VA Center of Excellence for Wheelchairs and Associated Rehabilitation Engineering (WARE)
Center Director: Rory A. Cooper, Ph.D.
Medical Director: Michael L. Boninger, M.D.
2004-2009
Projects:
Wheelchair Driving Characteristics During and Post National Veterans Wheelchair Games
Effectiveness and Use of Tilt-In-Space and Recline Wheelchairs
Ultrasonographic Evaluation of the Upper Extremity in Manual Wheelchair Users
Musculoskeletal Ultrasound Repeatability
Assistive Technology Use in Adult Spina Bifida
Wheelchair Mobility Characteristics
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Wheelchair Driving Characteristics During and Post National Veterans Wheelchair Games
Principal Investigators: Rory A. Cooper, PhD
Co-Investigators: Rosemarie Cooper, MPT, ATP; Dan Ding, PhD; Annmarie Kelleher, MS, OTR/L, ATP; Michelle Tolerico, MS; Emily Teodorski, BS
The purpose of this study is to collect wheelchair usage data on manual and power wheelchair users at the National Veterans Wheelchair Games (NVWG) and in the home environment. Over the past four years, usage data and basic demographic information have been collected on over 130 wheelchair users. Wheelchair usage data have been obtained through the use of custom designed data logging devices. The logging devices were installed on the subjects’ wheelchairs and collected usage (e.g. distance, speed, movement time) data for one week at the NVWG and two weeks in the home environment (Post-NVWG). In addition, subjects who were recruited in 2007 were also asked to complete an additional questionnaire related to community participation. A manuscript describing the results found when monitoring manual wheelchair users was published in the Journal of Rehabilitation Research and Development. An abstract titled “Real World Validation of the Caster Data Logger and Pilot Measurements of Power Wheelchair Usage During and After the National Veterans’ Wheelchair Games”, which summarizes preliminary results collected from power wheelchair users, was published in the 2007 RESNA conference proceedings. Also, data collected for this study in 2007 was used as a part of a doctoral dissertation.
Effectiveness and Use of Tilt-In-Space and Recline Wheelchairs
Principal Investigator: Dan Ding, PhD
Co-Investigators: Michael L. Boninger, MD; Rosemarie Cooper, MPT, ATP; Annmarie Kelleher, MS, OTR/L, ATP
Pressure ulcers are a costly problem in the United States. Another common problem in wheelchair users is back pain and poor posture. For both of these conditions it is thought that tilt in space and recline may be of benefit. Tilt in space can significantly reduce static seating pressure a key ingredient in the development of pressure sores. In addition, using recline and tilt in space can allow for a change in position in the wheelchair and thus improve comfort. Based on these arguments tilt in space and recline are widely prescribed accessories on power wheelchairs. However, there is very little research in this important area. It is unknown if after being given these items, veterans are actually using them. Furthermore, it is unknown if the degree of tilt used provides adequate pressure relief. The purpose of this project is to study the usage pattern of power tilt in space and recline seating options and its overall effectiveness in a real world environment. The objective is to collect data on how often a user changes power seating options during a 14-day time frame, what are the common positions chosen, to what extent the positions chosen provide effective pressure relief.
Twelve individuals who use a power wheelchair with seating functions participated in the study. They drove their own wheelchair and used the seating functions as needed in their community environment for about two weeks while the usage of such seating functions was recorded with a portable device. It was found that subjects occupied their wheelchair for 11.8 ± 3.4 hours per day. Tilt-in-space, backrest recline, and seat elevation were accessed 19 ± 14 times for 64.1% of the occupied time, 12 ± 8 times for 76.0% of the occupied time, and 4 ± 4 times for 22.5% of the occupied time per day, respectively. Subjects chose to stay in tilted and reclined positions for 39.3% of their time in wheelchair per day. Little time was spent in a fully upright position. Subjects changed their seating positions every 53.6 ± 47.0 minutes. Time spent in positions of different seating pressures varied among subjects. The information collected could enhance wheelchair provision clinical practice, resulting in better compliance and appropriate usage of seating functions among wheelchair users.
Ultrasonographic Evaluation of the Upper Extremity in Manual Wheelchair Users
Principal Investigator: Michael L. Boninger, MD
Co-Investigator(s): Rosemarie Cooper, MPT; Annmarie Kelleher, OTR/L; Bradley Impink, BSE; Ian Rice, MS
Objective
The objective of this study is to use ultrasound to analyze the effects of wheelchair propulsion on the wrist and shoulder anatomy (specifically nerves and tendons) in manual wheelchair users.
Methodology
History and physical examination: Will focus on upper extremity problems common in manual wheelchair users.
Nerve conduction studies: Will be completed bilaterally on the upper extremities of subjects.
Biomechanical analysis: Upper extremity motion and propulsion forces will be recorded while subject propels continuously for 10 minutes on a dynamometer.
Ultrasound examinations: Will be completed before and after propulsion in order to determine changes in anatomy as a result of propulsion.
Clinical Significance
Research has shown that many manual wheelchair users suffer from upper extremity pain at both the shoulder and the wrist. This study aims to investigate, at an anatomical level, the effects of wheelchair propulsion on the upper extremity. This research should help to provide insight into the mechanism of injury. The manual wheelchair user population will be compared with the control population to investigate differences in upper extremity anatomy due to everyday propulsion.
Musculoskeletal Ultrasound Repeatability
Principal Investigator: Michael L. Boninger, MD
Co-Investigators: Bradley Impink, BSE; Jennifer Mercer, BSE; Michelle Tolerico, MS
The purpose of this research study is to use ultrasound to examine soft tissue structures (i.e., tendons, nerves, muscles) of the arm. Specifically we will examine the median nerve at the wrist and the biceps tendon and supraspinatus tendon at the shoulder. This study will determine a repeatable technique for collecting ultrasound images of structures in the arm. These ultrasound images will be analyzed to quantitatively describe properties of the nerves and tendons. For example, cross sectional area, mean greyscale, and measures of collagen organization within a tendon will be computed. Ultrasound imaging is highly dependent on the operator as well as the ultrasound machine. We have collected data for the Musculoskeletal Ultrasound Repeatability study on two different ultrasound machines with multiple operators. This will allow us to quantify inter- and intra-rater reliability for a specific ultrasound machine. In another study, we plan to examine acute changes in these measures in response to manual wheelchair propulsion. We believe that acute changes to the nerves and tendons of the upper extremity resulting from manual wheelchair propulsion lead to chronic pathology and pain over time. These acute changes will likely be small, thus data collected in this repeatability study will allow us to quantify the measurement error for the quantitative measures of nerve and tendon characteristics and health. We will also gain information about nerve and tendon appearance and health in a population of non-wheelchair users.
Principal Investigator: Michael L. Boninger, MD
Co-Investigators: Shirley Fitzgerald, PhD; Brad Dicianno, MD; Michelle Tolerico, MS; Annmarie Kelleher, MS, OTR/L, ATP; Rory A. Cooper, PhD; Bradley Impink, BSE; Jennifer Mercer, BSE; Emily Teodorski, BS; Garrett Grindle, MS; Sara Sibenaller, BS; Alicia Koontz, PhD, RET; Michelle Sporner, BS; Padmaja Kankipati, MS; Rosemarie Cooper, MPT, ATP
Manual wheelchair propulsion is a primary source of mobility for many individuals with spinal cord injury or dysfunction. Propelling a manual wheelchair over an extended period often leads to arm pain and, subsequently, to secondary disability. An analysis of the literature reveals that over 50% of manual wheelchair users with spinal cord injury or dysfunction (SCI/D) experience arm pain that limits one or more of their activities of daily living. A substantial number of these studies implicate manual wheelchair propulsion as a contributing factor in the development of arm pain. Our research to date confirms manual wheelchair propulsion as a likely contributing factor to arm pain and tissue degeneration. In addition, crutch use has been implicated in upper limb injuries. In this study we plan to use ultrasound to look at the shoulder and the wrist of crutch and/or manual wheelchair users.
Previously, we have examined changes to the median nerve and biceps tendon resulting from a wheelchair basketball or rugby game. We found a significant decrease in median nerve cross-sectional area (CSA) after activity. We believe the decrease in CSA is a result of compression of the median nerve due to the repeated impact associated with manual wheelchair propulsion. This acute compression associated with manual wheelchair propulsion may ultimately lead to the development of CTS. At the shoulder, the average diameter of the biceps tendon was calculated as well as the echogenicity ratio (the pixel intensity ratio of the biceps tendon to a reference just superficial to the tendon sheath). The echogenicity ratio of the tendon significantly decreased from 1.97 to 1.73 after the event (p=.038). The diameter of the biceps tendon increased from 4.60 to 4.82mm (p=.178). Also, it was found that the change in tendon diameter positively correlated with the time of play (p=.004). Acute changes in biceps tendon properties after exercise were found and likely represent edema, a first sign of overuse injury. The significance of continuous activity was shown by the fact that subjects who had more playing time showed a larger increase in tendon diameter.
Our current protocol will examine acute changes to the median nerve, biceps tendon, and supraspinatus tendon following a 15 minute propulsion period. This propulsion period is divided into three 4-minute blocks (with 90 seconds of rest in between) in which the manual wheelchair user propels at their self-selected maximum speed in a figure-8 pattern which incorporates turning and braking. This task was designed to provide a standard “stress-test” that replicates everyday propulsion with stops, starts, turns, and steady-state propulsion. Data was collected for 24 subjects at the 2007 National Veterans Wheelchair Games (NVWG) and we plan to collect additional subjects at the 2008 NVWG.
Assistive Technology Use in Adult Spina Bifida
Principle Investigators: Brad Dicianno, MD
Co-Investigator: Anna Gaines, MD
There are over 70,000 Americans with Spina Bifida (SB). Physicians prescribe a wide range of AT devices to allow individuals with SB to be more mobile not only in their homes but also in the community. However, research has shown that, despite using AT, some individuals with SB are still often socially isolated, sedentary, and unable to find employment. Transition from childhood to adolescence and adulthood for many with SB often means transitioning medical care, and facing a clear medical obstacle—an inadequate number of adult SB clinics that provide comprehensive rehabilitative care. Unfortunately, little is known about how this transition affects AT provision, and in turn, whether the type or quality of the devices individuals receive may improve or impede their social integration. We hypothesize that most individuals with SB receive higher quality devices, but a minority receive these devices from comprehensive AT clinics that provide custom seating and wheelchair configuration evaluations. We hypothesize that those individuals receiving devices from comprehensive clinics will have higher satisfaction scores, fewer repairs, and fewer wheelchair- related injuries. We hypothesize that, overall, social integration and mobility as measured by the Craig Handicap Assessment Reporting Technique Short Form (CHART-SF) will be lower for wheelchair users than for functional ambulators, after controlling for variables such as occupation domain score, cognitive independence domain score, number of shunt revisions, and Beck Depression Inventory scores. We also hypothesize that social integration and mobility will be lower in individuals who were prescribed lower quality wheelchairs, lack adequate transportation for their wheelchairs, or who did not receive their wheelchairs from a comprehensive AT clinic. All studies will be conducted at the Univ. of Pittsburgh. We will recruit 100 participants with SB between the ages of 16-80 to complete surveys on assistive device use, medical history, Beck Depression Inventory, and CHART-SF. We will use ANCOVA statistics with post hoc analyses to examine data for significant relationships. Identifying disparities in AT provision and an association with poor social integration or mobility may help identify interventions to improve social outcome and addresses key components of the Spina Bifida Association’s National Research Agenda.
Wheelchair Mobility Characteristics
Principal Investigator: Jonathan L. Pearlman, PhD
Co-Investigator: Annmarie Kelleher, MS, OTR/L, ATP
Currently, the only way to determine the fatigue life of wheelchairs, which is defined as the times it take the wheelchair to no longer serve as a functional mobility device, is to test them in a controlled laboratory environment. Wheelchair standards are developed through a consensus process to provide test methods and performance criteria to help ensure the safety and efficacy prior to introduction to the commercial market. The American National Standards Institute/ Rehabilitation Engineering and Assistive Technology Society of North America (ANSI/ RESNA) standard include two wheelchair durability tests that, when combined, simulate three to five years of wheelchair usage. These two tests are the double drum test (DDT) and the curb drop test (CDT). For the wheelchair to pass the standard, it must complete 200,000 double drum cycles (one rotation of the rear roller) and 6,666 drops by the CDT. ANSI/RESNA standards are an effective way to compare wheelchair fatigue life and failure type although wheelchair testing is voluntary. Several studies have been completed that examine failure between different models of wheelchairs. Significant differences have been found in type of failure between models of wheelchairs. Although this information is very useful, it has been completed in a laboratory setting. Little has been documented in a ‘real world’ setting showing the durability of a wheelchair or how much they are actually used.
The specific aim of this project is to investigate the usage patterns (i.e. speed, distance and time traveled) and community participation of wheelchair users and the wheelchair repairs needed. This pilot project is also being conducted to examine the feasibility of the research methods and data collection tools. Ultimately, the data collected will provide valuable information for a much larger scale study.
Principal Investigators: Rory A. Cooper, PhD; Michael L. Boninger, MD
Co-Investigators: Clinical Coordinators and Faculty of the Human Engineering Research Laboratories
The purpose of this registry is to enable the research team at the Human Engineering Research Laboratories to facilitate wheelchair related research and development by identifying potential subjects for future research studies. It is projected that the registry will have representation from various diagnoses that are similar to national statistics, as well as be representative of the age ranges, gender, and ethnicity of wheelchair users. The Wheelchair Users Registry will consist of a database of individuals over the age of 18 who use a wheelchair or scooter for mobility and are interested in learning more about current and future wheelchair related research projects that they may be eligible to participate in.
Wheelchair users will be recruited nationwide through personal contact at disability related venues, for example the National Veterans Wheelchair Games and Abilities Expos, as well as through mediums such as the Internet, flyers, magazines and newsletters. If the participant agrees to be included in the Wheelchair Users Registry informed consent will be obtained prior to data collection. Demographic, medical, and information about their current wheelchair will be obtained via questionnaire. This information will be used to identify subjects for specific research studies. In addition, each participant will be contacted once a year in order to keep demographic information up to date.
As of February 2008, there were 1168 individuals enrolled in the registry from across the United States. The Registry is predominantly Caucasian (80%), 64% male, with an average age of 50 years. Fifty-two percent used a manual wheelchair as their primary means of mobility. Fifty-five percent of individuals enrolled in the Registry have a spinal cord injury.
Implementation of this registry will enable us to develop an organized record of individuals who have participated in research studies and/or are interested in learning about future research opportunities. This registry will be a more effective and efficient method to recruit research subjects. Registries offer the ability to have a collected group of individuals that have some common purpose. For our purposes, the registry is a listing of wheelchair and scooter users who have indicated a willingness to participate in research.