William Miller

Background: Self-management education equips individuals with lower limb loss (LLL) with knowledge and skills to better manage their condition. Support of a peer mentor may also improve the effect of self-management programs and enhance the patient’s self-efficacy. Given the limited provision of rehabilitation programs, especially in remote areas, alternative approaches, such as eHealth, may improve delivery of programs. Purpose: To co-create an online self-management program for individuals with LLL, Self-Management for Amputee Rehabilitation using Technology (SMART), through stakeholders’ input, and to evaluate the feasibility and perceived benefits of SMART for community dwelling adults with LLL. Methods: We conducted three studies: Focus groups and interviews with clinicians and individuals with LLL; a systematic review and meta-analysis designed to assess the effect of eHealth interventions compared to usual care on mobility in peer-reviewed randomized controlled trials and identify the Behavior Change Techniques (BCTs) underpinning SMART content; assess the usability using a think-aloud approach; and a mixed-methods pre-post intervention study to assess feasibility.Results: Clinicians and individuals with LLL perceived education as important to adapt to amputation, however, in their experience, education was limited to traditional physical materials/booklets and inaccessible in remote areas. Goal setting and support of a peer mentor were identified as helpful program components to facilitate self-management. Participants indicated an accessible, complementary source for LLL education may augment their rehabilitation.Very-low certainty evidence showed a small positive change in mobility in favor of the eHealth intervention. The BCTs, such as goal setting, and action planning, were identified and embedded within SMART content. Difficulties with navigating SMART, content presentation, and unclear language were identified and addressed. SMART delivered with the support of a peer mentor was feasible and could potentially benefit individuals with LLL. Participants felt they had benefited from SMART and the support of a peer mentor who facilitated goal setting and goal achievement. Conclusion: SMART could support individuals with LLL to learn self-management skills in an effective timeframe, regardless of geographical boundaries, and serve as a complementary educational resource. Future studies should evaluate SMART efficacy compared to usual care and assess the feasibility of integrating SMART into clinical practice.

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Powered wheelchairs (PWCs) promote participation and well-being for individuals with limited mobility. However, many individuals who would benefit from a PWC do not have access to one. This is particularly true for older adults with cognitive limitations who are perceived as being unable to learn or require additional training to become safe and effective drivers. Novel training approaches which address the needs of this population, while maintaining safety in the training environment, are necessary.Purpose: To generate knowledge through end-user input to develop a wheelchair skills training program for older adults with cognitive impairment, using an errorless learning approach, and evaluate the feasibility of implementing this program in a randomized controlled trial for individuals living in residential care.Methods: To address the purpose, we conducted three studies: A North American survey of PWC skills training providers; qualitative interviews; a think-aloud task analysis; and a mixed-methods feasibility 2x2 factorial randomized controlled trial.Results: Evidence-based PWC skills training programs are rarely used in current practice. The most commonly used training techniques are trial-and-error methods using verbal and visual cues, with safety maintained through proximity to the wheelchair. Clinicians experience tensions in providing client-centred practice in resource limited environments and maintaining safety during training while meeting the learner’s needs. There is a perception shared control technology may enable safe training opportunities and reduce training related anxiety and stress, however, clinicians require training and practice with new technologies to ensure competence. The majority of the skills and abilities used when driving a PWC are mental functions, while knowledge of the self, environment, wheelchair, and activity or task are used during driving. An errorless intervention for PWC skills training, facilitated by shared control, is safe and effective for training new wheelchair users with cognitive impairment. Participants felt safe and benefitted from the use of shared control. Conclusion: Although many clinicians are hesitant to train individuals with cognitive impairments, learning is possible within this population. Shared control can facilitate errorless training strategies. Future research should incorporate alternative trial designs, integration into clinical practice, and wheelchair-related outcome measures validated for use with older adults with cognitive impairment.

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Background: There is a dearth of evidence about lower limb amputation (LLA) incidence, rehabilitation, and practice in Canada. Such data are crucial for assessing the burden of the disability and making informed healthcare decisions. We know from the literature that the current resource-intensive rehabilitation model is costly and perhaps not sustainable. This highlights the need for exploring interventions that are less resource-intensive and, therefore, more cost-effective. Purpose: To gain an understanding about the incidence of LLA, current practices, and rehabilitation services provided in Canada and to design and evaluate a novel approach that may ultimately provide cost-effective LLA rehabilitation. Methods: Five studies were conducted. Studies 1-2) analyses of Canadian data to determine the incidence of LLA and the provision of inpatient rehabilitation services from 2006 to 2011; studies 3-4) a Canadian survey to describe prosthetic rehabilitation practices and to explore therapists’ perspectives about the use of commercial games, particularly the Nintendo Wii Fit, in rehabilitation; and study 5) a feasibility randomized controlled trial (RCT) to evaluate the use of Wii Fit intervention (named Wii.n.Walk) in LLA rehabilitation. Results: The age-adjusted incidence of LLA was 22.9 per 100,000 individuals. Although there was a decline in the incidence rates, the number of LLAs increased for older age categories. In total, 18.0% (n=2,902/16,114) of the individuals received inpatient rehabilitation in Canada over the study years. When asked about the use of commercial games, 43.9% (n=36/82) of the therapists indicated that they use the Wii Fit in rehabilitation. Our feasibility RCT showed the intervention adherence was 83.4%. No adverse events occurred. Conclusions: Although the age-adjusted incidence rates have declined, the number of LLAs has increased in individuals older than 50. Given the increase in number of LLAs and the fact that only 18% of individuals receive inpatient rehabilitation, there is a need for other service deliveries. The Wii Fit is prevalently used in prosthetic rehabilitation in Canada and was found to be feasible for LLA rehabilitation. A future powered RCT is required to provide more evidence about the efficacy and cost-effectiveness of the Wii Fit in prosthetic rehabilitation.

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Many older adults rely on a manual wheelchair (MWC) for mobility but are not provided with skills for independent and effective use. Access to wheelchair skills training is constrained by the logistics, expense and limited availability of rehabilitation services. A supervised, home-based program specifically designed for older adults and delivered via a mobile computer tablet (mHealth) could potentially be a useful and efficient strategy to provide skills training.PurposeTo explore the experience and needs of older adults transitioning to MWC use (Chapter 2); collaboratively develop, refine and pilot test an mHealth training program (Chapter 3); evaluate the program’s feasibility (Chapter 4); estimate impact on skill capacity and clinical outcomes (Chapter 5); and explore user-perceived benefits (Chapter 6).MethodsQualitative methods were used to understand the MWC transition experience. A mixed-methods Participatory Action Design and pre-post pilot trial were used for program development. A feasibility randomized controlled trial (RCT) assessed feasibility and clinical indicators, and follow-up interviews explored participants’ experiences.ResultsOlder adult MWC users identified a lack of supports during transition to MWC use, particularly with skills training, often resulting in compromised community participation and increased care provider burden. The Participatory Action Design approach proved useful in constructing a viable prototype tablet-based home-training program that incorporated self-efficacy strategies and promoted principles of adult learning. In the feasibility RCT, the program was delivered safely and consistently, achieving most of the feasibility indicators; recruitment proved challenging but participants demonstrated good adherence with only one health-related dropout. There was a statistically significant difference and large effect size for measures of self-efficacy (p = 0.06; ηp² = 0.28) and performance of outdoor wheelchair activities (p = 0.02; ηp² = 0.40), but not for the primary outcome of skill capacity. Participants and care providers identified substantial clinical benefits in terms of confidence with wheelchair use, engagement in activities of life, and reduced care provider demands.Conclusions: The mHealth program shows promise as a potentially effective and appealing wheelchair skills training program for older adult MWC users. Future evaluation should enhance recruitment strategies, facilitating a larger RCT for more robust evaluation of clinical benefits.

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Independent mobility is vital for daily life, with emerging evidence suggesting it is an important foundation for overall development and life-long learning. However, children with mobility limitations are at risk for participation restrictions. Many believe that power mobility (PM) use (typically wheelchairs) makes a difference in children’s ability to participate in daily life, but research evidence is limited.Purpose: To advance understanding of how children (under 18 years) use PM to engage in meaningful life situations and to establish feasible research methods with reliable and valid measurement tools to investigate PM’s impact on children’s ability to participate.Methods: A systematic review identified and critically appraised participation tools appropriate for use; a four-round online modified Delphi survey advanced understanding of what participation-related information is important to measure and evaluated suitability of participation tools; and a feasibility study using an interrupted time series design examined process, resources, management and scientific indicators with children using PM.Results: Twenty potential participation tools were identified. Twenty-one elements describing the ‘who, what, where, when and how’ of measuring participation for children using PM achieved consensus from 74 parents, therapists and researchers. Then panelists used these elements to rank 13 participation tools, with six demonstrating suitability. Feasibility of conducting longitudinal research was examined with a sample of 32 children, and their everyday participation was described using three tools. Findings provided reliability and validity evidence, including initial responsiveness of tools for children needing PM. Change in participation was measured over 5 occasions within 4 months for 13/32 children receiving new PM devices.Conclusion: Employing integrative knowledge exchange, participation elements important to measure for children using PM, along with potential participation tools relating to these elements were identified to explore participation outcomes. Feasibility for larger, multi-site studies was established along with preliminary evidence of three participation tools’ measurement properties with children using PM and changes in participation outcomes following receipt of a new PM device. This thesis has provided foundational evidence on how children using PM participate in everyday life, and importantly provided a crucial underpinning for further discussions and investigations relevant to this topic.

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Wheelchair skills, required for manual wheelchair (MWC) use, are strongly associated with independent mobility, physical activity, and participation. Training can improve mobility and participation in meaningful activities for MWC users, but strategies are required to enhance skill development. Peer-led self-efficacy interventions have been effective at enhancing skills in other clinical areas, and present a novel approach to MWC training that may enhance use.Purpose: develop an understanding of MWC use and current MWC training education and practices, and to explore and evaluate a novel approach to improving MWC use. Methods: secondary analysis of a national survey to determine physical activity levels in older wheelchair users; surveys of rehabilitation centres and universities to describe MWC training practices and curriculum; systematic review and meta-analyses to evaluate the effect of peer-led interventions on physical activity and self-efficacy; and a pilot randomized controlled trial to evaluate a peer-led MWC training program for improving wheelchair self-efficacy and wheelchair use. Results: Only 8% and 41% of older wheelchair users participated in physical and leisure activity, and wheelchair use was found to be a primary risk factor for low levels of participation. A description of current MWC training in practice showed that 78% of clinicians provided basic MWC mobility training, but only 12% taught the advanced skills needed to achieve optimal community participation. Nearly 80% of entry-to-practice programs included MWC skills training in curriculum; however, only 38% used a validated training program. In a broad review, self-efficacy interventions had a small effect on physical activity (Cohen’s d = 0.2) and self-management self-efficacy (Cohen’s d =0.2). Peer-led MWC training had a large effect on wheelchair use self-efficacy (Cohen’s d =0.8), wheelchair skills capacity (Cohen’s d =0.7) and satisfaction with participation (Cohen’s d = 0.7), and no effect on wheelchair skills performance or life-space mobility. Conclusion: wheelchair use increases risk of physical inactivity. This may be related to wheelchair skills training, which currently relies on clinicians. Self-efficacy enhanced interventions can promote behaviour change. Peer-led MWC training may augment existing training, enhance self-efficacy and promote increased MWC use, which may elicit health benefits that are associated with physical activity.

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Self-efficacy with using a manual wheelchair is the belief individuals have in their ability to use their wheelchair in challenging situations. It is a new construct that may have important implications on the health and well-being of wheelchair users, but has received minimal investigation. There is a need to develop an understanding of this construct in community-dwelling wheelchair users. Purpose:To investigate: the associations between self-efficacy, participation frequency (Chapter 2), and life-space mobility (Chapter 3); the health, personal, and environmental factors that predict self-efficacy (Chapter 4); and the measurement properties of the 65-item Wheelchair Use Confidence Scale (WheelCon) (Chapter 5). Methods:Multiple regression analyses were used to: examine the self-efficacy effects on participation frequency, measured using the Late-Life Disability Instrument, and life-space mobility, measured using the Life-Space Assessment; and develop a predictive model of self-efficacy, measured with the WheelCon, in a sample (n=124) of wheelchair users, ≥50 years old. Principal components analyses were used to evaluate the dimensionality of the WheelCon. Rasch analyses were used to examine the WheelCon’s item reliability in a sample (n=220) of wheelchair users, ≥19 years old.Results:Self-efficacy was a statistically significant predictor of participation frequency and life-space mobility, after controlling for important confounders. The association between self-efficacy and participation frequency was mediated by life-space mobility and perceived participation limitations. The association with life-space mobility was mediated by wheelchair skills. The models accounted for 55.0% and 39.0% of the participation frequency, and life-space mobility variance, respectively. Age, sex, need for a seating intervention, hours of daily wheelchair use, and formal training and assistance with wheelchair use were statistically significant predictors of self-efficacy. The model accounted for 44.0% of the self-efficacy variance.The WheelCon was found to be comprised of two dimensions. Several items were eliminated due to their non-compliance with the Rasch model. The 13-item mobility efficacy, 8-item self-management efficacy subscales, and the combined 21-item short form have good reliability, and provide accurate and precise measurements. Conclusion:Self-efficacy has important implications on the participation frequency and life-space mobility in community-dwelling wheelchair users, ≥50 years old. The construct may be assessed efficiently and precisely.

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Wheelchairs are the primary means of mobility for most of the older adults living in residential care. Despite their intuitive benefits, little research has explored the outcomes of wheelchair use for facility residents. Therefore, a two-phase, mixed-methods project was undertaken.Phase 1: Exploratory Ethnographic Study.Objectives. 1. To explore the perceptions and experiences of facility life among residents who use wheelchairs as their primary means of mobility and to examine how wheelchairs are used in these settings.2. To identify nondemographic factors that enable or curtail the mobility, participation and life satisfaction of these residents.Method. Sixteen residents from two facilities took part in participant observations, and these residents or surrogate family members completed a series of in-depth interviews.Results. We drew upon the work of Pierre Bourdieu to understand how wheelchairs and other forms of capital could either enable or curtail the things residents did and the places that they went. These findings emphasize the critical role that the facility environment plays in the lives of residents. This study identified a wide range of potential wheelchair-related, environmental, and personal factors related to resident’s mobility, participation, and life satisfaction.Phase 2: Quantitative Cross-sectional Study. Objective. To identify the predictors of mobility, participation and life satisfaction of residents who use wheelchairs as their primary means of mobility.Method. We conducted a cross-sectional study with 268 residents from 11 facilities. To measure independent and dependent study variables we administered standardized personal, wheelchair-related and environmental tools and collected socio-demographic and wheelchair equipment data. Results. Wheelchair skills (including the capacity to engage brakes and manoeuvre) were the most important independent predictors of mobility. Depression was the most important independent predictor of life satisfaction among self-responding and proxy subjects and of participation for self-responding subjects. For proxy subjects, mobility was the most important independent predictor of participation; and depression approached significance. Significance. The study findings emphasize the pivotal role that wheelchairs play in the lives of residents, reveal institutional practices that may curtail their mobility and participation, suggest potential policy and practice changes, and lay the groundwork for future research.

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