Publications by authors named "Alicia M Koontz"

60 Publications

Comparison of trunk mechanics and spatiotemporal outcomes in caregivers using a robotic assisted transfer device and a mobile floor lift.

J Spinal Cord Med 2021 Sep 10:1-8. Epub 2021 Sep 10.

Human Engineering Research Laboratories, US Department of Veterans Affairs Pittsburgh Healthcare System, University Drive, Pittsburgh, Pennsylvania, USA.

Objective: The purpose of this study was to compare trunk mechanics, distance covered, and average instantaneous velocity and acceleration recorded with caregivers performing transfer tasks using a research mannequin with both a prototype robotic assisted transfer device (RATD) and a mobile floor lift.

Design: Cross-Sectional.

Setting: Biomechanics Lab and Human Engineering Research Laboratories.

Participants: Caregivers ( = 21).

Intervention: Robotic Assisted Transfer Device.

Outcome Measures: Range of flexion-extension, lateral bend, and axial rotation; distance covered; average instantaneous velocity and acceleration.

Results: Caregivers performing transfers using the RATD as compared to when using the moble floor lift reported significantly smaller range of trunk flexion-extension, lateral bending, and axial rotation, and reported lower pelvic based distance covered and slower average instantaneous velocity and acceleration (P < 0.001).

Conclusion: The design and usability of a RATD indicates design driven mobility advantages over clinical standard mobile floor lifts due to its ability to expand the workspace while further reducing risk factors for low back pain. While the concept is promising, further testing is required to address limitations and confirm the concept for clinical applications.
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http://dx.doi.org/10.1080/10790268.2021.1961071DOI Listing
September 2021

Automating the Clinical Assessment of Independent Wheelchair Sitting Pivot Transfer Techniques.

Top Spinal Cord Inj Rehabil 2021 13;27(3):1-11. Epub 2021 Aug 13.

Human Engineering Research Laboratories, Rehabilitation Research and Development Service, Department of Veterans Affairs, Pittsburgh, PA.

Background: Using proper transfer technique can help to reduce forces and prevent secondary injuries. However, current assessment tools rely on the ability to subjectively identify harmful movement patterns.

Objectives: The purpose of the study was to determine the accuracy of using a low-cost markerless motion capture camera and machine learning methods to evaluate the quality of independent wheelchair sitting pivot transfers. We hypothesized that the algorithms would be able to discern proper (low risk) and improper (high risk) wheelchair transfer techniques in accordance with component items on the Transfer Assessment Instrument (TAI).

Methods: Transfer motions of 91 full-time wheelchair users were recorded and used to develop machine learning classifiers that could be used to discern proper from improper technique. The data were labeled using the TAI item scores. Eleven out of 18 TAI items were evaluated by the classifiers. Motion variables from the Kinect were inputted as the features. Random forests and k-nearest neighbors algorithms were chosen as the classifiers. Eighty percent of the data were used for model training and hyperparameter turning. The validation process was performed using 20% of the data as the test set.

Results: The area under the receiver operating characteristic curve of the test set for each item was over 0.79. After adjusting the decision threshold, the precisions of the models were over 0.87, and the model accuracies were over 71%.

Conclusion: The results show promise for the objective assessment of the transfer technique using a low cost camera and machine learning classifiers.
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http://dx.doi.org/10.46292/sci20-00050DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8370707PMC
September 2021

Assessment of Wheelchair Propulsion Performance in an Immersive Virtual Reality Simulator.

Int J Environ Res Public Health 2021 07 29;18(15). Epub 2021 Jul 29.

Department of Occupational Therapy, College of Health Science, Kaohsiung Medical University, Kaohsiung 80708, Taiwan.

Maneuvering a wheelchair is an important necessity for the everyday life and social activities of people with a range of physical disabilities. However, in real life, wheelchair users face several common challenges: articulate steering, spatial relationships, and negotiating obstacles. Therefore, our research group has developed a head-mounted display (HMD)-based intuitive virtual reality (VR) stimulator for wheelchair propulsion. The aim of this study was to investigate the feasibility and efficacy of this VR stimulator for wheelchair propulsion performance. Twenty manual wheelchair users (16 men and 4 women) with spinal cord injuries ranging from T8 to L2 participated in this study. The differences in wheelchair propulsion kinematics between immersive and non-immersive VR environments were assessed using a 3D motion analysis system. Subjective data of the HMD-based intuitive VR stimulator were collected with a Presence Questionnaire and individual semi-structured interview at the end of the trial. Results indicated that propulsion performance was very similar in terms of start angle ( = 0.34), end angle ( = 0.46), stroke angle ( = 0.76), and shoulder movement ( = 0.66) between immersive and non-immersive VR environments. In the VR episode featuring an uphill journey, an increase in propulsion speed ( < 0.01) and cadence ( < 0.01) were found, as well as a greater trunk forward inclination ( = 0.01). Qualitative interviews showed that this VR simulator made an attractive, novel impression and therefore demonstrated the potential as a tool for stimulating training motivation. This HMD-based intuitive VR stimulator can be an effective resource to enhance wheelchair maneuverability experiences.
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http://dx.doi.org/10.3390/ijerph18158016DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8345396PMC
July 2021

Preliminary evaluation of an automated robotic transfer assist device in the home setting.

Disabil Rehabil Assist Technol 2021 Feb 2:1-8. Epub 2021 Feb 2.

Human Engineering Research Laboratories, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA.

Purpose: The purpose of this study was to examine the effects of six weeks of routine use of a novel robotic transfer device, the AgileLife Patient Transfer System, on mobility-related health outcomes, task demand, and satisfaction relative to previous transfer methods.

Materials And Methods: Six end users and five caregivers used the system in their homes for six weeks. Participants completed several surveys examining perceived demands related to preparing and performing a transfer and mobility-related health outcomes pre and post intervention. Participants were also asked about their satisfaction with using the technology compared to previous transfer methods.

Results: Both end users and caregivers reported reduction in perceived physical demand ( = 0.007) and work ( ≤ 0.038) when preparing for and performing a transfer. End users indicated that the device intervention had a positive impact, indicating some improvements to health-related quality of life as well as improved competence, adaptability, and self-esteem post-intervention. All participants were highly likely to recommend the technology to others.

Conclusion: The AgileLife Patient Transfer System is a promising new form of transfer technology that may improve the mobility and mobility-related health of individuals with disabilities and their caregivers in home settings.Implications for rehabilitationRobotic transfer assistance reduced physical demand and work among end users and caregivers.The robotic device had a positive impact on some quality of life outcomes after 6 weeks of use.Users were highly likely to recommend the robotic transfer device to others.
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http://dx.doi.org/10.1080/17483107.2021.1879283DOI Listing
February 2021

Assessment of Muscle Activation of Caregivers Performing Dependent Transfers With a Novel Robotic-Assisted Transfer Device Compared With the Hoyer Advance.

Am J Phys Med Rehabil 2021 09;100(9):885-894

From the Human Engineering Research Laboratories, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania (ERB, MG, SB, HK, GGG, RC, AMK, RAC); School of Health and Rehabilitation Sciences (ERB, MG, SB, HK, GGG, RC, AMK, RAC) and Department of Rehabilitation Sciences and Technology, School of Health and Rehabilitation Sciences (MG, SB, HK, GGG, RC, AMK, RAC), University of Pittsburgh, Pittsburgh, Pennsylvania; and University of Groningen, University Medical Centre Groningen, Centre for Human Movement Sciences, Groningen, the Netherlands (ERB, RV).

Objective: The purpose of this study was to compare muscle activity in caregivers while using a novel robotic-assisted transfer device (Strong Arm) to a clinical standard of care (Hoyer Advance).

Design: A quasi-experimental design was used in which 20 caregivers (33 ± 15 yrs old) performed transfers with three surfaces (toilet, bench, and shower chair) with the Strong Arm and Hoyer Advance. Transfer completion time (seconds), peak percentage surface electromyography (EMG), and integrated EMG of the bilateral erector spinae, latissimus dorsi, pectoralis major and anterior deltoid were measured.

Results: Caregivers required less transfer time when transferring from wheelchair to surface using the Hoyer Advance (P = 0.011, f = 0.39). For the lower back, significantly lower peak percentage EMGs were found using Strong Arm in 50% and for the integrated EMG in 25% of the cases, with the remaining cases showing no significant differences. For the shoulder, significantly lower peak percentage EMG values were found using Strong Arm in 19% of transfers and lower integrated EMG was found in 25% of transfers when using the Hoyer Advance, with the remaining cases showing no significant differences.

Conclusion: Although back muscle activation during Strong Arm transfers is statistically, but not clinically, lower, additional features that couple with significantly lower muscle activation make it an alternative to the clinical standard for further research and possible clinical applicability.
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http://dx.doi.org/10.1097/PHM.0000000000001665DOI Listing
September 2021

Rehabilitation professional and user evaluation of an integrated push-pull lever drive system for wheelchair mobility.

Assist Technol 2020 Nov 12:1-9. Epub 2020 Nov 12.

Human Engineering Research Laboratories, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA.

Wheeled mobility devices enable persons with limited mobility to maintain an independent lifestyle. Lever-drive propulsion options have been shown to increase wheeled mobility device efficiency while reducing physical strain on users. Despite these benefits, they have not been widely adopted for everyday use. Two novel lever-drive devices (RoScooter and RoTrike) provide an alternative to pushrim propulsion by using an integrated front-and-center push-pull lever mechanism. The objectives of this study were to assess the usability and performance of the lever-drive devices using both rehabilitation professional and user feedback. The study enrolled 17 rehabilitation professionals and 13 users who performed various mobility tasks to rate the performance of the RoScooter and RoTrike for ease of use, stability, safety, appearance, and comfort. Users were graded on their performance using a scoring system based on the Wheelchair Skills Test. Rehabilitation professionals suggested improvements in regard to adjustability, maneuverability, target population, and appearance, preferring the operations of the RoScooter to the RoTrike. Users reported that the devices were entertaining and easy to use, but improvements in adjustability, reversal methods, and operation options to appeal to a wider range of consumers are needed before lever-drive devices are suitable to replace or supplement current wheeled mobility devices.
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http://dx.doi.org/10.1080/10400435.2020.1836068DOI Listing
November 2020

Usability and task load comparison between a robotic assisted transfer device and a mechanical floor lift during caregiver assisted transfers on a care recipient.

Disabil Rehabil Assist Technol 2020 Sep 29:1-7. Epub 2020 Sep 29.

Human Engineering Research Laboratories, US Department of Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA.

Introduction: The RATD represents a novel methodology to reduce strain, manoeuvring, and cognitive load a caregiver experiences when conducting transfers on a mannequin. However, caregivers who used this new technology report suggested adjustments regarding the robot's human machine interface and shape as to improve transfer efficiency and comfort for care recipients. The purpose of this study was to test a redesigned RATD and compare its ergonomics during a transfer to those of a mechanical floor lift.

Methods: This was cross sectional protocol. As opposed to prior research which used a mannequin, caregivers in this study ( = 28) partnered with, and transferred, a mobility device user ( = 28) at three unique surfaces. Information about task demand and usability was collected from surveys after use of each device at each surface.

Results: Results indicated reduced physical demand ( = .004) and discomfort frequency ( = .01) in caregivers conducting the transfers with the RATD compared to the mechanical floor lift. Care recipients reported no significant differences between both transfer devices. Critiques with the interface, the harness and sling, and the robot's rigidity indicated more work is needed before introducing this technology to a larger market. Conclusions: The RATD represents a promising new intervention for transferring and handling care recipients who use wheelchairs. However, while caregivers report reduced physical demand and discomfort, more work is required to advance the ease of the human machine interface, the amount of space allowed for the robot to operate, and the ability of the care recipient to operate the technology independently.IMPLICATIONS FOR REHABILITATIONCaregivers report significant physical and mental stress while transferring clients in and out of a wheelchair.Clinical standard transfer equipment is limited in the space which it can be used.Robots, particularly those portable and powered, have the ability to not only make the transfer experience safer, but also expand the applications this equipment can provide.
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http://dx.doi.org/10.1080/17483107.2020.1818137DOI Listing
September 2020

Feasibility, acceptability, and preliminary efficacy of a handcycling high-intensity interval training program for individuals with spinal cord injury.

Spinal Cord 2021 Jan 9;59(1):34-43. Epub 2020 Sep 9.

Neuromuscular Research Laboratory/Warrior Human Performance Research Center, Department of Sports Medicine and Nutrition, University of Pittsburgh, Pittsburgh, PA, USA.

Study Design: Pilot nonrandomized clinical trial.

Objectives: To examine the feasibility, acceptability, and preliminary efficacy of performing handcycling high-intensity interval training (HIIT) for 6 weeks in wheelchair users with spinal cord injury.

Setting: Participant's home.

Methods: Participants completed pre- and postgraded exercise stress tests, exercise surveys and 6 weeks of handcycling HIIT. The HIIT program consisted of two weekly, 25 min supervised at-home sessions (2-3 min warm-up, then ten intervals of cycling with a ratio of 1 min work at 90% peak power output (PPO) to 1 min recovery at 0-20% PPO, then 2-3 min cool down). Real-time power output and heart rate were recorded via sensors and a bike computer. The sensor data were analyzed to evaluate training efficacy.

Results: Seven of the ten enrolled participants (70%) completed the study. All but one completed the required 12 sessions. The participants met at least 1 of the HIIT target intensity criteria in 76 out of 89 total sessions (85.4%) performed. Participants expressed a high level of enjoyment on the Physical Activity Enjoyment Scale, mean (SD) = 114.8 (11.3), and satisfaction with the overall experience. Five of the seven participants (71%) who completed the study felt an increase in endurance, function, and health. Objective physiological changes showed mixed results.

Conclusions: Six weeks of handcycling HIIT appears to be safe, feasible and acceptable. A longer HIIT work interval may be needed to elicit significant physiological responses. Future investigation of the feasibility and efficacy of differing HIIT parameters is needed.
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http://dx.doi.org/10.1038/s41393-020-00548-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7854955PMC
January 2021

An ergonomic comparison of three different patient transport chairs in a simulated hospital environment.

Appl Ergon 2020 Oct 8;88:103172. Epub 2020 Jun 8.

Human Engineering Research Laboratories, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA; Department of Rehabilitation Science and Technology, University of Pittsburgh, Pittsburgh, PA, USA; Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, USA. Electronic address:

The purpose of this study was to compare caregiver muscle activation and joint angles between two ergonomic transport chairs designed to mitigate discomfort and safety risks associated with patient transport, the Stryker® Prime TC and the Staxi® Medical Chair, and a depot wheelchair. Twenty-three caregivers completed level walking and ramped tasks with each device and an 84 kg manikin. Surface electromyography for the upper extremities and back muscles and motion data were collected. The Staxi showed a statistical trend for higher wrist extensor and flexor carpi ulnaris activity compared to the Stryker chair (p ≤ 0.078) and greater wrist flexion than the Stryker and depot chairs (p ≤ 0.004). The depot chair showed greater peak trunk flexion than the Stryker chair (p = 0.004). Overall results suggest that ergonomic chair design may improve joint positioning of the trunk and elbows when operating patient transport chairs over level and ramped surfaces.
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http://dx.doi.org/10.1016/j.apergo.2020.103172DOI Listing
October 2020

Accessibility facilitators and barriers affecting independent wheelchair transfers in the community.

Disabil Rehabil Assist Technol 2021 Oct 8;16(7):741-748. Epub 2020 Jan 8.

Human Engineering Research Laboratories, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA.

Purpose: The purpose of this study is to identify facilitators and barriers to wheelchair transfers in the community and to identify specific places and surfaces in the community where increasing transfer accessibility could enable greater participation.

Methods: This study enrolled 112 wheeled mobility device users who completed a survey describing barriers to independent transfers. Descriptive statistics (means, standard deviations, and percentages) were used to report the survey results.

Results: The majority of subjects (≥50% of the sample) who were impacted by the following features found them to be helpful while transferring: presence of transfer aids, presence of grab bars, large enough transfer surface size, storage space for a wheeled mobility device (WMD), large amounts of space and clearance for legs and feet, soft surfaces, and enough space next to the transfer surface. Ninety percent (90.5%) felt their participation was limited when surfaces higher than their WMD were encountered. Participants also reported feeling limited in their participation due to lack of transfer accessibility at a variety of community destinations, including medical facilities (35.1%), modes of transportation (38.5-52.1%), pools and hot tubs (45.4%), dressing rooms (50.0%), amusement parks (49.1%), and boating areas (52.1%).

Conclusion: Improving accessibility for independent transfers in the community may support greater participation and lead to a better quality of life. Study findings provide insight into changes that would make the built environment more accessible and safer for wheelchair users who independently transfer.Implications for rehabilitationTransferring independently is one of the most physically demanding tasks for wheelchair users, and physical and environmental factors may affect transferability in the community.Identifying environmental facilitators and barriers to transfers may improve accessibility for wheelchair users, allowing for greater community participation, reduced risk of falls and injuries, and improvements to quality of life.
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http://dx.doi.org/10.1080/17483107.2019.1710771DOI Listing
October 2021

Person transfer assist systems: a literature review.

Disabil Rehabil Assist Technol 2021 Apr 12;16(3):270-279. Epub 2019 Oct 12.

Human Engineering Research Laboratories, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA.

Objective: Novel developments in the robotics field have produced systems that can support person wheelchair transfers, maximize safety and reduce caregiver burden. The purpose of this study was to identify and describe these systems, their usability (or satisfaction), the context for which they have been or can be used and how they have been evaluated to determine evidence for their effectiveness.

Method: Available research on Person Transfer Assist Systems (PTAS) was systematically gathered using similar standards to the PRISMA guidelines. The search terms were derived from common terms and via exploring similar review articles. Initial search terms displayed 1330 articles and by using the inclusion/exclusion criteria 96 articles were selected for abstract review. After full- text reviewing 48 articles were included.

Results: 29 articles concerned research in robotic transfer systems, 10 articles used both ceiling and floor-mounted lifts and 9 articles used only floor-mounted lifts as an intervention/control group. The results of this analysis identified a few usability evaluations for robotic transfer prototypes, especially ones comparing prototypes to existing marketed devices.

Conclusion: Robotic device research is a recent development within assistive technology. Whilst usability evaluations provided evidence that a robotic device will provide better service to the user, the sample number of subjects used are minimal in comparison to any of the intervention/control group articles. Experimental studies between PTASs are required to support technological advancements. Caregiver injury risk has been the focus for most of the comparison articles; however, few articles focus on the implications to the person.IMPLICATIONS FOR REHABILITATIONCeiling mounted lifts are preferred over floor-based lifts due to lower injury rates.Many robotic transfer systems have been developed; however, there is a paucity of quantitative and qualitative studies.Based on the results of this review, rehabilitation settings are recommended to use ceiling over floor assist systems, and it is recommended to provide training on using devices to assist with patient transfers to lower the risk of injuries.
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http://dx.doi.org/10.1080/17483107.2019.1673833DOI Listing
April 2021

Assessment of Usability and Task Load Demand Using a Robot-Assisted Transfer Device Compared With a Hoyer Advance for Dependent Wheelchair Transfers.

Am J Phys Med Rehabil 2019 08;98(8):729-734

From the Department of Rehabilitation Sciences and Technology, School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, Pennsylvania (MG, HK, SB, SA, TMC, GGG, AMK, RAC); and Human Engineering Research Laboratories, Veterans Affairs Pittsburgh Health Care System, and University of Pittsburgh, Pittsburgh, Pennsylvania (MG, JML, JB, HK, SB, SA, ND, TMC, GGG, AMK, RAC).

Objective: Manual lifting can be burdensome for people who care for power wheelchair users. Although technologies used for dependent transfers are helpful, they have shortcomings of their own. This study compares the usability and task load demand of a novel robot-assisted transfer device to a clinical standard when performing dependent transfers.

Design: A cross-sectional study was conducted to assess caregivers (N = 21) transferring a 56-kg mannequin with the Strong Arm and Hoyer Advance at three transfer locations. Feedback was gathered through qualitative surveys.

Results: Usability was significant in multiple areas important for transfers. Caregiver fatigue and discomfort intensity were reduced, and the Strong Arm was preferred at the three transfer locations. Device ease and efficiency favored Strong Arm at two stations as was discomfort frequency. In addition, physical demand, frustration, and effort were significantly lower using Strong Arm compared with the Hoyer Advance.

Conclusions: Compared with the Hoyer, participants favored Strong Arm for transfer usability and task load demand. However, further Strong Arm developments are needed.
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http://dx.doi.org/10.1097/PHM.0000000000001176DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6649685PMC
August 2019

Start-up propulsion biomechanics changes with fatiguing activity in persons with spinal cord injury.

J Spinal Cord Med 2020 07 18;43(4):476-484. Epub 2019 Mar 18.

Department of Veterans Affairs, Human Engineering Research Laboratories, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA.

Shoulder pathology is a common condition in wheelchair users that can considerably impact quality of life. Shoulder muscles are prone to fatigue, but it is unclear how fatigue affects start-up propulsion biomechanics. This study determines acute changes in start-up wheelchair propulsion biomechanics at the end of a fatiguing propulsion protocol. Quasi-experimental one-group pretest-postest design. Biomechanics laboratory Twenty-six wheelchair users with spinal cord injury (age: 35.5 ± 9.8 years, sex: 73% males and 73% with a paraplegia). Protocol of 15 min including maximum voluntary propulsion, right- and left turns, full stops, start-up propulsion, and rests. Maximum resultant force, maximum rate of rise of applied force, mean velocity, mean fraction of effective force, and mean contact time at the beginning and end of the protocol during start-up propulsion. There was a significant reduction in maximum resultant force (P < 0.001) and mean velocity (P < 0.001) at the end of the protocol. Also, contact time was reduced in the first stroke of start-up propulsion (P < 0.001). Finally, propelling with a shorter contact time was associated with a greater reduction in performance (maximum velocity) at the end of the protocol. There are clear changes in overground propulsion biomechanics at the end of a fatiguing propulsion protocol. While reduced forces could protect the shoulder, these reduced forces come with shorter contact times and lower velocity. Investigating changes in start-up propulsion biomechanics with fatigue could provide insight into injury risk.
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http://dx.doi.org/10.1080/10790268.2019.1582603DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7480480PMC
July 2020

Effects of grab bars and backrests on independent wheelchair transfer performance and technique.

Physiother Res Int 2019 Jan 9;24(1):e1758. Epub 2018 Nov 9.

Human Engineering Research Laboratories, Rehabilitation Research and Development Service, Department of Veterans Affairs, VA Pittsburgh HealthCare System, Pittsburgh, Pennsylvania.

Objective: For individuals who rely on wheeled mobility devices for primary mobility, the ability to transfer independently greatly enhances participation in activities within and outside of the home. Nonlevel transfers are challenging and inevitable as not all surfaces in all settings can be made level with an individual's seat to floor height. The purpose of this study was to investigate the effects of two transfer aids, grab bars, and backrests, on the performance and quality of nonlevel transfers.

Methods: This study employed a repeated-measures design with transfer setup as the independent variable. Sixty-eight (53 men and 15 women) wheeled mobility device users performed level and nonlevel transfers to a bare surface, a surface with grab bars present, a surface with grab bars, and a backrest present. For each condition, participants were asked to transfer as high and as low as they could go while still performing an independent and safe transfer. The transfer assessment instrument was used to evaluate the quality of their transfer technique.

Results: Participants were able to transfer an absolute height up to 2.5 cm (1″) higher and lower when grab bars or grab bars and a backrest were present on the surface (p < 0.042) and 2.3 cm (~1″) higher relative to their wheelchair level seat high when grab bars were present on the surface (p < .001). Transfer technique significantly improved for both uphill and downhill transfers with the presence of grab bars and a backrest as shown by the transfer assessment instrument scores (p < 0.046).

Conclusions: The presence of grab bars and a backrest on transfer surfaces may help mobility device users to achieve higher and lower absolute transfer heights and facilitate better transfer technique.
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http://dx.doi.org/10.1002/pri.1758DOI Listing
January 2019

Upper-limb biomechanical analysis of wheelchair transfer techniques in two toilet configurations.

Clin Biomech (Bristol, Avon) 2018 06 12;55:79-85. Epub 2018 Apr 12.

Human Engineering Research Laboratories, Department of Veterans Affairs, Pittsburgh, PA, USA; Department of Rehabilitation Science and Technology, University of Pittsburgh, Pittsburgh, PA, USA. Electronic address:

Background: Using proper technique is important for minimizing upper limb kinetics during wheelchair transfers. The objective of the study was to 1) evaluate the transfer techniques used during toilet transfers and 2) determine the impact of technique on upper limb joint loading for two different toilet configurations.

Methods: Twenty-six manual wheelchair users (23 men and 3 women) performed transfers in a side and front wheelchair-toilet orientation while their habitual transfer techniques were evaluated using the Transfer Assessment Instrument. A motion analysis system and force sensors were used to record biomechanical data during the transfers.

Findings: More than 20% of the participants failed to complete five transfer skills in the side setup compared to three skills in the front setup. Higher quality skills overall were associated with lower peak forces and moments in both toilet configurations (-0.68 < r < -0.40, p < 0.05). In the side setup, participants who properly placed their hands in a stable position and used proper leading handgrips had lower shoulder resultant joint forces and moments than participants who did not perform these skills correctly (p ≤ 0.04). In the front setup, positioning the wheelchair within three inches of the transfer target was associated with reduced peak trailing forces and moments across all three upper limb joints (p = 0.02).

Interpretation: Transfer skills training, making toilet seats level with the wheelchair seat, positioning the wheelchair closer to the toilet and mounting grab bars in a more ideal location for persons who do sitting pivot transfers may facilitate better quality toilet transfers.
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http://dx.doi.org/10.1016/j.clinbiomech.2018.04.008DOI Listing
June 2018

Engineering and Technology in Wheelchair Sport.

Phys Med Rehabil Clin N Am 2018 05;29(2):347-369

Disability Resources & Educational Services, University of Illinois at Urbana-Champaign, Urbana-Champaign, Illinois, 1207 S. Oak Street, Champaign, IL 61820, USA.

Technologies capable of projecting injury and performance metrics to athletes and coaches are being developed. Wheelchair athletes must be cognizant of their upper limb health; therefore, systems must be designed to promote efficient transfer of energy to the handrims and evaluated for simultaneous effects on the upper limbs. This article is brief review of resources that help wheelchair users increase physiologic response to exercise, develop ideas for adaptive workout routines, locate accessible facilities and outdoor areas, and develop wheelchair sports-specific skills.
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http://dx.doi.org/10.1016/j.pmr.2018.01.013DOI Listing
May 2018

Cross-Sectional Investigation of Acute Changes in Ultrasonographic Markers for Biceps and Supraspinatus Tendon Degeneration After Repeated Wheelchair Transfers in People With Spinal Cord Injury.

Am J Phys Med Rehabil 2016 11;95(11):818-830

From the Human Engineering Research Laboratories, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania (NSH, LAW, AMK, MLB); Department of Physical Medicine and Rehabilitation, University of Pittsburgh, Pittsburgh, Pennsylvania (LAW, MLB); and Department of Rehabilitation Science and Technology (NSH, AMK), and School of Medicine (BLH), University of Pittsburgh, Pittsburgh, Pennsylvania.

Objective: The objectives of this work were to investigate how wheelchair transfers influence acute changes in ultrasound markers for biceps and supraspinatus tendon degeneration and to determine how such changes correlate with transfer technique and demographic characteristics.

Design: Participants underwent quantitative ultrasound examinations for markers of biceps and supraspinatus tendon degeneration (tendon width, echogenicity, variance, and contrast) before and after a stressful repeated-transfers protocol. The Transfer Assessment Instrument was completed for each participant to identify transfer skills. Linear regression tested whether demographics and transfer skills correlated with ultrasound measures.

Results: Sixty-two wheelchair users with spinal cord injury were included (39 with paraplegia and 23 with tetraplegia). Biceps tendon width increased after repeated transfers (P < 0.001). Participants with greater body weight experienced greater increases in biceps width after transfers (β = 0.109, P < 0.05). Skills evaluating body position relative to the target surface and safe and stable hand and arm positions affected changes in biceps and supraspinatus width and echogenicity (P < 0.05).

Conclusions: Repeated transfers caused measurable changes in biceps tendon width in a subset of participants. Changes in biceps and supraspinatus ultrasound measures were related to body weight and performance of specific transfer skills. Further testing is needed to confirm whether the clinical meaning of the observed relationships and whether using certain transfer skills and reducing body weight can attenuate the development of tendinopathy.
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http://dx.doi.org/10.1097/PHM.0000000000000509DOI Listing
November 2016

Relationship between linear velocity and tangential push force while turning to change the direction of the manual wheelchair.

Biomed Tech (Berl) 2017 Aug;62(4):439-445

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Wheelchair propulsion is a major cause of upper limb pain and injuries for manual wheelchair users with spinal cord injuries (SCIs). Few studies have investigated wheelchair turning biomechanics on natural ground surfaces. The purpose of this study was to investigate the relationship between tangential push force and linear velocity of the wheelchair during the turning portions of propulsion. Using an instrumented handrim, velocity and push force data were recorded for 25 subjects while they propel their own wheelchairs on a concrete floor along a figure-eight-shaped course at a maximum velocity. The braking force (1.03 N) of the inside wheel while turning was the largest of all other push forces (p<0.05). Larger changes in squared velocity while turning were significantly correlated with higher propulsive and braking forces used at the pre-turning, turning, and post-turning phases (p<0.05). Subjects with less change of velocity while turning needed less braking force to maneuver themselves successfully and safely around the turns. Considering the magnitude and direction of tangential force applied to the wheel, it seems that there are higher risks of injury and instability for upper limb joints when braking the inside wheel to turn. The results provide insight into wheelchair setup and mobility skills training for wheelchair users.
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http://dx.doi.org/10.1515/bmt-2015-0173DOI Listing
August 2017

Feasibility study of using a Microsoft Kinect for virtual coaching of wheelchair transfer techniques.

Biomed Tech (Berl) 2017 May;62(3):307-313

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The purpose of this study was to test the concurrent validity and test-retest reliability of the Kinect skeleton tracking algorithm for measurement of trunk, shoulder, and elbow joint angle measurement during a wheelchair transfer task. Eight wheelchair users were recruited for this study. Joint positions were recorded simultaneously by the Kinect and Vicon motion capture systems while subjects transferred from their wheelchairs to a level bench. Shoulder, elbow, and trunk angles recorded with the Kinect system followed a similar trajectory as the angles recorded with the Vicon system with correlation coefficients that are larger than 0.71 on both sides (leading arm and trailing arm). The root mean square errors (RMSEs) ranged from 5.18 to 22.46 for the shoulder, elbow, and trunk angles. The 95% limits of agreement (LOA) for the discrepancy between the two systems exceeded the clinical significant level of 5°. For the trunk, shoulder, and elbow angles, the Kinect had very good relative reliability for the measurement of sagittal, frontal and horizontal trunk angles, as indicated by the high intraclass correlation coefficient (ICC) values (>0.90). Small standard error of the measure (SEM) values, indicating good absolute reliability, were observed for all joints except for the leading arm's shoulder joint. Relatively large minimal detectable changes (MDCs) were observed in all joint angles. The Kinect motion tracking has promising performance levels for some upper limb joints. However, more accurate measurement of the joint angles may be required. Therefore, understanding the limitations in precision and accuracy of Kinect is imperative before utilization of Kinect.
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http://dx.doi.org/10.1515/bmt-2015-0206DOI Listing
May 2017

Transfer component skill deficit rates among Veterans who use wheelchairs.

J Rehabil Res Dev 2016 ;53(2):279-94

Human Engineering Research Laboratories, Department of Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA; and Department of Rehabilitation Science and Technology, University of Pittsburgh, Pittsburgh, PA;

The purpose of this study was to quantify the deficit rates for transfer component skills in a Veteran cohort and explore the relationship between deficit rates and subject characteristics. Seventy-four men and 18 women performed up to four transfers independently from their wheelchair to a mat table while a therapist evaluated their transfer techniques using the Transfer Assessment Instrument. The highest deficit rates concerned the improper use of handgrips (63%). Other common problems included not setting the wheelchair up at the proper angle (50%) and not removing the armrest (58%). Veterans over 60 yr old and Veterans with moderate shoulder pain were more likely to set up their wheelchairs inappropriately than younger Veterans (p = 0.003) and Veterans with mild shoulder pain (p = 0.004). Women were less likely to remove their armrests than men (p = 0.03). Subjects with disabilities other than spinal cord injury were less inclined to set themselves up for a safe and easy transfer than the subjects with spinal cord injury (p ≤ 0.001). The results provide insight into the disparities present in transfer skills among Veterans and will inform the development of future transfer training programs both within and outside of the Department of Veterans Affairs.
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http://dx.doi.org/10.1682/JRRD.2015.02.0023DOI Listing
January 2018

Immediate Biomechanical Implications of Transfer Component Skills Training on Independent Wheelchair Transfers.

Arch Phys Med Rehabil 2016 10 12;97(10):1785-92. Epub 2016 Apr 12.

Human Engineering Research Laboratories, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA; Department of Rehabilitation Science and Technology, University of Pittsburgh, Pittsburgh, PA. Electronic address:

Objective: To evaluate the immediate effects of transfer training based on the Transfer Assessment Instrument (TAI) on the upper limb biomechanics during transfers.

Design: Pre-post intervention.

Setting: Biomechanics laboratory.

Participants: Full-time manual wheelchair users (N=24) performed 5 transfers to a level height bench, while their natural transfer skills were scored using the TAI, and their biomechanical data were recorded.

Intervention: Participants with 2 or more component skill deficits were invited to return to receive personalized transfer training.

Main Outcome Measures: TAI part 1 summary scores and biomechanical variables calculated at the shoulder, elbow, and wrist joints were compared before and immediately after transfer training.

Results: Sixteen of the 24 manual wheelchair users met the criteria for training, and 11 manual wheelchair users came back for the revisit. Their TAI part 1 summary scores improved from 6.31±.98 to 9.92±.25. They had significantly smaller elbow range of motion, shoulder resultant moment, and rates of rise of elbow and wrist resultant forces on their trailing side during transfers after training (P<.05). On the leading side, shoulder maximum internal rotation and elevation angles, and shoulder resultant moments and rates of rise of shoulder resultant force and moment decreased after training (P<.04).

Conclusions: The TAI-based training showed short-term beneficial biomechanical effects on wheelchair users' upper limbs, such as better shoulder positioning and lower joint loadings. If the skills are practiced longer-term, they may help protect the upper limbs from developing pain and injuries.
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http://dx.doi.org/10.1016/j.apmr.2016.03.009DOI Listing
October 2016

Dynamic Three-Dimensional Ultrasound to Evaluate Scapular Movement Among Manual Wheelchair Users and Healthy Controls.

Top Spinal Cord Inj Rehabil 2015 16;21(4):303-12. Epub 2015 Nov 16.

Human Engineering Research Laboratories, Department of Veterans Affairs, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.

Background: A large percentage of individuals with spinal cord injury (SCI) report shoulder pain that can limit independence and quality of life. The pain is likely related to the demands placed on the shoulder by transfers and propulsion. Shoulder pathology has been linked to altered scapular mechanics; however, current methods to evaluate scapular movement are invasive, require ionizing radiation, are subject to skin-based motion artifacts, or require static postures.

Objective: To investigate the feasibility of applying 3-dimensional ultrasound methods, previously used to look at scapular position in static postures, to evaluate dynamic scapular movement.

Methods: This study evaluated the feasibility of the novel application of a method combining 2-dimensional ultrasound and a motion capture system to determine 3-dimensional scapular position during dynamic arm elevation in the scapular plane with and without loading.

Results: Incremental increases in scapular rotations were noted for extracted angles of 30°, 45°, 60°, and 75° of humeral elevation. Group differences were evaluated between a group of 16 manual wheelchair users (MWUs) and a group of age- and gender-matched able-bodied controls. MWUs had greater scapular external rotation and baseline pathology on clinical exam. MWUs also had greater anterior tilting, with this difference further accentuated during loading. The relationship between demographics and scapular positioning was also investigated, revealing that increased age, pathology on clinical exam, years since injury, and body mass index were correlated with scapular rotations associated with impingement (internal rotation, downward rotation, and anterior tilting).

Conclusions: Individuals with SCI, as well as other populations who are susceptible to shoulder pathology, may benefit from the application of this imaging modality to quantitatively evaluate scapular positioning and effectively target therapeutic interventions.
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http://dx.doi.org/10.1310/sci2104-303DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4750815PMC
October 2016

Ultrasonographic Median Nerve Changes After Repeated Wheelchair Transfers in Persons With Paraplegia: Relationship With Subject Characteristics and Transfer Skills.

PM R 2016 Apr 8;8(4):305-313. Epub 2015 Aug 8.

Human Engineering Research Laboratories, VA Pittsburgh Healthcare System, 6425 Penn Avenue, Suite 400, Pittsburgh, PA 15206; Department of Physical Medicine and Rehabilitation, University of Pittsburgh, Pittsburgh, PA(§). Electronic address:

Background: Wheelchair users with spinal cord injuries are susceptible to peripheral neuropathies from overuse, yet no studies have established a relationship between median neuropathy and wheelchair transfers. A more thorough understanding of how transfers and technique contribute to pathologic conditions may guide interventions that curtail its development.

Objective: To evaluate the effects of repeated transfers on ultrasound markers for carpal tunnel syndrome (CTS) in people with spinal cord injuries and to relate changes to subject characteristics and transfer skills.

Design: Cross-sectional, repeated measures.

Setting: Research laboratory and national wheelchair sporting events.

Participants: A convenience sample of 30 wheelchair users with nonprogressive paraplegia were recruited via research registries and at the 2013 National Veterans Wheelchair Games and 2014 Paralyzed Veterans of America Buckeye Games. Participants were older than 18 years and could complete transfers independently within 30 seconds without use of their leg muscles.

Methods: Demographic questionnaires and physical examinations for CTS were completed. Quantitative ultrasound techniques were used to measure changes in the median nerve after a repeated-transfers protocol. The Transfer Assessment Instrument (TAI) was completed to quantify transfer ability.

Main Outcome Measurements: Median nerve cross-sectional area at the level of the pisiform (PCSA) and swelling ratio (SR), transfer quality, and skills via the TAI.

Results: PCSA increased after repeated transfers (P < .025). Participants who used safe hand positions had a lower baseline SR (β = -0.728; P < .01). Participants with a higher body weight had a lower baseline SR provided they performed higher quality transfers. Participants who scooted to the front of the seat prior to transferring (TAI item 7; β = 0.144; P < .05) and who weighed more (β = 0.142; P < .05) exhibited greater increases in PCSA in response to transfers.

Conclusions: An acute increase was observed in median nerve CSA at the pisiform after repeated wheelchair transfers. Changes were greater in persons with higher body weight and in persons who did not perform certain transfer skills correctly (according to the TAI). It is possible that these factors contribute to chronic injury and possibly CTS.
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http://dx.doi.org/10.1016/j.pmrj.2015.08.001DOI Listing
April 2016

Effect of a Wheelie Training Method With the Front Wheels on a Ramp in Novice Able-Bodied Participants: A Randomized Controlled Trial.

Assist Technol 2015 ;27(2):121-7

a Department of Occupational Therapy , College of Health Science, Kaohsiung Medical University , Kaohsiung City , Taiwan.

The objective of this study was to determine if wheelie training that begins with learning how to balance with the front wheels on a ramp would increase the success rate, reduce the training time, and improve retention rates. A randomized controlled trial design was used to evaluate the effectiveness of wheelie training on a ramp setting (ramp group, n = 26) and conventional training (conventional group, n = 26). The main outcome measures were success rates in achieving wheelie competence, training time, and the retention rate in 7 and 30 days respectively. The results showed that the success rate for each training group both reached 100%. The mean training times for the conventional group and the ramp group were 86.0 ± 35.7 and 76.0 ± 25.8 minutes. Training time was not significantly affected by the training method (p = 0.23), but it was affected by gender, with women requiring an average of 92.0 ± 31.4 minutes in comparison with 70.0 ± 27.5 minutes for men (p = 0.01). The skill retention rate after 7 and 30 days was 100% for both groups. Neither success rate nor training time for wheelie skill acquisition by learners were improved by learning wheelie balance on a ramp. However, a high retention rate of wheelie skills for both training groups was found, which implies that success can be achieved by training on a ramp used in this study.
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http://dx.doi.org/10.1080/10400435.2014.986773DOI Listing
October 2015

Wheeled mobility.

Biomed Res Int 2015 1;2015:138176. Epub 2015 Apr 1.

Rehabilitation Engineering Research Program, Minneapolis VA Healthcare System, Minneapolis, MN 55417, USA ; Department of Physical Medicine and Rehabilitation, Program in Rehabilitation Science, University of Minnesota, Minneapolis, MN 55455, USA.

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http://dx.doi.org/10.1155/2015/138176DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4397418PMC
February 2016

Reliability of freehand three-dimensional ultrasound to measure scapular rotations.

J Rehabil Res Dev 2014 ;51(6):985-94

Human Engineering Research Laboratories, Department of Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA; Departments of.

The objective of this study was to evaluate the reliability of using freehand three-dimensional ultrasound to measure scapular rotations (internal/external, upward/downward, anterior/posterior). The scapular position in 22 healthy, nondisabled individuals was imaged three times in four testing positions of interest (arm at rest and humeral elevation in the sagittal, frontal, and scapular planes). We found substantial reliability across scanning positions and scapular rotations, with intraclass correlation coefficients ranging from 0.62 to 0.95. The highest reliability was found in the rest testing position. Our standard error of measurement was less than 2 degrees for all measurements and less than 0.5 degrees for most. Minimum detectable change ranged from 0.37 to 3.08 degrees. Our results agree with the pattern of movement found in other studies, with the scapula moving toward a more externally rotated, upwardly rotated, and posteriorly tilted position with humeral elevation. Further study is warranted to compare our methods to a gold standard, apply them to evaluating dynamic movement, and determine whether they can be used to detect shoulder pathology.
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http://dx.doi.org/10.1682/JRRD.2014.01.0006DOI Listing
July 2015

The relationship between independent transfer skills and upper limb kinetics in wheelchair users.

Biomed Res Int 2014 5;2014:984526. Epub 2014 Aug 5.

Human Engineering Research Laboratories, VA Pittsburgh Healthcare System, University of Pittsburgh, Pittsburgh, PA 15206, USA ; Department of Rehabilitation Science and Technology, University of Pittsburgh, Pittsburgh, PA 15260, USA ; Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA 15261, USA.

Transfers are one of the most physically demanding wheelchair activities. The purpose of this study was to determine if using proper transfer skills as measured by the Transfer Assessment Instrument (TAI) is associated with reduced loading on the upper extremities. Twenty-three wheelchair users performed transfers to a level-height bench while a series of forces plates, load cells, and a motion capture system recorded the biomechanics of their natural transferring techniques. Their transfer skills were simultaneously evaluated by two study clinicians using the TAI. Logistic regression and multiple linear regression models were used to determine the relationships between TAI scores and the kinetic variables on both arms across all joints. The results showed that the TAI measured transfer skills were closely associated with the magnitude and timing of joint moments (P < .02, model R(2) values ranged from 0.27 to 0.79). Proper completion of the skills which targeted the trailing arm was associated with lower average resultant moments and rates of rise of resultant moments at the trailing shoulder and/or elbow. Some skills involving the leading side had the effect of increasing the magnitude or rate loading on the leading side. Knowledge of the kinetic outcomes associated with each skill may help users to achieve the best load-relieving effects for their upper extremities.
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http://dx.doi.org/10.1155/2014/984526DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4139077PMC
May 2015

Upper limb joint kinetics of three sitting pivot wheelchair transfer techniques in individuals with spinal cord injury.

J Spinal Cord Med 2015 Jul 17;38(4):485-97. Epub 2014 Aug 17.

Study Design: Repeated measures design.

Objective: This study compared the upper extremity (UE) joint kinetics between three transfer techniques.

Setting: Research laboratory.

Methods: Twenty individuals with spinal cord injury performed three transfer techniques from their wheelchair to a level tub bench. Two of the techniques involved a head-hips method with leading hand position close (HH-I) and far (HH-A) from the body, and the third technique with the trunk upright (TU) and hand far from body. Motion analysis equipment recorded upper body movements and force sensors recorded their hand and feet reaction forces during the transfers.

Results: Several significant differences were found between HH-A and HH-I and TU and HH-I transfers indicating that hand placement was a key factor influencing the UE joint kinetics. Peak resultant hand, elbow, and shoulder joint forces were significantly higher for the HH-A and TU techniques at the trailing arm (P < 0.036) and lower at the leading arm (P < 0.021), compared to the HH-I technique.

Conclusion: Always trailing with the same arm if using HH-A or TU could predispose that arm to overuse related pain and injuries. Technique training should focus on initial hand placement close to the body followed by the amount of trunk flexion needed to facilitate movement.
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http://dx.doi.org/10.1179/2045772314Y.0000000258DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4612204PMC
July 2015

Ultrasonographic measurement of the acromiohumeral distance in spinal cord injury: Reliability and effects of shoulder positioning.

J Spinal Cord Med 2015 Nov 26;38(6):700-8. Epub 2014 Jun 26.

Objective: To investigate the reliability of ultrasonographic measurement of acromiohumeral distance (AHD) and the effects of shoulder positioning on AHD among manual wheelchair users (MWUs) with spinal cord injury (SCI) and an able-bodied control group.

Methods: Ten MWUs with SCI and 10 able-bodied subjects participated in this study. The ultrasonographic measurements of AHD from each subject were obtained by two raters during passive and active scapular plane arm elevation in neutral, 45°, 90° with and without resistance and in a weight relief raise position. The measurements were recorded again by each rater using the same procedures after a 30-minute time interval. All raters were blinded to each other's measurements.

Setting: University Laboratories and Veteran Affairs Healthcare System.

Results: Intra-rater (intraclass correlation coefficient, ICC > 0.83) and inter-rater (ICC > 0.78) reliability was excellent for both the MWUs with SCI and able-bodied groups across all arm positions except for the 45° position in the control group for one of the raters (intra-rater: ICC < 0.40 and inter-rater: ICC < 0.60). AHD significantly reduced when the shoulder was in the 90° arm elevated positions with or without resistance.

Conclusion: Findings from our study demonstrated that ultrasonography is a reliable means to evaluate AHD in both able bodied and individuals with SCI, who are known to have significant shoulder pathology. This technique could be used to develop reference measures and to identify changes in AHD caused by interventions.
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http://dx.doi.org/10.1179/2045772314Y.0000000205DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4725804PMC
November 2015

The impact of transfer setup on the performance of independent wheelchair transfers.

Hum Factors 2013 Jun;55(3):567-80

Human Engineering Research Laboratories, VA Pittsburgh Health Care System, 6425 Penn Ave., Suite 400 (151R-B), Pittsburgh, PA 15206, USA.

Objective: The aim of this study was to determine how selected environmental factors affect transfers and to compare our results to the Americans with Disabilities Act Accessibility Guidelines (ADAAG).

Background: Few data are available to support standards development related to transfers in the built environment.

Method: Participants were 120 wheeled mobility device (WMD) users who transferred to and from a modular transfer station that consisted of a height-adjustable platform with a lateral grab bar, optional obstacle to the transfer, and an optional height-adjustable front grab bar. Maximum and minimum vertical heights of the transfer surface, maximum gap distance between the WMD and transfer surface, grab bar use, and WMD space needs were recorded.

Results: The 95th percentile lowest and highest heights attained were similar to the median WMD seat-to-floor height (56 cm).We found that 42% (47/113) could not perform a transfer with the obstacle present. Participants transferred higher when the front grab bar was added to the setup (p = .005) and higher and lower with the front grab bar than without it when the obstacle was present in the setup (p = .003 and p = .005, respectively). We found that 95% of participants performed a transfer across an 8.9-cm gap. ADAAG recommendations fall short for the height and clear-space needs of the 50th-percentile WMD users.

Conclusion: Revisions concerning transfer heights, gaps, clear spaces, and grab bar heights are necessary to make transfers more accessible to WMD users.

Application: The data will be used to revise the guidelines related to transfers and to enable designers and engineers to create an environment that is more accessible.
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http://dx.doi.org/10.1177/0018720812460549DOI Listing
June 2013
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