Motorized Mobility

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August/September 2001

By Dorothy D. Aiello, PT; Julie K. Silver, MD; and Charles Henry, ATS

Charles Henry, ATS, and Dorothy Aiello, PT, give a driving lesson.

In her memoir, Tales from Inside the Iron Lung, polio survivor Regina Woods describes getting her first power wheelchair. "For the first time since the onset of polio, I could move to a different area of my room without a word to anyone. I could move closer to my mother in order to hear her better. I could go into another room to hassle [my sister]. I was soon learning that there was a whole new world right there inside my house."

Regina is not alone in embracing the "power" a wheelchair can offer. In the United States, there are approximately 100,000 full-time power wheelchair users, 60,000 full-time motorized scooter users, and several million part-time or temporary motorized mobility users.¹ For some people, using a motorized mobility device makes daily tasks easier to handle. For others, it makes the impossible possible.

Dissecting the Differences

Motorized mobility is separated into two types: power wheelchairs and scooters. In the past, scooters were considered primarily for community use and power wheelchairs were for indoor as well as outdoor use. Power wheelchairs were considered more appropriate for indoor use because of their maneuverability as well as the various driving controls and seating options for the more involved user. Scooters, particularly the four-wheeled model, were considered preferable for outdoor use because of their ability to negotiate uneven surfaces and their relative portability.

However, as manufacturers seek to improve chair designs, the distinction of when and why to use a scooter or power wheelchair has become blurred. There are now short base, three-wheeled scooters that feature a small turning radius, making them easier to use indoors. Moreover, with the advent of mid-wheel or center-wheel drive power chairs, access to nonhandicapped living and working environments has greatly improved. These chairs can turn in a very small radius, making them an ideal option for users who live in a small apartment or old house, or in a work situation such as an office cubicle. Obviously, not all environments are accessible for motorized mobility; however, newer models make previously inaccessible areas more accessible and offer users further opportunities for independence.

Selecting motorized mobility is always very individualized. The user's impairment, level of function, surrounding environment, activity level, and seating and positioning needs must be considered. In addition, appearance, style, and color of the equipment are also important. Choosing a model is not much different from selecting a car and evaluating the plethora of available options that provide added value.

Power wheelchairs have more drive control options than a scooter. For example, they can be driven with sip/puff control, head control, joystick, or foot control. These options can be crucial for someone with profound weakness or other complicating issues such as spasticity or movement disorders. Scooters have more limited options and are typically operated with a joystick or steering control similar to a motorcycle.

Seating Considerations

Power wheelchairs offer more seating options than scooters. A tilt-in-space seating system, a reclining system, or a combination of these two options makes power wheelchairs very specialized in terms of seating. A limited number of power wheelchairs also offer a standing feature; however, insurance reimbursement may be difficult as the medical necessity of this option is still under debate.

Tilt-in-space seating allows the user to perform independent pressure relief in the chair, which is essential for more involved users who spend a significant part of the day in the chair and do not have the physical ability to relieve pressure on their own.

Custom-molded seating can also be done for a person with specialized seating needs due to scoliosis, kyphosis, or other fixed musculoskeletal deformities.

Scooters primarily offer ergonomic seating. However, some models now allow for custom seating by offering a tubular seating frame as an option, which allows the provider to offer more options in proper and appropriate seating for the scooter user. A general rule of thumb is the larger the base, the more stable the vehicle, which gives three- and four-wheeled scooters an advantage in stability, especially the four-wheeled type. The four-wheeled scooter is the most appropriate model for uneven terrain. However, a corollary to this rule is that with increased stability comes decreased maneuverability. Consequently, the turning radius of a four-wheeled scooter is larger than any of the other models. Yet, this too is changing as manufacturers are making vehicles that are both stable and maneuverable.

Power wheelchairs generally have the smallest turning radius and are the most maneuverable. Often antitippers are added to a power chair to help increase safety.

Transportability

How will the individual transport the vehicle? Discussing the method of transporting the scooter or power wheelchair is as important as addressing the motorized unit itself. Generally, scooters are more portable than power chairs. There are a few models of foldable power wheelchairs; however, the frames of these chairs can still weigh more than 60 pounds. This fact can make a seemingly "portable" chair truly unportable depending on the user's or companion's ability to lift this much weight. Scooters can usually be folded and have removable seats. The user can be independent by transporting the chair with the use of a lift. Sometimes a family member or friend will transport the scooter by disassembling it into pieces. Scooters can be dismantled so that the heaviest part weighs approximately 35-45 pounds. Generally, a motorized wheelchair needs to be transported in an accessible van.

Minimizing Risks

Henry explains the features of the wheelchair as compared to the scooter.

There is a significant risk of injury for daily independent wheelchair users.2,3 One study notes tips and falls to be the most common problem (42%), followed by component failure (33%).²

Tips and falls are usually due to rapid deceleration. Using a seatbelt can reduce the risk of falling from a power wheelchair.³ Ideally, a pelvic belt will offer the same safety as a seatbelt and it will position the user better in the chair.

Typically, patients who report falling out of a wheelchair fall forward whereas scooter users usually fall laterally. Cooper et al showed that use of legrests reduced the risk of injury for motorized wheelchair users.3 Scooter users should consider pelvic belt use and armrests to help increase their safety.

Having maintenance checks at least yearly can reduce component failure. Active users should consider flat-free tire inserts. They do not provide as much shock absorption, but they do prevent a flat tire, which can strand the user. With flat-free inserts, the tire will continue to function even if there is a nail imbedded in it.

As both medicine and technology continue to advance, we will see new motorized mobility options. Currently, there is a model stair climber wheelchair, the iBot, that is awaiting federal Food and Drug Administration approval. The inventor of this chair, Dean Kamen, has also submitted a patent for Ginger, which is rumored (though not confirmed) to be an advanced type of scooter.⁴

Hugh Gregory Gallagher is a polio survivor who wrote of the transition he faced when going from a manual wheelchair to a power chair in his memoir Black Bird Fly Away: Disabled in an Able-Bodied World, "I resisted the thought...electric wheelchairs are for crippled people." Yet he physically could not go on using a manual wheelchair as his arms got weaker. He writes about what it is like to use his new chair, "It was a liberation for me to go out into the world independent of the strength of my arm muscles. I had not realized just how much in recent years my world had shrunk."

Even the most disabled person has enormous potential, and as clinicians who specialize in rehabilitation, our goal is to help people function at the highest possible level. In order to do this, we need to understand the various power wheelchair and scooter options (including style, safety, performance, and portability), which can greatly enhance the quality of life for the people who seek our expertise.

Dorothy D. Aiello, PT, is a senior physical therapist at Spaulding Rehabilitation Hospital in Framingham, Mass. Julie K. Silver, MD, is the medical director of the International Rehabilitation Center for Polio, at Spaulding. Silver is also an assistant professor at Harvard Medical School. Charles Henry, ATS, is vice president of sales and distribution for Hutchinson Medical Inc, Salem, Mass.

References

Cooper RA. Engineering manual and electric powered wheelchairs. Crit Rev Biomed Eng. 1999;27:27-73.
Gaal RP, Rebholtz N, Hotchkiss RD, Pfaelzer PF. Wheelchair rider injuries: causes and consequences for wheelchair design and selection. J Rehabil: Res Dev. 1997;34:58-71.
Cooper RA, Dvorznak MJ, O'Connor TJ, Boninger ML, Jones DK. Braking electric-powered wheelchairs: effect of braking method, seatbelt and leg rests. Arch Phys Med Rehabil. 1998;79:1244-1249.
What is ‘IT'? The IT question: seeking answers to Dean Kamen's latest invention. Available at: www.theitquestion.com. Accessed June 2001.

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August/September 2001