NIHR DC Discover

NIHR Signal Structured training improves skills of wheelchair users

Published on 18 July 2018

doi: 10.3310/signal-000621

Structured wheelchair skills training increases wheelchair users’ skills when compared with no training, standard care or education controls. The training, as developed in Canada, is more effective for new wheelchair users than experienced users. It includes difficult everyday challenges from wheeling through gravel to negotiating high curbs.

Links have been found previously between wheelchair skills capacity (reflecting what the user can do) and: independent mobility, reduced reliance on caregivers, and increased social participation. This systematic review was only able to show an increase in skills capacity using the specific Wheelchair Skills Test, as this was the common outcome measure. Other measures reflecting activities of daily living or frequency of independent movement weren’t used in enough trials to enable comparisons.

This Canadian programme appears to be a safe and effective way of increasing participants’ wheelchair skills. Most NHS trusts in England appear to offer only basic support in using a wheelchair. Implementing more advanced and standardised skills training programmes offers potential to improve these services, but could entail additional costs and staff training.

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Why was this study needed?

There are around 1.2 million wheelchair users in the UK, of whom two-thirds are regular users. A wheelchair offers an individual the chance to become more independent. Wheelchair skills capacity (what the wheelchair user can do) is important for independent mobility and social participation.

The Wheelchair Skills Training Program (WSTP) is a training method developed in Canada. It can be used by those with manual wheelchairs, powered wheelchairs and mobility scooters, as well as by their caregivers. There are sets of 29-34 skills (such as turning while rolling forwards), which cover indoor, community and advanced levels. The WSTP includes a standard manual and assessment tests. The training can take place anywhere (hospital, community, or home), and can be done as individual or group sessions.

This study aimed to assess the effectiveness of the WSTP. The review is part of on-going evaluation since the 1990’s by the WSTP development team at Dalhousie University and Nova Scotia Health Authority.

What did this study do?

This systematic review found 13 randomised controlled trials of moderate quality. The trials compared the WSTP with no training, standard care (as described in individual studies to include minimal training), or activities such as education.

The trials included adult wheelchair users with neurological or musculoskeletal conditions, spinal cord injuries, and stroke. Three trials used non-disabled people simulating wheelchair users. Six trials included only new wheelchair users, while seven included experienced people. Ten trials included only manual wheelchairs, two used powered wheelchairs, and one used both.

Training programmes ranged from one to 48 sessions, lasting 25-240 minutes per session. Eight trials used 1:1 training methods, three used workshop training, and two used group sessions.

None of the trials took place in the UK. Nine were done in Canada, two in the USA, and one each in Turkey and China. This may limit applicability to the UK. The reviewers included developers of the publicly-funded WST program, which could introduce bias in favour of the intervention.

What did it find?

The primary outcome was the Wheelchair Skills Training capacity score, a test which is part of the WSTP. The test documents an individual’s ability to perform representative wheelchair skills. Each skill is scored as either a pass or fail. The total capacity score is the sum of passed skills divided by the number of applicable skills, multiplied by 100. One hundred percentage points is, therefore, the maximum possible score.

  • Compared with the control groups, the programme increased the post-training total capacity scores by a mean difference of 14.1 percentage points (95% confidence interval [CI] 7.4 to 20.8 points; 13 trials, 581 participants). This equates to a relative increase over baseline in the trained wheelchair user group of 21.2% (which is over the 20% minimum increase that the authors determined as clinically meaningful). The control groups also improved but by significantly fewer points.
  • An analysis of experienced versus new wheelchair users showed that new users improved their scores about four times more than experienced users. The mean difference in score for new users was 22.6 percentage points (95% CI 9.0 to 36.3 points; 6 trials, 169 participants), while the mean difference in score for experienced users was 5.5 percentage points (95% CI 1.4 to 9.6; 7 trials, 412 participants).
  • Skills appeared to be retained over time: there was no significant decline in scores between tests carried out immediately after training, and after follow up periods of between three and 12 months (4 trials).
  • No serious adverse events were reported.

What does current guidance say on this issue?

No relevant guidance on providing wheelchair skills training is available. NHS England has produced a model service specification for wheelchair and posture services. This is a non-mandatory tool available to commissioners to help them commission higher-quality wheelchair services.

This states that services must provide on-going support and advice to service users and their carers in the use of their wheelchair and seating. It doesn’t include details about specific wheelchair skills.

What are the implications?

The training programme appears to be a safe intervention to improve skills capacity for wheelchair users.  If higher levels of confidence and competence in using a wheelchair lead to better outcomes for wheelchair users, then training programs such as the WSTP should be beneficial.

Most NHS trusts appear to offer only basic support in helping people use a wheelchair, though specialised training programmes are available. The evidence shows benefits to wheelchair users undergoing structured training. However, extra costs will be involved in providing training programmes, and in training staff to deliver them. These would need to be considered if this type of training is commissioned. The programme may need evaluating in the NHS first. Some questions remain about optimal duration, intensity and type of training in this country. 

Citation and Funding

Keeler L, Kirby RL, Parker K, et al. Effectiveness of the Wheelchair Skills Training Program: a systematic review and meta-analysis. Disabil Rehabil Assist Technol. 2018; Apr 4:1-19. doi: 10.1080/17483107.2018.1456566.

No funding information was provided for this study.

Bibliography

Dalhousie University. Wheelchair Skills Program. Halifax, Nova Scotia: Dalhousie University; accessed July 2018.

Kirby RL, Smith C, Parker K, et al. The Wheelchair Skills Program Manual, version 4.3. Dalhousie University, Halifax, Nova Scotia; 2016.

Leeds Teaching Hospitals NHS Trust. A beginner’s guide to NHS wheelchairs – part 2, using a wheelchair. Leeds: Leeds Teaching Hospitals NHS Trust; 2013.

NHS Choices. Getting a wheelchair, scooter or walking aid. London: Department of Health, 2018.

NHS England. Improving wheelchair services. London: NHS England; accessed June 2018.

NHS England. Model service specification for wheelchair and posture services. London: NHS England; 2017.

Salisbury NHS Foundation Trust. Wheelchair skills group. Salisbury: Salisbury NHS Foundation Trust; 2009.

Why was this study needed?

There are around 1.2 million wheelchair users in the UK, of whom two-thirds are regular users. A wheelchair offers an individual the chance to become more independent. Wheelchair skills capacity (what the wheelchair user can do) is important for independent mobility and social participation.

The Wheelchair Skills Training Program (WSTP) is a training method developed in Canada. It can be used by those with manual wheelchairs, powered wheelchairs and mobility scooters, as well as by their caregivers. There are sets of 29-34 skills (such as turning while rolling forwards), which cover indoor, community and advanced levels. The WSTP includes a standard manual and assessment tests. The training can take place anywhere (hospital, community, or home), and can be done as individual or group sessions.

This study aimed to assess the effectiveness of the WSTP. The review is part of on-going evaluation since the 1990’s by the WSTP development team at Dalhousie University and Nova Scotia Health Authority.

What did this study do?

This systematic review found 13 randomised controlled trials of moderate quality. The trials compared the WSTP with no training, standard care (as described in individual studies to include minimal training), or activities such as education.

The trials included adult wheelchair users with neurological or musculoskeletal conditions, spinal cord injuries, and stroke. Three trials used non-disabled people simulating wheelchair users. Six trials included only new wheelchair users, while seven included experienced people. Ten trials included only manual wheelchairs, two used powered wheelchairs, and one used both.

Training programmes ranged from one to 48 sessions, lasting 25-240 minutes per session. Eight trials used 1:1 training methods, three used workshop training, and two used group sessions.

None of the trials took place in the UK. Nine were done in Canada, two in the USA, and one each in Turkey and China. This may limit applicability to the UK. The reviewers included developers of the publicly-funded WST program, which could introduce bias in favour of the intervention.

What did it find?

The primary outcome was the Wheelchair Skills Training capacity score, a test which is part of the WSTP. The test documents an individual’s ability to perform representative wheelchair skills. Each skill is scored as either a pass or fail. The total capacity score is the sum of passed skills divided by the number of applicable skills, multiplied by 100. One hundred percentage points is, therefore, the maximum possible score.

  • Compared with the control groups, the programme increased the post-training total capacity scores by a mean difference of 14.1 percentage points (95% confidence interval [CI] 7.4 to 20.8 points; 13 trials, 581 participants). This equates to a relative increase over baseline in the trained wheelchair user group of 21.2% (which is over the 20% minimum increase that the authors determined as clinically meaningful). The control groups also improved but by significantly fewer points.
  • An analysis of experienced versus new wheelchair users showed that new users improved their scores about four times more than experienced users. The mean difference in score for new users was 22.6 percentage points (95% CI 9.0 to 36.3 points; 6 trials, 169 participants), while the mean difference in score for experienced users was 5.5 percentage points (95% CI 1.4 to 9.6; 7 trials, 412 participants).
  • Skills appeared to be retained over time: there was no significant decline in scores between tests carried out immediately after training, and after follow up periods of between three and 12 months (4 trials).
  • No serious adverse events were reported.

What does current guidance say on this issue?

No relevant guidance on providing wheelchair skills training is available. NHS England has produced a model service specification for wheelchair and posture services. This is a non-mandatory tool available to commissioners to help them commission higher-quality wheelchair services.

This states that services must provide on-going support and advice to service users and their carers in the use of their wheelchair and seating. It doesn’t include details about specific wheelchair skills.

What are the implications?

The training programme appears to be a safe intervention to improve skills capacity for wheelchair users.  If higher levels of confidence and competence in using a wheelchair lead to better outcomes for wheelchair users, then training programs such as the WSTP should be beneficial.

Most NHS trusts appear to offer only basic support in helping people use a wheelchair, though specialised training programmes are available. The evidence shows benefits to wheelchair users undergoing structured training. However, extra costs will be involved in providing training programmes, and in training staff to deliver them. These would need to be considered if this type of training is commissioned. The programme may need evaluating in the NHS first. Some questions remain about optimal duration, intensity and type of training in this country. 

Citation and Funding

Keeler L, Kirby RL, Parker K, et al. Effectiveness of the Wheelchair Skills Training Program: a systematic review and meta-analysis. Disabil Rehabil Assist Technol. 2018; Apr 4:1-19. doi: 10.1080/17483107.2018.1456566.

No funding information was provided for this study.

Bibliography

Dalhousie University. Wheelchair Skills Program. Halifax, Nova Scotia: Dalhousie University; accessed July 2018.

Kirby RL, Smith C, Parker K, et al. The Wheelchair Skills Program Manual, version 4.3. Dalhousie University, Halifax, Nova Scotia; 2016.

Leeds Teaching Hospitals NHS Trust. A beginner’s guide to NHS wheelchairs – part 2, using a wheelchair. Leeds: Leeds Teaching Hospitals NHS Trust; 2013.

NHS Choices. Getting a wheelchair, scooter or walking aid. London: Department of Health, 2018.

NHS England. Improving wheelchair services. London: NHS England; accessed June 2018.

NHS England. Model service specification for wheelchair and posture services. London: NHS England; 2017.

Salisbury NHS Foundation Trust. Wheelchair skills group. Salisbury: Salisbury NHS Foundation Trust; 2009.

Effectiveness of the Wheelchair Skills Training Program: a systematic review and meta-analysis()

Published on 5 April 2018

Keeler, L.,Kirby, R. L.,Parker, K.,McLean, K. D.,Hayden, J. A.

Disabil Rehabil Assist Technol , 2018

OBJECTIVE: To conduct a systematic review synthesizing the evidence for the effectiveness of the Wheelchair Skills Training Program (WSTP). DATA SOURCES: We searched PubMed, the Cochrane Library, CINAHL and Embase databases, as well as grey literature, up to 10 October 2017. STUDY SELECTION: Randomized controlled trials (RCTs) assessing the effectiveness of the WSTP. DATA EXTRACTION: Two independent reviewers screened articles and extracted data. Methodological quality was assessed using Cochrane's Risk of Bias Tool. DATA SYNTHESIS: Meta-analyses (including sub-group analyses) were conducted for the Wheelchair Skills Test (WST) and WST Questionnaire (WST-Q) total capacity scores. We qualitatively assessed retention, WST/WST-Q subtotal and individual-skill capacity scores and other identified outcomes. The quality of evidence was determined using the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) approach. Thirteen articles (581 participants) were included for analysis. The level of evidence was of moderate quality. The WSTP increased the post-training WST/WST-Q total capacity scores by 14.0% (95% CI: 7.4, 20.8; p < .0001) compared to no treatment, standard care or educational controls, a relative increase over baseline of 21.2%. Subgroup analyses showed that training was more effective for new wheelchair users. Retention of training effects was suggested by the absence of significant declines between tests post-training and at follow-up. The WSTP was found to have positive effects on some other outcomes. No serious adverse events were reported. CONCLUSIONS: There is moderate quality evidence that the WSTP is a safe intervention that has a clinically meaningful effect on WST/WST-Q capacity scores and some other outcomes. Implications for rehabilitation A systematic review and meta-analysis of 13 randomized controlled trials on a total of 581 participants, using the Wheelchair Skills Training Program (WSTP) as the intervention, found that the WSTP increased Wheelchair Skills Test (WST) and WST Questionnaire (WST-Q) total capacity scores by 21.2% relative to baseline. Subgroup analyses showed that training was more effective for new wheelchair users. The WSTP was found to have positive effects on some other outcomes and no serious adverse events were reported. The WSTP warrants cautious implementation in clinical and educational settings.

Expert commentary

The study reports a systematic review and meta-analysis of wheelchair skills training research. The review has been undertaken in rigorous and robust way. 

The findings acknowledge the limitations of the review but report a useful overview of wheelchair skills training research. The paper also highlights the need for future research to address the highlighted limitations and recommends inclusion of measuring additional variables of confidence, the Goal Attainment Score, satisfaction and qualitative outcomes which would identify training effects and further contribute to the knowledge base. 

Overall this is a useful article, but the authors recommend caution in implementation.

Dr Anne Mandy, Associate Professor, School of Health Research, University of Brighton