Test of Wheeled Mobility (TOWM) and a short wheelie test: a feasibility and validity study

Abstract

Objective:

To assess the feasibility and validity of both the Test of Wheeled Mobility (TOWM) and a wheelie test.

Design:

Cross-sectional study.

Setting:

KU Leuven gymnasium.

Subjects:

Thirty male manual wheelchair users (age range 23–53 years) with spinal cord injury.

Interventions:

Participants preformed both tests after completing a personal information form and a ‘Perceived self-efficacy in WM’ scale. The TOWM consists of 30 tasks reflecting functional wheeled mobility. The wheelie test consists of eight tasks measuring the ability to perform a ‘wheelie’ in challenging situations.

Main measure:

Ability, performance time, qualitative and anxiety scores were assessed. Convergent validity was tested by correlating the TOWM and the wheelie test scores. Construct validity was assessed by testing whether the four scores of both tests are significantly related to perceived self-efficacy in wheeled mobility, time since injury and sport participation.

Results:

TOWM average total testing time was 24.7 minutes (±5.93) and the wheelie test was 12.62 minutes (±5.08). Convergent validity was confirmed by the positive correlation between the TOWM and wheelie test total ability scores (r = 0.84; P < 0.001), quality scores (r = 0.88) and anxiety scores (r = 0.66). Moderate correlations were found between the total time scores of the TOWM and wheelie test (r = 0.47). Construct validity was confirmed by fair to moderate correlations between both test’s scores with time since injury, self-efficacy and sport participation after injury.

Conclusion:

The TOWM and the wheelie tests are feasible and valid instruments for assessing manual wheelchair mobility in persons with spinal cord injury.

Keywords

Wheeled mobility spinal cord injury evaluation validity wheelie wheelchair skill

Introduction

According to the International Classification of Functioning Disability and Health (ICF), the concept of wheeled mobility is a subcategory of ‘Moving around using equipment: moving the whole body from place to place, on any surface or space, by using specific devices, designed to facilitate moving or create other ways of moving around, such as moving down the street in a wheelchair or a walker’.¹

In a recent systematic literature review on wheelchair skill tests,² results showed that only few tests focus explicitly on wheeled mobility in persons with a spinal cord injury.^3–6 Wheelchair skill tests aimed at the general wheelchair user population failed to differentiate between levels of performance and resulted in a ‘ceiling effect’, mainly in individuals with paraplegia.² The review study revealed a lack of a broadly accepted wheelchair skills test, and disclosed large inconsistencies among the current available tests, which made comparison of study results difficult if not impossible.² Furthermore, constituting a standardized and worldwide accepted wheeled mobility skills test will enable the creation of norms and standards for wheelchair skills performance of individuals with different spinal cord injuries.

This study aimed to develop two wheeled mobility skill tests for manual wheelchair users with a spinal cord injury: one is the ‘Test of Wheeled Mobility’ (TOWM), which is a comprehensive test based on daily wheeled mobility skills; and the second is a short wheelie test, aimed at fast and easy screening, developed following the realization that: ‘The ability to master a wheelie (balancing on the rear wheels), is perhaps the most important skill for the wheelchair user as wheelies permit access to areas and environments that would otherwise be inaccessible’.⁷

The aim of this study was therefore to assess the feasibility, convergent construct and predictive validity of both tests and, when possible, to compare one test with the other. The main research questions were: (1) Will the tests be feasible in terms of duration and required equipment costs? (2) Will the scores of the TOWM be significantly correlated with the scores of the wheelie test (convergent validity)? Will the wheelie test scores predict the TOWM scores (predictive validity)? (3) Will the TOWM and the wheelie test scores be associated with the variables: ‘time since injury’, ‘perceived self-efficacy in wheeled mobility’ and ‘participating in sport after injury’ (construct validity)?

Methods

The development of the TOWM and the wheelie test

In order to promote a standardized wheeled mobility test, the TOWM includes dominant components from existing wheeled mobility tests as found in the critical literature review by Fliess-Douer et al.² Skill selection was based on the results of an international survey on essential wheeled mobility skills that was conducted during the Beijing Paralympics games 2008.⁸ The set of skills was linked to the UN norms, standards and architectural accessibility codes,⁹ to associate the skills with international environmental settings for wheelchair users. After completing the first test draft, a brainstorm session of experts was organized to increase the tests’ content validity. Eight manual wheelchair users with spinal cord injury (prototype representatives per lesion level) voluntarily participated in this ‘expert group’. A tryout was carried out following discussions and the participants were questioned whether they felt safe and whether they experienced the tasks to be either too difficult or too easy.

Outcome measures

The final version of the TOWM consists of 30 standardized tasks that are conditional to mobility in persons with a spinal cord injury. The short wheelie test includes eight tasks which are related to the ability to perform a mature wheelie in challenging situations. The TOWM and the wheelie test tasks present different difficulty levels and are hierarchically structured from the easiest to the most difficult. Including preparation and evaluation time, the estimated duration of the tests is 40 minutes.¹⁰ Appendix 1 illustrates a few examples of the TOWM and the wheelie test tasks. The TOWM and wheelie test protocols, including the score sheets and detailed explanation, may be freely obtained at: www.scionn.nl/inhoudp28.htm.

Both tests have the same four scoring methods: The ability score refers to all the tasks that can be performed adequately and independently. Scores are assigned as: 1 point if the participant completes the task successfully in the first trial; 0.5 point if he succeeds on the second trial; 0 score for either a failure or avoiding trying. All scores are summed to give an overall ability score (TOWM min = 0, max = 30, wheelie test min = 0, max = 8). The ability score is easy to calculate and evaluate on the spot, and provides information about the ability of participants to perform the various test items.

The quality score reflects the maturity pattern of skill performance. For ten skills of the TOWM and for all eight skills of the wheelie test, there are five behavioural components, which are presented as ‘performance criteria’. The establishment of these criteria was done by two experts with a large amount of knowledge about the theoretical and practical background of spinal cord injuries. This scoring method offers meaningful feedback regarding how well one performs each wheeled mobility task, and the maturity level of the overall wheeled mobility performance. All scores are summed to give an overall quality score (TOWM min = 0, max = 50, wheelie test min = 0, max = 40). Depending on the numbers of examiners, the quality score may be assessed on field, but may be also assessed afterwards by analysing videos.

The performance time score is the sum of the performance times of two tasks of the TOWM (level propulsion forward and one-hand propulsion on a marked 10 m line), and four tasks of the wheelie test (forward 10 m in a wheelie, backwards 10 m in a wheelie, uneven surface, and accelerate and stop in a wheelie).

The anxiety score is tested by using a visual analogue scale (VAS 0–10).⁸ Prior to each task performance, the participant is asked to indicate by placing a vertical mark | or X on a 10-cm line, how anxious he is about performing the specific task. This scoring technique is added to observe the effect of the psychological variable (anxiety) on the execution of each task. A total anxiety score is the sum of all the anxiety VAS scores.

Sample characteristics

Recruitment was done during the first two weeks of February 2011, and was performed by word of mouth, email and telephone calls. Communications targeted the heads of a spinal cord injury rehabilitation units and managers of organizations and sport clubs in Belgium. Inclusion criteria: Participants were eligible to join the study if they had a spinal cord injury, were between 18 and 65 years; categorized as A, B, C or D on the American Spinal Injury Association impairment scale (ASIA)¹¹; permanent manual wheelchair-dependent users; without progressive diseases or psychiatric disorders and who have sufficient knowledge of the Dutch and/or English language to understand the goal of the study and the testing methods. Exclusion criteria: Participants who were not allowed to perform physical tests, and/or had severe musculoskeletal complaints of the upper extremities, neck or back.

Participants

Thirty participants completed the entire set of questionnaires and performed the TOWM and the wheelie test on test occasion 1 (t1). One participant did not participate in the retest (t2) because of recurrence of an old shoulder injury unrelated to the wheeled mobility testing; therefore, the results of 29 participants were included in the presented data analysis. Spinal cord injury lesion level ranged from C5 to L1 (tetraplegic n =6, paraplegic n =23). The descriptive group statistics as well as the TOWM, the wheelie test scores and the perceived self-efficacy in wheeled mobility scale scores are presented in Table 1.

Table 1.

Descriptive group statistics and mean scores of perceived Self-Efficacy in Wheeled Mobility (SEWM), Test of Wheeled Mobility (TOWM) and wheelie test at t1 (n = 29)

Variable	n	Mean ± SD
Age, years, mean (SD) [range]	29	38.8 (±8.0) [23–53]
Time since injury, years, mean (SD) [range]	29	12.4 (±10.5) [1–35]
BMI (kg/m²),mean (SD) [range]	29	24.2 (±3.9) [16.5–32.2]
SEWM scale 0–40, mean (SD) [range]	29	34.5 (±4.2) [22–40]
TOWM ability score scale 0–30, mean (SD) [range]	29	20.6 (±4.5) [11.5–28.0]
TOWM time score in seconds, mean (SD) [range]	15	17.6 (±8.3) [10.9–41]
TOWM quality score scale 0–50, mean (SD) [range]	20	28.8 (±13.5) [7–48]
TOWM anxiety score VAS 0–10 × 30 items, mean (SD) [range]	29	14.6 (±21.5) [0–66]
Wheelie test ability score scale 0–8, mean (SD) [range]	29	5.2 (±2.3) [0–8]
Wheelie test time score in seconds, mean (SD) [range]	15	13.2 (±5.5) [6.6–23.6]
Wheelie test quality score scale 0–40, mean (SD) [range]	20	17 (±11.9) [0–35]
Wheelie test anxiety score (VAS 0–10 × 8 items), mean (SD) [range]	29	6.2 (±10.7) [0–32]

BMI, Body mass index; SEWM, Self-Efficacy in Wheeled Mobility; VAS, visual analogue scale.

Testing procedure

The test procedures were performed in accordance with the guidelines of the Helsinki Declaration. The study was approved by the Medical Ethics Committee of the KU Leuven, Belgium. Participation was strictly voluntary and participants signed a consent form. Participants were reimbursed by the Doctoral School of Biomedical Sciences at KU Leuven for transportation costs.

Following an explanation about the study aims and procedures, the participants completed a personal information form, including information about sport participation at present, and a ‘Perceived self-efficacy in wheeled mobility’ scale.^12,13 Body dimensions were measured by deriving the body mass index from the participant’s weight and height (BMI = weight (kg)/height² (m)).

Both tests (TOWM followed by the wheelie test) were performed while the participants were using their own daily wheelchair. Participants were instructed to perform each task as fast as possible while keeping continuous control over the wheelchair. Participants were given one trial for each task, and were told that it is more important to execute each task safely and in a controlled way than to do it quickly; if they failed, they could try once again (maximum two trials per task).

To further standardize the testing protocol, the same safety precautions were taken for all the participants. Participants were asked to refrain from smoking, drinking alcohol and taking caffeine products for at least 2 hours before each trial. All tests were videotaped by the same cameraman using the same high-speed camera (Canon, Basler 100 Hz, Canon Inc., Tokyo, Japan) placed on a marked line, and all the instructions were standardized and given by the same researcher who also completed the score sheet.

Statistical procedures and analysis

Descriptive statistic and validity analysis were performed using SPSS version 16.0 (SPSS Inc., Chicago, IL, USA). In this study, ability scores and anxiety scores were available for all 29 participants. Quality scores assessment was performed after the test by an experienced physiotherapist, based on a random selection of 20 participants’ videos. Only tasks that had an ability score (i.e. the participant successfully completed the task) were qualitatively evaluated. Time score analysis was done based on participants who had a complete set for both tests’ time scores (two tasks of the TOWM and four tasks of the wheelie test) (n =15).

Pearson correlation coefficients were calculated for testing the correlation between the TOWM and the wheelie test total ability, time and quality scores, and Spearman’s non-parametric correlation analysis was used to determine the correlations between both test anxiety scores (convergent validity). Correlations for testing the interrelationships of the four scales’ scores within a test were also calculated to inform the way these scores were interrelated. In addition, regression analysis for testing the ability of the wheelie test to predict the TOWM was performed (predictive validity).

To determine the relations between the TOWM and the wheelie test total scores with ‘time since injury’, Pearson correlation coefficients were calculated; to determine the correlations between both tests scores and the ‘perceived self-efficacy in wheeled mobility scale’ scores, Spearman’s non-parametric correlation analysis was used (construct validity). As suggested by Colton,¹⁴ correlations ranging from 0.00 to 0.25 indicate little or no relationship; those from 0.25 to 0.50 suggest a fair degree of relationship; values of 0.50 to 0.75 are moderate to good; and values above 0.75 are considered good to excellent.

For testing association between the TOWM and the wheelie test total scores and ‘participation in sports after injury’, a t-test for equality of means was used. The participants were divided into two groups: participating in any type of sport (n =18; being a member of an official sports club and had at least two years of involvement), and none (n =11; no member of an official sports club or less than two years of experience).

Results

Feasibility (research question 1)

The mean (SD) total testing time for the TOWM was 24.7 minutes (±5.93) and ranged between 18 and 40 minutes. For the wheelie test, the mean (SD) total testing time was 12.6 minutes (±5.08) and the range was 4–27 minutes. This total time includes instructions and test performance. All the participants were able to perform at least 11 out of the 30 tasks of the TOWM. Of the wheelie test, except for one participant (C5 tetraplegia), all the participant had an ability score of at least one task, but the majority (including the one who scored zero) made an attempt to perform at least the first two tasks. Figures 1 and 2 show for each participant, the wheelie test ability and quality scores relative to the TOWM ability and quality scores. The graph demonstrates two main outcomes: first, it shows the spread of scores over the full range of the scale among participants, which clearly confirms lack of ceiling or floor effects. Second, it illustrates the coherence of the two tests to one another as all points are relatively close to the line of identity.

Correlation between the TOWM and the wheelie test (convergent validity – research question 2)

The correlation between the total scores of the TOWM and wheelie test was positive and high (ability score r = 0.84; P < 0.001, quality score r = 0.88; P < 0.001, anxiety score r = 0.81; P < 0.001), except for the moderate correlation between the total time scores of the TOWM and the wheelie test (r = 0.47; P = 0.08).

Interrelationships of the scores of the four scales within the TOWM

The ability score was negatively correlated with the time score (r = −0.45; P = 0.09), with the anxiety score (r = −0.38; P = 0.06), and it was highly and positively correlated with the quality score (r = 0.97; P < 0.001). The quality score was strongly and negatively associated with the time score (r = −0.74; P = 0.01) and with the anxiety score (r = −0.45; P = 0.07). Little or no correlation was found between the TOWM anxiety score with the time score (r = 0.20; P = 0.48).

Interrelationships of the score of the four scales within the wheelie test

Comparable to the TOWM, the wheelie test ability score was negatively, and even stronger correlated with the time score (r = −0.70; P= 0.003), with the anxiety score (r = −0.43; P= 0.03), and it was highly and positively correlated with the quality score (r = 0.94; P < 0.001). The wheelie test quality score was strongly and negatively associated with the time score (r = −0.76; P = 0.01). No correlation was found between the wheelie test quality score with the anxiety score (r = 0.19; P = 0.45), and moderate correlation was found between the wheelie test anxiety score with the time score (r = 0.32; P = 0.25).

Wheelie test as a predictor for the TOWM (predictive validity)

A linear regression analysis resulted in a high explained variance of 71.3% for the ability scores, and an even higher explained variance of 78.7% for the quality scores. The regression analysis of the anxiety scores provided explained variance of 66%. However, for the time scores, a linear regression analysis resulted with explained variance of only 22.3%.

Association between the TOWM and the wheelie test scores with wheeled mobility-related variables (construct validity – research question 3)

Correlations between the TOWM and the wheelie test ability, quality and anxiety scores and ‘perceived self-efficacy in wheeled mobility scale’ total scores varied from fair to moderate (Table 2). No correlation was found between TOWM total time score and the ‘perceived self-efficacy in wheeled mobility scale’ total score (r = −0.20). Both correlations of the tests’ total anxiety scores with ‘perceived self-efficacy in wheeled mobility scale’ were negative, meaning that lower values of anxiety go with higher self-efficacy in wheeled mobility perceptions. Total scores of both tests for all four scales showed fair to moderate correlations with ‘time since injury’. However, the highest values were found between both tests’ quality scores with ‘time since injury’ (TOWM r = 0.45, wheelie test r = 0.57) (Table 2).

Table 2.

Pearson’s and Spearman’s coefficient of correlation showing the relationship of the Test of Wheeled Mobility (TOWM) and the wheelie test scores with wheelchair mobility-related variables

Variable	Time since injury (years)	SEWM	Sport participation after injury
Test and scale	Corr. (Sig.)	Corr. (Sig.)	Sig. (Mean diff)**
TOWM ability scores	0.31* (0.09)	0.36* (0.05)	0.001 (−5.3)
TOWM quality scores	0.45* (0.04)	0.42* (0.06)	<0.001 (−18.9)
TOWM time scores	−0.34* (0.22)	−0.12 (0.67)	NA
TOWM anxiety scores	0.02 (0.92)	−0.56* (0.003)	0.26 (13.4)
WT ability scores	0.42* (0.02)	0.37* (0.04)	<0.001 (−3.5)
WT quality scores	0.57* (0.007)	0.37* (0.11)	0.0001 (−17.4)
WT time scores	−0.28 (0.30)	−0.21 (0.45)	NA
WT anxiety scores	0.009 (0.96)	−0.50* (0.01)	0.31 (3.04)

Corr., correlation (Pearson/Spearman); Sig., significant (based on a t-test for equality of means, two-tailed); WT, wheelie test; NA, not applicable.

Fair and above degree of relationship.

Mean diff: mean difference (athletes versus non-athletes).

Associations between wheeled mobility and ‘participating in sport after injury’

Ability and quality scores showed significant differences between the active and the non-active individuals in both tests. Those who were not active in sport scored on an average 19 points less on the TOWM, and 17 points less on the wheelie test, compared to the active participants. Since the non-active in sport participants did not complete all six time score tasks, time score comparison between the active and non-active group could not be performed. No significant differences were found between the two groups based on the anxiety scores.

Discussion

Our main findings supported the feasibility of both tests in terms of duration and costs. Convergent validity was confirmed by the positive correlation between the TOWM and wheelie test total ability, quality and anxiety scores. Construct validity was confirmed by fair to moderate correlations between both tests’ scores with time since injury, self-efficacy and sport participation after injury.

Regarding the feasibility of the tests, the duration of a test is a consequence of the number and complexity of the skills included.² Testing the TOWM’s 30 tasks took, on average, 24.7 minutes, which is reasonable and shorter than other existing wheeled mobility tests (e.g. the Wheelchair Skill Test (WST 2.4)¹⁵ assessed 50 skills within 27 minutes, and the Wheelchair Users Functional Assessment (WUFA)¹⁶ assessed 13 skills in 1–1.5 hours). Based on the reported test times in Fliess-Douer’s et al. literature review,² the wheelie test developed in this study is the shortest wheeled mobility test.

A preference was made for equipment that is already available in most rehabilitation centres and training facilities and a choice was made to include materials that were limited in cost and space requirements. For the wheelie test, less expensive and simpler equipment was required.

In general, the skills were found to be safe, but there could be a risk of tipping backwards in certain tasks; therefore several safety notes were added to the test protocol following this study.

The type of wheelchair has an important impact on carrying out a task, especially when testing level of performance. Aiming the wheeled mobility test at daily activities, the use of the participants’ own wheelchair was chosen and it probably better reflects the participant’s wheeled mobility performance levels.

Accessibility to the test protocols is important in order to understand the instructions and settings of the tasks. This would also allow rehabilitation professionals and other researchers to use the same test, and may promote the use of a universal test of wheeled mobility (www.scionn.nl/inhoudp28.htm).

Scoring the ability score was easy, required minimal training and the results were easy to interpret and compare. The ability scores of the TOWM did not cover the entire possible score range. The absence of lower scores might be because the participants already received a minimum amount of wheelchair skills training as they had been discharged from rehabilitation for at least two months. It is important to state that there was no task which none of the participants could perform. The ability score enabled differentiation between participants’ wheeled mobility abilities; however, five people (paraplegics, top athletes) had reached the maximum ability score on the wheelie test.

Evaluating qualitatively the maturity pattern of wheeled mobility skill performance based on selected ‘performance criteria’ is a unique method that was developed in the current study and is different from all other existing scoring systems presented in previous wheelchair skill tests. This scoring method offers meaningful feedback to the participant and the therapist about the mistakes made and how to correct them in future trials.

The fact that only the active participants in the current study achieved all six possible time scores should be noted. It is questionable whether time scores are relevant at all when measuring skill performance. Time is a measure that can be used to clearly document the progress of an individual when repeated measures are taken.¹⁷ But from a rehabilitation perspective, therapists want to improve the quality of wheeled mobility performance rather than the time taken for executing a skill. Routhier et al.¹⁸ stated that one should be careful with the use of time in short tasks. If a wheelchair user takes 15 seconds instead of 10 (an extra 50%) to achieve a task, it does not necessarily mean that the wheelchair user has difficulties.

The high correlation found between the TOWM and wheelie test ability, quality and anxiety scores (convergent validity), supported by the prediction power of the wheelie test, indicate that the ability to master a wheelie is related to the functional tasks of the TOWM. The wheelie test has proven to be easy to test and much shorter than the TOWM; it enables differentiation between experienced and less-experienced wheelchair users and it encourages the participants to master their wheelie in order to integrate and coordinate the wheelchair, the body and the environment for optimal mobility. Further research is necessary in order to determine whether training wheelie skills will also result in a better performance on the functional tasks of the TOWM. A positive result may suggest that the shorter and more economical wheelie test may serve as an alternative for the TOWM.

Interrelationships of the four scale scores within a test showed that the ability score within both tests was positive and highly correlated with the quality score, demonstrated a relation between the ability to perform wheeled mobility task and the maturity of wheeled mobility skill performance. This logical finding was further supported by the negative correlation found within both tests’ ability and quality scores with the time scores, which indicated that those who were able to perform better also performed faster.

Correlations of the anxiety scores within both tests with the ability scores were negative, indicated that less anxiety was associated with higher wheeled mobility abilities. These correlations supported our pre-assumption that psychological variables may affect wheeled mobility abilities. Psychological variables such as anxiety should be measured and be considered when assessing wheeled mobility. However, the non-correlation found within the wheelie test anxiety score with the quality score, and within both tests’ anxiety scores with the time scores may indice for a lack of sensitivity, stability and consistency in the outcome related to the anxiety variable, tested in the current study with a visual analogue scale (VAS). Anxiety is expected to be related to the quality and speed of wheeled mobility performance; previous studies focusing on the influences of anxiety on movement behaviour patterns while executing a complex whole-body task (e.g. climbing a wall), provided evidence that under the influence of anxiety, performance was characterized by less fluent movements, less efficiency, increases in performance time and a less fluent displacement of the body’s centre of gravity.¹⁹

The significant correlation found between both tests’ ability, quality and anxiety scores with ‘time since injury’ (construct validity) is only logical, since more years of experience will probably lead to better wheeled mobility performance. There might be a critical amount of experience necessary in order to reach one’s maximal wheeled mobility level. But it is also possible that the high correlations between wheeled mobility and ‘time since injury’, as found in this study were because wheeled mobility skill training in rehabilitation was not optimal.

The significant fair to good correlations found between wheeled mobility ability, quality and anxiety scores, and perceived self-efficacy, is consistent with the result reported by Horn et al.,²⁰ who found in their retrospective study that self-efficacy was significantly associated with degree of impairment and disability.

The large distinction in wheeled mobility performance between people who are active in sport and those who do not is in accordance with studies that confirmed higher wheeled mobility perceptions among athletes with a spinal cord injury compared to non-active wheelchair users.¹² Participation in sports promotes interaction with other people in similar situations and may improve wheeled mobility techniques.¹³ It can be expected that sport activity itself has a positive impact on wheeled mobility skill level through an increase in strength, aerobic capacity, functional independence and a general healthy lifestyle.^15,21

The limitations of this study should be noted. Only associations were investigated; no causal relations as well as direction of associations were discerned among a relatively homogeneous and small group of manual wheelchair users with a spinal cord injury only. Another limitation of the study is the small sample size and the absence of females in the sample. In addition, it is unclear whether both tests are applicable in early rehabilitation. The validity of the tests should be investigated in a larger and more diverse sample, including spinal cord-injured patients during their rehabilitation period. The TOWM and the wheelie test should also be used to assess the effectiveness of intervention programmes in a randomized controlled trial. Further research should focus on deriving norms according to lesion level. This should enable clinicians and researchers to make a better prediction about someone’s maximal achievable functional level of wheeled mobility.

For clinical practice it is possible to recommend an integration of all the wheelchair skills presented in the TOWM into wheelchair training programmes, since these skills were considered to be the most relevant for participation in daily life. The quality assessment score sheet may be a useful tool in guiding wheelchair users into a more mature skill performance.

Clinical messages

The Test of Wheeled Mobility (TOWM) covers the range of wheeled mobility skills that are necessary for wheelchair users with spinal cord injury.

The wheelie test is the shortest wheeled mobility test and it differentiates between experienced and less-experienced wheelchair users.

Quality assessment prevents ‘ceiling effects’ when assessing wheeled mobility among individuals with paraplegia.

Footnotes

Appendix 1 – Several tasks in the Test of Wheeled Mobility (TOWM) and the wheelie test

Acknowledgements

The authors wish to thank Dr Joeri Verellen, Maarten Abeel, Elien Baeten, Melina Boeckmans, Thomas Witdouck and the eight wheelchair users with spinal cord injury who comprised the ‘brainstorming team’, for their assistance in providing relevant feedback, inspiring ideas and contributing to the development of the new instruments.

Contributors

OFD initiated the study, designed the study, conducted the research, completed the statistical analysis and drafted the manuscript. YCV initiated the study, designed the study, was involved in implementing of the assessment, and critically reviewed the manuscript. LvdW initiated the study, designed the study, monitored progress and critically reviewed the manuscript.

Conflict of interest

None declared.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

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