Kristi Rocole, PT, ATP, Seating and Positioning Specialist, Madonna Rehabilitation Hospitals, Lincoln, Neb, assists a power wheelchair user during a training session.
Once the restrictions on community interactions brought on by the COVID-19 pandemic end, many people share a common wish to return to their routine activities of work, travel, and daily living. That wish is shared by individuals who use wheelchairs and, thanks to the ongoing evolution of mobility equipment, they can look forward to technology-supported independence that will help them keep pace with friends, families, and the communities that surround them. In this Rehab Management roundtable, veteran rehabilitation therapists share their perspectives about how advances in power and manual wheelchair technologies have helped the people they serve to achieve greater independence. This panel of mobility experts also exchange insights about the critical aspects of mobility technologies they feel will pave the way for better health and safety for mobility users in the future.
Participating in the roundtable discussion are: Jillian Cacopardo, MPT, ATP/SMS, Clinical Program Coordinator, Wheelchair Assessment Services, Gaylord Specialty Healthcare; Amy Kirkner, MPT, ATP, staff therapist and wheelchair clinic coordinator, Good Shepherd Rehabilitation Network; and Kristi Rocole, PT, ATP, Seating and Positioning Specialist, Janelle Hansen, MSPT, and Christopher A. Lee, MSPT, FACHE, Vice President of Rehabilitation, Madonna Rehabilitation Hospitals.
How has the level of independence that mobility technologies provide to wheelchair users changed over the years? Especially for wheelchair users who are quadriplegic or paraplegic and have strong cognitive function?
Jillian Cacopardo: In terms of manual mobility, manufacturers are constantly advancing technologies to provide the lightest-weight, most ergonomic components. Lighter-weight components can allow a wheelchair user to remain in a manual mobility device for as long as possible. If combined with a power assist system, the ability to remain in a manual device may be even longer.
In terms of powered mobility, advancement in technologies have certainly allowed for improved and/or prolonged independence. The advancement of alternative drive controls, most recently with eye gaze and smart wheelchair controllers, has prolonged the time one is able to remain independent with their mobility and repositioning, despite debilitating conditions.
Amy Kirkner: Every year, we see updates in alternate drive controls for wheelchairs. For example, if people are unable to drive with their hands, they can drive with breath, head, foot or chin control. Through a variety of innovations and programming options, wheelchairs are more responsive for patients, which maximizes their independence.
Kristi Rocole: There have been drastic changes in the mobility technologies that are available to wheelchair users over my time in this career. There are now multiple options for power assist technology for manual wheelchairs to improve their independence and preserve their shoulder integrity. The options for programming a power wheelchair for improved user control are significantly greater. In addition, the Bluetooth capabilities of a power wheelchair, coupled with the voice-activated technologies available, provide endless opportunities for independence to power wheelchair users.
Janelle Hansen: Technologies have progressed to more complex motor capabilities (programming, phone access, environmental controls, to name a few) with more options for maneuvering power wheelchairs, including adaptive joysticks, eye-gaze technology and other alternative drive controls, which contribute to patient independence.
Christopher A. Lee: I’m even more excited about what I believe we will see within the next decade. Already robotic exoskeletons are allowing some wheelchair users to stand and walk. These devices are becoming more common in some clinical settings, including Madonna’s hospitals and outpatient clinics, but are not in wide use in the home or community in the US. However, we are starting to see exoskeleton use in the community in parts of Europe, Israel, and Japan. It’s only a matter of time before these devices begin to supplement wheelchair use in the US as well, providing increased mobility options for people with activity limitations.
In addition, there are new technologies that are wheelchair based, but that use hands-free control systems to improve independence. We recently had a demonstration of this new technology at one of Madonna’s hospitals, and I was struck by how intuitive it would be to simply shift one’s weight to move, change direction, or stop and be able to have full use of both hands at all times. The model we are evaluating even has easily changeable wheels to allow a person to be mobile at home, while camping, on the beach, or on a basketball court. This is a new paradigm in what it should be like to use a wheelchair. I believe these, and other yet-to-be-seen technologies, will greatly reduce participation restrictions and fundamentally change the way people with activity limitations access their home, community, and recreational opportunities. The next few years should be very exciting indeed.
What developments in materials and/or technologies have most improved the level of independent mobility today’s wheelchair users can enjoy?
Jillian Cacopardo: I think ultra-lightweight manual wheelchair frames are a constant progression with attempts to find the lightest-weight material which translates to independent and prolonged manual mobility. From 7000 series aerospace aluminum to titanium to carbon fiber, the lighter the weight, the easier and more efficient it is to propel. These materials have come a long way from Everest and Jennings steel manual wheelchairs without any ability to adjust the components. Even something as simple as an air/foam hybrid-type cushion may allow them to transfer easier with the more supportive foam front. And the ability to objectively measure air pressure through smart devices eliminates the guesswork and risk to users’ skin when set up appropriately.
Amy Kirkner: Manufacturers are consistently finding switches and alternate drive controls to help users. If anyone has the cognition and a little bit of movement, manufacturers are trying to capture that movement to allow them access to drive the wheelchair and use power-seat functions. Another development in technology is seat elevation that can go up 8 to 12 inches, which has improved quality of life and independence for users. Elevating seats help with transferring in and out of bed, getting on and off the toilet, reaching for or putting away items in the house, and completing other activities of daily living.
Kristi Rocole: In my experience, the greatest strides in mobility technologies have been for power wheelchair users. It used to be that a wheelchair user in a power wheelchair with impaired upper extremity function needed to purchase costly and cumbersome equipment to have control of things in their environment, such as a TV, lights and fans. Today, the Bluetooth capabilities that are available with a power wheelchair, coupled with the advancements in voice-activated technologies, allow a power wheelchair user great access to their environment that is much less costly and more user-friendly.
Janelle Hansen: Seating and positioning options (more adjustable, less obtrusive), eye-gaze and touch technologies have provided users with very little movement to be able to maneuver themselves in power wheelchairs and access control over their environment—like turning lights on/off, opening doors, etc.
How do advanced seating features and drive controls contribute to power wheelchair users’ independence? Are they generally safe and user-friendly?
Jillian Cacopardo: Functions such as tilt and recline are imperative to provide optimal independence. Such features have been studied and frequent use allows for muscle and/or tissue reperfusion, thus allowing a user to safely spend more time in their wheelchair. This is particularly important in an ever-changing healthcare system where caregivers are not as readily available. An elevating seat can be the deciding factor of whether or not a user can be independent getting in/out of their chair, be it via stand-pivot or sliding board. In terms of safety and user-friendliness, if you go about obtaining a wheelchair the “correct” way, education of how to operate these features upon delivery will enhance the features’ safety and their ability to be consistently utilized.
Amy Kirkner: The elevating seat is significant for activities of daily living, helping people do laundry, cooking, cleaning and countless other examples. For wheelchair users who are working, the elevating seat assists with providing a higher level of eye contact and access to work surfaces.
Tilt/recline helps users with their comfort, resting, protecting them against developing sores, clothing management, catheter management and positioning.
Yes, the advanced features are user-friendly and absolutely safe. Wheelchair manufacturers build in safeguards to reduce speed or stop the chair completely if it’s in an unsafe driving position.
Kristi Rocole: Backrest designs are continually evolving to enhance user performance. Not only is there a wider selection of backrests available, but many backrests are now also offered in a carbon fiber option, which significantly decreases the weight. In addition, there have been advancements that allow for less bulky and lighter-weight hardware, without sacrificing adjustability. A wider selection of backrests allows the end user to trial multiple options and really dial-in what works best for them.
Power seating functions continue to be more widely used than they have in the past. I think this is partly due to increased awareness of the capabilities and also due to improvements in the technologies. Tilt and recline combination provides maximal pressure relief for a patient. The technology to prevent shearing with use of these has improved over the years. In addition, the options for a patient to independently access these features are greater. Power seat elevate usage continues to increase and allows an end user up to 12 inches of elevation to allow them better access to their environment for reaching, performing level surface transfers, easier sit to stand, or better peer interaction. With the improvements in technology, these are very safe and user-friendly features.
Janelle Hansen: Seat back designs have evolved over the years to accommodate many user needs, providing appropriate support while also allowing for increased maneuverability of the use for access to environment. The materials are more lightweight, and there are many more adjustable options for support available. The lighter-weight materials and bracket options promote users’ increased independence to load/unload manual wheelchairs for vehicle access/transport. I think more attention to possible quad-release mechanisms would be helpful for lateral supports and chair brackets. Improved lateral support hardware is less obtrusive to the user’s inner arms, promoting comfort and skin integrity with less pressure and friction against the limbs. The adjustability and breathable materials promote health of the user by minimizing moisture against the user and providing adjustable support to minimize pressure points/maximize comfort.
I think they all [advanced features] contribute, but they are not all covered by insurances and thus are often not utilized (seat elevate, some alternative drive controls). Tilt/recline is very helpful for skin integrity and has advanced to minimize sheering forces.
At times, some wheelchair brands that have multiple programmable tilt/recline functions can confuse patients and they may tend to get out of desirable positions because of misuse; variable seat functions made available can be determined through programming, which is good.
What power/manual wheelchair designs or features are most helpful to users who need to drive, use public transportation, or fly? Do folding frames still offer significant travel advantages for manual chair users?
Jillian Cacopardo: I try to put myself in a wheelchair user’s proverbial shoes when it comes to travel. Frequently, users already have an established system in place. However, I think that advancements have been made to ease a user’s ability to travel on a day-to-day basis, as well as for business or pleasure. Rigid frames perform better and are lighter weight, thus making it easier to transfer into a vehicle. Power assist systems are lighter and can provide added muscle within a community setting. I do not think folding frames offer travel advantages when compared to rigid frames, particularly when traveling solo.
Amy Kirkner: The most helpful feature is the transport tie-down brackets, which have increased safety with transportation of manual and power wheelchairs. They have been crash tested so that the person can sit in the chair and be secured in transportation, including accessible vans and buses.
The biggest advantage of folding frames is that they can fit into small spaces. They’re lightweight and can fit into a trunk, for example.
Kristi Rocole: Most wheelchair designs available today are compatible with air travel and public transportation. There are also multiple options available to adapt a truck or a van so that a patient can drive. Despite potentially taking fewer steps to break down and fold, folding-frame wheelchairs are less common than rigid-frame wheelchairs for full-time, active end-users. The benefits of lighter weight and greater maneuverability of current rigid-frame manual wheelchairs far outweigh any transport benefits that would be gained by using a folding-frame wheelchair.
Janelle Hansen: The cleaner the wheelchair profile the better to minimize parts breaking or becoming disconnected. Footplate elevation assists with ramp clearance, recline/tilt features assist with vehicle entrance/exit clearance. I’m not sure folding frames have an advantage with travel as they are typically stowed with luggage anyway; rigid-frame ultra-lightweight manual wheelchairs are typically easy enough to stow with fewer moving parts.
In your experience, what impact have power assist devices had on independent mobility and musculoskeletal health for manual wheelchair users?
Jillian Cacopardo: The impact has been profound—particularly the newer power assist devices. Certain systems work better for a particular wheelchair user population over others. However, the lighter-weight cruise control-style systems seem to be the most popular and may provide greater independence as they are more readily transportable than traditional power assist systems. Either system provides benefit to upper extremity integrity. Without this technology, users could be put in a power chair sooner than they are ready, which could lead to difficulties with community accessibility—and even equipment abandonment.
Amy Kirkner: The power assist devices have been useful for people who still want to stay in manual wheelchairs but have trouble with inclines or longer distances. Power assist offers them more independence on rougher surfaces or inclines such as ramps. It also reduces the physical stress on their shoulders and arms. They don’t have to work quite as hard for their mobility, which reduces overuse injuries.
Kristi Rocole: Power assist devices have also progressed significantly over the last several years. It is known that almost all full-time manual wheelchair users will deal with shoulder pain at some time. Power assist technology can help preserve shoulder function in a new wheelchair user, but it can also be useful for a long-time wheelchair user to decrease their shoulder pain and allow them continued use of a manual wheelchair versus transitioning to a power wheelchair. In addition, community transportation with a power wheelchair is difficult due to the size and weight. A manual wheelchair with power assist wheels allows the chair to be loaded into vehicles that a power wheelchair cannot access, therefore improving community access for an end-user that does not have access to a vehicle that can transport a power wheelchair.
Janelle Hansen: Power-assist devices can make the difference at times between a person’s ability to use a manual versus full-power wheelchair. They also help to preserve shoulder integrity. However, power-assist options are not always covered by insurance: in the case of Medicare, the patient must be wheelchair-bound for a year before they will entertain coverage of a power-assist device. By that time, the patient may have developed UE compromise and require more than power-assist. RM
This article appears under the title “Living in the State of Independence” in Rehab Management’s July/August 2020 print and digital edition.