Development of Surface Roughness Standards for Pathways Used by Wheelchair Users: Final Report

APPENDIX A

QUESTIONNAIRE—ROUGHNESS VIBRATION STUDY

Instructions: For the following questions, please check your answer or fill in the blanks.

GENERAL INFORMATION
Test Date: ____ / ____ / ____
Age: _______

Gender:

[  ]Male
[  ] Female

Weight (lbs) ________
Height ________

Race/Ethnicity:

[  ] Black or African American ? American Indian or Alaskan Native
[  ] Asian ? Native Hawaiian or other Pacific Islander
[  ] White or Caucasian ? Two or more races
[  ] Hispanic or Latino

ACTIVITY
1. Are you able to walk? (check one answer)
[  ] No
[  ] Yes

1a. How far are you able to walk at one time? (Check one answer)
 1[  ] I can walk around the house
 2[  ] I can walk about one block
 3[  ] I can walk about two blocks
 4[  ] I can walk more than two blocks

1b. Is your wheelchair only for outdoor use? (Check one answer)
1[  ] No
2[  ] Yes

2. How many hours per day do you spend in a wheelchair? (Check one answer)
[  ] up to 1 hour per day
[  ] 6-12 hours per day
[  ] 1-2 hours per day
[  ] 12-24 hours per day
[  ] 3-5 hours per day

3. Please indicate the average amount of time you spend per day actually moving your wheelchair: (Propelling a manual chair or driving a power chair) (Check one answer)
[  ] 10-30 minutes per day
[  ] 1-2 hours per day
[  ] 30-60 minutes per day
[  ] other (please specify): __________________

4. In an average day, how many minutes or hours do you spend engaged in the following activities? (Responses may overlap: for example, if you spend 8 hours per day working on a computer at a desk, you would enter “8 hours” for “Working at a desk,” “Working at a computer,” and “Working with hands.” If you do not engage in any of these activities, enter “0” for both minutes and hours.)

Working at a desk: ________minutes OR ________hours
Working at a computer: ________minutes OR ________hours
Working with arms overhead: ________minutes OR ________hours
Working with hands: ________minutes OR ________hours
Driving (automobile): ________minutes OR ________hours
Reading: ________minutes OR ________hours

5. Please indicate the average number of transfers you do per day, from one place to another: (Example: Transferring from your wheelchair to the toilet and back again would be counted as 2 transfers)
 ________ transfers per day

6. On average, how many days a week do you leave your home in your wheelchair?

[  ] 1 day
[  ] 2 days
[  ] 3 days
[  ] 4 days
[  ] 5 days
[  ] 6 days
[  ] 7 days

7. On average, how far do you travel in your wheelchair per day?

[  ] <300 feet (1 block, 90 meters)
[  ] 300 to 3000 feet (1-10 blocks, 90-1000 meters)
[  ] 3000 to 5000 feet (10-17 blocks, 1000-1600 meters)
[  ] 5000 to 10,000 feet (1-2 miles, 1.5 to 3 km)
[  ] 10,000-25,000 feet (2-5 miles, 7.5 km)
[  ] Greater than 25,000 feet (5 miles, 7.5 km)

8. How satisfied are you with the pathways you typically travel on?

[  ] Very Unsatisfied
[  ] Somewhat Unsatisfied
[  ] Neutral
[  ] Somewhat Satisfied
[  ] Very Satisfied
[  ] No Answer

9. What is your biggest complaint with the pathways you typically travel on?

None   Roughness   Cross slope   Steepness   Damaged/Warped

10. What surfaces do you typically travel on during a normal day (Indicate Percent of Day)?

Indoor/Smooth _________________
Outdoor Concrete_______________
Outdoor Brick __________________
Outdoor Gravel/Sand __________ __
Other (please list surface type and percentage) _____________;____________

11. How difficult is it to propel or drive over these surfaces?

Indoor/Smooth          Very     Slightly   Not at all     No Answer
Outdoor Concrete      Very      Slightly   Not at all     No Answer
Outdoor Brick            Very      Slightly   Not at all    No Answer
Outdoor Gravel/Sand Very      Slightly   Not at all     No Answer
Other____________  Very      Slightly   Not at all    No Answer

WHEELCHAIR

1. What date did you start using a wheelchair? ______________________

2. Make (brand) of your primary wheelchair
[  ] Action/Invacare
[  ] Everest & Jennings
[  ] Guardian
[  ] Kuschall
[  ] Otto Bock
[  ] Colors
[  ] Permobil
[  ] Pride
[  ] Halls Wheels
[  ] Sunrise/Quickie
[  ] TiLite
[  ] Top End
[  ] Breezy
[  ] Evermed
[  ] Other: ________________

3. Model of your primary wheelchair: ____________________________________________
 (if unsure, please look for a label on your wheelchair):

4. Wheelchair frame type: [  ] Folding  [  ] Rigid

5. Does your wheelchair have shock absorbers in the frame?  [  ] Yes [  ] No

6. Does your wheelchair have shock absorbers in the casters? [  ] Yes [  ] No

MEDICAL HISTORY

1. What was the condition that caused you to use a wheelchair? (Check one answer)
 Date of injury or diagnosis: __________________
 [  ] spinal cord injury (SCI)/paraplegia  [  ] SCI/quadriplegia
Level of injury (e.g. T2, C4-6): _____________________
Is your injury:
[  ] Complete
[  ] Incomplete
[  ] upper extremity amputation
[  ] lower extremity amputation
[  ] spina bifida
[  ] brain injury
[  ] muscular dystrophy
[  ] stroke
[  ] arthritis
[  ] cerebral palsy
[  ] post-polio syndrome
[  ] multiple sclerosis
[  ] cardiopulmonary disease
[  ] other (please list): __________________________________________

2. Please indicate whether or not you have any of the following conditions: (Check all that apply)
[  ] arthritis (rheumatoid)
[  ] diabetes
[  ] liver disease
[  ] asthma
[  ] heart disease
[  ] depression
[  ] cancer
[  ] kidney problems
[  ] high blood pressure
[  ] circulation problems
[  ] thyroid
[  ] none of the above
[  ] other conditions (please list): ________________________________________________________
_____________________________________________________________________________________

3. Have you ever been diagnosed with any of the following conditions? (Check all that apply)
[  ] curvature of the spine (e.g., scoliosis)
[  ] myofascial pain syndrome
[  ] vertebral fracture
[  ] fibromyalgia
[  ] pinched nerve in neck
[  ] none of the above

4. For neck or back pain, are you currently taking any of the following types of medications? (If you check “yes,” please fill out the medication information in the space provided)
 4a. Anti-inflammatory (e.g., Motrin, Advil, aspirin, Celebrex):
      [  ] No
      [  ] Yes

Medication                          Dose              Frequency
_____________________ ____________ ____________________
_____________________ ____________ ___________________
_____________________ ____________ ___________________

4b. Analgesic/Pain medication (e.g., Tylenol, Darvocet):
     [  ] No
     [  ] Yes

Medication                          Dose              Frequency
_____________________ ____________ ____________________
_____________________ ____________ ___________________
_____________________ ____________ ___________________

5. Have you had any surgeries on your neck or back? (If you check “yes,” please list the surgeries and dates in the space provided)
    [  ]  No
    [  ]  Yes

Surgery or Site                                            Date (mo/yr)
_____________________________________ ____/____
_____________________________________ ____/____
_____________________________________ ____/____
_____________________________________ ____/____
_____________________________________ ____/____
_____________________________________ ____/____

NECK/UPPER BACK PAIN

1. Have you had any neck/upper back pain… (Check one answer for each of the following questions)

   1a. …since 1 year after the onset of the condition that caused you to use a wheelchair?
      [  ] No
      [  ] Yes
   1b. …within the past month?
      [  ] No
      [  ] Yes
   1c. …within the past 24 hours?
      [  ] No
      [  ] Yes

If your answer is “NO” to ALL OF THE ABOVE QUESTIONS (1a-1c), you are finished with the questionnaire. Thank you very much for your assistance.
If you answered “YES” to any of the above questions, please complete the following sections describing your neck and upper back pain:

2. Did you to see a physician about the neck/upper back pain? (Check one answer)
[  ] No
[  ] Yes

2a. How many total doctor visits have you made concerning your pain?
________total doctor visits

3. Did the neck/upper back pain cause you to limit your daily activities? (Check one answer)
[  ] No
[  ] Yes

3a. For how long? ________________________________________________

4. Please use the three scales below to rate your neck/upper back pain over the past 24 hours. Draw a line at the point along the scale that best describes your pain. Use the upper line to describe your pain level right now. Use the other scales to rate your pain at its worst and best over the past 24 hours.

Example:
No pain |_____________________________________________________| Worst pain imaginable

4a. Right now
No pain |_____________________________________________________| Worst pain imaginable

4b. Worst in past 24 hours
No pain |_____________________________________________________| Worst pain imaginable

4c. Best in past 24 hours
No pain |_____________________________________________________| Worst pain imaginable

5. Read the following adjectives, and if that word is one you would use to describe the neck/upper back pain you have had during the past month, rate the intensity of that particular quality of your pain. If you have not experienced pain in the past month, enter “0” for that adjective.
(Please rate each of the following adjectives)

0 - None 1- Mild 2 - Moderate 3 – Severe
___ throbbing ___ heavy ___ stabbing
___ shooting ___ sore ___ tender
___ sharp ___ splitting ___ cramping
___ tiring/exhausting ___ gnawing ___ sickening
___ hot/burning ___ fearful ___ aching
___ punishing/cruel ___ tingling/pins and needles

6. Please indicate which of the following best describe the nature of the neck/upper back pain you have experienced during the past month:

6a. How long, on average, does an episode of pain last? (Check one answer)
[  ] Less than 10 minutes
[  ] Greater than 60 minutes
[  ] 10 to 60 minutes
[  ] The pain is constant

6b. How does the pain behave throughout the day? (Check one answer)
[  ] Constant throughout the day
[  ] Intermittent (on and off) throughout the day

6c. Is there a time during the day when the pain is worse? (Check one answer)
[  ] No
[  ] Yes

6c.1 When is the pain at its worst during the day? (Check one answer)
[  ] Worst in the morning
[  ] Worst following physical exertion
[  ] Worst in the evening

 

7. What activities or actions bring on the neck/upper back pain? __________________________

_____________________________________________________________________________

 

8. Once you have the pain, what activities or actions make the pain worse? _________________
_____________________________________________________________________________

 

9. What relieves the neck/upper back pain? _____________________________________
_______________________________________________________________________

10. Does your neck/upper back pain radiate (spread) to other parts of your body?
(Check one answer)
[  ] No
[  ] Yes

10a. Where?

11. Does your neck/upper back hurt while you are propelling your wheelchair?
(Check one answer)
[  ] No
[  ] Yes

12. Do you experience numbness of the arms with your neck/upper back pain?
(Check one answer)
[  ] No
[  ] Yes

13. Do you experience weakness of the arms with your neck/upper back pain? (Check one answer)
[  ] No
[  ] Yes

14. Did you have neck/upper back pain before you started using a wheelchair? (Check one answer)
[  ] No
[  ] Yes

14a. Do you think the pain is worse now that you are in a wheelchair?
(Check one answer)
[  ] No
[  ] Yes

15. The following questions are designed to give information as to how your neck/upper back pain has affected your ability to manage in everyday life. Please READ ALL ANSWERS in each section before marking the ONE answer that best applies to you.

Section 1—Pain Intensity
[  ] I have no pain at the moment
[  ] The pain is very mild at the moment
[  ] The pain is moderate at the moment
[  ] The pain is fairly severe at the moment
[  ] The pain is the worst imaginable at the moment

Section 2—Personal Care
[  ] I can look after myself normally without causing extra pain
[  ] I can look after myself normally but it causes extra pain
[  ] It is painful to look after myself and I am slow and careful
[  ] I need some help but manage most of my personal care
[  ] I need help every day in most aspects of health care
[  ] I do not get dressed, I wash with difficulty, and stay in bed

Section 3—Lifting
[  ] I can lift heavy weights without extra pain
[  ] I can lift heavy weights but it causes extra pain
[  ] Pain prevents me lifting heavy weights off the floor, but I can manage if they are conveniently positioned, e.g., on a table
[  ] Pain prevents me lifting heavy weights but I can manage light to medium weights if they are conveniently positioned
[  ] I can only lift very light weights
[  ] I cannot lift or carry anything at all
[  ] Pain does not limit my ability to lift or carry; however, my disability does

Section 4—Reading
[  ] I can read as much as I want to with no pain in my neck
[  ] I can read as much as I want to with slight pain in my neck
[  ] I can read as much as I want with moderate pain in my neck
[  ] I cannot read as much as I want because of moderate pain in my neck
[  ] I can hardly read at all because of severe pain in my neck
[  ] I cannot read at all

Section 5—Headaches
[  ] I have no headaches at all
[  ] I have slight headaches which come infrequently
[  ] I have moderate headaches which come infrequently
[  ] I have moderate headaches which come frequently
[  ] I have severe headaches which come frequently
[  ] I have headaches all the time

Section 6—Concentration
[  ] I can concentrate fully when I want to with no difficulty
[  ] I can concentrate fully when I want to with slight difficulty
[  ] I have a fair degree of difficulty in concentrating when I want to
[  ] I have a lot of difficulty in concentrating when I want to
[  ] I have a great deal of difficulty in concentrating when I want to
[  ] I cannot concentrate at all

Section 7—Work (not only for pay; includes volunteer work, household work, etc.)
[  ] I can do as much work as I want to
[  ] I can only do my usual work, but no more
[  ] I can do most of my usual work, but no more
[  ] I cannot do my usual work
[  ] I can hardly do any work at all
[  ] I cannot do any work at all

Section 8—Driving
[  ] I can drive my car without any neck pain
[  ] I can drive my car as long as I want with slight pain in my neck
[  ] I can drive my car as long as I want with moderate pain in my neck
[  ] I cannot drive my car as long as I want because of moderate pain in my neck
[  ] I can hardly drive at all because of severe pain in my neck
[  ] I cannot drive my car at all
[  ] Pain does not limit my ability to drive; however, my disability does

Section 9—Sleeping
[  ] I have no trouble sleeping
[  ] My sleep is slightly disturbed (less than 1 hour sleepless)
[  ] My sleep is mildly disturbed (1-2 hours sleepless)
[  ] My sleep is moderately disturbed (2-3 Hours sleepless)
[  ] My sleep is greatly disturbed (3-5 hours sleepless)
[  ] My sleep is completely disturbed (5-7 hours sleepless)

Section 10—Recreation
[  ] I am able to engage in all my recreation activities with no neck pain at all
[  ] I am able to engage in all my recreation activities, with some pain in my neck
[  ] I am able to engage in most, but not all of my usual recreation activities because of pain in my neck
[  ] I am able to engage in a few of my usual recreation activities because of pain in my neck
[  ] I can hardly do any recreation activities because of pain in my neck
[  ] I cannot do any recreation activities at all

Thank you very much for your assistance in completing this questionnaire.

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