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Study completed.Participants were power wheelchair users.

Although the physiatric community increasingly embraces evidence-based medicine (EBM), the current state of EBM training for trainees in physiatry is unclear. The purposes of this article are to report the results of the Association of Academic Physiatrists’ surveys of physiatry residency programs in the United States, to discuss the implications of their findings, and to better delineate the “baseline” upon which sound and clear recommendations for systematic EBM training can be made. The two Association of Academic Physiatrists surveys of US physiatry residency programs reveal that most survey respondents report that they include EBM training in their programs that covers the five recommended steps of EBM core competencies. However, although most respondents reported using traditional pedagogic methods of training such as journal club, very few reported that their EBM training used a structured and systematic approach. Future work is needed to support and facilitate physiatry residency programs interested in adopting structured EBM training curricula that include recommended EBM core competencies and the evaluation of their impact.

Background: Current scales to measure motor impairment in adults with spina bifida (SB) are limited by their complexity, variable interpretation (i.e., subjectively defined impairment levels), or inclusion of muscles groups that are not always practical to test in a clinical setting. Objectives: A novel motor impairment tool for adults with SB was evaluated for content validity. The tool uses findings from the manual muscle testing of hip flexion and knee extension to categorize individuals into four motor impairment groups. Methods: Expert feedback was obtained on the tool, and content validity was measured using Lawshe’s content validity ratio (CVR) with critical values recommended by Ayre and Scally. Data from phase 1 and phase 2 were used to revise the survey and calculate the CVR of the tool, respectively (benchmark: CVR ≥ 0.636). Results: Of the 26 experts recruited, 17 received the survey and 15 participated in either phase 1 (n = 6) or 2 (n = 11). The CVR values for each impairment group were as follows: intact strength (0.95), thoracic strength (0.90), hip flexor dominant strength (0.89), and knee extensor dominant strength (0.82). The CVR of the tool overall was 0.89. Qualitative expert feedback revealed common barriers to manual muscle testing and suggestions for improving the tool. However, experts also noted the value in preserving the simplicity of the tool. Conclusion: The high content validity, coupled with expert feedback, suggests the tool may give clinicians and researchers a practical method of classifying an individual’s extent of motor impairment.

The COVID-19 pandemic has dramatically impacted delivery of outpatient care. Many people with spina bifida (SB) in the U.S. receive outpatient healthcare in a multidisciplinary setting. In accordance with state healthcare mandates, outpatient multidisciplinary clinic visits were deferred, postponed, or canceled, while telemedicine systems were implemented. A survey was created and distributed to all known SB clinics in the U.S. We explored the impact of the COVID-19 pandemic on the delivery of outpatient care for the SB population and the use of telemedicine in response. Novel uses of telehealth, benefits of use, suggestions for overcoming barriers, and future opportunities are identified and discussed.

The purpose of this study was to examine factors associated with variability in time from assessment to device delivery (cycle time). Our hypothesis was that device type and type of insurance would be the strongest predictor of cycle time.Data were extracted from the Functional Mobility Assessment/Uniform Dataset (FMA/UDS) Registry that at the time of analysis contained a sample of 2588 people with disabilities (PWD) who were provided with a wheeled mobility device (WMD) between 21 March 2016 and 29 June 2021. To examine the effect of individual factors on the variability in cycle time, a robust linear regression analysis was conducted.The average national cycle time was 101.5 (SD = 59.9) d. Geographic area (Capital Metro [Longer cycle time is likely related to variations in clinical practice, insurance coverage criteria and the level of customizability of the device needed for a particular diagnosis, especially long-term disabilities.Implications for rehabilitationThe national average number of days between initial evaluation and device delivery (cycle time) to deliver a wheeled mobility device (WMD) varies based on specific variables such as type of WMD, diagnosis and payer source.Geographic area, years since onset of disability, device type, primary diagnosis and funding source significantly impact cycle times.Increased complexity of the WMD, both manual and power wheelchairs (PWCs), was associated with longer cycle times.As more service delivery models emerge, specific benefits and challenges need to be reported on how they impact cycle time.

As a member of the Back Pain Consortium (BACPAC), the University of Pittsburgh Mechanistic Research Center's research goal is to phenotype chronic low back pain using biological, biomechanical, and behavioral domains using a prospective, observational cohort study. Data will be collected from 1,000 participants with chronic low back pain according to BACPAC-wide harmonized and study-specific protocols. Participation lasts 12 months with one required in person baseline visit, an optional second in person visit for advanced biomechanical assessment, and electronic follow ups at months 1, 2, 3, 4, 5, 6, 9, and 12 to assess low back pain status and response to prescribed treatments. Behavioral data analysis includes a battery of patient-reported outcomes, social determinants of health, quantitative sensory testing, and physical activity. Biological data analysis includes omics generated from blood, saliva, and spine tissue. Biomechanical data analysis includes a physical examination, lumbopelvic kinematics, and intervertebral kinematics. The statistical analysis includes traditional unsupervised machine learning approaches to categorize participants into groups and determine the variables that differentiate patients. Additional analysis includes the creation of a series of decision rules based on baseline measures and treatment pathways as inputs to predict clinical outcomes. The characteristics identified will contribute to future studies to assist clinicians in designing a personalized, optimal treatment approach for each patient.

PURPOSE: The objective of this study was to describe the knowledge, attitudes, and practices related to caring for youth with SB within a statewide pediatric primary care medical home network. METHODS: Health care professionals who were members of the Pennsylvania Medical Home Program (PAMHP) statewide network were surveyed on sociological demographics, confidence in and knowledge of topics that impact the spina bifida (SB) population, education on SB, designating responsibility of care, tasks completed in the office, and transition from pediatric to adult care from October 2016 through November 2016. RESULTS: Among 67 respondents, 78%believed counseling families/caregivers about the impact of SB on everyday life was a shared responsibility between primary care physicians (PCP) and SB clinics. Eighty five percent of participants indicated they had exposure to SB through clinical courses or didactics in training but only 54%of participants felt knowledgeable on the impact of SB on everyday life. CONCLUSION: Findings suggest a need for increased educational efforts, improved awareness of SB, and access to evidence-based guidelines for PCPs to promote accessible and coordinated care to individuals with SB.

The purpose of this study was to examine factors associated with variability in satisfaction with functional mobility (as measured by the Functional Mobility Assessment [FMA]) in users of mobility devices. Our primary hypothesis was that device type and Assistive Technology Professional (ATP) involvement will be the most significant predictors of FMA score. Our secondary hypothesis was that ATP involvement is associated with use of more custom-fitted manual wheelchairs and group 3 and 4 power wheelchairs.Retrospective cohort study.Data were collected from equipment suppliers who collaborate with clinicians to administer the FMA and associated Uniform Data Set within various settings (ie, rehabilitation clinic, school, supplier place of business).A data set of 4743 cases was included in the analysis (N=4743).Not applicable.FMA questionnaire collected at baseline, client age, gender, primary diagnosis, years since disability onset, device type, device age, living situation, ATP involvement, and geographic area.Ordinal logistic regression modeling showed that geographic area, device type, ATP involvement, primary diagnosis, gender, age, device age, and years since onset of disability significantly predicted the variance in FMA scores at P.05. Device type was the most significant predictor of variance in FMA score. Involvement of an ATP had a significant effect on the type of device that participants used (χThe relationship between ATP involvement and functional outcome supports the concept that ATP certification recognizes demonstrated competence in analyzing the needs of consumers with disabilities and selection of appropriate mobility assistive equipment with improved functional outcomes.

This study used a spina bifida electronic medical record and the National Spina Bifida Patient Registry to explore the relationship between neurosurgical/orthopedic surgeries and other variables on ambulation and transfer ability over time in individuals with spina bifida.This study was an analysis of longitudinal data collected within the National Spina Bifida Patient Registry and spina bifida electronic medical record. Logistic regression models were used to determine which variables were associated with ambulation/transfer ability in the myelomeningocele (MMC) and non-MMC populations.Longitudinal data from 806 individuals were collected. In the MMC group, decreased ambulation ability was associated with higher motor levels, tethered cord releases, spine/scoliosis surgeries, hip orthopedic surgeries, and having supplemental insurance. Increased ambulatory ability was associated with lower motor levels, tibial torsion/related surgeries, ankle/foot surgeries, being female, and being non-Hispanic/Latinx. Decreased transfer ability was associated with being Hispanic/Latinx and having higher motor levels. Lower motor level and ankle/foot surgeries were associated with increased transfer ability. No significant associations were found in the non-MMC group.Motor level is an important predictor of ambulation and transfer ability in MMC. Surgeries distal to the knee were associated with higher levels of function; surgeries proximal to the knee were associated with lower functional levels.

The objective of this project was to measure Veteran and provider satisfaction with a home-based telerehabilitation assessment for wheelchair seating and mobility. Forty-three Veterans were seen remotely at their place of residence by a provider, using a VA Video Connect synchronous videoconferencing system. Veteran and provider satisfaction were collected using the Telerehabilitation Questionnaire (TRQ). Mean individual TRQ scores for both Veterans and providers were significantly higher than the scale midpoint of 3.5. Veterans had higher scores than providers for five individual items on the TRQ. Higher scores by Veterans on the technology and quality and clarity of the video and audio likely correspond to the differences in environmental settings in which the visit occurred for the Veteran compared with the provider. High satisfaction scores with the telerehabilitation assessments are likely attributed to the positive working relationship between the provider and the rehabilitation technician, who provided in-person technical support to the Veteran in the home during the wheeled mobility evaluation. Overall, the results indicate a high level of Veteran and provider satisfaction using telerehabilitation for wheelchair seating and mobility evaluations.

The purpose of this study was to compare telehealth and in-person service delivery models for wheeled mobility devices in terms of functional outcomes. We hypothesized that clinically significant improvements in functional mobility measured by the Functional Mobility Assessment (FMA) will occur in individuals receiving both telehealth and in-person clinic evaluations. A total of 27 Veterans receiving telehealth visits were compared to 27 individuals seen in clinic, selected from a database, matching for age, gender, and primary diagnosis. All mean individual item and total FMA scores in both groups increased from Time 1 to Time 2. Within the telehealth group, all changes in individual item and total FMA scores were statistically significant, with changes in 8 of 10 items meeting threshold for clinical significance (change >1.85 points). Within the clinic group, changes in 7 of 10 individual items and total FMA scores were statistically significant, and these same 7 items met threshold for clinical significance. Change scores for individual item and total FMA scores did not differ significantly between the two groups. A larger and clinically significant change in transfer score was seen in the telehealth group, suggesting telehealth visits may confer an advantage in being able to assess and address transfer issues in the home.

A hybrid neuroprosthesis system is a promising rehabilitation technology to restore lower limb function in persons with paraplegia. The technology combines functional electrical stimulation (FES) and a powered lower limb exoskeleton to produce movements for walking and standing. The main control challenge in the hybrid neuroprosthesis is to achieve an optimal coordination between FES and electric motors. Model-based optimal control methods have been suggested for the control of the hybrid neuroprosthesis. However, it is often difficult to effect robust control performance with model-based optimal control methods due to modeling uncertainties. A tube-based model predictive control (MPC) method is developed to obtain robust and optimal coordination between FES and an electric motor during a knee regulation task. An external feedback control is used to limit the error between the actual position and the MPC-computed nominal position. The tube-based MPC method is proved to have recursive feasibility, compliance to input constraints, and exponentially bounded stability. The experimental results obtained from an able-bodied participant and a participant with spinal cord injury validate the controller’s ability to allocate control inputs to FES and the electric motor as well as method’s robustness to modeling uncertainties.

Objective To identify the specific features that contribute to the variability in baseline wheelchair transfer and the changes in transfer ability (gain or loss) over time for a large cohort of patients with spina bifida (SB) in the National Spina Bifida Patient Registry. Design Longitudinal cohort study. Setting A total of 35 United States outpatient SB clinic sites. Participants Individuals (N=1687) with SB ages 5-73 (median, 13.33) years who were therapeutic ambulators or nonambulators. Intervention Not applicable. Main Outcome Measure Ability to transfer from a wheelchair to another level surface. Results Bayesian Network Analysis was used to reduce the initial variable set to the following predictors: SB subphenotype, motor level, age, insurance, sex, race, ethnicity, surgical procedures, and number of visits. We used a multinomial logistic model with Wald Chi-square analysis of effects to examine the relationships between transfer ability and predictors. A total of 295 of 1687 eligible patients (17.56%) with myelomeningocele (MMC) and 6 of 58 eligible patients (10.32%) with non-MMC experienced changes in transfer ability during the period of the study. For those with MMC and non-MMC, the highest number of individuals exhibiting changes in motor level had changes from thoracic to high-lumbar, high-lumbar to thoracic, high-lumbar to midlumbar, and midlumbar to high-lumbar lesion levels. Results of the Bayesian Network Analysis revealed that motor level was the predominant factor associated with baseline transfer ability followed by age. The combination of SB sub phenotype, motor level, age, insurance status, number and type of surgical procedures, and time point accurately classified the loss, gain, or no change in transfer ability 82.7% of the time. Conclusions Motor level was the predominant factor associated with baseline transfer ability, and the change in transfer ability was directly related to a corresponding change in motor level that might be explained by changes in muscle strength of the iliopsoas and quadriceps.

A hybrid exoskeleton comprising of a powered exoskeleton and functional electrical stimulation (FES) is a promising technology for restoration of standing and walking functions after a neurological injury. Its shared control remains challenging due to the need to optimally distribute joint torques among FES and the powered exoskeleton while compensating for the FES-induced muscle fatigue, and ensuring performance despite highly nonlinear and uncertain skeletal muscle behavior. This paper develops a bi-level hierarchical control design for shared control of a powered exoskeleton and FES to overcome these challenges. A higher- level neural network-based iterative learning controller (NNILC) is derived to generate torques needed to drive the hybrid system. Then, a low-level model predictive control (MPC)-based allocation strategy optimally distributes the torque contributions between FES and the exoskeleton's knee motors based on the muscle fatigue and recovery characteristics of a participant's quadriceps muscles. A Lyapunov-like stability analysis proves global asymptotic tracking of state-dependent desired joint trajectories. The experimental results on four non-disabled participants validate the effectiveness of the proposed NNILC-MPC framework. \textcolor{blue}{The root mean square error (RMSE) of the knee joint and hip joint was reduced by 71.96 % and 74.57 %, respectively, in the fourth iteration compared to the RMSE in the 1st sit-to-stand iteration.

BACKGROUND Mobile health (mHealth) systems that support self-management can improve medical, functional, and psychosocial outcomes for individuals with disabilities and chronic conditions. The mHealth systems can potentially be expanded to support community integration. OBJECTIVE The purposes of this study were to (1) partner with a community-based organization that supports community integration of individuals with disabilities; (2) identify software requirements needed to support community participation; and (3) iteratively refine an existing mHealth application to include new requirements. METHODS Community Living and Support Services (CLASS), a nonprofit organization that serves individuals with disabilities in Pittsburgh, Pennsylvania, was identified as the focus group for this study. Key stakeholders within the Community Partners Program at CLASS proposed design requirements for an existing mHealth application, Interactive Mobile Health and Rehabilitation (iMHere) 2.0, that has been used to support self-management. RESULTS We gathered qualitative data from a focus group composed of CLASS members to develop and iteratively revise iMHere 2.0 to include new modules and features to support community integration. A caregiver app was also developed. The new system contains features to support finance, transportation, client and caregiver communication, calendar and checklist management, upcoming medical and nonmedical appointments, social engagement, pain management, and access to a personal profile. Modifications were made to the following existing modules: education, mood, personal health record, goals, medications, and nutrition. CONCLUSIONS A successful partnership with a community-based organization that supports individuals with disabilities resulted in a newly designed mHealth system with features to support community integration.

Over one billion people with disabilities (PWDs) and older adults with mobility impairment are currently in need of assistive technology devices (ATDs) and only 10% of those population have ordinarily access to them. The need for advancement in mobility-assistive technology is growing to address the gap in ATDs provision globally. The purpose of this review is to identify potential future areas of development and research in mobility-assistive technology.Publications were identified using scientific and medical electronic databases. Also, a limited grey literature search was conducted to muster a variety of sources. A combination of keyword search terms was used, corresponding to the medical subject heading (MeSH) terms.A total of 392 articles were identified, of which 75 were selected for detailed review. Twenty-eight articles were identified that met the review's inclusion criteria. Future areas of research for mobility-assistive technology were identified by grouping the publications into four main categories. The findings of this review identified several areas of research and development in ATDs in general and mobility-assistive technology, in particular, with special attention to the importance of engaging users and stakeholders in the process of research and design.It is apparent that users' needs and priorities vary between regions within countries. The majority of studies were noted to mainly identify consumers' perspectives on a national basis. The authors, therefore, suggest that further research should be conducted on a global level to determine the knowledge and perspectives concerning future research and development needs and priorities in mobility-assistive technologies.Implication for RehabilitationDespite the benefits derived from the use of ATDs, only 10% of people with disabilities have access to them.Increasing access, quality and affordable ATDs in all countries is global demand.Identifying mobility consumers' needs and priorities would help in enhancing their quality of life by translating research into new technologies that meet their environment and culture needs.Users' involvement in research and design process is a crucial approach to re-shape the future research agenda.

The aim of this project was to evaluate the 10-yr outcomes from the Rehabilitation Research Experience for Medical Students. A target benchmark was one high-quality output per student. Students were required to devise a research project and work full time with a mentor at an approved sponsor site for 8 wks. Longitudinal surveys were used to collect data about research outputs, match results, and decisions about whether to pursue academic careers. From 2008 to 2017, 73 (48%) of 153 applicants were awarded summer externships. Residency match results included the following: physical medicine and rehabilitation (45%), internal medicine (17%), emergency medicine (8%), orthopedic surgery (6%), neurology (6%), psychiatry (6%), OBGYN (6%), pediatrics (4%), and anesthesia (2%). The Rehabilitation Research Experience for Medical Students was successful in exceeding the target benchmark for quality scholarly output, which included 73 oral presentations at the Association of Academic Physiatrists meeting, 63 published and 20 in-review articles directly related to summer research, 5 book chapters, and 51 published and 20 in-review articles that were indirectly related to summer research. A total of 77% reported that the Rehabilitation Research Experience for Medical Students positively influenced their decision to pursue research in their future career, and 70% endorsed interest in becoming a clinician scientist.

OBJECTIVE The aim of the study was to identify which neurologic impairment scales correlate with ambulation status in adults with spina bifida. DESIGN A retrospective chart review was performed on patients seen at the University of Pittsburgh Medical Center Adult Spina Bifida Clinic. Findings were graded using several neurologic impairment scales: two versions of the National Spina Bifida Patient Registry classification, the International Standards for Neurological Classification of Spinal Cord Injury motor level, and the Broughton Neurologic Impairment Scale. Ambulation ability was ranked using the Hoffer classification system. RESULTS Data collected from 409 patient records showed significant correlations between Hoffer ambulation status and all neurologic impairment scales evaluated. The strongest correlation was noted with the Broughton classification (rs = -0.771, P < 0.001). High correlations were also noted with both versions of the National Spina Bifida Patient Registry: strength 3/5 or greater (rs = -0.763, P < 0.001), and strength 1/5 or greater (rs = -0.716, P < 0.001). For the International Standards for Neurological Classification of Spinal Cord Injury motor level, only a moderate correlation was observed (rs = -0.565, P < 0.001). CONCLUSIONS Multiple grading scales can be used to measure motor function in adult spina bifida patients. Although the Broughton classification seems to be the most highly correlated with ambulation status, the less complex National Spina Bifida Patient Registry scale is also highly correlated and may be easier to administer in busy clinic settings. TO CLAIM CME CREDITS Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME CME OBJECTIVES: Upon completion of this article, the reader should be able to: (1) Explain the clinical significance of identifying ambulation status and maximizing ambulation potential in adults with spina bifida; (2) Describe each of the neurologic grading scales examined in this study, identifying potential shortcomings in applying them to the adult spina bifida population; and (3) Administer the National Spina Bifida Patient Registry (NSBPR) impairment scale motor assessment in a standard adult spina bifida outpatient clinic visit. LEVEL Advanced ACCREDITATION: The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Association of Academic Physiatrists designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Providing comprehensive transition care for adolescents and young adults with spina bifida (AYASB) requires a structured approach to addressing chronic condition management, self-management, care coordination, and health care navigation that is adaptable to the various levels of cognitive ability, physical function, and family/community environments within the population. This commentary (1) highlights AYASB transition program needs identified in the literature and within a local community, (2) analyzes advantages and limitations of published AYASB transition care models in addressing these needs, (3) demonstrates how a spina bifida (SB) transition clinic used the Chronic Care Model (CCM) to develop a comprehensive AYASB transition program, and (4) examines the potential feasibility in adapting this model to other SB clinics. A SB-specific transition clinic based on the CCM model facilitates the complex chronic care management and transition planning for AYASB. Further study is needed to evaluate health care outcomes using the CCM for SB transition.

Objectives Power mobility devices (PMDs) such as power wheelchairs and scooters are crucial for mobility, self-care, employment, and leisure activities. The documentation process for insurance coverage is complex and requires communication and document delivery among multiple stakeholders. The objective of this project was to develop an electronic submission process for medical documentation of PMDs submitted for prior authorization to a Medicare Administrative Contractor (MAC) and implement a standardized means of communication between providers and payers. Methods A protocol was developed to create and securely transmit an electronic prescription and several documents that outline medical necessity from a clinical team using EpicCare to a MAC via a Health Information Handler. A Rehabilitation Technology Supplier (RTS) added detailed product information and specifications to the electronic package during transmission. Setting The setting involved in the study was University-based outpatient assistive technology clinic. Results The protocol demonstrated successful transmission of an order, medical documentation, and request for signature. Results were transcribed to a readable format for the clinical team and RTS. A set of quality metrics for use in future projects was also identified. Conclusion This pilot project demonstrated successful electronic exchange and transmission of medical documentation for durable medical equipment from the electronic health record to a MAC.

PURPOSE: Neurogenic bowel dysfunction (NBD) is a common comorbidity of myelomeningocele (MMC), the most common and severe form of spina bifida. The National Spina Bifida Patient Registry (NSBPR) is a research collaboration between the CDC and Spina Bifida Clinics. Fecal continence (continence) outcomes for common treatment modalities for NBD have not been described in a large sample of individuals with MMC. NSBPR patients with MMC and NBD were studied to determine variation in continence status and their ability to perform their treatment independently according to treatment modality and individual characteristics. METHODS: Continence was defined as < 1 episode of incontinence per month. Eleven common treatments were evaluated. Inclusion criteria were established diagnoses of both MMC and NBD, as well as age ≥ 5 years (n = 3670). Chi-square or exact statistical tests were used for bivariate analyses. Logistic regression models were used to estimate the odds of continence outcomes by age, sex, race/ethnicity, level of motor function, and insurance status. RESULTS: At total of 3670 members of the NSBPR met inclusion criteria between November 2013 and December 2017. Overall prevalence of continence was 45%. Prevalence ranged from 40–69% across different treatments. Among continent individuals, 60% achieved continence without surgery. Antegrade enemas were the most commonly used treatment and had the highest associated continence rate. Ability to carry out a treatment independently increased with age. Multivariable logistic regression showed significantly higher odds of continence among individuals aged ≥ 12 years, female, non-Hispanic white, and with private insurance. CONCLUSIONS: The prevalence of continence was generally low and varied between treatment modalities. Better treatment algorithms considering patient factors may result in improved outcomes.

Objective To investigate social determinants of health (SDoH) interventions on individual health outcomes, population health, and cost for persons in the United States over age 18 living with disabilities and receiving long-term services and supports (LTSS) in noninstitutional settings. Data Sources A review using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was conducted of literature from PubMed, PsycINFO, REHABDATA, and Web of Science Core Collection published between January 1997 and July 2020. Study Selection Search terms were based on the primary SDoH domains identified by the Centers for Medicare and Medicaid's Accountable Health Communities Model. A total of 5082 abstracts were screened based on identification criteria of persons age 18 and above living in non-institutional, community-based settings receiving LTSS. Data Extraction During Level 2 review, articles were reviewed based on population focus, type of LTSS (personal assistance services, home care, adult day care, home modification, durable medical equipment, community transition services, caregiver supports and/or prevention services related to home- and community-based care), SDoH intervention and association with health outcomes, population health and/or cost. A total of 1037 abstracts underwent Level 2 review, yielding 131 publications or 1.3% for full review. Data Synthesis Studies (n=33) designed a priori to test outcomes of interventions were rated according to Grading Recommendations Assessment Development and Evaluation (GRADE) criteria. Qualifying articles that did not include interventions (n=98) were included in our summary of the literature but were not assessed by GRADE. Conclusions The preponderance of research surrounding SDoH and health outcomes has focused on older adults living with disabilities, and most interventions scored low or very low using GRADE criteria. Evidence is limited to the extent SDoH interventions are measured against outcomes for persons of all ages living with disabilities. Robust evaluation of models that feature SDoH interventions in partnership with community-based organizations is recommended as home and community-based care infrastructure expands in response to the American Rescue Plan Act of 2021.

Background Mobile health (mHealth) systems that support self-management can improve medical, functional, and psychosocial outcomes for individuals with disabilities and chronic conditions. The mHealth systems can potentially be expanded to support community integration. Objective The purposes of this study were to (1) partner with a community-based organization that supports community integration of individuals with disabilities; (2) identify software requirements needed to support community participation; and (3) iteratively refine an existing mHealth application to include new requirements. Methods Community Living and Support Services (CLASS), a nonprofit organization that serves individuals with disabilities in Pittsburgh, Pennsylvania, was identified as the focus group for this study. Key stakeholders within the Community Partners Program at CLASS proposed design requirements for an existing mHealth application, Interactive Mobile Health and Rehabilitation (iMHere) 2.0, that has been used to support self-management. Results We gathered qualitative data from a focus group composed of CLASS members to develop and iteratively revise iMHere 2.0 to include new modules and features to support community integration. A caregiver app was also developed. The new system contains features to support finance, transportation, client and caregiver communication, calendar and checklist management, upcoming medical and nonmedical appointments, social engagement, pain management, and access to a personal profile. Modifications were made to the following existing modules: education, mood, personal health record, goals, medications, and nutrition. Conclusions A successful partnership with a community-based organization that supports individuals with disabilities resulted in a newly designed mHealth system with features to support community integration.

AIM To compare the frequencies of neurosurgical procedures to treat comorbid conditions of myelomeningocele in patients who underwent fetal surgery versus postnatal surgery for closure of the placode. METHOD By utilizing the National Spina Bifida Patient Registry in a comparative effectiveness study, 298 fetal surgery patients were matched by birthdate (±3mo) and spina bifida clinic site with one to three postnatal surgery patients (n=648). Histories were obtained by record review on enrollment and yearly subsequently. Multivariable Poisson regression was used to compare frequencies of procedures between cohorts, with adjustments for sex, ethnicity, insurance status, spinal segmental level of motor function, age at last visit recorded in the Registry, and, for shunt revision in shunted patients, age at cerebrospinal fluid (CSF) diversion. RESULTS The median age at last visit was 4 years. In fully adjusted analyses in patients aged at least 12 months old, fetal surgery was associated with decreased frequency of CSF diversion for hydrocephalus by ventriculoperitoneal shunt insertion or endoscopic third ventriculostomy compared with postnatal surgery (46% vs 79%; incidence rate ratio=0.61; 95% confidence interval [CI] 0.53-0.71; p

Introduction The provision of seating and wheeled mobility devices is a complex process that requires trained professionals and multiple appointments throughout the service delivery process. However, this can be inconvenient and burdensome for individuals with mobility limitations or for individuals who live in rural areas. Rural areas often present unique difficulties regarding the provision of healthcare services including lengthy travel times to medical facilities and lack of specialized providers and medical technology. The purpose of this article is to provide a comprehensive overview of the development and implementation of a service delivery protocol for a home-based telerehabilitation assessment for wheelchair seating and mobility. Materials and Methods The telerehabilitation team consists of a trained wheelchair seating and mobility therapist and a telehealth clinical technician (TCT). In order to determine veterans that are appropriate for a home-based telerehabilitation assessment, a three-phase pre-assessment screening process was conducted by the therapist and TCT, including consult, chart, and phone review. Veterans that met all of the predetermined eligibility criteria were recommended for a telerehabilitation wheelchair assessment. The TCT traveled to the veteran’s residence with necessary evaluation and safety equipment and connected with the therapist remotely using the VA Video Connect platform. Assessment and veteran data were collected during the initial evaluation and then during a 21-day follow-up. Results Forty-three veterans were successfully seen via telerehabilitation for a seating and wheeled mobility assessment between November, 2017 and July, 2018. The average travel distance between the veteran’s residence and the clinic was 34.1 miles. The total telerehabilitation encounter times ranged from 45 min to 145 min. Conclusions The implementation of this service delivery protocol for wheelchair seating and mobility assessments demonstrated the benefits of using telehealth services including reaching rural veterans, reducing distance traveled, maximizing efficiency of provider schedules, and conducting realistic assessments in veterans’ home environments. Success can be attributed to being able to deliver best practice remotely and to the rapport of the TCT with the providers. Cultivating provider buy-in, selecting appropriate outcome measures, and restructuring workflows were additional lessons learned. The VA Video Connect platform is an accessible tool that can be easily learned by both veterans and providers and used beyond initial wheelchair seating evaluations for improved access to follow-up healthcare services.

Background Mobile health systems have been shown to be useful in supporting self-management by promoting adherence to schedules and longitudinal health interventions, especially in people with disabilities. The Interactive Mobile Health and Rehabilitation (iMHere) system was developed to empower people with disabilities and those with chronic conditions with supports needed for self-management and independent living. Since the first iteration of the iMHere 1.0 app, several studies have evaluated the accessibility and usability of the system. Potential opportunities to improve and simplify the user interface were identified, and the iMHere modules were redesigned accordingly. Objective In this study, we aim to evaluate the usability of the redesigned modules within the iMHere 1.0 app. Methods We evaluated the original and redesigned iMHere modules—MyMeds and SkinCare. The Purdue Pegboard Test was administered to assess the participants’ dexterity levels. Participants were then asked to perform a set of tasks using both the original and redesigned MyMeds and SkinCare modules to assess their efficiency and effectiveness. Usability was measured using the Telehealth Usability Questionnaire to evaluate 10 new accessibility features that were added to the redesigned app. Participants were also asked which version they preferred. Results In total, 24 participants with disabilities and varying degrees of dexterity impairments completed the entire study protocol. Participants displayed improved efficiency and effectiveness when using the redesigned modules compared with the original modules. The participants also reported improved usability and preferred the redesigned modules. Conclusions This study demonstrated that the iMHere system became more efficient, effective, and usable for individuals with dexterity impairments after redesigning it according to user-centered principles.

Purpose Investigate the type and frequency of wheelchair repairs and resulting adverse consequences in a Veteran population. Design Convenience cross-sectional sample survey. Setting Data were collected at the 2017 National Veterans Wheelchair Games. Participants Veterans who use a wheelchair ≥ 40 h/wk (n = 60). Intervention Not applicable. Main outcome measures Repairs and associated adverse consequences, wheelchair age and usage, type of repairs completed, time elapsed between breakdowns and repairs, and who completed repairs. Results 60 participants reported 124 repairs in the previous 6 months with 88.3% of participants requiring at least one repair. Consequences were reported by 43.5% of those experiencing repairs and were most commonly secondary to repairs in the electrical system, wheelchair frame, power/control system, and wheels and casters. Travelling greater distances during the week and on weekends was associated with increased rates of repairs (p = 0.01 and p = 0.02, respectively) and consequences (p = 0.03 and p = 0.03, respectively). Power wheelchairs were more likely to require repairs than manual wheelchairs (p = 0.007). The median time to repair was 7 [0.8,30] days. Vendors completed 82.1% of the repairs. Those experiencing longer repair times were more likely to experience adverse consequences (p Conclusion A high number of repairs and resulting adverse consequences occur for wheelchair users, particularly power wheelchair users, in a sample of Veterans. Interventions to prevent breakdowns and to address repairs and adverse consequences in a time-efficient manner are needed. Implications for rehabilitation In a sample of Veterans, a high number of repairs and resulting adverse consequences occur for wheelchair users, particularly power wheelchair users. There is an important clinical opportunity to help wheelchair users avoid repairs in the first place and reduce adverse consequences after breakdowns occur by improving wheelchair quality, providing preventative chair maintenance, and repairing breakdowns in a timely and efficient manner. These interventions may prove impactful in reducing the adverse medical, functional, and social consequences of wheelchair breakdowns.

Tips and falls are the most prominent causes of wheelchair accidents that occur when driving on uneven terrains and less accessible environments. The Mobility Enhancement Robotic Wheelchair (MEBot) was designed to improve the stability of Electric Powered Wheelchairs (EPW) when driving over these environments. MEBot offers six independently height-adjustable wheels to control attitude of its seat over uneven and angled terrains. Its attitude control application uses an inertial measurement unit to detect seat angles changes to adjust each wheel-height accordingly. MEBot was compared to commercial EPWs in terms of EPW performance (seat angle changes and response time) and participant perception (satisfaction and task-load demand) towards each device. Ten participants drove their own EPW and MEBot for five trials each through driving tasks that replicated outdoor environments. Results showed less change in the pitch angle when driving up and down a 10° slope using MEBot (5.6 ± 1.6°, 6.6 ± 0.5°) compared to the participants’ own EPW (14.6 ± 2.6°, 12.1 ± 2.6°). However, MEBot required 7.8 ± 3.0 s to self-adjust to the minimum angle when driving over the tasks. Participants reported no difference in satisfaction and task load demand between EPWs due to similarities in comfort and ease-of-use. Improving the speed and efficiency of MEBot's attitude control application will be addressed in future work based upon participants’ feedback.

Objective Evidence is limited regarding clinical factors associated with ambulation status over the lifespan of individuals with myelomeningocele. We used longitudinal data from the National Spina Bifida Patient Registry to model population-level variation in ambulation over time and hypothesized that effects of clinical factors associated with ambulation would vary by age and motor level. Design A population-averaged generalized estimating equation was used to estimate the probability of independent ambulation. Model predictors included time (age), race, ethnicity, sex, insurance, and interactions between time, motor level, and the number of orthopedic, noncerebral shunt neurosurgeries, and cerebral shunt neurosurgeries. Results The study cohort included 5371 participants with myelomeningocele. A change from sacral to low-lumbar motor level initially reduced the odds of independent ambulation (OR = 0.24, 95% CI = 0.15-0.38) but became insignificant with increasing age. Surgery count was associated with decreased odds of independent ambulation (orthopedic: OR = 0.65, 95% CI = 0.50-0.85; noncerebral shunt neurosurgery: OR = 0.65, 95% CI = 0.51-0.84; cerebral shunt: OR = 0.90, 95% CI = 0.83-0.98), with increasing effects seen at lower motor levels. Conclusions Our findings suggest that effects of several commonly accepted predictors of ambulation status vary with time. As the myelomeningocele population ages, it becomes increasingly important that study design account for this time-varying nature of clinical reality. To claim cme credits Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME CME OBJECTIVES: Upon completion of this article, the reader should be able to: (1) Describe general trends in ambulation status by age in the myelomeningocele population; (2) Recognize the nuances of cause and effect underlying the relationship between surgical intervention and ambulation status; (3) Explain why variation of clinical effect over time within myelomeningocele population matters. Level Advanced ACCREDITATION: The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Association of Academic Physiatrists designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Currently controllers that dynamically modulate functional electrical stimulation (FES) and a powered exoskeleton at the same time during standing-up movements are largely unavailable. In this paper, an optimal shared control of FES and a powered exoskeleton is designed to perform sitting to standing (STS) movements with a hybrid exoskeleton. A hierarchical control design is proposed to overcome the difficulties associated with developing an optimal real-time solution for the highly nonlinear and uncertain STS control model with multiple degrees of freedom. A higher-level robust nonlinear control design is derived to exponentially track a time-invariant desired STS movement profile. Then, a lower-level optimal control allocator is designed to distribute control between FES and the knee electric motors. The allocator uses a person’s muscle fatigue and recovery dynamics to determine an optimal ratio between the FES-elicited knee torque and the exoskeleton assist. Experiments were performed on human participants, two persons without disability and one person with spinal cord injury (SCI), to validate the feedback controller and the optimal torque allocator. The muscles of the participant with SCI did not actively contract to FES, so he was only tested with the powered exoskeleton controller. The experimental results show that the proposed hierarchical control design is a promising method to effect shared control in a hybrid exoskeleton.

Technologies capable of projecting injury and performance metrics to athletes and coaches are being developed. Wheelchair athletes must be cognizant of their upper limb health; therefore, systems must be designed to promote efficient transfer of energy to the handrims and evaluated for simultaneous effects on the upper limbs. This article is brief review of resources that help wheelchair users increase physiologic response to exercise, develop ideas for adaptive workout routines, locate accessible facilities and outdoor areas, and develop wheelchair sports-specific skills.

The purpose of this study was to evaluate the opinions of providers of mobility assistive technologies to help inform a research agenda and set priorities.This survey study was anonymous and gathered opinions of individuals who participate in the process to provide wheelchairs and other assistive technologies to clients. Participants were asked to rank the importance of developing various technologies and rank items against each other in terms of order of importance. Participants were also asked to respond to several open-ended questions or statements.A total of 161 providers from 35 states within the USA consented to participation and completed the survey.This survey revealed themes of advanced wheelchair design, assistive robotics and intelligent systems, human machine interfaces and smart device applications. It also outlined priorities for researchers to provide continuing education to clients and providers. These themes will be used to develop research and development priorities. Implications for Rehabilitation • Research in advanced wheelchair design is needed to facilitate travel and environmental access with wheelchairs and to develop alternative power sources for wheelchairs.• New assistive robotics and intelligent systems are needed to help wheelchairs overcome obstacles or self-adjust, assist wheelchair navigation in the community, assist caregivers and transfers, and aid ambulation.• Innovations in human machine interfaces may help advance the control of mobility devices and robots with the brain, eye movements, facial gesture recognition or other systems.• Development of new smart devices is needed for better control of the environment, monitoring activity and promoting healthy behaviours.

A hybrid neuroprosthesis that combines human muscle power, elicited through functional electrical stimulation (FES), with a powered orthosis may be advantageous over a sole FES or a powered exoskeleton-based rehabilitation system. The hybrid system can conceivably overcome torque reduction due to FES-induced muscle fatigue by complementarily using torque from the powered exoskeleton. The second advantage of the hybrid system is that the use of human muscle power can supplement the powered exoskeleton's power (motor torque) requirements; thus, potentially reducing the size and weight of a walking restoration system. To realize these advantages, however, it is unknown how to concurrently optimize desired control performance and allocation of control inputs between FES and electric motor. In this paper, a model predictive control-based dynamic control allocation (DCA) is used to allocate control between FES and the electric motor that simultaneously maintain a desired knee angle. The experimental results, depicting the performance of the DCA method while the muscle fatigues, are presented for an able-bodied participant and a participant with spinal cord injury. The experimental results showed that the motor torque recruited by the hybrid system was less than that recruited by the motor-only system, the algorithm can be easily used to allocate more control input to the electric motor as the muscle fatigues, and the muscle fatigue induced by the hybrid system was found to be less than the fatigue induced by sole FES. These results validate the aforementioned advantages of the hybrid system; thus implying the hybrid technology's potential use in walking rehabilitation.

Rehabilitation Engineering is the use of engineering principles applied to rehabilitation, disability, and independent living. Google Scholar is a searchable resource that allows people from around the world to create profiles of their interests and collaborations, and it provides a means to search the broad scientific and technical literature. Google Scholar was used to identify the 150 most cited people who listed Rehabilitation Engineering in their profile. Research impact, characteristics, and areas of research of the most cited rehabilitation engineers were examined. Furthermore, gender and geographical differences in research metrics of the highest citied rehabilitation engineers were investigated. Consumer priorities in rehabilitation engineering were identified using a voice of consumer (VoC) survey and recent literature based on VoC studies. Gaps between research publication and activities and consumer priorities were identified to recommend seven areas of research with high demand and opportunity for growth and innovation. Implications. • Rehabilitation Engineering appears to be a male-dominated profession similar to other engineering disciplines. • There are disparities in the number of rehabilitation engineers and measures of scientific productivity between different regions of the world. • Despite people identifying as rehabilitation engineers in every region, the most cited were identified as working in the World Health Organization Region of Americas and the European Region. • There appears to be benefits for rehabilitation engineers who have multiple collaborations and who work in doctoral degree-granting institutions. • Seven areas of research identified as consumer priorities were not captured by the most cited rehabilitation engineers these include: 1) Transportation and automobile driving 2) Recreation/Leisure 3) Autonomous vehicles/wheelchairs 4) Smart home/IoT 5) Computer/mobile applications and telecommunications 6) Patient transfer devices 7) Power sources. These priorities are opportunities for growth and innovation.