Northland Community and Technical College

Occupational Therapy Assistant Program

Critically Appraised Topics Assignment

Focused Question:
How can Occupational Therapy increase community integration and environmental safety for
individuals in wheels chairs?

Clinical Scenario

Increased community integration and environmental safety is needed for individuals in

wheelchairs. According to the Wheelchair Travel (2016), the United States is one of the most
accessible countries in the world; however, there are many sidewalks, streets, and buildings that
are not accessible for individuals in wheelchairs. There are approximately 3.3 million wheelchair
users in the United States, and the number is increasing every year (Bakshi, 2015). In the 34
developed countries it is estimated that 1% or 10,000,000 people require a wheelchair. In the 156
developing countries, it is estimated that at least 2% or 121,800,000 people require a wheelchair,
and in developed countries more than 95% of people who need a wheelchair have access to a
wheelchair (Wheelchair Foundation, 2017). However, in the developing countries less than 10%
of people who require a wheelchair have access to one (Wheelchair Foundation, 2017). The
world population is increasing approximately by 187,500 each day, and there is an additional
need for almost 3,500 wheelchairs everyday (Wheelchair Foundation, 2017).

Individuals in wheelchairs have consistently described how transportation barriers affect

their lives (Rosenbloom, 2007). Over half of the population with a disability has stated that
transportation is a major problem for them (Rosenbloom, 2007). The 2004 NOD-Harris
Interactive poll, found that almost two-thirds of all the people with disabilities who reported
major transportation problems had annual incomes below $35,000 (Rosenbloom, 2007). With a
low annual income, it becomes very challenging for individuals in wheelchairs to pay for all of
their expenses including housing, food, and transportation (Rosenbloom, 2007). Many
individuals try to transport themselves, but find it challenging to get from one place to the next
due to environmental safety and sidewalks not being up to standards (Rosenbloom, 2007).

There are many public transportation modes for individuals in wheelchairs including
buses, light rail services, and taxi services (Rosenbloom, 2007). However, each of these modes
poses unique access and mobility problems for people with disabilities (Rosenbloom, 2007).
There are requirements by the Americans with Disabilities Act (ADA) for each mode and for
many of the modes provide more mobility to people with disabilities (Rosenbloom, 2007). The
National Council on Disability (NCD) notes public transit is substantially underfunded in this
country, and ADA mandates do not come with any additional funding so there is even less
money for additional or non-mandated services (Rosenbloom, 2007). Thus, This research is
intended to assist occupational therapy practitioners in increasing community integration and
environmental safety for individuals in wheelchairs.

Summary of Key Findings:

Level I.

Effectiveness of a wheelchair skills training programmed for community-living users of

manual wheelchairs in Turkey: A randomized controlled trial; Öztürk, and Ucsular (2011)

The purpose of this article was to examine the wheelchair skills of 24 wheelchair
participants. A comparison with a control and non-control group on how the Wheelchair Skills
Training Program would improve the total percentage performance and safety scores of the
wheelchairs users in Turkey was completed using randomized controlled studies. There were 13
females and 11 males that completed the study. The non-control group completed the training
session for 45 minutes for 3x/week for four weeks. The results from the wheelchair skills test
performance scores showed that community-living wheelchair users that did the wheelchair
skills training increased their performance and safety scores in both groups. The training group’s
scores increased more than the control group. In conclusion, the results of this study show that
being educated on proper use of wheelchairs increases the safety of the user.

Level III.

Exploring the impact of wheelchair design on user function in a rural South African
setting; Visagie, Duffield, and Unger (2015)

The purpose of this study was to determine what impact the wheelchair design has on the
user function and the variables that guided wheelchair prescription. There were 231 adults who
lived in the Western region of the Eastern Cape Province of Africa (WREC) who received a
wheelchair from the Eastern Cape Department of Health (ECDoH). Of these individuals only 30
were picked to participate in the study. The most common diagnosis was a spinal cord injury.
Individuals had to be 18 years or older. Individuals that participated completed the Functioning
Everyday with a Wheelchair (FEW) scale and a wheelchair specification checklist (WSC). The
FEW scale consists of three parts: Functioning Everyday with a Wheelchair, Functioning
Everyday with a Wheelchair-Capacity and Functioning Everyday with a Wheelchair-
Performance. The individuals were given a wheelchair to use and 10 therapists collected data.
Wheelchairs with urban designs were issued to 25 of the participants. The wheelchair size, fit,
support and functional features created challenges in the areas of transport, operating the
wheelchair, performing personal tasks, and indoor/outdoor mobility. Users using wheelchairs
designed for semi-rural environments achieved significantly better scores regarding the
appropriateness of the wheelchair than those using wheelchairs designed for urban use. The
therapists prescribed the basic, four-wheel folding frame design most often because of a lack of
funding, lack of assessment, lack of skills and user choice. In conclusion, using the urban type
wheelchairs for users living in rural settings might have a negative effect on their functional
outcomes.

Implementation of the hybrid course on basic wheelchair service provision for Colombian
wheelchair service providers; Burrola-Mendez, Maria, Goldberg, and Pearlman (2018)

The purpose of this study was to develop a satisfaction survey and then evaluate a
Spanish Hybrid Course among a group of wheelchair service providers located in Colombia. The
hypothesis was that trainees would have higher scores on the International Society of Wheelchair
Professionals (ISWP) Wheelchair Service Provision-Basic Test after receiving the training and
would have high levels of satisfaction with the training. The mean age of the individuals that
participated in the study was 36 years. Individuals that were included in the study were those that
had worked locally in wheelchair service delivery and had not taken the ISWP Wheelchair
Service Provision-Basic Test before. Individuals were then excluded if they were participating in
another wheelchair related study. Individuals completed a pre/post test on the International
Society of Wheelchair Professionals (ISWP) Hybrid Course on Wheelchair Service Training.
The main topics discussed were wheelchair assessment, fitting, user training, process of using a
wheelchair, and the follow up/ maintenance for a wheelchair. There was online training called
the Spanish Hybrid Course that involved eight modules regarding wheelchair training and each
participant had an online recitation period that would last 90 minutes to discuss what they had
learned. Participants also participated in a personal training session that was led by individuals
that had already taken a wheelchair course, which lasted for 3.5 days. All of the 15 participants
completed the intervention and there were no dropouts. Overall, The Spanish Hybrid Course was
positively evaluated and was proven beneficial by each of the participants. The Spanish Hybrid
Course had a statistically significant influence on the total score of the ISWP Wheelchair Service
Provision-Basic Test score and received overall high satisfaction ratings, demonstrating the
potential value of the Spanish Hybrid Course to train wheelchair service providers at the basic
level.

Mixed Study: Quantitative Level III and Qualitative

Impact of structured wheelchair services on satisfaction and function of wheelchair users in

Zimbabwe; Visagie, Mlambo, Van, Nhunzvi, Tigere, and Scheffler (2016)

The purpose of this study was to compare the participant’s satisfaction and function with
their wheelchairs before and after using the comprehensive wheelchair services. There were 55
participants (29 adults and 26 children) with an age range of 11-43. Sixty-two percent of the
participants were male and 38% female, 43.6% of participants had cerebral palsy, 18.2% had
spinal cord injury/ paraplegia, and 9% had myelitis. The individuals participated in two focus
group sessions. In the sessions, participants discussed experiences and problems in life
situations, satisfaction with their wheelchairs, and how the experience of wheelchair users in
Zimbabwe can be improved. The individual’s completed a pretest and posttest of the 16 seating
clinics where they assessed the Comprehensive Mobility Support Project (CMSP). The data was
collected through a self-designed demographic questionnaire and three standardized tools which
include: Quebec User Evaluation of Satisfaction with Assistive Technology (QUEST 2.0) for
adults, QUEST 2.1 for children, and Functioning Everyday with Wheelchair Questionnaire
(FEW). The QUEST 2.0 and QUEST 2.1 assesses user satisfaction with assistive devices and
service provision processes. The FEW assesses the user’s perceptions of the impact of the
wheelchair on their function through 10 items. The pre-test showed low levels of satisfaction
with all wheelchair features and all of the wheelchair service aspects. The post-test indicated
high levels of satisfaction with 76% or more users satisfied with every aspect of their wheelchair
and service delivery. According to focus group participants, non-folding wheelchairs and the
bulkiness of the folding rigid frame design of some of the wheelchairs limited transport options.
Users preferred folding wheelchairs for easy transportation although they recognized the
durability limitations of the basic folding frame wheelchairs with active use in harsh
environments. Similar to the adults, pre-test QUEST 2.1 ratings illustrate high levels of
dissatisfaction with all wheelchair features and all but one of the wheelchair service aspects. The
proportion of satisfied users improved to more than 75% through implementation of the CMSP.
This improvement was statistically significant in all categories (p ≤ 0.005) with a small
confidence interval range. The biggest improvement was shown in comfort needs (44.3%),
indoor mobility (43.2%), outdoor mobility (37.2%). safe, efficient, independent operation
(33.5%), and transport (31.4%). In conclusion the CMSP resulted in satisfactory wheelchair
services and improved user function in wheelchairs.

Level IV.

Association between self-efficacy and participation in community-dwelling manual

wheelchair users aged 50 years or older; Sakakibara, Miller, Routhier, Backman, and Eng
(2014)

This article looked at the association between self-efficacy and participation of

individuals using wheelchairs in the community. There were 124 individuals that participated in
the study. Each of them were 50 years and older, with the mean age being around 60 years.
There were 74 individuals from British Columbia and 50 individuals from Quebec that were
enrolled in the study. A majority of the participants were males. There was no actual
intervention completed but individuals completed a variety of tests/analysis’s. The individuals
completed a 16-item frequency dimension in the Late-Life Disability Instrument (LLDI). In this
individuals rated their participation frequency in social and personal roles using a response scale
ranging from 1-5, with 5 using a wheelchair frequently. The number of comorbidities, need for a
seating intervention, and perceived social support were captured with the Functional
Comorbidity Index, the Seating Identification Tool, and the Interpersonal Support and
Evaluation List. The Physical environmental barriers were captured using the Home and
Community Environment Instrument. The life-space mobility of wheelchair users was evaluated
with the Life-Space Assessment. The Wheelchair Skills Test–Questionnaire Version assessed
wheelchair skills. The Barthel Index, the Hospital Anxiety and Depression Scale and the
Wheelchair User Shoulder Pain Index measured ability to perform activities of daily living,
depression and anxiety symptoms, and shoulder pain. The study also used Kleinbaum’s 3-stage
modeling strategy to develop a valid regression model to establish effect of self-efficacy. The
results from tests support that the association between self-efficacy and participation frequency is
facilitated by multiple functioning and disability variables. The results of the analyses also
suggest a direction in which higher levels of self-efficacy improve life-space mobility and
perceptions about participation. In conclusion, self-efficacy with using a manual wheelchair has
both direct effects on the participation frequency of community-dwelling manual wheelchair
users age 50 years or older.

Development of a community mobility skills course for people who use mobility
devices; Walker, Morgan, Morris, DeGroot, Hollingsworth, and Gray (2010)

The purpose of this article was to develop and test a community mobility skills course
(CMSC) to assess and evaluate the mobility device skills of individuals in their natural
environment. The aim was to see their skills in a controlled clinical environment measured by an
inside mobility skills course (IMSC). This study was used to provide insight on mobility device
skills needed in community settings that may be useful to occupational therapists when
facilitating contextual participation for their clients. The six individuals completed the inside
mobility skills course (IMSC) and the community mobility skills course (CMSC) in the
controlled clinical environment. They all completed half or more of the CMSC tasks more
quickly than they completed the IMSC tasks. Participants improved on certain tasks depending
on variables such as the difficulty of the tasks and the devices used. The conclusion of this study
is that some mobility device skills used in managed environments appear to work in a
community setting while others do not. The skills used for the community participation might
depend on the mobility device that is being used.

Health, personal, and environmental predictors of wheelchair-use confidence in adult

wheelchair users; Sakakibara, Miller, Eng, Routhier, and Backman (2015)

The purpose of this study was to identify health-related, personal, and environmental
factors that show wheelchair-use confidence in adults living in the community with manual
wheelchairs. There were 125 individuals that were around the age of 50 years that participated in
the study. There were men and women in the study. Each individual had to have 6 months of
wheelchair use experience, and had no cognitive impairment. Individuals completed a 65-item
Wheelchair Use Confidence Scale (WheelCon). This measure assesses the confidence
individuals have in their ability to use their wheelchair in six areas. These areas include: moving
around the physical environment, completing activities, knowledge and problem solving, social
situations, advocacy, and emotions. These items were rated on a scale between 0 to 100. The 18-
item Functional Comorbidity Index (FCI) was used to identify the number of comorbid
conditions. Participants were asked if they have had any of the chronic conditions listed. The
wheelchair environment was assessed using the 11-item Seating Identification Tool (SIT), which
evaluated the individual’s need for a seating intervention. Individuals also completed a
sociodemographic information form and were given the Mini-Mental State Examination. The
results found that thirty-nine individuals (31.5%) required some form of assistance with using
their wheelchair (mobility, transferring, setup), and 22 (17.7%) received training to use their
wheelchair. They found that sixty-eight individuals (54.8%) had a need for a seating
intervention. Age and sex were observed to be statistically significant predictors of wheelchair-
use confidence. Male sex and younger age were associated with higher confidence. In
conclusion, the findings show that older women who use wheelchairs are shown to have lower
levels of confidence. The same is true for individuals who require assistance with their
wheelchair use, use their wheelchair for few hours throughout the day, or received no formal
wheelchair education prior.

Proposed pedestrian pathway roughness thresholds to ensure safety and comfort for
wheelchair users; Duvall, Sinagra, Cooper, and Pearlman (2016)

The data found in the article was completed by in previous research and was used to be a
proposal to increase safety for individuals in wheelchairs in the community. The Mechanical
Vibration and Shock standard analysis was used to help determine the threshold numbers and
acceleration of individuals in wheelchairs. Activity level and travel distances were analyzed, as
well as the whole-body vibrations of the individual in the wheelchair. After individuals
completed the travel over the rough surface they answered a short questionnaire based on the
international roughness index and pathway roughness tool. The results of the previously
completed research indicated that rough surfaces do cause discomfort and could cause some
concerns to the individual using their wheelchairs in the community. Futhermore, the results
recommend a pathway roughness threshold of 1.2 in./ft for a surface that is 328 feet in length,
and less then 1.2 in./ft for a surface 9.8 feet in length. Various communities were assessed and
only a few were said to be fully accessible for individuals in wheelchairs traveling long
distances. Due to the various vibrations and roughness of sidewalks individuals in wheelchairs
are at risk for safety and health concerns.

Bottom Line for Occupational Therapy Practice:

The purpose of this research was to determine how Occupational Therapy could increase

community integration and environmental safety for individuals in wheelchairs. Furthermore, how

Occupational therapy can advocate and educate the public on the on impacts of the environment and

safety for individuals that go out into the community using wheelchairs. Some of the ways Occupational

therapy can assist in this is by spreading awareness on the need for new sidewalks and streets (Duvall,

Sinagra, Cooper, and Pearlman, 2016), educating individuals on proper wheelchair uses (Öztürk &
Ucsular, 2011), providing assessments and courses that increase an individual’s performance in a

wheelchair in the community or at home (Walker et al., 2010). This research will demonstrate that an

increase in community integration and environmental safety is needed for those that use wheelchairs.

Occupational therapy can help to advocate and spread awareness on streets and sidewalks that are

unsafe for individuals in wheelchairs. Occupational Therapy can also use these assessments in their

practice when educating individuals on proper wheelchair use. Research completed by Duvall, Sinagra,

Cooper, and Pearlman, (2016), found that there are better sidewalks and streets for those in wheelchairs to

use. This study reported that proposals are being established that are promoting getting sidewalks and

streets fixed for individuals in wheelchairs and to increase their safety (Duvall, Sinagra, Cooper, and

Pearlman, 2016). A variety of studies report that individuals need to be educated on proper use of

wheelchairs, wheelchair mobility, and fall prevention techniques (Öztürk & Ucsular, 2011; Burrola-

Mendez, Maria, Goldberg, & Pearlman, 2018). Education on wheelchair maintenance and repair also

needs to be established and can be done so with the help from Occupational Therapy (Öztürk & Ucsular,

2011). Some of the resources that have proven to be successful are using the Community Mobility Skills

Course (Walker et al., 2010), Inside Mobility Skills Course (Walker et al., 2010), Functioning Everyday

with a Wheelchair (FEW) scale (Visagie, S., Duffield, S., & Unger, M., 2015), and the Spanish Hybrid

Course (Burrola-Mendez, Maria, Goldberg, & Pearlman, J., 2018). These assessments and courses help

to assess and evaluate individual’s mobility device skills, as well as, educate them on proper wheelchair

training (Walker et al., 2010, Burrola-Mendez, Maria, Goldberg, & Pearlman, J., 2018). Some other

assessments available are the Quebec User Evaluation of Satisfaction with Assistive Technology (QUEST

2.0) for adults, QUEST 2.1 for children, and Functioning Everyday with Wheelchair Questionnaire

(FEW) (Visagie, S., Mlambo, T., Van, D.V., Nhunzvi, C., Tigere, D., & Scheffler, E., 2016). The QUEST

2.0 and QUEST 2.1 assess user satisfaction with assistive devices and service provision processes

(Visagieet al., 2016). The FEW assesses users’ perceptions of the impact of the wheelchair on their

function (Visagieet al., 2016). Occupational therapy can use the 65-item Wheelchair Use Confidence
Scale (WheelCon) to measure the belief individuals have in their ability to use their wheelchair in six

areas (Sakakibara, Miller, Eng Routhier & Backman, C. L., 2015). These areas include: moving around

the physical environment, completing activities, knowledge and problem solving, social situations,

advocacy and emotions (Sakakibara et al. 2015).

Another way Occupational therapy can increase environmental safety is to increase an

individual’s self-efficacy by helping them to achieve their goals and allowing them to feel successful in

using their wheelchairs. In the study by Sakakibara, Miller, Routhier, Backman, and Eng, (2014), an

increase in self-efficacy can help improve an individual’s participation in using a wheelchair when they

are older and increase community involvement. This can be completed by providing positive feedback

and education on proper wheelchair use to the individuals (Sakakibara et al., 2014). Occupational

Therapy can use this technique when trying to increase community integration for those using

wheelchairs.

The necessity for providing environmental safety and increasing community integration for those

in wheelchairs can be improved with the help of Occupational Therapy. As stated above, Occupational

Therapy can help to educate the public on sidewalks and roads (Duvall, Sinagra, Cooper, and Pearlman,

2016), can educate individuals on proper wheelchair use (Öztürk, & Ucsular, 2011), and can help build an

individual’s confidence in using a wheel chair (Walker et al., 2010, Burrola-Mendez, Maria, Goldberg, &

Pearlman, J., 2018). Each of these is critical in helping to provide support and help for increasing

community integration and environmental safety for those that use wheelchairs in their daily life.

Review Process:

Inclusion Criteria: research articles, Peer reviewed articles, Articles from 2008-2018

Exclusion Criteria: non-research articles, non-peer reviewed articles, articles older than
2008
Search Strategy:
Categories Key Search Terms
Patient/Client Population Occupational therapy and wheelchair safety,
wheelchair safety and environment,
Community accessibility and wheel chairs,
Wheelchair safety and transportation,
Wheelchair safety on streets, Wheelchair
accessible playgrounds
Intervention Occupational therapy and wheelchair safety,
wheelchair safety, Wheelchair accessibility,
Occupational therapy and wheelchair safety,
How to increase wheelchair safety, Wheelchair
and safety, Wheelchair safety intervention,
Wheelchair interventions to improve safety,
Community integration and wheelchair
Comparison N/A
Outcome wheelchair safety and environment, wheelchair
safety, Wheelchair and public accessibility,
Wheelchair safety and transportation,
Wheelchair safety on streets , Wheelchair
accidents, Wheel chair accessibility,
Wheelchair and accessibility, Wheelchair
accessible playgrounds, Occupational therapy
and wheelchair safety, Wheelchair and safety,
Community integration and wheelchair

Databases and Sites Searched:

Databases:
All Ebscohost databases
Proquest

Sites:

Bakshi, J. (2015, January 29). Wheelchair Facts, Numbers and Figures. Retrieved from
https://kdsmartchair.com/blogs/news/18706123-wheelchair-facts-numbers-and-
figures-infographic

Rosenbloom, S. (2007). Transportation Patterns and Problems of People with Disabilities.

Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK11420/

Wheelchair Foundation. (2017). Analysis of Wheelchair Need. Retrieved from

https://wheelchairfoundation.org/programs/from-the-heart-schools-program/materials-
and-supplies/analysis-of-wheelchair-need/

Wheelchair Travel. (2016, June 25). Wheelchair Accessible Cities in the United States - Travel
Guides. Retrieved from https://wheelchairtravel.org/united-states-canada/
Quality Control/Peer Review Process (this is what you did throughout this time):

This topic question was created utilizing PICO to further understand how occupational
therapy can increase community integration and environmental safety for individuals in
wheelchairs. After completing the PICO form, a research question was created. The question
focuses on how occupational therapy can increase community integration and environmental
safety for individuals in wheelchairs. Then websites were searched to form a clinical scenario,
which supported reasoning for the question. Articles were found using Ebscohost and ProQuest.
There were eight specific articles that were analyzed and studied to help support the question. A
bottom line was created to show how occupational therapy could help answer the focus question.
This document was peer reviewed by two OTA students.

Results of Search:

Summary of Study Designs of Articles Selected for Appraisal:

Level of Evidence Study Design/Methodology of Selected Number of Articles Selected
Articles
Level I Systematic reviews, meta-analysis, 1
randomized controlled trials
Level II Two groups, nonrandomized studies (e.g., 0
cohort, case-control)
Level III One group, nonrandomized (e.g., before 4
and after, pretest, and posttest)
Level IV Descriptive studies that include analysis 4
of outcomes (single subject design, case
series)
Level V Case reports and expert opinion, which 0
include narrative literature reviews and
consensus statements
Qualitative 1

Limitations of the Studies Appraised:

Level I.

Effectiveness of a wheelchair skills training programme for community-living users of

manual wheelchairs in Turkey: a randomized controlled trial; Öztürk, and Ucsular (2011)
There was a small sample size (n=24), there were transportation challenges for the individuals,
same therapist completed the training and assessments, and the wheelchairs used were not the
wheelchairs of the individuals that completed the study.

Level III.

Exploring the impact of wheelchair design on user function in a rural South African
setting; Visagie, Duffield, and Unger (2015)

Only individuals above age 18, not enough comprehensive assessments to allow for appropriate
selection of wheelchairs, small group (n=30) that participated in study

Implementation of the hybrid course on basic wheelchair service provision for colombian
wheelchair service providers; Burrola-Mendez, Maria, Goldberg, M., and Pearlman (2018)

There was no evaluation of the retention of knowledge from users, individuals were not properly
trained for course, and there was a small group (n=15) of individuals assessed.

Mixed Study: Quantitative Level III and Qualitative.

Impact of structured wheelchair services on satisfaction and function of wheelchair users in

Zimbabwe; Visagie, Mlambo, Van, Nhunzvi, Tigere, and Scheffler (2016)

There was a small sample size, n=55 the reliability of the measuring instruments in the study
context was not assessed, and some questions answered by participants may have been biased.
Also there was not an equal number of men and women in the study.

Level IV.

Association between self-efficacy and participation in community-dwelling manual

wheelchair users aged 50 years or older; Sakakibara, Miller, Routhier, Backman, and Eng
(2014)

No intervention completed, there was no exclusion criteria, and some of the information was a
little confusing to understand about the various tests that were completed on the participants.

Development of a community mobility skills course for people who use mobility
devices; Walker, Morgan, Morris, DeGroot, Hollingsworth, and Gray (2010)

The sample size was small (n=6). The time between ISMC and CMSC completion was not
standardized for participants. The CMSC contained more open space and participants were less
likely to run into walls or furniture than they were on the IMSC, which may have partially
contributed to faster scores on CMSC tasks. Finally, participants completed the CMSC during
the winter, and the cold weather may have been an especially motivating factor for completing
the CMSC tasks as quickly as possible.
Health, personal, and environmental predictors of wheelchair-use confidence in adult
wheelchair users; Sakakibara, Miller, Eng, Routhier, and Backman (2015)

The findings were limited due to the participants only being ages 50 years and older who had at
least 6 months of wheelchair-use experience. There were not any younger ages evaluated and
none that completed the assessments.

Proposed pedestrian pathway roughness thresholds to ensure safety and comfort for
wheelchair users; Duvall, Sinagra, Cooper, and Pearlman (2016)

The article was a proposal of the initial research article. It did not state the actual number of
participants or how the intervention was completed. The study did not state the duration or how
long ago the research was completed.

Articles Selected for Appraisal:

Burrola-Mendez, Y., Maria, T., Goldberg, M., & Pearlman, J. (2018). Implementation of the
hybrid course on basic wheelchair service provision for colombian wheelchair service
providers. PLoS One, 13(10) doi:http://dx.doi.org/10.1371/journal.pone.0204769

Duvall, J., Sinagra, E., Cooper, R., & Pearlman, J. (2016). Proposed pedestrian pathway
roughness thresholds to ensure safety and comfort for wheelchair users. Assistive
Technology, 28(4), 209-215. doi:10.1080/10400435.2016.1150364

Öztürk, A. & Ucsular, F. (2011). Effectiveness of a wheelchair skills training programme for
community-living users of manual wheelchairs in turkey: A randomized controlled
trial. Clinical Rehabilitation, 25(5), 416-24.
doi:http://dx.doi.org.nctproxy.mnpals.net/10.1177/0269215510386979

Sakakibara, M., Miller, C., Routhier, F., Backman, L., & Eng, J. J. (2014). Association
between self-efficacy and participation in community-dwelling manual wheelchair users
aged 50 years or older. Physical Therapy, 94(5), 664-74. Retrieved from
http://nctproxy.mnpals.net/login?url=https://search-proquest-
com.nctproxy.mnpals.net/docview/1522956451?accountid=40780

Sakakibara, B. M., Miller, W.C., Eng, J. J., Routhier, F., & Backman, C. L. (2015). Health,
personal, and environmental predictors of wheelchair-use confidence in adult wheelchair
users. Physical Therapy, 95(10), 1365-1373. Retrieved from
http://nctproxy.mnpals.net/login?url=https://search- proquest-
com.nctproxy.mnpals.net/docview/1719244119?accountid=40780

Visagie, S., Duffield, S., & Unger, M. (2015). Exploring the impact of wheelchair design on user
 function in a rural south african setting. African Journal of Disability, 4(1), 1-8.
Retrieved from http://nctproxy.mnpals.net/login?url=https://search-proquest-
com.nctproxy.mnpals.net/docview/1737493559?accountid=40780

Visagie, S., Mlambo, T., Van, D.V., Nhunzvi, C., Tigere, D., & Scheffler, E. (2016). Impact of
structured wheelchair services on satisfaction and function of wheelchair users in
Zimbabwe. African Journal of Disability, 5(1), 1-11.
doi:http://dx.doi.org.nctproxy.mnpals.net/10.4102/ajod.v5i1.222

Walker, K. A., Morgan, K. A., Morris, C. L., DeGroot, K. K., Hollingsworth, H. H., &
Gray, D. B. (2010). Development of a community mobility skills course for people who
use mobility devices. The American Journal of Occupational Therapy, 64(4), 547-54.
doi:http://dx.doi.org.nctproxy.mnpals.net

Other Resources Utilized:

Bakshi, J. (2015, January 29). Wheelchair Facts, Numbers and Figures. Retrieved from
https://kdsmartchair.com/blogs/news/18706123-wheelchair-facts-numbers-and-
figures-infographic

Rosenbloom, S. (2007). Transportation Patterns and Problems of People with Disabilities.

Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK11420/

Wheelchair Foundation. (2017). Analysis of Wheelchair Need. Retrieved from

https://wheelchairfoundation.org/programs/from-the-heart-schools-program/materials-
and-supplies/analysis-of-wheelchair-need/

Wheelchair Travel. (2016, June 25). Wheelchair Accessible Cities in the United States - Travel
Guides. Retrieved from https://wheelchairtravel.org/united-states-canada/