When moving evidence-based programs into practice, adaptation is often required to improve the fit between the program and the local context (e.g., specific population needs, priorities, policies, resources) [20]. This study was the first to explore the perspectives of OTs regarding what adaptations, if any, to the WSP would be useful to enhance its implementation in pediatric-rehabilitation settings. Analyses of our qualitative data using the CFIR Intervention Characteristics domain provided guidance to identify recommendations of adaptations to respond to the study objective. Through the reflection, particular attention was given in order to find a balance between what can be adapted versus what should stay consistent to the actual WSP. With that consideration emerges the realization that many of the perceptions of the OTs required not adaptations to the program, but rather 3rd Generation WSP Knowledge (KT tools and products), or 1st Generation WSP Knowledge that will inform adaptations. A summary of the recommendations provided throughout the discussion are presented in Table 2.
Table 2
Proposed WSP adaptation for the pediatric rehabilitation context
WSP Implementation Issues | CFIR Intervention Characteristic Construct | Proposed adaptation | Need for Knowledge Creation? |
Knowledge Inquiry | KT Tool / Product |
WST needs to be adapted to the pediatric population (requires a more playful approach for young PMWCUs; developmental considerations) | Adaptability | Requires Knowledge Inquiry | WST measurement property study with PMWCUs and parents | Narrated WST PMWU/Parent videos |
Addition of ‘special considerations for children’ in WST scoring guide | N/A |
Some skills seem unrealistic for PMWUs and more applicable for parents | Adaptability | Requires Knowledge Inquiry | Developmental acquisition of wheelchair skills | Case studies, Training videos with PMWUs |
Addition of the existing caregiver assistance score column in the WST form | WST measurement property study with the added caregiver assistance score | N/A |
Difficulty to use the WSP for training children | Adaptability | Addition of ‘special considerations for children’ in WSTP guide | 1) Intervention study with PMWUs and parents; 2) Suggestions from clinical experts | N/A |
WST-Q too complex for self-administration with PMWCUs | Complexity & Design Quality and Packaging | Requires Knowledge Inquiry | WST-Q measurement property study with PMWUs | N/A |
Development of a tablet-based administration format |
WSP Manual is dense and detailed and thus difficult to quickly access pediatric-specific information | Complexity & Design Quality and Packaging | Optimization of tabs and internal links in the WSP Manual to facilitate easy access | N/A | Condensed pediatric-specific version of the WSP Manual |
PMWU training of community and advanced skills frequently avoided due to safety concerns and perceptions that it’s not possible or not important | Evidence Strength and Quality | Addition of ‘special considerations for children’ in WSP training guide | Intervention study with PMWUs and parents | Pediatric-specific training posters, narrated training videos, training workbook, case studies and storybook |
Unavailability (i.e., logistic and emotional) of parents to participate in assessment and training | Design Quality and Packaging | WST-Q in an electronic fillable format | N/A | Narrated parent-specific training videos, ‘train at home’ guide, training plan template, section on the WSP website or YouTube Channel |
Requires KT Tool / Product Development |
Perplexity on how to engage the parent for training | Design Quality and Packaging | N/A | N/A | Parent-specific promotional materials (e.g., pamphlet, promotional video) |
To begin, OTs perceived that the WSP was not perfectly adapted and tailored to meet the pediatric population needs in terms of playfulness and developmental considerations. Although play is considered a significant occupation for children [21], the suggestion of a more playful approach to the administration of the WST seems to contradict the prevalent use by pediatric OTs of norm-referenced and criterion-referenced standardized assessments [22, 23]. Indeed, play is predominantly used by OTs as a therapeutic tool [24], while the use of play-based assessments is infrequent [24, 25]. Further, studies that have used the WST with children [10, 11] have not reported the need to consider a more playful administration. While acknowledging the importance of play, but also considering the limited evidence to support the need to adapt the WST in a playful administration, we propose that a playful WST administration be considered as need for new first generation WSP knowledge in terms of the measurement properties of the WST for the pediatric population, taking into thoughts various pediatric age groups, diagnoses and developmental levels.
With regards to the need for developmental consideration in the WST, an important change in the scoring scale was made in Versions WST 5.0 and 5.1 of the WSP to increase the sensitivity and indirectly its applicability with PMWUs. Specifically, the 3-point response scale of previous versions [26] was changed to a 4-point scale (3 = advanced pass; 2 = pass; 1 = partial pass; 0 = fail) offering a more granular progression into each skill. For example, for the skill gets over obstacle, the child can now get a partial-pass score if he/she can get the casters over the obstacle but not the rear wheels, thus making the skill more accessible for younger or new wheelchair users. However, the scoring modification does not specifically point out aspects of ‘normal child development’ to consider in the evaluation. For example, there is no specification of the age expected for a child to perform an optimal propulsion pattern with respect to the normal development of fine motor skills and/or upper limb coordination. Thus, it may be challenging to know when is the right time for training this skill. In Version 5.1 of the WSP Manual, a section called ‘special considerations for pediatric wheelchair users’ has been added to the WST of each skill, sections that the WSP Manual Editorial Committee has set up a Subcommittee chaired by one of the coauthors of this paper (PWR) to populate on the basis such as the evidence provided in this study. These considerations for the WST adaptation also highlight the need for new first generation WSP knowledge in terms of the measurement properties for the pediatric population and exploration regarding the developmental progression of wheelchair skills acquisition, also questioned by M Huegel, S Otieno and LK Kenyon [11].
Regarding the applicability of certain skills in the WST, OTs suggested the removal of skills perceived to be inaccessible for the PMWUs. However, we think that this approach may limit perception of the need for training (PMWUs or their parents), and their potential progress. Perhaps a solution that would meet the needs of pediatric clinicians could be a modification in the presentation of the WST form. Explicitly, the already proposed Caregiver assistance score, which is now only presented in the WSP manual, could be added directly to the WST form. Addition of this 6-point score (5 = no assistance; 4 = stand-by assistance; 3 = verbal assistance; 2 = one-person physical assistance; 1 = two-person physical assistance; 0 = equipment needed) to the form itself may suggest more intuitively to include the parent in the test and provide assistance for skills that may be too hard for a child at a certain age. It may also provide needed quantification of assistance that can help to demonstrate progress over time which may not be reflected in the wheelchair skills score. Ultimately, collection of this information may facilitate an enhanced understanding of the pediatric continuum of wheelchair skills acquisition. The WSP Manual and Forms are already provided online in Word format and encourages customization to meet the needs of specific groups. Customization of the WST forms to also include more details in the scoring criteria could be a solution to answer the comments regarding the ambiguity with the general scoring guidelines and avoid the extra step of referring back to the Manual.
Modification in the presentation of the WST-Q form to decrease its complexity and enable the self-administration could be done through the development of a tablet-based format. As children and adolescents are building insight on their capacities, self-administration of the WST-Q by PMWUs by may be interesting to promote self-determination over learned helplessness [27]. These considerations for WST-Q adaption also highlight the need for new first generation WSP knowledge in terms of the measurement properties for the pediatric population. Until then, modification of the WST-Q form into an electronic fillable format could be a simple solution to facilitate the use of the questionnaire with the parent answering as a “proxy”.
To address the OTs perspectives regarding the complexity to perform wheelchair skills training with PMWUs, addition of developmental considerations, pediatric-specific motor learning principles and training tips in the training guide could be potentials solutions. For example, training tips for one-arm drive wheelchair propulsion would be helpful as it is often recommended for children (as opposed to hand-foot propulsion technique). Similar to the WST, sections have been added to Version 5.1 of the WSP Manual called special considerations for pediatric wheelchair users. Because the WSP manual is already dense and detailed, suggestion to optimize the presentation (e.g. table, tabs, internal link) or to create a condensed pediatric-specific version like the already developed condensed version for caregivers could facilitate the access of the pertinent information. The WSP Editorial Committee encourages such customization of the Manual’s content.
OTs preferred that PMWUs kept their anti-tippers and avoided to train community and advanced wheelchair skills because of safety concerns. It is true that the child is safe when she/he keeps the anti-tipper but at the same time restricted when faced to certain environmental obstacles (e.g. curb). Training good skills can permit the anti-tips to be removed and be more autonomous in different mobility situations. Provision of training for community and advanced wheelchair skills among PMWUs is also important given that such training, when transitioning into adult rehabilitation services, is not always available (Best et al., 2015). To promote WSP uptake for training community and advanced skills in pediatric rehabilitation, the identified concerns regarding safety issues cannot be dismissed. In fact, it determines the need for new first generation WSP knowledge in terms of effectiveness of the WSP in improving wheelchair skills among the pediatric population. It also emphasizes the need for third generation WSP knowledge in terms of the creation of pediatric-specific educational resources and knowledge translation materials that portray the use of the program with PMWUs (e.g., pediatric-specific case studies, narrated videos, training workbooks, posters).
Finally, our findings suggest that promotion of parent involvement is an important aspect of the WSP adaptability in order to facilitate the implementation in pediatric rehabilitation. One factor affecting involvement, however, is related to the uncertainty of OTs and the lack of tools to reach the parent for wheelchair skills training. As reported in the literature, clear and explicit information by service providers regarding interventions serves to positively influence parents’ expectations, thus facilitating engagement [28, 29]. We can hypothesize that the same would be required to engage parents in wheelchair skills training.
Given the demonstrated effectiveness of manual wheelchair skills training among caregivers [30, 31] and the associated benefits for the wheelchair user, parent involvement represents an important component of the wheelchair skills training process. This finding represents another avenue for the development of third generation WSP knowledge, with a caregiver focus (e.g., lesson plan wheelchair skills training templates for parents, a caregiver-specific section on the WSP website with targeted information such as ‘train at home’ guides, addition of caregiver-specific training videos). The availability of more targeted caregiver resources may facilitate a more informed approach by the OTs to encourage parent involvement, which may also serve to enhance parents’ acceptance of wheelchair skills training as a means of developing their child’s independence rather than a reinforcement of the losses related to the disability [29].
Strengths and limitations
A strength of this study was the diversity in perspectives obtained from OTs working with PMWUs having different characteristics and ages, which was useful to see factors affecting WSP uptake into the whole pediatric age continuum. Since the proposed recommendations do not necessarily address site-specific characteristics (e.g. organizational barriers), we are confident as to their generalizability to other pediatric settings.
Because feedback to propose adaptations are more informative when participants have some experience with the program [32], a major limitation in this study was the fact that most OTs had not used the WSP clinically with PMWUs prior to the focus groups. Since OTs had not really used the WSP in practice, their feedback was based on impressions about the challenges to use the WSP with PMWUs, as opposed to ‘lived’ challenges. Despite this limitation, these impressions were valuable for the recommendations of 1st and 3rd Generation WSP Knowledge. However, in terms of adaptations, many suggestions of adaptations lacked details. To obtain more detailed suggestions of adaptations, one potential modification in the study method could have been to require each participating OT to use the WST, WST-Q and conduct training with one PMWU in their caseload prior the study. Finally, we feel that their reactions and suggestions may have targeted more the WST since during the WSP presentation at the beginning of the focus group, a video of the WST administration with an adult MWU was used to show the skills.