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).
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.
