Wheelchair prescription

Definition

A wheelchair is a mobile chair used by individuals who have impairments that limit their ability to walk. A wheelchair prescription defines the specifications of a chair according to an individual's particular needs.

Purpose

Wheelchairs are used either as primary or secondary means of mobility, depending upon the extent of an individual's functional limitations. When using a wheelchair as a primary means of mobility, an individual may spend the majority of his or her day in the chair and use it for movement within his or her home, work, school or community setting. As a secondary means of mobility, a chair may be used just for longer distances by an individual who has low endurance or tolerance for walking. The wheelchair prescription is used to define the type of wheelchair required, seating needs, and details about components.

Description

Selection of a wheelchair, its fit, and components depends largely on the following factors:

• What are the patient's disability, medical, and management issues? These can include considerations such as level of independence, pressure relief, orthoses, etc.
• What is the patient's size, weight, and posture? Does the patient need a heavy-duty chair? Is there a fixed scoliosis or kyphosis that needs to be accommodated?
• What is the individual's functional ability? Sitting balance, ability to transfer oneself and provide pressure relief, upper extremity strength and dexterity, and cognitive level are just a few of the things that must be considered.
• What are the patient and family goals for using the chair? What has been tried already? Will the chair be used as a primary or secondary means of positioning and mobility? Will it be used around the house, at school/work, outside, for sports participation?
• What are the environmental concerns? Access to public and private settings, including work, school, libraries, and transportation, must be considered. Is the individual's own home wheelchair-accessible?
• What are the funding issues? The cost of basic and special features, sources of funding, rental/leasing options, future maintenance, and upgrade costs should all be considered.

The prescription should include the following categories of specifications:

Type of wheelchair

There are standard and heavy-duty adult chairs, in addition to junior, youth, and "growing" frames. In a user assessment study in 2000, ultra lightweight chairs with a high degree of adjustability were shown to be preferred over lightweight chairs for ride comfort and ergonomics in long-term wheelchair use. Chairs for people with hemiplegia include a seat that is lower to accommodate for propulsion with a lower extremity. One-hand drive chairs allow a chair to be propelled with one handrim controlling both wheels. Chairs for people with lower-extremity amputations are designed to widen the base of support, compensating for the loss of anterior weight. Sports wheelchairs are lighter and easier to maneuver, for active individuals. They include a lower back, canted

wheels for more efficient propulsion, and small handrims. Reclining and tilt wheelchairs offer individuals the opportunity to either recline, opening up the angle at the hips, or tilt their entire position back. Reclining chairs tend to be used for relief from orthostatic hypotension, while tilt chairs address pressure relief and gravity-assisted positioning. Power wheelchairs may be used by individuals who would have difficulty with operating a manual wheelchair. Dependent bases, which allow only for a caregiver to push the chair, also exist; however, great care must be taken in choosing this option because it does not allow for the user to self-propel the chair in any capacity.

Standard measurements

Measurements should be taken with the individual seated on a firm surface in an erect posture. The individual may require physical support to maintain this position while being measured. If an additional seat cushion or back will be used with the chair, those measurements also must be figured in to the individual measurements.

Specific formulas exist and should be used to determine: seat height, depth and width; back height and armrest height. The size of a standard adult wheelchair is:

• Seat width = 18 in (45 cm).
• Seat depth = 16 in (40 cm).
• Seat height = 20 in (50 cm).

Standard sizes exist for smaller adults and children as well; custom fabrication also is available but can be costly.

Components

Wheel locks are used to prevent movement of the chair while the user is moving into or out of it. The wheels of the chair may have solid rubber, pneumatic or semi-pneumatic tires. Pneumatic tires provide a smoother ride and are easier to maneuver on rough and soft surfaces, but they also create more friction, increasing the energy expenditure required. The caster wheels are the front, smaller wheels that allow turns to occur. The rear wheels are large and include an outer handrim that is used to propel the chair.

Lap and chest belts are used to prevent the user from falling out of the chair. Several types of armrests exist, including fixed, removable, reversible, desk-length, and adjustable. The front rigging supports the lower leg and foot. The leg rest may be swing-away, removable, or elevating. The footplates may be fixed or adjustable, and may include strapping for proper foot positioning. Antitipping devices often are attached to the lower rear support bar to prevent backward tipping of the chair.

All of these components may be included on the chair with various options that must be specified on the wheelchair prescription according to the patient's needs.

Seating

Seating is an important consideration, especially for users who will spend most of their waking day in the chair or for those with pressure relief concerns. Several cushion types exist: planar, contoured, and molded. A planar surface offers the least support and pressure relief, but may be the least expensive and simplest to maintain. A contoured surface may either assume contour with pressure through the use of foam, air, or gel within the cushion, or it may be preformed. It provides more support than the planar surface, but is more adjustable than the molded surface. A molded seat is created from liquid foam that follows the direct contours of the specific user. It offers the most support for an individual with low trunk control and may be formed to accommodate fixed deformities; however, it also is costly and room for growth is limited.

Operation

Operation of a wheelchair varies depending on the type. A user who is going to be active in self-propelling a manual wheelchair must learn the following techniques, if applicable to his or her individual needs:

• Locking brakes, swinging away or removing front riggings, and adjusting or removing armrests.
• Transferring into and out of the chair, which may include transfers to standing, to the floor, to an automobile seat, to various sitting surfaces, or to bed.
• Wheeling the chair, using the handrims, over various types of terrain including smooth tile, carpeting, gravel, sand, asphalt, and/or grass.
• Maneuvering the chair over curbs and ramps.
• Folding or disassembling the chair for transport in a car or for storage.

The user also should be able to educate another individual on how to assist with or perform any of the above activities, in case the user requires assistance at any time. A caregiver should be able to assist with reclining or tilt-in-space functions as well.

A user of a power wheelchair must learn to maneuver the chair using the control interface selected for his or her individual needs. This may be a joystick, sip-and-puff, tongue touch pad, eye gaze, or chin or head control, depending upon the level of disability. Research has found that in individuals with severe disabilities resulting from high-level spinal cord injury , nervous system diseases, cognitive impairment or blindness, 10% find it extremely difficult to perform activities of daily living with power wheelchairs, and up to 40% find many steering and maneuvering situations difficult or impossible. New technology using microprocessors and sensors to assist navigation may help to alleviate this problem in the future.

Maintenance

Maintenance, just like operation, depends on the type of wheelchair used. A solidly built manual chair may require minimal maintenance, while a power chair often requires nightly battery charges. Proper function of wheel locks and other components should be monitored frequently and adjusted as necessary by the wheelchair supplier or with his or her explicit instruction.

Health care team roles

A physician, physical therapist, occupational therapist, seating specialist, and assistive technology specialist all may be involved in making recommendations for the wheelchair type and specification of components.

Training

Training is required in order for an individual to successfully operate a wheelchair, regardless of the type. A physical therapist often is the health care team member who works with a patient to learn transferring, propulsion, and maneuvering techniques. The occupational therapist and assistive technology practitioner (who may also be an OT or PT) play key roles as well in training the patient for optimum use of hand, head, mouth, or other controls.

Resources

BOOKS

Minor, Mary Alice Duesterhaus, and Scott Duesterhaus Minor. Patient Care Skills. 4th ed. Stamford, CT: Appleton & Lange, 1999.

Pierson, Frank M. Principles and Techniques of Patient Care. Philadelphia: W. B. Saunders Company, 1994.

PERIODICALS

Cooper, Rory A. "Wheelchairs and Related Technology for the Millenium." Journal of Rehabilitation Research and Development 37 (May/June 2000).

DiGiovine, Michalle M., et al. "User Assessment of Manual Wheelchair Ride Comfort and Ergonomics." Archives ofPhysical Medicine and Rehabilitation 81 (Apr. 2000): 490–3.

Fehr, Linda, et al. "Adequacy of Power Wheelchair Control Interfaces for Persons with Severe Disabilities: A Clinical Survey." Journal of Rehabilitation Research and Development 37 (May/June 2000): 353–60.

ORGANIZATIONS

RESNA. 1700 North Moore Street, Suite 1540, Arlington, VA 22209-1903. 703-524-6686. <http://www.resna.org>.

OTHER

Bergen, Adrienne Falk. "Assessment for Seating and Wheeled Mobility Systems." WheelchairNet. Apr. 1998. <http://www.wheelchairnet.org>.

"Prioritizing and Making Decisions About Wheelchairs." WheelchairNet. <http://www.wheelchairnet.org/ProdServ/Docs>.

Peggy Campbell Torpey