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Manual wheelchair satisfaction among long-term users and caregivers: A French study

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Wheelchair mobility is a prerequisite to being able to carry out important activities and to participate in social life. Level of satisfaction with the wheelchair and overall quality of life were found to be positively associated. The aim of this study was to determine the level of satisfaction of French manual wheelchair (MW) users and caregivers with MW characteristics. A total of 132 users and 76 caregivers completed a questionnaire about their level of satisfaction with their MW characteristics. Satisfaction scores were independent of age, sex, reason for MW use, and time of use. As a whole, MW users are satisfied. However, a few parameters such as MW weight and difficulties propelling outdoors demonstrate a low level of satisfaction among users. MW weight, brakes, and height of pushing handles are the less satisfying elements among caregivers. In conclusion, the majority of French MW users are satisfied, but some characteristics, such as weight, must be optimized. Considering caregiver needs is paramount when aiming to improve MW parameters such as brakes or pushing handles. Improvement in some MW parameters seems to be important in achieving improved level of satisfaction and increased participation and active lifestyle among MW users and caregivers.
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181
JRRD
JRRD
Volume 52, Number 2, 2015
Pages 181–192
Manual wheelchair satisfaction among long-term users and caregivers:
A French study
Claire Marchiori;
1–2*
Djamel Bensmail, MD;
1
Dany Gagnon, PhD;
2
Didier Pradon, PhD
1
1
Raymond Poincaré Hospital, Garches, France;
2
Pathokinesiology Laboratory, Centre for Interdisciplinary Research
in Rehabilitation of Greater Montreal, Institut de Réadaptation Gingras-Lindsay-de-Montréal, Montreal, Canada
Abstract—Wheelchair mobility is a prerequisite to being able
to carry out important activities and to participate in social life.
Level of satisfaction with the wheelchair and overall quality of
life were found to be positively associated. The aim of this
study was to determine the level of satisfaction of French man-
ual wheelchair (MW) users and caregivers with MW character-
istics. A total of 132 users and 76 caregivers
completed a
questionnaire about their level of satisfaction with their MW
characteristics. Satisfaction scores were independent of age,
sex, reason for MW use, and time of use. As a whole, MW
users are satisfied. However, a few parameters such as MW
weight and difficulties propelling outdoors demonstrate a low
level of satisfaction among users. MW weight, brakes, and
height of pushing handles are the less satisfying elements
among caregivers. In conclusion, the majority of French MW
users are satisfied, but some characteristics, such as weight,
must be optimized. Considering caregiver needs is paramount
when aiming to improve MW parameters such as brakes or
pushing handles. Improvement in some MW parameters seems
to be important in achieving improved level of satisfaction and
increased participation and active lifestyle among MW users
and caregivers.
Key words: accessories, caregivers, French, French
wheel-
chair, manual wheelchair, parameters, satisfaction, users,
wheelchair characteristics, wheelchair satisfaction.
INTRODUCTION
Mobility is an essential component of activities of
daily living and is neces
sary for participation in social
activities [1]. Impaired body functions leading to limited
walking ability may restrict activity and participation [2].
Mobility assistive technology can be a means to improve
activity and participation [3]. Among mobility assistive
devices currently available, canes are used the most for
improving mobility among persons with motor impair-
ments and functional disabilities, whereas
wheelchairs
rank second; 1 percent of the world population requires a
wheelchair, but only 0.3 percent are wheelchair users [4].
In France, 62 persons per 10,000 (i.e., 360,000 people)
use a wheelchair [5]. This figure includes 59 persons per
10,000 who use a manual wheelchair (MW), which may
be foldable, rigid, sporty, or designed specifically for
comfort [5]. These people use an
MW for various rea-
sons: neurological disorders, genetic disorders, cognitive
deficits, p
athology of the lower limb and trunk, or age-
related changes. The age-related changes category
includes participants more than 60 yr old who have a
Abbreviations: GH = geriatric hospital, MW = manual wheel-
chair, MWU = manual wheelchair user, PAPAW = pushrim-
activated power-assisted wheelchair, QUEST = Quebec User
Evaluation of Satisfaction with Assistive Technology, RH =
retirement home, SCI = spinal cord injury, UH = university
hospital, UL = upper limb.
*
Address all correspondence to Claire Marchiori, UVSQ,
EA 4497, CIC-IT 805, Raymond Poincaré Hospital 92380,
Garches, France; +33 1 71 14 49 21.
Email: marchioriclaire@gmail.com
http://dx.doi.org/10.1682/JRRD.2014.04.0092
182
JRRD, Volume 52, Number 2, 2015
reduced level of independence and safety during ambula-
tion due to various age-related changes (e.g., balance
problems, muscle
weakness) and risk of falls. The major-
ity of MW users (MWUs) live at home (57%), but this
tren
d reverses with age and elderly MWUs mainly live in
institutions [5]. With a revenue of €133.8 million ($141.2
million) in 2007, the wheelchair industry is large and still
growing (8% growth between 1996 and 2001) [6].
The provision of an MW aims to improve the mobil-
ity of the MWU despite his or her impairments and dis-
abilities. Caregivers, mainly family members and health
professional
s who play an important role in the person’s
daily life, also help to improve mobility and promote
social integration.
Improved mobility among people with disabilities is
a prerequisite for int
egrating into the community and
gaining access to education, employment, and socializa-
tion, as well as preventing additional secondary compli-
cations (e.g., pressure sores). MW settings are also
important in
optimizing mobility. Dalyan et al. showed
that the use of a poorly configured MW may cause upper-
limb (UL) pathologies and actually decrease autonomy
[7]. Hence, a well-designed and -adapted MW may allow
MWUs to access the same opportunities as other mem-
bers of their community and improve their level of sati
s-
faction. The choice in the type of MW as well as
ad
justments must be individualized to enhance satisfac-
tion and usability [8].
MWU satisfaction is an important variable for
resea
rchers in the field of mobility [9–11]. Samuelsson
and Wressle demonstrated that users used their assistive
device (MWs and wheeled walkers) for more years when
the level of satisfaction was high [12]. One cause of dis-
continued use is user dissatisfaction. Moreover, studies
have shown that level of satisfaction with the wheelchair
and overall quality of life of persons with spinal cord
injury (SCI) were positively related in China and the
Netherlands [12]. de Groot et al. highlighted key aspects
of the wheelchair (i.e., dimensions and simplicity of use)
that are important for optimizing an active lifestyle and
social participation [10]. The importance of good wheel-
chair adjustments has been previously described in
wheelchair ergonomics
literature [13].
In some countries, assistive technology is free of
ch
arge, but in other countries, the provision of assistive
technology depends on insurance conditions. Further-
more, regulations and assistive technology service sys-
tems differ between countries [14]. In
the few studies
carried out in China, Denmark, the Netherlands, and Can-
ada, MWUs were found to be satisfied with their MWs
[9–1
2]. However, this question has not been investigated
in France. The French healthcare system is different and
covers only a few parts of the wheelchair by insurance.
The remainder of the cost must be paid by the user. To the
best of our knowledge, a few studies have evaluated the
level of satisfaction of wheelchair users with specific
types of wheelchairs (i.e., power wheelchairs) but not for
MWs. Based on a PubMed search using the key words
“satisfaction” and “wheelchair,” 224 results were found,
but when the key words “French” and “manual” were
added, only 2 results were found. One study evaluated
satisfaction with a lever-propelled wheelchair prototype
but not for MWs with traditional propulsion [15], and the
other study evaluated technological equipment in general
[16]. When the key word “caregivers” was added, no
results were found. Given the important role of caregiv-
ers in the mobility of MWUs, i
t
seems important to also
evaluate their level of satisfaction with the technical
aspects of MWs.
The aim of this study was to determine the satisfac-
tion of French MWUs and caregivers of MWUs with
MW characteristics, partic
ularly the wheels, brakes,
accessories, and MW dimensions and weight. We
believed that increasing our understanding of the satis-
faction of MWUs and caregivers would help to improve
the de
sign of MWs (dimensions, weight, etc.). MWUs
and caregivers each completed a different questionnaire
(Appendix, available online only) about their level of
satisfaction with the MW parameters. We hypothesized
that the level of satisfaction would not vary with age, sex,
cause of disability, or MW type and that MWUs would be
satisfied on the whole with their MW but that they might
not be satisfied with all the specific parameters. Particu-
larly, we hypothesized that they might be dissatisfied
with the MW weight.
W
e also hypothesized that full-time
MWUs would be less satisfied than occasional MWUs
and that the caregivers would be largely less satisfied
with the MW parameters than the MWUs.
METHODS
The study started in December 2011 and finished in
Ju
ne 2012. A convenience sample of MWUs and their
caregivers was recruited from various sources, including
a geriatric hospital (GH), a retirement home (RH), and a
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MARCHIORI et al. Manual wheelchair satisfaction
university hospital (UH). The questionnaire was also posted
on the Garches Foundation Web site (
www.handicap.org).
These different locations were chosen in order to target a
wide po
pulation. A total of 654 questionnaires was dis-
tributed. Individuals over 18 yr old who used a MW were
eligible to
participate. Participants who were unable to
understand and answer the questionnaire were excluded.
Caregivers included family members and health profes-
sionals of the MWU. They were defined as people who
help
ed a dependent person in activities of daily living
[17]. Caregivers over 18 yr old were eligible to partici-
pate. The study was approved by a local ethics commit-
tee. It was registered as a national multicenter
study of
MWs. Subjects were not paid for their participation in the
study.
Questionnaire
A questionnaire was developed for the purpose of the
study in collaborati
on with clinicians who prescribe
wheelchairs and by a physiotherapist with 20 yr of expe-
rience specialized in assisting pe
rsons choose and adjust
their wheelchairs. The items on the questionnaire
included the mechanical characteristics of wheelchairs
described by Cooper [18]. Table 1 describes the ques-
tions asked in each category.
Manual Wheelchair Users
Participants first provided demog
raphic information,
including age, sex, height, weight, profession, diagnosis,
etiology, and number of years of wheelchair use. They
then reported the characteristics of their wheelchair,
including type, model, and make. Participants were also
asked to report the total number of wheelchairs they had
used since their first wheelchair and whether they had a
pushrim-activated power-assisted wheelchair (PAPAW).
The main part of the questionnaire was related to satis-
faction with the MW and its parts, including the brakes
,
wheels, and accessories (i.e., armrest, head support). A 4-
point scale was used to rate global MW satisfaction. The
final part of the questionnaire related to participants’
needs. Participants were asked to choose their three main
criteria when selecting a new MW from a list and an
open-ended question was asked about aspects that should
be improved.
Caregivers
The caregiver questionnaire foc
used on age and sex
and the characteristics of the MW, including type, model,
make, and satisfaction related to parts of the MW that the
person whom they cared for used. It also asked whether
the MWU had a PAPAW. At the end, there was an open-
ended question relating to aspects that they felt should be
improved.
Data Analysis
Descriptive statistics (mean ± standa
rd deviation for
continuous variables and frequencies for categorical vari-
ables) were used to describe the study sample, MW char-
acteristics, satisfaction levels, and selection criteri
a if
they needed to buy a new MW. Differences between
groups (old/young, male/female, accident/disease, type
of MW) regarding global satisfaction score were ana-
lyzed with independent Student t-tests
. Theses compari-
sons were carried out to evaluate whether or not the
level
of satisfaction varied with age, sex, cause of disability, or
MW type. The 4-point satisfaction scale was divided into
two categories: “quite satisfied and very satisfied” and
“not very satisfied and not satisfied at all.” A McNemar
test was used to analyze global satisfaction and satisfac-
tion with each parameter. A chi-squa
re test was used to
analyze satisfaction with each parameter between full-
time MWUs and occasional MWUs and to compare satis-
faction among caregivers and MWUs. A Bonferroni cor-
rection was applied to an adjusted p-v
alue of 0.004,
which was used for all tests. Data were analyzed with
Statistica 10 software (Stat Soft Inc; Tulsa, Oklahoma).
RESULTS
A total of 132 MWUs and 76 caregivers completed
the questionnaire (re
sponse rate: MWUs: 35%; caregiv-
ers: 27%). Out of the 132 MWUs, 107 (81.1%) were
re
cruited from GHs, RHs, and UHs and 25 were recruited
from other sources (Internet).
Characteristics of Manual Wheelchair Users
Most participants reported that they spent all day in
their wheelchairs (69
.7%). The diagnosis and/or disabili-
ties reported included sensorimotor impairments of the
lower limbs and
trunk (43.2%), neurological diseases
(31.8%), genetic diseases (5.3%), and aging (17.4%). The
diagnoses were as follows: SCI, amputation, multiple
sclerosis, and cerebral palsy. The main cause of MW
use
among males was trauma (59.7%), while trauma
Information Category How Obtained
Users
Demographics
Sex Category (men, women).
Age Number of years.
Height and Weight Open-ended question.
Profession Open-ended question.
Years of Use in General Open-ended question.
Diagnosis Category (neurological disease, genetic disease, weight problem, sensory
de
ficit, mental deficit, lower-limb deficit, system deficit, old age with
motor impairment, other). Several categories can be chosen. Category
(birth, accident, disease, old age).
Wheelchair Characteristics
Number of Wheelchairs Owned Open-ended question.
Type Category (foldable, rigid, sport,
*
comfort,
power). Make and model.
Frequency of Use Category (sometimes [for particular activi
ties], often, always [for daily
life]).
Place of Use Category (indoors, outdoors, indoors and outdoors).
Difficulty Using Category (can be realized alone, very di
fficult, difficult, easy, very easy).
About propulsion, transfer, loading of wheelchair into car, folding of
wheelchair, crossing obstacles.
Satisfaction with Wheelchair Category (not at all satisfied, not very satisfied, q
uite satisfied, very satis-
fied). About wheelchair (dimensions, weight, ease of
indoors and out-
doors propulsion, ease of pivot), brakes, wheels, and accessories
(arm
rests, support head).
Improvements Open-ended question about points to improve on wheelchair.
Criteria Choose 3 from list of 11 criteria.
Caregivers
Demographics
Sex Category (men, women).
Age Number of years.
Wheelchair Characteristics: Type Category (foldable, rigid, sport,
*
comfort,
power). Make and model.
Satisfaction with Wheelchair Category (not at all satisfied, not very satisfied, q
uite satisfied, very satis-
fied). About wheelchair, brakes, wheels, and acces
sories.
Improvements Open-ended question about points to improve on wheelchair.
184
JRRD, Volume 52, Number 2, 2015
represented only 25 percent of causes for females, with
diseases (36.8%) and aging (29.4%) accounting for the
largest distribution of causes (Figure 1).
In terms of wheelchair skills, most MWUs were able
to propel (52.2%) and transfer (45%) easily, i.e., they
could perform these tasks independently without diffi-
culty regardless of the surface, slope, or height of the
tran
sfer surface. Some reported difficulties in loading
their MW into the car (27.2%), folding it (20.4%), and
crossing obstacles (39.4%). Many MWUs were unable to
load MW (58.3%), fold MW (48.5%), or cross obstacles
independently (43.2%)
Wheelchair Characteristics
Table 2 lists the characteristics of the MWs and the
MWUs
. Of the pa
rticipants, 100 (75.7%) used a foldable
MW, 22 used a rigid MW (16.7%), 8 used a comfort MW
(allows for movement, prolonged sitti
ng, and napping
Table 1.
Description of questionnaire.
*
Sport wheelchairs are designed for athletes with disabilities who are competing in sports that require agility and speed such as basketball, tennis, rugby, or racing.
Comfort wheelchairs are self-propelled and allow patients to displace themselves and sit for long periods of time, as well as to nap in chair without increasing num-
ber of transfers.
Figure 1.
Etiology of wheelchair use for (a) men and (b) women.
185
MARCHIORI et al. Manual wheelchair satisfaction
without an increased number of transfers) (6.1%), and
only 2 used a sport MW (1.5%). The average duration of
MW use was 12.5 ± 13.7 yr. Each patient had used an
average of 3.1 ± 3.3 wheelchairs and had changed their
wheelchair every 4.0 yr on average. Only 15 participants
(11.4%) owned a PAPAW. Most participants used the fol
-
lowing MW brands: Invacare (Elyria, Ohio) (n = 37;
28.0%) and Kuschall
(Witterswil, Switzerland) (n = 31;
23.5%).
Satisfaction Ratings
No differences were found between age groups (p =
0.
09),
sex (p = 0.93), or cause of MW use (p = 0.69)
regarding global satisfaction scores and satisfaction with
each parameter. Moreover, no differences were found
between the types of MW (p = 0.39). The majority of
MWUs was satisfied (71 MWUs gave a rating of 3 [satis-
fied] and 26 MWUs gave a rating of 4 [very satisfied]).
Only
13 and 22 of 132 MWUs were not satisfied, with
ratings of 1 (not satisfied at all) and 2 (not very satisfied),
respectively. Only five differences were found between
global satisfaction and satisfaction with each parameter
(Table 3). MWUs were satisfied with all items (Figure 2)
except for two: the MW weight (p < 0.001, 38%) and out-
door propulsion (p < 0.001, 39%). As
for acc
essories,
few MWUs had a head support (13.6%) or lateral trunk
supports (10.6%). MWUs were particularly satisfied with
the weight of the wheels (p = 0.001, 86%), MWU friend-
liness of the brakes (p = 0.
002, 81%), and indoor propul-
sion (p = 0.00
1, 82%). Concerning the differences among
full-time versus occasional MWUs, it appears that there
are no differences in mean
Characteristic n (%)
Users 132
Mean Age, yr (range) 55.4 (18–97)
Sex
Male 62 (47)
Female 70 (53)
Mean Time in Use, yr (range) 13.3 (0–52)
Caregivers 76
Mean Age, yr (range) 45.3 (16–81)
Sex
Male 26 (34)
Female 50 (66)
Relationship
Family Member 55 (72)
Health Professional 21 (28)
Pathology
Accident 54 (40.9)
Disease 42 (31.8)
Old Age 23 (17.4)
Birth 11 (8.3)
Other 2 (1.5)
Wheelchair
Foldable 100 (75.7)
Rigid 22 (16.7)
Comfort 8 (6.1)
Sport 2 (1.6)
Frequency of Use
Sometimes 22 (16.7)
Often 18 (13.6)
Always 92 (69.7)
Place Used
Indoors 27 (20.4)
Outdoors 27 (20.4)
Indoors and Outdoors 78 (59.2)
age (p = 0.8) and global satis-
faction (p = 0.5). F
ull-time and occasional MWU satis-
faction for MW parameters were similar (p > 0.99).
For MWUs, the most important
criterion was weight
(26.5%), followed by comfort (19%), durabilit
y (19%),
and maneuverability (16%).
Characteristics of Caregivers
Caregivers were recruited from GHs, RHs,
and UHs
(62, 81%) and other sources (Internet) (14, 19%). Out of
those, 55 (72%) were family members and 21 (28%) were
health professionals. Caregivers were mostly women (50,
65%) with a mean age of 46.0 ± 17.5 yr. Distribution of
MW type was the same as that of MWUs with a majority
having foldable MWs (64
.5%) followed by comfort MWs
Tabl e 2.
Characteristics of study population.
Item
Subjects “Quite Satisfied or
Very Sa
tisfied” (%)
Dimensions 78
Weight 62
*
Propulsion Indoors 82
*
Propulsion Outdoors 61
*
Ease of Pivot 78
Brake Position 80
Ease of Brakes 81
*
Clothes-Guards 65
Pushing Handles 80
Braking Quality 73
Ease of Handrim 73
Wheels Weight 86
*
Maintenance of Wheels 75
Armrests 73
Foot Rest 81
Support Head 78
Trunk Support 71
Global Satisfaction 73
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JRRD, Volume 52, Number 2, 2015
(19.7%) and rigid MWs (14.5%). The task of loading the
MW into the car and crossing obstacles was more diffi
-
cult for caregivers than pushing, folding, and other activ-
ities. Indeed, 65.8 and 59.2 percent of caregivers ha
d
difficulty in carrying out these activities, respectively.
Figure 3 depicts MW satisfaction
among caregivers.
Overall, they were satisfied with the MW (10/12 items
satisfied). However, 40 percent were dissatisfied with the
push handle, especially its adjustment (p = 0.001). Table 4
shows the comparison of satisfaction with each item
between MWUs and caregivers. Caregivers were less sat-
isfied with MW weight (p < 0.001
, 63% dissatisfaction)
and brake position (p < 0.001). The results of the open-
ended question revealed that the most important criterion
of an MW for caregivers was that they were lightweight,
designed for comfort, and durable (reported 22, 15, and
13 times, respectively). Other aspects also frequently
mentioned were compactness (10 times), ease of folding
(9 times), and aesthetic qualities (9 times).
DISCUSSION
The aim of this study was to evaluate the satisfaction
of French
MWUs and caregivers with MW characteris-
tics. To our knowledge, this has hardly bee
n evaluated
around the world and no studies have specifically been
conducted in France on MWUs and caregivers. We
believe that measuring satisfaction with an MW is an
important aspect of assessing the quality of an MW. The
major findings of this study are that French MWUs are
generally satisfied with their MW and its technical char-
acteristics, although some improvements do
seem nece
s-
sary. The results of this study sho
wed that weight and
outside propulsion were the main reasons of dissatisfac-
tion among MWUs. Caregivers were unsatisfied with
MW dimensions and the bra
k
es and were most unsatis-
fied with MW weight.
de Groot et al. showed a relationship between partici-
pation and simplicity of use and between an active life-
style and MW dimensions [10]. They showed that some
aspects of
the MW should
be optimized because they are
related to an active lifestyle and participation. MWUs
considered the wheelchair to have a positive influence on
their opportunity to work and have an active leisure life
[12]. Other studies have also shown that participants who
were more satisfied with MW dimensions or who were
satisfied overall had a more active lifestyle [9–11]. The
results of our study showed that MWUs are satisfied with
their MWs (73.5% satisfied, mean score of 2.8/4). The
global satisfaction scores and level of satisfaction for
each item did not depend on age, sex, or etiology. These
results are similar to those reported by de Groot et al.,
who did not find any differences between age or sex
groups [10]. Satisfaction with MW dimensions and sim-
plicity of use indoors was above 80
percent,
similar to the
previous study. The most important aspects perceived by
the MWUs were that the MW was lightweight, designed
for comfort, durable, and easy to maneuver. The same
items were found to be important in a study by Samuels-
son and Wressle [12].
As we hypothesized, despite the fact tha
t
the persons
were globally satisfied, they had many criticisms. MW
weight and outdoor propulsion were the aspects with the
most mixed responses for MWUs. Unlike MWUs, the
most mixed responses among caregivers concerned the
MW’s weight, dimensions, position, and ease of use of
the brakes and push handles. In the previously mentioned
studies, the authors reported lower levels of satisfaction
with MW weight [10–12]. The results of the study by
Samuelsson and Wressle showed that MW weight and
th
e
type of surface have an effect on propulsion [12].
Cowan et al. indeed showed that surface type substantially
Table 3.
Comparison of manual wheelchair user parameter satisfaction and global
satisfaction (n = 132).
*
p < 0.004.
Figure 2.
Percentage of answers given by manual wheelchair users to item of satisfaction questionnaire.
187
MARCHIORI et al. Manual wheelchair satisfaction
affects self-selected velocity, peak resultant force, and
peak tangential force and that the addition of 9 kg
reduces self-selected velocity and increases peak forces
on each surface [19]. Cowan et al. concluded that the
greatest reductions in the resultant peak force would be
obtained with the lightest possible wheelchair [19]. To
our knowledge, no studies have been carried out on satis
-
faction with wheelchair accessories. Caregivers are less
satisfied than MWUs in te
rms of push handles and
brakes.
It is interesting to note that despite the fact that
MWUs and c
aregivers were dissatisfied with several
aspects of the MWs, they expressed overall satisfaction.
It therefore appears that they are resigned to the fact that
they have to live with this reality. This is known as
accommodation. Accommodation is an effect of the envi-
ronment on the MWU that alters his or her way of seeing,
doing
, and thinking. It reflects the action of the environ-
ment on the cognitive activity of the subject, reor
ganizing
knowledge, and changing his or her way of seeing things.
Thus, to accommodate to the MW, the person must
accept its faults and qualities. In other words, the person
learns to put up with it whatever happens [20].
The caregivers in this study were family members
a
n
d health professionals with a majority of women (65%)
aged 46 yr on average. This is similar to a previous study
in which the caregivers were found to be generally
women (68%) with a mean age of 47 yr [21]. The main
sources of dissatisfaction among caregivers were MW
weight, dimensions, brakes, and push handles. This is
likely related to the fact that these elements can cause
discomfort or pain (such as low back pain) and limit the
caregivers actions. If the MW is too heavy, it is difficult
to move, especially for tasks such as loading it into a car.
Similarly, if the push handles are improperly adjusted or
not adjustable, this can cause back pain. A study by van
Figure 3.
Percentage of answers given by caregivers to item of satisfac-
tion questionnaire.
188
JRRD, Volume 52, Number 2, 2015
der Woude et al. showed that the biomechanical load
when pushing a wheelchair is partly influenced by push
handle height [22]. In general, higher push handles
appear to offer some advantages. Low push handles cre
-
ate greater net moments of force, compression forces,
an
d shear forces on lumbar 5 to sacral 1 and greater lift-
ing forces in comparison with higher push handles. van
der W
oude et al. determined that the push handles should
be positioned at 86.5 percent of shoulder height and
should therefore be adjustable. Moreover, caregivers
have a high-risk of developing low back pain [23]. This
can interfere with the caregivers own life as well as with
the mobility of the MWU. The brakes are also a problem
because of their low position on the MW.
The elements of satisfaction and dissatisfaction high-
lighted here and in other studies must be taken into
acco
u
nt in the design and modification of MWs since a
well-designed, well-adjusted MW can enhance the
mobility and community participation of individuals with
reduced mobility [4]. Moreover, a poorly adjusted or
adapted MW may cause secondary UL pathologies and
decreased independence [7]. The importance of a well-
adjusted wheelchair has been previously described in the
literature. For example, seat height has an effect on phys-
ical strain; a low, backward position of the seat allows
grea
ter efficiency of propulsion, but if the seat is too low
and the wheels too far back, this increases joint angles
and could increase the risk of UL injuries [24].
One major problem is that MWUs often have diffi-
culty in obtaining improved MW models,
such as lighter,
more compact MWs, because of the cost. In France, the
level of reimbursement from the state depends on the
type of wheelchair, e.g., €558 ($589) for a rigid and fold-
able wheelchair and €948 ($1,001) for a comfort wheel-
chair. These sums do not correspond with the price of
sophis
t
icated wheelchairs, which can be over €4,000
($4,224). If users do not have a complementary health
insurance plan to help them pay for their wheelchair, they
are often unable to access the one best suited to their MW
needs. In this study, MWUs and caregivers were unani-
mous in their belief that the price of wheelch
airs is too
high. A study of the France Paralyzed Association on
wheelchair funding showed that reimbursement is insuf-
ficient compared with the price and that it does not allow
persons wi
th disabilities to acquire a wheelchair that
reflects their needs [25]. MWUs hesitate to choose a
Item
Subjects “Quite Satisfied or Very Satisfied” (%)
Manual Wheelchair Users (n =
13
2) Caregivers (n = 76)
Dimensions 78 64
Weight 62
*
37
*
Propulsion Indoors 82 85
Propulsion Outdoors 61 63
Ease of Pivot 78 75
Brake Position 80
*
61
*
Ease of Brakes 81 68
Clothes-Guards 65 74
Pushing Handles 80
*
60
*
more
Table 4.
Comparison of parameter satisfaction of manual wheelchair users and caregivers.
*
p < 0.004.
189
MARCHIORI et al. Manual wheelchair satisfaction
expensive MW based on the amount of reimbursement
since most of them cannot cover the difference. Decreas
-
ing the cost, changing insurance regulations, or improv-
ing global insurance coverage should be a priori
ty in
order to allow access for all. Mobility should not be a
luxury, and rehabilitation professionals should lobby for
this alongside MWUs and caregivers.
LIMITATIONS
This study excluded MWUs who were unable to
understa
nd and answer the questionnaire. Vignier et al.
showed that half of this population has cognitive impair-
ments and two-thirds have some communication difficul-
ties and memory disorders [5]. The population studied
wa
s an average age of 55.4 ± 19.8 yr, with 70 women and
62 men. In comparison with the study by Vignier et al.
[5], our population is younger. This is likely related to the
recruitment method. The majority of MWUs who partici-
pated were recruited from Raymond Poincare Hospital
and
lived at home, whereas in the study by Vignier et al.,
the majority lived in institutions [5]. Vignier et al. deter-
mined five types of MWUs [5], but in our study only
three were
represented: elderly with physical impair-
ments, dependant elderly living in instit
utions, and active
MWUs with motor impairments. As for the type of
wheelchairs, most MWs were foldable and a few were
comfort wheelchairs. Since they are often used both
inside and outside, the MW is an essential tool for mobil-
ity. Nevertheless, it appears that a large number of
MWUs stay in the
ir room or their residence. This is par-
ticularly true for those who live in institutions and are
above the age of 60 [5]. This
is confirmed by the results
of our study, since all the MWUs who lived in institutions
used their MWs inside only. The younger subjects in our
sample used the MW both inside and outside. These
results cannot therefore be generalized to the entire popu-
lation of MWUs. Also, we did not use the Quebec User
Evaluati
on of Satisfaction with Assistive Technology
(QUEST) 2.0 questionnaire, which is a standardized
evaluation tool especially developed to measure user sat-
isfaction with assistive devices [26]. QUEST 2.0 has
been us
ed in several studies and is used in several coun-
tries. Using this index could be
interesting to compare
satisfaction with MWs in France and other countries
based on the same items.
CONCLUSIONS
The results of this study show that the majority of
French MWU
s express a good level of satisfaction with
their MWs. They also show that the global satisfaction
scores and satisfaction with MW-specific items do not
depend on age, sex, or etiology or the type of MW. The
results showed that some aspects of the MW (lightweight
design, comfort, durability, and maneuverability) and
MW parameters (dimensions and push handles) should
be optimized because they are related to an active life-
style and participation. It is also important to consider
caregiv
ers by improving parameters such as the push
handles, brakes, and MW weight. Improving these
aspects of the MW should decrease the risk of musculo-
skeletal injuries for both MWUs and caregivers, thus pos-
sibly improving mobility and satisfaction.
ACKNOWLEDGMENTS
Author Contributions:
Study concept and design: C. Marchiori, D. Pradon.
Acquisition of data: C. Marchiori.
Analysis and interpretation of data: C. Marchiori.
Drafting of manuscript: C. Marchiori, D. Bensmail.
Critical revision of manuscript for important intellectual content:
D. Pradon, D. Gagnon.
Final approval: D. Pradon.
Financial Disclosures: The authors have declared that no competing
interests exist.
Funding/Support: This material was based on work supported by the
Safran Foundation and the Garches Foundation.
Additional Contributions: We would like to thank Carolyn Bastable
Laidman for revising this article.
Institutional Review: All participants were informed of the objec-
tives and nature of the study, which was approved by the Researcher
Ethics Committee of the Raymond Poincaré Hospital.
Participant Follow-Up: The authors do not plan to inform partici-
pants of the publication of this study because contact information is
unavailable.
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Submitted for publication April 2, 2014. Accepted in
revised form January 23, 2015.
This article and any supplementary material should be
cited as follows:
Marchiori C, Bensmail D, Gagnon D, Pradon D. Manual
wheelchair satisfaction among long-term users and care-
givers: A French study. J Rehabil Res Dev. 2015;52(2):
181–92.
http://dx.doi.org/10.1682/JRRD.2014.04.0092
ORCID: Claire Marchiori: 0000-0002-4906-1387; Dany
Gagnon, PhD: 0000-0003-3464-4667
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