Spinal Cord Injury Update

Summer 2008: Volume 17, Number 3

 

Choosing a Wheelchair:

Thoughts from a physical therapist after attending the 2008 International Seating Symposium

By Debra Glazer, PT, MPH

 

When I first became a physical therapist 15 years ago, there were very few seating and mobility products to choose from. Things have changed tremendously since then, and this was never more apparent to me than when I walked into the massive convention halls at the International Seating Symposium (ISS) in Vancouver, BC last March. Hundreds of vendors, from large manufacturers to small start-ups, filled three rooms that were each the size of a football field. Thanks to new materials and engineering advances, the choices now are plentiful, and also somewhat overwhelming.

The new consumer

There also has been a parallel shift in the consumer’s role in choosing a wheelchair. In the past, the clinician made the choice based on the patient’s injury level: C6-C7 and above would get a power wheelchair; T1 or below would get a manual one. Consumers were not consulted in these medical decisions. Today they are active participants in deciding what wheelchair is best for their body and lifestyle; some even invent new products to meet their specific needs.

More wheelchair users today are choosing to “blend” features from both manual and power technologies to develop a chair that enables them to conserve energy, avoid overuse of joints and fit their lifestyle. Some people with low-level tetraplegia choose manual wheelchairs to fit their office environments but make sure they get assistance with transfers at home to protect their shoulders. College students with paraplegia sometimes choose to use power wheelchairs to get around campus and switch to manual chairs for the tighter spaces of the dorm.

Shoulder and wrist pain

According to Kendra Betz, MSPT, ATP, a conference speaker and nationally recognized wheelchair seating expert, there is ample research evidence showing that people who use manual wheelchairs are at risk for shoulder and elbow pathology and repetitive strain injury of the wrist and hand. The reason for these problems, however, is still being debated. Are they due to improper push technique or to wheelchairs that are incorrectly configured to the client’s anatomy? Are therapists too often recommending standard lightweight wheelchairs when ultra-light models might be a better choice? Which does more damage over time, pushing or transferring? Why do only some people get shoulder problems?

Most clinicians would agree that the way an individual propels a wheelchair in clinic is probably very different from the way he or she pushes uphill on a city sidewalk. If a person’s lifestyle regularly leads to poor wheelchair technique, a power wheelchair or hybrid device might be a better choice, such as a power-assist or electric manual wheelchair with a small, removable motor. Hybrids are lighter, less expensive and much easier to transport than traditional power wheelchairs. On the other hand, they are heavier than standard manual chairs and harder to push when using manual mode. Another option is the two-gear manual wheel, which allows the user to shift to a lower gear to help with hills.

Considerations

In the end, choosing a wheelchair is usually a trade-off. To make the best choice possible, clinicians and consumers will need to carefully consider all of these factors:

• Self-image and lifestyle
  • What is the client’s attitude about power wheelchairs? Some people don’t like the way they look, thinking it will make them look “too disabled.” Younger people especially may be concerned about self-image issues.
  • What about activity level? Does the user love exercise or prefer to do as little activity as possible?
    Will fatigue from using a manual chair all day affect energy, productivity or enjoyment?
• SCI severity
  • Is the injury complete or incomplete? This will make a big difference in functional ability.
  • Is this a new or long-standing injury? The first chair is often a “starter” chair because people continue to get return and gain strength during their first year after injury.
• Medical Problems
  Are there medical problems that increase the need for a power wheelchair because of weakness, fatigue or skin concerns? Examples:
  • Diabetes decreases circulation and increases the risk for skin breakdown. If a person is too tired from pushing a manual wheelchair all day to perform adequate pressure relief, a power chair with a tilting system might be the safer choice.
  • Obesity: Although pushing a manual chair takes more energy than using a power chair, it does not provide sufficient cardiovascular exercise to contribute to weight loss or justify getting a manual chair. For this reason, someone with paraplegia who has good arm strength but is obese may be better off with a power chair to protect the shoulders.
• Transfers status
  • Independence: How will wheelchair choice affect a person’s ability to perform transfers independently?
  • Safety: A manual wheelchair may enable the user to perform safer transfers with better technique than a power chair because it is more compact and easier to maneuver into a good transferring position.
• Accessibility in multiple environments
  • Can the wheelchair user self-propel up a ramp into the home? Is the terrain around the home paved, gravel, level, uneven?
  • Could a power wheelchair fit into the home environment? How wide are the doorframes? Are there tight corners to negotiate? What turning radius does the wheelchair need to have? How large is the bathroom?
  • What about the workplace or school environment? A power chair is easier in large open spaces but more difficult for tight corners around cubicles.
• Transportation from home to school or work.
  • Does the wheelchair need to fit in the trunk of a car, behind a seat, or in a van with a lift? It is very difficult to disassemble a power wheelchair to fit in a regular car trunk.
  • Does the user ride public transportation or a school bus?
• Funding Source
  • Does the consumer’s funding source ever consider dual justification for both a manual and a power wheelchair?
  • What is the equipment allotment under the individual’s insurance coverage? Is this an annual allotment? It is very important to make an educated equipment decision. If the wrong equipment is purchased, the funding source usually will not pay for more equipment for another five years or unless the consumer’s medical condition changes dramatically.
  • If insurance will pay for only one chair, consider getting the more expensive power chair first, and then look for other kinds of funding—non-profits, sports organizations or grant options—to help buy a manual chair.
• Hobbies and activities
  • What activities will the wheelchair user be involved with, such as indoor sports on a smooth floor vs. outdoor uneven terrain activities?

Parting thoughts

I did not find a “right” answer to the manual-versus-power debate, but I did learn about many new options in wheelchair technology that I can pass on to my patients.

Meanwhile, the most important take-home message hasn’t changed: thinking through everything ahead of time, before buying a wheelchair, will help you make the best choice for your physical and lifestyle needs.

References

• 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. Washington, DC.
• Betz, K. Pushing a Wheelchair: Simple Task or Accomplished Skill? Paraplegia News, 2007 March;61(3):30-5.
• Paleg, G. Not a Lightweight Decision: Selecting an ultralight wheelchair: six common mistakes and solutions. Rehab Management. 2007 Apr;20(3):26-9.
  

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