PHOTO CAPTION: When considering options, it is important to keep in mind the impact of product innovations on the client’s long-term needs.
Taking advantage of advances in complex rehab technologies for manual and power wheelchairs.
by Kathy Fisher, OT, and Steffen Tiskus, PT
From various types of tilt features to sensors that provide collision avoidance, today’s wheelchairs provide a plethora of options. To help parse the choices now available to best meet clients’ needs, Rehab Management presents a look at advances in complex rehab from two experts who specialize in technologies for power and manual wheelchairs.
Manual Wheelchairs for Complex Needs
By Kathy Fisher, OT
Manual wheelchairs have developed over the years to incorporate features to address the needs of clients with complex needs. The use of dynamic tilt-in-space chairs has grown dramatically, and they are now widely used not only in facilities but by clients in the community, in their own residences or residential group homes. Clinically, tilt chairs offer the following benefits: gravity assistance for positioning, reduction of trunk compression, postural alignment, pressure redistribution to manage skin issues, positioning to optimize respiration and swallowing, reduction of sliding, and promotion of function and social engagement.
Tilt wheelchairs are not all created equal. There are different styles of tilt chairs ranging from basic (single pivot tilt) to meet basic positioning needs to complex (center of gravity shift).
The selection of an appropriate chair and features is based on the findings of a full physical, functional, and environmental assessment of not only the patient’s needs but those of the caregivers who will manage the chair.
Single-pivot tilt chairs have been the traditional style of chair for clients who need dynamic positioning to manage postural support, pressure redistribution, and prevention of sliding. These are often seen in long-term care facilities where cost is a factor and where there is little need for ongoing changes. Typically, we see these chairs being used for clients whose postural needs can be managed with modular seating and where independent mobility is not the goal. However, more options are available today.
Current trends in tilt wheelchairs are now focused on portability, positioning for independent mobility, and accommodation of changing client needs including growth, management of uncontrolled movements, and accommodation of complex custom seating.
Portability—Folding tilt chairs were initially developed for the pediatric market to allow parents the flexibility to not only manage the seating needs of the child but also allow chairs to be more easily transported. These chairs offer lightweight frames that allow for growth and are easily collapsed. There has become a growing need to also offer this flexibility for adults who may not have access to accessible transportation. We now see manufacturers offering full adult sizes, but with some restrictions on weight limitations.
Independent Mobility—Center of gravity adjustments are achieved through wheel positioning to promote optimal propulsion and seat height adjustments to allow clients to be able to reach the rear wheels. “Dynamic tilt” has become the term used to describe chairs that tilt from the rear of the seat to maintain front seat to floor height so that those clients who are foot propelling can maintain their foot contact even in a tilted position. Typically, these chairs limit tilt range to 20 degrees, reducing the full benefit of pressure redistribution.
Enhancement of Movement—The innovation of dynamic wheelchair components allows the chair to absorb impact of body movements and tone. Incorporating springs/polymers into the chair structures allows back, knee, ankle, and head supports to move with the body.
Accommodation of Complex Client Needs—The “Rotational tilt” style of chairs has been developed to reduce the overall length of chairs by allowing the tilt to shift within the frame. This allows the chair to be more maneuverable, but also reduces the negative vestibular impact for the client who may find the movement of tilt uncomfortable or disturbing due to physical or cognitive challenges. This style of chair offers greater adjustability, allowing for changes in seat width/depth and back angle, and can accommodate attachments for medical devices such as ventilators and IV poles. Dynamic recline options are available for clients who need additional postural support and positioning.
When prescribing tilt chairs, it is important to consider the impact of product innovations on the client’s long-term physical, functional, and cognitive needs.
Kathy Fisher, BSc (OT), is manager, clinical sales support and education, at Invacare Canada.
Considerations for Power
By Steffen Tiskus, PT
Despite reimbursements remaining unchanged for several years, and at a time when the cost of goods and services have skyrocketed, there are continued advancements and innovations in complex rehab, particularly for power features.
Taking a Cue from Cars
Trusted technologies from the automotive industry are coming to our arena of complex rehabilitation via a few new startups. These companies recruit the use of photo sensors and radar technology to alert the client of obstacles, thereby avoiding potential collisions that wheelchair end users face on a daily basis. Visual, auditory, and vibratory feedback signals a potential hazard, ultimately overriding the end user’s drive commands to bring the wheelchair to a complete stop. This will avoid a collision once the obstacle becomes too close.
These technologies can be integrated into a variety of new power bases or retrofitted to existing systems. They bring an added layer of safety to the end user and those they encounter throughout their daily activities.
Trends of power standing and anterior tilt systems, although nothing new, have gained more acceptance as of late. Therapeutic benefits include improvement of the end user’s respiratory and circulatory status, improvements in bowel and bladder elimination, and reduction in hip and knee flexion contractures. This is in addition to aiding safer sit-to-stand or stand-pivot transfers.1 These systems also provide the end user greater access to their environs by putting them in a partial or full standing position, therefore requiring less likelihood of need for modifications to their home, school, or work environments.2
Shrinking Power Bases
Power bases have become smaller in width and to a certain extent in overall length, which improves access when negotiating small, confined areas, especially for the pediatric and small-statured adult populations. When prescribing these smaller-footprint power bases, be sure to keep in mind that if your patient requires a seat wider than 15 inches for hip width accommodations (on average), the overall seating system width then becomes wider than the power base itself, negating the advantages of having a narrower base. Also be cognizant that there are usually some trade-offs with narrower, more compact bases which may include limitations in power positioning options such as posterior tilt angle ranges.
Start with Seating
When performing an initial wheelchair seating and positioning assessment, I find it to be more advantageous to begin by determining the client’s seating needs, as this is the part of the system which makes direct contact with the end user and impacts their quality of daily life the most.
What power positioning options will they require for pressure redistribution and pain management? Would they benefit from an anterior tilt system to aid in various transfers or is a power standing system needed to be compliant with their standing therapy protocol? Are there fixed deformities that need to be accommodated with a more custom system? Once the seating system is agreed upon, we can then start to look at power base options that can accommodate the various power seating needs of the client.
Taking into consideration all of these options is integral to creating the best solution for an individual client’s needs. RM
Steffen Tiskus, PT, is training and development coordinator at Motion Concepts. For more information, contact [email protected].
- Paleg G, Livingstone R. Systematic review and clinical recommendations for dosage of supported home-based standing programs for adults with stroke, spinal cord injury and other neurological conditions. BMC Musculoskelet Disord. 2015;16:358. Published 2015 Nov 17. doi:10.1186/s12891-015-0813-x
- Goodwin J, Lecouturier J, Smith J, et al. Understanding frames: A qualitative exploration of standing frame use for young people with cerebral palsy in educational settings. Child Care Health Dev. 2019;45(3):433-439. doi:10.1111/cch.12659