Wheelchair Skills Training: Translating Research …...•Clinical for individual users •Outcome measure for clinical programs •Testing research hypotheses Systematic Reviews on

2015/04/07

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The Assessment and Training of

Wheelchair Skills: Low-Tech, High-

Impact Research with Global

Relevance

R. Lee Kirby, MD, FRCPC

Dalhousie University

Setting the Stage

• Conflicts of interest: none

• Acknowledgements:

– Wheelchair Research Team

– Funding bodies

• Handouts:

– pdf of the PPT presentation

– www.wheelchairskillsprogram.ca

Current Major Funding Bodies

• Canadian Institutes for Health Research (CIHR)

• US Department of Veterans Affairs (VA)

• US National Institute for Disability and

Rehabilitation Research (NIDRR)

• US Agency for International Development (USAID)

Session Objectives

On completion of the session, participants

will be able to: 1. Describe the rationale and evidence supporting

the assessment of wheelchair skills

2. Describe the rationale and evidence supporting

the effectiveness of wheelchair skills training

3. Describe the impact of wheelchair skills on

participation

4. Describe the global relevance of wheelchair skills

research

WHO. World Report on Disability, 2011, p 34

•~10% of the global population have disabilities

•2.2% (110M) of the population have very significant difficulties in

functioning

Wheelchairs as a Global Concern

• ~65M people need wheelchairs

• ~20M people who need them do not have them

• WHO guidelines on the provision of manual

wheelchairs in less resourced settings, 2008

http://www.wheelchairskillsprogram.ca/

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Wheelchair Pros and Cons

• Positive impacts:

– Mobility

– Participation

– Caregiver burden

– Long-term-care placement

• Problems:

– Improper wheelchair, fit or set-up

– Maintenance & repair

– Chronic overuse injuries

– Acute injuries

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

• N = 150 wheelchair users in Italy

• Mean (SD) age 46.7 (17.3) years

• 68% of wheelchairs were not suitable to

their users

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

Maintenance & Repair Problems

• 16 Model SCI Centers in US

• N = 2213

• 6 months follow-up

• 45% of full-time users completed a repair,

more often with PWCs

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

Chronic Overuse Injuries

• N = 100 people with paraplegia for > 30

years and 100 age- vs sex-matched AB

controls

• MRI evidence of rotator cuff tears: 63% vs

15%

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

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Acute Injuries • Deaths/year in US

• 50-70 (Calder & Kirby. Am J PM&R

1990;69:184-90)

• Injuries to ER/year in US

• 100K (Xiang et al, Injury Prevention

2006;12:8-11)

• Community wheelchair users injured/year

• 5-21% (Kirby et al. Am J PM&R 1994;73:319-

30; Berg et al, Am J Public Health 2002;92:48; Nelson et al. Arch PM&R 2010;91:166-73; Edwards et al. Dis Rehabil Asst Technol 2010;5:411-9)

Routhier F. Personal communication 2007.

Rear anti-tip devices contributing to tip/fall

BENEFITS PROBLEMS

Wheelchairs

Better wheelchair provision

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

World Health Organization 2008 2012

WHO Service-Delivery Model

1. Referral and appointment

2. Assessment

3. Prescription

4. Funding and ordering

5. Product preparation

6. Fitting

7. User training

8. Follow-up, maintenance and repairs

WHO Guidelines 2008, Section 3.2.1, p 76

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Established 1996

WHO Wheelchair Service-

Delivery Model


2. Assessment

3. Prescription



6. Fitting

7. User training



WST

WSTP

The Circle of Education

Objectives (identified problems)

Curriculum (WSTP)

Evaluation (WST)

WHO Wheelchair Service-

Delivery Model


2. Assessment

3. Prescription



6. Fitting

7. User training



WST

Versions of WSP by Type of Wheelchair and

Nature of the Subject

Type of Wheelchair Type of Subject

Manual Wheelchair user

Caregiver

Powered Wheelchair user

Caregiver

Scooter Scooter user

WST 4.2 Capacity Scores

Score Score What this means

Pass 2 Task independently and safely

accomplished without any difficulty

Pass with

difficulty

1 Evaluation criteria met, but the subject

experienced some difficulty worthy of

note (e.g. excessive time or effort,

inefficient method, minor injury)

Fail 0 Evaluation criteria not met

Not

possible

NP The wheelchair does not have this part

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

WST Comments re Diagnosis WST Comments re Training

http://www.wheelchairskillsprogram.ca/eng/tests_video.php

WST vs WST-Q

WST-Q Algorithm

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http://www.wheelchairskillsprogram.ca/eng/wstq.php

Total % Calculated Scores

• WST Capacity Score

• WST-Q Capacity Score

• WST-Q Performance Score

• Goal Attainment Score (GAS)

43 papers*

* April 2, 2015

N = 89

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Uses of the WST/WST-Q

• Clinical for individual users

• Outcome measure for clinical programs

• Testing research hypotheses

Systematic Reviews on

Assessments of Wheelchair Skills

Kilkens et al. Clinical Rehabilitation

2003;17:418-430 (24 papers)

Fliess-Douer O et al. Clin Rehabil

2010;24:867-86 (13 papers) oKirby RL. Clin Rehabil 2011;25:287

WHO Wheelchair-Provision

Service Model


2. Assessment

3. Prescription



6. Fitting

7. User training



WSTP

UN Convention on the Rights of

Persons with Disabilities (2006)

• Article 20 – Personal mobility

– States Parties shall take effective measures to

ensure personal mobility with the greatest

possible independence for persons with

disabilities, including by… Providing training

in mobility skills to persons with disabilities

and to specialist staff working with persons

with disabilities…

Prevalence of Manual Wheelchair Skills

Training

• 17% UK children: Whizz-Kidz 2004

• 18% US veterans: Karmarkar AM et al. JRRD

2009;46:567-76

• 66% US paraplegia: Zanca JM et al. Phys Ther

2011;91:1877-91

• 29% Bangladesh: Borg J et al. BMC Health

Services Res 2012;12:330

• 11% Canada stroke: Charbonneau R et al. Arch

Phys Med Rehabil 2013;94:1707-13

• 55% Canada: Kirby RL et al. RESNA 2013.

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Taylor-Schroeder et al. J Spinal Cord Med 2011;34:149-61

Wheelchair Skills Training Program

Process

(How to teach)

Content

(What to teach)

WSTP

Wheelchair Skills Training Program

Process

(How to teach)

WSTP

Example of motor-learning principle:

intrinsic learning

WST #1 (on meds) WST #2 (off meds)

Expected to be better:

actually worse

Expected to be worse:

actually better


demonstration

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practice variability

Example of motor-learning principles:

segmentation and feedback


progression Wheelchair Skills Training Program

Content

(What to teach)

WSTP

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

Example of training tip: propulsion

technique

Askari S et al. RESNA 2012.

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Example of training tip: backwards method

for foot propulsion

Charbonneau R et al. Arch Phys Med Rehabil 2013;94:707-13

0

20

40

60

80

100

120

Forwards Backwards

Tota

l m

odif

ied W

ST

Sco

re (

%)

Forwards

Backwards

Charbonneau R et al. Arch Phys Med Rehabil 2013;94:1707-13

2 steps, 0 bends, 7 seconds

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

10 steps, 8 bends, 25 seconds

WSTP Curriculum

• Individual or small group sessions

• 30-60 minute sessions, 1-5x/week

• ~2-4 hrs extra training time

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14 papers*

*April 2, 2015 Arch Phys Med Rehabil 2012;93:940-8

5.5 hrs

training

Mountain et al. Am J Phys Med Rehabil 2014; 93:1031-43

Some Current Research Projects

• Powered wheelchairs (CIHR) (n = 108)

• KT at GF Strong Rehab (CIHR) (n = 20 to date)

• SCI in US veterans (VA) (n = 109)

• SCI Model Systems (NIDRR) (n = 97 to date)

International Classification of Function (ICF)

WHO, 2001

Health

(Impairment)

Activities

(Disability)

Participation

(Handicap)

Organ or tissue

Whole person

Society

Other Outcomes - Confidence

• 20 manual wheelchair users, RCT

• WSTP 4.1: 2 x 1-hour training sessions

• WheelCon scores (0-100)

• WSTP group:

– Absolute change +13.7% (relative 24%)

• Control group:

– Absolute change -0.4% (relative -0.6%)

• P = 0.004

Sakakibara B et al. Arch Phys Med Rehabil 2013;94:1031-7

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

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

• Skills (WST) correlate with daily wheeled distance:

– Lemay V et al. Spinal Cord 2012;50:37-41

• Skills correlate with return to work:

– Van Velzen et al. J Rehabil Med 2012;44:73-9

• Skills correlate with participation measures:

– Kilkens O et al. JRRD 2005;42:65-73

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

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

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

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

Do Skills Improve Participation?

• N = 149 manual wheelchair users in Bangladesh

• Odds Ratios (p < 0.05) for the 29% who received

training:

– More satisfaction 7.79

– Less participation restrictions 4.27

– More improved quality of life 2.55

– Less activity limitations 2.47

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

Levels of Scientific Evidence

I. Large randomized trials with clear-cut results

(and low risk of error)

II. Small randomized trials with uncertain results

(and moderate-high risk of error)

III. Nonrandomized trials with concurrent controls

IV. Nonrandomized trials with historical controls

V. Case series with no controls

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

1. Satisfaction

2. Positive Effect

3. Changed Behavior

4. Impact

Kirkpatrick DL. 1994

Efficacy

Effectiveness

Economic

Capacity

Performance

Participation

Safety

Levels of Evidence

Evolution

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“The perfect is the enemy of

the good.”

Voltaire, 1694-1778 Dictionnaire Philosophique, 1764

Gold Standard of Practice 2015

1. Wheelchairs should be provided using the

8-step process of the WHO.

2. All people who use wheelchairs and their

caregivers should have their wheelchair

skills assessed.

3. Training should be provided, if

appropriate.

4. Assessment and training should be

documented in the health record.

Canadian Council on Health

Services Accreditation

• WSP one of two “leading practices” identified

• “…This innovative rehab area provides an excellent training environment that enhances the mobility skill set for wheelchair patients. … it will prove to be instrumental in establishing similar programs in other jurisdictions.”

Survey of Capital Health 2008 SCIRE 2012

Lukersmith S et al. Aust Occup Ther J 2013;60:378-86.

http://www.lifetimecare.nsw.gov.au/Brain_Injury.aspx Dec 3, 2013

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Web Site: December 31, 2014

(78,844 sessions/49,973 users/166 countries)

Implementation of WSP:

What is Needed?

People who need wheelchairs

Caregivers

Wheelchairs

Receptive environment

Trained personnel

Integration into Formal Education

of Health-Care Students

• Occupational Therapy

• Physiotherapy

• Nursing

• Recreational Therapy

• Health Science

• PM&R

Training Personnel

• Knowledge: reading, on-line resources

• Skills: practical training

• Attitudes: experience

Practical Training

• Ideally – multiple brief sessions

• Less ideal – wheelchair skills “boot-camp”

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Wheelchair Skills Bootcamp Boot-Camp Outcomes

• High satisfaction, positive perceptions

– Kirby et al. Proc RESNA 2009


• Improved wheelchair-skill abilities

– Routhier et al, Proc RESNA 2008

• Improved knowledge

– Kirby RL et al. 4th SCI Conference,

Niagara Falls Oct 30, 2010

• All outcomes


Wheelchair Skills Program

“Low tech, high impact”

Nenad Kostanjsek, WHO

ICF Conference, 2004 Peru India Tanzania

Jordan Bosnia

Belize

WSP Training Around the World

Nepal

United

States

Ireland Canada

Denmark Estonia

England

Tanzania (Dar) 2011 Bosnia (Sarajevo) 2006 & 2008

2006

2008

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Tanzania (Moshi) 2011 India (Jaipur) 2005

Example of training on job site in

Kanpur, India in 2005, years post-SCI Bosnia (Banja Luka) 2008

Bangalore, India 2012 Mannar, Sri Lanka 2012

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Nepal (Kathmandu) 2013

Session Objectives

On completion of the session, participants

will be able to: 1. Describe the rationale and evidence supporting

the assessment of wheelchair skills

2. Describe the rationale and evidence supporting

the effectiveness of wheelchair skills training

3. Describe the impact of wheelchair skills on

participation

4. Describe the global relevance of wheelchair skills

research

Established 1996

Documents

Wheelchair Skills Training: Translating Research …...•Clinical for individual users •Outcome measure for clinical programs •Testing research hypotheses Systematic Reviews on