SCI Forum

 

Ultralight Wheelchair Skills: From Rehab to Real World

Presented on November 8, 2011 at Harborview Medical Center, Seattle, WA

Learn the skills you need to successfully navigate your ultralight manual wheelchair in a variety of situations and environments so you can more fully participate in the activities you enjoy. In this video, physical therapist Elisa Smith, DPT, of Harborview Medical Center provides practical tips and explanations for learning and perfecting wheelchair skills, including wheelies for curbs and maneuvering in small spaces, on gravel roads, up and down hills, and more. Wheelchair users with spinal cord injuries are shown demonstrating several of these skills.
Click here to read the written report.

Caution! Consult with your physician and physical therapist before attempting any of these wheelchair skills. Always use a physical therapist or trained spotter to prevent falls while learning wheelchair skills like the ones described here.

 

Presentation time: 31 minutes. After watching, please complete our two-minute survey!

 

You can also watch this video on YouTube with or without closed-captioning.

For a complete list of our streaming videos, go to http://sci.washington.edu/info/forums/forum_videos.asp.

Report: Ultralight Wheelchair Skills: From Rehab to Real World

 

Contents

• The wheelie: an essential skill
• Why learn wheelies?
• Where to learn wheelies
• Wheelchair skills
• Stationary wheelie & pop-ups
• Dynamic wheelie
• Indoor skills
• Outdoor skills
• References
• For further reading

The wheelie: an essential skill

A “wheelie” is the act of balancing on your rear wheels in your wheelchair. Wheelies may look like tricks, but “they are the essential building blocks of community wheelchair skills,” said Elisa Smith, physical therapist at Harborview Medical Center. Unfortunately, many people don’t learn this skill before they are discharged home from rehab and then have few opportunities to learn them later on.

“Rehab stays now are getting so short that therapists only have time to focus on basic transfers, caregiver training and testing different chairs,” Smith said. “There isn’t much time to practice many ultralight wheelchair skills while still in the hospital.” Once patients get home, there may not be many therapists in their communities who are familiar with wheelchair skills.

“Newly injured patients often assume wheelies are simply tricks and not essential to their rehab,” Smith said. “People will say to me, ‘I don’t care about tricks right now. I just had this major tragedy in my life, and I don’t want to focus on doing stunts.’”

Other patients are just too overwhelmed and fearful in the early weeks. “They can’t imagine doing anything outside of the hospital by themselves,” Smith said. “They’ll say, ‘I’m always going to have somebody pushing my chair, so I don’t need to learn how to do this on my own,’ or ‘It seems like wheelies are impossible. I’m just getting used to a chair, and I don’t want to do anything where I’m going to put myself at risk for falling back and hitting my head or losing control of the chair.’”

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Why learn wheelies?

• Choosing the best wheelchair
  “The more skills you learn, the more you understand how a chair needs to fit you and what kinds of features and accessories you want,” Smith said. “Then when you are talking to therapists or vendors, you are more likely to get a chair that is ideally set up for you.”

• Improved quality of life
  Several studies have shown that learning wheelies and related skills can improve your quality of life because they help you be more independent and more active in the community, such as going to school, work and social activities. “And if you get invited to a barbecue at a friend’s house, you will be able to go through the grass to get to the back yard,” Smith said.

• Less pain, fewer falls
  For example, if you are able to pop a wheelie to hop off a curb at an intersection, you can see the traffic and have more control of the chair and be less likely to tip over than if you back down the curb.

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Where to learn wheelies

If you didn’t learn these skills while still in rehab, or if you want to improve your skills, you can get help and information from a variety of sources, such as:

• Physical therapists: see your physical therapist in your clinic or other outpatient setting.
• Wheelchair Skills Training Program (http://www.wheelchairskillsprogram.ca). by Dalhousie University (Canada). This website features “how-to” videos and detailed descriptions of many wheelchair skills.
• The Manual Wheelchair Training Guide, by P. Axelson, et al. 1st ed. San Francisco, CA: PAX Press; 1998.
• Other wheelchair users
  • Visit online forums such as Rutgers University's CareCure Forum (http://sci.rutgers.edu/forum/), where you can join a conversation thread about wheelchair skills and ask questions.
  • Attend local events like University of Washington's SCI Forums (http://sci.washington.edu/info/forums/) and SCI Support & Information Group (http://sci.washington.edu/info/sig.asp) where you can meet other wheelchair users with SCI.

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Wheelchair skills

Following is a brief summary of the wheelchair skills and techniques presented at this forum. Watch the video (see above) to get the full descriptions and see demonstrations of these different skills.

Caution! Always use a physical therapist or trained spotter to prevent falls while learning new advanced wheelchair skills like the ones described here. A therapist also can train a family member or friend to help spot you while you are learning these skills. Spotting is especially important while you are working on getting your balance in a wheelie.

Stationary wheelie & pop-ups

• Training progression involves three phases: take off, balance and landing.
• Balancing in a wheelie: surface, balance, tipping back. “Have a spotter put you back in your balance point on your back wheels so you can see how far back it is,” Smith said. “Usually it’s farther back than you might expect.”
• Popping into a wheelie: partial versus full. “It’s good to practice going into a partial wheelie, where you’re popping up, but not all the way to your balance point,” Smith said. “Partial wheelies help you go over obstacles and with being able to time a pop up so you can go up a curb.”
• Landing a wheelie: push the rim forward as you land to soften the impact.
• Take-off strategies:
  • Backward: pull back and then push forward on the rims.
  • Forward: push forward on the rims to pop up. This strategy may be slower and require more force, but it enables pop ups during forward propulsion and in tight spaces.
• Self-recovery: pull back on the rims to tip forward out of a wheelie.
• Safe falls: There is no ideal way to fall safely, Smith said. If you are falling backward, “try to keep your head as far forward as you can so the frame hits the ground first, and do some combination of blocking your knees (so they don’t hit you in the face) and blocking your head, or blocking your head with both arms.”

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Dynamic wheelie

A dynamic wheelie is moving or propelling while balancing on your rear wheels. You can go forward, backward, turn, and pivot in place.

Practice going forward by setting up a slalom course to propel around obstacles in a wheelie.

“Reverse is the most difficult and requires a lot of practice because pulling back to go in reverse tips the chair forward out of a wheelie,” Smith said.

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Indoor Skills

• Thresholds or flooring transitions: perform a partial pop-up to ascend.
• Thick carpet: propel in a wheelie.
• Tight spaces (restrooms, elevators): back into the space and turn in a wheelie.
• No-hands wheelie (against wall): back up against a wall, tip back, and lock your wheels. “The idea with a no-hands wheelies is that you can lean back and not have to be balancing your chair,” Smith said. “This can be good for reading, making phone calls or giving your back a rest. It can be used for pressure reliefs and provides a better neck position for looking up during conversations.”
• Stairs: Stairs are challenging and can be risky, Smith said. “Doing stairs is one of the most physically demanding skills. It’s not just about balance and technique, like most of these other skills. Stairs, especially going up, takes a tremendous amount of arm strength, and it can really go wrong. Even if it goes smoothly, there is a lot of wear and tear on your arms, especially your shoulders.” Like using escalators (below), going up and down stairs is the kind of skill you might want to know about just for emergencies, if you’re in a building and there’s a fire and the elevators stop working.”
• Escalators: “Some places will ask you to not go on an escalator because they’re afraid you’ll get stuck,” Smith said. “You need to ascend and descend facing up. Timing and trunk position are important.” There is a risk of falling or getting stuck, so proceed with caution.

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Outdoor Skills

• Uneven terrain (snow, grass, gravel, sand ): “You pop up into your wheelie and keep the wheels up as you propel forward,” Smith said. “This is a dynamic wheelie and is very labor-intensive because there’s a lot more friction to push against.” Consider knobby tires or larger casters for these activities. Also, some surfaces can damage wheelchair components.
• Depressions (potholes, grates): Pop into a partial or full wheelie, which lifts your casters out of the depression, and go across on your rear wheels.
• Freeing wheels from being stuck in a grate or hole: rock side to side.
• Raised obstacles (roots, railroad tracks, hoses): Pop your casters over the obstacle, flex your trunk, and use push strength or momentum to go over the obstacle with the rear wheels as your casters land beyond the obstacle.
• Hills and ramps
  • Crossing a slope: push faster with one hand than the other.
  • Going up: If you don’t have enough balance or momentum and you can’t stay forward enough to go up hills, get your chair configuration and fit evaluated by a therapist. You might want to consider mechanical assist or power assist options such as hill climbers, Magic Wheels, or Freewheel, or even a power chair.
  • Going down: pop into a wheelie while you’re on a level area, find your balance point, and lean back as you descend, letting the rims slowly slide through your hands. “Descending in a wheelie allows you to control your speed a little better,” Smith said, “and if the hill is really steep, it keeps you from pitching over as you go down.” Plastic rims will burn when descending quickly, so use gloves to increase your power and decrease burning.
• Avoid using a chest strap: “Even if it gives you some stability on the levels, if you’re always cinched down into the backrest with the chest strap, you can’t lean forward and back enough to keep your balance with many of these skills,” Smith said.
• Curbs—going up
  • Timing of caster pop-up: Low or late pop up may result in casters hitting the curb, abruptly stopping the wheelchair. High or early pop up may result in rear wheels hitting the curb too soon, decreasing momentum. “Practice going up to the curb and popping up without worrying about getting on top of it, so you can get comfortable with the timing of the pop up and with how high you need to get the casters up,” Smith said.
  • Rear wheel ascension: getting the rear wheels up on the curb after your casters are up there depends on wheelchair pitch angle, velocity, trunk position, and hand position.
  
• Curbs—going down
  • Face forward for improved visibility and shock absorption, and to avoid flipping over backward. (See photo on right.)
    If you do go down backward, flex your trunk to avoid flipping. Descending backward can cause more pain and discomfort than descending forward because the shock goes through the front casters, which can’t absorb it as well as the rear wheels.

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References

1. Wheelchair Skills Training Program.  Dalhousie University. Available at: http://www.wheelchairskillsprogram.ca/.  Accessed September 18. 2010.
2. Anneken V, Hanssen-Doose A, Hirschfeld S, Scheuer T, Thietje R. Influence of physical exercise on quality of life in individuals with spinal cord injury.  Spinal Cord. 2010;48:319-399.
3. Kilkens O, Post M, Dallmeijer A, van Asbeck F, van der Woude L. 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;42:65-74.
4. Coolen A, Kirby R, Landry J,  et al. Wheelchair Skills Training Program for clinicians: a randomized controlled trial with occupational therapy students. Arch Phys Med Rehabil. 2004;85:1160-1170.
5. Best K, Kirby R, Smith C, MacLeod D. Wheelchair Skills Training for community-based manual wheelchair users: a randomized controlled trial. Arch Phys Med Rehabil. 2005;86:2316-2123.
6. MacPhee A, Kirby R, Coolen A, Smith C, MacLeod D, Dupuis D.. Wheelchair Skills Training Program: a randomized clinical trial of wheelchair users undergoing initial rehabilitation. Arch  Phys Med Rehabil. 2004;85:41-50.
7. Axelson P, Chesney D, Minkel J, Perr A. The Manual Wheelchair Training Guide.  1st ed.  San Francisco, CA: PAX Press; 1998.
8. Kirby R, Smith C, Seaman R, Macleod D, Parker K. The manual wheelchair wheelie: a review of our current understanding of an important motor skill. Disabil Rehabil: Assistive Technology. 2006;1:119-127.
9. Bonaparte J, Kirby R, MacLeod. Learning to perform wheelchair wheelies: comparison of 2 training strategies. Arch Phys Med Rehabil. 2004;85:785-793.
10. Bonaparte J, Kirby R, MacLeod D. Proactive balance strategy while maintaining a stationary wheelie. Arch Phys Med Rehabil. 2001;82:475-479.
11. Kirby R, Gillis D, Boudreau A,  et al. Effect of a high-rolling-resistance training method on the success rate and time required to learn the wheelchair wheelie skill. Am J Phys Med Rehabil. 2008;87:204-211.
12. Koshi E, Kirby R, MacLeod D, Kozey J, Thompson K, Parker KE. The effect of rolling resistance on stationary wheelchair wheelies. Am J Phys Med Rehabil. 2006;85:899-907.
13. Kirby R, DiPersio M, MacLoed D. Wheelchair safety: effect of locking or grasping the rear wheels during a rear tip. Arch Phys Med Rehabil. 1996;77:1266-1270.
14. Kirby R, Bennett S, Smith C, Parker K, Thompson K. Wheelchair curb climbing: randomized controlled comparison of highly structured and conventional training methods. Arch Phys Med Rehabil. 2008;89:2342-2348.
15. Kwarciak A, Cooper RA, Fitzgerald SG. Curb descent testing of suspension manual wheelchairs. J Rehabil Res Dev. 2008;45:73-84.

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For further reading

1. Newton AM, Kirby RL, Macphee AH, Dupuis DJ, Macleod DA. Evaluation of manual wheelchair skills: is objective testing necessary or would subjective estimates suffice? Arch Phys Med Rehabil. 2002;83:1295-1299.
2. Kilkens O, Dallmeijer A, de Witte L, van der Woude L, Post M. The Wheelchair Circuit: construct validity and responsiveness of a test to assess manual wheelchair mobility in persons with spinal cord injury. Arch Phys Med Rehabil. 2004;85:424-431.
3. Groot S, Bevers G, Dallmeijer A, Post M, van Kuppevelt H, van der Woude L. Development and validation of prognostic models designed to predict wheelchair skills at discharge from spinal cord injury rehabilitation. Clin Rehabil. 2010;24:168-180.
4. Stanley R, Stafford D, Rasch E, Rodgers M. Development of a functional assessment measure for manual wheelchair users. J Rehabil Res Dev. 2003;40:301-308.
5. Kilkens O, Dallmeijer A, Angenot E, Twisk J, Post M, van der Woude L. Subject- and injury-related  factors influencing the course of manual wheelchair skill performance during initial inpatient rehabilitation of person with spinal cord injury. Arch Phys Med Rehabil. 2005;86:2119-2125.
6. Kilkens O, Dallmeijer A, Nene A, Post M, van der Woude L. The longitudinal relation between physical capacity and wheelchair skill performance during inpatient rehabilitation of people with spinal cord injury. Arch Phys Med Rehabil. 2005;86:1575-1581.
7. Best K, Kirby R, Smith, Macleod D. Comparison between performance with a pushrim-activated power-assisted wheelchair and a manual wheelchair on the Wheelchair Skills Test.  Disabil Rehabil. 2006;28:213-220.
8. Lighthall-Haubert L, Requejo P, Mulroy S, Newsam C, Bontrager E, Gronley J, Perry J. Comparison of shoulder muscle electromyographic activity during standard manual wheelchair and push-rim activated power assisted wheelchair propulsion in person with complete tetraplegia. Arch Phys Med Rehabil. 2009;90:1904-1915.
9. Algood S, Cooper R, Fitzgerald S, Copper R, Boninger M. Effect of a pushrim-activated power-assist wheelchair on the functional capabilities of person with tetraplegia. Arch Phys Med Rehabil. 2005;380-386.

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