Impact of a Wheelchair Education Protocol Based on Practice Guidelines for Preservation of Upper-Limb Function: A Randomized Trial Laura A. Rice, PhD,

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Impact of a Wheelchair Education Protocol Based on Practice Guidelines for Preservation of Upper-Limb Function: A Randomized Trial Laura A. Rice, PhD, MPT, ATP, Ian Smith, MS, Annmaire R. Kelleher, MS, OTR/L, ATP, CCRC, Karen Greenwald, RN, BSN, Michael L. Boninger, MD Archives of Physical Medicine and Rehabilitation Volume 95, Issue 1, Pages 10-19.e11 (January 2014) DOI: 10.1016/j.apmr.2013.06.028 Copyright © 2014 American Congress of Rehabilitation Medicine Terms and Conditions

Fig 1 Assessment of axle position. Archives of Physical Medicine and Rehabilitation 2014 95, 10-19.e11DOI: (10.1016/j.apmr.2013.06.028) Copyright © 2014 American Congress of Rehabilitation Medicine Terms and Conditions

Fig 2 Randomized controlled trial flowchart. *Only independent MWC users were included in the analysis for this article. †The specific number of participants analyzed varied depending on the variable analyzed. Abbreviation: PWC, power wheelchair. Archives of Physical Medicine and Rehabilitation 2014 95, 10-19.e11DOI: (10.1016/j.apmr.2013.06.028) Copyright © 2014 American Congress of Rehabilitation Medicine Terms and Conditions

Fig 3 Propulsion biomechanics. *P<.05. †P<.10. Archives of Physical Medicine and Rehabilitation 2014 95, 10-19.e11DOI: (10.1016/j.apmr.2013.06.028) Copyright © 2014 American Congress of Rehabilitation Medicine Terms and Conditions

Fig 4 Quality-of-life measurements. Abbreviations: 1Y, 1-year postdischarge study visit; 6M, 6-month postdischarge study visit; CHART, Craig Handicap Assessment and Reporting Technique; SWLS, Satisfaction With Life Scale. *P<.10. Archives of Physical Medicine and Rehabilitation 2014 95, 10-19.e11DOI: (10.1016/j.apmr.2013.06.028) Copyright © 2014 American Congress of Rehabilitation Medicine Terms and Conditions

Fig 1 Anterior lean pressure relief. Archives of Physical Medicine and Rehabilitation 2014 95, 10-19.e11DOI: (10.1016/j.apmr.2013.06.028) Copyright © 2014 American Congress of Rehabilitation Medicine Terms and Conditions

Fig 2 Lateral lean pressure relief. Archives of Physical Medicine and Rehabilitation 2014 95, 10-19.e11DOI: (10.1016/j.apmr.2013.06.028) Copyright © 2014 American Congress of Rehabilitation Medicine Terms and Conditions

Fig 3 (A) The recommended, semicircular propulsion pattern. This pattern shows a long, smooth stroke. (B) An example of a poor propulsion pattern. Notice how short the stroke is. The patient is using significantly less of the pushrim than in figure 3A. Reprinted with permission from the Paralyzed Veterans of America (PVA) Consortium for Spinal Cord Medicine Clinical Practice Guidelines “Preservation of Upper Limb Function Following Spinal Cord Injury: A Clinical Practice Guideline for Health-Care Professionals” Washington, DC: © 2005 Paralyzed Veterans of America. Archives of Physical Medicine and Rehabilitation 2014 95, 10-19.e11DOI: (10.1016/j.apmr.2013.06.028) Copyright © 2014 American Congress of Rehabilitation Medicine Terms and Conditions

Fig 4 Difference in elbow flexion angle (Q). (A) Angle is too small. (B) Correct angle (100°–120°). (C) Angle is too large. Reprinted with permission from the Paralyzed Veterans of America (PVA) Consortium for Spinal Cord Medicine Clinical Practice Guidelines “Preservation of Upper Limb Function Following Spinal Cord Injury: A Clinical Practice Guideline for Health-Care Professionals” Washington, DC: © 2005 Paralyzed Veterans of America. Archives of Physical Medicine and Rehabilitation 2014 95, 10-19.e11DOI: (10.1016/j.apmr.2013.06.028) Copyright © 2014 American Congress of Rehabilitation Medicine Terms and Conditions

Fig 5 (A) Provision of posterior pelvic support can prevent a kyphotic position of the trunk and anterior stability. (B) A fixed kyphotic posture can be accommodated through seat tilt and a contoured backrest. Reprinted with permission from the Paralyzed Veterans of America (PVA) Consortium for Spinal Cord Medicine Clinical Practice Guidelines “Preservation of Upper Limb Function Following Spinal Cord Injury: A Clinical Practice Guideline for Health-Care Professionals” Washington, DC: © 2005 Paralyzed Veterans of America. Archives of Physical Medicine and Rehabilitation 2014 95, 10-19.e11DOI: (10.1016/j.apmr.2013.06.028) Copyright © 2014 American Congress of Rehabilitation Medicine Terms and Conditions

Fig 6 Excercise program checklist. Archives of Physical Medicine and Rehabilitation 2014 95, 10-19.e11DOI: (10.1016/j.apmr.2013.06.028) Copyright © 2014 American Congress of Rehabilitation Medicine Terms and Conditions

Fig 1 Leaning forward in the chair. Archives of Physical Medicine and Rehabilitation 2014 95, 10-19.e11DOI: (10.1016/j.apmr.2013.06.028) Copyright © 2014 American Congress of Rehabilitation Medicine Terms and Conditions

Fig 2 Lean to one side and then the other. Archives of Physical Medicine and Rehabilitation 2014 95, 10-19.e11DOI: (10.1016/j.apmr.2013.06.028) Copyright © 2014 American Congress of Rehabilitation Medicine Terms and Conditions

Fig 3 Pushing your wheelchair. Archives of Physical Medicine and Rehabilitation 2014 95, 10-19.e11DOI: (10.1016/j.apmr.2013.06.028) Copyright © 2014 American Congress of Rehabilitation Medicine Terms and Conditions

Fig 4 (A) The wheelchair propulsion path of a person who pushes the wheel with a long, smooth stroke. The path starts when the person reaches as far back on the wheel as he or she comfortably can, and pushes forward with a long, smooth stroke. The path also shows the person letting the hand relax between strokes and then reaching as far back as possible on the wheel to start the next stroke. Notice how the person is using a lot of the wheel surface. This is the most efficient way to push the chair. (B) The path of a person using short, choppy strokes. Notice how he or she is not using much of the wheel surface at all. This is a bad way to push a wheelchair. Reprinted with permission from the Paralyzed Veterans of America (PVA) Consortium for Spinal Cord Medicine Clinical Practice Guidelines “Preservation of Upper Limb Function Following Spinal Cord Injury: A Clinical Practice Guideline for Health-Care Professionals” Washington, DC: © 2005 Paralyzed Veterans of America. Archives of Physical Medicine and Rehabilitation 2014 95, 10-19.e11DOI: (10.1016/j.apmr.2013.06.028) Copyright © 2014 American Congress of Rehabilitation Medicine Terms and Conditions

Fig 4 (A) The wheelchair propulsion path of a person who pushes the wheel with a long, smooth stroke. The path starts when the person reaches as far back on the wheel as he or she comfortably can, and pushes forward with a long, smooth stroke. The path also shows the person letting the hand relax between strokes and then reaching as far back as possible on the wheel to start the next stroke. Notice how the person is using a lot of the wheel surface. This is the most efficient way to push the chair. (B) The path of a person using short, choppy strokes. Notice how he or she is not using much of the wheel surface at all. This is a bad way to push a wheelchair. Reprinted with permission from the Paralyzed Veterans of America (PVA) Consortium for Spinal Cord Medicine Clinical Practice Guidelines “Preservation of Upper Limb Function Following Spinal Cord Injury: A Clinical Practice Guideline for Health-Care Professionals” Washington, DC: © 2005 Paralyzed Veterans of America. Archives of Physical Medicine and Rehabilitation 2014 95, 10-19.e11DOI: (10.1016/j.apmr.2013.06.028) Copyright © 2014 American Congress of Rehabilitation Medicine Terms and Conditions

Fig 5 Difference in elbow flexion angle (Q). (A) Angle is too small. (B) Correct angle (100°–120°). (C) Angle is too large. Reprinted with permission from the Paralyzed Veterans of America (PVA) Consortium for Spinal Cord Medicine Clinical Practice Guidelines “Preservation of Upper Limb Function Following Spinal Cord Injury: A Clinical Practice Guideline for Health-Care Professionals” Washington, DC: © 2005 Paralyzed Veterans of America. Archives of Physical Medicine and Rehabilitation 2014 95, 10-19.e11DOI: (10.1016/j.apmr.2013.06.028) Copyright © 2014 American Congress of Rehabilitation Medicine Terms and Conditions

Fig 6 (A) Provision of posterior pelvic support can prevent a kyphotic position of the trunk and anterior stability. (B) A fixed kyphotic posture can be accommodated through seat tilt and a contoured backrest. Reprinted with permission from the Paralyzed Veterans of America (PVA) Consortium for Spinal Cord Medicine Clinical Practice Guidelines “Preservation of Upper Limb Function Following Spinal Cord Injury: A Clinical Practice Guideline for Health-Care Professionals” Washington, DC: © 2005 Paralyzed Veterans of America. Archives of Physical Medicine and Rehabilitation 2014 95, 10-19.e11DOI: (10.1016/j.apmr.2013.06.028) Copyright © 2014 American Congress of Rehabilitation Medicine Terms and Conditions

Fig 7 Recommended sleeping positions. Reprinted with permission from the Paralyzed Veterans of America (PVA) Consortium for Spinal Cord Medicine Clinical Practice Guidelines “Preservation of Upper Limb Function Following Spinal Cord Injury: A Clinical Practice Guideline for Health-Care Professionals” Washington, DC: © 2005 Paralyzed Veterans of America. Archives of Physical Medicine and Rehabilitation 2014 95, 10-19.e11DOI: (10.1016/j.apmr.2013.06.028) Copyright © 2014 American Congress of Rehabilitation Medicine Terms and Conditions