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manual - Wheelchair Skills Program

1. General training tips See some of the general training tips for the Reaches 1 5m high object skill 7 16 which will not be repeated here The wheelchair user should use one hand on the chair or thigh to help with balance and the other hand to pick up the object For a wheelchair user with weak trunk muscles to reach the ground he she should move the arms to the thighs one at a time and then to the feet placing the chest on the thighs Turning the object on its side may help to get a better grip To make it easier to pick up the object the wheelchair user may pull the object up against one of the wheels so that it does not move If a wheelchair user has weak pinch strength increasing the friction between the fingers and the object e g by wearing gloves or wetting the fingers with saliva can help to prevent dropping the object Training tips for manual wheelchairs operated by wheelchair users Variations o If the wheelchair user holds the object against the wheel and rolls the wheel forward both hands can be used to grasp the object when it rotates to the top of the wheel This can be done on the move Training tips for manual wheelchairs operated by caregivers To pick a dropped object off the ground the caregiver may maneuver the wheelchair so that he she can keep one hand on the wheelchair for balance and control Then the caregiver can crouch and pick up the object with the other hand Traini
2. Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 35 Table 8 WSTP P CG Individual Skills for Powered Wheelchairs Operated by Caregivers Suggested Order of Training Individual Skills l Moves controller away and back pA Turns controller on and off 3 Selects drive modes and speeds 4 Controls tilt function 5 Controls recline function 6 Disengages and engages motors 7 Operates battery charger 8 Rolls forward 9 Rolls backward 10 Turns in place 11 Turns while moving forward 12 Turns while moving backward 13 Maneuvers sideways 14 Transfers 15 Doors 16 Rolls 100m 17 Avoids moving obstacles 18 Inclines 19 Side slope 20 Soft surface 21 Pot holes 22 Threshold 24 Gets from ground into wheelchair 23 Ascends descends 5cm level change Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 36 7 INDIVIDUAL SKILLS This section is organized by individual skills For a description of any suggested equipment and set up the starting position for the subject spotter position evaluation criteria and special considerations see the corresponding individual skill section of the Spotter Manual and WST Manual In the WSTP Manual only a brief description o
3. joystick because it is the most common device used Displacing the joystick will cause the wheelchair to move in that direction The farther the joystick is moved from its rest position the faster the wheelchair will move if Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 54 the controller is of the proportional control type If the joystick is of the proportional control type the user should move it forwards gradually to achieve a smooth start If the wheelchair user is over correcting when driving changing the contact point with the joystick e g from finger tips to web space between the thumb and index fingers may improve the smoothness of the driving When driving quickly if there is difficulty with directional control due to the apparent sensitivity of the joystick in that mode the joystick can be dampened by resting the palm of the hand on the base of the joystick If the wheelchair user s hand slips off the joystick or control is poor a different shape for the joystick may be appropriate e g U shape versus ball shape Powered wheelchairs may be rear front or mid center wheel drive The configuration will affect the path of the wheelchair and the ease with which the wheelchair can be kept moving in a straight line For instance a front wheel drive wheelchair tends to be more difficult to keep moving forward in a straight
4. e Variations e Wheelie down the incline stop half way perform a 360 turn in the wheelie position then continue down e An advanced exercise is for the wheelchair user to practice achieving wheelie take off while on the incline This is useful when an unexpected obstacle is encountered If the wheelchair user is facing downhill more force is needed for takeoff and the wheelchair may accelerate rapidly downhill On steep or slippery inclines or if the wheelchair has too much rear stability there may not be enough rear wheel traction to allow wheelie take off while facing downhill In such situations the wheelchair can be turned so that it is facing across the hill This will place more weight on the rear wheels and avoid runaway Once in the wheelie position a wheelie turn in place will allow the wheelchair user to proceed down the incline Training tips for manual wheelchairs operated by caregivers As for skill 7 24 Training tips for powered wheelchairs operated by wheelchair users As for skill 7 24 When stopping while descending a steep incline moving the joystick into reverse may work better than simply bringing the joystick to the resting neutral position Training tips for powered wheelchairs operated by caregivers As for skill 7 24 Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 105 7 27 Rolls
5. if using one under the body the wheelchair user should lean away from it The wheelchair user should push down on the transfer board and wheelchair to unweight the buttocks The wheelchair user should avoid fully extending the fingers and wrists This avoids overstretching the joints and tendons which may be of importance for people with spinal cord injury who use a tenodesis effect whereby active wrist extension causes passive finger flexion if the tendons are of appropriate length Keeping the wrists in a neutral position also functionally lengthens the arms making it easier to get the buttocks off the sitting surface The wheelchair user should keep the leading hand far enough away from the body to allow room for the body to move The trailing hand may be close to the body The wheelchair user should shift sideways in a single large movement or several smaller ones towards the target surface If possible the wheelchair user should lean well forward nose over toes During the actual transfer from this position the hips and the head move in opposite directions This technique reduces the forces needed from the arms Once fully supported by the target surface the Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 83 wheelchair user should remove the transfer board The wheelchair user should lean away from it to do so Fo
6. principles of motor learning Positive reinforcement e g an encouraging remark increases the likelihood of a behavior or skill being performed whereas negative reinforcement or no reinforcement has the opposite effect Initially the trainer s tolerance for the learner s errors should be broad but the bandwidth of acceptable performance is gradually narrowed as learning proceeds Behaviorists refer to this as shaping a behavior Intermittent positive reinforcement at irregular intervals is the ideal reinforcement schedule for sustaining behaviors Feedback can be provided during the skill attempt This is more practical for continuous skills e g rolling a long distance but there is a danger that this may interfere with the learner attending to intrinsic feedback Providing the feedback after the skill is usually preferable The trainer should wait a few seconds before providing feedback to allow intrinsic processes to work first Before beginning the next trial the trainer should allow the learner some time to plan the next attempt Any augmented feedback should be followed by an opportunity to practice 3 19 Specificity of Practice If a learner wants to improve his her ability to perform a task the task itself should be practiced Cross training may help to develop fitness but is of limited use for the development of motor skills There is mounting evidence for a broad range of motor skills that training in simulated
7. the learner progresses through stages Early in the process success may be partial inconsistent or only possible in a familiar setting As learning progresses preliminary success is eventually achieved skill acquisition consistency within training sessions improves success carries over into subsequent sessions skill retention and the learner is able to use the skill in more diverse settings skill transfer Ultimately the skill may become autonomous requiring little or no conscious effort The time course of motor learning includes an initial period of rapid improvement sometimes followed by a plateau that may be followed by additional gains The shape of the motor learning curve is not a straight line and may be punctuated by abrupt transitions from novice to skilled coordination patterns There is a distinction between aspects of the learning process that are in the form of facts and ideas sometimes called the declarative cognitive or explicit system versus those that relate to the actual performance of the skill sometimes called the procedural motor skill or implicit system Each can be acquired without the other If both are acquired this need not be in a fixed order The two can assist or interfere with each other Attempting to consciously control motor actions can disrupt optimal performance Skills learned implicitly through a discovery approach appear to be more robust under pressure Healthy
8. 2m across 5 side slope Versions applicable e WST M WCUY WST M CGY e WST P WCUY WST P CGY Description e The subject propels the wheelchair across a side slope without turning downhill significantly Rationale e Side or cross slopes are frequently encountered in man made and natural environments Sidewalks for instance are usually sloped 2 1 50 toward the street to allow water to run off although steeper grades are often found e g where sidewalks cross driveways General training tips e Downhill turning tendency will tend to pull the caster wheels downhill e The extent of downhill turning tendency is directly proportional to how far the combined center of gravity of the wheelchair and occupant is in front of or behind the drive wheels The person operating the wheelchair can take steps to minimize this distance by repositioning the center of gravity e g by leaning tilting or reclining e If there is room to do so on a path the person operating the wheelchair should stay away from the downhill edge to avoid veering off the path Training tips for manual e Side slopes require significantly more energy to push across wheelchairs operated by e The wheelchair user should lean backwards to keep the weight wheelchair users away from the casters e Two hand propulsion o To avoid turning downhill the wheelchair user should push harder on the downhill wheel o In some cases the uphill hand may be used e
9. April 11 2012 WSTP 4 1 Manual 17 enhancing learning e g by better participation faster skill acquisition However augmented feedback is not always needed and it can hinder learning if the learner becomes dependent on it The ultimate goal of skills learning is for the performer to be able to perform the skill without augmented feedback 3 17 Feedback Content The trainer should be supportive and encouraging even to the extent of slightly exaggerating how well the learner is doing However the trainer should be accurate with respect to feedback content It is counterproductive to tell a learner that his her performance was successful if it was not People learn at least as well from their failures as from their successes When learning wheelchair skills feedback from the trainer about the success or failure of an attempt at a skill knowledge of results KR is usually unnecessary for two reasons First the result is usually self evident Second if the learner is failing repeatedly he she may get discouraged by repeated statements about failure However if a learner performs in an unsafe manner and does not appear to be aware of it the trainer should point this out Another form of feedback is the provision of information about how the skill was performed knowledge of performance KP Ideally such feedback should be directed at what the trainer suggests the learner should try differently prescriptive KP in
10. Gets over 2cm threshold Versions applicable WST M WCUY WST M CGY WST P WCUY _WST P CGY Description The learner propels the wheelchair over a 2cm high threshold Rationale Wheelchair users often encounter low obstacles e g door thresholds or higher ones e g sticks uneven sidewalk sections that they cannot get over by merely rolling over them General training tips As for 7 29 in many respects Adjustment tips e Footrests or anti tip devices may contact the threshold before the wheels do making it impossible to negotiate the threshold without repositioning the wheelchair parts concerned e Footrests or anti tip devices may cause the wheelchair to get hung up on the threshold unable to proceed because the drive wheels are not in contact with the surface float Before attempting to negotiate a high obstacle the learner should be aware of how much vertical and horizontal clearance exists between the casters and the rear wheels to avoid getting hung up on the obstacle If the wheelchair does get hung up due to insufficient horizontal clearance wheelbase the learner may be able to escape by backing up slightly which swings the casters from the rear trailing position to the side or forward trailing one where there is more space Getting the larger drive wheels over the threshold is usually easier than getting the smaller caster wheels over Leaning away from the casters will unweight them an
11. March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 10 effectively Safety includes both the safety of the wheelchair user and the safety of others If there are two or more ways for a learner to perform a skill and one is considerably safer to perform than the other the trainer should encourage the learner to use the safer technique For some learners and some skills that cannot be performed in a consistently safe manner the most successful outcome of training will be if the learner recognizes that the skill should not be attempted without assistance A probationary period of supervision may be appropriate before coming to a decision that a person is safe to use a wheelchair independently 3 3 Spotters We strongly recommend careful attention to spotting during practice sessions Any person serving as a spotter during training should meet the criteria described in the Spotter Manual and position him herself as indicated in the individual skill sections of that Manual 3 4 Trainers It is possible to learn the skills by self training However a good trainer can be an important element in learning wheelchair skills The trainer should be knowledgeable about wheelchair skills and how to teach them The personal characteristics of the trainer are also important The trainer should be credible friendly supportive non judgemental interested and honest The trainer should be familiar with the structure and operati
12. Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 42 Training tips for manual e Not applicable wheelchairs operated by wheelchair users Training tips for manual e Not applicable wheelchairs operated by caregivers Training tips for e Turn the power on powered wheelchairs e The wheelchair user should be able to see or hear an indication of operated by wheelchair the mode and speed status users e The user may select different mode and speed settings for different skills e Progression The user should also learn to use other wheelchair functions e g the horn Training tips for e As for powered wheelchairs operated by wheelchair users powered wheelchairs operated by caregivers Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 43 7 4 Controls tilt function Versions applicable WST M WCU X WST M CGY WST P WCUY _WST P CGY Description The subject tilts the wheelchair back from the upright position and then restores the wheelchair to the upright position In a tilt the angle between the wheelchair seat and back remain the same but the angle from the horizon changes Rationale Wheelchairs capable of variable rear tilt are used for a variety of reasons including pressure relief comfort to enhance breathing postur
13. and in some respects tips for manual wheelchairs operated by wheelchairs above wheelchair users e If falling backwards the wheelchair user should tuck the chin and pull himself herself vigorously forward using the armrests or seat e After a fall the power should be turned off Watch out for spilled battery acid e The power should be turned off while the getting up skill is being practiced Training tips for powered e As for manual wheelchairs operated by caregivers wheelchairs operated by e As for powered wheelchairs operated by wheelchair users caregivers Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 137 Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 138 7 38 Ascends stairs Versions applicable e WST M WCUY WST M CGY e WST P WCU X_ WST P CGX Description e The wheelchair user and the wheelchair get from the bottom to the top of a set of stairs Rationale e Although alternative means of getting from a lower to a higher level are often present the use of stairs is frequently the only option Although 3 5 stairs are not many they are representative of the skills needed for a full flight of steps e This skill is not applicable for most powered wheelchairs because of the difficulty and danger involved General training tips e Re
14. applicable wheelchairs operated by caregivers Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012
15. are working properly but leave the user without a chair if the charger needs to go to the supplier for repairs e The charger port is usually near the controller or under the seat e To avoid electrical shocks avoid using the battery charger in a wet environment or where liquids may be spilled on it e Both the wheelchair and charger should be turned off when being connected to each other and the power source Then the power on the charger if not automatic should be turned on e The length of time required to charge a battery can vary due to the type of charger and nature of the battery e Ifthe battery charger is capable of charging different batteries e g 6 and 12 volts ensure that the appropriate setting is used e A battery with a slightly low charge may function reasonably well on smooth level surfaces but may be insufficient to get the wheelchair over obstacles e If the battery needs to be changed it should be replaced with an approved model The type of battery needed to start a combustion engine is different from the slow discharge type needed for a powered wheelchair Sealed gel batteries are preferable to those Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 49 with liquid acid that can leak if the battery or wheelchair is tipped over Training tips for manual e Not applicable wheelchairs operated by wheelchair user
16. arms can be moved to the thighs one at a time and then to the feet until the chest is resting on the thighs To get back into the upright position the stronger arm can be hooked over the push handle or armrest and the body pulled up through elbow flexion and wrist extension e If possible the learner should position the wheelchair so that the casters are trailing in the direction of the transfer to reduce the Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 87 likelihood of the wheelchair tipping in that direction To achieve this position the subject should finish the wheelchair positioning with a slight movement away from the direction of the transfer Training tips for manual wheelchairs operated by caregivers General This section only deals with transfers for wheelchair users who require minimal assistance to perform the final movement between the wheelchair and the bench If the caregiver must perform the majority of the effort or if a mechanical lift is needed additional training by experienced rehabilitation professionals is needed This is outside the scope of this Manual The caregiver should be attentive to the position of the wheelchair user s arms to avoid injuring them during the transfer If the wheelchair user is able to give direction then the caregiver should assist in ways such as off loading weight or gu
17. backwards between strokes If the brakes are not of the retractable type the backs of the thumbs can be injured if the wheelchair user is not careful The recovery path of the hands at the end of the propulsive stroke may be more like an arc than a loop for this skill e If the wheelchair user gets tired part of the way up the incline he she should put on the brakes or if there is sufficient room to do so turn the wheelchair to the side and rest e If the wheelchair starts to roll backward instead of grasping both hand rims which might cause a rear tip the wheelchair user can grab one As the other wheel rolls backward this will turn the wheelchair across the slope Variations o Asa learning exercise it may be helpful to have the wheelchair user try to ascend the incline with a spotter without leaning forwards o Use the ramp hand rails if available o For very steep inclines some wheelchair users will go up backwards in the wheelie position This requires a lot of skill and strength A Person With Hemiplegia e It is usually easier for a wheelchair user with hemiplegia who propels the wheelchair with one arm and one leg to go up the ramp backwards Whenever rolling resistance is encountered including when ascending inclines foot propellers find it easier to push backwards than to pull forward with the feet Training tips for manual wheelchairs operated by caregivers As for manual wheelchairs operated by whe
18. be used depending upon the armrest design e Fora flip up armrest the subject should unlock the front of the armrest from the receptacle and lift the front of the armrest so that it flips behind the chair back e For a swing away armrest the subject should lift the armrest up slightly to disengage it and then swing it to the rear far enough to clear the backrest posts e To completely remove an armrest the subject should unlock whatever locks are necessary There may be ones at both the front and back of the armrest The subject Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 85 should lift the armrest straight up so that the armrest is detached from the chair If the armrest is height adjustable the wheelchair user should be careful not to just remove the elevating arm pad e For a wheelchair with a tray e g for a person with hemiplegia the subject should first flip the tray away or slide it forwards to detach it e To restore the armrests e It is easy with some armrest designs to unintentionally reverse left and right To avoid this the learner should be encouraged to follow a routine with respect to where the armrests are placed when removed e The wheelchair user should reverse the process for moving the armrests away e The wheelchair user should make sure the armrest posts are lined up with the receptacles before locking
19. build speed later The trainer may provide a framework an organization or a way of thinking about a skill e g segments of a skill or use of the hands of a clock to refer to the position of the hands on the rear wheel The trainer may provide instructions about what to look for in the environment that might affect performance e g a lip at the bottom of a ramp Analogy learning has been found to be helpful e g during the rolling forward skill comparing the coasts between pushes to the coasts between strokes when paddling a canoe The trainer may provide verbal cues short precise words or phrases that direct attention or prompt movements Preferably these should be given in combination with a demonstration The trainer should limit the number of cues to those that are most critical It can be helpful to have the learner verbalize the cues prior to attempting the skill and during the attempt For instance when using the momentum method to ascend a curb see later in skills section the cues that we use are push coast pop and lean As noted earlier for people with dementia there is some evidence of superior learning of problem solving tasks with the help of cues errorless learning vs trial and error learning Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 16 3 14 Focus of Attention Intention interferes with performance at all skill leve
20. change 20 15cm curb ascent and backwards descent 21 Stationary wheelie 22 _ Wheelie turns in place 23 Wheelie forward back 24 Wheelie moving turns forward back variation no hands rest 25 Wheelie on soft surface forward 26 Wheelie incline descent 27 Wheelie curb descent 28 Gets from ground into wheelchair including falls 29 Descends stairs 30 Ascends stairs Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual Table 7 WSTP P WCU Individual Skills for Powered Wheelchairs Operated by Wheelchair Users Suggested Order of Training Individual Skills Moves controller away and back Turns controller on and off Selects drive modes and speeds Controls tilt function Controls recline function Disengages and engages motors Operates battery charger Rolls forward Rolls backward Turns in place Turns while moving forward 12 Turns while moving backward 13 Maneuvers sideways 14 Relieves weight from buttocks 15 Picks object from floor 16 Reaches 1 5m high object OO DB Pepto i 17 Transfers 18 Doors 19 Rolls 100m 20 Avoids moving obstacles 21 Inclines 22 Side slope 23 Soft surface 24 Pot holes 25 Threshold 26 Ascends descends 5cm level change 2T Gets from ground into wheelchair
21. hand rim of the rear wheel on the outside of the turn However for the wheelchair user with good arm function and a wall leading to an opening into which the person wishes to turn the turn can be accomplished more readily with less reduction in speed and with less demand on the shoulders if the wheelchair user performs a drag turn To do so the wheelchair user drags the arm along the wall to slow the wheelchair on one side and carry out the turn Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 24 4 LESSON PLANS Before each WSTP session the trainer should have a plan for how the session will be conducted Below we provide two sample lesson plans This is not intended to be restrictive 4 1 Intake Session 40 minutes A Welcome 2 minutes e Explain purpose of this and subsequent sessions e Obtain informed consent to proceed B Perform an intake assessment 25 minutes e Document demographic clinical and wheelchair experience data e Identify any contraindications for testing or training e Document wheelchair specifications e Wheelchair skills assessment questionnaire version of the WST and segments of the objective WST C Goal setting 5 minutes e From the intake assessment and discussion with the learner identify and record a set of relevant and potentially achievable training goals D Begin training 5 minutes e Begin work
22. help to offset the tendency for manual wheelchair users to become round shouldered due to muscle imbalance and loss of flexibility e A recovery path for the hands below the hand rims is commonly recommended for wheelchair users propelling on smooth level surfaces To reinforce this the trainer can ask the wheelchair user to touch the axles center of the rear Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 52 wheel during each recovery phase This allows the hands to make initial contact with the hand rims while moving upward reducing any impact Wheelchair users with weak and insensitive hands may prefer to slide the hands back along the hand rims rather than letting go at the end of the propulsive stroke but this may cause some braking to occur e To maintain a straight direction during the coast the wheelchair user may need to push harder on the side towards which the wheelchair is deviating or use the fingers on the hand rim on the other side but without gripping tightly e To stop the rate of slowing can be controlled by how hard the hand rims are gripped The hand rims should run through the wheelchair user s hands During the coast and stop the hands are in the 1 00 o clock position If the wheelchair user stops too quickly he she may fall forward out of the wheelchair or tip over forwards To prevent this the wheelch
23. lift with both arms on the seat at the same time or with one arm on the seat and one on the ground e If the wheelchair user has the use of the legs he she can use the wheelchair to help get up onto his her feet then pivot and sit down e Stay in wheelchair approach for getting up from the ground e Some wheelchair users are able to right themselves while remaining in the wheelchair e Start on a surface partway between seat height and ground with the wheelchair on its back as would be the case after practicing a fall backwards onto an elevated mat e Pull on rear wheels to get buttocks firmly against the wheelchair seat e Let the knees bend over the front of the seat e Lock one brake e Turn to other side e Use the forward hand to grab the hand rim of the rear wheel on the unlocked side as far forward as possible e Reach the rearmost hand to the floor e Push firmly with the floor hand and pull with the hand rim hand e Push and pull repeatedly moving the floor hand hand forward on the floor and the hand rim hand forward on the hand rim in a step wise fashion with each rock until upright Training tips for manual wheelchairs operated by caregivers The caregiver can assist the wheelchair user by helping to position and stabilize the wheelchair Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 136 e The caregiver should t
24. line some wheelchairs have built in compensation for this problem Stops When stopping the user should allow the joystick to return to the neutral position gradually for a smooth stop Simply letting go of the joystick will bring the wheelchair to a stop at a rate that has been programmed For a rapid stop the power can be turned off or the joystick can be put into reverse Progression o Practice moving the joystick in wide open spaces and progress to more enclosed ones o Begin at responsive but low torque settings and progress to different modes Training tips for powered wheelchairs operated by caregivers As for powered wheelchairs operated by wheelchair users Some wheelchairs permit the wheelchair to be operated from behind the wheelchair which is the preferred position For this and other moving skills the caregiver may operate the wheelchair by using the same joystick that the wheelchair user does Where space permits this should be done with the caregiver standing beside the wheelchair and facing forward In some situations e g going through a narrow opening the Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 55 caregiver may need to stand in front of the wheelchair The caregiver in this situation should be careful not to drive the wheelchair over his her own feet Standing behind the wheelchair and leaning for
25. little as 40 minutes immediately post training reduces the susceptibility to interference and results in earlier consolidation At the subsequent session the learner may even perform better than at the previous session without any intervening physical practice This is sometimes referred to as off line learning Sleep affects some types of skills more than others sequence specific skills less so Sleep is of most benefit to skills that were the most difficult before sleep Learning by observation and mental imagery is also enhanced by sleep Anticipated rewards can enhance off line learning during sleep Consolidation is a process with different components that are processed differently Memory progresses over time from a fragile state one that is susceptible to interference to a stabilized state Off line a skill becomes less vulnerable to interference stabilization and improves in performance enhancement During subsequent practice the consolidated memory can become unstable and susceptible to improvement reconsolidation or deterioration 3 22 Variability of Practice Most wheelchair skills are of little use if they can only be performed in highly controlled settings The purpose of wheelchair skills training is for the learner to use the skill in his her life skill transfer Once a skill is initially acquired and retained the learner should practice it in different contexts to promote transfer to everyday situations Di
26. of pressure ulcers with far less stringent regimens With the forward leaning method the trunk can be rested on the thighs Further unweighting can be achieved by grabbing the footrests and pulling on them Getting back upright from the forward bent position can be a challenge for some wheelchair users The hands can be walked up the thighs until an armrest or the backrest can be reached to allow the person to pull him herself the rest of the way Leaning on a table is a strategy that may be helpful for wheelchair users who have difficulty in getting back to the upright position after leaning forward onto the thighs It may be socially inconvenient to use the forward leaning technique in some circumstances Side leaning or shifting the weight onto one buttock can also be effective for those who cannot lean forward and recover or in situations when the wheelchair user might find it inconvenient to lean forward The armrests or rear wheels can be used to push or pull on Variations e The push up method applying forces to the armrests or seat to lift the buttocks straight up requires more force than some of the alternative methods e Bridging tilt and recline are alternative methods that may be adequate for some wheelchair users but these methods are not as effective in relieving pressure as the options mentioned earlier e The more tilt or recline the better but getting the trunk backwards Originally approved for distribution and u
27. on external objects rather than using the hand rims A Person with Hemiplegia e To turn to the side away from the stronger hand the wheelchair user should push forward on the hand rim e To turn toward the stronger hand the wheelchair user should pull back on the hand rim e The wheelchair user may use the feet e The wheelchair user may reach across to the opposite wheel with the stronger hand Training tips for manual wheelchairs operated by caregivers To turn in a tight space the caregiver should pull back on one push handle while pushing forward on the other The caregiver should stand close to the back of the wheelchair if space is limited If a knapsack prevents this it can be removed and placed in the wheelchair user s lap This skill can be performed in the wheelie position Training tips for powered wheelchairs operated by wheelchair users Adjustment tip o Adjusting the speed acceleration and deceleration for turning will affect the overall turning of the chair o The drive wheel and seating configurations have an impact on the turning radius of the system The closer the drive wheels are to the loaded wheelchair s center of Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 66 gravity the easier it is to turn in place by simply moving the joystick straight to the left or right The vertical axis o
28. order to achieve a safer or more effective result The trainer should identify the most critical error and suggest what might be done to correct this problem Pointing our errors is more effective than noting what the learner is doing correctly although the latter is important for motivation It can be useful to have learners attempt skills in inappropriate ways e g rolling through gravel while leaning forward causing the casters to sink into the gravel to help them better understand why a suggestion is being made Qualitative feedback is fine early e g you need to pop your casters higher Later quantitative feedback e g you need to pop your casters about 2cm higher may be better Feedback can be more effective if it directs the performer s attention away from his or her own movements and to the effects of those movements As part of the feedback process it can be useful to ask the learner about his her perceptions about the problem and intended solutions The objective is to develop a learner who is an independent problem solver 3 18 Timing of Feedback The optimum frequency for KR feedback is affected by the difficulties of the task the more difficult the task the higher the frequency of feedback can be without interfering with skill acquisition When providing KP feedback the trainer needs to exercise judgment and to be attuned to the chemistry of the training session The trainer should offer feedback statements n
29. situations can enhance skill performance in real life situations However practice should be as specific as possible with respect to the task itself and the context in which it is to be performed During practice the learner should match the desired final setting However if the goal is for the learner to be able to conduct the task in diverse settings then that is what should be practiced Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 19 3 20 Amount of Practice For motor skills to be learned well they need to be practiced If a learner is switching from an old to anew coordination pattern it may take 200 or more practice trials to achieve the change During the transition there may be numerous errors which the learner may find frustrating and discouraging The amount of practice needed may be much greater up to 50 fold for people with injury or disease of the brain The over learning strategy has a positive effect on skill retention This involves continuing to practice by 50 200 beyond the amount needed for initial success This can be done right away or during additional practice sessions later However more practice is not always better practice does not make perfect perfect practice does Also there may be a point of diminishing returns More than 4 6 hours of practice a day is unlikely to be productive If errors begin to occu
30. that provides more torque Positional control e g tilt recline can alter the weight distribution between the wheels It is easier to proceed on a soft surface if more of the weight is on wheels with larger diameter Clearance for feet can also be positively affected by this change On soft or irregular terrain there is an optimal speed that is fast Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 110 enough to maintain forward movement but not so fast that the motion is uncomfortable or leads to a loss of control Maintaining a steady speed is preferable to a series of stops and starts Training tips for powered wheelchairs operated by caregivers As for powered wheelchairs operated by wheelchair users With a rear wheel drive wheelchair a caregiver can push down on the back of the wheelchair to unweight the casters or to add traction to spinning wheels The caregiver can push forward to assist with overcoming resistance Alternatively the front of the wheelchair can be lifted or pulled on Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 111 7 29 Gets over 15cm pot hole Versions applicable e WST M WCUY WST M CGY e WST P WCUY WST P CGY Description e The learner gets the wheelchair over a pot hole that is 15cm acro
31. the other This is more likely to be necessary if the door resists opening o Fora door that opens away from the wheelchair and that is latched with a mechanism that will open when a force is applied to it the wheelchair user can approach the door without slowing down At the last moment the wheelchair user can reach forward with one or both hands and use momentum to open the door The feet should not strike the door This should be practiced at slow speeds initially e Door that Opens Towards the Wheelchair e The wheelchair user should push on the door frame with one hand farthest from the hinge to open the door more easily with the other closest to the hinge e The wheelchair user may keep one hand on the door handle and use the other to push both wheels one at a time e Variations e If there is a threshold or level change in the door opening it may be helpful to use the door frame to help provide the forces needed to proceed e For a doorway that is too narrow for the wheelchair to pass through it an option is for the wheelchair user to transfer from the wheelchair on one side to a regular chair on the other fold the wheelchair to get it through the door and then transfer back into it Other alternatives include removing both rear wheels and resting on the rear anti tip devices or transport wheels to get through the door For wheelchairs that fold from side to side some wheelchair users can partially fold the wheelchair and si
32. the rear wheel can be positioned in a way that prevents the door closing o The learner can experiment with negotiating the door in the forward or backwards direction Training tips for manual wheelchairs operated by wheelchair users e Two handed propulsion o The door frame can be used to help propel the wheelchair user through the door the slingshot method To do so the wheelchair user reaches forward and places one hand on the door frame and the other on the door Then by pulling with both hands the wheelchair is moved through the opening This has the advantage of keeping the hands from being injured It is common for a wheelchair user to injure the backs of his her hands by bumping or scraping them between the door frame and the wheelchair A person with hemiplegia e Using one hand to cross over from one wheel to the other can be helpful to keep the wheelchair straight while getting Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 71 through a door e Door that Opens Away From the Wheelchair e To open the door more easily the wheelchair user can turn sideways in front of it This allows the wheelchair user to get closer to the door and to resist the tendency of the wheelchair to roll backward when the door is pushed e The wheelchair user can hold onto the door frame with one hand as the door is pushed with
33. there may be short term benefits such as the social interaction during the training sessions the pleasure that some people get from challenging themselves or improving on a test Without creating anxiety the trainer should let the learner know that he she will be assessed at the end of the training period because this has a known positive effect on skill acquisition Encouragement and positive feedback from the trainer or fellow learners can be powerful incentives as well Rewards significantly enhance long term retention of motor learning 3 12 Demonstration Demonstration is one of the most powerful instructional methods in motor skills learning The demonstrator may be the trainer a model or a peer It may be in person or on a video The Pictures and Videos section of the WSP website contains numerous video clips that can be used The demonstrator should ideally be skilled but this is not a necessity One approach is to use an expert model to provide an accurate template of the movement followed by less successful models If the Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 15 model is at a similar level to the learner e g in a group setting the learner can learn from the feedback provided to the model The demonstration should occur before practice begins It may be repeated as often as needed The trainer should briefly describe important elements o
34. up the mat behind the wheelchair and moving it to the front proceeding forward in a step wise fashion Training tips for manual e Adjustment tips wheelchairs operated by e This is the first of several skills during which it may be wheelchair users necessary to reposition the rear anti tip devices to allow the Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 108 wheelchair to be tipped backwards sufficiently to perform a partial or full wheelie To reposition most rear anti tip devices the learner will need to press the button or release mechanism on the wheelchair frame that locks the anti tip device in place The learner should note the position of the anti tip devices so that he she will be able to restore them later Then the learner can either reposition the anti tip devices so that they face upwards or remove them altogether To restore the anti tip devices the learner should simply reverse the steps Note Whenever the rear anti tip devices have been inactivated the wheelchair user is at increased risk of a rear tip The spotter should be vigilant to spot the wheelchair user closely until he she becomes used to this new condition Even if left in place the wheelchair user should not rely on the rear anti tip devices to prevent rear tipping because they might sink into a soft surface e Forwards approach Because
35. user is seated on the transfer bench Rationale For transport or storage the size of the wheelchair may need to be reduced This can be done by folding the wheelchair Removal of the rear wheels or other parts is a useful way to further diminish the size and weight of the wheelchair General training tips The learner user should pay attention to each item as he she removes or alters it to ensure that he she will be able to reassemble the chair later Training tips for manual wheelchairs operated by wheelchair users Fold Wheelchair e The wheelchair user should remove anything that may prevent folding such as the cushion rigid seat backrest or knapsack e To lift the seat out the wheelchair user may need to release any restraining devices e If the rear wheels can be removed without tools they should be Usually there is a release mechanism at the center of the axle a button or lever that needs to be depressed If the wheel does not come off easily check to be sure the brake is not on and that the rear wheel is off the ground e To fold a cross braced wheelchair one that becomes narrower from side to side when folded the wheelchair user should first clear the footrests e g by flipping them up swinging them away or removing them e To close the chair more easily the wheelchair user_should position the wheelchair so that he she is on one side of it The wheelchair user should then tip the chair s
36. wheelchairs operated by caregivers The caregiver should push harder with the push handle on the outside of the turn and pull back slightly on the inside handle The caregiver should be careful to avoid having the wheelchair user s hands or feet hit any barriers The wheelie position can be used to turn in tight spaces Training tips for powered wheelchairs operated by wheelchair users See general training tips Training tips for powered wheelchairs operated by caregivers As for powered wheelchairs operated by wheelchair users Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 62 WSTP 4 1 Manual 63 7 12 Turns 90 while moving backward Versions applicable e WST M WCUY WST M CGY e WST P WCUY WST P CGY Description e The learner turns the wheelchair 90 to the left and right while moving backwards Rationale e Moving turns are often necessary to avoid obstacles or to change direction General training tips As for skill 7 11 Training tips for manual wheelchairs operated by wheelchair users As for skill 7 11 Training tips for manual wheelchairs operated by Training tips for powered wheelchairs operated by wheelchair users As for skill 7 11 caregivers As for skill 7 11 Training tips for powered wheelchairs operated by caregivers As for skill 7 11 Originally app
37. 1 Facilitate Rete O e r a ea e a e e e aaaea 19 3 22 Variability of Practice s s3cctisssccais aenneren ir EE EEE EE 20 3 23 Distib tion of Practices reee aE E A R a T EERE OEE aeS a 21 3 24 Whole versus Part Practice ncen e a R eia sexs oats eae ee 22 3 25 Simplification and Progression sseseseeesesresseseesresseseresresseestessersrssresseesesreesresee 22 MESS OT PAS ces aa N E E E A N AS 24 SULLA OUI aa a E E a N A E E Uataaetatt cos 26 5 1 How to operate the parts of the wheelchair ss ssnnssesssesssseeessressesssseessersssersssressesse 26 5 2 Understanding the dimensions of the wheelchair eeesesseseeseeessereesrssrersererrsrresressee 26 5 3 Getting into out of and repositioning oneself with respect to the wheelchair 26 5 4 Moving the wheelchair around on smooth level surfaces s sssssseseseeeesseesssresseesee 26 5 5 USS the environment 95 eo vd E E EEEE E T R wae asec TE 26 Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 4 5 6 Skills that require leaning forward or backwards in the wheelchair ceeeee 27 5 7 Skills that require popping the front wheels briefly off the surface eee 27 5 8 Skills for which balancing on the rear wheels is necessary sesseesssesesssressesseses 27 5 9 Working with a Hel per wc dcccisssccnin orense ine a EER E EEE ER ESEE 27 6 0 Tables f Individi
38. April 11 2012 WSTP 4 1 Manual 30 Table 4 WST 4 1 Master List of Individual Skills Skill Level Individual Skills Manual WC Powered WC WCU CG WCU CG 1 Indoor Moves controller away and back X X Y y 2 Indoor Turns controller on and off X X y 3 Community Selects drive modes and speeds X X y v 4 Indoor Controls tilt function X x X y 5 Indoor Controls recline function X y y Y 6 Indoor Disengages and engages motors X X af v 7 Indoor Operates battery charger X X y y 8 Indoor Rolls forward 10m v 3 of 9 Community Rolls forward 10m in 30s X y Y y 10 Indoor Rolls backward 5m M y x 11 Indoor Turns 90 while moving forward is K 12 Indoor Turns 90 while moving backward y y y x 13 Indoor Turns 180 in place X X Y 14 Indoor Maneuvers sideways y X X y 15 Indoor Gets through hinged door in both y directions 16 Indoor Reaches 1 5m high object y X y X 17 Indoor Picks object from floor M X y X 18 Indoor Relieves weight from buttocks y X X 19 Indoor Transfers from WC to bench and back v y X 20 Community Folds and unfolds wheelchair y y X X 21 Community Rolls 100m 24 lt x y 22 Community Avoids moving obstacles y y y x 23 Community Ascends 5 incline Y Y y 24 Community Descends 5 incline y y X 25 Advanced Ascends 10 incline Y y X y 26 Advanced Descends 10 incli
39. WSTP 4 1 Manual WHEELCHAIR SKILLS PROGRAM WSP VERSION 4 1 WHEELCHAIR SKILLS TRAINING PROGRAM WSTP MANUAL This manual and related materials can be downloaded from www wheelchairskillsprogram ca For further information contact wsp dal ca Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 2 Editorial Committee This Manual like the other materials in the Wheelchair Skills Program has resulted from the work of many people Those who have had the greatest involvement in this latest version constitute the Editorial Committee They are listed below R Lee Kirby MD Halifax Chair Cher Smith BScOT MSc Halifax Kim Parker MASc PEng Halifax Donald A MacLeod MSc Halifax Mike McAllister PhD Halifax Paula W Rushton PhD Vancouver Fran ois Routhier PhD Quebec City This Manual has been published electronically at Dalhousie University Halifax Nova Scotia Canada Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 3 TABLE OF CONTENTS Editorial Committee oa esras e e e tgs haga ten tas sheen e peas eeaeee etea air eh eels 2 Table oF COMments niisisssas eunin E RE E dae E apes 3 1 ntrodichion tothe WS LP asd elt cess cova cnaud locuasincehay organs garages cud casa ER AE coma ES aces 6 2 General Background on Motor Skills Learning 2 0 0 0 ce
40. ach As for skill 7 8 Endurance may be a limiting factor if the wheelchair user is deconditioned Variations o If the wheelchair user prefers to do so he she can perform this skill in the backwards direction Training tips for manual wheelchairs operated by Training tips for powered wheelchairs operated by wheelchair users As for skill 7 8 caregivers As for skill 7 8 and general tips For longer distances the controller mode and speed settings can be adjusted to ones that permit more speed and less sensitivity Also the deceleration distance should be increased so that a sudden stop does not cause the wheelchair user to fall or tip forward Because speeds are usually faster at least if the path is in a smooth open space the higher momentum can cause greater injury or damage if there is a collision with a fixed or moving obstacle O Training tips for powered wheelchairs operated by caregivers As for skill 5 8 As for powered wheelchairs operated by wheelchair users Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 93 5 22 Avoids moving obstacles Versions applicable e WST M WCUY WST M CGY e WST P WCUY WST P CGY Description e While moving the learner avoids obstacles approaching from different directions Rationale e In addition to stationary obstacles wheelchair users must avoid moving ob
41. adjustable settings include mode speed direction and whether cruise control is on or off The controller settings that are most appropriate for driving slowly in tight quarters are different from the settings that would work best when ascending inclines or curbs General training tips e Adjustment tips The type of mode switch used will have an impact on success for some users e Select a controller with the easiest access for people with cognitive or physical limitations e g three vs five drive modes toggle vs dial for speed control e In some wheelchairs the mode and speed controls are separate e Although the manufacturer may provide a representative set of modes the dealer and or therapist may adjust the settings to make them as ideal as possible for the user These settings can be altered later as skill improves For many powered wheelchairs it is possible to independently select the maximum speed acceleration and deceleration in different directions as well as the sensitivity to joystick deflections e The order of drive modes e g 1 2 3 4 may be different from one wheelchair to the next For instance some users may prefer to have the order reflect progressively increasing speed whereas other users may wish to order the modes to those from the most to least often used Through programming the dealer and or therapist can reduce the number of steps to get to the most commonly used drive modes or speeds
42. air user should lean back whenever he she is required to stop quickly e Variations e Asa game the wheelchair user can see how far he she can coast after 1 2 pushes The purpose of this learning exercise is to get the learner familiar with hand position and with letting the hand rims slide through the fingers Use single thrusts only of progressively increasing vigor The distance can be extended if the wheelchair user keeps his her weight back on the rear wheels or if he she swings the outstretched arms to either side e One hand propels at a time A person With Hemiplegia e The wheelchair user should propel the wheelchair with the sound side arm and leg e To avoid moving to the weaker side the wheelchair user should use the sound side foot to help steer the wheelchair e The wheelchair user should use the foot to help stop Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 53 e The height of the seat should be low enough to allow the full foot to be on the ground when it is directly below the knee e The wheelchair user should wear shoes that provide both protection for the foot and good traction e To use the foot to propel forward the wheelchair user should straighten the leg push down on the floor with the heel and then pull the wheelchair forward with the foot Training tips for manual wheelchairs operated by careg
43. al SKg irion E E E E EEES T SaF 29 7 0 Individual Skills pnns erensia EE AR ENE AE A A EARS 36 7 1 Moves controller away and back essesesesseeesessessessresressessrssressessressreseseresresseseresresse 37 7 2 T ris controller on and Offii erei eni ean a Ea ee ancees 39 T Sel cts drive modes and speedSieeoei e R A E AA 41 TA OUTOIS tilt TUNC e een a a a o aa a a a eres a ASe EE esain i 43 7 5 Controls recline functiones nnii aia aa iai e aaa dates 46 7 6 Disengages and engages MOCOLS sssessseessessseeesereeseeetsstessetsseessetessressseesseesseesseeessee 48 7 7 Operates battery ChaT ger zs rcsesii oerrinne eE E EREE EAE E PNS A Ea 49 TS R lls foward 0 05 epee meme mr AEE EERS 51 TORO MS Or Ware 10Min SUS 22302 aciecasade cece cececece E a es 57 TAROS AG KWAN SMr a a E 59 7 11 Turns 90 while moving forward ssssssessesssseesessesesseseeseeseseesesseseesessessesseseesesseseesesseses 6l 7 12 Turns 90 while moving backward sseesesseseesessesesseseeseesessessesseseesesesesseseesesseseesesseses 64 TT Turns PSO m placek en a R E A E E E R cela ad 65 PALA Mame Vers side W AY 8 necne irn n tng eu E EE EEEE E E EEEE EEE EEE 68 7 15 Gets through hinged door in both directions sesessseseseseessresseesseesseesseeesseesseesseessees 70 T16 Reaches LOm Heh Object ysis n a a sce E A E EN 75 1 47 Picksobject from MOOK seneso e i E E a TT 7 18 Relieves weight from DIEING KS 5 5 ioe oulaciity esis atenusirateus
44. al control stability e g to prevent falling forward from the wheelchair when striking an obstacle to enhance transfers facilitate bladder management reduce spasticity or reduce edema Tilt of 35 degrees or more may be needed to increase circulation over the ischial tuberosities but lesser degrees of tilt can be effective if combined with recline General training tips Adjustment tip o Not all wheelchairs have a tilt function o Programming by the dealer and or therapist should be considered to allow the wheelchair user to get into a tilted position with as few steps as possible e g using a preset position of 45 of tilt o Be careful to ensure that the wheelchair user has access to the controller when in the tilted position Before tilting the seat back or restoring it to the upright position the person performing the tilt should be sure that there is room behind the wheelchair and above the knees to change the tilt without damaging the environment the wheelchair the user or a bystander For the purpose of pressure redistribution the greater the extent of tilt the better For wheelchair users with limited trunk balance to reduce the likelihood of falling forward 5 10 of tilt is usually adequate at rest or when driving Depending upon the tilting mechanism the extent of forward and rear stability may differ with the wheelchair upright vs tilted back This should be taken into consideration when in a situation
45. an slalom down it by letting the hand rim of one wheel at a time slide through the fingers By descending using the slalom method the apparent slope of the incline is lessened Partially applied brakes Caution should be used when using wheel locks as moving brakes Equal and graded pressure should be used This is not a commonly recommended method but some users do use it effectively Use the handrails if available Wheelie method see section 7 26 for details Perform 360 turns using only friction and downhill turning tendency to effect the turns O Backwards If the wheelchair user has weak trunk muscles and a tendency to fall forwards when facing downhill on inclines he she may feel more comfortable descending the incline backwards The backwards approach may also be used if when descending forwards on a steeper incline the wheelchair user experiences loss of traction due to the unweighting of the uphill wheels When going downhill backwards the wheelchair user should lean uphill to reduce the likelihood of tipping over backwards As with any time the wheelchair is moving backwards it is important to proceed slowly with frequent shoulder checks and to avoid stopping suddenly to prevent rear tips The wheelchair user can proceed forward down the incline Originally approved for distribution and use March 14 Current edition WSTP Version 4 1 49 April 11 2012 2008 WSTP 4 1 Manual 101 Training
46. and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 46 Powered wheelchairs may slow down or stop if the user attempts to operate them in unsafe circumstances e g driving up a steep incline forward with the seat fully reclined If the wheelchair allows both tilt and recline it is advisable to recover to the upright from the recline position before recovering from the tilt position This reduces the tendency to slide forward on the cushion Progression o Adjusting to recline may involve starting at a small amount and progressing to full recline o If the rate of recline can be programmed it is advisable to begin with a slow rate and progress to a faster one This will provide more time in which to ensure that there are no body parts that are at risk of being injured Training tips for manual wheelchairs operated by wheelchair users Training tips for manual wheelchairs operated by caregivers Not applicable When first reclining a wheelchair the caregiver should be aware of the force that may be required to catch the person The set up and mechanics of the recline influence the amount of weight supported by the caregiver Training tips for powered wheelchairs operated by wheelchair users As for General tips Training tips for powered wheelchairs operated by caregivers As for powered wheelchairs operated by wheelchair users Originally appr
47. arate wearer amore 131 7 36 Turns 180 in place in wheelie position asztsatsvesusscasasuattedesscadecedecaddeedsuatieedeapidecautee nue 136 7 37 Gets from ground into wheelchair s ssesssseesesseseesesseseesesseseesessesessesesesseseesesseseessesees 137 TIS A CEN S SEAITS re T a a eee eee en ee 141 1 39 Descends Stalts cinri e e E A A A A OE 145 Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 6 1 INTRODUCTION TO THE WSTP A General Introduction to the Wheelchair Skills Program WSP can be found in a separate document posted on the web site The WSP includes the Wheelchair Skills Test WST the Wheelchair Skills Training Program WSTP and related materials This Manual focuses on the WSTP The WSTP is a standardized training method that addresses a set of representative wheelchair skills Research evidence regarding the safety and efficacy of the WSTP in general as well as some specific skills can be found in the Evidence and Publications sections on the web site There are also some excellent resources available in manuals textbooks and websites about various ways to perform specific wheelchair skills Examples include work by P Axelson I Denison L Harvey and M F Somers Some on line resources can be found on the Related Sites page of our WSP website However despite good progress there has been relatively little scientific study to date o
48. ard and power the rear wheels out of the pot hole Forward Approach Momentum Method This method is comprised of four steps push coast pop and lean As before they can be verbalized as they are performed The wheelchair user should initially approach at a slow speed It is simpler to pop the casters when moving slowly Also if the wheelchair user fails to pop the casters for long enough to clear the pot hole the sudden stop will be less jarring The wheelchair user should not lean forward to look at the feet when he she approaches the obstacle because that will increase the weight on the casters In timing the pop the wheelchair user should understand where the casters are often below the knees not under the feet A mirror can be used to provide augmented feedback In preparation to pop the front wheels while the Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 113 wheelchair user moves forward the wheelchair user briefly coasts and place the hands in the power stroke ready position to be in the right position when he she is at the proper distance from the pot hole The power stroke ready position is when the hands are ready to grasp the hand rims behind top dead centre 11 00 o clock on the right wheel using the clock analogy Then the wheelchair user should accelerate the chair eve
49. arners For wheelchair users who are elderly who are unfit or who have a number of co morbidities even a brief session can be fatiguing or cause overuse injury We have found it practical to use sessions of 15 30 minutes in duration Such sessions include a warm up some time on skills already acquired but requiring further practice a period during which instruction is received on the principal new skill that is the focus of the session and a cool down activity Depending upon the setting e g inpatient vs community sessions can be scheduled at intervals of 1 7 days When the learner has demonstrated the ability to do so safely the trainer should encourage the learner to practice between formal sessions 3 24 Whole versus Part Practice Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 22 For skills that consist of a sequence of sub skills initially it can be helpful to break the skill down into its components motor chunks For instance the stationary wheelie skill can be broken down into three phases take off getting onto two wheels maintaining balance on two wheels and landing returning to the condition of having all four wheels on the ground The goal of course is to build up to the point that the whole skill can be practiced as a unit There are some variations on this strategy For instance the learner can combine whole and part ski
50. ations o Starting and stopping on the incline o Steering slalom using pylons to steer around Training tips for manual e Two hand propulsion wheelchairs operated by e Forwards wheelchair users e The wheelchair user should keep his her weight back to maintain good traction on the rear wheels e The wheelchair user should not go too quickly should stay in control and should be prepared to stop at anytime e To slow down or steer the wheelchair user should hold the hands still at the 1 00 o clock position and let the hand rims slide through his her grip It is better to provide continuous friction than to use a jerky grasp and release method like milking a cow If the wheelchair is allowed to descend too rapidly the hands of the wheelchair user may get injured due to friction burns or lacerations due to hand rim irregularities Gloves help e There is the potential for thumb injury on the brakes if the wheelchair user grabs the wheels when moving too quickly because the hands can get pulled forward e If the wheelchair starts to roll too quickly and the incline is wide enough instead of grasping both Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 100 Hemiplegia hand rims to stop the wheelchair user can grab one turning across the slope Variations o Slalom If a ramp is wide enough the wheelchair user c
51. ay choose to use the wheelie position If the wheelchair user is in a tilt in space or reclining wheelchair tilting or reclining the wheelchair can be used to get the center of gravity farther back Training tips for powered wheelchairs operated by wheelchair users Although a rear wheel drive wheelchair will tend to turn downhill a front wheel drive wheelchair will tend to turn uphill Many chairs are now equipped with automatic correction of downhill turning tendency on side slopes If there is no automatic correction the wheelchair user should aim slightly away from the deviation i e aim uphill for a rear wheel drive wheelchair and downhill for a front wheel drive wheelchair If the wheelchair user is in a tilt in space or reclining wheelchair tilting or reclining the wheelchair can be used to get the center of gravity over the drive wheels Training tips for powered wheelchairs operated by caregivers As for powered wheelchairs operated by wheelchair users Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 107 7 28 Rolls 2m on soft surface Versions applicable e WST M WCUY WST M CGY e WST P WCUY WST P CGY Description e The learner propels the wheelchair 2m on a soft surface Rationale e There are many soft surfaces e g carpet dirt grass gravel sand or snow with increased rolling resistance Propulsio
52. ble to be used for propulsion or braking o The wheelchair may be equipped with grade aids or hill holders These are attachments that when activated allow the rear wheels to roll forward but not backwards The wheelchair user may apply them before he she starts up the incline This will allow the wheelchair user to rest on the incline without rolling back o Some wheelchairs have gears that permit inclines to be handled more easily e Two hand propulsion e When negotiating the lower incline floor transition during either ascent or descent the wheelchair user should be careful not to catch the unsupported feet as this could lead to a hyper flexion injury of the knee e When getting the casters onto the bottom of an incline it may be necessary to transiently tip the wheelchair if the footrests are low and to reduce the sudden braking that occurs at the transition e Some wheelchair users use a rocking action to get the Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 97 casters over the initial lip e The wheelchair user should lean forward as he she goes up the ramp to apply more force to the hand rims and to avoid tipping backwards The need for forward lean increases as the slope increases e Shorter propulsive strokes are used than on the level both because the wheelchair user is leaning forward and to avoid rolling
53. catch up This is like the reactive balance strategy described in the stationary wheelie skill but the imbalance is intentional e To initiate the dip the wheelchair user can move the head or lean slightly in the direction he she wishes to move Alternatively the wheelchair user can initiate the dip by pushing the wheels slightly in the opposite direction e The wheelchair user should be encouraged to take his her time to achieve control and to move slowly e The wheelchair user should grip the wheels lightly giving a light push on the wheels and letting the hand rims slide through the fingers e Incatching up to the center of gravity after the dip there is no need for the wheelchair user to catch up completely By undershooting slightly the wheelchair user can initiate the next dip e Once on the incline facing downhill the wheelchair user Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 104 should let the hand rims run smoothly through the hands to control the speed direction and the wheelchair pitch angle Letting the hand rims run more quickly through the hands will allow the wheelchair to pitch farther back Slowing the rate at which the hand rims slide through the fingers will cause the wheelchair to pitch forward e The subject should have the casters touch down shortly after the rear wheels reach the level surface
54. ce by pulling on it To completely remove the footrests the wheelchair user may need to first swing the footrest away The wheelchair user should then pull up on the footrest The wheelchair user should pay attention to how the footrest was attached to the chair to simplify restoring it later To replace the footrest the wheelchair user may need to start in the swung out position line up the post or pins with the hole s and put the footrest back in place The wheelchair user should then swing the footrest back to the front Some wheelchairs do not allow the footrests to be swung away or removed but it may be possible to flip the foot plates up The wheelchair user should pull the foot plates up until they are fully vertical To do so on some wheelchairs it may be necessary to push the heel loops if any forward To replace the footrests the wheelchair user should push the foot plates down The wheelchair user should push the heel loops back into place if they were displaced earlier To raise an elevating footrest the wheelchair user should grasp it near the end and lift it to the desired position This requires less force if the leg is not on the leg rest To lower the footrest the wheelchair user should support its weight and hold the position lock open while lowering the footrest The position lock is often located at the top of the leg rest near the knee For a wheelchair user with weak trunk muscles to reach the footrests the
55. ce ceeseecessececesececseneeceeeeceeeeecsteeeeeeeeenaes 8 3 Specific Issues of Importance for Motor Skills Learning eee eseeeseceeeeeeeeeeecsaeesseeeseeeeaees 9 5 Mer Pe Carmi PLO CESS aiene an a a seunsssaades secs sa ovacens ececateiora a 9 Bid DALEY sre alee a eee ele toca eae ates oe le cattle Aaah AE Se E uses 9 3J o OPOE e Sars eaanater pau aw sr conse cates tuba eaavad e E S TEE naen aa OSEE SESE 10 DA Trainers inca sages cages R E E E E A A 10 3 5 Assessment of Wheelchair Skills 205d wes raydutvetieteaatey aed degaevatseseaasansendeeetiaeiaaueuts ae 11 3 6 Set Achievable Goals iscsi scales tenei e ii a EEEE ES E 11 3 7 Individualize the Training Process s ssesesseessseessessseseseesseeessresseesseesseeeesseesssresseesse 11 3 8 Determine Who the Learner s Will Be ccccccesssccceccceesesessececceeececeeeessnseaeeeeecs 13 DO Struct re of Trainin oee a a E E E EE 13 3 10 Tr ning in Pairs Or Groups ore a a G T E Ea 14 3AT Motivationen aa Maeda Re A mein 14 3 12 Demonstrati oise ee E atiae eia tt 14 3 13 Verbal IMstructons scn A E A A ees ant 15 3 14 Foc s OF AMENUOD seeen ea a e a aa ea s nsi 16 a Pe Ima ery na a n e N E at EE 16 3 10 CSCC We mareen a Gna cua E a a e a O R 17 Jlr Feedba E OON Ot A a a aa 17 S18 Taming of Feedback anrnarecnonenean le hod eet ee a Oe E nade 17 3 19 Specificity OF Practice c4icacccint ce den lvecacentates etaeeseqseuss E E AE TE 18 3 20 Amount OF Practice sarees e a EA AE E a EEAS 19 3 2
56. chairs operated by wheelchair users Two Hand Propulsion Method e To make the turn more tightly the wheelchair user should pull back on one wheel while pushing forward on the other In such a case the vertical axis of rotation for the turn is midway between the drive wheels It may take a few cycles to complete the 180 turn e Progression o Begin with small arcs of the hands on the wheels and progress to larger ones o The snap turn is a more advanced version of the turn in place To perform it the wheelchair user positions one hand well forward and the other well Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 65 back Then in a single uninterrupted motion the wheelchair user snaps the wheelchair around letting the hand rims slide through the fingers until the wheelchair reaches the desired angle Depending upon the rolling resistance of the surface the wheelchair may continue to spin in a circle until wheel or hand rim friction brings the wheelchair to a stop e Variations e The skill may be performed in the wheelie position This minimizes the footprint and the corresponding size of the support surface needed even though the above ground space needed i e the turning circle will not diminish to the same extent e When turning around in confined spaces it can be helpful for the wheelchair user to push or pull
57. ckwards to the left followed by a moving turn forward to the right followed by a moving forward to the left will have moved the wheelchair to one side With a front wheel drive wheelchair the starting position will be behind the target position If the space available is limited the subject may need to shuttle the wheelchair forward and backward to get into the desired position moving more to one side with each attempt Progression o Start with ample fore aft room in which to maneuver and gradually decrease the space available o Start with small sideways steps and progress to larger ones o Start at a slow speed focussing on accuracy staying within the designated boundaries Increase the speed within the limits of accuracy Variations o Begin facing the target position at right angles to it rather than parallel to it Training tips for manual wheelchairs operated by Two handed propulsion e As for the general tips above Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 68 wheelchair users e Variations o An alternative for the wheelchair user with good upper body strength and co ordination is to use the bunny hop method To do so the wheelchair user hops to the side by pulling up on the rear wheels and shifting the body weight in the desired direction This is most useful when space is very limited Initially the
58. cult to spot so two spotters are recommended Person with hemiplegia wheelchairs operated by caregivers e As for 7 32 Training tips for manual As for 7 32 wheelchairs operated by caregivers Training tips for powered Not applicable wheelchairs operated by wheelchair users Training tips for powered Not applicable Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 128 7 35 Performs 30s stationary wheelie Versions applicable WST M WCUY WST M CGY WST P WCU X WST P CG X Description e The learner achieves the wheelie position maintains it for 30 seconds and brings the casters back to the floor Rationale e The stationary wheelie position can be used to avoid postural problems that can cause neck strain from looking up or to decrease the likelihood of pressure sores on the ischial tuberosities The stationary wheelie is also a foundation skill for a number of functional skills e g curb descent steep incline descent that can be best performed in the full wheelie position This skill is not applicable for powered wheelchairs because of the difficulty and danger involved General training tips Adjustment tips o The wheelchair type and set up influence the ease with which the wheelchair can be tipped backward into the wheelie position It is easier to achieve wheelie take off in a wheelchair that is les
59. d the wheelchair user should start with the hands near the top centre of the wheel i e 12 00 or 1 00 o clock using the clock analogy The wheelchair user should try not to pause between rolling back and pushing quickly forward otherwise he she may lose momentum and will not tip backwards as easily The method of only rolling the wheels forward is preferred because it can be used while the wheelchair is moving forwards as is often the case but the hands will need to start farther back on the wheels i e 10 11 o clock and more force will be needed by the wheelchair user than for the backward forward method The forward motion that is common to both methods can be thought of as an action to get the base of support the rear wheels under the centre of gravity located near the lap It can be helpful for the wheelchair user to focus on this than on getting the centre of gravity back Some wheelchair users may find it easier if they lean back into the backrest to cause or help with the initial rear tip However skilled wheelie performers can achieve the wheelie position while maintaining an upright or even forward leaning body position Whichever method is used the wheelchair user should try to tip backwards far enough to reach and slightly overshoot the wheelie balance point Once past the balance point the wheelchair user then should pull back on the wheels to prevent tipping too far and return to the balance point If the
60. d make it easier to get them over Progression e Start with low thresholds and progress to higher ones Obstacles of 10cm high or greater are negotiable in the right wheelchair Variations e Leading with the larger diameter wheels may be helpful Training tips for manual wheelchairs operated by wheelchair users See skill 7 29 re the stationary and momentum approaches The only differences from the pot hole skill are as follows e A bit more of everything is needed speed extent of caster pop and extent of forward lean after the rear wheels hit the obstacle Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 117 e The wheelchair user should pop the casters about 10 15cm before reaching the threshold to avoid striking them on the vertical section e Once the rear wheels are on top of the obstacle the wheelchair user should lean back to decrease the likelihood of a forward tip or falling forward out of the wheelchair Backwards Approach e The wheelchair user may find it easier to back over a low obstacle e The wheelchair user should approach the obstacle slowly because a sudden stop can cause a rear tip e As the wheelchair user approaches the obstacle backwards he she may find it easier if he she leans forward to slightly unweight the rear wheels e Using the foot on the floor might give the wheelchair user additio
61. d overuse injuries an improved sense of wellbeing through self esteem self efficacy confidence and personal control the sense of becoming newly abled empowerment and having accomplished something of worth improved development of children and having fun In addition to or instead of learning wheelchair skills there may be alternative ways to accomplish the learner s goals e g by changing wheelchairs by accepting the assistance of a caregiver or by eliminating accessibility barriers Alternatively if the goal is not a feasible one the most Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 7 appropriate strategy may be to assist the learner in adjusting his her expectations to a more realistic level Regardless of whether the wheelchair is a manual or a powered one the characteristics of the wheelchair its features fit and setup can have major effects on skill performance The process of wheelchair provision includes a number of components e g prescription fitting and set up training and follow up These components need not be sequential For instance following training it may be possible to revise the prescription and set up However a thorough discussion of how to optimize the wheelchair for the user goes beyond the scope of this Manual We will focus on the skills training component of the process Even within the skills training co
62. d rim e In wheelie forward one step at a time This is possible if there is an adequate horizontal distance run on each step The run needs to be greater than the radius of the rear wheel to permit this technique The wheelchair user drops down one step at a time like doing a wheelie down a curb pulling back to bring the rear wheels against the step before proceeding to the next step This should be practiced on a single curb first e In wheelie forward continuous method This method is difficult to spot It is only recommended for a short flight of stairs and when no handrails are available The wheelchair user approaches the top step at a comfortable speed and pops the casters just before the casters reach the drop off In this technique the wheelchair user treats Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 143 the stairs like an incline with the rear wheels skimming the edges of the steps If the wheelchair user is going to fall it is best to fall backwards not forwards Learn the method on curbs before attempting it on stairs The trick is in popping the casters enough but not too much Training tips for manual e As for 7 38 but in the reverse direction wheelchairs operated by caregivers Training tips for powered e Not applicable wheelchairs operated by wheelchair users Training tips for powered e Not
63. designed to be reasonably self explanatory and to reflect normal clinical practices 3 5 Assessment of Wheelchair Skills Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 11 As noted earlier evaluation is part of the circle of education Periods of formal evaluation e g using the WST before and after training and at follow up can be useful However predicting future performance on the basis of early attempts is of limited use The trainer should not prejudge the outcome of training Ongoing assessment by the trainer is also important What the trainer can do to facilitate the learning process varies continuously There are a variety of parameters that provide evidence of learning due to practice or experience The WST represents only one intermediate level of assessment Other more detailed parameters include increased speed improved consistency improved adaptability to other settings improved economy of movement and improved ability to detect and self correct errors Instrumented wheels can be used to record additional detail e g force profiles Examples of parameters at a level less detailed than the WST are hours per day of wheelchair use e g using a questionnaire and distance covered per day e g using dataloggers We suggest that a training log be used by the trainer and or learner to track the training process 3 6 Set Achievable Goals F
64. distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 80 7 19 Transfers from wheelchair to bench and back Versions applicable WST M WCUY WST M CGY WST P WCU _ WST P CGY Description e The wheelchair user transfers from the wheelchair to another surface and back again The subject positions the wheelchair removes and restores wheelchair components as necessary to complete the transfer Rationale e A transfer is a commonly used skill to move between the wheelchair and a chair bed tub toilet car or other surface This skill as part of the WSTP should only be considered a representative transfer General training tips There are a number transfer techniques and surfaces to which a wheelchair user may wish to transfer The methods described here are representative but by no means comprehensive Which type of transfer will be most suitable for a wheelchair user and or caregiver will depend on a number of factors An experienced clinician should make this determination A thorough discussion of these options is beyond the scope of the WSP Manual The learner should be careful to avoid catching his her catheter or other collection devices when transferring Adjust the height of the starting and target surfaces to the extent possible such that the target surface is slightly lower Clear the path between the starting and finishing surfaces Get the whee
65. e skills faster than females With respect to age although learning capacity is greater early in life and the young learn motor skills more rapidly and with less practice aged people can acquire new motor skills well Motor learning is affected by client factors e g emotion fatigue Neurological conditions may affect motor skills learning for instance e For people with stroke the post stroke brain has heightened sensitivity to rehabilitation early but this phenomenon declines somewhat with time Rehabilitation training whether early or late improves functional outcomes The extent of improvement is related to the intensity of training Explicit information disrupts skill acquisition even more than usual in people who have had strokes affecting the basal ganglia For people with language impairments it may be helpful to use nonverbal cues and feedback rather than verbal ones e People with Alzheimer s disease can learn and retain new motor skills Implicit learning strategies and demonstration appear to be particularly useful in this setting Consistent practice conditions may work better than variable ones e For people with dementia there is some evidence of superior learning of problem solving tasks with the help of cues errorless learning vs trial and error learning e People with Parkinson s disease can also learn new motor skills but do not retain them as well as people with Alzheimer s disease Rhythmic auditory cues can be he
66. e subject turns the controller on and off Rationale The functions of the powered wheelchair require power General training tips It is important to turn the power off when sitting in the wheelchair doing other activities Otherwise an article of clothing e g the cuff of a sleeve can catch on the joystick and unintentionally drive the wheelchair into a person or object Adjustment tips e A longer lever for the on off switch will reduce the force required e The location of the on off switch can vary greatly and may have an impact on independence e Alternative switches can be used for on off functions e g toggle depression switch auxiliary switch e Alternative locations e g head foot thigh can be used for the on off switch to improve access wheelchairs operated by Training tips for powered wheelchairs operated by wheelchair users Training tips for manual e Not applicable wheelchairs operated by wheelchair users Training tips for manual e Not applicable caregivers The joystick should be in a neutral position before the controller is turned on When the wheelchair is not being used for position changes or mobility the power should be turned off This is for safety reasons and to better maintain the battery charge Turning the controller off while the wheelchair is being operated will bring it to a sudden stop This can be useful when a sudden stop is needed or if the wheelchair begins
67. eelchairs operated by e Positioning i e tilt recline seat height may be useful while wheelchair users preparing the wheelchair for the transfer e The power should generally be turned off while the transfer is being performed e Although not the only consideration if all other factors are equal it will be easier to make a sideways transfer toward the non joystick side e The controller may need to be moved out of the way Training tips for powered e As for powered wheelchairs operated by wheelchair users wheelchairs operated by e If a mechanical lift is being used it can be helpful to put the seat in caregivers the tilted position to assist in ensuring that the wheelchair user is properly positioned in the sling e Ifamechanical lift is being used after the wheelchair user has been lifted sufficiently it may be easier to drive the wheelchair out from under the wheelchair user rather than moving the lift Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 90 7 20 Folds and unfolds wheelchair Versions applicable WST M WCUY WST M CGY WST P WCU X WST P CG X Description The learner folds the unoccupied wheelchair and then unfolds it This includes removal of the rear wheels if they can be removed without tools Note This skill is usually dealt with in combination with the transfer skill while the wheelchair
68. eels are supported at any time the wheelchair will remain upright That being the case an oblique approach to a pothole so that only one wheel is unsupported at a time may be a useful strategy The wheelchair user should keep his her weight away from the unsupported wheel Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 112 Training tips for manual wheelchairs operated by wheelchair users e The risks occur in sequence When the wheelchair user pops the casters from the surface there is the risk of a rear tip If the casters drop into the pot hole there is the risk of a forward tip or fall e Forward Approach Stationary Method The wheelchair user should approach the obstacle and stop with the casters near it This method is comprised of two steps pop and lean They can be verbalized as they are performed as cues The wheelchair user first briefly pops the casters from the floor just high enough to clear the pot hole To do so the wheelchair user can push quickly forward on the hand rims Alternatively the wheelchair user can use his her foot feet to pop the casters While popping the casters at the same time the wheelchair user should roll the wheelchair forward so that the casters land back on the floor beyond the pot hole After the rear wheels drop into the pot hole the wheelchair user should lean forw
69. egiver can provide some of the needed force e g rolling the non rail side wheel up the step while the wheelchair user pulls on the handrail with one or both hands With two caregivers and a wheelchair user who is able to assist one of the caregivers can be positioned uphill and pull on the push handles while the other caregiver is below and wheelchair user functions as described above The wheelchair user or one caregiver should take the lead in coordinating the timing e g to the count of ready set go for each step o Ifthe wheelchair user cannot physically assist much ideally there should be three caregivers available One caregiver positions him herself above pulling on the push handles but not too hard because of the awkward positioning that could injure the back This caregiver is turned slightly to one side with one foot on the stair above the wheel and the Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 141 other on the next higher stair Two caregivers below Each uses the inside hand to hold the frame of the wheelchair not a part that could come off e g footrests The footrests can be removed for easier access to the frame The outside hand is used to roll the wheel up onto the next step It begins at about the 3 00 o clock position and moves up to the 1 00 o clock position Training tips for powered wheelchai
70. elchair users If the wheelchair user has hemiplegia the caregiver can put the weak foot on the other footrest to avoid it getting caught on the Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 98 transition e To push the wheelchair forwards up an incline the caregiver should bend the knees and lean towards the wheelchair The caregiver should not use the knee to apply pressure to the backrest Training tips for powered e A small lip on the edge of an incline may be sufficient to prevent a wheelchairs operated by manual wheelchair from going over the edge but a powered wheelchair users wheelchair can go over such a lip more easily e Most powered wheelchairs can handle 5 degrees with ease at least from the perspective of having enough power to manage the slope Depending upon the wheelchair s characteristics front mid center or rear wheel drive acceleration settings etc and the user characteristics poor trunk control low self effficacy even the 5 degree incline can be challenging e Altering the position of the wheelchair seat i e with respect to tilt recline seat height may be helpful to improve stability or alter the weight distribution on the wheels e g for more traction e The tilt or leg elevation functions can be used to avoid scraping the footrests at the lower incline transition e Progression Begin training with t
71. ep Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 139 At the top of the stairs a stool is helpful as a half way step to the wheelchair seat Out of wheelchair on hands and knees o As for on buttocks above but facing up the stairs and using a crawling action In wheelchair Reposition the rear anti tip devices to allow the rear wheels to approach the first stair and to later permit the wheelchair to tip backwards into the wheelie position The starting position is with the wheelchair user in the wheelchair with the seat belt if any on Back up to the lowest step closest to the handrail on the side of the stronger arm The wheelchair user reachs back as far as he she can with the stronger arm and grabs the handrail with the palm facing up By pulling on the handrail the wheelchair user tilts the wheelchair back past the balance point using the other hand on the same side rear wheel to prevent it from rolling forward The wheelchair user uses the hand on the handrail to pull while using the other hand to roll the rail side wheel up the step Proceed up one stair at a time Progression In describing a set of stairs one refers to the horizontal and vertical dimensions as the run and rise respectively Ideally for training it is useful to have stairs with a variety of runs start big gradual
72. es are encountered frequently in the natural and built environments The 5 1 12 grade meets the current building codes for ramps in North America General training tips e Some of these tips apply to incline descent and to inclines of different degrees e The steeper the incline the greater is the likelihood of problems due to scraping the footrests or anti tip devices at the lower incline level transition loss of traction and tip overs e On inclines if the drive wheels are uphill they become relatively unweighted This can cause loss of traction so that propulsion braking and directional control may become problems If traction is lost to the extent that the wheels spin or the wheelchair begins to slide the wheelchair user should lean toward the affected wheels If this is insufficient then the wheelchair should be turned around so that the drive wheels are downhill It is best to turn around on the level but if that is not possible the wheelchair user should lean uphill during the turn e Edges and drop offs should be avoided to prevent tip over accidents e Momentum can be used to ascend short inclines by approaching at speed but the initial lip needs to be taken into consideration If the wheelchair user strikes the floor ramp transition too quickly he she may tip the wheelchair forward or fall forward out of the wheelchair This can be prevented by popping the casters over the lip e Ifaramp is wide enough the wheelcha
73. f rotation for such a turn is midway between the drive wheels If the drive wheels are farther forward or back the casters will swing more widely so that a series of to and fro motions may be needed to stay within the designated boundaries Training tips for powered wheelchairs operated by caregivers As for powered wheelchairs operated by wheelchair users Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 67 7 14 Maneuvers sideways Versions applicable WST M WCUY WST M CGY WST P WCUY _ WST P CGY Description e The subject maneuvers the wheelchair sideways parallel to an object e g bed or wall The skill is performed towards both the left and right sides Rationale e Positioning oneself in a tight space involves maneuvering of the wheelchair to move the wheelchair closer to or farther away from objects General training tips The user needs to be aware of the widest and longest points of the chair The length can sometimes be minimized through set up e g moving the axles forward Mirrors can be used to provide visual feedback on the size of the chair The trainer may use the analogy of parking a car if the subject has had such experience It may be helpful for the trainer to break the task into segments for instance a moving turn of about 30 degrees backwards to the right followed by a moving turn ba
74. f the skill and rationale for its inclusion will be provided The emphasis is instead on training tips The training tips are based on a number of excellent textbook chapters manuals and on line sources as well as papers from the scientific literature and our own experiences There is considerable variability among wheelchairs both with respect to their components and ways in which they may be modified for individual users The training tips may need to be altered in light of these differences The order of skills discussed reflects that of the Master Table Table 4 For each skill the following headings are used e Versions applicable For which of the four versions of the WSP Table 4 this skill is applicable e Description A brief general description of the skill e Rationale The reason why this skill has been included e Training tips e General training tips that apply to most or all of the subsequent sections e Training tips for manual wheelchairs operated by wheelchair users Wherever appropriate this section includes separate tips for wheelchair users using two hand propulsion and those more appropriate for people using one hand and one leg hemiplegic propulsion recognizing that other methods may also be used by some people e Training tips for manual wheelchairs operated by caregivers e Training tips for powered wheelchairs operated by wheelchair users e Training tips for powered wheelchairs operated by caregivers Ori
75. f the skill or provide attention directing cues as part of the demonstration The trainer should focus on what to do rather than what not to do at least until the learner has had an opportunity to try the skill several times Observation alone can result in learning but has limits if not followed by physical practice Demonstration is most effective for a novel task and less effective when refining a skill When demonstrating a skill the trainer should put equal emphasis on the movement and the outcome effects If there is a right handed and a left handed way of performing the skill it is more helpful if the person demonstrating the skill performs it in the same way that the learner will 3 13 Verbal Instructions Instructions are generally provided before practice as distinct from feedback that is provided afterwards Providing explicit instructions before task practice can be detrimental so instructions should be used with caution Learners have a limited capacity to attend the trainer should not overwhelm the learner with the quantity of information Instructions are more likely to be of help for advanced learners e g instructions regarding anticipation and decision making The length of time between the instructions and actual practice should be minimized As to the content of instructions some general examples follow Speed and accuracy are inversely related If both are desirable the learner will do better to start with accuracy and
76. f wheelchair skills training is long term retention i e months and years For practical purposes successful performance after such brief intervals as 3 days may need to be accepted as evidence of at least short term retention but long term retention is the target The literature on the retention of wheelchair skills is limited but there is evidence to date that skills are retained for periods of a year or more There are conditions within and following a practice session that affect whether training on a new skill will be retained To improve the likelihood of consolidation the trainer and other members Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 20 of the rehabilitation team should avoid the introduction of other new skills during the 4 6 hour period following practice Newly acquired skills may be abolished by subsequent learning of a different skill within four hours retrograde interference especially if the competing task involves the same muscles and movement direction Similarly learning one skill can interfere with the subsequent learning of the second skill antegrade interference The extent of this interference is related to the duration of the earlier task learning Performance saturation during training helps consolidation Ideally the learner should sleep before the next training session Although not always practical a nap of as
77. g because the pre tilted position of having the casters on top of the curb moves more weight to the back of the chair This shift of weight is present until the rear wheels are all the way up on the upper level e In the stationary approach if the wheelchair user has difficulty getting the rear wheels up onto the upper level the wheelchair user should roll the wheelchair backwards until the front wheels are almost off the edge of the level change This has two effects First it reverses the caster trail thereby reducing the extent of rear tip because the caster stems are no longer vertical This provides a greater safety margin between the resting position and the rear tip over threshold so the wheelchair user can push harder without tipping over Second because the rear wheels have been backed slightly away from the edge a small amount of momentum can be used Then the wheelchair user should lean forward and push the rear wheels up onto the upper level The forward Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 120 lean should be timed to coincide with when the rear wheels contact the obstacle A rocking motion may be needed e With the momentum method the wheelchair user should shift his her weight forward as or before the rear wheels hit the lip of the level change to ensure the casters are on the upper surface If this does not happen
78. gardless of method this is a challenging skill There is a risk of injury due to falling or due to straining the arms Stairs should be avoided whenever possible e When providing training proper spotting is important Training tips for manual e There are a variety of methods the choice of which depends upon wheelchairs operated by the characteristics of the wheelchair user e g strength wheelchair users flexibility ability to use the legs and the stairs e Out of wheelchair on buttocks e Position the wheelchair next to the stairs in a way similar to how the wheelchair would be positioned for any transfer Lock the brakes Clear the footrests e The wheelchair user transfers from the wheelchair to the 2 or 3 step usually using a standing pivot or a crouch pivot method The stair handrail may be used e A buttocks protector is a good idea e The wheelchair may be brought up the stairs by the wheelchair user or by an assistant If bringing it himself herself he she should pull the folded wheelchair up by facing it downhill and tipping it back fully The wheelchair user should push straight down with one hand on the wheelchair s push handles to keep the wheelchair from rolling or sliding down the stairs e As the wheelchair user moves up each step he she should flex the neck and hips and push down with the arms and feet to bring the buttocks up and back onto the next higher step Then the hands and feet are moved up to the next st
79. ginally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 37 7 1 Moves controller away and back Versions applicable WST M WCU X WST M CG X WST P WCUY _WST P CGY Description e The subject moves the controller e g joystick away from its usual operating position and then returns it to its original position Rationale e This skill is useful when the controller is in the way for some activities e g approaching a table feeding transfers Some wheelchair users may need to move the controller in order to change the modes or speed General training tips Adjustment tips e When attempting to initiate the move away it is usually necessary to overcome some initial resistance The amount of force needed can sometimes be adjusted e Adding a loop to the controller may allow users with limited hand function to independently move the controller Variations mounts can vary e g midline flip up swing away permanent mounting Training tips for manual e Not applicable wheelchairs operated by wheelchair users Training tips for manual e Not applicable wheelchairs operated by caregivers Training tips for powered wheelchairs operated by wheelchair users The controller should be moved sufficiently out of the way that it would not interfere with approach to a table or to another surface during a transfer When moving the c
80. hat prevent oncoming traffic from seeing you Cross with a standing person or a group so as to be better seen Training tips for manual wheelchairs operated by wheelchair users As for skill 7 8 Training tips for manual wheelchairs operated by caregivers As for skill 7 8 Training tips for powered wheelchairs operated by wheelchair users As for skill 7 8 Adjustment tip It may be necessary to adjust the drive mode and speed of the wheelchair to meet the time requirement Training tips for powered wheelchairs As for powered wheelchairs operated by wheelchair users Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 57 operated by caregivers Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 58 7 10 Rolls backward 5m Versions applicable e WST M WCUY WST M CGY e WST P WCUY WST P CGY Description e The subject moves the wheelchair 5 m backwards on a smooth level surface Rationale e Backward rolling is a skill used during many wheelchair activities General training tips e If backing up immediately follows rolling forward then the casters will be trailing backwards As the backing up begins there may be some initial resistance and directional instability as the casters move into the forward traili
81. he casters are trailing forwards they lie ahead of the portion of the wheelchair frame to which they are attached as is the case when the wheelchair is rolled backwards Adjustment tip o Caster locks can be helpful to keep the caster oriented in the correct direction Training tips for manual wheelchairs operated by caregivers Not applicable Training tips for powered wheelchairs operated by wheelchair users As for general tips If the wheelchair can be repositioned e g with respect to tilt recline or seat height this may be helpful For instance if the wheelchair user s balance is good and his her feet can be placed on the floor the wheelchair user can move to the front of the seat and obtain help in rising from the tilt mechanism Training tips for powered wheelchairs operated by caregivers Not applicable Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 76 7 17 Picks object from floor Versions applicable e WST M WCUY WST M CG X e WST P WCUY WST P CGX Description e The learner picks a small object up from the floor Rationale e Objects that need to be picked up from the floor or ground vary from those as small and light as a coin or a piece of paper to those as bulky and heavy as a young child This skill is not applicable for caregivers because it is not a challenge for most caregivers
82. he casters to return to the floor using a foot on the tipping lever to help slow the landing e In either case after the rear wheels are in the pot hole the casters can be lowered to the surface beyond the pot hole Then the wheelchair user is asked to lean forward and the wheelchair is rolled out of the pot hole e Variations e The backward direction may be easier for the caregiver If this technique is used the rear wheels of the wheelchair can be lowered into the pothole then the wheelchair tipped into a wheelie position to be pulled out of the pothole on the rear wheels Training tips for powered e Positional control e g tilt recline can be used to get the weight over wheelchairs operated by the drive wheels and improve traction wheelchair users e Smooth continuous forward movement is often the most successful method of traversing a pot hole e If the casters are rounded on their sides i e ball shaped they will Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 115 better resist the tendency to get caught sideways or to drop into gaps Training tips for powered wheelchairs operated by caregivers As for powered wheelchairs operated by wheelchair users Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 116 7 30
83. he controller in a low setting but ensure that the programming provides adequate power and torque for success The user may need to change to a different drive mode to accomplish this task Training tips for powered e As for powered wheelchairs operated by wheelchair users wheelchairs operated by e If the space is narrow and the caregiver must operate the caregivers wheelchair from in front the caregiver should be careful not to run over his her own toes e If the wheelchair does not have a headrest and if the wheelchair user is having difficulty maintaining an upright head position while ascending an incline the caregiver can provide support for the head with a hand Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 99 7 24 Descends 5 incline Versions applicable e WST M WCUY WST M CG Y e WST P WCUY WST P CGY Description e The learner gets the wheelchair down a 5 incline Rationale e As for the ascends 5 incline skill 5 23 General training tips e Some similarities to incline ascent see 7 23 above e Smooth straight control down the incline is the basic method e Drive slowly to maintain control e Dangers include wheelchair runaway and if the wheelchair strikes the lower ramp floor transition too quickly the wheelchair user may tip the wheelchair forward or fall forward out of the wheelchair e Vari
84. he door closed behind him her moving the wheelchair quickly through the door and out of the way e The wheelchair user may turn around once through the doorway and reach forward and pull the door towards him her using the other hand to push on the door frame or otherwise back away Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 70 The wheelchair user may go through the door backwards pulling the door with him her The wheelchair user can back up to close the door using the rear wheel to push on the door Reaching over the back of the wheelchair is effective but there is the risk of a rear tip in a manual wheelchair o The learner should not put his her fingers between the door and door frame on the hinged side because they may get pinched when the door closes e Progression o Start with a door that does not close on its own and progress to one that does The trainer can reduce or add resistance to door opening by applying forces through his her hand e Variations o There are many variations in the ways doors open and close alone or in sequence with other doors Also a variety of door handles exist A game that provides opportunities to practice these variations is to have a door scavenger hunt seeing how many different combinations and permutations can be successfully managed in a period of time o For doors that close themselves
85. he floor Rationale A combination of upward and sideways or forward reaching is often needed when reaching for a light switch elevator button or cupboard This skill is not applicable for caregivers because it is not a challenge for most caregivers General training tips Adjustment tip o Chair height and the length of the wheel base have an impact on the wheelchair user s ability to reach objects The wheelchair should be positioned to take advantage of the subject s reach strength and balance Reaching and leaning reduce stability putting the wheelchair user at risk of falling out of the wheelchair or if a manual wheelchair tipping the wheelchair over The learner may use a reaching aid but should carry it with him her To be safer when leaning or bending forwards the wheelchair user can move the footrests out of the way and place the feet on the floor If standing up the wheelchair user should first apply the brakes and clear the footrests out of the way If the wheelchair user stands up on the footrests a forward tip is likely The wheelchair user should keep one hand on the wheelchair to keep from falling For a person with weak trunk muscles to avoid falling in the direction that he she is leaning toward he she should hook the opposite arm behind the push handle or hold onto the armrest or wheel To help right him herself in the chair after reaching for the object the wheelchair user can
86. how to recognize when maintenance or repair are needed how often a battery needs to be charged 5 2 Understanding the dimensions of the wheelchair The dimensions of the occupied wheelchair are important to be familiar with for instance when judging the width of an opening or how much space is needed in which to turn around 5 3 Getting into out of and repositioning oneself with respect to the wheelchair This includes transferring between the wheelchair and various other surfaces unweighting pressure sensitive body parts and changing position in the wheelchair 5 4 Moving the wheelchair around on smooth level surfaces Although the method of propulsion may vary depending upon the impairments of the wheelchair user e g using two hands one hand and one foot or power basic propulsion includes being able to propel the wheelchair forwards and backwards being able to turn in place or while moving and being able to maneuver the wheelchair into position e g to pick something up off the ground getting close enough to a bed to make a transfer or negotiating doors 5 5 Using the environment Although the environment is often a barrier to activities there are times when it can be an asset For example when turning a manual wheelchair around a solid object placing a hand on the object can allow the wheelchair to swing around the object without slowing down rather than the usual approach of slowing down and turning using the hand rims O
87. iding the trunk The caregiver should inquire as to whether the wheelchair user has ever experienced falls and if so in which direction This may help the caregiver to know how best to provide assistance Care should be paid to good back ergonomics for the caregiver Feet shoulder width apart Avoid bending and twisting at the same time The caregiver should bend his her knees and keep the rest of his her body straight to avoid injury to the back Keep the wheelchair user close to the caregiver vs arms straight Get the wheelchair user involved as much as possible Use aids e g transfer belt sliding board and mechanical lift as needed Use two people if help is needed Coordinate your efforts with the wheelchair user and any Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 88 other caregiver e g on the count of 3 The wheelchair user should not hold the caregiver around the neck If the wheelchair user is falling it may be necessary to lower him her to the floor rather than risk injury to the caregiver Standing Pivot and Crouching Pivot Transfers To assist the wheelchair user in getting from sitting to standing the caregiver should stand or sit in front of the wheelchair or stand to one side The caregiver should apply an assisting force to the wheelchair user s body near the h
88. ing e Crouching Transfer e This transfer is like the standing pivot transfer except that the knees and hips are not fully extended e The wheelchair user may need to move the armrest out of the way on the bench side e The wheelchair user may need to remove the brake extension if any on the bench side e The wheelchair user should stay low and not try to stand all the way up However the buttocks need to be high enough to clear any obstacles e g the rear wheel e The hips and the head move in opposite directions e Sideways Transfer e The distance between the wheelchair and the target surface should be less than 3 generally with the wheelchair at an angle of 20 45 degrees from the target surface e People using sideways transfers tend to lead with their weaker or more painful arms However if the Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 82 arms are fairly symmetrical alternating the leading and trailing arms allows them to share the stresses The wheelchair user should move the armrest out of the way on the bench side The wheelchair user should remove the brake extension if any on the bench side The feet should be supported on the footrests if not easily removed or the floor The wheelchair user should move forwards on the seat to avoid such obstacles as the rear wheels To get the transfer board
89. ing toward the learner Rationale e Wheelchair users frequently encounter such hinged doors or gates General training tips Adjustment tips o Having a roller on the outer corner of the footrest can be useful when using them to apply force to a door o For doors in the wheelchair users own environments attaching something e g a handle or piece of rope in the middle of the door can make closing easier If there is a threshold in the doorway the principles for dealing with such an obstacle are dealt with in a separate section 7 30 Judging the width of doorways relative to wheelchair dimensions can require practice Although the footrests can be useful to help push doors open or closed this method should not be used on glass doors that might break Also the feet often extend out beyond the footplates so care needs to be taken to avoid injury to the toes If using the footrests to apply a force to a door it is best to approach the door at a slight angle toward the side that will open This ensures that it is the outer corner of the footrest that contacts the door and not the feet For a door that opens towards the wheelchair the wheelchair user should position the wheelchair to the side of the door to allow room for it to be swung open without striking the wheelchair To close the door after passing through it there are several options if the door does not close by itself e The wheelchair user may gently swing t
90. ips The caregiver should not pull on the wheelchair user s arms The caregiver may use a transfer belt around the wheelchair user s waist The caregiver may need to use his her knees to keep the wheelchair user s knees from buckling by blocking them Once standing the caregiver should ask the wheelchair user to pivot turning the back in the shortest possible route towards the bench Sideways transfers May be necessary to do in steps Transfer into the wheelchair The caregiver may simply reverse whatever procedure was used to get the wheelchair user out of the wheelchair Alternatively the caregiver may move the wheelchair to the other side if this is necessary and if there is room To move the wheelchair away from the bench and reposition it the caregiver may leave the brakes on Using the push handles at the rear of the wheelchair the caregiver should lift the rear wheels slightly off the floor and push or pull the wheelchair on the casters the wheelbarrow method This will save time avoid Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 89 strain on the back and ensure that the brakes are applied when the wheelchair user transfers back into the wheelchair Because the only wheels on the floor are the casters the wheelchair can be moved straight sideways Training tips for powered e See general tips wh
91. ips the wheelchair back to the balance point In this situation learning exercises include i having the wheelchair user experiment with the extent of tip more and less than the ideal balance point where the force to maintain position is minimal ii leaning forward which increases the amount of tip to be at the ideal balance point iii using only two fingers and a thumb of each hand iv sliding the hands backwards and forwards on the hand rims to find the ideal position v holding on with only one hand and vi closing the eyes Once these are mastered at the high rolling resistance level the sequence can be repeated with medium rolling resistance e g gravel or 10cm of foam then low resistance e g tile floor Two balance strategies have been reported the proactive and reactive Proactive balance strategy e In this strategy the wheelchair user keeps the wheels moving forwards and backwards over a small area The wheelchair user should try to move the hands only between the 12 00 and 1 00 o clock positions This will allow a safety margin so that the wheelchair user can react to a loss of balance in either Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 131 direction If the wheelchair user wants the wheels to move farther than the intermediate hand position permits the hand rims can be allowed to slide through the g
92. ir user can cut back and forth across the incline slalom to decrease the apparent slope This may allow the wheelchair user to carry items on his her lap or allow for successful completion when the user is unable to lean forward to prevent tipping Pylons can be set up to provide a path for the wheelchair user to follow e Although a slalom path up a steep incline will reduce the effective slope it will introduce an element of cross slope dealt with later in Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 96 the 7 27 section e Progression o Start with the wheelchair stationary at the lower end of the incline and progress to a moving approach o Start with a minimal incline and proceed to more extreme ones e Variations o Grassy inclines cobblestone or loose rock o Stopping and steering on the incline Training tips for manual wheelchairs operated by wheelchair users e Adjustment tips o A heavy knapsack will reduce rear stability It can be moved to the lap o At the lower transition either ascending or descending the clearance of footrests can create problems o The learner may need to adjust the height of the rear anti tip devices so they do not catch during the transition If they do this can cause rear wheel float whereby the rear wheels are not in contact with the surface and thereby una
93. is an advanced skill The Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 114 wheelchair user can flex the hips keeping the body upright Although leaning back into the backrest will also pop the casters off the ground there is an increased risk of the wheelchair user tipping over backwards and the body will not be well positioned for the forward lean needed during the second half of this skill This variation can be difficult to spot Training tips for manual e The caregiver may proceed in the forward direction using the wheelchairs operated by transient caster pop or full wheelie method caregivers e The caregiver should always let the wheelchair user know before he she tips the wheelchair backwards e To tip the wheelchair backwards the caregiver should use one foot on a tipping lever an extension of the wheelchair frame to which the rear anti tip device may be attached while pulling backwards with the hands on the push handles e For the full wheelie position the caregiver should tip the wheelchair back far enough so that it is balanced over the rear wheels How far back the chair needs to be tipped will vary depending on the wheelchair user and the wheelchair If the wheelchair has elevating footrests it will be easier to tip the wheelchair backward if they are lowered To land after the wheelie the caregiver should slowly allow t
94. is extensive with over 500 English language papers published per year Section 3 is not intended to be a treatise for researchers It is our attempt to synthesize the aspects of this literature that are most relevant to the learning of wheelchair skills We have attempted to express these principles in language that the average educated but not necessarily professional trainer and learner might understand For those seeking a more scholarly and thorough source we suggest Richard A Magill s excellent textbook Motor Learning and Control Concepts and Applications 9 Edition McGraw Hill New York 2011 Although there is a great deal of scientific evidence underlying these principles the principles themselves are fairly simple We strongly believe that trainers and or learners who understand and apply the principles summarized in Section 3 will be more effective than those who do not In addition to the general principles summarized in Section 3 more specific training tips are included with the individual skills later in Section 7 These have been derived from a number of excellent sources in the rehabilitation and wheelchair literature as well as from our own experience Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 9 3 SPECIFIC ISSUES OF IMPORTANCE FOR MOTOR SKILLS LEARNING 3 1 The Learning Process In the course of learning a new motor skill
95. ition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 84 Armrests Adjustment tip If the rear wheel moves with the brake locked the brake may need to be adjusted or the tire may need to be pumped up if it is pneumatic A wheelchair user with weak trunk muscles can avoid falling forward during brake handling by hooking an arm around a push handle or holding onto an armrest or wheel If strength is a limiting factor the wheelchair user may use brake extensions To apply a push to lock brake the wheelchair user grasps the handle of the brake and pushes it towards the front of the wheelchair until firmly in place To apply a pull to lock brake the wheelchair user pulls the handle backward until firmly in place Retractable brakes are ones that can be positioned completely out of the way when they are not in use so the wheelchair user does not scrape his her hands on them during wheelchair propulsion They are most often found on rigid frame ultralight wheelchairs To apply a retractable scissor brake the wheelchair user pulls or pushes the handle in the appropriate direction until firmly in place To release brakes the subject should reverse the action used to apply them For a retractable scissor brake the subject should fold the brake fully out of the way Generally it is easier to reposition the armrests than it is to remove them completely To move the armrests away any of the following options can
96. ivers The caregiver should keep the wheelchair close to his her body The caregiver should avoid starting or stopping suddenly because this may startle the wheelchair user or cause him her to lose trunk balance If there is only one footrest because the wheelchair user uses one arm and one leg to self propel the wheelchair the unsupported foot can be crossed over the supported one Training tips for powered wheelchairs operated by wheelchair users Adjustment tips o For this skill and later moving skills when it is possible to program the wheelchair modes e g with respect to speed torque and deceleration the trainer may wish to use a mode that is safest and most likely to be effective when training begins o When set in the slowest speed there may be a time lag between when a joystick is moved and when the action occurs This can lead to overcorrection while steering the wheelchair This illustrates the importance of proper programming Non proportional drives are just as dependent on proper programming as proportional drives if not more so Set up of non proportional drives can be graded to include more or less cognitive and physical loads depending on the user s needs and abilities This is the first powered wheelchair skill involving movement of the wheelchair in a drive mode With powered wheelchairs although there are a number of input devices that can be used to control the wheelchair we have used the term
97. lchair close to the other surface Ensure the wheelchair brakes are on and the footrests are cleared away if possible Apply the brakes of any other wheeled surface e g bed Transfer Out of Wheelchair e Standing Pivot Transfer e This is one of the most common types of transfer to or from a wheelchair The person stands fully upright from the original surface pivots in place until his her buttocks face the target surface then sits down e Wheelchair users with hemiplegia using standing pivot transfers tend to transfer to their stronger sides e The wheelchair user should angle the chair with its Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 81 near side about 30 from the bench e The wheelchair user should leave the armrests in place e The wheelchair user should try to flex the knees and the feet under the body in preparation for the sit to stand phase of the transfer During the transfer the hips should be flexed e If the wheelchair user is having trouble getting started he she should try to move forward on the seat before beginning the transfer with the feet under the body e To avoid the need for turning through a greater arc than necessary when pivoting the wheelchair user should turn the back towards the bench rather than away from it e The wheelchair user should use the armrest to help maintain balance while transferr
98. lded wheelchair up on the transfer bench gt into vehicle Variations e Remove and replace rear wheels by leaning sideways e g in a doorway or forwards tipping the wheelchair onto the footrests Training tips for manual wheelchairs operated by caregivers e As for manual wheelchair operated by wheelchair users Training tips for powered wheelchairs operated by wheelchair users Training tips for powered wheelchairs operated by caregivers e Not applicable e Not applicable Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 92 7 21 Rolls 100m Versions applicable e WST M WCUY WST M CGY e WST P WCUY WST P CGY Description e The learner moves the wheelchair 100m on a smooth level surface Rationale e The ability to propel for distances of this magnitude allows wheelchair users to get around to a limited extent in the community e g getting from a parking lot an office or getting around inside a store General training tips Training tips for manual wheelchairs operated by wheelchair users As for skill 7 8 rolls forward 10m Progression o Start at a slow speed and increase as tolerated o Start in a smooth level indoor space and progress to the outdoor setting Variations To work on directional control the learner can follow a wall or sidewalk edge while trying to stay within an arm s re
99. learners can sometimes engage explicit conscious and implicit automatic motor control simultaneously without deterioration of control compared to either alone People who have acquired expertise in performing a motor skill have some characteristics in common For instance they have greater awareness of their situations and better ability to anticipate changes in the environment They are better able to exclude intrusions on their attention and to remain focused on the task Their motor performances are less affected by stress and fatigue 3 2 Safety Wheelchair users and caregivers are at risk of acute or chronic injuries for instance due to tip over accidents or poor ergonomic technique The trainer should provide feedback to a learner if the learner uses potentially unsafe methods Indeed if concerned about the possibility of acute injury the trainer should interrupt a skill attempt For many of the skills the rear anti tip devices of a manual wheelchair need to be repositioned or removed While the rear anti tip devices are inactivated the trainer needs to be particularly attentive to the risk of a rear tip over At the end of the session the trainer should restore the rear anti tip devices to their original positions unless the learner has progressed to the stage where they can be abandoned The goal of wheelchair skills training is for the learner to be able to perform skills safely and Originally approved for distribution and use
100. lightly towards him herself so that the rear wheel on the side away from him her is off the ground This eliminates the friction of the far side rear wheel on the ground and allows gravity to Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 91 assist in folding the wheelchair The wheelchair user should then pull the seat or seat rails upwards with one or both hands to fold the chair For a person with hemiplegia to fold the chair the wheelchair user should put the stronger arm under the middle of the seat and lift up For a rigid frame wheelchair with a fold down back although the wheelchair cannot be completely folded the wheelchair user can make the chair easier to transport by folding down the back The subject may need to release any restraining devices before he she can do so e Unfold Wheelchair The wheelchair user should be careful not to tangle the seatbelt under the seat To get the process started the wheelchair user can lift the rear wheels off the ground and separate the push handles The wheelchair user usually needs to push the seat rails back down into the starting position The wheelchair user should keep the fingers on top of the rail to prevent them from being pinched The wheelchair user should remember to put the cushion back on the seat properly before transferring back into the chair Progression put fo
101. ll practice by focusing attention on different aspects of the skill even though performing the entire skill If the skill is to be segmented a progressive approach from start to finish is generally preferred because it eventually becomes whole skill practice However the order in which the segments are practiced is not critical Chunking is less often useful for the elderly Chunking may impair motor skill acquisition if learners could have taken advantage of cues related to an earlier chunk 3 25 Simplification and Progression For many wheelchair skills it is possible to begin with a simpler and less difficult version of the skill Reducing errors during initial practice attempts may encourage a more implicit method of learning The learner can master the simpler task before progressing to the ultimate skill level that is the goal of training For many wheelchair skills the simpler version may be useful itself even if the more difficult levels cannot be learned For instance getting the wheelchair up a 5cm level change is a useful skill and also a step toward getting up a full 15cm curb Another example is to learn the wheelie balance phase in a high rolling resistance setting before progressing to a low rolling resistance one This strategy for learning the stationary wheelie has the advantage of reducing the amount of forward backward movement of the rear wheels needed to maintain balance This reduces attentional demand It also elimina
102. ll up onto the upper level The caregiver should not lift the wheels clear of the surface The caregiver should stand close to the wheelchair but he she should Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 121 not use the knee against the backrest e Variations e For a small level change the caregiver can ascend backwards if preferred If the level change is large enough the caregiver may need to tip the wheelchair into the full wheelie position to avoid tipping the wheelchair user forward out of the wheelchair and pull the wheelchair up onto the upper level The caregiver should step well away from the edge of the level change before lowering the casters The caregiver should not use this technique for a large level change because he she would need to bend forward too far and might injure his her back e Caregiver in front with casters up the curb Shake hands with the wheelchair user and pull him her up the level change The wheelchair user uses his her free hand to push on the hand rim This technique looks more natural than pushing from behind Training tips for powered wheelchairs operated by wheelchair users The user may need to change to a drive mode with higher torque to accomplish this task Positional control i e tilt recline can be used to alter the weight distribution on the wheels Variation e I
103. lpful for them Although less helpful for people with normal brains paying conscious attention to motor tasks can be useful for people with Parkinson s disease Consistent practice conditions may work better than variable ones e People with early Huntington s disease can use either implicit or explicit control well but not in parallel e Medicated patients with schizophrenia may have difficulties with consolidation 3 8 Determine Who the Learner s Will Be A skill that may not be feasible for a wheelchair user to perform alone may be possible with the Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 13 assistance of a bystander or caregiver The training can be directed at the wheelchair user the caregiver or the two functioning together Other types of learners are clinicians or others serving as spotters testers or trainers The relationship between a wheelchair user and a helper whether a regular caregiver or a stranger is important The wheelchair user s needs and preferences should take precedence whenever possible The wheelchair user may need some help in learning how best to ask for help how to direct the nature of any assistance and how to politely decline offers of unwanted help There are ways for caregivers to relate well to wheelchair users For instance the caregiver should seek permission before taking any actions should speak clear
104. ls Early in training the trainer may need to have the learner focus on specific actions or processes e g lean forward if a crucial error has been identified However the research literature has suggested that when most individuals engaged in motor learning tasks concentrate on movements themselves the conscious intervention in the control processes results in poor performance and learning People with Parkinsonism may be an exception to this general rule As the skill becomes more automatic more advanced learners tend to do better if they focus on the overall goal or outcome of the skill performance e g get up the incline onto the platform This phenomenon is better documented in adults than for children Although automatic performance is ideal even experts may find it necessary from time to time to focus attention on aspects of the task that require it 3 15 Imagery There is evidence that imagery or mental practice can be helpful in the acquisition of motor skills Imagery can be assigned as homework Imagery can focus on what the learner would see during the performance of a skill with internal or external perspectives i e seeing through one s own eyes versus seeing oneself as though watching another person Alternatively imagery can focus on what the person might feel e g limb position external forces during a skill performance Most studies have used verbal live or recorded instructions have been performed with
105. ly should address the wheelchair user from the front and at eye level whenever possible and should treat the wheelchair as an item of the wheelchair user s personal property There are some general considerations for caregivers as the targets of training The caregiver should be cautioned to avoid applying excessive force to the wheelchair user and to avoid sudden movements The caregiver should always provide the wheelchair user with cues concerning what he she intends to do before attempting a skill When the caregiver is successfully trained the caregiver can serve as a spotter so the caregiver should be instructed in how to perform in this capacity The caregiver may also serve as a motivator and trainer e g during practice between formal training sessions with the primary trainer A caregiver can assist with powered wheelchairs in ways similar to manual wheelchairs even though the powered wheelchair is heavier and bulkier For instance with a rear wheel drive wheelchair a caregiver can push down on the back of the wheelchair to unweight the casters or to add traction to spinning wheels The caregiver can push forward to assist with overcoming resistance In addition to these general points caregiver issues related to specific skills are dealt with later when those skills are discussed 3 9 Structure of Training The essential elements for learning are only that there be a learner and a task that has yet to be mastered Beyond these ba
106. ly get smaller and rises start small and get gradually bigger Can use a curb first as an example of a single step Variations If the staircase is curved there is more run on the outside of the curve so it will be easier on the outside Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 140 Make sure the rear wheels are square to each step Training tips for manual wheelchairs operated by caregivers Wheelchair user out of the wheelchair The caregiver can assist by merely spotting and or bringing the wheelchair up the stairs For the latter the caregiver proceeds backwards up the stairs with the tipped wheelchair downhill e Variations e Piggy back style e Fire fighter s over the shoulder carry with one strong person e Two man carry either front and back or by creating a seat of their interlocked hands Wheelchair user in the wheelchair The starting position is with the wheelchair user in the wheelchair with the seat belt if any on Back up to the lowest step closest to the handrail on the side of the stronger arm Wheelchair user with the hands on wheels or handrails assisting to the extent possible To ascend tip the wheelchair back and roll not lift the wheelchair up one step at a time If only a single caregiver is available and the wheelchair user is able to assist then the car
107. mething rubbing on a wheel When first attempting to move forward the direction in which any swivel casters are pointing can lead to some initial resistance or lateral deviations The person handling the wheelchair can reposition the casters in the appropriate direction before setting out To do so the wheelchair should be moved short distances in a manner that causes the casters to swivel e g forward then left than backward then right The learner should maintain attention in the direction of travel avoiding distractions to either side but remaining alert to potential hazards Stopping is an important part of this skill It should be possible to stop the wheelchair at will on command and in response to obstacles Progression o Remember that speed and accuracy are inversely related It is advisable to begin movement skills with adequate accuracy before increasing the speed o Stop progressively closer to an obstacle but without touching it Progress from a tall obstacle that can be seen no matter how close the person is to it e g a wall to one that is lost to sight as the user gets closer e g a line on Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 51 the floor Variations o Experiment with different speeds o Experiment with how gradually or rapidly the wheelchair can be brought to a stop Training tips for man
108. mponent there are aspects e g maintenance skills that are outside the scope of this Manual Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 8 2 GENERAL BACKGROUND ON MOTOR SKILLS LEARNING Education can include one or more of three domains knowledge skills and attitudes All three are relevant to wheelchair skills training However in this Manual we will focus primarily on motor skills A motor skill is one that is voluntary observable has been learned and has a goal Motor skills have been classified on the basis of the size of the muscle groups involved gross versus fine on the basis of whether they are discrete tasks or more continuous ones and on the basis of how stable the environment is open versus closed In the context of the WSP there are three components of the education process objectives curriculum and evaluation These are conceptually linked in the circle of education Evaluation provides a baseline and a means of identifying goals and objectives The curriculum is used to accomplish the objectives This is followed by re evaluation to determine if the objectives have been fully met If not the objectives are reviewed and if appropriate the cycle continues The issues presented in Section 3 are based on the extensive motor skills learning literature and on our own experience with the WSP The motor skills literature
109. n faster than it is coasting by using a stroke powerful enough to pop the casters e Once the casters have cleared the pot hole and the rear wheels drop into it the wheelchair user should lean forward and propel the rear wheels to bring the rear wheels over the pot hole e Progression Segmentation Progress through the skill starting with the stationary approach then moving to the momentum method To practice getting the timing correct without the fear of having the casters drop into the pot hole the wheelchair user may practice propelling the wheelchair forward and transiently popping the casters at a predetermined point on the floor The horizontal distance over which the casters need to be off the floor can be gradually increased e Variations The wheelchair user can use a full wheelie for the entire skill or only until the rear wheels are in the pot hole Momentum can be used to carry the rear wheels out of the pot hole but this may be jarring to the wheelchair user If the wheelchair user moves forward more slowly this will allow the rear wheel drop to occur with minimal jarring To get the rear wheels out of the pot hole the wheelchair user should lean forward and power out of it Some rocking may be needed The hands free version of the skill achieving caster lift off by backwards trunk movement is useful because the wheels may be spinning too quickly for the hands to catch up with e g coming down a hill However this
110. n is more difficult on such surfaces and the wheels tend to sink into the surface General training tips e Adjustment tip o The diameter width and shape of the wheels will affect the extent to which they sink into the soft surface e When approaching a section of soft or irregular terrain the wheelchair user should look ahead and plan a route that will minimize difficulties e When moving from a smooth level surface onto a soft surface the wheelchair will decelerate so it is wise to slow down when approaching such a transition e Because rolling resistance is the challenge here reducing the weight on the small wheels casters and increasing the weight on the drive wheels is the focus e When proceeding across a soft or rough surface it is easiest to move forward in a straight line as the casters will be less free to swivel should the user wish to change direction or back up e If one drive wheel is spinning the wheelchair user should shift the weight in the direction of the slipping wheel to increase the traction e For rear wheel drive wheelchairs it may be easier to lead with the larger wheels i e in the backwards direction e Variations o A variety of surfaces e g sand thick carpet foam a gym mat gravel provide similar but not identical experiences o If the surface is too soft to proceed over a mat or other materials can be laid down over it If an assistant is available long distances can be covered by picking
111. n some instances especially with a _rear wheel drive wheelchair it may be easier to ascend the level change in the reverse direction Training tips for powered wheelchairs operated by caregivers As for powered wheelchairs operated by wheelchair users Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 122 7 32 Descends 5cm level change Versions applicable WST M WCUY WST M CGY WST P WCUY _WST P CGY Description The learner gets the wheelchair down a 5cm level change Rationale As for ascends 5cm level change skill 5 31 General training tips On a small level change such as this forward or backwards are both appropriate approaches to take Learning the backwards approach will be helpful when advancing to higher level changes The wheelchair may be able to simply roll forward off the upper level It may be as safe and effective to go off the lip at a moderate or full speed rather than slowly Training tips for manual wheelchairs operated by wheelchair users Two hand propulsion o Variations If the footrests catch on the ground or there is the danger of a forward tip or fall from the wheelchair the wheelchair user can use the backwards approach The wheelchair user should line the rear wheels up with the edge of the level change The wheelchair user should lean as far forward as p
112. n the optimum methods of either performing or teaching most wheelchair skills Nevertheless based on the evidence that does exist we strongly hold two convictions about wheelchair skills training that are the basis for the WSTP First for any motor skill being attempted by a specific person in a specific setting there is a better and worse way of performing the skill Second when learning to perform a motor skill or to perform it better there is a better and worse way to do so The goals of the WSP are to increase the likelihood that a wheelchair user or caregiver who needs and wants to improve his her ability to safely and effectively use a wheelchair will have an opportunity to do so to provide an evidence based means for wheelchair skills training to occur and to provide learning resources to those who wish to use them Wheelchair skills are not only ends in and of themselves they are also means to an end In terms of the World Health Organization s International Classification of Function 2001 wheelchair skills are activities The ability to perform them represents capacity and their use in everyday life represents performance The purpose of these activities is to overcome barriers in the environment and to thereby permit the wheelchair user to fulfill his her desired role in society participation Other potential benefits of wheelchair skills training for wheelchair users and caregivers include fewer acute an
113. nal power to get over the obstacle e The wheelchair user should pull the wheelchair straight backward by applying equal force to both wheels Otherwise the casters may turn and catch sideways on the obstacle e Once the rear wheels are over the low obstacle the wheelchair user should lean back enough to unweight the casters as they reach the obstacle but not so much as to cause a rear tip Variations o To get beyond a pair of bolsters that are too close to wheel between it may be possible to move one wheel or pair of wheels through the gap at a time especially in the wheelie position o Using two hands on one wheel to get one wheel over at a time may be helpful Training tips for manual wheelchairs operated by caregivers e As for 7 29 Training tips for powered wheelchairs operated by Positional control e g tilt recline can be used to alter the weight distribution and traction of the chair Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 118 wheelchair users Smooth continuous forward movement is often the most successful method of traversing the threshold Depending upon the size of the threshold it may be necessary to switch drive modes to have the necessary wheel torque If the powered wheelchair has come to a stop against the threshold as extra force is applied to the threshold the casters may sudde
114. ne Y y x 4 27 Community Rolls 2m across 5 side slope x y 28 Community Rolls 2m on soft surface ad ad ad y 29 Community Gets over 15cm pot hole y y y 30 Community Gets over 2cm threshold y X 31 Community Ascends 5cm level change x s 4 32 Community Descends 5cm level change y y y M 33 Advanced Ascends 15cm curb X X Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 31 34 Advanced Descends 15cm curb X X 35 Advanced Performs 30s stationary wheelie X X 36 Advanced Turns 180 in place in wheelie position X X 37 Advanced Gets from ground into wheelchair x Y 38 Advanced Ascends stairs X X 39 Advanced Descends stairs X X Abbreviations and symbols WC wheelchair WCU wheelchair user CG caregiver Y included X not included Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual Table 5 WSTP M WCU Individual Skills for Manual Wheelchairs Operated by Wheelchair Users Suggested Order of Training Order Individual Skills l Rolls forward 2 Rolls backward 3 Turns in place 4 Turns while moving forward 5 Turns while moving backward 6 Maneuvers sideways 7 Relieves weight from buttocks 8 Picks object fr
115. ng circle that is affected by parts such as footrests that stick out above the ground and the turning footprint that only includes the chair or body parts that touch the ground e For most wheelchairs the ability to turn is made possible by casters Casters are wheels that are free to swivel around a vertical axis The location of the casters front vs back will affect the nature of the turn This skill is a good opportunity for the learner to understand how casters swivel and how to control the extent and direction of the swivel The direction of caster trail can be utilized to ensure a smooth start or to enhance stability e The path of the wheelchair parts e g footrests will differ depending upon the characteristics of the wheelchair i e whether the chair has rear mid center or front wheel drive As a general rule when turning the vertical axis for the turn is midway between the drive wheels so the farther away from this axis that a wheelchair part or body part is the greater the arc through which it will swing e When driving a rear wheel drive wheelchair toward a 90 turn into a narrow pathway the wheelchair user should stay as far as possible away from the wall on which the opening is found With a front wheel drive wheelchair there is less problem steering a path close to the wall e When turning around an object e g a corner wall that the wheelchair is close to the turn should not begin until the axles of the d
116. ng position The casters can easily be repositioned by moving them in a circular path e The learner should proceed slowly and look over the shoulder to avoid obstacles and collisions e Slowing down will also make it easier for the subject to steer Directional stability is more difficult to maintain when backing up a rear wheel drive wheelchair This may lead to a sinuous path with a series of deviations and over corrections Training tips for manual e Two Hand Propulsion Pattern wheelchairs operated by e To propel the wheelchair straight backward the wheelchair user wheelchair users should grasp the hand rims and pull evenly e Unlike forward rolling it is not easy to coast backwards without deviating to one side or the other Therefore the length of the strokes is usually shorter when rolling backward e To avoid tipping over backwards when stopping the wheelchair user should avoid grabbing the wheels suddenly and should lean forward slightly e Variations o One hand at a time gt both hands o Fora person with weak arm muscles the wheelchair user can place both hands on the backs of the wheels about 11 00 o clock using the clock analogy with the arms straight and the shoulders shrugged Then the wheelchair user can use the body weight to push down on the wheels e A Person with Hemiplegia e As for rolling forward 7 8 except the sequence is to first flex the leg push down on the floor with the foot enough to en
117. ng tips for powered wheelchairs operated by wheelchair users If the wheelchair can be repositioned e g with respect to tilt recline or seat height this may be helpful There is a danger of unintentionally rolling the drive wheel over the fingers or pinching the fingers between the drive wheel and fender The safest approach is to first position the wheelchair shut off the Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual power then pick up the object Training tips for powered wheelchairs operated by caregivers As for manual wheelchairs operated by caregivers Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 78 7 18 Relieves weight from buttocks Versions applicable WST M WCUY WST M CG X WST P WCUY WST P CG X Description e The learner relieves weight from both buttocks although not necessarily at the same time Rationale e Pressure relief is important for the prevention of pressure sores Ideally pressure relief should be performed often and for prolonged periods of time General training tips It is generally suggested that a wheelchair user relieve pressure from the buttocks every 15 20 minutes and for prolonged periods i e at least 2 minutes However many wheelchair users have remained free
118. ning back and grabbing both hand wheelchairs operated by rims firmly and swerves leaning toward the direction of turn wheelchair users and grabbing one hand rim firmly Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 94 Training tips for manual wheelchairs operated by caregivers Adjustment tip secure push handles are important for this skill and the similar skill of stopping part way down a steep grade Sudden changes in speed or direction can cause the wheelchair occupant to fall forward or to the side The caregiver should use good spotting techniques reaching forward or to the side with a hand to stabilize the wheelchair occupant Training tips for powered wheelchairs operated by wheelchair users Adjusting the deceleration settings at top speeds is important for this skill However the higher the deceleration distance the more planning is required to avoid the obstacle Training tips for powered wheelchairs operated by caregivers As for powered wheelchairs operated by wheelchair users Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 95 7 23 Ascends 5 incline Versions applicable e WST M WCUY WST M CGY e WST P WCUY WST P CGY Description e The learner moves the wheelchair up a 5 incline Rationale e Inclin
119. nly pop up The wheelchair user should not apply any more force than is needed and should reduce the force applied to the joystick as soon as possible Training tips for powered wheelchairs operated by caregivers As for powered wheelchairs operated by wheelchair users Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 119 7 31 Ascends 5cm level change Versions applicable WST M WCUY WST M CGY WST P WCUY _WST P CGY Description The learner gets the wheelchair up a 5cm level change Rationale General training tips Level changes e g curbs steps are common obstacles in the natural and man made environments As for the threshold skill the footrests anti tip devices and clearance between the wheels may affect the ability to negotiate level changes This skill is similar to and builds on the previous ones specifically the soft surface pot hole and threshold skills To ascend or descend level changes it may be necessary to reposition or remove the rear anti tip devices Progression o Start with a minimal level change and progress to higher ones Training tips for manual wheelchairs operated by wheelchair users Two hand propulsion e This skill is similar to the pot hole and threshold skills in that it can be approached with stationary and momentum methods e Itis slightly more challengin
120. o more often than Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 18 after every second attempt The trainer should let the learner know that the absence of feedback means that the performance was adequate for the current stage of learning This gives the learner an opportunity to problem solve on his her own It also decreases repetitive feedback statements especially in the case of more advanced skills when it can take time for the learner to overcome a problem A common error is for the trainer to spend too much time talking and not enough time having the learner practice The feedback schedule is especially important for wheelchair users who have cognitive or behavioral impairments A self controlled feedback schedule i e letting the learner ask for feedback is generally preferable The trainer should gradually reduce the frequency of feedback statements as time goes on The weaning of the feedback schedule may need to be more gradual for children As the fading process leads to less and less frequent feedback the trainer should summarize a series of attempts rather than focusing only on the most recent attempt This technique can also be used when working with a group providing feedback that deals with a problem several of the group members are encountering Trainers should be aware of the principles of behavior modification which have similarities to the
121. om floor 9 Reaches high object 10 Transfers 11 Folds and unfolds wheelchair 12 Doors 13 Rolls 100m 14 Avoids moving obstacles 15 Inclines 16 _ Side slope 17 Soft surface 18 Pot holes 19 Threshold 20 5cm level change 21 15cm curb ascent and backwards descent 22 Stationary wheelie 23 Wheelie turns in place 24 Wheelie forward back 25 Wheelie moving turns forward back variation no hands rest 26 Wheelie on soft surface forward 27 Wheelie incline descent 28 Wheelie curb descent 29 Gets from ground into wheelchair including falls 30 Descends stairs 31 Ascends stairs Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 33 Table 6 WSTP M CG Individual Skills for Manual Wheelchairs Operated by Caregivers Suggested Order of Training Individual Skills 1 Controls tilt function 2 Controls recline function 3 Rolls forward 4 Rolls backward 5 Turns in place 6 Turns while moving forward 7 Turns while moving backward 8 Maneuvers sideways 9 Transfers 10 Folds and unfolds wheelchair 11 Doors 12 Rolls 100m 13 Avoids moving obstacles 14 Inclines 15 Side slope 16 Soft surface 17 Pot holes 18 Threshold 19 5cm level
122. on an initial goal so that the learner goes away with at least one skill to practice before the next session E Closing 2 minutes e Describe the nature of subsequent sessions e Schedule the next session e Assign homework e Answer any questions that the learner may have e Provide strong encouragement F Documentation 1 minute e Complete any final documentation of the session Times are rough guidelines only Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 25 4 2 Subsequent Sessions 25 minutes A Welcome 2 minutes e Check status Any new health concerns since the last session Any after effects from the last session Any practice since the last session e Review the goals and planned activities for the current session e Questions and answers B Practice skills that have already been acquired but that need work 10 minutes e Random order but begin with less stressful ones until the learner is warmed up e Variety of settings e Trainer role provide structure safety minimal feedback e This portion of the session can also serve to provide conditioning if the sessions are scheduled often enough to serve in that capacity i e at least 3 times a week e Games can be a fun way to carry out this stage of the session C Practice a skill that has not been acquired yet 10 minutes e Trainer role provide structure safety instruction
123. on of the specific wheelchair used by the learner The trainer may be a rehabilitation clinician e g an occupational therapist or physical therapist who is regularly involved in wheelchair prescription and training or someone specifically trained for the purpose Because practice outside formal training sessions can be useful members of the rehabilitation team e g members of the nursing profession personal care workers recreation therapists volunteers physicians other than the primary trainer can be of assistance Good team communication among team members about a learner s progress can help to ensure that the input from multiple team members is complementary rather than conflicting Both experts and non experts can play important roles in the training process Wheelchair using or caregiver peers may possess or be able to acquire the necessary knowledge skills and attitudes to function as trainers The trainer should be as familiar as possible with relevant elements of the WSTP including the general principles and the specific elements The trainer should feel free to refer to the WSTP Manual whenever necessary Those interested in becoming WSTP trainers should study the WSTP Manual and related materials and observe how a skilled trainer performs Ideally the WSTP should only be used by trainers who have been trained in its administration However good results should be possible by careful attention to the WSTP Manual because it has been
124. ontroller out of the way it should not be placed in a position that would make it impossible for that wheelchair user to restore it to its original position Many units have scissor like mechanisms that can pinch fingers or clothing Progression o The power should be turned off while this skill is initially being practiced o Start with moving the controller away then moving the Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 38 controller back o Then use the skill functionally such as moving the controller out of the way to allow closer approach to a table e Variations o If the wheelchair user has poor hand control he she can use a large gross motor movement to move the controller Using the side of the arm or hand along with shoulder movement may allow the controller to be moved independently o The powered wheelchair can be slowly driven against a fixed external object e g a desk top to help push the controller out of the way Training tips for e As for powered wheelchairs operated by wheelchair users powered wheelchairs operated by caregivers Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 39 7 2 Turns controller on and off Versions applicable WST M WCU X WST M CG X WST P WCUY _WST P CGY Description Th
125. operated by wheelchair users Altering the position of the wheelchair seat i e with respect to tilt recline seat height may be helpful to improve stability alter the weight distribution on the wheels e g for more traction or ensure footrest clearance at the lower transition Begin training with the controller in a low setting In a powered wheelchair unlike a two hand propelled manual one only one hand is needed to control speed and direction The other arm can be hooked around the backrest or push handle to prevent falling forward onto the lap Training tips for powered e wheelchairs operated by e caregivers As for powered wheelchairs operated by wheelchair users If the space is narrow and the caregiver must operate the wheelchair from in front the caregiver should be careful not to run over his her own toes Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 102 7 25 Ascends 10 incline Versions applicable e WST M WCUY WST M CGY e WST P WCUY WST P CGY Description e The learner gets the wheelchair up a 10 incline Rationale e Inclines with slopes greater than the standard recommended value are encountered frequently in the natural and built environments General training tips e As for skill 7 23 Training tips for manual e As for skill 7 23 wheelchairs operated by wheelchair users Training tips f
126. or manual e As for skill 7 23 wheelchairs operated by caregivers Training tips for powered e As for skill 7 23 wheelchairs operated by wheelchair users Training tips for powered e As for skill 7 23 wheelchairs operated by caregivers Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 103 7 26 Descends 10 incline Versions applicable e WST M WCUY WST M CG Y e WST P WCUY WST P CGY Description e The learner gets the wheelchair down a 10 incline Rationale e As for the ascends 10 incline skill 7 25 e The appropriate technique for a steep incline often differs from that used for a lesser slope e g descending a moderate or steep incline in the forward wheelie position has a number of benefits General training tips e As for skill 7 24 Training tips for manual e As for skill 7 24 wheelchairs operated by wheelchair users e Wheelie Descent e This is the preferred method for the descent of a steep incline e Achieve the wheelie position on the level at the top of the incline as described in section 7 35 e Then move forward onto the incline To move forward on the level above the incline in the wheelie position the wheelchair user should allow the wheelchair to begin to fall dip slightly in the direction in which he she wishes to move and then roll the rear wheels in the same direction to
127. ossible chest on lap and reach forward on the hand rims The wheelchair user should move backwards very slowly and let the rear wheels roll evenly down off the upper level under control Resisting the descent will reduce the impact shock Once the rear wheels are on the lower level the wheelchair user can sit more upright if this is possible without tipping over backwards If necessary the wheelchair user can turn to the left or the right to get the casters off the upper level without scraping the footrests by the time the second caster rolls off the edge the footrests are beyond the edge Alternatively the wheelchair user can use the full wheelie position to move away from the curb Full wheelie method see 7 34 Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 123 Person with hemiplegia e Reverse of 7 31 Training tips for manual wheelchairs operated by caregivers The caregiver should not attempt to descend the level change backwards with the wheelchair in the wheelie position because at greater heights this causes severe jarring of the wheelchair and its occupant To descend a level change the caregiver may alternatively do this in the forward direction The caregiver should slowly push the wheelchair off the upper level allowing the casters to gently land on the lower level followed by the rear wheels It is dangero
128. ot be seen stay to the right if that is the convention in the country in which the training is taking place and do not cut the corner Training tips for manual wheelchairs operated by wheelchair users Two Hand Propulsion Method e When ready to turn the wheelchair user should slow down the inside wheel and or push harder on the outside wheel e Variations e While coasting in a straight line experiment with the effect that rotating the outstretched arms from side to side has on direction swinging the arms Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 61 WSTP 4 1 Manual to one side causes the wheelchair to turn in the other side e The fixed environment can be used to assist with turning In the drag turn the wheelchair user drags a hand in a rear position along the wall to turn toward the wall and around a corner In the push off turn the wheelchair user uses a hand in a forward position to push away from the wall Timing intensity direction and hand position of the forces applied to the wall are important features of success Using the environment minimizes the need to slow down e The skill may be performed in the wheelie position A Person with Hemiplegia e The wheelchair user should use the foot to help steer e It is easier to turn away from the sound side than toward it Training tips for manual
129. other model for learners living in the community is to hold periodic group training courses e g for 1 2 hours weekly for several weeks Another alternative is a skill camp e g all day for 1 5 days in a central location or on a circuit basis The single training session format is commonly used for workshops when training trainers However the use of such an approach can cause even highly motivated learners to lose focus and become fatigued In addition to such problems this approach may lead to poor retention and consolidation Each of these models has advantages and disadvantages The research literature suggests that for the types of skills that wheelchair users and caregivers need it is generally less effective to carry out a large amount of training in a condensed manner than it is to spread the training out over a longer period that permits rest and consolidation of what has been learned However too much time between practice sessions can allow the learning to decay if the skill has not yet been acquired and consolidated Beyond this there is little research evidence to suggest that one of the models noted above is vastly superior to another so the choice of model s can be based on local considerations Whenever feasible we recommend that wheelchair skills training be spread over a series of brief sessions instead of one long one Brief practice periods are less likely to conflict with other therapy sessions or to fatigue the le
130. oved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 47 7 6 Disengages and engages motors Versions applicable WST M WCU X WST M CG X WST P WCUY _WST P CGY Description The learner disengages and engages the motors Rationale General training tips Disengaging the motors allows the wheelchair to be pushed manually without power e g by a caregiver if the battery is dead The power should be turned off before the motors are disengaged The wheelchair may be harder to push if the power is on even if the motors are disengaged For most powered wheelchairs there are two motors that need to be separately disengaged and engaged Ensure that the lever is being moved along the appropriate plane Depending on the type of chair rolling the chair slightly when disengaging the motors may ease the lever into the disengaged position Some chairs will be more difficult than others to push when disengaged Variations Various makes and models have different methods of disengaging the motors wheelchairs operated by caregivers Training tips for manual e Not applicable wheelchairs operated by wheelchair users Training tips for manual e Not applicable Training tips for powered wheelchairs operated by wheelchair users The wheelchair user may transfer out of the wheelchair onto the transfer surface to allow him her to perform this
131. owards one side can also affect the lateral stability of the wheelchair Also if one wheel is spinning due to a lack of traction this can often be corrected by leaning toward the spinning wheel 5 7 Skills that require popping the front wheels briefly off the surface As a natural extension of 5 6 there are some obstacles that require that the smaller usually front wheels clear the obstacle These skills are most appropriate for manual wheelchairs Examples include negotiating gravel potholes vertical obstacles e g door thresholds and getting up level changes e g curbs 5 8 Skills for which balancing on the rear wheels is necessary The full wheelie position balancing on the rear wheels can be used to deal with situations like those described in sections 5 6 and 5 7 that require the front wheels to be unweighted However there are some desirable skills that cannot be carried out without the ability to keep the front wheels off the surface These skills include the stationary wheelie e g to reduce sitting pressures and improve neck comfort turning around in a tight space the forward descent of steep inclines and the forward descent of large level changes e g a 15cm curb These skills require the ability to perform a stationary wheelie to turn around in the wheelie position and to move forward or backwards in the wheelie position These skills are impossible in most powered wheelchairs 5 9 Working with a helper Most wheelchai
132. pull on the opposite armrest or wheel If the armrest on the side to which the wheelchair user wishes to reach is moved out of the way it allows the wheelchair user to bend further sideways The wheelchair user needs to exercise caution when reaching across the body especially when reaching for or picking up something e g a heavy object on a high shelf hot coffee a knife that could injure the user if it were spilled or dropped onto the lap Also bending and twisting at the same time Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 75 can cause back injury Variations o Ifthe wheelchair user is reaching for an unbreakable object from a high shelf he she can use an improvised reaching aid e g a rolled up magazine or a cane to help to move the object off the shelf and catch it In a store when an object is out of reach an object e g a cereal box on a lower shelf can be used to ease the desired object off the shelf so it can be caught Training tips for manual wheelchairs operated by wheelchair users It is sometimes easier to approach the target backwards but the wheelchair user needs to be careful not to reach too far and tip the wheelchair over If the wheelchair user chooses to lean forward to accomplish the task he she should make sure the casters are trailing forward to decrease the likelihood of tipping forwards When t
133. r can use the hands or forearms to prevent the knees from striking the face e Forward falls the wheelchair user should twist to one side and try to roll sideways after striking the ground protecting the head with the hands e Sideways falls the wheelchair user should lean away from the direction of tip pulling vigorously on the uphill armrest e Out of wheelchair approach for getting up from the ground e Right the wheelchair lock the brakes and transfer back into it from the front e Ifthe wheelchair user is sitting in front of the chair then he she can reach back to the frame to pull himself herself back onto the seat e Ifthe person sits beside the wheelchair with the wheel locks off Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 135 he she can put one hand on top of the cushion and the other on the floor Then lifting the buttocks off the floor he she can pull the wheelchair under the buttocks e Many step approach Floor to foot stool to bench to wheelchair seat Reduce the number of steps with progression e One can use the seat cushion to increase the height of the floor and to lower the height of the wheelchair seat e One can approach from a 90 deg angle or straight in front of the wheelchair Flex the hips and knees fully before starting Can do in 2 steps lifting the buttocks onto the footrests first e Can
134. r due to fatigue or frustration it is probably wise to take a break For simple tasks continued practice may cause performance to diminish The literature on wheelchair skills training suggests that substantial improvements can be made on a group of skills with as little as 2 3 hours of formal training spread over several sessions but that the target for the clinical setting should probably be higher e g 10 12 hours if the situation allows There is no strong evidence as yet regarding the optimum dose of wheelchair skills training Although it is not necessary to be an expert to perform a skill in a safe and useful manner to achieve true expertise at a skill as a professional athlete musician or an assembly line worker may exhibit may require several hours per day of deliberate practice for periods of 10 or more years There is some evidence to support that millions of repetitions and 10 000 hours of practice may be required for true expertise Intervals of weeks or months between training are not barriers to learning As little as 6 minutes once a month has been shown to be effective Self control of the amount of practice and of the practice schedule has been shown to be superior 3 21 Facilitate Retention Although a learner may be able to acquire a skill during a practice session it is not uncommon for the learner to fail to perform the skill adequately at the next session This is a failure of skill retention The objective o
135. r users have at least some skills that they cannot safely perform themselves or that they find stressful In such situations the wheelchair user can benefit from the assistance of a helper Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 28 This may be in the form of minimal assistance e g someone standing nearby to respond to a tip the caregiver doing the task completely e g ascending a curb or the caregiver working in combination with the wheelchair user The helper may be a regular one e g friend or family member or a passerby who can be recruited to help under the wheelchair user s direction Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 29 6 0 TABLES OF INDIVIDUAL SKILLS In this section tables are shown of the skills included in each of the four versions of the WSP based on whether the learner is a wheelchair user or a caregiver and whether the wheelchair is manual or powered Following Table 4 the Master list are tables reflecting a suggested order of training for each of the four circumstances These can be modified to reflect local settings In addition to these core sets of skills many other skills exist but these are beyond the scope of this Manual Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49
136. rip It may be helpful to time the movement of the rear wheels to the breathing pattern because breathing has a subtle effect on wheelchair stability e Reactive balance strategy e If the wheelchair user begins to tip too far forward he she should roll the rear wheels forward to return to the balance point when you fall forward push forward The worst that can happen in this direction is that the wheelchair lands prematurely If the wheelchair user imbalances backwards he she should roll the rear wheels backwards to re establish balance when you fall back pull back Even if past the point of no return the preferred strategy to minimize injury due to striking the back of the head on the ground is for the wheelchair user to pull back hard on the rear wheels and flex the neck until the back hits the ground Falls will be practiced later under skill 7 31 e Landing Phase e Toland the wheelchair user pulls back on the wheels or leans forward to gently bring the front wheels to the ground e The description above can be summarized in the form of criterion referenced steps Step 1 Review relevant earlier wheelchair control work pushing on level hand position letting hand rims slide through fingers Step 2 Transient tip forward only push as used for the soft surface pot hole threshold and level change ascent skills Step 3 Self save pull back on hand rims lean forward from a trainer induced
137. risk of being injured Training tips for manual wheelchairs operated by wheelchair users Not applicable Training tips for manual wheelchairs operated by caregivers When first tilting a chair the caregiver should be aware of the force that may be required to catch the person The set up and mechanics of the tilt influence the amount of weight supported by the caregiver Training tips for Training tips for powered wheelchairs operated by wheelchair users Training tips for powered wheelchairs operated by caregivers As for general tips As for powered wheelchairs operated by wheelchair users Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 45 7 5 Controls recline function Versions applicable e WST M WCU X WST M CGY e WST P WCUY WST P CGY Description e The subject reclines the wheelchair from the upright position and then restores the wheelchair to the upright position Recline occurs when the seat to back angle increases as the back of the seating system moves away from the seat Rationale e Wheelchairs capable of variable recline are used for a variety of reasons including pressure relief comfort to enhance breathing postural control stability e g to prevent falling forward from the wheelchair when striking an obstacle to enhance transfers facilitate bladder management reduce spastici
138. rive wheels whether rear mid or front have reached the object e If the leading wheels are the drive wheels the trailing Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual castered wheels will swing wide of the path and may strike the wall on the far side The user should be especially careful not to catch the feet on an immovable external object if the foot stops and the chair continues to turn a serious injury can result The footrests can be moved out of the way in tight spaces to reduce the radius of the turning circle Progression o Start with small changes of direction e g around widely spaced pylons and progress to more closely spaced ones o Start with loose large radius turns and progress to tight small radius ones o When beginning training around full 90 corners learners may find it easier to break a turn down into its parts driving straight turning then driving straight again rather than following a smooth curved path Variations o To swivel the casters 180 in a tight space requires that a combination of forward backward and left right forces be applied to the casters As an exercise the trainer can ask the learner to point the casters at targets o When using this skill in real settings the learner should obey the rules of the road at corners slow down if the path around the corner cann
139. rning principles generally apply almost equally well to elite athletes and to those who have severe disabilities However there is usually benefit to tailoring the training process to the learner Learning style preferences exist and should be respected whenever possible Training can sometimes take the form of a problem solving exercise attempting to answer the question For this learner with this wheelchair in this context what would be the safest and most effective way to perform this task Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 12 Inability to perform a skill may be due to a variety of limiting factors alone or in combination Limiting factors may be intrinsic e g impairments such as cognitive limitations weakness pain shortness of breath limited range of motion spasticity poor coordination or movement disorders or extrinsic e g a faulty wheelchair part poor seating support or poor lighting The trainer should attempt to identify limiting factors and seek to have any remediable limiting factors addressed Motor skills learning can be affected by personal characteristics such as sex age and health conditions A trainer who understands these differences will be able to reassure learners who might be progressing more slowly than others The training process may need to be adapted to the individual With respect to sex males learn som
140. rom the baseline WST assessment questionnaire and or objective versions skills may be identified that are not performed as safely and or as effectively as they might be For each of these identified skills a decision needs to be made about whether improvement in the skill is a goal of the learner Goal pursuit and performance are related to the learner s beliefs about him herself and the task self efficacy The learner may need some help in coming to this decision because he she may not initially recognize the functional benefits of acquiring a new skill Additionally a decision needs to be made as to whether it is feasible for the person to learn this skill This is a judgement call and requires a good understanding of the learner s health and circumstances Ifin doubt we recommend that the person be given an opportunity to learn the skill If progress is not being made a learner can decide to abandon that skill The trainer can assist the learner in coming to this decision Involving the learner in the goal setting process can have a positive effect on motivation However the trainer has the right to refuse to provide training on any skill that he she does not believe to be safe and feasible The goals should be monitored and may be revised as training progresses The goals may be formalized in a Goal Attainment Scale see WST Manual that can be used to track progress and quantify outcomes 3 7 Individualize the Training Process Motor lea
141. roved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 64 7 13 Turns 180 in place Versions applicable WST M WCUY WST M CGY WST P WCUY WST P CG Y Description The learner turns the wheelchair around to face in the opposite direction while remaining within a square space with 1 5 meter sides This is done towards the left and the right Rationale Turning around in tight spaces is a common challenge for wheelchair users General training tips It may be helpful for the learner to shuttle forwards and backwards to stay inside the designated space turning part of the way with each cycle The longer the chair the more likely it is that this will be necessary The footrests for most wheelchairs increase the overall length of the wheelchairs so a larger turning circle is required Removing one or both footrests may make it easier to turn around in close quarters If only one footrest is removed the unsupported foot can be crossed over the supported one If both footrests are removed it is important to avoid injuring the feet by bumping them or running over them with a wheel Progression o Start with small angular changes of the wheelchair and progress to larger ones o Start at a slow speed focussing on accuracy staying within the designated boundaries Increase the speed within the limits of accuracy Training tips for manual wheel
142. rs operated by wheelchair users As for 7 31 in many respects See general tips Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 124 Training tips for powered e As for powered wheelchairs operated by wheelchair users wheelchairs operated by caregivers Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 125 7 33 Ascends 15cm curb Versions applicable WST M WCUY WST M CGY WST P WCU X WST P CG X Description The learner ascends a 15cm curb in the wheelchair Rationale As for ascends 5cm level change skill 5 31 This skill is not generally applicable for powered wheelchairs because of the difficulty and danger involved General training tips As for 7 31 The risks of tipping occur in sequence A rear tip may occur when the casters are popped from the surface A forward tip or fall can occur if the casters strike the curb A sideways tip can occur if one wheel ascends the curb but the other does not Progression o Begin with the stationary method and a small level change then gradually increase the height of the level change until it becomes difficult Then change to the momentum with a small level change and gradually increase the height Training tips for manual wheelchairs operated by wheelchair
143. rs operated by wheelchair users e Not generally applicable Training tips for powered wheelchairs operated by caregivers e Not generally applicable Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 142 7 39 Descends stairs Versions applicable WST M WCUY WST M CGY WST P WCU X WST P CG X Description The wheelchair user and the wheelchair get from the top to the bottom of a set of stairs Rationale As for ascends stairs skill 7 38 General training tips As for 7 38 but in the reverse direction Although there is still a potential for injury due to a fall descent is much less strenuous than ascent Many wheelchair users who cannot ascend stairs independently can descend them Training tips for manual wheelchairs operated by wheelchair users Out of the wheelchair on the buttocks or on hands and knees e Reverse of ascent procedure 7 38 In the wheelchair e The safest method is facing up the stairs The wheelchair user grabs one or both rails with both hands leans well forward lowers the rear wheels down one stair then slides the hands down the rail The trainer should alert the wheelchair user that this method can be noisy as the casters and or footplates bang down each stair e Variations e Backwards as above but using one hand with the other hand on the non rail side han
144. rward Transfer e When transferring straight on e g for a person with amputations of both legs the wheelchair user should pull the wheelchair as close as possible to the transfer bench e A transfer board may be used e Transfer Into Wheelchair eGeneral e This is the same as the transfer out of wheelchair except as noted below e Once the wheelchair user is back in the wheelchair the subject should restore the footrests fully and put the feet back on them e The wheelchair user should make sure that removed or repositioned wheelchair parts e g armrests footrests cushion seat belt are in the same position that they were before he she left the wheelchair e Wheelchair users who have used the forward transfer method to transfer out of the wheelchair may be able to enter the wheelchair in the forward direction and then turn around if they have short enough amputation stumps Persons with Hemiplegia e If the wheelchair user must transfer back into the wheelchair with the strong side leading he she will need to move the wheelchair to the other side e Progression e Once the basic transfer is mastered it should be practiced with different target surfaces at different relative heights Training tips for manual wheelchairs operated by wheelchair users Brakes e Prior to the actual transfer the subject should apply the brakes if any Originally approved for distribution and use March 14 2008 Current ed
145. ry to avoid bending and twisting at the same time and should lift with bent knees e Iftipping the wheelchair upright from the fully rear tipped position locking the brakes will prevent the wheelchair from rolling forward e A single caregiver may have difficulty in performing this skill without the help of the wheelchair user and or a second caregiver A mechanical lift or a team of people are recommended when lifting from the floor Without a mechanical lift maintaining proper ergonomics is challenging e Ifthe caregiver is large and strong and the wheelchair user is light the caregiver may be able to safely lift the wheelchair user with one arm around the back and under the arms and one under the bent knees e If there are two caregivers they may pick up the wheelchair user together This can be done in two ways o One option is to have one caregiver behind the wheelchair user holding the wheelchair user s arms by reaching under the upper arms and grasping the folded forearms The other caregiver lifts with his her hands behind the wheelchair user s knees o The other option is for the two caregivers to be on opposite sides of the wheelchair user each with one arm under one of the wheelchair user s arms and around the back and the other arm under the wheelchair user s bent knees e If a third caregiver is available he she can help with the legs or manage the wheelchair Training tips for powered e As for the general tips
146. s Training tips for manual e Not applicable wheelchairs operated by caregivers Training tips for e Manufacturers recommend that the battery not be charged in a room powered wheelchairs with people present because there is a risk of explosion with some operated by wheelchair batteries This recommendation is difficult to comply with for a users wheelchair user acting alone unless the wheelchair user has a second means of mobility Training tips for e As for powered wheelchairs operated by wheelchair users powered wheelchairs operated by caregivers Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 50 7 8 Rolls forward 10m Versions applicable WST M WCUY WST M CGY WST P WCUY _WST P CGY Description The subject moves the wheelchair 10m forwards on a smooth level surface Rationale Forward rolling is a skill used during many wheelchair activities The forward propulsion distance 10m is intended to simulate moving about indoors or the crossing of a two lane street General training tips Adjustment tip o The position of axle and weight over drive wheel have a great impact because rolling resistance is lower when the wheel diameter is greater o If the wheelchair user experiences difficulties maintaining a straight direction the problem may be due to a wheelchair part e g a flat tire or so
147. s demonstration and feedback D Closing 2 minutes e Questions and answers e Plan next session content e Assign homework e Schedule next session E Documentation 1 minute e Complete any final documentation of the session Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 26 5 0 SKILL GROUPS There are a great many individual skills that a wheelchair user and caregiver may be required to carry out during everyday activities A broad but not all inclusive set of such skills will be described in more detail in the later sections Most of these skills can be grouped as described below although some of these groupings only apply to manual wheelchairs 5 1 How to operate the parts of the wheelchair Wheelchairs vary widely in their components and how they work It is important that wheelchair users and caregivers learn about the structures and operating idiosyncrasies of the wheelchairs they use This includes normal daily operations transportation and storage of the wheelchair as well as regular maintenance duties At the time of sale new wheelchairs are delivered with user manuals Wheelchair users and caregivers can learn about special features of the wheelchair by studying the user manuals If the user manual has been lost instructions can often be found on line Maintenance and repair issues are also usually dealt with in the user manual e g
148. s stable to begin with e g removing the footrests and allowing the feet to dangle moving the rear axle position forward raising the rear axle position or switching to a less stable wheelchair o Rear anti tip devices usually need to be removed Training tips for manual wheelchairs operated by wheelchair users The description that follows is for people using two hands for propulsion but people have only the use of one arm can perform wheelies in a similar way When learning the wheelie the main risks are of injury due to a backward tip and striking the head on the floor or injuring an outstretched arm This skill should not be practiced without a spotter or a rear anti tip device that permits enough rear tip to achieve the wheelie balance point but prevents a full rear tip Most people require a total of 45 60 minutes of practice spread over 2 3 sessions to acquire this skill Take Off Phase e It may be useful to use simulation For instance the trainer may tip the wheelchair back into the balance position to give the wheelchair user a sense of how far back this is Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 129 If properly timed the wheelchair user should require little force to achieve take off For the wheelie take off many wheelchair users roll backward slowly then quickly forward If using this metho
149. se March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 79 by 30 degrees or more may be needed to increase circulation over the ischial tuberosities and sacrum Training tips for manual wheelchairs operated by wheelchair users The leaning techniques can cause tips in the direction towards which the wheelchair user is leaning If leaning forward the casters should be in the forward trailing position to increase forward stability A wheelie can be used to achieve tilt It can be sustained by balance by using the no hands wheelie rest with brakes locked and leaning against a wall or curb or by resting on the rear anti tip devices if they permit sufficient rear tilt Training tips for manual wheelchairs operated by caregivers A caregiver can assist in a variety of ways such as reminding the wheelchair user of the need to unweight the buttocks or by assisting the wheelchair user in getting into or recovering from the unweighted position A caregiver can sit behind the wheelchair and tilt the wheelchair backwards to provide pressure relief To prevent them from rolling forwards the rear wheels should have the brakes wheel locks applied Training tips for powered wheelchairs operated by wheelchair users See general tips Training tips for powered wheelchairs operated by caregivers As for manual wheelchairs operated by caregivers Originally approved for
150. sers Training tips for powered Not applicable wheelchairs operated by caregivers Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 133 7 36 Turns 180 in place in wheelie position Versions applicable e WST M WCUY WST M CG Y e WST P WCU X_ WST P CG X Description e In the wheelie position the learner turns the chair 180 in place both to the left and right Rationale e As for performs 30s stationary wheelie skill 7 35 e Wheelchair users often encounter situations in which they need to perform a wheelie to make a tight turn The area needed on the support surface is less than that at a higher level e This skill is not applicable for powered wheelchairs because of the difficulty and danger involved General training tips e This skill is a combination of skills 7 13 and7 35 Training tips for manual e As for skills 7 13 and7 35 wheelchairs operated by wheelchair users Training tips for manual e As for skills 7 13 and7 35 wheelchairs operated by e The caregiver should be careful not to let the wheelchair user s caregivers elevated feet hit anything Training tips for powered e Not applicable wheelchairs operated by wheelchair users Training tips for powered e Not applicable wheelchairs operated by caregivers Originally approved for distribution and use March 14 2008 C
151. sic requirements there are a variety of ways in which the safety effectiveness or efficiency of training can be enhanced The topics in this chapter can be thought of as the trainer s instructional tool kit with specific tools to be used as needed Training can take place anywhere e g in the hospital community or the learner s own environment Training can take place in an ad hoc format seizing teaching opportunities as they present themselves e g during community outings However in the clinical setting it can be helpful to provide more structure e g scheduled sessions with lesson plans Sample lesson plan templates for initial and subsequent sessions can be found in Section 4 of the Manual 3 10 Training in Pairs or Groups To permit an individualized approach we recommend that the ratio of trainers to learners be 1 1 or Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 14 1 2 although larger groups have also been successfully trained Training in pairs or groups is practical cost effective and has educational merit Such training can permit group discussions and problem solving Learners can serve as models for each other both for how and how not to perform a skill Whenever possible it is desirable to select groups on the basis of roughly similar skill level Learners should be reminded that skill capability is affected by a number of fac
152. skill It may be possible to perform this task while seated in the wheelchair if the armrests are removed or a reaching aid is used Training tips for powered wheelchairs operated by caregivers Good ergonomic principles should be used when engaging and disengaging the motors The caregiver s knees should be bent and the back straight In many cases a foot can be used to perform the task Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 48 7 7 Operates battery charger Versions applicable e WST M WCU X WST M CG X e WST P WCUY WST P CGY Description e The subject operates the battery charger Rationale e Powered wheelchairs utilize battery power The battery needs to be charged regularly as often as daily General training tips e Adjustment tips The user manual should be consulted for wheelchair specific elements of this skill e Only use a battery charger that has been specified for the wheelchair Failure to do so could cause damage to the battery e Generally the skill includes checking that the charger is plugged into the power source e g a wall socket switching it on and plugging the wheelchair into the charger The battery charger is usually a separate equipment item left where the wheelchair is stored overnight e Some powered wheelchairs have on board chargers that allow greater flexibility to users when they
153. ss in the line of progression and at least as wide as the wheelchair Rationale e Such loss of surface support is a commonly encountered barrier Gaps at elevator doors and sewer grates are similar challenges General training tips e Small pot holes that only affect one wheel at a time may be jarring but are not usually major obstacles In this section we will be considering only pot holes that are as wide as the wheelchair e Ifa pot hole is not readily available one can be easily simulated For instance two gym mats can be put close together with whatever space between them the trainer wishes e The best approach is to avoid pot holes steering around them or straddling them e Ifthe pot hole cannot be avoided but appears to be negotiable it is best to proceed at a slow speed but a steady pace Avoid stopping if possible e The wheelchair user should approach the pot hole as squarely as possible e If the casters drop into the pot hole and turn sideways a common problem if the wheelchair is moved forwards and backwards repeatedly in an attempt to get the casters out of the pothole it can be very difficult to proceed e Rear anti tip devices may cause the drive wheels to float i e with the weight being distributed on the casters and the anti tip devices unweighting the drive wheels e Progression o Start slow and add speed o Start with small pot holes and progress to larger ones e Variations o As long as 3 wh
154. stacles e g other wheelchair users pedestrians General training tips e This skill builds on the earlier skills of stopping 7 8 and turning 7 11 e The person operating the wheelchair should be alert to the moving environment while the wheelchair is moving e Ifa hallway is clear it may be advisable to drive in the middle of the hallway to avoid collisions with people unexpectedly coming around corners or out of doors e The learner should obey driving conventions etiquette or the rules of the road with respect to altering course to one side the right in North America when approaching others use of horn or verbal warnings overtaking and slowing down when approaching others or blind intersections e Sudden stops or changes of direction can lead to the user falling forward or to the side in the wheelchair e Progression o Start with a single moving obstacle moving slowly at a consistent speed seen well in advance to ones moving more rapidly and unpredictably with less warning e g actual pedestrian traffic in a crowded setting o Start with obstacles approaching from right angles and progress to ones coming from different angles including overtaking and being overtaken o Start slowly and progressively increase the speed of propulsion e Variations o Different moving obstacles can be used e g a rolled ball a swinging pendulum Training tips for manual e Practice both quick stops lea
155. sure Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 59 good traction then push the wheelchair backwards by straightening the leg Training tips for manual wheelchairs operated by caregivers As for 7 8 Training tips for powered wheelchairs operated by wheelchair users Adjustment tip The programming of a powered wheelchair is separate for the forward and backwards directions It is possible that a wheelchair that has not been programmed correctly could have difficulty backing up unless the speed control is adjusted upward Pull the joystick backwards If the wheelchair is fitted with a rear view mirror this eliminates the need to turn around to see where the wheelchair is going Training tips for powered wheelchairs operated by caregivers As for general tips Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 7 11 Turns 90 while moving forward Versions applicable e WST M WCUY WST M CGY e WST P WCUY WST P CGY Description e The subject turns the wheelchair 90 to the left and right while moving forwards Rationale e Moving turns are often necessary to avoid obstacles or to change direction General training tips e The learner should clearly understand the difference between the size of the turni
156. t may be easier to simply grasp the door handle with the hand on the side away from the joystick and then back the wheelchair up rather than doing all of the work with the arm Unlike with a manual wheelchair the force of a self closing door does not require the user to brace himself herself with the other hand on the door frame For a person with hemiplegia it can be difficult to use the one functional arm to both hold the door lever and to control the joystick It may be necessary to complete the task in several small steps Because of the risk of injury and because overcoming the force of a Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 13 self closing door mechanism is not a problem it is not recommended that momentum be used to open doors with latch mechanisms Training tips for powered wheelchairs operated by caregivers As for manual wheelchairs operated by caregivers This can be an awkward task because the caregiver s position is dictated by both the need to have access to the joystick and the door Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 74 7 16 Reaches 1 5m high object Versions applicable WST M WCUY WST M CG X WST P WCUY _WST P CGX Description The subject reaches up to touch an object 1 5m above t
157. t off further during the wheelie and provides better clearance during the dip e In some circumstances it may prove easier to use both hands on the same wheel to move one wheel at a time Person with hemiplegia e It is easier in the backwards direction because there is less rolling resistance with the large rear wheels than the smaller casters e When pushing backwards with the foot the casters become slightly unweighted which makes it easier to move them Training tips for manual wheelchairs operated by caregivers It may be necessary for the caregiver to lean forward to apply the extra force needed The caregiver should not use the knee against the backrest of the wheelchair to apply more force because this may be uncomfortable for the wheelchair user if the backrest is flexible or dislodge a rigid removable backrest Variations e The caregiver may find it easier to pull the wheelchair backward e The caregiver may find it easier to tip the wheelchair back into the full wheelie position so that all of the weight is on the rear wheels The caregiver should be sure to find the wheelie balance point before starting The caregiver may need to reposition the rear anti tip devices or remove them The wheelchair can be pushed forward or pulled backwards Training tips for powered wheelchairs operated by wheelchair users If possible and necessary the wheelchair user should adjust the controller setting to one
158. t on an armrest Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 12 Training tips for manual wheelchairs operated by caregivers e General e Before pushing a wheelchair through any type of door or narrow space the caregiver should make sure that the wheelchair user s hands or elbows are not extending beyond the sides of the wheelchair where they could be injured e The caregiver should keep part of his her body between the door and the wheelchair user e Fora narrow doorway one option is for the caregiver to remove one rear wheel With the wheelchair user leaning the other way and the caregiver supporting the push handle it may be possible to get through the door on 3 wheels e Door that opens away e The caregiver should open the door grasp the push handles at the rear of the wheelchair and push or pull the wheelchair through the doorway e The caregiver should use his her body to prevent the door from closing on the wheelchair e When the wheelchair and caregiver are completely out of the way the caregiver should close the door e Door that opens toward e If there is room the caregiver should angle the wheelchair away from the door on the side that will open Training tips for powered wheelchairs operated by wheelchair users With a powered wheelchair when applying a force to open the door toward you i
159. tes a degree of freedom forward backward movement of the rear wheels Reducing the degrees of freedom is a strategy that has been observed to be used by beginners learning non wheelchair skills Other examples of simplification and progression are adding speed to a task doing the task in a more challenging environment adding a second task reducing the amount of assistance provided by an assistant and reducing the proximity of the spotter Specific examples of simplification and progression can be found later in the training tips sections for individual skills Some of these strategies are similar to those used to increase the variability of practice with the goal of skill transfer In many cases more difficult skills will build on methods learned in performing simpler but similar skills For instance the ability to get over a threshold requires most of the techniques needed when later learning to get up a curb The order of individual skills listed in Tables 5 8 reflects this Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 23 Although a learner can perform a wheelchair skill with any safe and effective method different methods may be more suitable for some individuals or some situations For instance for the moving turns skills as performed by a user of a manual wheelchair who propels the wheelchair with two hands the basic method is to push harder on the
160. the edge staying as square as possible to the edge The wheelchair user should place the hands in the 11 o clock position clock analogy so that he she can firmly grip the hand rims until the rear wheels drop to the lower level As slowly as possible the wheelchair user should lower the rear wheels from the upper to the lower level pulling backwards to slow the descent The wheelchair user should let the rear wheels hit the lower level before the casters As soon as the rear wheels touch the ground the momentum should bring the casters down but the wheelchair user should lean forward as a precaution e Variations e The backwards approach see 7 32 is simple and generally safe if the wheelchair has adequate rear stability For this skill it is especially important to practice with a spotter until it has been mastered e The forward transient wheelie method is an advanced skill The wheelchair user approaches the curb edge squarely with all four wheels on the surface and pops the casters as they reach the edge The extent of the caster pop should be Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 127 sufficient to allow the rear wheels to have landed on the lower level by the time the casters land This method requires good timing and skill but is a natural way to maintain forward progression and to watch for traffic It can be diffi
161. the energy from the forward pitch caused by the collision of the rear wheels with the obstacle will be expended in crashing the casters down on the upper level rather than bringing the rear wheels up onto the upper level e Common errors are popping the casters too soon not popping high enough and popping too high e Backwards e The wheelchair user might find it easier to attempt to ascend the 5cm high level change backwards e Variations e Use the external environment if available e g door frame or street pole e Person with hemiplegia e The wheelchair is backed up until the rear wheels contact the obstacle Then leaning forward to slightly unweight the rear wheels the foot is used to push the rear wheels up the level change Then the wheelchair user sits upright and pushes down on the foot on the floor or top of the level change to bring the casters up to the upper level Training tips for manual e To ascend a level change forwards the caregiver should put the wheelchairs operated by wheelchair into the full or partial wheelie position to get the casters caregivers onto the upper level Then the caregiver should roll the chair forwards until the rear wheels touch the edge of the level change After the casters are on the upper level the caregiver should ask the wheelchair user to lean or shift forward to reduce the weight on the rear wheels Then the caregiver should apply a forward and upward force to help the rear wheels ro
162. the eyes closed and have used an internal perspective with a kinesthetic focus On average participants in such studies practiced for about 15 minutes at a time 3 times a week for a total of about three hours Even a short nap after motor imagery helps Imagery can be used for motivational purposes e g visualizing performing with confidence and ease Imagery can be used in advance to prepare to perform a skill or after the attempt to reinforce a well performed trial Imagery is not as effective as physical practice but it is better than no practice Used in combination with physical practice imagery is almost as effective as physical practice alone so it may be a useful strategy when there are factors that prevent physical practice e g bad weather lack of spotter availability a sore shoulder Imagery has a greater effect on closed skills ones that are always the same than open ones Imagery is less useful for a novel task than a familiar one 3 16 Feedback Implicit learning through intrinsic feedback e g from what the learner can see hear or feel is useful and may be all that is needed Feedback can be augmented in a variety of ways e g by watching oneself in a mirror by watching a video of one s performance by receiving biofeedback or by receiving feedback from a trainer Augmented feedback is generally an effective tool for Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49
163. them e The subject should check to make sure the armrests are locked in place by pulling up on them Footrests e People who need to propel their wheelchairs with their feet are effectively restrained if they cannot move the footrests out of the way e The wheelchair user should clear the footrests prior to a transfer whenever possible It may be easier to do so before moving the wheelchair into its final position e Before moving the footrests out of the way the wheelchair user should first remove the feet from the footrests A person with weak hands may need to use both hands or an extended wrist under the knee to lift the leg If one leg is stronger it may be used to assist in lifting the weaker leg Later after restoring the footrests the wheelchair user should put the feet back on the footrests e To move a swing away footrest out of the way the wheelchair user should unlock the footrest Locking mechanisms vary from wheelchair to wheelchair The Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 86 wheelchair user should swing the footrest completely out of the way Some footrests swing away to the side and others to the middle To replace the footrest the wheelchair user should push the footrest back towards the front of the wheelchair until it clicks into place The wheelchair user should check that it is locked in pla
164. ther examples are when the wheelchair user uses the hand rails on a ramp to pull himself or herself up the ramp or uses a doorframe to guide Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 27 passage through a door 5 6 Skills that require leaning in the wheelchair The wheelchair user s position in the wheelchair has a dramatic effect on the amount of weight that is on the front versus rear wheels because the wheelchair users trunk and upper body contribute a considerable proportion of the combined center of gravity of the wheelchair and wheelchair user This will affect the stability of the wheelchair in a predictable way For instance when ascending an incline in a manual wheelchair there is a risk of the wheelchair tipping over backwards To prevent this the wheelchair user should lean forwards enough to keep the front wheels on the surface In addition to stability the balance of weight between the front and back wheels has an effect on rolling resistance Wheels with large diameters have lower rolling resistance whereas small diameter wheels will tend to dig into soft surfaces When crossing soft surfaces e g carpet gravel grass the wheelchair user should keep his her weight primarily on the rear wheels When crossing side slopes the tendency for the wheelchair to turn downhill can be reduced by leaning away from the swivel casters Leaning t
165. there is more rolling resistance more force is required by the wheelchair user There is a risk of overuse injury Although leaning forward slightly may help the wheelchair user to apply more force and to prevent the additional force from causing a rear tip keeping the weight on the rear wheels will improve traction and keep the front wheels from digging in As a learning exercise the wheelchair user should try the skill while leaning forward and backward to different extents to find the optimum position for him her and the wheelchair The forward approach is preferred because the wheelchair user can see where he she is going The wheelchair user should use long slow strokes to keep the wheels from slipping in loose surfaces This is the first in a series of skills for which transient wheelies are useful or necessary Partial wheelies are a good option for the wheelchair user lifting the casters off the surface during each push but letting them touch down as the hands recover for the next push Variations Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 109 If using the full wheelie position a good option but one that requires more skill the wheelchair user needs a strong forward dip to get going If the casters touch the surface during the dip the wheelchair user can lean forward slightly This allows the casters to lif
166. tip into the wheelie position Step 4 Full take off progressive degrees of tip until overshoot self save Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 132 e Step 5 Balance strategies in high rolling resistance RR setting with trainer induced initial tip into the balance position e Step 6 Balance strategies in medium RR e g foam grass sand e Step 7 Balance strategies in low RR tile e Step 8 Add the take off phase and perform the balance phase thereafter May need to return to the medium RR setting for this e Step 9 Exercises change body position fingertips only one hand only eyes closed reduced spotter proximity e Step 10 Start wheelie related skills roll forward back Training tips for manual wheelchairs operated by caregivers To achieve a caregiver induced wheelie the caregiver should pull back on the push handles with one foot pushing down on a tipping lever to tip the wheelchair back to the balance point Once in the wheelie balance position only minimal force is needed by the caregiver to maintain balance To lower the wheelchair to the horizontal position the caregiver should put one foot on the tipping lever at the back of the wheelchair to keep the wheelchair from pitching forward too abruptly Training tips for powered Not applicable wheelchairs operated by wheelchair u
167. tips for manual e wheelchairs operated by caregivers using the foot to slow down e Caution that the foot does not get caught under the chair at the lower incline floor transition The basic method is in the forward direction with all four wheels on the incline The caregiver holds the push handles firmly and allows the wheelchair to roll down the ramp while controlling the speed The caregiver avoids sudden stops and slows down as he she reaches the bottom transition to level ground Coming down an incline the caregiver can put one hand on the wheelchair user s shoulder to prevent forward fall and also to steer the wheelchair as the wheelchair will tend to twist if only held by one hand Variations e The forward descent can be performed in the wheelie position This is useful on steep inclines to prevent the wheelchair user from falling forwards However this method may require the caregiver to bend too far forwards which may strain the back e Another method is to descend backwards This ensures that the wheelchair does not run away from the caregiver and that the wheelchair user does not fall forward The caregiver should look over the shoulder for obstacles e As a combined wheelchair user and caregiver method the wheelchair user can descend forwards holding onto a hand rim with one hand and putting the other hand on the low back of the caregiver walking beside the wheelchair Training tips for powered e wheelchairs
168. to behave erratically Variations o Rolling the hand onto and off of the on off switch may reduce the need for fine finger dexterity o Using larger movements and body parts may allow users Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 40 to switch toggle levers on and off independently if fine motor control is not available Training tips for e As for powered wheelchairs operated by wheelchair users powered wheelchairs e On off switches may be located on an attendant control unit operated by caregivers Depending on the control method used by the wheelchair user it may be necessary to turn the controller on before the attendant control can be operated e The attendant control will override that of the wheelchair user Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 4 7 3 Selects drive modes and speeds Versions applicable WST M WCU X WST M CG X WST P WCUY _ WST P CGY Description e The subject operates the controller to switch between drive modes and or speeds Rationale e Powered wheelchairs vary but most allow the user to select different performance parameters for different environments Most powered wheelchairs provide an opportunity for the user to operate the wheelchair in different modes and speeds User
169. tors e g age sex impairments and wheelchair type so they should not compare their progress with that of others For individuals with low self efficacy collaborative training with a more experienced partner aids skill acquisition 3 11 Motivation Motor skills learning is enhanced if the learner is motivated to learn The trainer can help to motivate the learner by making the learning meaningful and rewarding Game based exercises can help to maintain interest Working in either cooperation or competition with other learners can enhance motivation Children especially may learn best through play rather than through formal training on a skill by skill basis Helping the learner to understand the skill can be helpful such as by the use of memory aids e g relating hand placement on the wheelchair hand rims to the hands of a clock providing verbal labels for segments of a skill and organizing a way of thinking about the components of the skill Learning is enhanced by instructions that portray the task as a learnable skill versus one that is based on inherent ability Perceived good luck superstitions can enhance performance via improved perceptions of self efficacy Whenever possible the trainer should explain how the learner will benefit e g improved safety improved participation and quality of life by learning a new skill Training should be relevant to the learner and his her context In addition to the long term benefits of training
170. ty or reduce edema General training tips e Adjustment tip o Not all wheelchairs have a recline function o Programming should be considered to allow the wheelchair user to get into a reclined position with as few steps as possible e g using a preset position of 15 of recline e Be careful to ensure that the wheelchair user has access to the controller when in the reclined position e Before reclining the seat or restoring it to the upright position the person performing the recline should be sure that there is room to change the recline angle without damaging the environment the wheelchair the user or a bystander e In many wheelchairs moving from an upright to a reclined position may cause shear forces between the wheelchair user and the backrest e For the purpose of pressure redistribution the greater the extent of recline the better e Recline and tilt may be used in combination e Depending upon the reclining mechanism the extent of forward and rear stability may differ with the wheelchair upright vs reclined This should be taken into consideration when in a situation where reduced stability could be unsafe e g proceeding forward up an incline in the reclined position or when it might be helpful to alter the weight distribution between the front and rear wheels e g to increase traction or reduce the tendency for smaller diameter wheels to sink into a soft surface Originally approved for distribution
171. ual wheelchairs operated by wheelchair users Two Hand Propulsion Pattern e To propel the wheelchair straight forwards the wheelchair user should grasp the hand rims and push evenly with both hands He she should not wrap the thumbs around the hand rims but point them forward e The wheelchair user should lean forward as the arms are extended to get more contact time between the hands and the hand rims and to reduce the chance of a rear tip e The wheelchair user should avoid jerky accelerations that could cause him her to tip over backwards e Strokes should be smooth with the hands comfortably grasping the hand rims initially matching the speed of the moving wheels e If the subject strays too close to a wall it is acceptable for the subject to avoid injuring his her fingers by pushing off the wall to correct direction To do so the wall should be contacted well ahead of the rear wheels e To minimize shoulder strain and be mechanically efficient the wheelchair user should try to push with long slow strokes allowing the wheelchair to coast where possible Hand positions can be illustrated by having the wheelchair user imagine the right rear wheel as the face of a clock the initial and final contact positions for the wheel might then be referred to as 11 00 and 2 00 o clock An additional reason to reach back and use long strokes is to exercise the shoulder retractor muscles and maintain shoulder retraction range This may
172. urrent edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 134 7 37 Gets from ground into wheelchair Versions applicable e WST M WCUY WST M CGY e WST P WCUY WST P CGY Description e The wheelchair user gets from the ground into the wheelchair Rationale e This skill is useful when recovering from a fall or from an occasion when the wheelchair user is on the ground for another reason General training tips e After a fall unless there is some immediate danger the wheelchair user and or caregiver should take time to assess whether there has been any injury or damage to the wheelchair or occupant before getting back into the wheelchair Training tips for manual e Getting from the wheelchair onto the ground is an opportunity to wheelchairs operated by practice safe falls onto a mat wheelchair users e Generally the wheelchair user should not reach out towards the ground with an arm unless he she has exceptional flexibility and can prevent the tip fall with a gentle push on the ground e Rear falls the trainer should first lower the wheelchair user onto an elevated mat with the wheelchair user s neck flexed and hands pulling on the hand rims Failure to hold onto the hand rims will result in the rear wheels of the wheelchair rolling rapidly forward submarining Progress to real falls onto an elevated mat Gradually lower the height of the mat Immediately after hitting the ground the wheelchair use
173. us for the caregiver to use this technique for medium or large level changes the wheelchair user may tip forward out of the wheelchair or the footrests may dig in and prevent a smooth descent Variations e Approaching in the forward direction the caregiver can tip the wheelchair back into the full wheelie position and lower the wheelchair to the lower level The caregiver should be careful about the extent to which his her back is flexed However this technique has the advantage of allowing continuous progression along a street with the eyes facing any dangers in traffic e To descend a level change backwards the caregiver should turn the wheelchair around so that the rear wheels go off the edge first The caregiver should stand close behind the wheelchair and on the lower level The caregiver should align the rear wheels so that they are both on the edge of the upper level The caregiver then asks the wheelchair user to lean forward to reduce the weight on the rear wheels Controlling the movement of the chair the caregiver should slowly and evenly roll the rear wheels down onto the lower level avoiding any jarring Once the rear wheels are on the lower level the caregiver may need to tip the wheelchair back into the wheelie position to avoid the footrests from scraping on the upper level Alternatively the caregiver can turn the chair sideways to prevent the footrests from getting caught Training tips for powered wheelchai
174. users As for 7 31 for both two hand and hemiplegic propulsion patterns Training tips for manual wheelchairs operated by caregivers As for 7 31 Training tips for powered wheelchairs operated by wheelchair users Training tips for powered wheelchairs operated by caregivers Not generally applicable although some powered wheelchairs are capable of climbing full height curbs Not applicable Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 126 7 34 Descends 15cm curb Versions applicable WST M WCUY WST M CGY WST P WCU X WST P CG X Description The learner gets the wheelchair down a 15cm curb Rationale As for descends 5cm level change skill 5 32 Also the appropriate technique for a high curb may differ from that used for a lesser level change This skill is not generally applicable for powered wheelchairs because of the difficulty and danger involved General training tips As for 7 32 Training tips for manual wheelchairs operated by wheelchair users Two hand propulsion e The forward full wheelie method is the preferred method for the descent of a large level change but it requires good wheelie skills The wheelchair user should get into the wheelie position away from the edge of the level change The wheelchair user should roll forward in the wheelie position to
175. vaaeaasiesscdtusntesentiear antesiaeonceaore 79 7 19 Transfers from wheelchair to bench and back ee eeeeseeseeeseeeeeeseceeeeseceeeeaeceeeeeseeeeeas 81 7 20 Foldsand untolds wheelchair nicsen AA 91 TEAN LERO Ta E E EE EEES 94 7 22 Avoids moving obstacles sseesssseseesesseseesesetseeseseesessesesessesetsessesetsessesteseseseesesesessesets 95 EP SON SCE UAS I INC UNE aeee n E A E AREA ona ova sims oS 97 PA DescendS S MeNe a e ee e ae AALE AAEE AE aa a A A saute ews 101 DDS Ascends VO INCLINE rnnnnnns nne nne in p in n n a a eee nt 105 W20 Descends LO Imene ninss r r E ages using EERE E R E 106 Te 2 ROUS AY ACTOSS Or SIde 810 st eene eean aeran aeara aeee e A E E E E 108 TA LEA nE EOI ES u PTO E E E E E 110 7 29 Getsover ICM pothole ssasesedassdecadavadevatensdevedanadusaceaaiececaqscevadavedeseasvecensevetenseemsenstacasaeves 114 T20 Gets over 20m thresholds ssor seses eses eose ineo e ioe n Ee E E 119 7 31 Ascends 5cm level change ac sscscscasccadevcceaslesccasedaccinecdeciseasdesntenssasacava teeta rstertevaten veeeuerete 122 T32 Descends Sem level chang sonnn e o e E EE ewe 125 Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 5 Tos Ascends DOMACUTD lt 2 cciatadecetataiess a toca deca dade dada te caceciedecacesecea onsen aaa OURS 128 cde Descends FOCI CUTD A eee eea a a E E A 129 7 35 Performs 30s stationary wheelie 2 acacia sci aa eat
176. versification may include alterations of the environment e g surface lighting conditions time of day ambient temperature variations in how the skill is performed e g faster slower while multi tasking or variations in the learner s state e g with fatigue anxiety focus of attention To enhance skill retention and transfer random practice of a group of skills that have already been acquired is generally better than consistent blocked practice However there will be more errors during random practice The two approaches are not mutually exclusive For instance it may be reasonable to begin with consistent practice and to progress to serial practice of a few skills followed by random practice of those skills The approach may vary depending upon the personal characteristics of the learner e g children and the elderly do better with less variability and fewer distractions Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 21 3 23 Distribution of Practice Practice may be condensed massed or spread over several sessions distributed Our experience at a rehabilitation centre is primarily with brief individual and or group sessions at regular intervals e g 15 30 minutes 1 5 times a week for 2 4 weeks with practice encouraged between sessions One alternative model is to conduct training in and around the learner s home An
177. ward to reach the joystick is not recommended e When the caregiver is first learning to handle a powered wheelchair it is preferable to do so with the wheelchair unoccupied to avoid injury to the wheelchair user Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 56 7 9 Rolls forward 10m in 30s Versions applicable WST M WCUY WST M CGY WST P WCUY _WST P CGY Description The subject propels the wheelchair 10 meters forwards on a smooth level surface within 30 seconds Note this skill is usually dealt with together with the rolls forward 10m skill one 7 8 Rationale As for rolls forward 10m skill 5 8 Timing this skill provides a means of identifying whether the subject would be able to get across a street quickly enough to be safe e g when traffic flow is controlled by lights Although there is considerable variability most traffic signals provide at least 30s for a full cycle General training tips As for skill 7 8 Variations real street crossing 1 example of community application of skills Planning the crossing by looking ahead to the various obstacles that lie en route to the safe area on the other side Understand traffic signals cautions at road crossings the importance of looking both ways Avoid crossing at unmarked areas or coming into traffic from between parked cars t
178. wheelchair user can get used to just hopping up and down with no sideways movement e A Person With Hemiplegia e The wheelchair user should use the sound side foot to steer and the sound side arm to provide the power Training tips for manual e The caregiver should generally not try to lift the occupied wheelchairs operated by wheelchair sideways However it may be possible to use the caregivers wheelbarrow approach To do so the wheelchair user leans forward to unweight the rear wheels being careful not to tip over or fall from the wheelchair Then the caregiver may be able to slightly lift the rear wheels and move them sideways in small increments e The caregiver should be careful that the wheelchair user s arm or hand is not caught between the barrier and the rear wheel Training tips for e As for general tips powered wheelchairs operated by wheelchair users Training tips for e As for powered wheelchairs operated by wheelchair users powered wheelchairs operated by caregivers Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 69 7 15 Gets through hinged door in both directions Versions applicable WST M WCUY WST M CGY WST P WCUY _WST P CGY Description e The learner opens passes through and closes a hinged door that opens away from the learner then repeats the task in the opposite direction with the door open
179. wheelchair user is overshooting the balance point too vigorously a learning exercise is for him her to practice popping the casters up onto a small object 5cm high If the wheelchair user is having difficulty getting tipped far enough backward to reach the balance point he she should push forward more forcefully to pop the casters higher Steps noted earlier can be taken to reduce the rear stability of the wheelchair An additional strategy is to start the take off with Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 130 the casters uphill or on a small level change If the problem is fear of tipping over backwards the wheelchair user can pop back onto the spotter then progress to a self save e Balance Phase e The wheelchair user does not need to use a lot of force to maintain balance It is preferable for the wheelchair user to keep a light grip on the wheels The wheelchair user should try to relax and remember to breathe During the early learning stage some wheelchair users find it useful to isolate the variations of pitch from those of rear wheel displacement i e using the motor learning principle of reducing the degrees of freedom This can be done by reducing the extent to which the rear wheels can move e g obstacles such as bricks in front of and behind the rear wheels and foam under the rear wheels The trainer t
180. where reduced stability could be unsafe e g proceeding forward up an Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 44 incline in the tilted position or when it might be helpful to alter the weight distribution between the front and rear wheels e g to increase traction or reduce the tendency for smaller diameter wheels to sink into a soft surface When reversing direction from tilt back to tilt forward or vice versa it may be necessary to pause briefly For safety some powered wheelchairs will prevent the wheelchair from being driven while tilted past a set amount Powered wheelchairs may slow down or stop if the user attempts to operate them in unsafe circumstances e g driving up a steep incline forward with the seat fully tilted back If the wheelchair allows both tilt and recline it is advisable to recover to the upright from the recline position before recovering from the tilt position This reduces the tendency to slide forward on the cushion Progression o For the wheelchair user to adjust to tilt may involve starting at a small amount and progressing to full tilt o Ifthe rate of tilt can be programmed it is advisable to begin with a slow rate and progress to a faster one This will provide more time in which to ensure that the wheelchair user is adjusting to the new position and that there are no body parts that are at
181. xclusively for braking to minimize downhill turning tendency rather than for assisting with propulsion o On steep cross slopes problems e g loss of uphill wheel traction lateral tip over folding of the wheelchair may arise due to the lack of weight on the uphill wheel These problems can be minimized by leaning uphill o Variations A useful learning experience to demonstrate the Originally approved for distribution and use March 14 2008 Current edition WSTP Version 4 1 49 April 11 2012 WSTP 4 1 Manual 106 downhill turning tendency is to have the wheelchair user lean forward to illustrate how the downhill turning tendency increases In the wheelie position facing across a slope there is no downhill turning tendency because the center of gravity is between the rear wheels Person with hemiplegia o When learning the skill it may be less frustrating to cross the side slope with the sound side downhill first due to the downhill turning tendency Some users may choose to go backwards with the sound side downhill rather than forwards with the sound side uphill to help manage the downhill turning tendency Training tips for manual wheelchairs operated by caregivers To resist the downhill turning tendency while pushing the wheelchair across a side slope the caregiver needs to push harder on the downhill push handle and pull back on the uphill push handle For a steeper slope the caregiver m

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