The wheelchair is among the most common and important of rehabilitation devices, particularly for persons with mobility impairments, including persons with a spinal cord injury (SCI). Despite advances in wheelchair technology, users continue to face significant limitations to mobility and increased risk associated with falls and over-use injuries of the upper extremities. Mobility limitations arise as a result of environmental barriers (e.g., rough terrain, stairs, or steep inclines). In order to deal with these barriers, manual wheelchair users need to develop a set of specific wheelchair skills (e.g., turning around in tight spaces or negotiating a curb). Without these critical skills, wheelchair users may avoid these obstacles altogether, significantly limiting mobility, community participation, and independence in daily life.
The purpose of this study was to evaluate use of a Wheelchair Skills Training Program (WSTP) for veterans with SCI who use a manual wheelchair. Our immediate objectives include: 1) Determine the immediate and sustained effects of wheelchair skills training on ability and safety, performance time, and physical strain. 2) Examine how the intervention affects mental health variables (depression), physical variables (pain, spasticity), and wheelchair usage. 3) Examine the effects of wheelchair skills training on safety, community participation, and quality of life. 4) If successful, promote dissemination of the wheelchair skills training in VA SCI Centers.
A two-group randomized placebo controlled design was used. Veterans with SCI were assigned randomly to either the WSTP group or an education control (EC) group. Data were collected over three points in time: baseline, immediately post-intervention (1 month), and 12 months post-intervention. Data were collected through direct observation, questionnaires, and medical record review. Baseline and subsequent data consisted of self-reported survey data, results of a wheelchair skills test administered by a clinician, analysis of physical strain computed by the SmartWheel technology, and the extent of wheelchair use measured by the wheelchair datalogger. Brief bimonthly phone contacts were utilized between the post-intervention evaluation and final visit as a strategy for recruitment retention. This technique had been found to be effective in longitudinal studies, and allowed study staff to maintain updated contact information for each subject.
One hundred thirty-eight veterans were recruited, with 121 completing all training sessions and 109 completing the one year evaluation. The predominantly (93%) male population was an average of 45.7 +/- 13.2 years old. Seventy-nine percent had spinal cord injuries at the Thoracic level, and had been injured an average of 16.6 +/- 12.4 years. No significant differences existed between the groups for any of the baseline data. In addition, there were no significant differences between the groups at baseline with respect to the primary outcome measures which included scores for the Wheelchair Skills test, SF-36V (quality of life sub scales), and the CHART (Craig Handicap Assessment and Reporting Technique). Data were compared between those who dropped from the study and those who stayed in; the veterans who dropped from the study were not significantly different from those who stayed in the study.
Objective one was to determine the immediate and sustained effects of WSTP on ability, performance time, and physical strain. A repeated measures ANOVA was completed to determine changes immediately (after intervention) and one year later (sustained effects). After three time points of data collection, wheelchair skills improved significantly (p<0.001) for both groups, although those who received the training maintained improved scores one year post-training. Physical strain was measured by the SmartWheel, but because of issues surrounding the measurement method, data captured were inadequate to analyze. There were no significant differences in performance time between groups at any time point in the study; both groups were significantly faster (p=0.01) at time 2 and maintained the faster performance time at time 3 (one year later).
Objective two was to examine how the intervention affects mental health variables (e.g., depression), physical variables (e.g., pain, spasticity), and wheelchair usage (measured by a data logger). Those in the WSTP group traveled significantly farther one year post-training than those in the education group, as measured by the wheelchair datalogger. There were no other significant findings in relation to mental health and physical variables.
Objective three was to determine how the intervention impacted safety, community participation and quality of life. The safety score for wheelchair skills changed significantly over time for both groups, with the veterans randomized to the WSTP maintaining improved safety scores one year post-baseline. Quality of life, as measured by the SF-36V, showed significant changes in bodily pain over time for both groups, with scores decreasing (more pain). This would suggest that despite providing training on how to use one's wheelchair more appropriately, bodily pain as perceived by veterans continues. Community participation as measured by the CHART showed no significant changes over time for either group for any of the sub-measures.
Although not an objective when the proposal was written, it was decided to give the health education test to all participants to determine if the education arm was effective. Results indicate that the scores from the health education test, which was provided to all subjects at each visit, decreased significantly over time, although the education group maintained higher scores than the WSTP group.
Results from this study indicate that a wheelchair training program may be effective for improving wheelchair skills in veterans with SCI.
Optimal use of wheelchairs is hampered by inadequate training. This is the first randomized clinical trial in veterans to study the impact wheelchair skills has on community participation. This study provides evidence that wheelchair skills training may be beneficial to veterans and perhaps should be included as part of the life-long SCI continuum of care offered by the VA. We will report findings of the study to the Chief Consultant for Spinal Cord Injury and Disorders Strategic Healthcare Group, the National Consortium for Spinal Cord Injury Medicine Clinical Practice Guidelines, and the SCI QUERI.
- Groer S, Elliot MR. Implications of Manual Wheelchair Skills Training for Veterans with Spinal Cord Injury: Results of a Randomized Clinical Trial. Presented at: Rehabilitation Engineering and Assistive Technology Society of North America International Annual Conference; 2012 Jun 30; Baltimore, MD.