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ICF model as applied to elderly and aging MWC users. ICF indicates International Classifi cation of Functioning, Disability, and Health; MWC, manual wheelchair; ADL, activities of daily living; BMI, body mass index. 

ICF model as applied to elderly and aging MWC users. ICF indicates International Classifi cation of Functioning, Disability, and Health; MWC, manual wheelchair; ADL, activities of daily living; BMI, body mass index. 

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Article
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Elderly and aging manual wheelchair users have an increased risk for accelerated loss of function and mobility that greatly limits independence and affects quality of life. This review addresses important issues for preserving function and mobility among elderly and aging individuals who use a manual wheelchair by presenting the current available e...

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Context 1
... limitations and restrictions imposed by the pain and dysfunction in elderly and aging wheelchair users can be described in the framework defi ned by the International Classifi cation of Functioning, Disability, and Health (ICF) 73 ( Figure 1 ). The ICF can be an effective framework both for identifying key elements that must be addressed in reha- bilitation interventions 74-79 and for guiding provision and classifi cation of assistive technology. ...
Context 2
... 45 Pelvic obliquity exacerbates trunk imbalance and leads to an unstable base for the trunk in an upright position, necessitating the use of the hands to support the spine, compromising their ability to use their hands for ADL. 44 , 48 Pelvic obliquity also increases risk for pressure ulcer formation secondary to asymmetrical sitting pressures. 47 A posteriorly tilted pelvis is often seen in the elderly who have been primarily in a wheelchair or bed and have tight lumbar spines and hamstring muscles. 45 This slouched posture is associated with sacral sitting and sliding out of their wheelchair, possibly causing shearing-type pressure ulcers. This slouched posture starts with the posterior pelvic tilt and ultimately limits the active mobility in the upper extremities as the upper body is slumped forward. The associated decline in range of motion of the hips from a slouched posteriorly tilted pelvis signifi cantly limits upper extremity use and therefore ADL, such as positioning and transferring and maintenance of hygiene, thereby adversely affecting QOL. 49 Improvement in survival rate of persons with disabilities and in the general aging population has increased the number of persons at risk for pressure ulcers. It has been estimated that 5 million people in the United States have chronic pressure ulcers, there are 1.1 million to 1.8 million people developing new ulcers each year, and the fi nancial cost and the emotional burden are heavy. 50 The 2 groups at the highest risk are the elderly and those persons with SCI. However, advances in seating and mobility technologies have made a difference in controlling deformities, preventing pressure ulcers, and improving each individual’s QOL. Aging skin loses elasticity, fi rmness, thickness, moisture, sensitivity, and vascularity and may reduce the tolerance to pressure and shearing forces, resulting in a greater risk for pressure ulcer development. 51 The incidence of pressure ulcers in persons with SCI increases with the duration of injury, 15% at 1 year to 30% at 20 years of follow-up. 35 In a study completed in the United Kingdom for the prevalence of pressure ulcers among elderly patients in general medical practice, the probability of developing a pressure ulcer increased dramatically with increasing age. As compared with those 65 to 70 years of age, those older than 80 years were 4 to 20 times more likely to develop a pressure ulcer. 52 Advanced age played an important role in the development of pressure ulcers after accounting for demographic and clinical factors. An aging-related decrease in muscle mass and vascularity may reduce the tolerance of aged skin to pressure and shearing forces, leading to the development of pressure ulcers. 53 A decrease in the density of adr- energic receptors, which would have an effect on blood supply in the skin below the level of injury and collagen loss, 54 may also play a role in the skin’s ability to resist mechanical shear and pressure. 55 An increased risk of pressure ulcers among older adults has been shown by previ- ous studies in the SCI population. 56 , 57 Advanced age appears to be related not only to the frequency of pressure ulcers but also to their severity. The majority of people with mobility impairments, particularly older individuals who use an MWC for mobility, do not meet levels of physical activity recommended for health and disease prevention. 58-60 Inactivity in individuals with chronic disabilities who use an MWC results in signifi cant and costly secondary complications, such as pressure ulcers, obesity, diabetes, osteoporosis, and cardiovascular comorbidities. 61-66 In addition to the physiological benefi ts, participation in exercise and sports activities by MWC users is associated with decreased depression 67 and improved community integration and QOL 60 , 68-71 Increasing physical activity in this population, however, typically involves upper extremity exercise. Chronic shoulder pain with associated physical dysfunctions is a common secondary condi- tion in MWC users that further limits mobility and participation and negatively impacts QOL. 42 Gutierrez et al 42 interviewed 80 SCI participants with shoulder pain and identifi ed that higher intensities of shoulder pain (as determined by Wheelchair User’s Shoulder Pain Index scores 72 ) were associated with lower subjective QOL scores in persons with paraplegia ( r = − 0.35; P = .002) and decreased community mobility ( r = − 0.42; P < .001). The dilemma for those who use an MWC (particularly those who are elderly) because of lower extremity paralysis and overall weakness is how to increase physical activity for physiological and psychological health benefi ts without further increasing pain and pathology. The limitations and restrictions imposed by the pain and dysfunction in elderly and aging wheelchair users can be described in the framework defi ned by the International Classifi cation of Functioning, Disability, and Health (ICF) 73 ( Figure 1 ). The ICF can be an effective framework both for identifying key elements that must be addressed in rehabilitation interventions 74-79 and for guiding provision and classifi cation of assistive technology. 80 In particular, the concepts of “activity limitations” and “participation restric- tions” are classifi ed as 2 components of health level of the person and the society. Because the elderly and aging individuals who rely on an MWC are dependent on their upper extremities for ADL and instrumental activities of daily living (IADL), pain and dysfunction (body function and struc- ture) 81 , 82 can limit ADL/IADL 53 , 83-85 and negatively impact community participation and QOL (participation restric- tion). 75 Mortenson et al 86 , 87 used the ICF as a framework to identify and evaluate wheelchair-specifi c outcome instruments that are useful for measuring activity and participation. They determined that wheelchair-related factors were associated with participation frequency directly and indi- rectly through their relationship with mobility. 88 Specifi cally, wheelchair skills, including the ability to transfer in and out of and propel a wheelchair, were important predictors of life space mobility and frequency of participation and life space mobility was a signifi cant predictor of frequency of participation. Depression was associated with poorer wheelchair skills and mobility and less frequent participation. Similarly, better wheelchair skills predicted better self-perceived health, higher life satisfaction, more community participation, 89 and improved confi dence in older adults using an MWC. 90 The elderly population, once lively, active, and independent, slowly or abruptly becomes disabled. Elderly wheelchair users are the weakest and most frail individuals often with multiple diagnoses. Independence in mobility is a key factor in life satisfaction and contributes to maintaining the QOL for elderly and aging MWC users. The elderly frequently report having diffi culty using their wheelchairs. Unfortunately, they are typically relegated to standard sling seat and back MWC. These standard MWCs introduce a slumped posture, are not adjustable, and place the user at disadvantaged positions to perform basic daily activities. The result often is added cost to the system in having to provide caregiver assistance or institutionalization. Ganesh and colleagues 91 found that 61% of their sample of older adults reported diffi culty with MWC propulsion, indicating that mobility devices provided for older adults may not be meeting their needs. Trefl er et al 13 studied 30 persons, 60 years or older, who received an individualized MWC and seating. Discomfort, poor positioning and mobility, and skin integrity were the most common issues reported in their standard issued wheelchairs. Participants who received an individualized MWC found that they had less diffi culty independently propelling their wheelchairs and improved postural stability, which increased their ability to lean forward and reach. They reported a greater degree of satisfaction with their wheelchair technology and improved QOL for social function and physical role as than a control group of individuals with standard issued wheelchairs. 13 This review addresses important issues for preserving function and mobility for elderly and aging individuals using an MWC by presenting the current available evidence and recommendations. These include recommendations for reducing the mechanical loads and muscular demands through ergonomics, wheelchair selection and confi guration, and environmental adaptations and personal factors related to increasing the capacity to handle the daily mobility demands. Each recommendation is supported by current research in each relevant area. While much of the research evidence put forth in this review was from the SCI population, it nonetheless applies to individuals in the general population who use an MWC for daily mobility, particularly elderly and aging MWC users. This review also highlights the need for individualization of the wheelchair prescription process such that the characteristics of the wheelchair matched the functional capacity of the individual. It is important to note that while studies comparing different wheelchair technologies provide valuable information to guide clinical decision making and wheelchair selection, the evidence will not always apply to all wheelchairs within the same class or code, that is, all wheelchairs are not equal even within the same category. What is important is that clinicians must identify the wheelchair characteristics that are crucial for each consumer and then identify the appropriate wheelchair that results in a fi t that is specifi c and unique to a single individual user. The ability to order, modify, or adjust the frame or components to achieve a fi nal system that meets the medical and functional needs of the individual is the most important. The relatively high ...

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Citations

... The ICF is a framework for describing "dynamic interactions between a person's health condition, environmental factors, and personal factors" [8]. The ICF can therefore be used to identify key elements that need to be addressed in rehabilitation [9,10], to guide the classification of assistive technology [9], or even to determine the relationship linking wheelchair skills and capabilities with participation frequency and mobility [11]. From that, previous studies have, in particular, revealed the need for better training in overcoming environmental barriers [10]. ...
... The ICF is a framework for describing "dynamic interactions between a person's health condition, environmental factors, and personal factors" [8]. The ICF can therefore be used to identify key elements that need to be addressed in rehabilitation [9,10], to guide the classification of assistive technology [9], or even to determine the relationship linking wheelchair skills and capabilities with participation frequency and mobility [11]. From that, previous studies have, in particular, revealed the need for better training in overcoming environmental barriers [10]. ...
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... The three most compelling reasons to target the elderly and those ageing with and into disability are: 1) this is the fastest-growing age group in the world [7]; 2) healthcare costs are highest among the older group and 3) clinically, this group has a high rate of chronic conditions and functional limitations resulting in the high health care utilization [8]. While, longer life spans are generally considered desirable, particularly when healthy years of life are increased, with an ageing population and longer life expectancy comes an increasing prevalence of chronic diseases and conditions associated with ageing that can significantly reduce the quality of life [8]. ...
... The three most compelling reasons to target the elderly and those ageing with and into disability are: 1) this is the fastest-growing age group in the world [7]; 2) healthcare costs are highest among the older group and 3) clinically, this group has a high rate of chronic conditions and functional limitations resulting in the high health care utilization [8]. While, longer life spans are generally considered desirable, particularly when healthy years of life are increased, with an ageing population and longer life expectancy comes an increasing prevalence of chronic diseases and conditions associated with ageing that can significantly reduce the quality of life [8]. ...
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... 38 The design of SmartCane was based on the accurate integration of processor, software, and sensors. It can reduce the hazards of fall by continuous monitoring by- [1][2][3][4][5][6][7][8][40][41][42] • ...
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