Title: Development of a Test of Wheeled Mobility for Manual Wheelchair Users with Spinal Cord Injury
Other Titles: Ontwikkeling van een test voor hand-bewogen rolstoelmobiliteit in personen met een dwarslaesie
Authors: Fliess-Douer, Osnat; S0066556;
Issue Date: 23-Aug-2012
Abstract: Manual wheelchair mobility is important for a large number of people, especially for those who will not return to walking again, as individuals with a complete spinal cord injury. To function independently, manual wheelchair users must possess a variety of wheelchair skills, in order to deal with the physical barriers they will encounter in various situations in daily life. Wheelchair skill performance is defined as: “The ability to move around and overcome obstacles encountered when carrying out daily activities or social roles in a self-propelled wheelchair" (Routhier et al., 2003). Wheeled mobility (WM) is defined as: “Moving around using equipment: moving the whole body from place to place, on any surface or space, by using specific devices designed to facilitate moving or create other ways of moving around, such as moving down the street in a wheelchair or a walker" (ICF WHO 2001). WM skills learned during the rehabilitation period should reflect the daily activities and needs of the specific patient. They should maximize the patient’s functional capacity and minimize the dependence on others. Therapists should gain more knowledge and search for ways to improve a person’s wheelchair skill performance and by this, to promote participation in community activities and social roles. Furthermore, therapists should have a valid, reliable and sensitive measuring tool in order to objectively and systematically assess their patient's level of WM performances, before, during and after interventions. Functional outcomes after SCI vary from person to person, depending on the level and completeness of the injury, neurologic recovery, associated complications, the amount of rehabilitation training, age, body size, weight, family support and financial status (Haisma et al., 2007). It is assumed that maximizing WM and overall independency is also influenced by attitudinal factors as self-efficacy, rather than just disability-related factors. Therefore, when teaching and assessing wheelchair skills performances, psychological aspects (e.g. anxiety, motivation, etc.), should also be considered. A "WM test" consists of different tasks performed by the candidate under standardized conditions. A validated and reliable wheelchair skills test is necessary as a guiding instrument in the rehabilitation process of people with SCI. Measurement of mobility can assist choice of the appropriate therapy, and evaluation of a patient progress and the effects of treatment (Bussmann et al., 1998). Many tests are applied to measure wheelchair skill performance using different tasks and outcome measures. This makes it difficult to compare study results. Furthermore, a standardized and accepted WM skills test could be used to develop standards of wheelchair skills performance for individuals with different levels of impairment. Such common WM skills test was not available to date (Kilkens et al., 2003. Fliess-Douer et al., 2010).This study aimed to develop a standardized test of wheeled mobility (TOWM) for hand rim wheelchair users with SCI, in order to promote the establishment of norms and standards for WM skill performances. The main research question was: which skills, scale and equipment should comprise a wheelchair skills test that is valid, sensitive and reliable, aimed for fast and easy screening, differentiating between a wide range of performance levels of hand-rim wheelchair users with SCI?In the first study, a systematic literature review was carried out. The main objective of this review was to systematically review, document, analyze and critically appraise the performance-based wheelchair skills tests for manual wheelchair users, especially those with a spinal cord injury, currently available in the international literature. An added value of this study was that it facilitated a selection of the most suitable components from the existing wheelchair skills tests in order to develop a standardized test. To test the preliminary assumption about the level of WM gained during the acute rehabilitation phase, an assessment of differences in WM levels of persons with SCI between discharge from inpatient rehabilitation and 1 year after discharge was conducted. This was based on the Dutch prospective longitudinal study, using an existing data from the "Wheelchair circuit" (Kilkens et al., 2004). An attempt was made also to determine the personal and environmental factors that contribute the most to changes in wheelchair skill performances. Results showed that the scores of the Wheelchair Circuit were stable over the year after discharge from the rehabilitation center. Change in wheelchair skills performance in the year after discharge was not different between groups with different personal or lesion characteristics, while perceived self-efficacy was positively related to the course of wheelchair skill performance over time. The main conclusion of this study was that wheelchair skill performance, measured by means of the Wheelchair Circuit test, stabilizes during the first year after discharge from inpatient rehabilitation and perceived self-efficacy had a positive impact on changes in wheelchair skill performance during that time. The Wheelchair Circuit was found less suitable for testing wheelchair skill performances in the post-acute rehabilitation phase of people with SCI due to a ceiling effect of the ability score (most of the participants already reached the top level at the end of the rehabilitation program and could not further improve).The next study aimed to develop a valid and reliable scale assessing perceived Self-Efficacy in Wheeled Mobility (SEWM). This scale was developed for two main purposes: (a) recruiting the most competent people with SCI (in terms of WM perceptions) in order to create a panel of experts advising and sharing their knowledge with the research team when developing the new test of WM; and (b) to provide evidence for the validity of the test of WM developed in this study, by correlating both tests results. Furthermore, such scale can find wide applicability in clinical and community settings in wheeled mobility focused interventions for people with SCI. No self-efficacy in wheeled mobility scale was found in the international literature. The main results of this study (n=47, only paraplegic) showed high internal consistency of the SEWM but two items showed lower correlations with the total score. The conclusion of this study was that SEWM seems a reliable and valid instrument in manual wheelchair users with SCI, but items 8 and 9 were advised to be rephrased, and a larger sample (including individuals with tetraplegia) was suggested to support the statistical properties of the scale. An opportunity was given during the Beijing Paralympic games 2008, to support the preliminary psychometric findings of the SEWM scale, after rephrasing 2 items. A comparison of self-efficacy perceptions between athletes with SCI competing in dynamic wheelchair sports to athletes who participate in static and non-wheelchair sports was carried out. Results confirmed high internal consistency and construct validity of the SEWM, and athlete's subgroups investigation showed that athletes with tetraplegia perceived significantly lower WM levels than those with paraplegia. Furthermore, athletes who participate in dynamic team wheelchair sports perceived the highest level of WM while athletes competing in static wheelchair sports perceived the lowest WM levels. A survey among elite athletes with SCI was also conducted in Beijing Paralympic games, aiming to sort out the most essential wheeled mobility skills for daily life of manual wheelchair users, in order to incorporate those skills in the newly developed test of wheeled mobility. Aside the sorted list of skills, survey findings demonstrated that nearly half of the participants have learned the most essential WM skills after clinical rehabilitation in a community setting. Having in hands the critical literature review, the SEWM scale and the sorted list of the most essential WM skills for daily life, "an expert team" (including wheelchair users representing all level of SCI as well as physiotherapists and academic professionals) was composed in order to develop the Test of Wheeled Mobility (TOWM). In addition, an idea was raised to develop also a short Wheelie test based on the assumption that mastering wheelie would result in a better wheelchair skill functioning. The process of test development was iterative, with repeated reviews, try-outs and comments by the panel of experts. The TOWM and the short Wheelie test were evaluated for their feasibility, validity and reliability. Both tests were found to be feasible, valid and reliable when assessing wheeled mobility of manual wheelchair users with SCI. In the last part of the dissertation, methodological considerations, practical implications, and recommendations for future research were discussed. The main suggestion was that after refining few quality criteria and considering omitting the ‘Level propulsion’ task, to use the TOWM in a larger sample, including SCI patients during their rehabilitation phase, as well as assessing the effectiveness of intervention programs by using the TOWM. It was also advised to test if, by teaching, training and assessing wheelchair users to master a wheelie (based on the Wheelie test’s protocol), the performance of the TOWM skills will get improved substantially. A positive result, may suggest that the shorter and more economical Wheelie test may serve as an alternative to the TOWM.To conclude, the investigator expressed her hope that the final version of the TOWM and the short Wheelie test will be adopted by the rehabilitation community worldwide, and will be applied regularly, in order to derive norms and standards for wheeled mobility according to lesion level.
Publication status: published
KU Leuven publication type: TH
Appears in Collections:Department of Rehabilitation Sciences - miscellaneous
Research Group for Adapted Physical Activity and Psychomotor Rehabilitation

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