Wheelchairs, Community Mobility & Driving🦼🚘

Building W/C Compliance Dimensions (doorways, hallways, pathways, ramps, parking spaces, counters)

-Doorways- minimum 32” (but ideally 36”)

-Hallways- minimum of 36” (need room for person to propel W/C without scraping hands)

-Pathways/walkways- minimum of 36”

-Ramps- minimum of 36” wide

• for building ramps for every 1 inch of height, need 1 foot of length

• Railings should be 34-36” high

• Curbs/edge protectors should be 4” tall to prevent wheel/walker/cane/crutch tips from slipping off edge

• Landings should be a 5×5 ft and are needed for long ramps and ramps that lead to doorways

-Parking spaces- ideally 5 ft of adjacent space, but minimum 48”

-Countertops- maximum height of 36” (lower usually preferred)

Ways to Widen Existing Door

-removing door stops adds 3/4” of width

-replacing hangers with offset hinges can add up to 2” of width

What do state One-Stop Centers, Vocational and Educational Services for Individuals with Disabilities (VESID), Offices for Vocational Rehabilitation (OVRs) and Divisions of Vocational Rehabilitation (DVRs) do?

Pay for home/work mods AND/OR driver rehab if they enable a person to go to work or school

Different Types of Walkers & their Indications

Standard Walker

• Requires pt to have fair balance/ability to lift device with UE

Rolling Walker

• Useful for pts who cannot lift a standard walker

Hemi-Walker

• Pt uses on non-affected side

• Useful for those who are unable to use both hands AND need more stability than a cane

Rollator (Three-Wheeled Walker)

• Has large wheels and fold-down seat for pt’s who need increased stability and/or fatigue easily

Benefits, Purposes & Drawbacks of Scooters

-helpful for distances and navigating uneven/steep terrain

-good alternative to a manual W/C for people who have good trunk stability but poor strength/endurance for propelling W/C

-lighter/more portable/cheaper than power W/C

-less supportive/less customizable than power W/C

-larger turn radius than power WC

Wheelchair Arm Rest Types & Benefits (Detachable, Height Adjustable, Desk Arms, Full Arms, Wraparound)

Detachable

• helpful for transfers

Height Adjustable

• helpful for transfers

• Helps to support lap tray

Desk Arms

• allows person to move closer to work surfaces

Full Arms

• Helps to support lap tray

Wraparound

• AKA space saver arm rests

• Reduces width of W/C by 1 in.

Wheelchair Foot Rest Types & Benefits (Swing-away, Detachable, Elevating, Limb Board)

Swing-away

• helps for safe transfers and front approach to W/C without obstruction

Detachable

• gives safe path for transfers

Elevating

• good for edema management

Limb Board

• provides support to residual limb after a LE amputation

Wheelchair Heel Loop Purpose

Prevent feet from slipping off footrest posteriorally

Wheelchair Arm Trough Purpose

-Support hypotonic UE

-Prevent edema through elevation

-Good for individuals with stroke/hemiplegia

-Lapboards can help with the same while also adding a surface to work on

Wheelchair Head Support Purpose

-Improves neutral head positioning for better eye contact, communication, and feeding

Mobile Arm Support Purpose

-Helps to use UE that has proximal weakness for feeding and other activities

-Useful for high level SCI pts

Pelvic Stabilizer

-Limits pelvic tilt/rotation/obliquity

-AKA belt, SubASIS bar

Thoracic Supports

-Facilitates trunk stability, prevents/slows scoliosis

Wheelchair Thigh Supports

-Help to control abduction/adduction of thighs

-Good for windswept deformity

Hand-Rim Projection Purpose & Drawback

-Help ind. with weak hand grip to propel independently

-Inc. width of W/C

Hillholder Device Purpose

-Allow W/C to move forward but automatically brake when the chair goes backward with a level that attaches to each wheel

-Useful for ind. who have difficulty going up a steep grade without resting

What does increasing the camber (outward angle) of wheelchair wheels do?

Provides greater lateral stability, smoother ride, and increased maneuverability of W/C

⚡️helpful for W/C rugby

Standard Dimensions for Wheelchairs (Adult & Pediatric)

W/C Type	Seat Width (in.)	Seat Depth (in.)	Seat Height (in.)
Std. Adult	18	16	20
Narrow Adult	16	16	20
Slim Adult	14	16	20
Hemi-/Low Seat	14	16	17.5
Junior	16	16	18.5
Child	14	11.5	18.75
Tiny Tot	12	11.5	19.5

*Hemi-height W/C makes it easier for client to self-propel using their feet

What does observation of pt sitting on a mat table tell you? (Hands-free vs. hands-dependent vs. propped)

Hands-free

• W/C can emphasize mobility, stability (stable base of support), and comfort

Hands-dependent

• W/C needs pelvic and trunk support

Propped

• W/C needs total body support

Wheelchair Custom Measurements

Seat Width

• measure widest point at hips/thighs and add 2 in.

Seat Depth

• measure between back of butt and back of knee (popliteal fossa) then subtract 2 in.

• Measure both LEs and use SHORTEST length

• This prevents rubbing that could lead to skin irritation/ulceration

Back Height

• Varies depending on trunk control, size, activity level, and strength

• Higher back height

  • Provides more support for person with weak trunk

  • Can make W/C harder to fit into car

• Lower back height

  • Allows for better mobility

  • Useful for sports chairs

Seat Height

• Knees/ankles should be positioned at 90 degrees

• Measure from side of thigh to heel and use SHORTEST length between both LEs then add 2 in. To give clearance to floor

• Remember seat cushion adds height

Armrest Height

• Shoulders should be neutral with elbows flexed to 90 degrees

• Measure under each elbow to cushioned seating surface

• Armrests that are too low

  • Cause person to lean forward

• Armrests that are too high

  • Cause shoulder elevation

  • Make self propelling difficult

Reason to Move W/C Rear Axle Forward

-To maximize stability for obese individuals since they have a center of mass that is further forward

-Allows for more efficient arm push that requires less wrist extension

-Makes propulsion easier to have axle in front of center of gravity, but reduces stability (add rear anti-tippers)

Reason to Move W/C Rear Axle Backward

-To maximize stability for individuals with LE amputations since they have a center of mass that is further backward

-May instead want to add anti-tippers in back to avoid tipping over backwards

Tilt-and-Reclining Wheelchair

-High back reclines independently of rest of the chair

-Provides pressure relief, regulates BP, improves respiration, and provides support for individuals who are unable to independently maintain upright sitting position

-Since these W/C extend angle of hips, they can elicit flexor/extensor spasms and SHOULD NOT be used with clients who have spasticity

Tilt-in-space Wheelchair

-Entire seat and seat back tilt, maintaining 90 degree seated position

-Helps provide pressure relief, regulate BP, improve respiration, and mimics abnormal tone’s impact (like severe extensor spasms that can throw a person out of the chair)

⚡️Space Mountain (seat reclines like a rollercoaster)

One Arm Drive Wheelchair

-Individual can propel and steer W/C using cane-like device on one side

-Useful for clients with hemiplegia or a single UE amputation

Important Education to Provide for New Wheelchair Users

-Proper sitting posture

-Pressure relief methods and time schedule

• typically weight shift every 15-30 mins

-Purpose and use of devices added to wheelchair (cushions, lapboard, etc.)

-Methods to propel W/C

-W/C safety

• locks

• Moving leg rests/arm rest for transfers

• Safely using power W/C

• How to fall from W/C and get back in as safely as possible

• How to secure W/C on public transportation

-How to maneuver W/C through community

Wheelchair Cushions- Heavy vs. Light

-Light cushions often preferred by individuals who self-propel long distances

-Heavy cushions are more comfortable and are often preferred by individuals who spend long periods of time seated without propelling far

Passive (Static) Stander

-Remains in one place (CANNOT be self-propelled)

Prone Stander

-Requires good head control

-Can reduce effect of TLR

Dynamic Stander

-Stander remains stationary but ind. can move on base of stander

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Positioning Cushions (see page 574 in TherapyEd)

-Anti-thrust

• Keeps person from sliding forward

• Key for pts who have tendency to push against back of W/C

• May person with lumbar lordosis have a more neutrally positioned pelvis

-Wedge

• Reduces forward sliding for person who slumps by angling them to slide towards the back of the chair

• Useful for clients who have pelvic kyphosis

-Pommel

• Helps keep hips/knees separated

  • Good to prevent shearing

  • Good post hip replacement

• Blocks person from sliding out of chair

-Lateral Leaning Cushion

• Corrects position for Ind. with pelvic obliquity/tendency to lean to one side

Different Cushion Materials

Air Filled

• Lightweight

• Even pressure relief

• Bad for postural stability

Alternating Pressure

• Provides scheduled pressure relief through alternating levels of inflation/deflation

• Reduces postural stability

Foam

• Lightweight

• Cheap

• Can flatten out over time

• Heat and moisture can build up

• Shearing and wight=shifting capability are reduced

Gel

• Adequate for postural control/good postural stability

• Sensitive to temperature

• Heavy

• Can Leak

Honeycomb-shaped Plastic

• Lightweight compared to gel

• More stable compared to air filled

• Provides uneven pressure relief

How long can a custom W/C take to ship?

Up to 6 months

Ulcer Stages

Mobility-Related Activities of Daily Living (MRADLs)

-According to Medicare these include

• toileting

• Bathing

• Grooming

• Dressing

• FeedinG

-For Medicare to cover mobility assistive equipment (MAE) they must help a person participate in otherwise impaired MRADLs

General Transfer Advice for Patients

-Anterior pelvic tilt (to move the center of mass over the center of the client’s body)

-Angle heels toward the surface to which the client is transferring (for easier pivot)

-Pushing up from transfer surface (i.e. bed/WC armrest) to assists in the transfer; client may also reach toward surface they are transferring to (i.e. bed or wheelchair)

Medicare WC Codes

Standard- K0001 (weighs 36 lbs or more)

Lightweight- K0003 (weighs 34-36 lbs)

High-strength Lightweight- K0004 (weighs less than 34 lbs and has adjustable frame)

Ultra-lightweight- K0005 (weighs less than 30 lbs, has adjustable rear axle, rear wheels have quick release, chair is more customizable)

Heavy-duty- K0006/K0007

Assessment of primary client factors that are essential for driving (e.g. cognition, vision, visual-perceptual skills, motor skills)

Driving Risk Assessment

A comprehensive blueprint for maintaining social participation through diverse means of community mobility as an alternative to independent driving or to facilitate transition process to a non-driver

Transportation Plan

True/False- Community mobility is the right of every person?

True

True/False- Driving is the right of every person?

False- driving is a licensed and regulated privilege

Public Transportation (Fixed-Route Systems, Demand-Responsive Systems, Paratransit Service)

• Fixed-Route Systems

  • Use defined routes with predetermined stops on a schedule

  • Ex: bus, subway, train, light rail

  • Most economical and predictable

• Demand-Responsive Systems

  • Transport for ind. with impairments that limit access to regular fixed-route systems

  • Rides are generated by calling transit operator

  • Transportation is provided between specific point of origin and specific requested destination (i.e. from supervised apartment to work)

  • Often multiple passengers with different destinations in same vehicle

  • Availability of physical assistance for riders varies

• Paratransit Service

  • ADA compliant transportation that picks ideas up outside of their home and takes them to specific locations

    • Curb-to-curb- picks up passenger at curb of home and drops off at curb of destination

      • Drivers may assist with getting rider on and off vehicle, but not beyond the curb

    • Door-to-door- riders are assisted from doorway of origin to the entrance of their destination

      • Drivers do not assist beyond entries

  • Ex: van, shuttle, microbus

5 A’s for Determining Ideal Senior-Friendly Supplemental Transportation

• Availability

• Acceptability

• Accessibility

• Adaptability

• Affordability

Assistance Levels of Supplemental Transportation

• Door to door

• Door through door- assists passengers to exit from their pickup spot to vehicle and enter into the building of their destination

  • Arm through arm- similar to door through door, but species physical assistance

Commercial Transportation

• Airline/train- aka commercial carriers

• Taxi

• Rideshare

• Shuttle/Van Service aka small-vehicle fleet

Safe, Accountable, Flexible, Efficient Transportation Equity Act

(SAFETEA)

-Creates safer environments around schools to encourage children to bike/walk to and from school

Hierarchy of Driving Behavior (3 Levels)

- Strategic Behaviors- general goal decisions (trip decisions)

• Occur before/during driving

• Can occur in minutes or hours

- Tactical Behaviors- conscious decisions made while operating a vehicle in response to changes in road conditions and traffic/driving risks (maneuvers, car handling, staying safe distance from other cars)

• Can occur in seconds to minutes

- Operational Behaviors- primarily subconscious (steering, accelerating, turning, braking, backing up, parking)

• Occur in seconds

Driving & Vision

-Acuity

• test with Snellen chart

• If corrected vision is WORSE than 20/40, refer to vision specialist

-Ocular Motor Skills

• Fixation- ability to hold eyes steady

• Saccades- ability to accurately change visual targets

• Pursuits- ability of eyes to follow moving targets

-Visual Field- the more narrow the field, the more dangerous the driver

-Contrast Sensitivity- poor sensitivity is especially dangerous at night, in rain, or in fog

• Commonly associated with cataracts and glaucoma

Visual Perception & Driving

-Visual closure skills are important because drivers need to be able to mentally “fill in the blanks” when part of environment is occluded

• ex: part of sign is covered by tree branch

-Visual spatial skills are important because drivers need to know where they are relative to other drivers and objects in the environment

Cognition & Driving

-Limitations can lead to difficulty with finding the way, recognizing signs, dual-task driving, and could lead to increased distracted driving

-Minor limitation can be compensated for, but significant impairments warrant driving cessation

OT Driving Screening Skills & Tools

-Screen client’s reaction time, visual acuity, and decision making skills

-Common tools

• General Assessment of Driving Related Skills (Clinician’s Guide to Assessing and Counseling Older Drivers)

• Driving Health Inventory

• OT-Drive Model

• Motor-Free Visual Perception Test

• Clock Drawing Test

• Useful Field of View

• Assessment of Motor and Process Skills

• Trail-Making Test

-Refer to driving rehab specialist if there are concerns

General Assessment of Driving Related Skills (Clinician’s Guide to Assessing and Counseling Older Drivers)

Document from American Geriatric Society that includes screenings/assessments, clinical interventions, ethical/legal issues of driving, state licensing/reporting laws and medical conditions

Driving Health Inventory

Computer-based assessment that looks into various contributors to crash risk…

• vision

• Cognition

• Motor function

OT-Drive Model

Model that helps with decision making about driving/community mobility

• risk determination is based on evidence and clinical judgment

Motor-Free Visual Perception Test

Assesses various visual-perceptual abilities…

• spatial relationships

• visual closure

• visual discrimination

• visual memory

• figure ground

Do not need to use any motor skills to make responses

Clock Drawing Test

Can detect difficulties with visuospatial skills, visual perception, selective attention, memory, abstract thinking, and executive functioning

Useful Field of View

3-part computer-based cognitive assessment to determine crash risk by assessing…

• central vision loss

• cognitive processing speed

• Divided attention

• Selective attention

Assessment of Motor and Process Skills

-Standardized/observation-based assessment of quality of ADL performance

Trail-Making Test

Measure cognitive flexibility, motor control, perceptual complexity, visual scanning, and executive function

Driving Habits Questionnaire

Self-report that gathers info about avoidance behaviors that are often compensatory strategies in older drivers

Fitness-to-Drive Screening Measure Short-Form

Self-report with 21 items used to screen at-risk older drivers

Assessment of Readiness for Mobility Transitions

Assesses readiness of older adults to make transitions regarding mobility, including driving cessation

Assessment for Driving Related Skills (ADReS)

-Quick 10 minute clinic screening for driving related performance for DOCTORS/PHYSICIANS developed by AMA

When should OTs refer to certified driver rehab specialists?

When clients have community mobility issues that go beyond general evaluation and intervention

Driving Education, Adaptive Equipment & Compensatory Strategies

-Educate on visual scanning techniques

-Adaptive Equipment for Driving

• HandyBar/Stander/Logan/Utah- gives stability for entering/exiting car

• Leg Lifter- helps to position legs with weakness in/out of car

• Manual/power seat lifts- help with transfers in/out of car

• W/C Lifts/Ramps- help get W/C between street and car

-Compensatory Strategies for Driving

• Only use familiar routes

• Do NOT drive at night

• Drive during off-peak hours

• Avoid freeways

• For visual field deficits clients can compensate with extra head turns and eye movements

Driver Rehab Adaptations

Many help for individuals with amputations/hemiplegia/ high level SCIs

• Hand controls- replace gas and break foot pedals

• Steering knobs- for one-handed steering control

  • Standard Round Spinning Knob- need one intact UE

  • Ring- accommodates prosthesis

  • Tri-Pin/Cuff- accommodates absent/weak grasp

• Pedal extensions- help if feet do not reach standard pedals

• Zero/Reduced Effort Steering- accommodates for decreased ROM, strength, and endurance

• Back Up Camera- helps with limited neck mobility

CarFit

-Improves fit and use off vehicle to enhance performance and safety

-Developed by AAA, AARP, and AOTA

Driving Intervention Areas for Teens

• increasing independence

• Managing impulse control

• Reducing stress

• Regulating sensory input

• Handling an emergency

OT Services/Supports for Driving Cessation/Inability to Begin Driving

• Training in other transportation options

• Introducing client to community mobility resources

• Providing travel training for fixed-route transit systems

• Developing community mobility plan

What ethical principle does reporting unsafe driving fall under?

Nonmaleficence