RESNA 27th International Annual Confence
Wheelchair-Skill Performance By People With Hemiplegia: To What Extent Are The Limitations Due To The Difficulties Inherent In The Tasks Rather Than The Neurological Impairments?
To test the hypothesis that able-bodied people simulating hemiplegia (using the hemiplegic-propulsion pattern) have as much difficulty in performing wheelchair skills as people with hemiplegia, we used the Wheelchair Skills Test (WST 2.4) to compare 20 wheelchair users with hemiplegia (HP Group) and 20 able-bodied participants (AB Group). The mean ( ± SD) total WST score for the AB Group, 71.4 ( ± 3.8)%, was significantly greater than that for the HP Group, 53.1 ( ± 15.5)% (p = 0.0000), but both groups had difficulty ( £ 25% success rate) on 12 (24%) of the 50 skills. This suggests difficulties inherent in this subset of tasks, a finding that holds promise for solutions based on new techniques and technologies.
Hemiplegia; stroke; wheelchair; motor skills; Wheelchair Skills Test
Although there have been a number of excellent studies on wheelchair propulsion, surprisingly few have specifically investigated wheelchair users using the hemiplegic-propulsion pattern (using both the sound arm and sound leg). Webster et al (1) reported on some of the problems that people with hemiplegia, especially those with hemispatial neglect, experience when propelling a wheelchair. Kirby et al (2) compared the wheelchair propulsion pattern of wheelchair users using the hemiplegic-propulsion pattern with wheelchair users using a two-handed method of propulsion. In a study of wheelchair users performing a wide variety of wheelchair skills, Kirby et al (3) found that wheelchair users with stroke performed more poorly and asymmetrically than those in other diagnostic categories. Wong et al (4) reported on the effect of seat height on the hemiplegic-propulsion pattern.
In pilot work, we were surprised to find that young able-bodied people simulating the hemiplegic-propulsion pattern had great difficulty with some of the WST tasks. This led us to wonder about the extent to which the limitations in wheelchair-skill performance experienced by people with hemiplegia are inherent to the tasks, rather than solely due to their neurological impairments, as is commonly assumed.
The objective of this study was to test the hypothesis that able-bodied people simulating hemiplegia (using the hemiplegic-propulsion pattern) have as much difficulty in performing wheelchair skills as people with hemiplegia.
Ethical approval for this study was obtained from the Research Ethics Committee of the Queen Elizabeth II Health Sciences Centre and participants were studied with their informed consent. We studied 20 wheelchair users with hemiplegia (HP Group) and 20 age-matched able-bodied participants (AB Group). The participants in the AB Group simulated hemiplegia and received a brief period of wheelchair skills training. The main outcome measures were the total percentage scores on the Wheelchair Skills Test (WST 2.4) (5), the measurement properties of which have been reported (3), and success rates for individual skills. We used two-sample t tests to compare the total WST scores of the two groups.
The mean ( ± SD) total WST score for the AB Group, 71.4 ( ± 3.8)%, was significantly greater than that for the HP Group, 53.1 ( ± 15.5)% (p = 0.0000, 95 th percentile CI 10.9, 25.0). The AB Group had fewer difficulties than the HP Group (i.e., success rates at least 20% higher) for 21 (42%) of the skills. Both groups were generally successful ( ³ 75% success rate) on 21 (42%) skills. Both groups were generally unsuccessful ( £ 25% success rate) on 12 (24%) skills, notably those in which there was a high rolling resistance (e.g., incline ascent, gravel negotiation and curb ascent) or there were high balance demands (the wheelie skills).
Overall, we refuted our hypothesis, in that participants in the AB Group had greater total WST scores, to a clinically and statistically significant extent, than those in the HP Group. The AB Group had fewer difficulties in 21 (42%) of the individual skills than did the HP Group. Skills that people with hemiplegia have more difficulty with then able-bodied participants can probably be attributed to the neurological sequelae of stroke (e.g., cognitive impairment, neglect, sensory deficits) and/or comorbidities. However, both groups were similarly successful on 21 (42%) skills, particularly those at the Indoor Skill Level, and similarly unsuccessful on 12 (24%) skills. Notable skills in this latter subset were those in which there was a high rolling resistance or high balance demands.
The study had a few limitations. The sample size, although adequate to test the primary hypothesis, was under-powered to permit statistical comparisons between the groups for the individual skills. Although the groups were comparable from the demographic perspectives, it is likely that those in the HP were “biologically older” due to their comorbidities. There was also a potential bias against the participants in the AB Group, in that they had less wheelchair experience and training than participants in the HP Group; despite this disadvantage, the AB Group performed better. Future studies will be needed to further investigate specific skills, to determine the reasons for the difficulties and to identify potential solutions.
Although people with hemiplegia have more difficulties performing some wheelchair skills than able-bodied people simulating hemiplegia, the two groups experience similar difficulties when performing wheelchair skills involving high rolling resistance or a need for wheelie balance. This suggests that there are difficulties inherent in this subset of tasks, a finding that holds promise for solutions based on new techniques and technologies.
This study was funded by the Canadian Institutes of Health Research and the Queen Elizabeth II Health Sciences Centre Research Fund. We thank Lori Livington, PhD and Marie Earle, PhD for their advice.
Dr. R. Lee Kirby,
Queen Elizabeth II Health Sciences Centre,
Nova Scotia Rehabilitation Centre Site,
1341 Summer Street,
Halifax, NS, Canada
B3H 4K4.
Phone: (902) 473-1268;
E-mail: kirby@dal.ca.