Be systematic: Identifying key wheeled mobility issues
1. Medical diagnosis
The functional independence of the client will indicate the type of wheeled mobility required. The table below shows the typical mobility outcomes based on lesion level, for a complete lesion.
Indoor / level ground
“Wheelie” skill for descending ramp and kerb
Stowing MWC to vehicles
Use public transport
Grip enhancement required
May require grip enhancement
May require grip enhancement
May be independent
May also need powered mobility
T1 & below
Incomplete lesions can result in different motor skills as compared with a client with a complete lesion at the same level. These differences will affect the wheelchair configuration and selection of components. For example, a client who is able to do standing transfer would benefit from a ‘flip–back’ footrest (rigid frame chair) or a ‘swing-away’ legrest (folding frame wheelchair).
Co-morbidities and other medical conditions may limit functional manual wheelchair propulsion e.g. arthritis, cardiorespiratory capacity, and upper limb injuries. Power wheelchair or propulsion-assist mobility may be an option in such cases. For clients with cognitive and perceptual deficits, training and trials should be graded in terms of task performed, wheelchair and environment. Some propulsion-assist devices require a high level of attention, planning, judgement, problem solving, coordination and visual-spatial skills with timely responses.
2. Surgical history
Take note of any surgical and orthopaedic presentations or interventions that may result in asymmetrical upper limb movement or reduced muscle strength for manual chair use.
3. Upper limb pain
The upper limbs of clients with SCI are prone to pain and injury, particularly in the shoulders, elbows and wrists, including carpal tunnel syndrome. The consequences of upper limb pain and injury on SCI clients may include:
- Functional decline
- Increase dependency on personal care
- Reduced ability in activities of daily living
- Increased use of analgesic medications
- Lower quality of life
- Financial and vocational limitations, and
- Reduced community participation.
Apart from ‘wear and tear’ of the relevant joints over time, muscle tightness and weakness from different levels of paralysis causes muscle imbalance in the upper limbs which further contribute to fatigue and pain. Poor sitting balance in the chair can increase the strain on the upper limbs if used as a prop for the upper body.
The prescription of a manual wheelchair must take into account the preservation of upper limb function. It is worthwhile noting the client’s pre-injury pain history and any secondary injuries to the upper limbs and adjusting the manual wheelchair prescription and usage recommendations accordingly. Additional propulsion-assist devices may be suggested to prevent further injury. These are the relevant recommendations in “Preservation of Upper Limb Function Following Spinal Cord Injury: A Clinical Practice Guideline for Health-Care Professionals” from the Paralyzed Veterans of America (PVA)1 :
- PVA Recommendation #6:
- With high-risk patients, evaluate and discuss the pros and cons of changing to PWC system as a way to prevent repetitive injuries.
- PVA Recommendation #11:
- Promote an appropriate seated posture and stabilisation relative to balance and stability needs.
4. Weight gain or loss
Significant weight loss or gain indicates a need for wheelchair reassessment for adjustment or rescripting. A review of the body measurements against the seating and wheelchair dimensions will be required.
5. Functional tasks in environmental context
As wheeled mobility affects all aspect of a client’s daily activities and life roles, it is critical to investigate all environments of use of the wheelchair.
For the first time wheelchair user, it is important to ask the client about activities and roles that they expect after rehabilitation discharge. Liaise with clinical ward staff about client needs that may affect the wheelchair and configuration (See Module 2 for a comprehensive list).
- Transfers – can be impeded by seat to floor height and excessive seat tilt
- Self-catheterisation – excessive seat tilt may restrict pelvis position and access to perform catheterisation, consider access to bathroom basin and toilet
Vocational demands – consider the vocational prospect and select appropriate features for the wheelchair such as tyres and castors, size and type.
Community clients usually have a well-established environmental context, so any proposed changes to wheelchair dimensions or configuration should be explored thoroughly with the client. A trial should be conducted in all appropriate environments.
6. Wheelchairs in vehicles
The wheelchair must suit the client’s need for vehicle transport. An existing vehicle may need to be taken into account. Basic information required includes:
- Client as driver or passenger
- Whether the chair is to be used as a vehicle seat or stored as cargo
- Type of vehicle, e.g. taxi, public transport, private vehicle
- Method of stowage, e.g. car boot, rooftop, inside cabin.
- The weight of the wheelchair frame needs to be considered in relation to the manual handling and who is performing the task. This is particularly important if the client is lifting the wheelchair into a vehicle frequently. Adjustable and folding wheelchair frames are typically heavier, and
- The overall frame size and style are critical for car transfer and lifting of the frame into the vehicle.
- Assess front frame taper and legrest hanger angle to ensure the closest approach to car door opening for transfers.
When lifting the frame into the car while seated in the driver seat, the frame style (‘box’ vs. ‘Z’) and options for folding vs. non-folding back posts may influence the client’s technique and ability to manoeuvre the frame between the trunk and the steering wheel.
Tie-down systems, occupant restraints and head supports on wheelchair must be considered for clients who travel in the wheelchair.
With some clients, self-image and appearance of the wheelchair are important factors in the acceptance of a wheelchair. Ask the client about their preferences and access to funding. Some clients may elect to self-fund options that are not approved by the funding body. Include these as part of the goal setting process and provide the client with a range of choices.
- Consortium for Spinal Cord Medicine, Paralyzed Veterans of America, 2005. ‘Preservation of upper limb function following spinal cord injury: a clinical practice guideline for health-care professionals’. [cited Oct 2015] Available from: http://www.pva.org/atf/cf/%7BCA2A0FFB-6859-4BC1-BC96-6B57F57F0391%7D/cpg_upperlimb.pdf