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Wheelchair Skills

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Wheelchair skills represent the specific abilities that wheelchair users need to get around their environments and use their wheelchairs in daily activities. There are two main measures of wheelchair skills used in the SCI literature reviewed, 1) the Wheelchair Circuit and 2) the Wheelchair Skills Test. The Wheelchair Circuit Examples includes eight to nine tasks: figure-of-eight shape, doorstep crossing, mounting a platform, 15 m sprint, 15 m walk (for those who ambulate), driving on a treadmill up slopes of 3% and 6%, wheelchair driving (on treadmill five minutes at a speed of 0.83 m/s), and transfer. Sub-scale scores for ability (ordinal scale); performance time (seconds); and physical strain (using HR data) are calculated. The Wheelchair Skills Test is an evolving measure. There is an objective version in which a rater documents a wheelchair user’s capacity to perform indoor, community and advanced wheelchair skills. Indoor wheelchair skills include the ability propel the wheelchair forwards and backwards on level surfaces, turn the chair, get in and out of the chair, negotiate doors, get objects from the floor and upward reaching. Examples, of community skills include folding and unfolding the wheelchair, and negotiating curbs, shallow ramps and cross slopes. Advanced skills include negotiating steeper slopes and performing wheelie related skills. The Wheelchair Skills Training Program is a freely available skills training program for caregivers and users of manual wheelchairs, power wheelchairs and scooters, which uses the Wheelchair Skills Test as an outcome measure.

Lemay et al. (2012) and Oyster et al. (2012) describe Canadian and American profiles respectively, of manual wheelchair skills for people with tetraplegia and paraplegia injury levels. Fliess-Douer et al. (2012) sought to establish a hierarchy of wheelchair skills required for daily life from the perspective of people with spinal cord injury who use manual wheelchairs.

Table 15: Wheelchair Skills

Discussion

An observation study by Taylor et al. 2015 documented the most frequently taught wheelchair skills, among a sample of 1296 people with spinal cord injury who were in in-patient rehabilitation. Among manual wheelchair users the most frequent skills taught were propulsion (includes different surfaced and inclines) (median four sessions), wheelies (median three sessions) and curbs (median two sessions). Among power wheelchair users, the most frequently taught skills were propulsion (median three sessions), chair positioning (e.g., power tilt, recline, elevation) (median two sessions) and elevators (median one session).

Using the International Classification of Functioning Disability and Health as a Framework, Morgan et al. (2015) conducted focus groups with users and prescribers to identify wheelchair skills that should be taught. Important wheelchair skills identified included transfers, propulsion techniques, wheelchair maintenance, and negotiating curbs, ramps and rough terrain. Community based training was emphasized.

Three studies that explored predictors of Wheelchair Circuit scores found older people and those with higher level lesions generally performed less well. In an observational study using the Wheelchair Circuit, Fliess-Douer et al. (2013) found that performance time was significantly higher and ability scores were significantly lower among older patients, patients with tetraplegia, and those with lower self-efficacy. A cohort study by De Groot et al. (2010) that used multivariate analysis found that discharge performance time and ability scores on five non-treadmill tasks and all eight tests in the Wheelchair Circuit were significantly associated with baseline wheelchair ability scores on the five non-treadmill tasks, ability scores on all eight tasks and performance time. Age was negatively associated with discharge scores and lesion level was significantly predictive only for performance time.

Two studies found that Wheelchair Circuit scores were positively associated with participation and health outcomes. A cohort study by Kilkens et al. (2005b) that used multivariate analysis found that after controlling for demographic and SCI related variables, the addition of Wheelchair Circuit variables (ability, time and strain) increased the variance of Sickness Impact Scores explained by 33%, although ability was the only significant, independent predictor. A cohort study among patients with SCI in in-patient rehabilitation by Van Velen et al. (2012) identified that patients with higher peak aerobic power output higher wheelchair ability scores, lower performance time and lower physical strain scores were more likely to return to work.

Three intervention studies in this area were identified. Wang et al. 2015 compared conventional skills training and a video feedback intervention, in which the experimental group observed a video of a model performing the target skill and then attempted to perform the skill while being filmed. Patients then reviewed the model video and their own performance to identify differences in performance). The interventions were generally quite similar, although the experimental group needed less spotter interventions during the initial testing and required more during transfer testing and had a lower success rate (i.e., it may be less effective when getting participants to transfer curb climbing they have learned in one setting to a different setting). Routhier et al. (2012), examined the effect of skills training on wheelchair skills, measured using the Wheelchair Skills Test. This study found a significant improvement in skills immediately after training, but that the difference was not significant at three months follow up. Similarly, Ozturk et al. (2011) found a four-week skills training program for community dwelling manual wheelchair users in Turkey resulted in significant improvements in performance and safety immediately after training (measured using the Wheelchair Skills Test); however, longer term changes were not measured.

Lemay et al. (2012) described the manual wheelchair skills profile of 54 people with a spinal cord injury who had at least 12 months of experience with a manual wheelchair. Description was based on the speed and distance of w/c mobility at home and in the community compared with demographic data and manual w/c experience. The authors note that a score of 80% or better is empirically indicative of advanced wheelchair skills with advanced skills primarily being associated with wheelie skills. In their sample, they found 55.6% of participants scored over 80% on the Wheelchair Skills Test-M, however only 26% of participants with a tetraplegia injury level scored 80% or over (four of 14 participants). The profile of greater w/c skills suggested by the reported findings is that of younger, unemployed people with a lower level spinal cord injury; w/c use experience was not associated with higher level of skills. The authors identify this profile as consistent with other studies.

Oyster et al. (2012) examined wheelchair skill performance of people with a spinal cord injury who use a manual wheelchair as their primary means of mobility. Data was collected from six model SCI Systems resulting in a sample size of 212 participants however the findings reported in this article were limited. No statistical descriptions were provided outside of general percentage calculations for what was termed advanced level skills. The authors indicate that the majority of participants were unable to complete community and advanced level Wheelchair Skills Testskills, which they identified as being associated with wheelie skills. They suggest that this lack of wheelchair skill may relate to lack of training opportunity due to shorter lengths of rehabilitation stays and/or poor fit of the wheelchair.

Fliess-Douer et al. (2012) compared the results of a pilot study to the results of the current study as a means to establish a hierarchy of the most essential wheeled mobility (WM) skills for everyday life in order to develop a universal wheeled mobility test. Their goal was to develop a test, which included perspectives of people who use manual wheelchairs, not just clinical professionals. The authors developed a wheeled mobility survey in which participants were asked to rate each of 24 skills on a five-point scale as to their essentiality for people with spinal cord injury to function in daily life. The survey was piloted in a study which included purposively selected people with spinal cord injury (N=47, T4-L4) who represented different activity levels (non-active, recreational and elite athletes). The current study was conducted with Paralympians during the Beijing games, which the authors justified as proposing this group may demonstrate the best WM skills therefore could provide the benchmark of optimal w/c skills. These participants were also surveyed regarding their perceptions of the level of wheeled mobility skills gained during and post rehabilitation and the amount of time dedicated to teaching wheeled mobility skills during rehabilitation. The authors report similar findings between the current study and the pilot study in relation to the most and least essential skills, however it is worth noting that in the pilot group 25 of the 47 participants were also elite athletes. The authors also identify that less than half of participants in this study learned the most essential skills from professionals and slightly more than half while in rehabilitation. The authors did present the data from the pilot study related to the rating of the 24 WM skills, in groupings of the current study, the pilot study and the pilot study with the elite athletes’ data removed, however no comparisons were made or significance calculations completed for the latter group compared to the current study.

Hosseini et al. (2012) proposed, based on research literature, that community mobility and safety require proficiency in wheelchairs skills, and that the ability to be mobile in a wheelchair is an important component of quality of life and independent function. The purpose of their study was to examine the wheelchairs skill success rates of 214 people with paraplegia and tetraplegia who use manual wheelchairs, to determine characteristics associated with lower wheelchair skills, and to characterize the relationship between wheelchair skills and measures of community participation and quality of life. They found that eight wheelchair skills had a success rate of less than 75%. These eight skills are considered advanced wheelchair skills (folds/unfolds w/c, ascend and descend 15 cm curb, hold 30 second wheelie, turn 180° in wheelie, ground to w/c transfer, ascend and descend stairs). They found that participants with paraplegia performed this skills with greater success than participants with tetraplegia, but authors expressed surprise that the success rates were not higher in both groups given they use manual wheelchairs as their primary means of mobility. Characteristics associated with higher wheelchair skills included gender (male), employment status (employed), age (younger age at injury), and level of injury (paraplegia). The authors conclude that higher success rated in the above eight skills as well as total WST predict higher quality of life in six outcome measures including, self-perceived health, higher life satisfaction, and increased community participation.

Conclusion

There is level 1b evidence (from two RCT studies; Ozturk et al. 2011; Routhier et al. 2012) that manual wheelchair skills training causes an immediate improvement in wheelchair skills.

There is level 2 evidence (from one RCT study; Wang et al. 2015) that video feedback during training produced similar results as conventional training.

There is level 5 evidence (from one observational study; Kilkens et al. 2005c) that wheelchair skills improve from admission to three months post admission to discharge among inpatients in rehabilitation.

There is level 4 evidence (from two pre-post studies; Fliess-Douer et al. 2013; De Groot et al. 2010, one cross sectional post-test; Hosseini et al. 2012 and one observational study; Kilkens et al. 2005b) that wheelchair skills are affected by age and lesion level and lower self-efficacy is associated with slower wheelchair skill performance times and lower ability scores.

There is level 5 evidence (from two cross sectional studies; Lemay et al. 2012, Oyster et al. 2012) that advanced skills primarily associated with wheelie skills (e.g., ascending/descending a 15 cm curb or stairs, maintaining a stationary or moving wheelie position) are not learned by the majority of people who use manual wheelchairs.

There is level 5 evidence (from one cross sectional study; Fliess-Douer et al. 2012 and one qualitative study; Morgan et al. 2015) that the wheelchair skills that are essential for daily life functioning are a mix of basic and advanced skills, including negotiating curbs, ramps and rough terrain and propelling forward at least 50 meters.

There is level 5 evidence (from one observational study; Taylor et al. 2015) that the most frequent skills taught among manual wheelchair users are propulsion, wheelies and curbs.

There is level 4 evidence (from one pre-post study; Van Velzen et al. 2012 and one cross sectional post-test; Hosseini et al. 2012) that higher wheelchair skills in addition to higher peak aerobic power output, lower skill performance time and lower physical strain are associated with increased quality of life, and the likelihood of returning to work five years after SCI.

There is level 5 evidence (Kilkens et al. 2005a) that Wheelchair Circuit variables (ability, time and strain) are associated with the impact of disability on physical and emotional functioning.

  • There is good evidence that wheelchair skill training can improve skills in the short term and that video feedback produces similar results as conventional skill training.

    There is evidence that propulsion skills are most commonly taught to wheelchair users during in-patient rehabilitation and that advanced w/c skills, particularly wheelie related skills, are not learned by most people.

    The focus of wheelchair skills training during shortening rehabilitation stays should consider the person’s home and community environments and activities is needed as it is suggested that not all skills are essential to functioning in daily life.