Wheelchairs and seating systems allow individuals with mobility impairments to actively participate at home, work, school, and the community. The quality of life of an individual is reflective of the overall effectiveness of the wheelchair and seating system when considering activities of daily living (ADLs). Therefore it is imperative that the multidisciplinary team of rehabilitation professionals considers not only the individual and the wheelchair but also the activities, context, policies, and personal assistance associated with the technology. Historically, rehabilitation professionals have focused on functional mobility at the time of implementation of the wheelchair and seating system. Now, as a result of changes in the overall health care environment, driven by a need for increased value, rehabilitation professionals must integrate a more holistic approach to manage costs while improving outcomes at the time of implementation and throughout the life of the wheelchair and seating systems.To better understand the long-term effects of the wheelchair and seating system and to maximize the functional outcomes of the individual, rehabilitation professionals across the multidisciplinary health care team must understand the advances in current technology as well as best practices in the service delivery. process. The value of the wheelchair and seating system within the context of health care now extends beyond the four walls of a traditional clinic to the community in which the individual uses the wheelchair and seating system.

1. WHEELCHAIRS
Presented by,
Dr. Joe Antony
Junior Resident 2
Dept of PMR
Moderator,
Prof Dileep Kumar
Professor
Dept of PMR
1

2. Contents
• Goals for a wheelchair & its
seating system
• Basic dimensions
• Types of wheelchairs
• Transporting a wheelchair-
bound patient
• Clinical situations
• Architectural modifications
for a wheelchair user
2

3. • It should maximise functional independence
• It should minimise risk of secondary injuries
(shoulder impingement, carpal tunnel
syndrome, falls)
• It should be comfortable
• It should be aesthetically appealing
Goals for a wheelchair
3

4. Goals for a seating system
• It should stabilise the head, neck (so that
breathing, swallowing is facilitated), trunk,
pelvis, any paralysed limb (otherwise it collapses
to a ‘gravity’ position, leading to joint
subluxations / entanglement of limb in the chair)
• It should prevent pressure ulcers
• It should accommodate any contractures /
deformities
4

5. Seat height
Leg length (popliteal fossa to bottom of
heels)
+
Thickness of seat cushion
+
Must leave at least 2 inches under the
footrests to clear small obstacles
*adjustments may be done so that the
knees are able to fit under tables
Basic dimensions
5

6. Seat depth
Basic dimensions
2 inch gap is recommended
Popliteal area to back of buttocks
+
Thickness of back cushion (if any)
6

7. Basic dimensions
If too shallow if too deep
increased pressure increased pressure
on ischial area on popliteal area
Seat depth
7

8. Basic dimensions of a wheelchair
Back height
• Determined by the amount of postural
support the patient needs
• Should be low enough to have free arm
movements
• Inferior angle of scapula can be a pointer
Armrest height
• Distance between forearm and seated surface
• Forearm should be parallel to ground
• If too high- Shoulder will be elevated and will be
difficult to access pushrim
• If too low- Doesn’t support upper limb
(Shoulder complex)
Basic dimensions
8

9. Width of the widest parts of the
buttocks (with clothing / any braces)
+
1 inch
Seat width
Basic dimensions of a wheelchair
If too narrow if too wide
Increased pressure
on trochanteric area
Increased abduction
at shoulder, scoliosis
Basic dimensions
9

10. Basic dimensions of a wheelchair
Rear wheel camber
It is the angle that the rear wheel makes with the vertical.
Generally not more than 8 degrees
Basic dimensions
Advantages
1. Increased stability
2. Reduced shoulder abduction
3. Arms can access more of the pushrim
4. Quicker turning
5. It is more natural to push down & out
Disadvantages
1. Decreased maneuverability in tight areas
2. Uneven tire wear
10

11. Basic dimensions
Seat angle (dump)
Angle between the seat & horizontal
Adequate dump
• stabilises pelvis & spine
• Assist in people with limited trunk
control
• Easier to propel
• Decrease extensor tone and
posturing
Too much dump
• Increase pressure on sacrum
• makes transfers difficult 11

12. Basic dimensions
Back angle
Angle between the backrest & the vertical
Increased back angle
needed for patients in
whom hip flexion is
limited
12

13. Basic dimensions
Axle position- Horizontal Axle
if the axle is located forward – seat
is brought backward
• Advantages
• Less muscular effort, fewer strokes
are required for propulsion
(reducing risk of median nerve
compression)
• Easier to negotiate obstacles
• Disadvantages
• the wheelchair has a tendency to
tip backwards (ascending a ramp
becomes difficult)
If the axle is located backward seat
is brought forward
Advantage
• The wheelchair becomes more
stable
Disadvantages
• More muscular effort is required
• Caster flutter increases
13

14. Basic dimensions
Axle position
• Vertical position Must be such that
Or, when the patient lets the arm
hang, the fingers must be at the level
of the axle
100-120
14

15. Basic dimensions
• If the axle is too low – the patient has to push the chair with the arms
abducted, increasing risk of shoulder impingement
• If the axle is too high – lesser of the pushrim is accessible, therefore
more strokes are required
15

16. Types of wheelchairs
• Manual wheelchairs
• Power-assisted wheelchairs
• Power wheelchairs
16

17. Manual wheelchair - parts
17

18. Manual wheelchair - parts
• Frame folding rigid
Advantages 1.easy to transport 1. lighter
2. better shock absorption 2. more durable
18

19. Manual wheelchair - parts
• Wheels Advantages Disadvantages
types
• 1. Mag durable heavy
2. spoke smoother ride tendency to
wobble
19

20. Manual wheelchair - parts
• Tyres different types are available for different terrains/mobility
levels
• For indoor use – narrow, smooth tyres
• For outdoors – wide, rough
•Tyre inserts advantages disadvantages
1.pneumatic smoother ride flats
•2.solid foam
• Castor wheels
• Caster wheels 1. small- smaller turning get stuck in cracks
- increased manoeuvrability
2. large roll over uneven terrain easily
20

21. Manual wheelchair - parts
• Wheel locks/brakes Why are they required –
1. so that the wheelchair does not roll away on uneven surfaces
2. for stability during transfers
Types –
1. toggle type
2. lever type – consists of two levers- one is pulled (may be extended
to make it easier to reach)
the other pushes against the wheel
21

22. Manual wheelchair - parts
• Grade aids prevent the wheelchair from rolling backwards on slopes
• Antitippers
22

23. Manual wheelchair - parts
• Pushrims most commonly found – steel, ½ inch diameter, smooth
in patients with limited gripping ability – 1. larger diameter
2. high friction material (plastic/vinyl/rubber)
3. projections
23

24. Manual wheelchair - parts
in patients who cannot use both arms -
Single-hand drive pushrims Lever drive
24

25. Manual wheelchair - parts
Propulsion techniques
associated with lower
stroke frequency, more
time spent in push
phase
most prevalent
pattern in paraplegics
25

26. Manual wheelchair - parts
• Backrest Types -
sling
fabric
Custom-moulded
• Lateral pads may be added for – 1. trunk stabilisation
2. accommodating asymmetric deformities
26

27. Manual wheelchair - parts
• Armrests fixed / removable (for side transfers) / swingaway /
wraparound / height-adjustable / full-length / desklength /lapboards /
troughs (for those who cannot lift or self-stabilise the arm)
27

28. Manual wheelchair - parts
• Footrests fixed / swingaway / folding / elevating (to reduce
dependent edema) / length-adjustable / angle-adjustable (to
accommodate tight hamstrings) / calf pads
• Seatbelts
• Postural straps
28

29. Manual wheelchair - parts
• Headrests
• Positioning systems
Tilt-in-space Recline
29

30. Useful for – patients with
weakness / fatigue /
overuse injuries
Advantage
Reduces the physical effort
required to propel the chair
reduced incidence of secondary
injuries (wrist, shoulder)
Disadvantage
adds weight
Power-assisted wheelchair
30

31. Power wheelchairs - parts
• Drive configurations
front-wheel drive midwheel rearwheel
•can turn on its
centre, increasing
manoeuvrability
•tracks in a straight line,
steers predictably
•can climb obstacles
with ease,
“fishtailing” of the rear
portion can be a
problem
31

32. Power wheelchairs - parts
• Devices used to operate power wheelchairs
1.joystick 2.head-array 3.sip-&-puff control
4.tongue-touch keypad 5.voice-control
6.integrated control (a single device is used to control a wheelchair ,
a computer & other devices)
32

33. Power wheelchairs - parts
• Wheelchair-mounted accessories
• wireless controls for doors / lights / TV / radio / fan
• oxygen devices / ventilators
• electronic voice-communication devices
• cellphones
• portable entertainment devices
• computers
33

34. Standing wheelchair
Advantages 1.provides weight-bearing – good for bone density
2.psychologic (interacting with others face-to-face)
3.reduced incidence of bladder infections
Disadvantage COG is high – can topple over 34

35. Stair climbing wheelchair
35

36. Scooters
• Requirements – good upper limb strength & ROM, good trunk balance
• Drawbacks – 1. cannot accommodate user needs over time
2. modified seating is not possible
36

37. Transporting a wheelchair- bound patient
• How to transfer a wheelchair-bound patient into a vehicle
Ramps
Lifts
platform lift rotary lift hoist lift
37

38. Transporting a wheelchair-bound patient
Transporting a wheelchair- bound patient
• How to secure the wheelchair-bound patient in the vehicle
Strap securement system Docking devices
advantages can be used to secure a quick,
variety of chairs in a no attendant may be reqd.
variety of vehicles
disadvantages time-consuming, components have to be
attendant required customised to fit the vehicle
& the wheelchair
38

39. Clinical problems
• Spinal cord injury
Motor level C2-4
•Wheelchair type – power wheelchair
•Headrest
• Backrest must be solid, high
• Trunk supports (lateral pads, postural straps)
• Armrest – lapboard / arm trough
• Seat cushion – must provide excellent pressure relief
• Control device – sip puff device / head or chin-operated device
• Power tilt , recline function
• Accessories – ventilation tray
39

40. Clinical problems
C5
wheelchair type – power wheelchair
desirable features – hand-operated joystick control if possible
C6
wheelchair type – power OR manual
•desirable features - modified pushrim (with high-friction coating /
projections)
• Brake extensions
T2 & below
•wheelchair type – manual
•features – backrest height may be lowered according to degree of trunk
control
40

41. Clinical problems
• Limited hip flexion accommodated by recline function
• Hamstring tightness accommodated by angle-adjustable legrests
• Risk of pressure ulcers weight-shifting must be taught
( push-ups / forward bending /side-to-side bending)
if not possible due to weakness / pain- tilt-in-space
mechanism,seat cushion with excellent pressure relief
• Hemiplegia
• seat height is lower so that the patient can propel the
chair with the normal leg
• no legrest on the unaffected side
41

42. Clinical problems
• Lower-limb amputees
• axle is set back to bring the COG forward
• amputee board
•Anti tipper bar
•Swing away foot rest
•Recliner backseat
•Sliding board
•Removable arm rest
42

43. Clinical problems
• Paediatric age group
Desirable features -
• growth-adjustable backrests / armrests
• ability to facilitate interaction with other children
e.g. power wheelchair with seat that can be
lowered to the floor
43

44. Clinical problems
• Progressive disorders
power wheelchairs are preferred so that as the disease
progresses adjustments can be made in control devices seating &
positioning hardware
• Spasticity -custom-contoured seating
(provides total contact support )
44

45. Wheeled mobility in Cerebral palsy
• Encourage wheeled mobility in all
children who have poor potential for
walking.
• Strollers and wheelchairs are options
for wheeled mobility.
• Totally dependent children- Use
strollers, wheelchairs which tilt
backwards, or wheelchairs with
reclining backs.
45
Adduction prevention pillow

46. Architectural modifications for a wheelchair user
46
Discussion of entire modifications is beyond the scope of this presentation. Bathroom is
where maximum accidents happen, hence bathroom modifications only discussed here

47. Architectural modifications for a wheelchair user
Doors/Doorways
• Atleast 34 inch wide with
door opened to 90 degree
• Swing clear offset hinges
• Clear space on both sides
of door
• Swing Outward ( more
space for maneuvering
and prevent patient
blocking access
inadvertently)
• Lever door handle
Bathroom sink
• No cabinets underneath so
wheelchair can roll in
• Knee clearance of minimum
27 inch
• Widht of minimum 30inch
• Depth of minimum 19inch
• Sink top at maximum 34
inch
• All exposed hot water pipes
need to be insulated
47

48. Architectural modifications for a wheelchair user
Toilet
• Standard toilet height is 14-
15inch from floor
• Wheelchair ht is 19inch
• Toilet seat must be 17-19 inch
from floor
• 32 inch clearance on one side
to allow transfer from
wheelchair
• Easy to flush handles which
can be operated with closed
fist or elbow
• Grab bars at a side wall and
back wall
Showers
• Most ideal- Roll in shower
• Floor should be sloped toward drain
• Drain should be oversized
• Threshold should be flush
• Flooring of entire bathroom should
have non skid surface
• Atleast 60inch wide
• Next best option- Stall shower
• Last option- bath tub
48

49. Architectural modifications for a wheelchair user
49

50. Architectural modifications for a wheelchair user
• Coefficeint of friction in 0.5 range are considered
slip resistant.
• Vinyl tiles with embossed surface , ceramic
tiles,laminate boards are good options.
• Mirror in the bathroom, as well as in the rest of
home, should be mounted lower, be extra long, or
tilted so that it can be used by the wheelchair user.
50

51. Thank You
References
1.Physical medicine & rehabilitation –
Randall E. Braddom, 3rd edition
2.Physical medicine & rehabilitation –
DeLisa et al
3.Spinal cord medicine – Krishblum
4.Cerebral Palsy HELP manual
51