WHEELCHAIRS

MANUAL WHEELCHAIR COMPONENTS FRAME AND AXLE WHEELS AND TIRES HAND RIMS BRAKES AND GRADE AIDS CASTERS/ARMRESTS/LEGRESTS SEAT AND BACK

FRAME AND AXLE

Frame types include: Standard (50+ lbs.) Lightweight and Ultralight (40 lbs / 15-28 lbs) Semireclining and reclining (high back) Rigid vs folding Adjustable vs fixed axle plate

Amputee – fixed further back, harder to reach wheels but won’t tip

FRAME AND AXLE

Weight affects loading in cars, initial getting up to speed

Rigidity affects performance, stowage method some rigid have pop-off wheels, fold-down back some folding have good lockout

Axle plate adjustability control tipping, center of gravity vs rotation,

height and angle along with wheel size

WHEELS AND TIRES

SIZE AND PLACEMENT Height, ease of rolling and pushing, transfers Camber (bottom edge out) up to 7 degrees for stability and

performance – increases width

TYPES Solid smooth for indoors Threaded pneumatic smoother and maneuverable on rough

ground, require maintenance; no-flat inserts heavier Mag vs spoke wheels – weight, performance, maintenance

CASTERS

Usually in front, great turning but less stability if behind, used for first chair such as Quickie Kidz

Smallest (4”) and hard good turning, poor for outdoor use.

Large pneumatic for uneven or soft ground beach chairs with four of them may contact foot plate if footrests long and not

angled

The Roseannadanna Principle of Seating and Mobility

“It’s always something.”

(Welcome to Trade-Off City.)

HAND RIMS

Small diameter and smooth rims for high speed racing Push 360 degrees instead of just top

Large rims maximize maneuverability and power Modification for better grip (e.g. C5-6 quadriplegia)

Coating Increase tube size Add projections (“quad knobs”) or bumps

WHEEL LOCKS (Brakes)

Position handles for easy (or not so easy) reach and avoid interference with propulsion

Extensions may help with limited reach, grasp or poor balance

For active user with long stroke, position lower to avoid injury to digits

Omitted on some sports chairs

GRADE AIDS/HILL HOLDERS

Prevents wheeling backwards down a gradient; wheels locked soon after the wheelchair starts to reverse.

Can be flipped out of the way to allow reverse movement

Price about $200.00. Use with mild weakness; strong

pushers could activate in wheelie Info and pix courtesy of ILC

Australia http://www.ilcaustralia.org/search4.asp?State=NSW&MC=43&MinC=72&Item=2244&page=8

ARMRESTS

Aid in transfers and weight shifts, remove weight of arms from seat pressure

Recommended for T6 or above SCI for stability BUT not a true trunk support, active users may omit

Needed to support tray, arm trough, balanced forearm orthosis Types:

fixed (cheap, but bad for lateral transfer) adjustable (helpful with tray position, etc.) removable, flip or swing away (good for part time tray use, lateral

transfers) desk or full length (roll under desk, vs use with tray) (trays may be for positioning, not everyone needs one; can raise desk or

transfer out instead)

LEG AND FOOT RESTS

Protection Padded footbox for deformity, pressure

Positioning and partial weight bearing Correct length important May add shoe holders, ankle straps for antithrust

with spasticity Reduces equinus contracture risk

Balance

LEG AND FOOT REST TYPES

Standard fixed Swing away or flip up for forward transfer Removable – ditto, but may get lost Elevating

Help control edemaLess maneuverable, longer effective wheel baseMay not work if hamstrings or knees tightRequire calf padsRequire medical justification

SEAT AND BACK

Back height – support vs. freedom of movement Within 2” of lower scapula for moderate support

(e.g. partial trunk, normal head control) Shoulder height if needs harness Lower OK for sports and active users Too low decreases efficiency due to instability

SEATING TYPES

Assess spasticity, involuntary movement, and motor control

Assess fixed vs flexible and symmetric vs asymmetric deformity

Assess protective sensation Most people need at least solid (planar)

seating to avoid sling effect if using for more than temporary transport; fill-in cushions exist for inexpensive solution

THE GRID

Goals = HD to HF, Propped sitter upright and able to interact

SEATING TYPES / GROUPS

Group I – Mild or no deficit in postural control, no significant deformity – generally use planar seating

Group II – Moderate deficit in postural control, some flexible and/or symmetrical deformity (e.g. posterior tilt, “symmetrical slump”) – need contoured seating such as Jay systems

Group III – Severe deficit in postural control, fixed or asymmetrical deformities – both generally required to justify custom molded seating

SEATING TYPES / EXCEPTIONS

Short femur alone may need only seat cut-out

Movement disorder (e.g. athetosis) or ataxia may “move up” a notch (e.g. custom mold for functional stability even if not severe deformity) ASK PATIENT PREFERENCE!

Don’t take away ability to self-adjust or fidget for comfort and optimal pressure relief if you don’t have to; custom fit is good, but movement is better.

PRESSURE RELIEF AND STABILITY

Sensation and cognition as well as motor function protect from sores

Pressure mapping can help select Best pressure relief may be very unstable,

promote deformity in growing child Consider maintenance and temperature also Compromise seating readily available

SHIFT AND LIFT!

CONFIGURATION ISSUES

TILT VS RECLINE Fixed tilt back 3-5 degrees with 90 degree seat to back angle

stable and comfortable for anyone Recline (open seat to back) increases extensor tone effects

and shear forces, may be needed for some post-op casting as temporary measure or with hip extension contracture

Open seat to back may accommodate kyphus Closed seat to back has antithrust effect Reverse wedge seat is posture aid if tolerable and motor

control potential is there (e.g. hypotonia but good strength)

Tilt-In-Space chairs

Passive pressure relief Challenge and rest/support periods Heavier, foldability and

transportability question Respiratory care, feedings Can’t usually self-propel

TROUBLESHOOTING 101

CORRECT SIZE!!!!! Too wide = poor support, can’t reach wheels Too deep = forces slouch due to popliteal

impingement Too short footrest = knee to nose, high ischial

pressure

PELVIC POSITION AND STABILITY FIRST Legs can point off to one side, pelvis should not Then look at trunk, then look at head and neck.

WC MEASUREMENT

Seat 1" wider than widest part of buttock, 2” for growing child, want adjustable frame width

Seat height 2" higher than heel to popliteal fossa unless planning foot propulsion, make sure footrest can be angled to clear casters; child may be at 90 degrees and a little higher

Seat depth 1-2" shorter than back of buttock to popliteal fossa in child, OK for a little more in adult

PELVIC POSITION

ANTERIOR PELVIC TILT Top forward in sagittal plane Lordosis, tight or short back extensors Some cases with hypotonia Hip flexor or ITB contracture

POSTERIOR PELVIC TILT Top back in sagittal plane Slump, sacral sit, kyphosis Hamstrings Extensor tone

LATERAL TILT OR ROTATION (“OBLIQUITY”) Scoliosis, hip dislocation, asymmetric tone

BAD HAMSTRINGS

SPINAL DEFORMITY

Try to get upright, centered trunk position May use trunk supports, accommodate some

pelvic tilt or obliquity “Ya can’t do orthopedic surgery with a

wheelchair” – even custom mold may not stop progression, TLSO may be better

Lumbar supports, manipulate tilt and recline

HEAD POSITION

CRITICAL INFLUENCE ON PRIMITIVE REFLEXES MUSCLE TONE UE FUNCTION SWALLOWING VISUAL ORIENTATION

Anterior or posterior supports available Allow as much mobility as possible

Cervical support in transportation

Comfort rather than safety

Use any soft device, UNATTACHED

Danmar/Hensinger headrest/UMTRI

POWER CHAIRS

FOR INDIVIDUALS WHO CANNOT PROPEL A MANUAL WC DUE TO

WEAKNESS POOR ENDURANCE CARDIAC OR RESPIRATORY LIMITATIONS LIMB ABSENCE PARALYSIS DEFORMITY EXCESSIVE DISTANCE OR TERRAIN TOO SLOW FOR DISTANCE OR SITUATION

POWER PREREQUISITES

Reasonable cognitive function, behavior and judgement. (VERBAL SKILL, DRIVING PERMIT OR LICENSE NOT NEEDED; some discipline needs / doing donuts OK.)

Reasonable visual function usable for mobility (PILOT’S LICENSE NOT NEEDED EITHER)

Reliable method to interface with the motor and controls. Proportional (joystick) vs switch Adjustment can include speed limitation, high sensitivity if very weak, low if very ataxic Other options: Sip’n’Puff, stop with switch off for startles

Some way to store and transport the chair.

My Favorite Seating Clinic Story

U of Mich, A2

10 year old with CP

POWER BASE OPTIONS

DIRECT DRIVE MOTORS Small balloon tires used Durable, short wheel case and good for rough terrain Easy turning

DRIVE POWER LINKAGES Large solid rubber rear tires, small front pneumatic tires Higher speed, more stability

WC CHECKOUT

DO NOT HAVE WC DELIVERED DIRECTLY TO PATIENT

HAVE IT DELIVERED TO CLINIC P.T. CAN CHECK IT TO MAKE SURE IT FITS THE

PRESCRIPTION CHAIR CAN BE RETURNED IF SOMETHING IS

WRONG OR MISSING HAVE P.T. CHECK OUT PATIENT IN WC TO MAKE

SURE IT FITS AND THEY CAN USE IT CORRECTLY

POWER BASE OPTIONS

Scooters Limited seating options (captain’s chair) but some

regular power systems also problematic (La-Bac) Easier turn, easier in and out, a little less stable

Front, mid, or rear-wheel drive best traction and turn with mid (Jazzy, others)

Power tilt and recline Shear and repositioning if recline Adds height Independent pressure relief and comfort

Standing or elevating chairs, stair climbers May cover if vocational needs, very heavy and expensive

HOW TO RUN A SEATING CLINIC IN AN IDEAL WORLD

Seating and mobility is complicated, costly, and complex Physiatrist assesses medical and surgical history and

plans, does exam for spasticity, PROM, deformity, skin integrity, sensation

Physiatrist writes the Rx and medical necessity PT and/or OT and vendor are minimum team Vendor certification and conflict of interest issues need

attention “up front” Ideally have patients sign off, see pix, RTC for fitting

ALWAYS ADDRESS TRANSPORTATION SAFETY

Not OK to put power chair in back of pickup truck with patient in it, even in Arkansas.

Using regular seat safer as long as not excessively reclined for trunk control

Adaptive car seats and generally covered items. Everyone with a chair does not need a van and lift. If it is needed, ride forward facing with tie downs to

frame and separate occupant restraint.

MEDICAL NECESSITY

Medicare more strict if you are honest (NO walking ability, NO recreational use, NO bath equipment, 100% home use only

Theory is item not desirable in absence of disability Medicaid more based on need for item due to medical

diagnosis. “Payor of last resort” principle also. “Convenience” item never approved Social and educational reasons may not be medical

enough Time limits (2 years for child, 5 for adult on ANY

wheelchair or stroller, no chair until 2) absolutely rigid Police reports needed if lost in burglary or fire

Be prepared to appeal.