The SmartWheel Database, Development of Normative Standards, and SmartWheel Clinical Use

Another acheivement of the Users Group has been the creation of a database of wheelchair propulusion assessments. The creation and continued growth of this database is facilitated by:

  1. The propulsion assessment reports that are automatically generated by the SmartWheel following each session.
  2. The use of the standard protocol which makes the propulsion data readily comparable across different sites.

This database is helping to facilitate the development of normative standards which will assist in the processes of identifying individuals for whom wheelchair prescription is appropriate, justifying equipment selection (e.g., manual vs. power), and the quantification of the impact of wheelchair set-up or training on key propulsion indices of consistency and/or compliance with the clinical guidelines. The database also provides the invaluable ability to compare a client's propulsion characteristics from one clinic visit to the next. The creation of this database is presented in the following published article:

Cowan, RE, Boninger, ML, Sawatzky, BJ, Mazoyer, BD, & Cooper, RA. Preliminary Outcomes of the SmartWheel Users Group Database: A Proposed Framework for Clinicians to Objectively Evaluate Manual Wheelchair Propulsion. Archives of Physical Medicine and Rehabilitation, 2008, 89: 260-8.

The following is a brief summary. View the complete article.

The Challenge: Reimbursement Versus Meeting the Needs of the Patient

In introducing one of the challenges that motivates this work, the article:

  1. Notes the increasing demand on clinicians to tailor wheelchair prescriptions to what the Center for Medicare and Medicaid Services (CMS) will approve for reimbursement, rather than to the actual rehabilitation needs of each individual.
  2. Cites four additional articles that support this assertion.
  3. Argues that, "The gap between CMS policy and clinical guidelines, which are based on evidence-based practice, needs to be eliminated."

Objective Assessment of Manual Wheelchair Propulsion

The authors assert that:

  1. The objective assessment of manual wheelchair propulsion is a valuable tool in the effort to close the gap between what CMS will approve and what an individual needs.
  2. Objective data on users propelling across varying surfaces found in a home environment can bolster clinician opinion and help to minimize the discrepancy between best practice and third party payer policy.
  3. Efforts to standardize the objective assessment of manual wheelchair propulsion and to provide guidance on its implementation and application has been the focus of the SmartWheel Users Group (SWUG). These efforts are primary focus of this article

Key Factors in the Assessment of Wheelchair Propulsion

When evaluating propulsion, the article cites four factors as clinically most important:

  1. Velocity (Speed at which individuals are able to propel their wheelchairs.)
  2. Push Force (Amount of force exerted with each push on the handrim.)
  3. Push Frequency (Number of pushes on the handrim over a given time or distance.)
  4. Stroke Length (Average length of the push on the handrim -- distance from initial contact with the rim to removal of the hand from the rim.)

Velocity is important because wheelchair users need to be able to achieve a minimum speed threshold to safely complete activities of daily living such as crossing an intersection.

The importance of assessing force, push frequency, and stroke length is highlighted in the Clinical Practice Guidelines which recommend the minimization of force and frequency of repetitive upper limb tasks, and use of long strokes during propulsion.

Flow Chart Model for Clinical Application

The article presents a "framework to guide clinicians to intervention opportunities through evaluation of velocity in context with push frequency and force." This framework suggests the following sequence:

  1. Is the velocity at which a user is able to propel their wheelchair above the threshold to safely complete activities of daily living such as crossing an intersection? The article cites evidence in support of a minimum threshold of 1.06 meters/second.
  2. If not, clinician designs an intervention to achieve threshold velocity. Interventions may be strength training, propulsion training, alterations of chair set-up or use of an ultra-light, adjustable chair.
  3. Post-intervention testing; if target velocity is reached then goal is to try to maintain velocity while minimizing force and push frequency.
  4. The ideal is a user that propels at above threshold velocity, while at below average force or push frequency across all surfaces (e.g., tile, carpet, etc.)
  5. Users pushing with above average force or push frequency at below threshold velocity may require powered mobility options.

Importantly, the article states that, "Use of velocity to evaluate the potential of a manual wheelchair user to achieve successful community function is not diagnosis specific. Any manual wheelchair user should be able to achieve a minimal velocity for functional purposes, regardless of diagnosis." Otherwise, as noted in Step #5, power mobility may be required.

View the Decision Making Flow Chart contained in the article.

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