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Wheeled Mobility and Seating Equipment

Wheelchair Skills

Wheelchair skills represent the specific abilities that wheelchair users need to get around their environments and use their wheelchairs in daily activities. The Wheelchair Skills Training Program (WSTP) is the best known and most tested wheelchair skills training intervention. It is a freely available skills training program for caregivers and users of manual wheelchairs, power wheelchairs and scooters. There are two main measures of wheelchair skills used in the SCI literature reviewed, 1) the Wheelchair Circuit and 2) the Wheelchair Skills Test (WST) (it is the outcome measure used as part of the WSTP). 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. There is also a self-report version of the measure called the Wheelchair Skill Test Questionnaire (WST-Q). Among people with SCI, the best predictors of wheelchair skills on discharge from in patient rehabilitation (measured using the the Wheelchair Circuit) are performance time and ability score at baseline, age, sex and lesion level (de Groot et al. 2010). A study from eight rehabilitation centres in the Netherlands found that wheelchair skills performance, measured using the Wheelchair Circuit was negatively associated with age and lesion level and positively associated with self-efficacy perceptions (Fliess-Douer et al. 2013). The study also found that wheelchair skills performance remained stable during the first year after discharge from rehabilitation. Among people with SCI, return to work five years post injury has been associated with higher wheelchair ability scores, and lower performance time and physical strain as measured using the Wheelchair Circuit (van Velzen et al. 2012).

Author YearCountry
Research Design
Score
Total Sample Size
Methods Outcome
Outcomes of Wheelchair Skills Training
Yeo et al. 2018

Korea

RCT

PEDro=4

N=24

Population: WSTP Group (n=13): Mean age= 35.3 yr; Gender: males=10, females=3; Level of injury: C5-T1; Mean time since injury: 2.9 yr. CG (n=11): Mean age= 35.9 yr; Gender: males=9, females=2; Level of injury:  C5-T1; Mean time since injury: 2.9 yr.

Intervention:   Manual wheelchair users were randomized to either the WSTP (consisting of hands-on demonstrations and practice of wheelchair skills), or the control group (CG) consisting of conventional exercise sessions. Interventions occurred 3x/wk for 8wks.

Outcome Measures:  Wheelchair Skills Test Questionnaire (WST-Q),Van Lieshout Test short version (VLT-SV) (measures arm and hand function).

1.     Compared with the CG, the WSTP group improved in WST score at 4 and 8 wks.

2.     Compared with the CG, the WSTP improved on the VLT-SV at 8 wks.

Kirby et al. 2016

Canada

RCT

PEDro=7

Ninitial=106

Ninitial=82

Population:  WSTP Group (n=53): Mean age= 48.1 yr; Gender: males=51, females=2; Level of injury range: C-T; Mean time since injury: 16.6 yr.  EC Group (n=53): Mean age= 47.1 yr; Gender: males=50, females=3; Level of injury range: C-T; Mean time since injury: 18.2 yr.

Intervention:  Participants were randomized to either the Wheelchair Skills Training Program (WSTP), or the Educational Control (EC) group. Each participant received 5 one-on-one WSTP or EC sessions for 30-45min.

Outcome Measures: Wheelchair Skills Test (WST), Craig Handicap Assessment and Reporting Technique (CHART).

1.     WST scores improved significantly in the WSTP group compared to EC group from baseline to follow-up (p<0.001).

2.     CHART improved significantly for WST group compared to EC group from baseline to follow-up (p=0.21).

Worobey et al. 2016

USA

RCT

PEDro=7

Ninitial=114

Ninitial=79

Population: WSTP Group (n=36): Mean age= 40.1 yr; Gender: males=32, females=4; Level of injury: N/R; Mean time since injury: N/R. CG (n=43): Mean age= 41.0 yr; Gender: males=37, females=6; Level of injury: N/R; Mean time since injury: N/R.

Intervention:   Participants were randomized to either the Wheelchair Skills Training Program (WSTP) consisting of hands-on demonstrations and practice of wheelchair skills, or the control group (CG) consisting of PowerPoint presentation. WSTP group participated in six 90min classes. The CG participated in two 1hr active control sessions.

Outcome Measures:  Wheelchair Skills Test Questionnaire (WST-Q), Goal Attainment Scale (GAS)

1.     Compared with the active control group, the WSTP group improved in WST-Q capacity advanced score (p=0.02), but not in WST-Q capacity or WST-Q performance total scores (p=0.068, p=0.873, respectively).

2.     GAS score did not significantly differ between groups, however those who attended a greater number of classes had a higher GAS score (R=0.531, p=0.001).

Routhier et al. 2012

Canada

RCT

PEDro=7

N=39

Population: Wheelchair Skills Training Program (WSTP) group: Mean age: 48.9 yr, Gender: males=13, females=6; Mean height: 164.5 cm; Mean weight: 83.7 kg. Control group: Mean age: 43.1 yr, Gender: males=13, females=6; Mean height: 163.5 cm; Mean weight: 70.2 kg.

Intervention: Participants were randomly put into either the control group or WSTP group. Both groups were given standard care but the WSTP group was also given a mean of 5.9 training sessions with standard care.

Outcome measures: Wheelchair Skills testing.

1.     Total P(WSTP versus control at t2): p=0.030.

2.     P(t2 versust3): WSTP p=0.990, Control p=0.641.

3.     WSTP training shows improvement in wheelchair skill right after the training particularly in community skills level but the Statistical significance was not reached between groups at 3 mo. follow-up.

Ozturk & Dokuztug 2011

Turkey

RCT

PEDro=5

N=24

Population: Training Group (n=14): Mean age: 38.8 yr; Gender: males=5, females=9. Control Group (n=10): Mean age: 28.7 yr; Gender: males=6, females=4. Injury etiology: SCI=13, Other=11.

Intervention: Participants, who were manual wheelchair users (rear-wheel drive), were randomly assigned to either the training or control (no training) group. The training group received the Wheelchair Skills Program (45 min, 3x/wk for 4 wk). Supervised by a physiotherapist, sessions targeted basic skills and progressed to more advanced wheelchair skills. Session content was developed after a trainer observed the individual in their living environment.

Outcome Measures: Wheelchair Skills Test (WST).

1.     The mean time between baseline and follow-up was 35.5±6.4 days in the training group and 30.8±3.6 days in the control group (p=0.013).

2.     Within-group analysis showed a significant increase in WST performance scores for both the training (p=0.002) and control groups (p=0.01); however, statistically significant improvements for WST Safety scores were only found in the training group (p=0.001).

3.     Comparing between groups, when controlling for baseline WST values, the performance and safety scores remained significantly higher in the training group (p=0.001 and p<0.001, respectively).

Evaluation of Wheelchair Skills Training Approaches
Lalumiere et al. 2018

Canada

RCT Crossover

PEDro=4

N=18

Population: Mean age= 39.3 yr; Gender: males=17, females=1; Level of injury range: N/R; Mean time since injury= 11.7 yr.

Intervention:  Manual wheelchair (MWC) users performed wheelies on four different rolling resistances: natural hard floor (NAT), 5-cm thick soft foam (LOW), 5-cm thick memory foam (MOD), rear wheels blocked by wooden blocks (HIGH). The order of the tests was random. Measurements were taken pre and post intervention.

Outcome Measures: Center of pressure (CoP), center of pressure mean distance (MDIST), center of pressure mean velocity (MVELO), elliptical area (AREA-CE), mean power frequency (FREQ-50%), centroidal frequency (CFREQ), frequency dispersion (FREQ-D).

1.     The MDIST measure values significantly increased (p≤0.001) between the NAT versus LOW and MED versus HIGH conditions.

2.      The MVELO values significantly increased (p≤0.008) between the NAT versus LOW, LOW versus MOD, and MOD versus HIGH conditions.

3.     The AREA-CE significantly decreased (p≤0.002) between the NAT versus LOW and MED versus HIGH conditions.

4.     FREQ-50%, CFREQ and FREQ-D all significantly increased (p≤0.002, respectively) in NAT versus LOW and MOD versus HIGH conditions.

Wang et al. 2015

USA

RCT

PEDro=5

N=21

Population: Experimental Group (n=9): Mean age: 33.2 yr; Gender: males=6, females=3; Level of Injury: T1-L1=9.Controls (n=9): Mean age: 34.5 yr; Gender: males=6, females=3; Level of Injury: T2-12=9.

Intervention: Patients were randomly allocated to an experimental group with immediate video feedback during wheelchair training or a control group with conventional training. Three skills were taught: ramp wheelie and curb. The experimental group observed a video of a model performing the target skill and then attempted to perform the skill whilst being filmed. Patients then reviewed the model video and their own performance to identify differences in performance. All training sessions were conducted 2/wk until the patient had mastered the target skill they had been working on. A skill competency test was administered after 3-4 wks of training followed by a retention test 1 wk after passing the competency test. A transfer test (doing the skill in a different environment) was completed 1d after passing the retention test.

Outcome Measures: Time spent completing wheelchair skills during training and testing, Number of occurrences requiring spotter assistance, Success rates during testing.

1.     There were no significant differences between groups concerning training time required to complete each skill and in the number of spotter assistance for all three tasks, however, the experimental group required significantly less spotter assistance during the curb skill training (p<0.05).

2.     No significant differences were found between groups regarding completion time of the curb skill and the ramp skill during all three tests but the experimental group completed the wheelie skill significantly quicker than the control group during the competency test (p<0.05). There were no significant differences in completion time for the wheelie skill during the retention and transfer tests.

3.     The experimental group required more spotter assistance for the curb skill and yielded a significantly lower success rate than the controls (both p<0.05) during the transfer test.

Discussion

Five intervention studies explored outcomes associated with wheelchair skils training. 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. Yao et al. (2018) all found that after eight weeks participants who received wheelchair skills training had significantly better wheelchairs skills and upper extremity motor skill performance cmparted to people who received education. Worobey et al. (2016) found that after 4-6 weeks of intervention, only participants’ advanced wheelchair skills improved compared to those who received education. 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. In contrast, Kirby et al. (2016), found that significant improvements in Wheelchair Skills Test scores after five training sessions that was maintained 12 months after the intervention. Improvements in mobility participation were also noted. In summary, several studies have demonstrated that wheelchair skills training among people with spinal cord injury can result in immediate improvements in skills; however, there is less certaintly about maintenance of these improvements over time. There is limited research about other outcomes including safety, mobility and social participation.

Two studies evaluated wheelchair skills training approaches. A study by Lalumier et al. (2018), explored different strategies for training wheelchair users to perform wheelies. Although it did not develop a specific protocol, it recommends blocking the rear wheels initially and then rapidly progressing to foam or natural suraces to improve postural control strategies and refine skills. 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).

Conclusion

There is level 1b evidence (from five RCT studies: Kirby et al. 2016; Ozturk et al. 2011; Routhier et al. 2012; Worobey et al. 2016; Yeo et al. 2018) 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 1b evidence (from two randomized control studies by Routhier et al. 2012 and Kirby et al. 2018) that vary regarding how well skills learned are retained.

There is level 2 evidence (from one randomized control study: Lalumiere et al. 2018) that when learning to perform wheelies improvements in postural stability are noted when the rolling resistance is increased.

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