Even for Experienced Wheelchair Users, Learning New Techniques May Save Wrists, Arms, and Shoulders

A study funded by the National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR).

People who use wheelchairs for daily mobility may transfer in and out of their wheelchair up to 20 times per day. Frequent transfers can put stress on a person’s upper body over time. Previous research has shown that improper transfer techniques, such as placing the wheelchair at the wrong angle or not removing or dropping armrests, can lead to wrist or shoulder injuries and pain. Training on proper transfer techniques may help wheelchair users reduce those injuries. Such training can take place in a physical therapy clinic or rehabilitation center or, with the advent of telemedicine, could be offered online. In a recent NIDILRR-funded study, researchers conducted a study to compare the effectiveness of an in-person and a Web-based training module to teach wheelchair users about proper transfer techniques. The researchers wanted to find out whether the Web-based training was as effective as the in-person training for improving transfer skills, and whether both training formats improved those skills when compared to no training. They also wanted to find out who benefited most from transfer training.

Researchers at the project on Translating Transfer Training and Wheelchair Maintenance into Practice and the University of Pittsburgh Model Center on Spinal Cord Injury enrolled 71 wheelchair users in this study. The participants were athletes competing in wheelchair sporting events for veterans with disabilities. All of the participants could transfer independently but did not use their legs to assist in transferring. The participants were randomly assigned to one of three groups: 10 participants were assigned to an in-person training group, 39 participants were assigned to a Web-based training group, and 22 participants were assigned to a comparison group that was evaluated but received no training.

The participants in the in-person training group had an hour-long individual session with a physical therapist. The physical therapist demonstrated proper transfer techniques, gave the participants feedback on their current transfer techniques, and suggested improvements to reduce strain on their upper body. The participants had a chance to practice improved techniques with feedback from the therapist during the training session.

The participants in the Web-based training group were presented with an online module which took them about an hour to complete. The module consisted of four main components: (1) information about how improper transfers can cause wrist and shoulder problems; (2) a description of the three phases of a transfer; (3) ways to make transfers easier on the wrists and shoulders; and (4) information about how to adapt transfer techniques to more complicated transfers, such as transferring to the car or toilet seat. The online module included picture and video demonstrations along with the text.

The participants in the comparison group received no training or information on transfer techniques, either in person or via the Web.

Before the study began, all of the participants answered basic questions, such as their age, their type of disability, and how long they had been a wheelchair user. Then, all of the participants were evaluated by a trained researcher who observed them as they transferred into and out of their wheelchair. The participants in both training groups were evaluated three times: once before training, once right after training, and once 1-2 days after training, to see how long their new skills lasted. The participants in the no-training comparison group were evaluated twice, once when they enrolled in the study and again 1-2 days later. During the evaluation, the trained observer rated how many of 14 proper transfer techniques the participant used. For example, they observed whether the participant moved the armrest out of the way before transferring; whether the transfer angle was between 20 and 45 degrees; or whether the movement was smooth and well-coordinated.

The researchers found that the participants in both training groups improved their transfer techniques after the training compared with their techniques before the training. The participants in the in-person training group improved by an average of 14%, and those in the Web-based training group improved by an average of 29%.  In addition to the immediate improvement after the training, these improvements were maintained 1-2-day after the training. There were no changes in transfer techniques for the participants in the no-training control group between the two evaluations.

When the researchers looked at who improved most after training, they found that the participants with lower technique scores before training improved more than the participants with higher scores, regardless of whether they had in-person training or Web-based training. The participants with multiple sclerosis, amputations, or other disabilities improved more than the participants with spinal cord injury. However, the participants’ age or how long they had been a wheelchair user was unrelated to their level of improvement.

The authors noted that all of the participants in this study were athletes, and it is possible that a less athletic sample of wheelchair users might show different results. They also noted that the in-person group consisted only of individuals with paraplegia and their initial technique scores were higher than the more diverse Web-based group. This may help to explain less improvement seen in the in-person group based on the earlier finding that participants with higher initial scores showed less improvement than those with lower scores. Based on the results of this study, the authors also noted that even experienced, athletic individuals may be able to improve their transfer technique through training. Participants in this study even reported learning some techniques for the first time.

According to the authors, Web-based training may be an efficient way to give wheelchair users information about proper transfer techniques and therefore reduce risk of injury or chronic pain in wrists, arms, and shoulders. Web-based information may be especially helpful for people who live far away from a clinic. The training can be beneficial regardless of age or level of experience using a wheelchair. Future research may be useful to evaluate the effectiveness of Web-based training with a broader sample, and to develop open-access materials for wheelchair users to practice their transfer skills on their own.

To Learn More

The Independent Transfers Training module as it was used in this study is available online at http://www.upmc-sci.pitt.edu/book/independent-transfers-training. The training has been revised and improved as part of a current NIDILRR-funded study. Visitors can view the training and find out how to participate in the study at http://upmc-sci.pitt.edu/transfers/

Lead researcher Lynn Worobey, PhD, joined the RehabCast podcast from the Archives of Physical Medicine and Rehabilitation to discuss this project http://www.archives-pmr.org/content/podcast_collection

The Healthy Tomorrow YouTube channel, started by the Rehabilitation Research and Training Center on Prevention of Secondary Conditions in SCI, has several short videos demonstrating everyday tasks for wheelchair users including:

The Northwest Regional Spinal Cord Injury System and the Craig H. Neilsen Foundation collaborated on the SCI Empowerment Project: Health Partnerships for Successful Aging with SCI, which includes more than 20 health guides and more than 25 training videos on wheelchair skills and general health and wellness. http://sci.washington.edu/empowerment/index.asp

To Learn More About this Study

Worobey, L. et al. (2018) Investigating the efficacy of web-based transfer training on independent wheelchair transfers through randomized controlled trials. Archives of Physical Medicine and Rehabilitation, 99, 9-16. This article is available from the NARIC collection under accession number J77730.

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