Modified swing patterns and general exercises have been suggested for golfers with back problems. However, it is difficult to design a back-specific swing or exercise program for low back injury prevention and rehabilitation without knowing the differences in the kinematics and spinal loads of the golf swing and the physical characteristics associated with golfers with low back pain (LBP). The purpose of this study was to examine the kinematics of the trunk and spinal loads in golfers with and without LBP and their trunk and hip physical characteristics. Sixteen male golfers with a history of LBP were matched by age and handicap to 16 male golfers with no history of LBP. All golfers underwent a biomechanical swing analysis and physical characteristics assessment. Kinematics and spinal loads of the trunk were assessed using a 3D motion analysis system and two force plates. A bottom-up inverse dynamics procedure was used to calculate the spinal loads at L5/S1. In addition, trunk and hip strength and flexibility, back proprioception, and postural stability were measured. The LBP golfers demonstrated less trunk and hip strength. The LBP group also had less hamstring and right torso rotation flexibility. In addition, the LBP group demonstrated back proprioception deficits significantly in trunk flexion. No significant differences were found for postural stability. The LBP group demonstrated less maximum angular displacement between shoulders and hips during the backswing. No significant differences were found in other trunk kinematics and spinal loads during the golf swing. Deficits in physical characteristics have been found in golfers with a history of LBP. These differences may hinder dissipation of the tremendous spinal forces and moments generated by the golf swing over time and also limit trunk rotation during the backswing. These conditions may lead to lower back muscle strain, ligament sprain, or disc degeneration. Although differences found in this study can not be determined as causes or results of low back injuries in golfers, clinicians may be able to design an appropriate back-specific exercise program for golfers to prevent or rehabilitate low back injury based on these findings.

Ankle sprains are among the most common injuries in sports. The majority involve the lateral ligaments of the ankle following a rapid inversion of the weight bearing joint. The ability of prophylactic stabilization to minimize the impact of these forces has been studied extensively. An innovative device designed to evoke a 20º inversion perturbation was used to demonstrate that application of ankle prophylaxis is effective in improving muscular response in healthy individuals. Forty one volunteers (21 males, 20 females) underwent EMG analysis of the peroneus longus (PL) and tibialis anterior (TA), measuring reflex latency (RL) and time to peak amplitude (TPA) while performing a dynamic task. Data were collected while subjects were fitted with two types of ankle braces (lace-up and semi-rigid) and standard closed basketweave ankle taping, each compared with a no support control. In addition, a comparison of PL and TA was conducted to determine muscle differences on measures of RL and TPA. Significantly shorter RL in the PL were observed in the lace-up and semi rigid brace conditions compared to the no brace (p=0.004, p less than 0.001) control. Similarly, the semi-rigid brace was significantly shorter than the tape (p less than 0.001) condition. In the TA, RL were significantly shorter for the lace-up than the no brace (p less than 0.008) control. TPA values were significantly shorter for the lace-up and semi rigid brace conditions in the TA compared to the no brace (p=0.007, p=0.001) control; and the semi-rigid brace TPA was significantly shorter than tape (p less than 0.001). No significant differences were observed in either RL or TPA measurements (p greater than 0.05) between the PL and TA. The dynamic task in this study better replicates the conditions which often precipitate ankle injury. Results indicate the application of ankle support may be beneficial in heightening the sensitivity of dynamic restraints, thus minimizing the effects of a rapid inversion mechanism. In particular, the lace-up and semi-rigid braces appeared to be the most effective in hastening muscular responses observed during a dynamic task. The implications for these findings would be of particular interest to the clinician when recommending the type of prophylactic support to be employed during sport activity.

We systematically examined the standard of care for wheelchair provision, factors associated with wheelchair choice, disparities in access to wheelchair technology, and the impact of wheelchair use on quality of life among individuals with spinal cord injury (ISCI), participants of the National Model Spinal Cord Injury Systems (NMSCIS). We administered the Assistive Technology Survey developed by the consensus of the directors of the NMSCIS to a convenient sample of 635 adult full-time wheelchair users who met the eligibility criteria for the NMSCIS in 2 separate data collection periods. About 97% of manual and 54% power wheelchair users had customizable wheelchairs, lending evidence to show that ultralight weight customizable manual wheelchairs and customizable power wheelchairs with programmable controls are the standard of care for wheelchair users with SCI. Power wheelchair users were significantly older (p=0.000) than manual wheelchair users. However, regardless to the level of SCI, manual wheelchair users were able to use manual wheelchairs for an average of more than 10 years. Although the socioeconomic statuses (SES) of manual and power wheelchair users were similar, minorities with lower SES had less access to customizable wheelchairs and additional wheelchairs. We were not able to establish an association between the types and design features of wheelchair used on quality of life. Quality of life outcomes were measured in terms of physical/structural barriers, mobility, physical independence, social integration, and life satisfaction; all of these measures are part of the Craig Hospital Inventory of Environmental Factors, the Craig Handicap Assessment and Reporting Technique, and the Satisfaction With Life Scale. However, we were able to conclude that having additional wheelchairs significantly enhanced mobility for wheelchair users. The results of our study generated new knowledge for the field of SCI rehabilitation by elucidating the standard of care for wheelchair provision, the characteristics of wheelchair users with SCI, and the impact of wheelchair use for this population. Furthermore, this study also provided policy makers with valuable data to address disparities in access to customizable wheelchairs and the lack of insurance coverage for additional wheelchairs.

Purpose: To identify baseline impairments associated with physical function and to identify what changes in impairments are associated with functional outcome in patients with PFPS following a standardized physical therapy (PT) treatment at 2 and 6-month follow-ups. Subjects: 74 patients diagnosed with PFPS and referred to PT treatment. Methods: Correlational, predictive design. Baseline measurement session was performed to complete demographic questionnaires, self-reported measures, and undergo a physical exam. Impairments measured during physical exam included quadriceps strength, hip abduction strength, hip external rotation strength, hamstrings length, quadriceps length, plantar flexors length, ITB/TFL complex length, lateral retinacular length, foot pronation, Q-angle, tibial torsion, quality of movement, pain, and anxiety. Following the baseline, subjects participated in a standardized PT program. Then, measurement sessions were performed at 2 and 6-month follow-ups. Analyses: Association between baseline impairment and function used a stepwise multiple regression in which potential confounder variables (age, sex, activity level, height and weight) were forced into the model as a single block. Then, impairment measures were entered in a stepwise procedure. Function measured by the Activity of Daily Living Scale (ADLS) was the criterion variable. Association between changes in impairment and function outcome was investigated with two stepwise multiple regressions, one with the 2 and the other with the 6-month follow-up data. The criterion variable was the ADLS of the respective follow-up controlled by the baseline ADLS. First, potential confounders were forced into the model as a single block. Then, changes in impairments and baseline pain were entered in a stepwise procedure. Results and Clinical Relevance: At baseline our study indicates that after controlling the confounders, pain and tightness of lateral retinaculum predicted baseline function. Data suggested that pain may mediate the relationship between anxiety and function in patients with PFPS and the role of pain and anxiety in the prediction of function should be considered together with this population. At the 2 and 6-month follow-ups, after controlling the confounders, increased gastrocnemius length and increased quadriceps length predicted functional outcome, respectively. It seems that clinicians should specifically target impairments of soft tissue length in an attempt to improve functional outcome in patients with PFPS.

Abstract: The variability of symptoms in persons with multiple sclerosis (MS) leads to dilemmas in clinical decision-making related to mobility device prescription. When is a good time to consider a switch to wheeled mobility? What is the best type of wheeled mobility? What are the changes one can expect as they transition? Three studies addressed these questions. First, we investigated the characteristics of individuals with MS who are about to transition to wheeled mobility. Seven ambulatory individuals with MS performed the timed 25-foot walk test (T25FW), and completed questionnaires measuring quality of life (QoL), self-reported fatigue, and participation. These individuals were not able to ambulate at functional speeds and had sedentary activity levels. They also had QoL below that of the general population. Next, we investigated changes that accompany a transition in primary means of mobility. Eleven individuals with MS or other chronic conditions leading to a decline in mobility function participated. We collected strength, fatigue, participation and QoL data at baseline, and after mobility intervention. Substantive results revealed that individuals may not experience the expected declines in strength and endurance as they transition. Furthermore, they experienced improvements in QoL concomitant with amount of daily device use. Methodological results revealed difficulties in conducting longitudinal mobility studies, and addressed research design barriers. Finally, we investigated whether a difference exists in the type of wheeled mobility issued to veterans with MS when compared to veterans with a spinal cord injury (SCI). Using the National Prosthetic Patient Database, we isolated all veterans with MS or an SCI who received a wheelchair or scooter in 2000 and 2001. We found that the quality of wheeled mobility devices issued to individuals with MS was inferior to those issued to individuals with SCI. These studies provide preliminary evidence that individuals with MS may be waiting too long to transition to the use of wheeled mobility. When they do receive a wheelchair, veterans with MS tend to receive a lower quality of wheelchair. Finally, we made suggestions for conducting longitudinal mobility research in this population, and emphasized the need for future studies.

The specific aims of this work are as follow: 1) to develop the Virtual Reality Telerehabilitation System (VRTS) which can enable clinicians to assess the wheelchair accessibility of users homes from a remote location. 2) to investigate the effectiveness of this new accessibility assessment system using Virtual Reality technology and the Telerehabilitation concept as compared to a conventional assessment method. The development of VRTS begins with reliability analysis via data accuracy analysis, camera usability analysis, and a field feasibility test study, and it evolves into the development of algorithms to acquire information and images, make 3D models, and analyze accessibility in virtual environments. A guideline for taking good pictures and a survey form have been developed to collect images and descriptive information for the target environment. A field evaluation is proposed to test whether this new system is comparable to the traditional method of accessibility assessment. In cooperation with a regional architectural firm, three clients requesting an evaluation of accessibility of their houses will be recruited. A target house will be assessed via the Conventional In Person (CIP) method by an architect of the firm and via the VRTS by another architect. A descriptive analysis will be performed to compare the VRTS assessment with the CIP onsite evaluation.

Heart failure is a major cause of disability among older adults in the United States, costing approximately $28.8 billion in 2004. The majority of these costs can be attributed to HF-related activity limitations. This dissertation explored limitations in activities of daily living in community dwelling older women with HF in three studies. The first study explored the concordance of four activity assessment methods (self-report, proxy-report, clinical judgment, and performance observation in the clinic) with a criterion method (performance observation in the home) in a single sample (n = 55). Multitrait-multimethod matrix analyses revealed that the best concordance with the criterion was achieved with in-clinic performance observation, however, the concordance was marginal at best - fair for 3 activity domains (functional mobility, personal care, and cognitive instrumental activities) and poor for 1 (physical instrumental activities) domain. With the same sample, the second study examined the influence of the environment on activity performance, by performance testing the same activities in an occupational therapy clinic and in participants homes. The environment influenced the performance of daily living activities in neutral, enabling, and disabling ways, depending on whether activity independence, safety, or adequacy was being measured and whether measurement accounted for functioning at the global, domain, or individual activity level. The third study examined the trajectory of activity limitations and impairments in the same heart failure sample compared to a group of older women without disabling diseases (n = 57) over 6 months. At baseline and follow-up, the non-disabled group performed more independently and adequately than the heart failure group but equally safely. Both groups experienced a loss of independence and adequacy over time but not of safety. Physical impairment and depression emerged as the most likely candidates responsible for the group differences and changes in functioning. Findings from these studies suggest that performance observation in the home may be the most valid method of assessing disability, the influence of the environment on performance is variable, and older women with heart failure sustain greater activity limitations than those without disabling diseases but the rate of change over time is similar.

During wheelchair propulsion, in order to apply power to the pushrim effectively, shoulder and trunk stabilization is needed to control arm movements and the consequent transfer of power from the limbs through to the pushrim. Available trunk control may be one of the most important force-generating mechanisms during wheelchair propulsion, particularly when an individual is fatigued or propelling through a demanding situation. Consequentially it is a worthwhile pursuit to further understand and study the process of trunk muscle recruitment during propulsion and the effects of reduced trunk control on propulsion biomechanics. In the first of three studies contained in this dissertation is, trunk muscle recruitment patterns using surface electromyography (sEMG) electrodes during wheelchair propulsion under different speed conditions. The results of this first study provided insight into the functional role of specific trunk muscles during propulsion. In the second study, a biomechanical analysis was utilized to examine the effect of functional electrical stimulation (FES) on trunk musculature during five minutes of wheelchair propulsion. The findings revealed that a trunk FES device could help an individual to generate more propulsion power and increase gross mechanical efficiency during wheelchair propulsion. Consequentially, a user with a trunk FES device may be able to more easily negotiate demanding propulsion tasks, ultimately improving quality of life. The third study investigated the influence of surface electrical stimulation of trunk musculature on shoulder muscle recruitment patterns during wheelchair propulsion. The results showed that trunk FES may help individuals to generate wheelchair propulsion power without placing additional demands on shoulder musculature. With trunk stimulation, the functional role of the shoulders may shift from stabilizers to a prime movers contributing more directly to propulsion. In the future, improvements can be made with advanced programming. A FES device could be better synchronized with the propulsion cycle to avoid continuous stimulation causing muscle fatigue. It would be ideal to provide stimulation during pre-push and early push phase of the propulsion cycle when trunk stability has been shown to be most critical. Individuals could potentially benefit from using FES more during challenging tasks of short duration, such as pushing up a ramp.

The purpose of this study was to develop the Functioning Everyday with a Wheelchair Capacity (FEW-C), a valid and reliable performance-based observation tool to measure the effects of wheeled mobility and seating interventions on functional capabilities specific to consumers needs. The tool was modeled after the Functioning Everyday with a Wheelchair (FEW), a companion self-report measure and characteristics of the capacity qualifier of the World Health Organization International Classification of Functioning, Disability, and Health. Prior to the development of the tool a systematic review of the scientific literature revealed limited availability of performance based measures of functional outcome that could be applied across the spectrum of wheeled mobility and seating devices or types of impairments. Excellent interrater reliability coefficients (ICC 2,k = 0.98) were established with 13 wheeled mobility and seating device users and 8 trained raters. Internal consistency of the FEW-C, based on a sample of 25 wheeled mobility and seating device users, yielded Cronbach's alphas ranging from 0.74 to 0.89 indicating good internal consistency without redundancy. Multitrait-multimethod matrix analyses, yielded fair to good convergent and discriminant validity when compared with other tools that were measuring similar traits by different methods. A non-randomized clinical trial was implemented to test the ability of the performance-based FEW-C to detect statistical and practical change over time, and to ascertain if the FEW-C results differed from the companion self-report tools. Findings indicated that the FEW-C and other self-report tools were able to measure practical changes in function over time with very large Cohen's d effect sizes ( 2.28 - 3.18) following the provision of a new wheeled mobility and seating device, however, each of the tools behaved differently. These findings further confirmed the effectiveness of the wheeled mobility and seating interventions provided by the clinicians. Our findings also indicated that the operationalization of the items of the reliable and valid FEW self-report tool into a performance-based observational tool yielded another reliable and valid tool for gathering data about functioning with a wheeled mobility and seating device, and that each tool contributed unique information to wheeled mobility and seating assessments.

Depression is a leading cause of disability among older adults which can change the scope of daily life for older adults and threaten their ability to live independently in the community. This dissertation explored task disability in older adults with depression in three studies. A unique aspect of the studies was the assessment of disability through performance-testing. The first study examined task disability patterns in a sample of older adults with depression being treated as inpatients (n = 60) or outpatients (n = 59). Rasch analysis revealed that the degree of disability for task domains (functional mobility [FM], basic activities of daily living [BADL], instrumental activities of daily living [IADL] with a greater physical component [IADLphysical], and IADL with a greater cognitive component [IADLcognitive]), and task items, was different for older women whose depression resulted in inpatient versus outpatient treatment. With the same sample, the second study examined the impact of information processing speed on task disability. The patients were separated into groups by speed of processing (slower patients, n = 76; faster patients, n = 23) based on their performance on the Trail Making Test B. Speed of processing was associated with severity of depression and both depression and slower speed of processing interfered more with effortful processing tasks (i.e., IADLcognitive and IADL-physical) and less with tasks requiring automatic processing (i.e. FM). The third study compared physician rated disability on the Global Assessment of Function (GAF) Scale with performance-disability observed on the Performance Assessment of Self-Care Skills (PASS) in a hospitalized community-based sample separated into subgroups by readmission status (readmit patients, n = 15; non-readmit patients, n = 43). There was a lack of concordance between the measures with only the GAF Scale showing significant reduction in disability at discharge. Findings from these studies suggest that for older adults with depression, there may be sentinel tasks which are disability indicators and those tasks may differ based on speed of processing. The lack of concordance between the disability measures suggests the need for consideration of performance-based testing of daily life tasks as a component of usual care.