Motor Learning Approach for Manual Wheelchair Users

Study Overview
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Brief Summary
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The overall purpose of this project is to pilot test a manual wheelchair (MWC) training program based on motor learning theory to improve wheelchair propulsion for manual wheelchair users (MWUs) with spinal cord injury (SCI).

Detailed Description
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The project objective is to conduct a pilot randomized control trial (RCT) examining (1) the number of task-specific repetitions required to produce change in wheelchair propulsion techniques and (2) identifying the most conducive surface (overground or on a stationary device such as rollers) for implementing a repetition-based manual wheelchair propulsion training program. The long-term goals of this research are to minimize upper extremity pain and chronic overuse injury and to increase mobility efficiency in in persons with SCI who use MWCs for everyday mobility. The current project goal is to test the effects of a repetition-based manual wheelchair propulsion training program that emphasizes the recommended clinical practice guidelines (CPG). The expected outcome will be evidence to use in training MWUs with SCI in proper propulsion techniques in order to prevent or delay pain and chronic overuse injuries and maximize mobility through efficient wheelchair propulsion techniques. The long-term impact will be implementing evidence-based MWC propulsion training in appropriate amounts to facilitate a reduction in pain and dysfunction, a reduction in health costs, and prolonged participation in major life activities for MWUs with SCI. Our research aims are to: Compare wheelchair propulsion kinematics, kinetics, and wheelchair performance changes among three independent groups (Roller Group, Overground Group, Wheelchair Skills Group). Characterize the dose-response relationship of repetition-based propulsion practice. Evaluate the long-term impact of propulsion training on performance in the lived environment. A single-blind pilot RCT will be conducted. Forty-eight individuals with SCI who use MWCs and who do not follow the recommended clinical guidelines for propulsion will be recruited. Each participant will be randomized into one of three independent groups: motor learning repetitions on a roller system (RG), motor learning repetitions overground (OG), or the placebo-controlled group receiving conventional MWC skills training (WSG). The WSG will operate as a placebo by receiving basic MWC skills training-the current standard of rehabilitation care. Participants' kinematics (video motion analysis), kinetics (SmartWheel), and wheelchair performance overground (Wheelchair Propulsion Test) will be assessed pre-intervention (Baseline), immediately following intervention (Follow-up), and three months' post-intervention (3-Month Follow-up).

Official Title
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A Motor Learning Approach to Wheelchair Propulsion Training for Manual Wheelchair Users With SCI

Conditions
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Spinal Cord Injuries

Intervention / Treatment
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* Behavioral: Roller system group (RG)
* Behavioral: Overground group (OG)
* Behavioral: Placebo - Wheelchair skills group (WSG)


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Participants must be 18 to 60 years of age Have a mobility limitation due to SCI, which requires the use of a manual wheelchair (MWC) Be able to self-propel a MWC bilaterally with their upper extremities Plan to use a MWC for at least 75% of activities throughout the day Live in the community Understand English at a sixth-grade level or higher Be able to follow multi-step instructions Participants must be able to provide informed consent independently Be able to tolerate propelling their wheelchair independently for 10 meters Be willing to participate in three assessments and up to 13 training sessions at the Enabling Mobility in the Community Laboratory (EMC Lab). Exclusion Criteria: People will be excluded if they maneuver their MWC with their lower extremities or with only one upper extremity. Individuals who display the proper MWC propulsion techniques during the screening process, who already follow the CPG, or whose MWC position inhibits them from following the CPG will be excluded. Potential participants also will be excluded if they have bilateral incoordination due to strength inequality or neurological involvement that impairs propulsion in a steady, straight line. Specifically, if a person demonstrates upper extremity strength inequalities resulting in a 12-inch deviation from a marked pathway, he or she will be excluded. Other exclusionary criteria include surgeries compromising the integrity of the upper extremities or cardiovascular complications within the past year. Potential participants will also be excluded if upper extremity or overall bodily pain is rated 8/10 or higher per the Wong-Baker FACES Numeric Pain Scale (FACES). -In addition, potential participants will be excluded if they are currently receiving medical treatment for an acute upper extremity injury, have a Stage IV pressure injury, or are currently hospitalized.

Ages Eligible for Study
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Minimum Age: 18 Years
Maximum Age: 60 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Single


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Active Comparator: Roller system group (RG)<br>A group performing motor learning manual wheelchair propulsion repetitions on a roller system. | Behavioral: Roller system group (RG)<br>* They will first receive the standard of care that is often used in rehabilitation: a 30 minute educational session about recommended propulsion techniques with no motor learning principles implemented. In addition, they will execute 750-1250 wheelchair propulsion repetitions on the roller system per each 1 hour session (2-3 x per week for 4-6 weeks) until they reach approximately 10,000 repetitions (10 sessions). Each session will focus on minimizing the force and frequency of pushes while using longer push strokes during propulsion.<br>|
| Active Comparator: Overground group (OG)<br>A group performing motor learning manual wheelchair propulsion repetitions overground. | Behavioral: Overground group (OG)<br>* They will first receive the standard of care that is often used in rehabilitation: a 30 minute educational session about recommended propulsion techniques with no motor learning principles implemented. In addition, they will execute 750-1250 wheelchair propulsion repetitions overground per each 1 hour session (2-3 x per week for 4-6 weeks) until they reach approximately 10,000 repetitions (10 sessions). Each session will focus on minimizing the force and frequency of pushes while using longer push strokes during propulsion.<br>|
| Placebo Comparator: Placebo - Wheelchair skills group (WSG)<br>A group receiving conventional manual wheelchair skills training. | Behavioral: Placebo - Wheelchair skills group (WSG)<br>* They will receive the standard of care that is often used in rehabilitation: a 30 minute educational session about recommended propulsion techniques with no motor learning principles implemented.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Video Motion Capture-Hand Axle relationship Change | Kinematic data will be collected using a 3D infrared VMC system (VICON, Centennial, CO).106 The VMC system consists of 14 Vero 2.2 digital cameras to detect the location of reflective markers, which will be attached to the participant's third metacarpal and to the wheel axle of the participant's MWC. As the participant propels through the capture volume, the VMC will record the motion of the participant's third metacarpal in relation to the wheelchair axle. Hand-axle relationship will be measured in centimeters and compared across the three testing sessions. This variable corresponds to the recommendations outlined in the CPG (bringing the hand down toward the axle during recovery [hand-axle relationship]. | Baseline, Up to 4 weeks post intervention and 3-month post intervention | 
| Video Motion Capture-Push Angle Change | Kinematic data will be collected using a 3D infrared VMC system (VICON, Centennial, CO).106 The VMC system consists of 14 Vero 2.2 digital cameras to detect the location of reflective markers, which will be attached to the participant's third metacarpal and to the wheel axle of the participant's MWC. As the participant propels through the capture volume, the VMC will record the motion of the participant's third metacarpal in relation to the wheelchair axle. Push angle will be compared across the three testing sessions. This variable corresponds to the recommendations outlined in the CPG (use longer push strokes [push angle]. | Baseline, Up to 4 weeks post intervention and 3-month post intervention | 
| Wheelchair Propulsion Test (WPT)-Number of pushes Change | The WPT assesses wheelchair mobility and performance of MWUs. The WPT requires MWUs to propel using a self-selected natural velocity across 10 meters of a smooth, flat surface from a static start. The number of pushes needed to complete the 10 meters,will all noted. The WPT has excellent test-retest reliability (r = .72-.96), interrater reliability (r = .80-.96), and construct validity (p < .04).14 The data collected from the WPT will assist in identifying changes of propulsion performance pre- and post-intervention and how those changes relate to the Clinical Practice Guidelines for the Preservation of upper Limb function Following Spinal Cord Injury (CPG) recommendation for minimizing the frequency of pushes while retaining the same speed. | Baseline, Up to 4 weeks post intervention and 3-month post intervention | 
| Wheelchair Propulsion Test (WPT)-time to complete 10 meter push Change | The WPT assesses wheelchair mobility and performance of MWUs. The WPT requires MWUs to propel using a self-selected natural velocity across 10 meters of a smooth, flat surface from a static start. Observation of the participant's propulsion pattern as well as whether their hands make contact with the pushrims, recovery, time to complete the 10 meters will be collected. The WPT has excellent test-retest reliability (r = .72-.96), interrater reliability (r = .80-.96), and construct validity (p < .04).14 The data collected from the WPT will assist in identifying changes of propulsion performance pre- and post-intervention and how those changes relate to the Clinical Practice Guidelines for the Preservation of upper Limb function Following Spinal Cord Injury (CPG) recommendation for minimizing the frequency of pushes while retaining the same speed. | Baseline, Up to 4 weeks post intervention and 3-month post intervention | 
| Wheelchair Propulsion Test (WPT)-type of propulsion pattern comparison between time points | The WPT assesses wheelchair mobility and performance of MWUs. The WPT requires MWUs to propel using a self-selected natural velocity across 10 meters of a smooth, flat surface from a static start. The participant's dominant propulsion pattern will be noted. The WPT has excellent test-retest reliability (r = .72-.96), interrater reliability (r = .80-.96), and construct validity (p < .04).14 The data collected from the WPT will assist in identifying changes of propulsion performance pre- and post-intervention and how those changes relate to the Clinical Practice Guidelines for the Preservation of upper Limb function Following Spinal Cord Injury (CPG) recommendation for minimizing the frequency of pushes while retaining the same speed. | Baseline, Up to 4 weeks post intervention and 3-month post intervention | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Outdoor Propulsion Test-Total push count | Participants will be asked to propel their wheelchair in and around the parking lot on a fixed route. This is to assess under different environment the propulsion patterns may differ from the indoor lab environment. Total propulsion counts will be recorded and compared within and between subjects. | Baseline, Up to 4 weeks post intervention and 3-month post intervention | 
| Outdoor Propulsion Test-# of pushes meeting clinical guidelines | Participants will be asked to propel their wheelchair in and around the parking lot on a fixed route. This is to assess under different environment the propulsion patterns may differ from the indoor lab environment. Propulsion counts will be recorded and compared within and between subjects. | Baseline, Up to 4 weeks post intervention and 3-month post intervention | 
| Outdoor Propulsion Test-Type of propulsion pattern | Participants will be asked to propel their wheelchair in and around the parking lot on a fixed route. This is to assess under different environment the propulsion patterns may differ from the indoor lab environment. Propulsion patterns will be recorded and compared within and between subjects. | Baseline, Up to 4 weeks post intervention and 3-month post intervention | 
| Outdoor Propulsion Test-Time to complete route | Participants will be asked to propel their wheelchair in and around the parking lot on a fixed route. This is to assess under different environment the propulsion patterns may differ from the indoor lab environment. Time to complete the route will be recorded and compared within and between subjects. | Baseline, Up to 4 weeks post intervention and 3-month post intervention | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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manual wheelchair, wheelchair propulsion, occupational therapy, motor learning