Wheelchair Provision
Wheelchairs and scooters are critical devices to enable mobility among many people with spinal cord injury. However, the procurement process can be relatively complex as it frequently involves collaboration among people with spinal cord injury, their caregivers, device prescribers, and vendors (Mortenson & Miller 2008). The World Health Organization identified eight critical steps for wheelchair provision, which includes: 1) referral and appointment, 2) assessment, 3) prescription, 4) funding and ordering, 5) product preparation, 6) fitting/ adjusting, 7) user training, 8) follow-up, maintenance and repairs. For a wheeled mobility device to be fully integrated into the lives of potential users requires careful consideration of the user (i.e., their capabilities,), the activities that they want to perform (e.g., tasks, social participation), the characteristics of potential devices (e.g., dimensions, power options) and the environment in which the device will be used (Mortenson & Miller 2008). Funding is also an extremely important consideration given the cost of these devices (Mortenson & Miller 2008).
Discussion
Drawing on wheelchair related intervention data from 1,326 patients enrolled in the SCIRehab project, Taylor et al. (2015), found 98% of patients had a wheelchair fitting evaluation, the majority (62%) received their wheelchair prior to discharge and satisfaction with fit and function was >86% (Taylor et al. 2015). Groah et al. (2014) sought to identify insurance provider-related differences in the receipt of programmable power wheelchairs or customizable, lightweight manual wheelchairs among 359 individuals from six Spinal Cord Injury Model System centers.
They found funding was associated with receipt of lightweight customizable manual wheelchair, but not power and there were significant differences in terms of level of injury and type of funding.
Drawing on data from 27 patients at the National Rehabilitation Center in Ankara, Turkey, Ekiz et al. (2014) found the majority had incorrect wheelchair seat height (66.7%) and inappropriate cushions (59.2%). However, the study did not provide details about how appropriateness was determined/operationalized; therefore, it is difficult to interpret the study findings or reproduce this work.
When comparing 1,363 veterans with MS and 791 veterans with SCI who had received wheeled mobility, Ambrosio et al. (2007) found that those with SCI received wheelchairs (manual and power) more frequently than those with multiple sclerosis (who received scooters more frequently). However, the authors did not attempt to control for differences in age or race (which varied between the groups) or other variables such as function
DiMarco et al. (2003) evaluated their clinical wheelchair provision practice in their SCI clinic, finding many inconsistencies. To address these issues, they developed and implemented a standard wheelchair service delivery process. Based on data from 128 patients who attended their wheelchair SCI clinic, Di Marco et al. (2003) found that that return for follow up was high (79% at 12 months) which they attributed to their change in process. The article describes in detail the process they used to develop their service delivery process but statistical data are limited.
Kennedy et al. (2003) performed a retrospective chart analysis of patients who received, 1) a specialized seating assessment prior to their first needs assessment (a nine-category assessment of skin management, activities of daily living, bladder management, bowel management, community preparation, wheelchair and equipment, psychological issues and discharge coordination), 2) a specialized seating assessment after their first needs assessment, or 3) did not receive a specialized needs assessments. They found patients who received a specialized seating assessment prior to their first needs assessment had lower skin management needs compared to those who received none. Without randomization, however, the causal nature of these claims cannot be verified.
Samuelsson et al. (2001) explored the outcomes of a client-centered wheelchair intervention among 38 patients attending a wheelchair clinic. They found that the intervention was associated with a significant decrease in pain and that initial problems were addressed positively for the majority of patients (Samuelsson et al. 2001). Given the study design, there are a variety of threats to validity (e.g., maturation, attention bias); therefore, causality cannot be assumed as other factors may have caused these changes over time.
Conclusion
There is level 5 evidence (from three observational studies: Di Marco et al. 2003; Taylor et al. 2015; Ekiz et al. 2014) to suggest that there are differences in the wheelchair provision process between service providers
There is level 5 evidence (from two observational studies: Groah et al. 2014; Ambrosio et al. 2007) to suggest that diagnosis and funding is associated with the type of wheeled mobility received.
There is level 5 evidence (from one observational study: Di Marco et al. 2003) that suggests there is a benefit to following a standard process for wheelchair provision.
There is level 4 evidence (from one case series study: Kennedy et al. 2003; one pre-post study: Samuelsson et al. 2001; and one observational study: Taylor et al. 2015) to suggest that people who receive a specialized seating assessment and client-centered interventions may experience better outcomes.
