Elaine Trefler

A randomized control trial to evaluate pressure-reducing seat cushions for elderly wheelchair users.

OBJECTIVE To determine if the use of pressure-reducing wheelchair cushions for elderly nursing home resident wheelchair users who are at high risk for developing sitting-acquired pressure ulcers would result in a lower incidence rate of pressure ulcers, a greater number of days until ulceration, and lower peak interface pressures compared with the use of convoluted foam cushions over a 12-month period. To determine the feasibility of conducting a subsequent full-scale definitive trial to evaluate the use of pressure-reducing seat cushions for elderly nursing home resident wheelchair users. DESIGN Randomized control trial SETTING 2200-bed skilled nursing facilities (1 suburban and 1 urban academic medical center) PATIENTS 32 male and female at-risk nursing home residents who were wheelchair users > or = 65 years of age. Participants had Braden Scale scores < or = 18, Braden Activity and Mobilitysubscale scores < or = 5, no sitting surface pressure ulcers, and a daily wheelchair sitting tolerance of more than 6 hours. All met criteria for using the ETAC Twin wheelchair. INTERVENTIONS Seating evaluation with pressure-mapping and subsequent seating prescription. Subjects were assigned to either a foam (n=17) or pressure-reducing cushion (n=15) group and weekly assessments of skin and pressure ulcer risk were made. MAIN OUTCOME MEASURES Incidence of pressure ulcers, days to ulceration, and peak interface pressure. MAIN RESULTS At a 95% confidence interval, a 2-tailed analysis showed no differences between the FOAM and pressure-reducing cushion groups for pressure ulcer incidence, total days to pressure ulcer, or initial peak interface pressure. Pressure-reducing cushions were more effective in preventing sitting-acquired (ischial) pressure ulcers (P<.005). Higher interface pressures were associated with a higher incidence of pressure ulcers (P<.001). CONCLUSIONS A definitive randomized control multicenter cushion trial is feasible with a sample size of 50 to 100 per study group. In the definitive trial, the definition of sitting-acquired pressure ulcers should be limited to lesions occurring over the ischial tuberosities.

Development and consumer validation of the Functional Evaluation in a Wheelchair (FEW) instrument

Purpose : The purpose of the study is to develop an outcome measurement tool to investigate functional performance of consumers using seating and wheelchair systems as their primary seating and mobility device. The instrument is undergoing systematic development in three phases. The results of Phase 1 will be reported. Method : Manual and power wheelchair users were interviewed using a modified version of a client-centred outcome measure. An item bank was derived based on the interview data. Subjects were then asked to validate item categories of the new instrument, and finally to self-administer the first version of the instrument. Results : Subjects reported 154 self-care, productivity, and leisure occupational performance issues related to their current seating-mobility system. Based on their input, 10 categories (i.e. transfers, reach, accessing task surfaces, transportation-portability, human-machine interface, architectural barriers, transportation-accessibility, transportation-securement, natural barriers and accessories) were validated for inclusion in the new outcome measure, Functional Evaluation in a Wheelchair (FEW). Conclusion : The items on the FEW focus on the interaction between the consumer, the technology, and the milieu. Consumers viewed the overall importance of FEW categories for seating-mobility system users differently than when they self-administered the FEW.

Postural changes with aging in tetraplegia: effects on life satisfaction and pain.

OBJECTIVES (1) To measure kyphosis and scoliosis in individuals with tetraplegia; (2) to examine the relation between kyphosis and scoliosis and years since injury; and (3) to determine the association between kyphosis and scoliosis and measures of pain, depression, and life satisfaction. DESIGN Cross-sectional, case-control study. SETTING University medical center and a free-standing university-affiliated rehabilitation hospital. PARTICIPANTS (1) Ten individuals with tetraplegia I to 3 years postinjury (NT); (2) 10 individuals with tetraplegia 10 to 20 years postinjury (OT); and (3) 10 control individuals (C) matched to the other subjects on the basis of age, height, and weight. MAIN OUTCOME MEASURES Radiographic measurements of kyphosis and scoliosis taken in a seated position, pain as measured by the short form of the McGill Pain Questionnaire (SF-MPQ), depression as measured by the Center for Epidemiological Studies-Depression Scale (CES-D), and life satisfaction as measured by the Life Satisfaction Index Assessment (LSIA) and the Craig Handicap Assessment and Reporting Technique (CHART). RESULTS No significant differences were seen between the OT and NT groups with respect to age, height, or weight. In addition, no significant differences were found between the NT and OT groups with respect to measures of kyphosis and scoliosis. Individuals with tetraplegia had significantly higher (p < .05) measures of kyphosis (42 + 16.0 ) and scoliosis (14 degrees +/-9.2 degrees) than the C subjects (kyphosis, 32 degrees +/- 7.9 degrees ; scoliosis, 5 degrees+/-3.8 degrees). No correlation was found between scores on the SF-MPQ and degree of kyphosis or scoliosis. Significant differences were seen between the NT and OT groups on both CES-D (NT, 15.2+/-8.1; OT, 5.8+/-5.5) and LSIA (NT, 9.9+/-2.8; OT, 14.4+/-2.9). CONCLUSION This study indicates that seated kyphosis and scoliosis develop early in individuals with tetraplegia and may not be progressive. No association was seen between pain and kyphosis or scoliosis in this relatively young sample (mean age of OT and NT combined, 34.8 years). Future research is needed to determine whether pain becomes a problem in individuals with significant kyphosis or scoliosis as they age.

Wheelchair Seating: A State of the Science Report

Regardless of the field, agenda-setting processes are integral to establishing research and development priorities. Beginning in 1998, the National Institute on Disability and Rehabilitation Research mandated that each newly funded Rehabilitation Engineering and Research Center (RERC) hold a state-of-the-science consensus forum during the third year of its 5-year funding cycle. NIDRRs aim in formalizing this agenda-setting process was to facilitate the formulation of future research and development priorities for each respective RERC. In February 2001, the RERC on Wheeled Mobility, University of Pittsburgh, conducted one of the first such forums. The scope encompassed both current scientific knowledge and clinical issues. In preparation, expert interviews were carried out to establish the focus for the forum. Because a stakeholder forum on wheelchair technology had recently been held, opinion favored wheelchair seating as the focus and included the following core areas: seating for use in wheelchair transportation, seated postural control, seating discomfort, and tissue integrity management. The aim of this report is to present a summary of the workshop outcomes, describe the process, and increase awareness of this agenda-setting process in order to enhance future participation in a process that critically influences the field of wheeled mobility.

A Survey of Persons Who Use Integrated Control Devices

Integrated devices allow users to operate multiple pieces of assistive technology items from a single input device. Through this single input device, users with severe physical limitations are able to operate several other devices such as a wheelchair, telephone, computer, and communication aid. Twenty-four integrated control users completed a telephone survey to ascertain consumer satisfaction with integrated controls. Eighteen were either satisfied or very satisfied with the evaluation for an integrated control, one was neither satisfied nor dissatisfied, two were very dissatisfied, and three did not respond to the question. Twenty were very satisfied or satisfied and four were either dissatisfied or very dissatisfied with the training they received. Twenty-two respondents indicated they were either very satisfied or satisfied with their integrated control device, one was neither satisfied nor dissatisfied, and one was very dissatisfied. In general, respondents were satisfied with their integrated control devices. Specifically, respondents were satisfied with the increase in independence and the ability to control other equipment such as television sets and computers. Simplicity, touch sensitivity, and visual/auditory feedback appeared to play important roles in satisfaction.

Comparison of Anterior Trunk Supports for Children with Cerebral Palsy

The purpose of this study was to demonstrate outcome measures of one seating component--anterior trunk supports--when used by children with cerebral palsy during a functional activity. The functional activity was pressing a single switch to activate a computer software program. Seventeen children with a mean age of 9 years were included in the study. Subjects had mild to moderate spastic or athetoid cerebral palsy. Seven had a primary diagnosis of athetoid and 10 had a primary diagnosis of spastic cerebral palsy. All subjects needed supplemental seating to maintain an upright posture. The four trunk supports tested were an anterior chest panel, a 1-inch-wide single horizontal chest strap, an anterior shoulder support, and a tray with molded chest support. Data included prehits, response time, and the length of time the subject pressed the switch. A repeated analysis of variance test was used to analyze the data. Data for athetoid and spastic cerebral palsy subject groups were analyzed separately. No statistically significant differences were found between the four trunk supports. Therefore, the choice of trunk supports for this population should be based on client preferences, ease of removal for the caregiver, cost, and aesthetics.