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| '''Original Editor '''- Your name will be added here if you created the original content for this page. | | '''Original Editor '''- Lee Kirby as part of the [[Wheelchair Service Provision Content Development Project]] |
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| | '''Original Contributors '''- Lee Kirby with Paula W. Rushton, Cher Smith, François Routhier, Krista L. Best, Rachel Cowan, Ed Giesbrecht, Alicia Koontz, Diane MacKenzie, Ben Mortenson, Kim Parker, Emma Smith, Sharon Sonenblum, Amira Tawashy, Maria Toro, Lynn Worobey as part of the [[Wheelchair Service Provision Content Development Project]] |
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| '''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}} | | '''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}} |
| </div> | | </div> <div align="justify"> |
| == Introduction == | | == Introduction == |
| The 2008 World Health Organization (WHO) Guidelines on the Provision of Wheelchairs in Less-Resourced Settings <ref>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.</ref> 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. | | The 2008 World Health Organization (WHO) Guidelines on the Provision of Wheelchairs in Less-Resourced Settings <ref>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.</ref> 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. The Wheelchair Skills Programis a set of protocols that deal with two of these steps, the assessment and training of wheelchair skills.<ref name=":2" /> |
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| 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.<ref>Wheelchair Skills Program. Available at: www.wheelchairskillsprogram.ca.</ref> There has been a growing number of peer-reviewed papers <ref>Dynamic link to PubMed-cited Publications about the Wheelchair Skills Test and Wheelchair Skills Training Program. Available at: www.wheelchairskillsprogram.ca/eng/publications.php.</ref> about the measurement properties of the assessment methods and effectiveness of the training protocols (including two systematic reviews and meta-analyses).<ref>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.</ref><ref name=":0">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:<nowiki>https://doi.org/10.17483107.2018.1456566</nowiki> (Epub ahead of print).</ref> | | 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.<ref name=":2">Wheelchair Skills Program. Available at: www.wheelchairskillsprogram.ca.</ref> There has been a growing number of peer-reviewed papers <ref name=":3">Dynamic link to PubMed-cited Publications about the Wheelchair Skills Test and Wheelchair Skills Training Program. Available at: www.wheelchairskillsprogram.ca/eng/publications.php.</ref> about the measurement properties of the assessment methods and effectiveness of the training protocols (including two systematic reviews and meta-analyses).<ref name=":4">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.</ref><ref name=":0">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:<nowiki>https://doi.org/10.17483107.2018.1456566</nowiki> (Epub ahead of print).</ref> |
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| === Scope === | | === Scope === |
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| 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.<ref name=":1" /> | | 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.<ref name=":1" /> |
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| == '''Assessment of Wheelchair Skills''' == | | == 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. | | As recommended in the WHO Guidelines, a new wheelchair user should go through an 8-step process in the course of wheelchair service delivery.<ref>Gowran RJ, Bray N, Goldberg M, Rushton P, Barhouche Abou Saab M, Constantine D, Ghosh R, Pearlman J. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8036353/ Understanding the global challenges to accessing appropriate wheelchairs: position paper.] International Journal of Environmental Research and Public Health. 2021 Mar 24;18(7):3338.</ref> 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. |
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| The Wheelchair Skills Test (WST), details about which can be found in Chapters 4 and 5 of the Wheelchair Skills Program Manual,<ref name=":1" /> 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. <ref>WST video and WST Report Form for a Person with Spinal Cord Injury. See Example 7 at <nowiki>https://wheelchairskillsprogram.ca/en/skill-tests/</nowiki>.</ref> Information about the questionnaire version of the WST (WST-Q) can be found in Chapter 6 of the Wheelchair Skills Program Manual.<ref name=":1" /> 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.<ref>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.</ref> | | The [https://wheelchairskillsprogram.ca/en/skills-manual-forms/ Wheelchair Skills Test (WST)], details about which can be found in Chapters 4 and 5 of the Wheelchair Skills Program Manual,<ref name=":1" /> is a means of assessing the capacity of wheelchair users to safely perform the skills they need in their everyday lives. <ref>Giesbrecht E. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8750881/ Wheelchair Skills Test Outcomes across Multiple Wheelchair Skills Training Bootcamp Cohorts.] International Journal of Environmental Research and Public Health. 2021 Dec 21;19(1):21.</ref> There has been a growing number of [https://wheelchairskillsprogram.ca/en/publications-impact/ peer-reviewed papers] <ref name=":3" /> about the measurement properties of the assessment methods. The following video shows a complete WST being performed by a person with s spinal cord injury. You can also read the associated [https://wheelchairskillsprogram.ca/wp-content/uploads/2018/04/FORM_WST-M-WCU_4.2_Example_7.pdf WST Report Form].<ref>WST Video and WST Report Form for a person with a spinal cord injury. See Example 7 at <nowiki>https://wheelchairskillsprogram.ca/en/skill-tests/</nowiki>.</ref> |
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| == Training of Wheelchair Skills == | | {{#ev:youtube|PRWp9bCIj-g|250}} <div class="row"><div class="col-md-6 col-md-offset-3"><div class="text-right"><ref>Wheelchair Skills Program. Manual Wheelchair Skills Tests - Example 7 Spinal Cord Injury. Available from: https://youtu.be/PRWp9bCIj-g[last accessed 30/10/17]</ref></div></div></div> |
| 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.
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| Chapter 7 of the Wheelchair Skills Program Manual <ref name=":0" /> 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. | | Information about the questionnaire version of the WST (WST-Q) can be found in Chapter 6 of the Wheelchair Skills Program Manual.<ref name=":1" /> In addition to assessing capacity like the WST does, the WST-Q assesses confidence and performance (what the wheelchair user ''does'' do and how they do it). 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. (2016). <ref>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.</ref> |
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| | == Training of Wheelchair Skills == |
| | Another WHO step is training, that includes wheelchair skills training of the wheelchair user and/or caregiver. There has been a growing number of peer-reviewed papers <ref name=":3" /> about the measurement properties of the assessment methods and effectiveness of the training protocols (including two systematic reviews and meta-analyses).<ref name=":4" /><ref name=":0" /> |
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| | 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. |
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| | Chapter 7 of the Wheelchair Skills Program Manual <ref name=":1" /> 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 or groups of skills including; |
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| | === Basic Skills === |
| | # [[Wheelchair Skills Training - Pressure Relief|Pressure Relief]] |
| | # [[Wheelchair Skills Training - Rolling|Rolling]] |
| | #* Forwards |
| | #* Backwards |
| | #* Roll on Soft Surface |
| | # [[Wheelchair Skills Training - Stopping|Stopping]] |
| | # [[Wheelchair Skills Training - Turning|Turning]] |
| | #* Turn in Place |
| | #* Turn While Moving |
| | #* Maneuvers Sideways |
| | # [[Wheelchair Skills Training - Transfers|Transfers]] |
| | #* Level Transfer |
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| == Picks Objects from Floor == | | === Intermediate Skills === |
| | # [https://www.physio-pedia.com/Wheelchair_Skills_Training_-_Folds_%26_Unfolds_Wheelchair Fold & Unfold Wheelchairs] |
| | # [[Wheelchair Skills Training - Going Through Doors|Going Through Doorways]] |
| | # [[Wheelchair Skills Training - Obstacles|Obstacles]] |
| | # [https://www.physio-pedia.com/Wheelchair_Skills_Training_-_Hills_%26_Ramps Hills and Ramps] |
| | #* Ascends Inclines |
| | #* Descends Inclines |
| | #* Rolls Across Side-Slope |
| | # [[Wheelchair Skills Training - Curbs|Curbs]] |
| | #* Ascends Curbs |
| | #* Descends Curbs |
| | === Advanced Skills === |
| | <div align="justify"> |
| | # [[Wheelchair Skills Training - Transfers|Transfers]] |
| | #* Wheelchair to Ground |
| | # [[Wheelchair Skills Training - Picking Up Objects|Picking Up Objects]] |
| | # [[Wheelchair Skills Training - Stairs|Stairs]] |
| | #* Ascends Stairs |
| | #* Descends Stairs |
| | # [[Wheelchair Skills Training - Wheelie|Wheelie]] |
| | # [[Wheelchair Skills Training - Wheelie Dependant Skills|Wheelie Dependant Skills]] |
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| === Description and Rationale === | | == Resources == |
| * 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).
| | === Training Manual === |
| * The learner may use a reaching aid, but should carry it with him/her.
| | [https://wheelchairskillsprogram.ca/wp-content/uploads/2018/03/The_Wheelchair_Skills_Program_Manual.March_7_2016.pdf Wheelchairs Skills Program Manual - Version 4.3] |
| * 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: === | | === Forms === |
| * The object can be picked up using different approaches (e.g. front vs. side).
| | Wheelchair Skills Test (WST) Form; |
| * Objects of different sizes and weights can be used. | | * [https://wheelchairskillsprogram.ca/wp-content/uploads/2018/03/FORM_WST-M-WCU_4.3.3.pdf Manual Wheelchairs Operated by Their Users] |
| | | * [https://wheelchairskillsprogram.ca/wp-content/uploads/2018/03/FORM_WST-M-CG_4.3.3.pdf Manual Wheelchairs Operated by Caregivers] |
| === Variations: ===
| | Wheelchair Skills Test Questionnaire (WST-Q) |
| * 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.
| | * [https://wheelchairskillsprogram.ca/wp-content/uploads/2018/03/FORM_WSTQ-M-WCU_4.3.3.pdf Manual Wheelchairs Operated by Wheelchair Users Form] and [https://wheelchairskillsprogram.ca/wp-content/uploads/2018/03/SCRIPT_WST-Q_4.3-M-WCU.2.pdf Script] |
| * 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.
| | * [https://wheelchairskillsprogram.ca/wp-content/uploads/2018/03/FORM_WSTQ-M-CG_4.3.3.pdf Manual Wheelchairs Operated by Caregivers Form] and [https://wheelchairskillsprogram.ca/wp-content/uploads/2018/03/SCRIPT_WST-Q_4.3-M-CG.2.pdf Script] |
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| == Folds and Unfolds Wheelchair ==
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| === Description and Rationale ===
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| The learner folds or takes apart the unoccupied wheelchair to make it as small as possible, and then restores it to its original condition. For transport or storage, the size or weight of the wheelchair may need to be reduced. This can be done by folding the wheelchair.Removal of the rear wheels or other parts is a useful way to further diminish the size and weight of the wheelchair.
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| === General Training Tips ===
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| ==== Fold Wheelchair: ====
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| * The learner should pay attention to each item as he/she removes or alters it, to ensure that he/she will be able to reassemble the chair later.
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| * The learner should remove anything that may prevent folding (such as the cushion, rigid seat, backrest or knapsack).
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| * To remove a rigid seat or backrest, the learner may need to release restraining devices.
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| * For rear wheels that can be removed without tools, there is usually a release mechanism at the center of the axle, a button or lever that needs to be depressed. If the wheel does not come off easily, the learner should check to be sure the wheel lock is not on and that the rear wheel is off the ground.
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| * To fold a cross-braced wheelchair (one that becomes narrower from side to side when folded), the learner should first clear the footrests (e.g. by flipping them up, swinging them away or removing them).
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| * To fold a cross-braced wheelchair more easily, the learner should position the wheelchair so that he/she is on one side of it. The learner should then tip the chair slightly toward him/herself so that the wheels on the side away from him/her are off the ground. This eliminates the friction between the far-side rear wheel and the ground and allows gravity to assist in folding the wheelchair. The learner should then pull the seat or seat rails upwards, with one or both hands, to fold the chair.
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| * For a rigid-frame wheelchair with a fold-down back, although the frame cannot be folded, the learner can often make the chair easier to transport by folding down the back. The learner may need to release any restraining devices before he/she can do so. After folding the wheelchair, if the wheelchair does not have a latch mechanism to prevent the wheelchair from opening while it is being lifted, it may be helpful to use a strap.
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| * When lifting a folded wheelchair for which the rear wheels cannot be removed, injury can occur if the unlocked rear wheels are grasped, because the frame will be free to rotate.
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| * It may be possible to reduce the weight and size of the wheelchair by removing the armrests and footrests.
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| * The push-handles of some wheelchairs can be folded to further reduce the wheelchair dimensions.
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| ==== Unfold Wheelchair: ====
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| * Generally, the learner should reverse the steps used to fold the wheelchair and in roughly reverse order (e.g. starting by putting the rear wheels back on and finishing with putting the cushion back in place).
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| * To replace the rear wheels it may be necessary to push the quick-release plunger to allow the axle to get into the housing. To check that the axle is fully seated, the plunger should be out and it should not be possible to pull the rear wheel off.
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| * The learner should be careful not to tangle the seatbelt (if any) under the seat.
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| * To get the process of opening a cross-braced wheelchair started, the learner should use the push-handles to lift the rear wheels off the ground (thereby avoiding friction with the ground) and separate the push-handles.
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| * The learner usually needs to push the seat rails back down into the starting position. The learner should keep the fingers on top of the rails to prevent them from being pinched. | |
| * For wheelchairs with backrests that fold forward, the backrest may lock in the folded position, necessitating a release of the locking mechanism to unfold the backrest.
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| * The learner should put the cushion back on the seat properly before transferring back into the chair.
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| === Progression: ===
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| Once the learner is able to fold and unfold the wheelchair, he/she can progress toward full use of this skill by putting the folded wheelchair up on the transfer bench and into his/her vehicle.
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| === Variations: ===
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| The advanced wheelchair user may be able to remove and replace rear wheels while seated in the wheelchair by leaning sideways (e.g. in a doorway) or forward (tipping the wheelchair onto the footrests). This can be useful if the wheelchair user wishes to change the wheels for ones more suitable for a new activity. Also, removing the rear wheels can be helpful in getting through narrow spaces if there are transport wheels or rear anti-tip devices that can be used for the purpose.
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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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| == Ascends Inclines ==
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| === Description and Rationale ===
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| The learner moves the wheelchair upinclines of different slopes. Inclines with different slopes are encountered frequently in the natural and built environments.For instance, a 5°(~1:12) grade meets the current building codes for ramps in North America. Inclines with slopes greater than the standard recommended value are encountered frequently in the natural and built environments.
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| === General Training Tips ===
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| * The steeper the incline, the greater is the likelihood of problems due to scraping the footrests or anti-tip devices at the transition between the floor and the lower end of the incline.
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| * Momentum can be used to ascend short inclines by approaching at speed. However, if the wheelchair user strikes the floor-ramp transition too quickly, he/she may tip the wheelchair forward or fall forward out of the wheelchair.
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| * When negotiating the incline-floor transition at the lower end, during either ascent or descent, the wheelchair user should be careful not to catch an unsupported foot, as this could lead to a hyper-flexion injury of the knee.
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| * When getting the casters onto the bottom of an incline, it may be necessary to transiently tip the wheelchair (“popping” the casters, as will be described later) if the footrests are low and to reduce the sudden braking that occurs at the transition.
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| * The wheelchair user should lean forward as he/she goes up the ramp to apply more force to the hand-rims and to avoid tipping backward. The need for forward lean increases as the slope increases. In addition to a consistent forward lean, it can be helpful to lean forward a little more with each push to apply greater forces to the hand-rims.
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| * If the wheel locks are not of the retractable type, forward leaning can result in injury to the backs of the thumbs.
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| * It may be necessary to use shorter propulsive strokes than on the level, to avoid rolling backward between strokes.
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| * The recovery path of the hands at the end of the propulsive stroke may be more like an arc (following the hand-rim) than a loop (below the hand-rim) for this skill.
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| * If the wheelchair user gets tired part of the way up the incline, he/she should turn the wheelchair to the side and rest. This can be done without applying the wheel locks. Although it may seem counter-intuitive, the static rear stability of an occupied wheelchair is significantly lower with the wheel locks applied than not.
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| * If the wheelchair starts to roll backward, instead of grasping both hand-rims (that might cause a rear tip), the wheelchair user can grab one. As the other wheel rolls backward, this will turn the wheelchair across the slope.
| |
| | |
| === Progression: ===
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| * The learner should start with the wheelchair stationary at the lower end of the incline and progress to a moving approach.
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| * The learner should start with a minimal incline and proceed to more extreme ones.
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| | |
| === Variations: ===
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| * Inclines with different surfaces, such as grass, cobblestone or loose rock may be used.
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| * Stopping and turning around on the incline should be practiced.
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| * Alternating hands during propulsion may help to prevent roll-back.
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| * If the incline is wide enough, the learner can steer back and forth across the incline (“slalom” or “zig-zag”), to decrease the apparent slope. The more turns used, the lower is the effective slope (but the greater the distance travelled). Although a slalom path up an incline will reduce the effective slope, it will introduce an element of side-slope (dealt with more specifically later).
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| * The wheelchair user may use the ramp handrails if available.
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| * See wheelie variation later.
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| | |
| == Descends Inclines ==
| |
| | |
| === Description and Rationale ===
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| The learner moves the wheelchair down inclines of different slopes. The general rationale is as for “ascends inclines”.
| |
| | |
| === General Training Tips ===
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| * A smooth controlled descent in the forward direction is the basic method for descending inclines.
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| * The learner should proceed slowly to maintain control and should be prepared to stop at any time. It is easier to maintain speed control than to regain it after it has been lost.
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| * The wheelchair user should keep his/her weight back, to maintain good traction on the rear wheels and to avoid forward tips or falls.
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| * To slow down or steer, the wheelchair user should hold the hands still ahead of top dead center (at about the 1:00 o’clock position, using the clock analogy) and let the hand-rims slide through his/her fingers. It is generally better to provide continuous friction than to use a jerky grasp-and-release method. However, the grasp-and-release method may be useful to minimize the heat that builds up through friction, grasping either with both hands at the same time or alternating from one to the other.
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| * The wheelchair user can slalom down the incline by letting the hand-rim of one wheel at a time slide through the fingers. By descending using the slalom method, the apparent slope of the incline is lessened. Also, this technique may prevent the hands from overheating due to sustained friction. Downhill-turning tendency can be used to advantage when the wheelchair user wishes to turn downhill. Leaning forward will accentuate the tendency and ease the turn.
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| * As for ascending inclines, the wheelchair may be turned sideways on the incline to rest without applying the wheel locks. | |
| | |
| === Variations: ===
| |
| * If the drive wheels are uphill, they become relatively unloaded. This can cause loss of traction so that propulsion, braking and directional control become difficult. If traction is lost to the extent that the wheels spin or the wheelchair begins to slide, the wheelchair user should lean toward the affected wheels. If this is insufficient, then the wheelchair should be turned around so that the drive wheels are downhill. It is best to turn around on the level but, if that is not possible, the wheelchair user should lean uphill during the turn.
| |
| * If the wheelchair user has weak trunk muscles and a tendency to fall forward when facing downhill on inclines, he/she may feel more comfortable descending the incline backward. When going downhill backward, the wheelchair user should lean uphill to reduce the likelihood of tipping over backward. As with any time the wheelchair is moving backward, it is important to proceed slowly with frequent shoulder checks and to avoid sudden stops that can cause rear tips.
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| * The wheelchair user may use the handrails of the incline, if available.
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| * See wheelie variation later.
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| | |
| == Rolls Across Side-Slope ==
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| | |
| === Description and Rationale ===
| |
| The learner moves the wheelchair across a slightside-slope without turning downhill or uphill significantly, then repeats the task in the opposite direction. Side-slopes (or cross-slopes) are frequently encountered in built and natural environments. Sidewalks, for instance, are usually sloped 2% (1:50) toward the street to allow water to run off. Steeper grades are also often found (e.g. where sidewalks cross driveways). The yaw axis of a wheelchair (i.e. the vertical axis around which the wheelchair turns toward the left or right) is between the drive wheels. If the combined center of gravity of the wheelchair and user is ahead of the drive wheels and more on the casters that are free to turn (as is usually the case with rear-wheel-drive wheelchairs), the wheelchair will tend to turn downhill on a side-slope (“downhill turning tendency”).
| |
| | |
| === General Training Tips ===
| |
| * The extent of downhill-turning tendency is directly proportional to how far the combined center of gravity of the wheelchair and occupant is in front of the rear wheels. The person operating the wheelchair can take steps to minimize this distance by repositioning the center of gravity (e.g. by leaning, tilting or reclining).
| |
| * If there is room to do so on a path, the person operating the wheelchair should stay away from the downhill edge of a side-slope to avoid veering off the path.
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| * To avoid turning downhill, the wheelchair user should push harder on the downhill wheel.
| |
| * Different push frequencies may be used for the two hands. For instance, when moving across a side-slope with the right side downhill, the right hand may push 2-3 times for every 1 push on the left.
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| * When pushing longer distances, route planning can be used to avoid overuse on one side. For instance, part of the journey can be carried out on the right-hand sidewalk (where the left side is downhill) and part of the journey on the left-hand sidewalk.
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| * In some cases, the uphill hand may be used exclusively for braking (to minimize downhill-turning tendency) rather than for assisting with propulsion.
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| * Shorter stokes may need to be used to keep the wheelchair moving straight.
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| * On steep cross-slopes, problems (e.g. loss of uphill-wheel traction, lateral tip-over, folding of the wheelchair) may arise due to the lack of weight on the uphill wheel. These problems can be minimized by leaning uphill.
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| * As noted earlier, downhill-turning tendency can be used to advantage when the wheelchair user wishes to turn downhill. Leaning forward will accentuate the tendency and ease the turn.
| |
| | |
| === Progression: ===
| |
| Although only a 5°side-slope is mentioned specifically in the WSP Manual, for learners and wheelchairs capable of handling steeper inclines, it is reasonable to attempt these under the supervision of a trainer, even if only to help the learner recognize the limits of what is possible for him/her with that wheelchair.
| |
| | |
| === Variations: ===
| |
| * Slowly turning the wheelchair 360° in place on a side-slope will provide a good sense of how downhill-turning tendency affects the wheelchair at different angles.
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| * A useful learning experience to demonstrate the downhill-turning tendency is to have the wheelchair user lean forward as he/she rolls forward, to illustrate how the downhill-turning tendency increases.
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| * See wheelie variation later.
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| | |
| == Rolls On Soft Surface ==
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| | |
| === Description and Rationale ===
| |
| The learner moves the wheelchair a short distance on a soft surface. There are many types of soft surfaces (e.g. carpet, dirt, grass, gravel, sand or snow) that a wheelchair user may encounter. Propulsion is more difficult on such surfaces (increased rolling resistance) because the wheels tend to sink into the surface, especially wheels that are narrow or of small diameter.
| |
| | |
| === General Training Tips ===
| |
| * When approaching a section of soft or irregular terrain, the wheelchair user should look ahead and plan a route that will minimize difficulties. When proceeding across a soft or rough surface, it is easiest to move forward in a straight line because, if the casters sink into the soft surface, they will be less free to swivel should the user wish to change direction.
| |
| * When moving from a smooth level surface onto a soft surface, the wheelchair will decelerate, so it may be necessary to slow down (or pop the casters, if in a manual wheelchair) when approaching such a transition.
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| * To minimize rolling resistance, reducing the weight on the casters and increasing the weight on the rear wheels is a helpful strategy.
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| * If one drive wheel is spinning, the wheelchair user should shift his/her weight in the direction of the slipping wheel to increase the traction.
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| * The forward approach to negotiating soft surfaces is preferred because the wheelchair user can see where he/she is going.
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| * The wheelchair user should use long slow strokes to keep the wheels from slipping in loose surfaces.
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| * Because there is more rolling resistance on soft surfaces, more force is required by the wheelchair user.
| |
| * Leaning forward slightly may help the wheelchair user to apply more force to the hand-rims and to prevent the additional force from causing a rear tip. However, keeping as much weight as possible on the rear wheels (e.g. byleaning backwardslightly) will improve traction and keep the front wheels from digging into the soft surface. The wheelchair user should experiment with the extent of trunk lean to find the optimum (the “sweet spot” between too much and too little).As a learning exercise, the wheelchair user should try the skill while leaning forward and backward to different extents, to find the optimum position for him/her.
| |
| * Transient caster popsare a good option, lifting the casters off the surface during each push, but letting them touch the surface as the hands recover for the next push. During a caster pop, the longer the hands remain on the hand-rims, the farther forward the wheelchair will move with the casters off the surface. This can be thought of as analogous to taking a series of walking “steps” across the surface; a few long steps are preferable to many short steps.
| |
| | |
| === Progression: ===
| |
| * For wheelchair users who are unfamiliar with caster pops, it can be a useful exercise to practice such pops on a smooth firm surface. The emphasis is on pushing the hand-rims forward but more forcefully than to simply roll forward but less forcefully than is needed to achieve a full wheelie position.
| |
| * For a learner who is having difficulty applying enough force, the trainer can hold out his/her palm and ask the learner to use his/her own hand first to simply push against the trainer’s palm (to illustrate the amount and timing of the force needed to roll forward) and then to slap the trainer’s palm (to illustrate the amount and timing of the force needed to pop the casters off the surface).
| |
| | |
| === Variations: ===
| |
| * It may be easier to lead with the rear wheels (i.e. in the backward direction). The casters will trail backward and the resulting longer wheelbase may help as well because the casters will be farther from the center of gravity.
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| * A variety of surfaces (e.g. sand, thick carpet, foam,a gym mat, gravel) provide similar, but not identical, experiences.
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| * See wheelie variation later.
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| | |
| == Getting Over Obstacles Or Gaps ==
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| | |
| === Description and Rationale ===
| |
| The learner moves the wheelchair over an obstacle or a gap across the line of progression. Wheelchair users often encounter obstacles (e.g. door thresholds) of various sizes and shapes that they may not be able to simply roll over. Alternative strategies may be needed. For example, a wheelchair user might need to pop the casters over the obstacle. A gap in surface support is a commonly encountered barrier (e.g. due to a rut in the road, a water channel or a space between a subway platform and a subway train). Gaps that only affect one wheel at a time are not usually major obstacles. In this section, only gaps that are as wide as the wheelchair will be considered. Small-diameter wheels (such as casters) can drop into such gaps, causing a sudden deceleration that can tip the wheelchair over forward or lead to the wheelchair user falling out of the wheelchair. Even if no tip or fall occurs, it can be difficult to get the wheelchair out of the gap.
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| | |
| === General Training Tips ===
| |
| * The best approach is to avoid obstacles or gaps, steering around them or straddling them.
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| * If the wheelchair gets hung up on an obstacle due to insufficient distance between the front and rear wheels (short wheelbase), the learner may be able to escape by backing up slightly; this will swings the casters from the rear-trailing position to the side- or forward-trailing one, where there is more space between the front and rear wheels.
| |
| * The most common approach to getting over a gap, although not necessarily the safest or most effective, is to approach the gap squarely.
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| * If the casters drop into the gap and they turn sideways (a common problem if the wheelchair is moved forward and backward repeatedly in an attempt to get the casters out of the gap), it can be very difficult or impossible to proceed without assistance.
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| | |
| ==== Forward Approach, Stationary Method: ====
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| * The square-on forward approach is useful to include in training because the method used is part of a step-wise sequence leading toward the ascent of curbs.
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| * The wheelchair user should approach the obstacle and stop with the casters 5-10 cm before reaching the obstacle, to avoid striking the casters on the vertical section of the obstaclewhile popping them.
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| * This method is comprised of two steps: “pop” and “lean”. These cues can be verbalized as the steps are performed.
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| * The wheelchair user first briefly pops the casters from the floor, just high enough to clear the obstacle. To do so using the two-hand propulsion method, the wheelchair user applies forward forces of moderate intensity to the hand-rims (a “slap” vs. a “push”, as noted earlier). After the casters land beyond the obstacle and the rear wheels encounter resistance, the wheelchair user should lean forward to help power the rear wheels over the obstacleor gap and prevent rear tipping. Some rocking may be needed.
| |
| * Once the rear wheels are on top of a high obstacle, the wheelchair user should lean back to decrease the likelihood of a forward tip or fall out of the wheelchair.
| |
| * For a gap, the casters can be stopped at the edge of the gap. There is less need to pop the casters “high” than to pop them “long” to get across the gap. As for the “rolls on soft surface” skill, a long “step” can be achieved by ensuring that the hands remain on the hand-rims for as long as possible (i.e. 11:00-2:00 o’clock using the clock analogy).
| |
| | |
| ==== Forward Approach, Momentum Method: ====
| |
| * This method is comprised of three phases: “approach”, “pop” and “lean”. As for the stationary method, the cues can be verbalized as they are performed.
| |
| * In preparing to pop the casters while the wheelchair user moves forward during the approach, the wheelchair user may briefly coast to allow correct placement of the hands when he/she is at the proper distance from the obstacle.
| |
| * The wheelchair user should initially approach at a slow speed, square to the obstacle or gap. It is simpler to pop the casters when moving slowly. Also, if the wheelchair user fails to pop the casters for long enough to clear the front edge of the obstacle or back edge of the gap, the sudden stop will be less jarring at a slow speed.
| |
| * The wheelchair user should not lean forward to look at the feet when he/she approaches the obstacle or gap, because that increases the weight on the casters. In timing the caster pop, the wheelchair user needs to understand where the casters are (often below the knees rather than under the feet). A mirror placed to the side of the obstacle or gap can be used to provide feedback.
| |
| * The correct position of the hands, at the beginning of the popping phase, is when they are ready to grasp the hand-rims, behind top dead center (11:00 o’clock on the right wheel, using the clock analogy). Then, the wheelchair user should accelerate the chair even faster than it is coasting, by using a stroke of moderate force that is powerful enough to pop the casters from the surface high enough and long enough.
| |
| * Once the casters have landed beyond the obstacleor gap and the rear wheels strike the obstacle or gap, the wheelchair user should lean forward and propel the rear wheels to bring the rear wheels over the obstacle or up out of the gap. If the obstacle is a high one, the wheelchair user should lean back once the rear wheels are on top of the obstacle.
| |
| * When moving forward over an obstacle or gap, some advanced wheelchair users prefer to allow the rear wheels to reach the surface beyond the obstaclebefore having the casters land on the surface. However, when initially learning the skill, it is preferable that the casters land beyond the obstacleor gap before the rear wheels strike the obstacle. This will be especially useful when learning to ascend curbs, to avoid “caster slap”.
| |
| | |
| === Progression: ===
| |
| * Although the techniques used for getting over gaps and obstacles are very similar and the gap technique is easier, the gap can be more intimidating for learners so we usually teach the learner how to get over an obstacle before progressing to the gap.
| |
| * The learner should start with a slow speed and progress to faster ones.
| |
| * The learner should start with low obstacles and progress to higher ones. Obstacles with a height of 10 cm or greater are negotiable in the right wheelchair. Before attempting to negotiate a high obstacle, the learner should be aware of how much clearance exists between the wheels and under the frame or chassis of the wheelchair, to avoid getting hung up on the obstacle.
| |
| * The learner should start with small shallow gaps and progress to more challenging ones.
| |
| * This is the first of a series of skills for which the ability to pop the casters in a specific location and to move forward are very helpful.
| |
| * To practice getting the timing correct without the fear of having the casters strike the obstacle or gap, the wheelchair user may practice propelling the wheelchair forward and transiently popping the casters at a predetermined point on the floor. This can be a line on the floor or a strip of bubble wrap. The horizontal distance over which the casters need to be off the floor can be gradually increased.
| |
| * The learner should start with the stationary approach then progress to the momentum method.
| |
| * For learners experiencing difficulties in coordinating the sequence of the three phases of the skill (approach, pop and lean), it may be useful to practice them in segments before putting the segments together.
| |
| | |
| === Variations: ===
| |
| * The wheelchair user may use the external environment if available (e.g. door frame) to pull the rear wheels over the obstacle or gap.
| |
| * As noted earlier for the “maneuvers sideways” skill, to get beyond a pair of obstacles (e.g. concrete parking bolsters) or gaps that are too close to wheel between, it may be possible to move one wheel (or pair of wheels) through the space at a time, transiently straddling the obstacles with one wheel (or pair of wheels) on either side of the obstacles or gaps and the wheelchair parallel with the obstacles or gaps.
| |
| * The wheelchair user may find it easier to back over a low obstacle or gap. The wheelchair user should approach the obstacle or gap slowly, because a sudden stop can cause a rear tip. As the wheelchair user approaches the obstacle or gap backward, he/she should lean forward to unload the rear wheels and further reduce the likelihood of a rear tip. The wheelchair user pulls the wheelchair straight backward by applying equal force to both wheels. Otherwise, the casters may turn and catch sideways on the obstacle or in the gap. Once the rear wheels are over the obstacle or gap, the wheelchair user should lean back enough to unload the casters as they reach the obstacle or gap, but not so much as to cause a rear tip.
| |
| * The oblique approach to a gap is often safer and more effective than the square-on approach. As long as three wheels are supported at any time, the wheelchair will usually remain upright. That being the case, an oblique approach to a gap (e.g. 30-45° from the line of progression so that only one wheel is unsupported at a time) is a useful strategy. The wheelchair user should keep his/her weight away from the unsupported wheel.
| |
| * See the wheelie variation later.
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| | |
| == Resources ==
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| == References == | | == References == |
| <references /> | | <references /> |
| | |
| | [[Category: Wheelchair Service Provision]] |
| | [[Category:Occupational Health]] |
| | [[Category:Assistive Technology]] |
| | [[Category:Assessment]] |
| | [[Category:Interventions]] |
| | [[Category:Wheelchair Service Provision Content Development Project]] |
| | [[Category:Wheelchair Skills Training]] |
| | [[Category:Course Pages]] |
