By David Miller, OTR/L, ATP, and Stephen Sprigle, PhD, PT
Risk Management Secondary complications, falls, restraints, and transportation are all safety issues for wheelchair users that clinicians must address. One area of wheelchair seating that might not garner enough attention is safety, which can be increased by the appropriate selection of equipment, proper training of the user and caregivers, and education on the risks associated with the equipment. Secondary complications include pressure ulcers, abrasions, pinch points, and orthopedic deformities. The prevention of pressure ulcers should be a paramount consideration for all wheelchair users with diminished sensation, cognition, and mobility. Many clinicians are comfortable in selecting cushions to prevent pressure ulcers whether they use pressure measurements, periodic skin checks, or a combination of the two. But skin integrity problems can also occur due to improper use of the cushion (poor inflation, improper orientation) or continued use after cushion fatigue. For these reasons, wheelchair users and their caregivers must be properly trained in the proper use of cushions and taught to check if the cushion is in good repair. Abrasions, bruising, and pinch points can also lead to skin integrity problems. Abrasions or bruising can occur when mechanical lift slings are left in the chair, when trunk or head supports are poorly padded or poorly aligned, or when abductor pads are poorly padded or misused as restraints. Postural restraints and supports such as laptrays, belts, chest straps, or ankle straps and their buckles and fasteners can rub or bruise the skin when they are used to restrain movement so they should be properly padded and sized to distribute the load on the skin. Unpadded railings on the legrests or poorly padded armrests can also lead to skin problems. Pinch points from swing-away or removable hardware should be monitored. Certain seating systems are designed to correct or accommodate postural asymmetries or support postural instability. If improperly designed or fitted to the user, postural supports can promote poor alignment that can lead to orthopedic deformities such as subluxed joints (hips, shoulders), contractures, or obliquities. A proper seating evaluation during which orthopedic limitations and instabilities are identified is the most effective means to properly select postural supports. Too often, wheelchair users are asked to adopt a posture that their bodies cannot attain and an orthopedic deformity results. Examples include sitting a person with a kyphosis in a flat back that can further flex the trunk while encouraging hyperextension of the neck, or the spinal deformities that result from not supporting an unstable trunk. Falls Falls during transfer is a risk that can be influenced by the seating system. All components should remain stable while a person is moving during a transfer. A sliding cushion or a backrest that gives way can cause the occupant to lose his or her balance. Add-on hardware, such as that used to secure drop seats and the backrest, is designed to be released to allow removal of components during wheelchair transport or stowage. This operation can alter the alignment of the add-on hardware, resulting in poor securement when the seat or back is reattached. Often, slight misalignment permits the seat or back to be attached and to appear secure. However, the seat or back can release suddenly because it is not secure. Care must be taken to properly secure add-on hardware and to periodically check its attachment to seats and backs. During assisted transfers, seating system components can hinder access to the wheelchair occupant by caregivers. Poor access when helping a person transfer not only puts the caregiver at risk but can lead to a fall by the wheelchair occupant who is not properly lifted or guarded. Hindered access might be due to a lateral support or headrest or any component that prevents good body alignment for the caregiver. Users and caregivers must be properly trained in transfer techniques and in the operation of the seating system components to ensure this risk is reduced. Improper securement of a cushion or postural support can also lead to the user sliding or falling out of the chair. This risk is particularly present when the chair comes to an abrupt stop (ie, hitting a high door jamb) or when traversing uneven terrain. The risk of a fall is also present for the inattentive wheelchair user who, while slowing, slips down or leans over in response to gravity. The wheelchair cushion and the user’s buttocks both have a forward sliding tendency due to the body’s posture while sitting against a backrest. A reclined backrest or propelling with one’s feet significantly increases the sliding tendency. In these cases, proper securement of the pelvis via a lap belt or slightly inclining the seat can be used to provide needed stability. Often, risks of falling are minimized through proper use of postural supports such as lap belts or chest belts or harnesses. However, clinicians must be very cautious regarding the line between postural supports and physical restraints. While insufficient securement or stability might contribute to a fall from a chair, improper securement can also be dangerous. Restraints For the purpose of this article, the term postural restraint will be used as a means to focus on supports that address postural alignment of the trunk, pelvis, and lower extremities. They are considered a subset of physical restraints that include other restraints such as securing the extremities to prevent injury or wandering. They can offer stability and proper body alignment so that users can function at their best, and offer safety and securement when the users require restraint. Postural restraints must be considered in every safety assessment as they can contribute to severe injury or death. Most clinicians have heard of asphyxiation injury or death from restraints in wheelchairs and beds. However, postural restraints are a component of many seating systems so clinicians should understand several aspects of restraint safety. The majority of asphyxiation deaths due to restraints occur when the restraint is properly applied.1 In wheelchairs, vest-type and lap belt restraints are the most common with the vest-type representing the highest risk. A loosely secured vest restraint that is attached to the backrest allows neck compression when the user slides down in the chair. Vest restraints might need to be loose to allow the user some trunk mobility while preventing him or her from falling forward in the chair, so a tight vest restraint might hinder function. A lap belt should always be used in conjunction with a vest restraint. A lap belt, securely fastened over the bony pelvis, will prevent the user from sliding forward in the seat, resulting in increased seated stability and a reduction in the risk of vest-type restraints. Belts work best when applied over the bony skeleton because soft tissue deforms and deflects, thereby effectively loosening the belt or changing the line of pull. But because belts work best over bone, they must be sized and padded properly to adequately distribute load. The line of pull of belts is very important in determining effectiveness; because belts work in tension, they can be considered to have a single line of force. Many clinicians consider different lines of pull in lap belts (45, 60, 90 degrees) depending on their intended effect. But line of pull must be considered in chest and lower extremity belting. All belts (and all hardware in general) will loosen over time so they must be checked regularly to ensure proper operation. The more adjustable a device—whether headrest, trunk support, or pelvic support—the greater the likelihood for being out of adjustment. Poorly adjusted components can lead to safety problems. Transportation The transportation safety of wheelchair users is often poorly addressed by clinicians, who should become comfortable distinguishing between wheelchair tiedowns, occupant restraints, and postural support devices. Wheelchair tiedowns are how the chair is secured to the vehicle. This article will not discuss tiedowns except to make one plea: whenever a new chair is introduced to the market, clinicians should ask how the chair is tied down. Not all transportation-related injuries are due to a crash—abrupt vehicle maneuvers actually pose the greatest risk to wheelchair users. The latter issue needs to be addressed by appropriate wheelchair tie-downs. Postural supports must either break free at loads that do not injure a person or be able to withstand the forces occurring in a crash. Currently, the former must be considered although efforts are under way to design postural supports that also act as occupant restraints (see www.wheelchairstandards.pitt.edu for an update). A headrest or trunk support mount that fractures in a crash leaving an exposed support rod is an obvious danger. Less obvious might be a belt that runs over the abdomen and can induce serious internal injuries during a crash. Does this mean that postural supports should be removed during transport? In our opinion, absolutely not. One postural support device that breeds much discussion is the laptray, which is often used to help wheelchair users maintain a functional posture but is clearly an injury risk during abrupt stops or crashes. Some laptrays are meant to mount devices and are not postural supports so they should be removed during transport. The decision of whether they remain in place during transport is not a simple one. One judicious approach is to remove laptrays during transport unless the wheelchair rider is at high risk of sliding or falling out of the chair during noncrash vehicle maneuvers and no alternatives can be found. This approach considers the use of lap belts and other postural supports in lieu of a laptray during transportation. These alternative supports might not afford necessary postural control during functional activities but meet the rider’s needs when passively sitting during transport. David Miller, OTR/L, ATP, is a rehabilitation technologist and Stephen Sprigle, PhD, PT, is the director of the Center for Rehabilitation Technology, Helen Hayes Hospital, West Haverstraw, NY. Reference 1. Rubin BS, Dube AH, Mitchell EK. Asphyxial deaths due to physical restraint. Arch Fam Med. 1993;2:405-407.
