Titus L, Moir S, Casalino A, McIntyre A, Connolly S, Mortenson B, Guilbalt L, Miles S, Trenholm K, Benton B, Regan M. (2016). Wheeled Mobility and Seating Equipment Following Spinal Cord Injury. In Eng JJ, Teasell RW, Miller WC, Wolfe DL, Townson AF, Hsieh JTC, Connolly SJ, Loh E, McIntyre A, editors. Spinal Cord Injury Rehabilitation Evidence. Version 6.0: p 1-178.
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) (World Health Organization, 2008; 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.
Wheelchair and seating system provision is multifaceted and complex which must meet the individual’s needs for function, comfort, postural support to accommodate or prevent deformity, tone management (World Health Organization, 2008; May et al. 2004). Wheelchair and seating 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 (World Health Organization, 2008; 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 consumer input and strong clinical reasoning to obtain the best wheelchair fit.
There is a growing body of research evidence to guide clinical decision making in the wheelchair and seating equipment service delivery process however, the lack of level 1 and 2 scientific evidence is identified by some as a problem (May et al. 2004). The variability in the presentation of residual function after SCI and growing availability of wheelchair and seating products in addition to the unique interplay of postural, comfort, and pressure management needs of each individual with the ability to function in their day-to-day lives are reasons that clinically applicable level 1 and 2 evidence may be difficult to produce. As the body of level 3 and level 4 evidence grows and consistencies in results are demonstrated, there is potential for systematic reviews and meta-analyses to be completed, which may provide the means for the generation of high quality scientific evidence identified as lacking.
The following chapter presents an overview of studies of individuals with SCI who use wheeled mobility that examine: 1) manual wheelchair technology including propulsion, ‘set up’ or configuration, training and, use; 2) power mobility technology, including power mobility use, driving controls, power positioning devices and alternate power mobility options, 3) seating equipment including the use of pressure mapping, postural implications and impact of seating equipment on function, cushions, and changes in pressure during static sitting and dynamic movement while sitting; 4) position changes for managing sitting pressure/postural issues, fatigue and discomfort; 5) wheelchair and seating provision and service delivery process.