Wheelchair Prescription

Original Editor - Mereena Baby

Top Contributors - Mereena Baby, Naomi O'Reilly, Kim Jackson, Rucha Gadgil, Olajumoke Ogunleye, Robin Tacchetti and Amrita Patro  

Introduction ====== Definition:

• Prescription ( selection) is the third step in wheelchair service delivery.

• Prescription can be defined as a process of finding the best match possible between the wheelchairs available and the needs of the wheelchair user .

NOTE: The prescription (selection) should always be decided with the wheelchair user, including the family member or caregiver if appropriate.

Prescription (selection) process involves:

• Selecting the right wheelchair, cushion and wheelchair parts ;

• Selecting the right wheelchair and cushion size;

• Training the wheelchair user to help them use their wheelchair and cushion effectively.

It is very important that physical examination be complete and accurate because further on making changes can be difficult. Accurate records gives a permanent record of why certain decisions were made.

Function and posture in existing equipment

Throughout the first visit, a physiotherapist should continuously observe the equipment used, the patient, the caregivers and their physical and psychological interactions. The data should be gathered about the patient ‘s postural alignment at head, shoulder, trunk, pelvis and lower extremities using the visual observation and palpation skills.

Mat table measures

• Supine position

The patient should be assessed in the gravity minimized position {supine (preferred) or side lying}to check if range of motion limitations exist. This also allows preliminary linear measurements, which includes thigh length, calf length, trunk width and hip width.

• ROM

Hip flexion , knee extension with hips flexed and ankle dorsiflexion with knees flexed are the most important values that has to be measured.Other ROM measures are also important of both UEs and LEs, head /neck, trunk and pelvis.

• Seat to back support angle

Measurement of hip flexion will help in determining the trunk to thigh angle and further to the seat to back support angle. The combined data guides the determination of final seat to back support angle.

• Lower leg support to foot support angle

It is measured by taking into considering ankle range of motions , deformities, abnormal tones and movement patterns.

Seated Examination

Using this with a stimulator allows testing of the hypotheses generated during supine examination and provides an opportunity to check patient’s tolerance to the given angles and to determine if thigh length is accurate.

Wheelchair Testing

Functional needs of the wheelchair user should be addressed .

LOCALLY AVAILABLE WHEELCHAIRS AND CUSHIONS

It is very important to select the right wheelchair .The correct size wheelchair is more comfortable, helps to support upright sitting and is easier for the wheelchair user to use.

• Frame-for example, whether it is a long or short wheelbase; the frame length; whether it is a cross –folding or rigid frame.

• Features-including the type of seat, backrest, footrests, armrests, castor wheels, rear wheels.

• Wheelchair size-This is usually described by the wheelchair seat width and sometimes also the depth.The seat height from the floor is also very important to know.

• Adjustability options -Adjustment is usually possible to two or more different positions.For example, most wheelchairs have which can be adjusted to different heights spaced evenly apart.

The “range” of adjustments is from the smallest to the largest measurement.

• Cushion-Determine which type of cushion (if any) is provided with the wheelchair or check can it be available separately.

Some wheelchair suppliers also provide:

• Brochures or a product summary;
• Product (wheelchair) specifications.

NOTE: Wheelchair measurements, weights, features and sometimes optional parts are often mentioned in this information. Always check whether there is information available about the wheelchairs you are prescribing. Kindly read this information so that you are familiar with the products. If suppliers do not give this information, do not forget to ask for it.

RECORDING THE PRESCRIPTION (SELECTION)

The prescription (selection) needs to be written down. Adapt a form for your local service by listing the types of wheelchairs and cushions available in your service and sizes available.

WHEELCHAIR PRESCRIPTION (SELECTION) FORM

Wheelchair user information

Wheelchair user’s name :_______________________ Number:______________

Date of assessment: ____________________________Date of fitting:__________

Assessor’s name:_____________________________________________________

Type of wheelchair and size selected

Select the type of wheelchair :

• Discuss with the wheelchair user;
• Think about the most important needs of the wheelchair user;
• Check: wheelchair frame, castor and rear wheels, footrests, armrests, backrest height (or adjustability) , rear wheels position, support and comfort.

Type of wheelchair	Size

TYPE OF CUSHION SELECTED

Type of Cushion	Size
Eg:Foam pressure relief cushion
Eg:Flat foam cushion

AGREED WITH THE SELECTION

Signature of the user:___________________

Signature of the assessor:____________________

Signature of the manager:_____________________

Different conditions affecting wheelchair prescription (selection)

What you need to know	Always remember
CP affects people very differently. For a person with CP who can sit upright, it is important to remember that they may have difficulty to maintain their sitting position because they get tired easily.This makes doing things harder and more tiring.	Good support is very important. They may need additional postural support in a wheelchair. To do this safely and effectively, intermediate-level training is needed.
People who have poliomyelitis may have weakness or “floppiness” of body parts. It can affect legs, arms or trunk but most commonly it affects the legs. The muscles and bones become thinner and the limb does not grow so fast and so is shorter as compared to the normal . When the trunk is affected, it may appear shorter.	Although people with poliomyelitis do have intact sensation, a cushion is important for comfort. A higher cushion may provide a more comfortable pushing position.
People with spinal cord injury are very likely to develop a pressure sore. This is because most people with spinal cord injury cannot feel below the level of their injury.	Prescription of a pressure relief cushion in this case is mandatory
People who have had a stroke are usually affected on one side of their body.This means they may fall to one side in the wheelchair.They may not be able to feel normally on the affected side of their body. People who have had a stroke may be able to get in and out of the wheelchair by standing up.	Good support is important. Check if the person can feel properly.If not,then he/she may need a pressure relief cushion. A person with a stroke would prefer a wheelchair with footrests which move out of the way so that he/she can do a standing transfer.
People who are double amputees does not have weight of their legs to stop their wheelchair from tipping backwards.	Be very careful when an amputee first tries a wheelchair. Check for wheelchair balance.The rear wheel may need to move backwards to provide extra stability.
Elderly people may need a wheelchair for different reasons.Usually it is because they have difficulty in walking.The wheelchair will make their life easier and help them to continue to be a part of family and community life. Elderly people may be able to do a standing transfer, and will prefer a wheelchair with a flip up or swing away footrests.	Elderly people should always be given a wheelchair which provides good comfort and support .This will help them to sit well and avoid problems caused by poor posture. Flip up or swing away footrests may be the best choice.
Some people have problems with sudden jerking, jumping movements that they cannot control (spasms). These can throw their weight backwards, making it more likely for the wheelchair to tip backwards. The movement can cause the feet to “jump” suddenly off the footrests. This can be dangerous when propelling.	Select a safe back wheel position or a very stable wheelchair. Straps may help control the foot position. Note: Whenever straps are used, it is important that Velcro is used so that the strap releases if the user falls out of the wheelchair.
Some people cannot control their bladder or bowels . This problem can often be solved with the right equipment (catheters, for example), medication and a bladder and bowel training programme. People with bladder or bowel problems must not sit on a damp or soiled cushion, as their skin can rapidly break down. In addition, the bugs present in faeces can rapidly lead to infected pressure sores.	You have to identify who in your area (for example specialist doctors and nurses) can offer advice and training to avoid these complications. Make sure you provide a cushion with a waterproof cover. Do teach the user how to wash and dry the cushion. A second cushion may be required to enable the user to continue day to day activities while the cushion dries

SELECTING WHEELCHAIRS AND CUSHIONS

When prescribing a wheelchair for a wheelchair user who needs additional postural support to sit upright, prescription includes:

• Selecting the type and size of wheelchair most suitable for the wheelchair user;
• Describing any specific set-up for that wheelchair;
• Selecting the type and size of cushion;
• Selecting the PSDs or modifications needed to provide the wheelchair user with additional postural support he/she needs.

Always the prescription is decided in full partnership with the wheelchair user. The intermediate wheelchair prescription requires three signatures, which includes the wheelchair user, assessor ( wheelchair service personnel) and wheelchair service manager.

Types of wheelchair and cushion

To prescribe a wheelchair, wheelchair service personnel should know these things about the wheelchair:

• the type of frame;
• the size available and size range;
• features available;
• adjustments possible and adjustment range.

This knowledge will help wheelchair personnel to select the most appropriate wheelchair for the wheelchair user and describe how it should be set up.The relevant part of the intermediate wheelchair prescription form is shown below

Wheelchair type, size and set-up

Type of wheelchair	Wheelchair dimensions(mm)
	Seat width
	Seat depth
	Backrest height
	Footrest height
Wheelchair set-up
Rear wheel position Tilt		Other:

The type of frame

Wheelchair service personnel need to know the different types of frames that are available locally.For example is the wheelchair a three-wheel or four-wheelchair; a cross-folding or rigid frame;tilting frame; long or short wheelbase.

Size available and size range

Wheelchair size is usually described by the wheelchair seat width and seat depth.

The wheel chair seat width is measured from the outside of one seat rail to the outside of the opposite seat rail or between arm rests if these sit on top of seat rail. The wheelchair seat depth is measured from the front of the seat to the backrest.

Other important wheelchair dimensions include :

• The height of the seat (this is important for wheelchair users who propel with their feet);
• The height of the backrest. Features available:

Possible features include the type of seat, backrest, footrest, armrests, castor wheel, rear wheel and PSDs (for example side trunk pads, headrest, straps).

Adjustments possible and range of adjustment:

This will include the highest and lowest setting for the footrests, whether the backrest height is adjustable, and whether there are adjustments possible in the rear axle position.

Some manual wheelchairs have more features or adjustments than this.Some features or adjustments can be very helpful for wheelchair users who need additional postural support.These features include:

• Adjustable footrests

Most wheelchairs have footrests that can be adjusted up and down.Some have additional adjustments including moving forward or backwards and footrest angle can be increased or decreased. These adjustments give more flexibility to where the wheelchair user’s feet can be placed.

• Elevating leg rests:

• It can hold the foot up with knee extended.
• It is helpful for wheelchair users who cannot bend their knees to neutral for sitting.

• Backrest recline:

It helps to accommodate :

• Hips that cannot bend to neutral sitting posture.
• Fixed posterior pelvic tilt.
• Fixed bent posture of lower trunk.

• Tilt in space

Tilted seat position can benefit:

• Fixed posterior pelvis tilt with hip and knee flexion contractures.
• Low sitting tolerance or discomfort during normal sitting position;
• To increase comfort and rest.

• Rigid seat

This provides:

• A good base to build additional postural support for the pelvis and hips;
• More stability than a slung seat. This can be beneficial if a wheelchair user has strong uncontrolled movements or is very heavy.

• Rigid backrest:

It provides :

• More stability than slung/canvas backrest. This can be beneficial if a wheelchair user has strong uncontrolled movements;
• Better support for wheelchair users who are taller and heavier and/ or have very floppy trunks.

TYPES OF CUSHION

Features cover the following questions:

• From which material cushions are made from;
• Does the cushion provides pressure relief ;
• Is it easy to modify the cushion;
• Is the cushion cover water resistant.

Prescription of PSDs

Introduction

• Different designs of PSDs are available and many different ways that a wheelchair can be modified to provide a wheelchair user with additional postural support.
• Several different PSDs are often combined for one wheelchair user to provide the overall support he/she needs.

Definition

Postural support device can be defined as a physical device that gives an additional postural support and it is an important element of intermediate level wheelchair service.

Examples of PSDs are:

• Seat/Cushion- Pre seat bone shelf, lower seat front (one side), raised seat front, wedge for anterior tilt, build up under pelvis, pelvis side pads, outside thigh wedges, outside thigh pads, inside thigh wedge and knee separator pad
• Seat and Backrest-Open seat to backrest angle, seat and backrest tilt (tilt in space)
• Backrest: Rear pelvis pad, Adjust backrest shape, tension adjustable backrest, backrest recline, trunk side pads, trunk side wedges, trunk side pads used with pelvis side pads and moulded back supports
• Tray: Tray
• Headrest: Flat headrest and shaped headrest
• Lower leg supports: Footrest build-ups, footrest wedges, lower leg supports
• Straps: Pelvis strap, anterior tilt four point strap, calf strap, foot straps-behind the heel, foot straps-around the ankle, foot straps-over the front of the foot and shoulder harness.

Prescription of PSDs-To stabilize the pelvis

• A number of PSDs are used to provide support to the pelvis.
• When pelvis is in posterior tilt and/or slides forward, the following PSDs can be used:

1. 1. Pre seat bone shelf
   2. Rear pelvis pad
   3. Pelvis strap

• When pelvis in lateral tilt (fixed unlevel pelvis), the following PSD can be used:

1. 1. A build up under the pelvis.
   2. Pelvis side pads

• When pelvis moves to one side, pelvis side pads can be used.
• When pelvis is in anterior tilt (pelvis tilts forward), the following PSD can be used:

1. 1. A wedge for anterior tilt.
   2. An anterior tilt four-point strap.

Prescription (selection) of PSDs-supporting the hips

• When one hip cannot bend to neutral sitting posture (trunk to thigh angle is more than 90 degrees), lower seat front on one side can be used.
• When both hips cannot bend to neutral sitting posture (trunk to thigh angle is more than 90 degrees), an open seat to backrest angle can be used.
• When one or both hips cannot open to neutral sitting posture (trunk to thigh angle less than 90 degrees), raise of seat front can be used.

Prescription (selection) of PSDs-supporting the trunk

• To support slumped posture, forward trunk and posterior pelvis tilt. PSDs solutions are:

1. Pelvis support is provided by pre seat bone shelf, rear pelvis pad, pelvis strap (not always necessary) and pelvis side pads (not always necessary).
2. Backrest support is provided by adjusting the backrest shape.
3. Additional support can be provided by tray, shoulder harness and seat and backrest tilt.

• To support slumped posture, fixed posterior tilt pelvis and forward curved trunk. PSDs solutions are:

1. Pelvis support is provided by pre seat bone shelf, rear pelvis pad and opening up the seat to backrest angle and pelvis strap (not always necessary).
2. Backrest support is provided by backrest recline and adjusting the backrest shape.
3. Additional support can be provided by tray, shoulder harness and seat and backrest tilt.

• When trunk leans or falls to one side , PSDs solutions are trunk side wedges and trunk side pads.
• To support fixed or flexible sideways curve of the spine ,trunk side pads combined with pelvis side pads can be used.

Prescription of PSDs-To support the head and thighs.

• To support the head , flat headrest and shaped headrest can be used.
• To support the thighs, when legs are drawn outwards (abducted), the PSDs solutions are outside thigh wedges and outside thigh pads.
• To support the thighs, when legs drawn inwards (adducted), the PSD solutions are inside thigh wedges and a knee separator pads.

Prescription (selection) of PSDs-supporting lower legs and feet.

• When one or both knees bend and are fixed less than neutral sitting posture (trunk to thigh angle is more than 90 degrees).The following PSDs solutions are :

1. Adjust the footrests backwards if possible.
2. Adjust the angle of foot rests.
3. Provide a strap.
4. Shorten the seat lightly if the front of the seat is pushing on the back of the wheelchair.
5. For a tall wheelchair user consider raising the seat front or tilting the seat and backrest.

• When one or both knees cannot bend to neutral sitting posture. The following PSDs solutions are:

1. Provide a standard elevating leg rest.
2. Adjust the footrest forward.
3. Consider providing a 3-wheeled wheelchair if available. Add footrests to the top of horizontal centre bar.
4. Extend footrest forward by adding wood or metal.
5. Extend the footrest hanger to more forward .

References