In response to the need identified by Daoust et al. (2021), condensed, ready-to-use, child-friendly material was created to facilitate clinical use of the WSTP. Specifically, three KT tools were developed as a preliminary step to adapt the WSTP for pediatric clientele. This study evaluated OTs’ and PMWUs’ satisfaction and perspectives on usability, relevance, and feasibility of the three tools, with results demonstrating the tools have potential to foster the implementation of the WSTP in pediatric rehabilitation settings.
The inclusion of both OTs’ and PMWUs’ perspectives on the three tools provided in-depth feedback from the two primary end-users. Our findings highlight the critical importance of consulting both providers and users, especially children, in developing services that are aligned with their needs and preferences (18). OTs impressions influence whether or not the tools will be implemented in clinical practice, whereas PMWUs impressions will influence their level of engagement in the training sessions (19). Therefore, the current study aligns with the United Convention on the Rights of the Child (1989) and the Nothing About Us Without Us movement (1998) by supporting the rights of children to express their points of views on the decisions pertaining to them. Research incorporating the perspectives of children with disabilities regarding the interventions they receive are limited (20, 21).
In general, OTs and PMWUs provided positive feedback regarding the use of the tools with elementary school children and novice wheelchair users. All OTs expressed the desire to use the tools with their clients as soon as possible because they are easy to use in their context, may increase the efficiency of their interventions and make wheelchair skills training fun for children. Our findings demonstrate that the tools respond to the concerns regarding the playfulness of the WSTP, its practicality and its specificity in pediatrics, while decreasing the time barriers limiting its use (10). Three of five PMWUs perceived the tools could help them improve their mobility and were motivated to use them. The two PMWUs who felt they had already mastered the wheelchair skills (thus said they would not use the tools) were experienced wheelchair users who appeared to be ready to learn community and advanced skills. However, they did affirm that the tools could have benefits for younger children with less experience. Although this resonates with evidence supporting greater training effects in new wheelchair users (6), experienced children and adults have improved their wheelchair skills upon completion of the WSTP (5, 22). It is important to note that one PMWU had upper-body pain, a common wheelchair-related injury associated with overuse and poor propulsion techniques (23). Pediatric-onset wheelchair use is associated with activity-limiting pain in adulthood (23). Pain related to overuse might be prevented using more efficient techniques to perform wheelchair skills (23). As children may tend to have difficulties imagining themselves in the future and understanding the relationship between the techniques they use and pain, it might be useful to raise their awareness on the long-term benefits of wheelchair skills training.
OTs, PMWUs and mothers perceived that the tools could be used in a wide variety of contexts (e.g., home, kindergarten, school) and by diverse end-users (e.g., parents, peers, physical education teachers, physiatrist). This is particularly interesting given the need to increase children’s opportunities for wheelchair skills training and the importance of starting training as early as possible (5, 24). As health professionals working in rehabilitation and school settings have numerous competing priorities, training others such as teachers or peers could alleviate some clinician burden. Wheelchair skills training could be delivered across the environments in which children live and grow (e.g., summer camps, sport activities, community organizations) to expose children to various environments and contexts in which their manual wheelchair may be used. For example, power wheelchair mobility training was offered within a specialized summer camp to five school-aged children with severe cerebral palsy (25, 26). After the camp, the impacts of the intervention extended beyond significatively improving the children’s powered mobility skills to include positive changes in motor, cognitive, communication and social skills (25, 26).
Despite the recognized benefits of improved independent mobility on global development among children with disabilities’ (27–29), parents are frequently reluctant to introduce wheelchair skills training early and commonly prioritize walking (10, 18, 30). However, the literature does not indicate that wheelchair use limits the acquisition of walking skills (27). Moreover, children with mobility impairments frequently need a variety of mobility options, as walking may be difficult in certain circumstances (e.g., going shopping after school, long distances) (27). In fact, use of a wheelchair could limit fatigue and improve participation (e.g., wheel to the park and walk on the playground), thus reinforcing the importance of early familiarization with wheelchairs (27). In this regard, participants suggested the storybook could be distributed to families during wheelchair prescription to enhance acceptance and awareness about the increased independence children could gain by moving independently around their environments. Given the lack of such resources to support children and families during wheelchair procurement, the storybook may help to ease the transition (18). A precursor storybook may also help families to cope with the introduction to wheelchairs and could encourage wheelchair skills training. To date, such literature focuses mainly on power mobility (18). More evidence is needed to understand how PMWUs and their families could use a precursor storybook for manual wheelchairs.
The participants proposed several recommendations to improve the three WSTP KT tools. Adding more action to the plot, increasing playfulness, and writing two to three word-descriptions on the posters is relatively easy to modify. However, the suggestion to break the wheelchair skills into smaller steps (or add lower levels) in the training workbook to facilitate a level of success among all PMWUs may be harder to achieve. To date, there are no documented developmental milestones for manual wheelchair skills. Although the Wheelchair Skills Test classifies the wheelchair skills in order of difficulty (4), a developmental sequence of wheelchair skills acquisition could be helpful for pediatric clinicians with concerns about skill choice (10). A systematic review of pediatric occupational therapy interventions demonstrated that a common characteristic shared by the most effective interventions for improving motor skills is a scaffolding approach (i.e., breaking the skills down in small steps) (31). The scaffolding approach is one of the motor learning principles included in the WSTP (4), but more research is needed for pediatric wheelchair skills to provide a ‘just-right challenge’ and allow children to experience success throughout the learning process (10).
Other recommendations for improving the tools included improving the illustrations depicting how to perform the wheelchair skills, standardizing the visual cues in all three tools and rendering the tools available in formats to allow OTs to customize them to the specific needs of their clients. Electronic fillable formats also facilitate communication and collaboration with parents, since OTs frequently use emails to follow-up with them (10). Posters for adults are already available in PDF on the WSP website (32) and the WSP manual encourages clinicians to make adaptations to meet their clients’ needs (4, 10). The WSP website appears to be a strategic platform to diffuse the learning resources; as it has been accessed by 145,381 users from 193 countries and the WSP YouTube channel had 141,200 views up to June 17, 2021 (32). Following the suggestions of OTs and PMWUs, the tools developed in the current studies will be refined and additional tools addressing skills at the community and advanced levels will be developed. Finally, as a last step, the tools will be pilot tested by OTs with PMWUs.
Although our study was limited by a small sample size, the inclusion of both OTs and PMWUs’ provided in-depth feedback from two primary end-users (including children with disabilities who are often overlooked stakeholders in research). Despite the strategies used to elicit PMWU’s perceptions of the tools (e.g., PowerPoint visual support, pictograms, parental assistance), challenges arose when conducting the interviews that may have affected our results. PMWUs’ responses tended to be brief, and it was sometimes difficult to gain deeper insights on their perspectives (e.g., understand why they don’t want to use the tools). It was also difficult to maintain PMWU’s attention, concentration, and motivation to respond to the questions, which may be explained by several factors. The interviews were conducted by a student who had limited experience in collecting qualitative data with children. Moreover, children may have experienced fatigue during 60 and 90 minutes, or may have been distracted (e.g., by toys), potentially prompting parents to respond in their place. Parents sometimes interfered by distracting the PMWUs (e.g., laughing) or suggesting answers that could influence the child’s opinion. To prevent this, we could have obtained parents’ feedback on the tools before interviewing the children or provided ground rules regarding their participation.
Finally, the tools were provided in advance to PMWUs rather than seeing them on the screen for the first time. Although most PMWUs had time to review the tools with their parents prior to the interview, they may have had difficulties with recall, forgetting their first impressions on viewing them. Moreover, we observed that parents often described the tools to their children, which may have limited our ability to elicit their first impressions of them. It may have been more useful to introduce the tools on the call, and yet, sharing the tools in advance allowed PMWUs to try them out.