Head biomechanics of video recorded falls involving children in a childcare setting.

The objective of this study was to characterize head biomechanics of video-recorded falls involving young children in a licensed childcare setting. Children 12 to < 36 months of age were observed using video monitoring during daily activities in a childcare setting (in classrooms and outdoor playground) to capture fall events. Sensors (SIM G) incorporated into headbands worn by the children were used to obtain head accelerations and velocities during falls. The SIM G device was activated when linear acceleration was ≥ 12 g. 174 video-recorded falls activated the SIM G device; these falls involved 31 children (mean age = 21.6 months ± 5.6 SD). Fall heights ranged from 0.1 to 1.2 m. Across falls, max linear head acceleration was 50.2 g, max rotational head acceleration was 5388 rad/s2, max linear head velocity was 3.8 m/s and max rotational head velocity was 21.6 rad/s. Falls with head impact had significantly higher biomechanical measures. There was no correlation between head acceleration and fall height. No serious injuries resulted from falls-only 1 child had a minor injury. In conclusion, wearable sensors enabled characterization of head biomechanics during video-recorded falls involving young children in a childcare setting. Falls in this setting did not result in serious injury.

Ramps remain a barrier to safe wheelchair user transit bus ingress/egress.

Background: Wheelchair users (WCUs) often rely on ramps for access to transit buses. Previous studies indicate WCUs have difficulty using ramps for bus ingress/egress and many transportation-related incidents occur on ramps. However, experiences of WCU ramp usage during ingress/egress have not been fully described.Methods: Cross-sectional, internet-based survey of WCUs who ride transit buses was conducted. The participants were queried on frequency of bus usage, difficulty and incidents involving ramps, and factors contributing to difficulty and incidents. Wheelchair characteristics, primary condition, and whether participants received travel training were also captured. Chi-square was used to describe relationships between wheelchair type and frequency of difficulties and incidents, and odd ratios were used to determine likelihood of the incidents.Results: The majority (55.7%) of 384 participants reported using public transportation ≥ 1 per week. Seventy-eight percent of WCUs had ≥ 1 ramp incident over the past 3 years, with an increased likelihood of incidents occurring during ingress (OR = 1.53; CI 1.21-1.86). Of those who had an incident, 22% were injured or had damage to their wheelchair. Over 60% of those who had an incident identified steep ramp slope as being the contributing factor. Steep ramp slope, exterior ramp thresholds and wet surfaces were the most common contributing factors to difficulty using ramps.Conclusion: This is the first large-scale US study enabling WCUs to describe their experiences using transit bus ramps. Despite ADA guidelines, steep ramps remain the primary factor contributing to incidents and difficulty when using ramps to access transit buses.Implications for rehabilitationThe discrepancy between ADA maximum allowable ramp slopes for the built environment and transit buses may require an increased level of effort that is a barrier to transportation accessibility for some wheelchair users.Wheelchair users who access transit buses should be made aware of, and trained, to navigate ramp configurations found in the environment.We suggest rehabilitation therapists provide skills training specific to navigating transit bus ramp slopes that may be steeper and narrower than building ramps.

Manual wheelchair propulsion on ramp slopes encountered when boarding public transit buses.

Objective: To compare the kinetics of manual wheelchair (MWC) propulsion on ramps of varying slopes that may be encountered when accessing large accessible transit vehicles (LATVs). Design: Observational study. Setting: Biomechanics research laboratory. Participants: A convenience sample of able-bodied adults (n = 7) having no propulsion experience propelled a MWC on ramps of slope 3.5°, 9.5° and 15°. Interventions: Not applicable. Main outcome measures: Resultant (Fres), radial (Fr) and tangential (Ft) forces applied to the wheelchair pushrim, rate of rise of resultant force (ROR), peak power output (P), temporal characteristics and thigh to trunk angle were analyzed across three ramp slopes. Results: Pushrim forces and power output significantly increased with increasing slope, with peak Fres more than doubling from 107 N on a 3.5° slope to 230 N on a 15° slope. ROR was 1.76 times higher at 9.5° and 2.47 times higher at 15° compared to a 3.5° slope. Minimum thigh to trunk angle decreased sharply from 80° (3.5° slope) to 50° (9.5° slope) and then to 30° (15° slope) as ramp slope increased. Conclusions: Ascending bus ramps require greater power and pushrim force on steeper ramp slopes, presenting a potential barrier to transportation accessibility. Given this finding, it is imperative that bus operators minimize ramp slope to assure MWC users are able to access LATVs. Implications for Rehabilitation Although transit bus ramps are intended to provide wheelchair access to public transportation, limitations in MWC user physical strength and function may prevent safe access. Transit bus ramp slopes encountered during ingress can present a challenge to MWC users given power output and pushrim force requirements to ascend the ramp. MWC users and therapists should be aware of ramp slopes that may be encountered when boarding transit buses; wheelchair training should incorporate skills needed to ascend transit bus ramps.

Femur loading in feet-first fall experiments using an anthropomorphic test device.

BACKGROUND: Femur fractures are a common orthopedic injury in young children. Falls account for a large portion of accidental femur fractures in young children, but there is also a high prevalence of femur fractures in child abuse, with falls often provided as false histories. Objective information regarding fracture potential in short distance fall scenarios may aid in assessing whether a child's injuries are the result of abuse or an accidental fall. Knowledge of femur loading is the first step towards understanding likelihood of fracture in a fall. OBJECTIVE: Characterize femur loading during feet-first free falls using a surrogate representing a 12-month-old child. METHODS: The femur and hip joint of a surrogate representing a 12-month-old were modified to improve biofidelity and measure femur loading; 6-axis load cells were integrated into the proximal and distal femur. Femur modification was based upon CT imaging of cadaveric femurs in children 10-14 months of age. Using the modified 12-month-old surrogate, feet-first free falls from 69 cm and 119 cm heights onto padded carpet and linoleum were conducted to assess fall dynamics and determine femur loading. Femur compression, bending moment, shear and torsional moment were measured for each fall. RESULTS: Fall dynamics differed across fall heights, but did not substantially differ by impact surface type. Significant differences were found in all loading conditions across fall heights, while only compression and bending loads differed between carpet and linoleum surfaces. Maximum compression, bending, torsion and shear occurred in 119 cm falls and were 572 N, 23 N-m, 11 N-m and 281 N, respectively. CONCLUSIONS: Fall dynamics play an important role in the biomechanical assessment of falls. Fall height was found to influence both fall dynamics and femur loading, while impact surface affected only compression and bending in feet-first falls; fall dynamics did not differ across carpet and linoleum. Improved pediatric thresholds are necessary to predict likelihood of fracture, but morphologically accurate representation of the lower extremity, along with accurate characterization of loading in falls are a crucial first step.

Wheelchair tiedown and occupant restraint practices in paratransit vehicles.

The purpose of this study was to characterize wheelchair tiedown and occupant restraint system (WTORS) usage in paratransit vehicles based on observations of wheelchair and scooter (wheeled mobility devices, collectively, "WhMD") passenger trips. A retrospective review of on-board video monitoring recordings of WhMD trips was conducted. Four hundred seventy-five video recordings were collected for review and analysis. The use of all four tiedowns to secure the WhMD was observed more frequently for power WhMDs (82%) and manual WhMDs (80%) compared to scooters (39%), and this difference was significant (p< 0.01). Nonuse or misuse of the occupant restraint system occurred during 88% of WhMD trips, and was most frequently due to vehicle operator neglect in applying the shoulder belt. Despite the absence of incidents or injuries in this study, misuse and nonuse of WTORS potentially place WhMD seated passengers at higher risk of injury during transit. These findings support the need for improved vehicle operator training and passenger education on the proper use of WTORS and development of WTORS with improved usability and/or alternative technologies that can be automated or used independently.

Healthcare utilization and associated barriers experienced by wheelchair users: A pilot study.

BACKGROUND: More than twenty-five years after passage of the ADA, little remains known about the experiences of wheelchair users when attempting to access health care and how accessibility may influence health care utilization. OBJECTIVE/HYPOTHESIS: To describe health care utilization among wheelchair users and characterize barriers encountered when attempting to obtain access to health care. METHODS: An internet-based survey of wheelchair users was conducted. Measures included demographics, condition, socioeconomic status, health care utilization and receipt of preventive services within the past year, physical barriers encountered at outpatient facilities, and satisfaction with care. RESULTS: Four hundred thirty-two wheelchair users responded to the survey. Nearly all respondents (97.2%) had a primary care appointment within the past year and most reported 3-5 visits to both primary and specialty care providers. Most encountered physical barriers when accessing care (73.8% primary, 68.5% specialty). Participants received most preventive interventions at rates similar to national averages with the exception of Pap tests. Most participants remained clothed for their primary care evaluation (76.1%), and were examined seated in their wheelchair (69.7%). More than half of participants (54.1%) felt they received incomplete care, and 57% believed their physician had no more than a moderate understanding of their disability-specific medical concerns. CONCLUSIONS: Wheelchair users face persistent barriers to care, may receive less than thorough physical evaluations, receive fewer screenings for cervical cancer, and largely believe they receive incomplete care.

Public transit bus ramp slopes measured in situ.

PURPOSE: The slopes of fixed-route bus ramps deployed for wheeled mobility device (WhMD) users during boarding and alighting were assessed. Measured slopes were compared to the proposed Americans with Disabilities Act (ADA) maximum allowable ramp slope. METHODS: A ramp-embedded inclinometer measured ramp slope during WhMD user boarding and alighting on a fixed-route transit bus. The extent of bus kneeling was determined for each ramp deployment. In-vehicle video surveillance cameras captured ramp deployment level (street versus sidewalk) and WhMD type. RESULTS: Ramp slopes ranged from -4° to 15.5° with means of 4.3° during boarding (n = 406) and 4.2° during alighting (n = 405). Ramp slope was significantly greater when deployed to street level. During boarding, the proposed ADA maximum allowable ramp slope (9.5°) was exceeded in 66.7% of instances when the ramp was deployed to street level, and in 1.9% of instances when the ramp was deployed to sidewalk level. During alighting, the proposed ADA maximum allowable slope was exceeded in 56.8% of instances when the ramp was deployed to street level and in 1.4% of instances when the ramp was deployed to sidewalk level. CONCLUSIONS: Deployment level, built environment and extent of bus kneeling can affect slope of ramps ascended/descended by WhMD users when accessing transit buses. Implications for Rehabilitation Since public transportation services are critical for integration of wheeled mobility device (WhMD) users into the community and society, it is important that they, as well as their therapists, are aware of conditions that may be encountered when accessing transit buses. Knowledge of real world ramp slope conditions that may be encountered when accessing transit buses will allow therapists to better access capabilities of WhMD users in a controlled clinical setting. Real world ramp slope conditions can be recreated in a clinical setting to allow WhMD users to develop and practice necessary skills to safely navigate this environment. Knowing that extent of bus kneeling and ramp deployment level can influence ramp slope, therapists can educate WhMD users to request bus operators further kneel the bus floor and/or redeploy the ramp to a sidewalk level when appropriate, so that the least practicable slope will be presented for ingress/egress.

Accessibility of outpatient healthcare providers for wheelchair users: Pilot study.

The Americans with Disabilities Act (ADA) requires full and equal access to healthcare services and facilities, yet studies indicate individuals with mobility disabilities receive less than thorough care as a result of ADA noncompliance. The objective of our pilot study was to assess ADA compliance within a convenience sample of healthcare clinics affiliated with a statewide healthcare network. Site assessments based on the ADA Accessibility Guidelines for Buildings and Facilities were performed at 30 primary care and specialty care clinics. Clinical managers completed a questionnaire on standard practices for examining and treating patients whose primary means of mobility is a wheelchair. We found a majority of restrooms (83%) and examination rooms (93%) were noncompliant with one or more ADA requirements. Seventy percent of clinical managers reported not owning a height-adjustable examination table or wheelchair accessible weight scale. Furthermore, patients were examined in their wheelchairs (70%-87%), asked to bring someone to assist with transfers (30%), or referred elsewhere due to an inaccessible clinic (6%). These methods of accommodation are not compliant with the ADA. We recommend clinics conduct ADA self-assessments and provide training for clinical staff on the ADA and requirements for accommodating individuals with mobility disabilities.

Biomechanical investigation of the classic metaphyseal lesion using an immature porcine model.

OBJECTIVE: The classic metaphyseal lesion is highly associated with abuse in infants. Classic metaphyseal lesions, also referred to as corner or bucket-handle fractures, are fractures through the metaphyseal region of the long bones near the growth plate. Knowledge of the biomechanics and mechanisms necessary to produce a classic metaphyseal lesion may provide insight into the injury causation associated with this unique fracture type. Thus, the purpose of this study was to investigate loading conditions necessary to create a classic metaphyseal lesion using an immature porcine model. MATERIALS AND METHODS: Twenty-four pelvic limb specimens from 7-day-old and 3-day-old piglets were tested in lateral bending (varus and valgus) using an electromechanical testing machine. All specimens were loaded dynamically in four-point bending at a rate of 100 inches/min. Microcomputed tomography was performed on specimens before and after testing. Pre- and posttest CT images were compared to assess whether fracture had occurred. RESULTS: Fractures resembling classic metaphyseal lesions were identified in 12 of the 24 specimens. Microcomputed tomography images revealed trabecular disruptions visually similar to classic metaphyseal lesions in children. CONCLUSION: Metaphyseal fractures, consistent with clinical classic metaphyseal lesions, resulted from a single loading event delivering varus or valgus bending to the stifle (knee). A classic metaphyseal lesion is a unique type of fracture with specific morphologic characteristics. Therefore, we suggest using the term "classic metaphyseal fracture" in lieu of classic metaphyseal lesion to improve precision of terminology.

Ramp-related incidents involving wheeled mobility device users during transit bus boarding/alighting.

OBJECTIVES: To estimate the prevalence of wheeled mobility device (WhMD) ramp-related incidents while boarding/alighting a public transit bus and to determine whether the frequency of incidents is less when the ramp slope meets the proposed Americans with Disabilities Act (ADA) maximum allowable limit of ≤9.5°. DESIGN: Observational study. SETTING: Community public transportation. PARTICIPANTS: WhMD users (N=414) accessing a public transit bus equipped with an instrumented ramp. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Prevalence of boarding/alighting incidents involving WhMD users and associated ramp slopes; factors affecting incidents. RESULTS: A total of 4.6% (n=35) of WhMD users experienced an incident while boarding/alighting a transit bus. Significantly more incidents occurred during boarding (6.3%, n=26) than during alighting (2.2%, n=9) (P<.01), and when the ramp was deployed to street level (mean slope=11.4°) compared with sidewalk level (mean slope=4.2°) (P=.01). The odds ratio for experiencing an incident when the ramp slope exceeded the proposed ADA maximum allowable ramp slope was 5.4 (95% confidence interval, 2.4-12.2; P<.01). The odds ratio for assistance being rendered to board/alight when the ramp slope exceeded the proposed ADA maximum allowable ramp slope was 5.1 (95% confidence interval, 2.9-9.0; P<.01). CONCLUSIONS: The findings of this study support the proposed ADA maximum allowable ramp slope of 9.5°. Ramp slopes >9.5° and ramps deployed to street level are associated with a higher frequency of incidents and provision of assistance. Transit agencies should increase awareness among bus operators of the effect kneeling and deployment location (street/sidewalk) have on the ramp slope. In addition, ramp components and the built environment may contribute to incidents. When prescribing WhMDs, skills training must include ascending/descending ramps at slopes encountered during boarding/alighting to ensure safe and independent access to public transit buses.

Health care utilization and barriers experienced by individuals with spinal cord injury.

OBJECTIVES: To identify from whom individuals with spinal cord injury (SCI) seek health care, the percentage who receive preventative care screenings, and the frequency and types of barriers they encounter when accessing primary and specialty care services; and to examine how sociodemographic factors affect access to care and receipt of preventative screenings. DESIGN: Cross-sectional, observational study using an Internet-based survey. SETTING: Internet based. PARTICIPANTS: Adults (N=108) with SCI who use a wheelchair as their primary means of mobility in the community. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Health care utilization during the past year, barriers encountered when accessing health care facilities, and receipt of routine care and preventative screenings. RESULTS: All but 1 participant had visited a primary care provider within the past 12 months, and 85% had had ≥ 1 visit to specialty care providers. Accessibility barriers were encountered during both primary care (91.1%) and specialty care (80.2%) visits; most barriers were clustered in the examination room. The most prevalent barriers were inaccessible examination tables (primary care=76.9%; specialty care=51.4%) and lack of transfer aids (primary care=69.4%; specialty care=60.8%). Most participants had not been weighed during their visit (89%) and had remained seated in their wheelchair during their examinations (85.2%). Over one third of individuals aged ≥ 50 years had not received a screening colonoscopy, 60% of women aged ≥ 50 years had not had a mammogram within the past year, 39.58% of women had not received a Papanicolaou smear within the previous 3 years, and only 45.37% of respondents had ever received bone density testing. CONCLUSIONS: Individuals with SCI face remediable obstacles to care and receive fewer preventative care screenings than their nondisabled counterparts. We recommend that clinics conduct Americans with Disabilities Act self-assessments, ensure that their clinical staff are properly trained in assisting individuals with mobility disabilities, and take a proactive approach in discussing preventative care screenings with their patients who have SCI.