by Keith McWilliams, OTR/L, OTD, CBIS, DRS
Mobility device users are able to access an increasing number of activities as advances occur in wheelchair technology and durability. For example, the light weight of many manual wheelchair frames allows for better transportability while power wheelchairs have evolved into mechanized marvels that can be operated from myriad control points and perform in nearly any type of terrain. The responsibilities of job-related travel and recreational travel, too, make the efficiency with which a wheelchair can be packed into an automobile an essential part of the total needs equation. This article reviews some of the important components in wheeled mobility that therapists and users should understand as they set about building 21st century solutions for engaging at home, in the community, and wherever the open road may lead.
Manual Moves Ahead
In most cases the cost of a manual wheelchair makes its purchase more alluring compared to the expense of a power assist or fully power wheelchair. However, while the price of a manual mobility device may be more attractive, there are several disadvantages associated with the long-term use of a manual wheelchair that should be recognized.
One such disadvantage is that oftentimes a manual wheelchair user may have to battle fatigue. Dealing with the potential for fatigue typically requires the user to pre-plan for many activities and may even cause that person to avoid certain activities. Human shoulders are not built to continuously propel a wheelchair. As a result of extensive use of the shoulders for this activity—especially among long-term users—repetitive stress injuries (RSI) can occur and cause a decrease to their mobility or even require surgical repair. An article by Mercer et al reports that there is a need to reduce the overall force required to propel a wheelchair to preserve upper limb integrity.1 Potential interventions that may help reduce the force needed include changes to wheelchair setup, propulsion training, or alternative means of mobility.
Other factors that can help lessen the amount of force needed for propulsion are composition and construction of the devices. To this end, wheelchair manufacturers are focused on making manual wheelchairs lighter and stronger than ever with most new designs built of titanium, carbon fiber, aluminum, and plastics. These materials decrease the wheelchair’s weight and help it withstand use over time. A versatile and personalized fit is also important to today’s wheelchair users, which is supported by a choice of mono tube and dual tube frame designs. Dual tube frames may be useful in reducing flex in the wheelchair frame, increasing efficiency of the user’s push stroke, and creating a responsive push. Mono tube designs, however, may provide a ride that feels softer to the user.
Tilt-in-space design offers another level of versatility to mobility users and their caregivers by providing clinical benefits such as the ability to change position for individuals unable to shift their body weight independently or who lack the ability to maintain position of the head, thoracic, or pelvic regions. Tilt-in-space models are available in a wide range of sizes that can accommodate children and adults, with some pediatric models designed to accommodate the changes of very young children as they grow and develop.
Power assist wheels are another notable technology available to manual wheelchair users that can make propulsion easier while reducing wear on the upper limbs. One available model is designed as battery-powered push-rim drives that provide speed of up to 6 miles per hour and a range of up to 12 miles. Several manufactures offer power assist devices of different weights that can be attached to manual wheelchair wheels and elsewhere that offer utility to a range of users from active to geriatric.
Power to the People
Often, therapists consider power assist wheelchairs for mobility users who are at high risk of RSI. Moving a user from a manual wheelchair to a power wheelchair allows that person to expend less energy and therefore expand the distance that may be traveled. Likewise, moving from a manual wheelchair to a power wheelchair decreases the force required to propel the device. Thus, the user is able to maintain all of the functionality of a standard manual wheelchair while decreasing the risk of developing an RSI.
The technology advances among some manufactures are also yielding improved components and accessories such as batteries, sensors, and wheels that can aid in decreasing the weight of a mobility device and improve its durability. Today’s power systems also offer functions that aim to increase independence and convenience, such as seat elevators that can facilitate eye-level interaction or extend the user’s reach. Among their significant features, the latest power wheelchairs can provide varying degrees of anterior and posterior tilt to ease transfer and are offered in front-, mid-, or rear-wheel drive configurations. Integrated drive systems are also available for today’s power wheelchairs that offer users an extremely wide range of points to control their wheelchairs from joysticks to head arrays, tray arrays, and sip-and-puff.
Cushions and Pressure Sore Prevention
Another common concern associated with manual wheelchair use of which therapists should be aware is risk of the user developing pressure sores. Many users spend a large part of the day sitting in a wheelchair with or without proper cushioning. As a result, the user may experience a lack of proper blood flow and therefore be at increased risk of developing further medical complications. Management of pressure sores often requires extensive education about the importance of proper blood flow and helping the user understand the ideal amount of time to be spent in and out of the chair. Therapists have clients who often spend too much time in their chair without proper offloading and therefore are at a greater risk for developing pressure sores. Pressure-relieving cushions are often utilized as a preventative method, and a variety of materials are available to help optimize a cushioning solution.
Gel cushions reduce pressure by immersing a user’s pressure points in a gel pak and typically offer good stability. Likewise, foam cushions can provide good stability and are generally quite affordable. Air cushions can be highly adjustable, offer deep immersion, and excellent pressure reduction, but may be less stable than other materials. Hybrid cushions can combine the stability of foam with the high level of pressure reduction provided by air cushions. Another technology designed to help prevent pressure sores are alternating cushions that change pressure points to stimulate circulation. This is achieved by air bladders that automatically inflate and deflate to create movement that does not rely on motion initiated by the user.
With advancements in wheelchair technology, pressure relief is better managed by standing wheelchairs. The best way to avoid the development of pressure ulcers is to avoid pressure altogether. Standing wheelchairs allow clients to do just that. It is also important to consider the psychosocial impact that standing chairs can have for their users. Having the ability to stand may help the user to feel less handicapped. They likewise can enable the user to be at eye level during conversations as well as increase functional reaching ability. They can improve the client’s ability to participate in more activities for longer periods of time than if they were restricted exclusively to the use of a wheelchair.
Location, Location, Location
An important consideration for therapists when choosing a type of wheelchair is where the client is having the most trouble getting around. What locations or activities would he or she like to access? What method or technology will be used by the wheelchair user to transport the device? Will he or she be alone or will a caregiver be involved? Careful consideration should be given to how the wheelchair will be used in each of the user’s environments. Critical questions to ask include whether the wheelchair will be required for home, community, work, school, or leisure activities.
Home Setting
The most important consideration for dwellings in which wheelchair users live concerns the overall width of the chair. Will the device fit through the home’s doorways? The client and family or other individuals who share the dwelling must be made aware whether any adjustments to the chair or the home may be necessary in order to accommodate the specific needs of the mobility device user.
Wheelchair features will impact the user’s ability to transfer to and from the wheelchair. Specific features that should be considered are: seat height, arm rests, tires/wheels, and overall size of the chair. All can play a key role in transfer. It is likewise important for the therapist to consider where in the home the client will need the chair the most and ask the following: What is the height of the seat from the floor? How does that height compare to the bed, the commode, the shower? How do the armrests or foot supports move out of the way to make transfer easier?
Many arm rests are removable and come in the following options:
Swing Away: This type can be rotated back to aid in a transfer.
Tubular: Curve down, usually flip down with hardware on the uprights.
Desk Length: Adjustable height and removable. Made specifically to fit under a desk or table.
Adjustable Full Length: Adjustable height, push pin mechanism.
Fixed Full Length: Non-adjustable fixed armrests, bolted down, provide support from back to front of seat.
Tubular: Flip-down attaching to the rear upright tubes, adjustable depending tubular style.
There are typically three options regarding foot support:
Footrest: Removable, swing away—most common.
Legrest: most common on reclining and tilting wheelchairs.
Footplate: Most common on fixed front end wheelchairs. Used for performance and light weight. Options available include: standard (90-degree), angled, and footboards (common for sports chairs).
Community Setting
To fully optimize a mobility device so that it meets a highly specfic set of needs a therapist must, again, ask several key questions, including: Where does the user want to go? What is the distance the user will need to travel in the community? Would a power chair provide more efficient means of access? There are various options for power mobility devices that help determine the answers to these questions, such as battery range, motor characteristics, and power base configurations. The user and therapist together must determine whether mid-, front-, or rear-wheel drive power chairs are more appropriate for the user’s lifestyle and environment.
It is always recommended that the user set up test drives with each type of chair to determine the best fit. During these test drives the answers to several other critical questions must be answered:
• Are there any other medical considerations that might impact the choice of equipment?
• Will the user need to be able to maneuver through many types of terrain?
• Does the place the user wishes to go have wide open doorways and ramps? Users are now able to purchase suitcase-style ramps that can be transported from place to place. However, wide doorways remain an issue.
All of these questions will impact the choice of tires (pneumatic, flat free, and solid tires are available), wheels (composite mag, spoked, high performance), weight, and power versus manual decisions. Each answer can make a difference in the ability of the user to access the community.
Transportation: Key Piece of the Complete Mobility Puzzle
Where the mobility device user lives and the transportation options that are available will directly influence the choice of wheelchair. Many major cities offer public transportation. However, most rural and suburban areas are limited. Private transportation may also impact the decision. A mobility user must consider whether the current motor vehicle he or she owns or has access to can transport the chair. In cases where the motor vehicle is unable to transport the chair, there must be a consideration for whether the purchase of an adapted vehicle will be required.
Storage is also a consideration, and it must be determined whether the mobility device can be stored in the vehicle’s trunk or elsewhere within the interior of the car, truck, or van. It also must also be determined whether the user can load the wheelchair into the trunk and subsequently move to the vehicle’s door. Adapted vehicles can be quite costly, and oftentimes this solution is not financially feasible for a client.
The purchase of a wheelchair is not a simple process. It is one that weighs many variables associated with the user, the user’s environment, and the user’s lifestyle, each to be carefully considered in making a choice that assures the optimum outcomes and user satisfaction. It is important, therefore, for the therapist to be fully informed in considering the pros and cons of each mobility device model. Over time, the functions that a wheelchair user needs from the device he or she uses may change. For one reason or another, the user’s priorities may shift and thus create circumstances for which a different type of mobility device is required to meet the user’s needs moving forward.
Regardless of the type of device and options used, a wheelchair’s performance and reliability are vital for success in the long run for each wheeled mobility user and, with routine maintenance and quality care, these devices can provide many years of community access. Also critical to long-term success, especially if a client’s needs have changed and a different feature set is in order, is having the client trial a similar chair before making a purchase decision. Most lifelong wheelchair users will require multiple chairs and will begin to understand the pros and cons behind each chair type and its features. Ultimately, the goal of the therapist is to provide the client with the best information about wheelchair options that will help to gain access to that person’s functional independence and improve overall quality of life. RM
Keith McWilliams, OTR/L, OTD, CBIS, DRS, is the Center Manager for Baylor Las Colinas—Day Neuro Treatment Center, Baylor Institute for Rehabilitation, Irving, Texas. He specializes in driving and community mobility for individuals who have an acquired brain injury. McWilliams is also certified by the Brain Injury Association of America as a brain injury specialist and is licensed as a teaching assistant through the Texas Education Agency. For more information, contact [email protected].
Reference
1. Mercer JL, Boninger M, Koontz A, Ren D, Dyson-Hudson T, Cooper R. Shoulder joint kinetics and pathology in manual wheelchair users. Clin Biomech (Bristol, Avon). 2006;21(8):781-789. doi:10.1016/j.clinbiomech.2006.04.010
