Development of a Wheelchair maintenance Training program and Wheelchair maintenance questionnaire

Maria Luisa Toro, MS1,2, Michelle Oyster, MS1,3, Emily Krobot, MSW1,3, Lynn Worobey, PhD1,3, Michael Boninger, MD1,3, Jon Pearlman, PhD1,2
1Human Engineering Research Labs, VA Pittsburgh Healthcare System
2Department of Rehabilitation Science and Technology, University of Pittsburgh
3Department of Physical Medicine and Rehabilitation, University of Pittsburgh


In the United States (US), approximately 3.6 million non-institutionalized people older than 15 years of age use wheelchairs (Brault, 2012). For this population, access to an appropriate wheelchair is an important step towards participation in society (World Health Organization, 2008). Therefore, wheelchair related problems, such as breakdown, can have a negative impact on wheelchair users (Mann, Hurren, Charvat, & Tomita, 1996). Poorly maintained wheelchairs have been linked to an increased risk of breakdowns, injuries and increased costs of care (Calder & Kirby, 1990; Kirby & Ackroyd-Stolarz, 1995; Toro, Garcia, Ojeda, Dausey, & Pearlman, 2012; Ummat & Kirby, 1994) . Studies have found an increase in the number of wheelchair users with spinal cord injury who report at least one wheelchair breakdown in the past 6 months (McClure et al., 2009; Toro, Pearlman, Oyster, & Boninger, 2014; Worobey, Oyster, Nemunaitis, Cooper, & Boninger, 2012) . In addition, wheelchair users have been stranded, injured and have missed school and medical appointments due to these wheelchair breakdowns (McClure et al., 2009; Toro, Pearlman, Oyster, & Boninger, 2014; Worobey, Oyster, Nemunaitis, Cooper, & Boninger, 2012) . Research indicates that wheelchair maintenance performed by occupational therapists reduced the number of accidents and injuries for wheelchair users (Hansen, Tresse, & Gunnarsson, 2004). The World Health Organization (WHO) also suggests that performing regular maintenance and servicing of wheelchairs could improve their reliability (World Health Organization, 2008). Based on the evidence of increasing breakdown frequency, the associated consequences and the benefits of maintenance, there is a need to increase the number of wheelchair users and caregivers who receive training in wheelchair maintenance (World Health Organization, 2008). Therefore, the goal of this project was to develop a maintenance training program to increase the number of manual wheelchair users (MWUs) and power wheelchair users (PWUs) who can benefit from improved maintenance.


Wheelchair Maintenance Training Program

Figure 1. WMTP Iterative Development. +Indicates study approved by the University of Pittsburgh IRB
Determination of measures of wheelchair maintenance and frequency+
Online survey with maintenance tasks and option to select frequency 19 experts completed survey providing feedback
Wheelchair Maintenance Training Program 1st draft
Selected maintenance tasks to include and frequency they should be performed. Outlined sessions  for training clinicians /wheelchair users 5 experts reviewed
Wheelchair Maintenance Training Program 2nd draft
Revisions to content, format and writing style
3 experts reviewed
Wheelchair Maintenance Training Program pilot+
Investigators trained clinicians who then trained manual and power wheelchair users
2 clinicians, 1 MWU, and 4 PWUs participated in the pilot
Wheelchair Maintenance Training Program launched
15 clinicians have been trained at 4 rehabilitation hospital sites
Wheelchair users will be trained in the Spring 2015

The initial draft of the Wheelchair Maintenance Training
Program (WMTP) was based on a list of inspection and action maintenance tasks found in existing resources on wheelchair maintenance such as websites and books (Cooper, 2013; Denison, 2006; Khasnabis & Mines, 2012; Koontz, NA) . The training materials were developed iteratively through expert advice and feedback (Figure 1). The WMTP’s content, timing, and format was revised for each iteration according to expert feedback. The experts consisted of wheelchair users, wheelchair technicians and seating and mobility clinicians. Materials were developed for two purposes: 1) to train clinicians on how to train wheelchair users (i.e. training of trainers) and 2) for use by clinicians to educate wheelchair users (and caregivers when applicable). Materials included power point presentations, videos, checklists, reminders cards, and a clinician’s reference manual.

Wheelchair Maintenance Training Questionnaire

In addition, three versions of the Wheelchair Maintenance Training Questionnaire (WMT-Q), a knowledge-based wheelchair maintenance questionnaire, were developed for the follow groups: clinicians, MWUs, and PWUs. These questionnaires were developed to evaluate whether the training impacted the knowledge of wheelchair maintenance and frequency of wheelchair maintenance performance among clinicians and wheelchair users. Each questionnaire had three sections: open-ended questions about what maintenance should be performed, a multiple choice section about research evidence and best maintenance practices, and capacity and performance questions regarding whether the clinicians/wheelchair users know how to perform specific maintenance tasks and if so, how often they perform it (Mountain, Kirby, & Smith, 2004). Figure 2 shows the iterative process for evaluating test-retest reliability measures of the three questionnaires. Iterations of the questionnaires revised content, format, and writing style. The test-retest reliability was calculated for the total score of each section using the two-way mixed consistency model intra-class correlation coefficient ICC(3,1).

Figure 2. WMT-Q iterative process development. +These studies were approved by the University of Pittsburgh IRB.
WMT-Q 1st draft developed based on research evidence and maintenance tasks and revised by experts for face validity
5 experts reviewed and provided feedback
WMT-Q 2nd draft was revised
3 experts reviewed
Test-retest reliability of WMT-Q 3rd draft+
Participants took the questionnaire and retook it approx. one week later
11 clinicians, 4 MWUs and 4 PWUs participated
Test-retest reliability of WMT-Q 4th draft+
Participants took the questionnaire and retook it approx. one week later
14 clinicians, 12 MWUs and 18 PWUs participated
WMTP Launched
13 clinicians completed pre- and post-training questionnaires. Wheelchair users will complete quesionnaires before and after training in Spring 2015

The WMTP was launched in the summer of 2014. As of December 2014, two investigators from the University of Pittsburgh have trained 15 clinicians at four sites in the US. Clinicians provided feedback on the training they received. The WMT-Q clinician version was administered before training and then approximately one week after training. The Wilcoxon sign ranked test was used to explore if there were significant differences in scores before and after the training.


Table 1 contains each training material component and a brief description. Overall the training was found useful, relevant, understandable, easy to tolerate, and enjoyable. Positive comments from trainees included: “Now I am more comfortable with what to look for and what can be handled. Very well detailed and constructed.” Clinicians’ suggestions were to emphasize the importance of the use of the appropriate tools while tightening bolts and nuts as well as to include a checklist to guide the hands-on activity for wheelchair users. Both were implemented into the materials. Test-retest reliability of the WMT-Q’s sections is shown in Table 2 . Table 3 shows the scores for clinicians on the questionnaire. There was a significant increase in capacity score (p=.005), multiple choice maintenance knowledge score (p=.005), and in the manual wheelchair maintenance open ended question  score (p=.007). However, there was no significant difference between pre- and post-training scores for power wheelchair maintenance open ended questions.



Table 1. Materials that comprise the WMTP



When is it used?

  1. Clinician Training Power Point Presentation

Guide to train clinicians on how to train wheelchair users to perform maintenance

During clinicians’ training

  1. Clinician reference manual

Handed out to the clinicians during training. Includes detailed guidance on how to deliver the training to MWUs and PWUs

Clinicians use it to prepare for and during wheelchair users’ training

  1. WMTP power point presentation (MWU & PWU versions)

Used by clinicians to train wheelchair users on how to perform maintenance on their wheelchair

During wheelchair users’ training

  1. How to care for a wheelchair at home video (MWU & PWU versions)

5 minute video that demonstrates how to complete maintenance tasks

During wheelchair users’ and clinicians’ training

  1. Wheelchair Maintenance Reminder Cards (MWU & PWU versions)

Given to the wheelchair users at the end of the training as reference material

During wheelchair users’ training

The WMTP is a “living” program that will continue to improve based on the experience that is gained during the implementation. The WMT-Q test-retest reliability has significantly improved throughout the iterations and has reached an acceptable level for most sections. The questionnaires also have the potential to be translated and validated for use in different countries and contexts. The significant increase in WMT-Q score suggests that clinicians had increased knowledge of wheelchair maintenance following the training.

Table 2. WMT-Q test-retest reliability for each sub score.




Multiple choice

Capacity/  performance





Manual wheelchair users




Power wheelchair users




*p<.001; +p<.05; ^p>.05

Future work will investigate whether the clinicians who have received training can effectively train wheelchair users. This cohort of trained clinicians is expected to train MWUs and PWUs who have a non-progressive spinal cord injury in Spring 2015. The impact of this training program on wheelchair users will be evaluated. We will investigate whether the training improved the knowledge of wheelchair maintenance as well as if it resulted in a reduction in wheelchair breakdowns and the related consequences.  In addition, future work could evaluate clinicians at later follow-up time points to assess if they have retained the knowledge and if the frequency at which they are teaching or encouraging their clients to perform maintenance has increased.

Table 3. WMT-Q pre-training and post-training scores for clinicians.


Mean (IQ)

Post-training Mean (IQ)

Manual wheelchair open ended

26.8 (19.6) ^

51.8 (25.0) ^

Power wheelchair open ended

28.1 (21.9)

50.0 (43.0)

Multiple choice

56.8 (26.1) ^

84.1 (28.4) ^


48.4(48.4) ^

100 (0)^

Finally, we are working on disseminating this training program further. For instance, we are adapting it into an online training program that will be tested in 2016. In addition, the manual wheelchair portion of the training is also being translated to Spanish and adapted to the Mexican context. It will be launched in the Spring 2015.



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This training material was supported by the U.S. Department of Health and Human Services, National Institute on Disability Independent Living and Rehabilitation Research (H133A120004).  The contents are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department Health and Human Services. This training material has resulted from the work of a group of people, including Dr. Michael Boninger, Dr. R Lee Kirby, Michelle Oyster, Dr. Jonathan Pearlman, Dr. Rory A Cooper, Emily Krobot, Dr. Lynn Worobey, Michael Lain, Rosemarie Cooper, Annmarie Kelleher, Chad Evans, Samuel Bucior, Chika Eke, Maria Toro, Mark McCartney, Benjamin Gebrosky, and volunteers that helped to pilot the training.

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