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.

Changes in Internet Use Over Time Among Individuals with Traumatic Spinal Cord Injury.

OBJECTIVE: To investigate the changes in total internet and mobile internet use over time and determine how demographic characteristics are related to changes in internet and mobile internet use among individuals with spinal cord injury (SCI). DESIGN: Cross-sectional analysis of a multicenter cohort study. SETTING: National SCI Database. PARTICIPANTS: Individuals with traumatic SCI with follow-up data collected between 2012 and 2018 (N=13,622). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Proportion of sample reporting internet use at all or through a mobile device over time and specifically in 2018. RESULTS: The proportion of internet users increased from 77.7% in 2012 to 88.1% in 2018. Older participants (P<.001); those with lower annual income (P<.001), less education (P<.001), non-White race or Hispanic ethnicity (P<.001), or motor incomplete tetraplegia (P=.004); and men (P=.035) were less likely to use the internet from 2012-2018. By 2018, there were no longer differences in internet use based on race and ethnicity (P=.290) or sex (P=.066). Mobile internet use increased each year (52.4% to 87.7% of internet users from 2012-2018), with a participant being 13.7 times more likely to use mobile internet in 2018 than 2012. Older age (P<.001), income <$50,000 (P<.001), high school diploma or less (P=.011), or non-Hispanic White race/ethnicity (P=.001) were associated with less mobile internet use over time. By 2018, there were no differences in mobile internet use by education (P=.430), and only participants with incomes >$75,000 per year had greater odds of mobile internet use (P=.016). CONCLUSIONS: Disparities associated with internet access are decreasing likely as a result of mobile device use. Increased internet access offers an important opportunity to provide educational and training materials to frequently overlooked groups of individuals with SCI.

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.

Toward Improving the Prediction of Functional Ambulation After Spinal Cord Injury Through the Inclusion of Limb Accelerations During Sleep and Personal Factors.

OBJECTIVE: To determine if functional measures of ambulation can be accurately classified using clinical measures; demographics; personal, psychosocial, and environmental factors; and limb accelerations (LAs) obtained during sleep among individuals with chronic, motor incomplete spinal cord injury (SCI) in an effort to guide future, longitudinal predictions models. DESIGN: Cross-sectional, 1-5 days of data collection. SETTING: Community-based data collection. PARTICIPANTS: Adults with chronic (>1 year), motor incomplete SCI (N=27). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Ambulatory ability based on the 10-m walk test (10MWT) or 6-minute walk test (6MWT) categorized as nonambulatory, household ambulator (0.01-0.44 m/s, 1-204 m), or community ambulator (>0.44 m/s, >204 m). A random forest model classified ambulatory ability using input features including clinical measures of strength, sensation, and spasticity; demographics; personal, psychosocial, and environmental factors including pain, environmental factors, health, social support, self-efficacy, resilience, and sleep quality; and LAs measured during sleep. Machine learning methods were used explicitly to avoid overfitting and minimize the possibility of biased results. RESULTS: The combination of LA, clinical, and demographic features resulted in the highest classification accuracies for both functional ambulation outcomes (10MWT=70.4%, 6MWT=81.5%). Adding LAs, personal, psychosocial, and environmental factors, or both increased the accuracy of classification compared with the clinical/demographic features alone. Clinical measures of strength and sensation (especially knee flexion strength), LA measures of movement smoothness, and presence of pain and comorbidities were among the most important features selected for the models. CONCLUSIONS: The addition of LA and personal, psychosocial, and environmental features increased functional ambulation classification accuracy in a population with incomplete SCI for whom improved prognosis for mobility outcomes is needed. These findings provide support for future longitudinal studies that use LA; personal, psychosocial, and environmental factors; and advanced analyses to improve clinical prediction rules for functional mobility 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.

Effectiveness of Group Wheelchair Maintenance Training for People with Spinal Cord Injury: A Randomized Controlled Trial.

OBJECTIVE: To assess the effectiveness of group wheelchair maintenance training and investigate participant characteristics associated with responsiveness to training. DESIGN: Randomized controlled trial with an immediate group and a waitlist control group (WLCG) who received the intervention after a 6-month delay. SETTING: Four Spinal Cord Injury Model Systems Centers. PARTICIPANTS: Manual (MWC; n=80) and power wheelchair (PWC; n=67) users with spinal cord injury (N=147). INTERVENTIONS: Two 90-minute structured wheelchair maintenance training program classes with 12-20 people per class and separate classes for MWC and PWC users. Each class included in-person hands-on demonstrations and practice of wheelchair maintenance. MAIN OUTCOME MEASURES: Separate analysis was completed for MWC and PWC users using the Wheelchair Maintenance Training Questionnaire (WMT-Q) capacity (ability to complete), performance (frequency of completion) and knowledge at baseline, 1 month, 6 months, 6 months pretraining (WLCG only), and 1 year (immediate only). RESULTS: After the intervention, participants in both the immediate and WLCG improved in maintenance capacity (MWC and PWC, P<.001) and performance (MWC and PWC, P<.001) with training. Only PWC users improved knowledge of wheelchair maintenance (P<.001). For both WLCGs (MWC and PWC), there was no difference between the 6-month pretraining time point and baseline. MWC users who responded to training had lower WMT-Q scores for all domains, whereas this was only the case for knowledge for PWC users. CONCLUSIONS: Group wheelchair skills training is effective at improving capacity to complete maintenance and performance of maintenance activities for MWC and PWC users, even in a cohort of experienced wheelchair users. For MWC users, improvements were tied to lower WMT-Q scores at baseline, whereas PWC users improved in capacity and performance independent of baseline score. Delivering this training in a structured group format has a lower cost, which might improve adoption into clinical practice.

Efficacy of a Remote Train-the-Trainer Model for Wheelchair Skills Training Administered by Clinicians: A Cohort Study With Pre- vs Posttraining Comparisons.

OBJECTIVE: To test the hypotheses that remote training improves trainer confidence and when these trainers train others the capacity and confidence of the trainees improves. DESIGN: Cohort study with pre- vs posttraining comparisons. SETTING: Four spinal cord injury model systems centers. PARTICIPANTS: Convenience sample of 7 clinician trainers and 19 able-bodied trainees (N=26). INTERVENTIONS: Part 1 focused on trainer skill acquisition with self-study of the Wheelchair Skills Program Manual and instructional videos focused on motor learning, spotting, and 10 intermediate and advanced wheelchair skills. Trainers practiced in pairs, receiving asynchronous feedback on video recordings from a remote instructor. Part 2 included additional video modules targeted at "how to" assess and train others in 4 wheelchair skills: gets over obstacle, ascends low curb, ascends high curb with caregiver assistance, and performs stationary wheelie. Upon completion, the trainers each provided 1:1 in-person training for 2-3 trainees. MAIN OUTCOME MEASURES: Trainer confidence was assessed using the Self-Efficacy on Assessing, Training, and Spotting Test for Manual Wheelchairs. Trainee capacity ("Can you do it?") and confidence ("How confident are you?") were evaluated using the Wheelchair Skills Test Questionnaire (WST-Q). RESULTS: Trainer confidence increased for assessment (P=.003) and training (P=.002) but not spotting (P=.056). Trainee 4-item median (interquartile range) WST-Q scores significantly increased with training for capacity (13% [6-31] to 88% [75-88], P<.001) and confidence (13% [0-31] to 88% [81-100], P<.001). CONCLUSIONS: Remote training improves trainers' confidence with respect to wheelchair skills testing and training and the wheelchair skills capacity and confidence of their trainees.

Characterizing the Experience of Spasticity after Spinal Cord Injury: A National Survey Project of the Spinal Cord Injury Model Systems Centers.

OBJECTIVE: To characterize the qualities that individuals with spinal cord injury (SCI) associate with their experience of spasticity and to describe the relationship between spasticity and perceived quality of life and the perceived value of spasticity management approaches. DESIGN: Online cross-sectional survey. SETTING: Multicenter collaboration among 6 Spinal Cord Injury Model Systems hospitals in the United States. PARTICIPANTS: Individuals with SCI (N=1076). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Qualities of Spasticity Questionnaire, modified Spinal Cord Injury-Spasticity Evaluation Tool (mSCI-SET), and the modified Patient-Reported Impact of Spasticity Measure (mPRISM). RESULTS: Respondents indicated that spasms most often occurred in response to movement-related triggering events. However, spontaneous spasms (ie, no triggering event) were also reported to be among the most common types. Frequency of spasms appears to decline with age. The highest frequency of spasms was reported by 56% of respondents aged <25 years and by only 28% of those >55 years. Stiffness associated with spasticity was reported to be more common than spasms (legs, 65% vs 54%; trunk, 33% vs 18%; arms, 26% vs 15%). Respondents reported negative effects of spasticity more commonly than positive effects. Based on their association with negative scores on the mSCI-SET and the mPRISM, the 5 most problematic experiences reported were stiffness all day, interference with sleep, painful spasms, perceived link between spasticity and pain, and intensification of pain before a spasm. Respondents indicated spasticity was improved more by stretching (48%) and exercise (45%) than by antispasmodics (38%). CONCLUSIONS: The experience of spasticity after SCI is complex and multidimensional, with consequences that affect mobility, sleep, comfort, and quality of life. Stiffness, rather than spasms, appears to be the most problematic characteristic of spasticity. Physical therapeutic interventions to treat spasticity warrant in-depth investigation.

Limb accelerations during sleep are related to measures of strength, sensation, and spasticity among individuals with spinal cord injury.

BACKGROUND: To evaluate the relationship between measures of neuromuscular impairment and limb accelerations (LA) collected during sleep among individuals with chronic spinal cord injury (SCI) to provide evidence of construct and concurrent validity for LA as a clinically meaningful measure. METHODS: The strength (lower extremity motor score), sensation (summed lower limb light touch scores), and spasticity (categorized lower limb Modified Ashworth Scale) were measured from 40 adults with chronic (≥ 1 year) SCI. Demographics, pain, sleep quality, and other covariate or confounding factors were measured using self-report questionnaires. Each participant then wore ActiGraph GT9X Link accelerometers on their ankles and wrist continuously for 1-5 days to measure LA from movements during sleep. Regression models with built-in feature selection were used to determine the most relevant LA features and the association to each measure of impairment. RESULTS: LA features were related to measures of impairment with models explaining 69% and 73% of the variance (R²) in strength and sensation, respectively, and correctly classifying 81.6% (F1-score = 0.814) of the participants into spasticity categories. The most commonly selected LA features included measures of power and frequency (frequency domain), movement direction (correlation between axes), consistency between movements (relation to recent movements), and wavelet energy (signal characteristics). Rolling speed (change in angle of inclination) and movement smoothness (median crossings) were uniquely associated with strength. When LA features were included, an increase of 72% and 222% of the variance was explained for strength and sensation scores, respectively, and there was a 34% increase in spasticity classification accuracy compared to models containing only covariate features such as demographics, sleep quality, and pain. CONCLUSION: LA features have shown evidence of having construct and concurrent validity, thus demonstrating that LA are a clinically-relevant measure related to lower limb strength, sensation, and spasticity after SCI. LA may be useful as a more detailed measure of impairment for applications such as clinical prediction models for ambulation.

A Cross-Sectional Study to Investigate the Effects of Perceived Discrimination in the Health Care Setting on Pain and Depressive Symptoms in Wheelchair Users With Spinal Cord Injury.

OBJECTIVES: In a sample of wheelchair users with spinal cord injury (SCI), the objectives were to investigate which participant characteristics are associated with greater perceived discrimination in the health care setting, and how such discrimination relates to health outcomes of pain and depressive symptoms. DESIGN: Survey, cross-sectional. SETTING: Spinal Cord Injury Model Systems (SCIMS) Center. PARTICIPANTS: Full-time wheelchair users with SCI from 9 SCIMS centers (N=410), with data collected between 2011 and 2016. INTERVENTIONS: N/A. MAIN OUTCOMES: A 7-item questionnaire inquiring about perceived discrimination by hospital staff, self-reported pain severity over the past month using a 0-10 Numeric Rating Scale, and depressive symptoms using the 2-question Patient Health Questionnaire screener. RESULTS: Participants who were black or from the lowest income group were more likely to report experiencing more discrimination than those who were white or from the highest income group, respectively (incidence rate ratio=2.2-2.6, P<.01). Those who reported more perceived discrimination had greater risk of severe pain compared to no pain (relative risk [RR]=1.11; 95% confidence interval [95% CI], 1.01-1.23; P<.05), mild depressive symptoms (RR=1.09; 95% CI, 1.02-1.17; P<.05), and severe depressive symptoms (RR=1.12; 95% CI, 1.04-1.21; P<.05) compared to no symptoms. CONCLUSIONS: Wheelchair users with SCI who were from more disadvantaged groups (black, lower income levels) reported experiencing more discrimination in their health care setting. Furthermore, those who reported more discrimination were more likely to report worse mental and physical health outcomes. Attempts to reduce discrimination in health care settings may lead to better outcomes for people with SCI. These observations were correlational and not causal; a prospective analysis is necessary to prove causation. Future investigations should further explore the effect of discrimination on the many facets of living with an SCI.

Gait Training in Acute Spinal Cord Injury Rehabilitation-Utilization and Outcomes Among Nonambulatory Individuals: Findings From the SCIRehab Project.

OBJECTIVES: To investigate the relation of gait training (GT) during inpatient rehabilitation (IPR) to outcomes of people with traumatic spinal cord injury (SCI). DESIGN: Prospective observational study using the SCIRehab database. SETTING: Six IPR facilities. PARTICIPANTS: Patients with new SCI (N=1376) receiving initial rehabilitation. INTERVENTIONS: Patients were divided into groups consisting of those who did and did not receive GT. Patients were further subdivided based on their primary mode of mobility as measured by the FIM. MAIN OUTCOME MEASURES: Pain rating scales, Patient Health Questionnaire Mood Subscale, Satisfaction With Life Scale, and Craig Handicap Assessment and Reporting Technique (CHART). RESULTS: Nearly 58% of all patients received GT, including 33.3% of patients who were primarily using a wheelchair 1 year after discharge from IPR. Those who used a wheelchair and received GT, received significantly less transfer and wheeled mobility training (P<.001). CHART physical independence (P=.002), mobility (P=.024), and occupation (P=.003) scores were significantly worse in patients who used a wheelchair at 1 year and received GT, compared with those who used a wheelchair and did not receive GT in IPR. Older age was also a significant predictor of worse participation as measured by the CHART. CONCLUSIONS: A significant percentage of individuals who are not likely to become functional ambulators are spending portions of their IPR stays performing GT, which is associated with less time allotted for other functional interventions. GT in IPR was also associated with participation deficits at 1 year for those who used a wheelchair, implying the potential consequences of opportunity costs, pain, and psychological difficulties of receiving unsuccessful GT. Clinicians should consider these data when deciding to implement GT during initial IPR.

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

OBJECTIVES: To determine the efficacy of a web-based transfer training module at improving transfer technique across 3 groups: web-based training, in-person training (current standard of practice), and a waitlist control group (WLCG); and secondarily, to determine subject factors that can be used to predict improvements in transfer ability after training. DESIGN: Randomized controlled trials. SETTING: Summer and winter sporting events for disabled veterans. PARTICIPANTS: A convenience sample (N=71) of manual and power wheelchair users who could transfer independently. INTERVENTIONS: An individualized, in-person transfer training session or a web-based transfer training module. The WLCG received the web training at their follow-up visit. MAIN OUTCOME MEASURE: Transfer Assessment Instrument (TAI) part 1 score was used to assess transfers at baseline, skill acquisition immediately posttraining, and skill retention after a 1- to 2-day follow-up period. RESULTS: The in-person and web-based training groups improved their median (interquartile range) TAI scores from 7.98 (7.18-8.46) to 9.13 (8.57-9.58; P<.01), and from 7.14 (6.15-7.86) to 9.23 (8.46-9.82; P<.01), respectively, compared with the WLCG that had a median score of 7.69 for both assessments (baseline, 6.15-8.46; follow-up control, 5.83-8.46). Participants retained improvements at follow-up (P>.05). A lower initial TAI score was found to be the only significant predictor of a larger percent change in TAI score after receiving training. CONCLUSIONS: Transfer training can improve technique with changes retained within a short follow-up window, even among experienced wheelchair users. Web-based transfer training demonstrated comparable improvements to in-person training. With almost half of the United States population consulting online resources before a health care professional, web-based training may be an effective method to increase knowledge translation.

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.

Sensitivity of the SCI-FI/AT in Individuals With Traumatic Spinal Cord Injury.

OBJECTIVE: To examine the ability of the Spinal Cord Injury-Functional Index/Assistive Technology (SCI-FI/AT) measure to detect change in persons with spinal cord injury (SCI). DESIGN: Multisite longitudinal (12-mo follow-up) study. SETTING: Nine SCI Model Systems programs. PARTICIPANTS: Adults (N=165) with SCI enrolled in the SCI Model Systems database. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: SCI-FI/AT computerized adaptive test (CAT) (Basic Mobility, Self-Care, Fine Motor Function, Wheelchair Mobility, and/or Ambulation domains) completed at discharge from rehabilitation and 12 months after SCI. For each domain, effect size estimates and 95% confidence intervals were calculated for subgroups with paraplegia and tetraplegia. RESULTS: The demographic characteristics of the sample were as follows: 46% (n=76) individuals with paraplegia, 76% (n=125) male participants, 57% (n=94) used a manual wheelchair, 38% (n=63) used a power wheelchair, 30% (n=50) were ambulatory. For individuals with paraplegia, the Basic Mobility, Self-Care, and Ambulation domains of the SCI-FI/AT detected a significantly large amount of change; in contrast, the Fine Motor Function and Wheelchair Mobility domains detected only a small amount of change. For those with tetraplegia, the Basic Mobility, Fine Motor Function, and Self-Care domains detected a small amount of change whereas the Ambulation item domain detected a medium amount of change. The Wheelchair Mobility domain for people with tetraplegia was the only SCI-FI/AT domain that did not detect significant change. CONCLUSIONS: SCI-FI/AT CAT item banks detected an increase in function from discharge to 12 months after SCI. The effect size estimates for the SCI-FI/AT CAT vary by domain and level of lesion. Findings support the use of the SCI-FI/AT CAT in the population with SCI and highlight the importance of multidimensional functional measures.

Longitudinal Prediction of Quality-of-Life Scores and Locomotion in Individuals With Traumatic Spinal Cord Injury.

OBJECTIVES: To examine (1) differences in quality-of-life scores for groups based on transitions in locomotion status at 1, 5, and 10 years postdischarge in a sample of people with spinal cord injury (SCI); and (2) whether demographic factors and transitions in locomotion status can predict quality-of-life measures at these time points. DESIGN: Retrospective case study of the National SCI Database. SETTING: Model SCI Systems Centers. PARTICIPANTS: Individuals with SCI (N=10,190) from 21 SCI Model Systems Centers, identified through the National SCI Model Systems Centers database between the years 1985 and 2012. Subjects had FIM (locomotion mode) data at discharge and at least 1 of the following: 1, 5, or 10 years postdischarge. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: FIM-locomotion mode; Severity of Depression Scale; Satisfaction With Life Scale; and Craig Handicap Assessment and Reporting Technique. RESULTS: Participants who transitioned from ambulation to wheelchair use reported lower participation and life satisfaction, and higher depression levels (P<.05) than those who maintained their ambulatory status. Participants who transitioned from ambulation to wheelchair use reported higher depression levels (P<.05) and no difference for participation (P>.05) or life satisfaction (P>.05) compared with those who transitioned from wheelchair to ambulation. Demographic factors and locomotion transitions predicted quality-of-life scores at all time points (P<.05). CONCLUSIONS: The results of this study indicate that transitioning from ambulation to wheelchair use can negatively impact psychosocial health 10 years after SCI. Clinicians should be aware of this when deciding on ambulation training. Further work to characterize who may be at risk for these transitions is needed.

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.

Transfer Technique Is Associated With Shoulder Pain and Pathology in People With Spinal Cord Injury: A Cross-Sectional Investigation.

OBJECTIVES: To evaluate how transfer technique and subject characteristics relate to ultrasound measures of shoulder soft tissue pathology and self-reported shoulder pain during transfers in a sample of wheelchair users with spinal cord injury (SCI). DESIGN: Cross-sectional observational study. SETTING: Research laboratory, national and local veterans' wheelchair sporting events. PARTICIPANTS: A convenience sample of wheelchair users (N=76) with nonprogressive SCI. Participants were aged >18 years, >1 year postinjury, and could complete repeated independent wheelchair transfers without the use of their leg muscles. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Transfer pain items from the Wheelchair User's Shoulder Pain Index; transfer technique assessed using the Transfer Assessment Instrument (TAI); and shoulder pathology markers examined using the Ultrasound Shoulder Pathology Rating Scale (USPRS). RESULTS: Better transfer technique (higher TAI) correlated with less injury (lower USPRS) (partial η(2)=.062, P<.05) and less pain during transfers (partial η(2)=.049, P<.10). Greater age was the strongest predictor of greater pathology (USPRS total: partial η(2)=.225, supraspinatus grade: partial η(2)=.174, P<.01). An interaction between technique and weight was found (P<.10): participants with lower body weights showed a decrease in pathology markers with better transfer technique (low weight: R(2)=.422, P<.05; middle weight: R(2)=.200, P<.01), while those with higher weight showed little change with technique (R(2)=.018, P>.05). CONCLUSIONS: Participants with better transfer technique exhibited less shoulder pathology and reported less pain during transfers. The relationship between technique and pathology was strongest in lower-weight participants. While causation cannot be proven because of study design, it is possible that using a better transfer technique and optimizing body weight could reduce the incidence of shoulder pathology and pain.

Type and Frequency of Reported Wheelchair Repairs and Related Adverse Consequences Among People With Spinal Cord Injury.

OBJECTIVE: To investigate the frequency and types of wheelchair repairs and associated adverse consequences. DESIGN: Convenience cross-sectional sample survey. SETTING: Nine Spinal Cord Injury Model Systems Centers. PARTICIPANTS: People with spinal cord injury who use a wheelchair >40h/wk (N=591). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Number of repairs needed and resulting adverse consequences, number and types of repairs completed, and location where main repair was completed in the previous 6 months. RESULTS: There were 591 participants responded to the survey, 63.8% (377/591) of them needed ≥1 repair; of these, 27.6% (104/377) experienced ≥1 adverse consequence, including 18.2% (69/377) individuals who were stranded. Of those who needed repairs, 6.9% did not have them completed (26/377). Repairs completed on the wheels and casters were the most frequent repair to manual wheelchairs, whereas repairs to the electrical and power and control systems were the most frequent type of repair on power wheelchairs. Forty percent (79/201) of manual wheelchair users reported completing repairs at home themselves compared with 14% (21/150) of power wheelchair users. Twelve percent of the variance in the odds of facing an adverse consequence because of a wheelchair breakdown can be described as a function of occupation, funding source, and type of wheelchair. CONCLUSIONS: Wheelchair repairs are highly prevalent. There are differences in types of repairs and who completes the repairs based on the type of wheelchair. Wheelchair breakdowns result in adverse consequences for users, and there is a deficit between repairs needed and those completed, highlighting the need for interventions that address these problems.

Effectiveness of Group Wheelchair Skills Training for People With Spinal Cord Injury: A Randomized Controlled Trial.

OBJECTIVE: To assess the effectiveness of group wheelchair skills training to elicit improvements in wheelchair skills. DESIGN: Randomized double-blinded controlled trial. SETTING: Four Spinal Cord Injury Model Systems Centers. PARTICIPANTS: Manual wheelchair users with spinal cord injury (N=114). INTERVENTION: Six 90-minute group Wheelchair Skills Training Program (WSTP) classes or two 1-hour active control sessions with 6 to 10 people per group. MAIN OUTCOME MEASURES: Baseline (t1) and 1-month follow-up (t2) Wheelchair Skills Test Questionnaire (WST-Q) (Version 4.2) for capacity and performance and Goal Attainment Scale (GAS) score. RESULTS: Follow-up was completed by 79 participants (WSTP: n=36, active control: n=43). No differences were found between missing and complete cases. Many users were highly skilled at baseline with a WST-Q capacity interquartile range of 77% to 97%. There were no differences between groups at baseline in WST-Q measures or demographics. Compared with the active control group, the WSTP group improved in WST-Q capacity advanced score (P=.02) but not in WST-Q capacity or WST-Q performance total scores (P=.068 and P=.873, respectively). The average GAS score (0% at t1) for the WSTP group at t2 was 65.6%±34.8%. Higher GAS scores and WST-Q capacity scores were found for those who attended more classes and had lower baseline skills. CONCLUSIONS: Group training can improve advanced wheelchair skills capacity and facilitate achievement of individually set goals. Lower skill levels at baseline and increased attendance were correlated with greater improvement.