Wheelchair Assessment

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Introduction

Assessment is the second wheelchair service step. Information collected from the assessment will help the wheelchair service personnel and wheelchair user to; choose the most appropriate wheelchair from those available; determine the most appropriate wheelchair components from those available including any possible additional postural support required and decide what training or support the wheelchair user family member/caregiver may need to use and maintain their wheelchair. Assessments should always be carried out in a clean, quiet space, which may be a space within the wheelchair service, at another health care or community facility, or at the user’s home. If it is necessary to check whether a person has a pressure sore, do this in a private space. Respect the dignity and privacy of the wheelchair user irrespective of their age, gender, religion or socioeconomic status. The assessment process should incorporate two parts:

• Assessment Interview
• Physical Assessment

Assessment Interview

The first part of the assessment is the assessment interview. During this part of the assessment the wheelchair service personnel gather information about the wheelchair user, which will help to identify the most appropriate wheelchair for the wheelchair user. Even though the assessment interview components at basic and intermediate levels are very similar, more information is gathered at intermediate level about the wheelchair user’s diagnosis and any physical issues.

The assessment interview components at both basic and intermediate level include information about the wheelchair user, their physical condition, their lifestyle and environment and also examines their existing wheelchair, if applicable. Even though the assessment interview components at basic and intermediate levels are very similar, more information is gathered at intermediate level about the wheelchair user’s diagnosis and any physical issues in order to determine the requirements for additional postural support devices..

Information about the Wheelchair User

The ‘information about the wheelchair user’ part of the wheelchair assessment form has an administrative purpose and ensures that the wheelchair service has the wheelchair user’s basic personal and contact information so that the wheelchair user can be contacted for the follow up in the future. They also give statistical information about the users seen by the service. Goals for the individual is vital to understand what the wheelchair user expects from their wheelchair.

Wheelchair service personnel should also record here what the wheelchair user’s goals are for a new or improved wheelchair. The word ‘goal’ may not be familiar to a wheelchair user. It is up to the wheelchair service personnel to ask questions to find out what the wheelchair user’s goal or goals are. The following are examples of possible questions wheelchair service personnel may ask to find out what the wheelchair user’s goal or goals are:

• Why did you come to the wheelchair service today?
• What should your wheelchair help you do?

The following are examples of possible goals:

• I need to be able to reach the well to collect water.
• I need to be able to get into a lift to reach my apartment.
• I need to be able to get my wheelchair into a small car.
• I would like to be more comfortable when sitting.
• I would like to be able to sit for longer in my wheelchair before I get tired.
• I need to be able to get in and out of the wheelchair myself.
• I need to be able to sit at a desk to use the computer.
• I would like to be able to visit my family and need a wheelchair that I can take on the bus.

Physical Condition

The ‘diagnosis/physical issues’ part of the wheelchair assessment form is important because some of the features of different diagnosis and physical issues, as we covered under Wheelchair Users, can affect the choice of wheelchair and additional postural supports. Sometimes the wheelchair user may not know the name of their diagnosis or condition. It is also possible that no diagnosis has been made. In this case identify any specific physical issues and continue the assessment. Some physical issues that wheelchair users may experience can have a direct impact on choosing the most appropriate wheelchair.

Spasticity / Uncontrolled Movement

Some wheelchair users may have problems with sudden uncontrolled movements and spasticity, which can be triggered in a number of different ways including; the position of the person’s hip, knee and ankle; touch and movement of the wheelchair, particularly over rough/bumpy ground such as cobble stones.

Considerations for Wheelchair Provision

• Find out how the uncontrolled movements affect the wheelchair user and problem solve with them.
• Some supports or adjustments to the wheelchair may help to reduce spasms and uncontrolled movements including:
  • supporting to help control the posture of the pelvis;
  • adjusting the wheelchair seat to backrest angle so that the wheelchair user sits with their hips bent slightly more than neutral;
  • positioning the footrests so that the knees are bent slightly more than neutral, ‘tucking’ the feet in; trying different angles of footrests.
• Straps may help give a wheelchair user more control over their legs and feet. If a strap is used, it should fasten with Velcro so that it will release if the wheelchair user falls out of the wheelchair.
• If the movements are very strong, consider:
  • a solid seat and backrest support;
  • selecting a wheelchair with an adjustable rear wheels position. The rear wheels can be positioned in the ‘safe’ position to make the wheelchair more stable/less tippy;
  • Providing an anti-tip bar to stop the wheelchair from tipping over backwards.
  • This is why it is very important for a wheelchair user to propel the wheelchair.
    

Altered Muscle Tone

Problems with muscle tone can be a problem for some wheelchair users. It is a common problem for people who have cerebral palsy , brain injury , spinal cord injury , and stroke . The term muscle tone refers to the resistance/tension in resting muscle when it is being moved. Normal muscle tone allows the limb or joint to be moved freely and easily. However some people may have muscle tone that is too high or too low.

High Tone There is more resistance/tension, so it is harder to move a limb or joint. A person with high muscle tone will usually find it difficult/awkward to move the affected limb or joint, and movement may be slow. Some people with high tone can move only in a certain ‘fixed’ pattern. If the muscle tone is very high, almost no movement is possible.

Low Tone There is less resistance, so it is easy to passively move the limb or joint. However, a person with a low muscle tone may find it difficult to begin movement, and may also find controlling their movement difficult. Low muscle tone is sometimes described as ‘floppy or flaccid’. If the tone is very low, it may be very difficult for the person to move.

Common Characteristics that may affect Wheelchair Provision

The degree of difficulty caused by muscle tone depends on how severe the problem is, and which muscles are affected. Some possible difficulties for wheelchair users who have problems with muscle tone include:

• reduced balance;
• difficulty sitting upright and comfortably;
• reduced muscle control, which can affect how easily the wheelchair user can carry out different tasks including propelling their wheelchair and transferring;
• When there is considerable high or low muscle tone, there can be difficulty and increased risk of aspiration with eating, drinking, swallowing and breathing. Aspiration is a life-threatening problem;
• Increased risk of the development of fixed non-neutral postures;
• For some wheelchair users, high muscle tone can become greater with emotion, or when he/she is trying very hard to do something;
• High and low muscle tone can be a risk factor for hip dislocations.

Considerations for Wheelchair Use

When touching or helping to move a wheelchair user who has high or low muscle tone, these tips may help:

• explain what you are going to do before you do it;
• move slowly and allow for the time it takes for a wheelchair user with low or high muscle tone to react;
• provide firm, comfortable support with your hands and arms so that the wheelchair user is well supported;
• when strong high tone causes the whole body or whole limb to straighten, the tone can sometimes be calmed by bending one joint. For example, if a whole leg straightens, bending the knee or hip can reduce the tone.

The amount of postural support needed will depend on a wheelchair user’s assessment. However some particular considerations for wheelchair users with high tone include:

• postural supports must be made strong enough to be effective with high muscle tone;
• high tone can cause points of high pressure between the user’s body and the wheelchair. Reduce this by distributing force over a larger surface area.
• Check for pressure. Teach the wheelchair user or their family member/caregiver to check the skin for signs of pressure;
• reducing the thigh-to-trunk angle can help to reduce strong patterns of high tone.

Fatigue

Some wheelchair users may regularly become tired during the day. This may be because of the additional effort and energy they use to sit upright and carry out activities, or the nature of their condition. Fatigue can be a problem for some elderly people, or some people with progressive conditions .

Common Characteristics that may affect Wheelchair Provision

• may be able to sit upright, however cannot stay upright for long due to fatigue;
• if wheelchair users find it hard to maintain an upright posture due to fatigue, they are at more risk of developing postural problems.

Considerations for Wheelchair Use

• Try to find out what it is that makes the wheelchair user tired. This will help you to find the best solution for them.
• When deciding how much postural support to provide, consider the effect of fatigue. During the wheelchair assessment the wheelchair user may have more energy, and appear to need less support. Discuss carefully with the wheelchair user how much support they need when they are most tired.
• Consider alternative resting positions i.e. a tray with a cushion can allow someone to lean forward on their arms; tilt in space is another resting position.
• Planning to have rests out of the wheelchair during the day may make it possible to sit more comfortably for longer.

Dislocated Hips

There is a higher prevalence of the hip dislocation in children who have never been able to walk independently  . This is because the socket (acetabulum) on the pelvis is soft when children are born, and the round head of the femur shapes the socket when the leg is moving,or when weight is pushing through it when standing. If the hip joint does not form correctly, this can lead to dislocation.

It is also very common with children who have tight muscles and high tone around the hip and pelvis and tend to always sit or lie with their legs to one side . This can be a problem for people with cerebral palsy or traumatic brain injury .

For children who haven’t walked and have a tendency to lie with both legs to one side (windswept): the hip, which is closest to the mid line of the body (adducted) and turned in (internally rotated) is the one most likely to dislocate .

When children have low tone around the hip joint, they can also be at risk of hip dislocation. This is because the muscles and ligaments are not strong enough to hold the two parts of the hip joint together (the acetabulum and the head of the femur). A dislocated hip is not always painful .

Considerations for Wheelchair Use

• Some indications that a person may have a dislocated/subluxed hip are:– one leg appears shorter than the other leg (60);
  • their leg is always positioned closer to the mid line;
  • there is pain when the hip is moved ;
  • when carrying out a range of motion of the hip it may not be possible to take the thigh to the neutral position or to the outside of the body;
  • it is not possible to fully straighten the hips.
• Research shows that the following can help to reduce the tendency for hip dislocation:
  • supporting a neutral posture in sitting and lying from an early age. For young children this includes supporting the hips/thighs in abduction ;
  • standing in a neutral posture e.g. in a standing frame.
• When assessing a child or adult who has any of the signs of a possible dislocated hip, move the hips gently and avoid causing pain.
• If you are not sure if a child or adult has dislocated hips refer the child to a doctor/paediatrician or experienced physiotherapist (if possible) for further advice.
• When providing a wheelchair and postural support for any child or adult with a hip dislocation or suspected hip dislocation:
  • avoid postures, which cause pain;
  • support their pelvis and trunk in neutral (as close to neutral as possible); and then support the hips and thighs as close to neutral as possible. Avoid ‘overcorrecting’ the leg posture as this may cause the pelvis to move away from neutral and/or cause pain;
  • check what position the person sleeps in. Advise on a sleeping position that avoids windsweeping of the legs, and the legs from being squeezed tightly against each other.

Epilepsy

Epilepsy is a disruption of the normal activity of the brain that results in seizures (67, 68, 69, 70). Under certain circumstances anyone can have a seizure (70). The term epilepsy is used only for recurrent, unprovoked seizures (69, 70). Some wheelchair users may have epilepsy.Seizures may be partial or generalized (70). During a partial seizure a person may or may not have impaired consciousness (70). If the consciousness is not impaired the seizure lasts less than a minute and a person is usually experiencing uncontrolled movements (72). If the consciousness becomes impaired, the seizure lasts one or two minutes and the person is slightly aware of what is going on but cannot respond or change his behaviour (70, 73). During a generalized seizure, a person has a complete loss of consciousness(70). A person experiencing a generalized seizure may suddenly fall unconsciousness and injure themselves (70).

Common Characteristics that may affect Wheelchair Provision

• What to do if a wheelchair user has a seizure during a wheelchair assessment: When providing a wheelchair for a person who has epilepsy remember: When a wheelchair user has a minor seizure, wait for it to be over and then continue with the assessment.
• If a wheelchair user has a major seizure the first priority is to protect them from injury (71). If the wheelchair user falls forward, try to ease the fall. If the wheelchair user is a child or a small adult, it may be possible to safely lift them onto the floor. If they are a large adult, it will be necessary for the wheelchair user to remain where they are (due to potential risk of injury to those assisting) and once the seizure stops, gradually lift them with the help of co-workers/family members or caregivers.

During the seizure:

• do not try to remove the wheelchair user from the wheelchair, unless there is food, water or vomit in their mouth. In this case, remove the wheelchair user from their wheelchair and lie them on the side, so that saliva and mucus can run out of the mouth(70, 73);
• make space around the wheelchair user to protect him/her from injury or move them away from anything that can harm them (70);
• protect the wheelchair user’s head by placing soft padding underneath it (70, 73);
• loosen tight clothing, remove any objects that can harm them and make sure the wheelchair is secure (70, 73);
• time the duration of the seizure and give this information to the wheelchair user or his/her caregiver after the seizure (70).
• Wait calmly with the wheelchair user until the seizure is over. Seek medical attention if:
  • the wheelchair user does not regain consciousness when the seizure has ended (69);
  • the seizure lasts longer than five minutes (70).

Considerations for Wheelchair Use

When providing a wheelchair for a person who has epilepsy remember:

• the wheelchair user will need straps that can be undone easily to help them out of the wheelchair;
• if a wheelchair user often has seizures, which cause them to fall forward suddenly, pad their tray (if used) so that they do not hurt their head;
• if a wheelchair user has epilepsy, which is not being treated, refer them to a doctor.

Lifestyle and Environment

The ‘lifestyle and environment’ part of the wheelchair assessment form gathers information about where the wheelchair user lives and the things that they needs to be able to do in their wheelchair. It is important to consider how the wheelchair and any additional postural support provided will help the wheelchair user to manage to the best of their abilities considering their immediate environment and their lifestyle.

Lifestyle and Environment Questions
Describe where the wheelchair user will use their wheelchair; The wheelchair needs to be practical for the wheelchair user’s home, work or school. For example: if the wheelchair will be used at home, the wheelchair user needs to be able to move about the home easily to carry out important day-to-day activities; a wheelchair user who works in an office will need a wheelchair, which can fit easily into the office space; a wheelchair user who goes to school will need the wheelchair to fit comfortably in the classroom and under a desk, or will need a tray built on to the wheelchair; a wheelchair user who needs to travel to the market or to work on a rough track needs a wheelchair, which works well on rough terrain.
Distance travelled per day; Just as someone may walk if going a short distance, but use a bicycle for longer distances, a wheelchair user may use a wheelchair for shorter distances and a tricycle for longer distances. A tricycle takes less energy to cover the same distance and is faster.
Hours per day using the wheelchair; The longer the wheelchair user sits in the wheelchair, the greater the risk of fatigue or a pressure sore. Think about how much support the wheelchair user needs and whether the cushion provides enough pressure relief and comfort. For any wheelchair user who is ‘active’ in their wheelchair during the day, the wheelchair should be set up to make pushing and other activities as efficient as possible. The position of the wheels is important. It is also important to check that the backrest supports the wheelchair user, but does not restrict freedom of movement of the shoulder blades.
When out of the wheelchair, where does the wheelchair user sit or lie down and how (posture and surface)? If a wheelchair user stays in the same position for long periods of time, he or she can become stiff and eventually stuck in that position. It may become impossible to sit comfortably in the wheelchair. It is very important to avoid this situation and provide the wheelchair user with various options of comfortable positions to sit or lie in when not in the wheelchair. Does the wheelchair user always sit or lie in the same position? if possible, ask him or her to demonstrate the position; it is important to know what the preferred position is so that a ‘counter’ (opposite) position can be suggested. It may not always be possible to go straight to the ‘counter’ position. If the wheelchair user has used their preferred posture for a long time, going for a completely opposite position straight away may be too uncomfortable, strange and potentially frightening; work out ways in which to support the trunk and limbs to position them in more neutral and comfortable positions. Is the wheelchair user able to change his or her position? if the wheelchair user is not able to change position, there is an increased risk of developing problems with posture or pressure sores.
Transfers Armrests and footrests can affect how a wheelchair user gets in and out of the wheelchair: For standing transfers, it is helpful to have footrests, which move out of the way and armrests that the wheelchair user can use to push up; For non-standing transfers, removable armrests or armrests, which follow the profile of the wheels can make the transfer easier; When providing additional postural support, check that the wheelchair user can transfer easily. For example, by adding a seat or a cushion with a wedge, it may be more difficult for the wheelchair user to transfer. A change in technique may be needed, or a different PSD selected.
Type of Toilet The type of toilet and physical access to the toilet will affect how easy it is for the wheelchair user to use it. It may not be possible to use the toilet because of the design. For example, most wheelchair users find it very difficult to use squat toilets. By asking about the toilet and where the toilet is, the wheelchair service personnel can offer advice on how to transfer to and from the toilet. Wheelchair service personnel may also offer advice on how to adapt the toilet.
Does the wheelchair user often use public/private transport? If a wheelchair user frequently uses transport, they will need to be able to transport the wheelchair easily. Different features of a wheelchair, which make transporting the wheelchair easier include the following: lighter wheelchairs are easier to lift in and out; removable wheels and folding frame and/or backrest make a wheelchair easier to transport. If using public transport, removable parts can be an advantage, as this makes the wheelchair easier to load. However, removable parts can also be a disadvantage, as parts may become separated and lost or stolen.

Existing Wheelchair

These questions help to find out if the wheelchair user’s existing wheelchair is meeting his/her needs, and if not, why not.

Physical Assessment

Physical assessment is the second part of the assessment process and includes:

Identifying the Presence, Risk of or History of Pressure Sores

Identifying the Method of Propulsion

it is important to find out how the wheelchair user will push, as this can affect the choice of wheelchair and the way it is set up

Taking Measurements

Four measurements from the wheelchair user are needed to choose the best available size of wheelchair for that person. each measurement relates to the wheelchair.

Measuring Tools

• Use a retractable metal tape measure (pictured on the right).
• clipboards/bookscanbeusedtohelpmeasure accurately (see How to take body measurements).
• Largecallipersareanadditionaltoolthatcanbe very useful. These can be made locally from wood.
• Foot-blocks can be used to support the wheelchair user’s feet at the correct height.

How To Take Body Measurements

• Ask the wheelchair user to sit as upright as possible.
• The wheelchair user’s feet should be supported on the floor or on foot-blocks if they cannot reach the floor comfortably.
• For all measurements, make sure the tape measure is held straight and the wheelchair user is sitting upright. Holding a clipboard/book on either side of the wheelchair user can help in obtaining an accurate measurement.
• Bend down to ensure you are viewing the tape measure at the correct angle.

Assessing Wheelchair Skills

• Finding out how the wheelchair user sits and what additional postural support they may need through:
  • Observing sitting posture without support;
  • Carrying out a pelvis and hip posture screen. Pelvis and hip posture screening helps to understand how any problems around the pelvis or hips may be affecting the wheelchair user’s sitting posture;
  • Carrying out hand simulation. The wheelchair service personnel uses their hands to ‘simulate’ the support that a wheelchair and additional postural supports may provide; 
  • Taking Measurements.

Good Practice

Resources

References