Alright, let's go ahead and get started. I want to welcome everybody to the AAP virtual didactics for today. We're excited for today's lecture. As always, want to recognize and appreciate those folks who have been affected more than others with regard to this COVID-19 pandemic. Recognize that not everyone has been affected equally and we know that there are those, even some on the call today, who are in so-called hot spots. So we hope that you and yours are doing well. If there's anything further we can do to support you, please let us know. The goals of this, as always, are to augment didactic curricula that are ongoing in your home institutions, to offload overstretched faculty due to some of the difficulties associated with the pandemic, to provide additional learning opportunities for off-schedule residents. As you know, there have been a lot of scheduling problems as a result of all this crisis that's going on, to develop more digital learning resources and to support physiatrists in general during COVID-19. We are going to keep everybody video and audio muted except for our presenter. If you have any questions that come up over the course of the lecture, please send them to me. My name is Sterling Herring. I'm a PGY3 at Vanderbilt. If you click on your participants button, you should see my name up near the top somewhere. If you have any general questions about this series, feel free to email Candice there. Her email is on the screen or you can track us down on Twitter. One note is that there have been some technical difficulties over the weekend and so while all of these videos are being recorded and hosted on the AAP website, they kind of came down for a time over the weekend and they're going back up today. So if you didn't see them yesterday or if you don't see the one you're looking for today, just be patient and they should be back up hopefully at some point today. So without further ado, we're excited to have Dr. Kirby with us all the way from Halifax, Nova Scotia. Thank you Dr. Kirby. Nice to be here. All right, if you will click the green share screen button. Okay. Okay, so Now i've got that i'm not sure how to minimize this i'll take it back to my own, uh, my own meeting. Oh, yeah So I had that up before we started here, maybe i'll exit the full screen and uh, there you go see how that works Here we go You can hear me all right, yes Okay If you can see and hear me, that's great. I can't see and hear anybody there My topic today is a wheelchair skills assessment and training a special interest of mine I'm a physiatrist as mentioned here in halifax, nova scotia. The frcpc is how we designate specialty Qualifications in canada it stands for fellow of the royal college of physicians of canada So we often leave it out because it's a little bit of a mouthful I'd like to first start by declaring. I don't have any conflicts of interest, uh related to this talk I would like to acknowledge and thank the aap for this opportunity to talk to you about this special interest of mine Number of co-investigators and funding bodies over the years have supported this work and they can be found Acknowledged in more detail in our publications. I'm not going to spend time on that here. Dr. Kirby. Yes I can we can hear you but for some reason we can't see Uh your slides All right. Well, i'm not sure what to do about that. I apologize for that Let's try one more time. Click the green share screen button And then it should pop up a window that asks you which what you want to share and if you'll Kind of double click your slide deck. We should be able to see it from there Okay So share there we go. All right, can you see my slide deck I can see your desktop if you yep, click click. There you go Perfect that's perfect. Thank you. All right. Thank you. Um back on track uh i'm just working my way down the setting the stage slide here and just recognizing the target audience as being uh people in pm and r either practicing physicians or residents I'll focus a little bit with that in mind, although hopefully it would be of some use to others as well Uh as mentioned future reference this talk can be found through the aap recording of it and i'll also post the pdf of the of the powerpoint presentation on the Wheelchair skills program website more about which coming up Excuse me So the objectives for this particular section are listed here. I'll let you read them yourself It's going to work through wheelchairs in general and the provision process then getting into wheelchair skills in particular Talk a little bit about the research evidence not too much Detail, you'll be pleased to hear and then finish up with what the physician's role in wheelchair provision might be especially people in our specialty Regarding the importance of wheelchairs in my opinion the wheelchairs the Rehab intervention with the single greatest impact on the lives of people with serious mobility restrictions i've been saying that for years and inviting people to Contradict me with any kind of evidence and no one's come forward yet, but i'd be happy to hear about any If you're unconvinced you can sometimes think about this this statement in the reverse sense you think about the knockout model we use for studying what a particular gene does in mice, for instance the knockout model of Gene deletion and you see what's what happens after you knock out such a gene Well, you knocked out the wheelchair from all some any one person who's a regular wheelchair user And consider the impact on their life. It's a pretty tremendous one and I would argue the most important What I really like to discourage you from using is are these terms here The term that someone is wheelchair bound or that they're confined to a wheelchair Probably a more appropriate term would be wheelchair mobile or wheelchair empowered There's a term called n wheeled en hyphen wheeled w-h-e-e-l-e-d that is found in the literature as well But wheelchairs are not without their problems the benefits are listed on the left left side of this slide Mobility and participation we'll come back to later in this talk but also in reducing caregiver burden and There's some evidence that they were a good good wheelchair will reduce the likelihood of placement in a long-term care facility That's not to say they're without their problems listed on the right side and i'll give you an example of each of these I have studies that have documented each of these the first related to wheelchair fit or setup This is a relatively small study from italy But two-thirds of the wheelchairs that they looked at Wheelchair users were not suitable for them by the standards that they were using at that time pretty high percentage If you look at maintenance and repair problems, this is a study that came out of pittsburgh on over 2 000 people in various sci model centers And by six months 45 of these people had had to complete a repair. We wouldn't tolerate that in a car, but That they're fairly routine in wheelchairs In terms of chronic overuse injuries, there are a number of studies that have looked at this, but i'll just show this one example This is from germany there were 100 people with paraplegia And had had paraplegia for over 30 years and they used 100 age and sex matched able-bodied controls Then they did mris on them looking at for rotator cuff tears And for people with paraplegia the incidence was 63 Of the prevalence I should say versus 15 in the controls the dramatic differences there As far as acute injuries go 5 to 21 percent of people living in the community who are wheelchair users Experience injuries each year and that's cumulative So if you're in your chair for 10 years your chances of being injured at least once is pretty much 100 Just as an example of how that might occur i'm just going to show a little video clip here i'll show it Show it twice You watch you're on your own first. He's trying to get over a gap And That's an example of a tip or fall i'm going to show it again in a second but what happened there was that When he tried to pop his casters over the gap he bounced off his rear anti-tip devices and this sort of pushed his casters into the gap rather than over it and the Spotter wasn't quick enough to prevent that from happening. Here we go again. See if you can see that what i'm talking about So Yeah Now that might seem like a fairly slow motion, uh injury or accident I should say without uh injury in that case something i'm pleased to say But for someone who has osteoporotic lower extremities, uh that that amount of a fall is enough to cause a fracture of a tibia or femur They're well documented But even if you did nothing quote nothing more than injure a wrist If you're using your hands and wrists to get around Founding your chairs transferring and so forth then even a so-called minor injury can be major to that person So if we're going to try and check the balance here between The benefits and problems in favor of the benefits. One of the ways of doing that is better wheelchair provision Which leads me to the world health organization and it's 2008 guidelines on the provision of manual wheelchairs It says here in less resource settings and that was the focus of this particular set of guidelines But it's since been recognized that these guidelines apply in all parts of the world more and less resource This was a major Change in the way wheelchairs are considered or major recognition of how they ought to be considered And there's been a number of subsequent training packages shown here on this slide That have come out based on those guidelines and there's others as well that are under currently underway Essentially for this wheelchair service delivery model of the who there are eight steps and they're listed here To get referred assessed and measured The wheelchair prescribed funding and order needs to take place the product comes in it gets assembled Fitting takes place the person in the chair You're trained in how to use it and maintain it and that follow-up occurs nothing very surprising there but Certainly a difference from the commodity model of going into the local pharmacy and picking up a chair for your mom or dad Now the wheelchair skills program is is something we've developed here at Dalhousie back starting in 1996 and it's under continuous revision and upgrading and I encourage you to Have a look at some of the items on that website which we're going to show some of as we go forward here The wheelchair skills program deals with two of those who eight steps namely assessment and training And the two components of the wheelchair skills program are the wheelchair skills test wst and the wheelchair skills training program wstp Wstp Now if you go back to the website you click on the on the left side Where it says skills manual and forms you'll come up with a page looks like this if you click on the manual Link, you'll come up with a 300 page manual which goes into lots of details on specific skills on the general issues of assessment and general issues of motor skills learning And I encourage you to have a peek at that it's a reference manual not intended for everyday use Amongst those the things in that manual the wheelchair skills test has gone into a fair bit of detail The forms for the wheelchair skills test are shown here on that same page. I showed you earlier Of which i'll show the example of the manual wheelchair version. There's also a powered version And as you can see here in the second column of the individual skills i've only shown 21 of the 33 that make up the manual wheelchair skill set And they start with the simplest ones and move to the more difficult ones. This is just a simple single page Form that can be used to record the capacity From zero to three and i'll show you what that means in just a second but also room for comments if you go to the flip side of that form, you'll see that the Scoring rubric So to get a score of three you have to be able to carry out the skill In a highly proficient or advanced manner a two would be if you can do it independently and safely, but there's room for improvement A partial pass would be if you can do the majority of the evaluation criteria, but not all And so forth an NP means not possible. For instance, if a wheelchair doesn't fold you can't measure whether A person can fold it and there's also an opportunity to recognize any testing errors that occur Now the comments are as important as the scoring so in this particular example now this gentleman with a left above knee amputation was admitted to our rehab unit and prescribed an artificial limb and all this various therapies got started and we eventually got around to Looking at a wheelchair something we should have done earlier and as you'll see within a few seconds the whole process changes As you can see, this gentleman has the wheelchair equivalent of Arsha Petipa, or walking with small steps, which is characteristic of Parkinsonism. Of course, he wasn't doing any walking, so we couldn't have diagnosed this in advance. But that single five-second look at how he was propelling his chair sent us back to the drawing board. We canceled the artificial limb, got him on anti-Parkinson medications, got him a power chair. So the whole course of his rehab changed with just five seconds of observation. Now, this young lady has meningomyelocytes. She has used a chair at least part-time for many years, and she's attempting to get over one version of our soft surface, a gravel pit here. And she's making the common mistake that when you walk and push through something like this, you lean forward to try and apply more force to the wheels. But unfortunately, that causes the castors to dig into the soft surface and impair your forward progress. So you really should be leaning back. So that was something you can see from the wheelchair skills test, and it will be written in the comments, and the trainer would use that when coming back and helping her learn how to do that more appropriately. Now, if you go back to the website and go to the Pictures and Videos section there, you would come up with a page that looks like this. I'm going to show a full wheelchair skills test now. It takes about 15 minutes, so I'll comment as we go through. The one I'm showing is there on this website. It's this one here, manual wheelchair example number one, and the completed report form is on there as well. So let's go to that video. I think there's lots there for us to see and talk about. This is an able-bodied therapist who's simulating paraplegia. So we'll start with the first thing, which is rolling forward a short distance. She's got good propulsion, but her recovery pattern is not good. She should be recovering her hands below the level of hand rinse. Part of the skill is stopping at a predetermined location. Rolling backward a short distance, this is only five meters because you usually don't go very far. You'll see she starts to, what we call, fishtail there. She's having a little difficulty controlling her direction. She did a good job of looking over both shoulders, and she stopped well. Stopping on command instead of stopping at a predetermined location is currently part of the test, both forward and backward. And after you've asked them to stop, you see how much space they've taken just to come to a stop, and the same going backwards. And if they don't know where they're stopping, you just tell them to stop. This part is going to be integrated into the previous two in the next version of the test coming up in the next few months. Turning in place is done over a cross on the floor, as shown here. We look at how far she's displaced to one side, which gives us an indication that she's moving forward with one hand farther than she is moving back with the other. She does the same when going the other direction. So you start her off centered over the cross with the rear axles in the center of the chair. Turning while moving forward, there's different ways of doing this, but this one involves using our high-tech pylons, which is to say beer cups, spaced two meters apart, then 1.5 meters apart, and then one meter apart. And the farther you get, the higher your score of getting a three versus a two versus a one. This can also be done in a shorter space as an optional. Same thing is done in the rear direction. You see she's not quite as smooth in her turns, so she'd be getting already a two rather than a three. She would've had a three on the previous going forward, but she's more tentative here, swinging a little widely. And swinging widely can be a problem because the casters may strike obstacles that are... You're not just hitting the pylons, but you're hitting obstacles laterally. For training purposes, we do a variety of other turning methods, including drag turns and so forth, but this is for the test purposes. Swinging sideways is just starting about a meter and a half away from an obstacle, using as little forward-back space as you can, such as in an elevator, moving to one side and back when you're starting. You can count the number of steps that she takes and how much forward-back movement she takes, various ways of adding more sensitivity to the test if you choose to do so, for research purposes, for instance. Next is picking objects from the floor. There's three of them. There's a coin, a pen, and a cell phone. And she's doing a good job of this, so she would get a three on that. If there's any risk of her falling forward because she was shifting forward too far, we would've expected her to get swinging her casters to the forward trailing position as they are shown here. For relieving the weight on the buttocks, we encourage people to use the side-leaning or forward-leaning technique. Push-ups are no longer recommended because you can't sustain them for long enough, although you should be doing this for a couple of minutes, every 20 minutes. For testing purposes, we just do it for 15 seconds to ensure that someone's capable of getting into the position and sustaining it for a reasonable period. The level transfer can be done. She's simulating paraplegia. You start basing the transfer surface. They have to maneuver themselves into position. These breaks are a little sticky. We'd make note of those. The therapist, there's a scissor variety. She hasn't swung her casters forward, but she didn't tip her chair partly, so forgive her for that as far as scoring goes. While she's out of the chair, we would have her fold and unfold the chair, which is the next one on the list, before getting back into it. Now, if it's a rigid-frame chair, it still does hold. You try and get it into a smallest configuration by removing the rear wheels and folding it back down, which is what she's doing here. If someone can't remove the rear wheels easily, it's usually because the brake is on. Of course, the back folds down by pulling a little string that releases the latch and having... Most of these skills, they're two-directional, so if you're going to fold the chair, you have to unfold it. She's pretty accomplished at this. It doesn't take very long. This objective test may not be as representative of real performance as using a questionnaire because people usually do this sort of chair breakdown when they're getting into their car, where they may have their steering wheel or the seat belt strapped to lean on. In that way, the questionnaire version may be more valid than the objective. Getting through a door, go through it both opening towards you and opening away from you. As she initially moved herself out of the way of the door, that's the first step. Her closing technique is just to pull it with her as she goes through. Don't lose any points by turning the chair. Don't lose any points by turning around and coming back and closing it behind you. Opening the door or going away from you. This is an unweighted door for the purposes of the wheelchair skills test, but for training purposes, we stand behind the door and put a little pressure on it to convert it into one that's an automatic closing type. The longer distance in the current version of the wheelchair skills test is 50 meters. Again, she's having the same problem with her propulsion. She's got nice long strokes with a 90-degree contact angle, but her recovery is back along the hand rims, the so-called arc recovery pattern, rather than the recommended semicircular pattern where your hands come back to the starting position below the level of the hand rims. But she's got good long coasts, so there's not a lot to improve on here, but she would get a two rather than a three. The slight incline is five degrees. That's the standard one-inch rise in 12. She leans forward nicely when going up. We would go up the steep one immediately afterwards, but for the purposes of the video, we're coming down. On the way down, we expect her to lean back and on command to be able to stop and show control and stop at the bottom without any runaway. So she'd get pretty much full points for that. The steep incline, she has some transient tips here. A couple of them there on the way up, but they recovered on their own, so she wouldn't be deducted any points. Then coming back down, she stops partway. Probably should be leaning back a little farther. We'll see her come down a little later in the wheelie position, but that's a separate skill. If she came down in the wheelie position here, she'd get full points for both of those scores. This is the side slope, which is five degrees. We expect her to get across it without drifting downhill more than 10 centimeters from her starting position. Again, doing it in both directions. People with hemiplegia may have a little difficulty. Their propelling foot and arm is downhill, but when they attempt to do it uphill, it's almost impossible. The soft surface can be the gravel we showed earlier or a gym mat, as we showed here. Keeping your weight back enough that she's getting her casters up and out of the surface for each push. They don't have to come all the way off, but it's nice to see that they're not digging in. Getting over an obstacle, she does a good job here. Popping her casters. The casters are still in the air when the rear wheels hit. We would call that caster slap, the same thing she does here at the gap. That can lead to problems when getting up curves, but in fact, on the slow curve, she doesn't have that problem. Getting down a two-inch curve like this, you can just simply roll forward. It's reasonably safe, but for a higher curve, we don't allow that forward technique. You start them a meter and a half away from the high curve, but you're allowed to back out farther if you wish to use the momentum that you pretty much have to do for a high curve ascent. Pretty good job on that. Coming down the high curve, do it in the wheelie position. That's something we do later as a separate skill. She could do it as that, but she's chosen to demonstrate for us here how to come down backwards. It's important to keep the wheels moving here, because if you were to stop once the rear wheels hit, she would tip over backwards. Now, we have a level transfer, but there's also a wheelchair to floor and back transfer. See how she backed up there to get her casters trailing forward, so that improves the forward stability of the chair. Shifting the bottom forward, getting your feet on the floor, and she uses just like before, hips move one direction, while the head moves in the other direction. Now, before getting back in, she's taking the cushion off. The reason why we teach people to do that is that it has two effects. One, it raises the starting position. Let's say it's a two-inch cushion by two inches. Second, it decreases the target position by two inches, so you get a net gain of four inches by taking the cushion off. Now, once she's back in her chair, she doesn't have to get the cushion into position. This is recognizing that many people get back into the chair after falling out of it, and once they get back into the chair, they can wheel somewhere to it, or they can transfer out of the chair, reposition the cushion, and so forth. The stationary wheelie has to be maintained for 30 seconds. She would not get full points for this. 30 seconds, but she's a little jerky, so showing reactive balance strategy here, the initial few seconds anyway, and then she gets a little bit of proactive balance strategy where she keeps the wheels moving forward and backwards slightly to help maintain her balance. When she lands, we'll check where she is relative to her starting position to see if she used too much reactive balance. She's not bad there. She pretty much lands where she started from. This is a prerequisite to being able to do the subsequent skills, such as, well, that she missed on her first attempt, so she wouldn't get a three. She would get no more than a two for this attempt at turning in both directions. She's a little jerky as well, and she's a little offset to one side, so there's a couple of things to work on with that. Now, she does the same thing the other direction. You're permitted to land between, from the wheelie if they start over again before going in the second direction, but you don't have to. You can see she's leaning forward a little bit. The fact that she's leaning forward that much means her casters have to be farther off the ground for her to be in a wheelie balance position, so we would have her sitting more erectly for that. Next one is moving forward and backward in the wheelie position. Especially the forward is important for approaching the edge of a curve or an incline. You do it by allowing yourself to dip forward and then catching up with the wheels. It's like standing balance. If you move balance forward, you step to correct your balance. We use that for walking. It's a control fall. The same thing with wheeling forward or backwards. It's a control fall. Like most people, she's a little more tentative going backwards, a little more fear-generating. You don't usually have to go back as much as forward for your advanced wheelchair skills, but we test in both directions. Here she is. She's declining to come down from the high curve six inches, but she could get partial points if she does it well from the intermediate height, which is four inches. She's going to try that. Here we're using two spotters. One behind to guard against rear tips and one in front to help guard against her falling forward out of the chair if her pastures were to land before her rear wheels. She doesn't make it. She falls backwards, spotter intervention. That's a fail, a zero for that. Similarly, she's not good enough control to get down the incline. She falls backwards. She's got a zero for that. She needs to be a little better with her wheeling forward in the wheelie position before really attempting those skills, but she's showing it for demonstration purposes here. Getting up the stairs can be done in the wheelchair by exceptional individuals, but it's not great for the shoulders, so we don't recommend it. We will teach it if someone assists, but we recommend people, if they have stairs to deal with, to get out of the chair and bring the chair up one step at a time in a sitting position so you do basically a level transfer from the wheelchair over onto the stair. Reposition yourself over to one side. Create room for the wheelchair. Position the wheelchair so that you can get it up at the same time you're getting yourself up. These are only three stairs. That's sort of the minimum we expect for testing and training purposes. Obviously, if you've done more stairs, you just repeat the same thing over and over again. She tips the chair back and brings it up to the same level she's sitting on. Now she can push down on the backrest to keep the chair from rolling away and use that as she's pushing down to raise her buttocks up onto the next level. She's got a nice little trick here where she takes the wheelchair up and positions it out of the way before she gets herself that last little bit. We expect her to get completely up onto the upper surface, but we don't expect her to get into the chair because we've already assessed that previously around the wheelchair transfer. Now she could come back down the stairs, which is the next skill. She could come back down the same way. But for demonstration purposes and what we usually teach is coming down the stairs backwards, holding onto one or both handrails. She's a little indecisive about which technique to use, but she would still get full points for this. She uses two hands on one handrail. The spotting position for this and for the high curve is the hands near the push handles. Not actually touching them, but ready to prevent rear tips run away or asymmetry, sideways tip. That's the complete wheelchair skills test in 15 minutes. And as I say, you can watch that online yourself. Now there is a questionnaire version of the WST, the so-called WST-Q. The form is shown here. They're the same skills that we just talked about and illustrated. But in addition to the capacity column here, which is pretty much the same as for the objective version, we can also assess confidence and performance. And of course, going to record whether this is a goal or not. If you move over on to page two, the definitions for capacity, confidence, and performance are shown, and I'm not going to take the time to go into that level of detail. The therapist can either administer this questionnaire and record the answers on the front, or you can pass the script version of it, shown here, to the wheelchair user with or without the caregiver's help to complete on their own so you don't have to spend time doing it. Now, in addition to the scores and comments for each of the individual skills, we also can calculate total scores. For the wheelchair skills test, the objective test, only the capacity score can be calculated. This is based on the number of skills passed over the total possible, subtracting, of course, any no part or testing error from both the numerator and denominator. But for the questionnaire version, as you can see, in addition to capacity, I can assess someone's confidence and performance, and I get an overall percentage score. If you go back to the website and move down the left-hand menu there to the section called publications and impact, click on that, you'll get a page that looks like this. And if you click on this top link, it's a dynamic link set up by our healthcare librarian that will do an immediate search for anything related to the wheelchair skills test or questionnaire version, either studies that are directly about those two assessment methods or that have used them as outcome measures. So as of last week, there were 84 papers that came up in that. Now, just as an example of one of those papers, measurement properties of the wheelchair skills test for scooters, for instance, what's the reliability, validity, and so forth. That's the type of paper you'll tend to find in there. So let's move on to the wheelchair skills training program, the user training part of this presentation. The wheelchair skills training program consists of two main components, the process, how to teach, and what we try and use here, the best available evidence from the motor skills literature, of which there are about 50 papers a week in the English literature. It's amazing. And content, what to teach, what are the training tips. We'll show an example of each. So in this video here, we're going to be seeing two motor skills principles. All of these principles would be recognizable to anyone who's ever taught anything or learned something like tennis or bowling or how to play the flute. So segmentation is one of them. So in this case, the person demonstrating here is showing how to pop the wheels up onto the curb, just getting used to test popping them the right amount. And she's using augmented feedback through the mirror. So those are two motor skills principles illustrated by this video. If she leaned forward to look at her casters, of course, she would imbalance the chair and she wouldn't be getting the right feedback. Now, this is about content. We showed one way of coming down stairs backwards. But if you're highly skilled and if the run, the horizontal part of the stairs long enough, then one can come down in the wheelie position. You'll see this gentleman's technique is just excellent. As he lands in each stair, he leans back on the vertical part of the stair before re-positioning his hands, moving forward. You see that forward dip and then he moves forward. This gentleman was a peer trainer that we were doing some work with in Nepal. Now, if you go back to that publications and information, you'll see tha peer trainer that we were doing some work with in Nepal. Now, if we go back to that Publications and Impact page and move down to this lower dynamic link and clicked on that, you would be taken to anything that, any paper that's been published about the Wheelchair Skills Training Program, of which, as of last week, there were 51, including 16 randomized control trials and two meta-analyses. As you know, the meta-analysis, the systematic review is considered the pinnacle of the evidence pyramid. So we'll just give one example. This is the more recent of the two meta-analyses. The one we published in 2018, it was based on the first 13 of those randomized control trials. And I won't show all of the forest plots, but I will show this one as an example. So I'm sure you're familiar with forest plots, that anything that ends up on the right-hand side of this line is good and anything that's bad is bad. If you look at the 13 papers overall, this would be the representative diamond showing the positive effect of about 20% relative to pre-training levels. However, if you break this down, as we've done in this forest plot into experienced users at the top and new users at the bottom, you can see there is an effect, even with experienced users, and we've seen that in our own practice, but there's a much bigger effect, about five times larger effect for people who are new wheelchair users. So that's really the state of that. In addition to the classic evidence pyramid, there's also the levels of evidence by Kirkpatrick, first published in 1994, to talk about different aspects, not just about the evidence for improvement, but so what. So down at the lowest level here, satisfaction that people enjoy, they like to receive the training, and yes, they are almost always very positive about it. Does it have a positive effect on what it is you are training, which is capacity? Yes, we've seen that. That's been shown in the meta-analyses. Does this alter their behavior, which is to say, do they then use those new skills out in the real world? That's where the performance part of the questionnaire comes in, and there's less evidence on that, but that is just accumulating. And then finally, is there an impact? So what? So you can do these skills, and you do do the skills, but does that make any change in your life? Well, there have been a number of studies relating wheelchair skills to other positive outcomes, such as return to work, and so forth. But I'm just gonna show one example of a study that where you can look at this. I'll come to the study in just a moment. This is just another indication of the impact of the Wheelchair Skills Program, as such, sort of a graded map of where in the world people are using our website. And we post our web statistics there about every six months. And as of January of this year, there were almost 120,000 users from 188 different countries. So that suggests a certain amount of impact out there. And we've also done training programs in a variety of parts of the world, and they seem to work well no matter where you are. It's a very low-tech form of intervention, so it's not difficult to do it in remotest areas. How we're using a study is probably a better way to look at impact. And in this particular study, which was published in 2019 in the archives, looked at wheelchair users in Kenya and the Philippines, a total of about 800 people overall. And the focus of this particular paper was on looking at which particular wheelchair, World Health Organization services were associated with positive outcomes. So along the left-hand column here, these are the services received with the current wheelchair. We've taken those eight services and broken them down into more detail, such as did the provider check for unsafe pressure at a seat surface? Did the assessment take place at home? Did it assess more than one thing? Did those sorts of things. And at the bottom, a total composite score, zero to 13 of the number of services that were received by people. And across the top here are some broad outcome measures related to participation, such as daily wheelchair use, outdoor unassisted wheelchair use, high performance of ADLs, absence of serious falls. And here's a composite of positive outcomes. So the key line here that we're looking at is over on this side. And if you look at all of the outcomes and all of the services, there's a positive relationship between the number of services received and the extent of the positive outcomes. But if you look at the individual skills here, and each of them see how well it contributed to the overall positive outcome. The one that had the greatest benefit was provider did training. So there's an example of how training, there's some evidence of training providing a positive impact on things that aren't related specifically to the Wheelchair Skills Program. So you might say that I've made a convincing case that wheelchair skills assessment and training is fairly easy to do, and there's evidence that it's beneficial, and it's a reasonable assessment method. So you would think that it would be out there and being used on a regular basis. However, knowledge translation doesn't always occur as quickly as it ought to. So this study, which was just published last month, it's only available online at the moment, as an e-publication, the Disability and Rehabilitation Assistive Technology. We looked at 110 occupational therapists practicing in Nova Scotia, and less than half of them said that they, yes, regularly trained either wheelchair users or their caregivers about the same percentage for each of those. This is in spite of about three quarters of these therapists that believing that was very important to do so, and only half of them actually did it. The training that they did describe doing was inadequate, really. It would be 30 minutes to 60 minutes, and on one or two occasions. So really an inadequate dose of training, even for those who did do it. So this is really suboptimal for sure. So if you think about knowledge translation, as illustrated here, more cartoon we made up. Currently, you may have a fair amount of evidence that it's accumulated, but only after a long time do you get some of it going into practice, simple evidence-based practice. Now, this would be better if everything for which there was evidence did make it into practice, and it did so in an even shorter period of time. That would certainly be a step in the right direction. However, our view of this is that you don't need to wait till all the evidence is before you begin to use it, and that this arrow should be bidirectional. So in the course of using it, you develop new questions and come up with new evidence. So that's sort of really an iterative, upward spiraling way of progress rather than a simple moving from left to right. And Voltaire said that perfect is the enemy of the good, so we don't need to wait until this wheelchair skills program is perfect before we begin using it. Now, I said as one of our objectives that the physician's role would be something worth chatting about briefly. Now, I've just jotted down a few of them here, a few ways in which physicians, especially physiatrists, might become involved in the wheelchair provision process. Well, this first one about detecting problems. We tend to work as physicians in a team format, almost always, especially in rehabilitation. And the nurses, for instance, are our ears and eyes, so that we're making rounds in the morning. If they come up to us and say that Mr. Jones has cloudy, smelly urine and has got a slight temperature, then that's a detection of a problem. We go in and figure out that he's got a urinary tract infection, decide whether to treat it or not. So just in that same way, we can be the detectors for other members of the team who have responsibilities. The team member who's most responsible for wheelchair provision is usually one person on your team. In Canada, it's usually an occupational therapist. In the U.S., it's maybe an OT or a physiotherapist. But for whomever is doing it, you can be the detector to identify when somebody seems to perhaps need a wheelchair that has been walking up until now, or has a problem with a wheelchair that needs to be solved or an unmet. They should be functioning at a higher level than they are actually functioning. That's us detecting problems and passing it on to the people who can help solve the problem. In the example of, for bullet number two, we're being an advocate. All too often, in the early rehabilitation phases of people with acute loss of function, for instance, after a spinal cord injury or an amputation or a stroke, people hope to get back to walking, and some of them do. However, that emphasis on walking can mean that they're unprepared to really take very seriously the notion of getting back their mobility through the use of a wheelchair. We can help to advocate for those who are, not to say that walking should be off the menu, but move forward, rolling for now, maybe walking later, or do the two simultaneously. If they're saying, well, no, I don't wanna learn how to use a wheelchair, I don't wanna order a wheelchair, well, we need to help talk them out of that. We need to support our team members in achieving that. As far as facilitating the process, of course, it's for the OT or the PT to begin the process. They have to get the referral. And also, once the process is completed, you need to see people back and follow up to make sure that the chair is still working for them. It doesn't need to be modified in some way. We can also be in a position to suggest solutions. So, for instance, someone who's having no difficulty getting around indoors, but is having problems meeting all of their environmental needs due to weak upper extremities or the distances they need to travel. If we're aware of the fact that power assist can be added to the wheels of a manual wheelchair or added to the camber tube at the back of the chair, we can suggest these solutions. And if the person's willing to consider it, again, make the referral with that in mind. We can also participate in the assessment and training of wheelchair skills, looking for those opportune moments. For instance, in the clinic, when somebody is coming into the clinic from the waiting room, watch them come in. Watch how they wheel. Don't open the door for them, ask them to open it themselves. Watch as they transfer to and from the plinth on which you're going to be examining them. You see somebody on your ward, rolling using that same pattern I showed you just a moment ago, not using the appropriate propulsion technique, and sort of stop and say, hey, I thought you were supposed to bring your hands back below the push rims. And you could be reinforcing the things that they're learning in therapy. And of course, you can participate by helping to close knowledge gaps by carrying out research in this area of mobility, which is so important. So return to our session objectives. Hopefully, let's just review them. Hopefully, we've kind of made the point about the importance of wheelchairs, the eight steps involved in the wheelchair provision process advocated by the World Health Organization. You're aware of the Wheelchair Skills Program, which is a free online resource and how you might maneuver yourself inside that website. All of the materials are free there. The extent of supporting research evidence, all you really need to know is there's a fair bit of it about measurement properties of the wheelchair skills test and questionnaire. And there are a couple of meta-analyses supporting the use of wheelchair skills training. And finally, the physician's role in wheelchair provision. There are several opportunities for you to get involved in this and to stay involved in it. So that concludes the formal part of this presentation. And I will get rid of that. Can we go back to unsharing the screen now, please, Sterling? So we just get back to seeing people or taking questions. Oh, yes. Sorry, I'm trying to, there we go. There we go. All right. All right, excellent. Thank you. I have a couple of questions for you. One is, so, hold on, I'm looking at my notes here. Oh, yes. So there appear to be a fair amount of, how do we say this? It felt like there was a fair amount of experience required to appropriately score these tests. There were a couple of times that you said she would get two points here instead of three because she swung her wheels wide or because of this technique or because the way she was managing the wheelie and that sort of thing. So are all of these scoring criteria like fairly explicitly spelled out or is there a subjective kind of experience-based component? Both, there's a car going by in the background. Sorry for the noise. It's a garbage truck pulling up in front of our house. Yes, there's the general scoring criteria which are on page two of the form. You flip it over and refer to it as you're going along. But they're written in such a way that it's fairly straightforward. If you can't see any way of improving on this, then you should get a three. If they do what they were supposed to have done and there's room for improvement, it's a two. But then more detail about each of the skills in turn can be found in the manual. So there's like maybe five pages of details if you were gonna use this as a research technique, let's say turning in place. But you don't need to use it at that level of granularity. I mean, at the low level of granularity, you just watch them do it and say, just use the comments. Tina, they seem to do it well and I can't see any room for improvement. That's all you really need to do. You don't need to use the form. You don't need to use the wheelchair skills test but you should be doing some assessment of the wheelchair skills either by asking them, tell me about your chair. Where do you use it? What do you find difficult? It's just the usual sorts of things we do in interviews are things that a physician can do. And the therapist can easily, we've written the manual in a way that if you just went through and used nothing but, you would be able to do the testing. We wrote it with that in mind. We didn't want it to be that you had to come and take a course or pay for any credentialing to be able to use the materials. And as a testament to that, it's been translated by a number of other countries into their own language without ever taking any training on it and they're using it, doing studies on it. Okay, that's helpful. I also know that there's a, you showed this map and there's obviously wide uptake across the world including low and middle income countries. Is this designed more specifically for low income settings or is this just as effectively introduced in like high resource settings? No, it's for anybody. You don't have, in the examples I showed, we have a 2,400 square foot room where we have these obstacles laid out and that's nice to have them all there when it's snowing or raining outside. But in fact, all of these obstacles are based on ones that are there in the real world. Whenever we go on the road, either to less resourced areas or to give courses at conferences, we never have any trouble. We usually walk around for about an hour ahead of time before the course, find all the obstacles we need to say, okay, we're gonna check the incline there and the stairs there and the soft surface over there. There's no difficulty in finding these things. But yes, it was back in about 1994, I think, that we had a visitor from the World Health Organization come and have a look at what we were doing. And he sort of sat there and he pondered and put his hand on his chin and said, this is a very low tech, high impact intervention. And we never really thought of it that way, but we thought and said, yeah, you're right, it is. We like the fact that it is, but we've also tried to stick with that, even though we've used other higher tech means, such as instrumented wheels and so forth to help document the content part of the training. Why should you do a wheelie using a proactive balance strategy? For instance, we've done studies on that and we don't use low tech outcomes necessarily for that. So we use high tech for answering questions, but once the question is answered, we try and implement it in a low tech way, where is it accessible anywhere? That's helpful. And I think that goes to address my next question. I was gonna ask that your setup, you mentioned this 2,400 square foot room, which is fantastic with all the, you had a curb in there, you had some false curbs, you had marks on the floor and this big wooden contraption for stairs and ramps and that sort of thing. It seems like if you don't have a 2,400 square foot room that you could kind of cruise around the community and find similar obstacles, is that correct? Yeah, I bet you any one of you who are on the call could in the next hour, if you went out, you could find every one of those obstacles, probably less time than that. And so if you're working in a rehab center, your physios or your OTs already know where those places are and they're already taking their patients there to assess them and train them. And if they're not, they should be. Okay. One question that came in, I think is relevant. So basically, some of these skill sets might be impacted by an ill-fitting chair. So can you kind of comment briefly on the wheelchair fitting process that we can identify patients who might score differently because their chair is improperly fitted? Yeah, well, that's a good point. And it's a point we make in the manual, but the wheelchair skills test is a sensitive test. So that if you've changed something as simple as the rear axle position, moving it two inches forward, you dramatically change the performance of the chair. So that doesn't mean that you shouldn't be using the wheelchair skills test, it's a way of identifying when you're making the right intervention or the wrong intervention. And it's not uncommon in our center for us to get in sort of test chairs when we're looking at prescribing something with a new chair, allow people to try the couple of chairs. And we put them through all 33 skills with each chair, but a reasonable facsimile of skills in the two different chairs and see how they like them for those purposes. I like that one for going up the incline, but it burns the high friction on the push handles or hand rims, burns my hands on the way down. I'd rather have the slippery metal ones than those rubberized ones. It's just building the assessment in the chair into the process. That study I told you about just published last year in Kenya and the Philippines, I didn't tell you that the second most common individual thing to have a positive impact was assessing the person in the chair during the fitting stage. I told you training was the number one while assessing them during fitting was the second most powerful one. And the third was a peer trainer. So those are the top three, but you can read the paper if you like for more detail. That kind of deals with your question, I think. Yes, it does. Thank you very much. I appreciate it. All right. Sorry, kind of lost audio there for a second. I think, yes, we do. We have your email address here. If you are available for further questions, if they come up, can they contact you at that email address? Yes, of course. I'd love to hear from people. Excellent. Thank you so much for joining us today. We appreciate you taking the time. And again, thank you to everyone who joined us today. If you have any questions, Dr. Kirby's email address there on the screen, you can track us down on Twitter. And again, as I mentioned before, there were some technical difficulties this weekend, so there may be some delay in getting some of these videos back up. But hopefully by the end of today, first thing tomorrow, these all should be back up. And if any of your residency colleagues or anyone are unable to see these live, then please encourage them to go to the website there and see them there. Again, Dr. Kirby, thank you. And- Thank you for the opportunity. I appreciate it. Absolutely. And we'll see everybody tomorrow. Thank you.

wheelchair skills assessment

wheelchair skills training

World Health Organization

eight-step wheelchair provision process

Wheelchair Skills Program

Wheelchair Skills Test

Wheelchair Skills Training Program

mobility

physiatrists