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WHEELCHAIR SKILLS PROGRAM (WSP)© VERSION 4.2

1. Training tips for Not generally applicable powered wheelchairs operated by wheelchair users Training tips for Not generally applicable powered wheelchairs operated by caregivers Originally approved for distribution and use April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 WSTP 4 2 Manual 143 7 39 Descends stairs Versions applicable e WSTP M WCUY WSTP M CGY e WSTP P WCU X WSTP P CG X Description e The wheelchair user and the wheelchair get from the top to the bottom of a set of stairs General training tips e As for the ascends stairs skill but in the reverse direction e 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 Out of the wheelchair on the buttocks or on hands and knees wheelchairs operated by e Reverse of ascent procedure wheelchair users e 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 Facing up the stairs as above but using one hand with the other hand on the no
2. Originally approved for distribution and use April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 33 WSTP 4 2 Manual 7 1 Moves controller away and back Versions applicable WSTP M WCU X WSTP M CG X WSTP P WCUY _ WSTP 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 General training tips e 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 e Not applicable manual wheelchairs operated by wheelchair users Training tips for e Not applicable manual 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 controller 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 fing
3. Not applicable powered wheelchairs operated by caregivers Originally approved for distribution and use April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 WSTP 4 2 Manual 123 7 33 Performs stationary wheelie 30 sec Versions applicable e WSTP M WCUY WSTP M CGY e WSTP P WCU X WSTP P CG X Description e The learner achieves the wheelie position maintains it for 30 seconds and brings the casters back to the floor General training tips e Adjustment tips e 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 less 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 e If any rear anti tip devices do not allow the wheelchair to be tipped back far enough they need to be adjusted out of the way or removed Even for rear anti tip devices that do permit a wheelie to be performed they may not be sufficiently stable to prevent a full rear tip To check this tip the occupied wheelchair until it is resting on the rear anti tip devices With a spotter behind the wheelchair the wheelchair user should try to tip the wheelchair over backwards by reaching and leaning backwards Training tips for manual e The descript
4. 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 Originally approved for distribution and use April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 17 WSTP 4 2 Manual 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 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 doin
5. and performs stationary wheelie 30 sec skills The caregiver should be careful not to let the wheelchair user s elevated feet hit anything Training tips for Not applicable powered wheelchairs operated by wheelchair users Training tips for Not applicable powered wheelchairs operated by caregivers Originally approved for distribution and use April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 133 WSTP 4 2 Manual 134 7 37 Gets from ground into wheelchair Versions applicable e WSTP M WCUY WSTP M CGY e WSTP P WCUY WSTP P CGY Description e The wheelchair user gets from the ground into the wheelchair 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 e To get from the wheelchair to the ground the trainer may assist using a lift if available If it is a feasible goal of the wheelchair user to be able to independently get to the ground then the steps described below for getting from the ground to the wheelchair can be reversed Training tips for manual e Getting from the wheelchair onto the ground is an wheelchairs operated by opportunity to practice safe falls onto a mat wheelchair users e Generally the wheelchair user should not reach out towards t
6. 2013 Current edition WSTP Version 4 2 2 April 17 2013 12 WSTP 4 2 Manual 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 helpful 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 D
7. Originally approved for distribution and use April 4 Current edition WSTP Version 4 2 2 April 17 2013 2013 75 WSTP 4 2 Manual wheelchair user should remove the transfer board The wheelchair user should lean away from it to do so Forward 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 Transfer Into Wheelchair e General 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 he she 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 residual limbs s Persons with Hemiplegia e Ifthe 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 diff
8. 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 Training tips for manual wheelchairs operated by wheelchair users Not applicable Training tips for manual wheelchairs operated by caregivers Not applicable Training tips for powered wheelchairs operated by wheelchair users 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 to behave erratically Variations e Rolling the hand onto and off of the on off switch may reduce the need for fine finger dexterity e Using larger movements and body parts may allow Originally approved for distribution and use April 4 2013 Current edition WSTP Version 4 2 2 April
9. commonly recommended for wheelchair users propelling on smooth level surfaces After releasing the hand rims at the end of the propulsive phase the arms can be allowed to swing in a pendular fashion back towards where the propulsive phase will begin for the next propulsive cycle To reinforce this the trainer can ask the wheelchair user to touch the axles center of the rear wheel during each recovery phase This allows the hands to make initial contact with the hand rims while moving upward reducing any impact e Wheelchair users with weak and insensitive hands may prefer to slide the hands back along the hand rims the arc recovery pattern rather than letting go at the end of the propulsive stroke but this may cause some braking to occur Short strokes with arc recoveries may be appropriate for propelling short distances in confined spaces when fine control is needed 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 Originally approved for distribution and use April 4 2013 Current e
10. 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 April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 22 WSTP 4 2 Manual 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 skill 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 eve
11. 17 2013 WSTP 4 2 Manual users to switch toggle levers on and off independently if fine motor control is not available Training tips for powered wheelchairs operated by caregivers As for powered wheelchairs operated by wheelchair users On off switches may be located on an attendant control unit 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 The attendant control will override that of the wheelchair user Originally approved for distribution and use April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 WSTP 4 2 Manual 7 3 Selects drive modes and speeds Versions applicable WSTP M WCU X WSTP M CG X WSTP P WCUY WSTP P CGY Description The subject operates the controller to switch between drive modes and or speeds General training tips Adjustment tips The type of mode switch used will have an impact on success for some users 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 In some wheelchairs the mode and speed controls are separate 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
12. 4 2 Manual 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 e Not applicable Training tips for powered wheelchairs operated by caregivers e Not applicable Originally approved for distribution and use April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 86 WSTP 4 2 Manual 7 19 Rolls 100 m Versions applicable WSTP M WCU WSTP M CGY WSTP P WCUY WSTP P CGY Description The learner moves the wheelchair 100 m on a smooth level surface General training tips As for the rolls forwards 10 m skill Progression e Start at a slow speed and increase as tolerated Start ina 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 reach Training tips for manual wheelchairs operated by wheelchair users As for the rolls forwards 10 m skill Endurance may be a limiting factor if the wheelchair user is deconditioned Variations e If the wheelchair user prefers to do so he she can perform this skill in the backwards direction Tr
13. Ascends curb 15 cm v i x X Originally approved for distribution and use April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 WSTP 4 2 Manual 32 Advanced Descends curb 15 cm y X X 33 Advanced Performs stationary wheelie y y X X 30 sec 34 Advanced Turns in place in wheelie x y X X position 180 35 Advanced Descends 10 incline in y X X X wheelie position 36 Advanced Descends curb in wheelie K X X X position 15 cm 37 Advanced Gets from ground into y X y x wheelchair 38 Advanced Ascends stairs X X X 39 Advanced Descends stairs y v X X Abbreviations and symbols WC wheelchair WCU wheelchair user CG caregiver Y included X not included Originally approved for distribution and use April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 WSTP 4 2 Manual 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 of 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 li
14. Children especially may learn best through play rather than through formal training on a skill by skill basis Originally approved for distribution and use April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 14 WSTP 4 2 Manual 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 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 train
15. Current edition WSTP Version 4 2 2 April 17 2013 WSTP 4 2 Manual 7 16 Relieves weight from buttocks 3 sec Versions applicable WSTP M WCU WSTP M CG Y WSTP P WCUY _ WSTP P CG Y Description The learner relieves weight from both buttocks although not necessarily at the same 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 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
16. X X y back 2 Indoor Turns controller on and off x X y 4 3 Community Selects drive modes and X X y speeds 4 Indoor Operates body positioning X X X options 5 Indoor Disengages and engages X X x motors 6 Indoor Operates battery charger X X y y 7 Indoor Rolls forwards 10 m y 4 8 Indoor Rolls backwards 2 m y y 9 Indoor Turns while moving forwards K y 90 10 Indoor Turns while moving y y x backwards 90 11 Indoor Turns in place 180 y y y x 12 Indoor Maneuvers sideways 0 5 m y X y 13 Indoor Gets through hinged door x X K 14 Indoor Reaches high object 1 5 m y X k X 15 Indoor Picks object up from floor X y X 16 Indoor Relieves weight from y y x buttocks 3 sec 17 Indoor Transfers to and from bench v y 18 Community Folds and unfolds wheelchair y y X X 19 Community Rolls 100 m y E X x 20 Community Avoids moving obstacles 7 y a x 21 Community Ascends 5 incline Y y y 22 Community Descends 5 incline y v x 23 Advanced Ascends 10 incline Y y x 24 Advanced Descends 10 incline v y y y 25 Community Rolls across side slope 5 v af Ms 26 Community Rolls on soft surface 2 m x x 27 Community Gets over gap 15 cm x y x 28 Community Gets over threshold 2 cm y E 4 y 29 Community Ascends low curb 5 cm y y y 30 Community Descends low curb 5 cm Y Y y 31 Advanced
17. all If using this method 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 Originally approved for distribution and use Apr
18. approved for distribution and use April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 WSTP 4 2 Manual 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 through a door e Variations e Ifthere 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 sit on an armrest 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 For a narrow doorway one option is for the caregiver to remove one rea
19. 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 April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 WSTP 4 2 Manual 3 SPECIFIC ISSUES OF IMPORTANCE FOR MOTOR SKILLS LEARNING 3 1 The Learning Process In the course of learning a new motor skill the learner progresses through stages Early in the process success may be partial inconsistent or only possible in a familiar setting As le
20. downhill edge to avoid veering off the path Training tips for manual Adjustment tip Moving the rear axles forward reduces the wheelchairs operated by downhill turning tendency wheelchair users e Side slopes require significantly more energy to push across e The wheelchair user should lean backwards to keep the weight away from the casters e Two hand propulsion e To avoid turning downhill the wheelchair user should push harder on the downhill wheel e Different push frequencies may be used for the two hands For instance when moving across a side slope with the right side downhill the right hand may push 2 3 times for every 1 push on the left e When pushing longer distances route planning can be used to avoid overuse on one side For instance part of the journey can be carried out on the right hand sidewalk where the left side is downhill and part of the journey on the left hand sidewalk Insome cases the uphill hand may be used exclusively for braking to minimize downhill turning tendency rather than for assisting with propulsion e Shorter stokes may be used to keep the wheelchair Originally approved for distribution and use April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 WSTP 4 2 Manual moving straight e 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
21. forth across the incline slalom or zig zag to decrease the apparent slope Pylons can be set up to provide a path for the wheelchair user to follow The more turns used the lower the effective slope but the greater the distance travelled 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 the rolls across side slope skill Progression e Start with the wheelchair stationary at the lower end Originally approved for distribution and use April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 WSTP 4 2 Manual of the incline and progress to a moving approach e Start with a minimal incline and proceed to more extreme ones e Variations e Grassy inclines cobblestone or loose rock e Stopping and steering on the incline Training tips for manual wheelchairs operated by wheelchair users e Adjustment tips e A heavy knapsack will reduce rear stability It can be moved to the lap e At the lower transition either ascending or descending the clearance of footrests can create problems e 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 unable to be used for propulsion or braking e The wheelchair may be equipped with gra
22. goals are Use a reaching aid to pick up a 1 coin from the floor Tilt seat to 40 degrees and return to the upright position Get the wheelchair up a 2cm level change Appropriately modify the tilt position of the wheelchair to maintain trunk stability while descending a steep incline and Cross a 2 lane city street with curb cuts A broader goals e g to go shopping can be broken down into the constituent skills that make it up 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 learning 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 For another wheelchair user
23. has been designed to be reasonably self explanatory and to reflect normal clinical practices 3 5 Assessment of Wheelchair Skills As noted earlier evaluation is part of the circle of education Periods of formal evaluation e g using the WST or WST Q 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 and WST Q represent only intermediate levels 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 The Wheelchair Propulsion Test see our website or instrumented wheels can be used to record additional detail e g push frequency 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 data loggers We suggest that a training log be used by the trainer and or learner to track the training process 3 6 Set Achievable Goals From the baseline WST or WST Q assessment skills may be identi
24. is being used it can be helpful to put the operated by caregivers seat in 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 April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 WSTP 4 2 Manual 7 18 Folds and unfolds wheelchair Versions applicable WSTP M WCU WSTP M CGY WSTP P WCU X WSTP P CG X Description The learner folds the unoccupied wheelchair or breaks it down into smaller parts if this can be done without tools and then restores the wheelchair to its original condition This includes removal of the rear wheels Note This skill is usually dealt with in combination with the transfer skill while the wheelchair user is seated on the transfer bench 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
25. 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 April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 55 WSTP 4 2 Manual 7 10 Turns while moving backwards 90 Versions applicable WSTP M WCU WSTP M CG Y WSTP P WCUY WSTP P CGY Description The learner turns the wheelchair 90 to the left and right while moving backwards General training tips As for the turns while moving forwards 90 skill Training tips for manual wheelchairs operated by wheelchair users As the turns while moving forwards 90 skill Training tips for manual wheelchairs operated by caregivers As the turns while moving forwards 90 skill Training tips for powered wheelchairs operated by wheelchair users As the turns while moving forwards 90 skill Training tips for powered wheelchairs operated by caregivers As the turns while moving forwards 90 skill Originally app
26. 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 distance that one can coast or freewheel between pushes to the distance that one can move forward 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 3 14 Focus of Attention Intention interferes with performance at all skill levels 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 p
27. to release any restraining devices e Ifthe 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 slightly 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 assist in folding the wheelchair The wheelchair user should then pull the Originally approved for distribution and use April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 WSTP 4 2 Manual 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 use
28. wheel These problems can be minimized by leaning uphill e Variations A useful learning experience to demonstrate the 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 e 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 may 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 powered wheel
29. wheelchair e Reposition the rear anti tip devices to allow the rear wheels to contact the first stair and to later permit the wheelchair to tip backwards into the wheelie position e The starting position is with the wheelchair user in the wheelchair with the seat belt if any on e Back up to the lowest step closest to the handrail on the side of the stronger arm e The wheelchair user reaches back as far as he she can with the stronger arm and grabs the handrail with the palm facing up e By pulling on the handrail the wheelchair user tilts the wheelchair back If the extent of the rear tip is past the balance point the rear wheels will tend to roll forwards away from the stair riser submarining If this occurs the wheelchair user can use the other hand on the same side rear wheel to prevent it from rolling forward If the degree of tilt is less than the balance point submarining should not occur e The wheelchair user uses the hand on the handrail to pull while using the other hand starting well forward to roll the rail side wheel up the step e Proceed up one stair at a time e At the top of the stairs do not bring the casters down until there is surface to support them Progression e In describing a set of stairs one refers to the horizontal and vertical dimensions as the run and Originally approved for distribution and use April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 1
30. wheelchair up a 10 incline General training tips As for the ascends 5 incline skill Training tips for manual wheelchairs operated by wheelchair users As for the ascends 5 incline skill For very steep inclines some wheelchair users will go up backwards in the wheelie position This requires a lot of skill and strength The uphill movement is initiated by allowing the wheelchair to fall backwards followed by a strong pull backwards on the hand rims to re achieve balance a short distance up the slope Training tips for manual wheelchairs operated by caregivers As for the ascends 5 incline skill Training tips for powered wheelchairs operated by wheelchair users As for the ascends 5 incline skill Training tips for powered wheelchairs operated by caregivers As for the ascends 5 incline skill Originally approved for distribution and use April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 WSTP 4 2 Manual 7 24 Descends 10 incline Versions applicable e WSTP M WCUY WSTP M CGY e WSTP P WCUY WSTP P CGY Description The learner gets the wheelchair down a 10 incline General training tips e As for the descends 5 incline skill Training tips for manual wheelchairs operated by e wheelchair users As for the descends 5 incline skill The descent in the wheelie position is dealt with in a l
31. wheelchairs operated by wheelchair users Adjustment tip e Adjusting the speed acceleration and deceleration for turning will affect the overall turning of the chair e 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 gravity the easier it is to turn in place by simply moving the joystick straight to the left or right The vertical axis of 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 April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 59 WSTP 4 2 Manual 7 12 Maneuvers sideways 0 5 m Versions applicable WSTP M WCU WSTP M CGY WSTP P WCUY _ WSTP P CGY Description 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 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 ca
32. wheelchairs operated by 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 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 e Because there is more rolling resistance more force is required by the wheelchair user There is a risk of overuse injury e 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 tract
33. 13 61 WSTP 4 2 Manual 7 13 Gets through hinged door Versions applicable WSTP M WCU WSTP M CG Y WSTP P WCUY WSTP P CG Y Description 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 opening toward the learner General training tips Adjustment tips e Having a roller on the outer corner of the footrest can be useful when using them to apply force to a door For doors in the wheelchair users own environments attaching something e g a handle or piece ofrope 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 later 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 away from the wheelchair the wheelchair user can begin the skill by positioning t
34. 39 WSTP 4 2 Manual rise respectively Ideally for training it is useful to have stairs with a variety of runs start big gradually get smaller and rises start small and get gradually bigger Can use a curb first as an example of a single step It is reasonable to start with the caregiver assisted versions of this skill Caregivers can apply upward rolling forces to the rear wheels to assist in getting up the stair and to prevent the rear wheel on the side away from the hand rail from moving away from the stair riser e Variations If the staircase is curved there is more run on the outside of the curve so it will be easier on the outside Make sure the rear wheels are square to each step Escalators are beyond the scope of the WSTP but those that are wide enough and not excessively steep can be safely managed in a manual wheelchair Permission should be obtained before practicing on escalators in public places To ascend an escalator approach the lower end in the forwards direction slowly grasp both or one moving hand rail and allow the wheelchair to be pulled onto the escalator The wheelchair will settle itself in a stable position The wheelchair user should lean forward until on the level at the top The major difficulty comes at the top where there is usually a lip that will stop or tip the wheelchair To prevent this the wheelchair user should lean well back still holding onto the hand rails A spotte
35. 4 2 Manual 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 e Start with small changes of direction e g around widely spaced pylons and progress to more closely spaced ones e Start with loose large radius turns and progress to tight small radius ones e 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 e 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 e 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 cannot 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 Slowing down the inside wheel results in a tighte
36. April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 WSTP 4 2 Manual Some highly skilled wheelchair users by throwing the trunk backwards can induce a controlled wheelie while moving quickly forwards The goal is to overshoot the balance point and then grasp the hand rims firmly to brake the wheelchair and prevent a rear tip With a different amount of force applied to the two hand rims a rapid turn can be made 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 April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 89 WSTP 4 2 Manual 7 21 Ascends 5 incline Versions applicable WSTP
37. M WCU WSTP M CGY WSTP P WCUY _ WSTP P CGY Description The learner moves the wheelchair up a 5 incline General training tips Some of these tips apply to incline descent and to inclines of different degrees 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 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 difficult 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 Edges and drop offs at the sides of the incline or the platform at the top of the incline should be avoided to prevent tip over accidents 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 If a ramp is wide enough the wheelchair user can cut back and
38. STP 4 2 Manual 7 31 Ascends curb 15 cm Versions applicable e WSTP M WCUY WSTP M CGY e WSTP P WCU X_ WSTP P CG X Description e The learner ascends a 15cm curb in the wheelchair General training tips e As for the ascends low curb 5 cm skill 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 e 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 Variations e Approach the curb faster and slower than the self selected speed e Reduce the distance available for the approach e Approach at an angle that requires the wheelchair user to square up before the rear wheels contact the curb Training tips for manual wheelchairs operated by wheelchair users As for the ascends low curb 5 cm skill for both two hand and hemiplegic propulsion patterns Training tips for manual wheelchairs operated by caregivers As for the ascends low curb 5 cm skill Training tips for powered wheelchairs operated by wheelchair users Not generally applicable although some powered wheelchairs are capable of climbing full
39. WSTP 4 2 Manual WHEELCHAIR SKILLS PROGRAM WSP VERSION 4 2 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 April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 WSTP 4 2 Manual 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 April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 WSTP 4 2 Manual 3 TABLE OF CONTENTS Editoral Commute av ceasnuseisceed oat diene anaerud cae E aun neo ulncaanainslnedas 2 Table of Contents eoe cots aE A E iy aaa E E A E R A ET 3 l Introduction to the WSTEP erisip aaa a a eda acon alata A E duds pont alat aah 6 2 General Background on Motor Skills Learning soseseeseesesesseseeseesressessre
40. aa a auido a 88 122 Descends Se MCN Esener a e aa AEEA AE EEA E ENEO KEEA GaS N AETS 92 hee Sid NS COMUS NO CE r a ta a aah a L cae ait 96 P24 Descends 10 ine hhinn ia a Cvalassueniuch a aa a a ee Ee 97 7 25 Rolls across side slope Sannan iuciriiiecnriiia te ten o a a iaai 98 7 26 Rolls on soft surface 2 M ssssesnesnessnseseessoseesesnessessssessessenessestessssesnesessessesessessesne 101 1 21 Gets over gap LIe M ere nre a E a E E E E EREET 105 T28 Gets Over threshold VCM mieren wiadarclang aa E E EOE tee 110 7 29 Ascends low curb 5 cM s sssseesesnesnessesseseosssneesesesnessssessesnesnessesoesesnesnesneseeseesesnesnesne 113 730 Descends low Curb 3 0Ml asc2 5421 v decsnecus outocderutiawe Sata A wa tet occa et ee wae 116 el PASO CIES CUT SCE ecco tot see da a cation a steed AA es aeteed eal g 119 132 Descends c rb LS CIID ea e rE AEE EREA EAE eie AEEA A AESA ARETES 120 7 33 Performs stationary wheelie 30 sec s sssssssssesesessesessesesessesessesesssrsstsesesesrsresesresesese 121 Originally approved for distribution and use April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 WSTP 4 2 Manual 5 7 34 Turns in place in wheelie position 180 cccccescsseseeeecesseseeseescseeseeeceeeeeseeeeseeseeaees 127 7 35 Descends 10 incline in place in wheelie position ccceccesseeeceseeseeseeseseeseeeeteeseesees 128 7 36 Descends curb in wheelie position 15 CM eeeeceseessesseesees
41. ackward if they are lowered To land after the wheelie the caregiver should slowly allow the casters to return to the floor using a foot on the tipping lever to help slow the landing Originally approved for distribution and use April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 110 WSTP 4 2 Manual 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 wheelchairs operated by wheelchair users Positional control e g tilt recline can be used to get the weight over the drive wheels and improve traction Smooth continuous forward movement is often the most successful method of traversing a gap If the casters are rounded on their sides i e ball shaped they will 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 April 4 2013 Current editio
42. adily 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 April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 24 WSTP 4 2 Manual 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 WST Q and or 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 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 m
43. aining tips for manual wheelchairs operated by caregivers As for the rolls forwards 10 m skill Training tips for powered wheelchairs operated by wheelchair users As for the rolls forwards 10 m skill 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 Training tips for powered wheelchairs operated by caregivers As for the rolls forwards 10 m skill As for powered wheelchairs operated by wheelchair users Originally approved for distribution and use April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 WSTP 4 2 Manual 7 20 Avoids moving obstacles Versions applicable WSTP M WCU WSTP M CGY WSTP P WCUY _ WSTP P CGY Description While moving the learner avoids obstacles approaching from different directions General training tips This skill builds on the earlier skills that involved stopping and turning The person operating the wheelchair should be alert to the moving environment while the wheelchair is moving If a hallway is clear it may b
44. air on buttocks e A buttocks protector is a good idea 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 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 Originally approved for distribution and use April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 WSTP 4 2 Manual moved up to the next step e Atthe top of the stairs a stool is helpful as a half way step to the wheelchair seat Otherwise this final phase is the same as for the gets from ground to wheelchair skill Out of wheelchair on hands and knees e As for the buttocks approach above but facing up the stairs and using a crawling action In
45. ally 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 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 sho
46. and use April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 WSTP 4 2 Manual 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 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 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 Th
47. arning 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 learners can sometimes engage explicit conscious and implicit automatic motor control simultaneously without deterioration of control compa
48. assage 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 user s 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 towards 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 n
49. at if they are wide enough and if sitting on them does not tip the wheelchair forwards Otherwise the footrests should be moved out of the way 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 If the person sits beside the wheelchair with the wheel locks off 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 lift with both arms on the seat at the same time or with one arm on the seat and one on the ground e Ifthe 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 Ifthere is another stable object nearby e g a chair or low table the wheelchair user can put one hand on the object and the other hand on the wheelchair e Stay in wheelchair approach for getting up from the ground e Some wheelchair users are able to right thems
50. ater skill Training tips for manual wheelchairs operated by caregivers As for the descends 5 incline skill Training tips for powered wheelchairs e operated by wheelchair users As for the descends 5 incline skill 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 e powered wheelchairs operated by caregivers As for the descends 5 incline skill Originally approved for distribution and use April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 99 WSTP 4 2 Manual 100 7 25 Rolls across side slope 5 Versions applicable e WSTP M WCUY WSTP M CGY e WSTP P WCUY WSTP P CGY Description e The subject moves the wheelchair across a side slope without turning downhill significantly 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
51. ation 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 learners 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
52. atural 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 15 cm 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 Originally approved for distribution and use April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 28 WSTP 4 2 Manual 5 9 Working with a helper Most wheelchair users have at least some skills that they cannot safely perform themselves or that they find stressful In such situations the wheelcha
53. ay 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 April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 25 WSTP 4 2 Manual 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 instructions 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 dist
54. battery charger General training tips Adjustment tips The user manual should be consulted for wheelchair specific elements of this skill Only use a battery charger that has been specified for the wheelchair Failure to do so could cause damage to the battery 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 Some powered wheelchairs have on board chargers that allow greater flexibility to users when they are working properly but leave the user without a chair if the charger needs to go to the supplier for repairs The charger port is usually near the controller or under the seat To avoid electrical shocks avoid using the battery charger in a wet environment or where liquids may be spilled on it 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 The length of time required to charge a battery can vary due to the type of charger and nature of the battery If the battery charger is capable of charging different batteries e g 6 and 12 volts ensure that the appropriate setting is used A battery with a slightly low charge may function reasonably well on smooth level surface
55. bution and traction of the chair 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 suddenly 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 April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 114 WSTP 4 2 Manual 115 7 29 Ascends low curb 6 cm Versions applicable WSTP M WCUY WSTP M CGY e WSTP P WCUY WSTP P CGY Description e The learner gets the wheelchair up a 5cm level change General training tips e As for the gets over threshold 2 cm skill the footrests anti tip devices and clearance between the wheels may affect the ability to negotiate level changes It may be necessary to reposition or remove the footrests or rear anti tip devices e This skill is similar to and builds on the previous ones specifically the soft surface gap and threshold skills e Progression e Start with a minimal level change and progress to highe
56. 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 of 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 reten
57. ccdeedsvcers Stes dicaetbaateeabs qcsacasvccua dees duaauis yaatecsts ccsaespeewexs 41 17 0 Operates battery charger srren er E EE KE BE E a as E ERa AE EEEE Tk 42 F ROMS forwards 10 m icesiniinni a a a a a ai 44 PS ROMS backwards Q M rsszocnnenennierenennnia i a a i 50 7 9 Turns while moving forwards 90 sex sors aihus anauuruncintimaSesiG dxd aloleueaenenca 52 7 10 Turns while moving backwards 90 2 ccsoswvassevedtebsatidcotssieierdiccenennnntieianiiabiies 55 ed AA UTS implace 180 Jri eena e E E E AREER EAE EEE E E 56 7 12 Maneuvers sideways 0 5 M sssssssssssesesesssseseeresesrsstsesresesrsresesresesesresesrsresesrsresesresesesrese 59 7 13 Gets through hinged door 555 eras esac ay cance ee sae pes otisec cea cast equten erate pemimateoee 61 7 14 Reaches high object LSM erre ee aaa N aE Ra ENERET ASE 66 TIS Picks object Up from loots punecnia ann aa a i R ne e aa Mes 68 7 16 Relieves weight from buttocks 3 sec sy ssisi des ccoasvecnncadesedeeccuninbobesuecaccevesseaadeaeduactevabiaaed 70 7 17 Transfers to and from bench sssesessesosesesseseeresesrsstsesresesesresesresesesresesrsresesreresesresesrerese 72 7 18 Folds and unfolds wheelchair y cs cesccsccsdesscscacesnecriasatnuar Gddeavadevssavesssccadaneesisaseniscersscoak Seon 82 TAD OIRO OE a EE E E E E E 85 7 20 Avoids moving obstacles s seseseeseseeroseseseseeresesrssestsresestsresesseresesresestsesesrsseseseesesesrese 86 12V Ascends S2inel ineen a n aan a e
58. chairs are equipped with automatic correction of downhill turning tendency on side slopes If there is no automatic correction the wheelchair user should Originally approved for distribution and use April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 101 WSTP 4 2 Manual 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 April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 102 WSTP 4 2 Manual 103 7 26 Rolls on soft surface 2 m Versions applicable e WSTP M WCUY WSTP M CGY e WSTP P WCUY WSTP P CGY Description e The learner moves the wheelchair 2 m on a soft surface General training tips e Adjustment tip e 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 wheelchai
59. cline e Achieve the wheelie position on the level at the top of the incline 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 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 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 to move them forwards 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 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
60. d to avoid rolling 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 using a slalom path up the incline the wheelchair user will generally turn uphill at the end of each traverse to go back the other way However if this is not possible due to limitations of strength or stability the turn may be downhill e Ifthe 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 e Variations e Asa learning exercise it may be helpful to have the wheelchair user try to ascend the incline with a spotter without leaning forwards e Use the ramp hand rails if available e A Person With Hemiplegia e Itis 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 w
61. d 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 them e The subject should check to make sure the armrests are locked in place by pulling up on them People who need to propel their wheelchairs with their feet are effectively restrained if they cannot move the footrests out of the way 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 Before moving the footrests out of the way the Originally approved for distribution and use April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 78 WSTP 4 2 Manual 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 wheelchair user should swing the footrest completely out of the way Some footrests sw
62. d use April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 WSTP 4 2 Manual 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 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
63. de 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 e 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 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 Originally approved for distribution and use April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 91 WSTP 4 2 Manual lean increases as the slope increases In addition to a consistent forward lean it can be helpful to lean forwards a little more with each push Shorter propulsive strokes are used than on the level both because the wheelchair user is leaning forward an
64. dition WSTP Version 4 2 2 April 17 2013 WSTP 4 2 Manual quickly he she may fall forward out of the wheelchair or tip over forwards To prevent this the wheelchair user should lean back whenever he she is required to stop quickly e Variations As a 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 One hand propels at a time e A person With Hemiplegia The wheelchair user should propel the wheelchair with the sound side arm and leg To avoid moving to the weaker side the wheelchair user should use the sound side foot to help steer the wheelchair The wheelchair user should use the foot to help stop 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 The wheelchair user should wear shoes that provide both protection for the foot and good traction 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 e The caregiver sho
65. ds he she may find it easier if he she leans forward to slightly unweight the rear wheels Using the foot on the floor might give the wheelchair user additional power to get over the obstacle 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 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 To get beyond a pair of obstacles e g concrete parking 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 transiently straddling the obstacles with one wheel or pair of wheels on either side of the obstacles Originally approved for distribution and use April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 113 WSTP 4 2 Manual and the wheelchair parallel with the obstacles The wheelie position can be very helpful in performing this skill e 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 gets over gap 15 cm Training tips for powered wheelchairs operated by wheelchair users Positional control e g tilt recline can be used to alter the weight distri
66. ds 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 wheelchairs 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 Originally approved for distribution and use April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 96 WSTP 4 2 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 As for powered wheelchairs operated by wheelchair users powered wheelchairs e If the space is narrow and the caregiver must operate the operated by caregivers wheelchair from in front the caregiver should be careful not to run over his her own toes Originally approved for distribution and use April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 WSTP 4 2 Manual 7 23 Ascends 10 incline Versions applicable WSTP M WCU WSTP M CG Y WSTP P WCUY WSTP P CG Y Description The learner gets the
67. e 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 Learning the backwards approach will be helpful when advancing to higher level changes 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 possible 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 The wheelchair user should avoid braking suddenly when the rear wheels land on the lower level because this can induce a rear tip keeping the wheelchair moving backwards reduces the likelihood of this problem If the wheelchair can be brought to a stop with the rear wheels on the lower level and the casters on the upper level 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 Originally approved for distribution and use April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 WSTP 4 2 Manual wh
68. e advisable to drive in the middle of the hallway to avoid collisions with people unexpectedly coming around corners or out of doors The learner should obey driving conventions 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 Sudden stops or changes of direction can lead to the user falling forward or to the side in the wheelchair Progression e 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 e Start with obstacles approaching from right angles and progress to ones coming from different angles including overtaking and being overtaken e Start slowly and progressively increase the speed of propulsion Variations e Different moving obstacles can be used e g a rolled ball a swinging pendulum Training tips for manual wheelchairs operated by wheelchair users Practice both quick stops leaning back and grabbing both hand rims firmly and swerves leaning toward the direction of turn and grabbing one hand rim firmly However this can transfer weight forward onto the casters allowing the unweighted rear wheels to skid Originally approved for distribution and use
69. e 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 higher 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 the 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 e 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 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 Trainin
70. e 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 gaps steering around them or straddling them e Ifthe gap 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 may approach the gap squarely e Ifthe casters drop into the gap 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 gap 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 e Start slow and add speed e Start with small gaps and progress to larger ones e Variations e As long as 3 wheels 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 Training tips for manual This is the first of a series of skills including gets over wheelchairs operated by threshold 2 cm ascends low curb 5 cm and ascends Originally approved for distribution and use Ap
71. e 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 guiding 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 Originally approved for distribution and use April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 80 WSTP 4 2 Manual 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 One option is for one caregiver to be behind the wheelchair user reaching under the axillae to grasp the wheelchair user s forearms that have been crossed in front of the body The second caregiver is positioned in front of or to the side of the wheelchair and lifts the legs from behind the knees Coordinate your efforts with the wheelchair user and any oth
72. e large rear wheels than the smaller casters 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 The caregiver may find it easier to pull the wheelchair backward 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 Originally approved for distribution and use April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 105 WSTP 4 2 Manual 106 backwards Training tips for If possible and necessary the wheelchair user should adjust powered wheelchairs the controller setting to one that provides more torque operated by wheelchair e Positional control e g tilt recline can alter the weight users distribution between the wheels It is easier to proceed on a soft sur
73. e 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 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 e Practice moving the joystick in wide open spaces and progress to more enclosed ones e 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 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 wh
74. ee 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 is an advanced skill The wheelchair user can flex the hips keeping the body upright Although actively leaning back into the backrest at the intended moment 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 wheelchairs operated by caregivers The caregiver may proceed in the forward direction using the transient caster pop or full wheelie method The caregiver should always let the wheelchair user know before he she tips the wheelchair backwards 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 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 b
75. eelchair and leaning forward to reach the joystick is not recommended 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 April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 50 WSTP 4 2 Manual 7 8 Rolls backwards 2 m Versions applicable WSTP M WCU WSTP M CGY WSTP P WCUY _ WSTP P CGY Description The subject moves the wheelchair 2 m backwards on a smooth level surface General training tips 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 trailing position The casters can easily be repositioned by moving them in a circular path The learner should proceed slowly and look over the shoulder to avoid obstacles and collisions 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 wheelchairs operated by wheelchair users Two Hand Propulsion Pattern e To propel the wheelchair straight backward the wheelchair user should grasp the
76. eelchair user can use the full wheelie position to move away from the curb e Variations Approaching the curb edge in the forward direction the wheelchair user can transiently pop the casters as they reach the curb edge Full wheelie method see the descends curb in wheelie position 15 cm skill e Person with hemiplegia e Reverse of ascends low curb 5 cm skill Training tips for manual wheelchairs operated by caregivers e 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 e To descend a level change the caregiver may 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 dangerous 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 e 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 st
77. eeseeseeeeeeeeceseeseeseeseeneens 130 7 37 Gets from ground into wheelchair aics0d daiussceaca Greta Vescenesacyavedarondeicesaz deel Mon vweceten ens 132 FBO PASCENOS SEALS e Terea a a E E E tune lax A eai 136 TBD DIEL O REE EEEE A A EEEE TE TN E E 141 Originally approved for distribution and use April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 WSTP 4 2 Manual 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 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 on the optimum methods of either performing or teaching most wheelchair skills Nevertheless based on the evidence that does exist we strongly hold t
78. elves while remaining in the wheelchair e Start on a surface partway between seat height and Originally approved for distribution and use April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 WSTP 4 2 Manual 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 The caregiver should try to avoid bending and twisting at the same time and should lift with bent knees If tipping the wheelchair upright from the fully rear tipped position locking the brakes will prevent the wheelchair from rolling forward A single caregiver may have difficulty in performing this skill without the help of the wheelchair user and or a second care
79. er caregiver e g on the count of Dine 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 e Standing Pivot and Crouching Pivot Transfers e 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 e The caregiver should apply an assisting force to the wheelchair user s body near the hips The caregiver should not pull on the wheelchair user s arms e The caregiver may use a transfer belt around the wheelchair user s waist e The caregiver may need to use his her knees to keep the wheelchair user s knees from buckling Originally approved for distribution and use April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 81 WSTP 4 2 Manual by blocking them e Once standing the caregiver should ask the wheelchair user to pivot turning the back in the shortest possible route towards the bench e Sideways transfers e May be necessary to do in steps e Transfer into the wheelchair e The caregiver may simply reverse whatever procedure was used to get the wheelchair user out of the wheelchair e 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
80. er or fellow learners can be powerful incentives as well Rewards significantly enhance long term retention of motor learning The trainer should not be reluctant to challenge the learner to try ever more difficult but possibly achievable skills 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 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 of 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
81. erent relative heights Originally approved for distribution and use April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 76 WSTP 4 2 Manual Training tips for manual wheelchairs operated by wheelchair users Brakes Armrests Prior to the actual transfer the subject should apply the brakes if any 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
82. ers or clothing Progression e The power should be turned off while this skill is initially being practiced e Start with moving the controller away then moving the controller back e Then use the skill functionally such as moving the controller out of the way to allow closer approach to a table Originally approved for distribution and use April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 WSTP 4 2 Manual Variations e Ifthe 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 e 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 powered wheelchairs operated by caregivers As for powered wheelchairs operated by wheelchair users Originally approved for distribution and use April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 35 WSTP 4 2 Manual 7 2 Turns controller on and off Versions applicable WSTP M WCU X WSTP M CG X WSTP P WCUY _ WSTP P CGY Description The subject turns the controller on and off 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
83. ete the task in several small steps Because of the risk of injury and because overcoming the force of a 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 April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 WSTP 4 2 Manual 7 14 Reaches high object 1 5 m Versions applicable WSTP M WCUY WSTP M CG X WSTP P WCUY _WSTP P CG X Description The subject reaches up to touch an object 1 5 m above the floor General training tips Adjustment tip e Chair height and the overall length of the wheelchair can have impacts on the wheelchair user s ability to reach objects depending upon the methods used 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 in 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 f
84. etermine 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 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 clearly 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 ser
85. face if more of the weight is on wheels with larger diameter Clearance for the feet can also be affected by this change e On soft or irregular terrain there is an optimal speed that is fast enough to maintain forward movement but not so fast that the motion is uncomfortable or leads to a loss of control e Maintaining a steady speed is preferable to a series of stops and starts Training tips for As for powered wheelchairs operated by wheelchair users powered wheelchairs e With a rear wheel drive wheelchair a caregiver can push operated by caregivers 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 April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 WSTP 4 2 Manual 107 7 27 Gets over gap 15 cm Versions applicable WSTP M WCU WSTP M CGY e WSTP P WCUY _WSTP P CGY Description e The learner gets the wheelchair over a gap that is 15 cm across in the line of progression and at least as wide as the wheelchair General training tips e Small gaps 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 gaps that are as wide as the wheelchair e Ifa gap is not readily available on
86. ffects the stability of the wheelchair rolling resistance and traction Leaning is a strategy used often in the later skills The wheelchair user should avoid jerky accelerations that could cause him her to tip over backwards Strokes should be smooth with the hands comfortably grasping the hand rims initially matching the speed of the moving wheels 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 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 Originally approved for distribution and use April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 WSTP 4 2 Manual 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 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
87. fied 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 Generally only 5 10 goals should be identified at the beginning of a series of training sessions The goal may be from the Wheelchair Skills Program skill set a full skill a part of a skill a variation of a skill or any other skill that is important to 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 a decision about the goals of training 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 If in 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 Goals should be brief specific significant non trivial achievable in the training time available and observable Examples Originally approved for distribution and use April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 11 WSTP 4 2 Manual of
88. forward The armrests or rear wheels can be used to push or pull on As for leaning forwards the wheelchair user can lean on a table 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 If tilt or recline are used the more the better Getting the trunk backwards by 40 degrees or more may be needed to increase circulation over the ischial tuberosities and Originally approved for distribution and use April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 WSTP 4 2 Manual 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 a
89. from downhill e g rolling the non rail side wheel up the step while the wheelchair user pulls on the handrail with one or both hands The position of the wheelchair user s feet will affect whether a single caregiver can reach both wheels or just one 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 the 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 If the 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 other on the next higher stair Originally approved for distribution and use April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 141 WSTP 4 2 Manual 142 Two caregivers below Each uses the inside hand to hold the frame of the wheelchair not a part e g a footrest that could come off The outside hand is used to roll the wheel up onto the next step The hand begins at about the 3 00 o clock position and moves up to the 1 00 o clock position
90. g 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 no more often than 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 pr
91. g tips for powered wheelchairs operated by caregivers Not applicable Originally approved for distribution and use April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 68 WSTP 4 2 Manual 7 15 Picks object up from floor Versions applicable WSTP M WCUY WSTP M CG X WSTP P WCUY WSTP P CG X Description The learner picks a small object up from the floor General training tips See some of the general training tips for the Reaches 1 5 m high object skill which will not be repeated here The wheelchair user should use one hand on the wheelchair 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 If reaching forwards the stability of the wheelchair can be increased by orienting the casters so as to lengthen the wheelbase This is a good opportunity to teach the wheelchair user about how to s
92. giver A mechanical lift or a team of people are recommended when lifting from the floor Without a mechanical lift maintaining proper ergonomics is challenging If the 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 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 Originally approved for distribution and use April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 136 WSTP 4 2 Manual 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 If a third caregiver is available he she can help with the legs or manage the wheelchair Training tips for powered wheelchairs operated by wheelchair users As for the general tips and in some respects tips for manual wheelchairs above If falling backwards the wheelchair user should tuck the chin and pull himself herself vigorously for
93. h for the rear wheels to drop all the way 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 Variation The forward transient wheelie method is an advanced skill especially from this height As for this variation described earlier for the descends low curb 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 This is similar to the technique used to pop the casters for the gets over gap 15 cm and gets over threshold 2 cm skills The extent of the caster pop should be 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 Originally approved for distribution and use April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 WSTP 4 2 Manual forward progression and to watch for traffic It can be difficult to spot so two spotters are recommended Training tips for manual wheelchairs operated by caregivers As for the descends curb 15 cm
94. hand rims and pull evenly e Some wheelchair users with very weak arms e g people with tetraplegia may find it more effective to make contact under the hand rims with their palms up Others may reach backwards and push down on the tires 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 For a 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 Originally approved for distribution and use April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 51 WSTP 4 2 Manual shrugged Then the wheelchair user can use the body weight to push down on the wheels A Person with Hemiplegia e As for the rolls forward 10 m skill except the sequence is to first flex the leg push down on the floor with the foot enough to ensure good traction then push the wheelchair backwards by straightening the leg Training tips for manual wheelchairs operated by caregivers As for the rolls forward 10 m skill Training tips for powered wheelchairs
95. he wheelchair directly in front of the door 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 Once a self closing door has been opened enough to allow the wheelchair to proceed the widest part of the wheelchair can be used to prevent the door from closing To avoid scraping the door the wheelchair user can use his her hand or elbow to bump the door open briefly to allow progress While moving past the door the wheelchair user should be Originally approved for distribution and use April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 WSTP 4 2 Manual careful to avoid catching any clothing or body parts on the door handle because injury could occur e 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 the 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 e The wheelchair user may go through the door backwards pulling the door with him her e The wheelchair user can back up to close the door using the rear wheel to push on the door e Reaching over t
96. he 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 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 the other This is more likely to be necessary if the door resists opening e 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 hand closest to the hinge on the door frame or hand rim to prevent the wheelchair from being pulled forwards e The wheelchair user may keep one hand on the door handle and use the other to push both wheels one at a time Originally
97. he back of the wheelchair is effective but there is the risk of a rear tip in a manual wheelchair e 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 e 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 e 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 e The learner can experiment with negotiating the door in the forwards or backwards direction Training tips for manual wheelchairs operated by wheelchair users e Two handed propulsion e The door frame can be used to help propel the wheelchair user through the door the slingshot Originally approved for distribution and use April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 63 WSTP 4 2 Manual 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 t
98. he 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 user 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 The wheelchair user gets into the sitting position with the Originally approved for distribution and use April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 WSTP 4 2 Manual 135 hips and knees flexed as much as possible e Right the wheelchair orient the casters so that they are trailing forwards lock the brakes and transfer back into it from the front e The footrests can be used as an intermediate level between the ground and the wheelchair se
99. he wheelchair may continue to spin in a circle until wheel or hand rim friction brings the wheelchair to a stop 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 on external objects rather than using the hand rims A Person with Hemiplegia To turn to the side away from the stronger hand the wheelchair user should push forward on the hand rim To turn toward the stronger hand the wheelchair user should pull back on the hand rim The wheelchair user may use the feet 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 Originally approved for distribution and use April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 58 WSTP 4 2 Manual removed and placed in the wheelchair user s lap This skill can be performed in the wheelie position Training tips for powered
100. height curbs Training tips for powered wheelchairs operated by caregivers Not applicable Originally approved for distribution and use April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 121 WSTP 4 2 Manual 7 32 Descends curb 15 cm Versions applicable WSTP M WCUY WSTP M CG Y WSTP P WCUX WSTP P CG X Description The learner gets the wheelchair down a 15 cm curb Rationale As for the descends low curb 5 cm skill 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 2 As for the descends low curb 5 cm skill Training tips for manual wheelchairs operated by wheelchair users Two hand propulsion e The backwards approach see the descends low curb 5 cm skill 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 Person with hemiplegia e As for the descends low curb 5 cm skill Training tips for manual wheelchairs operated by caregivers As for the descends low curb 5 cm skill Training tips for Not applicable powered wheelchairs operated by wheelchair users Training tips for
101. hysical 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 Originally approved for distribution and use April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 10 WSTP 4 2 Manual 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
102. ification 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 Originally approved for distribution and use April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 23 WSTP 4 2 Manual reflects this 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 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 re
103. il 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 124 WSTP 4 2 Manual on the wheels to prevent tipping too far and return to the balance point If the 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 Scm 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 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 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 It should be possible to slide the hands forwards and backwards on the hand rims 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 obs
104. 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 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 Training tips for e Not applicable manual wheelchairs operated by wheelchair users Training tips for e Not applicable manual wheelchairs operated by caregivers Training tips for powered wheelchairs operated by wheelchair users Turn the power on The wheelchair user should be able to see or hear an indication of the mode and speed status The user may select different mode and speed settings for Originally approved for distribution and use April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 WSTP 4 2 Manual 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 dist
105. in the learner s state e g with fatigue anxiety focus of attention To enhance skill retention and transfer random practice ofa 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 3 23 Distribution of Practice Originally approved for distribution and use April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 21 WSTP 4 2 Manual 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 Another 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 loc
106. ing 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 place by pulling on it e 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 e 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 e 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 Originally approved for distribution
107. instead of grasping both hand rims to stop the wheelchair user can grab one turning across the slope Variations e Slalom If a ramp is wide enough the wheelchair user can 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 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 Originally approved for distribution and use April 4 Current edition WSTP Version 4 2 2 April 17 2013 2013 WSTP 4 2 Manual backwards it is important to pr
108. ion 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 e The forward approach is preferred because the wheelchair user can see where he she is going e The wheelchair user should use long slow strokes to keep the wheels from slipping in loose surfaces e This is the first in a series of skills for which transient Originally approved for distribution and use April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 WSTP 4 2 Manual 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 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 lift off further during the wheelie and provides better clearance during the dip 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 It is easier in the backwards direction because there is less rolling resistance with th
109. ion that follows is for people using two hands for wheelchairs operated by propulsion but people have only the use of one arm can wheelchair users perform wheelies in a similar way e 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 e Most people require a total of 45 60 minutes of practice spread over 2 3 sessions to acquire this skill e The sequence of phases trained is not critical It is reasonable to start with the balance phase before proceeding to the take off phase but we have described the natural sequence below Originally approved for distribution and use April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 WSTP 4 2 Manual e Take Off Phase 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 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 This method is very effective and is to be preferred when the wheelchair user wishes to perform a wheelie without moving forwards at
110. ir user can benefit from the assistance of a helper 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 April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 29 WSTP 4 2 Manual 6 0 TABLE OF INDIVIDUAL SKILLS In this section a table is 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 Table 4 reflects 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 April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 30 WSTP 4 2 Manual Table 4 WSTP 4 2 Master List of Individual Skills Skill Level Individual Skill Names Manual WC Powered WC WCU CG WCU CG l Indoor Moves controller away and
111. ith the feet Training tips for manual As for manual wheelchairs operated by wheelchair users Originally approved for distribution and use April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 WSTP 4 2 Manual wheelchairs operated by caregivers If the wheelchair user has hemiplegia the caregiver can put the weak foot on the other footrest to avoid it getting caught on the transition 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 wheelchairs operated by wheelchair users A small lip on the edge of an incline may be sufficient to prevent a manual wheelchair from going over the edge but a powered wheelchair can go over such a lip more easily 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 e g the degree of trunk control or self effficacy even the 5 degree incline can be challenging 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 The tilt or
112. ity 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 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 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 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 drive wheels whether rear mid or front have reached the object If the leading wheels are the drive wheels the trailing castered wheels may swing wide of the path and may strike the wall on the far side depending upon the radius of the turn The user should be especially careful not to catch the feet on Originally approved for distribution and use April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 WSTP
113. ive wheels over the threshold is usually easier than getting the smaller caster wheels over Leaning away from the casters will unweight them and make it easier to get them over e Progression e Start with low thresholds and progress to higher ones Obstacles of 10cm high or greater are negotiable in the right wheelchair e Variations e Leading with the larger diameter wheels may be helpful Training tips for manual See the gets over gap 15 cm skill re the stationary and Originally approved for distribution and use April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 WSTP 4 2 Manual wheelchairs operated by wheelchair users momentum approaches The only differences from the gap skill are as follows A bit more of everything is needed speed extent of caster pop and extent of forward lean after the rear wheels hit the obstacle The wheelchair user should pop the casters about 10 15cm before reaching the threshold to avoid striking them on the vertical section 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 The wheelchair user may find it easier to back over a low obstacle The wheelchair user should approach the obstacle slowly because a sudden stop can cause a rear tip As the wheelchair user approaches the obstacle backwar
114. l be practiced later e The reactive balance strategy will be used later to deliberately move the wheelchair forwards and backwards when beginning the descends 10 incline in wheelie position and descends curb in wheelie position 15 cm skills e Landing Phase e To land 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 tip into the wheelie position Step 4 Full take off progressive degrees of tip until overshoot self save Step 5 Balance strategies in high rolling resistance RR setting with trainer induced initial tip into the balance position Step 6 Balance strategies in medium RR e g foam grass sand Step 7 Balance strategies in low RR tile Step 8 Add the take off phase and perform the balance phase thereafter May need to return to the medium RR setting for this Step 9 Exercises lean forward to increase caster height in wheelie position maintain balance with fingertips only maintain balance with
115. leg elevation functions can be used to avoid scraping the footrests at the lower incline transition Progression Begin training with the 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 wheelchairs operated by 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 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 April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 93 WSTP 4 2 Manual 7 22 Descends 5 incline Versions applicable WSTP M WCU Y WSTP P WCU Y WSTP M CG Y WSTP P CG Y Description The learner gets the wheelchair down a 5 incline General training tips forward out of Variations e Some similarities to the ascends 5 incline skill Smooth straight control down the incline is the basic method Drive slowly to maintain control Dangers include wheelchair runaway and if the wheelchair strikes the lower ramp floor transition
116. ly 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 e Variations Various makes and models have different methods of disengaging the motors Training tips for e Not applicable manual wheelchairs operated by wheelchair users Training tips for e Not applicable manual wheelchairs operated by caregivers 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 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 April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 42 WSTP 4 2 Manual 7 6 Operates battery charger Versions applicable WSTP M WCU X WSTP M CG X WSTP P WCUY WSTP P CGY Description The subject operates the
117. 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 In 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 April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 117 WSTP 4 2 Manual 7 30 Descends low curb 5 cm Versions applicable WSTP M WCU WSTP M CG Y WSTP P WCUY WSTP P CG Y Description The learner gets the wheelchair down a 5 cm level change General training tips On a small level change such as this forwards or backwards are both appropriate approaches to take 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 e Simply rolling forwards off the low curb may be all that is needed This is less of a problem for wheelchairs with long wheelbases
118. 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 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
119. 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 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 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 Originally approved for distribution and use April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 WSTP 4 2 Manual 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 eas
120. n A thorough discussion of these options is beyond the scope of the WSTP 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 wheelchair as close as possible to the other surface with the casters oriented in a way that enhances stability in the direction of transfer Ensure the wheel locks 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 The wheelchair user should leave the armrests in place Originally approved for distribution and use April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 WSTP 4 2 Manual The wheelchair user should try to flex the knees to get the feet under the body in preparation for the sit to stand phase of the transfer During the transfer the hips should be flexed The wheelchair user
121. n WSTP Version 4 2 2 April 17 2013 WSTP 4 2 Manual 112 7 28 Gets over threshold 2 cm Versions applicable e WSTP M WCUY WSTP M CGY e WSTP P WCUY WSTP P CGY Description e The learner propels the wheelchair over a 2cm high threshold General training tips e As for the gets over gap 15 cm skill in many respects e 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 e Wheelchairs with large diameter leading wheels are able to roll over higher obstacles than those with small diameter wheels e Wheelchairs with longer wheelbases are less likely to tip forwards while the rear wheels surmount higher thresholds e Before attempting to negotiate a high obstacle the learner should be aware of how much vertical and horizontal clearance exists between the wheels to avoid getting hung up on the obstacle e Ifthe wheelchair gets 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 e Getting the larger dr
122. n 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 backwards 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 forwards and backwards to get into the desired position moving more to one side with each attempt Progression e Start with ample fore aft room in which to maneuver and gradually decrease the space available e Start with small sideways steps and progress to larger ones e Start at a slow speed focussing on accuracy staying within the designated boundaries Increase the speed within the limits of accuracy Variations e Begin facing the target position at right angles to it rather than parallel to it Training tips for manual wheelchairs operated by wheelchair users Two handed propulsion e As for the general tips above e Variations o An alternative for the wheelchair user with good upper body strength and co ordination is to use the Originally approved for distributi
123. n escalator as described above in the ascends stairs skill The wheelchair user approaches the upper end of the escalator backwards grasps the hand rails of the escalator and allows the wheelchair to be pulled onto the escalator While descending the wheelchair user leans forwards At the bottom although there is a lip it presents little difficulty because it is first struck by the rear wheels Training tips for manual wheelchairs operated by caregivers As for the ascends stairs skill but in the reverse direction Training tips for Not applicable powered wheelchairs operated by wheelchair users Training tips for Not applicable powered wheelchairs operated by caregivers Originally approved for distribution and use April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 144
124. n rail side hand rim e In the wheelie position forwards 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 as for he descends curb in wheelie position 15 cm skill The difference is that the casters cannot land after the rear wheels do The wheelchair user pulls back on the hand rims to bring the rear wheels against the step riser before proceeding to the next step This should be practiced on a single curb first e In the wheelie position forward continuous method This method is difficult to spot It is only recommended for a short flight of stairs and when no Originally approved for distribution and use April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 WSTP 4 2 Manual 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 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 e Variation Descending an escalator is similar to ascending a
125. ne 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 For those interested in better understanding the rationale for including this skill in the WSTP skill set as well as suggested equipment with which to practice the skill please see the section on individual skills of the WST 4 2 Manual e Training tips e General training tips that apply to most or all of the subsequent sections for this skill 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
126. ng 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 Other Originally approved for distribution and use April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 27 WSTP 4 2 Manual examples are when the wheelchair user uses the hand rails on a ramp to pull him herself up the ramp or uses a doorframe to guide p
127. ntually 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 eliminates 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 simpl
128. oblem 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 Originally approved for distribution and use April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 18 WSTP 4 2 Manual 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 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 Initi
129. oceed slowly with frequent shoulder checks and to avoid stopping suddenly to prevent rear tips Hemiplegia e The wheelchair user can proceed forward down the incline using the foot to slow down e Caution that the foot does not get caught under the chair at the lower incline floor transition Training tips for manual wheelchairs operated by caregivers 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 Asacombined wheelchair user and caregiver method the wheelchair user can descend forwar
130. ogrammed 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 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 As for general tips Training tips for powered wheelchairs operated by caregivers As for powered wheelchairs operated by wheelchair users Originally approved for distribution and use April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 41 WSTP 4 2 Manual 7 5 Disengages and engages motors Versions applicable WSTP M WCU X WSTP M CG X WSTP P WCUY WSTP P CGY Description The learner disengages and engages the motors General training tips 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 separate
131. on and use April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 WSTP 4 2 Manual 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 wheelchair user can get used to just hopping up and down with no sideways movement 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 wheelchairs operated by caregivers The caregiver should generally not try to lift the occupied wheelchair sideways However it may be possible to use the 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 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 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 approved for distribution and use April 4 2013 Current edition WSTP Version 4 2 2 April 17 20
132. one hand maintain balance with Originally approved for distribution and use April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 127 WSTP 4 2 Manual eyes closed perform wheelie with spotter farther and farther away 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 Not applicable powered wheelchairs operated by wheelchair users Training tips for Not applicable powered wheelchairs operated by caregivers Originally approved for distribution and use April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 128 WSTP 4 2 Manual 7 34 Turns in place in wheelie position 180 Versions applicable WSTP M WCU WSTP M CG Y WSTP P WCU X WSTP P CG X Description In the wheelie position the learner turns the chair 180 in place both to the left and right General training
133. oor 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 Originally approved for distribution and use April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 16 WSTP 4 2 Manual 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 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
134. ootrests 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 especially in a manual wheelchair a forward tip is likely unless the footrests are behind the front wheels 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 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 Originally approved for distribution and use April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 WSTP 4 2 Manual the user if it were spilled or dropped onto the lap Also bending and twisting at the same time can cause back injury e Variations o Ifthe wheelchair user is reaching for an unbreakable object from a high shelf he she can us
135. operated by wheelchair users Adjustment tip The programming of a powered wheelchair is separate for the forwards 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 April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 52 WSTP 4 2 Manual 7 9 Turns while moving forwards 90 Versions applicable WSTP M WCU WSTP M CG Y WSTP P WCUY WSTP P CG Y Description The subject turns the wheelchair 90 to the left and right while moving forwards General training tips The learner should clearly understand the difference between the size of the turning 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 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 opportun
136. or another wheelchair a different solution may be appropriate 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 some 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 Originally approved for distribution and use April 4
137. ose 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 the floor e Variations e Experiment with different speeds Originally approved for distribution and use April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 WSTP 4 2 Manual Experiment with how gradually or rapidly the wheelchair can be brought to a stop Training tips for manual wheelchairs operated by wheelchair users Adjustment tip The friction between the hands and the hand rims can be increased by the use of gloves high friction covering on the hand rims or surgical tubing wrapped in a spiral fashion around the hand rims Two Hand Propulsion Pattern 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 To improve friction the wheelchair user can rest the palms of the hands on the tires in addition to using the hand rims 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 This is the first example of a skill that can benefit by leaning Because the weight of most wheelchair users is large relative to the weight of the wheelchair leaning can have a major effect on the relative weight on the different wheels This a
138. out 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 Diversification 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
139. owerment 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 Originally approved for distribution and use April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 WSTP 4 2 Manual 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 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 World Health Organization s process of wheelchair service delivery includes eight steps 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 component there are aspects e g maintenance skills that are outside the scope of this Manual Originally approved for distribution an
140. portunities 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 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 factors 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
141. r turn but causes the wheelchair to slow down Pushing harder on the outside wheel causes the wheelchair to speed up The decision on the relative speeds of the two wheels to use to make a turn depends on how tight a turn is needed and a consideration of the speed desired 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 April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 54 WSTP 4 2 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 unaffected side than toward it Training tips for manual wheelchairs operated by caregivers The caregiver should push harder with the
142. r at the top can help to pop the casters over the lip until the wheelchair user has mastered this on his her own Training tips for manual wheelchairs operated by caregivers e As for the section above in many respects e Wheelchair user out of the wheelchair e 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 Originally approved for distribution and use April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 140 WSTP 4 2 Manual 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 e Wheelchair user in the wheelchair The starting position is with the wheelchair user in the wheelchair with the seat belt if any on It can be helpful to remove the footrests Back the wheelchair up to the lowest step The wheelchair user may place his her hands on wheels or the handrails assisting to the extent possible A single strong caregiver can help a light wheelchair user up stairs from behind uphill tipping the wheelchair back and rolling it up one step at a time Alternatively if only a single caregiver is available and the wheelchair user is able to assist then the caregiver can provide some of the needed force
143. r 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 After folding the wheelchair it may be helpful to use a strap to prevent the wheelchair from opening while it is being lifted When lifting a folded wheelchair injury can occur if the unlocked rear wheels are grasped because the frame will be free to rotate e Unfold Wheelchair If the rear wheels have been removed they should be replaced It may be necessary to push the quick release plunger to allow the axle to get into the housing To check that the axle is fully seated the plunger should be out and it should not be possible to pull the rear wheel off 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 folded wheelchair up on the transfer bench gt into vehicle Variations Originally approved for distribution and use April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 85 WSTP
144. r ones Training tips for manual Two hand propulsion wheelchairs operated by e This skill is similar to the gets over gap 15 cm and wheelchair users gets over threshold 2 cm skills in that it can be approached with stationary and momentum methods e It is slightly more challenging 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 lean should be timed to coincide with when the rear wheels Originally approved for distribution and use April 4 2013 Current edition WSTP Version 4 2 2 Ap
145. r 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 Originally approved for distribution and use April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 65 WSTP 4 2 Manual 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 it 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 compl
146. r will decelerate so it is wise to slow down when approaching such a transition e Because rolling resistance is a challenge reducing the weight on the small wheels casters and increasing the weight on the drive wheels is a helpful strategy e When proceeding across a soft or rough surface it is easiest to move forwards in a straight line because the user will find the casters less free to swivel should the user wish to change direction 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 The larger diameter wheels make it easier to get started The casters will trail backwards and the resulting longer wheelbase may help as well e Variations e A variety of surfaces e g sand thick carpet foam a gym mat gravel provide similar but not identical experiences e 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 up the mat behind the wheelchair and moving it to the front proceeding forward in a step wise fashion Originally approved for distribution and use April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 WSTP 4 2 Manual 104 Training tips for manual Adjustment tips
147. ractice 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 It is helpful for the wheelchair user to understand that the only difference between rolling forwards transiently popping the casters from the ground and popping he casters far enough to do a wheelie is the amount of force applied to the hand rims A small force causes rolling a medium force causes a transient pop and a large force causes a wheelie Segmentation Progress through the skill starting with the stationary approach then moving to the momentum method Originally approved for distribution and use April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 109 WSTP 4 2 Manual Variations e 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 e The hands fr
148. red 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 Originally approved for distribution and use April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 WSTP 4 2 Manual can be abandoned The goal of wheelchair skills training is for the learner to be able to perform skills safely effectively and efficiently Safety includes both the safe
149. reet 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 Originally approved for distribution and use April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 119 WSTP 4 2 Manual 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 wheelchairs operated by wheelchair users As for ascends low curb 5 cm skill in many respects See general tips Training tips for powered wheelchairs operated by caregivers As for powered wheelchairs operated by wheelchair users Originally approved for distribution and use April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 120 W
150. regiver 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 roll 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 not use the Originally approved for distribution and use April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 116 WSTP 4 2 Manual knee against the backrest e Variations 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 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
151. 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 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 wheelchairs operated by wheelchair users Positioning e g tilt recline seat height may be useful while preparing the wheelchair for the transfer The power should generally be turned off while the transfer is being performed 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 If the wheelchair user is using a standing pivot transfer the tilt mechanism of the wheelchair can be used to assist in lifting the buttocks if the wheelchair user has moved well forward on the seat The controller may need to be moved out of the way for a sideways transfer Originally approved for distribution and use April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 82 WSTP 4 2 Manual Training tips for As for powered wheelchairs operated by wheelchair users powered wheelchairs Ifa mechanical lift
152. ribution and use April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 WSTP 4 2 Manual 7 4 Operates body positioning options Versions applicable WSTP M WCU X WSTP M CG Y WSTP P WCUY WSTP P CG Y Description The subject changes body position e g tilt recline seat elevation legrest elevation using the available wheelchair options and then restores the wheelchair to the original position This skill is for powered wheelchairs as well as manual wheelchairs operated by caregivers General training tips Adjustment tip e Not all wheelchairs have a body positioning options e Programming by the dealer and or therapist should be considered to allow the wheelchair user to get into the desired position with as few steps as possible e g using a preset position of 45 of tilt e Be careful to ensure that the wheelchair user has access to the controller when in the altered position Before changing position or restoring the wheelchair to the original position the person performing the action should be sure that there is room behind the wheelchair and above the knees to change the position without damaging the environment the wheelchair the user or a bystander For the purpose of pressure redistribution the greater the extent of tilt or recline the better For wheelchair users with limited trunk balance to reduce the likelihood of falling forward 5 10 of tilt or recline is usually adequate a
153. ribution and use April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 26 WSTP 4 2 Manual 5 0 SKILL GROUPS There are 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 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 openi
154. ril 17 2013 WSTP 4 2 Manual 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 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 caster slap 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 Backwards e The wheelchair user might find it easier to attempt to ascend the 5cm high level change backwards Variations e Use the external environment if available e g door frame or street pole 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 wheelchairs operated by caregivers To ascend a level change forwards the caregiver should put the wheelchair into the full or partial wheelie position to get the casters onto the upper level Then the ca
155. ril 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 WSTP 4 2 Manual wheelchair users curb 15 cm for which the ability to pop the casters and move forwards is very helpful 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 forward 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
156. roved for distribution and use April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 56 WSTP 4 2 Manual 7 11 Turns in place 180 Versions applicable WSTP M WCU WSTP M CGY WSTP P WCUY _ WSTP P CGY Description The learner turns the wheelchair around to face in the opposite direction while remaining within a square space with 1 5 m sides This is done towards the left and the right General training tips The ease of making a turn in a tight space depends on the overall length and width of the occupied wheelchair the distance between the wheels and how free the casters or steering wheels are to swivel The footrests for some 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 If elevated footrests are lowered the turning circle will be smaller The rear anti tip devices for some wheelchairs increase the overall length of the wheelchairs Adjusting or removing them may decrease the radius of the turning circle If a wheelchair is in the tilted or reclined position it may be helpful to reposition the wheelchair in a more upright position It may be helpf
157. rts of the wheelchair 0 0 0 ec ceccecscesseeeneceteeeeeeeseeesaeeeteeesaes 26 5 2 Understanding the dimensions of the wheelchair26 5 3 Getting into out of and repositioning oneself with respect to the wheelchair 26 5 4 Moving the wheelchair around on smooth level surfaces26 5 3 Using Ae environment aoe shay cased ed cease del cokte dans dha shaves anda EE SEEE aden ames 26 Originally approved for distribution and use April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 WSTP 4 2 Manual 4 5 6 Skills that require leaning forward or backwards in the wheelchair27 5 7 Skills that require popping the front wheels briefly off the surface27 5 8 Skills for which balancing on the rear wheels is necessary27 59 Working with Ne lpet ania caieusesinieda eintaaeBianearain tat E 27 6 0 Table of Individual SKU Sitesi 05 coreah det gents a ta rash takes Vaan lea A EE 29 70c Gaya Skills se rae at Ges oe gine Orsate gine oan ah cidade Oca EEA E RS 32 7 1 Moves controller away and DACK oii ct acct ives sea anetodacaownsanitengh saannencdcwsdadbdteavensantubabwnust sucess 33 12 T rns controller on and OLE ccs6sissteissinentanl seernd ous tian rear E a a nieces 35 7 3 Selects drive modes and SHCCOS ss yoacas chsh av eidawaeaneseend exwacanaad Savane ata cancbendensisceseht resp 37 7 4 Operates body positioning GPMONSrs cds sae al sbanebildstaesiade Granted nok ak patetlMenv daa Heston 39 7 5 Disengages and engages MOLOES a ders
158. s but may be insufficient to get the wheelchair over obstacles 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 with liquid acid that can leak if the battery Originally approved for distribution and use April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 WSTP 4 2 Manual 44 or wheelchair is tipped over Training tips for Not applicable manual wheelchairs operated by wheelchair users Training tips for Not applicable manual wheelchairs operated by caregivers Training tips for powered wheelchairs operated by wheelchair users Manufacturers recommend that the battery not be charged in a room with people present because there is a risk of explosion with some batteries This recommendation is difficult to comply with for a wheelchair user acting alone unless the wheelchair user has a second means of mobility Training tips for powered wheelchairs operated by caregivers As for powered wheelchairs operated by wheelchair users Originally approved for distribution and use April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 WSTP 4 2 Manual 7 7 Rolls forwards 10 m Versions applicable WSTP M WCUY WSTP M CGY e WSTP P WCUY WSTP P CGY De
159. s 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 distribution and use April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 72 WSTP 4 2 Manual 7 17 Transfers to and from bench Versions applicable WSTP M WCU WSTP M CGY WSTP P WCUY _ WSTP P CGY Description The wheelchair user transfers from the wheelchair to another surface and back again The subject positions the wheelchair then removes and restores wheelchair components as necessary to complete the 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 determinatio
160. scription e The subject moves the wheelchair 10 m forwards on a smooth level surface General training tips e Adjustment tip e The position of axle and weight over drive wheel have a great impact because rolling resistance is lower when the wheel diameter is greater e Ifthe wheelchair user experiences difficulties maintaining a straight direction the problem may be due to a wheelchair part e g a flat tire or something rubbing on a wheel e When first attempting to move forwards 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 forwards then left than backwards then right e The learner should maintain attention in the direction of travel avoiding distractions to either side but remaining alert to potential hazards e 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 e Progression e Remember that speed and accuracy are inversely related It is advisable to begin movement skills with adequate accuracy before increasing the speed e Stop progressively closer to an obstacle but without touching it Progress from a tall obstacle that can be seen no matter how cl
161. should move forward on the seat before beginning the transfer 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 The wheelchair user should use the armrest to help maintain balance while transferring e Crouching Transfer This transfer is like the standing pivot transfer except that the knees and hips are not fully extended The wheelchair user may need to move the armrest out of the way on the bench side The wheelchair user may need to remove the brake extension if any on the bench side 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 The hips and the head move in opposite directions e Sideways Transfer People using sideways transfers tend to lead with their weaker or more painful arms However if the 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 Originally approved for distribution and use April 4 Current edition WSTP Version 4 2 2 April 17 2013 2013 74 WSTP 4 2 Manual The feet should be supported on the footrests if not easily removed or
162. 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 Originally approved for distribution and use April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 108 WSTP 4 2 Manual user should understand where the casters are often below the knees not under the feet A mirror can be used to provide augmented feedback e In preparation to pop the front wheels while the 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 even 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 Progression To p
163. sressessesresseeseessesseseese 8 3 Specific Issues of Importance for Motor Skills Learning ssenssseesesssseseeseesreseesssssressessressesse 9 3 1 The Learning Process 9 3 2 Safety 9 3 3 Spotters10 3 4 Trainers10 3 5 Assessment of Wheelchair Skills 11 3 6 Set Achievable Goals11 3 7 Individualize the Training Process12 3 8 Determine Who the Learner s Will Be13 3 9 Structure of Training14 3 10 Training in Pairs or Groups14 3 11 Motivation14 3 12 Demonstrations sia sanaa a a a a a a aa 15 Slt Verbal Instructions e E a a e a a a ee 15 A A OROI A ALATO a AE E E A T 16 e o Ea at 121S D AEE TY Wir RNS See EA E EA E N RC Wir ARNE 16 SCRA DAC ea let e a E a hove oh a E aR E E E 17 3 17 Feedback Content17 3 18 Timing of Feedback18 3 19 Specificity of Practice19 3 20 Amount of Practice19 3 21 Facilitate Retentions esen eenen e SE eaa war EEE n ENEON Eer TENE OSE a 20 3 22 Variability of Practicerieicnisioutenu ninan a e EA A 21 3 23 Distribution of Practice ozs ccs ce aanwsseriuds tien steavads dusaeives eciedtey sade uioachdcaeasada stweasedsiencateestes 21 3 24 Whole versus Part Practices reei noieta e EEE EA a TE hae E WeeoNaies Ronee 22 3 25 Simplification and Progression s ssessssseessesseeseesresstesresresseesressresresrtsseesresresseesresse 22 Mite SSOUMA LAS 51 e a e E A a se ane eee 24 50 Skill Group ss ipanaa a E R stun sites uedepaeiG A A E noes an E aaieeiaes 26 5 1 How to operate the pa
164. t rest or when driving Depending upon the positioning mechanism the extent of forward and rear stability may differ in the new position 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 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 positioning direction e g from tilt back to tilt forward it may be necessary to pause briefly For safety some powered wheelchairs will prevent the Originally approved for distribution and use April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 WSTP 4 2 Manual wheelchair from being driven while in some positions 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 e For the wheelchair user to adjust to a position change may involve starting at a small amount and progressing to the full desired position change e Ifthe rate of position change can be pr
165. tacles such as bricks in front of and behind the rear wheels and foam under the rear wheels The trainer tips the wheelchair back to the balance point while the wheelchair user rests his her hands in the lap The trainer then turns over control to the wheelchair user by having the wheelchair user grasp the hand rims The trainer should take his her hands off the wheelchair and wheelchair user it can be confusing to have two people attempt to maintain balance at the same time Once the wheelchair user is in control Originally approved for distribution and use April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 125 WSTP 4 2 Manual 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 i11 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 e Two balance strategies have been reported the proactive and reactive e Proactive balance strategy e In this stra
166. tegy 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 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 grip 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 e 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 Originally approved for distribution and use April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 126 WSTP 4 2 Manual 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 wil
167. the floor This is less likely to cause a problem with forward tipping in wheelchairs that have the footrests behind the casters The wheelchair user should move forwards on the seat to avoid such obstacles as the rear wheels To get the transfer board 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
168. 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 Originally approved for distribution and use April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 15 WSTP 4 2 Manual 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 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
169. tilt farther back Slowing the rate at which the hand rims slide through the fingers will cause the wheelchair to pitch forward Originally approved for distribution and use April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 WSTP 4 2 Manual e The subject should have the casters touch down shortly after the rear wheels reach the level surface 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 e As for the descends 10 incline and performs stationary wheelie 30 sec skills e The caregiver should be careful not to let the wheelchair
170. tion 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 ona new skill will be retained To improve the likelihood of consolidation the trainer and other members 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 Originally approved for distribution and use April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 20 WSTP 4 2 Manual 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 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 with
171. tips This skill is a combination of the turns in place 180 and performs stationary wheelie 30 sec skills Training tips for manual wheelchairs operated by wheelchair users As for the turns in place 180 and performs stationary wheelie 30 sec skills Training tips for manual wheelchairs operated by caregivers As for the turns in place 180 and performs stationary wheelie 30 sec skills The caregiver should be careful not to let the wheelchair user s elevated feet hit anything Training tips for Not applicable powered wheelchairs operated by wheelchair users Training tips for Not applicable powered wheelchairs operated by caregivers Originally approved for distribution and use April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 WSTP 4 2 Manual 130 7 35 Descends 10 incline in wheelie position Versions applicable e WST M WCUY WST M CG X WST P WCU X WST P CG X Description e In the wheelie position the subject descends a 10 incline General training tips e This skill is a combination of the descends 10 incline and performs stationary wheelie 30 sec skills Training tips for manual e As for the descends 10 incline and performs stationary wheelchairs operated by wheelie 30 sec skills wheelchair users e This is the preferred method for the descent of a steep in
172. 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 be used depending upon the armrest design e For a 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 Originally approved for distribution and use April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 WSTP 4 2 Manual Footrests chair back 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 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 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 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 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 encourage
173. too quickly the wheelchair user may tip the wheelchair forward or fall the wheelchair Starting and stopping on the incline Steering slalom using pylons to steer around Training tips for manual wheelchairs operated by wheelchair users Two hand propulsion Forwards The wheelchair user should keep his her weight back to maintain good traction on the rear wheels The wheelchair user should not go too quickly should stay in control and should be prepared to stop at any time It is easier to maintain speed control than to regain it after it has been lost 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 There is the potential for thumb injury on the brakes if the wheelchair user grabs the wheels when they are rolling too quickly because the hands can get pulled forward into the brakes Originally approved for distribution and use April 4 Current edition WSTP Version 4 2 2 April 17 2013 2013 WSTP 4 2 Manual by the wheels If the wheelchair starts to roll too quickly and the incline is wide enough
174. ty 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 operation of the specific wheelchair used by the learner The trainer may be a rehabilitation clinician e g an occupational therapist or p
175. ul 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 Progression e Start with small angular changes of the wheelchair and progress to larger ones e 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 wheelchairs operated by wheelchair 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 Originally approved for distribution and use April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 WSTP 4 2 Manual users 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 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 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 t
176. uld keep the wheelchair close to his her manual wheelchairs body operated by caregivers The caregiver should avoid starting or stopping suddenly because this may startle the wheelchair user or cause him her Originally approved for distribution and use April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 48 WSTP 4 2 Manual 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 e 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 e 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
177. uld 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 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 a new 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 Originally approved for distribution and use April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 19 WSTP 4 2 Manual 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 occur 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
178. user s elevated feet hit anything Training tips for powered wheelchairs operated by wheelchair users e Not applicable Training tips for powered wheelchairs operated by caregivers e Not applicable Originally approved for distribution and use April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 131 WSTP 4 2 Manual 132 7 36 Descends curb in wheelie position 15 cm Versions applicable e WST M WCUY WST M CGX e WST P WCU X WST P CG X Description In the wheelie position the subject descends a 15 cm curb in the forwards direction General training tips e This skill is a combination of the descends curb 15 cm and performs stationary wheelie 30 sec skills Training tips for manual As for the descends curb 15 cm performs stationary wheelchairs operated by wheelie 30 sec and descends 10 incline in wheelie wheelchair users position skills 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 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 long enoug
179. ve as a spotter so the caregiver should be Originally approved for distribution and use April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 13 WSTP 4 2 Manual 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 drive 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 motor learning are only that there be a learner and a task that has yet to be mastered Beyond these basic 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 op
180. ward using the armrests or seat After a fall the power should be turned off Watch out for spilled battery acid The power should be turned off while the getting up skill is being practiced Training tips for powered wheelchairs operated by caregivers As for manual wheelchairs operated by caregivers As for powered wheelchairs operated by wheelchair users Originally approved for distribution and use April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 137 WSTP 4 2 Manual 138 7 38 Ascends stairs Versions applicable e WSTP M WCU X WSTP M CG Y e WSTP P WCUX WSTP P CG X Description e The wheelchair user and the wheelchair get from the bottom to the top of a set of stairs General training tips e Regardless 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 e Although not officially part of the skill set for manual wheelchairs operated by their users training tips are provided below for the occasional wheelchair user who would like to acquire this skill Training tips for manual e There are a variety of methods the choice of which wheelchairs operated by depends upon the characteristics of the wheelchair user wheelchair users e g strength flexibility ability to use the legs and the stairs e Out of wheelch
181. wivel the casters into different directions a skill that will be useful for later skills Training tips for manual wheelchairs operated by wheelchair users Variations e If the wheelchair user holds the object against the wheel with one hand and rolls the wheel forward then 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 Training tips for powered wheelchairs operated by wheelchair 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 Originally approved for distribution and use April 4 2013 Current edition WSTP Version 4 2 2 April 17 2013 WSTP 4 2 Manual users 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 power then pick up the object Training tips for As for manual wheelchairs operated by caregivers powered wheelchairs operated by caregivers Originally approved for distribution and use April 4 2013
182. wo 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 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 and overuse injuries an improved sense of wellbeing through self esteem self efficacy confidence and personal control the sense of becoming newly abled emp

WHEELCHAIR SKILLS PROGRAM (WSP)© VERSION 4.2

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WHEELCHAIR SKILLS PROGRAM (WSP)&copy; VERSION 4.2

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WHEELCHAIR SKILLS PROGRAM (WSP)© VERSION 4.2