Wheelchair Fitting

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Introduction

Wheelchair fitting is the sixth step in the key steps to wheelchair service delivery.  Fitting entails trial of the wheelchair by the user and final adjustments to ensure the wheelchair is correctly assembled and set up. During the fitting, the wheelchair user and personnel together check that:

• the wheelchair is the correct size and all the necessary modifications and adjustments have been made to ensure an optimum fit;

• the wheelchair and cushion support the wheelchair user in sitting upright;

• if a pressure relief cushion has been prescribed, the cushion really relieves pressure.

A properly fitted wheelchair provides comfortable seating and good back support, improving posture and ultimately optimizing function. It has been estimated that 80-90% of individuals are not properly fitted in their current wheelchair as their bodies and needs change over time. A wheelchair that does not fit properly may lead to pressure ulcers, poor posture, reduced balance, difficulty propelling the wheelchair, and difficulty with transfers. The ideal sitting position for most people in a wheelchair follows the 90-90-90 rule; 90° bend in the hips. 90° bend in the knees and 90° bend in the ankle.

An appropriate wheelchair is one that meets the user’s needs and environmental conditions; provides proper fit and postural support and is safe and durable; is available in the country; and can be obtained and maintained and services sustained in the country at the most economical and affordable price.

A wheelchair fitting for a wheelchair user who needs additional postural support takes longer because additional fittings may be needed.

Always check the fit with the wheelchair stationary, and then while the wheelchair user self-propels or is pushed.

Measures of Wheel Chair Fitting

Wheelchair fitting focuses on six measurements.

1. Seat width: It is measured from the widest aspect of the user’s buttocks, hips or thigh. It should be wide enough to avoid pressure on the hips. Average adult size is 18 inches.
2. Seat depth: It is measured from the user’s posterior buttock, along the lateral thigh to the popliteal fold with your palm horizontal to the seat. Usually, a space of about 2 inches is preserved to avoid pressure from the front edge of the seat against the popliteal space. You should be able to fit 3-4 fingers between the front edge of the seat and the back of your knee. Average adult size is 16 inches.
3. Seat height: It is determined by the height of the individual and if the wheelchair is self-propelled. When using the feet to propel. the seat height should allow for them to reach the floor with their heel. Those using footrests have higher seat heights. It is measured from the user’s heel to the popliteal fold. The bottom of the footrest is 2 inches from the floor. Average adult size is 19.5 to 20.5 inches
4. Armrest height: Should allow user sit erect, with level shoulders when bearing weight on the forearms as they rest on the armrest. It is determined by measuring the distance between the seat of the chair and olecranon and adding one inch. Average adult size is 9 inches above the chair seat.
5. Backrest Height: The inferior angles of the scapula should be approx. 1 finger-breadth above the back when the user sits with erect posture. It is determined by measuring the distance between the seat of the chair to the patient’s axilla, and subtracting four inches. Average adult size is 16 – 16.5 inches. The height of the backrest depends on the needs of the user. Wheelchair users who push themselves need a backrest which allows their shoulders to move freely. Wheelchair users who have difficulty sitting upright may need a higher backrest which gives more support to the spine.
6. Footrest length: It affects the support of both the feet and the thighs and the clearance of the footplates and the ground. The footplate must be about 1 to 2 inches off the ground to permit adequate clearance.

Process of Wheelchair fit

Wheelchair fitting should be carried out in this order: check size and adjustments, check posture, check pressure, check fit while the wheelchair user is moving.

1.) Check size and adjustments

• Seat width: A correct fit should fit closely. Run your fingers between the outside of the user’s thighs and the sides of the wheelchair. Your fingers should fit comfortably without being pinched.
• Seat depth: A correct fit should have a two-finger gap (30 mm) between the back of the knee and the cushion. It gives the thigh good support which will reduce pressure under the seat bones and helps to stop pressure sores. Check that the wheelchair user is sitting upright and then slide hand between the cushion and the back of the knee, there should be a gap large enough to admit two fingers. There may be a bigger gap for wheelchair users with long legs, up to 60 mm is acceptable. Always check both sides.
• Footrest height: For a correct fit, the thighs are fully supported on the cushion with no gaps and the feet are fully supported on the footrests with no gaps. Check by sliding hand between the thigh and the cushion. There should be even pressure along the thigh and no gaps. Look at each foot on the footrest. The foot should be supported at the front and the back with no gaps. If there are gaps under the thigh, the footrest may be too high. If there are gaps under the foot, the footrest may be too low.
• Backrest height: The correct fit should give the wheelchair user the support needed and allow an active person the freedom to move the shoulders to push. Check by observing whether the trunk is balanced over the hips and ask the wheelchair user whether the backrest is comfortable. Also check that the wheelchair user able to push the wheelchair without the backrest interfering.
• Rear wheels position for hand propelling: Is correctly fit if the user’s elbows should be at a right angle when hands are placed on the push rims, Ask the wheelchair user to grip the push rims at the top of the wheels. The elbow should be bent at 90 degrees. Also check with the user if the rear wheels are positioned correctly for balance (forward for active, back for safe).

2.) Check posture: Observe how the wheelchair user is sitting in the wheelchair from the side, and from the front. Is the user sitting in an upright posture?

3.) Check pressure: For every wheelchair user at risk of developing a pressure sore – check if the pressure under the seat bones is safe.

4.) Check fit while the wheelchair user is moving: The final part of fitting is to check how the wheelchair fits when the wheelchair user is moving. If a wheelchair user cannot push the wheelchair independently, ask a family member/caregiver to push the wheelchair. You should look out for:

• Backrest- should give enough support and allow the wheelchair user freedom to move the shoulders to push
• Rear wheel position- should allow positioned correctly to allow the user to push
• Seat height and depth- should be correct for the wheelchair user to push with their legs
• Posture supports- should allow for unrestricted and safe wheelchair mobility
• Footrest- user’s feet should stay on the footrests
• Movement of the wheelchair- movement or pushing should not cause the wheelchair user to change their posture or feel uncomfortable or unstable in any way

Wheelchair fitting checklist

• Is the wheelchair ready?
• Check size and adjustments
• Check posture
• Check pressure
• Check fit while the wheelchair is moving

Resources

Rosen L. Fit to Function: Four areas where function can be improved by selecting the proper fit of the manual wheelchair. Rehab Management: The Interdisciplinary Journal of Rehabilitation [serial online]. November 2010;23(10):14-15.

Sprigle S. Measure it: Proper wheelchair fit is key to ensuring function while protecting skin integrity. Adv Skin Wound Care. 2014;27(12):561-572.

References