Wheelchair Selection and Mobility

Wheelchair Maneuverability

  • Front-wheel drive chairs:
    • Advantages: Better at navigating ruts and potholes, good turning radius, easier to get close to walls (e.g., for sink access).
  • Mid-wheel drive chairs:
    • Advantages: Smaller turning radius compared to front-wheel drive.
  • Rear-wheel drive chairs:
    • Disadvantages: Largest turning radius, difficult to maneuver in tight spaces, poor for close wall access.

Special Purpose Wheelchairs

  • Sports Chairs (Ultralight Chairs):
    • When ordering, specify "multi-adjustable ultralight wheelchair" to avoid insurance denial.
    • Features:
      • Rigid frames.
      • Lower backrests for greater maneuverability.
      • Cambered wheels for enhanced propulsion.
      • Specific handrims.
      • Adjustable axles for personalized positioning.
  • Standing Wheelchairs:
    • Enable users to stand for professions or activities like golf.
    • Example: A medical student with paraplegia used a standing power wheelchair in the OR.
  • Aquatic Wheelchairs:
    • Designed for water activities like fishing.
  • Rock Climbing Wheelchairs
  • Standing Frame Chairs:
    • Facilitate reaching counters or filing cabinets.
  • IBOT Chairs:
    • Unique chairs designed to navigate stairs.

Wheelchair Cushions

  • Importance:
    • Essential for individuals sitting for extended periods to maintain blood flow and prevent skin breakdown.
    • Enhance comfort.
  • Types:
    • Foam Cushions:
      • Pros: Inexpensive, washable.
      • Cons: Poor memory (compress over time), can develop permanent depressions.
      • J Cushions: Contoured foam cushions for postural adjustment (can cost up to 300).
    • Memory Foam Cushions:
      • Pros: Recovers shape after compression, better positioning tool.
      • Cons: More expensive than standard foam.
    • Gel Cushions (e.g., Jay Cushions):
      • Types: Full gel base or gel-foam combination.
      • Pros: Excellent support and cushioning for ischial tuberosities, easily cleaned.
      • Cons: Heavy, more expensive, gel can leak if punctured, can freeze in cold temperatures.
    • Air Bladder Cushions (e.g., Roho Cushions):
      • Price range: 200-$400+.
      • Features: Individual air bladders for pressure relief and support.
      • Low Profile: More stability, less pressure relief.
      • High Profile: More pressure relief, less stability.
      • Custom Options: Combine high and low profiles for optimal support and stability.
      • Pros: Washable, patchable.
      • Cons: Deflation renders them ineffective; requires a spare.
    • Honeycomb Cushions (e.g., Stimuli Cushions):
      • Features: Honeycomb-shaped plastic for pressure relief.
      • Pros: Good pressure relief, easy to wash (machine washable in cold water, no dryer), sturdy, lightweight.
      • Cons: Less soft than air or foam cushions, limited customizability, moderately expensive.

Wheelchair Parts and Modifications

  • Components:
    • Push handles.
    • Seat and back (can be modified).
    • Armrests.
    • Wheels.
    • Footrests and footplates.
    • Caster wheels.
  • Brakes:
    • Push to lock: Push forward to lock.
    • Scissor brakes: Scissor-like structure under the chair.
    • Pull to lock: Pull up to lock.
  • Footrests:
    • Standard footrests: Swing away.
    • Elevating leg rests.
    • Full footrests: Support entire calf and foot.
    • Rigid frame footrests: Attached, minimalist support.
  • Heel Loops and Leg Loops:
    • Heel loops: Prevent feet from sliding off the footrest.
    • Leg loops: Provide more support for individuals with difficulty keeping feet on the footrest.
  • Caster Wheels:
    • Size: 3 to 8 inches in diameter.
    • Types: Hard plastic, pneumatic, semi-pneumatic (air core, flat-free).
    • Larger, cushiony casters: Better shock absorption and rough terrain navigation.
    • Smaller, harder casters: Easier mobility but prone to getting stuck.
  • Drive Wheels (Rear Wheels):
    • Size: Typically 24 inches.
    • Types: Solid rubber, semi-pneumatic, fully pneumatic.
    • Rims: Spoked or mag (plastic) rims.
      • Spoked rims: Absorb shock, keep tire true.
      • Mag rims: Sturdier, require less maintenance but provide a rougher ride.
  • Push Rims:
    • Basic: Small tube, often steel (sometimes rubber-coated for traction).
    • Ergonomic: Contoured for better grip.
    • Quick Release Wheels: Facilitate car transport.
    • Propulsion Assist Handrims: Provide powered assistance to reduce effort.
      • Constant assist or resistance-matching assist.
      • Prevents backward rolling on ramps.
  • Rim Projections:
    • Oblique or vertical projections for those with weak grip.
    • Enable propulsion using the heel of the hand.
    • Considerations: Can widen the chair, risk of thenar eminence injury, difficult to use downhill.
  • Grade Aids:
    • Mechanism that prevents backward rolling on ramps.
  • Gloves:
    • Recommended for protecting hands during propulsion and braking.
  • Armrests:
    • Swing away, removable armrests.
    • Full length: Covers entire space between elbow and hand.
    • Desk length: Cutout for desk/table access.
    • Pivot armrests: Foam supports that swing away.
    • Swing back armrests: Swing back but remain attached to the chair.
  • Leg Rests:
    • Elevating, swing away, fixed.
    • Heel loops and toe straps (prevent foot sliding).
  • Anti-Tip Extenders:
    • Safety Feature.
  • Safety Belts:
    • Essential for rigid frame chairs, prevent falls.
  • Additional Options:
    • Lap trays, adjustable armrest height.

Wheelchair Dimensions

  • Frame Sizes:
    • Standard: 16-18 inches wide.
    • Narrow/Slim Adult: 14-16 inches wide.
    • Extra Wide: 20+ inches wide.
    • Child: Below 14 inches wide.
  • Depth: Usually 16-18 inches, extra depth up to 22 inches for longer legs.
  • Measurements:
    • Seat Height: Supports lower leg without ground contact.
    • Seat Width: Adds at least two inches (one inch on each side) to prevent contact with wheels/armrests.
    • Seat Depth: Measure and subtract two inches to clear the popliteal fossa.
    • Back Height: Adjust for maneuverability/support.
    • Armrest Height: Adjust for comfort and function.

Wheelchair Fit Considerations

  • Maximize independence and wheelchair use.
  • Protect soft tissues.
  • Positively affect posture (for cardiovascular, respiratory function, and prevention of soft tissue shortening).
  • Ensure comfort.

Wheelchair Mobility Instruction

  • Optimize propulsion method based on user's strengths.
  • Instruct on basic functional mobility.
  • Demonstrate and practice propulsion styles on various surfaces (level, uneven, curbs, doors, ramps).
  • Consider:
    • Speed: Sufficient to cross streets and enter elevators safely.
    • Endurance: Ability to travel desired distances without over-fatigue.

Propulsion Types

  • Semi-Circular:
    • Grip, push and drop hands for efficient motion.
    • Most efficient and effective, requires fewer strokes, best shoulder position.
  • Arcing:
    • Small contact angle, requires more work to maintain speed.
  • Single Loop Over:
    • Arc with extravagant return, inefficient.
  • Double Loop Over:
    • Fancy extra loop, more efficient than single loop but less efficient than semi-circular.

Wheelchair Performance Evaluation

  • Objective measures:
    • FIM level.
    • Wheelchair FIM.
    • Wheelchair Skills Test.
    • Wheelchair Outcome Measure.
    • Six-Minute Push Test (endurance).
  • Efficiency: Documented by speed and stroke count.
  • Quality and Safety: Fall prevention, trauma prevention, overuse prevention.
  • Range of Motion: Assess shoulder, elbow, wrist, and hand ROM required for propulsion.

Focus of Wheelchair Selection

  • Poor Trunk Control: Prioritize stability.
  • Good Trunk Control: Prioritize mobility and upper extremity comfort/efficiency.
  • Sports/Complex Environments/Active Users: Prioritize propulsive speed, upper extremity clearance, and posture.