Post on 24-Jul-2020
2015/04/07
1
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
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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
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)
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 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
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
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
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
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
– 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
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