Cher Smith

Ability of people with stroke to learn powered wheelchair skills: a pilot study.

OBJECTIVES Our primary objective was to test the hypothesis that people with stroke can learn to use powered wheelchairs safely and effectively. Our secondary objective was to explore the influence of visuospatial neglect on the ability to learn powered wheelchair skills. DESIGN Prospective, uncontrolled pilot study using within-participant comparisons. SETTING Rehabilitation center. PARTICIPANTS Inpatients (N=10; 6 with visuospatial neglect), all with a primary diagnosis of stroke. INTERVENTIONS Participants received 5 wheelchair skills training sessions of up to 30 minutes each using the Wheelchair Skills Training Program (version 3.2). MAIN OUTCOME MEASURES Powered wheelchair skills were tested before and after training using the Wheelchair Skills Test, Power Mobility version 3.2 (WST-P). RESULTS The groups total mean WST-P scores improved from 25.5% of skills passed at baseline to 71.5% posttraining (P=.002). The participants with neglect improved their WST-P scores to the same extent as the participants without neglect, although their pretraining and posttraining scores were lower. The training and testing sessions were well tolerated by the participants, and there were no serious adverse events. CONCLUSIONS Many people with stroke, with or without visuospatial neglect, can learn to use powered wheelchairs safely and effectively with appropriate training.

The manual wheelchair wheelie: A review of our current understanding of an important motor skill

Purpose. To review the current understanding of the manual wheelchair wheelie. Method. Review of the literature. Results. A rear wheelchair wheelie occurs when the front wheels, ordinarily in contact with the support surface, are intentionally caused, by means of a transient or sustainable rear pitch, to lift from the surface while the rear wheels remain on the surface. Pitch control (partial or full) is the foundation of many wheelchair skills (e.g., negotiating thresholds, potholes, curbs, steep inclines and gravel). Yet, most wheelchair users never learn to perform this valuable skill. Wheelie capability is affected by the characteristics of the clinician, the wheelchair user, the wheelchair and the environment. Although our understanding of wheelie biomechanics and training methods is evolving, much remains to be learned. Three recent wheelchair developments have wheelie-related implications: a new type of rear anti-tip device (Arc-RAD) that permits wheelie-like function, pushrim-activated power-assisted wheelchairs (PAPAWs) that make wheelie-dependent skills more dangerous and difficult, and a powered wheelchair that has robotic wheelie capabilities (the IBOT). Conclusions. Improvements in our understanding of the nature of wheelies, formalization of training protocols and innovations in wheelchair design hold promise for improved activities and participation by wheelchair users.

Comparison between performance with a pushrim-activated power-assisted wheelchair and a manual wheelchair on the Wheelchair Skills Test.

Purpose. To test the hypothesis that people using a pushrim-activated power-assisted wheelchair (PAPAW) can accomplish a wider range of wheelchair skills than when using a manual wheelchair (MWC). Methods. We studied 30 able-bodied participants, using within-participant comparisons. Participants used a manual wheelchair equipped with both PAPAW and regular MWC rear wheels, and rear anti-tip devices (Arc-RADs) that permitted wheelie-like function. We trained participants to perform the wheelchair skills of the Wheelchair Skills Training Program (WSTP, Version 2.4). From the Wheelchair Skills Test (WST, Version 2.4), we calculated pass-fail success rates for the 50 individual skills and a total percentage WST score. Results. The mean (±SD) total WST scores were 89.3 (±7.0)% for the PAPAW and 88.8 (±8.4)% for the MWC, with a mean difference of 0.6 (±5.6)% (p = 0.59). Qualitative observations suggested that skills requiring a higher force on the pushrim (e.g., incline ascent) were performed more easily with the PAPAW, whereas skills requiring greater control of the wheelchair (e.g., wheelie-dependent skills) were performed more easily with the MWC. Conclusion. Overall wheelchair skill performance with the PAPAW is not superior to that when using the MWC. The PAPAW may be helpful for specific skills that require more wheel torque, but the additional torque appears to be disadvantageous when performing skills that require greater control.

Neck discomfort of wheelchair users: effect of neck position

Purpose: To test the hypothesis that wheelchair users experience more discomfort when holding their necks in extended and/or rotated positions than when in their self-selected most comfortable positions (MCPs). Methods: We studied 20 wheelchair users, first determining their MCPs with the eyes closed. Then, subjects assumed and maintained (for 5 min each) four neck positions in random order: level (L) and elevated (E), both straight ahead of the subject (S) and with the neck rotated (R). We measured neck extension angles (from digital photographs) and neck discomfort (using visual analogue scales [VAS], in %). Results: The mean neck-extension angles were MCP − 2.6°, LS 9.5°, LR 8.1°, ES 23.9° and ER 25.4° (ANOVA p < 0.0001). The mean VAS neck discomfort scores were LS 5.7%, LR 17.4%, ES 24.0% and ER 34.1% (ANOVA p < 0.0001). Conclusions: Sustained extension and rotation of the neck, alone or in combination, increase the neck discomfort of wheelchair users. The MCP for most wheelchair users is straight ahead with the neck slightly flexed, about 11° and 27° more flexed, respectively, than when looking at an average-height sitting or standing person. These findings have implications for wheelchair design, the behaviour of clinicians and wheelchair users, and the built environment.

Measurement properties of the Wheelchair Skills Test – Questionnaire for powered wheelchair users

Abstract Purpose: To evaluate the test–retest reliability, concurrent validity and responsiveness of the Wheelchair Skills Test – Questionnaire (WST-Q) Version 4.1 for powered wheelchair users. Methods: A volunteer sample of 72 community-dwelling, experienced powered wheelchair users, ranging in age from 50 to 77 years, participated in this study. Participants completed measures at baseline and 1 month later. Results: Mean ± standard deviation total percentage WST-Q scores at baseline and 1 month were 83.7% ± 10.9 and 86.3% ± 10.0 respectively. Cronbach’s alpha was 0.90 and the 1 month test–retest intraclass correlation coefficient (ICC1,1) was 0.78 (confidence interval: 0.68–0.86). There were no floor or ceiling effects. Percentages of agreement between baseline and 1 month for individual skills ranged from 72.2% to 100%. The correlations between the WST-Q and the objective Wheelchair Skills Test (WST), WheelCon and Life Space Assessment were r = 0.65, r = 0.47 and r = 0.47 respectively. The standard error of measurement (SEM) and smallest real difference (SRD) were 5.0 and 6.2 respectively. Conclusion: The WST-Q 4.1 has high internal consistency, strong test–retest reliability and strong support for concurrent validity and responsiveness. Implications for Rehabilitation: There is evidence of reliability, validity and responsiveness of the Wheelchair Skills Test – Questionnaire (WST-Q) among experienced older adult powered wheelchair users. The WST-Q can be used to measure powered wheelchair skills, guide intervention and measure change over time.

Powered wheelchair skills training for persons with stroke: a randomized controlled trial.

Objective The aims of this study were to test the hypothesis that people with stroke who receive formal powered wheelchair skills training improve their wheelchair skills to a significantly greater extent than participants in a control group who do not and to explore the influence of spatial neglect. Design Seventeen participants with stroke (including nine with spatial neglect) were randomly allocated to intervention (n = 9) or control (n = 8) groups. Those in the intervention group received up to five 30-min training sessions based on the Wheelchair Skills Training Program 4.1. The powered Wheelchair Skills Test version 4.1 was administered at baseline (T1) and after training (T2). Results A rank order analysis of covariance on the T2 Wheelchair Skills Test score, having adjusted for the T1 score, showed a significant effect caused by group (P = 0.0001). A secondary analysis showed no significant effect caused by spatial neglect (P = 0.923). Conclusions People with stroke who receive formal powered wheelchair skills training improve their powered wheelchair skills to a significantly greater extent (30%) than participants who do not (0%). The extent of change was not affected by the presence of spatial neglect. These findings have significance for the wheelchair provision process and the rehabilitation of people with stroke.

Fall during a wheelchair transfer: a case of mismatched brakes.

Kirby RL, Smith C: Fall during a wheelchair transfer: a case of mismatched brakes. Am J Phys Med Rehabil 2001;80:302–304.We report the case of a patient who had a transtibial amputation and whose wheelchair had been inadvertently fitted with a push-to-lock brake on one side and a pull-to-lock brake on the other. During a standing-pivot transfer from bed to wheelchair, during which the patient thought that she had applied both brakes, the wheelchair turned away from the patient toward the side of the unlocked brake and the patient fell to the floor. This case report has implications for wheelchair design, wheelchair system management, and for user training.

Effect of a high rolling-resistance training method on the success rate and time required to learn the wheelchair wheelie skill: a randomized controlled trial

Kirby RL, Gillis DJ, Boudreau AL, Smith C, Rushton P, Clark-Gallant L, Parker KE, Webber A: Effect of a high-rolling-resistance training method on the success rate and time required to learn the wheelchair wheelie skill: a randomized controlled trial. Am J Phys Med Rehabil 2008;87:204–211. Objective:The primary objective of this study was to test the hypotheses that a wheelie training method that begins in a high-rolling-resistance (RR) setting (1) improves the success rate and (2) reduces the training time. Our secondary objectives were to assess the effects of other factors (e.g., age, gender) on training time and to acquire data on the perceptions of the participants that would assist us in refining our training methods. Design:Randomized controlled study including 48 able-bodied participants with no significant wheelchair experience. Each participant was taught the wheelie skill, using up to five training sessions. Participants in the conventional group did all of their training on a smooth, level, tile surface. The RR group began training in a high-RR setting (rear wheels initially prevented from moving at all, progressing to being on 12-cm-thick foam that permitted some movement) before moving to the tile surface. Outcome measures were success rate (%), training time (mins) to achieve wheelie competence (defined as the ability to perform two consecutive 30-sec wheelies within a 1.5-m-diameter circle, assessed at least 2 days after training), and a questionnaire. Results:The success rates for those in the conventional and RR groups were 96% and 100%, respectively (P = 1.000). The mean (±SD) training times for the conventional and RR groups were 55.9 mins (±27.1) and 51.8 mins (±18.7) (P = 0.549). Training time was not significantly affected by trainer or age, but it was affected by sex, with women requiring an average of 21.4 mins more than men (P = 0.002). Perceptions of participants in both groups about the training were positive. Of the participants in the RR group, 14 (74%) perceived the RR technique as “very effective,” and five (26%) perceived it as “moderately effective.” Conclusions:Neither success rate nor training time for wheelie skill acquisition by able-bodied learners are improved by a training method using high RR. Women require more time to learn than men. Learners using the RR technique perceive it to be effective. These results have implications for training practices.

Are wheelchair-skills assessment and training relevant for long-standing wheelchair users? Two case reports

Purpose. We present two case reports that shed light on the question of whether routine periodic wheelchair-skills assessment and training are relevant for long-standing wheelchair users. Case 1. A 60-year-old man with a 15-year history of T12 complete paraplegia sustained an intertrochanteric fracture of his femur due to a tip-over accident that occurred 2 days after a follow-up clinic visit at which no limitations in wheelchair-skill performance were identified. If a procedure had been in place to identify and correct his wheelchair-skill deficiencies, this injury might have been prevented. Case 2. A 34-year-old woman with spina bifida, whose wheelchair use had gradually increased, came to our attention during the provision of a new wheelchair. She was able to significantly improve her wheelchair abilities through training. The newly learned skills enhanced her community participation. Conclusions. These cases suggest that, even in long-standing wheelchair users, wheelchair skills should be routinely assessed as part of the periodic functional assessment and, when the skill level is determined to be less than appropriate for that person, formal training should be offered.

Sitting pressure in the tilted position: manual tilt-in-space wheelchair vs. manual wheelchair with a new rear antitip device.

MacDonald B, Kirby RL, Smith C, MacLeod DA, Webber A: Sitting pressure in the tilted position: Manual tilt-in-space wheelchair vs. manual wheelchair with a new rear antitip device. Am J Phys Med Rehabil 2009;88:61–65. To test the hypothesis that, in comparison with a heavier, larger and more expensive manual tilt-in-space wheelchair, a lightweight manual wheelchair equipped with new rear antitip devices provides comparable mean sitting pressures in the tilted position, each of eight able-bodied participants sat for 8 mins in each wheelchair, upright, and tilted back (38–39 degrees). The mean (±SD) sitting pressures (of all active sensors in a force-sensing array) at the eighth minute in the upright and tilted positions with the new rear antitip device wheelchair were 58.6 (±14.0) and 45.8 (±9.3) mm Hg (a 20.7% reduction) (P = 0.005). For the tilt-in-space wheelchair, the mean values were 55.7 (±13.9) and 47.2 (±10.8) mm Hg (a 26.3% reduction) (P = 0.008). There were no significant differences between the wheelchairs in the upright (P = 0.843) or tilted (P = 0.624) positions. A lightweight manual wheelchair equipped with a new rear antitip device provides equivalent reductions of sitting pressures in the tilted position to a comparably tilted tilt-in-space wheelchair.