Taking Control: An Exploratory Study of the Use of Tilt-in-Space Wheelchairs in Residential Care

Tilt-in-space (TIS) wheelchairs are common in residential care, but little empirical evidence exists regarding how they are used by residents and staff in these settings. As part of a larger study exploring the use of wheeled mobility in these facilities, we conducted a substudy to examine how TIS wheelchairs are used in practice and to explore the experiences of the residents who use them. We conducted a series of three participant observations and interviews with 6 residents or their family members and interviewed 10 staff. Our analysis identified taking control as the main overarching theme, subsuming two subthemes: promoting comfort and mobilizing to participate. Findings suggest that power TIS wheelchairs enable user control, whereas manual TIS wheelchairs promote staff control. These findings illustrate how TIS wheelchairs may enable or inhibit occupational engagement and suggest that vigilance is necessary to prevent their use as a restraint.

Discharge Criteria and Follow-Up Support for Dementia Care Units

Specialized dementia care units (DCUs) house individuals whose behaviors cannot be managed in other settings. To ensure environmental fit, admission/discharge criteria are recommended for DCUs; however, there is no consensus about what criteria should be used. This study aimed to describe, in a random sample of DCUs, the current admission criteria, current/recommended discharge criteria, and services to support discharge. Usable surveys were returned by 23 of 30 facilities. Residents were most frequently admitted because they had a diagnosis of dementia and exhibited cognitive/behavioral problems. The four most common discharge criteria in place/recommended were resident ability to manage in a non-specialized long-term care environment, lack of socially inappropriate behaviors, dependency in activities of daily living, and inability to participate in dementia care activities. These findings suggest that discharge from DCUs is relatively ad hoc. The study lays the groundwork for future research to evaluate the use/appropriateness of these criteria.

A survey of stakeholder perspectives on exoskeleton technology

Background

Exoskeleton technology has potential benefits for wheelchair users’ health and mobility. However, there are practical barriers to their everyday use as a mobility device. To further understand potential exoskeleton use, and facilitate the development of new technologies, a study was undertaken to explore perspectives of wheelchair users and healthcare professionals on reasons for use of exoskeleton technology, and the importance of a variety of device characteristics.

Methods

An online survey with quantitative and qualitative components was conducted with wheelchair users and healthcare professionals working directly with individuals with mobility impairments. Respondents rated whether they would use or recommend an exoskeleton for four potential reasons. Seventeen design features were rated and compared in terms of their importance. An exploratory factor analysis was conducted to categorize the 17 design features into meaningful groupings. Content analysis was used to identify themes for the open ended questions regarding reasons for use of an exoskeleton.

Results

481 survey responses were analyzed, 354 from wheelchair users and 127 from healthcare professionals. The most highly rated reason for potential use or recommendation of an exoskeleton was health benefits. Of the design features, 4 had a median rating of very important: minimization of falls risk, comfort, putting on/taking off the device, and purchase cost. Factor analysis identified two main categories of design features: Functional Activities and Technology Characteristics. Qualitative findings indicated that health and physical benefits, use for activity and access reasons, and psychosocial benefits were important considerations in whether to use or recommend an exoskeleton.

Conclusions

This study emphasizes the importance of developing future exoskeletons that are comfortable, affordable, minimize fall risk, and enable functional activities. Findings from this study can be utilized to inform the priorities for future development of this technology.

Electronic supplementary material

The online version of this article (doi:10.1186/1743-0003-11-169) contains supplementary material, which is available to authorized users.

Measurement properties of the late life disability index among individuals who use power wheelchairs as their primary means of mobility

OBJECTIVE

To examine the reliability, validity, and factor structure of the Late Life Disability Instrument (LLDI) in individuals who use power wheelchairs as their primary means of mobility.

DESIGN

A 4-week, test-retest study design.

SETTING

Five Canadian cities.

PARTICIPANTS

The validity sample included 115 new and experienced power mobility users, and the reliability sample included 85 experienced users (N=115). These volunteer samples included individuals who were aged ≥50 years and independently used power mobility as their primary means of mobility.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

The LLDI measures participation in 2 dimensions of 16 life activities: frequency and perceived limitations. Validity measures included the Wheelchair Skills Test-power version, the Assistive Technology Outcomes Profile for Mobility, the Hospital Anxiety and Depression Scale, the Power Mobility Wheelchair Confidence Measure, and the Life Space Assessment.

RESULTS

For the reliability sample, raw intraclass correlational coefficients for limitation and frequency dimension scores ranged from .855 (95% confidence interval .781-.905) to .883 (95% confidence interval, .822-.924), respectively. For the validity sample, scores on the LLDI were correlated as hypothesized with scores on validity measures. The factor structure that was identified with the original sample was not replicated among power wheelchair users. For LLDI frequency, exploratory factor analysis indicated that 5 of the original 16 items did not perform similarly among power wheelchair users. For LLDI limitations, a 1-factor, rather than a 2-factor, solution was identified.

CONCLUSIONS

The study provides evidence in support of the reliability and validity of the measure but suggests that the original subscale scores may not be applicable to power wheelchair users.

Power mobility with collision avoidance for older adults: user, caregiver, and prescriber perspectives

Collision avoidance technology has the capacity to facilitate safer mobility among older power mobility users with physical, sensory, and cognitive impairments, thus enabling independence for more users. Little is known about consumers' perceptions of collision avoidance. This article draws on interviews (29 users, 5 caregivers, and 10 prescribers) to examine views on design and utilization of this technology. Data analysis identified three themes: "useful situations or contexts," "technology design issues and real-life application," and "appropriateness of collision avoidance technology for a variety of users." Findings support ongoing development of collision avoidance for older adult users. The majority of participants supported the technology and felt that it might benefit current users and users with visual impairments, but might be unsuitable for people with significant cognitive impairments. Some participants voiced concerns regarding the risk for injury with power mobility use and some identified situations where collision avoidance might be beneficial (driving backward, avoiding dynamic obstacles, negotiating outdoor barriers, and learning power mobility use). Design issues include the need for context awareness, reliability, and user interface specifications. User desire to maintain driving autonomy supports development of collaboratively controlled systems. This research lays the groundwork for future development by illustrating consumer requirements for this technology.

Prescribers' experiences with powered mobility prescription among older adults

Despite the potential benefits of powered mobility, many older adults do not have access to this technology. To date, few studies have explored how prescribers make decisions regarding provision of powered mobility. Therefore, we undertook a qualitative study to develop a better understanding of prescribers' attitudes toward and practices with older adult candidates for powered mobility devices. Our analysis of 10 in-depth interviews identified three main themes: (1) "Deciding who should be entitled" explored how therapists decided who should have access to powered mobility, (2) "power wheelchair negotiation" described the discord between clients and therapists that became apparent during this process, and (3) "practical considerations" revealed how contextual factors shaped the provision of powered mobility. The findings suggest that the ways in which powered mobility is funded, provided, and accommodated should be improved so that more older adults have access to these devices and can use them to their full potential.

How assistive technology use by individuals with disabilities impacts their caregivers: a systematic review of the research evidence

Informal caregivers are a critical yet frequently unacknowledged part of the healthcare system. It is commonly presumed that providing assistive technology will decrease the burden of their care provision; however, no review has evaluated the evidence behind this assumption. Therefore, a systematic review was undertaken to evaluate evidence of the impact of assistive technology use by care recipients on their informal caregivers. Data sources included EMBASE, MEDLINE, Cumulative Index to Nursing and Allied Health Literature, Web of Science, PsychINFO, PubMed, and active researchers in this area. Twenty-two studies met the specified inclusion criteria. Collectively, the findings suggest that assistive technology use helps caregivers by diminishing some of the physical and emotional effort entailed in supporting individuals with disability. However, confidence in this causal connection is limited because of the study designs that were used. This undermines the understanding of the impacts of assistive technology use on the users' informal caregivers.

Commentary on "ICF from an occupational therapy perspective in adult care: an integrative literature review"

This letter to the editor is in response to the article by Pettersson, Pettersson and Frisk entitled, "ICF from an occupational therapy perspective in adult care: an integrative literature review". Given the breadth of this topic, the authors have done an admirable job in their survey of the topic. One area we felt deserved additional attention was the inadequate way the ICF classification system codes mobility assistive technology use. We also offer a point of clarification about the Wheelchair Outcome Measure, which was identified incorrectly as the only wheelchair specific measure that could measure activity and participation.

Association between mobility, participation, and wheelchair-related factors in long-term care residents who use wheelchairs as their primary means of mobility

OBJECTIVES

To explore how wheelchair-related factors, mobility, and participation are associated in a sample of long-term care residents who use wheelchairs as their primary means of mobility.

DESIGN

Cross-sectional survey.

SETTING

Eleven residential care facilities in the lower mainland of British Columbia, Canada.

PARTICIPANTS

One hundred forty-six self-responding residents and 118 proxy respondents: mean age 84 (range 60-103). Most were female (69%), and a small proportion (9%) drove a power wheelchair.

MEASUREMENTS

The Nursing Home Life Space Diameter Assessment was used to measure resident mobility, and the Late Life Function and Disability Instrument: Disability Component was used to measure participation frequency in daily activities.

RESULTS

Path analysis indicated that wheelchair-related factors were associated with participation frequency directly and indirectly through their relationship with mobility. The final model explained 46% of the variance in resident mobility and 53% of the variance in resident participation frequency. Wheelchair skills, which include the ability to transfer in and out of and propel a wheelchair, were important predictors of life-space mobility and frequency of participation, and life space mobility was a significant predictor of frequency of participation. Depression was associated with poorer wheelchair skills and mobility and less-frequent participation. Counterintuitively, perceived environmental barriers were positively associated with frequency of participation.

CONCLUSION

The findings suggest that, by addressing wheelchair-related factors, resident's mobility and participation may be improved, but the efficacy of this approach needs to be confirmed experimentally.

Grey spaces: the wheeled fields of residential care

Many individuals living in residential care use a wheelchair as their primary means of mobility. Although studies have documented challenges encountered by residents in these facilities, few have addressed the role that wheelchairs, as potential enablers and barriers to mobility and participation, play in their lives. To better understand residents' experiences, an ethnographic study was conducted drawing on Bourdieu's theoretical constructs of capital, field, and habitus. Participant observations were conducted at two facilities, and residents, family members and staff took part in in-depth individual interviews. Our analysis revealed three themes. Ready to roll detailed how residents used wheelchairs as a source of comfort and means for expanding their social space, while staff could use them as a means to move and control some residents. Squeaky wheels described how residents solicited assistance from staff and family amid having to wait to perform activities of daily living. In, out and about revealed diversity in the places residents went, spaces they shared and the social activities in which they engaged inside and outside their residential facilities. The study findings emphasise how wheelchairs constitute capital that governs many fields of practice for residents and staff and suggest how practice and policy might be adjusted.

Prevalence and facility level correlates of need for wheelchair seating assessment among long-term care residents

BACKGROUND

Wheelchairs are frequently prescribed for residents with mobility impairments in long-term care. Many residents receive poorly fitting wheelchairs, compromising functional independence and mobility, and contributing to subsequent health issues such as pressure ulcers. The extent of this problem and the factors that predict poor fit are poorly understood; such evidence would contribute greatly to effective and efficient clinical practice in long-term care.

OBJECTIVE

To identify the prevalence of need for wheelchair seating intervention among residents in long-term care facilities in Vancouver and explore the relationship between the need for seating intervention and facility level factors.

METHODS

Logistic regression analysis using secondary data from a cross-sectional study exploring predictors of resident mobility. A total of 263 residents (183 females and 80 males) were randomly selected from 11 long-term care facilities in the Vancouver health region (mean age 84.2 ± 8.6 years). The Seating Identification Tool was used to establish subject need for wheelchair seating intervention. Individual item frequency was calculated. Six contextual variables were measured at each facility including occupational therapy staffing, funding source, policies regarding wheelchair-related equipment, and decision-making philosophy.

RESULTS

The overall prevalence rate of inappropriate seating was 58.6% (95% CI 52.6-64.5), ranging from 30.4 to 81.8% among the individual facilities. Discomfort, poor positioning and mobility, and skin integrity were the most common issues. Two facility level variables were significant predictors of need for seating assessment: ratio of occupational therapists per 100 residents [OR 0.11 (CI 0.04, 0.31)] and expectation that residents purchase wheelchair equipment beyond the basic level [OR 2.78 (1.11, 6.97)]. A negative association between facility prevalence rate and ratio of occupational therapists (r(p) = -0.684, CI -0.143 to -0.910) was found.

CONCLUSION

Prevalence of need for seating assessment in long-term care is high overall but it varies considerably between facilities. Increasing access to occupational therapy services appears to mediate this need.

Predictors of mobility among wheelchair using residents in long-term care

OBJECTIVE

To identify predictors of mobility among long-term care residents who use wheelchairs as their main means of mobility. Based on the Matching Person to Technology Model, we hypothesized that wheelchair-related, personal, and environmental factors would be independent predictors of mobility.

DESIGN

Cross-sectional study.

SETTING

Eleven long-term residential care facilities in the lower mainland of British Columbia, Canada.

PARTICIPANTS

Residents (N=268): self-responding residents (n=149) and residents who required proxy respondents (n=119).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Mobility was measured using the Nursing Home Life-Space Diameter. Standardized measures of personal, wheelchair-related, and environmental factors were administered and sociodemographic data were collected as independent variables.

RESULTS

Independent mobility decreased as the distance from the resident's room increased: 63% of participants were independently mobile on their units, 40% were independently mobile off their units within the facilities, and 20% were independently mobile outdoors. For the total sample, the significant predictors of mobility, in descending order of importance, were: wheelchair skills (including the capacity to engage brakes and maneuver), functional independence in activities of daily living, having 4 or more visits per week from friends or family, and use of a power wheelchair. This regression model accounted for 48% of variance in mobility scores.

CONCLUSIONS

Limited independent mobility is a common problem among facility residents. Residents may benefit from interventions such as wheelchair skills training or provision of powered mobility, but the effectiveness of these interventions needs to be evaluated.

Measurement properties of the wheelchair outcome measure in individuals with spinal cord injury

STUDY DESIGN

One-week retest methodological study.

OBJECTIVES

To assess the reliability and validity of the wheelchair outcome measure (WhOM) in a sample of individuals with spinal cord injury (SCI).

SETTING

Vancouver, British Columbia, Canada.

METHODS

The WhOM measures the impact of wheelchair interventions on a user's self-selected participation outcomes. The WhOM was administered to 50 participants on two occasions by the same rater, 1 week apart, to assess test-retest reliability. To determine inter-rater reliability, the WhOM was administered a third time approximately 72 h later by a different rater. Validity was evaluated by correlating scores from the WhOM with scores from the Assessment of Life Habits (LIFE-H).

RESULTS

The test-retest intraclass correlation coefficients (ICC(2, 2)) for the WhOM satisfaction (Sat) and WhOM importance (Impt) × Sat scores were 0.83 (95% confidence interval (CI), 0.72-0.90) and 0.88 (95% CI, 0.79-0.93), respectively. The inter-rater ICC for the WhOM Sat and WhOM Impt × Sat scores were 0.91 (95% CI, 0.85-0.95) and 0.90 (95% CI, 0.83-0.94), respectively. As hypothesized, most scores on the WhOM were fair to moderate (r=0.3-0.5) and positively correlated with scores on the LIFE-H.

CONCLUSION

The WhOM is a new outcome measure that demonstrates good reliability and validity among individuals with SCI. It is designed to assist wheelchair users identify and evaluate the impact of wheelchair interventions on participation level outcomes. The WhOM may be applicable for clinical- or research-oriented purposes.

Reliability and validity of the telephone administration of the wheelchair outcome measure (WhOM) for middle-aged and older users of power mobility devices

OBJECTIVE

To examine the measurement properties of the tele-phone administration of the Wheelchair Outcome Measure (WhOM).

SUBJECTS

Power mobility device users aged 50-89 years.

METHODS

Two independent cohorts were recruited: (i) a prospective cohort (n = 40) to estimate test-retest reliability and to determine the applicability of the telephone format, and (ii) a cross-sectional cohort to examine construct validity with 3 groups: (a) people waiting for a first power mobility device (n = 44); (b) initial users (n = 35; 1-6 months); and (c) long-term users (n = 39; 12-18 months).

RESULTS

The tool demonstrated good test-retest reliability (intraclass correlation coefficient 0.77-1.00), took 10.9 min (standard deviation = 5.2) to administer and was practical to use over the telephone. Validity testing showed moderate correlations with the Quebec User Evaluation of Satisfaction with Technology (rS = 0.36-0.45) and the Psychosocial Impact of Assistive Devices Scale (rS = 0.31-0.43). WhOM scores could discriminate non-users from users (wait-list vs initial users; wait-list vs long-term users, p < 0.001) and power wheelchair from scooter users (total WhOM scores, p < 0.05).

CONCLUSION

The WhOM is a stable, valid and applicable measure for telephone administration with older power mobility device users. It is moderately linked to satisfaction with the device and to the psychosocial impact of the device, and therefore complements rather than replaces those measures.

Satisfaction with participation using a manual wheelchair among individuals with spinal cord injury

STUDY DESIGN

Cross-sectional.

OBJECTIVES

To describe self-identified indoor and outdoor wheelchair-oriented participation outcomes and to report satisfaction with the identified outcomes by people with spinal cord injury (SCI).

SETTING

Vancouver, British Columbia.

METHODS

Participation outcomes were identified using the Wheelchair Outcome Measure and classified using the International Classification of Functioning, Disability, and Health (ICF).

RESULTS

The average age of the 51 community-dwelling subjects with SCI was 43.7(+/-10.7) years. Of them, 84% were men, 64% had tetraplegia and 66% used a manual wheelchair. There were 258 indoor and 257 outdoor participation outcomes identified by this sample with most outcomes falling into the 'community, social, and civil life' (36.5%), 'domestic life' (23.7%) and 'mobility' (18%) domains of the ICF. All domains had a mean satisfaction score of 7.1/10 or greater except for the indoor 'mobility' domain that had a mean satisfaction score of 6.1/10. Satisfaction scores with performance of the specific participation outcomes ranged from high (10/10) to low (2/10) with most scores falling above 7/10.

CONCLUSION

Community-dwelling people with SCI commonly engage in wheelchair-oriented participation outcomes related to 'community, social, and civil life', 'domestic life' and 'mobility' and tend to be satisfied with their performance of these participation outcomes. This information is useful for clinicians and may help to guide assessment and intervention.

Mixed Methods Research in Occupational Therapy: A Survey and Critique

Mixed qualitative and quantitative studies are becoming popular in social sciences research and are recognized as legitimate project designs. However, diverse definitions and applications are common and little consensus exists about exactly what constitutes a mixed methods approach. In this article, the authors provide an overview of various approaches to mixed methods and present the findings derived from a survey of mixed methods research published between 2000 and 2005 in nine occupational therapy journals. The results from this survey indicate that, although the use of mixed methods is relatively common (14% of all research articles published), there are several methodological issues to be considered. These include the subordinate positioning of qualitative findings and lack of justification for using mixed methods. Recommendations are offered to conceptually advance future applications and guide occupational therapy researchers considering the use of mixed methods.

The wheelchair procurement process: perspectives of clients and prescribers

BACKGROUND

Increasing choices in assistive technology have made the process of procuring a wheelchair more complex and challenging.

PURPOSE

To explore the intricacies of the procurement process from the perspectives of clients and therapists.

METHODS

Thirty-four participants were interviewed, including 13 wheelchair prescribers, 14 wheelchair users, and 7 wheelchair associates (family members and caregivers).

FINDINGS

Analysis revealed five main themes. "Who decides?" described varying degrees of client involvement in the procurement process. "Expert knowledge" reflected the expert knowledge that all parties possessed. "Form versus function"captured the primary and, at times, conflicting outcomes that participants wanted to achieve. "Fitting in" depicted the environmental factors that affected wheelchair procurement. "(Re)solutions" illustrated strategies that participants felt improved the process.

IMPLICATIONS

This study reveals clients' experiences with wheelchair procurement, identifies potential issues therapists may encounter, and suggests possible remedies they might consider when prescribing wheelchairs within a client-centred framework.

A review of scales for assessing the risk of developing a pressure ulcer in individuals with SCI

BACKGROUND

Pressure ulcers are a common secondary condition that occur post-spinal cord injury (SCI). These ulcers come at tremendous personal and societal cost. There are a number of scales that can be used to identify those who are at risk.

OBJECTIVES

This review critically evaluates risk assessment scales designed for identifying and predicting skin ulcers. Specifically, studies on the psychometric properties and utility for individuals with SCI were assessed.

METHODS

The MedLine, CINHAL, Embase, HaPI, Psycinfo, Sportdiscus and Cochrane databases were searched to identify studies. To be included, the scale needed to have at least one study, published in a peer-reviewed journal, which examined its psychometric properties with a sample of individuals with SCI.

RESULTS

Seven scales were included in this review: Abuzzese, Braden, Gosnell, Norton, SCIPUS, SCIPUS-A and Waterlow. None of the tools reported reliability data with this population. Validity evidence ranged from poor to adequate across scales. Most were readily available, quick to administer and had minimal respondent burden; however, the SCIPUS-A and SCIPUS, two scales developed specifically for individuals with SCI, required laboratory blood testing.

CONCLUSION

Although the SCIPUS-A and SCIPUS show promise, utility issues and limited psychometric testing suggest that these tools cannot be recommended at this time. While the Braden scale has the best combined validity and utility evidence, more specific testing with individuals with SCI is required for it and all other scales included in the review.