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  2. Wheelchair Skills Test 4.1

Wheelchair Skills Test 4.1

Last Updated

Purpose

The WST is a comprehensive and generic instrument for the objective evaluation of manual wheelchair skills.

Link to Instrument

instrument details

Acronym WST

Cost

Free

Diagnosis/Conditions

  • Brain Injury Recovery
  • Spinal Cord Injury
  • Stroke Recovery

Populations

Spinal Injuries
Movement and Gait Disorders

Key Descriptions

  • The most recent version of the WST is version 4.1. Prior versions include 1.0, 2.4 and 3.2.
  • Grading for version 4.1 is pass/fail.
  • 2 total scores for version 4.1: Safety & Performance. The safety component was added to help clinician distinguish between the completion of a skill based on a patient’s judgment.
  • There are 32 skills in version 4.1.

Number of Items

32

Equipment Required

  • Obstacle course
  • patient’s own wheelchair
  • hinged doorway
  • bench
  • 5˚ and 10˚ incline
  • 15cm pot-hole
  • 2cm threshold
  • 5cm level change
  • 15cm curb
  • stairs

Time to Administer

30 minutes

Mean testing times were 34.5 ± 14.2 minutes and with repeat testing was 27.9 ± 8.5 minutes (p = 0.356).

Required Training

Reading an Article/Manual

Instrument Reviewers

Initially reviewed by Irene Ward, PT, DPT, NCS and the TBI EDGE task force and Phyllis Palma, PT, DPT, Rachel Tappan, PT, NCS, and the SCI EDGE task force of the Neurology Section of the APTA in 10/2012.

ICF Domain

Activity

Professional Association Recommendation

Recommendations for use of the instrument from the Neurology Section of the American Physical Therapy Association’s Multiple Sclerosis Taskforce (MSEDGE), Parkinson’s Taskforce (PD EDGE), Spinal Cord Injury Taskforce (PD EDGE), Stroke Taskforce (StrokEDGE), Traumatic Brain Injury Taskforce (TBI EDGE), and Vestibular Taskforce (Vestibular EDGE) are listed below. These recommendations were developed by a panel of research and clinical experts using a modified Delphi process.

For detailed information about how recommendations were made, please visit:  http://www.neuropt.org/go/healthcare-professionals/neurology-section-outcome-measures-recommendations

Abbreviations:

 

HR

Highly Recommend

R

Recommend

LS / UR

Reasonable to use, but limited study in target group  / Unable to Recommend

NR

Not Recommended

Recommendations for use based on acuity level of the patient:

 

Acute

(CVA < 2 months post)

(SCI < 1 month post) 

(Vestibular < 6 weeks post)

Subacute

(CVA 2 to 6 months)

(SCI 3 to 6 months)

Chronic

(> 6 months)

SCI EDGE

LS

LS

R

Recommendations based on level of care in which the assessment is taken:

 

Acute Care

Inpatient Rehabilitation

Skilled Nursing Facility

Outpatient

Rehabilitation

Home Health

TBI EDGE

NR

NR

NR

NR

NR

Recommendations based on SCI AIS Classification: 

 

AIS A/B

AIS C/D

SCI EDGE

LS

LS

Recommendations for use based on ambulatory status after brain injury:

 

Completely Independent

Mildly dependant

Moderately Dependant

Severely Dependant

TBI EDGE

N/A

N/A

N/A

N/A

Recommendations for entry-level physical therapy education and use in research:

 

Students should learn to administer this tool? (Y/N)

Students should be exposed to tool? (Y/N)

Appropriate for use in intervention research studies? (Y/N)

Is additional research warranted for this tool (Y/N)

SCI EDGE

No

No

Yes

Not reported

TBI EDGE

No

No

No

Not reported

Considerations

  • There are older versions of the WST (1.0 and 2.4) that have been tested for their psychometric merit. This review focused on the most recent version of the WST 4.1 since this is the one available for download from the website listed above. 
  • Previous versions of the WST have been found to be reliable and valid. However, further testing is recommended on the current version, (WST 4.1) to establish its psychometric data and clinical utility. 
  • With the addition of a safety measure, the WST 4.1 may be a helpful tool in identifying whether a person demonstrates good judgment when using a wheelchair. This may be especially helpful with individuals with TBI who may have impaired judgment due to their injury. 

 

WST:

  • No published studies have investigated the psychometric properties of the WST versions intended for use by power wheelchair users or by caregivers. Questionnaire version of the WST (WST-Q) 

 

Manual Wheelchair Users, WST-Q version 2.4:

(Mountain 2004; n = 20; 7 with amputation, 4 with musculoskeletal disorder, 4 with spinal cord and peripheral neurologic disorders, 5 with stroke and acquired brain disorder; Mean age = 64.6 (13.6) years; mean experience using wheelchair = 93.9 (240.2) weeks)

  • Development of the WST-Q was based on literature review, pre-existing evaluation criteria for the objective WST, and pilot data.
  • Excellent correlation between objective WST score and WST-Q score (r = 0.91) 

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Spinal Injuries

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Cut-Off Scores

Chronic SCI, WST version 4.1:

(Lemay 2012; n = 54; mean age = 46.7 (12.8) years; time since initiating wheelchair use = 16.0 (11.2) years, range = 1-40 years; Level of injury: 25.9% C4-C8, 18.5% T1-6, 55.6% T7-L2; severity of injury: 50% complete SCI, 50% incomplete SCI)

  • People with score ≥ 80% have advanced manual wheelchair skills based on observation

Normative Data

Chronic SCI, WST version 4.1:

(Lemay 2012)

  • Mean scores by level of injury:
    • All levels (C4-L2) combined = 80.7 ± 11.8 
    • Tetraplegia (C4-C8) = 72.1 ± 7.9 
    • High paraplegia (T1-6) = 82.8 ± 9.1 
    • Low paraplegia (T7-L2) = 84.0 ± 12.4

Criterion Validity (Predictive/Concurrent)

Predictive Validity

Chronic SCI:

(Hosseini 2012; n = 214; Mean age = 38.8 (12) years; Mean time since injury = 11.7 (11) years (range = 0.9-50 years); Level of injury = C3-L5, 72% with paraplegia, 28% with tetraplegia) 

  • WST version 4.1 score predicted CHART score, Satisfaction with Life Scale score, and self-perceived health status on multiple linear regression (p < 0.05)

Construct Validity

Chronic SCI, WST version 4.1:

(Lemay 2012)

  • Adequate correlation between WST version 4.1 score and wheeled distance per day (r = 0.36) and age (r = -0.32)
  • People with tetraplegia (C4-8) scored lower than people with low level paraplegia (T7-L2) (mean score = 72.1% ± 7.9% and 84.0% ± 12.4% respectively) 

SCI, WST version 3.2:

(Pradon 2012; n = 40; mean age = 36.9 (11.2) years; mean time of wheelchair use = 79.8 months (range 1-360); 18 with low paraplegia (T10-L3), 15 with high paraplegia (T1-9), 7 with tetraplegia (C6-7))

  • Excellent correlation between WST version 3.2 and maximum velocity of wheelchair propulsion (r = 0.72) 
  • Adequate correlation between WST version 3.2 and spontaneous velocity of wheelchair propulsion (r = 0.57)

Content Validity

  • The evolution of the WST has been based on clinical and research experience, feedback from users, and assessments of its measurement properties. (Lindquist et al, 2010)
  • In the pilot testing of WST version 1.0, 30 of 33 wheelchair skills were unanimously supported by occupational therapists performing testing (n = 9) (Kirby, 2002)
  • Mean visual analog scale rating of usefulness of WST version 1.0 = 59% ± 22% (Kirby, 2002)

Floor/Ceiling Effects

Chronic SCI:

(Lemay 2012)

  • Ceiling effect: 83% of study participants had a score of 100% on safety subscale (range = 87.5%-100%). No issue noted for performance subscale (mean performance score = 80.7% ± 11.8%)

Movement and Gait Disorders

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Normative Data

Community manual wheelchair users:

(Lindquist et al, 2010, version 4.1, n = 11; Age (years): 42.16 ± 16.2; Sex (male/female) 9/2; 30 of the 32 items tested)

  • Mean WST 4.1 score for performance 80.1% (± 8.5%) range 63.3%-100.0%
  • Mean WST 4.1 score for safety 98.0% (± 2.8%) range 89.7%-100.0%

Test/Retest Reliability

Community manual wheelchair users:

(Lindquist et al, 2010, version 4.1, n = 11)

  • Performance score (substantial agreement)
    • Test-retest reliability, ICC= 0.901
  • Safety score Excellent (none to slight agreement) 
    • Test-retest reliability, ICC= 0.254

 

Wheelchair Users and Non-Wheelchair Users, WST version 2.4:

(Kirby 2004; n = 298, 129 able-bodied, 62 with amputation, 20 with musculoskeletal disorders, 34 with SCI, 52 with CVA; mean age = 43.8 (22.5) years)

  • Excellent test-retest reliability (ICC = 0.904)

Interrater/Intrarater Reliability

Community manual wheelchair users:

(Lindquist et al, 2010, version 4.1, n = 11)

  • Performance score (substantial agreement)
    • Excellent interrater reliability, ICC = 0.855
    • Excellent intrarrater reliability, ICC = 0.950
  • Safety score Excellent (none to slight agreement)
    • Poor interrater reliability, ICC = 0.061
    • Poor iIntrarater reliability, ICC = 0.228
  • Most (54%) performance and safety discrepancies occurred because of scoring rule interpretations. 

Wheelchair Users and Non-Wheelchair Users, WST version 2.4:

(Kirby 2004)

  • Excellent interrater reliability (ICC = 0.959)
  • Excellent intrarater reliability (ICC = 0.968)

Criterion Validity (Predictive/Concurrent)

Concurrent Validity

Manual Wheelchair Users, WST version 1.0:

(Kirby 2002; n = 24, 11 with amputation, 4 with stroke, 3 with musculoskeletal disorders, 3 with SCI, 3 with neuromuscular disorders); Mean age = 59 (19) years; mean time using any wheelchair = 51 (144) weeks)

  • Adequate correlation between WST scores and occupational therapists’ global ratings of wheelchair skills (r = 0.40-0.54)
  • Adequate correlation between changes in WST scores and changes in occupational therapists’ global ratings of wheelchair skills before and after rehabilitation (r = 0.45)

Construct Validity

Convergent Validity

Wheelchair Users and Non-Wheelchair Users, WST version 2.4:

(Kirby 2004)

  • Adequate correlation between WST version 2.4 and age (r = -0.434)

Floor/Ceiling Effects

  • Version 4.1 includes more advanced skills (i.e. getting up off the floor and ascending and descending stairs). This was done to reduce the likelihood of a ceiling effect. 

Manual Wheelchair Users, WST version 4.1:

(Lindquist 2010)

  • Possible ceiling effect for safety score with mean score of 98% ± 2.8% (range 89.7%-100%)

Responsiveness

Manual Wheelchair Users, WST version 3.1:

(Best 2005; mean age = 49 (16) years for experimental group, 48 (23) years for control group; Mean wheelchair experience = 11 (151) months for experimental group, 34 (66) months for control group) 

  • People who participated in a “Wheelchair Skills Training Program” (WTSP) had a relative improvement of 24.0% on WST version 3.1 score, which was statistically significantly greater than the relative improvement of 4.8% in the control group.

Bibliography

Best, K. L., Kirby, R. L., et al. (2005). "Wheelchair skills training for community-based manual wheelchair users: a randomized controlled trial." Arch Phys Med Rehabil 86(12): 2316-2323. Find it on PubMed

Coolen, A. L., Kirby, R. L., et al. (2004). "Wheelchair skills training program for clinicians: a randomized controlled trial with occupational therapy students." Arch Phys Med Rehabil 85(7): 1160-1167. Find it on PubMed

Hosseini, S. M., Oyster, M. L., et al. (2012). "Manual wheelchair skills capacity predicts quality of life and community integration in persons with spinal cord injury." Arch Phys Med Rehabil 93(12): 2237-2243. Find it on PubMed

Kirby, R. L., Dupuis, D. J., et al. (2004). "The wheelchair skills test (version 2.4): measurement properties." Archives of Physical Medicine and Rehabilitation 85(5): 794-804. Find it on PubMed

Kirby, R. L., Swuste, J., et al. (2002). "The Wheelchair Skills Test: a pilot study of a new outcome measure." Arch Phys Med Rehabil 83(1): 10-18. Find it on PubMed

Lemay, V., Routhier, F., et al. (2012). "Relationships between wheelchair skills, wheelchair mobility and level of injury in individuals with spinal cord injury." Spinal Cord 50(1): 37-41. Find it on PubMed

Lindquist, N. J., Loudon, P. E., et al. (2010). "Reliability of the performance and safety scores of the wheelchair skills test version 4.1 for manual wheelchair users." Arch Phys Med Rehabil 91(11): 1752-1757. Find it on PubMed

Mountain, A. D., Kirby, R. L., et al. (2004). "The wheelchair skills test, version 2.4: Validity of an algorithm-based questionnaire version." Arch Phys Med Rehabil 85(3): 416-423. Find it on PubMed

Phang, S. H., Martin Ginis, K. A., et al. (2012). "The role of self-efficacy in the wheelchair skills-physical activity relationship among manual wheelchair users with spinal cord injury." Disabil Rehabil 34(8): 625-632. Find it on PubMed

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