Wheelchair Skills Training Manual

Table of contents:

Safety

Safety:

• Safety of the clinician

Basic movement skills

• Propelling forward
• Propulsion patterns
• Propelling on carpet
• Turning left and right
• 360
• Cross slope
• Propelling backwards
• Navigating around obstacles
• Ramps:
• Ascending
• Stopping in the middle to rest
• Descending
• Slaloming down
• Wheelie down
• Ramps with uneven terrain at the bottom
• Caster trail
• Reaching:
• Reaching forward high
• Reaching forward low
• Reaching to the r/l side high
• Reaching to the r/l side low
• Reaching behind

Doors

• Opening a door that opens away from user
• Closing a door that closes away from user
• Opening a door that opens toward user
• Closing a door that closes toward user

Fall safety.

• Falling backward

Caster pop

• Stationary pop
• Rolling pop
• Pop over  very short threshold
• Pop over short threshold
• Pop over tall threshold
• Pop through gravel/sand/grass

Wheelies

• Stationary wheelie
• Rolling forward wheelie
• Backward wheelie
• Wheelie over gravel/sand/grass
• Wheelie down a ramp

Thresholds/curbs

• Descending backward
• Negative thresholds (such as the space between the floor and an elevator or the space between Metrolink train cars and the platform)
• Thresholds with assistance
• Thresholds with assistance, handshake assist

Extras

• Changing wheels without transferring out of chair
• Leaning against a wall
• Touch wall turns
• Elevator shift

Pressure shifts

• Push off armrests
• Push off wheels
• Lean forward
• Lean to the side

Equipment skills

• Setting brakes
• Removing armrests
• Removing footrests
• Removing cushion
• Folding back (rigid)
• Folding chair (folding)

Caregiver/assistant skills

• Assisting over rough terrain
• Assisting up/down stairs

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Safety

Safety: When a wheelchair user learns new skills, it is important to keep safety in mind. Here are some things to remember:

• Use a safety strap on the back of the wheelchair when the user is learning a skill that may result in a backward fall. Such skills include: ramps, curbs, wheelies, etc.
• If a wheelchair user has impaired trunk stability, the trainer may need to use a hand to stabilize the trunk while performing skills to prevent the wheelchair user from falling forward.
• Do a blood pressure check before beginning any skills training and, if the subject has difficulty with blood pressure regulation, it is advised to check blood pressure during skills training.

Safety of the clinician

• Practice catching people using the safety strap by having experienced wheelchair users simulate a backward fall
• Use proper body mechanics I.E. stay close to the wheelchair user, use legs to lift without bending back, be attentive to the wheelchair user’s movements, etc.

Basic movement skills

Propelling forward

• To propel forward using the rear wheels, the wheelchair user needs to grab or press on the rear wheels and push forward.
• The wheelchair user may also use one or both feet to propel forward.

Propulsion patterns

• There are several propulsion patterns that wheelchair users can use. It is best if the wheelchair user utilizes a circular propulsion pattern, one in which the hand drops below the handrim when the hand is not pushing the handrim.

Propelling on carpet

• Propelling on carpet is more difficult than propelling on a smooth surface due to the increased rolling resistance of the carpet. Certain carpets may also cause the wheelchair to track to one side or the other due to the weave of the carpet. Smaller front casters will also make propulsion over carpet more difficult
• Lean forward in the wheelchair, this generally gives the user a better angle to propel the wheelchair.

Turning left and right

• To turn left or right, the wheelchair user needs to apply unequal force fo the rear wheels. To turn left, push on the right wheel. To turn right, push on the left wheel.

360

• To perform a 360 degree turn in a wheelchair, grab both rear wheels and turn them in opposing directions.

Cross slope

• Cross slopes are challenging due to the fact that a cross slope cause a wheelchair to roll toward the downhill portion of the cross slope. Being able to navigate a cross slope is essential for safety when traveling in the community. Sidewalks are often cross sloped, especially where there are driveway cuts for cars. This creates an unsafe condition because manual wheelchairs tend to roll downward and can roll into the street.
• Navigating a cross slope requires the wheelchair user to push primarily on the downslope wheel, while sometimes pushing in reverse on the upslope wheel, depending on the severity of the slope. This can at times require quite a bit of strength and skill of the downslope wheel.
• Because the front casters turn toward the downslope of a cross slope, while the rear wheels do not, it is helpful for the wheelchair user to lean back to put more of the weight on the rear wheels.

Techniques for teaching:

• Demonstrate the affect center of gravity has on the difficulty of a cross slope by having the wheelchair user lean forward and then go over the cross slope, then lean back and attempt the same cross slope.
• Show the wheelchair user that he or she can grip the upslope wheel to slow it down while propelling the downslope wheel

Propelling backwards

• Level pushing backward is more difficult than pushing forward due to the setup of a manual wheelchair. For most manual wheelchairs, the casters that allow for the wheelchair to turn are located on the front of the wheelchair. Pushing the wheelchair forward in a straight line generally causes the wheelchair to move forward in a straight line. However pushing a manual wheelchair backward in a straight line often causes the front of the wheelchair to fishtail to the right or left – in some cases turning completely around if enough force is applied. As such, it is much harder to maneuver a wheelchair backward than it is to maneuver a wheelchair forward. This is due to the center of gravity of the chair being in “front” of the casters.
• When maneuvering a wheelchair backward, it is actually easier to control the wheelchair if the user uses short strokes, with much less coasting time. It is when the wheelchair is coasting that it has a tendency to fishtail.
• Encourage the user to look over his or her should for obstacles when moving backwards, much like when maneuvering a car.

Navigating around obstacles

• Navigating around obstacles requires that the wheelchair user be aware of the footprint of his or her wheelchair. He or she needs to also be aware that the turning point of the wheelchair is at the rear axle.
• Set up cones or other obstacles that can be moved around in a figure 8 and have the wheelchair user practice maneuvering around cones.

Ramps:

Ascending

• When going up, lean forward in the chair. This will prevent the wheelchair user from tipping over backward, and make it easier to ascend the ramp. The steeper the ramp, the more the wheelchair user will need to lean forward.

Stopping in the middle to rest

• A wheelchair user may stop in the middle to rest by turning the wheelchair so that the wheels are perpendicular to the slop and applying the brakes. Exercise case when removing the brakes, as the chair needs to be held in place or it may turn and roll down the slope.

Descending

• To descend a ramp, apply pressure to the handrim to slow the wheelchair as it goes down the ramp.
• Slow down to a near stop at the end of the ramp so that turning is possible.
• Do not use the wheelchair brakes, this will ruin the wheels and is not a safe way to descend a ramp.

Slaloming down

• If a ramp is too steep for a user to safely descend using pressure on the handrims alone, the user may slalom down by alternating pressure on the wheels so that the wheelchair user descends the ramp in a zig-zag pattern.

Wheelie down

• If the ramp is very steep or has very uneven terrain at the bottom, the wheelchair user may wheelie down the ramp. This is an advanced skill (explained later in this manual) but may be useful if the wheelchair user is skilled at wheelies but lacks the ability to apply enough pressure to the handrim to slow down enough when descending a ramp.

Ramps with uneven terrain at the bottom

• If there is uneven terrain at the bottom of a ramp, the speeds of descent may cause the wheelchair user to flip forward when he or she hits the uneven terrain. Therefore, when navigating a ramp with uneven terrain, the wheelchair user should stop before encountering the uneven terrain, and proceed using techniques for handling uneven terrain.

Caster trail

• When performing floor transfers or reaching forward to retrieve items, a wheelchair user may want to use caster trail to increase the stability of the front of the wheelchair.
• When the front casters are turned around so that they are in the same position they would be if the wheelchair user were going backward (rear caster trail) the wheelchair is less likely to tip over.
• This can be demonstrated by placing the front casters in the typical position when the wheelchair is moving forward (forward caster trail) and stepping on the footrest of the empty wheelchair. The wheelchair is likely to tip forward. Then, place the front casters in the rear caster trail position and step on the footrest. The chair should be more stable, and one might be able to put their entire weight on the footrests without the chair tipping over.

Reaching:

Reaching forward high

• Place the front casters in the rear caster trail position. Lock the front brakes. Place one hand on the armrest or leg for stability, and reach for the object. The wheelchair user may also use a seat belt or a reacher. Do not stand on the footrests.

Reaching forward low

• Place the casters in the rear caster trail position. Lock the front brakes. Place one hand on the armrest or leg for stability, and reach for the object. The wheelchair user may also use a seat belt or a reacher

Reaching to the r/l side high

• Lock the front wheels. Place one hand on the armrest or rear wheel for stability, or hook the opposite arm over the push handle.

Reaching to the r/l side low

• Lock the front wheels. Place one hand on the armrest or rear wheel for stability, or hook the opposite arm over the push handle. A wheelchair user can also pick up an object using the rear wheels by sliding the object up the rear wheels.
• Wheelchair users could also pick up objects while rolling forward by reaching down and pressing the object to the rear wheel, and allowing the rotation of the wheel to bring the object to the wheelchair user.

Reaching behind

• When reaching behind, it is important to not go behind the tipping point of the wheelchair, causing the wheelchair to tip backward

Doors

Each type of door presents its own challenge, and all should be practiced.

Opening a door that opens away from user

• A wheelchair user may employ several different techniques for opening doors depending on the skill of the user.
• Come close enough to the door that the wheelchair footrests are touching the door, then turn the handle to open the door. Propel through the door, using the feet/footrest to open the door.
• Come close enough to open the door, turn the handle, and then grab the doorjamb with the opposite hand. Pull through the door using the doorjamb
• If the wheelchair user is unable to reach far enough forward to open the door, have the user attempt to open the door from the side.

Closing a door that closes away from user

• Push the door closed, or use the wheelchair to close the door

Opening a door that opens toward user

• Roll up to the door, turn the handle to open the door, and then push away from the door with the other hand, allowing the momentum of the wheelchair user to open the door.
• Roll up to the door, turn the handle to open the door. Open the door slightly, then use one hand to back up the wheelchair while the other hand holds the doorknob

Closing a door that closes toward user

• Pull the door hard enough as you roll through the doorway to cause the door to shut.
• Back through the door, pulling the door shut.

Fall safety. Make sure there are no contraindications before attempting to simulate falls.

Falling backward

• First, practice falling backward using several mats to decrease the distance the user needs to fall.
• For the first simulated fall, hold the wheelchair so that it falls gently.
• To fall backward, it is best to grab the rear wheels (to prevent the wheelchair from rolling away) and tuck the head to the chest.

Caster pop

Stationary pop

• The ability to “pop” or raise the front casters off the ground is an important skill for community mobility. Popping the front casters enables wheelchair users to navigate over curbs and potholes, as well as other obstacles. Popping the front casters involves raising the caster wheels off the ground several inches, without placing the chair in a full wheelie position.
• A spotter should be used when teaching caster pop to ensure that the user does not tip backward – additionally, having a spotter should increase the confidence of the wheelchair user such that he or she will be less afraid of falling.
• This skill should be demonstrated by a video or by the clinician. The user should be instructed to throw his or her weight into the back of the chair while pushing forward on the rear wheels. It may take several tries for this to be accomplished.

Rolling pop

• After the wheelchair user is capable of stationary caster pop, he or she should attempt a rolling caster pop.
• While moving forward slowly, pop the casters during a propulsion stroke by having the wheelchair user throw his or her weight to the back of the chair while pushing forward.
• Continue this with increased speed

Pop over  very short threshold

• Instruct the wheelchair user to perform a caster pop over a very short threshold (1/2”). Popping over this short of a threshold is not necessary to get over the threshold, but will enable the wheelchair user to safely practice the timing of the caster pop to move over a curb.
• Use a mirror so that the wheelchair user can see the front casters as they go over the threshold.
• When the wheelchair user is able to pop the front casters over a short threshold, he or she can move to taller thresholds and curbs.

Pop over short threshold

• The wheelchair user should roll up to the short threshold, pop his or her front wheels and then roll forward slightly.
• The wheelchair user should set his or her wheels down on the threshold.
• The wheelchair user should roll over the threshold, putting some of his or her weight forward on the front casters so that the rear wheels roll up the curb.

Pop over tall threshold

• To pop over a taller threshold, the wheelchair user needs to roll toward the threshold and perform a caster pop to get the front wheels over the threshold
• As the rear wheels roll toward the threshold, the wheelchair user needs to throw his or her weight forward on the front casters while pushing on the rear wheels to propel over the threshold.
• Have the wheelchair user practice becoming very smooth and fluid on lower thresholds and then progress to taller thresholds
• If the wheelchair user pops his or her front wheels too high, they will be unable to shift his or her weight to the front of the wheelchair, and the rear wheels will stop at the threshold without going over.
• If the wheelchair user does not pop the casters high enough, they will hit the threshold.

Pop through gravel/sand/grass

• While rolling through sand and grass, it is easier to roll if the wheelchair user can pop the front wheels up while moving forward.
• Have the wheelchair user roll through gravel/sand/grass while leaning back and lifting weight off of the front wheels while rolling forward.

Wheelies

Stationary wheelie

• Performing a wheelie is a skill that not every wheelchair user can master due to limitations of coordination and balance. It is often considered a basic skill, yet takes some time to master.
• Generally, techniques for teaching wheelies center around grading wheelie skills until the client is able to perform a moving and turning wheelie on various surfaces.
• Use a spotter strap
• Stop the rear wheels from moving by placing the wheelchair against a curb and then using cinder blocks to block the movement of the rear wheels. The client can then be placed in the wheelie position. In this way, the client can use his or her arms to control the wheelie while the rear wheels remain stationary. This shows the client how to control his or her balance with the trunk and arms. As the client becomes comfortable with this, the blocks can be moved out, while will allow the rear wheels to move more. The blocks can be moved further and further away until the client can wheelie without them.
• Wheelies can be performed on a mat, which increases rolling resistance
• Wheelies can be performed on carpeting, which increases rolling resistance

Rolling forward wheelie

• After the user has learned to perform a stationary wheelie, the user should learn to propel forward in a wheelie. This involves moving the front wheels forward while remaining in the wheelie position. It is very likely that the wheelchair user has already done this attempting to remain stationary in a wheelie, so it is a matter of moving forward in a purposeful manner.
• Start out on carpet for more rolling resistance. Have the user attempt to move forward by propelling the wheelchair and then quickly replacing the hands on the handrims. The user may also try propelling forward one hand at a time.
• Continue until the wheelchair user is able to propel forward smoothly

Backward wheelie

• Rolling backward in a wheelie is more challenging than moving forward in a wheelie due to the fact that the wheelchair user must let their center of gravity drop backwards. This is generally uncomfortable for a wheelchair user as makes the wheelchair user feel like they could fall backward

Wheelie over gravel/sand/grass

• Performing a wheelie over gravel/sand/grass is at times more challenging than performing a wheelie over a smooth surface due to the unexpected texture or uneven surface of the gravel/sand/grass. The best way to learn how to perform wheelies on uneven surfaces is through practice.

Wheelie down a ramp

• A useful skill if the ramp is very steep or there is uneven terrain at the bottom
• When the ramp begins, the wheelchair user will have to shift his or her weight further back to maintain a wheelie
• Let the handrims slip through the hands to descend, varying pressure on the handrims to remain in a wheelie

Thresholds/curbs

Descending backward

• Thresholds under 6” can usually be safely descended backward
• The wheelchair user should turn the wheelchair around and lean forward while rolling the wheelchair backward off the threshold
• The wheelchair user should stop the wheelchair before sitting back up to prevent falling over backward

Negative thresholds (such as the space between the floor and an elevator or the space between Metrolink train cars and the platform)

• Roll over negative thresholds by performing a caster pop or wheelie so that the front casters do not get caught in the space.

Thresholds with assistance

• Have the assistant roll the wheelchair up to the threshold until the front wheels touch the threshold.
• Have the assistant place his or her foot on the wheelie bar (if equipped) and pull backward on the chair to lift the front wheels.
• Have the assistant place the front wheels on the threshold, roll the rear wheel up to the threshold, and lift to push the wheelchair user over the threshold
• The wheelchair user can assist by leaning forward or pushing on the rear wheels

Thresholds with assistance, handshake assist

• Have the wheelchair user pop his or her front casters and place them on the threshold
• Have the wheelchair user roll forward so the rear wheels touch the threshold
• Have the assistant stand in front of the wheelchair user , stand with feet apart and one foot in front of the other, and extend a hand.
• Have the wheelchair user grasp the assistant at the wrist
• Both wheelchair user and assistant should pull, while the assistant steps backward, to pull the wheelchair user over the threshold.

Extras

Changing wheels without transferring out of chair

• To change the wheels without transferring out of the chair, roll up to a counter or railing
• Position the chair so that it is 1-2 feet from the surface.
• Lock the wheels
• Position the second set of wheels in front of the user, leaning on the legs or somewhere within easy reach
• Grab the surface with one hand and pull so that the wheelchair tips to the side and rests on the surface
• Stabilize the wheelchair with one hand while pulling off one wheel. Replace the wheel.
• Turn around to repeat with the other wheel

Leaning against a wall

• Leaning against a wall is an important skill for reducing pressure or relaxing. It also simulates a tilt.
• Face away from a wall and perform a wheelie.
• Wheelie backwards until the wheelchair user’s back is touching the wall.
• Lock one brake, one hand at a time
• Or, back up to the wall and stop about 1-2 feet from the wall
• Lock the brakes
• Throw weight backward so that the wheelchair tips backward to rest against the wall. The wheelchair user may have to reposition several times for the preferred tilt

Touch wall turns

• While rolling down a hall, a wheelchair user can turn a corner without touching the wheels of the wheelchair
• Roll down a hall, approaching a wall. Rolls near the wall where you intend to turn I.E. Roll near the right wall if intending to turn right.
• Reach out and touch the wall. The momentum of the chair and the fulcrum created by the wheelchair user’s arm will cause the chair to turn

Elevator shift

• Sometimes, lateral movement of the chair is needed in tight spaces, such as elevators. In this case, a wheelchair user can use body weight to shift the chair side to side.
• Shift weight to the side so that the wheels of the wheelchair raise up on one side slightly
• While the wheels are in the air, pull up on the handrim of the wheel that is touching the ground, essentially pulling it out from under the wheelchair user
• The wheelchair should shift to the side.

Pressure shifts

Push off armrests

• Push off the armrests to raise the buttocks off of the wheelchair cushion surface for 30 seconds-2 minutes

Push off wheels

• If there are no armrests, push off the wheels to raise the buttocks off the surface for 30 seconds-2 minutes

Lean forward

• Lean forward to reduce pressure on the rear of the buttocks for 30 seconds-2 minutes

Lean to the side

• Lean from side to side to reduce pressure on either side of the buttocks for 30 seconds-2 minutes

Equipment skills

Setting brakes

• Typically, a wheelchair user can set the brakes independently, though the brakes may need too be adjusted to accommodate for strength or range of motion issues. Consider the type of brake being used and modify it accordingly so that the wheelchair user is able to use the brakes easily.
• The wheelchair user should be aware that brakes are not designed for slowing the wheelchair down, they are designed for “parking” the wheelchair. Using the brakes to slow down the wheelchair will damage the tires

Removing armrests

• Fixed desk arm: These armrests are not removable or adjustable. They may be removable via screws or bolts, or they may be welded on. This type of armrest may not be ideal for the wheelchair user, as armrests interfere with propulsion and transferring.
• Lift-off removable desk arm. The armrests are removable by pressing quick release buttons on the armrest, or by rotating the armrest latches to the side, or by some other method depending on the brand and model of wheelchair. These generally can be completely removed. They may or may not be adjustable in height. They may have one receiver tube or two receiver tubes. These often require two handed use to remove, for example if they require simultaneous pressing of release buttons while lifting off.
• Swing away desk arm (up or down): These armrests detach from the wheelchair at the front of the armrest via a button or latch and pivot up or down to swing out of the way while remaining on the chair. They may or may not be able to be removed completely without tools. They may or may not be adjustable in height.
• Swing away tubular (clockwise or counterclockwise): These armrests are generally found on ultralight wheelchairs. They consist of a tubular piece fashioned in an L shape, and a receiver tube generally located on the back of the wheelchair frame. These are removed by pulling straight up on the armrest, and swing away by pulling slightly up and then swing clockwise or counterclockwise away from the wheelchair frame. They are generally not height adjustable without tools.

Removing footrests

• Swing-away Removable footrests typically have a flip up footplate, and the entire footrest hanger can be removed via a latch or button. In this case, the footrest swings away and then can be removed.
• Rigid frame footrests can be equipped with a flip up footplate or footplates, or they can be equipped with a single footplate which cannot be flipped up. Rigid footplates cannot be removed.

Removing cushion

• Cushions are often velcroed to the chair, removal is a matter of pulling on them until the Velcro releases. It is important to remember to replace the cushion facing the correct way, as many cushions are shaped for the user and will be shaped incorrectly if put on backward.

Folding back (rigid)

• Some folding backs fold by merely pushing down on the back. Other backs may have a latch that needs to be pulled to fold the back. Check the chair to see which type of folding back it has.

Folding chair (folding)

• Typical folding chairs fold by removing the cushion and pulling up on the seat sling.
• To prevent the wheelchair frame from becoming bent, tip the chair to the side slightly when folding and unfolding, so that one wheel is slightly off the ground.

Caregiver/assistant skills

Assisting over rough terrain

• To assist over rough terrain, push down on the back of the chair or on the push handles to remove some of the weight from the front casters, while pushing forward.
• Put the wheelchair into a wheelie and, while in a wheelie, push the wheelchair through the terrain
• Pull the wheelchair through the terrain backward

Assisting up/down stairs

• To assist a wheelchair user going down stairs, make sure the wheelchair is positioned backward so that the chair goes down the stairs backward
• As the wheelchair user rolls toward the stairs, place your hands on the back of the chair to prevent the chair from rolling too fast down the stairs, to stabilize the chair, and to prevent the wheelchair from tipping backward
• Gently lower the wheelchair down the stairs, one step at a time.

• Two people should be used to assist going up stairs
• Stairs should be navigated with the wheelchair user’s back facing the stairs
• Tip the wheelchair back into a wheelie
• One assistant holds the push handles or back of the chair, while the other assistant holds and stabilizes the front of the chair
• Lift the wheelchair up the stairs, one step at a time