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| # [[Wheelchair Skills Training - Wheelie|Wheelie]] | | # [[Wheelchair Skills Training - Wheelie|Wheelie]] |
| # [[Wheelchair Skills Training - Wheelie Dependant Skills|Wheelie Dependant Skills]] | | # [[Wheelchair Skills Training - Wheelie Dependant Skills|Wheelie Dependant Skills]] |
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| == Picks Objects from Floor ==
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| === Description and Rationale ===
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| * 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).
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| * The learner may use a reaching aid, but should carry it with him/her.
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| * 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.
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| * 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.
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| * 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.
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| * 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.
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| * 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.
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| * Turning an object on its side may help to get a better grip.
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| * 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.
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| * 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.
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| * 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.
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| * 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.
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| * To help right him/herself in the chair after reaching for the object, the wheelchair user can pull on the opposite armrest or wheel.
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| * 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.
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| * 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.
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| === Progression: ===
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| * The object can be picked up using different approaches (e.g. front vs. side).
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| * Objects of different sizes and weights can be used.
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| === Variations: ===
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| * 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.
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| * 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.
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| == Gets Through Hinged Door ==
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| === Description and Rationale ===
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| The learner opens, passes through and closes a hinged door that opens away from the learner, then repeats the task in the opposite direction (with the door opening toward the learner). Although there are a variety of door types, this is considered a representative skill.
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| === General Training Tips ===
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| * Although the footrests can be useful to help push doors open or closed, this method should not be used on glass doors that might break.
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| * The feet often extend beyond the footplates, so care needs to be taken to avoid injury.
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| * If using the footrests to apply a force to a door, it is best to approach the door at a slight angle toward the side that will open. This ensures that it is the outer corner of the footrest that contacts the door and not the feet.
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| * For a door that opens away from the wheelchair, the wheelchair user can begin the skill by positioning the wheelchair directly in front of the door. To open a door that opens away from the wheelchair more easily, the wheelchair user can turn sideways in front of it. This allows the wheelchair user to get closer to the door and to resist the tendency of the wheelchair to roll backward when the door is pushed. Alternatively, the wheelchair user can hold onto the door-frame with one hand, as the door is pushed with the other. This is more likely to be necessary if the door resists opening.
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| * For a door that opens toward the wheelchair, the wheelchair user should position the wheelchair to the side of the door to allow room for it to be swung open without striking the wheelchair or a body part. To open a door that opens toward the wheelchair, the wheelchair user should push on the door-frame with the hand farthest from the hinge to open the door more easily with the other hand. Turning the wheelchair sideways will also prevent the wheelchair being pulled forward as the wheelchair user pulls on the door.
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| * Once a self-closing door has been opened enough to allow the wheelchair to proceed through it, the widest part of the wheelchair can be used to prevent the door from closing. To avoid scraping the door, the wheelchair user can use his/her hand or elbow to push the door open briefly to allow progress.
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| * While moving past the door, the wheelchair user should be careful to avoid catching any clothing or body parts on the door handle or the surface of the door if it is rough.
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| * The door-frame can be used to help propel the wheelchair user through the door (the “slingshot” method). To do so, the wheelchair user reaches forward and places one hand on the door frame and the other on the door or the door frame on the other side. Then, by pulling with both hands, the wheelchair is moved through the opening. This has the advantage of keeping the hands from being injured by bumping or scraping them between the door frame and the wheelchair.
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| * To close a door that opens toward the wheelchair, after passing through it, there are several options (if the door does not close by itself):
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| * The wheelchair user may gently swing the door closed behind him/her, moving the wheelchair quickly through the door and out of the way.
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| * The wheelchair user may turn around once through the doorway, reach forward and pull the door toward him/her while backing away.
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| * The wheelchair user may go through the door backward, pulling the door with him/her.
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| * The wheelchair user should not put his/her fingers between the door and door-frame for any longer than necessary (preferably not at all) because they may get pinched when the door closes.
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| * Reaching over the back of the wheelchair to close the door is effective, but there is risk of a rear tip.
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| * To close a door that opens away from the wheelchair after passing through it, there are several options (if the door does not close by itself):
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| * The wheelchair user can swing the door closed.
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| * The wheelchair user can turn the wheelchair around and push the door closed with the footrests.
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| * The wheelchair user can back up to close the door using the rear wheel or other wheelchair part to push on the door.
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| === Progression: ===
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| * Judging the width of doorways relative to wheelchair dimensions can require practice. To avoiddamage to the hands, wheelchair or door frame, it can be useful to attempt getting through progressively more narrow openings using objects that are not firmly fixed (e.g. pylons). Bubble wrap can be used to provide audible feedback.
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| * The learner should start with a door that does not close on its own and progress to one that does. The trainer can reduce or add resistance to door opening by applying forces with his/her hand.
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| * The space available to the side of the door can be varied.
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| === Variations: ===
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| * The learner can experiment with negotiating the door in the forward or backward directions.
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| * If there is a threshold or level change in the door opening, after popping the casters over the threshold or up not the higher level, it may be helpful to use the door frame to help provide the forces needed to proceed.
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| * For a door that opens away from the wheelchair and that is latched with a bar mechanism that will open when a force is applied to it, the wheelchair user can approach the door without slowing down. At the last moment, the wheelchair user can lean and reach forward with one or both hands and use momentum to open the door. The feet should not strike the door. This should initially be practiced at slow speeds.
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| == Resources == | | == Resources == |
The 2008 World Health Organization (WHO) Guidelines on the Provision of Wheelchairs in Less-Resourced Settings [1] 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.[2] There has been a growing number of peer-reviewed papers [3] about the measurement properties of the assessment methods and effectiveness of the training protocols (including two systematic reviews and meta-analyses).[4][5]
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 [6] 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.
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.[6]
Assessment of Wheelchair Skills[edit | edit source]
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,[6] 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. [7] Information about the questionnaire version of the WST (WST-Q) can be found in Chapter 6 of the Wheelchair Skills Program Manual.[6] 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.[8]
Training of Wheelchair Skills[edit | edit source]
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 [5] 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.
- Rolling
- Stopping
- Turning
- Pressure Relief
- Transfers
- Fold & Unfold Wheelchairs
- Going Through Doorways
- Obstacles
- Curbs
- Stairs
- Wheelie
- Wheelie Dependant Skills
- ↑ World Health Organization (WHO) Guidelines on the Provision of Wheelchairs in Less-Resourced Settings. Available at: www.who.int/disabilities/publications/technology/wheelchairguidelines/en/2008.
- ↑ Wheelchair Skills Program. Available at: www.wheelchairskillsprogram.ca.
- ↑ Dynamic link to PubMed-cited Publications about the Wheelchair Skills Test and Wheelchair Skills Training Program. Available at: www.wheelchairskillsprogram.ca/eng/publications.php.
- ↑ Tu C-J, Liu L, Wang W, Du H-P, Wang Y-M, Xu Y-B, Li P. Effectiveness and Safety of Wheelchair Skills Training Program in Improving the Wheelchair Skills Capacity: A Systematic Review. Clin Rehabil. 2017;31:1573-1582.
- ↑ 5.0 5.1 Keeler L, Kirby RL, Parker K, McLean KD, Hayden J. Effectiveness of the Wheelchair Skills Training Program: A Systematic Review and Meta-analysis. Disability and Rehabilitation: Assistive Technology 2018:https://doi.org/10.17483107.2018.1456566 (Epub ahead of print).
- ↑ 6.0 6.1 6.2 6.3 Kirby RL, Rushton PW, Smith C, Routhier F, Best KL, Cowan R, Giesbrecht E, Koontz A, MacKenzie D, Mortenson B, Parker K, Smith E, Sonenblum S, Tawashy A, Toro M, Worobey, L.Wheelchair Skills Program Manual. Available at: https://wheelchairskillsprogram.ca/wp-content/uploads/2018/03/The_Wheelchair_Skills_Program_Manual.March_7_2016.pdf
- ↑ WST video and WST Report Form for a Person with Spinal Cord Injury. See Example 7 at https://wheelchairskillsprogram.ca/en/skill-tests/.
- ↑ Kirby RL, Worobey LA, Cowan R, Presperin Pedersen J, Heinemann AW, Dyson-Hudson TA, Shea M, Smith C, Rushton PW, Boninger ML.Wheelchair Skills Capacity and Performance of Manual Wheelchair Users with Spinal Cord Injury.Arch Phys Med Rehabil. 2016;97:1761-9.
