More Than a Chair

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March 2004

By Sharron E. Guillett, RN, PhD

The author’s daughter, Alexis, has found the wheelchair accessories that work best for her.

My daughter Alexis was born with cerebral palsy. Now 21, she has been using powered and manual chairs for 17 years. During this time we have used a variety of seating systems, backrests, shoulder straps, lap belts, pelvic bars, foot plates, armrests, and even wheels. What we have learned is that wheelchairs are more than vehicles for individuals who spend the majority of their time seated in them. Many people like Alexis come to view these chairs as extensions of themselves. Therefore, in addition to functional mobility, safety, and comfort, one should also consider self-image and self-expression when choosing wheelchair accessories. It is important to get to know clients and involve them and their families in selecting the accessories that will work best for them.

Seating
Choosing the appropriate seating system is the most important decision for the client and clinician to make. It affects position, and therefore functional ability and comfort, more than any other accessory. Additionally, improperly fit seating systems can lead to skin breakdown and poor physiologic functioning. Standard seats and backs on wheelchairs are upholstered and designed so that the chair can be collapsed for storage and transport. These provide very little support for clients with poor posture, tone, and/or sitting balance. Furthermore, upholstered seats tend to sag in the middle, creating not only uncomfortable sitting positions but pressure areas that can lead to skin breakdown. A variety of options are available to enhance comfort, support, posture, and safety.

Standard seats can be made more firm by using inserts. Wooden inserts that are positioned beneath the seat are the most economic way to accomplish this, and they work well for people who are concerned only with the issue of sagging or “slinging.” However, people who are concerned about pressure sores and cannot shift position independently need firm cushioned support. Cushioned pads can be used along with wooden inserts. Seats can also be sculpted to fit the contours of the client’s body with cushioning provided in exact locations.

Alexis has such a seat. It is slightly higher on the sides and in the middle to keep her legs in neutral positions and distribute her weight evenly. As a small child, she had a pommel insert between her legs to help keep her legs in good position, as she had very high tone at that time. At the age of 21, even though it might be helpful, she would not even consider putting a pommel between her legs. It does not fit with her perception of herself and what is appropriate.

Her seat is therefore designed to do some of that work. Seat backs can also be molded. Alexis has a severe lordosis, and her previous chairs have had lumbar roll inserts to cushion her lower back and help maintain her posture. She also tends to lean to the right, and until recently we have not been successful in finding a seating system that provides enough lateral correction to hold her upright.

Fairly new on the market, Alexis’s seat back was molded to her body while she was seated in her chair. A mixture was poured into an empty seat back cover. The mixture undergoes a chemical reaction and turns into a thick foam cushion that molds itself to the client’s back and shoulders perfectly. The advantage of this process over other systems is that there is no slippage or recontouring of the cushion. A disadvantage is that there is not much room for error or growth. This cushion is a solid piece that can be carved, but pieces cannot be added, removed, or exchanged with ease.

Armrests
Armrests provide support and stability. There are not many options available for armrests. Clients can choose length (desk or standard) and whether the armrest is removable. Again, these are matters of individual preference. Full-length armrests provide more surface area to help clients with position changes and getting out of the chair. However, they make it difficult to get close to a table, sink, or desk.

One must take into account the client’s lifestyle. Alexis, for example, does not get out of her chair very often, spends a lot of time at the computer, and enjoys eating out. Her self-esteem is enhanced by her ability to be independent socially and publicly. Therefore, desk-size arms are her preference, although it is difficult for her to shift her position independently and she frequently asks for assistance with this.

Legrests and foot supports
Legrests and footrests support the lower extremities and maintain proper alignment and flexion of both feet and knees. Legrests can be made to swing out away from the chair, and they can also be removable. Adjustable legrests allow the client to change the degree of knee flexion. These work much like a reclining chair with the client decreasing flexion by raising the legs and increasing flexion with a hand release. The hand release mechanism proved difficult for Alexis, who could raise her legs but not lower them. This became a bothersome issue for her and the family, and she no longer has adjustable legrests. Similarly, footrests can be made to swing completely out of the way, or the foot plate (the metal plate that comes in contact with the foot) can fold up out of the way to allow for standing transfers. Straps or shoe holders can be attached to the foot plates to hold the feet in place.

Safety Belts
Interestingly, wheelchairs do not come with seat belts. A variety of lap and shoulder belts are available to provide both safety and security. The locking mechanism for these belts should be carefully considered so clients can operate them with ease. Alexis uses a padded lap belt that locks and unlocks like a car seatbelt and can be adjusted for a tight fit. Placement of the lap belt is also important, as improper placement can act like a tourniquet and decease blood supply to lower extremities. Shoulder harnesses can be used to control upper body movement, especially when traveling. Hip belts can also be used to prevent pelvic tilting.

Wheels and tires
A number of options are available for wheels and tires. The rear tires can be solid, with or without tread, or pneumatic. Solid tires last longer, but pneumatic tires offer a more comfortable ride over terrain. Tires with tread grip better, but this makes them harder to propel on carpeted surfaces. Again, it is important to talk this through with the client and family to determine what is best for the client from his or her perspective.

Front wheels vary in size from three to eight inches. Larger wheels make it easier to get over bumps, but they are harder to maneuver. Wheels and tires can also be enhanced with some fun accessories. Alexis has a set of front wheels that have colored lights that flash when they are in motion, much like the lights in some brands of tennis shoes. These are especially fun for dances and sporting events. She only uses these for special events because they are small and make it difficult for her to get through doorways and in and out of elevators. There are also colorful spoke cover inserts that can be used to express one’s personality.

Brakes
Wheel brakes are designed to be operated by either pushing or pulling on the braking mechanism. This is a matter of client preference. Clients with poor balance or poor upper body strength and mobility may want long-handled brake extensions. These allow the client to apply the brakes without leaning forward. Another safety device that some clients like, especially those in lightweight chairs, is what Alexis calls “tippy bars.” These are bars in the back of the chair that prevent the chair from tipping backward. They make it difficult to navigate rough terrain and have to be removed to negotiate curbs and steps. In our experience, removing them and carrying them around made them more trouble than they were worth for us.

Other considerations
Some things to think about that may truly be considered accessories include table or desk tops that can be attached to the armrests or back of the chair. These are useful for students who cannot sit at regular desks or cafeteria tables. Cup holders, horns, and baskets are also useful accessories.

Another thing we have learned along our journey is that life is hard enough as it is—things that make life easier should be pursued. However, it is important to remember that although the majority of accessories are really necessities, third-party payors may not reimburse for them. Therefore, all decisions must be made with client/family resources in mind.

Again, in our experience, the chair Alexis lives in is an extension of herself. Choosing the right accessories allows her to experience and enjoy herself to the fullest extent possible.

Sharron E. Guillett, RN, PhD, is assistant professor and chair of the associate degree program in nursing at Marymount University, Arlington, Va, and a member of the board of directors for Easter Seals-Virginia.

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