Adapted Manual Wheelchair Circuit: Test-Retest Reliability and Discriminative Validity in Persons With Spinal Cord Injury

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

OBJECTIVE

To evaluate the measurement properties of clinical instruments used to assess manual wheelchair mobility in individuals with spinal cord injury (SCI).

DATA SOURCES

This systematic review was conducted according to the Consensus-Based Standards for the Selection of Health Measurement Instruments guidance and Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. The search was conducted up to December 2021 on MEDLINE/PubMed, Cochrane Central Register of Controlled Trials, Web of Science, Biblioteca Regional de Medicina, and Cumulative Index to Nursing and Allied Health databases without time restriction.

STUDY SELECTION

Peer-reviewed original research articles that examined any clinical wheelchair mobility and/or skill assessment instrument among adults with SCI and reported data on at least one measurement property or described the development procedure were evaluated independently by two reviewers.

DATA EXTRACTION

Data were independently extracted according to Consensus-Based Standards for the Selection of Health Measurement Instruments methodology. Measurement property results from each study were independently rated by two reviewers as sufficient, insufficient, indeterminate, or inconsistent. The evidence for each measurement property was rated as high, moderate, low, or very low (Grading of Recommendations, Assessment, Development, and Evaluation). Recommendations for highly-rated instruments were performed.

DATA SYNTHESIS

Twenty-nine studies with 21 instruments were identified. The methodological quality of studies ranged from insufficient to sufficient, and the quality of evidence ranged from very low to high. Six instruments reported content validity. Reliability and construct validity were the most studied measurement properties. Structural validity and invariance for cross-cultural measurement were not reported. The highly rated instruments were the Wheelchair Outcome Measure and Wheelchair Skills Test Questionnaire.

CONCLUSIONS

Although numerous instruments for assessing wheelchair mobility and/or skills among individuals with SCI were identified, not many measurement properties have been sufficiently established. The Wheelchair Outcome Measure and Wheelchair Skills Test Questionnaire show the current best potential to be recommended for clinical and research use. Further studies are needed to strengthen or change these recommendations.

The effectiveness of community-based upper body exercise programs in persons with chronic paraplegia and manual wheelchair users: A systematic review

Context: Physical activity has been beneficial to health, functional independence and quality of life in individuals with spinal cord injury. However, there is no consensus concerning the effects of community-based upper-body exercise for people with paraplegia who use a manual wheelchair.Objective: Conduct a systematic review of evidence of upper-body exercise effects able to be developed in a community-setting, on both functional independence and quality of life, for individuals with chronic paraplegia who use a manual wheelchair.Methods: PubMed, Scopus, Ebsco, SportDiscus and Web of Science databases were browsed, searching for studies that combined words as paraplegia, exercise, functional independence and quality of life and their synonyms, published from January/1998 to December/2018 in English. PEDro scale and the Cochrane tool analyzed methodological quality and risk of bias, respectively.Results: Four studies were selected out of 4004. Studies conducted aerobic arm-ergometer and resistance training predominantly at home. Upper-limb functionality and wheelchair propulsion assessed functional independence, but only the first presented positive effects after resistance training. Resistance and aerobic arm-ergometer training seemed to improve health-related and subjective quality of life.Conclusion: Studies have shown low methodological quality and high risk of bias. Aerobic arm-ergometer and resistance training were the most upper-body exercises used. Resistance training improved functional independence while both types of exercise induced positive effects on quality of life. Future studies with uniform and high-quality methodology should be conducted with exercise in community-dwelling people with paraplegia who use a manual wheelchair.

Handgrip Strength Cutoff Points for Functional Independence and Wheelchair Ability in Men With Spinal Cord Injury

Objectives

To determine optimal handgrip strength (HGS) cutoff points for greater functional independence and wheelchair skills in men with spinal cord injury (SCI), and to establish predictive equations for functional independence and wheelchair ability in men with SCI, based on demographic characteristics, HGS, and functionality.

Methods

In this cross-sectional study conducted at a rehabilitation hospital, 54 men with SCI were recruited and stratified into high and low paraplegia groups. All participants performed a maximum HGS test to determine cutoff points for the Spinal Cord Independence Measure (SCIM-III) and Adapted Manual Wheelchair Circuit (AMWC). The primary outcomes were the SCIM-III, AMWC, and HGS. Demographic characteristics obtained from participants' electronic medical records were the secondary outcomes, used as predictor variables of functional independence.

Results

The SCIM-III scale, performance score, and 3-minute overground wheeling test presented significant regression equations (R = 0.45, R = 0.69, and R = 0.72). The HGS showed a cutoff point of 102.5 kilogram force (kgf) to achieve a score of 70 on the SCIM-III and a 3-minute overground wheeling distance of 270 m. The HGS cutoff point to obtain a performance score of 23.7 seconds was 93.0 kgf.

Conclusion

The HGS was a significant predictor for the SCIM-III score, AMWC performance score, and 3-minute overground wheeling test. Three significant predictive equations were established based on HGS. The cutoff points could be adopted as parameters for optimal functional independence and wheelchair skills.

[Psychometric properties of observational instruments to evaluate wheelchair skills in persons with a spinal cord injury: A systematic review]

A total of 60% of people with a spinal cord injury are completely dependent on a wheelchair. There is a wide variety of instruments that assess wheelchair skills, but they are not specific for this population. OBJECTIVE: To identify, assess, compare and summarize the psychometric properties of instruments that assess wheelchair skills in persons with a spinal cord injury. A systematic review was conducted and observational instruments were included that assessed wheelchair skills in persons with spinal cord injury. Eleven articles were identified that evaluated eight instruments. Most of them reported activities according to the International Classification of Functioning, Disability and Health. Reliability was the most frequently evaluated psychometric property. The Queensland Evaluation of Wheelchair Skills and the Adapted Manual Wheelchair Circuit had the best degrees of confidence in the evidence, and their application could guide the selection of pertinent therapeutic strategies. PROSPERO registration: CRD42020161430.

Are Body Composition, Strength, and Functional Independence Similarities Between Spinal Cord Injury Classifications? A Discriminant Analysis

CONTEXT

There seems to be no consensus on which aspects better distinguish the different levels of spinal cord injury regarding body composition, strength, and functional independence.

OBJECTIVE

The study aimed to determine which variables better differentiate tetraplegia (TP) from paraplegia and high paraplegia (HP) from low paraplegia (LP).

DESIGN

Cross-sectional study.

SETTING

Rehabilitation hospital network.

PATIENTS

Forty-five men with spinal cord injury, n = 15 for each level (TP, HP, and LP) causing complete motor impairment (American Spinal Injury Association Impairment Scale: A or B) were enrolled in the study.

MAIN OUTCOME MEASURES

The 1-maximum repetition test, functional independence measure, spinal cord independence measure, and body composition (skinfold sum, body fat percentage, and body mass index) were assessed. Discriminant analysis was carried out using the Wilks lambda method to identify which strength and functional variables can significantly discriminate subjects for injury classification (TP, HP, and LP).

RESULTS

The discriminant variable for TP versus HP was body mass index and for TP versus LP was 1-maximum repetition (P ≤ .05). There were no variables that discriminated HP versus LP.

CONCLUSIONS

The discriminant variables for TP versus HP and TP versus LP were body mass index and 1-maximum repetition, respectively. The results showed that HP and LP are similar for strength and functional variables.

Motor learning outcomes of handrim wheelchair propulsion during active spinal cord injury rehabilitation in comparison with experienced wheelchair users

PURPOSE

To investigate changes in wheelchair propulsion technique and mechanical efficiency across first five weeks of active inpatient spinal cord injury rehabilitation and to compare the outcomes at discharge with experienced wheelchair users with spinal cord injury.

METHODS

Eight individuals with recent spinal cord injury performed six weekly submaximal exercise tests. The first and last measurement additionally contained a wheelchair circuit and peak graded exercise test. Fifteen experienced individuals performed all above-mentioned tests on one occasion.

RESULTS

Mechanical efficiency and propulsion technique did not change during the five weeks of inpatient rehabilitation. Peak power output during peak graded test and performance time on the wheelchair circuit improved between the first and the last week. No difference in propulsion technique, peak power output, and performance time was found between the persons with a recent injury and the experienced group. Mechanical efficiency was higher after the correction for the difference in relative power output in the experienced group.

CONCLUSION

The group with a recent injury did not improve mechanical efficiency and propulsion technique over the period of active rehabilitation, despite significant improvements on the wheelchair circuit and in work capacity. The only significant difference between the groups was found in mechanical efficiency.Implications for rehabilitationThe lack of time-dependent changes in mechanical efficiency and propulsion technique in the group with a recent spinal cord injury, combined with the lack of differences in technique, work capacity and on the wheelchair circuit between the groups, suggest that important adaptations of motor learning may happen even earlier in rehabilitation and emphasize that the group in active rehabilitation was relatively skilled.Standardized observational analyses of handrim wheelchair propulsion abilities during early spinal cord injury rehabilitation provide detailed understanding of wheelchair technique, skill as well as wheelchair propulsion capacity.Measurement of external power output is critical to interpretation of gross efficiency, propulsion technique, and capacity.Wheelchair quality and body weight - next to wheelchair fitness and skill - require careful consideration both in early rehabilitation as well as in the chronic phase of spinal cord injury.

Utrecht Pediatric Wheelchair Mobility Skills Test: Reliability, Validity, and Responsiveness in Youths Using a Manual Wheelchair

BACKGROUND

The assessment of wheelchair mobility skills (WMS) in youths using a manual wheelchair is important. More information is needed regarding the psychometric properties of the newly developed Utrecht Pediatric Wheelchair Mobility Skills Test (UP-WMST).

OBJECTIVE

The purpose of this study was to evaluate the reliability, content validity, construct validity, and responsiveness of the UP-WMST 2.0 in youths using a manual wheelchair.

DESIGN

This was a repeated-measurements, cross-sectional study.

METHODS

A total of 117 children and adolescents who use a manual wheelchair participated in this study. The UP-WMST 2.0 contains the same 15 WMS items as the original UP-WMST but has an adaptation of the scoring method. Test-retest reliability was estimated in 30 participants. Content validity was assessed through floor and ceiling effect analyses. Construct validity was assessed through hypothesis testing. Preliminary estimates of responsiveness were assessed in 23 participants who participated in a WMS training program.

RESULTS

Test-retest reliability analysis showed weighted Cohen kappa coefficients ranging from 0.63 to 0.98 for all but 1 item. The total UP-WMST 2.0 score had an intraclass correlation coefficient of 0.97. No floor or ceiling effects were detected. Independent-sample t test analysis confirmed our hypotheses regarding direction and difference in scores between age and diagnostic groups. Within-group analysis in the responsiveness study showed a positive significant change in UP-WMST 2.0 score (8.3 points).

LIMITATIONS

The small sample size used in the responsiveness study was a limitation of this study.

CONCLUSIONS

This study provided evidence of the test-retest reliability, content, and construct validity of the UP-WMST 2.0. It also provided initial evidence of the responsiveness of the UP-WMST 2.0 for measuring change in WMS in youths using a manual wheelchair.

Good association between sprint power and aerobic peak power during asynchronuous arm-crank exercise in people with spinal cord injury

PURPOSE

To (1) investigate the association between sprint power and aerobic power output (POpeak_GXT) during a graded peak exercise test (GXT); and (2) validate the prediction models of POpeak_GXT based on sprint power and personal and lesion characteristics.

MATERIALS AND METHODS

Wheelchair users with tetraplegia (N = 35) and paraplegia (N = 58) performed a 30 s-Wingate test and GXT on an asynchronous arm-crank ergometer. Data were split into samples to develop and validate the model. Sprint power (POmean_Wingate and POpeak_Wingate, respectively) and POpeak_GXT were determined. Regression analyses were performed to develop POpeak_GXT prediction models. Candidate independent variables included POmean_Wingate or POpeak_Wingate, age (years), sex, body mass (kg) or BMI (kg/m²), time since injury (TSI, years) and lesion level (tetraplegia/paraplegia). The best model was validated by comparing the predicted POpeak_GXT with measured POpeak_GXT.

RESULTS

The best model (R ² = 0.76) to predict POpeak_GXT included POmean_Wingate, BMI and all other independent variables. No significant difference was found between measured (68 ± 35 W) and predicted POpeak_GXT (68 ± 30 W, p = 0.97). The ICC was excellent (0.89 with 95% confidence intervals: 0.75-0.95). The 95% limits of agreement for the Bland-Altman plots were wide (-30 to 31 W).

CONCLUSIONS

Strong associations were found between POmean_Wingate and POpeak_GXT. Although relative agreement was excellent, absolute agreement was low. Implications for rehabilitation There is a strong relationship between peak aerobic power output and sprint power output, both tested on an arm-crank ergometer, in people with spinal cord injury. A prediction model for peak aerobic power output, based on sprint power output and personal and lesion characteristics, showed a high explained variance. The predictive model can give a guideline for choosing the right graded exercise test protocol but should be used with caution.

The addition of three new items in the Adapted Manual Wheelchair Circuit improves the discrimination between different levels of spinal cord injury

Purpose: To determine whether the inclusion of three additional items improved the discriminative capacity of the Adapted Manual Wheelchair Circuit (AMWC). Design: Cross-sectional study. Methods: A total of 126 men (median age 28.9 years [percentiles 25 and 75: 23.7; 38.5 years]) with spinal cord injury were consecutively enrolled and divided into three subgroups: high paraplegia (HP), medium paraplegia (MP), and low paraplegia (LP). The participants performed the AMWC with three additional items. Ability score and total time of AMWC (AMWC_AS and AMWC_TT) and AMWC plus the three additional items (AMWC+3_AS and AMWC+3_TT), 3 min of overground wheeling test and performance score were evaluated. Results: AMWC was not able to discriminate HP from MP and LP (Wilks' lambda = 0.93; P= 0.07). In contrast, AMWC+3 was able to discriminate between the three subgroups (Wilks' lambda = 0.86; P≤ 0.05). AMWC+3_AS presented a better sensitivity compared to AMWC_AS (lower success rate for all subgroups, 38.5% vs. 82.1% for HP; 49.0% vs. 75.5% for MP; 78.9% vs. 94.7% for LP). The LP group presented a significant higher AMWC+3_AS compared to MP and HP (17.0 vs. 16.5 and 16.5, respectively, P≤ 0.05). AMWC+3_TT was significantly lower in LP compared to MP and HP (139.85 s vs. 242.52 s and 326.21 s, respectively, P≤ 0.05). Conclusion: The AMWC+3 outcomes were able to discriminate between HP, MP, and LP subgroups, and the addition of the three items enhanced the sensitivity of the wheelchair circuit. The performance of LP was more evident with significant differences compared to HP and MP for all AMWC+3 outcomes.

Relationship between wheelchair skills scores and peak aerobic exercise capacity of manual wheelchair users with spinal cord injury: a cross-sectional study

Purpose: Although both wheelchair skills and fitness are important and probably inter-related, the extent and nature of the relationship between them are not well understood. The objective of this study was to test the hypothesis that there are significant relationships between wheelchair skills scores and the peak exercise capacity of community-dwelling manual wheelchair users with spinal cord injury.Materials and methods: We studied 26 participants, recording Wheelchair Skills Test Questionnaire scores and peak power output from graded aerobic wheelchair exercise testing on a motorized treadmill.Results: The median Wheelchair Skills Test Questionnaire capacity, confidence, and performance scores were 83.3%, 81.5%, and 76.7% and the median peak power output was 58.2 W. On regression analysis, there were significant relationships between the total Wheelchair Skills Test Questionnaire capacity, confidence, and performance scores and peak power output (R² 0.270-0.709, odds ratios 1.043-1.150, p < 0.05).Conclusions: Significant relationships exist between the wheelchair skills capacity, confidence, and performance scores and the peak exercise capacity of community-dwelling manual wheelchair users with spinal cord injury. These findings suggest that both wheelchair skills training and exercise training may be useful during the rehabilitation of people with spinal cord injury.Implications for rehabilitationModerate positive relationships exist between wheelchair skills capacity and the peak exercise capacity of community-dwelling manual wheelchair users with spinal cord injury.Moderate positive relationships exist between wheelchair skills confidence and the peak exercise capacity of community-dwelling manual wheelchair users with spinal cord injury.Although further research is needed, these findings suggest that clinicians should address both wheelchair skills training and exercise training during the rehabilitation of people with spinal cord injury and not assume that either alone is sufficient.

Cross-cultural validation of a Brazilian version of the adapted manual wheelchair circuit (AMWC-Brazil)

Purpose: To translate, culturally adapt and validate the Adapted Manual Wheelchair Circuit (AMWC) into Brazilian-Portuguese. Design: Cross-sectional study. Methods: Sixty-six men (median age of 30.5 years [percentiles 25 and 75: 24.0; 38.3 years]) with traumatic spinal cord injury were consecutively enrolled and divided into two groups: tetraplegia (TP) and paraplegia (PP). The participants performed the AMWC-Brazil and were evaluated by the Spinal Cord Injury Measure version III (SCIM-III). Translation, translation synthesis, back-translation, committee review and construct validity were adopted for the cross-cultural adaptation. Construct validity was performed by testing whether the test scores were significantly correlated (Spearman's correlation coefficient) to the subjects' injury level, age, time since injury, body mass index (BMI) and SCIM-III scale. Results: All the AMWC-Brazil's outcomes were significantly correlated with SCIM-III total score and subscales (P ≤ 0.01). However, when the analyses were stratified over injury level, only the TP showed a high correlation between the AMWC-Brazil's outcomes and the SCIM-III. For construct validity, 4 of 5 hypotheses were confirmed. Only BMI was not a significant predictor of the AMWC-Brazil outcomes. Conclusion: The AMWC was successfully translated to the Brazilian-Portuguese (AMWC-Brazil) and presented high and satisfactory construct validity.

Development of a wheelchair mobility skills test for children and adolescents: combining evidence with clinical expertise

Background

Wheelchair mobility skills (WMS) training is regarded by children using a manual wheelchair and their parents as an important factor to improve participation and daily physical activity. Currently, there is no outcome measure available for the evaluation of WMS in children. Several wheelchair mobility outcome measures have been developed for adults, but none of these have been validated in children. Therefore the objective of this study is to develop a WMS outcome measure for children using the current knowledge from literature in combination with the clinical expertise of health care professionals, children and their parents.

Methods

Mixed methods approach. Phase 1: Item identification of WMS items through a systematic review using the ‘COnsensus-based Standards for the selection of health Measurement Instruments’ (COSMIN) recommendations. Phase 2: Item selection and validation of relevant WMS items for children, using a focus group and interviews with children using a manual wheelchair, their parents and health care professionals. Phase 3: Feasibility of the newly developed Utrecht Pediatric Wheelchair Mobility Skills Test (UP-WMST) through pilot testing.

Results

Phase 1: Data analysis and synthesis of nine WMS related outcome measures showed there is no widely used outcome measure with levels of evidence across all measurement properties. However, four outcome measures showed some levels of evidence on reliability and validity for adults. Twenty-two WMS items with the best clinimetric properties were selected for further analysis in phase 2. Phase 2: Fifteen items were deemed as relevant for children, one item needed adaptation and six items were considered not relevant for assessing WMS in children. Phase 3: Two health care professionals administered the UP-WMST in eight children. The instructions of the UP-WMST were clear, but the scoring method of the height difference items needed adaptation. The outdoor items for rolling over soft surface and the side slope item were excluded in the final version of the UP-WMST due to logistic reasons.

Conclusions

The newly developed 15 item UP-WMST is a validated outcome measure which is easy to administer in children using a manual wheelchair. More research regarding reliability, construct validity and responsiveness is warranted before the UP-WMST can be used in practice.

Electronic supplementary material

The online version of this article (doi:10.1186/s12887-017-0809-9) contains supplementary material, which is available to authorized users.

Development, reliability and validity of the queensland evaluation of wheelchair skills (QEWS)

STUDY DESIGN

Psychometric studyObjectives:To develop and test a valid and reliable assessment of wheelchair skills for individuals with spinal cord injuries (SCI); the Queensland Evaluation of Wheelchair Skills (QEWS).

SETTING

Hospital, Australia.

METHODS

Phase 1: Four Delphi panel rounds with clinical experts were used to develop the QEWS. Phase 2: Intra-rater and inter-rater reliability of the QEWS items were examined in 100 people with SCI. Phase 3a: Concurrent validity was investigated by examining the association between QEWS total scores and physiotherapists' global ratings of wheelchair skill performance. Phase 3b: Construct validity was tested in 20 people with recent SCI by examining change in QEWS total scores between when they first mobilised in a wheelchair and scores obtained 10 weeks later.

RESULTS

Phase 1: The QEWS was developed. Phase 2: The intra-class correlation coefficients reflecting the intra-rater reliability and the inter-rater reliability for the QEWS total score were 1.00 and 0.98, with scores being within one point of each other 96 and 91% of the time, respectively. Phase 3a: The QEWS total scores were comparable with the global rating of wheelchair skill performance (r2=0.93). Phase 3b: The QEWS scores changed by a median (interquartile range (IQR)) of 4 (1 to 6) points over the 10-week period following first wheelchair mobilisation.

CONCLUSION

The QEWS is a valid and reliable tool for measuring wheelchair skills in individuals with SCI. The QEWS is efficient and practical to administer and does not require specialised equipment.

Relationships between wheeling parameters and wheelchair skills in adults and children with SCI

STUDY DESIGN

Cross-sectional.

OBJECTIVES

To determine the relationships between (1) wheeling parameters using the SmartWheel Clinical Protocol (SCP) and wheelchair skills (wheelchair skills test 4.1 (WST)) and (2) push effectiveness (m per push) and the WST, among individuals with spinal cord injury.

SETTING

Biomechanics Laboratory, Canada.

METHODS

Sixteen adults and eight children participated in this study. Multiple regression analyses were used to determine significant SCP predictors (that is, weight-normalised peak force, speed, push frequency and mechanical effectiveness) of WST score. To determine relationships between push effectiveness and WST scores, Pearson's correlations were calculated.

RESULTS

SCP-TILE: speed and mechanical effectiveness explained 36% of the variance in the WST score. SCP-RAMP and SCP-CARPET: speed explained 58% and 37% of the variance in the WST score, respectively. Push effectiveness was significantly correlated with the WST score on all three surfaces (tile, ramp and carpet).

CONCLUSION

Wheeling speed was a significant predictor of the WST score for all surfaces tested. Regression analyses demonstrated that SCP-RAMP had the strongest relationship with WST score. Therefore, when time is restricted, the SCP-RAMP may be the most predictive test and speed may be the most useful variable to evaluate. However, the authors do not believe that one single variable should ever replace a full assessment of skills.

Test-retest reliability and minimal detectable change of the SmartWheel clinical protocol

OBJECTIVES

(1) To quantify the intra- and intersession reliability and minimal detectable change (MDC) of the SmartWheel clinical protocol (SCP) and (2) to compare the reliability of the SCP between experienced and naïve wheelchair users.

DESIGN

Test-retest study.

SETTING

Biomechanics laboratory.

PARTICIPANTS

Manual wheelchair users (WCUs) (n=10) with 1 to 32 years of wheeling experience and able-bodied (AB) naïve users (n=15).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Wheelchair propulsion parameters including average peak force, push frequency, push length, and velocity were measured according to the SCP but with 5 trials per session, for 2 sessions. WCUs and AB users were analyzed separately. Intraclass correlation coefficients ([ICC](2,1) and ICC(2,5)) were calculated to assess intrasession reliability. ICC(2,1) and MDC (with 95% confidence) were calculated for each SCP parameter using a single trial from each session and with the mean of 5 repeated measures to evaluate intersession reliability.

RESULTS

Intra- and intersession reliability for WCU parameters ranged from high to very high correlation (ICC range, .70-.99). For AB parameters, intrasession ICC(2,1) ranged from moderate to very high (ICC range, .50-.92), while intersession ICC(2,1) indicated low to very high correlation (ICC range, .25-.90). Estimates of standard error of measurement and MDC were provided for each parameter. For both WCUs and AB users, using the means from 5 trials increased intra- and intersession ICC and decreased MDC values. All MDC values were lower for WCUs compared with AB users.

CONCLUSIONS

The SCP is a reliable method for assessing propulsion parameters in WCUs, even if just 1 trial is taken per session. AB users showed lower intra- and intersession reliability compared with WCUs. Therefore, for AB users or individuals with minimal wheeling experience, averaging multiple trials is recommended for the SCP.