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## Complete Summary

#### GUIDELINE TITLE

Wheelchair biking for the treatment of depression.

#### BIBLIOGRAPHIC SOURCE(S)

Wheelchair biking for the treatment of depression. Iowa City (IA):
University of Iowa Gerontological Nursing Interventions Research Center,
Research Dissemination Core; 2003 Feb. 53 p. \[86 references\]

#### GUIDELINE STATUS

This is the current release of the guideline.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Depression

#### GUIDELINE CATEGORY

Evaluation\
Management\
Risk Assessment\
Treatment

#### CLINICAL SPECIALTY

Geriatrics\
Nursing\
Psychiatry

#### INTENDED USERS

Advanced Practice Nurses\
Health Care Providers\
Nurses\
Physicians

#### GUIDELINE OBJECTIVE(S)

-   To describe a specific recreation therapy program, wheelchair
    biking, for the treatment of depression in older adults, with and
    without cognitive impairments

-   To reduce depressive mood in older adults and to provide a
    complementary or alternative treatment to medications

#### TARGET POPULATION

Older adults in long-term care facilities who are depressed or at risk
for depression

#### INTERVENTIONS AND PRACTICES CONSIDERED

1.  Use of assessment criteria in the selection of clients for the
    wheelchair biking program through use of Geriatric Depression Scale
    (short or long form) or Cornell Scale for Depression in Dementia

2.  Assessment of resident´s ability to participate safely in wheelchair
    biking program

3.  Training of staff and implementation of wheelchair biking (Duet™
    Tandem Wheelchair Bicycle) program

#### MAJOR OUTCOMES CONSIDERED

Risk of undiagnosed/untreated depression

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Hand-searches of Published Literature (Primary Sources)\
Hand-searches of Published Literature (Secondary Sources)\
Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

Searches of Medline were performed using the following keywords: biking
and older adults; depression and geriatrics; depression and nursing
homes; depression and nursing homes and psychosocial.

#### NUMBER OF SOURCE DOCUMENTS

43

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

The grading schema used to make recommendations in this evidence-based
practice protocol is:

A.  Evidence from well-designed meta-analysis.

B.  Evidence from well-designed controlled trials, both randomized and
    nonrandomized, with results that consistently support a specific
    action (e.g., assessment, intervention or treatment).

C.  Evidence from observational studies (e.g., correlational,
    descriptive studies) or controlled trials with inconsistent results.

D.  Evidence from expert opinion or multiple case reports.

#### METHODS USED TO ANALYZE THE EVIDENCE

Review of Published Meta-Analyses\
Systematic Review

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Not stated

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Not stated

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

External Peer Review\
Internal Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Reviewed by series editor Marita G. Titler, PhD, RN, FAAN and expert
reviewers David R. Austin, PhD, Professor, Department of Recreation and
Park Administration, Indiana University, Bloomington, Indiana, and
Judith E. Voelkl, PhD, CTRS, Associate Professor, Department of Parks,
Recreation and Tourism Management, Clemson University, Clemson, South
Carolina

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

The grades of evidence (A-D) are defined at the end of the Major
Recommendations.

**Assessment Criteria**

The Wheelchair Biking program is indicated for older adults with mild to
moderate depression, with or without cognitive impairments. Clients
should be selected for screening based on a diagnosis or history of
depression, use of an antidepressant medication without a depression
diagnosis, or signs and symptoms of depression noticed by staff, family
or friends (Fitzsimmons, 2001. Evidence Grade = B). Frequently
depression in the elderly has atypical presentation and thus is not
diagnosed and therefore not treated and not in their medical records
(Devanand et al., 1994). Signs of depression include sadness, weepiness,
apathy, passivity, sleep disturbance, agitation, anxiety, decreased
socialization, decreased verbalization, weight loss, mobility problems
and frequent unspecific somatic complaints. (U.S. Dept. of Health, 1999)
(For further information, see the Evidence-Based Protocol: Detection of
Depression in the Cognitively Intact Older Adult, by Piven, 1998).
Depression is common in the elderly, but unless a mood assessment is
performed, the diagnosis may be missed. Although mood assessment can be
performed upon admission to a residential setting home, many patients
may need time to adjust to their new surroundings. Allow one to two
weeks to adjust to the new environment before screening for depression.
Several formal assessment tools (listed below) are available to assess
patients with depression. These tools and their descriptions can be
found in Appendix A of the original guideline document.

-   Geriatric Depression Scale - Short Form (Sheikh & Yesavage, 1986)

-   Geriatric Depression Scale - Long Form (Yesavage et al., 1983)

-   Cornell Scale for Depression in Dementia (Alexopoulos et al., 1988)

**Assessment Tools**

Keep in mind there are few older adults that cannot participate in the
Wheelchair Biking program. After identifying residents with depression
the next step is to determine if the resident is able to safely
participate (See Appendix B in the guideline: Wheelchair Biking Resident
Selection Checklist) and if the resident has an interest in
participating. As it is difficult to describe the wheelchair bike, it is
best to show the bike to the resident and ask them if they would like to
take a ride on it sometime. If they are uncertain, ask them if they
would like to watch others riding. Residents that CAN participate
include those with and without dementia, those requiring assistance to
transfer or a Hoyer lift to transfer, individuals with urinary drainage
devices, portable oxygen and portable tube feedings (Fitzsimmons, 2001.
Evidence Grade = B). Residents that CANNOT participate are individuals
who have postural or other conditions, such as a decubitus ulcer, that
prohibit them from sitting upright, those with extreme, unpredictable
behaviors, and those with acute illnesses. If you are uncertain, ask the
patient´s physician or nurse practitioner.

A sample physician order for the therapy would be:\
Recreational Therapy: Wheelchair biking every day X 2 weeks for
depressive symptoms

**Description of the Practice**

This program uses a specialized piece of therapy equipment called the
Duet wheelchair bike. The Duet™ wheelchair bike is an innovative
intervention as it can be used with the majority of nursing home
residents (see Figure 1 in the guideline document). This psychosocial
treatment links two familiar items\--a wheelchair and a bike, using the
Duet™ wheelchair bicycle. The bike consists of a rugged wheelchair which
attaches to a half a bicycle, and which is unusable on its own. The
specially designed chair, orthopedically shaped from fiberglass,
reinforced plastic, has padding and adjustable foot and headrest. When
fixed to the cycle the chair tilts back, lifting the small front guide
wheels off the floor. This gives a relaxed, stable seating position and
makes conversation between resident and rider easier. The chair has good
suspension and light handling, and it\'s off road tires are excellent on
gravel and dirt tracks. There are twin drum brakes on the chair\'s
wheel, and a back-pedal brake on the cycle wheel. Standard on the bike
is a three-speed hub gear allowing easier pedaling up inclines. The bike
comes with many additional safety features including a chest harness
seat belt and wheel-spoke covers. This system enables residents, at all
levels of functioning, especially those individuals with severe
disabilities, to ride in the wheelchair while the therapist pedals and
steers from the back. This provides the older adult with an opportunity
to enjoy extended mobility and a sense of freedom, an opportunity to be
outdoors, to feel the wind and the sun, to socialize with others, and to
bring back familiar childhood memories. The therapy biking program
combines the approaches of small group socialization, reminiscing, and
exercise therapies without the required mobility or advanced cognitive
skills thereby making this treatment available to a wide range of older
adults.

The cost of a Duet™ wheelchair bike and helmets is under \$4000. The
Duet™ is very well built and should last indefinitely and has the
advantage that it can be used by persons other than facility staff
members. It is an ideal intervention for family members to use as they
are often at a loss of what to do while visiting. Facility staff members
who use the bike enjoy riding residents and have commented that it makes
the residents less depressed (Fitzsimmons, 2001). It provides the staff
members with something meaningful and \"fun\" to do with their residents
besides the daily bathing, dressing, feeding and toileting.

**Steps to Take to Set Up a Wheelchair Biking Program**

Step 1: Determine the feasibility of a biking program. Is there safe
space to ride outdoors? Minor hills are not a problem but a paved area
with little traffic is important. A large facility with wide halls and
good turn-around spots can also use the bike indoors. If there is an
interest in this program by facility management, staff, residents and
family members, all disciplines, family members and even volunteers can
be taught how to assist with the program.

Step 2: Determine who will be responsible for training the riders, as no
one should ride a resident without understanding all functions of the
bike. Make certain that everyone who is to ride residents is properly
trained and rides another staff member **before** riding any residents
(see Appendix C: **Wheelchair Bike Staff and Volunteer Training**, and
Appendix D: **Wheelchair Biking Training Record** in the guideline
document). Although the bike is easy to pedal, the steering is different
from a conventional bicycle and takes some practice.

Step 3: Determine a safe bike route or course. This will be specific to
your location but try to include areas of interest on your campus such
as a pond or gardens. Consider having walkie-talkies available, one for
the bike rider and one to remain with a staff member in the facility.
Or, use a cellular telephone. Have sunglasses available for residents on
bright days. Other items you may want to have is a squeeze-type horn for
your resident to use, bread to throw to fish, nuts for the squirrels
along the way, and binoculars. Taking pictures of the resident on the
bike allows residents to show their friends and family when they visit.

Step 4: Other things to consider include: 1) set up a designated space
to house the bike when not in use, and 2) select a maintenance crew for
minor repairs, and tire inflation (They also make wonderful bike
peddlers).

Step 5: Ordering the equipment: The Duet™ Tandem Wheelchair Bicycle is
made in Germany and distributed in the United States by:

Frank Mobility Systems, Inc.\
1003 International Drive\
Oakdale, PA 15071\
Toll Free (888) 426-8581\
Phone (724) 695-7822\
Fax (724) 695-3710\
Email info@frankmobility.com\
http://www.frankmobility.com

The basic model bike, called the economy Duet™, has 3 speeds and is
adequate for most settings. Optional equipment recommendations are based
on past equipment used in research with older adults and is recommended
for safety purposes (Benson & Tatham, 2002; Fitzsimmons, 2001;
Fitzsimmons & Buettner, 2002). Contact authors for assistance and advise
on purchasing the Duet. The recommended optional equipment includes:

-   An adjustable headrest: which is helpful for patients with poor neck
    control.

-   Swing away brackets for the footrest: making transferring on and off
    easier and safer.

-   \"H\" style harness: which is helpful for patients who are
    post-stroke or have difficulty maintaining an upright position. The
    bike does come with a seatbelt that is adequate for most riders.

-   Wheelchair spoke protectors: these prevent hands and fingers from
    injury from the wheelchair spokes when riding.

**The Program**

Optimal effectiveness is achieved by implementing the intervention for a
two-week period, five days per week (Fitzsimmons, 2001; Fitzsimmons &
Buettner, 2002). As it is not feasible to provide recreational therapy
indefinitely to an individual resident, this two week intensive is
followed by a maintenance period where the patient rides 2 days per week
and encouraged to attend other facility activities the remaining days of
the week. This one-hour program is designed for groups of three to five
participants for each session and has two components (see Appendix E:
**Therapy Biking Protocol for Older Adults in Residential Settings** in
the guideline document). The residents should be grouped based on
similar cognitive functioning levels with consideration given to the
personalities of the individual residents. For example, you may not want
to place two residents in the same group that have a known dislike for
each other. Consideration must also be given to the physical functioning
levels of the participants. For example, you may not wish to include, in
the same group, four residents that require lifting devices to transfer
to the wheelchair bike, unless you have the staff end equipment
available during your program time to complete all of the transfers.
Once the group is assembled the first rider is assisted into the
wheelchair portion of the bike. The rest of the group sits with a second
staff member and discusses biking and other activities from the past.
One-by-one each rider is encouraged to put his or her safety helmet and
H-harness on independently and take a ride. When he or she returns to
the group a discussion is held about things seen during the ride. Ask
the participant how he or she enjoyed his or her ride and record it on
their ride record (see Appendix F: **Wheelchair Biking Ride Record** in
the guideline document). This continues until all participants have had
the opportunity to ride. This daily intervention may be best viewed as
an intense two-week therapy period with the objective of initiating a
change in symptoms of depression. It is then followed up with a
maintenance biking therapy period of eight to ten weeks, with rides
given two times a week in addition to encouragement and opportunity to
participate in routine facility activities (Buettner & Fitzsimmons,
2002). During the maintenance period, staff informs residents of other
facility activities that are available and assists, or arranges
assistance, to transport the resident to the facility activities that
interest the resident. These activities are unique to each facility but
may include music, entertainment, arts & crafts, intergenerational
programs, pet visits, church and other on-going facility activities.
Staff may also consider using the wheelchair bike to transport residents
to these activities.

**Using the Duet**[™]{.underline} **Wheelchair Bicycle**

The Duet™ bike has two parts to it: the wheelchair, which is usable on
its own and the bike portion, which is unusable on its own. The
wheelchair, by itself, may be brought on a unit or into a residents´
room for loading (See steps 4, 5, 6 listed below). Or residents may be
brought outdoor and loaded onto the chair while it is attached to the
bike. The two pieces of the wheelchair bike clip together with a u-bar,
shackle and locking clip. Always check the tires of the bike and
wheelchair, refill when they feel soft according the manufacturer
recommendation. Caution should be taken on wet, slanting, uneven and
slippery road surfaces.

**Loading Riders**:

1.  Lock the front brakes of the wheelchair by pulling up on the parking
    brake bar on the back of the wheelchair and pushing the bar into the
    parking brake clip.

2.  Align the back of the bike frame with the wheelchair and slip the
    u-bar into the catch on the back of the wheelchair.

3.  Push the shackle forward into the catch. All four wheels of the
    wheelchair are still on the ground and you will want to seat your
    rider before proceeding (see Figure 2 in the guideline document).

4.  Unclip one side of the footrest by pulling out the slip pin and
    swing the footrest away prior to loading rider. Keep one side of the
    footrest attached. If using a lifting device to load a resident on
    the bike, you do not need to unclip the footrest.

5.  Transfer rider to seat making certain s/he is sitting back in the
    chair. The chair angle may be adjusted using the directions from the
    manufacturer. This should be done prior to loading your passenger
    (see Figure 3 in the guideline document).

6.  Latch seat belt around rider and adjust to a comfortable tightness.
    Like with all seat belts they should be worn low around the hips
    rather than the waist.

7.  Adjust the footrest height to a comfortable level by loosening the
    bolts and sliding the rest up or down. Tool for this adjustment is
    mounted on the back of the wheelchair. Then swing the footrest back
    into riding position and replace the slip pin. The headrest may also
    be raised up or down by loosening the bolts and sliding the headrest
    up or down. Be sure to tighten all bolts before proceeding.

8.  Offer helmet and sunglasses and hat if sunny. If cool outdoors,
    offer a lap blanket or a sweater.

9.  Tell your passenger that s/he will be lifted up a short distance,
    then push down on shackle locking clip. This will elevate the front
    wheels of the wheelchair approximately 2\" off of the ground.

10. The pedaler should then mount the bike, unlock the front brake, and
    then start riding.

**Unloading riders**:

1.  Stop bike and lock the parking brakes by pulling up on the brake bar
    and slipping it into the parking brake clip (see Figure 4 in the
    guideline document).

2.  Inform rider that her/his chair will lower a short distance. Push up
    on shackle locking clip and the front wheels of the wheelchair will
    touch the ground (see Figure 4 in the guideline document).

3.  If you wish to bring the rider back to the unit in the wheelchair,
    pull up on the bike frame near the shackle and the two parts will
    separate. Unlock the parking brake and return the passenger to the
    unit. Otherwise,

4.  Unclip one side of footrest by pulling out the slip pin on one side
    and swing the footrest to one side.

5.  Unfasten seat belt (see Figure 5 in the guideline document).

6.  Assist passenger out of wheelchair.

**Cautions**:

**Never load or unload patients without the front brake on**.

**Never ride the bike without a passenger as this causes a load
imbalance and can ruin the wheelchair inner tire tubes. The wheelchair
bike is also less stable to ride without a passenger**.

**Never allow anyone to ride a patient without receiving training
first**.

**Wheelchair bike should be locked when not in use by trained staff to
prevent both the theft of the bike and use by untrained personnel**.

**Definitions**

**Evidence Grading**

A.  Evidence from well-designed meta-analysis.

B.  Evidence from well-designed controlled trials, both randomized and
    nonrandomized, with results that consistently support a specific
    action (e.g., assessment, intervention or treatment).

C.  Evidence from observational studies (e.g., correlational,
    descriptive studies) or controlled trials with inconsistent results.

D.  Evidence from expert opinion or multiple case reports.

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### REFERENCES SUPPORTING THE RECOMMENDATIONS

[References open in a new
window](http://www.guideline.gov/summary/select_ref.aspx?doc_id=3682)

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of supporting evidence is identified and graded for selected
recommendation (see \"Major Recommendations\").

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

The introduction of this powerful intervention, wheelchair biking,
provides a positive experience and may interrupt the cycle of
depression. The protocol may reduce depressive mood in older adults and
may provide a complementary or alternative treatment to medications.

**Subgroups Most Likely to Benefit**:

**Individuals/patients at risk for depression**:

-   Medication Usage: Some antihypertensive, hormonal and neuroleptic
    agents, Carbidopa/levodopa, Beta blockers, Clonidine,
    Benzodiazepines, Barbiturates, Anticonvulsants, Histamine-2
    blockers, Calcium channel blockers, Thiazide diuretics, Digoxin, and
    narcotics Polypharmacy, defined as three or more medications per
    day, was also found to place patients at high risk

-   Medical Causes:

    -   Chronic illness: Late-life mental disorders are often detected
        in association with somatic illness. The prevalence of
        clinically significant depression in later life is estimated to
        be highest, approximately 25 percent, among those with chronic
        illness, especially with ischemic heart disease, stroke, cancer,
        chronic lung disease, arthritis, Alzheimer´s disease, and
        Parkinson\'s disease.

    -   Cardiovascular accidents: Six prospective evaluations of
        depressive symptoms/syndromes using various criteria revealed
        the prevalence of major depressive disorder to be between 10 and
        27 percent in post-stroke patients, with an additional 15 to 40
        percent showing less severe forms of illness within 2 months of
        the stroke.

    -   Dementia: Approximately 30 to 40 percent of Alzheimer\'s disease
        patients demonstrate formal depressive mood syndromes and/or
        psychotic symptoms sometime during their illness.

    -   Parkinson\'s disease: Approximately 50 percent of Parkinson\'s
        patients with dementing symptoms have major depressive disorder
        sometime during the course of the illness.

    -   Diabetes: Numerous recent studies that have estimated the
        prevalence of depression in treated samples of diabetic adults
        suggest that major depressive syndrome is approximately three
        times more common in patients with diabetes than in the general
        population.

    -   Coronary Artery Disease: The relationship between depression and
        increased morbidity and mortality is well documented in both
        post-myocardial infarction patients and in coronary artery
        disease patients without myocardial infarction.

    -   Persistent insomnia, occurring in 5 to 10 percent of older
        adults, is a risk factor for the subsequent onset of new cases
        of major depression in older persons.

    -   Impaired Vision: The rate of depression among nursing home
        residents with visual impairments exceeds 45%.

    -   Hearing Impairment: Older adults with hearing impairments have
        significantly more depressive symptoms than normal hearing older
        adults.

    -   Posttraumatic Stress Disorder: PTSD studies have found high
        levels of comorbid major depressive disorders.

    -   Pain: Correlates with depression and more severe if the
        depression is unrecognized.

    -   Urinary Incontinence: There is an association between depression
        and patients with urinary incontinence.

-   Psychological Conditions:

    -   Risk factors for late-onset depression, based on results of
        prospective studies, include educational attainment less than
        high school, impaired physical functioning status, and heavy
        alcohol consumption.

    -   Social Isolation: Social isolation correlates with depression
        among community dwelling elders and for nursing home residents
        lack of social relationships with other residents is a strong
        predictor of depression.

    -   Bereavement: At least 10 to 20 percent of widows and widowers
        develop clinically significant depression during the first year
        of bereavement.

    -   Losses: Correlations have been found between depression and a
        variety of losses including loss of family home, friends, social
        activities, volunteering, financial security, and marital
        harmony.

#### POTENTIAL HARMS

As with any outdoor activity getting caught in bad weather, too much sun
or heat exposure, can cause dehydration or heat stroke.

**Biking specific**: flat tire. Potential of falling from bike has
similar, yet slightly greater risks, than falling from a wheelerchair,
as speed and terrain may increase this possibility. Untrained pedalers
pose greater risk of falling from a bike. This should not occur if
guidelines are followed.

**Other risks**: injury during transfer into wheelchair portion of bike.

**Subgroups Most Likely to be Harmed**:

*Individuals who cannot participate in the wheelchair biking program:*

-   those with postural conditions, such as decubitus ulcer, that
    prevent them from sitting upright

-   those with extreme unpredictable behavior

-   those with acute illness

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

This evidence-based practice protocol is a general guideline. Patient
care continues to require individualization based on patient needs and
requests.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

**Evaluation of Process and Outcomes Indicators**

**Process Indicators**

Process indicators are those interpersonal and environmental factors
that can facilitate the use of a protocol.

One process factor that can be assessed with a sample of staff is
knowledge about Wheelchair Biking for Depression. The **Wheelchair
Biking for Depression Knowledge Assessment Test** (see Appendix G in the
guideline document) should be assessed before and following the
education of staff regarding use of this protocol.

The same sample of staff for whom the Knowledge Assessment test was
given should also be given the **Process Evaluation Monitor** (see
Appendix H in the guideline document) approximately one month following
his/her use of the protocol. The purpose of this monitor is to determine
his/her understanding of the protocol and to assess the support for
carrying out the protocol.

**Outcome Indicators**

Outcome indicators are those expected to change or improve from
consistent use of the protocol. The major outcome indicators that should
be monitored over time are:

-   Decrease in depressive symptoms: This will be individualized and
    specific for each patient and may include:

    -   Sadness/weepiness

    -   Loss of interest/apathy

    -   Decreased socialization/verbalization

    -   Weight gain or loss

    -   Low energy/fatigue

    -   Unspecific complaints

For this protocol, direct observation, patient record audit or
standardized formal assessment instruments (see below) may be used to
evaluate whether depression has decreased:

Geriatric Depression Scale - Short Form (see Appendix A.1 in the
guideline document).\
Geriatric Depression Scale - Long Form (see Appendix A.2 in the
guideline document).\
Cornell Scale for Depression in Dementia - (see Appendix A.3 in the
guideline document).

Activity participation may be obtained from activity records. It is
important to use the same method of evaluating depression before and
after implementing the Wheelchair Biking intervention. It is recommended
that post testing with an assessment instrument be performed after 2
weeks of intervention and monthly thereafter.

The Wheelchair Biking Outcomes monitor (see Appendix I in the guideline
document) is to be used for monitoring and evaluating the usefulness of
the Wheelchair Biking protocol in improving outcomes of patients with
depression. Please adapt this outcome monitor to your organization or
unit and add outcomes you believe are important.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Getting Better\
Living with Illness\
Staying Healthy

#### IOM DOMAIN

Effectiveness\
Patient-centeredness\
Safety

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Wheelchair biking for the treatment of depression. Iowa City (IA):
University of Iowa Gerontological Nursing Interventions Research Center,
Research Dissemination Core; 2003 Feb. 53 p. \[86 references\]

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2003 Feb

#### GUIDELINE DEVELOPER(S)

University of Iowa Gerontological Nursing Interventions Research Center,
Research Translation and Dissemination Core - Academic Institution

#### SOURCE(S) OF FUNDING

Developed with support provided by Grant #P30 NR03979, National
Institute of Nursing Research, National Institutes of Health (NIH).

#### GUIDELINE COMMITTEE

University of Iowa Gerontological Nursing Interventions Research Center,
Research Dissemination Core

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Authors*: Suzanne Fitzsimmons, MS, ARNP; Linda Buettner, PhD, CTRS

*Series Editor*: Marita G. Titler, PhD, RN, FAAN

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### GUIDELINE STATUS

This is the current release of the guideline.

#### GUIDELINE AVAILABILITY

Electronic copies: Not available at this time.

Print copies: Available from the University of Iowa Gerontological
Nursing Interventions Research Center, Research Dissemination Core, 4118
Westlawn, Iowa City, IA 52242. For more information, please see the
[University of Iowa Gerontological Nursing Interventions Research Center
Web
site](http://www.nursing.uiowa.edu/products_services/evidence_based.htm).

#### AVAILABILITY OF COMPANION DOCUMENTS

None available

#### PATIENT RESOURCES

None available

#### NGC STATUS

This NGC summary was completed by ECRI on June 12, 2003. The information
was verified by the guideline developer on July 15, 2003.

#### COPYRIGHT STATEMENT

This summary is based on the original guideline document, which is
copyrighted by the guideline developer. For complete copies of this
guideline, please contact Kim Taylor, phone: 319-384-4429; fax:
319-353-5843; e-mail: <research-dissemination-core@uiowa.edu>.

### DISCLAIMER

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Date Modified: 11/3/2008