Be systematic: Identifying key issues for appropriate power wheelchair prescription
1. Medical diagnosis
The level of injury may dictate features and accessories of the power wheelchair that the client requires. Clients with an incomplete spinal cord injury may present with asymmetrical head control or upper limb function that will alter the selection of power wheelchair options. Therapists should understand the effects of co-morbidities and other medical conditions on functional abilities e.g. acquired brain injury, arthritis, shoulders and upper limb injuries.
A general guide to seating requirements for clients with a complete spinal cord injury
Thoracic/Lumbar/Sacral-level injuries, T1 and below
- Manual wheelchair is usually the initial primary mobility. PWC may be considered with other co-morbidities, overuse syndrome or injuries (refer to Module 9).
Lower cervical-level C7-C8 injuries
- Clients able to drive with standard joystick. This client group may elect to use the PWC as the primary mobility aid over a manual wheelchair. Factors such as age, concurrent injuries, social support and environment will influence the decision.
Lower cervical-level C6 injuries
- Clients able to drive with adapted or standard joystick
Lower cervical-level C5 injuries
- Clients able to master driving with an adapted joystick or utilises a mobile arm support over the joystick
- Custom armrests and hand supports may be required to allow client use of a hand controller
High cervical-level C4 injuries
- Clients able to drive a PWC with chin control
- Functional capacity similar to C1-C3 but may not require respiratory aids at discharge
- Mouth sticks are used for accessing other controls and keyboards
- Postural stability and wheelchair tray set up is vital for the client to access these aids
High cervical-level C1-C3 injuries
- Requires chin control devices, power tilt-in-space seating function and custom wheelchair mount for a respiratory ventilator
- Depending of the client’s ability to utilise the neck muscles for their head control, a chin control device will most likely be used. Other speciality controls devices including sip and puff and head control device such as head array, switches or ‘mini–joy’ can be trialled. A ‘sip and puff’ control device is used for clients who are able to control breathing but have poor control of head and neck position
- Ventilators and batteries, suction equipment and manual ventilation bag are required to be carried on the power wheelchair
- Clients who have a phrenic nerve paced diaphragm usually require the transmitter to be secured to the wheelchair
2. Surgical history
Take note of any surgical or orthopaedic factors that may restrict the range of joint movement and can compromise the client’s ability to operate control devices or rule out the use of power backrest recline or legrest elevation.
3. Upper limb pain
“Upper limb pain and injury are highly prevalent in people with spinal cord injury, and the consequences are significant”.1
The most common types of upper limb pain and injury experienced by clients with a SCI are8 :
- Wrist and carpal tunnel syndrome
- Shoulder pain, and
- Rotator cuff injury.
In the PVA guidelines, recommendations relating to seating and power wheelchair interventions include:
- PVA Recommendation #6:
- With high-risk patients, evaluate and discuss the pros and cons of changing to a power wheelchair system as a way to prevent repetitive injuries.
- PVA Recommendation #11:
- Promote an appropriate seated posture and stabilisation relative to balance and stability needs.
- PVA Recommendation #12:
- For individuals with upper limb paralysis and / or pain, appropriately position the upper limb in bed and in a mobility device. The following principles should be followed:
- - Avoid direct pressure on the shoulder
- - Provide support to the upper limb at all points
- - when the individual is in supine, position the upper limb in abduction and external rotation on a regular basis, and
- - Avoid pulling on the arm when positioning individuals.
- PVA Recommendation #13:
- Provide seating elevation or possibly a standing position to individuals with SCI who use power wheelchairs and have arm function.
- PVA Recommendation #34:
- Encourage manual wheelchair users with chronic upper limb pain to seriously consider use of power wheelchair.
4. Neck pain
Clients with high lesion spinal cord injury may experience neck pain and discomfort. The use of tilt-in-space power seating function can provide restful support options for the head and neck muscles.
Neck pain can derive from poor posture associated with the awkward use of typical joysticks and chin control devices. A review of the clients seating and driving posture may be required which may result in the provision of more appropriate neck and upper limb support. Specialty control devices may be considered to allow the client to operate the PWC while maintaining optimal skeletal alignment.
5. Pressure injuries
6. Bladder management
Power seating functions such as seat elevation and backrest recline can facilitate the client to perform transfers to the toilet or to perform self-catheterisation in the wheelchair. Assessment should be conducted with supervision of a continence nurse and a physiotherapist or occupational therapist.
7. Weight gain or loss
Weight loss or gain is an indication for an assessment to resize or make adjustments to the seating system. For the client who tends to fluctuate in weight, adjustments to seat width and depth are available in many seating systems with a power base type of PWC. This selection must be considered in new powered wheelchair prescription.
8. Psychosocial and carers issues
For a new user, learning to drive a PWC requires a range of skills:
- Cognition and ability to learn and retain new skills
- Perceptual skills, such as motor planning and visual spatial orientation
- Communication skills, interpersonal and intrapersonal skills
- Judgement and safety awareness.
The client’s self-image and own preferences can influence the client’s decision to accept or reject a potential PWC. Some manual wheelchair users may feel that they are ‘giving in’, deteriorating or becoming more dependent with the idea of a PWC. This transition requires practical input and psychological adjustment. Several PWC trials or short term loans can allow the client to assess progress with pain management and functional capacities before a decision is made for a PWC or power add-on prescription.
Clients who live in residential care, independent living units or group homes often have many care staff, inexperienced or poorly educated carers. Ease of operation, clear labelling or familiarity of commonly used electronics or wheelchair modules should be considered in the power wheelchair selection. Keep the system as simple as possible without compromising the key seating and mobility goals. Discuss the pros and cons, ‘trade-offs’ with the client and facility supervisors.
9. Functional tasks
Explore and discuss with the client the features of the seating and PWC required to carry out their activities of daily living.
When reviewing functional tasks consider:
- The type of armrest required for transfers
- Resting position in wheelchair using power seating functions
- Leisure activities
- Carer duties
- Voluntary work, and
- Community participation.
For clients with a high lesion spinal cord injury, options and accessories in power wheelchairs should facilitate these essential functions:
- Head or hand control: selection and adaptations to control devices and head or arm supports
- Vision: provide adequate head support and vision alignment to operate display, select appropriate enhanced display unit
- Feeding and other in-chair tasks: wheelchair trays options and setup for equipment such as mouth sticks, phones, tablets and other technology.
10. Environmental context
As wheeled mobility impacts on all aspects of a client’s daily activities and life roles, investigate the area around the home, work, transport vehicles, shopping areas and other leisure activity environments for factors that will influence PWC interventions.
For the first time user, it is important to ask the client the activities and roles that they wish to participate in following discharge from rehabilitation. Liaise with the nursing staff and allied health staff about the appropriate wheelchair options and accessories in order for the client to carry out functional tasks in the wheelchair post-discharge, such as:
- Educational or vocational activities: appropriate features for the wheelchair such as electronic modules, power seating functions, interface with computers, and
- Leisure and social activities: select the drive wheel configuration for optimal wheelchair performance.
Community clients usually have established their home environment to maximise their functional abilities. Thus, any changes to the PWC dimension and set up should be discussed openly and thoroughly with the client. A trial should be conducted at home where possible.
Selection of PWC options includes:
- Wheelbase configuration: influenced by indoor circulation space and client preference
- Drive wheel size: influenced by likely outdoor terrain
- Battery size: determined by distance needed to travel between recharging
- Power seating functions: influenced by a variety of factors including pressure care, accessibility, comfort (funding options may vary with clinical need).
Considerations relating to transport are important in determining the wheelchair features. Consider the following aspects:
- Whether the client is a driver or passenger in a motor vehicle
- The type of vehicles being used
- The gradient of the access ramp – for mid-wheel or centre-wheel drive PWC. Test the transition from the ground to ramp or incline to ensure the drive wheels have good traction
- Suitability of wheelchair loading ramps or platforms for the trial wheelchair - weight capacity, dimensions and gradients
- Tie down points, docking systems and sufficient head support must be considered for clients who sit in their wheelchair while travelling in a vehicle
- Crash worthiness of the PWC
- The overall wheelchair dimensions, width, length and height are particularly important when entering and exiting the vehicle - the selection of a PWC with very low seat-to-floor height (with power seat elevation) enables many tall clients access to a wider range or transport vehicles, and
- Manoeuvrability if travelling in public transport such as buses and trains.
12. Existing seating and wheeled mobility limitations
A detailed record of the current mobility system is often the baseline for all wheelchair assessments and interventions. Investigate the problems identified and note the essential features of the components in the PWC required.
- Preservation of upper limb function following spinal cord injury: a clinical practice guideline for health-care professionals’, Consortium for Spinal Cord Medicine, Paralyzed Veterans of America, 2005 Apr. Accessed 06-03-2016. Available from: http://www.pva.org/site/DocServer/upperlimb.pdf?docID=705
- ‘Pressure injury prevention and treatment following spinal cord injury.’ “Recommendation 30.2:” Consortium for Spinal Cord Medicine, 2000 Aug (reviewed 2005), published by Paralyzed Veterans of America
- Clarke, T., 2015. Transportation of people seated in wheelchairs. Independent Living Centre WA. Accessed online: 08/03/16. Available from: http://ilc.com.au/wp-content/uploads/2015/03/Transportation-of-People-Seated-in-Wheelchairs.pdf
- Transport for NSW Motorised wheelchairs. [Internet]. Transport for NSW; 2014 [cited Oct 2015]. Available: http://roadsafety.transport.nsw.gov.au/stayingsafe/pedestrians/motorisedwheelchairs/