A Systematic Review of Outcomes Measured Following New Wheelchair and Seating-Prescription Interventions in Adults

Abstract

Objectives

To determine the outcomes and outcome-measurement tools currently used during the prescription of new wheelchairs and/or seating systems. A systematic review of studies was performed to identify outcome-measurement tools.

Data Sources

MEDLINE, CINAHL, EMBASE, and PsycINFO were searched from earliest available to March 2022.

Study Selection

Studies were included if they focused on a new wheelchair or seating-system prescription with adults.

Data Extraction

Data extraction and quality assessments were conducted by 2 reviewers; disagreements were resolved by consensus. Risk of bias was assessed using the PEDro scale (for randomized controlled trials) and the Newcastle–Ottawa Quality Assessment Scale (for non-randomized studies).

Data Synthesis

48 articles were included which identified 37 standardized outcome-measurement tools. Use of study-specific outcome-measurement tools was common. Wheelchair use, user satisfaction, activity, and participation were the most studied outcome domains. Commonly used standardized assessments included the QUEST 2.0, functional independence measure, WHODAS II, IPPA, and PIADS.

Conclusion

Outcome measures to evaluate wheelchair and seating-system prescription vary, and the use of study-specific outcome-measurement tools is high. There is a need to choose consistent outcome measures that are reliable and valid, and deal with this complex area through ensuring carefully constructed study designs.

Assistive devices are frequently recommended or prescribed to promote the independence of people living with disability.¹ A wheelchair is one of the most commonly prescribed assistive devices for enhancing mobility.² The United Nations have declared access to a wheelchair as a basic human right,³ as not only does a wheelchair provide mobility and postural support, but it also allows the user to have independence and participate in life roles and valued occupations and supports health and wellbeing.4, 5, 6

It is estimated that 65 million people worldwide (1% of the world population) require a wheelchair¹ and the capabilities and needs of adults who use a wheelchair to assist with mobility vary.^5,7 Each person will have individual needs, goals, and expectations relating to their wheelchair needs.^5,6 For these reasons, ensuring access to an appropriate wheelchair or seating can be a complex, time-consuming, and costly but important process for people with mobility limitations. Successful prescription of a wheelchair and seating system can increase a person's participation and independence and improve quality of life.⁸ In contrast, an inappropriate prescription can lead to injury, feelings of abandonment and dissatisfaction, and limited activity and participation.⁹

Successful prescription depends on a thorough assessment through which outcomes are appropriately measured.^8,10 The wheelchair and seating assessment process typically involves the assessment of function, range of movement, user needs, environmental barriers or enablers, and person's roles and routines.¹⁰ The prescription process can be multidisciplinary including, but not limited to, occupational therapists, physiotherapists, and rehabilitation engineers.

The use of outcome-measurement tools is essential to evaluate and demonstrate the effect of an intervention such as wheelchair prescription.¹¹ Researchers and health professionals should use tools that meet their needs, are suitable for the target population, and have sound psychometric properties.¹² In addition, the use of commonly applied outcome-measurement tools facilitates the comparison of different studies and services. However, in the area of wheelchair prescription, there is a lack of information about which tools are most commonly used and a lack of consensus regarding which measurement tools should be used by clinicians.

The aim of this systematic review was to determine: following new wheelchair prescriptions for adults, which outcomes are being measured and which measurement tools are being used?

Methods

Identification and selection of studies

A protocol for the systematic review was developed a priori. See appendix 1 for details of the protocol. Searches were conducted in MEDLINE, CINAHL, EMBASE, and PsycINFO databases, from the earliest date available to March 2022, for relevant studies without language restrictions. Search terms included terms related to wheelchairs (eg, mobility device, powered indoor outdoor chair, and power chair); terms related to use of wheelchairs (eg, participation, occupation, and activities of daily living); and terms related to satisfaction and quality of life (eg, personal satisfaction, confidence, and self-efficacy). (Search strategy presented in appendix 2). All titles and abstracts of citations were screened by 2 authors to identify potentially relevant studies and exclude those that were clearly not relevant. The third author checked 20% of the citations. Three authors independently assessed all studies obtained in full text to determine eligibility using pre-determined inclusion criteria. Disagreement or ambiguities were resolved by consensus or decision by a fourth author when required.

Eligibility criteria

This review considered all quantitative or mixed-methods study designs: randomized controlled trials, non-randomized controlled studies, before-and-after studies, interrupted time-series studies, observational studies (including cohort studies), case-control studies, and case-series studies.

Studies involving participants aged 18 years and over (or ≥75% aged 18 years and over), who were living in private dwellings, group homes, or residential care were included. People with all health conditions were included, provided that a new wheelchair prescription was required on a likely permanent basis. Prescription of the wheelchair may have occurred in any setting (inpatient, outpatient, community) and via any service. Prescription involved provision of a manual or power wheelchair, scooter, or seating system.¹³ Data were extracted for all outcome measures identified within the study.

Quality assessment of included studies

The quality of all studies was independently assessed by 2 authors using the PEDro scale (for randomized controlled trials) and the Newcastle–Ottawa Quality Assessment Scale (for non-randomized studies).¹⁴ A third author resolved any disagreements.

Data analysis

Data were extracted by 1 author and checked for accuracy and completeness by a second author. Extracted data included design, participants, intervention, and outcome measures. Data were presented in tables to enable the reader to understand the domains of assessment as well as the tools that have been used.

Results

Flow of the studies through the review

The electronic search strategy identified 7056 papers (after the removal of duplicates). After screening titles and abstracts, 155 papers were retrieved for full text review. Of these 155 papers, 48 met the inclusion criteria. Six papers reported data from the same studies, therefore 45 studies were included in this review. The flow of studies is presented in figure 1.

Fig 1.

Flow of studies in the review.

Characteristics of included studies

There was significant heterogeneity in the study designs and outcomes assessed. Characteristics of the included studies are provided in Table 1. The included studies were published between 1992 and 2021. Most studies (40/45; 89%) used a cross-sectional or cohort design. Studies were conducted in a range of countries including several studies conducted in low- and middle-income countries. There did not appear to be trends in terms of different outcomes assessed in different regions.

Table 1.

Summary of study characteristics and outcome measures

Study	Study Design	Participants	Diagnosis	RegionLiving Arrangements	Mobility Device	Outcome MeasuresFollow-up
Amosun et al15	Cross-sectional	N=75 Age (y)=34.48 Sex=93% men	SCI, CP, traumatic injuries, post poliomyelitis, lower limb amputations, stroke, spina bifida, other	Africa Community dwelling	Manual wheelchair	QUEST 2.0 FEW Wheelchair use Overall satisfaction with wheelchair Influence of the wheelchair on activity and participation in working, leading an active leisure life, shopping, general mobility, and participating in sports Timing=at least 3 months
Andrich et al16	Observational	N=79 Age (y)=20-90 Sex=NR	CP, MS, stroke, rheumatic diseases, and other neurologic, orthopedic or vascular diseases	Italy NR	Power wheelchair	PIADS QUEST 2.0 FABS/M SCAI Wheelchair use Timing=NR
Armstrong et al17	Cohort	N=100 Age (y)=34.48 Sex=93% men	Lower extremity paralysis and amputation	Afghanistan NR	Manual wheelchair	Wheelchair use, performance, and user satisfaction in relation to service and training Timing=3 and 10 weeks
Auger et al18	Multi-cohort	N=116 Age (y)=65 (SD 10) Sex=41% men	Neurological, musculoskeletal and medically complex	Canada Community dwelling or residential care	Power wheelchairs or scooter	WhOM Life-Space Assessment Timing=Two follow-up phone calls over 2 weeks
Barlow et al19	Cross-sectional	N=30 Age (y)=experimental 72.2, control 1 36.7, control 2 52.0 Sex=53% men	MS, PD, SCI, dementia, TBI, CVA, CP, cancer, dystonia, developmental delay	Canada Community dwelling and residential care	Seating system	QUEST 2.0 (clients and therapists) Wait times, travel costs, therapist time Goal attainment Timing=1 month
Bolin et al20	A-B-A single subject experimental	N=4 Age (y)=25.75 Sex=100% men	SCI	Sweden NR	Seating in a new manual wheelchair	MFRT FIM—transfers component Ashworth Scale Spirometer test Wheelchair skills, maximum heart rate during wheelchair skills, perceived changes using a 5-point scale Timing=3-6 week period pre-intervention 2-14 months during intervention 6-8 weeks post intervention
Buning et al21	Cross-sectional	N=8 Age (y)=44 Sex=50% men	SCI, MD, MS, cardiopulmonary insufficiency, TBI	US Community dwelling	Transition from manual to power wheelchair	PIADS OPHI Satisfaction using a Likert scale Timing=13.5 months (median) post provision
Chan and Chan22	Cross-sectional	N=31 Age (y)=41.68 (SD 11.17) Sex=81% men	SCI	China Community dwelling	Manual or power wheelchair	WHO QOL–BREF HK C-QUEST Selected items (ie, “Participation Restriction” and “Environmental Factors”) of the ICF Timing=3.79 (SD 3.72) years post injury (follow-up time post prescription of wheelchair not provided)
Cullen et al23	Cross-sectional	N=103 Age (y)=65.6 (SD 13.5) Sex=55% men	Arthritis, MS, CVA, MND, PD, MD, CP, amputation, respiratory disease, SCI, other	Scotland Community dwelling	Power wheelchair	FEW Wheelchair use Timing=1 month post wheelchair provision
D'Innocenzo et al24	Mixed methods	N=142 Age (y)=48.9 (SD 13.9) Sex=72% men	Polio, SCI, CP, MD, OI, amputation, brain injury, stroke, other	Indonesia NR	Manual wheelchair	Interviews composed of questions from: ISWP-MUD (demographics, self-reported wheelchair usage, satisfaction with wheelchair) WST-Q (wheelchair skills) LiSAT-11 (life satisfaction) BAC-Q (wheelchair maintenance and repairs) Timing=prior to provision of wheelchair and 3-6 months post-provision
Davies et al25	Cohort	N=64 Age (y)=52 (SD 21) Sex=44% men	MS, MD, other neurologic, CP, SCI, CVD, musculoskeletal, mixed disabilities, RA, polio, other	UK Community dwelling	Power wheelchair	EQ-5D Impairments/health conditions, activity, participation, and quality of life using a visual analog scale Timing=Prior to provision of wheelchair 97 (SD 16) days post provision of wheelchair
de Groot et al26	Cross-sectional	N=109 Age (y)=40.4 (SD 14.2) Sex=73% men	Acute SCI (not progressive such as a tumor)	Netherland Community dwelling	Manual wheelchair	D-QUEST PASIPD UAL SIP68 (SIPSOC)—mobility range and social behavior subscales Timing=1 year post discharge from inpatient rehabilitation
Federici et al27	Observational	N=49 Age (y)=71.02 (SD 13.49) Sex=38% men	NR	Italy NR	419 issued with a mobility device (N=279, 66.59%; manual wheelchairs 85%; powered wheelchairs 15%)	QUEST 2.0 (Italian version) ATUFS-MD User's evaluation of the service Number of visits to service and if user felt number was appropriate Timing=At least 6 months
Frank et al28	Cohort study	N=124 Age (y)=43 (SD 20) Sex=42% men	MS, MD, CP, RA, other neurologic conditions, polio, mixed impairments, SCI, CVD, spina bifida, other musculoskeletal conditions, other	UK Community dwelling	Power wheelchair	Wheelchair use, benefits for carers, component failures, collisions/mishaps Timing=3.9 (SD 1.4) months post provision of wheelchair
Fuchs and Gromak 29	Cross-sectional	N=42 Age (y)=79.3 Sex=26% men	CVA, OA, CVD, heart failure, TIIDM, pulmonary disease, dementia, other	Canada Residential care	Power and manual wheelchair, with 2 participants who received new seating components only	FIM—transfer and locomotion Therapist and patient goals, onsite evaluation of fit, function, and effectiveness Timing=11.9 (range 1-26) months post approval of wheelchair
Ganesh et al30	Cohort study	N=99 Age (y)=65.68 (SD 12.90) Sex=100% men	Heart disease, lung disease, stroke, PD, falls, fracture, joint fusion/replacement, arthritis, osteoporosis, amputation, diabetes, pressure ulcer, eye disease, cancer, depression/emotional problems	US Community dwelling	Manual wheelchair	Wheelchair transfers and propulsion and bathroom mobility method Wheelchair-related and environmental characteristics Timing=7-21 days and 1 month post wheelchair provision
Garber et al31	Cross-sectional	N=49 Age (y)=64.71 (SD 9.25) Sex=92% men	CVA	US NR	NR	FIM CHART MMSE Geriatric Depression Scale (Short Form) Health status and wellbeing—Health Status Questionnaire Major Life Events Scale Use and satisfaction Timing=27 months (range 1-119) post provision of wheelchair
Hoenig et al32 Hoenig et al. [53]	Cohort study	N=153 Age (y)=64.8 (SD 13) Sex=92% men	Weakness, neurologic, acute orthopedic	US Community dwelling	Manual or power wheelchair	Wheelchair use in different life spaces, wheelchair and environmental characteristics Timing=7-21 days post provision of wheelchair
Hoenig et al33	Quasi-experimental by day of the week	N=84 Age (y)=65 (SD 13.7) Sex=94% men	Weakness, poor balance/dizziness, fear of falling, pain, shortness of breath, other	USA Community dwelling	Manual wheelchair	Shoulder pain, wheelchair confidence, comfort and use and home modifications Timing=2 weeks, 3 and 6 months post provision of wheelchair
Kettle et al34	Cross-sectional (quasi-random sample)	N=3082 Age (y)=70.9% between 60 and 90; 15% between 40 and 60; just over 4% up to age 14 Sex=33% men	Arthritic conditions, stroke, other neurologic conditions, amputations, cardiovascular conditions, respiratory conditions, ageing (including immobility)	UK NR	Manual and/or power wheelchair	Type of wheelchair, delivery of the wheelchair, instructions in use, ease of use, suitability, comfort and reliability of wheelchair, extent of use, knowledge of approved repairers and Disablement Services Authority Qualitative analysis: comfort, suitability, environmental issues, instructions on use Timing=NR
Lee et al35	Cohort study	N=70 Age (y)=44.6 (SD 13.2) Sex=61% men	CP, stroke, TBI, SCI, amputation, myopathy, arthropathy, MND, occupation	Korea Community dwelling	Power wheelchair	MBI FIM Socioeconomic status, current wheelchair use, social participation, psychiatric influences, difficulties and barriers, self-reported independence Timing=1 year (at least) post provision of wheelchair
Löfqvist et al36	Cohort study	N=34 Age (y)=69 (SD 13.3) Sex=68% men	NR	Sweden Community dwelling	Power wheelchair or power scooter	NOMO 1.0 Timing=Pre-provision of wheelchair/scooter 4 months and 1 year post provision of wheelchair/scooter
May and Rugg37	Mixed methods	N=12 Age (y)=56.75 (SD 19.75) Sex=68% men	Most had neurologic impairments	UK Community dwelling and residential care	Power wheelchair	COPM Perceived quality of life—semi-structured interview (6 participants) Timing=Pre-provision of wheelchair 4 and 12 weeks post provision of wheelchair
Perotti et al38	Cross-sectional	N=110 Age (y)=53.23 Sex=45.2% men	Paraplegia, MS, spasticity syndromes, neurodegenerative disorder, polio, orthopedic condition, muscle disease, other paralysis	Germany NR	Manual or power wheelchair	Information about assistive device (device type, finance method, usage behavior, reason for applying for device, waiting time until receipt, hours use of device per day) QUEST 2.0 KWAZO Timing=within 2 years post-wheelchair provision
Pettersson et al39 Hagberg et al. [37]	Cohort study	N=45 Age (y)=79.1 (SD 5.76) Sex=80% men	Clients with mobility limitations	Sweden Community dwelling	Three wheeled power scooter	RAND SF-36 EQ 5D EQ VAS IPPA WHODAS II Health economic analysis from a societal perspective considering costs, savings, and quality of life—cost-utility analysis using costs per quality adjusted life year as the incremental cost-effectiveness ratio Use time, driving distance, effect of the PMD, satisfaction with PMD, mishaps related to the use of PMD–getting stuck or flat tyre Timing=Pre-provision of scooter and 4 months post provision
Pettersson et al40 Pettersson et al. [20]	Cohort study	N=32 Age (y)=67 Sex=69% men	Stroke	Sweden Community dwelling	Power wheelchair or power scooter	PIADS EQ-5D IPPA WHODAS II Importance and satisfaction Checklist of significant life events Timing=Pre-provision of wheelchair 4 (range 3-5) months post provision of wheelchair
Rousseau-Harrison et al41	Cohort study	N=42 Age (y)=64.2 (SD 18.5) Sex=38% men	Neurological, cartilage, bone or muscle, multi-factor condition	Canada Community dwelling and residential care	Manual or power wheelchair	RNLI Timing=Pre-provision on day of assessment 3-7 months post provision of wheelchair
Salatino et al42	Observational	N=79 Age (y)=<20 - >80 Sex=62% men	CP, MS, stroke, rheumatic and connective tissue diseases, sequelae of poliomyelitis, spinal muscular atrophy, arthrogryposis, MD, spina bifida, ABI, amputee, myelopathy, SCI, ALS, heart diseases, and other movement disorders	Italy NR	Power wheelchair	PIADS QUEST FABS/M SCAI Wheelchair use, functional limitations and participation restrictions, overall perception of satisfaction and effectiveness Timing=At least 6 months post provision of power wheelchair
Samuelsson et al43	Cohort study	N=38 Age (y)=43 Sex=NR	SCI, MS, stroke, CP, spina bifida and mental disability	Sweden NR	Manual or power wheelchair and/or seating system	Clients estimated effect of intervention on wheelchair functionality, as well as pain and other aspects related to wheelchair seating Pressure distribution Rhombo Medical Sensor Mat System Examination of pressure ulcer Timing=Pre-provision of wheelchair 6.5 (SD 3.3) months post provision of wheelchair
Samuelsson and Wressle44	Cohort study	N=24 Age (y)=67 Sex=38% men	NR	Sweden Community dwelling	Power wheelchair or power scooter	Occupational performance, social participation, need for assistance, prescription process, cost benefit Health and life satisfaction using EQ-5D VAS Timing=Pre-provision of wheelchair/scooter 4 months post provision of wheelchair/scooter
Shore40	Cohort	N=191 Age (y)=38.81 (SD 27.31) Sex=41.4% men	Stroke, CP, SCI, polio, trauma/fracture, amputee, arthritis, other	Peru, Uganda and Vietnam Community dwelling	Manual wheelchair	Overall health status, pain, pressure injuries employment, income, distance traveled, breakdowns, and satisfaction with wheelchair Timing=12 and 30 months post provision
Shore and Juillerat45	Cohort study	N=519 Age (y)=54 Sex=57% men	Stoke, CP, hydrocephalus, spina bifida, MD, club foot, cancer, SCI, polio, PD, trauma/fracture, amputee, arthritis	Vietnam, Chile, India Community dwelling	Manual wheelchair	Quality of life, access to medical care, employment, income, physical and emotional health, and independent function Change in health, function and integration into society associated with wheelchair use, days of personal illness, hospitalization, nutrition and emotional-health status, pressure ulcers and pain Lifestyle evaluated using ICF framework and time and distance traveled from home and wheelchair maintenance requirements Timing=Pre-provision of wheelchair 12 months post provision of wheelchair
Shore46	Cross-sectional	N=188 Age (y) =50 (SD 25) Sex=56.4% men	Amputee, collision, stoke, congenital disability, SCI, arthritis, other orthopedic/neurologic/general conditions	India and Peru Community dwelling	Manual wheelchair	Usage of wheelchair (hours per day) Change in function (activities and participation using ICF framework) Wheelchair maintenance and repair Health and quality of life of users Timing=79.9 (SD 8.0) months post provision of wheelchair
Sund and Brandt47	Cross-sectional	N=59 Age (y)=74.5 (SD 12.3) Sex=54.2% men	Vision or hearing impairment, reduced balance, endurance, function in arms, back and/or legs, problems with co-ordination of movements, problems with head/neck movements, memory problems or tiredness	Denmark and Norway Community dwelling	Scooter	QUEST 2.0 NOMO 1.0 Frequency of use Timing=mean 387 days
Sund et al48	Cohort study	N=180 Age (y)=68.7 (SD 14.7) Sex=47.8% men	Vision or hearing impairment, reduced balance, endurance, function in arms, back and/or legs, problems with co-ordination of movements, problems with head/neck movements, memory problems or tiredness	Denmark, Finland and Norway Community dwelling	Power wheelchair or scooter	NOMO 1.0 Changes in health condition and social events Timing=Before provision and approx. 1 year post provision Mean 386.9 days (SD 52.78
Sund et al49	Cohort study	N=134 Age (y)=73.8 (SD 13.3) Sex=52% men	A, asthma, chronic bronchitis, MS, angina, stroke, polio, hypertension	Denmark and Norway Community dwelling	Power scooter	SATS Service-delivery process Timing=Pre-provision of scooter 72.1 (SD 49.4) days post provision of scooter
Suzuki and Lockette50	Cross-sectional	N=26 Age (y)=NR Sex=NR	NR	Hawaii NR	NR	Satisfaction with service delivery Timing=NR
Taylor et al51	Cohort study	N=1376 Age (y)=NR Sex=NR	NR	US NR	Manual and/or power wheelchair	Type and quantity of wheelchair-skills training provided by OT and PT, methods used to determine wheelchair prescription, patient satisfaction with and continued utilization of the wheelchair 1 year post injury Timing=1 year post injury
Trefler et al52	Cohort study with semi-crossover design	N=34 Age (y)=82.4 (SD 9.8) Sex=19% men	Fear of falling, frailty, arthritis, paralysis	US Residential care	Manual wheelchair	QUEST 2.0 RAND SF-36 Wheelchair skills: forward propulsion in straight lines and 90 degree turns Forward and lateral reach Timing=Pre-provision of wheelchair and post provision at 3 and 6 months
Visagie et al53	Mixed method	N=30 Age (y)=43.4 Sex=80% men	SCI, amputee	South Africa Community dwelling	Manual wheelchair	FEW Wheelchair specification checklist—demographic data, w/c size, environment, postural support, function, biomechanics Timing=At least 3 months post provision of wheelchair
Ward et al54	Cohort study	N=50 Age (y)=46-85 Sex=52% men	ALS	US NR	Power wheelchair	PIADS Expectations at delivery, feature use, satisfaction and comfort, positive and negative outcomes, daily living tasks, pain, edema, quality of life Timing=1 and 6 months post provision power wheelchair
Ward et al55	Cross-sectional	N=45 Age (y)=57.9 Sex=60% men	ALS/MND	US NR	Power wheelchair	Patterns of selection, satisfaction and frequency of use, technical and psychometric influences, other aspects of decision making Timing=28.79 months post provision of wheelchair
Warner et al56	Cross-sectional	N=123 Age (y)=64.8 (SD 13) Sex=92% men	Arthritis, heart disease, eye disease, respiratory condition, dementia, broken bones, stroke, diabetes, cancer, depression, joint fusion, amputation, OA, PD	US Community dwelling	Manual or power wheelchair	Hours per week spent doing physical types of activities such as sports, exercise, swimming, fishing, or other similar types of activities, health status using 2 additive scales and modified version of CHART (ie, hours out of bed, hours unpaid/paid personal assistance, number of friend/relatives contacted per month and able to move independently in the home) Timing=21 days (within) post provision of wheelchair
White and Lemmer57	Mixed method	N=130 service users and 125 wheelchair therapists Age (y)=NR Sex=NR	NR	UK NR	Manual, or power wheelchair or specialized seating system	Referral and assessment methods, supply and follow-up procedures, staffing details, wheelchairs supplied, users’ knowledge of the wheelchair and repair services, fulfilment of user and caregiver needs and satisfaction with the service Wheelchair use, assessment modes and venues, delivery and repair aspects of the wheelchair, training needs, role of carers Case study—seating clinic observations Timing=NR
Wressle and Samuelsson58	Cross-sectional	N=209 Age (y)=68 Sex=35% men	NR	Sweden NR	Manual or power wheelchair (100 manual, 40 power)	QUEST 2.0 Wheelchair usage, users’ opinions on device's influence on daily living, and prescription of the mobility device Timing=14-26 months post prescription of wheelchair

Abbreviations: ALS, amyotrophic lateral sclerosis; ATUFS-MD, Assistive Technology Use Follow-up Survey; BAC-Q, Breakdown and Adverse Consequences Questionnaire; CHART, Craig Handicap Assessment and Reporting Technique; COPM, Canadian Occupational Performance Measure; CP, cerebral palsy; CVA, cerebral vascular accident; CVD, cerebrovascular disease; C-QUEST, Chinese version of Quebec User Evaluation of Satisfaction with Assistive Technology; D-QUEST, Dutch version of Quebec User Evaluation of Satisfaction with Assistive Technology; EPIOC, electric-powered indoor/outdoor chair; EQ-5D, EuroQol 5D; EQ-5D VAS, EuroQoL 5D visual analog scale; FABS/M, facilitators and barriers survey/mobility; FEW, functioning every day with a wheelchair; FIM, functional independence measure; ICF, International Classification of Functioning, Disability and Health; IPPA, individually prioritized problems assessment; ISWP-MUD, International Society of Wheelchair Professionals Minimum Uniform Dataset; KWAZO, “Kwaliteit van Zorg” questionnaire; LiSAT-11, 11-Item Life Satisfaction Questionnaire; MBI, Modified Barthel Index; MD, muscular dystrophy; MFRT, Modified Functional Reach Test; MMSE, Mini Mental Status Examination; MND, motor neurone disease; MS, multiple sclerosis; NOMO 1.0, Nordic Mobility-related Participation Outcome Evaluation of Assistive Device Interventions; NR, not reported; OA, osteoarthritis; OPHI, occupational performance history interview; OT, occupational therapist; PASIPD, Physical Activity Scale for Individuals with Physical Disabilities; PD, Parkinson's disease; PIADS, Psychosocial Impact of Assistive Technology Scale; PT, physiotherapist; QUEST 2.0, Quebec User Evaluation of Satisfaction with Assistive Technology 2.0; RA, rheumatoid arthritis; RAND SF-36, RAND Short Form-36; RNLI, Reintegration into Normal Living Index; SATS, Satisfaction with Assistive Technology Services; SCAI, Siva Cost Analysis Instrument; SCI, spinal-cord injury; SIP68, Sickness Impact Profile 68; SIPSOC, mobility range and social behavior subscales of the SIP68; TBI, traumatic brain injury; TIIDM, type 2 diabetes mellitus; UAL, Utrecht Activity List; WHODAS II, World Health Organization Disability Assessment Schedule II; WhOM, Wheelchair Outcome Measure; WHO QOL-BREF HK, abbreviated Hong Kong version of the World Health Organization Quality of Life Questionnaire; WST-Q, Wheelchair Skills Test-Questionnaire.

Quality

This review incorporated studies of varying study designs, including an experimental study (n=1), observational studies (n=40), and mixed-methods studies (n=4). Tables 2 and 3 present the results of the critical appraisal of all included studies. There was only 1 quasi-experimental trial identified,³³ and this was considered low quality. Observational studies were of mixed quality as presented in table 2 although most studies included representative samples, correctly ascertained exposure, and involved adequate duration of follow-up.

Table 2.

PEDro scores of included studies

Study	Random Allocation	Concealed Allocation	Groups Similar at Baseline	Participant Blinding	Therapist Blinding	Assessor Blinding	<15% Dropouts	Intention-to-Treat Analysis	Between-Group Difference Reported	Point Estimate and Variability Reported	Total (0-10)
Hoenig et al33	Y	N	N	Y	N	N	N	N	N	Y	2

N, no; Y, yes.

Table 3.

Quality appraisal of included studies (Newcastle–Ottawa Quality Assessment Scale)

Study	Selection					Outcome
	Representativeness of Exposed Cohort	Selection of Non-exposed Cohort	Ascertainment of Exposure	Outcome Not Present at Baseline	Comparability of Cohorts	Assessment of Outcome	Sufficient Follow-up Duration
Amosun et al15	Y	NA	Y	NA	NA	N	Y
Andrich et al16	N	NA	Y	NA	NA	N	Y
Armstrong et al17	N	NA	N	NA	NA	N	Y
Auger et al18	Y	Y	Y	N	N	Y	Y
Barlow et al19	Y	Y	N	NA	Y	N	N
Bolin et al20	N	NA	N	NA	NA	N	Y
Buning et al21	N	NA	Y	NA	NA	N	Y
Chan and Chan22	Y	NA	Y	NA	NA	N	Y
Cullen et al23	Y	NA	Y	NA	NA	N	N
D'Innocenzo et al24	Y	NA	Y	NA	NA	N	Y
Davies et al25	Y	NA	N	NA	NA	N	Y
de Groot et al26	Y	NA	Y	NA	NA	N	Y
Federici et al27	Y	NA	Y	NA	NA	N	Y
Frank et al28	Y	NA	Y	NA	NA	N	Y
Fuchs and Gromak29	Y	NA	N	NA	NA	N	Y
Ganesh et al30	Y	NA	Y	NA	NA	N	N
Garber et al31	N	NA	Y	NA	NA	N	Y
Hoenig et al32 Hoenig et al59	Y	NA	Y	NA	NA	N	N
Kettle et al34	Y	NA	N	NA	NA	N	Y
Lee et al35	Y	NA	Y	NA	NA	N	Y
Löfqvist et al36	Y	NA	Y	NA	NA	N	Y
May and Rugg37	Y	NA	Y	NA	NA	N	Y
Perotti et al38	Y	NA	N	NA	NA	N	Y
Pettersson et al39 Hagberg et al60	Y	NA	Y	NA	NA	N	Y
Pettersson et al40 Pettersson et al61	Y	NA	Y	NA	NA	N	Y
Rousseau-Harrison et al41	Y	NA	Y	NA	NA	N	N
Salatino et al42	Y	NA	Y	NA	NA	N	Y
Samuelsson et al43	Y	NA	Y	NA	NA	N	Y
Samuelsson and Wressle44	Y	NA	N	NA	NA	N	Y
Shore62	N	NA	Y	NA	NA	N	Y
Shore and Juillerat45	N	NA	N	NA	NA	N	Y
Shore46	N	NA	Y	NA	NA	N	Y
Sund and Brandt47	Y	NA	Y	NA	NA	N	Y
Sund et al48	Y	NA	Y	NA	NA	N	Y
Sund et al49	Y	NA	Y	NA	NA	N	Y
Suzuki and Lockette50	Y	NA	Y	NA	NA	N	Y
Taylor et al51	Y	NA	Y	NA	NA	N	Y
Trefler et al52	N	Y	N	NA	N	N	Y
Visagie et al53	N	NA	Y	NA	NA	N	Y
Ward et al54	Y	NA	Y	NA	NA	N	Y
Ward et al55	N	NA	N	NA	NA	N	Y
Warner et al56	Y	NA	Y	NA	NA	N	N
White and Lemmer57	Y	NA	N	NA	NA	N	N
Wressle and Samuelsson58	Y	NA	N	NA	NA	N	Y

N, no; NA, not applicable; Y, yes.

Participants

The age of the participants varied across the studies, with some including a number of children in the data, and others focusing on older people (maximum age, 102 years). Diagnostic categories also varied: while more than half of the studies 69% (31/45) included people with a range of diagnoses, 13% (6/45) included people with a single primary diagnosis such as spinal-cord injury, stroke, or amyotrophic lateral sclerosis/motor neurone disease. The remaining 8 studies (18%) did not report on the diagnoses of participants. Follow-up times from wheelchair prescription to outcome assessment ranged from 7 days to 3.8 years. More than half of the studies (51%, 23/45) reported that participants lived in their own home, 9% (4/45) resided in residential care or their own home, and 4% (2/45) in residential care. The remaining 36% (16/45) of studies did not report living arrangements.

Intervention

Less than one-third (27%; 12/45) of studies included prescription of either power or manual wheelchairs, 27% (12/45) included prescription of only manual wheelchairs, 40% (18/45) included prescription of power wheelchairs or scooters, 4% (2/45) did not report on the type of wheelchair used, and a single study included only seating systems.

Outcome measures

A total of 37 standardized outcome-measurement tools were used. Study-specific outcome-measurement tools were used in 39 studies. We categorized outcomes into 12 domains. These domains were caregiver assistance required, wheelchair use, cost, wheelchair skills, environmental factors, satisfaction (eg, with the wheelchair and/or service delivery), process outcomes related to service provision, impairments/health conditions, activity and activity limitations/participation and participation restrictions, goal attainment, quality of life, and major life events. The tools used according to outcome domains are presented in table 4.

Table 4.

Summary of tools used to measure outcomes

Outcome Domains	Reference
Caregiver assistance required
Levels of dependence	Davies et al25; Frank et al28; Hoenig et al32; Pettersson et al40; Pettersson et al61; Samuelsson and Wressle44; Shore and Juillerat45
Assistance required from another person for activities such as mobilizing outdoors, transferring, personal care or charging the battery of the power wheelchair/scooter	Pettersson et al40; Pettersson et al61; Samuelsson and Wressle44
Self-reported levels of independence	Shore and Juillerat45
Perceived benefits of provision of a power wheelchair for carers, family or friends from the users perspective only and from the user and carers perspective	Frank et al28
Role of carers in the use of a power wheelchair	White and Lemmer57
Use of paid personal assistance and relation between hours of carer availability and the use of a wheelchair in certain life spaces	Hoenig et al32
Wheelchair use ATUFS-MD	Federici et al27
ISWP-MUD (self-reported wheelchair usage)	D'Innocenzo et al24
Wheelchair Specification Checklist	Visagie et al53
How often the wheelchair was used; number of hours of use per day; distance traveled; frequency of indoor vs outdoor use; most frequent destination; and frequency of use of power features	Armstrong et al17; Frank et al28; Garber et al31; Kettle et al34; Lee et al35; Perotti et al38; Pettersson et al40; Pettersson et al61; Pettersson et al39; Samuelsson and Wressle44; Shore46; Ward et al55; Wressle and Samuelsson58; Ward et al54; Amosun et al15; Andrich et al16; Pettersson et al39; Hagberg et al60; Salatino et al42; Shore62; Sund and Brandt47
Relation between rate of use, and rates of repairs and returns exists, and predictors or influences of wheelchair use	Cullen et al23; White and Lemmer57
Wheelchair characteristics; fit, function, comfort, suitability, and performance	Armstrong et al17; Fuchs and Gromak29; Ganesh et al30; Hoenig et al33; Kettle et al34; Samuelsson et al43; Ward et al54
Ease of learning to use the wheelchair, collisions, mishaps, component failures, reliability, breakdowns, repairs and maintenance	Frank et al28; Hagberg et al60; Kettle et al34; Lee et al35; Pettersson et al40; Pettersson et al61; Pettersson et al39; Shore46; Shore and Juillerat45; Shore62
BAC-Q (wheelchair maintenance and repairs)	D'Innocenzo et al24
Wheelchair abandonment	Garber et al31
Cost SCAI	Andrich et al16; Salatino et al42
Cost of providing a rental power wheelchair or scooter compared with cost of in-home services (including personal assistance)	Samuelsson and Wressle44
Costs of clinic-based assessment compared with telerehabilitation assessment	Barlow et al19
Health economic analysis from a societal perspective considering costs, savings, and quality of life	Pettersson et al39; Hagberg et al60
Wheelchair skills Type and quantity of wheelchair-skills training	Taylor et al51
Ability to perform forward and rear propulsion, turning, rear-wheel balancing, and climbing curbs	Armstrong et al17; Bolin et al20; Trefler et al52
Cooper test	Bolin et al20
WST-Q	D'Innocenzo et al24
Environment factors Home adaptations and the difficulties, barriers or facilitators encountered with the physical environment (eg, uneven terrain, tight space, street crossing, steps in/out of house)	Chan and Chan22; Hoenig et al59; Hoenig et al33; Hoenig et al32; Lee et al35
Satisfaction with the wheelchair and/or service delivery QUEST 2.0 (English, Dutch, Italian, and Chinese version)	Barlow et al19; Chan and Chan22; de Groot et al26; Perotti et al38 Trefler et al52; Wressle and Samuelsson58; Amosun et al15; Andrich et al16; Federici et al27; Salatino et al42
QUEST 2.0—Device subscale only (Danish and Norwegian version)	Sund and Brandt47
KWAZO	Perotti et al38
SATS instrument	Sund et al49
Satisfaction with service-delivery process	Samuelsson and Wressle44; White and Lemmer57
Satisfaction with the device and if expectations met	Ward et al55
Satisfaction with service, service providers, and device	Suzuki and Lockette50; Samuelsson and Wressle44
Overall satisfaction with device only	Fuchs and Gromak29; Pettersson et al40; Pettersson et al61; Pettersson et al39; Hagberg et al60; Shore and Juillerat45; Amosun et al15; Salatino et al42; Shore62
ISWP-MUD (self-reported satisfaction with wheelchair)	D'Innocenzo et al24
Device effectiveness	Salatino et al42
Overall satisfaction and positive and negative outcomes of having a power wheelchair	Ward et al54
LiSAT-11	D'Innocenzo et al24
Overall life satisfaction	Samuelsson and Wressle44
Process outcomes related to service provision Steps taken in the service-delivery process and time spent on different steps	Sund et al49
Provision of wheelchair-skills training, evaluations with a physiotherapist and/or occupational therapists, fitting sessions and mat evaluations	Taylor et al51
Percentage of participants who received their evaluation from an experienced clinic therapist, as well as information on the evaluation process, number of wheelchairs trialed, timeframe from assessment to delivery, and the delivery process	Ward et al55
User's opinion on the prescription process and opportunity to participate in and influence the process, opportunity to receive and gather information and training, as well as the user's opinion on the fulfilment of their expectations, provision of follow-up and satisfaction with follow-up	Wressle and Samuelsson58
Staff and consumer perspectives on referral, assessment, supply and follow-up procedures, assessment modes and venues, range of wheelchairs available, staff training, user knowledge of the wheelchair and repair services	White and Lemmer57
Information provided in relation to the wheelchair and demonstration of its use, and the condition of the wheelchair on delivery	Kettle et al34
User's evaluation of the service, number of visits, and user's perspective on number of visits	Federici et al27
Waiting time to receive wheelchair	Perotti et al38
Reasons for wheelchair acquisition	Perotti et al38
Impairments/health conditions Rhombo Medical Sensor Mat System	Samuelsson et al43
Ashworth Scale—spasticity	Bolin et al20
Spirometer test—respiration	Bolin et al20
Geriatric Depression Scale Short Form	Garber et al31
MMSE	Garber et al31
The Health Outcomes Institute Stroke Form–Later Outcomes	Garber et al31
Presence and/or number of pressure injuries, examination of pressure injuries and skin breakdown	Garber et al31; Samuelsson et al43; Shore46; Shore and Juillerat45; Shore62; Visagie et al53
Pain and discomfort	Davies et al25; Garber et al31; Hoenig et al33; Löfqvist et al36; Samuelsson et al43; Shore46; Shore and Juillerat45; Shore62; Ward et al54
Edema	Ward et al54
Health status or medical changes	Davies et al25; Garber et al31; Löfqvist et al36; Shore and Juillerat45; Shore62; Sund et al48
Falls and contractures	Garber et al31
Perceived change in spasticity and respiration from the users’ perspective	Bolin et al20
Medical visits to establish which factor or factors predicted the number of medical visits	Hoenig et al59; Hoenig et al32
Activity and activity limitations/participation and participation restrictions FIM	Bolin et al20; Fuchs and Gromak29; Garber et al31; Lee et al35
PASIPD	de Groot et al26
NOMO 1.0	Löfqvist et al36; Sund et al48; Sund and Brandt47
WHODAS II	Pettersson et al39; Hagberg et al60; Pettersson et al40; Pettersson et al61
Life-Space Assessment	Auger et al18
FEW	Amosun et al15; Visagie et al53; Cullen et al23
MBI	Lee et al35
IPPA	Pettersson et al39; Hagberg et al60; Pettersson et al40; Pettersson et al61
RNLI	Rousseau-Harrison et al41
Mobility range and social behavior subscales of the SIP68 (SIPSOC)	de Groot et al26
CHART	Garber et al31
MFRT	Bolin et al20
OPHI	Buning et al21
COPM	May and Rugg37
FABS/M	Andrich et al16; Salatino et al42
World Health Organization's ICF framework—activity and participation	Chan and Chan22; Shore46; Shore and Juillerat45
UAL	de Groot et al26
Change in mobility	Davies et al25
Forward and lateral reach	Trefler et al52
Physical mobility	Löfqvist et al36
Effect of power wheelchair on activity	Samuelsson and Wressle44
Performance of activities that were not expected at the time of prescription	Pettersson et al40; Pettersson et al61
Participation in employment, occupation and leisure or social activities	Warner et al56; Davies et al25; Samuelsson and Wressle44
Users’ perceived changes in sitting balance, transfers, and wheelchair propulsion	Bolin et al20
Self-estimation of the effect of the intervention on propulsion and transfers	Samuelsson et al43
User perception, exploring how the device influenced daily living (ie, being active, socializing, being mobile, participating in leisure activities, feeling a healthy level of self-esteem, and feeling safe and secure, and independent)	Samuelsson and Wressle44; Wressle and Samuelsson58
Fulfilment of mobility needs from the perspective of the consumers and carers	White and Lemmer57
Activity limitations and difficulties encountered with the ambulation of a power wheelchair	Lee et al35
Influence/effect of the wheelchair on activity and participation in daily activities, working, leading an active leisure life, shopping, general mobility, and participating in sports	Amosun et al15; Pettersson et al39; Hagberg et al60
Functional limitations and participation restrictions	Salatino et al. 42
Employment status and income over time	Shore62
Social events	Sund et al48
Performance of daily living tasks	Ward et al54
Goal attainment Rate of goal achievement from the perspective of the user and the therapist	Barlow et al19
Frequency of the achievement of each identified goal from the perspective of the therapist only	Fuchs and Gromak29
Fulfilment of the users’ expectations following prescription of a power wheelchair or scooter from the participants perspective	Löfqvist et al36; Samuelsson and Wressle44; Ward et al54
Quality of life PIADS	Buning et al21; Pettersson et al40; Andrich et al16; Salatino et al42; Ward et al54
EQ-5D	Davies et al25; Pettersson et al40; Hagberg et al60
WHO QOL–BREF HK	Chan and Chan22
Health Status Questionnaire	Garber et al31
RAND SF-36	Löfqvist et al36; Trefler et al52; Pettersson et al39; Hagberg et al60
Effect wheelchair had on users’ quality of life	Shore46; Ward et al54
Self-reported health status or a change in health status	Shore46; Shore and Juillerat45
Major life events Study-specific tools	Garber et al31; Pettersson et al40; Pettersson et al61

Abbreviations: ATUFS-MD. Assistive Technology Use Follow-up Survey; CHART, Craig Handicap Assessment and Reporting Technique; COPM, Canadian Occupational Performance Measure; EQ-5D, EuroQol 5D; FABS/M, Facilitators and Barriers Survey/Mobility; FEW, functioning every day with a wheelchair; FIM, functional independence measure; ICF, International Classification of Functioning, Disability and Health; IPPA, individually prioritized problems assessment; MBI, Modified Barthel Index; MFRT, Modified Functional Reach Test; MMSE, Mini Mental Status Examination; NOMO 1.0, Nordic Mobility-related Participation Outcome Evaluation of Assistive Device Interventions; OPHI, occupational performance history interview; PASIPD, Physical Activity Scale for Individuals with Physical Disabilities; PIADS, Psychosocial Impact of Assistive Technology Scale; RAND SF-36, RAND Short Form-3; RNLI, Reintegration into Normal Living Index; SATS, Satisfaction with Assistive Technology Services; SCAI, Siva Cost Analysis Instrument; SIP68, Sickness Impact Profile 68; SIPSOC, mobility range and social behavior subscales of the SIP68; QUEST 2.0, Quebec User Evaluation of Satisfaction with Assistive Technology; UAL, Utrecht Activity List; WHODAS II, World Health Organization Disability Assessment Schedule II; WHO QOL-BREF HK, abbreviated Hong Kong version of the World Health Organization Quality of Life Questionnaire.

Overall, the most common domain measured in the included studies was wheelchair use (eg, frequency of use, type of use). However, studies used a variety of self-developed methods to measure use with only 3 standardized tools used. The next most common domain measured was user satisfaction with the wheelchair; 11 studies used the QUEST tool 2.0 tool to measure satisfaction whereas other studies used alternative standardized tools or self-developed methods. Activity and participation and quality of life where the next most commonly measured domains with several studies using the functional independence measure and WHODAS 2 to measure activity and the Psychosocial Impact of Assistive Technology Scale and SF-36 to measure health-related quality of life. The person's health status was measured in a total of 13 studies, typically with disease-specific tools. Less commonly evaluated was goal attainment and cost outcomes.

Caregiver assistance

Following the provision of a wheelchair, caregiver assistance was measured in 6 studies (7 papers)25, 28, 32, 40, 44, 45, 61 using study-specific tools. Variables such as levels of dependence or self-reported independence, assistance required from another person, perceived benefits for carers, family or friends from the users perspective, role of carers in the use of power wheelchair, and relation between hours of carer availability and the use of wheelchair in certain life spaces were reported.

Wheelchair use

The outcomes associated with wheelchair use and wheelchair characteristics were reported in 27 studies^33,28,15, 16, 17, 23, 24, 27, 29, 30, 31, 34, 35, 38, 39, 40, 42, 43, 44, 45, 46, 47, 53, 54, 55, 57, 58, 60, 61, 62; all except 3 used study-specific tools. Wheelchair use was measured using variables such as how often the wheelchair was used; number of hours of use per day; distance traveled; frequency of indoor vs outdoor use; most frequent destination; and frequency of use of power features.^28,40, 44, 61^,17,31, 34, 35^,46,55,15, 16, 39, 42, 47, 58, 60, 62^,38 Data on wheelchair use were also collected to determine if a relation existed between rate of use, and rates of repairs and returns, and to establish predictors or influences of wheelchair use.^23,57 Wheelchair characteristics were measured using variables such as fit, function, comfort, suitability, and wheelchair performance.^{33,17,29,30,34,43,54} Further outcomes associated with wheelchair characteristics and use included ease of learning to use the wheelchair, collisions, mishaps, component failures, reliability, breakdowns, repairs and maintenance, and abandonment.^{28,40,61,45,34,35,46,60,39,62,24} Standardized tools were used in 3 studies.^24,27,53

Cost

The Siva Cost Analysis Instrument (SCAI) was used in 2 studies^16,42 to estimate the economic effect of wheelchair provision. In a prospective before-and-after study,⁴⁴ the total cost of providing a rental power wheelchair or scooter was compared with the cost of in-home services (including personal assistance). A further study¹⁹ compared the costs of clinic-based assessment and telerehabilitation assessment. One further study (2 papers)^60,39 completed a health economic analysis from a societal perspective considering costs, savings, and quality of life. A cost-utility analysis using costs per quality adjusted life year as the incremental cost-effectiveness ratio was used.

Wheelchair skills

Wheelchair skills were measured using study-specific tools in 4 of the included studies^17,20, 51, 52 and a standardized tool (Wheelchair Skills Test Questionnaire) in 1 study.²⁴ Data were collected on variables such as type and quantity of wheelchair-skills training provided during inpatient rehabilitation⁵¹ and the ability to perform forward and rear propulsion, turning, rear-wheel balancing, and climbing curbs.^17,24,20,52 The method for measuring wheelchair skills also varied across studies. Methods included timing the participants in propulsion tasks,^20,52 recording participants’ perceived changes using a 5-point scale,²⁰ assessing whether participants could or could not perform a list of activities,²⁴ or ranking participants using a Likert scale from 1 (cannot perform activity) to 5 (mastered activity) based on participants’ ability to perform each activity.¹⁷ In addition, Bolin et al²⁰ used the Cooper test,⁶³ which is a 12-minute run test used to measure aerobic fitness but did not provide details on how this was modified for wheelchair users.

Environmental factors

Five studies^{33,32,35,22,59} reported data on home adaptations and the difficulties, barriers, or facilitators encountered with the physical environment (eg, uneven terrain, tight space, street crossing, steps in/out of house) following the prescription of a wheelchair.

Satisfaction with the wheelchair and/or service delivery

Measures of satisfaction were found in 23 included studies.40, 44, 45, 61^,29,15, 16, 24, 27, 38, 39, 42, 47, 54, 55, 57, 58, 60, 62^,19,52,22,26, 49, 50 All measured satisfaction with the wheelchair and/or the service-delivery process, and in addition, 2 studies measured overall life satisfaction using a study-specific tool⁴⁴ or standardized questionnaire (11-Item Life Satisfaction Questionnaire).²⁴

Process outcomes related to service provision

Several studies^34,55, 57, 58^,38,27,51,49 used study-specific tools to collect data on the service-delivery process or the methods used in prescribing a wheelchair. Variables such as staff or consumer perspectives on the process, who provided the service, timeframes, wheelchair trials, and follow-up were reported on.

Impairments/health conditions

A change in health condition following the prescription of a wheelchair was measured in 13 studies.^{33,25,32,45,31,43,46,62,54,53,20,59,36,48} Health conditions included: pressure injuries and skin breakdowns, pain and discomfort, edema, falls, contractures and perceived change in spasticity, and respiration from the users’ perspective. Standardized tools were used to measure depression, cognition, occurrence of health issues, spasticity, and respiration. One further study⁵⁹ collected data on medical visits to establish which factor or factors predicted the number of medical visits. The Rhombo Medical Sensor Mat System was also used to measure changes in pressure distribution following intervention.⁴⁴

Activity and activity limitations—participation and participation restrictions

Activity is considered to be the execution of a task or action by an individual, and participation is defined as involvement in a life situation.⁶⁴ Many studies and tools measure both activity and participation, thus these outcomes have been described together in this review. Nineteen studies were identified as having measured activity or participation following the prescription of a wheelchair and/or seating system using a standardized measurement tool.^{40,61,23,29,31,35,}15, 16, 39, 42, 60^{,47,53,20,26,36,48,}18, 21, 37, 41 The most commonly used tool was the functional independence measure. Details of the other tools used are presented in table 4. In addition, 21 studies used a study-specific measurement tool or adapted a pre-existing tool for the study to measure variables such as users’ perceived changes in activity, effect of the device on participation, and fulfilment of mobility needs. See table 4 for other variables. Only 2 studies^35,42 reported on activity limitations/participation restrictions and difficulties encountered with the ambulation of a power wheelchair. The World Health Organization's International Classification of Functioning, Disability and Health (ICF) framework was used in 3 studies^45,46,22 to create a tool that captured data on changes in mobility, self-care, domestic life, interpersonal interactions and relations, major life areas (eg, education, leisure, and non-remunerative work) and community, social, and civic life.

Goal attainment

Client or caregiver goals or expectations were used as an outcome measure in 5 of the included studies. Data collected included the rate of goal achievement from the perspective of the user and the therapist¹⁹; frequency of the achievement of each identified goal from the perspective of the therapist only²⁹; and fulfilment of the users’ expectations following prescription of a power wheelchair or scooter from the participants perspective^44,54,36.

Quality of life

Thirteen studies^{25,40,61,45,31,46,}16, 39, 42, 60^{,54,52,22,36,21} measured quality of life following the prescription of a wheelchair. Standardized tools, such as the Psychosocial Impact of Assistive Technology Scale (PIADS) and the RAND Short Form-36 (RAND SF-36), were used along with study-specific tools. Self-reported health status or a change in health status was also reported using standardized^31,52,36 and study-specific tools.^45,46

Major life events

Two studies (3 papers) measured “major life events” based on the hypothesis that this information needed to be captured because it can affect the success (or lack of success) of wheelchair use or influence the quality of life experienced by the wheelchair user^19,20,27.

Discussion

The aim of this review was to identify which outcomes are measured following the prescription of a new wheelchair and/or seating system. We found that a large number of outcomes measuring a number of domains are currently being used. To synthesize the findings, outcomes from the included studies were classified into 12 categories: wheelchair use and activity and participation were the most studied outcomes. The categories least reported were major life events, goal attainment, cost, and environmental factors.

The finding that a wide range of outcomes (most commonly more than 1 per study) are captured is not new. In a similar review that included only middle-aged and older-aged adults who used a power wheelchair, Auger et al¹⁸ reported similar findings, reporting 52 outcome-measurement tools were used across their included studies. The diversity of outcomes measured may reflect the complexity inherent in wheelchair prescription; the complexity of the clinical populations, the device itself, and the different factors (eg, participation, mobility, quality of life or health status) that the provision of a wheelchair and/or seating system can influence. The difficulties in measuring an intervention related to personal need that are affected by various contextual and environmental factors also presents a unique challenge in this context.⁶⁵

In addition to a large range of outcome categories, there are many tools being used in research following the prescription of a new wheelchair. The present review found that study-specific tools were most frequently used, with 14 (31%) studies using only study-specific tools, and a further 25 (56%) using a combination of study-specific tools alongside standardized outcome-measurement tools. Study-specific tools enable the researcher to be specific about the outcomes of interest; however, the use of study-specific tools makes it difficult to compare the outcomes across different studies or settings. Differing priorities between clinicians and researchers may be 1 explanation for the ongoing use of study-specific tools. It is also plausible, however, that the known difficulty in locating a single-outcome measurement tool to measure all outcome areas relevant to wheelchair and/or seating prescription and is valid and reliable^4,8 gives rise to the use of study-specific tools. Kenny and Gowran⁴ support this suggestion, concluding that no single outcome measure can capture all the information needed to evaluate the process of providing a wheelchair and/or seating system. It is likely that clinicians and researchers will create their own measurement tool to conduct a study if outcome-measurement tools appropriate to their aims are not available. Given that there are standardized outcome measures available for most domains and that some measures appear to be particularly common it would be useful to develop a consensus on which measures should be used. This would lead to greater consistency across studies and facilitate improved pooling of data. Because of the large number of domains which may be affected by wheelchair prescription, it is unlikely that a single tool could be used to measure all possible outcomes.

Previous systematic reviews have attempted to use the available research to determine the effect of wheelchair prescription on activity engagement,⁶⁶ the occupational performance of users of wheeled mobility devices and their caregivers,⁶⁷ and the efficacy of mobility devices in promoting activity and participation.⁶⁸ All 3 reviews stated that due to the poor methodological quality of studies, and the heterogeneous interventions and outcome measures, drawing conclusions was problematic.

Strengths and limitations of study

As with any review, the findings are drawn from the existing body of research. The included studies varied in the populations studied, the types of outcomes reported, and importantly, in the quality ratings. The level of quality scores may have been influenced by the inclusion of studies from a large timeframe. Including studies from database inception provided us the opportunity to investigate whether there have been significant changes over time with the outcome measures used, but because the quality of reporting research has improved over the years, it is acknowledged that the earlier studies may have influenced the overall quality score. The exclusion of studies in languages other than English may have prevented the review of high-quality studies reporting on alternative tools. Further, gray literature and conference proceedings were excluded.

Conclusions

The population requiring wheeled mobility devices is heterogeneous and there are multiple interacting factors that can affect assistive device use and related outcomes.⁶⁵ This can create substantial challenges for practitioners in this field; however, there is a clear need to choose consistent outcome measures that are reliable and valid, and deal with this complex area through ensuring carefully constructed study designs.⁶⁵ Bringing experts together (including consumer and community members) to come to consensus about recommended measures would assist researchers and clinicians in evaluating wheelchair prescription and also improve data sharing and pooling.