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A More Formal Process for Wheelchair Skills Assessment and Training – An

Idea Whose Time Has Come!

R. Lee Kirby & Cher SmithDalhousie University and the

Capital District Health AuthorityHalifax, Nova Scotia, Canada

Setting the Stage

• Conflicts of interest: WSP Software• Acknowledgements:

– Wheelchair Research TeamF di b di– Funding bodies

• Handouts: – pdf of the PPT presentation– www.wheelchairskillsprogram.ca

Handouts• www.wheelchairskillsprogram.ca/eng/lectures.php• http://www.wheelchairskillsprogram.ca/eng/publications.php

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 Department of Veterans Affairs (VA)• 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 skillsthe assessment of wheelchair skills 2. Describe the rationale and evidence supporting

the effectiveness of wheelchair skills training3. Describe the impact of wheelchair skills on

participation4. Move one step along the “stages of change”

WHO. World Report on Disability, 2011, p 34

•15% (1 billion) some form of disability

•2.2% (110M) very significant difficulties in functioning

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Prevalence of Wheelchair Use• World: ~65M people need wheelchairs

(~20M people do not have them).– WHO guidelines 2008.

• US: 3.86M non-institutionalized users by 2009 (~30% PWCs or scooters).– Flagg JF. Buffalo, February 2009.

• US: similar proportion of powered wheelchair use (5-11%) in the US VA– Hubbard SL et al. J Rehab Re Dev 2007;44:581-92.

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• Chronic overuse injuries are common• Acute injuries are common

Improper Wheelchair, Fit or 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.

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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

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• 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– 56K* (Ummat & Kirby. Am J Phys Med Rehabil 1994;73:163-167)

100K (Xiang et al Injury Prevention 2006;12:8 11)– 100K (Xiang et al, Injury Prevention 2006;12:8-11)

• Community wheelchair users injured/year– 5%* (Kirby et al. Am J PM&R 1994;73:319-30)

– 18% (Berg et al, Am J Public Health 2002;92:48)

– 14%* (Nelson et al. Arch PM&R 2010;91:166-73)

– 21% (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%

Rear anti-tip devices contributing to tip/fall

Routhier F. Personal communication 2007.

BENEFITS PROBLEMS

Wheelchairs

BENEFITS PROBLEMS

Better wheelchair provision

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World Health Organization

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

WHO Service-Delivery Model

1. Referral and appointment2. Assessment3. Prescription4. Funding and ordering5. Product preparation6. Fitting7. User training8. Follow-up, maintenance and repairs

WHO Guidelines 2008, Section 3.2.1, p 76

WHO Wheelchair Service-Delivery Model

1. Referral and appointment2. Assessment3. Prescription4. Funding and ordering5. Product preparation6. Fitting7. User training8. Follow-up, maintenance and repairs

WHO Guidelines 2008, Section 3.2.1, p 76

www.wheelchairskillsprogram.ca Established 1996

What’s Different About the WSP?

• Evidence-based• Both assessment and training• Both wheelchair users and caregivers• 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)

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WHO Wheelchair Service-Delivery Model

1. Referral and appointment2. Assessment3. Prescription

WST

4. Funding and ordering5. Product preparation6. Fitting7. User training8. Follow-up, maintenance and repairs

WHO Guidelines 2008, Section 3.2.1, p 76

WSTP

The Circle of Education

Objectives (identified problems)

Evaluation(identified problems)

Curriculum (WSTP)

(WST)

WHO Wheelchair Service-Delivery Model

1. Referral and appointment2. Assessment3. Prescription

WST

4. Funding and ordering5. Product preparation6. Fitting7. User training8. Follow-up, maintenance and repairs

WHO Guidelines 2008, Section 3.2.1, p 76

Versions of WST by Type of Wheelchair and Nature of the Test Subject

Type of Wheelchair Type of Test Subject

Manual Wheelchair user

C iCaregiver

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

C iCaregiver

Powered Wheelchair user

Caregiver

Scooter Scooter user

Individual Skills:WST 4.2 examples

Individual Skills Manual WC Powered WC

WCU CG WCU CG

Turns controller on and off X X b b

Controls positioning options X b b b

Rolls forward 10m b b b b

Turns 90° while moving forward

b b b b

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WST 4.2 Capacity ScoresScore 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 ofdifficulty experienced some difficulty worthy of note (e.g. excessive time or effort, inefficient method, minor injury)

Fail 0 Evaluation criteria not metNot possible

NP The wheelchair does not have this part

WST Comments

WST vs WST-Q WST-Q 4.2 Answer CodeCapacity question: “Can you do this skill?”

Answer Score What this meansYes 2 I can safely do the skill, by myself,

without any difficulty. Yes with difficulty

1 Yes, but not as well as I would like.

No 0 I have never performed the skill or I do not feel that I could perform it right now.

Not possible

NP My wheelchair does not have this part.

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Capacity (‘can do’)vs

Performance (‘does do’)

WST-Q 4.2 Answer CodePerformance question: “How often do you actually do this skill during your daily life?”

Answer Score What this means

Daily 4 At least once a day.

Weekly 3 At least once a week.

Monthly 2 At least once a month.

Yearly 1 At least once a year.

Never 0 Less often than once a year or never.

WST-Q 4.2 Answer CodeGoal question: “Is this is a skill for which you would be interested in receiving some training?”

Answer What this means

Yes I would be interested.

No I would not be interested.

WST-Q Algorithm

Evolution of the WST-Q

• Semi-structured interview• Dichotomous (yes/no) responses• Ordinal scale of responses• Tester-administered script (in-person, phone)• Self-administration (in-person, postal)• Computer-Assisted Testing (CAT)

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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?

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WST (Manual) Measurement Properties

• WST 1.0:– Kirby et al. Arch PM&R 2002;83:10-18

• WST 2.4:– Kirby et al Arch PM&R 2004;85:794-804

• WST 3.2: – Routhier F et al, Rehab International 2008

• WST 4.1: – Lindquist NJ et al. Arch PMR, 2010;91:1752-7– Lemay V et al. Proc 4th Nat SCI Conf Oct 2010

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;93:1009-13p• 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

Wheelchair Skills Assessment• Rushton P, Kirby RL, Miller WC. Manual

Wheelchair Skills: Objective Testing versus Subjective Questionnaire. Arch Phys Med Rehabil 2012;93:2313-8

N = 89

• 26 Manual wheelchair users•WST-Q 4.1•WST Capacity Score: 72 5 (19 2)%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)

Example of Assessment

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

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Example of a full WST 4.2

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!

WHO Wheelchair Service-Delivery Model

1. Referral and appointment2. Assessment3. Prescription4. Funding and ordering5. Product preparation6. Fitting7. User training8. Follow-up, maintenance and repairs

WHO Guidelines 2008, Section 3.2.1, p 76

WSTP

Prevalence of Manual Wheelchair Skills Training

• 17% in UK got any formalized training (Whizz-Kidz 2004)

• 18% in US got any formalized training (Karmarkar AM et al. JRRD 2009;46:567-76)

• 66% in US of 223 people with paraplegia (Zanca JM et al. Physical Therapy 2011;91:1877-91)

• 29% in Bangladesh of 149 (Borg J et al. BMC Health Services Res 2012;12:330)

• 11% in Canada of 18 people with stroke (Charbonneau R et al. Arch Phys Med Rehabil 2013;epub.

Wheelchair Skills Capacity of WCUs with SCI

• US Model Spinal Cord Injury System• 214 participants (~75% with paraplegia)• WST 4.1, cross-sectional studyS , c oss sect o a 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 Principlesp

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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Example of training tip: propulsion technique

Kwarciak AM et al. Arch PM&R 2009;90:20-6 5 deg incline ascent: forward then backward approach

Example of training tip: wheelie training

Koshi et al. Am J PM&R 2006

10 steps, 8 bends, 25 seconds

2 steps, 0 bends, 7 seconds

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

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WSTP Curriculum

• Individual or small group sessions

• 15-30 minute sessions, 1-5x/week

• ~2-4 hrs extra training time

• Based on wheelchair and motor learning principles literature

Mobility Centre

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

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Other Outcomes - Confidence• 20 manual wheelchair users, RCT• WSTP 4.1: 2 x 1-hour training sessions• WheelCon scores (0-100)

WSTP• WSTP group: – Absolute change +13.7% (relative 24%)

• Control group:– Absolute change -0.4% (relative -0.6%)

• P = 0.004Sakakibara B et al. Arch Phys Med Rehabil 2013;Feb 2 (epub ahead of print)

International Classification of Function (ICF)

Participation

(Handicap)Society

WHO, 2001

Health

(Impairment)

Activities

(Disability)

Organ or tissue

Whole person

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: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– 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)( g )

III. Nonrandomized trials with concurrent controlsIV. Nonrandomized trials with historical controlsV. Case series with no controls

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

Evolution

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Implementation of WSP: What is Needed?

People who need wheelchairsCaregiversWheelchairsReceptive environmentTrained 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

Integration into Formal Education of Health-Care Students

• Occupational Therapy• Physiotherapy• Nursing• 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 2011I d h l h i kill biliti• Improved wheelchair-skill abilities – Routhier et al, Proc RESNA 2008

• Improved knowledge – Kirby RL et al. 4th SCI Conference,

Niagara Falls Oct 30, 2010

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Certification Wheelchair Skills Program

“Low tech, high impact”

Nenad Kostanjsek, WHO ICF Conference, 2004

JordanBosnia

WSP Training in Less-Resourced Settings

(Indonesia)(Nepal)

Peru IndiaTanzania

Belize

Tanzania (Dar) 2011

Tanzania (Moshi) 2011 India (Jaipur) 2005

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Bosnia (Banja Luka) 2008

Released at RESNA June 30, 2012

Bangalore, India 2012 Bangalore, India 2012

Bangalore, India 2012 Mannar, Sri Lanka 2012

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Gold Standard of Practice 2013

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 wheelchaircaregivers should have their wheelchair skills assessed.

3. Training should be provided.

“Nothing is as powerful as an idea whose time has come.”

Victor Hugo, 1802-1885

Peter Gough. Fresh Paint.