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Assistive Technology: The Official Journal of RESNA

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Patients' and Health Care Providers' Knowledge of

Wheelchair Transportation Issues
a a a
Lori Brinkey MPT , Christopher Savoie ATS CRTS , Edward A. Hurvitz MD & Carol
b
Flannagan PhD
a
Department of Physical Medicine and Rehabilitation , University of Michigan Health
System/C.S. Mott Children's Hospital , Ann Arbor, Michigan, USA
b
University of Michigan Transportation Research Institute , Ann Arbor, Michigan, USA
Published online: 01 Jul 2009.

To cite this article: Lori Brinkey MPT , Christopher Savoie ATS CRTS , Edward A. Hurvitz MD & Carol Flannagan PhD (2009)
Patients' and Health Care Providers' Knowledge of Wheelchair Transportation Issues, Assistive Technology: The Official Journal
of RESNA, 21:1, 35-46, DOI: 10.1080/10400430902945488

To link to this article: http://dx.doi.org/10.1080/10400430902945488

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 Assistive Technology, 21:35–46, 2009
Copyright © 2009 RESNA
ISSN: 1040-0435 print
DOI: 10.1080/10400430902945488

Patients’ and Health Care Providers’

1040-0435Technology,
UATY
Assistive Technology Vol. 21, No. 1, May 2008: pp. 0–0

Knowledge of Wheelchair
Transportation Issues
Lori Brinkey, MPT,1
Knowledge
L. Brinkey etofal.
Wheelchair Transport Safety

Christopher Savoie, ATS, CRTS,1 ABSTRACT The objective of this study was to determine the level of knowl-
Downloaded by [University of Auckland Library] at 20:32 16 October 2014

Edward A. Hurvitz, MD,1 and edge about wheelchair transportation safety practices among wheelchair users
Carol Flannagan, PhD2 (WCUs) and caregivers, therapists, physicians, and other professionals (CTPs).
1
Department of Physical
Two 10-question surveys were designed. One was administered to a conve-
Medicine and Rehabilitation,
University of Michigan Health nience sample of 107 WCUs, average age 31 years (range: 4 to 86). Diagnoses
System/C.S. Mott Children’s included cerebral palsy (39%), spinal cord injury (19%), and others. The sec-
Hospital, Ann Arbor, Michigan ond was given to a convenience sample of 87 caregivers (33%), therapists
2
University of Michigan (27%), physicians (18%), and others. Results indicated that most WCUs (67%)
Transportation Research and about half of the CTPs had not received education about best transporta-
Institute, Ann Arbor, Michigan
tion practices. Less than 20% in either group had heard of the transit option or
a transit wheelchair, and less than 7% were aware of SAE J2249 and ANSI-
RESNA WC/19 standards for wheelchairs and transportation. Sixty-seven percent
of WCUs and 46% of CTPs felt lack of knowledge restricted their use of best
transportation practices, followed by cost and vehicle space. Education about
best practices was related to increased knowledge as well as increased use of
occupant and wheelchair restraints. We concluded that there is a poor level of
knowledge about wheelchair transportation safety practices among WCUs,
caregivers, and professionals who prescribe wheelchairs. This knowledge defi-
cit leads to a lack of standardized transport and a potential compromise of
safety. Education can be beneficial, and should be pursued.

KEYWORDS equipment safety, rehabilitation, transportation of patients, wheelchairs

INTRODUCTION
As concern for motor vehicle occupant safety grows in the general popula-
tion, it is understandable that similar concerns are now being raised in the
special needs population.
Address correspondence to Lori Fortunately, over the last several years, rehabilitation and safety engineers
Brinkey, MPT, 1500 East Medical have made great strides in developing systems that allow individuals to ride
Center Drive, Room F2593,
Ann Arbor, MI 48109-0224. more safely while seated in a wheelchair. These systems are comprised of
E-mail: lbrinkey@umich.edu tiedowns, used to secure the wheelchair to the vehicle; occupant restraints,
35
 which restrain the person to the wheelchair; and
transit wheelchairs, which meet crash test standards.
In 1996, the Society of Automotive Engineers (SAE)
adopted Recommended Practice 2249 (SAEJ2249),
which set design and performance requirements for
wheelchair tiedowns and occupant restraint systems
(WTORS). Briefly, the standard requires that the
WTORS successfully pass a 30-mph frontal impact
test, include pelvic and shoulder occupant restraints,
provide a mechanism to secure the wheelchair to the
vehicle (such as using four tiedown straps or a dock-
ing system), and include appropriate labels and
instructions.
Recognizing that securing the wheelchair to the
vehicle appropriately was only part of the solution
FIGURE 1 Example of a transit wheelchair and occupant
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for safer transportation, engineers then focused on

secured with a wheelchair tiedown and occupant restraint
developing a standard for wheelchairs that can serve system.
as a motor vehicle seat. In 2000, the ANSI/RESNA
standard (WC/Volume 1, Section 19, or WC/19) was
published. This standard specifies general design and pelvis at an angle of 45–75 degrees when viewed
performance requirements for a transit wheelchair from the side, to prevent submarining or abdominal
(ANSI/RESNA, 2000). It requires that the wheelchair injuries; and a diagonal shoulder belt positioned
pass a 30-mph frontal impact test, provide four easily across the middle of the shoulder and center of the
accessible wheelchair tiedown securement points, chest and attached to the lap belt near the opposite
provide a crash-tested pelvic/lap belt, include infor- hip to prevent excessive forward flexion, which could
mation about lateral stability and vehicle anchored result in head, neck, or trunk injuries (see http://
seatbelt compatibility in presale literature, and pro- www.travelsafer.org for additional recommendations
vide appropriate labels and instructions. Both the and illustrations).
tiedown and wheelchair standards are voluntary, and Providing a mobility device that complies with
manufacturers are not required to comply with those the standards is quite a challenge due to the complex
standards when developing their products. More variety of wheelchairs and almost infinite possible
detailed information about the standards can be combinations of wheelchair and seating components.
found at the Rehabilitation Engineering Research In addition to the mobility base, a variety of indi-
Center on Wheelchair Transportation Safety Web site vidual components from a variety of different man-
(http://www.rercwts.org). ufacturers are frequently used to achieve optimal
Figure 1 presents an example of a transit wheel- positioning and function of a person in a wheel-
chair and occupant secured with a wheelchair tiedown chair. This further complicates attempts to ensure
and occupant restraint system. Note the following that a wheelchair and its seating components are
best practice recommendations as shown in the illus- crashworthy.
tration: tiedown straps attached to four crash-tested Unfortunately, there is limited systematic collec-
securement points located on the wheelchair frame; tion of data on wheelchair rider motor vehicle crash
forward facing orientation of the wheelchair and incidents. However, there are a few studies that
rider; rear tiedown straps attached at a 30–45-degree identify areas of concern for wheelchair riders during
angle to floor anchor points, located directly behind normal driving. In 1997, the National Highway Trans-
the rear of the chair; front tiedown straps attached to portation Safety Administration (NHTSA) examined
floor anchor points spaced wider than the wheel- data on non-crash-related activity associated with
chair, to increase lateral stability; use of a headrest injury or death to wheelchair users involving motor
with the goal of protecting the neck in a rear impact; vehicles during a 5-year period. More than one third
positioning of the lap belt across the front of the of the incidents associated with wheelchair user

L. Brinkey et al. 36
 injuries were due to improper or no securement information was available to nonresearchers who
(NHTSA, 1997). were looking for information written in simple, clear,
In 2000, Shaw reviewed literature and databases to concise language that the average person could under-
assess wheelchair rider risk in motor vehicles. Due to stand. The few articles that had been published in
the small number of wheelchair vans and any reported nonscientific journals were primarily in school trans-
associated crashes, as well as the limitations of the portation periodicals and had an emphasis on trans-
database used in the study, he was not able to identify porting children on school buses (Henke, 1994; Hirano,
any data specific to wheelchair-related crashes. He was 2000; Marks et al., 1995; Zimmerman, 2003; Schneider,
however, able to identify a limited number of mostly 1987).
minor injuries caused by non-crash-related events. The Since then, more resources have become available
most common cause of injury was improper wheel- to consumers and health care providers on the subject
chair securement or occupant restraint, such as the (see later discussion). A recent study by Blake et al.
wheelchair tipping over or the person falling out of (2006), however, demonstrates that health care provid-
the wheelchair during vehicle maneuvers. He con- ers may not be utilizing the available resources to edu-
cluded that the majority of these injuries could have cate themselves and consumers about wheelchair
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been prevented by providing adequate protection and transportation issues. More than half of the rehabilita-
that persons riding in smaller passenger vans were at a tion therapists who completed an online survey indi-
much greater risk of injury than persons riding large cated that they had little or no knowledge (53%) or
public transit or school buses (Shaw, 2000, 2003). experience (54%) on the subject, while 79% indicated
Another study completed in California at the Wheeled that they had no formal training and 61% conducted
Mobility Center reported nine instances of wheelchair little or no counseling with families regarding the safe
riders getting injured during transportation (Gaal et al., transport of children who have special health care
1997). needs.
Studies conducted in Europe also reported several When questioned in the clinic, most wheelchair
incidents among wheelchair-seated passengers. In users as well as a variety of rehabilitation profession-
England, 21 respondents reported that they had expe- als were unaware that both transportation standards
rienced “mishaps” or “accidents,” most of which could and transit wheelchairs are available. Many individu-
be attributed to inadequate clamping (an older form als reported that they guessed at correct transporta-
of tiedown that was still being used at the time of that tion practices or trusted transportation employees to
study but is no longer recommended) or restraint follow best practices. Our observations have shown
(Belcher & Frank, 2004). Swedish researchers also that private and public transportation providers as
reported that 12% of their respondents reported “mis- well as adapted driving companies do not always fol-
haps,” while 5% experienced personal incident-related low best practices when installing tiedown systems in
injuries while using special transportation services a vehicle or when restraining individuals in their
(Wretstrand et al., 2004). wheelchairs during transport. Several wheelchair
Although the number and severity of documented users have reported that their wheelchair moved or
injuries to wheelchair riders may be low, the poten- even tipped over while they were sitting in it during
tial for injury does exist, especially in smaller passen- transportation.
ger vans. Therefore, product standards for transit Due to this anecdotal information, we hypothe-
wheelchairs and WTORS play an important role in sized that among wheelchair users there would be
providing the same level of safety for wheelchair- poor general knowledge regarding wheelchair trans-
seated occupants as for those in a vehicle seat. As cli- portation issues. Considering the lack of general infor-
nicians involved in wheelchair seating, we have mation available on the topic, we felt that caregivers
noted that many health care providers and wheel- and professionals involved with the care of wheelchair
chair users have not given much thought about the users would lack information in this area as well. To
safety aspects of being transported in a wheelchair. test this hypothesis, a survey was developed to ascer-
Prior to the past couple of years, there was limited tain wheelchair users’ and health care providers’
information available on the subject. Although arti- knowledge of wheelchair transport practices and
cles had been published in research journals, very little standards.

37 Knowledge of Wheelchair Transport Safety

 METHODS RESULTS
Survey Instrument All variables from the survey were categorical, with
the exception of age. For analysis purposes, age was
Two separate surveys were developed with ques-
treated as a categorical variable with cutpoints at 25
tions containing similar content. One survey was
and 40 years. Thus, all statistical comparisons
designed for wheelchair users or the parents of chil-
involved analysis of tables. Two-way tables were ana-
dren who use wheelchairs (WCUs). The other was
lyzed using a standard chi-square test. Three-way
designed for professional caregivers, physicians, thera-
tables were modeled using SAS PROC CATMOD.
pists, rehabilitation coordinators, nurses, and wheel-
Significance tests on the effects were based on likeli-
chair vendors (CTPs). The 10-question surveys
hood ratio chi-squares.
addressed several wheelchair transportation issues (see
The sample used in our study was a convenience
appendix). Specifically, the survey asked demographic
sample of 194 respondents, 107 WCUs and 87 CTPs.
questions, questions relating to wheelchair transporta-
Table 1 presents data on gender, age, and respondent
tion practices, and questions about education and
categories.
knowledge of wheelchair transport safety practices.
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The principal criterion for formulating questions was

to tap the antecedents, behaviors, and consequences Knowledge and Education About
that were thought to be important to wheelchair trans-
Transit Wheelchairs and Standards
portation. One key item assessed knowledge of SAE
J2249 and ANSI/RESNA WC/19 standards for wheel- Knowledge of the transit option and transit wheel-
chairs and transportation. Specifically, respondents chairs was very poor. Only 18% of WCUs and 20% of
were asked if they had ever heard of either of these CTPs recognized the term “transit wheelchair” or
standards. Respondents were also asked if they would “transit option” (Table 2). Less than 1% of WCUs and
use or recommend best practices for wheelchair trans- 7% of CTPs knew of the SAE J2249 best practice rec-
portation if they knew about them, and what factors ommendation for wheelchair tiedown systems and the
could prevent use of those practices. The survey was ANSI/RESNA WC/19 standards for wheelchairs and
assessed for content validity through pretesting with transportation (Figure 2). When asked about limiting
potential survey subjects. After these tests, questions factors that interfere with the use of best practices, the
were edited for clarity. Reliability was not assessed. most common response chosen was “don’t know the
best practices.” WCUs were more likely to report this
lack of knowledge (67%) than CTPs (46%), c2(1) =
Interview Procedures 9.42, p = .0021 (Figure 3).
Surveys were distributed to patients attending the To investigate whether knowledge was related to
University of Michigan Health System’s Physical demographic variables for either group, chi-square
Medicine and Rehabilitation Clinic and Wheelchair tests were performed for each group. Three age groups
Seating Service as well as Marquette General Hospital (25 and below, 26–40, over 40) were used for WCUs
Specialty Clinic. The survey was offered to each and two for CTPs (40 and below, above 40), because
patient who came into the clinic. Surveys were also so few CTPs were younger than 26. Neither age nor
distributed to professionals and vendors associated gender nor diagnosis (for WCUs) was significantly
with those clinics. The study sample represents those related to knowledge of the term “transit option/tran-
subjects who agreed to fill out the survey. The number sit wheelchair” or standards. For the CTP group, reha-
of patients who turned down the survey is unknown. bilitation technology specialists were more likely to be
Official surveys were distributed for 2 months. The aware of the term “transit wheelchair” or “transit
survey required 10–15 minutes to complete. Respon- option” (71%) than other types of CTPs, c2(3) =
dents were informed that the survey was being con- 11.99, p = .0074.
ducted for the University of Michigan and that their The relationship between knowledge and education
responses would remain confidential. The institu- for the two groups was investigated through analysis
tional review board at the University of Michigan of two three-way tables. The first 2 × 2 × 2 table
Health System approved the study. crossed group with Question 7 (education) and Question

L. Brinkey et al. 38
 TABLE 1 Characteristics of respondents

Caregivers, therapists,
Wheelchair users physicians, others

Number 107 87
Age (years) 31 (range: 4–86) 41 (range: 21–63)
Female (%) 40 62
Respondent categories 39% cerebral palsy 33% caregivers
19% spinal cord injury 27% therapists
10% brain injury 18% physicians
10% multiple sclerosis 8% suppliers
7% neuromuscular 6% nurses
4% orthopedic 8% other
2% amputee
9% other
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TABLE 2 CTPs’ titles and knowledge of the terms “transit wheelchair” and “transit option” (percentages)

Response to Rehabilitation
question Caregivers Physician technologists Therapists Other

Yes 7 18 71 20 20
No 93 82 29 80 80

p < .01 (Pearson chi-square).

50 70
% Respondents

60
25

50

0
% Respondents

WCU CTP 40
WCU

50 30 CTP
% Respondents

20
25

10

0
WCU CTP 0
Lack of Cost Space
FIGURE 2
Knowledge of wheelchair transport safety knowledge
practices: Percentage of subjects recognizing the term “transit
option” or “transit chair” (top) and percentage of subjects
familiar with SAE J2249 and ANSI-RESNA WC/19 standards FIGURE 3 Factors interfering with using best practices.
(bottom).

8 (knowledge of the term “transit wheelchair”). Based the term, c2(1) = 14.75, p = .0001, as well as the
on Question 7, each respondent was categorized as interaction between group and education, c2(1) =
having received education (regardless of the source) 6.79, p = .0092. These effects indicate that WCUs are
or not. The best-fitting model for this table included less likely to have received education about best prac-
the interaction between education and knowledge of tices than CTPs and that, for both WCUs and CTPs,

39 Knowledge of Wheelchair Transport Safety

 those who received education were more likely to be have been due to the feeling that other reasons were
familiar with the term “transit wheelchair” or “transit more pertinent for limiting use of best practices.
option.”
A similar analysis was conducted replacing Question 8
with Question 9 (knowledge of SAE or ANSI standards).
Wheelchair Transportation Practices
This analysis proved to be more challenging because Type of Vehicle (Privately Owned Versus
there were no cases in either group in which the respon- Public Transportation)
dent had not received education but knew of the stan- Among WCUs, 87% had access to a privately
dards. Even when the zero cells were treated as sampling owned vehicle, with 55% using only this method of
zeroes, the education by knowledge interaction was still transportation; 13% relied on public or private trans-
inestimable. The group by education interaction was portation services, without access to a personal vehi-
significant, as before, c2(1) = 6.80, p = .0091. To deal cle. Among CTPs, 34% prescribed or designed for
with the inestimability problem, two separate tables privately owned vehicles only. The remainder worked
crossing education with knowledge of standards, one for with patients who used a combination of transporta-
each group, were analyzed using simple chi-square tests. tion methods. Only a few CTPs (9%) did not work
For CTPs, the chi-square test was significant, c2(1) = 8.18,
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with private vehicles at all.

p = .0042, with a 13% knowledge rate among those who
had received education. Among WCUs, the chi-square
test was not significant, with only one respondent (who Type of Tiedown System
had been educated) reporting knowledge of standards. WCUs strongly favored the strap-type tiedown sys-
Neither CTPs (48%) nor WCUs (67%) had received tem, with 63% choosing that option, including 12%
much education relating to transporting individuals in who used both the strap-type system and a docking
wheelchairs. For both groups, any training received gen- system (Figure 5). Only 7% used docking systems
erally came from the adaptive driving company or manu- exclusively. The CTPs were more divided, with 24%
facturer or from their therapist. (Figure 4). In general, it prescribing, providing, or noting that their clients had
seemed that education was successful in increasing only the strap-type system, 8% only the docking sys-
knowledge. Those CTP subjects who were educated were tem, and 18% using both. A surprising 15% of CTPs
less likely to choose “lack of knowledge” as a limiting fac- and 16% of WCUs did not recommend or use a
tor for using best practices (p < .001, Pearson chi-square). securement system. Twenty-four percent of CTPs “did
There was no relationship among WCUs between educa- not know” what sort of system they recommended.
tion and choosing “lack of knowledge” (i.e., it was not This may simply indicate that they did not include a
less likely) as was noted for CTPs, although this may tiedown recommendation or other securement recom-
mendation in their prescriptions. For WCUs, only 7%
did not know what type of system they were using.

70
Wheelchair Tiedown Securement Locations
60
WCUs used the tiedown securement locations
50 recommended by the tiedown manufacturer more

40
WCU 80
30 CTP
% Respondents

60
WCU
20 40 CTP
20
10
0
0 Strap Dock None Don't Know
Doctor Therapist Company Other None
FIGURE 5 Securement systems. Many subjects used or
FIGURE 4 Sources of education about wheelchair transport recommended both the strap and docking type systems. A
safety practices. surprisingly high number chose “none.”

L. Brinkey et al. 40
 frequently (53%) than other locations. A large number 100
of CTPs (32%) and WCUs (23%) did not know which
90
securement locations they recommended or used. The
relationships among group, education, and use of 80
wheelchair restraints were analyzed using CATMOD. 70
In this analysis, responses to Question 3 were divided

% Respondents
into those who either did not use or recommend 60

tiedowns or did not know what was used and those 50

who specified some type of tiedown system (for use or CTP
40
recommendation). All three two-way interactions were
significant in the analysis, but not the three-way inter- 30
action. The group by education effect has been seen
20
previously, indicating that WCUs are less likely to
receive education than CTPs, c2(1) = 8.93, p = .0028. 10
The group by restraint effect, c2(1) = 8.96, p = .0028, 0
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indicated that WCUs were more likely to use tiedowns VF Chair None

than CTPs were to recommend them. The education FIGURE 6 Equipment transport. VF = respondent secures
by restraint effect, c2(1) = 5.07, p = .0244, indicated equipment to vehicle frame; Chair = respondent secures
equipment to frame of the chair; None = respondent does not
that respondents from either group who had received
transport equipment.
some form of education in best practices were more
likely to use or recommend wheelchair tiedowns than
those who had not received any education.
of using or recommending restraint, c2(1) = 6.16,
p = .0130.
Occupant Restraint During Travel
Both groups favored lap and shoulder belt combi- Transport of Medical Equipment
nations, supplied from either the tiedown manufac- Most WCUs stated that they did not transport
turer or the automobile manufacturer (WCUs, 50%; equipment such as ventilators and oxygen tanks
CTPs, 49%). CTPs frequently (28%) noted that they (93%). Of the few who did, most secured the equip-
do not include restraint systems as part of their care or ment to their wheelchair (5%), among other choices.
their recommendations. Surprisingly, 11% of WCUs Among CTPs there was more variance, with 40% indi-
indicated that they do not use any type of restraint. cating that they worked with people who did not
There was no relationship noted between having had transport medical equipment (Figure 6). The remain-
education about wheelchair transit best practices and der generally made multiple choices. Securing equip-
either using restraints (WCUs) or including restraints in ment to the vehicle frame with cargo straps was a
prescriptions or among caregivers (Pearson chi-square). popular answer (24%), as well as the client’s wheel-
A three-way table combining group, education, and chair (17%). Other choices included using a seat belt
occupant restraint was analyzed in the same way as for or bungee cords to secure equipment to the vehicle
wheelchair restraint above. Responses to Question 5 frame.
were divided into those who said they did not usually
use or recommend any type of restraint and those who
indicated use or recommendation of some type of DISCUSSION
occupant restraint. Again, all three two-way interac- Unfortunately, many wheelchair users and/or their
tions were significant, and the pattern of results was families are unaware that standards have been devel-
the same. WCUs were less likely than CTPs to have oped that outline elements of safe transportation for
received education, c2(1) = 9.46, p = .0021; WCUs those who use their wheelchair as a seat in a motor
were more likely to use an occupant restraint than vehicle. This survey indicates that the greatest barrier
CTPs were to recommend it, c2(1) = 10.41, p = .0013; to using safer transportation practices among wheel-
and education corresponded to higher likelihood chair users was lack of knowledge. There was also good

41 Knowledge of Wheelchair Transport Safety

 evidence that education is beneficial. Educated con- standards to refer to, it is difficult to provide a credi-
sumers (both WCUs and CTPs) demonstrated greater ble educational intervention on this subject.
knowledge of the terms “transit wheelchair” and “tran- Recently (after completion of this survey), resources
sit option.” Educated WCUs and CTPs were more to provide information on wheelchair transportation
likely to use or recommend both wheelchair tiedowns safety have become available. Web sites have either
and occupant restraints. CTPs were less likely to been developed or modified to provide information
choose lack of knowledge as a limiting factor for using about wheelchair transportation safety. The University
best practices if they had been educated. Therefore, of Pittsburgh and University of Michigan’s Rehabilita-
this survey suggests that educational materials that can tion Engineering and Research Center for Wheelchair
be provided to health care professionals and patients Transportation has a Web site (http://www.rercwts.org)
in the clinical setting are likely to be beneficial. that provides consumer information. In addition to a
Certain factors should be considered when plan- variety of articles about wheelchairs and transporta-
ning an educational intervention. For example, we tion safety, it includes research summaries rewritten in
noted that 9%–13% of WCUs did not have full con- layman’s language, allowing consumers to better
trol over their options, as they did not have personal understand the sometimes complicated issues without
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vehicles. Many other subjects very likely use public becoming confused by the technical jargon. It also pro-
transport at some time, and also do not have control vides a list of wheelchair and seating systems that offer
over the type of securement system. Providing wheel- transit options.
chair users with practical information from a credible A brochure titled “Ride Safe” (available at http://www.
source would assist them in advocating for safer trans- travelsafer.org or as a hard copy; contact umtridocs@
portation while using public and private transporta- umich.edu) was developed at the University of Michigan
tion services. They could use this information to along with its companion Web site. The brochure
instruct transport operators in the securement of their was designed for consumers and describes the neces-
wheelchair and restraint. In addition, educated con- sary equipment required for safer transportation and
sumers would be better advocates with governmental the features of a transit wheelchair. It also reinforces
bodies that control public transportation. the need to use a wheelchair tiedown and occupant
We are unaware of any specific standards for trans- restraint system along with a summary of best prac-
porting medical equipment, such as ventilators, oxy- tices for those who travel while seated in a wheel-
gen tanks, and feeding pumps. The WC/19 standard chair. Unfortunately, manufacturers are less likely to
does not directly address this other than to recom- continue to design crashworthy wheelchairs and
mend removing or securing auxiliary equipment adaptive equipment unless there is consumer demand
separately in the vehicle whenever possible. At a for these products. Without adequate education,
minimum, medical equipment should be secured to consumers will not be able to effectively advocate for
the wheelchair so that it does not break away and further development of safer adaptive equipment and
harm occupants in a crash. If trays cannot be transportation devices. For example, there are many
removed during transit, the use of soft or padded pediatric wheelchairs that meet the ANSI/RESNA
trays is recommended. The American Academy of WC/19 standard but few adult wheelchairs that meet
Pediatrics (AAP) does provide general guidelines in the standard.
its policy statement on transporting children with The limitations of this study include the fact that
special needs. The AAP (1999) states that medical the survey population was a convenience sample from
equipment should be secured to the vehicle floor, a single geographic area. It could be argued that the
under the vehicle or wheelchair seat or to the bus amount of education and types of practices in our
wall during transit. Although the vast majority of study group reflected practices in Michigan but not in
those surveyed do not transport equipment, there are other areas. While this is certainly true to some extent,
still a significant number who do, as can be seen there is no reason to think that WCUs and CTPs in
from the 60% of CTPs who deal with this issue. Michigan are notably different from those in the rest
Perhaps a follow-up study could address best practice of the country, especially regarding knowledge and
recommendations for transporting medical equip- practices associated with wheelchair transportation
ment and supplies. Without formal studies or safety. The study group came from a wide variety of

L. Brinkey et al. 42
 environments (urban, suburban, and rural) and back- Blake, E., Sherman, K., Morris, L., & Lapidus, G. (2006). Self-reported
experience with safe transport of children with special healthcare
grounds. Despite the exposure to a wheelchair seating needs: A rehabilitation therapist perspective. American Journal of
service associated with a tertiary medical center, there Physical Medicine & Rehabilitation, 85, 181–184.
was still a very poor level of knowledge. We could Gaal, R. P., Rebholtz, N., Hotchkiss, R. D., & Pfaelzer, P. F. (1997).
Wheelchair rider injuries: Causes and consequences for wheelchair
conjecture that, unless an area has a focus on educat- design and selection. Journal of Rehabilitation Research and Devel-
ing clients about this topic, their level of knowledge opment, 34, 58–71.
Henke, C. (1994, March). Medical technology outpaces safe transporta-
would be similar or worse. However, a broader study tion measures. School Bus Fleet, pp. 38–41.
population and additional questions about demo- Hirano, S. (2000, February). The ‘next generation’ of protection for
wheelchair passengers. School Bus Fleet, pp. 35–37.
graphics and life experience relating to wheelchairs
Marks, J. A., Cotzin, B. S., Schneider, L. W., & Thomas, D. (1995). School
would provide more generalizable data. Bus Transportation of Students in Wheelchairs, January.
It seems that any clinic or professional practice that National Highway Transportation Safety Administration. (1997). Wheel-
chair users injuries and deaths associated with motor vehicle related
deals with wheelchair users should provide informa- incidents. Washington, DC: Author.
tion in this area as part of its wellness/baseline evalua- Rehabilitation Engineering and Assistive Technology Society of North
America. (2000). Wheelchairs used as seats in motor vehicles (ANSI/
tion/checklist care and treatment. At the very least,
RESNA Wheelchairs Standards, Volume 1, Section 19. Arlington, VA:
written materials should be available to provide to Author.
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people about these issues, and a few words to familiar- Schneider, L. W. (1987). Transportation of wheelchair-seated students:
Physical management of multiple handicaps. Baltimore: Paul
ize clients with them are in order. Several excellent Brookes.
resources now exist. One of the current challenges in Shaw, G. (2000). Wheelchair rider risk in motor vehicles: A technical
wheelchair transportation safety is to educate consum- note. Journal of Rehabilitation Research and Development, 37, 89–
100.
ers, vendors, and clinicians that these resources exist Shaw, G. (2003). Appropriate protection for wheelchair riders on public
and to encourage them to learn about transportation transportation buses. Journal of Rehabilitation Research and Devel-
opment, 40, 309–320.
issues so that thoughtful decisions can be made when Society of Automotive Engineers. (1996). SAE recommended practice,
purchasing wheelchairs and transportation equipment. wheelchair tiedown and occupant restraint systems for use in motor
vehicles (SAE J2249) Washington, DC: Author.
Transportation safety is not a small concern.
Wretstrand, A., Petzall, J., & Stahl, A. (2004). Safety as perceived by
wheelchair-seated passengers in specialized transportation services.
Accident Analysis and Prevention, 3, 3–11.
CONCLUSION Zimmerman, J. M. (2003, August/September). Get on the bus. Rehab
Management, 74, 48–51.
There is a poor level of knowledge about wheel-
chair transportation safety practices among WCUs,
caregivers, and professionals who prescribe wheel-
APPENDIX A: SURVEY FOR
chairs. This knowledge deficit leads to a lack of stan-
dardized transport in the field and a potential WHEELCHAIR USERS
compromise of safety. Education appears to be benefi-
1. Please circle or fill in the appropriate answer:
cial and should be provided for wheelchair users, pre-
scribers, suppliers, and caregivers. Gender: Male or Female
Age: ____
ACKNOWLEDGMENTS Diagnosis: Cerebral Palsy Multiple Sclerosis
Traumatic Brain Injury Spinal Cord Injury
We gratefully acknowledge the assistance of the
University of Michigan Physical Medicine and Reha- Other: __________________________
bilitation Department Staff and Marquette General
Hospital Specialty Clinic staff. 2. The mode of transportation I use most is (circle all
that apply):

REFERENCES a. Privately owned vehicle (i.e., car or van)

American Academy of Pediatrics. (1999). Transporting children with spe- b. Public transportation (i.e., city bus)
cial health care needs. Pediatrics, 104, 988–992. c. Private transportation company (i.e., cab service,
Belcher, M. J. H, & Frank, A. O. (2004). Survey of the use of transport by
recipients of Regional Electric Indoor/Outdoor Powered (EPIOC)
adapted van company)
Wheelchair Service. Disability and Rehabilitation, 2, 563–575. d. Other ______________________________

43 Knowledge of Wheelchair Transport Safety

 3. The type of tiedown system I use to secure the a. Wheelchair
wheelchair to the motor vehicle is (circle all that b. Vehicle seat belt
apply): c. Vehicle frame using cargo straps
d. Vehicle frame using bungee cords
a. Docking system (such as EZ Lock) e. Other _____________________________
b. Strap system (such as Qstraint or Kinedyne) f. I do not usually secure medical equipment dur-
c. Other ______________________________ ing transportation
d. I do not usually use tiedowns to secure the g. I do not travel with medical equipment
wheelchair to the vehicle
e. Don’t know 7. Have you received any education about transport-
ing individuals in wheelchairs? (circle all that apply)
4. The wheelchair tiedowns are secured to the wheel-
chair at (circle all that apply): a. Yes, from a doctor
b. Yes, from a therapist
a. Locations designated by the tiedown c. Yes, from an adaptive driving company or
manufacturer manufacturer
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b. Locations designated by the wheelchair d. Other ______________________________

manufacturer e. No, I have not received any education about
c. Various locations on the wheelchair frame itself wheelchair transportation
d. The wheelchair armrests and legrests
e. Other ______________________________ 8. Have you ever heard of a “transit wheelchair” or a
f. Don’t know “transit option” available on a wheelchair?

a. Yes (in 1–2 sentences, please describe what

5. I am restrained to the wheelchair and vehicle using
that means to you)
the following (circle all that apply):
________________________________________
a. Lap belt only supplied by the tiedown _________________________
manufacturer b. No (I do not know what a transit wheelchair is)
b. Shoulder belt only supplied by the tiedown
9. Are you familiar with SAE J2249 and ANSI-RESNA
manufacturer
WC/19 standards for wheelchairs and transportation?
c. Lap and shoulder belt combination supplied by
the tiedown manufacturer
a. Yes (in 1–2 sentences, please describe what
d. Positioning lap belt and/or chest strap supplied
that means to you)
by the wheelchair manufacturer
________________________________________
e. Lap belt only supplied by the automobile
_________________________
manufacturer
b. No (I am not familiar with those standards)
f. Shoulder belt only supplied by the automobile
manufacturer 10. Are there any limiting factors that prohibit you
g. Lap and shoulder belt combination supplied by from using the best practices while being trans-
the automobile manufacturer ported in your wheelchair?
h. Other _______________________________
i. I do not usually use any type of restraint a. Cost
b. Physical space in your motor vehicle
6. When transporting medical equipment such as ven- c. Don’t know the best practices
tilators, oxygen tanks, feeding pumps, etc., I usually d. Physical limitations
secure the equipment to the (circle all that apply): e. Other ______________________________

L. Brinkey et al. 44
 APPENDIX B: SURVEY FOR c. Lap and shoulder belt combination, supplied by
CAREGIVERS, THERAPISTS, AND the tiedown manufacturer
d. Positioning lap belt and/or chest strap supplied
OTHER PROFESSIONALS
by the wheelchair manufacturer
1. Please circle or fill in the appropriate answer: e. Lap belt only, supplied by the automobile
manufacturer
Gender: Male or Female
f. Shoulder belt only, supplied by the automobile
Age: ____
manufacturer
Profession: Physician Therapist
g. Lap and shoulder belt combination, supplied by
Rehabilitation Technology Supplier Case Manager
the automobile manufacturer
Other: _______________________
h. Other __________________________
i. I do not usually recommend use of any type of
2. The mode of transportation my clients are involved
restraint
with is (circle all that apply):

a. Privately owned vehicle (i.e., car or van) 6. When transporting medical equipment such as ven-
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b. Public transportation (i.e., city bus) tilators, oxygen tanks, feeding pumps, etc., I usually
c. Private transportation company (i.e., cab service, recommend/use to secure the equipment to the
adapted van company) (circle all that apply):
d. Other ___________________
a. Wheelchair
3. The type of tiedown system I recommend/use to b. Vehicle using a vehicle seat belt
secure a wheelchair to the motor vehicle is (circle c. Vehicle frame using cargo straps
all that apply): d. Vehicle frame using bungee cords
e. Other _____________________________
a. Docking system (such as EZ Lock) f. I do not usually recommend securing medical
b. Strap system (such as Qstraint or Kinedyne) equipment during transportation
c. Other __________________________ g. I do not travel with medical equipment
d. I do not usually recommend/use tiedowns to
secure the wheelchair to the vehicle 7. Have you received any education about transport-
e. Don’t know ing individuals in wheelchairs? (circle all that apply)
4. The wheelchair tiedowns that I recommend/use are a. Yes, from a physician
secured to the wheelchair at (circle all that apply): b. Yes, from a therapist
c. Yes, from an adaptive driving company or
a. Locations designated by the tiedown manufacturer
manufacturer
b. Locations designated by the wheelchair
d. Other __________________________
manufacturer
e. No, I have not received any education about
c. Various locations on the wheelchair frame itself
wheelchair transportation
d. The wheelchair armrests and legrests
e. Other _________________________
f. Don’t know 8. Have you ever heard of a “transit wheelchair” or a
“transit option” available on a wheelchair?
5. I recommend restraining persons in wheelchairs for
transportation by (circle all that apply): a. Yes (in 1–2 sentences, please describe what that
means to you)
a. Lap belt only, supplied by the tiedown manufacturer ________________________________________
b. Shoulder belt only, supplied by the tiedown _________________________
manufacturer b. No (I do not know what a transit wheelchair is)

45 Knowledge of Wheelchair Transport Safety

 9. Are you familiar with the SAE J2249 and ANSI- 10. Are there any limiting factors that you feel inter-
RESNA WC/19 standards for wheelchairs and fere with following the best practices for transport-
transportation? ing an individual who is seated in a wheelchair
during transportation?
a. Yes (in 1–2 sentences, please describe what that
means to you) a. Cost
________________________________________ b. Space in the vehicle
_________________________ c. Don’t know the best practices
b. No (I am not familiar with those standards) d. Physical limitations
e. Other __________________________
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L. Brinkey et al. 46