Using high-resolution imaging to study the impact of the Kalogon wheelchair cushion on blood flow in the gluteal area.

AIM OF THE STUDY: This study investigated how the air-bladder offloading mode of the Orbiter by Kalogon wheelchair cushion (Orbiter) affected blood flow in the gluteal region of non-disabled subjects. The hypothesis was that the cushion's offloading mode would improve blood flow, resulting in reduced reactive hyperemia when compared to the static setting, or Loaded Control (LC). Furthermore, the study proposed a technique using a high-resolution image laser speckle contrast system to measure blood flow in the gluteal area. METHODS: Two procedures were carried out, one with the participant sitting on a cushion in LC, and the second, the cushion was set to offloading mode. Blood flow was measured through data imaging after each procedure. Three trials were performed, starting and ending in different cushion bladders. Customized algorithms were used to select regions of interest on the images for calculations. The Wilcoxon Signed-Rank Test was conducted to compare the offloads and loaded control values of each region of interest. Results were considered significant at α = 0.05. RESULTS: Ten healthy, non-disabled adults participated in the study, seven females and three males. There were no significant differences among the participants. However, results showed that seven subjects tended to decrease reactive hyperemia in the offload sequence of trial when the last two bladders offloaded were the sacrum followed by the right ischial tuberosity. CONCLUSIONS: The high-resolution imager showed that the Orbiter Offloads helped reduce reactive hyperemia in seven subjects, potentially improving blood flow. More research is necessary to comprehend the mechanisms of these effects fully.

Mini-review: Robotic wheelchair taxonomy and readiness.

Robotic wheelchair research and development is a growing sector. This article introduces a robotic wheelchair taxonomy, and a readiness model supported by a mini-review. The taxonomy is constructed by power wheelchair and, mobile robot standards, the ICF and, PHAATE models. The mini-review of 2797 articles spanning 7 databases produced 205 articles and 4 review articles that matched inclusion/exclusion criteria. The review and analysis illuminate how innovations in robotic wheelchair research progressed and have been slow to translate into the marketplace.

Evaluation of interface pressure and temperature management in five wheelchair seat cushions and their effects on user satisfaction.

BACKGROUND: Factors such as the manufacturing materials, shape or even the mechanical and thermal response of sitting Pressure Redistribution Support Surfaces (PRSS) can be potential contributors to pressure ulcers. However, few studies have compared a number of characteristics of the most frequently used devices. OBJECTIVE: To compare three potential contributors to pressure ulcers in five commercial PRSS: pressure redistribution, temperature and perceived comfort. METHOD: Study with a cross-over randomized design in healthy volunteer participants. Data was collected in a temperature and relative humidity controlled environment. To assess thermal response, the temperature (Flir-E60) of the region of interest was captured before and after use of each PRSS for further analysis. The region of interest was the gluteal zone. To assess the pressure redistribution a pressure mat (XSensor®) was used between the 5 cushion and each study participant using a standardized method. Finally, a subjective perception questionnaire recorded comfort, adaptability and thermal sensation parameters. Data analysis levels of significance were set at 0.05. RESULTS: A total of 22 participants completed the assessments. There were no statistically significant differences in baseline temperatures between PRSS (>0.05). Pressure redistribution analysis showed significant differences between all PRSS in all variables evaluated except in the maximum and peak pressure index al sacrum. The subjective assessment suggested no major user-perceived differences between PRSS. CONCLUSION: Seat cushions made of open cell polyurethane foam blocks of variable hardness and the horseshoe cushion (also open cell polyurethane foam) seem to provide a more effective pressure relief characteristic than those injected with polyurethane foam and gel in most of the studied pressure variables. However, the cushions provide similar thermal response and perceived comfort.

Feasibility and preliminary reliability and validity of remote sitting balance assessments among wheelchair users.

The aim of this study was to investigate the feasibility and preliminary validity and reliability of remote sitting balance assessment. Seven wheelchair users (mean age: 42.7 ± 19.74 years) participated in an in-person and remote sitting balance assessment. The assessments were compared to investigate the concurrent validity of the remote assessment. Reliability of remote assessment was evaluated using intraclass coefficient correlation (ICC) and the Bland-Altman. No significant differences were observed between the mean scores of in-person and remote administrations of the clinical tests (P's > 0.05). High to very high agreement was found between in-person and remote assessments (ICC = 0.88-0.982, P < 0.05). The agreement was confirmed by Bland-Altman graph analysis. Preliminary results indicate remote sitting balance assessment is feasible to perform, valid, and reliable.

Measuring practice gaps in the delivery of evidence-based seating assessments: a retrospective chart review.

PURPOSE: To measure if a knowledge-to-practice gap exists between desired practice and current practice in wheelchair assessment after the implementation of a new seating assessment tool at a university affiliated rehabilitation centre. METHODS: A 6-month retrospective chart review of 61 wheelchair assessments was undertaken to determine if the assessment was consistent with a newly implemented and evidence-based seating assessment tool. Descriptive statistics were used to analyse the data to determine the degree of completion of the 69-item assessment and across 61 individual assessments. RESULTS: Of the 61 assessments reviewed, 69% were documented using the new seating assessment tool, 21% were documented using the previous seating assessment tool, and 10% were not documented on any seating assessment tool. Completion of the 69-item assessment tool was greater than 80% in 39% of the 61 assessments. The highest rates of completion were in the categories of patient information, clinical reasoning, and goals with an average completion of 73%, 71% and 65% respectively. The categories of linear measurements, mat assessment in supine, and postural alignment in wheelchair had the lowest average completion of 45%, 40% and 30% respectively. CONCLUSION: This chart review successfully identified and quantified areas of wheelchair assessment documented in adherence to current evidence-based guidelines, as well as gaps in assessment practice that should be addressed.Implication for rehabilitationCompletion of chart review is a simple tool to describe current practice and evaluate adherence to practice standards.Identifying practice gaps is an important first step in determining areas of focus in the improvement of clinical care.Ongoing support and monitoring is required in the development and implementation of evidence-based wheelchair assessment to ensure adoption in clinical practice.

Preliminary steps of the development of a Minimum Uniform Dataset applicable to the international wheelchair sector.

Assistive products outcomes are needed globally to inform policy, practice, and drive investment. The International Society of Wheelchair Professionals developed a Minimum Uniform Dataset (MUD) for wheelchair services worldwide with the intent to gather data that is comparable globally. The MUD was developed with the participation of members from around the globe and its feasibility piloted at 3 sites. Three versions of the MUD are now available-a short form with 29 data points (available in English, Spanish, and French) and a standard version with 38 data points in English. Future work is to validate and complete the translation cycles followed by promoting the use of the MUD globally so that the data can be leveraged to inform policy, practice and direct investments.

Road vehicle transportation of children with physical and behavioral disabilities: A literature review.

Background: A literature review in 2001 found that children with disabilities were frequently transported in unsafe conditions and further research was required to investigate the gap between regulations, standards and actual transportation practices.Objectives: To synthesize available evidence on the transportation of children with disabilities in road vehicles.Methods: Four databases were systematically searched: CINAHL; Medline; National Transport Library Catalogue (Sweden); and Transport Research International Documentation.Results: Nineteen studies ranging in methodological quality from poor to excellent were included in the review. The findings are presented under the following six major themes: child safety restraints, wheelchairs, vehicles, travel habits, parental and professional knowledge. The results are mapped onto two groups of children, those with behavioral problems and those with physical disabilities.Conclusion: The literature reflected little change across the six major themes since the previous review. Children with disabilities continue to be inappropriately restrained in vehicles, constituting an ongoing road safety problem. There is a strong need to increase parent knowledge, upskill health professionals and provide families with financial assistance to enable them to ensure the safe transportation of children with disabilities to minimize the risk of injury and fatalities on the road, and enhance their participation in the community.

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.

Developing a process for assessing equivalency of wheelchair cushion pressure redistribution performance.

For wheelchair users who are at risk for developing pressure ulcers, cushion prescription seeks to address tissue integrity. Because many designs of wheelchair cushions exist, a need exists to estimate their performance in supporting the body. The objective of this research was to develop an approach to assess the equivalency of cushions with respect to their pressure redistribution performance.Two instrumented compliant buttock models, differing in form, were used in the evaluation. Stress and strain parameters were used to characterize load-bearing performance. A cohort of 8 wheelchair cushions was compared to a standard reference material, HR45 foam. Each cushion was measured using both models under two loading conditions.The use of compliant buttock models that are capable of measuring both stress and strain parameters offer greater capability in measuring load-bearing performance compared to previously described methods. The proposed approach was able to evaluate cushion performance and use a logic-based approach to define whether or not a cushion was equivalent to the HR45 material. Additional study is needed to further validate the approach and to define the thresholds and criteria used to define cushion equivalency.

Development of Wheeled Mobility indicators to advance the quality of spinal cord injury rehabilitation: SCI-High Project.

Background: Wheeled mobility is critical for individuals with Spinal Cord Injury or Disease (SCI/D) related paralysis. The World Health Organization (WHO) developed guidelines highlighting eight steps in wheelchair service delivery: (1) referral and appointment; (2) assessment; (3) prescription; (4) funding and ordering; (5) product preparation; (6) fitting; (7) user training; and, (8) follow-up maintenance/repairs. This article describes the processes used to develop structure, process and outcome indicators that reflect the WHO guidelines within the Domain of Wheeled Mobility rehabilitation for Canadians. Methods: Wheeled mobility experts within the SCI-High Project Team used the WHO guideline to inform the Construct refinement and development of a Driver diagram. Following seven meetings, the Driver diagram and review of outcome measures and literature synthesis regarding wheelchair service delivery informed indicator selection and group consensus. Results: The structure indicator examines the proportion of SCI/D service providers within a rehabilitation program who have specialized wheelchair training to ensure prescription, preparation, fitting, and maintenance quality. The process indicator evaluates the average number of hours of wheelchair service delivery provided per patient during rehabilitation. The intermediary outcome indicator (rehabilitation discharge), is a target capacity score on the Wheelchair Skills Test Questionnaire (WST-Q). The final outcome indicators (at 18 months post rehabilitation admission) are the Life Space Assessment (LSA) and the Wheelchair Use Confidence Scale (WheelCon) short form mean scores. Conclusion: Routine implementation of the selected Wheeled Mobility structure, process and outcome indicators should measurably advance care within the Wheeled Mobility Domain for Canadians living with SCI/D by 2020.

Reliability and normative values of the Wheelchair Propulsion Test: A preliminary investigation.

BACKGROUND: Normative data for the equivalent of gait speed via the Wheelchair Propulsion Test (WPT) do not exist for wheelchair users. OBJECTIVE: The purposes of the current study were to: 1) determine the reliability of the WPT, 2) propose and compare normative values for the WPT for young adult males and females utilizing three different propulsion techniques, and 3) compare how different wheelchair types affect performance on the WPT. METHODS: 50 young adults (25 of each sex) performed the WPT using three different propulsion techniques in three different types of wheelchairs. Participants were asked to propel a wheelchair over 10 m at a comfortable speed. Time and number of pushes were recorded for three trials for each propulsion technique in each type of wheelchair. RESULTS: All of the ICC(2,2) values were >0.83 for speed and number of pushes. Normative values for speed, number of pushes, push frequency and effectiveness categorized by propulsion technique, sex and wheelchair type were developed. CONCLUSIONS: Preliminary normative values have been established for young adults performing the WPT. This study highlights the need to maintain consistency of the wheelchair type and propulsion technique between trials in order for the WPT to be reliable.

Comparing the effectiveness of a hybrid and in-person courses of wheelchair service provision knowledge: A controlled quasi-experimental study in India and Mexico.

BACKGROUND: Evidence highlights a global shortage of wheelchair service provision education and training that results in inappropriate wheelchair provision with associated health and economic consequences. Two learning methodologies, a hybrid and an in-person course, based on the World Health Organization Wheelchair Service Training Package Basic Level, currently are available to train wheelchair service providers worldwide. The effectiveness of the in-person methodology, used as the standard of practice, has never been tested. Meanwhile, the Hybrid Course, which combines online and in-person training, was developed to reduce training costs and to scale training interventions and has shown potential effectiveness in increasing basic level wheelchair service provision knowledge. The objective of this study was to compare the effectiveness of both learning methodologies based on knowledge and satisfaction among a group of wheelchair service providers in India and Mexico. METHODS: We conducted a controlled quasi-experimental study to evaluate changes in basic wheelchair knowledge and levels of satisfaction between Hybrid and In-person course learners in India and Mexico. A convenience sampling method guided by local stakeholders' input was used to recruit participants. Outcomes were assessed using self-administered online surveys, the International Society of Wheelchair Professionals Wheelchair Service Provision Basic Test (primary outcome) completed pre- and post- the learning intervention and an anonymous Satisfaction Survey (secondary outcome) completed post- intervention. Baseline characteristics were compared among groups using hypothesis tests based on their assumptions. The primary analysis was intention-to-treat. To address missing values and lost to follow-up, multiple chained imputations were conducted. The primary outcome was analyzed using linear mixed models. The secondary outcome was analyzed using a two-tailed two independent samples t-test. RESULTS: A total of 81 participants, 43 (53.1%) in the In-person group and 38 (46.9%) in the Hybrid group, participated in the study. Mean baseline knowledge scores were below the passing cutoff of the test (53 points) in both groups. Both study groups experienced statistically significant improvements in the primary outcome when comparing pre- and post-test scores (p<0.0001) with total mean scores above the passing cutoff of the test. The in-person group experienced, on average, larger effects on the primary outcome. The difference in mean change from post-test to pre-tests between In-person groups and Hybrid was 3.6 (95% Confidence Interval: 1.7;5.4), Cohen's d = 0.36, with a small effect size favoring the In-person training. With regards to satisfaction, the difference between the two interventions was 0.23±0.07 in favor of the In-person group (p = 0.0021). CONCLUSIONS: Both learning methodologies had a statistically significant effect in increasing wheelchair service knowledge with overall high levels of satisfaction. However, the In-person group reported overall larger effects when compared with the Hybrid methodology. This study provided recommendations on how organizations can improve blended learning interventions to enhance participants' learning experiences and reduce potential barriers and limitations.

Comparison of different wheelchair seating on thermoregulation and perceptual responses in thermoneutral and hot conditions in children.

We examined the effects of 4 different wheelchair seatings on physiological and perceptual measures in 21 healthy, pre-pubertal children (9 ±â€¯2 years). Participants were able-bodied and did not regularly use a wheelchair. Participants sat for 2 h in Neutral (∼22.5 °C, ∼40%RH) and Hot (∼35 °C, ∼37%RH) conditions. Four seating technologies were: standard incontinent cover and cushion (SEAT1); standard incontinent cover with new cushion (SEAT2) were tested in Neutral and Hot; new non-incontinent cover with new cushion (SEAT3); new incontinent cover and new cushion (SEAT4) were tested in Neutral only. Measurements included skin blood flow (SkBF), sweating rate (SR) and leg skin temperature (TlegB) on the bottom of the leg (i.e. skin-seat interface), heart rate (HR), mean skin temperature, tympanic temperature, thermal comfort, and thermal sensation. During Neutral, SkBF and TlegB were lower (∼50% and ∼1 °C, respectively) and SR higher (∼0.5 mg cm-2·min-1) (p < 0.05) with SEAT3 compared to all other seats. SkBF was ∼30% lower (p < 0.05) for SEAT2 and SEAT4 compared to SEAT1. No other differences were observed between SEATs (all p > 0.05). During Hot, HR and temperatures were higher than in Neutral but there were no differences (p > 0.05) between SEATs. New cover and cushion improved thermoregulatory responses during Neutral but not Hot. An impermeable incontinent cover negated improvements from cushion design. Seat cover appears more important than seat cushion during typical room conditions.

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.

Accessible machining for people who use wheelchairs.

Despite the Americans with Disabilities Act mandate for reasonable accommodations, wheelchair users are often placed in the role of observer and note-taker when learning machining and fabrication skills due to a lack of accessibility. The focus of this case study report is to identify and develop reasonable accommodations for wheelchair users in an academic machine shop environment to address accessibility limitations of original equipment manufacturer (OEM) machines. Individual wheelchair users working and learning within the Human Engineering Research Laboratories (HERL) were observed and interviewed about their experiences using the machine shop equipment without modifications, followed by further observations after accommodations were implemented.

Reliability and Criterion-Related Validity of the Seated Posture Scale.

PURPOSE: Earlier, we reported development and initial testing of a rapid, low burden measure of wheelchair seated posture (the Seated Posture Scale [SPS]) for research and clinical use. The purpose of this study was to test the intrarater reliability, interrater reliability, and criterion related validity of the SPS. DESIGN: We used a descriptive design to test and develop the instrument. METHODS: We used the method described by Walter, Donner, and Eliasziw to determine 46 participants were needed, from two Veterans Administration nursing homes or CLCs (community living centers). Using a digital goniometer to score rapidly and with two trained raters, we scored individual participants simultaneously and again in succession. For criterion related concurrent validity, we also scored each participant with Section 2 of the Seated Postural Control Measure for Adults. Intrarater reliability, interrater reliability, and criterion related, concurrent validity were assessed using kappa statistics for individual instrument items (and corresponding 95% confidence intervals where appropriate) and intraclass correlation coefficients (ICC) for total scores. FINDINGS: The intrarater intraclass correlation coefficient (ICC) was .995; interrater ICC was .80; interrater reliability kappas ranged from -.03 to .80. Criterion-related, concurrent validity kappas ranged from .13 to .91. ICC for total scores was .85. CONCLUSION: The SPS has sufficient preliminary validity and reliability to support measurement of wheelchair-seated posture in outcomes research and clinical use. CLINICAL RELEVANCE: In the future, rehabilitation nurses may use the SPS to improve management of wheelchair seated posture, to improve clinical outcomes, particularly for those who do not reposition themselves.

Microclimate evaluation of strap-based wheelchair seating systems for persons with spinal cord injury: A pilot study.

STUDY PURPOSE: The purpose of this pilot study was to assess microclimate characteristics of two versions of a strap-based wheelchair seating system (perforated and solid straps) and to conduct preliminary microclimate comparisons of subjects' current wheelchair seating systems. MATERIALS AND METHODS: In this pilot study, the microclimate properties of two variations (solid and perforated) of a strap-based seating system were compared with two commonly used seating systems. Six subjects sat on three different seating systems each for 100-min test periods, while temperature and relative humidity were measured with a single sensor adjacent to the skin-seat interface. Additionally, thermal images of the seat interface were collected before and after each test period. RESULTS: The thermal images revealed that the maximum surface temperature of the solid-strap-based seating system was significantly lower than the other seating systems, -1.21 °C. (95% CI -2.11 to -0.30, p = 0.02), immediately following transfer out of the seat. Five minutes after transferring out of the seat, the perforated-strap seat was significantly cooler than the other seats -0.94 °C. (95% CI -1.59 to -0.30), p = 0.01, as was the solid-strap-based seat, -1.66 °C. (95% CI -2.69 to -0.63), p = 0.01. There were no significant differences in interface temperature or relative humidity measured with the single sensor near the skin-seat interface. CONCLUSION: This pilot study offers preliminary evidence regarding the microclimate of the strap-based seating systems compared with other common seating systems. Clinically, the strap-based seating system may offer another option for those who struggle with microclimate management.

Measuring the impact of cushion design on buttocks tissue deformation: An MRI approach.

AIM: To establish a research approach for describing how different wheelchair cushion designs impact buttocks tissue deformation during sitting. MATERIALS AND METHODS: The buttocks of 4 individuals with spinal cord injury and significant atrophy were scanned sitting in a FONAR Upright MRI. Scans were collected with the individuals' buttocks fully suspended without pelvic support, and seated on 3 different commercially available wheelchair cushions. Multi-planar scans were analyzed to provide 3D renderings and measurements of tissue thickness and shape. RESULTS: Bulk tissue thicknesses at the ischium, which rarely included muscle, were reduced by more than 60% on enveloping cushion designs studied (i.e., Roho HP and Matrx Vi), and more variably (23-60%) on an orthotic off-loading design (i.e., Java). Adipose was typically displaced posterior and superior from the unloaded condition, with more lateral displacement on the Roho HP and Matrx Vi and more medial displacement present on the Java. Large changes in angle at the sacro-coccygeal joint indicated significant loading on the region. Deformation at the greater trochanter was more consistent across surfaces. Greater interface pressures tended to be associated with greater deformation, but the relationship varied by individuals and was highly non-linear. CONCLUSIONS: The buttocks in this study all deformed significantly, but at different locations and in different manners across all 3 surfaces. Attention needs to be paid to the regions of greatest deformation. A future metric of shape compliance should consider cushion performance at all high risk regions, and changes to the amount and shape of tissue in the regions of interest.

School Bus Transportation of Children With Special Health Care Needs.

School systems are responsible for ensuring that children with special needs are safely transported on all forms of federally approved transportation provided by the school system. A plan to provide the most current and proper support to children with special transportation needs should be developed by the Individualized Education Program team, including the parent, school transportation director, and school nurse, in conjunction with physician orders and recommendations. With this statement, we provide current guidance for the protection of child passengers with specific health care needs. Guidance that applies to general school transportation should be followed, inclusive of staff training, provision of nurses or aides if needed, and establishment of a written emergency evacuation plan as well as a comprehensive infection control program. Researchers provide the basis for recommendations concerning occupant securement for children in wheelchairs and children with other special needs who are transported on a school bus. Pediatricians can help their patients by being aware of guidance for restraint systems for children with special needs and by remaining informed of new resources. Pediatricians can also play an important role at the state and local level in the development of school bus specifications.