Reasons for Initiation and Discontinuation of Pharmacological Therapies for Osteoporosis in Veterans with Spinal Cord Injury and Disorders.

INTRODUCTION: Medications for osteoporosis have not been reported to reduce fracture rates in patients with spinal cord injury and disorders (SCI/D), yet these medications are still prescribed. Clinical decision-making underscoring the initiation and discontinuation of osteoporosis medications in SCI/D remains poorly understood. METHODOLOGY: Veterans with a SCI/D with at least one prescription for an osteoporosis medication (bisphosphonate, calcitonin, denosumab, raloxifene, and teriparatide) who received healthcare within Veterans Affairs (VA) from 2005 to 2015 were identified using VA administrative databases. A 10% subsample of Veterans was selected for electronic health record review. RESULTS: Two hundred and sixty-seven Veterans with 330 prescriptions underwent electronic health record review. Bisphosphonates were the most frequently prescribed medication for osteoporosis (n = 223, 67.6%). Of the 187 Veterans with prescriptions for prevention or treatment of osteoporosis, the primary reason for initiation was Dual Energy X-ray Absorptiometry (DXA) scan with osteopenia or osteoporosis (n = 119, 63.6% of Veterans), primarily at the hip (81.0% of DXAs). The majority (79.0%) of DXAs were "screening tests," with SCI/D being the sole reason for the scan. Fractures (n = 51, 27.3%) and fall risk concerns (n = 29, 15.5%) were other major reasons for initiation. On average, oral bisphosphonates were filled for <3 yr, with medication-related side effects (n = 23, 15.8% of bisphosphonates discontinued), predominately gastrointestinal (n = 17, 73.9% of reported side effects), the most common reason for discontinuation. Drug holidays occurred in 14.3% of 35 oral bisphosphonates used for ≥5 yr. No cases of osteonecrosis of the jaw were found. There was one case of an atypical femoral fracture which could not be confirmed. CONCLUSIONS: The decision to initiate pharmacological therapies in SCI/D is primarily based on osteopenia or osteoporosis at the hip by screening DXAs. Gastrointestinal side effects are the major reason for discontinuation of oral bisphosphonates. New therapies for osteoporosis in SCI/D are needed.

Factors influencing providers' decisions on management of bone health in people with spinal cord injury.

STUDY DESIGN: Survey. OBJECTIVES: Managing osteoporosis in persons with chronic spinal cord injury (SCI) is difficult as little evidence exists regarding effective strategies. We examined the effect of key factors on providers' bone health management decisions in persons with SCI. SETTING: USA. METHODS: Providers reviewed blocks of 9 hypothetical cases that varied on four factors: osteoporosis, osteopenia, or normal bone mineral density using dual-energy X-ray absorptiometry (DXA); DXA region of interest (lumbar spine, hip, knee), prior lower extremity fracture; and no or limited ambulation. They indicated how likely they would recommend pharmacological management, what treatment(s) they would recommend, and whether they would request another DXA before treatment. RESULTS: Eighty-two healthcare providers completed the survey. Treatment recommendations for bisphosphonates and Vitamin D/calcium supplements, respectively, were more likely if there was a prior fracture (OR: 2.65, 95%CI: 1.76-3.99, p < 0.0001; OR: 2.96, 95%CI: 1.40-6.26, p = 0.004) and if a DXA scan found osteopenia (OR: 2.23, 95%CI: 1.41-3.54, p = 0.001; OR: 6.56, 95%CI: 2.71-15.85, p < 0.0001) or osteoporosis (OR: 12.08, 95%CI: 7.09-20.57, p < 0.0001; OR: 4.54, 95%CI: 2.08-9.90, p < 0.0001). Another DXA scan was more likely to be requested if there was a prior fracture (OR: 1.75, 95%CI: 1.10-2.78, p = 0.02) but less likely if the person was nonambulatory (OR: 0.41, 95%: 0.19-0.90, p = 0.03). CONCLUSIONS: Prior fracture and DXA findings influenced treatment recommendations for bone health management in SCI. Reliance on lumbar spine scans to determine bone loss and treatment identifies a knowledge gap for which future education is required.

Spinal cord injury providers' perspectives on managing sublesional osteoporosis.

Objective: Persons with spinal cord injuries (SCI) experience rapid sublesional bone loss following injury (1, 3). Evidence on preventing/managing osteoporosis in SCI is lacking. This project examined how providers manage bone loss in SCI. Design: Telephone interviews with SCI providers. Setting: VA SCI centers and clinics. Participants: Veterans Administration SCI centers and clinics were categorized on their average number of dual-energy X-ray absorptiometry (DXA) scans (FY2014-2016). Twelve SCI providers from high and low DXA-ordering sites were interviewed. Questions included osteoporosis screening/diagnosis, prevention/treatment strategies, secondary causes of osteoporosis, and osteoporotic fracture complications. Interviews were audio-recorded, transcribed, and analyzed. Results: Providers described a lack of standardized guidelines for managing osteoporosis in SCI. They most often screened for osteoporosis using DXA when: (1) considering use of a new device or activity, (2) for patients with a history of fracture. Some providers assumed that non-ambulatory SCI patients already have osteoporosis so infrequently ordered DXAs. Assessment of secondary causes of osteoporosis was uncommon. Fracture prevention strategies identified included weight-bearing and engaging in activities like adaptive sports. Vitamin D and calcium were frequently prescribed as a result of deficiencies identified during lab testing. Providers seldom prescribed FDA-approved medications for osteoporosis. Post-fracture complications encountered included nonunion/malunion and compartment syndrome. Providers indicated that patients often experienced psychological stress, anxiety and depression following fractures. Conclusion: Providers described a lack of evidence for screening and management of patients with SCI and osteoporosis. Future efforts should include developing evidence-informed guidelines to aid providers in osteoporosis management.

A historical study of appendicular fractures in veterans with traumatic chronic spinal cord injury: 2002-2007.

OBJECTIVE: Describe the incidence and distribution of appendicular fractures in a cohort of veterans with spinal cord injury (SCI). DESIGN: Retrospective, observational study of fractures in veterans with a chronic traumatic SCI. SETTING: The Veterans Health Administration (VA) healthcare system. PARTICIPANTS: Veterans included in the VA Spinal Cord Dysfunction Registry from Fiscal Years (FY) FY2002-FY2007. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Description of fractures by site and number. Mortality at one year following incident fracture among men with single vs. multiple fractures. RESULTS: Male and female veterans sustained incident fractures with similar observed frequency (10.5% vs 11.5%). The majority of fractures occurred in the lower extremities for both men and women. In men, a complete extent of injury (compared to incomplete) was associated with 41% greater relative risk (RR) of incident fracture (RR 1.41, 95% confidence interval [1.17, 1.70]) among those with tetraplegia, but not paraplegia. Furthermore, many men (33.9%, n = 434) sustained multiple fractures over the course of the study. There were no differences in mortality between men who sustained a single fracture and those who had multiple fractures. CONCLUSIONS: The extent of injury may be an important predictor of fracture risk for male veterans with tetraplegia. Once a fracture occurs, male veterans with SCI appear to be at high risk for additional fractures.

Delayed and unmet need for medical care among publicly insured adults with disabilities.

BACKGROUND: While Medicaid is an important source of insurance coverage for persons with disabilities, barriers remain to accessing care for this population. OBJECTIVES: This study addresses 3 research questions: (1) do adults with disabilities experience greater unmet need/delayed care?; (2) do barriers related to cost, providers, or structure vary by disability status?; and (3) do barriers mediate the relationship between disability and access to care? RESEARCH DESIGN: Data were obtained from a 2008 stratified random sample of Minnesota Health Care Program's nonelderly adult enrollees (n=1880). The survey was administered by mail, with a telephone follow-up for nonresponders. MEASURES: Disability is defined by self-report. Access to care is measured by reported delayed and unmet need for medical care within the past year. Respondents were asked about their experiences with a variety of cost-related, provider-related, and structural barriers to care. RESULTS: Respondents with a disability were more likely to experience delayed (40%) and unmet need (23%) for medical care than persons without disabilities (24% and 10%, respectively). Persons with disabilities also reported multiple barriers to health care, especially structural barriers, such as making a timely appointment and accessing transportation (74% vs. 59%). The greater likelihood of facing a structural barrier partially explained increased risk of delayed or unmet care among adults with disabilities. CONCLUSIONS: Disparities in access to health care based on disability status remain even for persons who have insurance. These disparities deserve further research and policy attention to better address the particular needs of this population.

Life satisfaction and life values in people with spinal cord injury living in three Asian countries: a multicultural study.

OBJECTIVE: To compare the differences in life satisfaction and life values among people with spinal cord injury (SCI) living in three economically similar Asian countries: India, Vietnam, and Sri Lanka. DESIGN: Cross-sectional and comparative investigation using the unified questionnaire. SETTING: Indian Spinal Injuries Centre in New Delhi (India), Spinal Cord Rehabilitation Department of the Bach Mai Hospital in Hanoi (Vietnam), and Foundation for the Rehabilitation of the Disabled in Colombo (Sri Lanka). PARTICIPANTS: Two hundred and thirty-seven people with SCI using a wheelchair; 79 from India, 92 from Vietnam, and 66 from Sri Lanka. OUTCOME MEASURES: Life Satisfaction Questionnaire, Chinese Value Survey. RESULTS: People with SCI in Vietnam had significantly higher general life satisfaction than participants in India and Sri Lanka. Significant differences were identified in several demographic and life situation variables among the three Asian countries. With regard to "Traditional", "Universal", and "Personal" life values significant differences among three participating countries were identified in all domains. No significant relationships were identified between life satisfaction and life values for people with SCI in India, Vietnam, or Sri Lanka. CONCLUSION: It could be presumed that particular demographic and life situation variables are more powerful factors of life satisfaction following SCI than the dominant culture of a country expressed by life values.

Development and testing of a vaccination message targeted to persons with spinal cord injuries and disorders.

BACKGROUND/OBJECTIVE: Individuals with spinal cord injuries and disorders (SCI&D) are at high-risk of complications and death after influenza and pneumonia. Respiratory vaccinations are effective in reducing infection and complications. The aim of this study was to test the feasibility and effectiveness of a multimedia educational message developed using a strong theoretical basis and targeted consumer input to modify negative perceptions, increase knowledge, and positively influence intentions and beliefs regarding respiratory vaccinations. METHODS: Veterans with SCI&D (n = 36) completed a pretest questionnaire, viewed the message, and, after a clinic visit, completed a posttest questionnaire. Mean differences were examined using paired t tests. Providers (n = 25) were surveyed about the content, comprehension, and reception of the message; response frequencies were examined. RESULTS: Respondents showed positive changes in beliefs from pre- to posttest on multiple items related to knowledge, severity, and self efficacy and response efficacy. There were no changes in perception of personal susceptibility to these diseases. Most providers were in favor of using the message in this population. CONCLUSIONS: A brief theory-based multimedia intervention is a feasible way to improve knowledge and attitudes about respiratory vaccinations in high-risk populations.

Investigation of soft-tissue stiffness alteration in denervated human tissue using an ultrasound indentation system.

BACKGROUND/OBJECTIVE: Differences in soft-tissue stiffness may provide for a quantitative assessment and detection technique for pressure ulcers or deep-tissue injury. An ultrasound indentation system may provide a relatively convenient, simple, and noninvasive method for quantitative measurement of changes in soft-tissue stiffness in vivo. METHODS: The Tissue Ultrasound Palpation System (TUPS) was used to quantitatively measure changes in soft-tissue stiffness at different anatomical locations within and between able-bodied persons and individuals with chronic spinal cord injury (SCI). The stiffness of soft tissue was measured at the ischial tuberosity, greater trochanter, posterior midthigh, and biceps brachii. Additionally, soft-tissue thickness and soft-tissue deformation were also measured. RESULTS: Significant differences in soft-tissue stiffness were observed within the various anatomical locations tested, in both the able-bodied and SCI groups. Differences in soft-tissue stiffness were also observed between the 2 groups. Participants with SCI had significantly softer tissue in their buttock-thigh area. CONCLUSIONS: TUPS is a clinically feasible technology that can reliably and effectively detect changes in soft-tissue stiffness. The study has provided a better understanding of the tissue mechanical response to external loading, specifically in the SCI population, suggesting the use of tissue stiffness as a parameter to detect and assess pressure-related soft-tissue injury.

Epidemiology of hospital-acquired infections in veterans with spinal cord injury and disorder.

OBJECTIVE: To describe the epidemiology of hospital-acquired infections (HAIs) in veterans with spinal cord injury and disorder (SCI&D). DESIGN: Retrospective medical record review. SETTING: Midwestern Department of Veterans Affairs spinal cord injury center. PARTICIPANTS: A total of 226 patients with SCI&D hospitalized at least once during a 2-year period (October 1, 2001, through September 30, 2003). RESULTS: A total of 549 hospitalizations were included in the analysis (mean duration of hospitalization, 33.7 days); an HAI occurred during 182 (33.2%) of these hospitalizations. A total of 657 HAIs occurred during 18,517 patient-days in the hospital (incidence rate, 35.5 HAIs per 1,000 patient-days). Almost half of the 226 patients had at least 1 HAI; the mean number of HAIs among these patients was 6.0 HAIs per patient. The most common HAIs were urinary tract infection (164 [25.0%] of the 657 HAIs; incidence rate, 8.9 cases per 1,000 patient-days), bloodstream infection (111 [16.9%]; incidence rate, 6.0 cases per 1,000 patient-days), and bone and joint infection (103 [15.7%]; incidence rate, 5.6 cases per 1,000 patient-days). The most common culture isolates were gram-positive bacteria (1,082 [45.6%] of 2,307 isolates), including Staphylococcus aureus, and gram-negative bacteria (1,033 [43.6%] of isolates), including Pseudomonas aeruginosa. Multivariable regression demonstrated that predictors of HAI were longer length of hospital stay (P=.002), community-acquired infection (P=.007), and use of a urinary invasive device (P=.01) or respiratory invasive device (P=.04). CONCLUSIONS: The overall incidence of HAIs in persons with SCI&D was higher than that reported for other populations, confirming the increased risk of HAI in persons with spinal cord injury. The increased risk associated with longer length of stay and with community-acquired infection suggests that strategies are needed to reduce the duration of hospitalization and to effectively treat community-acquired infection, to decrease infection rates. There is significant room for improvement in reducing the incidence of HAIs in this population.

Measuring tissue perfusion during pressure relief maneuvers: insights into preventing pressure ulcers.

BACKGROUND/OBJECTIVE: To study the effect on tissue perfusion of relieving interface pressure using standard wheelchair pushups compared with a mechanical automated dynamic pressure relief system. DESIGN: Repeated measures in 2 protocols on 3 groups of subjects. PARTICIPANTS: Twenty individuals with motor-complete paraplegia below T4, 20 with motor-complete tetraplegia, and 20 able-bodied subjects. METHODS: Two 1-hour sitting protocols: dynamic protocol, sitting configuration alternated every 10 minutes between a normal sitting configuration and an off-loading configuration; wheelchair pushup protocol, normal sitting configuration with standard wheelchair pushup once every 20 minutes. MAIN OUTCOME MEASURES: Transcutaneous partial pressures of oxygen and carbon dioxide measured from buttock overlying the ischial tuberosity and interface pressure measured at the seat back and buttocks. Perfusion deterioration and recovery times were calculated during changes in interface pressures. RESULTS: In the off-loading configuration, concentrated interface pressure during the normal sitting configuration was significantly diminished, and tissue perfusion was significantly improved. Wheelchair pushups showed complete relief of interface pressure but incomplete recovery of tissue perfusion. CONCLUSIONS: Interface pressure analysis does not provide complete information about the effectiveness of pressure relief maneuvers. Measures of tissue perfusion may help establish more effective strategies. Relief achieved by standard wheelchair pushups may not be sufficient to recover tissue perfusion compromised during sitting; alternate maneuvers may be necessary. The dynamic seating system provided effective pressure relief with sustained reduction in interface pressure adequate for complete recovery of tissue perfusion. Differences in perfusion recovery times between subjects with spinal cord injury (SCI) and controls raise questions about the importance of changes in vascular responses to pressure after SCI.

Long-term outcomes from nosocomial infections in persons with spinal cord injuries and disorders.

BACKGROUND: Nosocomial infection may contribute to poor long-term consequences in persons who have spinal cord injuries and disorders (SCI&D). METHODS: This is a cohort study of individuals who had SCI&D and were hospitalized at least once during 2002. They were followed for 3 years to assess inpatient (IP) admissions, total IP length of stay (LOS), outpatient (OP) visits, and mortality. Count data models and a Cox proportional hazards model were used to assess the relationship between previous infection and subsequent IP and OP use and long-term mortality, respectively. RESULTS: Of persons who had SCI&D, 59% had at least one nosocomial infection. Multivariable regression indicated that veterans who had SCI&D had more IP admissions (b = 0.405; P < .0001) and longer IP LOS (b = 0.843; P < .0001) if they had a previous infection; however, infection status was not a predictor of future OP visits. Survival time was lower (913.93 versus 1034.75 days, P = .004) in the infection group. Death rate was higher in the nosocomial infection group (30.11% versus 10.77%; P = .004), but the association did not achieve significance in the Cox proportional hazards model (P = .12). CONCLUSIONS: Nosocomial infections have serious subsequent consequences that result in future hospitalization and shorter survival. Efforts to prevent nosocomial infections are needed to reduce long-term adverse effects in persons who have SCI&D.

Spinal cord injury medicine. 1. Epidemiology and classification.

UNLABELLED: This self-directed learning module reviews the demographics of traumatic and nontraumatic spinal cord injuries (SCIs). It is part of the study guide on SCI medicine in the Self-Directed Physiatric Educational Program for practitioners and trainees in physical medicine and rehabilitation. This article specifically focuses on the changing demographics of traumatic SCI, the classification of SCI, the common causes of nontraumatic SCI, and the incidence and prevalence of myelomeningocele. OVERALL ARTICLE OBJECTIVE: To summarize the demographics and classification of traumatic and nontraumatic spinal cord injuries in adults and children.

Spinal cord injury medicine. 2. Acute care management of traumatic and nontraumatic injury.

UNLABELLED: This self-directed learning module highlights the basic acute care management of traumatic and nontraumatic spinal cord injury (SCI). It is part of the chapter on SCI medicine in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. Acute traumatic SCI is optimally managed in a level 1 trauma center. Decompression of the neural elements, stabilization of the spine, and maintenance of tissue perfusion are fundamental to optimizing outcomes. SCI patients are at high risk of pressure ulcers, venous thromboembolism, stress ulceration, bowel impaction, dysphagia, and pulmonary complications. Physiatric interventions are needed to prevent these complications. Prognostication of neurologic outcome based on early examination is an important skill to aid in creating a rehabilitation plan and to test for efficacy of early interventions. Nontraumatic SCI is an increasing population in rehabilitation centers. Establishing a diagnosis and treatment plan is essential, in conjunction with prevention of complications and early physiatric intervention. OVERALL ARTICLE OBJECTIVES: (a) To describe the diagnostic evaluation of traumatic and nontraumatic spinal cord injuries and (b) to summarize the medical, surgical, and physiatric interventions during acute hospitalization for these injuries.

Spinal cord injury medicine. 3. Rehabilitation phase after acute spinal cord injury.

UNLABELLED: This self-directed learning module highlights the rehabilitation aspects of care for people with traumatic spinal cord injury (SCI). It is part of the chapter on SCI medicine in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article specifically focuses on the formulation of a rehabilitation plan based on functional goals by level of injury. Such a plan includes mobility, activities of daily living, equipment needs, and adjustment issues after injury. The effect of a concomitant brain injury on rehabilitation is discussed. Medical complications seen in the rehabilitation stage such as autonomic dysreflexia, heterotopic ossification, neurogenic bowel, and orthostasis are addressed. Preparation for discharge is crucial to allow for a smooth transition to home. There have been advances in SCI rehabilitation research including in wheelchair technology, functional electric stimulation, and partial body weight-supported ambulation. OVERALL ARTICLE OBJECTIVE: To describe outcomes and issues that may arise during the rehabilitation phase after spinal cord injury.

Spinal cord injury medicine. 4. Community reintegration after spinal cord injury.

UNLABELLED: This self-directed learning module highlights community reintegration after spinal cord injury (SCI). It is part of the study guide on spinal cord injury medicine in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article specifically focuses on physical, social, psychologic, and environmental barriers that affect people with SCI and on how these issues affect relations with others. Recreational and exercise options are also discussed. OVERALL ARTICLE OBJECTIVE: To summarize the barriers and opportunities of community reintegration for people with spinal cord injury.

Spinal cord injury medicine. 5. Long-term medical issues and health maintenance.

UNLABELLED: This self-directed learning module highlights long-term care issues in patients with spinal cord injury (SCI). It is part of the study guide on SCI in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. The most common secondary medical complications include pressure ulcers, pneumonia, and genitourinary issues. Health care maintenance is important to prevent medical complications, for general health as well as for issues specific to SCI. Women with SCI have gender-specific issues regarding amenorrhea, sexuality, fertility, and menopause. Options exist to assist disabled men with sexuality and fertility complications. Pain is a common complication after SCI. Many new areas of research in the field of SCI are discussed. OVERALL ARTICLE OBJECTIVE: To discuss long-term care issues in patients with spinal cord injury, including health maintenance, secondary conditions, women's health, sexual function, pain, and spinal cord regeneration and recovery.

Spinal cord injury medicine. 6. Economic and societal issues in spinal cord injury.

UNLABELLED: This self-directed learning module presents a variety of social and economic issues facing people with spinal cord injury (SCI). It is part of the study guide on SCI medicine in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article focuses on the economic consequences of SCI, ethical issues in SCI, and the legislative efforts that have improved access and quality of life for people with disabilities. Costs of SCI include direct health care expenditures and lost earnings as a result of unemployment after SCI. Lifelong costs can be anticipated with the development of a comprehensive life care plan. Barriers to vocational reintegration continue to limit full participation for most people with SCI. Ethical issues central to SCI are related to the principles of autonomy and justice. As cure research becomes clinically applicable, the SCI community must work together to develop appropriate procedures to respect moral decision-making by all parties. Key legislation in the past century has resulted in important advances in the rights of people with disabilities. OVERALL ARTICLE OBJECTIVES: (a) To review the economic consequences of spinal cord injury, including lifelong direct costs, life care planning, and factors affecting employment and (b) to identify current ethical issues facing the spinal cord injury community and review the advances made in the rights of people with disabilities in the United States through legislation.

Impact of StatLock securing device on symptomatic catheter-related urinary tract infection: a prospective, randomized, multicenter clinical trial.

BACKGROUND: The objective of this study was to assess the impact of using the StatLock securing device on symptomatic catheter-related urinary tract infection (UTI). METHODS: In this prospective, randomized, multicenter clinical trial, adult patients with spinal cord injury or dysfunction because of multiple sclerosis were randomized to have their indwelling bladder catheters secured in place by using the StatLock device (experimental group) versus preexisting methods (control group that included tape, Velcro strap, CathSecure, or none). Patients were monitored for the development of symptomatic UTI within the subsequent period of 8 weeks. RESULTS: Of a total of 127 enrolled patients, 118 (60 in the experimental group and 58 in the control group) were evaluable. The 2 groups of evaluable patients were comparable in terms of clinical characteristics and risk factors for infection. Symptomatic UTI was diagnosed in 8 of 60 (13.3%) patients in the experimental group versus 14 of 58 (24.1%) patients in the control group (P = .16; RR = 0.55, 95% confidence interval: 0.25-1.22). CONCLUSION: Although the trial size precluded the demonstration of statistically significant differences, the finding of a 45% reduction in the rate of symptomatic UTI in patients who received the StatLock securing device is clinically relevant and prompts further investigations.

Preventable wheelchair-related thermal injury.

BACKGROUND/OBJECTIVE: Wheelchair-related injuries are common, and with proper reporting of injuries, advanced technologic support may offer new ways to prevent those injuries. METHOD: Case REPORT AND FINDINGS: A man with tetraplegia who retains only minimal use of his right hand experienced a right-sided armrest malfunction of his wheelchair resulting in his wheelchair controls being out of reach. This left him stranded in the sun for almost 2 hours in 86 degrees F weather. During that time, he developed full thickness sunburns of his left forearm and deep partial thickness burns of the left fingertips where they were in contact with the left armrest. CONCLUSION: This patient's full thickness burns could have been prevented if his motorized wheelchair had back-up communication in the event of a malfunction. Technology developers must realize the need for such systems. Health care professionals must advocate for a higher standard of safety and report injuries related to wheelchair malfunction.