Wheelchair Skills Assessment and Training

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Introduction

The 2008 World Health Organization (WHO) Guidelines on the Provision of Wheelchairs in Less-Resourced Settings has been discussed in earlier sections of this Course. The WHO Guidelines suggest an 8-step service-delivery process that includes assessment by professionals, the development of a wheelchair prescription with the involvement of the wheelchair user and family, assistance (if needed) with the organization of funding for the wheelchair, proper fitting and adjustment of the wheelchair, training of the wheelchair user and caregiver in maintenance and wheelchair handling skills, and long-term follow-up for refinements, routine servicing and periodic replacement. 

Two important elements in this care pathway are wheelchair skills assessment and training for wheelchair users and their caregivers. The Wheelchair Skills Program is a set of assessment and training protocols related to wheelchair skills. There has been a growing number of peer-reviewed papers about the measurement properties of the assessment methods and effectiveness of the training protocols (including two systematic reviews and meta-analyses).

Scope

Due to constraints of time and space in this Course and the scope of practice of most physiotherapists, this page will focus on the training of manual wheelchair users using two-handed propulsion (e.g. those using wheelchairs due to spinal cord injury). Therapists interested in material beyond this scope, can use the Wheelchair Skills Program Manual to complement the material presented here. The materials presented in this page of the Course here have been excerpted from Version 5.0 of the Manual.

Warning

Some of the wheelchair skills addressed in this section can be dangerous and result in severe injury or death if attempted without the assistance of one or more experienced spotters.Details about spotting can be found in Chapter 2 the Wheelchair Skills Program Manual.

Assessment of Wheelchair Skills

As recommended in the WHO Guidelines, a new wheelchair user should go through an 8-step process in the course of his/her wheelchair service delivery. One of those steps is assessment. As part of this assessment, the wheelchair skills of the wheelchair user should be assessed. This should be done at intake, as part of the prescription and fitting steps (e.g. to compare how well the wheelchair user can perform skills with a rigid vs. a folding wheelchair, or with the rear axles in more and less stable positions) and during follow-up to determine what revisions in the wheelchair are needed. 

The Wheelchair Skills Test (WST), details about which can be found in Chapters 4 and 5 of the Wheelchair Skills Program Manual, is a means of assessing the capacity of wheelchair users to safely perform the skills they need in their everyday lives. Interested Course participants may optionally view a video of a complete WST being performed by a person with spinal cord injury and read the associated WST Report Form. Information about the questionnaire version of the WST (WST-Q) can be found in Chapter 6 of the Wheelchair Skills Program Manual. In addition to assessing capacity like the WST does, the WST-Q assesses confidence in performing the skill and how often these skills are performed. To better understand what can reasonably be expected of a person with spinal cord injury, you may wish to read the paper by Kirby et al.

Training of Wheelchair Skills

Another WHO step is training, that includes wheelchair skills training of the wheelchair user and/or caregiver. 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 the initial provision of the wheelchair and as necessary at follow-up. 

Chapter 7 of the Wheelchair Skills Program Manual provides a practical overview of the motor skills learning literature, addressing such topics as goal setting, demonstration, the structure of practice sessions, the focus of attention, the use of imagery, the nature and timing of feedback, skill segmentation, progression from simple to more complex versions of skills and steps that can be used to facilitate skill retention and transfer. However, for the purpose of this Course, we will focus on technique, that is how best to train manual wheelchair users to perform specific skills.

Rolls Forward

Description and Rationale

The learner moves the wheelchair forward on a smooth level surface. Forward rolling is a skill used during many wheelchair activities. Most bouts of wheelchair use are relatively short but occur many times a day.The ability to manage longer distances allows wheelchair users to get around in the community (e.g. getting from a parking lot to an office or getting around inside a store). 

General Training Tips

There are three segments of this skill: starting, rolling straight and stopping. Stopping will be dealt with separately later.

• When first attempting to move forward, the direction in which any swivel casters are trailing can lead to someinitial resistance to movement or lateral deviation as movement begins. The learner should reposition the casters in the appropriate direction before setting out. Learning how to reposition the casters is a technique that is useful for a number of skills. To reposition the casters, the wheelchair should be moved short distances in a manner that causes the casters to swivel (e.g. forward, then left, than backward, then right).
• When starting to roll forward, the wheelchair user should lean forward slightly and avoid overly vigorous accelerations that could cause the wheelchair to tip over backward.
• Once up to speed, each propulsion cycle includes propulsion and recovery phases.

Propulsion Phase:

Propulsion mechanics vary with the task and the characteristics of the wheelchair user. However, on smooth, level surfaces there are some general guidelines that should be considered the starting point.

• During the propulsion phase, the hands should initially match the speed of the moving wheels. 
• To propel the wheelchair straight forward, the wheelchair user should grasp the hand-rims and push evenly with both hands. He/she should not wrap the thumbs around the hand-rims, but point them forward.
• The wrists should be in a roughly neutral orientation, avoiding the extremes of range.
• To improve friction, if necessary, the wheelchair user may rest the palms of the hands on the tires in addition to using the hand-rims.
• The wheelchair user should lean forward as the elbows are extended during the latter part of the propulsion phase, to get more contact time between the hands and the hand-rims and to reduce the chance of a rear tip. This is the first example of a skill that can benefit by leaning. Because the weight of most wheelchair users is large relative to the weight of the wheelchair, leaning can have a major effect on the relative weight on the different wheels. Leaning affects the stability of the wheelchair, traction and rolling resistance. Leaning is a strategy used often in the later skills. 
• To minimize shoulder injury due to repetitive strain, it is generally accepted that the wheelchair user should try to push with long, slow strokes, allowing the wheelchair to coast between strokes where possible. However, thistechnique may actually increase the loads on the shoulders during each cycle (although it is generally assumed that the reduction in the number of cycles offsets this). 
• As noted earlier, hand positions can be illustrated by having the wheelchair user imagine the right rear wheel as the face of a clock; the initial  and final contact positions for the wheel might then be referred to as 11:00 and 2:00 o’clock. This “three-hour time period” corresponds to a contact angle of 90°.  
• To maintain a straight direction during the coast between pushes, the wheelchair user may need to push harder on the side toward which the wheelchair is deviating or use the fingers on the hand-rim to apply friction on the other side. Although it is possible to coast for several meters from a single push, a cadence of about 1 push per second is commonly used, at least in part to maintain directional control. If the learner is having difficulties in achieving the desired cadence, the trainer can provide audible cues (e.g. by clapping).

Recovery Phase:

A recovery path for the hands below the hand-rims is usually recommended for wheelchair users propelling for any distance on smooth level surfaces. After releasing the hand-rims at the end of the propulsive phase, the arms can be allowed to swing in a relaxed pendular fashion below the hand-rims (the “semi-circular” recovery pattern) back toward where the propulsive phase will begin for the next cycle.  (The hands need to move slightly outward as well as backward, to avoid contact with the rear wheels.) To reinforce the desired path of the hands, the trainer can ask the wheelchair user to touch the rear-wheel axles during each recovery phase (“like the drive shaft of a choo-choo train”). This allows the hands to make initial contact with the hand-rims while moving upward. 

• An additional reason to reach back during the recovery phase and to use long strokes is to exercise the shoulder retractor muscles and maintain shoulder retraction range. This may help to offset the tendency for manual wheelchair users to become round-shouldered due to muscle imbalance and loss of flexibility.
• Wheelchair users with weak or insensitive hands may prefer to slide their hands back along the hand-rims (the “arc” recovery pattern), rather than letting go at the end of the propulsive phase, but any friction should be minimized to avoid braking. Short strokes with arc recoveries may be appropriate for propelling short distances in confined spaces when fine control is the priority. 

Progression: 

Speed and accuracy are inversely related. It is advisable to begin movement skills with accuracy before increasing the speed. Start in a smooth level indoor space and progress to the outdoor setting.

Variations: 

• The learner can experiment with different speeds.

• A strip of bubble wrap can be used for the wheelchair to straddle, providing audible feedback if a straight path is not followed.
• To work on directional control, the learner can follow a wall or sidewalk edge while trying to stay within an arm’s reach.
• The wheelchair user can see how far he/she can roll on a single push.
• The wheelchair user can see how quicklyhe/she can cover a distance.
• The wheelchair user can try propelling with one hand at a time (e.g. as when carrying a cup of coffee).
• The wheelchair user can try to straddle objects of various heights and widths (e.g. using a few bricks) to better understand theclearance between the wheels and under the wheelchair.
• After weaving around objects, it is important to remember to return to the proper propulsion/recovery pattern. An easy, multi-task activity is to weave through cones (e.g. during the “turns while moving” skill) and then transition into a few pushes in a straight line before returning to the cones.

Rolls Backwards

Description and Rationale

The learner moves the wheelchair backward on a smooth level surface. Backward rolling is a skill used during many wheelchair activities. However, a short distance is usually all that is necessary, unless overcoming high rolling resistance (e.g. on a soft surface or ascending an incline using foot propulsion). 

General Training Tips

If backing up immediately follows rolling forward, then the casters will be trailing backward rather than forward as they will while moving backward. As the backing up begins, there may be some initial resistance and directional instability as the casters move into the forward-trailing position. The casters can easily be repositioned by moving them in a circular path. 

• The learner should proceed slowly and look over both shoulders regularly to avoid obstacles and collisions. Using the analogy of backing up a motor vehicle may be helpful. Directional stability is more difficult to maintain when backing up a rear-wheel-drive wheelchair. This may lead to a sinuous path, with a series of deviations and over-corrections (“fish-tailing”). This may not be apparent when wheeling backward for a short distance, so a longer distance should be used for training purposes. Slowing down will make it easier for the learner to steer.
• In many ways, the technique is the opposite of what is used for rolling forward (as dealt with in the previous skill). To propel the wheelchair straight backward, the wheelchair user should reach forward, grasp the hand-rims and pull evenly backward. 
• Some wheelchair users with very weak arms (e.g. people with tetraplegia) may find it more effective to make contact under the hand-rims with the palms up. Others may prefer to place both hands on the backs of the wheels (about 11:00 o’clock, using the clock analogy) with the arms straight and the shoulders shrugged. Then, the wheelchair user can lean back and use the body weight to push down on the wheels.
• Unlike forward rolling, it is not easy to coast backward without deviating to one side or the other. Therefore, the length of the strokes is usually shorter when rolling backward.
• Because the distances are usually short, there is no need to use long propulsion strokes or to recover the hands below the hand-rims.

Variations: 

• As for the “rolls forward” training section. 
• Bubble wrap can be placed behind a moving rear wheel without the learner’s knowledge to provide audible feedback that shoulder checks are needed.

Stops

Description and Rationale

While the learner is moving the wheelchair forward or backward, he/she may intentionally come to a stop at a pre-determined location (e.g. next to a table or wall) or need to come to a sudden stop in reaction to an unexpected event (e.g. other wheelchairs or pedestrians moving into the path) to avoid injury to themselves or others.

General Training Tips

• The learner should be alert to the fixed and moving environment while the wheelchair is moving.
• Sudden stops or changes of direction can lead to the wheelchair user falling forward or to the side in the wheelchair.
• When attempting to stop as close as possible to a rear target without contacting it, the learner may need help to understand what is the rearmost point on the wheelchair (e.g. a knapsack or rear anti-tip devices) because it may not be visible to the wheelchair user.
• When there is ample space in which to stop, on a level surface the wheelchair will coast to a gradual stop due to frictional forces and rolling resistance when the wheelchair user stops pushing.
• If the wheelchair user wishes to stop more quickly, the rate of slowing can be controlled by how hard the hand-rims are gripped. The hand-rims should be allowed to run through the wheelchair user’s hands. While stopping, the hands should be ahead of top dead center (about 1:00 o’clock using the clock analogy). 
• If the wheelchair user stops too quickly while moving forward, the wheelchair user may fall forward out of the wheelchair or tip over forward. To prevent this, the wheelchair user should lean back whenever he/she is required to stop quickly.
• When stopping while moving backward, to avoid tipping backward when stopping, the wheelchair user should avoid grabbing the wheels suddenly and should lean forward slightly.
• On a slope, the wheelchair will continue to roll (or even accelerate) unless stopping forces are applied. If the wheelchair starts to roll too quickly down an incline that is wide enough, instead of grasping both hand-rims to stop, the wheelchair user can grab one, turning across the slope.
• On a slope that is being descended in the wheelie position, when stopping part-way down the incline, the learner may remain facing downhill or turn the wheelchair across the slope.
• Sudden stops can transfer weight forward onto the casters, allowing the unloaded rear wheels to skid.

Progression:

• Start at a slow speed before stopping and increase as tolerated.
• Start in a smooth level indoor space and progress to the outdoor setting.
• Start on the level and progress to inclined surfaces.
• Re avoidance of moving obstacles, the learner should start with a single moving obstacle moving slowly at a consistent speed, seen well in advance, to obstacles moving more rapidly and unpredictably, with less warning (e.g. actual pedestrian traffic in a crowded setting). 

Variations: 

• The learner can practice stopping progressively closer to an obstacle, but without touching it. This can include progress from a tall obstacle that can be seen no matter how close the person is to it (e.g. a door), to one that is lost to sight as the user gets closer (e.g. a line on the floor).This requires good awareness of the most forward and rear-most aspects of the wheelchair. A mirror positioned to the side of the wheelchair can provide useful feedback.
• The wheelchair user can see how quickly he/she can stop on command.
• Different moving obstacles can be used (e.g. a rolled ball, a swinging pendulum).
• When moving forward, the wheelchair user can practice both quick stops (leaning back and grabbing both hand-rims firmly) and swerves (leaning toward the direction of turn and grabbing one hand-rim firmly). 
• See wheelie variation later.

Turns In Place

Description and Rationale

The learner turns the wheelchair around to the left and right to face in the opposite direction, in as tight a space as possible. Turning around in tight spaces is a common challenge for wheelchair users. The type of wheelchair and its dimensions affect the ease with which this skill can be performed. The environment may be such that the preferred direction of turn is not possible, so the learner must be capable of turning in both directions.

General Training Tips

• The ability to turn is made easier by casters. Casters are wheels that are free to swivel around a vertical axis. The location of the casters (front vs. back) will affect the nature of the turn.
• To make the turn as tightly as possible, the wheelchair user should pull back on one hand-rim, while pushing forward to an equivalent extent on the other. In such a case, the vertical axis of rotation for the turn is midway between the drive wheels. It may take a few cycles to complete the turn. If the arc moved through by one hand is less than that for the other hand, on completion of the turn, the wheelchair will come to rest closer to the hand that moves less.
• It may be helpful for the learner to shuttle forward and backward – e.g. forward turn to the left, backward turn to the right, repeating as necessary – to minimize the space required, turning part of the way with each cycle. The longer the chair, the more likely it is that this will be necessary.
• The trainer should help the learner to clearly understand the difference between the size of the turning circle (that is affected by parts, such as footrests, that stick out above the ground) and the size of the turning footprint (that only includes the chair or body parts that touch the ground). A mirror may be used to provide feedback to the learner.
• The footrests can be moved out of the way in tight spaces to reduce the radius of the turning circle.
• The user should be especially careful not to catch the feet on an immovable external object – if the foot stops and the chair continues to turn, a serious injury can result.

Progression: 

• The wheelchair user should begin with small angular displacements and progress to larger ones.
• The learner should start with a larger space in which to turn and progress to smaller ones.
• The learner should start at a slow speed, focussing on accuracy and increase the speed as skill develops.  
• The wheelchair user can practice on progressive smaller areas of support.
• The wheelchair user can practice on a soft surface.
• Small displacements do not require that the hands be repositioned on the hand-rims. 
• The wheelchair user should then progress to larger displacements that require the hands to be repositioned, using several steps to get all the way around to 180°.
• Some wheelchair users may be able to get all of the way around to 180°(or beyond) in a single movement (the so-called “snap turn”) by allowing the hand-rims to slide through the fingers. To prepare for a snap turn, the wheelchair user places one hand as far forward as possible on one hand-rim and the other hand as far back as possible on the other hand-rim.Then, in a single uninterrupted motion, the wheelchair user “snaps” the wheelchair around, letting the hand-rims slide through the fingers until the wheelchair reaches the desired angle. Depending upon the rolling resistance of the surface, the wheelchair may continue to spin in a circle until wheel or hand-rim friction brings the wheelchair to a stop.

Variations: 

• Game: Ask the learner to pretend that his/her feet are the hour hand of a clock facing up from the floor and see how quickly and accurately he/she can respond to times that the trainer calls out (e.g. from a starting position of 12:00 o’clock, “turn to 3:00 o’clock”).
• When turning around in confined spaces, it can be helpful for the wheelchair user to push or pull on external objects rather than using the hand-rims.
• See wheelie variation later.

Turns While Moving

Description and Rationale

• The learner turns the wheelchair to the left and right while moving forward or backward. Such moving turns are often necessary to avoid obstacles or to change direction. The amount of space needed for turning is affected by such wheelchair factors as the wheelbase (distance between the ground contact points for the front and back wheels), For most wheelchair users, turns while moving backward are usually required less often in everyday life than moving turns in the forward direction.
• The path of the wheelchair parts (e.g. footrests) will differ depending upon the characteristics of the wheelchair. As a general rule when turning, the vertical axis for the turn is midway between the drive wheels, so the farther away from this axis that a wheelchair part or body part is, the greater the circumference through which it will swing. 
• When turning around an object (e.g. a pylon or a corner) that the wheelchair is close to, the wheelchair user should focus on ensuring that rear wheel, specifically the contact point between the wheel and the ground, clears the obstacle. 
• When driving a rear-wheel-drive wheelchair toward a 90°turninto a narrow opening, when space is available the wheelchair user should stay as far as possible away from the wall on which the opening is found. This is analogous to parking a car between two other cars in a crowded parking lot.
• If the approach path is narrow but the opening is wide, approaching the corner close to the wall is preferable, watching closely that the axle of the near-side rear wheel is slightly beyond the corner before turning sharply. 
• If maneuvering around a series of fixed obstacles (such as the pylons used in the WST) that are widely spaced, a useful strategy is to use a path that takes the drive wheels close to the obstacles. If the obstacles are closer together, the wheelchair may need to be driven farther away from each obstacle to have sufficient room in which to complete the turn.
• When ready to turn, the wheelchair user should slow down the inside wheel and/or push harder on the outside wheel. Slowing down the inside wheel results in a tighter turn, but causes the wheelchair to slow down. Pushing harder on the outside wheel causes the wheelchair to speed up. The decision on the relative speeds of the two wheels depends on how tight a turn is needed and safety considerations.

Progression: 

• The learner should start with small changes of direction (e.g. around widely spaced pylons) and progress to more closely spaced ones. 
• When beginning training around full 90°corners, learners may find it easier to break a turn down into its segments – driving straight, turning, then driving straight again, rather than following a smooth curved path. 

Variations:

• Three-point turns (e.g. using an opening like a doorway to turn around and go back in the opposite direction) can be carried out by making the first turn into the opening while moving forward, followed by a backward turn in the opposite direction. 
• Alternatively, the initial turn into the opening can be backward (after rolling past the opening), followed by a forward turn in the opposite direction.
• When using the moving-turns skill in real-life settings, the learner should obey the rules of the road at corners – he/she should slow down if the path around the corner cannot be seen, he/she should stay to the right or left (whichever is the convention in the country in which the training is taking place) and he/she should not cut the corner.
• While coasting forward in a straight line, the wheelchair user can experiment with the effect that rotating the outstretched arms from side to side has on direction – for instance, swinging the arms counterclockwise causes the wheelchair to turn clockwise.
• The fixed environment can be used to assist with turning. Timing, intensity, direction and location of the forces applied to a fixed object such as a wall are important features of success. Using the environment minimizes the need to slow down. 
• In the “drag” turn, the wheelchair user drags a hand, in a rear position, along the wall to turn toward the wall and around the corner. If the learner is having difficulties, the skill can be simplified by segmenting the skill, for instance having the trainer push the wheelchair forward toward the corner while the wheelchair user has the wall-side hand in the ready position and the opposite hand on the lap.
• In the “push-off” turn, the wheelchair user uses a hand, in a forward position, to push away from the wall. 
• See wheelie variation later.

Manoeuvres Sideways

Description and Rationale

The learner maneuvers the wheelchair sideways to the left and right parallel to an object (e.g. a window, bed or table). Repositioning the wheelchair sideways in a tight space is commonly necessary to get closer to or farther away from objects.

General Training Tips

• The learner needs to be aware of the widest and longest points of the wheelchair as well as the footprint created by the wheels on the floor. 
• If the space available in a real-life situation is limited, the learner may need to shuttle the wheelchair forward and backward a number of times to get into the desired position, moving more to the side with each attempt. 

Progression: 

• The learner should start with ample forward-backward room in which to maneuver and gradually decrease the space. 
• The learner should start with small sideways steps and progress to larger ones.
• The learner should start at a slow speed, focussing on accuracy (staying within any designated boundaries), increasing the speed within the limits of accuracy. 

Variations:

• The learner may mimic parallel parking a car, pulling forward ahead of the target opening, then backing into the opening.
• An alternative for the wheelchair user with good upper-body strength and co-ordination is to use the “bunny-hop” method. To do so, the wheelchair user hops the rear wheels to the side by shifting the body weight in the desired direction and pulling up on the rear wheels to have them move in the same direction. Although there remains some controversy regarding this, it seems that the head should move initially in the direction intended, then in the opposite direction while moving the hips over (analogous to the head-vs.-hips method used in the sideways transfer discussed later). The wheels do not need to get fully off the ground to be successful. The bunny hop is most useful when space is very limited (e.g. when very close to a wall). Initially, the wheelchair user can get used to just hopping up and down, with no sideways movement. If the hands holding onto the hand-rims are not at the top dead center, the rear wheels will rotate when they become unloaded. This can be prevented by applying the wheel locks.
• A similar effect can be created by rocking the wheelchair from side to side, although the wheelchair may move forward as well as to the side. The wheelchair user should lean hard in the direction that he/she wishes to move and return more gently to the upright position.
• The learner may use the sideways-maneuvering technique to negotiate to the other side of two barriers with a space between them (e.g. two concrete bolsters in a parking lot) that is too narrow to drive straight through but is low enough from the ground to allow clearance between the wheels. It may be possible to move one pair of wheels through the gap at a time, transiently straddling the obstacles with one pair of wheels on either side of the obstacles and the wheelchair parallel with the obstacles. 
• The learner may perform the basic sideways-maneuvering skill or the bolster variation of it in the wheelie position.

Picks Objects from Floor

Description and Rationale

• The learner picks objects up from the floor and passes them to the tester. Objects that need to be picked up from the floor or ground vary from those as small and light as a coin or a piece of paper to those as bulky and heavy as a young child. This is also an opportunity for the trainer to work on other reaching tasks (e.g. horizontally across a table or overhead as when removing an object from a shelf). 
• The learner may use a reaching aid, but should carry it with him/her.
• To be safer if leaning or bending forward, the wheelchair user can move the footrests out of the way and place the feet on the floor. 
• If standing up and crouching, the wheelchair user should first apply the wheel locks and clear the footrests out of the way. If the wheelchair user stands up on the footrests, a forward tip is likely unless the footrests are behind the front wheels. If standing and crouching, the wheelchair user should keep one hand on the wheelchair to keep from falling. 
• If the wheelchair user chooses to lean forward to accomplish the task, he/she should make sure the casters are trailing forward to decrease the likelihood of tipping forward. As noted earlier, when the casters are trailing forward, they lie ahead of the portion of the wheelchair frame to which they are attached, as is the case when the wheelchair is rolled backward. 
• The wheelchair user should use one hand on the wheelchair or thigh to help with balance and the other hand to pick up the object.
• For a wheelchair user with weak trunk muscles, to reach the ground he/she should move the arms to the thighs one at a time, and then to the feet, placing the chest on the thighs.
• Turning an object on its side may help to get a better grip. 
• To make it easier to pick up an object, the wheelchair user may pull the object up against one of the wheels so that it does not move.
• If a wheelchair user has weak pinch strength, increasing the friction between the fingers and the object (e.g. by wearing gloves or wetting the fingers with saliva) can help to prevent dropping the object.
• Reaching and leaning reduce stability, putting the wheelchair user at risk of falling out of the wheelchair or, if in a manual wheelchair, tipping the wheelchair over. 
• For a person with weak trunk muscles, to avoid falling in the direction that he/she is leaning, he/she may hook the non-reaching arm behind the push handle or hold onto the armrest or wheel.
• To help right him/herself in the chair after reaching for the object, the wheelchair user can pull on the opposite armrest or wheel. 
• If the armrest on the side to which the wheelchair user wishes to reach is moved out of the way, it allows the wheelchair user to bend further sideways. 
• The wheelchair user needs to exercise caution when reaching across the body, especially when reaching for or picking up something (e.g. a heavy object on a high shelf, hot coffee, a knife) that could injure the user if it was spilled or dropped onto the lap. Also, bending and twisting at the same time can cause back injury.

Progression:

• The object can be picked up using different approaches (e.g. front vs. side).
• Objects of different sizes and weights can be used.

Variations:

• If the wheelchair user is reaching for a light and unbreakable object from a high shelf, he/she can use an improvised reaching aid (e.g. a rolled up magazine or a cane) to help move the object off the shelf and catch it. In a store, when an object is out of reach, an object (e.g. a cereal box) on a lower shelf can be used to ease the desired object off the higher shelf so that it can be caught.
• A moving pick-up can be accomplished if the wheelchair user holds the object against the bottom of the rear wheel with one hand as the wheelchair rolls forward, then both hands can be used to grasp the object when it rotates to the top of the wheel. 

Relieves Weight from Buttocks

Description and Rationale

The learner relieves weight from both buttocks, although not necessarily at the same time. Weightrelief is important for comfort and the prevention of pressure sores. 

General Training Tips

• Partial unloading (30-90%) of each buttock for 15 seconds every 25 minutes and complete off-loading (90% or more) of both buttocks for at least 15 second every 2 hours is recommended. 
• Trainers should recognize that susceptibility to pressure ulceration varies among wheelchair users (e.g. due to such factors as variations in co-morbidities, sensation, local anatomy, blood supply, nutrition, moisture, nature of clothing worn), many of which are not affected by skills training. However, if the trainer notices any such correctable factors, these should be pointed out to the learner and/or an appropriate health-care provider.
• If using any of the leaning methods (practiced earlier for the “picks objects from ground” skill) to relieve weight from the buttocks, the extent of weight relief is proportional to the extent of the lean.
• With the forward leaning method, the elbows can be rested on the thighsor a table. Further unloading can be achieved by resting the trunk on the thighs, grabbing the footrests and pulling on them. It may be socially inconvenient to use the full forward-leaning technique in some circumstances. A more moderate forward lean may be adequate. Getting back upright from the forward-bent position can be a challenge for some wheelchair users. The hands can be walked up the thighs until an armrest or the backrest can be reached to allow the person to pull him/herself the rest of the way.
• Side leaning or shifting the weight onto one buttock can also be effective, for those who cannot lean forward and recover, or in situations when the wheelchair user might find it inconvenient to lean forward. The armrests or rear wheels can be used to push or pull on. As was the case for leaning forward, the wheelchair user can lean sideways on a table.
• The leaning techniques can cause tips in the direction toward which the wheelchair user is leaning. 
• If leaning forward fully, the casters should be in the forward-trailing position to increase forward stability.

Variations:

• Bridging (lifting the weight off the buttocks by pushing down firmly on the feet) is effective but difficult to maintain for prolonged periods.
• Tilt and recline are alternative methods that may be adequate for some wheelchair users. If tilt or recline are used, the greater the extent of tilt or recline the better, preferably at least 45°.
• Reclining a wheelchair can cause shear forces between the backrest and trunk that can be compensated for by lifting the trunk away from the backrest after the reclining has taken place. Some wheelchairs provide built-in compensation for such shear forces, but the extent of such compensation may not exactly match the amount needed.
• Standing up is effective, but if it is done using a stand-up wheelchair feature, there may be new pressure areas to consider related to how the wheelchair user is supported in the upright position. Standing on the footrests is generally not recommended, although it can be safe if the footrests are not too far forward and/or the casters are oriented in the forward-trailing position.After a weight-relief maneuver, the wheelchair user’s buttocks should be gently repositioned on the seat rather than dropped back into place.
• Transferring out of the wheelchair (e.g. onto a bed), where the wheelchair user can lie on his/her side or front is also effective.
• Push-ups are not recommended because of the high loads on the upper limbs (that may contribute to overuse symptoms) and because they cannot be sustained for long.
• The tilt-rest position (with the wheel locks applied [or hands holding the hand-rims] and the wheelchair or wheelchair user leaning against a wall or curb) may permit sufficient rear tilt that can be sustained for many minutes. This position can be achieved in a variety of ways, for instance:
• Pull-back technique: The wheelchair user positions the wheelchair close to the object (e.g. a sofa or wall) that he/she intends to lean against. Some trial and error may be needed to select the correct distance from the object; it is better to start too close to the object than too far from it. The wheel locks are applied and are checked to ensure that they are functioning. The wheelchair user then reaches back and pulls on the external object to tilt the wheelchair back just beyond the balance position, so that the wheelchair or wheelchair user rests against the object.
• Push-back technique: As for the pull-back technique except that the wheelchair user pushes against an external object to create the tilt. This can include using the foot to push on the ground.
• See wheelie variation later.
• When returning from the tilt-rest to the upright position, the wheelchair user should leave the wheel locks on and tilt forward by leaning or by pushing against the object being leaned against.
• Resting on the rear anti-tip devices may permit sufficient rear tilt but can result in a rear tip. With a spotter in place behind the wheelchair resting on the rear anti-tip devices, the wheelchair user can lean and rock backward to see if the wheelchair tips over; if so, this technique should not be used. 

Performs Level Transfers

Description and Rationale

The wheelchair user transfers from the wheelchair to another surface that is about the same height as the wheelchair seat and back again. A level transfer is a commonly used skill to move between the wheelchair and a chair, bed, tub, toilet, car or other surface. The average wheelchair user spends about 10 hours per day in the wheelchair and performs about 8 transfers a day but the range is high.A higher number of transfers per day increases the likelihood of overuse injuryto the upper limbs. Proper technique is advisable as a means of reducing overuse and minimizingpain during transfers.The level wheelchair transfer should only be considered a representative transfer. More difficulty may be experienced when transferring to and from other surfaces or heights.

General Training Tips

There are a number of transfer techniques and surfaces to which a wheelchair user may wish to transfer. The sideways transfer described here is representative for people who propel their wheelchairs with two hands. Standing pivot and crouch transfers will not be covered here but can be found in the Wheelchair Skills Program Manual.¹

• The sideways transfer is sometimes called a “sliding” transfer but actual sliding is not recommended (to avoid shear forces or injury to the buttocks).
• Care should be taken to avoid catching the wheelchair user’s intravenous line, urinary catheter or other collection devices when transferring.
• The height of the starting and target surfaces should be adjusted, to the extent possible, such that the target surface is slightly lower. 
• The wheelchair should be positioned as close as possible to the targetsurface, with the casters trailingin a way that enhances stability in the direction of transfer.
• If possible, the learner should position the wheelchair so that the casters are trailing in the direction of the transfer to reduce the likelihood of the wheelchair tipping in that direction. To achieve this position, the learner should finish the wheelchair positioning with a slight movement away from the direction of the transfer. For wheelchairs that are equipped with them, caster swivel locks can be used to help maintain caster orientation.
• The path between the starting and finish surfaces should be cleared of any obstacles. 
• The wheelchair user should move the armrest (if any) out of the way on the bench side.
• The footrests should be cleared away (if possible). The feet should be stably supported on the floor if the footrests can be easily moved out of the way. If the footrests cannot be moved, it is acceptable to leave one or both feet on the footrests as long as forward tipping does not occur during the transfer. In addition to an actual tip, when the rear wheels become unloaded the wheel locks become ineffective and the rear wheels may move sideways due to caster swivel. In considering where to place the feet, the wheelchair user should try to avoid situations in which the feet are not free to swivel when the buttocks are moved to the new surface – this could lead to a torsion injury of the lower leg.
• The wheel locks (if any) should be appliedand the wheel-lock extension (if any) on the bench side should be removed.
• The comments below generally apply to the transfer out of or into the wheelchair, but will be described as though the transfer is out of the wheelchair. Transfer into the wheelchair is generally the same except that, once the wheelchair user is back in the wheelchair, he/she should restore the footrests fully and put the feet back on them. The wheelchair user should also make sure that any removed or repositioned wheelchair parts (e.g. armrests, footrests, cushion, seat belt) are in the same position that they were before he/she left the wheelchair.
• People using sideways transfers tend to lead with the weaker or more painful arm. However, if the arms are fairly symmetrical, alternating the leading and trailing arms allows them to share the stresses. 
• A forward tip is less likely to cause a problem in wheelchairs that have the footrests behind the casters and will not happen if caster swivel locks (if any) are applied with the caster trailing in the appropriate direction. 
• The wheelchair user should move forward on the seat, to avoid such obstacles to sideways movement as the rear wheels.
• To get the transfer board (if using one) under the buttock, the wheelchair user should lean away from it.
• The wheelchair user should push down on the transfer board and wheelchair to unload the buttocks. 
• The wheelchair user should avoid fully extending the fingers and wrists, allowing the fingers to wrap around the edge of the target sitting surface. This avoids overstretching the joints and tendons, which may be of importance for people with tetraplegia who use a tenodesis grip (whereby active wrist extension causes passive finger flexion if the tendons are of appropriate length). Keeping the wrists in a neutral position also functionally lengthens the arms, making it easier to get the buttocks off the sitting surface.
• The wheelchair user should keep the leading hand just far enough away from the body to allow room for the buttocks to land on the target surface, but no farther. The trailing hand should be close to the body.
• The wheelchair user may shift sideways toward the target surface in a single large movement or several smaller ones. 
• If possible, the wheelchair user should lean well forward (“nose over toes”). During the actual transfer from this position, the hips and the head move in opposite directions. For instance, if the wheelchair user wishes to move the buttocks up and to the left, the head should move down and to the right. This technique reduces the forces needed from the arms.
• Once the buttocks are fully supported by the target surface, the wheelchair user should remove the transfer board. The wheelchair user should lean away from it to do so.