RESNA position on the application of dynamic seating.

Dynamic Seating is an intervention used as a part of a manual or power wheelchair to provide movement against resistance in response to client force. This technology can be used for various clinical applications including preventing client injury and equipment breakage; dissipating extensor forces; providing movement for sensory input, calming, and increased alertness; increasing muscle strength, trunk and head control; and other medical benefits. The purpose of this RESNA Position Paper is to provide a definition for this technology in relation to other seating and wheeled mobility technologies as well as present clinical indicators for this seating intervention including literature to substantiate these claims. Although more recent and stronger evidence is needed, existing research does support the application of dynamic seating in numerous clinical scenarios.

Wheelchair Seated Posture and Health Outcomes of Older Veterans in Community Living Centers.

PURPOSE: Nursing home residents sit in wheelchairs (WCs) for extended periods, often with slumped posture. They often experience pneumonia, pressure ulcers, and pain. This study described WC seated posture with its selected predictors and outcomes in the nursing home environment, throughout the daytime hours of 1 day. DESIGN AND METHODS: This observational study (n = 45) in two Veterans Administration Community Living Centers introduced a new measure of WC fit and described WC seated posture of older Veterans, with selected predictors and outcomes. FINDINGS: Wheelchair seated posture was predicted by cognitive status, WC fit, WC skills, and duration of sitting, but not by level of sitting ability. Poor posture measured by the Seated Posture Scale was associated with pain. Highest interface pressures measurable were seen in peak pressure index (PPI = 200 mm Hg), indicating risk of pressure injury. Veterans often denied discomfort, possibly lowering overall pain scores, while reporting severe pain in specific body parts. CONCLUSIONS: Wheelchair seated posture was predicted by cognitive status, WC fit, WC skills, and duration of sitting. Poor posture was associated with pain, and poor posture was an outcome of poor WC fit. Poor WC fit in this study supported earlier findings in non-Veterans Administration nursing homes.

Reliability and Criterion-Related Validity of the Seated Posture Scale.

PURPOSE: Earlier, we reported development and initial testing of a rapid, low burden measure of wheelchair seated posture (the Seated Posture Scale [SPS]) for research and clinical use. The purpose of this study was to test the intrarater reliability, interrater reliability, and criterion related validity of the SPS. DESIGN: We used a descriptive design to test and develop the instrument. METHODS: We used the method described by Walter, Donner, and Eliasziw to determine 46 participants were needed, from two Veterans Administration nursing homes or CLCs (community living centers). Using a digital goniometer to score rapidly and with two trained raters, we scored individual participants simultaneously and again in succession. For criterion related concurrent validity, we also scored each participant with Section 2 of the Seated Postural Control Measure for Adults. Intrarater reliability, interrater reliability, and criterion related, concurrent validity were assessed using kappa statistics for individual instrument items (and corresponding 95% confidence intervals where appropriate) and intraclass correlation coefficients (ICC) for total scores. FINDINGS: The intrarater intraclass correlation coefficient (ICC) was .995; interrater ICC was .80; interrater reliability kappas ranged from -.03 to .80. Criterion-related, concurrent validity kappas ranged from .13 to .91. ICC for total scores was .85. CONCLUSION: The SPS has sufficient preliminary validity and reliability to support measurement of wheelchair-seated posture in outcomes research and clinical use. CLINICAL RELEVANCE: In the future, rehabilitation nurses may use the SPS to improve management of wheelchair seated posture, to improve clinical outcomes, particularly for those who do not reposition themselves.

Georgia Primary Care Providers' Knowledge of Hereditary Breast and Ovarian Cancer Syndrome.

Hereditary breast and ovarian cancer syndrome (HBOC) is an inherited condition associated with mutations in the BRCA1 or BRCA2 (BRCA) genes. Identification of individuals with HBOC requires that primary care providers understand the genetic principles required to appropriately collect family history and refer individuals for genetic evaluation. A survey was developed and administered to primary care providers in Georgia to assess their existing knowledge of HBOC and direct targeted educational efforts.We found that Georgia providers demonstrate some knowledge of basic genetic principles but were unable to consistently identify individuals at risk for HBOC. Knowledge deficits included lack of understanding of inheritance patterns and failure to recognize the significance of ovarian cancer history. Strategies for improving identification of patients with HBOC include increasing provider knowledge and integrating HBOC risk assessment tools into practice. Identification of individuals at risk is the critical first step in the process of reducing incidence of breast and ovarian cancer associated with BRCA mutations.

Orthotic-Style Off-Loading Wheelchair Seat Cushion Reduces Interface Pressure Under Ischial Tuberosities and Sacrococcygeal Regions.

OBJECTIVE: To assess the efficacy of an off-loading wheelchair seat cushion in removing pressure from high-risk ischial tuberosities and the coccyx/sacrum in wheelchair sitting. DESIGN: Repeated-measures design. SETTING: Private research laboratory. PARTICIPANTS: Manual wheelchair users with chronic spinal cord injuries (N=10). INTERVENTIONS: Three configurations of an off-loading wheelchair seat cushion compared with a flotation style (10-cm air inflation) wheelchair seat cushion. MAIN OUTCOME MEASURES: Outcome measures included peak pressure index (PPI), ischial tuberosity peak pressures, and the dispersion index or ratio of pressures under the ischial and sacral regions to the total of all pressures recorded. RESULTS: PPI and ischial tuberosities peak pressure ranged from a low of 39±18 and 68±46mmHg in the fully off-loaded cushion to a high of 97±30 and 106±34mmHg, respectively, for the flotation style cushion (2-way analysis of variance main effect across 4 conditions, P<.001). Dispersion index ranged from a low of 8%±3% in the fully off-loaded cushion to a high of 16%±3% in the flotation style cushion. Pairwise comparisons yielded significance in all cushion-pair analyses (P<.05 after multiple corrections). CONCLUSIONS: The force-removal approach of this orthotic off-loading cushion design effectively reduces a known extrinsic risk factor for pressure ulcers-interface pressure-in the high-risk ischial tuberosity and sacral/coccygeal regions of the buttocks.

Product limit estimation for capturing of pressure distribution dynamics.

Measurement of contact pressures at the wheelchair-seating interface is a critically important approach for laboratory research and clinical application in monitoring risk for pressure ulceration. As yet, measures obtained from pressure mapping are static in nature: there is no accounting for changes in pressure distribution over time, despite the well-known interaction between time and pressure in risk estimation. Here, we introduce the first dynamic analysis for distribution of pressure data, based on the Kaplan-Meier (KM) Product Limit Estimator (PLE) a ubiquitous tool encountered in clinical trials and survival analysis. In this approach, the pressure array-over-time data set is sub-sampled two frames at a time (random pairing), and their similarity of pressure distribution is quantified via a correlation coefficient. A large number (here: 100) of these frame pairs is then sorted into descending order of correlation value, and visualized as a KM curve; we build confidence limits via a bootstrap computed over 1000 replications. PLEs and the KM have robust statistical support and extensive development: the opportunities for extended application are substantial. We propose that the KM-PLE in particular, and dynamic analysis in general, may provide key leverage on future development of seating technology, and valuable new insight into extant datasets.

A comparison of strategies for imputing saturated pressure array data with application to the wheelchair-seating interface.

PURPOSE: The common responses to pressure sensor saturation are extreme: either discarding of data, or wholesale alteration of experimental protocol. Here, we test four simplistic strategies for restoring missing data due to sensor saturation, avoiding such drastic measures. METHODS: We tested these algorithms on 62 pressure maps collected from 42 individuals (20 M/22 F, 54.1 ± 26.2 years, 1.7 ± 0.1 m, 71.9 ± 17.8 kg) under a variety of seating conditions. These strategies were tested via a cross-validation design, censoring the maximum pressure value in the datasets and measuring prediction error. RESULTS: The four strategies showed various prediction error rates: ? = 0.43 ± 0.14 (simple substitution), ? = 0.16 ± 0.21 (scaled substitution), ? = 0.19 ± 0.21 (feature extraction), and ? = 0.24 ± 0.32 (extrapolation by non-linear modeling). CONCLUSION: For single-sensor saturation, it may be possible to restore missing data using simple techniques. Implications for Rehabilitation We present a method for imputing missing data from pressure sensor arrays. The implications for rehabilitation are as follows. Improved flexibility in design of protocols concerning interfacial pressure measurement. Restoration of missing data from existing datasets. Reduction in recruitment burden for future studies. Reduction in exposure risk to study participants.

Multidisciplinary Testing of Floor Pads on Stability, Energy Absorption, and Ease of Hospital Use for Enhanced Patient Safety.

OBJECTIVES: A major improvement in hospital safety could be realized if serious injury did not accompany falls. We studied several commercially available floor pads made of different materials to determine which (if any) would be practical in a hospital room and reduce injury without posing a threat to the balance of patients. METHODS: A multidisciplinary approach was undertaken to (1) measure upper and lower body motion in 17 young (<50 years) and 17 older (>55 years) adults during an instrumented sit to stand test from a hospital bed onto the different floor pads, (2) predict the energy dissipation available in floor pads by quantifying the relative mechanical properties, and (3) obtain professional feedback from hospital nurses via a questionnaire (8 questions) following a period of working on the different floor pads. Five floor pads, composed of foam, gel, and/or rubber were tested. All pads were compared with a typical hospital floor (concrete covered with linoleum tiles, considered the control). RESULTS: All of the pads subject to mechanical testing showed at least 3 times more energy absorption compared with the control. Balance testing showed that three of the pads resulted in minimal or no significant increases in body motion during sit-to-stand. Nursing feedback revealed that only 2 of these 3 pads may be feasible for hospital room use: one made primarily of firm rubber and one made of foam. CONCLUSIONS: Floor pads do exist that show promise for hospital use that absorbing energy without major impacts on balance during sit-to-stand. Although only commercially available pads were investigated, results may inform the design and multidisciplinary testing of other floor surfaces.

Proxy study on minimizing risk of sacral pressure ulcers while complying with ventilator-associated pneumonia risk reduction guidelines.

Bed positioning poses a subtle, yet important, tradeoff in the competing needs of hospitalized patients, particularly those susceptible to lower respiratory tract infections and/or pressure ulcers. Although it is widely held that a minimum 30° incline is necessary to mitigate risk of ventilator-acquired pneumonia, it is unclear what effect semirecumbent positioning has on the risk of pressure ulcerations. The authors test several hypotheses with the objective of elucidating the relationship between bed incline, posture, and incline, pursuant to a more evidence-based recommendation for practice in clinical care. To this end, interfacial pressures from 40 healthy subjects were analyzed following observation in both supine and sidelying positions, at shallow (30°) and moderate (45°) bed-angle incline. Summarily, the authors report that supine postures reduce pressure signatures associated with pressure ulceration versus sidelying position: 15% increase area of contact (P = 1.3×10), and 17% decrease in ratio of peak to average pressure (P = 3.1×10). Within supine posture, the authors found significant increases in 4 measures of local pressure, including average pressure (10.4% decrease, P = .005) and coefficient of pressure variation (22.1%, P = 2.2×10) at moderate incline. The authors conclude that supine bed positionings at moderate incline appear to reduce predictors of pressure ulceration.

Prevalence of Sensor Saturation in Wheelchair Seat Interface Pressure Mapping.

Pressure mapping is a frequently used tool with great power to provide information about the forces between a patient and a wheelchair seat. One widely recognized limitation to this paradigm is the possibility of data loss due to sensor saturation. In this study, we seek to quantify and describe the saturation observed in the measurement of interface pressures of wheelchair users. We recorded approximately two minutes of interface pressure data from 22 elderly wheelchair users (11M/11F, 80 ± 10 years) and found that 4.7% of data frames had 1 saturated sensor, and 9.0% had more than one saturated sensor, for a total of 13.7% of all frames of data. Data from three of the 22 subjects (13.6%) were substantially affected by the persistent presence of saturated sensors. We conclude that for this population of elderly wheelchair users, sensor saturation may be a concern and should be factored properly into study design a priori.

The Activities and Impact of State Programs to Address Hereditary Breast and Ovarian Cancer, 2011-2014.

In 2011, the Division of Cancer Prevention and Control (DCPC), at the United States Centers for Disease Control and Prevention (CDC), released a three-year funding opportunity announcement (FOA) for a competitive, non-research cooperative agreement. The agreement enhanced the capacities of state health departments to promote the application of best practices for evidence-based breast cancer genomics through education, surveillance, and policy activities. The FOA required that applicants focus on activities related to hereditary breast and ovarian cancer (HBOC). The DCPC funded three states: Georgia, Michigan, and Oregon. Georgia was a first-time recipient of cancer genomics funding, whereas Michigan and Oregon had long standing activities in cancer genomics and had received CDC funding in the past. By the end of the funding period, each state had well-functioning and impactful state-based programs in breast cancer genomics. This article highlights the impact of a few key state activities by using CDC's Science Impact Framework. There were challenges to implementing public health genomics programs, including the need to develop relevant partnerships, the highly technical nature of the subject matter, a lack of genetic services in certain areas, and the difficulty in funding genetic services. Georgia, Michigan, and Oregon have served as models for others interested in initiating or expanding cancer genomics programs, and they helped to determine what works well for promoting and integrating public health genomics into existing systems.

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.

Public education and targeted outreach to underserved women through the National Breast and Cervical Cancer Early Detection Program.

The National Breast and Cervical Cancer Early Detection Program (NBCCEDP) was established to provide low-income, uninsured, and underinsured women access to cancer screening and diagnostic services with the goal of increasing the early detection and prevention of breast and cervical cancer. Although this is a valuable resource for women who might not have the means to get screened otherwise, providing services at no cost, by itself, does not guarantee uptake of screening services. Public education and targeted outreach facilitate the critical link between public service programs and the communities they serve. The purpose of public education and outreach in the NBCCEDP is to increase the number of women who use breast and cervical cancer screening services by raising awareness, providing education, addressing barriers, and motivating women to complete screening exams and follow-up. Effective strategies focus on helping to remove structural, physical, interpersonal, financial, and cultural barriers; educate women about the importance of screening and inform women about the services available to them. This article provides an overview of the importance of public education and targeted outreach activities for cancer screening through community-based programs including examples from NBCCEDP grantees that highlight successes, challenges, and solutions, encountered when conducting these types of interventions.

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.

Implementing a screening tool for identifying patients at risk for hereditary breast and ovarian cancer: a statewide initiative.

BACKGROUND: The Georgia Breast Cancer Genomic Health Consortium is a partnership created with funding from the Centers for Disease Control and Prevention (CDC) to the Georgia Department of Public Health to reduce cancer disparities among high-risk minority women. The project addresses young women at increased risk for hereditary breast and ovarian cancer (HBOC) syndrome through outreach efforts. METHODS: The consortium provides education and collects surveillance data using the breast cancer genetics referral screening tool (B-RST) available at www.BreastCancerGeneScreen.org . The HBOC educational protocol was presented to 73 staff in 6 public health centers. Staff used the tool during the collection of medical history. Further family history assessments and testing for mutations in the BRCA1/2 genes were facilitated if appropriate. RESULTS: Data was collected from November 2012 through December 2013, including 2,159 screened women. The majority of patients identified as black/African American and were 18-49 years old. Also, 6.0 % (n = 130) had positive screens, and 60.9 % (n = 67) of the 110 patients who agreed to be contacted provided a detailed family history. A total of 47 patients (42.7 %) met National Comprehensive Cancer Network guidelines when family history was clarified. Fourteen (12.7 %) underwent genetic testing; 1 patient was positive for a BRCA2 mutation, and 1 patient was found to carry a variant of uncertain significance. CONCLUSIONS: The introduction of genomics practice within public health departments has provided access to comprehensive cancer care for uninsured individuals. The successful implementation of the B-RST into public health centers demonstrates the opportunity for integration of HBOC screening into primary care practices.

Effect of interpolation on parameters extracted from seating interface pressure arrays.

Interpolation is a common data processing step in the study of interface pressure data collected at the wheelchair seating interface. However, there has been no focused study on the effect of interpolation on features extracted from these pressure maps, nor on whether these parameters are sensitive to the manner in which the interpolation is implemented. Here, two different interpolation paradigms, bilinear versus bicubic spline, are tested for their influence on parameters extracted from pressure array data and compared against a conventional low-pass filtering operation. Additionally, analysis of the effect of tandem filtering and interpolation, as well as the interpolation degree (interpolating to 2, 4, and 8 times sampling density), was undertaken. The following recommendations are made regarding approaches that minimized distortion of features extracted from the pressure maps: (1) filter prior to interpolate (strong effect); (2) use of cubic interpolation versus linear (slight effect); and (3) nominal difference between interpolation orders of 2, 4, and 8 times (negligible effect). We invite other investigators to perform similar benchmark analyses on their own data in the interest of establishing a community consensus of best practices in pressure array data processing.

Comparison of muscle and skin perfusion over the ischial tuberosities in response to wheelchair tilt-in-space and recline angles in people with spinal cord injury.

OBJECTIVE: To compare the efficacy of wheelchair tilt-in-space and recline on enhancing muscle and skin perfusion over the ischial tuberosities in people with spinal cord injury (SCI). DESIGN: Repeated-measures and before-after trial design. SETTING: University research laboratory. PARTICIPANTS: Power wheelchair users with SCI (N=20). INTERVENTIONS: Six combinations of wheelchair tilt-in-space and recline angles were presented to participants in a random order. The testing protocol consisted of a baseline 5 minutes sitting with no tilt/recline and 5 minutes positioned in a tilted and reclined position at each of 6 conditions, including: (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. MAIN OUTCOME MEASURES: Muscle and skin perfusion were assessed by near-infrared spectroscopy and laser Doppler flowmetry, respectively. RESULTS: Muscle perfusion was significantly increased at 25° and 35° tilt-in-space when combined with 120° recline, and skin perfusion was significantly increased at 3 tilt-in-space angles (15°, 25°, 35°) when combined with 120° recline and at 35° tilt-in-space when combined with 100° recline (P<.05). Even in the positions of increased muscle perfusion and skin perfusion (25° and 35° of tilt-in-space combined with 120° of recline), the amount of muscle perfusion change was significantly lower than the amount of skin perfusion change (P<.05). CONCLUSIONS: Our results indicate that a larger angle of tilt-in-space and recline is needed to improve muscle perfusion compared with skin perfusion. A position of 25° tilt-in-space combined with 120° recline is effective in enhancing muscle and skin perfusion of weight-bearing soft tissues at the ischial tuberosities.

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.