VA Center of Excellence for Wheelchairs and Related Technology (WART)
Projects:
Ability to Propel a Manual Wheelchair and Length of Use in Multiple Sclerosis
Mobility Device Use, Strength, Fatigue, and Quality of Life in Persons with MS
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Ability to Propel a Manual Wheelchair and Length of Use in Multiple Sclerosis
Principal Investigator/s: Michael L. Boninger, MD
Co-Investigator/s: Rory Cooper, PhD, Fabrisia Ambrosio, MPT, MS
The long-term goals of this research are to develop guidelines for the prescription of mobility devices in people with Multiple Sclerosis (MS). Due to the degenerative nature of MS, patients often rely on some type of assistive device to improve mobility. The decision between manual and power wheelchair prescription is critical considering the fatigue and weakness that commonly accompany this disease. This decision is especially difficult in a population such as MS, where disease presentation varies greatly between individuals. Phase I of this study focused on kinetic and kinematic variables to describe the biomechanics of wheelchair propulsion in people with MS compared to control counterparts. In addition social involvement and quality of life was examined. Inclusion criteria for participation in this study included: MS as diagnosed by a neurologist, the use of a manual wheelchair as the primary means of mobility, and the absence of upper extremity injury or cardiovascular problems that would limit the ability to propel a manual wheelchair. Results from phase I research demonstrate significant kinetic and kinematic differences in wheelchair propulsion between the MS and the SCI and ND groups. Individuals with MS demonstrated ineffective propulsion moments paired with an inability to propel at walking speed. Furthermore, clinical techniques are not sensitive enough to detect the inability to functionally propel a wheelchair in individuals with MS. Longitudinally, individuals with MS did not alter their social participation.
Principal Investigator/s: Shirley G. Fitzgerald, PhD
Co-Investigator/s: Laura J. Cohen PT, ATP; Michael Boninger MD; Rosemarie Cooper MPT; Annmarie Kelleher OTR/L
The Script Concordance Test: A Tool to Assess Clinical Expertise in Seating
and Wheeled Mobility Prescription
The primary purpose of this research project is to develop and provide
validity evidence for the Seating and Mobility Script Concordance Test (SMSCT).
The (SMSCT) is an assessment tool grounded in the hypothetico-deductive and
the schema theories of clinical reasoning.
Background: Currently, there is no method of evaluating and discriminating the clinical knowledge and expertise of clinicians involved in the evaluation and prescription of wheelchairs and their seating systems. Because of this lack of an evaluation tool, there is no way to assess the impact of educational experiences or clinical practice on the ability to make clinical decisions when prescribing wheelchairs. The SMSCT is designed to probe whether the organization of clinical knowledge (i.e., whether the nature of links between items of knowledge) allows appropriate clinical decisions. The test intends to assess the meaningfulness of the links among items, rather than assessing items in isolation. The scoring system of the test is designed to measure the distance, or the gap, that exists between examinees’ scripts and scripts of a panel of experts.
Initial SMSCT test items were developed by two expert clinicians who
described problematic clinical situations, findings and interventions
representative of the field of adult seating and mobility specific to
individuals with spinal cord injury. Draft SMSCT test items were reviewed by
3 expert clinicians for content to determine if they reflect real
diagnostic, treatment and intervention situations, and to determine if
clinicians typically pose these types of questions to themselves during
practice. Once test development was complete, additional validity evidence
was completed: testing the concurrent validity of the SMSCT to determine if
the measure is capable of discriminating between individuals with differing
levels of expertise, in a subspecialty of seating and wheeled mobility:
spinal cord injury, and two determine if the SMSCT is sensitive enough to
assess the effectiveness of a short-term (one day) continuing education
training
intervention. Results from the studies have been submitted for publication.
The references are shown below. Results indicated that the SMSCT was found
to differentiate between seating and mobility experts and orthopedic
experts’ intervention subtest scores (t= -2.2, p= 0.04). The proxy measure
of clinical expertise, seating and mobility hours/week was found to predict
SMSCT intervention scores (F= 10.62, p= 0.002). The internal structure of
the SMSCT may include evidence of reduced item performance but satisfactory
convergent and discriminate evidence by construct definition. Further SMSCT
development, revision, pilot testing and validation are planned.
Cohen LJ, Fitzgerald SG, Lane S, Boninger ML Development Of The Seating And Mobility Script Concordance Test (Smsct) For Spinal Cord Injury: Obtaining Content Validity Evidence, Submitted to Assistive Technology, December, 2003.
Cohen LJ, Fitzgerald SG, Lane S, Boninger ML, Minkel J, McCue M. Validation of the Seating and Mobility Script Concordance Test (SMSCT), Submitted to Archives of Physical Medicine and Rehabilitation, February, 2004.
Mobility Device Use, Strength, Fatigue, and Quality of Life in Persons with
MS Principal
Investigator/s: Michael Boninger, MD Co-Investigator/s: Shirley Fitzgerald, PhD, Fabrisia Ambrosio, MS, MPT Multiple sclerosis (MS) is the most common cause of disability, other than
accidents, in young adults. Although MS causes a wide variety of problems,
difficulty moving and walking is the most common form of disability. As a
result, the majority of the people with MS will need some type of mobility
device such as a wheelchair or scooter within 15 years of the onset of the
disease. Decrease mobility also reduces quality of life. Studies looking at
walking and wheelchair use tell us that many people with MS continue to
walk, beyond the point that it is considered safe. Part of the resistance to
wheelchair use comes from a fear that using a wheelchair means more
dependence and may lead to more weakness. “Use it or lose it” is a common
thought shared by both doctors and patients. Unfortunately, individuals who
continue to walk when unsafe are at risk for falls and resulting injuries.
In addition, with reduced ability to walk there may be increased social
isolation, as fear of falling and decreased ability to walk leads to
avoidance of activities like eating out, shopping, and going to religious
services. Despite these problems, there have been few studies specifically
looking at when is the best time to switch to a wheelchair or scooter.
Doctors and patients have no information on what effects wheelchair or
scooter use may have on strength or participation in outside activities. In this study, we will measure strength, fatigue and quality of life as
individuals with MS transition from walking to using a wheelchair or
scooter. Subjects will be tested before they receive their wheelchair, when
they receive their wheelchair, and after they have been using their new
wheelchair. We believe subjects who receive a wheelchair will become weaker
in their legs and that their muscles will tire more easily. We also believe
however, that subjects who receive a wheelchair will have improvement in
their quality of life, will go out and engage in more activities and will
report less fatigue. This study will allow us to test these beliefs. By
completing this study we will gain a better understanding about what happens
to a person as they begin to rely on a mobility device. This information
will be useful to both patients and their doctors and therapist when making
a decision about when is the best time to consider using a wheelchair.
Principal Investigator/s: Michael Boninger, MD
Co-Investigator/s: Fabrisia Ambrosia, MS, MPT, Shirley Fitzgerald, PhD, Annmarie Kelleher, OTR/L, Rachel Cowan, MS
Phase II of this project involves 2 sites, Pittsburgh and Denver, and continues to examine the effect of primary means of mobility on quality of life measures. Furthermore, we are investigating alterations in muscular strength and fatigue in individuals with MS as they transition primary means of mobility. Inclusion criteria for participation in this study included: MS as diagnosed by a neurologist, currently ambulate or use a manual wheelchair as their primary means of mobility, have been referred to an assistive technology clinic for a wheelchair (power or manual) or scooter, and are between the ages of 18 to 65. Currently 3 individuals have completed the initial visit, with an additional individual scheduled. Research questions include: Do people will MS experience a decreased generalized fatigue as they transition to a powered means of mobility? How does the rate of strength decline after a change in mobility compare to the rate of strength decline prior to intervention? Do individuals experience an increase in social participation, and consequent increased quality of life, after a change to a more appropriate means of mobility?