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1.5. A guide to wheelchair selection
By Jean Minkel, MA, PT
A United Spinal Association TechGuide publication
How you get around has a big impact on what things you can do and where you can go.
Being able to take even a couple of steps, can be a huge advantage to getting around in your home. Some people are able to use the tight bathroom environment to their advantage, holding on to the sink, walls or grab bars. Counters may offer some support when standing or walking in the kitchen.
Once you get to the front door of your home, however, there are no walls for support and your lifestyle might require long distance mobility to do the things you want to do shopping, visiting family friends, going to school or work.
Many people who have lived with a disability for a long time, have found that careful consideration of what is the best way to get around has been a key to their independence. For some people the solutions have included multiple devices - different environments, different devices - a manual wheelchair in the home, a scooter for work and even a handcycle for exercise.
Mobility Assistance Equipment comes in many forms, shapes and sizes. The options include:
- Assistive Devices for Ambulation items to help you when walking cane, crutches, and walkers
- Manual wheelchair including chair with moveable wheels to improve your ability to self-propel as well as chairs designed to be pushed by someone else.
- Power Assist Devices devices added to manual wheelchairs to make it easier for the wheelchair rider to get around.
- Scooters three wheeled (some are available with 4 wheels) devices with a tiller for steering, which help in getting around, but do not look like a wheelchair.Power Wheelchairs Front wheel, Mid wheel and Rear wheel drive options, controlled through a joystick or an alternate control device and available with multiple seating options including power seating.
Be an informed consumer. Ask other users about their own experiences. Ask lots of questions.
Very often mobility assistance equipment is purchased through a third party payer for example medical insurance, Medicare/Medicaid, VA, or vocational rehabilitation. Each payer has their own set of "coverage criteria" and a system for purchasing. As you explore the mobility options available, keep in mind all of these products can be purchased directly by you. If you have the resources, your private pay purchase can offer you greater selection, at less than manufacturer's suggested retail price (MSRP) in a more timely fashion no need to wait for "authorization".
As you explore options, you may find it helpful to consult with a health care provider with experience in mobility devices. There are Occupational and Physical Therapists (OTs and PTs) who specialize in assistive technology. There are suppliers, Rehab Technology Suppliers (CRTS®), who specialize in individualized fitting and service of the devices. Ask other users, they are often a great source of information of the people in your local area who may be able to help you.
"My physical functioning was unchanged, just my mind and my world had finally opened up. With the scooter, I could get around again. And I loved the freedom." 1 In her recent book, When Walking Fails Dr. Lisa Lezonni eloquently articulates the challenges faced by persons for whom the "acceptable" method of mobility, upright walking, is less than functional. Dr. Lezonni speaks from personal experience as a woman with Multiple Sclerosis (MS) who after many years of assisted ambulation, first with one cane and then with two canes, decided to try a scooter.
Adding a wheeled mobility device to your mobility options is a lot like looking for a new car.
There are so many options and many choices, how can you begin to make an informed decision. To be really satisfied over time, requires you do some homework up front. There is no one best chair. The best choice is the product (or products) that allows you to go where you want to go, when you want to go! To achieve that goal you really need to consider the environments where you will be using the device and what things you will be doing. Some users have no choice about using a chair, it is the only form of mobility available to them. For others, a wheelchair may be "augmented mobility", allowing for longer distance travel, without fatigue or fear of falling.
Options to think about. Do your homework!
Mobility Needs A careful consideration of what things you want to be able to do, while using the device, will assist you in focusing on your choices. As noted earlier, like a car purchasing decision, you may need to prioritize your functions to identify the key features your need in a mobility assistance device. You may come to the conclusion that more than one device is, ultimately, what is needed. Many users have come to this conclusion and achieve their mobility goals by adding different devices to their options over time. Meet your top priority needs first. Overtime you can purchase different items to meet your needs in different environments.
An important first consideration is where are you having the most trouble getting around. If ambulation, even with an assistive device like a cane or a walker, is not an option, then you will be a full-time wheelchair rider. If walking around your home or other small spaces is functional, then you may only be looking for a device to increase your community mobility or a device to allow you access to a recreational / leisure activity.
You need to think of the chair in each of your environments, home, community, and for work/school/volunteering activities.
- Home critical features of the wheelchair will effect your ability to transfer (getting in and out of the chair). What is the height of the seat from the floor? How does that height compare to your bed, for example? How do the armrests or foot supports move out of the way, to make your transfer easier? What is the overall width of the chair, will it fit through your doorways?
- Community How do you want to travel in the community? Do you need to fold the walker when riding in the car? If you are using your arms or your legs to propel a manual wheelchair, will you get too tired, just getting to the store or to visit friends? Would a power option (power assist wheels, power chair or scooter) provide more efficient (you will be less tired) method of getting around? Are there sidewalks and curbcuts where you want to travel, or are you "sharing the road" with cars and truck? Do you want to be in the great outdoors trails, grass, gravel or are you a "mall walker" smooth finished floors, wide open doorways. Your choice of tires, wheels and type of base can make a world of difference getting around the store versus hitting the trail.
- Transportation Where you live and what are your transportation options will have great impact on your device choices. Public transportation bus or subway are increasingly accessible for passengers using a wheeled mobility device, providing you want to go where the bus is going. Private transportation (owning your own vehicle) gives you the most flexibility and freedom, when relying on a wheelchair to get around. However, fitting your wheeled mobility device into the car will present a series of questions. Can the chair fold? Can you store it in the trunk or within the car? Can you get it in the trunk and then walk to the car door? Many wheeled mobility device users find a van or a minivan, especially one adapted with a ramp or a lift are the real key to independent mobility. Modified vans are expensive and for many people, just not an option.
- Cane or walking stick The key is to get the cane fitted to be the right height. Ideally when you hang your arm by your side, your hand should hang just over the top of the cane, your wrist lining up with the very top of the cane. An adjustable cane is easiest to use when seeking the right height. Once you have established the height, if you are a long time user, you may choose to use a non-adjustable (cut to your specific height) cane or even a walking stick to add a little style. When you grasp the top of the cane, your elbow should bend about 30 degrees. If you are using a cane because of weakness on one side of your body, place the cane in the hand of the stronger (opposite) side.
- Crutches - There are basically two type of crutch styles under the arm (axcillary) or cuffed to the forearm (Lofstrand or Canadian crutches). A proper fit and some instruction on safe use is important. Seek the assistance of a health care provider when first using crutches. Long time crutch users have found the style tip (rubber tip on the bottom of the crutch) and the grip style for your hand can add to overall comfort for long term use.
- Walkers Walkers now come in many styles pick-up walker (no wheels), Sliders with little skis or tennis balls on the rear legs, or rollator walkers with 4 wheels. Some walkers are three wheeled triangular in shape (offering a little less support but not as bulky). 4 wheeled walkers come designed for primarily indoor use with 4 little wheels or much more robust walkers with 4 larger wheels, a full basket and even a fold down seat.
Styles of wheelchairs and scooters
Broadly speaking there are three categories of products that are referred to as "wheeled mobility devices" Manual wheelchairs, Scooters and Power Wheelchairs. As mentioned previously, many long-time wheelchair users have several of types of chairs each chair functions differently in different environments, together they provide functional mobility for the person. Initially most people only purchase one device, but they hang on to that device later on and find "niche" uses.
Manual Wheelchairs- Manual wheelchairs are designed for two very different purposes to be pushed by someone other than the rider or to provide self-prolusion by the rider.
Dependent/Transport mobility bases, not designed for self-prolusion often have small rear wheels and may look and function much like a stroller. For transport purposes, these chairs often fold compactly to store in the trunk of a car and provide "light duty" mobility. You may find a transport chair is a convenient "back-up" to your primary chair, easily folded when not needed, but readily available if your chair breaks down.
Specialty Positioning bases are dependent mobility devices that allow for changes in positioning by tilting the seating system or reclining the backrest or both. These devices are not easy to transport, but are designed to provide comfortable, full day seating for the user, who is not able to propel or operate a power wheelchair.
Self-propelling manual wheelchairs are equipped with a large wheel used for propelling. Riders self-propel using either both arms, both legs or one arm/one leg. If you are using your leg(s) for propulsion, then the seat to floor height is a critical feature to insure maximum mobility.
The most active manual wheelchair riders are able to balance the chair just on the back wheels. This is called, "doing a wheelie". The ability to do a wheelie significantly improves environmental access for the wheelchair rider. By "popping a wheelie" you can negotiate a high threshold, get over a 2" curb and, if able to ride in a wheelie, cross soft terrain like grass and gravel, without the front casters getting stuck and stopping the person in their tracks. Manual chairs with adjustable rear wheels (able to move the rear wheel forward and backward on the frame) need to be fitted to the user to get the best combination of "tippiness" (ease of popping a wheelie) and stability (not tipping over when just pushing on the wheels). If you have good balance and want to learn to do a wheelie, ask for training from your PT or OT.
Scooters provide power mobility, but have the distinct advantage of "not looking like a wheelchair." For many people who have experienced difficulty with walking, a scooter is a great benefit to "restore" mobility. Scooters are most often 3-wheeled devices (4-wheeled scooters are also available), equipped with a tiller for steering and a seat mount on a platform, which serves as a footrest.
If you have even a limited ability to walk, there may be some good transportation options, such as using a lift into the trunk of car, when using a scooter. For children, who may be walking only limited distances, a scooter can provide "a cool" option to make longer distances to the cafeteria or recess much more feasible. Functionally the three-wheel design creates a longer turning radius, when operating indoors as compared to a traditional wheelchair. However, most scooters come with a swivel seat, allowing easier transfers from sitting to the standing position. Outside, the scooter will not be a stable as a power chair, especially when turning the scooter at high speed. Exercise good judgment and slow down when turning or traveling on unfamiliar ground.
An important consideration when considering a scooter is how stable is your medical condition. Unlike many power chairs which can be adjusted and re-configured with changes in your physical status, scooters are not nearly as flexible. You will need to be able to use the tiller to steer (you can not change the drive controller). Changing seating options, if your sitting balance is poor, is much more limited in a scooter than compared to a power chair.
Historically, the power chair was simply a manual wheelchair equipped with motors, batteries and a joystick. Today the power chair is a dramatically different design. Most power chairs, today, are designed to have two major components, the power base (containing the motors, wheels, batteries and control module) and the seating component. Each component (power base and seat) are offered with a wide variety of options. The following is just a general list of options you may want to consider
Power Base The most obvious difference in power bases is the position of the drive wheel. Power wheelchair manufacturers now offer three types of "drives" rear wheel, mid wheel and front wheel drive chairs. The placement of the drive wheel has a significant impact on "how" the chair moves. Each method has its advantages and disadvantages in both indoor and outdoor driving conditions. Your best bet is to arrange for a test drive, ideally with three different chairs, each with a different drive wheel position. Riders quickly identify the drive wheel placement, which feels most comfortable to control. Once a particular drive wheel placement has been chosen, there are several different models (from different manufacturers) from which to choose.
There are many options available when looking at seating on a power chair. The options range from fairly simple automotive style seats, often referred to as "Captain's seats" to very sophisticated power seating which may tilt, recline, elevate your leg rests and some seats even provide a standing feature. For children, there is even a power-seating feature that lowers the entire seat down to the floor to participate in peer-to peer activities.
Determining your seating needs requires a good look at your sitting balance (do you need external support to use both your hands) and your risk for pressure sores (do you need a mechanical method of taking weight off your buttock). If you have had "pressure sores" or you have trouble sitting up (over the edge of the bed for example), you should work with a health care provider to determine the seating options to best meet your needs.
Many power chair and scooter riders are able to use the standard controls, which come on the chair, the joystick or the tiller. For those who are unable to use the standard controls, several manufacturers now offer "alternate controls". These alternate controls replace the joystick and use other voluntary movements to allow the person to operate the chair.
- Examples include Sip "n Puff, which uses a straw and the person's sips and puffs to control the direction of the chair or head arrays a series of switches mounted into the headrest which allow head movements to operate the chair. If you are in need of an alternate control system, you will need to be evaluated by a seating team, a supplier and a therapist who specialize in customized assistive technology solutions.
A new technology is now available which offers hybrid or "cross-over" products, between traditional manual and power wheelchairs. The power-assist systems are equipped with new wheels (the larger rear wheel for a manual wheelchair) that are battery operated and designed to increase the number of revolutions the wheel makes with just one push on the rim.The goal is to increase the efficiency of manual propulsion while reducing the amount of effort the rider must put into the wheels.
Add-on power systems are designed to give power chair operation, while mounted onto a manual wheelchair base. With a quick release system, these add-on power systems are more easily transportable than traditional power chairs, but do not have the long-term performance or durability of traditional power chairs.
Wheelchair type advantages and disadvantages:
| Advantages | Disadvantages | |
| Manual Wheelchairs | 1. Lighter in weight 2. Greater reliability 3. Easier to transport 4. Less expensive 5. Provides a level of exercise 6. Easier to overcome accessibility problems |
Self-Propulsion: 1. Possible secondary complications (sore shoulders, wrists and elbows) after long-term use. 2. Requires physical effort to be mobile |
| Scooters | 1. Aesthetics, does not look like a wheelchair. 2. Increases mobility range without increased exertion 3. Swivel seat may allow for easier transfers in and out of the seat. |
1. More complicated to transport in a car than a manual chair. 2. Needs charging 3. Less flexible to modify to changing physical conditions than a power chair. |
| Power Wheelchairs | 1. Greatest mobility range with least exertion. 2. Easier to modify over time, if needed. 3. Available with power seating options tilt and/or recline. |
1. More Expensive. 2. More difficult to transport. 3. Less reliable than manual wheelchairs. |
The Internet has opened a great opportunity for product exploration before ever going to a wheelchair clinic or a medical store showroom. Each manufacturer has a website describing their own product line. Major manufacturers include Invacare, Permobile, Pride Mobility and Sunrise Medical. Other valuable resources include:
- www.usatechguide.org large database of available products by category and wheelchair user reviews.
- www.wheelchairjunkie.com consumer direct information regarding commercial products and a wheelchair users forum.
- www.resna.org provides a directory of therapists (Assistive technology Practitioners (ATP) and Suppliers (ATS) who specialize in rehab products.
- www.nrrts.org list of suppliers by state specializing in rehabilitation products.
Conculsion
In closing, the purchase of a wheeled mobility device is not a simple purchase. Much like the car, there are aesthetic considerations, what image do you want to project? Also like a car, what functions do you need to accomplish, may influence your selection. Many a "soccer mom" would love the 2-seater, convertible roadster, too bad there is no room for the kids. Function often wins out.
Both the image of ourselves and the functions we need to perform as a part of our everyday lives change over time. Over time you may have different priorities and thus "move" from one type of mobility device to another. Always do your homework. Ask others about function, reliability, personal experiences of people with similar needs as your own. With routine maintenance and a little tender loving care, your mobility device can provide years of mobility.
Get out there. Talk to other riders, they are a great source of information. Check out the options which can take YOU where you want to GO!
References:
1. Iezzoni LI. When walking fails. JAMA. 1996;276:1609-1613.
2. Hokenberry, J.: Moving Violations, Hyperion, New York, 1995
3. .Karp, G. Life on Wheels: For the Active Wheelchair User, O'Reilly & Associates, Sebastopol, CA. 1999.
4. Bates PS, Spencer JC, Young ME, Rintala D. Assistive technology and the newly disabled adult: Adaptation to wheelchair use. American Journal of Occupational Therapy, 1993, 47, 1014-1021.
5. Axelson P, Chesney D, Minkel J, Perr A. The Manual Wheelchair Training Guide. Minden, NV PAX Press, 1998.
6. Axelson P, Chesney D, Minkel J, Perr A. The Power Wheelchair Training Guide. Minden, NV PAX Press, 2001.
7. Denison I, Shaw J, Zuyderhoff R, Wheelchair Selection Manual: The Effect of Components on Manual Wheelchair Performance Vancouver, BC BC Rehab, 1994 (604) 321-3231 x762
*Jean L. Minkel, MA, PT is an educator and master clinician widely recognized for her expertise in assistive technology. She currently directs Minkel Consulting, a company providing educational and consulting services to clinicians, consumers, manufacturers and payers. She is the author and director of the videotape series: Spending or Investing: Funding Assistive Technology and co-author of the book A Guide to Wheelchair Selection and The Manual Wheelchair Training Guide. Ms. Minkel has over a decade of experience in seating and mobility service delivery to clients of all ages. She has lectured extensively in the United States, Canada, Europe and China.
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