Wheelchair Basics:
form echoes function
Meg Allyn Krilov, M.D.
Michele D. Mills, MA, OTR/L
William C. Tobia, RPh
The Goals of Wheelchair
Prescription
• Maximize mobility and functional capacity
• Prevent morbidity
• Provide proper measurement and ensure
safety
• Maintain physiological function
• Promote participation in ADLs (BADL,
MRADL, and IADL)
ELEMENTS OF PRESCRIPTION
Medical History
Physical Capability
Abilities/Impairment
Medicare Rules
The In Home Rule:
• Patient must have difficulty
mobilizing in their home to complete
Mobility Related ADLs (MRADLs)
• Patient must be unable to perform
MRADLs with cane, walker, or crutch
in order to qualify for a wheelchair
• Community Mobility is not Medicare’s
primary concern
Assuring Appropriate Fit
• In order to promote optimal seating
and positioning a patient must be
properly measured and fitted for a
wheelchair
Types of Wheelchairs
Medicare K CODES
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K0001 = Standard Wheelchair
K0002 = Hemi Wheelchair
K0003 = Lightweight Wheelchair
K0004 = High strength Lightweight
Wheelchair
• K0005 = Ultralightweight High
strength Wheelchair
Types of Wheelchairs
Medicare K CODES
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K0006 = Heavy Duty Wheelchair
K0007 = Bariatric Wheelchair
K0009 = Other Manual Wheelchair
K0010 = Standard Weight Frame
Motorized Wheelchair
• Medicare pays to rent for the first 10
months, then becomes purchase.
Wheelchair Features
and Considerations
WHEELCHAIR WEIGHTS
• Standard (Steel) 40-65 lbs.
• Lightweight (Aluminum or steel) 3035 lbs.
• Ultralightweight (aircraft quality
aluminum) <30 lbs.
• Titanium <25-15 lbs.
Light Weight and Ultra lightweight
Chair Types
• Decreased weight
• Ease of adjustability
• Decrease in repetitive strain injuries
with prolonged use
• Ability to lower seat-to-floor height
• Better hand contact with push rim
• Improved efficiency with propulsion.
Ultra Lightweight
Frames – Folding
Frames - Folding
• Easy to transport
• Heavier than rigid
Frames - Rigid
Frames - Rigid
• Can be difficult to transport
• Lighter than folding frame
• More durable
Frames - Titanium
• Enables self propulsion for patients
with decreased strength
• Lighter for transport
• Durable
• Corrosion/abrasion resistant
Sling vs. Solid Seat
SLING SEAT
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Pros
Easy to fold
Easy to clean
Light
Cons
• Promotes perspiration
• Promotes poor posture - posterior pelvic
tilt, hip IR/Adduction
Solid Seat Base and Solid
Seat Insert
Pros
• Firm
• Promotes postural control
Cons
• heavier
• harder to fold
Seat width - too narrow
• Difficulty with transfers
• Promotes skin pressure
• Danger of pressure ulcers on greater
trochanters
• Uncomfortable
Seat width - too wide
• Promotes unequal weight distribution
on ischial tuberosities
• Promotes shearing
• Promotes back and shoulder pain
• Leads to difficulty with self propulsion
Seat depth - too short
• Increases pressure on distal thigh
• Alters weight distribution
• Wheelchair may tip over
Seat Depth - too long
• Promotes sacral seating
• Promotes posterior pelvic tilt
• Promotes skin pressure in the
popliteal fossa
Seat Height
• Consider mobility requirements and
transfers
• Lower if utilizing lower extremities to
propel
• Too low, there is increased pressure
on buttocks
• Too high, difficulty with transfers,
wheelchair may not fit under table.
RECLINE
• Recliner
Recline
• Overall length of wheelchair is longer
a full recliner reclines to 180 degrees
• Difficult to propel - in its upright
position it is 6” longer than a
standard wheelchair
• May promote shearing during
positional changes
• When reclined, does not enable end
user with an adequate view of the
environment
Tilt-in-space
• Tilt-in-Space
Tilt-in-space
• Entire seat and back tilt as single unit
maintaining original angle.
• Minimal to no shear
• For effective pressure relief, tilt must be
>45 degrees
Tilt-in-space: Advantages
• Alleviates shear
• Enhances postural control
• Decreases effects of gravity that may
lead to spasticity
• Maintains seating position during
weightshifts
• Has a tight turning radius
Tilt-in-space: Disadvantages
• No ROM benefits
• Difficult to self perform pressure relief
• Urine may run backwards from leg
bag during tilt.
• Difficult to perform catheterization
• Items on UESS may slide off
• Increases height of wheelchair
Combining recline & tilt
• Useful for patients at risk for
pressure ulcers, orthostasis, and hip
flexion contractures
• Assists with achievement of
weightshifts
• Enhances overall seating and
positioning for patients with
complicated seating and positioning
requirements
• Adds weight, width and bulk.
Backrests
• Provides balance support
• Provides freedom of movement
• Higher backrest, provides more
support, but contributes to less
freedom of UE movement
• Lower backrest promotes freedom of
movement, but offers less support
• If backrest is too low, it may
contribute to decreased trunk stability
Armrests
Desk Arms
Full-length arms
Adjustable arms
Fixed height arms
Removable arms
Flip back arms
Armrests
Maintain trunk balance and comfort during
propulsion
Armrests-positioning
• Too High: poor posture, shoulder
elevation and pain, will not fit under
table.
• Too Low: poor posture, increased
trunk flexion, may compromise
respiration.
Wheels
• Mag - heavier with less shock
absorption
• Spoke - lighter with better shock
absorption, easier to propel but more
maintenance
Tires
• Pneumatic with airless insert - rubber
inner tube. FLAT FREE
• Pneumatic - air inner tube, light,
smoothest ride, flats
• Solid rubber - durable, heavy, harsh
ride on rough terrain, no flats,
primarily indoor use
Camber
• Definition: The angle that the wheel
makes with the vertical axis between 2-12 degrees
• Advantages: increased stability,
easier to propel at fast speeds and
easier to turn.
• Disadvantages: increased width and
increased wear and tear on tires.
Sports Wheelchair
• Example of Camber
Casters
• Small - tighter turns and greater curb
clearance
• Large - smoother ride and better on
rough terrain
Handrims
• Aluminum - good friction
• Friction-coated - for impaired hand function
• Projection knobs increase weight and width
but enable self propulsion for patients with
decreased grasp
Foot rests and Leg rests
• Swingaway detachable: most commonly
prescribed.
Elevating legrests: used as an aid for
improving LE circulation and minimizing
edema *when used with tilt
One-piece footboard / foot box: with LE
contractures or malformations
Adjustable angle footplates to
accommodate contractures
Foot rests and Leg rests
• Too high - increase pressure on
ischial tuberosities
• Too low - feet will hit floor, drag on
curbs, and sidewalks
Brakes (wheel locks)
• Toggle lock (most common) : push to
lock or pull to lock.
• Scissor: on sports wheelchairs
• Extensions -standard on one-arm
drive so patient can reach across
and operate wheel lock on opposite
side of wheelchair using only one
hand
Cushions
• Foam - heavy, but provides
positioning and pressure relief
• Gel – heavy, but provides pressure
relief, stability and positioning
• Air (Roho) – provides pressure relief
Requires Careful Maintenance!
Is not for everyone!
• Custom Molded
Cushions
Examples of Common Cushions
Cushions
Pressure mapping
Headrests
• Adjustable for support
Lateral Supports
• Provide trunk support
HIP GUIDES
• Prevent pelvic migration laterally and keep
patient centered in seat.
Putting it All Together: Headrest,
Lateral Supports, and Hip guides
Pommel / Abductor
• Prevents scissoring and keeps
femurs in neutral alignment
• May promote pressure on groin if
patient is not properly positioned
Upper Extremity Support
Surface (UESS) / Lap tray
• Support and positioning device
• Promotes activity performance
• Can be difficult to justify with some
insurances
Harness and Seatbelt
• Harness for postural alignment.
• Seat belt to prevent pelvic tilt and
rotation
Anti-tippers
• Anti-tippers to prevent backwards
tipping of wheelchair.
Power wheelchair vs. scooter
Scooters
Advantages
• Highly desired among patients
• Appear less disabled (as per patient
report)
• Can be disassembled for transport in car
Disadvantages
• Increased turning radius
• Tippy on rough terrain
• Does not fit in elevators or standard
apartment setting
Power Wheelchair
• Requires letter of medical necessity
(LMN)
• Requires a reliable motor output to
operate the powered mobility vehicle
• Requires screening of cognitive,
visual, and auditory skills
Power Wheelchair
Advantages
• Promotes mobility for patients with
complex conditions
• Can fit in elevators and standard
apartment settings
• Can be customized to meet patients
seating and positioning requirements
• Promotes participation in “in-home”
BADLs and MRADLs
Goals of Prescription
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Maximize mobility and functional capacity
Prevent morbidity
Maintain physiological function
Promote participation in ADLs (BADL,
MRADL, and IADL)
Case Study P.A.
P.A. is a 19 year old male with diagnosis of T6 paraplegia
sustained postoperatively in the Dominican Republic during
scoliosis surgery.
Assessment
• ROM: BUEs WNLs AROM & PROM
BLES Contractures at Hips and knees
• Tone: BUES Grossly Intact
BLES Hypertonicity
Trunk Mild Hypotonicity
• Strength: BUEs Good 4/5
BLEs – unable to fully assess due to spasticity
• Coordination: Grossly Intact
• Sensation: Grossly Intact
• Balance: Static Short Sitting Balance Fair +
Dynamic Short Sitting Balance Fair
Case Study P.A. continued
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Vision / Hearing: Intact
Skin Integrity: hx stage 3 pressure ulcer on sacral region,
healed with darkened skin over region
Cognition / Perception: Grossly Intact
BADL: Independent (Self Catheterizes)
Performs Push-up Transfer
IADL: Independent
MRADL: Performs all ADL from Wheelchair
Accessibility: Lives in Accessible Apartment with Family
Vocational Goal: Attend College
Weight 125 Height 5’4”
What type of wheelchair would you prescribe?
What are key features for consideration?
What type of seat cushion is indicated?
Case Study R.H.
RH is a 74 year old divorced male with diagnosis of COPD,
Emphysema, Chronic Systolic Heart Failure, and CAD with
Ejection Failure of 25%, DM Type II
Assessment
• ROM: BUEs WFL AROM & PROM
BLEs WFL AROM & PROM
• Tone: Intact Trunk & Extremities
• Strength: Good 4/5 Trunk & Extremities
• Coordination: Intact
• Sensation: Impaired Light Touch on Bilateral Feet
• Balance: Static & Dynamic Short Sitting Balance Good
Static & Dynamic Standing Balance Poor
• Vision & Hearing: Grossly Intact
• Skin Integrity: Intact
• Cognition / Perception: Grossly Intact
Case Study R.H. continued
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BADL: Modified Independence with Dressing, Bathing and light
Meal Preparation using DME and Adaptive Devices
• Transfers with Supervision – Contact Guard
• IADL: Assistance from HHA 3 days 4 hours weekly (Laundry,
Shopping, Household Maintenance, and Cooking)
• MRADL: Ambulates with Rollator Walker due to decreased
endurance and increased fatigue, uses oxygen via nasal
cannula
• History of falls while performing MRADL within the home
• Lives alone in private home with accessible entrance
• Travel: Ambulette Service
• Weight 200 lbs Height 5’11”
• Vocational Goals: Retired
What type of wheelchair would you prescribe?
What are key features for consideration?
What type of seat cushion is indicated?
Case Study R.E.
RE is a 69 year old female with diagnosis of CVA with Left
Hemiplegia and COPD
Assessment
• ROM: RUE & RLE WNL PROM & AROM
LUE PROM moderately limited all joints
LUE AROM No Volitional Movement
LLE PROM WFL
LLE AROM No Volitional Movement
• Tone: LUE Moderate Hypertonicity
LLE Moderate Hypotonicity
Trunk Mixed Abnormal Tone
• Strength: RUE & RLE Good 4/5
LUE: 0/5
LLE 0/5
Case Study R.E. continued
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Coordination: RUE Grossly Intact
LUE Severely impaired
Sensation: RUE, RLE, Trunk Intact
LUE, LLE, Trunk Impaired
Balance: Static Short Sitting Balance Fair
Dynamic Short Sitting Poor Balance Poor
Static Standing Balance Poor
Dynamic Standing Poor
Skin Integrity: Sacral Pressure Ulcer Stage 2,
Left Ischial Pressure Ulcer Stage 2-3
Vision & Hearing Grossly Intact
Cognition: Intact
BADL: Moderate to Maximum Assist from Husband
IADL: Maximum Assist from Husband and Daughter
Case Study R.E. continued
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MRADL: Non-Ambulatory, Performs all ADL in Manual
Wheelchair, Dependent on Family for Mobility Indoors and
Outdoors
• Sitting Position: Left Side Head, Neck, and Trunk Leaning with
Trunk Rotation
• Lives with Husband in Accessible Apartment Building with
Elevator
• Vocational Goal: Retired Since CVA
• Weight 160 lbs Height 5’3”
What type of wheelchair would you prescribe?
What are key features for consideration?
What type of seat cushion is indicated?
Conjoined Twins: Mobility
Challenge
Family Goal: Promote
Independence in MRADL
Promoting Mobility Without
Dependence on Mom
Promoting Participation in the
Environment
Look out world…Independence!
References
Biodynamics
http://www.biodynamics.us/index.php, accessed
10/17/14
Cooper, RA: Wheelchair selection and
configuration, New York, 1998, Demos.
Garstang, SV, Rand, R: Wheelchairs and power
mobility. In PM&R Knowledge Now.
http://me.aapmr.org/kn/, accessed 10/20/14
References
Koontz, AM, et al: Wheelchairs and seating
systems. In Braddom, RL, editor: Physical
medicine and rehabilitation, ed. 4, 2011,
Philadelphia.
NHIC: Power Wheelchairs and Power Operated
Vehicles - Documentation Requirements
http://www.medicarenhic.com/viewdoc.aspx?id=5
05, accessed 9/30/10
References
• RESNA: Rehabilitation Engineering and
Assistive Technology Society of North
America
http://www.resna.org/, accessed 10/1/14
Wilson, PE, Kishner, S: Seating evaluation and
wheelchair prescription. In Medscape.
http:emedicine.medscape.com/article/31809
2-overview