A plethora of data has been collected documenting the need for assistive technology. There is little information however about the efficacy, distribution, and impact of assistive technology. Three related studies investigating demographic, cost, and health related quality of life (HRQoL) factors of the provision of wheelchairs and scooters were completed. The first investigated demographic and clinical differences. The second investigated differences in wheelchair costs among Veteran Integrated Service Networks (VISNS) and vendors. The third investigated the relationship between wheelchairs provided by the Veterans Health Administration (VHA) and HRQoL. Using a cross-sectional, retrospective study design, three years of data from VHA National Prosthetic Patient and National Patient Care yielding 191,324 observations. Databases, and one year of data from the SF-36V of the Veterans Health Study were merged. Descriptive statistics, t-test, chi-square, ANCOVA, ANOVA, and logistic regression were used to analyze the data. The first study found more evidence for differences between Hispanics and Caucasians than between African Americans and Caucasians. When comparing manual wheelchairs, Hispanics (Odds Ratio=1.7), African Americans (Odds Ratio =1.1), and American Indians & Asians (Odds Ratio =1.6) were more likely than Caucasians to receive depot wheelchairs, and Hispanics were more likely than Caucasians to receive ultralight chairs (Odds Ratio=1.8). When comparing power wheelchairs Hispanics (Odds Ratio=1.6) were more likely than Caucasians to receive custom power chairs. Older veterans were more likely to receive standard depot wheelchairs (p=<.0001) and younger veterans ultralight wheelchairs (p=<.0001). The most frequently prescribed wheelchairs for all diagnoses were the standard manual wheelchair (51%), the lightweight manual wheelchair (15%), and the scooter (14%). The second study found variation in cost by VISN and by vendor. During FY00 and FY01, of the $109 million spent by the VHA to provide over 131,000 wheelchairs and scooters, 7%, or $7,747,405 was considered excessive cost. The third study found veterans who received adjustable, ultralight manual wheelchairs had significantly lower physical function scores, as measured by the SF-36V, and significantly higher mental function, general health, and mental component summary scores than veterans who received nonadjustable, standard manual chairs, when adjusting for clinical and demographic factors.

Children with disabilities often cannot be seated in standard child seats or automobile seats because of physical deformities or poor trunk and head control. Therefore, when children with disabilities are transported to schools and developmental facilities, they often remain seated in their wheelchairs in vehicles such as school buses and family vans. Children who must travel seated in their wheelchairs are excluded from the protections dictated by the federal and state laws related to child protection in motor vehicle crashes. This dissertation investigated the safety of children in wheelchairs in transit, mainly using computer simulation software. Three pediatric manual wheelchairs were tested with a Hybrid III 6-year-old ATD in accordance with the ANSI/RESNA WC-19 standard. Using sled test data, a computer model representing a Zippie wheelchair seated with a Hybrid III 6-year-old ATD subjected to a 20g/48kph frontal crash was developed and validated in MADYMO. The injury risks of 6-year-old wheelchair occupants in a frontal impact motor vehicle crash was investigated by analyzing sled test data and by using the pediatric wheelchair computer model. The loads imposed on the wheelchair and occupant restraint system under 20g/48kph frontal impact conditions with varying wheelchair setup conditions was also investigated using the computer model. The study results showed that a 6-year-old wheelchair seated occupant may be subjected to a risk of neck and chest injuries in a frontal impact motor vehicle crash. Results also showed that altering wheelchair settings does have impact on kinematics and injury risk of a 6-year-old wheelchair occupant in a frontal motor vehicle crash. Changing wheelchair settings also had impact on wheelchair kinematics and loads imposed on the wheelchair and occupant restraint system. The study results presented in this dissertation will provide guidelines for manufacturers designing pediatric transit wheelchairs, seating, and occupant restraint system. The pediatric wheelchair model developed in this study will provide a foundation for studying the response of a manual pediatric wheelchair and a child occupant in crashes. Moreover, the model will promote the study of associated injury risks for pediatric wheelchair users in motor vehicle crashes.

Pressure damage in intact skin is difficult to detect, particularly in individuals with dark skin, because color changes and tissue blanching are masked by the skins pigmentation. Tissue reflectance spectroscopy (TRS) may be able to detect the blanch response regardless of skin color by measuring the change in total hemoglobin (delta tHb) that occurs when pressure is applied to the skin. The objective of this dissertation was to examine the ability of TRS to detect the blanch response at sites at risk for pressure ulcer development in individuals with various levels of skin pigmentation. Three studies were conducted to address this objective. In Study 1, delta tHb was assessed at the heel and sacrum of light and dark-skinned healthy participants using a portable TRS system. Study 1 showed that a significant decrease (p less than 0.001) in tHb could be measured in both light and dark skinned-participants with good intra-rater reliability (ICC greater than or equal to 0.80) at the heel, but not at the sacrum. Study 2 was conducted to identify a reliable method of skin color description for use in subsequent studies of the spectroscopic blanch response. Two examiners (B and C) performed three skin color assessments at the volar forearm of ten healthy participants using Munsell color tile matching and colorimetry. Intra and inter-rater reliability was excellent for colorimetry (ICCs typically greater than or equal to 0.90). Reliability for Munsell color tile matching was highest for Munsell value within Examiner B (93% agreement, kappa 0.871.00), which was determined to be sufficiently high for use in subsequent studies. In Study 3, delta tHb was assessed at the heels of light, moderate, and dark-skinned elderly nursing home residents at risk for pressure ulcers. As in the pilot study, a significant decrease in tHb was observed in all skin color groups (p less than 0.05). Intra-rater reliability for delta tHb was moderate or greater (ICC greater than or equal to 0.61). In combination, the results of Study 1 and Study 3 demonstrated that a significant spectroscopic blanch response could be detected with moderate or greater intra-rater reliability at the heel regardless of age or pressure ulcer risk status.

This cross sectional descriptive study sought to identify perceived barriers to follow-up care for adult asthmatics who are followed in two community health care facilities. A second purpose of the study was to determine the effect of any barriers to Health Related Quality of Life (HRQL) and compliance in the sample. Thirty-four adults who receive follow-up care for asthma at either Bloomfield-Garfield (BG) or Latterman Family Health Care Center (LFHC) completed a demographic and health status survey, the MiniAQLQ and the EWash Access to Health Care Survey. Long waiting time in providers office, someone had to miss work, cost of care too much, and long wait for an appointment were the most prevalent perceived barriers in the sample. Lack of transportation was significantly associated with study participants who receive health care at LFHC or who stated the emergency room as their usual place of care. Someone had to miss work was significantly correlated with the following variables: employment, a higher annual household income, 1-2 daily medications for asthma, no overnight hospitalizations for asthma and no psychological co-morbidities. A higher reported quality of life was significantly correlated with study participants whose medical care needs were met and found access to local health care services. The only perceived barrier that was significantly correlated with compliance was study participants who sometimes had to reschedule an appointment with a health care provider due to lack of transportation. The present study suggests that strategies designed to decrease the perceived barriers of lack of transportation, a patient or family member missing work, long wait for an appointment, and inconvenient office hours may improve follow-up care in this population. Such strategies would operate primarily (or even exclusively) through improving access and thus fostering asthma care in the community where it can be effectively managed. A program that limits barriers might improve compliance with the treatment regime, thus decreasing costs, absenteeism, and lack of continuity.

Purpose: The purpose of this study was to establish reliability and validity of a clinically useful gait classification system for older adults using gait and physical performance measures in 2 different populations. Methods: We classified gait patterns using structured clinical observation and expected the gait patterns to be defined by variability of movement (consistent, inconsistent) and postural biomechanical factors (usual, flexed, extended, crouched) observed in walking. Male veterans (n=106) referred to the VA GEM Program (mean age, 76; SD, 7.1; range, 63-97 years) were videotaped for analyses. The inter- and intra-rater reliability was determined. Pair-wise comparisons across various groups were performed to validate the gait classification using gait parameters (gait speed, step length, width and variability), lower extremity range of motion and muscle strength, physical function in ADL (Physical Performance Test, PPT) and gait abnormalities (GARS-M). The validity of the gait classification system was further validated in a different population consisting of 34 community-dwelling older adults (mean age, 84; SD, 5.0; range, 70-91 years). Results: Kappas for interrater reliability of the variability and postural components of the gait classification system were 0.59 and 0.75, respectively; for intrarater reliability, 0.82 and 0.72, respectively. Consistent and inconsistent groups were different in gait speed (0.66 and 0.49m/s, respectively; p=0.003), step length (0.46 and 0.38m; p=0.008), step length variability (7.47% and 12.74%; p=0.043), the PPT (15.80 and 11.73; p<0.001) and GARS-M (5.83 and 10.66; p<0.001). Within both consistent and inconsistent groups, three postural pattern groups (usual, flexed, crouched) differed in gait speed, step length, PPT and GARS-M (p<0.05). When validated in a different population, the mean difference of gait speed across groups was greater than the reported meaningful change. Conclusions: Gait patterns of older adults, based on biomechanics and movement control, were reliably recognized and validated by mean differences in abnormal characteristics of gait and physical performance measures across patterns. The variability and postures determined by observation of gait by the therapists can be used to quickly identify and classify older adults with mobility problems in clinical settings, allowing for possible targeted interventions for specific gait deficits.

Background: Plantar fasciitis is an overuse injury causing inflammation at the origin of the plantar fascia and is characterized by plantar heel pain that is provoked by taking the first few steps in the morning and by prolonged standing. Dorsiflexion night splints are used to address early morning pain by preventing contracture of the plantar fascia and Achilles tendon overnight. Medial arch supports, on the other hand, address the end of the day pain by preventing overstretch of the plantar fascia during prolonged weight bearing. Therefore, both night splints and arch supports may be necessary to treat plantar fasciitis as they complement each other by both controlling nocturnal contracture of the plantar fascia and Achilles tendon and reducing stresses imposed on the plantar fascia during the day, respectively. Hypotheses: We hypothesized that the night splint and arch support together would be more effective in the treatment of plantar fasciitis than a night splint or arch support alone in terms of increasing the range of pain-free passive ankle dorsiflexion, relieving heel tenderness and pain, and reducing disability imposed by the heel pain/plantar fasciitis. A secondary hypothesis of this study was that those with less passive dorsiflexion of the ankle would benefit from a night splint more than those with greater passive dorsiflexion of the ankle and those with a lower medial longitudinal arch would benefit from an arch support more than those with a higher medial longitudinal arch in terms of the previously mentioned outcome measures. Methodology: Subjects of this study were randomly assigned to one of three treatment groups. Group I was treated with night splints, group II with arch supports, and group III with a combination of night splints and arch supports. Range of motion was measured with a goniometer; heel tenderness was measured with a pressure algometer; and pain and disability were measured by the Foot Function Index before and after six weeks of treatment. Results: Ninety patients with plantar fasciitis (23 men and 67 women) were enrolled in the study, 30 in each group. Demographic, compliance and baseline evaluation data showed no significant differences between the groups. Analysis of the post-intervention evaluation data demonstrated significant differences between group I and III and group II and III, but not between group I and II, for all outcome measures. The range of pain-free passive ankle joint dorsiflexion and medial longitudinal arch height were not useful predictors of the success of treatment with a night splint and arch support for all outcome measures. Discussion: Using night splints and arch supports together may speed time to recovery by accelerating the healing process. Limitations of the study include observers bias, subjects bias, and short follow-up period. Conclusion: It was concluded that a night splint and arch support together may be more effective in the treatment of plantar fasciitis than either a night splint or arch support alone. Patients with plantar fasciitis who have less passive dorsiflexion of the ankle joint do not benefit from a night splint more than those with greater passive dorsiflexion of the ankle joint. Patients with plantar fasciitis who have a lower medial longitudinal arch do not benefit from an arch support more than those with a higher medial longitudinal arch.

Participation in whitewater kayaking is growing faster than any other outdoor recreational pursuit. With increases in participation, an increase in the number of injuries associated with whitewater kayaking may also become apparent. Overuse injuries are the most prevalent type of injury found in whitewater kayakers. Due the large range of motion and forces that occur through the shoulder while kayaking, the most common injury location is the shoulder. Little scientific inquiry has been performed assessing the kinematics of kayaking and the musculoskeletal attributes of these athletes. Sixteen whitewater kayakers with shoulder pain and sixteen whitewater kayakers without shoulder pain participated in this study. Each subject underwent kinematic and electromyographic analysis of the forward kayak stroke. Additionally, participants underwent clinical examination of shoulder injury, clinical assessment of shoulder and torso range of motion, posterior shoulder tightness assessment, isokinetic strength testing at the shoulder, and a scapular kinematic evaluation during a standardized humeral elevation task. The most common type of injury found was related to overuse. Statistical comparisons occurred between the involved and uninvolved limb in the shoulder pain group and between the involved and uninvolved and matching shoulders in the control group, respectively. Significant differences were found between in involved and uninvolved shoulder for shoulder internal rotation and abduction range of motion. Additional differences were found for these variables between the involved shoulder in the pain group and the matching shoulder in the control group. Kayakers with shoulder pain present with decreased shoulder range of motion on their involved shoulder. Assessment of the specific types of injuries seen in whitewater kayakers should be further evaluated. Additionally, the role of increasing range of motion through injury prevention programs in whitewater kayakers with shoulder pain should be investigated.

Low back pain is a prevalent problem afflicting approximately 80% of the population during their lives. Subjects with back pain demonstrate deficits in trunk proprioception. Spinal manipulation is a treatment with known effects in pain control, increased motion and other neurophysiological effects. The purpose of this study was to examine the treatment effects of spinal manipulation on trunk proprioception in subjects with chronic low back pain (CLBP) and to determine if those effects lasted one week. Thirty-three subjects with CLBP, aged 24-54 years participated in this unbalanced, randomized controlled crossover design. Subjects presented for two or three testing sessions and agreed to a general physical examination followed by proprioception testing with joint position sense (JPS), threshold to detect passive motion (TTDPM), direction of motion (DM) and force reproduction (FR). After proprioception testing, each subject received either a lumbar manipulation or a sham procedure followed by retesting of proprioception. This procedure was repeated the following week using the opposite treatment. Those subjects receiving spinal manipulation in the second session returned for a third session and received the sham procedure a second time. Spinal manipulation produced a significant effect for TTDPM in the Manip 1st Group, the sham procedure produced a significant immediate effect for JPS in the Sham 1st Group, and manipulation resulted in a significant one-week residual effect for the Manip 1st Group. All other time comparisons were not significant. The results of this study minimally support the proposed hypotheses. The results of this study suggest that spinal manipulation has minimal effect on trunk proprioception in subjects with CLBP who are painfree at the time of testing. Subjects in this study did not demonstrate as large a deficit in proprioception as previously reported. This study might suggest that a lack of demonstrable deficit in painfree subjects at the time of testing is the result of diminished pain level. Strong conclusions cannot be made from these results but suggest further testing comparing manipulation with no intervention or other interventions while controlling for pain level, may be important for understanding the functional implications of the neurophysiological effect of spinal manipulation.

Objective: develop a Clinical Prediction Rule (CPR) for identifying postpartum women with Low Back (LBP) or Pelvic Girdle Pain (PGP) who demonstrate short-term improvement with Sacroiliac Joint (SIJ) mobilization. Significance: Development of a CPR for classifying subjects a-prior would improve the clinical decision-making process and research. Methods: a prospective cohort of 69 postpartum women was conducted at the University of Pittsburgh Medical Center. Subjects were six weeks to one year postpartum and had a chief complaint of pain in the lower back, pelvic girdle, or thigh. Subjects completed several self-report measures, questionnaires and underwent a physical examination. Subjects then underwent a grade V mobilization to the SIJ. Success with treatment was determined using percent changes in disability scores after one mobilization and served as the reference standard for determining accuracy of the examination variables. Variables with univariate prediction of success and non-success were combined into multivariate CPRs. Results: Fifty-five subjects (80%) had success with the mobilization and 14 (20%) were categorized as non-success. A CPR for success with four variables (seated flexion test, prone knee bend test, negative posterior superior iliac spine symmetry test, and symptom location in the lower lumbar spine and/or SIJ areas only) was identified. The presence of 2/4 criteria (+LR=3.05) increased the probability of success with mobilization from 80% to 92%. A CPR for non-success with three variables (age > 35 years, visual analogue score-best > 3, and negative prone knee bend test) was identified. The presence of 2/3 criteria (+LR=11.79) increased the probability of non-success with the mobilization from 20% to 75%. Conclusion: In our sample, 80% of subjects were successful after one mobilization without an attempt at prediction. This success rate was higher than the success rate of the general LBP population of a previously developed CPR. There is a low risk accompanying this intervention, it does not take long and benefits would be experienced after one session. The broad inclusion criteria of women with LBP or PGP allows clinicians to include women without a traditional diagnosis. Clinicians may opt to try the mobilization; an alternate approach can be used if it fails.

Depression is a serious mental health illness and one of the most burdensome diseases to society. In fact, it is the most costly disease among mental illnesses in the United States (Murray & Lopez, 1997). The assessment of task performance is an important contribution provided by occupational therapists in the care of patients with depression. Such assessment can detect various difficulties experienced by patients. In older patients these difficulties are more complicated due to aging. Examples of difficulties may be failing to dress oneself, inability to take medication on time, and needing assistance in preparing a meal. Factors that underlie these difficulties might be age-related factors (e.g., cognitive and physical impairments), environment-related factors (e.g., novelty of the context in which the task was performed), or depression-related factors (e.g., negative symptoms associated with depression [e.g., loss of motivation]). The purpose of this dissertation is to determine difficulties in task performance experienced by older women with late life depression.