Skills Training and Education

Over time, there has been increasing interest and recognition in SCI-related education during rehabilitation. Patient education aims to help patients reintegrate into the community and improve quality of life through instruction on a variety of topics (Bernet et al. 2018; van Wyk et al. 2015). Educational topics that are often addressed include: learning how to self advocate, how to prevent, recognize and respond to adverse health complications, as well as coping strategies (Bernet et al. 2018). As a result, patients learn how to manage their everyday life, take responsibility for their health and assume an active role in the treatment process (van Wyk et al. 2015). Consequently, patients may feel more motivated and confident in their abilities to deal with the physical and psychological consequences of a SCI (van Wyk et al. 2015).

The efficacy of patient education in other chronic diseases, such as diabetes or arthritis, has been well documented. Multiple systematic reviews reported that patient education improves disease specific knowledge (Barlow et al. 2002; Bennett et al. 2009; Shaw et al. 2009; Coster & Norman 2009) and reduces symptoms (Deakin et al. 2005; Gibson et al. 2009; Riemsma et al. 2009; Warsi et al, 2004). However, a lack of research investigating the effects of patient education or educational strategies in individuals with SCI exists.

The majority of skills training and education literature found focused on upper limb function in wheelchair use. The methodological details and results from these studies are presented in Table 3.

Table 3 Education Interventions

Author Year

Research Design

Total Sample Size

Methods Outcome
Yeo et al., 2018





Population: Intervention (n=13): Mean age=35.3±4.7 yr; Gender: males=10, females=3; Time since injury: 2.9 yr; Level of injury: T1 – C7; Severity of injury: AISA A=0, B=8, C=5, D=0.

Control (n=11): Mean age=35.9±5.3 yr; Gender: males=9, females=2; Time since injury: 2.8 yr; Level of injury: T1 – C7; Severity of injury: AISA A=0, B=7, C=4, D=0.

Intervention: Participants were randomized to a training group (n=13) or a control group (n=11). The training group attended wheelchair skills training sessions, whereas the control group attended conventional exercise sessions (three d/wk for eight wk). Outcome measures were assessed at baseline, four and eight wk.

Outcome Measures: Wheelchair skills test (WST); Van Lieshout test (VLT).

1.     WST significantly improved over time compared with controls (p<0.05); WST significantly improved from baseline within the training group.

2.     No significant differences occurred in VLT between groups over time (p>0.05); VLT significantly improved from baseline in both groups (p<0.05).

Rice et al., 2014





Population: Intervention Group (IG; n=12): Mean age: 33.2±14.3 yr; Gender: males=9, females=3; Level of injury: paraplegia=12, tetraplegia=0; AIS level: A=6, B=1, C=3, D=1, Not rated=1.

Standard Care Group (SCG; n=25): Mean age: 40.8±16.4 yr; Gender: males=19, females=6; Level of injury: paraplegia=22, tetraplegia=3; Severity of Injury: AIS A=14, ASI B=3, AIS C=5, AIS D=1, N/R=2.

Intervention: All participants were independent manual wheelchair (MWC) users. The intervention group was strictly educated on the Paralyzed Veterans of America’s Clinical Practice Guidelines (CPG) for Preservation of Upper Limb Function by a physical therapist and an occupational therapist in an inpatient rehabilitation facility. The standard of care group received standard therapy services.

Outcome Measures: Comparison of wheelchair setup, selection, propulsion biomechanics, Numeric Rating Scale (NRS), Wheelchair Users

Shoulder Pain Index (WUSPI), and Satisfaction With Life Scale (SFWL), Craig Handicap Assessment and Reporting Technique (CHART) scores.

1.     In wheel chair set-up, no significant interaction, between-subject differences, or within subject differences were found between study groups (p>0.05).

2.     Although differences were not significant, the percentage of IG participants within the guideline recommendation increased by 25% while the percentage of SCG participants within the guideline recommendation decreased by 5%.

3.     No significant differences were found between groups in wheelchair selection (p>0.05); however, 100% of the IG participants had an ultralight MWC at 6mon and 1 yr compared with 68.8% (6 mon) and 77.8% (1Y) of the SCG participants.

4.     IG propelled with a significantly lower push frequency than the SCG on tile (p<0.02) and on a ramp (p<0.03) but not carpet (p=0.10).

5.     No significant differences were found between NRS or WUSPI scores in the IG and SCG (p>0.05).

6.     A simple main effect trend (p=0.07) found that the IG had an increase in the CHART physical subsection scores between 6-mon and 1 yr and an increase in the occupational subsection scores between 6 mon and 1 yr (p=0.07).

Effect Sizes: Forest plot of standardized mean differences (SMD±95%C.I.) as calculated from pre- and post-intervention data.

Curtis et al., 1999





Population: Mean age: 35 yr; Gender: males=35, females=7; Level of injury: cervical-lumbar; Mean duration of wheelchair use: 24 yr.

Intervention: Both groups completed the Wheelchair Users Shoulder Pain Index (WUSPI) every two mo for six mo. The experimental group attended a 60 min educational session where they were instructed in five shoulder exercises.

Outcome Measures: Wheelchair User’s Shoulder Pain Index (WUSPI), Visual Analog Scale (VAS).

1.     There were no significant differences between control and experimental group in age, yr of wheelchair use or activity levels.

2.     When looking at the effect of exercise of intervention on performance corrected (PC) WUSPI, a two factor repeated measures ANOVA showed a significant effect of time only (p=0.048).

Effect Sizes: Forest plot of standardized mean differences (SMD±95%C.I.) as calculated from pre- and post-intervention data.


The majority of studies evaluated the effects of wheelchair education on preventing shoulder pain or increasing wheelchair skills. Rice et al. (2014) tested the efficacy of providing educational training using the PVA Clinical Practice Guidelines for Preservation of Upper Limb Function among manual wheelchair users. As a result of educational training, individuals with new SCI were able to increase their wheelchair skills to improve push frequency and length. However, no significant differences were reported in Craig Handicap Assessment and Reporting Technique (CHART) scores. Similarly, Yeo and colleagues found a significant increase in wheelchair skills with educational training (2018). However, both of these studies did not utilize outcome measures reporting on quality of life via ADL task assessment or functional independence measures (FIM). One study found that shoulder exercise education improved shoulder pain, which may translate to improvements in QOL, however this was not objectively measured (Curtis et al. 1999). In summary, providing patient education may improve wheelchair skills and reduce shoulder pain, however, it is unclear whether this directly impacts patient quality of life.

Further research in this area should focus on: (1) practical components of the educational program, (2) determining if differences in propulsion skills result in improvements in pain and/or quality of life, and (3) determining if improvements are maintained over the long-term.


There is level 1b evidence (from two randomized controlled trials: Yeo et al. 2018; Rice et al. 2014) that education improves wheelchair skills.

There is level 2 evidence (from one randomized controlled trial: Curtis et al. 1999) that education about shoulder exercises reduces the intensity and duration of shoulder pain post SCI.