Proceedings of the Web-Based Workshop on Independent Wheelchair Transfers (IWT): September 26, 2012
The U.S. Access Board and the National Institute on Disability and Rehabilitation Research (NIDRR) has sponsored a multi-year research project on independent transfers to gain a better understanding of how the built environment impacts transfer performance. One of the purposes of the project was to form an international workgroup of experts with various backgrounds in independent wheelchair transfers in order to facilitate an exchange of ideas and to develop future research directions. The ultimate outcome of the Independent Wheelchair Transfer (IWT) Workgroup is a research agenda that addresses current unmet needs concerning independent transfers in the built environment.
A live web-based IWT Workgroup meeting was held on September 26th, 2012. It was organized and facilitated by project investigators from the University of Pittsburgh’s Human Engineering Research Laboratory (HERL). An online web-based videoconferencing program was used to conduct the meeting. The daylong event was comprised of a combination of two all-participant meetings and three small group breakout meetings. The following small group meeting topics were chosen to focus the discussions on specific areas concerning independent wheelchair transfers.
Sub-topic Area 1 Standards: Identifying areas where current accessibility standards for elements designed for independent transfers need updating.
Sub-topic Area 2 Research: Identifying what additional research is needed concerning independent transfers, particularly as it relates to the impact of setup on the transfer process.
Sub-topic Area 3 Other Issues: Identifying other issues (e.g., multi-step transfers, transfer-aids, surface stability, surface slope/cross-slope, seat-to-surface gap, etc.) related to independent transfer in the built environment that requires further examination.
Potential participants were identified by the University of Pittsburgh study investigators’, the U.S. Access Board, NIDRR project managers personal networks of collaborators and acquaintances in the field, authors of scientific papers related to transfers among wheelchair users, and by internet searches for individuals whose work closely related to this study's purpose. Of the 67 people invited, 31 participated in the live event. The primary occupations of the participants included university professors, clinicians, human factors & ergonomic specialists, architects, assistive device manufacturers, researchers, and engineers. The majority of the participants had at least 15 years or more experience in their current profession (67.7%), 9.7% had 10 to 15 years, 9.7% had 5 to 10 years, and 12.9% had 2 to 5 years of experience. Prior to the meeting, participants were asked to read the research project report from Phase 1 of this research study and the existing standards pertaining to transfers. Participants were assigned to sub-topic groups prior to the live meeting based on preference and so that each group had a relatively even distribution of the occupations and wheelchair users represented. Full verbatim transcriptions were obtained from the audio recordings of the live discussions that transpired during each sub-topic meeting. Three reviewers independently reviewed the transcriptions and identified main 'themes' for each of the sub-topic group discussions. The reviewers met to discuss and reach consensus on the main themes for each group. The transcriptions were independently reviewed again to assign each participant’s remarks to one of the main themes. Afterwards, reviewers met to compare and contrast their findings and reach consensus on the themes and assignments for each remark. The following graph (Figure 1) lists all the main themes identified in each sub-topic group and shows where there was overlap in the themes among the groups. All three groups, despite the difference in the sub-topic area of discussion raised points concerning user issues, the transfer process, the built environment, and considerations regarding future research studies. The Research and Other Issues groups both made remarks related to transfer training and evaluation, education and outreach and the complex interaction that exists between the environment, user, and/or transfer process. The Current Standards and Other Issues groups both expressed that the wheelchair design has an impact on transfers. The Research Group remarked about the lack of standardized transfer terminology and definitions in the field. Participant remarks that were made under each group for each main theme were combined across the groups and are outlined below followed by a summary statement for each theme.
Figure 1 - Overlapping Themes of the Three Sub-Topic Areas
Alternate Text Figure 1: This illustration shows three overlapping circles. Each circle contains the name of the sub-topic area and letters that symbolize all the main themes that were identified within that sub-topic area. Contained within the overlap area formed by all three circles are the themes that were present in all three sub-topic groups (Transfer Process/Techniques/Preferences, Built Environment, User Issues, Factors and Concerns, and Considerations regarding Future Studies. An area of overlap between two of the circles (sub-topic Research and sub-topic Other Issues) contains the themes: Transfer Training and Evaluation, Interactions between the Environment, User, and Transfer Processes/Techniques and Preferences, and Education and Outreach. An area of overlap between two other circles (sub-topic Current Standards and sub-topic Research) was Wheelchair Configuration and Design. One circle (sub-topic Research) shows that Terminology and Definition of Transfer Movement/Technique was unique to that sub-topic area.
IWT Workshop Themes and Remarks
Summary Statement: Current wheelchair designs that are optimally designed for efficient propulsion or stability can make it harder to do transfers. Current wheelchair designs do not match up properly with areas designed for parallel wheelchair transfers. Future wheelchair designs should consider incorporating adjustments that make transfers easier.
Summary Statement: Little is known about the cohort of people who perform independent wheelchairs and their requirements for transfer with regards to the type of device they use, their disability, physical characteristics, preferences, level of wheelchair transfer skills, and length of time using a wheelchair. The environmental and personal barriers to transfers in relation to lifestyle and the desire to perform a transfer are not well understood. More information is needed to determine where users face the greatest difficulties with transfers. More information is also required to determine environmental factor(s) that most often impacts transfers.
Summary Statement: Users tend to choose a type of transfer (e.g. forward, lateral, etc.) based on the characteristics of the transfer surface. Factors to consider in the initial stages of transfer include the position of the user in the WMD, WMD orientation with respect to the transfer surface which is dependent on footrest placement and wheelchair design, and preferred direction of transfer. During the transfer, hand placement and foot contact are important. The transfer surface must not only be designed to enable for a successful transfer but also supports the user in a position that meets their functional needs. The transfer back from the surface may involve repositioning of the device and require different space needs. Transfer technique has an impact on how efficiently and safely someone transfers. Users are pressured when they have limited time to perform transfers.
Summary Statement: Environmental factors impacting transfers include the transfer surface (size, height, firmness, stability, texture, and presence of obstacles), the space next to the transfer surface that is available for maneuvering and positioning the device, space under the transfer surface, and space for stowing the device where applicable. Characteristics of the floor surface where the transfer takes place should be considered. A number of environmental accommodations to consider include multiple fixed setups (e.g. more than one accessible bathroom stall), adjustable accessibility features, and availability and public access to transfer assist devices. Transfer assist devices are needed to help stabilize someone who needs to transfer to an unstable surface, minimize or bridge the gap and/or height differential between the mobility device and transfer surface, provide foot support, and act as an anchor to help pull or assist with transfer. More information is needed on grab bar/handhold physical characteristics, positioning and placement which needs to consider functional reach, strength of the user and indications for their use. Certain environments such as motor vehicle transfers, boat transfers, amusement park ride transfers and transfers into movie theater seats have unique challenges. Non-compliant installations of equipment, errors in construction, and broken down surfaces cause problems with transfers. Consider that changing an environment for a specific group of wheeled mobility device users may limit another. Consider a ‘level of difficulty’ rating system that would indicate the type of transfer and degree of transfer difficulty for a given environment.
Summary Statement: Transfers are difficult to learn for newly injured users with limited strength. Equipment should be developed to support transfer training for these users. Short-term wheelchair users may not have been provided with adequate information or practice on how to properly transfer. It’s difficult for long-term users who use “poor” techniques to learn and adopt “correct” techniques. The field needs a way to describe clinically what “correct” technique is. Essential wheelchair skills may not be taught in rehabilitation due to limited time. Rehab stays are too short and have resulted in less time spent on transfer training. More data is needed on transfer training outcomes to help justify longer rehab stays. Clinicians have limited time to learn, teach and evaluate transfer skills. Educational materials are needed that teach clinicians how to teach transfers that go beyond the “basics”. Tele-rehabilitation and video training would enable remote training opportunities for clinicians.
Summary Statement: Interactions exist between the transfer environment, user characteristics, and transfer skill sets. These interactions make it difficult to understand the problems that wheelchair users have with transferring in different kinds of environments. Should the environment be tailored around the skill set or vice versa and what is the economic cost to configuring an environment when someone is missing a skill set? In what ways does designing an easier environment impact users? What is the relationship between the kind of transfer and the environment that is to be made accessible? The goals for making the environment more accessible need to be better defined –do we design for everybody that can independently transfer or for those with certain capabilities. A greater understanding is needed of the types of transfers that work best for users with certain conditions and in each environment.
Summary Statement: The field needs clear and consistent terminology for describing the movements involved for various types of transfers so technique during an event can be characterized. This would enable for uniformity in communicating, sharing and distributing evidence.
Summary Statement: There is a knowledge translation gap with transfers that exists among stakeholders. For example, users are not aware of the durable medical equipment and assistive devices that are available to help them transfer, clinicians are not aware of the evidence that exists on transfer technique and mainstream designers are not aware of the needs of those who transfer. Healthcare and wheelchair manufacturers do not regard transfer issues as a high priority. A number of potential solutions to these issues were identified including showing outcomes on what a 'good' or 'bad' environment causes, users advocating for more accessible environments, educating mainstream students and professionals who would be involved with environmental design on the needs of those who transfer early on in their careers, educating wheelchair manufacturers on why they need to keep stability during transfer in mind when designing wheelchairs, and educating clinicians on how to select and configure chairs to make transferring easier. Collaboration among stakeholders is needed to share data and bring about design changes that make transfers easier.
Summary Statement: Research on transfers should consider the variability that exists among user groups regarding the range in transfer abilities and needs, that there are many variables that impact transfers, studies involving certain user groups means the environment will be designed around that group's needs, and that laboratory based research isn't directly applicable to real-world. Much can be learned by surveying and watching users perform transfers in natural environments. Biomechanics research outside of the lab would be more ecological and may be possible with portable instrumentation. Research is needed to support the importance of transfer training and to determine what types of movements should be avoided and those that are least injurious on tissues. Data is needed on clear space for those who transfer within the ADA transfer height allowances. Guidelines should be expanded to address assisted transfers.
The purpose of the IWT workshop was to bring together experts in the field to discuss the issues that wheelchair users currently face within the built environment with regard to independent transfers. The IWT web-based meeting presented a unique opportunity to gather and share information among experts in the field. Rich information and new ideas in each sub-topic area were attained through the use of focus groups that were designed to encourage an open flow of ideas amongst participants. The diversity of professional experience and interests in each group added breadth of knowledge to the content of the information obtained from each group. Although a systematic process was followed to translate the transcripts into a summary and decide upon themes, the results are the opinions of experts based on their experience and may or may not represent the opinions of other experts in the field who were not part of the focus groups.
While some clear main themes arose from the discussions in each group, there were some conflicting areas between and within sub-topic groups. For example there were comments about addressing wheelchair design to adapt to the environment while other remarks were made about adapting the environment to accommodate for current wheelchair designs. Similarly, questions were raised as to whether the environment needs to accommodate what may be deficits in transfer skill or is it a matter of training better transfer technique to overcome environmental challenges to performing transfers. Other questionable areas pertained to the degree that the environment needs to be adapted in order to accommodate specific types of transfers or degrees of physical capacity. The comments received indicate that the area of independent transfers is multi-faceted and several factors need to be taken into consideration when considering how to make environments more accessible to wheelchair users who independently transfer.
It was surprising that despite choosing different small group topics to discuss, many overlapping themes were discovered. Only one unique theme was uncovered: Terminology and Definition of Transfer Movement/Technique in sub-topic meeting 2 (Research). This is because the discussion went to developing materials and guidelines to be used by clinicians for transfer training. Before that can happen, the field needs to standardize terms that everyone agrees on.
All things considered, advancements in technology have led to new wheelchair designs and an opportunity for a more diverse group of individuals with disabilities to participate in their communities. The interface of newer wheelchairs with the built environment is different now than it was when the standards were originally developed. Moreover changes in healthcare policy and insurance coverage have decreased the time that individuals spend in inpatient rehabilitation. Subsequently, therapists have less time to spend with the patient addressing the wheelchair and transfer skills necessary to perform transfers in different environments. Individuals may be released from a rehabilitation program before they have had an opportunity to develop adequate strength and physical conditioning needed to do biomechanically correct transfers. Transfer performance cannot be attributed to just one factor, but some combination of the users' preferences, physical ability, technique, WMD, and the environment.
Although a significant amount of research has already been done, the focus groups identified additional areas where future research is warranted. Tremendous opportunity exists for collaborative research amongst the stakeholders (e.g. United States Access Board, engineers, physical and occupational therapists, university researchers, architects, and manufacturers of assistive technology) which could lead to better transfer technology, environments and techniques for wheelchair users.
The material used for this study was funded by the Department of Education (NIDRR), United States Access Board grant H133E070024 and Project #84.133E. The contents do not represent the views of the Department of Veterans Affairs or the United States Government. A special thank you to all the participants who contributed to the content in these proceedings.
Name: Todd Andersen
Title: Building Code Consultant
Affiliation: Member of the ICC/ANSI A117.1 Committee on Accessibility
Name: Rex Bellar
Title: Manager, Domestic Accessibility Program
Affiliation: Walt Disney Parks & Resorts
Name: Kendra Betz, PT
Title: Physical Therapist – Prosthetics Clinical Coordinator
Affiliation: VA Central Office
Name: Roland Binker, AIA, NCARB, LEED-AP
Title: Principal, Medical Planning Director
Affiliation: AECOM (legacy Ellerbe Becket)
Name: Karen Braitmayer, FAIA
Title: Studio Pacifica Ltd. Principal Architect/ US Access Board Member
Affiliation: US Access Board and Studio Pacifica, Ltd
Name: Sarah Brown
Title: Product Manager
Affiliation: Invacare Corp.
Name: Rory A. Cooper, PhD (Facilitator)
Title: Distinguished Professor/Director
Affiliation: University of Pittsburgh/Human Engineering Research Laboratory (HERL)
Name: Theresa Crytzer, DPT, ATP (Facilitator)
Title: Assistant Professor
Affiliation: University of Pittsburgh/Human Engineering Research Laboratory (HERL)
Name: Clive D'Souza
Title: PhD Student Researcher
Affiliation: University of Buffalo
Name: Trevor Dyson-Hudson, MD
Title: Interim-Director of Spinal Cord Injury / Assistant Professor at the University of Medicine and Dentistry of New Jersey – New Jersey Medical School (UMDNJ-NJMS)
Affiliation: Kessler Foundation Research Center
Name: Dany Gagnon, PT, PhD
Title: Assistant Professor
Affiliation: University of Montreal
Name: Dianne Goodwin
Title: President and Founder /Director of R&D
Affiliation: BlueSky Designs
Name: Peggy Greenwell
Title: Accessibility Specialist
Affiliation: US Access Board
Name: Garrett Grindle
Title: Research Associate/PhD Candidate
Affiliation: University of Pittsburgh/Human Engineering Research Laboratory (HERL)
Name: Jennifer Hastings, PT, PhD
Title: Director of Physical Therapy / Associate Professor
Affiliation: University of Puget Sound
Name: Damon Jurkiewicz
Title: Senior Industrial Designer
Affiliation: Invacare Corp.
Name: Padmaja Kankipati, PhD
Title: Post-Doctoral Associate
Affiliation: University of Pittsburgh/Human Engineering Research Laboratory (HERL)
Name: Kati Karinharju
Title: Senior Lecturer, MSc
Affiliation: Satakunta University of Applied Sciences, ltd / Faculty of Social Services and Health Care Pori, Finland
Name: Alicia M. Koontz, PhD, RET (Facilitator)
Title: Associate Professor/Research Biomedical Engineer
Affiliation: University of Pittsburgh/Human Engineering Research Laboratory (HERL)
Name: Howard Loewenthal
Title: Principal Engineer
Affiliation: Invacare Corp.
Name: Linda Madaris, PhD, DNP, ARNP-C, CRRN
Title: Program Director for Spinal Cord Injury
Affiliation: James A Haley VA Hospital Tampa, Florida
Name: Marsha Mazz
Title: Director of the Office of Technical and Information Services
Affiliation: US Access Board
Name: Nicole McCune
Title: RN Nurse Educator HJH Community Living Center Site Leader for Safe Patient Handling
Affiliation: VA Pittsburgh Health Care System Email: nicole.mcCune@va.gov
Name: Jean L. Minkel, PT, ATP
Title: Senior Vice President
Affiliation: Independence Care System/Minkel Consulting
Name: Bob Minnick, PE, CSP
Title: Technical Director (Disney Safety and Accessibility Expert)
Affiliation: Walt Disney Parks & Resorts
Name: Steven Mitchell, OTR/L, ATP
Title: Clinical Specialist Seating/Wheeled Mobility & Assistive Technology
Affiliation: VA Cleveland Medical Center
Name: Rex Pace
Title: Technical Assistance Coordinator
Affiliation: US Access Board
Name: Michael Pavol, PhD
Title: Associate Professor
Affiliation: Oregon State University
Name: Phillip Requejo, PhD
Title: Director of Rehabilitation Engineering Program / Adjunct Assistant Professor
Affiliation: Rancho Los Amigos National Rehabilitation / University of Southern California
Name: Laura Rice, PhD, MPT, ATP
Title: Visiting Assistant Professor
Affiliation: University of Illinois at Urbana-Champaign
Name: Linda M. Riek, DPT, PhD
Title: Academic Professor
Affiliation: Department of Physical Therapy Nazareth College
Name: Mary Esther Van Shura, Ed.D
Title: Director of Community Affairs
Affiliation: Office of the County Executive (Allegheny County Pennsylvania)
Name: Karen St. Germain, OT
Title: Occupational Therapist
Affiliation: Ottawa Hospital Rehabilitation Centre
Name: Maria Toro
Title: Graduate Student Researcher
Affiliation: University of Pittsburgh/Human Engineering Research Laboratory (HERL)
Name: Tom Tuckowski
Title: Director of Engineering
Affiliation: Invacare Corp.