Should We Change How We Prescribe Wheelchairs?​

Cropped photo of Man sat in Motion Composites Wheelchair

Trends within our industry have led to the idea that ultra-lightweight wheelchairs are reserved for what is categorised as young and active users. Although funding for custom equipment for the older or geriatric population varies greatly geographically, high-end manual equipment tends to reserve these devices for those who can be deemed independent and highly active within the home and community. However, recommendations for evaluation and funding for custom manual wheelchairs are easily justified for the geriatric population when normal ageing progression and specific wheelchair features are understood. Especially when the prescription of a customised manual wheelchair can be the solution that allows the client to be deemed highly active and independent, we will review these aspects here.

Changes with age: strength, form and posture

Muscle strength declines as we age due to sarcopenia, leading to a loss of independence and an increased risk of falls, particularly in the lower extremities. Older adults exhibit a significant reduction in shoulder muscle volume compared to younger adults. This can be problematic for manual wheelchair users who rely on their shoulder muscles for propulsion, as it may hinder their ability to maintain independence.

Prescribing preventive measures can help preserve independence and reduce pain. Age-related spinal changes, such as thoracic kyphosis and forward head posture, can affect posture and range of motion. These conditions, when combined, increase the likelihood of aspiration and related health complications like pneumonia, ultimately impacting physical function and mobility independence in the elderly disabled population. To counteract postural changes, recommendations include using an inclined backrest, solid support, and a pelvic belt to prevent sliding. Ageing also leads to decreased fluid levels in intervertebral discs, especially in the lumbar and thoracic regions, resulting in reduced flexibility.

The ageing process significantly affects musculoskeletal and postural changes in the trunk, upper, and lower extremities, impacting the ability of wheelchair users to propel themselves independently. By understanding the unique features of ultralightweight wheelchairs, we can make appropriate recommendations, ensure proper setup, and justify the necessity for optimal outcomes.

Man sat in Motion Composites Wheelchair

Shoulder muscles and manual wheelchair propulsion

It is well understood that multiple shoulder muscles are required for manual wheelchair propulsion, making it one reason users have such a high incidence of shoulder pain and/or dysfunction. Due to the high demand for the musculature of the shoulder and the impact, this has on the wheelchair user, there are clinical recommendations for proper wheelchair set-up.

Clinical recommendations for wheelchair set-up

The RESNA position paper on The Application of Ultralightweight Manual Wheelchairs discusses, “The most appropriate manual wheelchair for individuals with disabilities who will utilize the wheelchair for an extended period is a properly configured, fully customizable wheelchair of the lightest weight possible.” Manual wheelchairs often provided to geriatric clients do not meet these recommended criteria. A fully adjustable, ultra-lightweight manual wheelchair is recommended and will have the ability to be customised to the needs of the individual. These individual adjustments include an adjustable axle, so the center of gravity can be moved as forward as possible without compromising safety.

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Individual adjustments for ultralightweight manual wheelchairs

When a client has thoracic kyphosis with FHP and/or shoulder weakness and decreased ROM, a forwardly placed axle will allow them to access more of the rear wheel for a larger propulsion stroke as well the place most of the body weight over the rear wheel for more ideal weight distribution.

Other adjustments available in an ultra-lightweight manual wheelchair include back and seat angle adjustments, simultaneously or independently of each other, and wheel camber. A back angle adjustment, if slightly open, can allow for the accommodation of trunk weakness or limitations in the trunk or hip ROM, and a slightly closed angle can allow for better wheel access if necessary. Seat angles and therefore user position can be individualised, allowing the specific seat to floor heights for transfers, or super low for foot propelling. Another option within the category of ultra-lightweight wheelchairs is the availability of performance materials such as high-end aluminum, carbon fiber, or titanium.

Prescribing the right manual wheelchair for geriatric clients

Although not always considered for the geriatric population, the clinical benefits are obvious: lightweight, increased durability, reliability, and even vibration damping. Vibration damping is known to lessen the effects of road noise coming from the environment, which can, in turn, decrease pain and fatigue, which based on findings of changes with age can be a present factor.

Prescribing a manual wheelchair involves finding the best equipment to ensure safe and effective mobility and increased functionality. Understanding how aging physically affects the body opens the door to understanding how to specifically qualify a geriatric client for an ultra-lightweight manual wheelchair. Compared to a standard wheelchair, a custom manual wheelchair that fits to the client specifically can provide optimum outcomes and hopefully better quality and quantity of life that may not have been possible before.

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