Wheelchair Skills Assessment and Training

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Introduction

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

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

Scope

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

Warning

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

Assessment of Wheelchair Skills

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

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

Training of Wheelchair Skills

Another WHO step is training, that includes wheelchair skills training of the wheelchair user and/or caregiver. The Wheelchair Skills Training Program (WSTP) combines the best available evidence on motor skills learning principles with the best available evidence on wheelchair skill techniques. The WSTP can be used during the initial provision of the wheelchair and as necessary at follow-up. 

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

Rolls Forward

Description and Rationale

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

General Training Tips

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

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

Propulsion Phase:

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

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

Recovery Phase:

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

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

Progression: 

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

Variations: 

• The learner can experiment with different speeds.

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

Rolls Backwards

Description and Rationale

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

General Training Tips

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

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

Variations: 

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

Stops

Description and Rationale

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

General Training Tips

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

Progression:

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

Variations: 

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

Turns In Place

Description and Rationale

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

General Training Tips

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

Progression: 

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

Variations: 

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

Turns While Moving

Description and Rationale

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

Progression: 

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

Variations:

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

Manoeuvres Sideways

Description and Rationale

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

General Training Tips

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

Progression: 

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

Variations:

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

Picks Objects from Floor

Description and Rationale

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

Progression:

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

Variations:

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

Relieves Weight from Buttocks

Description and Rationale

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

General Training Tips

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

Variations:

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

Performs Level Transfers

Description and Rationale

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

General Training Tips

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

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

Folds and Unfolds Wheelchair

Description and Rationale

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. 

General Training Tips

Fold Wheelchair:

• 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.
• The learner should remove anything that may prevent folding (such as the cushion, rigid seat, backrest or knapsack).  
• To remove a rigid seat or backrest, the learner may need to release restraining devices. 
• 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.
• 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). 
• 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. 
• 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.
• 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. 
• It may be possible to reduce the weight and size of the wheelchair by removing the armrests and footrests. 
• The push-handles of some wheelchairs can be folded to further reduce the wheelchair dimensions.

Unfold Wheelchair:

• 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).
• 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. 
• The learner should be careful not to tangle the seatbelt (if any) under the seat.
• 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.
• 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.
• The learner should put the cushion back on the seat properly before transferring back into the chair. 

Progression: 

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. 

Variations:

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.

Gets Through Hinged Door

Description and Rationale

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.

General Training Tips

• 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. 
• The feet often extend beyond the footplates, so care needs to be taken to avoid injury. 
• 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.
• 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.
• 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.
• 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.
• 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.
• 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.
• 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):
• The wheelchair user may gently swing the door closed behind him/her, moving the wheelchair quickly through the door and out of the way.
• The wheelchair user may turn around once through the doorway, reach forward and pull the door toward him/her while backing away.
• The wheelchair user may go through the door backward, pulling the door with him/her. 
• 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.
• Reaching over the back of the wheelchair to close the door is effective, but there is risk of a rear tip.
• 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):
• The wheelchair user can swing the door closed.
• The wheelchair user can turn the wheelchair around and push the door closed with the footrests.
• The wheelchair user can back up to close the door using the rear wheel or other wheelchair part to push on the door.

Progression:

• 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.
• 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.
• The space available to the side of the door can be varied.

Variations: 

• The learner can experiment with negotiating the door in the forward or backward directions.
• 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.
• 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.

Ascends Inclines

Description and Rationale

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.

General Training Tips

• 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. 
• 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. 
• 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.
• 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. 
• 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. 
• If the wheel locks are not of the retractable type, forward leaning can result in injury to the backs of the thumbs.
• It may be necessary to use shorter propulsive strokes than on the level, to avoid rolling backward between strokes. 
• 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.
• 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.
• 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: 

• The learner should start with the wheelchair stationary at the lower end of the incline and progress to a moving approach.
• The learner should start with a minimal incline and proceed to more extreme ones.

Variations: 

• Inclines with different surfaces, such as grass, cobblestone or loose rock may be used. 
• Stopping and turning around on the incline should be practiced.
• Alternating hands during propulsion may help to prevent roll-back.
• 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).
• The wheelchair user may use the ramp handrails if available.
• See wheelie variation later.

Descends Inclines

Description and Rationale

The learner moves the wheelchair down inclines of different slopes. The general rationale is as for “ascends inclines”. 

General Training Tips

• A smooth controlled descent in the forward direction is the basic method for descending inclines. 
• 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.
• The wheelchair user should keep his/her weight back, to maintain good traction on the rear wheels and to avoid forward tips or falls.
• 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. 
• 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.
• 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.
• The wheelchair user may use the handrails of the incline, if available.
• See wheelie variation later.

Rolls Across Side-Slope

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.
• 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. 
• 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. 
• In some cases, the uphill hand may be used exclusively for braking (to minimize downhill-turning tendency) rather than for assisting with propulsion.
• Shorter stokes may need to be used to keep the wheelchair moving straight.
• 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.
• 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. 
• 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.
• See wheelie variation later.

Rolls On Soft Surface

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.
• To minimize rolling resistance, reducing the weight on the casters and increasing the weight on the rear wheels is a helpful strategy.
• 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.
• The forward approach to negotiating soft surfaces is preferred because the wheelchair user can see where he/she is going.
• The wheelchair user should use long slow strokes to keep the wheels from slipping in loose surfaces.
• 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.
• A variety of surfaces (e.g. sand, thick carpet, foam,a gym mat, gravel) provide similar, but not identical, experiences. 
• See wheelie variation later.

Getting Over Obstacles Or Gaps

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. 

General Training Tips

• The best approach is to avoid obstacles or gaps, steering around them or straddling them.
• 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. 
• 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.

Forward Approach, Stationary Method:

• 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. 
• 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.
• This method is comprised of two steps: “pop” and “lean”. These cues can be verbalized as the steps are performed.
• 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.

Ascends Curbs

Description and Rationale

The learner gets the wheelchair up curbs of various heights. Level changes (e.g. curbs, home entries, uneven sidewalk sections) are common obstacles in the natural and built environments. The ability to manage low curbs (~5 cm) is useful but practice on low curbs also provides an opportunity to hone techniques that will be needed for higher curbs (~15 cm). Although curb cuts (“pedestrian ramps”) are now commonplace in many parts of the world, curbs or large level changes are still commonly encountered. 

General Training Tips

• This skill is similar to and builds upon the previous ones, specifically the “rolls on soft surface” and “gets over obstacles or gaps” sections. 
• A low curb can be approached with stationary and momentum methods but the momentum method is usually necessary for high curbs. 
• It is slightly more challenging to deal with the rear wheels than for the preceding skills because the tilted position, due to having the casters on top of the curb, moves more weight to the back of the wheelchair. This shift of weight is present until the rear wheels are all the way up on the upper level.
• In the stationary approach, if the wheelchair user has difficulty getting the rear wheels up onto the upper level, the wheelchair user should roll the wheelchair backward until the front wheels are almost off the edge of the curb. Before backing the rear wheels away from the curb edge, the wheelchair user should lean forward and place his/her hands on the hand-rims in the position where the most force can be applied. The hands should remain on the hand-rims as the wheelchair user sits up and the rear wheels are backed away from the curb, ensuring that the hands and trunk will be optimally placed when moving forward again. When the rear wheels strike the curb, the wheelchair user should lean forward and push the rear wheels up onto the upper level. The forward lean should be timed to coincide with when the rear wheels contact the curb. 
• As noted earlier, with the momentum method, the wheelchair user should ensure the casters are on the upper surface (rather than in the air) when the rear wheels strike the curb. If the casters are still in the air, the energy from the forward pitch caused by the collision of the rear wheels with the curb will be expended in noisily bringing the casters down onto the upper level (“caster slap”) rather than bringing the rear wheels up onto the upper level.

Progression:

• The learner should start with a minimal level change and progress to higher ones. 

Variations:

• The wheelchair user might find it easier to ascend low curbs in the backward direction.
• The wheelchair user may use the external environment if available (e.g. door frame) to pull the rear wheels up onto the upper level.

Descends Curbs

Description and Rationale

The learner gets the wheelchair down curbs of various heights. The rationale is the same as that for the “ascends curbs” section.The appropriate technique for a high curb differs in some respects from that used for a lower curb height.

General Taining Tips

• The wheelchair may be able to simply roll forward off the upper level of a low curb. This is less of a problem for wheelchairs with long wheelbases. The forward roll-off approach for low curbs is convenient and allows the learner to watch for traffic. It may be as safe and effective to go off the lip at a moderate or full speed as it is to go slowly.
• For a high curb, the backward approach is simple and generally safe if the wheelchair has adequate rear stability and sufficient visibility is available to avoid oncoming traffic. However, even more so than for descending low curbs, it is important to keep the rear wheels moving backward to avoid a rear tip. Learning the backward approach on low curbs is helpful when advancing to higher curbs. To perform the backward approach, the wheelchair user should line the rear wheels up with the edge of the curb. The wheelchair user should lean as far forward as possible (chest on lap, if necessary) and reach forward on the hand-rims. The wheelchair user should move backward very slowly and let the rear wheels roll evenly down off the upper level under control. Once the rear wheels are on the lower level, the wheelchair user can sit more upright if this is possible without tipping over backward. The wheelchair user should avoid braking suddenly when the rear wheels land on the lower level because this can induce a rear tip; keeping the wheelchair moving backward reduces the likelihood of this problem. If the wheelchair can be brought to a stop with the rear wheels on the lower level and the casters on the upper level, the wheelchair user can turn to the left or the right to get the casters off the upper level without scraping the footrests use the full-wheelie position to move backward away from the curb. 

Variations:

• Approaching the curb edge in the forward direction, the wheelchair user can transiently pop the casters as they reach the curb edge. The wheelchair user approaches the curb edge squarely with all four wheels on the surface and pops the casters as they reach the edge. This is similar to the technique used to pop the casters transiently for the “gets over threshold” and “gets over gap” skills. The extent of the caster pop should be sufficient to allow the rear wheels to land on the lower level at about the same time or slightly before the casters land. This method requires good timing and skill, but is a natural way to maintain forward progression and to watch for traffic. It can be difficult to spot, so two spotters are recommended.
• See the wheelie variation later.

Performs Wheelchair Ground Transfers

Description and Rationale

The wheelchair user gets from the wheelchair to the ground and back.Getting onto the ground is useful for an activity (e.g. gardening or playing with a child). Getting from the ground back into the wheelchair can also be helpful when recovering from a fall.

General Training Tips

• There are a number of techniques that wheelchair users can use to get safely from their wheelchairs to the ground and back, the variations reflecting differences in the nature of the wheelchair user’s impairments and wheelchair characteristics. Only a few of the more commonly used techniques will be described. 
• Getting from the wheelchair to the ground:
• If there is a removable seat cushion and the learner can remove it (either while seated in the wheelchair or after transferring to another surface), the cushion may be placed on the ground in the position that the buttocks will land. This provides a surface that will protect the buttocks from excessive pressure. Additionally, doing so lowers the effective seat height and raises the effective floor height. 
• The technique is similar to that for a level transfer, the major exception being that the hand of the reaching arm should be positioned on the ground before any significant weight is transferred to it. The learner should not use a controlled fall due to the potential for injury to the hand or wrist. The non-reaching hand is on the seat. 

Getting from the Ground to the Wheelchair:

• As noted above, the wheelchair user can use the seat cushion to increase the starting height above the floor and to lower the height of the wheelchair seat.
• The casters of the wheelchair should be oriented so that they are trailing forward, the wheel locks and caster locks (if any) should be applied and, unless they will be used as an intermediate sitting surface, the footrests should be moved out of the way if possible. 
• A commonly used technique is with the wheelchair user in the sitting position on top of the seat cushion facing sideways in front of the wheelchair as close to the seat as possible, with the hips and knees flexed as much as possible. The wheelchair user can lift the buttocks with one arm on the seat and one on the ground. This approach is similar to a sideways level transfer (discussed earlier). Moving the head in the direction opposite to the direction to the hips is useful (i.e. move the head down when moving the hips up). 
• After getting up onto the wheelchair seat, the cushion can be placed back under the buttocks by rolling to a transfer surface that is the same height as the wheelchair seat and transferring out of the wheelchair. When replacing the cushion, the learner should ensure that the well area (if any) is at the back of seat and the cushion is oriented evenly between the seat rails. Although it is possible for some wheelchair users to replace the cushion without getting out of the wheelchair, the methods for doing so vary widely.

Variations:

• The technique described above can also be performed with the wheel locks off. As the wheelchair user lifts the buttocks off the floor, he/she can use the hand on the wheelchair to simultaneously pull the wheelchair under the buttocks.
• The wheelchair user with his/her back facing the front of the wheelchair can lift the buttocks with both arms on the seat or front rigging. The footrests can be used as an intermediate level between the ground and the wheelchair seat, if they are wide enough and if sitting on them does not tip the wheelchair forward. Even if the footrests are not wide enough for both buttocks, by turning slightly to one side, if may be possible to support one buttock.
• The wheelchair user can move progressively from the floor to a foot stool, a bench and finally to the wheelchair seat. The number of steps can be gradually reduced.
• Some wheelchair users may find it easier to face the wheelchair, getting up onto the knees (which may be on top of the seat cushion) before moving up to the seat level and twisting into the forward-facing position. If one leg has adequate knee-extension strength, the wheelchair user can kneel on the knee of the weaker leg with the foot of the stronger leg on the ground. 
• If the wheelchair user has the use of both of his/her legs, he/she can use the wheelchair to help get up onto his/her feet, then pivot and sit down.
• If there is another stable object nearby (e.g. a chair or low table), the wheelchair user can put one hand on the object and the other hand on the wheelchair seat.
• Some wheelchair users are able to right themselves while remaining in the wheelchair. To train someone to perform this technique, the wheelchair user can start on a surface partway between seat height and the ground, with the wheelchair on its back on an elevated mat. The wheelchair user should first pull on the rear wheels to get the buttocks firmly against the wheelchair seat. The wheelchair user may let the knees bend over the front of the seat. The wheel lock should be applied on the side of the stronger arm. The wheelchair user turns the trunk to the other side and uses the forward (stronger) hand to grab the hand-rim of the rear wheel on the unlocked side, with the hand as far forward as possible. The wheelchair user then reaches with the other hand to the surface on which the backrest of the wheelchair rests. The wheelchair user simultaneously and vigorously pushes with the floor hand and pulls with the hand-rim hand. This step is repeated as necessary, moving the floor hand progressively forward on the surface until the wheelchair is upright.

Ascends Stairs

Description and Rationale

The wheelchair user and the wheelchair get from the bottom of a set of stairs to the top. Although alternative means of getting from a lower to a higher level are often present (e.g. using a ramp or elevator), stairs may sometimes be the only option. 

General Training Tips

• Alternative routes (e.g. ramps or elevators) to get to the upper level should be sought wherever possible.
• With the exception of the initial preparation for the first step of a set of stairs and concluding the task after ascending the last step, the same technique is used for each step. 
• Safety is of particular importance, given the consequences of a loss of control.

Out of the Wheelchair, on Buttocks: 

• A strapped-on buttocks protector is advisable.
• The wheelchair should be positioned next to the stairs, in a way similar to how the wheelchair would be positioned for the “performs level transfers” skill. 
• The wheelchair user transfers from the wheelchair to a sitting position on the second or third step. The stair handrail may be used.
• The wheelchair may be brought up to the top the stairs by the wheelchair user or by an assistant. If bringing the wheelchair up the stairs himself/herself, the wheelchair user should pull the wheelchair up by facing it downhill, and tipping it back fully. The wheelchair user should push straight down with one hand on the wheelchair’s push-handles that are resting on a step, to keep the wheelchair from rolling or sliding down the stairs.
• For the wheelchair user to move up each step, he/she should flex the neck and hips and push down with the arms and feet to bring the buttocks up and back onto the next higher step (another example of the hips-vs.-head strategy described in the “performs level transfers” skill). Then the hands, feet and wheelchair are moved up to the next step.
• At the top of the stairs, a stool is helpful as a half-way step to the wheelchair seat. Otherwise, this final phase is the same as for the getting from ground into wheelchair phase of the “performs wheelchair-ground transfers” skill.

Variations: 

Out of the wheelchair, on hands and knees: 

• As for the buttocks approach above, but facing up the stairs and using a crawling action, advancing one limb at a time. A caregiver is usually needed to bring the wheelchair up the stairs.

In the Wheelchair:

• Although this technique is not recommended for wheelchair users acting alone, because of the long-term consequences of the stresses placed on the shoulders, the following tips are provided for the exceptional wheelchair user who wishes to acquire this skill for the unusual occasion when it would be helpful.
• The rear anti-tip devices (if any) should be repositioned to allow the rear wheels to contact the first stair and to permit the wheelchair to tip backward sufficiently.
• The starting position is with the wheelchair userin the wheelchair, with the seat belt (if any) on.
• The wheelchair should be backed up to the lowest step, closest to the handrail on the side of the stronger arm.
• The wheelchair user reaches back as far as he/she can with the stronger arm and grabs the handrail with the palm facing up.
• By pulling on the handrail, the wheelchair user tilts the wheelchair back but not beyond the wheelie balance point to avoid having the rear wheels roll forward  (submarining). 
• The wheelchair user uses the hand on the stair handrail to pull while using the other hand on the hand-rim (starting well forward) to roll the rail-side wheel up the step.
• Because both hands are acting on the same side of the wheelchair, the front of the wheelchair will tend to turn toward the hand-rail. The wheelchair should be squared-up (i.e. bringing both rear wheels against the step rise) before each new stair is attempted.
• At the top of the stairs, the casters should not be brought down until there is surface to support them.

Progression:

• It is useful to have stairs with a variety of dimensions to permit gradual progression. The wheelchair user can use a curb first, if there is a rail beside it, as an example of a single step. 

Descends Stairs

Description and Rationale

The wheelchair user and the wheelchair get from the top of a set of stairs to the bottom. The rationale is as for the “ascends stairs” skill. Although there is still a potential for injury due to a fall, descent is much less strenuous than ascent. Many wheelchair users who cannot ascend stairs independently can descend them. 

General Training Tips

To descend stairs with the occupant out of the wheelchair, on the buttocks or on hands and knees, the procedure is the reverse of the “ascends stairs” skill.

Variations:

In the Wheelchair:

• The safest method is facing up the stairs. The wheelchair user grabs one or both stair rails, leans forward enough to keep the casters from lifting off, lowers the rear wheels down one stair, then slides the hands down the rail. 
• If the footrests interfere with smooth progression down the stairs and they can be removed, this may be done. 
• Another option is to face up the stairs as above, but to use one hand on the stair hand-rail and the other hand on the hand-rim of the wheelchair. This technique can prevent the tendency of the non-rail-side wheel to roll away from the stair riser.
• See wheelie variation later.

Performs Wheelie 

Description and Rationale

The learner achieves the wheelie position (balancing on the rear wheels), maintains it for a period of time and brings the casters back to the floor. The stationary wheelie position can also be used to avoid postural problems that can cause neck strain from looking up. The stationary wheelie is also a foundation skill for a number of functional skills that can be best performed in the full wheelie position and that will be dealt with in the next section. 

General Training Tips

The sequence of phases trained is not critical but the more natural sequence (and one that is supported by the general motor skills literature) is described below.

Take-off Phase:

• The learner will already have learned how to transiently pop the casters from the surface in earlier skills. 
• It may be useful to use simulation, having the trainer tip the wheelchair back into the balance position, to give the wheelchair user a sense of how much tilt will be needed. 
• If properly timed and the wheelchair is appropriately set up, the wheelchair user should require little force to achieve take-off.
• For the wheelie take-off, many wheelchair users roll backward slowly, then quickly forward. This method is very effective and is to be preferred when the wheelchair user wishes to perform a wheelie in the same position in which he/she started. If using this method, the wheelchair user should start with the hands just ahead of the top center of the wheel (i.e., ~1:00 o’clock on the right rear wheel, using the clock analogy). The wheelchair user should try not to pause between rolling back and pushing quickly forward, otherwise he/she may not tip backward as easily.
• However, the method of only rolling the wheels forward is preferred when the available space is not an issue because the forward-only method can be used while the wheelchair is moving forward (as is occasionally necessary). The hands will need to start farther back on the wheels (i.e., ~11 o’clock) and slightly more force will be needed by the wheelchair user than for the backward-then-forward method. 
• The forward motion that is common to both methods can be thought of as an action to get the base of support (the rear wheels) under the center of gravity (located near the lap of the wheelchair user). 
• Some wheelchair users may find it easier if they lean back into the backrest to cause or help with the initial rear tip. However, skilled wheelie performers can achieve the wheelie position while maintaining an upright body position. Leaning forward is a natural tendency to prevent rear tip-over but this makes it more difficult to achieve take-off.
• Whichever method is used, the wheelchair user should progressively pop the casters higher and higher until he/she can tip backward far enough to reach and slightly overshoot the wheelie balance point. Once past the balance point, the wheelchair user should then pull back on the hand-rims to prevent tipping too far and to return to the balance point.
• If the wheelchair user is having difficulty getting tipped far enough backward to reach the balance point, he/she should push forward more forcefully. An alternative is to start the take-off with the casters uphill or on a small level change although there needs to be room for the rear wheels to roll forward if using the forward-only method. 
• If a learner is having difficulties due to fear of tipping over backward, the wheelchair user can pop back onto the spotter then progress to a self-save (flexing the neck and trunk while pulling back vigorously on the hand-rims). Once the learner is able to tip backward far enough to be caught by the spotter, in subsequent attempts he/she should gradually reduce the amount of overshoot until it is possible to self-save without the spotter’s assistance.
• Once the learner can consistently perform the wheelie take-off, attention should be shifted to the balance phase.

Balance Phase:

• The wheelchair user does not need to use much force to maintain balance. It is preferable for the wheelchair user to keep a light grip on the wheels (“avoid the grip of death!”). It should be possible for the wheelchair user to slide his/her hands forward and backward on the hand-rims.
• During the early learning stage, some wheelchair users find it useful to isolate the variations of pitch from those of rear-wheel displacement (i.e. using the motor-learning principle of “reducing the degrees of freedom”). This can be done by reducing the extent to which the rear wheels can move (e.g. by using obstacles such as bricks or pieces of wood in front of and behind the rear wheels). If the wheelchair is well set up and the wheelchair user has adequate strength, he/she may be able to push forward hard enough to tilt the wheelchair into the balance position with the rear wheels blocked. Otherwise, the trainer can tip the wheelchair back to the balance point while the wheelchair user rests his/her hands in the lap. The trainer then turns over control to the wheelchair user by having the wheelchair user grasp the hand-rims. The trainer should then take his/her hands off the wheelchair – it can be confusing to have two people attempt to maintain balance at the same time – and let the learner know (“It’s all you now”). 
• Once the wheelchair user is in control with the rear wheels blocked, learning exercises can include any or all of the following: 
• Having the wheelchair user experiment with the extent of tip (more and less than the ideal balance point, where the force to maintain position is minimal).
• Leaning forward (which increases the amount of tip needed to be at the ideal balance point).
• Using only two fingers and a thumb of each hand on the hand-rims.
• Sliding the hands backward and forward on the hand-rims to find the ideal position.
• Holding on with only one hand while waving the other.
• Closing the eyes and focussing on the feel of the balance position. 
• Once these variations are mastered at the high rolling-resistance level (i.e. with the wheels fully blocked), the barriers in front of the rear wheels can be moved a few cm away while the wheelchair leans against the rear barrier. This allows a small amount of forward and backward movement of the rear wheels. At either extreme of movement, the wheelchair user can lean the rear wheel against the front or rear barriers. This stage can be considered analogous to having “training wheels” like those used by children learning to ride bicycles. Once the wheelchair user is familiar with this, the barriers can be moved progressively farther away and removed.
• When the wheelchair user has become comfortable with not spending too much time leaning on the barriers, the wheelchair can be moved to a surface with medium rolling resistance (e.g. on a gym mat). Here the take-off and balance phases can be combined. The soft surface allows the learner to perform a “slow-motion” wheelie.
• Once this is mastered, the wheelchair can be moved to a low rolling-resistance surface (e.g. a tile floor).
• When a basic wheelie can be performed on a low rolling-resistance surface, the learner can refine his/her skill by becoming familiar with and practicing the two balance strategies that have been reported in the scientific literature:
• Proactive balance strategy: In this strategy, analogous to balancing a meter stick on a finger, the wheelchair user keeps the wheels moving forward and backward over a small area. The wheelchair user should try to move the hands only between the 12:00 and 1:00 o’clock positions. This will allow a safety margin, so that the wheelchair user can react to a loss of balance in either direction. If the wheelchair user wants the wheels to move farther than the intermediate hand position permits, the hand-rims can be allowed to slide through the grip. It may be helpful to time the movement of the rear wheels to the breathing pattern while using the proactive balance strategy.
• Reactive balance strategy: The reactive balance strategy is analogous to the step strategy used in standing balance – if a standing person is pushed forward or backward hard enough that he/she would otherwise fall, the person steps forward or backward to bring the base of support under the displaced center of gravity. If the wheelchair user begins to tip too far forward, he/she should roll the rear wheels forward to return to the balance point (“when you fall forward, push forward”). If the wheelchair user imbalances backward, he/she should roll the rear wheels backward to re-establish balance (“when you fall back, pull back”). 

Landing Phase:

• To land from the balance position, the wheelchair user pulls back on the wheels, or leans forward to gently bring the front wheels to the ground.

Progression: 

• Once the full wheelie can be performed with the spotter nearby, the wheelchair user can practice performing the stationary wheelie with variations (e.g. with the spotter progressively farther away, with low lighting, while multi-tasking).

Variations:

• During the balance phase, the wheelchair user can lean forward or place a knapsack on the lap or footrests to increase the caster height needed for the wheelie position. The wheelchair user can practice this by placing the casters on different height targets (e.g. pylons, steps).
• See other wheelie variations in the next section.

Performs Wheelie-Dependent Skills

Description and Rationale

The learner performs a variety of previously discussed skills for which non-wheelie methods are available, but that can be performed (and sometimes need to be performed) in the wheelie position. Once the learner has mastered the stationary wheelie, the learner should return to these earlier skills and attempt to learn them using the wheelie position. 

General Training Tips

The training tips for the skills in this section build upon the tips presented earlier where the non-wheelie methods were described. Only aspects specific to the wheelie method will be presented here.

Rolls Forward and Backward in the Wheelie Position

Rolling forward in the wheelie position is useful whenapproaching obstacles for which it is advantageous to have the casters off the surface (e.g. for the descent of high curbs).Moving backward in the wheelie position is useful in tight spaces, where it is not possible to turn around, for instance to raise the casters over an obstacle (e.g. a stick on the ground or a towel on a bathroom floor). Also, the backward skill allows the wheelchair user to ease up to a wall or object against which he/she can lean (i.e. for the tilt-rest variation of the “relieves pressure from buttocks” skill).

Moving the wheelchair forward and backward in the wheelie position utilizes the reactive balance strategy noted in the previous section. The wheelchair user should allow the wheelchair to begin to fall (dip) slightly in the direction in which he/she wishes to move, and then roll the rear wheels in the same direction to catch up. To initiate the dip, the wheelchair user can move the head or lean slightly in the direction he/she wishes to move. Alternatively, the wheelchair user can initiate the dip by pushing the wheels slightly in the opposite direction. The wheelchair user should be encouraged to take his/her time to achieve control and to move slowly. The wheelchair user should grip the wheels lightly, giving a light push and letting the hand-rims slide through the fingers. In catching up to the center of gravity after the first dip, there is no need for the wheelchair user to catch up completely.  By undershooting slightly, the wheelchair user can initiate the next dip. Some wheelchair users may find it easier to move forward or backward with one hand at a time.It is easier to begin with short steps then proceed to longer ones. 

Stops

Some highly skilled wheelchair users can induce a controlled wheelie by throwing the trunk backward while coasting quickly forward. The goal is to overshoot the balance point and then grasp the hand-rims firmly to stop the wheelchair and prevent a rear tip. With a different amount of force applied to the two hand-rims, a rapid turn can be made. 

Relieves Weight from Buttocks 

A wheelie can be used to achieve the tilt-rest position discussed earlier. To do so, the wheelchair user achieves the wheelie position with the back of the wheelchair facing the object that will be leaned against. The wheelchair is then rolled back in the wheelie position until the rear wheel or backrest of the wheelchair or back of the wheelchair user (for low and high objects respectively) contacts the object. Then the wheelchair is allowed to tilt back slightly further and the wheel locks are applied one at a time (or the hand-rims are held with the hands). The wheelchair user must not let go of both wheels at the same time or the rear wheels will roll rapidly forward (“submarining”) and a rear tip will occur.

Rolls on Soft Surface

If using the full wheelie position to move on a soft surface, the wheelchair user needs a strong forward “dip” to get going as was discussed earlier. If the casters touch the surface during the dip, the wheelchair user canlean forward slightly. This allows the casters to lift off further during the wheelie and provides better clearance during the dip. 

Turns in Place 

Wheelchair users often encounter situations in which they need to perform a wheelie to make a tight turn. The area needed on the support surface (the “footprint”) is less in the wheelie position than when all wheels are on the surface. The learner should be careful not to let the elevated feet hit any external object. 

Turns while Moving Forward and Backward

These skills are similar to moving straight forward and backward in the wheelie position except that, in correcting for the initial “dip”, the rear wheels are rolled forward or backward to different degrees. 

Alternatively, this skill can be broken into two components performed sequentially (e.g. rolling straight forward to a slight extent, then turning in place to a slight extent, repeating these steps) rather than simultaneously.

Maneuvers Sideways

In tight spaces, the wheelie allows the wheelchair to be moved sideways by a series on forward and backwards turns.

Descends Curbs

Using a wheelie to descend a curb in the forward directionallows the wheelchair user to maintain forward movement and to see any dangers that lie ahead. Also, the wheelie position prevents the footrests from making contact with the lower level, which can decelerate the wheelchair and cause a forward tip or fall from the wheelchair.

If the wheelchair user descends a curb in the wheelie position, a single spotter should stand on the upper level with both hands near the push-handles to react to forward or sideways tips. A removable seat belt can prevent the wheelchair user from falling forward from the wheelchair. 

The forward full-wheelie method is an excellent method for the descent of a large level change. The wheelchair user should get into the wheelie position slightly away from the edge of the level change. The wheelchair user should roll forward to the edge of the curb in the wheelie position, staying square to the edge. The “wheelie forward and backward” skill will have prepared the learner to approach the curb edge under control. After initiating the forward dip to move the rear wheels over the edge of the curb, the wheelchair user should quickly slide the hands backward from just ahead to just behind top dead center of the hand-rims, so that he/she can firmly grip the hand-rims and pull backward to slightly slow the descent. The wheelchair user should let the rear wheels hit the lower level before the casters. As soon as the rear wheels touch the ground, the momentum should bring the casters down to the surface, but the wheelchair user should lean forward as well. The skill should be practiced first on a low curb, increasing the height of the curb as skill and confidence allow.

As a variation, the wheelchair user can land on the lower level and maintain the wheelie position rather than allowing the casters to land, either maintaining balance or leaning back against the curb rise. This is useful where there is little space for the casters to land, such as on a series of widely spaced stairs.

Ascends Inclines

For the ascent of very steep inclines, some wheelchair users will go up backward The uphill movement is initiated by allowing the wheelchair to fall (“dip”) partially backward, followed by a strong pull backward on the hand-rims to re-achieve balance a short distance up the slope. 

Descends Inclines

Descending a steep incline in the forward direction in the wheelie position lessens the problem of loss of traction (affecting braking and control) when the uphill wheels become unloaded. This technique also reduces the likelihood of forward tips or digging the footrests into the floor at the transition between the bottom of the incline and the level surface. For very steep inclines, this technique may be the only way to get down the incline without tipping over.

The wheelchair user usually achieves the wheelie position on the level at the top of the incline. Then he/she moves forward onto the incline. Moving forward and backward in the wheelie position will already have been practiced. When initially moving onto the incline, the wheelchair user may be startled to feel as though the wheelchair is tilting farther backward. Once on the incline, facing downhill, the wheelchair user shouldlet the hand-rims run smoothly through the hands to control the wheelchair’s speed, direction and pitch angle. Letting the hand-rims run more quickly through the hands will allow the wheelchair to pitch (tilt) farther back. Slowing the rate at which the hand-rims slide through the fingers will cause the wheelchair to pitch forward. The learner should have the casters touch down shortly after the rear wheels reach the level surface at the bottom of the incline.

When stopped facing downhill in the wheelie position, the sensation is similar to that felt while leaning back on a barrier, as when learning the balance phase of the “performs stationary wheelie”.

A variation is for the learner to achieve wheelie take-off while on the incline and facing downhill. This is useful when an unexpected obstacle is encountered. If the wheelchair user is facing downhill, more force is needed for take-off (because the wheelchair is pre-tilted in the wrong direction) and the wheelchair may accelerate rapidly downhill.

On steep or slippery inclines, or if the wheelchair has too much rear stability, there may not be enough rear-wheel traction to allow wheelie take-off while facing downhill. In such situations, the wheelchair can be turned so that it is facing across the hill or even uphill. This will place more weight on the rear wheels and avoid runaway. Once in the wheelie position, a wheelie turn-in-place will allow the wheelchair user to proceed down the incline.

Rolls Across Side-Slope

In the wheelie position facing across a slope, there is no downhill-turning tendency, because the center of gravity is between the rear wheels. 

Descends Stairs

In the full wheelie position, the wheelchair user can descend forward, one step at a time. This is possible if there is an adequate horizontal distance (“run”) on each step. 

At least two spotters should be involved. One or two spotters should be below the wheelchair with the hands near a fixed front part of the wheelchair to resist tipping or runaway. The uphill spotter should be above the wheelchair with the hands near the push-handles to react to forward, backward or sideways tips, or runaway.

The wheelchair user drops down one step at a time as for the “descends high curb in wheelie position” skill. The difference is that the casters cannot land after the rear wheels do. The wheelchair user instead balances on the rear wheels or, more simply, allows the wheelchair to tilt back after the rear wheels land on the step such that the rear wheels push against the step rise (analogous to the “tilt rest” version of the “relieves weight from buttocks” skill) before proceeding to the next step. This should be practiced on a single curb first.