Effectiveness of wheelchair skills training for improving manual wheelchair mobility in children and adolescents: protocol for a multicenter randomized waitlist-controlled trial.

BACKGROUND: Self-directed mobility during childhood can influence development, social participation, and independent living later in life. For children who experience challenges with walking, manual wheelchairs (MWCs) provide a means for self-directed mobility. An effective MWC skills training program exists for adults, but controlled trials have not yet been documented in children and adolescents. This paper outlines the protocol for a multi-centre randomized wait-list controlled trial. The primary objective is to test the hypothesis that children and adolescents who receive MWC skills training will have higher MWC skills capacity compared to children and adolescents in the control group who receive usual care. The secondary objectives are to explore the influence of MWC skills training in children and adolescents (MWC use self-efficacy and satisfaction with participation in meaningful activities), and parents (perceived MWC skills); and to measure retention three months later. METHODS: A multi-centre, parallel-group, single-blind randomized wait-list controlled trial will be conducted. A sample of 60 children and adolescents who use MWCs will be recruited in rehabilitation centres, specialized schools, and the communities of three Canadian cities. Participants will be randomized (1:1) to the experimental (Wheelchair Skills Training Program [WSTP]) or wait-list control group (usual care). Performance-based and self-report measures will be completed at baseline (T1), three months (post-intervention, T2), and three months post-intervention (T3). The primary outcome will be MWC skills capacity post-intervention. Secondary outcomes will be MWC use self-efficacy and satisfaction with participation of the child/adolescent, and parent-perceived MWC skills. The WSTP will consist of 12 sessions, 45-60 min each, delivered 1-2 times per week by trained personnel with health professions education. Training will be customized according to the child's baseline skills and participation goals that require the use of the MWC. The wait-list control group will receive usual care for 3 months and then receive the WSTP after completing T2 evaluations. Data will be analysed using ANCOVA (controlling for baseline scores). DISCUSSION: MWC skills training may be one way to improve self-directed mobility and related outcomes for children and adolescents. The results of this multi-centre randomized wait-list controlled trial will allow for the effectiveness of the intervention to be evaluated in a variety of clinical contexts and geographical regions. TRIAL REGISTRATION: ClinicalTrials.gov: NCT05564247, Version October 3, 2022.

Measuring leg-length discrepancy by the "iliac crest palpation and book correction" method: reliability and validity.

OBJECTIVE: To determine the reliability and validity of a clinical measurement of leg-length discrepancy (LLD), by using the iliac crest palpation and book correction (ICPBC) method. DESIGN: Intra- and interrater reliability and validity determinations. SETTING: Rehabilitation center. PARTICIPANTS: Thirty-four healthy subjects, none of whom had an apparent LLD, as determined by iliac crest palpation. INTERVENTIONS: We induced a simulated LLD (7-53 mm) for each subject. To measure the LLD, the examiner performed the ICPBC method by palpating the iliac crests and correcting identified differences with a book opened to the required number of pages. The thickness of the book correction was measured. MAIN OUTCOME MEASURES: Reliability LLD measurement (n = 20), by using the ICPBC method to measure the LLD; construct validity (n = 34), comparing ICPBC measurement with the extent of the induced LLD; and concurrent validity (n = 14), the difference in heights of the superior aspect of the femoral heads from standing radiographs. RESULTS: The intraclass correlation coefficients (ICCs) for the intrarater and interrater reliabilities were.98 and.91, respectively. The ICCs for the construct and concurrent validities were.62 and.76, respectively. The ICPBC method underestimated the induced LLD by a mean difference +/- standard deviation of 3.8 +/- 10.3mm (p =.055) and the radiologic measure by 5.1 +/- 8.6 mm (p =.043). CONCLUSIONS: The ICPBC technique for measuring LLD is highly reliable and moderately valid. When there is no history of pelvic deformity and the iliac crests can be readily palpated, we recommend using iliac crest palpation to detect LLD, and the book correction to quantify it.

The effect of knee-flexion angle on wheelchair turning.

The increasingly popular hyperflexed knee-flexion angle was evaluated to determine its effects on wheelchair turning. Twenty able-bodied subjects were tested comparing the effect of full knee extension and full knee flexion on a number of parameters. We empirically measured the angular velocity of subjects spinning 720 degrees in place, subjects' perceived ease of wheelchair turning, the overall length of the wheelchair, the anteroposterior position of the center of mass (COM), rolling resistance, turning resistance and rear-wheel traction. The combined moment of inertia of the wheelchair and system was modeled. We found that, in comparison with full extension, fully flexing the knees increased angular velocity by 40% and was perceived to be 66% easier by subjects. Overall length decreased by 39%, COM moved rearward 38%, rolling and turning resistance decreased by 21% and 17% respectively, rear-wheel traction increased by 12% and moment of inertia decreased by 42%. All empirically tested parameters were statistically significant (p<0.007). We conclude that the knee-flexion angle has a significant effect on wheelchair turning. The implications of these findings for wheelchair design and prescription will need to be validated on actual wheelchair users and for smaller increments in knee-flexion range.

The primary erythermalgia-susceptibility gene is located on chromosome 2q31-32.

Primary erythermalgia is a rare disorder characterized by recurrent attacks of red, warm, and painful hands and/or feet. The symptoms are generally refractory to treatment and persist throughout life. Five kindreds with multiple cases of primary erythermalgia were identified, and the largest was subjected to a genomewide search. We detected strong evidence for linkage of the primary erythermalgia locus to markers from chromosome 2q. The highest LOD score (Z) was obtained with D2S2330 (Z(max) = 6.51). Analysis of recombination events identified D2S2370 and D2S1776 as flanking markers, on chromosome 2q31-32. This defines a critical interval of 7.94 cM that harbors the primary erythermalgia gene. Affected members within the additional families also shared a common haplotype on chromosome 2q31-32, supporting our linkage results. Identification of the primary erythermalgia gene will allow a better clinical classification of this pleomorphic group of disorders.

Proactive balance strategy while maintaining a stationary wheelie.

OBJECTIVE: To test the hypothesis that a reactive balance strategy is used while maintaining a stationary wheelie, specifically that a forward pitch from the wheelie equilibrium position is associated with a forward displacement of the wheelchair and a rear pitch with rear displacement, with the displacement slightly after the change in pitch. DESIGN: Descriptive and quantitative kinematic analysis. SETTING: Kinesiologic laboratory. PARTICIPANTS: A convenience sample of 10 able-bodied adults. INTERVENTION: Subjects taught to pop and maintain a stationary wheelie for 15 seconds while remaining within a .75 x .75 m2. Three trials of 5 seconds; digitized targets videotaped for analysis. MAIN OUTCOME MEASURES: Pitch angle and rear-wheel position of the wheelchair, derived from digitized videotape and time-series analysis of phase lag. RESULTS: There was an inverse relationship between the direction of pitch and linear displacement-rear pitch was associated with forward wheel displacement and forward pitch was associated with rearward wheel displacement. The mean pitch angle +/- standard deviation was 13.6 degrees +/- 2.3 degrees and the mean horizontal position of the wheelchair was 0.0 +/- 4.9cm. There was little or no phase lag between pitch and displacement. CONCLUSIONS: Wheelie performers maintaining a stationary wheelie appeared to use a proactive balance strategy, in which they used a functional base of support that was larger than the geometric one. These findings may have significance for those who are learning and teaching wheelies and provide broader insights into the nature of dynamic balance.

Fall during a wheelchair transfer: a case of mismatched brakes.

We report the case of a patient who had a transtibial amputation and whose wheelchair had been inadvertently fitted with a push-to-lock brake on one side and a pull-to-lock brake on the other. During a standing-pivot transfer from bed to wheelchair, during which the patient thought that she had applied both brakes, the wheelchair turned away from the patient toward the side of the unlocked brake and the patient fell to the floor. This case report has implications for wheelchair design, wheelchair system management, and for user training.

New wheelie aid for wheelchairs: controlled trial of safety and efficacy.

OBJECTIVE: To test hypotheses that people learning to perform aided wheelies (AW) with a new self-deploying wheelie aid (WA) (1) are safer than those who use the conventional wheelie (CW), (2) are more successful at learning the skills, (3) learn more quickly, and (4) find such skills less difficult. DESIGN: Randomized, controlled study. SETTING: Wheelchair obstacle course. PARTICIPANTS: Forty-two subjects (12 wheelchair users, 30 able-bodied) randomly assigned to the CW (n = 23) or AW (n = 19) groups. INTERVENTIONS: We performed static tests on a WA-modified wheelchair occupied by a test dummy. We also attempted to teach each subject to perform a set of 14 wheelie-related skills. MAIN OUTCOME MEASURES: Visual analog scale (VAS) of safety, percentage of subjects able to learn the skills, the time required, and subjective difficulty scores (from 1 for "very easy" to 5 for "very difficult"). RESULTS: Up to 11.2 degrees of antitip-device stability was available without the WA extending beyond the rearmost aspect of the rear wheel in the resting position. For the CW and AW groups, the mean +/- standard deviation VAS safety scores were 43% +/- 27% and 98% +/- 2% (p <.0001), respectively; the overall success rates were 93% and 96% (p =.079), respectively; the mean times required to learn a skill (in 5-min increments) were 1.56 +/- 1.08 minutes and.72 +/-.35 minutes (p =.002), respectively; and the mean difficulty scores were 2.94 +/-.38 and 2.23 +/-.34 (p <.0001), respectively. CONCLUSIONS: The new WA provides stability and wheelie-like function without interfering with maneuverability. Although both groups were equally successful, learning to perform AWs is safer, faster, and less difficult than learning CWs.

Locomotor-respiratory coupling during axillary crutch ambulation.

OBJECTIVE: To test the hypotheses that locomotor-respiratory coupling occurs in humans using axillary crutches in a swing-through ambulation pattern and that expiration occurs during crutch-stance phase during locomotor-respiratory coupling. DESIGN: Eighteen able-bodied persons were trained in one-footed swing-through gait with axillary crutches. Then, as subjects walked at "somewhat hard" speeds (Borg) on a motorized treadmill for 5 min, we recorded signals from a crutch pressure switch and a mouthpiece-mounted thermocouple. Coupling was defined as being present when the onset of inspiration varied by < or = 5% with respect to the onset of the crutch gait cycle for a minimum of 10 consecutive gait cycles and when there was no drift on a raster plot of the respiratory phases relative to the onset of the gait cycle. RESULTS: Ten (56%) of the 18 subjects exhibited locomotor-respiratory coupling on 1-4 occasions each, with episodes lasting 11.3-148 sec. In 17 (89%) of the 19 episodes of 1:1 locomotor-respiratory coupling, expiration occurred during the crutch-stance phase of the gait cycle and inspiration occurred during crutch swing. CONCLUSIONS: Transient 1:1 locomotor-respiratory coupling occurs in many able-bodied subjects ambulating with axillary crutches and a swing-through gait. Expiration is most often associated with the crutch-stance phase of the gait cycle. This study may have implications for training axillary crutch users.

The contribution of vision to wheelie balance.

OBJECTIVE: To test the hypothesis that vision plays an important role in the maintenance of balance during a stationary wheelchair maneuver in which the wheelchair user lifts and maintains the chair's front wheels off the floor (wheelie). DESIGN: Within-subject comparisons of the ability of subjects to perform wheelies with their eyes open (EO) and their eyes closed (EC). SETTING: Kinesiologic laboratory. PARTICIPANTS: Ten able-bodied adults, a sample of convenience. MAIN OUTCOME MEASURES: Postural sway, as reflected by the standard deviation of sagittal-plane movements of the center of pressure of the chair's right rear wheel on a force platform during a 10-second stationary wheelie balance, and the number of mistrials. RESULTS: The postural sway for all trials (3 EO and EC data collections at the end of each of 3 one-hour training sessions) was 88% greater with the EC than with the EO condition (p < .001) and the number of mistrials was 324% greater (p = .001). By the end of the final training session, the postural sway with the EC (4.0cm) was still 100% greater than with the EO (2.0cm) (p < .001) although there was no longer a difference in the number of mistrials. CONCLUSION: Vision plays an important role in the maintenance of a stationary wheelie, but wheelies can be maintained with the eyes closed. These findings are relevant to the training of wheelchair users and also provide broader insights into the nature of wheelchair function and dynamic balance.

Spotter strap for the prevention of wheelchair tipping.

Injuries caused by wheelchair rear-tipping accidents are common. This article reports on the safety and effectiveness of a spotter strap that attaches to the cross-brace or frame below the center of gravity of an occupied wheelchair. We videotaped five therapists spotting 89 wheelchair users while the users each performed six tasks that were designed to induce rear instability. We induced 16 episodes of complete rear tipping. In all cases, the spotter strap allowed the spotter to stay out of the way during the task, but step in easily when necessary to prevent the wheelchair user from being injured. In one instance, the spotter needed assistance lifting a heavy subject to the upright position after catching the subject with the strap. In summary, the spotter strap is a safe and effective device. We recommend its use when there is a high risk of a rear-tipping accident.

Prostheses for persons with lower-limb amputations: an extra joint increases range of motion.

This report describes two cases in which the addition of an extra joint enhanced range of motion and improved function in persons with unilateral lower-limb amputation. Both individuals had significant disability in the workplace and at home before this modification. In the first case, an individual with a hemipelvectomy had inadequate hip-joint flexion for maneuvering during photo shoots. In the second case, the individual's transfemoral prosthesis provided insufficient knee flexion for kneeling and working in tight spaces. In each case, a manual-locking, single-axis knee joint was added adjacent to the joint with the limited range of motion. In both cases, the addition of the second joint provided the increased flexibility needed. The first person's hip-flexion range improved from 125 degrees to 190 degrees, and the second person's knee-flexion range improved from 140 degrees to 170 degrees. In repeated follow-up, both patients remained highly satisfied with the intervention. The addition of an extra joint is an option that should be considered when inadequate range interferes with function.

Walker inlet-closure strap for unsteady patients with lower-extremity amputations.

Some patients with lower-extremity amputations who use a walker fall backwards after advancing too far forward into the walker's base of support. In a pilot study of 14 patients with unilateral lower-extremity amputations who stepped into the forward two thirds of the walker base, this problem was corrected by using a knee-high elastic strap to close the open posterior "inlet" of the walker. Without the strap, the stance-phase position of the leading ankle was in the forward third of the walker base for 8 subjects and in the middle third for 6. With the walker strap, the ankle position was in the middle third for one subject, in the posterior third for 6, and at or behind the walker inlet for 7 (p < .0002). This simple intervention appears to correct the potentially dangerous behavior of stepping too far into the walker base.

Wheelchair propulsion: descriptive comparison of hemiplegic and two-hand patterns during selected activities.

Most manual wheelchair users with hemiplegia use both the unaffected arm and leg to propel their wheelchairs. The objective of this study was to compare the wheelchair propulsion of subjects using the hemiplegic pattern (one arm and one leg) with subjects using two hands. In a case-controlled study in a kinesiologic laboratory, nine wheelchair users who used the hemiplegic pattern were compared with nine matched controls who used the two-handed pattern. Participants were tested for propelling and stopping the wheelchair, forward and backward, on a level surface and on a 5 degree incline. Video recording was used to assess deviation from the midline, foot slippage, the number of propulsive cycles, and the propelling velocity. Also, on the 5 degree incline, we noted the need for support when unlocking the wheel locks, instances of grabbing the side rail, or rollback between propulsions. The participants using the hemiplegic pattern when propelling up the incline deviated more to the hemiparetic side (P < 0.05), used more propulsive cycles per unit of distance (P < 0.01), were slower (P < 0.001), and used the side rail more often (P < 0.05). When propelling forward on level ground, the participants using the hemiplegic pattern were slower (P < 0.005). When stopping after moving backward down the incline, they were more likely to deviate to the unaffected side (P < 0.01). In conclusion, wheelchair users who use the hemiplegic pattern experience more difficulties than those using two hands, some of which may be amenable to improvements in wheelchair prescription and training.

Clinical measurement of the static rear stability of occupied wheelchairs.

OBJECTIVE: To evaluate a new clinical test, platform testing of the static rear stability of wheelchairs occupied by their users (using methods adapted from the International Organization for Standardization [ISO]), from the perspective of its measurement properties, safety, and comfort. DESIGN: Within-subject comparisons. SETTING: Rehabilitation center. PATIENTS: Ninety-seven wheelchair users. MAIN OUTCOME MEASURES: Static stability (with the brakes locked and unlocked, the occupant leaning forward and back, and with antitip devices in place), dynamic stability (the criterion measure), reliability, validity, sensitivity, specificity, predictive values, and likelihood ratios. RESULTS: Test-retest reliabilities (n = 18 to 24) were all >.93. The test's construct validity was demonstrated by the finding that static stability was appropriately affected by locking the brakes, body position, and antitip devices (p < .0001). Spearman's rank correlations between static and dynamic stability ranged from .29 to .65. Sensitivity ranged from 46% to 85%, specificity from 59% to 78%, positive predictive values from 76% to 86%, negative predictive values from 42% to 69%, positive likelihood ratios from 1.56 to 2.95, and negative likelihood ratios from .22 to .71. There were no adverse events, and the subjects tolerated the tests well. CONCLUSIONS: In the clinical setting, the ISO platform test of static rear stability has good to excellent measurement properties, is safe, and is well tolerated. Static-stability testing in this setting should be performed in the context of a comprehensive evaluation of wheelchair safety and performance.

Ergonomics in rehabilitation: a comparison of two methods of moving an empty manual wheelchair short distances.

OBJECTIVE: To test the hypothesis that most health care workers use the conventional method to move an empty wheelchair short distances (bending to release and apply the wheel locks), but that the "wheelbarrow method" (in which the push handles are used to lift the locked rear wheels off the floor) can be easily taught, requires less bending of the trunk, is faster, and is perceived by health care workers as easier, more efficient, and more comfortable for the back than the conventional method. DESIGN: Within-subject controlled study. SETTING: Kinesiology laboratory. SUBJECTS: Twenty-three health care workers. INTERVENTION: Using both methods, subjects moved a wheelchair from the side to the foot of a simulated bed, and back. MAIN OUTCOME MEASURES: Each move was timed and videotaped. SUBJECTS rated each method using a 10-cm visual analog scale (VAS). RESULTS: The conventional method was ordinarily used by 74% of subjects, but subjects easily learned the wheelbarrow method. While using the conventional method, subjects bent an average+/-SD of 5.9+/-1.5 times, whereas there was no bending in the wheelbarrow method. SUBJECTS required an average of 48% less time to perform the task when using the wheelbarrow method (p < .0001) and rated it (with the VAS) as 20.7%+/-36.0% easier (p < .05), 53.2%+/-25.9% more efficient (p < .0001), and 20.0%+/-35.9% (p < .05) more comfortable for the back. One year later, 95% of 19 subjects who could be reached for follow-up could correctly describe the wheelbarrow method and 74% regularly used it. CONCLUSION: The wheelbarrow method is a superior method of moving an empty wheelchair short distances. Health care workers should be instructed in its use.

Participatory research with native community of Kahnawake creates innovative Code of Research Ethics.

Participatory research requires ethical guidelines to incorporate the needs of the partners, i.e., the researchers and the community. This paper describes the background, development and implementation of an innovative Code of Research Ethics developed for a participatory research project with a Native community in Canada. The document ensures that responsibility and control will be shared by both researchers and community throughout the project including joint publication of the results. It defines community control of data, means of resolving dissension at time of publication, incorporation of new researchers and the differences between community-based and academic researchers.

Hypodermic needles in the neuropathic foot of a patient with diabetes.

A 54-year-old woman with insulin-dependent diabetes mellitus, diabetic neuropathy, neuropathic arthropathy of the feet and a plantar ulcer underwent plain radiography, which showed 2 clipped-off hypodermic needles, of which she had been unaware, in the soft tissue of one foot. This previously unreported complication is clinically instructive in that it demonstrates the importance of counselling patients about the protection of insensitive extremities. This case also has public health implications, suggesting as it does that the still-common practice of breaking hypodermic needles before disposal should be strongly discouraged.

Effects of rear-wheel camber on wheelchair stability.

OBJECTIVES: To evaluate how using a wheelchair with rear-wheel camber (when the bottoms of the wheels are farther apart than the tops) is associated with the risk of instability incidents, and to determine the effect of camber on wheelchair stability. DESIGN, SETTING, PATIENTS: Epidemiologic data were analyzed from a sample of 576 users of manually propelled wheelchairs in Nova Scotia. A controlled trial was performed using a representative wheelchair occupied by an anthropomorphic test dummy, altering the camber in 5 degrees increments from -15 degrees to +15 degrees. MAIN OUTCOME MEASURES: For the epidemiologic study, univariate and multivariate analyses were used. To measure the static stability, a tilting platform was used according to the guidelines of the International Organization for Standardization. RESULTS: Camber users reported significantly more instability incidents; of these incidents, more were in the rear direction (40% vs 27%) and fewer in the lateral direction (17% vs 28%) (p < .01). When controlling for other factors, camber was associated with a 3.91-fold increased risk of sustaining an instability incident (p < .001). With increases in camber angle in the laboratory, lateral and forward stability increased and rear stability decreased (with the wheels unlocked and locked) (p < .001). CONCLUSION: Camber use is negatively associated with instability incidents in the lateral direction and positively associated with incidents in the backward direction, probably due in part to the effects of camber on lateral and rear stability.

Transtibial prosthesis for a patient with Kaposi's sarcoma lesions on the residual limb.

A man with acquired immunodeficiency syndrome (AIDS) and widespread Kaposi's sarcoma (KS) presented with a transtibial amputation secondary to foot infection and intractable pain. Several open and draining KS lesions were present on the residual limb. There were two concerns: (1) prescribing a prosthesis to a person who likely had a limited future as a prosthetic user; and (2) how the lesions would tolerate pressure and shear forces in a prosthesis. There have been no previous reports of KS lesions of residual limbs. We prescribed a patellartendon-bearing prosthesis with supracondylar suspension. The lesions did not worsen with weight-bearing, and healed with concomitant treatment. The patient remains a functional ambulator 1 year after amputation. This case suggests that KS lesions can tolerate pressure and shear forces, which is important in considering prosthetic prescriptions as well as prescriptions of orthoses and other devices.