2. Wheelchair Flashcards
What are the goals of using wheelchairs for patients?
- Maximize function (eg. Improve ability to perform ADLs with wheelchair)
- Correct or accommodate for skeletal deformities
- Minimize risks of injuries (eg. Falling out of chair)
- Ensure comfort
- Promote positive and unobtrusive self-image.
Ref: braddom pg 373.
What are 3 absolute contraindications to manual wheelchairs? 🔑🔑
- ischial pressure ulcers (grade 3 or 4).
- blindness.
- poor judgment/cognition to operate safely.
Ref: Tan, pg 305
What are 5 relative contraindications to manual wheelchairs? 🔑🔑
💡 Think about DMD patient, weak trunk, scoliosis and has spine fracture.
- Vertebral fractures.
- Disc/nerve root compression
- Surgical/post-op conditions of pelvis or proximal femur.
- Truncal weakness
- Postural defects
Ref: Tan pg 305
Wheelchair components
WC Measurements
Seat Width, Too Wide s Too Narrow
Measurement
Approximately 1 inch wider than the width of the widest part of the buttocks.
Extra space can be beneficial for patients to be more independent with their ADLs, such as dressing in their wheelchair or performing bladder management in their wheelchair.
Too Narrow
- Transfers will be more difficult
- Pressure on greater trochanters
- Uncomfortable
- More stable (athletic wheelchair)
Too Wide
- Difficulty with propulsion
- Shoulder pain
- Less trunk support
- Risk of scoliosis can increase with poor pelvic alignment
- Risk of back pain
- Uneven weight/pressure distribution
Cuccurollo 4th Edition Chapter 12 Wheelchair pg879
Seat Depth, Too Long/Deep vs Too Short/Shallow
💡 From posterior buttock to popliteal fossa -2
Measurement
2 inch gap between the popliteal area and front edge of the cushion
If the backrest is cushioned, the thickness of the cushion must be considered.
Too Shallow
- Increased pressure on the ischial tuberosities.
- Anterior pelvic tilt
- Shifting weight anterior thus chair may tip over (Bonus)
Too Deep
- Sliding forward
- Excess pressure behind the knees and calves (popliteal fossa).
- Posterior pelvic tilt
- Constricts vasculature
Cuccurollo 4th Edition Chapter 12 Wheelchair pg879
Seat Height, Too High vs Too Low
Measurement
- from bottom of the heel of the shoe to the posterior thigh +2
- Subtract the height of the compressed seat cushion from the measurement
Hemi-Height
- Without adding +2 inch, just compressed cushion
- This will allow the patient’s foot to rest comfortably flat on the floor, which is essential for the patient to obtain adequate leverage and heel strike during foot propulsion.
Allow
- Knee angle of 90 degrees
- Fit under tables, and sinks at home, work, school, and in the community
- Access the steering wheel or hand controls.
- Efficient wheelchair propulsion
Too High
- Constantly sliding out of the wheelchair as the patient try to propel the wheelchair
- Achilles tendon contracture due to the ankle resting in a plantarflexed position.
- Chair may not fit under table
Too Low
- Feet hit floor
- Pressure injury to the ischial tuberosities
- Hip flexion contracture
Cuccurollo 4th Edition Chapter 12 Wheelchair pg879
Posterior Seat Slope, Too Much Dump
Measurement
- The angle of the seat with respect to horizontal.
- About 5 degrees of posterior tilt is common
- Increasing pelvic-stability by pushing the pelvis into the backrest.
Benefits
- Improve pelvic and spine stability
- Making it easier to propel the wheelchair.
- Reduce falling out of w/c
- Prevents anterior pelvic tilt
Too Much “Dump”
- Increase risk of pressure injuries on the sacrum
- Shifting center of gravity more posteriorly
- Decreased posterior stability
- Increase tipping of the chair
- Make transferring out of the wheelchair more difficult
- May cause posterior pelvic tilt
Cuccurollo 4th Edition Chapter 12 Wheelchair pg880
Back Support Height, Too High vs Too Low
Measurement
Distance from the bottom of the buttocks to the inferior angle of the scapula + add the “compressed” wheelchair cushion height to get the true back support height measurement.
Guides
- For patients who will be utilizing their arms for propulsion, the height of the back support should be just below the inferior angle of the scapula.
- The scapula should not hang over the back support
Too High (DMD or SMA: no upper extremity strength and poor trunk control)
- May block the scapula and interfere with shoulder movement
- Restrict shoulder range of motion
- Adequate postural support and sitting balance
- Headrest for adequate support.
Too Low (Athletes)
- Greater freedom of motion (e.g., leaning, turning)
- Less restrictive (i.e., does not interfere with arms when pushing)
- Low trunk stability (hyperextending over the back support for stability)
Cuccurollo 4th Edition Chapter 12 Wheelchair pg880
Armrest Height, Too High vs Too Low
Measurement
- Arm height from the buttocks to the bottom of the patient’s bent elbow at 90 degrees.
- Then add the height of the compressed seat cushion to obtain the armrest height.
Too High
- Poor posture and shoulder discomfort
- Difficult to access the pushrims
- Wheelchair will not fit under the table
Too Low
- Poor posture
- Shoulder discomfort
- Compromised breathing.
- Excess pressure on ischial tuberosities
Cuccurollo 4th Edition Chapter 12 Wheelchair pg880
Footrest Height ارتفاع راحة القدم
Measurement
- Distance from the heel of a patient’s shoe to the posterior surface of the thigh at the popliteal fossa.
- Footrests are usually adjustable and should have at least 2 inches of leg clearance
Cuccurollo 4th Edition Chapter 12 Wheelchair pg881
Advantages of light weight WC
- faster speeds
- traveled farther
- used less energy
Why a tailored, fitted seat is important? 4 marks.
- Stability
- Postural support
- Comfort
- Skin integrity.
- Ease of propulsion
Cuccurollo 4th Edition Chapter 12 Wheelchair pg877
Types of seating surface🔑🔑
VINYL SLING SEAT
Advantages
- Easy to fold
- Easy to clean
- Lightweight
- Short term hospital or institutional use
- Folds for storage and transportability
Disadvantages
- Posterior pelvic tilt
- Hip internal rotation, adduction & flexion
- Collapsed trunk with corresponding head forward flexion
- Neck hyperextension
- Protracted and elevated shoulder girdle
- Does not provide pressure relief (Hammock)
- Unstable
SOLID SEAT
Advantages
- Base of support
- Better postural control
Disadvantages
- Slightly heavier (1–5 lb.)
- Removed before folding WC
Cuccurollo 4th Edition Chapter 12 Wheelchair pg877
Name 6 goals of a Cushion Rx.
💡 Recall the advantages and disadvantages of cushions
- Trunk and pelvic stability
- Lower extremity and pelvic alignment
- Pressure redistribution and relief
- Comfort
- Durability
- Minimize perspiration and odor
- Safe transfers
Types and material of cushions (advantage/disadvantage/use) 🔑🔑
FIXED
- Foam
- Memory Foam
- Gel
- Fluid Filled
ADJUSTABLE
- Air ”Roho” Cushion
- Offloading “Java” Custom Cushion
List 5 variables to consider when choosing a wheelchair cushion 🔑🔑
- pressure relief ability.
- seating stability.
- heat dissipation.
- cleaning.
- durability.
- cost.
Ref: Review notes.
Wheels, how to choose? 🔑🔑
SPOKE WHEELS
Advantages
- Lighter weight
- Less force needed for propulsion
- More shock absorption
Disadvantages
- More maintenance due to bending and loosening
- Tightening the spokes annually.
- Less durable
MAG WHEELS
Advantages
- Less maintenance
- More durable
Disadvantages
- Heavier
- Expensive
- Less shock absorption
Cuccurollo 4th Edition Chapter 12 Wheelchair pg883-884
Tires, how to choose? 🔑
SOLID RUBBER TIERS
- Heavier
- Low rolling resistance in smooth surface
- Rough & Uncomfortable on Rougher Terrain/Curb
- High WC Wear & Tear
- No risk of running flat
- No Maintenance
PNEUMATIC TIRES
- Lighter
- Low rolling resistance with higher psi
- Smooth & Comfortable ride on Hard ride on Rougher Terrain/Curb
- Grip the environment for increased control with uneven surface negotiation or carpet
- Low WC Wear & Tear
- Risk of running flat, but do come airless (flat-free) soft rubber or latex gel filled
- Require Maintenance Monthly or Bi weekly
Cuccurollo 4th Edition Chapter 12 Wheelchair pg884-885
Axle, where to put? Anterior vs Posterior Wheel Positions.
1. FIXED AXLE
- Appropriate for someone who is not using the wheelchair as a primary means of mobility. (i.e. transfer inside hospital or for infrequent outside ambulation)
2. ADJUSTABLE AXLE
POSTERIOR AXLE - REAR WHEEL
Advantages
- Increase wheelchair stability (amputee)
Disadvantages
- Greater the rolling resistance
- More energy required for propulsion
- Greater the turning radius
- Increase repetitive stress injuries
ANTERIOR AXLE - REAR WHEEL
Advantages
- Less the rolling resistance
- Less energy required to propel
- Relieve shoulder pain
- Smaller the turning radius
- Facilitates “wheelies”
- Shorter rear wheel access
Disadvantages
- Decreased wheelchair stability
What is Camber? Advantages and Disadvantages.
Specs
- Wheel angle against the vertical axis
- Negative camber is when bottom of the wheel is out further than the top of the wheel.
- Usually kept at 5 degrees of camber
Advantages of Negative Camber
- Brings wheels inward and closer to the body, which enables the arms to access more of the pushrim
- Reduces shoulder abduction because the wheels are closer to the body
- Increases lateral stability
- Easier to propel (especially at higher speeds), pushrims more ergonomically for propulsion (it is more natural to push down and out).
- Helps to protect the hands, because bottom of the wheels will hit the obstacle first
- Decrease rolling resistance
- Increased maneuverability yaw axis control
Disadvantages of Negative Camber
- Increased overall width of the chair, keep width < standard doorway (28 inches)
- Difficult to maneuver indoors
- Increased tire wear on the inside part of the tire
- Diminished traction
Cuccurollo 4th Edition Chapter 12 Wheelchair pg885
Braddom 6th Edition Chapter 13 Wheelchair pg272 Box 14.2
Footrest, list 2 modification to increase support of lower limbs.
- Padded Calf Pads
- Calf Strap
- Comfort Calf Protector
How to ease propulsion for patient with limited upper extremity function.
Push Rim
- Larger-diameter pushrim
- High-friction surface “grip cover”
- Pushrim with angled projections
Extra Modification
- Pushrim lever
- Hand cycle or hand pedal
- Motorized (Complete or added strokes)
List 4 propulsion techniques for wheelchair. Which is the best? 🔑🔑 Dr Jamal
Wheelchair Propulsion
- Semicircular (most efficient).
- Arc.
- Single loop over (most common in paras).
- Double loop over (figure eight).
Best type : Semicircular
- Lower stroke frequency
- Better biomechanics
Contact Phase
When the hand is in contact with the pushrim applying forces
Recovery Phase
When the hand is off the rim and preparing for the next stroke
Ref: Braddom pg 379.
List 2 types of Power Assist for manual wheelchair 🔑 What are the benefits of power-assist wheelchairs?
POWER ASSIST WHEELS
1. E-Motion (Alber)
Types of power assist
- Proportional to the patient’s effort “Assist Mode”
- Preset ahead of time “Throttle Mode” like E-Motion and Twion wheels (Alber)
Advantages (Heart, Energy, Injuries)
- Lower oxygen consumption (energy demand)
- Decreased heart rate on outdoor course
- Decreased stroke force required for propulsion
- Reduce the risk of upper limb injury, neuropathy, and fatigue
Disadvantages
- Assistance required to load/unload wheelchair in/out of a car
POWER ASSIST DEVICES
-
Twion (Alber)
- Automated with preset setting, patient activate and deactivated it via on-buttons.
-
Smart Drive via Bluetooth band tapping
- Power wheel mounted on the rear of the wheelchair and the patient will have a wristband on that communicates via Bluetooth to the wheel.
- Patient taps his or her arm with the wrist band twice to turn on the wheel, then taps once to set the speed as it accelerates up.
Recline Mechanisms. Advantages & Disadvantages. 🔑🔑
Mechanism
- Important to remember that shear forces are increased as an individual is being reclined and unreclined in the wheelchair.
- The seat of the wheelchair stays in the same position relative to the floor while the back support is adjustable.
Advantages
- Independent pressure relief
- Postural support from gravity
- Pain relief
- Allows for PROM of hips and knees — not a substitute for a PROM program.
- Easier to perform bladder catheterization
- Can help with dressing/undressing
- Can help mobilize secretions
- Can maintain items on lap tray during a weight shift
- Can maintain position under table or desk during “pressure relief”
- Can transport in car with a large trunk
Disadvantages
- Increased shear forces can result in shearing pressure injuries
- Can increase spasticity due to the hip position change
- Less maneuverability due to increased turning radius
- Patient does not maintain an “ideal” seated position after several weight shifts
Cuccurollo 4th Edition Chapter 12 Wheelchair pg882
Tilt-in-Space Mechanisms. Advantages & Disadvantages. 🔑🔑
Mechanism
- The angle of the seat and back does not change when the seat is tilted back. The patient remains in the same position, but orientation in space changes. This allows pressure to be redistributed from the seating surface to the back support. Since there is no movement of the back away from the seat, shear forces are minimized.
- In order to redistribute sufficient pressure for a weight shift, the system must tilt at least 45 degrees
Advantages
- Independent pressure relief
- Postural support from gravity
- Can assist in orthostatic episodes
- Minimizes shear
- Diminishes effects of spasticity during position changes
- Maintains seating position during weight shifts
- Helps mobilize secretions
- Smaller turning radius, more maneuverability than a reclining wheelchair
Disadvantages
- No passive ROM (PROM) benefits
- May not offer as much pressure distribution relief as a recliner to 180 degrees
- Urine may run backward in the tilted position (antireflux valve can manage this)
- Difficult to maintain items on a lap tray when tilted
- Need to come away from desk or table to perform weight shift
- More difficult to perform catheterization
- These systems do not disassemble sufficiently for transport by car
Cuccurollo 4th Edition Chapter 12 Wheelchair pg883
List 4 advantages for manual wheelchairs and power wheelchairs. 🔑🔑
Manual WC
💡 Looks cool, easy to pack and fix
- Aesthetics: Less appearance of disability
- Transportation: Easy to transport without special vehicles
- Maintenance: Can be worked on independently
- Exercise: Theoretical benefit to the user from using own force to propel
Power WC
💡 Climbing high mountain faster with ease
- Distance: Can travel long distances without fatigue
- Speed: Can travel at higher speed without fatigue
- Terrain: May be able to traverse rougher terrain
- Protect the arm: Avoid repetitive strain injuries that are due to manual wheelchair propulsion
DeLisa 5th Edition Chapter 78 Wheelchair pg2106 Table 78.3
Where to put the power wheel drive?
REAR WHEEL
Advantages
- Naturally tracks straight, appropriate for high-speed applications.
- Preferred for reduced fine motor coordination
- Stability with tilt feature
- Preferred for special input devices (chin joystick, head array ..etc)
Disadvantages
- Limited obstacle climbing by the small front casters
- Largest turning radius among the three drive locations.
MID WHEEL
Advantages
- Good Maneuverability for indoors (smallest tuning radius)
Disadvantages
- Getting stuck in front or rear casters when riding on uneven terrain or curb
- Bumpier ride (eg. people w back pain don’t tolerate)
FRONT WHEEL
Advantages
- Very stable for uneven terrain and hills
- Best capability to climb forward over small obstacles
- Turning radius is smaller than rear wheel drive but larger than mid wheel drive
Disadvantages
- Tendency for the back of the chair to wander side to side (“fishtailing”)
- Directional instability
- Requires steering corrections
Braddom 6th Edition Chapter 13 Wheelchair pg280-282
Scooter. Advantages & Disadvantage 🔑🔑 EXAM 2020
Advantages
- Lower cost
- Easier to assemble and disassemble for transportation
- Better than some chairs at rough terrain
- Less perceived stigma of disability
Disadvantages
- Less stability
- Require greater arm strength and control to drive
- Fewer seating options
- Poor turning radius
- Must transfer out of chair for many activities
- Limited control options
DeLisa 5th Edition Chapter 78 Wheelchair pg2112 Table 78.5
List 6 Wheelchair Modification options after a hemiplegic stroke 🔑🔑 EXAM
- Hemi-height for foot propulsion: seat closer to the floor, to allow the unaffected leg to propel the chair.
- Remove footrest on strong side
- Leg rests elevating on Hemiplegic side (Improve edema)
- One-hand-drive chair (increased potential of a repetitive stress injury from the patient’s one functioning upper extremity performing a repetitive task → power wheelchair is often the best)
- Lap tray board (Reduce sublimation and UL edema)
- Excellent pressure relief cushion
- Full-length arms (Improve transfer)
- Footrest with heel loops (prevent planter flexion contracture)
- Brake extension on hemiplegic side
List 4 Wheelchair Modifications for a patient a Below Knee Amputation 🔑🔑
- More posterior wheel axel for added stability
- Increase seat angle “posterior seat slope.”
- Rear anti-tippers for added stability
- Pelvic (seat) belt for added stability
- Amputee board on amputated side to limit knee flexion contracture & Edema control
- Full-length arms if patient has difficulty transferring
- Lightweight or ultra-lightweight
Cuccurollo 4th Edition Chapter 12 Wheelchair pg893 Table 12-7
What are four important considerations in prescribing a sports wheelchair. List 6 Wheelchair Modifications for Athletes 🔑
ESSENTIAL
- Lightweight frame
- Low back support
- More negative camber of rear wheel
- Small castors
OPTIONAL
- Wheel locks are low mounted or scissor style
- Armrests are usually removed
- Footrests are rigid footplate with leg strap
- Pelvic (seat) belt
- 5th wheel (anti-tipper)
- Increase slope angle or seat dump
