Wheelchair Skills Assessment and Training

Original Editor - Lee Kirby as part of the Wheelchair Service Provision Content Development Project

Original Contributors - Lee Kirby with Paula W. Rushton, Cher Smith, François Routhier, Krista L. Best, Rachel Cowan, Ed Giesbrecht, Alicia Koontz, Diane MacKenzie, Ben Mortenson, Kim Parker, Emma Smith, Sharon Sonenblum, Amira Tawashy, Maria Toro, Lynn Worobey as part of the Wheelchair Service Provision Content Development Project

Top Contributors - Naomi O'Reilly, Kim Jackson, Simisola Ajeyalemi, Robin Tacchetti, Tarina van der Stockt, Rucha Gadgil, Amrita Patro, Olajumoke Ogunleye, Ewa Jaraczewska and Stacy Schiurring  

Introduction

The 2023 World Health Organization (WHO) Wheelchair Provision Guidelines represent a significant evolution in wheelchair service delivery, updating the 2008 Guidelines on the Provision of Wheelchairs in Less-Resourced Settings. These new guidelines are global in scope and apply to all wheelchair users and types of wheelchairs, including manual wheelchairs, powered wheelchairs, and scooters. The guidelines emphasise that the best outcomes in wheelchair access occur when wheelchair users have the benefit of an individual process of assessment, fitting, training, and follow-up, provided by appropriately trained personnel.

According to the 2023 WHO Wheelchair Provision Guidelines the four wheelchair service steps are Select, Fit, Train, and Follow-up. The Select step involves individual assessment and selection of an appropriate wheelchair. The Fit step includes preparation and fitting of the wheelchair for the wheelchair user. The Train step provides information and training for wheelchair users to maximise their safe and efficient use and care of the product. The Follow-up step ensures the wheelchair continues to meet the user's needs over time. These four steps begin once a person identifies, or has been identified, as needing a wheelchair and accesses a wheelchair service. The guidelines emphasise that wheelchair provision through this service model provides the foundation for positive outcomes related to health, function, and participation.

This Physiopedia Page provides an introductory overview of wheelchair skills assessment and training applicable to various wheelchair users. While examples may reference specific populations (such as people with spinal cord injury or cerebral palsy), the principles and approaches discussed are broadly applicable across diagnoses and age groups.

Important Safety Consideration

Some wheelchair skills, particularly advanced skills such as wheelies, curb negotiation, and stair climbing, can be dangerous and result in severe injury or death if attempted without the assistance of one or more experienced spotters. Proper spotting techniques and safety protocols must always be followed during skills training. Details about spotting can be found in the Wheelchair Skills Program Manual (see Resources section at bottom of page).

Assessment of Wheelchair Skills

Purpose and Timing of Assessment. As recommended in the WHO 2023 Guidelines, wheelchair skills assessment should be integrated throughout the wheelchair provision process. Assessment serves multiple purposes and should occur at several key timepoints. Initial assessment establishes baseline capacity and identifies training needs. During the selection and fitting process, assessment allows comparison of how well the wheelchair user can perform skills with different wheelchair configurations such as rigid versus folding frames, different axle positions, or manual versus powered mobility. Post-training assessment evaluates the effectiveness of training interventions. During follow-up, assessment helps determine what revisions in the wheelchair or additional training may be needed.

Wheelchair Assessment Outcome Measures

The Wheelchair Skills Test (WST). The Wheelchair Skills Test is an objective, standardised measure for assessing the capacity of wheelchair users to safely perform the skills they need in their everyday lives. The WST has demonstrated good measurement properties and is available in multiple versions for manual wheelchairs, powered wheelchairs, and scooters, with separate versions for wheelchair users and caregivers.

The WST assesses both safety and performance. The manual wheelchair version includes 33 skills while the powered wheelchair version includes 25 skills. The test typically takes approximately 30 minutes to administer and demonstrates strong test-retest reliability and validity. The WST evaluates skills across a range of difficulty levels while remaining functional and relevant to everyday wheelchair use. Skills are scored on a pass/fail basis, with separate scores for safety and performance components.

The Wheelchair Skills Test Questionnaire (WST-Q). The WST-Q is a questionnaire version of the WST that offers a practical alternative when objective testing is impractical or impossible. The WST-Q assesses three important dimensions: capacity (what the wheelchair user is able to do, similar to the objective WST), performance (what the wheelchair user actually does in daily life), and confidence (how confident the wheelchair user feels performing each skill). The WST-Q typically takes approximately 10 minutes to complete and has demonstrated high internal consistency, strong test-retest reliability, and good concurrent validity with the objective WST. The questionnaire format makes it particularly useful for large-scale assessments, research studies, and situations where in-person testing is not feasible.

Beyond skills assessment, comprehensive evaluation of wheelchair provision outcomes may include various measures. Participation can be assessed using tools such as the Canadian Occupational Performance Measure (COPM) or the Wheelchair Outcome Measure (WhOM). The Wheelchair Use Confidence Scale (WheelCon) measures self-efficacy in wheelchair use. The Quebec User Evaluation of Satisfaction with Assistive Technology (QUEST) evaluates satisfaction with both the device and services provided. General quality of life measures can assess the broader impacts of wheelchair provision on overall well-being.

Training of Wheelchair Skills

Research evidence supporting wheelchair skills training has grown substantially in recent years. Research has provided moderate quality evidence that wheelchair skills training is effective and safe. Training improves wheelchair skills capacity scores by approximately 14% compared to no treatment or standard care, representing a relative increase of 21% over baseline scores. Training effects are particularly pronounced for new wheelchair users. Skills improvements are retained over time, with no significant declines between immediate post-training and follow-up assessments. Training has positive effects on other outcomes including confidence, participation, and satisfaction. Importantly, no serious adverse events have been reported in training studies. Recent evidence has expanded beyond manual wheelchair users to demonstrate effectiveness in powered wheelchair training for both adults and children, including young people with cerebral palsy who showed improvements in both mobility skills and participation outcomes.

Wheelchair Skills Training Program

The Wheelchair Skills Training Program (WSTP) combines the best available evidence on motor skills learning principles with the best available evidence on wheelchair skill techniques. The WSTP can be used during initial provision of the wheelchair and as necessary at follow-up.

Foundation in Motor Learning Principles:

The WSTP integrates established motor learning principles to optimise skill acquisition and retention. Key principles include goal setting (establishing clear, achievable goals collaboratively with the wheelchair user), demonstration (providing visual models of correct technique), and practice structure (organising practice sessions to promote learning, including considerations of blocked versus random practice and whole versus part practice). Attentional focus directs attention to optimal aspects of performance, typically using an external focus rather than an internal focus. Appropriate feedback in terms of type, timing, and frequency supports learning. Skills progression moves systematically from simple to more complex versions. Strategies to promote retention and transfer ensure long-term maintenance of skills and their application to real-world contexts. Recent research has emphasised the importance of explicitly grounding training programmes in motor learning theory, though only a minority of published wheelchair training programmes have reported doing so. Programmes that incorporate motor learning principles with adequate practice repetitions (typically 300-700 repetitions per session) have demonstrated favourable changes in wheelchair propulsion technique and skills performance.

Training Content and Skills Progression

Wheelchair skills training typically progresses through levels of increasing complexity, though the specific skills addressed should always be individualised based on the user's goals, environment, and functional requirements.

Basic skills may include getting in and out of the wheelchair (transfers), maintaining posture and performing pressure relief, propelling forwards and backwards on level surfaces, stopping safely, turning in place and whilst moving, manoeuvring through doorways, and managing brakes and other wheelchair components.

Intermediate skills may include folding and unfolding wheelchairs (if applicable), navigating different surfaces (carpet, grass, gravel), managing inclines and ramps (ascending and descending), negotiating side-slopes, and performing transfers to different surfaces and heights.

Advanced skills may include ascending and descending curbs, navigating stairs (with assistance where appropriate), performing wheelies and wheelie-dependent skills, picking up objects from the ground, and managing complex environmental challenges. For powered wheelchair users, training content focuses on control proficiency, spatial awareness, and safe navigation through various environments including managing thresholds, tight spaces, and different terrains.

Please read this optional Physiopedia Page to learn more about Wheelchair Skills.

Delivery of Training

Training Format. Research supports various training formats, including (1) individual one-on-one training sessions, (2) small group training, (3) peer-led training approaches, (4) caregiver training (when the caregiver will be assisting with wheelchair use), and (5) hybrid approaches combining in-person and virtual training. The optimal number and duration of training sessions varies depending on the individual's needs and goals. Published studies have used formats ranging from three intensive sessions to 12 sessions over several weeks. Generally, 5-12 training sessions of 30-60 minutes appear effective for achieving meaningful improvements in skills.

Training Environment. Training should progress from controlled clinical environments to real-world community settings. This progression helps ensure skills transfer to the environments where they will actually be used. Community-based training approaches have shown promise for improving not only skills but also participation and social inclusion.

Individualisation. While training programmes provide structured protocols, personalisation according to individual needs and goals is essential. Each training session should target skills that are meaningful and relevant to the wheelchair user's specific life context. Goal Attainment Scaling can be used to document individualised goals and measure their achievement throughout the training process.

Follow-Up and Ongoing Support

The WHO 2023 guidelines emphasise follow-up as an essential component of wheelchair provision. Follow-up serves multiple purposes including reassessment (evaluating whether the wheelchair continues to meet the user's needs as their condition, lifestyle, or environment changes), maintenance and repair (addressing equipment issues promptly to prevent breakdowns that impair mobility and participation), additional training (providing refresher training or teaching new skills as needed), and participation monitoring (assessing whether the wheelchair is enabling participation in desired activities). Research demonstrates that wheelchair quality, including repairability and reliability, plays a significant role in participation outcomes. Systematic evaluation of wheelchair provision, including follow-up services, is important for continuous improvement of wheelchair services.

Emerging evidence suggests that telehealth may offer one option for improving access to follow-up services, particularly for wheelchair users in rural areas or those facing significant travel burdens, though further research is needed to establish effectiveness across different populations and service contexts.

Conclusion

Wheelchair skills assessment and training are essential components of wheelchair provision, as emphasised in the 2023 WHO Wheelchair Provision Guidelines. High-quality evidence demonstrates that structured wheelchair skills training is effective, safe, and leads to clinically meaningful improvements in wheelchair skills, confidence, and participation outcomes.

Rehabilitation professionals play a crucial role in ensuring wheelchair users have the skills necessary to use their wheelchairs safely and effectively in their daily lives. By integrating evidence-based assessment and training approaches into practice, clinicians can help wheelchair users achieve optimal outcomes in mobility, independence, and quality of life.

Resources

Clinical Resources

• Wheelchair Skills Program Manual (Version 5.4)
• WHO Wheelchair Service Training Package - Basic level (available in Arabic, Chinese, English, French, Italian, Japanese, Khmer, Portuguese, Romanian, Spanish, Thai, Turkish, Ukrainian, and Vietnamese)
• WHO Wheelchair Service Training Package - Intermediate level (available in Chinese, English, French, Japanese, Korean, Romanian, and Spanish)

Forms

Wheelchair Skills Test (WST) Form;

• Manual Wheelchairs Operated by Their Users
• Manual Wheelchairs Operated by Caregivers

Wheelchair Skills Test Questionnaire (WST-Q)

• Manual Wheelchairs Operated by Wheelchair Users Form and Script
• Manual Wheelchairs Operated by Caregivers Form and Script

References