Occupational therapy programs tables of content

The

WHEELCHAIR

User

The subject matter of this series of Handbooks has been concerned with a study of the human body and some of the problems that result from disease or injury. Now the knowledge gained will be applied to the use of the most common assistive device for the wheelchair user.

Basic Needs

Determining the Use

Environmental Considerations

Measuring the Patient

The objective of the text immediately following, then, is to indicate considerations necessary to determine the needs of the user who will require a wheelchair.
Every wheelchair must have certain elements of safety, construction, comfort, and appearance. The variations in such basic parts and the design of the wheelchair account for the many models that are presently available. Many features can be added to the basic design of wheelchair and parts to increase the benefits to the user: such additions are reflected in a higher cost of the produce.
Basic Needs
The parts that make a wheelchair should be so assembled to provide:

Safety:

The frame design should allow for normal activities within the seating enclosure and transfers in or out of the chair without tipping. The wheel locks should operate easily and efficiently.

Comfort:

The seat and back of the wheelchair should be comfortable and provide support in good posture position for the trunk and extremities.

Ease of Maneuvering:

The size of the wheels and casters, the system of ball bearings used, and the balance of the chair all contribute to the “rollability” of the wheelchair–the ease of propelling the chair over rough or uneven surfaces.

Durability:

The design of the wheelchair, the materials and workmanship used in construction, and the assembly of the finished product should all be of good quality to allow continuous use of the wheelchair with a minimum of maintenance.

Service:

The supplier who sells the wheelchair must offer service and repair of the product when necessary. Repair parts for the wheelchair must be readily available.

Attractiveness:

The wheelchair is an extension of the individual: an integral part of the user’s life and as such, should be as attractive as possible. The design of well-proportioned and simple lines, the finish of metal parts, and the upholstery materials and color should all blend into an eye-pleasing array.

Combining the essential elements with the required benefits is the challenge presented to the wheelchair manufacturer and how well this is accomplished is immediately evident in the resultant product.

There are two important considerations in an evaluation of how a wheelchair is to be used:

How the chair will be used by the patient for propulsion and transfer.

Use of the chair for the patient’s general mode of living and/or occupation.

Up to this point, the wheelchair has been referred to in general terms. Now we must be concerned with specifics of dimension, frame and arm styles, front-end accessories (footrests, legrests), and other accessories that may be added to increase the safety, comfort, or efficiency of the product to satisfy an individual requirement. The disability analysis–a must for the long term user or the short term user who must remain active–will help to determine certain of the requirements of the wheelchair. From the analysis, we will know how the patient will propel the wheelchair and what provision must be made.
Use of both hands, normal or adequate strength: Standard wheelchair equipment.
Use of one hand: A one-arm drive chair may be used.
Use of one or both feet: The seat-to-floor height must be low enough to allow the user to reach the floor with his feet.
Use of both hands, limited function: Projections may be required on the handrims with they type or number determined by the extent of limited function, or the handrims may need a plastic coating or other non-slip finish.

Environmental Considerations
The width of a wheelchair seat determines the overall width of the wheelchair. The challenge in engineering design of a wheelchair is to provide a seat of acceptable width, usually 18" for the adult, then make the supporting framework and the wheels as narrow as possible. The width increases for standard removable arms by another 1 ½". An overall width of from 25" to 26 ½ “ must be remembered in whatever architectural surroundings the chair will be used.
In the home, if the overall length and turning radius are a problem, furniture may be arranged to compensate. The width of the wheelchair is more important in travel through halls and doorways. The approaches to home or apartment such as stairs, narrow hallways, or elevations may become barriers to independent use of a wheelchair.
Surprises await the new user, introduced to a wheelchair as a means of mobility. It is only fair to openly discuss the possible problems that may be encountered with the wheelchair user and attempt to accommodate the wheelchair under such conditions.
If the wheelchair is to be used to provide gainful employment, then the environment of the work area must also be considered in the selection of the arm style, footrests and method of propulsion of the wheelchair. Transport of the wheelchair from home to work may require a lightweight model for east of handling.
Consider the environment, satisfy the need.

Transfers
Poor trunk stability: If the patient is unable to maintain normal sitting posture, due to a weakness or severe involvement of trunk muscles, they will require a higher back on the wheelchair, or a semi-or full-reclining back. A seat belt and possibly a torso belt may also be needed. A patient in a body cast or brace might also need a reclining back wheelchair. The severe arthritic may experience greater comfort in a reclined position.
The disability analysis will also determine if the patient may transfer from the wheelchair without assistance, or if partial or full assist is required. The wheelchair must be equipped to allowed the following types of transfers:
Standing transfers: Used by the patient who can reach a standing position on one or both legs, with or without assistance. The hemiplegic is typical of this type patient transfer. The footrests must be swing-away, removable. The arms of the wheelchair may be fixed, removable or swing-back, but if removable desk arms are used, then they must be reversible and lock in either position.
In most of the transfers described, it will be necessary for the patient to move forward on the seat of the wheelchair before they can transfer. If the front casters of the wheelchair are in the trailing position, there is a possibility that too much weight forward on the seat will cause the chair to tip in that direction. The casters should always be rotated to extend as far forward as possible to lend this added stability to the chair. If sitting transfers are made from the front of the chair, or for standing transfers, it is recommended that caster swivel locks be provided on the wheelchair to fix the casters in this more stable position.
Wheel locks must be used to safely hold the wheelchair in position. Extension handles may be required if there is difficulty in reaching one, or both, wheel locks.
Sitting transfer: Used by the patient with sufficient strength in the upper body and extremities to raise his weight. Such transfer may be made from the front of the wheelchair, to either side of a removable or swing-back arm chair. The wheelchair for a patient capable of sitting transfers must have swing-away, removable footrests and removable arms. If desk-style removable arms are needed, then they should be reversible (front and back) and lock in either direction to assist in transfer.
Manual lifting or Patient Lift Transfer: Used for the patient who cannot transfer alone or with partial assistance. One or more attendants may manually lift or transfer the patient, or a hydraulic lift or mechanical lift may be used. Removable arms on the wheelchair will facilitate attendant handling of the patient and footrests or legrests must be swing-away type, removable.

Measuring the......

Seat & Back Width:
Objective: To provide a wheelchair user with a comfortable wheelchair, properly supporting the body in good position, with a minimum of pressure on areas prone to tissue breakdown. Keep in mind this overall objective in the practice of measuring patients, as the details of method that follow propose this end result.
Fit the wheelchair to the user....not the user tot he wheelchair. Every person who requires a wheelchair – short or long term use – should be measured for the wheelchair they will use.
Measuring by physical characteristics: Often, the provider of a wheelchair cannot make personal contact with the short term user to record the essential measurements for a correct fitting. In such cases, they physical characteristics of the user may be readily obtained and such information then used as a guide to selection of a wheelchair. With such simple details as height and weight, and their respective distribution, there is a greater possibility for a more correct fitting.
Height: The overall height of the user and the sitting height, measured from head-to-seat surface will determine an average frame size, or a person with a long torso/short lower extremities, or the reverse: short torso/long lower extremities.
Weight: The total weight of the user, with information regarding distribution of weight. A muscular build will distribute weight evenly over the body frame. The obese person tends to deposit fat in the abdomen and hips. The chest and torso may be large with tapered hips, or the hips and thighs may be the widest part of the body frame. Two people of the same height and weight could have considerably different physical size.
A wheelchair is a substitute for the ability to walk normally. If the wheelchair is to provide a means of necessary transportation, then it must offer comfort and convenience to by physically and psychologically acceptable to the user. Comfort is obtained only if the user is correctly measured and a wheelchair selected or prescribed to suite physical size and the activities of the patient. Convenience requires that the wheelchair and accessories provide maximum usefulness and ease of mobility.
Measuring: Some fittings will require measuring the user while in a wheelchair of approximately correct size, as when the user is unable to sit in the chair as recommended below. Th user may be confined to a hospital bed, where measurements must be taken by evaluation of the head and knee section. Measuring under adverse conditions is possible, but care must be taken to obtain correct dimensions.
The optimum position for measuring is to seat the user in a straight-backed chair. Allow time for the user to assume their natural sitting position, as they may sit further back in the chair than normal when first positioned.

Seat Width: Measure the user across the widest point of the hips or thighs. If braces are to be worn measure width of widest point to include brace.
Wheelchair seat upholstery width: Add one inch to the above measurement. If a side cushion is used also add the total thickness of both the side cushions.
Possible error in fitting: Seat upholstery should be as narrow as possible to obtain the minimum possible overall width of the wheelchair, but wide enough to insert the thickness of an extended hand between the clothing guard and the bony prominence on the side of the hip–on both sides of the user.
Seat Depth: Measure the user from the rear of the buttocks to the inner surface of the back of the knee (popliteal area).
Wheelchair seat upholstery depth: Subtract 2 to 3 inches from the above measurement. If the back cushion is to be used add back the entire thickness of the cushion.
Possible error in fitting: If depth is too shallow, excessive pressure on the ischial tuberosities will result with the possibility of pressure sores. If upholstery is of greater depth than recommended, undue rubbing and chafing of the user’s skin at the back of the knee and leg may result.
Footrest Height: Measure the user from the bottom of the heel to the under-surface of the thigh at the back of the knee (popliteal area).
Wheelchair seat height and footrest adjustment: Add 1 inch to the above measurement. If a seat cushion is to be used, subtract one-half the thickness of the cushion from the total.
The footrests cannot extend beyond a level two inches above the floor surface.
The dimension calculated above must fall within the adjustment range of the footrest on the wheelchair and allow floor clearance, otherwise the seat height must be raised.
Special large footplates for the user with a shoe size larger than 9 ½ may be desirable.
Possible error in fitting: If footrests are adjusted too high, excessive pressure is forced onto the ischial tuberosities. Footrests that are adjusted too low will force user’s feet into dropfoot position, or if adjusted too low to the floor, they will trip over uneven surfaces or hit a ramp during ascent. The combination of seat height and footrest adjustment must be considered in the final determination.

Back Height: The user’s back height is measured from the rear underside of the buttocks to the underside of the extended arm (the axilla at the level of the spine of the scapula).
Wheelchair Upholstery Back Height: When taking the back height measurement, ask the user to extend and elevate one arm forward.

For patients with good trunk muscles and capable of actively propelling the wheelchair: Subtract 4 inches from the above measurement. If a seat cushion is used, add back one-half the thickness of the cushion.

For users with poor trunk muscles but good shoulder muscles and good elbow flexors: Subtract 3 inches from above measurement. If a seat cushion is used, add back one-half the thickness of the cushion.

For users with no use of the upper extremities and poor trunk stability: Use the full measurement taken above. A headrest extension may be required, or a reclining back wheelchair for trunk stability.

Possible error in fitting: Providing a back upholstery that is too high will interfere with shoulder movement while propelling the wheelchair. A back upholstery that is too low will not provide upper trunk stability.
Arm Height: Taking the arm height measurement, ask the user to bend one arm at the elbow, keeping the forearm parallel to the floor, take the measurement on that side.
Measure the user from the lateral underside of the buttocks to the bottom of the bent elbow. If there is a visible difference in shoulder height, measure both left and right sides.
Wheelchair Arm Height: Add 1 inch to the above measurement. If a seat cushion is to be used, also add one-half the thickness of the cushion.
If there is a difference in left and right side measurements, use adjustable height arms on the wheelchair.
Possible error in fitting: Armrests too high, user is forced into a poor posture position. Armrests too low, shoulder discomfort will result due to weight drag.

THE WHEELCHAIR USER

Special Fitting Problems
The Hemiplegic: The seat height must be low enough to allow both the user’s feet to rest on the floor. During use, the foot of the affected side is supported on a footrest. The footrest on the opposite side is removed and the user uses the active foot to propel the chair. (Hemi chairs are not necessarily 17" seat-to-floor height).
The Arthritic: If the user has difficulty in standing up from a seated position, the seat height may need to be elevated, within reason, to allow standing transfer. The elevated seat height will demand a change in other chair dimensions to satisfy a correct fitting.
Patient with Respiratory Difficulty: A reclining back wheelchair may serve to ease breathing.
Safety/Handling

of

Wheelchairs

INITIAL INSPECTION CHECKLIST

GENERAL:

Wheelchair opens and closes with ease.

Wheelchair rolls straight (no excessive drag).

WHEEL LOCKS:

Locks to not interfere with tires when rolling.

Locks easily engage.

CROSSBRACES:

Free floating style: should allow chair to fold smoothly.

Pivot bolt secure but loose enough to keep all four wheels on the ground when crossing uneven surfaces.

Over center style: pivot bolt tight.
ARMS:

Secure but easily released, removed.

Adjustable height arms operate and lock securely.

20"/24" WHEELS:

No excessive side movement or binding when lifted from ground and spun.
6"/8" CASTER:

Inspect axle for proper tension by spinning caster. Caster should come to a gradual stop.

Adjust bearing system if wheel wobbles noticeably or binds to a stop.

TIRES:

If pneumatic tires, check for proper inflation.

REMOVABLE ARMS: (Push button removal) To remove arms: Depress spring button on front of arm above socket on frame and lift arm upward out of front and rear sockets.
ADJUSTABLE HEIGHT ARMS: To adjust arm height: Flip release lever up while holding armrest. Move arm to desired location. Return release lever to locked position.
SWING BACK ARMS: To swing arms back: Using tab, rotate quad release collar to outside of chair and swing arm toward back of chair.
To remove swing back arms: Rotate quad release collars on front and back of arm to unlock arms then lift arm out of sockets. To lock arms in place: Rotate quad release collars to face in the same direction as their location. (Front to front, back to rear).

Note: See note to attendants:

CAUTION Always be sure arms are securely locked before using the wheelchair!

“Safety and Handling” of the wheelchair requires close attention of the wheelchair user as well as the attendant. This manual points out the most common procedures and techniques involved in the safe operation and maintenance of the wheelchair. It is important to practice and master these safe techniques until you are comfortable in maneuvering around the frequently encountered architectural barriers.

Use this booklet only as a “basic” guide. The techniques that are discussed on the following pages have been used successfully by many.
Individual wheelchair users are subject to various capabilities and limitations and often develop skills to overcome their disabilities in daily living activities that may differ from those described in this manual. Invacare recognizes and encourages each individual to try what works best for him/her in overcoming architectural obstacles that the wheelchair user may encounter. Techniques in the manual are a starting point for the new wheelchair user and attendant with “safety” as the most important consideration for all.

FOLDING AND UNFOLDING THE WHEELCHAIR
To Open:

Open the wheelchair by grasping one push handle nearest you, tilt chair to one side (raising opposite wheel and caster off the ground) and push downward on seat rail nearest you at seat upholstery until fully open.

Set both wheel locks, open the footrest/legrest for clearance, and transfer to chair.

Note: If the wheelchair is equipped with carry straps, the wheelchair may be closed by pulling up on the straps.

To Close:

Swing footrest/legrest in locked position to front of chair.

Pivot footplates upward to vertical position.

With both hands, grasp middle of seat upholstery at front and back edge, then lift up. Or, tilt the chair to one side and close by push handles.

Solid-Seat Models:

From behind the wheelchair grasp right hand edge of solid seat.

Raise the seat to hinged side, and follow above procedure.

CAUTION: To avoid injury, keep hands and fingers clear of moving parts.

INVACARE RECLINER-OPERATING INSTRUCTIONS
OPENING THE WHEELCHAIR:

While standing to the side of the chair, tilt chair sideways slightly toward you. While tilted, press downward on the crossbrace seat rail nearest you. This operation will partially open the chair.

Stand in front of the chair and press downward on crossbrace seat rails with both hands until seat upholstery is taut.

Slide headrest extension into open tubes at the top of back.

From back of chair, swing push bar upward to a horizontal position. Match threads on knob lock with threaded hole in back cane. Turn knob lock (clockwise) to tighten push bar in horizontal position.

Rotate center section of push bar to take slack out of back upholstery (DO NOT OVERTIGHTEN).

Attach pillow to headrest by snapping to headrest tubes (NOTE: There are two snap locations to accommodate different height users).

CLOSING THE WHEELCHAIR:

Reverse steps 1-6 above.

OPERATING THE RECLINING BACK:

To recline the back, grip both release handles at the same time, while supporting the chair back. Gently lower the back to desired angle and then release grips until locked. Reverse procedure to raise, and lift upwardly gently. If the wheelchair is equipped with a lift package you will feel a lift assist in raising the back from any reclined position to fully upright. This unique feature helps prevent back strain for attendants.

CAUTION: Do not allow the occupant to leave the chair while the back is still reclined. Do not allow the chair back to raise vertically without an occupant in it, as the lift package will cause the front of the chair to lift suddenly. Maintenance of the lift package mechanism should be attempted by authorized personnel only.

Stability and Balance
To ensure stability and proper operation of your wheelchair, you must at all times maintain proper balance. Your wheelchair has been designed to remain upright and stable during normal daily activities as long as you do not move beyond the center of gravity.
Virtually all activities which involve movement in the chair have an effect on the center of gravity. Invacare recommends using body belts for additional safety while involved in activities that shift your weight.
DO NOT lean forward out of the chair any further than the length of the armrests. Make sure the casters are pointing in the forward position whenever you lean forward. This can only be achieved by advancing the chair then reversing it in a straight line.