A versatile array of options helps form the foundation for independence and guides users toward optimized function.
Finding the appropriate wheelchair for a patient involves a detailed process to ensure all of the patient’s specific needs are met. At Kennedy Krieger Institute, Baltimore, this process begins by having the patient meet with the seating evaluation team, which can include the patient, caregiver, physical therapists, occupational therapists, speech therapists, Assistive Technology Professionals (ATPs), and the patient’s vendor. During the appointment, seating and positioning needs are identified and different types of wheelchairs and controls are trialed to decide what is best for the patient. Pressure mapping, outcome measures, and smart wheel technologies are often used to identify and justify a variety of seating components. This article will discuss types of wheelchairs, their controls, and different seating and positioning components.
Mobility Options To Increase Independence
There are many ways for patients to increase their independence with mobility in the home, community, and school/work environments. First, the team must determine the best mode of control. Decisions may include: whether the patient is a full-time or part-time user, upper extremity strength and endurance, transportation, terrains in which the patient will be using the wheelchair, and the patient’s daily lifestyle.
There are now many options for power wheelchair mobility transportation. However, the patient must be able to access these or able to utilize public transportation. Patients who are full-time users and travel long distances must consider upper extremity strength and endurance when deciding which type of control is most appropriate. These are just a few factors to consider at the beginning of the process.
If a patient has good upper extremity strength and endurance, that person benefits from manual mobility.
Manual wheelchairs can vary in weight depending on the material used and components added. Manual wheelchair frames can be made with different materials and are classified as ultra-lightweight, lightweight, and standard. To determine which weight is most appropriate, the patient’s upper extremity strength, range of motion, endurance, and posture all are assessed. Shoulder preservation is a key component when determining what weight is most appropriate to prevent overuse injuries. A patient’s daily lifestyle and use of the chair should be assessed as well to determine the terrains, obstacles, and distances over which the user will be propelling. A computerized axel-mounted assessment tool can provide data to optimize propulsion techniques to prevent overuse injuries to the shoulder, elbow, and wrist. Chair customization can include different types of wheels, rims, backrests, cushions, and adjustments to seat width/depth, dump, and more for optimum positioning during propulsion.
Typically, patients with decreased upper extremity strength and/or range of motion trial a variety of power wheelchair controls to determine the most efficient mode of driving. If a patient has use of the arms, a joystick control can be trialed. Depending on the patient’s hand abilities, there are a variety of joystick controls including a goal post, mushroom, straight, rubber dome, and microswitch adaptation. For a patient without use of the arms, there are wide arrays of drive control options. For example, a sip and puff control drives the chair by the force of the patient’s inhalation and exhalation. Head array is controlled by the use of cervical flexion/extension and lateral flexion movements. Chin control is a type of joystick placed at the chin that can be used with small chin movements. Tongue controls and retina (eye) controls are also available for patients with more limited mobility. These controls can be set up and customized for the patient so a button, switch, or even light beam can be set up based on the patient’s available movements; profiles can be saved to a card to be accessed by the providing dealer at any time.
Increased programmability of the power chair allows for adjustment of parameters such as the tone of the horn, the time, distance traveled, turning, total power, sensitivity, tremor dampening, etc. It is not uncommon to set up a power chair one way for a new user, then reprogram once the user has gained experience and is ready for another level of driving and use of the power chair.
Power chairs can be used for much more than a seating device that assists with mobility. Controls can be set up to allow a patient to be independent with pressure reliefs to prevent pressure sores, which is invaluable to a patient who has limited mobility. Power chairs also can be set up to act as environmental control units. This includes anything that is operated and controlled by infrared or Bluetooth, and can include televisions, radios, or computers. A joystick can be linked to a computer and act as a mouse emulator. Power chairs offer accessories such as cup holders, grab bars, hydration systems, and many more that can be customized for each individual. Over the last few years, power chairs have improved their aesthetics; there are now more color selections where accents on the seating system match those of the base. This provides the user with a truly custom feel and the ability to personalize the chair to their liking.
There are times when a patient is not appropriate for a power wheelchair, but requires assistance to be independent for longer distances. There are power assist options that can be added to manual wheelchairs. These components often add weight to the chair, which can limit a patient’s ability to transfer the chair in and out of a car and may limit the ability to propel without the use of power. Power assist accessories include joystick, power assist wheels, or an added power wheel to the back of the chair depending on the patient’s upper extremity function and endurance. Some require lessened propulsion and others can drive the chair by a push of a button or joystick. Power assistance can allow a patient to be independent, drive longer distances, negotiate hills, and help preserve the patient’s upper extremities.
Components to Optimize Positioning and Function
Seating and positioning components such as backrests, cushions, lateral supports, head supports, and many more can be used to optimize the patient’s positioning in the chair and level of function. Backrests come in a variety of types depending on needs of the patient. Sling backs provide the least amount of support and positioning for the patient and are used for patients without postural needs and with good trunk strength. Solid backrests provide more support for the patient; however, they can vary in height depending on the amount of support needed. The higher the backrest, the more support provided. For power wheelchair users, the height of the backrest is for support and positioning and can go above the scapulae. During manual wheelchair propulsion, clearance of the scapulae is ideal to improve kinematics. Custom backrests can be designed for the patient with custom needs such as orthopedic deformities. Supports, such as trunk laterals, can be added for more support and adjusted on each side to customize the support for the patient. Backrests and lateral supports are important to decrease risk for orthopedic deformities such as scoliosis and also can give a patient increased trunk support to allow for ideal upper extremity use.
One type of mobility accessory that can help today’s users gain vertical access is a seat-elevating device. These types of mechanized lift systems are designed to raise and lower the mobility device user while maintaining a seated position. They may not require the seat angle to change, and can bring the user lower to the ground than the standard height or raise the user higher as a way to help perform mobility-related activities of daily living. The value of seat-elevating devices includes obvious applications such as helping the user to reach surfaces at home or in the community such as shelves, cabinets, and stovetops, or facilitating a higher degree of eye-to-eye contact during conversation. Among young children who are developing language skills, eye-to-eye interaction may be especially beneficial.
Seat-elevating devices also can provide valuable utility for performing transfers from the mobility device to another surface. A seat-elevating device can help optimize positioning for transfers to decrease risk of shoulder overuse injuries. This would allow gravity to be of help during transfers, reducing strain on the upper extremities.
Teamwork and Success
There are many mobility options that can be trialed with a patient, and products and accessories for both power and manual wheelchairs enable therapists to meet the user’s needs with a high degree of flexibility. Mobility in the home or community, at work, or in school can create different demands, and should all be accounted for when making this decision. Key variables such as terrain, environment, and the user’s level of function can all be important to consider, which makes it important to work as a team in creating the ideal mobility solution. With the patient and caregivers leading and making the ultimate decisions, supported by guidance from the ATP and therapists, the road to success is more easily traveled. RM
Kaitlin MacDonald, MOT, OTR/L, is an Occupational Therapist II at the International Center for Spinal Cord Injury at Kennedy Krieger Institute.
Sarah Murdoch, PT, DPT, Physical Therapy, works in the International Center for Spinal Cord Injury at Kennedy Krieger Institute. For more information, contact RehabEditor@nullallied360.com.