The Sum of Its Parts

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June 2003

By William Robinson, MSPT, ATC

Wheelchair accessories are added to the frame of the wheelchair for the purposes of stability, positioning, improved propulsion, pressure relief, and comfort. Although most wheelchairs come standard with a variety of accessories included in the base price, one must assess whether these components adequately address the client’s needs. It may be medically necessary to add components that allow for improved stability, positioning, or pressure relief to enhance the client’s independence in functional mobility. More often than not, these accessories have associated upcharges that must be justified to third-party payors. It is important to understand the variety of commonly ordered wheelchair accessories, as well as the reasons for their use.

BACKS AND SEATS The back and seat surfaces will heavily influence a client’s positioning and alignment. There are a multitude of seat and back accessories to address positioning. Standard seats and backs on manual wheelchairs are upholstered. Reinforced upholstery is a consideration for clients with large body mass or who place additional force through the upholstery. Adjustable upholstery for backs offers the convenience of tension in the lumbar area to support the pelvis while allowing the upper torso to recline. This optimizes surface contact with the upholstery.¹ Firm surfaces support posture better than flexible surfaces.² Solid seats and backs provide clients with durable surfaces that promote upright seating and a neutral pelvis. These solid surfaces are more durable and supportive than upholstery and should be considered for clients with poor strength and control, or variable tone, and for clients whose posture and function are improved with a firm surface. A solid seat insert is an inexpensive way to prevent upholstery slinging by placing the insert (applewood) between the seat rails. Additionally, this device can be used with a cushion to lengthen the seat depth. For example, the use of an 18-inch-deep cushion with an 18-inch-deep solid seat insert can be used to change a 16-inch seat depth to an 18-inch seat depth. Optimal pressure distribution is attained by increasing the surface contact area to disperse the pressures over a larger area with submersion of the pelvis in a foam, gel, air, or hybrid pressure-relieving seat cushion or by molding a back.²

ARM, TRUNK, AND HEAD SUPPORT

Armrests can serve a client in one of several ways. Armrests prevent a client’s upper extremities from being placed in a dependent position that could lead to shoulder injuries or edema. Additionally, armrests may provide some degree of lateral stability to the pelvis. Armrests provide a stable surface for many clients to perform pressure-relief raises or assist with forward or side leans. Commonly, clinicians are faced with selecting between a desk-length and full-length armrest pad. A desk-length armrest pad may allow a client to position in closer proximity to a table, sink, or work station to complete activities of daily living, or vocational or school-related tasks. A full-length armrest pad provides a larger area to support an arm trough or laptray. An additional advantage of a full-length armrest pad is that it provides distal leverage to assist with standing. Further, clinicians have an option to chose a flip-back or removable armrest. A flip-back armrest may offer the client a greater degree of independence because it will remain attached to the wheelchair during transfers rather than being separate from the wheelchair. Tubular armrests are options on many lightweight and ultralightweight wheelchairs. They are less stable than other armrests and provide little lateral stability. However, tubular armrests offer a surface for upper extremity support during pressure-relief raises or leans and are efficiently removed for transfers. Arm troughs are armrest pads that prevent dependent positioning of the shoulder and offer lateral support to the pelvis. Arm troughs further assist with upper body balance.² A variety of hand pads can be used with the arm trough for placing the wrist and hand in positions of function, stretch, or comfort.

Trunk supports, also referred to as lateral supports, provide points of contact to control or support a client’s trunk to allow for improved alignment, posture, balance, and function. With many clients, trunk supports serve to control scoliosis.

Head rests are used to support weak neck muscles, correct or support deformities, or support the head during pressure relief in a tilt-in-space or recline seating system.²

PUSH HANDLES AND FOOT, LEG, AND PELVIC SUPPORT

Push handles come standard on most manual wheelchairs, but some clients choose to omit them because they interfere with shoulder and scapular range of motion during manual wheelchair propulsion. Conversely, clients with balance impairments can use push handles for support during activities that involve a reach.¹ Push handles are also important for providing assistance to a client ascending or descending stairs. Bolt-on push handles offer a solution for those clients who need a provider to push the wheelchair in emergent situations, yet be able to move the shoulders and scapulae without interference. These handles are bolted on the rigid back bar posterior to the back canes and can be adjusted laterally to avoid shoulder and scapular interference.

Footrests or legrests work in coordination with the seating surface to provide support to the client’s lower extremities. Swing-away footrests allow the client to move the footrests to the side for safety in standing transfers. Elevating legrests allow the knee position to vary from approximately neutral to 90 degrees of flexion. These are necessary for clients who lack full knee range of motion secondary to surgery, contractures, or spasticity. In clients with diabetes, these may assist in preventing further lower extremity edema. Most ultra-lightweight wheelchairs have a rigid legrest/footrest built into the frame and offer some options for improved positioning and function with an 80- or 90-degree knee angle.

A platform footplate is a single plate that covers the footrest tubing. The platform is useful for positioning a client’s feet together in a wheelchair with a tapered front end. The platform provides a large surface area for the feet to contact. With fewer moving parts, there is little maintenance and less weight involved.³ For clients in wheelchairs with rigid legrests who stand for transfers and cannot safely stand in front of the rigid front end, a flip-up platform is an option to consider. The client would move the platform to a position against the footrest tubing and stand in the area the platform occupied.

The footplate itself is usually composite or aluminum and offers little adjustability. Angle-adjustable footplates are useful for clients with ankle range of motion limitations due to contractures or spasticity. These allow the footplate to be adjusted in plantar flexion or dorsiflexion to promote maximum surface contact or decrease excessive extensor tone by dorsiflexing the foot. A calf strap or calf pad prevents knee flexion and will assist in maintaining the lower extremities on the footplate, preventing injury to the knee, calf, and ankle. Ankle huggers or shoe holders may be used to securely strap the client’s feet to the footrest to ensure positioning and injury prevention.

Hip belts secure the client’s pelvis at the rear of the wheelchair and prevent the pelvis from sliding into a posterior pelvic tilt. Overall, upright posture alignment begins with pelvic positioning.²

WHEEL AND TIRE OPTIONS

Multiple options exist for the front casters and rear tires. Pneumatic rear tires offer improved suspension over solid tires; however, the potential for flats is a precaution with pneumatic tires. Pneumatic tires will wear down quicker and be replaced more often than a solid tire.³ Rear tires with tread improve grip on outdoor terrain, but require more energy expenditure on carpet.² The size (3", 5", 6", or 8") of the front caster influences maneuverability. Large casters provide a smooth ride and improved negotiation of door thresholds, yet turning is more difficult.² A smaller caster offers improved maneuverability for an experienced wheelchair user. Additionally, small casters allow for a footrest angle closer to 90 degrees.¹

Handrims are the contact point between the client and the wheels for propulsion. Handrims with a smaller radius from the center of the wheel require more force to propel the wheelchair but propel the wheel faster, as in racing.¹ Plastic-coated handrims cover the standard metal handrim and provide friction for a client with impaired hand function.² For clients with hypersensitive sensation, the plastic coating protects one from touching hot or cold metal handrims.² Projection handrims are vertical or oblique extensions from the handrim to allow a client with poor grip to be able to push on the projection to generate propulsion.

Wheel locks prevent the tires from moving to allow for safe transfers and provide a stable base for pressure-relief raises or leans. Depending on which is easier for the client, a push to lock, pull to lock, or beneath the seat locking mechanism can be obtained. Wheel lock extensions provide a greater lever arm to apply and remove the locking mechanism. This makes wheel locks easier to apply for a client with decreased upper extremity strength. The client will not have to reach as far to apply the wheel lock with extension; consequently, less trunk lean is needed and stability is maintained. Some clients may prefer to have low mount brakes to avoid interference during depression or sliding board transfers. Other clients prefer low mount brakes to avoid thumb injuries while propelling the wheelchair.¹ Antitip bars are small wheels mounted to the posterior wheelchair frame via tubing to prevent the wheelchair from falling backwards. These serve as an important safety measure, but can be removed to ascend and descend stairs or curbs.²

THE NECESSITY OF ACCESSORIES

A client’s functional mobility in the wheelchair is improved when stability, positioning, pressure relief, propulsion efficiency, and comfort are considered. The selection of appropriate wheelchair accessories is critical to ensure the client’s independence, health, and safety. There are many categories of wheelchair accessories and a variety of choices within those categories to meet a client’s needs.

William Robinson, MSPT, ATC, is a staff physical therapist in the Seating Center of Rancho Los Amigos National Rehabilitation Center in Downey, Calif. References

Karp G. Choosing a Wheelchair: A Guide for Optimal Independence. 1st ed. Cambridge, Mass: O’Reilly; 1998.
Furumasu J, Gilinsky G, Krapfl B. Positioning and wheeled mobility for children and adults with disabilities. In: Goldberg B, Hsu JD, eds. Atlas of Orthoses and Assistive Devices. 3rd ed. St Louis: Mosby; 1997.
Karp G. Life on Wheels: For the Active Wheelchair User. 1st ed. Cambridge, Mass: O’Reilly; 1999.

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June 2003