TEchnical WC Flashcards
(127 cards)
1
Q
Minimum clear width for a wheelchair is
A
36 inches for a hall and 32 inches for a door
Minimum clear space for a T-shaped turn of 180 degrees is 36 inches in all directions.
The minimum passage width for one wheelchair and one ambulatory person is 48 inches
2
Q
PELVIS IN WC
obliquity
forward
back
A
Pelvic obliquity will lead to uneven weight bearing through ischial tuberosities and unequal WB: skin breakdown, increase energy cost of movement, compensation deformities: this
Pelvis can be rotated with one side more forward than the other
Excess anterior pelvic tilt: fall forward
Excess posterior pelvic tilt: fall backwards, sacral WBing
–Sacrum is superficial, want to WB on ITs
3
Q
Intrinsic factors that affect the pelvis:
A
i. Contractures
ii. Spasticity
iii. Diminished ROM
iv. Surgical stabilization
4
Q
Extrinsic factors that affect the pelvis:
A
i. Type of seat back
ii. Cushion type
iii. Positioning straps
iv. Seat angle (can be tilted backwards)
5
Q
Posterior Pelvic Tilt:
A
- Promotes spinal kyposis
- Sliding forward in seat
- Sacral WBIng
- Diminished UE function
- increase UE pain due to movement dysfunction
- Diminished thoracic space for air exchange
- Forward head
6
Q
What three positions to evaluate for sitting in wc: Observation the individual in three settings
A
1) Sitting in existing mobility system
how well does it address their needs
2) Short sitting on the mat with minimal external support
Effect of gravity on sitting
3) Supine on firm mat
Minimizes effect of gravity
Transition from sitting in current system to mat indicates effect of current seating system:
how well does it address their needs: if a bad system we can see what to change i.e. the foot rest, seat back angle, casters, etc
Sitting on the mat unsupported indicates response to gravity without the support
Supine testing eliminates (or minimizes effect of gravity)
7
Q
Fixed deformity: what to do in WC
A
A fixed deformity may worsen over time: Even if it is a limb not being used it can progress
They must be treated, even if that is only preventing from progressing
Accommodation must therefore take this into account
Prevent further deformity!!!
Even a fixed deformity can progress and get worse so they must be tx even if cannot reduce them we can prevent them from getting worse
8
Q
Mat Evaluation: how do these effect pelvic motion: We will evaluate:
A
1) Pelvis – A/P mobility
2) Pelvis Obliquity
3) Pelvis Rotation
4) Skin
5) LE’s hip flexion with stable pelvis
if pelvis is stable and we flex the hips or extend the knees with the hips flexed, movement of hip into abduction or adduction: what happens to the pelvis: we take this into account
6) Knee extension with hip flexed
7) Hip abduction / adduction / rotation
8) Ankle ROM
9
Q
Test Posterior pelvic mobility:
A
(B): knee to chest in SUPINE
Find his ASIS, knee up to chest
If pelvis starts moving at 90 degrees this is a concern
may hinder neutral pelvis when he is at 90 degrees
10
Q
Test Anterior pelvic mobility:
A
(to decide on cushioning and back)
both hands on pelvis and move into an anterior tilt in sitting
—Patient sits [palpate his ASIS and PSIS rock the pelvis to see pelvic mobility anteriorly and posteriorly]
Don’t stretch hamstring and low back but enough so person can get into a mild anterior pelvic tilt
11
Q
Test Pelvic Obliquity:
A
Purpose: is one side higher than the other?
- -Can affect ability to maintain a neutral position
- -can lead to scoliosis or uneven WBing
TEST:
thumb and web space of each hand on ASIS and iliac crest
If oblique: can patient correct? If yes flexible and if not then fixed
( ASIS with web space over iliac crests: note obliquity where one side is higher than the other: see if he has flexibility to bring it down this is a flexible pelvic obliquity, if we cannot it is a fixed pelvic obliquity)
12
Q
Hip Flexion Test to 90
A
Start with pelvis in good position
Can patient bring both hips to 90 without pelvic motion? If not lumbar lordosis will decrease
TEST: in pelvic neutral, palpate ASIS, flex contralateral hip. Check for pelvic motion prior to 90 degrees. Switch side and repeat. Excessive pelvic motion prior to 90 degrees predisposes to posterior pelvic tilt
(we did in supine when we did posterior pelvic mobility and then here it is against gravity)
13
Q
Hip Flexion with knees extended:
A
Purpose: determine if tight hamstring will effect pelvis positioning: can knees be extended without moving pelvis
TEST: in (best) pelvic neutral, palpate ASIS, flex hip (with knee flexed) to first point of pelvic motion, then extend knee to see if pelvis moves
Repeat test for ABDUCTION and ADDUCTION and IR and ER
(If patient has severe edema and bring up his leg rests it can bring him into posterior pelvic tilt)
14
Q
Ankle position:
A
If no neutral DF can lead to uneven foot weight bearing, excessive anterior tilt, feet sliding off footplates
15
Q
Sitting Measurements
A
Done in ideal posture
1) Width
2) Depth (popliteal to sacral spine)
3) Inferior angle of scapula / axilla to seat (seat back height)
4) Popliteal to heel
16
Q
Sitting Evaluation
what landmarks we measure (9)
A
1) Popliteal to calcaneus
2) Seat base to top of shoulder
3) Popliteal to sacrum
4) . ASIS to axilla
5) Seat base to axilla
6) . ASIS to seat base
7) . Across greater trochanters
8) . Axilla to axilla
9) . Xiphoid process to back base
17
Q
CASTERS
diameter
PRO CON of
Large
Small
Narrow
Wide
A
(the small wheels in the front of the chair)
Diameters: 3-8 inches
Larger Caster: better for uneven terrain,
Problem: requires more forward foot position
Smaller Caster: less roll resistance (good for sports), better turning,
Problem: shimmy: if going fast caster shake forward and back and lead to instability of the chair
Narrower Contact: easier mobility: less roll resistance,
Problem: increases vibration (wheel not dampen forces from the floor)
Wider contact: more stability
more roll resistance
18
Q
Larger Caster:
A
better for uneven terrain,
Problem: requires more forward foot position
19
Q
Smaller Caster:
A
less roll resistance (good for sports), better turning,
Problem: shimmy: if going fast caster shake forward and back and lead to instability of the chair
20
Q
Narrower Contact Caster:
A
easier mobility: less roll resistance,
Problem: increases vibration (wheel not dampen forces from the floor)
21
Q
Wider Contact Caster:
A
Wider contact: more stability
more roll resistance
22
Q
Rear Wheel
Large vs Small
A
Diameter: consider axle position and diameter to ensure good arc of push without excess joint motion
Large wheel size – in diameter and width more resistance but better for uneven terrain
Smaller wheel size-in diameter and width better for maneuvering (more mobility, less stability)
23
Q
Rear Wheel Material
A
- Aluminum spokes
- Mag Wheel
- Air tire
- Airless insert
- tread
24
Q
Rear Wheel: Aluminum spokes:
A
lightweight
some shock absorption
high maintenance
25
Rear Wheel: Mag Wheel
heavy
stable
low maintenance
26
Rear Wheel: Air Tire
good shock absorption
LOW PRESSURE: more air in tire at lower pressure gives good shock absorption
HIGH PRESSURE: less shock absorption but less roll resistance
note: the more shock that comes through the chair the person has to dissipate with energy and stabilize themselves in the chair, make them fatigue
27
Rear Wheel: Airless Insert
1. adds weight: a zero pressure tire or a ZPT
3. It will not go flat = low maintenance
3. No shock absorb
28
Rear Wheel: Tread
more tread adds
1. roll resistance
2. traction
----more tread has more resistance so want more for paths of unstable terrain and less on city streets, it adds traction
29
Armrests: (2)
1) T shaped Armrest: (not meant to support body weight and can erode) no armrests are designed for support full body weight
2) Flip back Armrest: less stable laterally, easier for rider to remove
30
Push handles:
what to consider (2)
con (1)
(other person pushes the chair with them)
1. Can be removable or fold down
2. Consider ease of reach if rider uses for hooking or stability
CON:
if seat to backrest angle is OBTUSE : interfere with ability to push
31
Upholstery
= SLING SEAT
advantages (3)
disadvantages (5)
the thing the person is sitting on: SLING SEAT:
Sling Seat Advantages:
1. cheap
2. lightweight
3. washable
Sling Seat Disadvantages:
1. stretches out
2. no support
3. sling Seat Leads to pelvic obliquity
4. LE internal rotation
5. excessive kyphosis
Address it: when patient is in a straight sling wheelchair, it bottoms out and can lead to deformities: if it is firm, then it has issue of being to hard
32
Seat Belt: 2 purposes
how is it positioned
what can you do with a seatbelt to prevent posterior pelvic tilt? anterior pelvic tilt
1. hold someone in
2. for positioning,
many patient don’t want a seatbelt . Pad to protect skin
Seatbelt is:
1) 45 degree angle to seat surface
2) over proximal thighs to decrease posterior pelvic tilt
To prevent Anterior Pelvic tilt****If person has excess anterior pelvic tilt
1) parallel to seat
2) over ASIS
33
Why do you need something between cushion and seat?
to keep its form: usually a wooden board, otherwise the cushion will take properties of a sling, want an insert about ¼ inch thick between the cushion and sling
consider material, weight, shape, depth, support, cost, hygiene etc
34
Pressure Mapping
cons (4)
cushion interface pressure mapping system: use for baseline/intervention comparisons
2. interface pressure is a static assessment: ulcers from shear force and pressure mapping doesn’t measure shear, just static
* **CONS of Pressure Mapping System:
1) it is a static measurement : measures interface pressure only, not shear, capillary pressure, or skin profusion
2) does not replace skin inspection, pressure relief,
3) not able to generalize
4) expensive
35
Purpose for cushion (3)
1. pressure relief
2. positioning
3. optimal amount of mobility and stability at the same time
36
Properties of cushion
1. load deflections
2. decrease forces on tissues
3. dissipate heat/moisture
4. allow for mobility
37
Load Deflection:
which ones are compressed?
which ones displace?
cushion can either compress under a load (foam, air) or displace under a load (gel or viscous fluid):
1. If it is a foam or air: can be compressed
2. If it is something that moves like gel or viscous fluid it can move
38
What happens if cushion is too stiff?
too soft?
cushion is too stiff: the cushion itself will be unstable if there is too much pressure—doesn’t hold them in place (doesn’t adjust to person sitting on it): no stability
too soft: will bottom out, difficult for user to move (ie in too soft a mattress hard to move around): no mobility
39
Types of Cushion Material: how they address stiffness of cushion
Foam
Gel
Air
Foam: different densities and heights of foam
Gel: viscosities and configurations
Air: increasing or decreasing amount of air
40
Cushion property: Force Redistribution: 2 methods
1) ENVELOPMENT: cushion envelops body part of the body that is in contact with the seating surface: want it to equalize across support surface
2) OFFLOADING: completely removing WB to the bony structures by cutting out the area: an area of skin breakdown that you don’t want to be in contact you cut out that section
41
Envelopment:
Requires X inches of immersion to encompass the buttocks
support surface conforms to the body: cushion envelops body part of the body that is in contact with the seating surface: want it to equalize across support surface
==>should equalize pressure to the entire support surface
FLAT cushions have to deflect more body weight than pre-contoured
Requires about TWO INCHES OF IMMERSION to encompass the buttocks because of inferior position of ischial tuberosity: person should sink in about 2inch
42
Offloading:
what two important things to keep in mind?
can be customized or pre-cut: completely removing WB to the bony structures by cutting out the area: an area of skin breakdown that you don’t want to be in contact you cut out that section
MUST BE EXACT otherwise it can lead to increased pressure ulcer risk
POSITIONED PERFECTLY OVER THE CUT OUT area: otherwise increased risk of pressure ulcer
43
cushion FORCES: friction and shear:
Friction force opposes the movement, friction a force that opposes the movement of 2 bodies in contact
Shear = gravity + friction
44
Friction
why we want it
why we dont
Friction force opposes the movement, friction a force that opposes the movement of 2 bodies in contact
1. PRO: prevents patient from sliding forwards, we want friction to prevent forward sliding
2. CON: but the more friction makes transfers difficult
(note that we don’t want them to transfer so much by sliding and want them pushing up from chair)
45
Shear
what causes it
why dont we want it
Shear = gravity + friction
1. increase one or the other increases shear
2. increasing SHEAR increases to HEAT increase to skin which leads to SKIN BREAKDOWN
46
Cushion: why do we have to be careful about heat
WC cushion must allow for heat dissipation : cushion can be heat build up apparatus: cushion need to allow heat dissipation
1) SCI has poor thermoregulation
2) Increase heat --> increases moisture--> tissue maceration and pressure ulcer
How do different cushions react with heat
1. Foam: acts as insulator, so temperature can raise higher than desired (easy contour, cheapest)
2. Fluid/gel (can put into fridge!) can conduct and absorb heat, good is it can be put into a fridge to cool the person off
3. Air: varies depends on covers: it is a fair conductor of heat but because the air cannot escape the cushion the covering of the cushion can be what is conducting heat
47
How do different cushions react with heat
FOAM
FLUID / GEL
AIR
How do different cushions react with heat
Foam: RETAIN HEAT: acts as insulator, so temperature can raise higher than desired (easy contour, cheapest) (RETAIN HEAT)
Fluid/gel (can put into fridge!) can conduct and absorb heat, good is it can be put into a fridge to cool the person off (FLUID DOES NOT RETAIN HEAT)
Air: varies depends on covers: it is a fair conductor of heat but because the air cannot escape the cushion the covering of the cushion can be what is conducting heat
48
Foam Cushion:
pro (4)
con (6)
Benefits:
1. Lightweight
2. Contours
3. Cheap
4. Firm transfer surface
Limitations:
1. Bottom out if too soft (squish)
2. Polyfoam foam (open cell, air can go out) vs vsico foam (closed cell, maintain shape a little longer)
3. Short life span
4. Heat retention
5. Difficult to keep clean (bad if bad bowel and bladder: foam will keep the scent)
6. Custom contours which are good in that allow for flexibility can make transfers harder
49
FOAM
pro
1. Lightweight
2. Contours
3. Cheap
4. Firm transfer surface
50
FOAM
con
1. Heat retention
2. Bottom out if too soft (squish)
2. Polyfoam foam (open cell, air can go out) vs vsico foam (closed cell, maintain shape a little longer)
3. Custom contours which are good in that allow for flexibility can make transfers harder
4. Short life span
5. Difficult to keep clean (bad if bad bowel and bladder: foam will keep the scent)
51
FLUID cushion
Benefits and limitations
Fluid cushions: such as a “J” cushion
Benefits
1. CONFROM to individual shape
2. Increases surface areas and good PRESSURE DISTRIBUTION
3. DECREASE SHEAR FORCE
4. Does NOT RETAIN heat
5. Easy to CLEAN
Limitation
1. Heavy: adds to weight of WC
2. Less stable transfer surfaces
3. Affected by extreme cold
a. poikolothermia: if cannot regulate body temp and gel take on temp of cold outdoors
4. Can pop and fluid leak out
5. Can bottom out if not enough fluid
52
FLUID cushion
Benefits
Benefits
1. Conforms to individual shape
2. Increases surface areas and good pressure distribution
3. Decreases shear forces
4. Does not retain heat
5. Easy to clean
53
FLUID cushion
Limitation
Limitation
1. Heavy: adds to weight of WC
2. Less stable transfer surfaces
3. Affected by extreme cold : poikolothermia: if cannot regulate body temp and gel take on temp of cold outdoors
4. Can pop and fluid leak out
5. Can bottom out if not enough fluid
54
Air Cushions
Benefit:
1. Lightweight
2. Immersion increases surface area—better pressure distribution (protect against skin breakdown)
3. Easy to clean
4. Some can accommodate postural deformities
Limitations: not so comfy
1. Lengthy initial adjustment
2. Higher maintenance
3. Puncture/leaks/tears
4. Unstable transfer surface (not good for someone who is very mobile, more for stability and skin protection)
5. Some do not accommodate for asymmetries
55
Air Cushion
benefit
1. Lightweight
2. Immersion increases surface area—better pressure distribution (protect against skin breakdown)
3. Easy to clean
4. Some can accommodate postural deformities
56
Air Cushion Limitation
1. Lengthy initial adjustment
2. Higher maintenance
3. Puncture/leaks/tears
4. Unstable transfer surface (not good for someone who is very mobile, more for stability and skin protection)
5. Some do not accommodate for asymmetries
57
Cushion Material Summary:
Foam
Gel
Air
Foam: best for positioning, worst for heat buildup
1. Most lightweight, most durable
2. Best for someone who is mobile
Gel: moderate for both, allows for modular units
1. Less stable transfer surface, better conformity
Air: best for skin protection, good for stability, worst for positioning
1. Best for need stability and skin protection
2. Not good for mobility
3. Not good for positioning
58
Which cushion best for mobile person
Foam: best for positioning, worst for heat buildup
1. Most lightweight, most durable
2. Best for someone who is mobile
59
Which cushion best for skin protection person?
Air: best for skin protection, good for stability, worst for positioning
1. Best for need stability and skin protection
2. Not good for mobility
3. Not good for positioning
60
Which cushion best for positioning?
Foam: best for positioning, worst for heat buildup
1. Most lightweight, most durable
2. Best for someone who is mobile
61
Which cushion worst for positioning?
Air: best for skin protection, good for stability, worst for positioning
1. Best for need stability and skin protection
2. Not good for mobility
3. Not good for positioning
62
Which cushion best durable?
Foam: best for positioning, worst for heat buildup
1. Most lightweight, most durable
2. Best for someone who is mobile
63
Which cushion good for conformity?
Gel
| Foam
64
Which cushion good pressure distribution?
fluid
| air
65
Which cushion decrease shear force?
fluid/gel
66
which cushion not retain heat?
gel/fluid
67
which cushion unstable transfers?
gel/fluid
air
68
which cushion not good for mobility?
air
69
Cushion covers
(3) what most ideal
can be washed and allow for cushion to breathe more
Ideally wants one that allows air to go through (don’t want heat buildup)
Moisture resistance with or without airflow
More active patient may sweat more
Want one that will:
1) Increase pressure relief
2) increase airflow
3) increase heat dissipation
70
Seating System vs Mobility System
Seating system = cushion + base for cushion + backrest (can maybe also leg rest and foot rest)
Mobility system = wheels
71
Wheelchair: Accommodate vs correction:
Correction for flexible deformities
Can use cushion or seating system to correct a flexible deformity
Accommodation for fixed deformities
Hold it in place and keep it from progressing
72
Lower limb positioning:
LE position can effect the pelvis
--Can make hips neutral that will keep the pelvis stable
Ideally: thigh level with seating surface and fully supported (this will lock pelvis more)
Neutral hip adduction / abduction and ER / IR
73
Footplate height
what if too low or high?
to achieve proper LE position:
Foot plate that allow feet to be in 90 degrees to stabilize hips on the cushion to stabilize the pelvis
If too LOW: too much pressure on distal thigh (not enough hip flexion)
If too HIGH: too much pressure on proximal thigh (knees above 90 degrees, too much hip flexion)
74
What is needed to achieve proper LE positioning?
3
1. footplate height
2. solid seat
3. proper seat depth and width
75
Front Frame/Footrest Drop Angle:
what if footplate out too far?
what if decreased drop angle?
what things to consider? (3)
The angle that the footrests come out: Impacts leg position and overall frame length
TOO FAR FORWARD: increase footprint of chair, more frame length, sometimes this is done to put person further back in the chair?
DECREASED DROP ANGLE PAST NEUTRAL to inhibit extensor tone if knees flexed past 90 degrees. Sometimes need because of deformities in knee or hip
things to consider
1. Consider relative to seat slope and front seat floor height
2. Consider ROM , spasticity
3. Closer to vertical may inhibit extensor spasticity
76
What issues caused by decreased hip flexion?
we want the person in the chair to have about 90 knee and 90 hip
a. Can lead to compensation at pelvis
b. If unilateral relieve one side
c. If bilateral, increase back angle
if they cannot do about 90 knee and 90 hip and have a contracture then solve this by increasing the back angle
77
Ankle Position
ideal?
in case of PF contracture?
we want neutral with slight DF with entire foot supported
hold in place with strap
if PF contracture: accomodate by increasing angle of footplate (floor scrape precautions)
solutions to the floor scrape precaution issue:
1. tilt back the chair (but harder to transfer out when gravity sucks them in)
2. elevate the chair (harder to transfer back in, also whole chair less stable and shake around more)
78
Trunk Position:
what is it dictated by?
what is the most common problem?
1. Dictated by pelvic position
2. Dictated by backrest
3. Excessive *kyphosis*, most common problem
In the video we watched the man who had kyphosis was stable—do we accommodate, support, fix and correct or not.
79
Flexible Kyphosis with GOOD balance:
Correctable!!
Supports at PSIS to increase lumbar extension, thoracic extension (more in thoracic spine extension—note sometimes the slouch helps with the stability)
80
Flexible Kyphosis with POOR balance:
they are stuck in this position but this is the position that they need
Must do concurrent rearward shift in the system tilt of the wheelchair to regain a functional balance point:
---tilt in space: we need to do a tilt in space of the chair itself, play with the angle until the person can find an optimal balance point (either by adjusting or having the back of the chair contoured)
Use adjustable or pre-contoured back
81
Scoliosis Support
3 points of contact on WC back
1. lateral pelvis
2. contralateral side on apex of curve
3. original side as high as possible on lateral thorax without interfering with UE function
82
Back Height
too low
too high
Back Height: no standard back height, generally we say inferior angle of scapula but really depends on the level of the injury
TOO LOW: loss of balance posterior
(nothing to hold them up if force pushes them posteriorly, don’t want for hight thoracic or cervical lesion—only for low thoracic and lumbar lesions)
TOO HIGH:
interfere with manual propulsion
increase kyphosis unless contoured
83
WC: UE positioning
Too low
Too High
ELBOW 90, forearm parallel to the floor ( neutral position of humeral head in glenoid at rest)
TOO HIGH: shoulder and scapula elevated leading to neck and shoulder pain (ie due to seat being too low or wheel being too high)
TOO LOW: subluxation and kyphosis/scoliosis
Armrests may not be needed based on level and activity---if have enough UE strength and trunk control they wont need it—DON’T ALWAYS NEED ARMRESTS
Spasticity (arms move around a lot)//flaccidity (arms flop around a lot)-Armrests may require padding
84
T/F always need armrests?
Armrests may not be needed based on level and activity---if have enough UE strength and trunk control they wont need it—DON’T ALWAYS NEED ARMRESTS
85
Head positioning
a. Neutral neck position
b. Posterior and lateral supports
c. Avoid strapping-skin breakdown
d. Tilt chair and/or recline backrest can assist
—gravity holds head in place (if tilt the chair so that gravity keeps head in place)
the better it holds the head in place the less mobile the head becomes
86
Seats and back widths:
excess
tight
how much space for clothing per side?
what for access?
Excessive: postural deformities : body shifts to fit into the contours extra space
Too snug: adverse pressure at trochanters and posterior lateral ribs
Consider 1-2 inches of space for clothing/side
Most inside doors are 32 inches wide and about 80 inches high
1. 2’8 X 6’8 inch standard for inside doors
2. exterior doors are 3’ X 6’8 inch –a bit wider
87
Seat Depth
Too Long (1)
Too Short (3)
TOO LONG-
1) PPT: posterior pelvic tilt (to fit the space)
2) Excess frame length impacts accessibility (hard to get in and out of the chair)—transfers
TOO SHORT-
1) Inadequate support (also can fall if not smooth ground)
2) Increased pressure on pelvis
3) Interferes with transfers—less room to maneuver on seat surface
Want: Adequate space between popliteal fosssa and beginning of seat upholstery
1) Dependent fully on transfers: less than 2 inches of space ie c4, c5
2) Independent without whole hand function: 2 inch or less
3) Independent with full hand function: 2 inch or more
88
Seat Depth
1) dependent in transfers
2) independent without whole hand function
3) independent with whole hand function
Want: Adequate space between popliteal fosssa and beginning of seat upholstery
1) Dependent fully on transfers: LESS THAN 2 inches of space ie c4, c5
2) Independent without whole hand function: 2 inch or less
3) Independent with full hand function: 2 inch or more
89
Seat Slope / Dump:
what is it
how much for no trunk/have trunk
what 2 things to take into account?
Difference between front and rear seat to floor heights (and the frame width): Seat is tilted back so you are dumped into the seat
Greater slope for increasing trunk paralysis
no loss: 1-2 inch
complete loss trunk: 3-4 inch
can affect transfers
must be addressed with BACKREST
90
Increased Dump:
more stability, less mobility = makes transfers more difficult
1) More stability
1. Easier to wheel
2. easier to do a wheelie because COG more behind
2) Excess kyphosis
3) Excessive IT shear (on the ischial tuberosity, skin breakdown)
91
Decreased Dump:
```
less stability, more mobility
1) Less stable
harder to wheel
harder to wheelie
decreased elbow flexion, Ideal = 120
```
2) Easier transfers
92
Front Seat Height:
LOW ENOUGH FOR
HIGH ENOUGH FOR
front of the seat should not be too high: transfers, fitting under tables
Low enough: must allow for clearance under tables and desks, steering columns
High enough to allow for adequate clearance under footplates
93
Rear seat height:
what it determines
what can it be affected by
what should elbow flexion be
a. Determines actual sitting height of the individual
b. Can be affected by suspension systems
c. Consider seat height relative to rear wheel position—with hand at top of wheel elbow flexion should be 100-120 degrees (100-120 degrees elbow flexion)
94
Seat to floor height:
how we calculate
what if not enough
For Ground Clearance: Heel to popliteal + 2 inches
a. Heel to popliteal space plus two inches minimum for ground clearance:
b. Add cushion height
c. Too little height and unable to ascend curbs (need to do bigger wheelie if footplates too low)
The higher you get the bigger the footprint of the chair, the higher you are off the ground
95
Armrests:
3 types
a. Desk arms: goes under table or desk
b. Full arms: easier for transfer and pressure relief
c. Some patients go without armrests at all, if good trunk function (T8 or better—don’t need balance or pressure relief assistance)
96
2 types of legrests
Swingaway vs rigid
Swingaway Legrests:
- ---Advantages: easier for stand pivot TRANSFERS , standing if ambulatory
- ---Disadvantages: More moving parts—more legrest itself breakdown
Rigid Legrests:
- ---Advantages: LESS HEAVY CHAIR
- ---Disadvantages: decreases types of transfers a person can do
97
2 wheel types:
mag vs spoke
Spoke Wheels:
i. Advantages: more SHOCK ABSORB and LIGHTER
ii. Disadvantages: Fingers get caught, high maintenance
Mag Wheels:
i. Advantages: more rigid, less maintenance, STABLE
ii. Disadvantages: Heavier, less shock absorbance
98
Rear Axle position:
further back vs closer to caster
Further back: more stable, wider turning radius (HARDER TO DO WHEELIE)
Closer to caster: less stable , tighter turning radius (EASIER WHEELIE)
99
Camber:
what is it
what is normal
changes the turning responsiveness and turning stability
Angling that brings the top of the wheels closer to each other Increasing turning responsiveness and stability
0-6 degrees for everyday use—more angle for athletics
widens chair—0.42 inches wider of the chair for each degree of camber increase
100
Breaks
push vs pull
Push to lock:
can use without finger function; can catch thumb
(ER shoulder to lock out arm and lean forward to push forward in themar eminance)
Pull to lock—need minimal finger function,
can interfere with transfers: extension lever to have enough brake to manipulate: (C7, C6 need an extension lever for there to be enough brake for them to manipulate)
101
Wheelchair frames:
ultralight
folding
rigid
high cost, housing for the seating system,
Ultralights: customized configuration to the
individual
----Higher initial cost but better durability
Folding frame: easier to store but postural support is compromised, least support, less push efficiency
–more energy to use the chair
Rigid Frames: efficient to use, hard to store
102
WC Frame
Box Frame vs Cantilever Frame
Box-frame –greater strength and rigidity, More stable
Cantilever frame wheelchair –less energy to push the chair: can absorb shock, fewer tubes, fewer welds, frame can act as suspension
103
WC Steel Frame
Strong but heavy, cheaper
1) Inexpensive
2) easy to work with (to build?)
3) heavy
4) low strength to weight ratio (this is a con, strong but heavy)
104
Aluminum:
less strong, lighter, expensive
1. lighter than steal,
2. non corrosive,
3. more expensive,
4. malleable (chair is lighter but less strong, so not a good strength to weight ratio really eaither)
105
Titanium
lightest, durable, good strength weight ratio, EXPENSIVE
1. lightest,
2. durable,
3. high strength to weight ratio,
4. expensive,
5. hardest to fabricate
106
Frame types:
1. Rigid
2. Folding
3. Tilt in space
4. Recliner
Rigid: most durable, BUT heavy
Tilt in space: pressure relief and positioning, diminish spasticity BUT heavy, hard to transport or self propel
Recliner: Opens up back angles BUT Heavy, transport, increase sacral pressure, increase spasticity (increase stretch on quads and hip flexors)
Folding: easy transport, BUT moving parts-breakdown parts
107
Frame types:
| Rigid:
most durable, BUT heavy
108
Tilt in space: frame type
pressure relief and positioning, diminish spasticity BUT heavy, hard to transport or self propel
109
Recliner: frame type
Recliner: Opens up back angles BUT Heavy, transport, increase sacral pressure, increase SPASTICITY (increase stretch on quads and hip flexors)
110
Folding: Frame type
Folding: easy transport, BUT moving parts-breakdown parts
111
Power Vs Manual WC
pain: overuse UE, exacerbate with propulsion, energy cost vs other tasks
endurance: functional distances, hills and terrain, disuse atrophy vs energy cost
deformity:
environment: stairs, curbs, home, transport
1. Stairs: manual
2. Curbs—manual better for curbs
3. Home—power chair is bigger
4. Transport—power chair is heavy
112
Impact of prolonged manual propulsion:
a. Repetitive strain injury
b. CTS: carpal tunnel syndrome
c. RC injuries: rotator cuff injury
d. These injuries may prevent ability to perform other ADL’s
113
Power WC
Same seating options as manual but for options such as power tilting, recline, leg rests, elevation
Very expensive, more prone to breakdown
114
power WC seating
Simple vs Modular
MODULAR IS GOOD
- Simple: AVOID: ie captains chair
- -no modular ability in backrest which is rigid
- -no tilt in space
- -seat is just padded foam
- -no seating system to use
- -If rip in upholstery whole seat has to be repaired
- -No flexibility
Often pt is not happy in it and medicare has a 5 year rule and cannot change it
If anyone tries to put on a modular component they lose the warranty
115
Power Tilt
4 good things about it
1) Weight shift: power tilt allows for weight shifting in the chair
2) Gravity assisted positioning: if sitting forward in the chair can power tilt and gravity will let them slide back
3) Postural alignment
4) Allows for resting without transfer to bed
116
Power Recline
4 good things about it
seat goes back
1) Postural hypotension
2) Pressure distribution
3) Gravity assisted positioning
4) Cathetrization
5) Rest without transfers
Precautions: shear forces? Adequate ROM
117
why it is better to get a tilt in space then a power recline by itself
If hip flexion contracture and they are comfortable in a 90 degree backrest but as the back goes back the need for hip extension ROM increases, and this is why better to get a tilt in space then a power recline by itself. Can combine a power recline with power elevating leg rests so the person can get to fully supine in the wheelchair and don’t have to transfer to bed
118
Power Stand
i. Physiologic weight bearing
ii. Accessibility
iii. Physiological benefits
iv. ROM adequate?—allows ROM of hips and knees
v. Orthostatic hypotension
vi. Insurance probably wont cover it
119
Vertical seat elevation:
help for reaching higher stuff:
i. Transfers easier
ii. Accessibility easier
iii. Insurance more likely to pay for it
120
Power elevating leg-rests
i. Edema control
ii. Clearance over uneven terrain
iii. Can change length of WC
121
Front Wheel Drive
power wc
1. ascends small curbs
2. good maneuverability in TIGHT SPACES
3. smooth ride,
4. but hard to keep in straight line (front wheels are the movers)
122
mid wheel drive:
power wc
1. best TURNING radius,
| 2. straight line is hard to do
123
rear wheel drive
power wc
1. best for CONTROL and tracking,
| 2. poor turning radius
124
Joystick:
Must be fitted to patient (arm length, hand contours, etc)
Adjusted for grip strength (and sensation)
iii. Other Control options
1. Head control
2. Chin control
3. Sip and puff
iv. Power can be turned off to make chair free wheeling: but very heavy (good if battery dies)
125
WC ordering process
start the process ASAP: need to do home visit, letter of medical necessity, long waiting period: start a year in advance to order a wheelchair
a. Team of patient, PT/OT, assistive tech specialist, vendor, doctor
b. Establish needs through evaluation, interview, home visit
c. LMN: letter of medical necessity
126
WC ACTIVITIES
a. Going down a ramp person need to be in a wheelie position (back tilt chair)
b. Ascent onto curb: tilt it back, rest chair on my thigh to lift up chair
c. ramp: wheelie position and pul back as slide forwad so chair doesn’t craash down
When possible pt keep weight forward as propel up incline
Shoulder extension and want a long stroke of the wheels
Head hips relationship help to power the chair, not short multiple movements but long strokes using the entire body including head forward
Move the wheels in opposite direction to turn, if it’s a wide turn one wheel at a time
When go down incline be in a wheelie
Onto curb: pop wheels up onto curb and then continue with the long strokes
127
Teach a wheelie
a. Teach getting front wheels off the floor: push wheels back and then bring the wheels forward really fast, bring head forward –with us holding the chair
b. Let them understand as wheels go forward they go back and as wheels o back they go forward—I hold the back and let them figure it out
c. Hook to ceiling to let them get used to the feeling of that position
d. Teach to maneuver curbs, up and down, and for ramps
