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2/18/2014
1
Wheelchair Skills Assessment and
Training: Translating Research
Evidence into Clinical Practice
R. Lee Kirby, MD, FRCPC
Division of Physical Medicine and
Rehabilitation
Dalhousie University and the Capital District
Health Authority
Halifax, Nova Scotia, Canada
Setting the Stage
• Conflicts of interest: None
• Acknowledgements:
– Wheelchair Research Team
• Handouts:
– pdf of the PPT presentation
– www.wheelchairskillsprogram.ca
Current Funding Bodies
• Canadian Institutes for Health Research (CIHR)
• US National Institute for Disability and
Rehabilitation Research (NIDRR)
• US Department of Veterans Affairs (VA)
• US Agency for International Development (USAID)
This Project
• Knowledge Translation of a Wheelchair
Skills Program for Rehabilitation
Clinicians: A Feasibility Study. William C.
Miller, Linda Boronowski, Louise Demers,
R. Lee Kirby, S. Rowe, Paula W. Rushton.
Operating Grant: Knowledge to Action,
application #290080.
Bringing coals to Newcastle
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. Move one step along the “stages of change”
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Wheelchairs as a Global Concern
• ~10% of the global population have disabilities
• ~10% of them (~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
Importance of Wheelchairs
• Prevalence of use is high and rising
• Positive impacts on:
– Mobility
– Participation
– Caregiver burden
– Long-term-care placement
Problems of Wheelchairs
• Improper wheelchair, fit or set-up
• Maintenance & repair problems
• Chronic overuse injuries are common
• Acute injuries are common
Improper Wheelchair, Fit or Set-Up
• 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
– 8.7% had an adverse consequence, more
often with MWCs
McClure LA et al. Arch Phys Med Rehabil 2009;90:2034-8
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Chronic Overuse Injuries
• N = 100 people with paraplegia for > 30
years and 100 age- vs sex-matched AB
controls
• MRI evidence of rotator cuff tears: 63% vs
15%
Akbar M et al. (Heidelberg) J Bone Joint Surg Am 2010;92:23-30
Acute Injuries
• Deaths/year in US – 50-70 (Calder & Kirby. Am J PM&R 1990;69:184-90)
• Injuries to ER/year in US – 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)
•Ummat & Kirby. Am J Phys Med Rehabil 1994;73:163-7. ~72%
•Xiang et al, Injury Prevention 2006;12:8-11. 81% Routhier F. Personal communication 2007.
Rear anti-tip devices contributing to tip/fall
BENEFITS PROBLEMS
Wheelchairs
Better wheelchair provision
www.who.int/disabilities/publications/technology/wheelchairguidelines/en/index.html.
World Health Organization
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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 Established 1996
What’s Different About the WSP?
• Evidence-based
• Both assessment and training
• Both wheelchair users and caregivers
• Manual wheelchairs, power and scooters
• The process and sequencing used
• Updated often
• It’s FREE! (“open source”)
Wheelchair Skills Program (WSP)
• Wheelchair Skills Test (WST)
• Wheelchair Skills Training Program (WSTP)
WHO Wheelchair 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
WST
WSTP
The Circle of Education
Objectives (identified problems)
Curriculum (WSTP)
Evaluation (WST)
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WHO Wheelchair 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
WST
Versions of WST by Type of Wheelchair and
Nature of the Test Subject
Type of Wheelchair Type of Test Subject
Manual Wheelchair user
Caregiver
Powered Wheelchair user
Caregiver
Scooter Scooter user
Versions of WST by Type of Wheelchair and
Nature of the Test Subject
Type of Wheelchair Type of Test Subject
Manual Wheelchair user
Caregiver
Powered Wheelchair user
Caregiver
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
WST Comments WST Comments
Worley et al. Am J Phys Med Rehabil 2006;85:931-4
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Example of a full WST 4.2
http://www.wheelchairskillsprogram.ca/eng/tests_video.php
Mobility Centre
• 2400 square feet
• ~$100,000 renovations and equipment
• Compression of time and space
• A wheelchair skills simulator
• Great to have? – Absolutely!
• Needed to get started? – Absolutely not!
WST vs WST-Q
WST-Q Algorithm
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WST Total % Calculated Scores
WST:
• Capacity Score = # skills passed/total x 100%
WST-Q:
• Capacity Score = # skills passed/total x 100%
• Performance Score = # skills passed/total x 100%
Goal Attainment Score (GAS)
• GAS = goals achieved/set x 100%
• Notes:
–Optional
–Number of goals: 5-10
–Goal setting process important
What’s the evidence?
WST Measurement Properties • Manual:
• Kirby et al. Arch PM&R 2002;83:10-18
• Kirby et al Arch PM&R 2004;85:794-804
• Routhier F et al, Rehab International 2008
• Lindquist NJ et al. Arch PMR, 2010;91:1752-7
• Lemay V et al. Proc 4th Nat SCI Conf Oct 2010
• Powered: • Rushton et al. RESNA 2012
• Rushton et al. RESNA 2013
Questionnaire Version (WST-Q)
Manual: Newton et al. Arch PM&R 2002;83:1295-9
Mountain et al. Arch PM&R 2004;85:416-23
Inkpen P et al. Arch PM&R 2012;93:1009-13
Rushton PR et al. Arch PM&R 2012;93:2313-8
Powered: Rushton PR et al. (O vs S) RESNA Proceedings 2012
Rushton PR et al. (reliability) RESNA Proceedings 2012
WST vs WST-Q
• Rushton P, Kirby RL, Miller WC. Manual
Wheelchair Skills: Objective Testing versus
Subjective Questionnaire. Arch Phys Med
Rehabil 2012;93:2313-8
N = 89
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• 26 Manual wheelchair users
•WST-Q 4.1
•WST Capacity Score: 72.5 (19.2)%
•WST Performance Score: 58.1 (21.2)%
Systematic Reviews on
Assessments of Wheelchair Skills
Kilkens et al. Clinical Rehabilitation
2003;17:418-430 (24 papers)
Fliess-Douer O et al. Clin Rehabil
2010;24:867-86 (13 papers) oKirby RL. Clin Rehabil 2011;25:287
WHO Wheelchair 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
WSTP
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
Wheelchair Skills Capacity of
WCUs with SCI
• US Model Spinal Cord Injury System
• 214 participants (~75% with paraplegia)
• WST 4.1, cross-sectional study
• Curb ascent: 20%
• Curb descent: 47%
• Wheelie: 60%
Hosseini SM et al. Arch Phys Med Rehabil 2012; 93:2237-43
Wheelchair Skills Training Program
Process
(How to teach)
Content
(What to teach)
WSTP
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Wheelchair Skills Training Program
Process
(How to teach)
WSTP
Resources
• www.wheelchairskillsprogram.ca
– WSTP Manual, pages 8-23
• Richard A. Magill. Motor Learning and
Control: Concepts and Applications.
9th Edition. McGraw-Hill, New York.
2011
Examples of Motor Learning
Principles
Example of motor-learning principle:
intrinsic learning Example of motor-learning principle:
demonstration
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Example of motor-learning principle:
practice variability
Example of motor-learning principles:
segmentation and feedback
Example of motor-learning principle:
progression Wheelchair Skills Training Program
Content
(What to teach)
WSTP
Research-Based Techniques
Askari S et al. RESNA 2012.
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Kwarciak AM et al. Arch PM&R 2009;90:20-6
Example of training tip: propulsion
technique
5 deg incline ascent: forward then backward approach
Example of training tip: wheelie training
Koshi et al. Am J PM&R 2006
2 steps, 0 bends, 7 seconds
Woolfrey & Kirby. Arch Phys Med Rehabil 1998;79:955-8
10 steps, 8 bends, 25 seconds
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WSTP Curriculum
• Individual or small group sessions
• 30-60 minute sessions, 1-5x/week
• ~2-4 hrs extra training time
What’s the evidence?
WSTP Evidence: Groups of Skills • Skills training for wheelchair users, initial rehab:
– MacPhee et al. Arch Phys Med Rehabil 2004;85:41-50
– Routhier et al. Arch Phys Med Rehabil 2012;93:940-8
• Skills training for wheelchair users, community: – Best et al. Arch Phys Med Rehabil 2005;86:2316-23
– Tangsagulwatthana S et al. Thai J Phys Ther 2010;32:173-80
– Ozturk A & Ucsular FD. Clin Rehabil 2011;25:416-24
– Sawatzky et al. Aust Occup Ther J 2012;59:2-9
– Groer et al. RESNA 2012
• WSTP for caregivers: – Kirby et al. Arch Phys Med Rehabil 2004;85:2011-9
• WSTP for health-care students: – Coolen et al. Arch Phys Med Rehabil 2004;85:1160-7
– Kirby RL et al. Am J Phys Med Rehabil 2011;90:197-206
Arch Phys Med Rehabil 2012;93:940-8
Other Outcomes - Confidence
• 20 manual wheelchair users, RCT
• WSTP 4.1: 2 x 1-hour training sessions
• WheelCon scores (0-100)
• WSTP group:
– Absolute change +13.7% (relative 24%)
• Control group:
– Absolute change -0.4% (relative -0.6%)
• P = 0.004
Sakakibara B et al. Arch Phys Med Rehabil 2013;Feb 2 (epub ahead of print)
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International Classification of Function (ICF)
WHO, 2001
Health
(Impairment)
Activities
(Disability)
Participation
(Handicap)
Organ or tissue
Whole person
Society
Do Skills Improve Participation? • Training increases amount of wheelchair use:
– Hoenig H et al. J Am Geriatr Soc 2005;53:1712-20
• Skills (WST) correlate with daily wheeled distance:
– Lemay V et al. Spinal Cord 2012;50:37-41
• Skills correlate with return to work:
– Van Velzen et al. J Rehabil Med 2012;44:73-9
• Skills correlate with participation measures:
– Kilkens O et al. JRRD 2005;42:65-73
– Mortenson WB. Arch Phys Med Rehabil 2011;92:1587-93
– Krause J et al. J Spinal Cord Med 2009;32:237-4
– Phang SH et al. Disabil Rehabil 2012;34:625-32
– Borg J et al. BMC Health Services Res 2012;12:330
Do Skills Improve Participation?
• N = 149 manual wheelchair users in Bangladesh
• Odds Ratios (p < 0.05) for the 29% who received
training:
– More satisfaction 7.79
– Less participation restrictions 4.27
– More improved quality of life 2.55
– Less activity limitations 2.47
Borg J et al. BMC Health Services Res 2012;12:330
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
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
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SCIRE 2012
Implementation of WSP:
What is Needed?
People who need wheelchairs
Caregivers
Wheelchairs
Receptive environment
Trained personnel
Training Personnel
• Knowledge: reading, on-line resources
• Skills: practical training
• Attitudes: experience
Practical Training
• Ideally – multiple brief sessions
• Less ideal – wheelchair skills “boot-camp”
Wheelchair Skills Bootcamps
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Integration into Formal Education
of Health-Care Students
• Occupational Therapy
• Physiotherapy
• Nursing
• Recreational Therapy
• Health Science
• PM&R
Boot-Camp Outcomes
• High satisfaction, positive perceptions
– Kirby et al. Proc RESNA 2009
– Kirby et al. Proc RESNA 2011
• Improved wheelchair-skill abilities
– Routhier et al, Proc RESNA 2008
• Improved knowledge
– Kirby RL et al. 4th SCI Conference,
Niagara Falls Oct 30, 2010
• All outcomes
– Kirby et al. Proc RESNA 2014
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
Tanzania (Dar) 2011 Tanzania (Moshi) 2011
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India (Jaipur) 2005 Bosnia (Banja Luka) 2008
India (Bangalore) 2012 Nepal (Kathmandu) 2013
Evolution Gold Standard of Practice 2014
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 needed.
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Peter Gough. Fresh Paint.
