Wheeled Mobility and Seating Equipment

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Titus L, Moir S, Casalino A, McIntyre A, Connolly SJ, Trenholm K, Regan, M. (2014). Wheeled Mobility and Seating Equipment Following Spinal Cord Injury. In Eng JJ, Teasell RW, Miller WC, Wolfe DL, Townson AF, Hsieh JTC, Connolly SJ, Noonan VK, Loh E, McIntyre A, editors. Spinal Cord Injury Rehabilitation Evidence. Version 5.0: p 1-77. 

The wheelchair is one of the most important pieces of assistive technology that enables activity and participation for the individual with a spinal cord injury (SCI) (Bergstrom & Samuelsson 2006; Di Marco et al. 2003). Estimates suggest that approximately two million individuals, many with spinal cord injuries, use wheelchairs in North America. The demands on the wheelchair are many; it must be a source of effective mobility conducted in different environments and enable and influence the extent and quality of activity while providing comfort, stability and safety not only when sitting, but also when participating in dynamic activities.

Prescribing a wheelchair and seating system is a multifaceted and complex intervention. The prescription must meet the “management of abnormal tone, accommodation or prevention of deformity, improvement or maintenance of functional skills, accommodation for impaired sensation and provision of comfort” (May et al. 2004). Appropriate wheelchair prescription must also address and prevent secondary complications such as pressure ulcers, spinal deformity, pain (upper limb and back) from the mechanical stress of pushing a wheelchair (Curtis et al. 1999).

Historically, there were few choices with regards to wheelchair frame styles and seating products. With the development and improvement of materials and manufacturing, the availability and diversity of these products has increased dramatically. There are numerous wheelchair frames to choose from, with a plethora of adjustments to “fine tune” the wheelchair to the individual’s needs. This has made the process of choosing an appropriate wheelchair more complex (Gagnon et al. 2005) both for the person with SCI and the clinician prescribing the equipment. The same issues have occurred with wheelchair seating equipment and in particular cushions. The acceleration of development related to seat cushions is likely in response to estimates that indicate 50% to 80% of persons with SCI will develop a pressure ulcer (Brienza & Karg 1998) in their life time and the costs associated with treating wounds.

The selection of appropriate wheelchairs and seating products presents a clinical challenge because of the number of intrinsic and extrinsic variables that interact when providing a product that maximizes function, safety and individual preference. The wheelchair set up, whether manual or power, influences the user’s positioning, and postural support, which impacts their comfort and skin integrity and ultimately their ability to function in the wheelchair. This is of particular importance because maximizing function is the ultimate goal for the client using a wheelchair (Minkel 2000). While there is no such thing as a perfect wheelchair or seating system (Garber 1985; Garber & Dyerly 1991) the prescribing clinician must consider a multitude of variables to obtain the best fit. The underlying theme in many of the articles reviewed in this chapter suggests that objective evaluation is needed in conjunction with strong clinical reasoning to obtain the best wheelchair fit.

The lack of high quality (level 1 and 2) scientific evidence to guide clinical decision making in the prescription of wheelchair and seating equipment remains a problem (May et al. 2004).The lack of evidence may be due to the variability in the presentation of residual function after SCI and growing availability of wheelchair and seating equipment. Perhaps of greater influence on this variability is the unique interplay of postural, comfort, and pressure management needs of each individual with the ability to function in their day-to-day lives.

The following presents an overview of studies that: 1) examine the ‘set up’ or configuration of manual wheelchairs, 2) examine power mobility technology, 3) describe alternate power mobility that may provide advanced mobility options, 4) examine the outcomes of seating solutions, and 5) examine the use of pressure mapping on seating among individuals with SCI who use wheeled mobility.