Wheelchair Users

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Introduction

Wheelchair users are people who already have a wheelchair or who can benefit from using a wheelchair because their ability to walk is limited. The needs of each wheelchair user will vary. However, they all need an appropriate wheelchair. Every well-fitting wheelchair provides the user some postural support. The backrest, cushion, footrests and armrests all provide postural support when adjusted to suit the wheelchair user’s size. However many children and adults need additional postural support in their wheelchair. Wheelchair users include Children, Adults and the Elderly; both men and women who have a wide range of mobility impairments, lifestyles, life roles and backgrounds; living and working in different environments including rural, semi-urban and urban.

About 10% of the global population, i.e. about 650 million people, have a disability with research indicating that some 10% or 65 million people require the use of a wheelchair. In 2003, it was estimated that 20 million of those requiring a wheelchair for mobility did not have one. There are indications that onlya minority of those in need of wheelchairs have access to them, and of these very few have accessto an appropriate wheelchair (2).Epidemiology

Neurological Conditions

Cerebral Palsy

Cerebral Palsy has been defined as a group of permanent, but not unchanging, disorders of movement and/or posture, causing activity limitations which are due to a non-progressive interference, lesion, or abnormality of the developing or immature brain, resulting in a wide range of impairments which affect people very differently.

Personal mobility can range from independent, unaided walking through to totally dependent wheelchair mobility with up to one third of children and adults with Cerebral Palsy being non-ambulant and reliant on some form of wheelchair mobility, either manual or powered, indoor or outdoor.

A recent study by Rodby-Bousquet and Hägglund describe the use of manual and powered wheelchair indoors and outdoors in relation to the degree of independent wheelchair mobility or need for assistance in children with Cerebral Palsy, suggesting that environmental factors, influence of parents, personal factors (e.g. choice, motivation, acceptance of disability) and body functions (e.g. spasticity, fatigue) are important when it comes to use of a manual or powered wheelchair, both indoors and outdoors.

Children at GMFCS Level III predominantly used manual wheelchairs for self-mobility, while powered wheelchairs were more frequent at GMFCS Level IV, although overall children at level III-IV achieved a higher degree of independent mobility using manual and powered wheelchairs, with the largest increase in mobility through use of a wheelchair was seen at GMFCS Level IV (Fig 1).

More children used a wheelchair for outdoor mobility than indoor mobility, with the number using both manual and powered wheelchair outdoors increasing with GMFCS Levels. At GMFCS Level I 2% used a wheelchair, 39% at Level II and 85-90% at Levels III-V. Similarly the number of children requiring adult assistance increased with increasing GMFCS Levels, with only 14% overall being able to independently self-propel for outdoor mobility. (Fig.1).

Rodby-Bousquet and Hägglund also found a difference in wheelchair use between different subtypes of cerebral palsy, with a higher incidence of wheelchair use for indoor mobility among the dyskinetic subtype. In this group of children only 11% could self propel (Fig.2).

On the other hand all those who were utilising Powered Wheelchairs indoors had predominantly dyskinetic cerebral palsy or spastic diplegia. Of those with spastic diplegia 40% used a wheelchair for personal mobility, and of those 23% self-propelled (manual and powered) and 17% were pushed in manual wheelchairs, while 16% of children with ataxic cerebral palsy used manual wheelchairs, of those half self-propelled and the other half were pushed. More children with spastic bilateral cerebral palsy had independent wheeled mobility compared to the other subtypes, in total 24% (Fig.2).

Fig.1 Wheelchair Use by Type of Cerebral Palsy

Fig. 2 Wheelchair Use by Type of Cerebral Palsy

Finally Rodby-Bousquet and Hägglund found that the use of manual wheelchairs for indoor mobility was similar for boys (30%) and girls (29%) with overall indoor wheelchair mobility increasing with age, although the same was not evident for powered wheelchair use.

Fig.3 Age Related Wheelchair Use in Cerebral Palsy

Postural instability was seen as one of the key areas that can restrict functional performance and upper extremity function in children with cerebral palsy, in some cases leading to difficulties in self propulsion in wheelchair mobility both in manual and powered wheelchair use, with up to 89% showing instability during manual wheelchair self-propulsion and 61% during powered wheelchair self-propulsion.

There is sometimes a resistance to prescribe a wheelchair to children, in particular younger children who may have some ability to walk. Current evidence suggests that there are many benefits for children with impaired walking ability to access a wheelchair to increase their independence in their environment, with early self-produced mobility crucial for the child's cognitive and psychosocial development. Use of wheelchairs in children with impaired walking ability has been shown to have a less negative impact on visuomotor accuracy than walking with assistive devices due to a lower energy cost, while social interaction and participation in the improved. Self-initiated behaviours including interaction with objects, communication and changes in location were also more evident in children, as young as 23-38 months when provided with access to wheelchair mobility. 

To achieve as high a level of independent mobility as possible, both manual and powered wheelchairs should be considered at an early age for children with cerebral palsy who show impaired walking ability, ensuring provision of a stable sitting posture to improve function and wheeled mobility.

Spina Bifida

Spina Bifida in general is defined as "a neural tube defect (NTD) that results when the inferior neuropore does not close.  Developing vertebrae do not close around an incomplete neural tube, resulting in a bony defect at the distal end of the tube." [1]

Spinal Cord Injury

Spinal cord injury is defined as traumatic damage to the spinal cord or nerves at the end of the spinal canal, which can affect conduction of sensory and motor signals across the site of the lesion. Symptoms of a spinal cord injury vary widely dependant on both on the severity of injury and the location on the spinal cord, which are also the key factor in determining the type of wheelchair mobility.

Personal mobility can range from independent, unaided walking through to totally reliant on some form of wheelchair mobility, either manual or powered.

Level of Injury	Type of Wheelchair Mobility
C1 - C4 Tetraplegia	mobilise in a chin-control, sip and puff or head array power wheelchair use attendant operated manual wheelchairs that have been specifically set-up for their needs are unable to self propel a manual wheelchair
C5 Tetraplegia	mobilise in a hand-control power wheelchair can propel a manual wheelchair on flat smooth surfaces with the assistance of adaptive equipment such as plastic push rims and textured gloves, however this is not their main form of mobility are dependent on an attendant for propelling a manual wheelchair on uneven surfaces and slopes
C6 - C8 Tetraplegia	mobilise independently in a manual wheelchair over most surfaces and terrains with varying degrees of skill may find the assistance of adaptive equipment such as plastic push rims and textured gloves useful mobilise in a hand-control power wheelchair as an alternate form of mobility
T1 - T12 Paraplegia	mobilise in a manual wheelchair with varying degrees of skill use power mobility if they are not functional in a manual wheelchair due to impairments such as poor cardiovascular fitness and shoulder pain

People with a spinal cord injury are very likely to be at risk of developing a pressure sore. This is because most people with a spinal cord injury cannot feel below the level of their injury. Always prescribe a pressure relief cushion.

Polio

Multiple Sclerosis

Motor Neuron Disease

Orthopaedic Conditions

Amputations

Amputation is the removal of a limb or part therof, as a result of trauma, prolonged constriction or surgery (see Pathology leading to amputation). As a surgical measure, it is used to control pain or a disease process in the affected limb such as a malignancy, infection or gangrene, while in some cases it is carried out on individuals as a preventative surgery for such problems (see Principles of Amputation). Amputations can be both congenital or acquired. When we look at describing congenital amputation the term limb difference or limb deficiency is used and simply means the partial or total absence of a limb at birth (see Paediatric Limb Deficiency).

Although lower extremity amputation continues to be a major source of morbidity and mortality worldwide, the extent of this burden cannot be accurately quantified because of international variation and a lack of standardized reporting measures.

The improvement of an individual post amputation is impacted by age, physical and mental health, nutritional status, tissue perfusion, complications post amputation (e.g. poor wound healing or infection), the individual’s motivation, level of amputation, presence of other medical conditions, smoking habits, suitability for prosthesis and the availability of rehabilitation programs (Statewide Rehabilitation Clinical Network 2012). Amputations caused by vascular disease generally occur in aging populations with numerous other comorbidities such as cardiovascular disease, hypertension, renal disease, and arthritis. The overall goals of rehabilitation after amputation are to optimize the patient’s health status, quality of life and functional independence including personal mobility either through use of a prosthetic and/or wheelchair.

.Many individuals with amputations will require the use of a wheelchair post-operatively and during the early stage early stage of rehabilitation, inparticulalr those individuals with bilateral lower limb amputations.

Functional training to maximise independence in everyday activities needs to be addressed in both a wheelchair and with a prosthesis (Statewide Rehabilitation Clinical Network 2012). Competent wheelchair skills are essential as even for those patients prescribed a prosthesis there are likely to be times when it is not possible to use a prosthesis including poor fitting, and injury to residual limb (Statewide Rehabilitation Clinical Network 2012).

Use of a wheelchair

It should be noted that use of a wheelchair as “back up” mobility when a prosthesis is not available is considered to be standard practice and in some instances may be preferable to using a prosthesis in some situations due to comfort, function and energy factors. A wheelchair may increase and enhance function e.g. when a participant may have been using the prosthesis during the day but returns home in the evening and “can’t wait” to get the prosthesis off, they may find accessing the home in the wheelchair is convenient and requires less physical demands compared to using crutches.

The impact of lower limb amputation on the geriatric patient can be complex. Taking into account all possible complications and post-operative goals is paramount for effective management of these patients. It is well documented that with age comes increased incidence of chronic disease. The numerous co-morbidities associated with chronic disease have several implications on the status of an elderly patient post amputation (Fried et al. 2004) and depending on the past medical and functional history of the geriatric amputee patient, the goals and expectations of rehabilitation can be variable.

Fleury et al. [1] describe a low prosthetic success rate in geriatric amputee patients, with only 36% being successfully fitted with a prosthesis, thus wheelchair mobility tends to be the most common means for personal mobility with this specific population. While in some cases a prosthesis can aid the ability of the patient to transfer more effectively, the tendency for more fragile skin leading to increased risk for wound break down combined with often decreased range of movement around the hip and knee joint often make the applicability of a prosthesis less suitable.

The Amputee Mobility Predictor (AmpPro / AmpNoPro): is an instrument to assess determinants of the Lower-Limb Amputee's Ability to Ambulate and measure function post-rehabilitation. It was developed to provide a more objective approach to rating amputees under the various "K Classifications". The test can be performed with or without the prosthesis.The AmpPro form & instructions can be viewed here AmpNoPro (In Appendix 2 for instructions).

Catering for Children with a Disability

When providing a child with a wheelchair, it is important to think about how children’s lives are different from adults’. These differences affect the way the wheelchair service personnel work with children and the choices about wheelchairs and additional postural support. Some important differences are;

• the activities children carry out are different to activities of adults (play, school);
• children are often very active and do not stay in one position for very long;
• children are in the care of adults;
• children cannot always speak for themselves;
• children are still developing;
• young children have a different sitting posture to adults;
• children are still growing.

Wheelchairs that meet children’s needs should support them be a part of the activities that children carry out every day. Features in a wheelchair that are important for children include:

If children push themselves, the wheelchair should:

• fit well to allow them to reach the push rims with comfort;
• be light enough for children to control, particularly going up or down hill.
• Try always to make sure the child is more visible than their wheelchair.
• Extended push handles can help family members or caregivers push the wheelchair without having to bend over.
• A wheelchair that can ride over uneven and soft surfaces such as grass and sand will make it easier for children to play with their friends.

A child’s wheelchair should make it easier for them to access education and enable them to both get to school and be mobile within their school environment:

• If most children in the child’s community walk to school, consider whether a wheelchair can travel on these paths?
• Does the child need a wheelchair that is good for rough terrain?
• If the child will go to school in transport (for example car, bus, rickshaw, taxi), think about how the wheelchair will be transported.
• The wheelchair should make it easy for them to be at school. The child should be able to pull up to a desk, or the wheelchair needs a tray as a work surface.

Ideally, children’s wheelchairs should:

• enable children to push themselves (if they are able);
• have push handles to allow adults to assist;
• be able to ride over uneven and soft surfaces such as grass and sand;• make it easier for children to get to school;
• attractive enough in terms of design, size and colour;
• make it easier for children to be at school.

References