Demographic and clinical variation in Veterans Health Administration provision of assistive technology devices to veterans poststroke.

OBJECTIVES: To examine variation in provision of assistive technology (AT) devices and the extent to which such variation may be explained by patient characteristics or Veterans Health Administration (VHA) administrative region. DESIGN: Retrospective population-based study. SETTING: VHA. PARTICIPANTS: Veterans poststroke in fiscal years 2001 and 2002 (N=12,046). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Provision of 8 categories of AT devices. RESULTS: There was considerable regional variation in provision of AT. For example, differences across administrative regions in the VHA ranged from 5.1 to 28.1 standard manual wheelchairs per 100 veterans poststroke. Using logistic regression, with only demographic variables as predictors of standard manual wheelchair provision, the c statistic was .62, and the pseudo R(2) was 2.5%. Adding disease severity increased the c statistic to .67 and the pseudo R(2) to 6.2%, and adding Veteran Integrated Network System further increased the c statistic to .72 and pseudo R(2) to 9.8%. CONCLUSIONS: Our research showed significant variation in the provision of AT devices to veterans poststroke, and it showed that patient characteristics accounted for only 6.2% of the variation. VHA administrative region and disability severity accounted for equivalent amounts of the variation. Our findings suggest the need for improvements in the process for providing AT and/or provider education concerning device provision.

Cost, utilization, and policy of provision of assistive technology devices to veterans poststroke by Medicare and VA.

BACKGROUND: The increase in provision of assistive technology devices (ATDs) has spurred controversy over Medicare policy aimed at reducing cost-policy that forces social isolation and conflicts with legislation, facilitating participation for individuals with disabilities. In contrast, Department of Veterans Affairs (VA) policy does not limit provision of AT to "in home" use only but rather, states "all enrolled and some non-enrolled veterans are eligible for all needed prosthetics." OBJECTIVES: Examine ATD provision policy by comparing 2 systems, Medicare and VA. Empirically analyze differences in ATDs provided, cost, and duplication in provision. RESEARCH DESIGN: Retrospective study of VA databases, including VA Medicare data. SUBJECTS: A population based study of 12,0461 veterans post-stroke. MEASURES: Frequency of provision of ATDs by Health Care Common Procedural Code, purchase price, and capped rental payments. RESULTS: Of the poststroke veteran cohort, 39% received no AT, 56% received AT from the VA only, 1% received AT from Medicare only, and 3% received AT from both the VA and Medicare. Most ATDs were for activities of daily living, followed by walkers/canes/crutches. In specific ATD comparisons, VA costs were substantially lower than Medicare for purchased items and slightly lower than Medicare for capped rental payments. CONCLUSION: VA provides a broader variety of ATDs at a lesser cost than Medicare. Analyses of policy differences between VA and Medicare suggest VA policy is driven by veteran need whereas Medicare policy is driven at least in part, by containing costs that have skyrocketed as a result of fraudulent claims.

Prosthesis and wheelchair use in veterans with lower-limb amputation.

We determined the demographic, health, functional, and satisfaction factors related to lower-limb prosthesis or wheelchair use among veterans with lower-limb amputation. Forty-two veterans were recruited from the 20th National Disabled Veterans Winter Sports Clinic and the 26th National Veterans Wheelchair Games. Participants were at least 18 years of age, had a lower-limb amputation, and were either prosthesis or wheelchair users. Level of amputation was the most significant health-related characteristic determining the veterans' use of a prosthesis versus a wheelchair (p = 0.02). Veterans who had a higher level of amputation and used a prosthesis reported significantly greater difficulty navigating a ramp (p = 0.03), getting in and out of cars and buses (p = 0.03), carrying 10 lb of groceries (p = 0.02), and participating in sports and leisure activities (p = 0.03). The parameter "satisfaction related to prosthesis" did not determine selection of mobility device type. The interaction of demographics, health-related characteristics, and mobility device characteristics affects functional performance and influences the use of prostheses, wheelchairs, or both in persons with lower-limb amputation. Long-term outcome assessments may help determine factors associated with either transition from one device to another or combined use of the devices over time.

Carpal tunnel syndrome in manual wheelchair users with spinal cord injury: a cross-sectional multicenter study.

OBJECTIVE: To investigate relationships between carpal tunnel syndrome, functional status, subject demographics, physical examination findings, and median nerve conduction study findings in manual wheelchair users with paraplegia. DESIGN: Multicenter cross-sectional study. One hundred twenty-six manual wheelchair-using individuals with chronic paraplegia answered self-administered questionnaires on demographics, symptoms, and functional status. They underwent physical examination specific for carpal tunnel syndrome and upper-limb nerve conduction studies. RESULTS: Fifty-seven percent of subjects had symptoms (72.2% bilateral); hand numbness was most common. Sixty percent of subjects had carpal tunnel syndrome physical examination findings (59.2% bilateral). Those with physical examination findings were more likely to have longer duration of injury (P = 0.003). Seventy-eight percent of subjects had electrophysiologic evidence of median mononeuropathy. Symptomatic subjects had significantly greater median-ulnar motor latency difference in the dominant hand (P = 0.02) and smaller compound muscle action potential amplitudes bilaterally (dominant hand, P = 0.01; nondominant hand, P = 0.04). Persons with carpal tunnel syndrome symptoms and physical examination findings had significantly worse functional status (symptoms, P < 0.001; physical examination, P = 0.02) and symptom severity scores (symptoms, P < 0.001; physical examination, P = 0.01), but a similar difference between subjects with and without median mononeuropathy was not seen. Logistic regression analysis revealed that the presence of symptoms was predicted by median-ulnar motor latency difference in the dominant hand (odds ratio, 4.38; 95% confidence interval 1.72-11.14) and sensory nerve action potential amplitude in the nondominant hand (odds ratio, 0.97; 95% confidence interval, 0.94-0.99). CONCLUSIONS: The interaction among symptoms, physical examination, and nerve conduction study findings is complex. Carpal tunnel syndrome and median mononeuropathy are highly prevalent and functionally significant. This study highlights the need for primary prevention and patient education for preserving upper-limb function.

Validation of the seating and mobility script concordance test.

The purpose of this study was to develop the scoring system for the Seating and Mobility Script Concordance Test (SMSCT), obtain and appraise internal and external structure evidence, and assess the validity of the SMSCT. The SMSCT purpose is to provide a method for testing knowledge of seating and mobility prescription. A sample of 106 therapists and 15 spinal cord injury experts contributed to the development of the scoring system. Validity evidence was obtained using 15 seating and mobility experts, 10 orthopedic experts, and 66 therapists with varying levels of seating and mobility expertise. Proxy measures of clinical expertise were used for external validity evidence since no criterion measures exist. The SMSCT was found to differentiate between seating and mobility experts' and orthopedic experts' intervention subtest scores (p = 0.04). The proxy measure of clinical expertise, seating and mobility hours/week, was found to predict SMSCT intervention scores (p = 0.002). The internal structure of the SMSCT may include evidence of reduced item performance but satisfactory convergent and discriminate evidence by construct definition. Although the SMSCT may be a promising approach for measuring seating and mobility expertise, limitations exist in the corrected content. Future application of the SMSCT should only be used after further development of the tool occurs.

Randomized controlled trial of mindfulness-based stress reduction (MBSR) for survivors of breast cancer.

OBJECTIVES: Considerable morbidity persists among survivors of breast cancer (BC) including high levels of psychological stress, anxiety, depression, fear of recurrence, and physical symptoms including pain, fatigue, and sleep disturbances, and impaired quality of life. Effective interventions are needed during this difficult transitional period. METHODS: We conducted a randomized controlled trial of 84 female BC survivors (Stages 0-III) recruited from the H. Lee Moffitt Cancer and Research Institute. All subjects were within 18 months of treatment completion with surgery and adjuvant radiation and/or chemotherapy. Subjects were randomly assigned to a 6-week Mindfulness-Based Stress Reduction (MBSR) program designed to self-regulate arousal to stressful circumstances or symptoms (n=41) or to usual care (n=43). Outcome measures compared at 6 weeks by random assignment included validated measures of psychological status (depression, anxiety, perceived stress, fear of recurrence, optimism, social support) and psychological and physical subscales of quality of life (SF-36). RESULTS: Compared with usual care, subjects assigned to MBSR(BC) had significantly lower (two-sided p<0.05) adjusted mean levels of depression (6.3 vs 9.6), anxiety (28.3 vs 33.0), and fear of recurrence (9.3 vs 11.6) at 6 weeks, along with higher energy (53.5 vs 49.2), physical functioning (50.1 vs 47.0), and physical role functioning (49.1 vs 42.8). In stratified analyses, subjects more compliant with MBSR tended to experience greater improvements in measures of energy and physical functioning. CONCLUSIONS: Among BC survivors within 18 months of treatment completion, a 6-week MBSR(BC) program resulted in significant improvements in psychological status and quality of life compared with usual care.

Psychosocial impact of participation in the National Veterans Wheelchair Games and Winter Sports Clinic.

PURPOSE: The purpose of this study was to determine the characteristics of individuals who participate in the National Veterans Wheelchair Games (NVWG) and the Winter Sports Clinic (WSC) for veterans with disabilities. In addition, it was of interest to determine how these events had impacted their lives. METHOD: Participants were recruited at the 20th Winter Sports Clinic, held in Snowmass Colorado and the 26th National Veterans Wheelchair Games held in Anchorage, Alaska. Data of interest included demographic, sport participation information, community integration, self-esteem, and quality of life. A secondary data analysis was completed to determine how comparable individuals who attended the NVWG/WSC were to individuals who did not participate in these events. RESULTS: The 132 participants were a mean age of 47.4 + 13.4 and lived with a disability for an average of 13.4 + 12.1. Participants felt that the NVWG/WSC increased their knowledge of sports equipment (92%), learning sports (89%), mobility skills (84%), and acceptance of disability (84%). The majority of participants stated that the NVWG/WSC improved their life. Of those who participated at the NVWG/WSC, they tended to be more mobile, but have increased physical and cognitive limitations as measured by the CHART when compared to the non-attendees. CONCLUSIONS: Recommending veterans participate in events such as the NVWG and WSC can provide psychosocial benefits to veterans with disabilities.

Pressure ulcers and occipital alopecia in Operation Iraqi Freedom polytrauma casualties.

OBJECTIVE: Several of the casualties from Operation Iraqi Freedom arriving at one Veterans Administration (VA) polytrauma rehabilitation center (PRC) were noted to have occipital pressure ulcers or hair loss. The objective of this study was to determine the prevalence and severity of pressure-related injuries in VA PRC admissions. METHODS: A retrospective review of admissions from active duty from 2004 to 2006 was performed. RESULTS: Thirty-eight percent of admissions to this VA PRC had pressure-related injuries on the day of admission. Casualties from Iraq had a higher rate of pressure ulcers (53%) than did those from elsewhere (22%). Occipital lesions constituted 50% of non-stage I pressure ulcers and were more severe than those of the sacrum or extremities. CONCLUSIONS: Further epidemiological research should be performed to identify risk factors for pressure injury in the military continuum of care, by linking specific military medical evacuation and treatment processes and characteristics of casualties with outcomes.

Effect of multiple impacts on protective properties of external hip protectors.

A variety of external hip protectors are available on the market but no standards for their performance exist and it is unknown if their properties change after repeated fall impacts. The purpose of this study was to determine if protective properties change in different types of new (unused) hip protectors after repeated, simulated falls. Five hip protector brands were chosen to represent different products available on the market and the two mechanisms employed in reducing the force of an impact (shunting or absorbing). Ten pairs of each type (20 pads for each brand) were tested using a 1.8-m Instron Dynatup 9250 HV vertical impact testing tower. The impact testing system was specifically designed for this study by creating a simulated trochanter to provide more accurately a impact area similar to that of a real hip bone. The hip protectors were impacted once a day for 3 consecutive days. Repeated impacts demonstrated the pads' decreased ability to either absorb or shunt force in all types of hip protectors. However, the mean forces were still in the protective range (force below fracture threshold of 3100 N) for 3 of the 5 brands tested after 3 impacts. The protective properties of external hip protectors do degrade after repeated impacts. The degree of degradation differs from brand to brand. Regardless of type, most pads were still able to bring the force of impact below the fracture threshold of 3100 N. Future studies need to address the issue of durability of different types/brands of hip protectors after repeated laundering and fall impacts to determine when should they be replaced. Additionally, a national or international standard needs to be developed against which the performance of different brands of hip protectors can be compared.

A preliminary study on the impact of pushrim-activated power-assist wheelchairs among individuals with tetraplegia.

OBJECTIVES: This preliminary study was to evaluate the impact of pushrim- activated power-assist wheelchairs (PAPAWs) on mobility, community participation, satisfaction, and psychosocial impact among individuals with tetraplegia. DESIGN: Fifteen manual wheelchair users with tetraplegia completed a 4-wk protocol including a 2-wk trial where they used their personal wheelchairs for mobility and a 2-wk trial where they were provided with a PAPAW and could choose either wheelchair for mobility. The mobility levels with both wheelchairs were recorded by a datalogger. Participants completed daily questionnaires regarding community participation and their satisfaction with the wheelchair used. The Psychosocial Impact of Assistive Devices Scale was used to compare the psychosocial impact of PAPAWs with their personal wheelchairs. RESULTS: Participants chose to use PAPAWs and their personal wheelchairs at a similar frequency in the PAPAW trial. The distances traveled with both wheelchairs were not statistically different (P = 0.09). Participants traveled significantly faster with PAPAWs (P = 0.03). PAPAWs did not result in significantly greater community participation, satisfaction, and psychosocial impacts than the personal wheelchairs. CONCLUSIONS: PAPAWs could be a viable mobility option for individuals with tetraplegia, which can provide independent mobility especially for outdoor activities. A user's preference, life style, physical conditions, transportation issues, and environmental factors should be considered in prescribing such a device.

Acute mountain sickness in disability and adaptive sports: preliminary data.

Acute mountain sickness (AMS) is a frequent complication for military personnel, veterans, athletes, and travelers at high altitudes. Symptoms may occur in individuals with less cerebrospinal fluid volume and less ability to accommodate increased brain volume. No studies on AMS exist in individuals with neurological impairments. We studied 64 subjects, including active and sedentary controls and those with tetraplegia, paraplegia, multiple sclerosis, and traumatic brain injury at the 2007 National Veterans Winter Sports Clinic in Snowmass, Colorado. Subjects completed three Lake Louise Score surveys to quantify symptoms. We found a higher than expected occurrence of AMS overall (51.6%) but no differences among groups, and few participants sought treatment. Fatigue and weakness were common symptoms. High subject activity levels may explain these findings. More research is warranted on larger sample sizes and on preventative medications and treatments for AMS, especially since many military personnel with neurological impairments are returning to full active service.

Curb descent testing of suspension manual wheelchairs.

Manual wheelchair users are subjected to whole-body vibrations (WBV) on a regular basis as they traverse obstacles and uneven surfaces. One way users could protect themselves from secondary injuries related to WBV is by using a suspension manual wheelchair. This study investigated the ability of suspension manual wheelchairs to reduce seat accelerations during curb descents of various heights (5, 10, and 15 cm). Sixteen manual wheelchairs (four suspension, four folding, four rigid, and four rigid titanium) were tested. Suspension wheelchairs transmitted significantly lower peak seat accelerations than folding wheelchairs during the 5 cm curb descents (p = 0.048) and significantly lower frequency-weighted peak seat accelerations during the 5 and 10 cm curb descents (p = 0.03 for both heights). However, when the suspension wheelchair Quickie XTR (Sunrise Medical; Carlsbad, California) was removed from the analysis, the suspension wheelchairs were not significantly different from the nonsuspension wheelchairs. When weight was considered, the suspension wheelchairs had significantly lower peak seat accelerations than the lighter rigid wheelchairs during 5 cm curb descents (p = 0.047). While suspension manual wheelchairs offer some reduction in WBV during curb descents, their limitations should be considered when a wheelchair is selected for everyday use.

Progression of carotid intima-media thickness and plaque in women with systemic lupus erythematosus.

OBJECTIVE: Women with systemic lupus erythematosus (SLE) are at high risk of cardiovascular disease (CVD). The goals of this study were to determine the extent of atherosclerotic progression among women with SLE compared with a group of healthy controls and to determine whether factors attributed to SLE or its treatment were associated with atherosclerotic progression independent of traditional CVD risk factors. METHODS: A longitudinal study of women with SLE from the Pittsburgh Lupus Registry was conducted. Women 18 years of age and older (n = 217) underwent carotid ultrasound at baseline and at followup, an average of 4.19 years later. Clinical, serologic, and SLE-related factors, and disease treatment were evaluated. Outcomes were changes in carotid intima-media thickness (IMT) and plaque. Progression of CVD in a sample of women without lupus was used for comparison. RESULTS: The patients' mean +/- SD age at baseline was 45.1 +/- 10.3 years, and the mean +/- SD IMT progression rate was 0.011 +/- 0.03 mm per year. After controlling for traditional CVD risk factors, higher serum creatinine levels were associated with IMT progression (P = 0.0006). Plaque prevalence was 31% at baseline and 40% at followup; plaque progression occurred in 27% of the patients. Higher serum C3 levels and immunosuppressant use at baseline were related to plaque progression (P = 0.04 and P = 0.02, respectively) independent of traditional CVD risk factors. The plaque progression rate was higher than, and the IMT progression rate was similar to, those in the control group. CONCLUSION: SLE patients have accelerated plaque progression compared with controls. SLE-related risk factors are associated with the progression of IMT and plaque after controlling for traditional CVD risk factors. Carotid B-mode ultrasound may serve as a surrogate end point in SLE intervention trials and clinically to track SLE management.

Usage of tilt-in-space, recline, and elevation seating functions in natural environment of wheelchair users.

This study examined the usage of powered seating functions, including tilt-in-space, backrest recline, and seat elevation, among a group of wheelchair users during their typical daily activities. Twelve individuals who used 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 2 weeks while the seating function usage was recorded with a portable device. We found that subjects occupied their wheelchair for 11.8 +/- 3.4 hours a day (all data shown as mean +/- standard deviation). While occupying their wheelchairs, they accessed tilt-in-space, backrest recline, and seat elevation 19 +/- 14 times a day for 64.1% +/- 36.8%, 12 +/- 8 times for 76.0% +/- 29.8%, and 4 +/- 4 times for 22.5% +/- 34.9%, respectively. Subjects chose to stay in tilted and reclined positions in their wheelchair for 39.3% +/- 36.5% of their time each day. They spent little time 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 clinical practice of wheelchair provision, resulting in better compliance with clinical instructions and appropriate use of seating functions among wheelchair users.

Comparison of mobility device delivery within Department of Veterans Affairs for individuals with multiple sclerosis versus spinal cord injury.

Individuals with multiple sclerosis (MS) report decreased satisfaction with their mobility devices compared with individuals with spinal cord injuries (SCIs). This study (1) investigated the demographic differences between veterans with MS (V-MS) and veterans with SCI (V-SCI) who were issued a wheelchair by the Veterans Health Administration (VHA) and (2) described differences in mobility device prescription. We merged two VHA databases to obtain demographic and wheelchair information for all V-MS and V-SCI in 2000 and 2001. Descriptive information for issued wheelchairs was available for 2,154 V-MS and V-SCI. We found that V-MS were significantly less likely to receive higher quality wheelchairs (manual or power) compared with V-SCI (p < 0.001). The disparity in VHA wheelchair prescription between these two groups indicates a need for further research regarding the assistive device prescription process in these populations.

Force control strategies while driving electric powered wheelchairs with isometric and movement-sensing joysticks.

Innovations to control interfaces for electric powered wheelchairs (EPWs) could benefit 220000 current users and over 125000 individuals who desire mobility but cannot use a conventional motion sensing joystick (MSJ). We developed a digital isometric joystick (IJ) with sophisticated signal processing and two control functions. In a prior study, subjects' driving accuracy with our IJ was comparable to using an MSJ. However, we observed subjects using excessive force on the IJ possibly because its rigid post provides no positional feedback. Thus, this paper examines the time-series data recorded in the previous study to characterize subjects' force control strategies since weakness is a concern. Eleven EPW users with upper limb impairments drove an EPW using an IJ with two different control functions and an MSJ in a Fitts' law paradigm. Subjects relied upon positional feedback from the MSJ and used appropriate force. In contrast, subjects using the IJ with either control function applied significantly higher force than necessary (p < 0.0001 and p = 0.0058). Using higher average force was correlated with quicker trial times but not associated with accuracy. Lack of positional feedback may result in use of excess isometric force. Modifying control functions, adjusting gain, or providing additional training or feedback might address this problem.

The development of a nationwide registry of wheelchair users.

This paper provides an overview of the development of a wheelchair users registry and subsequently describes a population of individuals who use wheelchairs. The characteristics of Americans who permanently use wheelchairs and scooters are currently unknown. As the result of developing a Registry of individuals who use wheeled mobility devices for systematic recruitment for research studies, this study provides a description of a nationwide sample of over 1000 individuals who used wheelchairs or scooters for their daily mobility. The Registry is predominantly Caucasian (83%), 63% male, with a mean age of 50 years. Some 54% used manual wheelchairs for an average of 16 years. When quality of wheelchairs was compared, results indicated those in more customizable manual wheelchairs were significantly more likely to be younger. Males were significantly more likely to receive more customizable, heavy duty power wheelchairs than females. The Wheelchair Users Registry provides an organized and systematic way to maintain contact with previous research participants. Expected to grow in size, the Registry may enable an even more diverse pool of subjects interested in participating in research studies.

Riding a bus while seated in a wheelchair: A pilot study of attitudes and behavior regarding safety practices.

A total of 283 wheelchair-seated bus riders responded to a 35-item Web-based survey investigating their experiences on public, fixed-route buses. The survey addressed the use of wheelchair tiedowns and occupant restraint systems (WTORS), the attitudes and behaviors of wheelchair users toward the use of this equipment, and the transit experience. Results indicate that consistent use of four-point tiedown and occupant restraint systems is fairly low. Only 33.2% of the participants reported always securing their wheelchair, and 62.2% reported using occupant restraints consistently. A preference for fixed-route over para-transit was related to larger city size. Implementation of transit agency policy regarding WTORS was found to be inconsistent. Easier-to-use WTORS and improved operator training in larger transit agencies would likely increase the correct use of safety equipment and improve wheelchair users' bus-riding experiences.

Motor vehicle transportation use and related adverse events among persons who use wheelchairs.

For the 2.2 million people who use wheelchairs in the United States, transportation is often needed for independence in the community. The purpose of this study was to investigate the characteristics of transportation use in a population of wheelchair users and to examine the motor vehicle crash involvement and injury frequency of these users. Responses were collected from 596 individuals from June 2002 to November 2003. Approximately 20% of the sample population was involved in a motor vehicle crash in the previous 3 years, resulting in a rate of 3.6 accidents/incidents per 100,000 miles traveled. Crashes were defined as any motor vehicle accident that the person was involved in during the previous 3 years. Persons who did not transfer from their wheelchair were more likely to be involved in a crash than those individuals who transferred to vehicle seats. Eighteen percent of the population reported involvement in a non-crash-related incident during the previous 3 years. Passengers reported a greater frequency of non-crash-related injuries than did drivers. The results of this study provide documentation of transportation use and safety in people who use wheelchairs. It provides insight into the risk of crash and injury in this population.

Assessing mobility characteristics and activity levels of manual wheelchair users.

Although engaging in an active lifestyle is beneficial for maintaining quality of life, a majority of wheelchair users are inactive. This study investigated the mobility characteristics and activity levels of manual wheelchair users in the residential setting and at the National Veterans Wheelchair Games (NVWG). Demographic factors that may have influenced activity in the home environment were also identified. Fifty-two manual wheelchair users completed a brief survey, and their activity was monitored with a custom data logger over a period of 13 or 20 days. We found that they traveled a mean +/- standard deviation of 2,457.0 +/- 1,195.7 m/d at a speed of 0.79 +/- 0.19 m/s for 8.3 +/- 3.3 h/d while using their primary wheelchair in the home environment. No significant differences in mobility characteristics or activity levels were found for level of spinal cord injury or disability. We also found that subjects traveled significantly farther and faster and were active for more hours during an average day at the NVWG than in the home environment (p < 0.001). We found that manual wheelchair users who were employed covered more distance, accumulated more minutes, and traveled a greater average maximum distance between consecutive stops than those who were unemployed. Results from this study provide a better understanding of the activity levels achieved by manual wheelchair users and insight into factors that may influence this activity.