WHEELCHAIRS

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

2. 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

3. 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

4. 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

5. 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

6. The Roseannadanna Principle of Seating and Mobility • “It’s always something.” • (Welcome to Trade-Off City.)

7. 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

8. 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

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

10. 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)

11. 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

12. LEG AND FOOT REST TYPES • Standard fixed • Swing away or flip up for forward transfer • Removable – ditto, but may get lost • Elevating • Help control edema • Less maneuverable, longer effective wheel base • May not work if hamstrings or knees tight • Require calf pads • Require medical justification

13. 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

14. 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

15. THE GRID

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

18. 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

19. 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.

20. 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

21. SHIFT AND LIFT!

23. 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)

24. 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

25. 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.

26. 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

28. 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

29. BAD HAMSTRINGS

30. 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

31. 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

33. Cervical support in transportation • Comfort rather than safety • Use any soft device, UNATTACHED • Danmar/Hensinger headrest/UMTRI

34. 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

35. 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.

36. U of Mich, A2 10 year old with CP My Favorite Seating Clinic Story

37. 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

38. 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

39. 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

40. 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

41. 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.

43. 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

44. Be prepared to appeal.