Fitting, training, and Dispensing the Wheelchair
Contents
1. Jones and Bartlett Publishers LLC NOT FOR SALE OR DISTRIBUTION CHAPTER 11 Fitting Training and Dispensing the Wheelchair The Wheelchair Fitting Once the wheelchair is ordered and delivered by the supplier it should be prop erly fitted to the patient before it is dispensed Depending on the complexity of the order anywhere from one to several fittings may be required before the wheelchair is acceptable and ready to go home with the patient Evaluate 1 the wheelchair 2 the patient s positioning in the wheelchair and 3 the patient caregiver s knowledge of the equipment Make sure the wheelchair is properly configured e g rear wheel axle location relative to shoulders correct seat back angles and seat depth and fits well to accommodate unique postural needs so if patients self propel they do it with greater efficiency In a systematic review of adaptive equipment use in older adults 55 years or older Kraskowsky and Finlayson found that a poor fit was the chief reason for abandoning equipment In the end everyone should be happy before the patient goes home with the equipment If the final product is not acceptable don t have the patient sign for the equipment until legitimate issues are resolved Evaluate the Wheelchair Is the order correct Were all items delivered Go through the order with the supplier and check off each item ordered to determine if it was delivered e Are postural supports insta2. Safety Precaution When instructing to open unfold a wheelchair make sure the fingers are not caught under the seat rails where they can be entrapped and injured Point fingers inward toward the center of the seat upholstery prior to exerting downward pres sure on the seat rails when unfolding opening the chair Figure 11 3 ax Z a L 4 EJ 2 a g gt z NN a m z n a 4 m m m m a E Jones and Bartlett Publishers LLC NOT FOR SALE OR DISTRIBUTION 232 Chapter 11 Fitting Training and Dispensing the Wheelchair FIGURE 11 3 Unfold a wheelchair A Point fingers toward the center of the seat B Keep fingers away from side rails where they can get pinched How to Clean the Wheelchair Most wheelchair components can be cleaned using warm water and mild soap but because materials vary in wheelchairs check the owner s manual e Naugahyde Clean with warm water and mild soap Metal parts Use wax with a cleaner i e auto wax Avoid dripping liquid into openings of metal parts Wood leather and leatherette Use upholstery wax e Completely dry all components Wheelchair Maintenance Have the patient family check the wheelchair routinely for wear and tear Wheel chair parts may loosen over time and tightening loose nuts periodically will help prevent losing parts later Owner manuals typically include a weekly and monthly maintenance
3. back using hips and legs for lift ing using an appropriate base of support and avoiding spine twisting movements Aside from two person lifts stand pivot and sliding board transfers are common patients using three different single assisted methods sliding board transfers were rated over scooting and modified stand pivot technique as being preferred safer more comfortable and performed in less time and with less force Instrument Jones and Bartlett Publishers LLC NOT FOR SALE OR DISTRIBUTION Training 229 Properly position the patient in the wheelchair Operate all the components i e antitippers wheel locks armrests front rigging Fold and unfold the wheelchair Properly and safely position straps harness and supports Engage the wheel locks during transfers Negotiate curbs ramps and maneuvering wheelchair Maintain the wheelchair Follow up In a study by Hess et al who had home health aides 7 16 transfer mock a 3 z gt 5 EJ 2 a gt NN ia m z a zZ D 4 P z z m m m a T Ez measurement properties were not mentioned in their study Proper Positioning in the Wheelchair No wheelchair will be good if the patient is positioned poorly In other words first properly position the patient 1 Engage the wheel locks on the wheelchair This is critical during any trans fer activity into or out of the wheelchair 2 Transfer the pati
4. schedule and check list If a part falls off and it is unclear how to reinstall it have them place it in a wheelchair parts box shoebox or bag and have the supplier or clinic reattach the part as soon as possible Tire Pressure Maintenance One of the easiest ways to foster efficient propulsion is to maintain the recom mended air pressure levels in the wheelchair s pneumatic tires These pressures should be checked periodically because 50 of tire pressure loss occurs within a month s time Jones and Bartlett Publishers LLC NOT FOR SALE OR DISTRIBUTION References 233 Dispensing and Follow Up Prior to dispensing the wheelchair make sure the patient receives all supplier contact information clinic contact information warranty information equipment manuals and any special instructions including follow up visits in writing Wheelchair Checkups Wheelchair maintenance checkups may help to reduce accidents In a randomized controlled trial RCT Hansen et al found that while providing a 3 month occu pational therapy initiated home maintenance checkup 73 of the 74 wheelchairs that is 99 of the chairs inspected were found to require maintenance work The accident rate declined in an active checkup group that received the home checkup from 5 accidents in the previous year to 0 but was unchanged in a stan dard care group that did not receive any checkups during the same year Attrition did occur in both group
5. UE movements e Is the footplate height acceptable The footplate height should support the weight of the LE so the thigh is approximately parallel with the seat cushion If foot plates are adjusted too high increased hip flexion and excessive pressure under the ischia can develop If footplates are adjusted too low excessive pressure under the distal posterior thigh can result e In the frontal plane is the pelvis anterior superior iliac spines level the shoul ders and eyes horizontal and nose vertical If the patient has a fixed scoliosis are the head and shoulders balanced over the base of support e In the sagittal plane is the pelvis in a neutral tilt with the shoulder and head balanced over the pelvis e In the transverse place birds eye view looking down from above are the pel vis shoulders and nose facing front and not rotated left or right relative to the midline If the patient has a fixed scoliosis is the head facing front e Are rear wheels ideally positioned relative to the UEs for propulsion Determine whether the patient propels most efficiently when the wheel axes are aligned with or slightly in front of the patient s shoulder axes and the elbows are in mild flexion when the patient s hands reach to the top of the rear wheels Is seat belt attached at the proper angle typically 45 degrees Ifa chest harness is used is adequate clearance provided for the neck Ifa pommel is used is it positioned
6. distally between the knees and not proxi mally into the groin o If lateral trunk supports are used is there acceptable clearance of the axillary region with no pressure into the brachial plexus e Ifa lap board is used is there sufficient space between the abdomen and the tray for clothes and respiration Is the frame stable from tipping when the patient is in the wheelchair Evaluate the Equipment Knowledge of Patients Caregiver and Family Does the caregiver know how to or can the patient or does the patient know how to instruct others to Training The owner s manual is the ultimate resource for model specific device operation and maintenance and should be given to the patient family The patient and fam ily should be able to operate the new wheelchair be it manual or power before dispensing If additional training is anticipated during the evaluation the patient should be placed on program for training before the device is dispensed to home e g training to perform wheelies Also ensure the following skills are learned by the patient and or caregiver Using Proper Body Mechanics During Manual Patient Lifts and Transfers Mechanical lifts are generally recommended for caregiver assisted transfers because manual lifting carries injury risks Nevertheless caregivers still manually transfer and lift patients Safety guidelines during manual lifting include keeping the load close to the lifter maintaining a straight
7. ent safely into the wheelchair 3 Move the patient s pelvis back into the rear of the seat until the back of their pelvis touches the back of the insert of the wheelchair This is not as Jones and Bartlett Publishers LLC NOT FOR SALE OR DISTRIBUTION 230 Chapter 11 Fitting Training and Dispensing the Wheelchair easy as it sounds Confirm that the patient s pelvis is back in the seat by gently leaning the patient s trunk forward if possible and then checking that there is no gap space between the back of the pelvis and the back insert of the wheelchair Figure 11 1 In some cases a gap is intention ally created between the back of the seat and the bottom of the back insert during the fitting i e back gap to provide clearance for the patient s posterior pelvic area in order to achieve a neutral pelvic position 4 Secure the seat belt across the patient s hips firmly so you can fit only two fingers between the seat belt and the patient s body The patient s pelvis must be maintained back in the seat while you secure the seat belt How Wheelchair Components Operate Become familiar with how parts operate Each company designs its components a little differently I remember scratching my head for 10 minutes before figuring out how to remove a high tech armrest Wheel locks Seat belt Armrests Front rigging Antitippers Caregivers should be instructed not to step on antitippers to raise the casters
8. lled securely Do not place a patient into the wheel chair unless you re sure it s properly and safely secured Do all components operate e g removable parts tilt mechanism Do wheel locks work Does the wheelchair fold if it s supposed to Is the frame stable and are antitippers on the wheelchair if ordered Are there any exposed sharp or hard edges that may cause injuries Is the seat to back angle of the inserts acceptable and set at the correct angle based on the patient s available hip flexion during the evaluation a z a EJ gt z a gt z wa ba m z ae a m m m pe a Ez 227 Jones and Bartlett Publishers LLC NOT FOR SALE OR DISTRIBUTION 228 Chapter 11 Fitting Training and Dispensing the Wheelchair Evaluate Patient in the Wheelchair First position the patient properly in the wheelchair Are postural supports properly installed and configured based on the initial evaluation e Is the seat depth acceptable There should be no more than 2 inches of space between the front of the seat and the back of the knee No pressure should exist against the back of the knee Is the seat width acceptable There may be up to 1 inch of space on either side of the hips Is the back height acceptable based on activity level and sitting ability The lower back must be supported If the patient self propels the back should not inter fere with
9. me Health Care Dealer Supplier 1995 Sept Oct 103 105 8 Sawatzky B Denison I Wheeling efficiency the effects of varying tyre pressure with children and adolescents Pediatr Rehabil 2006 9 2 122 126 9 Hansen R Tresse S Gunnarsson RK Few accidents and better maintenance with active wheelchair check ups a randomized controlled clinical trial Clin Rehabil 2004 18 63 1 639 an z A EJ gt 2 A amp gt wv ia m z a z D 4 m z z m m m a T Ez Jones and Bartlett Publishers LLC NOT FOR SALE OR DISTRIBUTION
10. off the ground i e for curb negotiation because the metal tubing is thin and can easily crack Figure 11 2 Use tipping sleeves located on the back of the chair instead e Removal of inserts e Proper use of straps harnesses and positioning devices 1 y X FIGURE 11 1 Positioning in a wheelchair Confirm that the patient s pelvis is back in the seat A Patient is not sitting back B Pelvis is back Jones and Bartlett Publishers LLC NOT FOR SALE OR DISTRIBUTION Training 231 FIGURE 11 2 Avoid stepping on rear anti tippers because they easily break How to Negotiate the Environment Patients and caregivers need to be taught how to safely ascend and descend ramps and curbs Some information can be found in the wheelchair s user manual If the wheelchair must be manually lifted up or down stairs it is critical that assisting caregivers do not lift the wheelchair from detachable or removable components like armrests or front rigging How the Wheelchair Folds and Unfolds I used to run into a family once a month who owned a wheelchair for years yet never knew it could fold This often involves removing the inserts first Folding a wheelchair can make it easier for a family to go on vacations Improve their quality of life teach the family to fold and unfold their wheelchair Caution them how ever not to get their fingers caught between the rails while unfolding the frame Unfolding
11. s during the year Interestingly users were not always aware they needed wheelchair repairs suggesting that they may not know to call for repairs if the decision were left to them Wheelchair Defects If problems arise with the device that can t be resolved by the supplier and manu facturer consult lemon laws in the patient s state which may offer protection for the first year following purchases e Warranties and lemon laws http www wheelchairnet org WCN_ProdServ Funding warranty html e For state by state listings search Wheelchair Lemon Law and your state e g wheelchair lemon law AND New York e Also see http www usatechguide org References 1 Kraskowsky LH Finlayson M Factors affecting older adults use of adaptive equip ment review of the literature Am 7 Occup Ther 2001 55 3 303 3 10 2 Batavia M Contraindications in Physical Rehabilitation St Louis MO Saunders 2006 3 Hess JA Kincl LD Mandeville DS Comparison of three single person manual patient techniques for bed to wheelchair transfers Home Healthcare Nurse 2007 25 9 577 579 4 Gilinsky G Smith C New wheelchair or new solution Rehab Manag 2006 19 1 34 39 5 Hazard report foldable wheelchairs injure patients fingers Health Devices 2006 35 6 23 1 233 6 Behrman AL Clinical perspectives on wheelchair selection factors in functional assess ment 7 Rehabil Res Dev 1990 2 Supp 17 27 7 Freney D Pediatric seating Ho
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