Colleen Gillette, PT, DPT, ATP, adjusts lateral support for client.

Colleen Gillette, PT, DPT, ATP, adjusts lateral support for client.

Wheelchair prescription used to be viewed as a one-size-fits-all type of order; an “off-the-shelf” model would be prescribed for individuals in need of a wheelchair with little customization offered. This solution is no longer adequate, and wheelchair prescription has evolved into a highly customized process. Individuals now undergo lengthy seating evaluations that involve not only the client but a distinct team of professionals. Members of this team include a seating specialist, vendor, physical therapist, occupational therapist, and other medical professionals who work together to determine the most appropriate seating platform for a mobility device user. All this is necessary because a client’s posture and fit in the wheelchair will greatly determine the user’s success in accessing the environment. The customization of the mobility device to the client plays an important role in providing the correct level of comfort, support, and functionality for clients, as well as enabling them to access recreation and leisure activities.

ALL POINTS PERSONALIZED

The base of the chair can be customized to be manual or power depending on the client’s functional ability. Power chairs can be driven in a multitude of ways such as sip and puff, head array, or joysticks. These options also can be customized based on the client’s available function, and built to use any functional body site on the user as the access point. Push rims on manual chairs can be customized based on the user’s hand function, and allow the most efficient grip for propulsion. Wheels are available in a variety of materials that can change the weight of the chair and life of the wheel itself. There are now even options such as folding wheels that allow increased independence with mobility while decreasing space required for transport.

The cushion of the chair can be widely customized based on positioning needs, wound history, comfort, and overall weight of the chair. The options include gel, foams, air-filled, and hybrid. Depending on what type of positioning is needed, foam cushions provide a more stable base for the client to sit on and require less maintenance compared to air-filled cushions. However, air-filled cushions are able to provide greater pressure relief and therefore are more appropriate for individuals with an increased risk of skin breakdown.

Backrests, too, can be highly customized to meet the individual user’s needs. Manufacturers offer standard backrests in a variety of contours that allow for a shallower or deeper positioning, as well as provide support for areas in the high or low back. Custom molded backs also can be formed for individuals who have highly specific postural needs. Lateral supports can be added for decreased trunk control or improved positioning for scoliosis or other positioning abnormalities.

The armrests of the chair can be molded into troughs to support the client’s upper extremities when in a power chair if they are using head controls. Manual wheelchairs can be adjusted to have swing away, flip up, or removable type armrests depending on what works best for transfers.

Optimizing client posture allows for optimal function. Function is important for wheelchair clients to make daily living easier and more accessible. Depending on the type of chair, there are specific options and accessories that can help the client personalize their means of mobility, and ultimately optimize their independence.

METAL MATTERS

Manual wheelchairs come in different types: standard, lightweight, and ultra lightweight. Standard chairs are the least customizable and are the heaviest, weighing more than 35 pounds, and are typically used only in a short-term situation. Lightweight manual wheelchairs are lighter than the standard wheelchairs (30-35 pounds), and can be more customizable to the client. However, lightweight manual wheelchairs do not offer the client many options. Ultra lightweight manual wheelchairs are the most customizable and weigh the least (less than 20 pounds). Titanium and aluminum are the metals used to manufacture most of today’s models.

With a custom ultra lightweight manual wheelchair, there are many options afforded to clients that will ultimately help optimize their independence. Many styles of cushions, hand rims, backrests, wheel locks, footplates, wheels, and other options are available to customize the function of the wheelchair for the client. For long-term, lifetime clients, an ultra lightweight manual wheelchair is the ideal option to achieve optimal function.

OPTIONAL POWER

Power assist options are available for wheelchair clients who have decreased upper extremity strength or endurance. Power assist capabilities can be accessed by adding mechanisms to the wheels, and made available through joystick control, or at a push of a button that engages a third wheel connected to the back of the wheelchair. These options can increase the client’s ability to propel longer distances, conserve energy, and decrease risk of upper extremity overuse injuries.

Power wheelchairs offer a variety of options and types of controls that accommodate various levels of user ability. Head array, chin movement, respiration, switches, joysticks, or tongue movements can drive, adjust modes, and connect with other electronics to increase the client’s independence in the environment. There are a variety of choices in joystick options, including dome, mushroom head, straight, u-shaped, ball knob, and custom. Types of control can be mounted in various positions on the chair, and additional mounts can be used to access tablets, cell phones, and other electronics or items that the owner uses.

ACCESSORIZED FOR LIFESTYLE

Therapists who recommend power mobility devices today have access to sophisticated technologies that can serve users’ needs and accent their lifestyles as never before. One such technology is seat elevators, designed to allow clients to reach into cabinets, interact with peers at eye level, and perform everyday tasks that require adjusted heights of the wheelchair. Other helpful technologies include tilt-in-space, recline, and elevating legrests that help distribute pressure and allow for positioning changes for clients affected by pain, sensory impairments, edema, and decreased functional mobility.

For pediatric clients, there are power wheelchairs that transition clients from the wheelchair to the floor, so the users can interact with their peers and engage in age-appropriate play. There are different types of drive for power wheelchairs, including front-wheel, mid-wheel, and rear-wheel drive. Mid-wheel drive provides the tightest turning radius, while front-wheel drive provides optimal navigation over uneven terrain and ability to navigate tighter turns. There is also an option for rear-wheel drive, although it is less frequently issued due to increased turning radius and decreased stability compared to other options. Batteries, too, represent another welcome advance among today’s power mobility users, providing long service life for a high level of reliability.

Environmental control units can be used with power wheelchairs to increase function within the home for clients. They can be used to control televisions, temperature, appliances, lights, phones, beds, and other electronics within the home to increase a client’s independence.

Wheelchairs and adaptive equipment become an extension of the client’s self. Customizing a chair to fit a person’s personality can greatly increase the acceptance of the chair by the individual client, as well as by those around that person. Power and manual wheelchairs now come with many customization options such as colors for frames and spoke guards and seat covers with designs. With the simple option of choosing the color or design, a client often takes increased ownership and pride in the chair.

STANDING WHEELCHAIRS

Being able to stand at eye level with peers and colleagues is invaluable in the workplace and home, and leads to improved social implications. Innovative technologies such as standing wheelchairs allow clients the opportunity to perform supported standing in any environment they choose. With this option, a client can stand to give presentations in the business environment, or a lecture in a classroom setting, or return to activities of daily living such as cooking and household chores. This greatly increases quality of life, self-image, and feelings of professional competence. This option also provides all the benefits of therapeutic standing and weight bearing, including improvements in bone, cardiovascular, and bowel/bladder health, as well as pressure relief. All this can be accomplished without the need for additional equipment of supported standers, increased transfers, or possible caregiver assistance.

OUTDOORS WITH CONFIDENCE

Power wheelchairs and manual wheelchairs now have many options that allow the client to engage in environments outside the home. Increased horsepower in power chairs and more durable flat-free tires in both manual and power mobility device models now allow clients to cross terrains such as gravel and some dirt surfaces, as well as navigate slopes and up to 3-inch obstacles.

For the outdoor enthusiast whose mobility needs exceed everyday terrain, there are exciting options. Some technology advances replace traditional wheels on chairs with treads similar to snowmobiles or tanks. These treads allow clients to traverse the roughest terrain such as sand, mud, snow, and rocks. Additionally, many companies now are providing adaptive hunting and fishing items that allow all individuals to continue to enjoy outdoor pursuits despite mobility or upper extremity concerns.

CUSTOMIZED FOR KEEPS

It is imperative for a client to have optimal positioning for function and independence. “One-size-fits-all” wheelchairs are no longer appropriate for clients with long-term seating needs. Wheelchair prescription needs to be client-based, taking into consideration each individual’s posture, function, and recreational needs. With these customizations, clients are able to maximize independence in home and community environments. RM

Colleen Gillette, PT, DPT, ATP, has been a physical therapist with the International Center for Spinal Cord Injury (ICSCI) at Kennedy Krieger Institute since July 2012.  She completed her Doctor of Physical Therapy at Duke University in Durham, NC, and her Bachelor of Science in Health Sciences at Lee University in Cleveland, Tenn. She is experienced at treating patients across the lifespan with various neuromuscular diagnoses, with particular interests in pediatrics and seating and mobility.

Sarah Murdoch, PT, DPT, ATP, has been a physical therapist with the International Center for Spinal Cord Injury (ICSCI) at Kennedy Krieger Institute since November  2012. She received her Bachelor of Biology and Health Sciences and Doctorate of Physical Therapy from Duquesne University in Pittsburgh. Her clinical interests include functional electrical stimulation, aquatic therapy, and seating and mobility. She is experienced as a land and aquatic therapist for children and adults with neuromuscular diagnoses.

Erin Neuland, PT, DPT, has been a physical therapist since 2011 working in an adult inpatient rehabilitation center prior to coming to the International Center for Spinal Cord Injury (ICSCI) at Kennedy Krieger Institute in October 2012. She received her Doctorate of Physical Therapy from Old Dominion University in Norfolk, Va, and her Bachelor of Arts degree in Mathematics from Hood College in Frederick, Md. She has a particular interest in aquatic therapy, casting, gait training, and early upright mobility. For more information, contact [email protected]