Module 10 - Power Mobility

The wheelchair should match the client's body size and shape to optimise pressure care and postural alignment and maximise functional abilities. It should enable the client to function in his/her life roles and environment.

Systematically identifying key issues for appropriate power mobility

1. Medical diagnosis

• The level of injury may indicate the features and accessories of power mobility the client requires. The following is a general guide for clients with a complete spinal cord injury at lesion level:
  • C1-3: requires chin control devices, power tilt-in-space seating function and custom mounting for ventilation unit
    • Depending on the client's ability to utilise neck muscles for head control, a chin control device will most likely be required. Other speciality control devices can be trialled, including 'sip and puff', and head control devices such as head array, switches or 'mini-joy'. A 'sip and puff' control device is used for clients who are able to control breathing but do not have head and neck movement downwards.
    • Ventilators with external batteries and a back-up respiratory system such as suction equipment and manual hyperinflation bag are required to be transported with the power wheelchair.
    • Clients who have a phrenic nerve-paced diaphragm usually have the pacer secured onto the wheelchair.
  • C4: able to drive a power wheelchair with a chin control device and has function at a similar level to C1-3, but may not require respiratory aids at discharge
    • Mouth sticks are used for accessing other controls and keyboards
    • Postural stability and wheelchair tray set-up is vital for the client to access these aids.
  • C5: able to master driving with an adapted joystick or utilise a mobile arm support over the joystick.
  • C6:  able to drive with adapted or standard joystick
  • C7-8: able to drive with standard joystick. This client group may elect to use the power wheelchair as the primary mobility aid over a manual wheelchair. Factors such as age, concurrent injuries, social support and environment will influence the decision.
  • T1 and below: manual wheelchair is usually the initial primary mobility. Power mobility may however be considered with other co-morbidities, overuse syndromes and injuries.
  • Clients with an incomplete SCI may present with asymmetrical head control or upper limb function that will impact on the selection of power mobility options.
  • Understand co-morbidities and medical conditions and their impact on functional abilities, for example acquired brain injury, arthritis and shoulders or other upper limb injuries.

2. Surgical history

• Take note of any surgical and/or orthopaedic presentations and interventions that may restrict range of movement. This can reduce the client's ability to operate control devices or contradict the benefits of power recline and leg-rest elevation.

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 clients with SCI categorised in this guideline are:

• wrist and carpal tunnel syndrome
• elbow
• shoulder

In this guideline, recommendations relating to seating and power mobility 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 of preventing repetitive injuries
Recommendation 11 - promote an appropriate seated posture and stabilisation relative to balance and stability needs
Recommendation 12: - for individuals with upper limb paralysis and/or pain, appropriately position the upper limb in bed and in a mobility device. The following principles should be followed:

• avoid direct pressure on the shoulder
• provide support to the supper limb at all points
• when the individual is in supine, position the upper limb in abduction and external rotation on a regular basis
• avoid pulling on the arm when positioning individuals

Recommendation 13 - provide seating elevation or possibly a standing position to individuals with SCI who use power wheelchairs and have arm function
Recommendation 34 - encourage manual wheelchair users with chronic upper limb pain to seriously consider use of power wheelchair.
Read more about these recommendations in this clinical practice guideline.

4. Neck pain

Clients with high lesion spinal cord injury may experience neck pain and discomfort. Provision of appropriate neck and upper limb supports, seated posture and stabilisation enables the client to operate the specialty device in optimal skeletal alignment. The use of tilt-in-space power seating function can provide rest periods for the head and neck muscles.