Understanding Wheelchair Use in Older Adults From the National Health and Aging Trends Study.

OBJECTIVE: To identify the trends of wheelchair use and physical characteristics among older people who used wheelchairs relative to those who did not. DESIGN: Cohort and survey. SETTING: General community. PARTICIPANTS: 7026 participants (N=7026) were selected from the 2011 cohort of the National Health and Aging Trends Study (NHATS), which is made up of Medicare beneficiaries over the age of 65. Repeated observations among participants in the 2011 cohort were analyzed in the 4 following rounds: 2013 (N=4454), 2015 (N=3327), 2017 (N=2623), and 2019 (N=2091). Participants were divided into 2 groups: those who used and did not use wheelchairs. INTERVENTIONS: Not applicable. MAIN OUTCOMES MEASURES: Physical characteristics, including pain, strength limitation, balance problems, mobility disability, as well as the frequency of going outside. RESULTS: The number of older adults who use wheelchairs had increased significantly from 4.7 per 100 people in 2011 to 7.1 in 2019 (P<.001). The logistic regression analysis indicated that participants who reported less frequently going out were at least 4.27 times more likely to be wheelchair users than non-wheelchair users (P<.01). Participants who reported health and physical problems were at least 2.48 times more likely to be wheelchair users than non-wheelchair users from 2011 to 2017 (P<.0001). Balance or coordination problems increased (24%-38%) significantly among non-wheelchair users from 2011 to 2019 (all P<.05). CONCLUSIONS: Current wheelchair users reported more physical difficulties and were much less likely to go outside. This lower outdoor mobility could be due to physical difficulties or potential barriers in physical and socio-cultural environments. In addition, older adults who do not use wheelchairs showed increasing physical problems over time (including balance or coordination problems). Clinicians should consider older wheelchair users' health and physical limitations when prescribing wheelchairs.

Influence of Transfer Quality and Wheelchair Type on Fear of Falling Among Full-Time Wheelchair Users.

OBJECTIVE: To evaluate the influence of transfer quality and demographics on fear of falling (FOF) among full-time wheelchair users. DESIGN: Secondary data analysis. SETTING: University research laboratory and community, United States. PARTICIPANTS: Ninety-six individuals (N=96) living with multiple sclerosis or spinal cord injury who use a manual or power scooter full time with median age of 54.00 years (interquartile range, 29.00 years), and median duration of health condition of 19.50 years (interquartile range, 23.00 years) were included. Fifty-two participants (54%) were manual wheelchair users. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Demographics information included age, sex, duration of health condition, height, weight, body mass index, and wheelchair type. To assess transfer quality, the Transfer Assessment Instrument versions 3.0 and 4.0 were used. The Spinal Cord Injury Falls Concern Scale was used to quantify FOF. Stepwise linear regression analysis was conducted to examine factors influencing FOF. RESULTS: Participant's age, sex, duration of health condition, wheelchair type, and transfer quality were associated with FOF. The regression analysis indicated transfer quality (ß=-0.25, P<.01) and wheelchair type (manual wheelchair, ß=- 0.32, P<.01) were significant predictors of FOF, R2=20% (F=11.19; P<.01). CONCLUSIONS: Compared with manual wheelchair users, power wheelchair/scooter users with poor transfer quality reported higher levels of FOF. Clinicians and researchers working with wheelchair users should emphasize quality of transfers and consider the type of wheelchair while developing interventions to reduce FOF in this population. Further longitudinal prospective studies on modifiable factors associated with FOF among full-time wheelchair users are warranted.

Measurement Properties of Clinical Instruments for Assessing Manual Wheelchair Mobility in Individuals With Spinal Cord Injury: Systematic Review.

OBJECTIVE: To evaluate the measurement properties of clinical instruments used to assess manual wheelchair mobility in individuals with spinal cord injury (SCI). DATA SOURCES: This systematic review was conducted according to the Consensus-Based Standards for the Selection of Health Measurement Instruments guidance and Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. The search was conducted up to December 2021 on MEDLINE/PubMed, Cochrane Central Register of Controlled Trials, Web of Science, Biblioteca Regional de Medicina, and Cumulative Index to Nursing and Allied Health databases without time restriction. STUDY SELECTION: Peer-reviewed original research articles that examined any clinical wheelchair mobility and/or skill assessment instrument among adults with SCI and reported data on at least one measurement property or described the development procedure were evaluated independently by two reviewers. DATA EXTRACTION: Data were independently extracted according to Consensus-Based Standards for the Selection of Health Measurement Instruments methodology. Measurement property results from each study were independently rated by two reviewers as sufficient, insufficient, indeterminate, or inconsistent. The evidence for each measurement property was rated as high, moderate, low, or very low (Grading of Recommendations, Assessment, Development, and Evaluation). Recommendations for highly-rated instruments were performed. DATA SYNTHESIS: Twenty-nine studies with 21 instruments were identified. The methodological quality of studies ranged from insufficient to sufficient, and the quality of evidence ranged from very low to high. Six instruments reported content validity. Reliability and construct validity were the most studied measurement properties. Structural validity and invariance for cross-cultural measurement were not reported. The highly rated instruments were the Wheelchair Outcome Measure and Wheelchair Skills Test Questionnaire. CONCLUSIONS: Although numerous instruments for assessing wheelchair mobility and/or skills among individuals with SCI were identified, not many measurement properties have been sufficiently established. The Wheelchair Outcome Measure and Wheelchair Skills Test Questionnaire show the current best potential to be recommended for clinical and research use. Further studies are needed to strengthen or change these recommendations.

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.

Effectiveness of Physical Therapy Interventions in Reducing Fear of Falling Among Individuals With Neurologic Diseases: A Systematic Review and Meta-analysis.

OBJECTIVE: To summarize the effectiveness of physical therapy interventions to reduce fear of falling (FOF) among individuals living with neurologic diseases. DATA SOURCES: PubMed, Physiotherapy Evidence Database, Scopus, Web of Science, PsycINFO, Cumulative Index to Nursing and Allied Health, and SportDiscuss were searched from inception until December 2019. STUDY SELECTION: Clinical trials with either the primary or secondary aim to reduce FOF among adults with neurologic diseases were selected. DATA EXTRACTION: Potential articles were screened for eligibility, and data were extracted by 2 independent researchers. Risk of bias was assessed by the Cochrane Risk of Bias tool for randomized controlled trials and the National Institutes of Health Quality Assessment Tool for pre-post studies. A meta-analysis was performed among trials presenting with similar clinical characteristics. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) was used to rate the overall quality of evidence. RESULTS: Sixty-one trials with 3954 participants were included in the review and 53 trials with 3524 participants in the meta-analysis. The included studies presented, in general, with a low to high risk of bias. A combination of gait and balance training was significantly more effective compared with gait training alone in reducing FOF among individuals with Parkinson disease (PD) (mean difference [MD]=11.80; 95% CI, 8.22-15.38; P<.001). Home-based exercise and leisure exercise demonstrated significant improvement in reducing FOF over usual care in multiple sclerosis (MS) (MD=15.27; 95% CI, 6.15-24.38; P=.001). No statistically significant between-groups differences were reported among individuals with stroke and spinal cord injury. The overall quality of evidence presented in this review ranges from very low to moderate according to the assessment with the GRADE approach. CONCLUSIONS: Gait with lower limb training combined with balance training is effective in reducing FOF in individuals with PD. Also, home-based or leisure exercise is effective among individuals with MS. However, because of several limitations of the included studies, further research is needed to examine the effectiveness of FOF intervention among individuals with neurologic diseases.

Fear of Falling, Community Participation, and Quality of Life Among Community-Dwelling People Who Use Wheelchairs Full Time.

OBJECTIVES: To examine the differences in community participation and quality of life (QOL) among individuals who use wheelchairs full time with and without fear of falling (FOF). DESIGN: Cross-sectional study design. SETTING: University research laboratory. PARTICIPANTS: Individuals (N=85) who use a manual or power wheelchair full time who are living with various health conditions and have a history of at least 1 fall in the past 12 months (age, 45.4±15.8y; disability duration, 21.5±13.6y) were included. Forty-six (54%) were manual wheelchair users. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: To quantify FOF, participants responded (yes/no) to the question: "Are you worried or concerned that you might fall?" Community participation and QOL were indexed by the Community Participation Indicator (CPI) and the World Health Organization Quality of Life-Brief version (WHOQOL-BREF), respectively. A multivariate analysis of variance (MANOVA) was performed to examine the differences in CPI and WHOQOL-BREF scores among wheelchair users who reported FOF and no FOF. RESULTS: A total of 54 participants (63.5%) reported that they were worried or concerned about falling. The MANOVA revealed significant differences in overall CPI (F2,82=4.714; P=.012; Wilks' λ=0.897) and WHOQOL-BREF (F4,63=3.32; P=.016; Wilks' λ=.826) scores. Participants who reported FOF demonstrated significantly lower CPI and WHOQOL-BREF scores compared with those who did not report FOF. CONCLUSIONS: FOF and associated activity curtailment are prevalent and may be a factor influencing full time wheelchair users' community participation and QOL. Prospective research is needed to better understand how FOF influences community participation and QOL among individuals who use wheelchairs full time. Findings would support the development of interventions, specifically for individuals who use wheelchairs full time, to reduce FOF and improve community participation and QOL.

The effectiveness of vigorous training on cardiorespiratory fitness in persons with spinal cord injury: a systematic review and meta-analysis.

DESIGN: Systematic review and meta-analysis. BACKGROUND AND PURPOSE: Traditional forms of upper-body moderate intensity exercise consistently provide little cardiovascular benefits for persons with spinal cord injury (PwSCI). Explorations of new training methods are vital to improve cardiovascular fitness among PwSCI. This study sought to evaluate the effectiveness of vigorous training on cardiorespiratory fitness in PwSCI. METHODS: Database search through PubMed, Web of Science, Scopus, SportDiscus, and Cumulative Index of Nursing and Allied Health Literature (CINAHL) was conducted from the databases' inception to November 2020 to identify relevant exercise studies with PwSCI. Two independent reviewers screened articles for inclusion. Data were extracted from included studies and methodological quality evaluated. RESULTS: Sixteen trials (eight pre-post trials and eight controlled trials [CTs]) with a total of 145 participants were analyzed. Results from pre-post studies revealed significant improvements in cardiorespiratory fitness following high-intensity interval training (HIIT) (Peak Oxygen Uptake [VO2peak], standardized mean difference [SMD] = 0.81; 95% CI 0.23-1.39; P < 0.01 and Peak Power Output [PPO], SMD = 0.91; 95% CI 0.32-1.5; P < 0.01) and circuit resistance training (CRT) (VO2peak, MD = 0.38; 95% CI 0.19-0.57; P < 0.01 and PPO, MD = 20.17; 95% CI 8.26-32.08; P < 0.01). Meta-analysis of CTs did not demonstrate significant improvements in cardiorespiratory fitness following vigorous training interventions in comparison to lower intensity training interventions. CONCLUSION: Evidence from HIIT and CRT interventions suggest benefits for cardiovascular functions; however, vigorous training was not more beneficial than other forms of endurance training. More CTs are needed to better understand the effectiveness of vigorous training on cardiorespiratory fitness in PwSCI.

Gait and Balance Assessments using Smartphone Applications in Parkinson's Disease: A Systematic Review.

Gait dysfunctions and balance impairments are key fall risk factors and associated with reduced quality of life in individuals with Parkinson's Disease (PD). Smartphone-based assessments show potential to increase remote monitoring of the disease. This review aimed to summarize the validity, reliability, and discriminative abilities of smartphone applications to assess gait, balance, and falls in PD. Two independent reviewers screened articles systematically identified through PubMed, Web of Science, Scopus, CINAHL, and SportDiscuss. Studies that used smartphone-based gait, balance, or fall applications in PD were retrieved. The validity, reliability, and discriminative abilities of the smartphone applications were summarized and qualitatively discussed. Methodological quality appraisal of the studies was performed using the quality assessment tool for observational cohort and cross-sectional studies. Thirty-one articles were included in this review. The studies present mostly with low risk of bias. In total, 52% of the studies reported validity, 22% reported reliability, and 55% reported discriminative abilities of smartphone applications to evaluate gait, balance, and falls in PD. Those studies reported strong validity, good to excellent reliability, and good discriminative properties of smartphone applications. Only 19% of the studies formally evaluated the usability of their smartphone applications. The current evidence supports the use of smartphone to assess gait and balance, and detect freezing of gait in PD. More studies are needed to explore the use of smartphone to predict falls in this population. Further studies are also warranted to evaluate the usability of smartphone applications to improve remote monitoring in this population.Registration: PROSPERO CRD 42020198510.

Do clinical balance measures have the ability to predict falls among ambulatory individuals with spinal cord injury? A systematic review and meta-analysis.

STUDY DESIGN: Systematic review and meta-analysis. BACKGROUND AND PURPOSE: Fall prevalence is high among individuals with spinal cord injury (SCI) and falls may lead to serious consequences. The objective of this study was to investigate the ability of clinical balance measures to predict falls among ambulatory individuals with SCI. METHODS: We searched the online databases MEDLINE, Web of Science, Scopus, SportDiscuss, and CINAHL. Two reviewers independently selected prospective and cross-sectional studies of ambulatory adults with SCI, with a method of falls tracking and a clinical balance evaluation. Risk of bias was assessed using the Newcastle-Ottawa Quality Assessment Scale. A meta-analysis of prospective and cross-sectional studies was performed using Review Manager 5.3. RESULTS: Ten studies from the 2672 studies identified were included in the qualitative synthesis. Nine studies were included in the meta-analyses. The Berg Balance Scale (BBS) and the Timed Up and Go Test demonstrate ability to differentiate between fallers and non-fallers, mean difference 5.25 (95% CI, 0.29 to 10.20) and 6.65 (95% CI, 0.17 to 13.12) respectively. The BBS presents moderate predictive ability (area under the receiver operating characteristic curve of 0.61 and sensitivity of 65%). Individuals with a BBS score ≥ 40 are likely at risk of falls. CONCLUSION: The BBS is the most appropriate and specific clinical balance measure with the ability to discriminate between ambulatory fallers and non-fallers. However, the fall predictive abilities of the measure need to be further explored and improved for this population.

Perceptions of fall circumstances, injuries and recovery techniques among power wheelchair users: a qualitative study.

OBJECTIVE: To understand the circumstances surrounding the worst fall experienced by power wheelchair users in the past year and to examine injuries sustained and recovery methods. DESIGN: A qualitative study using a semi-structured interview. SETTING: Community. PARTICIPANTS: A self-selected volunteer sample of 19 power wheelchair users who utilize their device for at least 75% of mobility. The most common disability represented was cerebral palsy ( n = 8). The mean (SD) age of participants was 41.9 (7.6) years, who lived with their disability for a mean (SD) of 20.5 (8.62) years and used their current device for a mean (SD) of 3.9 (1.9) years. INTERVENTION: None. MAIN OUTCOME MEASURES: A semi-structured interview examined the circumstances surrounding the worst fall experienced in the past year, injuries sustained and recovery techniques used. RESULTS: Upon examination of the circumstances of the worst fall, four main themes emerged: (1) action-related fall contributors, (2) location of falls, (3) fall attributions and (4) time of fall. Each fall described was found to involve multiple factors. As a result of the fall, participants also reported the occurrence of physical injuries and a fear of falling. Physical injuries ranged from skin abrasion and bruises to fractures and head injuries. Participants also reported that fear of falling diminished their desire to participation in activities they enjoyed doing. Finally, most participants reported the need for physical assistance to recover from a fall. CONCLUSION: Participant descriptions provide an in-depth description of the circumstances and aftermath of falls experienced by power wheelchair users.

Promoting Physical Activity Through a Manual Wheelchair Propulsion Intervention in Persons With Multiple Sclerosis.

OBJECTIVE: To examine the efficacy and feasibility of a multifactorial intervention to increase lifestyle physical activity in nonambulatory persons with multiple sclerosis (MS) based on wheelchair optimization, propulsion skill/technique training, and behavioral strategies based on social cognitive theory. DESIGN: Randomized controlled trial, 3-month postintervention follow-up. SETTING: Home and general community, and university research laboratory. PARTICIPANTS: Nonambulatory individuals with MS (N=14; mean age ± SD, 53.6±8.7y) were randomly assigned to an intervention group (IG) or a control group (CG). INTERVENTIONS: After baseline testing, the IG participants received custom-fit, ultralightweight manual wheelchairs with propulsion/skills training, followed by 3 months of at-home use with the custom ultralightweight wheelchair and weekly phone calls to deliver support through a multifactorial intervention. The CG participants received no training and used their own wheelchairs at home during this time. MAIN OUTCOME MEASURES: All subjects were assessed at baseline and 3 months later for fatigue (Fatigue Severity Scale), upper extremity strength (digital handheld dynamometer), and propulsion technique (on a treadmill [0.5m/s] with instrumented wheels). Two 1-week bouts of physical activity were measured in both groups from home with wrist-worn accelerometry at the beginning (IG and CG in own wheelchairs) and end (IG in study wheelchair, CG in own) of the 3-month period of home use. RESULTS: The intervention was well tolerated, and no adverse events were reported. The IG demonstrated increased strength (P=.008) and a trend toward less fatigue (P=.068), both with large effect sizes (d>0.8), as well as reduced application of braking torque during propulsion (P=.003) with a moderate/large effect size (d=.73), compared with the CG. CONCLUSIONS: Findings suggest a 3-month physical activity intervention based on manual wheelchair propulsion and training is safe and feasible for some wheelchair users living with MS and may produce secondary benefits in strength, fatigue, and propulsion technique.

Impact of a wheelchair education protocol based on practice guidelines for preservation of upper-limb function: a randomized trial.

OBJECTIVES: To determine if strict use of the Paralyzed Veterans of America's Clinical Practice Guidelines for Preservation of Upper Limb Function affects wheelchair setup, selection, propulsion biomechanics, pain, satisfaction with life, and participation of individuals with new spinal cord injuries (SCIs). DESIGN: Single blinded, randomized controlled trial. SETTING: Model SCI systems rehabilitation facility and community. PARTICIPANTS: Volunteer sample of manual wheelchair users with new SCIs (N=37). INTERVENTION: The intervention group was strictly educated on the clinical practice guideline by a physical therapist and an occupational therapist in an inpatient rehabilitation facility. The standard of care group received standard therapy services. MAIN OUTCOME MEASURES: Comparison of wheelchair setup, selection, propulsion biomechanics, pain, and Satisfaction With Life Scale and Craig Handicap Assessment and Reporting Technique scores at the time of discharge from inpatient rehabilitation and at 6 months and 1 year postdischarge. RESULTS: Participants in the intervention group pushed on tile with significantly lower push frequency (P=.02) at the discharge visit. On the ramp, the intervention group used a significantly larger push length (P=.03) across all time points. No significant differences were found between groups related to wheelchair setup, selection, pain, satisfaction with life, and participation. CONCLUSIONS: The intervention group showed better skills on key wheelchair propulsion biomechanics variables related to upper-limb health. Use of a structured education program may be an effective method of educating new manual wheelchair users to prevent the development of upper-limb impairments in an inpatient setting. Additional follow-up testing is necessary to determine whether the differences seen in propulsion skills translate into decreased pain and improved quality of life in the long term.

A mixed-methods study examining perceptions of fear of falling among community-dwelling people who use wheelchairs full-time.

Objective: There is growing evidence that fear of falling (FOF) is common in people who use wheelchairs full-time and negatively influence their performance of daily activities and quality of life. The purpose of this study was to gain an in-depth understanding of perceptions related to FOF among people who use wheelchairs full-time.Methods: Mixed-method analysis was conducted using semi-structured interviews and surveys to gain insight into FOF. Surveys included demographic information; Spinal Cord Injury-Fall Concerns Scale (SCI-FCS); a questionnaire that directly assesses FOF and associated activity curtailment; and Fall Control Scale (FCS).Results: Among 39 participants (age = 43.1 ± 15.6 years, disability duration = 21.2 ± 11.1 years), 27 participants (69%) reported FOF. Participants with less perceived ability to control falls indexed by FCS reported higher SCI-FCS scores, indicating greater FOF (rs = -0.384, p = 0.016). Qualitative findings revealed that participants felt that FOF developed due to sustaining fall-related injuries or limited ability to recover from a fall. Some participants perceived falling as a part of their lives. They believed that it was not the cause of developing FOF.Conclusions: Among people who use wheelchairs full-time, FOF is prevalent and may develop due to fears of sustaining injuries or being unable to get up after falling. Developing an evidenced-based education protocol aimed at managing falls (e.g., establishing a fall recovery strategy and education on techniques to reduce injury during falls) is needed to minimize FOF people who use wheelchairs full-time.

Fear of falling and associated activity curtailment are prevalent among people who use wheelchairs full-time.Fear of falling often develops as a result of prior fall-related injuries or the inability to recover from a fall independently.Evidence-based education protocols to reduce fear of falling among people who use wheelchairs full-time should contain content related to fall recovery and injury prevention.

Factors associated with fear of falling and fall-related injuries among people who use wheelchairs and motorized mobility scooters: a cross-sectional study.

PURPOSE: To identify the factors associated with the fear of falling (FOF) and fall-related injuries (FRI) among full-time wheelchair and motorized mobility scooter (WC/S) users with various health conditions. METHODS: This cross-sectional study included participants (≥18 years old) who used WC/S for at least one year for ≥ 75% of mobility and had a history of ≥ 1 fall in the past three years. Logistic regression models identified factors associated with FOF (yes/no) and FRI (yes/no) during the past year. Data on demographics, prior falls, mental health, environmental accessibility, and WC/S usage were used as independent variables. RESULTS: Among 156 participants, 96% reported at least one fall within the past year, among whom 94.6% reported FOF, and 74% reported FRI within the same period. FOF was associated with fall incidence in the past year (OR = 17.75, p = 0.001). FRI was associated with higher levels of anxiety (OR = 1.15, p = 0.003) and fewer hours of WC/S use per week (OR = 0.98, p = 0.012). CONCLUSION: This study highlights the high prevalence of FOF and FRI among WC/S users who had falls. The findings emphasized the relation between prior fall experiences and FOF and underscored the significance of addressing anxiety symptoms and WC/S usage in relation to FRI.

Among individuals with a variety of health conditions who use wheelchairs and motorized mobility scooters full-time for most of their mobility and have experienced at least one fall incident within the past year, the prevalence of psychosocial and physical consequences of falls (fear of falling and fall-related injuries) is relatively high.Given the significant association between an individual's previous fall experiences and the likelihood of fear of falling, continuous screening for falls is a crucial step toward fall prevention for people who use wheelchairs and motorized mobility scooters full-time.Recognizing the importance of the unique needs of individuals who use wheelchairs and motorized mobility scooters and tailoring interventions like wheelchair skills and anxiety management education may enhance overall rehabilitation outcomes.

Using reactive hyperemia to assess the efficacy of local cooling on reducing sacral skin ischemia under surface pressure in people with spinal cord injury: a preliminary report.

OBJECTIVES: To investigate the efficacy of local cooling on reducing sacral skin ischemia in a weight-bearing position, and to identify the underlying physiological mechanisms using wavelet-based spectrum analysis of reactive hyperemia in people with spinal cord injury (SCI). DESIGN: Repeated-measures and before-after trial design. SETTING: University research laboratory. PARTICIPANTS: Wheelchair users with SCI with injury level between C4 and T5 (n=10) and able-bodied controls (n=10). INTERVENTIONS: Three protocols consisting of pressure without temperature changes, pressure with local cooling (Δt=-10°C), and pressure with local heating (Δt=+10°C) were tested. Each protocol consisted of a 10-minute baseline period, a 20-minute loading period at 60 mmHg, and a 20-minute recovery period (reactive hyperemia). A 30-minute washout period was allowed between protocols. MAIN OUTCOME MEASURES: A compound sensor head consisting of laser Doppler and heating and cooling probes was used to measure sacral skin blood flow and control skin temperature. Reactive hyperemic response to pressure and temperature stimuli was characterized in the time and frequency (metabolic [.0095-.02 Hz], neurogenic [.02-.05 Hz], and myogenic [.05-.15 Hz] components) domains. RESULTS: Pressure with local cooling resulted in a smaller reactive hyperemic response in both people with SCI and able-bodied controls as compared with pressure with local heating (P<.017) and pressure without temperature changes (P<.017), and the smaller hyperemia was attributed to reduced metabolic and neurogenic activities. People with SCI showed an attenuated response in reactive hyperemia (P<.017). CONCLUSIONS: This study supports the concept of using local cooling to reduce skin ischemia under surface pressure in people with SCI.

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.

Basic psychometric properties of the transfer assessment instrument (version 3.0).

OBJECTIVES: To refine the Transfer Assessment Instrument (TAI 2.0), develop a training program for the TAI, and analyze the basic psychometric properties of the TAI 3.0, including reliability, standard error of measurement (SEM), minimal detectable change (MDC), and construct validity. DESIGN: Repeated measures. SETTING: A winter sports clinic for disabled veterans. PARTICIPANTS: Wheelchair users (N=41) who perform sitting-pivot or standing-pivot transfers. INTERVENTION: Not applicable. MAIN OUTCOME MEASURES: TAI version 3.0, intraclass correlation coefficients, SEMs, and MDCs for reliable measurement of raters' responses. Spearman correlation coefficient, 1-way analysis of variance, and independent t tests to evaluate construct validity. RESULTS: TAI 3.0 had acceptable to high levels of reliability (range, .74-.88). The SEMs for part 1, part 2, and final scores ranged from .45 to .75. The MDC was 1.5 points on the 10-point scale for the final score. There were weak correlations (ρ range, -.13 to .25; P>.11) between TAI final scores and subjects' characteristics (eg, sex, body mass index, age, type of disability, length of wheelchair use, grip and elbow strength, sitting balance). CONCLUSIONS: With comprehensive training, the refined TAI 3.0 yields high reliability among raters of different clinical backgrounds and experience. TAI 3.0 was unbiased toward certain physical characteristics that may influence transfer. TAI fills a void in the field by providing a quantitative measurement of transfers and a tool that can be used to detect problems and guide transfer training.

Impact of the clinical practice guideline for preservation of upper limb function on transfer skills of persons with acute spinal cord injury.

OBJECTIVES: To describe the development of a strict education protocol to implement the clinical practice guideline "Preservation of Upper Limb Function Following Spinal Cord Injury" into a clinical setting, and evaluate the effect of the protocol on transfer quality. DESIGN: Randomized controlled trial. SETTING: Acute Model Spinal Cord Injury Systems rehabilitation facility and community. PARTICIPANTS: Volunteer sample of full-time wheelchair users (N=70) with new spinal cord injuries randomized (1:1) to an intervention and standard-of-care group. INTERVENTION: The intervention group was educated on transfer skills with a structured protocol implemented by a physical and occupational therapist who were extensively educated on the clinical practice guidelines and current transfer research. The standard-of-care group received standard therapy services. MAIN OUTCOME MEASURES: Comparison of transfer quality evaluated by the Transfer Assessment Instrument at 4 time points during first year after injury. RESULTS: No significant differences were found between study groups. Secondary analysis based on type of transfer performed found that participants in the intervention group who performed assisted sitting pivot transfers performed higher-quality transfers (mean ± SE: 9.43±.55) compared with the standard-of-care group (mean ± SE: 7.81±.46) (P=.026) at 1 year after discharge. Also, participants who performed a dependent transfer had a higher average score across all 4 time points (mean ± SE: 9.14±.34) compared with the standard-of-care group (mean ± SE: 8.09±.29) (P=.019). CONCLUSIONS: For participants who perform assisted or dependent transfers, use of an evidenced-based, structured education program during acute inpatient rehabilitation has the potential to significantly improve the quality of transfers. Further follow-up testing is necessary with a larger sample size to determine the long-term effects.