Finding the Perfect Fit

By Dorothy D. Aiello, PT; Maryann M. Girardi, PT, ATP; and Charles Henry, ATS, CRTS

All factors must be considered from client preferences to sizing when deciding between manual and power wheelchairs and scooters.

Fitting patients with an appropriate wheelchair is crucial to improving their function. Optimizing fit allows clients increased ease of interaction with their environment. For example, chair selection can make the difference between transferring independently and needing assistance.

A client’s diagnosis may guide selection, but individualization is necessary to achieve a good outcome. Many characteristics of wheelchair design must be considered, including frame size height, weight, transportability, custom features, and accessories. Choosing a manual versus a power chair is a very important design consideration; long-term pros and cons must be weighed carefully. When selecting a motorized chair, some patients may find a scooter preferable because of portability and aesthetic value.

First, measurements are taken to size the chair. To determine seat width, the distance between the greater trochanters is measured and 2 inches are added to that figure. For seat depth, the distance between the posterior buttocks and the popliteal crease is measured and 2 inches are subtracted from that figure. When considering the height of the chair, the measurement should include the seat cushion selected for the client. For clients who have difficulty with transfers, the overall height as well as the height relative to other transfer surfaces may be an issue. Use of a drop seat, adjustable axle plates, casters, and wheel size can help in attaining the proper height for the client’s needs. The back height is selected on the basis of the client’s trunk strength and mobility needs.

Armrests and legrests should also be adjusted for height. When clients are seated up straight with their shoulders relaxed, their forearms should rest lightly and comfortably on the armrest pads. Adjustable height armrests should be used whenever possible. When the client is seated back in the wheelchair, the foot-plates should support their feet with their knees slightly below their hips.

Some frames are adjustable in width as well as depth. This is an important consideration for a growing child. Frame size adjustability may also be helpful for clients with significant weight fluctuations.

Client Input

Actively involving the client and/or caregivers in the selection process is key. The first step is to obtain medical history, activity level, daily routine, and transfer status information. Second, find out the client’s expectations and goals for the wheelchair. Third, address the environment in which the chair will be used and the transportation mode. Finally, it must be determined who will be responsible for the maintenance and transportation of the chair.

Listening to the client will often direct you to the individual key points. For example, if the client has decreased sitting tolerance because of back pain, specialized seating to optimize comfort will be needed. If the client cannot communicate his or her needs, the client’s caregivers can be an invaluable source of information.

Power versus Manual

Selecting a power versus a manual chair is a very important design consideration. If the client is unable to propel a manual chair and needs to be independent to function, a power chair may be prescribed. If the issue is overall extremity weakness, the client may be independent with a standard joystick-operated power chair. For a client with high-level quadriparesis, alternative drive control may be used such as sip and puff, chin, head array, or tongue controls.

The mechanisms for driving a power chair can be very specialized. We recently had a client whose motor control was best in her right foot. She was able to gain independence by using a right pedal control to drive her chair.

When selecting powered mobility, a scooter may best meet some clients’ needs. A scooter does not denote the appearance of being disabled. Some scooters can now be adapted, and with custom seating there are many new potential users who were until recently unable to sit properly in a standard scooter seat. Because of the large turning radius required, a scooter is more suited for community mobility and may inhibit clients’ function in their home.

Manual wheelchairs can be customized to help clients achieve independent mobility. A client status of post stroke may utilize a one-arm drive or wheels with projections in combination with a low seat to floor height to take advantage of functional lower extremities to increase independence.

Overall weight of the chair is a limiting factor to be considered. Increased ease of propulsion is associated with lighter weight wheelchairs.1 Studies have shown that ultralight rigid frame wheelchairs have a significantly higher fatigue life than lightweight wheelchairs; this increased durability could be a consideration when prescribing a wheelchair.2,3 For the active user, whose daily lifestyle submits the chair to a lot of stress, a rigid frame will decrease some of the effects and add to the life of the chair.

Features

Shopping for a wheelchair is like shopping for a car. There are many options to be considered. Individuals will have specific likes and dislikes; chairs are designed for specific purposes and the combination of options will provide the client with the right chair. For those clients who are wheelchair dependent for all mobility, customization of the chair is imperative to provide optimal function.

Customized seating includes cushions, backrests, and lateral and head supports. In addition to the client’s medical needs, the seating must be comfortable or the chair will never be used. Testing various options with clients will help them and you form opinions about what will work best for them.

Legrest options include fixed, swing away, removable, elevation, hanger angles, and foot-plate sizes and angles with or without calf pads; clients who are previous wheelchair users often have acquired preferences. Their range of motion and transfer methods will also influence the type of footrest selected.

Manual wheelchair frames can also include positioning components, such as a reclining back, tilt in space, or a combination of recline and tilt. These components are essential for enabling a client’s position to be changed without transferring out of the chair. Position changes are important for relieving pressure, decreasing fatigue, and maintaining good postural alignment throughout the day. The changes in position must be performed by a caregiver (or another person). Power wheelchairs offer the same positioning components, but they are motorized, thus enabling clients to change their positions independently.

Accessories can improve function for wheelchair users. Cane/crutch holders, legrest caddies, backpacks, and cup holders enable clients to transport objects without sacrificing mobility. Laptrays provide stable surfaces for upper extremity activities at the appropriate height for function. Their use can mean the difference between eating independently and being fed.

Chair Transport

Determining who will transport the wheelchair is the first step. Will the client transport the chair independently or with assistance? The person transporting the wheelchair must have the needed skills and equipment.

The transportation issues are wheelchair weight, compactness, assistive technology, and the vehicle. Most manual chairs are collapsible and therefore fit into most vehicles. If it is necessary to partially dismantle the chair for transport, clients or their helpers should be able to disassemble it, reassemble it, and lift the heaviest component, which may weigh up to 50 pounds. Power wheelchairs are significantly heavier than manual chairs; the heaviest part may weigh more than 65 pounds and each battery is usually approximately 40 pounds.

Lifts and ramps may be used to aid in transportation. Although a van is easiest to adapt, certain cars may be utilized depending on wheelchair type, and what assistive technology can be used. Whenever clients are to be transported in a vehicle in the wheelchair, a professional who specializes in wheelchair transportation safety should be consulted to ensure that the appropriate equipment is used to secure the patient and the chair while in the vehicle.

It is advisable to have clients or their helpers practice getting the chair into and out of their vehicles before making the final ordering determination.

Fitting clients with the right wheelchair is a complicated and important process. Any mistakes or oversights can adversely affect their ability to function. Listening to their goals and concerns can make the difference between independent mobility and the need for assistance.

With the multitude of options available, working with experienced providers and clinicians is also important. They will be able to tweak the chair to get the maximal performance and function for the client.

Dorothy D. Aiello, PT, is a senior physical therapist for Spaulding Framingham in Framingham, Mass. Maryann M. Girardi, PT, ATP, is the seating and mobility specialist for Spaulding Rehabilitation Hospital, Boston. Charles Henry, ATS, CRTS, is a certified rehabilitation supplier for PKP Rehabilitation Inc, Walpole, Mass.

References

1. Parziale JR. Standard vs lightweight wheelchair propulsion in spinal cord injured patients. Am J Phys Med Rehabil. 1991;70(2):76-80.
2. Cooper RA, Boninger ML, Rentschler A. Evaluation of selected ultralight manual wheelchairs using ANSI/RESNA standards. Arch Phys Med Rehabil. 1999;80:462-467.
3. Cooper RA, Gonzalez J, Lawrence B, Renschler A, Boninger ML, VanSickle DP. Performance of selected lightweight wheelchairs on ANSI/RESNA tests. American National Standards Institute-Rehabilitation Engineering and Assistive Technology Society of North America. Arch Phys Med Rehabil. 1997;78:1138-1144.