SmartWheel Overview

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SmartWheel Overview

• The Data Revolution is here

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What is the SmartWheel?

• It provides
• never before available
• wheelchair push data
• for the rehab professional

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The SmartWheel is a Data Revolution

• The SmartWheel measures the characteristics of
  every push on the handrim
• Examples of data provided by the SmartWheel
  include
• Average force it takes to push a wheelchair
• Length of each push on the handrim
• Smoothness of each push
• Push frequency

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SmartWheel Data Easy to Gather and Easy to Use

• The SmartWheel mounts quickly and easily to any
  wheelchair
• On board memory and Wi-Fi wireless enable data
  collection in the clinic, the hallway or outside
  at the park
• The SmartWheels Clinical Wizard Software
  provides
• Auto detection of the start and stop of client
  trials
• Real-time graphical display of each push
• MS Word report generation at the push of a button
• Client database management is automatic

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The SmartWheel Today

• There are 58 SmartWheels being used across
  the US, Canada, Europe and Asia
• The SmartWheel User Group
• Active advisory group (annual meetings
  quarterly teleconferences)
• Made up of leading rehab professionals using the
  SmartWheel
• Produced a standard clinical protocol for
  SmartWheel Usage
• Created a worldwide database to gather and store
  average push data
• The Consortium of Spinal Cord Medicine
• Created a Clinical Practice Guideline entitled
  Preservation of Upper Limb Function Following
  Spinal Cord Injury.
• The SmartWheel measures all the wheelchair push
  data specified by the clinical guidelines

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Sample Organizations Using the SmartWheel

• The Mayo Clinic
• Schwab Rehabilitation Hospital, Sinai Health
  System
• University of Illinois at Chicago
• Craig Hospital
• Banner Health, Banner Good Samaritan Medical
  Center
• BES Rehab, the United Kingdom
• 15 VA Medical Centers
• Washington University at St. Louis and the
  Enabling Mobility Center
• Center for Assistive Technology University of
  Pittsburgh Medical Center
• The Ohio State University Medical Center
• The University of Miami and The Miami Project
• Paralyzed Veterans of America

• Rehabilitation Institute of Chicago
• Human Engineering Research Laboratories,
  University of Pittsburgh
• Kessler Medical Rehabilitation Research and
  Education Corporation
• The University of Washington
• Rehabilitation Institute of Montreal
• University College London, Royal National
  Orthopaedic Hospital
• Vista Medical Europe
• Memorial Hermann TIRR
• University of Alberta
• University of British Columbia
• Shriners Hospital for Children-Philadelphia
• Richmond VA
• Rancho Los Amigos

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The SmartWheel In-Depth - Part 1Pain and
Injury Prevalence, Consequences, and the
Benefits of Quantitative Push Data

• The SmartWheels clinical application is
  supported by extensive research
• All research references that support the
  information provided in the slides that follow
  are available upon request or can be found at
  www.3rivers.com/swpapers.php

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High Prevalence of Upper Extremity Pain and Injury

• As much as 75 of wheelchair users develop pain
• Shoulder, elbow, wrist, and hand are all
  potentially involved
• Prevelance of pain increases with length of time
  in a wheelchair
• 65 of those with pain were found to have rotator
  cuff tears or tendinitis.
• 49-73 of wheelchair users have Carpal Tunnel
  Syndrome.

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Consequences of Pain and Repetitive Strain
Injury

• Lifestyle changes
• Decreased quality of life
• Functional decline
• Multiple cost factors
• Psychological costs
• Treatment costs
• New equipment costs

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Research Evidence of the Sources of Pain and
Injury

• Evidence Links How Someone Pushes to the onset
  of
• Wrist Pain Injury
• Shoulder Pain Injury
• Research Conclusion Propulsion Style Matters
• Long, smooth strokes maximize efficiency
  minimize wasted forces
• Long strokes minimize stroke frequency/cadence
• Smooth strokes minimize rapid loading (e.g.,
  pounding on the rim)
• Propulsion style and biomechanics are influenced
  by
• Training
• Wheelchair Selection (e.g., heavy vs. ultralight)
• Wheelchair Set-Up (e.g., axle position)

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The Importance of Quantitative Data

• Bolsters funding justification
• Medical Insurance and Vocational Rehab
• Provides data to support equipment decisions
• Client education
• Feedback to promote training (e.g., push
  technique)
• Provides visit-to-visit data to track client
  outcomes
• Database and knowledge base creation

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The SmartWheel In-Depth Part 2The SmartWheel
Standard Clinical Protocol
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Standard Protocol for Using the SmartWheel

• Criteria for the Development of the Protocol
• Can be completed quickly and easily
• Data collected is high value
• Majority of clients would be able to perform
• Taxing enough to elicit real differences in
  comparisons
• Protocol enables comparisons
• Compare push techniques
• Long strokes vs. short strokes
• Compare wheelchair configurations
• Location of axle plate
• Compare wheelchairs
• Heavy vs ultralight
• Adjustable vs. non-adjustable

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Protocol Tasks and Output

• Recommended Tasks
• 10 m on tile
• 10 m on carpet
• Ramp (ADA compliant)
• Figure 8 on tile

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SmartWheel Central Datapoolas of February 2007

• Data collected used the standard clinical
  protocol as defined by the SmartWheel User Group
• So far
• 128 Unique Individuals 1400 Separate Trials
• Averages Age (40), Weight (178 lbs), Height
  (510)
• 70 SCI
• Key Steady State averages for this population
  are
• Peak Average Force (newtons) Tile 72
  Carpet 87
• Velocity (m/s) Tile 1.2 Carpet1.0
• Push Frequency (Push/sec) Tile 1.1 Carpet1.1

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Hot Off the Press (soon) . . .

• Preliminary Outcomes of the SmartWheel Users
  Group Database A Proposed Framework for
  Clinicians to Objectively Evaluation Manual
  Wheelchair Propulsion
• Rachel Cowan, MS Michael Boninger, MD, Bonita
  Sawatzky, PhD, Brian Mazoyer, PTA, Rory Cooper,
  PhD
• In press. Archives of Physical Medicine and
  Rehabilitation.

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Summary of Objectives

• Describe a standard clinical protocol for the
  objective assessment of manual wheelchair
  propulsion
• Establish preliminary (reference) wheelchair
  propulsion values for temporal and kinetic
  parameters derived from the SmartWheel standard
  clinical protocol
• Develop graphical references and a proposed
  application process for use by clinicians for the
  objective assessment of manual wheelchair
  propulsion.
• Supports CLINICIANS in the evaluation
  determination of necessary interventions
  (treatment, equipment, education) to support
  individuals who propel manual wheelchairs.

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Why are the Paper Objectives Important?

• Medicare (CMS) requires clinicians to demonstrate
  why a wheelchair pre-defined by policy is
  insufficient.
• CMS is only concerned with mobility within the
  home
• Justifications based on community function are
  rejected
• Subjective clinical assessments are often
  considered insufficient
• What CMS will approve often ignores individual
  rehab needs
• The CMS and evidence-based rehab gap needs to be
  eliminated
• Quantitative assessment of wheelchair users on
  home surfaces may close the gap between CMS
  policy and actual rehab needs

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Key Parameter Selection

• 4 of the 21 SmartWheel parameters were selected
  as most clinically important.
• velocity
• average peak force
• push frequency
• stroke length
• Velocity was selected because all users should be
  able to achieve a minimum threshold velocity
• A velocity of 1.06 m/s is the minimum needed to
  safely cross an intersection
• Force, push frequency, and stroke length were
  selected based on recommendations from the
  Clinical Practice Guidelines
• The CPG recommends the minimization of force and
  frequency of repetitive upper limb tasks and use
  of long strokes during propulsion

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The Importance of Velocity

• Use of velocity to evaluate the potential of a
  MWU to achieve successful community function is
  not diagnosis specific.
• Any MWU should be able to achieve a minimal
  velocity for functional purposes, regardless of
  diagnosis.
• This is consistent with the CMS National Coverage
  Determination (NCD) which bases coverage of power
  and manual mobility on function, independent of
  diagnosis.

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How does it work in the Clinic?

• Is velocity above the threshold to safely cross
  the street (1.06 m/s)?
• If no, clinician designs an intervention to
  achieve threshold velocity
• Interventions could be strength training,
  propulsion training, alterations of chair set-up
  or use of an ultra-light, adjustable chair.
• Try to maintain velocity while minimizing force
  and push frequency
• The ideal is a user propelling above threshold
  velocity at below average force or push frequency
  across all surfaces (Area A).
• Users pushing with above average force or push
  frequency at below threshold velocity may require
  powered mobility options (Area C).

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A or B for velocityOnly A for Push Frequency and
Force
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How does it work in the Clinic?
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How much improvement?

• How much of a change in the key parameters is
  important?
• 0.16 m/s is the difference between a preferred
  walking velocity (1.22 m/s) and the minimum
  needed to safely cross a street (1.06 m/s).
• Because of this small difference of .16 m/s
  clinicians may argue that a small, consistent
  increase in self-selected velocity is important.
• The amount of force needed to propel a wheelchair
  is small, highly repetitive, and related to upper
  extremity injury
• Small reductions in force and/or push frequency
  would cumulatively decrease exposure 2000
  pushes per day
• Therefore systematic reductions in force or push
  frequency while maintaining a functional velocity
  indicate objective success of an intervention.

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Conclusions

• A protocol to evaluate manual wheelchair
  propulsion in the clinic is available
• A proposed framework and application process for
  clinicians to objectively evaluate manual
  wheelchair propulsion is presented.
• This method provides a general technique which
  clinicians may be able to use to compare a
  clients propulsion to a larger population
• And/or to compare a clients propulsion before
  and after an intervention to assess the impact of
  the intervention.

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Manual Wheelchair Propulsion Measurement
Clinical Applications Case Examples
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Real-Time Data Viewer
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Clinical Applications

• Education for push mechanics
• Automated Example
• SmartWheel used as a training device with visual
  feedback to encourage/train optimal push mechanics

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Braking wheel w/ initiation of each push
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Education visual feedback
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Implementation of CPG

• Implementation of Clinical Practice Guidelines
  Preservation of Upper Limb Function in Spinal
  Cord Injury.
• The following specific Recommendations from the
  CPG can be specifically applied to wheelchair
  propulsion . . .

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Implementation of CPG

• Recommendation 4. Minimize the force required to
  complete upper limb tasks.

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High Force Propulsion
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Lowered Forces . . .
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Implementation of CPG

• Recommendation 10. Educate the patient to
• a) use long, smooth strokes that limit high
  impacts on the pushrim and
• b) allow the hand to drift down naturally,
  keeping it below the pushrim when not in actual
  contact with that part of the wheelchair.

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Smooth Long Strokes - Observational
Reach back and contact rim
Release rim in full elbow extension
Slide courtesy of University of Pittsburgh
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Propulsion Education

• Semicircular pattern
• Propulsion
• Recovery

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Smooth Long Strokes automated
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Smooth Long Strokes automated
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Clinical Applications

• Patient and clinician feedback for manual
  wheelchair selection and configuration
• Comparative data used to look at one chair vs.
  another or same chair with different set-up (i.e.
  orientation of seat over rear wheel or position
  of rear wheel horizontally).

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Wheel Position
Wheel Back
Wheel now 2 fwd
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Wheel Back - original
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Wheel forward 2 inches
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Clinical Applications

• Power mobility justification
• Objective measurement to determine how well the
  individual can propel manual wheelchair
• Propel at speed safe to cross street?
• Able to contact handrim _at_ acceptable angles?
• (ROM or strength limitations impacting push
  angle)
• Able to generate adequate force to move chair?

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Power mobility?
1.3 mph .6 m/s
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Medicare and the SmartWheel

• Services provided by the SmartWheel are valuable.
• There are current Medicare codes, under which
  SmartWheel usage may fit, such as
• CPT 97542 (Wheelchair management/propulsion)
• CPT 97750 (Physical performance test or
  measurement)
• Medicare code usage and development is part of
  the SmartWheels clinical application process.

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Thank You and Acknowledgements

• Thank you for your interest in the SmartWheel
• Thank You to Our Granting Agencies
• National Center for Medical Rehabilitation
  Research (within NICHD/NIH). SmartWheel
  development was supported by NIH grants
  R41-HD39020-01 R42-HD39020-02.
• National Institute on Disability and
  Rehabilitation Research (U.S. Dept of Ed.)
• Paralyzed Veterans of America
• Thank to Kendra Betz and Rachel Cowan for their
  excellent Clinical Application of the SmartWheel