RESNA position on the application of ultralight manual wheelchairs.

The purpose of this RESNA Position Paper is to provide evidence from the literature and share typical clinical applications supporting the application of ultralight manual wheelchairs (ULWCs) to assist practitioners in decision-making and justification of wheelchair recommendations.

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

STUDY DESIGN: Cross-sectional study. OBJECTIVE: To evaluate the reliability of home-based remote and self-assessment of transfer quality using the Transfer Assessment Instrument (TAI) among wheelchair users with spinal cord injury (SCI). SETTING: Participant's home environment. METHODS: Eighteen wheelchair users with SCI transferred from their wheelchair to a surface of their choice (bed, sofa, or bench) in their homes. During a live video conference, the transfer was recorded and evaluated live using the TAI (rater 1). Participants completed a self-assessment of their transfer using the TAI- questionnaire (TAI-Q). Two additional raters (raters 2 & 3) completed asynchronous assessments by watching recorded videos. Interrater reliability was assessed using Intraclass Coefficient Correlations (ICC) to compare rater 1 with the average of raters 2 & 3 and TAI-Q. Intrarater reliability was assessed by rater 1 completing another TAI by watching the recorded videos after a 4-week delay. Assessments were compared using paired sample t-tests and level of agreement between TAI scores was evaluated using Bland-Altman plots. RESULTS: Moderate to good interrater and good intrarater reliability were found for the total TAI score with ICCs: 0.57-0.90 and 0.90, respectively. Moderate to good intrarater and interrater reliability were found for all TAI subscores (ICC: 0.60-0.94) except for interrater reliability of flight/landing which was poor (ICC: 0.20). Bland-Altman plots indicate no systematic bias related to the measurement of error. CONCLUSIONS: The TAI is a reliable outcome measure for assessing the wheelchair and body setup phases of home-based transfers remotely and through self-assessment among individuals with SCI.

Clinical utility during inpatient rehabilitation of a clinical prediction rule for ambulation prognosis following spinal cord injury.

Objective: Mobility prognosis is a key focus during rehabilitation following spinal cord injury (SCI). The goal of this study was to prospectively evaluate the clinical utility of the van Middendorp clinical prediction rule (CPR).Design: Observational studySetting: Inpatient rehabilitation unitParticipants: Physical therapists and their patients with acute SCI and SCI disorders (SCI/D) for whom long-term ambulation prognosis was judged difficult to determine.Interventions: N/AOutcome Measures: CPR-determined probability of ambulation, therapist reported clinical utility (yes/no), shared with the patient (yes/no), useful for motivation/setting realistic expectations, and Functional Independence Measure (FIM) Locomotion walk score.Results: Five therapists and 52 patients (8 non-traumatic SCI/D) participated. 91% had lesions classified as AIS C or D. The median [IQR] for CPR probability of ambulation was 96.0 [86.5,99.0] for traumatic SCI and 80.0 [64.5, 94.5] for non-traumatic SCI/D. Clinical utility was reported for 45% of those with SCI and 88% with non-traumatic SCI/D. Therapists with less experience were more likely to report clinical utility and share with their patients. Ambulation probability was higher for patients who did not meet their FIM goal. CPR probability was correlated with discharge FIM only for non-traumatic SCI/D.Conclusion: The CPR was not predictive of inpatient rehabilitation outcomes, in fact outcomes varied widely for individuals with similar probabilities emphasizing the importance of clinical judgement and continued need to identify individual factors that affect ambulation. However, greater utility in establishing prognosis and goal setting was noted for clinicians with less experience and for individuals with non-traumatic SCI/D.

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.

Type and frequency of wheelchair repairs and resulting adverse consequences among veteran wheelchair users.

PURPOSE: Investigate the type and frequency of wheelchair repairs and resulting adverse consequences in a Veteran population. DESIGN: Convenience cross-sectional sample survey. SETTING: Data were collected at the 2017 National Veterans Wheelchair Games. PARTICIPANTS: Veterans who use a wheelchair ≥ 40 h/wk (n = 60). INTERVENTION: Not applicable. MAIN OUTCOME MEASURES: Repairs and associated adverse consequences, wheelchair age and usage, type of repairs completed, time elapsed between breakdowns and repairs, and who completed repairs. RESULTS: 60 participants reported 124 repairs in the previous 6 months with 88.3% of participants requiring at least one repair. Consequences were reported by 43.5% of those experiencing repairs and were most commonly secondary to repairs in the electrical system, wheelchair frame, power/control system, and wheels and casters. Travelling greater distances during the week and on weekends was associated with increased rates of repairs (p = 0.01 and p = 0.02, respectively) and consequences (p = 0.03 and p = 0.03, respectively). Power wheelchairs were more likely to require repairs than manual wheelchairs (p = 0.007). The median time to repair was 7 [0.8,30] days. Vendors completed 82.1% of the repairs. Those experiencing longer repair times were more likely to experience adverse consequences (p < 0.001). CONCLUSION: A high number of repairs and resulting adverse consequences occur for wheelchair users, particularly power wheelchair users, in a sample of Veterans. Interventions to prevent breakdowns and to address repairs and adverse consequences in a time-efficient manner are needed.Implications for rehabilitationIn a sample of Veterans, a high number of repairs and resulting adverse consequences occur for wheelchair users, particularly power wheelchair users.There is an important clinical opportunity to help wheelchair users avoid repairs in the first place and reduce adverse consequences after breakdowns occur by improving wheelchair quality, providing preventative chair maintenance, and repairing breakdowns in a timely and efficient manner.These interventions may prove impactful in reducing the adverse medical, functional, and social consequences of wheelchair breakdowns.

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.

Using remote learning to teach clinicians manual wheelchair skills: a cohort study with pre- vs post-training comparisons.

PURPOSE: To test the hypothesis that remote learning to teach clinicians manual wheelchair skills is efficacious. MATERIALS AND METHODS: A convenience sample of therapists (physical and occupational) and students were enrolled in pairs in a cohort study with pre- versus post-training comparisons. The intervention was a hybrid of self-study and hands-on practice paired with remote feedback for ten intermediate and advanced manual wheelchair skills. Participants practiced with self-selected frequency and duration, uploading a session log and video(s) to an online platform. A remote trainer provided asynchronous feedback prior to the next practice session. Capacity and confidence in completing the ten skills were evaluated using the Wheelchair Skills Test Questionnaire (WST-Q). Knowledge of wheelchair skills training and motor learning was assessed using a 62-item Knowledge Test. Secondary outcome measures included skill achievement, as confirmed by submitted video recordings, and participant feedback about the training. RESULTS: Across 41participants, scores were higher at follow-up compared to baseline for WST-Q capacity (73.9 ± 19.1 vs 16.8 ± 15.6, p < 0.001), WST-Q confidence (80.1 ± 12.2 vs 47.6 ± 18.2, p = 0.003) and knowledge (70.8 ± 7.5 vs 67.0 ± 5.4, p = 0.004). CONCLUSIONS: Remote learning can increase wheelchair skills capacity and confidence as well as knowledge about such training and assessment. This model should be further investigated as a delivery method for training rehabilitation professionals. CLINICAL TRIAL REGISTRATION NUMBER: NCT01807728.Implications for rehabilitationWheelchair skills training is one of the 8 steps of wheelchair provision as outlined by the World Health Organization.Wheelchair skills are not a core part of most clinical curriculums and many clinicians cite a lack of resources and uncertainty on how to implement wheelchair skills training into practice as major barriers to providing such training.Remote learning offers the benefits of structured wheelchair skills training with expert feedback on an individual's own schedule that is not afforded by one-day "bootcamp"-type courses or on-the-job training, which are how many clinicians currently learn wheelchair skills.In a sample of physical and occupational therapists and students, remote learning was effective at increasing capacity and confidence to perform manual wheelchair skills as well as knowledge of wheelchair training.

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.

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.

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.

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.

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.

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

OBJECTIVES: To evaluate the psychometric properties of the Transfer Assessment Instrument Questionnaire (TAI-Q), a self-assessment measure to evaluate transfer quality compared with clinician-reported measures. DESIGN: Participants self-assessed transfers from their wheelchair to a mat table using the TAI-Q. For session 1, participants self-assessed their transfer both before and after reviewing a video of themselves completing the transfer (session 1). Self-assessment was completed for another transfer after a 10-minute delay (session 2, intrarater reliability) and after a 1- to 2-day delay (session 3, test-retest reliability). Self-assessment was compared with a criterion standard of an experienced clinician scoring the same transfers with the Transfer Assessment Instrument (TAI) version 4.0 (concurrent validity). SETTING: 2017 National Veterans Wheelchair Games. PARTICIPANTS: Convenience sample of full-time wheelchair users (N=44). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: TAI-Q and TAI. RESULTS: After video review of their transfer, acceptable levels of reliability were demonstrated for total TAI-Q score for intrarater (intraclass correlation [ICC], 0.627) and test-retest reliability (ICC, 0.705). Moderate to acceptable concurrent validity was demonstrated with the TAI (ICC, 0.554-0.740). Participants tended to underestimate the quality of their transfer (reported more deficient items) compared with the TAI. However, this deficit decreased and reliability improved from pre-video review to post-video review and from session 1 to session 2. The minimum detectable change indicated that a change of 1.63 to 2.21 in the TAI-Q total score is needed to detect a significant difference in transfer skills. CONCLUSIONS: When paired with video review, the TAI-Q demonstrates moderate to acceptable levels of reliability and validity for the total score. Self-assessment was completed quickly (<5min) and could help to potentially screen for deficiencies in transfer quality and opportunities for intervention.

Start-up propulsion biomechanics changes with fatiguing activity in persons with spinal cord injury.

Objective: Shoulder pathology is a common condition in wheelchair users that can considerably impact quality of life. Shoulder muscles are prone to fatigue, but it is unclear how fatigue affects start-up propulsion biomechanics. This study determines acute changes in start-up wheelchair propulsion biomechanics at the end of a fatiguing propulsion protocol. Design: Quasi-experimental one-group pretest-postest design. Setting: Biomechanics laboratory. Participants: Twenty-six wheelchair users with spinal cord injury (age: 35.5 ± 9.8 years, sex: 73% males and 73% with a paraplegia). Interventions: Protocol of 15 min including maximum voluntary propulsion, right- and left turns, full stops, start-up propulsion, and rests. Outcome measures: Maximum resultant force, maximum rate of rise of applied force, mean velocity, mean fraction of effective force, and mean contact time at the beginning and end of the protocol during start-up propulsion. Results: There was a significant reduction in maximum resultant force (P < 0.001) and mean velocity (P < 0.001) at the end of the protocol. Also, contact time was reduced in the first stroke of start-up propulsion (P < 0.001). Finally, propelling with a shorter contact time was associated with a greater reduction in performance (maximum velocity) at the end of the protocol. Conclusion: There are clear changes in overground propulsion biomechanics at the end of a fatiguing propulsion protocol. While reduced forces could protect the shoulder, these reduced forces come with shorter contact times and lower velocity. Investigating changes in start-up propulsion biomechanics with fatigue could provide insight into injury risk.

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.

Microdialysis to Quantify Inflammatory Cytokines in the Glenohumeral Joint: A Brief Methods Report.

Microdialysis quantifies in vivo soft-tissue biochemical concentrations via passive diffusion of interstitial molecules through a porous membrane into a dialysate. The purpose of this pilot study was to evaluate a technique to measure inflammatory cytokines associated with rotator cuff tendinopathy by inserting a microdialysis catheter into the posterior glenohumeral joint. The technique was tested in a convenience sample of six pain-free, able-bodied veterans. Complete dialysate samples were collected in two participants. Two participants' sample volumes were smaller than what was required for analysis (30 µl) and thus were diluted. Catheter failures in two participants prevented collection altogether. Three cytokine concentrations were quantified: interleukin-1 receptor antagonist, interleukin 8, and regulated on activation, normal T-cell expressed and secreted. Microdialysis is not recommended for use in the glenohumeral joint, yet quantification of glenohumeral joint cytokines could yield valuable information to better understand pathophysiology of the joint and its surrounding tissues. Another technique, such as joint lavage, may be a more attractive alternative to overcome the limitations of microdialysis in the glenohumeral joint.

Reliability and Validity of the Revised Transfer Assessment Instrument.

Background: Proper transfer technique is associated with improved biomechanics and decreased pain and pathology. However, many users do not use proper technique, and appropriate assessment and training are needed to address these deficits. The transfer assessment instrument (TAI) 4.0 was designed to meet those needs and improve on past versions by removing the need for clinician training, shortening administration time, and simplifying question content. Objectives: Evaluate the psychometric properties of the TAI 4.0. Methods: A convenience sample of full-time wheelchair users was scored on multiple transfers by four raters to assess interrater, intrarater, and test-retest reliability and concurrent validity of the TAI 4.0. Each user also was scored using a visual analog scale (VAS). Results: For 44 participants, the mean TAI 4.0 and VAS across all transfers were 7.58 ± 1.12 and 7.44 ± 1.78, respectively, and scores were significantly correlated (r = 0.52-0.7). VAS scores were more strongly influenced by the flight/landing and body setup phases of the transfer. There were no significant associations between TAI 4.0 score and demographics. Intraclass correlation coefficients (ICC) ranged from 0.80 to 0.85 for interrater reliability, 0.60 to 0.76 for intrarater reliability, and 0.55 to 0.76 for test-retest reliability. The minimum detectable change (MDC) for the total score ranged from 1.02 to 1.30. Conclusion: The TAI 4.0 provides reliable and valid quantitative assessment of an individual's transfer without the need for comprehensive training, as is the case with the TAI 3.0. The tool can be completed in 3 minutes (average) in a clinical setting with only a ruler and goniometer.

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.