Prescribing manual wheelchair with propulsion assist devices
Increasingly, the use of propulsion-assist devices is being considered for clients with:
- Reduced upper limb strength
- Increased risk of upper limb injury, and /or
- A requirement for management of co-morbidity.
Such devices allow the client to self-propel the wheelchair with the option of being assisted by mechanical lever drive or geared wheels or an attached power device. Propulsion-assist devices can assist in ascending inclines, reducing peak propulsion force to start the chair rolling, and reducing frequency of propulsion or effort to travel a distance.
Replacement of a manual wheelchair is an opportune time for the client and therapist to consider a propulsion-assist device, as the wheelchair frame selection may be affected depending on the choice of equipment to assist propulsion. Clients may wish to acquire such devices for injury prevention, improvement of community access and participation. Due to rapid changes in technology, it is important to obtain the latest updates from the manufacturers and suppliers. This module is not product specific.
There are currently two primary types of power propulsion-assist devices that fit manual wheelchairs for indoor and outdoor use.1
Each of these devices has pros and cons and the selection should be assessed according to the individual’s capacity and circumstances for usage, transport requirement, portability, environment and the required wheelchair configuration. The areas below should be prioritised according to individual need:
1. Client’s capacity:
- What motor skills, movement, and strength are required to start, drive, and stop the device safely?
- Are both upper limbs required to operate the device?
- Is it hard to learn? Would it require high level of wheelchair skill, attention, judgement and motor planning?
2. Device features meeting client’s capacity and usage in the environment
Appropriateness for client’s upper limb function
Can the client attach, detach and operate the device?
Is the device programmable or adjustable to the client’s strength or to accommodate for an asymmetrical upper limb propulsion pattern?
Does the device have steering, hill-hold and brake-assist if the client requires such assistance?
Will the device reduce strain on the upper limb(s) by adequately reducing force for propulsion, repetitions, or the level of pain experienced by the client in daily activities?
Does the device suit the client’s requirement for use indoors, outdoors, over uneven ground, ascending and descending slopes?
Will the device reduce or increase the number of transfers?
Will the device hinder transfer?
Can the device be attached, detached or stowed independently by the client into their vehicle?
Is the device too heavy to be lifted into a vehicle for transport, or
Is it compatible with stowage devices, e.g. roof hoist?
Can the device be easily removed when not required by client?
When the device is not active, will the weight hinder manual propulsion?
Device interface with wheelchair
Is the device limited to use with a rigid frame wheelchair?
Is it transferable if the client has more than one wheelchair?
How does the device and associated mounting hardware affect the configuration or components of the existing wheelchair? E.g. device requiring a specific rear seat to floor height, frame style, axle position, type of wheels or axle.
In NSW, devices that can be funded through EnableNSW according to the clinical criteria2 and are registered with the Therapeutic Goods Administration (TGA) are speed limited up to 10 Km/h . As this is an emerging and rapidly advancing area of assistive technology, therapists must provide adequate trials during the prescription process. Suppliers and the therapist should provide training to the client where the funded device is to be used. Client should be advised to use the device according to the NSW Road Rules as a pedestrian with a ‘motorised wheelchair’3.
Increasingly, manual wheelchair users are considering power-assisted hand cycle and ‘hand bikes’ for community access. Some emerging power-assist devices are capable of travelling at more than 10km/h. Therapists who encounter these devices when scripting a power ‘hand bike’ are advised to check with the NSW Roads and Maritime Services regarding the regulations for these devices, and advise the client accordingly. Bright clothing, lights and reflectors, horns or bells would also improve safety for all propulsion-assist devices used.
While there are benefits to using a power propulsion-assist device in terms of transfers, access and compatibility with existing vehicle and home and consideration should still be given as to whether a power wheelchair is more appropriate for the client’s ongoing needs. For example:
- Pressure management: using power seating such as tilt to rest and shift weight off bony prominences
- Postural intervention: some clients require extensive posture management equipment which is too heavy for manually propelled wheelchair use. The activity of manual wheelchair propulsion can compromise seating posture of some clients, and a change to powered mobility may permit significant postural improvement
- Functional implications: the extent of power mobility required throughout the day should be considered, e.g. power seat elevation may assist upper limb reach and side transfer.
Power wheelchairs are discussed in Module 10.
- Paralyzed Veterans of America. Glossary of wheelchair terms and definitions. Version 1.0 [Internet]. December 2013 [cited Oct 2015]. Available https://www.ncart.us/uploads/userfiles/files/glossary-of-wheelchair-terms.pdf
- Enable NSW. Draft seated mobility clinical criteria. [Internet]. 2015 [cited Oct 2015]. Available from: http://www.enable.health.nsw.gov.au/__data/assets/pdf_file/0008/282491/Seated_Mobility_-_DRAFT_2015.pdf