Focus On…Mobility & Rehabilitation

Wheelchairs: One size does not fit all

Interview with Deborah Gavin-Dreschnack, PhD

Would you discuss the assertion that wheelchairs designed for short-range perambulation-“standard” wheelchairs-are being used as chronic resting places by the elderly? Also, that wheelchairs in most common use are unlikely to help most elderly women?
Dr. Gavin-Dreschnack: While some community nursing homes are beginning to purchase a mix of wheelchairs (e.g., narrow, extra-wide, hemi [a chair that is or has the adaptability to be lower to the floor, enabling users to reach the floor for foot propelling], recliner, etc.), the majority still appear to buy “fleets” of wheelchairs, most of which are standard width with sling seats and backs. The problem is that these chairs, regardless of width, do not provide proper pelvic stability, but rather provide a “hammocking” effect that does not distribute weight effectively and causes the hips, legs, and knees to roll inward. Elderly women, particularly those who are short in stature and might have kyphotic spines, often cannot reach the wheels for independent propulsion. Another factor is the weight of the standard wheelchair, which can be 40 to 50 pounds, rendering it difficult, if not impossible, to self-propel. The height of the wheelchair seat from the floor also is an important consideration for nursing home residents who need to use their feet to propel. This is common after strokes that have affected one side of the body.

Would you discuss how someone might be perceived as dysfunctional because of poor wheelchair positioning or kyphosis?
Dr. Gavin-Dreschnack: Elderly wheelchair users who are not properly positioned often can be perceived as more dysfunctional than they are. For example, a person who cannot maintain upright trunk alignment may lean heavily to one side without adequate pelvic and/or lateral support. This can contribute to poor head and neck posture, inability to communicate and swallow, exhaustion, discomfort, and even drooling.

Let’s consider Mrs. X, an elderly woman, five-feet tall, with severe kyphosis, who has been admitted to a nursing facility after having a stroke. She is initially placed in a standard, 18″-wide wheelchair with a sling seat and back, fixed-height armrests, swing-away footrests, and a 21″ seat-to-floor height. As a result of the stroke, Mrs. X is limited to use of her left side only. She cannot reach the wheelchair wheel, since the armrest is as high as her shoulder, and she is too short to reach the floor with her feet. This situation renders Mrs. X totally dependent on staff for mobility, as she must be pushed in her wheelchair. Furthermore, her kyphosis causes her head to remain flexed forward, and swallowing is difficult. Her eyes are directed toward the floor, so it appears that she is unable or unwilling to interact meaningfully with others. Mrs. X appears to have many functional limitations, and she appears to require a great deal of assistance overall.

After a seating evaluation is conducted, Mrs. X is provided with a narrow, hemi (17″ seat-to-floor height) frame wheelchair, a pressure-relieving cushion with a stable base, adjustable height armrests, and a contoured, padded backrest that is angled backward and recessed to accommodate her kyphotic spine. Now Mrs. X has armrests that accommodate her shortened arm height, thus enabling her to easily reach the wheel with her left hand. The lower height of the chair allows her to simultaneously use her left foot for propulsion. The new backrest facilitates upright posture, and Mrs. X can now assume a level gaze and keep her head and neck upright without strain. Her swallowing is immediately improved, and she is more comfortable. The improved seating allows Mrs. X to become independent in her wheelchair mobility and promotes social interaction. The way that Mrs. X is perceived by others is dramatically different. While this is just an example, it is not an uncommon scenario in many nursing homes today.

What are some wheelchair modifications that might be considered to minimize the development of pressure ulcers and other physical problems?
Dr. Gavin-Dreschnack: Each resident should be evaluated individually. Generally speaking, good pressure-relieving cushions can help to minimize the effects of extended sitting. Cushions may be gel, foam, air, polymer, or a combination of these and other new materials. Contoured, padded backs also can provide comfort and protection, particularly for residents who have bony spines and scapulae, or deformities such as kyphosis and scoliosis. Padded legrest panels can be used to keep feet and legs from falling between foot/legrests and into the casters, thus preventing injury. Arm troughs and padded trays may be useful in supporting a flaccid upper extremity and reduce the risk of subluxation at the shoulder. By providing lower frames that allow the user to reach the floor, many sliding problems can be resolved, and resultant shear can be reduced or eliminated.

What are some of the more healthful and supportive seating alternatives available for the nursing home population, and how might a facility set up a practical seating evaluation program?
Dr. Gavin-Dreschnack: Wheelchair seating clinics should be an integral part of all nursing home protocol, and can be set up easily by rehabilitation staff with training and the support of administration. In establishing seating clinics, a multidisciplinary approach should be utilized. Ideally, the seating “team” would include the following:

• rehabilitation staff (occupational/physical therapist)
• speech therapist
• nursing representative
• family member
• funding person (e.g., social worker, case manager, etc.)
• experienced and reliable rehabilitation/wheelchair vendor (who often provides trial equipment)

To facilitate appropriate referrals to a formal seating clinic, I have developed a screening tool for use in nursing homes called the Resident Ergonomic Assessment Profile for Seating [REAPS]. It is simple, quick, and effective, and it can be used by any caregiver, with or without any previous wheelchair-seating experience.

Sitting in a reclined position with the head and neck supported provides kyphotic residents with a social link to their surroundings. Using a recliner may also help residents who have breathing problems, arthritis, or lower extremity swelling, or those recovering from surgery.

Transfers into the EasyStand Evolv are easier because of its wider seat and open base, which allow the user’s wheelchair to be positioned closer to the stander.

The open base also accommodates lifts.

Four chair configurations are available: Zero Elevation, Wedge, Gel Pac, and 4-Chamber Gel Pac. The 4-Chamber Gel Pac keeps the gel in place under the ischials. It prevents gel migration while reducing heat and pressure. The double layer foam construction includes a top layer of Visco Memory Foam that molds to bony prominences and a bottom layer that provides additional support.

An Alevio Back Cushion for use in a sling-seat wheelchair is also available.