As physical therapists, we prescribe wheelchair based on our patient’s needs. We look for things like ambulatory status, weight-bearing precautions, arm or leg injuries, cardiopulmonary problems, etc while prescribing an appropriate wheelchair. Wheelchair evaluation can be very simple and straightforward when it is used for short-term use. Contradictorily, it can be tricky for patients with neurological disorders. It starts with getting information regarding past history, checking muscle strength and balance, finding the cognitive abilities and the usage of the chair. Yes, it is your full-fledged thorough physical or occupational therapy evaluation. And let me tell you, it does not end only an evaluation! A patient needs to be well trained to propel the manual chair or drive the power chair for the safety of himself and safety of others.
Things to Consider for Wheelchair Evaluation:
- Screening the patients who may benefit from wheelchairs
- Finding out the short-term or long-term use of wheelchairs.
- Evaluating/assessing physical and cognitive abilities
- Taking body measurements for an appropriate fitting of the chair
- Finding out clinical needs for any specialized accessories
- Training with the wheelchair and making adjustments as needed
This should be it in the majority of cases. Sometimes, we need to change and reposition constantly based on necessity. Let’s talk about each section in detail.
1. Screening appropriate patients:
As a clinician, we need to find out who is going to benefit. Nonambulatory patients due to orthopedic or cardiopulmonary restriction, or just general deconditioning are the ones in need of other means of transportation. Some sub-acute care facilities have policies to provide an appropriate chair for all their nonambulatory patients.
2. Finding the short-term vs long-term use of wheelchairs:
This depends on level and extent of the injury. For example, a patient with non weight-bearing for 6 weeks, will need a wheelchair for short-term use. Conversely, a patient with moderate to severe CHF is going to use it for a long time, mainly for long distance ambulation.
3. Evaluating Physical and Cognitive Needs:
This will essentially guide a clinician what kind of chair a person will need. It also gives some idea if the patient is going to be able to propel a chair or not. The assessment mainly includes manual muscle testing for bilateral upper and lower extremities as well as trunk or core muscles, and static and dynamic balance. I also like to assess how long a person can sit upright (90 degrees) without any pain or discomfort.
Clinicians will also need to check cognition status of a patient. I also like to find if a patient is taking any medication that can alter or affect their alertness. If this is the case, I will gather information about type and time of medication as this is going to affect their judgment and decision-making abilities. In cases, where the judgment is affected severely or patient is drowsy, I will ask my patient not to be in a wheelchair for that particular two to four hours after that medication. When you drive a chair being sleepy or not fully alert, you can hurt yourself or someone else. So educate your patients regarding the cause and effect and advice them not to use the chair when they are under effects of medication.
4. Taking body measurement for Appropriate Fitting:
This is where you actually determine the size of the chair. It is also called wheelchair measurement. The main measurements for a wheelchair are seat depth, width, and height.
Seat Depth: is the distance from the front of the seat to the back of the seat.
It is determined by measuring the distance from the patient’s posterior buttock to the popliteal fold and subtracting two inches.
Seat Width: is the distance from one side of the seat to the other.
It is determined by measuring the widest part of the patient’s hips and adding two inches.
Seat height is the distance from the floor to the seat of the wheelchair.
It is determined by measuring the distance from the patient’s heel to their popliteal fold and adding two inches.
You also want to measure back height and armrest height.
Back Height is the distance from the top of the back portion of the seat to the bottom.
It is determined by measuring the distance between the seat of the chair to the patient’s axilla and subtracting four inches.
Arm Height: is the distance between the seat and the top of the armrest.
It is determined by measuring the distance between the seat of the chair and olecranon and adding one inch.
This describes the basics of wheelchair measurements. It should be enough if you are giving a standard wheelchair for a short-term duration. You may need to add a pair of leg rests with the chair for appropriate leg positioning.
5. Finding out clinical needs and adding accessories:
This is usually fun part. Sometimes, you may have to get creative and think outside of the box to align your patient properly and provide comfort while in the chair. Below are the main accessories that can be used with standard or customized chairs.
Armrests are important to provide proper positioning and to prevent dislocation or subluxation. They can be adjustable in length. It can be a flip back arm or completely removable one. This depends on what kind of transfer your patient is able to perform. Dropping the arm, or removable armrest helps with slide board transfer. You can also get padded armrests or grooved armrests. Your patient may benefit from molded armrest which is anatomically contoured to cradle patient’s arm. This is when a patient needs a complete support of arm. They are very comfortable as well. They are easily removable to perform pivot transfer or slide board transfer.
You can play with this part depending on the type of wheelchair your patient is in and what part of back they need the maximum support at. For example, for minimal support, you can provide mid contour back, for moderate support at thoracic region – you may want to choose moderate to deep contour back.
Lateral Support or Side Support:
Lateral or side support goes very close with the type of back support patient needs. It also takes some playing around on clinician’s part. For example, you can provide a side support with mid contour back in order to prevent side/lateral leaning in the chair. Or you can choose to use adjustable lateral support in standard wheelchairs to provide some extra cushioning and comfort.
Again, there are a variety of options out there for leg rests. You can choose standard or elevating leg rests. If your patient is not going to propel the chair with legs or in tilt-n-space chair, you can choose foot box, molded foot box, or complete feet support. In case of hemiplegia, you may choose single foot support on an affected leg and removable standard leg rest on a non-affected leg.
Foot pads/calf pads:
This is to provide some extra comfort. It also helps if your patient has some history of PVD or venous stasis or ulcer on the calf. I like to add calf pads or foot pads as it improves posture and promotes a proper anatomical alignment.
It is important, mainly to prevent any pressure ulcers but also provides comfort. A few common types of cushions are gel cushion, air cushion, foam cushion, Roho cushion. Pommel cushion or anti-thrust cushion are few examples that will assist in correcting the positioning in addition to providing support and comfort. Depending on height and weight, you can choose a high-profile (4” height) or a low profile (2” height) cushion.
Now, remember, you will have to consider the height of a cushion while measuring for wheelchair height.
Lap tray or half tray:
This is to provide arm support, prevent forward leaning or just position arms on the tray.
As the name suggests, it provides extra support on the head and cervical area. If you have a patient presenting with torticollis, excess forward and/or lateral leaning, you will need to provide some extra support on the affected side of the head.
This can be little tricky for a quadriplegic or stroke patient as there is a minimal to no muscle tone on a neck and you are constantly working against gravity. Fatigue is another challenge you will face when you are trying to find a proper adaptive equipment for head positioning. The sensitive skin of a patient is another challenge clinician will face in neck positioning. I like to use a gel padded headrest in these cases. Sometimes, I have to use this headrest as a type of braces or splint. Here, I develop a protocol for how many hours a patient can tolerate this headrest. If you need to go this route, you need to train/educate family member or a caregiver to change the headrest after few hours.
Facial pad or head support:
Sometimes, with extreme lateral leaning, the only headrest won’t fix the problem. So a small amount of medial push at a cheekbone or at forehead will do the magic! I like to use the facial pad with stroke or TBI patients as they are adjustable and very easy to use.
Few other accessories like beverage holder, oxygen cylinder holder, urinary drainage bag holder, or footrest bad are few other options available for patient and or for caregiver convenience.
6. Training with wheelchairs and making adjustments if needed:
Now that you have figured out what kind and size of wheelchair your patient should be in, its time to position them and train them to propel. I tell my patients, it is like you are learning to drive again! So it will take some repetition and patience.
If you are dealing with the neurological population like I do, you will need to adjust and readjust the chair several times. Their tone changes so do their clinical presentation!! Therefore, we constantly need to adjust the positioning. But once you have figured out the main issues, the little changes here and there will not take much time or effort.
So this is it for wheelchair evaluation!! I know it feels and looks like a long process (five pages long blog after all!!!). But it’s not that bad when you are actually doing it. I tried to give overall idea for all different options of positioning devices we can use. It comes really handy for clinicians when we need to use it. I did not have the knowledge of many of these fabulous devices until I started working with really complex patients. That is why I thought it will be a good topic to write on.
I hope you find it helpful!