WHEELCHAIR PRESCRIPTION

Developed by:
Assoc. Prof. Jocelyn F. Agcaoili, MHPEd, MSPT
Assoc. Prof. Anne Marie Aseron, MSPT
Physical Therapy 1 Lec (1 / 2015-16)
UST College of Rehab Sci
WHEELCHAIR

A device used to reintegrate a PWD

into the community
WHEELCHAIR

A mobility orthosis
Provides sufficient support to help deter
the effect of deforming forces or
weakened structures on function of the
system
WHEELCHAIR

Supportsthe PWD as needed to

allow maximum function
WHEELCHAIR
as a well made orthosis
Fits correctly
allows the px to function as normally as
possible
ensures px security and safety

Reasonably cosmetic to user

Lightweight but strong
WC Prescription
A complex therapy intervention which
aims to enhance a persons functioning.

When person and WC are well matched

the impact of the person's impairment
is reduced, enabling them to achieve
goals, participate in life roles and
improve their health and quality of life.
WC Prescription
WHO ICF .212

recognise the complex interaction between

a persons health condition
disease, disorder and injury
the contextual factors of the external
environment
social attitudes, architectural barriers and terrain,
as well as legal and social structures
personal factors
gender, age, coping style, character, past and
current experience
WC Prescription
UN Convention on the Rights of PWD

A human rights instrument which affirms

that people with a disability have a right
to, and are capable of, making decisions
(or being assisted to make decisions)
and being active members of society like
all citizens.

Reinforces the principle that the user

must be actively involved and thereby
placed at the centre of the therapy
intervention.
WHEELCHAIR FIT

The prescriptive WC
Match the individuals need to his
environment
INDIVIDUAL ENVIRONMENT
Patient history Physical and social
environment
Patient impairment The wheelchair
Patient skills Mobility base
Seating system
Unique body shape
WHEELCHAIR FIT
Type & components of WC depends on:
Patients impairment / decreased body function
Sensory awareness
Decreased subcutaneous soft tissue
Impaired peripheral circulation in LE
Abnormal skin integrity
Activity limitations
Participation restrictions
Patients age, stature, size, weight
Expected use of the WC
Temporary or permanent
Prognosis for change in patients condition
The Prescriptive WC

Evaluation of patient for WC:

Sitting balance
Stability,

Reaching ability,

Method of propulsion,

Transfer ability

Ability to change position

Sitting posture
The Prescriptive WC

A combination of a mobility base &

postural support system
Creates a dynamic seated environment

If properly prescribed, WC must:

promote function,
minimize energy expenditure
prevent deformity,
maintain trunk stability
improve body alignment,
reduce discomfort
prevent tissue damage &
prevent additional complications
WC types

Standard adult
Heavy duty adult Hemiplegic
Ultralight WC Amputee
Intermediate or One-hand drive
junior Externally powered
Growing Sports
Child or youth Reclining
Indoor
The Mobility Base

The structural foundation of the WC

Consists of the
Tubular metal frame
Armrests

Front rigging / foot support

Wheels

Manual or power
Wheelchair

Manual Power or electric

Wheelchair

Manual Power or electric

WHEELCHAIR FIT
The Wheelchair (OSullivan, Fig. 33.16)
WHEELCHAIR FIT
The Wheelchair
Wheelchair Basic Parts
 The Postural Support System

Made up of the surfaces

that contact the users
body directly
Consists of:
Seat
Back support

Foot support

Additional components to

maintain postural alignment

The Postural Support System
Additional components to maintain
postural alignment & keep user interfaced
with the support surfaces
Head support,
Lateral support for trunk
Lateral / medial support for hips &knees
UE support surfaces
Straps or bands for the chest or pelvis
The Postural Support System

Head support
The Postural Support System

Lateral supports for trunk

The Postural Support System

Lateral / medial supports for hips &

knees
The Postural Support System

UE support surfaces
Wheelchair Measurement
Patient Examination

To learn about patients:

Physical strength
Range of available movement

How movement of one body part affects

Muscle tone
Comfort

Position

Control

Performance in other segments

The Prescriptive WC

Evaluation of patient for WC:

Sitting balance
Stability,

Reaching ability,

Method of propulsion,

Transfer ability

Ability to change position

Sitting posture
Wheelchair Measurement
Patient Examination

Goal :
Preserve spinal alignment
Maintain natural lumbar curve

Position :
Gravity minimized
Supine or Sidelying
Gravity dependent
Sitting
Critical Areas Most Vulnerable to
Complications
Skin irritation, circulatory compromise,
pressure ulcers
Scapula
Trochanters

Ischial tuberosities

Popliteal space
Wheelchair Measurement
Provide a stable seating base
To ensure that WC is comfortable to sit in,
Make maneuvering more efficient

Reduce the skeletal and muscular stresses

caused by the unnatural motions of

propulsion
maintain posture
allow energy conservation for self propelled WC

Promote safety and security

Consider ergonomic concerns for daily use
Wheelchair Measurement
in Sitting
Should be made with
user seated on a firm,
flat surface
Sit with trunk erect in a
comfortable posture
User should wear
clothing similar to the
clothing usually worn
Put seat cushion or
backrest, if using
Wheelchair Measurement

Seat width
Seat depth
Leg or Footrest length
Seat height
Armrest height
Backrest height
Seat Width

To distribute pxs weight

in the widest surface area possible
Allowsufficient clearance for
transfers yet keeping the overall
width as narrow as possible for ease
in negotiating the environment
Seat Width
MEASUREMENT

Of
the patient: Measure hip or thigh,
whatever is wider (consider braces or
heavy clothing) then add 2 inches
Seat Width

To check:
Insert both hands between the skirt
guard and the thighs making sure that
there is no undue pressure to the thighs
Seat Width

Make sure that there is

enough room for the px
to move in
Avoid contact between
the skirt guard, thigh and
clothes to avoid skin
irritation
Seat Width
Too Wide
Difficulty in self propulsion
Difficulty in moving through
hallways
Difficulty in standing &
lateral transfer
Tendency to lean on one
side leading to postural
problems
Unstable seating due to
greater area to move in
Problems
Too Narrow
Can lead to skin irritation
May develop pressure
sores on the trochanter
Too rigid position so
weight is not shifted
easily
Difficulty in transfers
Difficulty wearing
orthoses or braces
Seat Depth
To achieve max postural control & support
Proper weight distribution on the thigh for
less pressure sores
Prevent skin irritation and circulatory
problems in the popliteal space
Seat Depth
MEASUREMENT

On the patient: Measure from the back of

the pelvis to the popliteal area, then
subtract 4 5 cm
On the WC: Measure from the back upright
to the front of the upholstery
Seat Depth

To check:
Insert 3 fingers in between the lower leg
and edge of the seat
Make sure that the patient is seated all

the way to the back of the seat

Seat Depth
Problems

Too Short Too Long

Decreased trunk stability Pressure area & skin
Not optimal weight irritation may develop
distribution = excessive behind the knee (popliteal
pressure transferred to the area)
buttocks (ischial tuberosity)
User may not get adequate
Poor balance since BOS is
reduced support from the backrest
COG moves forward =
danger of pitching out of
chair
Leg or Footrest Length
MEASUREMENT

Seat to footplate distance

On patient: Measure from
the popliteal area to the
heel
Consider if patient will wear
shoes
On WC: Measure from top
of seat rail at the front of
the chair to the rear of the
footplate
 Leg or Footrest Length
Consider:
Footplates must be at least 2 in or 5
cm from the ground for easier
propulsion & clearance
Provision of adequate thigh support to
ensure optimal seating distribution
Cushion height
Adequate clearance from casters
Different types of shoes or heel
heights of patient
Leg or Footrest Length
Too Low
Unsafe mobility since
footrests drag & patient
might tip over
Casters may injure
patients leg
Increased pressure under
the thighs or back of knees
Decreased function of UE
when propelling chair
Problems
Too High
Knees of the user will be
higher than the hips so that
pressure under the
buttocks is increased.
Difficulty positioning chair
& knees may not fit under
tables
Decreased trunk stability
due to lack of support by
the posterior area of thighs
Seat Height

WC seat must be high enough to

accommodate the length of patients
legs with feet on the footrests
To assist in supporting the pxs
weight and to prevent pressure sores
To place the px at proper level to
attain optimum propulsion
Front Seat Height
MEASUREMENT

From floor to seat rail or platform

Leg length plus at least 2 inches
Front Seat Height

Consider:
Transfer ability of
patient
Footplate clearance &

access under tables

Option for lowered or

drop seats (for sports)

Option for tall frames
Rear Seat Height
MEASUREMENT

From top of rear seat rail

to the floor

Will influence WC mobility

& stability
Consider:
Patients propulsion technique
Patients transfer ability
Comparison w front seat height
= influence on pressure
distribution
Seat Height
Seat height too high
Insufficient trunk support
since backrest will be low
Difficulty to utilize table or
desk
Difficult to propel since
may not be able to reach
hand rims
Poor posture when
forearms rest on arm rest
Problems
Seat height too low
Difficulty in standing or
lateral transfer since
COG may be lower
Improper weight
distribution while seated
Footplates may need to
be lowered & thus may
drag on floor
 Armrest Height
To assist in
maintaining correct
posture and trunk
balance by acting as
side to side stability
anchors for side
reaching
Provide for support of
the UE
Provide support
during transfers
Armrest Height
MEASUREMENT

From seat surface to

olecranon process with
the elbow flexed to 90
+ 1 inch

Consider seating surface

Armrest Height
Too High
Difficult to propel
Bad posture
Shoulders are not relaxed
Can lead to instability if the
patient does not use the
armrest
Transfer difficulty
Problems
Too Low
Poor posture and balance
Tendency to lean forward,
May affect respiration
Not enough arm support
Muscles are not rested, can
lead to fatigue
Difficulty in transfers &
standing
Backrest Height

Should provide the patient with support

appropriate to his needs
Should be high enough to stabilise the
upper lumbar region
With a stable seating base, a backrest
that comes halfway up the patients back.
not as supportive as one that extends to just
below shoulder height, but it enables the
user to propel without restriction.
Backrest Height
MEASUREMENT

From seat surface to floor of axilla with

shoulder flexed to 90 degrees (inferior
angle of the scapula)
Backrest Height
To check:
Insert 4 fingers from the tip of the
backrest to under the axilla
Consider:
Patients balance & posture
Ability for WC propulsion

Customized seating requirements

need for additional back support

Backrest Height
For more support
backrest should be up to midscapula
For more active users
lower height for easier maneuverability
Backrest Height

Rule of thumb:
For abnormal trunk
control but good
head control, back
height should be
within 2 inches of
the lower edge of
the scapula
Backrest Height
Too High
Pushes the scapula and
shoulders forward which
may cause difficulty in
balance
Difficulty in propelling
Skin irritation over
inferior angle of scapula
Problems
Too Low
Decreased trunk stability
Postural deviation due to
less back support
May cause skin irritation
due to excessive pressure
at its upper edge
Wheeling efficiency maybe
decreased due to poor
stabilization of the trunk
 Front Frame Angle

An angle measurement
from the seat to the
footplate hangers from the
floor

Standard measure: 60 - 85
Front Frame Angle

Consider:
Knee ROM & hamstring length
Size of caster & caster clearance

Improved access with compact frame

Patients visual field of his legs & feet

WHEELCHAIR
COMPONENTS
FRAMES

Rigid Folding
Energy efficient More comfortable
Lighter (< 20 lbs) ride, frame
Not easily absorbs shock
transportable Easily
Transfers rather transportable
than absorb shock
especially on X bar
rough terrain Heavier
FRAMES

Rigid Folding
Energy efficient More comfortable
Lighter (< 20 lbs) ride, frame
Not easily absorbs shock
transportable Easily
Transfers rather transportable
than absorb shock
esp. on rough X bar
terrain Heavier
WHEELS

Placement of rear wheels

Affect overall stability & ease of mobility

Up & down adjustments

affect seat height

Too small wheels

patient may use short inefficient strokes for pushing
= RSI (repetitive strain injury) or CTS (carpal tunnel syndrome)

Too large or too high wheels

shoulder elevation
Wheels
Propulsion:
Ideal UE position = with
hands posterior to
shoulder girdle and
elbows flexed between
100 - 120
Goal is to amplitude &

force needed to push

Decrease weight of wheel,
compression in wheel,
rolling resistance
WHEELS

Spoked type

Lighter but may

have more
maintenance
problems
WHEELS

Mag Spoked type

most commonly Lighter but may

used nowadays have more
maintenance
low maintenance
problems
very durable
heavy
expensive
WC Steering
effort required to propel a
wheelchair across a slope in a
straight line & ease of turning
the WC

rear wheels of a chair can be

cambered = increase stability
angled towards the chair at the
top
camber up to 5 is acceptable
For sports = may camber more
than 5
TIRES
Drive or rear wheels

Hard rubber Pneumatic

Durable & heavy Have increased rolling
With little or no tread
Have decreased
traction on uneven
surfaces
Less shock absorbing
but maintenance free
Have harsh ride on
rough terrain
resistance, increased
traction & absorbs road
shocks
lightweight best ride on
almost all surfaces
If not properly inflated
px need more force to
push
tendency for flats
TIRES
Drive or rear wheels
Pneumatic Pneumatic
with flat-free inserts with flat-free inserts

Soft rubber or gel

replaces the inner
tube
No flats
Heavier and more
expensive
TIRES
Drive or rear wheels

Kevlar tires Kevlar tires

Resists punctures
Better traction
Built to handle
rough surfaces
while still
maintaining a
smooth ride
CASTERS
small wheels in front of the
chair
5 or 8 inches (most
common) in diameter
may be interchangeable
may either be solid rubber,
pneumatic or semi-
pneumatic
WC Modifications

Back insert support

Seat surface
Foot rest & leg rests
Arm rests
Wheels & tires
Handrims
Back Insert Support
To add stability to the backrest
To provide postural support & comfort
May be used to alter overall depth of
sitting surface
Very firm foam
Promotes postural alignment
May not be tolerable for patients with

prominent bony protruberances

Seat Surface

Sling/ hammock style

Seat cushion
must take into account the ffg.:
stability and support for UE function
pressure distribution

ischial pressure < 50 mm Hg

coccyx < 20 mm Hg

posterior thigh < 100 mm Hg

Seat cushion

Must take into account the ffg.:

heat dissipation
maintenance of posture to prevent

deformity
weight

cleansability and durability

cost and appearance

Seat cushion

Types:
Foam
Contoured foam

Gel-filled

Contoured foam with gel insert

Air-filled villous
Footrest / Legrest / Front rigging

provide balance, positioning and

protection

Fixed foot rest

lighter and more rigid
chair
interferes with transfers

and portability
Footrest / Legrest / Front rigging

Swing-away / removable
leg rest
for easy transfers
improved portability
Heavier
Elevating leg rest
for minimizing edema
for conditions in which the
knee cannot or should not be
flexed
with calf panel for lower leg
support
Armrests

provide balance and stability

point of push-off for weight shifting,
transfers and pressure release
Fixed
may hinder with transfers (except standing
transfers)
Removable
for easy transfers
Armrests
Wrap-around armrest
reduces the width of the
chair by 1 to 1 inch

Desk-length / cut-out
may be fixed or
removable
able to get close to

tables and desks

Armrests / Laptrays
Brakes / Wheel Locks
safety feature
either push to lock or pull
to lock

Pull to lock mechanism

does not interfere with
lateral transfers as well as
transfers that utilize a
sliding board
HANDRIMS
Large diameter
Need less strokes to cover a
distance
decreased energy
expenditure

Small diameter
Need more strokes to cover a
distance
increased energy expenditure
Handrims / Pushrims
Thick
for easy gripping for persons
with poor hand grip
May increase weight of WC

Knobby
For easy propelling
May increase weight of WC
Specialized WC

Positioning

Power WC

For sports & recreation

Other Special Needs

Positioning
Recliner wheelchair
For patients who
use gravity to help balance their
trunks,
who cannot maintain an upright
sitting posture, or
who need to recline in order to
relieve pressure from their buttocks
rear wheels are further back
and may have anti-tippers
installed to prevent the chair
from tipping over backward
Recliner wheelchair
Positioning
Tilt-in Space
alternative to the
reclining types
entire seat and back

tilted
advantageous for

patients with tonal

abnormalities (e.g.
spasticity) which are
triggered by reclining
Power / Motorized WC
forpatients who do not have the strength
and dexterity to manually propel WC
control systems
Proportional (graded response)
Pressure on the joystick further increases
the speed or angle of turning
high brake bias WC brakes automatically
if there is no input from the joystick
Non-proportional (on-off)
e.g. sip and puff, head controlled, voice
controlled
M
Indications for manual mobility

physical limitation not compatible with

ambulation
need for increased independence at
work or in school
poor endurance / distance walking
Indications for powered mobility
physical limitations not compatible with
manual wheelchair mobility
need for
increased independence at work or in school
improved self-esteem
increased efficiency of mobility
the patient:
must not be mentally handicapped
could follow directions easily
can control the wheelchair
Sports WC
rigidframe
solid, lightweight materials (e.g. titanium)
low back rest for unrestricted
maneuverability
cambered rear wheels
lower and narrower seats
small handrims
adjustable axles
Special Needs
Reverse WC / Indoor chair
Larger wheel in front
Indicated for pxs with
limited shoulder & UE mobility,
severe knee flexion contractures,
for children who do better if they
see the wheels
disadvantage
prevents sliding transfers
causes the px to lean forward to propel
Difficult to use outdoors, cannot be pulled up to
curbs
Special Needs

One-arm / one-hand drive

both propelling rims are on one side with
the smaller rim controlling the opposite
side linkage bar
pumping lever on good side
Special Needs

Hemi-chair
for hemiplegics
lower seat height by 2 (difficult to stand)

uses good hand and good leg for

propulsion
Special Needs

Stand-up / standing chair

allows the px to stand
within the frame of the
chair
Provides

weight bearing benefits on

bone
improved pressure release

access to more jobs

Special Needs

Growing Chair
designed to allow
some adjustments for
growth of the user
WHEELCHAIR FIT
Individual needs of patient

A chair that:
Is easy to maneuver & steer
Is easy to transport

Is energy conserving

Is versatile / adaptable

Meet the needs of carers

Makes the user feel good and feel

confident
WC Training
How to
propel chair in all directions
negotiate WC in the community

operate wheel locks, foot supports & arm

rests
use mechanisms without tipping forward or

sideways
transfer in & out of chair

When & how to ask for help & how to

direct helpers
WC Maneuverability
Ability
to back-wheel
balance
user balances the chair on the
large rear wheels so that the
front castors are lifted clear off
the ground
to negotiate curbs or avoid
small obstacles such as an
uneven surface or grids.
Wheelies
WC Maneuverability

Ability to back-wheel balance

Affected by tippiness
Ease with which WC achieve back wheel balance
For active user chairs WC may have a multi-

adjustable axle plate which allows the wheels to

be set further forward under the body of the user.
PATIENT
AND FAMILY EDUCATION
operation of wheelchair components
skin inspection
pressure relief scheduling
observation of signs and symptoms of
decreased circulation in the LE
evaluation of pulses
observation of legs

maintenance and care of the wheelchair

SEAT x 2 CHECKLIST
Support (SCALPS)
For Safety and Comfort /
Cosmesis of Arms, Legs,
Pelvis, Spine and head
Easy self-propulsion
Alteration of tone
Transportability with safe
tie-down
Skin
Easy transferring
Accommodation
(GrOW FAST)
of Growth of Other misc.
requirements (like feeding,
ventilation equipment)
of Worsening medical
conditions
of Functional Activities
of Structural deformities
of Technology
Terrain
 References:
OSullivan, SB, Physical Assessment and Rehabilitation
Batavia, M, The Wheelchair Evaluation, 2nd ed., 2010, Jones and
Bartlett Publishers
Axelson P, Chesney D, Minkel J & Perr A, The Manual Wheelchair
Training Guide downloaded from
http://www.wheelchairnet.org/wcn_prodserv/Docs/MWTG/Sec2/sec2.ht
ml
Guidelines for the prescription of a seated wheelchair or mobility
scooter for people with a TBI or SCI, downloaded from
http://www.enable.health.nsw.gov.au/publications
Choosing an Active User Wheelchair downloaded from
http://www.assistireland.ie/eng/Information/Information_Sheets/Choosi
ng_an_Active_User_Wheelchair1.html
http://www.mccc.edu/~behrensb/documents/210wk15WCFit.pdf
http://colourswheelchair.com/wp-
content/uploads/2014/04/Colours_Everyday_Chair_Measurement_Gui
de_Ver.2.pdf
Good Day!