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A More Formal Process for Wheelchair Skills Assessment and Training – An

Idea Whose Time Has Come!

R. Lee Kirby & Cher SmithDalhousie University and the

Capital District Health AuthorityHalifax, Nova Scotia, Canada

Setting the Stage

• Conflicts of interest: WSP Software• Acknowledgements:

– Wheelchair Research Team

– Funding bodies

• Handouts: – pdf of the PPT presentation

– www.wheelchairskillsprogram.ca

Handouts

• www.wheelchairskillsprogram.ca/eng/lectures.php• http://www.wheelchairskillsprogram.ca/eng/publications.php

Current Funding Bodies

• US National Institute for Disability and Rehabilitation Research (NIDRR)

• Canadian Institutes for Health Research (CIHR)

• US Department of Veterans Affairs (VA)

• US Agency for International Development (USAID)

Session Objectives

On completion of the session, participants will be able to:1. Describe the rationale and evidence supporting

the assessment of wheelchair skills 2. Describe the rationale and evidence supporting

the efficacy of wheelchair skills training3. Recognize the practical steps involved in

conducting wheelchair skills assessment and training

4. Move one step along the “stages of change”

WHO. World Report on Disability, 2011, p 34

•15% (1 billion) some form of disability

•2.2% (110M) very significant difficulties in functioning

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Prevalence of Wheelchair Use• World: ~65M people need wheelchairs

(~20M people do not have them).– WHO guidelines 2008.

• US: 3.86M non-institutionalized users by 2009 (~30% PWCs or scooters).– Flagg JF. Buffalo, February 2009.

• US: similar proportion of powered wheelchair use (5-11%) in the US VA– Hubbard SL et al. J Rehab Re Dev 2007;44:581-92.

Importance of Wheelchairs

• Prevalence of use is high and rising• Positive impacts on:

– Mobility

– Participation

– Caregiver burden

– Long-term-care placement

Problems of Wheelchairs

• Improper wheelchair, fit or set-up• Maintenance & repair problems• Chronic overuse injuries are common• Acute injuries are common

Improper Wheelchair, Fit or Set-Up Improper Wheelchair, Fit or Set-Up

• N = 150 wheelchair users in Italy• Mean (SD) age 46.7 (17.3) years• 68% of wheelchairs were not suitable to

their users

Cherubini M & Melchiorri G. Eur J Phys Rehabil Med 2012;48:217-22.

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Maintenance & Repair Problems

• 16 Model SCI Centers in US• N = 2213• 6 months follow-up:

– 45% of full-time users completed a repair, more often with PWCs

– 8.7% had an adverse consequence, more often with MWCs

McClure LA et al. Arch Phys Med Rehabil 2009;90:2034-8

Chronic Overuse Injuries

• N = 100 people with paraplegia for > 30 years and 100 age- vs sex-matched AB controls

• MRI evidence of rotator cuff tears: 63% vs 15%

Akbar M et al. (Heidelberg) J Bone Joint Surg Am 2010;92:23-30

Acute Injuries• Deaths/year in US

– 50-70* (Calder & Kirby. Am J PM&R 1990;69:184-90)

• Injuries to ER/year in US– 56K* (Ummat & Kirby. Am J Phys Med Rehabil 1994;73:163-167)

– 100K (Xiang et al, Injury Prevention 2006;12:8-11)

• Community wheelchair users injured/year– 5%* (Kirby et al. Am J PM&R 1994;73:319-30)

– 18% (Berg et al, Am J Public Health 2002;92:48)

– 14%* (Nelson et al. Arch PM&R 2010;91:166-73)

– 21% (Edwards et al. Dis Rehabil Asst Technol 2010;5:411-9)

•Ummat & Kirby. Am J Phys Med Rehabil 1994;73:163-7. ~72%

•Xiang et al, Injury Prevention 2006;12:8-11. 81%

Routhier F. Personal communication 2007.

Rear anti-tip devices contributing to tip/fall

BENEFITS PROBLEMS

Wheelchairs

Better wheelchair provision

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www.who.int/disabilities/publications/technology/wheelchairguidelines/en/index.html.

World Health Organization WHO Wheelchair Provision

1. Design2. Production

3. Supply4. Service Delivery

WHO Guidelines 2008, Section 1.7, p 25

WHO Wheelchair-Provision Service Model

1. Referral and appointment

2. Assessment

3. Prescription

4. Funding and ordering

5. Product preparation

6. Fitting

7. User training

8. Follow-up, maintenance and repairs

WHO Guidelines 2008, Section 3.2.1, p 76

WHO Wheelchair-Provision Service Model

1. Referral and appointment

2. Assessment

3. Prescription

4. Funding and ordering

5. Product preparation

6. Fitting

7. User training

8. Follow-up, maintenance and repairs

WHO Guidelines 2008, Section 3.2.1, p 76

www.wheelchairskillsprogram.ca Established 1996

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What’s Different About the WSP?

• Evidence-based• Both assessment and training• Both wheelchair users and caregivers• Both power and manual wheelchairs

• The process and sequencing used• Updated often• It’s FREE! (“open source”)

Wheelchair Skills Program (WSP)

• Wheelchair Skills Test (WST)• Wheelchair Skills Training Program (WSTP)

WHO Wheelchair-Provision Service Model

1. Referral and appointment

2. Assessment

3. Prescription

4. Funding and ordering

5. Product preparation

6. Fitting

7. User training

8. Follow-up, maintenance and repairs

WHO Guidelines 2008, Section 3.2.1, p 76

WST

WSTP

The Circle of Education

Objectives (identified problems)

Curriculum (WSTP)

Evaluation(WST)

WHO Wheelchair-Provision Service Model

1. Referral and appointment

2. Assessment

3. Prescription

4. Funding and ordering

5. Product preparation

6. Fitting

7. User training

8. Follow-up, maintenance and repairs

WHO Guidelines 2008, Section 3.2.1, p 76

WST

Versions of WST by Type of Wheelchair and Nature of the Test Subject

Type of Wheelchair Type of Test Subject

Manual Wheelchair user

Caregiver

Powered Wheelchair user

Caregiver

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Individual Skills:WST 4.2 examples

Individual Skills Manual WC Powered WC

WCU CG WCU CG

Turns controller on and off X X b b

Controls positioning options X b b b

Rolls forward 10m b b b b

Turns 90° while moving forward

b b b b

WST 4.2 Capacity ScoresScore Score What this means

Pass 2 Task independently and safely accomplished without any difficulty

Pass with difficulty

1 Evaluation criteria met, but the subject experienced some difficulty worthy of note (e.g. excessive time or effort, inefficient method, minor injury)

Fail 0 Evaluation criteria not met

Not possible

NP The wheelchair does not have this part

WST vs WST-Q

WST-Q 4.2 Answer CodeCapacity question: “Can you do this skill?”

Answer Score What this meansYes 2 I can safely do the skill, by myself,

without any difficulty. Yes with difficulty

1 Yes, but not as well as I would like.

No 0 I have never performed the skill or I do not feel that I could perform it right now.

Not possible

NP My wheelchair does not have this part.

Capacity (‘can do’)vs

Performance (‘does do’)

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WST-Q 4.2 Answer CodePerformance question: “How often do you actually do this skill during your daily life?”

Answer Score What this means

Weekly 3 At least once a week.

Monthly 2 At least once a month.

Yearly 1 At least once a year.

Never 0 Less often than once a year or never.

WST-Q 4.2 Answer CodeGoal question: “Is this is a skill for which you would be interested in receiving some training?”

Answer What this means

Yes I would be interested.

No I would not be interested.

WST Comments WST-Q Algorithm

How often?

Can you do this skill?

Is this a training goal?

Proceed to next skill

Yes (1)

No part

(NP)

No (0)Yes with difficulty (0.5)

Never or Rarely (0)Occasionally (0.5)Frequently (1)

NoYes

Evolution of the WST-Q

• Semi-structured interview• Ordinal scale of responses• Tester-administered script (in-person, phone)• Self-administration (in-person, postal)

• Computer-Assisted Testing (CAT)

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WST Total % Calculated Scores

WST: • Capacity Score = # skills passed/total x 100%

WST-Q: • Capacity Score = # skills passed/total x 100%

• Performance Score = # skills passed/total x 100%

Goal Attainment Score (GAS)

• GAS = goals achieved/set x 100%

• Notes:–Optional

–Number of goals: 5-10–Goal setting process important

What’s the evidence?

WST (Manual) Measurement Properties

• WST 1.0:– Kirby et al. Arch PM&R 2002;83:10-18

• WST 2.4:– Kirby et al Arch PM&R 2004;85:794-804

• WST 3.2: – Routhier F et al, Rehab International 2008

• WST 4.1: – Lindquist NJ et al. Arch PMR, 2010;91:1752-7– Lemay V et al. Proc 4th Nat SCI Conf Oct 2010

Questionnaire Version (WST-Q)

• Manual:• Newton et al. Arch PM&R 2002;83:1295-9• Mountain et al. Arch PM&R 2004;85:416-23• Inkpen P et al. Arch PM&R 2012;93:1009-13• Rushton PR et al. Arch PM&R 2012;93:2313-8

• Powered:• Rushton PR et al. (O vs S) RESNA Proceedings 2012• Rushton PR et al. (reliability) RESNA Proceedings 2012

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Wheelchair Skills Assessment• Rushton P, Kirby RL, Miller WC. Manual

Wheelchair Skills: Objective Testing versus Subjective Questionnaire. Arch Phys Med Rehabil 2012;93:2313-8

N = 89

• 26 Manual wheelchair users•WST-Q 4.1•WST Capacity Score: 72.5 (19.2)%•WST Performance Score: 58.1 (21.2)%

Systematic Reviews on Assessments of Wheelchair Skills

• Kilkens et al. Clinical Rehabilitation 2003;17:418-430 (24 papers)

• Fliess-Douer O et al. Clin Rehabil 2010;24:867-86 (13 papers)

Example of Assessment

Worley et al. Am J Phys Med Rehabil 2006;85:931-4

Door toward: failure due to weak trunk muscles

Example of Assessment

Gravel: central cord syndrome

Example of Assessment

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Example of a full WST 4.2

WHO Wheelchair-Provision Service Model

1. Referral and appointment

2. Assessment

3. Prescription

4. Funding and ordering

5. Product preparation

6. Fitting

7. User training

8. Follow-up, maintenance and repairs

WHO Guidelines 2008, Section 3.2.1, p 76

WSTP

Prevalence of Manual Wheelchair Skills Training

• 17% in UK got any formalized training (Whizz-Kidz 2004)

• 18% in US got any formalized training (Karmarkar AM et al. JRRD 2009;46:567-76)

• 66% in US of 223 people with paraplegia (Zanca JM et al. Physical Therapy 2011;91:1877-91)

• 29% in Bangladesh of 149 (Borg J et al. BMC Health Services Res 2012;12:330)

• 11% in Canada of 18 people with stroke (Charbonneau R et al. Arch Phys Med Rehabil 2013;epub.

Wheelchair Skills Capacity of WCUs with SCI

• US Model Spinal Cord Injury System• 214 participants (~75% with paraplegia)• WST 4.1, cross-sectional study• Curb ascent: 20%

• Curb descent: 47%• Wheelie: 60%

Hosseini SM et al. Arch Phys Med Rehabil 2012; 93:2237-43

Wheelchair Skills Training Program

Process

(How to teach)

Content

(What to teach)

WSTP

Wheelchair Skills Training Program

Process

(How to teach)

WSTP

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Resources

• www.wheelchairskillsprogram.ca–WSTP Manual, pages 8-23

• Richard A. Magill. Motor Learning and Control: Concepts and Applications. 9th Edition. McGraw-Hill, New York. 2011

Motor Learning Principles

• Assessment of wheelchair skills• Set achievable goals• Individualize the training

process• Structure of training• Training in pairs or groups• Motivation• Demonstration• Verbal instructions • Focus of attention• Imagery

• Feedback• Feedback content• Timing of feedback

• Specificity of practice• Amount of practice

• Facilitate retention• Variability of practice• Distribution of practice

• Whole versus part practice• Simplification and progression

Examples of Motor Learning Principles

Example of motor-learning principle: intrinsic learning

Example of motor-learning principle: demonstration

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Example of motor-learning principle: practice variability

Example of motor-learning principles: segmentation and feedback

Example of motor-learning principle: progression Wheelchair Skills Training Program

Content

(What to teach)

WSTP

Research-Based Techniques

Kwarciak AM et al. Arch PM&R 2009;90:20-6

Example of training tip: propulsion technique

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Example of training tip: wheelie training

Koshi et al. Am J PM&R 20062 steps, 0 bends, 7 seconds

Woolfrey & Kirby. Arch Phys Med Rehabil 1998;79:955-8

10 steps, 8 bends, 25 seconds

WSTP Curriculum

• Individual or small group sessions

• 15-30 minute sessions, 1-5x/week

• ~2-4 hrs extra training time

• Based on wheelchair and motor learning principles literature

Mobility Centre

What’s the evidence?

Examples of Evidence re Specific Skills

• Propulsion mechanics: – Kwarciak et al. Arch PM&R 2009;90:20-6

• Rear fall strategy:

– Kirby et al. Arch PM&R 1996;77:1266-70• Ergonomics of moving an empty wheelchair:

– Woolfrey & Kirby. Arch PM&R 1998;79:955-8• Ergonomics of folding a wheelchair:

– White & Kirby. Appl Ergonomics 2003;34:571-9

• Learning to perform wheelies: – Kirby et al. Am J PM&R 2008;87:204-11

• Learning to perform curb-climbing: – Kirby et al. Arch PM&R 2008;89:2342-8

• Handling stairs on buttocks:

– Kirby et al. Arch PM&R 2009;90:1250-3

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WSTP Evidence: Groups of Skills• Skills training for wheelchair users, initial rehab:

– MacPhee et al. Arch Phys Med Rehabil 2004;85:41-50– Routhier et al. Arch Phys Med Rehabil 2012;93:940-8

• Skills training for wheelchair users, community:– Best et al. Arch Phys Med Rehabil 2005;86:2316-23– Tangsagulwatthana S et al. Thai J Phys Ther 2010;32:173-80– Ozturk A & Ucsular FD. Clin Rehabil 2011;25:416-24– Sawatzky et al. Aust Occup Ther J 2012;59:2-9– Groer et al. RESNA 2012

• WSTP for caregivers:– Kirby et al. Arch Phys Med Rehabil 2004;85:2011-9

• WSTP for health-care students: – Coolen et al. Arch Phys Med Rehabil 2004;85:1160-7– Kirby RL et al. Am J Phys Med Rehabil 2011;90:197-206

Arch Phys Med Rehabil 2012;93:940-8

Other Outcomes - Confidence

• 20 manual wheelchair users, RCT• WSTP 4.1: 2 x 1-hour training sessions• WheelCon scores (0-100) • WSTP group:

– Absolute change +13.7% (relative 24%)

• Control group:– Absolute change -0.4% (relative -0.6%)

• P = 0.004

Sakakibara B et al. Arch Phys Med Rehabil 2013;Feb 2 (epub ahead of print)

International Classification of Function (ICF)

WHO, 2001

Health

(Impairment)

Activities

(Disability)

Participation

(Handicap)

Organ or tissue

Whole person

Society

Do Skills Improve Participation?• Training increases amount of wheelchair use:

– Hoenig H et al. J Am Geriatr Soc 2005;53:1712-20

• Skills (WST) correlate with daily wheeled distance:– Lemay V et al. Spinal Cord 2012;50:37-41

• Skills correlate with return to work: – Van Velzen et al. J Rehabil Med 2012;44:73-9

• Skills correlate with participation measures: – Kilkens O et al. JRRD 2005;42:65-73

– Mortenson WB. Arch Phys Med Rehabil 2011;92:1587-93

– Krause J et al. J Spinal Cord Med 2009;32:237-4

– Phang SH et al. Disabil Rehabil 2012;34:625-32

– Borg J et al. BMC Health Services Res 2012;12:330

Do Skills Improve Participation?

• N = 149 manual wheelchair users in Bangladesh

• Odds Ratios (p < 0.05) for the 29% who received training:– More satisfaction 7.79– Less participation restrictions 4.27– More improved quality of life 2.55– Less activity limitations 2.47

Borg J et al. BMC Health Services Res 2012;12:330

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Levels of Scientific Evidence

I. Large randomized trials with clear-cut results (and low risk of error)

II. Small randomized trials with uncertain results (and moderate-high risk of error)

III. Nonrandomized trials with concurrent controls

IV. Nonrandomized trials with historical controls

V. Case series with no controls

Sackett DL. Chest (2 Suppl) 1989:2S-4S

Research Projects Currently Underway

Wheelchair Skills and Maintenance Training

• Boninger M, Kirby RL et al.• Manual wheelchair skills and maintenance

training in Spinal Cord Injury Model Systems

• Stage:– Funding received: Department of Education,

US National Institute for Disability and Rehabilitation Research (NIDRR) ($4.5M)

– Research assistant training April-May 2013

Evolution

Implementation of WSP: What is Needed?

� People who need wheelchairs� Caregivers� Wheelchairs� Receptive environment� Trained personnel

Training Personnel

• Knowledge: reading, on-line resources• Skills: practical training• Attitudes: experience

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Practical Training

• Ideally – multiple brief sessions• Less ideal – wheelchair skills “boot-camp”

Wheelchair Skills Bootcamps

Integration into Formal Education of Health-Care Students

• Occupational Therapy• Physiotherapy• Nursing• Recreational Therapy• Health Science• PM&R

Boot-Camp Outcomes

• High satisfaction, positive perceptions – Kirby et al. Proc RESNA 2009

– Kirby et al. Proc RESNA 2011

• Improved wheelchair-skill abilities – Routhier et al, Proc RESNA 2008

• Improved knowledge – Kirby RL et al. 4th SCI Conference,

Niagara Falls Oct 30, 2010

Boot-Camps Completed• Canada: Halifax, Quebec, Toronto, Vancouver,

CSMC, Windsor, Ottawa, Kingston, St John’s• United States: RESNA, ISS, Boston, Tampa,

Atlanta (adult), Atlanta (peds) • Europe: Dublin, Sarajevo, Banja Luka, Denmark• India: New Delhi, Bangalore• Jordan: Amman, Irbid• Tanzania: Moshi• Peru: Lima, Arequipa

Boot-Camps Upcoming in 2013• Canada: Halifax, Edmonton• United States: Miami, Pittsburgh, New Jersey,

Chicago • Central America: Belize City• Nepal: Kathmandu• Indonesia: Yogyakarta

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Peru IndiaTanzania

JordanBosnia

Belize

WSP Training in Less-Resourced Settings

(Indonesia)(Nepal)

Wheelchair Skills Program

“Low tech, high impact”

Nenad Kostanjsek, WHO ICF Conference, 2004

Tanzania (Dar) 2011 Tanzania (Moshi) 2011

India (Jaipur) 2005 Bosnia (Banja Luka) 2008

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Released at RESNA June 30, 2012

Bangalore, India 2012

Bangalore, India 2012 Bangalore, India 2012

Mannar, Sri Lanka 2012 Gold Standard of Practice 2013

1. Wheelchairs should be provided using the 8-step process of the WHO

2. All people who use wheelchairs and their caregivers should have their wheelchair skills assessed.

3. Training should be provided.

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“Nothing is as powerful as an idea whose time has come.”

Victor Hugo, 1802-1885

Peter Gough. Fresh Paint.