A Guide to Wheelchair Selections
Article originally featured on United Spinal Association
How you get around has a big impact on what things you can do and where you can go.
Being able to take even a couple of steps, can be a huge advantage to getting around in your home. Some people are able to use the tight bathroom environment to their advantage, holding on to the sink, walls or grab bars. Counters may offer some support when standing or walking in the kitchen.
Once you get to the front door of your home, however, there are no walls for support and your lifestyle might require long distance mobility to do the things you want to do, like shopping, visiting family and friends, or going to school or work.
Many people who have lived with a disability for a long time, have found that careful consideration of what is the best way to get around has been a key to their independence. For some people the solutions have included multiple devices - different environments, different devices - a manual wheelchair in the home, a scooter for work and even a hand-cycle for exercise.
Mobility Assistance Equipment comes in many forms, shapes and sizes. The options include:
Assistive Devices for Ambulation: items to help you when walking, e.g. cane, crutches, and walkers
Manual wheelchair: includes a chair with movable wheels to improve your ability to self-propel as well as chairs designed to be pushed by someone else.
Power Assist Devices: devices added to manual wheelchairs to make it easier for the wheelchair rider to get around.
Scooters: three wheeled (some are available in 4 wheels) devices with a tiller for steering, which help in getting around, but do not look like a wheelchair.
Power Wheelchairs: have Front wheel, Mid wheel and Rear wheel drive options, controlled through a joystick or an alternate control device and available in multiple seating options including power seating.
Be an informed consumer. Ask other users about their own experiences. Ask lots of questions.
Very often mobility assistance equipment is purchased through a third party payer, for example medical insurance, Medicare/Medicaid, VA, or vocational rehabilitation. Each payer has their own set of "coverage criteria" and a system for purchasing. As you explore the mobility options available, keep in mind all of these products can be purchased directly by you. If you have the resources, your private pay purchase can offer you greater selection, at less than manufacturer's suggested retail price (MSRP) in a more timely fashion, no need to wait for authorization.
As you explore options, you may find it helpful to consult with a health care provider with experience in mobility devices. There are Occupational and Physical Therapists (OTs and PTs) who specialize in assistive technology. There are suppliers, Complex Rehab Technology Suppliers (CRTS®), who specialize in individualized fitting and service of the devices. Ask other users, they are often a great source of information and may be able to help you.
"My physical functioning was unchanged, just my mind and my world had finally opened up. With the scooter, I could get around again. And I loved the freedom." 1 In her recent book, When Walking Fails Dr. Lisa Lezonni eloquently articulates the challenges faced by persons for whom the acceptable method of mobility, upright walking, is less than functional. Dr. Lezonni speaks from personal experience as a woman with Multiple Sclerosis (MS) who after many years of assisted ambulation, first with one cane and then with two canes, decided to try a scooter.
Adding a wheeled mobility device to your mobility options is a lot like looking for a new car.
There are so many options and many choices, how can you begin to make an informed decision. To be really satisfied over time, requires you to do some homework up front. There is no one best chair. The best choice is the product (or products) that allows you to go where you want to go, when you want to go! To achieve that goal you really need to consider the environments where you will be using the device and what things you will be doing. Some users have no choice about using a chair, it is the only form of mobility available to them. For others, a wheelchair may be augmented mobility, allowing for longer distance travel without fatigue or fear of falling.
Options to think about. Do your homework!
A careful consideration of what things you want to do or need to do, while using the device, will assist you in focusing on your choices. As noted earlier, like a car purchasing decision, you may need to prioritize your functions to identify the key features your need in a mobility assistance device. You may come to the conclusion that more than one device is, ultimately, what is needed. Many users have come to this conclusion and achieve their mobility goals by adding different devices to their options over time. Meet your top priority needs first. Overtime you can purchase different items to meet your needs in different environments.
An important first consideration is where are you having the most trouble getting around. If ambulation, even with an assistive device like a cane or a walker, is not an option, then you will be a full-time wheelchair rider. If walking around your home or other small spaces is functional, then you may only be looking for a device to increase your community mobility or a device to allow you access to a recreational/leisure activity.
You need to think of the chair in each of your environments, home, community, work, and school.
Home: Critical features of the wheelchair will effect your ability to transfer, getting in and out of the chair. What is the height of the seat from the floor? How does that height compare to your bed, for example? How do the armrests or foot supports move out of the way to make your transfer easier? What is the overall width of the chair? Will it fit through your doorways?
Community: How do you want to travel in the community? Do you need to fold the walker when riding in the car? If you are using your arms or your legs to propel a manual wheelchair, will you get tired getting to the store or to visit friends? Would a power option (power assist wheels, power chair or scooter) provide a more efficient method of getting around? Are there sidewalks and curb cuts where you want to travel, or are you sharing the road with cars and trucks? Do you want to be outdoors on trails, grass, gravel or will you be inside on smooth finished floors and wide open doorways? Your choice of tires, wheels, and base type can make a world of difference.
Transportation: Where you live and your transportation options will have a great impact on your device choices. Public transportation is becoming increasingly accessible for passengers using a wheeled mobility device, providing you want to go where the bus is going. Private transportation (owning your own vehicle) gives you the most flexibility and freedom, when relying on a wheelchair to get around. However, fitting your wheeled mobility device into the car will present a series of questions. Can the chair fold? Can you store it in the trunk or within the car? Can you get it in the trunk and then walk to the car door? Many wheeled mobility users find a van or a minivan, especially one equipped with a ramp or lift.
Options for ambulation aids:
Cane or walking stick: The key is to get the cane fitted to the right height. Ideally when you hang your arm by your side, your hand should hang just over the top of the cane, your wrist should line up with the very top of the cane. An adjustable cane is the easiest to use when seeking the right height. Once you have established the right height, if you are a long time user, you may choose to use a non-adjustable (cut to your specific height) cane or even a walking stick to add a little style. When you grasp the top of the cane, your elbow should bend about 30 degrees. If you are using a cane because of weakness on one side of your body, place the cane in the hand of the stronger (opposite) side.
Crutches: There are two types of crutch styles, axcillary (under the arm) and Lofstrand or Canadian (cuffed to the forearm). A proper fit and some instruction on safe use is important. Seek the assistance of a health care provider when first using crutches. Long time crutch users have found the style tip (rubber tip on the bottom of the crutch) and the grip style for your hand, can add to overall comfort for long term use.
Walkers: These come in many styles now, pick-up walker (no wheels), sliders (skis or tennis balls on the rear legs), or rollator walkers (4 wheels). Some walkers are triangular in shape with three wheels (offering a little less support but not as bulky). 4 wheeled walkers are primarily designed for indoor use. They have 4 wheels (small size or large size for more robust walkers), a full basket, and a folding seat.
Styles of wheelchairs and scooters
Broadly speaking there are three categories of products referred to as wheeled mobility devices, Manual wheelchairs, Scooters, and Power Wheelchairs. As mentioned previously, long-term wheelchair users have several types of chairs, each chair functions differently in different environments, together they provide functional mobility for the person. Initially most people only purchase one device, but they hang on to that device later on and find niche uses.
Manual Wheelchairs: Manual wheelchairs are designed for two very different purposes, to be pushed by someone other than the rider or to provide self-propulsion by the rider.
Dependent/Transport mobility bases, not designed for self-propulsion often have small rear wheels and may look and function much like a stroller. For transport purposes, these chairs often fold compactly to store in the trunk of a car and provide light duty mobility. You may find a transport chair is a convenient back-up to your primary chair, easily folded when not needed, but readily available if your chair breaks down.
Specialty Positioning bases are dependent mobility devices that allow for changes in positioning by tilting the seating system or reclining the backrest or both. These devices are not easy to transport, but are designed to provide comfortable, full day seating for the user, who is not able to propel or operate a power wheelchair.
Self-propelling manual wheelchairs are equipped with a large wheel used for propelling. Riders self-propel using either both arms and legs or one arm and leg. If you are using your leg(s) for propulsion, then the seat to floor height is a critical feature to ensure maximum mobility.
Scooters provide power mobility, but have the distinct advantage of not looking like a wheelchair. For many people who have experienced difficulty with walking, a scooter is a great benefit to "restore" mobility. Scooters are most often 3-wheeled devices but come in 4-wheeled options, equipped with a tiller for steering and a seat mount on a platform, which serves as a footrest.
If you have a limited ability to walk, there may be alternative transportation options, such as lifts, used to get in and out of vehicles. For children who walk limited distances, a scooter might be an option to ease long distance trips such like getting to the cafeteria or going out for recess. Functionally, three-wheel scooters create a longer turning radius, when operating indoors, as compared to a traditional wheelchair. However, most scooters come with a swivel seat, allowing easier transfers from sitting to standing positions. Outside, the scooter may not be as stable as a power chair, especially when turning at high speeds. Exercise good judgment and slow down when turning or traveling on unfamiliar ground.
When considering a scooter, it's important to thoroughly understand your medical condition. Unlike many power chairs which can be adjusted and re-configured with changes in your physical status, scooters are not as flexible. Driver controllers in the tillers aren't easily adjustable and it's difficult to modify the seating options compared to a power chair.
Historically, the power chair was a manual wheelchair equipped with motors, batteries and a joystick. Today the power chair is a dramatically different design. Most power chairs, today, are designed to have two major components, the power base (containing the motors, wheels, batteries and control module) and the seating component. Each components come with a wide variety of options. The following is just a general list of options you may want to consider.
Power Base: The most obvious difference in power bases is the position of the drive wheel. Power wheelchair manufacturers now offer three types of drives, rear wheel, mid wheel, and front wheel drive chairs. The placement of the drive wheel has a significant impact on how the chair moves. Each method has its advantages and disadvantages in both indoor and outdoor driving conditions. Your best bet is to arrange for a test drive, ideally with three different chairs, each with a different drive wheel position. Once a particular drive wheel placement has been chosen, there are several different models to choose from.
Wheelchair Seating: There are many options available when looking at seating on a power chair. Options range from simple automotive style to sophisticated power seating which may tilt, recline, elevate your leg rests, or provide a standing feature. For children, there is a power-seating feature to lower the seat to the floor for participation in peer-to-peer activities.
Determining your seating needs requires a good look at your sitting balance, do you need external support and does your seating posture put you at risk for pressure sores? If you have had pressure sores or you have trouble sitting up, you should work with a health care provider to determine the seating options that best meet your needs.
Many power chair and scooter riders are able to use the standard controls, which come on the chair, the joystick or the tiller. For those who are unable to use the standard controls, several manufacturers now offer alternate controls. These alternate controls replace the joystick and use other voluntary movements to allow the person to operate the chair.
Examples include Sip n Puff, which uses a straw and the person sips and puffs to control the direction of the chair or head arrays and a series of switches are mounted into the headrest which allow head movements to operate the chair. If you are in need of an alternate control system, you will need to be evaluated by a seating team, a supplier, and a therapist who specialize in customized assistive technology solutions.
Power Assist: A new technology is now available which offers hybrid or cross-over products, between traditional manual and power wheelchairs. The power-assist systems are equipped with new wheels that are battery operated and designed to increase the number of revolutions the wheel makes with just one push on the rim. The goal is to increase the efficiency of manual propulsion while reducing the amount of effort the rider must put into the wheels.
Add-on power systems are designed to give power chair operation, while mounted onto a manual wheelchair base. With a quick release system, these add-on power systems are more easily transportable than traditional power chairs, but do not have the long-term performance or durability of traditional power chairs.
Wheelchair type advantages and disadvantages:
The Internet offers you the ability to explore products before ever going to a wheelchair clinic or a medical store showroom. Each manufacturer has a website describing their own product line. Major manufacturers include Invacare, Permobil, Pride Mobility, and Sunrise Medical. Other valuable resources include:
www.usatechguide.org A large database of available products by category and wheelchair user reviews.
www.wheelchairjunkie.com Consumer direct information regarding commercial products and a wheelchair users forum.
www.resna.org Provides a directory of therapists (Assistive technology Practitioners (ATP) and Suppliers (ATS) who specialize in rehab products.
www.nrrts.org A list of suppliers by state specializing in rehabilitation products.
The purchase of a wheeled mobility device is not a simple process. Much like the car, you need to consider functionality and aesthetic needs before making your final decision.
Over time you may have different priorities and thus move from one type of mobility device to another. Always do your homework. Ask others about function, reliability, and personal experiences.
Get out there. Talk to other riders, they are a great source of information. Check out the options which can take YOU where you want to GO!
References: 1. Iezzoni LI. When walking fails. JAMA. 1996;276:1609-1613. 2. Hokenberry, J.: Moving Violations, Hyperion, New York, 1995 3. .Karp, G. Life on Wheels: For the Active Wheelchair User, O'Reilly & Associates, Sebastopol, CA. 1999. 4. Bates PS, Spencer JC, Young ME, Rintala D. Assistive technology and the newly disabled adult: Adaptation to wheelchair use. American Journal of Occupational Therapy, 1993, 47, 1014-1021. 5. Axelson P, Chesney D, Minkel J, Perr A. The Manual Wheelchair Training Guide. Minden, NV PAX Press, 1998. 6. Axelson P, Chesney D, Minkel J, Perr A. The Power Wheelchair Training Guide. Minden, NV PAX Press, 2001.
7. Denison I, Shaw J, Zuyderhoff R, Wheelchair Selection Manual: The Effect of Components on Manual Wheelchair Performance Vancouver, BC BC Rehab, 1994 (604) 321-3231 x762