Wheelchairs

Special attachments:

 Anti-tipping device: long projection

attached posteriorly: prevents backward
fall of the wheelchair
 Hill Holder device: Serrated breaks: holds
w/c in place on slopes
 Seat belts: 45°/90°: prevent falls /sliding

Footrest comprises of foot plate & heel

loop

Can be swing away type or elevated ones

They are removable and have an

adjustable height

The big wheels are used

to propel the wheelchair
forward: may have Castor wheels (8-inch wheels) give
projections for SCI direction to the wheelchair and stability
patients for tenodesis to transfer
grasp

Types of wheelchairs:
1. Reclining wheelchair: for patients with orthostatic hypotension. Electric reclining wheelchair helps to
redistribute weight-bearing, if patient can’t do active push-ups or pressure relief maneuvers.

2. Tilt-in wheelchairs: to break spastic LE extensor synergy and for pressure relief
The difference between reclining and tilt-in w/c is that in tilt-in w/c the hip and knee ankle doesn’t change
3. One-arm drive wheelchair: for hemiplegics in later stages of functionality. Cognition and thinking should be
intact

4. Hemiplegic wheelchair: 17.5 inches height from the ground (2 inches lower than the usual W/C) to help in
better propulsion and so that patient can get hold of the ground easily. If the seat is too high then in order to
reach the ground patient will tend to go into sacral sitting which is not good.

5. Bariatric Wheelchair: wider seat, sturdier material, axle of the wheel is 2.5 inches anterior as compared to the
usual wheelchair to accommodate for the anteriorly displaced center of gravity of an obese patient and it also
helps to get full arm stroke with less wrist extension. Additional changes that can be made are:
 Hard tires vs pneumatic tires for increased durability
 Adjustable backrest to accommodate excessive posterior bulk
  Reclining wheelchair to accommodate excessive anterior bulk, cardiorespiratory compromise (orthostatic
hypotension)

6. Amputee Wheelchair: For transtibial amputation with an extension for the amputated side
Transfemoral amputation doesn’t need any specific w/c. 2 inches backwards as compared to usual w/c.

7. Motorized wheelchairs/ Power wheelchairs: patients who aren’t capable of self-propulsion or have very low
endurance. They have additional controls like a joystick and head controls to maintain the position of the head
and neck.

8. Sports Wheelchair: variable, light-weight solid frame, low seat, low back, a seat that accommodates the tucked
position, leg straps, slanted drive wheels, and small push rims

Posture control system in wheelchair:

1. Seating:
a) Sling seat: ××NOT GOOD×× hips tend to slide forward; thighs tend to adduct and internally rotate.
Reinforces poor pelvic position (PPT)
b) Insert or contour seat: creates a stable and firm sitting surface; made of wood or plastic and padded
with foam
 It improves the pelvic position and reduces the chances of PPT
c) Seat cushion: distributes weight-bearing pressures, prevents decubitus/trophic/pressure ulcers in
patients with decreased sensation, and prolongs w/c sitting time
 Pressure relieving contoured foam cushion: moderate to severe postural deformity. Easy for
caregivers and low maintenance. May interfere with sliding transfer.
 Pressure relieving fluid/gel or combination: can be custom molded. Moderate to severe
postural deformity. Heavier and more expensive
 Pressure relieving air cushion: lightweight, improved pressure distribution, expensive but
unstable for some patients. For example, ROHO cushion

2. Back Support: Support to mid-scapular region provided by most standard wheelchairs

a) Low back height: increases functional mobility for sports wheelchairs but can also increase back strain
b) High back height: for patients with low trunk control and extensor spasms but will also restrict the UE
mobility
c) Inserts or contour backs: improve trunk extension and overall alignment
d) Lateral trunk supports: improved trunk alignment for patients with scoliosis, pusher’s syndrome (PCA
infarct), and poor trunk stability

3. Armrests: They can be full length or desk length: the desk length armrests facilitate the patient’s ability to go
closer to the desk or table when sitting down for eating etc. but they can inhibit sit-to-stand transfers.
 These can be fixed height or adjustable height
 Removable armrests are used to facilitate transfers
 Wraparound (space saver) armrests: decrease the width of the chair by 1.5 inches
 Upper extremity support surfaces like trays, etc.: postural assistance for people with dec use of UE and
easy for them to feed themselves.

4. Leg rests: these can be fixed or swingy

  Swing-away/ detachable facilitate transfers, front approach to a wheelchair while ambulation
 Elevation: for edema control, postural support, contraindicated for people with extensor spasms

5. Footrests: consists of footplate, heel loops, and straps.

 Footplate: provides resting base for feet, feet should be neutral with knees flexed to 90. These can be
removed or raised to facilitate transfers
 Heel loops: help maintain position and prevent posterior sliding of the foot
 Straps (ankle/calf): can be added to stabilize the feet on footplates.

Wheelchair measurements: Assessment should be done on a firm surface: sitting or supine

1. Seat width: width of the hips at the widest part + 2 inches

Excessive width Less width/ narrow seat

Difficulty in reaching the drive wheels and propelling Excessive pressure on lateral pelvis and thighs
the chair Lateral space should allow for thickness in clothing

For the bariatric population, measurement should consider the widest portion of the seated position (e.g., at the
forward edge of the seated position). Also, consider room for weight-shifting maneuvers for pressure relief and
possible use of lift devices

2. Seat depth: Posterior buttock to posterior aspect of lower leg in the popliteal fossa – 2 to 3 inches

Too short Too long

Fails to support the thigh and decreases surface area Compromises posterior circulation at knee
to redistribute the forces Sacral sitting> PPT>> kyphotic posture

3. Leg length/ Seat to footplate length: from the bottom of customary footwear to just below the thigh in
popliteal fossa; if a seat cushion is added then the height should be adjusted

Excessive length Too short

Uneven weight distribution on thigh and excessive
Sacral sitting>> PPT>> kyphotic posture
weight on ischial seat

4. Seat Height: minimum clearance between the floor and footplate should be 2 inches
It is measured from the lowest point on the bottom of the footplate

5. Armrest height: from seat platform to just below the elbow held at 90 with shoulder in neutral + 1 inch

Too high Too low

Cause shoulder elevation/ shrugging
Encourage leaning forward or laterally
Can lead to TOS (dec on costoclavicular space)
 6. Back height: from the seat platform to lower angle of scapula, mid-scapula, or top of the shoulder
 If the patient is using a seat cushion, the height of the cushion should be added to the patient’s
measurement
 Excessive height may increase the difficulty in getting the chair into a car/van
 Prevent the patient from hooking on to the push handle for stabilization and pressure relief
(quadriplegics)

Parameter Measurement

Seat width Widest part of the hips + 2 inches

Seat depth Posterior buttock to posterior part of the lower leg in popliteal fossa – 2 to 3”

Seat height Minimum 2 inches of clearance from ground

Armrest height Seat platform to elbow flexed at 90 with shoulder in neutral + 1 inch

Parameters that promote sacral sitting are: Increased seat depth and increased leg

Wheelchair training:
1. Encourage good sitting posture: sit upright, avoid sacral sitting
2. Practice pressure relief every 15 mins by push-off (SCI level C7) or leaning (SCI level C6)
3. Wheelie: push the big wheels forward and lean forward: SCI level T6 and below
4. To turn to left: move the left wheel slower and right wheel faster
5. For sharp turn to left: left wheel backward and right wheel forward
6. Going up a ramp: wheelie position>> use shorter strokes for propulsion
7. Descending ramps: descend in wheelie position from a steep ramp, grip hand rims loosely and control the
descent
8. During transfer angle between w/c and transferring surface should be 45-60
 Part Advantages/Purpose Disadvantages
Encourages PPT and adduction and IR
Sling seat Usually present in standard w/c
of hip
Moderate to severe postural
Pressure-relieving contoured foam deformity
May interfere with slide transfers
cushion Easy for caregivers
Low maintenance
Moderate to severe deformity Requires maintenance
Pressure-relieving fluid/gel cushion Can be custom-made Heavy
Easy for caregivers Expensive
Moderate to severe postural Expensive
deformity Base may be unstable for some
Pressure-Relieving air cushion
Light weight patients
Improved pressure distribution Continuous maintenance required
Sports W/C
Low back height Back strain
Increase functional ability
Used for people with poor trunk
High Low back support balance Limits UE mobility
Extensor spasms
Improve trunk extension and overall
Insert or contour back support
trunk alignment
Pusher’s syndrome (PCA infarct)
Lateral trunk supports Poor trunk alignment: Scoliosis
Poor trunk stability
Easy for sit to stand and vice versa Inhibits going near the desk while
Full-length armrests
functions sitting
Facilitate going proximal to the desk
Desk-length armrests Inhibit sit-to-stand functions
or table
Removable armrests Facilitate transfers
Wraparound (space saver) armrests Decrease total width by 1.5 inches
Ease in transfers
Swing-away detachable leg rests Facilitate front approach to w/c during
ambulation
Edema control
Elevated Leg rests CI for extensor spasms
Postural support
Can be removed or raised to facilitate
Footrests
transfers
Maintain foot in position
Heel loops
Prevent posterior sliding of the foot
Straps (ankle/calf) Stabilize feet on footplates
 Assistive Device Measurements Advantages and Disadvantages

Pros: Provide increased upper extremity

 Space between the top of the axillary rest
WB and NWB of LE
and axilla should be 2 inches/ 2-3 finger
widths
Con: Too much pressure at axilla can lead
Axillary crutches  Elbow flexion 20°-30° with wrist in neutral
to compression of axillary or radial nerve
 Tips of the crutch should be 2 inches
or cause TOS
lateral and 4-6 inches anterior to the tip of
Good functional strength of the upper
the shoes
extremities and lats required

Pros: Increased ease of movement

particularly with B/L movement
 Upper edge of the cuff should be 1-1.5 Freehand usage without dropping the
inches below the olecranon crutch
Lofstrand or forearm
 Elbow flexion 20°-25°
crutches or Canadian
 Tips of the crutch should be 2 inches Con: lesser stability as compared to axillary
crutches
lateral and 4-6 inches anterior to the tip of crutches
the shoes Functional standing balance required
No NWB for LE possible

Pros: Good for people with wrist fractures/

distal forearm fractures/ severe wrist or
finger deformities making it difficult to
grasp the handpiece
An additional attachment to a forearm crutch or
Platform crutch Below elbow amputation or if the patient
walker: known as a trough or shelf
can’t extend one or both elbows

Cons: help may be needed to put them on

Weakness of triceps eventually

Pros: used to compensate for impaired

 Elbow flexion 20°-30°
balance or to improve stability
 Tip of the cane should be 2 inches lateral
Canes More functional on stairs and in narrow
and 4-6 inches anterior to the tip of the
areas
shoes
Cons: Very limited support

Pros: Maximum patient stability and

 Maintain elbow in 20°-30° flexion support
Walkers  Hand grip height should be at the level of Cons: difficult to store or transfer
ulnar styloid or wrist crease Difficult to use on stairs, narrow areas
Reduces the speed of ambulation

 Elbow flexion 20°-25°

 2-4 inches space on each side between
patient’s hips and the parallel bars
Parallel Bars
 Height of the bar rails should be at the
level of Greater Trochanter or wrist crease
with arm on the side
 Gait Patterns

1. Two-point gait: 2 points are always in touch with the ground, WBAT/ FWB

 One crutch and the opposite extremity move together, followed by opposite crutch and extremity
 Requires 2 assistive devices (canes or crutches)

Crutch on the involved/ injured LE + Crutch on the normal side +

opposite normal leg forward first involved/ Injured LE

 Advantages: allows natural arm and leg motion during gait, good support, and stability

2. Three-point gait: NWB gait

 Requires good balance and upper extremity strength

 Can be executed with walker or B/L axillary crutches

Crutches and involved LE are Followed by uninvolved

advanced together extremity

 Indicated for LE fractures or NWB status

3. Delayed 3-point gait: indicated when the patient requires increased stability and slower movement

Crutches advance followed by

uninvolved LE
first involved extremity

4. 4-point gait: WBAT: Axillary crutches or B/L canes: only one thing moves at a time

crutch on the Followed by Followed by

Crutch on the
uninvolved the affected the uninvolved
affected side
side first side side

5. Modified 4-point gait: with one assistive device: cane or crutch on the good side

crutch on the followed by the step to - to the

good side first affected side affected side
 6. Swing-To gait pattern: NWB status or B/L LE involvement??? therapyEd

Crutches advance LE swing forward to meet

forward first the crutches

7. Swing-Through gait pattern: B/L LE involvement, SCI, patients who require increase BOS

LE swing forward beyond

Crutches advance first
the point of crutches

Types of walkers:
1. Standard walker: four legs, no wheels, patient has to lift it up every time he takes a step, able to fold to facilitate
mobility in the community, storage in cars is possible

2. Rolling walker: 2 or 4 wheels: facilitates continuous movement sequence (step through gait pattern), allows
increased speed
4 wheels walker needs additional hand brakes to provide stability for stopping

3. Hemi-walker: modified for use with one hand only

4. Rollator: has a seat for the patient to sit down: given to patients with poor endurance so that they can sit down
if they feel tired or SOB

5. Platform walker: similar to platform crutches: for patients who can’t bear weight on their hands/ wrists

Types of Canes:
1. Single-point cane: used for minor problems with balance or injury
 Patients who need minor reductions in weight-bearing

2. Quad cane: increased stability but slows speed

 Small-based quad cane (SBQC): good for stairs
 Wide-based quad cane (WBQC)/ large-Base quad cane (LBQC): doesn’t typically fit on stairs
 All four legs of the quad cane should be in contact with the ground as the patient walks
 Indicated for Hemiplegics or moderate to severe antalgic gait due to OA
Use of cane and crutches:
1. Walking with cane

Progress with
Hold cane on Followed by
the weak leg
the good side the good leg
+ the cane

2. Ascending stairs with a cane:

first step up with the Bring the weak leg and

good leg (cane stays on the cane together to the
the ground) same step

3. Descending stairs with cane:

Step down with the bad bring the bad leg to the
leg and the cane same step

4. Walking with a crutch:

Put your weight Move the crutches

Crutches and feet
on the good leg forward> Swing
should be in the
and the hands your body landing
shape of a triangle
(not the armpits) on good leg

5. Ascending stairs with a crutch:

Place the good leg up on the bring the weak leg and the
higher step crutches together to that step

 Always hold the railing on the bad side (the crutch or cane is on the good side)
 If there is no railing use both the crutches
 Come down with the bad leg first
6. Stand to sit with crutches:

Hold crutches
Hold both come to the
on the weak
crutches on the edge of the gradually sit
side and arm
weak side chair
rest on other

7. Sit to stand with crutches:

hold the arm rest on gradually stand up and

Hold both the crutches
the good side and push hold the crutches in
on the weak side
up from the good side both hands

TRANSFERS
1. Total Dependent transfers:
 Hoyer lift transfer/ hydraulic Lift transfer
 Quad-Pivot transfer
 Stand-Pivot transfer
 Three-person lift (same level surface)
 Two-person lift (different level surface)
 Sliding transfers: same level surface: draw sheet/sliding pad used

Indications: no active participation by patient

 Higher cervical level SCI
 No trunk control

2. Assisted transfers: requires some assistance from the patient

 The level of assistance varies from stand-by, minimal or moderate assist, or maximal assist
 Transfer belts, trapeze bars, and overhead loops to provide additional control

a) Stand pivot transfer: the patient is unable to stand independently but can bear some weight on LE (CVA,
incomplete SCI, hip fracture/ replacement)

b) Squat pivot transfer: when the patient can’t stand but can bear some weight on LE

c) Assisted Sliding board transfer

3. Independent transfers
 Sliding board transfers: C6 level SCI
 Lateral swing transfer: same level transfer: from W/C to toilet seat, etc.
 Sit Pivot transfer