Evaluation of Titanium Ultralight Manual Wheelchairs Using Ansi/resna Standards.

INTRODUCTION Choice of a suitable wheelchair requires serious consideration. The U.S. Food and Drug Administration recommends testing wheelchairs using American National Standards Institute (ANSI)/Rehabilitation Engineering and Assistive Technology Society of North America (RESNA) testing standards to assess performance and safety and estimate life expectancy of a wheelchair. Results from ANSI/RESNA standard tests are a source of information about technical quality and performance and allow comparison of results across devices. The content of the standard tests covers many aspects that affect wheelchair usage and selection, such as dimensions, static stability, braking effectiveness, strength, and durability.

Dimensions, weight, and turning radius clue consumers in to whether a wheelchair will fit in their homes, working environments, and transportation means. Wheelchair performance in the static stability tests reveals the estimated behavior of the wheelchair on an incline.

The results indicate how the stability of the wheelchair is affected by adjustment of the axle and other components. Determining wheelchair strength and durability from retail advertisements and user manuals is difficult. Although medical insurers' prescription guidelines typically require 3 to 5 years before a replacement wheelchair will be covered, previous research has shown that the predicted life expectancy of some wheelchairs is significantly less -. Premature wheelchair failure could potentially injure the users and may require them to pay for replacements, which can cost several thousand dollars. According to Smith et al., wheelchair users expect wheelchairs to improve their quality of life and help them maintain or achieve a desired level of mobility . Users expect their wheelchairs to be comfortable, easy to propel, safe, and attractive . In a survey of wheelchair users with amyotrophic lateral sclerosis, the most desirable features of manual wheelchairs were a lightweight frame and a small turning radius .

Comfortable propulsion and support, light weight, and small dimensions are very important features, especially for active manual wheelchair users -. A lighter wheelchair has lower rolling resistance, which reduces the force required to propel it. Thus, lighter wheelchairs are suggested for preserving upper-limb function of manual wheelchair users . Developing a lighter and more functional wheelchair is a goal for the design of many manual wheelchairs. The titanium wheelchair is a product in response to this goal.

ANSI/RESNA standard tests provide specific testing protocols to evaluate the performance and durability of wheelchairs and serve as a universal platform for data collection and comparison. Reports using ANSI/RESNA standards evaluated aluminum ultralight and steel lightweight wheelchairs. Ultralight wheelchairs lasted more than five times as long as lightweight wheelchairs before failures occurred during fatigue tests -. However, ultralight wheelchairs experienced more repairable component failures, such as bolt or caster-stem failures and screws loosening. Although repairable component failures do not damage frame integrity, multiple component failures require frequent maintenance and may place the user in hazardous situations.

Many ultralight wheelchairs have titanium frames and/or components.

Since titanium has a higher strength-to-weight ratio than aluminum, if engineered correctly, it could preserve the strength of the wheelchair frame while lowering the weight. Conventional wisdom in our wheelchair clinic has been that people who use titanium chairs benefit from their highly durable and lightweight properties, although no standards testing results of titanium wheelchairs have been reported in the literature.

Our goal in this study, similar to prior works in this area, was to test a series of commercially available titanium rigid-frame wheelchairs using ANSI/RESNA testing procedures. The standard test to determine braking effectiveness according to the International Organization for Standardization (ISO) was also incorporated in this study , since no braking effectiveness test for manual wheelchairs is included in the current version of the ANSI/RESNA standards. We hypothesized that these titanium wheelchairs would be in compliance with ANSI/ RESNA standards and that they would be more durable than previously tested aluminum ultralight and lightweight wheelchairs.

METHODS Study Wheelchairs Twelve titanium rigid-frame wheelchairs representing four models from three manufacturers were tested using ANSI/RESNA wheelchair standard tests: the Invacare Top End (Invacare; Elyria, Ohio), the Invacare A4, the Quickie Ti (Sunrise Medical; Longmont, Colorado), and the TiLite ZRA (TiLite; Kennewick, Washington) (Figure 1). They were the most popular titanium ultralight rigid-frame wheelchairs prescribed at the Center for Assistive Technology at the University of Pittsburgh Medical Center. They were ordered with the same seat dimension specifications and standard components. Because of the cost and time to test wheelchairs, we only tested three wheelchairs of each model.

Standards Testing Procedure We completed the whole battery of ANSI/RESNA manual wheelchair standard tests and assessed braking effectiveness using the ISO standard test. This article focuses on the test results of static stability; braking effectiveness; and static, impact, and fatigue strength tests.

The dummy used in this study was built according to the requirements of ANSI/RESNA standards.

[FIGURE 1 OMITTED] Static Stability The wheelchairs were tested in their most and least stable configurations (forward and rearward directions) in the static stability tests ([section]1 in the ANSI/RESNA wheelchair standards). A 100 kg dummy was loaded into the test wheelchair. The wheelchair was secured on a platform using straps that did not interfere with tipping movement. An engineer increased the platform angle slowly and recorded the angle at which the front casters lifted from the platform just enough for a piece of paper to pass between the casters and platform. In the rearward stability tests, the rear wheels were locked with parking brakes or by securing the wheels with straps that limited the rolling motion of the wheels relative to the frame. In the other portions of the static stability tests, blocks or brackets that did not impede the rolling motion of the wheels were used to stop the wheelchair from rolling downhill.

We placed the wheelchair in its least stable position in the rearward direction by moving the rear-wheel axle forward, reclining the backrest backward, and increasing the front seat height by adjusting the caster position. We positioned the wheelchair in the extreme least stable position, since no indication or limitation for the range of the rear-wheel axle position was noted on the wheelchairs or in the user manuals. Most of the wheelchairs in their least stable setting tipped backward on a horizontal plane with the dummy loaded. Although these extremely unstable positions in the rearward direction were not realistic wheelchair settings, we still proceeded and recorded the tests because the purpose of having the standardized tests is to reveal the actual properties of the wheelchair. To address this limitation, we modified the testing procedure by placing the wheelchair facing downhill on the platform and securing it with straps to prevent it from tipping over completely (Figure 2(a)). The slope was then increased, and the angle at which the front casters touched the platform was recorded (Figure 2(b)). The reading was a negative number.

Braking Effectiveness In the braking effectiveness tests ([section]3 in the ISO wheelchair standards), we kept the wheelchairs in the same setting as when they came out of the box (the axle was in the most rearward setting), loaded them with a 100 kg dummy, and engaged the rear brakes.

The tests were performed on the same platform as the static stability tests. While increasing the slope of the platform, we recorded the angle at which the wheelchair started to slide downhill. The wheelchair was tested in its forward and rearward orientations. Since the steepest slope that fulfills the requirement of the Americans with Disabilities Act (ADA) is 7[degrees] (1:8), with a maximum rise of 75 mm (3 in.) for existing buildings and facilities, we expected the wheelchair to be able to stay stationary on a 7[degrees] slope.

Static, Impact, and Fatigue Strength Tests (Durability Testing) Static, impact, and fatigue strength tests ([section]8 in the ANSI/RESNA wheelchair standards) evaluate the strength of the wheelchair structure by applying different types of loads on specific components. A pneumatic ram was used to apply static force to the footrest, armrests, and tipping levers (if present) according to the standard. Impact force was applied using a pendulum on several components of the wheelchair (footrest, caster wheels, pushrim) that are prone to impacting objects.

Any permanent deformation or component failure was considered a failure as denoted in the standards.

Fatigue strength was evaluated by the double-drum and curb-drop tests (DDT and CDT, respectively). Each wheelchair was loaded with a 100 kg dummy during the tests. In the DDT, the position of the drive wheels was set at the midaxle position according to the requirements in the standards. Because the titanium wheelchairs were unstable in this position, we set the rear axles in the most rearward position horizontally and the midposition vertically (which was how they arrived from the suppliers). Other wheelchair settings were set according to the requirements in the standard. The leg length of the dummy was adjusted to fit the wheelchair dimensions, and the feet were fixed on the footrests. The dummy's trunk and legs were secured to the wheelchair, although hip-joint motion was preserved through a spring-loaded damper system that allowed physiological-like motion during the testing. According to the standard, the dummy was positioned centrally on the seat. Generally, the weight of both legs is 32 percent of total body weight . Individuals who are 6 months post spinal cord injury may lose 15 to 46 percent of their lower-limb muscle area .

We carefully kept the weight-loading on the front casters within 20 to 25 percent of the total weight of the dummy and the wheelchair to approximate the influence of the occupant's body weight and the weight of the wheelchair and prevent overloading on the casters by adjusting the location of the dummy either in an anterior or posterior direction. The 12 mm-high slats on the drum simulate sidewalk cracks, door thresholds, potholes, and other small obstacles on the rolling surface. Two clamps attached to the rear-wheel axle held the position and balance of the wheelchair on the double-drum machine but allowed vertical movement without appreciable sideward drift (Figure 3). The rear drum runs at a speed of 1 m/s, and the front drum turns 7 percent faster to vary the frequency with which the front and rear wheels encounter the slats. A wheelchair that completed 200,000 cycles on the test machine was considered to have passed the DDT.

[FIGURE 2 OMITTED] Only the wheelchairs that passed the DDT continued on to the CDT.

In the CDT, the wheelchair was repeatedly dropped freely from a 5 cm height onto a concrete floor to simulate going down small curbs. A wheelchair passes the wheelchair standard tests when it survives 200,000 cycles in the DDT and 6,666 cycles in the CDT without harmful damage . The intensity of the fatigue tests mimics 3 to 5 years of daily use . We repeated the fatigue tests until each wheelchair had permanent damage to determine the exact survival life. For the purpose of comparing fatigue life, we used the following formula to compute the number of equivalent cycles (ECs) ,6-:

Total ECs = (DDT cycles) 30 x (CDT cycles). (1) [FIGURE 3 OMITTED] The EC counts the number of cycles before the occurrence of a class III failure in the fatigue test. A wheelchair that obtained an EC score of 400,000 cycles was denoted as passing the minimum requirements of the standard.

Failure severity was classified into three levels. Any failures, such as tightening screws or bolts or inflating the tires, that could be repaired by the user or any untrained personnel were counted as class I failures. Class II failures, such as replacing tires or spokes and doing complex adjustments, need to be repaired by a wheelchair or bicycle technician . Permanent damage to the frame or any failure that would put the user in a hazardous situation was counted as a class III failure in this study. In a previous ultralight wheelchair comparison study, three bolt failures were considered class III failures . Multiple minor failures were not counted as class III failures in this study to prevent premature discontinuation that would shelter the durability of the main frame and structure. All the failures were recorded to disclose the frequency and complexity of the repairs needed for each wheelchair.

Cost-Effectiveness Knowing the cost-effectiveness of a wheelchair is meaningful. We compared the cost-effectiveness of our test wheelchairs using the value derived from normalizing the number of ECs by the retail price of the wheelchair (cycles/dollar). The higher the value, the more cost-effective the wheelchair was deemed to be .

Data Analysis We performed primary analyses for static stability, braking effectiveness, EC, and cost-effectiveness using Kruskal-Wallis tests, followed by Mann Whitney U tests as univariate analyses with the level of significance set at p 7[degrees] slope in the rearward braking effectiveness test. The frame design and the position of the dummy's lower-limbs did play an important role in affecting rearward stability as we discussed previously. The compact dimensions of the wheelchairs with rigid frames increase their maneuverability but decrease their rearward stability.

Users have to adjust their trunk posture carefully to compensate for displacement of the center of gravity when pushing one of these four wheelchair models uphill. Novice users must be educated about this behavior and trained in wheelchair skills to manage on slopes.

[FIGURE 7 OMITTED] Impact and Static Strength Tests Although the three Invacare wheelchairs that failed in the armrest static strength test were still usable, the compromised material strength of the mounting plates could have caused a catastrophic failure (Figure 5(a)). The TiLite wheelchairs had a similar mounting mechanism for the armrest as the Invacare wheelchairs, but they had a stronger structure, having double plates to support the armrest bar. All of the TiLite wheelchairs failed in the handgrip static strength tests. The hazard will occur when an attendant is pulling the wheelchair backward with an occupant in it. The attendant would tend to fall backward when the handgrips slide off the handles. Moreover, the situation may endanger the user, who could roll away uncontrolled.

Fatigue Strength Tests (Durability Testing) This group of titanium wheelchairs survived fewer ECs (their average EC was 246,506 [ or -] 154,086) than was previously reported for aluminum ultralight wheelchairs, but their life expectancy was similar to that of steel lightweight wheelchairs -. Besides, the titanium rigid-frame wheelchairs exhibited less value than the aluminum ultralight and the steel lightweight wheelchairs (Figure 8). Figure 8 shows the value of each wheelchair model for titanium ultralight rigid-frame, aluminum ultralight folding-frame, and steel lightweight wheelchairs, respectively, and the average value of each group according to the results from this and previous studies. Although the results were different among manufacturers, the wheelchairs in each group had similar performances. The survival curves (Figure 9) show each step going down, indicating class III failures of the wheelchairs from each group. With 400,000 ECs the minimum requirement of ANSI/RESNA standards, 80 percent of the aluminum ultralight wheelchairs survived but less than 40 percent of the titanium rigid-frame wheelchairs survived to comply with current standards. The aluminum ultralight wheelchairs lasted about four times longer and had a value of about eight times higher than the wheelchairs in this study. Although a smaller caster size increases the impact load on the frame compared with the larger 203 mm casters on previously tested aluminum wheelchairs, testing these titanium rigid-frame wheelchairs with 80 mm casters is reasonable based on the following.

First, 80 mm casters are the standard components of the titanium wheelchairs tested in this study. According to the clinical experience of the clinicians in the Center for Assistive Technology at the University of Pittsburgh Medical Center, most users of this group of wheelchairs were prescribed these casters. Second, 203 mm casters are not available on these wheelchairs because the footrest and likely the users' feet would interfere with the free movement of these larger sized casters. If the test results of a wheelchair with its standard components are not revealed, estimating the quality and properties of the wheelchair after adjustment or with modification may be difficult.

[FIGURE 8 OMITTED] The test results of aluminum folding wheelchairs and titanium rigid-frame wheelchairs should be compared directly, even though they have casters of different sizes. The clinical guideline recommends that manual wheelchair users use lighter wheelchairs but gives no specific recommendation on caster size . Thus, manual wheelchair users at any level of injury or wheelchair skill may choose one of the ultralight titanium rigid-frame wheelchairs with 80 mm casters tested in this study or an ultralight aluminum folding-frame wheelchair with 203 mm casters.

Therefore, all types of wheelchairs should be tested with their various components to disclose their influence on performance of the wheelchairs and all test results of different types of wheelchairs should be directly compared to provide complete information for the consumer.

[FIGURE 9 OMITTED] The wheelchairs in this study had an estimated average usable life of 1.85 to 3.08 years based on the approximation that the intensity of the ANSI/RESNA fatigue tests represents regular use for 3 to 5 years . The Invacare and TiLite wheelchairs include a lifetime warranty, and the Quickie wheelchair includes a 5-year warranty on the titanium frame. A large discrepancy seems to exist between the warranty provided by the manufacturers and the test results in this study. To provide more reliable information to the consumer, manufacturers should disclose their testing methods and setup to determine the durability of their products.

Failure Modes Invacare Top End All of the Invacare Top End wheelchairs experienced fractures of the backrest canes. On the Invacare Top End04, we found white, light blue, straw, and gray colors in the weld vicinity on the inner surface of the fracture site (Figure 10). The colors on the inner surface were within the heat-affected zone, which indicates that the titanium had high levels of oxygen contamination during the welding process . The fracture surface in the picture is quite shiny and without plastic deformation. This implies that embrittlement may have contributed to the fracture of the backrest cane.

The other two Invacare Top End wheelchairs both fractured in the same area on the backrest canes around the welding site connecting the backrest crossbar (Figure 11 (a)(i)) and the top corner of the gusset (Figure 11(a)(ii)) without the evidence of oxygen contamination. Because of the anterior and posterior movement of the dummy hitting the backrest during the DDT, the superior area of the gusset was in the bending stress concentration point of the cantilever structure .

Additionally, a hole is present at the intersection of the backrest and the backrest crossbar (Figure 11(b)-(c)) for inserting the gas flow to prevent oxygen contamination from welding. One of the backrest canes fractured at this hole (Figure 11(c)) because it further weakened the structure strength. The other three fractured backrest canes were broken at the superior edge of the weld area with the crossbar. Heat treatment from welding likely decreased the strength of the titanium canes. The Invacare Top End had the same backrest-cane wall thickness as the Quickie Ti and TiLite ZRA (1.27 mm) and was slightly thinner than the Invacare A4 (2.29 mm) (Table 6). The Invacare Top End was the only model where all chairs fractured at the backrest canes. The four factors--the cantilever structure of the backrest, one weld area for the backrest crossbar on the backrest, a second weld area for the gusset on the backrest, and the hole for inserting the gas shield--all contributed to weaken the structure. Only the depot wheelchairs in our previous comparison study had similar failure rates as the Invacare Top End .

[FIGURE 10 OMITTED] Invacare A4 The Invacare A4-06 fractured at the right caster stem and the middle of the right tube in the seat plane in the first round of the DDT (Figure 12). Although the caster stem was made of steel, the beach marks on the fracture surface indicate the occurrence of metal fatigue (Figure 12 b)-(c)) -. Because only one fractured caster stem occurred in this study, it may be considered a defective component due to a small crack developed during manufacturing. However, this finding suggests that caster-stem fracture is possible and may damage the frame and endanger the user.

There were five holes around the fracture at the middle of the right seat frame of the Invacare A4-06 (Figure 13 and Figure 14(i)). The other two Invacare A4 wheelchairs that failed in the second round of the DDT had fractures around the screw holes of the mounting plate between the backrest and seat frame and the screw holes for the seat sling (Figure 15 and Figure 14(ii)). All these holes on the frame were for the seat sling, the mounting pieces of the backrest, and the mounting bracket of the T-shaped armrest. It is very intuitive in manufacturing to drill holes for mounting components on a frame; however, the fracture lines passing through the holes implied that the structural strength was decreased by the holes. The drawing with the translucent pattern in Figure 14 shows the proximity of the holes on the frame more clearly.

The footrests of the two Invacare A4 wheelchairs repeatedly slid down during the DDT. Although both the Invacare A4 and Top End wheelchairs had footrest tubes clamped by only a set screw (Figure 16(c)), the A4 had a larger discrepancy in the diameter between the tube of the footrest and the outer piece of the main frame (Table 6). The strength of a set screw was not enough to compensate for the discrepancy in tube diameters and the vertical vibration from the dummy's legs during the DDT, so the footrest slid down. In real-world settings, a footrest keeps sliding down, bothering the user, because of the vertical vibration resulting from riding on uneven terrain or the occurrence of clonuses. Although this mounting mechanism of the footrest would not affect the integrity of the main frame, the unanticipated repositioning of the footrest can be inconvenient and potentially cause injury.

[FIGURE 11 OMITTED] Quickie Ti and TiLite ZRA The Quickie Ti and TiLite ZRA wheelchairs had the same type of failures at the first or second screw holes near the cantilever turn of the frame. These screw holes are used to mount the sling to the frame (Figure 17). Both models are cantilever frames (Figure 18(a)). The cantilever frame does not have the same lower longitudinal tubes as the box frame. The impact force (Figure 18(a)(i)) produced a bending torque (Figure 18(a)(ii)) that bent the front vertical part of the frame rearward. The bending torque compressed the lower part of the tube (Figure 18 (a)(iii)) and extended the upper part of the tube (Figure 18 (a)(iv)). The first and second screw holes were just rearward of the frame bend and acted as stress concentration points. Therefore, the fracture inevitably occurred at this location. In the box frame design (Figure 18(b)), the lower longitudinal tube helped to distribute the force transmitted to the casters (Figure 18(b)(iii)). This decreased the bending torque on the frame (Figure 18 (b)(ii)). The Invacare A4 had screw holes near the corner of the front frame as well, but the lower stresses helped protect the chair from failure at these stress concentration locations. Alternative ways are available to fix the seat sling onto the frame other than using screws. For example, the Invacare Top End Terminator everyday rigid wheelchair uses Velcro straps to attach the seat sling , which may have ameliorated the premature failures.

[FIGURE 12 OMITTED] Wheelchair Material and Design Titanium alloys have higher resistance to brittle fracture than aluminum alloys when a crack is present . Although titanium has desirable mechanical properties, titanium is 1.6 times as heavy as aluminum. Balance between total weight of the product and structural strength needs to be considered carefully. The rigid-frame design and standard use of 80 mm casters are also critical issues that affect the stability and durability of this group of wheelchairs. On the basis of our results, manufacturers and designers need to evaluate the rigid-frame titanium wheelchair designs in greater detail in order to understand the impact of material choices and mechanical design on the strength, durability, and function of the wheelchair. If the future direction will be to classify the wheelchairs with similar rigid-frame designs as those in this article into a specific group, the wheelchair standard tests may be considered to have modified testing methods and normative values for these wheelchair models.

[FIGURE 13 OMITTED] [FIGURE 14 OMITTED] [FIGURE 15 OMITTED] [FIGURE 16 OMITTED] Limitations First, the sample size is a limitation of this study. We would have to test 12 to 60 wheelchairs of each model to have statistical power of 0.8, according to the test results in this study. It is not realistic to spend the time and money to test the required number of wheelchairs.

Second, a test dummy cannot precisely simulate a real wheelchair user. A real wheelchair user could adjust his or her posture dynamically and avoid a situation that may endanger him- or herself or the wheelchair.

For example, repeated impact from the dummy's trunk during the fatigue tests may not occur in real-world situations with this group of wheelchairs, but some users hang their backpacks on the backrests, which also causes bending stress on the backrests. ANSI/RESNA standard tests were originally designed to test K0001 wheelchairs 10 years ago, thus the requirements should not be as harsh for today's technology and manufacturing quality. Moreover, the test dummy weighs less than the maximum weight capacity of the wheelchairs in this study. Although the test dummy does not mimic a real wheelchair user completely, the general physical properties of the dummy actually produce less stress than the maximum weight capacity claimed by the manufacturers. Third, we could only draw general results from standard tests because the information was not thorough enough to discriminate the specific causes or mechanisms attributed to the vital failures in the fatigue tests.

Therefore, future studies are needed to address these issues.

[FIGURE 17 OMITTED] [FIGURE 18 OMITTED] CONCLUSIONS This group of rigid-frame titanium wheelchairs is widely prescribed. Their highly adjustable rear-wheel axles, ultralight weight, and compact dimensions help decrease physical stress on the user when propelling a wheelchair and increase ease of use. This study revealed important design concerns that need to be addressed. Our results should remind manufactures and designers that each weld point, screw hole, and change in structure and frame design has its impact on the strength and durability of the wheelchair. Our results indicate that manufacturers may need to perform more careful analyses before commercializing new products.

Abbreviations: ADA = Americans with Disabilities Act, ANSI = American National Standards Institute, CDT = curbdrop test, DDT = double-drum test, EC = equivalent cycle, ISO = International Organization for Standardization, RESNA = Rehabilitation Engineering and Assistive Technology Society of North America.

ACKNOWLEDGMENTS This material was based on work supported by the Department of Veterans Affairs Rehabilitation Research and Development Service (grant B3142C) and the National Science Foundation--Integrative Graduate Education and Research Traineeship program (grant DGE 0333420).

The authors have declared that no competing interests exist.

Submitted for publication December 7, 2007. Accepted in revised form June 23, 2008.

REFERENCES .] RESNA, American National Standards Institute. American national standard for wheelchairs. Arlington (VA): American National Standards Institute; 1998.

.] Cooper RA, Boninger ML, Rentschler A. Evaluation of selected ultralight manual wheelchairs using ANSI/RESNA standards. Arch Phys Med Rehabil. 1999;80(4): 462-67. [PMID:

.] Cooper RA, Gonzalez J, Lawrence B, Renschler A, Boninger ML, VanSickle DP. Performance of selected lightweight wheelchairs on ANSI/RESNA tests. American National Standards Institute-Rehabilitation Engineering and Assistive Technology Society of North America. Arch Phys Med Rehabil. 1997;78(10):1138-44. [PMID:

.] Cooper RA, Robertson RN, Lawrence B, Heil T, Albright SJ, VanSickle DP, Gonzalez J. Life-cycle analysis of depot versus rehabilitation manual wheelchairs. J Rehabil Res Dev. 1996;33(1):45-55.

[PMID:

.] Fass MV, Cooper RA, Fitzgerald SG, Schmeler M, Boninger ML, Algood SD, Ammer WA, Rentschler AJ, Duncan J. Durability, value, and reliability of selected electric powered wheelchairs. Arch Phys Med Rehabil. 2004; 85(5): 805-14. [PMID:

.] Fitzgerald SG, Cooper RA, Boninger ML, Rentschler AJ.

Comparison of fatigue life for 3 types of manual wheelchairs. Arch Phys Med Rehabil. 2001;82(10):1484-88. [PMID:

.] Pearlman JL, Cooper RA, Karnawat J, Cooper R, Boninger ML.

Evaluation of the safety and durability of low-cost nonprogrammable electric powered wheelchairs. Arch Phys Med Rehabil.

2005;86(12):2361-70. [PMID:

.] Smith C, McCreadie M, Unsworth J. Prescribing wheelchairs: The opinions of wheelchair users and their carers. Clin Rehabil.

1995;9(1):74-80.

.] Trail M, Nelson N, Van JN, Appel SH, Lai EC. Wheelchair use by patients with amyotrophic lateral sclerosis: A survey of user characteristics and selection preferences. Arch Phys Med Rehabil.

2001;82(1):98-102. [PMID:

.] Kittel A, Di MA, Stewart H. Factors influencing the decision to abandon manual wheelchairs for three individuals with a spinal cord injury. Disabil Rehabil. 2002;24(1-3): 106-14. [PMID:

.] Rogers H, Berman S, Fails D, Jaser J. A comparison of functional mobility in standard vs. ultralight wheelchairs as measured by performance on a community obstacle course. Disabil Rehabil.

2003;25(19):1083-88. [PMID:

.] Paralyzed Veterans of America Consortium for Spinal Cord Medicine. Preservation of upper limb function following spinal cord injury: A clinical practice guideline for healthcare professionals. J Spinal Cord Med. 2005;28(5):434-70. [PMID:

.] International Organization for Standardization (ISO).

Wheelchairs--Part 3: Determination of effectiveness of brakes. ISO 7176-3:2003. Geneva (Switzerland): ISO; 2003.

.] Winter DA. Biomechanics and motor control of human movement.

3rd ed. Hoboken (NJ): John Wiley & Sons, Inc; 2005.

.] Giangregorio L, McCartney N. Bone loss and muscle atrophy in spinal cord injury: Epidemiology, fracture prediction, and rehabilitation strategies. J Spinal Cord Med. 2006;29(5): 489-500.

[PMID:

.] Cooper RA. Wheelchair standards and testing. Wheelchair selection and configuration. New York (NY): Demos; 1998. p. 165-95.

.] Munro BH. Selected nonparametric techniques. Statistic methods for health care research. Lippincott Williams & Wilkins; 2005. p. 109-36.

.] Di Marco A, Russell M, Masters M. Standards for wheelchair prescription. Aust Occup Ther J. 2003;50(1):30-39.

.] TWI Ltd [homepage on the Internet]. Cambridge (England): The Welding Institute; c2008 [updated 2008; cited . Weldability of materials: Titanium and titanium alloys; [about 4 screens]. Available from:

.] eFunda [homepage on the Internet]. Sunnyvale (CA): eFunda, Inc; c2008 [updated 2008; cited 2007 Jun . Cantilever loading options; [about 1 screen]. Available from:

casestudy_bc_cantilever.cfm/.

.] Stephens RI, Faterini A, Stephens RR, Fuchs HO. Macro/ micro aspects of fatigue of metals. Metal fatigue in engineering. Wiley-IEEE; 2001. p. 33-41.

.] Callister J. Materials science and engineering: An introduction. 3rd ed. New York (NY): Wiley; 1994.

.] Invacare. Owner's operator and maintenance manual. TOP END everyday and sport series wheelchairs. Elyria (OH): Invacare; 2007.

Hsin-yi Liu, BS; (1-2) Rory A. Cooper, PhD; (1-3) * Jonathan Pearlman, PhD; (1-2) Rosemarie Cooper, MPT, ATP; (1-2) Samuel Connor, BS (1) (1) Human Engineering Research Laboratories, Department of Veterans Affairs (VA) Rehabilitation Research and Development Service, VA Pittsburgh Healthcare System, Pittsburgh, PA; Departments of (2) Rehabilitation Sciences & Technology and (3) Bioengineering and Physical Medicine & Rehabilitation, University of Pittsburgh, Pittsburgh, PA * Address all correspondence to Rory A. Cooper, PhD; Human Engineering Research Laboratories, 151R-1HD, VA Pittsburgh Healthcare System, 7180 Highland Dr, Pittsburgh, PA 15206; 412-954-5287; fax:

412-954-5340. Email: DOI:10.1682/JRRD.2007.12.0204

Evaluation of Titanium Ultralight Manual Wheelchairs Using Ansi/resna Standards. 1

HOT PRODUCTS
no data
GET IN TOUCH WITH US
recommended articles
Case Info Center AI Blog
Discovery of a Female Cat with Testicles Among Weirdest Pet Claims
Discovery of a Female Cat with Testicles Among Weirdest Pet Claims
A North Shore pet owner got the shock of her life to learn her female cat also had testicles. Along with the discovery of a hermaphrodite cat, other owners have been left perplexed after discovering their pets had consumed anything from a roll of dental floss, compact mirror, blanket, sewing needle to a chicken skewer. These discoveries were among the weirdest PetCare claims received by Southern Cross last year. Lisa Newlands adopted her domestic long haired cat Cameo in 2014 with the reassurance she had been spayed. But at the end of last year, Newlands became suspicious about whether it the standard neutering had worked when her usually feisty cat started befriending a stray male. After Cameo became really sick with a high temperature and stopped eating for the second time in two months, an ultrasound revealed she had a large mass in her stomach area. The ginger cat underwent surgery and for the first time in her vet's 13 year career, she discovered two cancerous testicles in the female feline. Cancerous testicles emit oestrogen, which was why the tom cat was hanging around. "The vet was just bamboozled. She had never seen anything like this in her entire career," Newlands said. Cameo's total vet bill was $2531, but Newlands said fortunately $2013 was covered by pet insurance. Newlands estimated Cameo had racked up almost $10,000 in vet bills since she had owned her because she was notorious for getting in fights with other cats and was grateful most of it had been covered by her pet insurance. Another pet owner also claimed on a hefty $8000 vet bill after their german shepherd cut its leg on a metal shoe rack as it tried to escape from two cats. The traumatic incident resulted in the dog having to undergo two surgeries and receive post operative care. In another case, a labrador retriever went under the knife to remove pieces of a blanket it had eaten from its stomach at a cost of $6000. Another owner commented that they were amazed that the chicken skewer eaten by their miniature poodle came out whole after being endoscopically removed. And a hungry beagle's desire to snaffle up a tasty fruit cake also backfired on it after the raisins caused it to have renal failure. The wee beagle had it's kidneys flushed at the vet. But the list of weird claims gets crazier after a french bulldog ate a whole roll dental floss it had found in a visitor's bag and a Shetland sheepdog had to be treated for munching on dish cloths on two separate occasions. The mischievous mutt managed to escape surgery and was given drugs to help it either poo or vomit the rags out. And it wasn't just playful pooches causing their owners angst, a domestic long haired cat also required surgery to remove a sewing needle it had swallowed and devon rex cat had 46 hair ties surgically removed from its stomach. Both treatments cost their owners more than $2000 each. Southern Cross Pet Insurance general manager Anthony McPhail said everyday, unexpected accidents could end up costing pet owners a lot of money at the veterinary clinic. McPhail said while most of the claims processed were for typical illnesses and routine checks, the ones where pets had managed to eat something they shouldn't have still surprised them. He said the stories could be amusing, but still caused quite a lot of stress to the pet and both its owner and their wallet. "We recommend owners prepare for those unexpected veterinary visits by either setting some money aside or considering pet insurance," McPhail said.
2021 07 27
read more
Citing Privacy Concerns, U.S. Panel Urges End to Secret DNA Testing
Citing Privacy Concerns, U.S. Panel Urges End to Secret DNA Testing
NEW YORK (Reuters) - They're called discreet DNA samples, and the Elk Grove, California, genetic-testing company easyDNA says it can handle many kinds, from toothpicks to tampons. Blood stains from bandages and tampons? Ship them in a paper envelope for paternity, ancestry or health testing. EasyDNA also welcomes cigarette butts (two to four), dental floss ("do not touch the floss with your fingers"), razor clippings, gum, toothpicks, licked stamps and used tissues if the more standard cheek swab or tube of saliva isn't obtainable. If the availability of such services seems like an invitation to mischief or worse - imagine a discarded tissue from a prospective employee being tested to determine whether she's at risk for an expensive disease, for instance - the Presidential Commission for the Study of Bioethical Issues agrees. On Thursday it released a report on privacy concerns triggered by the advent of whole genome sequencing, determining someone's complete DNA make-up. Although sequencing "holds enormous promise for human health and medicine," commission chairwoman Amy Gutmann told reporters on Wednesday, there is a "potential for misuse of this very personal data." "In many states someone can pick up your discarded coffee cup and send it for (DNA) testing," said Gutmann, who is the president of the University of Pennsylvania. "It's not a fantasy to think about how, without baseline privacy protection, people could use this in a way that would be really detrimental," such as by denying someone with a gene that raises their risk of Alzheimer's disease long-term care insurance, or to jack up life insurance premiums for someone with an elevated genetic risk of a deadly cancer that strikes people in middle age. "Those who are willing to share some of the most intimate information about themselves for the sake of medical progress should be assured appropriate confidentiality, for example, about any discovered genetic variations that link to increased likelihood of certain diseases, such as Alzheimer's, diabetes, heart disease and schizophrenia," Gutmann said. The commission took on the issue because whole genome sequencing is poised to become part of mainstream medical care, especially by personalizing medical treatments based on a patient's DNA. That has been driven in large part by dramatic cost reductions, from $2.5 billion per genome in the Human Genome Project of the 1990s and early 2000s to $1,000 soon. Several companies, including Illumina Inc. and Life Technology's Ion Torrent division, sell machines that can sequence a genome for a few hundred dollars, but that does not include the analysis to figure out what the string of 3 billion DNA "letters" means. A three-year-old federal law prohibits discrimination in employment or health insurance based on someone's genetic information but does not address other potential misuses of the data. Without such privacy protection, said Gutmann, people may be reluctant to participate in genetic studies that do whole genome sequencing, for fear their genetic data will not be secure and could be used against them. Recommendations from such panels are not binding but have been used as the basis for policy and legislation. One scenario the panel offers is a "contentious spouse" secretly having a DNA sample sequenced and using it in a custody battle "as evidence of unfitness to parent," perhaps because the DNA showed a genetic risk for mental illness or alcoholism. There are no federal laws against that. Or, the panel said, DNA information might be posted in a social networking site "by a malicious stranger or acquaintance," possibly hurting someone's "chance of finding a spouse, achieving standing in a community, or pursuing a desired career path." The bioethics panel recommends a dozen forms of privacy protection, including that "surreptitious commercial testing" be banned: No gene sequencing or other genetic testing should be permitted without consent from the person the DNA came from, it said. About 25 states currently allow such DNA testing. Critics of the lack of genetic privacy thought greater urgency was needed. "The report lays out a lot of important best practices and does endorse further state and federal regulations, but it doesn't offer a timeline," said Jeremy Gruber, president of the Council for Responsible Genetics, a private group that monitors genetic issues. "What will inevitably happen is whole genome sequencing will enter greater use and we won't have proper regulations to insure privacy." A bill introduced in California, home to many DNA testing companies, by state Senator Alex Padilla would ban surreptitious testing, requiring written authorization from the person the genetic sample was taken from. It is not clear how many labs are willing to analyze DNA without that authorization. In practice, well-known genetic testing companies such as privately held 23andMe test only saliva samples that are too large to acquire surreptitiously, such as from a drinking glass or licked stamp. "A person would really know that they are spitting into a tube," said 23andMe spokeswoman Jane Rubinstein. The full report from the presidential commission is at www.bioethics.gov.
2021 07 28
read more
How to Cut Corn Off the Cob Easily, Quickly, & Safely
How to Cut Corn Off the Cob Easily, Quickly, & Safely
We've all been there: we're enjoying a nice cob of corn, happily covering our face in butter and salt, when suddenly we realize that there's a thread of corn silk stuck in our teeth. We try to dislodge it with our tongue; no luck. We pick around with our fingers; still no luck. That silk is staying there until you return home to your toothbrush and dental floss. And if you think that corn silk is bad for most people, try having braces!Cutting the kernels off corn on the cob not only helps this problem, but also makes corn a lot easier to cook with.There is a problem, of course. I'd like to think I have above-average knife skills, and yet I'm completely scared to try and cut kernels off corn on the cob. There's no way to balance the oblong cob, and you have to cut straight down. To add insult to injury, the kernels corn go flying everywhere; it's nearly impossible to cut them in a neat and orderly manner. But worry not: there are some surprisingly easy (and safe!) ways to quickly and neatly cut corn off the cob.Use a Bundt or Angel Food Cake PanI only recently found out about this (big thanks to Saveur's amazing video channel), but it's now one of my favorite food hacks. Place one end of the cob in the middle of the pan, which will keep the corn stable while you cut down. Then, as you cut the ears off of the cob, they'll collect in the pan instead of scattering everywhere.Construct a Makeshift Bundt Cake PanIf you don't have a bundt or angel food cake pan, you can make your own version. Start with a cake pan, pie dish, or shallow bowl. Then add any stable item that can hold one end of the corn, such as a narrow cup or a shot glass. (My personal favorite is a toilet paper cardboard tube, but please be careful if you try this: these tubes are remarkably flimsy, so if you apply too much pressure they will collapse while you're cutting.) Then proceed just as you would with a bundt or angel food cake pan, until you have a bowl of perfectly cut corn.Cut the Corn in HalfThis is the quickest way to get the kernels off of the cob, but you want to avoid it unless you have a nice knife and are comfortable using it. Start by cutting the corn in half, which is harder than it looks: the core of the cob is extremely hard, and the corn will want to roll while you're trying to cut. So above all, be careful!Now that the corn is in half, each piece has a flat side, making it easier and safer to balance the cob while you cut it. And with each piece half the size of a full cob of corn, there's less mess when you cut the ears off.Then again, if you're hell-bent on keeping the corn on the cob, but still want to get rid of the strings of silk, you can always microwave it.Get More Food-Cutting HacksSometimes unflavored dental floss is better at cutting certain foods than your knife-seriously! And if cutting tomatoes befuddles you, be sure to read our indispensable guide on how to do it right. As for mangoes, turns out you need to bring a drinking glass in order to cut them the right way.
2021 07 28
read more
How to Make Jewelry From Seeds
How to Make Jewelry From Seeds
Using natural objects to decorate the human body has been practiced for thousands of years. In this day and age, going green with your jewelry can be fashionable in more ways than one. Grow and dry your own seeds, or find them at grocery stores, garden centers or in your backyard. Making jewelry can help satisfy your creative nature, and if you create patterns and designs that appeal to other people, you could market your jewelry and add some green to your pocketbook by utilizing simple materials provided by Mother Nature.Dried seedsCotton cloth1-inch-thick boardDrill1/16-inch drill bitSmall pliersTape measureScissorsRed marker penNeedlePlain dental flossMasking tapePrepare your seeds by sorting through them to eliminate debris and remove broken or misshapen seeds. Wash any seeds that are dirty, and dry them thoroughly. Rub the seeds with a cotton cloth to make them shine.Place a 1-inch-thick board on your work area, and place a seed on the board. Hold the seed securely with pliers. Drill a hole in the seed with a cordless drill with a 1/16-inch drill bit. so this with all your necklace seeds. Drill holes in all your seeds.Measure 32 inches of dental floss with the tape measure, and cut the floss, using scissors. Use a red marker to mark a spot 2 inches from one end of the dental floss. Mark that spot with a red marker. Mark a spot 2 inches from the other end of the dental floss. Wrap a small piece of masking tape around that end.Thread the end of your dental floss through the tiny opening at the top of your self-threading needle, above the eye. Pull the floss through the eye of your needle until you reach the spot marked with masking tape.Thread one seed at a time onto the floss by pushing the needle through the hole you've drilled in the seed. Pull the first seed to the spot marked with the masking tape. Keep adding seeds until you've filled the length of floss between the red mark and masking tape.Remove the masking tape from the end of the floss, and knot the ends of floss together securely. Clip the loose ends of floss close to the knot with scissors to finish your necklace.Drill holes in the center of each seed or at a point that will allow the seed to be threaded so it will lie at the angle of your choosing. Thread all of one kind of seed onto your floss, or alternate seeds of different shapes and sizes. Store pieces of finished jewelry in tightly covered glass jars.Use caution when using a drill. Place seed jewelry in a deep freeze for a couple of weeks, at least once a year, to kill any insects that may infest the seeds. Never eat seeds that you use to make jewelry.
2021 07 28
read more
Find the Right and Trustworthy Medical Equipment Suppliers in India
Find the Right and Trustworthy Medical Equipment Suppliers in India
No doubt, healthcare services need a diverse range of products and equipment. In order to fulfill your needs, there are equipment suppliers available who can give you a wide range of medical products and types of equipment. Meanwhile, it is essential to consider specific essentials before you look down for a supplier of medical items.Quality Medical Equipment ImportantThe good medical laboratories in India need some collection of good quality medical equipment. Medical equipment suppliers in India offer types of equipment that technicians would use for the purpose of the analysis of electrolytes and blood gas, immunology, chemistry, microbiology, hematology, urinalysis, coagulation, additionally to a comprehensive collection of ancillary laboratory tools, reagents, and controls. If you wish to have some good quality of products for the medical laboratories, it's especially significant to select a trustworthy medical equipment supplier. The suppliers generally have an account with a wide collection of regular laboratory products.Choose a Reliable dealer or SupplierSelecting a reliable supplier or dealer medical equipment will make sure that the laboratories are completely equipped with a diverse inventory of top quality products from the top brands. Not to add to the fact that all the analytical process will out efficiently and correctly.Apart from that, the recognized suppliers usually give post-sales services and proficient refurbish and packages of the repair that will make sure that all the items supplied are functioning in the right way. They also give the spare parts and delicates for the majority of the products.Medical equipment online storeNot just physical stores, but the online store is also ready to serve your needs for the medical types of equipment. Look for trustworthy suppliers that can give you amazing in-house services which include repairs when required, after-sales assistance and visits for material service.Contact Details:-Website : No: 9247871397 / 0891-2521379EmailId : indianmedicalmart@gmail.comAdrress : Door No: 14-11-2, Ramajogipeta, Maharanipeta,Back Side of Bharathi Hospital, Visakhapatnam - 530002, Andhra Pradesh, India·RELATED QUESTIONWhat are the key performance indicators for a surgical instrument sales company?Would depend on the company selling, but most likely a company selling such equipment would need to track:Number of units soldRevenue generated per month or quarterMRR (monthly recurring revenues)Tracking follow-up dates for re-stocksProduct rotation tracking (if items have an expiry date)Quality assurance (both stock and transport)Invoicing & payment trackingAnd of course, all of the relevant data of their clients.Perhaps worth contacting a hospital administrator and see if they can help you directly. Or indeed, another medical equipment supply company.We have several medical equipment suppliers using our software and each have different metrics and KPI's.Hope this helps!
2021 07 28
read more
What to Give Up for Lent? Smoking? Cursing? How About ...
What to Give Up for Lent? Smoking? Cursing? How About ...
LONDON - For Lent, many Christians give up indulgences like tobacco, alcohol or sweets, or transgressions like lying and swearing. And for Anglicans, don't forget synthetic fabrics, wet wipes, and those little boxes that hold dental floss.The Church of England has asked people to add a new culprit to the list of ills they forsake for the six weeks of penance that begin on Ash Wednesday: plastics. Specifically, the church wants people to avoid the plastic consumer products and packaging that have become a major environmental problem, polluting oceans and rivers, fouling beaches, killing wildlife and clogging landfills."I think it might well be a first for us, to have an entire Lent program on an environmental issue, but it is very much an integral part of what the church is about," said Ruth Knight, the Church of England's environmental policy officer. In fact, environmental stewardship "to safeguard the integrity of creation" is one of the five "marks of mission" the church lists in describing its purpose.The church's "Lent Plastic Challenge" arrives on a wave of anti-plastic sentiment and legislation in Britain and across Europe, as more people conclude that the first element of the motto "reduce, reuse, recycle" should take precedence. In December, the European Union announced binding waste-reduction targets for member nations, with particular emphasis on plastics.Last month, a ban on plastic microbeads in cosmetic products took effect in Britain, and Prime Minister Theresa May's government committed Britain to a 25-year environmental plan that includes eliminating most plastic waste. Several big cafe and restaurant chains have recently done away with plastic straws, or promised to do so, and the government of Scotland has said it will ban them by the end of next year.[Read how a 9-year-old boy's statistic shaped a debate on straws here.]In Wales, Scotland and Northern Ireland, stores must charge 5 pence for each single-use shopping bag, whether paper or plastic, and the same charge applies in England for plastic bags at larger retailers. The measure has sharply reduced plastic bag use, and lawmakers say they want to impose charging more widely in England.Last fall, a BBC documentary series on the oceans, Blue Planet II, which dealt extensively with environmental dangers, including from plastics, was the most-viewed program in Britain.The Church of England has created a calendar for a plastics-free Lent, each day bearing either an environmentally-themed Bible verse or a suggestion on how to avoid buying plastics.Along with some of the easier-to-follow suggestions, like buying clothes made of natural fibers or taking reusable bags to the grocery store, are others that might require more effort, like finding dental floss that does not come in a plastic box, or using "a bamboo toothbrush or a toothbrush with recyclable heads.""Yeah, some of them are more difficult than others," Ms. Knight said. "It's definitely not a commandment to do all of them, it's encouragement to do as much as you can."A large part of the world's plastic waste - estimates range from five million to 13 million tons per year - ends up in the oceans. Circulating currents have created immense rotating patches of waste, mostly plastic, in subtropical regions.Wave action and sunlight break floating plastics down in smaller pieces, but some of them are very slow to degrade chemically, and are toxic. Animals eat bits of plastic, with ill effects on them - and further up the food chain, all the way to humans - that are only beginning to be understood.
2021 07 28
read more
How to Mark Climbing Ropes
How to Mark Climbing Ropes
A climbing rope is literally a climber's lifeline, one of the few items of a gear system that usually isn't redundant. When you life depends on a single piece of nylon--and certain substances have been shown to degrade nylon--who can blame climbers for being nearly paranoid about what touches their ropes? There are two commonly accepted ways of marking the middle point on a climbing rope: using a specially designed rope marker or marking the middle with dental floss or thread.InstructionsDifficulty: Moderately EasyHold the two ends of the rope together in your right hand. Wrap your left hand around both strands of rope.Pull both strands of rope evenly through your left hand until you reach the middle of the rope.Pinch the rope in one hand, just below the middle of the rope, while you color in a 1- or 2-inch wide portion of the rope sheath, all the way around the circumference of the rope, centered on the middle of the rope. Make sure you use a marker specially designed for marking climbing ropes.Mark the middle with dental floss if you'd rather not use a marker on your rope. Thread a large sewing needle with dental floss. Work the dental floss around the middle of the rope, threading it through the rope's sheath, not directly through the core, until you've created a mark that's large enough to easily spot.Tips & WarningsResourcesArticle Written By Marie MulrooneyMarie Mulrooney has written professionally since 2001. Her diverse background includes numerous outdoor pursuits, personal training and linguistics. She studied mathematics and contributes regularly to various online publications. Mulrooney's print publication credits include national magazines, poetry awards and long-lived columns about local outdoor adventures.
2021 07 30
read more
no data
One-stop medical & laboratory equipment supplier,focus on medical equipments over 10 years
Contact us

If you have a question, please contact at contact info@mecanmedical.com

+86 020 8483 5259
no data
Copyright © 2021 Guangzhou MeCan Medical Limited  | Sitemap