Chapter 2 Assessment

The assessment process should include chair operation, maintenance, and safety. A consumer may use more than one device or walk part of the time.

I once worked with a woman who had an electric chair for long trips, a manual chair for when she had to travel in a car, a walker, quad-cane, and was learning to walk with two support canes. Students should be assessed with each of their devices. The assessment process should also involve consultations with a PT and an OT.
Scott Crawford

The assessment sequence presented here is not set in stone. Make adjustments to fit the needs of each student. Students who enter training with little to no travel skill or experience may only complete the initial portions of the assessment. Good travelers who have a lot of experience need a more thorough assessment.

Intake Interview

During the intake interview, ask the student about her eye condition, goals, health, stamina, living situation, and previous training. Students who feel they cannot complete portions of O&M training due to poor stamina, strength, or balance should be asked if they have considered using ambulatory aides. Many people feel that their vision precludes them from using aides. Others may have acquired aides that are not appropriate for them. Instructors should ask students where they acquired the aides and how much training they have had with them.

A checklist of skills for wheelchair users is included in Appendix A. Some of the skills are listed as being performed with assistance. If a student cannot perform a particular task herself, she will benefit from being able to describe the skill to a guide or other person who may assist her. Other skills on the checklist are broken down into the subsets of the particular skill. For example, negotiating and opening doors is divided into 19 different skills. Small differences in negotiation may cause problems for some students. Beginning students may have an easy time with doors that open to the right, but due to their disability, struggle with doors that open to the left.

Skills need to be assessed when the student is moving forward and backward in the chair. Wheelchair users frequently get into situations where they cannot turn around and must back out. Many consumers, especially those who have never driven a car, struggle when making adjustments while backing up. Small offices, elevators, train doors, and buses are examples of areas where the consumer may have to back up or back in to facilitate exiting.

The Wheelchair

The practical portion of the assessment of wheelchair skills should start with the student's familiarity with the chair.

  1. Can the student operate the chair controls?
  2. Can the student operate the brakes?
  3. Can the student name the chair accessories?
  4. Is the chair clean, lubricated, and in good working order?
  5. Can the student fold or disassemble the chair?
  6. Can the student put the chair back together? If not, can the student describe the process to an assistant?

Tasks that require vision may need to be reassessed under different lighting situations. Dim lighting, bright sun, or glare may impede the student's ability to complete a task or utilize a chair control. Often, consumers who can read the mode and battery charge indicators while indoors struggle outdoors in bright sunlight.

CAUTION: Many students do not realize the importance of chair safety features. Students have ignored seatbelts, buckled them behind the seat, or removed them entirely. Other students did not realize that they had faulty brakes on their powered devices until they attempted to stop on a steep slope and the chair suddenly turned sharply to the side of the faulty brake. On manual wheelchairs, anti-tip bars (anti-tippers or wheelie bars) are very important to prevent the chair from flipping over backward on a steep upslope, or when the students push hard on their wheel rails with their weight moving to the back of the chair. Anti-tip bars can be turned up for climbing curbs, to make the chair easier to store in a vehicle, or just to get them out of the way (it is easy for a person pushing a wheelchair to kick the anti-tippers). It is highly recommended that anti-tippers be in the down position whenever students are pushing themselves, but especially when on a slope or outdoors.

Movement

Assessment of movement should start with moving forward, stopping, backing up, and stopping again. This seems extremely basic, but the ability to move in a straight line is critical for navigating tight spaces. The transition from moving forward to moving back, or vice versa, is hard because the chair will wiggle as the casters turn around. With practice, the student can learn to minimize and compromise for the wiggle. Wheelchairs with larger caster wheels will move farther out of line than those with smaller caster wheels.

Watch Video 2a: Assessment: Maintaining the line of travel when reversing direction.

To back into tight spaces, such as wheelchair lifts or narrow doorways, the student will have an easier time if she approaches the opening from the side and turns 90 degrees instead of moving forward and then trying to back up. By turning first, the casters are already halfway through the turn and will fall into line with the large wheels with less movement out of the desired line of travel.

For manual chairs, if the student can use her legs, wheelchair movement should be assessed with the student using her hands only, and then again using her hands and her feet to assist. Hand position on the chair rails should be checked. Is the student holding the rails or the tires? Is she reaching too far back to grasp the rails?

Turns Around Obstacles

Most consumers don't think about the various types of turns that chairs can make. Descriptions of the various turns are in the chapters on Chair Operation and Navigating Tight Spaces. Chairs, trashcans, or other easily movable obstacles should be used to assess the student's ability to navigate around obstacles. After demonstrating the ability to turn with taller obstacles that the student can reach out and touch, the student should repeat the turns with low obstacles, such as phonebooks, to simulate working around curbs. The student should be able to do the following:

  • drive straight forward/straight back between two obstacles

    Watch Video 2b: Assessment: Moving forward and backward between two obstacles using an electric wheelchair



  • turn between two obstacles, turning right and left

    Watch Video 2c: Assessment: Turning 90 degrees to navigate an opening



  • back between two obstacles, turning right and left

    Watch Video 2d: Assessment: Turning 90 degrees to back through an opening



  • drive around the obstacles in a figure 8 pattern while moving forward

    Watch Video 2e: Assessment: Moving forward in a figure 8



  • drive around the obstacles in a figure 8 pattern while moving backward

    Watch Video 2f: Assessment: Moving backward in a figure 8



Keep in mind throughout the assessment and learning process that some students find it easier to turn in one direction than the other. This may be due to better vision in one eye, the ability to turn toward or away from the joystick, a better range of motion on one side, or numerous other variables. Students who rely on their canes for orientation may have an easier time when a backward turn is toward the opposite side of the joystick, or toward the cane hand. If the student doesn't understand the movement to be performed (e.g., figure 8), the instructor should walk through the obstacles and guide the student through the desired path, either visually or auditory. This may help the instructor distinguish between a student's confusion with the instructions given and problems with navigation around the obstacles. There is always the possibility that a student has a concept development deficit or a problem with spatial relationships.

Once the student has proven that she can navigate between movable objects, assess her ability to navigate doorways into rooms or offices. The assessment should include traveling into a room where the student can turn around and drive out, as well as a room where the student does not have the space to turn around and must back out. Also assess the student's ability to back into the rooms. Some students struggle when instruction switches from movable obstacles to actual doorways. A student may forget to continue to use the landmarks that indicate when to turn around obstacles.

Watch Video 2g: Assessment: Moving through and turning around stationary objects

Another problem students have is being able to correct for mistakes, especially when they back out of doorways. Students who have never driven a car may struggle with knowing which way to turn the chair to make it go through the opening. It may be confusing that if they back up and need to move to the left, they actually need to turn the chair to the right. It may be more beneficial to tell students which way to turn their feet than to tell them which way the back of the chair needs to turn.

Watch Video 2h: Assessment: Backing through stationary objects

Students who are learning to use scooters need to be assessed on their ability to travel forward, backward, and make all the same turns around obstacles as described for electric wheelchairs.

Watch Video 2i: Assessment: Navigating tight spaces with a scooter

Emergency Stops

Early in the assessment process, an instructor should establish how he can stop the chair if the student puts herself in danger. (See chapter 7 Consumer Safety.) The instructor may not always be in the ideal position to stop the chair. Thus, he needs to be able to stop the chair by different methods based on his position in relation to the chair.

Some powered chairs have secondary controls that can be used by an attendant to drive the chair. The secondary control can stop the chair or steer it away from an obstacle. Alternatively, a kill switch added to powered chairs allows the instructor to stop the chair as needed. Instructors should remember that powered devices do not stop immediately. The instructor needs to activate the kill switch a few feet before the student reaches the obstacle/hazard.

Speed

There are several different ways to determine if the student is driving too fast. The chair speed should be reduced until the student consistently detects the obstacle at an adequate distance to stop before she runs into it. After assessing the student's ability to detect the obstacle and stop, assess her ability to stop and then pull up to the obstacle. Many students have to turn the chair speed down to pull up accurately to obstacles without over shooting. It is important to assess this indoors with movable obstacles before trying to assess the student's ability to pull up to walls, doors, or especially drop-offs.

Watch Video 2j: Assessment: Reaction time to cane contact

  1. Obstacle Course: Place obstacles on the floor, such as chairs, trashcans, phonebooks, old canes, and old extension cords, and have the student drive up to the obstacles to see if she detects them. If the student runs into the obstacles, she is driving too fast for whatever method of obstacle detection she is using. If the student has mastered detecting and stopping for an obstacle, assess her ability to navigate through and around several obstacles set up in an obstacle course. If the student detects the obstacles visually, use full or lower field occluders to determine if the student can detect the obstacles with her cane. The decision to use or not to use occlusion should always be made with the full participation of the student. Partial occluders can be made easily by putting tape or Post-it® notes on the bottom half or two-thirds of a pair of sunglasses. The sunglasses should be transparent enough that the student can still see through them. Leaving the top portion exposed allows the student to use the walls or lights to maintain her general orientation, but still have to rely on her cane to keep track of the things she is driving around. Lower field occluders are good for people who have panic attacks when they put on full occluders. If using full occlusion, it is easier to do the assessment in hallways, where the student is limited on where she can go and is more likely to hit the obstacles without input from the instructor. If the student has difficulty with the directionality of the course, use a portable sound source. If the student runs into the obstacles, the instructor should take note, but continue on to the next stage of the assessment. .

    Watch Video 2k: Assessment: Obstacle courses



  2. Verbal Prompts: Determine a landmark in the student's path. When the student's cane tip reaches the landmark, say, "Stop." If the student's chair passes the landmark before coming to a stop, she is driving too fast.
  3. Two Cane Method: Walk in front of the student with a cane pointed back toward the student. At some seemingly random point, allow the student's cane to hit the instructor's cane. Tell the student to stop when contact is made.
    • When contact is made, keep moving, but note where the student's cane tip was when contact was made. The instructor may choose to make contact when the student's cane tip is at an easy-to-remember landmark such as a transition in the flooring, a post, or a doorframe. If the front of the chair passes the landmark, the student is driving too fast. The instructor should switch landmarks to make sure the student is not keying in on the landmark instead of reacting to information from her cane.
    • When contact is made, the instructor leaves the tip of his cane in place. Once the chair comes to a stop, the instructor stands his cane straight up and puts it against the student's cane. Holding the two canes together at the point where they touch, the instructor picks up both canes. The student feels the distance from where the two canes touch to the tip of her cane. This gives the student an idea of how far her chair traveled after she recognized the need to stop.

Part of the assessment should include observations to determine if the student independently changes her speed settings as situations change, or if she needs prompts to make the appropriate changes. Also, the instructor should vary the point in the cane arc at which the canes make contact. Some students recognize cane contacts directly in front of them, but fail to react to cane contacts made to either side of midline. Other students react to cane contacts when the cane swings one direction, but misses the contacts made when the cane swings the opposite direction.

Watch Video 2l: Assessment: Two cane method

Turns at Corners

A common tendency is to turn too early and hit the corner. If the student has problems with corners while indoors, she needs to be monitored closely when she attempts turns on sidewalks. There is a tendency to start the turn when the cane detects it or when the eyes are at the corner. Depending on how sharp the turn is and the type of turn used, the student may need to let her shoulder or some other landmark pass the corner before starting the turn.

Doors

Students must be assessed at a wide variety of doors. Differences should include the following:

  • right versus left opening
  • push versus pull
  • spring-loaded versus free
  • heavy versus light

The amount of space around the door may also cause problems. Narrow hallways or stair landings can limit the positions from which the student is able to reach the door. If doors open into the top of a stair landing, the student may miss the top stair. If a pull door has no space to the handle side, the student may not be able to reach the handle without blocking the door.

Elevators

Students frequently struggle with getting on before the doors close, reaching the buttons, knowing when the door reopens, and turning around in the elevator. In general, it is recommended that wheelchair users back onto elevators. This leaves them facing the doors and the buttons. It is advantageous to be facing forward when one exits the elevator. In some locations, there are drop-offs outside the elevator. If the student struggles with navigating the doorway, she could end up missing her floor. Facing forward also makes it easier to navigate through people who are waiting to get on the elevator. If a student does back off of an elevator, she must turn around as soon as possible when the chair clears the elevator doors and turn to face the desired line of travel.

Building Ramps

When assessing the student's navigation of building ramps, there are several things to keep in mind. Students may have an easy time with gently sloped ramps, but struggle with steeper ramps. Some students may do well with ramps that have handrails but struggle on ramps without them. Controlling descent speed is sometimes a problem. Students may also have trouble with rolling backward when attempting to go up a ramp.

Sidewalks

Assessment on sidewalk travel should include the following:

  • maintaining position on the sidewalk
  • detecting drop-offs to the front and to the side
  • detecting/navigating obstacles
  • position on the sidewalk when crossing driveways
  • detecting overhanging hazards
  • navigating through pedestrian traffic

Curbs and Curb Ramps

Students need to learn to navigate curb ramps that are parallel, perpendicular, or diagonal. Some students have trouble with curb ramps when approached from the side.

Street Crossings

Depending on the student's skill level, street crossing assessment could include the following:

  • 4-way stop intersections
  • 2-way stop intersections
  • uncontrolled intersections
  • light-controlled intersections
  • intersections with or without curb ramps
  • dedicated turn islands
  • dedicated turn arrows

The assessment should also determine if the student can tell how far away the traffic is and whether or not it is safe to wait in the street.

Transportation (personal vehicle/bus/train)

Many consumers are not aware of the transportation resources available in their community. They may be aware of the fixed-route services, but not aware of para-transit, councils on aging, medical transportation, or other public entities that provide accessible transportation. All students should demonstrate the ability to board lifts and navigate to wheelchair spaces. They should understand how the chair is secured or strapped down, including where to attach the straps to the chair. For scooters and manual chairs, students should learn how to assemble and disassemble the chair so it can be put in a car.

Route Planning

In addition to the information ambulatory consumers get, wheelchair users need to ask about route accessibility, including transportation and architectural barriers.

Feasibility of Using Powered Chairs (electric wheelchairs or scooters)

For a student who wants to use a powered device, one method to determine if she has the ability to use the device is to put her in a manual wheelchair and push her through an assessment route. The student should be told to tell the instructor when to turn, stop, or slow down. The student can do so verbally or by use of hand signals. Having the student point in the direction she wants to go will test her ability to adjust her line of travel. Lifting the hand straight up can mean stop, while only lifting it part way up may mean slow down. If needed, the student can use a cane in the free hand. Other students may be tested on the ability to use residual vision to maintain their orientation and position on sidewalks. By having the instructor push the chair, the student can be tested on her ability to react to chair movements at higher speeds, separate from her ability to move the chair herself. The instructor should intentionally push the chair toward obstacles, walls, front drop-offs, and side drop-offs. If using vision to maintain the line of travel, the student should be pushed through varying light conditions, including indoor and outdoor environments. School-age children may also need to be pushed through grassy areas such as playgrounds.

Consultations

If possible, the instructor should talk to the student's OT or PT. The OT and PT can provide valuable information on the student's functioning level, strength, stamina, and limitations. O&M Specialists should be certain to reinforce the techniques suggested by the PT or OT. If the student is not seeing an OT and PT on a regular basis, it may not be feasible to meet with these professionals during the assessment period. The assessment report can include referrals to a PT or an OT. Vocational Rehabilitation Services may need the request for referral in a written report before it will be able to pay for the visit. If the funding source for the PT or OT is Medicare, Medicaid, or private insurance, the student may need to visit her primary care physician for a referral.

« Chapter 1 2 TOC Main Menu Chapter 3 »