A preliminary model of wheelchair service delivery

Provision and use of assistive products in patients after stroke and spinal cord injury in Germany: a qualitative interview study

PURPOSE

Mobility impairments are a common consequence of stroke and spinal cord injury (SCI). Assistive products (APs) such as wheelchairs are often needed for activities and participation. The aim of the study was to explore the provision and use of APs in Germany and to identify associated factors underlying this practice.

MATERIALS AND METHODS

Semi-structured interviews were conducted with 19 professionals from outpatient neurorehabilitation services (three general practitioners, five physical therapists, five occupational therapists, one speech therapist, one neuropsychologist, two outpatient nurses, one rehab technician and one social worker), two patient advocates (long-term survivors, each stroke and SCI) and 20 patients (10 each after stroke and SCI with mobility impairment, and first-ever affected). Analysis was performed by qualitative content analysis.

RESULTS

Reported experiences were mixed, varying from high satisfaction to unusable APs and unmet needs. Identified factors associated with these experiences were related to care pathways, care coordination, inter-professional collaboration, professionals' knowledge and patient information, cost coverage, and approval procedures.

CONCLUSION

Overall, patients seem satisfied with the APs they receive, but patients with more severe mobility impairments in particular experience deficits in the provision and use of APs. Further research is needed to develop and test strategies for the provision and use of APs.

Common reasons for non-participation during the outcome measurement process: wheeled mobility service delivery quality improvement reporting

OBJECTIVE

The purpose of this paper is to describe non-participation during the outcome measurement step of the wheeled mobility service delivery process (WMSDP) based on the Functional Mobility Assessment (FMA)-Uniform Dataset (UDS) Registry.

INTRODUCTION

The WMSDP is a standard framework for the provision of wheeled mobility devices, and several factors influence the client's experience throughout the process. Patient-reported outcomes are one way to measure the client's experience as part of a quality improvement program.

METHODS

A retrospective descriptive study was conducted on the FMA-UDS Registry to measure the response rate during the outcome measurement step of the WMSDP and describe the reasons an individual did not complete the FMA-UDS. The FMA-UDS was examined at two time points: pre-delivery and post-delivery of the wheeled mobility device.

RESULTS

As of September 2, 2021, 10,253 cases have been entered into the FMA-UDS Registry. 2,247 cases were no longer participating pre-delivery, and an additional 3,905 cases were no longer participating post-delivery. The most common reasons for non-participation in the FMA-UDS pre-delivery and post-delivery included: equipment not delivered; provider no longer participating in the FMA-UDS; funding issues; no new equipment; client opted out; loss in contact; deceased; returned equipment; and other.

DISCUSSION

The type and frequency of non-participation in the outcome measurement step of the WMSDP is critical to understanding why individuals participate in outcome measures and provides insight into the barriers and facilitators for the implementation of quality improvement programs.

Investigation of factors from assistive technology professionals that impact timeliness of wheelchair service delivery: a cross-sectional study

PURPOSE

The purpose of this study was to examine factors associated with variability in time from assessment to device delivery (cycle time). Our hypothesis was that device type and type of insurance would be the strongest predictor of cycle time.

MATERIALS AND METHODS

Data were extracted from the Functional Mobility Assessment/Uniform Dataset (FMA/UDS) Registry that at the time of analysis contained a sample of 2588 people with disabilities (PWD) who were provided with a wheeled mobility device (WMD) between 21 March 2016 and 29 June 2021. To examine the effect of individual factors on the variability in cycle time, a robust linear regression analysis was conducted.

RESULTS

The average national cycle time was 101.5 (SD = 59.9) d. Geographic area (Capital Metro [p < .001], Great Lakes [p = .016], and Northeast area [p < .001]), higher years since onset of disability (p < .001) and customizable devices (p = .021) were associated with higher cycle time. Non-customizable devices (p = .005), scooters (p < .001), Group 2 power wheelchairs (PWCs; p < .001), and funding source (Medicaid managed care (p < .001) and "other" (p = .028)) were associated with lower cycle time.

CONCLUSIONS

Longer cycle time is likely related to variations in clinical practice, insurance coverage criteria and the level of customizability of the device needed for a particular diagnosis, especially long-term disabilities.Implications for rehabilitationThe national average number of days between initial evaluation and device delivery (cycle time) to deliver a wheeled mobility device (WMD) varies based on specific variables such as type of WMD, diagnosis and payer source.Geographic area, years since onset of disability, device type, primary diagnosis and funding source significantly impact cycle times.Increased complexity of the WMD, both manual and power wheelchairs (PWCs), was associated with longer cycle times.As more service delivery models emerge, specific benefits and challenges need to be reported on how they impact cycle time.

Current state and conceptual framework of assistive technology provision in Saudi Arabia

PURPOSE

Assistive Technology (AT) devices provide essential means of mobility, employment, communication, social engagement for older adults and people with different disabilities, if prescribed correctly to match users' needs and goals. Regardless of the setting or location, a successful AT service delivery model includes the multidisciplinary collaboration of the people with disabilities and the specialists who have knowledge and expertise in the design and application of AT. In Saudi Arabia, unfortunately, the availability of AT devices is mainly limited to basic mobility and daily living aids such as wheelchairs and seating systems, prosthetics and orthotics, communication devices, low-vision devices, and adapted transportation equipment. The aim of this perspective is to provide clinicians and healthcare professionals in Saudi Arabia with a model for the optimisation of the provision of AT devices decision making regarding AT devices for people with disabilities by adhering to a user-centered team approach throughout the service delivery process.

METHOD

The policy, human, activity, assistance, technology, and environment (PHAATE) model is used as a conceptual framework and guideline for this paper.

RESULTS AND CONCLUSION

The PHAATE components could serve as a guideline for a wide range of stakeholders in Saudi Arabia (e.g., researchers, product developers, practitioners, clinicians, third-party reimbursement entities, consumers, and educators) when developing service delivery systems.IMPLICATION FOR REHABILITATIONDespite the support and funding resources of AT devices by the Saudi government, there is still the needs to increase awareness and knowledge about AT application and services, as well as optimal service delivery models of AT devices.AT service delivery provision models such as PHAATE model may help clinicians and other medical professionals in Saudi Arabia to make informed decisions about the provision of AT device services.

Use of supported standing in males with Duchenne muscular dystrophy: Individual and family perspectives

PURPOSE

This study aimed to explore stander use in individuals with Duchenne Muscular Dystrophy (DMD).

METHODS

This mixed method research study employed a survey with categorical and open-ended questions related to stander use. Categorical responses were analyzed quantitatively. Qualitative analysis of open-ended responses was linked to the International Classification of Function. Qualitative and quantitative results were merged to derive meta-inferences.

RESULTS

Of 147 respondents, 28.6% (n = 42) reported stander use. Equipment used included sit-to-stand stander (n = 27), power standing feature in a wheelchair (n = 13), and unspecified equipment (n = 2). Economic services were the most common barrier to stander obtainment. Age of loss of ambulation (LOA) and age of start of stander use were positively correlated (r = 0.61, p < 0.0001, n = 36), with 59.5% initiating stander use after LOA. Twenty-nine respondents reported standing less than the recommended dose of 60-90 minutes at least five days a week, with frequency directionally less than five days per week (p = 0.06) and time significantly less than 60-90 minutes (p = 0.002). Respondents' total dose was significantly lower than the recommended 300 minutes (p = 0.02). Lack of time and presence of contractures contributed to decreased duration of use.

CONCLUSION

This study provides a greater understanding of stander use among individuals with DMD and can assist with decision making about stander use prior to complications of disease progression to promote optimal health despite reported barriers.

Policy Analysis on Power Seat Elevation Systems

In the early 2000s the Centers for Medicare and Medicaid Services determined that power seat elevation systems did not meet the definition of durable medical equipment, and therefore are non-covered items. Yet, power seat elevation systems are covered by other funding sources, and many power wheelchair users utilize these systems regularly when performing tasks such as transferring, reaching, and looking at objects in environments designed for ambulatory people. Adjusting for height when performing these tasks may reduce the onset of pain and comorbidities. To improve access to power seat elevation systems, a clinical team of 4 Clinician Task Force members investigated applicable literature, compiled evidence, and evaluated existing policies to explain the medical nature of power seat elevation systems as a part of a greater interprofessional effort. This manuscript aims to analyze Medicare's policy decision that power seat elevation systems are not primarily medical in nature using Bardach's 8-step framework. As a special communication, this will inform health care professionals of the medical nature of power seat elevation systems and the evidence-based conditions under which power wheelchair users may need power seat elevation systems, as well as empower clinicians to engage in policy directives to affect greater change.

Service delivery for complex rehabilitation technology: a scoping review

PURPOSE

Complex rehabilitation technologies (CRT) support independence for individuals with disabilities by enabling mobility for function, employment, education, and independent living. CRT service delivery is evolving, with changes to funding, provider qualifications, consumer needs, and technological advances. This scoping review investigated service delivery processes for individuals with disabilities who have a mobility impairment, while specifically identifying best practices, barriers, and unique features of health delivery policies and practices.

METHODS

We used a framework described by Colquhoun et. al. for conducting scoping reviews, a six-step process that includes: 1) identifying the research question, 2) identifying studies, 3) selecting studies 4) data charting, 5) reporting results and 6) consultation. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) was also used for reporting results of the review.

RESULTS

Common categories were identified and organised into a hierarchical structure of four categories and 16 sub-categories. The primary categories included "policy", "consumer", "service delivery", and "wheeled mobility devices". The sub-categories described funding sources, consumer and professional populations, service delivery guidelines, and types of mobility devices. Analysis indicated the data were from 21 countries and 14 combinations of funding sources, and the articles were primarily descriptive studies.

CONCLUSION

This scoping review identified evidence from various countries, health systems, and stakeholder. Currently, this process does not proactively address the needs of individuals with mobility disabilities. The scoping review provides the foundation for the development of a novel policy on the provision of CRT services and devices to address these needs.Implications for RehabilitationExamination of national and international service delivery practices in diverse clinical and funding environments indicate various challenges and opportunities for improvement.CRT consumers are negatively impacted by current service delivery practices, including long wait times, lack of specialised clinical expertise, and limited consumer education opportunities.More consistent and widespread research is needed within the CRT provision industry to grow evidence-based practice related to complex rehabilitation technology and individuals with disabilities.

Policy analysis on power standing systems

Power wheelchairs provide people with mobility disabilities opportunities for independence in mobility and repositioning themselves. However, current power wheelchair power options covered by Medicare limit the person to a horizontal plane. In the home, access to the vertical plane is also required for mobility related activities of daily living. Power standing systems on power wheelchairs are one option for providing access to the vertical environment, although currently these systems are not covered by Medicare. Power standing systems also aid in medical management and in preventing common comorbidities associated with chronic neurological and congenital healthcare conditions. Therefore, a legal group led an interdisciplinary effort to change Medicare policy on power standing systems. A policy analysis using Bardach’s Eightfold policy framework was conducted to analyze a clinical groups’ action within this interdisciplinary team. The clinical team considered three viable options to address the problem and evaluated these options against five criteria. Ultimately, a national coverage determination reconsideration would provide a needed opportunity for the coverage of power standing systems. Suggested coverage criteria for power standing systems, based on existing literature and expert clinical experience, are proposed.

Retrospective Chart Review Examining Differences and Timelines in Delivered Wheelchair Equipment in a Midwestern Dedicated Seating Department

OBJECTIVE

This study compares recommended wheeled mobility equipment to delivered equipment, excluding custom seats and backs, considering demographic factors such as sex, age, and funding source, as well as the timeline of the procurement process.

DESIGN

Retrospective chart review.

SETTING

Dedicated wheelchair seating department within a Midwestern rehabilitation hospital and associated complex rehabilitation technology durable medical equipment suppliers.

SAMPLE

Wheelchair recommendations (n = 546) made between January 1, 2017 and December 31, 2017.

INTERVENTIONS

N/A.

MAIN OUTCOME MEASURE(S)

Recommended and delivered wheelchair equipment type and length of time between recommendation and delivery.

RESULTS

Differences were found between the recommended and delivered equipment in manual wheelchairs, power mobility devices, seat backs, cushions, and power option equipment groups (p = ≤.001). Delivered manual wheelchairs were 7% more likely to be different than recommended for each year decrease in age (p = ≤.001), although the model lacked sufficient predictive accuracy for clinical application. Average length of time from equipment recommendation to delivery was about 6 months (M = 176 days). Standard and complex power mobility devices were associated with longer timelines (Mdn = 137, 173 days respectively; p = .001); although, only complex power mobility device timelines were significantly associated with public funding sources (p = .02).

CONCLUSIONS

Wheelchair bases, positioning accessories, and power options may be delivered differently than originally recommended, and the process for procuring complex power mobility devices with public funding sources should be further studied. Health care professionals should consistently follow-up on delivered equipment to ensure expectations and needs of the wheelchair user are met. Reducing systemic barriers to interdisciplinary communication post-recommendation may improve patient outcomes.

An exploratory study analyzing demographics and opinions of assistive technology professionals within the complex rehab technology industry

This exploratory study investigated the demographics of Assistive Technology Professionals (ATPs) regarding their age, education, certifications, ethnicity, gender, veteran status, disability status, method of financial compensation, company type, and category. In addition, it analyzed opinions on the Complex Rehab Technology (CRT) industry regarding education level and licensure. An 18-question survey developed and disseminated by the University of Pittsburgh in collaboration with the National Coalition for Assistive & Rehab Technology (NCART) resulted in 252 responses from current ATPs in the Supplier/Manufacturing industry. The average age of respondents of 51.9 years showed to be above the national average workforce age of 42.2 years. Data were analyzed as a whole and by comparing answers for respondents below and above the average age. 92.4% of the respondents were Caucasian and 79.0% were male showing a need for diversity in the field. Forty-five percent of the younger age group had additional certifications compared to 30% of the older group. 79.8% of all respondents would recommend the ATP profession to someone looking for a career. Findings support the need to increase awareness of the ATP supplier/manufacturing profession to attract younger professionals including those from minority groups. Findings also support the need for additional training for the profession.

Understanding the Global Challenges to Accessing Appropriate Wheelchairs: Position Paper

Introduction: Appropriate wheelchairs are often essential for the health and wellbeing of people with mobility impairments to enhance fundamental freedoms and equal opportunity. To date, provision has mainly focused on just delivering the wheelchair instead of following an evidence-based wheelchair service delivery process. In addition, many governments have not committed to a national wheelchair provision policy. Approach: To prepare this position paper, a systemic development model, founded on the sustainable human security paradigm, was employed to explore the global challenges to accessing appropriate wheelchairs. Positions: I: Consideration of key perspectives of wheelchair provision across the life course is essential to meet the needs to children, adults, older people and their families; II: Comprehensive wheelchair service delivery processes and a competent workforce are essential to ensure appropriate wheelchair service provision; III: Evaluations on wheelchair product quality development, performance and procurement standards are key as wheelchair product quality is generally poor; IV: Understanding the economic landscape when providing wheelchairs is critical. Wheelchair funding systems vary across jurisdictions; V: Establishing wheelchair provision policy is a key priority, as specific policy is limited globally. Conclusion: The vision is to take positive action to develop appropriate and sustainable wheelchair service provision systems globally, for me, for you, for us.

Perspectives of Multidisciplinary Professional Teams during Assessment Processes for ATD Selection in the Japanese Public Provision System

Selection of assistive technology devices (ATDs), which are imperative for persons with disabilities to improve their quality of life, requires collaboration of users and multidisciplinary professionals. However, it is still unknown how to design and implement an adequate collaborative work flow and a professional team. Under Japanese governmental ATD provision system, based on the application by clients, ATDs are mainly selected through collaborative processes with the clients and health professionals in public organizations, rehabilitation counseling centers (RCCs). By employing qualitative study methods in this study, we investigated the ATD selection process in which health professionals in RCCs collaboratively assess clients with physical disabilities so as to support them in selecting the adequate ATDs. To identify the perspectives required for ATD selection completely, the assessment processes were recorded and analyzed with a pseudo setting in two RCCs. Content analysis of the conversations between the client and professionals revealed the characteristics of the information exchanged in the assessment processes. A total of 760 assessment items were identified, thus indicating a broad array of interest. Despite the richness of information collected for the assessment, half of the assessment items did not have corresponding items in the documents that were employed during the prescription process. Thematic analysis of the interviews that followed revealed the common values and collaborative processes in ATD selection, which were shared and elaborated among the staff in daily social interactions. To facilitate implementation of ATD provision in various areas with few resources, it may be effective to convert this tacit-to-tacit knowledge sharing into a more explicit sharing by promoting analyses of good practices.

User Perspectives on the Service Delivery of Complex Power Wheelchairs

The purpose of this study was to explore users' perspectives on power wheelchair service delivery and understand their involvement in the equipment trial and selection process. Five power wheelchair users participated in. Responses and interview data analysis supported four main themes describing variability in the evaluation practices of the provider team, how consumers' participation goals were impacted by equipment usability, consumer involvement in equipment selection influenced satisfaction, and illustrated the complexities in the service delivery process. The conclusion suggests consumer involvement in the trial and selection process may contribute to power wheelchair outcome usability, satisfaction, and occupational engagement.

Athletes with disability' satisfaction with sport wheelchairs: an Italian cross sectional study

PURPOSE

Physical activity is essential for health and well-being. People with physical disability often experience barriers in performing sports due to the lack of appropriate assistive technologies. The present research aimed to investigate athletes with disability satisfaction when using sports wheelchairs and to explore clinometric properties of the Quebec User Evaluation of Satisfaction with Assistive Technology (QUEST).

MATERIALS AND METHODS

One hundred and twenty-eight athletes were involved in the present study. Data on sport discipline and wheelchair provision were collected with qualitative approach. Internal consistency and reliability of QUEST were respectively analyzed with Cronbach's Alpha and Intraclass Correlation Coefficient. Validity was investigated with the correlation of the Wheelchair Use Confidence Scale for Manual users.

RESULTS

Results revealed good internal consistency (.858) and moderate inter-rater reliability for service subscale (.664) and for the total score (.675), while for device subscale (.802) reliability was high. Validity revealed moderate correlation (.300) with a p < 0.05. Qualitative analysis highlighted economic barriers as primary social determinant who affect participation in sport activities.

CONCLUSIONS

The present study confirms preliminary evidence of the QUEST for athletes with disability. The research group also recommends an international effort to promote a comprehensive evaluation of sports wheelchair involving rehabilitation professionals, sport technicians and people with disability.Implications for rehabilitationEconomic factors linked to the purchase of a wheelchair seem being the main barrier for practising sportThe Quebec User Evaluation of Satisfaction with Assistive Technology is a useful tool to measure athletes' satisfaction using a wheelchairRehabilitation professionals and sport technicians should collaborate together with people with disability in determining how choose appropriate sport wheelchairs.

Developing country-specific wheelchair service provision strategic plans for Romania and the Philippines

Background: Achieving appropriate wheelchair provision at a national level is complex, requiring regulations, funding and policies established through governments. Understanding wheelchair provision within different countries is key. This paper describes the process used to support the development of wheelchair service strategic plans in Romania and the Philippines. It considers the influences, meaning, challenges and developments when producing strategic priorities within two different contexts. Methods: The International Society of Wheelchair Professionals (ISWP) sponsored affiliates Motivation Foundation Romania and the Philippine Society of Wheelchair Philippine Society of Wheelchair Professionals (PSWP), to conduct organizational ethnographic mixed method stakeholder centred studies, to develop robust strategic plans. An affiliate coordinator for wheelchair provision in less resourced settings supported this process. Results: Diversity between the two-affiliate sites was evident, influencing value placed within both societies towards equality and participation. Common components to address included: advocacy; wheelchair service infrastructure; capacity building; education; training and research. Research process facilitation supported by affiliate coordinator is important. Conclusion: Understanding contextual dimensions, which sharp a countries wheelchair service, is essential. Member states should take action by conducting in-country wheelchair sector analysis, to create wheelchair provision strategies for sustainable development, to meet personal posture and mobility needs, primary for daily living, as a basic human right. Implications for rehabilitation Understanding the complexity of providing appropriate wheelchairs within different countries is essential to meet the diverse needs of citizens. Conducting situational analysis of the wheelchair sector involving key stakeholders in the process is important to understand different perspectives and develop strategic priorities towards sustainable development. Producing context specific wheelchair sector reports and strategic plans strengthens the evidence base when informing governments regarding the importance of developing sustainable wheelchair provision infrastructures. The affiliate coordinator role is important to support affiliates to produce robust documentation that clearly and objectively outlines the wheelchair sector issues and plans, to provide solutions.

Engineering and Technology in Wheelchair Sport

Technologies capable of projecting injury and performance metrics to athletes and coaches are being developed. Wheelchair athletes must be cognizant of their upper limb health; therefore, systems must be designed to promote efficient transfer of energy to the handrims and evaluated for simultaneous effects on the upper limbs. This article is brief review of resources that help wheelchair users increase physiologic response to exercise, develop ideas for adaptive workout routines, locate accessible facilities and outdoor areas, and develop wheelchair sports-specific skills.

Association of Admission Functional Status and Assistive Device Provision for Veterans Poststroke: A Retrospective Study

OBJECTIVES

The aims of the study were (a) to provide knowledge about the provision of assistive devices in practice and (b) to describe the challenges of standardizing device provision.

DESIGN

This is a retrospective study using Department of Veteran Affairs National Prosthetic Patient Database and other administrative databases. The cohort included all veterans treated by the Veterans Health Administration for stroke during fiscal years 2007-2008. Descriptive methods were used to analyze data with emphasis on inspecting relationships between device provision and motor and cognitive function using Functional Independence Measure scores.

RESULTS

A total of 8374 veterans treated for stroke and receiving at least one assistive device are included. Individuals who received standard or caregiver controlled wheelchairs tended to be older, and those who received ultralight or caregiver controlled wheelchairs had a higher proportion of Hispanics than the overall cohort. Veterans who received any type of wheelchair had lower motor, cognitive, and total functioning scores than the cohort as a whole. Veterans who received canes had the highest functioning. Veteran patients who received patient lifts and beds had lower cognitive scores compared with the overall cohort.

CONCLUSIONS

Functional status can provide some objectivity to the largely subjective assistive device provision decision-making process; however, many other factors must be considered simultaneously, complicating efforts to standardize provision.

Enabling appropriate personnel skill-mix for progressive realization of equitable access to assistive technology

BACKGROUND AND METHODS

This paper reviews the current capacity of personnel in enabling access to assistive technology (AT) as well as the systems and processes within which they work, and was reviewed, discussed, and refined during and following the Global Research, Innovation, and Education in Assistive Technology (GREAT) Summit.

FINDINGS

Key concepts addressed include a person-centred team approach; sustainability indicators to monitor, measure, and respond to needs for service design and delivery; education, research, and training for competent practice, using the six rehab-workforce challenges framework; and credentialing frameworks. We propose development of a competence framework and associated education and training programs, and development and implementation of a certification framework for AT personnel.

CONCLUSIONS

There is a resolve to address the challenges faced by People globally to access assistive technology. Context specific needs assessment is required to understand the AT Personnel landscape, to shape and strengthen credentialing frameworks through competencies and certification, acknowledging both general and specific skill mix requirements. Implications for Rehabilitation Personnel in assistive technology (AT) provision should be trained using a person-centred team approach, which emphasizes appropriate skill-mix to address multiple needs within the community. Sustainability indicators should be used which allow personnel to monitor, measure and respond to needs for service design and delivery. A competence framework with associated education and training program, coupled with the development and implementation of a certification framework for AT personnel needs, will promote quality in AT personnel training globally.

The future of the provision process for mobility assistive technology: a survey of providers

PURPOSE

The purpose of this study was to evaluate the opinions of providers of mobility assistive technologies to help inform a research agenda and set priorities.

MATERIALS AND METHODS

This survey study was anonymous and gathered opinions of individuals who participate in the process to provide wheelchairs and other assistive technologies to clients. Participants were asked to rank the importance of developing various technologies and rank items against each other in terms of order of importance. Participants were also asked to respond to several open-ended questions or statements.

RESULTS

A total of 161 providers from 35 states within the USA consented to participation and completed the survey.

CONCLUSIONS

This survey revealed themes of advanced wheelchair design, assistive robotics and intelligent systems, human machine interfaces and smart device applications. It also outlined priorities for researchers to provide continuing education to clients and providers. These themes will be used to develop research and development priorities. Implications for Rehabilitation • Research in advanced wheelchair design is needed to facilitate travel and environmental access with wheelchairs and to develop alternative power sources for wheelchairs.• New assistive robotics and intelligent systems are needed to help wheelchairs overcome obstacles or self-adjust, assist wheelchair navigation in the community, assist caregivers and transfers, and aid ambulation.• Innovations in human machine interfaces may help advance the control of mobility devices and robots with the brain, eye movements, facial gesture recognition or other systems.• Development of new smart devices is needed for better control of the environment, monitoring activity and promoting healthy behaviours.

Wheelchair service provision education and training in low and lower middle income countries: a scoping review

PURPOSE

Improving access to education and training for those providing wheelchair and seating assistive technology to meet personal posture and mobility requirements, as a basic human right, is a priority. This review considers education and training available to personnel within low and lower middle income countries (LLMIC), to ascertain where gaps in knowledge exist and identify human resource education priorities.

METHOD

A scoping review, mapping out existing scientific and grey literature within the field between 1993 and 2017 was conducted. The search strategy included use of online databases, manual analogue searches and key stakeholder informant advice. A content analysis process was applied to organize the literature retrieved and extract key themes.

RESULTS

Education and training in LLMIC appears ad hoc and limited, however, there is growing recognition as to its importance, notably by the World Health Organization and nongovernmental organizations, delivering education initiatives to a number of countries, along with the development of a credentialing test. Inconsistency exists regarding personnel responsible for wheelchair provision, with no specific professional clearly recognized to oversee the system within many LLMIC.

CONCLUSIONS

Education and training is required for all stakeholders involved in wheelchair provision. Advocating for programme development to enhance personnel skills, build capacity and ensure best practice is a priority. Pilot sites, delivering and credentialing appropriate wheelchair provision education and training within context should be considered. Measuring outcomes and transferable skills should be part of education programme delivery structures. Considering a new discipline responsible for oversight of wheelchair provision should be investigated. Implications for rehabilitation Education and training is an essential step in the wheelchair provision process in the bid to obtain an appropriate wheelchair via appropriate provision services. However, it is more than education and training; its a human rights issue. Mandatory education and training needs to be a requirement for all stakeholders involved in wheelchair provision. Key wheelchair personnel need to establish their central role in this arena. The study raises awareness as to the importance of working with governments to commit to building sustainable wheelchair provision infrastructures.

A conceptual framework to assess effectiveness in wheelchair provision

Background

Currently, inadequate wheelchair provision has forced many people with disabilities to be trapped in a cycle of poverty and deprivation, limiting their ability to access education, work and social facilities. This issue is in part because of the lack of collaboration among various stakeholders who need to work together to design, manufacture and deliver such assistive mobility devices. This in turn has led to inadequate evidence about intervention effectiveness, disability prevalence and subsequent costeffectiveness that would help facilitate appropriate provision and support for people with disabilities.

Objectives

In this paper, we describe a novel conceptual framework that can be tested across the globe to study and evaluate the effectiveness of wheelchair provision.

Method

The Comparative Effectiveness Research Subcommittee (CER-SC), consisting of the authors of this article, housed within the Evidence-Based Practice Working Group (EBP-WG) of the International Society of Wheelchair Professionals (ISWP), conducted a scoping review of scientific literature and standard practices used during wheelchair service provision. The literature review was followed by a series of discussion groups.

Results

The three iterations of the conceptual framework are described in this manuscript.

Conclusion

We believe that adoption of this conceptual framework could have broad applications in wheelchair provision globally to develop evidence-based practices. Such a perspective will help in the comparison of different strategies employed in wheelchair provision and further improve clinical guidelines. Further work is being conducted to test the efficacy of this conceptual framework to evaluate effectiveness of wheelchair service provision in various settings across the globe.

Quality and Equity in Wheelchairs Used by Veterans

OBJECTIVES

To assess in Veterans with spinal cord injury (SCI) or amputated limb (AL) the following: (1) patient demographics, medical factors, cultural and psychosocial characteristic by race; (2) wheelchair quality by race; and (3) the independent associations of patient race and the other factors with wheelchair quality.

DESIGN

Cross-sectional cohort study.

SETTING

Three Department of Veterans Affairs (VA) medical centers affiliated with academic medical centers.

PARTICIPANTS

Eligible participants were Veterans with SCI or ALs (N=516); 482 of them completed the interview. Analyses were restricted to white and African American participants. Because there was no variation in wheelchair quality among AL patients (n=42), they were excluded from all but descriptive analyses, leading to a final sample size of 421.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

Wheelchair quality as defined by the Medicare Healthcare Common Procedure Coding System.

RESULTS

We found race differences in many of our variables, but not in quality for manual (odds ratio [OR]=.67; 95% confidence interval [CI], .33-1.36) or power (OR=.82; 95% CI, .51-1.34) wheelchairs. Several factors including age (OR=.96; 95% CI, .93-.99) and income (OR=3.78; 95% CI, 1.43-9.97) were associated with wheelchair quality. There were no significant associations of cultural or psychosocial factors with wheelchair quality.

CONCLUSIONS

Although there were no racial differences in wheelchair quality, we found a significant association of older age and lower income with poorer wheelchair quality among Veterans. Efforts are needed to raise awareness of such disparities among VA wheelchair providers and to take steps to eliminate these disparities in prescription practice across VA sites.

Locally manufactured wheelchairs in Tanzania - are users satisfied?

BACKGROUND

The government of Tanzania created opportunity for the production of wheelchairs that would be appropriate to the local needs and environment.

OBJECTIVES

The study assessed the extent to which the wheelchairs met the activity and participation needs of the users, as well as the users' level of satisfaction with the provision, repair and maintenance of these wheelchairs.

METHODS

A descriptive cross-sectional analytical design was utilized to collect data through the administration of a questionnaire among 75 adult wheelchair users.

RESULTS

Participants had used wheelchairs for an average period of 9.3 years. Most participants (61%) had sustained spinal cord injuries, and used three-wheeler chairs (76%). More than 90% reported that their wheelchairs positively influenced their activity and participation needs, and 85% were satisfied with their ability to carry out daily activities. Participants expressed satisfaction with the durability of the wheelchairs (89%), and the professional services received (71%), but not with follow-up services (77%). There was difference in satisfaction with features of 3-wheeler and 4-wheeler rigid chairs (p=0.030).

CONCLUSION

The wheelchairs positively impacted participants' activity and participation needs. Participants were sat isfied with the features of the wheelchairs but not with follow-up services. The concerns of dissatisfied users should be addressed.

Understanding the Provision of Assistive Mobility and Daily Living Devices and Service Delivery to Veterans After Stroke

OBJECTIVE

The objective of this study was to determine whether facility-level, structural factors affect the provision of assistive devices and services.

DESIGN

A retrospective design was used. Activities of daily living and mobility-related devices were categorized into 11 types. Logistic regression models were performed for each type of device, controlling for patient-level and facility-level covariates.

RESULTS

Non-veteran-level factors significantly affect the provision of assistive devices, even after covariate adjustment. Increased rehabilitation clinician staffing by 1 full-time equivalent position was associated with increased provision odds of 1%-5% for 5 of 11 types of devices. Lower facility complexity was significantly associated with increased provision odds of 35%-59% for 3 types of devices and with decreased provision odds of 16%-69% for 3 types of devices.

CONCLUSION

System-level factors, in addition to patient need, significantly affect the provision of assistive devices. Provision guidelines could assist clinicians in making decisions about device provision.

Patterns in Wheeled Mobility Skills Training, Equipment Evaluation, and Utilization: Findings from the SCIRehab Project

Patients with traumatic spinal cord injury (SCI) participate in manual and power wheelchair (WC) skills training during inpatient rehabilitation; wheeled mobility evaluations aim to optimize use, fit, and function of equipment following discharge. Occupational and physical therapists documented treatment sessions during inpatient rehabilitation to describe types and quantity of WC skills training and adaptive equipment (AE) provided by neurological level of injury. Most patients participated in WC skills training; variation in type and frequency exists. Propulsion/driving skills were practiced most frequently. A majority of patients participated in equipment evaluations; assessment/prescription and fitting were performed frequently; mat evaluations were done infrequently. Most patients received mobility equipment in a timely manner; they continued to use their WC and were satisfied with its fit and function at the one-year injury anniversary. High levels of respondent satisfaction with fit and function of WCs suggest clinicians are prescribing mobility devices adequately and accurately supplementing information obtained during equipment assessment and fitting sessions with information from general treatment sessions. Variation in type and frequency of WC training provided by level of SCI and in types of WC prescribed use provides a foundation for future research to relate treatment modalities with functional and participation outcomes.

Measurement properties of the Wheelchair Skills Test-Questionnaire for powered wheelchair users

PURPOSE

To evaluate the test-retest reliability, concurrent validity and responsiveness of the Wheelchair Skills Test - Questionnaire (WST-Q) Version 4.1 for powered wheelchair users.

METHODS

A volunteer sample of 72 community-dwelling, experienced powered wheelchair users, ranging in age from 50 to 77 years, participated in this study. Participants completed measures at baseline and 1 month later.

RESULTS

Mean ± standard deviation total percentage WST-Q scores at baseline and 1 month were 83.7% ± 10.9 and 86.3% ± 10.0 respectively. Cronbach's alpha was 0.90 and the 1 month test-retest intraclass correlation coefficient (ICC1,1) was 0.78 (confidence interval: 0.68-0.86). There were no floor or ceiling effects. Percentages of agreement between baseline and 1 month for individual skills ranged from 72.2% to 100%. The correlations between the WST-Q and the objective Wheelchair Skills Test (WST), WheelCon and Life Space Assessment were r = 0.65, r = 0.47 and r = 0.47 respectively. The standard error of measurement (SEM) and smallest real difference (SRD) were 5.0 and 6.2 respectively.

CONCLUSION

The WST-Q 4.1 has high internal consistency, strong test-retest reliability and strong support for concurrent validity and responsiveness.

IMPLICATIONS FOR REHABILITATION

There is evidence of reliability, validity and responsiveness of the Wheelchair Skills Test - Questionnaire (WST-Q) among experienced older adult powered wheelchair users. The WST-Q can be used to measure powered wheelchair skills, guide intervention and measure change over time.

Comparison of activities of daily living (ADLs) in two different one arm drive wheelchairs: a study of individuals/participants with hemiplegia

AIMS

This pilot study measured activities of daily living performance in individuals/participants with hemiplegia propelling both a standard dual handrim Action 3 wheelchair and a standard Action 3 wheelchair with a Neater Uni-Wheelchair kit attachment. The kit consists of a steerable front.

RESEARCH QUESTIONS

Does the use of the NUW affect the performance quality of activities of daily living in individuals/participants with hemiplegia. Is there a difference in the motor and process skills during activities of daily living performance, and in the time taken to complete the activities.

METHODS

Four individuals/participants with hemiplegia were used in a cross over, repeated measures trial. Assessment of Motor and Process Skills of users undertaking making a bed and laying a table "Swedish style", tasks were measured and time taken to complete each task were recorded.

RESULTS

Bed making completion time was quicker in the Neater Uni-wheelchair (p < 0.03). Motor skills were significantly higher than the process ability skills (p < 0.05).

CONCLUSION

Activities of daily living tasks in the Neater Uni-wheelchair were completed more efficiently with no loss in quality of motor and process skills performance. This suggests that the Neater Uni-wheelchair is a viable alternative to current one arm drive provision. Implications for Rehabilitation Inappropriate wheelchair provision can result in capacity limitation and poorer quality of ADL motor skill as well-lowered process performance skill. AMPS can help to explain motor and process skill differences in complex activities.

Comparison of activities of daily living in two different one arm drive wheelchairs: a controlled trial

AIMS

This pilot study measured activities of daily living (ADLs) in users propelling both a standard dual handrim Action 3 wheelchair and a standard Action 3 wheelchair with a Neater Uni-Wheelchair (NUW) kit attachment. The kit consists of a steerable front castor and a single pushrim propelling both rear wheels via a differential.

HYPOTHESIS

There would be a difference in the efficiency of ADL skill performance, speed and heart rate.

METHODS

Twenty non-disabled participants simulating hemiplegia were used in a cross over, repeated measures trial. Assessment of Motor and Process Skills (AMPS) of users undertaking making a bed and laying a table 'Swedish style', tasks, were measured. Heart rate at rest and post-task and time taken to complete each task were recorded.

RESULTS

Heart rate when laying the table was lower in the NUW (p < 0.005) and task completion time was quicker (p < 0.0001). There was no difference in motor and process ability skills.

CONCLUSION

ADL tasks in the NUW were completed more efficiently with no loss in quality of motor and process skills performance. This suggests that the NUW is a viable alternative to current one arm drive provision.

The association of race, cultural factors, and health-related quality of life in persons with spinal cord injury

OBJECTIVE

To examine the association of race and cultural factors with quality-of-life factors (participation, life satisfaction, perceived health status) in people with spinal cord injury (SCI).

DESIGN

Cross-sectional multisite study using structured questionnaires.

SETTING

Six National SCI Model Systems centers.

PARTICIPANTS

People with SCI (N=275; age ≥16y; SCI with discernable neurologic impairments; used power or manual wheelchair for >1y as primary means of mobility; nonambulatory except for exercise purposes).

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Participation (Craig Handicap Assessment and Reporting Technique Short Form); satisfaction (Satisfaction With Life Scale); and perceived health status (2 items from 36-Item Short Form Health Survey).

RESULTS

African American (n=96) with SCI reported more experiences of discrimination in health care, greater perceived racism, more health care system distrust, and lower health literacy than whites (n=156; P range, <.001-<.05). Participants who reported experiencing more discrimination in health care reported better occupational functioning (odds ratio [OR], 1.5; 95% confidence interval [CI], 1.07-2.09; P<.05). Those who perceived more racism in health care settings reported better occupational functioning (OR, 1.65; 95% CI, 1.12-2.43; P<.05) and greater perceived health (β=.36; 95% CI, .05-.68; P<.05). Those who reported more distrust in the health care system reported better current health compared with 1 year ago (β=.38; 95% CI, .06-.69; P<.05). Those who reported better communication with their health care provider reported higher levels of mobility (OR, 1.5; 95% CI, 1.05-2.13; P<.05) and better general health (β=.27; 95% CI, .01-.53; P<.05).

CONCLUSIONS

In this cross-sectional study of people with SCI, higher levels of perceived discrimination and racism and better communication with health care providers were associated with an increase in participation and functioning and improvements in perceptions of well-being. These associations are different from those reported in other study populations and warrant confirmation in future prospective studies.

Vulnerable Groups Living with Spinal Cord Injury

There is considerable variation in rehabilitation outcomes within the population of spinal cord-injured individuals across racial and socioeconomic groups. This suggests that the long-term health following spinal cord injury (SCI) is determined, at least in part, by group differences in exposure to advantages and disadvantages among persons living in the community. This article conceptualizes the nature of vulnerability and how increased vulnerability leads to disparities in SCI outcomes. Demographic, socioeconomic, and geographic determinants of adverse outcomes among vulnerable groups are discussed. Finally, a research model that outlines potential processes that elicit vulnerability following SCI and clinical implications is reviewed.

The impact of consumer involvement on satisfaction with and use of assistive technology

PURPOSE

This exploratory study examined the relationships between consumers' involvement in the pre-purchase decision-making process, their perceptions of feeling informed, and their degree of being satisfied with and use of assistive technology (AT). Does consumer information and participation in decision-making process lead to improved satisfaction and use of AT?

METHOD

A link to an project-specific web-based survey, sent to several online disability forums and independent living centres, resulted in a sample of 145 individuals with a range of disabilities, who used a range of AT and were geographically dispersed.

RESULTS

There is a significant relationship between being feeling informed and being satisfied with an AT device (F(13,278) = 27.79, p = 0.000). Feeling that personal needs were not assessed led to lower satisfaction (β = -0.15, p < 0.07), while feeling informed resulted from a number of different factors. Lack of consumer involvement in the pre-purchase decision-making process led to somewhat greater rates of abandonment in some categories of AT (some with small n's).

CONCLUSIONS

Talking with other users, auditioning the device and searching the Internet are important ways for consumers to gather information. When consumers feel informed, they are more likely to be satisfied with the AT and retain it.

Wheelchair-related falls in veterans with spinal cord injury residing in the community: a prospective cohort study

OBJECTIVES

(1) To determine the incidence of wheelchair falls and fall-related injuries in persons with spinal cord injury (SCI) living in the community. (2) To predict wheelchair-related falls and associated injuries from specific parameters including characteristics of the wheelchair user, wheelchair type and features, health care practices, wheelchair activities, and physical environment.

DESIGN

This prospective cohort study followed participants monthly over 1 year; data were collected through surveys, interviews, performance testing, observation, and medical records.

SETTING

Three Veterans' Administration hospitals.

PARTICIPANTS

Convenience sample of community-dwelling persons with SCI who used a wheelchair as their primary means of mobility (N=702).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Self-reports of wheelchair falls and fall-related injuries, Wheelchair User Characteristics Survey, Health Status Checklist, Health-Related Behaviors, Zuckerman Sensation Seeking Scale, Wheelchair and Equipment-Related Behaviors, Wheelchair Characteristics, Wheelchair Skills Test, and Physical Environment Assessment.

RESULTS

Of the 659 subjects who completed the study, 204 participants (31%) reported 553 fall events, and 95 subjects (14%) were injured as a result of wheelchair falls. A logistic regression model for predicting wheelchair falls identified 6 significant risk factors: pain in previous 2 months, alcohol abuse, greater motor function, history of previous fall, fewer SCI years, and shorter length of wheelchair. Eighty-two percent of the variance for wheelchair fall events was explained by these 6 variables. A logistic regression model for predicting injurious falls identified 4 significant risk factors: pain in previous 2 months, greater motor function, history of previous fall, and inaccessible home entrance. These 4 factors were able to explain 81% of the variance for injurious falls.

CONCLUSIONS

This is the first study to determine the incidence of wheelchair-related falls in community-dwelling people with SCI who use a wheelchair. Results indicate the incidence of falls was 31% and injurious falls was 14%. Those at greatest risk can be predicted from some readily available information regarding their clinical status, wheelchair features, and home environment.