
==== Front
JBI Evid Synth
JBI Evid Synth
SRX
Jbi Evidence Synthesis
2689-8381
Lippincott Williams & Wilkins Hagerstown, MD

38803243
JBIES-22-00427
10.11124/JBIES-22-00427
00010
3
Protocols
Musculoskeletal
Nervous System
Wheeled mobility use outcomes: a systematic review protocol of measurement properties
https://orcid.org/0000-0003-4923-8493
Mendoza Kiera 1kimendoz@iu.edu

https://orcid.org/0000-0002-4699-2944
Loeser Madison 1mlloeser@iu.edu

https://orcid.org/0000-0002-3162-0099
Ouellet Béatrice 23beatrice.ouellet.1@ulaval.ca

https://orcid.org/0000-0001-7205-7725
Best Krista L. 23krista.best@fmed.ulaval.ca

https://orcid.org/0000-0001-7406-0477
Rushton Paula W. 4prushton@dal.ca

https://orcid.org/0000-0002-4116-121X
Kenyon Lisa K. 5kenyonli@gvsu.edu

https://orcid.org/0000-0003-0762-744X
Hinrichs Rachel J. rhinrich@iupui.edu
6
https://orcid.org/0000-0003-3488-5479
Chase Tony 1chaseam@iu.edu

1 Department of Occupational Therapy, Indiana University-Purdue University Indianapolis, IN, USA
2 Department of Rehabilitation, Faculty of Medicine, Université Laval, Québec City, QC, Canada
3 Centre for Interdisciplinary Research in Rehabilitation and Social Integration (Cirris[M1] [k2]), Québec City, QC, Canada
4 School of Occupational Therapy, Dalhousie University, Halifax, NS, Canada
5 Department of Physical Therapy and Athletic Training, Grand Valley State University, Grand Rapids, MI, USA
6 University Library, Indiana University-Purdue University Indianapolis, IN, USA
Correspondence: Tony Chase, chaseam@iu.edu
9 2024
27 5 2024
22 9 18981905
Copyright © 2024 The Author(s). Published By Wolters Kluwer Health, Inc. on Behalf of JBI.
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. http://creativecommons.org/licenses/by-nc-nd/4.0/

Introduction:

Numerous tools have been developed to measure constructs related to wheelchair use. Currently, no toolkit comprehensively details assessments of wheeled mobility device use based on the quality of their measurement properties. The current review aims to systematically identify high-quality assessment tools that measure different aspects of wheeled mobility use.

Objective:

The objectives are two-fold: i) to synthesize outcome measures that assess use of wheeled mobility devices, and ii) to evaluate measurement properties of the assessment tools.

Inclusion criteria:

The populations of interest are manual wheelchair users, power wheelchair users, and scooter users of any age, diagnosis, or setting. Instruments of any type will be included.

Method:

The JBI methodology for systematic reviews of measurement properties will guide this review. A search strategy will be developed to search the following databases: MEDLINE (Ovid), Embase, CINAHL (EBSCOhost), PsycINFO (EBSCOhost), PsycTests (EBSCOhost), Web of Science, and Google Scholar. The article selection process, data extraction, and quality appraisal will be performed by 2 independent reviewers, with a third reviewer being consulted to achieve consensus. The methodological quality of the studies will be assessed through the Consensus Standards for the Selection of Measurement Instruments (COSMIN) Risk of Bias tool and the COSMIN Checklist. The quality of the pooled evidence and individual measurement properties will be graded using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach and the COSMIN Criteria for Good Measurement Properties recommendations. Measurement properties of each instrument will be described, with the goal of developing a toolkit that identifies appropriate assessment tools for wheeled mobility use outcomes.

Review registration:

PROSPERO CRD4202276169

Keywords:

measurement properties
psychometric properties
scooter user
wheelchair user
wheeled mobility
OPEN-ACCESSTRUE
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pmcIntroduction

Wheeled mobility use is prevalent across ages, diagnoses, and clinical settings. Globally, it is estimated that 1 out of every 100 individuals would benefit from a wheelchair to support functional mobility.1 In the United States, approximately 13% of the population has a disability that affects mobility, and over 3 million individuals use a wheelchair to functionally navigate their environment.2,3 A disease or condition that requires the use of a wheelchair can be congenital or acquired, which contributes to the diversity of age at which individuals begin using a wheelchair. There are numerous diagnoses that require the use of a wheelchair, such as spina bifida, spinal cord injury, Parkinson’s disease, amyotrophic lateral sclerosis, amputations, traumatic brain injury, or muscular dystrophy.4 Given the diverse age ranges and diagnoses of wheeled mobility users, this population is present across the continuum of health care settings.

Wheeled mobility broadly refers to a personal device that uses wheels for functional mobility, such as a manual or power wheelchair or a scooter.5 Manual wheelchair users are defined as individuals who actively propel themselves in the wheelchair or who are actively propelled by someone else.1 Power wheelchair users, who may also be referred to as electric wheelchair users, use wheelchairs with an electric motor. Similarly, a scooter user uses an electrically powered scooter; however, unlike wheelchairs, scooters are typically not used for mobility in the home.

The prevalence of wheeled mobility use nationally and internationally highlights the importance of identifying strong assessments of wheelchair and scooter use and familiarizing health care professionals with the well-developed measurement tools in existence to create and support targeted interventions. The selection of the most appropriate tools is becoming challenging for clinicians due to the vast number of tools available and the time constraints of identifying and weighing the quality of such tools. Therefore, summarizing the measurement properties of current tools is important to aid in the selection of appropriate measurement tools and to identify gaps in the examined measurement tools’ functionality to perform in a clinical or research setting.

Wheelchair assessment research has been conducted; however, systematic collection of wheeled mobility use outcomes for all ages, diagnoses, and settings, as well as the review of their measurement properties has yet to be completed. A preliminary search of PROSPERO indicated that there are no comprehensive systematic reviews on measurement properties of all potential wheelchair or scooter use outcome measures. Although there are published systematic reviews on a singular outcome measure (eg, mobility skills), the proposed review will present all existing outcome measures that evaluate wheeled mobility use. As this review will encompass all outcomes, a comprehensive toolkit can be created for clinicians. Thoroughly describing the current literature on measurement properties of published wheelchair use assessments for any age, diagnosis, and setting will provide the opportunity to identify high-quality instruments that are reliable, valid, and responsive for targeted interventions. Further, these instruments can be distinguished as clinically relevant for certain contexts, populations, and outcomes.

Synthesizing and disseminating this research will allow clinicians to determine which assessments are best suited to provide the highest quality care. If clinicians are provided with assessment tools that are of high methodological quality, they will be empowered to select appropriate tools for their clients. Moreover, rehabilitation professionals will be equipped with assessment tools that fit their clients and context, allowing them to effectively measure wheelchair use outcomes to identify client progress and areas for growth and to maintain evidence-based practice.6

Review questions

What are the outcome measures developed to evaluate wheelchair use among manual wheelchair users, power wheelchair users, and scooter users?

What are the measurement properties of the identified outcome measures?

Inclusion criteria

Population

The inclusion criteria will include manual wheelchair, power wheelchair, and scooter users of any age, diagnosis, and setting. Populations will be excluded if their mobility devices are walkers, canes, or crutches.

Instruments

All instruments that measure wheelchair use will be considered, including objective, performance-based, observational, subjective, self-report, or proxy-report instruments. The instruments will be described by type. Modified versions of instruments will be considered as new instruments.7 A study will be excluded if an instrument is only used as an outcome.

Constructs

In this study, wheelchair use and wheeled mobility use includes manual wheelchair, power wheelchair, and scooter use cases. Wheeled mobility is defined by Bayley et al. as the “skilled use of any personal device with wheels, including power wheelchairs, and manual wheelchairs (with arm or foot propulsion), by individuals with physical impairments such as spinal cord injury … to allow full participation in daily life.”5 (p.S133) Outcomes of wheeled mobility use may include self-efficacy, activity, satisfaction, participation, skills capacity, and frequency of performance, depending on the systematic review findings. Wheeled mobility use outcomes may consider the physical and psychological status of the client, the client’s participation in valued activities, or the greater environmental context that surrounds the client. In totality, the outcomes measured will create the construct of wheeled mobility use.

Outcomes

The outcomes of interest in this review are measurement properties of instruments, including reliability (reliability, measurement error, internal consistency), validity (content validity, construct validity, criterion validity), and responsiveness. Measurement properties will be defined according to the Consensus Standards for the selection of Measurement Instruments (COSMIN) Taxonomy of Measurement Properties.8

Type of studies

Any peer-reviewed developmental study (development of tools) and any peer-reviewed study that reports measurement property data (including cross-cultural translations and validation studies) will be included.7 Conference abstracts, dissertations, or scholarly works that are not peer-reviewed will be excluded.

Methods

This review will follow the JBI methodology for systematic reviews of measurement properties7 and will be reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement.9 An overview of the review methods can be found in Figure 1.

Figure 1 Overview of review methods

Search strategy

The search strategies were developed by a health sciences librarian (RH) trained in the JBI 3-phase approach.7 Relevant articles collected by the authors were analyzed to select keywords and subject headings (Phase 1). An initial search strategy was iteratively developed and tested by adding and removing additional keywords and subject headings until all known, relevant articles were retrieved by the search, and no new relevant articles were found (Phase 2). To develop the search strategy for measurement properties, the librarian adapted the PubMed COSMIN search filter for psychometric properties.10 The final search terms incorporated subject headings and keywords associated with wheelchairs and assessment tools. The reference lists of the identified articles will then be reviewed to identify additional relevant studies (Phase 3).

Databases will be searched using the developed search strategies. The databases MEDLINE (Ovid), Embase, CINAHL (EBSCOhost), PsycINFO (EBSCOhost), PsycTests (EBSCOhost), Web of Science, and Google Scholar will be search from inception until March 2024. For Google Scholar, the first 100 references will be retrieved. Studies will be limited to English or French due to the authors’ proficiency in these languages. A draft search strategy can be found in Appendix I.

Study selection

References will be imported into Covidence (Veritas Health Innovation, Melbourne, Australia) and duplicates will be removed. Titles and abstracts of all articles will be screened against the inclusion criteria by 2 independent reviewers. Reasons for exclusion will be documented. Full-text articles will then be reviewed and verified for inclusion. Two reviewers will independently complete the screening and review process. Any disagreements between the reviewers will be resolved through discussion or with a third reviewer.

Assessment of methodological quality

The methodological quality of included studies will be assessed using the COSMIN Risk of Bias Checklist.11 This checklist considers 10 characteristics of studies. The first characteristic is “outcome measure development,” which describes the process of developing the measurement instrument.7 The remaining 9 characteristics are measurement properties, including content validity, structural validity, internal consistency, cross-cultural validity/measurement invariance, reliability, measurement error, criterion validity, hypothesis testing for construct validity, and responsiveness.7 The COSMIN checklist will be used to verify methodological quality and to produce additional descriptive information for assessment tool selection.12 In addition to the 9 criteria of the COSMIN Risk of Bias Checklist, the COSMIN Checklist includes criteria such as feasibility (generalizability), interpretability, and the statistical theory that guided the study’s methods in the assessment of methodological quality.12

As guided by the COSMIN Risk of Bias tool, studies will receive a score (very good, adequate, doubtful, or inadequate) for each of the 10 criteria. The lowest score among all criteria will determine the overall score of the given study.7

Data extraction

Data extraction will be conducted by 2 independent reviewers. A third independent reviewer will be consulted in case of disagreements to achieve consensus. To reduce errors and risk of bias, the reviewers will be trained on how to use the data extraction form and will practice using the form (Appendix II). The reviewers will independently extract data from 5 clinical articles to demonstrate their understanding of the extraction process and to achieve a standard of interrater reliability. This process will continue until the reviewers achieve interrater reliability as found by high percentage agreement of at least 0.80–0.90 between reviewers. A third author will review the completed piloted forms and determine interrater reliability through percentage of agreement between reviewers. Percentage of agreement will be determined by examining whether the extracted variables articulate the same content meaning. High percentage agreement will signify that the data extraction process is clear to reviewers. Data extraction will then be initiated.

All COSMIN Risk of Bias and COSMIN Checklist variables will be extracted, including, but not limited to, the instrument and constructs assessed, the country where the study was completed, the language of the instrument, the mode of administration of the instrument, the setting/context in which the instrument was administered, the study participants, and measurement properties of the instrument.7,12,13 Feasibility and interpretability of the instruments will be assessed descriptively. In addition to the strength of an instrument, feasibility (or generalizability) allows clinicians to determine whether instruments are suitable in certain contexts, populations, and settings.14 Interpretability provides information regarding whether an instrument’s outcome is easily understood and provides clinical meaningfulness.7 Feasibility and interpretability can be helpful when selecting an outcome measure if instrument quality is otherwise difficult to differentiate; therefore, it will be extracted using the COSMIN Checklist.12,14 A JBI extraction tool (see Appendix II) will be used to present the findings from the COSMIN Risk of Bias and COSMIN Checklist in a concise manner. Measurement properties will be further detailed using the table of results template in the JBI manual.

Wheelchair and scooter use outcomes will also be extracted and categorized according to the International Classification of Functioning, Disability, and Health (ICF) domains. Evidence supports the application of the ICF framework in improving rehabilitation and health outcomes. Categorizing the outcomes into ICF domains will ensure that terminology is consistent across health care professions and disciplines.15 The ICF domains include i) body functions and structures, ii) activities and participation, and iii) contextual factors.17 These 3 domains include sub-categories such as capacity, performance, environmental factors, and personal factors. Each identified outcome measure will be categorized within an ICF domain and then sub-categorized within its respective domain. For instance, in the Wheelchair Use Confidence Scale for Manual Wheelchair Users (WheelCon-M), the outcome being measured is confidence of the wheelchair user, which would fall within the ICF category of “body function” (b1266), as it is a belief or psychological factor of the subject.16,17

Data synthesis

The objective of data synthesis of measurement properties is to determine whether the measurement properties of each instrument are acceptable for implementing the instrument as planned.7 Currently, there are limitations in statical methodologies regarding meta-analysis for measurement properties.7 Therefore, a narrative synthesis will present the data to maintain methodological quality. Data will be presented using a narrative synthesis and tables to describe measurement properties of every instrument included in the systematic review. The reported findings will include information regarding the quality of the methods used in the studies as well as “consistency of the results, and homogeneity of the studies.”7 (p.467) Each property will be ranked as “sufficient,” “insufficient,” or “indeterminate,” as per the COSMIN Criteria for Good Measurement Properties recommendations.14

The systematic review will analyze instruments applicable to the sub-groups of manual wheelchair users, power wheelchair users, and scooter users of any age, diagnosis, and setting. Additionally, the sub-groups of pediatric and adult wheelchair and scooter users will potentially be analyzed by the sub-groups of diagnosis and setting as well. The results will then be synthesized in the final publication based upon findings. The authors anticipate that age will be the primary variable by which the results will be organized. After that, diagnosis within the age sub-groups will be reported and the setting of the intervention will be discussed therein. Authors will determine if this process needs adjustment based on the content of the articles that are found.

Assessing certainty of the findings

The COSMIN Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach will be used to assess the quality of evidence included in the systematic review.18 The studies will initially be considered of high quality. Studies will decrease in quality due to “risk of bias, inconsistency, imprecision, and indirectness.”7 (p.468)

Author contributions

KM and ML organized the sections of the manuscript, wrote sections involving methods, and planned manuscript submission. BO supervised planning of the protocol development. PWR, KLB, and LKK served as content experts in wheelchair skills assessment. They provided direction for the PICO, references for the strategy, and wrote sections of the paper. RH is a medical librarian who worked on the search terms, criteria, and databases to be used. TC supervised production of the manuscript, wrote sections, aided in PICO development, and put together the final publications. TC also served as a content expert in wheelchair skills assessment and assessment methods.

Appendix I: Draft search strategy

CINAHL (EBSCOhost)

Search conducted: March 29, 2024

(MH “Wheelchairs+” OR wheelchair* OR “wheel chair” OR “wheel chairs” OR scooter* OR ((wheel* OR power* OR manual) N1 (chair* OR mobilit*)))

AND

(MH “Psychometrics” OR MH “Reproducibility of Results” OR MH “Validation Studies” OR (psychometr* OR clinimetr* OR clinometr* OR test-retest OR interrater or inter-rater or intrarater or intra-rater OR reproducib* OR reliab* or unreliab* or validity OR validated OR checklist* OR discriminative OR concordance OR factor-analysis OR factor-analyses OR factor-structure* OR cross-cultural-adaptation* OR (test N3 questionnaire) OR ((tool* OR instrument* OR standard*) N3 assessment)) OR TI ((outcome* OR propert*) N2 (measure* OR assessment*)))

Limits: English and French; Academic journals source type

Results: 2285

Appendix II: Draft data extraction form

Study	
Instrument(s) assessed		
Construct/outcome assessed and ICF domain		
Country/language		
Mode of admin		
Setting/context		
Participants		
Results (measurement properties)		
ICF, International Classification of Functioning, Disability, and Health

The authors declare no conflicts of interest.
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References

1 World Health Organization . Guidelines on the provision of manual wheelchairs in less resourced settings [internet]. WHO; 2008 [cited 2023 Mar 1]. Available from: https://www.who.int/publications/i/item/9789241547482.
2 Centers for Disease Control and Prevention . Disability impacts all of us [internet]. CDC; 2020 [cited 2023 Feb 28]. Available from: https://www.cdc.gov/ncbddd/disabilityandhealth/infographic-disability-impacts-all.html.
3 Brault MW . Americans with disabilities: 2010 [internet]. United States Census Bureau; 2012 [cited 2023 Feb 23]. Available from: https://www2.census.gov/library/publications/2012/demo/p70-131.pdf.
4 Kirby RL Rushton PW Smith C Routhier F Archambault PS Axelson PW . Wheelchair skills program manual version 53 [internet]. Dalhousie University; 2022 [cited 2023 Mar 1]. Available from: https://wheelchairskillsprogram.ca/en/skills-manual-forms/.
5 Bayley MT Kirby RL Farahani F Titus L Smith C Routhier F . Development of wheeled mobility indicators to advance the quality of spinal cord injury rehabilitation: SCI-high project. J Spinal Cord Med 2019;42 (Sup 1 ):130–140.31573457
6 Grover P Holt D . Outcome measurement in rehabilitation [internet] 2017 [cited 2023 Feb 15]. Available from: https://now.aapmr.org/outcome-measurement-in-rehabilitation/.
7 Stephenson M Riitano D Wilson S Leonardi-Bee J Mabire C Cooper K . Chapter 12: Systematic reviews of measurement properties [internet]. In: Aromataris E, Munn Z, editors. JBI Manual for Evidence Synthesis. JBI; 2020 [cited 2022 Nov 7]. Available from: https://synthesismanual.jbi.global.
8 Mokkink LB Terwee CB Patrick DL Alonso J Stratford PW Knol DL . The COSMIN study reached international consensus on taxonomy, terminology, and definitions of measurement properties for health-related patient-reported outcomes. J Clin Epidemiol 2010;63 (7 ):737–745.20494804
9 Moher D Liberati A Tetzlaff J Altman DG . Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Ann Intern Med 2009;151 (4 ):264–269.19622511
10 Terwee CB Jansma EP Riphagen II de Vet HC . Development of a methodological PubMed search filter for finding studies on measurement properties of measurement instruments. Qual Life Res 2009;18 (8 ):1115–1123.19711195
11 Mokkink LB de Vet H Prinsen C Patrick DL Alonso J Bouter LM . COSMIN risk of bias checklist for systematic reviews of patient-reported outcome measures. Qual Life Res 2018;27 (5 ):1171–1179.29260445
12 Mokkink LB Terwee CB Patrick DL Alonso J Stratford PW Knol DL . The COSMIN checklist for assessing the methodological quality of studies on measurement properties of health status measurement instruments: an international Delphi study. Qual Life Res 2010;19 (4 ):539–549.20169472
13 COSMIN . Guideline for systematic reviews of outcome measurement instruments [internet]. COSMIN [cited 2022 Nov 7]. Available from: https://www.cosmin.nl/tools/guideline-conducting-systematic-review-outcome-measures/.
14 Prinsen C Mokkink LB Bouter LM Alonso J Patrick DL de Vet H . COSMIN guideline for systematic reviews of patient-reported outcome measures. Qual Life Res 2018;27 (5 ):1147–1157.29435801
15 World Health Organization . How to use the ICF: a practical manual for using the International Classification of Functioning, Disability and Health (ICF) [internet]. WHO; 2013 [cited 2023 March 1]. Available from: https://www.who.int/publications/m/item/how-to-use-the-icf---a-practical-manual-for-using-the-international-classification-of-functioning-disability-and-health.
16 World Health Organization. International Classification of Functioning, Disability, and Health: ICF [internet]. WHO; 2001. Available from: https://iris.who.int/handle/10665/42407.
17 Rushton PW Miller WC Kirby RL Eng JJ . Measure for the assessment of confidence with manual wheelchair use (WheelCon-M) version 2.1: reliability and validity. J Rehabil Med 2013;45 :61–67.23138341
18 Mokkink LB Prinsen CAC Patrick DL Alonso J Bouter LM de Vet HCW . COSMIN methodology for systematic reviews of patient-reported outcome measures (PROMs): user manual. Version 1.0. February 2018 [cited 2024 Aug 30]. Available from: https://cosmin.nl/wp-content/uploads/COSMIN-syst-review-for-PROMs-manual_version-1_feb-2018.pdf.
