelchair Fit Is Key to Ensuring Function while Protecting Skin Integrity

GENERAL PURPOSE

To review the biomechanics of posture, appropriate means to configure a wheelchair to permit proper postural support, and common problems arising from improper wheelchair fit.

TARGET AUDIENCE

This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care.

LEARNING OBJECTIVES/OUTCOMES

After participating in this educational activity, the participant will:1. Synthesize the concepts influencing proper wheelchair fit.2. Identify the biomechanics of posture as they apply to wheelchair fit.3. Summarize the appropriate assessment guidelines for determining and preparing to adjust wheelchair fit.

Head support in wheelchairs (scoping review): state-of-the-art and beyond

BACKGROUND

Many wheelchair users experience disabilities in stabilising and positioning of the head. For these users, adequate head support is required. Although several types of head supports are available, further development of these systems is needed to improve functionality and quality of life, especially for the group of severely challenged users. For this group, user needs have not been clearly established. In this article, we provide an overview of the state-of-the-art in wheelchair mounted head supports and associated scientific evidence in order to identify requirements for the next generation of head support systems.

MATERIALS AND METHODS

A scoping review was performed including scientific literature (PubMed/Scopus), patents (Espacenet/Google Scholar) and commercial information. Types of head support and important system characteristics for future head support systems were proposed from consultations with wheelchair users (n = 3), occupational therapists (n = 3) and an expert panel.

RESULTS

Forty scientific papers, 90 patents and 80 descriptions of commercial devices were included in the scoping review. The identified head support systems were categorised per head support type. Only limited scientific clinical evidence with respect to the effectiveness of existing head support systems was found. From the user and expert consultations, a need was identified for personalised head support systems that intuitively combine changes in sitting and head position with continuous optimal support of the head to accommodate severely challenged users.

CONCLUSIONS

This study presents the state-of-the-art in head support systems. Additionally, several important system characteristics are introduced that provide guidance for the development and improvement of head supports.Implications for rehabilitationEspecially for the group of severely challenged wheelchair users, current head support systems require further development to improve their users' quality of life.The desired system characteristics which are discussed in this review are an important step in the definition of requirements for the next generation of head supports.

Determining frictional properties of pants and cushion cover materials using human soft tissue and a rigid sled and how they affect seated shear forces

Shear forces on the buttocks while seated are directly linked to friction, yet the frictional properties at the seat interface are unknown. Shear forces are one of the factors related to increase risk of pressure injury formation. The goals of this study included determining coefficients of friction between three cushion covers and two clothing fabrics using a mechanical system as well as human participants and to evaluate the impact of the cushion covers on shear loading on the buttocks while seated. A chair with separate seat pan tilt and back recline movements was built and instrumented with reflective markers and a load cell. A motion capture system and load cell were used to determine the angles of seat pan tilt at which the sled and participants started sliding, as well as shear forces at three recline angles for three cushion covers (vinyl, one-layer nylon, and two-layer nylon). Results showed the vinyl and two-layer nylon cushion covers respectively had the largest and smallest coefficients of friction for both pants materials. The coefficients of friction calculated with the human participants and rigid sled were within 10% of each other, demonstrating similar results. Further, increasing back recline increased shear load on the buttocks, while the two-layer nylon cover reduced shear forces seen on the buttocks. This work furthers the understanding of shear loading on the buttocks, will aid in the protocols for reducing pressure injuries, and suggests that coefficients of friction found using rigid bodies may be applied to deformable bodies.

Policy Analysis on Power Seat Elevation Systems

In the early 2000s the Centers for Medicare and Medicaid Services determined that power seat elevation systems did not meet the definition of durable medical equipment, and therefore are non-covered items. Yet, power seat elevation systems are covered by other funding sources, and many power wheelchair users utilize these systems regularly when performing tasks such as transferring, reaching, and looking at objects in environments designed for ambulatory people. Adjusting for height when performing these tasks may reduce the onset of pain and comorbidities. To improve access to power seat elevation systems, a clinical team of 4 Clinician Task Force members investigated applicable literature, compiled evidence, and evaluated existing policies to explain the medical nature of power seat elevation systems as a part of a greater interprofessional effort. This manuscript aims to analyze Medicare's policy decision that power seat elevation systems are not primarily medical in nature using Bardach's 8-step framework. As a special communication, this will inform health care professionals of the medical nature of power seat elevation systems and the evidence-based conditions under which power wheelchair users may need power seat elevation systems, as well as empower clinicians to engage in policy directives to affect greater change.

Pressure redistributing static chairs for preventing pressure ulcers

BACKGROUND

Sitting can be viewed as a therapeutic intervention and an important part of a person's recovery process; but the risk of ulceration must be mitigated. Interventions for ulcer prevention in those at risk from prolonged sitting include the use of specialist cushions and surfaces, especially for wheelchair users. Whilst there is interest in the effects of different pressure redistributing cushions for wheelchairs, the benefits of pressure redistributing static chairs, compared with standard chairs, for pressure ulcer development in at-risk people are not clear.

OBJECTIVES

To assess the effects of pressure redistributing static chairs on the prevention of pressure ulcers in health, rehabilitation and social care settings, and places of residence in which people may spend their day.

SEARCH METHODS

In June 2021 we searched the following electronic databases to identify reports of relevant randomised clinical trials: the Cochrane Wounds Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE, Ovid Embase and EBSCO CINAHL Plus (Cumulative Index to Nursing and Allied Health Literature). We also searched clinical trials registers for ongoing and unpublished studies, and reference lists of relevant systematic reviews, meta-analyses and health technology reports. There were no restrictions by language, date of publication or study setting.

SELECTION CRITERIA

We sought to include published or unpublished randomised controlled trials that assessed pressure redistributing static chairs in the prevention or management of pressure ulcers.

DATA COLLECTION AND ANALYSIS

Two review authors independently performed study selection. We planned that two review authors would also assess the risk of bias, extract study data and assess the certainty of evidence according to GRADE methodology.

MAIN RESULTS

We did not identify any studies that met the review eligibility criteria, nor any registered studies investigating the role of pressure redistributing static chairs in the prevention or management of pressure ulcers.

AUTHORS' CONCLUSIONS

Currently, there is no randomised evidence that supports or refutes the role of pressure redistributing static chairs in the prevention or management of pressure ulcers. This is a priority area and there is a need to explore this intervention with rigorous and robust research.

Mini-review: Robotic wheelchair taxonomy and readiness

Robotic wheelchair research and development is a growing sector. This article introduces a robotic wheelchair taxonomy, and a readiness model supported by a mini-review. The taxonomy is constructed by power wheelchair and, mobile robot standards, the ICF and, PHAATE models. The mini-review of 2797 articles spanning 7 databases produced 205 articles and 4 review articles that matched inclusion/exclusion criteria. The review and analysis illuminate how innovations in robotic wheelchair research progressed and have been slow to translate into the marketplace.

Policy analysis on power standing systems

Power wheelchairs provide people with mobility disabilities opportunities for independence in mobility and repositioning themselves. However, current power wheelchair power options covered by Medicare limit the person to a horizontal plane. In the home, access to the vertical plane is also required for mobility related activities of daily living. Power standing systems on power wheelchairs are one option for providing access to the vertical environment, although currently these systems are not covered by Medicare. Power standing systems also aid in medical management and in preventing common comorbidities associated with chronic neurological and congenital healthcare conditions. Therefore, a legal group led an interdisciplinary effort to change Medicare policy on power standing systems. A policy analysis using Bardach’s Eightfold policy framework was conducted to analyze a clinical groups’ action within this interdisciplinary team. The clinical team considered three viable options to address the problem and evaluated these options against five criteria. Ultimately, a national coverage determination reconsideration would provide a needed opportunity for the coverage of power standing systems. Suggested coverage criteria for power standing systems, based on existing literature and expert clinical experience, are proposed.

Usability evaluation of attitude control for a robotic wheelchair for tip mitigation in outdoor environments

Tips and falls are the most prominent causes of wheelchair accidents that occur when driving on uneven terrains and less accessible environments. The Mobility Enhancement Robotic Wheelchair (MEBot) was designed to improve the stability of Electric Powered Wheelchairs (EPW) when driving over these environments. MEBot offers six independently height-adjustable wheels to control attitude of its seat over uneven and angled terrains. Its attitude control application uses an inertial measurement unit to detect seat angles changes to adjust each wheel-height accordingly. MEBot was compared to commercial EPWs in terms of EPW performance (seat angle changes and response time) and participant perception (satisfaction and task-load demand) towards each device. Ten participants drove their own EPW and MEBot for five trials each through driving tasks that replicated outdoor environments. Results showed less change in the pitch angle when driving up and down a 10° slope using MEBot (5.6 ± 1.6°, 6.6 ± 0.5°) compared to the participants' own EPW (14.6 ± 2.6°, 12.1 ± 2.6°). However, MEBot required 7.8 ± 3.0 s to self-adjust to the minimum angle when driving over the tasks. Participants reported no difference in satisfaction and task load demand between EPWs due to similarities in comfort and ease-of-use. Improving the speed and efficiency of MEBot's attitude control application will be addressed in future work based upon participants' feedback.

Development of a Web-Based Monitoring System for Power Tilt-in-Space Wheelchairs: Formative Evaluation

Background

In order to prevent pressure ulcers, wheelchair users are advised to regularly change position to redistribute or eliminate pressure between the buttocks region and the seat of the wheelchair. A power tilt-in-space wheelchair (allowing simultaneous pivoting of the seat and the backrest of the wheelchair toward the back or front) meets many clinical purposes, including pressure management, increased postural control, and pain management. However, there is a significant gap between the use of tilt as recommended by clinicians and its actual usage. A Web-based electronic health (eHealth) intervention, including a goal setting, monitoring, reminder, and feedback system of the use of power tilt-in-space wheelchairs was developed. The intervention incorporates behavior change principles to promote optimal use of tilt and to improve clinical postprocurement follow-up.

Objective

This study aimed to conduct a formative evaluation of the intervention prototype to pinpoint the functionalities needed by end users, namely, power wheelchair users and clinicians.

Methods

On the basis of an evaluation framework for Web-based eHealth interventions, semistructured interviews were conducted with power wheelchair users and clinicians. A content analysis was performed with a mix of emerging and a priori concepts.

Results

A total of 5 users of power tilt-in-space wheelchairs and 5 clinicians who had experience in the field of mobility aids aged 23 to 55 years were recruited. Participants found the Web interface and the physical components easy to use. They also appreciated the reminder feature that encourages the use of the tilt-in-space and the customization of performance goals. Participants requested improvements to the visual design and learnability of the Web interface, the customization of reminders, feedback about specific tilt parameters, and the bidirectionality of the interaction between the user and the clinician. They thought the current version of the intervention prototype could promote optimal use of the tilt and improve clinical postprocurement follow-up.

Conclusions

On the basis of the needs identified by power wheelchair users and clinicians regarding the prototype of a power tilt-in-space wheelchair monitoring system, 3 main directions were defined for future development of the intervention. Further research with new wheelchair users, manual tilt-in-space wheelchairs, various age groups, and family caregivers is recommended to continue the formative evaluation of the prototype.

A pilot investigation of anterior tilt use among power wheelchair users

PURPOSE

To examine the influence of use of the anterior tilt-in-space power seat function on performance of functional activities, physical health, and user satisfaction on among power wheelchair users.

MATERIALS AND METHODS

Ten full-time power wheelchair users with a seat elevator on their current chair participated in a mixed-methods, repeated measures study. At Visit 1 participants completed the Wheelchair Outcome Measure, Functional Mobility Assessment, Wheelchair Users Shoulder Pain Index, Fatigue Severity Scale, and the Spinal Cord Injury Secondary Conditions Scale. Physical assessments were performed to examine transfer quality (transfer assessment instrument), functional reach, activities of daily living (performance assessment of self-care skills), seated balance (function in sitting test), spasticity, respiratory function, and speech production. Approximately 3 days later (Visit 2), participants were trained on use and provided a power wheelchair with anterior tilt to trial for two weeks. After two weeks (Visit 3), the Visit 1 protocol was repeated and a semistructured interview conducted.

RESULTS

Participants lived with disabilities of cerebral palsy, spinal muscular atrophy and multiple sclerosis. With use of anterior tilt, significant improvements were seen among safety of meal preparation, p = 0.033, d_z = 0.91 and functional reach in the vertical direction, p = 0.000, d_z = 2.62. Subjectively, participants found anterior tilt helpful in performance of reaching tasks in but found the safety equipment restrictive.

CONCLUSION

Preliminary results indicate that use of the anterior tilt may help to improve performance of functional activities. Additional research is needed to examine the long-term influence of the technology.Implications for rehabilitationThe anterior tilt seat function changes the seat angle orientation in relation to the ground in the sagittal plane and angles the seat forward. As a result, the individual using the assistive technology is positioned in a semistanding position.Preliminary results of this study indicate that with use of anterior tilt, safety of meal preparation and functional reach in the vertical direction significantly improved. Subjectively, participants found anterior tilt helpful in performance of reaching tasks but found the safety equipment restrictive.Additional research is needed to examine the long-term influence of anterior tilt on functional activities, physical health and user satisfaction on among a large and diverse group of power wheelchair users.

Effects of adjustments to wheelchair seat to back support angle on head, neck, and shoulder postures in subjects with cerebral palsy

A wheelchair is usually a source of mobility for people with moderate to severe cerebral palsy, who are unable to walk. They spend long periods of time sitting in their wheelchair, which can affect their head and neck alignment. Opening the seat to back support angle of the wheelchair can modify realignment of body segments and improve posture. Aims: To examine the effect of seat to back support angle adjustments on head, neck, and shoulder postural alignment in people with cerebral palsy. Methods: Nine participants with cerebral palsy who use a wheelchair for mobility sat in a research wheelchair. Sagittal head angle (SHA), cervical angle (CVA), and shoulder angle (SA) from photographs were examined using the Coach's Eye device during three different seat to back support angles of the wheelchair (90°, 100°, 110°). Results: There were significant differences in mean SHA and CVA among the different seat to back support angles (p < .001). However, there was no significant difference in mean SA. Conclusion: Head (SHA) and (CVA) alignment was closest to neutral posture with seat to back support angles set at 110°. Thus, adjusting the wheelchair back support to a 110º would provide the most appropriate sagittal head and cervical angle for this population.

Wheelchair Breakdowns Are Associated With Pain, Pressure Injuries, Rehospitalization, and Self-Perceived Health in Full-Time Wheelchair Users With Spinal Cord Injury

OBJECTIVES

To evaluate the relation between wheelchair breakdowns, their immediate consequences, and secondary health complications after spinal cord injury. "Immediate consequences" occur when part of a wheelchair breaks and leaves an individual stranded or injured, or causes him or her to miss medical appointments, work, or school.

DESIGN

Survey, cross-sectional.

SETTING

Spinal Cord Injury Model Systems Centers.

PARTICIPANTS

Full-time wheelchair users (N=771) with SCI from 9 Spinal Cord Injury Model Systems Centers, with data collected between 2011 and 2016.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Incidence of self-reported wheelchair breakdowns within the past 6 months that did or did not result in immediate consequences (ie, injury, being stranded, missing a medical appointment, or an inability to attend school/work); self-perceived health status scale; pain severity numerical rating scale; rehospitalizations; and self-reported pressure injury development within the past 12 months.

RESULTS

A total of 610 participants with complete data sets were included in the analyses. When compared to those who reported no breakdowns, participants who reported 1 or more immediate consequences had worse secondary complications: higher self-perceived health status and pain scores (partial -η²=.009-.012, P<.05), and higher odds of rehospitalization (odds ratio: 1.86, P<.05) and pressure injury development (odds ratio: 1.73, P<.05). Secondary health complications were not different in those who reported no immediate consequences compared to those who reported no breakdown.

CONCLUSIONS

Wheelchair breakdowns that resulted in injury, being stranded, missing medical appointments, and/or an inability to attend work/school appear to have far-reaching impacts on health and secondary injury. Preventing wheelchair breakdowns, through either better maintenance or manufacturing, may be a means of decreasing secondary disability.

End user evaluation of a Kneeling Wheelchair with "on the fly" adjustable seating functions

A "kneeling" ultralight wheelchair prototype has been developed that allows users to adjust seat position "on the fly" for different activities throughout the day. The wheelchair includes independent adjustment functions for rear seat height, front seat height ("kneeling") and backrest angle.  Aim: This work aimed to gather feedback about the wheelchair's functionality and performance through end user evaluation trials.  Methods: Eight manual wheelchair users evaluated the prototype Kneeling Wheelchair for a range of activities. User perspectives on parameters such as usability, comfort, stability and effectiveness were obtained through both open-ended and Likert-scale rating questions.  Results: Results indicate several potential benefits of the adjustment functions of the Kneeling Wheelchair. Rear seat height adjustment may facilitate a number of activities of daily living, as well as provide benefits for comfort and social interactions. Back rest adjustment may increase comfort and stability on slopes. Front seat height adjustment may be beneficial for transfers and conducting sustained low-to-the-ground activities. While benefits of this adjustment function were described by many participants, some struggled with usability of the kneeling mechanism and rated this function less favourably than the other two.  Conclusion: The findings of this study will inform future iterations of the Kneeling Wheelchair design and may spur future developments in wheeled mobility. In the long-term, it is anticipated that novel wheelchair solutions, such as the one described in this paper, may support improved health, quality of life and community participation for people with mobility impairments. Implications for rehabilitation Wheelchairs that allow users to easily adjust seat and backrest position "on the fly" to better suit different tasks throughout the day may provide benefits such as facilitating activities of daily living. A front seat height adjustment feature on a new wheelchair prototype may be beneficial for transfers and conducting sustained low-to-the ground activities. End user evaluations can provide valuable insight to direct future design modifications and innovation.

Effect of Rear Wheel Suspension on Tilt-in-Space Wheelchair Shock and Vibration Attenuation

BACKGROUND

Suspension systems are designed to reduce shock and vibration exposure. An aftermarket rear-wheel suspension system is now available for manual tilt-in-space wheelchairs.

OBJECTIVE

To compare quantifiable shock and vibration on a rigid manual tilt-in-space wheelchair to published data on manual wheelchairs and to determine whether aftermarket rear suspension system will significantly decrease shock exposure when traversing common obstacles.

DESIGN

Cross-sectional.

SETTING

Research laboratory.

PARTICIPANTS

Ten healthy non-wheelchair users.

METHODS

Subjects seated in a manual tilt-in-space wheelchair were pushed over 4 different obstacles (an exterior door threshold, truncated domes, 2-cm descent, and 2-cm ascent) with the chair as manufactured and with the suspension system installed.

MAIN OUTCOME MEASUREMENTS

Superior/inferior and anterior/posterior accelerations were assessed at the seat pan with and without the use of ISO 2631-1 standards. Peak accelerations were analyzed from the door threshold, 2-cm descent and 2-cm ascent. Root mean square acceleration (RMSa) values were analyzed from the truncated domes, and vibration dose value (VDV) was analyzed for all surfaces.

RESULTS

There were no differences in time spent over the 4 obstacles between rigid and suspended conditions (P≥.064). Suspension decreased the peak acceleration at the rear wheel when it initially impacted the door threshold, and when the rear wheel traversed the 2-cm descent and ascent (P≤.043). ISO 2631-1 frequency weighting, placing emphasis on frequencies most harmful to humans, also supports suspension reducing peak accelerations at the rear wheel both when it initially impacted and left the door threshold, and when the rear wheel descended 2 cm (P≤.049). Suspension also reduced the truncated dome RMSa as well as the door threshold, 2-cm descent, and total VDV (P≤.041).

CONCLUSIONS

The results indicate that rigid manual tilt-in-space wheelchairs respond to rough surfaces in a similar fashion to previously studied rigid wheelchairs. Furthermore, the aftermarket suspension system reduces some aspects of shock and vibration exposure, also consistent with previously studied suspension systems.

LEVEL OF EVIDENCE

NA.

Comparison of seating, powered characteristics and functions and costs of electrically powered wheelchairs in a general population of users

PURPOSE

To profile and compare the seating and powered characteristics and functions of electrically powered wheelchairs (EPWs) in a general user population including equipment costs.

METHOD

Case notes of adult EPW users of a regional NHS service were reviewed retrospectively. Seating equipment complexity and type were categorized using the Edinburgh classification. Powered characteristics and functions, including control device type, were recorded.

RESULTS

482 cases were included; 53.9% female; mean duration EPW use 8.1 years (SD 7.4); rear wheel drive 88.0%; hand joystick 94.8%. Seating complexity: low 73.2%, medium 18.0%, high 8.7%. Most prevalent diagnoses: multiple sclerosis (MS) 25.3%, cerebral palsy (CP) 18.7%, muscular dystrophy (8.5%). Compared to CP users, MS users were significantly older at first use, less experienced, more likely to have mid-wheel drive and less complex seating. Additional costs for muscular dystrophy and spinal cord injury users were 3-4 times stroke users.

CONCLUSIONS

This is the first large study of a general EPW user population using a seating classification. Significant differences were found between diagnostic groups; nevertheless, there was also high diversity within each group. The differences in provision and the equipment costs across diagnostic groups can be used to improve service planning. Implications for Rehabilitation At a service planning level, knowledge of a population's diagnostic group and age distribution can be used to inform decisions about the number of required EPWs and equipment costs. At a user level, purchasing decisions about powered characteristics and functions of EPWs and specialised seating equipment need to be taken on a case by case basis because of the diversity of users' needs within diagnostic groups. The additional equipment costs for SCI and MD users are several times those of stroke users and add between 60 and 70% of the cost of basic provision.

Reasons for using power tilt: perspectives from clients and therapists

PURPOSE

A power tilt wheelchair allows independence in changing body position to address a variety of needs throughout the day; however, literature and clinical practice suggest that actual use varies greatly. This grounded theory study examined how power tilt was used in daily life from the perspectives of adults who used power tilt and therapists who prescribed this technology.

METHODS

A constant comparative approach was used to collect and analyze interview data from five people who use power tilt and six therapists who prescribe this technology.

RESULTS

This paper presents the findings specific to understanding the reasons why power tilt was used, focusing on the relationships between tilt use and (1) the reasons for use, (2) the reasons for prescribing power tilt and (3) the associated amplitudes of tilt.

CONCLUSIONS

This study advances knowledge related to how power tilt is used in daily life by elucidating that how the reasons for use are conceptualized is complex. The three relationships related to the reason for power tilt use identified in this paper have the potential to influence the quality of communication about power tilt use in clinical practice between therapist and client and in research between researcher and participant. Implications for Rehabilitation: Understanding the inconsistencies and variations in how power tilt is used in daily life is dependent on exploring the reasons beyond the words or terms expressed to describe use. Reasons for tilt use are context dependent, particularly the activity occurring at the time of tilt use, the associated amplitude of tilt and the influence of other reasons occurring at the same time.

Characterizing the community use of an ultralight wheelchair with "on the fly" adjustable seating functions: A pilot study

An ultralight manual wheelchair that allows users to independently adjust rear seat height and backrest angle during normal everyday usage was recently commercialized. Prior research has been performed on wheelchair tilt, recline, and seat elevation use in the community, however no such research has been done on this new class of manual ultralight wheelchair with "on the fly" adjustments. The objective of this pilot study was to investigate and characterize the use of the two adjustable seating functions available on the Elevation™ ultralight dynamic wheelchair during its use in the community. Eight participants had data loggers installed onto their own wheelchair for seven days to measure rear seat height, backrest angle position, occupied sitting time, and distance traveled. Analysis of rear seat height and backrest adjustment data revealed considerable variability in the frequency of use and positions used by participants. There was a wide spread of mean daily rear seat heights among participants, from 34.1 cm to 46.7 cm. Two sub-groups of users were further identified: those who sat habitually at a single typical rear seat height, and those who varied their rear seat height more continuously. Findings also showed that participants used the rear seat height adjustment feature significantly more often than the backrest adjustment feature. This obvious contrast in feature use may indicate that new users of this class of wheelchair may benefit from specific training. While the small sample size and exploratory nature of this study limit the generalizability of our results, our findings offer a first look at how active wheelchairs users are using a new class of ultralight wheelchair with "on the fly" seating adjustments in their communities. Further studies are recommended to better understand the impact of dynamic seating and positioning on activity, participation and quality of life.

Power seat function usage and wheelchair discomfort for power wheelchair users

OBJECTIVES

To investigate correlations between power seat functions (PSFs) usage and wheelchair discomfort.

DESIGN

Quasi-experimental design: Time series design.

SETTING

In-home trial in participants' home/community.

PARTICIPANTS

Thirteen power wheelchair users who independently used power wheelchairs equipped with PSFs as their primary means of mobility.

MAIN OUTCOME MEASURES

PSF usage variables include the frequency of performing repositioning and using PSFs (tilt, recline, legrests and seat elevation), wheelchair occupancy, and driving distance. The Tool for Assessing Wheelchair disComfort (TAWC) were used to evaluate general discomfort and discomfort intensity.

RESULTS

Spearman correlation coefficient showed that the frequency of using tilt, recline, and legrest is significantly correlated with discomfort intensity. Multiple regression analysis with backward stepwise indicated that these functions can explain 43.8% of the variance (R2 = .438, F(3,33) = 8.588, P < 0.01) in the discomfort intensity score. The best-first decision tree shows that the frequency of using the legrest function was the top node, followed by recline and tilt functions. The overall accuracy of prediction with ten-fold cross validation for discomfort intensity was 79.4%.

CONCLUSIONS

For people who used power wheelchairs equipped with PSFs, correlation analysis and regression modeling provided evidence from the quantitative data that increasing the frequency of using PSFs may decrease wheelchair discomfort. Future studies should include interventions to encourage people to use their PSFs appropriately.

Measure it: proper wheelchair fit is key to ensuring function while protecting skin integrity

The objectives of this article are to help the clinician to better recognize the basic biomechanics of posture, describe the appropriate means to configure a wheelchair to permit proper postural support, and to identify common problems arising from improper wheelchair fit.

Validity and reliability of wheelchair sitting posture measures using Coach's Eye in abled subjects

People in wheelchairs spend a long time in the sitting position and often incur alignment problems resulting in neck and back pain. This study: (1) assessed the validity/reliability of Coach's Eye (CE) smart device application, (2) examined the effect of seat to back support angle adjustments on head, neck, and shoulder posture in the sitting position, and (3) compared changes in cervical rotation at each back support angle. Abled subjects sat in a wheelchair with back support angles positioned at 90°, 100°, and 110°. CE, as well as ImageJ software, was used to analyze three angles: sagittal head angle (SHA), cervical angle (CVA), and shoulder angle (SA). There were highly significant differences for CVA and SA (p < 0.001) among the three seat to back support angles. Validity of CE was examined by correlating CE with ImageJ scores. CE had high validity for all angles (r = 0.99, 0.98, 0.99 respectively, p < 0.001). Inter-rater reliability for SHA, CVA, and SA was high (intraclass correlation coefficient [ICC] ranged from 0.95 to 0.99). Head (CVA) and shoulder (SA) alignment was closest to neutral posture with back support angles set at 110° and 90°, respectively.

Effectiveness of a Wellness Program for Individuals With Spina Bifida and Spinal Cord Injury Within an Integrated Delivery System

OBJECTIVE

To determine whether an evidence-based wellness program for individuals with spina bifida and spinal cord injury would improve health outcomes and patient experience of care, result in a positive return on investment (ROI), and provide evidence for scalability.

DESIGN

Nonrandomized, noncontrolled cohort study; 2 years of enrollment.

SETTING

Academic hospital-based outpatient physiatry clinic partnered with an insurance division within an integrated health care delivery and financing system.

PARTICIPANTS

Individuals (N=69) with spina bifida and spinal cord injury were consented; 4 were excluded (5.7%), and the remaining 65 (94.2%) participated in the intervention.

INTERVENTIONS

Evidence-based wellness program consisting of care coordination from a mobile nurse, patient education, and patient incentives.

MAIN OUTCOME MEASURES

Validated measures of function, mood, quality of life, and perception of care delivery; knowledge of preventable conditions; self-rating of health; and utilization and cost.

RESULTS

Improvements in all main outcome measures were seen after 2 years of enrollment. Although cost in year 1 of enrollment increased because of hospitalizations and the overall ROI was negative, a small positive ROI was seen in year 2 of enrollment.

CONCLUSIONS

Participation in an evidence-based wellness program was associated with improved health and experience of care. Scaling the program to larger numbers may result in an overall positive ROI.

Power Wheelchair Use in Persons With Amyotrophic Lateral Sclerosis: Changes Over Time

The objectives of this study were to survey persons with Amyotrophic Lateral Sclerosis (ALS) at 1 and 6 months after receiving power wheelchairs to determine long-term use, comfort, and function as well as the power wheelchair's impact on daily tasks and quality of life. A 33-question survey and Psychosocial Impact of Assistive Devices Scale (PIADS) were sent 1 month after getting a new power wheelchair; a follow-up survey was sent at 6 months. Based on satisfaction and feature use survey results, at 1 month, 81% of users found the power wheelchair overall comfort to be high, 88% found their overall mobility to be improved, and 95% found it easy to use. Their quality of life increased and pain decreased at 1 and 6 months. According to the PIADS, the power wheelchair gave users increased ability to participate and sense of competence. This study has important results for the ALS community, as it is the first to assess power wheelchair users at 1 and 6 months after power wheelchair procurement. The results demonstrate the impact the power wheelchair has on mobility, psychosocial issues, functional abilities, and quality of life for a person with ALS.

Evaluating the usability of a smartphone virtual seating coach application for powered wheelchair users

The aim of the smartphone virtual seating coach (SVSC) was to provide a personalized reminder/warning system to encourage powered wheelchair users to use their powered seating functions (PSFs) as clinically recommended. This study evaluated the usability of the SVSC system by gathering feedback from five powered wheelchair users and five rehabilitation professionals through questionnaires and interviews. The results indicated that clear and understandable instructions to adjust the PSFs are the most important requirement for SVSC application. The instructions must be intuitive, could benefit from animations or indications of PSFs control buttons so powered wheelchair users can adjust their PSFs immediately and appropriately.

Taking Control: An Exploratory Study of the Use of Tilt-in-Space Wheelchairs in Residential Care

Tilt-in-space (TIS) wheelchairs are common in residential care, but little empirical evidence exists regarding how they are used by residents and staff in these settings. As part of a larger study exploring the use of wheeled mobility in these facilities, we conducted a substudy to examine how TIS wheelchairs are used in practice and to explore the experiences of the residents who use them. We conducted a series of three participant observations and interviews with 6 residents or their family members and interviewed 10 staff. Our analysis identified taking control as the main overarching theme, subsuming two subthemes: promoting comfort and mobilizing to participate. Findings suggest that power TIS wheelchairs enable user control, whereas manual TIS wheelchairs promote staff control. These findings illustrate how TIS wheelchairs may enable or inhibit occupational engagement and suggest that vigilance is necessary to prevent their use as a restraint.

Effect of tilt and recline on ischial and coccygeal interface pressures in people with spinal cord injury

OBJECTIVE

Clinicians commonly recommend that power wheelchair users with spinal cord injury perform wheelchair tilt and recline maneuvers to redistribute seating loads away from the ischial tuberosities. However, ischial pressure reduction may be accompanied by coccygeal pressure increases. Although the coccyx is among the most common sites of pressure ulcers, few studies have reported coccygeal interface pressure. The purpose of this study was to investigate both ischial and coccygeal interface pressures in response to changes in wheelchair tilt and recline angles.

DESIGN

Thirteen power wheelchair users were recruited into this study. Six combinations of wheelchair tilt (15, 25, and 35 degrees) and recline (10 and 30 degrees, corresponding to traditional recline conventions of 100 and 120 degrees, respectively) angles were tested in random order. Each combination was tested with 5 mins of upright sitting, 5 mins of tilt and recline, as well as 5 mins of maximal pressure relief recovery. Peak pressure indices were calculated at the ischial and coccygeal sites.

RESULTS

Ischial pressures monotonically decreased in response to increasing combinations of tilt and recline. Increments of 15 degrees of tilt did not produce significant differences under either recline angle, whereas increments of 25 degrees of tilt produced significant differences under both recline angles. Coccygeal pressures increased in response to the four smallest (of six) combinations of tilt and recline, whereas they decreased in response to the largest two combinations.

CONCLUSIONS

Ischial pressures seemed to be redistributed to the coccyx in response to the four smallest angle combinations and redistributed to the back support in response to the two largest angle combinations. Future work should confirm this pressure redistribution to the back support and determine the back support locations of redistribution.

Perspectives on the evolution of mobile (mHealth) technologies and application to rehabilitation

Individuals with chronic conditions and disabilities who are vulnerable to secondary complications often require complex habilitative and rehabilitative services to prevent and treat these complications. This perspective article reviews the evolution of mHealth technologies and presents insights as to how this evolution informed our development of a novel mHealth system, iMHere (interactive mobile health and rehabilitation), and other technologies, including those used by the Veterans Administration. This article will explain the novel applications of mHealth for rehabilitation and specifically physical therapy. Perspectives on the roles of rehabilitation professionals in the delivery of health care using mHealth systems are included. Challenges to mHealth, including regulatory and funding issues, are discussed. This article also describes how mHealth can be used to improve patient satisfaction and delivery of care and to promote health and wellness.

Development and pilot testing of a kneeling ultralight wheelchair design

"Dynamic wheeled mobility" offers "on the fly" seating adjustments for wheelchair users such that various activities performed throughout the day can be matched by an appropriate seat position. While this has benefits for user participation and health, the added weight in existing dynamic wheelchairs may impact the user's ability to transport the frame, e.g. into cars. Other dynamic features to enable more participation avenues are also desirable. This paper outlines the development of a "kneeling" ultralight wheelchair design that offers dynamic wheeled mobility functionality at a weight that is comparable to many existing ultralight wheelchairs. In addition, the wheelchair's kneeling function allows a lowered seat position to facilitate low-to-the-ground tasks such as floor transfers and other activities where sustained low level reaching may be required (e.g. playing with children, changing a tire, etc.). This paper also describes the development and pilot testing of an end user evaluation protocol designed to validate the wheelchair's functionality and performance. Successful realization and commercialization of the technology would offer a novel product choice for people with mobility disabilities, and that may support daily activities, health, improved quality of life, and greater participation in the community.

Development of intelligent model for personalized guidance on wheelchair tilt and recline usage for people with spinal cord injury: methodology and preliminary report

Wheelchair tilt and recline functions are two of the most desirable features for relieving seating pressure to decrease the risk of pressure ulcers. The effective guidance on wheelchair tilt and recline usage is therefore critical to pressure ulcer prevention. The aim of this study was to demonstrate the feasibility of using machine learning techniques to construct an intelligent model to provide personalized guidance to individuals with spinal cord injury (SCI). The motivation stems from the clinical evidence that the requirements of individuals vary greatly and that no universal guidance on tilt and recline usage could possibly satisfy all individuals with SCI. We explored all aspects involved in constructing the intelligent model and proposed approaches tailored to suit the characteristics of this preliminary study, such as the way of modeling research participants, using machine learning techniques to construct the intelligent model, and evaluating the performance of the intelligent model. We further improved the intelligent model's prediction accuracy by developing a two-phase feature selection algorithm to identify important attributes. Experimental results demonstrated that our approaches held the promise: they could effectively construct the intelligent model, evaluate its performance, and refine the participant model so that the intelligent model's prediction accuracy was significantly improved.

Do tilt-in-space wheelchairs increase occupational engagement: a critical literature review

PURPOSE

A wheelchair can enhance the quality of life of an individual with limited mobility, poor trunk control and stability, by enabling activity and participation and so occupational engagement. High specification wheelchairs which can tilt-in-space enable the position of users to be altered to suit activity and context. Despite tilt-in-space wheelchairs being expensive little is known about their therapeutic value.

METHODS

A critical literature review of the evidence was undertaken to evaluate whether the use of tilt-in-space increases occupational engagement. A wide ranging search strategy identified 170 articles which were screened using inclusion criteria. The eligible literature (n = 6) was analysed thematically using open coding.

RESULTS

The majority of the participants used tilt-in-space but the data was too heterogeneous to combine. Measures of occupational engagement were not used so the therapeutic value could not be assessed.

CONCLUSION

There is a lack of high quality evidence about the therapeutic benefits of tilt-in-space wheelchairs. Given the expense associated with providing these wheelchairs, and the increase in their provision, research is needed to justify provision of high specification wheelchairs to meet the occupational needs of users within the limited resources of health and social care. Implications for Rehabilitation Tilt-in-space wheelchairs. Wheelchairs are an important and essential assistive device for promoting independence and function. Suggests there are benefits for tilt-in-space wheelchairs. Identifies the need for additional large scale research.

Investigation of peak pressure index parameters for people with spinal cord injury using wheelchair tilt-in-space and recline: methodology and preliminary report

The purpose of this study was to determine the effect of the sensel window's location and size when calculating the peak pressure index (PPI) of pressure mapping with varying degrees of wheelchair tilt-in-space (tilt) and recline in people with spinal cord injury (SCI). Thirteen power wheelchair users were recruited into this study. Six combinations of wheelchair tilt (15°, 25°, and 35°) and recline (10° and 30°) were used by the participants in random order. Displacements of peak pressure and center of pressure were extracted from the left side of the mapping system. Normalized PPI was computed for three sensel window dimensions (3 sensels × 3 sensels, 5 × 5, and 7 × 7). At least 3.33 cm of Euclidean displacement of peak pressures was observed in the tilt and recline. For every tilt angle, peak pressure displacement was not significantly different between 10° and 30° recline, while center of pressure displacement was significantly different (P < .05). For each recline angle, peak pressure displacement was not significantly different between pairs of 15°, 25°, and 35° tilt, while center of pressure displacement was significantly different between 15° versus 35° and 25° versus 35°. Our study showed that peak pressure displacement occurs in response to wheelchair tilt and recline, suggesting that the selected sensel window locations used to calculate PPI should be adjusted during changes in wheelchair configuration.

Concept proposal for a detachable exoskeleton-wheelchair to improve mobility and health

Wheelchair use has consequences to quality of life in at least two areas: 1) health issues such as pressure sores and chronic overuse injury; and 2) access problems due to the inaccessible nature of the built and natural environments that are most amenable to upright postures. Even with these concerns, wheelchairs are still the best form of mobility for many people (e.g. they are relatively easy to transfer into and propel). However, wheelchairs are simply not transformative, i.e. they do not allow a person with a disability to attain a level of mobility performance that approaches that of their non-disabled peers, nor do they typically allow for face to face interactions and full participation in the community. Wheelchairs also do not typically support ongoing therapeutic benefits for the user. To address the inadequacy of existing wheelchairs, we are merging two evolving technologies into a coherent new mobility device. The first is dynamic wheeled mobility, which adds significant functionality to conventional wheelchairs through the use of on-the-fly adjustable positioning. The second is powered walking exoskeletons, which enable highly desired standing and walking functions, as well as therapeutic benefits associated with rehabilitation gait training. Unfortunately, exoskeletons have significant usability concerns such as slow speed, limited range, potential to cause skin issues, and difficult transfers. A new concept of docking a detachable exoskeleton to a wheeled frame has been developed to address these issues. The design goal is a single mobility device that not only optimizes daily activities (i.e. wheelchair seating and propulsion with dynamic positioning), but also serves as an easy-to-use rehabilitation tool for therapeutic benefits (i.e. a detachable powered exoskeleton for walking sojourns). This has significant potential benefits for the lives of people with mobility impairments.

Pressure mapping to assess seated pressure distributions and the potential risk for skin ulceration in a population of sledge hockey players and control subjects

PURPOSE

Ice sledge (or sled) hockey is a fast-paced sport that enables individuals with physical disabilities to play ice hockey. As the attraction to the sport continues to rise, the need for developing better equipment and installing preventative measures for injury will become increasingly important. One such injury includes skin pressure ulceration.

METHOD

A total of 26 subjects including active controls and those with spinal cord injury, multiple sclerosis, limb amputation and traumatic brain injury were studied using a pressure mapping device at the 2012 National Disabled Veterans Winter Sports Clinic to determine the risk for skin pressure ulceration and the impact of cushioning and knee angle positioning on seated pressure distributions.

RESULTS

Sledge hockey athletes may be at increased risk for skin pressure ulceration based on seated pressure distribution data. This experiment failed to demonstrate a benefit for specialty cushioning in either group. Interestingly, knee angle positioning, particularly, knee extension significantly lowered the average seated pressures.

CONCLUSIONS

When considering the risk for skin pressure ulceration, knee angle positioning is of particular clinical importance. More research is warranted, specifically targeting novel cushion and sledge designs and larger groups of individuals with sensory loss and severe spinal deformities. Implications for Rehabilitation Ice sledge (or sled) hockey is a fast-paced and growing adaptive sport played at the Paralympic level. Rehabilitation professionals should consider the potential for skin ulceration in this population of athletes. The effects of cushioning used in the sledge design warrants further investigation. Knee angle positioning; particularly, knee extension significantly lowers seated pressures and may reduce the potential for skin ulceration.

Patient and equipment profile for wheelchair seating clinic provision

PURPOSE

To characterise the provision of wheelchair seating both pre- and post-clinical intervention and compare and contrast the two largest diagnostic groups.

METHOD

The case notes of those attending a wheelchair seating clinic for adults over a defined period were reviewed retrospectively. A classification system was devised that delineates between the complexity and type of equipment to gain a better understanding of provision.

RESULTS

146 patients were included; mean age 45 years (SD 16); 53.4% male. The two most prevalent primary medical diagnoses were cerebral palsy (CP) and multiple sclerosis (MS); 48.6% and 20.5%, respectively. The MS group, in comparison to the CP group, were significantly more likely to be older, new to seating provision, have been seen more recently, have a powered wheelchair, self-propel their manual wheelchair, have low rather than high complexity equipment and have their equipment changed following assessment.

CONCLUSIONS

The equipment classification system will allow results from different studies to be readily compared. The results for those with CP and MS reflect the respective stable and progressive nature of these conditions. Referrals for those with MS should be prioritised. Wheelchair seating users with MS should be reassessed ∼18 months after provision.

IMPLICATIONS FOR REHABILITATION

A detailed classification of wheelchair seating equipment based on a recognised standard vocabulary, such as the one proposed, is required to gain a better understanding of provision. Wheelchair seating equipment budget and staffing levels should reflect the diagnostic make up of a service's patient population. Referrals for people with MS should be prioritised as their current wheelchair seating provision is more likely not to be meeting their needs. People with MS should have a clinical review 18 months after wheelchair seating provision.

Wheelchair tilt-in-space and recline does not reduce sacral skin perfusion as changing from the upright to the tilted and reclined position in people with spinal cord injury

OBJECTIVE

To investigate the effect of various wheelchair tilt-in-space and recline angles on sacral skin perfusion in wheelchair users with spinal cord injury.

DESIGN

Repeated-measures, intervention and outcomes measure design.

SETTING

University research laboratory.

PARTICIPANTS

Power wheelchair users with spinal cord injury (N=11).

INTERVENTIONS

Six protocols of various wheelchair tilt-in-space and recline angles were randomly assigned to the participants: (1) 15° tilt-in-space and 100° recline, (2) 25° tilt-in-space and 100° recline, (3) 35° tilt-in-space and 100° recline, (4) 15° tilt-in-space and 120° recline, (5) 25° tilt-in-space and 120° recline, and (6) 35° tilt-in-space and 120° recline. Each protocol consisted of a 5-minute upright sitting and a 5-minute tilted and reclined period.

MAIN OUTCOME MEASURES

Skin perfusion over the sacrum (midpoint between the right posterior superior iliac spine and the adjacent spinous process) and right ischial tuberosity was measured using laser Doppler flowmetry.

RESULTS

Sacral skin perfusion did not show a significant difference in all 6 protocols of various tilt-in-space and recline angles when changing from an upright to a tilted and reclined position (not significant). However, as previously reported, skin perfusion over the ischial tuberosity showed a significant increase at 15°, 25°, and 35° tilt-in-space when combined with 120° recline and at 35° tilt-in-space when combined with 100° recline (P<.008).

CONCLUSIONS

Our results indicate that wheelchair tilt-in-space and recline enhances skin perfusion over the ischial tuberosities without reducing sacral skin perfusion when changing from an upright to a tilted and reclined position.

Effect of durations of wheelchair tilt-in-space and recline on skin perfusion over the ischial tuberosity in people with spinal cord injury

OBJECTIVE

To compare the efficacy of various durations of wheelchair tilt-in-space and recline on enhancing skin perfusion over the ischial tuberosity in people with spinal cord injury (SCI).

DESIGN

Repeated-measures, intervention and outcomes measure design.

SETTING

University research laboratory.

PARTICIPANTS

Power wheelchair users with SCI (N=9).

INTERVENTIONS

Three protocols of various durations (3min, 1min, and 0min) of wheelchair tilt-in-space and recline were randomly assigned to the participants. Each protocol consisted of a baseline 15-minute sitting, a duration of 0- to 3-minute reclined and tilted, a second 15-minute sitting, and a 5-minute recovery. The position at the baseline and the second sitting was no tilt/recline of the participant and at the reclined and tilted and recovery was at 35° tilt-in-space and 120° recline.

MAIN OUTCOME MEASURES

Skin perfusion response to tilt and recline was assessed by laser Doppler and was normalized to mean skin perfusion at the baseline sitting.

RESULTS

The results showed that mean skin perfusion during recovery at the 3-minute duration was significantly higher than that at the 1-minute duration (P<.017) and mean skin perfusion was not significantly different between the 1-minute and 0-minute durations (not significant). Skin perfusion during the second sitting was significantly higher at the 3-minute duration than at the 1-minute and 0-minute durations (P<.017).

CONCLUSIONS

Our findings suggest that performing the 3-minute duration of wheelchair tilt-in-space and recline is more effective than the 1-minute duration in enhancing skin perfusion of weight-bearing soft tissues.

An impact assessment and critical appraisal of the ISO standard for wheelchair vocabulary

Wheelchairs are, for users, a primary means of mobility and an important means of performing activities of daily living. A common, accepted vocabulary is required to support and foster evidence-based practice and communication amongst professionals and with users. The international standard for wheelchair vocabulary, ISO 7176-26:2007, specifies terms and definitions with the purpose of eliminating confusion from the duplication or inappropriate use of terms. The aim of this study was to assess its impact and, based on that assessment, critically appraise the standard. Two databases were searched returning 189 and 283 unique articles with wheelchair in the title published between 2004-2006 and 2009-2011 respectively. Compliance, based on title and abstract usage, was poor, ranging from 0 to 50% correct usage, with no significant difference between pre- and post-publication. A review of prescription forms found only 9% correct usage. A survey of NHS wheelchair managers found that only 30% were positive that they had a copy despite 67% agreeing that the standard is important. The ISO wheelchair vocabulary standard was found not to be achieving its stated purpose. It is recommended that it be revised taking into account the findings of this study including the need for targeted dissemination and increased awareness.

Targeted preventive care may be needed for adults with congenital spine anomalies

OBJECTIVE

To compare hospitalizations caused by spina bifida-sensitive conditions, ambulatory care-sensitive conditions in adults with spina bifida and in the general population, our aim was to provide information about whether preventive health efforts already underway in the hospitalized general population are adequate for preventive care in spina bifida and congenital spine anomalies.

DESIGN

Retrospective secondary data analysis.

PATIENTS (OR PARTICIPANTS)

Records of hospitalized individuals who were 18 years of age and older.

METHODS

Comparison between individuals hospitalized with spina bifida and the general population using data from the California State Inpatient Database from the Healthcare Cost and Utilization Project for 2004 of adults.

MAIN OUTCOME MEASUREMENTS

Prevalence of spina bifida-sensitive conditions and ambulatory care-sensitive conditions as reason for hospitalization and 30-day readmission.

RESULTS

As compared with the general population, persons with spina bifida who were hospitalized in 2004 had a significantly greater number of hospitalizations, number of hospitalizations associated with both spina bifida-sensitive conditions and ambulatory care-sensitive conditions, and number of 30-day readmissions. Stratification by age shows that the admissions for spina bifida sensitive conditions were greater in persons with spina bifida than in the general population for all age groups. In contrast, only in the youngest age group did those with spina bifida experience greater hospitalizations for ambulatory care-sensitive conditions.

CONCLUSIONS

This study provides further evidence that persons with spina bifida have hospitalizations that are beyond what the general population experiences. These conditions may be potentially preventable with appropriate ambulatory care. This group also had a greater risk for readmission within 30 days of discharge from their last hospitalization. More research is needed on the efficacy of programs aimed at prevention of these conditions.

Distinct tilting behaviours with power tilt-in-space systems

PURPOSE

To characterise the use of tilt-in-space systems and to form recommendations for tilt prescription and training based upon its use.

METHOD

Wheelchair occupancy and seat position of 45 full-time power wheelchair users were monitored for 1-2 weeks using an accelerometer, occupancy switch and data logger. Demographics, pressure ulcer history, functional and physical presentations of their disability, and sensation were also documented.

RESULTS

Participants spent 12.1 h in their wheelchairs daily, with a median typical position of 8° (0°-47°). The median participant tilted every 27 min (0.1-16.6 tilts per occupancy hour). Pressure-relieving tilts (i.e. a tilt ≥30° for ≥1 min) were performed, on average, once every 10 h (0-2.2/h). Participants spent 19% of their seated time tilted past 15°. Seventeen participants utilised the tilt feature frequently and spent >20% of the time in multiple positions. The remaining participants sat in a single tilt range for >80% of the time.

CONCLUSIONS

Given the limited pressure relief compliance, alternative approaches to pressure relief and improved training may be needed for some clients. Wheelchair design and prescriptions may also need to reflect participants' preferences for sitting in small and medium tilts and changing position frequently.

Measuring the effect of incremental angles of wheelchair tilt on interface pressure among individuals with spinal cord injury

STUDY DESIGN

This study was a repeated measures study.

OBJECTIVES

The objective was to systematically measure the relative reduction in interface pressure (IP) at the ischial tuberosities (IT) and sacrum through 10° increments of tilt in a manual wheelchair among individuals with motor complete spinal cord injury (SCI).

SETTING

This study was carried out in Manitoba, Canada.

METHODS

A total of 18 adults with ASIA A or B level of injury were recruited through an out-patient SCI clinic. Using a standardized protocol, participants were tilted in 10° increments between 0° and 50°, and IP readings were obtained at the IT and sacrum using pressure mapping technology. Relative pressure reduction from baseline was calculated and compared between tilt angles.

RESULTS

Tilt angle had a highly significant effect on pressure reduction at the IT (P=0.000) and the cosine relationship between these variables was expressed as quadratic. Reduction in sacral pressure did not occur until 30° tilt, with increased loading at smaller tilt angles. Pressure reduction at the IT and sacrum was not significantly different for tetraplegic and paraplegic participants.

CONCLUSION

Small tilt angles are more suitable for postural control than pressure management. A minimum tilt of 30° is required to initiate unloading the sacrum and to achieve a clinically important reduction in pressure at the IT. Larger tilt angles resulted in more substantial pressure reduction than previously reported. Tilt-in-space appears to have similar benefits for individuals with paraplegia and tetraplegia.

Development of intelligent model to determine favorable wheelchair tilt and recline angles for people with spinal cord injury

Machine-learning techniques have found widespread applications in bioinformatics. Such techniques provide invaluable insight on understanding the complex biomedical mechanisms and predicting the optimal individualized intervention for patients. In our case, we are particularly interested in developing an individualized clinical guideline on wheelchair tilt and recline usage for people with spinal cord injury (SCI). The current clinical practice suggests uniform settings to all patients. However, our previous study revealed that the response of skin blood flow to wheelchair tilt and recline settings varied largely among patients. Our finding suggests that an individualized setting is needed for people with SCI to maximally utilize the residual neurological function to reduce pressure ulcer risk. In order to achieve this goal, we intend to develop an intelligent model to determine the favorable wheelchair usage to reduce pressure ulcers risk for wheelchair users with SCI. In this study, we use artificial neural networks (ANNs) to construct an intelligent model that can predict whether a given tilt and recline setting will be favorable to people with SCI based on neurological functions and SCI injury history. Our results indicate that the intelligent model significantly outperforms the traditional statistical approach in accurately classifying favorable wheelchair tilt and recline settings. To the best of our knowledge, this is the first study using intelligent models to predict the favorable wheelchair tilt and recline angles. Our methods demonstrate the feasibility of using ANN to develop individualized wheelchair tilt and recline guidance for people with SCI.