OFF-LOADING PRESSURE RELIEF WITH FOAM CUT OUT CUSHIONS: EXPERIENCES FROM RANCHO LOS AMIGOS NATIONAL REHABILITATION CENTER.

This paper explores the efficacy of the cushion fitting technique using foam cut out cushions for off-loading bony prominences in the sitting position, with a particular focus on reducing the high risk of developing pressure injuries among aging wheelchair users. This technique, historically employed at Rancho Los Amigos National Rehabilitation Center, has shown promising results in reducing pressure injuries for patients with spinal cord injuries. However, its widespread adoption remains limited. This manuscript aims to raise awareness about foam cut out cushions, its historical context, and its contemporary relevance by presenting customized solutions for individual patients with specific deformities. Key clinical points are highlighted, emphasizing the importance of skilled clinicians in the fitting process and the need to consider foam cut out cushions alongside other preventive measures. Case examples illustrate successful outcomes, demonstrating improved pelvic stability, posture, and off-loading of bony prominences. By promoting foam cut out cushions as a valuable cushioning option, this manuscript equips clinicians with knowledge to utilize this technique effectively.

Reaction Force Generation and Mechanical Demand Imposed on the Shoulder When Initiating Manual Wheelchair Propulsion and at Self-Selected Fast Speeds.

Manual wheelchair (WC) users with spinal cord injury (SCI) experience shoulder pain and fatigue associated with their increased reliance on the upper extremity during activities of daily living (Bayley et al. 1987, "The Weight-Bearing Shoulder. The Impingement Syndrome in Paraplegics," J. Bone Jt. Surg. Am., 69(5), pp. 676-678). We hypothesized that the mechanical demand imposed on the shoulder, represented as resultant shoulder net joint moment (NJM) impulse, would be greater when initiating manual WC propulsion from a stationary position without momentum than when manually propelling at speed on a level sidewalk. Thirty manual WC users with paraplegia participated. Each individual initiated manual WC propulsion from a stationary position and propelled on a level sidewalk at their self-selected fast speed. Upper extremity kinematics and pushrim reaction forces (RFs) were measured and upper extremity joint kinetics were calculated and compared (α = 0.05) between cycle 1, initiated without momentum, and cycle 3 with momentum. Results indicate that multiple factors contributing to the mechanical demand imposed on the shoulder were significantly greater when manual WC propulsion was initiated without momentum than with momentum. Significant differences in resultant shoulder NJM impulse, push duration, orientation of RF relative to forearm, and resultant average shoulder NJMs during push were observed between momentum conditions. No significant differences in average resultant RF during push were found. These results indicate that mechanical loading of the shoulder during manual WC propulsion differs between momentum conditions; these differences in resultant shoulder NJM impulse during push need to be considered when assessing shoulder load exposure in stop-and-start activities.

Design and Evaluation of the Kinect-Wheelchair Interface Controlled (KWIC) Smart Wheelchair for Pediatric Powered Mobility Training.

BACKGROUND: Children with severe disabilities are sometimes unable to access powered mobility training. Thus, we developed the Kinect-Wheelchair Interface Controlled (KWIC) smart wheelchair trainer that converts a manual wheelchair into a powered wheelchair. The KWIC Trainer uses computer vision to create a virtual tether with adaptive shared-control between the wheelchair and a therapist during training. It also includes a mixed-reality video game system. METHODS: We performed a year-long usability study of the KWIC Trainer at a local clinic, soliciting qualitative and quantitative feedback on the device after extended use. RESULTS: Eight therapists used the KWIC Trainer for over 50 hours with 8 different children. Two of the children obtained their own powered wheelchair as a result of the training. The therapists indicated the device allowed them to provide mobility training for more children than would have been possible with a demo wheelchair, and they found use of the device to be as safe as or safer than conventional training. They viewed the shared control algorithm as counter-productive because it made it difficult for the child to discern when he or she was controlling the chair. They were enthusiastic about the video game integration for increasing motivation and engagement during training. They emphasized the need for additional access methods for controlling the device. CONCLUSION: The therapists confirmed that the KWIC Trainer is a useful tool for increasing access to powered mobility training and for engaging children during training sessions. However, some improvements would enhance its applicability for routine clinical use.

Evidence-Based Strategies for Preserving Mobility for Elderly and Aging Manual Wheelchair Users.

Elderly and aging manual wheelchair (MWC) users have increased risk for accelerated loss of function and mobility that greatly limits independence and affects quality of life. This review paper addresses important issues for preserving function and mobility for elderly and aging individuals who use a MWC by presenting the current available evidence and recommendations. These include recommendations for maximizing function, by decreasing pain, improving the ability to self-propel, and prolonging mobility and endurance through ergonomics, individualized wheelchair selection and configuration, and adaptations for increasing the capacity to handle the daily mobility demands through training, strengthening, and exercise. Each recommendation is supported by current research in each relevant area.

The positive effects of early powered mobility on children's psychosocial and play skills.

Powered mobility can have an important cognitive and psychosocial impact on young children who are unable to move independently. Twenty-three children with physical disabilities between the ages of 18 months and 6 years participated in this study. Data evaluating social skills, frequency of mobility play activities, frequency of interaction with toys/objects, and play/verbal developmental levels were collected at wheelchair evaluation, wheelchair delivery, and approximately 6 months later. Significant increases were found in parental perceptions of positive social skills for younger children after receiving a wheelchair; slightly older children showed improvements in social skills before the wheelchair was received; no changes were found in negative social skills. Parental ratings also indicated a significantly greater difficulty remaining engaged in tasks after receiving a wheelchair. A significant increase was noted in the number of mobility activities during indoor free play but no difference was seen in interaction with toys or objects. Improvement in the qualitative level of outdoor interactive free play was reported but there was no change in verbal interactions. This article discusses the potential positive impact of early powered mobility. These findings may be helpful in justifying the recommendation of powered mobility to young children and in justifying medical necessity of powered mobility for reimbursement by third party payers.

The impact of early powered mobility on parental stress, negative emotions, and family social interactions.

Powered mobility has been found to have positive effects on young children with severe physical disabilities, but the impact on the family has been less well documented. We evaluated the impact of early powered mobility on parental stress, negative emotions, perceived social interactions, and parental satisfaction with wheelchair characteristics such as size and durability. The participants were parents of 23 children with disabilities-10 with orthopedic disabilities (average age 30.1 months) and 13 with cerebral palsy (average age 47.0 months). Pretest assessments were completed two times: at initial wheelchair evaluation and at wheelchair delivery. A posttest assessment was completed after each child had used the wheelchair for 4-6 months. Parents reported a lower perceived level of stress at the time of wheelchair delivery, although the magnitude of this effect was fairly small, standardized mean difference (δ) = .27. They also reported an increased satisfaction with their child's social and play skills (δ = .38), ability to go where desired (δ = .86), sleep/wake pattern (δ = .61), and belief that the general public accepts their child (δ = .39) after several months using the wheelchair. Parents reported an increase in interactions within the family at the time of wheelchair delivery (δ = .66). There was no decrease in negative emotions. Parents were satisfied with most factors relating to the wheelchair itself, with areas of concern being wheelchair size and difficulty adjusting the wheelchair. The findings suggest that self-initiated powered mobility for a young child had a positive impact on the family.

A robotic wheelchair trainer: design overview and a feasibility study.

BACKGROUND: Experiencing independent mobility is important for children with a severe movement disability, but learning to drive a powered wheelchair can be labor intensive, requiring hand-over-hand assistance from a skilled therapist. METHODS: To improve accessibility to training, we developed a robotic wheelchair trainer that steers itself along a course marked by a line on the floor using computer vision, haptically guiding the driver's hand in appropriate steering motions using a force feedback joystick, as the driver tries to catch a mobile robot in a game of "robot tag". This paper provides a detailed design description of the computer vision and control system. In addition, we present data from a pilot study in which we used the chair to teach children without motor impairment aged 4-9 (n = 22) to drive the wheelchair in a single training session, in order to verify that the wheelchair could enable learning by the non-impaired motor system, and to establish normative values of learning rates. RESULTS AND DISCUSSION: Training with haptic guidance from the robotic wheelchair trainer improved the steering ability of children without motor impairment significantly more than training without guidance. We also report the results of a case study with one 8-year-old child with a severe motor impairment due to cerebral palsy, who replicated the single-session training protocol that the non-disabled children participated in. This child also improved steering ability after training with guidance from the joystick by an amount even greater than the children without motor impairment. CONCLUSIONS: The system not only provided a safe, fun context for automating driver's training, but also enhanced motor learning by the non-impaired motor system, presumably by demonstrating through intuitive movement and force of the joystick itself exemplary control to follow the course. The case study indicates that a child with a motor system impaired by CP can also gain a short-term benefit from driver's training with haptic guidance.

RESNA position on the application of power wheelchairs for pediatric users.

This document, approved by the Rehabilitation Engineering & Assistive Technology Society of North America (RESNA) Board of Directors in March 2007, shares typical clinical applications and provides evidence from the literature supporting the use of power wheelchairs for children.

Pediatric powered wheelchairs: results of a national survey of providers.

A national survey of providers of pediatric powered wheelchairs was conducted to collect background data on these professionals and to develop a "model" of their current assessment and recommendation practices. Data collected in the survey included provider demographics, frequency of powered wheelchair provision to young children, common reasons for not recommending a powered wheelchair, reasons why a child who is recommended a powered wheelchair does not receive one, current pediatric powered wheelchair assessment and recommendation practices, and subjective data regarding the efficacy of these practices and the impact of powered wheelchairs on children. Respondents rated the frequency with which they performed various wheelchair assessment and recommendation practices, and these ratings were analyzed to determine activities that were performed frequently. These activities were then combined into common "factors" using factor analysis, and the results of the factor analysis were used to create a model of current pediatric powered wheelchair assessment and recommendation practices. A total of 140 surveys were received from providers in 46 states. Of these providers, 54% were clinicians (e.g., physical therapists, occupational therapists), and 46% were suppliers (e.g., Rehabilitation Technology Specialists), representing a variety of geographic locations and facility types. The 3 major reasons for not recommending a powered wheelchair included cognitive, physical, and behavioral factors. The 3 major reasons why a child who is recommended a powered wheelchair does not receive one included funding issues, lack of family support, and transportation issues. The model of current pediatric powered wheelchair provision includes 4 assessment factors: Preliminary Clinical Assessment, Intake, Advanced Clinical Assessment, and Consideration of Other Factors. Typical recommendations include both therapeutic and nonclinical interventions. A modified version of this model, which addresses some issues identified in the survey that limit wheelchair recommendations, is currently being tested at 4 clinical sites.

Relevance of the Pediatric Powered Wheelchair Screening Test for children with cerebral palsy.

In a previous study we developed a cognitive assessment battery called the Pediatric Powered Wheelchair Screening Test (PPWST) to help clinicians determine a young child's readiness to drive a powered wheelchair. The current multicenter study sought to determine: (1) whether the PPWST is appropriate for use in a population of children with cerebral palsy (CP) who use joysticks to drive their wheelchair; (2) whether two additional factors (symbolic representation and coping) would increase the predictive power of the PPWST for this group and for children with orthopedic or neuromuscular disabilities only; and (3) whether the test was appropriate for children with severe motor impairments who use switches to control their wheelchair. Fifty children (27 males, 23 females) between the ages of 21 months and 6 years 11 months participated. Twenty-six children (mean age 4 years 4 months, SD 15 months) had triplegic or tetraplegic CP and 24 children (mean age 27 months, SD 5 months) had orthopedic or neuromuscular disabilities. Sixty-nine per cent of children had some limited form of mobility (such as rolling or scooting) but none was a functional ambulator. Each child was assessed with the PPWST and with measures of symbolic representation and coping. After six wheelchair training sessions, driving ability was scored. The PPWST was found to be predictive of functional driving ability for children with CP who used a joystick to control their wheelchair. Assessment of symbolic representation skills increased the predictive power for this group but not for children with orthopedic or neuromuscular disabilities; coping scores did not increase the predictive power for either group. The PPWST accounted for only 20% of the variance in overall driving skills for switch users, and thus is not yet considered an adequate screening device for this group. The PPWST is designed to help clinicians determine whether a child currently has the specific cognitive skills found to be related to powered wheelchair driving but is not intended to be used exclusively to determine whether or not a child is ultimately a candidate for powered mobility.