| | Wheelchair Use by Veterans Newly Prescribed a Manual WheelchairAbstract Ganesh S, Hayter A, Kim J, Sanford J, Sprigle S, Hoenig H. Wheelchair use by veterans newly prescribed a manual wheelchair. ObjectiveTo describe the characteristics of the wheelchairs, the users, and their wheelchair use among persons newly prescribed a manual wheelchair. SettingVeterans Affairs teaching hospital. ParticipantsNinety-nine consecutive, cognitively intact veterans prescribed a manual wheelchair. InterventionsNot applicable. Main Outcome MeasuresSelf-reported difficulty transferring into and propelling the wheelchair; and bathroom mobility method. ResultsStudy patients had a mean age of 66 and a mean of 10 comorbid medical conditions. Parkinsonism, osteoporosis, joint replacement, and amputation were uncommon (<30% of patients), but had a high impact on need for a wheelchair (when present were reported by >50% of patients as causing need for a wheelchair). Falls and arthritis were common (>50% of patients) and highly impacted need for a wheelchair. At 1 month, over 30% of patients had wheelchairs that did not meet common criteria for wheelchair fit; 36% and 61%, respectively, reported difficulty transferring and propelling the wheelchair. The wheelchairs were used for bathroom mobility by 38% of the patients. ConclusionsThe typical manual wheelchair recipient in this study sample was old with multiple medical problems. Despite provision of manual wheelchairs by trained professionals and availability of diverse wheelchair types, new wheelchair users commonly reported difficulty using the wheelchair. Key Words: Activities of daily living, Architectural accessibility, Durable medical equipment, Housing, Occupational therapy, Outcome and process assessment (health care), Physical therapy techniques, Rehabilitation, Residential mobility, Self-help devices, Walking, Wheelchairs ASSISTIVE TECHNOLOGY USE is an increasingly common method of managing mobility disability. Age-adjusted wheelchair use increased by 82.6% from 1980 to 1994, whereas the total U.S. population increased by only 19.1%.1 National surveys consistently show that assistive technology use rises steeply with age, and by 85 years of age, over 40% of the population report using a wheelchair.2 Although current estimates for wheelchair usage are not readily available, in 1995 1.6 million Americans were using a wheelchair, 55% of whom were over the age of 65.3 In recent years, federal expenditures on assistive technology have increased over 10% per year. By 2003, national health expenditures data estimates of total historical public and private expenditures on durable medical equipment were over $20 billion.4 Despite high utilization, data on assistive devices remain scarce and much of the data are either old and/or limited to special populations.5 Nonetheless, the data suggest that people in need of devices may not have access to them, those who have devices may not use them,6, 7, 8, 9 and devices often fit poorly or are in disrepair.10, 11 Although accessibility features are more commonly found in the homes of wheelchair users than in those of non-wheelchair users,12 key features such as ramps and widened doorways are present only 20% to 30% of the time.4 For wheelchairs in particular, these problems with device use have been attributed to deficiencies in the wheelchair delivery system and lack of professional assistance.13, 14 The Veterans Health Administration enables examination of assistive technology outcomes within a delivery system that includes clinicians in the delivery process and allows provision of the full spectrum of commercially available wheelchairs. Thus, it allows assessment of the extent of problems with wheelchair use that may be related to factors other than lack of clinical input or limited availability of technology. This study examines manual wheelchair use among 99 veterans recently prescribed a new wheelchair. Methods  This study was approved by the institutional review boards for the Durham Veterans Affairs Medical Center (VAMC) and Duke University Medical Center. The Durham VAMC provides wheelchairs to patients across the entire continuum of care ranging from outpatients in community settings to inpatients in the Extended Care and Rehabilitation Center (ECRC). All wheelchairs are provided by licensed physical or occupational therapists, or by physical or occupational therapy assistants operating under a protocol that specifies fit criteria, instructional methods, and the circumstances in which to involve a licensed therapist. Patient Sample We enrolled wheelchair recipients from the VAMC if they met the following inclusion criteria: age over 21, a Short Portable Mental Status Questionnaire score of 6 out of 10 or higher, receipt of a manual or motorized wheelchair, residence within a 104-km (65-mile) radius of the hospital, owned a telephone, and gave informed consent. Subjects were either new wheelchair users or current users who were receiving a different type of wheelchair than they currently had. Acute medical or surgical patients who received wheelchairs were not included in this study, because their wheelchairs are not provided on permanent basis. If the wheelchair provided was an exact replacement of a wheelchair the patient already owned, or if researchers were unable to contact the patient within 7 to 21 days of obtaining the wheelchair, the subject was excluded. The Veterans Affairs National Prosthetics Database allowed identification of all wheelchair recipients. In addition, the analysis was further limited to subjects prescribed a manual wheelchair and who were still using the wheelchair 1 month after receipt. The final sample size for this analysis was 99 (fig 1). Data Collection After obtaining informed consent, we interviewed patients either over the telephone or in-person, according to patient preference. Interviews occurred 7 to 21 days after wheelchair receipt with a follow-up interview and home visit 1 month after receipt. Interrater reliability and quality control were assured by periodic, mutual observation between raters. Study Variables The World Health Organization’s International Classification of Functioning, Disability and Health serves as the theoretical underpinning for the variables considered in this study. We chose variables for exploratory bivariate analyses based on a priori hypotheses that the characteristic was likely to be related to wheelchair usage. Dependent Variables Wheelchair transfers Difficulty transferring into the wheelchair was measured by self-report as any versus no difficulty, without further specification, so that respondents could include whatever type of transfers they might deem problematic. Wheelchair propulsion Wheelchair propulsion was measured by self-report as any versus no difficulty, without further specification, so that respondents could include whatever type of problem they might experience with pushing the wheelchair. Bathroom mobility method Day-to-day wheelchair usage was measured according to mobility method in the bathroom, because that location was pertinent to all study participants (ie, it included inpatient ECRC residents who use a communal dining room, lack a living room, but who all do have a bathroom adjacent to their sleeping area). In addition, the bathroom is a location in which wheelchair usage might be particularly vulnerable to environmental constraints. Bathroom mobility method was measured by response to the following question: “What was the main method you used to get to and move about the bathroom in the last 24 hours?” classified as either walking or wheeling. Only 3 of the 99 people in the sample did not use the bathroom (eg, used a catheter changed by nursing personnel), and they were excluded from this latter analysis. Independent Variables The independent variables considered in the exploratory analyses included personal and health characteristics, device characteristics, and environmental characteristics. Personal and health characteristics Sociodemographic characteristics included age, sex, race (white race vs all others), education (high school graduate or above vs all others), and income (<$15,000 per year vs all others). Medical characteristics included both diseases and impairments. Information on medical conditions was obtained by self-report using methods from work in prior studies in older populations,15, 16 and the conditions studied were selected from those used in the larger studies based on clinical judgment, to include the following medical conditions: heart disease, lung disease, stroke, parkinsonism, broken bones, joint fusion or replacement, arthritis, osteoporosis, amputation, diabetes, pressure ulcers, eye disease, falls, cancer, or psychiatric problems. Participants reporting a given medical condition then reported on whether that medical condition had contributed to their need for a wheelchair. The following impairments were also measured by self-report (present vs absent in the last 6 mo): chest pain and/or shortness of breath at rest or with exertion, weakness, dizziness, fear of falling, pain, or confusion. The following measures were obtained by direct physical measurement in persons who met relevant inclusion and exclusion criteria (eg, persons with unstable angina or leg surgery in the prior 4 months were excluded from standing balance measurement): visual acuity and visual field using a Students Optometric Service to Humanity chart and Hubbard disk, classified as unimpaired (vs impaired) if the visual acuity in the better eye was better than 20/50 and the visual field in better eye was greater than 80°. Grip strength was measured using a Smedley-type hand-held dynamometer (the mean for both hands). Based on prior work,17 the ability to stand and balance was measured by the number of seconds the participant could stand independently (dichotomized as 9 or fewer seconds versus 10 or more seconds). Wheelchair-related characteristics We measured wheelchair characteristics in person in the patient’s home by trained evaluators with the patient fully clothed and were based on clinical criteria in common usage at the time of the study.18 Seat width fit was determined by measuring the distance between the outside of the thigh and the edge of the seat, classified as fits (vs does not fit) if the width at all points between the outside of the thigh and the edge of the seat was greater than 2.54cm (1.0in) but less than 3.81cm (1.5in). The type of seat was classified as (1) sling/no cushion, (2) sling with cushion, (3) solid/no cushion, and (4) solid, with cushion. Footrest clearance was classified as footrest present and adequate if there was greater than 2.54cm but less than 5.08cm (2in) clearance (vs not present or inadequate clearance). The brand and make of the wheelchair was noted and the wheelchairs then were classified as standard, lightweight, high strength lightweight, ultra lightweight, extra heavy duty, and other. Environmental characteristics We classified participants according to their residence 1 month after receipt of the wheelchair (community vs institutional [ECRC n=23 or nursing home with rehabilitation unit n=7]). Participants reported whether they resided in an institutional setting and the number of persons in the home (classified as lives alone vs all others). Among institutional and community-dwelling participants who gave permission for a home or institution visit, trained evaluators assessed presence of carpet in the main living area (ie, living room), and among participants who permitted a second home visit at 3 months they examined the width of the bathroom doorway relative to the wheelchair (classified as wider vs narrower than the wheels on the wheelchair), and the height of the bathroom threshold (classified as >2.54cm vs <2.54cm). Further details on the study methodology may be found in Hoenig et al.19 Data Analysis We performed statistical analysis primarily using Minitab.a Percentages, frequencies, and means and standard deviations (SD), as appropriate, were used to describe the sociodemographic and medical characteristics of the study sample. Medical characteristics were reported both as summed scales of diseases and impairments and individually. Bivariate analyses were carried out to compare dependent and independent variables using chi-square tests. Due to the small sample size and consequent limitations in statistical power, multivariate analyses were not performed and we report statistical significance at the level of .10 or lower. Results Study participants had a mean age of 66 years, and were predominantly men (99%), white (59%), had at least a high school education (58%), an income of less than $15,000 a year (57%), and 68% lived in the community (table 1). In general, the participants were medically frail with multiple chronic medical conditions (mean, 10/11 possible), and multiple impairments (mean, 6/8 possible), and over 76% reported being hospitalized in the preceding 6 months. The majority (67%) of participants were provided a standard (K0001) wheelchair, although 23% were given a high strength, lightweight chair. | | |  | Characteristic | % | |
|---|
| Patient | | | |  Mean age ± SD (y) | 65.68±12.90 | | | Men | 99 | | | White race | 56.5 | | | High school education or greater | 57.5 | | | Low income⁎ | 50.5 | | | Medical/health | | | | Mean no. of medical conditions ± SD (range, 0−11)† | 10±2 | | | Mean no. impairments ± SD (range, 0−8)‡ | 6±2 | | | Hospitalized in the last 6 months | 75.8 | | | Surgery in the last 6 months | 37.4 | | | Type of wheelchair | | | | Standard | 57 | | | Lightweight | 5 | | | High strength, lightweight | 20 | | | Ultra lightweight | 3 | | | Extra heavy duty | 3 | | | Heavy duty | 1 | | | Missing | 10 | | | | |
| ⁎ Missing data = 11%. †Sum of the following medical conditions: heart disease, lung disease, “neuro” (stroke or parkinsonism), falls, “musculoskeletal” (fracture or joint fusion/replacement or arthritis or osteoporosis), amputation, diabetes, pressure ulcer, eye disease, cancer, depression or emotional problems. ‡Sum of the following impairments: chest pain, shortness of breath, muscle weakness, poor balance, dizziness, fear of falling, pain, confusion. |
Table 2 presents data on the prevalence of medical conditions in the study sample, and among those reporting a given condition, whether the participant believed that condition contributed to their need for a wheelchair. Conditions with a low prevalence in the population (<30%), and a high impact on needing a wheelchair (>50% of persons with the condition believed it contributed to needing the wheelchair) included parkinsonism, osteoporosis, joint replacement, and amputation. Conditions with a high prevalence in the population (>50%), and a high impact on needing a wheelchair included falls and arthritis. When probed about the reason(s) they needed a new wheelchair, the participants reported a variety of diseases, impairments, functional limitations, and equipment-related reasons, and many reported multiple reasons. The most commonly reported reason was functional limitation; specifically inability to walk long distances or to carry out community mobility (17%). The most commonly reported impairment, disease, and equipment-related problems were, respectively, weakness (12%), cardiopulmonary and neurologic conditions (both 9%), and problems with the patient’s current wheelchair (5%). | | | | Medical Condition | Condition Present (%) | Condition Contributed to Need for Wheelchair (%) | |
|---|
| Hospitalized in the last 6 months | 75.8 | 73.3 | | | Surgery in the last 6 months | 37.4 | 78.4 | | | Heart disease | 47.5 | 42.6 | | | Lung disease | 32.3 | 53.1 | | | Stroke | 37.4 | 62.2 | | | Parkinsonism | 2.0 | 50.0 | | | Falls | 58.6 | 55.2 | | | Fracture (ever) | 38.4 | 34.2 | | | Joint fusion/replacement | 18.2 | 66.7 | | | Arthritis | 64.6 | 60.9 | | | Osteoporosis | 7.1 | 57.1 | | | Amputation | 27.3 | 70.4 | | | Diabetes mellitus | 34.3 | 64.7 | | | Pressure ulcer (current) | 13.1 | 30.8 | | | Eye disease | 40.4 | 12.5 | | | Cancer | 32.3 | 31.3 | | | Depression/emotional problems | 31.3 | 16.1 | | | | |
Table 3 examines 2 aspects of wheelchair use—difficulty in transferring to the wheelchair and difficulty in propelling the wheelchair. Over 30% of the sample reported difficulty with transfers and more than half reported difficulty propelling the wheelchair. All of the physical impairments and problematic device characteristics were more common among those with versus without difficulty, although the differences did not reach statistical significance. For example, 50% of those with difficulty transferring were unable to stand independently, compared with 41% of those without difficulty. Similarly, 51% of those with difficulty propelling were unable to stand independently, compared with 37% of those without difficulty. Results of analyses examining actual use of the wheelchair in the home are found in table 4. Less than half (38/99 [38.4%]) of the sample used the wheelchair for bathroom mobility. Wheelchair usage for bathroom mobility was significantly more common among those who were unable to stand independently (P<.001) and less common among those reporting cardiopulmonary impairment (P<.05). In addition, 2 wheelchair characteristics and 1 environmental characteristic were associated with significantly lower use of the wheelchair for bathroom mobility—having a sling seat/no cushion (P=.01), a standard wheelchair (P<.001), and community residence (P=.035). As a supplemental analysis (data not shown), we compared community-dwelling participants with those who resided in an institutional setting at the time of the study. The community-dwellers were significantly more likely to have a wheelchair that had a sling seat without a cushion (30% vs 0%, P=.001), to have carpeting in their home (68% vs 0%, P≤.001), and to have received a standard wheelchair (66% vs 40%, P=.002). Discussion This study shows that difficulty with manual wheelchair use was common, even when provided by trained personnel with the ability to provide diverse types of manual wheelchairs. Over a third of the subjects had wheelchairs that did not meet commonly used fit criteria. A high percentage of respondents reported difficulty with functional wheelchair skills: transferring and propelling. When wheelchair usage in an environment common to all care settings (the bathroom) was examined, usage of the wheelchair was relatively infrequent and not clearly related to environmental constraints other than community residence. The exploratory analyses of factors associated with problematic wheelchair use appear to indicate that medical factors may be of importance. For example, persons with cardiopulmonary impairment had a trend to more difficulty transferring and propelling their wheelchairs, and they were significantly less likely to use the wheelchair. Two wheelchair characteristics (sling seat/no cushion, standard K0001 wheelchair) were associated with wheelchair use. Both of these were also more commonly found in wheelchairs provided to the community-dwellers. We do not know whether the community-dwellers were given these types of wheelchairs because they were perceived to be less likely to need a wheelchair full-time in their home or if the wheelchairs themselves were less functional and therefore less likely to be used. Prior studies have shown disturbingly frequent problems with manual wheelchairs, both among community-dwellers and nursing home residents.7, 8, 9, 10 Investigators have suggested the following factors may contribute to the high prevalence of problems among manual wheelchair users: lack of professional input, inadequate home modifications to support wheelchair use, and attitudes toward wheelchair use.11, 20, 21 This study did not examine home modifications or patient attitudes, but all of the patients had professional input as a part of the wheelchair provision process and custom chairs were commonly provided. Nonetheless, many of the patients reported difficulty using the wheelchair. Thus, although professional input and availability of custom chairs may improve wheelchair outcomes, these may not be sufficient. Although it may not be possible to eliminate difficulty with manual wheelchair usage for all manual wheelchair users, 50% of users reporting difficulty with usage seems far from optimal. Further enhancements may be achieved through systematic research and policy initiatives to address the provision process, equipment limitations, and environmental factors. Study Limitations This study has a number of important limitations due to the relatively small sample size and the cross-sectional study design. Due to sample size limitations, we performed only bivariate analyses, making it impossible to account for confounding factors, and the cross-sectional study design precludes determining causality. Thus, the analyses of the factors associated with problematic wheelchair use must be viewed as exploratory, and lack of a significant relationship should not be construed to indicate that factor is unimportant. The study enrolled 58% of all eligible patients; therefore, study findings should be generalizable to the other similar veterans prescribed a manual wheelchair. The findings may not generalize, however, to non-veteran populations with differing medical conditions,22 to populations in which limitations in insurance coverage or differences in prescribing patterns might affect which types of patients receive wheelchairs and the kinds of wheelchairs they receive, or even to veteran populations that differ significantly from this study sample. Other VAMCs may rely on different fit criteria or their methods of wheelchair provision may differ from those used at the time of this study. In addition, some of the measures of poor fit may be the result of actions after the wheelchair was dispensed (eg, removal of cushions or footrests). The time point at which wheelchair use was measured must also be considered. On one hand, 1 month after receiving a wheelchair the user may still be too ill to use the wheelchair as well or as often as they otherwise would, and they may not have had time to modify their home to accommodate the device. On the other hand, 1 month after receipt is likely too early for devices to have been abandoned on the basis of recovery from illness. Conclusions The high prevalence of perceptions of difficulty with wheelchair use seen in this study are troubling because all patients in the study were seen by trained clinicians and in a health care system with coverage of the entire spectrum of commercially available wheelchairs. Indeed, the provision of a specialized wheelchair to over a third of the participants suggests that an assessment of user needs was performed because an attempt was made to match proper equipment to user needs. Few studies have examined the effect of interventions to improve wheelchair provision and training,23, 24 and further research is needed. The bivariate analyses in this study may be used to power future research studies, helping to ensure that an adequate sample size is available to detect statistically significant differences. One immediate action would be to simply ask patients if they experience difficulty using the wheelchair at the time it is provided, and then use that information to fine tune the wheelchair prescription and training. Finally, the study results indicate that wheelchair design for older persons with multiple comorbid medical conditions should be a priority, focusing on those conditions that are both common and commonly cause a wheelchair to be prescribed. Supplier References 1. 1Russell JN, Hendershot GE, LeClere F, Howie LJ, Adler M. Trends and differential use of assistive technology devices: United States, 1994. Adv Data. 1997;292:1–9. 2. 2Cornman JC, Freedman VA, Agree EM. Measurement of assistive device use: implications for estimates of device use and disability in late life. 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a Duke University School of Medicine, Durham, NC b Rehabilitation Institute of Chicago/Northwestern University, Chicago, IL c Department of Industrial Engineering, Georgia Institute of Technology, Atlanta, GA d Center for Assistive Technology and Environmental Access, Georgia Institute of Technology, Atlanta, GA e Rehabilitation Research & Development Center, Atlanta Veterans Administration Medical Center, Decatur, GA f Department of Medicine/Geriatrics, Duke University Medical Center, Durham, NC g Physical Medicine & Rehabilitation Service, Durham Veterans Administration Medical Center, Durham, NC.  Reprint requests to Shanti Ganesh, MD, MPH, Rehabilitation Institute of Chicago/Northwestern University, 345 E Superior St, Chicago, IL 60611
Supported in part by the National Institutes of Health, National Institute on Aging, Duke University Claude D. Pepper Older Americans Independence Center (grant no. 2P60AG11268) and by the National Institute of Disability and Rehabilitation Research, RERC on Wheeled Mobility (grant no. H133E030035-04). No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the author(s) or upon any organization with which the author(s) is/are associated. PII: S0003-9993(06)01637-6 doi:10.1016/j.apmr.2006.12.045 © 2007 American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved. | |
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