NIHR: WSTP structured training improves wheelchair skills

Why was this study needed?

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

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

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

What did this study do?

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

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

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

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

What did it find?

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

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

What does current guidance say on this issue?

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

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

What are the implications?

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

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

The full NIHR Signal and additional expert commentary was published on 18 July 2018  

Expert view:

Benita Hexter and Emma Linley  Clinical specialists and lead physiotherapist and occupational therapist, London Spinal Cord Injury Centre, The Royal National Orthopaedic NHS Trust 

It is absolutely our experience that patients improve in the safe and effective use of their wheelchairs with training. In spinal cord injury centres, wheelchair skills training is a routine provision during inpatient rehab programmes. This is not mirrored in all other services that provide for those who become wheelchair users while under their care. A tool to support clinicians to train effectively and evaluate outcomes is very welcome and may help services develop their skills in this specialist area. While this tool provides detailed advice on how to deliver wheelchair skills, developing the best levels of competence and confidence in a new trainer might require external support. 

Using a wheelchair is a skill. This skill can only be fully developed with the optimal wheelchair for that individual and expert training in its use. The absence of either leaves users vulnerable through unsafe use and unable to realise their potential mobility. The lack of independent mobility restricts access and participation in societal norms of work, rest and play, which many of us take for granted. A skilled and available service to provide the training can be hard to find. 

Citation and funding:

Keeler L, Kirby RL, Parker K, et al. Effectiveness of the Wheelchair Skills Training Program: a systematic review and meta-analysis.  Disabil Rehabil Assist Technol. 2018; Apr 4:1-19. No funding information was provided for this study. 
 
Bibliography:

Dalhousie University. Wheelchair Skills Program. Halifax, Nova Scotia: Dalhousie University; accessed July 2018. Kirby RL, Smith C, Parker K, et al. The Wheelchair Skills Program Manual, version 4.3. Dalhousie University, Halifax, Nova Scotia; 2016. Leeds Teaching Hospitals NHS Trust. A beginner’s guide to NHS wheelchairs – part 2, using a wheelchair. Leeds: Leeds Teaching Hospitals NHS Trust; 2013. NHS Choices. Getting a wheelchair, scooter or walking aid. London: Department of Health and Social Care, 2018. NHS England. Improving wheelchair services. London: NHS England; accessed June 2018.  NHS England. Model service specification for wheelchair and posture services. London: NHS England; 2017. Salisbury NHS Foundation Trust. Wheelchair skills group.  Salisbury: Salisbury NHS Foundation Trust; 2009.