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).