Clinical assessment, design and performance testing ...

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validated clinical assessment tools. Performance testing to published standards is also needed. Keywords: Assistive technology devices, bathing, bowel care,.

Disability and Rehabilitation: Assistive Technology, 2013; 8(4): 267–274 © 2013 Informa UK, Ltd. ISSN 1748-3107 print/ISSN 1748-3115 online DOI: 10.3109/17483107.2012.704656

Review Article

 linical assessment, design and performance testing of mobile shower C commodes for adults with spinal cord injury: an exploratory review Disabil Rehabil Assist Technol Downloaded from informahealthcare.com by University of Queensland on 06/06/13 For personal use only.

Emma Friesen, Deborah Theodoros & Trevor Russell Telerehabilitation Research Unit, School of Health and Rehabilitation Sciences, University of Queensland, St Lucia, Australia

Implications for Rehabilitation

Purpose: The purpose of this article is to explore evidence concerning clinical assessment, design and performance testing of mobile shower commodes used by adults with spinal cord injury (SCI). Method: Searches of electronic databases, conference proceedings and key journals were undertaken with no restriction on language or study design. Keywords included spinal cord injury, lesion, sanichair, sanitary chair, shower chair, bowel chair and commode. Results: A total of 20 publications were included in this review. Common approaches to clinical assessments were questionnaires and observational analysis to assess bowel care routines, function and skin integrity. Design features addressed access for bowel care, postural support, transfers, stability, use in wet environments and skin integrity. Objective performance measures addressed requirements for static stability, backward-sloping seat angles, arm supports and seat materials. Conclusions: Evidence reviewed was of low methodological quality and lacking in validated instruments to guide clinical practice. Further high-quality research is needed to identify bathing, showering and personal hygiene tasks affecting mobile shower commodes use and to develop validated clinical assessment tools. Performance testing to published standards is also needed.

• Adults with spinal cord injury (SCI) use mobile shower commodes for functional activities including transferring, propelling, bowel care and showering, and the interactions between an adult with SCI, their mobile shower commode, and the physical environment are not well understood. • Current mobile shower commode designs may not facilitate functional activities and may contribute to falls and development of pressure ulcers. • Standardised and validated clinical assessment tools are needed to guide clinical practice, and should include questionnaires and observational analysis of functional activities performed in mobile shower commodes across all environments of use. chemical or digital (mechanical) means and digital stool removal by either the patient or caregiver [3,4]. Adults with SCI may require mobile shower commodes to undertake these routines [2,5,6], and concerns regarding the safe use these Assistive Technology (AT) devices have been raised in the literature. Zejdlik [7] observed that certain movements associated with bowel management, such as transferring, reaching for supplies, bending to access the perianal area for digital stimulation or stool removal or performing pressure relief, were potential causes of falls for adults with SCI. A recent study found movements such as inserting an enema and transferring on/off a commode or toilet were associated with concerns about falls in this population [8]. A retrospective study of medical records found 7% of fall-related fractures in adults with SCI were associated with showering [9]. The frequency and duration of toileting, bowel care and showering routines may also pose risks for skin breakdown and development of pressure ulcers [10–12]. SCI lesions above T12, or Upper Motor Neurone (UMN) lesions,

Keywords:  Assistive technology devices, bathing, bowel care, mobile shower commode, showering, spinal cord injury

Introduction Development of individualised toileting and bathing routines, including the management of neurogenic (dysfunctional) bowel, is an important aspect of rehabilitation for adults with spinal cord injury (SCI) [1–3]. Bowel management routines focus on training the bowel to evacuate “at a pre-specified time, when appropriate resources are available” [1] (p. 3). Strategies to promote effective evacuation of stools include triggering the gastro-colic reflex, abdominal massage, anal stimulation through

Correspondence: Ms Emma Friesen, PO Box 3015, Putney, NSW 2112, Australia. Tel.:+61 4 03442027. E-mail: [email protected] (Accepted June 2012)

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268  E. Friesen et al. are associated with reflexic/spastic bowels and managed primarily with alternate-day routines [2,6]. Lesions at or below T12, or Lower Motor Neurone (LMN) lesions, are associated with areflexic/flaccid bowels requiring daily or twice daily evacuation [2,6]. Internationally, studies have reported significant variations in duration of bowel care episodes, with some bowel care routines taking longer than an hour to complete [4,13–15]. Consequently, skin breakdown and development of pressure ulcers are associated with AT devices used during bowel management routines [16–18]. Despite these longstanding safety concerns, research on design and use of mobile shower commodes for adults with SCI appears limited [19]. A Clinical Practice Guideline (CPG) on neurogenic bowel management in adults with SCI, published in 1998 [2], located only three peer-reviewed studies on mobile shower commodes for this population [19–21]. A recent systematic review of strategies to address neurogenic bowel complications reported no studies on mobile shower commodes in its assessment of AT devices [3]. A review of evidence on mobile shower commodes for adults with SCI is therefore warranted.

Research and Development, Assistive Technology, Disability & Rehabilitation and Disability & Rehabilitation: Assistive Technology, RESNA conference proceedings and bibliographies of full text publications meeting the inclusion criteria. Hand searches were delimited to January 1990–April 2011 as previous literature reviews located no evidence prior to this time [2,19].

Aims

Data extraction and levels of evidence A study-specific table for data extraction, based on tables in the systematic review by Krassioukov et al. [3], was created in an Excel spreadsheet (Microsoft Corporation, 2007). Descriptive data were extracted and reported under three headings: (1) Author, year, level of evidence, study design and total cohort; (2) Methods (Participants, treatment/intervention, outcome measures); and (3) Outcomes and/or recommendations (Table II). Levels of evidence for each publication were assessed using the classification structure described in Table I, which demonstrates the rigor and strength of evidence reported in nine levels [25,26].

The aims of this exploratory review are to appraise the overall quality of evidence concerning mobile shower commodes used by adults with SCI and assess available evidence in the areas of clinical assessment, design and performance testing.

Methods Search strategy We searched for publications concerning mobile shower commodes for adults with SCI between February and April 2011. The key words [spinal cord injury OR spinal cord lesion] AND [sanichair OR sanitary chair OR shower chair OR bowel care chair OR commode] were selected based on previous reviews of toileting and continence AT devices for all populations with toileting disabilities [22], geriatric populations [23] and adults with SCI [19–21]; terminology described in “ISO 9999:2011 Assistive products for persons with disability – classification and terminology”[24]; and after discussions with experts in the New South Wales State Spinal Cord Injury Service (NSW SSCIS) and Standards Australia Committee ME-067 (Assistive Technology Products for Persons with Disability). We searched the indexes of Ovid Medline (from 1950), CINAHL (from 1982), Cochrane Library (from 1996), Joanna Briggs Institute (from 1996), OT Seeker (from 2002), Clinicaltrials.gov (from 2000), National Guidelines Clearinghouse (http://guideline. gov; no date restriction), National Institute of Clinical Studies’ Clinical Guidelines portal (http://www.clinicalguidelines.gov. au/; no date restriction) and Google Scholar (http://scholar. google.com; no date restriction). Australian and international standards were searched using SAI Global (SAI Global Limited, Sydney, Australia; no date restriction). We hand-searched the journals SCI Nursing, Spinal Cord, Journal of Rehabilitation

Inclusion and exclusion criteria No limitations were placed on the language of publication, the type of study or the type of publication. As this was an exploratory review, descriptive studies, published Standards, CPGs, research reports and abstracts from conference proceedings were all included. As the review’s focus was on mobile (movable) commodes used for toileting and showering, evidence relating to static (non-movable) commodes (such as bed-side commodes, and wheelchairs), and commodes not intended for use in a wet environment, was excluded. Evidence relating to the design of toilets, public restrooms, bathrooms and water closets was excluded, as these relate to the built environment. Evidence relating to paediatric SCI was also excluded.

Results Search and data extraction Figure 1 outlines the literature search and selection process. The initial database searches and hand searches located 1857 Table I.  Level of evidence classification structure developed by Jovell and Navarro-Rubio [26] and described by Roine et al. [27]. Level of evidence Description 1 Meta-analyses of randomised control trials (RCTs) 2 RCTs with large samples 3 RCTs with small samples 4 Prospective studies with non-randomised control groups 5 Retrospective trials with non-randomised control groups 6 Cohort studies 7 Case–control studies 8 Descriptive studies, clinical series and consensus techniques 9 Case reports and anecdotes

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Table II.  Descriptive summary of publications. Author, year; publication type; level of evidence; study design; total sample size Level 7 evidence Malassigné et al. 1993 [20]; PP; 7; Case–control study; N=64 Results also reported in: Malassigné et al., 1993 [29]; CO; 9; Case report; N = 64

Nelson el al., 1994 [21]; PP; 7; Case–control study; N = 3

Methods

Outcomes and/or recommendations

Participants: n = 39 patients with SCI, n = 25 caregivers.

1. Patients reported serious safety problems including falls and pressure ulcers. 2. ‘Severe’ design deficiencies found in all MSCs, Treatment/intervention: Three ‘commonly used’ affecting safety for transfers and transporting MSCs. (propelling), skin integrity, comfort and hand OM: Observational Ax of simulated bowel care access for bowel care & showering. routine in simulated bathroom environment; 3. Performance criteria developed or new MSC Ax of MSC design; clinical Ax questionnaire including safety in wet environments, static (no details provided). stability and hand access for showering and bowel care. Participants: n = 3 adults with SCI. 1. Pressure readings exceeded acceptable limits at sacral/coccyx & ischial tuberosities for all Treatment/intervention: Three commerciallysubjects on each chair; within acceptable limits available MSCs; IPM. over greater trochanters. OM: Pressure (mmHg) measured by Force 2. Pressure readings affected by body size, Sensing Array (FSA) system; results compared posture, chair design & seat materials. with criteria developed by Ferguson-Pell [52]; observational Ax of posture.

Level 8 evidence Nelson et al., 1993 [19]; PP, 8; Descriptive cross- Participants: n = 147 patients with SCI and 1. Typical bowel evacuation time was 2 hrs, 3 sectional study; N = 147 caregivers. times per week. 2. 54% reported never using their MSC. Treatment/intervention: NA. 3. 66% felt safety was compromised in MSC, 37% OM: Clinical Ax questionnaire including reported feeling generally unsafe in the MSC, frequency of MSC use, bowel evacuation time, 47% felt unsafe when transferring, 32% felt ease and safety of transporting (propelling) and unsafe when transporting (propelling), over transfers, skin integrity, and desired features of 35% reported falls and 24.2% reported skin MSC. integrity issues. 4. Brakes, seat cushioning and hand access for bowel care were important design features.  onsortium for Spinal Cord Medicine, 1998 C [2]; CPG; 8; Consensus opinion; N = NA

 alassigné et al., 2000 [30]; PP; 8; M Descriptive cross-sectional study; N = NR Results also reported in: Nelson et al., 2000 [31]; PP; 8; Descriptive cross-sectional study; N = NR

Malassigné et al., 2001 [34]; CO; 8; Descriptive cross-sectional study; N = NR

McIntosh et al., 2005 [35]; CPG; 8; Consensus opinion; N = NA

© 2013 Informa UK, Ltd.

Participants: NA.

1. Clinical Ax of level of SCI, cognition, bowel care routine, functional capacity, posture and Treatment/intervention: Appraisal of published reach, skin integrity and home environment evidence. should guide MSC selection[19,20]. 2. Safety straps or positioning devices to support OM: NA. seated position[21], and interventions to avoid pressure ulcers and falls related to use of AT devices[19–21], should be considered. Participants: Cohort not reported. 1. Design and performance criteria included safety during transfers, propelling, showering Treatment/intervention: Eight rigid MSC and bowel care; static stability to 20⁰; fit over prototypes. standard toilets; water and rust-proofing; rubOM: Clinical Ax questionnaire including MSC ber coated hand rims; rear-sloping seat to 4⁰; design for showering, bowel care, seating and foot lifting mechanism; underseat hand access transfers; focus groups. and appropriate seat cushioning. 2. New self-propelled and carer-propelled MSCs addressed all design and performance testing criteria. 3. Need for folding MSC identified. Participants: Cohort not reported. 1. Rigid and folding MSCs addressed all design and performance testing criteria previously Treatment/intervention: Rigid and folding MSC described[30,31]. prototypes. 2. Ongoing Ax of MSC prototypes and collaboOM: Clinical Ax questionnaire, observational ration with users, clinicians, designers and Ax and focus groups. manufacturers recommended. Participants: NA. Treatment/intervention: NA. OM: NA.

1. Clinical Ax, observational Ax and 2. IPM should guide MSC selection. 3. MSC frame and seat design should be customised to the individual user. (Countinued)

270  E. Friesen et al. Table II.  (Continued). Author, year; publication type; level of evidence; study design; total sample size Methods Spinal Outreach Team (SPOT), 2009 [36]; CPG; Participants: NA. 8; Consensus opinion; N = NA Treatment/intervention: NA. OM: NA.

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S pinal Outreach Team (SPOT), 2009 [37]; CPG; Participants: NA. 8; Consensus opinion; N = NA Treatment/intervention: NA. OM: NA.

Spinal Outreach Team (SPOT), 2009 [38]; CPG; Participants: NA 8; Consensus opinion; N = NA Treatment/intervention: NA. OM: NA. Spinal Outreach Team (SPOT), 2009 [39]; CPG; Participants: NA. 8; Consensus opinion; N = NA Treatment/intervention: NA. OM: NA. AS/NZS 3973:2009 Shower/toilet chairs (mobile Participants: NA. and static), 2009[40]; ST; 8; Consensus opinion; Treatment/intervention: Consensus opinion of N = NA authors[61]. OM: NA.

Level 9 evidence Malassigné et al., 1994 [41]; CO; 9; Case report; Participants: No cohort. N = NA Treatment/intervention: Five commerciallyavailable MSCs. OM: Static stability tested to published manual wheelchair standard[53]. Malassigné et al., 1997 [32]; CO; 9; Case report; Participants: Cohort not reported. N = NR Treatment/intervention: Eight rigid MSC protoAlso reported in: Malassigné et al., 1997 [33]; types. PR; 9; Case report; N = NR OM: Clinical Ax questionnaire, observational Ax and focus groups.

Outcomes and/or recommendations 1. Clinical Ax, observational Ax and 2. visual assessment of IPM should guide MSC selection. 3. MSC frame and seat design should be customised to the individual user. 1. MSC Ax tools available include clinical Ax questionnaire[38], observational Ax guide[36], MSC seat design guide[39]. 2. Skin integrity checks, MSC trials and multidisciplinary review recommended. 3. IPM not widely used for MSC seating Ax but may be useful for biofeedback. 1. 41-item questionnaire developed for clinical Ax, observational Ax and MSC design Ax. 2. Seven seat design templates reported[45–51]. 1. MSC seat design guide describing commercially-available MSC seats & seat toppers developed. 1. Performance criteria specified for brakes, arm supports, back supports, foot supports and castors; static stability to 10⁰; fit over standard toilets; water and rust-proofing; and rear-sloping seat to between 2⁰ and 6⁰; and waterproof and flexible seat cushioning. 2. Test methods specified for parking brakes, strength, stability, and durability. 3. Requirements for labelling and reporting of test results specified. 1. MSCs differed significantly in overall tippiness (stability). 2. Type of loading (human or dummy) was not significant. 3. 20 degree tip angle recommended.

1. Design of new rigid MSC addressed problems with existing MSCs. 2. Ongoing Ax of MSC prototypes and collaboration with users, clinicians, designers and manufacturers recommended. 3. Performance testing of static stability to published manual wheelchair standard[56] planned. Malassigné et al., 2002 [42]; CO; 9; Case report; Participants: n = 30 patients and caregivers. 1. Design features of folding MSC addressed N = 30 problems with existing MSCs. 2. Patients reported the folding MSC was comResults also reported in: Malassigné et al., 2003 Treatment/intervention: Folding MSC protofortable, fit in shower stalls and over toilets, [43]; CO; 9; Case report; N = NR type. was stable during transfers and propelling and OM: Clinical Ax questionnaire and focus useful for travel. groups assessing design of MSC for showering, 3. Ongoing Ax of MSC prototypes and collabobowel care, seating and transfers. ration with users, clinicians, designers and manufacturers recommended. Malassigné et al., 2002 [44]; PR; 9; Case report; Participants: NR 1. Design features of rigid and folding MSCs adN = NR dressed problems with existing MSCs. Treatment/intervention: Rigid and folding MSC prototypes. OM: Clinical Ax questionnaire, observational Ax and focus groups. Publications are grouped by level of evidence followed by year of publication. Publications reporting the same data are grouped together. Publication type: PP, peer-reviewed paper; CO, conference paper; PR, project report; CPG, clinical practice guideline; ST, published Standard. Ax, assessment; IPM, interface pressure mapping; MSC, mobile shower commode; NA, not applicable; NR, not reported; OM, outcome measures.

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[2,19,20,30,31,35–38], assessing functional capacity to undertake bowel care [2,19,20,29,35–38], reviewing postural stability and reach for bowel care and intimate hygiene [2,35–38], cleaning the feet and back of legs [30,31], and cleaning under the arms [35], reviewing transfers on and off mobile shower commodes [2,19,35,36,38], assessing pressure sores and skin integrity [2,19–21,29,35–39,45–48], and establishing client and caregiver goals [2,35–38]. One CPG [36] recommended assessing seat shapes using palpation and visual inspection of a patient’s bony prominences within the seat aperture.

Figure 1.  Flowchart showing the process of identifying and screening publications for inclusion in review.

publications, with two requiring translation into English prior to review [27,28]. Of these, 139 were duplicates leaving 1718 publications for screening. After applying the exclusion criteria, 60 publications were retrieved full text and screened. A further 40 met the exclusion criteria leaving 20 publications for inclusion in this review (Table II). Data were then extracted into the study-specific descriptive table described earlier (Table II). One conference paper [29] and one Level 7 study [20] reported the same data and were grouped together. Similarly, two peer-reviewed papers at Level 8 [30,31] were grouped together, as were a conference paper [32] and a project report [33] at Level 9 (Table II).

Levels of evidence Using the classification structure described in Table I, we determined that evidence in two case–control studies [20,21] met the requirements of Level 7 (Table II). Evidence at Level 8, developed through descriptive studies or consensus techniques, was present in three peer-reviewed papers [19,30,31], one conference paper [34], all CPGs [2,35–39] and one published Standard [40], although the majority [35–40] provided no supporting research or evidence of psychometric testing (Table II). Five conference papers [29,32,41–43] and two project reports [33,44] were considered case reports and anecdotes and classified at Level 9. No randomised control trials, or systematic reviews of such trials, were located. Based on the classifications structure described in Table I, the overall strength of evidence for clinical assessment, design and performance of mobile shower commodes for adults with SCI was found to be “fair to poor”[26], with case–control studies the highest levels of evidence located (Table II). Clinical assessment of mobile shower commodes All peer-reviewed papers [19–21,30,31] and all CPGs [2,35–39] described clinical assessments of bowel management and intimate hygiene activities involving mobile shower commodes. Components of clinical assessments Major components of the clinical assessment identified included reviewing current bowel care routines © 2013 Informa UK, Ltd.

Clinical assessment tools Questionnaires [19,20,29–31,36–38,42], observational assessments in dry or simulated bathroom environments [20,29,36–38,42] and interface pressure mapping (IPM) [21,35,36] were the most common clinical assessment methods cited (Table II). Five CPGs recommended observational assessment in the client’s home environment [2,35-38], and four recommended assessing alternative environments for when the patient was travelling [35–38]. Design of mobile shower commode frames and seats All literature included in this review commented specifically on design features or specifications for the frame, seat or both (Table II). All literature addressed design issues affecting use of mobile shower commodes for bowel management and showering, and most considered design issues affecting propelling and manoeuvring, and transfers. Four studies [19–21,29] and all CPGs [2,35-39] selected mobile shower commode features based on the user’s size, function, level of injury and interactions between the user and caregiver. Frame design Important frame design features included cutouts to allow access to the perianal area [20,29–36,38,42–44], designs allowing access to the body for cleaning [20,29–33,35,36,38], frame shape to fit over a toilet [20,29–34,36,38,40,42–44], effective parking brakes [20,30–34,36,40,42,44], arm supports for hooking, leaning or repositioning [20,29–32,34– 36,38,40,42–44], arms supports that could be removed or moved for transfers [20,29–32,34,36,40,42–44], pushrims for use in wet or slippery environments [20,29–34,42,44], safety straps and positioning supports [2,20,21,29,35,36,40], rust- or water-proofing [20,29–34,40,42,44], folding frames to facilitate storage and transport [20,30,31,34–36,40,42– 44], backward-sloping seat angles to facilitate positioning [30,31,34,35,40,42,44], static stability [20,29–34,40,41,44] and stability and safety during transferring, propelling and washing extremities [20,29–32,34–36,38,40,42–44]. Four publications described a new foot lifting mechanism designed to facilitate cleaning the feet [30,31,33,34]. Seat design Seat designs featured cutouts [20,29–36,38,39,42,44] or full openings [35,38,39] to facilitate underseat access to the perianal area. Seat shapes were designed to maximise seating surface area [2,30,31,34,35,39], distribute pressure through the thighs and greater trochanters (GTs) [2,30–35,39] and allow

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the ischial tuberosities (ITs) to ‘float’ [35] (p. 20) or position within the aperture of the seat [39]. One CPG [38] provided seven seat design templates for custom-made seats [45–51] although cited no evidence underpinning the recommendations. Considerations for seat materials and construction included adequate cushioning [2,30–35,39], no seams or joins on the inner edge of the aperture [2,30–35,39] and flexible upholstery [35,36,39,40]. One study [21] reported assessing seat designs and cushioning materials using quantitative IPM criteria developed for assessing wheelchair seating [52] (Table II). Two CPGs [35,36] described IPM as a clinical assessment tool used by expert clinicians as part of a comprehensive assessment.

Performance testing of mobile shower commode frames and seats Performance tests, or criteria to which performance could be objectively tested, were reported for backward-sloping seat angles [31–35,40–42], capacity to fit over a toilet [30– 33,36,38,40,42,44], locking arm supports [30-33,40,42,44], removable or movable arm supports [30–33,40,42,44] and parking brakes [30–33,40,42,44]. Performance tests for static stability were reported in the published Standard [40] and three studies [32,33,41], although the studies used a test method designed for manual wheelchairs [53].

Discussion Clinical assessment of mobile shower commodes The review found a paucity of high-quality research around clinical assessment of mobile shower commodes for adults with SCI. Publications were generally consistent in describing components of clinical assessments for bowel care and intimate hygiene [2,19,20,29,35–38], functional capacity [2,19,20,29,35–38] and skin integrity [2,19–21,29,35–39,45– 48], but less clear on clinical assessments of bathing, showering and cleaning extremities of the body. Similar problems exist in the broader bathing literature, where there is little consensus on processes and tasks involved [54] and a lack of evidence to guide clinical practice [55]. Clinical assessment methods such as observation in the client’s home [35–38], observation in a simulated dry or wet environment [20,29,36–38] and questionnaires [19,20,29–31,36,38,42], are consistent with clinical assessment methods described in studies of bathing disabilities in other populations[55]. Methodological quality was reduced in the case–control and cohort studies [19– 21,29] as none referenced existing validated tools for activities of daily living in the design of questionnaires and surveys [56,57]. Although comprehensive, the clinical assessment tools reviewed [36–38] reported no psychometric testing. A lack of standardised or validated clinical assessment tools is noted across both the bathing literature [55] and literature on assessment and selection of AT [58,59]. This area needs further development. Recent work on AT selection frameworks [59,60] could provide a basis for identifying factors affecting the assessment and selection of mobile shower commodes used by adults with SCI across all environments of use.

Design and performance testing of mobile shower commodes Five studies in this review [19–21,30,31] showed that design features of mobile shower commodes affected a user’s function and safety during transferring, propelling (transporting), bowel care and showering. The mobile shower commodes designs developed through these studies addressed these issues [30,34,42,43], however were not described in recent CPGs [35,36,39] and may not be widely implemented. Findings from this review strongly indicate a need for studies exploring interactions between an adult with SCI, their mobile shower commode, and the physical environment to establish if the design, safety and performance issues identified in studies [19–21,30,31] and CPGs [2,35-39] still exist. This work would inform development of performance testing criteria specifically for mobile shower commodes used by adults with SCI, using test methods in the existing published Standard [40] to ensure consistency in testing and reporting of test results [61]. Finally, recent literature has failed to show a causal relationship between numerical data gained through quantitative IPM and the development of pressure ulcers [62]. IPM provides information on vertical pressure on the seating surface and no information on “forces on the skin, inside the aperture, posture, transfers or function” [36] (p. 1). Quantitative IPM is therefore no longer encouraged as part of a quantitative performance assessment [35,36,63]. Limitations of search and levels of evidence This exploratory review used a comprehensive and transparent search strategy comprising database and hand searches. We anticipated finding little peer-reviewed evidence and therefore placed no limitations on the language or type of study. We included descriptive methodologies such as observation, interviews and surveys, and grey literature [56] in order to synthesise and disseminate ‘best available’ research and current perspectives on clinical practice [64]. This approach is suggested as part of Evidence-Based Rehabilitation (EBR) and Evidence-Based Clinical Practice (EBCP) [64]. We acknowledge relevant literature may have been inadvertently missed, particularly grey literature residing in websites or forums that are not readily accessible [64].

Conclusions As expected, there was no recent, high-level evidence regarding clinical assessment, design and performance testing of mobile shower commodes for adults with SCI. The highest levels of evidence found were case–control studies, followed by descriptive studies, CPGs based on clinical consensus techniques and published Standards and were therefore of low methodological quality. Research is needed to understand how adults with SCI use their mobile shower commodes across functional activities such as transfers, propelling, bowel management and showering. Validated or standardised tools for clinical assessment are also needed. Together, these measures would do much to improve the evidence base underpinning

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Declaration of interest The authors report no conflict of interest.

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Disability and Rehabilitation: Assistive Technology

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