Ed Giesbrecht

Participation in community-based activities of daily living: Comparison of a pushrim-activated, power-assisted wheelchair and a power wheelchair

Purpose. The purpose of this study was to evaluate pushrim-activated, power-assisted wheelchair (PPW) performance among dual-users in their natural environment to determine whether the PPW would serve as a satisfactory alternative to a power wheelchair for community-based activities. Methods. A concurrent mixed methods research design using a cross-over trial was used. The outcome measures used were number of hours reported using the different wheelchairs, Quebec User Evaluation of Satisfaction with assistive Technology (QUEST), Functioning Everyday with a Wheelchair (FEW), Psychosocial Impact of Assistive Devices Scale (PIADS) and Canadian Occupational Performance Measure (COPM). Results. The number of hours spent participating in self-identified activities was not significantly different. Only the Self-Esteem subscale of the PIADS identified a statistically significant difference between the PPW and power wheelchair conditions (p = 0.016). A clinically important difference for Performance and Satisfaction was suggested by the COPM, in favour of the power wheelchair. Conclusions. Additional knowledge was gained about the benefits of PPW technology. Participants were able to continue participating independently in their self-identified community activities using the PPW, and identified comparable ratings of satisfaction and performance with the PPW and the power wheelchair. For some individuals requiring power mobility, the PPW may provide an alternative to the power wheelchair.

Measuring the effect of incremental angles of wheelchair tilt on interface pressure among individuals with spinal cord injury.

Study design:This study was a repeated measures study.Objectives:The objective was to systematically measure the relative reduction in interface pressure (IP) at the ischial tuberosities (IT) and sacrum through 10° increments of tilt in a manual wheelchair among individuals with motor complete spinal cord injury (SCI).Setting:This study was carried out in Manitoba, Canada.Methods:A total of 18 adults with ASIA A or B level of injury were recruited through an out-patient SCI clinic. Using a standardized protocol, participants were tilted in 10° increments between 0° and 50°, and IP readings were obtained at the IT and sacrum using pressure mapping technology. Relative pressure reduction from baseline was calculated and compared between tilt angles.Results:Tilt angle had a highly significant effect on pressure reduction at the IT (P=0.000) and the cosine relationship between these variables was expressed as quadratic. Reduction in sacral pressure did not occur until 30° tilt, with increased loading at smaller tilt angles. Pressure reduction at the IT and sacrum was not significantly different for tetraplegic and paraplegic participants.Conclusion:Small tilt angles are more suitable for postural control than pressure management. A minimum tilt of 30° is required to initiate unloading the sacrum and to achieve a clinically important reduction in pressure at the IT. Larger tilt angles resulted in more substantial pressure reduction than previously reported. Tilt-in-space appears to have similar benefits for individuals with paraplegia and tetraplegia.

Prevalence of Wheelchair and Scooter Use Among Community-Dwelling Canadians

Background Mobility impairments are the third leading cause of disability for community-dwelling Canadians. Wheelchairs and scooters help compensate for these challenges. There are limited data within the last decade estimating the prevalence of wheelchair and scooter use in Canada. Objective The aims of this study were: (1) to estimate the prevalence of wheelchair and scooter use in Canada and (2) to explore relevant demographic characteristics of wheelchair and scooter users. Design This study was a secondary analysis of a cross-sectional national survey. Methods The Canadian Survey on Disability (2012) collected data on wheelchair and scooter use from community-dwelling individuals aged 15 years and over with a self-identified activity limitation on the National Household Survey. Prevalence estimates were calculated as weighted frequencies, with cross-tabulations to determine the number of wheelchair and scooter users in Canada, by province, and demographic characteristics (ie, age, sex) and bootstrapping to estimate the variance of all point estimates. Results There were approximately 288,800 community-dwelling wheelchair and scooter users aged 15 years and over, representing 1.0% of the Canadian population. The sample included 197,560 manual wheelchair users, 42,360 powered wheelchair users, and 108,550 scooter users. Wheelchair and scooter users were predominantly women, with a mean age of 65 years. Approximately 50,620 individuals used a combination of 2 different types of devices. Limitations The results are representative of individuals living in the community in Canada and exclude individuals in residential or group-based settings; estimates do not represent the true population prevalence. Conclusion This analysis is the first in more than 10 years to provide a prevalence estimate and description of wheelchair and scooter users in Canada. Since 2004, there has been an increase in the proportion of the population who use wheelchairs and scooters, likely related to an aging Canadian population. These new prevalence data have potential to inform policy, research, and clinical practice.

The Effect of Alternate Style Keyboards on Severity of Symptoms and Functional Status of Individuals with Work Related Upper Extremity Disorders

There is evidence that performing job tasks involving repetition, vibration, sustained posture or forceful movement may contribute to symptoms of work related upper extremity disorders. Typing is one such activity; symptoms that develop as a result of this activity can affect performance of work, self-care and leisure occupations. Studies investigating the impact of ergonomic keyboards on symptom reduction are limited, and little research exists regarding the reduction of key activation force as an intervention. Methods: This randomized, prospective study used a sample of 68 symptomatic workers employed by a single company. One group received a commercially available ergonomic keyboard, a second group used a modified version of the same keyboard designed to reduce activation force, vibration and key travel. We measured symptoms and clinical signs, functional status, and device satisfaction in both groups over a six-month study period. Results: Between-groups analyses indicated that the groups performed similarly on the outcomes of interest. Repeated-measure analysis identified a reduction of symptoms, an improvement in functional status, preference for and increased satisfaction with the intervention keyboards, and maintenance of typing speed and accuracy for both groups. Conclusions:

Experiences with using a pushrim-activated power-assisted wheelchair for community-based occupations: : A qualitative exploration

Background. Occupational therapists strive to engage individuals in occupation and enhance community access through wheelchair prescription. Previous research with pushrim-activated, power-assisted wheelchairs identifies a reduction in the physical demands of manual wheelchair propulsion but limited evidence exists regarding user evaluation in context. Purpose. This study explored the experience of using a power-assisted wheelchair in the community. Methods. Eight individuals who used both a power and manual device participated in focus groups after trialing a power-assist wheelchair for three weeks. Data were analyzed using a qualitative description approach. Findings. Three themes emerged from our analysis: relative advantages and disadvantages; environmental factors that affect accessibility; and evaluation of mobility device. Implications. Participants perceived the power-assist as improving performance and accessibility compared with the manual wheelchair, increasing the potential scope of occupations and environments, but not replacing their power mobility device. Sufficient time for adjustment of both user and device was important.

Pressure Ulcers and Occupational Therapy Practice: A Canadian Perspective

Background. Occupational therapists are involved in the prevention and management of pressure ulcers. While many therapists identify challenges with their clinical practice in this area, there is little information available regarding specific occupational therapy interventions or effectiveness. Purpose. The goal of this study was to gain a national perspective of practice in Canada and identify directions and trends in the management of pressure ulcers. Method. A survey was distributed to occupational therapists at 75 facilities across Canada, soliciting information on intervention, practice issues and satisfaction with their practice. Results. Thirty-seven therapists from 36 facilities responded, answering questions about risk assessment tools, referral patterns, interventions and decision-making models, satisfaction with practice, intervention rationales, and recommendations for change. Risk assessment, early intervention and continuity of care were identified as concerns, with a lack of resources identified as a limitation to practice. Seating and positioning were common interventions. Practice Implications. This information can be used by clinicians to direct best practice and professional development goals. Further research is indicated in risk assessment, team collaboration and mattress prescription.

Feasibility of the Enhancing Participation In the Community by improving Wheelchair Skills (EPIC Wheels) program: study protocol for a randomized controlled trial

BackgroundMany older adults rely on a manual wheelchair for mobility but typically receive little, if any, training on how to use their wheelchair effectively and independently. Standardized skill training is an effective intervention, but limited access to clinician trainers is a substantive barrier. Enhancing Participation in the Community by Improving Wheelchair Skills (EPIC Wheels) is a 1-month monitored home training program for improving mobility skills in older novice manual wheelchair users, integrating principles from andragogy and social cognitive theory. The purpose of this study is to determine whether feasibility indicators and primary clinical outcome measures of the EPIC Wheels program are sufficiently robust to justify conducting a subsequent multi-site randomized controlled trial.MethodsA 2 × 2 factorial randomized controlled trial at two sites will compare improvement in wheelchair mobility skills between an EPIC Wheels treatment group and a computer-game control group, with additional wheelchair use introduced as a second factor. A total of 40 community-dwelling manual wheelchair users at least 55 years old and living in two Canadian metropolitan cities (n = 20 × 2) will be recruited. Feasibility indicators related to study process, resources, management, and treatment issues will be collected during data collection and at the end of the study period, and evaluated against proposed criteria. Clinical outcome measures will be collected at baseline (pre-randomization) and post-intervention. The primary clinical outcome measure is wheelchair skill capacity, as determined by the Wheelchair Skills Test, version 4.1. Secondary clinical outcome measures include wheelchair skill safety, satisfaction with performance, wheelchair confidence, life-space mobility, divided-attention, and health-related quality of life.DiscussionThe EPIC Wheels training program offers several innovative features. The convenient, portable, economical, and adaptable tablet-based, home program model for wheelchair skills training has great potential for clinical uptake and opportunity for future enhancements. Theory-driven design can foster learning and adherence for older adults. Establishing the feasibility of the study protocol and estimating effect size for the primary clinical outcome measure will be used to develop a multi-site randomized controlled trial to test the guiding hypotheses.Trial registrationClinical Trials NCT01740635.

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 (rp = –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.

Development of a Wheelchair Skills Home Program for Older Adults Using a Participatory Action Design Approach

Restricted mobility is the most common impairment among older adults and a manual wheelchair is often prescribed to address these limitations. However, limited access to rehabilitation services results in older adults typically receiving little or no mobility training when they receive a wheelchair. As an alternative and novel approach, we developed a therapist-monitored wheelchair skills home training program delivered via a computer tablet. To optimize efficacy and adherence, principles of self-efficacy and adult learning theory were foundational in the program design. A participatory action design approach was used to engage older adult wheelchair users, care providers, and prescribing clinicians in an iterative design and development process. A series of prototypes were fabricated and revised, based on feedback from eight stakeholder focus groups, until a final version was ready for evaluation in a clinical trial. Stakeholder contributions affirmed and enhanced the foundational theoretical principles and provided validation of the final product for the target population.

Application of the Human Activity Assistive Technology model for occupational therapy research

BACKGROUND/AIM Theoretical models provide a framework for describing practice and integrating evidence into systematic research. There are few models that relate specifically to the provision of assistive technology in occupational therapy practice. The Human Activity Assistive Technology model is an enduring example that has continued to develop by integrating a social model of disability, concepts from occupational therapy theory and principles of assistive technology adoption and abandonment. METHODS This study first describes the core concepts of the Human Activity Assistive Technology model and reviews its development over three successive published versions. A review of the research literature reflects application of the model to clinical practice, study design, outcome measure selection and interpretation of results, particularly among occupational therapists. An evaluative framework is used to critique the adequacy of the Human Activity Assistive Technology model for practice and research, exploring attributes of clarity, simplicity, generality, accessibility and importance. Finally, recommendations are proposed for continued development of the model and research applications. RESULTS Most of the existing research literature employs the Human Activity Assistive Technology model for background and study design; there is emerging evidence to support the core concepts as predictive factors. Although the concepts are generally simple, clear and applicable to occupational therapy practice and research, evolving terminology and outcomes become more complex with the conflation of integrated theories. CONCLUSIONS AND SIGNIFICANCE The development of the Human Activity Assistive Technology model offers enhanced access and application for occupational therapists, but poses challenges to clarity among concepts. Suggestions are made for further development and applications of the model.