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WHEELCHAIR QUESTIONS:

1. Types of wheelchairs-32. Prescription and training of a wheelchair-53. Measurement of seat of a wheelchair-44. Electrically powered wheelchair-35. Describe PT management of wheelchair bound patient-46. Powered v/s Manual wheelchair-57. Discuss principles for wheelchair prescription. What are

measurements taken for wheelchair prescription?-88. Describe parts of a wheelchair. Discuss in detail the procedure to

prescribe a wheelchair for a patient-89. Key biomechanical components of wheelchair assessment-410.Wheelchair management-3

DEFINITION / INTRODUCTION: WHO definition: "A wheelchair is an assistive device which enhances

personal mobility and facilitates participation, for a person with walking limitation".

A wheelchair is a manually operated or power driven device designed primarily for use by an individual with a mobility disability for the main purpose of indoor, or of both indoor and outdoor locomotion.

Useful device in reintegrating a person with disability into the community. A wheelchair is truly a mobility orthosis. It provides appropriate support to

allow maximum functional mobility.

PARTS: COMPONENTS OF WHEELCHAIR:

1) Frames2) Seat3) Back4) Pelvic Positioner5) Wheels6) Tyres7) Wheel locks8) Hand/Push Rim9) Foot Plate10) Arm Rest11) Antitippers12) Grade-Aids13) Quick Release Hubs14) Push Handles/Hand Grip15) Tilt bars16) Rear Wheel Camber17) Specialized Support Components

1)Frames:

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There are two basic frame types:Rigid: Doesnt centrally fold- it collapses by back folding down and

removal of rear wheels. Most common rigid chair is box frame Can be very strong and very durable. More compact. Allows seat back angle adjustment. Easier to propel and turn due to frame rigidity. DA: More difficult to transport and store.Folding: This type of frame centrally folds via a cross-brace frame. Chair is folded by pulling upward on seat upholstery. Simple and easy to use. Have shock absorbers built into frame to smoothen out the ride

for patients. Esier to store and transport. DA: Tend to be heavier

No seat-back angle adjustment Difficulty maintaining correct frame alignment

2)Seat: Seat Type

Seat types available from wheelchair manufacturers are sling, or hammock, made of a flexible material, and solid seats which are generally removable.

Seat Surface A fabric or sling seat reinforces a poor pelvic position because the hips

tend to slide forward, creating a posterior pelvic tilt. The thighs typically move toward adduction and internal rotation, and the

patient tends to sit asymmetrically. A firm sitting surface enhances sitting posture and provides a stable BOS. The front of the seat should actually extend into popliteal fossa. Front edge should be well padded and contoured to provide relief for

hamstring tendons, calf bulk, and or/bracing. This surface may require specialized foam in one or varying firmnesses, or

a specific contour. Different types of sitting surface available:

o Firm Sitting surfaceo Solid Inserto Solid Folding Seato Solid Hook-on seato Standard Hammock Seat

Seat DimensionsSeat Depth

The depth of the seat provides support for the thighs. A seat that is too shallow causes higher sitting pressures because less of

the seat is in contact with the thighs. A seat that is too deep can cause excess pressure behind the knees and

calves. There can also be a tendency for the pelvis to slide into a posterior tilt so

that the back can be adequately supported by the backrest. Measurement: 1- to 2-inch gap between the popliteal area and front edge

of the cushion

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Seat Width The wheelchair seat width should be about 1 inch wider than the width of

the widest part of the buttocks. Special considerations will be needed for individuals who wear orthoses,

require control blocks at the hip or lateral/knee, wear bulky clothing, or experience weight fluctuations.

The goal is to create a chair that fits as close to the user's body as possible. This will make the chair easy to wheel and maneuver. It also will make the chair seem, visually, more congruent with the user's body lines.

If the seat is too narrow, the individual might develop pressure sores on the pelvic bony prominences.

A narrower wheelchair allows easier wheel access and propulsion. Narrowing a wheelchair by upholstery essentially creates a "growing" chair

out of any size chair. The chair is simply folded a bit. A limiter strap and/or narrower upholstery is mounted, preventing full

width opening. Narrowing devices are useful only for individuals who have sufficient

coordination to rock the chair from side-to-side. If the seat is too wide, the individual is forced to abduct their shoulders

excessively, making wheel access and propulsion more difficult for the patient.

Widening can be accomplished by:o Use of fixed offset or removable armso Use of attachable armrests receivers that space one or both arms

out furthero Construction design of a new chair

Seat Height The seat should be just high enough to accommodate leg length while

leaving enough space under the foot rests (about 2 inches or so) to clear obstacles

Optimal seat height: o Optimal independent functioning in foot-assisted self propulsiono Transferso Ground Clearanceunder footplates on various terrainso Approaching work surfaceso Interacting with peerso Transferring into a van via lift or ramp

Persons with longer legs often need angled or elevating leg rests that extend the legs slightly outward instead of straight down(knee angle of 90 degrees).

The height of the seat should be adjusted so that the person has enough knee clearance to fit under tables, counters, and sinks at home, at work, at school, and in the community.

Seat height can be altered by one or more methods, including:o Altering the frame constructiono Changing the wheel sizeo Altering the rear axle and front caster placemento Altering the thickness of seat inserts or cushions

SEATING SYSTEM OF WHEELCHAIR A seating system should assure a comfortable, healthy, and functional

sitting posture for work, study, and leisure.

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Disability can significantly affect the integrity and stability of the musculoskeletal system, putting the individual at risk for a number of secondary injuries.

Failure to provide adequate seating can cause serious secondary injuries, which can require hospitalization or surgery to correct.

Failure to provide adequate seating can cause serious secondary injuries, which can require hospitalization or surgery to correct.

Seat Cushions Different types of seat cushions available are as follows:

o Plain Rectangular Foamo Contoured foam with skino Carve and assemble foamo Contour molded with gel-filled insertso Air cushion with insert paddingo Matrix of air-filled elastic capsuleso Alternating air cell inflation

Custom-Molded Seating Systems Used to manage disabilities resulting in complex and fixed orthopedic

deformities and muscle tone. A plaster impression of the patient is used to make a positive model

that serves as the foundation for sculpting a seating orthosis constructed of foam and fiberglass.

The consumer sits on a large rubber “balloon” filled with tiny foam pellets similar to a “bean bag chair.” The therapist can freely push and shape the pellets or “beads” to obtain a comfortable, close-fitting contour.

Seat Functions Tilt and recline are useful for handling complex seating needs through

pressure distribution management. Seat elevators increase independence, productivity, and social

interactions by extending reach capability, enabling and facilitating transfers, and providing peer height at different ages.

Tilt Tilt is also called “tilt-in-space,” and refers to rotating the person’s

entire body, the seat base, and back and front rigging as a single unit in the sagittal plane.

Tilt provides weight relief for the sitting surfaces by redistributing the effects of gravity away from the buttocks and onto the back.

Tilt can also provide a position of rest and relaxation. A wheelchair with tilt is less stressful to the body than a reclining

wheelchair because shear forces to the skin are almost negligible. Recline Recline refers to a means of increasing the angle between the seat

base and back, typically between 90 and 170 degrees. Reclining forces some parts of the body to slide whcih is a risk factor

for skin injury. Many power wheelchairs have special linkages or mechanical

compensation to minimize skin shear during recline. Elevation

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Seat elevators provide 6 to 9 inches of additional height and can make transfers easier by placing the wheelchair at the same height as the target surface.

A seat elevator adds additional weight to the wheelchair and can increase the seat-to-floor height in some models.

3) Back: The backrest of the basic chair is made of a flexible material stretched

between the two side frames which are fixed with respect to the seat . BACK HEIGHT: The height of the back is determined by the amount of postural support

the person needs. The backrest should be low enough to provide adequate support, but still

allow the upper limbs access to as much of the pushrims as possible. Inferior angle of the scapula is used as a basis for determining backrest

height. The backrest should be high enough to provide support without inhibiting

motion, and not so low that the scapulae can hang over the back of the chair and cause discomfort.

Individuals who have a good trunk control usually require only back support to the mid-scapula.

BACK SUPPORTS: A back support should conform to the normal spinal curvature while

allowing movement as required by the user. The typical back support in a folding-frame wheelchair is sling upholstery,

not because it is good back support, but because it bends to allow the chair to fold.

Also Includes back upholstery with reinforcing straps. It increases the overall weight of the wheelchair and does not interfere

with wheelchair. In individuals with tetraplegia, the stretching of the sling back can mean

that the wheelchair user adopts a more posterior tilt of the pelvis, and this may contribute to a kyphotic spine.

For clients with truncal weakness, the stability from a contoured backrest with or without modular lateral supports is needed to maintain head and neck position.

Patients with significant kyphoscoliosis may need a custom-molded backrest to enable sitting in a more upright posture.

Types:o Basic upholstery fabric (vinyl or nylon) sling back found on standard

wheelchairso Fabric back with tension tieso Firm back, minimum contouro Contour-molded foam over hard backo Hardback with softer foam or gel central region

A well-chosen back cushion should meet the following criteria:o For folding chairs the backrest must be easily removable from the

frame with hand-operated fasteners or be collapsible.o The backrest must be the proper width and contour to support the

back for extended activities without discomfort.o For manual wheelchairs the backrest must not impose any

unnecessary weight burden.

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o Newer materials (e.g., carbon fiber) are available to keep backrest weight to a minimum.

Backrest height is a crucial feature and should be just high enough to maintain trunk stability. Unneeded extra height adds weight, blocks the ability to look over the shoulder during backing up, and increases the perception of medical frailty.

For patients who require comfort and /or postural control , an insert or cushion is placed in front of the back upholstery.

These supports add some amount of weight to the chair and must be removed for folding.

A back insert is fabricated from a firm base such as very firm foam, wood, plastic, or metal padded with foam or a layer of air-filled cells.

The padding can vary in thickness and firmness allowing more or less control at the pelvis or across the scapular and shoulder areas.

Solid inserts are available for the backrest when that type of support is required, usually for people with cerebral palsy .

Patients who cannot sit fully erect or otherwise need to be able to adjust the attitude of the back can be provided with a semi-reclining back that can be adjusted to 30 degrees with the vertical. From this, the patient can be transferred between bed and wheelchair somewhat easier.

For patients that have to enter the chair from the rear, backrests with a vertical zipper or snap fasteners for easy opening are available.

Seat and Back Angle Adjustments The angle that the seat makes relative to the horizontal plane can be

adjusted, as can the angle the back makes relative to the vertical plane. The adjustments separately or together are done to provide the best

postural support and comfort for the wheelchair user. Adjusting the seat so that it slopes downward toward the rear of the

wheelchair (also referred to as seat dump) can assist persons with limited trunk control by stabilizing their pelvis and spine, making it easier to propel the wheelchair.

Too much dump, can cause the pelvis to rotate backwards and the lumbar spine to flatten. This increases pressure on the sacrum, increases the risk of skin breakdown, and makes it more difficult to transfer into and out of the wheelchair.

An increased back angle or reclined back might be needed when the person’s hips do not flex well or gravity is needed to assist with balancing the trunk.

Using a combination of seat and back angle adjustments increases the number of possible postural accommodations.

4) Pelvic Positioner: A belt or pelvic positioner may be needed for safety and for assistance

with postural control. Padding may increase comfort and allow for tighter control thus

maintaining pelvic alignment. The direction, angle of pull and number of anchor points of belt is

important. Angle of Pull to the seating surface should face normanlly be 45 to 60 deg. Some patients prefer 90 deg placement which leaves the pelvis free for

anterior tilting, an assist for those patients who can use this mobility for added function.

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Style of closure is by Velcro( most common) but for those who require a great deal of control D-ring style closure belt, Cinching -style belt or Side-release buckles.

While mounting the belt to the wheelchair's seat rail, caution should be used with patients who push into excessive extension.

The width of the belt and size of the buckle will affect the level of control offered.

The belt and buckle must be correctly proportioned to the user's body.o Children-1" wideo Adults-2" wide

5) Wheels:Typically, wheelchair have two sets of wheels:

Rear WheelsCaster WheelsREAR WHEELS: Two types of rear wheels are available: Solid mag wheels and Spoke

wheels. Spoke Wheels- Spokes generally consist of thin aluminium or stainless

steel wiresLighterAid shock absorptionEasier to propelThey require more maintenance secondary to binding and loosening

Solid Mag Wheels- Consists of 3 or more (commonly 6) large spokes Heavier Less Maintenance More Durable Less shock absorption so gives bumpier ride

Other types of Wheels- Carbon-graphite Mag Wheels Power Assist Wheels

Rear Wheel Size: Adults-24" Pediatric-20" Too small or too low wheels- Difficult for seated riders to reach Too large or too high wheels- Result in shoulder elevation forcing

humerus into acromion. Adjusting axle position: Fig

FRONT WHEELS/ CASTERS: They are 2 in no. Allow steering of wheelchair in all directions Allow for greater foot clearance and agility but are more apt to get

stuck in cracks or bumps leading to forward falls. Size: 2" to 8" diameter.

PNEUMATIC CASTERS: Provide shock absorption. Good on uneven terrain. Allows least amount of ground clearance. High maintenance. Larger.

URETHANE CASTERS: Good on smooth terrain.

MODIFICATIONS:

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Adding an elastomer shock absorber "frog legs" in series with caster can produce/provide a means of shock absorption and vibration reduction.

6) Tyres: Tires are available in many different sizes, tread designs and widths to

accommodate almost any type of terrain, as well as the individual's mobility needs.

There are several types of tires available: SOLID TYRES:

o Made up of hard polyurethane or rubber.o Heaviero Lack "cushioning" on rough terrain.o Have a decreased rolling resistance on flat or smooth surfaces.o Designed for indoor use.o Puncture proof.

PNEUMATIC TYPES:o Lightweighto Provide cushioning against impact and vibration from rolling over

surfaces.o Increased rider comforto Improved wheelchair durabilityo Recommended for outdoor usageo They require maintenance as they puncture o High rolling resistanceo Come with airless(flatfeet)insert that is a soft rubber or a latex gel

that replaces inner tube.o Greater tread depth and lower tyre pressure provide more traction

but require more effort to propel the chair. ALL TERRAIN TYRES:

o Have a wire tread and are wider overall.o Used for mobility on soft and sandy terrain.

KEVLAR TYRES:o Provide a durable and smooth ride.

7) Wheel Locks: Aka Brakes. Vary in type of action and position they are mounted. The type and position will be influenced by:

o Clients reaching ability, balance and strength.o Clients hand function.o Impact of Wheel lock position on transfers.

Wheel locks act as parking brakes to stabilize the wheelchair when the rider transfers to other seats or when rider wishes to remain in a particular spot.

There are a variety of wheel locks used to restrain wheelchairs when transferring or parking.

High -Lock Brakes/Toggle: Located near front corner of seat, on upper tube of

wheelchair's frame. Requires least dextrity.

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Pull to Lock or Push to Lock: Low Lock B rakes:

Mounted at lower tube of wheelchair's side frame. Require more mobility to operate.

Retractable Locks:(Scissor or Butterfly) Requires more extended reach

More difficult to engage.

8) Push Rims(Hand Rims): They are attached to wheel rim to allow propulsion and control safely

without touching the tire directly to avoid soiling the hands. Smaller thn the wheel rim to make chair easiert o propel. The type of push rims depends on user's grip. 3 types:

o Standard Metal Rims: Circular steel tube Used when grip is good.

o Friction Rims: Standard Rims covered with a vinyl or foam tubing to provide

additional grip on rim surface. Used by patients with low level gripping ability. DA: Leads to burns when user attempts to slow down the

Wheelchairo Projection Rims:

There are vertical, horizontal or oblique projections to improve propulsion.

Horizontal or Oblique projections increases the width of the chair.

Used by people with limited reach and grip, like quadriplegics.

These are usually knobs which are placed at intervals to give the user better grip and leverage for propulsion.

The greater the no. of knobs the greater is the facilitation of movement. Variations of Hand Rims: For patients with good hand function-a push rim called "Natural-Fit" is an

ergonomically designed hand rim that has been shown to decrease stresses placed on UE during wheelchair propulsion.

One-Hand Drive wheelchairs- 2 push rims used in patients with plexus injury, UE amputee or hemiplegics.

9) Foot Plate: Front Rigging=Foot Rest+Leg Rest Foot Rest consists of a support bracket with a foot plate The footrest and legrest lengths are determined by measuring leg length

from popliteal fossa to heel. Footrests are commonly are 1"-2" from ground to ensure sufficient ground

clearance Footrests are the first part of chair to come in contact with an obstacle, so

they must be durable. The footrests must provide sufficient support for lower legs and feet in

presence of postural control problems, limited ROM and/or abnormal tone. Types of footrests available:

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o Swing Awayo Hook Lift Upo One Piece Lift Upo One Piece Lift Offo Rigido Rigid Adjustable Angle

Legrests consists of an elevating support bracket with swing away mechanism, a footplate and a calf pad to support the back of leg when elevated.

They are used for patients with impaired circulation or dependent edema. They are longer and heavier.

10) Arm Rests: Arm Rest provide a foam of support and are convenient handles to hold on

to when the rider leans to one side or other. They are helpful when attempting to reach to higher places. Commonly Used to perform a "push up" to assist with seat pressure relief. 3 basic types:

o Wrap-Aroundo Full-Lengtho Desk Length

Wraparound Arm Rest:o Mount at back of wheelchair onto the frame below backrest.o Comes up along the back of backrest support and wraps around to

the front of wheelchairo Doesnt increase the width of wheelchair.o Popular among active wheelchair users.o DA: Doesnt serve as a side guard to keep the rider's clothing away

from the wheels. Full-Length and Desk-Length:

o Similar in design but length varies.o Full-Length armrest provide support for nearly entire upperarm.o They are popular on electric-powered wheelchairs as they provide

convenient and functional location for the joystick.o They make it difficult to get close to some tables and desks.o Give more room for UESS to get secured.o Also afford the user a larger surface to grasp for pushups and

transfers.o Add as much as 5" to the width of wheelchair.

Armrests can be fixed or height adjustable. Height Adjustable Armrests:

o May move up and down to accommodate the length of rider's trunk and arms.

o Provide clearance for transferring in and out of wheelchair o Used for chairs ordered with built-in growth allowance.o Permit placement of UESS without extensive custom modifications.

Armrests can be tubular v/s standard. Tubular Armrests:

o More cosmetic but not suited for heavier individuals. Armrests-Too high-Excessive shoulder abduction Armrests-Too short-Encourage leaning Armrests- Space too far- Interfere with ability to wheel the chair.

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11) Antitippers: Antitippers are devices that attach to the rear of the wheelchair frame Antitippers are often placed on wheelchairs to assure they do not tip over

backward. These can inhibit the ability to climb curbs, but they do offer a measure of

safety. These are designed to minimise the risk of the wheelchair tipping fully

backwards when a client loses their balance. Can make it difficult for the user to ascend a curb or pop a wheelie. The tube length can be adjusted to allow the user to traverse over small

obstacles while still providing some stability. They are not designed for a client to rest on in the tipped back position

and this should always be discouraged.

12) Grade-Aids: Grade-Aids are devices that attach to the wheel and allow it to roll forward

but not backward. In this manner, they make it easier to roll up a hill. These should be considered for individuals who have UL weakness and

who must negotiate hills.

13) Quick Release Hubs: Push button mechanism which allows the easy removal of rear wheels for

transportation or storage purposes. For clients with limited hand function-a form of lever-Quad release axles

attached to quick release button allow easy removal of wheels.

14) Push handles/Hand Grip: Push Handles aka Canes are attached to the back of chair with the primary

purpose of making it easier for an assistant to propel the wheelchair. Canes can also be used by the wheelchair occupant to help with pressure

relief. The wheelchair user can hook the arm around the cane and pull to raise

the contralateral hip, even in the absence of triceps.

15) Tilt Bars: Tilt bars which project from the back of frame, usually 2"-3" above the

floor, are used by individuals who pushes the wheelchair. By placing foot on tilt bar and pushing down with the foot, the personcan

tilt lift the wheelchair back, allowing the casters to rise off the surface, thus enabling them to clear a doorstep or kerb.

16) Rear Wheel Camber: Camber is the angle of rear wheel tilt. Zero degrees of camber implies that the rear wheels line up vertically and

with the side of the wheelchair. Most wheelchairs generally have up to 8 degrees of camber. Advantages

o Brings wheels inward and closer to the body, which enables the arms to access more of the pushrim

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o Reduces shoulder abduction because the wheels are closer to the body

o Increases lateral stability Disadvantages

o Wider wheelchair, which can be problematic in tight areaso Diminished traction and uneven tire wear on a conventional tire

(some tires have offset treads that accommodate for camber).

17) Specialized Support Components: Head/Neck Supports:

o Provides support for patients with fair, poor, or absent head control.o Posterior, lateral and anterior head or neck controllers available.o Promotes maintenance of a neutral cervical spine and head

position.o Eliminates Lateral flexion and rotation.o Supports the head to assist with respiration, visual interaction with

environment, feeding and swallowing.o Improves safety during transport.

Lateral Trunk Supports:o Indicated in presence of weak or spastic trunk muscles.o Can be straight or contoured for controlo Improves trunk stability and alignment along with pelvic alignmento Controls lateral trunk flexion

Anterior Chest Supports:o Assists with maintenance of upright trunk posture and control of

shoulder position.o Supports trunk along anterior surface of trunk and shoulders,

eliminates forward lean.o May influence and discourage shoulder protraction.o Stabilizes trunk to allow improved UE function and head control.

Lateral Hip Guides:o Improves pelvic alignment on seat.o Assists with maintaining pelvic position on contoured seato Improves weight distribution on pelviso Improves pelvic positioning

Lateral Knee Guides: Medial Knee Block: Anterior Knee Block:

GOALS: The goals for a wheelchair or seating system are :

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1. Maximize Functional Independence With Activities of Daily Living The wheelchair or seating system should enable individuals to perform the

activities of daily living (ADLs) that are important to them with minimal to no assistance and with the least amount of energy expenditure.

Types of activities can include transfers, personal needs (e.g., bathing, toileting), working, preparing meals, cleaning, and shopping.

2. Minimize the Risk of Secondary Injuries It is imperative that individuals be provided with mobility devices that

comply with internationally recognized wheelchair standards and can be safely operated (as determined by a skilled therapist or assistive technology professional).

Seat belts, wheel locks, and a properly adjusted wheelchair can prevent serious wheelchair-related injuries.

Pressure ulcers are also a significant risk for those who use wheelchairs. Advanced cushion designs and seat functions can provide adequate

pressure relief for person who cannot independently off-load the buttocks. Shoulder pathology and nerve compression injuries at the wrist are

common among wheelchair users. Using proper wheelchair propulsion biomechanics and an optimal

wheelchair setup can help delay the onset of overuse injuries.3. Correct or Accommodate for Skeletal Deformities When the skeletal deformity is “flexible,” the seating system should

correct the deformity, and when the skeletal deformity is “fixed,” the seating system should accommodate the deformity.

The seating system should not create a “new” deformity such as a sacral posture (posteriorly tilted pelvis), which results from sitting in a seat that is too long or using footrests that do not account for tight hamstrings.

4. Ensure Comfort Along with mobility, comfort has been reported as the most important

attribute or function of a wheelchair. Research has shown that most wheelchair users experience regular

discomfort. Many either ignore it or seek relief by getting out of the wheelchair, using pain medications, or doing weight shifting (either manually or with tilt and recline).

A wheelchair that allows for “fine-tuning” of the adjustments provides greater options for achieving comfort, as well as meeting the individual’s postural and pressure needs.

5. Promote Positive and Unobtrusive Self-Image Because a wheelchair is often considered as an extension of one’s body, it

should be as aesthetically appealing as possible. Wheelchair designers and manufacturers are using materials that not only

have high-strength mechanical properties, but also have finishes that are smooth, polished, sleek, and attractive.

PRESCRIPTION PROCESS: A prescriptive wheelchair is a combination of a postural support system

and a mobility base that are joined to create a dynamic seated environment.

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Postural support system is made up of surfaces that contact the user's body directly. This includes seat, back and foot supports as well as any additional components needed to maintain postural alignment.

Mobility Base consists of tubular frame, armrests, foot supports and wheels.

Selecting the most appropriate wheelchair and seating system requires that information be obtained about type of disability, prognosis, physical capacity and limitations, involvement in work or related activities, physical and social environment, and means of transportation.

Criteria to be considered while selecting a Wheelchair

Include selecting a chair that: Has the lightest weight possible. Has a stable frame for most efficient movement. Is well-manufactured, with high-quality bearings for less roll resistance

when push forces are applied, and secure non-moving parts. Has optimal wheel size and type for individual patient function. Provides the best possible combination of ease of propulsion and stability.

Team Approach

It is important to involve an interdisciplinary team in the decision-making process.

The most important team member is the patient. The family and caregiver should also provide input, as they will be the

next most affected by the choice of wheelchair. To ensure that the most suitable device is obtained, the team must have a

clear idea of:- Who will be using it- What functional level is expected- Where the chair will be used

The assessment team can consist of :t Teamo Patiento Rehabilitation engineero Occupational therapisto Physical therapisto Rehabilitation technology suppliero Speech and language pathologisto Rehabilitation physician

Assessment

To complete a thorough assessment of a wheelchair for a client many different factors need to be considered.

These are described below and are guidelines for the assessment process :

CLIENT 1) Client goals - includes intended use of equipment, preferences,

importance of cosmesis, likes/ dislikes of current chair.

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2) Client profile – this includes client attributes such as physical strength and functional abilities, balance, pain, contractures or deformities, postural issues, experience of the client with the equipment

3) Seating requirements – for example this will include the type of cushion or back support that will be used

4) Environment – includes the home, community and the workplace/study facility etc. Consider the clients life style with respect to leisure and recreation

5) Portability and transport – ability for the client to collapse the wheelchair into the car, ability for storage in the vehicle with the rest of the family etc

6) Geographical location of client– access to repair centres, rural and remote issues

CARER 1) Carer goals and comments 2) Manual handling issues 3) Issues with any current equipment 4) Maintenance issues and abilities

WHEELCHAIR 1) Reliability and durability 2) Level of maintenance required 3) Options and accessories available 4) Supplier service and follow-up 5) Availability for the wheelchair to be trialled from supplier 6) Cost

Medical Variables: Age, past medical history and present medical history. The underlying medical conditions that require prescription of a

wheelchair should be assessed. The prognoses for certain conditions need to be considered in the

prescription decision, especially if a condition is progressive. Equipment should ideally address current and future needs based on the

anticipated natural progression of a disease or condition. In addition, other factors that need to be taken into account include pain,

obesity, cardiopulmonary or musculoskeletal problems, and risk for falls. Potential risks and secondary injuries such as pressure ulcers, postural

deformities, or upper limb repetitive strain injuries associated with the use of equipment need to be assessed and considered.

To assure that there are no ongoing medical problems or complications that can affect the wheelchair prescription and the patient’s health.

Physical and Functional Variables/ Physical Examination: A physical examination should focus on aspects of the patient that will

help:(a) justify the wheelchair and seating system, (b) determine the most appropriate wheelchair and seating system, and (c) assure that medical issues are appropriately addressed.

Often individuals require a wheelchair because of cardiopulmonary disease, musculoskeletal or neurologic deficits.

It is essential to determine if the individual’s physical impairment is changing rapidly or is stable.

It is important to understand both the intentions and the abilities of the user.

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Obvious examination items include physical-motor assessment of strength, range of motion, coordination, tone, and proprioception, balance, posture, contractures, endurance, sitting posture, cognition, perception, and use of external orthoses.

The physician should be thinking about how the individual will control the wheelchair. If there is poor hand coordination, head control or switch control, foot joystick may be needed.

It is important to establish how long the individual will be using the chair. Physical assessments should be followed by observation of performance in

ADLs that are reported by the person or the family or caregiver as being essential. These include self-care, reaching, accessing surfaces at various heights, transferring to various surfaces, and functional mobility.

Functional mobility should be assessed in the user’s home and community.

Ambulation should be assessed from the perspective of the surfaces and distances encountered in a routine day.

Access to a range of heights might be important to reach objects in the home and other environments.

Stability can be assessed by observing the individual in the current wheelchair or by asking him or her to sit unsupported on a mat table. Ask the patient to perform simple reaching tasks to determine the lateral and forward stability of the trunk, ,hand and arm strength, and hand fine motor skills.

Poor stability usually indicates the need for special attention to seating and position.

Appropriate seating can enhance reach and stability, thus improving the performance of manual activities from the wheelchair.

Likewise, spinal deformities like the presence of kyphosis, scoliosis, or other fixed deformities need to be accommodated in the design of the backrest, to allow the user to tolerate sitting.

Assessment of pelvic alignment is critical because the pelvis becomes the base of seating support. An obliquity of the pelvis to one side needs to be accommodated or corrected (if possible) to prevent leaning or development of spinal deformities.

ROM measurements: Hip Flex, Abd, Add, IR and ER; their effect on pelvic position and general body alignment should be noted as well.

Determine what seat-to-back angle can be tolerated. Tight hamstrings significantly affect the positioning of foot supports. It is important that excessive tension not be placed on the hamstrings

because this can be painful and pull the pelvis into a posterior tilt. It is also necessary to respect a person’s preference for different seated

postures, even if these postures do not appear appropriate. Examination of upper and lower extremities Evaluation in upper extremities include:

-ROM and strength-grasp patterns-eye-hand coordination-joint stability-movement patterns-functional use of hands

Evaluation in lower extremities include:-ROM-joint stability

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-movement patterns and function-foot propulsion-weight bearing and transfers

Skin Examination: This may not be needed for individuals with cardiopulmonary disease, but

it is essential for individuals with neurologic deficits or those with previous history of pressure sores.

The examination should include not only the buttocks but also the feet and calves, which can be affected by pressure against a leg rest.

Attention should be paid to bony prominences and previous scars. This examination will help with cushion selection and wheelchair setup.

Environmental Variables: It is important to assess both the physical and social environments. The assessment process involves obtaining critical information about the

user and his or her environment, family support, and past use of assistive technology.

A home assessment is often needed to ensure that the device will be compatible, especially when there are stairs, narrow doorways and hallways, or other tight spaces to be negotiated.

The assessment involves taking devices to the home, surveying the environment for accessibility, and having the user get into the device and maneuver it in the spaces used in a typical day.

The wheelchair model chosen should also be compatible with the user’s public and private transportation needs (such as a bus, train, car, van, or airplane) and home/Activities of Daily Living (ADL) environment.

The social environmental assessment includes the roles, interests, responsibilities, and occupation important to the user. The roles include being a parent, spouse, worker, homemaker, or community volunteer. The level of available assistance from others needs to be assessed from the perspective of the ability to maintain and troubleshoot complex equipment.

The physical capacity and health of caregivers need to be assessed. Family, social, and cultural values can be barriers or can facilitate a

person’s inclusion in the community. Also, if the patient has been using a chair, historical information about his

or her current chair should be addressed, including problems he or she may be having.

Aesthetics: Aesthetics is an increasingly extremely important factor in wheelchair

prescription. This is because a wheelchair is such a personal and intimate product. The appearance of the wheelchair is mainly a function of the frame design

and materials. It is important that wheelchairs have as attractive an appearance as

possible so that the user is pleased with using it and gains the most positive attention possible from peers and from the community.

Transportation Variables: The feasibility of assembling and disassembling equipment by the user or

caregiver, however, needs to be carefully assessed.

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The portable design can compromise durability as well as the capabilities of the device to negotiate uneven and soft surfaces.

If transporting the wheelchair and seating system is an essential goal, the person should get an opportunity to try it before the final prescription is written.

DocumentationMedicare Recommended Documentation Items• Symptoms• Related diagnoses• History

a) How long the condition has been presentb) Clinical progressionc) Interventions that have been tried and the resultsd) Past use of walker, manual wheelchair, scooter, or power wheelchair and

the results• Physical exam

a) Weightb) Impairment of strength, range of motion, sensation, or coordination of

arms and legsc) Presence of abnormal tone or deformity of arms, legs, or trunkd) Neck, trunk, and pelvic posture and flexibilitye) Sitting and standing balance

• Functional assessmenta) Any problems with performing activities including the need to use a

cane, walker, or the assistance of another personb) Transferring between a bed, chair, and wheelchairc) Walking around their home––to bathroom, kitchen, living room, etc.––

provide information on distance walked, speed, and balance

MeasurementsPATIENT MEASUREMENT: Supine postion: Fig 33.3 Sullivan

SEAT DEPTH- Examiner supports the LEs in an optimal position and neutralize pelvis. Measurement is done from the undersurface of the thigh from the popliteal fossa directly down to the support surface and obtain a right and left measurement.

FOOTREST LENGTH MEASUREMENT: Measure the leg length from the popliteal fossa to the heel.

Sitting position: Fig 33.5 SullivanA. SEAT DEPTH- Behind the buttock to the popliteal fossa.B. FOOTREST LENGTH- Popliteal fossa to heel.C. KNEE FLEXION ANGLE-

BACK HEIGHT D. Sitting surface to PSIS. E. Sitting surface to lower scapula F. Sitting surface to top of shoulder G. Sitting surface to occiput H. Sitting surface to Crown of head. ARMREST HEIGHT: I. Hanging Elbow from sitting surface to the elbow or forearm

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SEAT WIDTH: J. Between lateral aspects of trunk L. Between the lateral aspects of greater trochanters in sitting

K. SEAT DEPTH: M. MEASUREMENT OF FOOT LENGTH

WHEELCHAIR MEASUREMENT: SEAT WIDTH: measurement is generally from outside of frame to outside

of frame. SEAT DEPTH: measurement is from the front of the upholstery to the back

upright (where the upholstery is attached). BACK HEIGHT: measured from the top of the seat rail to the top of the

upholstery (at the side). SEAT TO FOOTPLATE DISTANCE: measurement is from the top of the seat

rail at the front of the chair to the rear of the footplate below. REAR SEAT TO FLOOR HEIGHT: measurement is from the top of the seat

rail (at the rear) to the floor. FRONT SEAT TO FLOOR HEIGHT: measurement is from the top of the seat

rail (at the front) to the floor. FRONT FRAME ANGLE: This is an angle measurement from the seat to the

footplate hangers from the floor.

Goals of Prescription A well-planned seating system may be able to:

Normalize tone Decrease pathological reflex activity Improve postural symmetry Enhance ROM Maintain or improve skin condition Increase comfort and sitting tolerance Decrease fatigue Improve function of ANS Effective in accomplishing all recreational and vocational activities Assist caregiver with patient management

Postural Goal: To achieve thr optimal trunk position because all function, both central and distal is based on position and control of trunk and limb girdles.Mobility Goal: To provide efficient ease of movement from the users and caregivers perspectives.System Outcome: To provide comfort and maximal functional independence.

Considerations for Selected PopulationsPediatric:

Children have special mobility needs. Those must have following features:

o Wheeled mobility that can be adjusted to accommodate growtho Mobility that can be managed by parents (i.e., wheelchairs that can

be readily disassembled for car transport).o Special technology to complete school assignments, such as

augmentative communication aids, alternative computer access, and sensory aids. These devices are often mounted on the wheelchair so they can travel with the child to and from school.

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o Wheelchairs that facilitate interaction with other children. One example is a power wheelchair that lowers the seating surface to the floor so that the child is at eye level with peers and can participate in exploratory activities that unimpaired children carry out while seated on the floor.

o Early utilization of powered mobility as medically necessary, to promote psychosocial development, reduce learned helplessness, and facilitate social and educational integration and independence

Progressive Disorders Progressive disorders such as amyotrophic lateral sclerosis, multiple

sclerosis, or Parkinson’s disease require special consideration when prescribing a wheelchair and seating system.

They might have trouble at times because of fatigue, tremors, and weakness.

Power wheelchairs with programmable functions are good choices because they can be tailored to the individual’s driving abilities as the disease progresses, and can accept multiple inputs (e.g., joystick, head array, sip and puff).

From a seating perspective, these patients will need periodic seating updates as the disease progresses.

Indoor-outdoor power wheelchairs allow for interchanging seating and positioning hardware, or adding a tilt or recline system, or both.

Vision Impairments Individuals with low vision have an additional challenge when using

wheeled mobility. When using wheeled mobility, the arms can no longer explore ahead of

the body and are partly occupied either with propulsion or using a joystick to drive.

Driving safety with wheeled mobility has to be assessed in individual cases.

Weight Disparity Individuals with chronic disabilities who use wheeled mobility are at risk

for weight problems. Reduced tissue thickness across bony prominences increases the risk of

pressure sores. On the other end of the weight disparity spectrum, the sedentary lifestyle

of wheeled mobility can result in poor fitness and obesity. In addition to the regular health risks, obesity has an impact on wheeled

mobility in the followingways:

o A wider, heavier wheelchair is required. This can impose navigation limits on access through narrow doorways and small rooms.

o Propulsion of manual wheelchairs is interfered with, and more force is required to overcome the increased rolling resistance.

o Transfers, pressure relief, and personal care are substantially more difficult, leading to an increased risk for skin breakdown and pressure ulcers.

o Third-party funding is sometimes delayed because some funding sources believe obesity is a preventable complication.

Older Adults Aging can be thought of as a collection of progressive disorders that can

complicate wheelchair prescription and seating.

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The older patient is frailer and requires extra diligence by the clinician. The partner should be included in the clinical decision-making, and it often

necessary to have a home assessment made to determine additional hazards or accommodations required.

Effects of aging vary widely, but pertinent problems include the following:o Osteoporosis, stress fractures and arthritis. These can increase

pain, limit range of motion, and reduce sitting tolerance.o Impaired circulation resulting from coronary artery disease and

diabetes, which can increase the risk of pressure ulcerso Sedentary lifestyle, with weight gain and reduced muscular strengtho Cognitive impairments and depressiono If an older patient relies on a partner for personal care, aging of the

partner can limit this assistance and result in a caregiver injury during a strenuous procedure such as a transfer.

o Older patients are often on fixed incomes and might be unable to absorb the cost of chair accessories.

Wheelchair Modifications There are five justifications for modifying specific wheelchair parts and

presenting new models:o To facilitate transferso To facilitate proper positioningo To allow its own transportationo To allow self-propulsiono To permit transportation of objects, in the wheelchairo To overcome architectural barriers

TYPES OF WHEELCHAIR: 1) Manual Wheelchair2) Pediatric Wheelchair3) Sports and recreation Wheelchair4) Power Wheelchair5) Scooter6) Stand Up Wheelchair7) Recliners

Manual WheelchairsPersons with good upper body function and stamina might well be able to use a manual wheelchair for mobility.

Advantages of Manual Wheelchairso Easy Transportationo Maintenance: Can be worked on independentlyo Exercise: Theoretical benefit to the user from using own force to propel

leading to promotion or maintenance of physical fitnesso Aesthetics: Less appearance of disabilityo Lighter weighto Lower costo Greater portabilityo Greater efficiency

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o Increased maneuverabilityo Easier to handle/operateo More easily covered by insurance and payment providers.

Disadvantages of Manual Wheelchairso The single greatest disadvantage of manual wheelchair use is the

possibility of contracting an upper body repetitive strain injury. o Less stabilityo Less comforto Require inflation of tireso Cannot be travelled to longer distances and at high speed without the user

getting fatigued.

Types of Manual Wheelchairs:1. Standard/Depot and Attendant-Propelled Wheelchairs2. Lightweight3. High strength Lightweight4. Ultralight Weight5. Heavy Duty6. Extra Heavy Duty

Depot and Attendant-Propelled Wheelchairso The depot or institutional wheelchair is the default chair intended for

institutional use.o These wheelchairs are typically used in airports, hospitals, and nursing

care facilities. o They are inappropriate for active people who use wheelchairs for personal

mobility, including older persons in nursing homes. o Depot wheelchairs are designed to be inexpensive, to accommodate large

variations in body size, to be low maintenance, and to be attendant propelled.

o Depot chairs are designed neither for the comfort of the person being transported nor for the person pushing the chair. A typical depot wheelchair will have swing-away footrests, often removable armrests, a single cross-brace frame, and solid tires.

o Depot wheelchairs have sling seats and back supports, which are uncomfortable and provide little support.

o Swing-away footrests add weight to the wheelchair; however, they make transferring into and out of the wheelchair easier.

o Armrests provide some comfort and stability to the depot wheelchair user and can aid in keeping clothing off the wheels.

o Depot chairs typically fold to reduce the area for storage and transportation.

o Solid tires are commonly used to reduce maintenance. o Solid tires typically dramatically reduce ride comfort, increase rolling

resistance, and add weight.o Leg-rest length is adjustable.o Depot chairs are available in various seat widths, seat depths, and

backrest heights.

Lightweight Wheelchairs

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o These chairs do not offer features suchas adjustable axle plates, quick-release wheels, or a method to change the seat to back angle of the wheelchair.

o Generally have sling-type upholstery. Sling upholstery has no capacity to provide pressure relief, and the hammock effect that occurs from wear causes uncomfortable and unstable inward rotation of the hips.

High Strength Lightweight Wheelchairso They are designed for long-term use by individuals who spend more than a

couple of hours each day in a wheelchair.

Ultralight Wheelchairso The ultralight wheelchair is the highest-quality chair that is designed

specifically as an active mobility device.o These chairs are usually highly adjustable and incorporate numerous

design features made to enhance the ease of propulsion and increase the comfort of the wheelchair user.

o Made of titanium or high strength aluminium and can easily weight less than 20 lb.

Heavy Duty and Extra Heavy Duty Wheelchairso Pertain to persons who weigh more than 250 lb.o These wheelchairs are heavier than the wheelchairs in the other classes,

to support more body weight.o Extra–heavy-duty” wheelchairs also referred to as bariatric wheelchairs

are built to support individuals who weigh between 300 and 1000 lb.o These chairs are built for transport and not self-propulsion.

Alternative Manual Wheelchairso Two alternatives worth mentioning are chairs for amputees and chairs for

individuals with hemiparesis.

o Wheelchairs for individuals with amputations are typically designed with the rear axle set far behind the user.

o This is needed because the absence of a leg causes the body’s center of gravity to be shifted posteriorly, thus reducing rearward stability.

o Unfortunately, all of the negative aspects of a rearward axle are present.o An alternative can be to add weight to the front of the wheelchair.

o For individuals with hemiparesis or other disability that makes propulsion with a leg or both legs superior to propulsion with the arms, a “hemiheight” chair is an alternative.

o In this chair, there is typically one footrest or none at all, and the seat is low enough to the ground so that the feet can reach the floor.

o For an individual with hemiparesis, the use of the uninvolved arm and leg can provide limited, but functional, propulsion.

o Another alternative for an individual with hemiparesis is a one-arm drive chair.

o This chair has two push rims on one side that control separate wheels. o One-arm drives are heavier than standard chairs and can be difficult to

control.o These limitations make them less than ideal for an elderly stroke patient.

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Pediatric Wheelchairso Pediatric manual wheelchairs are similar to the adult wheelchairs but are

smaller (seat width or depth <14 inches).o Several variables in system design need to be considered with children,

including developmental status, mobility, growth, age-appropriate activities, school, therapies, the environment, and family issues.

o Children not only change in size but their disability also often changes as they grow, even in nonprogressive disorders such as cerebral palsy.

o Mobility is the precursor to all childhood development. Children need to explore their environment to know where things are and how to get them. The need for specific types of mobility bases, such as strollers, self-propelled systems, and powered systems, will depend on the age and the physical, developmental, and functional capabilities of the child, as well as the environmental and transportation resources of the family.

o If the child is unable to self-propel the chair, a powered mobility device might provide independent mobility

Power Wheelchairs People who do not have the strength or stamina to propel manual

wheelchairs typically need power wheelchairs for mobility independence. Power wheelchairs can be grouped into four broad categories based on

wheelchair features and their intended use:(1) conventional power wheelchairs;(2) folding and transport power wheelchairs; (3)combination indoor-outdoor power wheelchairs;(4)heavy-duty indoor-outdoor power wheelchairs.

Use of powered mobility facilitates independence, improves occupational performance, and is correlated with a higher sense of quality of life for people who cannot ambulate or propel a manual wheelchair effectively.

1. Conventional Power Wheelchairs Conventional power wheelchairs are not programmable (e.g., no

adjustments in acceleration or deceleration, turning speed, joystick sensitivity) and have very basic seating with limited sizes available

They are low cost and low quality They are appropriate for limited indoor use for individuals with good trunk

control who do not need specialized seating.

2. Folding and Transport Power Wheelchairs Folding and transport power wheelchairs are designed for easy

disassembling to facilitate transport They are usually compact for indoor use and have a small footprint (i.e.,

area connecting the wheels) for greater maneuverability in confined spaces.

They might not, however, have the stability or power to negotiate obstacles outdoors.

The batteries are often housed in separate boxes having easy-to-separate electrical connectors.

These wheelchairs are typically used by individuals with reasonably good trunk and upper body control.

3. Combination Indoor-Outdoor Power Wheelchairs

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Combination indoor-outdoor power wheelchairs are often purchased by people who wish to have mobility indoors (home, school, work) and in the community, but who stay on finished surfaces (e.g., sidewalks,driveways, flooring).

These wheelchairs are equipped with standard proportional joysticks and standard programmable electronics (e.g., speed adjustment, tremor dampening, and acceleration control).

They come with either standard seating or rehabilitation seating . Rehabilitation seating allows for the attachment of modular seating

hardware (e.g., backrests, cushions, laterals, hip guides, and headrests).

4. Heavy-Duty Indoor-Outdoor Power Wheelchairs Heavy-duty indoor-outdoor power wheelchairs are for use by people who

live in communities without finished surfaces. These wheelchairs usually have large-diameter drive wheels with heavily

treaded tires or four-drive wheels for climbing obstacles and traversing rough terrains.

Wheelchairs that can support persons who weigh more than 250 lb also fall under this category.

These wheelchairs usually weigh 300 to 500 lb. Power seating options, such as tilt-in-space, power recline, and seat

elevation, can be integrated with wheelchairs to adapt for progressive medical conditions or severe disability.

Another advantage is that the position of the wheels with respect to the seat can often be changed.

Power wheelchairs typically use two deep-cycle lead acid batteries in series, each producing 12 V, for a total of 24 V.

There are two types of lead-acid batteries: wet-cell batteries and gel-cell batteries.

Power Bases The power base is the lower portion of a power wheelchair that houses the

motors, batteries, drive wheels, casters, and electronics to which a seating system is attached.

The base allows for the mounting of any variety or combination of different seating systems and seat functions, including tilt-in space, reclining back, elevating leg rests, and seat elevator.

Drive Classification: Power wheelchair bases can be classified as:

Rear wheel drive (RWD) Mid-wheel drive (MWD) Front wheel drive (FWD).

The classification of these three drive systems is based on the drive wheel location relative to the system’s center of gravity.

The drive wheel position defines the basic handling characteristic of any power wheelchair.

Each system has unique driving and handling characteristics.

RWD: In RWD power bases the drive wheels are behind the user’s center of

gravity, and the casters are in the front. The rear-wheel drive power wheelchair steers and handles predictably,

and naturally tracks straight, making it is the most appropriate drive configuration for high-speed. applications

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RWD systems are the traditional design and it is preferred by people who drive with special input devices (chin joystick, head array, etc.) or have reduced fine motor coordination.

A major advantage of an RWD system is its predictable drive characteristic and stability.

A potential drawback to an RWD system is its maneuverability in tight areas because of a larger turning radius.

MWD: Has been one of the fastest growing power bases in the wheelchair

industry In MWD power bases the drive wheels are directly below the user’s center

of gravity and generally have a set of casters or antitippers in the front and rear of the drive wheels.

The midwheel drive can be among the most effective at both ascending and descending obstacles for skilled and practiced users.

The advantage of the MWD system is a smaller turning radius to maneuver in tight spaces.

A disadvantage is a tendency to rock or pitch forward, especially with sudden stops or fast turns. When transitioning from a steep slope to a level surface (like coming off a curb cut), the front and rear casters can hang up, leaving less traction on the drive wheels in the middle.

These wheels are equipped with suspension and shock absorbance systems that enhance forward stability and small obstacle climbing capability.

FWD: A FWD power base has the drive wheels in front of the user’s center of

gravity, and the rear wheels are casters. The advantage of an FWD system is that it tends to be quite stable and

provides a tight turning radius. It is a very stable setup for uneven terrain and hills. It has the best

capability to climb forward over small obstacles. FWD systems may climb obstacles or curbs more easily as the large front

wheels hit the obstacle first. A disadvantage is that an FWD system has more rearward center of

gravity; therefore, the system may tend to fishtail and be difficult to drive in a straight line, especially on uneven surfaces.

The overall turning radius is smaller than that of rear-wheel drive, but larger than that of the midwheel drive power base.

The front-wheel drive power wheelchair has a tendency for the back of the chair to wander side to side (“fishtailing”), especially with increased speeds.

This directional instability requires steering corrections, which could make the wheelchair difficult for some users to steer.

Adavantages of Power Wheelchair Energy conservation Greater comfort Increased stability More accessories and extra options. Distance: Can travel long distances without fatigue Speed: Can travel at higher speed without fatigue Terrain: May be able to traverse rougher terrain

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Protect the arm: Avoid repetitive strain injuries that are due to manual wheelchair propulsion

Disadvantages of Power Wheelchair Less portability Weigh considerably more Require additional maintenance Decreased maneuverability (especially on certain terrains) Require more effort in terms of insurance coverage Expensive

Controls The majority of input controls are programmable, allowing changes in

speed and the amount of movement to determine the direction of the wheelchair.

Includes: Joysticks, Mini Joysticks, Sip and Puff, Switches and Buttons, Head array, Voice control.

Integrated Controls Wheelchair input devices are used for controlling both wheelchairs and

electronic aids to daily living or computers. When a single control interface (e.g., joystick, head switches, voice

recognition system, or keypad) is used to operate two or more assistive devices, the system is called an integrated control system.

Programmability Performance of a power wheelchair also depends on how the wheelchair

control module has been adjusted. Not all power wheelchairs are programmable, but programming or fine-

tuning the wheelchair to meet the needs of the individual user can improve control, safety, and maneuverability.

Fast and simple adjustments can be made for directional control (forward, reverse, and turning), speeds (acceleration and deceleration), and sensitivity of the joystick.

These adjustments affect how the wheelchair responds to different commands.

Power-Assisted Wheelchairs A developing class of wheelchairs provides a power assist when desired,

but allows the user to push the wheelchair as one would with a manual wheelchair.

Power-assisted wheelchairs have force/moment-sensing push rims that provide an additional torque to the rear axle proportional to the applied moment.

Such devices have potentially important benefits, such as allowing individuals to perform tasks faster and easier.

In addition, people who normally would need to use a power wheelchair are able to self-propel a power-assisted wheelchair despite obstacles such as steep ramps.

Finally, when using a power-assisted wheelchair, oxygen consumption and heart rate are significantly lower.

For individuals with upper-limb pain or tetraplegia, the power-assisted wheelchair may prove to be a good compromise between a manual wheelchair and a power wheelchair.

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These devices are particularly likely to help those with muscle paralysis or weakness, overuse, and fatigue.

They are also ideal for individuals who are apprehensive about transitioning to a fully powered wheelchair. This can be due to not wanting to be viewed by peers as being “more disabled,” having homes that do not accommodate the increased size, lacking the financial resources, or having difficulties with transportation.

Sports and recreation Wheelchair Sports and recreation wheelchairs are designed specifically for

participating in such athletic endeavours as racing, rugby, tennis, dancing and basketball.

Features:Lightweight frameWide wheel Camber

Some of the sport wheelchairs have only one wheel in the front, which allows quick turns and enhanced maneuverability

Individuals who compete in road racing will need competition chairs that have taken many of their design features from racing bicycles: narrow hard tires, lightweight frame, low seats, small pushrims for higher gearing.

For tennis and dance, the chair is slimmed down to its sleekest configuration with all its accessories, even wheel locks removed.

The backs are as low as possible to leave the user's upper body free for movement.

Scooters Provide intermittent mobility support for individuals with good arm

strength, trunk balance, and ability to transfer in and out of the device. These devices typically have a single front wheel for steering and two

drive wheels in the back. Steering is accomplished via hand bars that are intuitive to users who

have previously used a bicycle. Seating is provided in a chair having foam padding typical of a car seat. The backrest height ends at the level of the shoulder blades, which allows

for unencumbered rotation of the trunk. Have a greater degree of social acceptability than wheelchairs. Three-wheeled scooter are more common than four-wheeled scooters,

which can traverse more rugged terrain but are large for most indoor settings.

Compared with power wheelchairs, many scooters are relatively easy to disassemble for storage in a car or trunk.

Scooters also cost lesser than a typical power chair. They lack the capacity to allow modification of seating to accommodate

postural deformities and have limited control options. They cannot accommodate for changes as the user’s needs change, and

are not recommended for persons with progressive medical conditions such as multiple sclerosis and amyotrophic lateral

sclerosis. In general, scooters are a reasonable option for individuals who retain

some ability to ambulate, such as those with cardiopulmonary disease limiting the ability to walk.

AdvantagesLower Cost

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Easier to assemble and disassemble for transportationBetter than some chairs at rough terrain Less perceived stigma of disability

Disadvantages Less stabilityRequire greater arm strength and control to driveFewer seating optionsPoor turning radius

Stand-Up Wheelchairs Stand-up wheelchairs offer a variety of advantages over standard

wheelchairs. The ability of a person to achieve an almost vertical position has several

advantages, including physiologic (i.e., pressure relief, improved circulation and digestion, and improved bone density), practical (i.e., improved reach to higher surfaces, which increases functional independence), and psychological (i.e., interacting with colleagues face to face)

Stand-up wheelchairs are more complex than most manual or power wheelchairs.

All power wheelchairs with a stand-up feature use a separate electric drive system for the stand-up mechanism.

This type wheelchair has a very high center of gravity and can easily topple over.

User of a stand-up wheelchair should never transition into a standup position when outdoors or when on a cracked, rough, or broken floor indoors.

Stand-up wheelchairs are safe only on perfectly flat and smooth flooring, and only if the user is properly strapped and secured to the seat and seat back.

People who have not stood for a long time might not have the hip, knee, or ankle range of motion to accommodate standing, and can experience orthostatic hypotension.

The stand-up mechanism also adds weight to the wheelchair, making it more difficult to lift and transport.

Recliners Patients with poor postural control, abnormal tone, muscular shortening,

or skeletal deformities often require wheelchairs that offer varied positioning possibilities.

A frame which offers fixed or adjustable posterior tilt-in space orientation is needed.

These frames are combined with reclinable back or angle-adjustable seating surface.

Wheelchairs that tilt-in space with all their angles preset are called Tilt-in space Wheelchairs

They also offer components for positioning, such as head and torso supports.

Manual V/S Powered WheelchairManual Wheelchair Power WheelchairTransportation: Easy to transport; can Transportation: Difficult to transport

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travel with friends without special vehicles.

because of heavyweight; needs special vehicle to transport.

Maintenance: Doesnt require high maintenance; Can be workedon independently.

Maintenance: High maintenance concerns related to batteries or controllers.

Exercise: Theoretical benefitto the user from using own force to propel leading to promotion or maintenance of physical fitness

Exercise: Not much physical benefit to the user.

Chances of more RSI to UE due to wheelchair propulsion.

Protect the arm: Avoid repetitive strain injuries that are due to manual wheelchair propulsion

Aesthetics: Less appearance ofDisability

No Aestherics.

Distance: Cannot be travelled at longer distances; User gets fatigued.

Distance: Can travel long distances without fatigue

Speed: Cannot travel at higher speeds. Speed: Can travel at higher speed without fatigue

Terrain: Not much suitable for rougher terrain.

Terrain: May be able to traverserougher terrain.

WHEELCHAIR TRAINING: New wheelchair users should go through a wheelchair-training program. During this time the patient will learn:

- Basic movements within the chair- How to propel the chair in all directions.- How to operate the wheel locks, foot supports, and armrests.- Use the mechanisms safely without tipping forward or sideways out of the chair seat.- How to transfer in and out of the chair with maximum to least possible assistance.- To perform a Wheelie.- How to maintain Wheelchair

Wheelchair users can first practice basic maneuvers like wheelchair to bed, wheelchair to chair, or toilet(sideways and backwards).

Then in controlled environments like transition to uneven surfaces and slope transitions (i.e., level to sloped surfaces) in both the uphill and downhill directions and maneuvering through tight environments.

Once these skills are mastered, they should gradually tackle more challenging environments, such as steep grades and step transitions.

The rider should always practice with an appropriate lap belt and chest support in place, and a spotter (therapist) to assist if needed.

PROPULSION BIOMECHANICS

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The ability of an individual to propel their own wheelchair efficiently is influenced by many inter-related factors which can be summarised into three main categories:

Individual characteristics: Type and degree of disability, body dimensions, weight, co-morbidities, age, method of propulsion chosen by client, confidence and motivation

Properties of the wheelchair: Size and weight of wheelchair, size and type of wheels and tyres, adjustability of chair in relation to axle position, backrest height, footplate height and position, use of armrests

Wheelchair / client interface: The individual fit and set up of the wheelchair for an individual

Below are considerations when preparing a client for optimal propulsion efficiency in a manual wheelchair:

o Shoulder to axle alignment – the shoulder should be positioned over the rear wheel axle or slightly in front of the axle. This allows for the body’s centre of gravity to be slightly anterior to the axle resulting in minimal shoulder extension at the beginning of the push phase.

o If the wheel axle is placed too far back the individual must reach into the extremes of shoulder extension and wrist deviation to initiate an effective push.

o Rolling resistance increases as the axle is set further back, thus increasing the energy required to push the chair.

o A more forward axle has a detrimental effect on stability - in this situation anti-tip bars may be useful for client confidence

o Width of wheelchair compared to body - it is easiest to push a wheelchair if the wheels are close to the body, thus minimising shoulder abduction throughout the movement. Camber in the wheelchair is an advantage in propulsion.

o Distance of shoulder to axle of wheel – in the resting position with hands resting on the apex of wheel, shoulders should not be elevated and elbows should be flexed to approximately 60-70 degrees (from extended position)

o Stability of trunk in the wheelchair – this is especially important in high thoracic and cervical lesions

o Controlled slight forward trunk movement occurs in propulsion and aids in the application of force to the push rim.

Propulsion Techniqueo Propulsive strokes are generally described in two phases: when the hand

is in contact with the pushrim applying forces (push phase), and when the hand is off the rim and preparing for the next stroke (recovery phase).

o Four distinct propulsion patterns have been identified, which are defined by the path the hand takes during the recovery phase: arc, semicircular, single- looping over, and double-looping over.PUSH PHASE:

o The push rim is gripped between the thumb and index finger. The remaining fingers should be curled in to the palm to prevent getting caught in the spokes.

o With the hand positioned just behind the apex of the curve of the wheel, the user flexes at the shoulder and brings the hand (& wheel) forwards.

o The last segment of the push incorporates elbow extension and shoulder external rotation.

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o The wrist moves from radial to ulnar deviation. o This combination of muscle activity enables maximum force to be exerted. o Force is to be applied tangentially rather than vertically downwards.

RECOVERY PHASE:o Recovery of the arm involves release of grip from the wheelchair rim,

extension and internal rotation of the shoulder, flexion of the elbows and replacement of the hand behind the apex of the wheel ready for the next push.

TRANSFERSo The physical act of moving a patient from one surface to another is

described as a Transfer.o Wheelchair users generally need to transfer to the toilet, another chair or

to the bed.o When perfoorming transfers attention must be given to the use of body

biomechanics and forces needed by the patient and the assistant.Independent Transfers:

o For patients who perform standing transfers (independent or assisted), special attention should be given to the user's ability to get out of or back into the chair.

o Most chairs with cushioning allow a user to slide forward and come to standing.

o Some patients may benefit from adjustable height armrests.o The armrests are raised during sit-to-stand transfers.o Patients who are capable of independent community mobility benefit from

learning to do WHEELIES to negotiate existing curbs. The chair is balanced on the rear wheels while the front casters are elevated and then propelled forward to mount the curb.Dependent Transfers:

o Involve use of contraptions that help to tranfer.o This is done by:

Hydraulic Lifts or Hoists Manual Pivot Transfer Board Manual Lift Wheelchair Lifts

Hydraulic Lifts or Hoists: These are devices that are used for safer transfer of patients by raising

them with minimal effort from the helper. Hoists must have the capacity to lift weights of 100-150 kg, be stable

enough and have a braking system. Mobile hoists are used for severe disability like Quadriplegia, while static

hoists are used where transfers are more, like bathrooms. They work with hydraulic devices or electric motors and consists of a

metal framewith a canvas swinging from it. The patient is suspended from it, and hoists generate enough power to lift

him and transfer him. The caregiver must ensure good body alignment and positioning. One must assess patient's weight and check if it is within the capacity of

the particular lift. Then the hoist is moved to the bedside, and then brought to a level where

the leverage is minimal.

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Using the canvas sling, the patient is positioned and gently transferred to the sling, and later to the location where he or she needs to be transferred.

Care should be taken to prevent the head and LL from damage.

Manual Pivot: Helps swivel patient when getting out of a car or wheelchair.

Transfer Board: These are simple boards that come in many designs, but essentially

enable a patient to slide from wheelchair to bed, commode or carseat. They often come equipped with discs to enable pivoting and turning.

Manual Lifts: This is virtually the same as hydraulic lift except that manual power is

used instead of motors.

Wheelchair Lifts: This is a device that lifts the Wheelchair as a whole onto an area hitherto

inaccessible to it, like the first floor of building or a bus. Wheelchair lifts may be electrically or hydraulically operated.

POWER WHEELCHAIR TRAINING Power wheelchair training is slightly different and usually concentrates on

driving skill and safety. The initial challenge is to locate a reliable access control site and

method(e.g, hand control with a joystick, head control with individual switches).

Training then involves working with the user on consistent responses( especially to "stop" commands, or the recognized needs to stop based on the user's awareness) and accurate maneuverability.

Ensure the driver knows how to respond to a variety of situations, distractions and obstacles.

WHEELCHAIR MAINTENANCE A regular maintenance program for a manual wheelchair is important to

ensure it is functioning properly and to maximise durability. Below are some general guidelines for wheelchair maintenance and

troubleshooting problems. The wheelchair should be cleaned regularly. UPHOLSTERY Cloth upholstery fabrics and vinyl upholstery should be cleaned

weekly by wiping with a damp cloth and a mild detergent. Upholstery should be checked regularly for wear and tear. Sagging or torn upholstery in the backrest or seat sling can

cause significant deterioration in posture, and impact on pressure relief.

FRAME Chrome or painted surfaces should be wiped over weekly with a

cloth to remove dirt and maintain the finish The frame should be checked monthly for early signs of rust and

any evidence of metal fatigue or cracks in the welds.

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In folding frame wheelchairs, the folding mechanism should be checked for ease of use.

Any stiffness may be alleviated by using a small amount of silicone spray.

WHEEL TOE-IN/TOE-OUT The terms toe-in and toe-out refer to the alignment of the rear

wheels. Incorrect alignment may cause the wheelchair to veer in one

direction or affect how the wheelchair rolls. Adjustments to correct this are usually achieved by using

washers to space the axle block, either at the front or the back, whichever is appropriate.

It may be possible for one wheel alone to be toe-in or toe-out in relation to the other. This situation may cause the wheelchair to veer in one direction.

REAR WHEELS The wheels should be checked monthly to see if they spin freely

and stop smoothly. Check whether the wheels run parallel in a straight line. There should be little sideways movement present. Excessive sideways movement of the wheel may also be caused

by loosening of the nuts holding the axle or axle block in place. The tension of the nuts and bolts should be checked and

tightened if necessary. Spoke tension should be checked every few months, more

frequently if the client is an active user. Loose, broken or bent spokes may cause the wheel to buckle or

warp, leading to deterioration in performance. CASTERS Lint and hair can build up quickly around the inside and outside

of casters. This may restrict free movement, making it harder to push and

turn the wheelchair. This should be removed by removing the caster from the caster

fork assembly. Care should be taken not to over tighten the nuts when replacing the caster.

Grinding noises or excessive sideways movement may be due to worn bearings. Replacement may be necessary by a qualified person.

Excessive caster wobble may also be due to the loosening of the nuts on the caster fork or stem bolt. Check these nuts for tension, but take care not to over tighten them, as this may restrict free movement of the caster.

TYRES Tyre pressure should be checked weekly and kept inflated to the

manufacturer’s recommended levels. Tyres should be replaced if worn. If fabric or canvas is showing

through, they should be replaced immediately. Worn tread may result in poor traction, particularly in the wet,

and may affect the efficiency of brakes. The tyre will also be more susceptible to puncture.

BRAKES

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Brakes should be checked weekly to ensure that they are operating at their best.

As brakes are a safety feature of the wheelchair, malfunction may result in injury.

The mechanism should not be excessively loose, but should not be so tight that it makes them difficult to operate.

Once every 6 months, the wheelchair should have a complete overhaul by the manufacturer, particularly if used outdoors.