Manual wheelchair training is one of the eight key phases of for optimizing wheelchair service delivery outlined by the World Health Organization. There appears to be two distinct but related aspects of manual wheelchair training in the literature searched for this chapter; wheelchair skills training and manual wheelchair propulsion training. The former is covered in the Wheelchair Use section and relates to mastering management of the wheelchair in different situations and environments such as ramps, curbs, folding the wheelchair. Propulsion training relates to optimizing propulsion characteristics for each person using a manual wheelchair using the kinetics and kinematics of propulsion such as contact angle, stroke frequency and mechanical efficiency, to affect potential risk for chronic overuse injuries related to propulsion. The latter is reviewed in this subsection.
Table 10: Effect of Wheelchair Propulsion Training
Rice et al. (2013) compared two propulsion training methods to determine the effectiveness of training in relation to contact angle (CA) (angle along the arc of the hand rim), stroke frequency (SF) (number of strokes per unit of time), peak resultant force (Fr) (the maximum forces experienced during the push phase of propulsion), and peak rate of rise of resultant forces (rorF) (how rapidly the forces are applied to the hand rim). Testing was completed using two speeds (1.5 m/s and a speed the participant selected) and three over-ground conditions (tile, medium pile carpet and 1.2° ramp) over three training sessions. The findings suggest that there are immediate benefits to propulsion training with carryover of benefits long term (three months) as compared to the provision of opportunities to practice propulsion but without instruction (control group) regardless of the speed of propulsion or the type of surface used. It is worth noting however, the intervention groups also received weekly phone calls to remind them to continue to practice with the training techniques, the effect of which was not evaluated. Neither intervention required the presence of a health care professional; the multimedia presentation was a five minute video and slide presentation emphasizing the importance of proper technique and defined the key parameters for monitoring such as CA. The second intervention group also received real-time feedback provided using a specialized wheel that collects data related to CA, SF, and velocity. This real-time feedback was projected onto a screen for the participant to view as they were propelling on the dynamometer. Variables were presented randomly and discontinuously in keeping with motor learning theory. It was noted that CA feedback was easier to react to than SF feedback and CA feedback had an inadvertent effect on SF as well.
Rice et al. (2014) examined if intervention that strictly adhered to the Clinical Practice Guidelines for Preservation of Upper Limb Function (Paralyzed Veterans of America) recommendations for wheelchair set up, selection and propulsion skills would decrease shoulder pain and improve satisfaction with life and participation as compared to standard care. Both the intervention group and the control group (standard care group) testing occurred on the same inpatient spinal cord injury rehabilitation program. Similar to Rice, et al. 2013, the intervention protocol also used a multimedia approach (printed material, DVD of propulsion skills and pictures) however different to the above study, therapists provided this training in addition to ongoing education and feedback related to the key concepts from the practice guidelines. All involved therapists received motor learning training in addition to training related to the practice guidelines. The significant findings from this study are fewer than the Rice et al. study; the findings of significance were a lower push frequency on tile at discharge from inpatients and a larger push length across all time points (discharge and six months and one year post discharge) for those who received the training compared to the control group who did not. However, the study did not find significance differences in pain with either pain scale used which differed from previous studies (identified within the article). Ongoing testing and follow-up over several years may be needed to determine if these findings persistent and if pain levels are impacted in the long term.
deGroot et al. (2009) examined the effects, both immediate and sustained, of a verbal and visual training intervention for manual wheelchair propulsion, comparing difference in effects on people with paraplegia versus people with tetraplegia. Researchers found that push length increased and push frequency decreased immediately following training, however push forces increased which was not expected. The authors questioned if this latter finding was an inadvertent result of participants focusing on the propulsion pattern, or a result of efforts to decrease push frequency, participants felt they needed to push harder. Comparison of findings for participants who had a paraplegia and tetraplegia found that push frequency (pushes per second) showed that participants with tetraplegia had a lower push frequency and a higher number of pushes to complete the same ten-meter distance. It is important to note that these comparisons were based on one participant for each group and that the total number of participants with paraplegia versus tetraplegia was four and two respectively.
Blouin et al. (2015) explored the influence of haptic biofeedback on mechanical efficiency propulsion training. Training was completed in five, three-minute training blocks with two one minute pre-and post testing blocks without the feedback. This group developed a simulator which provides feedback by increasing or decreasing the rolling resistance and therefore mechanical effort, as propulsion patterns deviate from or approached the desired pattern respectively. The authors cite that unrestricted increases in propulsion mechanical effective force (MEF) which has been associated with an increase in load at the shoulders, and mechanical inefficiency in propulsion. The authors suggest that through training with haptic biofeedback the MEF can be moderated therefore more efficient with less negative effect on the shoulders. They found that participants could modify their MEF pattern to become more efficient but only during the middle portion of the push phase where the greatest push effort occurred. They also found that the effects of the training were not sustained at post-testing by all participants.
Van der Scheer et al. (2015) completed a multi-centre, non-blinded randomized control study to examine the effectiveness of a low intensity propulsion training program for inactive people with a spinal cord injury for more than 10 years. 29 participants were randomly assigned to the control group who received no intervention or the group who received six weeks of wheelchair propulsion training twice a week for 30 minutes per session. Each participant completed training a treadmill using their own wheelchair. The only difference noted at baseline between the training and control groups was the weight of the w/c. After training, no significant effects were found, with the push frequency being the only parameter that approached a significant decrease. The authors suggest that these results may be due to: 1) the lower intensity and frequency of training, other studies which showed increased had more frequent and more intense training; 2) motor adaption for people who have used a wheelchair long term may require more intervention than long propulsion periods. It is worth noting that the training in this study did not include feedback or training specific to a propulsion technique as in other studies reviewed here, which may also have contributed to the lack of training effect, especially since the participants had been propelling their wheelchair for at least ten years.
There is level 1b (from one blinded RCT study by Rice, L. et al. 2013; one RCT study by Rice et al. 2013; and two pre-post studies by deGroot et al, 2009 and Blouin et al. 2015) evidence that wheelchair propulsion training result in improved biomechanics of propulsion which are sustained over time.
There is level 1b (from one blinded RCT study by Rice, L. et al. 2013; one RCT study by Rice et al. 2013; and one pre-post study by deGroot et al. 2009) evidence that using a multimedia approach results in improved wheelchair propulsion training outcomes.
There is level 2 evidence (from one non-blinded RCT; van der Sheer et al. 2015) to suggest that training programs of low intensity (two 30 minute sessions per week) of only treadmill propulsion may not affect change in wheelchair propulsion for people who have used wheelchairs long term.
Propulsion characteristics of contact angle, stroke frequency and peak force at the handrim, all noted to be important to maintaining upper extremity health during propulsion, can be positively affected through w/c propulsion training.
Clinicians should consider incorporating a multimedia approach, such as video and verbal instruction with observational feedback, into wheelchair propulsion training particularly for people who are new to w/c use.