Prescription of a power wheelchair
As in manual wheelchair seating, power wheelchair seating has the following clinical objectives:
- To protect the tissue integrity of the user
- To allow optimal mobility of the user
- To create or to maintain normal anatomical alignment with particular attention to the spine1, and
- To provide a comfortable seating configuration.
While the four clinical objectives of seating generally support each other, there are occasions where improvements in one objective may adversely affect the outcomes in one or more of the other objectives. In discussion with the client and other relevant individuals, the clinician will also determine what goals the client has for daily living and community engagement.
When considering each of the four clinical objectives above it is prudent to consider seating goals as either essential or desirable. Essential goals relate to the clients daily needs and requirements, while desirable goals extend beyond that which is necessary. For example, the minimum essential goal for pressure care might be to allow for wheelchair seating for the duration of a necessary daily activity without skin marking, while the desirable goal might be to sit in the chair all day, or perform certain non-essential activities, without damage to the skin.
Once minimum essential goals are determined the clinician and client can discuss what the desired goals are, and determine what intervention/configuration is required to achieve this outcome, if it can be achieved.
A successful wheeled mobility prescription integrates the goals of postural alignment and pressure management as established in Module 7 and Module 8. Appropriate PWC and seating requirements are selected to achieve the best combination of client’s health status, functional independence and community participation, inaccordance with the seating goals of the client and relevant parties.
With the rapid rate of technological advancement in seating and wheeled mobility, a replacement PWC is unlikely to be exactly the same as the previous one. Minor changes can impact on the client’s posture, pressure management, functional abilities and their access to the environment. A thorough clinical assessment and up-to date technical support from the suppliers or specialists will be required to ensure that a replacement prescription meets the client’s needs.
For clients with a spinal cord injury who experience chronic upper limb pain and injury, assessment for PWC has been recommended in the ‘Preservation of upper limb function following spinal cord injury: a clinical practice guideline for health-care professionals’.2
A power wheelchair is clinically indicated for a range of clients. It is convenient to consider clients in three groups: new wheelchair users, existing PWC users needing replacement equipment, and clients whose seating and mobility needs have changed.
Indicators for PWC assessment and intervention:
- Client level of injury, balance or function which requires a PWC to meet seating goals
- Inability to independently perform an effective weight shift, requiring power seating functions for pressure management
- The presence of significant functional limitations, postural asymmetry and deformity which contraindicate manual wheelchair mobility
- A change in functional mobility status since the last prescription of equipment
- A change in the client’s ability to use existing PWC control devices
- Upper limb pain or deterioration relating to propulsion of a manual wheelchair
- Replacement of existing powered mobility equipment
- Powered wheelchair safety concerns of client or carers.
In the course of a clinical interaction, the therapist may be provided with information that highlights the need for a review of a client’s health, functional capability, equipment and/or environment. Such a review may lead to an assessment for a power wheelchair. PWC assessment and intervention may take different forms such as:
- An assessment of client function and capability in line with clinical objectives and client goals
- Adjustment of the current seating system or power base
- Upgrading or replacing of components of current power wheelchair,
- Trialling of equipment and qualitative/quantitative assessment of effectiveness, or
- Prescribing new PWC equipment and subsequent training for the client and/or carer(s).
In some instances there may be complicating factors, and local therapists may require support. In these cases, the client can be referred to a Spinal Seating Service.
Referrals to a Spinal Seating Service are indicated for clients with:
- Significant postural deformities
- An inability to maintain a good seating posture throughout the day
- Complex postural and functional needs where commercial products are not able to meet the desired outcome
- Custom-fabricated products that require replacement, such as: cushions, custom-made backrests, armrests and foot supports
- Unmanageable discomfort or skin marking
- Non-healing, sitting-acquired pressure injuries
- A history of recurrent pressure injuries
- Previous surgical interventions relating to pressure injuries
- Dependence on a respiratory ventilator, or
- Difficulty in resolving safety concerns with seating and mobility equipment.
- Hastings JD. Seating assessment and planning. Phys Med Rehabil Clin N Am.[Internet]. 2000 Feb;11(1):183-207, x. Available from http://www.ncbi.nlm.nih.gov/pubmed/10680165.
- “Recommendation 34: Encourage manual wheelchair users with chronic upper limb pain to seriously consider use of power wheelchair” Consortium for Spinal Cord Medicine, 2005 Apr, published by Paralyzed Veterans of America, accessed 2008.