Advertisement

Manual Wheelchair Skills Capacity Predicts Quality of Life and Community Integration in Persons With Spinal Cord Injury

      Abstract

      Hosseini SM, Oyster ML, Kirby RL, Harrington AL, Boninger ML. Manual wheelchair skills capacity predicts quality of life and community integration in persons with spinal cord injury.

      Objectives

      To determine wheelchair (WC) skills success rates for manual WC users with spinal cord injury (SCI), to determine subject characteristics associated with the lowest success rates of WC skills, and to characterize the relationship between WC skills and measures of community integration and quality of life (QOL).

      Design

      Cross-sectional multisite study.

      Setting

      Six Spinal Cord Injury Model Systems (SCIMS) centers.

      Participants

      Individuals with SCI (N=214) who were at least 11 months postinjury, treated at an SCIMS center, and who used a manual WC as their primary means of mobility.

      Intervention

      Not applicable.

      Main Outcome Measures

      Wheelchair Skills Test (WST) and questionnaires of demographics and characteristics, QOL, and community participation.

      Results

      Of the 31 skills in the WST assessed, success rates ranged from 19.6% to 100%. Eight skills had success rates of ≤75%: folding/unfolding the WC (71.5%), ascending (19.6%) and descending (47.2%) a 15-cm curb, ascending (23.2%) and descending (26.5%) stairs, transferring from ground to WC (40.6%), turning 180° in wheelie position (55.2%), and holding a 30-second stationary wheelie (59.9%). Male sex, paraplegia, employed status, lower education, younger age at injury, and white race were among the participant characteristics bivariately associated with higher success rates of several WC skills. After controlling for covariates, higher success rates of several WC skills and a higher total WST score predicted better self-perceived health, higher life satisfaction, and more community participation.

      Conclusions

      For people with SCI who use a manual WC as their primary means of mobility, their ability to perform manual WC skills is associated with higher community participation and life satisfaction. Factors contributing to low success rates need to be investigated, and interventions to improve these rates are needed.

      Key Words

      List of Abbreviations:

      CHART (Craig Handicap Assessment and Reporting Technique - Short Form), NS (not significant), NSCID (National Spinal Cord Injury Database), QOL (quality of life), SCI (spinal cord injury), SCIMS (Spinal Cord Injury Model Systems), SWLS (Satisfaction With Life Scale), WC (wheelchair), WST (Wheelchair Skills Test)
      PEOPLE WITH SPINAL CORD injury (SCI) often rely on manual wheelchairs (WCs) for mobility in the community. Mobility and safety in the community require proficiency in several WC skills.
      • Meyers A.R.
      • Anderson J.J.
      • Miller D.R.
      • Shipp K.
      • Hoenig H.
      Barriers, facilitators, and access for wheelchair users: substantive and methodologic lessons from a pilot study of environmental effects.
      For example, the environment requires the use of a transient or full wheelie in various situations such as steep inclines, potholes, gravel, curbs, and other obstacles.
      • Kirby R.L.
      • Smith C.
      • Seaman R.
      • MacLeod D.A.
      • Parker K.
      The manual wheelchair wheelie: a review of our current understanding of an important motor skill.
      WC-related tips and falls are common causes of injury.
      • Calder C.J.
      • Kirby R.L.
      Fatal wheelchair-related accidents in the United States.
      • Kirby R.L.
      • Ackroyd-Stolarz S.A.
      • Brown M.G.
      • Kirkland S.A.
      • MacLeod D.A.
      Wheelchair-related accidents caused by tips and falls among noninstitutionalized users of manually propelled wheelchairs in Nova Scotia.
      • Xiang H.
      • Chany A.M.
      • Smith G.A.
      Wheelchair related injuries treated in US emergency departments.
      • Gaal R.P.
      • Rebholtz N.
      • Hotchkiss R.D.
      • Pfaelzer P.F.
      Wheelchair rider injuries: causes and consequences for wheelchair design and selection.
      • Berg K.
      • Hines M.
      • Allen S.
      Wheelchair users at home: few home modifications and many injurious falls.
      • Nelson A.L.
      • Groer S.
      • Palacios P.
      • et al.
      Wheelchair-related falls in veterans with spinal cord injury residing in the community: a prospective cohort study.
      Because WC skills are important for safe mobility in the community, it is important to understand how proficient persons with SCI are at using each of the necessary WC skills. Determining success rates for manual WC users will be useful information for clinicians and therapists who design rehabilitation programs, since identified deficiencies can be highlighted in WC education programs for persons with paraplegia and tetraplegia. The rates of success for different manual WC skills have been reported by a variety of authors.
      • Lindquist N.J.
      • Loudon P.E.
      • Magis T.F.
      • Rispin J.E.
      • Kirby R.L.
      • Manns P.J.
      Reliability of the performance and safety scores of the Wheelchair Skills Test version 4.1 for manual wheelchair users.
      • Kirby R.L.
      • Swuste J.
      • Dupuis D.J.
      • MacLeod D.A.
      • Monroe R.
      The Wheelchair Skills Test: a pilot study of a new outcome measure.
      • MacPhee A.H.
      • Kirby R.L.
      • Coolen A.L.
      • Smith C.
      • MacLeod D.A.
      • Dupuis D.J.
      Wheelchair skills training program: a randomized clinical trial of wheelchair users undergoing initial rehabilitation.
      • Kirby R.L.
      • Dupuis D.J.
      • MacPhee A.H.
      • et al.
      The Wheelchair Skills Test (version 2.4): measurement properties.
      • Best K.L.
      • Kirby R.L.
      • Smith C.
      • MacLeod D.A.
      Wheelchair skills training for community-based manual wheelchair users: a randomized controlled trial.
      • Smith C.
      • Kirby R.L.
      Manual wheelchair skills capacity and safety of residents of a long-term-care facility.
      Only 1 study
      • Lemay V.
      • Routhier F.
      • Noreau L.
      • Phang S.H.
      • Martin Ginis K.A.
      Relationships between wheelchair skills, wheelchair mobility and level of injury in individuals with spinal cord injury.
      has reported Wheelchair Skills Test (WST) total performance success rates specifically for subgroups of WC users with paraplegia and tetraplegia. Differences in success rates between persons with paraplegia and tetraplegia may help to identify particular skills that need to be emphasized in the rehabilitation of each group of persons with SCI. Furthermore, by identifying subject characteristics associated with lower success rates of WC skills, clinicians can further identify persons at risk for deficiencies in WC skills and can plan rehabilitation programs accordingly.
      The ability to mobilize in a manual WC reflects an important aspect of independence and quality of life (QOL). New WC users who have been prescribed a manual WC by an expert therapist and trained in WC skills have been shown to use their WC more than new WC users who have received neither a WC nor WC training from an expert therapist.
      • Hoenig H.
      • Landerman L.R.
      • Shipp K.M.
      • et al.
      A clinical trial of a rehabilitation expert clinician versus usual care for providing manual wheelchairs.
      Time spent propelling the WC is associated with QOL measures including more extensive social integration and involvement in occupation, and further WC distance traveled is associated with greater involvement in occupation.
      • Oyster M.L.
      • Karmarkar A.M.
      • Patrick M.
      • Read M.S.
      • Nicolini L.
      • Boninger M.L.
      Investigation of factors associated with manual wheelchair mobility in persons with spinal cord injury.
      After discharge from inpatient rehabilitation, the speed with which one is able to perform manual WC skills has been associated with both return to work and participation after SCI.
      • van Velzen J.M.
      • de Groot S.
      • Post M.W.
      • Slootman J.H.
      • van Bennekom C.A.
      • van der Woude L.H.
      Return to work after spinal cord injury: is it related to wheelchair capacity at discharge from clinical rehabilitation?.
      • Kilkens O.J.
      • Post M.W.
      • Dallmeijer A.J.
      • van Asbeck F.W.
      • van der Woude L.H.
      Relationship between manual wheelchair skill performance and participation of persons with spinal cord injuries 1 year after discharge from inpatient rehabilitation.
      Identification of a relationship between WC skills and community participation and QOL may help rehabilitation advocates justify the need to include WC skills within rehabilitation programs. These data may provide evidence that WC skills education is an important covered component of rehabilitation after SCI.
      The objectives of this study were to report WC skills success rates for manual WC users with paraplegia and tetraplegia, to determine subject characteristics associated with the lowest success rates of WC skills, and to characterize the relationship between WC skills and measures of community participation and QOL.

      Methods

      Participants

      Study participants were recruited from 6 Spinal Cord Injury Model Systems (SCIMS) during the period of October 2007 to November 2010.

      Recruitment and Screening

      The SCIMS program, which is funded by the Department of Education, National Institute on Disability and Rehabilitation Research, maintains a longitudinal national database of people who have sustained a traumatic SCI. Participants enrolled in the National Spinal Cord Injury Database (NSCID) are contacted for a follow-up interview 1 year postinjury and every 5 years thereafter. Recruitment for this study occurred at the time of contact for the NSCID follow-up interviews, through local registries, flyers, or during clinic visits. Participants were eligible for inclusion in this study if they were 16 years or older, had an SCI with discernible neurologic impairments, were at least 11 months postinjury, used a manual WC as their primary means of mobility, were nonambulatory except for exercise purposes, and were willing to come in to their local SCIMS center for an appointment.

      Ethical Issues

      Approval for this study was obtained by each of the sites' local institutional review boards, and informed consent was obtained from each participant before the initiation of study procedures.

      Demographic and Clinical Data

      Participants completed a self-report questionnaire that included patient demographic data (ie, sex, race, education level, marital status, and work status) and clinical data (ie, age at time of injury, age at enrollment, number of years postinjury, self-reported SCI level, and total number of medical comorbidities). Medical comorbidities that were inquired about included asthma, emphysema, chronic bronchitis, arthritis, cancer diagnosed in the past 3 years, diabetes, digestive problems, human immunodeficiency virus infection or acquired immunodeficiency syndrome, heart disease, kidney disease, liver disease, and stroke. Total motor score and completeness of SCI lesion were not available for inclusion in our dataset.

      QOL and Community Participation Measures

      QOL and community participation were assessed using several measures. The Hospital Anxiety and Depression Scale–Anxiety subscale
      • Bjelland I.
      • Dahl A.A.
      • Haug T.T.
      • Neckelmann D.
      The validity of the Hospital Anxiety and Depression Scale An updated literature review.
      has been previously shown to have good psychometric properties in the outpatient SCI population.
      • Woolrich R.A.
      • Kennedy P.
      • Tasiemski T.
      A preliminary psychometric evaluation of the Hospital Anxiety and Depression Scale (HADS) in 963 people living with a spinal cord injury.
      Responses to the anxiety questions were based on symptoms over the past week; a higher score indicates more anxiety symptoms. Each item on the Satisfaction With Life Scale (SWLS)
      • Diener E.
      • Emmons R.A.
      • Larsen R.J.
      • Griffin S.
      The Satisfaction With Life Scale.
      uses a 7-point scale with responses ranging from strongly disagree to strongly agree. The score range was 5 to 35, with a higher score indicating a greater satisfaction with life; we term this variable “life satisfaction.” An item from the Medical Outcomes Study 36-Item Short-Form Health Survey
      • Ware J.E.
      • Kosinski M.
      • Keller S.K.
      SF-36 Physical and Mental Health Summary Scales: a user's manual.
      asked participants to assess their current general health. The score range was 1 to 5, with a lower score indicating better health. We term this variable “self-perceived health status.” Community participation was assessed using 4 items (mobility, occupation, social integration, physical independence) from the Craig Handicap Assessment and Reporting Technique–Short Form (CHART) and total CHART score.
      • Whiteneck G.
      • Charlifue S.W.
      • Gerhart K.A.
      • Overholser J.D.
      • Richardson G.N.
      Each domain was scored on a 100-point scale (higher scores being more favorable), and the scores were summed to calculate the total CHART score (0–400).

      Wheelchair Skills Test

      The WST was used to assess manual WC skills because it has been favorably identified in independent surveys of such tests.
      • Kilkens O.J.
      • Post M.W.
      • Dallmeijer A.J.
      • Seelen H.A.
      • van der Woude L.H.
      Wheelchair skills tests: a systematic review.
      • Fliess-Douer O.
      • Vanlandewijck Y.C.
      • Lubel M.G.
      • van der Woude L.H.
      A systematic review of wheelchair skills tests for manual wheelchair users with a spinal cord injury: towards a standardized outcome measure.
      The WST is a standardized method of evaluating a WC user's ability to safely and effectively complete skills of varying levels of difficulty.
      • Kirby R.L.
      • Smith C.
      • Parker K.
      • et al.
      Wheelchair Skills Test manual version 4.1.
      The WST for manual WCs has been well studied with respect to measurement properties.
      • Lindquist N.J.
      • Loudon P.E.
      • Magis T.F.
      • Rispin J.E.
      • Kirby R.L.
      • Manns P.J.
      Reliability of the performance and safety scores of the Wheelchair Skills Test version 4.1 for manual wheelchair users.
      • Kirby R.L.
      • Swuste J.
      • Dupuis D.J.
      • MacLeod D.A.
      • Monroe R.
      The Wheelchair Skills Test: a pilot study of a new outcome measure.
      • Kirby R.L.
      • Dupuis D.J.
      • MacPhee A.H.
      • et al.
      The Wheelchair Skills Test (version 2.4): measurement properties.
      • Routhier F.
      • Demers L.
      • Kirby R.L.
      • et al.
      Inter-rater and test-retest reliability of the French-Canadian Wheelchair Skills Test (version 3.2): preliminary findings.
      Participants completed the objective WST (version 4.1) for manual WC users.
      • Kirby R.L.
      • Smith C.
      • Parker K.
      • et al.
      Wheelchair Skills Test manual version 4.1.
      All data collectors received training using a web-based training system to ensure data were collected uniformly. Data collectors recorded a pass, fail, or no part (could not attempt skill because WC did not have part) score for each of 31 skills. The skill “turns 90° while moving backward” was inadvertently not collected.

      Procedure

      Each participant was studied on a single occasion. After the provision of informed consent, the demographic, clinical, QOL, and community participation questionnaires were administered. All data collectors received training before collecting any data to ensure they were collecting data uniformly. Each participant completed the WST using their own WC, and thus the type of WC varied between subjects. Data collection took approximately 1.5 hours for each subject. A total of 214 subjects participated in this cross-sectional study.

      Analysis

      SPSSa (versions 17.0 and 19.0) was used for all analyses. The Shapiro-Wilk test was used to assess the normality of all continuous variables.

      WC skills success rates

      Success rates of individual WC skills and total WST score were calculated separately for participants with paraplegia and tetraplegia. A composite total percentage WST score was computed for each participant by summing the pass scores and dividing by the number of applicable scores (31 minus the number of “no part” or “not tested” scores). Chi-square test and Mann-Whitney test of independent samples were used to determine significant differences in skill success rates between the 2 groups. Multiple comparison (Bonferroni) correction of the α level was used (α level=.05/[32 variables]=.0016).

      Association of participant characteristics and clinical data with WC skills success rates

      As an initial screen, we tested bivariate correlations (χ2 test and Mann-Whitney test of independent samples) of the 8 WC skills success rates that were ≤75% and total WST score with patient demographics and clinical data. The rationale for using a cutoff of 75% was based on a judgment that differences in the 20% to 25% range would be expected by clinicians in order to alter their practice.
      The following variables were dichotomized for the purposes of the analysis: SCI level (paraplegia vs tetraplegia); marital status (legally married or living with a partner vs single, divorced, separated, or widowed); work status (working or military vs homemaker, on-the-job training, sheltered workshop, retired, student, or unemployed); education level (high school diploma or less vs associate degree or higher); and race (African American vs white).

      Relationship between WC skills success rates and community integration and QOL outcomes

      As the next step in determining how community participation and QOL variables related to WC skills success, we examined the bivariate correlations (Mann-Whitney test of independent samples and Spearman correlation) of the 8 selected WC skills success rates and total WST scores with QOL and community participation outcomes, including anxiety symptoms, current self-perceived health, life satisfaction (total SWLS score), physical independence CHART score, mobility CHART score, social integration CHART score, occupation CHART score, and total CHART score. Those variables most strongly associated (P<.003) with lower WC skills success were selected for multivariate analyses. For these analyses, multiple comparison (Bonferroni) correction of the α level was used (α level=.05/[17 variables]=.003).
      The bivariate correlations between WC skills and community participation and QOL outcomes were used as a basis for building each of the multiple linear regression models. As a conservative approach, all participant characteristics that were correlated (P<0.1) with low WC skills were tested in a second step for associations (P<0.1) with the QOL outcomes. Each of the 8 WC skills and the total WST score were used as predictors (independent variables) of its respective QOL or community participation outcome (dependent variables). The covariates that were bivariately correlated (P<0.1) to both the WC skill and the QOL outcome were entered in the first step of the regression models. This approach allows for more variance to be potentially explained by the covariates, thus giving a conservative estimate of the variance explained by the independent variables (WC skills). The WC skill variable was entered in the second step. We report R2 change values for each WC skill variable that was a significant (P values <.05, <.01, and <.001) predictor of either community participation or QOL outcomes in the regression models.

      Results

      Participants

      A total of 214 subjects participated in this study. Demographic and clinical data for the total sample are shown in table 1. Most of our sample was male, white, unmarried, unemployed, and had lower education and paraplegia. The median time since injury was 8.9 years. QOL and community participation data are reported in table 2. Participant self-perception of health and life satisfaction both tended to be in the middle of the score ranges. Anxiety symptoms tended to be low for the sample. Of the 4 CHART subscale means, that for occupation was the lowest and that for social integration was the highest.
      Table 1Demographic and Clinical Characteristics
      Variablen (%)Mean ± SDMedianRange
      Female44 (20.6)
      Race
       White122 (57.0)
       African American76 (35.5)
       Other race14 (6.5)
      Married77 (36.0)
      Higher education73 (34.1)
      Not employed130 (61.0)
      Paraplegia154 (72.0)
      SCI levelC3 to L5
      Age at time of injury (y)27.6±11252–71
      Age at enrollment (y)38.8±123818–78
      Years postinjury11.7±118.90.9–50
      Comorbidities
      Number of medical comorbidities.
      0.5±100–7
      low asterisk Number of medical comorbidities.
      Table 2QOL and Community Participation Measures
      VariableMean ± SDMedianRange
      Self-perceived health status
      Higher score more favorable.
      2.62±131–5
      Life satisfaction score
      Higher score more favorable.
      20.8±8225–35
      Anxiety symptoms
      Lower score more favorable.
      4.7±340–15
      Physical independence score
      Higher score more favorable.
      85.6±261000–100
      Mobility score
      Higher score more favorable.
      83.8±21940–100
      Occupation score
      Higher score more favorable.
      70.9±34900–100
      Social integration score
      Higher score more favorable.
      93.0±171000–100
      Total CHART score
      Higher score more favorable.
      334.7±63.0347.50–400
      low asterisk Higher score more favorable.
      Lower score more favorable.

      WC Skills Success Rates

      No adverse events occurred during the WST testing. Table 3 lists each WC skill and shows the success rates for the subgroups with paraplegia and tetraplegia and for the total sample. The success rates tended to be higher for people with paraplegia as compared with those with tetraplegia; the differences between the 2 groups were significant for 6 of the WC skills and for the total WST. Success rates in the total sample were ≤75% for 8 manual WC skills (indicated by double vertical superscript in table 3). Chi-square values for these 8 variables were as follows: (1) folds and unfolds WC (χ2=15.31, P<.001); (2) ascends 15-cm curb (χ2=2.27, not significant [NS]); (3) descends 15-cm curb (χ2=.95, NS); (4) holds 30-second wheelie (χ2=4.08, P=.043); (5) turns 180° in wheelie (χ2=6.25, P=.012); (6) ground to WC transfer (χ2=6.57, P=.010); (7) ascends at least 3 stairs (χ2=2.31, NS); and (8) descends at least 3 stairs (χ2=4.00, P=.045).
      Table 3Success Rates for Manual WC Skills
      WST VariablenParaplegia
      Success rates of patients with paraplegia.
      n (%)
      Tetraplegia
      Success rates of patients with tetraplegia.
      n (%)
      Total
      Success rates of total sample.
      n (%)
      Rolls forward 10m208153 (100)55 (100)208 (100)
      Rolls forward 10m in 30s208153 (100)55 (100)208 (100)
      Rolls backward 5m210154 (100)56 (100)210 (100)
      Turns 90° while moving forward210154 (100)56 (100)210 (100)
      Turns 180° in place210152 (98.7)56 (100)208 (99.0)
      Maneuvers sideways210154 (100)56 (100)210 (100)
      Gets through hinged door210151 (98.1)52 (92.9)203 (96.7)
      Reaches 1.5-m-high object
      Statistically significant at the Bonferroni-adjusted α level of .0016 for comparisons between paraplegia and tetraplegia.
      210154 (100)52 (92.9)206 (98.1)
      Picks object up from floor
      Statistically significant at the Bonferroni-adjusted α level of .0016 for comparisons between paraplegia and tetraplegia.
      210152 (98.7)49 (87.5)201 (95.8)
      Relieves weight from buttocks210149 (96.8)52 (92.9)201 (95.8)
      Transfer between WC and bench208140 (91.5)42 (76.4)182 (87.5)
      Folds and unfolds WC
      Statistically significant at the Bonferroni-adjusted α level of .0016 for comparisons between paraplegia and tetraplegia.
      172101 (79.5)22 (48.9)123 (71.5)
      WC skills with success rates ≤75%.
      Rolls 100m209153 (100)56 (100)209 (100)
      Avoids moving obstacles207152 (100)55 (100)207 (100)
      Ascends 5° incline
      Statistically significant at the Bonferroni-adjusted α level of .0016 for comparisons between paraplegia and tetraplegia.
      209153 (100)51 (91.1)204 (97.6)
      Descends 5° incline209153 (100)53 (94.6)206 (98.6)
      Ascends 10° incline
      Statistically significant at the Bonferroni-adjusted α level of .0016 for comparisons between paraplegia and tetraplegia.
      209143 (93.5)38 (67.9)181 (86.6)
      Descends 10° incline
      Statistically significant at the Bonferroni-adjusted α level of .0016 for comparisons between paraplegia and tetraplegia.
      209151 (98.7)48 (85.7)199 (95.2)
      Rolls 2m across 5° side slope204148 (99.3)50 (90.9)198 (97.1)
      Rolls 2m on soft surface209149 (97.4)52 (92.9)201 (96.2)
      Crosses over 15-cm pothole209136 (88.9)44 (78.6)180 (86.1)
      Crosses over 2-cm threshold209148 (96.7)55 (98.2)203 (97.1)
      Ascends 5-cm level change205128 (84.2)38 (71.7)166 (81.0)
      Descends 5-cm level change205140 (92.1)46 (86.8)186 (90.7)
      Ascends 15-cm curb18430 (22.2)6 (12.2)36 (19.6)
      WC skills with success rates ≤75%.
      Descends 15-cm curb19771 (49.3)22 (41.5)93 (47.2)
      WC skills with success rates ≤75%.
      Holds 30-s wheelie20296 (64.0)25 (48.1)121 (59.9)
      WC skills with success rates ≤75%.
      Turns 180° in wheelie20190 (60.4)21 (40.8)111 (55.2)
      WC skills with success rates ≤75%.
      Ground to WC transfer18061 (46.2)12 (25.0)73 (40.6)
      WC skills with success rates ≤75%.
      Ascends at least 3 stairs15530 (26.3)6 (14.6)36 (23.2)
      WC skills with success rates ≤75%.
      Descends at least 3 stairs15535 (30.7)6 (14.6)41 (26.5)
      WC skills with success rates ≤75%.
      Total WST
      Statistically significant at the Bonferroni-adjusted α level of .0016 for comparisons between paraplegia and tetraplegia.
      21086%78%84%
      NOTE. n=sample size.
      low asterisk Success rates of patients with paraplegia.
      Success rates of patients with tetraplegia.
      Success rates of total sample.
      § Statistically significant at the Bonferroni-adjusted α level of .0016 for comparisons between paraplegia and tetraplegia.
      WC skills with success rates ≤75%.

      Association of Participant Characteristics and Clinical Data With WC Skills Success Rates

      The patient characteristics bivariately associated (P<0.1) with lower rates of WC success are indicated in table 4. All 8 of the WC skills with success rates of ≤75% and the total WST score were associated with at least 2 characteristics. Neither marital status nor medical comorbidities were bivariately associated with WC skills at the α level of <0.1.
      Table 4Bivariate Associations Between Participant Characteristics and WC Skills
      WC SkillsParticipant Characteristics
      SexRace
      White persons were compared with African Americans. For this analysis, subjects of other races (n=14) were excluded.
      EDUMSWSAIAEYPISCILMC
      WC fold/unfold<.05<.05<.10<.001
      Ascends 15-cm curb<.05<.10
      Descends 15-cm curb<.01<.05<.10<.01<.10
      Holds 30-s wheelie<.001<.05<.05<.01<.10<.05
      Turns 180° wheelie<.001<.05<.05<.01<.05<.05
      Ground/WC transfer<.10<.01<.05
      Ascends stairs
      At least 3 stairs.
      <.10<.05
      Descends stairs
      At least 3 stairs.
      <.05<.10<.05<.05
      Total WST<.001<.01<.01<.10<.01
      NOTE. Only P values for relationships that were <.10 are shown.
      Abbreviations: AE, age at enrollment; AI, age at time of injury; EDU, education level; MC, medical comorbidities; MS, marital status; SCIL, SCI level; WS, work status; YPI, years postinjury.
      low asterisk White persons were compared with African Americans. For this analysis, subjects of other races (n=14) were excluded.
      At least 3 stairs.

      Relationship Between WC Skills Success Rates and Community Integration and QOL Outcomes

      Multiple linear regressions for WC skills predicting QOL and community participation measures are reported in table 5. R2 values for each WC skill variable are reported in the table. Total WST significantly predicted all the outcomes except for one (social integration). The ability to descend a 15-cm curb significantly predicted 4 of the outcome measures, more than any of the other individual WC skills. The ability to fold and unfold a WC significantly predicted mobility and occupation CHART subscores, as well as total CHART score. Several WC skills predicted a higher mobility CHART subscore and total CHART score. The ability to ascend a 15-cm curb did not significantly predict any of the outcomes studied.
      Table 5Multiple Linear Regressions of WC Skills Predicting QOL Measures
      R2 change values after controlling for covariates.
      Independent VariablesDependent Variables
      SPHLSPhysMobOccupSocCTS
      WC fold/unfold.076
      P<.001. Significant (P<.05) covariates: a, white; b, higher education; c, male; d, paraplegia; e, younger age at injury; f, employed; g, younger age at enrollment.
      ac
      .078
      P<.001. Significant (P<.05) covariates: a, white; b, higher education; c, male; d, paraplegia; e, younger age at injury; f, employed; g, younger age at enrollment.
      a
      .136
      P<.001. Significant (P<.05) covariates: a, white; b, higher education; c, male; d, paraplegia; e, younger age at injury; f, employed; g, younger age at enrollment.
      a
      Ascends 15-cm curb
      Descends 15-cm curb.063
      P<.001. Significant (P<.05) covariates: a, white; b, higher education; c, male; d, paraplegia; e, younger age at injury; f, employed; g, younger age at enrollment.
      b
      .020
      P<.05;
      cef
      .039
      P<.01;
      f
      .056
      P<.01;
      f
      Holds 30-s wheelie.037
      P<.05;
      f
      Turns 180° wheelie.042
      P<.01;
      .051
      P<.01;
      f
      Ground/WC transfer.073
      P<.001. Significant (P<.05) covariates: a, white; b, higher education; c, male; d, paraplegia; e, younger age at injury; f, employed; g, younger age at enrollment.
      ag
      .066
      P<.01;
      a
      Ascends stairs
      At least 3 stairs.
      .031
      P<.05;
      c
      Descends stairs
      At least 3 stairs.
      .029
      P<.05;
      cf
      Total WST.038
      P<.01;
      b
      .036
      P<.01;
      ef
      .032
      P<.01;
      df
      .046
      P<.001. Significant (P<.05) covariates: a, white; b, higher education; c, male; d, paraplegia; e, younger age at injury; f, employed; g, younger age at enrollment.
      cef
      .045
      P<.001. Significant (P<.05) covariates: a, white; b, higher education; c, male; d, paraplegia; e, younger age at injury; f, employed; g, younger age at enrollment.
      bf
      .120
      P<.001. Significant (P<.05) covariates: a, white; b, higher education; c, male; d, paraplegia; e, younger age at injury; f, employed; g, younger age at enrollment.
      bf
      Abbreviations: CTS, CHART total score; LS, life satisfaction; Mob, Mobility CHART subscore; Occup, Occupation CHART subscore; Phys, Physical independence CHART subscore; Soc, Social integration CHART subscore; SPH, self-perceived health status.
      low asterisk R2 change values after controlling for covariates.
      P<.05;
      P<.01;
      § P<.001. Significant (P<.05) covariates: a, white; b, higher education; c, male; d, paraplegia; e, younger age at injury; f, employed; g, younger age at enrollment.
      At least 3 stairs.

      Discussion

      WC Skills Success Rates

      This study examined the success rates for manual WC skills and the relation of manual WC skill performance with participant characteristics and QOL and community participation measures in a sample of people with SCI. Although WC skills are important for enabling manual WC users to safely and effectively negotiate mobility tasks that they encounter in their environments, many of the manual WC users with SCI who we studied had difficulty performing WC skills. From the total sample, we identified 8 WC skills with success rates of ≤75%. The rates of success in our total sample are comparable or slightly higher than those reported by others noted in the introduction.
      • Lindquist N.J.
      • Loudon P.E.
      • Magis T.F.
      • Rispin J.E.
      • Kirby R.L.
      • Manns P.J.
      Reliability of the performance and safety scores of the Wheelchair Skills Test version 4.1 for manual wheelchair users.
      • Lemay V.
      • Routhier F.
      • Noreau L.
      • Phang S.H.
      • Martin Ginis K.A.
      Relationships between wheelchair skills, wheelchair mobility and level of injury in individuals with spinal cord injury.
      As expected, the success rates for a number of skills and the total WST score were higher for the subgroup with paraplegia as compared with that with tetraplegia. However, it is concerning that the success rates were not higher in this sample of persons who use a WC as their primary means of mobility. Possible reasons for low success rates are short inpatient SCI rehabilitation lengths of stay, lack of sufficient follow-up, absence of attention to these WC skills during the rehabilitation course, or lack of training of the therapists who teach WC skills.
      Our results are consistent with those of Middleton et al,
      • Middleton J.W.
      • Harvey L.A.
      • Batty J.
      • Cameron I.
      • Quirk R.
      • Winstanley J.
      Five additional mobility and locomotor items to improve responsiveness of the FIM in wheelchair-dependent individuals with spinal cord injury.
      who investigated mobility in WC users with SCI during a 6-month period. Similar to our findings, they reported that the ability to perform a ground to WC transfer discriminates between the paraplegia and tetraplegia groups. They found that negotiating a 15-cm curb was different between the 2 groups; however, this association was not significant in our sample. Middleton
      • Middleton J.W.
      • Harvey L.A.
      • Batty J.
      • Cameron I.
      • Quirk R.
      • Winstanley J.
      Five additional mobility and locomotor items to improve responsiveness of the FIM in wheelchair-dependent individuals with spinal cord injury.
      additionally found that the skill of curb negotiation demonstrates good improvement over time in the paraplegia group, whereas there was poor improvement over time in the tetraplegia group. Such subgroup analyses could be the topic for a future article examining each of the WC skills.

      Association of Participant Characteristics and Clinical Data With WC Skills Success Rates

      We found it surprising that persons with lower education had higher success rates of WC skills. It is possible that subjects with lower education may have more physically demanding jobs, thus necessitating more advanced WC skills. Additionally, it is possible that affluent subjects were able to complete more home and work modifications, thus reducing the need for certain skills. Those with more resources might also have had more access to caregivers to assist them or to switch to powered WCs if the need arose. As expected, male sex, employed status, younger age at injury, and paraplegia were significantly associated with higher success rates of several WC skills. Of these, male sex and employed status were significant covariates for several WC skills in the regression models. A few additional subject characteristics emerged as significant covariates in several of the regression models, including white race, higher education, and younger age at injury. These findings are in accord with those in the literature.
      • Hoenig H.
      • Landerman L.R.
      • Shipp K.M.
      • et al.
      A clinical trial of a rehabilitation expert clinician versus usual care for providing manual wheelchairs.
      • Kilkens O.J.
      • Post M.W.
      • Dallmeijer A.J.
      • van Asbeck F.W.
      • van der Woude L.H.
      Relationship between manual wheelchair skill performance and participation of persons with spinal cord injuries 1 year after discharge from inpatient rehabilitation.
      • Kilkens O.J.
      • Dallmeijer A.J.
      • Angenot E.
      • Twisk J.W.
      • Post M.W.
      • van der Woude L.H.
      Subject- and injury-related factors influencing the course of manual wheelchair skill performance during initial inpatient rehabilitation of persons with spinal cord injury.

      Relationship Between WC Skills Success Rates and Community Integration and QOL Outcomes

      We have shown that success in performing several specific WC skills is significantly related to community participation measures of mobility and occupational involvement. Of those individual WC skills examined in the regressions, descending a 15-cm curb was the single skill that was predictive of the largest number of QOL and community participation outcomes. The ability to fold and unfold the WC additionally predicted several outcomes. Total WST score predicted the most (6) QOL outcomes including better self-perceived health, higher life satisfaction, and more community participation. We did not find significant associations of WC skill success rates or total WST score with anxiety symptoms.
      The total WST scores for our total sample, and for subgroups with paraplegia and tetraplegia are comparable (although slightly higher) to those recently reported by Lemay et al.
      • Lemay V.
      • Routhier F.
      • Noreau L.
      • Phang S.H.
      • Martin Ginis K.A.
      Relationships between wheelchair skills, wheelchair mobility and level of injury in individuals with spinal cord injury.
      Our finding that total WST score predicts greater community mobility as measured by the CHART subscale is consistent with their report of an association between total WST and greater wheeled distance traveled.
      Surprisingly, in our study, paraplegia was a significant covariate in only 1 regression model, namely for that of total WST predicting physical independence. This is encouraging because it appears that it may be possible for individuals with tetraplegia to achieve similar levels of community participation and QOL as those with unimpaired arm function.

      Study Limitations

      In our study, we used only data from SCIMS centers, which are centers with specialized care in SCI. This limits the generalizability of our findings; we would expect those WC users undergoing rehabilitation in units not designated as specific to SCI to possibly have even lower rates of success. Our study is cross-sectional, and thus we are limited in our ability to determine the direction of the relation of failed WC skills with the studied variables. Another limitation of our dataset was that we did not have complete demographic data for our participants, specifically differences in body mass index, trunk control, the degree of SCI completeness, motor strength, or total motor score. It is possible that these variables would have been stronger covariates of WC skill failure than the gross categorization of paraplegia or tetraplegia. Although this is a limitation to our study, de Groot et al
      • de Groot S.
      • Bevers G.E.
      • Dallmeijer A.J.
      • Post M.W.
      • van Kuppevelt H.J.
      • van der Woude L.H.
      Development and validation of prognostic models designed to predict wheelchair skills at discharge from spinal cord injury rehabilitation.
      previously developed models to predict WC skills at discharge from inpatient rehabilitation and found that neither completeness of the lesion nor total motor score improved their models. A number of studies have shown that WC skills training, increasingly recognized as an important element in the WC provision process,
      World Health Organization
      Guidelines on the provision of wheelchairs in less resourced settings.
      significantly increases the total WST score as well as the success rates of some individual skills.
      • MacPhee A.H.
      • Kirby R.L.
      • Coolen A.L.
      • Smith C.
      • MacLeod D.A.
      • Dupuis D.J.
      Wheelchair skills training program: a randomized clinical trial of wheelchair users undergoing initial rehabilitation.
      • Best K.L.
      • Kirby R.L.
      • Smith C.
      • MacLeod D.A.
      Wheelchair skills training for community-based manual wheelchair users: a randomized controlled trial.
      • Ozturk A.
      • Ucsular F.D.
      Effectiveness of a wheelchair skills training programme for community-living users of manual wheelchairs in Turkey: a randomized controlled trial.
      • Routhier F.
      • Kirby R.L.
      • Demers L.
      • Depa M.
      • Thompson K.
      Efficacy and retention of the French-Canadian version of the Wheelchair Skills Training Program for manual wheelchair users: a randomized controlled trial.
      • Armstrong W.
      • Reisinger K.D.
      • Smith W.K.
      Evaluation of CIR-whirlwind wheelchair and service provision in Afghanistan.
      • Bullard S.
      • Miller S.E.
      Comparison of teaching methods to learn a tilt and balance wheelchair skill.
      • Sawatzky B.
      • Rushton P.W.
      • Denison I.
      • McDonald R.
      Wheelchair skills training programme for children: a pilot study.
      However, our database did not identify the duration of or extent to which such training had been received by our participants. Published work
      • Jenkins S.
      • Karmarkar A.M.
      • Collins D.M.
      • Wichman T.
      • et al.
      Prosthesis and wheelchair use in veterans with lower-limb amputation.
      • Salatin B.
      • Rice I.
      • Teodorski E.
      • Ding D.
      • Cooper R.A.
      A survey of outdoor powered wheelchair driving.
      on the prevalence of such training suggests that <20% of WC users receive much in the way of such training.

      Conclusions

      Many individuals with SCI who use a manual WC demonstrate deficiencies in a number of WC skills. Of those WC skills examined in detail, higher success rates for specific and total manual WC skills predict higher QOL as measured by better self-perceived health, higher life satisfaction, and more community participation. Future studies should also examine the impact of WC type (eg, lightweight vs ultralightweight) and WC setup on WC skills success rates and community integration and QOL outcomes. Longitudinal research is needed to discern whether there is a causal relation between WC skills and QOL and community participation. To more fully explore the role of WC skills in community integration, future studies could examine the proficiency of using escalators, buses, and accessible transportation. More research is also needed to investigate interventions such as WC skills training that improve manual WC skills in people with SCI. The clinical team should focus more attention on ensuring the adequacy of WC skills in their patients with SCI.
      • a
        SPSS Inc, 233 S Wacker Dr, 11th Fl, Chicago, IL 60606.

      References

        • Meyers A.R.
        • Anderson J.J.
        • Miller D.R.
        • Shipp K.
        • Hoenig H.
        Barriers, facilitators, and access for wheelchair users: substantive and methodologic lessons from a pilot study of environmental effects.
        Soc Sci Med. 2002; 55: 1435-1446
        • Kirby R.L.
        • Smith C.
        • Seaman R.
        • MacLeod D.A.
        • Parker K.
        The manual wheelchair wheelie: a review of our current understanding of an important motor skill.
        Disabil Rehabil Assist Technol. 2006; 1: 119-127
        • Calder C.J.
        • Kirby R.L.
        Fatal wheelchair-related accidents in the United States.
        Am J Phys Med Rehabil. 1990; 69: 184-190
        • Kirby R.L.
        • Ackroyd-Stolarz S.A.
        • Brown M.G.
        • Kirkland S.A.
        • MacLeod D.A.
        Wheelchair-related accidents caused by tips and falls among noninstitutionalized users of manually propelled wheelchairs in Nova Scotia.
        Am J Phys Med Rehabil. 1994; 73: 319-330
        • Xiang H.
        • Chany A.M.
        • Smith G.A.
        Wheelchair related injuries treated in US emergency departments.
        Inj Prev. 2006; 12: 8-11
        • Gaal R.P.
        • Rebholtz N.
        • Hotchkiss R.D.
        • Pfaelzer P.F.
        Wheelchair rider injuries: causes and consequences for wheelchair design and selection.
        J Rehabil Res Dev. 1997; 34: 58-71
        • Berg K.
        • Hines M.
        • Allen S.
        Wheelchair users at home: few home modifications and many injurious falls.
        Am J Public Health. 2002; 92: 48
        • Nelson A.L.
        • Groer S.
        • Palacios P.
        • et al.
        Wheelchair-related falls in veterans with spinal cord injury residing in the community: a prospective cohort study.
        Arch Phys Med Rehabil. 2010; 91: 1166-1173
        • Lindquist N.J.
        • Loudon P.E.
        • Magis T.F.
        • Rispin J.E.
        • Kirby R.L.
        • Manns P.J.
        Reliability of the performance and safety scores of the Wheelchair Skills Test version 4.1 for manual wheelchair users.
        Arch Phys Med Rehabil. 2010; 91: 1752-1757
        • Kirby R.L.
        • Swuste J.
        • Dupuis D.J.
        • MacLeod D.A.
        • Monroe R.
        The Wheelchair Skills Test: a pilot study of a new outcome measure.
        Arch Phys Med Rehabil. 2002; 83: 10-18
        • MacPhee A.H.
        • Kirby R.L.
        • Coolen A.L.
        • Smith C.
        • MacLeod D.A.
        • Dupuis D.J.
        Wheelchair skills training program: a randomized clinical trial of wheelchair users undergoing initial rehabilitation.
        Arch Phys Med Rehabil. 2004; 85: 41-50
        • Kirby R.L.
        • Dupuis D.J.
        • MacPhee A.H.
        • et al.
        The Wheelchair Skills Test (version 2.4): measurement properties.
        Arch Phys Med Rehabil. 2004; 85: 794-804
        • Best K.L.
        • Kirby R.L.
        • Smith C.
        • MacLeod D.A.
        Wheelchair skills training for community-based manual wheelchair users: a randomized controlled trial.
        Arch Phys Med Rehabil. 2005; 86: 2316-2323
        • Smith C.
        • Kirby R.L.
        Manual wheelchair skills capacity and safety of residents of a long-term-care facility.
        Arch Phys Med Rehabil. 2011; 92: 663-669
        • Lemay V.
        • Routhier F.
        • Noreau L.
        • Phang S.H.
        • Martin Ginis K.A.
        Relationships between wheelchair skills, wheelchair mobility and level of injury in individuals with spinal cord injury.
        Spinal Cord. 2012; 50: 37-41
        • Hoenig H.
        • Landerman L.R.
        • Shipp K.M.
        • et al.
        A clinical trial of a rehabilitation expert clinician versus usual care for providing manual wheelchairs.
        J Am Geriatr Soc. 2005; 53: 1712-1720
        • Oyster M.L.
        • Karmarkar A.M.
        • Patrick M.
        • Read M.S.
        • Nicolini L.
        • Boninger M.L.
        Investigation of factors associated with manual wheelchair mobility in persons with spinal cord injury.
        Arch Phys Med Rehabil. 2011; 92: 484-490
        • van Velzen J.M.
        • de Groot S.
        • Post M.W.
        • Slootman J.H.
        • van Bennekom C.A.
        • van der Woude L.H.
        Return to work after spinal cord injury: is it related to wheelchair capacity at discharge from clinical rehabilitation?.
        Am J Phys Med Rehabil. 2009; 88: 47-56
        • Kilkens O.J.
        • Post M.W.
        • Dallmeijer A.J.
        • van Asbeck F.W.
        • van der Woude L.H.
        Relationship between manual wheelchair skill performance and participation of persons with spinal cord injuries 1 year after discharge from inpatient rehabilitation.
        J Rehabil Res Dev. 2005; 42: 65-73
        • Bjelland I.
        • Dahl A.A.
        • Haug T.T.
        • Neckelmann D.
        The validity of the Hospital Anxiety and Depression Scale.
        J Psychosom Res. 2002; 52: 69-77
        • Woolrich R.A.
        • Kennedy P.
        • Tasiemski T.
        A preliminary psychometric evaluation of the Hospital Anxiety and Depression Scale (HADS) in 963 people living with a spinal cord injury.
        Psychol Health Med. 2006; 11: 80-90
        • Diener E.
        • Emmons R.A.
        • Larsen R.J.
        • Griffin S.
        The Satisfaction With Life Scale.
        J Pers Assess. 1985; 49: 71-75
        • Ware J.E.
        • Kosinski M.
        • Keller S.K.
        SF-36 Physical and Mental Health Summary Scales: a user's manual.
        The Health Institute, New England Medical Center, Boston1994
        • Whiteneck G.
        • Charlifue S.W.
        • Gerhart K.A.
        • Overholser J.D.
        • Richardson G.N.
        Guide for use of the CHART Craig Handicap Assessment and Reporting Technique. Craig Hospital, Englewood1992
        • Kilkens O.J.
        • Post M.W.
        • Dallmeijer A.J.
        • Seelen H.A.
        • van der Woude L.H.
        Wheelchair skills tests: a systematic review.
        Clin Rehabil. 2003; 17: 418-430
        • Fliess-Douer O.
        • Vanlandewijck Y.C.
        • Lubel M.G.
        • van der Woude L.H.
        A systematic review of wheelchair skills tests for manual wheelchair users with a spinal cord injury: towards a standardized outcome measure.
        Clin Rehabil. 2010; 24: 867-886
        • Kirby R.L.
        • Smith C.
        • Parker K.
        • et al.
        Wheelchair Skills Test manual version 4.1.
        (Accessed September 29, 2011)
        • Routhier F.
        • Demers L.
        • Kirby R.L.
        • et al.
        Inter-rater and test-retest reliability of the French-Canadian Wheelchair Skills Test (version 3.2): preliminary findings.
        in: Proceedings of the annual meeting of RESNA; 2007 June 15-19; Phoenix, AZ RESNA Press, Arlington2007
        • Middleton J.W.
        • Harvey L.A.
        • Batty J.
        • Cameron I.
        • Quirk R.
        • Winstanley J.
        Five additional mobility and locomotor items to improve responsiveness of the FIM in wheelchair-dependent individuals with spinal cord injury.
        Spinal Cord. 2006; 44: 495-504
        • Kilkens O.J.
        • Dallmeijer A.J.
        • Angenot E.
        • Twisk J.W.
        • Post M.W.
        • van der Woude L.H.
        Subject- and injury-related factors influencing the course of manual wheelchair skill performance during initial inpatient rehabilitation of persons with spinal cord injury.
        Arch Phys Med Rehabil. 2005; 86: 2119-2125
        • de Groot S.
        • Bevers G.E.
        • Dallmeijer A.J.
        • Post M.W.
        • van Kuppevelt H.J.
        • van der Woude L.H.
        Development and validation of prognostic models designed to predict wheelchair skills at discharge from spinal cord injury rehabilitation.
        Clin Rehabil. 2010; 24: 168-180
        • World Health Organization
        Guidelines on the provision of wheelchairs in less resourced settings.
        (Accessed February 1, 2012)
        • Ozturk A.
        • Ucsular F.D.
        Effectiveness of a wheelchair skills training programme for community-living users of manual wheelchairs in Turkey: a randomized controlled trial.
        Clin Rehabil. 2011; 25: 416-424
        • Routhier F.
        • Kirby R.L.
        • Demers L.
        • Depa M.
        • Thompson K.
        Efficacy and retention of the French-Canadian version of the Wheelchair Skills Training Program for manual wheelchair users: a randomized controlled trial.
        Arch Phys Med Rehabil. 2012; 93: 940-948
        • Armstrong W.
        • Reisinger K.D.
        • Smith W.K.
        Evaluation of CIR-whirlwind wheelchair and service provision in Afghanistan.
        Disabil Rehabil. 2007; 29: 935-948
        • Bullard S.
        • Miller S.E.
        Comparison of teaching methods to learn a tilt and balance wheelchair skill.
        Percept Mot Skills. 2001; 93: 131-138
        • Sawatzky B.
        • Rushton P.W.
        • Denison I.
        • McDonald R.
        Wheelchair skills training programme for children: a pilot study.
        Aust Occup Ther J. 2012; 59: 2-9
        • Jenkins S.
        Wheelchair training provision by NHS wheelchair services. Whizz-Kidz, London2002
        • Karmarkar A.M.
        • Collins D.M.
        • Wichman T.
        • et al.
        Prosthesis and wheelchair use in veterans with lower-limb amputation.
        J Rehabil Res Dev. 2009; 46: 567-576
        • Salatin B.
        • Rice I.
        • Teodorski E.
        • Ding D.
        • Cooper R.A.
        A survey of outdoor powered wheelchair driving.
        in: Proceedings of the annual meeting of RESNA; 2010 June 26-30; Las Vegas, NV RESNA Press, Arlington2010