1. No category

Efficacy of a Wheelchair Skills Training Program at
Improving Community and Advanced Level
Wheelchair Skills in Manual Wheelchair Users
Sheena McCormack
PT 209/910
Introduction
•
1.7 million wheelchair/scooter users
• 90% use manual wheelchairs
(UCSF disability statistics center, 2014)
Hunt 2004 Cross-Sectional study 412 people with SCI who
use w/c >40hrs per week
○ 97% of manual w/c users had
customizable wheelchairs. Of those that
had non-customizable wheelchairs, majority
were people of color with less than high school
education and low-income status.
http://www.spinlife.com/images/product/3941.jpg
Measuring Wheelchair Skill
● Wheelchair Skills Test (Most recent version 4.2.2)
Indoor
• Transfers, removing footrests, etc.
Community
• Curbs, ramps, etc.
Advanced
• All involve the wheelie
http://www.spinalistips.se/bilder/19/601_19_%20ff_till_sang_600wm.jpg http://www.ii.uni.wroc.pl/~eko/webquest/Niepelnosprawni/NIK-WebQuest/LocalSites/iglide_pliki/photo_on_curb.jpg
http://www.parish-without-borders.net/cditt/deaf/sportsday01/sports7.jpg
The Wheelie
Definition: a rear pitch
force causes the front
caster wheels to leave the
support surface
Use: negotiating uneven
terrain, curbs, and
descending steep inclines
http://news.bbcimg.co.uk/media/images/67869000/jpg/_67869075_wheel.jpg
(Kirby, 2006)
Wheelchair Skills
↑ Scores on wheelchair skills
tests
↑ Life satisfaction,
community
participation, and
return to work
Scores obtained at time of discharge from acute rehab tend to remain constant one year later
(Hosseini 2012, Van Velsen 2012, Flies 2013).
Wheelchair Skill Prevalence
Skill
Prevalence
Ascend a curb
<20%
Floor <> wheelchair
<41%
Wheelie
<60%
http://www.spinlife.com/images/product/3941.jpg
(Hosseini 2012)
Introduction
Clinical Problem
Many manual wheelchair users do not have community-level
wheelchair skills (navigating curbs, performing a wheelie, etc.)
which are important for being independent in the community
(Ganesh 2007, Kirby 2006, Hosseini 2012).
How do we train a skill?
• Principles of Motor learning/Neuroplasticity
▫ Use it or lose it
▫ Use it and improve it
▫
▫
▫
▫
▫
▫
▫
▫
Specificity
Repetition
Intensity
Time
Salience
Age
Transference
Interference
(Merzenich 1984, Merzenich 1978, Umphred 2013)
Wheelchair Skill Training Program
• Guidelines for instructors on
feedback (i.e. verbal cues) and
training schedules based on principles
of motor learning (specificity,
repetition, intensity, time)
• Each skill on the WST
• Gap: RCTs, No meta analysis
http://www.manfred-sauerstiftung.de/uploads/pics/mss_gz_rollstuhltraining1_01.jpg
Theoretical Construct
Standard rehab (low intensity/time/repetition)
Low acquisition of wheelchair skills which have
been correlated to QOL
Wheelchair skills training program (WSTP) is
intense, repetitive, and specific to wheelchair skills
WSTP + standard rehab may ↑ skill acquisition
Relevance to PT & Purpose
● Acute care, Rehab, Outpatient
● Functional training, assistive
device training, patient goals
● Community reintegration &
return to work
● Purpose: Guidance
http://www.manfred-sauer-stiftung.de/uploads/pics/mss_gz_rollstuhltraining1_01.jpg
Primary Question
● Do manual wheelchair users improve their capacity to
perform community and advanced-level wheelchair skills
after a high-level, focused wheelchair skills training program
as compared to treatment as usual?
P: Manual wheelchair users
I: Wheelchair Skills Training in high-level skills
C: No training
O: Wheelchair Skills Test (multiple versions)
Hypotheses & Expected Findings
Ho: Training in high-level wheelchair skills does not improve ability to
perform community-level wheelchair skills in manual wheelchair users
HA: Training in high-level wheelchair skills improves ability to perform
community-level wheelchair skills in manual wheelchair users
Expected findings:
● 3-10 primary articles, at least 1 with level 2b evidence or above.
● reject the null hypothesis
Inclusion/Exclusion Criteria
Inclusion
● Manual wheelchair users
● Age >18 years old
● Used the WST to analyze wheelchair skill
● Used a WSTP based on motor learning and wheelchair
biomechanics & administered by trained professionals
Exclusion
● Did not report itemized success rates for individual
wheelchair skills
Sources of Evidence
● PubMed, Cinahl, Pedro
● Search terms
o
o
o
o
o
wheelchair
manual wheelchair
skill
train
Wheelie
o
o
o
o
o
o
curb
kerb
confidence
quality of life
QOL
community
Statistics
Between group Absolute Risk
Reduction (ARR) and
Experimental Event Rate (EER)
for specific community and
advanced-level wheelchair skills
on the WST
https://do512blog.files.wordpress.com/2011/09/pirate_tweet.jp
g
PRISMA Diagram
PubMed, CINAHL, PEDro
N=81
N = 74
Excluded non-relevant
Exclusion for relevance
N=7
Studies included
N=4
N=1
Excluded pediatric
N=1
Excluded no WST
N=1
Excluded able bodied
Study
Level of evidence,
study design
Participants
Best et al. 2005
2b, RCT
20 neuro/msk, 2177yo, Community
& Center
Treatment
3-5 sessions x 60min
WSTP vs. phone
Community or
call
Rehabilitation
3-6 sessions x 30min
WSTP + standard
Center
rehab vs.
standard
spinal
cord injury,
rehab (includes
WCstroke,
training) amputation
MacPhee et al.
2004
2b, RCT
35 neuro/msk, 4177yo,
Rehabilitation
Centers
Ozturk et al. 2011
2b, RCT
32 neuro/msk, 20WSTP vs. no
53yo, Community
treatment
3-6 session
45min
Routhier et al.
2012
Description
12 sessions x
45min
2b, Multi-Center 39 MWU MSK/NL, WSTP + standard 4-8 sessions x 4521-66yo,
rehab vs. standard
60min
Single-Blinded
Rehabilitation
rehab
RCT
Centers
Results: Experimental Event Rate
• ERR = experimental event rate
▫ The proportion of people in the training program that
could perform that skill
0
⇊
0.5
Low success
1
High success
⇈
Large curbs
Wheelie, high curb
Wheelie, rolling
forward/backward
Wheelie, turn in place
Wheelie, incline descent
Wheelie, Stationary
Wheelie no hand rest
Threshold
Open Wheelchair
Fold Wheelchair
Potholes, large/small
Small curb ascent/descent
Cross Slope
Street Crossing
Incline ascent/descent
Advanced
Low
Success
Community
High
Success
Results: Absolute Risk Reduction
ARR = The difference between the proportion of
people in the WSTP acquiring the skill and the
control group acquiring the skill
-1
0
Favors Control
No
Difference
1
Favors WSTP
Advanced
WSTP =
Control
Low
Success
Community
High
Success
Advanced
WSTP >
Control
Low
Success
Community
High
Success
4 Levels of Skill
Level 4
WSTP
works
Gravel
High EER,
Small curb ascent (5cm)
ARR does not cross zero
Open/Fold Wheelchair
Incline descent (5deg)
High skill acquisition
which was greater in
the experimental than
the control group
http://wheelchairassistance.com/wheelchair-ramp/54.jpg
4 Levels of Skill
Level
3
WSTP or
High EER,
Standard
Threshold (2cm)
Potholes,work
large (30cm) &
small (15cm)
ARR crosses zero
Small curb descent (5cm)
Cross slope
Street Crossing
High skill acquisition
which did not differ
between the control
and experimental
groups
http://www.snrproject.com/images/floor.jpg
4 Levels of Skill
Level
WSTP2
Low EER, ARR doesn’t
cross zero
worked
Large curb ascent (15cm)
for a few
Wheelie, turn in place
Wheelie, stationary
Large curb descent
Minimal skill acquisition
which was greater in the
experimental than the
control group
http://sfdpw.org/modules/showimage.aspx?imageid=1989
4 Levels of Skill
Level
WSTP1
Low EER, ARR crosses
zero
didn’t
Wheelie, high curb descent
work
Wheelie, rolling
Wheelie, incline descent
Wheelie, moving turn
Wheelie, no hand rest
Minimal skill acquisition
which did not differ
between control and
experimental groups
http://news.bbcimg.co.uk/media/images/67869000/jpg/_67869075_wheel.jpg
Hypotheses & Expected Findings
Ho: Training in high-level wheelchair skills does not improve ability to
perform community-level wheelchair skills in manual wheelchair users
HA: Training in high-level wheelchair skills improves ability to perform
community-level wheelchair skills in manual wheelchair users
…BUT this is not true for ALL skills
Limitations
•
•
•
•
•
Only 4, low quality RCTs
Small sample sizes
None performed in U.S.
Many from the same research group
Limited follow-up
Harm & Cost
● No injuries
● Routhier - 2 falls out of
wheelchair, 1 tip backward
during testing
● Precautions - Spotter strap
(MacPhee & Best),
helmets, gloves, intervene
when unsafe techniques
were observed
● Cost = additional 3-12 3060min sessions with
PT/OT, equipment
http://www.backuptrust.org.uk/what-we-do/wcs-training
Discussion
http://wheelchairassistance.com/wheelchair-ramp/54.jpg
http://www.snrproject.com/images/floor.jpg
Why so
hard?
Power
•Balance
Anterior Deltoid,
UE Power
pectorals,
infraspinatus
Game-based,
Tai Chi,
Processing
- Push-Up
(Rankin 2011,
trunk
strengthening
in
Improved
with
practice in
Lalumiere
2014,
sitting
(Tsang 2015,
Confidence
Escamilla,
2009)
older
adults
with
Balance
Cabanas-Valdes
2013)
impairment
•cognitive
As important
as skill
performance
(Law,
2014) (Inkpen,
http://sfdpw.org/modules/showimage.asp
2012)
Processing9
• Self efficacy mediates
wheelchair skill effect
on participation (Phang,
Confidence
2012)
http://news.bbcimg.co.uk/media/images/67869000/jp
67869075_wheel.jpg
Looking at Practice
Would I use the WSTP?
Upper
extremity
power
Balance
Yes
Useful in training
some skills
Additional
assessment/training
of…
Processing
Confidence
Future
Research
http://macombhistory.us/miscitems/AmputeeWheelchair.jpg
Confidence
Measures & QOL
Adjunct Training
Training
prescription
(Diagnosis, Age,
Location, Needs)
Long term followup
http://rohan7things.files.wordpress.com/2013/
03/fear.jpg
Conclusion
● WSTP was more
effective than standard
care at training certain
wheelchair skills
● More research:
o
http://sites.duke.edu/atdesign/files/2012/10/lawn2.jpg
who & what else
References
•
•
•
•
•
•
•
•
1. UCSF Disability Statistics Center. Disability Statistics Center Web site. http://dsc.ucsf.edu/main.php2014.
2. Hosseini SM, Oyster ML, Kirby RL, Harrington AL, Boninger ML. Manual wheelchair skills capacity
predicts quality of life and community integration in persons with spinal cord injury. Arch Phys Med
Rehabil. 2012;93(12):2237-2243.
3. van Velzen JM, van Leeuwen CM, de Groot S, van der Woude LH, Faber WX, Post MW. Return to work
five years after spinal cord injury inpatient rehabilitation: Is it related to wheelchair capacity at discharge?
J Rehabil Med. 2012;44(1):73-79.
4. Mortenson WB, Miller WC, Backman CL, Oliffe JL. Predictors of mobility among wheelchair using
residents in long-term care. Arch Phys Med Rehabil. 2011;92(10):1587-1593.
5. Ganesh S, Hayter A, Kim J, Sanford J, Sprigle S, Hoenig H. Wheelchair use by veterans newly prescribed a
manual wheelchair. Arch Phys Med Rehabil. 2007;88(4):434-439.
6. MacPhee AH, Kirby RL, Coolen AL, Smith C, MacLeod DA, Dupuis DJ. Wheelchair skills training program:
A randomized clinical trial of wheelchair users undergoing initial rehabilitation. Arch Phys Med Rehabil.
2004;85(1):41-50.
7. Kirby RL, Smith C, Parker K, et al. Wheelchair skills test (WST) version 4.2 manual. Halifax, Nova Scotia,
Canada: Dalhousie University; 2013:79.
8. Kirby RL, Smith C, Seaman R, Macleod DA, Parker K. The manual wheelchair wheelie: A review of our
current understanding of an important motor skill. Disabil Rehabil Assist Technol. 2006;1(1-2):119-127
References
•
•
•
•
•
•
•
9. Fliess-Douer O, Vanlandewijck YC, Post MW, Van Der Woude LH, De Groot S. Wheelchair skills
performance between discharge and one year after inpatient rehabilitation in hand-rim wheelchair users
with spinal cord injury. J Rehabil Med. 2013;45(6):553-559.
10. O'Sullivan S, Schmitz T. Physical rehabilitation. 5th ed. Philadelphia, PA: F.A. Davis Company; 2007:776.
11. Esquenazi A, DiGiacomo R. Rehabilitation after amputation. J Am Podiatr Med Assoc. 2001;91(1):1322.
12. Medical Advisory Secretariat, Health Quality Ontario. Constraint-induced movement therapy for
rehabilitation of arm dysfunction after stroke in adults: An evidence-based analysis. Ont Health Technol
Assess Ser. 2011;11(6):1-58.
13. Wevers L, van de Port I, Vermue M, Mead G, Kwakkel G. Effects of task-oriented circuit class training on
walking competency after stroke: A systematic review. Stroke. 2009;40(7):2450-2459.
14. Kirby RL, Smith C, Parker K, MacLeod D, McAllister M. Wheelchair skills training program manual
version 4.2. Halifax, Nova Scotia, Canada: Dalhousie University; 2013:146.
15. Routhier F, Kirby RL, Demers L, Depa M, Thompson K. Efficacy and retention of the french-canadian
version of the wheelchair skills training program for manual wheelchair users: A randomized controlled
trial. Arch Phys Med Rehabil. 2012;93(6):940-948.
References
•
•
•
•
•
•
16. Ozturk A, Ucsular FD. Effectiveness of a wheelchair skills training programme for community-living
users of manual wheelchairs in turkey: A randomized controlled trial. Clin Rehabil. 2011;25(5):416-424.
17. Best KL, Kirby RL, Smith C, MacLeod DA. Wheelchair skills training for community-based manual
wheelchair users: A randomized controlled trial. Arch Phys Med Rehabil. 2005;86(12):2316-2323.
18. Sakakibara BM, Miller WC, Souza M, Nikolova V, Best KL. Wheelchair skills training to improve
confidence with using a manual wheelchair among older adults: A pilot study. Arch Phys Med Rehabil.
2013;94(6):1031-1037.
19. Phang SH, Martin Ginis KA, Routhier F, Lemay V. The role of self-efficacy in the wheelchair skillsphysical activity relationship among manual wheelchair users with spinal cord injury. Disabil Rehabil.
2012;34(8):625-632.
20. Chung CS, Pollock A, Campbell T, Durward BR, Hagen S. Cognitive rehabilitation for executive
dysfunction in adults with stroke or other adult non-progressive acquired brain damage. Cochrane
Database Syst Rev. 2013;4:CD008391.
21. Law LL, Barnett F, Yau MK, Gray MA. Effects of combined cognitive and exercise interventions on
cognition in older adults with and without cognitive impairment: A systematic review. Ageing Res Rev.
2014;15:61-75.
References
•
•
•
•
22. Rankin JW, Richter WM, Neptune RR. Individual muscle contributions to push and recovery subtasks
during wheelchair propulsion. J Biomech. 2011;44(7):1246-1252.
23. Lalumiere M, Gagnon DH, Routhier F, Bouyer L, Desroches G. Upper extremity kinematics and kinetics
during the performance of a stationary wheelie in manual wheelchair users with a spinal cord injury. J
Appl Biomech. 2014;30(4):574-580.
24. Escamilla RF, Yamashiro K, Paulos L, Andrews JR. Shoulder muscle activity and function in common
shoulder rehabilitation exercises. Sports Med. 2009;39(8):663-685.
25. Bonaparte JP, Kirby RL, Macleod DA. Proactive balance strategy while maintaining a stationary
wheelie. Arch Phys Med Rehabil. 2001;82(4):475-479.
Acknowledgements
Tania Yuen, DPT
Diane Allen, PT, Phd
Lauren Cochran, DPTc
Siobhan McOsker, DPTc
UCSF/SFSU DPT
class of 2015
• Family & Friends
•
•
•
•
•
Questions?
http://i.dailymail.co.uk/i/pix/2012/04/26/article-2135739-12C8C5EB000005DC-988_634x388.jpg