Content uploaded by Nuttaset Manimmanakorn
Author content
All content in this area was uploaded by Nuttaset Manimmanakorn on Oct 19, 2017
Content may be subject to copyright.
1
Asia-Pacific Journal of Science and Technology: Volume: 22. Issue: 03. Article ID.: APST-22-03-05. Research Article
Asia-Pacific Journal of Science and Technology
https://www.tci-thaijo.org/index.php/APST/index
Published by the Research and Technology Transfer Affairs Division,
Khon Kaen University, Thailand
Manual WheelchairLongevity and Related Factors among Spinal Cord Lesion Patients
Panya Ngamwongsa-nguan1, Preeda Arayawichanon1, Nuttaset Manimmanakorn1,*
1Department of Rehabilitation Medicine, Faculty of Medicine, KhonKaen University
*Correspondent author: natman@kku.ac.th
Received January 2016
Accepted June 2016
Abstract
The wheelchair is an essential mobility tool for paraplegic or tetraplegic patients. The wheelchair longevity and
related factors among spinal cord lesion patients in Thailand has not been reported. The objectives of the current
study were to determine the longevity of manual wheelchairs and the related factors amongspinal cord lesion
patients. Spinal cord lesion patients who received treatment at the In-and/or Out-patient Rehabilitation Medicine
Department were interviewed for demographic data and factors related to wheelchair use. Data were analyzed for
means, medians, and negative and positive factors related to wheelchair usage and life expectancy. Sixty patients
were included in the study. The respective mean and median manual wheelchair lifetime was 4 years and 4 months
(52.3 ± 28.7 months) and 4 years. Most participants required their first wheelchair repair within the first 2 years.
Survival analysis revealed that after 4 years of use, 50% of wheelchairs were still functioning. The negative factor
significantly affecting lifetime was navigating the wheelchair on a lawn (p = 0.003) while the positive factor was
navigating on smooth concrete (p = 0.006). Participants who navigated the wheelchair on a lawn surface had
greater chance of getting early wheelchair replacement.
Keywords: wheelchair, broken, repair, wheelchair lifetime, spinal cord lesion patients
1. Introduction
The wheelchair is an important mobility aid for
disabled patients. In 2014, 6.8 million Americans used
an assistive device for mobility, of which 1.7 million
used a wheelchair or scooter [1]. Spinal cord lesion
(paraplegia and quadriplegia) is the leading disorder
among those between 18 and 64 years of age needing
a wheelchair or scooter [1]. The number of spinal cord
injury patients in the USA in 2014 was 240,000 and
< 1% have full recovery at discharge from hospital [2].
McClure et al. (2009) reported that 70% of patients
with such an injury used a wheelchair [3].
There are many types of wheelchairs, including the
manual and electrical wheelchair. The majority of
patients (90%) who depended on wheelchairs or
scooters used a manual wheelchair, particularly those
living in a low family income [1]. The durability of a
wheelchair is influenced by how it is used and the
quality of manufacture. Chen et al. and Oyster et al.
determined that the factors affecting performance,
breakage and accidents were: (i) personal factors (i.e.,
body weight, level of spinal cord injuries, duration of
daily use, characteristic of use, maintenance, career,
duration of disease); (ii) environmental factors (i.e.,
type of surface); and, (iii) wheelchair factors (i.e.,
brand, type, material composition) [4-5].
In Thailand, the 2012 National Disability Survey
revealed that the number of disabled persons was 1.48
million or 2.0 percent of the population [6]. One-third
(34.4%) had difficulty walking and 11.8% could not
walk at all [6]. Patients who could not ambulate and
required a wheelchair was about 600,000 persons.
Most wheelchair users in the younger group were
paraplegics or tetraplegics requiring a wheelchair for
independence and the majority used a manual standard
wheelchair just as in developed countries.
The aims of this study were to determine (a) the
average lifespan of a manual standard wheelchair and
(b) the related factors affecting the longevity of manual
wheelchairs used by the patients with spinal cord
disorders. The benefits of this study are to provide (a)
evidence-based recommendations to the Thai
government on the timing of subsidies to replace
2
broken wheelchairs, and (b) information to wheelchair
users on the proper operation and maintenance of a
wheelchair.
2. Materials and Methods
This study included spinal cord disorder patients
between 18 and 70 years of age who required a
wheelchair. All patients received treatment from the
Department of Rehabilitation Medicine, KhonKaen
University between November 1, 2012 and September
30, 2013. The patients had all used at least one
wheelchair until it failed.
The patients gave written informed consent before
entering the study. The included patients were
interviewed and recorded their (a) demographic data,
(b) level and severity of spinal cord disorders, (c)
duration of wheelchair usage (the duration from start
using a new wheelchair until stop using due to
wheelchair broken and unrepairable), and (d) related
factors (i.e., frequency of use, activities, maintenance
program and breakage). The patients who changed the
wheelchair from other reasons before the wheelchairs
were broken,non-communicative patients or patients
with complications that obviated wheelchair use (i.e.,
having pressure sores) were excluded. The Human
Ethics Committee of KhonKaen University
(HE561422) approved the study protocol.
Descriptive statistics for the lifetime of each
wheelchair were calculated, including: means,
standard deviations (mean±SD) and median. A
univariate analysis for related factors (continuous
data) was done using an ANOVA, while the
categorical data were analyzed using the Wilcoxon-
Mann-Whitney test and the Kruskal-Wallis test. A
multivariate analysis was performed using multiple
linear regression. The probability of wheelchair
survival (long-term durability/usage) was reported
using a Kaplan-Meier survival curve. Statistical
analyses were conducted using STATA version 10.
The p-value was accepted at < 0.05.
3. Results
The data were collected from the interviews of 60
patients (48 males and 12 females; 50 paraplegics, 10
tetraplegics; average age 40.1±10.3 years, BMI
21.6±4.5 kg·m-1). Lesions included 9 cervical, 42
thoracic and 9 lumbar. The respective severity of
disability was: 32 ASIA A, 16 ASIA B, 9 ASIA C and
ASIA D (ASIA stand forThe American Spinal Injury
Association Impairment Scale). The causes of spinal
cord injury included: accident (n=43), spinal cord
tumor (n=4), degenerative spine (n=1), and other
medical conditions (n=12). The cost of treatment was
paid by: Universal Health Care Scheme (n=42), Social
Security Scheme (n=16) and Civil Servants Medical
Benefits Scheme (n=2). Thirty-three patients were
able to maintain their job while using a wheelchair.
The baseline data are presented in Tables 1 and 2.
Table 1 Patient characteristics
Characteristic
N = 60 (%)
Sex
Male
Female
48 (80)
12 (20)
Age (years)
Mean
40.06±10.32
BMI (kg·m-2)
Mean
21.6±4.5
Cause
Trauma
Medical disease
Spinal cord tumor
Degenerative disease
43 (71.7)
12 (20)
4 (6.7)
1 (1.7)
Type of disability
Paraplegia
Quadriplegia
50 (83.3)
10 (16.7)
Neurological level
Cervical
Thoracic
Lumbar
9 (15)
42 (70)
9 (15)
3
Table 1 Patient characteristics(Continue)
Characteristic
N = 60 (%)
ASIA classification
ASIA A
ASIA B
ASIA C
ASIA D
Unknown
32 (53.3)
16 (26.7)
9 (15)
1 (1.7)
2 (3.3)
Comorbidity
Asthma
Diabetes
Hepatitis
Hypertension
Thalassemia
Valvular heart disease
No underlying disease
1 (1.7)
4 (6.7)
1 (1.7)
2 (3.3)
1 (1.7)
1 (1.7)
50 (83.3)
Occupation
No
Self-employed
Government service
Freelance
Agriculture
Student
27 (45)
2 (3.3)
9 (15)
17 (28.3)
3 (5)
2 (3.3)
Sponsorship
Universal Health Care Scheme
Social Security Scheme
Civil Servants Medical Benefits Scheme
42 (70)
16 (26.7)
2 (3.3)
Broken part
Handles
Backrest
Armrests
Frame
Clothing guards
Seat cushion
Heel loop
Brakes
Foot plates
Casters
Caster housings
Push rims
Rear wheel
Rear wheel housing
Tyres
Pneumatic tyres
1 (0.4)
14 (5.4)
25 (9.6)
15 (5.8)
6 (2.3)
24 (9.2)
8 (3.1)
38 (14.6)
22 (8.3)
10 (3.8)
42 (16.1)
10 (3.8)
8 (3.1)
4 (1.5)
21 (8.0)
13 (5.0)
What happen after broken wheelchair?
Self-payment for new wheelchair
Continue using broken wheelchair
Stop using broken wheelchair
Received new wheelchair from government (broken after 5
years)
8 (12.3)
26 (40)
4 (6.2)
22 (36.7)
4
Table 2. Wheelchair use and repair characteristics
Characteristic
Number (%)
Floor
Concrete
Lawn
Sand
Impacted soil
Gravel
Tile
45 (36.3)
11 (8.9)
13 (10.5)
6 (4.8)
25 (20.2)
24 (19.4)
Independent
Dependent
58 (96.7)
2 (3.3)
Activity
Community (≥50 m)
Household
Using during shower
Sports and exercise
38 (26.0)
55 (37.7)
24 (16.4)
14 (9.6)
Cause
Accident
Deliberately damage
Stolen
Not specified
8 (13.3)
1 (1.7)
1 (1.7)
50 (83.3)
Maintenance program
Check up
First repaired
Never
< 6 months
6-12 months
1-2 years
>2 years
Method of repair
Owner
Bicycle shop
Dealer
Hospital
2 (3.3)
16 (26.7)
7 (11.7)
8 (13.3)
22 (36.7)
7 (11.7)
35 (40.2)
14 (16.1)
0 (0)
20 (23.0)
The average wheelchair lifetime was 4.3±2.4 years
(median, 4 years). Daily use averaged 7.4±5.0 h/day.
The types of floor on which the wheelchair was used
included smooth concrete floors (36.3%), compacted
soil (4.8%), lawn (8.9%), sand (10.5%), gravel
(20.2%), and tile (19.4%). Most (96.7%) of the
patients operated their wheelchair for independent
mobility. Community navigation (> 50 m) was 26.0%
vs. 37.7% who had only household use. Sport activity
and taking a shower both accounted for 16.4% of use.
The causes of damage were accidental (13.3%),
deliberate or someone broke (1.7%), vandalism (parts
stolen) (1.7%) and non-specified from routine use
(83.3%). The most common broken parts were the
front wheel bearing (16.1%), brakes (14.6%), arm rests
(9.6%), seat (9.2%), foot rest (11.4%), tyres (13.4%),
metal frame (8.1%), back rest (5.6%), front wheel
(3.8%), rear wheel (3.1%) and rear wheel bearings
(1.5%). Broken wheelchairs were repaired by: (a) the
owner (40.2%), (b) a bicycle shop (16.1%), or (c) a
hospital (23.0%): none was repaired by a wheelchair
dealer.
One-third (36%) of wheelchairs were broken
within 2 years. A large number (40%) of patients with
5
a broken wheelchair did not receive support for a new
wheelchair. Factor analysis revealed the negative
factor limiting wheelchair lifetime was handling it on
lawns (p = 0.003, 95%CI -44.32 to -9.57) while the
positive factor was handling on smooth concrete (p =
0.006, 6.12 to 35.02). Body weight, level of injury,
usage per day, occupation, duration of disease and
brand of wheelchair had no significant impact.
Survival analysis revealed that 50% of wheelchairs
had a 4-year life expectancy
, 62% were not working after 4.3 years (on the
average wheelchair lifetime), and 70% of wheelchairs
were broken by 5 years (Figure 1).
Figure 1. Survival analysis of wheelchair lifetime (a = 50% of patients without broken wheelchair at 48
months; b = 38% of patients without broken wheelchair at 52 months; c = 30% of patients without broken
wheelchair at 60 months).
4. Discussion
The study revealed the median wheelchair lifespan
was 4 years, while the average was 4.3±2.4 years.
Survival analysis showed that 50% of wheelchairs
were working for the median and 38% for the average
lifetime. The significant beneficial factor was driving
on smooth concrete and the harmful factor was driving
on lawn.
Survival analysis revealed that 50% of wheelchairs
had a 4-year lifetime, which means that half of the
patients suffered from limitations to community
mobility after 4 years if they were unable to afford a
new wheelchair. If they continued to use a broken
wheelchair, accident or injury was a real possibility.
Patients who have broken wheelchair should receive a
replacement as soon as possible; however, this is not
always feasible in developing countries where budgets
are limited. This study, therefore, suggested the most
appropriate time for the government to subsidize a new
wheelchair (replace a broken one) should be after not
more than 4 years of use.
The current study found that the type of surface
where the wheelchair was used affected its lifespan.
Use on smooth concrete lengthened wheelchair
longevity, while use on lawn or earth shortened it.
Chen et al. (2011) confirmed that use of a wheelchair
on a rough or uneven surface was related to accidents
and damage [4]. Factors not significantly related to
wheelchair lifespan included body weight, level of
injury, occupation, duration of disease, and usage per
day. Sooksomporn and Poosiripinyo (2014) reported
that the greater the distance (>50 m/day), the more
potential for significant damage [7]. Stated otherwise,
the driving impact distance has more than duration of
use per day. Previous studies suggested that the type of
wheelchair (manual or power) and type of frame
(standard, lightweight or ultralight weight) are related
to lifespan [8-10]. All patients in the study used the
same standard, manual wheelchairs but different
brands. The study did not find any significant
difference among the different brands. The results
indicate wheelchair quality by manufacturer in
Thailand were comparable.
6
Our study, as with that of Sooksomporn and
Poosiripinyo [7], demonstrated that the commonly
broken parts were the wheel bearings and brakes.
Fitzgerald et al. (2005) found that the most commonly
broken part was the tyre, but they did not confirm the
finding of damage to the wheel bearings or brakes[11].
For the most part, our patients used the wheelchair for
indoor activities (37.7%). The brakes of the
wheelchair may frequently be used for short distance,
indoor activities. Patients need to be taught how to
operate and maintain a wheelchair correctly.
There are three systems of social welfare to support
new wheelchair in Thailand. The Civil Servants
Medical Benefits Scheme provides only one
wheelchair for lifetime. The Social Security Scheme
subsidizes new wheelchair for every 5 years. The
Universal Health Care Scheme currently supports new
wheelchair every 3 years. The results of this study
suggested that the Civil Servants Medical Benefits
Scheme and the Social Security Scheme should
support new wheelchair similar to the Universal
Health Care Scheme.
The limitation of the current study was the
generalizability of the results. We included only
patients in the rehabilitation program at Srinagarind
Hospital: the people are not necessarily representative.
Additionally, the data were collected through
interviews with potential for a recall bias.
5. Conclusion
The average lifespan of a wheelchair was 4.3±2.4
years: the median lifetime was 4 years. Since 50% of
wheelchairs were broken before 4 years, the
government should consider that the most appropriate
time for supporting a new wheelchair be not greater
than 4 years of use. Giving information such as how to
operate a wheelchair and using it on a smooth surface
are recommended for extending wheelchair life
expectancy.
6. Acknowledgement
This study was granted by Faculty of Medicine,
Khon Kaen University, Thailand (Grant Number
I57122). Special thanks to Dr. Kaewjai
Thepsuthammarat at the Clinical Epidemiology Unit,
Khon Kaen University for assistance with the
statistical analysis, and Mr. Bryan Roderick Hamman
for assistance with the English-language presentation.
7. References
[1] Kaye HS, Kang T, LaPlante MP. Mobility device
use in the United States. Disability Statistics
Report 14. 2000.
[2] National Spinal Cord Injury Statistical Center.
Facts and figures at a glance. Birmingham, AL:
University of Alabama at Birmingham; February
2014.
[3] McClure LA, Boninger ML, Oyster ML,
Williams S, Houlihan B, Lieberman JA, et al.
Wheelchair repairs, breakdown, and adverse
consequences for people with traumatic spinal
cord injury. Arch Phys Med Rehabil.
2009;90(12):2034-8.
[4] Chen WY, Jang Y, Wang JD, Huang WN, Chang
CC, Mao HF, et al. Wheelchair-related
accidents: relationship with wheelchair-using
behavior in active community wheelchair users.
Arch Phys Med Rehabil. 2011 ;92(6):892-8.
[5] Oyster ML, Karmarkar AM, Patrick M, Read
MS, Nicolini L, Boninger ML. Investigation of
factors associated with manual wheelchair
mobility in persons with spinal cord injury. Arch
Phys Med Rehabil. 2011;92(3):484-90.
[6] National Statistical Office of Thailand. The 2012
Disability Survey. Ministry of Information and
Communication Technology. [Cited 2015 March
29]. Available from: www.nso.go.th.
[7] Sooksomporn P, Poosiripinyo E. Common
broken components of wheelchairs used by
persons with disability. J Thai Rehabil Med.
2014;24(2):67-72.
[8] Cooper RA, Boninger ML, Rentschler A.
Evaluation of selected ultralight manual
wheelchairs using ANSI/RESNA standards.
Arch Phys Med Rehabil. 1999;80(4):462-7.
[9] Cooper RA, Gonzalez J, Lawrence B, Renschler
A, Boninger ML, VanSickle DP. Performance of
selected lightweight wheelchairs on
ANSI/RESNA tests. American National
Standards Institute-Rehabilitation Engineering
and Assistive Technology Society of North
America. Arch Phys Med Rehabil.
1997;78(10):1138-44.
[10] Wang H, Liu HY, Pearlman J, Cooper R, Jefferds
A, Connor S, et al. Relationship between
wheelchair durability and wheelchair type and
years of test. Disabil Rehabil Assist Technol.
2010;5(5):318-22.
[11] Fitzgerald SG, Collins DM, Cooper RA,
Tolerico M, Kelleher A, Hunt P, et al. Issues in
maintenance and repairs of wheelchairs: A pilot
study. J Rehabil Res Dev. 2005;42(6):853-62.
