Wheelchair Selection

Abstract

After studying this chapter, the reader will be able to do the following: 1. Describe the factors that should be considered in wheelchair selection and explain how they interrelate. 2. Describe the three basic types of wheelchairs and reasons for each to be chosen. 3. Specify measurements typically taken to determine wheelchair and related seating system configurations for a particular individual. 4. Demonstrate knowledge of the components common to many wheelchairs, and describe why each merits consideration in wheelchair selection. 5. Discuss the roles and responsibilities of the occupational therapist in wheelchair selection. 6. Suggest how the occupational therapist can acknowledge user preferences and facilitate the user's participation in wheelchair selection. Wheelchair Selection Radomski_Chapter17.indd 498 7/11/13 2:39 AM

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ENVIRONMENT
ENVIRONMENT
ENVIRONMENT
ENVIRONMENT
ENVIRONMENT
ENVIRONMENT
ENVIRONMENT
ENVIRONMENT
ENVIRONMENT
CONTEXT
CONTEXT
CONTEXT
CONTEXT
CONTEXT
CONTEXT
CONTEXT
Satisfaction with
life roles
• Self-maintenance
• Self-advancement
• Self-enhancement
Sense of self-efficacy
and self-esteem
Competence in tasks
of life roles
Developed
capacities
First-level
capacities
Organic
substrate
Activities and habits
Abilities and skills
Brian J. Dudgeon, Jean C. Deitz, and Margaret Dimpfel
Learning Objectives
After studying this chapter, the reader will be able to do the
following:
1. Describe the factors that should be considered in wheelchair
selection and explain how they interrelate.
2. Describe the three basic types of wheelchairs and reasons for
each to be chosen.
3. Specify measurements typically taken to determine wheelchair
and related seating system congurations for a particular
individual.
4. Demonstrate knowledge of the components common to many
wheelchairs, and describe why each merits consideration
in wheelchair selection.
5. Discuss the roles and responsibilities of the
occupational therapist in wheelchair selection.
6. Suggest how the occupational therapist can
acknowledge user preferences and facilitate the user’s
participation in wheelchair selection.
Wheelchair Selection
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Chapter 17 Wheelchair Selection
499
“Mobility is a fundamental part of living. Being able to
moveabout, to explore, under one’s volitional control is a
keystone of independence” (Warren, 1990, p. 74).
Mobility is a major part of daily living, facilitating
participation in home, work, and community settings.
Mobility difculties are one of the most commonly
reported functional difculties, a problem that is com-
monly addressed by use of special devices or equipment
( Dudgeon et al., 2008). Walking aids and wheelchair
selection and use are also frequent needs arising for either
short- or long-term adaptation with disability. As such,
wheelchair selection and training necessitate consider-
ation of the user’s preferences and current as well as antic-
ipated performance needs, capacities, and environments.
The process of evaluating and choosing a wheelchair
system involves the user, an interdisciplinary team, and
equipment suppliers or vendors. Also, family members,
primary care providers, and others from the user’s work
and leisure environments may contribute important in-
formation useful in choosing an appropriate wheelchair
system to meet needs for mobility within and between
environments. Such information could affect choices
regarding seating and positioning, controls used, and
supports for engagement in activities at home as well as
mobility and transport in community settings.
Wheelchair selection has a functional orientation and
involves multiple factors including the user’s (1) needs and
goals; (2) home, work, recreational, and other community
environments; (3) physical and cognitive status and antic-
ipated course of impairments; (4) nancial and commu-
nity resources; (5) views about appearance, maintenance,
and social acceptability; and (6) needs for interface of the
wheelchair system with other assistive technology and care
provider or assistant requirements. A selection process in-
cludes issues such as current and changing needs of the
user and family, training needs for use and maintenance,
and anticipated changes in technology. A wide range of
wheelchair options are available, yet funding and commu-
nity-based resources for training and servicing of mobility
devices often limit choices for any given individual.
Some individuals use wheelchairs only occasionally to
meet brief transportation needs, whereas others use them
continuously to meet most day-to-day positioning and
mobility demands. Especially in the latter case, the events
that lead to the need for a wheelchair may be dramatic. For
some, acquiring a wheelchair system may create stress or
confusion, and this can hinder their contributions to the
assessment of needs and selection of a system. Others view
the acquisition of a wheelchair as a positive move toward
greater independence and freedom and make substantial
efforts to become informed about making choices. In ei-
ther case, the needs of the user are central to the overall
process of selection, prescription, and training, with the
wheelchair viewed not just as a means for mobility but as
AQ1
a highly personal device to be chosen with care and preci-
sion (Steins, 1998).
In contributing to the selection process, the occupa-
tional therapist must have a thorough understanding of
the user’s medical needs and personal factors, including
environment, daily routines, goals related to activities and
participation, and assistance or care provided by others. In
addition, the therapist should understand the seating and
positioning needs of the individual and wheelchair types,
control mechanisms, features, and accessories. Knowledge
of product resources and local area vendors is also im-
portant in creating device choice options. Although this
information is presented as separate components, all of
these factors interrelate in comprehensive planning for
functional mobility through a clinical reasoning process.
EVALUATION OF THE INDIVIDUAL
During evaluation, primary attention is given to user and
family goals for use of the wheelchair as part of a functional
mobility system. Further, the therapist evaluates the skills
of the user, the user’s ability to develop new skills, and
changes expected from the diagnosis (e.g., declining sen-
sorimotor skills). How the user plans to transport thesys-
tem is also an important consideration. Priorities of users
should be considered and are likely to include concerns
about both comfort as well as functioning with user sat-
isfaction typically being most related to comfort and ease
of use (Ward et al., 2010). Evaluation of needs should in-
clude interview, observation, and examination. Trials with
seating simulators, trial seating systems, self-propulsion
methods, and/or other control systems are often needed
to conrm appropriate prescription of these systems.
Figure 17-1 outlines evaluation needs; patient-specic in-
formation relates to Lisa (Case Example 17-1).
The evaluation typically involves both sitting posture
and mobility needs. The therapist can best assist in seat-
ing and wheelchair selection by understanding the client’s
personal capacity and needs and medical conditions.
Personal Capacity and Needs
The evaluation of the client includes attention to fac-
tors such as age and stature, developmental status, living
environment, educational or work routines and plans,
recreational pursuits, other assistive technology needs or
uses, and future anticipated needs. Special attention is
given to seating and operation of the chair in both pri-
vate and public environments. Specically, the therapist
should consider factors such as oor surfaces, outdoor
terrain, climate, doorways, hall spaces, restroom dimen-
sions, workspace design, transportability, and parking.
If a client has already used an adaptive mobility device
before, it is important for the therapist to determine
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Section IV Therapeutic Technologies
500
design, in which the typical wheelchair user sits at a
19-inch height and propels a manual wheelchair through
a 32-inch wide opening and turns around in a 5-foot open
oor space. Many people are served well by environments
that accommodate this type of user, but others continue
to be constrained by the environment and need individual
the user’s assessment of pros and cons regarding that
mobility method or system. A blending of walking aids
and wheelchair use may be planned. Therapists should
recognize that uses of adapted mobility systems often
conict with personal spaces and public accessibility.
Public accessibility is based in part on human-factors
Sample Wheelchair Evaluation: Needs of the Individual
Client information: Lisa, 17-year-old high-school senior with recent C7 level tetraplegia from traumatic SCI in MVC. Attends
evaluation with mother during inpatient stay in acute rehabilitation unit.
Functional Needs and Goals
Environments of use (home, school, work, community at large): Full-time at home, at school, and in other community locations.
Has interest in athletics, high school programs.
Seating needs (time, pressure relief, transfers): Postural support needs for trunk and thighs, cushioning for neurogenic skin, and
armrests for upper limb support.
Able to perform push-up pressure relief and can independent transfers to/from wheelchair to same level bed or other surface.
Control or propulsion methods (attendant, manual needs, power controls): With postural support and seat belt, self-propels
using friction push rims and wheel brakes. May benefit from grade aids for propelling up inclines.
Methods of wheelchair transport (car, van, truck; ground travel, air travel): Family owns full-sized truck and minivan. Lisa has
driver’s license, but has not yet explored or been oriented to adaptive driving.
Physical Examination
Head control: Now using a Minerva brace for cervical spine immobilization that will be discontinued use in several weeks with
healing. Otherwise, no limitations in head movements when trunk is stabilized.
Sitting balance and spinal deformity: Propped wheelchair seating, enables good head control when neck immobilization is
discontinued.
Pelvic rotation or obliquity: Symmetrical at this time, mobile pelvis, lumbar support through wheelchair seating back contour and
lateral trunk supports.
Lower limb mobility: Full PROM, flaccid at rest with periodic spasms into hip adduction, knee extension and ankle plantarflexion.
Neurogenic skin below C8 level.
Upper limb mobility: Full PROM, good to normal strength in shoulder, elbow flexion 5/5, extension 4/5, forearm rotation 4/5, wrist
extension 4/5, flexion 3/5, finger extension 3/5. Neurogenic skin lateral hand, 4th and 5th fingers.
Sitting and Balance Needs
Postural support: Now using brace for stability, lateral trunk supports for midline positioning. Seat belt and chest harness
necessary for support and safety. Explore back cushion contouring when brace is discontinued.
Cushioning: Solid base of support needed with cushion contour. Tried low-profile Roho and Jay Cushion. Lisa preferred latter for
balance, good cushioning effects.
Wheelchair Training Needs
Control or propulsion: Manual propulsion with seating components in place. Enlarged and rubberized friction rim tried and
preferred over plain rim or knobs. Wheel camber may assist in hand placement. Needs training for propulsion on level surfaces,
maneuvering corners and doorways, all outdoor settings.
Transfers to and from wheelchair and chair, bed, toilet, bathing tub or shower, floor, car: Is beginning transfer training
wheelchair to bed using sliding board. Removable armrests and swing-away footrests will enable independence. Will need car
transfer training, tub transfer, and floor to wheelchair instruction later.
Wheelchair Maintenance Resources
Lisa expresses interest in learning maintenance routine; father willing to assist as reported by Lisa and her mother. Wheelchair
vendor is within 15 miles from this family’s home.
Figure 17-1 Evaluation overview. Clinicians address these issues by interview, observation, and physical examination. SCI, spinal cord injury; MVC, motor
vehicle collision; PROM, passive range of motion.
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Chapter 17 Wheelchair Selection
501
guidance about making appropriate selection and accom-
modations. For example, some power mobility devices
have a larger turning radius or excessive weight that puts
limits on the user’s access to some buildings, assistance
that can be provided by others, and/or load limits of trans-
portation systems.
Medical Conditions
Evaluation of a user’s medical conditions includes a review
of medical history and physical assessment. The therapist
should be aware of the user’s diagnosis and prognosis; that
is, whether the medical condition is temporary, stable, or
progressive (i.e., declining capacity). Such factors inu-
ence choices related to complexity of options and need
for adjustment as well as preferences for rental, lease, or
purchase. For example, if a condition is temporary, a chair
may be selected with greater concern for cost factors. In
contrast, if a client’s condition is chronic, stable, and ne-
cessitates full-time use of a wheelchair, durability and in-
dividualization to meet needs are priorities. If a condition
is progressive, a chair that permits a range of adjustments
for both seating and wheelchair control may be indicated
in order to meet a client’s changing needs and maximize
function and independence for as long as possible. The
physical assessment should focus on neuromuscular sta-
tus (e.g., muscle tone, postural control, reexes, and coor-
dination); musculoskeletal status (e.g., range of motion,
deformity, strength, and endurance); sensory status (e.g.,
anesthetic skin and skin integrity); and physiological sta-
tus (e.g., temperature regulation, respiration, and cardio-
pulmonary needs). Cognitive skills are also considered
relative to capacity and safety in using and operating a
wheelchair mobility system.
Wheelchair products are currently evaluated using
standards put forth by the American National Standards
Institute (ANSI) and the Rehabilitation Engineering and
Assistive Technology Society of North America (RESNA),
an interdisciplinary association for the advancement of
rehabilitation and assistive technologies. Such standards
enable direct product comparisons regarding features
such as stability, safety, durability, and cost (Cooper etal.,
1997). These standards are changing and call for uses of
new terminologies as well as design elements that im-
pact choices regarding seating and positioning options,
wheelchair frame styles, and various control and equip-
ment attachment options.
SEATING AND POSITIONING
Critical to selection of a wheelchair system is the atten-
tion given to the seating and posture needs of the user.
Seating systems have a signicant effect on the abil-
ity of the user to perform functional activities and on
basicdecisions about choice of mobility base types and
components. Effectiveseating has several broad goals, in-
cluding (1)enhancing posture, comfort, respiration, and
skin protection; (2) preventing injury; (3) accommodating
existing and preventing future deformity; (4) enabling
vision readiness and limb use; (5) attending to cosmetic
appearance and social acceptance; and (6) assisting with
or enabling functional access and performance in specic
settings or environments. Evaluation and intervention
related to positioning often entails participation by team
members such as physical therapists to address postural
supports, speech therapists to address augmentative com-
munication, and family members and others to address
daily routines and schedules. Occupational therapists may
coordinate these concerns by incorporating the needs and
goals of the user and family with medical care concerns in
making recommendations and by analysis of functional
issues so that recommendations optimize the individual’s
access to activities and participation. The roles of team
members may vary somewhat in different locations and in
different organizations.
Seating Principles: Solid Base of Support
Seating strategies and particular techniques can be spe-
cic to age groups and diagnoses, although some princi-
ples can be applied to meet a variety of needs. One such
principle is the need to provide the individual with a solid
base of support that begins with appropriate pelvic posi-
tioning. The sling seat, common to folding and unlocked
wheelchair cross-brace frames, is a seating element that
tends to promote pelvic instability and malalignment of
the thighs. A solid seating base is accomplished by stabi-
lizing the pelvis on a rm surface with pressure distrib-
uted throughout the buttocks and nearly the full length
of each thigh. Seating pressure mapping can be used to as-
sess distribution of pressure and peak pressure problems
that may exist (Stinson, Crawford, & Porter-Armstrong,
2008). Although these systems give feedback to both clini-
cians and users, who can then visualize pressure difcul-
ties and how effectivepressure relief techniques may be,
specic uses of such technology remain somewhat uncer-
tain (see Fig. 17-2).
Postural Supports
Postural control is inuenced by the seat and back contact
surfaces and by orientation adjustments to the seat-back
angle and the angle in space (Fig. 17-3). There are three
commonly used seating positions. First is a sitting po-
sition with 90° hip, knee, and ankle positions. Second
is a slight anterior (forward) tilt of the upper pelvis to
distribute weight through the buttocks and thighs and,
for some individuals, to inhibit abnormal reexive re-
sponses (Fig. 17-4). Third is a 95° seat-back angle with
a 3–5° angle-in-space recline. Adjustable hardware that
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Section IV Therapeutic Technologies
502
A
B
Figure 17-2 A. Flexible pressure maps are placed over cushions to mea-
sure body contact pressures. High and low readings are displayed continu-
ously and can be saved for record keeping. B. Pressures are shown in color,
in grayscale, or graphed. Dynamic readings can be shown or summed over
variable lengths of time.
Backrest angle
Seat to back angle
Seat-plane angle
Angle in space
(tilt-in-space)
Figure 17-3 Adjustment of seat-back angle and angle in space helps to support posture and provide
appropriate pressure distribution.
Figure 17-4 Pelvic positioning with slight anterior tilt helps to distribute
tissue pressure throughout the buttock and thigh.
secures the seat and the back components to the frame are
often used to adjust these positions.
Seat Surfaces and Cushioning
The seat and back contact surfaces can be planar, precon-
toured, or custom contoured. Single-plane or at surfaces
are typically appropriate only for those who need little
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Chapter 17 Wheelchair Selection
503
considered. Table 17-1 lists advantages, disadvantages,
and examples of each. Selection of cushion coverings, for
both contact with the user and contact with wheelchair
seating surface, also should take into account factors such
as heat and moisture, friction, durability, and cosmetic ap-
pearance. The actual pressure characteristics of cushions
are being evaluated and compared with a focus on both
compression and sheering forces that are encountered
with use (Akins, Karg, & Brienza, 2011). Regardless of
cushion types, the techniques of pressure relief described
next are vital to consider as part of pressure management.
Skin should be monitored closely for tolerance when
use of any new positioning or cushion system is started.
Progressive sitting time schedules along with ongoing
skin inspection routines are essential, because no cush-
ion provides sufcient pressure relief during regular use.
Properties of materials vary, yet no cushion is considered
sufcient in relieving pressure enough to preserve capil-
lary blood ow to compressed tissues while a person is
seated. Pressure on sitting surfaces can be greatest dur-
ing manual propulsion, and users should be informed
about dynamic factors that may put at risk the health
of skin tissues. Although cushions help to reduce skin
pressures, other means of pressure relief are necessary.
Assisted or user-performed wheelchair push-ups, side
leans, or forward leans for pressure relief are typically
Table 17-1 Cushion Types and Examples
Classication Advantages Disadvantages Example
Foam Lightweight
Easily sized, shaped
Low cost
Uneven pressure relief
Poor durability
Hard to clean
T-Foam by Alimed®
Gel-lled Self-contouring
Posture control
Sitting balance
Heavy to move
Temperature sensitive
Leaking, maintenance
Jay® Cushion by
Jay Medical
Air-lled Lightweight
Even pressure relief
Little shear
Reduced control/balance
Requires attention to air-pressure tending
Potentially requires repair of puncture/air leaking
High or Low Prole by
Roho®
Honeycomb Lightweight
Easy to clean
Low maintenance
Uneven pressure relief
Difcult to shape
Excessive thickness
Supracor Stimulite®
Contoured
Custom-contoured
foam
Surface area coverage
Reduced shearing
Better postural control
Expense
Longevity with change
Reduced weight shift
Contour U® Pindot by
Invacare
Alternating pressure
systems
Scheduled relief cycle
Reduces user effort
Self-contouring
Cost and availability
Uneven pressure relief
Unsteady sitting balance
Bellows Air Support
Equipment™ by Talley
Medical
or no postural support and for those who can easily re-
position themselves to maintain balance and comfort.
Contoured designs are used to provide added contact for
postural support and distribution of pressure. Custom
contouring is often necessary for individuals who need
accommodation for deformity of the pelvis or spine, those
who have abnormal muscle tone, and those who have dis-
comfort from lack of support at the lumbar spine. These
customized cushions are individually fabricated by bead-
seat molding, foam-in-place techniques, or other shape-
sensing technology. Such devices are often fabricated and
added to an existing wheelchair seating system, such as to
improve seatback cushioning or enable better pelvic posi-
tioning for comfort and control.
Cushions are used to reduce peak pressures associated
with bony landmarks and to distribute pressure evenly
over a large area of skin contact. Shearing forces that com-
promise circulation also can be reduced by appropriately
shaped cushions. Although cushioning relieves skin and
soft tissue pressures, factors including postural stability
and control, ease of transfers, ability to accommodate de-
formity, moisture, and maintenance may be as important
for some users. Cushioning of the seat and back may call
for use of one or more materials such as variable-density
foams, gels, air, and honeycomb-shaped plastics. Custom
contouring and alternating pressure systems also may be
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Section IV Therapeutic Technologies
504
needed or recommended every 15–30 minutes. Alter-
natively, technologies for pressure relief include tilt-in-
space mechanisms, use of alternating pressure cushions
that continuously cycle varying pressure segments of a
cushion, and custom contouring of cushions (Fig. 17-5).
Options of powered tilt and recline systems are growing
and available for lesser cost and impact on the weight of
wheelchair systems ( Dicianno et al., 2009).
Adding Seating System Components
A seatbelt is often recommended because it serves an im-
portant role in stabilizing the pelvis as part of a thera-
peutic positioning in the seating system. This anterior
support is typically mounted on the wheelchair frame
so that it pulls on the pelvis at a 45° angle to the base
of the seat back, tting just under the anterior superior
iliac spines. Additional seating supports should be used
as needed to improve posture, restrict abnormal move-
ments, and promote head control and voluntary use of
Figure 17-5 Custom contouring. Specialty manufacturers make custom
cushions and backrests from a direct cast molding of the individual, through
an electronic sensing system or by foam-in-place methods. These systems
are typically used with individuals whose unique postural needs who cannot
be well supported by premade cushions or backrests.
the limbs. For example, if sitting balance and abnormal
postures are problematic, lateral trunk and thigh sup-
ports may be suggested. Use of anterior supports, in
addition to the seatbelt, may be necessary across the up-
per trunk, knee, or ankle for balance and stabilization.
Neck and head supports are used to promote head and
neck alignment and are sometimes recommended for
safety. Upper extremity positioning also may be a con-
cern, in which case specialized armrests or lap trays can
be recommended.
Justication of Seating Systems
Because sitting is a dynamic rather than a static state, seat-
ing devices should allow some element of pressure relief
and freedom of movement. The principle of less is more is
recommended when applying specialized seating systems
because as more seating apparatuses are used, freedom
of movement tends to diminish. Therefore, only compo-
nents that maximize individuals’ abilities to function,
correct their positions, and maintain comfort should be
applied. When considering additions to wheelchair sys-
tems, trade-offs between supports and function need to
be carefully considered.
Expense justication with a health insurance third-
party payer must relate to medical necessity. Inappropriate
seating and mobility base selection can exacerbate com-
plications and accelerate decline for the user. Functional
accessibility and protection of the user from secondary
complications that come with immobility or physiolog-
ical risks with seating may be cited as part of insurance
justications.
To justify specialized seating with users and families,
the experienced therapist can employ clinical observation
and literature evidence. Improved motor skills, comfort
and participation, physiological supports, and functional
independence are widely hoped for as part of specialized
seating and wheelchair selection. Some goals should be
viewed cautiously, however, because wheelchair and seat-
ing congurations can be considered specic to certain
diagnostic groups and mostly provide a prosthetic effect,
meaning that these benets are largely limited to the time
that the person spends in the seating system. Although
more wheelchair seating research is now being conducted,
methodology challenges and studies with small samples
have led to calls for a more focused research effort. Geyer
et al. (2003) assembled a variety of stakeholders who re-
viewed existing work addressing wheelchair seating and
called for future research efforts aimed to address wheel-
chair transportation, postural control, comfort, and
tissue integrity. Inclusion of the user in research regard-
ing wheelchair uses and consequences of use should be
considered (Sprigle, Cohen, & Davis, 2007) (see Evidence
Table 17-1, which is related to selection and uses of
powered posturalcontrols.)
Radomski_Chapter17.indd 504 7/11/13 2:39 AM

Chapter 17 Wheelchair Selection
505
Intervention
Description of
Intervention Tested Participants Dosage
Type of Best Evidence
and Level of Evidence Benet
Statistical
Probability Reference
Monitoring of power
seating activations
Tilt, recline, and/or
height adjustments
recorded and appraised
for patterns of use
Eleven adult power
wheelchair users,
ages 18–70years
Seating Function
Data Logger used to
monitor self-actuated
seating functions
over approximately
12 hours of use for
a 2-week period of
typical daily use
Description of seating
activations and likely
purposes of such self-
actuated changes in
sitting posture; level IV
Users made frequent
use of power seating
adjustments, with .50
times in at least partial
tilt or recline positions.
This increased reported
comfort but did not
achieve pressure
relieve guidelines.
Descriptive statistics
on each user’s
frequency and
duration of seating
posture change
activations
Ding et al. (2008)
Tilt-in-space seating
use and outcomes for
nonambulatory users
Systematic literature
review (19 studies)
appraising use ot tilt
by those children and
adults with neruologic
impairment
Nineteen selected
studies addressing
neurological
impairments
(e.g.,CP [n 5 8]
and SCI [n 5 8])
NA Systematic review
with metaanalysis;
citing level I and level II
research studies
Statistically signicant
reduction in pressure
under ischial tuberosities
when tilted backward
(20°–45°); evidence
lacking regarding effects
of tilt on function and
seating use
Varied per article
reviewed
Michael, Porter, &
Pountney (2007)
Participation and
activity measurement
approach used with
wheeled mobility
users
Nonintervention study;
semistructure prompted
recall interview about
wheeled mobility
at home and in
community; objective
use measures and
satisfaction reporting
as well
Five adult power
tilt-in-space
wheelchair users
with various
neurologic
disorders
NA; system use
recall reported;
2weeks of objective
use measures
Descriptive study and
systematic interview;
level N
Comfort was a
common reason for tilt
activation. Varied uses
and places of use of
tilt feature were part of
participation in varied
activities.
Descriptive
summaries and
satisfaction change
reporting
Harris et al.
(2010)
Relieving contact
pressure obtaining
tissue perfusion with
wheelchair push-ups
or dynamic seating
system uses
Contact pressure
measurement changes
and ischial tissue health
with wheelchair push-
ups or use of a dynamic
seating system device
Twenty individuals
with paraplegic
SCI, twenty
with tetraplegic
SCI, and twenty
nondisabled
participants
Laboratory setting
appraising hour-long
sitting protocols
and pressure as
well as tissue health
changes with use
of push-ups or
dynamic seating
systems
Contact pressure
relief achieved with
wheelchair push-up or
dynamic device, but
tissue recovery poor
with push-up method;
good with dynamic
system device; level III
Descriptive statistics
on contact pressure
reduction and tissue
reoxygenization
Skin contact
pressure reduction;
p # 0.05; tissue
perfusion varied with
poorer success with
SCI; not signicantly
improved p $ 0.05
Makhsous et al.
(2007)
Evidence Table 17-1 Best Evidence for Powered Seating Posture Features
(continued)
Radomski_Chapter17.indd 505 7/11/13 2:39 AM

Section IV Therapeutic Technologies
506
Evidence Table 17-1 Best Evidence for Powered Seating Posture Features (continued)
Intervention
Description of
Intervention Tested Participants Dosage
Type of Best Evidence
and Level of Evidence Benet
Statistical
Probability Reference
Evaluate
biomechanical
responses in seated
pressure and blood
ow with body tilt
Interface pressure
reduction at ischial
tuberosity and
oxygenated blood ow
with tilt sequences from
upright to 45° tilt recline
Eleven participants
with SCI who
used tilt-in-space
wheelchairs and
had no current
pressure ulcers
Laboratory-based
appraisal in different
tilt sequences,
single-session
testing
Highly variable
responses to tilt, with
increased blood ow
observed only with
maximum (45° tilt);
level IV
Maximal (45°) tilt in
wheelchairs can best
assure peak and mean
pressure relief and
tissue health, although
less than maximal
tilt may have some
benet.
Varied success
with 30° recline and
better success with
maximal 45° tilt
recline (p # 0.05)
Sonenblum &
Sprigle (2011)
Study of wheelchair
users with SCI
perception of
wheeled mobility
behaviors and
development of
pressure ulcer
Multiple participant
observations with
structured and
unstructured interviews
regarding wheelchair
use over approximately
1.5 years of use
Twenty
community-
dwelling adults
with SCI who
used manual
wheelchairs
NA Variable risks are
acknowledged and
based on minute-to-
minute decision making
regarding wheelchair
use; pressure ulcers
viewed as a failure
at in one or more
components; level N
Pressure ulcer risk
episodes are described
relative to wheelchair
and cushion use
routines. Lifestyle
choices, equipment
selection and
adjustments, and life
style contexts inuence
risks.
NA Fogelberg et al.
(2009)
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Chapter 17 Wheelchair Selection
507
WHEELCHAIR TYPES: MOBILITY BASES
Once the therapist has a full understanding of the user’s
personal capacities and medical issues, seating needs, and
environments of expected use (Karmarkar et al., 2011), it
is important to understand the types and uses of wheel-
chair systems. Wheelchairs used in everyday activity can
be divided into three general categories: (1) attendant-
propelled chairs, (2) manual chairs, and (3) power mobility
devices. Special-use chairs and attachments to standard
mobility bases for participation in recreation and sports
also can be considered.
Attendant-Propelled Chairs
Attendant-propelled chairs are designed to be pushed by
another individual because of the user’s inability to propel
or operate a manual or power wheelchair in a functional
or safe manner. This may be necessary for some users on a
temporary or circumstantial basis, for example as a means
to be mobile during community outings. Attendant as-
sistance also may be a full-time need for individuals who
have diminished cognitive capacities, severe judgment dif-
culties, or severely restricted physical capacities. These
chairs may be full size (e.g., those used in skilled nursing
facilities) or may be smaller and created for use in limited
spaces (e.g., folding stroller types). Attendant-propelled
chairs also are used as a substitute for power mobility
when the individual’s typical mobility system is being
repaired or when space constraints preclude power mo-
bility use. When assisting a user in selecting an attendant-
propelled chair, it is necessary to consider not only the t
and comfort of the chair for the person who will be seated,
but also the sizing needs of the person most likely to be
pushing it. As with all wheelchairs, attention to trans-
portation of the user and the wheelchair device between
environments needs attention and planning. In addition
to chairs specically designed to be attendant propelled,
many manual wheelchairs (described next) can be pro-
pelled by an attendant. In both situations, the capacities
of care providers, who may be family members, become
important considerations. For example, it is important
to consider needs of a partner assisting a patient in going
to doctors’ appointments, shopping malls, family events,
and various other settings. If a chair must be lifted into
the trunk of a car, consider the ability of the primary care
provider to do this. Consider not only the weight of the
chair, but also the ergonomics involved in picking it up
and positioning it in a specic vehicle.
Manual Chairs
Manual wheelchairs are for those who can propel and
brake using the upper limbs (Fig. 17-6). These chairs have
a variety of frame types, weights, and transport features.
In general, manual wheelchairs have rigid box frames or
1. Footrest
2. Legrest
3. Front Rigging
4. Frame
5. Seat
6. Metal Skirt
7. Armrests
8. Backrest
9. Push Handles
10. Push Axle
11. Rear Wheels
12. Handrims
13. Brakes
14. Tipping Lever
15. Crossbars
16. Caster Wheels
17. Anti-Tip Casters (Not Pictured)
10
11
12
13
14
15
16
9
8
7
6
5
4
3
2
1
Figure 17-6 Conventional manual wheelchair with component parts.
Radomski_Chapter17.indd 507 7/11/13 2:39 AM

Section IV Therapeutic Technologies
508
folding frames; folding frames are either free or locking
lever–secured. Quick-release wheels can also be selected.
Folding, locking-secured frames with quick-release wheels
and detachable front rigging may offer the greatest exi-
bility for transporting the wheelchair. Rigid-frame chairs
may provide greater energy efciency with propulsion,
and with quick release wheels users can nd this style to
be either easier or more difcult to transfer, depending
on the type of vehicle used. Manual wheelchairs may be
primarily user operated for most activities and many envi-
ronments, but consideration of how others may help pro-
pel the wheelchair can be considered as well.
The conventional manual wheelchair frame has large
rear wheels, which are used to propel the chair, with
smaller caster wheels in the front. Wheelchairs of this de-
sign are highly maneuverable and easy to propel, and they
allow freedom for tilting and wheeling pop-ups that can
be learned for ascending or descending curbs. Standard
designs, sometimes called depot or institutional wheel-
chairs (Cooper, 1998), weigh at least 50 pounds without
specialized seating systems. A distinction can be made be-
tween multiuser chairs, often found in health-care settings
or places of public transportation (e.g., depot wheel-
chairs), and single-user or rehabilitation chairs, usually
designated as lightweight and ultralight chairs. In recent
years, sturdy lightweight metals and designs have been
adapted from sport wheelchairs, resulting in lightweight
and ultralightweight wheelchairs ranging from less than
25 to 40 pounds. Lightweight chairs are often used on a
full-time basis. Many enable adjustable wheel positions
and seat heights, which can help optimize biomechanical
efciency for the user. Along with reduced weight, these
changes serve to enhance propulsion and ease transport
and also may reduce strains on user’s upper limbs.
Other types of manual wheelchair designs include the
amputee frame for the person with loss of or severely re-
duced weight of the lower limbs. In this design, the rear
axle is offset farther behind the seat back than is standard.
This concentrates a person’s weight farther in front of
the rear axle, reducing the risk of the chair tipping back-
ward. Another type of manual wheelchair, although not
commonly recommended, is the indoor frame. It has large
front wheels, which are used for propulsion, with smaller
casters in back. This design rolls easily over door sills and
rug edges, but larger barriers such as curbs are difcult to
traverse, transfers may be awkward because of the forward
placement of the large wheels, and access to tables and the
use of lap trays can be more awkward.
Manual propulsion is typically accomplished through
hand rims attached to the outside of each large wheel.
Often, the user is seated so that, with shoulders slightly
extended and elbows partially exed, each hand rests ap-
proximately at the 12 o’clock position of each hand rim.
Contact with rims generally occurs between the 11 and
2o’clock positions on each side. Circular steel tube hand
rims are common. For users who have difculty with grip,
hand rims can be covered with vinyl coating; knobs or
other projections can be added as part of the rims so that
grip is not required; and/or gloves or mitts can be worn
for traction and to protect the hands. Hand rims vary in
size. Small hand rims, often used on racing chairs, result
in a slower and more difcult start but may provide for a
high top speed that is sustainable with relatively little ef-
fort. For most users the push wheel axle is in line with the
nger tip of the middle nger with the arm at one’s side.
Foot propelling can also be considered as an option,
particularly indoors, making seat height considerations
important for foot placement on ground surfaces. This
may also be a common consideration for steering and
propelling with hemiparesis. Manual propulsion by a
person with hemiplegia or unilateral upper limb use ne-
cessitates additional adaptations. Commonly, the person
with hemiplegia uses the more capable side for the hand
rim and the leg and foot to steer and provide additional
propulsion and braking. This requires removal of the
unused footrest and lowering the seat height or using
small- diameter wheels to optimize foot contact with the
oor. For the user who plans to propel the wheelchair us-
ing only one arm, a chair can be ordered with both hand
rims on one side so that each wheel can be controlled in-
dependently or together. Learning to maneuver dual hand
rims on the same side can be perceptually and mechani-
cally difcult. Another option for unilateral control is the
single-lever drive. This less commonly used device option
uses a forward-and-backward motion to propel the chair
and rotation of the lever to turn the chair.
Parking brakes are used on each large wheel and are en-
gaged through a variable-length single- or dual-action le-
ver, depending on reach and force capabilities of the user.
Such levers press on the tire to resist rolling and require
that tires be fully inated with periodic tightening after
tire wear. Brakes restrict wheel turning when the chair is
parked but are not typically recommended for slowing or
stopping. In addition, antirotation locks also can be used
on casters.
Augmentation of manual propulsion and braking sys-
tems is available. As an aid to propelling on inclines, hill
climbers or grade aid devices restrict the rearward move-
ment of wheels through a friction stop engaged by a lever
on each tire. Speed control and braking to a stop simply
depend on slowing wheel rotation by use of the arms or
legs. New devices that augment propulsion through elec-
trical or mechanical means can also be considered. Such
devices provide supplemental power from an electric mo-
tor that amplify the user’s effort (e.g., Superwheel™ and
e-motion®) or give mechanical advantage through a gear
system and wheel changes (e.g., HandMaster™ and Magic
Wheels™). Another option for manual wheelchairs is to
provide power through add-on devices (e.g., viamobil®
and e-x®). Such systems can be engaged and disengaged
Radomski_Chapter17.indd 508 7/11/13 2:39 AM

Chapter 17 Wheelchair Selection
509
to switch between manual and power mobility. Because
a signicant amount of weight is added to the chair and
units are not easily taken on and off the frame, this option
is most commonly suggested as a trial for a transition to a
regular power wheelchair.
Power Mobility Devices: Motorized
Wheelchairs
Power mobility devices are used by individuals (1) who
cannot propel a chair using either the hands or the feet;
(2) for whom the energy expenditure required to walk or
propel a manual chair is contraindicated; (3) who have
musculoskeletal complications, such as arthritis, in upper
limb joints; (4) who are prone to repetitive stress injury;
and/or (5) who have neuromuscular dysfunction that may
cause associated reactions in the lower extremities when
the upper extremities are used for manual wheelchair pro-
pulsion. There are a number of types of power mobility
devices. Selection of power mobility can be a complex task
because of the variety of user needs and the many options
for wheels, controls, and environmental designs.
Power Wheelchairs
Most power wheelchairs have a power-base design so
that the wheels are, in effect, independent of the seating
components. Such bases may have front-, middle-, or
rear-wheel drive, with a variety of wheel diameters. For
each type of design, the wheels may be coupled to motors
through exposed or concealed chains or gear systems.
Middle-wheel–drive chairs generally have a smaller turn-
ing radius, which improves maneuverability. Power-base
wheelchair designs are noted for being sturdy and appro-
priate for the full-time user both indoors and outdoors.
These designs generally allow for ease in changing seating
dimensions, such as for a growing child or for an individ-
ual with changing seating system needs. Typically the rear
wheels are powered, but some designs have front wheel
drive (e.g., Permobil) or, as noted, middle-wheel power
(e.g., Invacare).
Several power-base chairs have options that enable the
user to change seat height or elevate toward a standing po-
sition independently. Similarly, some manual wheelchairs
have manual lever systems that allow the user to rise to a
near standing position. These allow the person greater ver-
tical exibility in environmental accessibility, enabling face-
to-face communication and easing performance in reaching
books in a library, accessing a high counter, or reaching and
operating controls. All environments of functioning should
be considered as wheelchairs best for use outdoors may not
work as well for indoor mobility (e.g., front wheel drive).
Tilt, recline, and elevating leg-rest equipment are powered
by wheelchair batteries and can be controlled by separate or
integrated controls. Power seating controls enable users to
sit more dynamically and can improve comfort and func-
tion (Dicianno etal., 2009).
The primary disadvantages of power wheelchairs are
that (1) they can be large and heavy and may be difcult
to maneuver in small spaces and transport from one place
to another; and (2) a 5 3 5–foot turning space, as part
of standard barrier-free design, may not be sufcient for
some power wheelchairs. Typically, van or bus transport
of the individual sitting in a power mobility device re-
quires special lifts or ramp devices, and the sizes of some
chairs necessitate a raised roof in these vehicles. Alterna-
tively, the user can transfer into the vehicle, and an atten-
dant can load the chair separately by use of a lift or by
breakdown into components. Some lightweight power
wheelchairs are designed to be taken apart for automo-
bile transport (e.g., the At’m Take-Along- Power Chair™).
Some of these chairs are built on folding frames and/or
have low- powered motors, making hill climbing and use
on uneven surfaces more challenging. Assistance with tak-
ing apart and reassembling the chair often is required.
Scooter
Another popular power mobility device is the scooter.
Scooters typically have three wheels, although four-wheeled
designs are available, and may have either rear- or front-
wheel drive. Most of these designs are characterized by
tiller control, wherein the user steers the scooter by ro-
tating the front wheel while using a lever-style switch for
forward or reverse power. This type of chair is appropri-
ate for the marginal walker and is often used to compen-
sate for a person’s inability to travel comfortably within
the community. Scooters are sometimes modular and can
be disassembled and loaded in and out of the trunk of
a car or the back of a station wagon or van more easily.
Steering and control of scooters can be difcult, so indi-
viduals with marginal control may be better served by use
of a power wheelchair with a variety of control options.
Scooters may also not be appropriate for individuals with
signicant posture control needs because special seating
and other components are difcult to attach. In addition,
scooters require a larger turning radius and may limit ma-
neuverability indoors or t with vehicle lifts and van and
bus tie-down systems.
Power Mobility Considerations
Specic factors unique to power mobility require consid-
eration. The therapist should determine whether the de-
vice will be used primarily indoors or both indoors and
outdoors. A device that is to be used in both settings must
have more stability, power, distance capability, and dura-
bility than an indoor-only model. User’s planned oper-
ating distances, slopes, and outdoor conditions such as
rain, temperature, and sunlight should be considered as
part of selection and training. In addition, the therapist
Radomski_Chapter17.indd 509 7/11/13 2:39 AM

Section IV Therapeutic Technologies
510
should consider the use and maintenance of the batteries
that provide power. Various sizes of deep-cycle lead-acid
batteries and sealed cell gel types have different expense,
longevity, and needs for recharging. Other power wheel-
chair characteristics to consider include noise, braking
systems, ride quality, and portability, including ease of
assembly and disassembly. If the device can be disassem-
bled, the weight and size of each part should be carefully
evaluated for transportability. Nonleaking sealed cell or
gel batteries are preferred for added safety in airline trans-
portation, with wet-cell lead-acid wheelchair batteries be-
coming somewhat obsolete. Such batteries require special
handling as part of airline travel.
Selection of appropriate controls for driving is critical,
and a graded approach to control training is often needed.
Wheelchair seating posture is key to determining the most
reliable and effective motor actions for control. Program-
mable controls are most common and enable careful selec-
tion of torque and speed control based on wheeling surface
resistance and safety. Power devices are driven using one
of two types of options: proportional or discrete control.
Most commonly, a proportional joystick is used, in which
directions and speeds are linked to angle and magnitude
of stick displacement. Proportional control also may be
achieved through proximity-sensing devices that, for ex-
ample, sense the position of the head. The user moves his
or her head as a joystick, and the wheelchair’s speed and
directional control are proportional to the head displace-
ment. Another alternative is discrete microswitch control
activated with a joystick, a multiple-switch array, or a sin-
gle-switch scan. Each switch activation engages a preset or
programmed speed and direction. Microswitch systems
require less skilled movement to achieve control, although
control of the wheelchair is often less precise than that
provided by proportional control. Also, learning to use
microswitch control is not simple. Each direction may be
controlled by activating a microswitch using a body part
(i.e., hand, arm, chin, foot, head, mouth, lips, or tongue),
and control may be organized through a combination
of special techniques such as sip and puff, scanning, or
switches imbedded in headrests (Fig. 17-7). For instance,
breath may be used for forward and reverse control, and
proximity-sensing switches may be used to activate turn-
ing control. When selecting controls, the therapist should
consider adjustment options provided by various systems
in relation to the needs of the individual. For example,
clients with poor motor control may benet from adjust-
ment of programmable electronics that enable wheelchair
speeds to be automatically restricted when turning or that
enable several levels of control to be programmed for new
learning and control training in various environments.
Power wheelchairs and scooters electronically brake,
meaning that drive wheels do not rotate except under
power and with activation. Gears are then released by
levers that allow the chair to roll freely.
Activity- or Environment-Specic Wheelchairs
For everyday use, attendant-propelled, manual, or power
wheelchairs are selected. Many users may also need
mobility to overcome unique barriers or for use in rec-
reation and leisure activities that require activity- or
location-specic technology. Special power-wheel cong-
urations have been designed for ascending or descending
stairs, although market availability for such models has
been inconsistent. Other special designs for wheelchairs,
including those for use at the beach and on other soft
and uneven surfaces, are available commercially or may
be custom made. For recreation, cycling congurations
may be requested. Row cycles are large, low to the ground
three-wheeled cycles propelled by a rowing action that
activates chain-driven rear wheels. Cycling action also
can be added to manual wheelchairs (Fig. 17-8) or be
Figure 17-7 College student uses a power wheelchair controlled with prox-
imity switches in a head array. The display in front of right armrest provides feed-
back regarding drive selection, environmental unit (ECU) functions, and battery
level. A switch on the right side of the head array permits selection of drive and
ECU functions. (Courtesy of Adaptive Switch Laboratories, Inc., Spicewood, TX.)
Figure 17-8 A father uses a cycling apparatus attached to his everyday-use
manual wheelchair for outdoor activity with his children.
disABILITY
Information and
Resources
http://www.makoa.org/
mobility.htm
Mainstream
Magazine-Online
www.mainstream-mag.
com
New Mobility
23815 Stuart Ranch Road
P.O. Box 8987
Malibu, CA 90265
www.newmobility.com
Paraplegia News &
Sports ‘N Spokes
http://pvamag.com/sns/
Paralyzed Veterans of
America
801 18th Street, NW
Washington, DC,
20006-3517
http://www.pva.org
USA Tech Guide
United Spinal Association
75-20 Astoria Boulevard
East Elmhurst, NY 11370
http://www.usatechguide.
org/reviews.php
AQ11
Radomski_Chapter17.indd 510 7/11/13 2:39 AM

Chapter 17 Wheelchair Selection
511
congured as a separate chair for outdoor sport. Sport
wheelchairs for racing, basketball, and other competi-
tions are commercially available, but often they require
customized sizing and expert instruction. For a thorough
review of options for using activity-specic or sport and
recreation chairs, see Cooper (1998) and Paraplegia Sports
‘N Spokes ( Resources 17-1). As described later, health in-
surance funding for wheelchairs is most often restricted
to one device purchased for up to 5 years or more of use,
and so most second wheelchairs, for any purpose, are
funded privately.
WHEELCHAIR SIZING AND ERGONOMIC
CONSIDERATIONS
Modern wheelchairs are engineered as modular systems
and are assembled to match the specic physical dimen-
sions of the user. Measurements of the individual form
the basis for determining wheelchair frame size, the need
for adjustable ranges in component parts, and the need
for customization to meet special needs.
Sizing
Appropriate size determinations of the wheelchair frame,
seat, back, leg rests, and armrests are based on measure-
ments typically taken with the user in an optimally seated
position. Alternatively, the therapist can evaluate the in-
dividual on a mat in a supine or side-lying position and
take careful measurements of distances between key land-
marks. These measurements are conrmed for accuracy
with the user seated. The user’s typical or specialized cloth-
ing needs should be considered during measurement. If
thoracolumbar bracing or lower limb orthotics and pros-
thetics are likely to be used in the wheelchair, they should
be worn during sizing measurements. Manufacturers of
wheelchairs and seating systems have differing standards
for measurement and sizing. Typically included are mea-
sures of pelvic or hip width; upper and lower leg lengths;
midback, midscapula, and top of shoulder heights; chest
and shoulder widths; elbow height; and overall sitting
height (Fig. 17-9).
● Seat width: The therapist determines the widest point
across the hips and thighs and may add a total of 5 cm
(2 inches) for adequate clearance on the sides for cloth-
ing and positioning comfort. However, keeping the seat
width as narrow as possible may be chosen, because
overall wheelchair width is dictated by the seat-width
measure. Wheelchairs should be as narrow as possible
while allowing for comfort, easy repositioning, cloth-
ing needs, and transfers. For manual users, narrower
wheelchairs are likely to improve ease of hand-rim pro-
pulsion and maneuverability.
● Seat depth: The therapist, for both the left and right
sides, measures the distance from the most posterior
part of the buttocks under the thigh to the popliteal
fossa crease of each knee. About 5 cm (2 inches) is sub-
tracted from the measure. This allows as much weight
bearing through the thigh as possible without the front
edge of the seat pressing into the back of the knee.
Right and left leg length discrepancies can be caused
by hip dislocation, pelvic rotation, or other anatomical
factors. The shorter side may be used to determine seat
depth, or if a greater than 1-inch discrepancy is found,
the front seat edge may be offset to accommodate the
length of each side. Individuals who use their feet to
AbleData
8630 Fenton Street
Suite 930
Silver Spring, MD 20910
www.abledata.com
Ability Magazine
1001 West 17th Street
Costa Mesa, CA 92627
www.abilitymagazine.com
Assistive Technology,
RESNA
1700 North Moore Street
Suite 1540
Rosslyn, VA 22209
www.resna.org
The Boulevard
jjMarketing, Inc.
1205 Savoy Street, Suite 101
San Diego, CA 92107
www.blvd.com/Wheelchairs
_and_Accessories/
Disabled
World: towards
tomorrow;Assistive
Technology
173 D’Youville
Chateauguay, Quebec J6J
5R1, Canada
www.disabled-world.com/
assistivedevices/mobility/
wheelchairs
disABILITY
Information and
Resources
http://www.makoa.org/
mobility.htm
Mainstream
Magazine-Online
www.mainstream-mag.
com
New Mobility
23815 Stuart Ranch Road
P.O. Box 8987
Malibu, CA 90265
www.newmobility.com
Paraplegia News &
Sports ‘N Spokes
http://pvamag.com/sns/
Paralyzed Veterans of
America
801 18th Street, NW
Washington, DC,
20006-3517
http://www.pva.org
USA Tech Guide
United Spinal Association
75-20 Astoria Boulevard
East Elmhurst, NY 11370
http://www.usatechguide.
org/reviews.php
AQ11
Resources 17-1
Wheelchairs and Accessories
Radomski_Chapter17.indd 511 7/11/13 2:39 AM

Section IV Therapeutic Technologies
512
propel or steer will need greater front-edge seat clear-
ance. Selected seat cushion height should be taken into
account with further measures of trunk, arm, and leg
positioning components.
● Back height and width: The therapist generally takes
three measures from the seat surface upward: (1) to the
midback just under the scapula, (2) to the midscapula
or axilla, and (3) to the top of the shoulder. Back height
is affected by seat cushions, which should be consid-
ered in sizing decisions. Height of the chair back is
based on the need for postural stability and freedom of
arm movements for propulsion or other functions. For
those who exclusively self-propel, a chair back height of
2–5 cm (1–2 inches) under the tip of the scapula may
be preferred. For sporting activities, the optimal back
height may be even lower. By contrast, for power wheel-
chair users, back heights to midscapula or the top of
the shoulder may be necessary to allow use of postural
supports for the upper trunk and the head. Chest and
shoulder width should be measured in cases of defor-
mity or to determine the space requirements for lateral
trunk supports or other trunk-positioning devices. Al-
terations of the standard sling back may be necessary
for improving trunk posture by using an adjustable or
exible sling back, curved backs, or additions of lateral
trunk supports or custom-contoured backs.
● Seat height and leg rests: Seat height is based on po-
sitioning of the individual such that footrests have
at least a 5-cm (2-inch) clearance from the oor. Use
of seat cushions affects this measurement by raising
overall seat height. Seat height is determined with the
individual’s knees and ankles positioned at about 90°.
Measurements are taken from under the distal thigh
to the heel of the individual’s commonly used foot-
wear or shoe. Several inches of adjustment are typically
available in leg rest lengths. Unusual leg lengths or hip
or knee deformity may necessitate special ordering.
Overall seat height may be determined and measured
from the ground with considerations of needs for in-
teractions with those who are standing, versus lower
height to aid propelling, and considerations for trans-
fer height surfaces.
● Armrest height: The therapist measures from under
each elbow to the cushioned seating surface with the
shoulder in neutral, the arms hanging at the sides, and
the elbows exed to 90°. Armrests must provide fore-
arm support with neutral shoulder position but should
not obstruct reach to hand rims for propulsion or to
brake levers.
Common and Special Components
In addition to overall sizing and seat and back surface, the
team and user should consider selection of head and neck
rests, armrests, leg rests, and other options. Table 17-2
lists options for head, neck, arm, leg, and foot support.
Users should consider armrest stability for performing
wheelchair push-ups for pressure release. Detachable or
swing-away styles may allow greater ease in sliding-board
and other sideways transfers and improve access to ta-
bles and desks. Guards can be used on armrests to keep
clothes from coming in contact with wheels. Attachment
of lap trays may require use of full-length armrests or
other specialized hardware. The front rigging consists of
J
F
E
D
F
H
E
D
C
B
I
A
GG
Figure 17-9 Seating measurements. For B. to G., all measurements are taken on both
right and left sides. A. Hip and thigh width. B. Thigh length. C. Leg length. D. Back height
to below scapula. E. Back height to midscapula. F. Back height to top of shoulder. G. Elbow
and forearm height. H. Chest width. I. Shoulder width. J. Sitting height.
Radomski_Chapter17.indd 512 7/11/13 2:39 AM

Chapter 17 Wheelchair Selection
513
leg rests and foot plates. Options are selected according
to needs for elevation of the calf and foot, ankle position,
and stabilization of the leg. Flip-down footplates or plat-
forms are common and popular because they can reduce
the overall length of the chair. Swing-away or detachable
front rigging may enable easy transfers and transportabil-
ity of the wheelchair in and out of vehicles.
Tires can be either pneumatic (air lled), semipneu-
matic (airless foam inserts), or solid-core rubber and are
mounted on spoke or molded wheels. Air-lled tires are
lightweight with low rolling resistance, providing a well-
cushioned ride and shock-absorber function that tends
to improve comfort and prolong the life of the chair, but
they do require regular maintenance. Semipneumatics
provide good cushioning and less maintenance, but tire
wear may be more of a problem. Solid-core tires are noted
for minimal maintenance and approach the weight and
low rolling resistance of high-pressure pneumatic tires,
but without concerns for getting a at and becoming
stranded.
Casters, as either front or rear wheels, vary in diameter,
and small ones better enable maneuverability. Pneumatic
and semipneumatic caster tires provide some shock ab-
sorption for use outdoors and on rough surfaces. Solid-
core caster tires are best for use indoors and on smooth
surfaces. Special designs (e.g., Frog Legs™) for manual
wheelchairs and power wheelchairs are promoted for
shock absorption and enhanced maneuverability.
Seatbelts, safety vests, and harnesses vary in design
and are used for both safety and positioning. These de-
vices should be considered for individuals who have severe
neuromuscular impairments and need control for posture
and safety. Restraints may be considered with individuals
who have poor judgment but should be avoided whenever
possible and be regarded separately from seating postural
needs. Restraint reduction efforts in long-term care facili-
ties may be enhanced by use of appropriate and comfort-
able seating, and with risks associated with wheelchair
seating restraints, planning for client’s control of releasing
belts and straps should considered (Chaves et al., 2007).
Frame and upholstery color and material options
are numerous. Users can personalize their chair through
selections of colors and other styling. Durability, cleaning,
ease of repair, and compatibility of materials with temper-
ature regulation, friction, moisture, and skin protection
requires careful planning. Trial use of the wheelchair seat
and back may be suggested with special consideration for
surface stability and handling of moisture and heat.
Other special considerations are specic to different
wheelchair mobility bases. On most manual wheelchairs,
placement of the rear axles can be xed or adjustable, es-
pecially with newer manual lightweight and ultralight
styles. Backward placement of the axle tends to increase
stability; by contrast, forward placement of the axle de-
creases stability but increases maneuverability and short-
ens turning radius. Sometimes rear wheels have a camber
adjustment. This orients the hand rim for easier propul-
sion and slightly widens the wheel base for better stability.
Although users often prefer a 6° camber, such cong-
urations do not appear to impact ease of propulsion or
handling (Perdois, Sawatzky, & Steel, 2007). Antitipping
extensions can be used on a wheelchair to prevent the
chair from tipping backward or forward. Typically used
on the back, these xed or adjustable extensions can im-
prove safety, particularly during mobility training.
Recline and tilt-in-space options, considered with
attendant-propelled and power mobility, enable pos-
tural changes for rest and pressure relief. In attendant-
propelled wheelchairs, semireclining up to 30° from
upright or full reclining up to 90° from upright can be
considered. In tilt-in-space systems, the seat and back as-
sembly pivot together. This feature makes the use of pos-
tural seating components more stable because the angle
between the seat and the back remains unchanged, reduc-
ing or eliminating the problem of shear. Power recline
systems can be used with conventional or power-base de-
signs. Such systems may involve tilt-in-space and/or low-
shear back recline, both of which can be used to provide
pressure relief and rest positioning. Tilt-in-space chairs
that go back 45–60° can achieve effective pressure relief
Table 17-2 Head, Arm, and Leg Supports
Component Attachment to Frame Adjustment Style
Head and neck supports Fixed or removable Height, depth, and rotation Flat, winged, lateral, occipital, or
wedged
Armrests Fixed, swing away, and/or
removable
Same height or adjustable
height
Full length or desk length, rigid or
padded
Leg rests Fixed rigid, swing away, and/
or detachable
Fixed or telescoping length Fixed angle or elevating
Calf pad and foot plate Rigid or ip up, ip away Variable sizes in pads or straps Plate, tubular, rigid, or padded
Radomski_Chapter17.indd 513 7/11/13 2:39 AM

Section IV Therapeutic Technologies
514
under the buttock and thigh and may have other benets
such as improved breathing These systems, however, add
to costs and increase wheelchair size and weight.
Other considerations are accessories that optimize
use and performance. Lap trays can be used for pos-
tural support of the upper limbs and serve a variety of
purposes related to function. Other accessories include
mounting bags or baskets for storage and carrying, cup
or bottle holders for taking fluids, and storage attach-
ments for a reacher or walking aids to enhance access
and mobility. Communication devices or environmen-
tal controls may be mounted on the wheelchair and
operated independently of wheelchair controls or can
be integrated with power wheelchair controllers. Other
medical equipment such as ventilators, oxygen tanks,
or other devices need to mount within the wheelchair
mobility system.
MOBILITY TRAINING
Mobility training with the wheelchair system can be essen-
tial and often involves interdisciplinary team members,
such as the physical therapist. Most users benet from
instruction and practice beyond the training provided
by vendors. Once the chair has been provided, a check
should be conducted, and appropriate training of the user
and attendants should commence. This includes review
of the user’s goals for mobility along with a check of the
device for t and adjustment. Instruction also should be
provided regarding (1) use of the chair indoors and out-
doors and on a variety of surfaces (e.g., level, carpeted, in-
cline, and uneven); (2) transfers (e.g., bed, toilet, and car);
(3) transport of the wheelchair (e.g., cars, trucks, vans,
and buses); and (4) maintenance of the wheelchair (e.g.,
cleaning the chair, lubricating moving parts, monitoring
tire pressure and wear, adjusting brakes, and caring for
batteries). Troubleshooting with the wheelchair system
ultimately becomes the responsibility of the user and
equipment supplier or vendor, but the therapist may ad-
vise about problem-solving strategies and organization of
maintenance routines and schedules. Throughout train-
ing, the therapist emphasizes safety issues because acci-
dents during day-to-day wheelchair use do occur and may
be preventable (Chen etal., 2011).
For more than a decade, functional skill evaluation
with wheelchair use has received increasing attention
(Kikens et al., 2003). Manual wheelchair skills assess-
ment (Mortenson, Miller, & Auger, 2008; Fliess-Douer et
al., 2010) has received the greatest attention, and overall,
increasing emphasis is also being place on participation
(Kikens et al., 2005).
Manual wheelchair users can benet from instruction
about propelling, braking, and transport. Hand placement
and trunk lean for effective and efcient wheeling can be
explored. General consumer use guidelines are available
for the user and trainer (Axelson et al., 1998). Power wheel-
chair users also need guidance about power functions
such as controllers, batteries, and accessory devices. With
all wheelchair users, the therapist should provide initial
checks; periodic follow-up to address safety issues, t, and
adjustment; and updated information about new options
to meet the changing needs of the user.
Transportability of the wheelchair system between
environments can be especially challenging. Loading and
unloading should be trialed with the vehicle most likely
to be used. As noted, car transfers of the user and loading
and unloading of the wheelchair need careful planning.
Breakdown of the wheelchair for portability or the addi-
tion of special lift accessories to vehicles should be consid-
ered during selection. The weight of the wheelchair and its
component parts may be limiting to users as well as care
providers who assist with vehicle transfers. Lifts are often
used with vans or buses. In these vehicles, wheelchair tie-
downs are necessary as safety mechanisms to keep chairs
stabilized when traveling. The necessary style may be de-
termined by wheelchair design. Such devices secure the
wheelchair to the base of the vehicle; the individual is in-
dependently secured in the wheelchair seat or in another
seating device within the vehicle.
WHEELED MOBILITY AND PARTICIPATION
As part of the wheelchair selection process, the impact
of devices on the users’ roles and participation needs to
be considered relative to home, work, and community
contexts. User roles and social interactions have implica-
tions for positioning, speed of mobility, and ease of access
within and between settings. For example, wheeling may
necessitate using different routes of travel to gain access,
and this may detract from user’s or other’s feelings of
inclusion. Speed of mobility may hinder shopping trips
within and between stores or with movements at work.
Armrest or other features of the wheelchair may preclude
positioning with peers at dinner or meeting room tables.
Professional rating tools that address needs (Miller et al.,
2004) and consumer rating tools that address satisfaction
with wheeled mobility devices are being proposed and ad-
dress issues and interactions between the person, the tech-
nology, and the environment (Mills et al., 2002).
Greater success in matching devices with environ-
ments of participation is needed. Although wheelchair
mobility can lead to successful independence, challenges
continue regarding integration of wheelchair users in
various settings. For example, data on disability and
workplace accommodation (http://www.infouse.com/
disabilitydata/workdisability/2_1.php) reveal that less
than 25% of wheelchair users are employed. Studies in-
volving wheelchair users often indicate that obstacles
created by use of wheeled mobility devices are seen as a
major reason for lack of community participation and as
Radomski_Chapter17.indd 514 7/11/13 2:39 AM

Chapter 17 Wheelchair Selection
515
a source of frustration (Chaves et al., 2004; Hoenig et al.,
2003). Nevertheless, use of wheelchairs, and powered mo-
bility devices in particular, is often credited with enhanc-
ing occupational performance and participation (Buning,
Angelo, & Schmeler, 2001; Davies, DeSouza, & Frank,
2003). Although the built environment is a major reason
for obstacles, attention also should be given to associated
factors such as wheelchair user tness and health, use of
assistants and other assistive technologies, social interac-
tions in the community, and the natural environment’s
weather conditions.
FINAL DETERMINATION
In making a nal determination regarding seating com-
ponents, style, size, and control systems, the user and
team take a comprehensive and functional view, simulta-
neously considering the current and future needs, desires,
and resources of the user; environments of participation;
and anticipated changes in technology. This can certainly
be a challenge in matching a client’s current needs with a
wheelchair mobility system, as well as forecasting future
needs in the weeks and months and years ahead in terms
of independence, participation, and well-being.
Decision Making and Justication
Costs and related funding issues are critical components
of the decision-making process. Expensive technology and
options should not be ordered unless justiable for in-
creased function, health, user satisfaction, or safety. When
expensive choices are being considered, it is important to
rule out the feasibility of using less costly alternatives. For
example, before selecting power mobility, it is important
to rule out the feasibility of using a manual chair because
the cost of providing and maintaining a powered system
may be much more costly than getting and using a man-
ual system. In such cases, appropriate justication must
be clearly delineated for users and third-party payers.
Some users decide to purchase devices or features on their
own or seek funding through other sources.
A comprehensive functional mobility system for an in-
dividual often includes more than one means of mobility
and selective use in different environments (Hoenig et al.,
2002). For example, an individual may use limited walking
skills within some settings (e.g., walking from the kitchen
table to the refrigerator); benet from a manual chair for
traveling longer distances within indoor environments
(e.g., moving from room to room within the home); and
use a power chair for traveling longer distances in the com-
munity and at school or work. Funding sources will typi-
cally pay for only one of these options, but with mobility
being unique to different activities, negotiation of options
may be explored with health insurance providers as well
as educational and vocational support programs. In many
cases, the expected term of use for a wheelchair by medical
insurance funding policies is 5 years, although expected
uses and benets for that period of time may be difcult
to predict. Private pay for assistive technology, including
wheelchairs, is common (Carlson & Ehrlich, 2006).
The Clinician’s Responsibilities
Therapists have a responsibility to keep abreast of new
technology, new products, and new product evaluation
research. They must be able to provide users with appro-
priate and updated information on the advantages and
disadvantages of wheelchair options and components. In
addition, they must have current knowledge of issues re-
lated to availability, serviceability, and performance of var-
ious wheelchairs and options. Professional and consumer
sources of information about wheelchairs, related options,
and manufacturers of mobility systems, controls, and
seating systems are useful for product information (see
Resources 17-1). Therapists also are encouraged to explore
wheelchair standards developed by the American National
Standards Institute (ANSI), the Rehabilitation Engineer-
ing and Assistive Technology Society of North America
(RESNA), and the International Standards Organization
(ISO) (http://www.wheelchairstandards.pitt.edu/). These
voluntary standards for wheelchair developers and man-
ufacturers provide guidelines for product specications
based on uniform measurements and testing. Use of these
standards facilitates product comparisons. In addition to
being aware of wheelchair standards, the therapist also is
responsible, along with the interdisciplinary team, for de-
veloping relationships with appropriate vendors of seat-
ing and wheelchair systems.
Wheelchairs, selected through a user-led team, can fa-
cilitate participation in multiple environments. Selection
of an appropriate wheelchair system results from a clin-
ical reasoning process that considers multiple variables,
particularly best t, function, and the user’s preferences.
Consumers’ satisfaction with seating and mobility systems
can be incorporated in critical program evaluations that
address outcomes. Ragnarsson (1990) stated, “Ultimately,
the most important factor in the success of a wheelchair
prescription is the user’s total level of acceptance and sat-
isfaction with [the] chair as it combines looks, comfort,
and function” (p. 8).
AQ2
Radomski_Chapter17.indd 515 7/11/13 2:39 AM

Section IV Therapeutic Technologies
516
case example
Ms. Lisa: Wheelchair Selection for a Student Who Has Tetraplegia
Clinical Reasoning Process
Occupational Therapy Intervention Process Objectives Examples of Therapist’s Internal Dialogue
Patient Information
Lisa is a 17-year-old high school senior with C7-level
tetraplegia from a traumatic spinal cord injury (SCI) that she
experienced in an automobile crash. She is expected to be a
long-term wheelchair user. In the hospital, she demonstrates
the ability to propel a manual ultralight wheelchair using
coated push rims. Lisa previously was active in soccer and
other sports and would like to match her school colors with
her wheelchair frame. She was intrigued to learn about
competitive wheelchair sports but is inexperienced with
independent mobility.
Appreciate the
context
Develop
intervention
hypotheses
Consider the
evidence
Select an
intervention
approach
Reflect on
competence
See Chapter 38 for a review of spinal cord injury
rehabilitation.
“Lisa may not endorse her need for long-term use of
a wheelchair but may agree to the interim reality and
specific wheelchair choices related to return to home and
school.”
“Based on prior experiences with this level of SCI and
supported by literature regarding manual versus power
mobility uses with SCI (Hastings et al., 2011) and skills
obtained with manual wheelchair uses (Lemay et al., 2012).”
“Ultralight wheelchair styles have good longevity and can
be customized in various ways for her size and needs. A
vendor and options for wheelchair choices from such a
vendor should be introduced to Lisa and her family.”
“A rehabilitative approach matches her adaptive capacities
and skills with training for use of appropriate assistive
technology, environmental accommodations, and care
providers.”
“My own knowledge of wheelchair needs is strong, but my
awareness of currently available products will be augmented
through the vendor and product representatives. Accessibility
needs at home, in school, and in the community will need to
be explored specifically for Lisa and her support network.”
Recommendations
The care team is preparing a wheelchair prescription and
considering these features:
Wheelchair
• Manualultralightcross-bracefoldingframe
• Purpleframewithblackupholstery
• Adjustableaxlepositionwithcambercontrol
• Lift-offdesk-lengthtubulararmrests
• Swing-awayfixed-anglefootrestswithheelloopson
flip-up foot plates
• Vinyl-coatedpushrimswithpneumatictiresand
nonpneumatic front casters
• Gradeaidsandstandardrubber-coatedbrakelevers
Seating
• Cloth-coveredJayseatcushionwithflexibleslingback,
midscapular height
• Seatbeltandcheststrap
Consider
the patient’s
appraisal of
performance
Consider what
will occur in
therapy, how
often, and for
how long
Ascertain
the patient’s
endorsement of
plan
“Lisa may regard the wheelchair as a short-term versus
a long-term strategy but seems interested in resuming
independent mobility, as seen in her use of a loaner
wheelchair. Helping her learn about customization of size,
cushioning, colors, and other features may encourage her
use of the wheelchair.”
“Her new wheelchair may not be available until after
inpatient hospital discharge.”
“Options to review with her for selection of chair include
frame type, cushioning, arm and leg rest features, frame and
upholstery color, and a variety of hand rim and brake features.”
“Gelcushionisencouragedforsittingbalanceandpressure
relief. Air demonstrated good pressure relief but can impair
sitting balance and necessitates tending to air pressure.
Foam or silicone have less even pressure distribution but
are lighter weight and do not need regular maintenance.
Gelhastheprecautionofcooling/freezingwithlowoutdoor
temperature and could puncture and leak.”
AQ12
AQ13
Radomski_Chapter17.indd 516 7/11/13 2:39 AM

Chapter 17 Wheelchair Selection
517
Summary of Short-Term Goals and Progress
A loaner rehabilitation wheelchair has been provided to Lisa,
and she makes use of this self-propelled device to go to
and from therapy and other appointments. When she is with
visitors, she is often pushed to other locations on the hospital
campus.
Sitting tolerance times have been increasing daily with
skin inspection performed by Lisa with nursing or therapy
supervision and guidance. Sitting tolerance and travel
distances are being staggered and staged to increase
time and range of mobility. By discharge, up to 6 hours of
wheelchair time is expected before bed-rest relief. Indoor
mobility independence is expected, including use of doorways
and elevators. Outdoor mobility is supervised initially to assure
safety with ramps, curb cuts, and cross-slopes.
Wheelchair-to-bed transfer training is proceeding with use
of a lightweight sliding board and standby supervision for
safety. Toilet and tub transfer skills are being introduced, and
she currently receives moderate assistance. Independence
in wheelchair transfers is expected with standby supervision
anticipated.
Assess the
patient’s
and family’s
comprehension
Understand what
the patient is
doing
Compare actual
to expected
performance
Know the person
Appreciate the
context
“Trial use of a loaner wheelchair has Lisa experiencing
transfers, self-propulsion, and environmental access on
hospital grounds. She is taking responsibility to go to and
from therapy sessions but is seen being pushed by family
and friends at other times.”
“Staging of wheelchair sitting time is scheduled, and Lisa
seems willing to observe this precaution and is accepting
of reminders to attempt pressure relief routines. She does
not appear to attend to time of day on a regular basis, so
she will likely need an external cue of some sort.”
“Lisa monitors her progress carefully in both occupational
and physical therapy with high hopes of regaining strength.
Nevertheless, she also is aware of her functional mobility
and capacity to self-propel and transfer.”
“Self-initiated goals for functional mobility in and around the
hospital campus are being suggested by her. These are being
encouraged with use of appropriate standby supervision.”
Next Steps
Lisa will be using the wheelchair full time at home, at school,
and in other community locations. Her own wheelchair is
being ordered and will be available at discharge or soon after
her return home. Accessibility at home and school need to be
assessed with Lisa and her family.
Loading her wheelchair into a personal vehicle as well
as public transportation need to be considered. Driver’s
retraining with adaptive hand controls also is being explored.
Anticipate present
and future patient
concerns
Analyze patient’s
comprehension
Decide if patient
should continue
or discontinue
therapyand/
or return in the
future
Determine what
referrals may
be needed to
appropriate
community-based
services for
advice regarding
community
mobility and driving
“Lisa has become aware and has concerns about
accessibility at home and school, where stairs are an issue
to enter and move between levels.”
“An accessibility audit of home and school through
interview will be conducted, and a home visit with Lisa and
family members is anticipated before inpatient discharge.
School access may be appraised in conjunction with the
school therapist.”
“Lisa continues to hope that she will again be able to walk,
but as weeks progress, she has focused increasingly on
her wheelchair skills.”
“Referral to and follow-along in community-based therapy
or outpatient visits to the SCI program are anticipated.
Goalswillbesafemobility;communitytransportation;and
full participation in school, work, and community settings.
Consideration for airline travel and sports participation
might be anticipated in coming years.”
Wheelchair Selection with a Student Who Has Tetraplegia
What else should be considered related to wheelchair selec-
tion and mobility training with Lisa? Consider uses of wheel-
chair accessories, capacity to carry items, performance in
transfers, transportation with the wheelchair, and mainte-
nance of the wheelchair. Under what circumstances might
power mobility be considered?
Clinical Reasoning in Occupational Therapy Practice
Radomski_Chapter17.indd 517 7/11/13 2:39 AM

Section IV Therapeutic Technologies
518
case example
Mr. R.: Dependent Mobility with Amyotrophic Lateral Sclerosis
Clinical Reasoning Process
Occupational Therapy Intervention Process Objectives Examples of Therapist’s Internal Dialogue
Patient Information
Mr. R. is a 48-year-old husband and father with amyotrophic
lateral sclerosis (ALS). He is near the end of his ability to
walk safely and has quit driving a car. He teaches in a
public school and expects to retire at the end of the month.
He coaches his children’s youth baseball teams. He lacks
sufficient strength in his arms to self-propel a wheelchair.
To address his needs now for mobility at home, at work, and
in the community, a prescription for a wheelchair is being
written. Family financial resources are limited.
Appreciate the
context
Develop
intervention
hypotheses
Consider the
evidence
Select an
intervention
approach
Reflect on
competence
See related assessment and intervention in Chapter35
regarding adults with neurodegenerative disorders.
“Power wheelchair prescriptions for those with ALS appear
to address needs (Ward et al., 2010), yet a full spectrum
of equipment and devices is likely needed in the latter half
this disease process (Bromberg et al., 2010 ).”
“Mr. R.’s walking difficulty with upper limb weakness will
necessitatepowerwheelchairmobilityand/ordependent
wheelchair use. Use of power mobility in homes is
problematic for maneuverability and will likely necessitate
a dependent wheelchair for function and care.”
“Medicare funding would address wheeled mobility for at-
home use and perhaps transportation to and from medical
appointments. Other community mobility needs should be
addressed separately.”
“A rehabilitative approach will attempt to match devices
and environments with abilities to address Mr. R.’s family
goals. Wheelchair use will take place along with uses of
other assistive devices and environmental accommodations
planned for home.”
“As a therapist, I am familiar with dependent mobility
devices and need to carefully match size and adjustment
options for the client’s home environment. Loaner
equipment or used devices are sometimes preferred
for cost savings. The ALS Association or other assistive
technology recycling programs could be explored.”
Recommendations
To address needs within the home, an attendant-propelled
wheelchair is needed. A tilt-in-space manual chair that
permits full upright position to 45° recline is selected, along
with a foam seat cushion and flexible sling back with a
winged headrest. A lap tray is added to enable positioning
of the arms and for attachment of communication devices.
This chair is requested through health insurance, and once
Mr. R. is unable to walk safely, it will be used at home and for
attending medical appointments. Community mobility may
be served by this device, but other options will need to be
explored as well.
Consider
the patient’s
appraisal of
performance
Consider what will
occur in therapy,
how often, and for
how long
Ascertain
the patient’s
endorsement of
plan
“Mr. R. is knowledgeable about his condition but is
reluctant to give up walking. Presenting the wheelchair as
an option rather than an exclusive device for mobility might
be best.”
“Selecting, fitting, and brief training are specifically needed
with the wheelchair device. Operation of brakes, recline
mechanism, and other features should be reviewed with
Mr. R. and his care providers.”
“Mr. R. is in agreement but views the wheelchair as being a
further indicator of his decline.”
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AQ15
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Chapter 17 Wheelchair Selection
519
Selection of Other Mobility Options
Mr. R. and his family also recognize his need for functional
mobility outside of the home. His extended family are discuss-
ing pooling resources to purchase another mobility device
he can use outdoors for coaching baseball, shopping, and
other activities. Given the progressive decline expected with
ALS, what might you suggest in terms of powered mobility?
What kind of comprehensive mobility system would you rec-
ommend, and why, if nancial resources were not an issue?
Clinical Reasoning in Occupational Therapy Practice
Summary of Short-Term Goals and Progress
Mr. R. needs consumer education about wheelchair products
and options that he could use. Funding mechanisms need
careful review in terms of requirements, dollar allowances,
and costs of options.
Client and family training in use of the wheelchair is a
service goal, with Mr. R. having informed options about
wheelchair use and the family’s community mobility with
wheeled mobility devices.
Assess the
patient’s
comprehension
Understand what
the patient is
doing
Compare actual
to expected
performance
Know the person
Appreciate the
context
“Mr. R. recognizes his mobility needs and is aware of and
concerned about costs and access within his home, such
as installation of ramps and widening of doorways.”
“Adjustable cushioning for comfort and function should be
devised. Foam cushions are likely the most cost-effective
and flexible option, both for seating and transport. He
will likely adjust his position easily on his own at first.
With more static seating later on, air cushioning could
be considered. This will then necessitate adjustment and
tendingofthecushionrelativetoairpressure.Gelcushions
could be considered, but they are heavy and may make Mr.
R.’s own adjustment of his position more challenging.”
“Resting and functional settings at home are likely to
include his bed, wheelchair, and another chair or couch
location. Transfer training with family care providers should
take place soon.”
Next Steps
Mr. R. obtains and uses the mobility devices, which appear to
meet his present needs. Occupational therapy is put on hold,
with plans for reassessment in 6 weeks.
Anticipate present
and future patient
concerns
Decide if patient
should continue
or discontinue
therapyand/
or return in the
future
“Monitoring of wheelchair operation and use, along with
other assistive devices, should occur as part of outpatient
follow-up, perhaps every 6 weeks depending on the speed
of Mr. R.’s decline. Coordination with home-health or
hospice care also may be considered.”
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Section IV Therapeutic Technologies
520
Summary Review Questions
1. Who should participate in the wheelchair selection
process?
2. What are the three basic types of wheelchairs, and why
would each be selected?
3. What factors should be taken into consideration in
wheelchair selection and use by children, adults, and
older adults?
4. Describe a situation in which the optimal decision for
an individual might involve the selection of more than
one mobility device.
5. What are the six broad goals of wheelchair seating and
positioning?
6. In determining wheelchair and related seating system
sizes for a particular individual, what measurements
typically are taken?
7. Contrast the benets and limitations of various
manual and power mobility frame types.
8. Name and describe two types of controls for power
mobility devices. Which would be preferable for a
person with cerebral palsy and extremely poor upper
extremity control? Why?
9. How can an occupational therapist keep abreast of
new product development and research related to
these products?
10. How can the occupational therapist facilitate the cli-
ent’s participation in wheelchair selection?
Glossary
Angle in space—Angle of the seat back in relation to the
true vertical when the seat and back are rotated counter-
clockwise as a unit. Sometimes called tilt-in-space or ori-
entation, this position may be altered for postural control.
Camber—The amount of angle on the wheels, creating
are-out at the bottom. A 6° camber is recommended for
push-rim convenience and wheelchair width.
Locking lever–secured—A locking mechanism on the
frame that holds folding frame parts in place for smoother
ride with less frame migration and reduced wheel and
caster utter.
Pelvic rotation— Asymmetrical position of the pelvis
with forward position of one side, typically because of low
back rotation, muscle asymmetry, or spinal deformity.
Proximity-sensing devices—Devices or systems that
remotely sense the position of a body part (e.g., head)
and use that position to control the wheelchair without
physical contact between the part of the body used for
control and the switch.
Scanning—Control option that presents choices one at a
time, grouped or singly, until the desired choice is offered
for the user to select by switch activation.
Seat-back angle—The angle of the seat surface relative to
the back surface. This angle is typically 90°–100°. Backrest
angles and seat-plane angles may be designated separately.
Sip and puff—A system typically involving a dual-action
switch, in which one action is controlled by the user sip-
ping on a tube held in the mouth and the second action is
controlled by pufng on the same tube. (In wheelchair op-
eration, the chair functions can be controlled by patterns
of switch closures.)
Third-party payer—Individual or organization (i.e., in-
surance company) other than the person receiving services
that pays for services or equipment.
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Chapter 17 Wheelchair Selection
521
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Section IV Therapeutic Technologies
522
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Acknowledgements
We thank and acknowledge clinicians from the University
of Washington Medicine Systems for contributing their
knowledge and expertise.
Ward, A. L., Sanjak, M., Duffy, K, Bravver, E., Williams, N., Nichols, M.,
& Brooks, B. R. (2010). Power wheelchair prescription, utilization,
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Rehabilitation Research and Development: Clinical Supplement, 2, 74–85.
Suggested Readings
Batavia, M. (2010). The wheelchair evaluation: A clinician’s guide (2nd ed.).
Sudbery, MA: Jones and Bartlett Publishers.
Radomski_Chapter17.indd 522 7/11/13 2:39 AM

QUERIES:
AQ1: Reference citation style for the book has been decided as using "et al." for sources with four or more authors.
AQ2: Abbreviation ISO is used only once in this chapter. Should it remain?
AQ3: Please note that reference style for the book does not abbreviate the journal titles. If any of the titles are missing
words, please insert them.
AQ4: Please verify that there is no space in "VanSickle"
AQ5: Please cite this reference in the text.
AQ6: Please provide the complete author list.
AQ7: Please provide the article title.
AQ8: "V" and "D" in "van der Woude" made lowercase to be consistent. Please verify.
AQ9 Please verify journal title.
AQ10: If possible, please provide the volume and page numbers.
AQ11: Please verify URLs for "Paraplegia News & Sports ’N Spokes" and "Paralyzed Veterans of America"
AQ12: Please verify reference to Chapter 38.
AQ13: Please complete this thought: "Based on experience and supported by literature ..." [I plan to] or [I believe that
Lisa will...]
AQ14: Please verify reference to Chapter 35.
AQ15: Year of publication for Bromberg et al. changed to match reference list. Please verify.
Radomski_Chapter17.indd 1 7/11/13 2:39 AM