Module 9 - Manual Wheelchair
Keep The Big Picture in mind
To optimise pressure care and postural alignment and maximise functional abilities, the wheelchair should match the client's body size and shape, enabling the client to function in his/her life roles and environment.Systematically identifying key wheeled mobility issues and appropriate intervention strategies:
- The cient's level of functional independence will indicate the type of wheeled mobility required. The optimal level of function in relation to the manual wheelchair for a client with a complete SCI at lesion level:
- C5: may be able to push on level surfaces with the aid of capstan wheel rims or grip mitts and apply wheel locks (brakes). However, a power wheelchair usually provides optimal mobility and functional outcomes for clients with a C5 lesion.
- C6: able to push on gentle sloping even ground, turn wheelchair, apply wheel locks and remove armrest and footplates. The client may use a manual wheelchair for indoor or short distance propulsion. Power wheelchair is generally selected as the means of mobility for community integration.
- C7/8: able to propel manual wheelchair on uneven ground or over small obstacles, or negotiate kerbs. Some clients with a C7/8 injury elect to use a manual wheelchair and return to driving with an adapted hand-control car for community integration. A power mobility device is likely to be considered by those who require it to mobilise independently and are dependent on public transport. A power mobility device may also reduce shoulder injury.
- T1-T5: able to balance on rear wheels and perform a "wheel stand or wheelie" to negotiate kerbs and ramps. Able to pull wheelchair into car. Manual wheelchair is likely to be the only mobility option at discharge. Power mobility may be considered if there are other co-morbidities and overuse syndromes and injuries.
- Consider the back support height to match to the level of injury and the type of sitter to maximise function and balance. A hands-free sitter may utilitise posterior support at the thoracic-lumbar level, while a hands-dependent sitter may require a higher support to the inferior angle of the scapulae, depending on balance and wheelchair skills identified in the MAT evaluation and functional assessments.
- Clients with an incomplete SCI may present with asymmetrical upper limb function that will impact on wheelchair management.
- Understand any co-morbidities and other medical conditions that may limit functional manual wheelchair propulsion, e.g acquired brain injury, arthritis and injuries to shoulders and upper limbs. Power wheelchair or assisted mobility may be the options.
2. Surgical history
- Take note of any surgical and/or orthopaedic presentations and interventions that may result in asymmetrical upper limb movement or reduced muscle strength during wheel propulsion.
3. Upper limb pain
"Upper limb pain and injury are highly prevalent in people with spinal cord injury, and the consequences are significant."
"Preservation of upper limb function following spinal cord injury: a clinical practice guideline for health-care professionals", Consortium for Spinal Cord Medicine 2005, published by Paralyzed Veterans of America, accessed 2008.
The type of pain and injury experienced by a client with SCI are categorised in this guideline as:
- wrist and carpal tunnel syndrome
- elbow
- shoulder
Recommendations relating to seating and manual wheelchair interventions include:
Recommendation 6
With high-risk patients, evaluate and discuss the pros and cons of changing to a power wheelchair system as a way to prevent repetitive injuries.
Recommendation 7
Provide manual wheelchair users with SCI a high-strength, fully customised manual wheelchair made of the lightest possible material, as lighter wheelchairs
- require less force to propel and lift
- are often adjustable
- are often made with better components
Recommendation 8
Adjust the rear axles as far forward as possible without compromising the stability of the user.
Recommendation 9
Position the rear axle so that when the hand is placed at the top dead-centre position on the push rim, the angle between the upper arm and forearm is between 100-120 degrees.
Recommendation 10
Educate the patient to:
- use a long smooth stroke that limits high impacts on the push rim
- allow the hand to drift down naturally, keeping it below the push rim when not in actual contact with that part of the wheelchair.
Recommendation 11
Promote an appropriate seated posture and stabilisation relative to balance and stability needs.
Click here for the details of these recommendations.