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The mobility of older individuals has often been only partially assessed, without considering all important aspects such as potential (available) versus effective (used) mobilities and the physical and psychosocial factors that modulate them. This study proposes a new model for evaluating mobility that considers all important aspects, applied here to lower-limb amputees with vascular origin. This model integrates the concepts of potential mobility (e.g. balance, speed of movement), effective mobility (e.g. life habits, movements in living areas) and factors that modulate these two types of mobility (e.g. strength, sensitivity, social support, depression). The main objective was to characterize potential and effective mobility as well as mobility modulators in a small sample of people with lower-limb amputations of vascular origin with different characteristics. The second objective of this pilot study was to assess the feasibility of measuring all variables in the model in a residential context.
An observational and transversal design was used with a heterogeneous sample of 10 participants with a lower-limb amputation of vascular origin, aged 51 to 83, assessed between eight and 18 months after discharge from an acute care hospital. A questionnaire of participant characteristics and 16 reliable and valid measurements were used.
The results show that the potential mobility indicators do not accurately predict effective mobility, i.e., participants who perform well on traditional measures done in the laboratory or clinic are not always those who perform well in the real world. The model generated 4 different profiles (categories) of participants ranging from reduced to excellent potential mobility and low to excellent effective mobility, and characterized the modulating factors. The evaluations were acceptable in terms of the time taken (three hours) and the overall measurements, with a few exceptions, which were modified to optimize the data collected and the classification of the participants. For the population assessed, the results showed that some of the negative modulators (particularly living alone, no rehabilitation, pain, limited social support, poor muscle strength) played an important role in reducing effective mobility.
The first use of the model revealed interesting data that add to our understanding of important aspects linked to potential and effective mobility as well as modulators. The feasibility of measuring all variables in the model in a residential context was demonstrated. A study with a large number of participants is now warranted to rigorously characterize mobility levels of lower-limb amputees with vascular origin.
Good mobility, considered very broadly in the field of health (walking, physical activity, participation in society, ability to drive, having access to public transportation, etc.) [1] is the key to autonomy for seniors in their living environment [2]. However, the global profile of mobility in seniors following surgery is not well known, especially in the year following their discharge from an acute care hospital. One of the reasons for this lack of an overall vision is the lack of a model for evaluating mobility that would be comprehensive enough to include all aspects of mobility [3]. Another reason is that certain populations who go through convalescence never undergo rehabilitation. This is particularly the case for people who have had lower-limb amputations of vascular origin in Quebec (Canada), 75% of whom are not referred for rehabilitation [4]. In addition to the absence of clinical follow-up in this population, there has been little research at the international level since most of the mobility studies identified in people with vascular amputation focused on individuals who received prosthetic rehabilitation [5]. What happened to those people who do not receive this specific service? The population concerned is substantial: some 158,000 Americans are hospitalized every year for an amputation [5]. In Canada, the data vary by province. In Quebec (7 million inhabitants), for example, every week more than ten individuals have a lower limb amputated following a vascular problem [4], with the main cause of amputation being diabetes [6-13].
Improved mobility is often related to better quality of life, which is influenced by different factors (movements, energy, pain, sleep, social relationships and emotional reactions) [14]. Amputees suffer from many major health problems, which have a negative effect on their mobility, social participation and quality of life [15]. Therefore it is essential to specify which variables truly influence the mobility of these at-risk groups if we want to take appropriate action in the continuum of services. From this perspective, the purpose of this study was to validate a model to evaluate the mobility of seniors with a lower limb amputated for vascular reasons, and to show that it is possible to take a series of standardized steps in a residential context that cover all three dimensions of the conceptual model.
Survey of the Literature
A survey of the literature was performed on mobility measures and factors that influence mobility (modulators). Several studies involved monitoring amputees at one year [5,7,11,16], two years [5,16-19], even five years [5,19-21] post-amputation. However, these studies primarily described patients' prognoses, evaluated using mortality rates [1,5-8,11,16,17,20-25] and the level of using assistive devices or a prosthetic leg [7,17,19,23,25,26]. Other studies focused on capabilities [27-32] (e.g. walking distance, walking speed, muscle strength, balance), participation in activities of daily life (ADL) at home [24,33], participation in community activities and the ability to drive a car [24,25]. However, most of these studies focused strictly on patients who had been fitted with a prosthetic or only on a few aspects related to mobility. No study documented mobility in the broadest sense (e.g. level of physical activity, time spent on daily activities), inside and outside the home of patients with amputations of vascular origin.
A review of the literature conducted by Rommers et al [3] on this patient group identified 18 studies measuring the ability of individuals (e.g. walking without assistance, with a cane, with a walker, using a wheelchair) and 17 studies measuring activities performed in a real context (e.g. walking outside the home, climbing stairs, walking in the neighbourhood, performing a number of household activities, driving a car). These authors noted that some of these studies had simultaneously used measurements of capabilities and activities as indicators of mobility, but were not exhaustive, i.e., did not cover all capabilities, activities and contextual factors. Surprisingly, in 2008, i.e., 11 years later, the same observations can be made: no study can be found on the longitudinal monitoring of mobility of vascular amputees that documents both capabilities and the performance of activities in the home and the community.
Twenty-four modulating factors that interfere with the underlying capabilities of mobility and the performance of activities overall were identified in the literature survey. Among these factors, certain studies highlighted the risks of co-morbidity found in vascular amputees: high blood pressure, heart disease, stroke, obesity and chronic obstructive pulmonary disease [1,5,8,15,17,22,24]. Smoking, drinking and inactivity are also some of the risk factors that negatively impact the precarious physical health of these individuals [8-11,17,21]. Moreover, the risk of amputation increases after age 60, and seems to be higher in men than women [6,8,22]. A longitudinal study also showed that a lack of social support, measured one month post-amputation, predicts symptoms of depression at one year and two years post-amputation [34]. This last study demonstrated the importance of using biopsychosocial intervention models to facilitate long-term adjustment, i.e., psychologically, socially and physically, especially for phantom pain [34].
Other studies identified several factors that positively influenced the resumption of certain significant activities for vascular amputees, such as social support [8,18,26-30], satisfaction with the prosthesis [23,28,31] or assistive devices [32,33,35], proactive coping strategies [23,26,28-30,36] and an optimistic personality [28,37]. It has also been acknowledged that the level of amputation below the knee, absence of pain, and possibility of maintaining social relationships support the underlying capabilities of mobility and performance of activities [23]. Lastly, environmental barriers (accessibility, attitude of other people, availability of resources, social support) interfere with the capabilities and activities of people with arm or leg amputations [38,39].
Given all the modulating factors identified, a model for evaluating mobility from a broader perspective was proposed by a team of researchers from various disciplines with a view to documenting the evolution of this population.
Model for Evaluating Mobility
Our team developed a model to evaluate mobility that takes into account two types of mobility that may change differently over time depending on different modulating factors experienced by people with a lower-limb amputation of vascular origin. The definitions and concepts are illustrated in Figure 1. Our team consists of 15 researchers from various disciplines, all of whom are interested in different aspects of mobility (see Table 1). They attended ten brainstorming meetings [40] over a period of a year-and-a-half, carried out in prepared face-to-face meetings.
In this model, effective mobility means the actual participation of people in society, in a "real environment", and is a determining factor in their quality of life. This mobility is modulated by various factors related to health (e.g. active rehabilitation, community support), the person's condition (e.g. comorbidity) and the physical and human environment (e.g. social support, use of assistive devices). Potential mobility, which is mainly based on certain physical capabilities required to carry out a movement, indicates the potential of a person to move in a "laboratory or clinical environment". Interaction between the variables of these two types of mobility and modulators can vary greatly from individual to individual. In this study, it was hypothesized that as multiple modulators influence mobility, potential mobility would be a poor predictor of effective mobility. For example, a participant in a power wheelchair may have had both legs amputated, may be unable to to walk, and may have no balance or low upper trunk mobility (low potential mobility), but may perform home ADL by substitution or with assistive technology, may participate in community activities and may be able to visit friends with adaptation of the human and physical environments (high effective mobility). A better understanding of the model variables and their interactions will help identify meaningful and useful data to better direct individuals and their families to the most appropriate services for them.
Study objectives
The main objective was to characterize potential and effective mobility indicators as well as mobility modulators in a small sample of people with lower-limb amputations of vascular origin with different characteristics. The second objective of this pilot study was to verify the feasibility of measuring all variables in the model in a residential context.
An observational design with multiple measures taken at a single point in time was used as part of this feasibility study. Since the objectives of this pilot study were to test the model and assess feasibility, all outcome measures including questionnaires, physical tests, ADL and community activity outcomes were assessed once between between eight and 18 months following discharge from an acute care hospital. A delay of at least eight months between amputation and assessment was chosen to make sure that participants had time to adjust to their amputation and resume their activities, in order to get a representative picture of their effective mobility. The research protocol was approved by the Research Ethics Committee of the participating institution (Hôpital St-François D'Assise) and all participants provided their informed consent.
Recruitment of Participants
A heterogeneous sample (n = 10) of various ages, including ambulatory and non-ambulatory participants, using different assistive devices to move, was selected for the study (mean age: 71 years, 8 men and 2 women). There were three recruitment phases based on a non-probabilistic sampling method. Of the 60 files selected by the archivist in an urban acute care hospital, 35 were selected based on the following eligibility criteria: be 55 years of age or older, have had an amputation of vascular origin of a lower limb above the ankle at least eight months following discharge from an acute care hospital and live within a 75-km radius of the recruitment site. People with severe cognitive or oral communication problems were excluded. Of these 35 files, only 22 were retained following a careful review of the medical files by a research assistant. All of them were contacted by phone to verify their eligibility. It was learned that some had died by the time of the study, while others no longer met the selection criteria. Finally, the eligibility of 18 people was confirmed and ten of them agreed to participate (acceptance rate of 55%).
Data Collection Procedure
Each participant was met at his/her home, and underwent an evaluation (three hours maximum) by a research assistant and a physiotherapist. All participants first filled in a consent form and then did the questionnaires and physical tests based on a standardized procedure. To minimize the effects of fatigue, tests involving intellectual and physical effort were alternated. The level of fatigue was evaluated using a visual analogue scale (VAS) for every four tests to ensure that participants were able to continue the evaluation. The left extremity of the VAS indicates no fatigue (0) and the right one, lots of fatigue (5 inches long). If the result exceeded 2.5 inches, a longer pause would be required. The tests or questions with a strong emotional dimension were left until the end.
Measuring Instruments
Ten instruments associated with the modulators of mobility were used to document the influence of 24 variables identified as factors influencing mobility [1,8-11,17,23,34,36,38,39,41-47]. Note that the term "negative" modulator refers to the idea that a personal or environmental factor, when it reaches a certain threshold, may limit or hinder mobility.
The sociodemographic, clinical, physical and psychosocial characteristics of subjects were collected using a questionnaire developed for the study. Negative modulators included age over 60 [25], an amputation below the knee [19], fatigue felt when performing ADL [19], daily consumption of cigarettes and alcohol [48,49], living alone or in a care centre [50], a physical environment that is not very accessible [38,39], dissatisfaction with the technical aids used [47], presence of another physical problem and lack of services (rehabilitation, etc.)[39].
The Charlson Comorbidity Scale adapted to a geriatric clientele [51] was used to identify medical conditions via the medical record. A score of 2 or more was considered to be a negative modulator [51].
The Interpersonal Support Evaluation List (ISEL), developed by Cohen et al. [52] and adapted by McColl and Skinner [53], measuring three types of support--instrumental (7 items), informational (6 items) and emotional (9 items) was used. It includes a four-level Likert scale, from 0 to 3, as well as a satisfaction scale for each type of support. The total score (average of three types of support) is the variable used. A score lower than 1 indicating low support is considered to be a modulator-influencing variable.
The MOS Social Support Survey [54] was used as a social support measurement. The French version of this tool has good psychometric qualities. It was validated in a rehabilitative context of patients with cardiovascular disease [55]. It includes 19 questions covering five types of support: tangible, emotional, affective, positive social interaction and informational. Scales of 0 to 5 ("never" to "always") showed an average score of 5 for each type of support. A score of < 75/95 was considered to be a negative modulator [56].
The Ways of Coping Questionnaire (WCQ) [53] was used to measure the adaptability of the individual following difficult events, such as returning home following discharge from an acute care hospital. Its internal coherence is good. The abridged version with 21 items is divided into three different aspects, i.e.: 1) distancing and avoidance, 2) looking for social support, and 3) positive re-evaluation and problem solving. A Likert-type scale allows to measure the level of use of different adaptive strategies. Adaptation was considered to be a negative modulator when Aspect 1 received an average score of > 1.5/3 or when aspects 2 and 3 received average scores of < 1.5 for aspects 2 or 3 [53].
The Modified Brief Pain Inventory (BPI) [57,58] was used to evaluate pain intensity and how this pain interferes with the person's activity. It was used with various types of patients including those with neuropathic pain [59-61]. A French version of the BPI was validated [62-66]. Scores of > 5/10 (Question 5) or > 7/10 (Question 9a) on the Likert scale were considered to be negative modulators [67].
A Body Mass Index (BMI) of more than 30 was considered to be a negative modulator [68,69]. Height (cm) and weight (kg) were taken from in the patient file.
The Yesavage Geriatric Depression Scale was used [70,71]. Depression was identified starting with a score of 11/30 downward, with 92-95% sensitivity and 84-89% specificity. Above the threshold (11/30), it was considered to be a negative modulator [72].
The Jamar dynamometer [73] is valid and reliable [74] for measuring hand-grip strength, which is also considered to be an overall strength index for the individual. Based on the standards established according to age, strength (the average of two tests) in the 30th percentile or less was a negative modulator [74].
The Semmes-Weinstein Monofilament Test (10 g) was used to test protection sensitivity of the intact foot [75]. Four sites of application were evaluated (big toe, top of the first, third and fifth metacarpals), at a rate of two actual stimulations plus one factice per site. The rest-retest reliability is good [75-77]. As soon as a monofilament was not felt, regardless of the site of application, sensitivity was considered to be a negative modulator [78].
Four instruments were used to evaluate potential mobility, i.e., capabilities to perform various activities requiring movement [27-31,42,79-85].
The Locomotor Capabilities Index (LCI) [86] is a measurement of the perception of a person's capability to perform activities with and without his/her prosthesis. The patient is asked whether he can do seven basic activities (from 'getting up from a chair' to 'going downstairs'), and seven advanced activities (from 'picking up an item from the ground when he is standing using a prosthesis' to 'walking while carrying an item'). Each task is rated on a scale (0 = no, 1 = yes with help, 2 = yes with surveillance, 3 = yes). Two sub-scores out of 21 were produced and a total score of 42. This potential mobility indicator "failed" if the score was equal to or less than 21/42, given that this threshold indicates frequent difficulties and the need for technical or human assistance [87].
The Timed Up and Go Test [88] (TUG) measures the time required to get up from a chair, walk three metres and then sit down again. The inter-rater and test-retest reliabilities are very high among ambulatory lower-limb amputees [30]. For individuals in wheelchairs, one task of the Wheelchair Skills Test [89,90] was used instead of the TUG, i.e., the transfer from a wheelchair to a flat surface (e.g. bed, chair), moving forward three metres in the wheelchair, turning, returning and once again going from the wheelchair to the to the initial surface. This indicator of potential mobility was considered to be "failed" if TUG > 14 seconds in both versions (prostheses and with assistive devices for walking) [88]. For the wheelchair-adapted TUG, since no standard cut-point has been established or recommended in the literature, the threshold was set at > 34 seconds, based on the average (n = 6) obtained during the pilot project.
The Berg Balance Test (BBT) [91] is a measurement of seated and standing balance. It is made up of 14 subtests, rated from 0 to 4. A score lower than 45 is predictive of the risk of multiple falls.
The Amputee Mobility Predictor (AMP) [92] is a measurement that predicts the movement capabilities of lower-limb amputees. Its psychometric qualities were demonstrated in English and French [93]. The AMP evaluates 21 situations requiring seated or standing balance, during movement or when reaching for objects. Scales from 0 to 2 are used, except for the last item. A failing mark in this potential mobility indicator was when the score was under 25/47. Under this threshold, the subject is unstable, loses balance and cannot reach objects [92].
Three instruments associated with effective mobility cover the evaluation of activities in a real environment [3,33,94] and the level of physical activity able to be performed.
The Assessment of Life Habits (LIFE-H) [95,96], abridged version 3.1, was used as the main way of measuring outcomes of effective mobility. This tool was developed from the Handicap Production Process [97] and evaluates handicap situations that hinder social participation. It includes 200 items that could be grouped daily activities as well as social roles. The score varies from 0 (high level of handicap situations) to 9 (optimal level of social participation) for each item. The reliabilities were excellent for the overall score studied in a group of 84 seniors who had lost autonomy (CCI and confidence intervals at 95%: 0.95 (0.91 to 0.98) (test-retest) and 0.89 (0.80 to 0.93) (inter-rater) [98]. This effective mobility indicator was considered to have "failed" for daily activities and for social roles if their average score is < 7/9, given that, at this threshold, the person can only carry out a given activity with an assistive device, or layout modifications or requires human assistance [96].
The Life Space Assessment (LSA) [99] identifies the regular mobility patterns during the month preceding the evaluation. Five levels of movement are assessed, from inside the home to outside the city. Its score varies from 0 (complete restriction of one's mobile space) to 120 (no restriction of one's mobile space). Validity, reliability and sensitivity to change in the LSA were studied in ambulatory seniors and wheelchair users [99,100]. Metric properties in the French-Canadian version are good [101]. This effective mobility indicator was deemed to have "failed" if the mobility space scores were below the standard values for people aged 65 and more [78].
The Human Activity Profile (HAP) [102] measures the capability to perform different levels of physical activity. It is a questionnaire with 94 questions, is self-administered and validated for different clienteles [102-104]. It begins with questions on the activities that require low energy expenditure and ends with questions associated with high energy levels. Each item must be answered using one of the following three statements: I still do this activity, I have stop doing this activity and I have never done this activity. The maximum activity score (MAS), which corresponds to the last item that the subject had done was selected. This potential mobility indicator was considered low if the MAS was lower than the standard values for the age [105].
Data Analysis
Descriptive statistics were calculated for all variables using SPSS software (version 15.0 for Windows Grad Pack) for the group of ten participants. The results were then grouped into three distinct themes: potential mobility, effective mobility and modulators for each participant (see Additional file 1). Given the limits or standards specified in the literature to judge whether a test has been failed, the scores deemed "negative ☹" and "positive" were transformed into dichotomous data (0: fail/negative, 1: success/positive). All items (0 or 1) were then added to quantify the potential mobility (number of successful items out of a maximum of four possible items assessed: LCI, TUG a or b, TUG c, AMP), effective mobility (number of successful items out of a maximum of four possible items assessed: LIFE-F personal care, LIFE-F social roles, LSA-F, HAP) and modulators (number of successful items out of a maximum of 24 possible items assessed). Then, all the total scores on these three indicators were weighted out of four (4), when they were not based on four items. This weighting of scores on the same scale allowed us to compare the two types of mobility and modulators, and also compare the patients. For example, if one patient did not do the TUG-c, his/her total potential mobility indicator based on 3 items (instead of four) would be weighted out of four, to make it possible to compare across the indicators and the other patients. If one patient only anwered 20 of the 24 possible modulator items, his/her total modulator score would also be weighted out of four. The scores weighted by category were interpreted as follows: low/negative (< 1), moderate (1 to < 3) and high/positive (3 to 4). These outcomes were then graphed to show the profile of each participant.
Additional file 1. Results of the Variables for Modulators, Potential Mobility and Effective Mobility
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The sociodemographic, clinical, physical and psychosocial characteristics are shown in Additional file 1 as modulator variables. Data analysis revealed that six participants showed low potential mobility (weighted score 0/4), three were moderate (1.33/4 or 2.66/4) and one revealed high potential mobility (weighted score: 4/4). Modulators were moderate for nine participants (lower score 7/16 and higher score 17/24, weighted scores 1.75/4, 1.83/4) and positive for a single participant (subject #8; weighted score: 3.17/4). For effective mobility, three participants highlighted in grey in Additional file 1 showed high effective mobility (weighted score: 4/4 for 2 subjects; 3/4 for one subject), six were moderate (weighted score: 1/4 for three subjects; 2/4 for three subjects) while only one had low effective mobility (weighted score: 0/4).
Additional file 1 reveals that some of the negative modulators (particularly living alone, no prosthetic rehabilitation, pain, low social support, poor muscle strength) played an important role in "low effective mobility". Those negative modulators were not present for the three participants with high effective mobility.
Additional file 1 presents the individual scores on the various tests and weighted scores for the three categories of measurements. Subject #1 had missing data for three assessments (not evaluated/n.e.) because the research assistant had to stop after three hours (ethical committee's requirement). Also, there are missing data (-) for two assessments because the research team decided to replace them for the last five subjects by more adapted tests; this is the case for the ISEL (replaced by the MOS) and the Berg Balance Test (replaced by the AMP). Finally, there are missing data (not applicable/n.a.) for subjects who did not use a wheelchair or prosthesis; this is the case for the TUG, AMP and LCI.
Figure 2 provides a graphic representation of the weighted scores for each of the three categories of measurements for the ten subjects. By grouping the subjects based on their weighted effective mobility score, four distinct groups were formed. First, two groups attained high effective mobility despite the fact that their potential mobility and their number of positive modulators are different: Group A (n = 1) presents high potential mobility as well as high positive modulators, whereas Group B (n = 2) displays potential mobility ranging from low to moderate, and moderate modulators. Next, Group C (n = 6) presented moderate effective mobility with low potential mobility and moderate modulators. Lastly, Group D (n = 1) demonstrated low effective mobility with low potential mobility and moderate modulators.
Figure 2. Graphic representation of the scores of ten participants in the study in terms of potential and effective mobility and modulators. Participant categories: Group A (n = 1): high effective mobility, positive modulators and high potential mobility. Group B (n = 2): high effective mobility, moderate modulators and low/moderate potential mobility. Group C (n = 6): moderate effective mobility, moderate modulators and low/moderate potential mobility. Group D (n = 1): low effective mobility, moderate modulators and low potential mobility.
This pilot study collected preliminary data on potential and effective mobility indicators as well as the modulators for these mobilities in people with a lower-limb amputation of vascular origin. It also assessed the feasibility of measuring, in a residential context, all variables in the proposed model for evaluating mobility. The data collected led to dividing the participants into four subgroups with different profiles of effective and potential mobility. Since we only had 10 subjects, we do not believe the number of participants under each profile is a valid representation of the number expected. However, it certainly indicates the substantial heterogeneity in mobility of the lower-limb vascular amputee population. It seems that our model was able to detect different patterns of level of mobility (described by others as capabilities [27-32]), participation in ADL at home [24,33] and community activities [24,25].
The seven participants who showed low/moderate effective mobility are different than the ones with high effective mobility, when considering the type of modulators reported but not the number of modulators. In fact, we observed that it was only in groups C and D (n = 7) showing moderate and low effective mobility that three or more of a specific subset of modulators were observed: living alone (n = 3), no prosthetic rehabilitation (n = 3), low social support (n = 2), no coping strategy to obtain social support (n = 4); general pain (n = 3), little strength in one of their arms (n = 5) and low sensitivity in the remaining limb (n = 3). As well, in group C and D, seven participants reported a low level of activity intensity. In previous studies, often focusing on one aspect, these modulators were also identified as risk factors for poor mobility [8,18,34,36,37,67,74,78,105]. Our results suggest that a given subject could present a complex situation where negative modulators interact with potential mobility in such a way that low effective mobility is observed. Clearly, this justifies taking a global approach using multidimensional assessments to better understand the complexity of factors underlying mobility in a larger group of amputees.
These initial outcomes of the different mobility groups suggest many possible areas of research. In particular, it appears important to assess the impact of resources and services, which are potential mobility modulators, on the profile of effective and potential mobility of amputees following their stay in an acute care hospital. In order to better document the temporal trajectory of mobility in vascular amputees, a large-scale longitudinal study is needed. These data would be useful for making recommendations on the main mobility modulators and could guide decision-making for resources and services to make available to this population. A better knowledge of mobility modulators and their impact at different times of motor recovery would make it possible to identify areas to develop physical and psychosocial activities adapted to the needs of these individuals. Knowledge regarding the different levels and types of mobility in vascular amputees is fragmented compared to other populations that could present similar needs for care and services (e.g. people with post-stroke hemiparesis). A vision of the mobility profile for all vascular amputees is essential for implementing strategies to facilitate a high level of effective mobility in these people. Data from representative samples would be helpful for practitioners and community partners in order to determine: 1) which patients (profile) are most likely to benefit from intervention; 2) when is the best time to intervene in the first nine months following the amputation; and 3) what is the optimal target for intervention (e.g. potential mobility or a subset of modulators) to improve effective mobility. This study offers a conceptual framework to establish such a profile for mobility and modulators of this mobility.
This study also helped confirm the feasibility of the proposed protocol. First, it was possible to collect most of the data by studying participants in their homes. All tests and questionnaires were administered without too much participant fatigue and within the anticipated period (maximum of three hours, minimum of 2 hours 45 minutes). All participants scored < 2.5/5 on the fatigue visual analogue scale, all the time, and none required a longer break between the tests. This study also resulted in certain improvements, which are currently being implemented. Two tests were replaced after meeting with half the participants. The Interpersonal Support Evaluation List [52] was too difficult to administer, and was therefore replaced by the MOS Social Support Survey [54]. The Berg Balance Test [83] was replaced by the Amputee Mobility Predictor [92] in order to be able to better document balance when sitting in a wheelchair. Further details on Ways of Coping were also broughtby the researchers to facilitate its administration, such as asking more directly "how returning home was a potentially stressful event". A rating (0 to 5) on overall satisfaction with all assistive devices used for movement was also added. In addition, future studies should involve recording the subjects' weight at home, instead of taking it from the file, in order to have the most current weight of the subject. It will then be possible to use anthropomorphic tables to add the weight of the missing part to the subject's weight. This is necessary in order to use the BMI standard tables developed for the entire body. For "potential mobility", we should note that a measurement instrument had to be developed (wheelchair version of the TUG). Although the results are promising, further information on the procedure for this modified version of the TUG is necessary. For example, it will have to be specified on which side to make the transfer (ipsilateral or contralateral to the amputation), and which parts of the wheelchair to take into account when crossing the finish line. The possibility of breaking down the final score (total time) into the time spent on certain activities must be considered, including transfer time and movement time. The ICL questionnaire was also adapted to people without prostheses in order to take into account mobility using other assistive devices. Investigations will be required to validate and establish standards for the adaptations of the known instruments.
The proposed model for evaluating mobility with its three dimensions (potential and effective mobility and their modulators) seems promising for characterizing mobility of lower-limb amputees. Preliminary data revealed that discrepancies might exist between potential mobility and effective mobility for a given individual, supporting the need to assess both types of mobility and the modulators. This pilot study provided the basis for a large-scale longitudinal assessment of mobility aiming to characterize profiles of mobility in vascular amputees over time. Ideally, in a longitudinal context, data should be collected sooner after the amputation and at different times to determine the evolution of the mobility indicators. Then, it would be possible to propose recommendations regarding their resource and service needs to optimize their mobility and quality of social participation.
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
The rehabilitation RQRV group 2006-2009 participated in the conception of the design of the study, data analysis and in all of the research meetings. CV was one of the two principal investigators, assumed the coordination of all the research meetings, conceived the design of the study, submitted the research protocol for its financing, participated in the data analysis, outlined and drafted the manuscript with a summer student in research (ED). ED managed the database, performed the data analysis and drafted more specifically the result section of the manuscript and commented the manuscript. HM was one of the two principal investigators, assume the coordination of the research assistants, conceived design the study, participated in the data analysis and commented the manuscript. HC, SN and CM also commented the manuscript. These authors contributed equally to this work. All authors approved the final manuscript.
The authors of this paper are alle member of the Rehabilitation RQRV group 2006-2009. This group is composed of Line Beauregard, Patrick Boissy, Martin Brochu, Hélène Corriveau, Yves Couturier, Cyril Duclos, Andrew Freeman, Diana Dawles, Christiane-Gauthier Gagnon, Nancy Mayo, Catherine Mercier, Hélène Moffet, Sylvie Nadeau, Line Robichaud and François Routhier, Claude Vincent. The RQRV group 2006-2009 collaborated for the overall research protocol. This study was carried out with the financial support of the Réseau québécois de recherche sur le vieillissement (RQRV) du Fonds de la recherche en santé du Québec (FRSQ). S. Nadeau holds a Senior Scientist salary and C. Mercier a Junior 1 salary from Fonds de la Recherche en Santé du Québec. Émilie Demers receive a student research summer grant from the Faculty of Medicine of Laval University. The authors want to underline the precious collaboration of their research assistants for their implication in the recruitment, data collection and data analysis (Maude Bastien, Andréanne Blanchette, Isabelle Deaudelin, Guylaine Roy, Marie-Josée Sirois). The authors would like to thank the participants for their contribution to this project and the geriatric rehabilitation services for their support.
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Hiring is up incrementally, with 9% of chief information officers looking to add staff by year's end, and IT professionals with network-administration skills are in demand, according to the latest Robert Half Technology IT Hiring Index and Skills Report. Most encouraging though is 84% of CIOs participating in the poll indicated they are "somewhat confident" in fourth-quarter growth.
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City council approves placing speed humps on residential streets | POLL
Majority of nearby residents have to agree to impediment
EVANSVILLE - Residents of South Saint James Boulevard said they don't mind motorists in general — only the ones who floor it when going down their quiet street.
With its grassy median and numerous trees, South Saint James is a haven for runners, walkers, strollers and pets. But residents say speeding vehicles have been on the rise, perhaps, due to drivers wanting to avoid traffic lights along Vann Avenue and Boeke Road, other north-south routes on Evansville's East Side.
"Some of us park on the street, and I notice people are going really fast," resident Joy Payne said. She was one of several residents who went to Monday's Evansville City Council meeting in support of an ordinance creating a mechanism for neighborhoods to apply for speed humps.
The ordinance sponsored by Councilman Dan Adams, D-At-large, passed 9-0. Residents interested in pursuing a speed hump must collect support — 55 percent of those living within 100 yards of the speed hump's placement must agree.
Requests must then be presented in writing to the city's Traffic and Engineering Department documenting the neighbors' support. The city engineer will then evaluate the request and make a recommendation about installing the speed hump to the Board of Public Safety.
If a request to the board is denied, the decision may be appealed to the City Council if an applicant wishes.
The process only applies to a two-lane or residential street.
Snow routes are excluded from getting speed humps. They also are not to be placed in intersections or in front of a driveway, and they are to be near street lighting if possible.
"All we are trying to do is make our roads safer, and this does it," Adams said.
It's estimated that installing one speed hump — which the ordinance defines as raised, trapezoid-shaped sections of rubber, asphalt or cement — will cost about $2,500.
"This is not an expensive project," said Gloria Bryant, a Southeast Riverside Drive resident in favor of the ordinance.
Bryant and other advocates said the ordinance gives neighbors who are concerned about vehicle traffic another alternative besides requesting additional police patrols.
If the city has multiple requests for speed humps, those in neighborhoods where residents are willing to help defray the costs are to receive higher priority, according to the ordinance.
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- Shopping Bag ( 0 items )
The Counterlife
Posted August 7, 2003
One of Roth's best- but
This it seems to me is one of Roth's best books.It is alive all the way. I would even want to say that his power of insight into characters and situations is so great as to make the work a ' perfection of brilliance'.But unfortunately the 'political Roth' is far too left for me. He does not understand deeply enough the meaning of Israel, especially in religious terms. His lack of Jewish education means he misses much of the meaning of Israel. Still he sees understands a lot, and when he is really into it writes more brilliantly than anyone else that I know of.
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Summer 2014 (August 1, 2014)
On The Job
Carleton's Career Center is on a mission to ensure that students' educations go beyond the classroom to prepare them for a competitive job market
Storytelling by the Numbers
Four Carleton internships added up to a career path for Pablo Kenney '09
A Passion for Public Health
The Woodside Endowed Fund for Career Exploration allowed Brendan Fowl '14 to pursue an unpaid internship at the University of Maryland School of Medicine
Planting Ideas
Joanna Reuter '00 and her husband hosted two Carleton students for a 10-day externship at their organic farm in central Missouri
Teacher, Mentor, Collaborator
When Carleton students work with professors outside the classroom, their interactions take on a new and exciting dynamic that foreshadows their future in the workplace
Project 60
As part of a milestone reunion gift, the Class of 1960 is helping Carleton students help the world
Growth Fund
The passing of beloved professor Roy Grow inspires a fellowship fund to continue his legacy of global discovery
Doing Well and Doing Good
When Eric Carlson '66 was a junior at Carleton, he took a class in the economics of underdeveloped nations that influenced the course of his life.
Join the Team
Carleton's innovative career preparation programs depend on broad support from the Carleton community. Your gifts of time and money make a difference.


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Home Concert Tickets Country and Folk Dirty Three
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Dear Sanjeeva, the Pics of Mayavati Ashram show how wonderfully sensitive you are in picking up the true spirit of spirituality in the shots. i am overwhelmed.God bless. Parthapratim Ray
What a holy place where a true patriotic saint sanctified it by his divine presence.
Serene surroundings sanctified by the footprints the lion of Vedanta, Swami Vivekananda.


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I see a lot of facebook timeline covers for 2$ that I would gladly buy, but none that fits me. I need someone willing to make one.
Let me know what you need exactly and how much is your budget, here or at email@example.com
emailed you.
Contact me at firstname.lastname@example.com with your specifications and i can start working on it right on .
feel free to contact me through my profile page
Contact me at : email@example.com
Hello there,
Feel free to contact me via my profile at: http://graphicriver.net/user/gbs and we may discuss further about the project. Thank you.
Best regards.
sent you your cover, please check your mail and reply if you want the files
@add1ct2, I know the job has already been completed, but I am interesting in hearing what you were looking for. Can you please contact me via my profile page?
Contact me via my profile at: http://graphicriver.net/user/StrokeSaiful
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text: Letters from Yellowstone : In the spring of 1898, A.E. (Alexandria) Bartram - a feisty young woman with a love for botany - is invited to join a field study in Yellowstone National Park. Its leader, a mild-mannered professor from Montana, mistakenly assumes she is a man, and is less than pleased to discover the truth. Once the scientists overcome the shock of having a woman on their team, they forge ahead on a summer of adventure, forming an enlightening web of relationships as they move from Mammoth Hot Springs to a camp high in the backcountry. But as they make their way collecting amid Yellowstone's pristine beauty - threatened even a century ago by misguided tourism - the group is splintered by differing views on science, nature, and economics. This delightful epistolary novel captures an ever-fascinating era and charts one woman's dramatic journey to a greater understanding of herself and her place in the world.


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Do I have to pay retail price?
I''m ready to purchase a Tracker Bass boat from a dealership. There price is called a "Nationally Advertised Retail Price." I would never pay retail for a car but is this the same that I can expect when buying a boat?
Do I have to pay retail price?
Even never having bought a boat, I can answer your question: ALL boat purchases are negotiable (new or used)!
Good luck.
Do I have to pay retail price?
Twenty-five years ago, local boat dealers wanted to discount a $25,000 boat by $200.-300. I found another dealer in Florida who discounted the same boat by almost $5,000. There''s always someone who will deal with you.
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Spotlight Article:
New and Notable: November/December 2013
NYSERDA's HPwES Program Completes 50,000 Projects The New York State Energy Research and Development Authority (NYSERDA) recently announced the achievement of a major milestone for its Home Performance with Energy Star (HPwES) program, with ...
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Conservation Clips is compiled by Cathlene Casebolt of the National Center for Appropriate Technology, a non-profit organization working in sustainable energy, agriculture, affordable housing, and environmental protection. Conservation Clips contains brief summaries of useful research reports and articles in related magazines, and other publications collected by the NCAT staff. [continue reading]
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Homeowners may continue to enjoy their single pane glass windows and gain energy efficient advantages for up to 80% ...


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Histology Technician Certification and Certificate Program Info
Diagnostic laboratories and healthcare facilities hire histology technicians, also known as histotechnicians, to prepare tissue samples for diagnostic examination. A histology technician certificate program should prepare students for entry-level positions in the field and for certification from the American Society of Clinical Pathologists. Read on to learn about education prerequisites, required courses and certification options for histotechnicians.
Essential Information
Community colleges offer histology certificate programs under titles like histotechnology certificate, histology certificate and histology technician certificate. Each of these certificate programs is designed to provide students with a solid background in the field of histology, which is the study of how human cells combine to make up tissue and organs. Many students can complete the certificate program in a year. Graduates can qualify to apply for professional certification, which is not mandatory, but could help with career advancement.
Histology certificate programs combine classroom learning with clinical instruction. Students receive technical instruction in preparing tissue samples for examination by learning how to freeze, cut and stain them for visual clarity. Some schools offer online coursework, but students must visit campus a couple of times a week for labs. Many programs also require clinical rotations in hospitals.
Education Prerequisites
Before students begin the core courses included within a histology technician certificate program, they are often required to complete basic courses in medical terminology, anatomy, biochemistry and English communication. A high school diploma or GED are also fairly standard prerequisites for such certificate programs.
Program Coursework
While working through the courses in a histology technician certificate program, students will gain a conceptual understanding of histology as well as a practical understanding of histologic techniques. Courses may include:
- Histologic procedures
- Tissue fixation and processing
- Histology clinical practicum
- Chemistry of staining
- Tissue identification
Employment Outlook and Salary Info
The U.S. Bureau of Labor Statistics (BLS), which includes histotechnicians within the category of medical and clinical laboratory technologists and technicians, reported that in May 2012, histotechnicians earned an average salary of $39,340. During the same month, histotechnicians working in hospitals earned an average of $40,050, while those employed in private physician offices made $39,600 and those in outpatient clinics received $39,610. The BLS also reported that medical and clinical laboratory technicians in general held 161,200 jobs nationwide in 2010.
Certification and Continuing Education
The American Society for Clinical Pathologists (ASCP) offers histotechnician certification. In order to gain certification, individuals must have either completed a histology program in the past five years, or else completed an associate's degree program as well as one full year of experience in the histology field. Histotechnicians with a certificate in the field can advance to the position of histotechnologist by completing an associate's degree program in histology.
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text:
Bath Chronicle list all of the beauty product shops in the Bath area. Read reviews from our local users and find the shop that sells all the products you need with Bath Chronicle.
Why not list your Bath beauty products on Bath Chronicle?
Address: 10 New Bond Street, , BATH, BA1 1BE
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Address: Unit 29 The Shires Shopping Centre, , TROWBRIDGE, BA14 8AT
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Address: Unit 22, Brassmill Enterprise Centre, BATH, BA1 3JN
Address: 35 Combe Park, , BATH, BA1 3NR
Address: The Shires, , Trowbridge, BA14 8AT
Address: Unit 11 14 Lansdown Mews, , BATH, BA1 5DY
Address: Newbury House, Aintree Avenue, TROWBRIDGE, BA14 0XB
Address: 6-7 Old Bond Street, , BATH, BA1 1BW
Address: 17 New Bond Street, , BATH, BA1 1BA


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Compare hundreds of teachers based on the criteria that matter to you, including background checks, age and experience.
When you've found the perfect match, schedule your lessons online using the teacher's real-time availability.
Your teacher will welcome you with a personalized curriculum to meet your specific goals and you'll be able to manage your entire schedule through our free online account.
Zero travel time is great for a busy schedule.
Typically priced lower than local lessons.
Online students stick with lessons as long as local students.
Whatever music you want to sing—any style, any time period—I promise I will teach you to sing it in your very best voice. My name is David and I look forward to the opportunity to teach you how to sing your best, whatever style it is you want to learn. I graduated with a Bachelor of Arts in Music at Oregon State University, where I learned how to sing classical music well. In addition to that, I have years of experience in rock-and-roll bands, and have learned how to apply the lessons I learned from my classical voice teachers to my career as a (very) minor rock star. That's exactly what I want to help you with: whatever you want to sing, from any period in music history, I know how to teach you to sing with your best voice. Singing is one of the things that makes us all human and I ...
Sam has been teaching private lessons since 2006 and is currently available to teach online via Skype. He prides myself in tailoring lessons to the specific needs/goals of each individual student. Sam has experience teaching a broad range of students, including individuals looking to gain an appreciation or greater understanding of music, to young musicians competing in state contests and for college scholarships. Sam received his training at the University of North Texas where he earned degrees in Jazz Studies and Music Education. While at UNT, he played lead-alto saxophone in the internationally acclaimed One O'Clock Lab Band for two years. He received his Master of Music degree from the University of New Mexico where he primarily studied classical music. He has recorded numerous ...
Hi, My name is Ken M and I can't wait to meet you! I love playing Saxophone. I've been playing 40+ years, and teaching private lessons for 10 years. I love helping students gain strength, courage and confidence to develop into the musician you're meant to be. We'll learn how you best learn and at your pace. All lessons are tailored specifically to your needs. Here are some general topics covered: posture, breathing, tone and sound quality, scales and chords, improvisation, performance techniques, how to read music & ear training. or just to stop that embarrassing squeaking. We'll discover your creative genius that's been waiting to be found and expressed, so you and others will enjoy the music you make. I look forward to helping you reach your goals!
Hi there, my name is Isaac. I have just started teaching private lessons and am excited to get started! I have been in music since I was in third grade. I started with the piano then progressed to the violin, percussion and the singing. I played piano for two years, violin for six, percussion for six and I have been singing for six. I teach basic piano, and intermediate perc. Voice, and violin. I also teach intermediate music theory. I am very interested in helping people with matching pitch and tonal retention. I am a fun quirky guy. I am a little shy at first but once we get to know each other I think we'll have a lot of fun. I look forward to working with you and helping you reach your goals! :)
Hello! Thanks for taking an interest in my studio! My name is Tad B. I am currently a student in oboe performance at Oregon State University. I am originally from this area and am glad to be back in the beautiful Willamette Valley. My studio includes comprehensive Oboe and English Horn study (technique, literature, reed making, audition preparation), Conducting (instrumental music conducting), beginning and intermediate saxophone, Music theory and Ear Training, and general music exploration. All ages and experiences are welcome, absolute beginner through preparing for serious music study. Please feel free to contact me with any questions, I look forward to hearing from you!
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September 25, 2007
LIMA — It wasn't that long ago that Chris Neff was hard at work, perhaps even goofing off or talking to a friend in the hall on the way to a class, at Apollo Career Center and the Shawnee middle and high schools. This morning, a police and motorcycle escort will take his body past those buildings on his way Patterson Air from Wright Force Base to Chamberlain-Huckeriede Funeral Home for calling hours Wednesday and Thursday. Neff, 19, an Army specialist, was killed Wednesday by an explosion while on patrol in Baghdad, Iraq. Neff's funeral plans were announced Monday. His body will arrive at Wright Patterson this morning with a military escort for a private ceremony, Army. Sgt. David Kuta said. And then, Neff will "come home," as his mother, Nancy Neff, is saying about the trip, Kuta said. A police-escorted procession, including members of the Patriot Guard, motorcyclists who volunteer their time escorting fallen soldiers, will leave the base between 9:30 and 10 a.m. and travel north on Interstate 75 to the Breese Road exit. The procession will travel in front of the Shawnee school buildings and Apollo Career Center on its way to the funeral home. Friends may call at the funeral home from 2 to 8 p.m. Wednesday and Thursday. His funeral will begin at 10:30 a.m. Friday at Shawnee United Methodist Church, with burial immediately after. Neff was assigned to the 1st Battalion, 64th Armor Regiment, 2nd Brigade Combat Team, 3rd Infantry Division at Fort Stewart, Ga. In Iraq, he was an M-1 Abrams tank driver and gunner and a Humvee driver. He completed basic training at Fort Knox, Ky. Neff graduated in 2006 from Apollo Career Center in computer applications programming.


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Cet article est présentement en rupture de stock. Veuillez vérifier plus tard.
Pour obtenir de plus amples renseignements, veuillez composer le 1-888-2020-888.
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Par Liz
de Maple Ridge, BC
I was quite pleased when I received this necklace, it had nice sparkle even though I thought the centre stone was a little too large to be mistaken for real diamonds. I would have kept it but, unfortunately, I couldn't separate the two pieces of the pendant to make it interchangeable, the reason I purchased it. There appeared to be a small bar of silver that was bent in the centre between the two heart sections stopping them from separating. For this reason I had to return this necklace. I would recommend this to a friend, however, if an interchangeable one was available.
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Sparkles Like Diamonds
Par Loyal Shopping Channel Fan
de Pembroke Ontario
This pendant is so brilliant it took my breath away. I purchased it as a gift but I had a very hard time parting with it. The fact that you are able to wear it two ways is an added bonus. It is definitely something that you will get plenty of compliments on.
This pendant surpassed all of my expectations. The diamonelle stones are brilliant and getting two pendants in one is wonderful. It certainly looks much more expensive than what I paid for it.


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Digging up history: Archaeologists pinpoint age of buried Calusa canal in Naples
NAPLES - A part of Naples' past, buried for nearly a century, is beginning to reveal some of its mysteries to a team of history sleuths.
For the first time, archaeologists announced Wednesday that they have carbon-dated wood and soil samples to more closely pinpoint the age of a canal that once ran for almost a mile through present-day Old Naples to connect the Gulf of Mexico and Naples Bay.
"It's starting to bring a piece of our history alive again," said Judy Bishop, executive director of the Naples Backyard History Old Naples Museum.
The oldest part of the sample dated to A.D. 1670, but because the sample was taken from 1 ½ feet above the bottom of the canal, experts estimate the canal could have been dug between A.D. 1200 and A.D. 1400, archaeologists said.
That estimate puts the canal's origin in an era when Calusa Indians ruled the region and seems to dispel nagging doubts about who achieved the engineering feat. Some scholars had credited Europeans, possibly pirates.
Archaeologists hope to return this fall to collect six to 10 more samples from the canal to solidify what is now only a best guess about the canal's age, said Bob Carr, executive director of the nonprofit Archaeological and Historical Conservancy, based in Davie.
"I don't think one date puts anything to rest," Carr said.
He said the canal is similar to four others that have been discovered across South Florida, the only place outside of Mexico where such canals have been found.
One thing surprised Carr about the Old Naples canal: Its relatively recent vintage. Others in Florida have dated to A.D. 200, Carr said.
The Old Naples canal's existence has been known since the 19th century. A survey documented it in 1874, and it appeared on early plat maps of Naples.
Because the canal was filled in the 1920s, present-day Neapolitans have only a tenuous connection to that part of Naples past.
The canal could become a more visible part of the Old Naples landscape with a proposal that the city of Naples create a kind of history trail by marking the canal's path.
The canal runs along a generally diagonal line that starts on the beach between Ninth and 10th Avenue South and ends in Naples Bay south of the City Dock.
It was a modern-day water line project that gave archaeologists their first glimpse of the long-buried canal, Carr said.
They followed backhoes for months until they got to the spot at 10th Avenue South and Gulf Shore Boulevard where maps showed the canal would be unearthed.
When workers began digging up black organic sediment instead of sand, they knew they had hit what had once been a body of water. The base of the canal at that spot was 12 feet wide. Earlier reports show the top of the canal was as wide as 40 feet, Carr said.
With just 20 minutes to work before crews would refill the hole, archaeological technician Scott Faulkner climbed into the trench to collect a soil and wood sample.
The job comes with a historical footnote: Faulkner's grandfather, Naples pioneer James Ernest Carroll Sr. did the work to fill the canal in the first place, history buffs said.
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Mon-Fri: 7am-1am EST / Sat-Sun: 7am-11pm EST
ApplianceMaytag Dryer
Level of DifficultyVery Difficult
Time to do repairMore than 2 hours
Age of Appliance5 - 10 years
NutdriverScrew drivers
4 out of 7 people found this instruction helpful
Getting to any of the parts in the Maytag dryer is easy. Tip the dryer back and slide a 4 x 4 block under the front edge. You remove the whole front panel after you remove two screws at the bottom corners of the front panel. You need to tip the dryer back to get a screwdriver on the screws. Swing the front panel up to release the top of the door panel from the top. Watch the short wires to the door switch. Unhook the door switch wires and move the front panel out of the way. The timer on the top is accessed by re-moving two screws along the top edge. There are four screws. Remove them all and tip the top of the front panel forward. You then see that two screws hold the panel and the other two screws just hold the trim.The dryer started normal. The drum motor run when the start button was operated. The fluff cycle operated normal to indicate the timer motor was OK. On the dry cycles, the igniter heated up. The gas came on. The dryer run for some period of time and then the flame went off. The thought was that the low temp cycle thermostat sensed the dryer was hot and thus switched over to time the cycle to its end. However, the low temp cycle thermostat tested good with a meter when the sensor was removed from the dryer and heated with a light bulb. Burnt contacts in the sensor were a possible problem. I also though the radiant sensor may be bad and not recycling after it got hot. After time, the igniter would cycle on but the gas flame would not come on. I thought the radiant heater might not be tripping the secondary coil on the gas valve. The gas valve coils tested good. I was checking them cold after the dryer had cooled down. I ordered a number of parts.I got lucky and did a test on the coils while the dryer was still hot. One of the coils in the dual booster holding coil was going open when hot. When cold it had enough continuity to let the gas valve cycle on once. After the coil got warm it went open and shut the gas valve off. When the coil did cool off, it again had continuity. I was about ready to trash the dryer when I finely found the problem. I am happy I persisted and worked the problem through to a solution. I purchased several extra sensors but saved money in the long-run. I rate this problem at the high end of complexity for the do-it your self home owner to solve. The problem was an easy fix once the real problem was found. Only 4 screws and 3 push on wire connectors (two were on the front panel for the door switch).
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Part Number: PS334310
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