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Elderly and aging manual wheelchair users have an increased risk for accelerated loss of function and mobility that greatly limits independence and affects quality of life. This review addresses important issues for preserving function and mobility among elderly and aging individuals who use a manual wheelchair by presenting the current available evidence and recommendations. These include recommendations for maximizing function by decreasing pain, improving the ability to self-propel, and prolonging mobility and endurance through ergonomics, individualized wheelchair selection and configuration, and adaptations for increasing the capacity to handle the daily mobility demands through training, strengthening, and exercise. Each recommendation is supported by current research in each relevant area.
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Top ic s i n Ge ri at ri c R eh ab il it at io n • V ol um e 31 , Nu m be r 1, 2 6- 41 • Co py ri gh t © 2 01 5 Wo lt er s Kl u we r He al th , I nc . Al l ri gh t s re se rved.
DOI: 10.1097/TGR.0000000000000042
Elderly and aging manual wheelchair users have an in-
creased risk for accelerated loss of function and mobility that
greatly limits independence and affects quality of life. This
review addresses important issues for preserving function
and mobility among elderly and aging individuals who use a
manual wheelchair by presenting the current available
evidence and recommendations. These include recommen-
dations for maximizing function by decreasing pain, improv-
ing the ability to self-propel, and prolonging mobility and
endurance through ergonomics, individualized wheelchair
selection and confi guration, and adaptations for increasing
the capacity to handle the daily mobility demands through
training, strengthening, and exercise. Each recommendation
is supported by current research in each relevant area.
Key words: elderly and aging , evidenced-based practice ,
functional mobility , manual wheelchair , pain and dysfunction ,
quality of life , seating and positioning
Evidence-Based Strategies for Preserving
Mobility for Elderly and Aging Manual
Wheelchair Users
Philip S. Requejo , PhD ; Jan Furumasu , BS, PT ; Sara J. Mulroy , PhD, PT
international problem requiring effective, practical, and
scalable solutions.
4-7 According to data from the US Census
Bureau, approximately 18% of Americans have a disability
involving an activity limitation and the incidence of disabil-
ity increases to 54% by 65 years of age.
8 The 3 most compel-
ling reasons to target the elderly and those aging with and
into disability are as follows: (1) this is the fastest growing
age group in the world
4 ; (2) health care costs are highest
among the older group; the elderly (65 years and older)
made up around 13% of the US population in 2010, but
they consumed 36% of total US personal health care
expenses. The average health care expense in 2010 was $18
320 per year for a person 65 years or older but only $6122
per year for a working-age person (aged 19-64 years); and
(3) clinically, this group has a high rate of chronic condi-
tions and functional limitations resulting in the high health
care utilization. About 5% of all older individuals in the
United States are currently living in institutional settings.
1
An estimated 1.5 million people in the United States
use a manual wheelchair (MWC) according to the National
Health Interview Survey on Disability.
9 Most use an MWC,
with the proportion of those using an MWC increasing
sharply with age (864 000 among those 65 years and
older). This population consists of many who have been
using an MWC as a result of sudden onset of disability or
gradual onset such as those persons with progressive dis-
eases and elderly individuals who require a wheelchair
for mobility.
10 These include those diagnosed with spinal
cord injury (SCI), stroke, transverse myelitis, osteoarthritis,
lower extremity amputation, poliomyelitis, myelomenin-
gocele, Guillain-Barré syndrome, multiple sclerosis (MS),
amyotrophic lateral sclerosis, and cerebral palsy, as well as
older adults with neurologic defi cits and unable to ambu-
late with the aid of a cane or walker. If prescribed and con-
gured to their individual needs, MWC use can increase
independence in activities of daily living (ADL), reducing
the need for caregiver assistance,
11 and, in turn, possibly
lowering the probability of placement in long-term care
facilities. However, a mismatch between the needs of indi-
viduals according to their functional capacities and the pro-
vided MWC may result in decreased mobility due to poorer
posture, pain and fatigue, and pressure ulcers, contribut-
ing to poorer QOL and an increased need for personal
assistance.
12-14
DEMOGRAPHICS OF ELDERLY AND AGING
MANUAL WHEELCHAIR USERS
By the year 2030, the number of elderly persons in the
United States will double to 71.5 million.
1 While longer life
spans are generally considered desirable, particularly when
healthy years of life are increased, with an aging population
and longer life expectancy come an increasing prevalence
of chronic diseases and conditions associated with aging
2
,
3
that can signifi cantly reduce the quality of life (QOL). There
is considerable recognition that aging and disability are 2
arenas that are increasingly viewed as a national and
Author Affi liations: Physical Therapy Department (Drs Requejo and Mulroy
and Ms Furumasu), Rehabilitation Engineering Program (Dr Requejo),
and Pathokinesiology Laboratory (Drs Requejo and Mulroy), Rancho Los
Amigos National Rehabilitation Center, Downey, California.
The contents of this review were developed under a grant from the Depart-
ment of Education, NIDRR grant nos. H133E080024 and H133N110018.
However, those contents do not necessarily represent the policy of the
Department of Education, and you should not assume endorsement by
the Federal Government.
The authors have no confl ict of interest to declare.
Correspondence: Philip S. Requejo, PhD, Rehabilitation Engineering
Program, Rancho Los Amigos National Rehabilitation Center, Bldg 500,
Room 64, 7601 E. Imperial Hwy, Downey, CA 90242 ( prequejo@
dhs.lacounty.gov ).
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PAIN AND PATHOLOGY IN MWC USERS
There is a signifi cant difference in life satisfaction between
people with a disability and those without. For those indi-
viduals with physical disabilities, life satisfaction increases
to a maximum point at about the age of 45 to 50 years and
then gradually begins to decline.
15 This age closely corre-
sponds to the age of change in physical functioning for
those people who have disabilities.
15-18 As people age, there
are many age-related changes. Changes in skeletal muscles
and joints include slower contractile speed, reduction in
elasticity, impaired healing of injured muscle, and increased
fatigability.
19 These changes have greater impact on indi-
viduals aging with a disability. In a study of more than 600
individuals with various diagnoses, including polio, SCI,
cerebral palsy, arthritis, and other impairments, the combi-
nation of weakness, fatigue, and pain marks the beginning
of change in function in major activities.
15
The elderly and persons aging with a neurologic con-
dition experience a greater level of sensory loss, fatigue,
pain, and depression
20 that further exacerbate dif culties
in ADL,
15 maintenance of physical activities,
21
,
22 increasing
needs for assistance,
23 and QOL.
24 The underlying causes
are generally impairment-specifi c, but the effects are often
similar across diagnosis groups.
15 For the MWC user, loss
of lower extremity function often places the burden for
mobility and ADL on the upper extremities. People who
use an MWC commonly report fatigue and musculoskel-
etal pain in the wrist, shoulder, neck, and back, most often
due to increased demands of mobility.
3
,
15 Mood and QOL
are negatively impacted when individuals experience gen-
eralized bodily pain.
25-27 Furthermore, wheelchair use and
aging amplify the health risk that further impacts func-
tional independence including shoulder
16,18,21,28,29
and car-
pal tunnel injuries,
29
,
30 pressure ulcers,
31
,
32 scoliosis or pos-
tural and pelvic deformities caused by muscle weakness,
paralysis, or osteoporosis,
32
,
33 fractures,
28
,
34
,
35 urinary tract
infection,
28
,
33 and gastrointestinal complications.
32 These
additional effects of age and duration of injury lead to sig-
nifi cant increases in the cost associated with their health
care.
36
Upper limb
Structurally, the shoulder (glenohumeral joint) is poorly
designed for weight-bearing since the shallow socket for
the humeral ball (glenoid) has only a fi brous labrum for
peripheral stability and the plane of the joint is vertical.
During MWC propulsion and depression transfers, the
arms are in low angles of elevation and the joint capsule is
loose and its reinforcing ligaments are slack. Consequently,
shoulder muscles must provide both joint stability and
power for forward propulsion, making them susceptible to
fatigue.
37
,
38 Decreased muscular force as a result of fatigue
or age-related weakness and neurologic defi ciencies can
result in inadequate dynamic stability and allow the exter-
nal loads of wheelchair propulsion to induce forces that
displace the humeral head upward from the center of the
socket.
39
,
40 This upward humeral head migration can com-
press the subacromial space and the rotator cuff tendons
(mainly the supraspinatus), the tendon of the long head of
biceps brachii, and the subacromial bursae, resulting in
chronic infl ammatory and impingement syndromes
30
,
41
and bicipital tendinitis.
29 Prolonged impingement leads to
degenerative changes in the tendons of the rotator cuff
and eventually to partial or complete tears, chronic pain,
and reduced function as well as decreased QOL.
42
Postural deformities
Spinal deformities
Elderly and aging wheelchair users are typically faced with
increasing postural deformities that negatively impact their
ability to function in a wheelchair. Kyphosis and scoliosis
are common spinal deformities due to a muscle imbalance,
osteoporosis, weakness or paralysis,
43
,
44 and immobiliza-
tion.
45 The most common problem associated with kypho-
sis and scoliosis is pain, usually more in the lumbar (lower
spine) than in the thoracic (upper spine). Severe curves in
the upper spine causing forward or lateral collapse of the
vertebral bodies and ribs can compromise the ability of
individuals to expand their lungs, swallow food or liquid,
and cause aspiration. Additional pressure from the muscu-
loskeletal ribs can affect stomach and intestinal functions.
Because kyphosis and scoliosis affect the spinal alignment,
wheelchair users are at an even higher risk for orthopedic
injuries and increased pain in the spine and shoulders.
Asymmetry in trunk alignment causes uneven arm use.
Self-propulsion becomes less effi cient and asymmetrical,
and wheelchair users may need to use their arms to hold
their trunk upright for sitting balance. Severe collapsing
scoliosis or kyphosis interferes with wheelchair propul-
sion
43
,
46 as well as breathing and eating.
47
Pelvic deformities
In the elderly and aging individuals who sit for long periods
of time secondary to weakness or paralysis, pelvic obliquity
and a posterior pelvic tilt are the 2 most common postural
deformities of the pelvis. Pelvic obliquity is described when
a person’s pelvis sits higher on one side than the other,
usually caused by asymmetry in muscle strength as in
hemiplegia or hip joint contractures caused by osteoarthri-
tis or heterotrophic ossifi cation.
45 Pelvic obliquity exacer-
bates trunk imbalance and leads to an unstable base for the
trunk in an upright position, necessitating the use of the
hands to support the spine, compromising their ability to
use their hands for ADL.
44
,
48 Pelvic obliquity also increases
risk for pressure ulcer formation secondary to asymmetri-
cal sitting pressures.
47 A posteriorly tilted pelvis is often
seen in the elderly who have been primarily in a wheelchair
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28 www.topicsingeriatricrehabilitation.com January–March 2015
or bed and have tight lumbar spines and hamstring mus-
cles.
45 This slouched posture is associated with sacral sit-
ting and sliding out of their wheelchair, possibly causing
shearing-type pressure ulcers. This slouched posture starts
with the posterior pelvic tilt and ultimately limits the active
mobility in the upper extremities as the upper body is
slumped forward. The associated decline in range of
motion of the hips from a slouched posteriorly tilted pelvis
signifi cantly limits upper extremity use and therefore ADL,
such as positioning and transferring and maintenance of
hygiene, thereby adversely affecting QOL.
49
Pressure ulcers
Improvement in survival rate of persons with disabilities
and in the general aging population has increased the
number of persons at risk for pressure ulcers. It has been
estimated that 5 million people in the United States have
chronic pressure ulcers, there are 1.1 million to 1.8 million
people developing new ulcers each year, and the fi nancial
cost and the emotional burden are heavy.
50 The 2 groups at
the highest risk are the elderly and those persons with SCI.
However, advances in seating and mobility technologies
have made a difference in controlling deformities, prevent-
ing pressure ulcers, and improving each individual’s QOL.
Aging skin loses elasticity, rmness, thickness, moisture,
sensitivity, and vascularity and may reduce the tolerance to
pressure and shearing forces, resulting in a greater risk for
pressure ulcer development.
51 The incidence of pressure
ulcers in persons with SCI increases with the duration of
injury, 15% at 1 year to 30% at 20 years of follow-up.
35 In a
study completed in the United Kingdom for the prevalence
of pressure ulcers among elderly patients in general medi-
cal practice, the probability of developing a pressure ulcer
increased dramatically with increasing age. As compared
with those 65 to 70 years of age, those older than 80 years
were 4 to 20 times more likely to develop a pressure ulcer.
52
Advanced age played an important role in the develop-
ment of pressure ulcers after accounting for demographic
and clinical factors. An aging-related decrease in muscle
mass and vascularity may reduce the tolerance of aged skin
to pressure and shearing forces, leading to the develop-
ment of pressure ulcers.
53 A decrease in the density of adr-
energic receptors, which would have an effect on blood
supply in the skin below the level of injury and collagen
loss,
54 may also play a role in the skin’s ability to resist
mechanical shear and pressure.
55 An increased risk of pres-
sure ulcers among older adults has been shown by previ-
ous studies in the SCI population.
56
,
57 Advanced age appears
to be related not only to the frequency of pressure ulcers
but also to their severity.
Physical activity and exercise
The majority of people with mobility impairments, particu-
larly older individuals who use an MWC for mobility, do not
meet levels of physical activity recommended for health
and disease prevention.
58-60 Inactivity in individuals with
chronic disabilities who use an MWC results in signifi cant
and costly secondary complications, such as pressure
ulcers, obesity, diabetes, osteoporosis, and cardiovascular
comorbidities.
61-66 In addition to the physiological benefi ts,
participation in exercise and sports activities by MWC users
is associated with decreased depression
67 and improved
community integration and QOL
60
,
68-71 Increasing physical
activity in this population, however, typically involves
upper extremity exercise. Chronic shoulder pain with asso-
ciated physical dysfunctions is a common secondary condi-
tion in MWC users that further limits mobility and partici-
pation and negatively impacts QOL.
42 Gutierrez et al
42
interviewed 80 SCI participants with shoulder pain and
identifi ed that higher intensities of shoulder pain (as deter-
mined by Wheelchair User’s Shoulder Pain Index scores
72 )
were associated with lower subjective QOL scores in per-
sons with paraplegia ( r = 0.35; P = .002) and decreased
community mobility ( r = 0.42; P < .001). The dilemma
for those who use an MWC (particularly those who are
elderly) because of lower extremity paralysis and overall
weakness is how to increase physical activity for physiolog-
ical and psychological health benefi ts without further
increasing pain and pathology.
CONSEQUENCES OF PAIN AND PATHOLOGY
The limitations and restrictions imposed by the pain and
dysfunction in elderly and aging wheelchair users can be
described in the framework defi ned by the International
Classifi cation of Functioning, Disability, and Health (ICF)
73
( Figure 1 ). The ICF can be an effective framework both for
identifying key elements that must be addressed in reha-
bilitation interventions
74-79 and for guiding provision and
classifi cation of assistive technology.
80 In particular, the
concepts of “activity limitations” and “participation restric-
tions” are classifi ed as 2 components of health level of the
person and the society. Because the elderly and aging indi-
viduals who rely on an MWC are dependent on their upper
extremities for ADL and instrumental activities of daily liv-
ing (IADL), pain and dysfunction (body function and struc-
ture)
81
,
82 can limit ADL/IADL
53
,
83-85 and negatively impact
community participation and QOL (participation restric-
tion).
75 Mortenson et al
86
,
87 used the ICF as a framework to
identify and evaluate wheelchair-specifi c outcome instru-
ments that are useful for measuring activity and participa-
tion. They determined that wheelchair-related factors were
associated with participation frequency directly and indi-
rectly through their relationship with mobility.
88 Speci -
cally, wheelchair skills, including the ability to transfer in
and out of and propel a wheelchair, were important predic-
tors of life space mobility and frequency of participation
and life space mobility was a signifi cant predictor of fre-
quency of participation. Depression was associated with
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poorer wheelchair skills and mobility and less frequent par-
ticipation. Similarly, better wheelchair skills predicted bet-
ter self-perceived health, higher life satisfaction, more com-
munity participation,
89 and improved con dence in older
adults using an MWC.
90
STRATEGIES TO PRESERVE MOBILITY FOR
ELDERLY AND AGING MWC USERS
The elderly population, once lively, active, and independ-
ent, slowly or abruptly becomes disabled. Elderly wheel-
chair users are the weakest and most frail individuals often
with multiple diagnoses. Independence in mobility is a key
factor in life satisfaction and contributes to maintaining the
QOL for elderly and aging MWC users. The elderly fre-
quently report having diffi culty using their wheelchairs.
Unfortunately, they are typically relegated to standard sling
seat and back MWC. These standard MWCs introduce a
slumped posture, are not adjustable, and place the user at
disadvantaged positions to perform basic daily activities.
The result often is added cost to the system in having to
provide caregiver assistance or institutionalization. Ganesh
and colleagues
91 found that 61% of their sample of older
adults reported diffi culty with MWC propulsion, indicating
that mobility devices provided for older adults may not be
meeting their needs. Trefl er et al
13 studied 30 persons, 60
years or older, who received an individualized MWC and
seating. Discomfort, poor positioning and mobility, and
skin integrity were the most common issues reported in
their standard issued wheelchairs. Participants who
received an individualized MWC found that they had less
diffi culty independently propelling their wheelchairs and
improved postural stability, which increased their ability to
lean forward and reach. They reported a greater degree of
satisfaction with their wheelchair technology and improved
QOL for social function and physical role as than a control
group of individuals with standard issued wheelchairs.
13
This review addresses important issues for preserving
function and mobility for elderly and aging individuals
using an MWC by presenting the current available evidence
and recommendations. These include recommendations
for reducing the mechanical loads and muscular demands
through ergonomics, wheelchair selection and confi gu-
ration, and environmental adaptations and personal fac-
tors related to increasing the capacity to handle the daily
mobility demands. Each recommendation is supported by
current research in each relevant area. While much of the
research evidence put forth in this review was from the SCI
population, it nonetheless applies to individuals in the gen-
eral population who use an MWC for daily mobility, particu-
larly elderly and aging MWC users.
This review also highlights the need for individualization
of the wheelchair prescription process such that the char-
acteristics of the wheelchair matched the functional capac-
ity of the individual. It is important to note that while stud-
ies comparing different wheelchair technologies provide
valuable information to guide clinical decision making and
wheelchair selection, the evidence will not always apply to
all wheelchairs within the same class or code, that is, all
Figure 1. ICF model as applied to elderly and aging MWC users. ICF indicates International Classifi cation of Functioning,
Disability, and Health; MWC, manual wheelchair; ADL, activities of daily living; BMI, body mass index.
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30 www.topicsingeriatricrehabilitation.com January–March 2015
wheelchairs are not equal even within the same category.
What is important is that clinicians must identify the wheel-
chair characteristics that are crucial for each consumer and
then identify the appropriate wheelchair that results in a fi t
that is specifi c and unique to a single individual user. The
ability to order, modify, or adjust the frame or components
to achieve a nal system that meets the medical and func-
tional needs of the individual is the most important.
Research on demands during MWC use
The relatively high magnitudes, frequency of loads, and
durations with daily wheelchair activities have been
reported as the source of primary pain and dysfunction in
persons who use an MWC.
92 To prevent further loss of func-
tional independence, it is imperative to fi nd ways to reduce
the strain and joint deterioration that may occur with MWC
use. Evaluation of the mechanical load on the musculoskel-
etal system is important in understanding the mechanisms
that may cause pain and pathology and guide recommen-
dations in prevention. Measurement and computing tech-
nologies such as electromyography, motion sensors, force,
and pressure transducers are required, given the needed
detail and accuracy for quantifying the physiology and bio-
mechanics during wheelchair sitting, propulsion, transfers,
and raises, in both laboratory and more realistic settings
over different conditions and across a variety of target pop-
ulations, including elderly and aging MWC users.
Simultaneous recording of muscle activity (electromy-
ography) using indwelling ne wire or surface electrodes
allows detailed studies of the demands on the specifi c
muscles or groups of muscles involved in MWC propul-
sion,
37
,
38
,
93-98 transfers and raises,
99-106 overhead activities,
107
and sitting.
108 Electromyographic recordings were used
to show the reduction in muscle demands when using a
power-assisted wheelchair in elderly MWC users.
109
Evaluation of the kinematics of the trunk and upper
extremities during transfers,
103
,
105
,
110 raises,
102
,110 and over-
head reaching
111 can identify movement patterns that
predispose the user to a greater risk for injury and guide
clinical interventions, including older adults with disabil-
ity.
109
,
112
,
113 Contoured or fl at cushions provide a fi rm sup-
port surface for the pelvis instead of sling upholstery and
immediately improve posture and upright alignment.
114
Determining the forces and moments experienced
by the user during propulsion and related activities
requires instrumented wheels,
115-118 an ergometer,
119 or
platforms
120-122 to accurately measure 3-dimensional reac-
tion forces and moments on the hand during wheelchair
propulsion, transfers, and raises. Instrumented handrim
have been used in documenting the distribution of pro-
pulsive forces at different speeds and resistances,
116
,
123-128
identifying optimal wheelchair confi guration,
112
,
129
,
130 and
examining the effectiveness of propulsion with different
strengths.
131-133 Evaluation of the joint kinetics can identify
excessive loading patterns that may predispose the user to
injury during wheelchair propulsion, transfers, and weight-
relief raises. To demonstrate the magnitude of loading at
the shoulder, studies have reported the net joint forces and
moments during wheelchair propulsion at various speeds
and power output,
124
,
134
,
135 on levels and ramps,
118 and dur-
ing exercise and fatigue states,
136
,
137 among elderly MWC
users.
112
,
113
,
127 Cowan,
138 in a study of wheelchair propulsion
in older adults, showed that surface type has a substantial
impact on the biomechanics of wheelchair propulsion that
magnifi es the differences in the individual’s functional
capacity and wheelchair confi guration.
Early studies on wheelchair propulsion documented that
the higher rate of energy expenditure (33% greater than
normal) attested to the increased arm work involved.
139
Metabolic energy measures have since been used to docu-
ment the reduced energy demands of propelling ultralight
versus lightweight wheelchair,
140 to document that alter-
native propulsion techniques and systems such as power-
assist rims reduce the energy demands of wheelchair pro-
pulsion,
141-147 among older adults with disability,
109 to show
that lower wheelchair seat height improves effi ciency,
148
,
149
and to determine which tires and tire pressure settings
require the least effort during propulsion.
128
,
150 Energy
expenditure recording also demonstrated that propelling
in a side slope increases energy requirements
151 and that an
individual’s stroke pattern during wheelchair propulsion is
related to effi ciency.
152-154
Determining the seat interface pressure during sitting
assists the selection of seat cushions
47
,
51
,
155-159 for pressure
management and positioning in the elderly.
156 Tam et al
159
investigated the movement of the ischial tuberosities and
the redistribution of interface pressure during MWC pro-
pulsion to gain insights into the cause of decubitus ulcers.
They determined that the average interface pressure over
the ischial tuberosity area was lower under dynamic wheel-
chair propulsion conditions. However, there is a concen-
tration of high-pressure gradients around the peak pres-
sure areas of the buttock.
159
,
160 In determining the optimal
design of seat support surface for the elderly, Brienza et
al
156 used a dynamic pressure-monitoring system to obtain
pressure-time profi les from elderly adult subjects. They
determined that support surfaces designed using tissue
stiffness criteria could provide loading conditions that
minimize stress in load-bearing soft tissue and decrease
the risk of pressure ulcer development. Therefore, seat
cushions with pressure-relieving properties that are used
appropriately are important in preventing pressure ulcer
development in elderly and aging MWC users.
161
The aforementioned research tools for assessing the
demands during MWC use has led to the development of
evidence-based guidelines for preserving mobility function
for MWC users, including prescriptions for ergonomics,
equipment selection, user-wheelchair interface (wheelchair
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seating), propulsion and transfer techniques, and exer-
cise prescription.
162
,
163 The Consortium for Spinal Cord
Medicine organized by the Paralyzed Veterans of America
(PVA) developed a guideline, “Preservation of Upper Limb
Function Following Spinal Cord Injury: A Clinical Practice
Guideline for Health-Care Professionals,” based on most
current scientifi c and professional information available.
164
A multidisciplinary panel of experts extensively debated
the merit and evidence-based information supporting each
of the recommendations. Most recently, the impact of the
application of the PVA guideline in transfer skill training
165
and wheelchair setup, selection, propulsion biomechanics,
pain, satisfaction with life, and participation
166 was evalu-
ated clinically. The investigators determined that for those
who were trained with the evidence-based, the structured
education program improved the quality of transfers
165
and better skills on key wheelchair propulsion biomechan-
ics.
166 Using the ICF framework, the recommendations put
forth in the PVA clinical guideline provide a foundation for
addressing key elements and strategies aimed at preserv-
ing mobility in persons who use an MWC as a chief mode
of mobility. Many of the recommendations put forth in the
guidelines apply to elderly and aging MWC users in general
regardless of specifi c diagnosis.
ERGONOMICS
Minimize the frequency of repetitive upper limb
tasks and reduce the forces required to complete
the task
On the basis of current ergonomic literature, repetitive per-
formances of the tasks and high forces associated with each
task place added demands on the upper extremities and
have been implicated as risk factors for strain injury and/or
pain during work-related activities.
167-169 The demands on
the upper extremities are dictated by the frequency of rep-
etition of tasks and the forces required for completing the
tasks. In particular, the most strenuous activities for MWC
users are entering or leaving a car,
170 ascending inclines,
171
performing heavy lifting with arms,
172 an d pr opel lin g whe el-
chairs outdoors.
171 For the elderly and aging adults with
diminished functional capacity, this is particularly challeng-
ing and can be problematic. During wheelchair propulsion,
the frequency and forces can be minimized through equip-
ment selection, particularly the use of properly sized equip-
ment and the use of lighter-weight wheelchairs.
173-175 In
addition, individualized adjustments to optimize the user-
wheelchair interface, such as the amount of seat bucket,
the seat to back angle, back height, and rear wheel place-
ment that promotes the most functional posture and bal-
ance,
114
,
176 should be adopted. Moreover, a lower frequency
of transfers and overhead arm activity tasks can help pre-
vent strain or injury, particularly in elderly and aging MWC
users. Finally, the forces required to transfer into and out of
the wheelchair can be reduced through optimal transfer
mechanics during independent
177-180 and dependent trans-
fers and the use of simple assistive technology such as slid-
ing transfer boards or mechanical lifts that are safe for both
wheelchair user and the assistant.
181
,
182
Minimize extreme or potentially injurious positions
at the shoulder by avoiding extreme internal
rotation and abduction
The classic position for impingement is when the arm is
internally rotated, forward exed, and abducted.
183 Internal
rotation and abduction are common positions during
wheelchair propulsion
94
,
135
,
149
,
184-186 (especially when the
wheelchair is too wide) and transfers.
180 Newsam et al
187
indicated that the marked posterior plane with the internal
rotation position of the humerus at initial wheel contact
places the greater tuberosity and supraspinatus tendon
close to the acromion, increasing the potential for impinge-
ment. It is recommended that MWC users minimize
extreme internal rotation and abduction during wheelchair
propulsion through proper equipment selection (adjusta-
ble wheelchairs), appropriately sized wheelchairs, individ-
ualized confi guration (moving the wheel forward or up/
down with an adjustable axle position in relation to the
seat), and better upright sitting posture to improve shoul-
der mechanics. The extreme shoulder positions experi-
enced during transfers into and out of the wheelchair can
be reduced through optimal transfer mechanics and use of
assistive technology,
181
,
182
,
188 such as sliding transfer boards
and mechanical lifts.
188 Assisted or dependent transfers that
are safe for both the wheelchair user and the caregiver
assistant
189 are recommended.
EQUIPMENT SELECTION
Recommend a customizable MWC and use wheels
and tires with the least rolling resistance
Manual wheelchairs are generally grouped into 3 categories:
standard frame ( 35 lb), a semiadjustable standard light-
weight frame (30-35 lb), and an adjustable ultralight frame
(<30 lb). Adjustable frames typically offer more customiza-
tion in seat widths, seat depth, back heights, and seat
heights, improving the user to wheelchair interface. Adjust-
ability in frames allows the seat-to-fl oor height to be lower
for foot propellers and allows for the rear wheel to be moved
forward to decrease shoulder demands for those individuals
using primarily their arms to self-propel. Lighter-weight
wheelchairs require less effort to propel, are adjustable, and
are made of stronger and higher-grade materials.
173-175
,
190-192
Overall, highly adjustable, rigid, lightweight chairs cost less
to operate
193 because they last longer
191 and are more dura-
ble.
192 In addition, use of caster wheels and tires that mini-
mize the rolling resistance will minimize the forces during
wheelchair propulsion.
128
,
194 Propelling a lighter-weight
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32 www.topicsingeriatricrehabilitation.com January–March 2015
wheelchair was shown to be more effi cient than propelling
a standard wheelchair. The energy cost of propelling the
lightweight wheelchair at a specifi c velocity was 17% less
than that of the standard, nonadjustable wheelchair. The
greater effi ciency of the lightweight wheelchair was attrib-
uted to differences in individualizing the wheelchair pre-
scription and confi guration in addition to the total mass of
the device.
127
,
195 Adjustable wheelchairs allow for different
rear axle positions, wheel camber, seat angles, seat inclina-
tions, and back heights that are important factors infl uenc-
ing ride comfort and MWC mechanics. Cowan et al
128 exam-
ined the impact of surface type, wheelchair weight, and rear
axle position on older adult propulsion biomechanics. They
concluded that increased surface resistance decreases self-
selected velocity and increases wheelchair propulsion peak
forces. Increased weight (wheelchair, seating, and user)
decreases self-selected velocity and increases wheelchair
propulsion forces. Anterior axle positions were found to
decrease wheelchair propulsion forces, especially on high
carpet. The greatest reductions in wheelchair propulsion
peak forces occurred in lighter-weight wheelchairs with
anterior axle positions.
127 Beekman et al
140 determined the
energy cost of wheelchair propulsion in people with SCI,
comparing 20-minute self-selected propulsion on an out-
door track in an lightweight and ultralight wheelchair by
group—persons with paraplegia (n = 44) and tetraplegia
(n = 33). Speed, distance travelled, and energy cost (V o
2 =
mL/kg/m) were compared by wheelchair, group, and over
time. In the ultralight wheelchairs compared with the heav-
ier chairs, speed and distance traveled were greater for both
paraplegic and tetraplegic participants. Sawatzky et al
150 , in
comparing the rolling resistance differences of 5 commonly
used wheelchair tires (3 pneumatic and 2 solid) under 4 dif-
ferent tire pressures (100, 75, 50, and 25 of infl ation), deter-
mined that solid tires (“no-more ats”) had greater rolling
resistance than all 3 pneumatic tires even when tires were
underinfl ated to 25% of tire pressure. Furthermore, energy
expenditure measured during wheelchair propulsion
showed that tire defl ation signifi cantly increased energy
consumption at 50% of tire infl ation. These ndings are rel-
evant to elderly wheelchair users to decrease unnecessary
demands on their already compromised arms and cardio-
vascular systems by having wheelchairs adjusted and com-
ponents selected to maximize effi ciency and minimize roll-
ing resistance that minimize energy expenditure while
meeting their mobility needs.
Optimize user-wheelchair interface for propulsion
and function
Prescribe a custom-confi gurable wheelchair
Individually confi gured wheelchairs have been important
in preserving wheeled mobility function by providing the
best fi t to the individual for energy-effi cient MWC propul-
sion, stable hands-free sitting balance for ADL, prevention
of pressure ulcers, and upper extremity function that help
avoid fatigue and pain. Adjustable and individually confi g-
ured wheelchair frames can address postural deformities
such as posterior pelvic tilt, kyphosis, and hip extension
that can result in a slumped head and neck posture and
affect upper extremity reach. Standard frames are not
adjustable in wheel position, seat-to-fl oor height, or seat-
to-back angle. Standard frames can accommodate limited
aftermarket seating to address minor postural deformities.
Wheelchair users who propel with their feet need a frame
that has adjustability in seat slope or seat height to allow
at position of the foot on the ground. The elderly who
propel only with their feet need wheelchairs that have
adjustability of seat height and do not require the adjusta-
bility of the axle forward. Some frames that have adjustabil-
ity of the axle to move the rear wheel forward or up and
down for upper extremity propulsion also have some
adjustability of the seat slope to change the position of the
body in space. The seat slope or backward seat angle posi-
tions where the hips are lower than the knees in such a way
as to prevent the hips from sliding forward in the seat or
tilting the seat to back angle in a manner to accommodate
for a kyphotic, forward head posture, thus improving
upright head position. A smaller seat-to-back angle can
improve pelvic stabilization but can make transfers diffi -
cult. If an individual is active and independent in the home
or community and is experiencing the effects of aging,
lighter-weight and adjustable frames can be individually
confi gured to maximize function and comfort in his or her
seating. The research and experience have shown that a
wheelchair that is poorly matched to the individual needs
adversely affects potential activities and participation, life-
style goals, and health status and is costly.
162 In a systematic
review of the literature for persons with MS and mobility
assistive technology, an MWC (60%) has been reported as
the most common mobility assistive technology used by
persons with MS.
196
,
197 The quality of wheeled mobility
devices recommended for persons with MS was inferior
(less adjustable for the user) to that of devices issued to
persons with SCI. Persons with MS may be issued a poorer-
quality (heavier and with limited options) MWC than those
with SCI because clinicians anticipate the slow progression
of this dynamic disease. Clinicians may view the use of an
MWC as an intermediate step in the disease progression of
MS to be followed by an increased reliance on a power
device for mobility. Since many individuals obtain prescrip-
tions for an MWC to alleviate some of their daily fatigue,
they are marginal users or may not initially use the wheel-
chair as their primary means of mobility and are therefore
issued a wheelchair with limited options. Ironically, this
lower-level, nonadjustable wheelchair may lead to an
increase in the fatigue symptoms they are attempting to
overcome because standard wheelchairs are heavier and
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33
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nonadjustable and hence require increased effort and
energy expenditure.
198 Perks et al
199 reported that the aver-
age age of the marginal users surveyed was 48 years and
the modal diagnosis was MS. Fifty-nine percent of the mar-
ginal users questioned felt that their wheelchairs were not
adequate for their requirements. They had diffi culty navi-
gating within different environments and did not feel their
wheelchairs met their mobility needs.
199 They were unable
to maintain a functional speed of wheelchair propulsion
when compared with a control group of persons with SCI
and a group of persons without disability.
200 The higher-
energy requirement for obtaining functional mobility is a
signifi cant problem for those with MS, for whom fatigue is
a major limiting factor. The reduced mobility caused by less
adjustable heavier wheelchairs can be generalized to the
elderly and aging population and is also associated with
diffi culty in ADL/IADL and reduced QOL.
Manual wheelchair users may also use foot propulsion
for mobility. Persons with hemiplegia typically use their
unaffected arm and leg for hemipropulsion; persons with
an amputation will use a combination of both arms and
1 leg; or persons may use both arms and legs for condi-
tions such as balance impairments, brain injury, Parkinson
disease, or weakness or debilitation. Without a lower seat
height position for foot propulsion, these users are either
dependent in mobility or at risk for sliding out of the seat
trying to reach the fl oor to push with their feet. Many
elderly individuals with multiple comorbidities such as
cardiovascular disease, hypertension, arthritis, and periph-
eral neuropathies that affect their physical capacity propel
with all 4 extremities for maximum benefi t. Typical MWC
users with hemiplegia propels their wheelchair using their
unaffected arm and leg.
201-205 The seat height must be low
enough and their pelvis stable on a supportive cushion to
prevent sliding out of the seat in an attempt to use their
leg for propulsion and steering.
203 Charbonneau et al
204
confi rmed that foot propelling backward up inclines, curb
cuts, and ramps was safer and more successful using quad-
riceps muscles than trying to propel in a forward direction.
In addition to hemiparesis, many people with stroke have
cognitive, sensory, and perceptual defi cits. These impair-
ments can adversely affect the ability of a person with
stroke to safely and functionally perform wheelchair skills
in a timely manner with good motor planning and safety
judgment. These impairments may also increase the risk
of adverse events in the wheelchair. Therefore, it is impor-
tant that the person’s MWC is best confi gured for seated
postural stability and effi cient and effective propulsion to
facilitate successful function and mobility.
Promote an appropriate seated posture and stabilization
relative to balance and stability needs
In the execution of daily tasks, constant adjustments and
corrections are made to maintain sitting balance, demon-
strating the inseparable connection between dynamic sit-
ting posture and function. Sitting posture and balance are
infl uenced by factors including age, type of disability, type
of activities, and preexisting conditions. For the MWC user,
seating and postural support can affect both wheelchair
propulsion and transfers. A high backrest may be neces-
sary to provide adequate trunk support, but it must allow
for scapular movement during wheelchair propulsion.
Aissaoui et al
114 demonstrated that using a cushion with a
contoured base improved pelvic stability and upper
extremity reach. Harms
206 evaluated the effect of wheel-
chair design and comfort in 58 subjects and found that
conventional wheelchairs with soft hammock or sling
seats and backs contributed to kyphotic postures and
caused low back pain in both nondisabled and disabled
persons ( Figure 2A ).
Slumped postures used to compensate for trunk insta-
bility during bimanual activities may contribute to chronic
fatigue and pain. Postures used to compensate for trunk
instability during bimanual activities may lead to nega-
tive biomechanical events that potentially contribute to
chronic pain. It has been suggested that postural control is
the most important factor in preventing and treating shoul-
der pain.
207 It is recommended that the pelvis should fi rst
be stabilized using a cushion mounted on a fi rm surface
to provide postural support as well as optimal pressure
distribution and comfort ( Figure 2B ). Anterior and lateral
trunk support should be used if an individual is unable
to maintain a stable posture when performing functional
tasks. Adjustments should be made for those persons with
a slouched posture through posterior stabilization of the
pelvis in its most corrected posture and accommodating
the xed kyphosis via back support shape and angle (eg,
Jay Back).
Redford
45 studied seating the elderly and made the fol-
lowing recommendations. In a well-aligned seated posture,
the head and the neck will be vertical with the hips fl exed
to 100 ° , the knees fl exed to 90 ° , and the feet fl at on the
oor. Holden et al
208 studied the seating needs of 46 elderly
persons using force plates and videotape analysis and rec-
ommended a 9 ° backward tilt of the seat. The seat inclina-
tion helped maintain the ischium in the rear of the seat
by blocking the pelvis from sliding forward. This pelvic-
stabilizing confi guration incorporates 3 points of control,
the back support, cushion, and anterior pelvic positioning
belt, providing passive postural support for the pelvis and
lower trunk, and allows a maintained position of increased
erectness even with muscle paralysis. This confi guration
produced less shoulder protraction, less forward head
position, greater humeral fl exion, greater vertical reach
above the seat plane, and less posterior pelvic tilt than the
conventional confi guration. It produced a more vertical
postural alignment and greater reach ability than the stan-
dard factory setup wheelchairs.
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34 www.topicsingeriatricrehabilitation.com January–March 2015
Special wheelchair seating systems have been widely
used in clinical practice to improve the sitting posture of
persons who have spinal deformities, inability to sit with-
out support, and possibly prevent progression of the pos-
tural deformities. Hsieh et al
209 determined that wheelchair
intervention signifi cantly correlated with an improvement
in anterior and posterior head tilt and horizontal eye gaze
while seated in the wheelchair. There are many types of
special seating, with different components prescribed for
different needs.
196
,
210 For persons with scoliosis, lateral
trunk and hip supports provide 3-point support system
needed for hands-free trunk balance. Lateral trunk and hip
supports have been demonstrated to reduce or correct the
magnitude of a fl exible deformity or accommodate a fi xed
spinal deformity preventing further spinal collapse.
197
Minimize the distance and obstacles between the
wheelchair and the transfer location before transferring
Independent transfer is known to be one of the most stren-
uous wheelchair-related activities
41
,
170
,
211-213 and is thought
to be a major contributor to the development of upper
limb pain and injuries.
214 Koontz et al
180 performed a
Figure 2. An elderly person sitting in (A) sling seat and back on a standard manual wheelchair and (B) fi rm contoured
seat base to correct pelvic obliquity, supporting pelvis in neutral alignment and a solid back support with a 95 ° open seat
to back angle to facilitate an upright trunk posture.
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literature review and obtained expert opinion on the rele-
vance and strength of the evidence concerning setup and
transfer performance. The aspects of setup that experts felt
were addressed to some degree included vertical transfer
distance, transferring across a gap, and position of the
mobility device relative to target destination. There is a
consensus among studies that transferring to a higher sur-
face implies greater exertion of the upper limb.
For elderly wheelchair users who are very week and
have poor trunk balance, assisted or dependent transfer
is recommended. If a dependent transfer is to be per-
formed, the horizontally assisted lift and minimized dis-
tance between the wheelchair and the transfer location is
also recommended to minimize loads on the lumbar spine
of the lifter.
215
MWC SKILLS TRAINING
Social participation in the elderly improved signifi cantly
following MWC acquisition.
11
,
216 However, not only inap-
propriate wheelchairs or seating affect the use of the
wheelchair, compromising independence, but also lack of
confi dence and training leads to ineffective use. Therefore,
treatment strategies that facilitate effective wheelchair use
are increasingly important. This is especially true for older
adults who have been reported to more frequently lack
independence using their wheelchair.
217
In order for individuals to effectively use their wheel-
chairs, they must possess a variety of wheelchair skills.
218
,
219
Tr a i n i n g t o i m p r o v e w h e e l c h a i r s k i l l s i s o f t e n u s e d t o p r o -
mote an individual’s ability to use the wheelchair. This
study examined the effects of wheelchair skills training on
confi dence when using an MWC among 65 years and older
individuals living in the community via a parallel-group,
randomized controlled trial study design. The results pro-
vide evidence in support of two 1-hour Wheelchair Skills
Tr a i n i n g P r o g r a m ( W S T P ) s e s s i o n s t o i m p r o v e c o n dence
among older adults who are inexperienced MWC users.
90
FLEXIBILITY AND RESISTANCE EXERCISE
Incorporate fl exibility exercises (endurance) and resist-
ance training into an overall adult fi tness program. The
training should be suffi cient to maintain normal gleno-
humeral motion. The training should be individualized and
progressive, should be of suffi cient intensity to enhance
strength and muscular endurance, and should provide
stimulus to exercise the entire major muscle groups to
pain-free fatigue.
For individuals who have neurologically intact shoulder
musculature, programs for the management of shoulder
pain are quite similar to programs designed for persons
without disability. These programs most often include rota-
tor cuff strengthening, steroid injections, and modalities as
indicated.
220-223 For persons who use an MWC, however,
exercise programs for the management of shoulder pain
should include training of the larger thoracohumeral mus-
culature in non–weight-bearing positions.
37
,
38 In addition,
stretching of the anterior structures of the shoulder joint
is recommended for MWC users to counter the internally
rotated posture of the shoulder that develops secondary
to tightness in the anterior capsule and the sternal pectora-
lis major. For improved program adherence, exercise pro-
grams should be performed using the wheelchair, which
may require modifi cation of the exercise setup. For per-
sons with shoulder weakness, shoulder exercise programs
require a unique design, as they may limit the amount of
shoulder musculature available for strengthening. In addi-
tion, impaired grasp function in some individuals requires
additional exercise modifi cation for complete indepen-
dence (eg, wrist weights take the place of dumbbells and
loops take the place of handles). Impaired balance may
necessitate the use of chest straps and posturing devices
attached to the backrest to maintain appropriate balance.
CONCLUSIONS
Most people modify their lifestyle as they age because of
decreasing physical capacity. Pain and secondary condi-
tions with being elderly and aging with disability further
accelerate loss of function and independence, resulting in
a decline in mobility and the ability to participate in social
roles, which affects their QOL. Being elderly and/or aging
with a disability can have a signifi cant impact on MWC use.
There has been an abundance of research documenting
the demands on the upper extremity muscles, energy
costs and kinematics of self-propulsion, and the effect of
seated posture on function and mobility. These studies
have been used to develop evidence-based recommenda-
tions to minimize the pain and onset of secondary condi-
tion that are even more prevalent in elderly and aging
MWC users.
Although research demonstrates the positive impact of
provision of customizable wheelchairs on the level of func-
tional performance and the QOL of MWC users, elderly
residents living in institutional settings have also demon-
strated improvements in posture and functional mobility
when provided with wheelchairs that were not standard
and nonadjustable.
13 However, it is common practice for
the elderly and aging individuals in these settings to be rel-
egated to standard, nonadjustable wheelchairs. The conse-
quences of poorly tted equipment can cause an acceler-
ated decline in function, pain and fatigue from poor posture,
an increase in need for caregiver assistance or alternative
mobility devices such as powered scooters or wheelchairs
to maintain levels of independence in pain-free mobil-
ity. Individualized confi gured MWCs and seating systems
can change postural alignment that improves comfort by
decreasing pain from poor posture and improves the abil-
ity and effi ciency to self-propel, prolonging mobility and
endurance and preventing the development of secondary
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36 www.topicsingeriatricrehabilitation.com January–March 2015
problems. An appropriate wheelchair and seating system
provides a stable base for using upper and lower extremi-
ties for all mobility-related ADL and, most important, pro-
pelling a wheelchair to maintain independent functional
mobility to maximize QOL.
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