Participation in community-based activities of daily living: Comparison of a pushrim-activated, power-assisted wheelchair and a power wheelchair

Abstract

The purpose of this study was to evaluate pushrim-activated, power-assisted wheelchair (PPW) performance among dual-users in their natural environment to determine whether the PPW would serve as a satisfactory alternative to a power wheelchair for community-based activities.
A concurrent mixed methods research design using a cross-over trial was used. The outcome measures used were number of hours reported using the different wheelchairs, Quebec User Evaluation of Satisfaction with assistive Technology (QUEST), Functioning Everyday with a Wheelchair (FEW), Psychosocial Impact of Assistive Devices Scale (PIADS) and Canadian Occupational Performance Measure (COPM).
The number of hours spent participating in self-identified activities was not significantly different. Only the Self-Esteem subscale of the PIADS identified a statistically significant difference between the PPW and power wheelchair conditions (p = 0.016). A clinically important difference for Performance and Satisfaction was suggested by the COPM, in favour of the power wheelchair.
Additional knowledge was gained about the benefits of PPW technology. Participants were able to continue participating independently in their self-identified community activities using the PPW, and identified comparable ratings of satisfaction and performance with the PPW and the power wheelchair. For some individuals requiring power mobility, the PPW may provide an alternative to the power wheelchair.

Full text

PRODUCTS AND DEVICES
Participation in community-based activities of daily living: Comparison
of a pushrim-activated, power-assisted wheelchair and a power
wheelchair
EDWARD M. GIESBRECHT, JACQUELINE D. RIPAT, ARTHUR O. QUANBURY &
JULIETTE E. COOPER
School of Medical Rehabilitation, University of Manitoba, Winnipeg, Manitoba
Accepted September 2008
Abstract
Purpose. The purpose of this study was to evaluate pushrim-activated, power-assisted wheelchair (PPW) performance
among dual-users in their natural environment to determine whether the PPW would serve as a satisfactory alternative to a
power wheelchair for community-based activities.
Methods. A concurrent mixed methods research design using a cross-over trial was used. The outcome measures used were
number of hours reported using the different wheelchairs, Quebec User Evaluation of Satisfaction with assistive Technology
(QUEST), Functioning Everyday with a Wheelchair (FEW), Psychosocial Impact of Assistive Devices Scale (PIADS) and
Canadian Occupational Performance Measure (COPM).
Results. The number of hours spent participating in self-identified activities was not significantly different. Only the Self-
Esteem subscale of the PIADS identified a statistically significant difference between the PPW and power wheelchair
conditions (p¼0.016). A clinically important difference for Performance and Satisfaction was suggested by the COPM, in
favour of the power wheelchair.
Conclusions. Additional knowledge was gained about the benefits of PPW technology. Participants were able to continue
participating independently in their self-identified community activities using the PPW, and identified comparable ratings of
satisfaction and performance with the PPW and the power wheelchair. For some individuals requiring power mobility, the
PPW may provide an alternative to the power wheelchair.
Keywords: Wheelchairs, community participation, activities of daily living, rehabilitation
Introduction
For most people in our society, personal mobility is
achieved through ambulation. When the ability to
walk is compromised by physical impairment, a
wheelchair may serve as a means to maintain
mobility [1,2]. Mobility via a wheelchair enables
continued participation in activities related to in-
dependence, work and social engagement [3]. This
enablement process is illustrated by the Human
Activity Assistive Technology (HAAT) conceptual
model, proposed by Cook and Hussey [4]. The
HAAT model identifies that the ability to participate
in these activities depends on an interaction between
the individual, the activity demands, and the
environment in which it occurs, and considers how
assistive technologies (such as the wheelchair) impact
system performance, rather than strictly human or
device performance. Consequently, the individual’s
perception of how a wheelchair bridges the gap
between environmental and task demands and the
intrinsic enablers of the system is paramount.
When the physical demands of using a manual
wheelchair interfere with participation, individuals
often must decide whether to continue using a
manual wheelchair or convert to using a power
wheelchair or scooter – often reluctantly because of
the implications for accessibility and perceived social
stigma [5]. A power wheelchair is much heavier
than a manual chair and presents limitations to
Correspondence: Edward M. Giesbrecht, School of Medical Rehabilitation, University of Manitoba, R214 – 771 McDermot Avenue, Winnipeg, Manitoba,
R3E 0T6. Tel: 204-977-5630. Fax: 204-789-3927. E-mail: giesbre3@cc.umanitoba.ca
Disability and Rehabilitation: Assistive Technology, May 2009; 4(3): 198–207
ISSN 1748-3107 print/ISSN 1748-3115 online ª2009 Informa Healthcare USA, Inc.
DOI: 10.1080/17483100802543205
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portability, often requiring use of wheelchair-
accessible transit or van, rather than smaller, more
economical and readily available vehicles. Power
wheelchairs are typically larger and wider than a
manual wheelchair, creating accessibility issues,
particularly within the home environment. A power
wheelchair may be perceived by the user as creating a
more disabled image, and appear more obvious than
a manual wheelchair [5]. Some individuals prefer to
use a manual wheelchair to maintain their physical
status and fear a transition to a power wheelchair
may diminish their health [6].
Although all of these reasons might discourage
individuals from moving from a manual to a power
wheelchair, the demands for successful performance
(both individual and environmental) may ultimately
compel them to change their mode of mobility. Some
individuals choose to use both methods – a power
wheelchair for specific activities and environments
that require it, and a manual wheelchair for others
(i.e., these are dual users). Using two different
wheelchairs for different activities can prove to be
complicated and costly. Until recently, individuals
who experienced difficulty propelling a manual
wheelchair had only three options: continue using a
manual wheelchair with difficulty; have an attendant
push their wheelchair; or transition to using a power
wheelchair [7]. The pushrim-activated, power-
assisted wheelchair (PPW) was developed as another
alternative to these existing options, particularly for
those individuals who have difficulty propelling a
manual wheelchair but may not want to use a power
wheelchair [7–11]. The PPW is a manual wheelchair
with electrically powered motors located in the hubs
of the rear wheels. When the user applies tangential
force to the pushrim (i.e., manually propels the
wheelchair), the motors are engaged temporarily.
The motors briefly supplement the manual push,
proportional to the user’s input [8,12,13]. The user
continues to propel as with a traditional manual
wheelchair; however, the push requires less force and
produces supplemental torque, suggesting propul-
sion should be easier [11,12,14] and propelling on
uneven terrain or up an incline would require less
effort [8,12–14].
According to the International Classification of
Functioning, Disability and Health, or ICF [15],
individual performance results from the interaction
between the person and the context in which they
live; the ability to perform activities within the
situations that life normally presents is a measure of
Participation. Published PPW research has focused
primarily on the impact of the device on body
function, measuring the physical demands of propel-
ling the wheelchair and the physiological benefits
derived from using power-assisted rather than
manual propulsion. Compared with use of a manual
wheelchair, the PPW reduces the metabolic demands
of propulsion, resulting in lower heart rate [11],
oxygen consumption [9,13] and ventilation rate [8].
Biomechanically, joint range of motion and stroke
frequency during propulsion is also reduced [7,8].
Several studies used subjective rating scales to
evaluate ease of use [11,13] and perceived exertion
[11], and found that users responded more favour-
ably to the PPW than their manual wheelchair on
both variables. Corfman et al. [10] found that, in a
group of 10 participants with spinal cord injury, the
use of PPW resulted in a significant reduction in
required shoulder, elbow and wrist range of motion
during propulsion. Mechanical efficiency was re-
ported to increase up to 80%, particularly at higher
speeds, and less torque was required to propel the
PPW [7,9], reducing muscle activation demands
[11,16].
A small number of studies comparing PPW and
manual wheelchairs have evaluated performance of
predetermined functional activities within a standar-
dised clinical environment (i.e., Activity level of the
ICF). One study, using 30 able-bodied participants,
found no statistical difference in performance on the
Wheelchair Skills Test, although nearly 85% of
participants indicated a preference for the PPW [6].
A second study [13], using 10 wheelchair users,
incorporated a standardised driving course with a
variety of common conditions and obstacles (e.g.,
carpet, tile, door threshold, 58ramp, speed bumps),
as well as several tasks (e.g., open and close a door,
transfer into a simulated car, disassemble the wheel-
chair and load it into the simulated car after
transferring). Using a 10-point Likert scale devel-
oped by the authors, a significant difference, in
favour of the PPW, was reported between partici-
pants’ rating of ergonomics, comfort and appearance
of the two devices. However, 5 of the 10 participants
in the study were unable to fully complete the car
transfer portion of the ADL course as a result of
difficulty removing and replacing the PPW wheels.
Levy et al. [11] developed a questionnaire, using a
5-point Likert scale, to investigate differences among
11 elderly wheelchair users in ease of wheeling over
various surfaces. The order of wheelchair use was
randomly assigned. The authors indicated that 10
participants self-reported propulsion to be easier
with the PPW on level or inclined terrain, and nine
reported likewise on carpeted surfaces. After com-
paring the two devices, 7 of the 11 participants
reported a strong willingness to exchange their
manual wheelchair for a PPW. However, this study
took place within a controlled laboratory setting, and
not in the participants’ natural environment.
Investigation of function using a PPW in a
community setting has not yet been undertaken.
Various authors have identified a pressing need for
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investigation of time spent in the PPW, locations
visited, distance covered and users’ perception of the
impact of PPW use on quality of life, affect,
satisfaction, independence and community partici-
pation [8–11,14]. As well, no investigation to date
has been made comparing performance of the PPW
with traditional powered mobility, although this
research has been strongly recommended by several
investigators [9,11,13]. Therefore, the purpose of
this study was to evaluate PPW performance in a
user’s natural environment to determine whether the
PPW would serve as a satisfactory alternative to a
power wheelchair. The specific objective was to
compare user satisfaction with and measurable
performance during community-based activities
using a PPW and a power wheelchair among dual-
users. Activities evaluated were those that partici-
pants identified as currently being performed using
their power wheelchair.
Methods
Experimental design
A concurrent mixed methods research design was
used, using a two-phase sequential explanatory
strategy [17] (see Figure 1). Phase 1 focused on
collection of descriptive quantitative data using a
repeated measures crossover design. This allowed for
some control over individual differences between
participants and minimised potential bias from the
sequence in which the mobility devices were intro-
duced [18]. Phase 2 of the study used two focus
groups to collect qualitative data to explore and then
elaborate on the quantitative results [17]. This article
will report on the results of the quantitative com-
ponent of the study (Phase 1).
Participants
Participants were recruited using two strategies.
Advertisements were published in newsletters and
posted in agencies that served individuals appro-
priate to this study, and provided a phone number to
contact the investigator. In addition, the Canadian
Paraplegic Association (Manitoba) agreed to review
their member records and contact individuals who
met the inclusion criteria, briefly explaining the
purpose of the study and requesting permission for
the investigator to make contact. The primary
inclusion criteria were a self-identified use of both a
manual wheelchair and a power mobility device
(either a power wheelchair or a scooter); ability to
complete the outcome measurement tools; reside
within 75 km of the research centre and a stable
medical condition. Each participant was contacted
by telephone, and arrangements were made for an
introductory meeting to review the study purpose
and obtain written consent. Prior approval for this
study was obtained from the Health Research Ethics
Board at the University of Manitoba, and all
participants provided informed consent before be-
ginning the study.
Ten individuals volunteered to participate in the
study. The investigator met with two individuals
who signed consent forms, but were unable to
participate in the study due to non-stable medical
conditions. Eight participants (see Table I) were
assigned to one of two groups. The first four listed
used the power wheelchair first and PPW second; the
remaining four used the PPW first and power
wheelchair second.
Outcome measures
Four outcome measures were selected for this study,
addressing both the Activity and Participation levels
of human function as set out by the ICF. The
psychometric properties of these tools are referenced
in Table II. The Quebec User Evaluation of
Satisfaction with assistive Technology (QUEST)
[19] is a standardised outcome measure designed
to evaluate user satisfaction with assistive devices
using a 5-point Likert scale. The tool includes a
Device subscale (eight questions related to the device
itself) and a Service subscale (four questions related
Figure 1. Experimental design.
200 E. M. Giesbrecht et al.
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to service delivery), as well as a composite score. For
the purposes of this study, only the Device subscale
was used. The QUEST has been used extensively in
research for comparison between assistive technology
devices [20–22]. Functioning Everyday with a
Wheelchair (FEW) [23] is a standardised tool that
measures the quality of wheelchair operation from
both a user and a prescriber perspective. In Section 1,
the user rates performance in ten environmental or
activity-based categories using a 6-point Likert scale.
In Section 2, the clinician rates the wheelchair user
on performance in a series of criterion-referenced
tasks: placing and retrieving an object from a variety
of heights and distances, and performing two wheel-
chair transfers. These measures target outcomes at
the Activity level of the ICF [24]. The Psychosocial
Impact of Assistive Devices Scale (PIADS) measures
quality of life using three component subscales (i.e.,
Adaptability, Competence and Self-esteem) as well
as a composite Total score. The tool lists 26 words or
phrases, and the user identifies whether the assistive
device increases, decreases or has no effect on his
or her experience. The Canadian Occupational
Performance Measure (COPM) [25] uses a semi-
structured interview to identify specific activities of
daily living that the user perceives to be problematic.
A 10-point Likert scale is used to rank the activities
on the basis of Importance to the user (1 ¼not
important at all; 10 ¼extremely important). Each
activity is then rated by the user on Performance
(1 ¼not able to do it; 10 ¼able to do it extremely
well) as well as Satisfaction (1 ¼not satisfied at all;
10 ¼extremely satisfied), using comparable 10-point
Likert scales. Composite Performance and Satisfac-
tion scores are calculated by summing the individual
activity scores and dividing by the number of
activities rated. The COPM has been recommended
for evaluation of assistive technology devices [26–
28]. This tool provides an assessment of perfor-
mance in the actual lived environment, suggesting it
can measure at the ICF Participation level [24]. In
addition, data were collected on the number of hours
per day spent in the power wheelchair or PPW; the
number of hours per day spent in any wheelchair
(manual, power or PPW); and the number of hours
per week spent in self-identified activities.
Experimental protocol
1
Two identical PPW devices were used in this study
(Alber e motion power assist). As participants were
enrolled in the study, they were alternately assigned
to one of two groups (i.e., ABAB); half of the
participants began the study using the PPW and the
other half began the study using their power wheel-
chair (see Figure 1). It was anticipated that a
cumulative effect would not occur; consequently,
no washout period between the treatment applica-
tions was used. The COPM [39] was administered
before participants commencing wheelchair use to
identify activities the participants currently accom-
plished with their power wheelchair, and were willing
to attempt using the PPW during the study.
Activities were ranked by Importance for the
participant, as described previously. Up to five
activities were selected for evaluation; if more were
identified, only the five highest ranking activities
were included for evaluation in the study. If an
individual participant did not perform an identified
activity with both wheelchair configurations (PPW
and power wheelchair), that activity was excluded
from the data analysis. Participants spent 3 weeks
performing the self-identified activities using their
assigned mobility device; at the end of this period,
data were collected using the outcome measures.
Participants then switched to the second mobility
Table I. Demographics of study participants.
ID Gender Age Diagnosis Years in MWC* Years in PWC* MWC used
1 M 40 SCI C4/5 (quadriplegia) 7 9.5 Own
4 M 63 Spinal cord stenosis (quadriplegia) 8 6 Study
6 M 58 Multiple sclerosis 8 8 Study
8 F 42 Multiple sclerosis 5 4 Study
2 M 53 SCI C5/6 (quadriplegia) 17 27 Own
3 F 39 Hereditary spastic paraparesis 8 3 Study
5 M 33 SCI C5/6 (quadriplegia) 10 10 Own
7 M 60 Polymyositis 4 4 Study
*Some participants had used a power wheelchair (PWC) before using a manual wheelchair (MWC), and vice versa.
Table II. Outcome measures selected.
ICF level Outcome measure Validity Reliability
Activity QUEST [29,30] [31,32]
FEW [23] [33]
PIADS [34,35] [36,37]
Participation COPM [38] [25]
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device, used it for a 3-week period, and data were
collected again at the end of this period. During each
of the two periods of use, the investigator contacted
participants by telephone once per week and asked
for an estimate of: the average number of hours per
day spent using the prescribed device (i.e., PPW or
power wheelchair); the average number of hours per
day spent using a manual wheelchair and the total
number of hours per week spent participating in
identified occupations.
Immediately before the beginning of the PPW
segment of the study, the investigator installed the
required equipment on the participant’s own manual
wheelchair and provided training in use of the PPW
until the participant indicated he or she was suffi-
ciently familiar with its operation. Adjustments were
made to the PPW settings where required. Partici-
pants who owned a manual wheelchair without
removable rear wheels were provided with a light-
weight manual wheelchair (Sunrise Quickie 2)
already configured with the PPW wheels, and
adjustments were made as described above. Partici-
pants were encouraged to use the PPW for their
identified activities whenever possible; however, they
had to option to use their own manual or power
wheelchair for these or any other activities of daily
living.
Statistical analysis
The data collected for each measurement tool was in
the form of paired values – each participant’s score
using PPW was compared with their score using
power wheelchair. The small sample size precluded a
normal distribution of results; consequently, non-
parametric data analysis was employed. The
Wilcoxon signed rank sum test was used to identify
a significant overall difference between PPW and
power wheelchair scores by ranking the magnitude of
each individual difference and its direction, positive
or negative [40]. Using Sigmastat (version 3.5), it
was determined that the number of hours partici-
pants spent in the different wheelchair devices did
follow a normal distribution; therefore, this data were
analysed using a two-tailed paired t-test [40]. The
level for statistical significance for all tests was set
at 0.05.
Results
The two groups (i.e., power wheelchair first versus
PPW first) were not significantly different with
respect to age, years using a manual wheelchair or
years using a power wheelchair. Participants identi-
fied between one and five activities to evaluate during
the study. These were related to productivity, such as
going to work; self care, such as home management;
and leisure, such as visiting friends (see Table III).
Thirteen out of the 16 activities identified were
included in the data analysis; because of lack of
opportunity, not all participants were able to
complete all of their targeted activities within the
3-week study period.
Temporal outcomes
The mean number of hours per day spent in the
PPW or power wheelchair on a daily basis was 5.5 h
(SD ¼3.63) and 6.1 h (SD ¼5.36), respectively, and
was not significantly different (t(7) ¼70.33,
p¼0.75). The mean number of hours spent per
day in any wheelchair (both manual and powered) on
a daily basis was 8.83 (SD ¼5.34) and 9.17
(SD ¼5.83), respectively, for the PPW and power
wheelchair blocks, and was also not significantly
different (t(7) ¼70.54, p¼.60). The total number
of hours per week spent participating in identified
occupations (56.1, SD ¼52.0; 62.8, SD ¼42.6) was
not significantly different between the PPW and
power wheelchair blocks (t(7) ¼70.33, p¼0.75).
Outcome measures at the Activity level: QUEST, FEW,
PIADS
Statistical analysis of the Activity level outcome
measures is summarised in Table IV. No difference
was identified between the PPW and power wheel-
chair on the QUEST Device subscale; however, it
Table III. Occupations identified by participants for evaluation
(frequency of response).
Activity identified
No. of
participants
selecting
activity
Performed
in power
wheelchair
and PPW
Shopping 5 3
Going out to a restaurant 3 3
Going for a ‘wheel’/stroll 3 3
Doing laundry/housekeeping/cooking 3 3
Going to work 2 2
Attending support/self help group 2 1
Visiting/socialising 2 1
Attending community social events 2 1
Watching TV 1 1
Exercising 1 1
Walking the dog 1 1
Going to the library 1 1
Performing self-care/hygiene 1 1
Attending medical appointments 1 0
Going to see a movie 1 0
Playing outside with daughter 1 0
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was noted that participants rated four Device
subscale items higher for the PPW (i.e., Weight,
Comfortable, Dimensions, and Ease in adjusting)
and four items higher for the power wheelchair (i.e.,
Durability, Easy to use, Safe and secure, and
Effective). The PIADS Self Esteem subscale was
the only measure that demonstrated a statistically
significant difference, with the power wheelchair
rated higher.
Outcome measure at the Participation level: COPM
For the Performance component, no statistically
significant difference was found (see Table IV).
However, most participants (6 out of 8) scored the
PPW lower by at least 2 points, which is identified as
a clinically significant difference [25]. Only one
participant rated the PPW higher by a clinically
significant difference of six points. For the Satisfac-
tion component, there was also no statistically
significant difference (see Table IV). Four partici-
pants rated Satisfaction lower with the PPW by at
least 2 points, suggesting a clinically significant
difference, whereas three rated Satisfaction higher
with the PPW, and one rated the wheelchairs equally.
Participants 3 and 4 had particularly divergent
evaluations of the two devices, with the former
showing a strong preference for the PPW and the
latter scoring the power wheelchair much higher
(Figures 2 and 3).
Dual-users’ preference for power vs. manual wheelchair
use
Some dual-users spend more time in their power
wheelchair whereas others use their manual wheel-
chair more frequently. In this study, participants
appeared to fall into two groups: those who are
primary power wheelchair users (i.e., more than 80%
of the time) and those who are moderate users (i.e.,
use their power wheelchair 30–60% of the time).
Research to date has not explored the relationship
between preference for power or manual wheelchair
use and how that preference impacts their perception
of the PPW. Figure 4 plots participants’ PPW
Performance and Satisfaction scores against the
percent of time they spent using a power wheelchair.
The median score for each group is indicated by a
dotted line. Given the exploratory nature and low
power in this study, these variables were not
compared statistically.
Table IV. Outcome measure scores and statistical analysis.
Outcome measure Max score available Median (range) PPW score Median (range) PWC score p
QUEST (Device subscale) 5 3.8 (3.0–4.5) 3.8 (1.9–5.0) 0.945
FEW (Section 1) 6 4.9 (2.8–5.8) 4.9 (1.8–5.7) 0.938
FEW (Section 2) 63 47.0 (18–63) 43.0 (18–63) 1.00
PIADS (total score) 78 12.0 (723–68) 30.0 (5–58) 0.313
PIADS (Competence subscale) 36 9.0 (713–31) 15.0 (5–29) 0.313
PIADS (Adaptability subscale) 18 3.0 (77–15) 6.5 (71–11) 0.250
PIADS (Self Esteem subscale) 24 1.5 (74–7) 7.5 (72–18) 0.016*
COPM (Performance) 10 6.5 (4.0–9.0) 8.2 (4.3–10.0) 0.195
COPM (Satisfaction) 10 7.2 (2.7–8.4) 8.1 (2.3–10.0) 0.469
PWC: power wheelchair.
*p50.05.
Figure 2. COPM Performance scores for PPW and power
wheelchair (PWC).
Figure 3. COPM Satisfaction scores for PPW and power
wheelchair (PWC).
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Discussion
The purpose of this study was to evaluate PPW
performance among dual-users in their natural
environment to determine whether the PPW would
serve as a satisfactory alternative to a power wheel-
chair. As dual-users, participants employed both a
power and manual wheelchair, depending upon the
situation, to mediate environmental demands when
performing daily activities. They were asked to
temporarily suspend use of their existing method of
power mobility (the power wheelchair) and use an
alternative, and novel, device in its place (the PPW).
Questions have been raised about how introduction
of the PPW might impact participation by changing
wheelchair usage patterns such as time spent in the
wheelchair, distance traveled and activity level
[8,11,41]. The study results suggest that after
introducing the PPW, participants continued to be
equally active in their community. They spent a
similar period of time using a PPW instead of their
power wheelchair, and participated equally in the
activities that they identified as important. These
results are consistent with another study comparing
manual wheelchair and PPW use, in which time in
the wheelchair and distance traveled did not differ
significantly [41]. Not all identified activities were
completed in both the power wheelchair and PPW;
however, participants reported that lack of opportu-
nity within the 3-week time period was the only
reason the PPW was not used for some select
activities. Physical difficulty with performance or
apprehension using the PPW were not reported.
Satisfaction with performance in the PPW has
been an important issue raised in the literature [11].
In particular, direct comparison of the PPW and
power wheelchair has been identified as a significant
gap in knowledge. The QUEST results were not
significantly different in composite satisfaction
scores, suggesting that neither wheelchair device
possesses a globally superior configuration. A
comparison of component scores indicated a
relatively equal distribution between the two de-
vices, with each wheelchair option scoring higher on
four attributes. Durability, Safety & Security, Ease
of Use, and Effectiveness were rated higher for the
power wheelchair, whereas the PPW rated higher
with respect to Weight, Comfort, Adjustability, and
Dimensions. This finding corroborates other reports
in the literature that attributes of the PPW (and
manual wheelchair), such as smaller size and
portability, increase accessibility for the user [5]
whereas the features of the power wheelchair
compensate for physical limitations and provide
freedom of movement leading to increased oppor-
tunity for community participation [3,42–45]. Simi-
larly, with the FEW, participants reported benefits
with each wheelchair device specific to needs and
activity type. For example, the power wheelchair was
typically preferred for activities based outdoors
whereas the PPW was preferred for tasks performed
in a confined space. These advantages and disad-
vantages of each device had a tendency to offset one
another, and generated comparable scores. Several
authors have identified individual evaluation of the
relative advantages of each device as an important
element in the process of deciding to adopt or reject
one assistive device over another [46–48]. From this
perspective, choice hinges on the user’s perception
of device value in meeting their expectations,
based on a cost-benefit measure. These relative
advantages and disadvantages of each device high-
light the difficulty wheeled mobility users have in
deciding between a manual and power wheelchair
[3,7,42,45].
Section 2 of the FEW entailed an external
assessment of two types of activities – reaching tasks
and performing transfers – in a predetermined
environment. All participants were experienced users
of both the manual and power wheelchair, which may
have contributed to their comparable performance.
Cooper et al. [13] found a similar outcome when
comparing the PPW and participants’ own manual
wheelchair (which they were experienced in using).
Figure 4. Comparison of participant PPW Performance and Satisfaction scores with percentage of time using a power wheelchair (PWC).
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The PIADS was used to measure the degree to
which the wheelchair device influenced participants’
perception of independence and participation –
important factors in determining satisfaction
[42,49]. Only the Self Esteem subscale identified a
statistically significant difference between the power
wheelchair and PPW. Several studies comparing
manual and power wheelchair use reported higher
PIADS scores for the power wheelchair condition
[42,50]. Although comparison to the manual wheel-
chair was not part of the current study, the PPW
appeared to be more acceptable than a manual
wheelchair as an alternative to the power wheel-
chair. It is not clear why the Self-Esteem subscale
score differed between the power wheelchair and
PPW, whereas the other subscales and total score
did not. The Self-Esteem subscale relates to
emotional response and self-perception, whereas
the Adaptability and Competence subscales con-
sider issues of independence, performance, enable-
ment and opportunity. The short time period of the
study may not have afforded participants sufficient
time to develop confidence in using the PPW.
Future studies should examine the Self Esteem
component after users develop competency with the
PPW device.
The COPM addressed evaluation of activities of
daily living in real life situations. The lack of a
statistically significant difference between the PPW
and the power wheelchair might suggest that both
Performance and Satisfaction were equivalent.
However, the majority of participants identified a
clinically significant difference in Performance in
favour of the power wheelchair, whereas only one
participant scored the PPW higher by at least two
points. The graphic presentation of the Perfor-
mance scores highlights this pattern toward better
performance with the power wheelchair. Satisfac-
tion scores followed a similar pattern, but were not
as dramatically different, with half of the partici-
pants identifying comparable ratings for the two
wheelchair options. This ‘difference of degrees’
indicates that many study participants may not
have found performance with the PPW comparable
with the power wheelchair, yet still found the PPW
to be appealing despite these performance short-
comings. The QUEST and FEW identified desir-
able attributes of each device, and participants
measured these relative advantages against their
performance in activities and occupations, and the
resultant effect on personal and social experience;
these tools were helpful in evaluating the impact of
the PPW at the ICF Activity level. The COPM
results suggest that the benefits of the power
wheelchair identified in the QUEST and FEW
may have had a greater bearing on overall perfor-
mance, and subsequent value in meeting participant
expectations on a global level. Therefore, in the
context of this study, the COPM was particularly
valuable in measuring performance at the ICF
Participation level.
One consideration may be that over time,
Performance scores might increase as a user
becomes more proficient with the PPW, and would
potentially revise personal expectations [41]. This
would be consistent with the concept of relative
advantage discussed earlier, and the belief that
assistive device adoption requires time and adapta-
tion to reach fruition. The degree to which
individuals have already adopted power wheelchair
use may have an influence on the perceived
potential benefit of the PPW. In this study, there
was evidence of lower ratings of satisfaction and
performance with the PPW among those individuals
who used their power wheelchair more frequently
than their manual one. One explanation for this
finding may be that changes to body function and
structure for some study participants had pro-
gressed to a point where the physical demands of
using the PPW device were still excessive. There
may be a ‘window’ of opportunity when decreasing
function is best addressed, and earlier introduction
of PPW technology would be beneficial for those
individuals. The PPW might serve as a precursor to
a power wheelchair, or be used when transitioning
between manual and power wheelchairs [6]. The
potential link between PPW preference and the
extent of power versus manual wheelchair use
merits further investigation.
The intent of this study was to evaluate use of
the PPW in the context of life situations (i.e.,
Participation). Using tools specifically designed to
measure the construct of Participation is critical.
The COPM provided valuable information related
to perception of function and performance among
wheelchair users. At the time of this study, other
existing measures of Participation did not ade-
quately address issues of performance in a natural
context and were limited in their scope of ICF
domains. More recently, the Participation Survey/
Mobility (PARTS/M) tool [51] has been published
and shows promise in addressing these concerns,
particularly in the evaluation of wheelchair devices
given its focus on people with mobility limitations.
Most recently, Mortenson, Miller and Auger [52]
highlight the need for wheelchair-specific outcome
measures of Participation, and identify the Wheel-
chair Outcome Measure (WhOM) as having
potential application for measurement across ICF
domains. Given that the WhOM is a modification
of the COPM tool specific to wheelchair evalua-
tion, we would recommend it be considered as a
potential alternative to the COPM in future
studies.
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Study limitations
Several limitations of this research study should be
identified. The small sample size increased the
possibility of a Type II error: that differences
between the power wheelchair and PPW scores that
truly exist were not uncovered. The use of nonpara-
metric data analysis, required because of the small
sample size and ordinal type data, also affected the
power of the study. The heterogeneity of the
participant group may have made it more difficult
to find common results and experiences related to
functional ability. More than half of participants
(N¼5) used a study wheelchair because theirs did
not have quick-release axles. Although the study
wheelchair provided to the participants was of a
superior quality and adjusted to individual needs,
participants may have found the wheelchair unfami-
liar, affecting their experience and therefore their
Performance and Satisfaction ratings. The time
period for use of the PPW was three weeks, which
may not have been sufficient for participants to
acclimatise to the PPW and achieve effective opera-
tion. Data regarding the number of hours spent in a
wheelchair was based on participant estimates and
may have been subject to self-report bias.
Conclusions
Through evaluation within the lived environment,
and performing activities of relevance, additional
knowledge was gained about the benefits of PPW
technology. For some individuals requiring power
mobility, the PPW may provide an alternative to the
power wheelchair. Participants in this study were able
to maintain participation in community-based activ-
ities using the PPW, instead of their power wheel-
chair. Evaluation at the ICF Activity level did not
identify a statistical difference between the two
devices. Measurement at the ICF Participation level,
using the COPM, suggested a clinically significant
trend towards preference for the power wheelchair.
This trend was less apparent when rating Satisfaction
than Performance. Dual users who use their manual
wheelchair more frequently may be better candidates
for the PPW. If this is the case, exposure to the PPW
at an earlier stage may benefit users transitioning
from manual to power mobility. Future investigation
should consider the characteristics of users and the
activities and environments of choice that prove most
optimal for PPW application and incorporate out-
come measures that target Participation. The COPM
was of considerable benefit, identifying and measur-
ing activities that were meaningful, user-centred and
performed in the lived environment. Other recently
developed Participation measures, particularly
those that are wheelchair-specific, should also be
considered.
Acknowledgements
The authors express their appreciation to the eight
study participants. Audrey MacIlraith provided
valuable insight and critique during the initial data
analysis and Mary Cheang provided expert consulta-
tion with statistical analysis. This study was partially
funded by the Manitoba Society of Occupational
Therapists Research Fund (Mary Judd Research
Grant). A set of Alber e-motion wheels was provided
for the study by Invacare Canada. Ethical approval
was obtained for this research from the University of
Manitoba Health Research Ethics Board prior to
commencement of the study.
Note
1. A detailed experimental protocol is available from the first
author.
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